MUSCULOSKELETAL 3 CLASSIC/PATHOGNOMONIC JOINT

DEFORMITIES: COMMON IN STAGE 4

1. RHEUMATOID ARTHRITIS 1. SWAN NECK DEFORMITY = DISTAL JOINT
IS FLEXED
● CAUSE: AUTOIMMUNE → OWN IMMUNE 2. BOUTONNIERE’S DEFORMITY = PROXIMAL
SYSTEM ATTACKS THE JOINT → PAIN & JOINT IS FLEXED
INFLAMMATION
● COMMON IN: FEMALES (“RHEA”)
● EXACERBATION & REMISSION PERIODS =
ON & OFF
● CHRONIC CONDITION = MANAGEABLE
● SYMMETRICAL EFFECT
● EARLIEST MANIFESTATION: SMALL
JOINTS (HANDS)
● RA is also a systemic condition:
VASCULITIS (inflammation of the blood
vessels) → stenosis (narrowing) →
ischemia of organs = MSOF! 3. ULNAR DEVIATION = THE HANDS ARE
● RA IS THE MOST DANGEROUS TYPE OF DRIFTING TOWARDS THE ULNAR SIDE
ARTHRITIS

STAGE 1: SYNOVITIS
● Synovial inflammation
● Edematous
● “Spongy joints”
● Low grade fever

STAGE 2: PANNUS FORMATION

● Thickening of synovial area
● Tissue overgrowth
● Limited motion due to stiffening =
decreased mobility esp in morning OTHER S/S:
● Morning stiffness = lasts for > 30 mins ● LOW GRADE FEVER
● FATIGUE , WEAKNESS, MALAISE
● ANOREXIA (LOA)
● IMPAIRED ORGAN FUNCTION

WATCH OUT FOR!!! JUVENILE RHEUMATOID

Stage 3: FIBROUS ANKYLOSIS
● FIBER FIXATION = CONNECTIVE TISSUES
ARE IMMOBILE/LIMITED ROM
ARTHRITIS (<16 YO)
● ADVERSE EFFECT: IRIDOCYCLITIS =
PERMANENT BLINDNESS CAUSED BY
SWELLING OF BLOOD VESSELS IN THE
EYES BEFORE THEY BECOME FULLY
DEVELOPED
COMORBIDITIES: SLE, RAYNAUD’S
PHENOMENON, SCLERODERMA

STAGE 4: BONY ANKYLOSIS DIAGNOSTIC TEST:

● BONE FIXATION ● RH FACTOR (BLOOD TEST)
● BONE AND JOINT BECOME FUSED ● X-RAY
TOGETHER ● CT SCAN/MRI = BONE DENSITY
● CRIPPLING EFFECT ● ESR & CRP = ELEVATED IN ALL
● IRREVERSIBLE CONDITIONS WITH INFLAMMATION
● JOINT DEFORMITY ● LATEX AGGLUTINATION TEST

MANAGEMENT:
● PRIORITY: PAIN
○ DOC: CORTICOSTEROIDS
(IMMUNOSUPPRESSANT,
ANTI-INFLAMMATORY)
 ○ NSAIDS
○ CYCLOSPORINE =
IMMUNOSUPPRESSANT
○ METHOTREXATE
○ HYDROXYCHLOROQUINE
● PHYSICAL THERAPY
○ EXERCISE: SWIMMING/AQUATIC
EXERCISES = MORE TOLERABLE
FOR THE PATIENT
○ ROM EXERCISES = PRESERVE
JOINT FUNCTION
● PLASMAPHERESIS
○ REMOVAL OF EXCESS ANTIBODIES
IN THE PLASMA
● COMPRESS: HEAT & COLD COMPRESS
○ WARM COMPRESS FOR JOINT
STIFFENING
○ COLD COMPRESS TO RELIEVE THE
PAIN
● GOLD SALTS (AURONAFIN) = REDUCES
PAIN & INFLAMMATION
○ TAKES 3-6 MONTHS TO GET
THERAPEUTIC BENEFITS
○ ADVERSE EFFECT: BONE MARROW
SUPPRESSION
OSTEOARTHRITIS
● DEGENERATIVE JOINT DISEASE
● NON-GENDER SPECIFIC
● CAUSE: WEAR & TEAR OF JOINTS
(WEIGHT)
● EARLIEST JOINTS AFFECTED:
WEIGHT-BEARING JOINTS (KNEES, HIPS,
ANKLES)
● OBESE → DAMAGED SYNOVIAL
MEMBRANE & CARTILAGE = BONE TO
BONE FRICTION “KISSING OF THE
BONES”
● CONSIDERED AS NON-INFLAMMATORY
ARTHRITIS = DOES NOT SPREAD AROUND
OTHER PARTS OF THE BODY
● PREDISPOSING FACTORS:
○ OBESITY
○ OLD AGE
○ HIGH IMPACT SPORTS
○ FAMILY HISTORY
○ GENETIC DISORDERS/CONGENITAL
DISORDERS: MARFAN’S
SYNDROME, TRISOMY 21 (DOWN’S
SYNDROME), TRISOMY 18
(EDWARD’S), TRISOMY 13 (PATAU)
○ OVERUSE THE JOINTS
DIAGNOSTIC TESTS:
● X-RAY = BEST
● ARTHROSCOPY = INVASIVE = INCISION IS
MADE OVER THE JOINT AND A SCOPE IS
INSERTED TO DIRECTLY VISUALIZE
● MANIFESTATIONS: OA
○ PAIN UPON MOVEMENT
○ PAIN UPON BEARING OF WEIGHT
○ ASYMMETRICAL JOINT
INVOLVEMENT
○ NO FEVER
○ NO ELEVATION OF ESR & CRP
○ (+) CREPITUS = GRATING
SOUND/SENSATION OF BONES
RUBBING TOGETHER
○ MORNING STIFFNESS LASTS FOR
<30 MINS (DUE TO
INACTIVITY/IMMOBILITY DURING
THE NIGHT)
■ WORSENED BY COLD (OA &
RA)
○ DIFFICULTY GETTING UP FROM A
PROLONGED LYING DOWN OR
SITTING POSITION
○ DECREASED MOBILITY →
CONTRACTURES & ATROPHY
● PATHOGNOMONIC SIGNS:
○ HEBERDEN = NODES ON DISTAL
JOINT
○ BOUCHARD = NODES IN THE
PROXIMAL JOINT
MANAGEMENT:
● PRIORITY: PAIN
○ ANALGESIC: NSAID
○ NO STEROIDS!!! THERE’S NO
INFLAMMATION!
● PT, REHABILITATE JOINTS
● ROM EXERCISES
● SWIMMING
● MODIFY LIFESTYLE:
○ REDUCE WEIGHT!
● SURGICAL MANAGEMENT:
○ ARTHROPLASTY = REPAIR OF THE
JOINTS
GOUTY ARTHRITIS
● (+) INFLAMMATION
● CHRONIC, SYSTEMIC METABOLIC
CONDITION
○ GENETIC PREDISPOSITION
○ FAMILY HISTORY
 ○ EXCESSIVE BREAKDOWN OF
PURINES → URIC ACID CRYSTALS =
GET DEPOSITED IN THE JOINTS
● EARLIEST: INFLAMMATION OF THE BIG
TOE = “PODAGRA”
RISK FACTORS:
● GENETIC
● FAMILY HISTORY
● FAMILY PRACTICES: DIET & ALCOHOL
INTAKE
● Food high in purine:
○ Organ meats
○ Seafood = anchovies, mackerel,
sardines, shellfish
○ Alcohol (VODKA & WHISKEY)
○ Red meat
○ Processed food, Fast food
G- great toe or big toe (attacks at night)
O- only one joint involved( monoarticular)
U- ulasimang bato (HERBAL MED)
T- tophi formation (hallmark), TUMOR LYSIS
SYNDROME
● TUMOR LYSIS SYNDROME:
○ AN EVENT THAT HAPPENS AFTER
CHEMO/RADIATION THERAPY
○ SEVERE ELEVATION OF URIC ACID
IN THE BLOOD → GOUT
○ S/S:
■ HYPERKALEMIA
■ HYPONATREMIA = DUE TO
HEMODILUTION
■ METABOLIC ACIDOSIS
● MEDICATIONS:
○ PRE-PROCEDURE: ALLOPURINOL
○ SODIUM BICARBONATE TO
RELIEVE THE ACIDOSIS
○ KAYEXALATE TO LOWER K+
Diagnostic Tests:
● X-ray
● CBC: Elevated ESR & CRP
● Serum Uric Acid (<7 mg/dL)
● Kidney Function Tests = uric acid crystals
may also deposit in the kidneys and lead to
renal calculi
○ GFR
○ BUN
○ Creatinine
○ Crea Clearance
Manifestations:
● Pain & inflammation (commonly in lower
extremities)
● Monoarticular joint pain and inflammation
● Common: BIG TOE & ankles
● Low grade fever
● Fatigue, weakness, malaise
● Complication:
○ RENAL CALCULI
■ Hematuria
■ Cloudy urine
■ SEVERE PAIN (Costovertebral
pain/Flank pain)
■ Dribbling urine
● CARDINAL SIGN:
○ “TOPHI FORMATION” = uric acid
crystals deposited in the joints
MANAGEMENT:
● PROMOTE HYDRATION = >3000 ML/DAY
● STOP ALCOHOL!!!
● LIMIT PURINE IN THE DIET
● ALKALINE ASH DIET = VEGETABLES,
NUTS, GRAINS, SEEDS
MEDICAL MANAGEMENT:
● DOC: MANAGE THE PAIN CAUSED BY
INFLAMMATION IN GOUT: COLCHICINE
● NSAIDS = SECOND BEST
● ALLOPURINOL = LOWERS THE QUANTITY
OF URIC ACID
○ PRE-CHEMO FOR TLS
● PROBENECID = PROMOTES EXCRETION
OF UA CRYSTALS
PAGET’S DISEASE
● OSTEITIS DEFORMANS
● PATHOPHYSIOLOGY:
○ RAPID RESORPTION OF BONES →
RAPID RAPID BONE GROWTH =
DEFORMITIES & FRACTURES
● CAUSES:
○ IDIOPATHIC
○ GENETIC PREDISPOSITION:
■ MUTATION SQSTM1 GENE
○ LINKED TO VIRAL INFECTIONS:
TRIGGERED BY: MEASLES
3 PHASES: PAGET’S DISEASE ● KYPHOSIS
● SCOLIOSIS
1. PHASE 1: LYTIC PHASE ● KYPHOSCOLIOSIS
● OVERACTIVITY OF THE ● MAY COMPLICATE INTO CANCER =
OSTEOCLASTS → AGGRESSIVE OSTEOSARCOMA (PAGET’S SARCOMA)
DEMINERALIZATION (20X MORE ● BOW-LEGGED APPEARANCE
THAN NORMAL)
2. PHASE 2: MIXED PHASE (LYTIC & ● HYPERCALCEMIA
BLASTIC) ○ DYSRHYTHMIAS
● OSTEOBLASTS → DISORGANIZED ○ RENAL CALCULI
PROLIFERATION OF BONE TISSUE ○ VISCOUS = HTN
3. PHASE 3: SCLEROTIC PHASE ○ MUSCLE DYSFUNCTIONS =
● NEW BONE TISSUE EXCEEDS THE HYPOREFLEXIA
RATE OF BONE ○ CLOT FORMATION
RESORPTION/DEMINERALIZATION) ● OVERGROWTH OF BONE → PINCHING OF
NERVES
= STRUCTURALLY DISORGANIZED & WEAKER ○ OPTICAL NERVE = BLIND
BONES ○ AUDITORY NERVE = HEARING LOSS

● INC ICP

DIAGNOSTIC TESTS:
● X-RAY
● BONE SCAN
● CT/MRI
● SERUM CALCIUM
○ CLOTTING TIME
● BONE BIOPSY = DONE TO EXCLUDE BONE
CANCER OR MALIGNANCIES
○ DONE TO CONFIRM PAGET’S
SARCOMA
● ALKALINE PHOSPHATASE

MANAGEMENT:
● DIET: LOW CALCIUM, HIGH PHOSPHATE
● CALCITONIN
● MGMT FOR INC ICP:
○ MANNITOL
S/S: ○ SEMI-FOWLERS (30 DEG)
● PRIMARILY AFFECTED AREAS: ○ PREVENT STRAINING:
○ SKULL ■ AVOID VALSALVA = HIGH
○ PELVIS FIBER, STOOL SOFTENERS
○ FEMUR ■ AVOID COUGHING =
○ LUMBAR AREA ANTITUSSIVES
● PATHOLOGICAL FRACTURES ○ SEIZURE PREC
● STRUCTURAL DEFORMITIES ● MILD TO MODERATE ACTIVITY
○ SKULL = LEONTIASIS ● NO CONTACT SPORTS!

EXERCISES:
 1. ISOKINETIC = REHABILITATIVE
EXERCISES WITH USE OF EQUIPMENT
THAT APPLY CONSTANT RESISTANCE
● MUSCLE CONTRACTION IS EQUAL
● SAME SPEED
EG: LEG PRESS, TREADMILL, STATIONARY BIKE,
SHOULDER PRESS
2. ISOMETRIC = STATIC OR SETTING
EXERCISES
● EXERTING PRESSURE AGAINST THE
OBJECT
EG: WALL SITS, PLANKING, PUSH UPS
3. ISOTONIC = DYNAMIC EXERCISES,
AEROBIC EXERCISES
● ACTIVITIES THAT QUICKEN HR & CO
● CARDIO EXERCISES
EG: RUNNING, SWIMMING, ZUMBA, ADLS,
ACTIVE ROM, JUMP ROPE
BODY MECHANICS:
● WIDER THE BASE = THE MORE STABLE
THE SUPPORT
● MOVE LINE OF GRAVITY CLOSE TO
CENTER OF BASE OF SUPPORT
● BEND AT THE KNEES, NOT THE HIPS!
● HOLD THE OBJECT CLOSE TO THE BODY
USE OF CRUTCHES:
● ENSURE PROPER CRUTCH FIT
○ CRUTCH PAD SHOULD BE 2
FINGERBREADTHS UNDER THE
AXILLA
○ ELBOWS MUST BE FLEXED AT A 30
- DEGREE ANGLE
○ HAND GRIPS SHOULD BE IN LINE
WITH THE WAIST
● STARTING TO AMBULATE:
○ TRIPOD POSITION
● CRUTCH TIPS = 6 INCHES TO THE SIDE OF
THE FOOT
● USE GAIT BELT FOR SAFETY WHEN
TEACHING CLIENTS TO AMBULATE
DIFFERENT GAITS:
1. TWO-POINT GAIT = “MILITARY GAIT”
● CRUTCH ON INJURED SIDE + GOOD
LEG = MOVE AT SAME TIME
● GOOD LEG CRUTCH + INJURED
LEG
2. THREE-POINT GAIT = THE INJURED LEG
NEVER TOUCHES THE GROUND =
“CLASSIC GAIT” = NON-WEIGHTBEARING
● BOTH CRUTCHES + INJURED LEG
TOGETHER
● GOOD LEG
3. FOUR POINT GAIT = MOST STABLE GAIT &
SAFEST = SLOWEST GAIT
● CRUTCH ON INJURED LEG
● GOOD LEG
● GOOD SIDE CRUTCH
● BAD LEG
4. SWING TO GAIT
● BOTH CRUTCHES ARE MOVED
FORWARD
● AND THEN SWING BOTH LEGS UP
TO SAME POINT OF CRUTCHES
5. SWING THROUGH GAIT = FASTEST GAIT
● BOTH CRUTCHES ARE MOVED
FORWARD
● AND THEN SWING BOTH LEGS
BEYOND THE POINT OF CRUTCHES
GOING UP THE STAIRS:
● “GOOD LEG GOES TO HEAVEN”
● GOOD LEG
● CRUTCHES
● BAD LEG
GOING DOWN
● “BAD LEG GOES TO HELL” :(
● BOTH CRUTCHES FIRST → BAD LEG →
GOOD LEG