ic15 soft tissue injury

Question 1

TYPES OF joint pain

Answer 1

articular and non-articular
- articular is the joint itself

non-articular includes:
- referred visceral pain (eg MI pain radiate from chest)
- tissue pain
- neuropathic pain (eg prolapsed intervetebral disc)
- periarticular pain (soft tissue: relating to ligament, muscles, tendons)
- bone pain (fractures, dislocation)

Question 2

significant characteristics of periarticular joint pain?

Answer 2

on palpitation, point of maximal tenderness is typically not at the joint line

pain usually worse on active movement rather than passive movement

pain maximal in certain lines of muscle pull (worse pain with certain kinds of movements).

Question 3

[general] when to refer

Answer 3

fractures
ligament rupture
infection
malignancy/metastases
underlying visceral causes (eg lower back pain referred form other internal organs)

Question 4

characteristics of soft tissue injuries (non lower back)?

Answer 4

consequence of chronic repetitive low grade trauma or overuse

focal and non systemic

self limiting

responds to conservative measures

Question 5

non phx for non lower back pain

Answer 5

RICER: rest, ice, compress, elevate, referral.
- Rest = stop activity.
- Ice = ice cubes, cold spray/wrap to the injured area and applied for not more than 15minutes in the first hour. DO NOT APPLY DIRECTLY TO THE SKIN. Allow to rewarm before reapplying again if remains painful. This will help to relieve pain and limit swelling.
- Compress = elastic stocking to the limb (should be of double thickness around injury site and far enough below and above to avoid swelling and pooling of tissue fluid around the bandage edges). This will help to limit swelling.
- Elevate = limit swelling.
- Referral = always refer due to risk of underlying fractures or dislocation.

Question 6

what to avoid for non phx non lower back pain

Answer 6

Avoid HARM: heat, alcohol, re-injury, massage.

Question 7

what are the common types of non-lower back soft tissue injuries

Answer 7

1) plantar fasciitis
2) sprains (stretching, partial rupture, complete rupture of the ligament; bone to bone)
3) bursitis: fluid-filled sacs around joints that cushion tendons
4) tendonitis (tendon = muscle to bone connective tissue)

Question 8

phx treatment for non-lower back soft tissue injuries?

Answer 8

1) topical nsaid
2) po nsaid
3) po paracetamol

do not advise use of opioids for soft tissue injuries

Question 9

what is the mechanism for lateral ankle sprains

Answer 9

inversion of foot (inward)

usually sustained during sport
sudden onset of pain and swelling

more likely in children/adolescents > adults, and adult females > males

Question 10

grade 1 sprain description?

Answer 10

grade 1:
- mild stretching of ligament with microscopic tears
- mild swelling and tenderness
- able to bear weight and ambulate w minimal pain
- usually will not require medical help…

Question 11

grade 2 sprain description

Answer 11

grade 2:
- incomplete ligament tear
- moderate pain, swelling, tenderness, ecchymoiss (bruising)
- painful weightbearing and ambulation

some mild to moderate joint instability, restriction in range of motion and function

Question 12

management of grade 2 sprains

Answer 12

RICER
consider pharmacotherapy if necessary…

Question 13

grade 3 sprain description

Answer 13

complete tear of the ligament
severe pain, swelling, tenderness, ecchymosis

cannot bear weight or ambulate
(significant instability, loss of motion & function)

Question 14

management of grade 3 sprain

Answer 14

refer to a&e…

Question 15

tendonitis features

Answer 15

local pain and dysfunction on active use (unlikely to be painful on passive movement)

inflammation (unlikely to have visible swelling)

degeneration

Question 16

what is tendinosis

Answer 16

persistent tendinopathy for at least 3 months…

REFER if pain for several days to weeks

Question 17

common sites for tendonitis

Answer 17

1) shoulder: rotator cuff (supraspinatus); bicipital
2) elbow: lateral and medial OR tennis or golfer elbow
3) wrist: flexor carpi radialis and ulnaris
4) hip (lateral): gluteus
5) ankle: achilles

Question 18

etiology of tendonitis

Answer 18

NO NEED TO REFER
overuse (repeated mechanical loading)
sports injury

TO REFER
inflammatory rheumatic disease
calcium apatite deposition
drug induced: fluoroquinolones and statins…

Question 19

when to refer for tendonitis

Answer 19

1) when pain persists for days to weeks (possibly tendinosis)
2) pain associated with calcium apatite deposition, drug-induced (FQ, statins), inflammatory rheumatic disease.

Question 20

mechanism of bursitis

Answer 20

inflammation of bursa
pain occurs when motion compresses adjacent bursa to the point where intra-bursal pressure increases

Question 21

etiology of acute bursitis

Answer 21

1) trauma or injury
2) crystal-induced processes (eg gouty bursitis)
3) infection (septic bursitis)

Question 22

etiology of chronic bursitis

Answer 22

overuse
prolonged pressure (kneeling or leaning)
inflammatory arthritis in RA/spondyloarthritis

Question 23

what are the more significant characteristics of acute bursitis

Answer 23

active and passive pain

Question 24

what are the more significant characteristics of chronic bursitis

Answer 24

more swelling and thickening
minimal pain
secondary changes of contracture and muscle atrophy relating to immobility

Question 25

common sites of bursitis

Answer 25

superficial
- elbow (olecranon),
- knee cap (prepatellar),
- ishcial region = posterior upper thigh region (between glutes and ischial tuberosity)

DEEP
- hip
- shoulder

Question 26

when to refer for bursitis?

Answer 26

deep bursitis = refer and get proper assessment, might require intra-bursal GC management

if acute pain = refer

Question 27

plantar fasciitis etiology

Answer 27

heel pain; younger peak if runner

prolonged standing/jumping/running on hard surfaces
flat feet or high arched feet
tight hamstring muscle = decreased knee extension = increase loading of forefoot = increase stress on plantar fascia
reduced ankle dorsiflexion = associated w poor calf muscles? ankle injury?
obesity?

Question 28

presentation for plantar fasciitis

Answer 28

pain worse when walking or running ESP in the morning or after period of inactivity

pain lessens with increased activity but worse at end of the day with prolonged weight bearing.

Question 29

when to refer for heel or sole pain

Answer 29

1) paresthesia and numbness = nerve entrapment or compression syndrome?

2) nocturnal symptoms (and alcohol abuse, diffuse pain, PMH DM) = neuropathic pain?

3) radiating pain from posterior leg to heel = S1 radiculopathy?

4) trauma (and overuse) = calcaneal stress fracture

5) fever or constant pain = osteomyelitis?

6) sudden onset (with visible swelling & ecchymosis) = rupture or plantar fascia?

7) history of inflammatory disease = RA, spondyloarthritis

8) erythema nodosum = sarcoidosis

firm, solid, deep nodules or plaques ; painful on palpation

Question 30

presentation of adhesive capsulitis

Answer 30

unilateral (typically non-dominant side)

LIMITED ROTATION: reaching over overhead, to side, across chest
- reduced function

SELF LIMITING

Question 31

three phases of adhesive capsulitis

Answer 31

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

intermediate (4-12 months): stiffness, severe loss of shoulder motion, pain gradually lessens

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

Question 32

management of adhesive capsulitis

Answer 32

SELF-LIMITING

analgesics: paracetamol, nsaid, weak opioids

range of motion exercises = abduction, external rotation, internal rotation exercises.

last line: refer = intra-articular glucocorticoid + physical therapy

Question 33

WHEN TO REFER for adhesive capsulitis

Answer 33

when there is marked loss of motion

Question 34

lower back pain length

Answer 34

most cases typically self limiting strain of appx 10-14 day

Question 35

differentials of lower back pain WHEN TO REFER?

Answer 35

1) neurologic symptoms: motor weakness, fall, gait instabiliy, loss of bowel or bladder function, numbness
= spinal cord compression? due to herniated disc?

2) chronic GC use, age, trauma, PMH OP or traumatic fracture = osteoporotic fractures?

3) unintended weight loss, PMH malignancy = malignancy or cancer?

4) fever, malaise, recent spinal injection or epidural catheter placement, immunocompromised, hemodialysis, recent infection = SPINAL EPIDURAL ABCESS?

5) fever or constant pain = osteomyelitis

Question 36

phx management of lower back pain

Answer 36

chronic: (>12weeks)
- nsaids 1st line > tramdol/duloxetine

acute (4-12 wks) or subacute (< 4wk)
- nsaids
- orphenadrine

generally if due to muscle strain = should be self limiting episode (about 10-14 days)

Question 37

counselling for lower back pain

Answer 37

1) engage in low impact core strengthening exercises to improve stability E.G., swimming, bicycling, brisk walking.
2) Use correct lifting and moving techniques e.g., avoid bending back when lifting heavy objects.
3) Maintain correct posture when sitting/standing.
4) Quit smoking (risk factor for atherosclerosis).
5) Avoid stressful situations (can cause muscle tension).
6) Maintain healthy weight (less strain on the lower back).

Question 38

types of myalgia

Answer 38

diffuse and focal
if diffuse.= refer

Question 39

myalgia management

Answer 39

usually self limiting if related to exercise or overuse
1) RICE
2) topical nsaids

PREVENTION via proper warm up before exercise

Question 40

differential diagnosis for diffuse myalgia

Answer 40

infection
- esp bacterial eg endocarditis and impending sepsis = diffuse myalgia + fever, chills, arthralgia, fatigue, back pain

med toxicity
- rhabdomyolysis = muscle pain + weakness, red brown tea coloured urine

• may also be associated with ciprofloxacin, bisphosphonates, aromatase inhibitors

Question 41

when to send to A&E for SAMS

Answer 41

when rhabdomyolysis
- increase in SCr ≥0.5 mg/dL

Question 42

description of SAMS + management

Answer 42

usually proximal symmetric muscle weakness and/or weakenss of hips, thighs, calf (larger muscles)

• may also have nocturnal cramping, stiffness, tendon pain, fatigue and tiredness

DISCONTINUE if sx are bothersome (should resolve in days to weeks) OR if CK > 10xULN (with or without unexplained muscle sx)

• consider switching to pravastatin, fluvastatin, rosuvastatin (less SE), alt day dosing, lower dosing…
• advise drinking large qty of fluids to facilitate renal excretion of myoglobin to prevent renal failure.