Acute Shoulder Injury and Pain

Overview

• Clavicle

  • Acromioclavicular injury

  • Clavicle fracture

• Glenohumeral dislocation (most common dislocation)

• Proximal humerus fracture

Acromioclavicular Joint Injury

Young adult presents with shoulder pain after falling onto shoulder while being tackled during a football game. Patient was carrying the football and suffered medial/inferior joint stress at the time of the injury. No swelling, deformity of clavicle with a negative cross body adduction test. Active and passive shoulder range of motion intact. Full strength with shoulder abduction, adduction, extension and flexion. Radial pulses 2+, capillary refill < 2 seconds, and no skin discoloration bilaterally. Sensation normal in shoulders, arms, and hands bilaterally.

• Obtain anteroposterior view, Zanca view, axillary x-rays of clavicle

• Treatment

  • Pain management: Acetaminophen, ibuprofen (age/weight based dosing)

  • Management per clavicle elevation (see below)

• Clavicle elevation and injury classification (Rockwood system)

  • < 25%

    • Discontinue shoulder sling once symptoms are tolerable with pain management alone

    • Encourage range of motion exercises

    • Refer to physical therapy

    • Patient counseled that pain may last up to 6 weeks

  • ≥ 25%

    • Refer to orthopedics

    • Patient counseled that pain may last for 3 months

• Patient counseled that he is at increased risk for future AC joint arthritis and/or degenerative changes

Clavicle Fracture

A football player for a Charlotte-based professional football team sustains a shoulder injury while performing a “superman” dive into the endzone. Player reports he landed on the anterior aspect of his shoulder during the descent. Denies shortness of breath. Radial pulses 2+ and capillary refill < 2 seconds. Patient able to touch thumb to each finger and spread fingers against resistance. Sensation intact in shoulders/arms/hands bilaterally.

• Obtain x-ray of affected clavicle

• Treatment

  • Refer to orthopedics if any of the following are present: Open injury, skin tenting, displaced group 1, any group 2 injury

  • Orthopedic referral not required

    • Place arm in sling during day for 2 to six weeks

    • Refer to physical therapy

    • Patient instructed to present to the emergency department immediately if he develops dyspnea or severe unilateral paresthesias

    • Follow-up for re-evaluation in 4 weeks

• Notes

  • Grouping system determines risk for brachial plexus injuries

    • Group 1 = proximal 3rd of clavicle

    • Group 2 = distal 3rd of clavicle

    • Group 3 = middle third of clavicle

  • Ask about shortness of breath to rule out pneumothorax

Glenohumeral Dislocation

Young adult patient with h/o glenohumeral instability, shoulder dislocation/subluxation, and participation in overhead sports present with acute onset shoulder pain s/p fall from bicycle. Reports lateral arm numbness. Patient noted to be holding affected arm in contralateral hand. Palpable humeral head in axilla, dimpling inferior to acromion, reduced range of motion, and lateral arm numbness on exam.

• Imaging

  • Obtain AP, scapular Y, and axillary x-ray to r/o fracture and to confirm successful reduction (see treatment)

  • Concern for axillary nerve injury due to lateral arm numbness, neurovascular deficits: Obtain baseline EMG

• Treatment

  • Injection and reduction

    • Prepare 20 mL intra-articular lidocaine 1% without epinephrine

    • Inject 1.5 cm distal and 2 cm medial to posterolateral corner of acromion

    • Reduce shoulder and repeat radiographs to confirm success

  • Instruct patient to wear sling x 4 weeks

• Follow-up 2 weeks s/p injury

  • No pathology on initial plain films: Repeat AP, scapular Y, and axillary views

  • repeat EMG if no significant improvement has occured

  • Encourage early mobilization to prevent frozen shoulder

• Consults

  • Recurrent dislocation: Refer to orthopedics for evaluation

  • Elite athlete: Consider orthopedics referral due to high risk for repeat dislocation

• Patient counseled that repeat dislocation risk increases with age and each repeat injury

Proximal humerus fracture

Elderly patient with h/o osteoporosis presents with acute shoulder/upper arm pain following a fall from standing position. Radial pulses and 2+ capillary refill bilaterally. Sensation present over lateral deltoid and in the medial, ulnar, and radial nerve distributions of the hand on the affected arm.

• Imaging

  • Obtain anteroposterior view of glenoid, scapular Y view, axillary view

  • If imaging is normal, repeat radiographs at 3 weeks to rule out occult fracture

• Treatment

  • Non-displaced fracture

    • Non-operative management recommended as it provides better outcomes

    • Apply sling x 6 weeks and then start range of motion exercises

  • Displaced fracture and/or cool, pulseless extremity: Refer to orthopedics for evaluation

Glenohumeral Instability

Pt with h/o shoulder dislocation/subluxation presents with shoulder pain s/p collision sustained while playing an overhead sport. Reports numbness over lateral deltoid. Generalized ligamentous laxity, positive apprehension test and joint relocation on exam.

• Consider shoulder x-ray; evaluate for Hill-Sachs lesion, dislocation, and inferior glenoid avulsion fracture

• Refer to PT for strength training

• Consider surgery if recurrent dislocation/subluxation occurs

Rotator Cuff Injury

Note: If the initial exam is concerning enough to warrant MRI, the patient should be referred to orthopedics where an MRI will likely be performed. (In other words, MRIs are rarely ordered by primary care physicians in areas with reasonable access to specialists.)

Adhesive Capsulitis (Frozen Shoulder)

Pt > age 40 with h/o DM, thyroid d/o, previous shoulder surgery presents with diffuse shoulder pain. Gradual onset of pain and stiffness, pain present at night. Decreased active/passive ROM in all planes, pain with movement on exam.

• Obtain HbA1c, TSH, free T4

• Consider shoulder x-ray

• Refer to PT and start acetaminophen vs NSAID

• Consider intra-articular corticosteroid injection

• Refer to orthopedics if no improvement in 6-12 weeks

• Pt advised that condition will most likely resolve spontaneously within 1-2 years

Shoulder Arthritis

Acromioclavicular Arthritis

Pt with h/o trauma presents with anterior/superior shoulder pain. Acromioclavicular joint tenderness, painful cross-body adduction test on exam.

• Obtain shoulder x-ray

• Start Tylenol/NSAIDs, heat, and stretching for pain

• Consider intra-articular corticosteroid injection vs. surgery if symptoms do not improve

Glenohumeral Osteoarthritis

Patient age > 50 years with h/o autoimmune disease/arthritis, shoulder injury, and previous shoulder surgery presents with progressive, diffuse shoulder pain in deltoid region. Reports gradual onset of shoulder stiffness and loss of motion due to pain with activity. Sometimes experiences pain at night on the affected side. Joint line tenderness under the coracoid process, crepitus with active/passive range of motion, restricted external rotation, weakness with overhead arm raise, and a positive Apley scratch test on exam.

• Obtain shoulder x-ray and evaluate for joint space narrowing, spurring/osteophytes

• Conservative therapy

  • Start Tylenol/NSAIDs, heat, and stretching for pain

  • Refer for 6 week course of physical therapy

  • Patient advised to avoid overhead activity

  • Follow up in 6 weeks

• Additional treatment

  • No improvement after 6 weeks: Inject glenohumeral joint with mixture of

    • 1 mL triamcinolone acetonide 40 mg/mL

    • 2 mL 1% lidocaine without epinephrine

  • No improvement at 3 months

    • Consider repeating radiographs to evaluate for disease progression

    • Schedule repeat joint injection 3 months after initial injection

  • Refer to orthopedics for persistent pain affecting quality of life and no improvement after 3 months of conservative therapy and 2 shoulder injections at least 3 months apart; patient counseled that treatment options may include

    • Osteophyte debridement in patients younger than 50 years

    • Prosthetic joint replacement

  • Patient counseled that the results of shoulder surgery are variable and that symptoms generally recur to some degree within 10 years of the procedure

Notes

• Overall, glenohumeral osteoarthritis an uncommon cause of shoulder pain

• Generally preceded by remote history of shoulder injury

Superficial Bursitis

Olecranon Bursitis (Draftsman’s Elbow)

50 y/o plumber with h/o alcoholism, immunocompromised state, DM and end-stage renal disease on hemodialysis presents with acute onset, mildly tender unilateral elbow swelling after repeatedly striking the affected elbow against pipes while working. Pt can expel serous fluid from lesion with minimal manipulation, but swelling returns within a few hours. Denies fever, chills. Denies personal, family history of rheumatologic disease and/or gout. Bursal enlargement with mild tenderness and surrounding edema noted on exam. Decreased ROM due to swelling, but not pain.

Prepatellar Bursitis (Housemaid’s Knee)

Presentation is similar to olecranon bursitis, but microtrauma is due to frequent kneeling/crawling. Associated professions/activities include plumbers, roofers, wrestling, and gardening.

Aseptic Bursitis

• Significant bursal enlargement

  • Consider aspiration of elbow/knee for symptom relief; if performed, obtain BMP and send aspirate for analysis

  • Aspirated fluid serosanguinous with

    • < 1,500 WBC/mm^3 and fluid:serum glucose ≥ 0.5

    • No crystals and negative Gram stain/culture

• Imaging

  • Ultrasound shows enlarged bursa, thickened bursal sac

  • Color Doppler negative for hyperemia

  • Recent trauma or concern for foreign body: Obtain plain radiography

• Initial management

  • Rest, ice, and elevation to resolve acute swelling

  • Naproxen 500 mg BID for swelling and pain

  • Elbow padding to reduce future trauma

• If swelling persists or is bothersome to the patient, consider intralesional corticosteroid injection vs. referral to orthopedics for surgical bursectomy

• Pt instructed to contact provider if s/sx of septic bursitis develop (see below)

Septic Bursitis

Pt returns with increased pain and decreased ROM at the bursitis-affected elbow. Reports skin trauma at bursa site due to repeat attempts to aspirate sac at home. Fever, erythema, surrounding edema, and tenderness to palpation noted on exam. Temperature of skin overlying bursitis 2°C greater as compared to non-affected elbow.

• Obtain CBC, CMP, ESR, CRP, and blood culture

• Cloudy/purulent aspirate shows > 1,500 WBC/mm^3, fluid:serum glucose < 0.5, positive Gram stain, no crystals; f/u culture results

• Start cephalexin 500 mg q6h x 10 days and adjust therapy pending culture

• Imaging

  • Ultrasound shows enlarged bursa +/- surrounding cellulitis

  • Hyperemia on color Doppler indicating infection

  • Bursa aspiration unsuccessful: Obtain MRI

• Failed outpatient management and/or concern for systemic infection: Admit to hospital, start vancomycin, and consult orthopedics

Notes

• Differential diagnosis includes rheumatoid arthritis and gout

• Olecranon bursitis

  • Most common in patients with repeat elbow microtrauma, e.g. students, draftsmen, plumbers, technicians, and miners

  • Increased prevalence in hemodialysis patients; the pathophysiology responsible for this association is unknown

• Septic bursitis

  • 80-85% of cases associated with S. aureus

  • Risk factors

    • Patients with h/o alcoholism, immunocompromised state, DM, and ESRD

    • Skin injury at or near bursa site

    • Repeat attempts to aspirate bursa at home

Carpal Tunnel Syndrome

Pregnant, early middle-aged female with h/o obesity, DM, hypothyroidism, rheumatoid arthritis presents with pain and paresthesias in distribution of median nerve. Pain often awakens patient from sleep and is reduced by shaking hand (flick sign). Square shaped-wrist with loss of two-point discrimination, positive Phalen/Tinnel/median nerve compression tests on exam.

• Obtain HbA1c, TSH

• Consider obtaining rheumatoid factor, anti-CCP antibodies

• Ultrasound showing median nerve cross-sectional area < 9mm

• Treatment

  • Consider median nerve glide exercises, yoga

  • Start neutral wrist splint

  • No improvement after 6 weeks of conservative therapy

    • Consider prednisone 20 mg x 10 days

    • Consider 80 mg methylprednisolone local injection

  • Failure of conservative management after 4-6 months: Refer for nerve conduction studies/needle electromyography and consider surgical intervention

Notes

• More common in women

• Flick sign

  • Patient experiences relief s/p shaking hand

  • 93% sensitive and 96% specific for carpal tunnel syndrome

• Pathophysiology and physical exam

  • Median nerve distribution: Palmar aspect of thumb/index/middle fingers and radial half of ring finger

  • Sensory nerves are more susceptible to compression that motor nerve fibers

  • Two point discrimination: Inability to distinguish between points less than 6 mm apart

• Treatment

  • Ineffective therapies: NSAIDs, vitamin B6

  • Oral corticosteroids can improve pain for up to 8 weeks

  • Corticosteroid injection

    • Can reduce pain for 1 month and delay need for surgery at 1 year

    • Risks include median nerve injury and tendon rupture

  • Avoid routine physical therapy referral after surgery

De Quervain Tenosynovitis

35 y/o F with no h/o trauma presents with insidious onset wrist pain. Pain worse with gripping/grasping objects and picking up her 6 month old child. Pain is affecting her work as a calligrapher. Mild wrist swelling with tenderness upon palpation of radial styloid/anatomic snuff box, positive Finkelstein test, and negative grind test on exam.

• Pain relief with diagnostic lidocaine injection of first extensor compartment

• Treatment

  • Naproxen 500 mg BID

  • Mild case: Thumb spica splint for pain relief

  • Moderate to sever case: Administer glucocorticoid injection

Notes

• Most common in females age 30-50 years

• Inciting factors may include picking up a child or occupations that include prolonged gripping/grasping

• Pathophysiology: Inflammation of the extensor pollicis brevis and abductor pollicis longus tendons that form the border of the anatomic snuff box

• Diagnosis

  • Finkelstein test:

    • Arm is held with elbow at approximately 90 degrees with the radial aspect of the wrist superior. A fist is made with the fingers covering the thumb and the hand is flexed inferiorly at the wrist.

    • Good sensitivity and specificity

  • Grind test: Pressure is placed on the DIP of the thumb as it is rotated; a positive test would suggest basal thumb arthritis instead of de Quervain's tenosynovitis

  • Consider obtaining CBC, CRP, ESR if suspicious for infectious tenosynovitis

  • Pain relief with lidocaine rules out arthritic cause

• Persistent inflammation may produce stenosing tenosynovitis

Distal Radial Fracture

70 y/o F with h/o osteoporosis presents with acute onset wrist pain s/p fall on outstretched hand (FOOSH). Denies h/o peripheral vascular disease, previous wrist injury/surgery. Wrist swelling, but no open fracture/deformity or pain with palpation of anatomic snuff box. Appropriate capillary refill; motor/sensory function intact in region of median, radial, and ulnar nerves.

• Postero-anterior (PA), lateral, and oblique wrist views reveal distal radial fracture

• Pain control

  • Opiate naive: Administer 1 time dose 2.5 mg morphine IV if necessary

  • Calculated CrCl ≥ 30 mL/minute: Start naproxen 500 mg BID

• Apply sugar-tong splint allowing for full MCP flexion/extension

• Counseling

  • Pt instructed to elevate arm and apply ice to affected extremity

  • Pt encouraged to perform shoulder and finger range of motion exercises

  • Pt advised to seek medication attention if widespread discoloration or numbness/tingling develop in affected extremity

• Follow-up outpatient with orthopedics

Notes

• Pain with palpation of anatomic snuff box should raise suspicion for scaphoid fracture

• Obtain emergent orthopedic consult for

  • Open fractures

  • Development of neuropathy/vascular compromise

Finger Injury

Extensor Tendon Injury at DIP (Mallet Finger)

Pt presents with acute onset pain at distal interphalangeal (DIP) joint after being struck by a basketball with finger in full extension. Injury occurred within the previous 3 months. Dorsal DIP tenderness with no active DIP extension when isolated during exam.

• Imaging

  • Initial 3-view radiography (anteroposterior, true lateral, and oblique views) shows bone fragment on dorsal surface of proximal distal phalanx

  • 3-view radiography s/p splinting shows confirms alignment of fracture fragment

• Intervention

  • Continuously splint in extension DIP x 8 weeks

  • Unable to perform full passive extension and/or avulsion fracture involving > 30% of the joint: Refer to orthopedics

• Counseling

  • Pt counseled that failure to adhere to splinting recommendations and not to flex joint during treatment as it could result in permanent injury

  • Pt reassured that athletic activities that do not place joint at risk of re-injury may continue during splinting

  • Pt instructed to contact provider if distal phalanx blanching is noted during splint as reduced blood supply can result in distal finger necrosis

Notes

• Most common tendon injury of the hand

• Can be treated for up to 3 months s/p injury

• Passive extension is performed by examiner

• Patient adherence to splinting determines treatment success

• See link for more information and images

Flexor Digitorum Profundus Tendon Injury (Jersey Finger)

Pt presents with acute onset pain at the distal interphalangeal (DIP) joint after grabbing an opponent’s jersey during a game. Per description, mechanism of injury resulted in forceful hyperextension of DIP. Volar DIP joint tenderness and inability to actively flex DIP when isolated.

• 3-view radiography shows bone fragment at volar surface of proximal distal phalanx

• Finger splinted and patient urgently referred to hand surgeon due to risk for tendon retraction

• Pt advised that surgery may be required within 7-10 days to prevent permanent injury

Mnemonic device: The term ‘Jersey Finger’ also describes Garden State residents’ inability to perform active finger flexion while driving

Ulnar Collateral Ligament Injury (e.g. Skier’s Thumb)

Pt with presents with acute onset thumb pain that occured when s/p falling while holding a ski pole. Per description, mechanism of injury resulted in forced abduction and hyperextension of metacarpophalangeal joint. Exam reveals swelling and tenderness along ulnar aspect of thumb, inability to form a pinch grip with thumb and index finger.

• Obtain 3-view radiography of thumb

• Intervention

  • Stable joint: Immobilize with thumb-spica splint x 4 weeks; refer to orthopedics for instability persisting s/p splinting

  • Refer to orthopedics in cases of

    • Pediatric patient

    • Instability with MCP flexion when finger held at 30 degrees of flexion

• Pt advised to avoid heavy gripping or grasping until hand strength returns to baseline

Note: Ulnar collateral ligament injuries are knows as skier’s or gamekeeper’s thumb as they are commonly occur with repeat force applied by ski poles or breaking the necks of small animals (e.g. pheasants, rabbits)

Common Back Pain

Acute/Chronic Nonspecific Low Back Pain

Pt with no h/o osteoporosis, osteoarthritis, malignancy presents with low back pain. Denies fever, weight loss, morning stiffness, gynecologic symptoms, urinary/GI problems. Negative straight leg raise on exam, 2+ reflexes and 5/5 LE strength b/l.

• Initial management

  • Review/establish reasonable goals for pain control

  • Apply superficial heat

  • Obtain CMP prior to starting standing NSAID, Tylenol if concern for renal/hepatic dysfunction

    • Start naproxen 500 mg BID

    • Start Tylenol 500 mg 4 times daily PRN x 6 weeks

  • Consider cyclobenzaprine immediate release 5 mg TID x 2 weeks

  • Refer to physical therapy x 6 weeks (moderate quality evidence)

• Follow-up at 6 weeks: If pt has not achieved reasonable pain control goals

  • Consider acupuncture (moderate quality evidence)

  • NSAIDs ineffective, consider alternative therapies for chronic back pain (low quality evidence):

    • Duloxetine 30 mg qd for 1 week then increase to 60 mg qd as tolerated

    • Tramadol ER 100 mg qd then increase daily dose by 100 mg per week to maximum of 300 mg qd

  • Consider lumbar spine radiography in 1-2 months and/or referral to orthopedics vs. pain management

• Counseling

  • Pt advised to remain active and engage in low-impact exercise (moderate quality evidence)

  • Pt counseled about realistic expectations for pain relief

Lumbosacral Radiculopathy

Pt with no h/o recent trauma presents acute onset back pain. Describes sharp/shooting low back pain with unilateral lower extremity radiation in a dermatomal distribution. Denies red flag symptoms including fevers, chills, night sweats, unexplained weight loss, leg weakness, urinary retention, fecal incontinence. Denies h/o vertebral fracture, malignancy, HIV, IV drug abuse. Positive straight leg raise, no lower extremity strength/sensory deficits, and no hyperreflexia with patellar/achilles reflexes on exam.

• Initial treatment

  • Obtain CMP prior to starting standing NSAID, Tylenol if concern for renal/hepatic dysfunction

    • Start naproxen 500 mg BID

    • Start Tylenol 500 mg 4 times daily PRN x 6 weeks

  • Refer to physical therapy

  • Pt instructed to call office if any red flag symptoms develop (see HPI)

• Schedule follow-up visit at 6 weeks

  • If NSAIDs ineffective consider

    • Amitriptyline 50 mg qhs; titrate to 150 mg qhs as tolerated

    • Gabapentin immediate release 100 mg qhs; increase daily dose by 100 mg per week to 100 mg TID (maximum daily dose 1,200 mg TID)

  • Continued pain/radicular symptoms and/or new onset disability

    • Obtain MRI

    • Refer to orthopedics for epidural steroid injection

Notes

• Most common etiologies include nerve root compression associated with

  • Disc herniation

  • Spondylosis (neural foraminal stenosis generally due to degenerative arthritis)

• Nonskeletal etiologies include acute infection, vascular disease, and/or neoplasm

Emergent Back Pain Red Flags

Cauda equina

Pt with no significant PMH presents with back pain. Reports progressive motor/sensory deficit, bilateral sciatica, leg weakness, difficulty urinating, and fecal incontinence. Saddle anesthesia on exam.

• Emergent MRI consistent with spinal cord compression

• Concern for neoplastic epidural spinal cord compression

  • Refer for emergent surgery to be performed within 24 hours

  • Start dexamethasone

    • Day 1: 10 mg IV followed

    • Day 2 until surgery: Continue dexamethasone 8 mg PO BID

    • S/p surgery: Taper total dexamethasone dose by half every three days

Note: Urinary retention has 90% sensitivity for this condition; the probability of cauda equina in the absence of urinary retention is 1 in 10,000

Back pain with red flags for fracture:

Pt age >50 y/o with h/o osteoporosis, chronic oral steroid use, and IV drug use presents with chronic back pain. Reports recent trauma. Pain with palpation on exam.

• Obtain CBC, ESR, CRP

• Obtain plain radiography

• Consider MRI if initial testing negative and pain persists

• Pt advised to seek emergency treatment for new onset neurologic disability

Back pain with red flags for infection:

Pt with h/o immunosuppression, IV drug use, and recent UTI presents with back pain with no improvement s/p 6 weeks conservative therapy. Reports fever, chills, peri-spinal penetrating wound. Fever, pain with palpation of back on exam.

• Obtain CBC, ESR, CRP

• Obtain plain radiography

• Consider referral for emergency treatment

Back pain with red flags for cancer:

Pt age >50 y/o with h/o cancer presents with chronic back pain with no improvement s/p six weeks conservative therapy. Reports unrelenting pain at night, progressive motor/sensory deficits, unexplained weight loss. Pain with palpation on exam.

• Obtain CBC, ESR, CRP

• Obtain plain radiography

• Consider emergent MRI due to progressive motor/sensory deficits

• Pt advised to seek emergency treatment for unexplained fever, new onset neurologic disability

Ankylosing Spondylitis

Young male pt with h/o acute anterior uveitis, aortic regurgitation, restrictive lung disease, IgA nephropathy presents with low back pain/stiffness for > 3 months. Pain improves with exercise/activity. Decreased chest expansion and reduced range of lumbar spine forward flexion on Schober testing.

• Evidence of sacroiliitis on anteroposterior and lateral x-ray

• Obtain HLA B27 assay

• X-ray of anteroposterior/lateral lumbar spine, lateral c-spine, and pelvis in 3 months to monitor disease progression

• Start NSAIDs

• Pt advised to engage in regular aerobic exercise

Spinal Compression Fracture

Elderly female with history of osteoporosis, multiple myeloma presents with acute onset midline back pain status post fall. Reports recent coughing, heavy lifting prior to injury. No sensory deficits, focal weakness, clonus on exam.

• Obtain CBC, CMP, 25-hydroxyvitamin D

• Consider MRI if focal neurologic deficits develop

• Schedule DEXA scan to assess future fracture risk

• Pain management

  • Acetaminophen, ibuprofen

  • Administer intranasal calcitonin 200 units (1 spray) in one nostril once daily x 4 weeks

  • Consider tramadol 50 mg q6h for additional pain control

  • DEXA scan T-score indicating osteoporosis:

    • Start alendronate 70 mg once weekly

    • Patient advised to take alendronate in the morning and remain upright for ≥ 30 minutes before any additional PO intake, including medications

Notes

• Risk factors

  • Medical conditions: Osteoporosis, multiple myeloma

  • Fracture generally occurs following coughing, heavy lifting, or fall

• Evaluation

  • Obtain testosterone levels for compression fractures that occur in men

  • MRI indicated for neurologic deficits, e.g. sensory deficits, focal weakness, clonus

• Treatment

  • Calcitonin treats short term pain, i.e. < 4 weeks

  • Bisphosphonates (e.g. alendronate) treat osteoporosis and prevent recurrent fractures

  • Weak evidence for kyphoplasty

  • Strong evidence against vertebroplasty

Osteoporosis

Postmenopausal white female > 40 y/o with presents for follow-up status post hip fracture. Reports sedentary lifestyle, poor diet, active smoking status, consuming > 2 alcoholic drinks daily. Medications include chronic glucocorticoids. Mother suffered hip fracture. Low BMI on exam.

• Obtain CMP, TSH, and 25-hydroxyvitamin D

• Obtain DEXA for any of the following:

  • Age ≥ 65 years with no previous DEXA

  • FRAX calculation indicates 10-year risk > 8.5% risk for major osteoporotic fracture and > 1.0% for hip fracture: Refer for DEXA scan

• DEXA scan shows bone mineral density (BMD) ≤ 2.5: Start treatment

  • No esophageal abnormalities: Alendronate 35 mg weekly x 5 years

    • Patient counseled to take medication with water only and remain upright for 30 minutes afterward

    • Discussed small, but potential risk for jaw osteonecrosis/fracture

  • Bisphosphonates (e.g. alendronate) contraindicated

    • Obtain CMP: Verify creatinine clearance ≥ 35 mL/min and no hypocalcemia

    • Start zoledronic acid 4 mg IV every 4 weeks

  • Consider

    • Vitamin D 800 IU daily

    • Intranasal calcitonin x 4 weeks for vertebral compression fracture pain

• Counseling

  • Stop smoking, consume 7 or fewer alcoholic drinks/week (females), and reduce caffeine consumption to ≤ 2.5 cups of coffee daily

  • Exercise to maintain bone mineral density

  • Fall prevention

Notes

• Epidemiology

  • Fifty percent and 20% of white women and men, respectively, will suffer an osteoporosis-related fracture

    • 20% require long-term nursing care

    • 10% mortality rate

  • Risk factors include: Postmenopausal state, parental history of hip fracture, smoking, excessive alcohol consumption, low body weight, previous fracture/fall within the past year

  • Secondary causes of osteoporosis: Primary hyperthyroidism, vitamin D deficiency, chronic glucocorticoid use (≥ 5 mg prednisone daily for ≥ 3 months)

• Risk assessment

  • FRAX tool: Calculates 10 year risk for major osteoporotic and hip fractures for men and women

  • Average 10-year risk for 65 y/o white woman with no other risk factors:

    • Major osteoporotic fracture ~8.5%

    • Hip fracture ~1.0%

• DEXA scan screening

  • Recommended by USPSTF for

    • All women age ≥ 65 years

    • Women age < 65 years with fracture risk ≥ average risk for a 65 y/o white woman (8.5%) with no additional risk factors

  • Osteoporosis z-score (standard deviation)

    • Defined in relation to the young adult female mean (z = 0)

    • Osteoporosis defined as z ≤ 2.5 (consider bisphosphonate therapy)

  • Do not repeat for at least 2-3 years

• Therapy

  • Start bisphosphonates per National Osteoporosis Foundation criteria, i.e. one of the following:

    • DEXA score ≤ 2.5 and FRAX ≥ 20%

    • Hip fracture risk ≥ 3%

  • Second line medications for women who cannot take bisphosphonates include teriparatide and raloxifene

Knee Osteoarthritis

Elderly F pt h/o obesity, knee injury presents with chronic knee pain. Reports joint pain that is worse with movement and affects activities of daily living. Denies h/o gastric ulcers, GI bleeding. Family h/o knee osteoarthritis. Joint effusion, valgus/varus deformity, lateral instability, and pain/crepitus with passive ROM on exam.

• Obtain baseline BMP

• Knee x-ray shows joint space narrowing, sclerosis, and osteophytosis

• Initial treatment

  • Regular icing for improved range of motion and strength

  • Start naproxen 500mg BID

  • Start acetaminophen; titrate to 1.3g TID as needed for pain control

  • Start topical capsaicin cream

  • Refer for PT and start aerobic/strength training program

• Patient education

  • Pt counseled about importance of exercise-based therapy

  • BMI >25; pt counseled about weight loss to reduce pain

• For refractory pain consider

  • Corticosteroid injections for short-term relief

  • Tramadol 50 mg q6h

  • Referral to orthopedics

Notes

• Icing knees does not improve pain

• Knee arthroscopy

  • Choosing Wisely: Avoid routinely performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee

  • Acute physical therapy is as effective as arthroscopy for improving pain and function

• Rule out history of GI ulcers/bleeding and evaluate renal function (BMP) before starting chronic NSAIDs

• Pain relief from corticosteroid injections lasts approximately 2 weeks

• Lateral wedge insoles, glucosamine/chondroitin supplementation, and hyaluronic acid injections are not recommended for pain control

Anterior Hip Pain

Adult Predominant Pathology

Femoral Neck Stress Fracture: Female with h/o osteopenia risk factors presents with deep anterolateral hip/groin pain with weight bearing after sudden increase in physical activity. No fevers. Pain with greater trochanter palpation, active leg raise, log roll test, hopping.

• X-ray showing cortical disruption

• MRI showing early bony edema

• Refer to orthopedics; evaluate for management with PT vs. surgery

• Pt advised to increase vitamin D intake

Femoroacetabular Impingement: Pt with h/o athletic involvement presents with insidious onset anterolateral hip pain provoked by rising from seated position. Positive FADIR and FABER tests on exam.

• Radiography shows Cam or pincer deformity, acetabular retroversion, coxa profunda

• PT x2-3 months; refer to orthopedics if no improvement s/p PT

Hip Labral Tear: Pt with h/o hip dislocation presents with painful hip catching/clicking with weight bearing. Pain radiates to lateral hip/anterior thigh/groin/buttock; no fevers. Antalgic gait, loss of internal rotation, positive FADIR and FABER tests on exam.

• Consider hip x-ray prior and or MRI prior to magnetic resonance arthrography

• Refer to orthopedics pending imaging

• Notes

  • FADIR test

    • Knee flexion; adduction and internal rotation of leg

    • Sensitivity: 75-96%

  • FABER

    • Knee flexion; abduction and external rotation of leg

    • Sensitivity: 88%

  • Magnetic resonance arthrography

    • Gold standard test

    • Sensitivity 90%, accuracy 91%

Hip Osteonecrosis: Elderly pt with h/o limited motion presents with gradual onset of constant/deep/aching hip stiffness worse with prolonged standing/weight bearing. Decreased ROM and pain with extremes of motion on exam.

• Plain radiographs show asymmetrical joint-space narrowing, osteophytes, subchondral sclerosis/cyst formation

• Nonpharmacologic intervention: Weight loss (5% or more), exercise, physical therapy

• Acetaminophen 650 to 1,000 mg four times per day

• BMP to evaluate renal function prior to starting regular NSAID use

• Ibuprofen 600 mg TID PRN, Naproxen 500 mg BID PRN, Diclofenac 50 mg TID PRN

• Intra-articular lidocaine/triamcinolone (10mg) injection

• Refer to surgery

Iliopsoas Bursitis: Pt with h/o athletic involvement presents with anterior hip pain. Reports intermittent catching/snapping/popping sensation; no fevers. Pain/snapping sensation with hip extension on exam.

• No bony involvement on radiography

• U/S showing bursitis, tendinopathy with fluid collection

• Conservative management x4-6 weeks; pt advised to use NSAIDs, ice, heating pad for pain relief PRN

• Deep bursa involvement: Refer to orthopedics as corticosteroid injection may provide additional relief

Transient Synovitis vs. Septic Arthritis

[3-8 y/o child] vs. [adult with h/o DM, RA, recent hip surgery] presents with acute onset, atraumatic anterior hip pain. Reports fevers; non-weight bearing due to pain. Unilateral limited ROM, positive log roll test.

• Obtain CBC, ESR, CRP

• Obtain MRI to differentiate septic arthritis vs. transient synovitis

  • If no evidence of septic arthritis, start ibuprofen

  • If effusion present on MRI, aspirate and send for culture

• If MRI non-diagnostic, consider arthrocentesis of affected joint

• Start ibuprofen

Notes

• Commonly occurs in two populations

  • Pediatrics

    • Common between ages 4-11 years

    • Most common between ages 3-8 years

  • Adults with risk factors including

    • Diabetes mellitus

    • Rheumatoid arthritis

    • Recent hip surgery

• Diagnosis

  • Fever only occurs in 60% of patients and is less common in the immunocompromised and elderly

  • Probability of a septic hip:

    • Weight bearing and CRP < 20: < 1%

    • Non-weight bearing and CRP > 20: 74%

  • Arthrocentesis is the diagnostic test of choice; imaging is not sensitive enough to rule out the condition

• Ibuprofen shortens duration of transient synovitis; dosing will be age-dependent

Posterior Hip Pain

Piriformis syndrome: Pt with no h/o trauma presents with buttock pain with posterior thigh radiation. Pain worse with sitting/walking. No weakness, bowel/bladder dysfunction. Positive log roll test, sciatic notch tenderness on exam.

• MRI shows no disc herniation

• Refer to physical therapy

• Consider orthopedics referral if pain does not improve s/p PT

Sacroiliac joint dysfunction: Pt with h/o minor sacral injury presents with posterior hip pain localized to sacroiliac joint that radiates to lumbar back/buttock/groin. Pt is currently pregnant. Sacroiliac pain elicited with palpation, positive FABER test.

• Tylenol PRN for pain

• Re-evaluate if pain persists s/p delivery

Greater Trochanteric Bursitis

Middle-aged F with presents with lateral hip pain that radiates down lateral thigh. Trendelenburg gait and pain with palpation over greater trochanter on exam.

• Dynamic U/S showing iliotibial band snapping over greater trochanter

• Acetaminophen 2g/day x2 weeks followed by NSAIDs if pain persists

• Pain persisting for 4+ weeks: Local injection of bursa with 40mg methylprednisolone/5mL 1% lidocaine

• Consider surgery if pain persists for greater than 1 year

Meralgia Paresthetica

Obese pt with h/o wearing restrictive clothing presents with numbness/tingling/burning of anterior thigh. Pt advised to lose weight and wear less restrictive clothing

ACL Injury

Female athlete involved in running/jumping sports presents with sudden onset knee pain. Reports that she was playing basketball and landed with her foot planted laterally and her upper leg rotated medially when she heard a popping sound. She noted instant knee pain and instability immediately after the injury and was unable to bear weight on the joint. Knee effusion with a ballotable patella and positive Lachman test, anterior drawer test, and lateral pivot-shift test tests on exam.

• Suspected ACL injury with knee effusion and/or instability: Obtain MRI

• Confirmed ACL tear:

  • Refer to physical therapy

  • Pt informed that operative reconstruction is recommended for

    • Young athletes planning to continue sports involvement

    • Patients with significant knee instability affecting quality of life

• Pt counseled that

  • Non-operative management may increase risk for chronic pain and future meniscal tears

  • Risk for degenerative arthritis is the same with operative and non-operative management

Notes

• Mechanism of injury: Sudden deceleration or change in direction resulting in rotation or valgus knee stress

• Injury may produce an audible “pop” and sensation of knee instability

• Physical exam

  • Effusion due to hemarthrosis

  • Anterior translation with Lachman test and/or anterior drawer test

  • Lateral pivot-shift test produces posterior movement (reduction) of tibia at 30 to 40 degrees of flexion

Meniscal Tear

Treatment

• Patient counseled that arthroscopic meniscal surgery is equivalent to nonoperative management

Stress Fracture

18 y/o F military recruit with h/o eating disorder, smoking, and consuming > 10 alcoholic drinks per week presents with acute onset tenderness/edema in the lower extremities shortly after starting basic training. Recent physical activity has included running > 25 miles/week. Pain reproducible with ambulation; no tenderness along length of posteromedial tibial shaft.

• Imaging

  • Obtain plain film x-ray; if negative and pain persists, repeat in 2 weeks

  • Need for immediate diagnosis or suspected 5th metatarsal stress fracture: Obtain MRI

• Treatment

  • Acetaminophen 500 mg QID; consider naproxen 500 mg BID if additional pain control needed

  • Non-weight bearing crutches for 4 days before transitioning to a walking boot for 4 weeks, and then a rigid sole shoe for an additional 4 weeks

  • Suspected tibial stress fracture: Recommend pneumatic compression device to reduce time to resumption of full activity

  • Proximal 5th metatarsal stress (Jones) fracture: Refer to orthopedics

• Counseling

  • Pt counseled that she may resume physical activity upon pain resolution, but that this may require up to 12 weeks

  • Pt encouraged to adopt balanced diet and engage in cross-training to prevent future stress fractures

• Schedule follow-up in 4 weeks

Notes

• Epidemiology

  • Risk factors include female sex/female athlete triad, sudden increase in activity (e.g. military recruit), smoking, and > 10 drinks per week

  • Approximately 75% of stress fractures occur in the tibia/fibula, tarsal navicular bone, or metatarsals

• Differential diagnosis

  • Includes tendinopathy, nerve/artery entrapment syndrome and compartment syndrome

  • Medial tibial stress syndrome (shin splints) presents with tenderness along posteromedial tibial shaft and no edema

• Treatment

  • NSAIDs may slow healing time

  • Fifth metatarsal stress fractures may require surgery if located proximally and should be evaluated with MRI

Ankle Spain

Pt with h/o ankle sprains presents with ankle pain s/p inversion foot injury. Pt is not intoxicated; no h/o peripheral neuropathy. Was able to walk s/p injury. No pain in malleolar zone, at medial/lateral malleolar edge, along posterior fibula. Able to take 4 weight-bearing steps in office without assistance.

• Imaging not indicated per Ottawa ankle rules

• Start RICE therapy, apply elastic compression bandage

• NSAIDs for pain

• Pt advised to perform ankle exercises including plantar flexion, dorsiflexion, foot circles

Gout

Elderly male patient with history of HTN, cardiovascular disease, and excess meat/pate/beer/high-fructose corn syrup consumption presents with painful first metatarsal joint swelling. Pain present x 1 day and reports similar, previous flares in the same joint. Denies fever, chills, trauma at affected site. Recently started on a diuretic for control of hypertension. Family history positive for gout. Unilateral first metatarsal joint inflammation and tophi noted on exam.

• Obtain CBC, uric acid level

• Diagnosis

  • Risk for gout ≥ 82.5% per Acute Gout Diagnosis Rule

  • Evaluation of joint aspirate with compensated polarized light microscopy shows negatively birefringent monosodium urate crystals

• Treatment

  • Stop thiazide and/or loop diuretic and start losartan

  • Acute therapy

    • CrCl > 30: Indomethacin 50 mg TID

    • CrCl < 30: Colchicine 0.3 mg daily until flare resolves

    • Concern for pseudogout: Prednisone 40 mg x 4 days, then 20 mg x 4 days, then 10 mg x 4 days

  • Recurrent gout: Start allopurinol 100 mg qd s/p flare and increase by 100 mg (max 800 mg qd) every 2-4 weeks until serum urate < 6 mg/dL

• Counseling

  • Pt advised to reduce consumption of meats, alcohol, and beverages sweetened with high-fructose corn syrup to reduce risk of gout flares

  • Pt encouraged to lose weight

Notes

• Pathophysiology

  • Due to precipitation of monosodium urate crystals in joint space

  • Repeat flares can permanently damage joints leading to chronic pain

• Risk factors

  • Age: Present in > 10% of patients > 80 years old

  • Loop and thiazide diuretics that increase uric acid levels

  • Purine-rich foods such as red meat, organ meats (liver), and shellfish

  • Two or more beer or spirit drinks per day; no increase risk with wine

  • Beverages sweetened with high-fructose corn syrup

• Protective factors

  • Female sex: Hormones increase uric acid excretion (i.e. protective); gout is rare in premenopausal women

  • Losartan increases uric acid excretion

• Diagnosis

  • Rule out trauma, infection and consider possibility of pseudogout

  • Diagnosis per American College of Rheumatology requires either

    • Identification of uric acid crystals in joint aspirate

    • Presence of ≥ 6 clinical, laboratory, or radiologic findings

• Treatment

  • NSAIDs are first line; consider intra-articular injection to limit systemic absorption

  • Colchicine has no analgesic properties and has limited effect if started 72 to 96 hours s/p symptom onset

  • Patients of Korean, Chinese, or Thai descent are at higher risk for a severe skin hypersensitivity reaction when starting allopurinol

  • Stop thiazide diuretics and start losartan in their place as it lowers gout risk