Soft Tissue Injuries Flashcards
How do you differentiate between articular and periarticular pain? List their respective features (periarticular 3).
Articular pain:
- Pain at joint line
- Tenderness on palpation of joint line
Periarticular pain:
- Point of maximal tenderness away from joint line
- Pain on active movement > passive movement
- Pain is maximal in certain lines of muscle pull
What is a sprain?
- Stretch or tear of ligaments, which connect ends of bones
What are the 3 types of sprains, their features and their respective management options?
1) Mild stretch or microtear
- Mild pain, swelling and tenderness
- Minimal pain on bearing weight and ambulation
- Self-limiting, rest is usually sufficient
2) Partial rupture
- Moderate pain, swelling, tenderness, ecchymosis
- Pain on bearing weight and ambulation (limp)
- Moderate instability (joint feels like giving way); some restriction in motion and function
- PRICE +/- analgesics
3) Complete rupture
- Severe pain, swelling, tenderness, ecchymosis
- Cannot bear weight and ambulate
- Severe instability; loss of joint motion and function
- Refer to ED
What is the most common cause of sprains? And list the mechanism of injury.
Lateral ankle sprain due to trauma/injury from sports via INVERSION of foot
Define tendonitis and its hallmark features (3)
Acute inflammation and irritation of tendon, which connects muscle to bone
Features:
- Local pain and dysfunction on active use (typically dull ache) and only occurs in certain direction of pull
- Pain on active movement; unlikely on passive movement
- Inflammation, but swelling likely not visible
What are the common causes of tendonitis? (3 key, 2 optional)
1) Overuse (mechanical loading)
2) Injury (from sports)
3) Drug-induced (FQs, statins; more FQ rather than statin)
Others:
- Inflammatory diseases (e.g. RA)
- Calcium apatite deposition
What are the common sites of tendonitis? (total 5, 3 more impt)
1) Shoulder (rotator cuff and bicepital tendonitis)
2) Elbow
- Golfer’s elbow (inside = medial epicondylitis)
- Tennis elbow (outside = lateral)
3) Ankle (Achilles heel)
Less commonly: lateral hip (gluteus medius/minimus) and wrist (radialis/ulnaris tendonitis)
When should a case of tendonitis be referred?
Pain lasts more than weeks
Define bursitis and how the pain from bursitis occurs
Inflammation of bursa, a fluid-filled saclike structure lined by synovial membrane that surrounds joints (helps to cushion muscles and tendons from adjacent bones)
Pain occurs when adjacent bursa are compressed to the point that intrabursal pressure increases
State the 2 broad types of bursitis and their corresponding causes (3 per type).
1) Acute bursitis - pain when fully flexing joint
- Infection (septic bursitis)
- Gouty bursitis
- Trauma/injury
2) Chronic bursitis - more swelling/thickening, less pain
- Overuse
- Prolonged pressure (kneeling/leaning)
- Systemic diseases (e.g. RA, spondylarthritis)
List the common sites of bursitis (superficial and deep). (5)
Superficial sites
- Knee cap (prepatellar)
- Elbow (olecranon)
- Posterior upper thigh (Ischial)
Deep sites
- Shoulder (subacromial)
- Hip (trochanteric)
What are the management options for bursitis?
TOP NSAIDs are the DOC, especially for superficial bursitis
Intrabursal glucocorticoids can be considered for deep bursitis that cannot be reached by TOP NSAIDs
Define plantar fasciitis
Inflammation of the plantar fascia, a fibrous structure that connects heel to base of toes
Most common cause of heel pain
What are the common causes of plantar fasciitis? (2 key, 6 optional)
1) Prolonged standing/jumping/running on hard surfaces
2) Flat/highly-arched feet
Others:
- Obesity
- Lower SES
- Impaired physical/mental health
- Tight hamstring –> increased load on forefoot
- Reduced ankle dorsiflexion (poor calves/ankle injury)
- Systemic rheumatic diseases
What are the hallmark features of plantar fasciitis? (3)
- Heel pain
- Pain increases when walking/running (esp in the morning or after a period of inactivity)
- Pain lessens with increased activity, but worsens at the end of the day
What are the red flags for heel pain? (9)
- Sudden onset
- Trauma
- Signs of malignancy: PMH of malignancy/ unexplained weight loss
- Radiating pain from posterior leg to foot
- Paresthesia/numbness
- Fever, malaise
- Constant pain
- Nocturnal pain
- PMH/ Family history of inflammatory diseases
Describe the hallmark features of frozen shoulder (adhesive capsulitis). (3)
- Unilateral (non-dominant) shoulder pain and stiffness, which may affect the other shoulder within 5 years
- Loss of certain degree of function and range of motion (across chest, overhead, scratching back, wearing a coat)
- Peak prevalence among 50+ yo
What are the management options for frozen shoulder? (4)
Usually self-limiting, but symptoms progress through a long course
- Analgesics only if pain present (NSAIDs, paracetamol)
- Range-of-motion exercises (physiotherapy)
- Intraartciular glucocorticoid+ physical therapy (if pain is severe)
- Avoid opioids as it may cause constipation given the potential long term nature of frozen shoulder
When should a case of frozen shoulder be referred?
Stiffness and severe loss of shoulder motion
What is the most common cause of back pain?
Lumbar strain
Self-limiting (10-14 days)
What are accompanying symptoms of back pain that warrant referral? (8)
- Pain >4w, especially if not responsive to treatment
- Signs of malignancy: PMH of malignancy/ Unintended weight loss
- Radiating pain from glutes to foot
- Neurologic symptoms
- Risk of fractures: PMH of osteoporotic/ traumatic fractures or recent Trauma
- Signs of infx: e.g Fever, constant pain
- Severe abdominal pain
- Recent spinal injection/ epidural catheter insertion
What are the general management options for back pain?
Acute/sub-acute
- Non-pharm (massage, acupuncture, heat) + NSAIDs/SMR
Chronic
- Non-pharm (exercise, acupuncture, tai chi, yoga, CBT) + NSAIDs +- SMR
Opioids only considered if above have failed, severe pain and benefits > risks
TLDR: Pharmaco for both acute and chronic back pain are same; Non-pharm measures are slightly different
What are some counselling points for a patient with back pain? (9)
- Improvement in pain and function from treatment may be small
- Reassure that acute/sub-acute back pain is usually self-limiting (in 1-2weeks)
- Encourage patient to remain active as tolerated
- Engage in low-impact core-strengthening exercises (swimming, stationary cycling, brisk walking)
- Ensure proper lifting techniques (squat down to lift heavy objects)
- Avoid placing unnecessary stress on back
- Ensure correct sitting/standing posture
- Maintain a healthy weight
- Quit smoking
Define myalgia
Muscle ache, soreness, stiffness or pain
Most commonly related to overuse/exercise
Describe the management of myalgia relating to overuse/ exercise. And state how myalgia may be prevented.
- RICE (1st line)
- NSAIDs
- (prevention) proper warm-up before exercise
Describe the presentation (incl typical onset of sx, which body parts affected) statin-associated muscle symptoms (SAMS) and how to manage them incl non-pharm advice to tell patients.
Onset usually within 6 months of statin use
Symmetrical, proximal muscle weakness (calves, thighs, hips) (rarely arms)
Might also experience tendon pain, fatigue, nocturnal pain, stiffness etc
Management:
- Discontinue if CK >10x ULN, or if sx are intolerable
- Restart statin at lower dose
- Consider switching to pravastatin or fluvastatin
- Advise patient to drink lots of fluids to help excretion of myoglobin and prevent renal failure
Which ligament is the most likely to get torn/ ruptured from ankle sprain (inversion type)?
Anterior Talofibular Ligament
What type of ankle sprains may be associated with what type of fracture?
Eversion type sprains may cause avulsion fracture of malleolus
What drugs may cause myalgia? (4)
Statins, Bisphosphonates, Aromatase inhibitors, Ciprofloxacin (FQs)
When is urgent referral to ED needed in myalgia? (2)
1) Infection related especially bacterial
* Esp endocarditis and impending sepsis (diffuse myalgia, fever, chills, arthralgia, fatigue, back pain)
2) Medication toxicity
* Esp statin-induced rhabdomyolysis (muscle pain + muscle weakness + red-brown “tea-colored urine related to myoglobinuria)
