Winter Quarter Intro & Clinical Cases: Musculoskeletal Pain

1. Karen A. McDonough MD Winter Quarter Intro & Clinical Cases: Musculoskeletal Pain

2. Winter Quarter • Clinical Cases • Musculoskeletal Pain • Sexually Transmitted Infections • Critical Issues in Caring for LGBT Patients • Patient Panel • Working with Interpreters • Substance Abuse and Addiction • Cases and interview techniques • Required AA ‘tutorial’

3. AA tutorial logistics • Attend an AA meeting with a friend • Interview an AA member after the meeting • Meeting site or café • Focus on HPI of substance use • Write up an HPI of the member’s substance abuse OR a reflection on the experience and submit to your portfolio by March 12 • See website for further information

4. Special Skills Interviews • College Groups • Either Feb 10 or 11 • Rotate through 3 simulated patients (30 minutes each) • Interpreted visit • Patient with substance abuse • Patient with sexual concern • Take turns interviewing and receiving feedback • Preparation: attend lecture, required reading

5. Caring for Patients with Life Threatening Illness • One of the most critical, rewarding, yet challenging of physicians roles • Series of lectures, panel, & small groups • 3/9 “Breaking Serious News” lecture and small group • 3/11 End of Life interest groups – sign up for two • Required reflection due by Friday of the second week of spring quarter

6. Building toward clerkships: • Caring for Kids and their Families • Working as Part of a Medical Team

7. Remember: “Every Investigation Probably Requires Several Specimens.” • Expose: compare with the opposite side • Inspect • Palpate • ROM: active, and if abnormal, passive • Strength • Stability and Special testing

8. Mrs. A A 58 y.o. woman with diabetes and hypertension presents with two months of shoulder pain and increasing stiffness.

9. Common causes of chronic shoulder pain in older adults Rotator cuff tendinitis Adhesive capsulitis (a.k.a frozen shoulder) Glenohumeral arthritis (usually osteo) Bicipital tendinitis

10. Up to Date Online 16.3 www.uptodate.com, Evaluation of the patient with shoulder complaints

11. http://www.eorthopod.com/public/patient_education/6526/adhesive_capsulitis.htmlhttp://www.eorthopod.com/public/patient_education/6526/adhesive_capsulitis.html

12. HISTORY Age Pain Risk factors RCTany diffuse, deltoid overhead activity AC> 50 diffuse,deltoid, DM, thyroid, stroke GHA> 50 diffuse, deltoid prior injury, RA BTany anterior, worse overhead activity night pain night pain Prior RC prob with lifting heavy lifting

13. Inspection RCTmay have SS or IS atrophy with chronic tear AC normal GHAmay have anterior swelling BTnormal

14. Palpation RCTTTP of subacromial structures AC crepitus,TTP over joint line GHAcrepitus, TTP over joint line BTtender over LH BT

15. Up to Date Online 16.3 www.uptodate.com, Evaluation of the patient with shoulder complaints

16. Up to Date Online 16.3 www.uptodate.com, Evaluation of the patient with shoulder complaints

17. ROM • NFL ‘touchdown’ sign • Apley scratch tests Adduction ER, Ad IR, Ab Up to Date Online 16.3 www.uptodate.com, Evaluation of the patient with shoulder complaints

18. ROM AROM PROM RCTpain @ 60-100° Ab, less painful IR/ER AC limited Ab, IR, ER same GHA painful or limited Ab, IR/ER same BTnormal

19. Strength Testing RCTweakness of that persists after subacromial injection suggests tear AC normal unless impaired by pain or longstanding atrophy GHAditto BTarm flexion against resistance worsens pain ** Remember pain may limit effort. To confidently call weakness, effort must be full.

20. Special Tests RCT Impingement tests Drop arm rotator cuff test Empty-can supraspinatus test Lift-off subscapularis test External rotation/infraspinatus strength AC Plain films to exclude GHA GHA Plain films to rule in BT Speed’s test Yergason’s test

21. Rotator cuff tendinitis • History • Any age • Anterolateral pain, worse at night and with overhead movement • Overhead sports or work a risk factor • Exam • I: Atrophy of IS or SS suggests tear • P: TTP of subacromial structures • R: Pain with AROM > PROM • S: Weakness may be due to pain or tear • S: Multiple special tests

22. Adhesive Capsulitis& Glenohumeral OA History • Older age • Deltoid area pain and stiffness Exam I may have anterior swelling with GHA P tender joint line R decreased active and passive S may be decreased by pain S need an x-ray to tell them apart

23. Bicipital tendinitis History • Any age • Pain anterior, often well localized • Overhead activity a risk factor Exam I normal (popeye muscle suggests rupture) P tender over bicipital groove R typically normal S arm flexion against resistance worsens pain S Speed’s test, Yergason’s test

24. What if the shoulder exam is normal? • Radiating pain • Cervical spine disease • Pain radiating from neck or to elbow or hand • Often tingling or burning • Referred pain • From other organs • Apices and bases of lungs, stomach, gallbladder, spleen, liver

25. Classic Examples of Referred Pain: • Low back pain in an older male or smoker • Acute back pain with hematuria • Right shoulder pain after an ice cream binge • Left shoulder pain with cough and fever • Exertional shoulder pain Abdominal aortic aneurysm, sometimes leaking Kidney stones Choledocholithiasis Pneumonia Angina

26. REMEMBER A musculoskeletal complaint may actually be referred from elsewhere – and may be potentially fatal.

27. Mrs. B A 72 y.o. woman presents with 2 months of progressive L knee pain. Her knee has no bony tenderness or enlargement, no crepitus and no palpable warmth or effusion. ROM is normal without pain. Special testing for meniscal and ligamentous injury is negative. The L hip demonstrates severe pain with internal rotation and crepitus.

28. REMEMBER For any joint complaint, consider an abnormality one joint above and one joint below.

29. Mr. C: A 51 y.o. man with knee pain Acute or chronic? CHRONIC

30. Chronic Knee Pain • Osteoarthritis • Patellofemoral pain • Bursitis • Prepatellar • Anserine • Less common: inflammatory, chronic infection, chronic meniscal or ligamentous injury

31. ACR Clinical Criteria for OA • Age > 50 • Morning stiffness < 30 minutes • Crepitus • Bony tenderness • Bony enlargement • No palpable warmth • If 3 criteria: Sn 95%, Sp 69% • If 4 criteria: Sn 84%, Sp 89%

32. Patellofemoral Syndrome • Overuse syndrome, more common in women • Most common cause of knee pain < 45 • Anterior knee pain, worse with going down hills or stairs, or sitting for long periods “theater sign” • Give-way weakness due to inhibition of quads by pain • Exam findings +/- • Patellofemoral compression test

35. MrsD A 62 y.o. woman presents with 3 days of increasingly severe knee pain.

36. Acute Knee Pain (< 1 week) Meniscal injury (9% in 1° care) Ligamentous injury (11%) Gout (2%) Fracture (1.2%, 6-11% in the ER) Less common: RA, infectious, pseudogout Osteoarthritis (34%) Jackson, Annals of Internal Med 2003; 139:575

37. Are plain films needed? Ottawa Knee Rules Radiographs indicated for knee pain after fall or blow to the knee if at least 1 of: • Age > 55 • Tenderness of head of fibula or patella • Inability to bear weight for at least 4 steps • Inability to flex the knee to 90°

38. Ottawa Knee Rules • Sensitivity of rules for fracture on plain films: 100% • Specificity: 54% • Validated in 7 other studies • Would reduce plain films by ~ 25% • Plain films aren’t perfect: FU film if pain persists in 10 days

39. REMEMBER You don’t always need an x-ray Even an insured patient is likely to have a 20% out of pocket co-pay.

40. 5 questions in acute knee pain: Does the patient meet Ottawa criteria? If yes, plain films to rule out fracture Is there an effusion? If yes, arthrocentesis for crystals, cell count, culture. Does the PE suggest meniscal or ligamentous injury? If yes, referral for further evaluation Does the patient have 3+ clinical criteria for OA? If yes, start conservative therapy. Is there evidence of systemic rheumatologic disorder? If yes, check ANA, RF, consider referral.

41. Question 6 Has there been improvement at FU in 7-10 days? If not, consider • X-ray to rule out missed fracture • Alternate diagnoses • Referral for further assessment

42. Mr. E A 38 year old tennis playing carpet layer presents with 2 weeks of elbow pain.

43. Elbow pain • Lateral epicondylitis (tennis elbow) • Medial epicondylitis (golfer’s elbow) • Olecranon bursitis • Radiating from cervical nerve root impingement • Nerve entrapment • Intraarticular (uncommon) • Sepsis • Crystals • Inflammatory • Reactive • Spondyloarthropathy

44. Lateral epicondylitis History: pain over lateral elbow, worse with repetitive wrist flexion Exam • I normal • P tenderness over lateral epicondyle • R normal • S normal but: • S pain increased with resisted wrist extension

45. Medial epicondylitis History: pain over medial elbow, worse with repetitive wrist flexion Exam • I normal • P tenderness over medial epicondyle • R normal • S normal but: • S pain increased with resisted wrist flexion

46. Olecranon bursitis History: • CC is usually swelling but may have some pain • May become infected, with warmth, erythema and increased pain Exam • I prominent swelling of bursa • P fluid filled, warmth and tenderness if infected • R normal (the joint is not involved) • S normal • S aspiration of bursa

47. http://www.apmsurgery.com/Diagnoses/Bursitis.html

48. Intraarticular Elbow History • Decreased ROM, pain Exam • I swelling, with loss of normal depression • P warmth, joint line tenderness • R decreased active and passive • S limited by pain • S joint aspiration

49. Patterns of Arthritis

50. Mechanical or Inflammatory? • Mechanical pain (e.g. OA) • Minimal morning stiffness • Progressive with increased activity • +/- swelling • No associated sx • Inflammatory pain (e.g. RA, PMR) • Morning stiffness > 30 minutes, improved with activity • Usually swelling • Associated symptoms: fatigue, other specific sx