Module 7 Musculoskeletal Flashcards
(88 cards)
1
Q
What is the patho of neck pain?
A
• Strains and sprains caused by overuse, stretching or tearing
• If acute phase if no neurologic symptoms
– Strain or sprain
• Cervical radiculopathy can extend to arm
• Cervical myelopathy possible complication of cervical spondylosis
2
Q
What risk factors are associated with neck pain?
A
- Older age
- Female
- Obesity
- Physically or psychologically strenuous work
- Sedentary lifestyle
- Acute trauma
3
Q
What are differential diagnosis of neck pain?
A
- Infection
- Fracture
- Inflammatory disease
- Neoplasm
4
Q
What history (subjective) should be reviewed with neck pain?
A
– OLDCARTS – Special attention to radiation of pain – loss of sensation – weakness
5
Q
What should be checked in ROS (subjective) for neck pain?
A
– What do you need to rule out? – CV, GI, GU, respiratory, neuro, integumentary, psych – Chronic or acute pain – Radicular: > in the arm than neck
6
Q
What are the red flags for neck pain?
A
• History of cancer • History of (or risk for) osteoporosis • Progressive neuro deficit • Greater than 6 weeks without improvement
7
Q
What should be assessed on the physical exam for neck pain?
A
• Inspection – Gait and posture – structural abnormality • Palpation – pain over spinous processes – paraspinous muscles for pain or spasm • Motor system – ROM – flexion, extension, rotation – Strength • Neuro system: – Sensation by dermatome
8
Q
What diagnostics can be done for neck pain?
A
• Imaging – X-ray – CT or MRI • Other – EMG • CBC, ESR, CRP
9
Q
How can neck pain be treated?
A
• If a sprain or strain: -Conservative care -Heat, ice, and massage -Physical therapy for guided exercise • Pharmacology – NSAIDS, muscle relaxants • Activity – as tolerated • Lifestyle management: -Work on appropriate posture (decrease screen use!) -Avoid repetitive movement/lifting
10
Q
What medications can be used for neck pain?
A
- NSAIDS, muscle relaxants
- May need short course (2-3 days) opioids
- Duloxetine (SNRI)
- Gabapentin
11
Q
What patient education should be done for neck pain?
A
• Reassurance and support
• Explain the history of mechanical neck pain
• Preemptive exercise in conditioning
• Postural exercises
• Recommends of a lumbar support when sitting helps
the patient maintain proper head and neck alignment
• Warning signs and symptoms of serious complications
12
Q
What complications are associated with neck pain?
A
- Sudden or progressive weakness
- Bowel or bladder changes
- Constitutional symptoms
13
Q
What patients with neck pain should be referred?
A
- Abrupt-onset cervical myelopathy associated with gait disturbance
- Upper motor neuron signs
- Bowel and bladder incontinence
- Incapacitating neck pain refractory to conservative methods
- Trauma
- Fracture or instability of cervical spine
- Epidural steroids
- Surgery
14
Q
What is the patho of low back pain?
A
• Mechanical – Injury – Deformity – Imbalance – Overuse • Systemic medical illness – Inflammatory infection – Neoplastic – Visceral sources
15
Q
What are the risk factors of low back pain?
A
• Broad • Genetics • Smoking • Obesity • Older age >65 • Female • Physically or psychologically strenuous work • Sedentary lifestyle • Acute trauma
16
Q
What are the differential diagnosis for low back pain?
A
• Diabetic amyotrophy • Vascular claudication • Sacroiliitis • Shingles with or without rash • Pancreatitis, intra-abdominal or gynecologic pathology • Renal colic • Priority dx – Spinal cord compression, fracture, inflammatory disease, neoplasm, infection
17
Q
What subjective data may we see with low back pain?
A
• Pain disturbing sleep, work, and activities • Acute onset • Chronic in nature “I have had this for years.” • Exacerbated by prolonged activates – Pain mitigated by frequent position change • Lumbar radiculopathy – Leg and thigh pain – Neurologic symptoms • Numbness • Tingling • Weakness • Reflex changes
18
Q
What should be done on a physical assessment for low back pain?
A
• Inspection – Gait and posture – structural abnormality • Palpation – pain over spinous processes – paraspinous muscles for pain or spasm • Motor system – ROM – flexion, extension, rotation and lateral bending – Strength • Neuro system: – DTRs – Sensation by dermatome • Special tests: – Straight leg raising – Abduction relief • Waddell signs
19
Q
What diagnostics can be done for low back pain?
A
None
20
Q
How can low back pain be managed?
A
Conservative care
• self-limited; 90% resolve in 1-6 wks.
• Ice, heat, TENS
• Pharmacology – NSAIDS, muscle relaxants
• Activity – as tolerated, bed rest no longer than 2
days; walking important.
• Do not advise patients with acute low back pain to remain at bed rest
• Lifestyle management:
• Weight loss
• physical activity, exercise X30 min per day to strengthen back and abdomen
• Good body mechanics
• Massage, yoga, acupuncture, spinal manipulation
21
Q
What patient education should be reviewed with low back pain?
A
- Reassurance and support
- Typically benign
- Exercise is important
- Eliminate risk factors
22
Q
What are the red flags associated with low back pain?
A
– New limb weakness
– Change in bowel and bladder
– Constitutional signs
23
Q
What patient with back pain warrants immediate referral?
A
If significant neurologic weakness or cauda equina syndrome is occurring, the need an URGENT SURGEON referral
24
Q
What is the patho of arthritis?
A
- Soft cartilage becomes overhydrated
- Collagen loses its stiffness
- Surface layers fibrillate, and cartilage loses thickness, developing surface crevices, thus losing integrity
- Whole-joint disease
25
What are risk factors associated with arthritis?
* Female
* Middle-aged
* Obesity
* Prior trauma
* Repetitive activities
* Metabolic disorders
* Neurologic diseases
* Hematologic conditions
26
What are differentials associated with arthritis?
– Fracture
– Avascular necrosis
– Infectious arthritis
– Lyme disease
27
What subjective data is associated with arthritis?
* Insidious, progressive pain or stiffness
* Pain upon arising, with duration <1 hour
* Favoring one side
* Pain after prolonged activity and relieved by rest
* Difficulty with weight bearing activities
* Neuropathy and radiculopathy may develop if the cervical or lumbar spins is involved
28
What objective data is associated with arthritis?
* Trendelenburg gait noted
* Deformity of an extremity
* Pain on palpation
* Atrophic quadriceps muscles to affected side
* Heberden nodes (distal interphalangeal joints)
* Bouchard nodes (proximal interphalangeal joints)
29
What diagnostics can be done with arthritis?
```
• Additional
– Joint aspirate for
crystal/white blood cells
• Imaging
– X-ray
```
30
How can arthritis be managed?
```
• Acetaminophen
• Consider Tramadol (nonopioid)
• NSAIDS
– Consider H2 Blocker or proton pump inhibitor to protect the gut
• Exercise
• Weight management
• Acupuncture
```
31
What patient education should be reviewed for arthritis?
```
• Progressive disease
• Lifestyle modifications
– Weight management
– Low-moderate intensity
exercise
• Assistive devices
```
32
What complications are associated with arthritis?
```
• Pain
• Immobility
• Medication side effects
• Failure of prosthetic
components
• Infection or microfractures
of damaged joints
```
33
When should a patient be referred with arthritis?
Suspected fracture
34
How is fibromyalgia defined?
```
• Are characterized by symptoms of:
– widespread musculoskeletal pain
– Fatigue
– Nonrestorative sleep
– Depression
– Headaches
– Gastrointestinal complaints
• Defined as having more than three months of musculoskeletal pain present above and below the waist bilaterally, associated with pain on palpation of specific tender points
```
35
What is the patho of fibromyalgia?
• Pain getting in the periphery is processed in the spinal cord and transmit it to the brain. For unclear reasons the pain becomes louder at the level of the spinal cord and brain, a condition called central
sensitization
• Follows physical or mental trauma, viral illness, and stress
36
What are the risk factors for fibromyalgia?
* Female
| * Age 40-50 years old
37
What are the differentials for fibromyalgia?
* Myofascial pain syndrome
* Chronic fatigue syndrome
* Hypothyroidism
* Bursitis
* Tendinitis
* Depression
* Anxiety
* Rheumatoid arthritis
* Lupus
38
What subjective data is seen with fibromyalgia?
```
• Persistent widespread pain
• Chronic fatigue
• Cognitive difficulties
• Auditory, vestibular, and
ocular complaints
• Chronic rhinitis or
“allergies”
• Migraines
• Palpitations
• Irritable bowel syndrome
• Mood disorders
• Sense of joint swelling
```
39
What objective data is seen with fibromyalgia?
* Normal muscle strength
* No soft tissue inflammation
* No evidence of synovitis
40
What diagnostics can be used for fibromyalgia?
```
• Widespread Pain Index (WPI) >/7
and Symptom severity scale (SSS)
>/5
• Or a WPI of 4-6 with a SSS of >/ 9
• Labs
– CBC, Chemistry profile, TSH,
ESR, C-Reactive protein
```
41
What is the goal of treatment with fibromyalgia?
Goal is to empower patients to control their own pain, to enhance sleep, and to maintain function
42
How can fibromyalgia be treated?
```
• Pharmacologic
– Tri-cyclic drugs-Amitriptyline
– Cyclobenzaprine
– Gabapentin
– Lyrica
• Cognitive behavioral therapy
• Exercise
```
43
What patient education should be reviewed for fibromyalgia?
* Goal is to empower patients to control their own pain, to enhance sleep, and to maintain function
* Education to individualize treatment and reduce symptoms
* Support groups
44
What is a strain?
Result of overuse and overstretching of muscles and tendons
45
What is a sprain?
Stretching and tearing of a ligament
46
What is a fracture?
Break in the bone
47
What are risk factors for acute sprain/strain/stress fx?
```
• Arthritis
• Diabetes
• Past surgery resulting in
deformity
• Intense athletic activity
• Workplace injury
• Other trauma
```
48
What are differential diagnosis for acute sprain/strain/stress fx?
• Infection
• Rheumatoid arthritis
• Sprain, strain, and
fracture
49
What subjective data Is associated with a strain?
– Local mild swelling
| – Muscle spasm
50
What objective data is associated with a strain?
– Local mild swelling
51
What subjective and objective data is associated with a sprain?
– Swelling
– Bruising
– Pain with movement
52
What subjective and objective data is associated with fractures?
– Pain
– Possibly no swelling
– Skin discoloration
– Decreased range of motion
53
What diagnostics can be done for strains/sprains/fx?
– X-ray studies
54
How can strain/sprain/fx be treated?
```
• RICE
– Rest, Ice, Compression, Elevate
• Crutches, splinting, or casting
• Therapy/Exercise
• Anti-inflammatories
– Oral and topical
```
55
When should a patient be referred with a sprain/strain/fx?
Refer to an Orthopedist if a
| fracture is noted
56
What patient education should be reviewed for strain/sprain/fx?
```
• Adhere to treatment and follow up
• Take Ibuprofen with food
• Fracture
– Compartment syndrome
• Infection
• Thrombosis
• Complex regional pain syndrome
```
57
What is tennis elbow?
• Inflammation of tendon at epicondyles
• Overuse syndrome
– Lifting, hammering, gripping
– Sports
58
What subjective data is associated with tennis elbow?
pain, burning, radiation down forearm, weaker grip
59
What objective data is associated with tennis elbow?
– Pain at affected epicondyle
| – Exacerbation with resisted flexion (medial) or extension (lateral)
60
How is tennis elbow treated?
Treatment: weeks to months
– Support band, decrease activity, stretching and strengthening,
NSAIDS, cold packs
– Steroid injections, surgery
61
What is Carpel tunnel?
* Median nerve compression
| * Often overuse, repetitive hand movement
62
What are risk factors/causes of carpel tunnel?
* 3 x more common in women
| * Other causes – weight gain, swelling, PREGNANCY, diabetes, hypothyroidism
63
What subjective data is associated with carpel tunnel?
pain and numbness in wrist, palm, thumb and first 2-3 fingers, loss of strength
64
What exams should be performed for suspected carpel tunnel?
Tinel and Phalen's tests, EMG if referring
65
How is carpel tunnel treated?
splints, activity change, OTC pain reliever, steroids
66
When should a patient with carpel tunnel be referred?
Referral: persistent, worsening symptoms, loss of strength
– Steroid injection
– Surgery
67
What is plantar fasciitis?
* Inflammation of the fascia that supports the arch of the foot
* Overuse injury, also with unusual activity, flat feet, obesity
68
What subjective data is associated with plantar fasciitis?
sharp stabbing pain when first getting up, better as the fascia loosens, worse after activity
69
How is plantar fasciitis diagnosed?
by hx and exam
70
How is plantar fasciitis treated?
– Stretching the fascia – exercises
– Cold
– Night splints, heel cushions and arch support
71
What should a patient with plantar fasciitis be referred for?
Steroid injection, orthotics, rarely surgery
72
What are the differentials for tennis elbow?
– Sprains, fractures, bursitis, and epicondylitis
73
What are the differentials for carpel tunnel?
Sprain, fracture, dislocation, arthritis, vascular abnormality
74
What are the differentials for plantar fasciitis?
– Calcaneal fracture
| – Retrocalcaneal or infracalcaneal bursitis, and gout
75
What diagnostics can be done for tennis elbow?
– X-ray, MRI, US, Joint aspiration
76
What diagnostics can be done for carpel tunnel?
– X-ray
77
What diagnostics can be done for plantar fasciitis?
– X-ray, ultrasound, or MRI
78
What is osteoporosis?
Defined as a bone mineral density of 2.5 standard deviations or less below the young normal mean (T-score
79
What is the patho of osteoporosis?
* Rate of bone resorption exceeds that of bone formation
* Producing a net loss of bone
* This is due to estrogen deficiency
80
What are risk factors for osteoporosis?
```
• Unmodifiable
– Age
– Genetics
– Sex
– Inflammatory disorders
– Race: White or Asian
– Dementia
– Metabolic disorders
• Modifiable
– Low body weight
– Overuse injury
– Trauma
```
81
What are differentials for osteoporosis?
* Endocrine disease
* Gastrointestinal disease
* Hematologic disease
* Rheumatologic disease
* Connective tissue disease
* Anorexia nervosa
* End-stage renal failure
* Medications side effects
* Cigarette Smoking
82
What subjective data is associated with osteoporosis?
* Frequent falls
* Pain at the hip, lower back or any major joint after a fall
* Dowagers hump
83
What objective data is associated with osteoporosis?
* Direct the exam at finding signs of secondary osteoporosis
* Fall risk
* Visual acuity
* Grip strength
* Romberg sign
* Excessive body sway
84
What diagnostics can be done with osteoporosis?
* Serum calcium with albumin
* Serum phosphorus
* 25-Hydroxyvitamin D
* Intact PTH
* TSH
* Serum and urine protein electrophoresis
* Liver function test
85
How is osteoporosis treated?
• Co-management
– Fracture and pain control
– Physical therapy
– Nutritionist
– Orthopedic surgeon
• Calcium 1,000mg daily ages 19-50, 1,200mg > 70 years old
• Vitamin D 600IU (19-70), >70- 800IU daily
• 25-Hydroxyvitamin D2,000IU daily to maintain levels >30ng.ml
• Exercise, weight bearing
• Bisphosphonates to help prevent fracture
86
What patient education should be done with osteoporosis?
* Prevent fractures
* Adhere to treatment
* Change modifiable risk factors
87
What complications are associated with osteoporosis?
* Acute pain from fractures
* Altered activity
* Chronic pain
88
What referrals should be done for osteoporosis?
* Endocrinologist
* Pain specialist
* Physical Therapist
* Nutritionist
* Orthopedic Surgeon
