Musculoskeletal injury

Question 1

Describe the difference amongst:
1) Ligament
2) Tendon
3) Bursae
4) Plantar fascia

Answer 1

Ligament - bone to bone connective tissue;
Tendon - bone to muscle connective tissue;
Bursae - fluid-filled sacs around joints;
Plantar Fascia - fibrous attachment which connects Heel bone to base of Toes.

Question 2

Periarticular pain presents as:

Answer 2

Palpation, Movement, Direction
- Maximal tenderness at join line (on palpation);
- pain on Active movement > Passive movement;
- Certain lines of muscle pull: where maximal pain is experienced.

Question 3

Conditions for Urgent Referral of soft tissue injuries are:

Answer 3

• Fracture
• Ligament rupture
• Infection-related causes

Specific to lower back pain:
- Malignancy / metastasis
- Relating to underlying visceral conditions (eg. Gynae, GI)

Question 4

Conditions for (Non-urgent / Urgent) Referral of Heel / Sole pain are:

Answer 4

• Paresthesia / numbness
• Nocturnal smx: neuropathic pain / neoplasm
• Radiating pain from posterior aspect of leg to heel
• Trauma
• Inflammatory PMH

Urgent:
- Fever, constant pain
- Sudden onset pain (rupture?)
- Erythema nodosum (sarcoidosis?)

Question 5

what is RICER HARM?

Answer 5

Rest
Ice - w cloth
Compression - stocking or bandage
Elevation - higher than heart level
Referral

No HARMs:
Heat
Alcohol
Re-injury
Massage

Question 6

Which action of the ankle is most likely to be affected by sprain?

Answer 6

Plantarflexion and Inversion (rolling ankle)

Question 7

Which ligament is most likely to be at risk from inversion (rolling ankle)?

Answer 7

Anterior talofibular ligament

Question 8

when should a patient be referred to A&E for a Sprain?

Answer 8

Severe pain, swelling ->
Cannot bear weight or ambulate
- leading to significant instability
- loss of motion and function.

Question 9

Describe the etiology of Tendonitis.

Answer 9

(!) Overuse
(!) Sports Injury
- Inflammatory rheumatic disease
- Calcium apatite deposition
- Drug-induced: FQ antibiotics and Statins

Question 10

common sites where Tendonitis may occur are:

Answer 10

Shoulder- rotator cuff tendinopathy
Elbow - tennis / golfer’s elbow
Ankle - achilles (jumping, running)

Wrist
Hip

Question 11

how does Bursitis occur? What are the causes?

Answer 11

Compression of bursa -> increase in intrabursal pressure -> inflammation of bursa

Acute (Key Sx: pain on active and passive flexing)
- Trauma
- Crystal-induced process
- Infection

Chronic (Key Sx: swelling and thickening)
- Overuse
- Prolonged pressure
- Inflammatory arthritis

Question 12

describe the Etiology of Plantar Fasciitis.

Answer 12

• Prolonged standing / jumping / running on hard surfaces
• Flat feet / high arched feet
• Tight hamstring muscle
• Reduced ankle dorsiflexion

Question 13

Differentials for Heel / sole pain are:

Answer 13

1) Neurologic causes -> paresthesia, numbness, nocturnal smx, diffuse pain, radiating pain)
2) Skeletal causes -> trauma, bone contusion
- Osteomyelitis: fever, constant pain
- Neoplasm: nocturnal smx
3) Soft Tissue causes
- Achilles, Bursitis: closer to back of heel
- Fat-pad atrophy
- No tenderness when palpating plantar fasciia
- Plantar Fasciia rupture: sudden onset, visible swelling, ecchymosis
4) Inflammation
- arthritis: PMH of inflammatory Dx
- Sarcoidosis

Question 14

describe the Presentation of Frozen Shoulder.

Answer 14

• Unilateral - non-dominant hand (bilateral in the long-term)
• Limited overhead reach, to side, across chest, rotation.

Question 15

describe the Stages of recovery for Frozen Shoulder.

Answer 15

• Initial 2-9 mo: severe disabling pain, diffuse, worse at night, increasingly stiff.
• Intermediate 4-12 mo: stiffness, severe loss of shoulder motion, gradually improving pain.
• Recovery 5-24 mo: gradual return of range of motion.

Question 16

Conditions for (Non-urgent / Urgent) Referral of Shoulder Pain are:

Answer 16

Marked loss of motion

Urgent:
- Systemic Sx of infection
- Malignancy
- Associated chronic illness (RA, Gout, Septic arthritis)

Question 17

Treatment for Frozen Shoulder are:

Answer 17

1) Analgesic (paracet / NSAIDs / weak opioids)
2) Range of motion exercises
3) IA glucocorticoid + physical therapy

Question 18

Treatment for Bursitis are:

Answer 18

1) Analgesic (paracet / Top NSAIDs / Oral NSAIDs)
2) IA glucocorticoid (for deep regions)

Question 19

Conditions for (Non-urgent / Urgent) Referral of Lower Back Pain are:

Answer 19

• Subacute (4-12 wk) or Chronic (>12 wk) pain

Urgent:
- neurologic Sx: motor weakness, fall, gait instability, numbness, loss of bowel/bladder function.
- Osteoporotic fractures: Glucocorticoid (chronic), age, trauma, had fragility / traumatic fracture before)
- Malignancy: unintended weight loss, PMH of malignancy
- Osteomyelitis: fever, constant pain
- Visceral issues: eg. severe abdo pain

Question 20

Treatment for Acute / Subacute (<12 wks) Lower Back Pain are:

Answer 20

1) NSAIDs / SMR (orphenadrine)
2) Superficial heat

Low-quality evidence:
3) Massage
4) Acupuncture
5) Spinal manipulation

Question 21

Treatment for Chronic (>=12 wks) Lower Back Pain are:

Answer 21

1) NSAIDs -> Tramadol / Duloxetine (2nd line)
2) Exercise
3) Multidisciplinary rehab
4) Acupuncture
5) Mindfulness-based stress reduction

Low-quality evidence:
6) Tai Chi
7) Yoga
8) Motor control exercise
9) Progressive relaxation
10) Electromyography biofeedback
11) Low-level laser therapy
12) Operant therapy
13) Cognitive behavioural therapy
14) Spinal manipulation

Question 22

Counselling Points for patients w Lower Back Pain are:

Answer 22

• Impvt may be small.
• Acute/subacute pain are usually self-limiting.
• Avoid potentially harmful & Costly tests / Tx.
• Low-impact core strengthening exercises (eg. swimming, stationary bicycling, brisk walking). NOT jogging (high-impact).
• Correct lifting & moving techniques.
• Maintain correct sitting / standing posture.
• Maintain healthy weight.
• Quit smoking -> hardening of arteries cause low back pain & degenerative disc disorders.

Question 23

Management for Myalgia is:

Answer 23

• RICE
• Topical NSAIDs
• Prevention: doing proper warm-up before exercise.

Question 24

Conditions for (Non-urgent / Urgent) Referral of Myalgia are:

Answer 24

Urgent:
- Infection: diffuse myalgia, fever, chills, arthralgia, fatigue, back pain.
- Med toxicity: statin-induced rhabdomyolysis (muscle pain, weakness, red-brown “tea-coloured” urine)