Feb 23, 2024 NURS 6512 Assessing Musculoskeletal Pain
NURS 6512 Assessing Musculoskeletal Pain
NURS 6512 Assessing Musculoskeletal Pain
I enjoyed reading your post; however, there could be a few more possible considerations for the patient’s complaint and symptoms presented with the visit, such as peroneal tendon subluxation. The gradual onset pain is usually in the outer part of the ankle or just behind the fibula. Swelling with palpable fluid in the tendon sheath with crepitation (Walt, 2022). The patient may report that the ankle gives away as well as a click feel as the patient moves in the ankle should alert the clinician to the possibility of peroneal tendon subluxation. (Walt, 2022). The peroneal tendon is the primary location for tenderness.
A popping and clicking sound on the outer side of the ankle may be present. Dorsiflexion and eversion of the foot against resistance can be used to test for peroneal tendon subluxation. The ankle may feel as if it is unstable, and sometimes, the patient will be able to demonstrate the subluxation of the tendon. The fleck sign is also an indication of peroneal tendon subluxation. Peroneal tendon subluxation usually occurs more in younger individuals and usually is a sports-related injury, such as in soccer and skiing (Chauhan & Miller, 2017)
During ROM, palpation of the ankle tendons and evaluation of hindfoot biomechanics, such as varus and valgus alignment, should occur with the patient standing. To assess ankle ligamentous stability ankle drawer test should be done. Laying prone with a knee to 90 degrees flexion and examine for the peroneal tendon. An MRI or ultrasound is beneficial in visualizing this condition of the peroneal tendons and assessing the position of the superior perennial retinaculum and if the tendons are subluxated or not tendon has tares or not (Walt, 2022). The click, weakness, and pain in the ankle warrant testing and consideration for peroneal tendon subluxation. This common injury in sports such as soccer is considered a differential diagnosis(Chauhan & Miller, 2017).
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References :
Chauhan, Y., & Miller,, J. R. (2017, October). How To Diagnose And Treat Subluxing Peroneal Tendons In The Athlete. Hmpgloballearningnetwork.com. Retrieved April 21, 2023, from https://www.hmpgloballearningnetwork.com/site/podiatry/how-diagnose-and-treat-subluxing-peroneal-tendons-athlete
Walt, J. (2022, May 29). Peroneal tendon syndromes. StatPearls. Retrieved April 21, 2023, from https://www.statpearls.com/ArticleLibrary/viewarticle/27040
Week 8: Assessment of the Musculoskeletal System
agree with the diagnosis of Osgood-Schlatter disease and Patellar tendinitis.
Osgood-Schlatter disease is one of the most common conditions in adolescent males. It consists of painful swelling on the anterior portion of the tibial tubercle (Dains et al., 2019). I t usually caused by the strenuous activity of the quadriceps muscles, and the pain increases with activity. It causes the person to limp. When the person is examined, a provider will notice a warm, swollen, tender tibial tubercle, and flexion and extension will increase the intensity of the pain (Dains et al., 2019).
Patellar tendinitis of the jumper’s knee is an overuse syndrome where the knee joint has inflammation and is common in athletes or people who regularly jump or run (Dains et al., 2019. These sports place excessive strain on the athlete’s knees causing complaining of dull, achy knee pain that is associated with clicking or popping (Dains et al., 2019)
Other diagnoses I would choose are:
Chondromalacia patella is a condition with a change in the patellofemoral joint cartilage that results in anterior knee pain. The disease can be caused by trauma, anatomic anomalies, and misalignment of the patella. Patients often complain that knee pain is worst while exerting themselves physically (Dains et al., 2019).
Baker cyst. A popliteal cyst is found when fluid from the patient’s knee joint enters the bursa and cannot escape causing pain and swelling (Dains et al., 2019).
Medial Collateral Ligament (MCL) Sprain. It is an injury that is the result of valgus stress to the knee. Upon examination of the injured knee, mild effusion and tenderness are present (Dains et al., 2019).
My diagnostic tests would include the following:
Ultrasound because it is effective in finding joint effusion, cartilage defects and quadriceps tendinopathy with accuracy as high as 85% (Basha et al., 2020).
X-ray since it is simple and readily available to diagnose musculoskeletal complaints.
MRI provides better soft tissue contrast than CT and can differentiate better between fat, water, muscle, and other soft tissue than CT ( Food and Drug Administration (Food and Drug Administration (FDA), 2017). MRI is useful in evaluating soft tissue detail, such as disk herniation, tumors, and spinal cord pathologies (Dains et al., 2019).
The McMurray test is helpful in diagnosing a torn meniscus. The patient lies supine and flexes their knee; the provider holds the knee in one hand and the heel in the other and rotates the foot/knee outward (laterally); any palpable or audible clicks are positive signs of a torn meniscus (Ball et al., 2019).
The bulge sign is another proper examination technique for determining if excess fluid is present in the knee. The patient extends their knee, and the provider milks the medial portion of the knee upwards 2-3 times, followed by milking the lateral portion of the patella; a positive sign will be if a bulge of fluid returns to the hollow area located medial to the patella (Ball et al., 2019).
References
Basha, M., Eldib, D., Aly, S., Azmy, T., Mahmoud, N., Ghandour, T. Aly, T., Mostafa, S., Elaidy, A., &
Algazzar, H. (2020). Diagnostic accuracy of ultrasonography in the assessment of anterior knee pain.
Insights into Imaging, 11(1), 1–13. https://doi-org.ezp.waldenulibrary.org/10.1186/s13244-020-00914-2
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to
physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mos
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical
diagnosis in primary care (6th ed.). St. Louis,MO: Elsevier Mosby. Basha,
Food and Drug Administration. (2017). Magnetic Resonance Imaging (MRI) Benefits and Risks. Retrieved
January 19, 2023 from fda.gov/radiation-emitting-products/MRI-magnetic-resonance-
imaging/benefits-and-risks
Case Study 2
Patient name: Angel Rodriguez Age: 46 Gender: Female Ethnicity: Hispanic
Angel Rodriguez is a 46-year-old Hispanic female with complaints of pain in both of her ankles, but more pain and concern about the right ankle. She heard a “pop” when she was playing soccer this past weekend. She has the ability to bear weight, but expresses some discomfort.
SUBJECTIVE DATA:
Chief Complaint (CC): “I have pain in both my ankles, but more in the right.”
History of Present Illness (HPI): AR is a 46 years-old-female who presents to the clinic for bilateral
NURS 6512 Assessing Musculoskeletal Pain
ankle pain for 3 days. The pain started after she was playing soccer over the weekend and noticed a “pop” sound while playing. She reports the pain as “throbbing, sore, and sharp.” She can bear weight on both ankles but the pain is worse on the right. Her pain is a 6/10 on the severity scale. The pain increases to a 9/10 on the right ankle when ambulating or standing for an extended amount of time. AR has been elevating her ankles on pillows and applied heat and ice packs with no relief. She reports her right ankle is swollen and tender to touch. Currently her pain is 3/10 on the left ankle and 8/10 on the right ankle.
Current Medications
Multivitamin PO daily- name unknown
Ibuprofen 800 mg Q6 PRN for pain
Tylenol 650 mg Q6 PRN for pain
Allergies:
No drug, food, seasonal, or animal allergies.
Past Medical History (PMH): No recent hospitalizations were reported. Broke left wrist in May 2015. Osteoporosis at age 45.
Past Surgical History (PSH): No surgery history.
Sexual/Reproductive History: Last menstrual cycle was 3 weeks ago. Engaged to fiance for 8 months. Fiance is AR’s only sexual partner.
Personal/Social History: AR’s occupation is a Recreational Therapist at University of Chapel Hill (UNC)- Nash for 5 years. Her fiance and her own their home for the past year. They only share their home with 2 dogs. Rodriguez enjoys playing soccer, reading, shopping, and volunteering at her neighborhood garden. She drinks 2-3 glasses of wine every weekend. She denies smoking tobacco/vapes and illicit street drugs.
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Immunization History:
Influenza: 09/13/2022. 46 years old.
Hep B: 3 dose series completed at 6 months old.
Hep A: 2 dose series completed at 15 months old.
Pneumococcal: 4 dose series completed at 15 months old.
DTaP: 5 dose series completed at 6 months old.
MMR: 2 dose series completed at 6 months old.
Varicella: 2 dose series completed at 6 months old.
Polio: 4 dose series completed at 7 months old.
Significant Family History:
Mother- age 76, DM2, HTN, HLD,
Father- age 74- tobacco smoker, HTN, COPD
Maternal Grand-mother- deceased- age 88- CVA
Maternal Grand-father- deceased- age 86- MI, tobacco smoker, COPD, HTN
Paternal Grand-mother- age 87- HTN
Paternal Grandfather- deceased- age 85- CVA
ROS:
General:Reports feeling fatigued and “extra tired” from ambulating/bearing weight on her ankles. Reports lack of sleep due to pain.
HEENT:
Head:No headaches reported. Denies dizziness.
Eyes:Denies problems with eyes. Denies eye itching, redness, watery or pain. Does wear reading eyeglasses.
Ears: No history of frequent ear infections. Denies ear surgery history. Denies
ear pain, no swelling or drainage from bilateral ears. Denies hearing difficulties. Denies ear popping.
Nose:Denies runny nose, bleeding, or pain. Denies sinus pain.
Throat:Denies sore throat pain and coughing every few minutes. Denies discolored sputum.
Cardiovascular:Denies chest pain, tightness, and palpitations
Respiratory:Denies shortness of breath, wheezing, and cough.
Musculoskeletal:Denies history of arthritis, limited range of motion. Positive for right ankle swelling, tenderness to touch, pain 9/10. Left ankle full range of motion, no signs of swelling or tenderness, pain 3/10.
Objective:
VS: B/P:120/84 T-98.7 F P-80 R-20 SPO2 -100%RA
Weight: 200 lbs.
Height: 5’ 8’’ ft
General: AAOx4, cooperative, calm, appropriate to age. Able to answer all questions
appropriately. Appears fatigued and grimaces facial expressions.
HEENT:
Head: Normal size and shape, hair evenly distributed, no masses.
Cardiovascular/ Peripheral Vascular: S1 and S2 heard on auscultation, no murmurs or extra heart sounds. Right ankle with ecchymosis. edema, tender, and warm to touch. Left ankle no
edema or ecchymosis. Bilateral posterior tibial pulses 2+ No thrill. Bilateral dorsalis pedis 2+ pulses no thrill. Capillary refills in digits and phalanges less than 3 seconds.
Respiratory: Clear breath sounds present in all lung fields. No shortness of breath observed. No posterior/anterior masses, bulges, or crepitus felt on palpation. No adventitious breath sounds on auscultation.
Skin: No lesions, bruises, or bumps. Ecchymosis noted on the right ankle.
Muskuloskeletal: Right ankle edema with 4X4 cm ecchymosis on mid-lateral malleolus area with tenderness upon palpation on the lateral side. Active range of motion with pain bilateral ankles and limitation with dorsiflexion, plantar flexion, and inversion. Positive pain on rotation of ankles bilaterally with worsen pain on right. No bony tenderness, deformity, or crepitus.
Diagnostic Results
X-Ray: Internal/external rotation of bilateral ankles
Anterior/posterior drawing test: applied to assess the integrity of ATFL as it prevents anterior translation of the talus under the distal tibia. Ten millimeters of displacement in the injured ankle or more than 3-4 mm of difference in translation compared with the healthy side indicate an ATFL tear.In an ATFL tear, a dimple sign may also be visible in the anterior side of the joint in 50% of cases anterior and posterior cruciate ligament integrity (Halabchi & Hassabi, 2020)
Talar tilt test: evaluates the integrity of the CFL. In this test, the angle between the talar dome and the tibial plafond is measured during forced heel inversion while the tibiotalar joint is in the neutral position. If there is more than 5° of difference with the normal side, the test is considered positive (Halabchi & Hassabi, 2020)
ASSESSMENT
Angel is having persistent pain in bilateral ankles, more in right than left. With her past medical history of fractured left wrist, there could be an underlying etiology that needs short- term treatment and follow up appointments. With Angel working as a Recreational Therapist and playing soccer for leisure, she is up on her feet the majority of the time. Therefore, diagnosing and treating Angel’s chief complaint is crucial.
Differential Diagnoses:
Ankle fracture- Can be a partial or complete break in the bone. Most likely caused by direct or indirect trauma. Patients can complain of being unable to bear weight at all for extended periods of time, swelling, pain, and limited movement. Felt a “pop” or “snap” with injury (Ball et al., 2019). Site appears swollen, deformity, tender to touch, or deformity.
Ankle sprain- Acute ankle sprains are one of the most common musculoskeletal injuries and have a particularly high incidence among physically active individuals (Herzog, 2019). They are most common in athletes. In a typical lateral ankle sprain, ecchymosis and tenderness are located over the ATFL and calcaneofibular (CFL) ligaments (Halabchi & Hassabi, 2020).
Tenosynovitis (Tendonitis) –Inflammation of the synovial-lined sheath/affected tendon. Patients can complain of pain, especially with movement. The patient can point to the involved tendon. Pain with active movement and some limitation of movement in the affected joint (Ball et al., 2019).
Anterior Ankle Impingement-ankle pain that is caused from consistent dorsiflexion (Tausen et al., 2014). The symptoms of anterior ankle impingement are instability, limited range of motion of the ankle, and pain with any movements (Tausen et al., 2014)
Osteoarthritis- deterioration of the articular cartilage covering the end of synovial joints. Onset begins at age 40 and further develops with age. The joints may be enlarged and painful range of motion (Ball et al., 2019).
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World journal of orthopedics, 11(12), 534.
Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 603-610.
Tausen, P., Toy, J., Perez, J. L., Milewski, M. D., & Reach, Jr, J. S. (2014). Anterior ankle impingement: Diagnosis and treatment.
Journal of the American Academy of Orthopaedic Surgeons, 22(5), 333. Retrieved from https://doi-org.ezp.waldenulibrary.org/10.5435/JAAOS-22-05-333.
Thank you for sharing your discussion with us. Your assessment and outlining of the patient’s signs and symptoms indicate an assessment of patellar tendinitis. This is the most likely diagnosis for the patient based on the patient’s history of being an athlete and prior involvement in long jumping, which could have put excessive and repetitive strain on the knee and led to inflammation. Additionally, jumps and movements from basketball could also put additional stress on the knee resulting in pain complaints.
Bursitis is also a condition secondary to tendinitis that has a similar presentation to that of the patient and is associated with overuse and trauma, leading to inflammation (Dains et al., 2019). It, therefore, is an appropriate diagnosis to examine and assess the patient to provide appropriate treatment. It is important to include it as a differential diagnosis as the location of the inflammation can differ. Therefore, treatment can be specifically directed to the inflamed location once a diagnosis is confirmed or ruled out.
The diagnosis that is least likely for the patient from the assessment would be juvenile arthritis (JA). While JA is also an inflammation of the joint that can present as pain, the characteristics of the presenting complaint are not in line with the patient’s presentation. According to Dains et al.(2019), JA can also present with fatigue, low-grade fever, and weight loss. As outlined in your discussion, the patient does not present with these findings. The diagnosis is further less likely due to the differences in aggravation of symptoms. The patient reports worsening pain with intensive training, and after playing in games while in JA, the pain and stiffness are mostly noted in the night and morning and get better with activity. Swelling at the joint is also a common factor and was not present in this patient. JA is, therefore, the least likely assessment for this patient and the differential diagnosis I would reject.
The patient’s history of sporting activity and athletic training does justify the inclusion of chondromalacia of the patella as a differential diagnosis. According to Habusta et al.(2022), patients with chondromalacia patella do present with pain as the most common presentation and is frequently seen in patients that experience post-traumatic injuries, wear and tear to the hyaline cartilage. The pain worsens with activities that increase stress on the patellofemoral joint, such as running and jumping, as outlined by the patient. Pain is a common symptom for most musculoskeletal conditions; therefore, it’s important to perform tests and diagnostics to rule out the possible cause of the pain to prevent misdiagnosis. Additionally, including the chondromalacia patella is important as it is sometimes diagnosed via the method of elimination.
References
Dains, J., Baumann, L., & Scheibel, P. (2019). Advanced health assessment & clinical diagnosis in primary care (6th ed.). St. Louis MO: Elsevier Mosby.
Habusta, S., Coffey, R., Ponnarasu, S., Mabrouk, A., & Griffin, E. (2022). Chondromalacia patella. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459195/
Response
Hello Ashley! This is an in-depth and compelling post about assessment of the musculoskeletal system. I agree with you that due to the patient’s past medical history of fractured left wrist, there could be an underlying etiology that needs short- term treatment and follow up appointments. There are various diagnostic tests that can further be performed on this patient. Blood tests can be done to establish whether or not there are underlying infections or conditions that trigger pain in patient (Chisari & Parvizi, 2020).
Electromyography (EMG) can also be conducted to study nerves and gauge the electrical impulses produced by the nerve and muscles. EMG can validate nerve compression linked to constricted spinal canal or herniated disks. CT scans or MRI can also be conducted to produce images that may show problems in the blood vessels, nerves, bones, tendons, muscles, and nerves (Guo et al., 2019). On the other hand, this patient should also be given dietary and physical activity education to help in addressing weight and reduction of weight at the ankles.
References
Chisari, E., & Parvizi, J. (2020). Accuracy of blood-tests and synovial fluid-tests in the diagnosis of periprosthetic joint infections. Expert Review of Anti-infective Therapy, 18(11), 1135-1142. https://doi.org/10.1080/14787210.2020.1792771
Guo, S., Yan, Y. Y., Lee, S. S. Y., & Tan, T. J. (2019). Accessory ossicles of the foot—an imaging conundrum. Emergency Radiology, 26(4), 465-478. https://doi.org/10.1007/s10140-019-01688-x
A 15-year-old Caucasian male Justin Timberland presents to the clinic with reports of dull pain in both knees. He states sometimes one or both knees click, and he describes a catching sensation under the patella.
To start assessing my patient’s knee pain, I’ll approach the interview with “a useful framework to differentiate whether the limb pain involves symptoms caused by musculoskeletal injury, musculoskeletal or joint disease, systemic disease, or a combination of factors.” Pain can be caused by a direct reaction in tissues, a secondary reaction in adjacent tissues, a proximal or distal lesion, or organs such as the heart or kidney.” (Dains,2019.p.1.) .
Knowing this, I decided to begin with a Focused history, in which I would ask the patient questions such as, does he have any of the common childhood bone diseases that would make him prone to bone injury or pain, i.e. Osteogenesis Imperfecta, also known as brittle bone disease, as it is usually diagnosed at birth as a bone is broken during the delivery process, from the fetus traveling down the bony structures of the birth canal? I’ll then ask him if the pain is the result of an injury. If it was an injury, how did it happen? Is this a new injury, or is it a recurrence of an old one? Finally, I’ll ask him to rate his pain on a scale of 0 to 10, with 0 being the least pain and 10 being the most pain.
Chief Concern (CC): I’ve been having dull pain in both of my knees, and I have also noticed that my knee and sometimes both of them click.”
History of Physical Illness (HPI): 15-year-old male patient presents today with a history of dull pain in both knees. The patient is concerned that one or both knees intermittently click, and he feels something catch below the patella (Walden University, n.d.).
Additional History Needed to Determine Cause of Knee Pain:
As a future APRN, it would be important to know if the patient’s pain is acute or chronic. I would use a mnemonic, such as OLDCARTS, to guide me as I interview the patient (Ball et al., 2019). Questions that I would want to know from the patient would include: Does the clicking sound occur with knee movement? How often does the clicking sound occur? Has the patient sustained any recent injuries? I would be interested to know what makes the pain worse and better. Additionally, I want to know the treatments the patient has used for his knee pain (e.g., rest, ice [or heat], elevate, immobilize, non-steroid inflammatory drugs, or acetaminophen). I would conduct the interview with the parent or caregiver out of the room, and then with the patient’s permission, ask the parent for more information.
Categories to Differentiate Knee Pain:
There are different categories to differentiate knee pain: bones, cartilage, ligaments, muscles, and tendons (National Institute of Arthritis and Musculoskeletal and Skin Diseases [NIAMS], n.d.). Each of these categories has conditions with clinical presentations, such as arthritis (bones and cartilage), chondromalacia and meniscus injury (cartilage), anterior and posterior cruciate ligaments injuries (ligament), tendinitis (tendon), and more (NIAMS).
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