Management In FM: Common MSK Problems Flashcards
Common MSK problems in Primary care
- Acute injury
- Ankle / Knee sprain
- Muscle strain - Overuse syndrome / Repetitive strain related to ADL / Work / Postural problem
- Chronic muscle / joint strain due to overuse / posture problems
- Frozen shoulder / Rotator cuff syndrome
- Tennis elbow
- De Quervain’s tenosynovitis / Carpal tunnel syndrome / Trigger finger
- Plantar fasciitis - Degenerative
- OA (knee > hip > hand)
- Cervical / Lumbar spondylosis (i.e. Neck / Low back pain)
- +/- Radiculopathy (Cervical / Lumbar) (e.g. sciatica, neck compression) - *Infective —> Send to hospital
- Skin infection
- Septic arthritis
- Osteomyelitis - *Inflammatory
- Gout»_space; RA - *Neoplastic (rarely, presented with bone pain / mass) —> Send to specialist
*: Must rule out, Red flag
MUST KNOW (Top 30):
- OA
- Low back pain
- Gout
Principles of management
Patient may present at different stages of any of the conditions:
- Different concerns
- Different functional requirement (need to ask in history)
—> Different intervention needed
Considerations:
1. Time of presentation
2. What stage
3. 1st line vs 2nd line treatment
4. ICE of patient
MUST consider:
- Feasibility
- Motivation
- Adherence
- Empowerment
- Always review, step-up approach
RAPRIOP:
R: Reassurance, address bio-psycho-social concerns to relieve anxiety / stress
A: Advice on activity modification to limit extent of injury / disease (acute), promote healing (subacute), prevent deterioration / complications
P: Drug +/- Exercise to reduce symptoms + improve functions, sick leave for rest / time for other interventions
R: Orthopaedic surgeon for operative intervention, PT / OT / Allied health team to reduce symptoms + improve function
I: Confirm Dx, rule out fracture / serious pathology if necessary
O: Monitor progress always
P: Prevent future episodes / injury
Management algorithm:
1. Refer to AED / Specialist for urgent / early assessment / management?
2. Options of treatment in Primary care
- No treatment needed —> Reassurance / Watchful waiting
- Non-operative
—> Rest
—> Drugs
—> Physical modalities
—> Support / Bracing
—> Injection
—> Exercise / Manipulation
—> Activity modification
—> Rehabilitation
- Operative
Acute injury
3 recovery phases for muscle / tendon / ligament (X bone since will refer to specialist):
1. Inflammatory phase (week 0-1)
- Acute onset of pain
- Swelling
- Red
- Increased temperature
- Loss of function
—> Treatment goal: Control of inflammation
—> Rest, Ice, Pain relief, Gentle exercise to improve circulation (for pain relief)
- Proliferative phase (week <1-3)
- Swelling gradually subsides
- Pain from immature scar
—> Treatment goal: Promote formation + protection of immature scar
—> Must start gentle therapeutic exercise to avoid scarring, contracture, atrophy
—> Avoid complete rest / excessive strain - Maturation / Remodeling phase (> week 3)
- Muscle: 1-2 weeks
- Ligament / tendon: 4 months
- Reduced pain, may become stiff / contracted, muscle atrophy (if nothing done by 3 weeks)
—> Treatment goal: Improve strength + flexibility of scar, promote function
—> Therapeutic exercises + rehabilitation according to functional requirement
—> Prevent complications e.g. weakness, chronic pain, fibrosis
Overuse syndromes / Repetitive strain
Presents with Insidious onset of pain»_space;> Redness / Swelling / Warmth
- Differentiate from Acute injury
2 main factors for muscle / tendon:
1. Repetitive microtrauma
- body part cannot adapt to cumulative stress from repetitively applied force (esp. shear / compression) —> weakness
- Failure to repair
- diminished / absent inflammation and degeneration of fibrocytes + matrix component of scar —> suboptimal circulation
Predisposing / Perpetuating factors of Overuse injury:
Intrinsic:
- Aging
- DM
- Vascular insufficiency
- Post-menopausal
- Malalignment of joints
- Muscle imbalance (i.e. weakness)
- Poor flexibility
Extrinsic:
- Improper training technique
- Equipment
- Unfavourable environment
Treatment goal:
1. Limit further injury
2. Improve muscle / tendon strength + flexibility
3. Improve circulation to promote healing
Management:
1. Activity modification (Relative rest)
2. Support / Brace
3. Therapeutic exercise + Rehabilitation
4. **Physical modalities (e.g. Ice)
5. Injection (steroid: may not work since already not much inflammation in overuse syndromes)
Degenerative joint disorders
- Degeneration + inflammation from biochemical breakdown of articular cartilage + subchondral bone + synovium
- Irreversible + Progressive
Presents with:
- Chronic / Wax and wane deep achy joint pain exacerbated by extensive use
- Crepitus
- Reduced ROM / Stiffness
- Bony enlargement / deformity
- + Minimal / Occasional flare of inflammation
Treatment goals:
NOT cure but palliative / symptomatic relief / protect joint
1. Minimise progression through modifying perpetuating factors (e.g. obesity)
2. Maximise function + QoL
3. Prevent complication (e.g. fall / injury) through muscle strengthening
Management:
1. Symptomatic relief
2. Activity modification
3. Rehabilitation / Functional training
4 Operation (reserved for patient could not carry out ADL)
Common presentations of MSK problems
- Pain
- Weakness (∵ pain is inhibitory)
- Loss of sensation (∵ pain is inhibitory)
- Stiffness / Excessive ROM (seldom a primary symptom)
- Swelling / Tumour
- Deformity
- Loss of function
Weakness / Loss of sensation alone =/= Pain with weakness / loss of sensation (in this case these are associated symptoms)
- 痺 =/= 痺痛
Assessment of MSK problem
- Determine diagnosis
- Injury vs Overuse vs Degenerative
- Mechanism of injury / Precipitating factors
- Previous treatment + response —> Determine need to refer to AED / Specialist - Severity
-
Recovery stage
- Inflammatory phase —> Rest
- Maturation phase —> Mobilise + get back to shape - Presence of complications (i.e. Biological problems)
- ICE
-
4Ps (Predisposing, Precipitating, Perpetuating, Protective factors)
- Prevent recurrence -
Effect on ADL, Psychological effects —> Bio-psycho-social problems —> Intervention required during rehabilitation course (i.e. back to normal function)
- family, relationships
- work, income
- sexuality
- acute: anxiety / stress
- chronic: depression
- sleep
- behavioural
Yellow flags
- Older age
- More intense pain
- Longer duration of pain
- More days of reduced activity (passive role of recovery)
- Patient believes pain is likely to persist
- Patient reports feeling depressed
- Compensable (e.g. on CSSA, injury compensation, social allowance, financial support)
- More yellow flags —> Worse the outcome
- Require multi-disciplinary approach
Rehabilitation
- Most patients with MSK problems are unlikely to recover fully after 1 visit
- Rehabilitation plan should be planned according to:
1. Underlying pathology
2. Stage of recovery
3. Pre-morbid functional requirement - Aim to prepare the patient to resume normal pre-injury function as much / quick as possible
- Should include follow aspects:
1. Pain free state
2. Achieving + maintaining normal ROM of involved joint + Flexibility of muscles around this joint
3. Strengthen muscles around site
4. Maximise power + endurance
5. Restore balance, proprioception, coordination, agility, speed
6. Return to normal function / sports / occupation
Rehabilitation goal:
Acute:
- Pain control
- Protect from further damage
- Reduce inflammation / Improve circulation
- Maintain / Improve ROM / muscle flexibility
Intermediate:
- Achieve normal ROM / posture / alignment
- Improve muscle flexibility + strength
- Improve function e.g. walking, sitting standing tolerance
Long-term:
- Normal ROM / strength
- Improve endurance, power, balance, coordination
- Restore normal function, return to work / sports
- Prevent further injury
MUST consider:
- Feasibility
- Motivation
- Adherence
- Empowerment
- Always review, step-up approach
Prescription tool box
- Pain relief
- Pharmacotherapy
- Exercise
- Physical modalities (Ice vs Heat) (PT)
- Orthotic (P+O (Prosthetic + Orthotic)) - Rehabilitation
- Exercise
- Walking aids
- PT / OT - Social needs
- Money (support for IOD / RTA)
- Sick leave
- Medical reports (for IOD / RTA)
Ice vs Heat
Ice:
Indications:
- Widely used in acute phase of soft tissue injury (first 48 hours) / inflammatory condition
- Reduce recovery time
- Little evidence on clinical outcomes improvement (improve symptoms but not function)
Effects:
- Diminution of cellular metabolic activity and amount of inflammatory agents released into the area
- Decrease pain and swelling
Application:
- Melting ice water / frozen gel pad applied through a wet towel for repeated periods of 10 mins (NOT prolonged ∵ disrupt circulation to that area)
Heat:
Indications:
- Later stage of acute injuries (NOT in acute phase ∵ worsen inflammation)
- Chronic overuse injuries / biomechanical stress (∵ poor circulation)
- Chronic inflammation (e.g. RA) / arthritis
Effects:
- Increase blood flow to area to promote healing
- Reduce pain, stiffness and muscle spasm
Application:
- Wrap heat pack in a dry towel (wet may cause burn) and applying it over the injured site for 15-20 mins
- For deep tissue heating: USG, shockwave (衝擊波), infrared (by PT)
Exercise
- Improve CVS + muscle fitness
- Improve carbohydrate metabolism
- Prevent future injury / fall
- Improve circulation (∵ muscle contraction improve lymphatic drainage + venous return), promote healing of injured tissues
- Reduce pain (∵ circulation carry away cytokine, prostaglandin)
- Improve / Maintain flexibility + Reduce stiffness / contracture
- Improve muscle strength, endurance, power
Exercise prescription:
- Specific plan of fitness-related activities designed for a specified purpose
1. Type of exercise / activity (e.g. walking, swimming, cycling)
2. Intensity / Specific workloads (e.g. watts, walking speed, target heart rate (THR), range, estimated rate of perceived exertion (RPE))
3. Duration / Frequency of activity / exercise session
4. Progression
5. Precautions regarding certain orthopaedic concerns / related comments
- Example: Bridging exercise: Lift buttock while in supine, hold for 5s, 10 reps, 3 times per day, every other day
MUST consider:
- Feasibility
- Motivation
- Adherence
- Empowerment
- Always review, step-up approach
2 types of exercise:
1. ROM / Flexibility exercise
Active vs Active assisted vs Passive
- Target: Joint
- Moving joints (with attaching muscle) across available ranges with different level of supports
- vs Stretching (beyond available range)
- 2-3 sets per day, 10 reps per set
- Suitable for ALL, immediately from pain onset
- CI: fracture / complete tear of ligament / muscle
- Resistive exercise
- Target: Muscle
- Resistance to contracting muscles to increase strength, endurance, power
- e.g. Gravity, hydrotherapy, weights
- 2-3 times per week, 10-15 reps per set, aim moderate intensity
- Suitable for subacute pain due to muscle weakness (i.e. after acute inflammation subsided)
- Endurance: low resistance, high repetition
- Strength: high resistance, low repetition
- Power: strength + speed
—> Change type of exercise by changing reps, resistance, frequency
Walking aids
Types:
1. Straight cane
- not good support esp. slippery floor
2. Quadripod cane (1st to recommend)
- good for patients prone to fall
- hold on contralateral side of affected limb
3. Elbow crutches
- require good upper body strength
- provide better mobility
4. Walking frame
- good for frail elderly
Choice depends on:
1. Weight bearing status
2. UL power
3. Side affected
4. Environment
Correct height of walking aid —> Against wrist level when standing upright with arms putting down —> Wrist should bend 20-30o when holding walking aid —> Strongest push / grip
Multidisciplinary team
- PT
- OT
- P+O (Prosthetic + Orthotic)
- OT surgeon
- Pain team
- Clinical psychologist
- MSW
- Labour department / Insurance company
Physiotherapy
- Rehabilitation therapy using mechanical force / means and movements
- Treat Gross motor function loss (e.g. weak, poor balance, reduced ROM)
- Reduce symptoms, promote mobility, function, fitness, QoL
-
Physical modalities
- USG / Shockwave
- TENS / Interferential therapy
- Ice / Heat -
Exercise
- Strengthening vs ROM vs Endurance
- Mobility, balance, proprioception, sports training
- Hydrotherapy - Traction
- For Cervical / Lumbar spondylosis / prolapsed disc - Acupuncture for pain control
- Manual therapy for joint mobilisation
