ic15 soft tissue injuries

Question 1

differentiate the types of articular pain vs non articular pain

Answer 1

articular:
i) OA
ii) RA
iii) gout
iv) osteoporosis

non articular:
i) referred visceral pain (shoulder pain assoc w MI)
ii) tissue pain (cellulitis, necrotising fasciitis)
iii) neuropathic pain (relating to prolapsed intervertebral disc)
iv) periarticular pain (relating to ligaments, tendons, muscles)
v) bone pain (related to fractures or dislocation from trauma or injury)

Question 2

what are the accompanying features for articular types of pain

Answer 2

i) swelling
ii) erythema
iii) tender on palpitation of joint line
iv) restricted motion

Question 3

what are the features of periarticular pain

Answer 3

i) point of maximal tenderness not at joint line on palpitation
ii) pain on active movement > passive movement
iii) pain maximal in certain lines of muscle pull

Question 4

what are the characteristics of soft tissue injuries

Answer 4

i) consequence of chronic repetitive low grade trauma or overuse
ii) focal and non systemic
iii) self-limiting
iv) responds to conservative measures

Question 5

when are urgent referrals req for soft tissue injuries

Answer 5

i) fracture
ii) ligament rupture (if tear or microtear still ok)
iii) infection related causes
iv) malignancy/ metastasis (lower back pain)
v) relating to underlying visceral conditions like pancreatitis, gall stones etc (lower back pain)

Question 6

what are the common types of soft tissue injuries (elaborate on each type incl pain features, etiology, common sites if any)

Answer 6

1. sprains: stretching, partial rupture or complete rupture of the ligament

features:
likely alot of instability and if complete rupture then would not be able to put weight at all

most common site:
lateral ankle injury which occurs due to inversion of the foot and puts the anterior talofibular ligament most at risk, will have sudden onset of pain and swelling after ‘pop’ sound

2. tendonitis: inflamm of the tendon

features:
likely pain when moving muscle to extend or flex arm bc doing so req stretching of tendon, local pain and dysfunc, inflamm and degeneration

etiology:
i) overuse
ii) sports injury
iii) inflamm rheumatic disease
iv) calcium apatite deposition resulting from metabolic disturbances
v) drug induced (more commonly FQ abx and statins but statins more assoc w myalgia)

common sites:
i) shoulder
ii) elbow
iii) wrist
iv) hip (lateral)
v) ankle

3. bursitis: inflamm of the bursae

features: pain occurs when motion compresses adjacent bursa to the point where intrabursal pressure incr

etiology:
i) trauma/ injury
ii) crystal induced processes like gouty bursitis
iii) infection (septic bursitis)
iv) overuse
v) prolonged pressure like kneeling on hard surfaces
vi) inflamm arthritis (RA/ spondyloarthritis)

types:
i) acute (etiology is i to iii and there would be pain when joints are fully flexed both actively and passively)
ii) chronic (etiology is iv to vi and there would be more swelling and thickening, likely minimal pain bc hardy alr and there would be secondary changes of contracture and muscle atrophy relating to immobility)

sites:
i) superficial = cushion skin and bones (olecranon = elbow, prepatellar = knee cap, ischial = posterior upper thigh region between gluteus maximus and ischial tuberosity)
ii) deep = reduces friction of muscles as they glide over each other/ bone prominences (trochanteric = hip, subacromial = shoulder) *intrabursal GC prob more effective than TOP GC

4. plantar fasciitis: inflamm of the plantar fascia

features:
i) peak prevalence 40-60yo (can be younger if runner)
ii) pain worse when walking or running (esp in morning or after period of inactivity)
iii) pain lessens w incr activity but worse at end of the day

etiology:
i) prolonged standing, jumping, running on hard surfaces
ii) flat feet/ high arched feet
iii) tight hamstring muscle which decr knee extension thus incr loading of forefoot and incr stress on plantar fascia
iv) reduced ankle dorsiflexion
v) obesity
vi) assoc w systemic rheumatic diseases

5. adhesive capsulitis (frozen shoulder)

features:
i) peak prevalence >50yo
ii) unilateral (usually non dominant side although other side may become affected within 5yrs)
iii) limited reaching overhead, to the side, across chest and limited rotation (reduced func for ADL like clasping bra, scratching back, putting on jacket)
iv) to refer if there is marked loss of motion
v) self limiting but goes through three very long phases (initial, intermediate and recovery)

etiology:
i) idiopathic
ii) secondary to shoulder injuries
iii) often assoc w DM, hypothyroidism, dyslipidemia, prolonged immobilisation etc

6. low back pain

features:
i) classified and tx based on duration of sx, potential cause, presence or absence of radicular sx, corresponding anatomical or radiographic abnormalitis
ii) most are self limiting strains (10-14d)
iii) acute low back pain lasts <4w, subacute lasts 4-12w, chronic lasts >12w
iv) to refer for further investigations if no improvement for tx

Question 7

differentiate between the ligament, tendon, bursae, plantar fascia

Answer 7

ligament: bone to bone connective tissue

tendon: bone to muscle connective tissue

bursae: fluid filled sac surrounding the joints that cushions tendons or muscles from adjacent bones

plantar fascia: fibrous attachment connecting the heel bone to the base of toes

Question 8

what is “tendinosis”

Answer 8

persistent tendinopathy (tendon is repeatedly strained until microtears form)

Question 9

what are the three phases of recovery from adhesive capsulitis

Answer 9

adhesive capsulitis refers to frozen shoulder

initial: (2-9m) diffuse, severe disabling shoulder pain, worse at night, incr stiffness

intermediate: (4-12m) stiffness and severe loss of shoulder motion which can be very delibitating and decr QoL (consider PT), pain gradually lessens

recovery: (5-24m) gradual return of range of motion

Question 10

how to classify sprains

Answer 10

classify sprains based on severity of sprains

grade I:
i) refers to stretching of ligament with microscopic tears
ii) presented as mild swelling and tenderness
iii) able to bear weight and ambulate with minimal pain
iv) pharmacotx not necessary, RICE

grade II:
i) incomplete tear of the ligament
ii) presented as moderate pain, swelling, tenderness and ecchymosis (bruising)
iii) painful weightbearing and ambulation (likely limping), mild to moderate joint instability with some restriction in range of motion and func
iv) P + RICE + pharmacotx

grade III:
i) complete tear of ligament
ii) presented as severe pain, swelling, tenderness and ecchymosis (bruising)
iii) cannot bear weight or ambulate, significant instability and loss of motion and func
iv) refer

Question 11

what are the common sites of tendonitis and which tendon would be affected at each site

Answer 11

1. shoulder
   i) suprasipinatus tendinitis
   ii) bicipital tendinitis
2. elbow
   i) lateral epicondylitis
   ii) medial epicondylitis
3. wrist
   i) flexor carpi radialis tendonitis
   ii) flexor carpi ulnaris tendonitis
4. hip
   i) gluteus medius/ minimus tendinopathy
5. ankle
   i) achilles tendinopathy

Question 12

what are the differentials for heel or sole pain

Answer 12

i) neurologic causes (nerve entrapment/ compression syndromes, neuropathic pain, S1 radiculopathy)

ii) skeletal causes (calcaeneal stress fracture, bone contusion, osteomyelitis, neoplasm, paget disease, haglund deformity)

iii) soft tissue causes (achilles tendinopathy, fat-pad atrophy, bursitis, painful heel pad syndrome, plantar fascia rupture)

iv) inflamm disorders (reactive arthritis and other spondyloarthritis, sarcoidosis)

Question 13

what are the differentials of shoulder pain

Answer 13

i) inflamm (RA, psoriatic arthritis, gout, pseudogout)

ii) infection (septic arthritis, osteomyelitis)

iii) degenerative (OA)

iv) connective tissue disorders (inflamm myositis, systemic vasculitis, soft tissue rheumatism, truama)

v) tumors

Question 14

what are the differentials of lower back pain

Answer 14

i) mechanical (lumbar strain, herniated disc, osteoporotic fractures, sciatica L5/S1 radiculopathy)

ii) non mechanical spine disease (malignancy, infection = osteomyelitis, septic discitis, paraspinous abscess, epidural abscess)

iii) visceral (sx pointing to underlying causes)

iv) inflamm (spondyloarthritis)

v) degenerative (OA)

vi) trauma (osteoporotic, non osteoporotic)

Question 15

what are the red flags sx

Answer 15

i) infection (fever, constant pain, nocturnal sx, severe pain)

ii) malignancy (FMHx, PMHx, unintended weight loss, fatigue, ROS, pain travel to or from other structures)

iii) parasthesia

iv) complete rupture

Question 16

what is the tx approach (pt counselling), goals of tx and tx methods for soft tissue injuries

Answer 16

tx approach:
i) exclude systemic disease, refer if present
ii) eliminate aggravating factors
iii) explain illness
iv) provide self help strategies (pharmaco and non pharmacotx)
v) provide pain relief
vi) explain prognosis (whether self limiting or has to be managed on long term basis, when to see doc)
vii) pt edu on preventing future similar injuries

goals of tx:
i) decr pain
ii) regain func
iii) prevent future injury

non pharmacotx (for acute soft tissue injuries):
R est
I ce (do not apply directly to bare skin but instead wrap in wet towel or cloth and not for more than 15mins to relieve pain and limit swelling)
C ompression (of injured area can help limit swelling, use elasticated stockings for limbs)
E levate (allows gravity to help limit swelling of damaged tissues)

non pharmacotx (for frozen shoulder):
i) range of motion exercises
ii) PT (beneficial bc supervised)

non pharmacotx (for lower back pain):
i) low impact core strengthening exercises to improve spine stability (eg. swimming, stationary bicycling, brisk walking, yoga, stretching, pilates, taichi)
ii) use correct lifting and moving techniques (eg. squatting to life and not bend and life, get help)
iii) maintain correct posture when sitting or standing
iv) quit smoking bc smoking is a risk factor for atherosclerosis
v) avoid stressful situations bc can cause muscle tension
vi) maintain healthy weight bc extra weight around midsection can strain lower back)

pharmacotx (for acute non lower back pain):
i) TOP NSAIDs (first line bc fewer s/e)
ii) PO NSAIDs/ coxib
iii) PO paracetamol
*typically used for 7d or lesser

pharmacotx (for frozen shoulder):
i) analgesics for pain (paracetamol, NSAIDs, weak opioids)
*but consider s/e of opioids bc recall that recovery of frozen shoulder have three very long phases
ii) intra articular GC for severe cases

pharmacotx (for acute and subacute lower back pain):
i) NSAID
ii) skeletal muscle relaxant (anarex)
*pharmacotx with non pharmacotx

pharmacotx (for chronic lower back pain):
i) NSAID
ii) tramadol/ duloxetine
*pharmacotx w non pharmacotx

Question 17

what is “myalgia”

Answer 17

muscle pain, soreness, stiffness

sx are either diffuse or focal

Question 18

how is myalgia managed

Answer 18

for strains relating to overuse or exercise, it is acute and self limiting thus

i) RICE
ii) maybe TOP NSAIDs if necessary
iii) prevention: proper warm up before exercise

Question 19

what are the differentials for diffuse myalgia

Answer 19

i) infection (viral, bacterial, spirochetal)
*bacterial infection will present with diffuse myalgia, fever, chills, arthralgia, fatigue, back pain

ii) medication related (based on medical and medication hx; look out for statins, FQ abx, bisphosphonates, aromatase inhibitors (that is used for breast cancer))
*statin induced rhabdomyolysis will present with muscle pain with weakness, red brown coloured urine related to myoglobinuria

Question 20

what are the distinguishing features of the different kinds of infections that can cause diffuse myalgia

Answer 20

i) viral: fever, resp or GI sx, viral diagnostic testing
ii) bacterial: hypotension, rash, heart murmur, leukocytosis, bacteremia
iii) spirochetal: rash, lyme, RPR serology

Question 21

what are the differentials for focal myalgia

Answer 21

i) unusually strenuous exercise or overuse (based on hx)
ii) trauma (based on hx, hematoma, ecchymosis)

Question 22

what is the spectrum of SAMS (elaborate on the features and management strategies)

Answer 22

1. myalgia
   i) unexplained muscle discomfort often described as flu like sx with normal CK level
   ii) muscle aches, soreness, stiffness, tenderness, cramps with or shortly after exercise
   iii) onset anytime
   iv) typically proximal symmetric muscle weakness
   v) nocturnal cramping, stiffness, tendon pain, fatigue, tiredness
   *discontinue statin if sx untolerable (sx usually resolves over days to weeks after)
2. myopathy
   i) muscle weakness not attributed to pain and not necessarily assoc w elevated CK
   ii) onset anytime
   iii) typically proximal symmetric muscle weakness
   iv) nocturnal cramping, stiffness, tendon pain, fatigue, tiredness
   *discontinue statin if sx untolerable (sx usually resolves over days to weeks after)
3. myositis
   i) inflamm of muscle
   ii) onset anytime
   iii) typically proximal symmetric muscle weakness
   iv) nocturnal cramping, stiffness, tendon pain, fatigue, tiredness
   *discontinue statin if sx untolerable (sx usually resolves over days to weeks after)
4. myonecrosis
   i) muscle enzyme elevations (hyperCKemia): mild = >3xULN, moderate = >10xULN, severe = 50xULN or more
   *discontinue statins if CK 10xULN or more w/wo unexplained muscle sx
   *advise to drink large qty of fluid to facilitate renal excretion of myoglobin to prevent renal failure
5. myonecrosis with myoglobinuria (rhabdomyolysis)
   i) incr in SCr 0.5mg/dl or more
   *emergency