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Adult Primary Care Musculoskeletal

Terms in this set (70)

Common Musculoskeletal Complaints
-Duration: acute or chronic.
-Origin: articular or nonarticular.
-Nature: inflammatory or noninflammatory.
-Distribution: localized or systemic (UNILATERAL VS. BILATERAL).
-Inside or outside the joint.
-Osteoarthritis: intra-articular.
-Strain (Muscle) vs. Sprain(Joint)
-Rheumatoid arthritis (inflammatory) bilateral.
-Osteoarthritis (wear and tear) unilateral.
-Stenosis spinal cord: Narrowing
Bulging of s disc
Infectious process.
-Quality of life.
Differentials in MS Problems
-Trauma
-Metabolic or circulatory disorders (Gout, renal failure, Rhabdomyolisis, Lupus).
-Degenerative disorders
-Systemic problems.
-Infection
-Tumors
-Synovial conditions
-Developmental problems (Cerebral Palsy). Inability to use knees to stand. Lower extremities weakness hallmark for MD.
-Congenital problems.
-Synovial (Intraarticular)issues pain with active and passive ROM.
-Extra-articular: Issues with active ROM only.
Role of Laboratory Diagnostics
-Minimal laboratory testing; primarily to rule out systemic illness. ANA, Uric acid, lyme antibody test, CRP or ESR
-Reserve imaging studies for cases with persistent symptoms >4-6 weeks or "red flags". Refer to specialist.
Red flags:
-Radicular symptoms >4-6 weeks.
-Increasing symptoms
-Osteomyelitis
-Cauda equina
-Herniation of disc
-Epidural abscess.
Imaging studies
Imaging studies are indicated:
-When examination cannot localize the anatomical structure that is causing symptoms
-After a significant trauma.
-When there is a loss of joint function (e.g., unable to bear weight)
-When pain continues despite conservative management
-When a fracture or bone infection is suspected.
-When there is a history of malignancy.
-Clinicians who are unfamiliar with what views to order should contact the radiologist for guidance.
Neck Pain
-Discomfort and limited ROM arising from the structures in the neck.
-Can be referred pain
Causes: trauma, degenerative, spasms.
-Contributing Factors
-Onset
-Location
-Character

-Very common loss of work type of pain.
-MVA caused
-Self limiting and benign in nature.
Neck Pain Assessment
-Precipitating event
-Active ROM
-Presence of palpable muscle spasm.
-Character of pain—numbness, tingling, radiation or localized.
-Age of patient; history of degenerative arthritis.
-Red flags: fever, loss of function, erythema, systemic symptoms.
-list claim film
-Vertebral tenderness
Cervical Muscle Sprain/Strain & Spasms
-Injury in the neck, a common and largely self-limited condition.
-All encompassing term for ligamentous injuries of the facet joints or intervertebral discs.
-Strain: Muscle involvement
-Sprain: Bone and cartilage.
-Cervical spondolosis: Arthritis.
-Menningitis
Anatomy of the neck
-Document muscle group involved.
Cervical Muscke Sprain/Strain/Spasm presentation
-Pain
-Dull
-Aching
-Nonfocal
Neck Pain Physical Exam
-ROM
-Spasms
-Spurling's Maneuver: Could be traumatic. Carefully.
-Lhermitte's sign
-Palpation of neck
-Vascular structures
-Musculoskeletal and neurovascular assessment.
-Dermatomes- sensation.
-Deep tendon reflexes.
Cervical Compression Test
-This test attempts to duplicate patient's symptoms by increasing pressure on the cervical nerve roots.
-Careful if patient has a herniation.
Spurling Test
-Tilting the neck to release the compression.
-Don't do until you r/o compression fx. or dislocation.
Neck Pain Dx
-EMG
-Radiographs
-CT or MRI (better indicated for soft tissue).
-What are u trying to see?? Start with Xray
MRI, CT, MRI.
-Soft tissue injury: MRI (herniation of a disk).
-CT: questionable Fx.
-Further analyze the Fx.
Neck Srain/Strain Differential
-Disc herniation
-Tumor
-Cervical Infection
-Dislocation or subluxation of spine.
-Inflammatory conditions.
-Spinal fractures.
-Cervical infarction: Aortic dissection.
Neck Pain Management
-Immobilization and physical therapy.
-Conservative treatment
-Rest followed by gentle ROM as tolerated.
-NSAIDs if no contraindications for inflammation.
-Short-term muscle relaxant if no contraindication.
-Ice or heat
-Physical therapy if indicated.
-Topical capsaicin cream
-Refer to orthopedist or neurologist if emergent symptoms.
-ICE vs. Heat
Start with ice and then heat.
***Cautious with Flexeril w the elderly. Anticholinergic symptoms. Norflex is better indicated.
Low Back Pain
-Any pain perceived by the patient as originating from the lumbosacral region of the spinal column.
-May be localized
-May radiate to the leg and/or feet.
Etiology and Incidence
-The 2nd leading cause of visits due to pain.
-Leading cause of lost work days in America.

Common causes:
-Mechanical strain
-Obesity
-Poor body mechanics
-Trauma
-Repetitive twisting, bending, lifting
-Herniated lumbar disks
-Other.
-Movement injury do not need imaging studies, unless the symptoms don't improve conservatively.
-Fall on back—xray.
Watch video on back exam on BB.
Pathophysiology Low Back Pain
-Annular Tear
-Spinal Stenosis
-Osteoporosis
-Scoliosis
-Spinal Hyperextension
-Spondyloysis
Low Back Pain S/S-
-Pain
-Numbness
-Bowel/ Bladder dysfunction
-Muscle Strength
-Reflexes
-Gait- ataxic
-Proprioception
-Possible- Straight leg raise pain under 60 degrees-Sciatica-Spinal eval. by specialist.
-Faber's/ Patrick's test
Straight-leg Raising
L5, S1 and sciatic nerve roots.
Reverse Straight-leg Raising
L1,L4
Prone rectus femoris Test
L1,l4 pain suggest compression of the upper lumbar nerve roots.
Low Back Pain Differentials
-Ankylosing spondylitis
-Drug-seeking behavior
-Extraspinal causes
-Fracture of the vertebral body.
-Herniated nucleus pulposus or ruptured disc.
-Infection
-Myeloma
-AAA: assess femoral pulse if unequal emergency.
Low Back Pain Dx.
-Radiographs
-AP/Lateral films of the spine.
-CT (waste)
-MRI(usually straight to it).
-Imaging not recommended for acute phases.
Low Back Pain Management
-Rest: Limit activities
-Physical Therapy
-Heat
-Bracing
-Weight loss
-Education about mechanics.
-US/Transcutaneous electric nerve stimulators (TENS).
-NDAIDS (first line drug)
-Muscle Relaxers
-Psychosocial assessment and stress management.
-Avoid prolong seating.
-Refer.
Herniated Lumbar Disc
-Pain that results in part from direct mechanical compression of the nerve root.
-Usually affects L4-L5 or L5 -S1.
-Spinal Stenosis- elders
Risk Factors: aging, cigarette smoking, narrowed lumbar vertebral canal, obesity, osteoporosis, stress, and muscle tension.
-Causes: trauma, body mechanics, vibration, prolonged seating.
Pathophysiology of Herniated Disc
-When a disc herniates, the nucleus pulposus pushes through a tear in the annulus fibrosis. The location and the amount will determine the symptoms.
Herniated Disc Physical Exam
-Paraspinal muscle spasm.
-Lumbar scoliosis
-Trunk tilt
-ROM
-Leg Raise
-Reflexes
-Straight leg raise
-Patrick's test
Patrick's Test
Herniated Disc Presentation
Lumbar Nerve Root Findings:
-L3-L4 Disk Pathology:
Quadriceps muscle
Pain- radiating
Reflexes
-L4-L5 Disk Pathology:
Dorsiflexion Mechanism
Pain- radiating
Screening: Heel walk
-L5-S1 Disk Pathology:
Plantar Flexion
Pain.
-Achilles reflex
Screening- walking on toes or heels.
Cauda Equina
-Continuation of the spinal cord below the first lumbar level in the adult.
-Spinal cord ends at L1
Severe lower back pain, Parestisia, loss bowel and bladder control.
-Extremity weakness
Parathesia of perineum and buttock (saddle anesthesia).
-Bowel and Bladder retention or incontinence.
Emergency!
Herniated Disc Dx.
-Radiographs
-AP/Lateral films of the spine.
-CT
-MRI
Herniated Disc: Differentials
-Demyelinating conditions.
-Extra spinous nerve entrapment.
-Hip or knee arthritis
-Lateral femoral cutaneous nerve entrapment.
-Spinal stenosis (older population).
-Thoracic cord compression.
-Trochanteric bursitis
-Vascular insufficiency
Herniated Disc Management
-Limit movement at first- followed by progressive walking program after 7-10 days.
-NSAIDS
-Oral Steroids (warranted for herniation of a disc to suppress inflammation).
-Epidurals
-Surgery
Lumbar Spinal Stenosis
-Narrowing of one or more levels of the lumbar spinal canal and subsequent compression of the nerve roots.
Obesity is a predisposing factor.
-Lumbar stenosis: sustained lower back pain.
-Leaning forward releases the pain. (Opens the canal). Pseudoclaudication.
LSS Presentation
-Pseudoclaudication & redicular pain.
-Pain- walking, sitting, standing.
Objective:
-Impaired Proprioception
-Romberg- positie
-Reflexes diminished
-Bowel/Bladder & Sphincter tone changes.
LSS Dx.
-Radiographs
-AP/Lateral films of the spine.
-CT
-MRI best picture.
LSS Differentials
-Abdominal aortic aneurysm.
-Arterial insufficiency
-Diabetes mellitus
-Folic acid or vitamin B12deficiency
-Infection
-Tumor
LSS Management
-NSAIDS
-Folic Acid or B12
-Physical Therapy
-Exercise program focus on flexing spine.
-Weight loss
-Epidurals
-Surgery- Decompression
-Laminectomy
Ostearthritis
-Multifaceted; "degenerative joint" disease.
-Typical joints affected are hands, knees, hips.
-Early morning stiffness, interfering with usual activities, usually improves with activity.
-Clinical diagnosis; functional assessment is important.
-X-ray findings do not correlate well with clinical symptoms.
-Wear and tear type of dx process.
-Early am stiffness for less than 30 min.
-AS the day progresses the pain becomes more severe.
-Unilateral asymetric type of findings.
-Some joint swelling not hot and no erydema.
-Crepitus
-Close together joints
Hallmark:
-Herbeden's: DIP
-Bouchard's: PIP
-Asymmetric joint involvement (Proximal joints.)
-X ray findings: space narrowing, bony cysts and osteophytes
-Locking or giving away feeling of the knee joints.
OA Differentials
-Bursitis
-Tendinitis
-Avascular necrosis of femoral head.
-Lyme disease
-Rheumatoid arthritis
-Vasculitis
-Lupus erythematosus
-Neuropathy
-Osteopenia
-Bone malignancy
OA DX.
-History and Physical may be enough to make diagnosis.
-X rays to assess hip, pathology, establish baseline and assess severity.
-MRI and CT for suspected spinal stenosis.
-CBC
-C reactive Protein
-ESR
-Rheumatoid factor +
-Serum Uric acid ro gout
-Synovial fluid analysis
OA Management
-Nonnarcotic analgesics are the first step.
-NSAIDs are used with more caution due to cardiovascular concerns; Consider COX-2 selective for patients not responding well to non selective.
-Intra-articular corticosteroids may be used.
Other medications:
-Tramadol, capsaicin (topical).
-Referral to pain management for intractable pain when surgery is not a consideration
-Arthritis Society patient support resources.
-Counseling on living with a chronic illness.
-Patient teaching about weight loss.
-Activity modifications
Exercise as tolerated—water exercise
Heat/cold.
-Physical therapy or self-help groups.
Surgical consultation if indicated.
Rheumatoid Arthritis
-RA is a chronic, progressive, systemic inflammatory disease that primarily affects the synovial joints.
-It may affect other organs
Structural deformities which cause physical and psychological stress are common as the disease progresses.
-Symmetric
AM stiffness for more than an hour.
-Pain worse in the AM and will get worse in the PM.
-More seen in women
-Peak 40-60 yoa.
Differentials RA
-OA
-Gout
-Septic arthritis
-Cellulitis
-Trauma
-Bursitis
-Other soft tissue disorders .
Clinical Presentation
Subjective:
-Malaise
-Diffuse arthritis
-Weight loss
-Anorexia
-Neuropathic pain to extremities.
-Wakes up with joint pain and it improves with activity.
-Joint swelling

Objective:
-Symmetric distribution
-Stiffness lasts longer than one hour.
-Swelling, redness and tenderness to PIP, MCP of hands and wrists and knees. Heat to the actual joint.
-Ulnar Deviation
-Boutonniere deformity
-Neck swan deformity
-Increased ESR, CRP elevated.
-Positive RA factor in 80% of cases.
Boutonniere Deformity
-Also known as "jammed finger" or "central slip extensor tendon injury.
Caused by rupture of the central portion of the extensor tendon at its insertion into the middle phalanx.
-Finger is held partially flexed at the PIP joint and extended or hyperextended at the DIP.
-PIP joint is TENDER and PAINFUL
Treatment: Splint in extension for 6 weeks in young, 3 weeks in elderly, inactive passive ROM at DIP.
Neck Swan Deformity
-Hallmarks of the Dx.
Diagnostic Test
-Rheumatoid Factor
-ESR
-C reactive Protein
-CBC
-Joint fluid analysis
-Quantitative Antinuclear Antibody (ANA) r/o Lupus.
-X rays of joints
-MRI may be considered
-X rays may not show anything in the first 6 months. As the disease progresses then shows bony erosion up to 30% in one year, up to 90% in two years.
RA Management
-Early in the disease may treat with heat/ice, PT/OT, splints, assistive devices and weigh loss.
-Warm water may be helpful.
-Exercise reduces pain but not indicated if the joint has an acute inflammatory event.
-For inflamed joints use isometric exercises.
-Systemic rest and rest of the joints.
-When recommending systemic rest (sleep) instruct the patient to do it in the prone position to avoid contractures of the hip.
-Drugs such as analgesics APAP and NSAIDs
-Corticosteroids
-Non biological
-Biological drugs (DMARDs). most preferred.
TNF blockers such as Adalimumab (Humira), infliximab (Ramicade)
Hydroxychloroquine (Plaquenil). Heavy SE profile.
Methotrexate .
Follow up RA
-Follow up every 90 days for routine blood work (CBC and Chem 7. Serum Albumin if methotrexate is used).
-CRP to monitor effectiveness of treatment
Normal is less than 0.8 mg/ld.
-Referral to rheumatologist if initial treatment of NSAIDs fails.
Gout
-Gout is a disorder as a results of increased uric acid accumulation.
-Uric acid accumulate in the joints causing pain and swelling.
-Typically affects the first metatarsophalangeal joint (Podagra).
-It may affect other joints such as wrists, elbow and fingers
-Usually affects a single joint but about 10% of individuals may have multiple involvement.
-70% of people with gout are men.
-Peak incidence between 40-50.
-Risk factors are obesity, alcohol abuse, genetic predisposition, DM, CKD, hemolytic anemia, excessive daily intake of purine.
Clinical Presentation Gout
Subjective
-Pain, swelling and redness to joint area.
-Monoarticular involvement usually, first metatarsal joint.
-Excruciating pain that awakens the patient at night (Hallmark).
-Does not tolerate anything touching the joint.
-Cant bear weight on foot.

Objective
-Podagra in 90% of patient's first attack.
-Joint is tender, warm to touch.
-Skin is erythematous and tout.
-Tophi may be present
-Serum uric acid elevated
-Fluid aspirate positive for crystals if UA normal.
-CBC with leukocytosis.
-Serum uric acid may be normal in 15-20 % of patients with gout.
Differentials
-Septic arthritis
-Cellulitis
-Trauma
-OA
-RA
-Bursitis
Diagnostic Test Gout
-History and physical with bilateral joint evaluation.
-Serum Uric Acid
-Joint fluid analysis
-CBC
-X ray
Management of Gout
Initial management
-NSAIDs (first line drug)
-Colchicine (if symptoms less than 36 hrs acute) give 1-1.2 mg PO on onset of symptoms and then 06 mg PO every hour until symptoms improve. Max is 6 mg.
-Steroids

Subsequent management
-Probenecid
-Allupurinol chronic maintenance.
-Febuxostat
Normally not started within a month of acute attack.
-NSAIDs medication of choice
-Allopurinol can be started a month after and acute attack.
-Subsequent mangement lowers uric acid in plasma.
-Dietary modifications
-Bed rest for 24 hours during acute attack.
-Hot compress after acute attack not during.
-Surgical removal of tophi if large.
FU and referral Gout
-Follow up in the office 1-2 weeks post the attack.
-If antihyperuricemia therapy initiated follow up in 4-6 weeks to revaluate.
-Patients who are younger than 35, with frequent attack or Renal disease should be referred to Rheumatologist.
Carpal Tunnel Syndrome
-CTS is the most common cause of peripheral nerve compression.
-Pain and numbness affects some part of the median nerve distribution.
-Some genetic predisposition and work related exposure (No agreement).
Clinical Presentation CTS
Subjective
-Aching sensation
-Paresthesia and numbness in the median distribution (Thumb and index).
-Pain to affected area
-Hallmark symptom is night time awakening with pain and numbness. circadial Rhythm.
-Flairs at night bc circadium rhythm levels of cortisol are lower at night. Less anti-inflammatory release from body.
CTS Assessment
-Tinel's Test
-Phalen Maneuver
Diagnostics Test CTS
-History and Physical exam
X rays (limiting).
-Median Nerve conduction velocity (Invasive and most effective). not use frequently.
Differentials CTS
-Arthritis
-Cervical radiculopathy affecting C6 nerve root.
-DM
-Median nerve compression at the elbow.
-Wrist arthritis.
Management CTS
-Conservative treatments
50-75% of patients will achieve symptom relieve with these methods.
NSAIDs
Splints very useful, OT very helpful.
GCS injections
Vitamin B6
-Surgical evaluation by hand specialist.
FU and Referral CTS
-Presence of Thenar atrophy.
-Unrelieved symptoms need surgical evaluation.
-Post op patients can expect to have hand splinted for 8-14 days.
Costochondritis
-Also known as anterior chest wall syndrome.
-Inflammation of one or more costochondral junctions that manifests with chest wall pain.
-Pain may be sharp or dull
-More common in women and peaks from 20-40 years of age.
-Inflammation of the costal area. Sharp pain, worse with deep breathing. 20-40 yoa.
Clinical Presentation Costochondritis
Subjective:
-Intermittent chest pain
Increased with movement and deep breathing.
-May have some radiation to the arm.
-May have recent history of URI or MVA.
Objective:
-May have lack of objective findings.
-Pain reproducible to palpation and movement of the arm.
Costochondritis Dx.
-Need to consider from benign causes to life threatening etiologies for chest pain.
-CXR
-ESR
-EKG
Differentials Costochondritis
-MI
-Pericarditis
-Aortic aneurism
-Asthma
-Pneumonia
-GERD
-Esophagitis
Manangement Costochondritis
-Most of the time self limiting and benign.
-NSAIDs first line medications.
-ICE/HEAT
Follow up and referral
-Should evaluate patient in 7-10 days after via phone.
-Need to r/o other possible etiologies if not improved.
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