All movement, including the movement of the body itself and of the internal organs, is performed by muscle tissue. The three types of muscle tissues, defined histologically, are striated (skeletal), nonstriated (smooth), and cardiac (Figure 7-2). Muscle is also classified as either voluntary or involuntary. Skeletal muscle is voluntary and is under the control of the conscious mind; this includes the muscles used to move the extremities, which have been stimulated by nerves at the request of the brain. The point of attachment of a muscle to a stationary bone is referred to as the origin of the muscle, and the point of attachment to a bone that is moved by the muscle is referred to as its insertion (Figure 7-3). When a muscle contracts, the insertion moves toward the origin. Smooth muscle and heart muscle are involuntary and function without conscious control or awareness. Examples are the muscles of the intestines that move the bowels and cardiac muscles, which cause the beating of the heart.

The skeletal system is composed of 206 bones. These serve to provide an important support system for the many body parts, enabling a person to assume various body postures (Figure 7-4). In coordination with muscles and joints, bones assist body movement.

FIGURE 7–4 Normal skeletal system, anterior view.

Some bones encase and protect specific organs (e.g., the skull protects the brain, and the rib cage and the backbone protect the heart, lungs, and spinal cord). The blood cells are formed in the bone marrow inside the bones in a process called hematopoiesis. E7-1

Bones are not lifeless structures, but instead are structures infused with living cells arranged in a hard framework of minerals (calcium and phosphorus). The bone cells are continuously forming new bone; bone formation is counterbalanced by bone reabsorption or breakdown. Normally the balance of these two processes prevents bones from becoming excessively thick, as with Paget’s disease of the bone, or too thin, as with osteoporosis. It also serves to maintain the normal blood level of calcium and phosphorus in the body.

Bones are complete organs; they are composed mainly of connective tissue with a rich supply of blood vessels and nerves. They develop through a process called osteogenesis, and the complete skeleton is formed by the end of the third month of fetal age. The fetal skeleton is composed of cartilage tissue, which is replaced gradually by bone cells in a process called ossification. Ossification depends on an adequate supply of calcium and phosphorus getting to the bone tissue.

Several different types of bone make up the skeleton. Long bones are strong and have broad ends and large surface areas for muscle attachment. They are found in the humerus (arm), the ulna and radius (forearm), the femur (thigh), and the tibia and fibula (leg). Short bones have small, irregular shapes and include the carpal (wrist) and the tarsal (ankle) bones. Flat bones cover soft body parts; they include the scapula (shoulder), ribs, and pelvic bones. Sesamoid bones are small and rounded and are found near joints. The patella (kneecap) is the largest sesamoid bone.

Joints, or articulations, are body structures in which bones are joined or the surfaces of two bones come together for the purpose of creating motion. With the help of ligaments, joints hold bones firmly together yet allow movement between them. Joints are classified by the type of material found between the bones: fibrous, cartilaginous, and synovial. Joints also are classified according to the degree of movement (Figure 7-5) they can make. Immovable (synarthrodial) joints (e.g., suture joints between the bones of the skull) are connected by fibrous tissue; slightly movable (amphiarthrodial) joints (e.g., the intervertebral joints and the pubic symphysis) are connected by cartilage; and freely movable (diarthrodial) joints (e.g., the knee and the elbow) are called synovial joints because they are lined with the fluid-producing synovial membrane. Also within synovial joints are bones, cartilage that covers the ends of the bones, ligaments that hold bones together, a joint capsule containing synovial fluid, blood and lymph vessels, and nerves.

Most joints are the freely movable type. The amount or degree of movement that a joint has is referred to as its range of motion (ROM). Only the freely movable joints can execute a wide range of movements; examples are the shoulder, wrist, and hip.

Ligaments are tough, dense, fibrous bands of connective tissue that hold bones together, either around a joint capsule (e.g., the hip joint) or across a joint (e.g., the knee [Figure 7-6]). They allow movement in some directions while restricting it in other directions, thereby providing some stability. Injury to ligaments can occur in several ways; they can be overstretched and sustain partial or complete tears (sprains) or be torn completely loose from their attachment to a bone, an injury called an avulsion.

FIGURE 7–6 Ligaments and tendons of the knee joint.

Tendons are tough strands, or cords, of dense connective tissue. They serve to attach muscles to bones and other parts (see Figure 7-6). Tendons are nonelastic and are capable of withstanding great forces from contracting muscles without sustaining damage. Injury to a tendon is called a strain.

Fascia is a specialized flat band of tissue located just below the skin that covers and separates underlying tissues, commonly muscle layers. Inflamed or injured fascia is referred to as fasciitis.

Cartilage is a semismooth, dense, supporting connective tissue that is found at the ends of bones. It forms a cap over the ends of bones and provides support and protection when they are engaged in weight-bearing activities. Cartilage absorbs the energy force of weight pressed or thrust against joints to prevent injury to joints, bones, and the cartilage itself; in effect, it functions as a “shock absorber.” To remain healthy, cartilage at the joints must receive nutrients from the joint fluid and maintain normal joint movement and weight-bearing activities.

Also necessary for the functioning of the musculoskeletal system are the bursae, closed sacs or cavities of synovial fluid lined with a synovial membrane. Positioned between tissues such as tendons, bones, and ligaments, bursae make it possible for these tissues to glide over each other without creating friction. Bursae are located in the shoulder (see Figure 7-15), elbow, and knee joints.

Another substance found throughout the musculoskeletal system is a fibrous protein called collagen. Collagen constitutes 30% of the total body protein and is the major supporting element, or glue, in the connective tissues between the cells that holds them together. In adults, collagen makes up one third to one half of the total body protein (see “Connective Tissue Diseases” section in Chapter 3).

Fibromyalgia

Spinal Disorders

Lordosis

Description

Lordosis is an exaggerated inward curvature of the spine. Lordosis is sometimes referred to as a swayback or saddleback deformity.

ICD-9-CM Code 737.20

ICD-10-CM Code M40.40 (Postural lordosis, site unspecified)

(M40.40-M40.57 = 8 codes of specificity)

Symptoms and Signs

The lumbar spine normally curves inward. This normal anterior curve of the lumbar spine can become exaggerated by a variety of conditions. Excessive inward curvature, or lordosis, occurs as the person compensates for added abdominal girth caused by pregnancy, obesity, or large abdominal tumors. Lordosis also can occur developmentally for unknown reasons. Lordosis may cause no symptoms, or the patient may experience low back pain because of strains on the muscles and ligaments. As compared with normal spine posture (Figure 7-8), lordosis results in a protruding abdomen and buttocks and an arched lower back (Figure 7-9).

Patient Screening

Schedule the patient complaining of persistent low back pain, but no history of injury or symptoms of infection, for the first convenient appointment.

Etiology

Excessive abdominal weight gain and mass cause an individual to compensate by unconsciously tightening muscles in the low back to maintain balance when standing. Lordosis often is noted in prepubescent girls. One possible cause is rapid skeletal growth that occurs without the necessary natural stretching of the posterior soft tissues. Osteoporosis, with resulting loss of bone mass, may cause lordosis in the older population.

Diagnosis

Patients who have persistent low back pain should be evaluated for degenerative and congenital diseases of the spine, and inflammation of the spine (spondylitis) and conditions involving adjacent internal organs, such as the kidneys, prostate gland, aorta, and pancreas.

Observation of the spine in various postural positions and an examination of the lower spine are the primary steps in diagnosis. When the condition is a result of pregnancy, no additional information usually is required to make the diagnosis. Further investigation can include radiographic studies to determine the extent of lordosis, along with a thorough history and physical examination to discover the underlying cause of the condition.

Treatment

When lordosis is caused by pregnancy, delivery of the infant usually resolves the condition. When obesity is the cause, weight loss and exercises to strengthen abdominal muscles are beneficial. Performing pelvic tilt exercises and maintaining good posture help to correct the condition. Progressive untreated lordosis can lead to degenerative lumbar disk disease or ruptured lumbar disks. Additional treatment of the condition can include the use of a brace. For severe lordosis, spinal fusion and displacement osteotomy are considered. This latter procedure requires the surgical division of a vertebra with shifting of the bone segments to change the alignment of, or alter weight-bearing stress on, the spine.

Prognosis

Lordosis may never cause symptoms, but patients who do have symptoms usually respond to conservative management techniques.

Prevention

Optimal prevention measures center around developing ideal posture habits, exercises, and support devices, such as braces and lumbar support when seated.

Patient Teaching

Patients can benefit from a brief review of the normal anatomy of the affected areas, particularly addressing the spine and paraspinous musculature, as well as specific exercise instructions. Recommendations on proper posturing and adjustments to their specific sitting environments can be extremely valuable.

Kyphosis

Description

Kyphosis is an abnormal outward curvature of the spine (convexity backward).

ICD-9-CM Code 737.10

ICD-10-CM Code M40.00 (Postural kyphosis, site unspecified)

M40.209 (Unspecified kyphosis, site unspecified)

(M40.00-M40.299 = 19 codes of specificity)

Symptoms and Signs

Kyphosis, an excessive posterior curve of the thoracic spine, often has an insidious onset and is asymptomatic until the hump becomes obvious. As the curve progresses, the patient may begin to experience mild pain, fatigue, tenderness along the spine, and decreasing mobility of the spine. The shoulders appear rounded, and the head protrudes forward (Figure 7-10, A).

FIGURE 7–10 A, Kyphosis. B, Kyphosis associated with Scheuermann’s disease. (B from Mourad LA: Orthopedic disorders-Mosby’s clinical nursing series, St Louis, 1991, Mosby.)

Patient Screening

Schedule the individual complaining of persistent upper back pain, without history of injury or symptoms of infection, for an appointment at his or her convenience.

Etiology

Kyphosis that occurs in very young children has no specific cause and is believed to be developmental. Adolescent kyphosis usually is related to Scheuermann’s disease, a degenerative deformity of the thoracic vertebrae (Figure 7-10, B). Additional disease processes that contribute to the occurrence of kyphosis include tumors or tuberculosis of the vertebral bodies and ankylosing spondylitis. Collapse of vertebrae from the weakened bone of osteoporosis is often responsible for the hunchback that develops in the older person, particularly the postmenopausal woman. Wearing away of the anterior portion of the vertebrae in a wedge type of manner (anterior wedging) or deterioration of the vertebrae, from whatever cause, results in the excessive curvature with kyphosis.

Diagnosis

Visual inspection of the spine discloses the excessive curve in the thoracic region. Radiographic films and bone scans document the concave curvature of the thoracic spine along with the wedging of the anterior aspect of the vertebral bodies (see Figure 7-10, B). Older patients with osteoporosis have a loss of bone density.

Treatment

Exercises to strengthen the muscles and ligaments are prescribed. Back braces also are used to stabilize the condition. The underlying cause must be determined and treated. When other measures fail to produce results and when the respiratory and cardiac systems are compromised, spinal fusion with instrumentation and temporary immobilization is performed. Kyphosis that is caused by a sudden collapse of a vertebra because of osteoporosis is sometimes treated with a new procedure called vertebroplasty, in which a balloon is inflated within the vertebra and methyl methacrylate is inserted to provide a “cement” foundation to maintain reestablished vertebral height.

Prognosis

The outlook for patients with kyphosis depends on the cause. Optimal outcome results from accurate diagnosis and early treatment.

Prevention

Optimal prevention measures center around developing ideal posture habits, exercises, and support devices, such as braces and back support when seated. Medications may be needed for osteoporosis, pain, or inflammation of the spine.

Patient Teaching

Patients with kyphosis who are found to have significant osteoporosis should be instructed regarding exercise programs, calcium and vitamin D supplementation, and prescription medications.

Scoliosis

Description

Scoliosis is a lateral (sideways) curvature of the spine. Scoliosis typically is congenital, but some diseases also can cause it.

ICD-9-CM Code 737.30 (Acquired; postural)

754.2 (Congenital)

ICD-10-CM Code M41.20 (Other idiopathic scoliosis, site unspecified)

(M41.00-M41.9 = 55 codes of specificity)

Q67.5 (Congenital deformity of spine)

Q76.3 (Congenital scoliosis due to congenital bony malformation)

Q76.425 (Congenital lordosis, thoracolumbar region)

Q76.426 (Congenital lordosis, lumbar region)

Q76.427 (Congenital lordosis, lumbosacral region)

Q76.428 (Congenital lordosis, sacral and sacrococcygeal region)

Symptoms and Signs

Scoliosis, a lateral curvature of the spine, often has an insidious presentation, possibly going unnoticed for years before detection. In women, for example, the first indication is often unequal bra strap lengths. The patient, usually an adolescent female, reports back pain, fatigue, and sometimes shortness of breath with exertion. Observation of the back reveals a lateral curve of the spine, one shoulder higher than the other, one scapula more prominent than the other, one hip higher than the other, and when the patient bends over, an enlarged muscle mass on one side of the back (Figure 7-11).

Patient Screening

Referrals may come from school scoliosis screening programs that have detected possible scoliosis.

Etiology

Idiopathic scoliosis is the most common form; however, the cause is postulated to be genetic in some cases. Other suggested causes of scoliosis are deformities of the vertebrae, uneven leg lengths, and muscle degeneration or paralysis from diseases, such as poliomyelitis, cerebral palsy, and muscular dystrophy.

Diagnosis

Patients with scoliosis are evaluated for muscle disease and weakness, congenital conditions, neurologic disorders, and degeneration of the bones and disks of the spine. Diagnosis is made from visual examination of the back, which reveals uneven shoulder and hip heights, a prominent scapula on one side, an enlarged muscle mass on one side, and a definite torsional curve of the vertebral column. It is important to examine the lengths of the lower limbs because discrepancy of the leg lengths can lead to spinal curvature. Radiographic films not only confirm the diagnosis but also provide the physician with a means of measuring the degree of curvature. This is also useful for long-term monitoring.

Treatment

Treatment depends on the extent and cause of the curve. Mild scoliosis is treated with exercise to strengthen the weak muscles. Bracing of the back with a Milwaukee brace or a molded plastic clamshell jacket, along with an exercise program, is the suggested course of treatment for the growing girl or boy. This bracing may take from 2 to 5 years to prevent further curvature. Curves that do not respond to the bracing or that are severe (greater than 40 degrees) need surgical intervention to decrease the curve and to realign and stabilize the spine. These procedures include fusion of the vertebrae and internal fixation with instrumentation by means of rods, wires, or plates and pedicle screws. Some patients are placed in body casts or plastic jackets to maintain the integrity of the fixation until the fusion heals. The respiratory and cardiac systems may be compromised if the curvature is left untreated.

Prognosis

The outlook for patients with scoliosis depends primarily on the severity of the curvature. Optimal outcome results from accurate diagnosis and early treatment.

Prevention

Prevention measures center around developing ideal posture habits, performing beneficial exercises, and wearing support devices, such as the braces described above. Timely surgical intervention is key for severely affected children.

Patient Teaching

Posture training, regular use of proper bracing, and instructions for avoiding stresses to the affected spine are essential for ideal management. Children with significant scoliosis should avoid aggressive contact sports, such as football and rugby.

Osteoarthritis

Description

Osteoarthritis is a type of arthritis that results from the breakdown and eventual loss of the cartilage of one or more joints.

ICD-9-CM Code 715.9 (Requires 5th digit)

ICD-10-CM Code M15.9 (Polyosteoarthritis, unspecified)

(M15.0-M15.9 = 7 codes of specificity)

M19.90 (Unspecified osteoarthritis, unspecified site)

(M19.01-M19.93 = 49 codes of specificity)

Osteoarthritis is coded according to the site affected. Refer to the physician’s diagnosis and then to the current editions of the ICD-9-CM and ICD-10-CM coding manuals for most accurate specificity.

Symptoms and Signs

Osteoarthritis, also known as degenerative joint disease or degenerative arthritis, is by far the most common form of arthritis. It develops as a result of normal wear and tear on the joints and is most common in the elderly, being almost universal in those older than 75 years. Osteoarthritis occurs mainly in the large weight-bearing joints, especially the knees and hips (Figure 7-12). There is a tendency for the smallest joints at the ends of the fingers to be affected by spur formation that leads to the classic bony enlargement referred to as a Heberden’s node. To a lesser degree, involvement of the joints of the fingers at the proximal interphalangeal joints (Bouchard’s nodes, Figure 7-13)—wrists, elbows, and ankles—can occur. Degenerative changes in the spinal vertebrae and the joints of the pelvis can lead to abnormal curvature and local pain.

FIGURE 7–12 Schematic presentation of the pathologic changes in osteoarthritis. Fragmentation and loss of cartilage denude the subchondral bone, which undergoes sclerosis and cystic change. Osteophytes form on the lateral sides and protrude into the adjacent soft tissues, causing irritation, inflammation, and fibrosis. (From Damjanov I: Pathology for the health professions, ed 4, St Louis, 2012, Saunders.)

The onset of osteoarthritis is usually insidious, and the symptoms vary with the severity of the disease. Some of the common symptoms are joint soreness, aching, and stiffness, especially in the morning and with changes in the weather; edema; dull pain; and deformity. Stiffness is noted, particularly after the patient has been immobile for a period of time. Clicking or crackling sounds (crepitation) often are heard with joint movement. Decreased ranges of motion, joint instability, and an increase in pain with use of the joints are also common.

Patient Screening

When a patient develops a persistent joint problem, a thorough history and physical examination is essential. Schedule the first available appointment. Subsequently follow office policy for referral to a rheumatologist.

Etiology

The exact cause of most osteoarthritis is unknown, but it appears to be generally associated with aging. The tendency toward developing osteoarthritis is sometimes inherited. In some persons, osteoarthritis may follow injury to the joint, or be associated with hormonal disorders or underlying diseases, such as diabetes and obesity.

Diagnosis

Patients must be evaluated to exclude the more than 100 other forms of arthritis, and any underlying diseases or conditions must be detected as well. The diagnostic investigation begins with physical examination and patient history. Radiographic films, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans confirm the presence and document the severity of osteoarthritis. Plain radiographic testing can be very helpful for excluding other causes of pain in a particular joint. Radiographic tests also can measure the severity of the osteoarthritis and assist in deciding when surgical intervention should be considered.

Treatment

Because osteoarthritis cannot be cured, the goal of treatment is to reduce inflammation, to minimize pain, and to maintain functioning joints. Treatment of osteoarthritis involves physical and drug therapy, nutritional management, and supportive care. Surgery also may be needed in severe cases. Physical therapy includes range-of-motion exercises, alternation of moist heat and cold applications, massage therapy, and the use of elastic bandages and splints for limb support. Drug therapy can include the use of analgesics, muscle relaxants, and NSAIDs. Intraarticular steroid injections may be used for specific or individual joints. Intraarticular hyaluronic acid can be used to reduce pain in affected knee joints. Fish oils have been suggested to have some antiinflammatory properties. Food supplementation with glucosamine and chondroitin may reduce pain and stiffness in some patients. For supportive care, it may be necessary to use a cane, walker, braces, or crutches to lessen the strain on some joints. Restricting physical activity or resting affected joints also may be necessary. Surgery for osteoarthritis may involve total joint replacement. Joints commonly replaced are the base of the thumb, the hip, and the knee. Ankle, wrist, elbow, and shoulder joints also can be replaced. Joint fusion may be done to increase stability for the cervical and lumbar vertebrae.

Prognosis

The outlook for patients with osteoarthritis depends primarily on the severity and location of the involved joints. Optimal outcome results from accurate diagnosis and early management.

Prevention

Avoiding injury and reinjury to joints is important in preventing future osteoarthritis. Persons with flaccid (overstretched) ligaments may require support devices to engage in some activities. Early contact with health care practitioners can optimize long-term health.

Patient Teaching

Providing specific guidance on food supplementation, medications, and proper exercise can significantly improve the quality of life for these patients.

Lyme Disease

Description

Lyme disease is an infectious disease caused by the spirochete bacterium. Ticks that bite the skin spread Lyme disease by injecting the bacterium from their gut into the human body. Lyme disease can affect the skin, joints, heart, and nervous system.

ICD-9-CM Code 088.81

ICD-10-CM Code A69.20 (Lyme disease, unspecified)

(A69.20-A69.29 = 5 codes of specificity)

Symptoms and Signs

Lyme disease, also known as Lyme arthritis, was first detected in 1975 in Lyme, Connecticut. Lyme disease is more prevalent in the northeast part of the United States, especially New York, New Jersey, and Connecticut, where large areas of forests and fields provide a habitat for ticks. The disease has been found, however, in all 50 states and on five continents.

Lyme disease can occur in any age group, and no one is immune to the infection. Approximately half of all patients with Lyme disease have a characteristic red, itchy rash with a red circle center resembling the bull’s eye on a target (target lesion) (Figure 7-14, A) early in the illness. Lyme disease can masquerade as arthritis and cause influenza-like symptoms, such as headache, fever, fatigue, joint pain, and general malaise. If the person does not seek medical attention for the symptoms, complications of muscle weakness, paralysis, and neurologic conditions (e.g., learning difficulties, excessive fatigue, and muscle coordination problems) can develop as the bacterium spreads unchecked internally. Encephalitis, gastritis, or carditis may develop in some patients.

FIGURE 7–14 A, Target lesion of Lyme disease. B, Tick that causes Lyme disease. (From Stone DR, Gorbach SL: Atlas of infectious diseases, Philadelphia, 2000, Saunders.)

Patient Screening

Early detection of Lyme disease is imperative because treatment can avoid more significant organ-threatening consequences. In areas where the deer tick is prevalent and/or the patient reports a “target lesion,” a visual inspection and diagnostic laboratory tests are necessary. Likewise, if a patient reports flulike symptoms 2 to 4 weeks after receiving a tick bite, an appointment for prompt diagnostic evaluation is indicated.

Etiology

Lyme disease is caused by a spirochete bacterium, which is transmitted to humans by a bite from a small tick (Figure 7-14, B) that is carried by mice or deer. In the United States, the bacterium is Borrelia burgdorferi. In Europe, the bacterium Borrelia afzelii also causes Lyme disease. The disease is usually transmitted to humans while they are camping or hiking in woods, fields, or other areas that ticks inhabit. After infiltrating the skin, the bacterium can infect internal organs of the body, causing a variety of symptoms, which often leads to delay in making the correct diagnosis.

Diagnosis

The evaluation of patients with the nonspecific symptoms of early Lyme disease, such as headache, fever, fatigue, joint pain, and general malaise can be exhaustive. A complete history, physical examination, and laboratory tests are important for excluding other infectious diseases, forms of arthritis, immune diseases, muscle diseases, and even cancer.

The diagnosis of Lyme disease can be based on physical examination (the discovery of a tick on the skin), the presence of the classic target lesion, and the patient history. Confirmation is attained by positive test results for the Lyme antibodies or by directly identifying the bacterium in the infected skin via biopsy if necessary.

Treatment

Treatment of Lyme disease begins with removal of the tick, if it is found on skin or clothing. Early treatment is imperative because treatment in the early stages of disease leads to a complete cure with simple oral antibiotics. The drug of choice for Lyme disease is doxycycline. The CDC also recommends amoxicillin or cefuroxime. Lyme disease in the later stages requires intravenous antibiotics, such as ceftriaxone or penicillin, to cure the disease. Antipyretics are given for headache and fever. Bed rest is necessary if neurologic symptoms are present, and physical therapy is prescribed for impaired musculoskeletal mobility. Joint symptoms are often treated with antiinflammatory medications and hydroxychloroquine.

Prognosis

Lyme disease is curable with antibiotics. The outlook for patients with Lyme disease is a function of how early it is detected. Early stage Lyme disease involves a minor skin rash with muscle aching that easily resolves with antibiotics. Later stage Lyme disease can cause residual damage to the joints, heart, or nervous system. Optimal outcome results from accurate diagnosis and early treatment.

Prevention

Avoiding tick bites is the best prevention of Lyme disease. When inhabiting locations known to harbor ticks, persons should wear long clothing to protect the skin. Carefully examine all clothing first and then the entire body, including the scalp, to detect the presence of ticks after being in high-risk areas. Close inspection of children and pets is especially important. Ticks can be removed gently with tweezers and saved in a jar in case identification of the vector is needed later. Bathing the skin and scalp and washing clothing after possible exposure to ticks may prevent the bite and subsequent transmission of the disease. Vaccines were once available, but these have been removed from the market. Further studies of vaccines are needed.

Patient Teaching

Community awareness of tick-avoidance measures is essential for prevention. Patients who develop Lyme disease should be instructed to closely follow the specific instructions provided by their qualified health care practitioners regarding therapeutic medications.

Bursitis

Description

Bursitis is inflammation of a bursa. A bursa is a tiny fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body. Bursae are found between muscles and tendons and cover bony prominences to facilitate movement. They can become inflamed, infected, or traumatized. The major bursae are located adjacent to the tendons of the large joints, such as the shoulders, elbows, hips, and knees.

ICD-9-CM Code 727.3

727.2 (Specific bursitis often of occupational origin)

ICD-10-CM Code M71.50 (Other bursitis, not elsewhere classified, unspecified site)

(M71.10-M71.19 = 24 codes of specificity; M71.50-M71.58 = 20 codes of specificity)

M70.039 (Crepitant synovitis [acute] [chronic], unspecified wrist)

(M70.031-M70.049 = 6 codes of specificity)

M70.30 (Other bursitis of elbow, unspecified elbow)

(M70.30-M70.32 = 3 codes of specificity)

M70.40 (Prepatellar bursitis, unspecified knee)

(M70.40-M70.52 = 6 codes of specificity)

Symptoms and Signs

The classic symptoms of bursitis are tenderness, pain when moving the affected part, flexion and extension limitation, and edema at the site of inflammation. The most frequently affected bursae are those of the shoulder (Figure 7-15), elbow, knee, hip, and between the tendons and muscles of the tibia. Point tenderness may be present, in which case the patient actually can point to the spot of greatest tenderness. If bursae are continually or chronically irritated and inflamed, calcifications can develop. In addition, adhesions can occur around an affected bursa, which limits the movement of the tendons.