MSK Medicine: Common Orthopedic Problems

Question 1

lower back pain Imaging – “Red Flags”

History and exam findings

Answer 1

History Findings

• Cancer metastatic to bone (breast, lung, thyroid, renal, prostate)
• Urinary or fecal incontinence • Urinary retention
• Progressive lower extremity motor or sensory loss
• Significant trauma related to age
• Severe pain and lumbar spine surgery in the prior 12 months

Exam Findings

• Major motor weakness or sensory loss
• Saddle anesthesia
• Loss of anal sphincter tone

These are all STRONG findings and the presence of a STRONG finding indicates need for imaging.

Question 2

Acute LBP • Beneficial Therapies

Answer 2

NSAIDs (A) Advice to remain active (A)

• Likely Beneficial

Therapies Muscle relaxants – weigh side effects

Epidural steroids (for discogenic pain)

Physical therapy–directed home exercise program

Question 3

The straight leg raise test is used to assess for

Answer 3

the impingement of a nerve root from a herniated disc or from a space-occupying lesion by stretching that root.

Question 4

Lumbar Herniated Nucleus Pulposus recommendations

Answer 4

1. Advice to remain active (A)
2. Oral steroids and NSAIDs have limited benefit (B)
3. ESI provides (short-term) symptom improvement (B)
4. If no “red flags,” then radiculopathy may be managed conservatively, without imaging, for up to 6 wks (A)
5. Radiculopathy not improving after 6 wks of conservative management may benefit from diskectomy for more rapid clinical relief (A)
6. Diskectomy has similar long-term outcomes as nonsurgical treatment (A)

Question 5

Lumbar Spinal Stenosis

Answer 5

neurogenic claudication, bilateral buttock/leg pain, symptoms improve with lumbar flexion and worsen with walking, relief with sitting

Question 6

diagnostic test of choice for lumbar spinal stenosis

Answer 6

MRI without contrast

Question 7

Lumbar Spinal Stenosis Management

Answer 7

• Nonoperative
• PT beneficial and mainstay of nonsurgical management
• Pharmacological therapy

Acetaminophen ► NSAIDs ► gabapentin (B)

• Lumbar epidural steroid injections (B)
• Lumbosacral corset can ▲ walking distance and ▼ pain (B)

Question 8

Adhesive capsulitis

Answer 8

loss of both active and passive shoulder range of motion

• 3-4 weeks or oral prednisone (20 mg/d) was superior to PT or acetaminophen in improved function and reduced pain in the short term (1-2 months)

Question 9

Morton’s Neuroma

Answer 9

• Irritation or trauma to the intermetatarsal plantar nerve
• 3rd – 4th web space most common
• ♀ (8-10x) >> ♂
• Burning pain in forefoot with toe numbness
• Palpable mass or click between metatarsals (Mulder’s sign)
• Treatment: shoes with wide toe box and low heels, orthotics, injection [80% improve with these measures]

Question 10

Carpal Tunnel Syndrome

Answer 10

Question 11

Carpel Tunnel Syndrome Treatment

Answer 11

Wrist splints, ultrasound, yoga, carpal bone mobilization – possibly beneficial in short term

Corticosteroid injection – beneficial at 1 & 4 mo, superior to oral corticosteroids

Surgical release – beneficial over splinting at 6 mo

Question 12

Plantar Fasciitis

Answer 12

Question 13

Plantar Fasciitis Is More Likely to Occur in Persons Who…

Answer 13

• Are obese
• Spend most of the day on their feet
• Have limited ankle dorsiflexion, tight Achilles
• Have pes cavus or pes planus foot structure
• Participate in excessive running

Question 14

Plantar Fasciitis Management

Answer 14

1. Initiate patient-directed therapies

Relative rest, ice massage, analgesics, stretching, weight loss

2. Initiate physician-directed therapies

Physical therapy, stretching, deep myofascial massage Orthotics (B) Night splint (B) CS injection (B) Autologous blood injection (B)

Question 15

Tarsal Tunnel Syndrome

Answer 15

Question 16

Tarsal Tunnel Syndrome versus plantar fascitiis

Answer 16

TTS pain is more often described as burning or tingling and is felt with palpation just below the ankle bone. Commonly a tingling sensation extends to the heel, toes, or arch. Plantar fasciitis pain is located more along the bottom of the foot, primarily near the heel.