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3154 MSK > Soft Tissue Injuries > Flashcards

Soft Tissue Injuries Flashcards

1
Q

Examples of non-articular joint pain:

A

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)
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2
Q

What are the features of periarticular pain?

A
  • 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
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3
Q

Characteristics of soft tissue injuries

A
  • 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)
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4
Q

When might urgent referral to ED be necessary?

A
  • Ligament rupture
  • Infection-related cause
  • Malignancy/metastasis (metastasis to spine - lower back pain)
  • Relating to underlying visceral conditions (lower back pain)
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5
Q

Treatment goals:

A
  • Reduce pain
  • Regain function
  • Prevent future injury
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6
Q

Non-pharmaco for soft tissue injuries: RICE, no HARM

A

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)
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7
Q

Pharmaco for non-lower back pain soft tissue injuries

A
  1. Topical NSAIDs (Ketoprofen patch/gel, Diclofenac gel)
  2. PO NSAIDs/coxibs (Pharmacist: Ibuprofen, Naproxen)
  3. 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
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8
Q

[Sprain]

What is a sprain?

A

Stretching, partial rupture, or complete rupture of the ligament

  • cause inability to move well + instability
  • ligament is the bone to bone connective tissue
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9
Q

[Sprain]

What is most common?

  • Mechanism
  • Cause
  • Characteristic
  • Prevalence
A

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

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10
Q

[Sprain]

Grades of sprain

  • Severity
  • Clinical presentation
  • Function
  • Pharm approach
A

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

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11
Q

[Tendonitis]

What is tendonitis?

A

Inflammation of tendon

  • Tendon: muscle to bone connective tissue
  • VS tendinosis/tendinopathy: degeneration of tendon collagen in response to chronic overuse
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12
Q

[Tendonitis]

Etiology

A
  • 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

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13
Q

[Tendonitis]

Features

A
  • Local pain and dysfunction
  • Inflammation
  • Degeneration
  • Pain in a certain direction of pull only
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14
Q

[Tendonitis]

Common sites

A
  • Shoulder
  • Elbow (lateral/medial epicondylitis, aka tennis/golfer)
  • Wrist
  • Hip (lateral)
  • Ankle (Achilles tendinopathy)
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15
Q

[Bursitis]

What is it?

A

Inflammation of bursae

  • Bursae: fluid-filled sacs, lined by synovial membrane in clefts between mobile structures - cushions tendons/muscles from adjacent bones
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16
Q

[Bursitis]

Features (when does pain occur?)

A

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

17
Q

[Bursitis]

Etiology

A

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)
18
Q

[Bursitis]

Common sites

A

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
19
Q

[Plantar Fasciitis]

What is it?

A

Inflammation of plantar fascia

  • Plantar fascia: fibrous attachment connecting heel bone to base of toes - most common cause of heel pain
20
Q

[Plantar Fasciitis]

Etiology

A
  • 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 (?)
21
Q

[Plantar Fasciitis]

Pain characteristics

A
  • 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
22
Q

[Plantar Fasciitis]

Differentials of heel pain

  • When to refer?
A

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)

23
Q

[Frozen shoulder]

Presentation

A
  1. Unilateral (usually non-dominant side, but other side may be affected within 5y)
  2. Limited reaching overhead, to side, across chest, limited rotation => reduced function
  3. 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

24
Q

[Frozen shoulder]

Prevalence and Pathophysiology

A
  • 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
25
Q

[Frozen shoulder]

Management

A
  • Analgesics
  • Range of motion exercises to preserve range of motion (e.g., abduction, external rotation, internal rotation)
  • Intraarticular glucocorticoid + physical therapy
26
Q

[Low back pain]

Classification and treatment:

A

Classification and treatment is based on:

  1. 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
  1. Potential cause
  • E.g., infection, malignancy, visceral disease
  1. Presence (or absence) of radicular symptoms
  • radiation of pain, lower extremity pain, paresthesia and/or weakness as a result of nerve root impingement
  1. Corresponding anatomical/radiographic abnormalities
27
Q

[Low back pain]

Differential diagnosis of low back pain

A

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
28
Q

[Low back pain]

Non-pharmaco for acute/subacute low back pain:

Pharmaco for acute/subacute low back pain:

Counseling points:

A

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
29
Q

[Low back pain]

Non-pharmaco for chronic low back pain:

Pharmaco for chronic low back pain:

Counseling points:

A

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
30
Q

[Low back pain]

General counseling points

A
  1. Engage in low-impact core strengthening exercises to improve spine stability
  • E.g., swimming, stationary bicycling, brisk walking
  • Physiotherapy
  1. Use correct lifting and moving techniques
  • Squatting, not bending back
  1. Maintain correct posture when sitting/standing
  2. Quit smoking
  • Risk factor for atherosclerosis - hardening of arteries can cause low back pain and degenerative disc disorders
  1. Avoid stressful situations (that may cause muscle tension)
  2. Maintain a healthy weight
  • Extra weight around midsection can add strain on lower back
31
Q

[Myalgia]

What is it?
Characteristics?
Hx taking

A

Muscle pain, soreness, stiffness

Usually focal rather than diffuse

History taking:

  • onset
  • location
  • associated symptoms
  • known reasons? - exercise, overuse, trauma
32
Q

[Myalgia]

Management (given strain is related to overuse, hence acute and self-limiting)

A
  1. RICE
  2. Topical NSAIDs
  3. Preventon: proper warm up before exercise
33
Q

[Myalgia]

Differential diagnosis for diffused myalgia

A

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
34
Q

[Myalgia]

Differential diagnosis for focal myalgia

A
  • Strenous exercise
  • Overuse
  • Trauma
35
Q

[Myalgia]

Statin-associated muscle symptoms (SAMS)

  • Onset
  • Clinical presentation
  • Management
  • Discontinue
  • Advice
A

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

3154 MSK (12 decks)

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