soft tissue injuries Flashcards
differentiate the types of joint pain
articular
- OA, RA, gout, osteoporosis
non-articular
- tissue injury, bone pain (fractures, dislocation), referred visceral pain, neuropathic pain, periariticular pain (tendon, ligament)
what is the likely presentation of articular joint pain
swelling, erythematous, tender on palpation of joint, restricted motion
what is the likely presentation of non-articular joint pain
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
list types of soft tissue injuries and define each of them
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)
what are the key features of soft tissue injuries
- consequence of chronic repetitive low grade trauma or overuse
- focal and non-systemic, self-limiting
- responsive to conservative measures
what is the presentation of sprains and how would you classify sprains
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
what is the presentation of tendonitis
local pain and dysfunction, inflammation, degeneration
what are the common etiology of tendonitis
- overuse
- sports injury
- inflammatory rheumatic disease
- calcium apatite deposition from metabolic disturbances
- drug induced (FQ, statins)
what are the common sites that tendonitis occurs at
- shoulder
- wrist
- elbow
- hip
- ankle
what is the presentation of bursitis
pain occurs when motion compresses adjacent bursa to the point where intrabursal pressure increases
what are the common etiology of acute and chronic bursitis
acute
- crystal-induced
- trauma/ injury
- infection (septic bursitis)
chronic
- overuse
- prolonged pressure
- inflammatory arthritis
what are the common sites for superficial and deep bursitis
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
what is the presentation of plantar fasciitis
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
what are the common etiology of plantar fasciitis
- 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
what are the differentials of heel pain and their associated red flags
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)
what are other red flags and situations for urgent referral
- infection-related
- fracture
- ligament rupture
- malignancy/ metastasis
- relating to underlying visceral conditions
what is the initial management approach for soft tissue injuries
- exclude systemic diseases as it is a criteria for referral
- 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)
what are the goals of therapy for management of soft tissue injuries
- reduce pain
- regain function
- prevent future injury
what is the presentation of adhesive capsulitis
- 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
what are the three phases of adhesive capsulitis
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
what are the common etiology of adhesive capsulitis
- 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)
what are the differentials of shoulder pain
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
what is the pharmacological management of adhesive capsulitis
analgesics
- NSAIDs
- paracetamol
- IA GC (plus physiotherapy)
what is the non-pharmacological management of adhesive capsulitis
range of motion exercises
- abduction
- external rotation
- internal rotation
how can lower back pain be classified
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
what are the differentials of lower back pain
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)
what are the pharmacological management for acute and chronic lower back pain
acute
- w/wo NSAIDs or SMR
chronic
- first line is NSAIDs
- alternatively tramadol or duloxetine
what are the non-pharmacological management of lower back pain
- 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
what are the characteristics of myalgia
diffuse and focal symptoms
what are the differentials for diffuse myalgia
infection-related
- viral
- bacterial
- spirochetal
medication
- statin
- ciprofloxacin
- bisphosphonates
- aromatase inhibitors
what are the red flags for urgent referral relating to diffuse myalgia
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
what is the management strategy of myalgia
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!
what is the typical presentation of SAMS
SAMS is statin-associated muscle symptoms that typically presents as proximal symmetric muscle weakness, and also nocturnal cramping, stiffness, tendon pain, fatigue and tiredness
