Soft Tissue Injury

Question 1

What is the initial immune response to injury?

Answer 1

• When there is tissue damage, Damage-associated molecular patterns (DAMPs) are released
• Pattern recognition receptors of macrophages recognise DAMPs, activating immune response (Inflammatory cytokines released – IL-1, IL-6, IFN-γ, TNF-α etc.)
• Neutrophils recruited by neutrophils – also release inflammatory cytokines
• Tissue stem cells stimulated by inflammatory cytokines to repair damaged tissue
• Monocytes get recruited from the blood to site of injury by CCL2 – IFN-γ, TNF-α and IL-1 stimulate it to differentiate into inflammatory macrophages
• Inflammation till needs to be resolved – inflammatory macrophages eventually differentiate into tissue repair macrophages, stimulated by IL-4, IL-10 and IL-13 (Tissue repair macrophages release growth factors to stimulate repair, inflammation subsides)
• Either impaired healing (IL-4 stimulated) or regeneration (IL-10 stimulated) predominate in the healing processes, depending on the interleukins released (both still take place at the same time)

Question 2

How does fibrosis take place?

Answer 2

• Tissue repair macrophage becomes pro-fibrotic macrophages in the presence of IL-4
• Extracellular matrix gets deposited at injury site
• Wound healing macrophages secrete MMPs (matrix metalloproteases) to cause more deposition of ECM
• Pro-fibrotic macrophages in presence of TGF-β or PDGF will form scar-forming myofibroblasts
• TNF-α and IL-1 stimulate tissue stem cells to form more cells

Question 3

How does regeneration take place?

Answer 3

• TH2 cells and Treg cells secrete IL-4 and IL-10
• Tissue repair macrophage becomes anti-inflammatory anti-fibrotic macrophages in the presence of IL-10
• Anti-inflammatory anti-fibrotic macrophages and growth factors prevent scarring
• γδT cells secrete IGF-1 to stimulate stem cells
• Pericytes cause angiogenesis – important to regrowth of circulatory system

Question 4

What are the soft tissue injuries that require urgent referral to A&E?

Answer 4

• Ligament rupture – inability to bear weight on or use the joint (though not the only possible cause)
• Infection-related causes – fever, rash associated with injury
• Malignancy/metastasis (esp for lower back pain) – chronic, no clear cause, rapid unintentional weight loss
• Relating to underlying visceral conditions (esp for lower back pain) – referred/radiating pain from elsewhere (think about what other organs are in the area, check for other associated symptoms)

Question 5

What are the treatment options for acute non-lower back pain?

Answer 5

Base on the prognosis – how long will the patient be in pain for?
- TOP NSAIDs
- PO NSAIDs/coxib
- PO Paracetamol

Question 6

How can the severity of a sprain be staged?

Answer 6

Grade I
- Mild swelling & tenderness
- Able to bear weight and ambulate w minimal pain

Grade II
- Moderate pain, swelling, tenderness, ecchymosis
(discoloration of skin resulting from bleeding underneath, eg bruise)
- Painful weight bearing and ambulation (mild-moderate joint instability, some restriction in range of motion & function

Grade III - A&E referral
- Severe pain, swelling, tenderness, ecchymosis
- CANNOT bear weight or ambulate

Question 7

What are the clinical features of tendonitis?

Answer 7

→ Local pain & dysfunction on active use
→ Inflammation (but unlikely to cause visible swelling)
→ Degeneration
→ Common Sites: shoulder, elbow, wrist, hip (laterally), ankle

Question 8

What are the possible causes of tendonitis?

Answer 8

→ Overuse – repeated mechanical loading
→ Sports injury
→ Inflammatory rheumatic disease
→ Calcium apatite deposition (from metabolic disturbances)
→ Drug-induced: fluoroquinolone antibiotics and statins

Question 9

What is bursitis?

Answer 9

• inflammation of bursae (fluid-filled sacs around joints that cushion tendons/muscles from bones)
• pain occurs when motion compresses adjacent bursa to the point where intrabursal pressure increases

Question 10

What are the possible causes of acute bursitis?

Answer 10

• Trauma/injury
• Crystal-induced process e.g. gouty bursitis
• Infection i.e. septic bursitis

Question 11

What are the possible causes of chronic bursitis

Answer 11

• Overuse
• Prolonged pressure e.g. kneeling, leaning on
• Inflammatory arthritis e.g. RA, spondylarthritis

Question 12

What is plantar fasciitis?

Answer 12

inflammation of plantar fascia (fibrous attachment connecting heel bone to base of toes)

Question 13

What are the possible causes of plantar fasciitis?

Answer 13

→ Prolonged standing/jumping/running on hard surfaces
→ Flat/High-arched feet
→ Tight hamstring muscle – ↓knee extension ↑s the loading of forefoot, which increases stress on plantar fascia
→ Reduced ankle dorsiflexion
→ Associated with systemic rheumatic diseases

Question 14

How does plantar fasciitis present?

Answer 14

→ Pain worse when walking/running – esp in morning or after a period of inactivity (needs “warm up”)
→ Pain lessens w increased activity but worse at the end of the day (prolonged use)

Question 15

What are the red flags for referral of heel/sole pain?

Answer 15

• Parasthesia
• Numbness
• Nocturnal pain
• Radiating pain
• Trauma
• Fever
• Sudden onset

Question 16

How does frozen shoulder present?

Answer 16

Unilateral – usually non-dominant side, but other side may also be affected within 5 years

Limited ability to reach overhead, side and across chest
→ Reduced function e.g. inability to scratch back, put on clothes

Self-limiting, but symptoms progress through 3 very long phases
→ Initial (lasts 2-9/12): diffuse, severe disabling shoulder pain, worse at night, increasing stiffness
→ Intermediate (4-12/12): stiffness & severe loss of shoulder motion, pain gradually lessens
→ Recovery phase (5-24/12): gradual return of range of motion

Question 17

How can frozen shoulder be managed?

Answer 17

• Analgesics for pain – paracetamol, NSAIDs, weak opioids
• Range of motion exercises
• Intraarticular glucocorticoid injections
• Physiotherapy

Question 18

What are the red flags for back pain?

Answer 18

• unexplained weight loss
• neurologic Sx: – sensory loss, motor weakness, fall, gait instability, numbness, loss of bowel/bladder function etc
• signs of infection: fever, malaise, neck pain (meningitis)

Question 19

How should acute lower back pain be managed?

Answer 19

non-pharm therapy e.g. heat + NSAID

Question 20

How should chronic lower back pain be managed?

Answer 20

non-pharm incl exercise, then NSAIDs as 1st line (possibly tramadol, anarex)

Question 21

What are the counselling points for back pain management

Answer 21

Improvement in pain and function from Tx may be small

Reassure that acute/subacute pain is usually self-limiting

Remain active as tolerated – low-impact core strengthening exercises to improve spine stability

Avoid potentially harmful and costly tests and treatment

Prevention
→ Use correct lifting and moving techniques (e.g. squat to lift heavy objects)
→ Maintain correct posture when sitting or standing
→ Avoid stressful situations – muscle tension
→ Maintain a healthy weight
→ Quit smoking – theoretically atherosclerosis affects lower back pain and degenerative disc disorders (a bit farfetched, but no harm in attempting smoking cessation)

Question 22

When should myalgia be referred to A&E?

Answer 22

Infection-related, or medication toxicity related (e.g. rhabdomyolysis)

Question 23

What are the treatment options for myalgia?

Answer 23

RICE, topical NSAID, prevention (e.g. proper warm up before exercise