Soft Tissue Injuries Flashcards
Examples of non-articular joint pain:
Non-articular joint pain (pain in the muscle/bone, but NOT the joints)
- Referred visceral pain (e.g., shoulder pain a/w MI, back pain a/w pancreatitis)
- Tissue pain
- Neuropathic pain
- Periarticular pain (relating to ligaments, tendons, muscles)
- Bone pain (fracture, dislocation, osteoporosis)
What are the features of periarticular pain?
- On palpitation: point of maximal tenderness not at joint line
- Pain on active movement > passive movement
- Pain maximal at certain lines of muscle pull
Other features (for joint pain)
- Swelling
- Erythematous
- Tender on palpation of joint line
- Restricted motion
Characteristics of soft tissue injuries
- Consequence of chronic repetitive low-grade trauma/overuse (microtear, microinflammation)
- Focal: able to point out where
- Non-systemic
- Self-limiting
- Responds to conservative measures (non-pharm: e.g., RICE)
When might urgent referral to ED be necessary?
- Ligament rupture
- Infection-related cause
- Malignancy/metastasis (metastasis to spine - lower back pain)
- Relating to underlying visceral conditions (lower back pain)
Treatment goals:
- Reduce pain
- Regain function
- Prevent future injury
Non-pharmaco for soft tissue injuries: RICE, no HARM
RICE: aim to relieve pain and limit swelling
- R: rest
- I: ice (constrict blood vessels, reduce inflammation)
- C: compression
- E: elevation
No HARM:
- No heat (except for lower back pain)
- No alcohol
- No re-injury
- No massage (bruising)
Pharmaco for non-lower back pain soft tissue injuries
- Topical NSAIDs (Ketoprofen patch/gel, Diclofenac gel)
- PO NSAIDs/coxibs (Pharmacist: Ibuprofen, Naproxen)
- PO Paracetamol (not anti-inflammatory)
Others:
- Consider specific acupressure, transcutaneous electrical nerve stimulation
- DO NOT use opioids including tramadol => risk for neurologic and GI adverse events, prolonged use >7d a/w longer term addiction and overdose
[Sprain]
What is a sprain?
Stretching, partial rupture, or complete rupture of the ligament
- cause inability to move well + instability
- ligament is the bone to bone connective tissue
[Sprain]
What is most common?
- Mechanism
- Cause
- Characteristic
- Prevalence
Lateral ankle sprains:
- Mechanism: inversion of foot; typically affects the anterior talofibular ligament
- Causes: usually sustained during sport
- Characteristics: sudden onset of pain and swelling after “pop” sound
- Prevalence: children > adults; adult females > males
Other examples: Anterior cruciate ligament (ACL) injury in the knee
[Sprain]
Grades of sprain
- Severity
- Clinical presentation
- Function
- Pharm approach
Grade I:
- Severity: mild stretching of ligament with microscopic tears
- Clinical presentation: mild swelling and tenderness
- Function: able to bear weight and ambulate with minimal pain
- Pharm: med not frequently sought
Grade II:
- Severity: incomplete tear of the ligament
- Clinical presentation: mod pain, swelling, tenderness, ecchymosis
- Function: painful weight-bearing and ambulation, some restriction in range of motion and function
- Pharm: RICE, protection, +/- analgesics
Grade III:
- Severity: complete tear of the ligament
- Clinical presentation: severe pain, swelling, tenderness, ecchymosis
- Function: cannot bear weight or ambulate, significant instability and loss of motion and function
- Pharm: refer to ED
[Tendonitis]
What is tendonitis?
Inflammation of tendon
- Tendon: muscle to bone connective tissue
- VS tendinosis/tendinopathy: degeneration of tendon collagen in response to chronic overuse
[Tendonitis]
Etiology
- Overuse (repeated mechanical loading)
- Sports injury
- Inflammation rheumatic disease
- Calcium apatite deposition (from metabolic disturbances)
- Drug-induced: fluoroquinolone antibiotics and statins
Stop FQ if: sudden onset of unexplainable muscle ache or joint pain
Stop statins if: myalgia, rhabdomyolysis - muscle weakness, dark brown urine or if liver injury - light colored stools, N/V, LOA, yellowing of skin or eyes
[Tendonitis]
Features
- Local pain and dysfunction
- Inflammation
- Degeneration
- Pain in a certain direction of pull only
[Tendonitis]
Common sites
- Shoulder
- Elbow (lateral/medial epicondylitis, aka tennis/golfer)
- Wrist
- Hip (lateral)
- Ankle (Achilles tendinopathy)
[Bursitis]
What is it?
Inflammation of bursae
- Bursae: fluid-filled sacs, lined by synovial membrane in clefts between mobile structures - cushions tendons/muscles from adjacent bones
[Bursitis]
Features (when does pain occur?)
Pain occurs when motion compresses adjacent bursa to the point where intrabursal pressure increases (fluid-filled sac is being compressed)
May be swollen, may see a bump
[Bursitis]
Etiology
Acute bursitis: pain when joins are fully flexed, both active and passive
- Trauma/injury
- Crystal-induced process (e.g., gouty bursitis)
- Infection (septic bursitis)
Chronic bursitis: more swelling and thickening, minimal pain, secondary changes of contracture and muscle atrophy relating to immobility
- Overuse
- Prolonged pressure (e.g., kneeling/leaning)
- Inflammatory arthritis (e.g., RA/spondyloarthritis)
[Bursitis]
Common sites
Superficial: cushions skin and bone
- elbow: olecranon
- knee cap: prepatellar
- posterior upper thigh region: ischial
Deep: reduce friction of muscles as they glide over each other/bone prominences may treat with intrabursal glucocorticoids as topical NSAIDs may not penetrate deep enough
- hip: trochanteria
- shoulder: subacromial
[Plantar Fasciitis]
What is it?
Inflammation of plantar fascia
- Plantar fascia: fibrous attachment connecting heel bone to base of toes - most common cause of heel pain
[Plantar Fasciitis]
Etiology
- Prolonged standing/jumping/running on hard surfaces
- Flat feet/high arched feet
- Tight hamstring muscle (e.g., never warm up) => dcr knee extension, incr loading of forefoot, incr stress on plantar fascia
- Reduced ankle dorsiflexion
- Obesity (?)
- Lower SES (?)
- A/w systemic rheumatic disease (?)
[Plantar Fasciitis]
Pain characteristics
- Pain worse when walking/running (esp in morning/after period of inactivity)
- Pain lessens with increased activity but worse at end of the day due to prolonged weight-bearing
[Plantar Fasciitis]
Differentials of heel pain
- When to refer?
Plantar fascia rupture
- sudden onset (except for sprain)
Neurologic causes
- Paresthesia and numbness
- Nocturnal symptoms
- Radiating pain from posterior aspect of leg to heel
Infection:
- Systemic symptoms: fever, fatigue, overall aches/pains
- Recent infections
- Constant pain
Cancer/Malignancy:
- PMH or FH of cancer
- Nocturnal symptoms
- Unintentional weight loss (E.g., more than 5kg in 1 month)
Inflammatory disorder:
- PMH or FH of inflammatory disease (red flag for bursitis and fasciitis)
- PMH or FH of autoimmune diseases
- Erythema nodusum (tender red bumps)
[Frozen shoulder]
Presentation
- Unilateral (usually non-dominant side, but other side may be affected within 5y)
- Limited reaching overhead, to side, across chest, limited rotation => reduced function
- Self-limiting (but very long time, symptoms progress through 3 very long phases)
- Initial phase (2-9m): diffuse, severe disabling shoulder pain, worse at night, increasing stiffness
- Intermediate phase (4-12m): stiffness and severe loss of shoulder motion, pain gradually lessens
- Recovery phase (5-24m): gradual return of range of motion
Refer if marked loss of motion is present
[Frozen shoulder]
Prevalence and Pathophysiology
- Peak prevalence: among 50+ years old; onset <40y is rare
- May be idiopathic or secondary to shoulder injuries
- Pathophysiology not fully understood: a/w presence of DM, hyperthyroidism, dyslipidemia, prolonged immobilization
[Frozen shoulder]
Management
- Analgesics
- Range of motion exercises to preserve range of motion (e.g., abduction, external rotation, internal rotation)
- Intraarticular glucocorticoid + physical therapy
[Low back pain]
Classification and treatment:
Classification and treatment is based on:
- Symptom duration
- Majority are non-specific, self-limiting “strains” aka muscle pulls that can resolve in 10-14 days
- Acute: <4w
- Subacute: 4-12w (refer for further investigation esp if no improvement with treatment)
- Chronic: >12w
- Potential cause
- E.g., infection, malignancy, visceral disease
- Presence (or absence) of radicular symptoms
- radiation of pain, lower extremity pain, paresthesia and/or weakness as a result of nerve root impingement
- Corresponding anatomical/radiographic abnormalities
[Low back pain]
Differential diagnosis of low back pain
Mechanical low back pain:
- lumbar strain (self-limiting 10-14 days)
- herniated disc (neurological symptoms: motor weakness, loss of bowel/bladder function => REFER), sciatica (radiating pain, sensory loss => REFER)
Nonmechanical spine disease
- Neoplasia/malignancy (FH/PMH, unexplained weight loss, fatigue)
- Osteomyelitis, Tuberculosis (fever, constant pain)
- Spinal epidural abscess (fever, malaise, recent spinal injection, epidural catheter placement, immunocompromised)
- Inflammatory arthritis - spondyloarthritis (inflammatory/autoimmune disorders)
Visceral disease
- Pancreatitis - severe abdominal pain
- Renal disease, pyelonephritis - flank pain
[Low back pain]
Non-pharmaco for acute/subacute low back pain:
Pharmaco for acute/subacute low back pain:
Counseling points:
Non-pharmaco for acute/subacute low back pain:
- Superficial heat
- Massage
- Acupuncture
- Spinal manipulation
Heat therapy (use of heat pack 10-15 mins, 3-4 x a day) can be a non-pharm management for lower back pain due to muscle strain
Pharmaco for acute/subacute low back pain:
- NSAIDs
- Skeletal muscle relaxants (Anarex) - Orphenadrine
- Do not use steroids, not shown to have benefits, should not be used even if pt has radicular symptoms
Counseling:
- Usually self-limiting, improve over time
- Remain active as tolerated
[Low back pain]
Non-pharmaco for chronic low back pain:
Pharmaco for chronic low back pain:
Counseling points:
Non-pharmaco for chronic low back pain:
- Exercise - Tai Chi, Yoga
- Multidisciplinary rehabilitation
- Acupunture
- Stress reduction, relaxation
- CBT
- Spinal manipulation
Pharmaco for chronic low back pain:
- 1st line: NSAIDs
- 2nd line: Tramadol/Duloxetine
- Opioids are only considered if the patient has failed 1st and 2nd line, and if benefits outweigh risk
Counseling points:
- Improvement in pain and function from tx may be small
- Remain active as tolerated
- Avoid long-term use of opioids
[Low back pain]
General counseling points
- Engage in low-impact core strengthening exercises to improve spine stability
- E.g., swimming, stationary bicycling, brisk walking
- Physiotherapy
- Use correct lifting and moving techniques
- Squatting, not bending back
- Maintain correct posture when sitting/standing
- Quit smoking
- Risk factor for atherosclerosis - hardening of arteries can cause low back pain and degenerative disc disorders
- Avoid stressful situations (that may cause muscle tension)
- Maintain a healthy weight
- Extra weight around midsection can add strain on lower back
[Myalgia]
What is it?
Characteristics?
Hx taking
Muscle pain, soreness, stiffness
Usually focal rather than diffuse
History taking:
- onset
- location
- associated symptoms
- known reasons? - exercise, overuse, trauma
[Myalgia]
Management (given strain is related to overuse, hence acute and self-limiting)
- RICE
- Topical NSAIDs
- Preventon: proper warm up before exercise
[Myalgia]
Differential diagnosis for diffused myalgia
Infection (e.g., dengue fever, influenza, covid-19)
- diffuse myalgia, fever, chills, arthralgia, fatigue, back pain
Medications
- statins: muscle pain, muscle weakness, red-brown urine
- ciprofloxacin
- bisphosphonates
- aromatase inhibitors
[Myalgia]
Differential diagnosis for focal myalgia
- Strenous exercise
- Overuse
- Trauma
[Myalgia]
Statin-associated muscle symptoms (SAMS)
- Onset
- Clinical presentation
- Management
- Discontinue
- Advice
Onset
- Typically within 6 months
Clinical presentation
- Proximal, generalized, symmetric muscle weakness and/or weakness (hips, thighs, calfs, rarely arms)
- Nocturnal cramping, stiffness, tendon pain, fatigue, tiredness, pain worse with exercise
Management
- Med review
- Administer SAM-CI to assess likelihood of muscle symptoms with statins use
- Restart at lower dose
- Try alternate day dosing
- Switch to hydrophilic statins: Pravastatin, Fluvastatin, Rosuvastatin => less muscle toxicity
Discontinue
- Symptoms intolerable
- CK >10x ULN w / w/o muscle symptoms => Rhabdomyolysis - A&E
Advice:
- Drink large qty of fluids to facilitate renal excretion of myoglobin to prevent renal failure
