IC15 Management of soft tissue injuries

Question 1

What are the 2 types of joint pain?

Answer 1

1. Articular
2. Non-articular

Articular pain - pain from the joint
Articular pain is most painful at the joint line.

Non-articular pain - pain that is due to musculoskeletal
Pain is not at the joint. The pain on active movement and not passive movement.

Question 2

A type of non-articular pain is periarticular pain.

Periarticular sources of pain originate in structures surrounding the joint.

What are these structures?

Answer 2

1. Ligaments
2. Tendons
3. Muscles

Question 3

What are the characteristics of soft tissue injuries?

Answer 3

1. A consequence of chronic overuse / repetitive low-grade trauma
2. Focal & non-systemic
3. Self-limiting
4. Responds to conservative measures / non-pharmacotherapy

Question 4

What are some soft tissue injuries that require urgent referrals to the emergency department?

Answer 4

1. Ligament rupture
2. Infection-related causes
3. Malignancy / metastasis
4. Associated w lower back pain

Question 5

What are the 3 main treatment goals for soft tissue disorders?

Answer 5

1. Reduce pain
2. Regain function
3. Prevent future injury

Question 6

Another type of treatment goal goes by the acronym RICERHARM.

What does RICERHARM represent?

Answer 6

R - rest
I - ice
C - compression
E - elevate
R - referral
H - no heat
A - no alcohol
R - no reinjury
M - no massage

Question 7

If patient were to use ice for their injury, how should they go about doing it?

Answer 7

Patient should not put ice directly on the skin.

Wrap the ice around some cloth or plastic.

Ice the area for 10-15 mins. If it is still very painful, ice the area again.

Question 8

What are the top 3 agents to use for pain relief in non-lower back pain?

Answer 8

For acute non-lower back pain:
1. PO paracetamol (not as effective)
2. Topical NSAIDs
3. Oral NSAIDs

Question 9

What are the pros and cons of topical and oral NSAIDs?

Answer 9

Topical NSAIDs:
- (Pros) Fewer side effects as compared to oral NSAIDs
- (Cons) Unable to reach deeper regions

Oral NSAIDs:
- (Pros) Able to reach deeper regions - e.g hip injury.
- (Cons) Has more side effects

Question 10

What are the 4 common types of soft tissue injury that we learnt in this IC?

Answer 10

1. Sprain
2. Tendonitis
3. Bursitis
4. Plantar fasciitis

Question 11

What are the definition of the 4 soft tissue injuries?

1. Sprain
2. Tendonitis
3. Bursitis
4. Plantar fasciitis

Answer 11

1. Sprain - 3 types of sprains –> (1)stretching, (2)partial rupture, (3)complete rupture of ligament (bone-to-bone connective tissue)
2. Tendonitis - inflammation of tendonitis (muscle-to-bone connective tissue)
3. Bursitis - inflammation of bursae (fluid filled sacs around joints that cushion tendons / muscles from adjacent bones)
4. Plantar fasciitis - inflammation of plantar fascia (fibrous attachment connecting heel bone to base of toes)

Question 12

What is the most common type of sprain?

Answer 12

Lateral ankle sprain.
- Can be inversion or eversion of foot

Sprain is an injury involving ligaments.

Question 13

What are 2 risk factors of sprain?

Answer 13

1. Adult females > males
2. Children & adolescents > adults

Question 14

There are 3 grades of sprains - Grade I, Grade II, Grade III.

What is the severity of the injury that each grade represents?

Answer 14

Grade 1 - mild stretching of the ligament

Grade 2 - Incomplete tear of the ligament

Grade 3 - Complete tear of the ligament

Question 15

What is the main characteristic of a Grade 3 tear?

Answer 15

Cannot bear body weight or move

Question 16

What is tendonitis and what causes it?

Answer 16

Tendonitis - inflammation of the tendon.

It is often caused by:
- Overuse of the tendon (most common)
- Injury
- Drug induced (e.g fluoroquinolones, statins)

Question 17

Where are the common sites for tendonitis?

Answer 17

1. Shoulders
2. Elbows
3. Ankles

Question 18

What is the best treatment for tendonitis?

Answer 18

Rest.

Other treatment can be topical or oral anti-inflammatory NSAIDs.

Question 19

What is bursitis and what causes it?

Answer 19

Bursitis - the inflammation of the bursa

Causes of acute bursitis are:
- Trauma / injury
- Gout
- Infection

Causes of chronic bursitis:
- Overuse
- Prolonged pressure
- Inflammatory arthritis (e.g rheumatoid arthritis)

Question 20

What are telltale signs of bursitis?

Answer 20

Pain and pressure arises when joints are bent, resulting in compression of the bursae.

Question 21

What is plantar fasciitis and what causes it?

Answer 21

Plantar fasciitis - inflammation of plantar fascia

Causes of plantar fasciitis:
- Prolonged standing, jumping, running on hard surfaces
- Flat feet / high arched feet

Question 22

What are the signs & symptoms of plantar fasciitis?

Answer 22

1. Pain worsens when walking / running
2. Pain lessens w increased activity, but worsens at the end of the day

Question 23

What are the red flags of plantar fasciitis?

Answer 23

1. Numbness & pins and needles
2. Nocturnal pain
3. Trauma
4. Fever
5. Constant pain
6. Sudden onset
7. History of inflammatory condition
8. Erythema

Question 24

What is adhesive capsulitis (aka frozen shoulder)?

Answer 24

Adhesive capsulitis - an inflammatory condition characterized by shoulder stiffness, pain, and significant loss of passive range of motion.

Question 25

What are the risk factors of adhesive capsulitis?

Answer 25

1. 50+ years old 2. DM 3. Hypothyroidism 4. Dyslipidaemia 5. Prolonged immobilization

Question 26

What are the S&S of adhesive capsulitis?

Answer 26

1. Unilateral 2. Reduced function of the shoulders (e.g cannot put on shirt) 3. Self-limiting - Worse at night - Stiffness & severe loss of shoulder motion

Question 27

What are the red flags of adhesive capsulitis?

Answer 27

1. Systemic symptoms of infection 2. Malignancy 3. Associated chronic illness

Question 28

What is the treatment for adhesive capsulitis?

Answer 28

1. Paracetamol / NSAIDs / Weak opioids 2. Range of motion exercises

Question 29

Majority of lower back pain are non-specific and self-limiting strains. What are the red flags to look for in lower back pain?

Answer 29

Red flags of lower back pain are: - Chronic pain - Worse at night - Unintended weight loss - History of previous malignancy

Question 30

Which causes of lower back pain requires referral?

Answer 30

1. Herniated disc 2. Osteoporotic fractures 3. Malignancy / metastatic cancer 4. Infection

Question 31

What are the treatments for: - Acute & subacute lower back pain? - Chronic lower back pain?

Answer 31

Acute & subacute lower back pain: - Heat therapy + NSAIDs Chronic lower back pain: - Exercise + NSAIDs

Question 32

What are some counselling points for pt w lower back pain?

Answer 32

1. Do low-impact core strengthening exercises 2. Use correct lifting & moving techniques 3. Maintain correct posture when sitting/standing 4. Quit smoking 5. Reduce stress 6. Maintain healthy weight

Question 33

What are some S&S of Statin Associated Muscle Symptoms (SAMS)?

Answer 33

1. Onset can occur at anytime 2. Muscles weakness 3. Nocturnal cramping, stiffness, tendon pain, fatigue & tiredness

Question 34

When would you consider discontinuing statins in SAMS?

Answer 34

1. When Sx becomes intolerable 2. CK > 10x ULN

Question 35

Summary on when you need to refer for the following conditions: 1. Sprains 2. Tendonitis 3. Bursitis 4. Plantar fasciitis 5. Adhesive capsulitis

Answer 35

1. Sprains - Cannot bear weight - Loss of motion/function - Significant instability 2. Tendonitis - Pain for days or weeks 3. Bursitis - Acute onset - Severe pain - Prior trauma - PMH of inflammatory conditions 4. Plantar fasciitis - Acute onset - Severe pain - Prior trauma - Fever - PMH of inflammatory conditions 5. Adhesive capsulitis - decrease in range of motion - Fever - PMH of malignancy - Trauma / history of fractures - Neurological sx (e.g pins & needles, muscle weakness, loss of bowel & urine function)