Shoulder Pain (Adult & Pediatric)

Assessment: Shoulder pain, differential includes: rotator cuff injury, bursitis,

impingement, fracture/dislocation, referred pain from neck, inflammatory causes.

1. Tests / Physical Exam

a. Drop Arm Test

How to perform: Patient abducts arm to 90°, slowly lowers it.

Positive: Arm drops suddenly or patient cannot control lowering → suspect rotator
cuff tear.

Negative: Arm lowers smoothly → rotator cuff tear less likely.

Plan:

Positive → order shoulder MRI, refer to orthopedics.

Negative → proceed with conservative management (ice, NSAIDs, gentle PT).

b. Neer Impingement Test

How to perform: Stabilize scapula, passively elevate arm forward.

Positive: Pain in shoulder → suspect impingement/bursitis.

Negative: No pain → impingement less likely.

Plan:

Positive → start PT, anti-inflammatory measures; consider orthopedic referral if no

improvement in 4–6 weeks.

Negative → evaluate for other causes (cervical referral if nerve symptoms).

c. Hawkins-Kennedy Test

How to perform: Flex shoulder and elbow to 90°, internally rotate arm.

Positive: Pain → suspect subacromial impingement.

Plan: Same as above.

d. Shoulder X-ray

When: Trauma, suspected fracture/dislocation, chronic pain unresponsive to

conservative care.

Positive (fracture/dislocation): Refer to orthopedics urgently.

Negative: Rule out bony injury; proceed with soft tissue management.

e. Ultrasound (if available)

When: Evaluate rotator cuff, bursitis, effusions.

Positive: Tear or fluid collection → refer to orthopedics.

Negative: Suggests soft tissue strain; treat conservatively.

f. Range of Motion & Strength Testing

Document active vs passive motion, strength deficits, tenderness.

Guides PT, activity modification, or referral.

-----------------

Management / Plan Actions

Conservative Care (first-line if no red flags):

Ice 10–15 min 2–3x/day

OTC NSAIDs if no contraindication

Gentle ROM exercises; avoid overhead lifting

Educate patient on posture, activity modification

Referrals:

Physical therapy: If pain persists >2 weeks, positive impingement tests, or

functional limitation.

Chiropractor: Only if musculoskeletal strain/poor posture suspected, no fracture or

red flag signs.

Orthopedics: Positive rotator cuff tear, fracture, dislocation, persistent pain >4–
6 weeks despite PT.

Patient Education:

Explain what the test is checking for.

Describe expected recovery with conservative care.

Advise red flags: sudden swelling, severe pain, numbness, inability to move arm →
go to ER.

For children: reassure parents, explain exercises, and monitor for activity
limitations.

3. Follow-Up

1–2 weeks: Check response to conservative measures.

4–6 weeks: Reassess; if persistent pain or positive test results → refer to

specialist.

Document test results, patient understanding, and plan in chart.

----------
Wrist Pain (Adult & Pediatric)

Assessment: Wrist pain, differential includes: sprain/strain, fracture, tendonitis

(De Quervain’s, extensor/flexor tendons), carpal tunnel syndrome, arthritis,
ganglion cyst, referred pain from forearm/elbow/neck.

1. Tests / Physical Exam

a. Finkelstein’s Test

How to perform: Patient makes a fist with thumb inside, ulnar deviation of wrist.

Positive: Pain over radial wrist → suspect De Quervain’s tenosynovitis.

Negative: No pain → De Quervain’s less likely.

Plan:

Positive → splint thumb/wrist, NSAIDs, refer to hand therapy/orthopedics if

persistent.

b. Tinel’s Sign (for carpal tunnel)

How to perform: Tap over median nerve at wrist.

Positive: Tingling or numbness in thumb, index, middle → suspect carpal tunnel

syndrome.

Negative: No symptoms → carpal tunnel less likely.

Plan:

Positive → wrist splint, ergonomic modification, consider referral to PT or hand

specialist.

c. Phalen’s Test

How to perform: Patient flexes wrists, presses backs of hands together for 30–60
sec.

Positive: Tingling/numbness → supports carpal tunnel.

d. Wrist X-ray

When: Trauma, suspected fracture, persistent pain.

Positive: Fracture or dislocation → orthopedic referral.

Negative: Rule out bony injury; consider soft tissue causes.

e. Range of Motion & Strength Testing

Document active vs passive motion, grip strength, swelling, tenderness.

Helps guide PT or splinting.

2. Management / Plan Actions

Conservative Care:

Rest, avoid aggravating activities

Ice 10–15 min, 2–3x/day

NSAIDs if no contraindication

Splinting (especially for De Quervain’s or carpal tunnel)

Gentle ROM exercises as tolerated

Referrals:

Physical therapy / hand therapy: Persistent pain, limited function, positive

Finkelstein/Tinel/Phalen.

Chiropractor: Only for musculoskeletal strain without fracture.

Orthopedics / hand specialist: Fractures, dislocations, persistent or severe pain,

suspected tendon rupture, or nerve compression not improving with conservative
care.

Patient Education:

Explain purpose of each test and what a positive/negative result means.

Educate on activity modification, splint use, and signs of worsening nerve

involvement (numbness, weakness).

Advise red flags: sudden swelling, deformity, inability to move fingers/wrist → go

to ER.

For children: instruct parents on monitoring and safe exercises, avoid rough play
until healed.

3. Follow-Up

1–2 weeks: Reassess response to conservative care.

4–6 weeks: Persistent pain or functional limitation → consider referral.

Document tests performed, results, patient understanding, and plan in chart.

--------------

Elbow Pain (Adult & Pediatric)

Assessment: Elbow pain, differential includes: lateral epicondylitis (tennis

elbow), medial epicondylitis (golfer’s elbow), bursitis, tendonitis, sprain/strain,
fracture, arthritis, nerve entrapment (ulnar or radial), referred pain from
shoulder or neck.

1. Tests / Physical Exam

a. Cozen’s Test (Lateral Epicondylitis)

How to perform: Patient makes a fist, pronates forearm, extends wrist against
resistance.
Positive: Pain over lateral epicondyle → suspect lateral epicondylitis.

Negative: No pain → lateral epicondylitis less likely.

Plan:

Positive → rest, ice, NSAIDs, PT, consider elbow brace, refer to orthopedics if no
improvement in 4–6 weeks.

b. Medial Epicondylitis Test (Golfer’s Elbow)

How to perform: Resisted wrist flexion with forearm supinated.

Positive: Pain over medial epicondyle → suspect medial epicondylitis.

Plan: Same as above.

c. Tinel’s Sign (Ulnar Nerve at Elbow)

How to perform: Tap over ulnar nerve at cubital tunnel.

Positive: Tingling/numbness in 4th and 5th fingers → suspect ulnar nerve

entrapment.

Negative: No symptoms → less likely.

Plan:

Positive → activity modification, elbow pad, refer to PT or orthopedic specialist

if persistent.

d. Valgus / Varus Stress Test

How to perform: Apply medial and lateral stress with elbow slightly flexed.

Positive: Pain or laxity → suspect ligament injury.

Plan: Acute injury → consider X-ray or MRI, orthopedic referral.

e. Elbow X-ray

When: Trauma, suspected fracture, dislocation, chronic pain unresponsive to

conservative care.

Positive: Fracture or dislocation → urgent orthopedic referral.

Negative: Rule out bony injury; treat soft tissue conservatively.

f. Range of Motion & Strength Testing

Assess flexion, extension, pronation, supination, grip strength.

Guides PT, splinting, or referral decisions.

2. Management / Plan Actions

Conservative Care:
Rest and activity modification

Ice 10–15 min, 2–3x/day

NSAIDs if no contraindications

Elbow brace or counterforce strap for epicondylitis

Gentle stretching and strengthening exercises as tolerated

Referrals:

Physical therapy: Persistent pain, positive epicondylitis or nerve tests,

functional limitation.

Chiropractor: Only for musculoskeletal strain without fracture or nerve

compression.

Orthopedics: Fracture, dislocation, persistent or severe pain, tendon rupture, or

nerve entrapment not improving with conservative care.

Patient Education:

Explain purpose of each test and meaning of positive/negative results.

Educate on activity modification, splinting, and exercises.

Advise red flags: swelling, numbness, weakness, inability to move elbow → go to ER.

For children: instruct parents on monitoring and safe activity restrictions.

3. Follow-Up

1–2 weeks: Assess response to conservative care.

4–6 weeks: Persistent pain or functional limitation → consider referral.

Document tests performed, results, patient understanding, and plan in chart.

------------

Pointing Finger Pain / Limited ROM (Adult & Pediatric)

Assessment: Pain and limited motion in a finger, differential includes: trigger

finger (stenosing tenosynovitis), flexor tendon injury, ligament sprain, arthritis
(osteoarthritis or juvenile), fracture, infection (septic tenosynovitis), or
referred pain from hand/wrist.

1. Tests / Physical Exam

a. Trigger Finger Test

How to perform: Patient actively flexes and extends finger; palpate A1 pulley at
base of finger.

Positive: Finger catches or locks → suspect trigger finger.

Negative: Smooth motion → less likely trigger finger.

Plan:

Positive → activity modification, splinting, NSAIDs; refer to hand therapy or

orthopedics if persistent or severe.

b. Flexor / Extensor Tendon Test

How to perform: Isolate movement of each joint (MCP, PIP, DIP) and resist motion.

Positive: Inability to flex or extend → suspect tendon injury.

Plan: Urgent orthopedic / hand referral, possible imaging.

c. Ligament / Collateral Stress Test

How to perform: Apply lateral stress to PIP or DIP.

Positive: Pain or laxity → suspect sprain or ligament tear.

Plan: Immobilize with splint, refer if severe.

d. X-ray of Finger

When: Trauma, persistent pain, swelling, deformity, limited ROM.

Positive: Fracture, dislocation, bone abnormality → orthopedic referral.

Negative: Suggest soft tissue problem → conservative care or further imaging

(ultrasound, MRI).

e. Range of Motion Assessment

Assess active and passive flexion/extension at MCP, PIP, DIP.

Guides splinting, exercises, and therapy plan.

2. Management / Plan Actions

Conservative Care:

Rest, avoid repetitive gripping or pinching activities

Splinting / buddy taping as indicated

NSAIDs if no contraindication

Gentle ROM exercises once pain allows

Referrals:

Hand therapy / occupational therapy: Persistent pain, stiffness, or trigger finger.

Chiropractor: Only for minor musculoskeletal strain without fracture or

tendon/nerve compromise.

Orthopedics / hand surgeon: Tendon injury, severe ligament injury, fracture, locked
trigger finger, persistent pain >4–6 weeks.

Patient Education:
Explain purpose of each test and meaning of positive/negative results.

Educate on activity modification, splinting, and safe finger exercises.

Advise red flags: severe pain, swelling, redness, inability to move finger,
numbness → seek urgent care.

For children: instruct parents on monitoring, gentle exercises, and limiting rough
play until resolved.

3. Follow-Up

1–2 weeks: Check response to splinting and activity modification.

4–6 weeks: Persistent pain, locking, or functional limitation → consider referral

to hand therapy or orthopedics.

Document tests performed, results, patient understanding, and plan in chart.

-----------

Ulna Pain (Adult & Pediatric)

Assessment: Ulna pain, differential includes: fracture (ulnar shaft, distal ulna),
stress fracture, tendonitis (extensor/flexor carpi ulnaris), ulnar nerve
entrapment, arthritis, bursitis (olecranon), trauma-related soft tissue injury,
referred pain from elbow or wrist.

1. Tests / Physical Exam

a. Palpation and Tenderness Assessment

How to perform: Palpate along ulna from elbow to wrist, check for tenderness,
swelling, deformity.

Positive: Localized pain → may suggest fracture, tendon injury, or bursitis.

Plan: If trauma history → order X-ray; if no trauma → consider tendonitis or nerve

entrapment.

b. Ulnar Nerve Assessment (Tinel’s at Elbow/Wrist)

How to perform: Tap over ulnar nerve at cubital tunnel or Guyon’s canal.

Positive: Tingling/numbness along ulnar distribution → suspect ulnar nerve

entrapment.

Plan: Activity modification, splinting, refer to PT or orthopedics if persistent.

c. Forearm Rotation / Muscle Testing

How to perform: Resist forearm pronation and supination, test wrist

flexion/extension.

Positive: Pain → suspect muscle/tendon strain or tendonitis.

Plan: Rest, ice, NSAIDs, PT for strengthening/stretching.

d. X-ray
When: Trauma, deformity, persistent pain.

Positive: Fracture or dislocation → urgent orthopedic referral.

Negative: Suggests soft tissue cause → conservative care, consider ultrasound or

MRI if tendon/nerve involvement suspected.

e. Range of Motion & Strength Testing

Assess wrist/forearm/elbow motion, grip strength.

Guides conservative therapy or referral decisions.

2. Management / Plan Actions

Conservative Care:

Rest and activity modification

Ice 10–15 min 2–3x/day

NSAIDs if no contraindications

Splint or brace if needed (especially for tendonitis or nerve irritation)

Gentle stretching and strengthening once pain allows

Referrals:

Physical therapy: Persistent pain, tendonitis, nerve irritation, functional

limitation.

Chiropractor: Only for musculoskeletal strain without fracture or nerve compromise.

Orthopedics: Fracture, dislocation, severe tendon/nerve injury, persistent pain >4–

6 weeks.

Patient Education:

Explain purpose of each test and meaning of positive/negative results.

Educate on activity modification, splinting, and exercises.

Advise red flags: sudden swelling, deformity, numbness, inability to move

hand/wrist → go to ER.

For children: instruct parents on monitoring, gentle activity restriction, and safe
exercises.

3. Follow-Up

1–2 weeks: Assess response to conservative care.

4–6 weeks: Persistent pain, limited motion, or functional impairment → referral to

PT or orthopedics.

Document tests performed, results, patient understanding, and plan in chart.

---------------------

Lower Back Pain (Adult & Adolescent)

Assessment: Lower back pain, differential includes: muscle strain, ligament injury,
herniated disc, degenerative disc disease, facet joint arthropathy, sciatica,
spinal stenosis, spondylolisthesis, inflammatory conditions (e.g., ankylosing
spondylitis), kidney/urinary causes, or referred pain.

1. Tests / Physical Exam

a. Straight Leg Raise (SLR) Test

How to perform: Patient lies supine; lift leg with knee extended.

Positive: Radiating pain down leg → suspect lumbar disc herniation / nerve root
compression.

Negative: No leg pain → disc herniation less likely.

Plan:

Positive → consider MRI if severe or persistent, refer to orthopedics / neurology.

Negative → manage conservatively, monitor symptoms.

b. Patrick / FABER Test

How to perform: Flex, ABduct, External Rotate hip while patient supine; apply
gentle pressure.

Positive: Pain in lower back or SI joint → suspect sacroiliac joint dysfunction.

Plan: Conservative care, PT, consider chiropractic referral if musculoskeletal.

c. Palpation & Range of Motion

Assess lumbar spine, paraspinal muscles, tenderness, flexibility, and muscle spasm.

Guides therapy and referral decisions.

d. Neurologic Exam

Check strength, sensation, reflexes in lower extremities.

Positive findings → consider nerve compression or radiculopathy, refer to neurology

/ orthopedics.

e. Imaging (X-ray / MRI)

When: Trauma, neurologic deficits, persistent pain >4–6 weeks, or red flags (fever,
weight loss, incontinence).

X-ray Positive: Fracture, spondylolisthesis → orthopedic referral.

MRI Positive: Disc herniation, nerve compression → orthopedic / neurology referral.

Negative: Suggests muscular or nonspecific back pain → conservative care.

2. Management / Plan Actions

Conservative Care (first-line for non-red flag cases):

Activity modification, avoid heavy lifting initially

Heat or ice 15–20 min, 2–3x/day

OTC NSAIDs if no contraindication

Gentle stretching and core strengthening exercises

Educate on proper posture, ergonomics

Referrals:

Physical therapy: Persistent pain, limited motion, or positive SLR/FABER tests.

Chiropractor: Musculoskeletal strain without neurologic deficit or fracture.

Orthopedics / Neurology: Neurologic deficits, severe radiculopathy, suspected

fracture, persistent pain >6 weeks, or imaging findings.

Patient Education:

Explain purpose of each test and interpretation of positive/negative results.

Discuss activity modification, posture, and home exercises.

Advise red flags: numbness, weakness, bowel/bladder changes, severe unrelenting

pain → seek urgent care.

For adolescents: instruct parents on safe activity limits and encourage appropriate
physical activity.

3. Follow-Up

1–2 weeks: Reassess pain, mobility, and response to conservative care.

4–6 weeks: Persistent pain or neurologic symptoms → referral to PT, orthopedics, or

neurology.

Document tests performed, results, patient understanding, and plan in chart.

----------------

Rib Pain (Adult & Pediatric)

Assessment: Rib pain, differential includes: musculoskeletal strain,

costochondritis, rib fracture, intercostal muscle strain, pleuritic pain
(pneumonia, pleurisy), pulmonary embolism, shingles (herpes zoster), referred pain
from spine or abdomen, or less commonly cardiac causes.

1. Tests / Physical Exam

a. Palpation / Tenderness Assessment

How to perform: Palpate ribs and costal cartilage along the anterior, lateral, and
posterior chest wall.
Positive: Localized tenderness → suggests musculoskeletal or costochondral pain.

Negative: No tenderness → consider pulmonary, cardiac, or referred causes.

Plan:

Positive → conservative care, activity modification, PT if needed.

Negative → evaluate for visceral causes.

b. Rib Compression Test / Chest Wall Movement

How to perform: Gently compress ribs from front/back or laterally.

Positive: Pain → suspect rib fracture or costochondritis.

Negative: Less likely fracture; consider soft tissue or referred pain.

c. Breathing / Cough Assessment

How to perform: Observe for pain with deep inspiration or cough.

Positive: Sharp pain with inspiration → consider pleuritic pain, rib fracture, or
intercostal strain.

d. Imaging (X-ray / CT if indicated)

When: Trauma, persistent pain >1–2 weeks, suspected fracture, or red flags
(difficulty breathing, chest trauma).

X-ray Positive: Rib fracture → orthopedic or trauma referral.

Negative: Suggests soft tissue injury, costochondritis, or musculoskeletal strain →

conservative care.

e. Additional Considerations

Assess for shingles if rash develops along a dermatome.

Evaluate for referred pain from lungs, heart, or upper abdomen if atypical
features.

2. Management / Plan Actions

Conservative Care (for musculoskeletal / costochondral pain):

Rest, avoid heavy lifting or twisting movements

Ice 10–15 min, 2–3x/day

OTC NSAIDs if no contraindication

Gentle stretching as tolerated

Referrals:

Physical therapy: Persistent musculoskeletal pain, posture-related rib strain.

Chiropractor: Musculoskeletal strain without fracture or organ involvement.

Orthopedics / trauma: Rib fracture, severe trauma, persistent pain.

Other specialists: Pulmonology, cardiology, or infectious disease if non-

musculoskeletal causes suspected.

Patient Education:

Explain tests performed and what positive/negative results indicate.

Advise on activity modification, proper posture, and gentle movement.

Red flags: difficulty breathing, chest tightness, fever, severe pain → seek urgent
care.

For children: advise parents on safe play and monitoring for worsening pain.

3. Follow-Up

1–2 weeks: Reassess pain and functional status.

4–6 weeks: Persistent pain, new symptoms, or fracture confirmed → referral to PT or

orthopedics.

Document tests performed, results, patient understanding, and plan in chart.

-------------------------

Sciatica Pain (Adult & Adolescent)

Assessment: Sciatica (pain radiating along the sciatic nerve), differential

includes: lumbar disc herniation, spinal stenosis, spondylolisthesis, piriformis
syndrome, muscle strain, or less commonly, tumor/infection causing nerve
compression.

1. Tests / Physical Exam

a. Straight Leg Raise (SLR) Test

How to perform: Patient lies supine; lift one leg with knee extended.

Positive: Radiating pain down leg along sciatic distribution → suspect lumbar disc
herniation / nerve root compression.

Negative: No radiating pain → disc herniation less likely.

Plan:

Positive → consider lumbar MRI if pain severe/persistent, refer to orthopedics or

neurology.

Negative → evaluate for muscular or piriformis syndrome.

b. Slump Test (optional for quick in-office assessment)

How to perform: Patient seated, slumps forward, extends one leg at the knee.

Positive: Radiating leg pain → supports nerve tension.

c. Neurologic Exam

Test lower extremity strength, sensation, and reflexes (patellar, Achilles).

Positive deficits → urgent neurology/orthopedic referral.

d. Imaging (X-ray / MRI)

When: Red flags (weakness, bowel/bladder changes, trauma), or persistent pain >4–6
weeks.

MRI Positive: Herniated disc, nerve compression → specialist referral.

Negative: Suggests non-structural causes → conservative care.

2. Management / Plan Actions

Conservative Care (first-line if no red flags):

Activity modification (avoid prolonged sitting, heavy lifting)

Heat/ice as tolerated

OTC NSAIDs if no contraindication

Gentle stretching, core strengthening, low-impact exercise

Educate patient on ergonomics and posture

Referrals:

Physical therapy: Persistent pain, positive SLR, limited function, or muscular

strain.

Chiropractor: Musculoskeletal origin, no neurologic deficits.

Orthopedics / neurology: Significant weakness, bowel/bladder changes, persistent or

severe radiating pain, MRI-confirmed nerve compression.

Patient Education:

Explain purpose of SLR and neurologic tests, and what positive/negative results
indicate.

Educate on activity modification, exercises, and posture.

Red flags: severe leg weakness, numbness, loss of bowel/bladder control → seek
urgent care immediately.

For adolescents: parents should monitor activity and encourage safe movement.

3. Follow-Up

1–2 weeks: Assess response to conservative care.

4–6 weeks: Persistent pain, neurologic symptoms, or functional limitation →

referral to PT or specialist.
Document tests performed, results, patient understanding, and plan in chart.

---------------------

Hip Pain (Adult & Pediatric)

Assessment: Hip pain, differential includes: osteoarthritis, labral tear, bursitis

(trochanteric), hip impingement, muscle/tendon strain, ligament injury, fracture,
referred pain from spine or knee, inflammatory arthritis, or pediatric conditions
(SCFE, Legg-Calvé-Perthes disease).

1. Tests / Physical Exam

a. Trendelenburg Test

How to perform: Patient stands on one leg, lift opposite leg.

Positive: Pelvic drop on opposite side → suspect gluteus medius weakness or hip
abductor dysfunction.

Negative: Stable pelvis → abductor function intact.

Plan:

Positive → PT referral for strengthening and gait training.

b. FABER Test (Flexion, ABduction, External Rotation)

How to perform: Patient supine, place hip in figure-4, gently press down on knee.

Positive: Pain in groin → suspect hip joint pathology; pain in posterior hip →
sacroiliac involvement.

Plan: Positive → imaging or PT depending on location and severity.

c. Log Roll Test

How to perform: Supine, roll leg internally/externally.

Positive: Pain or restricted rotation → intra-articular hip pathology.

d. Palpation & Range of Motion

Assess hip flexion, extension, internal/external rotation, abduction/adduction,

tenderness over greater trochanter, groin, or buttock.

e. Imaging (X-ray / MRI / Ultrasound if pediatric)

When: Trauma, persistent pain, limited ROM, suspected fracture or developmental

issue.

X-ray Positive: Fracture, osteoarthritis → orthopedic referral.

MRI Positive: Labral tear, avascular necrosis → orthopedic referral.

Negative: Suggests soft tissue strain → conservative management.

2. Management / Plan Actions

Conservative Care:

Rest and activity modification

Ice or heat 10–15 min, 2–3x/day

NSAIDs if no contraindications

Gentle ROM exercises; PT for strengthening hip muscles and improving gait

Avoid high-impact activities until pain improves

Referrals:

Physical therapy: Persistent pain, positive Trendelenburg or FABER tests,

functional limitation.

Chiropractor: Musculoskeletal strain without fracture or intra-articular pathology.

Orthopedics: Fracture, labral tear, avascular necrosis, developmental disorders

(SCFE, Perthes), or persistent pain >4–6 weeks.

Patient Education:

Explain purpose of tests and interpretation of positive/negative results.

Educate on activity modification, exercises, and posture.

Red flags: severe pain, inability to bear weight, swelling, numbness, or limb
length difference → seek urgent care.

For children: parents should monitor activity, gait, and ensure safe play.

3. Follow-Up

1–2 weeks: Assess response to conservative care.

4–6 weeks: Persistent pain or functional limitation → consider PT or orthopedic

referral.

Document tests performed, results, patient understanding, and plan in chart.

-----------------------------

Knee Pain (Adult & Pediatric)

Assessment: Knee pain, differential includes: ligament injury (ACL, PCL, MCL, LCL),
meniscus tear, patellofemoral pain syndrome, bursitis, tendonitis (patellar or
quadriceps), osteoarthritis, juvenile idiopathic arthritis, fracture, or referred
pain from hip or spine.

1. Tests / Physical Exam

a. Lachman Test (ACL)

How to perform: Knee flexed 20–30°, stabilize femur, pull tibia anteriorly.

Positive: Excessive anterior translation → suspect ACL tear.

Negative: Normal movement → ACL likely intact.

Plan: Positive → orthopedic referral, consider MRI.

b. McMurray Test (Meniscus)

How to perform: Flex knee, rotate tibia while extending.

Positive: Clicking, popping, or pain → suspect meniscus tear.

Negative: Smooth motion → meniscus tear less likely.

Plan: Positive → orthopedic referral, consider MRI.

c. Valgus / Varus Stress Tests (MCL/LCL)

How to perform: Apply medial or lateral stress at 30° knee flexion.

Positive: Pain or laxity → suspect MCL or LCL injury.

Plan: Mild → conservative care; severe → orthopedic referral.

d. Patellar Apprehension Test

How to perform: Push patella laterally.

Positive: Apprehension or pain → suspect patellar instability.

e. Range of Motion & Strength Assessment

Assess knee flexion, extension, swelling, tenderness, and quadriceps/hamstring

strength.

f. Imaging (X-ray / MRI)

When: Trauma, suspected fracture, persistent pain, locking, or instability.

X-ray Positive: Fracture, dislocation → orthopedic referral.

MRI Positive: Ligament or meniscus injury → orthopedic referral.

Negative: Suggests soft tissue strain → conservative care.

2. Management / Plan Actions

Conservative Care:

Rest, avoid aggravating activities

Ice 10–15 min, 2–3x/day

NSAIDs if no contraindication

Knee brace or supportive taping if needed

PT for strengthening, flexibility, and functional exercises

Referrals:
Physical therapy: Persistent pain, positive ligament or meniscus tests, functional
limitation.

Chiropractor: Only for mild musculoskeletal strain without ligament/meniscus

injury.

Orthopedics: Suspected ligament tear, meniscus tear, fracture, dislocation,

persistent pain >4–6 weeks.

Patient Education:

Explain tests performed and meaning of positive/negative results.

Educate on activity modification, brace use, exercises, and injury prevention.

Red flags: swelling, inability to bear weight, locking, instability, numbness →

seek urgent care.

For children: monitor activity, encourage safe play, and avoid high-impact sports
until healed.

3. Follow-Up

1–2 weeks: Reassess pain, swelling, ROM, and response to conservative care.

4–6 weeks: Persistent pain, instability, or functional limitation → referral to PT

or orthopedic specialist.

Document tests performed, results, patient understanding, and plan in chart.

-----------------

Calf Pain (Adult & Adolescent)

Assessment: Calf pain, differential includes: muscle strain or cramp, Achilles

tendinopathy, deep vein thrombosis (DVT), peripheral arterial disease, compartment
syndrome, Baker’s cyst, referred pain from knee or spine, or less commonly
infection/trauma.

1. Tests / Physical Exam

a. Palpation and Inspection

How to perform: Examine calf for tenderness, swelling, redness, warmth, or

deformity.

Positive: Localized tenderness, swelling, redness → consider DVT, muscle strain, or

Baker’s cyst.

b. Homan’s Sign (historical / optional)

How to perform: Dorsiflex foot with knee extended.

Positive: Pain in calf → possible DVT (not highly sensitive or specific).

c. Calf Circumference / Edema Assessment

Compare both calves for swelling.

Significant asymmetry → suspect DVT or edema.

d. Range of Motion & Strength

Assess ankle dorsiflexion/plantarflexion and calf strength.

Pain with resisted plantarflexion → suspect muscle strain or Achilles tendinopathy.

e. Imaging / Tests

Doppler Ultrasound: If DVT suspected (swelling, redness, tenderness, risk factors).

X-ray or MRI: If trauma or persistent pain suggesting muscle tear or cyst.

f. Red Flags:

Swelling, redness, warmth, sudden severe pain → rule out DVT or compartment
syndrome urgently.

2. Management / Plan Actions

Conservative Care (if musculoskeletal):

Rest, avoid aggravating activity

Ice 10–15 min, 2–3x/day

Compression or supportive bandage if tolerated

NSAIDs if no contraindication

Gentle stretching and strengthening once pain allows

Referrals:

Physical therapy: Persistent calf strain, tendon pain, or functional limitation.

Chiropractor: Only for mild musculoskeletal strain without vascular concern.

Vascular / Orthopedics / Urgent Care: Suspected DVT, compartment syndrome, severe

trauma, or persistent pain >4–6 weeks.

Patient Education:

Explain purpose of tests and meaning of positive/negative results.

Educate on activity modification, stretching, and signs of worsening condition.

Red flags: sudden swelling, redness, warmth, severe pain, shortness of breath →
seek urgent care immediately.

For adolescents: advise parents on monitoring activity, cramps, and safe exercises.

3. Follow-Up

1–2 weeks: Reassess pain, swelling, and response to conservative care.

4–6 weeks: Persistent pain or functional limitation → referral to PT, orthopedics,

or vascular specialist.
Document tests performed, results, patient understanding, and plan in chart.

Calf Pain – Assessment & Plan

Differential: Muscle strain or cramp, Achilles tendinopathy, deep vein thrombosis

(DVT), peripheral arterial disease (PAD), compartment syndrome, Baker’s cyst,
referred pain from knee or spine, infection, trauma.

1. Manual / Office Tests

a. Palpation and Inspection

How to perform: Examine both calves for tenderness, swelling, redness, warmth,
bruising, or deformity.

Interpretation:

Positive: Local tenderness/swelling → consider muscle strain, DVT, Baker’s cyst, or

infection.

Negative: Suggests less likely local pathology; consider referred pain or PAD.

b. Homan’s Sign (historical, low sensitivity/specificity)

How to perform: Patient supine, knee extended, dorsiflex foot, observe for calf
pain.

Positive: Pain → raises suspicion for DVT.

Negative: Does not rule out DVT; further testing needed.

c. Calf Circumference Measurement

How to perform: Measure both calves at the same level.

Positive: >2 cm difference → supports DVT or significant swelling.

d. Achilles Tendon / Calf Strength Test

How to perform: Resisted plantarflexion and calf raise.

Positive: Pain or weakness → muscle strain or Achilles tendinopathy.

e. Compartment Syndrome Check

How to perform: Palpate calf compartments for firmness, swelling, pain with passive
toe extension.

Positive: Pain out of proportion, tense compartments → urgent referral to ED /

orthopedics.

f. Peripheral Vascular Assessment (PAD suspicion)

How to perform: Palpate dorsalis pedis and posterior tibial pulses; check capillary
refill.

Positive: Weak or absent pulses → suspect PAD → vascular referral.

g. Knee and Spine Screening for Referred Pain

How to perform: Assess knee ROM, palpation, lumbar spine exam, straight leg raise.

Positive: Pain reproduced → consider referred pain from knee or lumbar spine.

--------------
Imaging & Labs

a. Doppler Ultrasound (Venous)

Indicated: Suspected DVT (positive Homan’s, swelling, risk factors).

Positive: Confirmed DVT → start anticoagulation per protocol, refer to vascular

medicine.

Negative: DVT unlikely → continue workup for musculoskeletal or other causes.

b. Duplex / ABI (Peripheral Arterial Disease)

Positive: ABI <0.9 → PAD → vascular referral.

Negative: PAD less likely → evaluate for other causes.

c. X-ray / MRI

Indicated: Suspected trauma, persistent calf pain, suspected Baker’s cyst, or

compartment syndrome.

Positive: Fracture, cyst, or soft tissue abnormality → orthopedic referral.

Negative: Supports muscular or tendon pathology.

d. Labs

CBC, CRP, ESR: Infection or inflammation suspected.

D-dimer: If DVT suspected and low-to-moderate risk (can guide need for imaging).

Creatine kinase (CK): If severe muscle injury or suspected rhabdomyolysis.

referral Guidance
Disorder Referral
DVT Urgent / ED or vascular medicine
Compartment syndrome Urgent / ED / orthopedic surgery
Achilles tendinopathy PT or orthopedics if severe
Muscle strain PT if persistent or functional limitation
PAD Vascular specialist
Baker’s cyst Orthopedics or podiatry
Referred pain from knee/spine Orthopedics / PT / neurology
Infection / cellulitis Urgent care / infectious disease if systemic
-------

Patient Evaluation Questions

Onset, duration, location of pain?

Recent trauma, activity change, or overuse?

Swelling, redness, warmth, numbness, or weakness?

History of clotting disorders, immobility, or surgery?

Fever, malaise, or other systemic symptoms?

Family history of PAD or DVT?

Patient Education

Red flags: Severe swelling, sudden pain, numbness, weakness, shortness of breath →
seek emergency care.

Ice or gentle stretching for muscular pain; elevate leg if swelling.

Avoid prolonged immobilization if DVT risk exists; report any worsening symptoms
immediately.

Educate on activity modification, footwear, and gradual return to exercise for

muscle/tendon injuries.

-----------------------------------------

Foot Pain (Adult & Pediatric)

Assessment: Foot pain, differential includes: plantar fasciitis, Achilles

tendinopathy, metatarsalgia, stress fracture, ligament sprain, tendon strain,
arthritis, gout, neuropathy, bunion, or infection (cellulitis).

1. Tests / Physical Exam

a. Palpation / Tenderness Assessment

How to perform: Palpate heel, arch, metatarsals, toes, and Achilles tendon.

Positive: Localized tenderness → suggests plantar fasciitis, tendon injury, stress

fracture, or arthritis.

b. Thompson Test (Achilles tendon rupture)

How to perform: Patient prone, squeeze calf.

Positive: Lack of plantarflexion → suspect Achilles tendon rupture.

Negative: Normal plantarflexion → tendon intact.

c. Range of Motion & Strength

Assess dorsiflexion, plantarflexion, inversion, eversion, and toe

flexion/extension.

Pain with movement → identify involved structures.

d. Tuning Fork / Percussion (for suspected stress fracture)

Positive: Localized pain → suspect stress fracture.

Negative: Pain absent → fracture less likely.

e. Imaging (X-ray / MRI / Ultrasound)

When: Trauma, persistent pain, swelling, or suspected fracture.

X-ray Positive: Fracture, bone spur → orthopedic referral.

MRI / Ultrasound Positive: Tendon or ligament injury → orthopedic / podiatry

referral.

f. Special Tests

Windlass Test (for plantar fasciitis): Dorsiflex toes while patient stands → pain
at heel → plantar fasciitis.

2. Management / Plan Actions

Conservative Care:

Rest, avoid aggravating activities (high impact, prolonged standing)

Ice 10–15 min, 2–3x/day

NSAIDs if no contraindication

Stretching exercises for Achilles tendon and plantar fascia

Supportive footwear, heel pads, or orthotics

Referrals:

Physical therapy / podiatry: Persistent pain, limited function, plantar fasciitis,

tendon injury.

Chiropractor: Musculoskeletal strain without fracture or tendon rupture.

Orthopedics / Podiatry: Fracture, tendon rupture, persistent pain >4–6 weeks,

deformity, or severe functional limitation.

Patient Education:

Explain purpose of tests and interpretation of positive/negative results.

Educate on activity modification, stretching, footwear, and supportive devices.

Red flags: severe pain, inability to bear weight, swelling, redness, numbness →
seek urgent care.

For children: advise parents on activity restrictions, safe footwear, and

monitoring for changes.
3. Follow-Up

1–2 weeks: Assess response to conservative care and functional status.

4–6 weeks: Persistent pain or functional limitation → referral to PT, podiatry, or

orthopedics.

Document tests performed, results, patient understanding, and plan in chart.

--------------

Plantar Fasciitis

Tests / Manual Exam:

Palpation of plantar fascia: Press heel and along medial arch.

Positive: Pain at medial calcaneal tubercle → plantar fasciitis likely.

Negative: Pain absent → consider other causes (nerve, arthritis, tendonitis).

Windlass Test: Dorsiflex toes while patient standing.

Positive: Pain at heel → plantar fasciitis.

Labs: Usually not required; consider ESR/CRP if inflammatory arthritis suspected.

Referral: PT or podiatry if persistent >4–6 weeks; orthopedics for recalcitrant

cases.

Patient Questions / Evaluation:

Pain worse with first steps in morning or after rest?

Recent increase in activity or poor footwear?

Patient Education:

Stretch plantar fascia and Achilles tendon.

Use cushioned footwear, heel pads.

Ice, NSAIDs as needed.

Avoid prolonged standing initially.

---------

Achilles Tendinopathy

Tests / Manual Exam:

Palpation of Achilles tendon: Tenderness along tendon or insertion.

Positive: Local pain, thickening → Achilles tendinopathy.

Thompson Test: Squeeze calf, watch for plantarflexion.

Positive: Lack of plantarflexion → tendon rupture (urgent referral).

Calf Raise Test: Pain with resisted plantarflexion.

Labs: Rarely needed; consider ESR/CRP if inflammatory disease suspected.

Referral: PT for persistent pain; orthopedics if rupture or failed conservative

therapy.

Patient Questions / Evaluation:

Pain with running, stairs, or heel raises?

History of steroid injections or fluoroquinolone use?

Patient Education:

Stretch and strengthen calf.

Ice after activity, NSAIDs if safe.

Limit high-impact activity until pain improves.

----------

Metatarsalgia

Tests / Manual Exam:

Palpation of metatarsal heads: Identify point tenderness.

Positive: Pain over metatarsal heads → metatarsalgia.

Morton’s Test: Squeeze forefoot laterally.

Positive: Sharp pain → neuroma possible.

Labs: Not usually needed unless systemic disease suspected (e.g., gout → uric
acid).

Referral: PT or podiatry for orthotics and footwear adjustment.

Patient Questions / Evaluation:

Pain with walking, standing, or wearing certain shoes?

History of foot deformities or high-impact sports?

Patient Education:

Cushioning shoes or metatarsal pads.

Reduce high-impact activity.

Ice and NSAIDs as needed.

---------

Stress Fracture
Tests / Manual Exam:

Palpation over metatarsals / tarsals: Localized point tenderness.

Positive: Pain at site → suspect stress fracture.

Percussion / Tuning Fork Test: Tap bone, ask if pain increases.

Labs: Not required unless evaluating bone health (Vit D, calcium, CBC if metabolic
concern).

Referral: Orthopedics if positive or persistent pain.

Patient Questions / Evaluation:

Recent increase in activity, running, or jumping?

Pain improves with rest, worsens with activity?

Patient Education:

Rest and activity modification.

Avoid weight-bearing until cleared.

Ice, elevation, and supportive footwear.

--------

Ligament Sprain

Tests / Manual Exam:

Anterior Drawer (ankle): Stabilize tibia, pull calcaneus anteriorly.

Positive: Laxity → ligament injury.

Talar Tilt Test: Invert / evert ankle.

Positive: Pain or laxity → ligament tear.

Labs: Usually not needed.

Referral: PT for rehab; orthopedics if severe grade III or failed therapy.

Patient Questions / Evaluation:

Mechanism of injury? Twisting, falling?

Swelling, bruising, or instability?

Patient Education:

RICE: Rest, Ice, Compression, Elevation.

Gradual rehab and strengthening.

Avoid high-impact activity until cleared.

----------

Tendon Strain

Tests / Manual Exam:

Palpation over tendon: Tenderness or swelling.

Resisted motion: Pain with resisted muscle action indicates strain.

Labs: Usually not needed unless systemic disease suspected.

Referral: PT for strengthening and stretching. Orthopedic referral if severe or

rupture suspected.

Patient Questions / Evaluation:

Onset of pain? Acute trauma or repetitive activity?

Pain with resisted motion?

Patient Education:

Rest, ice, NSAIDs.

Gradual strengthening and stretching.

--------------

Arthritis (Osteoarthritis / Inflammatory)

Tests / Manual Exam:

Joint palpation: Tenderness, swelling, deformity.

Range of motion: Limited or painful ROM.

Crepitus: Grinding during movement.

Labs: CBC, ESR, CRP; consider uric acid if gout suspected.

Referral: Rheumatology if inflammatory; podiatry or orthopedics for severe OA.

Patient Questions / Evaluation:

Morning stiffness? Swelling or redness?

Chronicity and activity limitation?

Patient Education:

Footwear modifications, orthotics.

Low-impact exercises.

NSAIDs or topical analgesics.

---------

Gout
Tests / Manual Exam:

Palpation of joint: Warmth, swelling, tenderness (commonly first MTP).

Labs: Serum uric acid, CBC, ESR/CRP.

Referral: Rheumatology if recurrent attacks or uncontrolled uric acid.

Patient Questions / Evaluation:

Sudden severe pain, redness, swelling?

Diet, alcohol, diuretic use?

Patient Education:

Avoid triggers (alcohol, high-purine foods).

Ice for acute flare.

Medication adherence if on allopurinol or colchicine.

-----

Neuropathy

Tests / Manual Exam:

Monofilament test: Sensory loss in plantar surface.

Pinprick / vibration testing: Assess peripheral sensation.

Labs: HbA1c, fasting glucose, B12, TSH.

Referral: Podiatry or neurology for persistent deficits.

Patient Questions / Evaluation:

Numbness, tingling, burning?

History of diabetes, alcohol, chemotherapy?

Patient Education:

Foot care and daily inspection.

Proper footwear.

Blood sugar control if diabetic.

----------

Bunion (Hallux Valgus)

Tests / Manual Exam:

Palpation of 1st MTP joint: Tenderness, swelling, deformity.

Range of motion: Limited or painful ROM.

Labs: Usually not needed.

Referral: Podiatry for severe deformity or pain; orthopedics for surgical

evaluation.

Patient Questions / Evaluation:

Pain with shoes, swelling, or toe deviation?

Family history?

Patient Education:

Proper footwear, wide toe box.

Padding, orthotics, activity modification.

---------------

Infection (Cellulitis)

Tests / Manual Exam:

Inspection and palpation: Redness, warmth, swelling, tenderness.

Check pulses: Perfusion status.

Systemic symptoms: Fever, chills.

Labs: CBC, CRP, blood cultures if severe.

Referral: Urgent care or ED if severe, spreading, or systemic signs.

Patient Questions / Evaluation:

Recent trauma, insect bite, ulcer, or nail infection?

Fever or malaise?

Patient Education:

Elevate affected foot.

Complete prescribed antibiotics.

Monitor for worsening redness, swelling, or systemic symptoms.

------------
=============

Impingement Syndrome (Shoulder)

PHI / History Questions:

Shoulder pain with overhead activity?

Pain at night or waking from sleep?

Any weakness or limited range of motion?

History of trauma or repetitive activity?

Previous treatments tried?

Assessment / Plan (A/P):

Red flags: Severe weakness, acute trauma, deformity → refer to orthopedics

Labs / Tests: Usually clinical; X-ray to rule out AC joint pathology

Treatment:

1st line: Rest, NSAIDs (Ibuprofen 400–600 mg PO TID PRN), physical therapy

2nd line: Corticosteroid injection (e.g., Triamcinolone 20 mg into subacromial

space)

Patient Education: Avoid painful movements initially, gradual strengthening

exercises

Work/School/Sports Notes: Modify overhead activity; return gradually to sports/work

2. Rotator Cuff Tear

PHI / History Questions:

Shoulder pain with lifting or reaching behind back?

Weakness or inability to lift arm?

History of trauma or chronic overuse?

Night pain or difficulty sleeping on affected side?

Prior shoulder injury or surgery?

Assessment / Plan (A/P):

Red flags: Acute full-thickness tear, inability to lift arm → urgent referral

Labs / Tests: MRI shoulder for tear confirmation; X-ray for chronic changes

Treatment:

1st line: NSAIDs, physical therapy, activity modification

2nd line: Corticosteroid injection; surgical repair if severe/failed conservative

care

Patient Education: Avoid heavy lifting or overhead activities, adhere to rehab

program

Work/School/Sports Notes: Activity restriction; post-op restrictions if surgery

performed

3. Adhesive Capsulitis (Frozen Shoulder)

PHI / History Questions:

Gradual onset shoulder stiffness and pain?

Limited active and passive range of motion?

Any history of diabetes or prior shoulder injury?

Night pain present?

Duration of symptoms?

Assessment / Plan (A/P):

Red flags: Severe pain unrelieved by medication → consider imaging

Labs / Tests: Usually clinical; X-ray to rule out arthritis

Treatment:

1st line: Physical therapy with gentle stretching, NSAIDs PRN

2nd line: Corticosteroid injection (Triamcinolone 20 mg)

Patient Education: Expect slow recovery (months), adhere to stretching program

Work/School/Sports Notes: Avoid overhead activity; gradual return to work/sports

4. AC Joint Osteoarthritis (AC OA)

PHI / History Questions:

Pain localized to AC joint, worsened with cross-body adduction?

Swelling or tenderness over AC joint?

History of trauma or repetitive overhead activity?

Night pain?

Prior treatments tried?

Assessment / Plan (A/P):

Red flags: Severe deformity → orthopedic referral

Labs / Tests: X-ray AC joint

Treatment:

1st line: NSAIDs, activity modification, physical therapy

2nd line: Corticosteroid injection into AC joint

Patient Education: Avoid provocative movements, maintain shoulder mobility

Work/School/Sports Notes: Modify overhead/weight-bearing activity

5. Tendonitis (General)

PHI / History Questions:

Pain at tendon site with activity?

Swelling or warmth over tendon?

History of repetitive motion or overuse?

Any previous tendon injuries?

Night pain or morning stiffness?

Assessment / Plan (A/P):

Red flags: Severe swelling, erythema → rule out infection

Labs / Tests: Usually clinical; consider ultrasound for diagnosis

Treatment:

1st line: Rest, NSAIDs, ice, physical therapy

2nd line: Corticosteroid injection if conservative care fails

Patient Education: Avoid aggravating activity, gradual strengthening

Work/School/Sports Notes: Modify activity; return gradually

6. Muscle Strain

PHI / History Questions:

Onset of pain after sudden movement or lifting?

Pain location, severity, and radiation?

Weakness or loss of function?

Any swelling or bruising?

Prior injuries in same muscle?

Assessment / Plan (A/P):

Red flags: Severe pain, loss of function, palpable defect → imaging

Labs / Tests: Usually clinical; ultrasound if severe

Treatment:

1st line: RICE (rest, ice, compression, elevation), NSAIDs

2nd line: Physical therapy, gradual return to activity

Patient Education: Avoid re-injury, gradual strengthening

Work/School/Sports Notes: Temporary activity modification; gradual return

7. Supraspinatus Tendonitis

PHI / History Questions:

Pain with lifting arm to the side or overhead?

Night pain or difficulty sleeping on affected side?

History of repetitive overhead activity?

Any weakness or loss of motion?

Previous shoulder injury?

Assessment / Plan (A/P):

Red flags: Weakness suggesting tear → imaging/MRI

Labs / Tests: Clinical; consider ultrasound or MRI

Treatment:

1st line: NSAIDs, physical therapy

2nd line: Subacromial corticosteroid injection

Patient Education: Avoid overhead activity initially, adhere to rehab

Work/School/Sports Notes: Activity modification until improved

8. Lateral Epicondylitis (Tennis Elbow)

PHI / History Questions:

Pain at lateral elbow worsened by gripping or lifting?

Any history of repetitive wrist extension activity?

Weak grip strength?

Duration of symptoms?

Prior treatments tried?

Assessment / Plan (A/P):

Red flags: Neurological deficits, sudden severe pain → referral

Labs / Tests: Usually clinical; consider ultrasound if uncertain

Treatment:

1st line: Rest, NSAIDs, physical therapy, counterforce brace

2nd line: Corticosteroid injection (e.g., Triamcinolone 10 mg)

Patient Education: Avoid aggravating activity, stretching and strengthening

exercises

Work/School/Sports Notes: Modify activity; gradual return

9. Medial Epicondylitis (Golfer’s Elbow)

PHI / History Questions:

Pain at medial elbow worsened by gripping or wrist flexion?

Any history of repetitive wrist flexion or golf?

Weak grip strength?

Duration of symptoms?

Previous treatments tried?

Assessment / Plan (A/P):

Red flags: Neurologic deficits, sudden severe pain → referral

Labs / Tests: Usually clinical

Treatment:

1st line: Rest, NSAIDs, physical therapy, counterforce brace

2nd line: Corticosteroid injection

Patient Education: Avoid aggravating activity, home stretching

Work/School/Sports Notes: Modify activity; gradual return

10. Tenosynovitis

PHI / History Questions:

Pain, swelling, or stiffness along tendon sheath?

Pain with movement of affected tendon?

History of repetitive activity or infection?

Any redness or warmth?

Prior tendon injuries?

Assessment / Plan (A/P):

Red flags: Severe swelling, fever, pus → rule out infection / surgical referral

Labs / Tests: Usually clinical; ultrasound if needed

Treatment:

1st line: Rest, NSAIDs, splinting

2nd line: Corticosteroid injection

Patient Education: Avoid aggravating activity, gradual return to motion

Work/School/Sports Notes: Activity modification

11. Sprain

PHI / History Questions:

Pain after acute ligament injury?

Swelling, bruising, or instability?

Ability to bear weight/use joint?

Mechanism of injury?

Prior injuries?

Assessment / Plan (A/P):

Red flags: Severe instability, neurovascular compromise → imaging / orthopedic

referral

Labs / Tests: Usually clinical; X-ray if fracture suspected

Treatment:

1st line: RICE, NSAIDs, support/splint

2nd line: Physical therapy for rehabilitation

Patient Education: Gradual return to activity, avoid reinjury

Work/School/Sports Notes: Temporary activity modification

12. Rheumatoid Arthritis (RA)

PHI / History Questions:

Joint pain, swelling, stiffness, worse in morning?

Symmetrical involvement?

Fatigue or systemic symptoms?

Any family history of autoimmune disease?

Prior treatments tried?

Assessment / Plan (A/P):

Red flags: Rapid progression, deformity → rheumatology referral

Labs / Tests: ESR, CRP, RF, anti-CCP, CBC

Treatment:

1st line: NSAIDs for symptom relief, DMARD initiation (Methotrexate 7.5–25 mg PO
weekly)

2nd line: Biologic DMARDs if inadequate response

Patient Education: Joint protection, monitor for medication side effects, adherence

Work/School/Sports Notes: Modify activities; avoid high-impact stress on joints

13. Osteoarthritis (OA)

PHI / History Questions:

Joint pain, stiffness worse with activity?

Morning stiffness <30 min?

Any swelling or crepitus?

Previous injuries or family history?

Functional limitation?

Assessment / Plan (A/P):

Red flags: Rapid worsening, joint deformity → referral

Labs / Tests: Usually clinical; X-ray for joint space narrowing, osteophytes

Treatment:

1st line: NSAIDs, acetaminophen, activity modification, physical therapy

2nd line: Intra-articular corticosteroid injection

Patient Education: Weight management, low-impact exercise, joint protection

Work/School/Sports Notes: Modify activity; use supportive devices if needed

---------
Navicular (Scaphoid) Fracture

PHI / History Questions:

Mechanism of injury: fall on outstretched hand?

Pain in anatomical snuffbox?

Swelling, bruising, or limited wrist motion?

Difficulty gripping objects?

Previous wrist injuries?

Assessment / Plan (A/P):

Red flags: Severe pain, deformity → orthopedic referral

Labs / Tests: X-ray wrist; if initial X-ray negative and high suspicion → MRI or
repeat X-ray in 10–14 days

Treatment:

1st line: Thumb spica cast 6–12 weeks

2nd line: Surgical fixation if displaced or nonunion

Patient Education: Avoid weight-bearing on affected wrist, follow-up imaging

Work/School/Sports Notes: Activity restriction; gradual return post-immobilization

2. Colles Fracture

PHI / History Questions:

Fall on outstretched hand?

Pain, swelling, or deformity at distal radius?

Numbness or tingling in fingers?

Dominant hand involvement?

Previous wrist injuries?

Assessment / Plan (A/P):

Red flags: Neurovascular compromise, open fracture → urgent referral

Labs / Tests: X-ray wrist

Treatment:

1st line: Closed reduction + splint/cast

2nd line: Surgical fixation if unstable or displaced

Patient Education: Elevate hand, monitor for numbness, follow-up X-ray

Work/School/Sports Notes: Temporary activity restriction; gradual return

3. Hip Fracture

PHI / History Questions:

Recent fall or trauma?

Pain in groin, thigh, or buttock?

Inability to bear weight or ambulate?

Leg shortening or external rotation?

Previous fractures or osteoporosis?

Assessment / Plan (A/P):

Red flags: Inability to walk, deformity, neurovascular compromise → urgent hospital

referral

Labs / Tests: X-ray hip; CBC, CMP if admitted

Treatment:

1st line: Surgical repair (ORIF or arthroplasty)

2nd line: Pain control (Acetaminophen 500–1000 mg PO PRN, avoid NSAIDs in renal
impairment)

Patient Education: Fall prevention, weight-bearing precautions post-op

Work/School/Sports Notes: No ambulation without assistive device; PT post-op

4. Pelvic Fracture

PHI / History Questions:

High-impact trauma or fall?

Pain in pelvis, hips, or lower back?

Inability to bear weight?

Hematuria, urinary retention, or vaginal/rectal bleeding?

Previous pelvic injuries?

Assessment / Plan (A/P):

Red flags: Hemodynamic instability, neurovascular compromise → immediate ED

referral

Labs / Tests: X-ray or CT pelvis; CBC, CMP, coagulation

Treatment:

1st line: Hospitalization, pelvic binder if unstable, pain control

2nd line: Surgical fixation if unstable fracture

Patient Education: Fall precautions, gradual mobilization, follow-up imaging

Work/School/Sports Notes: Non-weight-bearing until cleared; PT as directed

5. Cauda Equina Syndrome

PHI / History Questions:

Acute lower back pain radiating to legs?

Weakness, numbness, or tingling in saddle area?

Urinary retention or incontinence?

Bowel dysfunction?

History of lumbar disc disease or spinal trauma?

Assessment / Plan (A/P):

Red flags: Urinary retention, saddle anesthesia, progressive weakness → emergency

Labs / Tests: MRI lumbar spine emergently

Treatment:

1st line: Emergent surgical decompression

2nd line: Pain control with acetaminophen or short-term opioids PRN

Patient Education: Recognize red flags, urgent ED presentation

Work/School/Sports Notes: N/A; hospitalization required

6. Medial Tibial Stress Syndrome / Shin Splints

PHI / History Questions:

Pain along the medial tibia with activity?

Onset after exercise or training change?

Swelling or bruising?

History of flat feet or improper footwear?

Pain at rest or only with activity?

Assessment / Plan (A/P):

Red flags: Persistent pain, swelling, night pain → rule out stress fracture

Labs / Tests: Usually clinical; X-ray or bone scan if fracture suspected

Treatment:

1st line: Rest, ice, NSAIDs, proper footwear, stretching

2nd line: Gradual return to activity, orthotics if needed

Patient Education: Avoid high-impact activity until pain-free, gradual training

Work/School/Sports Notes: Temporary activity modification; return to sports

gradually

7. Plantar Fasciitis

PHI / History Questions:

Heel pain, worse with first steps in morning?

Pain after prolonged standing or activity?

Any history of flat feet or high arches?

Previous treatments tried?

Numbness or tingling in foot?

Assessment / Plan (A/P):

Red flags: Night pain, swelling, redness → rule out infection or fracture

Labs / Tests: Usually clinical; X-ray if persistent pain

Treatment:

1st line: Rest, ice, stretching, NSAIDs, supportive footwear

2nd line: Night splint, corticosteroid injection if refractory

Patient Education: Avoid barefoot walking on hard surfaces, gradual return to

activity

Work/School/Sports Notes: Modify standing or running activities

8. Morton’s Neuroma

PHI / History Questions:

Pain, burning, or tingling between toes (usually 3rd/4th)?

Pain worsens with tight shoes or walking?

Numbness or radiating pain to toes?

Prior foot trauma?

Any previous treatments?

Assessment / Plan (A/P):

Red flags: Persistent numbness or severe pain → podiatry referral

Labs / Tests: Clinical; ultrasound or MRI if diagnosis unclear

Treatment:

1st line: Wide-toed shoes, NSAIDs, metatarsal pad

2nd line: Corticosteroid injection; surgical excision if refractory

Patient Education: Proper footwear, avoid high-impact activities

Work/School/Sports Notes: Activity modification until symptoms improve

9. Degenerative Joint Disease (Osteoarthritis) – Knee/Hip/Other

PHI / History Questions:

Joint pain worsened with activity, relieved by rest?

Morning stiffness <30 minutes?

Swelling, crepitus, or reduced range of motion?

History of trauma or prior joint disease?

Functional limitations?

Assessment / Plan (A/P):

Red flags: Rapid worsening, deformity → ortho referral

Labs / Tests: Usually clinical; X-ray for joint space narrowing, osteophytes

Treatment:

1st line: NSAIDs, acetaminophen, activity modification, physical therapy

2nd line: Intra-articular corticosteroid injection; referral for surgical

evaluation if severe

Patient Education: Weight management, low-impact exercise, joint protection

Work/School/Sports Notes: Modify activity; supportive devices if needed

--------

Systemic Lupus Erythematosus (SLE)

PHI / History Questions:

Joint pain, swelling, or morning stiffness?

Skin rashes (especially malar “butterfly” rash)?

Photosensitivity or oral ulcers?

Fever, fatigue, or unexplained weight loss?

Prior autoimmune or family history?

Assessment / Plan (A/P):

Red flags: Fever, nephritis, neurologic symptoms → urgent referral

Labs / Tests: CBC, CMP, ANA, anti-dsDNA, urinalysis (for proteinuria), ESR/CRP

Treatment:

1st line: Hydroxychloroquine 200–400 mg PO daily

2nd line: Corticosteroids for flares (Prednisone 10–40 mg PO daily)

Patient Education: Sun protection, adherence to medications, infection precautions

Work/School/Sports Notes: Activity modification during flares; avoid excessive sun

2. Rheumatoid Arthritis (RA)

PHI / History Questions:

Symmetrical joint pain and swelling?

Morning stiffness >30 minutes?

Fatigue or low-grade fever?

Family history of autoimmune disease?

Prior DMARD or NSAID use?

Assessment / Plan (A/P):

Red flags: Rapid joint deformity, persistent systemic symptoms → rheumatology

referral

Labs / Tests: CBC, ESR, CRP, RF, anti-CCP

Treatment:

1st line: Methotrexate 7.5–25 mg PO weekly

2nd line: Biologic DMARDs (e.g., Etanercept) if inadequate response

Patient Education: Joint protection, medication adherence, monitoring for side

effects

Work/School/Sports Notes: Modify high-impact activities; ergonomic support

3. Gout

PHI / History Questions:

Sudden onset of severe joint pain, swelling, redness?

Most commonly affecting big toe?

History of hyperuricemia or previous attacks?

Alcohol intake, dietary triggers?

Medications (diuretics, low-dose aspirin)?

Assessment / Plan (A/P):

Red flags: Fever, polyarticular acute flare → rule out septic arthritis

Labs / Tests: Serum uric acid, CBC, CMP, joint aspiration if uncertain

Treatment:

1st line (acute attack): NSAIDs (Indomethacin 50 mg PO TID × 5–7 days)

2nd line: Colchicine 1.2 mg PO initially, then 0.6 mg PO 1 hr later, then 0.6 mg PO
BID until resolution

Chronic management: Allopurinol 100–300 mg PO daily

Patient Education: Avoid triggers (red meat, alcohol), hydrate, medication

adherence

Work/School/Sports Notes: Rest affected joint during flare

4. Ankylosing Spondylitis (AS)

PHI / History Questions:

Chronic back pain worse in morning, improves with activity?

Stiffness >30 minutes?

Sacroiliac or buttock pain?

Family history of HLA-B27 associated conditions?

Previous NSAID or biologic use?

Assessment / Plan (A/P):

Red flags: Neurologic deficits, severe pain → imaging and rheumatology referral

Labs / Tests: CBC, ESR, CRP, HLA-B27, X-ray pelvis for sacroiliitis

Treatment:

1st line: NSAIDs (Naproxen 250–500 mg PO BID)

2nd line: TNF inhibitors (Etanercept 50 mg SC weekly) if inadequate response

Patient Education: Regular exercise, posture training, physical therapy

Work/School/Sports Notes: Activity modification; avoid high-impact exercises

5. Meniscus Tear (Knee)

PHI / History Questions:

Knee pain, swelling, or locking?

Pain with twisting or squatting?

History of trauma or sports injury?

Instability or “giving way” sensation?

Previous knee injuries or surgery?

Assessment / Plan (A/P):

Red flags: Locked knee, inability to bear weight → ortho referral

Labs / Tests: MRI knee preferred; X-ray to rule out fracture or arthritis

Treatment:

1st line: RICE, NSAIDs, physical therapy

2nd line: Arthroscopic repair if symptomatic or unstable

Patient Education: Activity modification, gradual return, adherence to rehab

Work/School/Sports Notes: Avoid twisting/squatting; gradual return to sports

6. Bursitis (Including Ruptured Baker’s Cyst)

PHI / History Questions:

Pain, swelling, or warmth over affected bursa?

Any history of trauma or repetitive motion?

Pain with movement or pressure?

Redness or fever?

Previous bursitis or knee injuries?

Assessment / Plan (A/P):

Red flags: Severe swelling, redness, fever → rule out septic bursitis

Labs / Tests: Clinical; ultrasound if uncertain

Treatment:

1st line: Rest, ice, NSAIDs, compression

2nd line: Corticosteroid injection if conservative fails

Patient Education: Avoid repetitive pressure or trauma; monitor for infection

Work/School/Sports Notes: Activity modification; gradual return

7. Sarcoidosis

PHI / History Questions:

Respiratory symptoms: cough, dyspnea, chest pain?

Fatigue, fever, or weight loss?

Skin lesions, ocular symptoms, or joint pain?

Prior history of granulomatous disease?

Family history?

Assessment / Plan (A/P):

Red flags: Severe pulmonary, cardiac, or neurologic involvement → refer

Labs / Tests: CBC, CMP, ACE level, chest X-ray, possible biopsy

Treatment:

1st line: Observation if mild; corticosteroids (Prednisone 20–40 mg PO daily) if

symptomatic

2nd line: Methotrexate or hydroxychloroquine if steroid-refractory

Patient Education: Monitor symptoms, adherence to meds, regular follow-up

Work/School/Sports Notes: Modify activity if symptomatic

8. Reactive Arthritis (Formerly Reiter Syndrome)

PHI / History Questions:

Joint pain/swelling following infection (GI or GU)?

Conjunctivitis or uveitis?

Dysuria or urethral discharge?

Skin lesions (keratoderma blennorrhagicum)?

Previous similar episodes?

Assessment / Plan (A/P):

Red flags: Severe joint involvement, eye involvement → urgent referral

Labs / Tests: CBC, ESR/CRP, urinalysis, STD testing if GU infection suspected

Treatment:

1st line: NSAIDs (Ibuprofen 400–600 mg PO TID)

2nd line: Corticosteroids (oral or intra-articular) if refractory

Treat underlying infection (e.g., antibiotics if Chlamydia)

Patient Education: Infection prevention, adherence to medications, eye symptom

monitoring

Work/School/Sports Notes: Limit activity if joint pain significant; gradual return