MSK I

Musculoskeletal Disorders

Introduction

  • Lecturer: Christina Aplin-Snider, DNP, MSN, FNP-BC, PMHNP-BC, Associate Professor of Nursing at University of Michigan-Flint.

Course Objectives

  • Analyze diagnostic tests to indicate musculoskeletal abnormalities.

  • Analyze presentation and management of sprains vs. strains, including etiology and testing.

  • Analyze assessment and management of osteoarthritis (OA) vs. rheumatoid arthritis (RA).

  • Define the etiology and pathophysiology of osteoporosis.

  • Analyze management of low back pain (LBP).

  • Analyze assessment and management of lumbosacral strain vs. lumbar radiculopathy.

  • Analyze assessment and management of elbow, ankle/foot, gout, knee, and fibromyalgia disorders.

  • Analyze assessment and management of hip pain, infectious arthritis, hand/wrist pain, and neck & shoulder pain.

  • Analyze assessment and management of chronic pain.

Key Terms to Know

  • Dorsal: Relating to the back surface.

  • Plantar: Relating to the sole of the foot.

  • Inversion: Movement of the foot turning inwards.

  • Eversion: Movement of the foot turning outwards.

  • Supination: Rotation of the forearm or foot resulting in palm or sole facing upward.

  • Phalanges: Bones of the fingers.

  • Metatarsal: Bones of the toes.

  • Anterior drawer test: Evaluates possible anterior cruciate ligament damage. The patient is supine with hips flexed at 45 degrees and knees at 90 degrees. The examiner pulls the leg forward.

  • Lachman’s test: Tests knee stability by stabilizing the femur and pulling the tibia forward to compare with the other knee.

  • McMurray test: Specific test for meniscal tears (details provided later).

  • Tinel’s sign: Test for carpal tunnel syndrome, assessing nerve damage through direct percussion at the wrist.

  • Straight leg raising test: Evaluates for lower back pain, where the patient's leg is lifted straight off the exam table.

  • Know all of these terms and what each test assesses!

Test Matching

  • Match the test with the condition:

    • Meniscal tear → A. McMurray Test

    • Anterior cruciate ligament tear → C. Lachman’s test

    • Lumbar nerve root compression → D. Straight leg raising test

    • Cervical nerve root compression → B. Tinel’s sign

Patient Evaluation

  • Essential to review the assessment and plan of the musculoskeletal system.

  • Formulate questions for symptom analysis.

  • RICE protocol is commonly used in treatment for musculoskeletal injuries: Rest, Ice, Compression, Elevation.

  • Referral indications include:

    • History of significant trauma.

    • Hot, swollen joint.

    • Constitutional signs.

    • Focal or diffuse weakness.

    • Neurogenic pain.

    • Claudication.

Sprains vs. Strains

  • Sprain:

    • Definition: Stretching or tearing of a ligament and/or a joint capsule.

    • Commonly affects the ankle, but can involve any joint.

    • Often caused by inversion or eversion injuries.

    • Symptoms include swelling, ecchymosis, and tender area.

    • Rule out bony injuries with X-ray examination.

Classification of Sprains

  • Sprains are graded on a continuum:

    • Grade I: No joint instability; minor ligamentous stretch without tear; treatment includes NSAIDs, RICE, and progressive weight bearing.

    • Grade II: Moderate joint instability; partial ligamentous tear; requires immobilization for 4-6 weeks.

    • Grade III: Marked joint instability; complete rupture of ligament; immobilization and referral to an orthopedist necessary.

  • Strain:

    • Definition: Stretching or tearing of muscle fibers at the musculotendinous junction.

    • Occurs more commonly in lower extremities (i.e., hamstring, quadriceps, and gastrocnemius muscles).

    • Symptoms include a grabbing sensation, weight-bearing pain, swelling, tenderness, and worsening pain when stretching the involved muscle.

    • Treatment includes RICE and muscle strengthening; X-ray if in doubt.

Preventative Treatments for Strains and Sprains

  • Fitness and Conditioning: Strengthening muscle groups.

  • Stretching: Regular stretching routines.

  • Exercise Correctly: Warm-up slowly, engage in rigorous activity, and follow with a cool down.

Hand & Wrist Pain

  • Common injuries to the hands/fingers in primary care settings.

  • Overuse injuries such as carpal tunnel syndrome are frequent, presenting with localized pain, numbness, tingling, weakness, or immobility.

  • Diagnosis involves taking a comprehensive medical, recreational, and occupational history alongside precise anatomical location of pain.

Common Clinical Presentations

  • Trigger finger: Disorder affecting flexor tendons; common in diabetes.

  • Chronic stenosing tenosynovitis: Often occupational; involves repetitive motions causing catching sensations in the thumb.

  • Degenerative joint disease (DJD) in the wrists and fingers: Presents with pain and some weakness around the base of the thumb and fingers.

Diagnostics & Differential Diagnosis

  • X-ray if bony abnormalities are suspected.

  • Labs include TSH, ESR, ANA, and Rh factor if RA or systemic disease is suspected.

  • Electromyography (EMG) to check for nerve damage.

Management

  • Trigger Finger: Referral to orthopedic if finger extension is not possible; otherwise, RICE.

  • Tenosynovitis: RICE; refer to ortho if no improvement in a few weeks.

  • DJD: Splinting, NSAIDs, and referral to ortho if no improvement.

Carpal Tunnel Syndrome

  • Definition: Compression of the median nerve.

  • Symptoms include paresthesias in the thumb, index, long, and radial aspects of the ring finger.

  • Treatment may involve wrist splints for 6-8 weeks and NSAIDs; surgery may be necessary in persistent cases.

Bursitis

  • Definition: Inflammation of fluid-filled sacs in joints; commonly seen in shoulder, elbow, knee, and hip.

  • Treatment includes NSAIDs, steroid injections, rest, heat, or ice.

Shoulder Pain

  • Prevalent in middle and older age.

  • Anatomy of the shoulder is critical; stability depends on periarticular structures, the glenohumeral joint, and sites distant from the shoulder.

  • Pain locations may indicate specific conditions; rotator cuff tendinitis is a common source of shoulder pain.

Rotator Cuff Tendinitis

  • Etiology: Degenerative changes in the rotator cuff tendons.

  • Symptoms include night pain and difficulty sleeping on the involved side, pain on resisted abduction and external/internal rotation, and a painful arc during shoulder abduction.

Management

  • Options include physical therapy, medications, injection therapy, and preventative exercises.

Persistent Symptoms

  • Indicate possible continued impingement, tear, or instability; referrals to ortho required.

Rotator Cuff Tear

  • Most tears occur proximal to the supraspinatus tendon insertion.

  • Symptoms vary with the size of the tear; larger tears result in greater weakness and may require surgical intervention.

Adhesive Capsulitis (Frozen Shoulder)

  • Unknown etiology, more prevalent in women aged 40-60; often follows rotator cuff tendinitis.

  • Symptoms include difficulty lifting the arm overhead and significantly reduced range of motion (ROM).

  • Treatment involves analgesics, injections, and progressive exercise through physical therapy.

Differential Diagnoses of Shoulder Pain

  • Includes visceral sources like dissecting aortic aneurysm, phrenic nerve irritation, and more, such as RSD, nerve compression, and thoracic outlet syndrome.

Elbow Pain

  • Common conditions include lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer’s elbow).

Lateral Epicondylitis (Tennis Elbow)

  • Originates from lateral epicondyle inflammation, causing localized pain upon wrist extension and is worsened by repetitive use.

Management

  • Rest, NSAIDs, steroid gels, corticosteroid injections, grip exercises, and physical therapy.

Medial Epicondylitis (Golfer’s Elbow)

  • Involves tissues around the medial epicondyle, causing pain during resisted wrist flexion and when stretching wrist flexors.

Neck Pain

  • Common sources of referred pain include migraines, temporomandibular joint issues, shoulder problems, and cervical strain.

  • Diagnosis involves physical examination, ROM assessment, and lab tests if neurological concerns are present.

Cervical Sprain Syndrome (Whiplash)

  • Characterized by acute neck injuries due to sudden extension; treatment includes immobilization, NSAIDs, and heat therapy. Immediate referral is necessary for neurological abnormalities.

Low Back Pain (LBP)

  • Definition: Acute (<3 weeks) vs. chronic (>7 weeks) pain.

  • Referral indicators: neurological deficits, abnormal pulses, bowel/bladder dysfunction, or lack of improvement from standard treatment.

Diagnosis

  • Most commonly caused by muscular/ligamentous injuries or degenerative joint disease (DJD).

  • Symptoms of radiculopathy indicate possible nerve root irritation, often associated with disc herniation.

Clinical Presentation & Differential Diagnosis

  • Complete history essential, focusing on past injuries.

  • Examination should include straight leg raise (SLR) tests and checking reflexes for L4, L5, and S1 nerves.

Management

  • Typical treatment modalities: physical therapy, rest, muscle relaxants, NSAIDs, and possibly corticosteroids.

  • Expect 85% of patients to recover in 3-5 days with full recovery in 6-8 weeks.

Lumbosacral Strain (LSS) vs. Lumbar Radiculopathy (LR)

  • LSS: Caused by spine irritation or muscle spasms. Symptoms involve spasm, ache, and discomfort positions; neurological exams are within normal limits (WNL).

  • LR: Irritation of nerve structures with possible altered neurological exam and increased abnormal reflexes.

Diagnostic Testing

  • LSS usually does not require testing; LR may require MRI in specific cases.

Interventions

  • Conservative treatments like physical conditioning for both conditions. Special evaluations for LR after 4-6 weeks if symptoms persist.

Rule of Thumb for Radiology

  • X-rays indicated for suspected fractures, inflammatory diseases, malignancies, scoliosis, and infections.

MRI Recommendations

  • MRI is warranted if back pain hasn't responded to treatment after 4-8 weeks, considering 'red flags' like new neuro findings or systemic symptoms.

Hip Pain

  • A symptom rather than a specific disease, with different causes based on the patient's age group (e.g., OA in elders vs. SCFE in adolescents).

Etiology

  • 15% of US adults have OA; bursitis typically results from overuse injuries.

  • Rarely, infections occur in hip joints among adults.

Clinical Presentation

  • Diagnoses rely heavily on symptom analysis and physical examination focusing on gait, ROM, point tenderness, and potential muscle spasms.

Diagnostics

  • Typically arise from clinical exam; labs and imaging (like X-rays, MRI) recommended based on trauma or undiagnosed conditions.

Management

  • Mainly symptomatic; physical therapy and prevention of falls are crucial, particularly in the elderly. Short courses of NSAIDs and referrals for serious issues.

Osteoporosis

Definition

  • A disease characterized by reduced bone mass per unit volume.

  • Women are more affected post-menopause. Loss averages 0.3-0.5% per year.

Incidence/Risk Factors

  • Accounts for significant numbers of bone fractures, particularly in older populations. Risk increases with age, genetics, lifestyle choices, etc.

Implications

  • Leading cause of fractures with high mortality rates post-fracture in elderly.

Clinical Presentation

  • Bone pain, acute pain upon rest, and spontaneous fractures.

Diagnostics

  • Typically normal lab profiles except may test for Vitamin D and calcium. Bone mass densitometry is key to assessing risk.

Management & Prevention

  • Focus on risk factor modification: weight-bearing exercises and proper calcium/Vitamin D intake.

  • Medications like alendronate and bisphosphonates are indicated for postmenopausal women.

  • Emphasis on fall prevention practices.

Fibromyalgia

Definition

  • Characterized by chronic, widespread musculoskeletal pain, fatigue, and a range of other symptoms that are often present for over three months.

Incidence/Etiology

  • More common in women, affecting 3-6 million individuals. Etiology not clearly understood; possible autoimmune or genetic links.

Clinical Presentation & PE

  • Diagnosis criteria include widespread pain in specific tender points. Patients may experience dysfunctional sleep, fatigue, and digestive issues.

Diagnostics & Differentials

  • Comprehensive history required; normal lab results typically do not indicate fibromyalgia. Various other conditions to rule out.

Management

  • No standard treatment, focus on multi-faceted approaches including medication (NSAIDs, antidepressants) and therapeutic lifestyle changes. Consider counseling and support groups.

Chronic Pain

Definition

  • Pain lasting longer than six months beyond typical healing time, integrating physiological and psychological aspects.

Incidence/Etiology

  • Affects over 50 million US individuals, with individual responses varying significantly.

Pathophysiology

  • Driven by both somatic dysfunction and CNS changes; categorized into organic or idiopathic.

Clinical Presentation

  • Often manifesting as psychological impacts, altered daily function, and potential substance abuse due to chronic pain management.

Management Strategies

  • Involve multi-disciplinary approaches ensuring patient control over pain management. Consider psychosocial aspects critically.

Medications

  • Follow WHO guidelines for a stepwise approach to medication management for chronic pain.

Non-Pharmacologic Management

  • Incorporation of cognitive behavioral therapies, alternative medicine, and endorphin-producing exercises.

Referral Criteria

  • Necessary if the pain etiology is unclear or treatment is ineffective, particularly with significant psychological components present.