Feb 23, 2024 NURS 6512 Discussion Assessing Musculoskeletal Pain
NURS 6512 Discussion Assessing Musculoskeletal Pain
NURS 6512 Discussion 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
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.
I 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
NURS 6512 Discussion Assessing Musculoskeletal Pain
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
Subjective
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).
Medications:
Name, dosage, frequency, indication for taking medication, and last dosage should be noted.
Medications should include prescribed, over the counter, vitamins, minerals, supplements, and complementary alternative medications (Ball et al., 2019).
Past Medical History (PMH):
Recent trauma
Cancer
Connective tissue disorders (e.g., Marfan’s syndrome)
Juvenile Rheumatoid Arthritis
Hemophilia
Osteoporosis
Renal
Neuromuscular disorders
Neurological disorders
Past Surgical History (PSH):
Orthopedic surgeries or procedures, such as arthroplasty
Family History [FH]: (Ball et al., 2019)
Arthritis
Abnormalities of the hips, knees, or feet
Osteogenesis imperfecta
Hypophosphatemia
Hypercalciuria
Marfan’s Syndrome
Social History (SH)
Information needs to be collected regarding the patient’s usage of tobacco products, alcohol, or illicit drugs. It is essential to get a baseline assessment of the patient’s usual activity of daily living. Is the patient involved in organized sports (e.g., soccer, football, baseball, basketball, martial arts)? I would also gather information about the patient’s average diet, including a balanced diet with protein and nutrients to help heal his condition.
Allergies:
Allergies to prescribed medications, over-the-counter medications, vitamins, minerals, and supplements should be noted with the type of reaction and severity.
Immunizations:
Review of current immunizations that should include last T-dap, Influenza, and COVID-19 boosters, and vaccines.
Review of Systems (ROS)
General
Recent fatigue, malaise, fever, chills, night sweats, unusual bruising, unusual bleeding, and unintentional weight loss will need to be asked of the patient.
Cardiovascular:
Inspection, percussion, palpation, and auscultation of the heart are part of all focused episodic exam.
Pulmonary:
Inspection, percussion, palpation, and auscultation of the lungs are also part of a focused episodic exams.
Musculoskeletal:
Inspection, percussion, palpation, and auscultation of both knees will be performed.
Physical Examination Performed (Ball et al., 2019)
Inspect knees for symmetry, concavity, and contour in the flexed and extended positions.
Observe the patient’s lower legs for alignment, specifically the femur and tibial angle should be at or less than 15 degrees to rule out either genu valgum or genu varum.
Palpate popliteal and joint space in the flexed and extended positions.
Test the patient’s range of motion (e.g., flexion-130 degrees, extension-0 to 15 degrees).
Test the patient’s strength during flexion and extension while providing oppositional force against movement.
Anatomic Structures Being Assessed (Ball et al., 2019)
Patella
Meniscus
Anterior and Posterior Cruciate Ligaments
Lateral and Medial Ligaments
Special Maneuvers Performed (Lee et al., 2017; Ball et al., 2019)
Hughston’s Plica Test
Strutter Test
Ballottement test
Bulge test
McMurray Test
Apley Test
Thessaly Test
Anterior and Posterior Drawer Test
Lachman Test
Varus and Valgus Stress Tests
Objective
Vital Signs: (VS) height, weight, body/mass index (BMI), or vital signs
General: patient’s race, patient’s preference for gender identity will be ascertained.
Cardiovascular: The patient’s heart sounds (e.g., nl S1, nl S2, S3, S4), murmurs (e.g., type and location), adventitious sounds, clubbed fingers, capillary refill, jugular vein distension, carotid bruits or thrills, pedal edema would be noted in this section.
Pulmonary: Breath sounds in all areas of the anterior and posterior lungs (e.g., bronchial, bronchovesicular, vesicular, dull, resonant, and hyper-resonant) would be noted.
Musculoskeletal- symmetry, skin condition (e.g., bruising), swelling, pain with range of motion, and effusion around knee should be noted.
Diagnostic Tests:
Radiograph of knees would be indicated this patient if it was determined his condition was secondary to an acute knee injury with the following findings: tenderness at fibula head, patella tenderness that is isolated, and the inability of the patient to flex his knee at a 90-degree angle (Ball et al., 2019). The patient has bilateral knee pain, which decreases the probability of malignancy; however, I would consult with my preceptor regarding ordering X-rays of his knees to rule out bony pathology.
An MRI may be indicated if the patient has an injury to the medial or lateral meniscus and to the anterior or posterior cruciate ligaments (Rastegar et al., 2016). I would consult with my preceptor if the patient had a positive McMurray test before ordering an MRI. Additionally, if the patient’s symptoms did not improve with therapy, I would again consult with my preceptor about ordering an MRI for this patient.
CBC with differential-if indicated depending on the patient’s H&P (Thatayatikom, 2021).
Sedimentation rate-if indicated depending on the patient’s H&P (Thatayatikom, 2021).
Anti-nuclear antibody test- if indicated depending on the patient’s H&P (Thatayatikom, 2021).
Rheumatoid factor- if indicated depending on the patient H&P’s (Thatayatikom, 2021).
Assessment
Differential Diagnosis according to Song et al. (2018); Lee et al. (2017):
Synovial Infrapatellar Plica Syndrome of the knee is associated with anterior knee pain and clicking or popping sounds (Casadei & Kiel, 2021). The authors report that plica, a thick fibrotic band of tissue extending from a synovial joint, most commonly the knee[s] becomes inflamed due to overuse. Bilateral anterior knee pain is common. This patient has clicking sounds with pain around the knees. This diagnosis needs to be supported by more evidence from the history and physical of the patient.
Medial or Lateral Meniscal Tears are associated with knee sounds such as clicking, catching, and locking around the knee (Bhan, 2020). The author reports meniscal tears are common, and MRIs are inevitably required to confirm a diagnosis. This patient has bilateral clicking noise and a sensation of catching to the back of his knees.
Patellar Tendinopathy, commonly referred to as ‘Jumpers Knee’ is caused by small tears to the patella tendon that can be painful (Santana et al., 2021). The authors note this condition is seen with sporting activities that require jumping. The patient is complaining of dull pain in both knees. It is essential to gather more subjective and objective data from this patient and possibly his parents for an accurate working diagnosis.
Patellofemoral pain syndrome is characterized by anterior knee pain reproduced with running, climbing, and squatting (Bump & Lewis, 2021). The authors report patients generally describe an achy pain located around the knee. This diagnosis is part of the differential because the patient is experiencing pain around the knee. However, more information is required to give a presumptive diagnosis.
Anterior Cruciate Ligament Sprain or Tear is considered the most common injury to a knee ligament associated with sporting activities such as football, soccer, and basketball (Evans & Nielson, 2021). The authors state that the injury sustained to the ACL is most commonly a non-contact injury seen with skiers, soccer players, and basketball players from rotational movements. Patients generally complain of a popping sound and the knee giving out (Evans & Nielson). The patient is not complaining of a popping sound but rather a clicking sound with a catching sensation under the patella. This diagnosis is less likely because of the patient’s clinical presentation.
Juvenile Rheumatoid Arthritis (JRA) is diagnosed in patients younger than 16 years of age with joint and soft tissue pain (Thatayatikom, & Modica, 2021). An inflammatory, autoimmune process must be considered, especially if there is a family history of autoimmune disorders.
Osteochondrosis is also known as Osgood Schlatter disease, is a frequent cause of adolescent knee pain (Smith & Varacallo, 2020). The authors state it is caused by repetitive athletic movements seen more often in boys 12 to 14 years of age. They report that patients complain of anterior knee pain caused by microvascular tears and swelling when a piece of the tendon pulls away from the patella (NIAMS, n.d.). This diagnosis is less likely because the patient is complaining of dull bilateral pain to the knees, and he is not complaining of a bony bump to his kneecap, which is common with this disorder.
Primary Diagnosis/Presumptive Diagnosis
Synovial Infrapatellar Plica Syndrome.
Plan
This section is not required for the assignment in this course (NURS 6512) but will be required for future courses.
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.). Elsevier.
Bhan, K. (2020). Meniscal tears: Current understanding, diagnosis, and management. Cureus,
12(6), e8590. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359983/
Bump, J.M., & Lewis, L. (2021, May 8). Patellofemoral syndrome. In: StatPearls. StatPearls
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