Common MSK

    .Plantar Fasciitis

    - See attached doc.

    Lower Back Pain

    Back Pain (acute and chronic):

    -       Acute < 6 weeks, Subacute: 6-12 weeks, Chronic >12 weeks (<5% chronic)

    -       90% lifetime prevalence, peak between ages 45-60, 90% resolves within 6 weeks

    -       98% mechanical: ligamentous/muscle strain, facet joint degeneration, disc injury, spondylosis, compression #, spinal stenosis, pregnancy.

    o   Wore with movement, relieved with rest

    -       2% non-mechanical: concerning when present at rest and no change with position

    -       Red flags: bowel/bladder dysfunction, saddle anesthesia, constitutional symptoms, chronic disease, paresthesia, age > 50, IV drug user, neuromotor deficits.

    -       Surgical emergencies:

    o   Cauda equine syndrome: LBP, areflexia, lower extremity weakness, fecal incontinence, urinary retention, saddles anesthesia, decreased anal tone.

    o   Abdominal aortic aneurysm: pulsatile abdominal mass, tearing pain radiating to back, uncorrectable HoTN.

    -       Medical conditions:

    o   Neoplastic: primary or mets (PrCa, and multiple myeloma)

    o   Infectious (osteomyelitis, TB)

    o   Metabolic (osteoporosis, osteomalacia, Paget’s disease)

    o   Rheumatologic (AS, PMR)

    o   Referred pain (perforated ulcer, pancreatitis, pyleonephritis, ectopic, HZV)

    -       Hx: OPQRST, trauma, Hx back surgeries, constitutional symptoms, bowel/bladder dysfunction, fever, claudication/leg pain, worse in morning or night, how what makes it better, medication for pain, Rx corticosteroids, FHx Prostate, Colon, Breast, Lung Ca, back pain 

    -       PEx:

    o   Inspection: masses, lesions, scars, kyphosis, scoliosis, bamboo spine, erythema

    o   Palpation: spinous processes and paravertebral muscle bulk, tenderness, swelling

    o   ROM: forward flexion, extension, rotation, side to side, chest expansion, occiput to wall test, Schober’s ( PSIS, 5 cm below and 10 above, should increase to 20 on flex).

    o   Motor screen: L4 = dorsiflexion, L5 = EHL, S1 = plantar flexion. Trendelenburg (L5)   

    o   Reflexes: L4/L5 = extensor (patellar) reflex, S1 = ankle reflex, Babinski (up-going)

    o   SLR: pain between 30-60º is positive; lower and dorsiflex => radicular pathology. Centrally displaced disc may affect contralateral leg (crossed SLR). Examine pedal pulses for potential for vascular component (claudication). 

    o   Femoral stretch test: while supine, flex knee to rest heel on buttock. If unilateral, reproducible pain ensues in the lumbar area, buttock, and/or posterior thigh, may indicate nerve root lesion (L2 or L3).         

    -       Investigations: plain films not recommended initially unless:

    o   No improvement after 6 weeks, fever (> 38º C), unexplained weight loss, prolonged corticosteroid use, significant trauma, progressive neuromotor deficit, suspicion of AS (pseudowidening), Hx cancer, EtOH/drug abuse (falls, osteomyelitis)

    o   CBC, ESR/CRP, urinalysis, PSA, bone scan, infection/tumor/occult #, EMG

    o   Consider CT/MRI if indicated (cauda equina!)       

    Rx: reassurance and education (symptom management if no serious underlying process); 70% resolves within 2 weeks, 90% within 6 weeks.

    -       Conservative: limited bed rest (<2-4d), maintain daily activities with modifications PRN, heat/cold therapies, consider note for work/WSIB.

    -       Pharmacologic: Tylenol, NSAIDs, muscle relaxants, avoid narcotics

    -       Physical methods: massage, acupuncture, injections, TENS  

     

     

    Shoulder Impingement

     

    • The shoulder capsule is encased with rotator cuffs tears.  Sometimes a tendon can get trapped between the humerus and the acromion, causing pain with certain movements.  The entrapment of the tendon causes tendonpathy and can even cause bursitis.  Any of the rotator cuff tendons can become entrapped, but the most common is the supraspinatus because its tendon runs superiourly over the humeral head underneath the acromion.
    • Over time chronic tendon inflammation can become sclerosed causing thickening of the tendon, thereby worsening the problem.
    • Risk factors are typically forward-slanted shoulders and poor posture. 
    • Exam
      • Examine each of the rotator cuff muscles:
        • Ext rotation (infraspinatus, teres minor)
        • Int rotation (Petoralis + subscapularis)
        • Hand behind back, palm facing out, push back against resistance (subscapularis isolated).  Can also "pat abdomen".
        • Straiten arm, forward flexion, internally rotate ("empty can test") (supraspinatus) - examiner pushes down, patient resists.
          • Note if arm drops -- cannot hold --> rotator cuff tear.
      • Specific tests for shoulder impingement (supraspinatus) - pinch rotator cuff underneath the acromion
        • Neers test (empty beercan test): raise arm into forward flexion (eblow extended) - tries to pinch the humerus against the acromion.  Pain = Positive.
        • Hawking-Kennedy test - abduct arm, internally rotate (eblow flexed) - this brings the greater tuberosity under the acromion to further impinge the tendon - pain = positive.
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