Joint Trauma: Chronic Conditions

• Repetitive trauma to a joint can cause a chronic condition.
  • Trauma does not have to be severe or catastrophic.
• Chronic or recurrent joint pain is commonly caused this way.
• Any joint can experience this condition.
  • It is often seen in the shoulder, hip, knee, and ankle joints of service members.
  • Which joints are impacted may depend on one's occupation and recreational activities.

Signs and Symptoms

• Pain is felt in the joint with movement, particularly impact.
• Intraarticular effusion may develop.
• Pain radiates along the joint line.

Focused History

• Enquire about any history of trauma.
• Ask about the nature of occupation and recreational activities.
• Note any loss of range of motion.
• Be mindful of instability or lack of confidence when weight-bearing.

Physical Exam

• There may be a decreased range of motion.
  • If decreased in active range of motion, perform passive range of motion to assess for mechanical blocks.
• Palpation along the joint line can reveal tenderness.
• Swelling is occasionally noted.

Tools

• X-rays may help rule out fracture, but they may not be necessary.

Differential diagnoses

• Septic arthritis: Accompanied by fever, erythema, edema, and warmth of the joint. The knee is often held in slight flexion to maximize joint space.
• Bucket handle meniscal tear: prevents full extension of the leg.
• ACL injury: causes effusion of the knee.
• Fracture: Tenderness to palpation over bone.
• Soft tissue injuries: Maximal pain is localized away from the joint line.

Treatment

• PRICE (Protection, Rest, Ice, Compression, Elevation)
• NSAIDs for pain relief
  • Topical or oral administration.
• Battlefield Acupuncture (BFA)
• Physical therapy can help.
  • Range of motion exercises
  • Strengthening the muscular support of the knee.
  • “Aquatic therapy” can reduce impact stress on joints.
• If a patient is unable to straighten their leg, consider leg-EVAC/orthopedics consult (this may represent a “mechanical block").

Follow up Actions

• Re-evaluation is needed for increased pain, instability, inability to walk, or inability to fully extend the leg.
• Weight loss, physical therapy, and activity modification are vital for management.
• Chronic osteoarthritis management may be augmented by intraarticular injections of corticosteroids and/or hyaluronic acid.
• Return in 48-72 hours if symptoms worsen.
• Routine review by a preceptor IAW 44-103 is pertinent.

Lower Extremity Strains

• The body has more than 600 muscles that may be injured in various ways.
• Lower extremity strains are very common injuries that can be caused by trauma or overuse

Signs and Symptoms

• Pain is felt over the affected muscle.
• Pain increases with movement.

Focused History

• Ascertain the ability to bear weight if dealing with a lower extremity muscle injury.
• Inquire about activities of daily living (ADL's).
• Take note of numbness or tingling.

Physical Exam

• Palpation at the origin/insertion of the affected muscle reveals tenderness.
• Ecchymosis and swelling may be present.
• Tenderness occurs with AROM, but is reduced or absent with PROM.
• Tenderness is detectable with resisted ROM.

Tools

• X-rays are to be considered if the pain is over bone or if the mechanism suggests a possible fracture.

Differential Diagnosis

• Avulsion fracture: Patient is unable to perform AROM if the tendon is avulsed.
• Osteoarthritis: Chronic recurrent pain localized to a joint, possibly with swelling.
• Osteonecrosis of the associated joint: causes chronic dull ache.
• Bone tumor/cancer: pain at rest or at night, increased pain with weight bearing.

Treatment

• Avoid aggravating activities.
• Gentle stretching throughout ROM should begin once pain has started to resolve.
• Use PRICE (Protection, Rest, Ice, Compression, Elevation).
• NSAIDs.
• Battlefield Acupuncture (BFA).

Follow-up Actions

• Avoid aggravating activities.
• Manage expectations; it may take several weeks to fully resolve.
• Return if pain increases, if numbness or tingling develops, or if the patient is unable to bear weight or perform ADL's.
• Return in 2 weeks.
• If there is no improvement, consider physical therapy consult if available.
• Consider X-rays if available.
• If no improvement is seen after 6 weeks, consider routine EVAC for PCM/orthopedics.
• Routine review by a preceptor IAW 44-103, No BFA
• Battlefield Acupuncture (BFA)

Rhabdomyolysis

• Describes the acute and excessive damage to skeletal muscle.
• Damage results in necrosis and the release of intracellular myoglobin, creatinine kinase, and multiple electrolytes.
• Can be caused by extreme physical exertion, use of dietary supplements, and poor hydration, and is not an uncommon occurrance for military personnel.
  • Members with Sickle Cell Disease or Sickle Cell Trait are at higher risk.
• Crush injuries, toxins, compartment syndrome, and prolonged immobilization are all common causes.
• Build up of myoglobin can potentially obstruct the renal tubular system, ultimately leading to renal failure.

Signs and Symptoms

• Severe and proximal muscle pain is usually present.
• Weakness.
• Limb swelling.
• Dark urine.

Focused History

• Consider physical activity.
• Enquire about injuries or trauma.
• Supplement use.
• Illicit drug use
• Recent illnesses.

Physical Exam

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

Labs

• Serum creatinine kinase (CK) will be at least 5 times the upper limit of normal (ULN usually ~200 U/L), often in the 10,000s initially.
  • Peaks 24-72 hours after injury.
• Urinalysis (dipstick) exhibits hematuria.
  • Includes myoglobin.
• Metabolic panel (monitor Na+, K+, Ca+, Phos, and Creatinine for renal function).
• Liver function tests (AST/ALT are usually elevated).
• Consider CBC to monitor for hemolysis or infection.
• Uric acid levels help to monitor for potential renal injury.

Differential Diagnoses

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

Treatment

• Fluids (IV or oral) help to maintain a higher urine output to dilute myoglobin to forestall renal injury.
  • CK < 20,000 U/L can often be treated in an outpatient setting with oral hydration.
  • Recommend normal saline at 1-2L/hr initially if starting IV fluids.
  • An adequate goal for urine output is > 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 for outpatient treatment.

Gradual return to duty

• Phase 1:
  • Strict light indoor duty for 72 hours, with encouragement for oral hydration and salting of food.
  • No weight training.
  • Seven to eight consecutive hours of sleep per night.
  • Maintenance in a thermally controlled environment.
  • Patients must follow-up in 24-72 hours for repeat CK/UA.
  • Phase 2 may begin after the first 72 hours of limited duty if the CK value at 24-72 hours continues to be <5X ULN and UA continues to be normal.
  • If CK value at the 24-72 hour follow-up is >5X ULN or UA is positive for blood with no RBC's, the Warfighter is considered a high-risk marker and inpatient versus continued outpatient follow up should be considered.
  • If the clinician continues with outpatient management, the Warfighter is to continue on Phase 1 delineated above (Low Risk Rhabdomyolysis Profile) and followed in 24-72 hours with CK, creatinine and UA as per clinical judgment.
  • Phase 2 may begin if the CK value is <5X ULN and UA has normalized. Remain in Phase 1 and return every 72 hours for repeat CK/UA until the indicated criteria are met.
  • If CK remains >5X ULN or UA is persistently abnormal for 2 weeks after injury or hospitalization, refer for expert consultation.
• Phase 2:
  • Light outdoor duty, with no strenuous physical activities.
  • Lightweight resistance training.
  • Supervised physical activity at own pace and distance (i.e., physical therapy, athletic trainer).
  • Follow-up with a caregiver in one week.
  • If clinical symptoms subside, begin Phase 3. Otherwise, remain in Phase 2 and revert to 1-week intervals. Progress to Phase 3 when there is no significant muscle weakness, swelling, pain, or soreness. Consider specialty evaluation to include psychiatry, if myalgia persists beyond 4 weeks with no objective findings.
• Phase 3:
  • Return to regular outdoor duty and physical training.
  • Follow-up with care provider as needed.

Additional Treatment

• Rest is essential.
• Monitor urine output (goal more than 200mL/hr), titrate fluids to reach goal.
• Seek medical evaluation with increasing pain, chest pain, shortness of breath, palpitations, and significantly increasing edema.

Follow up Actions

• Return in 24 hours for reevaluation and labs if outpatient treatment. Contact preceptor immediately, which may lead to a transfer or evacuation that depends on severity.

Compartment Syndrome

• Skeletal muscles are surrounded by connective tissue called fascia.
• The surrounding fascia is strong and non-compliant, separating muscles into sections or compartments
• The pressure in a compartment can rise if excessive fluid builds, possibly resulting in tissue/muscle damage and compromising circulation distal to the edema.
• Causes of trauma: crush injuries, penetrating injuries, long bone fractures, construction from circumferential burns, construction bandages or splints, bites and stings.
• The forearm and lower leg are frequent sites given their well defined compartments.
• Foot, thigh, and gluteal region may occur.
  • Compartment syndrome can occur inside the abdomen as well when patients ar given large volumes of IV fluids.
    • Both the pathophysiology and management are similar to compartment syndrome of the extremities.
• Compartment syndrome can be intermittent (exercise induced) and mandates measurement of intracompartmental pressures during exercise to diagnose

Signs and Symptoms

• Pain is out of proportion
• Swelling
• Distally Decreased pulses
• Late signs are decreased sensation and paralysis

Focused History

• Recent trauma
• Recent physical activity

Physical Exam

• Pain with passive stretch of the muscle group
• Tense woody texture or the affected muscle group
• Edema or Swelling of limb
• Weakness
• Distal to the injury, decreased pulses
• Distal to the injury, diminished sensation
• Check for circumferential burns as they may act as a tourniquet

Tools

• Measurement of Intracompartmental pressures requires the services of Orthopedics.
• Labs are NOT necessary for diagnosis, but CK, Metabolic panel, LFTs, UA, and Uric acid may be requested as for Rhabdomyolysis.

Differential Diagnosis

• Rhabdomyolysis: Muscle pain and swelling without elevated intracompartmental pressures.
• Muscle strain: Muscle pain although not disproportionate and without addition lab and exam findings.
• Heat Injury can cause liver, renal, and muscle organ damage as a result of excessive activity that causes elevated body temperature.

Treatment

• Requires that the pressure be released.
• Fasciotomy requires the services of a trained provider.
• Pain management and risks for renal and hepatic toxicity has to be assessed.
• Fluids which could be considered include injuries to the muscle, and therefore potential rhabdomyolysis.

Hospital Care and Follow up

• Hospital admission and close monitoring are necessary, as fasciotomies should remain covered with frequently changed wet sterile dressings.
• A follow up action will be scheduled after hospital discharge.
• The patient may need skin grafts in order to cover fasciotomies.

Red Directive:

• Immediate Evacuation and contact the preceptor ASAP.

Red Flags

• Trauma
• Duration of pain >6 weeks
• Neurologic deficit (bowel/bladder incontinence, saddle anesthesia, lower extremity weakness)
• Fever
• Severe nocturnal or disabling pain
• Unexplained pain after age 55
• Unexplained weight loss
• Steroid use

Cervical/Thoracic region

• Consists of anterior and posterior ligaments.
  • Anterior and posterior ligaments limit motion and provide support
• The region is divided into 5 areas
  • Cervical, thoracic, lumbar, sacrum, coccyx
• Sternocleidomastoid (SCM):
  • Rotate, forward flex Other head movements:
  • Extend, bend, rotate - Splenius capitus - Semispinalis
• Etiology:
  • 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
• Pain can also be musculoskeletal in nature
  • Secondary to poor posture, trauma (like whiplash), stress, tension, r apidly advancing an exercise program, etc

Signs and Symptoms

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

Focused History

• OPQRST – Onset, Provocation/Palliation, Quality, Region or Radiation, Severity, Tim
• Presence of numbness, tingling, or weakness
• Assess for red flag symptoms
• History of back or neck problems
• Recent activity
• History of Fever -could indicate meningitis

Physical Exam

• 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

• Most atraumatic neck pain does not require imaging (traumatic does) Consider imaging: (UpToDate has a good algorithm)
  • Progressive neurologic findings
  • Constitutional symptoms
  • Infectious risk with systemic symptoms
  • History of malignancy
  • Persistent moderate to severe neck pain lasting >6 weeks and affecting sleep or ADLs

Differential

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

Treatment

• Rest, ice or heat (whichever feels better)
• Gentle ROM stretching
• NSAIDs
• if certified in Battlefield Acupuncture (BFA) and with preceptor concurrence, consider administering up to 10 treatment sessions as an alternative to NSAIDS as long as there is clinical benefit and no worsening of the patient's condition
• Muscle relaxants if the most likely diagnosis is spasm
  • Cyclobenzaprine with preceptor guidance -Methocarbamol
• Avoid narcotics/steroids

Follow-up Actions

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

Lower 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

Upper/Lower Back Pain Symptoms

• Pain may occur in the lower back with or without ROM. Acute pain (pain may last <4 weeks)
• Subacute Pain lasts for 4-12 weeks
• Chronic pain lasts longer than 12 weeks
• There also may be redicular symptoms and radiate into the buttock region.
• Standing may prove difficult.

Upper/Lower Back Pain Focused History

• History of injury.
• PMHx of back pain.
• Numbness or tingling in LE.
• Difficulty controlling bowel or bladder function.
• Radiation of pain.

Upper/Lower Back Pain Physical Exam

• Tenderness of the lumbar paraspinal muscles, muscle spasms in the lumbar paraspinal, are palpable and often tender. -ROM is frequently limited due to pain, so it's important to differentiate this cause of limitation from a neurological issue.
• Perform a straight leg raise, it will be negative if there is no sciatic nerve involvement with lumbar strain -Motor and sensory deficits with a more ominous problem.

Tools

• If no “red flag” symptoms, X-rays are not appropriate unless the pain has been present for greater than 6 weeks.

Differential Diagnosis

• Cauda Equina Syndrome: This is evidenced by paralysis and bowel/bladder dysfunction.
• Disk herniation: Exhibits unilateral redicular symptoms that extend below the knee.
• Infection: Indicated by fever, chills, and night sweats.
• Consider Causes outside the spine such as: constipation, pancreatitis, kidney stones
• Fracture: Important to note the mechanism of injury

Treatment (if no red flag)

• Follow these symptoms, treat the patient rest, ice, and or heat (whichever feels better)
• Gentle ROM stretching
• NSAIDs
• Battlefield acupuncture
• Muscle relaxants
• Do not provide narcotics/steroids

If red flag symptoms or gross motor weakness is present: - EVAC or transfer immediately

Lower back pain Treatment

• It 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 require months for symptoms to resolve.
• National Institute of Neurological Disorders and Stroke

Follow-up Actions:

• Return in 2 weeks if no improvement.
• Recommended physical therapy if available.
• If physical therapy unavailable continue stretching and or consider changing muscle relaxants or NSAIDs. Re-evaluate after 6 weeks if pain persists despite following conservative management.

Lower Limb disk herniation

• Prolapse of an intervertebral disk through a tear in the surrounding annulus fibrosus
• The tear causes pain when the disk impinges on an adjacent nerve root, a segmental radiculopathy with paresthesias and a weakness in the distribution of the affected root results
• C6 and C7 are most commonly affected in the cervical area

• 80% of disk ruptures affect L5 or S1 nerve roots in the lumbar area

Etiology

• Common cause is as humans age the nucleus Pulposus central part of the disk becomes less hydrated and weakens
• 2nd most common trauma.
• Other congenital tissue disorders connect it to such.
• Likely to occur posterolaterally and therefore more likely to compress the nerve root.
• (The symptomology associated with lumbar disk herniation is commonly referred to as Sciatica.) NCBI StatPearls 11/2020)

Lower Limb disk herniation - Signs and Symptoms

• Back Pain

• Potential for Nerve root compression (weakness in UE/LE).

• Sciatica.

• Pain worsening from sitting, coughing, sneezing, raising Arms over your head.

• Focused History: Assess for Red flags and or possible injury

disk herniation - Physical Exam

• Tenderness to palpation at paraspinal Muscles
• Possible muscle spasm in the paraspinal
• ROM (ROM is in pain)
• Straight leg raise tests can provide information regarding sciatic nerve involvement
• Red flag motor and or sensory deficits

Tools

• No “Red Flags” symptoms means X-rays will not be appropriate unless symptoms last greater than 6 weeks
• https://www.youtube.com/watch?v=GfNLPgbnpAg

disk herniation - Differential Diagnosis

• Cauda Equina Syndrome: Evidence of bowel and or bladder disfunction
• Trochanteric bursitis pain: down lateral thigh, Exquisite tenderness to palpation over greater trochanter
• Fever: Chills and night sweats
• Outside of the spine such as Constipation and pancreatitis + kidney stones Fracture: Note mechanism of injury

disk herniation - Treatment: if no "red flags" symptoms

• Treat those symptoms
• Encourage rest ice or use heat, encourage gentle movements/Stretching 🧘‍♀️ Follow-up actions after 24 hours

Cauda Equina Syndrome

• Cauda Equina Syndrome occurs when the nerve roots at the caudal end of the cord, become compressed or damaged this causes disruption to the motor and sensory pathways to the Lower body with eventual bladder issues
• Most commonly this happens because of herniated disc in the lumbar section of spinal cord
• Congenital anomalies spinal cord infection spinal epidural abscess tumor or trauma it can occur from stenosis as well
• Although this is classified as very rear medical event it is emergent and is potentially caused by several back pain patients
• Symptoms can include but need not be limited to* - Distal leg and or any type of leg weakness and also loss or change in both muscle Sensory and muscle responses
  • Loss of Feeling of needing to defecate or urinate -Dysfuctionial bowels (late sign)
• Incontinence (late sign): Erection's or erections is a sign you may need immediate attention Loss over sensory or muscle feedback

CAUDA Equina -Focused history

-Check for all previous listed symptoms but also add: Recent incident or injury

History of spinal stenosis or herniated disc

• Ask the patient and inquire: Is there any bowel/bladder following symptoms?

Physical exam

   - Low back exam
   - Note: any loss of rectal tone
   - Unable to move from chair
   - Inability to feel or move toes
       - Check neurology and or sensory dysfunction and for any possible issues related to the Legs

Tools for Checkup

• If X-rays are available, lumbar films are May be appropriate if EVAC or transfer but have limited benefit

Differential exams

• Look for: intact reflexes in legs because its a very complex issue which requires immediate expert atnntion and consultation
• • If suspicious:**
• Immediate transfer -Consider Foley Catheter -And to encourage and administer support well awaiting transportation

Shoulder Impingement

• Shoulder dislocation / Instability
• Adhesive capsulitis
• AC joint separation
• Brachial plexus injury
• Biceps tender rupture

The humerus will not be centered on the glenohumeral joint

AC (Separation of the Acromioclavicular Ligaments)

• AC: acromioclavicular
• Known as a shoulder separation this injury occurs most frequently when the patient has fallen on the shoulder will less if they have out stretched hand
• Severe strains tear the AC and coracoclavicular ligaments which can displace the distal clavicle superiorly or inferiorly from the acromion

Symptoms for AC joint and/or Separation

Symptoms include pain at the AC joint from range of motion of the shoulder as well as swelling that can be caused depending on the severity of injury

• Focused history:* Fall on shoulder from outstretched hand Hands domination and occupation

Physical exam :

Perform palpation to the a-c joint but look at the shoulders to confirm or examine any other injuries ( SC joint to clavicle as well as humerus) and then reduced the range of motion in the shoulder • Tools;Bilateral Calvi

• Use tools: Bilateral Clavicle X-ray if available, it May to be helpful in finding the grade of the sprain -Use the tools to determine what the symptoms are (Active range of motion to passive range motion)
• Tendenitis : look for history and or injuries • Shoulder and or joint dislocated or great deltoid range pain and can not perform
• Differential*: Range of motion will be reduced and passive movement be full/
• Treatment*
  • Sling for7-10 days
  • Gentle stretching * -PRICE NSAIDS and or BATTLEFIELD ACUPUNCTURE:
• if symptoms are showing you need to treat as if neuroCompromise or orthopedic as mentioned

Shoulder impingement:

• In the shoulder the ligaments from the deltoid to a-c to humerus there are often mechanisms of injury *
• Symptoms:* -Symptoms such as pain and loss of motion are all side effects of shoulder issues -Nocturnal pain with muscle fatigue
• Focused History: Note the patients' hand Dominance or injuries or sports
• *Physical exam: possible muscle waste; and possible inflammation

Tools

• Tools do need to be used unless there appears to be trauma
• Differentials; trauma and biceps injury
• If the goal is the gentle process of restoration you need to also protect the area by following the symptoms

Use the listed treatments; - The first seven to ten days after the injury you may begin stretching you can Ask them review a PT before you go

• PRICE the affected pain with non-steroidal and Battlefield -Acupuncture and or any other listed options

If needed and or if pain continues evaluate by calling the Preceptor for extra procedures / tests, or or to discuss orthopedic’s