Regional MSK Pain Syndromes Flashcards
overuse syndromes - defined
*repetitive action causes chronic trauma / irritation
*trauma → inflammatory cascade → painful range of movement & swelling → disability
overuse syndromes - epidemiology
*fairly common in the general population
*increase in incidence in systemic diseases (diabetes, rheumatoid arthritis)
*increase in incidence in particular occupations
overuse syndromes - general treatment principles
*education & prevention are most important
1. treatment of active inflammation:
-NSAIDs, anti-inflammatories
-ice initially, heat later
2. RICE: rest, ice, compression, elevation
3. decrease causative movements/triggers: time off sport or work; braces
4. control pain: NSAIDs (oral, topical), aspirin
5. steroid injections: pain control, decrease inflammatory process
stenosing tenosynovitis - symptoms
*aka “trigger finger”
*“locking” of the digit of the finger in flexed position
*describe having to use their other hand to extend their finger
*may also click or catch
stenosing tenosynovitis - physical exam
*aka “trigger finger”
*nodule/thickening of flexor tendon
*may have inflammation of retinacular sheath
*diagnosed based on history & exam
stenosing tenosynovitis - treatment
*steroid injection
*NSAIDs for pain relief (oral or topical)
*surgery if refractory
Dupuytren’s contracture - pathophysiology
*fibroproliferative disease of the palmar fascia with resultant deformity (most commonly 4th and 5th digit)
Dupuytren’s contracture - epidemiology
*men > women
*age > 50
*risk factors: DM, EtOH, smoking
Dupuytren’s contracture - symptoms
*often painless
*contracture of the 4th and 5th digits
*difficulty extending fingers (even with the other hand) and grasping objects
Dupuytren’s contracture - physical exam
*flexion contractures of most commonly the 4th and 5th digits (MCP, PIP joints)
*diagnosis based on history and exam
Dupuytren’s contracture - treatment
*no great therapy (surgery? collagenase injections?)
carpal tunnel syndrome - overview
*aka median nerve entrapment syndrome
*carpal tunnel bound on dorsal and lateral surfaces by carpal bones; on volar surface by transverse carpal ligament
*numerous flexor tendons and median nerve pass through this canal
*pressure on median nerve causes the symptoms; may be intrinsic or extrinsic to tunnel
carpal tunnel syndrome - risk factors
*aka median nerve entrapment syndrome
*risk factors include:
-pregnancy
-rheumatoid arthritis
-repetitive tasks involving wrist flexion (hairdresser, typist, receptionist)
carpal tunnel syndrome - symptoms
*aka median nerve entrapment syndrome
*symptoms include:
-paresthesia, pain, and numbness in the median nerve distribution: palmar side thumb, index, and middle fingers
-often worse at night
carpal tunnel syndrome - physical exam
*aka median nerve entrapment syndrome
* Tinel’s sign: percussion over median nerve reproduces the symptoms
*Phalen’s maneuver: wrist in complete flexion; pushing the dorsal surface of both hands together for 30-60 seconds; reproduces the symptoms
*diagnosis based on history and physical exam
carpal tunnel syndrome - treatment
*aka median nerve entrapment syndrome
*splints to keep wrist extended (night time)
*NSAIDs for pain control, if needed
*treat underlying cause, if present
*consider steroid injection
*surgery to remove transverse carpal ligament if conservative measures fail
important board information for carpal tunnel syndrome
*associated with:
1. acromegaly
2. hemodialysis-related amyloidosis
De Quervain’s tenosynovitis - overview
*noninflammatory thickening of abductor pollicis longus & extensor pollicis brevis tendons → pain or tenderness at radial styloid
*EPB (extensor pollicus brevis) and APL (abductor pollicus longus) tendons pass through a synovial sheath
De Quervain’s tenosynovitis - epidemiology
*women > men
*often seen post-partum
De Quervain’s tenosynovitis - symptoms
*pain on radial aspect of the wrist
*wrist pain
*difficulty grabbing objects, pinching
De Quervain’s tenosynovitis - physical exam
*Finkelstein test: fingers wrap around thumb and ulnar deviate the hand sharply; pain at the base of the thumb
*diagnosis = clinical
De Quervain’s tenosynovitis - treatment
*SPICA splint to rest thumb
*NSAIDs, rest
*injection if severe
lateral epicondylitis - pathophysiology
*aka tennis elbow
*inflammation/micro-trauma of extensor tendons at insertion on lateral epicondyle
lateral epicondylitis - risk factors
*aka tennis elbow
*age > 50
*non-professional tennis players
*gardeners
*carpenters
lateral epicondylitis - symptoms
*aka tennis elbow
*pain on lateral aspect of the elbow
*pain worsens with activity
*difficulty lifting up heavier objects
lateral epicondylitis - physical exam
*aka tennis elbow
*localized tenderness 1.5 cm distal to the origin of the extensor carpi radialis brevis (ECRB)
*painless ROM at the elbow
*restricted wrist extension with elbow in full extension reproduces pain
lateral epicondylitis - treatment
*aka tennis elbow
*stop activities that aggravate, correct improper techniques
*NSAIDs for pain control
*counter-force brace
*steroid injections
medial epicondylitis - pathophysiology
*aka Golfer’s elbow
*inflammation/micro-trauma of flexor tendons at insertion on medial epicondyle
medial epicondylitis - epidemiology
*aka Golfer’s elbow
*age 45-55
*seen in golfing / throwing sports
medial epicondylitis - symptoms
*aka Golfer’s elbow
*aching pain over the medial elbow
*ulnar nerve symptoms possible
medial epicondylitis - physical exam
*aka Golfer’s elbow
*pain with resisted wrist flexion with the elbow in full extension
medial epicondylitis - treatment
*aka Golfer’s elbow
*stop activities that aggravate
*correct improper techniques
*NSAIDs for pain control
*physical therapy
olecranon bursitis - epidemiology
*ages 40-50 yo
*male > female
*50% with preceding trauma
*associated with repetitive trauma or systemic disease (RA, gout), can be infectious
olecranon bursitis - symptoms
*pain, redness, swelling over bursa of olecranon (elbow)
*can have asymptomatic swelling
olecranon bursitis - physical exam
*erythema and swelling at bursa
*tenderness to area
*may have decreased ROM
olecranon bursitis - treatment
*aspirate the bursa to rule out infection, other causes
*aspiration improves pain (decreases swelling)
*elbow protection (if repetitive trauma)
*consider steroid injection if persistent (and not infected)
trochanteric bursitis - pathophysiology
*acute or repetitive trauma leads to inflammation of the trochanteric bursa and surrounding tendons (sac surrounding the hip joint)
trochanteric bursitis - symptoms
*lateral hip pain, localized but may radiate
*worsens with ambulation, standing, climbing stairs, or inclines
*patient complains that they cannot lie on that side (may keep them up at night)
trochanteric bursitis - physical exam
*point tenderness over trochanteric bursa
trochanteric bursitis - treatment
*short course of NSAIDs
*rest, stretching (especially IT band)
*physical therapy for stretching
*consider steroid injection if conservative therapy does not help
pes anserine bursitis - pathophysiology
*area on medial aspect of knee joint where tendons of 3 muscles (semitendinosus tendon, gracilis tendon, sartorius tendon) joint to form a common insertion point
pes anserine bursitis - risk factors
*obese
*females
*osteoarthritis
pes anserine bursitis - symptoms
*painful medial knee
*exacerbated by activities such as rising from a chair or going up and down the stairs, walking up inclines (hills)
pes anserine bursitis - physical exam
*painful palpation around pes anserine (medial knee)
*erythema
pes anserine bursitis - treatment
*NSAIDs
*rest
*RICE therapy
*physical therapy
*consider steroid injection
popliteal (Baker’s) cyst - pathophysiology
*caused by distention of connecting gastrocnemius and semi-membranous bursae
*often from underlying joint pathology (causes swelling)
popliteal (Baker’s) cyst - symptoms
*may be asymptomatic
*posterior leg edema/mass at back of knee (can look like DVT)
*discomfort, potentially decreased ROM if big enough
popliteal (Baker’s) cyst - treatment
*rest, ice, NSAIDs
*ultrasound-guided drainage
*treat underlying causes (arthritis of the knee)
plantar fasciitis - pathophysiology
*plantar fascia connects MTPs to calcaneus
*insertion sites and the fascia itself can become inflamed
plantar fasciitis - risk factors
*peak incidence 40-60yo
*obesity, excessive standing, runners, military recruits
plantar fasciitis - symptoms
*inferior heel pain
*worse with movement (first few steps in the morning very painful)
plantar fasciitis - physical exam
*pain with dorsiflexion of the toes (like when walking on heels; toes to sky)
*palpation along fascia from heel to forefoot elicits pain
plantar fasciitis - treatment
*NSAIDs, rest, RICE therapy
*stretching exercise
*rolling cold coke can/frozen water bottle along fascia
*consider steroid injection
Morton’s Neuroma - pathophysiology
*entrapment neuropathy of an interdigital nerve
*more common in females > males
Morton’s Neuroma - symptoms
*burning pain in third intermetatarsal space that can radiate towards the toes
*numbness or pain that increases with activity
Morton’s Neuroma - physical exam
*Mulder’s sign: clicking sensation upon palpation of the involved interspace while squeezing the metatarsal joints
*tenderness to palpation
Morton’s Neuroma - diagnosis
*clinical
*MRI and ultrasound are options if diagnosis is questionable
Morton’s Neuroma - treatment
*mechanical (inserts in shoes, proper shoe fit)
*consider injection
