MSK disorders Flashcards
Bursitis treatment
Prepatellar bursitis → US guided aspiration
Others → eliminate offending activity, apply ice for 15 minutes x4/day, elevate, take NSAIDs
- If does not work after 4-8 weeks, intrabursal corticosteroid injection
Septic bursitis → antibiotics while waiting for culture results
Tendinitis treatment
- Limit or discontinue contributing activity
- Apply ice
- NSAIDs
- Splinting for hands/wrist/achilles
- For biceps tendonitis, limit overhead movement and intrabursal corticosteroid injections to prevent bursitis
Tendonosis (chronic state of tendonitis) treatment
- PT
- Extracorporeal shock wave therapy (ESWT)
Lateral vs medial epicondylitis
Lateral → tennis elbow
Medial → golfer’s elbow
Tennis elbow (lateral epicondylitis) clinical presentation
- Can be due to other repetitive activities that are not tennis
- Pain increases with resisted wrist extension (especially when lifting object in front of patient) and elbow extension
- Tender to palpation
- Without warmth or redness
Golfer’s elbow (medial epicondylitis) clinical presentation
- Associated with racquet sports, bowling, archery, weight lifting
- Local tenderness and pain
- Wrist and forearm weakness
- Pain aggravated by wrist flexion and pronation
- Decreased grip strength
Epicondylitis treatment
- Rest, applying ice, avoidance of precipitating activity
- Topical or oral NSAIDs and/or corticosteroids for short term relief
- PT
- Counterforce bracing
Gout risk factors
- Obesity
- DM
- Family history
- Medications → thiazides, niacin, ASA, cyclosporine
- Chronic alcohol use
Gout clinical presentation
- Sudden pain
- Most commonly affect MCP joint of great toe
- Unable to walk, move joint, tolerate weight of bed sheet on affected joint
- Red and enlarged
- Chronic gout → tophi
Gout diagnostic testing
- First episode → uric acid level
- Diagnostic → joint aspiration
- X-ray
After acute flare subsides → 24 hour urine collection for uric acid
Gout treatment
Inflammation prevention/management
- Loading dose of NSAID followed by lower doses
- Short course of systemic corticosteroid (replaced colchicine)
Reduction of uric acid
- Complete at least 6 months of anti inflammatory therapy first
- Xanthine oxidase inhibitors → allopurinol or febuxostat
- Probenecid
Chronic gout refectory to other meds → pegloticase (krystexxa)
Gout diagnostic testing
Serum uric acid should be maintained below 6 mg/dL
- Levels monitored at 6 month intervals
Dietary modifications to prevent gout
Avoid high purine foods
- Seafood (scallops, mussels)
- Organ and game meat
- Beans
- Spinach
- Asparagus
- Oatmeal
- Baker’s and brewer’s yeast
Osteoarthritis clinical presentation
- Insidious/gradual onset
- Joint pain relieved with rest
- Joint stiffness worse at rest but resolves with <15 minutes of activity
- Reduced ROM
- Discomfort increases as day progresses
- Heberden’s nodes on DIP joints of hands
Osteoarthritis treatment
- Weight loss with minimal weight bearing (water based activities)
- Application of heat before activity and ice after activity
- Acetaminophen (if using NSAIDs for long term, also add PPI)
- Duloxetine (cymbalta) as alternative for chronic MSK pain
- Topical analgesics
- Intra articular corticosteroid joint injection
- Knee or hip joint replacement
Rheumatoid arthritis clinical presentation
- Initial presentation → acute polyarticular inflammation
- Slowly progressive malaise, weight loss, stiffness
- Morning stiffness (lasts about 1 hour)
- Symmetric
- Involves at least three joint groups
- Smaller joints (hands, toes, etc.)
Rheumatoid arthritis diagnostic testing
- Labs: ANA, ESR, CRP, ACPA, RF
- X-rays at early stages of disease can determine progression
Rheumatoid arthritis treatment and management
- Referral to rheumatology
- Anti inflammatory → NSAIDs, cox-2 inhibitors (celecoxib), corticosteroids
- Analgesic → NSAIDs, cox-2 inhibitors, acetaminophen, opioids, topicals
- DMARDs (methotrexate)
- Monitored every 3-6 months
- Non biologic and biologic DMARD (TNF inhibitor) indicated for moderate to high disease
- PT, water exercises
SLE clinical presentation
- Malar rash (covering cheeks and nasal bridge, spares nasolabial folds)
- Fever without identifiable cause
- Unexplained fatigue
- Headaches
- Involuntary weight loss
- Joint pain, stiffness, swelling
SLE diagnostic testing
- Labs: anemia, elevates ESR, proteinuria, positive ANA
- Chest x-ray → inflammation in lungs
- Echocardiogram → changes in heart
SLE treatment and management
- Pregnancy should be delayed until SLE under control for at least 6 months
- NSAIDs
- Hydroxychloroquine for long term treatment
- Systemic corticosteroids for inflammation
- Immune suppressants for those who do not respond to initial therapy
What is sjogren syndrome?
Autoimmune disease that occurs in conjunction with another chronic inflammatory condition (RA or SLE)
- Affects the eyes, mouth, parotid gland, lungs, kidneys, skin, nervous system
- Symptoms: oral and ocular secretions, underlying disease with RA and SLE, dry eyes (xerophthalmia), dry mouth (xerostomia), bilateral parotid swelling
- Diagnosis: salivary gland biopsy, schirmer’s test
Sjogren syndrome treatment and management
- NSAIDs or medications that suppress immune system
- Methotrexate, hydroxychloroquine
- Eye lubricants
- Sips of water, artificial saliva, sugar free mouth drops
- Routine dental care and fluoride treatment
Meniscal tear clinical presentation
Can be due to injury or degenerative changes
- Knee locking
- Popping sound or “gives out”
Diagnostic tests and maneuvers for meniscal tears
- McMurray test → palpable popping of joint
- Apley grinding test
- Squatting for kneeling impossible for large tears
- MRI if symptoms do not resolve within 2-4 weeks
Carpal tunnel syndrome clinical presentation
- Burning, aching, tingling pain radiating to forearm along median nerve
- Can radiate to shoulder, neck, chest
- Worse at night (acroparesthesia): waking up at night with numbness and burning pain in fingers
- Positive Tinel and Phalen test
- Muscle weakness later on
Carpal tunnel syndrome diagnostic testing
- EMG
- Nerve conduction studies
- MRI and high resolution US to rule out other causes of wrist pain
Carpal tunnel syndrome treatment and management
- Limit activity that cause CTS
- Elevate affected extremity
- Nighttime use of solar splints
- NSAIDs and acetaminophen
- Corticosteroid injections at 6 week intervals
- PT
- Surgery
What is sarcoidosis?
Inflammatory condition that results in production of noncaseating granulomas in various sites of the body
- Predominantly in the lungs, lymph nodes, eyes, skin
- Likely due to exaggerated immune response to unidentified antigen
Sarcoidosis clinical presentation
- Derm → rash, lesions, color change, nodule formation under skin
- Ocular → blurred vision, eye pain, severe redness, sensitivity to light
- Resp → DOE, cough, chest pain
- Systemic → fever, fatigue, anorexia, arthralgia
Sarcoidosis diagnostic testing
- Serological markers: serum amyloid A, soluble interleukin-2 receptor, ACE, glycoprotein KL-6
- Hypercalcemia
- Hypercalciuria
- Chest x-ray → lung damage, enlarged lymph nodes
- CT → alveolitis, fibrosis
- Biopsy to check for noncaseating granulomas
Sarcoidosis treatment and management
Often self limiting
- NSAIDs for arthralgia
- Corticosteroids
- Hydroxychloroquine and immune suppressing medications used to treat RA
What is cauda equina syndrome?
When associated with lumbar radiculopathy, will have:
- Rectal or perineal pain
- Disturbance in bowel and bladder function (neurologic deficits in Les)
- Medical emergency
Lower back pain conservative management
- Cold packs for 20 minutes 3-4 times/day
- Heat application before gentle stretching exercises
- NSAIDs or acetaminophen
- Muscle relaxants for short periods of time
- Anticonvulsants (gabapentin) for neuropathic pain
What is reactive arthritis?
Acute non purulent arthritis complicating an infection elsewhere in the body
- Occurs after exposure to certain GI and GU infections
- Develops about 2-4 weeks after infection
Reactive arthritis clinical presentation
- Acute onset malaise, fatigue, fever
- Unilateral LE arthritis (especially knees)
- Lower back pain
Reactive arthritis diagnostic testing
- Bacterial urethral or urine testing
- Stool cultures
- Elevated ESR
Reactive arthritis treatment and management
- Symptomatic and supportive care
- NSAIDs or systemic corticosteroids
- Can consider corticosteroid injections
- DMARDs for chronic states
- If associated with urethritis, doxycycline x7 days or single dose azithromycin
Osteoporosis treatment and management
- Calcium and vitamin D supplementation
- Bisphosphonates
- Taken in the AM with full glass of water, wait 30 minutes before food or drinks, remain upright for at least one hour
- Selective estrogen receptor modulators (SERMs)
- Raloxifene, calcitonin, estrogen
- Bone forming medications (teriparatide)
- For women with low bone density or prior fracture
Are drug holidays necessary when considering treatment with bisphosphonates?
Yes - bisphosphonates provide a degree of anti fracture reduction when treatment is discontinued; recommend a drug holiday after 5-10 years of therapy
- If low risk for fracture, consider stopping after 5 years and remain off treatment until bone mineral density is stable
- If high risk, can be treated for 10 years and have drug holiday of no more than 1-2 years with consideration of a non bisphosphonate treatment
Grade I ligamentous sprain (pathology and presentation, intervention)
Pathology: slight stretching or microscopic tear
Presentation: no instability
Intervention:
- RICE
- Immobilizer
- Limit weight bearing
- Analgesia
- Length of disability usually limited to a few days
Grade II ligamentous sprain (pathology and presentation, intervention)
Pathology: partial ligamentous tear
Presentation: moderate joint instability, moderate swelling, mild to moderate ecchymosis
Intervention:
- RICE
- Immobilizer
- Limit weight bearing
- Analgesia
- Length of disability usually several weeks to a few months
- Ortho referral
Grade III ligamentous sprain (pathology and presentation, intervention)
Pathology: complete ligamentous tear
Presentation: complete ankle instability, significant swelling, moderate to severe ecchymosis
Intervention:
- RICE
- Immobilizer
- Limit weight bearing
- Analgesia
- Length of disability may be many months
Ottawa Ankle Rules criteria
- Is imaging necessary for an ankle sprain?
Only if the patient experiences malleolar pain and any of the following:
- Bone tenderness at posterior edge or tip of lateral malleolus
- Bone tenderness at posterior edge or tip of medial malleolus
- Inability to bear weight immediately after injury and in ED
What is fibromyalgia?
Chronic pain syndrome diagnosed by widespread presence of body pain
- Sometimes begins after physical trauma, surgery, infection, or significant psychological stress
Fibromyalgia clinical presentation
- Burning, aching, sore pain
- Point tenderness
- Lasted for at least 3 months
- Persistent fatigue, non refreshing sleep
- Tension headaches
- TMJ
- IBS
- Anxiety and/or depression
Is diagnostic testing required for fibromyalgia?
No imaging or labs are diagnostic but can be used to rule out other causes
- Labs: CBC w/ diff, metabolic panel, UA
- TSH, vitamin D, vitamin b12 for fatigue and muscle pain
- IDA normal
Fibromyalgia conservative management
- Physical activity → flexibility exercises, progressive stretching, low impact activities (aquatics)
- Stress management
- Maintain healthy lifestyle
- Eat healthy foods
- Limite caffeine
- Get sufficient sleep
Fibromyalgia pharmacotherapy
- Acetaminophen and NSAIDs for pain
- Trazadone for sleep
- Antidepressants
- TCAs
- SNRIs (duloxetine)
- Anti epileptics (gabapentin, pregabalin)
Causes of vitamin D deficiency
- Sun avoidance and use of sun protection
- Increased skin pigmentation
- Inadequate dietary and vitamin D supplemental intake
- Breastmilk only without vitamin D supplementation
- Malabsorptive syndromes (gastric bypass, hepatic and renal disease)
- Obesity
- Medications (phenytoin, phenobarbital)
Vitamin D deficiency clinical presentation
Often mistaken for fibromyalgia
- Muscle weakness and muscles aches
- Osteomalacia → pain to palpation
- Dull, aching pain
- Difficulty arising from a chair or walking
- Pseudofractures
Vitamin D deficiency diagnostic testing
- Serum 25-hydroxyvitamin D
- Increased PTH levels with vitamin D levels of at least 20
- Normal vitamin D range is 20-100
Vitamin D deficiency treatment and management
- Vitamin D intake recommendations
- Infants (400 IU/day)
- Ages 1-70 years, pregnant and lactating women (600 IU/day)
- Older than 70 years (800 IU)
- Vitamin D3 supplementation
- 50,000 IU PO once/week for at least 8 weeks
Foods high in vitamin D
- Fortified milk, OJ, infant formulas, yogurts, breakfast cereals
- Salmon
- Tuna
- Mackerel
- Cod liver oil
- Shitake mushrooms
- Egg yolk
