The document discusses musculoskeletal pain and disease, providing definitions and discussing the burden of musculoskeletal disorders. It examines different types of musculoskeletal pain, including nociceptive, neuropathic, and central pain, and principles for managing pain based on mechanism. The document also presents a case study of a 50-year-old patient with shoulder pain.

1. KEVIN L. BROWNE, PT, SCD, OCS, COMT
DEC 1, 2016
Medical Topics: Musculoskeletal
Disorders

2. Burden of Musculoskeletal Disease

3. Primary Care & MSK Disease
Burden of Musculoskeletal Disease
 1 Trillion Dollars representing about 6% US GDP
 Yearly Prevalence 18+: Nearly 50%
 Office visits: 18-24%
 NIH: 2% Budget
 Medical Sequela
 Aging of Population

4. Musculoskeletal Pain
A Beneficial Sensory Phenomenon
 Reflexive Protection Through Withdrawal: Heat
 Withdrawal Initiated by Fast Myelinated A Fibers
 First Pain sensory response by A delta fibers
 Maintained by C Fibers = Sensitivity
 Musculoskeletal Pain is Similar: Ankle Sprain
 Withdrawal Initiated by Fast Myelinated A Fibers
 First Pain sensory response by A delta fibers
 Maintained by C Fibers = Sensitivity

5. Musculoskeletal Pain
 Ligament, Capsule and Muscle: Nocioceptors
 Sensitive to Mechanic Stress and Inflammatory Processes
 Silent Nocioceptors: C Fibers
 Activated by Inflammation
 Significant Mechanosensitivity
 Altered Neuromuscular Control
 Forced Joint Protection

6. Musculoskeletal Pain
Subject of Relatively Basic Research
Three Primary Neurophysiologic Mechanisms
 Nociceptive (what we normally think about pain)
 Neuropathic: Direct insult to nervous system
 Central: Sensitized pain (heat and match)

7. Musculoskeletal Pain
Delphi Study: Instrument of Expert Opinion
Nociceptive Pain
Clear and Proportional Nature to Aggravating and Easing Factors
Pain is Proportional to Traumatic or Inflammatory Process and Movement
Localized to area of injury with or without referral
Resolves in accordance to usually healing time
Responsive to Simple Analgesics and/or NSAIDS

8. Musculoskeletal Pain: Nociceptive
Injury, Repair, Recovery
 Stages of Tissue Healing:
 Inflammatory Stage up to 7 days: Modify activity but keep
moving
 Fibroblastic Stage up to 20 days: Active motion: limit
stretching
 Remolding Stage over a Year: Stretch, Gradual resume all
activities

9. Musculoskeletal Pain
Delphi Study: Instrument of Expert Opinion
Neuropathic Pain
Described as burning, shooting, sharp, shock-like, aching and radicular in a
dermatomal or cutaneous distribution
Indicative of (history) nerve injury, pathology or mechanical compromise
Less Responsive to Simple Analgegics and/or NSAIDS and More
Responsive to anti-epileptic or anti-depressant medication
Mechanical Pattern consistent with loading/compressing neural tissue
Spontaneous Pain and associated with Dysthesias: heaviness, crawling

10. Musculoskeletal Pain
Delphi Study: Instrument of Expert Opinion
Central Pain
Disproportional, non-mechanical and unpredictable in response to
aggravating/easing factors
Pain persists beyond usual/expected recovery times and disproportional
to injury or pathology
Maladaptive psychosocial factors: poor self-efficacy, negative emotions
History of Failed Intervention and high levels of functional disability.
Unresponsive to NSAIDS and simple analgesics
High levels of tissue irritability, more constant, disturbed sleep.
Widespread, non-anatomical distribution of pain

11. Musculoskeletal Pain
Principles of Management: Pain Mechanism
 Nociceptive: Business as Usual & Straightforward
 Many patients will get well on their own, need education
 Follow philosophy of conservative to more interventional
 Peripheral Neuropathic: Simple or Complex
 Mild disorder respond well to conservative rx: no atrophy
 More severe may require medical intervention: atrophy
 Central: Requires a Multimodal Rx Regimen
 Best referred to pain management specialist for coordination

12. Musculoskeletal Pain: INSIDIOUS ONSET
Task of Primary Care
Truly Insidious MSK = Ischemia or Degeneration
Musculoskeletal Non-Musculoskeletal
Worst with Specific Activity Worst at Night
Better with Rest Not Relieved with Rest
Position/Movement Related Change Does Not Relieve
Consistently Variable Mind of its Own
Relatively Few Non-MSK Disorders Mimic Upper Extremity Pain Disorders:
Organs: Heart and Gallbladder, Pleura
Pancoast Tumor at the Apex of the Lung

13. Key Definitions in MSK Care
ITIS and OSIS
 Arthritis:
 Inflammation through trauma or systemic causes
 Generic term: does NOT technically indicated degeneration
 Arthrosis/Osteoarthrosis/Osteoarthritis:
 Primary: wear and tear
 Secondary: in response to injury
 May or may not have pain

14. Key Definitions in MSK Care
ITIS and OSIS
 Tendinosis:
 Quite common and may or may not be symptomatic
 Degenerative process in the tendon: 35+ years old
 Tendonitis:
 Strictly an inflammation in the tendon
 Less common than you might think

15. Key Definitions in MSK Care
 Referred Pain: Pain perceived at a location other
than the site of the painful stimulus
 Example: Rotator cuff tear causes pain in the lateral arm
 Radicular Pain: Pain that radiates into the upper
extremity directly along the course of a spinal
nerve root and dermatomal pattern
 Example: Cervical Radiculopathy

16. Common Differential Diagnosis: Pain Localization
Pain Localization: Mapping of Sensory Cortex
Good Localization Uncertain Localization
Distal Structures Proximal Structures
Superficial Structures Deep Structures
Ventral Structures Dorsal Structures
Good/Certain Localization: Wrist Tendinopathy or Ligament Injury
Uncertain Localization: Cervical Disc or Subacromial Shoulder
Exception: Nerve Entrapment

17. Subjective Exam/Patient Interview
Who?
 Age can be very helpful!
 Don’t expect degenerative tendinosis in young people
 Don’t expect OA in young people (unless secondary)
 Occupation, Hobbies and Sport
 Identify potentially aggravating stresses

18. Subjective Exam/Patient Interview
What?
 What is/are the primary complaint/s?
 Weakness is a red flag in healthy individuals
 Sensory Changes: Nervous System
 Usually it will be pain

19. Subjective Exam/Patient Interview
When?
 When did it start? Chronicity
 Less than 2 wks good chance to self-limit
 6-8 weeks start to have adaptive changes
 Is it getting better?
 MSK complaints some improvement within 10-14 days
 Is this recurrent? Has it happened before?
 Yes: More likely to require a form of treatment

20. Subjective Exam/Patient Interview
Where?
 Where is/are your symptoms?
 Helps us to think about pain generators
 Ask about the full extent of symptoms
 Ask about seemingly unrelated symptoms

21. Subjective Exam/Patient Interview
Why?
 Why did it happen? How did it start?
 “Have you done anything out of the ordinary or changed your
exercise routine?”
 Insidious onset? There is almost always a reason: find it
 Delayed symptoms: Ask about the 2-3 days prior

22. Subjective Exam/Patient Interview
What
Extent?
 Is the pain constant, intermittent or episodic?
 Constant often inflammation
 Intermittent may be postural/positional
 Episodic usually mechanical
 Think about tissue irritability: guides exam
 Low irritability may be difficult to provoke during the exam
 High irritability do as little as possible to provoke

23. Clinical Examination
Be S.M.A.R.T. and Palpate Last
 S=Scan/Survey Observing the Patient
 First tool: Make sure you look at the area
 Watch how they spontaneously move
 Compare sides

24. Clinical Examination
Be S.M.A.R.T. and Palpate Last
 M=Motion/Mobility (active range of motion)
 Assess willingness to move and quality of motion
 Compare to the opposite side for a reference
 WHO are you examining? (Expectations)

25. Clinical Examination
Be S.M.A.R.T. and Palpate Last
 A=Assisted Motion (passive range of motion)
 Potentially more useful information
 True mobility to assess Capsular Pattern
 End feel: example bony hard end feel
 Normal in elbow extension
 Pathological in elbow flexion

26. Clinical Examination
Be S.M.A.R.T. and Palpate Last
 R=Resisted Testing (Strength and Provocation)
 No extraneous motion and Aim for good stability
 Four Performance Categories:
 Strong and pain free: Likely no pathology to muscle/tendon
 Strong and painful: Not likely to have a large tear, likely
mm/tendon
 Weak and painful: Ask for best effort. Possible significant tear
 Weak and pain free: complete tear or nerve supply disruption

27. Clinical Examination
Be S.M.A.R.T. and Palpate Last
 T= Tests that are Special (Special Testing)
 Varies depending on the joint involved: not exhaustive
 Aim to do tests that are potentially actionable
 Specificity and Sensitivity??

28. Clinical Examination
Be S.M.A.R.T. and Palpate Last
 Use as a confirmation of your suspicions
 Palpation can fool you.
 Referred tenderness
 Tissue sensitization

29. Case of the 50-Year Old Shoulder

30. Case Study: The 50 Year Old Shoulder
Background
 Had already seen Orthopedic Surgeon and had MRI
 Partial thickness tear supraspinatus
 Moderate AC joint OA
 Mild GH joint OA
 Bursitis
Treated for Bursitis: Complete resolution of pain

31. Case Study: The 50 Year Old Shoulder
Who?
 54 yo male, professional photographer, lifts weights

32. Case Study: The 50 Year Old Shoulder
What?
 Shoulder pain that is constant, dull and throbbing
pain.
 No sensory, motor or constitutional signs

33. Case Study: The 50 Year Old Shoulder
When?
 Started 9 months ago and gotten a some better
 Long history of minor “twinges” in the shoulder

34. Case Study: The 50 Year Old Shoulder
Where?
 Pain in the lateral proximal ½ of the right humerus
 Denys pain in the neck, chest, scapula, upper trap

35. Case Study: The 50 Year Old Shoulder
Why?
 Suspects from “heavy” weight lifting. He cut back
some
 Does not recall a specific incident

36. Case Study: The 50 Year Old Shoulder
What
Extent?
 Constant, worse with overhead reach and lying R
side
 Pain 2/10 at rest and 7/10 overhead reach
 Wakes at night occasionally

37. Case Study: The 50 Year Old Shoulder
What are we thinking?
 Start with location of symptoms: lateral arm, localized
 Generally pain referral site for many pain generators
 Constant nature for 9 months (NSAIDS help)
 May be related to weight lifting
Hypothesis?
Chronic, possibly inflammatory, subacromial pathology

38. Case Study: The 50 Year Old Shoulder
What are the Differential Diagnoses
 1. Referred C-Spine
 2. Tendinopathy
 3. Rotator Cuff Tear
 4. Subacromial Bursitis
 5. Glenohumeral OA

39. Case Study: The 50 Year Old Shoulder
Clinical Exam Objective Signs
Be S.M.A.R.T. and Palpate Last
 S = Scan/Survey
 M= Motion/Mobility completed by the patient
 A = Assisted Motion completed by the examiner
 R = Resisted Tests loads the muscles
 T = Tests (Special Tests)

40. Case Study: The 50 Year Old Shoulder
Clinical Exam Objective Signs
 Be S.M.A.R.T. and Palpate Last:
 S = Scan/Survey
 No muscular atrophy
 No clear asymmetry

41. Case Study: The 50 Year Old Shoulder
Clinical Exam Objective Signs
 Be S.M.A.R.T. and Palpate Last
 M= Mobility/Motion
 Rule out C-Spine: Mild limits and no pain
 Lacks 5 degrees of elevation, worse end range, worse abduction
 No crepitus, but there is clicking mid-range

42. Case Study: The 50 Year Old Shoulder
Clinical Exam Objective Signs
 Be S.M.A.R.T. and Palpate Last
 A = Assisted Motion (passive)
 Mild limit of glenohumeral external rotation
 Mild increase pain with overpressure elevation

43. Case Study: The 50 Year Old Shoulder
Clinical Exam Objective Signs
 Be S.M.A.R.T. and Palpate Last
 R = Resisted Tests
 Moderate increased pain resisted Abduction, ER, IR
 Strength 5- to 5/5 (no clear weakness)

44. Case Study: The 50 Year Old Shoulder
Clinical Exam Objective Signs
 Be S.M.A.R.T. and Palpate Last
 T = Tests (Special Tests)
 Hawkins: Mild increase pain
 Labral Test: Very mild increase pain
 Pull Test: Eliminate pain on resisted ER

45. Case Study: The 50 Year Old Shoulder
Clinical Exam Objective Signs
 Be S.M.A.R.T. and Palpate Last
 Palpate Last:
 No tenderness to AC joint, biceps tendon, supra and
infraspinatus
 No tenderness to deltoid insertion

46. Case Study: The 50 Year Old Shoulder
What have we learned?
Tendinopathy, Rotator Cuff Tear, Bursitis, OA
 Full or Near-Full Resistance : Large RC Tear
 Pain all resisted tests: Tendinopathy, RC Tear

47. Case Study: The 50 Year Old Shoulder
Bursitis or Osteoarthritis?
 Each can cause constant pain laying on the involved side
 Each can result in increase pain on multi-resisted test
 Special Test? Pull Test was dramatic for decrease pain R
Bursitis

48. Initial Management and Informed Consent
What about NSAIDS? UK Study
 NSAIDS beyond 3 wks for fracture increase risk non-union
 Likely useful for early tendonitis and useless for tendinosis
 AT THE RIGHT TIME! Can interfere with healing beyond a few days
 Ligament injury: decrease swelling and increase function
 Apparently not harmful for muscle tissue
 Long term use carries usual risks
Recommendation: Use Acetaminophen or limit NSAIDS
If not helpful, addition of a codeine pharmacological agent