Musculoskeletal Medicine, Common Overuse Injuries

Resident Review Lecture, #32Shane Garon MD, PGY I

LSUFP-Alexandria

Overuse Injuries • Insidious onset•Not acute in nature• Low contact activities jobs or sports that require long training activities and repetitive motion. • Present with more dull achy pain that has capability to become acute in nature.

Common Overuse Injuries

• Low Back Pain (LBP)• Tendonopathies• Shoulder Pain• Rotator Cuff Injuries• Tendon Ruptures• Adhesive Capsulitis• Carpal Tunnel Syndrome• Tarsal Tunnel Syndrome

• Dupuytren’s Contracture• Plantar Fasciitis • Morton's Neuroma • Shin Splints/Stress Fractures• PFPS• ITBS• Osgood-Schlatter Disease

Tedinosis vs itis• -itis – Inflammatory • -osis – Non-imflammatory • Tendinosis: Non-inflammatory degenerative condition caused by insufficient tensile strength exposed to external loads which ultimately cause progressive damage.

Lower Back Pain “The spectrum of illness and morbidity associated with low back

pain is broad.”

“For many individuals, episodes of back pain are self-limited and resolve without specific therapy.”

“For others, however, back pain is recurrent or chronic, causing significant pain that interferes with employment and quality of life.”

“Rarely, acute back pain is a harbinger of serious medical illness, including infection, malignancy, or other systemic disease.”

http://www.uptodate.com/contents/approach-to-the-diagnosis-and-evaluation-of-low-back-pain-in-adults?source=search_result&search=low+back+pain&selectedTitle=1~ 148

LBP – Common Causes•Strain/Sprain 70%•Degenerative 10%•Discogenic•Osteoporotic Fx•Spinal Stenosis•Spondylolisthesis •Other

LBP – Statement•4 Studies all report:

“Among all primary care patients with low back pain, less than 5 percent will have serious systemic pathology.

Although patients are often told a specific diagnosis for their back pain, reproducibility of these diagnoses (ie, muscle spasm, sacroiliac pain, trigger points) among providers is

poor.”

LBP – Approach 3 Key Areas

1: Evidence of Systemic Disease? • History of cancer• Age over 50 years• Unexplained weight loss• Duration of pain greater than one month• Nighttime pain• Unresponsiveness to previous therapies• History of abdominal aortic aneurysm

2: Evidence of Neurologic Compromise?3: Evidence of Social/Psychological component?

“Chou R. In the clinic. Low back pain. Ann Intern Med 2014; 160:ITC6.”

LBP – H&P• As with everything in medicine, Red Flags first, then we move to less

threatening DDX.

•Hx: •Hx of Cancer, Urinary or Fecal Incontinence or retention, progressive loss of lower extremity motor/sensory loss, lumosacral pain/surgery within the past year, or significant trauma.

•Exam: •motor/sensory loss, saddle anesthesia, loss of anal sphincter tone, infectious signs in spinal region

LBP: Definition: Sciatica

“Evidence of nerve root irritation typically manifests as sciatica, a sharp or burning pain radiating down the posterior or lateral aspect of the leg, usually to the foot or ankle. Pain radiating below the knee is more

likely to represent true radiculopathy than proximal leg pain [48]. Sciatic nerve pain is often associated with numbness or tingling. Sciatica due to disc herniation

usually increases with coughing, sneezing, or performance of Valsalva maneuver.”

Morris EW, Di Paola M, Vallance R, Waddell G. Diagnosis and decision making in lumbar disc prolapse and nerve entrapment. Spine (Phila Pa 1976) 1986; 11:436.

LBP

LBP:AAFP reports from a study in the Annals of IM that:“Use of routine imaging vs usual care without routine imaging in patients without indications for diagnostic

imaging suggest no clinically meaningful benefits on outcomes related to pain, function, WOL, or mental

health.”

So, if imaging is not warranted, then treat initially. Saves $$, Time, exposure to radiation, and incidentalomas

Morris EW, Di Paola M, Vallance R, Waddell G. Diagnosis and decision making in lumbar disc prolapse and nerve entrapment. Spine (Phila Pa 1976) 1986; 11:436.

Tendinosises • Stuides found the Eccentric Strengthening improved all three. • Stuies also found when performed on all three –opathies, that Corticosteroid Injection, at best, reduced acute pain only, and was inferior to other treatment methods, such as ES.

Eccentric Strengthening • Basically is the way to prevent tendonosis/itis/rupture• Stretching surrounding muscles and gradually increasing tension on tendons• Physical therapy in a sense, controlled strengthening of the muscles which leads to balanced strengthening of tendons rather than unbalanced which leads to damage

Posterior Tibilais Tendonosis• Acute or Overuse Injury• Excessive inversion, flexion, or high impact sports that require stabilization. • Sxs: Pain behind the medial malleolus • Risk factors: female, >40, Obese, DM, HTN• Sx: Pain with passive dorsiflexion and heel rise• Tx: RICE, NSAIDs, +- boot for 3-6 weeks, orthotics, PT, ES•Duration – can extend into the 3-6 month period.

Shoulder Injuries • Impingement• Age>35• Overuse injury with an insidious onset of pain

• AC spurring & tendon degeneration• Pain with overhead activity• Supraspinatus tendon most commonly involved followed by

infraspinatus

• RC Tendonitis• Age<35, Typically acute • Pain with manual muscle testing• Partial tears may be associated with night pain

Shoulder Management•PT – reduces pain, improves function•Corticosteroid Injection – SubAC•NSAIDS •If calcific tendonitis - ECSWT

More Shoulder• Rotator Cuff Tears:•Will present with supraspinatous weakness, external rotation• Positive impingement signs (Neer’s and Hawkin’s)

Adhesive Capsulitis • AKA Frozen shoulder• Pain constant, worse at night, and with cold weather, decreased ROM• Associated with DM, CAD, Thyroid Dz, Parkinsons Dz, Lung Dz, and CVA• Progressive loss of both Active and Passive ROM• Three Stages: Freezing, Frozen, Thawing stages. • Tx: Corticosteroids, NSAIDS, manual manipulation, arthoscopy

Carpal Tunnel Syndrome• Compression of the Median Nerve• Phalens Test• Flick Test (more sensitive at night)• Tinels sign (tapping on affected nerve)•Monofilament testing •Weak thumb abduction

•Treatment• Splints•NSAIDS• Steroid Injections (superior to PO)• Surgical release – prevents progression rather than return to normal condition.

Dupuytren’s Contracture• Affects males > 40• 4th finger most common• Associated with smoking, elcohol, and beetus •Development of nodules to progressive fibrosis of the palmar fascia which shortens and thickens with flexion of the digit • Tx: CS Injections, splinting not helpful, Collagenase injections, lastly surgical release

Plantar Fasciitis • Associated with: Obesity, minimal ankle mobility, tight achilles tendon, pes cavus/planus, excessive running/marathoning • Sx: Heel pain, worse with first steps in the morning, tender at the medial calcaneal tubercule • Tx: RICE, stretching, PT, myofascial massage, orthotics, night splints, CSI, ECSWT

Morton’s Neuroma• Irritation, trauma or excessive force on the intermetatarsal planar nerve•3-4 web space most common, female more common•“burning pain” in foot with toe numbness•Tx: shoes with wide toe box, low heels, orthotics and injection

MN

Tarsal Tunnel Syndrome• AKA: Posterior Tibialis Nerve entrapment/Posterior Tibial Neuralgia• Rare, however commonly found in RA. Association with autoimmune dz is high. Also ass. w/ pregnancy, DM, thyroidal dz. • Sxs: Numbness in the foot radiating to the big toe and the first 3 toes, pain, burning, electrical sensations, and tingling over the base of the foot and the hee.• Often mistake for plantar fasciitis except that the medial calcaneal tubercle is nontender• Dx: Electrodiagnostics, Grade C• Tx: Same as everything else, biomechanical correction, NSAIDS, injections, surgery if all else fails.

•Tarsur Turner Surndrum

Shin Splints/Stress Fractures• Natural Progression: Shin Splints Stress Fracture• Shin Splints (Medial Tibial Stress Syndrome): present with diffuse

tenderness over the middle to distal third of the tibial border (usually medial but sometimes lateral) is typically present.• Stress fractures may be the result of a small number of repetitions with a relatively

large load (eg, a military recruit marching for several miles with a heavy backpack), a large number of repetitions with a usual load (eg, an athlete training for a long-distance race), or a combination of increased load and increased repetitions.• Risk Factors: decreased physical fitness, low Vitamin D, more common in females,

improper/worn footwear, abnormal foot anatomy, older age• Hop test: Have the patient hop on affected leg, it will reproduce pain at affected

site. They like doing this specifically when femoral neck fracture is suspected.

Shin Splints/Stress Fractures

• Imaging: if low risk, diagnose from history alone. +/- plain radiograph• Higher risk:

• Plain radiograph (If +) can diagnose (higher specificity), if negative, further imaging needed (b/c it has low sensitivity) MRI (both sensitive and specific)

• Bone scan (high sensitivty, low specificity)

• Tx: Pain control (NSAIDS), alteration in exercise with tremporary reduction in intensity, PT, Ice

Osgood Schlatter Disease • AKA: Tibial Tuberosity Avulsion• Is a “traction apophysitis of the proximal tibial tubercle at the insertion of the patellar tendon.”• Disorder of younger adults• Presents with anterior knee pain that is worsened by running, squatting, jumping, etc…, and relieved by rest • Dx: Ely test, Pyhysical exam, Plain radiograph to rule out other pathology. • Tx: “The Management of OS has not been formally studied in RCT”• However, continuance of activity, short term pain control with NSAIDS, and

physical therapy are the mainstays, and rarely, surgical intervention.

OS

PFPS: AKA Runners Knee• Patellofemoral pain syndrome (PFPS) is a frequently encountered overuse disorder that

involves the patellofemoral region and often presents as anterior knee pain.

• PFPS is the most common cause of knee pain seen by primary care physicians, orthopedic surgeons, and sports medicine specialists. More common in women 2:1 ratio

• Sx: Typically knee pain from PFPS worsens with squatting, running, prolonged sitting, or when ascending or descending steps.

• Patellofemoral compression test – Directly compress the patella into the trochlear groove while the leg is extended. Pain marks a positive test, which is consistent with PFPS.

• Patella facet/retinaculum tenderness – With the patient's knee in full extension and the quadriceps relaxed, displace the patella laterally and palpate its lateral facet (undersurface) through the retinaculum and synovium. Tenderness is a positive finding.

• Patellar glide – With the knee extended and the quadriceps relaxed, manually displace the patella laterally and medially. Translation less than one-quarter of the patella's width signifies a tight retinaculum, while translation of three-quarters of the patella's width signifies a hypermobile patella.

PFPS: AKA Runners Knee• Treatment/Management: • During rehabilitation, reduce weight bearing, reduce amount of extreme

exercising, treat pain with NSAIDs, ICE• Barefoot/Minimalist Running Shoes: One study revealed that these

decreased PFPS by up to 12%, more studies are being performed. • Intra-articular steroid injections/Glycosaminoglycans showed no

significance

ITBS (IT Band Syndrome)• An overuse injury of the lateral knee that occurs primarily in runners

• Pain develops where the iliotibial band courses over the lateral femoral epicondyle (LFE), just proximal to the lateral joint line

• It is typically sharp or burning and occurs just prior to or during foot-strike when running, or as the knee extends (down-pedal position) when cycling, or when walking/running up stiars/incline

• Physical Exam: focal tenderness at the distal ITB where it courses over the Lateral femoral epicondyle

• Radiographs: Don’t get, only finding (low specificity) is tendon thickening at insertion to LFE.

• Dx: Clinically from history

• Tx: Same as PFPS

ITBS

Sources•UpToDate.com• AAFP.org• American Orthopedics Association •Medscape.com•Massachusets General Medicine