HOME > EDUCATION > TRAINING > Regional Musculoskeletal Disorders

Regional Musculoskeletal Disorders

Contributor: Leslie Staudt, MD

+ CASE 1

A 38 year-old accountant notes persistent joint pain and fatigue that have worsened over the past several months. She has had similar but milder pain for the past 4-5 years. She notes pain in her neck, shoulders, arms, back and knees. The pain interferes with her sleep most nights and she never awakens feeling rested. She has trouble making it through a full day at work because she is so tired. She has tried various over-the-counter non-steroidal anti-inflammatory therapies along with sleep aids, all without significant improvement. She denies depression but does admit to a fair amount of stress at work trying to keep up with the work load. The only past medical history is a prior diagnosis of irritable bowel syndrome. The rest of her review of systems is negative.

In addition to fibromyalgia, what other disorders might present with widespread pain and fatigue?

  • The differential for diffuse pain is broad. Rheumatologic causes include polymyalgia rheumatica, lupus, rheumatoid arthritis, myositis and scleroderma. Infectious entities that can cause widespread pain include hepatitis C and HIV. Endocrinopathies such as hypothyroidism and hyperparathyroidism should be considered. Drug toxicity as a cause is best exemplified by the muscle pain complicating statin therapy. Other considerations include malignancy, neurologic disorders and psychogenic pain from depression.
  • On joint exam, there is no synovitis or joint deformity. She has full range of motion of all extremities and passive joint movement does not reproduce her pain. On palpation though, she displays increased tenderness over multiple juxta-articular muscle groups including over her upper trapezius, posterior cervical muscles, lumbar, paraspinous, greater trochanter, medial knees and lateral epicondyles. The rest of her examination is normal including head and neck, skin, cardiac, pulmonary, abdominal, and neurologic testing.
  • Basic laboratory testing including CBC, CMP, ESR, viral hepatitis, thyroid studies and vitamin D levels are normal.
  • This patient’s presentation and clinical findings are consistent with a diagnosis of fibromyalgia as the cause of her widespread chronic pain and fatigue.
  • The utility of laboratory testing is for reassurance that there is no other underlying disorder to explain the symptoms. How extensive this testing should be is debatable.
  • The patient returns to review the results of her studies. Extra time is spent in counseling in regards her diagnosis of fibromyalgia, what it is and how it can be managed. She is reassured that this is not a progressively destructive or life-threatening illness. The need for regular daily exercise and life-style modification is stressed. The diagnosis and treatment of any barriers to sleep is also essential, and referral to a sleep physician may be warranted. Therapeutic options are discussed and a trial of low dose, nighttime amitriptyline is begun.

+ CASE 2

A 68 year-old female is evaluated for several months of left hip pain. She has multiple medical problems including diabetes, hypertension, coronary artery disease and osteoarthritis. She has known degenerative disease of her knees and has used a cane for ambulation for several years. Five years ago she underwent lumbar surgery for degenerative disc disease. She takes 2-3 hydrocodone-acetaminophen tablets a day for the back and knee pain.

The hip pain is new for the past 2-3 months. She localizes the pain to the upper outer thigh overlying the greater trochanter. The pain is particularly problematic when she lies on her left side and it interferes with her sleeping. She does not note any increased pain with walking. Her knee and back symptoms are unchanged. The pain does not radiate down the leg. She denies any numbness to the area of the pain.

What is the differential for hip pain that localizes to the lateral thigh/hip region?

  • The differential should include articular abnormalities of the hip, bursa and tendon disorders, neurologic disorders, referred pain from the knee, and bone disorders.
  • Pain from disorders of the hip articulation such as osteoarthritis and avascular necrosis generally are noted in the groin but pain may be more diffuse. Trochanteric bursitis pain is localized over the greater trochanter with tenderness elicited in that area. Meralgia paresthetica causes paresthesias and numbness over the lateral thigh. The iliotibial band syndrome, a syndrome most commonly seen in runners and high-intensity work-outs, causes lateral but typically distal thigh pain. Lumbar spine disease with nerve root entrapment especially involving L2 to L4 may cause pain described as in the hip and thigh, while lumbar spinal stenosis typically produces bilateral leg pain with walking. Bone abnormalities including primary bone malignancies, metastatic bone lesions and Paget’s may present with localized hip and leg pain. Inter-abdominal abnormalities causing referred pain include abscesses, renal stones and hernias.

How does the positional nature of the pain aid in localizing the source of the pain?

  • Pain occurring with palpation or pressure over the greater trochanter would be most characteristic of trochanteric bursitis. Local bone abnormalities should also be considered. Unlikely in this scenario would be referred pain from an intra-abdominal or lumbar spine process.
  • On examination, she is 5’2’’ and weighs 180 lbs. She is stiff on arising and walks with a cane. There is no tenderness over her spine or back. There is increased tenderness to palpation over the left greater trochanter but not on the right side. Rotation, flexion and abduction of the left hip are normal but she notes pain in her left lateral thigh with adduction of the left hip. On knee exam there is coarse crepitance bilaterally but no effusion. Range of motion of the knee does not reproduce the pain. Neurologic exam of the lower extremities is intact and there is no loss of sensation elicited over the lateral left thigh.
  • A diagnosis of trochanteric bursitis is made on the basis of the history and exam findings.

Are any additional studies warranted at this time?
No further studies are warranted giving the typical nature of the history and exam findings.

What history and exam findings would have been characteristic for degenerative hip disease, radicular pain from degenerative back disease, metastatic bone pain, referred pain from the knee and meralgia paresthetica?

  • Degenerative hip disease would typically cause pain with weight bearing and ambulation, and be relieved with recumbency; pain is often reproduced with range of motion testing of the hip articulation. Radicular pain from the lumbar spine should not cause localized tenderness in the hip or thigh but would instead be associated with abnormalities on neurologic testing. Metastatic bone lesions classically cause constant pain which is not positional. Meralgia paresthetica causes numbness and paresthesia over the lateral thigh.
  • Using sterile technique and 25 gauge 1 ½ inch needle, 2 cc of local anesthetic and 40 mg of injectable corticosteroid preparation are injected deep in the area of greatest tenderness overlying the left greater trochanter. Immediately following the procedure, the patient relates significant improvement in the pain when palpated. On occasion, a 2 ½ inch spinal needle may be needed to get the depot steroid to the bursa in obese patients.
  • The initial response to the local injection of anesthetic helps confirm the diagnosis of trochanteric bursitis and rule out other entities. The steroid injected may provide long term benefit. Recurrent symptoms would warrant other therapy including physical therapy and evaluation for precipitating factors.

PATIENT CARE

Fibromyalgia

  1. Recognize the typical history and symptoms for a patient with fibromyalgia The American College of Rheumatology has published classification criteria for fibromyalgia in 1990 and has recently revised these in 2010 with preliminary criteria.
  2. Demonstrate the characteristic tender points of fibromyalgia on examination -Utilize the appropriate evaluation tools in the diagnosis of widespread chronic pain
  3. Describe pharmacological and non-pharmacologic modalities of treatment

Regional Musculoskeletal Disorders:

  1. Demonstrate a complete physical examination of the shoulder, elbow, hand and wrist, hip, knee, foot and ankle, neck and low back including inspection, palpation, range of motion, strength testing and neurological evaluation
  2. Recognize the expected history, symptoms, physical and radiographic examination findings associated with common disorders of the shoulder including: rotator cuff tendinitis, rotator cuff tear (1, 2, 3), impingement syndrome (1, 2, bicipital tendinitis, subacromial bursitis, subdeltoid bursitis, frozen shoulder (adhesive capsulitis) and thoracic outlet syndrome, and distinguish these from osteoarthritis of the glenohumeral joint and acromioclavicular joint
  3. Recognize the expected history, symptoms physical and radiographic examination findings associated with common disorders of the elbow including olecranon bursitis, lateral epicondylitis (tennis elbow), medial epicondylitis and ulnar entrapment neuropathy
  4. Recognize the expected history, symptoms, physical and radiographic examination findings associated with common disorders of the hand and wrist including Dupuytren’s contracture (1, 2, 3), trigger finger, de Quervain’s tenosynovitis, ganglion cyst, and carpal tunnel syndrome (median neuropathy) (1, 2, 3), and distinguish these from osteoarthritis of the hand
  5. Recognize the expected history, symptoms physical and radiographic examination findings associated with common disorders causing pain in the hip including trochanteric bursitis, ischial bursitis, iliopsoas bursitis, coccydynia, and meralgia paresthetica (entrapment of the lateral femoral cutaneous nerve), and distinguish these from osteoarthritis of the hip
  6. Recognize the expected history, symptoms and physical examination findings associated with common disorders of the knee including anserine bursitis, chondromalacia patella, prepatellar bursitis, meniscal tear (1, 2, 3), and tear of the anterior and posterior cruciate ligaments (1, 2), and compare these to osteoarthritis of the knee
  7. Recognize the expected history, symptoms physical and radiographic examination findings associated with common disorders of the foot and ankle including plantar fasciitis, retrocalcaneal bursitis, Achilles tendinitis (1, 2, 3), hallux valgus and bunion formation (1, 2), Morton’s neuroma, and metatarsal stress fracture , and distinguish/compare these to osteoarthritis of the foot
  8. Recognize the expected history, symptoms and physical examination findings associated with common disorders of the neck and cervical spine including cervical strain, degenerative disc disease and herniated disc syndromes (1, 2), cervical spinal stenosis (99-04-0024) and cervical myelopathy
  9. Recognize the expected history, symptoms, physical and radiographic examination findings associated with common disorders of the low back and lumbar spine including back strain, degenerative disc disease and herniated disc syndromes (1, 2, 3), radiculopathy, lumbar spinal stenosis (1, 2), and cauda equina syndrome
  10. Review the expected history and risk factors, symptoms and physical examination findings for complex regional pain syndrome (reflex sympathetic dystrophy) (1, 2, 3) and a neuropathic joint (Charcot joint) (1, 2, 3)
  11. Identify the appropriate evaluation and diagnostic studies, including radiography, related to each of the above entities
  12. Describe the therapeutic options, including the appropriate indication and associated cost of the above entities including pain medications, physical therapy, splinting, local injection and surgical referral
  13. Identify the appropriate approach and method for intra-articular and soft tissue glucocorticoid injections

Medical Knowledge

  1. Review normal structure of a diarthrodial joint (1, 2) and vertebral body (99-01-0004)
  2. Review the normal joint structure and radiographs of the hand (1, 2), wrist (1, 2, 3), elbow (1, 2, 3), shoulder (1, 2, 3), cervical spine (1, 2, 3), lumbar spine (1, 2, 3) , hip (1, 2), knee (1, 2, 3) , ankle (1, 2, 3), and foot (1, 2, 3), including major muscle groups, tendons, bursae, vascular structures and innervations
  3. Identify both inflammatory and non-inflammatory causes of widespread chronic pain and relate distinguishing differences
  4. Recognize common areas for bursitis and tendinopathy, including trochanteric bursitis and adhesive capsulitis
  5. Identify causes of neck and back pain, including spondylosis, spinal stenosis, and spondylolisthesis
  6. Summarize basic indications and contraindications to musculoskeletal plain radiography, ultrasound, computerized tomography and magnetic resonance imaging
  7. Review basic indications, components and the potential complications for localized injections
  8. Contrast physical and occupational therapy including basic indications and modalities available (1, 2, 3)

Interpersonal Communication

  1. Explain the anticipated course and choices of therapy and the rationale for intervention, including the potential risks and benefits in a patient centered approach
  2. Review lifestyle modification which may limit or enhance recovery
  3. Acknowledge and include family and social support as designated by the patient
  4. Provide reassurance and adequate time and accessibility to address patient concerns
  5. Discuss treatment recommendations with other physicians and healthcare providers involved in the care of the patient

Professionalism

  1. Display integrity and honesty in discussing patient care issues and management
  2. Ensure patient privacy
  3. Promote patient autonomy in clinical and therapeutic decisions
  4. Communicate in a timely fashion regarding study results
  5. Provide adequate time and accessibility to address patient concerns
  6. Communicate in a timely fashion with the other members of the patient’s health care team including the primary care physician
  7. Serve as the patient’s advocate

Problem-based Learning

  1. Utilize web-based resources to supplement and update current knowledge base and to explore patient-specific problems
  2. Incorporate evaluation and feedback into practice and management
  3. Utilize errors and complications to improve understanding and future management
  4. Set learning goals in diagnostic strategies and management

Systems-based Practice

  1. Identify barriers to accessing optimal medical care for each individual patient and utilize alternative resources when available to overcome these barriers
  2. Engage and incorporate the input of all medical providers including other physicians, the nursing staff, and physical and occupational therapists as necessary
  3. Serve as a source of learning and education for other members of the health care team for the patient
  4. Utilize the existing health care system to support and establish patient care goals
  5. Incorporate considerations of cost and risk-to-benefit ratios in clinical evaluations, monitoring and therapeutic decisions, for the individual patient
  6. Recognize the impact of both the diagnostic and therapeutic interventions on the health care system, both locally and globally

Keywords: Fibromyalgia, Complex Regional Pain Syndrome, Neuropathic joint, Joint pain, Widespread pain, Regional pain, Tendinopathy, Bursitis, Joint Injection, Arthrocentesis

References