IC 15: Approach to the Management of Soft Tissue Injuries Flashcards
What are the two types of joint pain?
Articular and non-articular
What are the accompanying features for articular joint pain?
- Swelling
- Erythematous
- Tender on palpation of joint line
- Restricted motion
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
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)
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)
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
What is the first line pharmacological treatment for acute soft tissue injuries that result in non-lower back pain?
- Topical NSAIDs
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
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
Who are more susceptible to sprains?
- Children and adolescents > adults
- Adult females > males
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
What is tendinosis?
Persistent tendinopathy (chronic)
What are the features of tendonitis?
- Local pain and dysfunction
- Inflammation
- Degeneration
What is the etiology of tendonitis?
- Overuse (repeated mechanical loading)
- Sports injury
- Inflammatory rheumatic disease
- Calcium apatite deposition (from metabolic disturbances)
What drugs can induce tendonitis?
- Fluoroquinolone antibiotics
- Statins
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
