Examples of non-articular joint pain:
Non-articular joint pain (pain in the muscle/bone, but NOT the joints)
- Referred visceral pain (e.g., shoulder pain a/w MI, back pain a/w pancreatitis)
- Tissue pain
- Neuropathic pain
- Periarticular pain (relating to ligaments, tendons, muscles)
- Bone pain (fracture, dislocation, osteoporosis)
What are the features of periarticular pain?
- On palpitation: point of maximal tenderness not at joint line
- Pain on active movement > passive movement
- Pain maximal at certain lines of muscle pull
Other features (for joint pain)
- Swelling
- Erythematous
- Tender on palpation of joint line
- Restricted motion
Characteristics of soft tissue injuries
- Consequence of chronic repetitive low-grade trauma/overuse (microtear, microinflammation)
- Focal: able to point out where
- Non-systemic
- Self-limiting
- Responds to conservative measures (non-pharm: e.g., RICE)
When might urgent referral to ED be necessary?
- Ligament rupture
- Infection-related cause
- Malignancy/metastasis (metastasis to spine - lower back pain)
- Relating to underlying visceral conditions (lower back pain)
Treatment goals:
- Reduce pain
- Regain function
- Prevent future injury
Non-pharmaco for soft tissue injuries: RICE, no HARM
RICE: aim to relieve pain and limit swelling
- R: rest
- I: ice (constrict blood vessels, reduce inflammation)
- C: compression
- E: elevation
No HARM:
- No heat (except for lower back pain)
- No alcohol
- No re-injury
- No massage (bruising)
Pharmaco for non-lower back pain soft tissue injuries
- Topical NSAIDs (Ketoprofen patch/gel, Diclofenac gel)
- PO NSAIDs/coxibs (Pharmacist: Ibuprofen, Naproxen)
- PO Paracetamol (not anti-inflammatory)
Others:
- Consider specific acupressure, transcutaneous electrical nerve stimulation
- DO NOT use opioids including tramadol => risk for neurologic and GI adverse events, prolonged use >7d a/w longer term addiction and overdose
[Sprain]
What is a sprain?
Stretching, partial rupture, or complete rupture of the ligament
- cause inability to move well + instability
- ligament is the bone to bone connective tissue
[Sprain]
What is most common?
- Mechanism
- Cause
- Characteristic
- Prevalence
Lateral ankle sprains:
- Mechanism: inversion of foot; typically affects the anterior talofibular ligament
- Causes: usually sustained during sport
- Characteristics: sudden onset of pain and swelling after “pop” sound
- Prevalence: children > adults; adult females > males
Other examples: Anterior cruciate ligament (ACL) injury in the knee
[Sprain]
Grades of sprain
- Severity
- Clinical presentation
- Function
- Pharm approach
Grade I:
- Severity: mild stretching of ligament with microscopic tears
- Clinical presentation: mild swelling and tenderness
- Function: able to bear weight and ambulate with minimal pain
- Pharm: med not frequently sought
Grade II:
- Severity: incomplete tear of the ligament
- Clinical presentation: mod pain, swelling, tenderness, ecchymosis
- Function: painful weight-bearing and ambulation, some restriction in range of motion and function
- Pharm: RICE, protection, +/- analgesics
Grade III:
- Severity: complete tear of the ligament
- Clinical presentation: severe pain, swelling, tenderness, ecchymosis
- Function: cannot bear weight or ambulate, significant instability and loss of motion and function
- Pharm: refer to ED
[Tendonitis]
What is tendonitis?
Inflammation of tendon
- Tendon: muscle to bone connective tissue
- VS tendinosis/tendinopathy: degeneration of tendon collagen in response to chronic overuse
[Tendonitis]
Etiology
- Overuse (repeated mechanical loading)
- Sports injury
- Inflammation rheumatic disease
- Calcium apatite deposition (from metabolic disturbances)
- Drug-induced: fluoroquinolone antibiotics and statins
Stop FQ if: sudden onset of unexplainable muscle ache or joint pain
Stop statins if: myalgia, rhabdomyolysis - muscle weakness, dark brown urine or if liver injury - light colored stools, N/V, LOA, yellowing of skin or eyes
[Tendonitis]
Features
- Local pain and dysfunction
- Inflammation
- Degeneration
- Pain in a certain direction of pull only
[Tendonitis]
Common sites
- Shoulder
- Elbow (lateral/medial epicondylitis, aka tennis/golfer)
- Wrist
- Hip (lateral)
- Ankle (Achilles tendinopathy)
[Bursitis]
What is it?
Inflammation of bursae
- Bursae: fluid-filled sacs, lined by synovial membrane in clefts between mobile structures - cushions tendons/muscles from adjacent bones
[Bursitis]
Features (when does pain occur?)
Pain occurs when motion compresses adjacent bursa to the point where intrabursal pressure increases (fluid-filled sac is being compressed)
May be swollen, may see a bump
[Bursitis]
Etiology
Acute bursitis: pain when joins are fully flexed, both active and passive
- Trauma/injury
- Crystal-induced process (e.g., gouty bursitis)
- Infection (septic bursitis)
Chronic bursitis: more swelling and thickening, minimal pain, secondary changes of contracture and muscle atrophy relating to immobility
- Overuse
- Prolonged pressure (e.g., kneeling/leaning)
- Inflammatory arthritis (e.g., RA/spondyloarthritis)
[Bursitis]
Common sites
Superficial: cushions skin and bone
- elbow: olecranon
- knee cap: prepatellar
- posterior upper thigh region: ischial
Deep: reduce friction of muscles as they glide over each other/bone prominences may treat with intrabursal glucocorticoids as topical NSAIDs may not penetrate deep enough
- hip: trochanteria
- shoulder: subacromial
[Plantar Fasciitis]
What is it?
Inflammation of plantar fascia
- Plantar fascia: fibrous attachment connecting heel bone to base of toes - most common cause of heel pain
[Plantar Fasciitis]
Etiology
- Prolonged standing/jumping/running on hard surfaces
- Flat feet/high arched feet
- Tight hamstring muscle (e.g., never warm up) => dcr knee extension, incr loading of forefoot, incr stress on plantar fascia
- Reduced ankle dorsiflexion
- Obesity (?)
- Lower SES (?)
- A/w systemic rheumatic disease (?)
[Plantar Fasciitis]
Pain characteristics
- Pain worse when walking/running (esp in morning/after period of inactivity)
- Pain lessens with increased activity but worse at end of the day due to prolonged weight-bearing
[Plantar Fasciitis]
Differentials of heel pain
- When to refer?
Plantar fascia rupture
- sudden onset (except for sprain)
Neurologic causes
- Paresthesia and numbness
- Nocturnal symptoms
- Radiating pain from posterior aspect of leg to heel
Infection:
- Systemic symptoms: fever, fatigue, overall aches/pains
- Recent infections
- Constant pain
Cancer/Malignancy:
- PMH or FH of cancer
- Nocturnal symptoms
- Unintentional weight loss (E.g., more than 5kg in 1 month)
Inflammatory disorder:
- PMH or FH of inflammatory disease (red flag for bursitis and fasciitis)
- PMH or FH of autoimmune diseases
- Erythema nodusum (tender red bumps)
[Frozen shoulder]
Presentation
- Unilateral (usually non-dominant side, but other side may be affected within 5y)
- Limited reaching overhead, to side, across chest, limited rotation => reduced function
- Self-limiting (but very long time, symptoms progress through 3 very long phases)
- Initial phase (2-9m): diffuse, severe disabling shoulder pain, worse at night, increasing stiffness
- Intermediate phase (4-12m): stiffness and severe loss of shoulder motion, pain gradually lessens
- Recovery phase (5-24m): gradual return of range of motion
Refer if marked loss of motion is present
[Frozen shoulder]
Prevalence and Pathophysiology
- Peak prevalence: among 50+ years old; onset <40y is rare
- May be idiopathic or secondary to shoulder injuries
- Pathophysiology not fully understood: a/w presence of DM, hyperthyroidism, dyslipidemia, prolonged immobilization
