MSK Medicine: Common Orthopedic Problems Flashcards
lower back pain Imaging – “Red Flags”
History and exam findings
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.
Acute LBP • Beneficial Therapies
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
The straight leg raise test is used to assess for
the impingement of a nerve root from a herniated disc or from a space-occupying lesion by stretching that root.
Lumbar Herniated Nucleus Pulposus recommendations
- Advice to remain active (A)
- Oral steroids and NSAIDs have limited benefit (B)
- ESI provides (short-term) symptom improvement (B)
- If no “red flags,” then radiculopathy may be managed conservatively, without imaging, for up to 6 wks (A)
- Radiculopathy not improving after 6 wks of conservative management may benefit from diskectomy for more rapid clinical relief (A)
- Diskectomy has similar long-term outcomes as nonsurgical treatment (A)
Lumbar Spinal Stenosis
neurogenic claudication, bilateral buttock/leg pain, symptoms improve with lumbar flexion and worsen with walking, relief with sitting
diagnostic test of choice for lumbar spinal stenosis
MRI without contrast
Lumbar Spinal Stenosis Management
- 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)
Adhesive capsulitis
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)
Morton’s Neuroma
- 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]
Carpal Tunnel Syndrome
Carpel Tunnel Syndrome Treatment
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
Plantar Fasciitis
Plantar Fasciitis Is More Likely to Occur in Persons Who…
- 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
Plantar Fasciitis Management
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)
Tarsal Tunnel Syndrome
Tarsal Tunnel Syndrome versus plantar fascitiis
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.
