{"id":557,"date":"2023-08-25T01:46:44","date_gmt":"2023-08-25T05:46:44","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/pathophysiology\/?post_type=chapter&p=557"},"modified":"2025-10-17T19:31:06","modified_gmt":"2025-10-17T23:31:06","slug":"musculoskeletal-injuries-diseases-and-disorders-learning-objectives","status":"web-only","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/pathophysiology\/chapter\/musculoskeletal-injuries-diseases-and-disorders-learning-objectives\/","title":{"raw":"Musculoskeletal Injuries, Diseases, and Disorders - Learning Objectives","rendered":"Musculoskeletal Injuries, Diseases, and Disorders – Learning Objectives"},"content":{"raw":"
\r\n

Chapter Learning Outcomes and Specific Learning Objectives Study Guide<\/p>\r\n\r\n<\/header>\r\n

\r\n\r\nChapter Learning Outcomes:<\/strong>\r\n\r\nBy the end of this chapter you will be able to:\r\n\r\nDescribe key aspects (etiology, risk factors, pathogenesis, diagnostic tools, common treatments and typical outcomes)\u00a0 of the following Musculoskeletal Disorders:<\/strong>\r\n
    \r\n \t
  1. Bone fractures, healing, exuberant callus formation, and compartment (acute, chronic and crush) syndromes<\/li>\r\n \t
  2. Aspects of trauma including nerve damage, fat emboli, DIC, rhabdomyolysis, shock<\/li>\r\n \t
  3. Dislocation and subluxations, sprains and strains, tendinitis, bursitis, and meniscus tears<\/li>\r\n \t
  4. Osteoporosis, Osteomalacia, and Rickets<\/li>\r\n \t
  5. Muscular Dystrophy and Fibromyalgia<\/li>\r\n \t
  6. Rheumatoid Arthritis, Osteoarthritis, and Gout<\/li>\r\n<\/ol>\r\n\r\n
    \r\n\r\nSpecific Learning Objectives Study Guide:<\/strong>\r\n\r\nBy the end of this section you will be able to:\r\n\r\nDescribe and explain the following terms and facts associated with Trauma:<\/span><\/strong>\r\n
      \r\n \t
    • \r\n
      Leading cause of death in people aged 1-44.<\/div><\/li>\r\n \t
    • Due to sports, automobile accidents, falls, workplace accidents, assault, child abuse, etc.<\/li>\r\n<\/ul>\r\nTrauma<\/strong> always involves inflammation<\/strong> - usually in proportion to the amount of cellular damage.\r\n
      Trauma can possibly involve:<\/div>\r\n
        \r\n \t
      • \r\n
        Contusions<\/strong> \u2013 bruise under closed skin involving:<\/div>\r\n
          \r\n \t
        • \r\n
          microscopic rupture of blood vessels; Swelling & inflammation<\/div><\/li>\r\n \t
        • \r\n
          Possibly includes damage to underlying muscle cells;<\/div><\/li>\r\n \t
        • \r\n
          Ecchymotic (black & blue) due to local hemorrhage \u2192 changing to yellow<\/div><\/li>\r\n \t
        • \r\n
          RICE Treatment; Usually full recovery<\/div><\/li>\r\n \t
        • \r\n
          Contusions \u2013 can affect any tissue: e.g. brain, lungs, muscle, bones<\/div><\/li>\r\n \t
        • Bone bruise:<\/strong>\u00a0 microscopic damage of bone blood vessels, and possibly some trabeculae; will not be visible in MRI or other imaging<\/li>\r\n \t
        • Pain due to irritation of nociceptors by chemicals released from damaged cells, by swelling, and be chemicals released by WBCs.<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
        • \r\n
          Bone Fractures:<\/strong>\u00a0 will be visible with x-ray and MRI;\u00a0 Most Common Fractures:<\/div>\r\n
          a) Males 15-24yrs (tibia, clavicle, lower humerus) - clavicle most common childhood fracture<\/div>\r\n
          b) Elderly 65+yrs (hip)<\/div>\r\n
          c) Workplace (hands and feet)<\/div>\r\nd) Osteoporosis (upper femur, upper humerus,\u00a0 vertebrae, & pelvis)<\/li>\r\n<\/ul>\r\nDescribe different types of Bone Fractures:<\/span><\/strong>\r\n
          \r\n
            \r\n \t
          • Simple<\/strong> - bone ends maintain their alignment & position<\/li>\r\n \t
          • Oblique<\/strong> - break at an angle to the shaft of a long bone<\/li>\r\n \t
          • Comminuted<\/strong> - many fracture lines and many fragments involved in bone break<\/li>\r\n \t
          • Open<\/strong> - bone end penetrates the skin to be exposed to the outside environment; is a risk factor for osteomyelitis and osteonecrosis; classified Type I to Type IIIC increasing in terms of severity; Type I opening is smaller than 1cm;<\/li>\r\n \t
          • Segmented<\/strong> - 2 or more breaks in the same bone - one bone fractured into 3 or more parts<\/li>\r\n \t
          • Spiral<\/strong> - spiral direction of fracture in a long bone<\/li>\r\n \t
          • Transverse<\/strong> - fracture is perpendicular to the length of long bone<\/li>\r\n \t
          • Impacted<\/strong> - bone telescoped into itself.<\/li>\r\n \t
          • Compression<\/strong> fracture of vertebrae<\/li>\r\n \t
          • Colle\u2019s<\/strong> fracture = fracture of distal radius (& possibly ulna) from falling forward<\/li>\r\n \t
          • Pott\u2019s<\/strong> fracture = fracture of distal fibula (possibly tibia) from excess stress on ankle<\/li>\r\n \t
          • Pathologic<\/strong> \u2013 infection, cyst, tumor, osteoporosis, Paget disease<\/li>\r\n \t
          • Greenstick\/Incomplete<\/strong>\u00a0\u2013 until age 10 bones are more resilient than adult\u2019s<\/li>\r\n \t
          • Avulsion<\/strong> - fragment of bone connected to a ligament or tendon detaches from main bone<\/li>\r\n \t
          • Stress<\/strong> fracture - usually incomplete<\/li>\r\n \t
          • Fracture through growth\/epiphyseal plate<\/strong> - may result in premature bone fusion and growth cessation; usually an incomplete fracture with proper reduction and fixation will offset any chance of premature fusion;\u00a0 crush injuries are more likely to lead to stoppage of bone growth.<\/li>\r\n \t
          • Transchondral fractures<\/strong> - frequent in teens; separation of cartilaginous joint surface (articular cartilage) from main shaft of bone\u2013 may not be painful except during movement; may hear clicking (crepitus).<\/li>\r\n<\/ul>\r\n \r\n\r\nDescribe possible signs & symptoms of Bone Fractures:<\/span><\/strong>\r\n
            \r\n
              \r\n \t
            • Nerve damage<\/strong> - pain, numbness, surrounding muscles become flaccid (may be temporary or take time to subside<\/em>) = phenomenon called local shock<\/li>\r\n \t
            • Muscle spasms<\/strong> - due to irritating chemicals<\/li>\r\n<\/ul>\r\nDescribe shin splints (Medial Tibial Stress Syndrome, MTSS):<\/span><\/strong>\r\n
              \r\n
                \r\n \t
              • Pain<\/strong> along the shinbone associated with repeated trauma (excessive running or walking) that has damaged Sharpey's (collagen) fibers that connect fascia to the periosteum of the tibia (where it inserts into the tibia bone).<\/li>\r\n \t
              • Risk factors<\/strong> include: improper footwear, overdoing it without proper conditioning or training<\/li>\r\n<\/ul>\r\nSigns & Symptoms of Bone Fractures:<\/strong>\r\n
                  \r\n \t
                • Pain<\/li>\r\n \t
                • Numbness<\/li>\r\n \t
                • Deformity<\/li>\r\n \t
                • Swelling<\/li>\r\n \t
                • Muscle spasms<\/li>\r\n \t
                • Tenderness<\/li>\r\n \t
                • Crepitus = grating sound if bone ends move over each other<\/li>\r\n \t
                • Decreased mobility<\/li>\r\n \t
                • Bleeding (if open fracture)<\/li>\r\n \t
                • Shock (low blood pressure) = pallor, diaphoresis tachycardia, nausea\/vomiting<\/li>\r\n<\/ul>\r\nEmergency Treatment of Bone Fractures in the Field:<\/strong>\r\n
                    \r\n \t
                  • Cover open wound with sterile dressing material.<\/li>\r\n \t
                  • Splint for support, & immobilize for transport including joint above & below fracture.<\/li>\r\n \t
                  • Elevate limb slightly; Apply cold compress.<\/li>\r\n \t
                  • Keep patient warm; check for signs of shock.<\/li>\r\n<\/ul>\r\nDescribe Fracture Healing of Cortical\/Compact and Cancellous\/Trabecular\/Spongy Bone - 5 Stages<\/strong>\r\n
                      \r\n \t
                    • Stage 1: Hematoma Formation<\/strong> - collection of blood & subsequent clot and inflammation zone forms at fracture line; stage lasts 1-3 days; macrophages begin removing dead osteocytes and debris<\/li>\r\n \t
                    • Stage 2: Hematoma Organization<\/strong> - fibrin (ropy protein) in blood clot (thrombocytes & RBCs) strengthens, organizes into mesh and contracts - granulation tissue in that zone fills with chondroblasts as mesenchymal stem cells within the periosteum produce more and more daughter chondroblasts and osteoblasts, capillary buds form and neovascularization begins; stage lasts 3 days - 2 weeks<\/li>\r\n \t
                    • Stage 3: Pro-callus Formation<\/strong>\u00a0- chondroblasts are producing fibrocartilage-like extracellular matrix as they mature to chondrocytes, creating an external and internal pro-callus;\u00a0 this replaces the hematoma which is degraded by phagocytes (e.g. macrophages)\u00a0 and fibrin which is dissolved by plasmin; the pro-callus is full of collagen and joining the two bone ends and forming a bulge (collar) around the fracture<\/li>\r\n \t
                    • Stage 4: Bony Callus Formation<\/strong> - daughter osteoblasts being to produce more and more osteoid (extracellular matrix glycoprotein material) containing calcium phosphate hydroxyapatite minerals which turn the cartilage pro-callus into a bony callus which is stronger; the bone matrix in this zone is not organized and is termed woven bone<\/li>\r\n \t
                    • Stage 5: Remodeling<\/strong> - as the osteoblasts mature into osteocytes, the collagen matrix becomes more organized, the compact bone of the diaphysis becomes more apparent; the osteoclasts assist in remodeling the bone to form a medullary cavity as well as trabecular bone.\u00a0 Bone transitions from woven bone to lamellar bone to becoming fully regenerated and can support weight.<\/li>\r\n<\/ul>\r\nDiscuss Healing and Factors that Affect Healing:<\/strong>\r\n
                        \r\n \t
                      • Healing Time<\/strong> - is usually 4 months to a year;\u00a0 healing time is affected by age:\u00a0 Children healing fastest, and older adults healing more slowly.<\/li>\r\n \t
                      • Amount<\/strong> of local damage<\/li>\r\n \t
                      • Proximity<\/strong> of bone ends to each other<\/li>\r\n \t
                      • Presence of foreign material or infection<\/strong> & acceptance of bone graft<\/strong> (if required)<\/li>\r\n \t
                      • Blood supply to fracture site; amount of hypoxia<\/strong><\/li>\r\n \t
                      • Osteonecrosis<\/strong> (ischemic death of bone cells) can occur \u2013 usually due ischemia of bone tissue for many reasons including:\u00a0 trauma, thrombosis, embolism, radiation therapy for cancer, blood vessel injury \u2013 perhaps due to vasculitis or long-term glucocorticoid use)<\/li>\r\n \t
                      • Systemic factors<\/strong> \u2013 age (older people take longer to heal), nutrition, circulatory problems (e.g. diabetes), anemia, RA (rheumatoid arthritis), glucocorticoid use, etc.<\/li>\r\n \t
                      • Low blood pressure<\/strong> (due to excessive bleeding or widespread inflammation)<\/li>\r\n<\/ul>\r\n \r\n\r\nDiscuss Possible Complications of Bone Fractures:\u00a0<\/strong>\r\n
                          \r\n \t
                        • Muscle spasms<\/strong> \u2013 triggered by pain\/irritation can pull bones out of alignment & damage soft tissue<\/li>\r\n \t
                        • Neurovascular<\/strong> damage: due to:\r\n
                            \r\n \t
                          • a) damage during fracture (from force, fracture fragments, joint dislocation, or hemorrhage)\u00a0 or<\/li>\r\n \t
                          • b) during treatment of fracture (moving\/splinting fracture)<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                          • Infections<\/strong> \u2013 osteomyelitis; bacterial toxins (tetanus), risk factors: open fracture, surgery<\/li>\r\n \t
                          • Septic = infected by harmful microbes<\/li>\r\n \t
                          • Aseptic = free from harmful microbes<\/li>\r\n \t
                          • Ischemia<\/strong> \u2013 \u2191edema in 1st 48hr tightens cast<\/li>\r\n \t
                          • Be careful that cast not become too loose later as edema decreases & muscle atrophies<\/li>\r\n \t
                          • Fat<\/strong> emboli - fat marrow escapes into vein<\/li>\r\n \t
                          • Fracture blisters<\/strong> (edema between epidermis & dermis)<\/li>\r\n \t
                          • Failure<\/strong> to heal (non-union) due to infection, or gap, or repetive stress, poor circulation<\/li>\r\n \t
                          • Deformity<\/strong> (mal-union) during healing due to improper alignment<\/li>\r\n \t
                          • Residual effects such as osteoarthritis<\/strong> or stunted growth<\/strong><\/li>\r\n \t
                          • Exuberant Callus<\/strong> formation<\/li>\r\n<\/ul>\r\n \r\n\r\nCompartment Syndrome<\/strong>\u00a0(acute, chronic, or crush) = high pressure in muscle compartment that is enclosed in fascia reduces blood flow leading to hypoxia (& therefore damage).\r\n
                              \r\n \t
                            • a) Plasma protein & fluid leak<\/strong> into tissue causing more swelling.\r\n
                                \r\n \t
                              • Exudate<\/strong> = fluid that leaks from blood vessels<\/li>\r\n \t
                              • Edema<\/strong> = fluid accumulating beneath skin or in a cavity, due to increased interstial fluid (during inflammation) and\/or impaired fluid removal by lymph\/capillary vessels<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                              • b) Necrosis<\/strong> of muscle & nerves can occur (within 4-8hr).<\/li>\r\n \t
                              • c) Symptoms:<\/strong> 5Ps (Severe Pain, Paralysis, Paresthesia, Pallor & Pulselessness).<\/li>\r\n \t
                              • d) Monitor:<\/strong>\u00a0 Used tonometer (>30mmHg = bad);\u00a0 Capillary refill time of less than 2sec (hold hand higher than heart and press fingernail until white then watch for return to colour)<\/li>\r\n \t
                              • e) Acute Compartment Syndrome<\/strong> requires immediate surgery (Fasciotomy)<\/strong> to reduce pressure accompanied by skin grafts.<\/li>\r\n<\/ul>\r\nIf not treated = Compartment Tamponade<\/strong> \u2192\r\n
                                  \r\n \t
                                • 1. muscle ischemia<\/strong> (hypoxia) \u2192 muscle infarction and leads to Crush Injury:\r\n
                                    \r\n \t
                                  • Rhabdomyolysis<\/strong> = muscle cell lysis \u2191 potassium, phosphate, creatine, myoglobin in ECM which draws in fluid (ECF shift) and myoglobinemia\u00a0\u00a0\u2192 kidney damage (\u2192Renal Failure<\/strong>)<\/li>\r\n \t
                                  • and (lactic) acidosis\/hyperkalemia<\/strong> \u2192\u00a0 Cardiac Dysrhythmia<\/strong> (\u2192Shock)<\/li>\r\n \t
                                  • and permanent skeletal muscle damage<\/strong><\/li>\r\n \t
                                  • muscle necrosis\/damage fibrosis & shortening of muscle, if in forearm, leads to \u2192 Volkmann's ischemic contracture<\/strong> (permanently flexed wrist\u00a0 and finger joints into claw)<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                  • 2. neural injury<\/strong> \u2192 if permanent \u2192 loss of function (muscle weakness and\/or loss of sensations)<\/strong><\/li>\r\n \t
                                  • *Need to watch out for Reperfusion Injury<\/strong> = sudden restoration of blood flow introduces a lot of Reactive Oxidative Species (ROS) which can induce apoptosis and more cell damage<\/li>\r\n \t
                                  • **must prevent by releasing pressure slowly and treating with bicarbonate.<\/li>\r\n \t
                                  • *Need to watch out for Disseminated Intravascular Coagulation (DIC)<\/strong> - which may occur due to necrotic muscle tissue.<\/li>\r\n \t
                                  • Acute Compartment Syndrome<\/strong> -requires immediate fasciotomy - causes include: bone fracture, burn, drug overdose, thrombosis, reperfusion injury, vascular damage.<\/li>\r\n \t
                                  • Crush Syndrome<\/strong> - worsening of untreated acute compartment syndrome, often due to crush injury<\/li>\r\n \t
                                  • Chronic Compartment Syndrome<\/strong> - usually caused by repetitive activities (e.g. running) - characterized by pain that doesn't go away even with ibuprofen, decreased sensation, paleness of skin, weakness, swollen shiny skin, pain on movement, .<\/li>\r\n<\/ul>\r\n \r\n\r\nShock <\/strong>= not enough blood flow to tissues\r\n\r\nSigns of Shock<\/strong> = pallor, diaphoresis, hypotension, reflex tachycardia, nausea\/vomiting\r\n\r\n \r\n\r\nRhabdomyolysis = <\/strong>Rapid breakdown of muscle, releasing myoglobin into extracellular space & bloodstream, which travels to kidney & is excreted in urine.\r\n
                                      \r\n \t
                                    • Causes: <\/strong>crush, burn, compression injury, drug overdoses, earthquake victims, serious infections, toxins, diabetic ketoacidosis, extreme hypothermia\/heatstroke<\/li>\r\n \t
                                    • Signs & Symptoms:<\/strong> muscle pain, weakness, swelling, & dark urine; oliguria; hyperkalemia may trigger cardiac dysrhythmias; low BP; electrolyte imbalance can cause nausea, vomiting, confusion, coma<\/li>\r\n \t
                                    • Urinalysis:\u00a0<\/strong> reveals brown urine, due to myoglobinuria<\/li>\r\n \t
                                    • Evaluation:<\/strong> \u2191 serum CK, K+, PO4 levels<\/li>\r\n \t
                                    • Treatment:<\/strong> rapid IV hydration to maintain adequate urinary flow (with bicarbonate if metabolic acidosis is occurring); & possibly hemodialysis<\/li>\r\n \t
                                    • Potential Complications of Rhabdomyolysis:<\/strong>\r\n
                                        \r\n \t
                                      • myoglobin breakdown products damage kidney \u2192 <\/span>Renal Failure<\/strong><\/li>\r\n \t
                                      • Disseminated Intravascular Coagulation (DIC, formation of small blood clots in bloodstream) initiated by released components of necrotic muscle\u2026 which can lead to organ failure & uncontrolled bleeding.<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\nDisseminated Intravascular Coagulation (DIC) = <\/strong>results from an imbalance of clotting\/hemostasis factors.\r\n
                                          \r\n \t
                                        • Causes: <\/strong>serious infections (e.g. sepsis), trauma, burn, placental abruption, pre-eclampsia, toxins, snake bites<\/li>\r\n \t
                                        • Pathogenesis:<\/strong>\r\n
                                            \r\n \t
                                          • Severe endothelial damage \u2192 <\/span><\/li>\r\n \t
                                          • leads to release of large amounts of pro-inflammatory cytokines \u2192<\/span><\/li>\r\n \t
                                          • stimulate too much thrombin \u2192<\/span> lead to too many fibrin\/platelet clots \u2192 <\/span><\/li>\r\n \t
                                          • leads to clot obstructions of capillaries throughout the body leads to \u2192<\/span> ischemia\/hypoxia\/damage of tissues and multiple organ failure and<\/li>\r\n \t
                                          • risk of bleeding out (as platelets are all \"used up\").<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                          • Signs & Symptoms:<\/strong> purpura (blood-spotted skin), pain<\/li>\r\n \t
                                          • Diagnostic Test:<\/strong> measure of coagulant (e.g. fibrin, platelets) and anti-coagulant factors<\/li>\r\n<\/ul>\r\n \r\n\r\nMethods to Reduce Chances of Complications of Bone Fractures:<\/strong>\r\n
                                              \r\n \t
                                            • Wound debridement<\/strong><\/li>\r\n \t
                                            • Windowed cast<\/b><\/li>\r\n \t
                                            • Realign and Reduction<\/strong> using: intramedullary nails, pins, plates, wire meshes, casts, and\/or traction<\/li>\r\n \t
                                            • Tetanus booster<\/strong><\/li>\r\n \t
                                            • Antibiotics<\/strong><\/li>\r\n \t
                                            • Monitor for signs of fat emboli<\/strong> - may travel to:\r\n
                                                \r\n \t
                                              • lungs, causing ARDS (pallor, diaphoresis, chest pain, dyspnea, tachycardia, cyanosis)<\/li>\r\n \t
                                              • brain, causing CVA<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                              • Bone graft<\/strong> (taken from iliac crest, fibula, or rib)<\/li>\r\n \t
                                              • Bone cement<\/strong><\/li>\r\n \t
                                              • Exercise<\/strong> - maintain muscle function<\/li>\r\n<\/ul>\r\n**********************************************************************************************************************************************************************************************************\r\n
                                                \r\n
                                                \r\n
                                                \r\n
                                                \r\n
                                                \r\n

                                                Joints - Dislocation & Subluxation:<\/strong><\/h2>\r\n
                                                  \r\n \t
                                                • Dislocation:<\/strong>\r\n
                                                    \r\n \t
                                                  • Bones in a joint bones in joint lose contact with each other due to tearing of surrounding tissue (e.g. joint capsule, ligament(s), and or muscles\/tendons)<\/li>\r\n \t
                                                  • Most common in shoulder, elbow, wrist, finger, hip, and knee<\/li>\r\n \t
                                                  • Shoulder most susceptible due to its high mobility<\/li>\r\n \t
                                                  • Can occur due to joint disease or previous damage<\/li>\r\n \t
                                                  • Can damage surrounding ligaments, muscles, nerves, and blood vessels<\/li>\r\n \t
                                                  • Risk Factors:<\/strong> joint diseases (e.g., rheumatic arthritis)<\/li>\r\n \t
                                                  • Symptoms:<\/strong> pain, tenderness, swelling, possible anesthesia or paralysis<\/li>\r\n \t
                                                  • Diagnosis:<\/strong> imaging (X-ray, MRI, arthroscope)<\/li>\r\n \t
                                                  • Treatment:<\/strong> reduction, analgesics, anti-inflammatories, PRICE (protection, rest, ice, compression, elevation), possible surgical repair<\/li>\r\n \t
                                                  • Rehabilitation:<\/strong> physiotherapy to regain function and range of motion<\/li>\r\n \t
                                                  • Complications<\/strong> include:\r\n
                                                      \r\n \t
                                                    • Adhesive capsulitis (e.g., Frozen Shoulder) in which scarring and adhesions forming in connective tissue surrounding the glenohumeral joint - causing stiffness and loss of range of motion.<\/li>\r\n \t
                                                    • Prevent this from occurring by following prescribed stretching and exercise regime.<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                    • Subluxation:<\/strong>\r\n
                                                        \r\n \t
                                                      • Partial loss of contact between one or more bones in a joint<\/li>\r\n \t
                                                      • Less severe than dislocation, often self-resolves<\/li>\r\n \t
                                                      • Similar signs and symptoms: pain, stiffness<\/li>\r\n \t
                                                      • Can also lead to frozen shoulder (adhesive capsulitis) if not properly rehabilitated<\/li>\r\n \t
                                                      • Importance of physiotherapy to prevent loss of range of motion and muscle atrophy<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                      • Frozen Shoulder:<\/strong>\r\n
                                                          \r\n \t
                                                        • Also known as adhesive capsulitis<\/li>\r\n \t
                                                        • Excessive scarring reduces range of motion long-term<\/li>\r\n \t
                                                        • Importance of following doctor and physiotherapist guidance for recovery and rehabilitation.<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n**********************************************************************************************************************************************************************************************************<\/span>\r\n

                                                          Differentiate between Sprains and Strains and Describe Features of Each\u00a0<\/strong><\/h2>\r\nDefinitions of Sprains and Strains:\u00a0<\/strong>\r\n
                                                            \r\n \t
                                                          • Sprain:<\/strong> ligament tear<\/li>\r\n \t
                                                          • Strain:<\/strong> muscle or tendon tear (which can cause tendon inflammation, also known as tendonitis)<\/li>\r\n \t
                                                          • Common Locations:<\/strong>\r\n
                                                              \r\n \t
                                                            • Sprains:<\/strong> Knees, elbows, wrists, ankles.<\/li>\r\n \t
                                                            • Strains:<\/strong> Hands, feet, knees, biceps, triceps, quadriceps, ankles, Achilles heel.<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                            • Severity Levels:\u00a0<\/strong>\r\n
                                                                \r\n \t
                                                              • Grade 1 or 1st degree:<\/strong> Mild - fibers are stretched but stable;\r\n
                                                                  \r\n \t
                                                                • will slowly self repair<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                                • Grade 2 or 2nd degree:<\/strong> Moderate - some fibers are torn;\r\n
                                                                    \r\n \t
                                                                  • will slowly self repair,<\/li>\r\n \t
                                                                  • follow prescribed stretching\/exercise regime to:\r\n
                                                                      \r\n \t
                                                                    • avoid scarring\/shortening<\/li>\r\n \t
                                                                    • increase muscle strength surrounding joint to provide more stability<\/li>\r\n \t
                                                                    • make joint more resilient against future injuries<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                                    • Grade 3 or 3rd degree:<\/strong> Severe - fibers are completely torn;\r\n
                                                                        \r\n \t
                                                                      • surgical repair is required, if possible (dependent on age, co-morbidities etc.)<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                                      • Grade 4 tear<\/strong> of ligament involves avulsion as well (complete tear plus bone fracture)\r\n
                                                                          \r\n \t
                                                                        • surgical repair involving bone fracture alignment and reduction is required<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                                        • Signs & Symptoms:\u00a0 <\/strong>\r\n
                                                                            \r\n \t
                                                                          • pain (especially on movement) due to micro\/macro-tears, bleeding, and inflammation,<\/li>\r\n \t
                                                                          • swelling,<\/li>\r\n \t
                                                                          • dislocation,<\/li>\r\n \t
                                                                          • weakness of joint,<\/li>\r\n \t
                                                                          • less mobility.<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                                          • Risk Factors:<\/strong>\r\n
                                                                              \r\n \t
                                                                            • Sports;<\/li>\r\n \t
                                                                            • Overweight,<\/li>\r\n \t
                                                                            • Age \u2013 collagen fibers have decrease elasticity & are more susceptible to injury<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                                            • Examples:<\/strong>\r\n
                                                                                \r\n \t
                                                                              • Strains - Rotator Cuff tear:<\/strong>\u00a0 tear to one of the 4 muscles that stabilize the glenohumeral shoulder joint<\/li>\r\n \t
                                                                              • Sprains - Tear of Ligaments and Tendons<\/strong> - consists of dense regular connective tissue (e.g. organized collagen) E.g.,\u00a0 Tennis Elbow<\/strong> = stretch\/tear of tendon<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                                              • Diagnostic Tools:<\/strong> MRI, radiography, arthroscopy, or arthrography.\r\n
                                                                                  \r\n \t
                                                                                • Arthroscopy allows surgeons to view and repair joint injuries, such as ligament tears or meniscus tears<\/li>\r\n \t
                                                                                • Viewing scope and surgical instruments for repairing damaged tissue<\/li>\r\n \t
                                                                                • Arthrography: X-ray or CT scan to view joint damage<\/li>\r\n \t
                                                                                • Radio-dense dye (iodine) for X-ray, MRI contrast medium for MRI<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                                                • Prevention:\u00a0<\/strong> Proper warm-up; appropriate sport wear and technique; avoid over-use; ramp up exercise slowly over months when first starting<\/li>\r\n \t
                                                                                • Treatment:\u00a0 <\/strong>\r\n
                                                                                    \r\n \t
                                                                                  • Protection; Rest; Ice; Compression; Elevation (<\/span>PRICE) for first 48-72hrs (possibly alternate heat & cold)<\/li>\r\n \t
                                                                                  • If infection - fluid aspiration, antibiotics for infection<\/li>\r\n \t
                                                                                  • Compression bracing to provide support while healing<\/li>\r\n \t
                                                                                  • Anti-inflammatories, physical therapy, massage, rest<\/li>\r\n \t
                                                                                  • Gradual, Prolonged Rehabilitation Exercises (first without weight & only if no pain)<\/li>\r\n \t
                                                                                  • Gradual increase in exercise activity levels (helps to strengthen tissues and blood flow will help with healing)<\/li>\r\n \t
                                                                                  • Occupational Therapy \u2013 identify ergonomic problems in the work place or home to prevent re-injury<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
                                                                                  • Recovery:<\/strong> Sprains tend to heal more slowly than strains.\u00a0 Typical Recovery Time:\u00a06 to 8 weeks for more complete healing.<\/li>\r\n \t
                                                                                  • Healing Process:\u00a0<\/strong> Inflammation, white blood cells activity, angiogenesis, collagen production, scar tissue formation.<\/li>\r\n<\/ul>\r\n**********************************************************************************************************************************************************************************************************\r\n\r\nDescribe Meniscus Tears <\/strong>= tears to white or red zone in knee cartilages\r\n
                                                                                      \r\n \t
                                                                                    • Terrible Triad:\u00a0 <\/strong>Knee injury involving tear to MCL, ACL & medial meniscus (frequent soccer injury)\r\n
                                                                                        \r\n \t
                                                                                      • Prevent by strengthening surrounding muscles, using proper footwear<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n
                                                                                        \r\n\r\nDiscuss Overuse Injuries <\/strong>= damage to muscles\/tendons\/nerves due to repetitive movements, perhaps with no warm-up, with inappropriate equipment\/training\/technique - can lead to fibrous scar tissue & loss of range of motion, & is a risk factor for osteoarthritis\r\n
                                                                                          \r\n \t
                                                                                        • Repetitive Strain Injuries:<\/strong> e.g. carpal tunnel syndrome<\/span><\/li>\r\n \t
                                                                                        • Tendinitis:<\/strong> caused by tennis, golf, painting, keyboard use, running, massage<\/li>\r\n \t
                                                                                        • Epicondylopathy<\/strong> = most often tendinopathy = microtears in tendon inflammation & pain (e.g. tennis\/golfer's elbow)<\/li>\r\n \t
                                                                                        • Bursitis<\/strong> = inflammation due to kneeling or gout or infection<\/li>\r\n \t
                                                                                        • Treat with PRICE, surgery, physiotherapy, massage, antibiotics as appropriate<\/li>\r\n<\/ul>\r\nDiscuss Diagnostic Tools and Treatments<\/strong>\r\n
                                                                                            \r\n \t
                                                                                          • Arthroscopy <\/strong>= use of arthroscope (camera on thin bendy wire) to view inside joint through small incision<\/span><\/li>\r\n \t
                                                                                          • Arthrography <\/strong>= injection of MRI or x-ray contrast dye (e.g. gadolinium or iodine respectfully) to better visualize joint in MRI or CT scan<\/span><\/li>\r\n \t
                                                                                          • Prolotherapy <\/strong>= <\/span>Prol<\/strong>iferation <\/span>Therapy<\/strong> = injections of dextrose, thought to cause local inflammation, which stimulates increased blood flow and supply of nutrients; possibly speeding up tissue repair<\/span><\/li>\r\n \t
                                                                                          • Extracorporeal Shockwave Therapy <\/strong>= use of shockwaves; thought to cause local inflammation, which stimulates increased blood flow and supply of nutrients; possibly speeding up tissue repair<\/span><\/li>\r\n<\/ul>\r\n<\/div>\r\n
                                                                                            \r\n\r\n**********************************************************************************************************************************************************************************************************\r\n

                                                                                            Osteopenia and Osteoporosis:<\/strong><\/h2>\r\n
                                                                                            \r\n\r\nBoth are bone weakening diseases characterized by reduced bone volume due to loss of both:<\/span>\r\n
                                                                                              \r\n \t
                                                                                            • Organic bone matrix (osteoid) = collagen, glycoproteins and proteoglycans<\/li>\r\n \t
                                                                                            • Inorganic bone matrix (calcium salts\/minerals) = CaPO4<\/sub><\/li>\r\n \t
                                                                                            • Osteoporosis is more severe than osteopenia and is depicted by greater loss of bone volume and bone density putting an individual at risk for low-impact bone fractures.<\/span><\/li>\r\n \t
                                                                                            • Osteopenia can be treated by ensuring sufficient dietary nutrients required for bone maintenance as well as taking part in regular recommended exercises (e.g., prescribed weight-training).<\/li>\r\n \t
                                                                                            • Osteoporosis is characterized by irreplaceable loss of bone microstructure and density.<\/li>\r\n<\/ul>\r\n

                                                                                              Osteoporosis:<\/strong><\/h2>\r\nOsteoporosis is considered a chronic disease that affects many older adults, in which old cortical (compact) and trabecular (spongy\/cancellous) bone is being resorbed faster than new bone matrix is being made.\u00a0 The most severe loss of bone density typically occurs in the femoral neck, vertebrae, and wrist.\u00a0 Bone maintenance and synthesis is impacted by various hormone levels:\u00a0 Thyroid Hormone (TH), Cortisol, Growth Hormone (GH), estrogen and testosterone are important for maintaining osteoblast activity.\u00a0 Lower levels of estrogen and testosterone in old age, result in lower levels of osteoblast activity.\r\n
                                                                                                \r\n \t
                                                                                              • reduced CaPO4<\/sub> within osteoid;<\/li>\r\n \t
                                                                                              • bones become soft;<\/li>\r\n \t
                                                                                              • most often due to low levels of Vitamin D3 and\/or calcium & causes bow-legging.<\/li>\r\n<\/ul>\r\n
                                                                                                \r\n\r\nRisk factors:<\/strong>\r\n
                                                                                                  \r\n \t
                                                                                                • age<\/li>\r\n \t
                                                                                                • post-menopausal biological (XX) females due to lower estrogen levels<\/span><\/li>\r\n \t
                                                                                                • sedentary lifestyle<\/li>\r\n \t
                                                                                                • use of corticosteroids<\/li>\r\n \t
                                                                                                • low intake of dietary Ca++<\/sup> and\/or vitamin D<\/li>\r\n \t
                                                                                                • excessive alcohol or caffeine<\/li>\r\n \t
                                                                                                • smoking<\/li>\r\n \t
                                                                                                • rheumatic arthritis<\/li>\r\n \t
                                                                                                • diabetes mellitus<\/li>\r\n \t
                                                                                                • genetics<\/li>\r\n<\/ul>\r\nCategories of Osteoporosis:<\/strong>\r\n
                                                                                                    \r\n \t
                                                                                                  • 1st Degree Osteoporosis<\/strong> = due age related decline in hormones (e.g., sex hormones)<\/li>\r\n \t
                                                                                                  • 2nd Degree Osteoporosis<\/strong> = due to underlying disease\r\n
                                                                                                      \r\n \t
                                                                                                    • Celiac disease, due to malabsorption of Ca++ and\/or vitamin D<\/li>\r\n \t
                                                                                                    • Hyperthyroidism, due to increased metabolic activity<\/li>\r\n \t
                                                                                                    • Hyperparathyroidism due to increased osteoclast activity<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\nSigns & Symptoms:<\/strong> low-impact fractures (1.5 million\/yr in USA), hip fractures, height reduction, kyphosis, vertebral compression fractures\r\n\r\nRoutine Check-Ups:\u00a0 <\/strong>regular bone mass density scan tests after the age of 50\r\n\r\nDiagnostic Evaluation:<\/strong>\r\n
                                                                                                        \r\n \t
                                                                                                      • monitoring bone density using dual energy X-ray absorptiometry (DEXA) or other imaging (CT scans, MRI)<\/li>\r\n \t
                                                                                                      • monitoring serum\/urine\u00a0 for low serum levels of Ca++, PO4<\/sub>,\u00a0 low levels of parathyroid hormone (PTH),<\/li>\r\n \t
                                                                                                      • assessing for bone deformities<\/li>\r\n<\/ul>\r\nPrevention: <\/strong>through avoidance of modifiable risk factors\r\n\r\nTreatment:<\/strong>\r\n
                                                                                                          \r\n \t
                                                                                                        • bisphosphonates (work by decreasing osteoclast activity)<\/li>\r\n \t
                                                                                                        • weight-bearing exercises<\/li>\r\n \t
                                                                                                        • calcium carbonate and vitamin D supplementation<\/li>\r\n<\/ul>\r\n
                                                                                                            \r\n \t
                                                                                                          • Vitamin D Recommended Dietary Allowance for adults 19 years and older is 600 IU (15 mcg) daily for men and women, and for adults >70 years it is 800 IU (20 mcg) daily.<\/li>\r\n \t
                                                                                                          • Caution should be used not to exceed this dosage as vitamin D can build up to excessive and harmful levels in the body.<\/li>\r\n<\/ul>\r\nPhysiotherapy:<\/strong>\u00a0 to alleviate pain & maintain function of muscles, tendons, and nerves, recommendations include use of proper warm-up, appropriate equipment, training.\r\n\r\n<\/div>\r\n<\/div>\r\n**********************************************************************************************************************************************************************************************************<\/span>\r\n

                                                                                                            Osteomalacia:<\/strong><\/h2>\r\n
                                                                                                            \r\n\r\nA bone weakening disease affecting adults caused by the reduced mineralization of bone.<\/span>\r\n
                                                                                                              \r\n \t
                                                                                                            • Both Osteomalacia and Rickets are similar in pathogenesis,<\/strong> in that the reduced mineral levels (CaPO4<\/sub>) within osteoid results in bones become soft.<\/span><\/li>\r\n<\/ul>\r\n

                                                                                                              Rickets:<\/strong><\/h2>\r\nA bone weakening disease affecting infants, children, and adolescents caused by reduced mineralization of bone due to:\r\n
                                                                                                                \r\n \t
                                                                                                              • reduced CaPO4<\/sub> within osteoid;<\/li>\r\n \t
                                                                                                              • bones become soft;<\/li>\r\n \t
                                                                                                              • most often due to low levels of Vitamin D3 and\/or calcium & causes bow-legging.<\/li>\r\n<\/ul>\r\n
                                                                                                                \r\n\r\nRisk factors:<\/strong>\r\n
                                                                                                                  \r\n \t
                                                                                                                • age<\/li>\r\n \t
                                                                                                                • vegetarians, malnourishment, vitamin D deficiency (caused by diet and\/or lack of sunlight exposure (typically 15min per day during lower UV times of day is sufficient)<\/li>\r\n \t
                                                                                                                • different drugs or diseases (e.g., renal diseases negatively affect calcitriol production)<\/li>\r\n \t
                                                                                                                • metabolic disorders affecting calcium levels in osteoid<\/li>\r\n<\/ul>\r\nSigns & Symptoms:<\/strong> skeletal pain, bone deformities (e.g., \u201cknock-knees\u201d, \u201cbow legs\u201d,) easy fractures\r\n\r\nDiagnostic Evaluation:<\/strong> monitoring for low serum levels of Ca++, PO4<\/sub>,\u00a0 low levels of parathyroid hormone (PTH), bone deformities, bone biopsy\r\n\r\nTreatment:<\/strong> calcium carbonate and vitamin D supplementation\r\n
                                                                                                                    \r\n \t
                                                                                                                  • Vitamin D Recommended Dietary Allowance for adults 19 years and older is 600 IU (15 mcg) daily for men and women, and for adults >70 years it is 800 IU (20 mcg) daily.<\/li>\r\n \t
                                                                                                                  • Caution should be used not to exceed this dosage as vitamin D can build up to excessive and harmful levels in the body.<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n**********************************************************************************************************************************************************************************************************<\/span>\r\n
                                                                                                                    \r\n

                                                                                                                    Muscular Dystrophy:<\/strong><\/h2>\r\n
                                                                                                                    \r\n\r\nA group of autosomal recessive\/dominant genetic disorders that causes degeneration of skeletal muscle over time<\/span>\r\n
                                                                                                                    \r\n\r\nRisk factors:<\/strong> inherited genetic mutations within or affecting the expression of the dystrophin gene\r\n
                                                                                                                    Duchenne\u2019s Muscular Dystrophy (DMD)<\/strong> is most common type of MD and it affects young biological (XY) males, as it is an X-linked recessive disease; biological (XX) females that are heterozygous for the mutation are carriers<\/div>\r\n
                                                                                                                    \r\n\r\nSigns & Symptoms:<\/strong> ascending weakness of muscles starting at age 2-3yrs affecting legs, hips shoulders etc. degeneration of skeletal muscle progresses rapidly\r\n
                                                                                                                      \r\n \t
                                                                                                                    • Early onset muscle weakness<\/li>\r\n \t
                                                                                                                    • Waddling gait, Gower Maneuver (pushing to get up),<\/li>\r\n \t
                                                                                                                    • Pseudohypertrophy of calf muscles, reduced tendon reflexes<\/li>\r\n \t
                                                                                                                    • Kyphoscoliosis<\/li>\r\n \t
                                                                                                                    • Frequent respiratory infections<\/li>\r\n \t
                                                                                                                    • Cardiac myopathy<\/li>\r\n \t
                                                                                                                    • Respiratory or heart failure by age 20<\/li>\r\n<\/ul>\r\n
                                                                                                                      Pathophysiology:\u00a0<\/strong> the dystrophin protein is required for structural support within skeletal muscle cells.\u00a0 Loss of this protein leads to skeletal muscle cell necrosis and regeneration, with continuous loss of skeletal muscle cells over time.\u00a0 Dead cells are phagocytosed by macrophages and are replaced by connective tissue including adipose tissue which preserves and sometimes increases the volume\/mass of the area particularly in the calves (lower leg muscles), leading to the deceptive appearance of increased muscle, a phenomenon known as pseudohypertrophy.<\/div>\r\n
                                                                                                                      <\/div>\r\n
                                                                                                                      Diagnostic tests:<\/strong><\/div>\r\n
                                                                                                                        \r\n \t
                                                                                                                      • \r\n
                                                                                                                        Genetic Tests<\/span><\/div><\/li>\r\n \t
                                                                                                                      • \r\n
                                                                                                                        Prenatal screening - chorionic villus (placenta) testing and amniocentesis is avail.<\/span><\/div><\/li>\r\n \t
                                                                                                                      • \r\n
                                                                                                                        Elevated serum creatine kinase levels<\/div><\/li>\r\n \t
                                                                                                                      • \r\n
                                                                                                                        Electromyography<\/div><\/li>\r\n \t
                                                                                                                      • \r\n
                                                                                                                        Muscle biopsy to check dystrophin levels<\/div><\/li>\r\n \t
                                                                                                                      • \r\n
                                                                                                                        Blood test shows abnormal dystrophin levels<\/div><\/li>\r\n \t
                                                                                                                      • Abnormal ECG and echocardiograph<\/li>\r\n<\/ul>\r\nTreatment:<\/strong>\r\n
                                                                                                                          \r\n \t
                                                                                                                        • moderate exercise<\/span><\/li>\r\n \t
                                                                                                                        • mobility devices<\/span><\/li>\r\n \t
                                                                                                                        • physiotherapy & massage<\/span><\/li>\r\n \t
                                                                                                                        • ventilator<\/span><\/li>\r\n \t
                                                                                                                        • possible future genetic therapies<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n**********************************************************************************************************************************************************************************************************<\/span>\r\n
                                                                                                                          \r\n

                                                                                                                          Fibromyalgia:<\/strong><\/h2>\r\nA syndrome characterized by idiopathic chronic pain, numbness, tingling, stiffness, cognitive and memory problems; fatigue and sleep disturbances, anxiety, depression, possible irritable bowel syndrome and possible jaw pain;\u00a0 with no obvious inflammation or atrophy.\r\n
                                                                                                                          \r\n\r\nRisk factors:<\/strong>\r\n
                                                                                                                            \r\n \t
                                                                                                                          • biological females; 20-50yrs;<\/li>\r\n \t
                                                                                                                          • history of auto-immune disease (e.g. Rheumatoid Arthritis, Lupus, Ankylosing Spondylitis)<\/li>\r\n \t
                                                                                                                          • physical\/psychological trauma, or chronic pain<\/li>\r\n<\/ul>\r\n
                                                                                                                            Signs & Symptoms:<\/strong><\/div>\r\n
                                                                                                                            \r\n
                                                                                                                              \r\n \t
                                                                                                                            • chronic pain in soft tissues<\/li>\r\n \t
                                                                                                                            • characterized by widespread pain, fatigue, stiffness<\/li>\r\n<\/ul>\r\n<\/div>\r\n
                                                                                                                              Pathogenesis:\u00a0 <\/strong>Causes unknown, hypothesized neurotransmitter imbalance.<\/span><\/div>\r\n
                                                                                                                              <\/div>\r\n
                                                                                                                              Diagnostic Tests:\u00a0\u00a0<\/strong>tender points examination, blood tests, elimination of other possible diseases\/disorders.<\/div>\r\n
                                                                                                                              <\/div>\r\n
                                                                                                                              Treatments:<\/strong><\/div>\r\n
                                                                                                                                \r\n \t
                                                                                                                              • \r\n
                                                                                                                                Stress avoidance or reduction<\/div><\/li>\r\n \t
                                                                                                                              • \r\n
                                                                                                                                Regular exercise in the morning (when pain is often lower)<\/div><\/li>\r\n \t
                                                                                                                              • Pace activity & rest as needed<\/li>\r\n \t
                                                                                                                              • Applications of heat or massage<\/li>\r\n \t
                                                                                                                              • Analgesic drugs, NSAIDs, new drugs<\/li>\r\n \t
                                                                                                                              • Low doses of antidepressants (SSNRIs,\u00a0Serotonin Norepinephrine Reuptake Inhibitors)<\/li>\r\n \t
                                                                                                                              • Massage therapy<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n**********************************************************************************************************************************************************************************************************\r\n

                                                                                                                                Osteoarthritis:<\/strong><\/h2>\r\nan inflammatory joint disease due to \"wear and tear\", most often affecting hips and knees<\/span>\r\n\r\n \r\n
                                                                                                                                Risk factors:<\/strong><\/div>\r\n
                                                                                                                                  \r\n \t
                                                                                                                                • obesity<\/li>\r\n \t
                                                                                                                                • biological males; 40+yrs; biological females 55+yrs<\/li>\r\n \t
                                                                                                                                • history of auto-immune disease (e.g. Rheumatoid Arthritis, Lupus, Ankylosing Spondylitis)<\/li>\r\n \t
                                                                                                                                • physical\/psychological trauma, or chronic pain<\/li>\r\n<\/ul>\r\n
                                                                                                                                  Signs & Symptoms:<\/strong><\/div>\r\n
                                                                                                                                    \r\n \t
                                                                                                                                  • \r\n
                                                                                                                                    Joint pain<\/strong> that is relieved when joint is rested<\/div><\/li>\r\n \t
                                                                                                                                  • Heberden nodes<\/strong> in distal finger joints = thickening of subchondral bones (sclerosis = \u2191 bone density)<\/li>\r\n \t
                                                                                                                                  • Bouchard nodes<\/strong> in middle joints of fingers = ditto (thickening of subchondral bones (sclerosis = \u2191 bone density)<\/li>\r\n<\/ul>\r\n
                                                                                                                                    Pathophysiology:<\/strong><\/div>\r\n
                                                                                                                                      \r\n \t
                                                                                                                                    • \r\n
                                                                                                                                      articular cartilage degenerates, and fibrillation (deep long fissures in articular cartilage occur),<\/div><\/li>\r\n \t
                                                                                                                                    • \r\n
                                                                                                                                      joint capsule thickens, becomes fibrotic and sticks to deformed underlying bone narrowing joint space, limiting ROM, causing:<\/div><\/li>\r\n \t
                                                                                                                                    • \r\n
                                                                                                                                      pain & stiffness, swelling, paresthesia (e.g. numbness), stiffness, creaking, limp, predisposition to falls, joint deformation.<\/div><\/li>\r\n \t
                                                                                                                                    • irritation of many sensory nerve endings in joint capsule<\/li>\r\n \t
                                                                                                                                    • Bone spurs (osteophytes) form & can break off (\u201cjoint mice\u201d) into synovial cavity & irritate synovial membrane causing synovitis; subchondral cysts form; exudate buildup<\/li>\r\n<\/ul>\r\n
                                                                                                                                      Diagnostic Evaluation:<\/strong>\u00a0 clinical assessment, X-ray<\/div>\r\n \r\n\r\nTreatment:<\/strong> rest, orthotics, ROM exercises, physio & massage therapy, optimizing BMI may involve loss of excess body fat through healthy diet and exercise, pain & anti-inflammatory meds, possible surgery if deformation, excess pain and\/or loss of mobility (hip & knee replacements are common), acupuncture, canes, hand braces.\r\n

                                                                                                                                      Rheumatoid Arthritis:<\/strong><\/h2>\r\nA chronic, systemic, inflammatory auto-immune disease causing joint swelling, tenderness, destruction of synovial joints leading to disability & premature death.<\/span>\r\n\r\nRisk Factors:<\/strong>\r\n
                                                                                                                                        \r\n \t
                                                                                                                                      • age (young adult onset is most common)<\/li>\r\n \t
                                                                                                                                      • genetics (specific HLA antigens)<\/li>\r\n \t
                                                                                                                                      • biological female<\/li>\r\n \t
                                                                                                                                      • smoking<\/li>\r\n \t
                                                                                                                                      • possible T cell defect in telomere repair<\/li>\r\n \t
                                                                                                                                      • prior viral infection resulting in cross-affinity to self antigens<\/li>\r\n \t
                                                                                                                                      • imbalance of chemokines involved in triggering an immune response<\/li>\r\n \t
                                                                                                                                      • long-term exposure to antibodies.<\/li>\r\n<\/ul>\r\nSigns & Symptoms:<\/strong>\u00a0 joint pain and inflammation, stiffness, joint deformation\r\n\r\nPathophysiology:<\/strong> Inflammation spreads to articular cartilage, fibrous joint capsule, surrounding ligaments & tendons<\/span>\r\n
                                                                                                                                        \r\n\r\nMost common in fingers, feet, wrists, elbows, ankles, knees; also shoulders, hips, cervical spine (lungs, heart, kidneys, & skin).\r\n
                                                                                                                                          \r\n \t
                                                                                                                                        • \r\n
                                                                                                                                          Synovitis<\/strong> \u2013 marked inflammation, cell proliferation<\/div><\/li>\r\n \t
                                                                                                                                        • \r\n
                                                                                                                                          Pannus<\/strong> - made of granulation tissue = new connective tissue with tiny blood vessel that typically forms in a wound during the healing process; but in this case healing doesn't occur and it spreads<\/div><\/li>\r\n \t
                                                                                                                                        • \r\n
                                                                                                                                          Cartilage erosion<\/strong> \u2013 creates unstable joint<\/div><\/li>\r\n \t
                                                                                                                                        • \r\n
                                                                                                                                          Fibrosis (scar tissue)<\/strong> \u2013 calcifies and obliterates joint space<\/div><\/li>\r\n<\/ul>\r\nPossible Complications:<\/strong>\r\n
                                                                                                                                            \r\n \t
                                                                                                                                          • \r\n
                                                                                                                                            Ankylosis<\/strong> \u2013 joint fixation and deformity develop if untreated<\/div><\/li>\r\n \t
                                                                                                                                          • \r\n
                                                                                                                                            Atrophy<\/strong> of muscles<\/div><\/li>\r\n \t
                                                                                                                                          • \r\n
                                                                                                                                            Bone alignment<\/strong> shifts (Ulnar drift, deformation and swanning of fingers); Boutonniere deformity<\/div><\/li>\r\n \t
                                                                                                                                          • \r\n
                                                                                                                                            Muscle spasms<\/strong> due to inflammation\/pain<\/div><\/li>\r\n \t
                                                                                                                                          • \r\n
                                                                                                                                            Contractures<\/strong> and deformity<\/strong> develop.<\/div><\/li>\r\n \t
                                                                                                                                          • \r\n
                                                                                                                                            Flare-ups<\/strong> associated with anemia<\/strong> (e.g. iron-deficiency)<\/div><\/li>\r\n \t
                                                                                                                                          • \r\n
                                                                                                                                            More prone to lung fibrosis, atherosclerosis, MI, and stroke<\/strong><\/div><\/li>\r\n \t
                                                                                                                                          • Chronic anti-inflammatory use can cause bleeds<\/li>\r\n<\/ul>\r\nDiagnostic Tests:\u00a0<\/strong> Appearance of auto-antibodies (Rheumatoid Factors, RF) in blood tests, imaging, \u2191ESR (faster Erythrocyte Sedimentation Rate), \u2191CRP (increased C Reactive Protein levels in blood), presence of Anti-Nuclear Antibodies (ANA) in blood\r\n\r\nTreatment:<\/strong> anti-inflammatory drugs, disease-modifying antirheumatic drugs, supportive care, cessation of smoking, healthy diet\r\n

                                                                                                                                            Gouty Arthritis:\u00a0<\/strong><\/h2>\r\nA chronic inflammatory arthritis, characterized by hyperuricemia and the formation of urate crystals in joints causing joint swelling, tenderness, destruction of synovial joints which can lead to disability as well a chronic nephropathy.\r\n\r\n \r\n
                                                                                                                                            Risk factors:<\/strong><\/div>\r\n
                                                                                                                                              \r\n \t
                                                                                                                                            • biological males >40yrs<\/li>\r\n \t
                                                                                                                                            • sedentary lifestyle<\/li>\r\n \t
                                                                                                                                            • low fluid intake and\/or use of diuretics<\/li>\r\n \t
                                                                                                                                            • low intake of fruits containing vitamin C<\/li>\r\n \t
                                                                                                                                            • high meat (purine-rich) diet (sometimes called the \u201crich man\u2019s disease\u201d, as high meat consumption is a risk factor, particularly shrimp, lobster, liver, kidney and red meats such as pork and beef<\/em>)<\/li>\r\n \t
                                                                                                                                            • alcohol (beer, wine, spirits)<\/li>\r\n \t
                                                                                                                                            • obesity<\/li>\r\n \t
                                                                                                                                            • family history, genetic susceptibilities<\/li>\r\n \t
                                                                                                                                            • chemotherapy<\/li>\r\n \t
                                                                                                                                            • consumption of sweetened beverages and foods containing high-fructose corn syrup<\/li>\r\n<\/ul>\r\nSigns and Symptoms:<\/strong>\r\n
                                                                                                                                                \r\n \t
                                                                                                                                              • \r\n
                                                                                                                                                Acute gout flares due to tophaceous deposits (tophi) of urate crystals in joints.<\/div><\/li>\r\n \t
                                                                                                                                              • \r\n
                                                                                                                                                Gout is associated with co-morbidities such as hypertension, diabetes mellitus, ischemic heart disease, congestive heart failure, metabolic syndrome, chronic kidney disease, and obesity.<\/div><\/li>\r\n \t
                                                                                                                                              • Most people with asymptomatic hyperuricemia do not develop gout.<\/li>\r\n<\/ul>\r\nPathophysiology:<\/strong>\r\n
                                                                                                                                                  \r\n \t
                                                                                                                                                • \r\n
                                                                                                                                                  Results from deposits of uric acid and crystals in the joint, causing inflammation, leukocytosis and sometimes fever.<\/div><\/li>\r\n \t
                                                                                                                                                • \r\n
                                                                                                                                                  Uric acid & crystal formation resulting from any combination of the above risk factors, which may also include inadequate renal excretion of uric acid.<\/div><\/li>\r\n \t
                                                                                                                                                • Formation of tophus \u2013 large, hard nodule of urate crystals<\/li>\r\n \t
                                                                                                                                                • \r\n
                                                                                                                                                  Tophi cause local painful inflammation and occur after the first attack of gout.<\/div><\/li>\r\n \t
                                                                                                                                                • \r\n
                                                                                                                                                  Tophi can be found in cartilage, bone, joints, tendons and even skin, though predominantly within articular and subcutaneous regions.<\/div><\/li>\r\n \t
                                                                                                                                                • \r\n
                                                                                                                                                  Tophi can cause erosion of bone and joint tissues, and synovial fluid becomes yellow and cloudy.<\/div><\/li>\r\n \t
                                                                                                                                                • Joint damage can cause joint deformities and osteoarthritis; additionally urate nephropathy and conjunctivitis can occur.<\/li>\r\n<\/ul>\r\n
                                                                                                                                                  Diagnosed<\/strong> by examination of synovial fluid, imaging, and blood tests.\u00a0 High ESR (Erythrocyte Sedimentation Rate) and CRP (C reactive Protein) levels are common due to the inflammatory response that has been provoked by the tophi.\u00a0 Synovial fluid will exhibit high WBC counts, and the absence of bacteria within synovial fluid distinguishes gouty arthritis from septic arthritis.<\/div>\r\n<\/div>\r\n \r\n
                                                                                                                                                  Treated<\/strong> by reducing uric acid levels through medications & dietary changes.\u00a0 Acute flares are usually self-limiting resolving within days to weeks, often without treatment.\u00a0 Treatment of flares involves the use of ice packs as well as NSAIDs and sometimes glucocorticoids.<\/div>\r\n<\/div>\r\n<\/div>\r\n \r\n\r\n \r\n\r\n ","rendered":"
                                                                                                                                                  \n
                                                                                                                                                  \n

                                                                                                                                                  Chapter Learning Outcomes and Specific Learning Objectives Study Guide<\/p>\n<\/header>\n

                                                                                                                                                  \n

                                                                                                                                                  Chapter Learning Outcomes:<\/strong><\/p>\n

                                                                                                                                                  By the end of this chapter you will be able to:<\/p>\n

                                                                                                                                                  Describe key aspects (etiology, risk factors, pathogenesis, diagnostic tools, common treatments and typical outcomes)\u00a0 of the following Musculoskeletal Disorders:<\/strong><\/p>\n

                                                                                                                                                    \n
                                                                                                                                                  1. Bone fractures, healing, exuberant callus formation, and compartment (acute, chronic and crush) syndromes<\/li>\n
                                                                                                                                                  2. Aspects of trauma including nerve damage, fat emboli, DIC, rhabdomyolysis, shock<\/li>\n
                                                                                                                                                  3. Dislocation and subluxations, sprains and strains, tendinitis, bursitis, and meniscus tears<\/li>\n
                                                                                                                                                  4. Osteoporosis, Osteomalacia, and Rickets<\/li>\n
                                                                                                                                                  5. Muscular Dystrophy and Fibromyalgia<\/li>\n
                                                                                                                                                  6. Rheumatoid Arthritis, Osteoarthritis, and Gout<\/li>\n<\/ol>\n
                                                                                                                                                    \n

                                                                                                                                                    Specific Learning Objectives Study Guide:<\/strong><\/p>\n

                                                                                                                                                    By the end of this section you will be able to:<\/p>\n

                                                                                                                                                    Describe and explain the following terms and facts associated with Trauma:<\/span><\/strong><\/p>\n

                                                                                                                                                      \n
                                                                                                                                                    • \n
                                                                                                                                                      Leading cause of death in people aged 1-44.<\/div>\n<\/li>\n
                                                                                                                                                    • Due to sports, automobile accidents, falls, workplace accidents, assault, child abuse, etc.<\/li>\n<\/ul>\n

                                                                                                                                                      Trauma<\/strong> always involves inflammation<\/strong> – usually in proportion to the amount of cellular damage.<\/p>\n

                                                                                                                                                      Trauma can possibly involve:<\/div>\n
                                                                                                                                                        \n
                                                                                                                                                      • \n
                                                                                                                                                        Contusions<\/strong> \u2013 bruise under closed skin involving:<\/div>\n
                                                                                                                                                          \n
                                                                                                                                                        • \n
                                                                                                                                                          microscopic rupture of blood vessels; Swelling & inflammation<\/div>\n<\/li>\n
                                                                                                                                                        • \n
                                                                                                                                                          Possibly includes damage to underlying muscle cells;<\/div>\n<\/li>\n
                                                                                                                                                        • \n
                                                                                                                                                          Ecchymotic (black & blue) due to local hemorrhage \u2192 changing to yellow<\/div>\n<\/li>\n
                                                                                                                                                        • \n
                                                                                                                                                          RICE Treatment; Usually full recovery<\/div>\n<\/li>\n
                                                                                                                                                        • \n
                                                                                                                                                          Contusions \u2013 can affect any tissue: e.g. brain, lungs, muscle, bones<\/div>\n<\/li>\n
                                                                                                                                                        • Bone bruise:<\/strong>\u00a0 microscopic damage of bone blood vessels, and possibly some trabeculae; will not be visible in MRI or other imaging<\/li>\n
                                                                                                                                                        • Pain due to irritation of nociceptors by chemicals released from damaged cells, by swelling, and be chemicals released by WBCs.<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                        • \n
                                                                                                                                                          Bone Fractures:<\/strong>\u00a0 will be visible with x-ray and MRI;\u00a0 Most Common Fractures:<\/div>\n
                                                                                                                                                          a) Males 15-24yrs (tibia, clavicle, lower humerus) – clavicle most common childhood fracture<\/div>\n
                                                                                                                                                          b) Elderly 65+yrs (hip)<\/div>\n
                                                                                                                                                          c) Workplace (hands and feet)<\/div>\n

                                                                                                                                                          d) Osteoporosis (upper femur, upper humerus,\u00a0 vertebrae, & pelvis)<\/li>\n<\/ul>\n

                                                                                                                                                          Describe different types of Bone Fractures:<\/span><\/strong><\/p>\n

                                                                                                                                                          \n
                                                                                                                                                            \n
                                                                                                                                                          • Simple<\/strong> – bone ends maintain their alignment & position<\/li>\n
                                                                                                                                                          • Oblique<\/strong> – break at an angle to the shaft of a long bone<\/li>\n
                                                                                                                                                          • Comminuted<\/strong> – many fracture lines and many fragments involved in bone break<\/li>\n
                                                                                                                                                          • Open<\/strong> – bone end penetrates the skin to be exposed to the outside environment; is a risk factor for osteomyelitis and osteonecrosis; classified Type I to Type IIIC increasing in terms of severity; Type I opening is smaller than 1cm;<\/li>\n
                                                                                                                                                          • Segmented<\/strong> – 2 or more breaks in the same bone – one bone fractured into 3 or more parts<\/li>\n
                                                                                                                                                          • Spiral<\/strong> – spiral direction of fracture in a long bone<\/li>\n
                                                                                                                                                          • Transverse<\/strong> – fracture is perpendicular to the length of long bone<\/li>\n
                                                                                                                                                          • Impacted<\/strong> – bone telescoped into itself.<\/li>\n
                                                                                                                                                          • Compression<\/strong> fracture of vertebrae<\/li>\n
                                                                                                                                                          • Colle\u2019s<\/strong> fracture = fracture of distal radius (& possibly ulna) from falling forward<\/li>\n
                                                                                                                                                          • Pott\u2019s<\/strong> fracture = fracture of distal fibula (possibly tibia) from excess stress on ankle<\/li>\n
                                                                                                                                                          • Pathologic<\/strong> \u2013 infection, cyst, tumor, osteoporosis, Paget disease<\/li>\n
                                                                                                                                                          • Greenstick\/Incomplete<\/strong>\u00a0\u2013 until age 10 bones are more resilient than adult\u2019s<\/li>\n
                                                                                                                                                          • Avulsion<\/strong> – fragment of bone connected to a ligament or tendon detaches from main bone<\/li>\n
                                                                                                                                                          • Stress<\/strong> fracture – usually incomplete<\/li>\n
                                                                                                                                                          • Fracture through growth\/epiphyseal plate<\/strong> – may result in premature bone fusion and growth cessation; usually an incomplete fracture with proper reduction and fixation will offset any chance of premature fusion;\u00a0 crush injuries are more likely to lead to stoppage of bone growth.<\/li>\n
                                                                                                                                                          • Transchondral fractures<\/strong> – frequent in teens; separation of cartilaginous joint surface (articular cartilage) from main shaft of bone\u2013 may not be painful except during movement; may hear clicking (crepitus).<\/li>\n<\/ul>\n

                                                                                                                                                             <\/p>\n

                                                                                                                                                            Describe possible signs & symptoms of Bone Fractures:<\/span><\/strong><\/p>\n

                                                                                                                                                            \n
                                                                                                                                                              \n
                                                                                                                                                            • Nerve damage<\/strong> – pain, numbness, surrounding muscles become flaccid (may be temporary or take time to subside<\/em>) = phenomenon called local shock<\/li>\n
                                                                                                                                                            • Muscle spasms<\/strong> – due to irritating chemicals<\/li>\n<\/ul>\n

                                                                                                                                                              Describe shin splints (Medial Tibial Stress Syndrome, MTSS):<\/span><\/strong><\/p>\n

                                                                                                                                                              \n
                                                                                                                                                                \n
                                                                                                                                                              • Pain<\/strong> along the shinbone associated with repeated trauma (excessive running or walking) that has damaged Sharpey’s (collagen) fibers that connect fascia to the periosteum of the tibia (where it inserts into the tibia bone).<\/li>\n
                                                                                                                                                              • Risk factors<\/strong> include: improper footwear, overdoing it without proper conditioning or training<\/li>\n<\/ul>\n

                                                                                                                                                                Signs & Symptoms of Bone Fractures:<\/strong><\/p>\n

                                                                                                                                                                  \n
                                                                                                                                                                • Pain<\/li>\n
                                                                                                                                                                • Numbness<\/li>\n
                                                                                                                                                                • Deformity<\/li>\n
                                                                                                                                                                • Swelling<\/li>\n
                                                                                                                                                                • Muscle spasms<\/li>\n
                                                                                                                                                                • Tenderness<\/li>\n
                                                                                                                                                                • Crepitus = grating sound if bone ends move over each other<\/li>\n
                                                                                                                                                                • Decreased mobility<\/li>\n
                                                                                                                                                                • Bleeding (if open fracture)<\/li>\n
                                                                                                                                                                • Shock (low blood pressure) = pallor, diaphoresis tachycardia, nausea\/vomiting<\/li>\n<\/ul>\n

                                                                                                                                                                  Emergency Treatment of Bone Fractures in the Field:<\/strong><\/p>\n

                                                                                                                                                                    \n
                                                                                                                                                                  • Cover open wound with sterile dressing material.<\/li>\n
                                                                                                                                                                  • Splint for support, & immobilize for transport including joint above & below fracture.<\/li>\n
                                                                                                                                                                  • Elevate limb slightly; Apply cold compress.<\/li>\n
                                                                                                                                                                  • Keep patient warm; check for signs of shock.<\/li>\n<\/ul>\n

                                                                                                                                                                    Describe Fracture Healing of Cortical\/Compact and Cancellous\/Trabecular\/Spongy Bone – 5 Stages<\/strong><\/p>\n

                                                                                                                                                                      \n
                                                                                                                                                                    • Stage 1: Hematoma Formation<\/strong> – collection of blood & subsequent clot and inflammation zone forms at fracture line; stage lasts 1-3 days; macrophages begin removing dead osteocytes and debris<\/li>\n
                                                                                                                                                                    • Stage 2: Hematoma Organization<\/strong> – fibrin (ropy protein) in blood clot (thrombocytes & RBCs) strengthens, organizes into mesh and contracts – granulation tissue in that zone fills with chondroblasts as mesenchymal stem cells within the periosteum produce more and more daughter chondroblasts and osteoblasts, capillary buds form and neovascularization begins; stage lasts 3 days – 2 weeks<\/li>\n
                                                                                                                                                                    • Stage 3: Pro-callus Formation<\/strong>\u00a0– chondroblasts are producing fibrocartilage-like extracellular matrix as they mature to chondrocytes, creating an external and internal pro-callus;\u00a0 this replaces the hematoma which is degraded by phagocytes (e.g. macrophages)\u00a0 and fibrin which is dissolved by plasmin; the pro-callus is full of collagen and joining the two bone ends and forming a bulge (collar) around the fracture<\/li>\n
                                                                                                                                                                    • Stage 4: Bony Callus Formation<\/strong> – daughter osteoblasts being to produce more and more osteoid (extracellular matrix glycoprotein material) containing calcium phosphate hydroxyapatite minerals which turn the cartilage pro-callus into a bony callus which is stronger; the bone matrix in this zone is not organized and is termed woven bone<\/li>\n
                                                                                                                                                                    • Stage 5: Remodeling<\/strong> – as the osteoblasts mature into osteocytes, the collagen matrix becomes more organized, the compact bone of the diaphysis becomes more apparent; the osteoclasts assist in remodeling the bone to form a medullary cavity as well as trabecular bone.\u00a0 Bone transitions from woven bone to lamellar bone to becoming fully regenerated and can support weight.<\/li>\n<\/ul>\n

                                                                                                                                                                      Discuss Healing and Factors that Affect Healing:<\/strong><\/p>\n

                                                                                                                                                                        \n
                                                                                                                                                                      • Healing Time<\/strong> – is usually 4 months to a year;\u00a0 healing time is affected by age:\u00a0 Children healing fastest, and older adults healing more slowly.<\/li>\n
                                                                                                                                                                      • Amount<\/strong> of local damage<\/li>\n
                                                                                                                                                                      • Proximity<\/strong> of bone ends to each other<\/li>\n
                                                                                                                                                                      • Presence of foreign material or infection<\/strong> & acceptance of bone graft<\/strong> (if required)<\/li>\n
                                                                                                                                                                      • Blood supply to fracture site; amount of hypoxia<\/strong><\/li>\n
                                                                                                                                                                      • Osteonecrosis<\/strong> (ischemic death of bone cells) can occur \u2013 usually due ischemia of bone tissue for many reasons including:\u00a0 trauma, thrombosis, embolism, radiation therapy for cancer, blood vessel injury \u2013 perhaps due to vasculitis or long-term glucocorticoid use)<\/li>\n
                                                                                                                                                                      • Systemic factors<\/strong> \u2013 age (older people take longer to heal), nutrition, circulatory problems (e.g. diabetes), anemia, RA (rheumatoid arthritis), glucocorticoid use, etc.<\/li>\n
                                                                                                                                                                      • Low blood pressure<\/strong> (due to excessive bleeding or widespread inflammation)<\/li>\n<\/ul>\n

                                                                                                                                                                         <\/p>\n

                                                                                                                                                                        Discuss Possible Complications of Bone Fractures:\u00a0<\/strong><\/p>\n

                                                                                                                                                                          \n
                                                                                                                                                                        • Muscle spasms<\/strong> \u2013 triggered by pain\/irritation can pull bones out of alignment & damage soft tissue<\/li>\n
                                                                                                                                                                        • Neurovascular<\/strong> damage: due to:\n
                                                                                                                                                                            \n
                                                                                                                                                                          • a) damage during fracture (from force, fracture fragments, joint dislocation, or hemorrhage)\u00a0 or<\/li>\n
                                                                                                                                                                          • b) during treatment of fracture (moving\/splinting fracture)<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                          • Infections<\/strong> \u2013 osteomyelitis; bacterial toxins (tetanus), risk factors: open fracture, surgery<\/li>\n
                                                                                                                                                                          • Septic = infected by harmful microbes<\/li>\n
                                                                                                                                                                          • Aseptic = free from harmful microbes<\/li>\n
                                                                                                                                                                          • Ischemia<\/strong> \u2013 \u2191edema in 1st 48hr tightens cast<\/li>\n
                                                                                                                                                                          • Be careful that cast not become too loose later as edema decreases & muscle atrophies<\/li>\n
                                                                                                                                                                          • Fat<\/strong> emboli – fat marrow escapes into vein<\/li>\n
                                                                                                                                                                          • Fracture blisters<\/strong> (edema between epidermis & dermis)<\/li>\n
                                                                                                                                                                          • Failure<\/strong> to heal (non-union) due to infection, or gap, or repetive stress, poor circulation<\/li>\n
                                                                                                                                                                          • Deformity<\/strong> (mal-union) during healing due to improper alignment<\/li>\n
                                                                                                                                                                          • Residual effects such as osteoarthritis<\/strong> or stunted growth<\/strong><\/li>\n
                                                                                                                                                                          • Exuberant Callus<\/strong> formation<\/li>\n<\/ul>\n

                                                                                                                                                                             <\/p>\n

                                                                                                                                                                            Compartment Syndrome<\/strong>\u00a0(acute, chronic, or crush) = high pressure in muscle compartment that is enclosed in fascia reduces blood flow leading to hypoxia (& therefore damage).<\/p>\n

                                                                                                                                                                              \n
                                                                                                                                                                            • a) Plasma protein & fluid leak<\/strong> into tissue causing more swelling.\n
                                                                                                                                                                                \n
                                                                                                                                                                              • Exudate<\/strong> = fluid that leaks from blood vessels<\/li>\n
                                                                                                                                                                              • Edema<\/strong> = fluid accumulating beneath skin or in a cavity, due to increased interstial fluid (during inflammation) and\/or impaired fluid removal by lymph\/capillary vessels<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                              • b) Necrosis<\/strong> of muscle & nerves can occur (within 4-8hr).<\/li>\n
                                                                                                                                                                              • c) Symptoms:<\/strong> 5Ps (Severe Pain, Paralysis, Paresthesia, Pallor & Pulselessness).<\/li>\n
                                                                                                                                                                              • d) Monitor:<\/strong>\u00a0 Used tonometer (>30mmHg = bad);\u00a0 Capillary refill time of less than 2sec (hold hand higher than heart and press fingernail until white then watch for return to colour)<\/li>\n
                                                                                                                                                                              • e) Acute Compartment Syndrome<\/strong> requires immediate surgery (Fasciotomy)<\/strong> to reduce pressure accompanied by skin grafts.<\/li>\n<\/ul>\n

                                                                                                                                                                                If not treated = Compartment Tamponade<\/strong> \u2192<\/p>\n

                                                                                                                                                                                  \n
                                                                                                                                                                                • 1. muscle ischemia<\/strong> (hypoxia) \u2192 muscle infarction and leads to Crush Injury:\n
                                                                                                                                                                                    \n
                                                                                                                                                                                  • Rhabdomyolysis<\/strong> = muscle cell lysis \u2191 potassium, phosphate, creatine, myoglobin in ECM which draws in fluid (ECF shift) and myoglobinemia\u00a0\u00a0\u2192 kidney damage (\u2192Renal Failure<\/strong>)<\/li>\n
                                                                                                                                                                                  • and (lactic) acidosis\/hyperkalemia<\/strong> \u2192\u00a0 Cardiac Dysrhythmia<\/strong> (\u2192Shock)<\/li>\n
                                                                                                                                                                                  • and permanent skeletal muscle damage<\/strong><\/li>\n
                                                                                                                                                                                  • muscle necrosis\/damage fibrosis & shortening of muscle, if in forearm, leads to \u2192 Volkmann’s ischemic contracture<\/strong> (permanently flexed wrist\u00a0 and finger joints into claw)<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                  • 2. neural injury<\/strong> \u2192 if permanent \u2192 loss of function (muscle weakness and\/or loss of sensations)<\/strong><\/li>\n
                                                                                                                                                                                  • *Need to watch out for Reperfusion Injury<\/strong> = sudden restoration of blood flow introduces a lot of Reactive Oxidative Species (ROS) which can induce apoptosis and more cell damage<\/li>\n
                                                                                                                                                                                  • **must prevent by releasing pressure slowly and treating with bicarbonate.<\/li>\n
                                                                                                                                                                                  • *Need to watch out for Disseminated Intravascular Coagulation (DIC)<\/strong> – which may occur due to necrotic muscle tissue.<\/li>\n
                                                                                                                                                                                  • Acute Compartment Syndrome<\/strong> -requires immediate fasciotomy – causes include: bone fracture, burn, drug overdose, thrombosis, reperfusion injury, vascular damage.<\/li>\n
                                                                                                                                                                                  • Crush Syndrome<\/strong> – worsening of untreated acute compartment syndrome, often due to crush injury<\/li>\n
                                                                                                                                                                                  • Chronic Compartment Syndrome<\/strong> – usually caused by repetitive activities (e.g. running) – characterized by pain that doesn’t go away even with ibuprofen, decreased sensation, paleness of skin, weakness, swollen shiny skin, pain on movement, .<\/li>\n<\/ul>\n

                                                                                                                                                                                     <\/p>\n

                                                                                                                                                                                    Shock <\/strong>= not enough blood flow to tissues<\/p>\n

                                                                                                                                                                                    Signs of Shock<\/strong> = pallor, diaphoresis, hypotension, reflex tachycardia, nausea\/vomiting<\/p>\n

                                                                                                                                                                                     <\/p>\n

                                                                                                                                                                                    Rhabdomyolysis = <\/strong>Rapid breakdown of muscle, releasing myoglobin into extracellular space & bloodstream, which travels to kidney & is excreted in urine.<\/p>\n

                                                                                                                                                                                      \n
                                                                                                                                                                                    • Causes: <\/strong>crush, burn, compression injury, drug overdoses, earthquake victims, serious infections, toxins, diabetic ketoacidosis, extreme hypothermia\/heatstroke<\/li>\n
                                                                                                                                                                                    • Signs & Symptoms:<\/strong> muscle pain, weakness, swelling, & dark urine; oliguria; hyperkalemia may trigger cardiac dysrhythmias; low BP; electrolyte imbalance can cause nausea, vomiting, confusion, coma<\/li>\n
                                                                                                                                                                                    • Urinalysis:\u00a0<\/strong> reveals brown urine, due to myoglobinuria<\/li>\n
                                                                                                                                                                                    • Evaluation:<\/strong> \u2191 serum CK, K+, PO4 levels<\/li>\n
                                                                                                                                                                                    • Treatment:<\/strong> rapid IV hydration to maintain adequate urinary flow (with bicarbonate if metabolic acidosis is occurring); & possibly hemodialysis<\/li>\n
                                                                                                                                                                                    • Potential Complications of Rhabdomyolysis:<\/strong>\n
                                                                                                                                                                                        \n
                                                                                                                                                                                      • myoglobin breakdown products damage kidney \u2192 <\/span>Renal Failure<\/strong><\/li>\n
                                                                                                                                                                                      • Disseminated Intravascular Coagulation (DIC, formation of small blood clots in bloodstream) initiated by released components of necrotic muscle\u2026 which can lead to organ failure & uncontrolled bleeding.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

                                                                                                                                                                                        Disseminated Intravascular Coagulation (DIC) = <\/strong>results from an imbalance of clotting\/hemostasis factors.<\/p>\n

                                                                                                                                                                                          \n
                                                                                                                                                                                        • Causes: <\/strong>serious infections (e.g. sepsis), trauma, burn, placental abruption, pre-eclampsia, toxins, snake bites<\/li>\n
                                                                                                                                                                                        • Pathogenesis:<\/strong>\n
                                                                                                                                                                                            \n
                                                                                                                                                                                          • Severe endothelial damage \u2192 <\/span><\/li>\n
                                                                                                                                                                                          • leads to release of large amounts of pro-inflammatory cytokines \u2192<\/span><\/li>\n
                                                                                                                                                                                          • stimulate too much thrombin \u2192<\/span> lead to too many fibrin\/platelet clots \u2192 <\/span><\/li>\n
                                                                                                                                                                                          • leads to clot obstructions of capillaries throughout the body leads to \u2192<\/span> ischemia\/hypoxia\/damage of tissues and multiple organ failure and<\/li>\n
                                                                                                                                                                                          • risk of bleeding out (as platelets are all “used up”).<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                          • Signs & Symptoms:<\/strong> purpura (blood-spotted skin), pain<\/li>\n
                                                                                                                                                                                          • Diagnostic Test:<\/strong> measure of coagulant (e.g. fibrin, platelets) and anti-coagulant factors<\/li>\n<\/ul>\n

                                                                                                                                                                                             <\/p>\n

                                                                                                                                                                                            Methods to Reduce Chances of Complications of Bone Fractures:<\/strong><\/p>\n

                                                                                                                                                                                              \n
                                                                                                                                                                                            • Wound debridement<\/strong><\/li>\n
                                                                                                                                                                                            • Windowed cast<\/b><\/li>\n
                                                                                                                                                                                            • Realign and Reduction<\/strong> using: intramedullary nails, pins, plates, wire meshes, casts, and\/or traction<\/li>\n
                                                                                                                                                                                            • Tetanus booster<\/strong><\/li>\n
                                                                                                                                                                                            • Antibiotics<\/strong><\/li>\n
                                                                                                                                                                                            • Monitor for signs of fat emboli<\/strong> – may travel to:\n
                                                                                                                                                                                                \n
                                                                                                                                                                                              • lungs, causing ARDS (pallor, diaphoresis, chest pain, dyspnea, tachycardia, cyanosis)<\/li>\n
                                                                                                                                                                                              • brain, causing CVA<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                              • Bone graft<\/strong> (taken from iliac crest, fibula, or rib)<\/li>\n
                                                                                                                                                                                              • Bone cement<\/strong><\/li>\n
                                                                                                                                                                                              • Exercise<\/strong> – maintain muscle function<\/li>\n<\/ul>\n

                                                                                                                                                                                                **********************************************************************************************************************************************************************************************************<\/p>\n

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                                                                                                                                                                                                \n
                                                                                                                                                                                                \n
                                                                                                                                                                                                \n
                                                                                                                                                                                                \n

                                                                                                                                                                                                Joints – Dislocation & Subluxation:<\/strong><\/h2>\n
                                                                                                                                                                                                  \n
                                                                                                                                                                                                • Dislocation:<\/strong>\n
                                                                                                                                                                                                    \n
                                                                                                                                                                                                  • Bones in a joint bones in joint lose contact with each other due to tearing of surrounding tissue (e.g. joint capsule, ligament(s), and or muscles\/tendons)<\/li>\n
                                                                                                                                                                                                  • Most common in shoulder, elbow, wrist, finger, hip, and knee<\/li>\n
                                                                                                                                                                                                  • Shoulder most susceptible due to its high mobility<\/li>\n
                                                                                                                                                                                                  • Can occur due to joint disease or previous damage<\/li>\n
                                                                                                                                                                                                  • Can damage surrounding ligaments, muscles, nerves, and blood vessels<\/li>\n
                                                                                                                                                                                                  • Risk Factors:<\/strong> joint diseases (e.g., rheumatic arthritis)<\/li>\n
                                                                                                                                                                                                  • Symptoms:<\/strong> pain, tenderness, swelling, possible anesthesia or paralysis<\/li>\n
                                                                                                                                                                                                  • Diagnosis:<\/strong> imaging (X-ray, MRI, arthroscope)<\/li>\n
                                                                                                                                                                                                  • Treatment:<\/strong> reduction, analgesics, anti-inflammatories, PRICE (protection, rest, ice, compression, elevation), possible surgical repair<\/li>\n
                                                                                                                                                                                                  • Rehabilitation:<\/strong> physiotherapy to regain function and range of motion<\/li>\n
                                                                                                                                                                                                  • Complications<\/strong> include:\n
                                                                                                                                                                                                      \n
                                                                                                                                                                                                    • Adhesive capsulitis (e.g., Frozen Shoulder) in which scarring and adhesions forming in connective tissue surrounding the glenohumeral joint – causing stiffness and loss of range of motion.<\/li>\n
                                                                                                                                                                                                    • Prevent this from occurring by following prescribed stretching and exercise regime.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                    • Subluxation:<\/strong>\n
                                                                                                                                                                                                        \n
                                                                                                                                                                                                      • Partial loss of contact between one or more bones in a joint<\/li>\n
                                                                                                                                                                                                      • Less severe than dislocation, often self-resolves<\/li>\n
                                                                                                                                                                                                      • Similar signs and symptoms: pain, stiffness<\/li>\n
                                                                                                                                                                                                      • Can also lead to frozen shoulder (adhesive capsulitis) if not properly rehabilitated<\/li>\n
                                                                                                                                                                                                      • Importance of physiotherapy to prevent loss of range of motion and muscle atrophy<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                      • Frozen Shoulder:<\/strong>\n
                                                                                                                                                                                                          \n
                                                                                                                                                                                                        • Also known as adhesive capsulitis<\/li>\n
                                                                                                                                                                                                        • Excessive scarring reduces range of motion long-term<\/li>\n
                                                                                                                                                                                                        • Importance of following doctor and physiotherapist guidance for recovery and rehabilitation.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n

                                                                                                                                                                                                          **********************************************************************************************************************************************************************************************************<\/span><\/p>\n

                                                                                                                                                                                                          Differentiate between Sprains and Strains and Describe Features of Each\u00a0<\/strong><\/h2>\n

                                                                                                                                                                                                          Definitions of Sprains and Strains:\u00a0<\/strong><\/p>\n

                                                                                                                                                                                                            \n
                                                                                                                                                                                                          • Sprain:<\/strong> ligament tear<\/li>\n
                                                                                                                                                                                                          • Strain:<\/strong> muscle or tendon tear (which can cause tendon inflammation, also known as tendonitis)<\/li>\n
                                                                                                                                                                                                          • Common Locations:<\/strong>\n
                                                                                                                                                                                                              \n
                                                                                                                                                                                                            • Sprains:<\/strong> Knees, elbows, wrists, ankles.<\/li>\n
                                                                                                                                                                                                            • Strains:<\/strong> Hands, feet, knees, biceps, triceps, quadriceps, ankles, Achilles heel.<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                            • Severity Levels:\u00a0<\/strong>\n
                                                                                                                                                                                                                \n
                                                                                                                                                                                                              • Grade 1 or 1st degree:<\/strong> Mild – fibers are stretched but stable;\n
                                                                                                                                                                                                                  \n
                                                                                                                                                                                                                • will slowly self repair<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                                • Grade 2 or 2nd degree:<\/strong> Moderate – some fibers are torn;\n
                                                                                                                                                                                                                    \n
                                                                                                                                                                                                                  • will slowly self repair,<\/li>\n
                                                                                                                                                                                                                  • follow prescribed stretching\/exercise regime to:\n
                                                                                                                                                                                                                      \n
                                                                                                                                                                                                                    • avoid scarring\/shortening<\/li>\n
                                                                                                                                                                                                                    • increase muscle strength surrounding joint to provide more stability<\/li>\n
                                                                                                                                                                                                                    • make joint more resilient against future injuries<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                                    • Grade 3 or 3rd degree:<\/strong> Severe – fibers are completely torn;\n
                                                                                                                                                                                                                        \n
                                                                                                                                                                                                                      • surgical repair is required, if possible (dependent on age, co-morbidities etc.)<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                                      • Grade 4 tear<\/strong> of ligament involves avulsion as well (complete tear plus bone fracture)\n
                                                                                                                                                                                                                          \n
                                                                                                                                                                                                                        • surgical repair involving bone fracture alignment and reduction is required<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                                        • Signs & Symptoms:\u00a0 <\/strong>\n
                                                                                                                                                                                                                            \n
                                                                                                                                                                                                                          • pain (especially on movement) due to micro\/macro-tears, bleeding, and inflammation,<\/li>\n
                                                                                                                                                                                                                          • swelling,<\/li>\n
                                                                                                                                                                                                                          • dislocation,<\/li>\n
                                                                                                                                                                                                                          • weakness of joint,<\/li>\n
                                                                                                                                                                                                                          • less mobility.<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                                          • Risk Factors:<\/strong>\n
                                                                                                                                                                                                                              \n
                                                                                                                                                                                                                            • Sports;<\/li>\n
                                                                                                                                                                                                                            • Overweight,<\/li>\n
                                                                                                                                                                                                                            • Age \u2013 collagen fibers have decrease elasticity & are more susceptible to injury<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                                            • Examples:<\/strong>\n
                                                                                                                                                                                                                                \n
                                                                                                                                                                                                                              • Strains – Rotator Cuff tear:<\/strong>\u00a0 tear to one of the 4 muscles that stabilize the glenohumeral shoulder joint<\/li>\n
                                                                                                                                                                                                                              • Sprains – Tear of Ligaments and Tendons<\/strong> – consists of dense regular connective tissue (e.g. organized collagen) E.g.,\u00a0 Tennis Elbow<\/strong> = stretch\/tear of tendon<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                                              • Diagnostic Tools:<\/strong> MRI, radiography, arthroscopy, or arthrography.\n
                                                                                                                                                                                                                                  \n
                                                                                                                                                                                                                                • Arthroscopy allows surgeons to view and repair joint injuries, such as ligament tears or meniscus tears<\/li>\n
                                                                                                                                                                                                                                • Viewing scope and surgical instruments for repairing damaged tissue<\/li>\n
                                                                                                                                                                                                                                • Arthrography: X-ray or CT scan to view joint damage<\/li>\n
                                                                                                                                                                                                                                • Radio-dense dye (iodine) for X-ray, MRI contrast medium for MRI<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                                                • Prevention:\u00a0<\/strong> Proper warm-up; appropriate sport wear and technique; avoid over-use; ramp up exercise slowly over months when first starting<\/li>\n
                                                                                                                                                                                                                                • Treatment:\u00a0 <\/strong>\n
                                                                                                                                                                                                                                    \n
                                                                                                                                                                                                                                  • Protection; Rest; Ice; Compression; Elevation (<\/span>PRICE) for first 48-72hrs (possibly alternate heat & cold)<\/li>\n
                                                                                                                                                                                                                                  • If infection – fluid aspiration, antibiotics for infection<\/li>\n
                                                                                                                                                                                                                                  • Compression bracing to provide support while healing<\/li>\n
                                                                                                                                                                                                                                  • Anti-inflammatories, physical therapy, massage, rest<\/li>\n
                                                                                                                                                                                                                                  • Gradual, Prolonged Rehabilitation Exercises (first without weight & only if no pain)<\/li>\n
                                                                                                                                                                                                                                  • Gradual increase in exercise activity levels (helps to strengthen tissues and blood flow will help with healing)<\/li>\n
                                                                                                                                                                                                                                  • Occupational Therapy \u2013 identify ergonomic problems in the work place or home to prevent re-injury<\/li>\n<\/ul>\n<\/li>\n
                                                                                                                                                                                                                                  • Recovery:<\/strong> Sprains tend to heal more slowly than strains.\u00a0 Typical Recovery Time:\u00a06 to 8 weeks for more complete healing.<\/li>\n
                                                                                                                                                                                                                                  • Healing Process:\u00a0<\/strong> Inflammation, white blood cells activity, angiogenesis, collagen production, scar tissue formation.<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                    **********************************************************************************************************************************************************************************************************<\/p>\n

                                                                                                                                                                                                                                    Describe Meniscus Tears <\/strong>= tears to white or red zone in knee cartilages<\/p>\n

                                                                                                                                                                                                                                      \n
                                                                                                                                                                                                                                    • Terrible Triad:\u00a0 <\/strong>Knee injury involving tear to MCL, ACL & medial meniscus (frequent soccer injury)\n
                                                                                                                                                                                                                                        \n
                                                                                                                                                                                                                                      • Prevent by strengthening surrounding muscles, using proper footwear<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n
                                                                                                                                                                                                                                        \n

                                                                                                                                                                                                                                        Discuss Overuse Injuries <\/strong>= damage to muscles\/tendons\/nerves due to repetitive movements, perhaps with no warm-up, with inappropriate equipment\/training\/technique – can lead to fibrous scar tissue & loss of range of motion, & is a risk factor for osteoarthritis<\/p>\n

                                                                                                                                                                                                                                          \n
                                                                                                                                                                                                                                        • Repetitive Strain Injuries:<\/strong> e.g. carpal tunnel syndrome<\/span><\/li>\n
                                                                                                                                                                                                                                        • Tendinitis:<\/strong> caused by tennis, golf, painting, keyboard use, running, massage<\/li>\n
                                                                                                                                                                                                                                        • Epicondylopathy<\/strong> = most often tendinopathy = microtears in tendon inflammation & pain (e.g. tennis\/golfer’s elbow)<\/li>\n
                                                                                                                                                                                                                                        • Bursitis<\/strong> = inflammation due to kneeling or gout or infection<\/li>\n
                                                                                                                                                                                                                                        • Treat with PRICE, surgery, physiotherapy, massage, antibiotics as appropriate<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                          Discuss Diagnostic Tools and Treatments<\/strong><\/p>\n

                                                                                                                                                                                                                                            \n
                                                                                                                                                                                                                                          • Arthroscopy <\/strong>= use of arthroscope (camera on thin bendy wire) to view inside joint through small incision<\/span><\/li>\n
                                                                                                                                                                                                                                          • Arthrography <\/strong>= injection of MRI or x-ray contrast dye (e.g. gadolinium or iodine respectfully) to better visualize joint in MRI or CT scan<\/span><\/li>\n
                                                                                                                                                                                                                                          • Prolotherapy <\/strong>= <\/span>Prol<\/strong>iferation <\/span>Therapy<\/strong> = injections of dextrose, thought to cause local inflammation, which stimulates increased blood flow and supply of nutrients; possibly speeding up tissue repair<\/span><\/li>\n
                                                                                                                                                                                                                                          • Extracorporeal Shockwave Therapy <\/strong>= use of shockwaves; thought to cause local inflammation, which stimulates increased blood flow and supply of nutrients; possibly speeding up tissue repair<\/span><\/li>\n<\/ul>\n<\/div>\n
                                                                                                                                                                                                                                            \n

                                                                                                                                                                                                                                            **********************************************************************************************************************************************************************************************************<\/p>\n

                                                                                                                                                                                                                                            Osteopenia and Osteoporosis:<\/strong><\/h2>\n
                                                                                                                                                                                                                                            \n

                                                                                                                                                                                                                                            Both are bone weakening diseases characterized by reduced bone volume due to loss of both:<\/span><\/p>\n

                                                                                                                                                                                                                                              \n
                                                                                                                                                                                                                                            • Organic bone matrix (osteoid) = collagen, glycoproteins and proteoglycans<\/li>\n
                                                                                                                                                                                                                                            • Inorganic bone matrix (calcium salts\/minerals) = CaPO4<\/sub><\/li>\n
                                                                                                                                                                                                                                            • Osteoporosis is more severe than osteopenia and is depicted by greater loss of bone volume and bone density putting an individual at risk for low-impact bone fractures.<\/span><\/li>\n
                                                                                                                                                                                                                                            • Osteopenia can be treated by ensuring sufficient dietary nutrients required for bone maintenance as well as taking part in regular recommended exercises (e.g., prescribed weight-training).<\/li>\n
                                                                                                                                                                                                                                            • Osteoporosis is characterized by irreplaceable loss of bone microstructure and density.<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                              Osteoporosis:<\/strong><\/h2>\n

                                                                                                                                                                                                                                              Osteoporosis is considered a chronic disease that affects many older adults, in which old cortical (compact) and trabecular (spongy\/cancellous) bone is being resorbed faster than new bone matrix is being made.\u00a0 The most severe loss of bone density typically occurs in the femoral neck, vertebrae, and wrist.\u00a0 Bone maintenance and synthesis is impacted by various hormone levels:\u00a0 Thyroid Hormone (TH), Cortisol, Growth Hormone (GH), estrogen and testosterone are important for maintaining osteoblast activity.\u00a0 Lower levels of estrogen and testosterone in old age, result in lower levels of osteoblast activity.<\/p>\n

                                                                                                                                                                                                                                                \n
                                                                                                                                                                                                                                              • reduced CaPO4<\/sub> within osteoid;<\/li>\n
                                                                                                                                                                                                                                              • bones become soft;<\/li>\n
                                                                                                                                                                                                                                              • most often due to low levels of Vitamin D3 and\/or calcium & causes bow-legging.<\/li>\n<\/ul>\n
                                                                                                                                                                                                                                                \n

                                                                                                                                                                                                                                                Risk factors:<\/strong><\/p>\n

                                                                                                                                                                                                                                                  \n
                                                                                                                                                                                                                                                • age<\/li>\n
                                                                                                                                                                                                                                                • post-menopausal biological (XX) females due to lower estrogen levels<\/span><\/li>\n
                                                                                                                                                                                                                                                • sedentary lifestyle<\/li>\n
                                                                                                                                                                                                                                                • use of corticosteroids<\/li>\n
                                                                                                                                                                                                                                                • low intake of dietary Ca++<\/sup> and\/or vitamin D<\/li>\n
                                                                                                                                                                                                                                                • excessive alcohol or caffeine<\/li>\n
                                                                                                                                                                                                                                                • smoking<\/li>\n
                                                                                                                                                                                                                                                • rheumatic arthritis<\/li>\n
                                                                                                                                                                                                                                                • diabetes mellitus<\/li>\n
                                                                                                                                                                                                                                                • genetics<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                  Categories of Osteoporosis:<\/strong><\/p>\n

                                                                                                                                                                                                                                                    \n
                                                                                                                                                                                                                                                  • 1st Degree Osteoporosis<\/strong> = due age related decline in hormones (e.g., sex hormones)<\/li>\n
                                                                                                                                                                                                                                                  • 2nd Degree Osteoporosis<\/strong> = due to underlying disease\n
                                                                                                                                                                                                                                                      \n
                                                                                                                                                                                                                                                    • Celiac disease, due to malabsorption of Ca++ and\/or vitamin D<\/li>\n
                                                                                                                                                                                                                                                    • Hyperthyroidism, due to increased metabolic activity<\/li>\n
                                                                                                                                                                                                                                                    • Hyperparathyroidism due to increased osteoclast activity<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                      Signs & Symptoms:<\/strong> low-impact fractures (1.5 million\/yr in USA), hip fractures, height reduction, kyphosis, vertebral compression fractures<\/p>\n

                                                                                                                                                                                                                                                      Routine Check-Ups:\u00a0 <\/strong>regular bone mass density scan tests after the age of 50<\/p>\n

                                                                                                                                                                                                                                                      Diagnostic Evaluation:<\/strong><\/p>\n

                                                                                                                                                                                                                                                        \n
                                                                                                                                                                                                                                                      • monitoring bone density using dual energy X-ray absorptiometry (DEXA) or other imaging (CT scans, MRI)<\/li>\n
                                                                                                                                                                                                                                                      • monitoring serum\/urine\u00a0 for low serum levels of Ca++, PO4<\/sub>,\u00a0 low levels of parathyroid hormone (PTH),<\/li>\n
                                                                                                                                                                                                                                                      • assessing for bone deformities<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                        Prevention: <\/strong>through avoidance of modifiable risk factors<\/p>\n

                                                                                                                                                                                                                                                        Treatment:<\/strong><\/p>\n

                                                                                                                                                                                                                                                          \n
                                                                                                                                                                                                                                                        • bisphosphonates (work by decreasing osteoclast activity)<\/li>\n
                                                                                                                                                                                                                                                        • weight-bearing exercises<\/li>\n
                                                                                                                                                                                                                                                        • calcium carbonate and vitamin D supplementation<\/li>\n<\/ul>\n
                                                                                                                                                                                                                                                            \n
                                                                                                                                                                                                                                                          • Vitamin D Recommended Dietary Allowance for adults 19 years and older is 600 IU (15 mcg) daily for men and women, and for adults >70 years it is 800 IU (20 mcg) daily.<\/li>\n
                                                                                                                                                                                                                                                          • Caution should be used not to exceed this dosage as vitamin D can build up to excessive and harmful levels in the body.<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                            Physiotherapy:<\/strong>\u00a0 to alleviate pain & maintain function of muscles, tendons, and nerves, recommendations include use of proper warm-up, appropriate equipment, training.<\/p>\n<\/div>\n<\/div>\n

                                                                                                                                                                                                                                                            **********************************************************************************************************************************************************************************************************<\/span><\/p>\n

                                                                                                                                                                                                                                                            Osteomalacia:<\/strong><\/h2>\n
                                                                                                                                                                                                                                                            \n

                                                                                                                                                                                                                                                            A bone weakening disease affecting adults caused by the reduced mineralization of bone.<\/span><\/p>\n

                                                                                                                                                                                                                                                              \n
                                                                                                                                                                                                                                                            • Both Osteomalacia and Rickets are similar in pathogenesis,<\/strong> in that the reduced mineral levels (CaPO4<\/sub>) within osteoid results in bones become soft.<\/span><\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                              Rickets:<\/strong><\/h2>\n

                                                                                                                                                                                                                                                              A bone weakening disease affecting infants, children, and adolescents caused by reduced mineralization of bone due to:<\/p>\n

                                                                                                                                                                                                                                                                \n
                                                                                                                                                                                                                                                              • reduced CaPO4<\/sub> within osteoid;<\/li>\n
                                                                                                                                                                                                                                                              • bones become soft;<\/li>\n
                                                                                                                                                                                                                                                              • most often due to low levels of Vitamin D3 and\/or calcium & causes bow-legging.<\/li>\n<\/ul>\n
                                                                                                                                                                                                                                                                \n

                                                                                                                                                                                                                                                                Risk factors:<\/strong><\/p>\n

                                                                                                                                                                                                                                                                  \n
                                                                                                                                                                                                                                                                • age<\/li>\n
                                                                                                                                                                                                                                                                • vegetarians, malnourishment, vitamin D deficiency (caused by diet and\/or lack of sunlight exposure (typically 15min per day during lower UV times of day is sufficient)<\/li>\n
                                                                                                                                                                                                                                                                • different drugs or diseases (e.g., renal diseases negatively affect calcitriol production)<\/li>\n
                                                                                                                                                                                                                                                                • metabolic disorders affecting calcium levels in osteoid<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                                  Signs & Symptoms:<\/strong> skeletal pain, bone deformities (e.g., \u201cknock-knees\u201d, \u201cbow legs\u201d,) easy fractures<\/p>\n

                                                                                                                                                                                                                                                                  Diagnostic Evaluation:<\/strong> monitoring for low serum levels of Ca++, PO4<\/sub>,\u00a0 low levels of parathyroid hormone (PTH), bone deformities, bone biopsy<\/p>\n

                                                                                                                                                                                                                                                                  Treatment:<\/strong> calcium carbonate and vitamin D supplementation<\/p>\n

                                                                                                                                                                                                                                                                    \n
                                                                                                                                                                                                                                                                  • Vitamin D Recommended Dietary Allowance for adults 19 years and older is 600 IU (15 mcg) daily for men and women, and for adults >70 years it is 800 IU (20 mcg) daily.<\/li>\n
                                                                                                                                                                                                                                                                  • Caution should be used not to exceed this dosage as vitamin D can build up to excessive and harmful levels in the body.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n

                                                                                                                                                                                                                                                                    **********************************************************************************************************************************************************************************************************<\/span><\/p>\n

                                                                                                                                                                                                                                                                    \n

                                                                                                                                                                                                                                                                    Muscular Dystrophy:<\/strong><\/h2>\n
                                                                                                                                                                                                                                                                    \n

                                                                                                                                                                                                                                                                    A group of autosomal recessive\/dominant genetic disorders that causes degeneration of skeletal muscle over time<\/span><\/p>\n

                                                                                                                                                                                                                                                                    \n

                                                                                                                                                                                                                                                                    Risk factors:<\/strong> inherited genetic mutations within or affecting the expression of the dystrophin gene<\/p>\n

                                                                                                                                                                                                                                                                    Duchenne\u2019s Muscular Dystrophy (DMD)<\/strong> is most common type of MD and it affects young biological (XY) males, as it is an X-linked recessive disease; biological (XX) females that are heterozygous for the mutation are carriers<\/div>\n
                                                                                                                                                                                                                                                                    \n

                                                                                                                                                                                                                                                                    Signs & Symptoms:<\/strong> ascending weakness of muscles starting at age 2-3yrs affecting legs, hips shoulders etc. degeneration of skeletal muscle progresses rapidly<\/p>\n

                                                                                                                                                                                                                                                                      \n
                                                                                                                                                                                                                                                                    • Early onset muscle weakness<\/li>\n
                                                                                                                                                                                                                                                                    • Waddling gait, Gower Maneuver (pushing to get up),<\/li>\n
                                                                                                                                                                                                                                                                    • Pseudohypertrophy of calf muscles, reduced tendon reflexes<\/li>\n
                                                                                                                                                                                                                                                                    • Kyphoscoliosis<\/li>\n
                                                                                                                                                                                                                                                                    • Frequent respiratory infections<\/li>\n
                                                                                                                                                                                                                                                                    • Cardiac myopathy<\/li>\n
                                                                                                                                                                                                                                                                    • Respiratory or heart failure by age 20<\/li>\n<\/ul>\n
                                                                                                                                                                                                                                                                      Pathophysiology:\u00a0<\/strong> the dystrophin protein is required for structural support within skeletal muscle cells.\u00a0 Loss of this protein leads to skeletal muscle cell necrosis and regeneration, with continuous loss of skeletal muscle cells over time.\u00a0 Dead cells are phagocytosed by macrophages and are replaced by connective tissue including adipose tissue which preserves and sometimes increases the volume\/mass of the area particularly in the calves (lower leg muscles), leading to the deceptive appearance of increased muscle, a phenomenon known as pseudohypertrophy.<\/div>\n
                                                                                                                                                                                                                                                                      <\/div>\n
                                                                                                                                                                                                                                                                      Diagnostic tests:<\/strong><\/div>\n
                                                                                                                                                                                                                                                                        \n
                                                                                                                                                                                                                                                                      • \n
                                                                                                                                                                                                                                                                        Genetic Tests<\/span><\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                      • \n
                                                                                                                                                                                                                                                                        Prenatal screening – chorionic villus (placenta) testing and amniocentesis is avail.<\/span><\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                      • \n
                                                                                                                                                                                                                                                                        Elevated serum creatine kinase levels<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                      • \n
                                                                                                                                                                                                                                                                        Electromyography<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                      • \n
                                                                                                                                                                                                                                                                        Muscle biopsy to check dystrophin levels<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                      • \n
                                                                                                                                                                                                                                                                        Blood test shows abnormal dystrophin levels<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                      • Abnormal ECG and echocardiograph<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                                        Treatment:<\/strong><\/p>\n

                                                                                                                                                                                                                                                                          \n
                                                                                                                                                                                                                                                                        • moderate exercise<\/span><\/li>\n
                                                                                                                                                                                                                                                                        • mobility devices<\/span><\/li>\n
                                                                                                                                                                                                                                                                        • physiotherapy & massage<\/span><\/li>\n
                                                                                                                                                                                                                                                                        • ventilator<\/span><\/li>\n
                                                                                                                                                                                                                                                                        • possible future genetic therapies<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n

                                                                                                                                                                                                                                                                          **********************************************************************************************************************************************************************************************************<\/span><\/p>\n

                                                                                                                                                                                                                                                                          \n

                                                                                                                                                                                                                                                                          Fibromyalgia:<\/strong><\/h2>\n

                                                                                                                                                                                                                                                                          A syndrome characterized by idiopathic chronic pain, numbness, tingling, stiffness, cognitive and memory problems; fatigue and sleep disturbances, anxiety, depression, possible irritable bowel syndrome and possible jaw pain;\u00a0 with no obvious inflammation or atrophy.<\/p>\n

                                                                                                                                                                                                                                                                          \n

                                                                                                                                                                                                                                                                          Risk factors:<\/strong><\/p>\n

                                                                                                                                                                                                                                                                            \n
                                                                                                                                                                                                                                                                          • biological females; 20-50yrs;<\/li>\n
                                                                                                                                                                                                                                                                          • history of auto-immune disease (e.g. Rheumatoid Arthritis, Lupus, Ankylosing Spondylitis)<\/li>\n
                                                                                                                                                                                                                                                                          • physical\/psychological trauma, or chronic pain<\/li>\n<\/ul>\n
                                                                                                                                                                                                                                                                            Signs & Symptoms:<\/strong><\/div>\n
                                                                                                                                                                                                                                                                            \n
                                                                                                                                                                                                                                                                              \n
                                                                                                                                                                                                                                                                            • chronic pain in soft tissues<\/li>\n
                                                                                                                                                                                                                                                                            • characterized by widespread pain, fatigue, stiffness<\/li>\n<\/ul>\n<\/div>\n
                                                                                                                                                                                                                                                                              Pathogenesis:\u00a0 <\/strong>Causes unknown, hypothesized neurotransmitter imbalance.<\/span><\/div>\n
                                                                                                                                                                                                                                                                              <\/div>\n
                                                                                                                                                                                                                                                                              Diagnostic Tests:\u00a0\u00a0<\/strong>tender points examination, blood tests, elimination of other possible diseases\/disorders.<\/div>\n
                                                                                                                                                                                                                                                                              <\/div>\n
                                                                                                                                                                                                                                                                              Treatments:<\/strong><\/div>\n
                                                                                                                                                                                                                                                                                \n
                                                                                                                                                                                                                                                                              • \n
                                                                                                                                                                                                                                                                                Stress avoidance or reduction<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                              • \n
                                                                                                                                                                                                                                                                                Regular exercise in the morning (when pain is often lower)<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                              • Pace activity & rest as needed<\/li>\n
                                                                                                                                                                                                                                                                              • Applications of heat or massage<\/li>\n
                                                                                                                                                                                                                                                                              • Analgesic drugs, NSAIDs, new drugs<\/li>\n
                                                                                                                                                                                                                                                                              • Low doses of antidepressants (SSNRIs,\u00a0Serotonin Norepinephrine Reuptake Inhibitors)<\/li>\n
                                                                                                                                                                                                                                                                              • Massage therapy<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n

                                                                                                                                                                                                                                                                                **********************************************************************************************************************************************************************************************************<\/p>\n

                                                                                                                                                                                                                                                                                Osteoarthritis:<\/strong><\/h2>\n

                                                                                                                                                                                                                                                                                an inflammatory joint disease due to “wear and tear”, most often affecting hips and knees<\/span><\/p>\n

                                                                                                                                                                                                                                                                                 <\/p>\n

                                                                                                                                                                                                                                                                                Risk factors:<\/strong><\/div>\n
                                                                                                                                                                                                                                                                                  \n
                                                                                                                                                                                                                                                                                • obesity<\/li>\n
                                                                                                                                                                                                                                                                                • biological males; 40+yrs; biological females 55+yrs<\/li>\n
                                                                                                                                                                                                                                                                                • history of auto-immune disease (e.g. Rheumatoid Arthritis, Lupus, Ankylosing Spondylitis)<\/li>\n
                                                                                                                                                                                                                                                                                • physical\/psychological trauma, or chronic pain<\/li>\n<\/ul>\n
                                                                                                                                                                                                                                                                                  Signs & Symptoms:<\/strong><\/div>\n
                                                                                                                                                                                                                                                                                    \n
                                                                                                                                                                                                                                                                                  • \n
                                                                                                                                                                                                                                                                                    Joint pain<\/strong> that is relieved when joint is rested<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                  • Heberden nodes<\/strong> in distal finger joints = thickening of subchondral bones (sclerosis = \u2191 bone density)<\/li>\n
                                                                                                                                                                                                                                                                                  • Bouchard nodes<\/strong> in middle joints of fingers = ditto (thickening of subchondral bones (sclerosis = \u2191 bone density)<\/li>\n<\/ul>\n
                                                                                                                                                                                                                                                                                    Pathophysiology:<\/strong><\/div>\n
                                                                                                                                                                                                                                                                                      \n
                                                                                                                                                                                                                                                                                    • \n
                                                                                                                                                                                                                                                                                      articular cartilage degenerates, and fibrillation (deep long fissures in articular cartilage occur),<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                    • \n
                                                                                                                                                                                                                                                                                      joint capsule thickens, becomes fibrotic and sticks to deformed underlying bone narrowing joint space, limiting ROM, causing:<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                    • \n
                                                                                                                                                                                                                                                                                      pain & stiffness, swelling, paresthesia (e.g. numbness), stiffness, creaking, limp, predisposition to falls, joint deformation.<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                    • irritation of many sensory nerve endings in joint capsule<\/li>\n
                                                                                                                                                                                                                                                                                    • Bone spurs (osteophytes) form & can break off (\u201cjoint mice\u201d) into synovial cavity & irritate synovial membrane causing synovitis; subchondral cysts form; exudate buildup<\/li>\n<\/ul>\n
                                                                                                                                                                                                                                                                                      Diagnostic Evaluation:<\/strong>\u00a0 clinical assessment, X-ray<\/div>\n

                                                                                                                                                                                                                                                                                       <\/p>\n

                                                                                                                                                                                                                                                                                      Treatment:<\/strong> rest, orthotics, ROM exercises, physio & massage therapy, optimizing BMI may involve loss of excess body fat through healthy diet and exercise, pain & anti-inflammatory meds, possible surgery if deformation, excess pain and\/or loss of mobility (hip & knee replacements are common), acupuncture, canes, hand braces.<\/p>\n

                                                                                                                                                                                                                                                                                      Rheumatoid Arthritis:<\/strong><\/h2>\n

                                                                                                                                                                                                                                                                                      A chronic, systemic, inflammatory auto-immune disease causing joint swelling, tenderness, destruction of synovial joints leading to disability & premature death.<\/span><\/p>\n

                                                                                                                                                                                                                                                                                      Risk Factors:<\/strong><\/p>\n

                                                                                                                                                                                                                                                                                        \n
                                                                                                                                                                                                                                                                                      • age (young adult onset is most common)<\/li>\n
                                                                                                                                                                                                                                                                                      • genetics (specific HLA antigens)<\/li>\n
                                                                                                                                                                                                                                                                                      • biological female<\/li>\n
                                                                                                                                                                                                                                                                                      • smoking<\/li>\n
                                                                                                                                                                                                                                                                                      • possible T cell defect in telomere repair<\/li>\n
                                                                                                                                                                                                                                                                                      • prior viral infection resulting in cross-affinity to self antigens<\/li>\n
                                                                                                                                                                                                                                                                                      • imbalance of chemokines involved in triggering an immune response<\/li>\n
                                                                                                                                                                                                                                                                                      • long-term exposure to antibodies.<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                                                        Signs & Symptoms:<\/strong>\u00a0 joint pain and inflammation, stiffness, joint deformation<\/p>\n

                                                                                                                                                                                                                                                                                        Pathophysiology:<\/strong> Inflammation spreads to articular cartilage, fibrous joint capsule, surrounding ligaments & tendons<\/span><\/p>\n

                                                                                                                                                                                                                                                                                        \n

                                                                                                                                                                                                                                                                                        Most common in fingers, feet, wrists, elbows, ankles, knees; also shoulders, hips, cervical spine (lungs, heart, kidneys, & skin).<\/p>\n

                                                                                                                                                                                                                                                                                          \n
                                                                                                                                                                                                                                                                                        • \n
                                                                                                                                                                                                                                                                                          Synovitis<\/strong> \u2013 marked inflammation, cell proliferation<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                        • \n
                                                                                                                                                                                                                                                                                          Pannus<\/strong> – made of granulation tissue = new connective tissue with tiny blood vessel that typically forms in a wound during the healing process; but in this case healing doesn’t occur and it spreads<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                        • \n
                                                                                                                                                                                                                                                                                          Cartilage erosion<\/strong> \u2013 creates unstable joint<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                        • \n
                                                                                                                                                                                                                                                                                          Fibrosis (scar tissue)<\/strong> \u2013 calcifies and obliterates joint space<\/div>\n<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                                                          Possible Complications:<\/strong><\/p>\n

                                                                                                                                                                                                                                                                                            \n
                                                                                                                                                                                                                                                                                          • \n
                                                                                                                                                                                                                                                                                            Ankylosis<\/strong> \u2013 joint fixation and deformity develop if untreated<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                          • \n
                                                                                                                                                                                                                                                                                            Atrophy<\/strong> of muscles<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                          • \n
                                                                                                                                                                                                                                                                                            Bone alignment<\/strong> shifts (Ulnar drift, deformation and swanning of fingers); Boutonniere deformity<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                          • \n
                                                                                                                                                                                                                                                                                            Muscle spasms<\/strong> due to inflammation\/pain<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                          • \n
                                                                                                                                                                                                                                                                                            Contractures<\/strong> and deformity<\/strong> develop.<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                          • \n
                                                                                                                                                                                                                                                                                            Flare-ups<\/strong> associated with anemia<\/strong> (e.g. iron-deficiency)<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                          • \n
                                                                                                                                                                                                                                                                                            More prone to lung fibrosis, atherosclerosis, MI, and stroke<\/strong><\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                          • Chronic anti-inflammatory use can cause bleeds<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                                                            Diagnostic Tests:\u00a0<\/strong> Appearance of auto-antibodies (Rheumatoid Factors, RF) in blood tests, imaging, \u2191ESR (faster Erythrocyte Sedimentation Rate), \u2191CRP (increased C Reactive Protein levels in blood), presence of Anti-Nuclear Antibodies (ANA) in blood<\/p>\n

                                                                                                                                                                                                                                                                                            Treatment:<\/strong> anti-inflammatory drugs, disease-modifying antirheumatic drugs, supportive care, cessation of smoking, healthy diet<\/p>\n

                                                                                                                                                                                                                                                                                            Gouty Arthritis:\u00a0<\/strong><\/h2>\n

                                                                                                                                                                                                                                                                                            A chronic inflammatory arthritis, characterized by hyperuricemia and the formation of urate crystals in joints causing joint swelling, tenderness, destruction of synovial joints which can lead to disability as well a chronic nephropathy.<\/p>\n

                                                                                                                                                                                                                                                                                             <\/p>\n

                                                                                                                                                                                                                                                                                            Risk factors:<\/strong><\/div>\n
                                                                                                                                                                                                                                                                                              \n
                                                                                                                                                                                                                                                                                            • biological males >40yrs<\/li>\n
                                                                                                                                                                                                                                                                                            • sedentary lifestyle<\/li>\n
                                                                                                                                                                                                                                                                                            • low fluid intake and\/or use of diuretics<\/li>\n
                                                                                                                                                                                                                                                                                            • low intake of fruits containing vitamin C<\/li>\n
                                                                                                                                                                                                                                                                                            • high meat (purine-rich) diet (sometimes called the \u201crich man\u2019s disease\u201d, as high meat consumption is a risk factor, particularly shrimp, lobster, liver, kidney and red meats such as pork and beef<\/em>)<\/li>\n
                                                                                                                                                                                                                                                                                            • alcohol (beer, wine, spirits)<\/li>\n
                                                                                                                                                                                                                                                                                            • obesity<\/li>\n
                                                                                                                                                                                                                                                                                            • family history, genetic susceptibilities<\/li>\n
                                                                                                                                                                                                                                                                                            • chemotherapy<\/li>\n
                                                                                                                                                                                                                                                                                            • consumption of sweetened beverages and foods containing high-fructose corn syrup<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                                                              Signs and Symptoms:<\/strong><\/p>\n

                                                                                                                                                                                                                                                                                                \n
                                                                                                                                                                                                                                                                                              • \n
                                                                                                                                                                                                                                                                                                Acute gout flares due to tophaceous deposits (tophi) of urate crystals in joints.<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                              • \n
                                                                                                                                                                                                                                                                                                Gout is associated with co-morbidities such as hypertension, diabetes mellitus, ischemic heart disease, congestive heart failure, metabolic syndrome, chronic kidney disease, and obesity.<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                              • Most people with asymptomatic hyperuricemia do not develop gout.<\/li>\n<\/ul>\n

                                                                                                                                                                                                                                                                                                Pathophysiology:<\/strong><\/p>\n

                                                                                                                                                                                                                                                                                                  \n
                                                                                                                                                                                                                                                                                                • \n
                                                                                                                                                                                                                                                                                                  Results from deposits of uric acid and crystals in the joint, causing inflammation, leukocytosis and sometimes fever.<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                                • \n
                                                                                                                                                                                                                                                                                                  Uric acid & crystal formation resulting from any combination of the above risk factors, which may also include inadequate renal excretion of uric acid.<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                                • Formation of tophus \u2013 large, hard nodule of urate crystals<\/li>\n
                                                                                                                                                                                                                                                                                                • \n
                                                                                                                                                                                                                                                                                                  Tophi cause local painful inflammation and occur after the first attack of gout.<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                                • \n
                                                                                                                                                                                                                                                                                                  Tophi can be found in cartilage, bone, joints, tendons and even skin, though predominantly within articular and subcutaneous regions.<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                                • \n
                                                                                                                                                                                                                                                                                                  Tophi can cause erosion of bone and joint tissues, and synovial fluid becomes yellow and cloudy.<\/div>\n<\/li>\n
                                                                                                                                                                                                                                                                                                • Joint damage can cause joint deformities and osteoarthritis; additionally urate nephropathy and conjunctivitis can occur.<\/li>\n<\/ul>\n
                                                                                                                                                                                                                                                                                                  Diagnosed<\/strong> by examination of synovial fluid, imaging, and blood tests.\u00a0 High ESR (Erythrocyte Sedimentation Rate) and CRP (C reactive Protein) levels are common due to the inflammatory response that has been provoked by the tophi.\u00a0 Synovial fluid will exhibit high WBC counts, and the absence of bacteria within synovial fluid distinguishes gouty arthritis from septic arthritis.<\/div>\n<\/div>\n

                                                                                                                                                                                                                                                                                                   <\/p>\n

                                                                                                                                                                                                                                                                                                  Treated<\/strong> by reducing uric acid levels through medications & dietary changes.\u00a0 Acute flares are usually self-limiting resolving within days to weeks, often without treatment.\u00a0 Treatment of flares involves the use of ice packs as well as NSAIDs and sometimes glucocorticoids.<\/div>\n<\/div>\n<\/div>\n

                                                                                                                                                                                                                                                                                                   <\/p>\n

                                                                                                                                                                                                                                                                                                   <\/p>\n

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