Musculoskeletal (MSK) Injuries

Background 

• >90% of back pain is nonspecific and musculoskeletal in nature 
• Acute = < 3 months, Chronic = > 3 months 
• Can’t Miss: spinal cord compression, cauda equina, cancer, infection (spinal abscess, discitis, or osteomyelitis), fracture 
• Corresponding “Red Flags”: urinary/bowel incontinence, weight loss, history of cancer/known active cancer, fevers/chills, IVDU, recent major trauma or osteoporosis risk factors. 
• Radicular pain = pain radiating down legs; radiculopathy = nerve deficit (weakness, numbness, etc.) 
• Note: can have radiating pain that is NOT from a neurologic etiology 
• Axial pain = pain localized to back 
• Spondylosis = degeneration of vertebral column
• Sponydylolysis = pars interarticularis defect 
• Spondylolisthesis = Vertebral malalignment compared to vertebra below 
• Anterolisthesis = forward movement of vertebra relative to one below it 
• Retrolisthesis = backward movement of vertebra relative to one below it.

Presentation 

• Lumbar strain: diffuse pain in lumbar muscles, may radiate 
• Degenerative disk or facet process: localized lumbar pain, similar to lumbar strain 
• Inflammatory arthritis: morning stiffness, improves with movement, systemic symptoms 
• Osteoarthritis: pain with activity, improves with rest 
• Herniated disk: radiating pain to legs, often below the knees 
• Compression fracture: older pts or osteoporosis, trauma, spine tenderness on exam 
• Spinal stenosis: pain improves with flexion (shopping cart sign) 
• Spondylolysis: pain with extension 
• Spondylolisthesis: pain with activity, improves with rest, vertebrae out of alignment on imaging 
• Scoliosis: abnormal spine curvature, seen on physical exam inspection

Evaluation 

• Inspection: posture, Adam’s Forward Bend Test (screens for scoliosis), limb length discrepancy, spine curvature (kyphosis, lordosis, scoliosis); compare to normal anatomy 
• Palpation/Percussion: sensitive for identifying spinal infection, metastases, or compression fractures 
• Spinous processes, lumbar “step-offs,” paravertebral muscles and SI joint 
• Range of motion: flexion pain = disc / anterior column pathology; extension pain = facet pathology / spinal stenosis 
• Neurologic examination 
• L2: halfway between hip and knee on medial aspect of thigh; L3: medial femoral condyle; L4: medial malleolus; L5: first dorsal webspace; S1: lateral malleolus 
• ***Radicular pain does NOT have to match dermatome*** 
• ESR/CRP: if concern for infection or malignancy 
• Lumbosacral nerve roots: Seated Slump Test, Straight Leg Raise, Ankle Dorsiflexion Test, Femoral Nerve Stretch Test
• SI Joint: Gaenslen’s Test, FABER, Sacral Thrust

Imaging 

• Indications: risk of fracture, red flag symptoms, evaluating for ankylosing spondylitis, no improvement in pain after conservative therapy after 6-12 weeks 
• AP and lateral plain films; bilateral oblique films (evaluate for spondylolysis); flextion/extension imaging (evaluates for instability iso listhesis) 
• Can show fractures, degenerative disc disease, neuroforaminal narrowing 
• MRI with and without contrast for suspected cancer, infection 
• MRI without contrast for suspected cauda equina (unless cancer or infection are suspected causes), fracture (can differentiate acute from chronic), refractory to conservative management (in combination with referral to spine specialist

Management 

• First line: conservative therapy for 4 to 6 weeks, avoid bedrest 
• Refer to Spine PT program at VUMC 
• Medications: Tylenol +/- muscle relaxer (Robaxin / Flexiril) 
• Steroids (Medrol Dosepak) often prescribed, not demonstrated to improve outcomes 
• Indications to refer to Orthopedics or PM&R spine specialist 
• Refractory to conservative treatment 
• Severe, debilitating pain at the outset / unable to tolerate PT

Background 

• Location of pain 
• Weight bearing, systemic symptoms (e.g. fevers) 
• Activities that worsen pain: Squatting, twisting, stair climbing 
• Trauma and mechanism of injury 
• High-energy trauma: high risk of bony and/or ligamentous injury 
• Low-energy trauma and atraumatic etiologies organized by location (see table) 
• Presence/absence of effusion and swelling 
• History of prior trauma to the knee

Presentation 

• Patellofemoral pain syndrome: anterior pain worse with stair climbing 
• Patellar tendonitis: anterior pain worse with jumping 
• IT band syndrome: lateral pain worse with walking/jogging, but better with running 
• Bursitis: pain at location of bursa 
• Traumatic Effusion: 
  • Consider ACL (usual acute ~hrs) or PCL rupture, meniscus tear (usually within 24hrs), patellar instability (dislocation of subluxation), bone bruise, fracture 
• Atraumatic Effusion: 
  • Activity related: consider osteoarthritis or osteochondral injury 
  • Non activity related: autoimmune, crystalline arthropathy, Lyme disease, septic arthropathy (including gonococcal) 
• Less common causes: primary bone tumor, viral infection (Parvo), hyperparathyroidism, hemochromatosis, syphilis, sarcoid, Whipple’s 
  • Edema in patient with TKA can indicate hardware failure; refer to surgeon

Evaluation 

• Physical Exam 
• Gait 
• IPASS: Inspection, palpation, active/passive ROM, strength, special tests (see below) 
• Check for effusion with milk maneuver, balloting 
• Neurovascular exam including reflexes if applicable 
• Aspirate if effusion present and no clear diagnosis or concern for septic joint (order cell count with diff, crystal analysis, +/- gram stain and culture) 
• Ottawa Knee Rule = Imaging if 1 of following: 
  • > 55 y/o 
  • Isolated tenderness of patella 
  • Tenderness of fibular head 
  • Unable to flex 90° 
  • Unable to ambulate 4 steps at time of injury and at time of evaluation

Imaging 

• X-ray: AP, lateral, and sunrise view 
• OA hallmarks: Subchondral sclerosis, osteophyte, joint space narrowing, bone cyst 
• Obtain in standing position to evaluate joint narrowing 
• MSK U/S: Allows for dynamic imaging. ~100% sensitive for effusion and can visualize ligaments, muscles, tendons, joint space, and vasculature 
• MRI: indicated after failure of conservative management or when considering surgical repair

Treatment 

• RICE (rest, ice, compression, elevation) for acute injuries 
• Bracing is good for kinesthetic reminder and stability 
• NSAIDs, topical Diclofenac, antibiotics if effusion or bursa tapped indicates infection 
• PT for 4-6 weeks for OA, ligamentous, muscular, or meniscal injury 
• Referral to Sports Medicine or PM&R for non-operative interventions (corticosteroid/viscosupplement injections)

Background 

• Most common cause of neck pain in adults: Degenerative changes of the cervical spine 
• Most atraumatic neck pain does not require imaging

Presentation 

• Cervical muscle strain: pain + stiffness with movement due to muscular injury 
• Degenerative disc disease/osteoarthritis: pain + stiffness with movement from derangement in disc architecture leads to inability to distribute pressure in the joint 
• Cervical radiculopathy: neuropathic pain, sensory abnormalities, and/or weakness in an upper extremity (often radiating to hand) 
• Cervical myelopathy: spinal cord compression causing neurologic dysfunction 
• Earliest symptom is gait disturbance. Pain is uncommon 
• Non-cervical conditions: shoulder pathology, migraine/headaches, occipital neuralgia, torticollis, thoracic outlet syndrome, angina pectoris/MI, bony metastases, vertebral artery or carotid artery dissection, fibromyalgia, meningitis, transverse myelitis 
• Posterior neck pain 
• Axial only MSK (sprain vs degenerative disc disease) 
• Axial + Extremity Pain Radiculopathy 
• Anterior neck pain 
• Common sources: esophageal, thyroiditis, carotidynia, lymphadenitis, Ludwig’s angina 
• Red flags: recent rauma, lower extr

Evaluation 

• Determine MSK (axial pain) vs. radiculopathy/myelopathy vs non-spinal

• Imaging indications: neuro deficits, red flag symptoms, persistent pain (> 6 weeks) 
• Cervical X-ray: 2-view (AP and lateral) 
• Cervical MRI: Visualizes spinal cord, nerve roots, bone marrow, discs and soft tissues 
• Usually w/o contrast; can consider contrast if malignancy or infection suspected 
• EMG/Nerve Conduction Studies: Not routinely used for neck pain evaluation, but can be used to distinguish cervical radicular pain from peripheral causes of extremity dysesthesia 
• Management
  • First line: conservative therapy for 4 to 6 weeks, 
  • Refer to Spine PT program at VUMC 
  • Medications: Tylenol +/- muscle relaxer (Robaxin / Flexiril) 
  • Steroids (Medrol Dosepak) often prescribed 
  • Indications to refer to Orthopedics or PM&R spine specialist 
  • Refractory to conservative treatment 
  • Severe, debilitating pain at the outset / unable to tolerate PT 
  • Cervical myelopathy requires urgent surgical evaluation

Presentation 

• Brachial plexopathy: varied in presentation but usually some component of pain, weakness, or paresthesias 
• Brachial neuritis (Parsonage-Turner): sudden unilateral shoulder pain with subsequent weakness and/or muscle atrophy 
• Vascular pathology (e.g. thoracic outlet syndrome, thrombus, atherosclerosis, vasculitis): Typical symptoms include tightness, heaviness, cramping, or arm weakness with or without activity. 
• Rotator cuff injuries: 
• Impingement syndrome: pain with abduction and internal rotation; supraspinatus is most susceptible 
• Tendinopathy: develops after repetitive motions; pain worsens with active movement 
• Tendon tear: develops as a progression of tendinopathy; develops weakness and pain 
• Labral tear and SLAP (superior labral tear from anterior to posterior): develops in repetitive overhead motions (swimming, baseball, tennis); often described as a “catching” sensation 
• Adhesive capsulitis “frozen shoulder”: stiffened glenohumeral joint, diminished active and passive ROM; increased frequency in diabetics 
• AC (acromioclavicular) joint pain: usually secondary to trauma or fall on outstretched arm; anterior shoulder pain with AC tenderness; can develop OA 
• Glenohumeral OA: Degeneration of articular cartilage and subchondral bone with narrowing of the glenohumeral joint. Presents in older adults with progressively worsening anterior shoulder pain and stiffness in both passive and active ROM 
• Biceps tendinopathy: Localized anterior shoulder pain, worsened with overhead lifting. When rupture develops, will often have a “lump” and acute worsening of symptoms - Posterior shoulder/periscapular pain often related to cervical radiculopathy

Evaluation 

• Physical exam 
• IPASS. Be sure to palpate SC joint, AC joint, biceps groove, acromion, spine of scapula, greater tuberosity of humerus
• C -pine: Evaluate C-spine as origin of pain that may be referred to the shoulder 
• Palpate common myofascial trigger points: trapezius, levator scapulae 
• Imaging: 
• Not as useful as a thorough physical exam, especially if non-traumatic pain 
• X-ray: AP (internal rotation, external rotation), lateral, scapular and axillary views 
• CT: Often reserved for traumatic fracture and artificial joint assessment 
• MRI w/out contrast: used to evaluate soft tissues, tendons, muscle and bursae 
• Ultrasound: becoming more useful for initial evaluation of rotator cuff and bicepts tendon

Management 

• Fractures: require assessment by Orthopedics for reduction and surgical intervention 
• Brachial plexopathy: Send for EMG, evaluation by PM&R 
• Tendon/ligament injuries, arthritis 
• Conservative management: Refer to PT for muscle strengthening, flexibility, and postural improvement 
• Consider short course of NSAIDs, 7-10 days (meloxicam, diclofenac) for pain relief 
• Injections can often be diagnostic and therapeutic – refer to PM&R or Orthopedics 
• Refer to Orthopedics for interventional/surgical evaluation if pt fails conservative therapy

Background 

• 12-15% of adults over 60 have hip pain 
• 30-40% of adults who play sports have hip pain 
• Buckets to help differentiate etiology 
  • acute vs subacute vs chronic 
  • arthritic/MSK vs vascular/infectious/rheumatologic/malignancy 
  • Anterior vs lateral vs posterior pain patterns

Presentation 

• Hip Fracture: older patient, trauma, anterior/lateral pain with weight bearing and rotation 
• Osteonecrosis: commonly progressive groin pain, can be traumatic or non-traumatic 
• Bone Tumor: localized pain, can wax and wane, consider systemic symptoms (fever, weight loss) 
• Septic Arthritis: acute severe hip pain with fever, exquisite tenderness with any movement 
• Osteitis Pubis: pain in anterior groin ISO repetitive ab/adduction (think athletes) 
• Aortoiliac Arterial Insufficiency: claudication/weakness buttock, hip, thigh ISO CAD/PAD 
• Femoroacetabular Injury (FAI): common in younger athletes, overgrowth of bone around ball-insocket joint, pain on FADIR/FABER exam 
• Osteoarthritis: chronic insidious anterior hip/groin pain in older patients, worse with exertion, often has pain with passive movements 
• Rheumatoid/Seronegative Arthritis: hip pain with associated rash, fevers, recent illness 
• Nerve Compression: typically accompanied by weakness/paresthesia that can involve the hip, think radiculopathy or pelvic mass effect (tumor, retroperitoneal hematoma, etc.) 
• Greater Trochanteric Pain Syndrome: pain in lateral hip in older population, unable to lay on affected side, pain worse with prolonged walking/standing but hip ROM preserved

Evaluation 

• Physical Exam 
• Inspection: deformity, resting internal/external rotation, bruising, swelling, limb length discrepancy 
• Palpation: location and character of pain narrows differential 
• greater trochanter (lateral), SI joint, piriformis (can cause radicular pain), pubic symphysis (osteitis pubis) 
• Range of Motion: check hip flexion, extension, internal and external rotation, abduction, adduction 
• ROM often preserved in pathology that does not involve the hip joint 
• Neurologic Exam 
• Ensure sensation intact; can help rule out radiculopathy 
• L2: hip flexion; L3: medial femoral condyle; L4: medial malleolus; L5: first dorsal webspace; S1: lateral malleolus 
• Strength exam less reliable given often limited by pain 
• Labs: consider CBC, CRP/ESR, HLA-B27, ANA, RF

Management 

• First Line: conservative treatment (if no red flags/cancer/infection/fracture) 
• Referral to physical therapy 
• Medications: NSAIDs, Tylenol, ice/heat 
• Medrol dose pack lacks efficacy & carries risk of osteonecrosis 
• Indications to refer to Orthopedics or PM&R spine specialist 
  • Refractory to conservative treatment 
  • Severe, debilitating pain at the outset / unable to tolerate P