IC15: Management of Soft Tissue Injury

Question 1

State 4 accompanying features of joint pain

Answer 1

• Swelling
• Erythematous
• Tender on palpation of joint line
• Restricted motion

Question 2

Define active & passive movment

Answer 2

Active: Voluntary, muscle contraction initiated by the individual
Passive: Movement produced by external force eg. assistance of someone & does not involve muscle contraction

Question 3

State the pharmacological treatment(s) used for soft tissue injuries (non-lower back pain)

Answer 3

1. Topical NSAIDs
2. PO NSAIDs/Coxibs (if topical cannot reach)
3. PO paracetamol

Opioids eg. tramadol - avoid bc drowsy, abuse potential, dependence,

Question 4

State at least 3 non-articular causes of joint pain

Answer 4

• Referred visceral pain
  e.g. “shoulder pain” associated with MI
• Tissue pain e.g. limb pain associated with DVT, ischemia, infection
  (cellulitis, necrotizing fasciitis)
• Neuropathic pain e.g. relating to prolapsed intervertebral disc
• Periarticular pain
  e.g. relating to ligaments, tendons, muscles (soft tissues)
• Bone pain
  e.g. relating to fractures or dislocation from trauma/injury

Question 5

State 4 situations requiring urgent referrals to the ED

Answer 5

1. Ligament rupture
2. Infection related causes
3. Malignancy/metastasis (lower back pain)
4. Relating to underlying visceral conditions (lower back pain) (eg. GI, liver etc…)

Question 6

List 4 types of soft tissue injuries

Answer 6

1. Sprains (stretching, partial rupture, complete rupture of ligament)
2. Tendonitis (inflamamtion of tendon)
3. Bursitis (inflammation of bursae)
4. Plantar fasciitis (inflammation of plantar fascia

Question 7

Sprains involves injury to …

What type of bone structures?

Answer 7

Ligaments

Question 8

What is the most common type of ankle sprains?

State the mechanism, prevelance and onset

Answer 8

Lateral ankle sprains.
Mechanism: Inversion (rolling) of foot, usually from sports

In children & adolescents > adults,
Adult F > M

Sudden onset & swelling

Question 9

Describe the severity of 3 the 3 grades of sprain, clinical presentation, function and management

Answer 9

Grade 1:
mild stretching of ligament with microscopic tear.
CP: mild swelling & tenderness. Function: Able to bear weight & ambulate with minimal pain. Mgmt: Medical help not freq sought

Grade 2
Severity: Incomplete tear of ligament
CP: Moderate pain, swelling, tenderness & ecchymosis
Function: Painful weightbearing & ambulation, mild-moderate joint instability, some restriction in ROM & fxn
Mgmt: Protection, rest, ice, compression, elevate +/- analgesics

Grade 3
Complete tear of ligament
CP: severe pain, swelling & tenderness, ecchymosis
Function: Cannot bear weight or ambulate (sf instability, loss of fxn)
Mgmt: Refer to emergency room

Question 10

State the clinical features of tendonitis

Answer 10

1. local pain & dysfunction on active use (unlikely painful on passive movement)
2. Inflammation (but unlikely to cause visible swelling)
3. Degeneration (after chronic duration, >3mth, leading to tendonosis)

Question 11

State at least 3 etiologies of tendonitis

Answer 11

1. Overuse (repeated mechanical loading)
2. Sports injury
3. Drug induced: Fluoroquinolones & statins
4. Inflammatory rheumatic disease
5. Calcium apatite deposition (from metabolic disturbances)

Question 12

State 5 common sites for tendonitis to occur

Answer 12

1. Shoulder (rotator cuff tendinopathy, bicipital tendinitis)
2. Elbow (lateral epicondylitis aka tennis elbow ; medial epicondylitis aka golfer’s elbow)
3. Ankle (Achillies tendinopathy)
4. Wrist (Flexor carpi radialis/ulnaris tendonitis)
5. Lateral hip (gluteus madius/minimus tendinopathy)

Question 13

Describe what is a bursa

Answer 13

Fluid filled, sac like structure lined by synovial membrane in clefts between mobile structures

Question 14

State the causes of acute and chronic bursitis

Answer 14

1. Trauma/injury
2. Crystal-induced process eg. gouty arthritis
3. Infection (septic bursitis)
4. Overuse
5. Prolonged pressure eg. kneeling, leaning
6. Inflammatory arthritis eg. RA/spondyloarthritis

1-3 = acute bursitis
4-6 = chronic bursitis

Question 15

Compare & Contrast the symptoms of acute and chronic bursitis

Answer 15

Acute:

• Pain when joints are fully flexed in active & passive movment (eg. elbow joint)

Chronic:

• More swelling & thickening, minimal pain,
• secondary changes of contracture & muscle atrophy relating to immobility

Question 16

Statethe common locations for bursitis

Superfical & deep locations

Answer 16

Superficial
1. Elbow (olecranon)
2. Knee cap (prepatellar)
3. Ischial (posterior upper thigh region bw gluteal maximus & ischial tuberosity)

Deep
1. Hip (trochanteric)
2. Shoulder (subacromial)

Question 17

What treatment option(s) can be given for bursitis in deeper regions?

Answer 17

Intrabursal glucocorticoid

Question 18

List at least 2 etiology for plantar fasciitis

Answer 18

1. Prolonged standing/jumping/ running on hard surfaces
2. Flat feet/high arched feet
3. Tight hamstring muscle –> dec knee extension, incr loading of forefoot, leading to stress of plantar fascia
4. Reduced ankle dorsiflexion
5. Obesity?
6. Lower SES, impaired physical & mental health?
7. A/W systemic rheumatic diseases

Question 19

Describe the clinical presentation of plantar fasciitis

in relation to physical activity, walking

Answer 19

1. Pain worse when walking/ running esp in morning or after period of inactivity
2. Pain lessens with increased activity but worse at end of day (prolonged weight bearing)

Question 20

Describe the clinical presentation of Frozen Shoulder

Answer 20

1. Unilateral, usually on nondominant side, but other side might be affected within 5 years
2. Limited reaching overhead, to side, across chest & limited rotation, leading to reduced function eg. cannot scratch back & wear coats

Question 21

Differentials of shoulder pain

Answer 21

referto slide 25

Question 22

When should sprains be referred?

Answer 22

Grade III
unable to bear weight or ambulate

Question 23

List & Describe the 3 stages of Frozen Shoulder

Answer 23

1. Initial (2-9mth): diffuse, severe disabling soulder pain, worse at night, increasing stiffness
2. Intermediate (4-12mth) stiffness & severe loss of shoulder motion, pain gradually lessen
3. Recovery (5-24mth) Gradual return of motion

Question 24

When to refer for frozen shoulder?

Answer 24

When there is marked loss of motion

Question 25

State the pharmacological treatment option(s) for Frozen Shoulder

Answer 25

Rmb: ARI 1. Analgesics for pain (Paracetamol/NSAIDs/Weak opioids) 2. Range of motion exercises 3. Intraarticular glucocorticoid + physical therapy

Question 26

State the timeframe for acute, subacute and chronic low back pain

Answer 26

Acute: < 4 weeks; Subacute: 4-12 weeks; Chronic: > 12 weeks

Question 27

List back pain differentials

Answer 27

**Inflammatory**:spondyloarthrtis **Infection**: Tuberculosis, osteomyelitis **Degenerative**: osteoarthritis **Trauma**: osteoporotic, non-soteoporotic **Malignancy**: Metastases, myeloma

Question 28

State the treatment for acute and subacute low back pain

Answer 28

1. Nonpharmacological tx eg. heat therapy 2. NSAIDs/ Skeletal muscle relaxant (ophenadrine)

Question 29

State the treatment for chronic low back pain

Answer 29

1. Nonpharm eg. exercise 2. NSAIDs, or alternatives eg. tramadol or duloxetine

Question 30

List down at least 4 counselling points for low back pain

Answer 30

1. Improvement in pain & function from tx **may be small** 2. Reassure that acute/ subacute pain is **usually self-limiting** 3. Remain active as tolerated 4. Avoid potentially harmful & costly tests & tx 5. Engage in **low-impact core strengthening exercises** to improve spine stability e.g. swimming, stationary bicycling, brisk walking 6. Use **correct lifting & moving techniques** i.e. Squatting to lift heavy object. Do not bend and lift. Get help if object is too heavy or awkward. 7. Maintain **correct posture** when sitting / standing 8. **Quit smoking ** (smoking is a risk factor for arthrosclerosis - hardening of arteries, which can cause low back pain & degenerative disc disorders) 9.** Avoid stressful situations** (these can cause muscle tension) 10. Maintain a **healthy weight** (extra weight especially around the midsection can add strain on lower back)

Question 31

State the management for myalgia **due to overuse or exercise**

Answer 31

Exercise myalgia is acute and self limiting * RICE (self limiting) * Topial NSAIDs? (if pt wants sth for pain relief) * Prevention: inform pt to warm up before exercise

Question 32

State 2 scenarios requiring urgent referral for diffuse myalgia

Answer 32

1. Infection related esp bacterial, esp for endocarditis & impending sepsis (CP: diffuse myalgia, fever, chills, arthralgia, fatigue, back pain) 2. Medication toxicity (esp statins) (CP: muscle pain, muscle weakness, red brown tea colured urine)

Question 33

SAMs usually present? | Onset & location

Answer 33

Can occur anytime CP: Usually muscle weakness &/or weakness (hips, calf, RARELY arms), noctural cramping, stiffness, tendon pain, fatigue & tiredness

Question 34

How should SAMs be managed?

Answer 34

1. Discontinue statin if sx intolerable, sx will resolve over days-weeks

Question 35

List 3 statins that less tendency to cause SAMs

Answer 35

Pravastatin Fluvastatin Rosuvastatin