DIP Episode 619 - USMLE MSK Series (Elbow, Neck, Back)

All right, welcome to episode 619 of the Divine Intervention Podcasts. In today's podcast, I'm going to be addressing the elbow, the back, and the neck, and the USMLE. So, just think of this as an MSK podcast, and I'm going to be discussing the elbow, the back, and the neck. These MSK topics are things that you either know or you don't know. You know, testing and strategy many times is not going to help you. Now one big problem I've noticed with these MSK topics for many people is that many resources just go overboard on the things they emphasize that you need to know. The thing is, in my experience with the USML Es, there are just a very discrete series of things that they require you to know with these MSK complaints. If you know those things, then you're going to be good to go. And also one thing I've also found to be helpful is knowing certain things you see in the QSTEM, in the question stem that helps you rule out certain pathologies. So I'm really going to try to emphasize those things as we go today and hopefully should be in pretty good shape. Alright, so let's start off with the elbow. So what if they give you a question about a patient? And this patient tells you that for the last couple of weeks, he has been having this pins and needle sensation in his hand. And he tells you that he notices that his ring finger feels weird. He has this pins and needle sensation in kind of last for a couple of hours. And then after a while, it stops.

And then they tell you that he has this distribution of these symptoms in the distribution of his fourth and fifth digits. And sometimes even has this redid in pain in his forearm on the inside of his forearm. And then they tell you that you tap the back of the person's elbow and you can reproduce the person's pain. What should you be thinking about in this circumstance? I really hope you're saying that, ooh, divine. This is a Cupid O' Tonal Syndrome. Cupid O' Tonal Syndrome. Cupid O' Tonal Syndrome is a classically tested disorder on the USMEL exams. And basically, the thing that happens is that the owner nerve is compressed within the Cupid O' Tonal. The owner nerve is literally compressed within the Cupid O' Tonal. And it's like the funny bone you have are on your elbow. So the owner nerve can get compressed. And there are many things that can cause that compression. You can be from repetitive trauma, like repetitive activities. Or let's say you have a fracture, you have a dislocation, you have arthritis, you have like a cyst that's growing there. All those things can cause compression. And typically, if you're asking about diagnosis, the person will have tenderness typically when you press on the Cupid O' Tonal. And sometimes, if you even do the Tinell sign, I don't mean to think of Tinell sign only for a couple of tonal. But Tinell sign also applies to the Cupid O' Tonal. If you tap on that Cupid O' Tonal, you tap on it, it hurts. You reproduce the symptoms.

So typically, how you're going to manage Cupid O' Tonal Syndrome? Basically, on your exams, you want to rest it. You want to use like an elbow splint. You want to, you know, I sit down. Right? And you want to modify your activities. You want to do activity modification. Right? If you're really hurting, you can give an answer. But honestly, that's about as much as you need to do. Many of these MSK problems, you don't have to do very serious things for them. Right? So I will encourage you, I'm not saying always, but in general, you don't do serious things for these MSK problems. All right. Now, what if they give you a question about a patient? And the patient says that, ooh, that the back of my elbow really, really hurts. Right? And then they tell you that on physical exam, you feel this fluid. You feel this floctrine mass in the back of the person's elbow. If you see that, I'd really hope you're thinking about olecranon, bercitis, olecranon bercitis. Right? We know that, you know, a bursa is like a collection of fluid. Right? So sometimes that bursa can become inflamed. Right? The olecranon bursa is in the back of the elbow. Right? It's in the posterior part of the elbow and it can become inflamed. Right? And typically, it will hurt and then you will feel like this floctrine mass. It will be like a mass that has fluid in the back. Right? And again, many times the same things that cause a cubital tonal syndrome cause this. Right?

Again, repetitive motion, repetitive activities that involve the elbow. Although sometimes you can arise from an infection, believe it or not. Or sometimes you can get it from like an inflammatory problem. You know, like rheumatoid arthritis, for example. Right? Now, one high-yield thing to keep in mind is that when people have this problem, when people have this problem, they can actually move their elbow just fine. It hurts. It hurts, but they can actually move their elbow just fine. Right? If a person has restricted range of motion at their elbow, please do not pick olecranon bursitis as your answer. I'm going to say that again. If a person has restricted range of motion at their elbow, please, please, please, thou shall not pick olecranon bursitis as the answer on your exams. Right? It doesn't cause restricted range of motion. It causes pain, but it doesn't cause restricted range of motion. Right? The thing that's going to mess up your range of motion at the elbow is if you have an actual joint problem. You have an actual joint problem. So please, keep that at the back of your mind for your exams. All right. So how do we manage olecranon bursitis? Well, typically, just NSAI Ds, right? Because it's an inf- you know, it can help. Excuse me. Okay. Excuse me. It can help calm down the inflammation, right? NSAI Ds are cycloxygenase inhibitors. You can also put there. You can also, you know, just rest the elbow, use elbow protection pads. That's really what you need to do.

Although there is, and that's first line, that's first line. That's what you're supposed to do. Now, here's one thing I'm going to say. There are two things you need to be watchful for with olecranon bursitis. Number one, if the bursa is tender or it looks red or warm, if it has signs of inflammation, and they're asking you for your next step on your exams, aspirate that bursa. Go ahead and aspirate that bursa because you just want to make sure that they don't have like some kind of infection, right? Or there's no crystals, right? You want to make sure it's not a crystalline and a thropathy or something like that, right? Now, what is the second thing you want to keep at the back of your mind? Please steroid injections, steroid injections are not indicated for olecranon bursitis. You see many people, once it's a joint problem, and they see an inject steroids answer, they want inject steroids. Don't do that for olecranon bursitis. It actually makes things worse. It actually makes things worse, so please do not do that. All right. Now, what if they give you a question about a patient, and they tell you that this patient is a tennis player, right? This patient is a tennis player, and for the last three weeks, the patient has been having very severe tenderness around his elbow, right? Then, they tell you that when you press the outsides, the lateral part of his elbow, you know, you can pretty much reproduce his symptoms.

When you see something like this, what should you be thinking about? I really hope you're saying that, ooh, divine. It sounds like this person has a lateral epicon de litis, lateral epicon de litis. Remember lateral epicon de litis is what we call tennis elbow, right? Basically, the thing that's going to happen is that these people tend to have pain on the outer part of the elbow, on the lateral side of the elbow. Many times, they'll have pain that is radiating down, therefore, right? Pain that's radiating down, therefore, right? And the thing is, typically, this pain, this tenderness they have is just basically at the point of insertion of the extensor reditendants, right? The extensor reditendants like the extensor capyridialis brevis, right? The point of insertion, right? It just hurts. It just really, really hurts, right? Remember, the extensor capyridialis brevis, right? It's one of those tendons that helps you with wrist extension, right? With wrist extension, right? So what usually causes this? Again, repetitive, repetitive, repetitive movements, right? Think about it. If you're a tennis player, you keep doing these, uh, these are backhand swings, backhand swings, right? So as you keep, oh, backhand swings, think about it. What are you doing when you do a backhand swing? Do it right now where you are. Well, if you're driving, maybe you shouldn't do that, right? But backhand swing, backhand swing, backhand swing, right?

You extending your elbow, extending your elbow, extending your elbow, right? So if you're repetitively extend your elbow, right? Like we do if you're a tennis player, that repetitive motion can ultimately cause injury, right? And these people also, you can reproduce their symptoms when they try to extend your wrist, you know, when they try to extend their wrist, so they try to lift objects, it kind of worsens their, reproduces their symptoms or worsens them, right? When you see that, I want you to think of lateral epicon delitis. Um, a close cause in here that you should keep on the back of your mind for your exams is medial epicon delitis, medial epicon delitis. Um, many times this is known as golfer's elbow. Uh, the way I remember this is like milligrams, mg, you know, like milligrams, um, medial goes with G golfer's, right? Medial epicon delitis, that's golfer's elbow, right? When people have medial epicon delitis, where do they have the pain? Remember, we said for lateral epicon delitis, the pain is on the outside of the elbow, lateral side of the elbow. For these people, it's actually going to be on the medial side of the elbow, the medial side of the elbow, right? And again, sometimes they can have pain, rediting down the forearm like we saw in lateral epicon delitis, right? And again, what are the, where do you have this tenderness? You pretty much have this tenderness at the point of insertion of your flexor capy radialis tendons, right?

Your flexor capy radialis tendons, right? So like your flexor capy radialis, sometimes your predator teris tendons, uh, the point where the insert is, is what hurts basically, right? Remember, those things are wrist flexor, right? They're part of the muscle groups and tendons that help with like wrist flexion and the pronation, right? wrist flexion and the pronation. Remember, for lateral epicon delitis, it was wrist extension, that was the big thing, right? It was the wrist extension, it was the big thing. For medial epicon delitis, it's the wrist flexion, that is the big thing, right? And again, what causes this? Well, remember, we said for, I'm trying to make parallels here, so you can learn this and learn this one, right? We said that for lateral epicon delitis is repetitive, uh, extension of the elbow. Well, what do you think is going to be the case for medial epicon delitis? Repeded what? Flexion of the elbow. Well, who are the people that do a lot of flexion of the elbow? Well, like a person that is a golfer, right? A person that is a golfer, right? Because remember, in golf, when you do your swings, right, you're going to be flexing your elbow a lot, right? Or if you're in a sport that involves a lot of throwing, right? You're going to be flexing your elbow a lot. That's going to cause problems, right? And the thing is, what are some things that can worsen this or can, you know, aggravate these people's symptoms, right?

If you try to flex the wrist, right, or you try to prune it, right? That worsen those people's symptoms. When you see stuff like that, think of medial epicon delitis, right? And again, just anatomically, really lateral epicon delitis, it's an issue with the tendons at the back of the, of the forearm. Because if you really think about it, right, the extensors, the cross posteriorly around your, at least for the upper extremities, the cross posteriorly around your joints. I remember learning this many, many years ago in medical school. And then the flexors, they go in front of the, in front of your joints, right? Like in front of the extremity, right? Like your, the tendons that cross the front of your forearm, those are those tendons that handle flexion, the ones that go behind your forearm, those are the ones that handle extension, right? So in general, how do you manage these problems? How do you manage the two, you know, lateral epicon delitis or medial epicon delitis? Pretty straightforward, actually. Basically, conservative measures, conservative measures, like what? Stretch strengthening, right? Muscle strengthening, stretch your muscles, stretch these tendons, right? And avoid activities that meet you have this pain, right? Pretty much avoid those activities. And if, you know, you also see an answer that says to put a brace, you can totally do that on the exam. That's perfectly fine.

They are not going to put multiple conservative measures in the same cue stem on your exams, right? Or if the person is having a lot of pain and you don't see any of these conservative manovars, like exercise and stuff, you know, you can give the person an answer. That's perfectly fine, right? But again, what is the one thing you should not do? They're actually two things, you know, kind of high-gift two warnings for the cron number side is, the two warnings I want to give here. Number one, do not get imaging for epicon delitis, please. Do not do that. Do not get imaging on your test. Number two, do not inject steroids, right? See, let me tell you this. Many times for these elbow pathologies, injecting steroids is not a good idea on your exams. It's just not. It's just not. Right. Keep going. All right, so I think I've kind of hit the elbow pretty well. Let's go ahead and talk about the neck. Let's talk about the neck, right? The neck, right? So the thing is, most times for the neck, there are a few discrete pathologies they love to test, right? So many times how will a neck issue present? Let's use a few of the needs, right? So what if they give you a question about a patient? And they tell you that this patient has been having a neck pain for the past like two weeks, right? And they tell you that on physical exam, you know, the person's low extremity reflexes are increased, right? The person has like hyperreflexia, the person has like clonus in the low extremities, right?

And then they tell you that they have a lot of just weaknesses, hyperreflexia in their upper extremities, but then they have a lot of neck pain. When you see something like that, what should you think about? Huh. This pattern should tell you something. You're noticing that in the low extremities, you're seeing a lot of upper motor neuron symptoms, hyperreflexia, right? And hypertonia, but in the upper extremities, you're seeing a lot of low motor neuron symptoms. So let me emphasize low extremities, upper motor neuron symptoms, upper extremities, low motor neuron symptoms like hyperreflexia, muscle weakness and things like that. And then this person has neck pain. What structure is damaged? It's the spinal cord, right? I've said this in so many of my previous podcasts, right? That this is a classic pattern of a my lapathy, a spinal cord disorder. Where in upper regions of the body, you have low motor neuron symptoms and in lower regions of the body, you have upper motor neuron symptoms, right? This person in this question, in this vineyard that I've emphasized has a cervical my lapathy, right? Surveillance my lapathy again, upper motor neuron symptoms in the low extremities, low motor neuron symptoms in the upper extremities, right? You know, they have arm problems, they have low extremity problems and they're going to have neck pain, they're going to have neck pain, right? That's going to be a cervical my lapathy.

Now my question is this, to you is this, how do you differentiate a cervical my lapathy for a cervical radical lapathy? Because remember my lapathy, my lapathy, my lapathy is a spinal cord problem, but radical lapathy is a nerve root problem, nerve root problem. Radical lapathy is where you compress the spinal, you know, like a cervical spinal root, right? So these people will have neck pain just like we have in cervical my lapathy, but in addition to that, they will have pain radiating to the arm. When you have a radical lapathy on the USMEL exams, they have to give you radiation to the arm, they have to give you radiation to the arm, right? They will have like symptoms in a drama, tumble distribution, right? They have symptoms in a drama, tumble distribution, they can have like decreased deep tendon reflexes, right? They can have decreased deep tendon reflexes, they may have like, you know, reduced strength in the in the extremity, right? If you notice, do you see me seeing any upper motor neuron symptoms for these people? No, I'm not, right? So please in general on the USMEL exams, radical lapathy will not be as real upper motor neuron symptoms. You may see predominantly low motor neuron symptoms in these people, right? Please these things I'm emphasizing are very, very high you to know for your exams, very, very high you to know for your exams. All right. Now let's talk about how to deal with these problems, how do you deal with these problems?

The thing is, if a person has cervical my lapathy, what is going to be your next step on your exams? Go ahead and get an MRI. Go ahead and get what? An MRI. But another situation where you may say you know what, let me get an MRI is if you've tried conservative management, right? You've tried conservative management and it's not working, right? Like for example, if you have like a cervical radical lapathy or whatever, you should probably go ahead and do conservative management. What is conservative management for like these neck issues? Pretty much physical therapy, I sit down, heat, using said that's it, that's it, that's it, right? And other variant you may see here in your exams and there are so many little decisions, this thing is almost like OB guy where it's like, oh, if you see this, do this, if you see this, do that, right? But the thing is, if they tell you in the question and the question is really emphasizing that this person has a lot of like muscle spasms in the neck, then go ahead and give like a muscle relaxant like backlofen, for example, that is perfectly fine for these people. That's perfectly fine for these people. Okay? That's perfectly fine for these people. Again, generally conservative measures, conservative conservative conservative measures, right? conservative measures, right? But if these conservative measures are not working, right? Then you need to consider getting an MRI and then those people at some point may need surgery, right?

At some point, those people may need surgery, right? So, especially if they tell you in the question that man, these person symptoms are progressive, right? They keep worsening and worsening and worsening. Despite you trying conservative measures, then in those circumstances, you need to go ahead and do surgery, right? That person is going to need surgery. Okay? That person is going to need surgery. So, again, are your symptoms worsening? Despite conservative measures, right? You've gone for weeks. You're still having symptoms. Even if you've done the icing, the incense, the physical therapy, then you're going to need surgery. You're going to need surgery. Okay? You're going to need surgery. When do you get an MRI? If you suspect that cervical myelopathy, right? Or you've tried conservative measures for weeks. It's not working. Go ahead and get an MRI, right? Go ahead and get an MRI, right? Again, please, these things are very important to know for you exams. Okay? Very important to know these things for you exams. All right. Now, the next time I'm going to talk about, let's talk about the back, right? And then we'll wrap this up, right? So, on the USMEL Es, what if they give you a question? What if they give you a question about a person? They tell you that, oh, this person was lifting heavy boxes or whatever. They always lift in heavy boxes, right? See, if you're lifting stuff, just be wise, just be wise, you know, just be wise, right?

You don't want your back to give out on you, right? But here's the thing, lifting heavy items. And they're like, oh, my lube back hurts, right? And then they tell you that, oh, that they use this term. Now, when you pop it, the back, the person has like paraspinal muscle tenderness, right? When you see something like that, that's a, that's a, that's a lumbar sprain, right? It's like a lumbar strain. For those people, literally, just tell them, they'll give you an answer that says bed rest, please, do not do bed rest, right? Just conservative therapy, they can take insides, they can massage the back, that's it, right? That's a lumbar muscle strain, that's it. Don't do anything for those people, don't do anything for those people, okay? Don't do anything for those people, right? Don't do anything for those people. All right, now, what if they tell you that a person has like low back pain, right? And they tell you that, oh, this person has like this person when they lay back, you know, on an examination table, and you raise their legs that they have like very significant pain, right? Or they have like this rededing pain. Then obviously in that case, the person has some kind of herniated disc, right? They have some kind of herniated disc, right? So, you know, that's like the street leg race test, right? The street leg race test, positive street leg race test, that tells you that, okay, this person probably has some kind of herniated disc, right?

And sometimes when people have herniated discs, be careful. Our friends at the USML is there some, almost like devious things they do sometimes, because the positive street leg race is in every onky deck known to mankind. Everybody knows about this stuff, right? So, what would they do every now and then with these, with these things? What would they do every now and then with these things? They do things like, oh, they'll put the, they may not put the positive street leg race, but you may notice a person has low back pain and you notice that, wow, this person is having issues with dorsiflexing their ankles or the great toe, you know, like for example, like it's like you're trying to move your ankles up and you can't do that or move your great toe up and you can do that. That's an L5 problem, right? That's an L5 radical apathy issue, right? Or they tell you that, ooh, this person you're trying to, you know, you're trying to test their ankle reflexes and their ankle reflexes are like super, super weak, right? That's an S1 radical apathy, right? Make sure you can recognize the nerve roots that go with those problems, right? So again, they may be kind of giving the positive street leg race. That's great. You're done. But if they don't, if they don't, you may have a herniated disc. If your ankle and great toe dorsiflexion is messed up, that's L5 or your ankle reflexes are messed up, that's S1. Remember, I give this rule when I talked about the neck.

I said that when you have radical apathys, you may have lower moron neurons symptoms. You may have lower moron neurons symptoms, right? But if you have a myelopathy, a spinal cord problem, in general, low moron neurons symptoms are not going to be a predominant symptom. You're going to have a lot of upper moron neurons symptoms. You're going to have upper and lower moron neurons symptoms, right? So let me clarify this. Radical apathys, you're going to have redid in pain and lower moron neurons symptoms. Myelopathys, you're going to have upper moron neurons symptoms in lower levels of the body and lower moron neurons symptoms in upper levels of the body. I've said this so, so, so, so, so many times, right? This is something you need to kind of grind into your brain for your exams. All right, so pressing has a herniated disc, right? They're going to have those classic symptoms. The thing is, what will be the clue in your question? Because another thing that may cause back pain on your exams is if a person has like spinal stenosis, for example, right? The big thing you're going to see with spinal stenosis is going to be what? Neurogenic clodication, neurogenic clodication, right? Basically, like your spinal canal narrows and it begins to compress a component of your spinal cord, right? So what are going to be the things, what do I mean by neurogenic clodication? Well, the thing is, the person is going to have like numbness of their lower extremities.

They can have like redid in back, you know, low back pain, right? And typically, what is the thing that's going to make it worse, right? The thing that makes it worse is going to be a dead giveaway, walking or extension of your spine. Basically, are you like standing up straight? Are you walking up straight? That's going to make it hurt. But what's going to make it feel better? Well, if you sit down or you lean forward, right? You use a shopping cart, right? They're not going to use the term shopping cart on your exam. That's ridiculous, right? That's, that's too easy, right? But it, they tell you that this person symptoms improving the sit down, right? When they lean forward, that tells you that, okay, this person probably has a spinal stenosis, right? Spinal stenosis, right? In fact, sometimes the spinal stenosis can be so bad that it compresses the gross stenosis, right?

And then, the spinal stenosis can be so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad tha

t it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad

that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that it's so bad that's absolutely something you can see on your exams but just to summarize because I feel like I've said many different permutations for for back pain for low back pain the thing is so let me just kind of summarize low back pain most times on your exams is going to be from like a lumber strain or a lumber spring right, paraspino muscle tenderness paraspino muscle tenderness that's the big big big thing right now I also talked about how or pressing me have a herniated disc I talked about how they'll have redid in pain right and then they'll also have sometimes they can give you low motor on your own symptoms right but that's a short leg raise that's a slam dunk that's a herniated disc right I talked about spinal stenosis right neurogenic clodication is going to be the big big big thing you're looking for on your exams right and then I also talked about like what if they give you like a histra of like prostate cancer or breast cancer right and the person is having like back pain neuro deficits and all those things right that's metastasis right that's metastasis and then I talked about how if you see a bowel bladder dysfunction pressing a sadula anesthesia have a lot they have like low motor neuron symptoms I've talked about how you should think about a correct whine syndrome on the two circumstances right and then again remember spinal stenosis again sometimes may ext

end and actually compress the spinal cord itself right then you have like a positive rumberg test you have a positive rumberg test right because remember the rumberg test is a test of brosoculum function right or them even have like a white base gig see whenever our friends at the mbm is let me see this this is why MSK is it's kind of difficult because there's all these permutations you need to learn whenever our friends at the mbm is talk about a person that has neurogenic clodication and the person has a positive rumberg test or the person has a white base gate sometimes on the exams instead of putting spinal stenosis as an answer you'll put lumber my lopathy as an answer lumber my lopathy as an answer or spinal my lopathy as an answer and this should not be a surprise to you why is it a my lopathy again remember my lopathy is when you have an issue with your spinal cord radical lopathy is when you have an issue with your nerve root right spinal stenosis may present as a radical lopathy may present as a my lopathy or may present as both right but the presence of this abnormal rumberg test telenoids that all the brosoculum is messed up or the white base gate telenoids that the person spinal cerebellar tract is messed up it kind of tells us that oh the spinal cord is now involved right because those are spinal cord pathways the spinal cord is now involved the person now has a my lopathy right so the thing is the u.s.m.l.s and this is something I emphasize a lot in my testic and strategy class the u.s.m.l.s they love to occasionally you know give like alternate names for things just to throw people off because they know that everybody that has the job description medical student has memorized oh if you see neurogenic clodication big spinal stenosis right but why put spinal stenosis as an answer where you can just put lumber my lopathy right just to see if a person trul

y understands what's going on right and one other thing I want to say about low back pain is if you see low back pain in a young male that's worse in the morning and then it gets better as this young male you know kind of stretches exercises and stuff like that they can make this a military question believe it or not then you want to think about ankylosing spondylitis on the those circumstances you won't think of ankylosing spondylitis on the those circumstances so again just as a summary what are the people that you get imaging for when they have low back pain when you suspect korea quina syndrome although give the dexamethasone first when you suspect that you have some kind of malignancy that's compressing things right go ahead and get imaging get an MRI when you suspect that it's an infection right especially like when they tell you that oh the person is like an IV drug user right an IV drug user and then this person has like fever has low back pain right and you know they may have these neuro deficits right that that's an infection the person may have like spinal osteomyitis for example in those circumstances you need to get an MRI you absolutely need to get an MRI right and I don't know these good ideas keep popping in my head let me tell you something the usml is love to do because they know that many people have memorized again sorry I'm gonna continue but this thing's important to know sorry right many people know oh IV drug user IV drug user back pain fever oh back pain fever that's a that's a spinal infection right that's like spinal osteomyitis or whatever let me tell you one devious thing our friends at the mb and used to do you know that it's not only IV drug users that can get spinal osteomyitis they can give it to a person that has a UTI a person that either has an ongoing UTI or a person that has recently had a UTI and then they have like fever and low

back pain think of a spinal infection that infection from the that that UTI the box can actually spread and then involve the spinal cord that is a very very high your situation you want to know for your for your exams very high your situation you want to know for your exams right so again please what are the people that get imaging if you suspect that it's cancer you suspect that it's infection right you suspect it's called a quina syndrome right or if a person has like very severe neurologic deficits on presentation right that tells you that man there's something really bad going on go ahead and get imaging in those circumstances right go ahead and get imaging in those circumstances go ahead and get imaging in those circumstances right but again for most cases of low back pain when you don't have these crazy red flags what are you supposed to do right remain active don't pick the answer that says bed rest right remain active you know you can apply heat right you can do a massage of the you know you could do like massages you can give NSAI Ds right although many times even on the exams they don't put NSAI Ds as answers they just want you to use these conservative measures right they want to use these conservative measures okay they want to use these conservative measures now the let me tell you two things you should not pick on your exams for a spinal pain right for like back pain please do not pick opioids for low back pain opioids no no no no no no that'll be a ginormous mistake on your exam so please don't do that oh another classic one is okay inject steroids into the low back for low back pain no please do not do that do not do that the only time you're gonna be using steroids is if it's cancer right if it's cancer that's causing a person's low back pain or malignancy that's the only time you're gonna use steroids that's the only time you're gonna use steroids rig

ht that's the only time you're gonna do what you're gonna use steroids right and those steroids you're you're getting IV steroids we're not like injecting steroids directly into the into the back no that's not what we're doing that's not what we're doing please be very very careful about this I would really hope that you're realizing from this podcast why many people tend to get these questions you know supremely wrong on the exams right you know if a person has a lot of like muscle spasms you may also just give them like a muscle relaxant again like something like a backloaf in for example but again those things should only be used for a short time don't use them for a long period of time don't use them for a long period of time please them for a long period of time all right so I think this is what I'm gonna largely discuss and I'm gonna kind of stop things here right I'm gonna go ahead and stop things here again please make sure you know this make sure you know these things for your exams and I think you're gonna be in pretty good shape all right so let's go ahead and stop here if you love the way I teach you love the way I make integrations I think you'd really benefit from my classes I have a 20 hour class for step two step three I know a lot of people are pining to take their exams you know and get their scores in before eras right so I have a class literally this weekend Friday evening all of Saturday and some part of Sunday so that you can getting that material and dwell on your exams again I've had many people that are taking this exact same class that I've got in the 250's 260's 270's on their exams right and then the next week I have like a test taking class for step one to step three I have a four-hour biostatistics class I have a five-hour social sciences quality improvement and healthcare systems class and ethics class as well and then on Friday I have a

last minute review again many people have taken these classes found them to be extremely helpful I also offer one on one tutoring for the US Emily exams all the US semiles all the complex exams shelf exams and things like that and then in addition I also offer I also offer help with eras applications mock interviews recommendation letters personal statements I edit all those things if you're interested in any of these things just shoot me an email through the website and I can give you some more information and then I have this podcast on Apple Google and Spotify so please go ahead and check those out and then I also offer these I have a You Tube channel where I post the videos that I make and then have another website titled divineinterventionlifelessons.com divineinterventionlifelessons.com every week I post like one or two podcasts many of you know I'm a Christful or I'm a Christian so every week I post like one or two podcasts where from I I discuss a life lesson from a biblical perspective there's actually an Apple podcast associated with that called the divine intervention life lessons podcast so thank you for listening to me today I will see you God willing episode 620 have a wonderful rest of your day God bless you and bye for now thank you

Numbness/tingling in the 4th and 5th digits, tenderness at the medial elbow crease, positive Tinel sign over the cubital tunnel.

Lateral epicondylitis (Tennis Elbow).

Myelopathy shows mixed UMN/LMN signs; Radiculopathy typically shows a more localized pattern dominated by LMN signs.

Fever + Low Back Pain, or any history suggesting malignancy/infection (e.g., IV drug use, recent UTI).

Steroid injections and assuming restricted range of motion indicates a joint problem (it does not).

Symptoms worse with extension/standing, but relieved by flexion/sitting or leaning forward.

The ulnar nerve.

Wrist flexion and pronation.

Cervical myelopathy (spinal cord compression).

Spinal stenosis (Neurogenic claudication).

Conservative measures (rest, stretching, activity modification); avoid imaging and steroid injections.

Spinal cord involvement/myelopathy.

The ulnar nerve.

Wrist flexion and pronation.

Cervical myelopathy (spinal cord compression).

Spinal stenosis (Neurogenic claudication).

Conservative measures (rest, stretching, activity modification); avoid imaging and steroid injections.

Spinal cord involvement/myelopathy.