Download Wisconsin Board Review Course in Geriatric Medicine

Approach to upper limb pain
By : S. Khosrawi M.D. , Physiatrist
Dept. of Physical Medicine &Rehabilitation
Faculty of Medicine
Isfahan Univ. of Med. Sci.
• Upper extremity pain is a leading cause of physician visits
particularly in sports and the workplace, contributing
significantly to disability and lost productivity.
• This seminar describes some of the more common causes
of upper limb pain , identifies potential mechanisms of
injuries , and present some remedies for successful
rehabilitation.
Consider:
Nonmusculoskeletal problems may present
with musculoskeletal symptoms
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Hypo(er)thyroidism
Paraneoplastic
Lyme
Acute/subacute BE
Hepatitis C (cryoglobulinemia)
Question?
Peri-articular
◦ Anatomic region
◦ Tendons, bursae,
muscles, nerves
Vs.
Articular
Dysfunction?
◦ Joint swelling
◦ Joint abnormality
Question?
Inflammatory
Vs.
Degenerative
Problems?
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Fatigue
Fever
Rash
Anemia
Inc ESR/CRP
Morning Stiffness
Weight loss
Raynaud’s
phenomenon
Instrinsic Causes :
Extrinsic Causes :
Periarticular Disorders
Regional Disorders
Tendinitis
Impingement syndrome
Calcific tendinitis
Tearings
Acute strain
Bursitis
Myofascial Trigger Points
Articular Disorders
Inflammatory arthritis
Osteoarthritis
Osteonecrosis
Septic arthritis
Adhesive capsulitis
Joint instability
Cervical radiculopathy
Brachial neuritis
Nerve entrapment syndromes
Reflex sympathetic dystrophy
Fibrositis
Neoplasms
Miscellaneous
Gallbladder disease
Splenic trauma
Subphrenic abscess
Myocardial infarction
Thyroid disease
Diabetes mellitus
Renal osteodystrophy
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Along the spectrum of potential
conditions, musculoskeletal soft-tissue
injuries are the most common.
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A detailed understanding of the relevant
functional anatomy and potential
mechanisms of injury allows for the most
accurate diagnosis and is directly related
to the likelihood of successful treatment.
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The soft tissues constitute a diverse group of
connective tissues, including ligament, tendon,
muscle, cartilage, fascia, synovium, articular
cartilage, adipose tissue, and intervertebral disc.
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There are numerous factors influencing the
integrity of soft tissues, including age, sex,
temperature, body weight, exercise, nutrition,
drugs, immobilization, injury, and systemic
illnesses such as inflammatory arthritis and the
collagen vascular disorders.
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The most common mechanisms of injury include
acute trauma and repetitive overuse or overload.
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Musculotendinous structures are especially
vulnerable to failure from sudden overloading, as
with forceful muscular contractions, particularly
when weakened as a result of concurrent illness
(connective tissue disorders) or medications
(steroids).
Ligament Sprains
Grade
Signs and Symptoms
Functional Implications
First degree
(Mild sprains)
Minimal pain and swelling
No ligamentous instability
Minimal localized tenderness
No significant loss of function
Bracing often unnecessary
Rapid return to activity
Second degree
(partial rupture)
Significant pain and swelling
Subtle structural instability
Occasional joint effusion
Protective bracing indicated
Significant activity limitations
Susceptible to recurrence
Functional recovery within 4 to
6 weeks
Third degree
Marked swelling and hemarthrosis
Structural instability
Immobilization indicated
Surgery may be required
Prolonged functional limitation
Tendon Injuries
Injury
Characteristics
Paratenonitis
or/tenosynovitis
Inflammation of the paratenon with associated pain, swelling, and
tenderness
Tendinitis
Inflammation of the tendon with associated vascular disruption and
inflammation
Tendinosis
Intratendinous atrophy and degeneration with a relative absence of
inflammation; a palpable nodule may be present over tendon
Paratenonitis
with tendinosis
Acute inflammation superimposed on chronic tendinitis
Partial or
Acute inflammation is often superimposed on chronic inflammation with
complete rupture tendinosis
 Muscular injuries are particularly common in sports.
These are typically classified as contusions, strains,
avulsions, and delayed-onset muscle soreness.
 Contusions result as a direct blow and are graded as
mild, moderate, or severe based on the degree of softtissue swelling, motion restriction, and functional
impairment.
 Intramuscular contusions tend to be more severe,
resolve slowly, have more extensive scarring and are
susceptible to developing myositis ossificans
 Muscular strains result from overstretching or peak
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contraction of the musculotendinous unit, particularly during
eccentric muscular contractions.
These injuries tend to occur more commonly at the
musculotendinous junction.
The classification is similar to that of muscular contusions.
Contractile forces begin to recover as soon as 1 week after an
acute strain; however, there is often prolonged and sometimes
permanent loss of complete contractile ability .
Therefore, the functional ability of a patient recovering from a
muscular strain may be significantly limited, and premature
return to activity may increase the risk for further injury.
 Delayed-onset muscle soreness typically
occurs within the first 24 to 48 hours after an
intense bout of exercise that often involves
repeated eccentric muscular contractions.
 Both inflammatory and metabolic
mechanisms have been proposed for muscle
damage in this condition .
 In most cases, the condition is self-limiting
but occasionally requires activity modification
and antiinflammatory medication.
 It is useful to approach the treatment and
rehabilitation of soft-tissue injuries through a
conceptual framework that begins with
establishing the most anatomically correct
diagnosis and ultimately returns the patient to
normal athletic or occupational performance.
 Protecting the injured site and controlling pain
and inflammation set the stage for an active
therapy program toward improving the
flexibility, strength, and endurance of the
damaged tissue.
Major Goals of Treatment in
Musculoskeletal Problems
Relieve Pain
Maximize Function