SAS 19

• Musculoskeletal complaints and disorders are leading causes of health care visits in clinical practice.
• The musculoskeletal system is enervated by the neurologic system, examinations of the two systems are closely aligned.
• These systems may be examined at the same time.
• Careful questioning during the history and acute observations will help the nurse distinguish the cause of the patient’s symptoms.
• Articular structures include the joint capsule and articular cartilage, the synovium and synovial fluid, intra-articular ligaments, and juxta-articular bone.
• Articular disease typically involves swelling and tenderness of the entire joint and limits both active and passive range of motion.
• Extra-articular structures include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin.
• Extra-articular disease typically involves selected regions of the joint and types of movement.
• Ligaments are rope-like bundles of collagen fibrils that connect bone to bone.
• Tendons are collagen fibers connecting muscle to bone.
• Another type of collagen matrix forms the cartilage that overlies bony surfaces.
• Bursae are pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures.
• The extent of movement of cartilaginous joints is freely movable.
• Radicular pain from spinal nerve compression, most commonly C7 followed by C6, is usually due to foraminal impingement from degenerative joint changes (70% to 75%) rather than disc herniation (20% to 25%).
• The knee is an example of a spheroidal joint.
• The nucleus pulposus is the fibrocartilaginous material at the center of each vertebral disc that serves as a cushion or shock absorber between bony surfaces.
• In 45% to 60% of cases with cervical radiculopathy, the compressed nerve root is usually the C7.
• If a patient is currently experiencing calf wasting, weak ankle dorsiflexion, absent ankle jerk, positive crossed straight-leg raise, it may indicate referred pain to the low back due to a disease such as osteoarthritis, pancreatitis, dissecting aortic aneurysm, or cauda equina syndrome.
• The periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and the overlying skin are included in the anatomy of a fibrous joint.
• Examples of fibrous joints are the knees, shoulders, vertebral bodies of the spine, and skull sutures.
• Unlike low back pain, which is usually from disc herniation, radicular pain is usually from foraminal impingement from degenerative joint changes (70% to 75%) rather than disc herniation (20% to 25%).
• Suspect Cauda equina syndrome from S2-4 midline disc or tumor if bowel or bladder dysfunction (usually urinary retention and overflow incontinence).
• In cases of low back pain plus a red flag, there is a 10% probability of serious systemic disease.
• Be sure to elicit symptoms related to the “red flags” listed above.
• Hinge joints are flat, planar, or slightly curved, allowing only a gliding motion in a single plane, as in flexion and extension of the digits.
• Low back pain is the second most common reason for office visits, and using open-ended questions gives a clearer picture of the problem, especially the location of the pain.
• Extra-articular pain in inflammation of bursae (bursitis), tendons (tendinitis), or tendon sheaths (tenosynovitis); also sprains from stretching or tearing of ligaments.
• Joint pain is one of the leading complaints of patients seeking health care, and may be due to sprains from stretching or tearing of ligaments, muscle or tendon strain, bursitis, or tendinitis.
• Bursae are roughly disc-shaped synovial sacs that allow adjacent muscles or muscles and tendons to glide over each other during movement, lying between the skin and the convex surface of a bone or joint or in areas where tendons or muscles rub against bone, ligaments, or other tendons or muscles.
• Neck pain is also common, and although usually self-limited, it is important to ask about radiation into the arm, arm or leg weakness or paresthesias, or change in bladder or bowel function.
• Midline back pain, suggests musculoligamentous injury, disc herniation, vertebral collapse, spinal cord metastases, or rarely epidural abscess.
• Elicit any “red flags” for serious underlying systemic disease: age older than 50 years, history of cancer, unexplained weight loss, pain lasting more than 1 month or not responding to treatment, pain at night or increased by rest, history of intravenous drug use, or presence of infection.
• Spheroidal joints have a ball-and-socket configuration, allowing a wide range of rotatory movement, as in the shoulder and hip.
• Migratory pattern of spread in rheumatic fever or gonococcal arthritis; progressive additive pattern with symmetric involvement in rheumatoid arthritis.
• Pain in one joint suggests trauma, monoarticular arthritis, possible tendinitis, or bursitis.
• In condylar joints, such as the knee, the articulating surfaces are convex or concave, termed condyles.
• Persisting pain after blunt trauma or a motor vehicle accident warrants further evaluation.
• Pain off the midline, suggests sacroiliitis, trochanteric bursitis, sciatica, or hip arthritis.
• Leg pain that resolves with rest and/or lumbar forward flexion suggests spinal stenosis.
• Radicular gluteal and posterior leg pain in the S1 distribution in sciatica that increases with cough or Valsalva maneuver.