Feb 23, 2024 Discussion: Musculoskeletal Pain
Discussion: Musculoskeletal Pain
Discussion: Musculoskeletal Pain
I agree with your differential diagnoses of Patellar Tendonitis and Osgood-Schlatter Disease (OSD). Knee pain in teens is a typical result of overuse but also from specific knee injuries and medical conditions affecting the knee. Knee pain can also be temporary and unrelated to an injury but a change in the teen’s activity level or sport.
In addition to the intrinsic causes, knee pain can be referred pain from the hip or lumbar spine pathology. Hip conditions include slipped capital femoral epiphysis, Legg-Calve-Perthes disease, and femoral neck stress fracture, whereas spine conditions to be considered include tumors of the spine or the cord, herniated disk, or spinal stenosis (Patel & Villalobos, 2017).
Jumper’s knee (irritation and inflammation of the patellar tendon) most commonly occurs in teenage boys, particularly during a growth spurt. The patient reports vague anterior knee pain that has persisted for months and worsens after activities such as walking down stairs or running.
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Knee pain in teens results from overuse, specific knee injuries (blow to the knee), or medical conditions, including Osgood-Schlatter disease, juvenile arthritis, and osteochondritis dissecans. Treatment depends on the cause of the pain but may include RICE (rest, ice, compression, elevation), anti-inflammatories, and physical therapy.
Plica Syndrome: is another possible differential diagnosis that presents with almost similar clinical features
Patients with plica syndrome experience anterior knee pain localized to the affected plica associated with snapping, clicking, catching, clunking, grinding, or popping inside the knee during flexion and extension. Pain can be brought on by repetitive knee flexion, extension, or prolonged knee flexion. In addition, patients may have a history of a recent increase in activity level or twisting injury with subsequent development of an effusion (Kuwabara & Fredericson, 2021).
On physical exam, the plica is typically tender to palpation, with the knee extended and relaxed. The knee joint may be mildly swollen and stiff. Plica syndromes are often missed because they are difficult to distinguish from meniscal tears, articular cartilage injuries, or osteochondritic lesions. Plica syndrome is diagnosed clinically, but imaging can help identify predisposing causes, rule out other etiologies, and assist in surgical planning. Weight-bearing anteroposterior, lateral, and skyline radiographs should be obtained to rule out bony intra-articular pathology.
Arthrography, US, and MRI can demonstrate the presence of a plica but are unreliable in predicting pathology. However, MR arthrography can improve plica syndrome diagnosis (Kuwabara & Fredericson, 2021).
References
Evaluation of patients presenting with knee pain: Part ii. differential diagnosis. (n.d.). https://www.aafp.org/pubs/afp/issues/2003/0901/p917.htmlLinks to an external site.
Knee pain in teens: Causes, symptoms, treatment & prevention. (n.d.). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/16716-knee-pain-in-teensLinks to an external site.
Kuwabara, A., & Fredericson, M. (2021). Narrative: Review of anterior knee pain differential diagnosis (other than patellofemoral pain). Current Reviews in Musculoskeletal Medicine, 14(3), 232–238. https://doi.org/10.1007/s12178-021-09704-9Links to an external site.
Patel, D. R., & Villalobos, A. (2017). Evaluation and management of knee pain in young athletes: Overuse injuries of the knee. Translational Pediatrics, 6(3), 190–198. https://doi.org/10.21037/tp.2017.04.05Links to an external site.
I enjoyed reading your post! In your episodic/SOAP note, you gave detailed information and painted a “realistic picture” of the patient. Recently, a medical doctor told me, “our bodies give us warning signs when it’s in distress. When the body is in distress, it tries to repair the issue. If the body does not repair the issue on its own, it’s up to healthcare professionals to figure out the etiology and treatment.”
Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
Case Study 3
In your assigned case study, the patient, PH, is a 15-year-old Filipino boy with complaints of bilateral knee pain for over a week. He describes the pain as dull intermittent “clicking” or “catching in one or both knees. PH reports that the pain started a couple weeks after basketball season started this year. PH stated he had pain similar to this last spring during track when he started competing in long jump. PH reports that it hurts more after practice than it does after a game stating, “coach has me doing extra running and jumping drills, he’s really hard on us.” He has a history of an ulnar fracture and multiple sprained ankles from basketball and track, but no previous knee injuries.
Patellar injury differential diagnosis- Patellar Tendonitis
Your differential diagnosis were Patellar Tendonitis, Chondromalacia of the Patella, Juvenile Arthritis, Bursitis, and Patellar Maltracking. Agreeably so, I believe Patellar Tendonitis is the primary diagnosis. Your description of the condition is best with PH reported signs and symptoms. Chronic inflammation, such as patellar tendonitis, leads to a weakened tendon and can increase the likelihood of tendon rupture. Certain medical conditions can lead to an overall weakened tendon and can also predispose an individual to tendon rupture such as patellar degeneration, overuse injury, and previous injury (Hsu & Siwiec, 20121).
Patellar injury differential diagnosis- Chondromalacia of the Patella
Chondromalacia of the Patella occurs with activity rather than a result of the activity. Chondromalacia patella (CMP) is when the posterior articular surface of the patella starts losing its density when in a healthy state and turns to be softer with subsequent tearing, fissuring, and erosion of the hyaline cartilage (Habusta et al., 2021). You stated that the condition is found more in women than men. According to (Habusta et al., 2021), CMP is more common in women than men and this is attributed to increased Q angles in women. Therefore, this will be a least likely primary diagnosis for PH since he is male gender.
Patellar injury differential diagnosis- Juvenile Arthritis
Juvenile Arthritis (JA), isn’t a specific condition. It is a broad term that describes numerous rheumatoid conditions in children. Similar to arthritis observed in adults, pathogenesis involves autoimmune and autoinflammatory mechanisms (Martini et al., 2022). Agreeably so, the majority of JA conditions are diagnosed at age 16 and older. One with JA can exhibit a fever, joint inflammation, swelling, pain and tenderness, but some types of JA have few or no joint symptoms or only affect the skin and internal organs (Arthritis Foundation, 2021). As you stated, it is least likely that PH has JA, but should not be completely eliminated until ruled out by further testing.
Patellar injury differential diagnosis- Bursitis
Bursitis does require treatment by a physician. The olecranon and prepatellar bursae are the most often involved sites, as their superficial location exposes them to injury. Among patients with bursitis, 80% are males aged 40 to 80 years who constitute the population most exposed to trauma and micro trauma during manual labor or recreational activities (Lormeau et al., 2019). PH unlikely has Bursitis due to the big gap in age and presenting symptoms. Therefore, I would eliminate this differential diagnosis.
Patellar injury differential diagnosis- Patellar Maltracking
Your last differential diagnosis was Patellar Maltracking. Patellar Maltracking refers to the dynamic relationship between the patella and trochlea during knee motion. Patellar maltracking occurs as a result of imbalance of this relationship often secondary to anatomic morphologic abnormality. Usually, young individuals, particularly women, suffer the consequences of this disorder (Jibri et al., 2019).
References
Arthritis Foundation. (2023). Juvenile Arthritis (JA). Retrieved January 17, 2023 https://www.arthritis.org/diseases/juvenile-arthritis
Habusta, S. F., Coffey, R., Ponnarasu, S., & Griffin, E. E. (2021). Chondromalacia patella. In StatPearls [Internet]. StatPearls Publishing.
Hsu, H., & Siwiec, R. M. (2021). Patellar tendon rupture. In StatPearls [Internet]. StatPearls Publishing.
Jibri, Z., Jamieson, P., Rakhra, K. S., Sampaio, M. L., & Dervin, G. (2019). Patellar maltracking: an update on the diagnosis and treatment strategies. Insights into imaging, 10(1), 1-11.
Lormeau, C., Cormier, G., Sigaux, J., Arvieux, C., & Semerano, L. (2019). Management of septic bursitis. Joint Bone Spine, 86(5), 583-588.Martini, A., Lovell, D. J., Albani, S., Brunner, H. I., Hyrich, K. L., Thompson, S. D., & Ruperto, N. (2022). Juvenile idiopathic arthritis. Nature Reviews Disease Primers, 8(1), 1-18.
Martini, A., Lovell, D. J., Albani, S., Brunner, H. I., Hyrich, K. L., Thompson, S. D., & Ruperto, N. (2022). Juvenile idiopathic arthritis. Nature Reviews Disease Primers, 8(1), 1-18.
JJ 46-year-old Caucasian female
S.
CC: right ankle pain
HPI: This 46-year-old Caucasian female presents with c/o right ankle pain that has been persistent since she injured it, “twisted it” playing soccer 3 days ago. She states she heard a “pop” and has been able to bear weight, but it is “uncomfortable”. She describes the pain as continuously “sore”, and “stabbing” with ROM and ambulation, with 7/10 pain, that is worse in the evening after walking on it all day. Applying ice and Ibuprofen 400mg is helpful but does not relieve the pain completely. She reports increased swelling to the right foot and some bruising around the ankle.
Current Medications: MVI 1 tablet po daily for supplement
Levothyroxine 112mcg po daily for hypothyroidism
Ibuprofen 400mg po every 6 hours as needed for pain
Claritin 10mg po daily as needed for allergies.
Allergies: Pollen- causes increased congestion, itching watery eyes
PMHx: Hypothyroidism
Denies surgical history
Para 2 gravida 2 both vaginal births (2000 and 2001) without complications
Denies mental health history
Immunizations: dTap 11/2022
Flu vaccine: refuses annually; education provided
CoVid vaccine up to date; last booster 12/2022
PNA vaccine: 12/2019
Childhood vaccines were received as scheduled
Soc Hx: JJ teaches 2nd grade elementary school, works out at the gym 3X/ week and plays soccer on the weekends. She is married 23 years and has 2 daughters both away at college until the summer. Her elderly mother lives with her. She denies tobacco and illicit drug use. Reports 1-2 glasses of wine weekly. She reports she follows up with an annual mammogram and her last Pap Smear was 3 years ago. She engages her seatbelt when in the car and does not text and drive. She changes the batteries in her smoke detectors when she changes the clock for daylight savings.
Fam Hx: Father- died from CoVid 2021
Mother- ASHD, depression
Brother- ASHD
Paternal grandfather- Died in Korean war
Paternal grandmother- Died from PNA in 1987
Maternal grandfather- ASHD, Died from CVA in 1995
Maternal grandmother- Died from CHF in 2000
Both daughters are healthy, denies PMH
ROS: BP 110/62, HR 68, O2 sats 99% on RA, T 97.6
Ht 65 inches, Wt 152 lbs, BMI 25.29
GENERAL: A&Ox4; denies weight changes, afebrile, denies chills, weakness or fatigue.
HEENT: Eyes: wears “readers” when reading, denies blurred vision or double vision. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Right ankle bruising to outer ankle
CARDIOVASCULAR: No chest pain, chest pressure, chest discomfort, palpitations, cyanosis, or edema. No HTN. No h/o strep or Rheumatic fever.
RESPIRATORY: No shortness of breath, dyspnea, cough or sputum.
GASTROINTESTINAL: Eats a general diet. LBM 4/18/2022. Denies anorexia, nausea, vomiting constipation or diarrhea. No abdominal pain or blood.
GENITOURINARY: Denies dysuria, hematuria,or incontinence. Last menstrual period, 04/10/2023.
NEUROLOGICAL: No seizures, fainting, headache, dizziness, paralysis, ataxia, tremors, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Bil ankle pain, more-so in the right ankle. No back or neck pain.
HEMATOLOGIC: No anemia, bleeding; no h/o transfusion. Right ankle bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety, denies hallucinations or delusions, speech clear, judgement appropriate.
ENDOCRINOLOGIC: No weight changes, sweating, cold or heat intolerance. No polyuria or polydipsia. h/o hypothyroid, last TSH level was 11/2022.
ALLERGIES: No history of asthma, hives, eczema. Rhinitis from pollen.
O.
Physical exam:
General: A&Ox4; well groomed, pleasant and smiling, appropriate responses.
Cardiovascular: HR regular, S1 S2 present, no JVD; nail beds acyanotic, <3 cap refill. LLE no edema, dorsalis pedis +3, skin pink, warm and dry. RLE +2 edema, dorsalis pedis +3, skin with bruising noted to outer ankle, warm, dry and no redness noted, limited ROM.
Respiratory; Resp even/ unlabored, chest rise symmetrical; LSCTA.
Neurological: Full sensation to all extremities and able to respond to commands
Musculoskeletal: RLE +2 edema, dorsalis pedis +3, skin with bruising noted to outer ankle, warm, dry and no redness noted, limited ROM.
Diagnostic results: Ottawa ankle exam
X-ray right ankle R./O fx
A.
Differential Diagnoses:
Achilles tendon rupture: Is common in patients 30 yrs and older that are intermittently active in sports and affects up to 1 million athletes annually (Shamrock et al, 2023). Patients will report a “pop” sound with a sudden onset of pain (Shamrock et al, 2023). Studies show there is a tendency when the tendon is pulled more than 8% of its actual length. Thyroid disorders are a systemic disease that is thought to be related to Achilles tendon ruptures (Shamrock et al, 2023). Initial treatment is rest, elevation of the affected limb, managing pain and a brace which has shown to be as affective as surgical intervention (Shamrock et al, 2023).
Sprain: Early diagnosis and appropriate treatment of sprains can decrease the risk of recurrent injuries to the area and unstable function ability (Melanson, 2022). Ankle sprains are the most common sports injury and make up to over 2 million ED visits annually between the US and the UK (Melanson, 2022). A low-grade sprain is microscopic tears or stretching of the ligament structures, and a high-grade sprain compromises or completely disrupts the integrity of a ligament (Melanson, 2022). Initial treatment is rest and elevation for 72 hours, ice and compression dressing, and pain management (Melanson, 2022).
Ankle FX: Ankle fractures could affect a number of bone structures and determining which structures are involved will aid to render the best treatment options to stabilize and restore alignment which could include a surgical or non-surgical interventions (Wire et al, 2022).
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References:
Melanson, S.W. (2022). Acute ankle sprain. Stat Pearls. https://www.statpearls.com/articlelibrary/viewarticle/17600/Links to an external site.
Shamrock AG, Varacallo M. Achilles Tendon Rupture. [Updated 2023 Mar 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430844/Links to an external site.
Wire, J., et al (2022). Ankle fractures. Stat Pearls. https://www.statpearls.com/articlelibrary/viewarticle/17597/Links to an external site.
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Question Description
Discussion: Assessing Musculoskeletal Pain
Photo Credit: Getty Images/Fotosearch RF
The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To prepare:
By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
Review the following case studies:
Case 1: Back Pain
Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
With regard to the case study you were assigned:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Note: Before you submit your initial post, replace the subject line (“Discussion – Week 8”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
By Day 3 of Week 8
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
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