Care of Musculoskeletal Problems in the Outpatient Setting - part 1 pptx

Shahady, MDTallahassee, FL, USA Editor Primary Care of Musculoskeletal Problems in the Outpatient Setting With 207 Illustrations... Exercise can induce MS problems if the potential for t

in the Outpatient Setting

Edward J Shahady, MD

Tallahassee, FL, USA

Editor

Primary Care of Musculoskeletal Problems in the

Outpatient Setting

With 207 Illustrations

Printed on acid-free paper.

© 2006 Springer Science+Business Media, LLC

All rights reserved This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden.

The use in this publication of trade names, trademarks, service marks and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights.

While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect to the material contained herein.

Printed in the United State of America (SPI/MV)

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This book is dedicated to my lovely wife Sandra, our six beautiful and gifted children, their wonderful spouses and our ten lovely and talented grandchildren.

Through them I have learned the real joy

and meaning of life.

Contributors ix

PART I GENERAL TOPICS

1 Key Principles of Outpatient Musculoskeletal Medicine 3

10 Back Problems 178

Edward J Shahady

PART IV LOWER EXTREMITY

11 Hip and Thigh Problems 203

Edward J Shahady

12 Knee Problems 228

Jocelyn R Gravlee and Edward J Shahady

13 Lower Leg Problems 268

Eugene Trowers MD, MPH, FACP

Assistant Dean, Department of Clinical Sciences, Florida State UniversityCollege of Medicine, Tallahassee, FL, USA

plaints are common in the physically active especially the weekend warrior who

is too busy during the week to be active and overextends himself or herself on theweekend Unfortunately, many patients do not receive effective care for MS prob-lems In order to provide effective care there are key principles that should be followed:

1 Knowledge of the anatomy of the area involved is critical to diagnoses andtreatment Devoting a few extra minutes to rediscovering the anatomy willfacilitate a more accurate diagnosis and prescription of effective treatment

2 A focused history and examination that includes the mechanism of injury

is 95% accurate in making the diagnosis of MS problems

3 Imaging for MS problems is sometimes overordered and used as a tute for the physical examination and history

substi-4 Rehabilitation for an injury begins with rest, ice, compression, and elevation(RICE) The next phase of rehabilitation includes stretching, strengthening,heat, ultrasound, and stimulation Medications have a role but only a tem-porary one Medications should never be used alone with MS problems

5 Treatment always includes a reduction of training errors and use oforthotics if needed

6 Older patients, especially those with chronic disease, will have minor MSproblems that will lead to major disability if not properly addressed

7 Exercise is an excellent medication for many chronic diseases.Understanding how to motivate patients and yourself to prescribe exercise

is difficult and may require a change in clinician and practice attitude

8 Exercise can induce MS problems if the potential for training errors andanatomic risks are not properly accessed and addressed

9 Medications for relief of pain and inflammation are helpful but can alsohave negative effects especially in the elderly

10 The place where physical activity occurs can represent a risk High andlow altitudes as well as heat and cold are environments that can lead to

3

problems The most important role for the primary care clinician is vention and early recognition of these problems.

pre-11 When does being sick limit physical activity? An upper respiratory tion (URI) or infection of any type should not necessarily limit physicalactivity Infectious mononucleosis (MONO) is not necessarily a con-traindication to physical activity

infec-1 Principle 1

Each chapter of this book stresses some aspect of the anatomy of the MSproblems of that chapter The anatomy stressed is not the total anatomy ofthe area but the key anatomy most often involved in the diagnosis andtreatment of MS problems For example, Chapter 5 describes the impor-tance of the difference between the shoulder joint and the hip joint This dif-ference allows for more movement of the shoulder than the hip The hip isnot as movable because the head of the femur fits into a socket from thepelvis, so bone aids in preventing it from dislocation and excessive movement.The head of the humerus fits on a flat glenoid process that covers only 1/3 ofthe surface of the humerus A rim of cartilage (labrum) ligaments and rota-tor cuff muscles provide the rest of the stability for the shoulder Thisanatomical arrangement permits the shoulder to move the arm in multipledirections Many of the activities of daily living are possible because of thisflexibility Unfortunately, this anatomical arrangement places the shoulder

at greater risk of dislocation, making it the most commonly dislocated joint

in the body

Knowledge of the shoulder anatomy also helps with rehabilitation Therotator cuff muscles originate on different parts of the scapula and insert onthe humeral head in different sites Knowledge of the origin and insertion aids

in understanding the exercises that need to be prescribed Review the shoulderexercises to help you understand this principle For example, the infraspinatusmuscle originates on the posterior scapula and inserts on the humeral head.Look at the exercise for strengthening this muscle and you will see theanatomy in action

2 Principle 2

The history helps the clinician not only make the diagnosis but better stand the risks for injury and the mechanism that led to the injury Many ofthe cases presented in the different chapters highlight this importance Forexample, the boy with leg pain in Chapter 13 was not in shape over the sum-mer so he was not well conditioned at the start of practice His shoes were

under-2 years old and had been used by his brother for a full season They provided

minimal support medially and the cleats were worn out on the medial side.This information helped with both diagnosis and treatment of his condition.The physical examination helps confirm the history and make the diagnosis.Knowledge of the anatomy helps the clinician perform the examination Forexample, in Chapter 15 in the case of the 36-year-old man with foot pain,examination revealed pain upon palpation of the left heel over the medicaltubercle of the calcaneus The plantar fascia attaches at this site The pain wasaggravated by dorsiflexion of the great toe and standing on the tips of his toes.Both of these maneuvers stretch the plantar fascia Dorsiflexion of the leftfoot was decreased, indicating tightness in the posterior calf muscles Tappingover the area posterior to the medial malleolus does not produce any numb-ness or tingling (negative Tinel’s sign) This helps the clinician rule out othercauses of the foot pain The examination confirmed the history, and the patientwas diagnosed with plantar fasciitis Treatment was instituted and thepatient improved The patient’s history and examination were all that wasneeded to make the diagnosis and start treatment.

Unfor-4 Principle 4

Treatment of MS problems follows a logical sequence Chronic problems aretreated differently than acute problems but many of the treatment strategies aresimilar The foundation for chronic problem treatment is stretching andstrengthening Most patients with chronic MS problems do not understand this.This is especially true of patients with osteoarthritis (OA) Osteoarthritis usu-ally begins as a mild discomfort that the patient self-treats with a nonsteroidal

1 Key Principles of Outpatient Musculoskeletal Medicine 5

anti-inflammatory drug (NSAID) If the pain is mentioned in the early stages,

it is an afterthought and not the primary reason for the complaint and NSAIDsare usually prescribed In an effort to protect the osteoarthritic joint, patientsdecrease joint movement This leads to muscle atrophy and decreased strengthand flexibility Osteoarthritis of the knee is a good example Knee extension isdecreased in order to reduce the discomfort in the knee The decreased exten-sion leads to atrophy and weakness of the quadriceps Weakness of the quadri-ceps reduces the patient’s ability to perform activities of daily living like risingfrom a chair This places more stress on the knee joint and increases pain anddisability This could have been prevented if quadriceps-strengthening exerciseswere the initial treatment strategy employed when the patient was first seen.Exercises given at the end of most chapters can be used to prevent and treat theproblems discussed

If it is an acute problem, the treatment will depend on the phase of tissueinjury The first 48 to 72 h is the acute or the first phase Control of pain andedema decreases the associated inflammatory process in this phase RICE isthe mainstay of treatment at this point Ice reduces the release of inflamma-tory chemicals at the injury site Application of ice for 15 min decreases painand inflammation Elevation of the extremity above the heart and compres-sion also aid in reduction of the swelling Immobilization can be employeddepending on the extent of the injury Immobilization can include casting,splinting (air, rigid, etc.), orthotics, taping, crutches, and bracing Prolongedimmobilization can cause muscle atrophy, weakness, and loss of range ofmotion (ROM) The R in RICE may mean immobilization and/or protection

of the injured part but does not mean stopping all activities bearing movement is encouraged to decrease stiffness Some strengtheningexercises can be performed in this phase in order to prevent atrophy Anexample is an isometric contraction of the quadriceps The patient fully con-tracts the quadriceps muscle while the limb is supported on a bed or floor.The knee joint does not move during this exercise

Non-weight-Beyond 72 h is considered the recovery or tissue-healing or the secondphase It may last for days to weeks Stretching techniques are instituted inthis phase Stretching can decrease pain and reduce loss of ROM and flexi-bility For example, in ankle injury, towel stretching and non-weight-bearingmovement increases the ability to dorsiflex and plantar-flex the foot.Stretching also reduces the incidence of reinjury Once pain-free weightbearing is achieved, strengthening exercises should be initiated Examplesinclude both closed kinetic chain (CKC) and open kinetic chain (OKC) exer-cises Closed kinetic chain exercises are those in which the distal end of thelimb is fixed on a surface A standing squat where the foot is planted is anexample of a CKC exercise for quadriceps strengthening Closed kineticchain exercises are less stressful for the knee joint because the distal limb isnot moving Closed kinetic chain exercises are started before OKC exercises.Use of a leg extension machine or placing a weight on the ankle and extend-ing the knee against resistance is an example of an OKC exercise The distal

end of the limb is moving in OKC exercises so the stress is greater on theknee Wait until the CKC exercises are performed with ease before prescrib-ing OKC exercises.

The third phase is the functional phase Identification of the patients’ workand/or specific recreational activities is required for this phase Patients mayfeel they can return to performing the functions required for work or theirsport but if they return too early, they may suffer a reinjury or a new injury.Proprioception and compensatory movement patterns are key to the func-tional phase Review the suggested exercises at the end of Chapter 14 for abetter understanding of this issue

Another issue in rehabilitation is cross training to maintain conditioning

If tolerated, alternative activities such as water jogging, swimming, walking,running, or using a stationary exercise bike should be considered while thepatient is recovering from the injury or the chronic problem

Other modalities like heat and electrotherapy may be helpful in decreasingpain and edema, promoting healing, and increasing flexibility Heatingmodalities facilitate stretching and strengthening by increasing blood flow tomuscle and inducing muscle relaxation Heat is not used during the acutephase because of increased edema and inflammation Ultrasound, a deepheating agent, is used to promote heating of the joint and to drive medica-tions into the tissue Electrical modalities like transcutaneous electrical nervestimulation (TENS) units are used to modulate the pain response and mayhelp acutely in managing edema

5 Principle 5

Training errors and the need for orthotics are often overlooked areas in ing MS problems The patient with medial tibial stress syndrome presented inChapter 13 is an example of training errors leading to an MS problem Thispatient started football practice without conditioning and was wearing an oldworn pair of shoes He was also an unrecognized pronator His pronation,old shoes, and poor conditioning predisposed him to overstressing his poste-rior tibial muscles This stress resulted in a periosteal reaction and the medialtibial stress syndrome This entity, commonly mistaken for shin splints, will

treat-be discussed in more detail in Chapter 13 He responded very well to the use

of an orthotic, proper shoe size, exercises, and a more appropriate tioning program

condi-Stress fractures are another good example of a training error Boneresponds to overload or additional stress by increasing its rate of turnoverand by repairing itself A balance between bone resorption and bone forma-tion keeps the bone intact A stress fracture occurs when the repetitive loaddisrupts the balance, resulting in a spectrum of injury that results in a fracturethrough the cortex The balance between normal repair and bone breakdowncan be compromised The majority of the time, excessive training and/or

1 Key Principles of Outpatient Musculoskeletal Medicine 7

training errors like a change in footwear, training on different surfaces (hardsurfaces or the sand on the beach), or failure to modify activities at the onset

of symptoms compromises the balance Stress fractures occur in women oradolescent girls who are less than 75% of the ideal body weight The primarycare clinician is in an excellent position to recognize these training errors anduse this knowledge to prevent and treat the associated problems

6 Principle 6

Older patients with seemingly minor MS complaints may develop significantdisability if the problem is not aggressively treated Aging individuals are likely

to have osteoarthritis (OA), past MS injuries, decreased strength secondary

to a loss of muscle mass, and less coordination and may be deconditionedbecause of chronic disease All of these issues make the elderly individualmore susceptible to a minor injury, resulting in major disability

An example is a 65-year-old woman who is caring for a spouse disabled

by a stroke, is mildly depressed, and has type 2 diabetes and OA of her rightknee While lifting her husband she felt a pull in her right thigh Shethought it was a muscle strain and did not seek medical attention initially.Three days after her injury she developed swelling and significant pain inher right knee She was evaluated by her clinician and treated with an injec-tion of steroids into her knee joint and prescribed NSAIDs This treatmentrelieved the knee pain but she began to experience decreased ability to get

up from a chair and within 1 week, she was bed-bound Her blood sugarbecame more difficult to manage with oral agents and she required injec-tions of insulin Both she and her husband had to be admitted to a nursinghome because they were unable to perform activities of daily living withoutassistance

This woman had multiple problems that made her susceptible to what pened Type 2 diabetes is characterized by decreased glucose delivery to mus-cle, therefore contributing to the normal muscle weakness associated withaging The pain of OA of the knee decreases leg extension and leads to weak-ness of the quadriceps She then sustained a strain in the quadriceps whenlifting her husband This strain added to the burden of a muscle that wasalready weak There was minimal reserve and she quickly lost the ability touse her quadriceps muscle effectively, leading to increased stress on the kneejoint and an exacerbation of her OA Her clinician then treated her OA withNSAIDs and steroids in her joint Unfortunately, the patient’s muscle weak-ness increased and she became bed-bound and required admission to a nurs-ing home In the nursing home, she received intensive physical therapy andwas able to return to her home and care for herself within 3 weeks She con-tinues to do her quadriceps-strengthening exercises daily and is now able

hap-to take her daily walk because of less arthritic pain in her knee Increased

walking has aided in relieving her depression and increased her diabetes trol If this patient had been instructed in quadriceps strengthening as part ofher treatment for OA, it may have prevented her admission to the nursinghome For a more extensive discussion of OA of the knee and knee exercises,see Chapter 12.

con-7 Principle 7

Exercise is an excellent medication for many chronic diseases Exercisereduces cardiovascular disease by decreasing low-density lipoprotein (LDL)cholesterol and triglycerides, increasing high-density lipoprotein (HDL) cho-lesterol, decreasing blood pressure, and improving endothelial function bydecreasing the inflammatory mediators of atherosclerosis and improved leftventricular function It also increases longevity and decreases the risk of themetabolic syndrome and diabetes by decreasing visceral fat Exercise alsoprevents and treats disability by decreasing some of the changes attributed tothe aging process, reducing the incidence of falls in the elderly and increasingbone mass It also reduces the incidence of breast and colon cancer and con-tributes to psychologic health and well-being

Understanding how to motivate patients and yourself to prescribe cise is difficult and may require a change in clinician and practice attitude.Patients will not exercise if they do not realize a net benefit The positivesmust outweigh the negatives Patients need to feel comfortable and compe-tent with the exercise prescribed If these issues are not addressed the exer-cise prescription will not be followed Another significant patient barrier is

exer-their trust and respect for the clinician Patients do not care how much you

know until they know how much you care Patients respond much better to

positive messages than negative ones Negative messages just increase thefeelings of guilt, shame, and depression that accompany obesity, diabetes,and sedentary lifestyle

Change in patient behavior goes through several stages and patients are atdifferent stages at different times Different strategies are needed for the dif-ferent stages Questions that seek patient partnership are more effective thanlectures about exercise Clinicians who understand the stages of change andhave different strategies for each stage are usually more successful in assistingtheir patients with performing exercises

The exercise prescription should be individualized and be one that thepatient feels is achievable Write the prescription out on your prescriptionpad Give patients an opportunity to disagree or modify the plan Also,include the little things they can do with their daily activities, like walking upone flight of stairs rather than taking the elevator, parking at a distancerather than close to their work or destination Chapter 2 provides more dis-cussion on addressing patient and clinician obstacles to exercise

1 Key Principles of Outpatient Musculoskeletal Medicine 9

8 Principle 8

The advice to exercise should always include suggestions that prevent MS lems from developing Training errors and anatomic issues like pronationincrease risk of injury Training errors are common in individuals who have justbegun an exercise program Exercise has not been a regular part of their livesand they lack knowledge of proper shoe wear, exercise surface, exercise terrain,and stretching and strengthening routines Even exercises like daily walkingrequires appropriate preparation The clinician should be prepared to evaluatecurrent shoe wear by looking at the shoes patients intend to use Chapter 15 has

prob-a good discussion on how to evprob-aluprob-ate prob-and purchprob-ase shoes Surfprob-ace for exerciseshould be consistent when first starting a program Switching from one surface

to another without acclimatizing to one can create problems Different terrainscreate different demands on the lower extremities Hills stress different muscleswhen going downhill than when going uphill Slanted surfaces like those on abeach stress one leg differently than the other Stretching and strengtheningmuscle groups, especially the lower leg muscles, aid in the prevention of mostcommon exercise-related MS problems Chapters 11 to 15 provide good insightinto how to stretch and strengthen all muscle groups below the waist

Anatomic risks if not recognized and treated before an exercise program isstarted may lead to MS problems Two good examples are pronation andincreased quadriceps (Q) angle in the knee Pronation is associated with severalknee, lower leg, and foot problems like patellar femoral tracking syndrome(PFTS), posterior tibial tendonitis, and plantar fasciitis These clinical prob-lems may be prevented or minimized with the use of orthotics Further discus-sion of the treatment of pronation and use of orthotics is included in Chapter 15

An increased Q angle is more common in women because of their hip anatomy.The increased angle changes the movement of the patella through the femoralgroove with knee extension and flexion and increases the risk of PFTS The sizeand strength of the lateral quadriceps muscles increase in individuals who startexercise programs This creates an imbalance between the lateral and medicalquadriceps muscles and causes the patella to move more laterally with exten-sion and flexion of the knee This imbalance can cause the PFTS The individ-ual with an increased Q angle starts out with an increased risk of PFTS andexercise adds to the risk The PFTS can be prevented or at least minimized ifthe patient is taught how to perform quadriceps-strengthening exercises, espe-cially straight leg raising, before the exercise program is started and continuesthem once the exercise program begins Chapter 12 further discusses the PFTS.Exercises for PFTS are at the end of Chapter 12

9 Principle 9

Medications for relief of pain and inflammation are helpful but can alsohave negative effects, especially in the elderly Tylenol (acetaminophen) andNSAIDs are the most commonly used medication for pain relief in MS injury

Tylenol is an analgesic with minimal anti-inflammatory action that is tive in relieving mild to moderate pain The mechanism of action does notinterfere with prostaglandin synthesis, thus giving it a safer gastrointestinal(GI) profile Its action is mediated through the central nervous system.Acetaminophen is equal to aspirin in analgesic properties and it is unlikely toproduce many of the side effects associated with aspirin and aspirin-containingproducts Tylenol has to be given in the appropriate doses every 6 to 8 h for

effec-it to be effective When given in doses of 4000 mg a day effec-it works as well asNSAIDs for pain relief Unfortunately, most patients are not informed of theneed to take full doses and lose confidence in Tylenol because of inadequatepain relief Adult Tylenol comes in a 500- and 650-mg tablets and caplets Ifthe dose does not exceed 4000 mg a day, the risk of liver toxicity is minimal.Tylenol Arthritis Extended Relief caplets (650 mg) have a two-layer formula-tion The first layer dissolves quickly to provide prompt relief while the time-released second layer provides up to 8 h of relief

NSAIDs are the most frequently prescribed medications for MS problems.They work by blocking the conversion of arachidonic acid to prostaglandin.The side effects include increased incidence of hypertension and heart dis-ease, gastric ulceration, GI bleeding, edema, and renal disease The incidence

of these side effects increases with age, use for greater than 2 weeks, and usewith other drugs like alcohol There are two types of NSAIDs: COX-1 andCOX-2 inhibitors The COX-2 inhibitors are more selective and block onlyCOX-2 enzymes They have fewer GI side effects but have recently been impli-cated in increased cardiovascular risk Some controversy exists about the use

of anti-inflammatory drugs with injury Most view them as helpful by ing inflammatory response but a few believe that the healing process isblunted by the use of NSAIDs [1]

reduc-The evidence for either opinion is limited reduc-The major benefit is pain reliefand that is a well-documented effect of NSAIDs The reader is encouraged touse caution in the use of NSAIDs Some good rules to follow include limitinguse for no longer than 7 to 10 days, not mixing with alcohol or other medica-tions that cause GI distress, and monitoring closely for edema, hypertension,proteinuria, cardiovascular disease, GI distress, and/or bleeding

10 Principle 10

Physical activity performed at high and low altitudes as well as excessive heatand cold are environments that can lead to problems The most importantrole for the primary care clinician is prevention and early recognition of theseproblems If the primary care clinician practices in an area where these prob-lems are more likely then recognition and early treatment will be more impor-tant to the clinician All clinicians should be aware of the risks of altitude,heat, and cold and educate their patients about how to prevent problems inthese environments High-altitude illness can be prevented with Diamoxtaken before ascending to altitudes and limiting the distance climbed to 1000 ft

1 Key Principles of Outpatient Musculoskeletal Medicine 11