IC 15: Approach to the Management of Soft Tissue Injuries Flashcards by Si Hui Lee

What are the two types of joint pain?

Articular and non-articular

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What are the accompanying features for articular joint pain?

Swelling
Erythematous
Tender on palpation of joint line
Restricted motion

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What are the features of periarticular joint pain?

On palpation: point of maximal tenderness not at joint line
Pain on active movement > passive movement
Pain maximal in certain lines of muscle pull

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What are the traits of soft tissue injury?

Consequence of chronic repetitive low-grade trauma/overuse
Focal and non-systemic
Self-limiting
Responds to conservative measures (supportive measures)

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Which soft tissue injury requires urgent referral?

Ligament rupture
Infection-related causes
Malignancy/metastasis (lower back pain)
Relating to underlying visceral conditions (lower back pain)

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What is non-pharm treatment for soft tissue injuries?

To do: rest, ice, compression, elevation, referral (if required)
Not to: heat, alcohol, re-injury, massage

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What is the first line pharmacological treatment for acute soft tissue injuries that result in non-lower back pain?

Topical NSAIDs

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What are the common types of soft tissue injury and which part is damaged?

Sprains: stretching ligaments
Tendonitis: inflammation of tendon
Bursitis: inflammation of bursae
Plantar fasciitis: inflammation of plantar fascia

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What are the functions the different connective tissues?

Ligament, tendon, bursae, plantar fascia

Ligament: connect bone to bone
Tendon: connect muscle to bone
Bursae: cushions tendons/muscles from adjacent bones
Plantar fascia: connect heel bone to base of toes

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Who are more susceptible to sprains?

Children and adolescents > adults
Adult females > males

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What are the different presentations for different severity of sprains and what is the treatment?

Mild stretching of ligaments: mild swelling and tenderness, able to bear weight and ambulate with minimal pain. Medical help not often sought
Incomplete tear of ligament: moderate pain, swelling, tenderness and bruising, painful weightbearing and ambulation. To protect, rest, ice, compress, elevate and pharm treatment if necessary
Complete tear of ligament: severe pain, swelling, tenderness and bruising, cannot bear weight or ambulate. Refer to ER

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What is tendinosis?

Persistent tendinopathy (chronic)

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What are the features of tendonitis?

Local pain and dysfunction
Inflammation
Degeneration

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What is the etiology of tendonitis?

Overuse (repeated mechanical loading)
Sports injury
Inflammatory rheumatic disease
Calcium apatite deposition (from metabolic disturbances)

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What drugs can induce tendonitis?

Fluoroquinolone antibiotics
Statins

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What are the common sites for tendonitis?

Shoulder: rotator cuff tendinopathy
Elbow: tennis or golfer’s elbow
Wrist
Hip
Ankle: achilles tendinopathy (athletes involved in jumping sports/running over hilly terrain)

What is the etiology of bursitis?

Trauma/injury (acute)
Crystal-induced process e.g. gouty bursitis (acute)
Infection (acute)
Overuse (chronic)
Prolonged pressure (chronic)
Inflammatory arthritis (chronic)

What is the difference between acute bursitis and chronic bursitis?

Acute bursitis: pain when joints are fully flexed
Chronic bursitis: more swelling and thickening, minimal pain

What are the commonly affected locations of bursitis?

Superficial: elbow, knee cap, posterior upper thigh region
Deep: hip, shoulder

What can be given for bursitis that is located at a deep area?

Intrabursal glucocorticoid can be given

What is the possible etiology of plantar fasciitis?

Prolonged standing/jumping/running on hard surfaces
Flat feet/high arched feet
Tight hamstring muscle
Reduced ankle dorsiflexion
Obesity
Lower SES
Associated with systemic rheumatic diseases

What is the presentation of plantar fasciitis?

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

What is frozen shoulder associated with?

Presence of DM
Hypothyroidism
Dyslipidemia
Prolonged immobilisation

What is the presentation of frozen shoulder?

Unilateral
Limited reaching overhead, to side, across chest
Limited rotation

What are the various stages of frozen shoulder?

* Initial (2-9 months): diffuse, severe disabling shoulder pain, worse at night, increasing stiffness * Intermediate (4-12 months): stiffness and severe loss of shoulder motion, pain gradually lessen * Recovery (5-24 months): gradual return of range of motion

When should frozen shoulder be referred?

Marked loss of motion is present

What is the management of frozen shoulder?

* Analgesics for pain * Range of motion exercises * Intraarticular glucocortocoid + physical therapy

How is low back pain classified according to it's duration?

* Acute < 4 weeks * Subacute 4-12 weeks * Chronic > 12 weeks

What are some differential diagnosis that should be excluded for low back pain?

* Lumbar strain * Herniated disc (spinal cord or cauda equina compression) * Osteoporotic fractures * Sciatica * Neoplasia * Infection (spinal epidural abscess) * Malignancy/metastatic cancer * Osteomyelitis

What symptoms require a referral to ER?

* Neurologic symptoms like motor weakness, loss of bowel/bladder function * Chronic glucocorticoid use * Age * Trauma * PMH of osteoporotic/traumatic * Unintended weight loss * PMH of malignancy * Fever and malaise * Recent spinal injections/epidural catheter placement * Immunocompromised * Fever * Constant pain

What is the treatment for low back pain?

* Acute and subacute low back pain: non-pharm + NSAID/SMR * Chronic back pain: non-pharm inc exercise, then NSAIDs as first line; alternatively tramadol/duloxetine

What are some counselling points for patients with low back pain?

* Engage in low-impact core strengthening exercises to improve spine stability * Use correct lifting and moving techniques * Maintain correct posture when sitting/standing * Quit smoking * Avoid stressful situations * Maintain healthy weight

What should we pay attention to for myalgia?

* Onset * Location * Associated symptoms

What is the management for myalgia?

* RICE * Topical NSAIDs (?) * Proper warm up before exercise

When is urgent referral to the emergency department required when there is myalgia?

* Infection-related especially bacterial * Medication toxicity like statin-induced rhabdomyolysis

What are the symptoms associated with statin-associated muscle symptoms?

* Proximal symmetric muscle weakness and/or weakness * Nocturnal cramping * Stiffness * Tendon pain * Fatigue and tiredness