Musculoskeletal System
Musculoskeletal System: Conditions, Diagnostics, and Management
Acute Osteomyelitis
Definition: An acute infection of the bone that causes inflammation and destruction.
Causes: Can be caused by bacteria (most commonly Staphylococcus aureus, including MRSA), mycobacteria, and fungi.
Spread Mechanisms:
Contiguous Spread: Most cases are due to spread from a nearby infected wound to the bone.
Example: An infected pressure sore on the heel leading to osteomyelitis of the calcaneus (via nonhematogenous spread).
Hematogenous Spread: Seeding of the bone from an infection in the bloodstream (bacteremia).
Example: A patient with bacteremia complaining of refractory vertebral pain and tenderness (hematogenous osteomyelitis).
Direct Trauma: Trauma to the bone can also result in infection.
Symptoms: Patient complains of localized bone pain, swelling, redness, and tenderness of the affected area, along with fever.
If on the leg or hip, the patient may refuse to walk and bear weight.
Diagnosis:
Imaging: An MRI can show changes to the bone and bone marrow earlier than plain x-ray or radiograph.
Laboratory Tests: White blood cell (WBC) count, erythrocyte sedimentation rate (ESR; sed rate), and C-reactive protein (CRP) are often elevated.
Cultures: Blood cultures may be positive.
Treatment:
Antibiotic treatment is based on culture and sensitivity (C&S) results.
May require surgical debridement, amputation, and bone grafts.
Bone Metastases
Pain Characteristics: Bone pain can be described as:
Achy, sharp, and well localized.
Neuropathic (burning, shooting pain).
Can be severe, with night pain and/or pain with weight bearing.
Can be constant or intermittent, and exacerbated with movement of the joint or bone.
Associated Symptoms: May be accompanied by night sweats, malaise, fever, and weight loss.
Complications: Pathologic fractures may occur.
Prevalence: Bone is one of the most common sites of distant metastases.
Laboratory Findings: Routine labs may show elevated levels of alkaline phosphatase and/or serum calcium (hypercalcemia).
Primary Cancers: Cancers of the prostate, breast, lung, thyroid, and kidney make up the majority (80\%) of cases of bone metastases.
Imaging:
Radiograph (X-ray): Has poor sensitivity, but it can show bony lesions and may show early lesions.
MRI: In general, MRI is the most sensitive and specific imaging test.
Cauda Equina Syndrome
Definition: Occurs when there is dysfunction or damage to the lumbar and sacral nerve roots of the cauda equina.
Causes: Examples include disc herniation, epidural abscess, or tumor.
Etymology: The term "cauda equina" is Latin for "horseâs tails," describing the collection of nerve roots at the end of the spinal cord.
Symptoms (Acute Onset): Low back pain accompanied by:
Pain radiating down one or both legs.
Saddle anesthesia and sensory loss of the affected nerve roots.
Bladder incontinence (or retention of urine) and fecal incontinence.
Bilateral lower extremity numbness and weakness.
Management: This is a surgical emergency. Needs spinal decompression. Refer to ED immediately.
Colles Fracture
Definition: Fracture of the distal radius (with or without ulnar fracture) of the forearm, along with dorsal displacement of the wrist.
Mechanism of Injury: History of falling onto an outstretched hand, or "FOOSH" (similar to navicular fracture).
Appearance: Also known as the "dinner fork" fracture due to the characteristic appearance of the arm and wrist after the fracture.
Prevalence: A common type of wrist fracture.
Hip Fracture
History: Patient typically has a history of slipping or falling.
Symptoms: Sudden onset of one-sided hip pain.
Severity Dependent: If a mild fracture, the patient may still bear weight on the affected hip. If a displaced fracture, there will be severe hip pain with external rotation of the hip/leg (abduction) and leg shortening.
Unable to walk and bear weight on the affected hip.
Epidemiology: More common in older adults.
Mortality: The one-year mortality rate for older adults is approximately 21\% secondary to complications of immobility, such as pneumonia and deep vein thrombophlebitis.
Pelvic Fracture
History: Requires significant or high-energy trauma, such as a motor vehicle or motorcycle accident.
Signs and Symptoms: Depend on the degree of injury to the pelvic bones and other pelvic structures (e.g., nerves, blood vessels, pelvic organs).
Assess for ecchymosis and swelling in the lower abdomen, hips, groin, and/or scrotum.
May present with bladder and/or fecal incontinence, vaginal or rectal bleeding, hematuria, and numbness.
Complications: May cause internal hemorrhage, which can be life-threatening.
Initial Management: Check airway, breathing, and circulation first (the ABCs).
Scaphoid (Navicular) Fracture
Symptoms: Wrist pain on palpation of the anatomic snuffbox and pain on axial loading of the thumb.
History: History of falling forward with an outstretched hand (hyperextension of the wrist) to break the fall.
Imaging: Initial x-ray of the wrist is often normal, but a repeat x-ray in 2 weeks will show the scaphoid fracture (due to callus bone formation).
Complications: High risk of avascular necrosis and nonunion.
Treatment: Place into a thumb spica splint and refer to an orthopedist.
Tip: If palpation in the anatomic snuffbox elicits pain, place a thumb spica splint and refer to orthopedics, even if x-rays are negative.
Joint Anatomy
Synovial fluid: Thick serous clear fluid (sterile) that provides lubrication for the joint. Cloudy synovial fluid can be indicative of infection; order C&S.
Synovial space: The space between two bones in a synovial joint, filled with synovial fluid.
Articular cartilage: The cartilage lining the open surfaces of bones in a joint.
Meniscus or menisci (plural): Crescent-shaped cartilage located in each knee (two menisci in each knee). They aid in dissipating loading forces placed on the knee, stabilization during rotation, and lubricating the knee joint.
Tendon: Connects muscle to the bone (a partial or complete tear of a tendon or muscle is a strain).
Ligament: Connects bone to bone (a partial or complete tear of a ligament is a sprain).
Bursae: Saclike structures located on the anterior and posterior areas of a joint that act as padding. They become filled with synovial fluid when inflamed (bursitis). Cloudy fluid is abnormal and suggestive of infection.
Orthopedic Terminology
Types of Movement
Abduction: Movement going away from the body.
Adduction: Movement going toward the body.
Flexion: Decreases the angle between two bones; bending.
Extension: Increases the angle and straightens the joint.
Hands and Feet
Metacarpals: Bones of the hands.
Carpals: Bones of the wrist. There are a total of eight wrist bones.
Phalanges: Fingers and the toes; the singular form of the term is phalanx.
Metatarsals: Bones of the feet.
Talus: Ankle bone.
Calcaneus: Heel bone.
Proximal and Distal
Proximal: Body part located closer to the body (compared with distal).
Distal: Body part farther away from the center of the body.
Benign Variants
Genu recurvatum: Hyperextension or backward curvature of the knees.
Genu valgum: Knock-knees. Tip: To remember valgum, think of âgum stuck between the kneesâ (knock-knees).
Genu varum: Bowlegs. Tip: The opposite of valgus.
Exercises and Injuries
Within the First 48 Hours of an Injury
Avoid vigorous or strenuous exercise and exacerbating activities; rest is key to reduce the risk of increased inflammation and damage to the affected joints.
Engage in gentle range-of-motion (ROM) exercises.
RICE Mnemonic
Within the first 48 hours after musculoskeletal trauma, follow these rules:
Rest: Avoid using the injured joint or limb.
Ice: Apply cold packs on the injured area (e.g., 20 minutes on, 20 minutes off) for the first 24 to 48 hours.
Compression: Use an elastic bandage wrap over joints (e.g., ankles, knees) to decrease swelling and provide support.
Elevation: This prevents or decreases swelling. Avoid bearing weight on the affected joint.
Exercise Guidelines
Adults: 150 minutes weekly of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity or a combination of both; add muscle strengthening exercise at least 2 days a week. In hypertensive adults, aerobic exercise has been found to lower resting systolic/diastolic BP.
Children and Teens (6 to 17 years): 60 minutes daily of moderate-to-vigorous physical activity (mostly aerobic); include muscle-strengthening and bone-strengthening activity three times per week.
NonâWeight-Bearing Exercise: Isometric exercises are non-weight-bearing exercises that are performed in a fixed state in which the muscle is flexed against a stationary object.
Examples: Pushing one fist against the palm of the other hand. Biking and swimming are aerobic exercises, which are nonâweight-bearing (they do not strengthen bones).
Weight-Bearing Exercise: In weight-bearing exercises, the bones/muscles are forced against gravity. Weight-bearing exercise is recommended for treating osteopenia and osteoporosis to help strengthen bone durability.
Examples: Dancing, high-impact aerobics, hiking, jogging/running, jumping rope, stair climbing, and tennis.
Orthopedic Maneuvers
General Principle: Test both extremities. Use the normal limb as the baseline for comparison.
Finkelsteinâs Test (for De Quervainâs Tenosynovitis)
Condition: De Quervainâs tenosynovitis is caused by an inflammation of the tendon sheath, which is located at the base of the thumb (affecting the abductor pollicis longus and extensor pollicis brevis tendons).
Procedure:
Tell the patient to flex the thumb toward the palm.
Then make a fist by folding remaining fingers over the thumb.
Tell the patient to ulnarly deviate their wrist.
Positive Test: If the patient complains that the tendon (on the side of the thumb) hurts with ulnar deviation.
Drawer Sign (for Knee Stability)
Purpose: Test for knee stability. Excessive laxity of the affected knee is suggestive of a torn ligament.
Anterior Drawer Sign (for ACL Tear):
Procedure: Patient lies on examination table (supine). The hip is flexed to 45 degrees, and the knee is bent to 90 degrees. The examiner sits on the forefoot/toes to stabilize the knee joint. Then the examiner grasps the lower leg by the joint line and pulls the tibia anteriorly (like opening a drawer).
Positive Test: Indicative of a damaged or torn anterior cruciate ligament (ACL).
Posterior Drawer Sign (for PCL Tear):
Procedure: Patient lies on examination table (supine). The hip is flexed to 45 degrees, and the knee is bent to 90 degrees. The examiner sits on the forefoot/toes to stabilize the knee joint. Then the examiner grasps the lower leg by the joint line and pushes it posteriorly (like closing a drawer).
Positive Test: Indicative of a damaged or torn posterior cruciate ligament (PCL). Sensitivity is 90\%, and specificity is 99\%.
Lachmanâs Sign (for ACL Tear)
Procedure: With the patientâs knee in 30 degrees of flexion, the femur is stabilized with one hand, and the other hand is used to apply force to the tibia to displace the tibia forward on the femur.
Positive Test: Suggestive of a tear to the ACL.
Collateral Ligaments (Knees)
Positive Finding: An increase in laxity of the damaged knee (ligament tear).
Valgus Stress Test of the Knee: Tests for the medial collateral ligament (MCL).
Varus Stress Test of the Knee: Tests for the lateral collateral ligament (LCL).
Joint Injections
Indications: Administering intra-articular/periarticular joint injections with steroids (e.g., triamcinolone) is indicated for inflammatory arthritis (in patients that have long periods of near remission) as well as soft tissue structures (such as the subdeltoid bursa and tendon sheathing).
Usage Frequency: The use of injections should be limited for any given indication; there is no absolute number, but it varies with each disease and patient specifics.
Technique: If high resistance is felt when pushing the syringe, do not force. Withdraw the needle slightly (do not remove from the joint) and redirect.
Complications: Include tendon rupture, nerve damage, infection, bleeding, hypothalamicâpituitaryâadrenal (HPA) suppression, among others.
Anticoagulation Therapy: Joint injections are generally safe in patients who are on anticoagulation therapy; evidence has shown no significant difference in bleeding risk.
Imaging Modalities
Plain X-ray Films (Radiographs):
Shows: Bone fractures, osteoarthritis (OA; joint space narrowing, osteophyte formation), damaged bone (osteomyelitis, metastases), metal, and other dense objects.
Limitations: Not recommended for soft tissue structures such as menisci, tendons, and ligaments.
Initial Modality: Often used as the initial imaging modality.
Pearls: Best for bone injuries such as fractures. Some radiographs are normal for the first 2 to 3 weeks after the onset of injury (e.g., stress fractures).
CT Scan (Computed Tomography):
Mechanism: Combines x-rays (gamma radiation) that are rotating in a continuous circle around the patient with computer software to show slices of three-dimensional images.
Use: Can be done with or without contrast. Detects bleeding, aneurysms, masses, pelvic and bone trauma, fractures.
MRI (Magnetic Resonance Imaging):
Gold Standard: Often, the gold standard for injuries of the cartilage, menisci, tendons, ligaments, or joints.
Mechanism: MRI uses a magnetic field and radio waves, not radiation (compared with x-rays and CT scans).
Use: Can be done without or with contrast.
Contraindications: Contraindicated in metal implants, certain cardiovascular (CV) implantable devices, cardiac valves, aneurysm clips, drug infusion pumps, âtriggerfishâ contact lens, cochlear implant, neurostimulators, electrodes for deep brain stimulation, and bullets, shrapnel, and other metal fragments.
Pearls: Best for soft tissue, joints, and occult fractures.
Acute Musculoskeletal Injuries Treatment: RICE
RICE Mnemonic: Rest, Ice, Compression, Elevation.
Ice: Best during the first 48 hours post-injury; apply for 15 to 20 minutes per hour several times/day (frequency varies).
Rest and Elevation: Rest and elevate the affected joint to help decrease swelling.
Compression: Compress joints as needed. Use elastic bandage wrap; helps with swelling and provides stability.
Medication: Administer nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., naproxen BID, ibuprofen QID) for pain and swelling PRN.
Ankylosing Spondylitis
Definition: A chronic inflammatory disorder (seronegative arthritis) that affects mainly the spine (axial skeleton) and the sacroiliac joints (axial spondylarthritis).
Other Joints Affected: Shoulders, hips, knees, and sternoclavicular joints.
Rare Manifestation: A few may develop diffuse swelling of the fingers (dactylitis).
Classic Case: Young adult male complains of a chronic case of back pain (>3 months) that started at the neck and progressed down to the spine. Neck pain is an early symptom.
Reports the pain gradually progressed from the neck to the upper back (thoracic spine) and then the lower back.
Impaired spinal mobility. Joint pain keeps him awake at night.
Associated with generalized symptoms such as low-grade fever and fatigue.
May have chest pain with respiration (costochondritis) and costovertebral tenderness.
Long-term stiffness improves with activity. Some may have mid-buttock pain (sciatica indicates sacroiliac spine is involved).
Pain is diminished with exercise and is not relieved by rest.
Insidious onset.
Objective Findings:
Causes a marked loss of ROM of the spine such as forward bending, rotation, and lateral bending.
Decreased respiratory excursion down to <2.5 cm (normal 5 cm).
Some have lordosis. Hyperkyphosis (hunchback) occurs after 10 years or more with the disease.
Uveitis: Occurs in 25\% to 35\% of patients. Complaints of eye irritation, photosensitivity, and eye pain. Scleral injection and blurred vision occur. Unilateral eye involvement is common. Refer to an ophthalmologist as soon as possible (treated with steroids).
Labs:
ESR and CRP: Slightly elevated.
Rheumatoid factor (RF) is negative.
Spinal Radiograph: Classic âbamboo spineâ in late ankylosing spondylitis (resembles bamboo).
Treatment Plan:
Refer to a rheumatologist.
If a smoker, advise smoking cessation. Screen for anxiety and depression.
Refer for physical therapy for initial evaluation and training, including postural training, ROM, and stretching.
Exercise therapy combined with hydrotherapy is more effective than exercise alone.
Advise the patient to buy a mattress with good support.
First-line Initial Treatment: NSAIDs such as naproxen up to 500 mg twice a day or ibuprofen (up to 800 mg TID). Any NSAID may be effective; usually, the maximum dose is needed to control pain.
If high risk of bleeding, consider gastro-prophylaxis with a proton-pump inhibitor (PPI) in patients taking NSAIDs long term.
For Severe Cases: Treatment options include tumor necrosis factor (TNF) inhibitors, biologics (e.g., etanercept), disease-modifying antirheumatic drugs (DMARDS; methotrexate), and spinal fusion.
Complications:
Anterior uveitis.
Osteopenia, vertebral and nonvertebral fractures.
Neurologic manifestations: Spinal cord injury, atlantoaxial subluxation, cauda equina syndrome.
Renal and pulmonary disease.
Possible pregnancy complications.
CV disease: Hypertension, heart failure, acute coronary syndromes, strokes, venous thromboembolism, conduction abnormalities, aortic disease.
Tips:
Ankylosing spondylitis: Know signs and symptoms for diagnosis. Bamboo spine is pathognomonic for ankylosing spondylitis.
Uveitis: Swelling of the uvea, the middle layer of the eye that supplies blood to the retina (refer to ophthalmologist). Initial treatment includes topical steroids. Oral glucocorticoids are recommended for those resistant to initial therapy. Higher risk of uveitis with inflammatory disease (e.g., ankylosing spondylitis, sarcoidosis, inflammatory bowel disease).
Elbow Tendinopathy
Definition: Represents a chronic tendinosis at the origin of the wrist flexors or extensors. A common cause of elbow pain, usually caused by overuse injury.
Types:
Lateral epicondyle tendon pain: Tennis elbow.
Medial epicondyle tendon pain: Golferâs elbow.
Risk Factors: Increased age, repetitive wrist movement, forceful activity, and poor stroke mechanics among tennis and golf players.
Lateral Epicondylitis (Tennis Elbow) & Medial Epicondylitis (Golferâs Elbow)
Lateral Epicondylitis (Tennis Elbow) Classic Case: Gradual onset of pain on the outside of the elbow that sometimes radiates to the forearms. Pain is worse with twisting or grasping movements (e.g., opening jars, shaking hands). Physical exam shows local tenderness over the lateral epicondyle.
Medial Epicondylitis (Golferâs Elbow) Classic Case: Gradual onset of aching pain on the medial area of the elbow (the side of the elbow that is touching the body), which can last a few weeks to months. Pain can be mild to severe. More common in women aged 45 to 64 years. Occurs over the medial aspect of the elbow (ulnar nerve). Physical exam shows localized tenderness over the medial epicondyle.
Complications of Elbow Tendinopathy
Ulnar nerve neuropathy and/or palsy (long-term pressure/damage).
Symptoms: Complaint of numbness/tingling on the little finger and the lateral side of the ring finger, and weakness of the hand.
Worst-Case Scenario: Development of a permanent deformity called âclaw hand.â
Referral: Refer to a neurologist if ulnar nerve palsy is suspected.
Gout
Definition: Deposits of uric acid crystals (monosodium urate) inside joints and tendons due to genetic excess production or low excretion of purine crystals (a by-product of protein metabolism).
High levels of uric acid can crystallize in the peripheral joints such as the first joint of the large toe (metatarsophalangeal [MTP] joint), ankles, hands, and wrists.
Epidemiology: More common in middle-aged males older than 30 years of age.
Diagnosis:
Gold Standard: Performed by joint aspiration of the synovial fluid. Microscopy exam using a polarized light is used to identify uric acid crystals in the synovial fluid to diagnose gout.
Most Common Way to Diagnose: Recurrent flares that are accompanied by an elevated serum uric acid (>6.8 mg/dL) level.
Classic Case: Middle-aged man presents with a painful, hot, red, and swollen MTP joint of the great toe (podagra). Patient is limping due to severe pain from weight bearing on the affected joint.
Reports onset is more often at night. History of previous attacks at the same site.
Precipitated by ingestion of alcohol, meats, or seafood.
Chronic gout has tophi (small white nodules full of urates on ears and joints). History of recurrent inflammatory arthritis (gout flare).
Labs:
Uric acid level is elevated (>6.8 mg/dL). Treatment target is <6 mg/dL.
During the acute phase, the uric acid level is normal; the uric acid level does not begin to rise until after the acute phase.
An elevated urate level can support a diagnosis but is not diagnostic.
The most accurate time to assess for serum urate is 2 weeks or more after a gout flare subsides.
Other conditions that increase serum uric acid include chemotherapy and radiation therapy.
Medications that increase uric acid include hydrochlorothiazide and furosemide.
WBC is often elevated.
ESR is elevated.
CRP is elevated.
Treatment Plan:
Gout Flare:
First goal is to provide pain relief. Treatment for a gout flare should be started as soon as possible for best results.
Medications Used: Oral steroids, NSAIDs, or colchicine.
During flares, if the patient is taking daily urate-lowering therapy (ULT; e.g., allopurinol, probenecid, febuxostat, lesinurad, pegloticase), do not discontinue it. These medications can continue to be taken with gout flare medications.
Glucocorticoids: Such as prednisone or prednisolone 30 to 40 mg given once a day PO or divided into BID dosing; taper the dose over the next 7 to 10 days. Shorter duration (5 days) or tapered packs (Medrol Dosepak) are also available. May be given IV if unable to tolerate oral medications.
NSAIDs: Can be used as alternative therapy if the patient has contraindications to steroids (and does not have renal, CV, or active GI disease); e.g., indomethacin BID, naproxen sodium BID, diclofenac BID, celecoxib BID, or ibuprofen (800 mg TID). Do not use narcotics (not effective for gout pain). Can discontinue NSAIDs after 2 to 3 days of complete resolution.
Tip: NSAIDs injure the GI tract by blocking cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2), resulting in lower levels of systemic prostaglandins.
Tip: Aspirin (acetylsalicylic acid) is a type of NSAID. It affects platelets and clotting permanently, but its effects will resolve once the affected platelets (life span about 10 days) resolve (if not on chronic NSAIDs).
Colchicine:
Dosing: Two tablets (1.2 mg) at the onset of pain and then one tablet (0.6 mg) in 1 hour. Total dose on day 1 not to exceed 1.8 mg. Advise avoiding eating grapefruit or drinking grapefruit juice with colchicine.
Common Side Effects: Diarrhea, abdominal pain, cramps, nausea, and vomiting.
Drug Interactions: Macrolides, azole antifungals, some antivirals, calcium channel blockers (CCBs), cyclosporine, tacrolimus, others.
Contraindications: Moderate to severe renal or hepatic impairment.
Serious and Life-Threatening Effects: Blood cytopenias, rhabdomyolysis, liver failure, neuropathy.
Joint Injection: For patients unable to take oral medications with actively inflamed joints and no infection.
Maintenance (Urate-Lowering Therapy - ULT):
In general, wait several weeks after an acute gout flare before starting on ULT. However, in select patients, a reasonable alternative is to initiate ULT during a flare.
Indications for ULT: Frequent or disabling gout flares, clinical or radiographic signs of chronic gouty arthritis, tophaceous deposits, and a high risk of future severe gout flares.
Titrate ULT medication to achieve a serum urate in the range <6 mg/dL. Serum urate levels should be monitored to assure concentrations stay within the goal range.
Urate-Lowering Medications:
Xanthine Oxidase Inhibitors (XOI): Allopurinol (Zyloprim), febuxostat (Uloric).
Boxed Warning for Febuxostat (Uloric): Gout patients with heart disease treated with febuxostat have a higher rate of CV death compared with those treated with allopurinol.
Allopurinol (Zyloprim): Initial dose is 100 mg daily; increase dose until serum uric level is <6 mg/dL. Check CBC (affects bone marrow), renal function, and liver function at baseline, then periodically. Preferred urate-lowering agent and generally well tolerated.
Uricosoric Agents: Probenecid, lesinurad (Zurampic).
Uricase: Pegloticase IV can cause anaphylaxis and infusion reactions; premedicate with antihistamines and corticosteroids.
Allopurinol Hypersensitivity: If renal disease, at higher risk. Manifests as fever, rash (toxic epidermal necrolysis), and hepatitis. Stop allopurinol immediately if it occurs and refer. Consider febuxostat (Uloric) if allergic to allopurinol. Alternative medication is probenecid.
Lifestyle Modifications:
Patients should be instructed to avoid/minimize alcohol (<2 servings for males/<1 serving for females).
Avoid fructose- or corn syrupâsweetened beverages, which increase uric acid. Remain well hydrated.
Recommend Dietary Approaches to Stop Hypertension (DASH) or Mediterranean diet. Advise dietary moderation in purine intake.
Potential benefit in consumption of cherries, vitamin C, fish, and omega--3 fatty acids.
Complications: Joint destruction, joint deformity, tophi.
Hamstring Muscle Injury
Anatomy: The hamstring is composed of three muscles and is located in the posterior thigh. Hamstring muscles are used for knee flexion and hip extension.
Referral: If a complete tear is suspected, refer patients to an orthopedic specialist.
Classic Case: Most hamstring injuries are acute. The patient will report hearing a popping noise accompanied by the sudden onset of posterior thigh pain while performing activities such as sprinting.
Physical Exam: There may be swelling, bruising, warmth, and tenderness on the posterior thigh. A muscular mass might be palpable.
Imaging: Musculoskeletal ultrasonography and MRI are the best methods of assessing hamstring injuries.
Low Back Pain
Prevalence: Very common disorder.
Common Causes: Usually due to soft-tissue inflammation, sciatica, sprains, muscle spasms, or herniated discs (usually on L5âS1).
Primary Care: The majority of patients seen in primary care have nonspecific low-back pain, which is usually self-limited. Rule out fracture and other serious etiology.
Duration Classifications:
Acute back pain: Up to 4 weeks.
Subacute back pain: 4 to 12 weeks.
Chronic back pain: Persists for 12 weeks or longer.
Risk Factors: Age, smoking, anxiety, depression, psychologically strenuous work, physically strenuous or sedentary work, obesity.
Indications for Further Evaluation ("Red Flags"):
History of significant trauma.
Suspect cancer metastases.
Suspect infection (osteomyelitis).
Suspect spinal/vertebral fracture (older adult with osteopenia/osteoporosis, chronic steroid use).
Patient age older than 50 with new onset of back pain (rule out cancer) or pain that wakes the patient from sleep.
Suspect spinal stenosis (rule out ankylosing spondylitis).
Suspect cauda equina or spinal cord compression.
Suspect radiculopathy (spinal nerve root inflammation such as sciatica).
Suspect ankylosing spondylitis.
Fevers, night sweats, weight loss, or signs of systemic illness.
Symptoms worsening despite usual treatment.
Common site for herniated disc with symptoms is at L5 to S1 (buttock/leg pain).
Labs:
MRI is the best method for diagnosing a herniated disc.
Bone scan may be helpful in identifying occult, lytic lesions.
Imaging for low-back pain without other symptoms increases the risk of additional or invasive procedures.
Treatment Plan:
Treatment depends on the etiology. For uncomplicated back pain, use NSAIDs (naproxen sodium); apply warm packs if muscle spasms.
Muscle relaxants if associated with muscle spasms (causes drowsiness; warn patient).
Abdominal and core-strengthening exercises after the acute phase.
Consider a chiropractor for uncomplicated low-back pain.
Note: Complete bedrest is usually not recommended except in severe cases of low-back pain because it will cause deconditioning (loss of muscle tone and endurance) and an increased risk of complications from immobility.
Complications:
Cauda Equina Syndrome: Acute pressure on a sacral nerve root results in inflammatory and ischemic changes to the nerve. Sacral nerves innervate pelvic structures such as the sphincters (anal and bladder). Considered a surgical emergency. Needs spinal and/or nerve root decompression. Refer to ED.
Tips: Learn how to treat gout flare-up. Learn signs/symptoms of cauda equina. If suspected, refer to ED.
Red Flags (Cauda Equina):
Bladder and bowel incontinence.
Sensory loss in the distribution of the affected nerve roots; may cause saddle anesthesia.
Low back pain accompanied by pain radiating into one or both legs.
Bilateral leg weakness.
Medial Tibia Stress Syndrome (Shin Splints) and Stress Fractures of the Tibia and Fibula
Classic Case: Runner reports increased frequency/distance running and complains of recent onset of pain on the inner edge of the tibia. Pain may be sharp and stabbing or dull and throbbing. Aggravated during and after exercise. Complains of a sore spot on the inside of the lower leg or the shin (tibia). Some patients may have pain on the anterior aspect of the shin.
Focal area is tender when touched. Tenderness is much more diffuse and there is no discrete palpable lesion in those with MTSS.
Treatment Plan:
Follow RICE (rest, ice, compression, elevation) mnemonic. Periods of rest are recommended.
Apply cold packs during acute exacerbation, for 20 minutes at a time, several times a day for the first 24 to 48 hours and then as needed.
Take NSAIDs as needed.
A compression bandage or sleeve may help decrease swelling. Using cushioned shoes (sneakers) for daily activity helps decrease tibial stress.
When pain is gone, wait about 2 weeks before resuming exercise. Avoid hills and very hard surfaces until the shin splints have resolved.
If a stress fracture is suspected, recommend lower-impact exercises (e.g., swimming, stationary bike, elliptical trainer).
Stretch before exercise and start at a lower intensity. Wear supportive sneakers.
Imaging (for suspected stress fracture): Plain radiographs are often the first imaging study; however, they are often normal initially. MRI is highly sensitive and specific. Refer to an orthopedic specialist.
Meniscus Tear (Knees)
Anatomy: The two menisci are crescent-shaped pads of fibrocartilage located within the knee joint.
Causes: Tears in the meniscus result from trauma and/or overuse. Sports with higher risk are soccer, basketball, and football.
Classic Case: Patient may complain of clicking, locking, or buckling of the knee(s). Some patients are unable to fully extend the affected knee. Patient may limp. Complains of knee pain and difficulty walking and bending the knee. Some complain of joint line pain. Decreased ROM. Certain movements aggravate symptoms.
Physical Examination:
Assess for joint line tenderness and knee ROM. Look for locking or inability to fully extend or straighten the leg, squat, or kneel. Will be unable to squat or kneel. The knee may be swollen (joint effusion). Observe the patientâs gait.
Steinmanâs Test: Flex the knee joint and palpate the joint line. Pain over the posterior joint line with flexion is positive for a meniscus tear.
Apleyâs Test: Patient is prone with the affected knee flexed at 90 degrees. Stabilize the patientâs thigh (with the examinerâs knee or hand). Press the patientâs heel downward (push heel toward the floor) while the foot is internally and externally rotated. The examiner is compressing the meniscus between the tibia and femur while twisting the foot. A positive sign is pain elicited with compression of the knee.
Treatment Plan:
Follow the RICE (rest, ice, compression, elevation) rules. Rest the knee and avoid or minimize positions that overstress the knees, such as squatting, kneeling, and climbing stairs.
Apply ice/cold pack for 20 minutes every 4 to 6 hours, elevate the limb. Many need crutches.
When the pain and swelling are resolved, start quadriceps-strengthening exercises. The quadriceps are the largest muscles of the body; they will help to stabilize the knees. Swimming, water aerobics, and light jogging are possible exercises. NSAIDs or acetaminophen for pain as needed.
Locking or unstable knees should be referred to an orthopedist; many need arthroscopy to repair menisci.
Imaging: Most sensitive imaging for detecting meniscal tear is MRI.
Mortonâs Neuroma
Definition: Inflammation of the digital nerve of the foot between the third and fourth metatarsals.
Increased Risk Factors: High-heeled shoes, tight shoes, obesity, dancers, runners.
Classic Case: Middle-aged woman complains of many weeks of foot pain that is worsened by walking, especially while wearing high heels or tight narrow shoes. The pain is described as burning and/or numbness, and it is located on the space between the third and fourth toes (metatarsals) on the forefoot.
Physical Exam: May reveal a small nodule on the space between the third and fourth toes. Some patients palpate the same nodule and report it as âpebble-like.â
Mulder Test:
Procedure: Grasp the first and fifth metatarsals and squeeze the forefoot.
Positive Test: Hearing a click along with a patient report of pain during compression. Pain is relieved when the compression is stopped.
Treatment Plan:
Avoid wearing tight, narrow shoes and high heels. Use a forefoot pad. Wear well-padded shoes.
Diagnosed by clinical presentation and history. Refer to a podiatrist.
Osteoarthritis (OA)
Definition: OA is often misnamed as degenerative joint disease (DJD) because it was formerly considered a simply degenerative âwear and tearâ process. However, the pathogenesis is more complex and involves an inflammatory process with altered joint function that is associated with characteristic pathologic changes in the joint tissue and destruction of the articular cartilage.
Commonly Affected Joints: Large weight-bearing joints (hips and knees) and the hands (Bouchardâs and Heberdenâs nodes) are most commonly affected. It can affect one side or bilaterally.
Risk Factors: Older age, overuse of joints, and positive family history.
Goal of Treatment:
Relieve pain.
Preserve joint mobility and function.
Minimize disability and protect the joint.
Classic Case: Insidious onset (slow progression over years). Middle-aged or older adult complaining of early-morning joint pain and stiffness with inactivity and motor restriction.
Shorter duration of joint stiffness (<30 minutes) compared with rheumatoid arthritis (RA).
Pain aggravated by overuse of the joint. During exacerbations, the involved joint may be swollen and tender to palpation (absence of warmth).
May be one-sided (e.g., right hip only). Absence of systemic symptoms (compared to RA).
Deformities such as Heberdenâs and/or Bouchardâs nodes may be noted. Crepitus and reduced ROM may be noted on exam.
Heberdenâs nodes: Bony nodules on the distal interphalangeal (DIP) joints.
Tip: For Heberdenâs, the -den ending on the word is the letter D for DIP joint.
Bouchardâs nodes: Bony nodules on the proximal interphalangeal (PIP) joints.
Tip: The letter B comes before the letter H, so Bouchardâs nodes come before Heberdenâs nodes when working proximally to distally.
Nonpharmacologic Management:
Exercise (with caution) at least three times a week. Lose weight. Stop smoking.
Do isometric exercises to strengthen quadriceps muscles (knee OA).
Engage in weight-bearing exercise (walking, lifting weights), resistance-band exercises.
Avoid aggravating activities. Use cold or warm packs and ultrasound treatment.
Use walking aids. Patellar taping by a physical therapist can reduce the load on the knees.
Consider the use of glucosamine supplements (limited evidence of benefit), transcutaneous nerve stimulation, tai chi exercises, and acupuncture.
Treatment Plan:
In patients with one or a few joints affected, start with topical NSAIDs.
Oral NSAIDs recommended in patients with inadequate relief with topical NSAIDs or those with symptomatic OA in multiple joints. Use the lowest dose of oral NSAIDs such as ibuprofen (Advil), one to two tablets every 4 to 6 hours; naproxen (Aleve) BID; or Anaprox DS one tablet every 12 hours PRN.
Use Caution/Avoid Oral NSAIDs: In patients with kidney dysfunction, CV disease, peptic ulcer disease (PUD), and those with high bleeding risk (especially those taking anticoagulants).
All NSAIDs have a Boxed Warning for the Risk of CV Thrombotic Events: Including MI and stroke; risk is higher for COX-2-selective NSAIDs (e.g., celecoxib). If a patient is at high risk for both GI bleeding and CV side effects, avoid NSAIDs.
GI Bleed Risk Factors: History of uncomplicated ulcer, warfarin (Coumadin), PUD, and platelet disorder.
Tips: Ketorolac (Toradol) is limited to 5 days of use. The first dose is given intramuscular or IV. Other treatments include steroid injection on inflamed joints (not routinely recommended), surgery (e.g., joint replacement).
Duloxetine: Recommended for patients with OA in multiple joints and contraindications to oral NSAIDs.
Topical Capsaicin: Recommended when a few joints are involved, and other interventions are contraindicated.
Intraarticular Glucocorticoid Injections: Not routinely used due to the short duration of their effects.
Acetaminophen: No longer recommended given safety concerns and nonclinically significant effects on pain.
Opioid Analgesics: Should be avoided if possible given side effects (e.g., nausea, dizziness, drowsiness).
Rule out Osteoporosis: Order bone mineral density test (postmenopausal females, chronic steroid treatment males/females).
Topical Medicine:
Diclofenac gel (Voltaren gel) (NSAID); apply to the painful area and massage well into the skin QID.
Capsaicin cream: Applied to the painful area QID. Avoid contact with eyes/mucous membranes. Capsaicin comes from chili peppers. Also used to treat neuropathic pain (e.g., post shingles). Do not use on wounds/abraded skin. Avoid bathing/showering afterward (so that it is not washed off).
Nonsteroidal Anti-Inflammatory Drug Risk:
High risk of GI bleeding: Ketorolac (Toradol).
Low risk of GI bleeding: Celecoxib (Celebrex).
High risk of CV events: Diclofenac.
Low risk of CV events: High-dose naproxen (can increase BP).
Piriformis Syndrome
Definition: The piriformis muscle, located in the buttocks, can compress, irritate, and entrap the sciatic nerve between its muscle layers. May account for 0.3\% to 6\% of sciatic-like syndromes.
Classic Case: Patient complains of sciatica symptoms. Sciatica symptoms may include pain and numbness of the buttocks, which may radiate down the leg. Reports that the pain is worsened by prolonged sitting, driving. Pain can be episodic. History of running, lifting heavy objects, falls, or excessive stair climbing.
Objective Findings:
Obtain history of injury. Perform a physical examination of the hip and groin, which includes inspection, palpation, ROM testing, pulses, deep tendon reflexes, and strength testing.
Freiburg Test: Positive when pain or sciatic symptoms are caused by placing the hip in extension and internal rotation, and then resisting external rotation.
Pace Sign: Pain elicited when the seated patient resists abduction and external rotation.
Maneuvers: FAIR (flexion, adduction, internal rotation).
Imaging:
Radiograph (X-ray): Consider if limited hip ROM or chronic groin pain. Can help diagnose OA of the hip.
Ultrasound: Can help diagnose tendon and soft-tissue injury around the hip and groin.
MRI: Can help diagnose sciatic nerve compression, stress fracture of the femoral neck, cartilage tears, and tendon ruptures.
Treatment Plan:
Avoid positions that trigger pain. Follow RICE (rest, ice, compression, elevation) guide; cold packs or heat can be used.
Warm up and stretch before sports or exercises. Rest, cold packs, and heat may help symptoms.
NSAIDs and muscle relaxants are the most common method of treatment.
Refer for physical therapy for stretching and exercises.
Muscle Relaxants (Centrally Active Skeletal):
Cyclobenzaprine (Flexeril).
Metaxalone (Skelaxin).
Tizanidine (Zanaflex).
Baclofen (Gablofen).
Carisoprodol (Soma) can be addicting; it is a U.S. Food and Drug Administration (FDA) schedule IV substance.
Side Effects: Drowsiness, dizziness, nervousness, reddish-purple urine, hypotension; do not mix muscle relaxants with sedating drugs or alcohol.
Pearls:
Naproxen is the NSAID with the fewest CV effects, but it has the same GI adverse effects as other NSAIDs. It can, however, increase BP, so this should be monitored.
The innervation of the bladder and anal sphincter comes from the sacral nerves and, with cauda equina, symptoms include new-onset incontinence of urine (and/or bowel), saddle-pattern paresthesia, and sciatica.
Plantar Fasciitis
Definition: Acute or recurrent pain in the plantar region of the foot that is aggravated by walking. Caused by microtears in the plantar fascia due to tightness of the Achilles tendon.
Higher Risk with: Body mass index (BMI) >30, diabetes, aerobic exercise, flat feet, prolonged standing.
Classic Case: Middle-aged adult complains of plantar foot pain (either on one or on both feet) that is worsened by walking and weight bearing. Complains that foot pain is worse during the first few steps in the morning and continues to worsen with prolonged walking.
Treatment Plan:
NSAIDs: Naproxen (Aleve) orally twice a day, ibuprofen (Advil) orally every 4 to 6 hours.
Topical NSAID: Diclofenac gel (Voltaren gel) applied to soles of feet twice a day.
Orthotic Foot Appliance: Used at night for a few weeks; it will help to stretch the Achilles tendon.
Stretching and Massaging of the Foot: Roll a golf ball with the sole of the foot several times a day.
Weight Loss: If overweight.
Shoes: Well-padded soles and/or a heel cup on the affected foot.
Popliteal (Bakerâs) Cyst
Definition: A Bakerâs cyst is a type of bursitis that is located behind the knee (popliteal fossa). The bursae are protective, fluid-filled synovial sacs located on the joints that act as a cushion and protect the bones, tendons, joints, and muscles. Sometimes when a joint is damaged and/or inflamed, synovial fluid production increases, causing the bursa to enlarge.
Risk Factors: History of trauma, coexistent joint disease; most common include OA, RA, and meniscal tears.
Classic Case: Adult patient with a history of OA complains of a ball-like mass behind one knee that is soft and smooth. The mass will soften when the knee is bent at 45 degrees (Foucherâs sign) because there is less tension.
Asymptomatic or will have symptoms such as pressure sensation, posterior knee pain, and stiffness.
If the cyst ruptures, the patient will complain of severe calf pain, erythema, distal edema, and a positive Homanâs sign (resembling venous thrombosis).
Imaging:
Diagnosed by clinical presentation and history. If imaging is desired or the diagnosis is in question, the initial test is ultrasound and plain radiography of the knee and calf. MRI if the diagnosis is uncertain.
If patients have concern for thrombophlebitis or vascular compromise, ultrasound can be used to identify the enlarged or ruptured cyst and exclude a deep vein thrombosis (DVT).
Rule out plain bursitis from bursitis with infection (âseptic jointâ).
Treatment Plan:
Follow RICE (rest, ice, compression, elevation) procedures. Gentle compression with an elastic bandage wrap.
Administer NSAIDs as needed.
Large bursa can be drained with a syringe using an 18-gauge needle if causing pain. Synovial fluid is a clear, golden color. If cloudy synovial fluid is present and the joint is red, swollen, and hot, order a C&S to rule out a septic joint infection.
After it is drained, an intraarticular injection of a glucocorticoid (triamcinolone acetonide) can decrease inflammation.
Warn the patient that the cyst can recur in the future. Most popliteal cysts are asymptomatic and do not require intervention.
Tips:
Recognize Bakerâs cyst presentation.
Plain radiograph of a joint (such as an x-ray of the knee) will show bony changes or narrowing of the joint space (OA), but not soft tissue such as the meniscus or ligaments. The best imaging test for cartilage, meniscus, or tendon damage is MRI. The gold-standard test for assessing any joint damage is MRI.
Pearls:
Do not forget that NSAIDs increase CV risk, renal damage, and GI bleeding.
The best imaging test for suspected stress fractures is MRI. Plain radiographs do not show stress fractures initially after injury.
Rheumatoid Arthritis (RA)
Definition: Chronic, systemic autoimmune and inflammatory disorder that is more common in women (nearly twice as high as in males; 9:1 ratio). Characterized by remissions and exacerbations. More common in African American and Hispanic women. Organ systems affected are the skin, kidneys, heart, and blood vessels.
A milder form of lupus is called cutaneous lupus erythematosus.
Goal of Treatment: To prevent joint and organ damage.
Associated Risks: Patients are at higher risk for other autoimmune disorders, including Gravesâ disease and pernicious anemia.
Classic Case: Adult, commonly middle-aged, woman complains of gradual onset of symptoms over months with daily fatigue, low-grade fever, generalized body aches, and myalgia. Complains of generalized joint pain, stiffness, and swelling, which usually involves multiple joints bilaterally.
It usually starts on the fingers/hands (PIP and metacarpophalangeal [MCP] joints) and the wrists.
Commonly reports early-morning stiffness/pain (lasting at least 1 hour and present for >6 weeks) and warm, tender, and swollen fingers in the DIP/PIP joints (also called âsausage jointsâ). It eventually involves the majority of joints in the body bilaterally.
Objective Findings:
Joint involvement is symmetric with more joints involved compared with DJD (OA).
Joint may feel âboggyâ due to synovial thickening.
Most common joints affected are hands, wrist, elbows, ankles, feet, and shoulders.
âSausage jointsâ.
Rheumatoid nodules present (indicative of chronic disease).
Ulnar deviation or âulnar driftâ.
Swan neck deformity: Flexion of the DIP joint with hyperextension of the PIP joint.
Boutonniere deformity: Hyperextension of the DIP with flexion of the PIP joint.
Tips: Swan neck deformity and boutonniere deformity are signs of late and/or severe RA disease. Distinguish between RA and OA in terms of classic presentation. With RA, joint stiffness lasts longer. It involves multiple joints and has a symmetric distribution. RA is accompanied by systemic symptoms such as fatigue, fever, and normocytic anemia.
Labs:
ESR and CRP: Elevated.
CBC: Mild microcytic or normocytic anemia common, may show thrombocytosis and a mild leukocytosis.
RF: Positive in 75\% to 80\% of patients.
Radiographs: Bony erosions, joint space narrowing, subluxations (or dislocation).
Serology/antibodies: Anticyclic citrullinated peptide/protein antibodies (ACPA), others.
Treatment Plan:
Refer to a rheumatologist for early aggressive management to minimize joint damage.
Nonpharmacologic management includes physical and occupational therapy.
Joint replacement (hip, knees) ameliorates RA.
Careful assessment is necessary. Never prescribe a biologic or anti-tumor necrosis factor (anti-TNF) medication if signs and symptoms of infection (e.g., fever, sore throat) are present. Tuberculosis (TB) testing should be ordered prior to the start of anti-TNF therapy.
Medications:
DMARDs: Recommended as soon as possible following diagnosis, rather than using anti-inflammatory drugs alone.
Nonbiologic DMARDs: Methotrexate, sulfasalazine, hydroxychloroquine.
Biologic DMARDs: TNF-alpha inhibitors such as adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade). Warning: Anti-TNFs increase the risk of infections, squamous cell skin cancer, and lymphoma.
Targeted Synthetic DMARDs: JAK inhibitors such as tofacitinib and baricitinib.
Adjuncts: NSAIDs (e.g., ibuprofen, naproxen sodium) and glucocorticoids to relieve inflammation and pain. Glucocorticoid therapy may be used during the treatment of a flare.
Steroid Joint Injections: (synovial space) may be used to reduce synovitis in inflamed joints during a flare.
Tips:
Plaquenil is a DMARD that can be used to treat malaria.
Methotrexate is a DMARD. It is contraindicated for use during pregnancy. When prescribing methotrexate to childbearing women, contraception must be prescribed and adhered to while taking methotrexate.
Complications:
RA increases the risk of certain malignancies, such as lymphoma.
Bone loss, muscle weakness, changes in body compositions.
Pulmonary and cardiac involvement with pleurisy, parenchymal lung diseases, pericarditis, and myocarditis.
Neurologic complications such as carpal tunnel syndrome, myelopathy, or radiculopathy.
Ocular Complications:
Inflammation of the uvea (middle layer eyeball). Sudden onset of eye redness, pain, blurred vision. Can cause vision loss (rare). Refer to an ophthalmologist stat. Initial treatment includes topical steroids.
RA increases the risk of Sjogrenâs syndrome, scleritis, and episcleritis.
When prescribing hydroxychloroquine (Plaquenil), all patients must have an eye exam prior to starting the medication. Frequent eye-exam monitoring should be performed every 6 months or as recommended by the ophthalmologist to assess and prevent retinal damage, which can lead to blindness.
Sprains
Definition: Sprains are overstretching or tearing of a ligament.
Commonality: Ankle sprains are usually due to sports participation. The most common sports that cause ankle injuries are basketball, indoor volleyball, and soccer.
Mechanism: Caused by overstretching of the joint, partial rupture, or complete rupture of a ligament.
Types of Ankle Sprains:
Lateral Ankle Sprain: The most common type. The most common mechanism of injury is inversion of the plantar-flexed foot.
Medial Ankle Sprain: Infrequently injured in isolation. The most common cause is forced eversion of the ankle; it can cause an avulsion fracture of the medial malleolus due to pulling by the ruptured deltoid ligament.
Ottawa Rules (of the Ankle)
Purpose: Ottawa rules are used to determine whether a patient needs radiographs of the injured ankle in the ED. They are highly sensitive (96.4\%â99.6\%) for excluding ankle fracture.
Plain Radiographs of the Ankle are Only Indicated If: There is pain in the malleolar zone AND:
Bone tenderness over the posterior edge or tip of the medial or lateral malleolus (igure ext{ }15.9) or
Inability to bear weight both immediately after the injury and for four steps into the ED or providerâs office.
Plain Radiographs of the Foot are Only Indicated If: There is pain in the midfoot zone AND:
Bone tenderness at the base of the fifth metatarsal or at the navicular or
Inability to bear weight both immediately after the injury and for four steps into the ED or doctorâs office.
Regarding Ottawa Ankle Rules:
Bearing weight includes the ability to transfer weight twice to each foot (even if limping).
Assess for bone tenderness by palpating the distal 6 cm of the posterior edge of the fibula.
Grading of Sprains
Grade I Sprain (Mild):
Slight stretching and some damage to ligament fibers.
Patient is able to bear weight and ambulate.
No joint instability present during the ankle evaluation.
Grade II Sprain (Moderate):
Partial tearing of the ligament.
Ecchymoses, moderate swelling, and pain are present.
Joint is tender to palpation.
Ambulation and weight bearing are painful.
Mild-to-moderate joint instability occurs.
Consider X-ray, referral.
Grade III (Complete Rupture of Ligaments):
Severe pain, swelling, tenderness, and ecchymosis.
Significant mechanical ankle instability and significant loss of function and motion.
Unable to bear weight or ambulate.
Refer to ED for ankle fracture.
Physical Examination for Sprains
First, ask about the mechanics of the injury along with symptoms. Look for swelling and ecchymosis.
Palpate the entire ankle (lateral side and medial side), Achilles tendon, and the foot.
Check for weight bearing, ROM, ability to ambulate, pedal and posterior tibial pulses.
Grade the sprain.
Treatment Plan for Sprains
Grade the sprain and determine if an ankle x-ray series is needed or refer to an orthopedic specialist if there is concern for a severe sprain, unstable fracture, tendon rupture, or uncertain diagnosis.
In mild-to-moderate sprains during the acute phase, use RICE and an elastic bandage wrap.
NSAIDs (oral) and topical NSAIDs (e.g., Voltaren gel, diclofenac patches) can be used to treat pain and swelling. Can use a combination of topical and PO NSAIDs.
Grade I Sprains (mild): Do not require immobilization. Use an elastic wrap (ACE bandage) for a few days.
Grade II Sprains (moderate): May need more support. Use ACE and an Aircast or similar splint for a few weeks. May require a brief period of immobilization and non-weight bearing.
Grade III Sprains: Often managed by an orthopedic or sports specialist. Non-weight bearing and immobilization for a brief period (about 10 days). May require surgery and functional rehabilitation.
Early rehabilitation is important. Refer for physical therapy after initial swelling and pain have decreased so that the patient can tolerate simple exercises.
Systemic Lupus Erythematosus (SLE)
Definition: A multisystem autoimmune disease that is more common in women (9:1 ratio). Characterized by remissions and exacerbations. More common in African American and Hispanic women. Organ systems affected are the skin, kidneys, heart, and blood vessels.
Milder Form: Cutaneous lupus erythematosus.
Classic Case: Typical patient is a woman between age 16 and 55 years who presents with symptoms such as fever, fatigue, weight loss, and arthralgias.
Classic Rash: Maculopapular butterfly-shaped rash on the middle of the face (malar rash).
May have nonpruritic thick scaly red rashes on sun-exposed areas (discoid rash).
Photosensitivity, ocular manifestations, abdominal pains, and joint symptoms.
May have cardiac symptoms, vascular abnormalities (e.g., Raynaudâs phenomenon), pleuritis, pulmonary hypertension, cognitive dysfunction, anemia, and leukopenia.
Urinalysis (UA) may be positive for proteinuria with kidney involvement.
Laboratory Findings: Antinuclear antibodies (ANA) are positive in virtually all patients.
Treatment Plan:
Refer to a rheumatologist (NSAIDs, analgesics, steroids, antimalarial [Plaquenil], immune modulators [methotrexate, biologics], monoclonal antibodies).
For mild symptoms: Bedrest, naps, avoidance of fatigue.
Patient Education:
Avoid sun between 10 a.m. and 4 p.m. (causes rashes to break out).
Cover skin with high sun protection factor (SPF; UVA and UVB) sunblock.
Wear sun-protective clothing, such as hats with wide brims and long-sleeved shirts.
Use nonfluorescent light bulbs (more sensitive to indoor fluorescent lighting).
Tendinitis
Definition: Inflammation of a tendon, resulting in pain. Usually due to repetitive microtrauma, overuse, or strain. Gradual onset.
Treatment: Follow RICE mnemonic for acute injuries.
Rotator Cuff Injury
Involvement: Usually involves damage to the supraspinatus tendon, which helps move the shoulder during abduction and external rotation. Caused by inflammation of the supraspinatus tendon.
Risk Factors: Jobs or sports with repetitive overhead activity, such as swimming, tennis, golf, weightlifting, gymnastics, and volleyball, increase the risk for injury.
Classic Case: Patient with a history of repetitive overhead activity (sport or job). Complains of shoulder pain with overhead movements such as brushing hair or putting on a shirt. There is local point tenderness over the tendon located on the anterior area of the shoulder. May have pain at night when sleeping on the side of the affected shoulder.
Maneuvers:
Painful Arc Test (igure ext{ }15.10): Pain with shoulder ROM; >90 degrees of adduction or pain with internal rotation is suggestive of rotator cuff tendinopathy. Positive result is shoulder pain that occurs between 60 and 120 degrees of active abduction.
Jobeâs Test (Empty Can Test; igure ext{ }15.11): Test for the strength of the supraspinatus muscle.
Procedure: Instruct the patient to straighten the arm at 90 degrees of abduction with 30 degrees of forward flexion, then internally rotate the shoulder. Tell the patient to resist when the examiner attempts to adduct the arm.
Positive Result: Shoulder pain without weakness (tendinopathy); shoulder pain with weakness suggests a tendon tear.
Imaging: MRI can identify rotator cuff tear(s).
Treatment:
For initial treatment, rest the affected shoulder and apply cold packs (20 minutes cold pack, repeated about two to four times per day), especially during the acute phase for 24 to 48 hours.
NSAIDs for pain as needed.
Physical therapy to rehabilitate the shoulder.
Referral to an orthopedic specialist if there is an inadequate or poor response to conservative management.