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 American Academy of Orthopaedic Surgeons
American Academy of Pediatrics

Essentials of
Musculoskeletal
Care
April D. Armstrong, BSc(PT), MSc, MD, FRCSC
Mark C. Hubbard, MPT
Editors
 Board of Directors, 2015-2016
Published 2016 by the
David D. Teuscher, MD
American Academy of Orthopaedic Surgeons
President
9400 West Higgins Road
Gerald R. Williams, Jr, MD Rosemont, IL 60018
First Vice President
William J. Maloney, MD Fifth Edition
Second Vice President Copyright 2016
Frederick M. Azar, MD by the American Academy of Orthopaedic Surgeons
Treasurer
Frederick M. Azar, MD The material presented in Essentials of Musculoskeletal Care, 5th Edition
Past President has been made available by the American Academy of Orthopaedic
Lisa K. Cannada, MD Surgeons for educational purposes only. This material is not intended
Howard R. Epps, MD
to present the only, or necessarily best, methods or procedures for the
medical situations discussed, but rather is intended to represent an
Daniel C. Farber, MD
approach, view, statement, or opinion of the author(s) or producer(s),
Daniel K. Guy, MD which may be helpful to others who face similar situations.
Lawrence S. Halperin, MD
David A. Halsey, MD Some drugs or medical devices demonstrated in Academy courses or
David J. Mansfield, MD described in Academy print or electronic publications have not been
cleared by the Food and Drug Administration (FDA) or have been cleared
Raj D. Rao, MD
for specific uses only. The FDA has stated that it is the responsibility
Brian G. Smith, MD of the physician to determine the FDA clearance status of each drug or
Ken Sowards, MBA device he or she wishes to use in clinical practice.
Jennifer M. Weiss, MD
Karen L. Hackett, FACHE, CAE (ex officio) Furthermore, any statements about commercial products are solely the
opinion(s) of the author(s) and do not represent an Academy endorsement
Staff or evaluation of these products. These statements may not be used in
Ellen C. Moore, Chief Education Officer advertising or for any commercial purpose.
Hans Koelsch, PhD, Director, Department of
All rights reserved. No part of this publication may be reproduced, stored
Publications
in a retrieval system, or transmitted, in any form, or by any means,
Lisa Claxton Moore, Senior Manager, Book electronic, mechanical, photocopying, recording, or otherwise, without
Program
prior written permission from the publisher.
Laura Goetz, Managing Editor
Steven Kellert, Senior Editor Library of Congress Control Number: 2015945905
Michelle Wild, Associate Senior Editor
Courtney Dunker, Editorial Production Manager ISBN 978-1-62552-415-7
Abram Fassler, Publishing Systems Manager Printed in the USA
Suzanne O’Reilly, Graphic Designer
Susan Morritz Baim, Production Coordinator Cover art
Karen Danca, Permissions Coordinator Robert Liberace
Charlie Baldwin, Digital and Print
Production Specialist Anatomic Illustrations
Scott Thorn Barrows, MA, CMI, FAMI
Hollie Muir, Digital and Print Production
Specialist
Emily Nickel, Page Production Assistant
Genevieve Charet, Publications Assistant
Brian Moore, Manager, Electronic Media
Programs
Katie Hovany, Digital Media Specialist

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

 Essentials of Musculoskeletal Care, 5th Edition
Editorial Board
April D. Armstrong, BSc(PT), MSc, MD, FRCSC
Professor, Chief Shoulder and Elbow Surgery
Bone and Joint Institute
Penn State Milton S. Hershey Medical Center
Hershey, Pennsylvania

Mark C. Hubbard, MPT

Physical Therapist
Bone and Joint Institute
Penn State Milton S. Hershey Medical Center
Hershey, Pennsylvania

Joseph A. Abboud, MD Letha Y. Griffin, MD, PhD

Orthopaedic Surgeon, Associate Professor Peachtree Orthopaedic Clinic
Shoulder & Elbow Surgery Team Physician
The Rothman Institute Georgia State University
Philadelphia, Pennsylvania Atlanta, Georgia

Julie E. Adams, MD, MS Joseph A. Janicki, MD, MS

Associate Professor Assistant Professor of Orthopaedic Surgery
Orthopaedic Surgery Northwestern University Feinberg School of Medicine
Mayo Clinic Attending Physician, Orthopaedic Surgery
Rochester, Minnesota Ann & Robert H. Lurie Children’s Hospital
Chicago, Illinois
Daniel T. Altman, MD, FACS
Associate Professor of Orthopaedic Surgery Robert Z. Tashjian, MD
Drexel University College of Medicine Associate Professor
Allegheny General Hospital Orthopaedics
Pittsburgh, Pennsylvania University of Utah School of Medicine
Salt Lake City, Utah
Umur Aydogan, MD
Assistant Professor of Orthopaedics Kelly L. VanderHave, MD
Foot and Ankle Surgery Carolinas Medical Center
Bone and Joint Institute Levine Children’s Specialty Center
Penn State Milton S. Hershey Medical Center Pediatric Orthopaedics
Hershey, Pennsylvania Charlotte, North Carolina

Robert A. Gallo, MD Kathleen Weber, MD, MS

Associate Professor Assistant Professor
Orthopaedic Surgery Midwest Orthopaedics at Rush
Hershey Medical Center Rush University Medical Center
Hershey, Pennsylvania Chicago, Illinois

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

 Editorial Board Disclosures
Dr. Armstrong or an immediate family member is a member Dr. Gallo or an immediate family member serves as a
of a speakers’ bureau or has made paid presentations on board member, owner, officer, or committee member of the
behalf of, serves as a paid consultant to or is an employee of, American Academy of Orthopaedic Surgeons, the American
and serves as an unpaid consultant to Zimmer; and serves as Orthopaedic Association, the American Orthopaedic Society
a board member, owner, officer, or committee member of the for Sports Medicine, and the Arthroscopy Association of
American Orthopaedic Association. North America.
Dr. Abboud or an immediate family member serves as a Dr. Griffin or an immediate family member serves as a
board member, owner, officer, or committee member of the board member, owner, officer, or committee member of the
American Shoulder and Elbow Surgeons and the Mid- American Orthopaedic Society for Sports Medicine, the
Atlantic Shoulder and Elbow Society; serves as a paid Orthopaedic Research and Education Foundation, and the
consultant to or is an employee of DePuy, A Johnson & Piedmont Hospital Board of Directors.
Johnson Company, DJ Orthopaedics, Integra, MinInvasive,
Mr. Hubbard or an immediate family member serves as a
and Tornier; has received royalties from and has stock or
paid consultant to or is an employee of and serves as an
stock options held in MinInvasive; and has received research
unpaid consultant to Zimmer.
or institutional support from DePuy, A Johnson & Johnson
Company, Integra, Tornier, and Zimmer. Dr. Janicki or an immediate family member serves as a
board member, owner, officer, or committee member of the
Dr. Adams or an immediate family member has received
Pediatric Orthopaedic Society of North America and has
royalties from Arthrex; serves as a board member, owner,
stock or stock options held in Pfizer.
officer, or committee member of the American Association
for Hand Surgery, the American Shoulder and Elbow Dr. Tashjian or an immediate family member serves as a paid
Surgeons, the American Society for Surgery of the Hand, consultant to or is an employee of Mitek and Tornier.
the Arthroscopy Association of North America, and the
Minnesota Orthopaedic Society; and is a member of a Neither Dr. VanderHave nor any immediate family member
speakers’ bureau or has made paid presentations on behalf of has received anything of value from or has stock or stock
Arthrex. options held in a commercial company or institution related
directly or indirectly to the content of this publication.
Dr. Altman or an immediate family member is a member of a
speakers’ bureau or has made paid presentations on behalf of Neither Dr. Weber nor any immediate family member has
AO North America. received anything of value from or has stock or stock options
held in a commercial company or institution related directly
Neither Dr. Aydogan nor any immediate family member has or indirectly to the content of this publication.
received anything of value from or has stock or stock options
held in a commercial company or institution related directly
or indirectly to the content of this publication.

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

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

Pooya Hosseinzadeh, MD Brien Rabenhorst, MD

Assistant Professor Assistant Professor of Orthopaedic Surgery
Department of Pediatric Orthopedics University of Arkansas for Medical Sciences
Baptist Children’s Hospital Little Rock, Arkansas
Miami, Florida
Brian A. Shaw, MD
Thomas G. McPartland, MD Associate Professor of Orthopaedic Surgery
Assistant Clinical Professor Orthopedic Surgery Children’s Hospital Colorado
Department of Orthopedic Surgery University of Colorado School of Medicine
Rutgers-Robert Wood Johnson Medical School Colorado Springs, Colorado
New Brunswick, New Jersey

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

 Contributors’ Disclosures
Dr. Aboulafia or an immediate family member has received KeraNetics, Orthovatum, and Zellko; and serves as a board
royalties from and has stock or stock options held in Amgen member, owner, officer, or committee member of the Southern
and serves as a board member, owner, officer, or committee Orthopaedic Association and the American Orthopaedic
member of the Musculoskeletal Tumor Society. Association.
Dr. Andras or an immediate family member serves as a board Dr. Lane or an immediate family member serves as a
member, owner, officer, or committee member of the Pediatric board member, owner, officer, or committee member of the
Orthopaedic Society of North America and has stock or stock American Academy of Orthopaedic Surgeons, the Association
options held in Eli Lilly. of Bone and Joint Surgeons, the American Osteopathic
Neither Dr. Bellaire nor any immediate family member has Association, the American Society for Bone and Mineral
received anything of value from or has stock or stock options Research, the Musculoskeletal Tumor Society, and the
held in a commercial company or institution related directly Orthopaedic Research Society; serves as a paid consultant
or indirectly to the content of this publication. to or is an employee of Bone Therapeutics, Inc., CollPlant,
Harvest, Inc., ISTO, BiologicsMD, and Graftys; has stock or
Neither Dr. Bergfeld nor any immediate family member has stock options held in Dfine and CollPlant; and has received
received anything of value from or has stock or stock options research or institutional support from Merck.
held in a commercial company or institution related directly
or indirectly to the content of this publication. Neither Dr. Lemasters nor any immediate family member has
received anything of value from or has stock or stock options
Dr. Dodds or an immediate family member serves as a held in a commercial company or institution related directly
board member, owner, officer, or committee member of the or indirectly to the content of this publication.
Arthroscopy Association of North America.
Neither Ms. Maxwell nor any immediate family member has
Neither Dr. Faucher nor any immediate family member has received anything of value from or has stock or stock options
received anything of value from or has stock or stock options held in a commercial company or institution related directly
held in a commercial company or institution related directly or indirectly to the content of this publication.
or indirectly to the content of this publication.
Dr. McPartland or an immediate family member has stock
Dr. Garrard or an immediate family member is an employee or stock options held in Johnson & Johnson and serves as a
of Sanofi-Aventis. board member, owner, officer, or committee member of the
Neither Dr. Gilli nor any immediate family member has Pediatric Orthopaedic Society of North America.
received anything of value from or has stock or stock options Neither Dr. Moore nor any immediate family member has
held in a commercial company or institution related directly received anything of value from or has stock or stock options
or indirectly to the content of this publication. held in a commercial company or institution related directly
Dr. Griffin or an immediate family member serves as a or indirectly to the content of this publication.
board member, owner, officer, or committee member of the Mr. Murphy or an immediate family member serves as a
American Orthopaedic Society for Sports Medicine and the board member, owner, officer, or committee member of the
Orthopaedic Research and Education Foundation. College Athletic Trainers’ Society.
Neither Dr. Guild nor any immediate family member has Dr. Pinzur or an immediate family member serves as a
received anything of value from or has stock or stock options board member, owner, officer, or committee member of the
held in a commercial company or institution related directly American Academy of Orthopaedic Surgeons; is a member of
or indirectly to the content of this publication. a speakers’ bureau or has made paid presentations on behalf of
Neither Dr. Hamilton nor any immediate family member has Smith & Nephew, Stryker, and Wright Medical Technology;
received anything of value from or has stock or stock options and serves as a paid consultant to or is an employee of Wright
held in a commercial company or institution related directly Medical Technology.
or indirectly to the content of this publication. Neither Dr. Rabenhorst nor any immediate family member has
Neither Dr. Hollern nor any immediate family member has received anything of value from or has stock or stock options
received anything of value from or has stock or stock options held in a commercial company or institution related directly
held in a commercial company or institution related directly or indirectly to the content of this publication.
or indirectly to the content of this publication. Neither Dr. Schiff nor any immediate family member has
Neither Dr. Hosseinzadeh nor any immediate family member received anything of value from or has stock or stock options
has received anything of value from or has stock or stock held in a commercial company or institution related directly
options held in a commercial company or institution related or indirectly to the content of this publication.
directly or indirectly to the content of this publication. Dr. Shaw or an immediate family member serves as a
Dr. Kercher or an immediate family member serves as a board member, owner, officer, or committee member of
board member, owner, officer, or committee member of the American Academy of Pediatrics and the Pediatric
the American Academy of Orthopaedic Surgeons and the Orthopaedic Society of North America and has stock or stock
American Orthopaedic Society for Sports Medicine. options held in Biomet, Johnson & Johnson, Medtronic,
Neither Dr. Knowles nor any immediate family member has Merck, Pfizer, Stryker, and Zimmer.
received anything of value from or has stock or stock options Neither Dr. Sousa nor any immediate family member has
held in a commercial company or institution related directly received anything of value from or has stock or stock options
or indirectly to the content of this publication. held in a commercial company or institution related directly
Dr. Koman or an immediate family member has stock or or indirectly to the content of this publication.
stock options held in DT Scimed, KeraNetics, Orthovatum, Neither Dr. Starr nor any immediate family member has
and Zellko; has received nonincome support (such as received anything of value from or has stock or stock options
equipment or services), commercially derived honoraria, or held in a commercial company or institution related directly
other non-research–related funding (such as paid travel) from or indirectly to the content of this publication.

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

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

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

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

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

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

Pain diagram opens each section.

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

Table of contents lists conditions in

alphabetic order.

Anatomic art at beginning of section

for handy reference.

Physical examination shows

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

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

Home exercise program includes:

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

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

xiii
 Table of Contents

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

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

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

SECTION THREE

Elbow and Forearm

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

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

 SECTION FOUR

Hand and Wrist

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

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

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

 SECTION SIX

Knee and Lower Leg

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

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

 SECTION SEVEN

Foot and Ankle

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

SECTION EIGHT

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

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

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

1222 Glossary

1239 Index

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

 PAIN DIAGRAM
General Orthopaedics

Osteoporosis

Osteoarthritis

Rheumatoid arthritis

Diffuse idiopathic
skeletal hyperostosis
(DISH)

Seronegative
spondyloarthropathies

Rheumatoid arthritis

Complex regional pain

syndrome (CRPS)

Osteoarthritis

Rheumatoid arthritis

Deep vein thrombosis

Complex regional pain

syndrome (CRPS)

Osteoarthritis

Rheumatoid arthritis Rheumatoid arthritis

Crystal deposition disease
Crystal deposition
disease

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

 SECTION 1

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

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

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

Skull

Clavicle Mandible

Scapula

Humerus

Spinal column

Radius
Pelvis
Ulna

Carpal bones
Metacarpals

Phalanges

Femur

Patella

Fibula Tibia

Metatarsals
Tarsal bones
Phalanges

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

Overview of General
Orthopaedics

SECTION 1 GENERAL ORTHOPAEDICS

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

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

Bursitis and Tenosynovitis

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

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

 Overview of General Orthopaedics
SECTION 1 GENERAL ORTHOPAEDICS

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

localized pain that is exacerbated by specific movements and is

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

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

 Overview of General Orthopaedics

Table 1
Characteristics of Osteoarthritis Versus Rheumatoid Arthritis

SECTION 1 GENERAL ORTHOPAEDICS

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

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

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

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

 Overview of General Orthopaedics

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

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

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

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

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

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

 Overview of General Orthopaedics

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

SECTION 1 GENERAL ORTHOPAEDICS

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

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

 Principles of
Musculoskeletal
SECTION 1 GENERAL ORTHOPAEDICS

Evaluation
Patients presenting with musculoskeletal problems may report pain,
stiffness, deformity, or weakness. General principles for evaluating
these patients are described here.

History
The history of the presenting condition should include onset, location,
duration, aggravators/relievers, character, and temporal factors
tailored to the specific symptom or symptoms (Table 1). Additional
questions about the patient’s medical history, social history, and
family history, and a review of systems may reveal clues that suggest
the correct diagnosis. For example, substantial weight loss in a
person who smokes may suggest that low back pain is secondary
to metastatic disease, whereas back pain in a postmenopausal
woman with a history of a fragility fracture may suggest a vertebral
compression fracture. In persons with musculoskeletal disorders, it
is important to understand the patient’s level of function before the
injury or illness.

Physical Examination
The general principles of examining the musculoskeletal system,
including inspection, palpation, range of motion, muscle testing,
motor and sensory evaluation, and special tests, are described later
in this section. The specific techniques are detailed in subsequent
anatomic sections. When examining the extremities, comparison with

Table 1
History Questions Pertinent to Musculoskeletal Conditions

Pain Joints Back

Nature: sharp, dull, achy, Decreased range of motion? Radiation to buttocks or legs?
radiating, associated with Swelling? Midline versus paravertebral?
fatigue or weakness? Warmth/erythema? Sharp or aching?
Timing: increasing, decreasing, Morning or activity-related pain/ Postural or height change?
intermittent, related to time stiffness? Paresthesias?
of day, related to activity,
Catching or giving way? Night pain?
related to injury?
Instability? Bowel or bladder incontinence?
Loss of function?
Unilateral or bilateral?
Crepitus?
Related to deformity?

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

 Principles of Musculoskeletal Evaluation

the opposite, asymptomatic extremity often is helpful in defining the

specific abnormalities in the symptomatic extremity.
Inspection/Palpation

SECTION 1 GENERAL ORTHOPAEDICS

Inspect the patient’s standing posture. Compare the affected
extremity with the opposite extremity for any difference in symmetry
or length. Note if the patient has any abnormal spine curvature or
axial asymmetry. Watch the patient walk. Analyze the stance and
swing phases of gait. Look for an antalgic gait, which is characterized
by limited stance phase on the affected extremity. Watch for
weakness of the swing-phase muscles—for example, weakness of the
ankle dorsiflexors (peroneal nerve dysfunction)—which is manifested
Figure 1 Photograph shows
by a footdrop gait.
a patient pointing to the one
Ask the patient to place one finger on the one spot that hurts the
spot that hurts the most, that is,
most to localize the problem and narrow the differential diagnosis localizing the point of maximal
(Figure 1). After exposing the area, look for swelling, erythema, tenderness.
ecchymosis, and muscular atrophy.
Palpate the affected area for tenderness, abnormal masses,
fluctuance, crepitus, or temperature changes.
Range of Motion
Measure the motion of the joints in the affected extremity or spine
and compare with normal range of motion measurements on the
unaffected side. Restricted joint motion may herald trauma, infection,
arthritis, or another inflammatory process. Measure both passive
and active range of motion. A discrepancy between active and
passive range of motion may indicate joint injury or may represent an
underlying muscle weakness.
Basic Principles
Joint range of motion is an objective measurement. The parameters
for rating musculoskeletal disability, whether for government or other
agencies, are based on the degree to which joint motion is impaired.
Joint motion can be estimated visually, but a goniometer enhances
accuracy and is preferred for evaluating motion of the elbow, wrist,
digits, knee, ankle, and great toe. A goniometer is less useful in
measuring hip and shoulder motion because the overlying soft tissues
do not allow the same degree of precision.
Zero Starting Position
Describing joint motion with reference to the accepted Zero
Starting Position for each joint is necessary to provide consistent
communication between observers. The Zero Starting Position for
each joint is described in the examination chapter of each section and
in Figures 2 and 3. For most joints, the Zero Starting Position is the
anatomic position of the extremity in extension.
To measure joint motion, start by placing the joint in the Zero
Starting Position. Place the center of the goniometer at the center
of the joint. Align one arm of the goniometer with the bony axis of
the proximal segment and the other end of the goniometer with the
bony axis of the distal segment (Figure 4). Hold the upper end of
the goniometer in place while the joint is moved through its arc of

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 9

 Principles of Musculoskeletal Evaluation
SECTION 1 GENERAL ORTHOPAEDICS

Figure 2 Illustrations show means of measuring joint motion in the upper extremity. (Reproduced from Greene
WB, Heckman JD, eds: The Clinical Measurement of Joint Motion. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 1994.)

motion. When the joint is at the farthest extent of the arc of motion,
realign the distal arm of the goniometer with the axis of the distal
segment and read the degree of joint motion from the goniometer.
Definitions of Limited Motion
The terminology for describing limited motion is illustrated in
Figure 5. The knee joint depicted in this photograph can be neither

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

 Principles of Musculoskeletal Evaluation

SECTION 1 GENERAL ORTHOPAEDICS

Figure 3 Illustrations show means of measuring joint motion in the lower extremity. (Reproduced from Greene
WB, Heckman JD, eds: The Clinical Measurement of Joint Motion. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 1994.)

fully extended nor fully flexed. The restricted motion is recorded as

either “The knee flexes from 30° to 90° (30° → 90°),” or “The knee
has a 30° flexion contracture with further flexion to 90° (30° FC →
90° or 30° FC W/FF 90°).”
Range of motion is slightly greater in children, particularly those
younger than 10 years. Decreased motion occurs as adults age, but the
loss of motion is relatively minimal in most joints. Except for motion
at the distal finger joints, it is safe to say that any substantial loss of
mobility should be viewed as abnormal and not attributable to aging.

© 2016 American Academy of Orthopaedic Surgeons Essentials of Musculoskeletal Care 5 11

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Chief-Justice Marshall. Jefferson did not touch upon legal tender; but
the assumption of power implied in the issue of paper money
seemed to require that the government should exercise the right of
obliging its creditors to accept it. The actual interest-bearing
Treasury notes stood then at a discount of about twenty per cent.
The proposed paper money could hardly circulate at a better rate,
and coin was not to be obtained. Under such conditions the notes
must be a forced currency if they were to circulate at all.
The scheme was reported to the House by the Committee of
Ways and Means through its chairman, John W. Eppes, Jefferson’s
son-in-law.[360] For the report Eppes was alone responsible, and the
plan in his hands varied in some points from that of Jefferson.
Starting from the admitted premise that loans were not to be
obtained, and that money could not be transferred from one point to
another in any existing medium at the disposition of government,
Eppes proposed to issue Treasury notes “in sums sufficiently small
for the ordinary purposes of society,” which were not to be made
payable on demand in coin, but might at any time be exchanged for
eight per cent bonds, and were to be received “in all payments for
public lands and taxes.” Nothing was said of legal tender, or of
driving bank-notes from circulation; but Eppes proposed to double
the taxes at one stroke.
Eppes’s scheme lost the advantages of Jefferson’s without
gaining any of its own. It abandoned the hope of abolishing bank
paper; and in want of such a restraint on private issues, the
proposed government paper would merely add one more element of
confusion to the chaos already existing. Eppes further altered
Jefferson’s plan by adding some ten millions instead of two millions
to the burden of taxation; but even Jefferson protested that this part
of the scheme was impracticable.
“This is a dashing proposition,” he wrote to Monroe;[361] “but if
Congress pass it, I shall consider it sufficient evidence that their
constituents generally can pay the tax. No man has greater
confidence than I have in the spirit of the people to a rational extent.
Whatever they can, they will. But without either market or medium, I
know not how it is to be done. All markets abroad and all at home are
 shut to us, so that we have been feeding our horses on wheat. Before
the day of collection, bank-notes will be but as oak-leaves; and of
specie there is not within all the United States one half of the
proposed amount of the taxes.”
This was the situation of the Virginia scheme when Dallas took the
matter in hand. Immediately after entering into office, Dallas wrote to
Eppes an official letter, dated October 17, expressing views wholly at
variance with the Virginia plan.
“Under favorable circumstances and to a limited extent,” he said,
[362] “an emission of Treasury notes would probably afford relief; but
Treasury notes are an expensive and precarious substitute either for
coin or for bank-notes, charged as they are with a growing interest,
productive of no countervailing profit or emolument, and exposed to
every breath of popular prejudice or alarm. The establishment of a
national institution operating upon credit combined with capital, and
regulated by prudence and good faith, is after all the only efficient
remedy for the disordered condition of our circulating medium. While
accomplishing that object, too, there will be found under the auspices
of such an institution a safe depository for the public treasure and a
constant auxiliary to the public credit. But whether the issues of a
paper currency proceed from the national Treasury or from a national
Bank, the acceptance of the paper in a course of payments and
receipts must be forever optional with the citizens. The extremity of
that day cannot be anticipated when any honest and enlightened
statesman will again venture upon the desperate expedient of a
tender-law.”
Without a tender-law the Virginia scheme would hardly answer the
purposes required, since the government must restrain the issue of
paper within a limit too narrow for usefulness. Dallas did not press
this point, but developed his own scheme, which required, like that of
Eppes, a duplication of taxes to produce twenty-one million dollars,
and the creation of a national Bank with a capital of fifty million
dollars.
Either Eppes’s or Dallas’s plan might answer the immediate object
of providing a currency, and both required the exercise of implied
powers by Congress. Apparently Congress had only to choose, but
in truth choice was most difficult. The House readily adopted Dallas’s
recommendation in principle, and voted, October 24, by sixty-six to
forty, that it was expedient to establish a national Bank; but the
problem of establishing a specie-paying bank without specie passed
its powers. Dallas abandoned the attempt at the outset. He proposed
a bank of fifty millions capital, of which forty-four millions might be
subscribed in government bonds and Treasury notes, and six
millions in coin. The bank was at once to lend to government thirty
millions,—of course in bank-notes,—and no one denied that an
immediate suspension of specie payments must follow such an
issue. To any bank, strong or weak, the old Virginia influence
represented by Eppes was hostile; and to a bank insolvent from the
start the Federalists also were opposed.
When the bill, reported November 7, was printed, it was found to
contain a provision authorizing the suspension of specie payments at
the President’s discretion. The discussion began November 14, and
every successive day revealed objections and increased the
opposition. Calhoun complicated the subject still further by bringing
forward, November 16, a plan of his own, requiring the capital to
consist “one tenth in specie, and the remainder in specie or in
Treasury notes to be hereafter issued,” and taking away all
government control. Ingham of Pennsylvania, representing Dallas,
combated Calhoun with force, but could not make his own measure
agreeable to the House. His phrase in regard to the suspension of
specie payments was significant. Congress, he said, would be to
blame for “frantic enthusiasm” if it did not provide for the case. “It
may happen, and probably will happen, that their specie payments
cannot be continued, and what will then be the situation of the bank?
Failing to fulfil the purposes designed, its credit is blighted, its
operations are stopped, and its charter violated; and if this should
take place before your Treasury notes are sold, the government will
scarce obtain a moment’s relief.” That the new bank could not pay
specie was obvious. The Bank of England itself could not pay
specie, and had not attempted to do so for nearly twenty years.
The House in committee adopted Calhoun’s amendment by a
majority of about sixty, in spite of Ingham’s opposition; and thus
substituted for Dallas’s scheme a large private bank, over which the
government was to exercise no control, with a capital of fifty millions,
nine tenths of which were to be Treasury notes. The House then
discovered so many unforeseen difficulties, that November 25 it
recommitted the bill to a select committee, of which Lowndes,
Calhoun, Ingham, Forsyth, and two Federalists were members.
Dallas was obliged openly to enter the lists against Calhoun, and
wrote to the committee a letter, dated November 27,[363] sounding
like a defiance: “The dividend on the funded debt has not been
punctually paid; a large amount of Treasury notes has already been
dishonored; and the hope of preventing further injury and reproach in
transacting business with the Treasury is too visionary to afford a
moment’s consolation.” Calhoun’s scheme, he plainly intimated, was
impracticable and mischievous.
The next day, November 28, Lowndes brought back Calhoun’s bill
to the House, together with Dallas’s letter, and told the House that
the committee could come to no agreement. Upon this admission of
helplessness, Hanson addressed the House in a speech which
seemed to carry Federalist exultation to the extremest point.
Protesting his anxiety to defend the country, Hanson uttered a cry of
triumph over the destruction of the government:—
“Not only had government bills been dishonored and the interest of
the public debt remained unpaid, but ... so completely empty was the
Treasury and destitute of credit, that funds could not be obtained to
defray the current ordinary expenses of the different Departments.
Disgraceful, humiliating as the fact was, it ought not to be concealed
from the nation, and he felt it his duty to state to the House that the
Department of State was so bare of money as to be unable to pay
even its stationery bill. The government was subsisting upon the
drainings of unchartered banks in the District, which felt themselves
compelled to contribute their means lest the rod in terrorem which was
held over them should be applied, and an Act of incorporation
refused.”
No one contradicted or answered Hanson. The House wavered in
incapacity that suggested dissolution. At last Richard M. Johnson, in
order to force a decision right or wrong, moved the previous question
and brought the House to a vote. Then the majority turned against
Calhoun, as they had before turned against Dallas, and rejected the
bill by a vote of one hundred and four to forty-nine.
 The Southern preference for government paper currency lay at
the bottom of Calhoun’s scheme as of Jefferson’s, and seemed to
Dallas to combine ignorance with dishonesty. Treasury notes bearing
interest could not be made to serve as a currency, and were useless
as a foundation for government paper. “What use is there,” asked
Ingersoll,[364] “in such a mass of banking machinery to give
circulation to some millions of Treasury notes? Why not issue them
at once without this unwieldy, this unnecessary medium?” Yet when
Bolling Hall of Georgia, in pursuance of Macon’s aphorism that
“paper money never was beat,” moved, November 12, Resolutions
authorizing the issue of Treasury notes as legal tender, the House
refused to consider it by a vote of ninety-five to forty-two. Eppes did
not vote; Calhoun voted against it, and of the twenty-five Southern
members who supported it Macon and Stanford were the most
prominent.
Nothing could be plainer than that the House must ultimately
come to inconvertible government paper, whether issued by the
Treasury or by a Bank. Dallas, Eppes, and Calhoun were all agreed
on that point, if on no other; but after Congress had sat two months
and a half, the House was no nearer a decision than when it met.
The Federalists, voting at one time with Calhoun, at another with
Dallas, were able to paralyze action. Eppes wrote to Dallas,
December 2, inviting further information; and Dallas wrote back the
same day, recounting the needs of the Treasury for the current
month, merely on account of the national debt. Dallas reported that
$5,726,000 in Treasury notes and dividends were due, or would fall
due by January 1; and that including unavailable bank-credits, and
subject to possible contingencies, the Treasury might contain
resources to meet these demands to the amount of $3,972,000.[365]
Eppes could do no more for immediate relief than report a bill for the
issue of some ten millions more of interest-bearing Treasury notes,
which was passed without debate and became law, December 26,
without improving the situation.
The House also passed the heavy tax-bills without much
opposition except from Federalists who wished to stop military
operations on the part of the government. Between thirty and forty
members, or about one half of the Federalists, carried their
opposition to that point. The bill raising the direct tax to six million
dollars passed the House, December 22, by a vote of one hundred
and six to fifty-three, and passed the Senate, January 5, 1815, by
twenty-three to seven. Dallas and Eppes hoped to raise about twenty
million dollars through the new taxation, or twice what had been
previously attempted. Jefferson held that these taxes could not be
paid, and expressed his opinion without reserve.
“If anything could revolt our citizens against the war,” wrote
Jefferson, November 28,[366] “it would be the extravagance with
which they are about to be taxed.... The taxes proposed cannot be
paid. How can a people who cannot get fifty cents a bushel for their
wheat, while they pay twelve dollars a bushel for their salt, pay five
times the amount of taxes they ever paid before? Yet this will be the
case in all the States south of the Potomac.”
If any conclusion was intended to be drawn from the official
return[367] sent to Congress, October 13, of internal taxes received
to that date in each State, the evil predicted by Jefferson seemed
already to exist. In Massachusetts, of taxes to the amount of
$200,000, accrued for the first two quarters of the year, $170,000
had been received before October 10. In New York $393,000 had
accrued, and $303,000 had been received; thus New York was
nearly one fourth in arrears. Pennsylvania was worse; of $470,000
accrued the government had received $280,000,—leaving two fifths
in arrears. Virginia was in somewhat worse condition than
Pennsylvania; of $247,000 accrued $136,000 had been paid,—
leaving four ninths in arrears.
Yet Pennsylvania and Virginia paid taxes in their own depreciated
bank paper, while New York and New England paid chiefly in
Treasury notes. The new taxes were still to be paid in the same
medium, although the laws gave no express authority for it. In the
next Congress, when the subject was discussed, Wright of Maryland
said:[368] “When Congress passed the revenue laws and imposed
the six million and three million land tax, did they contemplate the
payment of specie? No! they knew the people had it not, and of
course could not pay it.... Does any man doubt that Congress
intended these taxes being paid in bank paper? Nay, has not the
Secretary of the Treasury ... sealed this construction of the law by
taking the bank paper in discharge for these taxes?” That the bank
paper was worth less than Treasury notes was shown by the
Southern States paying their taxes in such paper, when they might
equally well have paid them in Treasury notes except for the
difference in value.
The medium of depreciated and depreciating bank paper in which
the taxes were to be paid, secured the States outside of New
England from intolerable pressure by giving the means of indefinite
depreciation; but to the government such a resource meant merely a
larger variety of bank-credits, which were of no certain value even in
the towns where the banks existed, and were of no value at all
elsewhere. The burden of taxation would be thrown chiefly on New
England; and if the Hartford Convention did nothing else, it was sure
to take measures for sequestering the proceeds of taxation in New
England for military purposes. The hope of restoring the finances by
taxation was faint. Until the currency could be established and
exchanges made secure, the government was helpless.
The House having broken down November 28, the Senate next
took the matter in hand. Rufus King reported, December 2, a bill to
incorporate a bank, which was in effect the bill recommended by
Dallas. After a week’s consideration the Senate passed the bill,
December 9, by the vote of seventeen to fourteen,—King and the
Federalists, with four Republican senators, voting against it. The
House referred it to the Committee of Ways and Means, which
reported it, December 14, with amendments. The debate began
December 23, and was cut short December 27 by C. J. Ingersoll,
who by the close vote of seventy-two to seventy obliged the House
to call for the previous question, and order the bill to its third reading.
This energy was followed by a reaction; the bill was recommitted for
amendment, again reported, and vehemently attacked.
Never had the House shown itself more feeble. The Federalists
took the lead in debate; and January 2 Daniel Webster, in a speech
that placed him at the head of the orators of the time, dictated the
action of Congress:—
 “What sort of an institution, sir, is this? It looks less like a bank than
like a department of government. It will be properly the paper-money
department. Its capital is government debts; the amount of issues will
depend on government necessities; government in effect absolves
itself from its own debts to the bank, and by way of compensation
absolves the bank from its own contracts with others. This is indeed a
wonderful scheme of finance. The government is to grow rich because
it is to borrow without the obligation of repaying, and is to borrow of a
bank which issues paper without the liability to redeem it.... They
provide for an unlimited issue of paper in an entire exemption from
payment. They found their bank in the first place on the discredit of
government, and then hope to enrich government out of the
insolvency of the bank.”
Webster was a master of antithesis, and the proposed bank was
in effect what he described; but had he been a member of the British
Parliament he might have made the same objections, with little
alteration, to the Bank of England. The Hartford Convention was in
session while he spoke. Every word of his speech was a shock to
the government and the Union, for his only suggestion was
equivalent to doing nothing. He moved to instruct the committee to
report a bill creating a bank with thirty millions of capital, composed
one fourth of specie and three fourths of government securities;
without power to suspend specie payments, and without obligation to
lend three fifths of its capital to the government. To such a bank he
would give his support, “not as a measure of temporary policy, or an
expedient to find means of relief from the present poverty of the
Treasury,” but as an institution most useful in times of peace.
The House came to a vote the same day, and divided eighty-one
to eighty. Then the Speaker, Langdon Cheves, rose, and after
denouncing the proposed bank as “a dangerous, unexampled, and
he might almost say a desperate resort,” gave his casting vote
against the bill.
No sooner had the House struck this blow at Dallas than it shrank
back. The next day, amid complaints and objections, it reconsidered
its matured decision by the sudden majority of one hundred and
seven to fifty-four. Once more the bill was recommitted, and once
more reported, January 6, in the form that Webster proposed. Weary
of their own instability, the majority hastened to vote. Most of the
Federalists supported the bill; but Grosvenor of New York, one of the
ablest, frankly said what every one felt, that the proposed institution
could not be a specie bank, or get a million of its notes into
circulation. “The government relying on it would be disappointed, and
ruin soon stare them in the face.” With this understanding the House
passed the bill, January 7, by a vote of one hundred and twenty to
thirty-eight; and the Senate, after a struggle with the House,
accepted it, January 20, by a vote of twenty to fourteen.
Dallas was not a man to be easily daunted even in so desperate a
situation. After ten days deliberation, the President sent to Congress
a veto message.
“The most the bank could effect,” said Madison, “and the most it
could be expected to aim at, would be to keep the institution alive by
limited and local transactions ... until a change from war to peace
should enable it, by a flow of specie into its vaults and a removal of
the external demand for it, to derive its contemplated emoluments
from a safe and full extension of its operations.”
“I hope this will satisfy our friends,” wrote Webster to his brother,
[369] “that it was not a bank likely to favor the Administration.” Either
with or without such a bank, the Administration was equally helpless.
The veto left the Treasury, February 1, without a resource in
prospect. The unsatisfied demands reached nearly twenty millions.
The cash balance, chiefly in bank-credits, was little more than six
millions. A further deficit of forty millions remained to be provided
above the estimated revenue of 1815. United States six-per-cents
commanded only a nominal price, between fifty and sixty cents on
the dollar,[370] and were quoted in Boston at a discount of forty
cents.[371] Treasury notes being in demand for taxes, were worth
about seventy-five cents in the dollar. Dallas had no serious hope of
carrying on the government. In a letter to the Committee of Ways
and Means, dated January 17, he could only propose to add six
millions more to the taxes, issue fifteen millions in Treasury notes,
and borrow twenty-five millions on any terms that could be obtained.
In making these recommendations he avowed in grave words his
want of confidence in their result:[372]—
 “In making the present communication I feel, sir, that I have
performed my duty to the Legislature and to the country; but when I
perceive that more than forty millions of dollars must be raised for the
service of the year 1815, by an appeal to public credit through the
medium of the Treasury notes and loans, I am not without sensations
of extreme solicitude.”
Young George Ticknor of Boston happened to be in the gallery of
the House of Representatives when Eppes read this letter, January
21, and the next day he wrote,[373]—
“The last remarkable event in the history of this remarkable
Congress is Dallas’s report. You can imagine nothing like the dismay
with which it has filled the Democratic party. All his former
communications were but emollients and palliations compared with
this final disclosure of the bankruptcy of the nation. Mr. Eppes as
Chancellor of the Exchequer, or Chairman of the Committee of Ways
and Means, read it in his place yesterday, and when he had finished,
threw it upon the table with expressive violence, and turning round to
Mr. Gaston, asked him with a bitter levity between jest and earnest,—
“‘Well, sir! will your party take the government if we will give it up to
them?’
“‘No, sir!’ said Gaston; ... ‘No, sir! Not unless you will give it to us as
we gave it to you!’”
 CHAPTER X.
While Dallas struggled with Congress to obtain the means of
establishing a currency in order to pay the army, Monroe carried on a
similar struggle in order to obtain an army to pay. On this point, as on
the financial issue, Virginian ideas did not accord with the wishes of
Government. The prejudice against a regular army was stimulated
by the evident impossibility of raising or supporting it. Once more
Jefferson expressed the common feeling of his Virginia neighbors.
[374]

“We must prepare for interminable war,” he wrote to Monroe,

October 16. “To this end we should put our house in order by
providing men and money to an indefinite extent. The former may be
done by classing our militia, and assigning each class to the
description of duties for which it is fit. It is nonsense to talk of regulars.
They are not to be had among a people so easy and happy at home
as ours. We might as well rely on calling down an army of angels from
heaven.”
As Jefferson lost the habits of power and became once more a
Virginia planter, he reverted to the opinions and prejudices of his
earlier life and of the society in which he lived. As Monroe grew
accustomed to the exercise and the necessities of power, he threw
aside Virginian ideas and accepted the responsibilities of
government. On the same day when Jefferson wrote to Monroe that
it was nonsense to talk of regulars, Monroe wrote to Congress that it
was nonsense to talk of militia. The divergence between Monroe and
Jefferson was even greater than between Dallas and Eppes.
“It may be stated with confidence,” wrote Monroe to Congress,[375]
“that at least three times the force in militia has been employed at our
principal cities, along the coast and on the frontier, in marching to and
returning thence, that would have been necessary in regular troops;
and that the expense attending it has been more than proportionately
augmented from the difficulty if not the impossibility of preserving the
same degree of system in the militia as in the regular service.”
 In Monroe’s opinion a regular force was an object “of the highest
importance.” He told the Senate committee that the army, which was
only thirty-four thousand strong on the first of October, should be
raised to its legal limit of sixty-two thousand, and that another
permanent army of forty thousand men should be raised for strictly
defensive service. In the face of Jefferson’s warning that he might as
well call down an army of angels from heaven, Monroe called for one
hundred thousand regular troops, when no exertions had hitherto
availed to keep thirty thousand effectives on the rolls.
The mere expression of such a demand carried with it the train of
consequences which the people chiefly dreaded. One hundred
thousand troops could be raised only by draft. Monroe affirmed the
power as well as the need of drafting. “Congress have a right by the
Constitution,” he said, “to raise regular armies, and no restraint is
imposed on the exercise of it.... It would be absurd to suppose that
Congress could not carry this power into effect otherwise than by
accepting the voluntary service of individuals.” Absurd as it was,
such had been the general impression, and Monroe was believed to
have been one of the most emphatic in maintaining it. “Ask him,”
suggested Randolph, “what he would have done, while governor of
Virginia and preparing to resist Federal usurpation, had such an
attempt been made by Mr. Adams and his ministers, especially in
1800. He can give the answer.” Doubtless the silence of the
Constitution in respect to conscription was conclusive to some minds
in favor of the power; but the people preferred the contrary view, the
more because militia service seemed to give more pay for less risk.
The chance of carrying such a measure through Congress was
not great, yet Monroe recommended it as his first plan for raising
men. He proposed to enroll the free male population between
eighteen and forty-five years of age into classes of one hundred,
each to furnish four men and to keep their places supplied.[376] The
second plan varied from the first only in the classification, not in the
absence of compulsion. The militia were to be divided into three
sections according to age, with the obligation to serve, when
required, for a term of two years. A third plan suggested the
exemption from militia service of every five militia-men who could
provide one man for the war. If none of these schemes should be
approved by Congress, additional bounties must be given under the
actual system. Of the four plans, the secretary preferred the first.
The Senate committee immediately summoned Monroe to an
interview. They wished an explanation of the failure in the recruiting
service, and were told by Monroe that the failure was chiefly due to
the competition of the detached militia for substitutes.[377] The
military committee of the House then joined with the military
committee of the Senate in sounding the members of both bodies in
order to ascertain the most rigorous measure that could be passed.
According to the report of Troup of Georgia, chairman of the House
committee,[378] they “found that no efficacious measure, calculated
certainly and promptly to fill the regular army, could be effectually
resorted to. Measures were matured and proposed by the [House]
committee, but were not pressed on the House, from the solemn
conviction that there was no disposition in the Legislature to act
finally on the subject.”
Yet the issue was made at a moment of extreme anxiety and
almost despair. In October, 1814, the result of the war was believed
to depend on the establishment of an efficient draft. The price of
United States six-per-cents showed better than any other evidence
the opinion of the public; but the military situation, known to all the
world, warranted deep depression. Sir George Prevost, about to be
succeeded by an efficient commander,—Sir George Murray,—was
then at Kingston organizing a campaign against Sackett’s Harbor,
with an army of twenty thousand regular troops and a fleet that
controlled the Lake. Another great force, military and naval, was
known to be on its way to New Orleans; and the defences of New
Orleans were no stronger than those of Washington. One half the
province of Maine, from Eastport to Castine, was already in British
possession.
To leave no doubt of England’s intentions, despatches from
Ghent, communicating the conditions on which the British
government offered peace, arrived from the American
commissioners and were sent, October 10, to Congress. These
conditions assumed rights of conquest. The British negotiators
demanded four territorial or proprietary concessions, and all were
vital to the integrity of the Union. First, the whole Indian Territory of
the Northwest, including about one third of the State of Ohio, two
thirds of Indiana, and nearly the entire region from which the States
of Illinois, Wisconsin, and Michigan were afterward created, was to
be set aside forever as Indian country under British guaranty.
Second, the United States were to be excluded from military or naval
contact with the Lakes. Third, they had forfeited their rights in the
fisheries. Fourth, they were to cede a portion of Maine to strengthen
Canada.
These demands, following the unparalleled insult of burning
Washington, foreshadowed a war carried to extremities, and military
preparations such as the Union had no means ready to repel.
Monroe’s recommendations rested on the conviction that the nation
must resort to extreme measures. Dallas’s financial plan could not
have been suggested except as a desperate resource. Congress
understood as well as the Executive the impending peril, and stood
in even more fear of it.
Under these circumstances, when Troup’s committee refused to
act, Giles reported, on behalf of the Senate committee, two military
measures. The first, for filling the regular army, proposed to extend
the age of enlistment from twenty-one to eighteen years; to double
the land-bounty; and to exempt from militia duty every militia-man
who should furnish a recruit for the regular service.
The second measure, reported the same day, November 5,
purported to authorize the raising an army of eighty thousand militia-
men by draft, to serve for two years within the limits of their own or
an adjoining State.[379] The provisions of this measure were ill-
conceived, ill-digested, and unlikely to answer their purpose. The
moment the debate began, the bill was attacked so vigorously as to
destroy whatever credit it might have otherwise possessed.
Of all the supporters of the war, Senator Varnum of
Massachusetts was one of the steadiest. He was also the highest
authority in the Senate on matters pertaining to the militia. When
Giles’s bill came under discussion November 16, Varnum began the
debate by a speech vehemently hostile to the proposed legislation.
He first objected that although the bill purported to call for an army of
eighty thousand men, “yet in some of the subsequent sections of it
we find that instead of realizing the pleasing prospect of seeing an
ample force in the field, the force is to be reduced to an indefinite
amount,—which contradiction in terms, inconsistency in principle,
and uncertainty in effect, cannot fail to produce mortification and
chagrin in every breast.” Varnum objected to drafting men from the
militia for two years’ service because the principle of nine months’
service was already established by the common law. If the nation
wanted a regular force, why not make it a part of the regular army
without a system of drafting militia “unnecessary, unequal, and
unjust?” The machinery of classification and draft was “wholly
impracticable.” The limit of service to adjoining States abandoned
the objects for which the Union existed. The proffered bounties
would ruin the recruiting service for the regular army; the proffered
exemptions and reductions in term of duty left no permanency to the
service. The bill inflicted no penalties and charged no officers with
the duty of making the draft. “I consider the whole system as
resolving into a recommendation upon the patriotism of the States
and Territories and upon the patriotism of the classes.”
The justice of Varnum’s criticism could not fairly be questioned.
The bill authorized the President “to issue his orders to such officers
of the militia as he may think proper,” and left the classification and
draft in the hands of these militia officers. Every drafted man who
had performed any tour of duty in the militia since the beginning of
the war was entitled to deduct a corresponding term from his two
years of service; and obviously the demand created for substitutes
would stop recruiting for the regular army.
Hardly had Varnum sat down when Senator Daggett of
Connecticut spoke.
“The bill,” said the Connecticut senator, “is incapable of being
executed, as well as unconstitutional and unjust. It proceeds entirely
upon the idea that the State governments will lend their aid to carry it
into effect. If they refuse, it becomes inoperative. Now, sir, will the
 Executives, who believe it a violation of the Constitution, assist in its
execution? I tell you they will not.”
Every member of the Senate who heard these words knew that
they were meant to express the will of the convention which was to
meet at Hartford within a month. The sentiment thus avowed was
supported by another New England senator, whose State was not a
party to the Convention. Jeremiah Mason of New Hampshire was
second to no one in legal ability or in personal authority, and when
he followed Daggett in the debate, he spoke with full knowledge of
the effect his words would have on the action of the Hartford
Convention and of the State executives.
“In my opinion,” he said, “this system of military conscription thus
recommended by the Secretary of War is not only inconsistent with
the provisions and spirit of the Constitution, but also with all the
principles of civil liberty. In atrocity it exceeds that adopted by the late
Emperor of France for the subjugation of Europe.... Such a measure
cannot, it ought not to be submitted to. If it could in no other way be
averted, I not only believe, but I hope, it would be resisted.”
Mason pointed to the alternative,—which Massachusetts was then
adopting, as the necessary consequence of refusing power to the
government,—that the States must resume the powers of
sovereignty:
“Should the national defence be abandoned by the general
government, I trust the people, if still retaining a good portion of their
resources, may rally under their State governments against foreign
invasion, and rely with confidence on their own courage and virtue.”
At that time the State of Massachusetts was occupied for one
hundred miles of its sea-coast by a British force, avowedly for
purposes of permanent conquest; and the State legislature, October
18, refused to make an inquiry, or to consider any measure for
regaining possession of its territory, or to co-operate with the national
government for the purpose,[380] but voted to raise an army of ten
thousand men. The object of this State army was suggested by
Christopher Gore, the Federalist senator from Massachusetts who
followed Mason in the debate. In personal and political influence
Gore stood hardly second to Mason, and his opinions were likely to
carry the utmost weight with the convention at Hartford. With this
idea necessarily in his mind, Gore told the Senate,—
“This [bill] is the first step on the odious ground of conscription,—a
plan, sir, which never will and never ought to be submitted to by this
country while it retains one idea of civil freedom; a plan, sir, which if
attempted will be resisted by many States, and at every hazard. In my
judgment, sir, it should be resisted by all who have any regard to
public liberty or the rights of the several States.”
These denunciations were not confined to New England. Senator
Goldsborough of Maryland, also a Federalist, affirmed that the
sentiment of abhorrence for military duty was almost universal:—
“Sir, you dare not—at least I hope you dare not—attempt a
conscription to fill the ranks of your regular army. When the plan of the
Secretary of War made its appearance, it was gratifying to find that it
met with the abhorrence of almost every man in the nation; and the
merit of the bill before you, if such a measure can be supposed to
have merit at all, is that it is little else, as regards the militia, than a
servile imitation of the secretary’s plan.”
Nevertheless, when Goldsborough took his seat the Senate
passed the Militia Bill by a vote of nineteen to twelve,—Anderson of
Tennessee and Varnum of Massachusetts joining the Federalists in
opposition. The Regular Army Bill, which was in effect a bill to
sacrifice the regular army, passed November 11, without a division.
Both measures then went to the House and were committed,
November 12, to the Committee of the Whole.
Ordinarily such a measure would have been referred to the
Military Committee, but in this instance the Military Committee would
have nothing to do with the Senate bill. Troup, the chairman, began
the debate by denouncing it.[381] The measure, he said, was
inadequate to its object. “It proposed to give you a militia force when
you wanted, not a militia, but a regular force.... You have a deficiency
of twentyodd thousand to supply. How will you supply it? Assuredly
the [Regular Army] bill from the Senate will not supply it. No, sir, the
recruiting system has failed.” On the nature of the force necessary
for the next campaign Troup expressed his own opinion and that of
his committee, as well as that of the Executive, in language as
strong as he could use at such a time and place. “If, after what has
happened, I could for a moment believe there could be any doubt or
hesitation on this point, I would consider everything as lost; then
indeed there would be an end of hope and of confidence.” Yet on
precisely this point Congress showed most doubt. Nothing could
induce it to accept Troup’s view of the necessity for providing a
regular army. “The bill from the Senate,” remonstrated Troup,
“instead of proposing this, proposes to authorize the President to call
upon the States for eighty thousand raw militia; and this is to be our
reliance for the successful prosecution of the war! Take my word for
it, sir, that if you do rely upon it (the military power of the enemy
remaining undivided) defeat, disaster, and disgrace, must follow.”
The House refused to support Troup or the President. Calhoun
was first to yield to the general unwillingness, and declared himself
disposed to accept the Senate bill as a matter of policy. Richard M.
Johnson, though sympathizing with Troup, still preferred to accept
the bill as the only alternative to nothing: “If it was rejected, they
would have no dependence for defence but on six months’
militia.”[382] On the other hand, Thomas K. Harris of Tennessee
protested that if the British government had it in their power to
control the deliberations of Congress, they could not devise the
adoption of a measure of a military character better calculated to
serve their purposes. The people, he said, were in his part of the
country prepared to make every sacrifice, and expected Congress,
after the news from Ghent, to do its share; but Congress was about
to adopt a measure of all others the best calculated to prolong the
war.[383]
While the friends of the government spoke in terms of open
discouragement and almost despair of the strongest military
measure which Congress would consent to consider, the Federalists
made no concealment of their wishes and intentions. Daniel Webster
used similar arguments to those of his friend Jeremiah Mason in the
Senate, affirming that the same principle which authorized the
enlistment of apprentices would equally authorize the freeing of
slaves,[384] and echoing pathetic threats of disunion.[385] Other
Federalists made no professions of sadness over the approaching
dissolution of government. Artemas Ward of Massachusetts spoke
December 14, the day before the Hartford Convention was to meet,
and announced the course which events were to take:[386]—
“That the Treasury is empty I admit; that the ranks of the regular
army are thin I believe to be true; and that our country must be
defended in all events, I not only admit but affirm. But, sir, if all the
parts of the United States are defended, of course the whole will be
defended. If every State in the Union, with such aid as she can obtain
from her neighbors, defends herself, our whole country will be
defended. In my mind the resources of the States will be applied with
more economy and with greater effect in defence of the country under
the State governments than under the government of the United
States.”
Such avowals of the intent to throw aside Constitutional duties
were not limited to members from New England. Morris S. Miller of
New York made a vehement speech on the failure of national
defence, and declared the inevitable result to be “that the States
must and will take care of themselves; and they will preserve the
resources of the States for the defence of the States.”[387] He also
declared that conscription would be resisted, and echoed the well-
remembered declamation of Edward Livingston against the Alien Bill
in 1798, when the Republican orator prayed to God that the States
would never acquiesce in obedience to the law.
“This House,” replied Duvall of Kentucky, “has heard discord and
rebellion encouraged and avowed from more than one quarter.”
Indeed, from fully one fourth of its members the House heard little
else. Under the shadow of the Hartford Convention the Federalist
members talked with entire frankness. “This great fabric seems
nodding and tottering to its fall,” said Z. R. Shipherd of New York,
December 9;[388] “and Heaven only knows how long before the
mighty ruin will take place.” J. O. Moseley of Connecticut “meant no
improper menace” by predicting to the House, “if they were
determined to prosecute the war by a recourse to such measures as
are provided in the present bill, that they would have no occasion for
future committees of investigation into the causes of the failure of
their arms.”[389] The latest committee of investigation had recently