ic15 soft tissue injury Flashcards
TYPES OF joint pain
articular and non-articular
- articular is the joint itself
non-articular includes:
- referred visceral pain (eg MI pain radiate from chest)
- tissue pain
- neuropathic pain (eg prolapsed intervetebral disc)
- periarticular pain (soft tissue: relating to ligament, muscles, tendons)
- bone pain (fractures, dislocation)
significant characteristics of periarticular joint pain?
on palpitation, point of maximal tenderness is typically not at the joint line
pain usually worse on active movement rather than passive movement
pain maximal in certain lines of muscle pull (worse pain with certain kinds of movements).
[general] when to refer
fractures
ligament rupture
infection
malignancy/metastases
underlying visceral causes (eg lower back pain referred form other internal organs)
characteristics of soft tissue injuries (non lower back)?
consequence of chronic repetitive low grade trauma or overuse
focal and non systemic
self limiting
responds to conservative measures
non phx for non lower back pain
RICER: rest, ice, compress, elevate, referral.
- Rest = stop activity.
- Ice = ice cubes, cold spray/wrap to the injured area and applied for not more than 15minutes in the first hour. DO NOT APPLY DIRECTLY TO THE SKIN. Allow to rewarm before reapplying again if remains painful. This will help to relieve pain and limit swelling.
- Compress = elastic stocking to the limb (should be of double thickness around injury site and far enough below and above to avoid swelling and pooling of tissue fluid around the bandage edges). This will help to limit swelling.
- Elevate = limit swelling.
- Referral = always refer due to risk of underlying fractures or dislocation.
what to avoid for non phx non lower back pain
Avoid HARM: heat, alcohol, re-injury, massage.
what are the common types of non-lower back soft tissue injuries
1) plantar fasciitis
2) sprains (stretching, partial rupture, complete rupture of the ligament; bone to bone)
3) bursitis: fluid-filled sacs around joints that cushion tendons
4) tendonitis (tendon = muscle to bone connective tissue)
phx treatment for non-lower back soft tissue injuries?
1) topical nsaid
2) po nsaid
3) po paracetamol
do not advise use of opioids for soft tissue injuries
what is the mechanism for lateral ankle sprains
inversion of foot (inward)
usually sustained during sport
sudden onset of pain and swelling
more likely in children/adolescents > adults, and adult females > males
grade 1 sprain description?
grade 1:
- mild stretching of ligament with microscopic tears
- mild swelling and tenderness
- able to bear weight and ambulate w minimal pain
- usually will not require medical help…
grade 2 sprain description
grade 2:
- incomplete ligament tear
- moderate pain, swelling, tenderness, ecchymoiss (bruising)
- painful weightbearing and ambulation
some mild to moderate joint instability, restriction in range of motion and function
management of grade 2 sprains
RICER
consider pharmacotherapy if necessary…
grade 3 sprain description
complete tear of the ligament
severe pain, swelling, tenderness, ecchymosis
cannot bear weight or ambulate
(significant instability, loss of motion & function)
management of grade 3 sprain
refer to a&e…
tendonitis features
local pain and dysfunction on active use (unlikely to be painful on passive movement)
inflammation (unlikely to have visible swelling)
degeneration
what is tendinosis
persistent tendinopathy for at least 3 months…
REFER if pain for several days to weeks
common sites for tendonitis
1) shoulder: rotator cuff (supraspinatus); bicipital
2) elbow: lateral and medial OR tennis or golfer elbow
3) wrist: flexor carpi radialis and ulnaris
4) hip (lateral): gluteus
5) ankle: achilles
etiology of tendonitis
NO NEED TO REFER
overuse (repeated mechanical loading)
sports injury
TO REFER
inflammatory rheumatic disease
calcium apatite deposition
drug induced: fluoroquinolones and statins…
when to refer for tendonitis
1) when pain persists for days to weeks (possibly tendinosis)
2) pain associated with calcium apatite deposition, drug-induced (FQ, statins), inflammatory rheumatic disease.
mechanism of bursitis
inflammation of bursa
pain occurs when motion compresses adjacent bursa to the point where intra-bursal pressure increases
etiology of acute bursitis
1) trauma or injury
2) crystal-induced processes (eg gouty bursitis)
3) infection (septic bursitis)
etiology of chronic bursitis
overuse
prolonged pressure (kneeling or leaning)
inflammatory arthritis in RA/spondyloarthritis
what are the more significant characteristics of acute bursitis
active and passive pain
what are the more significant characteristics of chronic bursitis
more swelling and thickening
minimal pain
secondary changes of contracture and muscle atrophy relating to immobility
common sites of bursitis
superficial
- elbow (olecranon),
- knee cap (prepatellar),
- ishcial region = posterior upper thigh region (between glutes and ischial tuberosity)
DEEP
- hip
- shoulder
when to refer for bursitis?
deep bursitis = refer and get proper assessment, might require intra-bursal GC management
if acute pain = refer
plantar fasciitis etiology
heel pain; younger peak if runner
prolonged standing/jumping/running on hard surfaces
flat feet or high arched feet
tight hamstring muscle = decreased knee extension = increase loading of forefoot = increase stress on plantar fascia
reduced ankle dorsiflexion = associated w poor calf muscles? ankle injury?
obesity?
presentation for plantar fasciitis
pain worse when walking or running ESP in the morning or after period of inactivity
pain lessens with increased activity but worse at end of the day with prolonged weight bearing.
when to refer for heel or sole pain
1) paresthesia and numbness = nerve entrapment or compression syndrome?
2) nocturnal symptoms (and alcohol abuse, diffuse pain, PMH DM) = neuropathic pain?
3) radiating pain from posterior leg to heel = S1 radiculopathy?
4) trauma (and overuse) = calcaneal stress fracture
5) fever or constant pain = osteomyelitis?
6) sudden onset (with visible swelling & ecchymosis) = rupture or plantar fascia?
7) history of inflammatory disease = RA, spondyloarthritis
8) erythema nodosum = sarcoidosis
firm, solid, deep nodules or plaques ; painful on palpation
presentation of adhesive capsulitis
unilateral (typically non-dominant side)
LIMITED ROTATION: reaching over overhead, to side, across chest
- reduced function
SELF LIMITING
three phases of adhesive capsulitis
initial (2-9 months): diffuse, severe disabling shoulder pain, worse at night, increasing stiffness
intermediate (4-12 months): stiffness, severe loss of shoulder motion, pain gradually lessens
recovery (5-24 months): gradual return of range of motion
management of adhesive capsulitis
SELF-LIMITING
analgesics: paracetamol, nsaid, weak opioids
range of motion exercises = abduction, external rotation, internal rotation exercises.
last line: refer = intra-articular glucocorticoid + physical therapy
WHEN TO REFER for adhesive capsulitis
when there is marked loss of motion
lower back pain length
most cases typically self limiting strain of appx 10-14 day
differentials of lower back pain WHEN TO REFER?
1) neurologic symptoms: motor weakness, fall, gait instabiliy, loss of bowel or bladder function, numbness
= spinal cord compression? due to herniated disc?
2) chronic GC use, age, trauma, PMH OP or traumatic fracture = osteoporotic fractures?
3) unintended weight loss, PMH malignancy = malignancy or cancer?
4) fever, malaise, recent spinal injection or epidural catheter placement, immunocompromised, hemodialysis, recent infection = SPINAL EPIDURAL ABCESS?
5) fever or constant pain = osteomyelitis
phx management of lower back pain
chronic: (>12weeks)
- nsaids 1st line > tramdol/duloxetine
acute (4-12 wks) or subacute (< 4wk)
- nsaids
- orphenadrine
generally if due to muscle strain = should be self limiting episode (about 10-14 days)
counselling for lower back pain
1) engage in low impact core strengthening exercises to improve stability E.G., swimming, bicycling, brisk walking.
2) Use correct lifting and moving techniques e.g., avoid bending back when lifting heavy objects.
3) Maintain correct posture when sitting/standing.
4) Quit smoking (risk factor for atherosclerosis).
5) Avoid stressful situations (can cause muscle tension).
6) Maintain healthy weight (less strain on the lower back).
types of myalgia
diffuse and focal
if diffuse.= refer
myalgia management
usually self limiting if related to exercise or overuse
1) RICE
2) topical nsaids
PREVENTION via proper warm up before exercise
differential diagnosis for diffuse myalgia
infection
- esp bacterial eg endocarditis and impending sepsis = diffuse myalgia + fever, chills, arthralgia, fatigue, back pain
med toxicity
- rhabdomyolysis = muscle pain + weakness, red brown tea coloured urine
- may also be associated with ciprofloxacin, bisphosphonates, aromatase inhibitors
when to send to A&E for SAMS
when rhabdomyolysis
- increase in SCr ≥0.5 mg/dL
description of SAMS + management
usually proximal symmetric muscle weakness and/or weakenss of hips, thighs, calf (larger muscles)
- may also have nocturnal cramping, stiffness, tendon pain, fatigue and tiredness
DISCONTINUE if sx are bothersome (should resolve in days to weeks) OR if CK > 10xULN (with or without unexplained muscle sx)
- consider switching to pravastatin, fluvastatin, rosuvastatin (less SE), alt day dosing, lower dosing…
- advise drinking large qty of fluids to facilitate renal excretion of myoglobin to prevent renal failure.
anarex dosing and counselling points (moa, indications ,se, caution, c/I, ddi)
paracetamol 450mg
orphenadrine 35 mg
total 485 mg
2 tab TDS
may cause anticholinergic side effects such as urine retention, dry mouth, constipation and dry eyes
may also cause drowsiness
avoid if patient has hx of BPH, CAG/glaucoma
avoid if DDI (meds): anticholinergic, cns depressants, antiparkinsonian (NMDA receptor antagonism, NE & dopamine reuptake inhibitor, sodium channel blocker)
tramadol
include dosing and counselling points (moa, indications ,se, caution, c/I, ddi)
acugesic 50mg q6 max 400mg/day
μ-receptor agonist → suppresses GABA interneurons in PAG → prevents nociceptive signals from periphery to thalamus.
Drowsiness and/or dizziness, sedation → avoid driving/operating heavy machinery.
Nausea → take with or after food.
Constipation → Drink more water if your doctor did not tell you to restrict fluid intake and take more food that contains fibre.
Depression
Dry mouth
Headache
Risk of addition and abuse; when overdosed can cause respiratory depression
Caution:
Pregnancy (risk to mother and fetus)
Hepatic/renal impairment.
Elderly >65yo (fall risk).
Personal/family hx of substance use disorder.
Neurologic disease (epilepsy, psychosis, sleep-related disorders, etc).
Respiratory disease (affects respiratory centre).
Orthostatic hypotension/syncope.
CI:
Respiratory depression, acute/severe bronchial asthma
Hypersensitivity/allergy (incl to other opioids).
DDI:
CNS depressants
Concomitant MAOi ±14 days → serotonin syndrome → agitation, restlessness, mental changes (e.g. hallucination), heavy sweating/shivering, tachycardia, irregular heartbeat, rigid or twitching muscles.
