MSP unit 2

Soft Tissue, Joint, and Bone Disorders

• Musculoskeletal disorders include strains, sprains, and ruptures.
• Other musculoskeletal disorders include fractures.
• Osteoarthritis falls under musculoskeletal disorders.
• Degenerative disc disorders are also musculoskeletal disorders.
• Spondylolysis/spondylolisthesis and apophysitis are degenerative disc diseases.

Sprains, Strains, and Ruptures

• A strain involves the stretching or tearing of the musculotendinous unit.
• A sprain is an injury to the ligamentous structures around a joint.
• Classifications of sprains and strains are based on the degree of tearing and loss of integrity
• First-degree injuries involve minor tearing with no loss of integrity,
• Second-degree injuries partial tearing with a clear loss of function,
• Third-degree injuries severe tearing with complete loss of integrity.
• Rupture, the most severe classification, leaves the tissue most vulnerable to tension.

Fractures

• A fracture involves a partial or complete break of a bone.
• Causes of fractures include chemical, immune, mechanical, or repeated stress.
• A single load, high stress, or repetitive and forceful tasks can cause a fracture.
• Repeated moderate-magnitude forces can lead to stress fractures.
• Weakness caused by pathological processes in bone or the immune system can also lead to fractures.
• Fractures are diagnosed through imaging, special tests, and assessment of the inability to bear weight.
• Treatment options vary based on the severity of the fracture.

Osteoarthritis (OA)

• Osteoarthritis (OA) is a slowly evolving articular disease originating in cartilage and affecting bone, soft tissues, and synovial fluid.
• The incidence and prevalence of OA show that 60% of men and 70% of women over 65 years are affected.
• Etiology is primary and secondary.
• Risk factors include serious injury, genetics, and ligamentous laxity, with active disease, joint tissue destruction and abnormal repair.
• Osteoarthritis treatment focuses on non-pharmacological measures and aims to manage pain and maintain an active lifestyle.

Pharmacological Intervention for Osteoarthritis

• Acetaminophen is often the first choice for mild-to-moderate symptoms of OA, effective for pain control without gastric irritation.
• NSAIDs are effective for pain control in moderate to severe OA, reducing synovitis.
• DMOADs slow or reverse OA pathology with viscosupplementation (hyaluronan sulfate) of glucosamine and chondroitin sulfate.

Degenerative Disc Disease (DDD)

• Degenerative Disc Disease (DDD) etiology involves changes to the disc with age and nucleus losing water.
• Tears may form around the annulus.
• Risk factors genetics, age, and body weight.
• Possible correlation to repeated loading from physical demands.
• In spondylolysis, there is a unilateral or bilateral defect in the pars interarticularis,
• This can occur without vertebral body slippage.
• In spondylolisthesis, one or more vertebrae slip forward.

Clinical Manifestations and Diagnosis of DDD

• DDD can manifest as a gradual onset of midline lower back pain and a stiff back with radiating pain.
• Specific signs of disc herniation can include ankle dorsiflexion or great toe extension weakness, impaired ankle reflexes and loss of light touch sensation.
• Severe cases may involve gait abnormalities, sensory changes, and bowel and bladder dysfunction
• Diagnosis involves a history, physical examination, and imaging protocol. X-rays can assess disc space, and MRIs can assess soft tissues and disc consistency.
• Pharmacological treatment includes NSAIDs and targeted corticosteroid injections.

Pharmacology of NSAIDs and Tylenol

• Acetylsalicylic acid (aspirin) is the original NSAID, and there are aspirin-like and non-aspirin-like NSAIDS.
• NSAIDs treat mild-to-moderate pain and inflammation, various pains, post-operative pain, and musculoskeletal joint disorders.
• NSAIDs also help with menstrual cramps, fever, excessive blood clotting, and colorectal cancer prevention
• For OA, NSAIDs are a short-term option that inhibits prostaglandin (PG) synthesis via cyclooxygenase (COX) enzyme that aids normal function
• COX-2 enzyme is induced by inflammatory mediators and produces other types of prostaglandins.
• Aspirin and traditional NSAIDs(ibuprofen and naproxen) are non-selective (COX-1 and COX-2) inhibitors.
• Selective COX-2 inhibitors provide anti-inflammatory relief without compromising other prostaglandins.

Potential Adverse Effects of NSAIDs

• Risk of thrombotic events, hypertension, and higher cardiovascular risks with selective COX-2 inhibitors.
• Risk of ulceration, bleeding, and perforation, especially with advanced age, history of ulcers, and concomitant use of steroids/anticoagulants, and high doses.
• NSAIDs can cause renal and hepatic problems, aspirin intolerance/hypersensitivity (especially in asthmatics at 10-25%), acute bronchospasm, urticaria, and cardiovascular shock.
• Reye's Syndrome is a rare, potentially fatal condition. High fever, vomiting, liver dysfunction, unresponsiveness. Reye's occurs following influenza or chickenpox in children/teenagers.

Acetaminophen

• Acetaminophen (paracetamol) - Tylenol treats fever and noninflammatory conditions associated with mild-to-moderate pain.
• primary treatment in disorders not associated with inflammation.
• The mechanism of action is unclear and can cause fatal hepatic necrosis at high doses.

Metabolic Musculoskeletal Disorders

• Metabolic musculoskeletal disorders include osteoporosis, the most common metabolic bone disease.
• The osteoporosis affects women and men.
• The musculoskeletal diseases include osteomalacia, with unknown incidence and prevalence.
• Also Paget's disease, second most common bone disease, affecting women and men.
• Gout, metabolic disorders, affecting men and women.

Osteoporosis

• Osteoporosis is a chronic, progressive disease characterized by low bone mass, impaired bone quality, decreased bone strength, and an increased risk of fractures.
• In the US, 10 million people have osteoporosis and 43 million have osteopenia.
• It affects more females than males, especially post-menopausal Caucasian women.
• Bone resorption exceeds bone deposition.
• Osteoporosis manifests clinically as low back pain, fractures(often silent), and postural changes like thoracic kyphosis along with a loss of body height.
• Primary osteoporosis is the most common form, affecting both genders at all ages but often follows menopause in women.
• Secondary osteoporosis caused medications or conditions.
• Non-modifiable risk factors older age, race (Caucasian/Asian), family history, lactose intolerance, depression, and immobilization.
• Modifiable risk factors include inactivity/sedentary lifestyle, diet, tobacco/alcohol use, estrogen deficiency, and long-term use of certain medications.

Osteomalacia, Clinical Manifestation, & Paget's Disease

• Osteomalacia is a generalized, progressive bone condition with insufficient bone matrix mineralization causing softening without loss of bone.
• Largely unknown incidence. Often occurs with increased skin pigmentation and in areas with little Vitamin D in diet and sufficient intestinal calcium absorption as well as increased renal phosphorus losses.
• Risk factors Older age, residence in cold geographic area, vitamin D deficiency, gastrectomy or intestinal malabsorption, long-term medication use.
• Clinical manifestations are diffuse aching, fatigue, bone pain with periarticular tenderness, proximal myopathy along with Sensory poly-neuropathy, and muscular weakness.
• Paget's Disease: Progressive disorder of the adult skeletal system, increased bone resorption by osteoclasts and excessive, unorganized
• New bone formation by osteoblasts.
• Affects men and women after 35yrs and 3% over age 50 and 10% over age 70. the disorder is possible genetic susceptibility,

Understanding Gout: Etiology & Pathogenesis

• Gout is a metabolic disorder where elevated serum uric acid (hyperuricemia) causes urate crystal deposition in joints, soft tissues, and kidneys.
• It occurs in men before women, peaking in the 50s with uric acid accumulation and decreased urinary excretion.
• Acute, monoarticular, inflammatory arthritis with Exquisite joint pain.
• Gout primarily affects the first MTP joint, ankle, knee, wrist, elbow, or finger locations.
• Symptoms erythma, warmth, extreme tenderness, hypersensitivity.

Pharmacological Options for Metabolic Disorders

• Osteoporosis treatment includes biphosphonates, hormone replacement therapy, calcitonin, denosumab, PTH analogs, and calcium/vitamin D.
• Osteomalacia treated with antibiotics, calcium supplements, and vitamin D.
• Paget's disease treated with biphosphonates, calcitonin, and calcium plus vitamin D.
• Gout treated with NSAIDs, glucocorticoids, colchicine, and allopurinol.
• Osteoporosis treatment goals involve preventing/treating bone loss, improving bone mineral density, and decreasing fracture risk.

Pharmacologic Treatment of Osteoporosis

• Biphosphonates are a primary osteoporosis treatment that increases bone mineral density (BMD) and reduces the risk of fractures.
• Inhibit osteoclast activity as Bisphosphonates get absorbed into calcium crystals.
• Examples include alendronate (Fosamax), ibandronate (Boniva), zoledronate (Reclast), and lisendronate (Actonel)
• Serious side effects include Osteonecrosis the jaw +Typical femur fractures ( subtrochanteric ) and Symptoms include new or unusual pain in the hip, groin/thigh.
• Monoclonal antibody therapy reserved for those that have not responded adequately to other antiosteoporosis therapies.
• Common side effects include back pain, arthralgia, and pain in the extremities and osteonecrosis of the jaw.

Further discussion of bone medications

• Calcitonin - hormone that decreases blood calcium levels/mineralization that is Used mainly to treat hypercalcemia and Paget's disease.
• Can be used to treat postmenopausal osteoporosis and glucocorticoid induced osteoporosis. And local redness/swelling at the injection site, GI disturbances, loss of appetite.
• Treatment of postmenopausal osteoporosis by estrogen replacement increases BMD and reduces fracture risk.
• SERMS (Selective Estrogen Receptor Modulators) preferentially activate estrogen in bone/blocking those in breast/uterine tissues and common side effects include hot flashes, leg cramps.

PTH Analogs & Managing Gout

• PTH analogs are Useful in patients who are at high risk of vertebral and nonvertebral fractures due to postmenopausal osteoporosis and glucocorticoid-induced osteoporosis + stimulate new bone formation.
• Contraindications: bone cancer. Both drugs cause orthostatic hypotension + hypercalcemia (Forteo causes joint pain also with these adverse effects).
• Goals of Treating Gout: prevent and treat gout attacks, correct hyperuricemia, lifestyle modification.

Treatments for Gout

• Anti-inflammatory therapies: NSAIDs (e.g., indomethacin, ibuprofen, naproxen, and colchicine) to decrease pain.
• Systemic use of Glucocorticoids may lead to multiple side effects
• Xanthene oxidase inhibitors (Allopurinol or Febuxostat). Allopurinol is typically first line treatment but both can gout flares during initiation.
• The uricosuric drugs (probenecid) and are Started at low dose with gradual dose increase that can cause liver enzyme elevations.
• With Gout avoid purine high, high fructose as well as alcohol. Topically apply in ice.

Infectious Musculoskeletal Disorders

• Infectious musculoskeletal disorders include osteomyelitis and myositis.
• Infection caused by an infectious organism that can be found with imaging, blood data, physical examination and medical history.
• Most common infection agent is bacterial and need to be treated Systemically and locally with high dose antibiotics and/or surgery

Osteomyelitis & Associated Side-effects

• Relatively uncommon disease that is potentially fatal and impacts Children adults + boys>girls from, staphylococcus aureus.
• SpreadExogenous in outside body + Hematogenous in within body that has inflammatory response in metaphysis of long bones
• Clinical manifestations include Radiculopathy, myelopathy, paralysis +Back pain in adults.
• In early identification of osteomyelitis + lab values and radiographs often come back early.
• Side effects from antibiotics: Hypersensitivity reactions (skin rashes, itching, and respiratory difficulty/ Light sensitivity/dependent on what antibiotic).
• Fluoroquinolones increase risk of tendon pain and inflammation(tendonitis) that is mostly frequent on the Achilles and complaints evaluated.

Myositis

• Inflammatory conditions directly caused by viral, bacterial, autoimmune conditions or parasitic agents or immune.
• Early diagnoses and aggressive treatment improve prognosis to have Improved prognosis.

Autoimmune Disorder: Rheumatiod Arthirits

• Autoimmune disorders: rheumatoid arthritis +Ankylosing Spondylitis with Juvenile Idiopathic Arthritis.
• Rheumatiod Arthirits (RA): Insious onset, progresses slowly as the disease process moves from cartilage degradation to ligamentous laxity and, finally, synovial expansion with erosion complaints are fatigue weight loss weakness.

Juvenile Idiopathic Arthritis (JIA) & Ankylosing Spondylitis

• JIA (Juvenile Idiopathic Arthritis of unknown cause and classified based on the number of joints involved, presents before 16 years old and in all races.
• Each subtype has a different presentation + genetic background.
• In Ankylosing Spondylisties (AS)= inflmmatory arthropathy the AXIAL skeleton that has 1/rd asymmetric involvement and there are three tendons types based on Healing, Surgical and Pain
• Multiple tendons + Healing
• Intrensic, vascular, celllar and inflammoatry.

Musculoskeletal Disorders relating to Micro trauma and Tendon

• An alteration that has increase mechanical load tissue. There the changes in this with are Pain, altered loading and decrease function.
• Stage 1 = inflammation Stage 2 = disorganized collagen.
• Tenocytes account for 95% that have spindle shapes or altered shapes.
• Affective are Lateral side of Enthesis where structures to have Load.
• Load = affects more at the lateral side.

Tendon Healing

• Tendons have intrinsic and extrinsic capabilities to heal that relates to intrensric, vascular, celllar, and cellular response adjacent to it.
• The healing can lead on the degree of the injury = repair and mobilization with controlled stressing tensile.

Stages of Tendon Healing

• Tendon has three stages of Heals that occur:
• Hemostasis and inflammation.
• Repair and Heals.
• Chronic = maturation and remodeling.
• 7-10 days is weakest that has to regain with 21-28. days with to and having near full strength when 6mm.
• The nature to the micro Vs. Macro, the need and tension