1/13 - Musculoskeletal Injuries & Disorders

What what points of severe pain should a patient be referred to another level of care (red flags)?

>6/10 on pain scale, lasted >10 days, worsening

What symptom characteristics are red flags and indicate a patient should be referred to another level of care (red flags)?

• inability to bear weight

• deformity

• numbness/weakness

• fever

• bowel/bladder dysfunction

• fracture

After how many days of topical NSAID use should a patient be referred to a higher level of care (red flag)?

>21 days

When should cryotherapy/RICE be used?

• acute injury and swelling

• first 24-48 hours

When should thermotherapy be used?

• osteoarthiritis, muscle stiffness

• after inflammation resolves

Nonpharmacological therapies for musculoskeletal injury/disorders

• cryotherapy

• thermotherapy

• RICE

• activity modification

• exercise/weight management

Systemic pharmacologic therapy for musculoskeletal injury/disorders

• acetaminophen (if NSAIDs contraindicated)

• NSAIDs (≤10 days self-care)

  • ibuprofen

  • aspirin

  • naproxen

What should be considered when planning systemic pharmacologic therapy?

• assess GI, renal, CV risk

• avoid chronic use without provider oversight

Topical pharmacologic therapy

• topical NSAIDs for knee/hand

• counterirritants

• lidocaine

What should be considered when planning topical pharmacological therapy?

• avoid methyl salicylate in children

• aspirin allergy

• limit application sites

At what point should a patient be referred after using internal analgesics?

>10 days

At what point should a patient be referred after using external analgesics?

>7 days

Components of musculoskeletal system

• muscles

• tendons

• ligaments

• cartilage

• bone

Tendons

bind muscle to bone

Tendon and ligaments ability to stretch

• limited

• can be damaged due to hyperextension of the joint or overuse

• rarely rupture outside of extreme force

Synovial bursae

fluid filled sacs between join spaces to provide lubrication and cushioning

Cartilage

serves as protective padding between joints and in the vertebral column

Pain receptors location

skeletal muscle

Pain receptors stimulation

overuse or injury to the muscle or surrounding structures

Somatic pain

occurs when pain impulses are transmitted from peripheral nociceptors to the CNS by nerve fibers

• usually results from muscle strains or due to musculoskeletal causes

Overexertion cause

often caused by repeated unaccustomed eccentric muscle contraction (e.g. lifting weights)

Overexertion onset

• delayed muscle soreness, ~8 hours or more

• may last several days, peaking at 24-48 hours

Prolonged tonic contraction

seen with exercise, tension, poor posture, or improper body mechanics; can also produce muscle pain

When is overexertion commonly seen?

among people who do not exercise regularly but then begin an exercise regimen at a high level of intensity

Myalgia causes

• system infections (flu)

• chronic disorders (fibromyalgia)

• medication effects (statins)

• alcohol abuse

• vitamin D deficiency

Myalgia symptoms

widespread pain, not specifically associated with a recent injury

Strain

results from an injury to a muscle or tendon:

• tendons can become strained when their stretch capacity is exceeded (hyperextension)

• eccentric contraction of the muscle fibers while muscle is lengthening

• a tear of a muscle or tendon

Grade 1 strain

stretching, minor tear

Grade 2 strain

partial tear

Grade 3 strain

ruptured

Tendonitis

inflammation of a tendon resulting from acute injury or chronic repetitive movements/overuse of a body part

Carpal tunnel syndrome

repetitive use of hand and wrist

• tingling/numbness, weakness in hand

• symptoms persist during sleep

Sports related tendonitis

from overuse, old age, poor technique, etc.

• tennis elbow

• golfer’s elbow

• swimmer’s shoulder

• jumper’s knee

Bursitis

common cause of localized pain, tenderness, and swelling in the affected joint & usually worsened by movement of adjacent structures

Bursitis cause

• acute injury to joint

• repetitive joint action

What should be assessed when considering bursitis?

if pain is seen alongside a local puncture, a nearby infection or sever inflammation, an infectious cause should be ruled out before self-treatment is receommended

Shoulder injury related to vaccine administration (SIRVA)

caused by administration of the vaccine too close to the shoulder joint, may cause an inflammatory reaction including tendonitis and bursitis of the shoulder

SIRVA symptoms

• should pain

• impacted normal range of motion

Sprain

most common problem with ligaments

Grade 1 sprain

excessive stretching

Grade 2 sprain

partial tear

Grade 3 sprain

complete tear of the tissue

Grade 2 and 3 sprain symptoms

• moderate to severe pain

• loss of function of the affected limb

• inability to bear weight

Low back pain risk factors

• sedentary lifestyle

• poor posture

• wearing improper shoes

• excessive body weight

• poor quality mattress

• faulty sleeping posture

• improper technique lifting heavy objects

When is low back pain considered “chronic”?

pain lasts >3 months

Osteoarthiritis

characterized by a gradual softening and destruction of the cartilage between bones

Aggravating factors of osteoarthritis

heavy physical activity and repititive movement

Alleviating factors of osteoarthritis

routine moderate exercise (strengthening, swimming, walking, tai chi)

Patient-specific factors precluding self treatment

• pregnancy

• <2 years old

• contraindications/intolerances to OTC analgesics

Treatment goals

1. decrease pain severity

2. decrease pain duration

3. restore function

4. prevent re-injury/disability

5. prevent acute pain → chronic pain

RICE therapy

R: rest injured limb, slings, splints, crutches

I: ice

C: compression

E: elevation

What conditions is RICE/cryotherapy helpful for?

• muscle/joint injuries

• osteoarthritis when pain and swelling is present

How should you apply ice to the injured area?

• 15-20 minute increments

• 3-4 times/day

• remove if/when skin feels numb

• continue until swelling subsides or after 1-3 days

What can excessive icing cause?

vasoconstriction, blistering, or burning

Contrast bath

alternating the injured limb between warm and cold water to reduce swelling, improve circulation, and speed healing by creating a pumping action on blood vessels, flushing out excess fluid

When should contrast baths be used?

• >3 days after injury

• 1-3 times/day

Thermotherapy

may relieve stiffness for pain of noninflammatory nature

How should thermotherapy be used?

• 15-20 minutes, 3-4 times/day

• warm wet compress, heating pad, hot water bottle, heat generating adhesive, wrap product

Precautions of thermotherapy

do not apply to inflamed areas, can intensify vasodilation and exacerbate vascular leakage

TENS therapy

transcutaneous electrical stimulation; helps relieve pain associated with sore aching muscles, joint pain, or chronic intractable pain

• can be helpful for acute non-low back pain

How should TENS therapy be used?

• 15-30 minutes up to 3 times daily

• electrodes placed on various areas, directions are product specific

TENS precautions

• avoid placing on/over throat, chest, head, or carotid arteries

• do not use in osteoarthritis of knee and hip

• not helpful for low back pain

Pharmacologic therapy for osteoarthritis of hip/knee (NSAID or acetaminophen?)

oral NSAIDs are more effective than acetaminophen

Max acetaminophen dose for adults

4000 mg/day

Max acetaminophen dose for children

1625 mg/day

Acetaminophen black box warning

liver failure

Aspirin dosing ≥12 years

1-2 tablets q4h or 3 tablets q6h

• do not exceed 12 tabs in 24 hours

Aspirin consideration <12 years

consult a doctor

Reyes syndrome

children and teens who have/are recovering from chicken pox or flu-like symptoms should not use aspirin

Naproxen consideration

• heart attack and stroke warning

• children <12 consult a doctor

• serious condtions

Ibuprofen adult dosing

200 mg q4-6h

• use 400 mg if not working

• max 1200 mg/day

Ibuprofen dosing in children <11 years

• 15 mL of 100mg/5mL = 250mg

  • max 4x daily

When should a proton pump inhibitor be considered for NSAID use?

for GI protection if the patient is high risk or if a systemic nonselective NSAID will be used chronically or osteoarthritis

What should be considered prior to use of systemic NSAIDs?

diclofenac gel

Systemic analgesic for acute, subacute, or chronic back pain

• nonpharm. therapy recommended 1st line

• NSAIDs are 1st line for pharmacologic if no contraindications

Topical NSAID usage

• only 6% is absorbed systemically, reducing adverse effects

• may take 7 days to work, stop product after 21 days

Counterirritants

reduces pain by producing a less severe pain to counter a more intense one

• do not use after 10 days

Topical anesthetics

lidocaine, inhibits conduction of nerve impulses

• q6-8h prn pain

• 3 applications in 24 hours max

• only apply to intact skin

4 categories of counterirritants

1. produce redness by increasing blood flow

2. cool

3. vasodilate

4. incite irritation, but do not produce redness