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
Occupational therapy
- Work on Function
- Enhance both physical + psychological functions, prevent illnesses, facilitate independent living, improve QoL of people with disabilities / special needs, promote reintegration into home, work, society through carefully designed activities + therapeutic processes
- ADL skills assessment + training
- Sensory
- Splinting
- Adaptive aids
- Home modifications, community living skills assessment + training
- Work skills assessment + training
- Occupational health + ergonomics
Prosthetics + Orthotics (義肢矯形師)
Correct malalignment problems
Prosthetic: restore form + function of person with disability by using appropriate substitute i.e. prosthesis
Orthotic: restore function of person with disability using augmentative devices i.e. orthosis
Compensation for IOD (工傷賠償)
Prerequisite:
1. Injury must occur within workplace
2. Someone must know (e.g. Employer)
Steps:
1. Must notify employer + report in full details about injury —> Employer report case to Labour department within 14 days
2. Receive medical examination + treatment
3. Compensation up to 24 +/- 12 months (require sick leave certificate from doctors as proof)
An employee is entitled to receive periodical payments during period of temporary incapacity (sick leave) up to 24 months
- Cannot be fired
- (Monthly earnings before accident - Monthly earnings after accident) x 80%
Role of doctors:
1. Careful assessment + documentation of progress
- subjective vs objective
- psycho-social impact
- grant appropriate duration of sick leave to rest / attend rehabilitation
- Multidisciplinary approach
- maximise function to facilitate return to work - Referral to Medical Assessment Board (MAB) (判工傷 vs Compensation 工傷賠償)
- when progress of recovery static with residual disability (can no longer go back to previous state)
- disability compensation (one-off payment: proportional to degree of function loss)
- counsel patient getting back to work is much better than getting disability compensation since many people won’t get a lot of money anyway + will be labelled as disabled which affect future employment
Compensation for TAVA (Traffic accident victims assistance scheme) (交通意外傷亡援助計劃)
- Operated by Social Welfare Department
- Provide speedy financial assistance to RTA victims (or to surviving dependents in case of death) on a non-means-tested basis, regardless of element of fault leading to accident
- Amount much less than compensation for IOD
Types:
1. Burial grant
2. Death grant
3. Disability grant
4. Injury grant
5. Interim maintenance grant
- Up to 180 days
Sick leaves
MCHK code of professional conduct:
- Only issued after proper medical consultation by doctor
- Date of consultation + date of issue must be truly stated in certificate, including certificate recommending retrospective sick leave
- No fixed limit of duration
Issued based on:
1. Diagnosis
2. Condition
3. Prognosis (expected time of recovery)
4. Time to receive treatment
5. Functional needs (e.g. sprain ankle for athlete vs home worker)
Exercise for neck, shoulder, elbow, low back, knee, ankle pain
Neck pain:
1. Back and forward bend
2. Head tilt
3. Neck retraction
Shoulder pain:
1. Shoulder shrug
2. Wall angel
Elbow pain:
1. Forearm flexor stretch
2. Forearm extensor stretch
Low back pain:
1. Bridging
2. Extension exercise
3. Quadruped arm / leg raise
Knee pain:
1. Seated knee extension
2. Step up
3. Straight leg raise
Ankle pain:
1. Toe circle
2. Alphabet exercise
3. Towel stretch
