Intro to MSK Conditions (Week 1--Pham) Flashcards
HPI for MSK complaint
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)
Physical exam for MSK complaint
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
MSK pain differential diagnosis
Joint injury
Bone injury/disease
Muscle injury or repeated strain
Ligament/tendon injury or strain
Rheumatological condition
Referred pain from nerves/vessel injury
What would make you think something is referred pain?
If all imaging and physical exam is normal and you can’t reproduce pain with motion
If skin is causing pain
Look for skin changes (redness, induration, swelling, excoriation, bruising, etc)
Pain usually reproducible with touch or pressure
If muscle is causing pain
Pain associated with joint movement and reproducible with palpation
If spasm present, pain is slightly relieved with gentle traction and worse with resisted contraction
If tendon/ligament is causing pain
Pain associated with joint movement and reproducible with palpation
Pain is worse with stretching and resisted contraction
If joint is causing pain
Pain associated with range of motion
Joint effusion and/or deformity may be present
Pain reproducible with palpation if joint accessible to palpation
If bone is causing pain
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
If nerve/vessels are causing pain
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
Imaging studies for work-up/confirmation
Help confirm diagnosis, but need clinical correlation to establish diagnosis
Abnormal findings on imaging studies may or may not correlate with patient’s symptoms
Laboratory for work-up/confirmation
Useful to look for signs of infection and to screen for rheumatological or genetic disorders
Usually not useful in MSK disorders
Electrodiagnosis for work-up/confirmation
Electromyography (EMG): needle examination of muscle (painful; specific but not sensitive)
Nerve conduction studies: nerve stimulation with electrical pulse (very sensitive)
Injection for work-up/confirmation
Last resort to help determine pain generator
Lidocaine injection to painful area to see if pain can be abolished
Clinical uses of electromyography (EMG)
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
Clinical uses of nerve conduction studies
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)
PRICE principles for managing many MSK conditions
Protection (brace/splint to prevent further injury)
Rest (allow tissue to heal)
Ice (reduce pain and local inflammation)
Compression (reduce swelling)
Elevation (reduce edema)
Medications for MSK injuries
NSAIDs are most common
Opioids used for severe pain but are addictive
When might you need surgery for MSK injury?
If neurovascular compromise
Surgery to restore alignment, stability, correct tendon tear, decompressed nerves, etc
Heat vs. ice
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
Long term management for chronic or recurring injury
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
How do muscle relaxants work?
In the brain (centrally acting), not at the level of the muscle!
Degeneration
Wear and tear that comes with age or injuries
Overuse syndrome
AKA cumulative trauma or repetitive strain over time
Joint/tendon gets injured when natural healing lags behind trauma
Deconditioning
Decreased ability to perform at normal level
Brought on by inactivity, inadequate training
Overexertion
Occurs when workload performed exceeds body’s ability to handle stress
Can result in fracture, sprain (tear of ligaments), strain (overstretched muscles/tendons)
Inflammatory vs. non-inflammatory arthritis
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
Joint stability
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)
Long term joint instability
Increase wear and tear on joing
Produce secondary pain from muscle overexertion
How can torn ligament cause pain?
Torn ligament –> excessive joint movement/wear and tear –> muscles activated in attempt to stabilize joint –> muscle spasm due to constant activation –> pain
The domino effect
Disc herniation –> nerve root impingement/radiculopathy –> leg pain –> limping/abnormal gait –> sacroiliac joint dysfunction –> muscle spasm –> decreased activity –> muscle deconditioning
What does it mean if an EMG shows active fibers when muscle is at rest?
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
