Ortho Conditions: Symptoms and Diagnosis Part 1

Chronic Joint Conditions

• A chronic joint condition results from repetitive trauma, which does not have to be severe or catastrophic.
• It is one of the most common causes of chronic or recurrent joint pain
• It can occur at any joint
• It is often seen in shoulder, hip, knee, and ankle joints of service members
• Occupation and recreational activities may dictate which joints are affected

Signs and Symptoms of Chronic Joint Problems

• There is pain in the joint with movement, particularly impact
• Intraarticular effusion may develop
• Pain is along the joint line

Focused History Questions for Chronic Joint Problems

• Ask about the history of trauma
• Ask about occupation
• Recreational activities impact joint issues
• There may be a loss of range of motion
• Instability or lack of confidence may be present when weight-bearing

Physical Examination for Chronic Joint Problems

• There may be a decreased range of motion
  • Perform a passive range of motion assessment for mechanical blocks if there is a decreased active range of motion
• Tenderness to palpation is along the joint line
• Occasionally, swelling will be noted

Tools to Diagnose Chronic Join Problems

• X-rays, if available, may help rule out fracture, but may not be necessary

Differential Diagnoses

• Septic arthritis: Look for fever, erythema, edema, and warmth of joint. The patient is often holding the joint, knee, in slight flexion to maximize joint space
• Bucket handle meniscal tear: The patient is unable to fully extend the leg
• ACL injury: Effusion of the knee
• Fracture: Tenderness to palpation over bone
• Soft tissue injuries: Maximal pain is localized away from the joint line

Treatment for Chronic Joint Problems

• Use PRICE: protection, rest, ice, compression, and elevation
• NSAIDs for pain can be topical or oral
• Battlefield Acupuncture (BFA)
• Physical therapy is helpful
  • ROM exercises
  • Strengthening of muscular support of knee
    • Aquatic therapy can reduce impact stress on joints
• If a patient cannot straighten their leg, seek leg-EVAC/orthopedics consult as this likely represents a “mechanical block.”

Follow Up Actions

• The patient should return as needed for increased pain, instability, or inability to walk or extend the leg
• Weight loss, physical therapy, and activity modification are the mainstay of management
• Chronic osteoarthritis management may be augmented by intraarticular injections of corticosteroids or hyaluronic acid
• Follow-up Actions:
  • Return in 48-72 hours if symptoms are worsening

Lower Extremity Muscle Strains

• There are more than 600 muscles in the body, all of which can be injured by a variety of means
• Strains of the lower extremities are exceedingly common injuries and can be caused by trauma or overuse

Signs and Symptoms of Lower Extremity Muscle Strains

• Pain is over the affected muscle
• Pain is also present with movement

Focused History for Lower Extremity Muscle Strains

• Note whether the patient can bear weight if it a lower extremity muscle strain
• Take note of activities of daily living (ADL's)
• Ask about numbness or tingling

Physical Exam to Diagnose Lower Extremity Muscle Strains

• Tenderness to palpation at the origin/insertion of affected muscle
• Ecchymosis, swelling possible
• Tenderness present with active ROM (AROM), but less or absent with passive ROM (PROM)
• Tenderness with resisted ROM

Tools for Diagnosing Lower Extremity Muscle Strains

• Consider X-rays if pain is over bone, or if the mechanism suggests possible fracture

Differential Diagnoses for Lower Extremity Muscle Strains

• Avulsion fracture: The patient will be unable to perform AROM if they have an avulsed tendon
• Osteoarthritis: Chronic recurrent pain is usually localized to a joint, may or may not include swelling
• Osteonecrosis of the associated joint: Chronic dull ache
• Bone tumor/cancer: Pain at rest or at night, increased pain with weight bearing

Treatment for Lower Extremity Muscle Strains

• Avoid aggravating activities
• Gentle stretching throughout ROM once pain has begun to resolve
• Use PRICE: protection, rest, ice, compression, and elevation
• NSAIDs
• Battlefield Acupuncture (BFA)

Follow Up Instructions for Lower Extremity Muscle Strains

• Avoid aggravating activities
• Manage expectations; it may take several weeks to fully resolve
• Return if pain increases, if numbness or tingling develop, or if unable to bear weight or perform ADL's
• Follow-up Actions:
  • Return in 2 weeks
  • If no improvement, consider physical therapy consult, if available
  • Consider X-rays if available
  • If no improvement after 6 weeks, consider routine EVAC for PCM/orthopedics

Return to Duty Directives

• Blue Directive: Battlefield Acupuncture (BFA)
• Green Directive: Routine review by preceptor IAW 44-103, No BFA

Rhabdomyolysis

• Rhabdomyolysis is the result of acute and excessive damage to skeletal muscle
• Damaged results in necrosis and the release of intracellular myoglobin, creatinine kinase, and multiple electrolytes
• A buildup of myoglobin can obstruct the renal tubular system and ultimately result in renal failure
• It is not uncommon in the military population as a result of extreme physical exertion, the use of dietary supplements, and poor hydration
  • Members with Sickle Cell Disease or Sickle Cell Trait have a higher risk
• Prolonged immobilization, compartment syndrome, crush injuries, and toxins are other common causes
• 2020 Exertional Rhabdomyolysis Clinical Practice Guideline (CPG) - https://champ.usuhs.edu/sites/default/files/2020-11/hprc_whec_clinical_practice_guideline_for_managing_er.pdf

Signs and symptoms of Rhabdomyolysis are:

• Severe muscle pain usually present
  • Usually proximal muscles
• Weakness
• Limb swelling
• Dark urine ("coca-cola colored urine")

Focused History questions to ask regarding Rhabdomyolysis include:

• Physical activity
• Injuries/Trauma
• Supplement use
• Drug use
• Recent illnesses

Physical Exam aspects to consider include:

• Tenderness to palpation of muscles
• Weakness
• Swelling of affected muscles
• Evidence of trauma or compartment syndrome

Lab work to determine Rhabdomyolysis:

• Serum creatinine kinase (CK) at least 5 times upper limit of normal (ULN usually ~200 U/L), though often in 10's of thousands initially
  • Peaks 24-72 hours after injury
• Urinalysis (dipstick shows hematuria)
  • Actually myoglobin
• Metabolic panel (monitor Na+, K+, Ca+, Phos, and Creatinine for renal function)
• Liver function tests (AST/ALT usually elevated)
• Consider CBC to monitor for hemolysis or infection
• Uric acid helps monitor potential renal injury

Differential diagnoses to consider other than Rhabdomyolysis

• Compartment syndrome: Muscle pain is out of proportion (particularly with passive stretching of muscle), woody texture or muscle, weakness, diminished sensation, and decreased pulses distally
• Muscle strain: Muscle pain, though not out of proportion and without additional exam and lab findings
• Heat injury: Excessive activity resulting in elevated core body temperature and end-organ damage (liver, renal, and muscle)
• Urinary tract infection: Hematuria, though without muscle pain

Treatment

• Fluids (IV or oral) maintains higher urine output to dilute myoglobin to prevent renal injury
  • CK < 20,000 U/L can often be treated as outpatient with oral hydration
  • If starting IV fluids, recommend NS at 1-2L/hr initially
  • Goal urine output > 200mL per hour or 1L every 6 hours
  • Monitor electrolytes and renal function frequently given high levels of fluids
• Rest
  • Bed rest for 24-72 hours if outpatient treatment

Gradual Return to Duty After Potential Rhabdomyolysis

• Phase 1:
  • Strict light indoor duty for 72 hours and encourage oral hydration, and salting of food;
  • No weight training;
  • Must sleep seven to eight consecutive hours nightly;
  • Must remain in a thermally controlled environment;
  • Must follow-up in 24-72 hours for repeat CK/UA;
  • If the CK value at 24-72 hours continues to be <5X ULN and UA continues to be normal, Phase 2 may begin after the initial 72 hours of limited duty. (Physiologic Muscle Breakdown Profile)
  • If a CK value at 24-72 hours follow-up is >5X ULN and/or UA is positive for blood with no RBC's the Warfighter needs to be considered for high-risk markers and inpatient versus continued outpatient follow up.
  • The Warfighter is to continue on Phase 1 delineated above (Low Risk Rhabdomyolysis Profile) with clinical judgment and followed in 24-72 hours with CK, creatinine, and UA
  • When CK value is <5X ULN and UA has returned to normal, begin Phase 2. Otherwise, remain in Phase 1 and return every 72 hours for repeat CK/UA until the criteria above are met;
  • If CK remains >5X ULN and/or UA is persistently abnormal for 2 weeks after injury or hospitalization, refer for expert consultation.
• Phase 2:
  • Begin light outdoor duty, no strenuous physical activities;
  • Lightweight resistance training;
  • Supervised (i.e., physical therapy, athletic trainer) physical activity at their own pace and distance;
  • Follow-up with a care provider in one week;
  • If clinical symptoms do not return, begin Phase 3. Otherwise, remain in Phase 2 and return at 1-week intervals. Progress to Phase 3 when there is no significant muscle weakness, swelling, pain, or soreness. If myalgia persists without objective findings beyond 4 weeks, consider specialty evaluation to include psychiatry.
• Phase 3:
  • Return to regular outdoor duty and physical training;
  • Follow-up with care provider as needed.

Additional Information Regarding Rhabdomyolysis

• Rest is essential
• Monitor urine output, goal > 200mL/hr, titrate fluids to reach goal
• Seek medical evaluation if there is increasing pain, chest pain, shortness of breath, palpitations, significantly increasing edema

Follow Up Actions

• Return in 24 hours for reevaluation and labs if outpatient treatment.
• Blue Directive: Contact preceptor immediately, may require transfer/evacuation depending on severity

Compartment Syndrome

• Skeletal muscles are surrounded by connective tissue known as fascia
• The surrounding fascia is strong and non-compliant, separating muscles into sections or compartments
• If there is a buildup of excessive fluid within a compartment, the pressure in that compartment rises ultimately resulting in tissue/muscle damage and compromising circulation distal to the edema
• Trauma (crush injury or penetrating), long bone fractures, construction from circumferential burns, constructing bandages or splints, bites and stings are all common causes
• The lower leg and forearm are common sites given their well-defined compartments
  • The foot, thigh, and gluteal region are other likely sites
  • Compartment syndrome can occur within the abdomen when patients are provided a high volume of IV fluids
    • The pathophysiology and management are similar to compartment syndrome of the extremities
• Compartment syndrome can be intermittent (exercise-induced) and requires the measurement of intracompartmental pressures during exercise to diagnose

Signs and symptoms of Compartment Syndrome

• “Pain out of proportion”
• Swelling
• Decreased pulses distally
• Decreased sensation and paralysis are late signs

Focused History Questions for Compartment Syndrome

• Recent trauma
• Physical activity

Physical Exam signs for Compartment Syndrome

• Pain with passive stretch of the muscle group
• Tense woody texture or the affected muscle group
• Edema/Swelling of limb
• Weakness
• Decreased pulses distal to injury
• Diminished sensation distal to injury
• Look for circumferential burns that may act as a tourniquet

Tools for Diagnosing Compartment Syndrome

• Intracompartmental pressures may be obtained by Orthopedics
• Labs are not necessary for diagnosis
  • May order CK, Metabolic panel, LFTs, UA, and Uric acid as with Rhabdomyolysis

Differential Diagnoses for Compartment Syndrome

• Rhabdomyolysis: Muscle pain and swelling without elevated intracompartmental pressures
• Muscle strain: Muscle pain, though not out of proportion and without additional exam and lab findings
• Heat injury: Excessive activity resulting in elevated core body temperature and end-organ damage (liver, renal, and muscle)

Treatment for Compartment Syndrome

• Release of the pressure is required and it is a medical emergency.
  • Fasciotomy performed by a trained provider
  • Pain management, consider the risk for renal and hepatic toxicities
  • Fluids may be considered given likely underlying muscle injury and possible rhabdomyolysis

Treatment Follow-Up

• Requires hospital admission, close monitoring
• Fasciotomies require coverage with wet sterile dressings which are changed frequently
• Follow-up action:
  • Will be set after hospital discharge
  • May require skin grafts to cover fasciotomies
• Red Directive: Immediate Evacuation; Contact preceptor ASAP

Red Flags That Merit Additional Investigation

• Trauma
• Duration of pain lasting more than six weeks
• Neurologic deficit such as bowel or bladder incontinence, saddle anesthesia, or lower extremity weakness
• Fever
• Severe nocturnal or disabling pain
• Unexplained pain after age 55
• Unexplained weight loss
• Steroid use

Anterior and posterior ligaments of the Spine

• Limit motion and provide support
• Divided into 5 areas
  • Cervical area
  • Thoracic area
  • Lumbar area
  • Sacrum area
  • Coccyx area

Muscles of the Head and Neck

• Sternocleidomastoid (SCM) muscles: rotate and flex forward.
• Other head movements (extend, bend, rotate):
  • Splenius capitus
  • Semispinalis

Neck Pain

• Etiology is often multifactorial with the underlying disorder exacerbated by fatigue, physical deconditioning, muscle pain, poor posture, weakness of stabilizing muscles, decreased flexibility, and sometimes psychosocial stress or psychiatric abnormality
• Degenerative disk disease is a common cause of pain in the cervical spine and will respond well to conservative therapy
• Pain can also be musculoskeletal in nature - secondary to poor posture, trauma (like whiplash), stress, tension, and rapidly advancing an exercise program

Signs and Symptoms of Neck Pain

• Depending on the cause, the pain can manifest as stiffness, muscle tension, spasm, and tenderness
• May be accompanied by neurologic symptoms
• Pain, and limited ROM, encourage patient to describe
• If the nerve root is affected, pain may radiate distally along the distribution of that root; radicular pain
  • Strength, sensation, and reflexes of the area innervated by that root may be impaired
• If the spinal cord is affected:
  • Strength, sensation, and reflexes may be impaired at the affected spinal cord level and all levels below

Focused History Questions for Neck Pain

• OPQRST - Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, and Time
• Presence of numbness, tingling or weakness
• Assess for red flag symptoms
• Tobacco/ETOH use
• History of back or neck problems
• Recent activity
• History of fever; could indicate meningitis

Physical Exam for Neck Pain

• Assess posture
• Limited ROM secondary to pain
• Motor and sensory dysfunction represent radicular symptoms.
• Spurling test:
  • Specific for cervical radiculopathy
  • Negative does not rule out radicular pain

Tools used to Detect Neck Pain

• Most atraumatic neck pain does not require imaging, although a traumatic even does
• Consider imaging using the UpToDate algorithm - Progressive neurologic findings - Constitutional symptoms (weight loss, fatigue, fever) - Infectious risk with systemic symptoms - History of malignancy - Persistent moderate to severe neck pain lasting greater than 6 weeks and affecting sleep or ADLs

Differential Diagnoses for Neck Pain

• Shoulder problems: pain may be radiating from shoulder
• Peripheral nerve entrapment (CTS): positive Phalen, Tinel at elbow or wrist where pain radiates proximal to distal
• Cervical radiculopathy: numbness or tingling in the upper extremity
• Cervical sprain/strain: neck pain without associated symptoms

Treatment Plan to Consider for neck pain

• Rest, ice, or heat whatever feels better
• Gentle ROM stretching
• NSAIDS
• Battlefield Acupuncture (BFA - Only if certified in BFA: Can administer up to 10 treatments if provider is a certified acupuncturist as long as there is a clinical benefit to the patient and no adverse issues
• Muscle relaxants if most likely diagnosis is spasm
  • Cyclobenzaprine with preceptor guidance
  • Methocarbamol
• Avoid narcotics/steroids

Course of Action for Neck Pain

• Avoid aggravating activities
• Gentle stretching throughout ROM
• Modify posture
• Follow-up Actions:
  • Return in 2 weeks if no improvement
    • Consider physical therapy
  • If gross motor weakness is present, then arrange EVAC or transfer

Follow Up Directives for Neck Pain

• Blue Directive: Contact preceptor immediately for approval if considering Battlefield Acupuncture (BFA)
• Green Directive: Routine review by a preceptor IAW 44-103, No BFA

Low Back Pain

• LBP is among the most common medical complaints although it is a symptom, not a disease
• The exact cause is often difficult to diagnose and is often multifactorial
• Because of the multifactorial nature, clinicians should determine whether pain has a spinal or extra spinal cause and whether the cause is a serious disorder

Signs and Symptoms of Low Back Pain

• Pain in the lower back with or without ROM
• Acute up to four weeks, subacute between 4-12 weeks, or chronic after 12 weeks
• May present with radicular symptoms
  • Pain that traverses the length of the affected nerve root
• Radiation into the buttock is common
• Difficulty standing

Focused History Questions for Lower Back Pain

• Use “OPQRST”
• Note History or Mechanism of Injury
• Pay attention to PMHx of back pain
• Note numbness or tingling in LE
• Difficulty controlling bowel or bladder function
• Observe radiation of pain

Physical Exam

• Tenderness to palpation at the lumbar paraspinal muscles
• Muscle spasm in the lumbar paraspinal muscles may be appreciable and tender
• ROM is limited by pain
• Straight leg raise assesses whether sciatic nerve is involved.
• Assess Motor and Sensory deficits as they represent a more ominous problem

Guidelines for Low Back Pain Diagnoses

• If no “red flag symptoms," x-rays are not appropriate unless the patient has had pain greater than 6 weeks.
• Refer to VA/DoD Clinical Practices Guidelines for low back pain.

Differential Diagnoses

• Cauda Equina Syndrome: evidence of paralysis, bowel/bladder dysfunction
• Disk herniation: unilateral radicular symptoms that extend below the knee
• Infection: fever, chills, night sweats
• Causes outside the spine: constipation, pancreatitis, kidney stones
• Fracture: mechanism of injury

"If No Red Flag", Low Back Pain Treatment to Consider

• Rest, ice or heat whatever feels better
• Gentle ROM stretching
• NSAIDs
• Battlefield Acupuncture (BFA)
• Muscle relaxants

AVOID

• Narcotics/steroids are to be avoided

In the event of "Red Flag" symptoms or "Gross Motor Problems"

• If present, EVAC or transfer immediately

Recovery Expectations of Pain

• Most low back pain is acute and will resolve on its own within a few days with self-care and there is no residual loss of function
• Some cases may last a few months
• Refer patient to The National Institute of Neurological Disorders and Stroke

Follow-Up Action

• Follow up in 2 weeks if there is still no improvement.
  • Reccomend physical therapy if able
  • If therapy is unavailable, continue stretching and consider changing muscle relaxants or NSAIDs.
• Return at 6 weeks is still in pain.
  • Perform and X-ray if available
  • Consider EVAC/transfer/specialist consult

Treatment Directives to consider

• Blue Directive: Battlefield Acupuncture (BFA)
• Green Directive: Routine review by a preceptor IAW 44-103, No BFA

Disk Herniation

• Prolapse of an intervertebral disk through a tear in the surrounding annulus fibrosus
  • See image above in Low Back Pain
• The tear causes pain when the disk impinges on an adjacent nerve root, a segmental radiculopathy with paresthesias, and weakness in the distribution of the affected root results – The disc will compress onto nerve
• In the cervical area, C6 and C7 are most commonly affected
• In the lumbar area, over 80% of disk ruptures affect L5 or S1 nerve roots

Etiology

• Most common cause is a degenerative process in which as humans age, the nucleus pulposus; central part of the disk, becomes less hydrated and weakens
• Second most common cause is trauma -Other causes include connective tissue disorders and congenital disorders.
• Most likely to occur posterolaterally; more likely to compress the nerve root.
  -Lumbar disc herniation is commonly referred to as Sciatica (NCBI StatPearls 11/2020)

Signs and Symptoms

• Back Pain
• Presence of nerve root compression causes Weakness in UE/LE
• Potential numbness or tingling in affected limb; Sciatica
• Pain worse with sitting, coughing, sneezing, raising arms over head

Focused History Questions

• Assess for “red flag" symptoms
• History of injury
• Physical Examination:

Actions to take with Physical Exam

• Tenderness to palpation at the paraspinal muscles
• Muscle spasm in the paraspinal muscles may be noted
• limited by pain
• Straight leg raise: will be + with sciatic nerve involvement
• Motor and sensory deficits represent a more ominous problem

In order from least to worst, action items include:

• If there are no "red flag" symptoms, x-rays are not appropriate unless the patient has had pain for >6 weeks.
• https://www.youtube.com/watch?v=GfNLPgbnpAg

Differential

• Cauda Equina Syndrome: evidence of paralysis, bowel/bladder dysfunction
• Trochanteric bursitis: pain down lateral thigh, exquisite tenderness to palpation over the greater trochanter
• Infection: fever, chills, night sweats
• Causes outside the spine: constipation, pancreatitis, kidney stones
• Fracture: mechanism of injury
• Piriformis syndrome: "pseudo-sciatica"

Treatment for Herniated Disks

• If no “red flag" symptoms
  • Rest, ice, or heat whichever-feels better
  • Gentle ROM stretching
  • NSAIDs
  • Battlefield Acupuncture, BFAMuscle relaxants
• Medication to Avoid: -Aviod narcotics and steroids
• If Red-Flag symptoms
  • Evacuation to a higher level facility.

General Muscle Strength Advice

• Exercises include those in the area below the diaphragm to upper thigh both anterior and posterior.
• Daily stretching should be incorporated
• Should likely resolve gradually on its own in 6 weeks
• Bed rest is contraindicated
• PT or Home exercises to improve posture and strength back muscles are key to relieve nerve compression

Follow Up Action Advise

• In 2 weeks if no improvement with conservative management,

  • manage patient expectations that improvement is gradual and total is not predictable or immediate.

• **No Improvement" - "Refer to Physical Therapy"

• **Unable to go to PT," - "Continue Stretches" - "Muscle Relaxtants

  if still there at six weeks with no improvement then, X-RAYS and/or EVAC Consider EVAC/transfer/specialist consult

CAUDA EQUINA SYNDROME

Definition and Cause:

• Occurs when the nerve roots at the caudal end of the cord are compressed or damaged, disrupting motor and sensory pathways to the lower extremities and bladder
• Most commonly results from a herniated disc in the lumbar spine
• Congenital neurologic anomalies, spinal cord infection, spinal epidural abscess, tumor, trauma, stenosis, etc. also are potential causes

Action Items

• Must be considered in the differential of all low back pain patients which is why good neuro exams are essential Distal leg paresis and sensory exam important along with Saddle Anesthesia exam.

Symptons:

• Distal leg paresis and sensory loss in and around the perineum and anus with Saddle anesthesia.
• Muscle tone and reflexes decreased in legs
• Dysfunctional bowel or bladder - considered late finding Possible
• bowel incontinence
• Erectile dysfunction Latterly a patient
• Urinary retention/frequency/incontinence issues
• Paralysis of lower extremiities- will be a later finding

HISTORY:

Consider the history of:

• Recent injury
• Spinal Stenosis
• Herniated disc
• Bowel or bladder problems following injury

physicals;

-Low back exam

• Neurology exam with focus on the LE Consider abilities of patient
• Unable to rise from chair unassisted
• Inability to walk on heels or toes
• Motor or sensory dysfunction Loss of rectal tone

Physical tools

There if the patient -IF- the patient is available then lumbar film to help make the decision can be valuable, but doesn't need to be done

Diagnostics - CONSIDER WHAT THE GOAL IS

Additional differentials

• Guillain-Barre Syndrome (Symmetrical Weakness) -intact sensation -symmetrical -spinal cord issues -Disk herniation unilateral radicular -Multiple sclerosis - history of various previous events or Vision and diplopia problems Spinal chord tumor - positive Babinski, spasticity

If the suspicion of "Cauda Equina Syndome is there, consider the steps of transfer by EVAC

• The goal being to transfer immediately,

• but if not possible then add a Foley catheter

• supportive care while EVAC is awaited.

• Action for treatment - patient to call for an EVAC so that they can then self- monitor for the red flags

• Patients may requires EVAC and/or surgical decompression

Shoulder Problems

• Differential Diagnoses:
  • Impingement Syndrome
  • Shoulder Dislocation/Instability
  • Adhesive Capsulitis
  • AC Joint Separation
  • Brachial Plexus Injury
  • Biceps Tendon Rupture
• Important Considerations:
  • Treatment of shoulder pain and disorders should focus on return to acceptable function (if full function is not likely) and ROM with acceptable pain
    • Pain free is not always possible!
• The objective of tx is the patients shoulder pain and what can provide them acceptable function.

Acromioclavicular Joint Separation (AC)

• AC, also known as = acromioclavicular
• Also known as a shoulder separation
• This injury occurs most frequently when the patient has fallen on the shoulder or less often on an outstretched hand
• Severe sprains tear the AC and coracoclavicular ligaments, which can displace the distal clavicle superiorly or inferiorly from the acromion

Signs of injury

• Pain at and around the AC Joint with possible associate deformity
• Swelling

Physical exam tests

• Exan and palpate ENTIRE shoulder
  • SC joint entire length.
  • clavicle. -AC joint.
  • acromion - Spine of scapula.. - Coracoclavicular ligaments. If injured there could be Increased ROM (Springy) joint due to increased ROM.

Tools:

• Reduced ROM
• Bilateral clavicle X-ray if able as this could characterize degree of sprain and/or deformity.

Additional Information:

• Impingement Syndrome" active ROM will be reduced but passive ROM will be full; patient can move that shouddler but they need someone elses help
• Shoulder - Dislocation will be IN an incredible amount of pain and will be unlikely to even attempt a ROAM.
• Tendinitis can have a history of overuse -If severe get evacuation

Action taken based on degree the degree of pain

• Sling for 7-10 days
• Gentle Exercises
• Once pain subsides then we consider gentle exercises where before giving out, it would be considered for PT, so long as they know what they are doing. Treatments:
• PRICE; "Protect, Rest, Ice, Compression, Elevate
• NSAIDS
• Battlefield Acupuncture (BFA) Sometime a patient with all of these is just needed to have an EvaC and have orthopedics fix the injury completely.

ACTION

After injury consider the following actions.

• Avoid Aggravating activities Follow recommendation for PT and if not. Return for follow up in 5 to 7 days

Impingement syndrome

• Impingement on the rotator cuff, subacromial bursa and other soft tissues compressed between the humeral head and undersurface of acromion, AC joint or coracoacromial arch. UpToDate 01/2021
• Muscle strengthening imbalances, poor scapula control, rotator cuff tears, and subacromial bone spurs can be linked to it.

What to look for

Signs

• PAIN with reaching or overhead motion

• May include shoulder pain if they are sleeping on it

• May be localized to an arm as well

• Weakness, Pain rotating joint

• Instability

what to consider in History of injury

• Hand dominance,

• Injury history.

• Work habits

• The physicals may be difficult because the area of palpation is hard in the Infraspinatus or supraspinatus fossa

• X-Rays: are not going to be needed unless the injuries from trauma may have caused issues

Consider treating it from that area

• Gentle Exercises - or Gentle Stretching without pain,
• RICE -Rest, Ice, Elevate
• NSAIDs
• Acunpunture.
• Avoid activities that make injury worse or "aggravating behaviors" Take medications as prescribed

Other action is needed then consider

• In 2 weeks, - If not better then get a Physical Exam.

Directives if no improvment

Blue= contact Preceptor Green- review