Common Musculoskeletal Problems.pptx

Presentado por:
Dr. Alexis A. Cuevas
R1 Medicina Interna
Common
Musculoskeletal
Problems

Table of contents
2
Acute Musculoskeletal Pain
Low Back Pain
Neck Pain
Upper Extremity Disorders
Lower Extremity Disorders

is caused by various soft tissue injuries,
strains (injury to a tendon or a muscle), and
sprains (injury to a ligament).
3

4
are inaccurately
treated with
opioids
20%
Substantial potential harms
➔ Risk for longer-term use
➔ Addiction
➔ Overdose
MKSAP 19. General Internal Medicine I. Common Musculoskeletal Problems
acute pain
(<4 weeks duration)
Topical
NSAIDs
second line
improved pain and function
Oral
NSAIDs
not recommended
Opioids

Low Back Pain
6
Most common identifiable causes
➔ spinal stenosis
➔ disk herniation
➔ compression fractures
Chronic Pain
(>12 weeks)
Subacute Pain
(4 - 12 weeks)
Acute Pain
(<4 weeks)
Less common identifiable causes
➔ vertebral metastases
➔ infection
Diagnosis and Evaluation

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8

Low Back Pain
9
History and Physical Examination
fever and
neurological signs
strength, sensory and
reflex testing of the
legs
ipsilateral and
contralateral straight
raise leg test

Low Back Pain
10
History and Physical Examination

Low Back Pain
11
Further Diagnostic Testing
Within the first 6 weeks of symptoms
➔ avoid performing images routinely
➔ imaging abnormalities are
common
➔ obtaining images is not associated
with improved outcomes
➔ their discovery may lead to
unhelpful and costly interventions
Imaging indications
➔ severe or progresive neurologic
compromise
➔ suspicion of a life/function
threatening cause
➔ MRI is the preferred test for most
suspicions

Low Back Pain
12
Treatment
Nonpharmacologic treatment Pharmacologic treatment
Acute Low Back Pain
➔ Physical therapy
➔ Local heat
➔ Acupuncture
➔ Spinal manipulation therapy
Chronic Low Back Pain
➔ Exercise therapy
➔ Massage therapy
➔ Acupuncture
➔ Yoga
➔ Cognitive Behavioral therapy
Acute Low Back Pain
➔ NSAIDs
➔ Non-benzodiazepine muscle
relaxants
Chronic Low Back Pain
➔ NSAIDs
relaxants
➔ SNRIs

Neck Pain
14
A priority in evaluating neck pain is differentiating musculoskeletal pain from
conditions that may cause serious complications.
The most common causes
are musculoskeletal
➔ cervical strains
➔ spondylosis
➔ cervical facet osteoarthritis
Pain and stiffness in the absence of
neurologic abnormalities

Neck Pain
15
Radiculopathy and myelopathy are the most common causes of neurological neck pain.
Cervical radiculopathy
Paresthesia in a dermatomal
distribution
Radiating arm pain
Neck pain
Decreased deep tendon reflexes
Diminished strength

Neck Pain
16
Compressive cervical myelopathy
➔ neck pain with leg weakness
➔ gait/coordination disturbances
➔ bladder and bowel dysfunction
On examination
➔ upper motor neuron signs in upper
extremities
➔ lower motor neuron signs near
compression level

Neck Pain
17
Treatment
A multimodal approach that is tailored for each individual appears to work best
➔ range of motion exercise
➔ physical therapy
➔ ice / heat applications
➔ stretching / strengthening
exercises
Analgesic agents
➔ NSAIDs
relaxants
➔ SNRIs
➔ Neuromodulators

Thoracic Outlet Syndrome
19
Arterial
(1-3%)
➔ subclavian artery
compression
➔ w/wo thrombosis
➔ abnormal cervical rib
➔ arm or hand pain
➔ weakness
➔ paresthesia
➔ coolness
➔ pallor
Neurogenic
(>90%)
➔ compression of the
brachial plexus
➔ arm paresthesia
➔ pain
➔ weakness
Venous
(3-5%)
➔ axillary vein
compression
➔ thrombosis
➔ arm pain/fatigue
➔ swelling
➔ cyanosis
Thoracic Outlet Syndrome (TOS), refers to signs and symptoms due to compression of the
upper extremity neurovascular bundle.
Neurogenic TOS is a clinical diagnosis (electro-diagnostic testing may be
useful). Vascular causes require US. Arterial TOS may be identified using
chest x-ray imaging.

Thoracic Outlet Syndrome
20
Treatment
Venous/Arterial TOS
➔ Catheter directed
thrombolysis
➔ Prompt surgical
decompression of the
thoracic outlet
Neurogenic TOS
➔ Improving posture
➔ Strengthening
shoulder girdle
muscles
➔ Surgical treatment if
disabling symptoms
are present

Shoulder Pain
22
Shoulder examination should be performed with both shoulders fully exposed, including
inspection, palpation, range-of-motion assessment, and specialized maneuvers.
Anterolateral shoulder pain
➔ most common shoulder pain
➔ impingement syndrome
➔ rotator cuff tendinopathy
➔ adhesive capsulitis
➔ labral tear
➔ biceps tendinitis
Posterior shoulder pain
➔ rotator cuff tendinopathy
➔ referred back pain
➔ glenohumeral joint pathology
➔ acromioclavicular pathology

Shoulder Pain
23
Rotator Cuff Disease
➔ most common cause of shoulder
pain
➔ encompases all rotator cuff
disorders
➔ pain is worsened with overhead
activities
Risk Factors
➔ increasing age
➔ activities that require repetitive
overhead arm use
Pharmacologic treatment
➔ Acetaminophen
➔ Oral or topical NSAIDs
➔ Glucocorticoid injections
Surgery
(if conservative therapy has failed)

Shoulder Pain
24
Adhesive Capsulitis
➔ anterolateral pain associated
with stiffness
➔ worse at night and in cold
weathers
Associated with
➔ prolonged immobilization
➔ history of shoulder injury
➔ diabetes
➔ hypothyroidism
➔ autoimmune disorders
➔ Physical therapy
➔ Glucocorticoid injections
Surgery
(if conservative therapy has failed)

Shoulder Pain
25
Acromioclavicular Joint Degeneration
➔ poorly localized pain on the
superior shoulder
➔ pain usually elicited on palpation
of the acromioclavicular joint
➔ the crossed-arm adduction test
often reproduces the pain
➔ Activity modifications

Shoulder Pain
26
Labral Tears
➔ superior labrum anterior and posterior
(SLAP) tears are common in athletes
and laborers
➔ pain worsens with abduction and
external rotation
➔ catching sensation, crepitus and
instability of the joint
early referral to an orthopedic surgeon
with experience in treating shoulder
injuries is recommended

Elbow Problems
28
Elbow problems may be caused by pathology within the elbow joint, surrounding tissues, or
nerves. Evaluation focuses on the patient history and physical examination.
Epicondylitis
➔ caused by repetitive strain of extensor
tendons
➔ pain and tenderness are located over the
lateral epicondyle and increase with
resisted wrist extension
Management
➔ avoidance of pain inducing activities
➔ NSAIDs
Radial or Ulnar Nerve Entrapment
➔ the radial nerve is susceptible to
compression
➔ prolonged unconsciousness
➔ wrist drop
➔ sensory loss on the dorsum of the first 3
fingers
Management
➔ avoidance of elbow trauma
➔ nocturnal splinting
➔ NSAIDs

Elbow Problems
29
Olecranon Bursitis and Synovitis
➔ most common cause of swelling of the
elbow
➔ secondary to trauma, crystal disease or
infection
➔ bursa or joint aspiration with culture and
fluid analysis (for severe pain), when there
is any suspicion of infection, or when crystal
disease is suspected.
Management
➔ joint rest
➔ elbow protection
➔ NSAIDs

Elbow Problems
30
Wrist and Hand Pain
may be caused by trauma or overuse leading to musculoskeletal abnormalities and nerve
compression.
➔ acute pain associated with trauma
suggests fracture - requires imaging
➔ ulnar nerve entrapment
↪ wrist pain
↪ interosseous muscle weakness
↪ diminished sensation
➔ ganglion cysts
herniated synovial tissue around tendon
sheaths Finkelstein test for de Quervain stenosing
tenosynovitis

Elbow Problems
31
Carpal Tunnel Syndrome
➔ median nerve compression
➔ wrist / hand pain
➔ paresthesia and weakness first 3
digits
➔ worse at night and with repetitive
wrist motion
Some findings include
➔ hipoalgesia
➔ thenar muscle atrophy
➔ weakened thumb abduction
Treatment
➔ activity modification
➔ wrist splinting
➔ short course of oral glucocorticoids
➔ surgery

Hip Pain
33
The location of the pain (anterior/groin, lateral, or posterior) is often helpful in focusing the
evaluation.
Anterior hip pain
➔ insidious pain that worsens standing
(suggests osteoarthritis) older patients
(labral tear) younger patients
(infectious) fever
➔ gradual onset
↪ avascular necrosis
↳ alcoholism
↳ glucocorticoid use
↳ sickle cell anemia
↳ SLE

Hip Pain
34

Hip Pain
35
Lateral Hip Pain
➔ commonly caused by greater
trochanteric pain syndrome (GTPS)
➔ pain that worsens with lying on the
affected side suggests GTPS
➔ distal anterolateral thigh paresthesia
associated with tight-fitting clothes or
obesity
Symptoms follow the distribution of the lateral
femoral cutaneous nerve
Posterior Hip Pain
➔ lumbar radiculopathy
➔ vascular claudication
➔ sacroiliac joint dysfunction
➔ gluteal tendinopathy
The presence of morning stiffness, fever, or
peripheral joint symptoms should prompt
consideration of sacroiliitis

Hip Pain
36
FABER (Flexion, ABduction, and External Rotation) Test

Hip Pain
37
Treatment
Labral Tears
➔ muscle strengthening
➔ arthroscopic surgery if conservative
measures fail
➔ hip arthroplasty
(advanced avascular necrosis)
Greater Trochanteric Pain Syndrome
➔ NSAIDs
➔ glucocorticoid injection
Meralgia Paresthetica
➔ reassurance
➔ avoidance of tight-fitting clothes
➔ weight loss

Knee and Leg Pain
39
The history should focus on timing (acute, subacute, or chronic) and pain characteristics. History of
knee injury or surgery, osteoarthritis, and crystal arthropathies should also be elicited.
Knee examination
(with both full knees exposed)
➔ inspection
➔ palpation
➔ range of motion testing
➔ special maneuvers
Radiography
➔ suspicion of
↪ fracture
↪ bone pathology
↪ osteoarthritis
MRI
➔ internal derangements
➔ surgery considerations
Joint Aspiration
➔ palpable effusion
(exclude inflammatory
or infectious arthritis)
Ligament and Meniscal Tears

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41

Knee and Leg Pain
42
Patellofemoral Pain Syndrome
➔ caused by disordered patellar tracking
with knee movement
➔ poorly localized anterior knee pain
and/or stiffness with prolonged sitting,
climbing, or descending stairs, and with
running or squatting
➔ abrupt patellar deviation may be noted
during squatting and standing
Treatment
➔ NSAIDs
➔ ice
➔ strengthening exercises

Knee and Leg Pain
43
Other disorders
Disorder Manifestations Causes Treatment
Bursitis acute or chronic swelling anterior to
the patella, tenderness, warmth, and
erythema
infection, trauma and gout Septic bursitis
knee immobilization, systemic antibiotics, and
re-aspiration if needed
Gouty bursitis managed with appropriate gout
therapy
Traumatic bursitis managed with activity
modification (avoidance of kneeling) and NSAID
Tendinopathies
and Tears
knee pain with movement, such as
jumping, running, or squatting
tendon tear causes acute
knee pain with effusion after
low-impact trauma or
fluoroquinolone or
glucocorticoid use
strengthening and stretching exercises and
NSAIDs
Osteochondral
Injury
diffuse knee pain significant trauma to the
knee or as an overuse injury
surgical

Knee and Leg Pain
44
Other disorders
Medial Tibial Stress
Syndrome
pain in the mid to distal shins,
usually after activity
structural stress avoidance of high-impact activities
(e.g., running) and using shock-
absorbing insoles
Chronic Exertional
Compartment
Syndrome
swelling of a specific muscle bed,
throbbing pain during exercise
exercise modification of the exercise regimen
and occasionally surgical fasciotomy
Iliotibial Band
Syndrome
poorly localized lateral knee and
distal thigh pain
exercise abstaining from the inciting activity
and using ice, followed by a gradual
return to activity, stretching,
strengthening, and local massage
Popliteal Cysts posterior knee pain and swelling knee trauma, osteoarthritis, or
inflammatory arthritis
joint aspiration and intra-articular
glucocorticoid injection. Ruptured
cysts can be treated with rest,
elevation, and NSAIDs, surgical
excision

Ankle and Foot Pain
46
Ankle Sprains ecchymosis and swelling with
tenderness of involved ankle
ligaments
excessive ankle inversion intermittent cryotherapy and a lace-up support or air
stirrup brace combined with elastic compression
wrapping, acetaminophen and NSAIDs can be used for
pain control
Stress
Fracture
bony tenderness, pain with
percussion, or pain with hopping
on a single leg
structural stress immobilization and serial imaging or surgical fixation;
specialist involvement should be considered
Hindfoot
Pain
activity-related posterior heel
pain and stiffness that improves
with rest, tenderness of the
Achilles tendon
strenuous activities, although it
may occur spontaneously in
the elderly or rarely with
fluoroquinolone useral stress
treatment includes activity modification, eccentric
exercises (muscle lengthening in response to external
resistance), and use of appropriate footwear. NSAIDs
can be used for pain control
Midfoot Pain posteromedial heel paresthesia
that radiates distally into the
plantar foot surface
posterior tibial nerve
compression as it passes
through the tarsal tunnel
First-line treatment consists of activity modification,
orthotics, NSAIDs, and neuromodulators
Forefoot Pain pain between the metatarsal
heads and the sensation of
walking on a pebble
Morton neuroma, Hammertoe
deformities and Hallux or
bunion deformity
Ffootwear modification and padding. Glucocorticoid
injections may provide temporary relief. Interdigital
nerve resection is reserved for those who do not
respond to conservative measures

Common Musculoskeletal Problems.pptx

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