Musculoskeletal Pain: Diagnosis and Management Michael Binder, MD SW Ohio Board Review February 8, 2018 Outline I.
Low back pain II. Neck pain III. Upper extremity disorders IV. Lower extremity disorders Material adapted from MKSAP 17 and other sources as listed
Question # 1 A 43 year-old man is evaluated for 2-week history of low back pain. He says pain is worse just left of the center of his lumbar spine. He thinks his back gave out when was helping a friend of his move furniture. He has been resting in bed since his symptoms started and feels his pain is unchanged. He denies fevers, chills, and weight loss. Vital signs are normal and he has no weakness or sensory deficits on exam. Straight-leg raise produces an electric sensation from the patients left hip to his ankle. What is the next best step? A. MRI of the lumbar spine B. Advise mobilization C. Start nortriptyline
D. Advise bed rest until symptoms improve E. Plain radiographs of the lumbar spine Answer and explanation Answer: B. Advise mobilization This patient has acute low back pain He has radiculopathy, possibly due to herniated disk. The straight-leg test is 91% sensitive for diagnosing disk herniation. Grade B evidence supports advising patients in this scenario to remain active, providing information on
low back pain, applying superficial heat, and trialing acetaminophen and/or NSAIDs. Antidepressants (especially SNRI and TCAs) may be considered if symptoms are subacute or chronic in duration (greater than 4 weeks). Diagnostic testing and surgical evaluation should be pursued if: Symptoms persist greater than 6 weeks after conservative management Rapidly progressive symptoms, including neuromotor deficits Low Back Pain Source: www.paindoctor.com
Source: www.hellawella.com Low Back Pain Diagnosis and Evaluation Duration: Acute: <4 weeks vs. Chronic: >12 weeks Prognosis is excellent regardless: Full recovery in 9/10 patients within 6 weeks
Low Back Pain History and Physical: Nonspecific pain is most common (85% of patients) Radiculopathy (7%) Rule-out alarm features: Neurologic features (e.g. urinary retention, saddle anesthesia) Fevers, chills Weight loss Progressive weakness
Low Back Pain Treatment strategies, nonpharmacologic: Education is key The biopsychosocial model of pain Start with nonpharmacologic treatment: activity, superficial heat, massage Encourage activity and help the patient set treatment goals Works best when the patient owns the treatment plan Screen for depression
Cognitive behavioral therapy has strong evidence for helping patients with chronic pain improve their quality of life Reference: ACP Clinical Guidelines, 2017 A comprehensive approach to pain Biopsychosocial model 1. Chronic pain is complex 2. Environment and psychological factors 3. Takes a team-based approach
4. Medications are only part of the treatment plan 5. Change the locus of control Source: Vasudevan, S. Multidisciplinary Management of Chronic Pain: A Practical Guide for Clinicians (2016), figure 8.1 Low Back Pain Treatment strategies, pharmacologic: 1st line Rx treatment: NSAIDs and/or muscle relaxers
2nd line Rx treatment: tricyclic antidepressants Opioids should generally be avoided Gabapentin is indicated in patients with radiculopathy Systemic corticosteroids have not been shown to be more effective than placebo Reference: ACP Clinical Guidelines, 2017 Scale of the epidemic Opioids are not a cure for chronic
pain Source: Health and Retirement Study, 19982010. Credit: Sarah Frostenson, vox.com United states vs. the rest of the world Roots of the epidemic Question # 2 A 33 yo female presents to the emergency with acute on chronic low back pain. Her PMH is unremarkable except for chronic, intermittent low back pain. Usually her pain is manageable and does not interfere with her daily activities. However, over the past day she has
noticed rapidly progressive pain that has prevented her from working. Naproxen usually brings her relief, but today it has not improved her pain. She otherwise has been feeling okay, and denies any recent fevers, chills or weight loss. On her way in to see her doctor about her back pain, she had an episode of urinary incontinence. On physical exam, she is afebrile, HR 92, BP 144/82, spo2=99% on RA. Her general exam is largely unremarkable; however, on musculoskeletal exam, she has absent achilles reflex. She has saddle anesthesia and lower extremity weakness on her neurologic exam. What is the next step in management? A. Surgical evaluation B. Lumbar spine x-ray C. Glucocorticoid therapy D. Lumbar puncture
Answer and explanation Answer: A. Surgical evaluation This patient has cauda equina syndrome, which is a surgical emergency. Pain is generally the most common early symptom, before patients develop neurologic findings. Early surgical intervention decreases the chance of permanent neurologic damage. Treatment with glucocorticoids is not indicated with no evidence of an inflammatory disorder.
Low Back Pain Cauda equina syndrome is compression of the lumbar and sacral nerves below the termination of the spinal cord (conus medullaris). It is usually caused by a large, centrally herniated disc. Other etiologies include malignancies. Characterized by: Back pain and radicular pain Sensory changes in the S3-S5 dermatome (saddle anesthesia) Bowel, bladder or sexual dysfunction Bilateral motor weakness of the lower extremities Absent ankle reflexes bilaterally
Question # 3 A 68 year-old woman is evaluated for 6-month history of right sided neck and shoulder pain with occasional headaches. She feels her right arm is weaker when trying to raise it above her shoulder. She has some burning and tingling over the lateral aspect of her right arm. She denies trauma. She has a history significant for obesity, hypertension, and hyperlipidemia and takes hydrochlorothiazide and atorvastatin. Vital signs are normal and exam reveals reduced sensation over the lateral aspect of the patients upper arm and reduced abduction and flexion at the right shoulder. Shoulder maneuvers do not elicit pain. Pushing down on the patients head while her head is extended and tilted toward the right reproduce pain. She does not have spasticity or hyperrelexia. Neurogenic neck pain is diagnosed. What disc is causing the patients symptoms? A. C4-C5 B. C5-C6 C. C6-C7
D. C7-T1 E. T1-T2 Explanation Answer: a: C4-C5 This patient likely has neurogenic neck pain. Her symptoms of dermatomal weakness and numbness at the deltoid, biceps and rhomboid are caused by disk protrusion affecting the C5 nerve root. Her biceps reflex may be reduced on examination. Spinal cord is unlikely involved as she does not have spasticity or hyperreflexia.
Degenerative osteoarthritis is a likely cause of this patient neurogenic neck pain causing disk herniation. It is reasonable to pursue imaging because of her neurologic signs of weakness. Gabapentin or tricyclic antidepressants may provide some relief. Neck Pain Three categories: 1. Mechanical 2. Neuropathic 3. Neck pain from a systemic disease
Conservative treatment (PT, NSAIDs, acetaminophen) generally works well Upper Extremity Disorders 1. Thoracic Outlet Syndrome 2. Shoulder pain 3. Elbow pain 4. Wrist and hand pain Thoracic Outlet Syndrome Three main subtypes:
1. Neurogenic: most common subtype. Caused by compression of the brachial nerve roots - Symptoms: paresthesias of hand or arm - Treatment: PT, conservative measures - Second line Tx: surgery 2. Venous: caused by thrombosis of the subclavian or axillary veins - First-line treatment: catheter-directed thrombolysis 3. Arterial: due to compression of the subclavian
artery - Treatment: surgery Source: www.freedbodyworks.com Shoulder Pain Is it coming from the shoulder or somewhere else (referred pain)? Intrinsic shoulder pain: Pain with shoulder movement Stiffness Limited ROM
Referred pain (usually from cervical spine): Normal shoulder exam Shoulder Pain Rotator cuff disorders: Partial tears: Strength is usually preserved Treatment: conservative therapy, including strengthening exercises and NSAIDs
Full tears: MRI is the diagnostic test of choice Treatment: surgery (with exceptions) Shoulder Pain Adhesive capsulitis (frozen shoulder): Glenohumeral joint capsule thickening and fibrosis Loss of both active and passive range of motion Treat early. PT and steroid injections are helpful If no improvement by 2-3 months, refer for surgery
Shoulder Pain Acromioclavicular Joint Degeneration: Pain located on superior aspect of shoulder Often tender to palpation Diagnose: cross arm test positive; x-ray Treatment: NSAIDs and activity modification Elbow Pain Pain from one of 3 areas:
Epicondylosis: Lateral epicondylosis (tennis elbow): pain with resisted wrist extension Medial epicondylosis (golfers elbow): pain with resisted wrist flexion Treatment: NSAIDs and rest Elbow Pain: olecranon bursitis Olecrenon bursa inflammation can be caused by trauma, gout, rheumatoid arthritis, and infection.
- Most cases are benign - Aspirate the fluid if you suspect infection (fevers, severe pain) - Treatment depends on the cause; generally involves patient education and joint protection Elbow Pain due to ulnar nerve entrapment (aka cubital tunnel syndrome)
Can be caused by: - Bone spurs - Ganglion cysts - Ulnar nerve subluxation - Constriction from fibrous tissue - Symptoms worsen with flexion of the elbow and can progress to numbness of the 4th and 5th fingers and
interosseous muscles. - Treatment: NSAIDs, splinting at night. Surgery if patient does not respond to conservative measures. Source: www.orthoinfo.aaos.org Carpal Tunnel Syndrome - Etiology: median nerve compression within the carpal tunnel
- Risk factors: obesity, female, pregnancy, hypothyroidism, DM2, connective tissue diseases - Pain frequently is worse at night and with repetitive actions. Most patients present with bilateral pain. - Diagnosis: clinical diagnosis, confirmed with nerve conduction testing - Treatment: splinting, local steroid injections for mild to moderate symptoms. Surgery for patients with severe symptoms.
The lower extremities Hip pain Knee pain Ankle and foot pain Question # 4 A 55 year-old man presents with 2-week history of numbness over the lateral aspect of his right thigh. He denies leg weakness, falls, or radiation of his symptoms. He denies trauma. Past medical history is significant for morbid obesity, sleep apnea, type 2 diabetes mellitus, and hypertension. He takes metformin and Lisinopril. He works at a desk most of the day. Vital signs are normal and physical exam is positive for reduced sensation over the anterolateral aspect of the right thigh and limited hip abduction and extension. Glycosylated hemoglobin (Hgba1c) was 9.6% four months ago. What is recommended treatment for this patient?
A. Glucocorticoid injection of the lateral hip B. Add glipizide C. Physical therapy D. Acupuncture Answer and explanation Correct Answer: B. Add glipizide This patient has lateral femoral cutaneous nerve entrapment or meralgia paresthetica. Obesity and poorly controlled diabetes mellitus are risk factors in this patient for this
syndrome. Other risk factors include pregnancy and wearing tight clothing or belts around the waist. Weight loss should be advised and more aggressive management of diabetes is indicated. He does not have trochanteric bursitis, which would present as an aching sensation over the greater trochanteric bursa or lateral hip worse when lying on the affected side. Trochanteric bursitis pain does not radiate to the groin. Iliotibial band syndrome often presents with sharp pain over the lateral femoral epicondyle at the lateral aspect of the knee, and can occur with overuse (i.e. running). Hip pain
Common etiologies: Degenerative hip disease: pain radiates to groin, worse with weight-bearing Trochanteric bursitis: aching over the lateral hip; does not limit range of motion Meralgia paresthetica: caused by entrapment of the lateral femoral cutaneous nerve Piriformis syndrome: caused by compression of the sciatric nerve by the piriformis Osteonecrosis (avascular necrosis): caused by lack of blood supply; usually requires surgery Knee Pain
Common etiologies: - Ligament and meniscal tears: - ACL: pop, effusion, laxity on anterior drawer test - PCL: car accidents; laxity on posterior drawer test - MCL or LCL: joint instability, tenderness and swelling - Meniscus tear: Lock and catch; Tx: RICE - Patellofemoral Pain syndrome: - Anterior knee pain, gradual; worse with activity - Bursitis: - Acute anterior knee pain and swelling over the patella
- Illiotibial Band Syndrome: - Treat with ice, NSAIDs - Popliteal (Baker) Cyst: - Due to OA or knee trauma; usually asymptomatic - Can mimic a DVT Image source: radiopaedia.org Ankle and Foot Pain Ankle sprains Midfoot pain
Forefoot pain Question # 5 A 48 year-old woman presents to the office with a 1-day history of acute right ankle pain. She missed a step from the curb carrying bags to her car and felt her ankle buckle out. She is very concerned about the swelling, bruising and pain she has on the lateral aspect of her right ankle. Vital signs are normal and exam is positive for generalized tenderness over the right anterolateral ankle but no pain at the malleolus. She has pain on standing but is able to bear weight. What criteria does this patient meet to warrant obtaining ankle radiograph series? A.
She has swelling and ecchymosis. B. She has pain at the anterolateral aspect of the ankle. C. She does not warrant radiographs.
D. She has pain on standing. Answer and explanation Correct Answer: C Explanation: This patient likely inverted her right ankle during plantar flexion, stepping down from the curb. She has suffered a lateral ankle sprain, most commonly of the anterior talofibular ligament. Exam findings are not concerning for fracture according to the Ottawa ankle and foot
rules, which have a sensitivity of over 95% to diagnose ankle fractures. If the Ottawa rules are met then plain radiographs are indicated. Ottawa rules for ankle radiographs are: Pain at the malleolar zone plus any of the following: bone tenderness at the posterior edge or tip of the lateral malleolus, bone tenderness at the posterior edge or tip of the medial malleolus, or an inability to bear weight immediately and in the emergency department or (physicians office). Ottawa rules continued Ottawa rules for foot radiographs are:
Pain in the midfoot zone and any of the following: bone tenderness at the base of the fifth metatarsal, bone tenderness at the navicular bone, or inability to bear weight immediately and in the emergency department (or physicians office). Though this patient has pain at the lateral aspect of her ankle, the exam does not reveal pain at the edge of the lateral malleolus or in the malleolar zone. Her pain is likely from a sprained anterior talofibular ligament.
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