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 Dedication
To healthcare providers everywhere—who devote their careers to the health
and well-being of individual patients and families, both young and old.

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 ix

 Preface
Essentials of Musculoskeletal Care bridges the gap conditioning programs are available in the text and as
between what primary care physicians were taught in patient handouts that can be printed from the website
medical school and what they need to know to evaluate that accompanies this publication. This title is also
and manage common musculoskeletal conditions. This available as an eBook.
text is used for immediate, point-of-care guidance I am indebted to the Board of Directors of the
in decision making and intervention. Physicians and American Academy of Orthopaedic Surgeons
allied healthcare providers also often use the images in (AAOS) and to the executive staff of AAOS for their
this text to educate their patients regarding conditions commitment to excellence in education. My thanks
and treatments, as well as suggested at-home exercises. also go to the Editorial Board for this fifth edition
Essentials also helps physicians decide which cases for their commitment to this project: section editors
to treat themselves and which to refer. Since the first Letha Yurko Griffin (General Orthopaedics); Robert
edition of Essentials of Musculoskeletal Care was Z. Tashjian (Shoulder); Joseph A. Abboud (Elbow and
published in 1997, more than 150,000 copies have been Forearm); Julie E. Adams (Hand and Wrist); Kathleen
sold. Weber (Hip and Thigh); Robert A. Gallo (Knee and
Essentials of Musculoskeletal Care is used by Lower Leg); Umur Aydogan (Foot and Ankle); Daniel
physicians in family practice, internists, specialists in T. Altman (Spine); Kelly L. VanderHave and Joseph
physical medicine and rehabilitation, pediatricians, A. Janicki (Pediatric Orthopaedics); and Mark C.
physicians in the armed forces, physicians in Hubbard, who oversaw the rehabilitation content
occupational medicine, physicians in sports medicine, and served as coeditor. I also would like to thank
athletic trainers, physical therapists, emergency the following AAOS staff for their work on this
medicine physicians, nurse practitioners, physician publication: Hans Koelsch, Director, Publications;
assistants, residents in family practice and orthopaedic Maureen Geoghegan, Director of Marketing; Monica
surgery, orthopaedic surgeons, osteopathic physicians, Baum; Lisa Claxton Moore; Laura Goetz; Genevieve
and many others. In addition, although not designed as Charet; Courtney Dunker; Abram Fassler; Susan
a textbook, Essentials has been adopted as a required Baim; Charlie Baldwin; Emily Nickel; Hollie Muir;
or recommended text by numerous teaching programs, Karen Danca; Suzanne O’Reilly; Michelle Wild;
both for clinical rotations and for courses such as Steven Kellert; Brian Moore; Katie Hovany; Laszlo
Concepts in Primary Care, Orthopaedic Injuries, Dianovsky; Susan Reindl; Mike Johnson; Derrick
Primary Care of Adults, and Musculoskeletal Clinical Philips; and Abel Jimenez.
Medicine. Students indicate that Essentials is the only Once again, the AAOS is grateful for the support of
text that follows them from the classroom into clinical the American Academy of Pediatrics (AAP) and thank
practice. them for serving as a valuable professional Academy
This fifth edition of Essentials of Musculoskeletal partner in the Essentials project. The comments from
Care has been improved and enhanced with additional the AAP as well as from the internists, physiatrists,
illustrations, tables, and injection/aspiration videos. family practitioners, orthopaedic residents, medical
Sections and chapters have been reviewed and students, and others who use this book have helped
updated, and new topics have been added, including us continuously improve this publication, leading to
a chapter on sports-related concussions in the improvements in musculoskeletal education and
General Orthopaedics section and another chapter patient care.
on concussion in the Pediatric Orthopaedics section. April D. Armstrong, BSc(PT), MSc, MD, FRCSC
In addition, rehabilitation prescriptions with home
exercise programs and general musculoskeletal Editor

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 xi

 How to Use
Essentials of Musculoskeletal Care 5th Edition
Essentials of Musculoskeletal Care provides concise content in a practical and easy-to-use format. To access
the associated videos (physical examinations, maneuvers, injections, aspirations) and printable PDFs of home
exercise programs, click the video icons and links throughout the text.

Pain diagram opens each section.

Shows areas of pain and identifies
conditions typically associated with
each pain location. Names chapter in
which condition is discussed.

Table of contents lists conditions in

alphabetic order.

Anatomic art at beginning of section

for handy reference.

Physical examination shows

photographs and step-by-step
descriptions of physical examination
maneuvers: inspection and palpation,
range of motion, muscle testing, and
special tests. Symbol indicates that
video demonstrations are available by
clicking the video icon.

xii
Conditions chapters include:
a. Synonyms
b. Clinical symptoms
c. Physical examination pearls
d. Diagnostic tests
e. Differential diagnosis
f. Adverse outcomes of the disease
g. Treatment
h. Rehabilitation prescription
i. Adverse outcomes of treatment
j. Referral decisions/Red flags

Home exercise program includes:

a. Symbol indicating customizable, printable
PDF of the home exercise program is
available by clicking the PDF icon (AAOS
access app) or the resources arrow at
digital.aaos.org (see image)
b. Concise table of exercises
c. Step-by-step instructions and illustrations

Procedures include:
a. Symbol indicating video is
available by clicking the
link.
b. List of materials
c. Step-by-step instructions

xiii
 Table of Contents

SECTION ONE
General Orthopaedics
xx Pain Diagram 90 Diffuse Idiopathic Skeletal 181 Preoperative Evaluation of
2 Anatomy Hyperostosis Medical Comorbidities
3 Overview of General 92 Drugs: Corticosteroid 188 Rehabilitation and
Orthopaedics Injections Therapeutic Modalities
8 Principles of 96 Drugs: Nonsteroidal 198 Musculoskeletal
Musculoskeletal Evaluation Anti-Inflammatory Drugs Conditioning: Helping
100 Falls and Traumatic Injuries Patients Prevent Injury and
15 Amputations of the Lower Stay Fit
Extremity in the Elderly Patient
109 Fibromyalgia Syndrome 201 Home Exercise Program for
24 Anesthesia for Orthopaedic Shoulder Conditioning
Surgery 115 Fracture Evaluation and
Management Principles 209 Home Exercise Program for
32 Arthritis: Osteoarthritis Hip Conditioning
39 Complementary and 122 Fracture Healing
219 Home Exercise Program for
Alternative Medicine 127 Fracture Splinting Knee Conditioning
Therapies for Osteoarthritis Principles
226 Home Exercise Program
46 Arthritis: Rheumatoid 135 Imaging: Principles and for Foot and Ankle
Arthritis Techniques Conditioning
53 Arthritis: Seronegative 144 Infection: Osteomyelitis 233 Home Exercise Program for
Spondyloarthropathies 147 Infection: Septic Arthritis Lumbar Spine Conditioning
58 Compartment Syndrome 152 Lyme Disease 238 Rehabilitation: Canes,
65 Complex Regional Pain 156 Osteoporosis Crutches, and Walkers
Syndrome 244 Sports Medicine Evaluation
166 Overuse Syndromes
72 Concussion: Sports-Related and Management Principles
173 Pain Management in the
76 Crystal Deposition Diseases Orthopaedic Patient 249 Sprains and Strains
82 Deep Vein Thrombosis 177 Pain: Nonorganic 253 Tumors of Bone
Symptoms and Signs

xiv Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

 SECTION TWO
Shoulder
258 Pain Diagram 298 Fracture of the Clavicle 334 Rotator Cuff Tear
260 Anatomy 301 Fracture of the Humeral 338 Home Exercise Program for
261 Overview of the Shoulder Shaft Rotator Cuff Tear
265 Home Exercise Program for 304 Fracture of the Proximal 341 Rupture of the Proximal
Shoulder Conditioning Humerus Biceps Tendon
271 Physical Examination 308 Fracture of the Scapula 344 Shoulder Instability
of the Shoulder 311 Frozen Shoulder 350 Procedure: Reduction
282 Acromioclavicular Injuries 314 Home Exercise Program for of Anterior Shoulder
Frozen Shoulder Dislocation
286 Home Exercise Program for
Acromioclavicular Injuries 316 Procedure: Shoulder Joint 353 Superior Labrum Anterior
Injection and Aspiration: to Posterior Lesions
289 Procedure:
Acromioclavicular Posterior 356 Home Exercise Program for
Joint Injection 318 Impingement Syndrome SLAP Lesions
291 Arthritis of the Shoulder 322 Home Exercise Program for 358 Thoracic Outlet Syndrome
294 Burners and Other Brachial Shoulder Impingement 361 Home Exercise Program for
Plexus Injuries 325 Procedure: Subacromial Thoracic Outlet Syndrome
Bursa Injection
327 Overhead Throwing
Shoulder Injuries

SECTION THREE

Elbow and Forearm

364 Pain Diagram 386 Fracture of the Distal 407 Procedure: Olecranon Bursa
366 Anatomy Humerus Aspiration
367 Overview of the Elbow 389 Fracture of the Olecranon 409 Nerve Compression
and Forearm 392 Fracture of the Radial Head Syndromes
370 Physical Examination 395 Lateral and Medial 413 Home Exercise Program for
of the Elbow and Forearm Epicondylitis Radial Tunnel Syndrome
377 Arthritis of the Elbow 399 Home Exercise Program for 416 Rupture of the Distal Biceps
Epicondylitis Tendon
381 Procedure: Elbow Joint
Injection and Aspiration— 402 Procedure: Tennis Elbow 418 Ulnar Collateral Ligament
Lateral Approach Injection Tear
383 Dislocation of the Elbow 404 Olecranon Bursitis

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 xv

 SECTION FOUR

Hand and Wrist

422 Pain Diagram 466 Home Program for Carpal 502 Fracture of the Metacarpals
424 Anatomy Tunnel Syndrome and Phalanges
425 Overview of the Hand 468 Procedure: Carpal Tunnel 507 Fracture of the Scaphoid
and Wrist Injection 510 Ganglion of the Wrist
430 Physical Examination 470 de Quervain Tenosynovitis and Hand
of the Hand and Wrist 472 Procedure: de Quervain 515 Procedure: Dorsal Wrist
442 Animal Bites Tenosynovitis Injection Ganglion Aspiration
445 Arthritis of the Hand 474 Dupuytren Contracture 517 Human Bite Wounds
448 Procedure: 477 Fingertip Infections 520 Kienböck Disease
Metacarpophalangeal or 481 Procedure: Digital 522 Mallet Finger
Proximal Interphalangeal Anesthetic Block (Hand) 525 Nail Bed Injuries
Joint Injection 483 Fingertip Injuries/ 528 Procedure: Fishhook
450 Arthritis of the Thumb Amputations Removal
Carpometacarpal Joint 486 Flexor Tendon Injuries 531 Sprains and Dislocations
453 Procedure: Thumb 490 Flexor Tendon Sheath of the Hand
Carpometacarpal Joint Infections
Injection 537 Trigger Finger
493 Fracture of the Base of the 540 Procedure: Trigger Finger
455 Arthritis of the Wrist Thumb Metacarpal Injection
457 Procedure: Wrist 495 Fracture of the Hook
Aspiration/Injection 542 Tumors of the Hand
of the Hamate and Wrist
459 Boutonnière Deformity 498 Fracture of the Distal 546 Ulnar Nerve Entrapment
462 Carpal Tunnel Syndrome Radius at the Wrist

SECTION FIVE
Hip and Thigh
550 Pain Diagram 585 Fracture of the Proximal 619 Strains of the Thigh
552 Anatomy Femur 622 Home Exercise Program
553 Overview of the Hip 589 Hip Impingement for Strains of the Thigh
and Thigh 593 Inflammatory Arthritis 627 Stress Fracture of the
558 Home Exercise Program 596 Lateral Femoral Cutaneous Femoral Neck
for Hip Conditioning Nerve Syndrome 630 Transient Osteoporosis
566 Physical Examination of 599 Osteoarthritis of the Hip of the Hip
the Hip and Thigh 602 Osteonecrosis of the Hip 632 Trochanteric Bursitis
574 Dislocation of the Hip 605 Snapping Hip 635 Home Exercise Program
(Acute, Traumatic) for Trochanteric Bursitis
608 Home Exercise Program
578 Fracture of the Femoral for Snapping Hip 638 Procedure: Trochanteric
Shaft Bursitis Injection
612 Strains of the Hip
581 Fracture of the Pelvis
615 Home Exercise Program
for Strains of the Hip

xvi Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

 SECTION SIX

Knee and Lower Leg

640 Pain Diagram 692 Claudication 730 Home Exercise Program
642 Anatomy 694 Collateral Ligament Tear for Patellar/Quadriceps
Tendinitis
643 Overview of the Knee 698 Home Exercise Program for
and Lower Leg Collateral Ligament Tear 732 Patellar/Quadriceps Tendon
Ruptures
651 Home Exercise Program for 701 Compartment Syndrome
Knee Conditioning 735 Patellofemoral Maltracking
705 Contusions
657 Physical Examination of the 739 Patellofemoral Pain
707 Fractures About the Knee
Knee and Lower Leg 743 Home Exercise Program for
711 Iliotibial Band Syndrome Patellofemoral Pain
668 Anterior Cruciate
Ligament Tear 713 Gastrocnemius Tear 746 Plica Syndrome
672 Home Exercise Program for 715 Home Exercise Program for 749 Home Exercise Program for
ACL Tear Medial Gastrocnemius Tear Plica Syndrome
675 Procedure: Knee Joint 717 Meniscal Tear 751 Popliteal Cyst
Aspiration/Injection 722 Home Exercise Program for 754 Posterior Cruciate
678 Arthritis of the Knee Meniscal Tear Ligament Tear
683 Home Exercise Program 724 Osteonecrosis of the 758 Home Exercise Program
for Arthritis Femoral Condyle for PCL Injury
686 Bursitis of the Knee 727 Patellar/Quadriceps 760 Shin Splints
Tendinitis
690 Procedure: Pes Anserine 762 Stress Fracture
Bursa Injection

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 xvii

 SECTION SEVEN

Foot and Ankle

766 Pain Diagram 825 Dance Injuries to the Foot 872 Nail Fungus Infection
768 Anatomy and Ankle 874 Orthotic Devices
769 Overview of the Foot 830 The Diabetic Foot 877 Plantar Fasciitis
and Ankle 834 Procedure: Care of Diabetic 881 Home Exercise Program for
773 Home Exercise Program Feet Plantar Fasciitis
for Foot and Ankle 837 Fracture-Dislocations 883 Procedure: Plantar Fasciitis
Conditioning of the Midfoot Injection
779 Physical Examination of the 840 Fractures of the Ankle 885 Plantar Warts
Foot and Ankle 843 Fractures of the Calcaneus 887 Posterior Heel Pain
794 Achilles Tendon Tear and Talus
890 Home Exercise Program for
797 Home Exercise Program for 846 Fracture of the Metatarsals Posterior Heel Pain
Minor Achilles Tendon Tear 849 Fracture of the Phalanges 892 Posterior Tibial Tendon
800 Ankle Sprain 851 Fracture of the Sesamoid Dysfunction
804 Home Exercise Program 854 Procedure: Digital 896 Rheumatoid Arthritis of the
for Ankle Sprain (Initial Anesthetic Block (Foot) Foot and Ankle
Program)
855 Hallux Rigidus 899 Sesamoiditis
808 Arthritis of the Foot
and Ankle 858 Hallux Valgus 901 Shoe Wear
812 Procedure: Ankle Joint 861 Ingrown Toenail 905 Soft-Tissue Masses of the
Injection 863 Procedure: Nail Plate Foot and Ankle
814 Bunionette Avulsion 907 Stress Fractures of the
865 Interdigital (Morton) Foot and Ankle
816 Procedure: Application of a
Metatarsal Pad Neuroma 910 Tarsal Tunnel Syndrome
817 Chronic Lateral Ankle Pain 868 Procedure: Interdigital 913 Toe Deformities
(Morton) Neuroma Injection 916 Home Exercise Program for
821 Corns and Calluses
870 Metatarsalgia Toe Strengthening
824 Procedure: Trimming a
Corn or Callus 919 Turf Toe

SECTION EIGHT

Spine
922 Pain Diagram 965 Cervical Strain 985 Home Exercise Program
924 Anatomy 968 Home Exercise Program for Low Back Stability and
for Cervical Strain Strength: Introductory
925 Overview of the Spine
970 Fractures of the Cervical 987 Lumbar Herniated Disk
934 Home Exercise Program
for Lumbar Spine Spine 992 Lumbar Spinal Stenosis
Conditioning 973 Fractures of the Thoracic 996 Metastatic Disease
939 Physical Examination of or Lumbar Spine 999 Scoliosis in Adults
the Spine 976 Low Back Pain: Acute 1002 Spinal Orthoses
956 Cauda Equina Syndrome 980 Home Exercise Program 1006 Spondylolisthesis:
958 Cervical Radiculopathy for Acute Low Back Pain Degenerative
961 Cervical Spondylosis 982 Low Back Pain: Chronic 1008 Spondylolisthesis: Isthmic

xviii Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

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 SECTION NINE
Pediatric Orthopaedics
1011 Overview of Pediatric 1090 Discitis 1159 Metatarsus Adductus
Orthopaedics 1093 Evaluation of the 1163 Neonatal Brachial Plexus
1013 Pediatric Physical Limping Child Palsy
Examination 1098 Procedure: Hip Aspiration 1166 Osgood-Schlatter Disease
1025 Anterior Knee Pain 1100 Flatfoot 1168 Osteochondral Lesions of
1028 Back Pain 1104 Fractures in Children the Talus
1032 Elbow Pain 1106 Fractures of the Growth 1170 Osteochondritis Dissecans
1037 Foot and Ankle Pain Plate 1173 Osteomyelitis
1041 Growing Pain 1109 Fractures About the Elbow 1177 Pediatric Sports
1043 Accessory Navicular 1114 Fractures of the Clavicle Participation
1045 Calcaneal Apophysitis and Proximal Humerus 1180 Preparticipation Physical
1117 Fractures of the Distal Evaluation
1047 Cavus Foot Deformity
Forearm 1188 Scoliosis
1051 Child Abuse
1120 Fractures of the Proximal 1193 Septic Arthritis
1055 Clubfoot and Middle Forearm 1197 Seronegative
1059 Complex Regional Pain 1122 Fractures of the Femur Spondyloarthropathies
Syndrome
1125 Fractures of the Tibia 1199 Shoes for Children
1062 Concussion
1128 Genu Valgum 1201 Slipped Capital Femoral
1066 Congenital Deficiencies of Epiphysis
the Lower Extremity 1132 Genu Varum
1135 Intoeing and Outtoeing 1205 Spondylolysis/
1071 Congenital Deficiencies of Spondylolisthesis
the Upper Extremity 1141 Juvenile Idiopathic
Arthritis 1209 Tarsal Coalition
1074 Congenital Deformities of
the Lower Extremity 1146 Kyphosis 1212 Toe Walking
1080 Congenital Deformities of 1150 Legg-Calvé-Perthes 1215 Torticollis
the Upper Extremity Disease 1220 Transient Synovitis
1084 Developmental Dysplasia 1155 Little Leaguer’s Elbow of the Hip
of the Hip

1222 Glossary

1239 Index

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 xix

 PAIN DIAGRAM
General Orthopaedics

Osteoporosis

Osteoarthritis

Rheumatoid arthritis

Diffuse idiopathic
skeletal hyperostosis
(DISH)

Seronegative
spondyloarthropathies

Rheumatoid arthritis

Complex regional pain

syndrome (CRPS)

Osteoarthritis

Rheumatoid arthritis

Deep vein thrombosis

Complex regional pain

syndrome (CRPS)

Osteoarthritis

Rheumatoid arthritis Rheumatoid arthritis

Crystal deposition disease
Crystal deposition
disease

xx Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

 SECTION 1

General Orthopaedics
xx Pain Diagram 65 Complex Regional Pain 127 Fracture Splinting 201 Home Exercise
Syndrome Principles Program for Shoulder
2 Anatomy
72 Concussion: 135 Imaging: Principles and Conditioning
3 Overview of General
Sports-Related Techniques 209 Home Exercise Program
Orthopaedics
76 Crystal Deposition 144 Infection: Osteomyelitis for Hip Conditioning
8 Principles of
Diseases 147 Infection: Septic Arthritis 219 Home Exercise Program
Musculoskeletal
82 Deep Vein Thrombosis for Knee Conditioning
Evaluation 152 Lyme Disease
90 Diffuse Idiopathic 226 Home Exercise Program
15 Amputations of the 156 Osteoporosis
Skeletal Hyperostosis for Foot and Ankle
Lower Extremity
166 Overuse Syndromes Conditioning
24 Anesthesia for 92 Drugs: Corticosteroid
Orthopaedic Surgery Injections 173 Pain Management in the 233 Home Exercise Program
Orthopaedic Patient for Lumbar Spine
32 Arthritis: Osteoarthritis 96 Drugs: Nonsteroidal Conditioning
Anti-Inflammatory Drugs 177 Pain: Nonorganic
39 Complementary Symptoms and Signs 238 Rehabilitation: Canes,
and Alternative 100 Falls and Traumatic Crutches, and Walkers
Medicine Therapies for Injuries in the Elderly 181 Preoperative Evaluation
Osteoarthritis Patient of Medical Comorbidities 244 Sports Medicine
Evaluation and
46 Arthritis: Rheumatoid 109 Fibromyalgia Syndrome 188 Rehabilitation and Management Principles
Arthritis Therapeutic Modalities
115 Fracture Evaluation and 249 Sprains and Strains
53 Arthritis: Seronegative Management Principles 198 Musculoskeletal
Conditioning: Helping 253 Tumors of Bone
Spondyloarthropathies 122 Fracture Healing
Patients Prevent Injury
58 Compartment Syndrome
and Stay Fit

Section Editor
Letha Y. Griffin, MD, PhD
Peachtree Orthopaedic Clinic
Team Physician
Georgia State University
Atlanta, Georgia

Contributors
Albert J. Aboulafia, MD, FACS, MBA Julie A. Dodds, MD George N. Guild III, MD Lindsey S. Knowles, DPT, STC Thomas J. Moore, MD
Medical Director, Weinberg Associate Clinical Professor Orthopaedic Surgeon Owner, Physical Therapist Associate Professor
Cancer Institute Division of Sports Medicine Peachtree Orthopaedic Clinic Department of Outpatient Department of Orthopaedics
Director, Sarcoma Services Michigan State University Northside Hospital Orthopaedics and Sports Emory School of Medicine
Associate Professor of East Lansing, Michigan Atlanta, Georgia Physical Therapy Atlanta, Georgia
Orthopaedics and Oncology, Atlanta Sport & Spine Physical Therapy
Gregory K. Faucher, MD Stephen C. Hamilton, MD Robert A. Murphy, MS, ATC
Georgetown University School of Atlanta, Georgia
Resident Physician Orthopaedic Surgeon Associate Athletic Director for Sports
Medicine
Orthopaedic Surgery Beacon Orthopaedics L. Andrew Koman, MD Medicine and Nutrition
Franklin Square Hospital and Sinai
Emory University Cincinnati, Ohio Professor and Chair Athletic Department
Hospital
Atlanta, Georgia Orthopaedic Surgery Georgia State University
Baltimore, Maryland Douglas Hollern, MD
Wake Forest Baptist Health Atlanta, Georgia
Eli C. Garrard, MD Medical Student
Lindsay M. Andras, MD Winston-Salem, North Carolina
Resident College of Medicine Michael S. Pinzur, MD
Assistant Professor of Orthopaedics
Department of Orthopaedic Surgery University of Cincinnati Joseph M. Lane, MD Professor of Orthopaedic Surgery
Children’s Orthopaedic Center
Emory University Cincinnati, Ohio Professor of Orthopaedic Surgery Department of Orthopaedic Surgery
Children’s Hospital Los Angeles
Atlanta, Georgia Department of Orthopaedics and Rehabilitation
Keck School of Medicine of the Mark C. Hubbard, MPT
Weill Cornell Medical College Loyola University Health System
University of Southern California Marcel Gilli, MD Physical Therapist
New York, New York Maywood, Illinois
Los Angeles, California Anesthesiologist Bone and Joint Institute
American Anesthesiology of Georgia Penn State Milton S. Hershey Laurel R. Lemasters, MD David A. Schiff, MD
Laura L. Bellaire, MD
Piedmont Hospital Medical Center Musculoskeletal Radiologist Orthopaedic Surgeon
Resident
Atlanta, Georgia Hershey, Pennsylvania Northwest Radiology Consultants Peachtree Orthopaedic Clinic
Orthopaedic Surgery
Atlanta, Georgia Atlanta, Georgia
Emory University Jordyn R. Griffin, MD James S. Kercher, MD
Atlanta, Georgia Resident Physician Orthopaedic Surgeon Tanya Maxwell, MS, L/ATC Ted Sousa, MD
Internal Medicine, Pediatrics Peachtree Orthopaedic Clinic Clinical Coordinator for Dr. Letha Griffin Clinical Fellow
John A. Bergfeld, MD
University of Kentucky Atlanta, Georgia Peachtree Orthopaedic Clinic Children’s Hospital Los Angeles
Senior Surgeon
Lexington, Kentucky Atlanta, Georgia University of Southern California
Department of Orthopaedic Surgery
Los Angeles, California
Cleveland Clinic
Cleveland, Ohio Harlan McMillan Starr, Jr, MD
Orthopaedic Surgeon
Georgia Hand, Shoulder, & Elbow
Atlanta, Georgia
© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 1
 ANATOMY—MAJOR BONES OF THE BODY

Skull

Clavicle Mandible

Scapula

Humerus

Spinal column

Radius
Pelvis
Ulna

Carpal bones
Metacarpals

Phalanges

Femur

Patella

Fibula Tibia

Metatarsals
Tarsal bones
Phalanges

2 Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

Overview of General
Orthopaedics

SECTION 1 GENERAL ORTHOPAEDICS

Bone, cartilage, muscle, tendon, ligament, and their supporting nerve
and vascular supplies are the specialized structures that make up the
musculoskeletal system. In combination, these structures provide
remarkable strength, movement, durability, and efficiency. Disease
or injury to any of these tissues may adversely affect function and
the ability to perform daily activities. This General Orthopaedics
section of Essentials of Musculoskeletal Care describes conditions
that affect multiple joints, bones, or regions; conditions that have
systemic effects; and therapeutic modalities commonly used in the
nonsurgical treatment of musculoskeletal conditions. An anatomic
drawing showing the major bones of the human body is on page 2;
a detailed anatomic drawing showing the bones and muscles of the
various anatomic areas appears at the beginning of each anatomic
section. A glossary of commonly used orthopaedic terms is provided
immediately after section 9.

Arthritis
The etiologies of arthritis range from degenerative processes
associated with aging (osteoarthritis) to acute infectious processes
(septic arthritis). Likewise, disability from arthritis ranges from
stiffness to severe pain and crippling dysfunction. Two of the most
common forms of adult arthritis encountered in clinical practice are
osteoarthritis and rheumatoid arthritis (Figure 1). Distinguishing
characteristics are listed in Table 1.
Other types of inflammatory arthritis include the seronegative
spondyloarthropathies, crystal deposition diseases, and septic
arthritis. Of these conditions, septic arthritis is the most urgent
because immediate diagnosis and efficacious treatment are required
to prevent joint destruction. Diagnosis typically involves joint
fluid analysis, in which a leukocyte count greater than 50,000 or
a differential count of 90% polymorphonucleocytes is concerning
for bacterial arthritis. Joint aspiration and culture, followed by
appropriately tailored antibiotics, and in most cases, surgical drainage
and lavage, are imperative. The crystal arthropathies present as
acute monoarticular arthritis with an abrupt onset of intense pain
and swelling. The seronegative spondyloarthropathies are a group
of disorders characterized by oligoarticular peripheral joint arthritis,
enthesitis, inflammatory changes in axial skeletal joints (sacroiliitis
and spondylitis), extra-articular sites of inflammation, association
with HLA-B27, and negative rheumatoid factor.

Bursitis and Tenosynovitis

Sterile inflammation of bursae (bursitis) and tendon sheaths
(tendinitis) occurs frequently in adults, particularly following
an injury or repetitive motion. Characteristic symptoms include

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 3

 Overview of General Orthopaedics
SECTION 1 GENERAL ORTHOPAEDICS

Figure 1 Illustration shows joints commonly affected by arthritis. Blue asterisks indicate joints predominantly
affected by osteoarthritis; red asterisks indicate joints predominantly affected by rheumatoid arthritis.
DIP = distal interphalangeal, MCP = metacarpophalangeal, MTP = metatarsophalangeal, PIP = proximal
interphalangeal.

localized pain that is exacerbated by specific movements and is

frequently relieved with rest. Classic locations of bursitis include
the olecranon, greater trochanter, and prepatellar bursa, whereas
tenosynovitis frequently affects tendon sheaths of the wrist and hand
flexor tendons and tendons about the ankle (peroneal, posterior tibial,
and Achilles). Common treatments for bursitis and tenosynovitis
include activity modification, NSAIDs, splinting, and the judicious
use of corticosteroid injections. Infectious tenosynovitis or infectious
bursitis can follow minor trauma, especially if the skin is violated.

4 Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

 Overview of General Orthopaedics

Table 1
Characteristics of Osteoarthritis Versus Rheumatoid Arthritis

SECTION 1 GENERAL ORTHOPAEDICS

Characteristic Osteoarthritis Rheumatoid Arthritis
Pathophysiology Noninflammatory, asymmetric, Autoimmune, inflammatory cytokines
articular cartilage deterioration target synovial membranes
“Wear and tear”
Demographics Most common arthritis Affects 1% of population
Incidence increases with age 3:1 female-to-male
Obesity Peak onset in the fourth and fifth
History of joint trauma or other joint decades
disease (secondary to OA)
Clinical Increased pain with use, fast-resolving Morning stiffness
stiffness Classically affects MCP, PIP, wrists,
Classically affects knees, hips, spine, MTP joints
DIP joints, thumb CMC joint Symmetric and deforming joint erosion
Crepitus, decreased joint ROM Synovial thickening and joint
tenderness to palpation
Workup Radiographs: asymmetric joint space Laboratory tests: RF (high sensitivity),
narrowing, subchondral sclerosis, anti-CCP (high specificity)
osteophytes Radiographs: bony erosions,
symmetric joint space narrowing
Treatment Exercise and weight loss, NSAIDs, NSAIDs, DMARDs, TNF-α
corticosteroid injections, antagonists, glucocorticoids
glucosamine and chondroitin Goal of treatment is to prevent
sulfate, hyaluronic acid, total irreversible joint erosion and
joint arthroplasty deformity
CCP = cyclic citrullinated peptide, CMC = carpometacarpal, DIP = distal interphalangeal, DMARDs = disease-
modifying antirheumatic drugs, MCP = metacarpophalangeal, MTP = metatarsophalangeal, OA = osteoarthritis,
PIP = proximal interphalangeal, RF = rheumatoid factor, ROM = range of motion, TNF-α = tumor necrosis factor-α.

The cardinal signs of Kanavel (Table 2) signal infection in pyogenic Table 2

flexor tenosynovitis of the finger; this condition should be addressed
urgently with surgery to prevent permanent finger dysfunction. All Cardinal Signs of Kanavel
infectious bursitis or tenosynovitis requires prompt recognition with for Hand Flexor Tendon
culture (if feasible) of the area and initial treatment with broad- Sheath Infection
spectrum antibiotics until culture results are known. Prompt referral Fusiform swelling of digit
for consideration of surgical drainage is essential.
Tenderness along tendon
sheath
Osteoporosis Digit held in flexed position
Osteoporosis is a common skeletal disorder with significant health Severe pain with passive digit
cost. Associated fragility (low-energy) fractures seen primarily in extension
the hip, distal radius, proximal humerus, and vertebrae are estimated
to total 9 million per year worldwide and are a significant source of
morbidity and mortality in an increasingly aging population. Patients
who sustain fragility fracture should be evaluated for osteoporosis
and treated when appropriate to reduce the risk for future fracture.
Dual-energy x-ray absorptiometry (DEXA) is used to screen for

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 5

 Overview of General Orthopaedics

Table 3
Major Risk Factors for Osteoporotic Fractures
SECTION 1 GENERAL ORTHOPAEDICS

Not Modifiable
Advanced age
Female sex
History of fracture as an adult
History of fracture in first-degree relative
Dementia
Poor health/frailty
Caucasian or Asian race
Possibly Modifiable
Low bone mineral density
Oral glucocorticoid use
Recurrent falls
Current tobacco use
Alcoholism
Estrogen deficiency, including menopause onset before age 45 years
Lifelong low calcium intake
Vitamin D deficiency
Low body weight
Little or no physical activity

osteoporosis, defined as a bone density 2.5 SDs below the healthy

young adult mean. Treatment of osteoporosis includes modifying
risk factors (Table 3), vitamin D and calcium supplementation, and
pharmacologic therapy. All physicians should encourage patients to
include calcium-rich foods in their diet, obtain appropriate “sunshine”
vitamin D, and exercise regularly to avoid the development of
osteoporosis. The high prevalence of vitamin D deficiency in the
United States justifies the regular screening of adolescents, adults,
and elderly patients for deficiency as part of the health maintenance
examination.

Trauma
Trauma to the musculoskeletal system may involve bones, ligaments,
or tendons. Initial management should include a thorough history;
physical examination, including assessment of neurovascular status;
imaging; and appropriate immobilization via splinting or bracing.
The skin should be inspected for wounds that extend into fractures
or joints. Open injuries necessitate urgent irrigation and débridement
to minimize the chance of infection. Injured patients should be
monitored for traumatic compartment syndrome, especially in leg
and forearm fractures; immediate surgical fasciotomy is required to
prevent catastrophic sequelae. Following trauma, immobilization of
the injured body part provides pain relief, limits further bone and

6 Essentials of Musculoskeletal Care 5 © 2016 American Academy of Orthopaedic Surgeons

 Overview of General Orthopaedics

soft-tissue damage, and may aid in the definitive treatment. Injury Table 4
type and severity, along with patient-specific considerations, factor
into the decision of nonsurgical versus surgical management in Signs of Elder Abuse
musculoskeletal trauma.

SECTION 1 GENERAL ORTHOPAEDICS

Signs of Physical Abuse
Abrasions
Musculoskeletal Oncology Bruises
Primary bone malignancy is uncommon. Evaluation involves clinical, Fractures
laboratory, radiographic, and pathologic correlation. Metastatic bone Signs of Emotional Abuse
disease in adults is substantially more prevalent than primary bone
Overbearing caregiver
cancer. Malignancies frequently associated with bone metastasis
include breast, prostate, lung, kidney, and thyroid tumors. New-onset depression
Dementia-like behavior
Signs of Sexual Abuse
Abuse Signs of minor trauma to
Abuse involving children, spouses, or the elderly is a complex social
anogenital area
and medical problem. Recognizing abuse can prevent catastrophic
consequences; therefore, it is essential that the appropriate social Sexually transmitted disease
service agencies be notified when a patient’s injuries are recognized (STD)
as potentially resulting from abuse. Child abuse is discussed in Signs of Neglect
the Pediatric Orthopaedics section. Spouse or elder abuse may be Malnutrition
identified by recognizing the signs listed in Table 4. The complexity Failure to take medications
of these problems and the seriousness of the consequences demand Poor grooming
familiarity with them and with available community resources. Bedsores
Signs of Financial
Exploitation
Abrupt changes in finances
Failure to pay bills
Suspicious changes in legal
documents

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 7

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