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This question will help you distinguish nociceptive pain from radicular pain hip pain and axial low back pain are both nociceptive pain and must ultimately be distinguished during the physical examination. Common causes of hip pain include dislocation, fracture, and osteoarthritis. Axial low back pain with a referral pain pattern may also occur in the hip. Lower extremity dermatome patterns. A Anterior, B posterior. Radicular pain, by contrast, is band-like and more easily localized as it radiates down the leg.

Radicular symptoms over the anterior thigh that end at the knee are typically associated with the L3 nerve root. Radicular symptoms that extend over the medial knee, medial calf, and medial malleolus are typically associated with the L4 nerve root. Radicular symptoms that occur over the dorsum of the foot are typically associated with L5. Radicular symptoms that occur along the back of the thigh and the lateral heel are typically associated with S1.

It is rare to have radicular symptoms from S2 or below. Photo 1 demonstrates the characteristic dermatomes of the lower extremity Photo 1. Although knowing the location and distribution of pain is helpful, further questioning is necessary to determine if the pain is truly radicular, axial low back with or without a referral pattern , or hip pain. What is the quality of your pain e. This is the question that will definitively tell you if the patient has radicular pain or axial pain.

Radicular pain is sharp, shooting, and electric. Nociceptive pain axial low back and hip pain and referred pain are not sharp, shooting, or electric. This is an easy, and very important, distinction to make. How long have you had pain? This is a particularly important question for low back pain. Acute low back pain is defined as low back pain lasting less than 3 months and is much more likely to spontaneously resolve than chronic low back pain.

Therefore, aggressive diagnosis and treatment of acute low back pain may not be necessary. Do any positions aggravate or relieve your symptoms? Patients with radicular symptoms caused by spinal stenosis will classically complain of pain aggravated by leaning backward. These patients also have improved symptoms with trunk flexion.

By contrast, patients with a disc herniation causing radicular symptoms will report increased symptoms with trunk flexion. This is because trunk flexion increases the intradiscal pressure. This question is most useful for when you are deciding which diagnostic studies to order, if any, and for selecting treatment options. Have you experienced any recent night sweats, weight loss, hematuria, urinary retention, frequency, hesitancy, or cough? Do you have a history of cancer, overseas travel, recent surgery, fever, or increased pain at rest?

Has your pain ever woken you from sleep? These questions should be asked of every patient with low back, hip, or radicular symptoms in order to help screen more serious underlying conditions such as a tumor or infection. Have you had any recent change in bowel or bladder habits?

Do you have any altered sensation in your groin, buttocks, or inner thighs? These questions should be asked of every patient with suspected spinal pathology to help rule out cord impingement, conus medullaris, and cauda equina syndrome. Low Back, Hip, and Shooting Leg Pain 69 Physical Exam Having completed the history portion of your examination, you have distinguished whether or not your patient has nociceptive pain remember that low back and hip pain must be distinguished during the physical examination or radicular pain.

You have also begun to narrow your differential diagnosis. Is the gait antalgic i. Instruct the patient to stand on one foot and then the other. This is the Trendelenberg test, and it is performed to examine the integrity of the gluteus medius muscle. Stimulated positive Trendelenberg sign. Palpate the vertebral bodies. Tenderness over the vertebral bodies should prompt further investigation for a vertebral metastasis or compression fracture. Palpate the paraspinal muscles for any muscle spasms, tender points, or trigger points Note: Palpate the soft tissues over the posterior portion of the greater trochanter Photo 3.

Tenderness in this region may indicate trochanteric bursitis. Greater trochanter bursa palpation. Instruct the patient to stand on one leg and have the patient pull the opposite leg to the chest Photo 4. In a patient with a normal sacroiliac joint, the ipsilateral posterior superior iliac spine should move inferiorly. Repeat the test in the opposite leg. Next, instruct the patient to bend over as far as the patient can comfortably go. Trunk flexion increases intradiscal pressures. If bending over reproduces shooting leg pain or other radicular symptoms e. Next, instruct the patient to lean backwards as far as is comfortable.

This maneuver stresses the posterior elements of the spine. If extension or oblique extension reproduces shooting leg pain or other radicular symptoms, the patient may have foraminal stenosis. Ask the patient to stand on one leg and extend backward toward the supporting leg Photo 6. Repeat the test with the patient standing on the other leg.

This is the Stork Standing test, and if pain is reproduced with the test, the patient may have a pars interarticularis stress fracture spondylolisthesis. If the stress fracture is unilateral, standing on the ipsilateral leg and bending backwards toward that leg will be most painful. Next, have the patient sit down. Instruct the patient to lean forward and touch the chin to the chest.

Then, slowly extend the leg Photo 7. This is a dural tension test. If this maneuver Photo 6. Seated dural tension sign.

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Next, have the patient flex the hip against resistance Photo Have the patient extend the knee against resistance Photo Hip flexion against resistance. Knee extension against resistance. Knee flexion against Photo Ankle dorsiflexion against resistance. Next, have the patient flex the knee against resistance Photo Next, have the patient plantarflex against resistance Photo Have the patient extend the big toe against resistance Photo Ankle plantar flexion against resistance.

Big toe extension against resistance. In a patient with a suspected radiculopathy, extensor hallucis longus weakness is a specific clinical indicator for involvement of the L5 nerve root. With the patient still seated, it is convenient to test the reflexes. Test the patella reflex L4 and the Achilles reflex S1 Photos 16 and Test for an upper motor neuron deficit by evaluating for a Babinski reflex. To evaluate for this reflex, the examiner runs a sharp instrument along the plantar surface of the foot, starting at the calcaneus and moving along the lateral border and then curving around to the big toe Photo The patient has a Babinski reflex if the patient extends the big toe and flexes the rest of the toes.

If the patient flexes the big toe or if there is no reaction, then there is no Babisnki reflex. In patients without an upper motor neuron lesion, the Babinski reflex disappears around the first year of life. The presence of a Babinski reflex therefore indicates an upper motor neuron lesion. It is now appropriate to perform a quick test of sensation Photo The L3 dermatome is tested over the medial femoral condyle; the L4 dermatome is tested over the medial malleolus; the L5 dermatome is tested over the dorsal aspect of the third or fifth digit; and the S1 der- Photo Compare both sides of the body for symmetry and note any numbness or dysethesias.

Finally, with the patient still seated, check for pulses behind the knees in the popliteal arteries bilaterally and the posterior tibial arteries behind the medial malleolus bilaterally. Now have the patient lie in the supine position. Instruct the patient to adduct the hips against resistance Photo The Hoover test is helpful in identifying potential malingering patients.

Instruct the patient to lift one heel off the table. When the patient is truly attempting to lift the leg off the table, he or she will automatically put downward pressure on the opposite heel which you will feel in your palm. If the patient states that pain prevents them from 80 Musculoskeletal Diagnosis Photo Lower extremity dermatomes with dots indicate where to test for sensation. This is the straight leg-raise test. It is at this amount of flexion that the nerves are maximally stretched.

If the patient complains of pain but is unclear if the pain is radicular in nature, dorsiflex the ankle. If ankle dorsiflexion does not increase the symptoms, then the symptoms are more likely to be the result of hamstring tightness. Hip adduction against resistance. This is a convenient and effective way to test for hip pathology again. With the patient still lying in the supine position, perform the Thomas test to assess for tight hip flexors. To perform the Thomas test, have the patient lie in the supine position and flex one hip so that the patient is hugging one knee to the chest.

If the patient has a tight hip Photo Stimulated positive Thomas test. Low Back, Hip, and Shooting Leg Pain 83 flexor, the extended leg the leg being tested will lift off the table Photo If the patient does not have a tight hip flexor, the extended leg will remain flat on the table when the patient hugs the other knee to the chest Photo Next, test for a sacroiliac joint or hip injury by performing the Faber test. Faber is an acronym for flexion, abduction, and external rotation. If this produces pain in the inguinal region, the hip joint may be involved. Further stress the sacroiliac joint by pushing down on the flexed knee, as well as on the contralateral superior iliac spine.

If this maneuver produces pain, the sacroiliac joint may be involved. Next, have the patient lie on his or her side. Instruct the patient to abduct the hip against resistance Photo Hip abduction against resistance. Stimulated positive Ober test. Hip extension against resistance. Next, slowly allow the upper leg to fall to the table. If the iliotibial band is not tight, the leg will fall to the table Photo If the iliotibial band is tight, the upper leg will not fall to the table but instead, will remain in the air Photo This test also places stress on the femoral nerve, and if it invokes paresthesias in the leg, femoral nerve pathology should be considered.

If the test is performed with the knee extended, less stress is placed on the femoral nerve. Have the patient lie in the prone position and instruct the patient to extend the hip against resistance Photo This tests the gluteus maximus, which is innervated by the inferior gluteal nerve S1. Table 1 lists the major movements of the hip and leg, along with the involved muscles and their innervation.

With your patient still in the prone position, passively extend the hip and flex the knee. If this maneuver reproduces shooting leg pain, there may be a radiculopathy involving L2—L4. Primary innervation Femoral nerve primarily L3. Hip extension Gluteus maximus. Inferior gluteal nerve primarily S1. Hip adduction Adductor longus. Hip abduction Gluteus medius and Superior gluteal nerve gluteus minimus. Knee flexion Hamstrings Primarily tibial but also semimembranosus, peroneal portion of semitendinosus, biceps sciatic nerve femoris.

Knee extension Quadriceps vastus Femoral nerve lateralis, vastus medialis, primarily L4. Ankle dorsiflexion Tibialis anterior. Deep peroneal nerve primarily L4. Ankle plantarflexion Gastrocnemius, soleus. Tibial nerve primarily S1. Big toe extension Extensor hallucis longus. Deep peroneal nerve primarily L5. X-rays, including anteroposterior AP and lateral views, are indicated. Magnetic resonance imaging MRI is also indicated. Electrodiagnostic studies may be used to better localize the exact lesion and evaluate for a potential peripheral neuropathy.

Conservative treatment, including physical therapy, nonsteroidal anti-inflammatory drugs NSAIDs , and fluoroscopically guided epidural steroid injections, have shown good efficacy for treating most radiculopathies. Surgery is reserved for refractory cases or cases with progressive neurological deficiencies i.

Unless a more serious underlying cause is suspected e. Physical therapy, ergonomic training, heat, activity modification, and NSAIDs may be used as first-line therapy. Instructions on good back hygiene, including sleeping with a pillow beneath the knees when supine and using a pillow between the knees when sleeping on the side, should also be offered. If any specific muscle tightness was identified during the exam, special attention should be paid to stretching for those muscles. If trigger points are identified, trigger point injections of a local anesthetic and normal saline with or without corticosteroids may be helpful.

The physical exam may suggest a particular cause for chronic low back pain, but the physical exam will not be able to offer a conclusive diagnosis in the majority of cases of chronic low back pain. To diagnose most cases, it is necessary to perform a needle procedure. All of these diagnostic procedures are routinely done by an orthopedist, interventional physiatrist, or pain medicine specialist. Your history, physical exam, and radiographic findings are important in helping to guide your decision of which needle procedure to perform first.

Needle procedures should be performed as mentioned. X-rays, including AP and lateral views, are indicated. Oblique X-ray should be obtained if a pars interarticularlis fracture is suspected. MRI is also indicated. Conservative care similar to that for acute low back pain may be tried if the patient has not previously had a trial of conservative modalities. If a discogram reveals that the disc is the source of pain, intradiscal electrothermal annuloplasty is a minimally invasive needle procedure that has been shown to help more than half of all patients.

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Surgical options, including fusion surgery, are also available. If con- Low Back, Hip, and Shooting Leg Pain 89 trolled blocks reveal the Z-joint to be the source of pain, radiofrequency neurotomy is an effective needle procedure for denervating the joints and relieving the pain. AP-, lateral-, and oblique-view X-rays Note: Computed tomography CT may also be necessary, particularly if the lesion is suspected e. Physical therapy with emphasis on posture and body biomechanics training is instituted. Activity modification is also important. Bracing may be used. Surgery should generally be considered only in those patients who have failed conservative care.

If surgical fusion of the lesion is considered, a successful diagnostic block of the pars defect is a good predictor of a successful response to fusion. X-rays, including AP and lateral views, may be used to rule out a fracture or bony lesion. Ice, NSAIDs, heat, and physical therapy with emphasis placed on stretching the iliotibial band, hip flexors, and hip extensors may be used.

A trochanteric bursa injection of anesthetic and corticosteroid injection should be considered. Treatment is based on degree of morbidity. The cornerstone of conservative care includes reducing stressful activities, resting, weight reduction when appropriate , using ambulatory aides e. Oral glucosamine sulfate mg and chondroitin sulfate mg are useful when taken daily. Intra-articular injections of anesthetic and corticosteroid may also be helpful. The most common surgery for hip osteoarthritis is total hip replacement. Acetabular fractures are less common and typically require a high energy trauma.

Surgery is indicated, and the sooner the fracture is reduced, the better. X-rays, including AP and lateral views are indicated. Surgery is indicated, and the sooner the hip is reduced, the better. Pes anserinus bursitis, Osgood-Schlatter disease, osteochondritis dissecans, and fractures are among the other less likely causes you will need to consider. A basic history will help you narrow the diagnosis. This is a very high-yield question. Have your patient point to the most painful point, if possible.

Pain at the joint line is the result of a collateral ligament or meniscus problem or both until proven otherwise. When did your pain begin, what were you doing at the time, and what were the initial symptoms? In fact, having already ascertained the location of pain, knowing the mechanism of injury and From: If the patient has a ligament injury, the patient will report a deceleration injury or twisting the knee that led to immediate symptoms of swelling and pain.

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In contrast, patients with meniscus injuries may have a similar mechanism of injury twisting or deceleration , but the patient will not notice swelling if swelling occurs at all until minutes or hours after the injury. In an older patient, a meniscus injury may be more insidious and the patient may not recall an inciting traumatic event. Patients with fractures will generally report a history of trauma.

Pocket Guide to Musculoskeletal Diagnosis - PDF Free Download

Do you experience any grinding, locking, catching, or giving way of the knee? This question is the last general high-yield question for most cases of knee pain. Grinding is characteristic of osteoarthritis; locking and catching are characteristic of meniscus injuries and osteochondritis dissecans meniscus injuries are much more common than osteochondritis dissecans ; and giving way is more characteristic of ligamentous injuries. Are there any positions that make your knee more or less comfortable? This question is specifically targeting the diagnosis of patellofemoral syndrome. Patients with patellofemoral disorders classically report pain with prolonged knee flexion, and pain relief with knee extension.

Often, to relieve the pain, the patient will report extending the leg into the aisle. What is the quality of your pain sharp, shooting, dull, etc. Knee Pain 93 6. Have you tried anything to help the pain and, if yes, has that been successful? This question is more useful for when you are contemplating diagnostic tests and treatment strategies. Other important questions to remember to ask include: Have you ever had surgery on your knee? Do you have any hip or ankle pain both hip and ankle pain can refer pain to the knee, and vice versa?

Physical Exam Having completed the history portion of your clinical exam, you are ready for the physical examination. Is the gait antalgic does the patient favor one leg over the other? This may not actually help you with the diagnosis, but it will help you gage the degree of impairment, guide what imaging studies to order, and help form your ultimate treatment plan. The Q-angle is formed by drawing an imaginary line from the anterior superior iliac spine to the center of the patella.

This line is intersected by a second line from the tibial tuberosity to the center of the patella and continues superiorly along the center of the anterior thigh Photo 1. The intersection of these two lines is called the Q-angle. Do not split hairs over angles. An abnormal Q-angle reflects abnormal patellar tracking and suggests an underlying patellofemoral disorder. Excessive lateral tracking is another indication of patellofemoral syndrome. Palpate under and around the patella with the knee in full extension the knee must be in extension to allow palpation under the surface of the patella.

Tenderness in this region is indicative of patellofemoral syndrome. Crepitus may be an incidental finding, but it is also consistent with osteoarthritis and patellofemoral syndrome. Pain and tenderness at the tibial tubercle in young individuals is consistent with Osgood- 94 Musculoskeletal Diagnosis Photo 1. Palpate posteromedial to the tibial tubercle approximately 2 inches below the joint line Photo 2.

This area is the pes anserinus, and it is the point at which the tendons of the sartorius, gracilis, and semitendinosus muscles attach to the tibia. These muscles can be remembered by the convenient pneumonic: Say Grace Before Tea. A bursa overlies the insertion of these tendons and can become inflamed. Tenderness at this point reflects inflammation in the bursa. Tenderness along the medial joint line suggests an injury of the medial meniscus or medial collateral ligament. Tenderness along the lateral joint line suggests a lateral meniscus or lateral collateral ligament injury.

Knee Pain 95 Photo 2. Next, palpate the popliteal fossa and appreciate the pulsation of the popliteal artery. This tests the quadriceps, which are innervated by the femoral nerve L2—L4. Next, have the patient bring the ankle underneath the table flexing the knee against resistance Photo 4. The common peroneal portion of the sciatic nerve L5—S2 innervates the short head of the biceps femoris. Table 1 lists the major movements of the knee, along with the involved muscles and their innervation. Knee flexion against resistance. Quadriceps vastus lateralis, vastus medialis, vastus intermedius, rectus femoris.

Primarily tibial, but also peroneal portion of sciatic nerve primarily L5. Femoral nerve primarily L4. Next, test the patellar reflex L4. With the patient still seated, test for stability of the medial collateral ligament MCL. Remember to keep your hand cupped around the lateral aspect of the joint in order to appreciate gapping, if present Photo 6. Next, have the patient lie in the supine position while you check for an effusion. If there is a large amount of fluid, the fluid will redistribute and push the patella into its former position.

If this happens, it is called a ballotable patella. A ballotable patella is a sign of a major effusion. To check for a smaller effusion, 98 Musculoskeletal Diagnosis Photo 5. Valgus stress to test the medial collateral ligament. Varus stress to test lateral collateral ligament. Knee Pain 99 you may need to milk the fluid from the suprapatellar pouch and the lateral side of the knee over to the medial side of the knee. Then, you would release the fluid and tap the medial aspect of the knee. In the next few seconds, if an effusion is present, then the fluid will redistribute laterally and a fullness will develop on the lateral side of the knee.

Now, test for an anterior cruciate ligament ACL tear. The most sensitive clinical test for an ACL tear is the Lachman test. First, test the normal leg to establish the baseline endpoint. This is important because a few degrees of anterior glide of the tibia on the femur may be normal. Next, test the pathologic leg. Increased glide or a loose endpoint suggests an ACL tear. The anterior drawer test is a similar test that should also be performed to evaluate for an ACL injury. If the tibia slides forward from under the femur more than a few degrees, there may be a tear in the ACL.

Repeating the maneuver with the leg in external rotation should tighten the posteromedial portion of the capsule. Repeating the test with the leg in internal rotation tightens the posterolateral capsule. The posterior sag sign is also used to evaluate for a PCL injury. In a patient with a PCL tear, the tibia will posteriorly translate on the femur. A torn meniscus is a common injury. Tenderness to palpation at the joint line which you have already assessed is a good indication that Knee Pain Photo 9. A few special tests are very useful to further investigate the menisci. The McMurray test was designed to diagnose a tear in the posterior medial meniscus because the posterior horn of the medial meniscus is difficult to palpate.

To perform the McMurray test, the examiner instructs the patient to lie supine with legs extended. The examiner then slowly extends the knee, maintaining the leg in external rotation and under valgus stress Photo Another good test to help differentiate between a meniscus tear and a collateral ligament tear is the Apley compression and distraction test.

To perform this test, the patient is instructed to lie in the prone position. Knee Pain Photo This is the Apley Compression test. When this maneuver elicits medial pain, the patient may have a medial meniscus or ligament tear. When this maneuver elicits pain on the lateral side, the patient may have a lateral meniscus or ligament tear. To help differentiate a torn meniscus from a torn ligament, the Apley distraction test is performed next.

This maneuver unloads the pressure from the meniscus. Therefore, if this maneuver also elicits pain, the pain is likely coming from an injured ligament and not the meniscus. OCD is a condition in which a fragment of cartilage and subchondral bone separates from an intact articular surface. Knee Pain rotates the leg, moving the tibial spine away from the medial femoral condyle. The following are some general recommendations for what to do next: X-rays, including anteroposterior AP , lateral, and sunrise views, are taken to rule out fracture.

Magnetic resonance imaging MRI may be ordered to better delineate the injury. Bracing, nonsteroidal anti-inflammatory drugs NSAIDs , and physical therapy emphasizing strengthening and stretching the quadriceps and hamstrings, is first-line treatment. Depending on the extent of injury, surgical reconstruction may be necessary. X-rays, including AP, lateral, and sunrise views, should be obtained. MRI may be ordered to delineate the injury. First-line treatment includes rest, ice, physical therapy emphasizing quadriceps strengthening and stretching, and bracing. Depending on the extent of injury, surgery may be required.

MRI may be ordered when an associated injury is suspected. First-line treatment includes rest, ice, elevation of the joint, physical therapy emphasizing stretching and strengthening exercises, bracing, and crutches until weight-bearing is comfortable. Surgery is rarely necessary. MRI may also be helpful. First-line treatment includes rest, ice, NSAIDs, and physical therapy emphasizing stretching and strengthening the quadriceps. Surgery may be required depending on the extent of injury. MRI should also be obtained to better evaluate the extent of injury.

Arthroscopy is the gold standard diagnostic tool for meniscal tears but may not be necessary. Small tears may be treated conservatively with rest, ice, bracing, and physical therapy. Larger tears and tears in patients who are competitive athletes and wish to return to competitive sport may require surgery. Surgery should be reserved for patients who fail to respond to at least several months of aggressive conservative care.

Conservative care, including rest, weight loss when appropriate , physical therapy—including nonimpact exercises, such as swimming—acetaminophen, NSAIDs, heat modalities, activity modification, ambulatory aids, such as a cane, should be used. Topical analgesic therapy with methylsalicylate or capsaicin cream may be beneficial. Oral glucosamine sulfate mg and chondroitin sulfate mg taken daily are also helpful. Intra-articular injections of hyaluronic acid improve symptoms temporarily but typically need to be repeated periodically about once every 6 months. Intra-articular injec- Knee Pain tions of corticosteroid and anesthetic may also be helpful.

Surgical options are reserved for persistent or severe symptoms and include arthroscopy, osteotomy, and total knee replacement. X-rays, including AP and lateral views, may be obtained to rule out a more serious underlying process. NSAIDs, activity modification, knee pads, and a corticosteroid and anesthetic injection may be helpful. X-rays, including AP and lateral views, may be obtained to rule out a more serious underlying disorder.

NSAIDs, rest, activity modification, physical therapy emphasizing stretching and strengthening of the hamstrings and quadriceps and a corticosteroid and anesthetic injection may be helpful. Conservative care includes physical therapy and bracing. Depending on the age of the patient and extent of injury, surgery may be necessary. Adults generally require surgery, whereas children and adolescents with skeletally immature bones may be treated conservatively.

X-rays, including AP and lateral views, may be obtained. Less common problems that you must still consider include capsular injury, posterior tibial tendonitis, tarsal tunnel syndrome, osteochondritis dissecans OCD , and anterior impingement syndrome. The history and physical examination will help you narrow your differential diagnosis. This is a high-yield question. Lateral pain suggests a ligament injury or a possible fracture.

Medial pain suggests a ligament injury rare on the medial side , possible fracture, or posterior tibial tendonitis. Anterior pain suggests anterior capsule injury or anterior bony impingement. Posterior pain suggests Achilles tendinitis. OCD may occur on the lateral or medial aspect of the ankle, but it is a relatively uncommon disorder. When did your pain begin and what were you doing at the time?

Almost all ankle sprains are lateral sprains and occur after an inversion injury. The typical history a patient will give is falling over a turned-in inverted ankle while playing a sport or walking in the street. However, if the patient suffered an ankle fracture, he or she will give a history of a more significant trauma, such as participation in a sporting event in which another player fell on the ankle.

If the patient has an anterior capsular strain, the patient may be a softball or baseball player who was injured during a hook-slide into a base. If the patient has Achilles tendonitis, he or she may be a runner, dancer, or other athlete who complains of gradually increasing pain in the Achilles tendon that is made worse with activity. If the patient has posterior tibial tendonitis, the patient is probably a young runner who presents with a complaint of pain at the medial aspect of the ankle with weight-bearing. The patient will report that the pain is worse in the morning and also increases with activity.

If the patient has anterior bony impingement syndrome, the patient may be a dancer or basketball player who recalls a history of trauma leading to acute pain followed by chronic, vague pain that is made worse on landing from jumps. Do you experience any locking or catching in your ankle? I find the content quite superficial and incomplete. For example the chapter on shoulder pain does not make a distinction between intrinsic and extrinsic shoulder pain.

Tips based on pain location are limited to distinguishing between rotator cuff tendinitis and bicipital tendinitis. About the kindle edition. The content does not seem fully digital. You can adjust font size and search the book, however, you cannot change the font face, and characters are poor quality. Images, are OK, but I would expect more from a digital edition. One person found this helpful. Easier to buy on-line than in-store.

I read the 1 star review and agree that there are some issues, but they are very few and far between. It is simple and quick. It is not quite as "pockety" as I'd thought it would be. It is thin, but at 8. Never-the-less, it is an easy concise reference that I am already using a lot. The book shown has wonderful color photographs and is published by Humana Press shown on the cover , but the book you actually received is published by Springer which I think owns Humana now No CD is included, and worst of all, the photographs are very poor quality black and white photographs, printed on poor quality paper the type of paper you would expect a paperback novel to have.

Now, the content is still great. And if the photographs where the amazing color ones shown, the book would be fantastic. But to charge almost fifty dollars for a book that less than half an inch thick and of such poor quality printing and paper is quite absurd. Based on past comments, it sounds like if you order the older version of this text then of the same ISBN, I believe, but it'll say "Humana Press" on the cover, as the photograph shows , then perhaps you'll get a book with wonderful color photographs.

I just received an older version of the text that I bought used through Amazon.

A pocket guide to musculoskeletal diagnosis

Now, while this version also has black and white photographs, they are of a much better quality, and so is the paper. I'm much happier with this version of the text. While still expensive considering the size, I'm now happy to change my review to 5 stars--I feel this is a great text for a medical student who is learning about MSK diagnosis. This book has excellent pictures and descriptions.

Not for a novice reader. It is expensive for a paperback, but the information is very accurate and useful. Good book, but more color pics would have been nice for the price. I'm a student FNP and this book is extremely helpful! So glad I bought it! Great book to carry for daily usage!

Especially a help for those who are in Ortho and Occ Med! Quick and easy to read! The author then discusses very basic procedures for managing and treating many disorders in each body area eg, shoulder. We have few criticisms of this publication. The pocket guide would have benefited from illustrations of the basic anatomy of each body area. Also, the author has been superficial in detailing the management of many ailments. Some would disagree with the notion of using modalities that are not evidence-based eg, oral glucosamine for managing osteoarthritis of the hip.

Further, the book mentions the importance of the Q angle of the knee as reflecting disordered tracking of the patella even though this idea remains highly controversial. Nonetheless, Dr Cooper has provided a rather tidy booklet outlining his experiences with many disorders and injuries of the locomotor system.