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soft tissue injuries Flashcards

1
Q

differentiate the types of joint pain

A

articular

  • OA, RA, gout, osteoporosis

non-articular

  • tissue injury, bone pain (fractures, dislocation), referred visceral pain, neuropathic pain, periariticular pain (tendon, ligament)
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2
Q

what is the likely presentation of articular joint pain

A

swelling, erythematous, tender on palpation of joint, restricted motion

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3
Q

what is the likely presentation of non-articular joint pain

A

point of maximal tenderness not at joint line on palpation, pain on active movement more than passive movement, pain maximal in certain lines of muscle pull

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4
Q

list types of soft tissue injuries and define each of them

A

sprains

  • stretching, partial rupture or complete rupture of ligament (bone-to-bone connective tissue)

tendonitis

  • inflammation of the tendon (muscle-to-bone connective tissue)

bursitis

  • inflammation of the bursa (fluid filled sacs around the joint that cushions tendons/ muscles from adjacent bones)

plantar fasciitis

  • inflammation of the plantar fascia (fibrous attachment connecting heel bone to base of toes)
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5
Q

what are the key features of soft tissue injuries

A
  • consequence of chronic repetitive low grade trauma or overuse
  • focal and non-systemic, self-limiting
  • responsive to conservative measures
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6
Q

what is the presentation of sprains and how would you classify sprains

A

sudden onset of pain and swelling after a pop sound

grade I (mild stretching and microscopic tears)

  • mild swelling and tenderness, able to bear weight

grade II (incomplete tear of ligament)

  • moderate pain, swelling and tenderness, ecchymosis (bruising), painful weight bearing and ambulation
  • mild to moderate joint instability, some restriction in joint motion and function

grade III (complete tear of ligament)

  • severe pain, swelling, tenderness and ecchymosis, unable to bear weight
  • significant joint instability, loss of joint motion and function
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7
Q

what is the presentation of tendonitis

A

local pain and dysfunction, inflammation, degeneration

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8
Q

what are the common etiology of tendonitis

A
  • overuse
  • sports injury
  • inflammatory rheumatic disease
  • calcium apatite deposition from metabolic disturbances
  • drug induced (FQ, statins)
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9
Q

what are the common sites that tendonitis occurs at

A
  • shoulder
  • wrist
  • elbow
  • hip
  • ankle
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10
Q

what is the presentation of bursitis

A

pain occurs when motion compresses adjacent bursa to the point where intrabursal pressure increases

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11
Q

what are the common etiology of acute and chronic bursitis

A

acute

  • crystal-induced
  • trauma/ injury
  • infection (septic bursitis)

chronic

  • overuse
  • prolonged pressure
  • inflammatory arthritis
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12
Q

what are the common sites for superficial and deep bursitis

A

superficial (those that cushions skin and bones)

  • elbow
  • knee cap
  • posterior upper thigh

deep (those that decreases friction of muscles as they glide over each other/ bone prominences)

  • hip
  • shoulder
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13
Q

what is the presentation of plantar fasciitis

A

pain worsens when walking/ jumping/ running, esp after a period of inactivity/ in the morning, pain lessens on activity but worse at end of the day

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14
Q

what are the common etiology of plantar fasciitis

A
  • prolonged standing/ jumping/ running on hard surfaces
  • flat/ high arched feet
  • reduced ankle dorsiflexion
  • tight hamstring muscle leads to decreased knee extension thus increasing loading of forefoot and increase stress on plantar fascia
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15
Q

what are the differentials of heel pain and their associated red flags

A

neurologic

  • paresthesia and numbness
  • nocturnal sx
  • radiating pain from posterior aspect of leg to heel

skeletal

  • prior trauma
  • nocturnal sx
  • fever
  • constant pain

soft tissue

  • sudden onset (may be suggestive of a rupture)

inflammatory

  • PMHx or FHx of inflammatory disorders
  • erythema nodosum (skin inflammatory disorder characterised by tender red nodules or lumps)
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16
Q

what are other red flags and situations for urgent referral

A
  • infection-related
  • fracture
  • ligament rupture
  • malignancy/ metastasis
  • relating to underlying visceral conditions
17
Q

what is the initial management approach for soft tissue injuries

A
  1. exclude systemic diseases as it is a criteria for referral
  2. if appropriate for self-care,
  • eliminate aggravating factors
  • explain the illness
  • provide self-help strategies (RICE)
  • provide pain relif
  • explain prognosis (for mild/ acute, a few weeks; for moderate to severe, 4-6w; 1-2w for mild sprain)
  • strategies to prevent future recurrences (awareness, proper warmup and cooldown, proper technique and form, gradual progression and rest)
18
Q

what are the goals of therapy for management of soft tissue injuries

A
  • reduce pain
  • regain function
  • prevent future injury
19
Q

what is the presentation of adhesive capsulitis

A
  • unilateral (usually non-dominant side but other side becomes affected in 5yrs)
  • limited reaching overhead, across chest and sideways, with limited rotation (refer if marked loss)
  • self-limiting but through three very long phases
20
Q

what are the three phases of adhesive capsulitis

A

initial (2-9m)

  • diffuse severe disabling shoulder pain that is worse at night, stiffness

intermediate (4-12m)

  • stiffness and severe loss of motion, pain gradually lessens

recovery (5-24m)

  • gradual return of range of motion
21
Q

what are the common etiology of adhesive capsulitis

A
  • shoulder injury
  • associated with presence of DM (chronic hyperglycemia and metabolic disturbances increases inflamm, impairs tissue healing and causes collagen deposition), hypothyroidism (THs important for regulation of metabolism and tissue repair), dyslipidemia (elevated lipids causes increase in inflamm and oxidative stress) and prolonged immobility (stiffness and contracture of surrounding tissues)
22
Q

what are the differentials of shoulder pain

A

inflammatory

  • RA
  • PsA
  • gout
  • pseudogout

degenerative

  • OA

infection

  • septic arthritis
  • osteomyelitis

trauma

  • fracture
  • dislocation
  • ligamentous injury

connective tissue disorders

  • inflamm myositis
  • systemic vasculitis

soft tissue rheumatism

  • rotator cuff syndrome
  • adhesive capsulitis
  • bursitis

tumors

23
Q

what is the pharmacological management of adhesive capsulitis

A

analgesics

  • NSAIDs
  • paracetamol
  • IA GC (plus physiotherapy)
24
Q

what is the non-pharmacological management of adhesive capsulitis

A

range of motion exercises

  • abduction
  • external rotation
  • internal rotation
25
Q

how can lower back pain be classified

A

by sx duration

  • acute if <4w
  • subacute if 4-12w
  • chronic if >12w

by potential causes

  • to identify red flags that point at infection-related or malignancy

by presence (or absence) of radicular sx

  • lower extremity pain, paresthesia and/or weakness

by corresponding anatomical/ radiographic abnormalities

26
Q

what are the differentials of lower back pain

A

mechanical

  • lumbar strain (self-limiting in 10-14d)
  • herniated disc (! neurologic sx such as paresthesia and numbness, loss of bowel/ bladder function, motor weakness)
  • fractures (! chronic GC use, PMHx of osteoporotic/ traumatic #, trauma)
  • sciatica – sharp burning pain that radiates from butt to posterior leg to heel, loss of senses, reflex changes (! refer if no improvement)

non-mechanical

  • infection (! fever and malaise, recent spinal inj/ epidural catheter placement, constant pain, immunocompromised)
  • neoplasm (! unintended weight loss, PMHx of malignancy)

visceral disease

  • !sx pointing towards underlying causes (eg. severe abdominal pain)
27
Q

what are the pharmacological management for acute and chronic lower back pain

A

acute

  • w/wo NSAIDs or SMR

chronic

  • first line is NSAIDs
  • alternatively tramadol or duloxetine
28
Q

what are the non-pharmacological management of lower back pain

A
  • assure self-limiting for acute or subacute pain
  • proper sitting and standing posture
  • correct lifting and moving techniques (squat to lift, get help if too heavy or awkward)
  • quit smoking (risk factor for atherosclerosis)
  • maintain active as tolerated (low impact core strengthening exercises such as swimming, briskwalking, bicycling, yoga, pilates, stretching)
  • maintain healthy weight esp around midsection as this can add additional strain on lower back
  • avoid stressful situations as these can increase muscle tension
29
Q

what are the characteristics of myalgia

A

diffuse and focal symptoms

30
Q

what are the differentials for diffuse myalgia

A

infection-related

  • viral
  • bacterial
  • spirochetal

medication

  • statin
  • ciprofloxacin
  • bisphosphonates
  • aromatase inhibitors
31
Q

what are the red flags for urgent referral relating to diffuse myalgia

A

bacterial infection-related myalgia presented as diffuse myalgia, fever, chills, arthralgia, fatigue, back pain

and

medication toxicity related, statin induced presented as muscle pain, muscle weakness, red-brown tea colored urine related to myoglobinuria

32
Q

what is the management strategy of myalgia

A

if symptoms are intolerable, discontinue statin (resolved in a few days to weeks), restart at lower dose or alternate day dosing or switch to pravastatin or fluvastatin (these have lower muscle toxicity)

if CK>10xULN w/wo unexplained muscle symptoms, discontinue statin and advice to drink large quantities of fluid to facilitate excretion of myoglobin to prevent renal failure

rhabdomyolysis is a clinical emergency!

33
Q

what is the typical presentation of SAMS

A

SAMS is statin-associated muscle symptoms that typically presents as proximal symmetric muscle weakness, and also nocturnal cramping, stiffness, tendon pain, fatigue and tiredness

34
Q
A

osce prep (21 decks)

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