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KEVIN L. BROWNE, PT, SCD, OCS, COMT

DEC 1, 2016

Medical Topics: Musculoskeletal Disorders

Burden of Musculoskeletal Disease

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% BudgetMedical SequelaAging of Population

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


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


Subject of Relatively Basic Research

Three Primary Neurophysiologic Mechanisms

Nociceptive (what we normally think about pain)

Neuropathic: Direct insult to nervous systemCentral: Sensitized pain (heat and match)


Delphi Study: Instrument of Expert Opinion

Nociceptive PainClear 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

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


Delphi Study: Instrument of Expert Opinion

Neuropathic Pain

Described as burning, shooting, sharp, shock-like, aching and radicular in a dermatomal or cutaneous distributionIndicative 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 medicationMechanical Pattern consistent with loading/compressing neural tissue

Spontaneous Pain and associated with Dysthesias: heaviness, crawling


Delphi Study: Instrument of Expert Opinion Central Pain

Disproportional, non-mechanical and unpredictable in response to aggravating/easing factorsPain persists beyond usual/expected recovery times and disproportional to injury or pathologyMaladaptive psychosocial factors: poor self-efficacy, negative emotions

History of Failed Intervention and high levels of functional disability. Unresponsive to NSAIDS and simple analgesicsHigh levels of tissue irritability, more constant, disturbed sleep. Widespread, non-anatomical distribution of 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

Musculoskeletal Pain: INSIDIOUS ONSET

Task of Primary CareTruly Insidious MSK = Ischemia or

DegenerationMusculoskeletal 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, PleuraPancoast Tumor at the Apex of the Lung

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


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


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

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 InjuryUncertain Localization: Cervical Disc or Subacromial Shoulder

Exception: Nerve Entrapment

Subjective Exam/Patient Interview

Who? What? When? Where? Why? What Extent?

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



What is/are the primary complaint/s? Weakness is a red flag in healthy individuals Sensory Changes: Nervous System Usually it will be pain



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



Where is/are your symptoms? Helps us to think about pain generators Ask about the full extent of symptoms Ask about seemingly unrelated symptoms



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



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

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



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)



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



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



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??



Use as a confirmation of your suspicions

Palpation can fool you. Referred tenderness Tissue sensitization

Case of the 50-Year Old Shoulder

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



54 yo male, professional photographer, lifts weights



Shoulder pain that is constant, dull and throbbing pain.

No sensory, motor or constitutional signs



Started 9 months ago and gotten a some better

Long history of minor “twinges” in the shoulder



Pain in the lateral proximal ½ of the right humerus

Denys pain in the neck, chest, scapula, upper trap



Suspects from “heavy” weight lifting. He cut back some

Does not recall a specific incident



Constant, worse with overhead reach and lying R side

Pain 2/10 at rest and 7/10 overhead reachWakes at night occasionally


What are we thinking?

Start with location of symptoms: lateral arm, localized

Generally pain referral site for many pain generatorsConstant nature for 9 months (NSAIDS help)May be related to weight lifting

Hypothesis?

Chronic, possibly inflammatory, subacromial pathology


What are the Differential Diagnoses

1. Referred C-Spine 2. Tendinopathy3. Rotator Cuff Tear4. Subacromial Bursitis5. Glenohumeral OA


Clinical Exam Objective Signs

Be S.M.A.R.T. and Palpate LastS = Scan/SurveyM= Motion/Mobility completed by the patientA = Assisted Motion completed by the

examinerR = Resisted Tests loads the musclesT = Tests (Special Tests)



Be S.M.A.R.T. and Palpate Last:

S = Scan/Survey No muscular atrophy No clear asymmetry



Be S.M.A.R.T. and Palpate LastM= 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




A = Assisted Motion (passive) Mild limit of glenohumeral external rotation Mild increase pain with overpressure elevation




R = Resisted Tests Moderate increased pain resisted Abduction, ER, IR Strength 5- to 5/5 (no clear weakness)



Be S.M.A.R.T. and Palpate LastT = Tests (Special Tests)

Hawkins: Mild increase pain Labral Test: Very mild increase pain Pull Test: Eliminate pain on resisted ER



Be S.M.A.R.T. and Palpate LastPalpate Last:

No tenderness to AC joint, biceps tendon, supra and infraspinatus

No tenderness to deltoid insertion


What have we learned?

Tendinopathy, Rotator Cuff Tear, Bursitis, OAFull or Near-Full Resistance : Large RC TearPain all resisted tests: Tendinopathy, RC Tear


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

Initial Management and Informed Consent

What about NSAIDS? UK Study

NSAIDS beyond 3 wks for fracture increase risk non-unionLikely useful for early tendonitis and useless for tendinosis

AT THE RIGHT TIME! Can interfere with healing beyond a few daysLigament 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

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