This document provides information on various rheumatological conditions including osteoarthritis, gout, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Sjogren's syndrome, and polymyalgia rheumatica. It describes the diagnostic criteria, clinical features, organ involvement, treatment recommendations, and important complications for each condition. Key points include the importance of Heberden's and Bouchard's nodes in diagnosing osteoarthritis, using allopurinol to treat gout and prevent attacks, methotrexate and TNF inhibitors for treating rheumatoid arthritis, and aggressive treatment of lupus nephritis to prevent morbidity.

1. Rheumatology
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2. Osteoarthritis

3. OA
Involvement of
first carpo-metacarpal joint.
DIP Joints
Hip joint
Stiffness lasting less than 30 minutes
Presence of Heberden’s nodes and Bouchard’s
nodes ( these are bony enlargements –
Heberdens are the ones at distal PIP joints and
very important clue to diagnosing OA)
Some times there is joint swelling and
arthrocentesis will reveal  non –inflammatory
wbc count < 2000/microliter
X-Ray findings – joint space narrowing,
osteophytes and subchondral sclerosis.

4. This patient has knee pain bilaterally. Likely cause? –
OA
Clue: Heberden nodes

5. Rx
General therapy :
Quadriceps strengthening exercises
Glucosamine and chondroitin sulfate role is
controversial – but if patient is already
taking them, do not contradict as noa
dverse effects and there might be subjective
relief with these.
Weight loss for Hip and Knee OA
Joint arthroplasty for Hip and Knee OA if the
pain is unresponsive to medical therapy

6. Rx
Tylenol – drug of choice for OA
NSAIDS – if patients do not respond to OA
or if the pain is very severe.
Tramadol – if NSAIDS are contraindicated
( CAD, renal disease, very elderly) or if
they are of no benefit
Topical capsaicin, lidocaine patches are
effective for hand and Knee OA especially
if your patient cannot tolerate tylenol or
NSAIDs.
Acute exacerbation of Knee OA  intraarticular corticosteroids – do not use more
often than every 4 months

7. OA - Prevention
Maintain adequate BMI ( Body
weight)
Continued moderate joint activity is
very important
– Normal joint use facilitates cartilage
remodeling ( cartilage repair will be
decreased if joint use is decreased –
do not advise complete rest etc for
early OA patients)

8. Septic Arthritis

9. Septic Arthritis
C/F : Fever, jointpain, warmth, joint
swelling and limited movements
Hematogeous spread is the most
common way of infection
If a patient with rheumatoid arthritis
has a flare in just “one” joint – think
septic arthritis – always do
arthrocentesis rather than just
dismissing it as RA flare

10. Septic arthritis
MCC – S.aureus
Can occur with disseminated
gonococcal infection ( clues – young
adult, presence of skin pustule,
migratory arthralgia, tenosynovitis of
wrist or ankle)
Diagnosis :
Do arthrocentesis – wbc count is 50,000 to
100,000 usually.
Get Gram stain and bacterial cultures

11. Septic Arthritis – Prosthetic joint
Difficult to treat
Surgical removal of prosthesis
needed
Antibiotic therapy
Suspect prosthetic joint infection if a
previously painless prosthetic joint
now becomes painful – examine the
joint for local signs like infection,
erythema and warmth.

12. Septic Arthritis - Therapy
Emperic therapy with ceftazidime
If MRSA is a concern in high risk
patients  add Vancomycin
In IV Drug users  use ceftazidime
+ gentamicin.

13. Rheumatoid Arthritis

14. Diagnosis - RA
Diagnostic Criteria of RA: (4 or more)
– 1) Morning stiffness>45 minutes for 6 weeks
– 2) Swelling of wrists, MCP, PIP’s for 6 weeks
– 3) Swelling of 3 joints for 6 weeks
– 4) Symmetric joint swelling for 6 weeks
– 5) Rheumatoid nodules
– 6) Erosive synovitis X-Ray changes in hands
– 7) Positive Rheumatoid Factor
RF is adjunctive test. If it is –ve it does not rule
out diagnosis
Anti-cyclic citrullinated Peptide ( CCP) has a
better sensitivity to detect RA in early disease
when RF is –ve.

15. Extra-Articular Manifestations of RA
Heart: Pericarditis
Renal: Drug related, amyloid
Lung: Pleurisy with effusion, diffuse
interstitial fibrosis
Blood: Anemia
Vasculitis: Nail fold infarct
Nerve: Mononeuritis multiplex
Rheumatoid Nodules
Most common cause of death in RA –
coronary artery disease

16. Rx
NSAIDS
Low dose oral and intra-articular
corticosteroids for quick relief of
symptoms in case of flares
For mild joint disease – use sulfasalazine
or Hydroxychloroquine
For Erosive arthritis or extra-articular
manifestations or nodules use
Methotrexate.
If Methotrexate not effective  use Anti
TNF inhibitors ( infliximab, adalimunab and
etanercept )  prior to using these place a
PPD and check HEP-C serology

17. Long Steroid Use
Many patients with Rheumatological disease are
often placed on long term steroids
Know the side effects – steroid acne ( no
comedones), cushings, HTN, peptic ulcer disease,
Immunosuppression and Osteoporosis
Screen for osteoporosis if your patient may
require more than 2 month steroids eg: DEXA
scan
Start calcium + vitamin D in all patients. If DEXA
shows osteopenia or osteoporosis, start
bisphosphanates also

18. Adult Still’s
High spiking fevers
Arthralgias, arthritis
Maculopapular rash
Lymphadenopathy
Serositis
Sore throat (90%), cultures negative
Negative RF and ANA
Leukocytosis
Hepatosplenomegaly

19. Felty’s Syndrome
Rheumatoid arthritis
+
Splenomegaly
+
Hematological manifestations :
leucopenia, thrombocytopenia and
anemia

20. Crystal Deposition Diseases
Gout
Pseudogout

21. Gout
Presence of at least 6 of the following 12
American College of Rheumatology criteria
confirms the diagnosis of gout:
Maximum joint inflammation within 1 day
More than one attack over time
Monoarticular arthritis (although gout can be polyarticular)
Redness of joint
Great metatarsophalangeal pain or swelling
Unilateral great metatarsophalangeal involvement
Unilateral tarsal involvement
Suspected tophus
Hyperuricemia
Asymmetrical swelling within the joint on x-ray
Subcortical cysts without erosion on x-ray
Joint fluid culture negative for organisms during attack

22. Gout
Screening asymptomatic patients for hyperuricemia – not recommended/
No treatment unless uric acid urine secretion > 1000mg/day
Consider gouty arthritis as a d/d in septic arthritis ( fever,
pseudoparalysis) – do arthrocentesis, intracellular monosodium urate
crystals
Acute Gout Rx
Do not start allopurinol
Give NSAIDS if no renal issues
May consider Colchicine ( GI side effects common, remember myopathy)
No colchicine if Renal or Hepatic insufficiency
In renal insufficiency and conditions where both NSAIDs and Colchicine are
contraindicated, USE INTRA –ARTICULAR STEROIDS if Monoarthritis. If many joints
are affected by gout  Use oral steroids ( R/O Septic arthritis first)
Prevention  In patients with recurrent acute attacks or more than 1 or
2 acute attacks in 1 year , use uric acid lowering therapy to prevent gout
 classify undersecretors or overproducers ( check 24 hr
urinary uric acid excretion)
 Undersecretors( excretion < 600mg per day)  Use
uricosuric drug such as probenecid or sulfinpyrazone ( do not use if renal
insufficiency or nephrolithiasis
 Over producers or in case of Renal insufficiency/
Nephrolithiasis/ urate nephropathy, use ALLOPURNOL ( Target to reduce
serum uric acid to less than 5 mg%)
While using uric acid lowering therapy, use colchicine to prevent gouty
attacks!

23. CPPD
Short stubby crystal
Weakly positively birefringent under polarized
compensated light
4 “H”s  associated conditions 
Hyperparathyroidism, Hemochromatosis,
Hypothyroidism, Hypomagnesemia and
Hypophosphatasia
Rx
Colchicine Q2h ( not in Liver/ Renal disease)
No NSAIDs with renal insufficiency
Allopurinol will not work here
Intra-articular steroid best Rx in renal or GI
disease

24. Raynaud’s Phenomenon
Defined as Hypersensitivity to cold temperatures associated
with color changes of digits during cold or stress exposure
– Mottling with acrocyanosis are common changes and are
benign where as "White attacks“( pallor) indicate severe
ischemia  may lead to digital ulcers
After exposure to cold, remember the course of events here
 blanching, cyanosis first and then erythema and pain on
rewarming.
Numbness or "pins and needles" sensation
Rx : smoking cessation, Avoid cold exposure, CCBs like
Nifedepine and Topical Nitroglycerineointment for attacks
If digital ulcers  use IV prostaglandins eg: Epoprostenol

25. Raynaud Phenomenon
Primary or Idiopathic
Secondary Raynaud's Phenomenon
Connective tissue disease
–
–
–
–
Scleroderma (95% have Raynaud's)
Systemic Lupus Erythematosus
Sjogren's Syndrome
Dermatomyositis
Trauma
– use of occupational tools (vibratory tool – driller etc)
– Carpal Tunnel Syndrome
Occlusive vascular disease
– Atherosclerosis , Systemic Vasculitis , Thromboembolism
Medications
– Cocaine, pseudoephedrine, amphetamine, non selective beta
blockers, Topbacco
Hyperviscosity state like Polycythemia vera
Cryoglobulinemia

26. Scleroderma
Diffuse Scleroderma
CREST Syndrome
( Remember Distal RTA, Pulmonary
Hypertension, GERD like symptoms, Dysphagia
and Renal Crises for HIGH YIELD Questions)

27. Scleroderma
Some key features in history
Raynaud's phenomenon
Skin thickening
Digital ulcers
Gastroesophageal reflux
Shortness of breath
Some Key Features on Physical :
Taut skin
Digital ulcers
Skin pigmentary changes
Basilar crackles on lung exam ( Get HRCT to check for ILD)
Accentuated P2 on cardiac exam ( Get an echo to evaluate
pulm HTN)
Diagnostic tests : ANA, Anti-scl70

28. Scleroderma
ACR classification : One major or two
minor criteria must be met to make
the diagnosis of scleroderma.
Major criterion:
– Scleroderma skin changes proximal to the
metacarpophalangeal joints
Minor criteria:
– Sclerodactyly
– Pits in the fingertips
– Chest x-ray evidence of basilar fibrosis

29. Rx - Scleroderma
Raynauds phenomenon
CCBs ( nifedepine) and antiplatelet agents (ASA)
Digital ulcers  use topical nitrates
Arthritis  NSAIDS
GERD  PPIs
Severe myositis, arthralgias  prednisone
Pulmonary HTN  high dose CCBs,
prostacyclin, bosentan

30. Scleroderma Renal Crisis
Scleroderma + ↑ BP + ↑ Creatinine =Renal
Crisis
Rx : ACE Inhibitors, Control BP aggressively. Continue
ACEI despite rise in creatinine
Captopril, usually, the choice as it’s short acting – so, can
be titrated

31. Sjogren’s Syndrome
Eye/mouth dryness, ocular complications
Parotid gland swelliing
Nasal congestion
Associated with Fibromylagias
High risk of lympomas
Autoantibodies : anti-Ro/SSA and/or anti-La/SSB, ANA
Rx : supportive – artificial tears and saliva. Cholinesterase inhibitor –
Pilocarpine
DMARDS : Cyclophosphamide

32. SLE

33. LUPUS word lupus, which
The
means "wolf" in Latin, was
first used in the Middle
Ages to describe a chronic
rash on the skin. The
name may have been
chosen because the rash
on the skin resembled the
effects of a bite from one
of these wild animals. Or,
some believe the name
arises from the fact that
the rash was common
about the cheeks, giving
lupus victims a werewolflike appearance.
Whichever the case, the
disease is not the bite of a
Canis lupus, but the bite
of a person's own immune
system.

34. SLE – Diagnostic criteria
Malar rash - red rash over cheeks & bridge of nose
Discoid rash – red scaly rash on face, scalp, ears, arms/
chest
Photosensitivity
Oral ulcers
Arthritis
Serositis: (a) pleuritis, or (b) pericarditis
Renal disorder: (a) proteinuria > 0.5g/24 h or 3+,
persistently, or (b) cellular casts
Neurological disorder: (a) seizures or (b) psychosis
(having excluded other causes, eg drugs)
Haematologic disorder: (a) haemolytic anaemia or (b)
leucopenia of < 4000/mm3 on two or more occasions
(c) lymphopenia of < 1500/mm3 on two or more
occasions (d) thrombocytopenia < 100k/mm3
Immunologic disorders: (a) positive anti-ds DNA
antibody or (b) positive anti-Sm antigen or (c) positive
test for lupus anticoagulant or (d) +ve antiphospholipid antibodies or (e) false positive serologic
test for syphilis, present for at least 6 months.
Antinuclear antibody in raised titers ( in the absence of
drugs associated with drug induced SLE )
- Presence of four or more of the 11 criteria, serially or
simultaneously, during any interval of observation…

35. Systemic Lupus Erythematosus
Clinical Features on Presentation
in SLE
– Arthritis or Arthralgia
55%
– Skin Involvement
– Nephritis
– Fever
5%
– Other
20%
5%

36. Systemic Lupus Erythematosus
Organ Involvement in the Course of SLE
•Joints
•SkinRashes
•Discoid Lesions
•Alopecia
•Pleuropericardium
•Kidney
•Raynaud’s
•Mucous Membranes
•CNS (Seizures/Psychosis)
90%
70%
30%
40%
60%
50%
20%
15%
15%

37. Mortality/ Morbidity Risk in SLE
The Most Risk Comes From :
– Early: Organ (esp Renal) Disease – Overt
Lupus nephritis is the most serious
manifestation of SLE. Differs in clinical
pattern, severity, prognosis and
treatment. Aggressive treatment is
warranted.
– Throughout the Course: Infection
– Late: Atherosclerosis and Coronary events

38. Lupus Nephritis
Clinical features :
– Hypertension – new onset
– Peripheral edema, Weight gain, Ascites
– Renal insufficiency or failure ( elevated
creatinine )
– Asymptomatic/ symptomatic urinary
findings: Proteinuria
- RBCs, less commonly WBCs
- Casts : RBC casts are
ominous

39. Dermatomyositis
Heliotropic erythema, Gottron’s
papules
Polymyositis

40. Polymyalgia Rheumatica
Temporal Arteritis

41. Polymyalgia Rheumatica
• Profound hip and shoulder
girdle stiffness
• Anemia
• Elevated ESR usually
greater than 100
• Very responsive to
prednisone trial – 15mg/d
Vascular symptoms may indicate
concomitant temporal arteritis:
• Headache
• Jaw claudication
• Visual changes (amaurosis/
blurring)
• Scalp tenderness
• Cough

42. Reiter’s Syndrome

43. Reactive Arthritis ( Reiter’s)
Pre-infection with These bugs are assocaited  chlamydia,
yersinia, shigella and campylopbacter and HIV
Arthritis onset 1-4 weeks after GI or GU infection
Classic Clinical Triad (Rarely present)
Arthritis
Conjunctivitis
Non-Gonococcal Urethritis
Clues for Reactive Arthritis ( Reiter’s):
hx of diarrhea OR non-gonococcal Urethritis
asymmetric polyarthritis, predominantly affecting lower
extremities, with enthesopathy and skin lesions on bottom
of feet.
In anyone with new onset Reactive Arthritis (Reiter’s) - get an
HIV test. ( Reactive arthritis may be initial presentation of HIV)
Sausage shaped fingers and toes seen ( d/d – psoriatic arthritis –
dactylitis seen there too)
CVS abnormalities like Heartblock and AR may be present

44. Gonococcal arthritis
DGI
For full details on DGI –
Refer ID slides

45. Migratory
polyarthritis.
Skin pustules.
Joint effusions are
often inflammatory
but usually sterile.
Culture all portals of
entry that are
exposed during
sex(pharynx, anus,
urethra). Culture
pustule if present.
Even if a sexual
history is negative,
suspect it!

46. Low Backache
Lumbar Muscle Strain
Lumbar disc herniation
Lumbar Disc Prolapse
Lumbar Canal Stenosis
Lumbar Radiculopathy
Ankylosisng Spondylitis
Medical Causes – Renal colic, Pancreatitis, AAA
rupture, aortic Dissection

47. Mechanical Back Pain
Mechanical back pain
Sudden onset (only 50% patients remember
an inciting incident)
Minimal stiffness
Hurts more with exercise
Gets better lying down
Pain may accentuate with cough or straining
Motion may be limited but Schober
test usually is negative
Causes : Lumbar Strain, Lumbar disc
prolapse, Disc Herniation, Lumbar

48. Ankylosing Spondylitis
Five factors differentiate inflammatory
back pain from mechanical back pain:
Onset before age 40 years
Insidious onset
Persistence for at least 3 months
Associated morning stiffness
Improvement with exercise
Only 10-20% of male first-degree
relatives who inherit B-27 actually
develop AS.
Rx for pain – NSAIDS ( use
antinflammatory agents)

49. Lumbar Stenosis

50. Clues- Lumbar stenosis
Maneuvers which extend the L/S spine narrow the canal (and compress the nerve roots),
while spine flexion opens the canal).
Increases symptoms:
Walking (pseudoclaudication*)
Walking down hill
Leaning backwards
Lying prone in bed
* Pulses are intact and ankle-brachial
index ≥ 1.0  but don’t let this fool
you because a man have
cluadication pain – may have both
PAD and Lumbar stenosis – your job
is to find out what’s the cause of his
claudication pain! So, go by other
differences  like Lumbar stenosis
pain first appears on standing and
decreases on bending forward. Also,
go by Releif time differences with
rest ( 5 mins of rest in PAD, 30 mins
after changing position or sitting in
LCS)
Decreases symptoms:
Sitting still
Bending forward while
walking (shopping cart)
Walking with cane
Walking uphill
Lying supine in bed

51. Fibromyalgia
Fibromyalgia is a diagnosis of exclusion
Criteria :
Widespread musculoskeletal pain ("I hurt all over")
Each of the body quadrant is involved - Pain on left and
right side of body and Pain above and below waist
Skeletal pain present : Cervical, Thoracic, lumbar spine
and anterior chest
Pain worse in the morning and at the end of the day
Symptoms present more than 3 months
Presence of 11 of 18 tender points

52. Fibromyalgia
Patient quotes:
“I hurt all over.”
“I feel like a truck
hit me.”
“This fatigue is the
worst.”
“I don’t sleep
worth a damn.”

53. Management
Reassurance
Exercise Program
Sleep hygiene
Drug Rx :
Amitryptiline
SSRIs
Anticolnvulsants – pregabalin
Tylenol

54. Behcet’s Syndrome

55. Behcet’s Syndrome
Recurrent oral ulcers (at least 3 per year)
And 2 of the following:
– Recurrent genital ulcers
– Eye lesions ( anterior, posterior uveitis)
– Skin lesions:
E. nodosum
Pseudofolliculitis
Papular pustular lesions
Acneiform lesions
– Pathergy  The pathergy test is a simple test in which the
forearm is pricked with a small, sterile needle. Occurrence of
a small red bump or pustule at the site of needle insertion
constitutes a positive test. Although a positive pathergy test
is helpful in the diagnosis of Behcet’s, only a minority of
Behcet’s patients demonstrate the pathergy phenomenon
(i.e., have positive tests).

56. Behcets - Rx
Disease confined to mucocutaneous regions (mouth,
genitals, and skin)  topical steroids and non–
immunosuppressive medications such as colchicine
Moderate doses of systemic corticosteroids are also
frequently required for disease exacerbations
In the event of serious end–organ involvement such as eye
or central nervous system disease  both high doses of
prednisone and immunosuppressive treatment are usually
necessary.
Immunosuppressive agents : azathioprine, cyclosporine,
cyclophosphamide, and chlorambucil.
With organ- or life-threatening disease, the combination of
prednisone and either cyclophosphamide or chlorambucil
(both of which are from the same class of drug —
“alkylating agents”) is the preferred therapy.

57. Orthopedics/ Sports Medicine
Very High-yield Topics Only!

58. Tendon Injuries
Injury to a a muscle tendon
Important topics
Rotator Cuff Tendinitis
Patellar Tendinitis ( Jumper’s Knee)
Achilles Tendon Rupture
Tendinopathy at Elbow
Medial Epicondylitis ( Golfer’s Elbow)
Lateral epicondylitis ( Tennis Elbow)

59. Rotator Cuff Tendinitis
Synonyms : Impingement Syndrome
Pain worse at nights
Inability to lie on the affected shoulder due to pain
Painful overhead activities ( combing hair etc)
Locking sensation with abduction
Tenderness maximum at supraspinatus insertion
Pain is worse between 60 to 120 degrees of abduction. ( painful
arc)
Presence of ecchymoses and shoulder atrophy may point towards
rotator cuff rupture. ( not just tendinitis)
Management :
Do not recommend complete rest of shoulder as it can lead to Frozen
shoulder
Avoid overhead work
NSAIDS for pain
If no improvement in 6 weeks, consider steroid injection in to sub-acromial
space
Improvement will typically occur in 3 to 5 weeks. If the
improvement in pain much delayed, suspect rotator cuff rupture
( Do MRI to rule out this)

60. Adhesive Capsulitis
Synonyms : Frozen Shoulder
Conditions that predispose to adhesive capsulitis
–
–
Diabetes Mellitus
Thyroid Disease
Insiduous onset of increasing shoulder stiffness
Onset of pain is typically after significant Shoulder ROM is
lost
Pain with shoulder activity  accompanied by progressively
decreasing passive and active shoulder movements ( passive
movements are possible in simple rotator cuff tendinitis)
Loss of shoulder motion evident in all planes ( Shoulder ROM
is extremely limited. If the Q says severe pain but normal
shoulder ROM, that rules out adhesive capsulitis)
Management :
Conservative measures : Heat, physical therapy, Home exercises
Analgesics
If symptoms do not improve after 6 weeks on conservative
management and physical therapy  Steroid inj in to subacromial
space
If symptoms refractory to 6 months of conservative management 
surgery

61. Patellar Tendinitis/ Patellar Tendon Rupture
Most common age is 25 to 40 years
Recurrent corticosteroid injections in to
knee joint can also lead to patellar tendon
rupture.
Can occur in teen boys – associated with
jumping sports if done during growth spurt
Signs include : large Knee Effusion and
palpable defect between tibial tubercle and
inferior patella, Active knee extension will
be difficult
Rx : Physical therapy, Surgery within 10
days and plaster cast immobilization for 6
weeks post surgery

62. Achilles tendonitis
Poor running techniques and poor fitting shoes
can predispose to achilles tendinitis.
Rheumatoid arthritis and spondylarthropathies
are some predisposing conditions.
Symptoms include stiffness and heel apin at
achilles tendon that are worse with exercise.
Signs :
Rx :
Pain and tenderness at the insertion of achilles tendon
Do Thompson test to differentiate from rupture ( with the
patient lying prone, squeeze the calf muscle. Normally,
there should be a plantar flexion as a reflex response.
However, in Achilles tendon rupture Plantar flexion is
absent)
Ice Therapy, NSAIDS, Stretching exercises
Never use cortocosteroid injection  can lead to achilles
tendon rupture

63. Achilles Tendon Rupture
Can be associated with Quinolones ( due
to tendon degeneration)
Sports associated with it : foot ball and
basket ball ( due to excess force)
C/F:
Hx of sudden stress on the tendon such as jumping
followed by a “pop” sound at the heel. Usually, there
is severe pain. Sometimes, pain is mild initially.
Patient walks with a flatfoot and there is loss of
plantar flexion. There might be ecchymoses at the
tendon site
Thompson's Test is abnormal
Rx : Ortho consult
– Surgical repair
– Non weight bearing ( use crutches) for 3 weeks.

64. Golfer’s Elbow
Also called as medial epicondylitis – is an
inflammation of common flexor origin
C/F
Dull pain at medial epicondyle
Tenderness on medial epicondyle
Pronation of forearm and wrist flexion against
resistance will elicit pain ( provacative maneuvers)
Rx : NSAIDS, Conservative rx – Rest and
ice therapy. Steroid injection in refractory
cases

65. Tennis Elbow
Lateral epicondylitis
Inflammation of common extensor origin
Sports involved : Throwing sports,
hammering, use of computer mouse
C/F :
Dull ache and tendernessat lateral epicondyle
Wrist extension and Supination against resistance
elicit pain
Rx : Similar to Medial epicondylitis

66. Nursemaid Elbow
This refers to Pediatric condition – Very Highyield
Synonyms : Radial head subluxation, Pulled elbow
Common between 1 to 3 years. Rare after 6 years of age
Occurs due to injury from longitudinal traction on hand
– Elbow extended and forearm pronated ( this happens
when child lifted by wrist or hand)
C/F
A snapping sound may be heard with radial head subluxation .
Radial head is tender
Child holds arm without any motion at side ( arm is kept in Slight
flexed, Pronated and Adducted position)
X-rays of elbow are normal
Rx : includes manual reduction ( while applying pressure
over the radial head, supinate ( palm up) and flex the
forearm to 90 degrees). Once reduced child can use the
forearm in 10 minutes

67. Knee Pain
 Bursitis : Pre-patellar bursitis, Anserine bursitis
Ligament injuries : medial collateral ligament
injury, lateral collateral ligament Injury, Anterior
cruciate ligament injury
Patellar tendinitis
Meniscal Injuries : medial meniscal tear and
lateral meniscal tear
Osteoarthritis
Inflammatory arthritis : RA, SLE, Septic, Gout
Iliotibial band syndrome ( focal aching or burning
pain at lateral femoral epicondyle. Rx :
conservative  RICE-M, NSAIDS)
Patellofemoral syndrome

68. Bursitis at Knee
Pes-anserine bursitis
Associated with direct trauma or over use
Seen in middle aged, obese women
Presents with “medial” knee pain – 3 to 5 cm below
the joint line
Repeated flexion and extension of knee will cause
pain ( “provocative” test)
Pain occurs both at motion and at rest ( esply at
nights)
Rx  ICE, NSAIDS, Steroid injs if refractory
Pre-patellar bursitis
Housemaids knee
Assocaiated with direct trauma to anterior patella
such as chronic kneeling
C/F  Anterior knee pain + swelling
 Tenderness over pre-patellar bursa i.e; on
the anterior knee overlying the patella
NSAIDS, Ice, Steroid injection if refractory

69. Medial Collateral Ligament Injury
Associated with tenderness and pain along the medial joint line.
Most common of all knee ligament injuries
caused by an injury involving valgus (abductor) stress to the
partially flexed knee with the foot fixed Eg: skiing or during
contact sports ( football), when another person falls across the
knee from the lateral to medial direction.
Signs : Valgus stress maneuver  keep knee in 30 degree
position and apply valgus stress. Presence of laxity (excess
movement) and pain on valgus stress confirms instability and
hence, MCL injury
Do a Knee MRI if the pain is persistent in the joint line even after
4 to 6 weeks of injury.
Rx : Rest, ICE, Compression(Elastic) bandage, Elevation of
extremity, Motion restriction and weight bearing as tolerated until
healed ( Mnemonic - “RICE-M” for all sprains)
Remember “ LORI” ( Valgus – outward, Varus – inward)

70. Lateral Collateral Ligament Injury
Associated with tenderness and pain
along the lateral joint line.
Caused by an injury involving
dramatic varus (adductor) stress –
Force against the medial knee
LCL injury usually occurs concurrent
with ACL or PCL injury
Rx : RICE-M
LCL tears heal much slowly than MCL
tears.

71. Anterior Cruciate Ligament Injury
Knee Hyper-extension injury – occurs after non-contact
deceleration, a cutting movement, or hyperextension.
( sudden stopping after running can cause tibial
displacement anteriorly and ther by, causing ACL rupture)
May be accompanied by pain and a "popping" sound at the time
of injury
Swelling (bleeding in to knee, Hemarthrosis) occurs within 12 hours of injury
"Giving way" or buckling sensation of knee
Most sensitive test “Lachman test” ( with the femur fixed,
pull the proximal tibia anteriorly and posteriorly +ve
Test is associated with pain and laxity on anterior
movement)
Other test – “Anterior Drawer’s” test ( with the pt’s feet
flat on the table, hold the lower leg above calf and
suddenly pull forward  excess laxity at the end indicates
ACL rupture)
Rx : Quadriceps strengthening exercises, Knee braces.
- Surgical reconstruction after conservative therapy
in adults. Knee Bracing not needed after surgical
reconstruction.

72. Posterior Cruciate Ligament Injury
Uncommon Injury
Mechanism : the dashboard being struck by the
anterior of the flexed knee in a motor vehicle
accident ( when a flexed knee decelerates
rapidly) or from hyperextension.
Pain is minimal/ does not restrict much
movement
Posterior Drawers test is positive
Get a lateral knee x-ray to rule out tibial avulsion
fracture
Rx : Knee braces, immobilization, quadriceps
strengthening exercises. Surgery indicated only if
associated with avulsion fractures

73. Meniscal Injury
Most common knee injury – medial meniscal injury is the most
common. Lateral is very rare
Mechanism of injury : Twisting injury of the knee or fixed rotation of
tibia with knee flexion or extension
Associated with Anterior Cruciate Ligament Tear in 33% of cases
C/F :
Twisting injury to knee followed initial tearing, painful sensation.
Pain localized to affected meniscus
Locking or buckling sensation
Gradual effusion following injury – may be seen on x-ray
Stair climbing or descent and Squatting can provoke pain
Medial joint line tenderness
McMurray's Test positive ( 97% specific)
If in doubt, MRI is the best study to evaluate menisci – not x-rays
Management: Conservative : RICE-M, NSAIDs , Quadriceps
strengthening Exercises for 2 weeks
Management: Surgery ( Diagnostic arthroscopy and repair) indicated
only in
Irreducible locking
Refractory meniscus symptoms despite above management
Complications of meiniscal injury include Osteoarthritis of knee

74. McMurray’s Test
Patient lies supine, Knee is flexed to 45
degrees and Hip flexed to 45 degrees
Examiner braces lower legs holds ankle
with one hand and knee with other
Medial meniscus assessment : apply
valgus stress and externally rotate leg
and then slowly extend the knee while
still in “valgus”  Assess for "click"
suggesting meniscus relocation.
Lateral meniscus  above is repeated
with varus stress and internal rotation
Interpretation: Test is positive for
Meniscal Injury  If "Click" heard or
palpated with above maneuvers

75. Patello-femoral syndrome
Most common cause of knee pain in patients younger than 45
years of age
common in women.
The patello-femoral joint is affected by the disease; the histologic
abnormalities observed in these patients are typically described as
"chondromalacia patellae".
The syndrome is classified as "overuse" injury, and is common in
athletes.
C/F
Anterior knee pain provoked by climbing the stairs or prolonged sitting.
IMP SIGN - Retropatellar crepitation and Pain on compressing the
-
patella.
Another imp test “ PATELLAR APPREHENSION TEST” – a provocative
test where when the examiner applies pressure on medial side of
patella and presses it laterally – produces pain. Patient will tighten
the quadriceps and refuses the test in anticipation of pain!!
NO “LOCKING” or “CATCHING” sensation unlike in meniscal injury
Rx : NSAIDS, patellofemoral knee exercises, quadricepsstrengthening exercises
Indications for surgery
Persistent symptoms >6-12 months
Refractory to rehab program
- Surgery involves - First ruling out other causes of knee pain
– do a diagnostic arthroscopy and then smooth the patellar
undersurface.

76. Osgood – Schattler’s disease
Common cause of knee pain in young boys near puberty
( 13 to 14 yrs)
Tibial apophysitis – cartilage detaches from tibial
tuberosity
Pathophysiology involves recent increase in athletic
activity at the same time as recent growth spurt.
Anterior knee pain increased by running, kneeling,
climbing stairs etc
Sign : localized tenderness and swelling at tibial
tuberosity.
D/D – SCFE (though involves hip area, pain refers to knee)
Rx :
–
–
–
Reduce Physical Activity, Quadriceps strengthening, Splint the
knee if required
Surgical excision of ossicle may be needed eventually
Never give local Steroid Injections as they can cause patellar
tendon rupture.

77. Limping Child
Transient Hip Tenosynovitis
SCFE
Legg-Calve-Perthe’s disease
Tibial apophysitis
Refer To PEDIATRICS SLIDES

78. Foot Pains
Plantar Fascitis
Metatarsalgia
Morton’s Neuroma
Bunions

79. Plantar Fascitis
Presents with heel pain – worse in the
morning i.e; worst with first few steps
after resting and improves on walking.
Signs : focal tenderness along the plantar
fascia or at the calcaneal origin
Rx :
Calf stretching exercises
Silicone heel inserts/ heel pads
Padded athletic shoes with good arch support
Steroid injections at tender points if refractory to
conservative rx.
Surgery in refractory cases

80. Metatarsalgia
Presents with anterior foot pain
Pain under metatarsal heads –
increases on walking or standing
Tenderness present on palpation of
plantar aspect of affected metatarsal
head
Rx : well padded shoes, taping
technique to keep affected toes in
plantar position

81. Morton’s Neuroma
Pain in the ball of the foot – radiates
to the third and fourth toes
Maximum tenderness in the 3rd
intermetarsal space
Rx :
– Silicon pads/ orthotics
– Steroid injection in to 3rd space
– Surgical excision

82. Hallux Valgus
Also called bunion
Pain and redness on medial aspect of 1st
MTP joint.
Lateral deviation of great toe, callosity of
the skin on medial aspect of 1st MTP joint
Rx :
Wide – toed shoes
Foam pad to protect bunion
Surgical correction of hallux valgus