Intro to MSK Conditions (Week 1--Pham)

Question 1

HPI for MSK complaint

Answer 1

Onset/Duration (gradual, sudden, intermittant, constant, etc)

Inciting event (injury, procedures, stress, etc)

Location

Characteristics (sharp, dull, aching, etc)

Intensity (1-10)

Alleviating/aggravating factors (positions, activities, temperatures, medications, etc)

Associated factors (swelling, redness, bone deformity, weight loss, nausea, weakness, numbness, bleeding, etc)

Question 2

Physical exam for MSK complaint

Answer 2

Inspection (asymmetry, atrophy, deformity, skin changes, etc)

Range of motion (full, limited): active, passive, assisted

Palpation (tenderness, swelling, spasm, etc)

Special testing (Spurling’s, Straight Leg Raise)

Neurological testing

Question 3

MSK pain differential diagnosis

Answer 3

Joint injury

Bone injury/disease

Muscle injury or repeated strain

Ligament/tendon injury or strain

Rheumatological condition

Referred pain from nerves/vessel injury

Question 4

What would make you think something is referred pain?

Answer 4

If all imaging and physical exam is normal and you can’t reproduce pain with motion

Question 5

If skin is causing pain

Answer 5

Look for skin changes (redness, induration, swelling, excoriation, bruising, etc)

Pain usually reproducible with touch or pressure

Question 6

If muscle is causing pain

Answer 6

Pain associated with joint movement and reproducible with palpation

If spasm present, pain is slightly relieved with gentle traction and worse with resisted contraction

Question 7

If tendon/ligament is causing pain

Answer 7

Pain associated with joint movement and reproducible with palpation

Pain is worse with stretching and resisted contraction

Question 8

If joint is causing pain

Answer 8

Pain associated with range of motion

Joint effusion and/or deformity may be present

Pain reproducible with palpation if joint accessible to palpation

Question 9

If bone is causing pain

Answer 9

Inflammation or trauma to periosteum produces pain

Bone pain usually vague

Pain from fracture is less with immobility

Expansion of periosteum (from injection for cancer) is usually constant and poorly localized

Question 10

If nerve/vessels are causing pain

Answer 10

Referred pain and neuropathic pain are poorly localized, vague and not reproducible with local palpation of muscles and soft tissue

Pain from nerve compression worse when compression reproduced with special testing (ie Spurling’s test and Tinnel’s test) or when nerve is stretched

Ischemic pain is worse with compression of vasculature and with activities during which the muscles’ oxygen demands exceed oxygen supply

Question 11

Imaging studies for work-up/confirmation

Answer 11

Help confirm diagnosis, but need clinical correlation to establish diagnosis

Abnormal findings on imaging studies may or may not correlate with patient’s symptoms

Question 12

Laboratory for work-up/confirmation

Answer 12

Useful to look for signs of infection and to screen for rheumatological or genetic disorders

Usually not useful in MSK disorders

Question 13

Electrodiagnosis for work-up/confirmation

Answer 13

Electromyography (EMG): needle examination of muscle (painful; specific but not sensitive)

Nerve conduction studies: nerve stimulation with electrical pulse (very sensitive)

Question 14

Injection for work-up/confirmation

Answer 14

Last resort to help determine pain generator

Lidocaine injection to painful area to see if pain can be abolished

Question 15

Clinical uses of electromyography (EMG)

Answer 15

Determine presence of nerve damage (lumbar or cervical radiculopathy, peripheral nerve compression)

Determine muscle pathology (myopathy)

Determine neuromuscular disorder (Duchenne’s muscular dystrophy)

Tells you if the problem is an ACTIVE problem versus an old problem

Question 16

Clinical uses of nerve conduction studies

Answer 16

Determine presence of nerve entrapment/compression

Determine degree and extent of damage (impt because management of diseases different)

(to do this you deliver a shock to nerve and pick up signal a measured distance away to determine how long it takes shock to travel)

Question 17

PRICE principles for managing many MSK conditions

Answer 17

Protection (brace/splint to prevent further injury)

Rest (allow tissue to heal)

Ice (reduce pain and local inflammation)

Compression (reduce swelling)

Elevation (reduce edema)

Question 18

Medications for MSK injuries

Answer 18

NSAIDs are most common

Opioids used for severe pain but are addictive

Question 19

When might you need surgery for MSK injury?

Answer 19

If neurovascular compromise

Surgery to restore alignment, stability, correct tendon tear, decompressed nerves, etc

Question 20

Heat vs. ice

Answer 20

Heat improves blood flow to produce muscles relaxation and reduce joint stiffness (don’t use in acute injuries)

Ice reduces inflammation after activities or injuries

Use heat in the morning when you haven’t been using your muscles for a while but use ice at night when you’ve been working your muscles and inflamming them and need to reduce inflammation

Question 21

Long term management for chronic or recurring injury

Answer 21

Heat

Ice

Exercises (stretching, strengthening, aerobic) to restore normal muscle length, improve strength and overall conditioning

Injections usually done with corticosteroid to reduce inflammation

Surgery to restore alignment, stability, correct tendon tear, decompressed nerves, etc

Question 22

How do muscle relaxants work?

Answer 22

In the brain (centrally acting), not at the level of the muscle!

Question 23

Degeneration

Answer 23

Wear and tear that comes with age or injuries

Question 24

Overuse syndrome

Answer 24

AKA cumulative trauma or repetitive strain over time

Joint/tendon gets injured when natural healing lags behind trauma

Question 25

Deconditioning

Answer 25

Decreased ability to perform at normal level

Brought on by inactivity, inadequate training

Question 26

Overexertion

Answer 26

Occurs when workload performed exceeds body’s ability to handle stress

Can result in fracture, sprain (tear of ligaments), strain (overstretched muscles/tendons)

Question 27

Inflammatory vs. non-inflammatory arthritis

Answer 27

Pathology for non-inflammatory (degenerative arthritis) is primarily due to wear and tear, not to immune factors

However, with overexertion, injuries, repetitive stress, joint can become inflamed in response

Question 28

Joint stability

Answer 28

Joint needs to be stable while moving

Dependent on: type of joine (hinge, socket, etc), ligaments (help align, guide, restrict movements), muscles and tendons (give flexibility, coordination, control)

Question 29

Long term joint instability

Answer 29

Increase wear and tear on joing

Produce secondary pain from muscle overexertion

Question 30

How can torn ligament cause pain?

Answer 30

Torn ligament –> excessive joint movement/wear and tear –> muscles activated in attempt to stabilize joint –> muscle spasm due to constant activation –> pain

Question 31

The domino effect

Answer 31

Disc herniation –> nerve root impingement/radiculopathy –> leg pain –> limping/abnormal gait –> sacroiliac joint dysfunction –> muscle spasm –> decreased activity –> muscle deconditioning

Question 32

What does it mean if an EMG shows active fibers when muscle is at rest?

Answer 32

It is abnormal if active fibers when muscle at rest (denervation means nerves not telling muscles what to do so muscles acting on their own)

Normal would be no activity (flat line) when muscle at rest