Musculoskeletal Problems: A Primary Care Guide

• Musculoskeletal issues frequently lead to primary care visits due to injury, pain, and dysfunction.
• These problems are a prevalent source of disability among workers.
• Over half of older Americans have musculoskeletal disorders.
• Nonorthopedic healthcare providers may face challenges with musculoskeletal complaints.
• Expertise in anatomy and physiology, as well as conservative measures like PRICE and medication, is important for clinicians because many acute complaints are self-limiting.
• Ignoring conditions can result in joint instability, disability, and a greater risk of subsequent injury.
• Ruling out urgent or emerging musculoskeletal conditions must be considered to avoid death or permanent disability.
• Diagnosis Accuracy depends on thorough patient history and physical exams.

The History

• Use mnemonics like PQRST or OLDCARTS to ensure organized history taking.
• Include details about triggering events like trauma.
• Understanding injury mechanisms can point to specific tissue damage.
• Document the start, duration, characteristics, and temporal aspects of the complaint.
• Further assessment is needed if a patient describes a specific anatomical area.
• Certain pain patterns may indicate particular diagnoses like greater trochanteric pain with trochanteric bursitis, carpal tunnel syndrome with nighttime hand numbness, and plantar fasciitis or early RA with morning foot pain.
• Record the location, quantity, and distribution of affected joints (monoarticular, oligoarticular, or polyarticular) as well as relevant medical history. Gout/OA is monoarticular, and RA/polymyalgia rheumatica, is polyarticular.
• Inquire about current or past medical issues that might be contributing to the primary complaint.
• A review of systems gives vital diagnostic data and can reveal systemic features like fever in SLE or infection.
• Note additional joint-related symptoms such as clicking, restricted movement, deformity, stiffness, weakness, pain, locking, and buckling. Clicking that doesn't cause pain or restriction may be innocuous, but may still be linked to pathologies.
• Degeneration, cartilage deterioration, edema, effusion, pain inhibition, or contractures can all result in decreased motion. Joint movement can also be hampered by the rupture of a tendon.
• Trauma (tendon rupture, dislocation, fracture), rheumatic nodules, gout, tumors, and spinal problems (scoliosis, kyphosis), or osteoarthritis can all lead to deformities.
• Stiffness may be continual or sporadic. OA stiffness resolves in <1 hour and returns following activity whereas RA stiffness lasts >1 hour following inactivity and is especially apparent in the morning.
• Weakness is different from fatigue as injury and pain inhibition are important factors. Weakness patterns (proximal, distal, or generalized) can aid diagnosis.
• Recognize discomfort based on its start (sudden or gradual), timing (morning vs. late day), and distribution (single vs. multiple joints, radicular).
• Mechanical issues such as loose fragments, ripped cartilage, dislocations, subluxations, or trigger finger are indicated by locking.
• Pain, muscular inhibition, effusion, or ligament/tendon/cartilage rips can all cause buckling.

The Physical Examination

• The physical exam is guided by the history, and is an effective way to narrow differential diagnoses.
• Assess overall appearance, gait, and posture.
• Compare the affected areas through visual inspection with the unaffected side for signs of trauma, ecchymosis, erythema, skin lesions, edema, masses, nodules, deformity, and atrophy.
• Palpate at, above, and below the joint in question to detect crepitus, effusion, tenderness (diffuse or point), edema, and variations in skin temperature; also look for sensitive spots and bony enlargements.
• Evaluate Range of Motion (ROM) actively, passively, and with assistance, noting degree, symmetry, and pain.
• Grading from 0/5 to 5/5 can be used to measure strength.
• Examine joint stability by performing stress tests for ligament laxity and evaluating joint play.
• Use special tests to diagnose particular disorders in the extremities, and in the cervical/lumbar spine.
• Perform a neurovascular examination on the upper and lower extremities to assess any sensory loss patterns, peripheral pulses, skin temperature, capillary refill, peripheral edema, and reflexes.
• Differentiate articular disorders, with deep/diffuse pain, limited ROM, swelling, crepitation, instability, locking, or deformity, from nonarticular ones, which have painful active but not passive ROM, point tenderness away from the joint capsule, and less crepitus or instability.
• Note any signs of malignancy or endocrinopathies. Extra-articular abnormalities may point to systemic disease.
• General assessments, such as rising from a chair, gait, and balance also help to make a diagnosis.

Diagnostic Tests

• Positive results may not always indicate a problem or negative results may not always mean there isn't a problem.
• A CBC can show anemia (inflammation) or leukopenia (infection, autoimmune, bone marrow).
• ESR and CRP levels can be used to identify non-specific inflammation; in polymyalgia rheumatica and giant cell arteritis they are quite elevated.
• Rheumatoid Factor (RF) occurs in RA, but also in other diseases.
• ANA tests are most often seen in SLE patients, however, they are also present in other inflammatory conditions and in healthy individuals.
• Lyme borreliosis antibody should be used to help identify the condition if there are risk factors.
• Although it is frequently elevated in gout, uric acid levels can fluctuate; synovial fluid analysis is required for a conclusive diagnosis.
• Screening panels may show false positives.

Imaging Tests

• Radiography (x-rays) can screen for joint erosions, narrowing, calcifications, cystic masses, osteoporosis, bone tumors/lesions, deformity, fractures, and dislocations by using x-rays. Radiographic OA symptoms can lag behind; they are of little value in cases of acute mechanical low back discomfort.
• Diagnostic ultrasonography can detect nerve entrapments, inflammation, subluxation, chondral defects, soft tissue injury, and fluid collections based on user experience.
• A CT scan is better for bone as well as fracture patterns, disc herniation, loose fragments and soft tissue tumors, but it emits more radiation.
• An MRI can show soft tissue injury, cartilage, intervertebral discs, bone marrow edema and inflammation (tumor, infection, stress fracture), and spinal disc degeneration.
• A bone scan can find changes in the physiological and metabolic tissues (osteomyelitis, avascular necrosis, fractures), especially those related to tumors, however, the anatomical detail is not as good.
• EMG/NCS are able to identify nerve injury and dysfunction (carpal tunnel syndrome, radiculopathy); used to differentiate between spinal and peripheral nerve problems.

Differential Diagnosis

• Differential diagnosis should include the injuries underlying the site of pathology, complaint and etiology.
• Such things as congenital or developmental abnormalities, tumors, metabolic or circulatory illness, infection and trauma should be evaluated.
• Acute monoarthritis needs infection exclusion as well as the use of synovial fluid analysis and joint aspiration. Chronic monoarticular symptoms with minimal effusion can be from OA.
• It is important to recognize polyarthritis through systemic symptoms, stiffness in the morning, sicca or Raynaud's syndrome.
• When active ROM is restricted but passive ROM is preserved (muscle injury, bursitis and tendinitis), point tenderness is often the diagnosis.
• Systemic symptoms, cardinal signs of inflammation and elevated ESR/CRP result from inflammatory disorders.
• Noninflammatory disorders such as pain amplification, degeneration or trauma, neoplasm can occur as well.
• Numerous conditions known as generalized arthralgias and myalgias must consider fibromyalgia, polymyalgia rheumatica, neuropathy, hypothyroidism, psychogenic conditions, infections, overuse and side effects from medication.
• Synovial fluid analysis is helpful to help determine inflammatory, infectious conditions.

Acute Musculoskeletal Injury

• Acute musculoskeletal injury is common across many age groups and settings, and the common causes change with age.
• Lower extremities injuries are usually most involved.
• Overuse injuries occur more frequently in older adults while injuries related to patellofemoral syndromes and stress fractures occur in younger patients.
• Signs like swelling, abnormal ROM, deformity and point tenderness, are crucial for a thorough evaluation.
• After the first rapid survey, follow up by doing a more detailed secondary survey that rules out other system involvement from the body.
• Pediatric/Adolescent Considerations: Tendons and ligaments are normally stronger, therefore porous bones are susceptible to greenstick fractures and fracture patterns that cause avulsion. Open growth plates are also prone to injuries, which result in angulation correction and faster healing for the condition.
• Strains, muscle and tendon fiber stretching or tearing caused by excessive activation and stretching can commonly injure more than one joint.
• Falls most often cause common injuries and the primary focus should be prevention. Decreased bone density, muscle strength, flexibility and cartilage resilience, contribute to this risk. Consider the effects of immobilization, on stiffness, the duration as well as medication side effects on GI and fall risks.
• Sprains commonly occur with strains and bony tenderness, and difficult to differentiate through stretching. Tenderness and physical exam is important because x-rays may be required to rule it out due to blunted pain perception in the elderly.
• Shoulder and AC joint sprains often result through a direct blow and have 6 classifications based on clavicle displacement and ligament involvement.
• Ankle sprains cause chronic pain through instability after recurrent sprains, it is classified through severity and is classified through many ligament involvements.
• Through history and physical exam sprains, including swelling and deformity can differ from strains, including limited ROM, no redness, or the possibility that severe strains cause function loss because severe strains may have complete tears.
• Remember there are times when sprains can appear as chest shoulder pain and mimic cardiac problems.
• Initial stabilization is most often the key to management; however, patients can be reradiographed in 10-12 days in the event there's any negative x-rays initially.
• Use PRICE.
• For pain use muscle relaxants and NSAIDS (for short term muscle spasm).

Fractures

• A fracture is typically, bone discontinuity due to high blunt force. Goal is the allign bones because it is transmitted to distant bony sites.
• Callus formation (visible on x-ray ~2-4 weeks), calcification/remodeling, consolidation, bone hematoma formation, inflammatory phase and the bone healing phases depend on age and bone.
• Shoulder Fracture: Humerus clavicle as well as acromion (less common) fractures can cause pain, however, heal with mobilization.
• Geriatric Considerations: Hip and distal radius factors are common due to fracture assessment tools.
• High mortality risks beyond osteoporosis include falls, medication, cognitive impairments and incontinence.
• Proximal Femoral (Hip) Fracture: Adult fracture with high mortality that increases with age in most females is due to visual impairment, prior fracture history, which requires surgical repair immediately, neurological function checks and evaluation immediately.
• Knee injuries which involve fibular, patella, distal femur, as well as neurovascular, should be evaluated as well as an effusion (fat globules).
• Distal tibiafibula is involved in stress fractures due to overuse trauma causing swelling and inability to bear weight.
• X-rays are often used to to determine guidance and rule it out.
• History of trauma is key to diagnose fractures from rheumatological or infectious disorders.
• Comparison x-rays should not be performed on children. To localize an injury, work with non-cooperative patients through palpation or MRI.

Reflex Sympathetic and Radiographic Reading

• Reflex Sympathetic Dystrophy (RSD): Post-traumatic syndrome should be diagnosed early for a better recovery and should use physical therapy, antidepressants and prednisone.
• Follow the bony vortex, internal trabecula, examine area, lesions, adjecent bone arrangements, soft tissue, assess joint space, be aware of signs.
• Fractures can be treated like fractures because they may not be visible; also, stabilize joints above and to protect against compartment syndrome.
• Healing of fractures follows a sequence, however, fractures with older patients heal slower and patients need to follow up on referral patients.
• Splints should be adjustable to avoid necrosis. Cast removal after adequate healing (6 weeks depending on factors).

Muscle Cramps, Paresthesias, and Myofascial Pain

• Muscle Cramps are involuntary painful contraction and can be linked to sports/exercise due to dehydration and motor neuron hyperexcitability.
• Paresthesias: Distinguishing location is important for central/peripheral lesions and may be non-specific, however, loss or ascendance is.
• Myofascial Pain can be distinguished with pain to trigger points and visualized by a diagnosis tool.

Regional Musculoskeletal Complaints

• Muscle strains in the cervical spine causes a head ache.
• This often causes neck pain, non-radicular for females and males.
• Canadian spine rules guide this.
• Whiplash can happen by deceleration (with rapid Extension) injuries and cause psychosocial factors, so, manage muscle strains.
• Disc Degeneratiom, facet, spinal compression is possible.
• Diagnosis is mostly EMG testing for pain in other radicular areas.

Low Back Pain (LBP) and Herniated Lumbar Disc

• Is often a system arising mostly from spine abnormalities as well as is often an injury radiating to the buttocks.
• Mechanical/ Non specific often cause dermatological complications.
• Risk factors associated with LBP include psychological factors, obesity, vibration or smoking.
• Discomfort can be detected after injury such as falls or trauma related injuries.
• Red Flags often indicate serious underlying pathology.
• After that, imaging may be used without indications of Red Flags and conservative treatments or, CT can be used.
• After, reassurance and activity are best to reduce the need for pharmacological, physical or therapy and medication.
• Herniated Lumbar Discs may compress spinal nerves and are common in 40-50 year olds and can be from smoking, vibration or degenerative changes.
• CES rare, may cause radiculopathy, radiating pain in legs or can cause changes of reflex.

Lumbar Sprain Disorders and Cauda Equina Syndrome (CES)

• Lumbar Sprain is a result from narrowing areas and structure.
• Risk factors are a number of factors due to spondylosis as well as in elders through claudication, myelopathy.
• Imaging is also performed, and management focuses from weight loss, exercising and cortico steroids which is often pharmacological.
• Cauda Equina Syndromes(CES) results from compression of the spinal equina.
• This often occurs in L4/5 disk disruption cases. CES often can lead to more weakness than what is present from prior exam or, may have complications resulting from altered sensation with sitting.

Vertebral Fractures and Soft Tissue Disorders

• Verteral Fractures are breaks caused mostly from fractures and need neurological examinations and possible spine correction (with immobilization) in order to allow proper soft tissue.
• Nonsystemic, localized syndromes that affect muscles, ligaments, and bursae and are classified as "nonarticular”.
• Regional discomfort around joints is a common complaint among patients.
• Initial treatment which is crucial, includes self-care education, explaining this disorder, short-term therapy, and ruling out underlying conditions.

Bursitis

• Bursitis is inflammation of fluid-filled bursae that cushion bones and lubricate tendon movement.
• Causes include overuse injury, trauma, infection, inflammation and neoplasms.
• Risk increases with skeletal maturity, male sex, obesity and advancing age
• Common sites: shoulder (subacromial, subdeltoid), elbow, hip, knee.
• Repetitive motion injuries lead to irritation, friction, and edema and inflammation of the bursae.
• Septic bursitis is from breaks in the skin barrier, from direct trauma ( Staphylococcus caused).Immunocompromised Individuals have higher risk from it.
• The symptoms: is pain along potential warmth over bursal sacs.
• Examination: effusion and induration can occur with limited motion.
• Diagnosis: is usually based on ESR and CRP. Aspiration for fluid assessment is conducted to rule out RA/arthritis/ gout infection.
• Management: Injections are used after an aspiration of fluid, if filled. In addition to ROM exercises, immobilization and avoiding triggering activities is needed.
• Patient Ed: medication adherence and activity stretching is needed.

Tendinitis/Tenosynovitis & Hand/Wrist Disorders

• Tendinitis: In the tendons there is inflammation.
• Tenosynovitis: synovials are inflamed.
• Common syndromes result from these conditions.
• Risk factors: obesity, imperfections in the anatomical setting, overtraining and certain works from repetitive motion.
• Symptoms: pain and better motion than with stretching. However, pain may be palpable.
• Management includes protection and PRICE initially and promotion of collagen remodeling.
• Evaluation of work and training as well economic modifications may also be needed.
• Hand and wrist common with women including tunnel carpal. This compresses nerves and causes risk.
• Nighttime pain can occur or in certain fingers during repetition. And can be prevented with rest, breaks antivibration and lifting techniques.
• De Quervain's Tenosynovitis: Results from repetitive Thumb use that inflames the abductor of thumb and base of wrist.
• Lastly ganglion cysts are related to tendon Sheaths.

Shoulder Disorders

• Adhesive Capsulitis (Frozen Shoulder): often happens idiopatically due to glenohumeral capsule contraction and more in females aged 40-60. Linked to diabetes and other medical cases.
• Three main phases in a process that can extend over time: freezing, painful and recovers last.
• Impingement Syndrome often results in tendon damage and it is managed throughout streching or subacromial space injections.
• Calcific Tendinitis causes can calcific issues so often is best with rest/therapy.

Hip Disorders and Management

• Hip: Can be caused from a number of tendinopathy combinations or lumbar spondylosis causes.
• Pain at external hip can be involved often with external rotation increases the pain.
• Meralgia Paresthetica is a common case for overweight patients and manages avoid overweight.
• Also AVascular Necrosis can disrupt the bone supply. With certain risks like rheumatoid arthritis. This would lead to death through the hip.
• Bone Tumors can be removed through surgeries or, bone replacement.
• Metastases are common with breast Kidney and prostate disorders. Management may be sufficient for a while. Bones may be weak and tumors, aggressive.

Knee Disorders And Cruciate Ligament

• Knee (ACL).
• Usually accompanied with injured meniscus, can be strains strains that are athletic mostly.
• Symptoms involve swelling, pain and a POP.
• Knee (MCL): Causes leg swelling and stability/pain.
• Medial Knee-often has positive test and requires xrays to make a diagnosis.
• Lastly. the Meniscus can be either chronic or acute and involves locking for a short time, may result a test may determine that.

Foot And Ankle Disorders

• Ankle Tendionpathy is often common and management happens just as it would for tendons.
• Plantar Fascitis is a long condition that weight baring or obesity.
• Can cause pain or require managing and stretching.
• For Interdigital Neuroma high healed are often involved or compression often involves surgery.

Osteoarthritis (OA)

• OA (degerative joint disease) occurs often in older adults.
• It is a disease in the articular cartilege. Risk factors include all trauma mechanical stress and history.
• Prone to joint abnormalities through degeneration. OBesity is a notable cause.
• In terms of clinical presentations there could be swelling and with better rest, and could be painful.
• Diagnoses tests (XRAYS) are performed.
• However it can easily be treated if not severe to maximize life quality. In addition treatment must range from education to theropy and exercise with the aim to strengthen quads and provide comfort.
• Severe OA requires surgery and should be followed up with specialist.

Osteoporosis

• Low mineralzation (BMD) levels on bone can disrupt bone.
• The risk factor includes (Calcium Levels with vitamine Deficiencies), is also something concern. This can even lead to fracture.
• Estrogen efficiency is a big risk of such thing. As a results we see bones disrupted with this in process. This is why this must be examined.
• Clinicals are something that is not seen through until fracture has often occurred, also, that a history with low trauma is a strong predictor.
• The management includes making sure to make healthy choices from cutting from alcohol, getting into the healthy weight as well as lifestyle as well as to increase maximize function and also by reducing the number in people.
• Some may give calcium and vitamin supplements on top. As long with other bones. Bisohosponates are often given to females.