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Common Musculoskeletal Problems Depression Although symptoms of anticipatory grief are common at the ¢ Pharmacologic therapy for constipation includes end of life, clinical depression is not experienced by most osmotic laxatives, such as polyethylene glycol, often in patients and should not be expected. Clinical depression wors- combination with a stimulant laxative, such as senna or ens quality of life and, if present, should be treated aggressively. bisacodyl. In contrast to neurovegetative symptoms that accompany ter- e Enteral or parenteral artificial nutritional support at the HVC minal illness (e.g., poor appetite, low energy), symptoms of end of life does not improve survival; is invasive; and unrelenting helplessness, hopelessness, and lack of pleasure can cause side effects, such as increased respiratory should raise concerns for depression. secretions and uncomfortable edema. Depression in terminally ill patients responds well to both pharmacologic and nonpharmacologic treatments, including * Clinical depression should not be expected in patients psychotherapy. Pharmacotherapy consists of antidepressant at the end of life and should be aggressively treated if agents that are appropriate for the patient’s estimated progno- present; pharmacotherapy consists of antidepressant sis. Selective serotonin reuptake inhibitors are effective and agents that are appropriate for the patient’s estimated safe in patients with end-organ dysfunction; however, their prognosis.

agents that are appropriate for the patient’s estimated progno- present; pharmacotherapy consists of antidepressant sis. Selective serotonin reuptake inhibitors are effective and agents that are appropriate for the patient’s estimated safe in patients with end-organ dysfunction; however, their prognosis. therapeutic effects may not be reached for several weeks. In patients with an estimated life expectancy of less than 6 weeks, psychostimulants, such as methylphenidate, are favored. Hospice Hospice is a form of palliative medicine that provides special- Anxiety ized interdisciplinary care to patients with life-limiting illness Anxiety isa common symptom in patients receiving palliative care, for whom disease-directed treatments are no longer effective often coexisting with depression. Potential triggers include exis- or desired. Hospice care is appropriate for patients with a life tential fears, the uncertainty inherent to the dying process, difficult expectancy of 6 months or less, if the disease takes its natural decisions, concern for loved ones, and financial issues. Some treat- course.

therapeutic effects may not be reached for several weeks. In patients with an estimated life expectancy of less than 6 weeks, psychostimulants, such as methylphenidate, are favored. Hospice Hospice is a form of palliative medicine that provides special- Anxiety ized interdisciplinary care to patients with life-limiting illness Anxiety isa common symptom in patients receiving palliative care, for whom disease-directed treatments are no longer effective often coexisting with depression. Potential triggers include exis- or desired. Hospice care is appropriate for patients with a life tential fears, the uncertainty inherent to the dying process, difficult expectancy of 6 months or less, if the disease takes its natural decisions, concern for loved ones, and financial issues. Some treat- course. ments, including hormone therapy, may also induce anxiety. Hospice can be provided in multiple settings, including Management includes nonpharmacologic means, includ- the home, skilled nursing facilities, and residential hospice ing social support, relaxation therapy, exercise, mindfulness homes. Hospice team members include physicians, advance meditation, and psychotherapy. Pharmacologic treatment practice clinicians, nurses, social workers, pharmacists, chap- with benzodiazepines may be appropriate, although close lains, and other providers whose goals are to maximize quality monitoring for adverse events, including delirium, is neces- of life for patients with advanced or terminal illness who are sary. Selective serotonin reuptake inhibitors can be helpful in no longer receiving life-prolonging treatment. Hospice teams patients with coexisting depression and anxiety. are associated with improved overall satisfaction with care for

ments, including hormone therapy, may also induce anxiety. Hospice can be provided in multiple settings, including Management includes nonpharmacologic means, includ- the home, skilled nursing facilities, and residential hospice ing social support, relaxation therapy, exercise, mindfulness homes. Hospice team members include physicians, advance meditation, and psychotherapy. Pharmacologic treatment practice clinicians, nurses, social workers, pharmacists, chap- with benzodiazepines may be appropriate, although close lains, and other providers whose goals are to maximize quality monitoring for adverse events, including delirium, is neces- of life for patients with advanced or terminal illness who are sary. Selective serotonin reuptake inhibitors can be helpful in no longer receiving life-prolonging treatment. Hospice teams patients with coexisting depression and anxiety. are associated with improved overall satisfaction with care for patients and caregivers. Delirium Hospice referral should be considered for all patients with Delirium at the end of life has many potentially reversible a limited life expectancy and is not restricted to those at the causes (medication side effects, inadequate analgesia, pain, very end of life. In addition, hospice is not limited to patients urinary retention, constipation), although a cause is often not with cancer; patients with a wide variety of underlying condi- identified. Treatment of reversible conditions and nonphar- tions receive benefit. Unfortunately, despite proven patient macologic interventions, such as maintaining hydration, pro- and caregiver benefits, hospice referrals often occur too late in viding orienting stimuli, and reducing noise, remain standard the disease process, denying patients comprehensive, quality care; however, for some patients, medications may be required care at the end of life. to maintain patient and caregiver safety and to ensure relief from suffering. There is little evidence, however, that antipsy- chotics are effective for this indication or that first-generation antipsychotics, such as haloperidol, are inferior to newer- Common Musculoskeletal generation antipsychotics. The combination of benzodiaz- epines and antipsychotics may be more effective than antipsy- Problems chotics alone in the treatment of delirium at the end of life. Acute Musculoskeletal Pain Acute musculoskeletal pain is caused by various soft tissue ¢ Opioids are the pharmacologic treatment of choice for injuries, strains (injury to a tendon or muscle), and sprains dyspnea in patients with advanced illness; when appro- (injury to a ligament). About 20% of musculoskeletal injuries priately selected and dosed, opioids do not cause respir- are inappropriately treated with opioids, which are associated atory depression or hasten death. with substantial potential harms but little or no benefit and (Continued) risk for longer-term use, addiction, and overdose.

patients and caregivers. Delirium Hospice referral should be considered for all patients with Delirium at the end of life has many potentially reversible a limited life expectancy and is not restricted to those at the causes (medication side effects, inadequate analgesia, pain, very end of life. In addition, hospice is not limited to patients urinary retention, constipation), although a cause is often not with cancer; patients with a wide variety of underlying condi- identified. Treatment of reversible conditions and nonphar- tions receive benefit. Unfortunately, despite proven patient macologic interventions, such as maintaining hydration, pro- and caregiver benefits, hospice referrals often occur too late in viding orienting stimuli, and reducing noise, remain standard the disease process, denying patients comprehensive, quality care; however, for some patients, medications may be required care at the end of life. to maintain patient and caregiver safety and to ensure relief from suffering. There is little evidence, however, that antipsy- chotics are effective for this indication or that first-generation antipsychotics, such as haloperidol, are inferior to newer- Common Musculoskeletal generation antipsychotics. The combination of benzodiaz- epines and antipsychotics may be more effective than antipsy- Problems chotics alone in the treatment of delirium at the end of life. Acute Musculoskeletal Pain Acute musculoskeletal pain is caused by various soft tissue ¢ Opioids are the pharmacologic treatment of choice for injuries, strains (injury to a tendon or muscle), and sprains dyspnea in patients with advanced illness; when appro- (injury to a ligament). About 20% of musculoskeletal injuries priately selected and dosed, opioids do not cause respir- are inappropriately treated with opioids, which are associated atory depression or hasten death. with substantial potential harms but little or no benefit and (Continued) risk for longer-term use, addiction, and overdose. 50

Common Musculoskeletal Problems A 2020 guideline from the American College of Physicians and American Academy of Family Physicians recommends that acute pain (<4 weeks’ duration) from non-low back mus- culoskeletal injuries should be treated with topical NSAIDs with or without menthol gel as first-line therapy. Such treat- ment reduces or relieves symptoms, improves physical func- tion, and improves the patient’s satisfaction with treatment. Dermatologic side effects do not differ significantly between any topical intervention and placebo. Oral NSAIDs or aceta- minophen are recommended as second-line therapies; they have proven ability to improve pain and function (but not patient satisfaction) and are associated with side effects, primarily gastrointestinal. Acupressure and transcutaneous electrical nerve stimulation also are recommended to reduce pain and improve function, on the basis of weaker evidence FIGURE 10. Straight leg raise test. With the patient lying supine on his or her back, the examiner lifts the patient's leg with the knee fully extended on the of efficacy. The American College of Physicians and American affected side (ipsilateral straight leg raise test) and then repeats on the opposite Academy of Family Physicians recommend against the use of side (contralateral straight leg raise test). The result is considered positive when opioids, including tramadol, in the treatment of acute muscu- pain radiates down the leg past the level of the knee when the hip is flexed loskeletal pain. between 30 and 70 degrees.

and American Academy of Family Physicians recommends that acute pain (<4 weeks’ duration) from non-low back mus- culoskeletal injuries should be treated with topical NSAIDs with or without menthol gel as first-line therapy. Such treat- ment reduces or relieves symptoms, improves physical func- tion, and improves the patient’s satisfaction with treatment. Dermatologic side effects do not differ significantly between any topical intervention and placebo. Oral NSAIDs or aceta- minophen are recommended as second-line therapies; they have proven ability to improve pain and function (but not patient satisfaction) and are associated with side effects, primarily gastrointestinal. Acupressure and transcutaneous electrical nerve stimulation also are recommended to reduce pain and improve function, on the basis of weaker evidence FIGURE 10. Straight leg raise test. With the patient lying supine on his or her back, the examiner lifts the patient's leg with the knee fully extended on the of efficacy. The American College of Physicians and American affected side (ipsilateral straight leg raise test) and then repeats on the opposite Academy of Family Physicians recommend against the use of side (contralateral straight leg raise test). The result is considered positive when opioids, including tramadol, in the treatment of acute muscu- pain radiates down the leg past the level of the knee when the hip is flexed loskeletal pain. between 30 and 70 degrees. Reproduced with permission from Moore G. Atlas of the Musculoskeletal Examination. Philadelphia, PA: American College of Physicians; 2003:65. ©2003, American College of Physicians. Low Back Pain Diagnosis and Evaluation Further Diagnostic Testing Low back pain can be classified by duration as acute Clinicians should not routinely perform imaging in patients (<4 weeks), subacute (4-12 weeks), or chronic (>12 weeks). with nonspecific low back pain, particularly within the first Approximately 90% of patients have nonspecific low back 6 weeks of symptoms, because obtaining imaging studies in pain, for which no specific cause can be determined. The most these patients is not associated with improved outcomes. common identifiable causes of low back pain are spinal steno- Notably, imaging abnormalities are common in asymptomatic sis, disk herniation, and compression fractures. Less common individuals and in patients with nonspecific low back identifiable causes include cancer (vertebral metastases) and pain. Their discovery may lead to unhelpful and costly infection (diskitis, osteomyelitis, epidural abscess). Visceral interventions.

Reproduced with permission from Moore G. Atlas of the Musculoskeletal Examination. Philadelphia, PA: American College of Physicians; 2003:65. ©2003, American College of Physicians. Low Back Pain Diagnosis and Evaluation Further Diagnostic Testing Low back pain can be classified by duration as acute Clinicians should not routinely perform imaging in patients (<4 weeks), subacute (4-12 weeks), or chronic (>12 weeks). with nonspecific low back pain, particularly within the first Approximately 90% of patients have nonspecific low back 6 weeks of symptoms, because obtaining imaging studies in pain, for which no specific cause can be determined. The most these patients is not associated with improved outcomes. common identifiable causes of low back pain are spinal steno- Notably, imaging abnormalities are common in asymptomatic sis, disk herniation, and compression fractures. Less common individuals and in patients with nonspecific low back identifiable causes include cancer (vertebral metastases) and pain. Their discovery may lead to unhelpful and costly infection (diskitis, osteomyelitis, epidural abscess). Visceral interventions. disease, such as nephrolithiasis, pyelonephritis, and abdomi- Imaging is clearly indicated when severe or progressive nal aortic aneurysm, may also cause low back pain. neurologic compromise or a life- or function-threatening cause is suspected. Plain radiography can be helpful for the History and Physical Examination initial evaluation of suspected fracture, sacroiliitis, or cancer, Evaluation of patients with low back pain includes a detailed although MRI should be obtained if clinical suspicion remains history directed toward factors that increase the likelihood of high. Measurement of inflammatory markers may be helpful specific causes of pain (Table 33). Psychosocial factors may also for suspected cancer or infection, but normal results do not affect the course of low back pain and should be assessed. rule out their presence. MRI is otherwise the preferred test for Psychosocial distress, comorbid psychiatric conditions, soma- suspected spinal infection, cancer, cord compression, or cauda tization, and maladaptive coping strategies (e.g., avoiding equina syndrome. work) are associated with poor clinical outcomes. Nonurgent imaging may be considered in patients with The physical examination should similarly include a pain persisting for longer than 6 weeks in the absence of red search for evidence of an underlying disorder (see Table 33). flags; persistent or progressive symptoms despite conservative Specific attention should be paid to “red flag” findings on therapies; or neurologic symptoms, such as radiculopathy or examination, including fever and neurologic signs. A thorough neurogenic claudication. Patients who are otherwise unfit for neurologic examination that includes strength, sensory, and invasive procedures, such as surgical laminectomy, are unlikely reflex testing of the legs, in addition to performing both the to benefit from imaging. ipsilateral and contralateral straight leg raise test (Figure 10), can identify patterns of deficits that point to lesions (most Treatment commonly disk herniation) at specific levels (Table 34). Patient education is a key component of the treatment of low Decreased anal sphincter tone and perianal sensation raise back pain regardless of pain duration. Education includes concern for cauda equina syndrome. Many examination find- providing information on the expected course of the back ings, however, are insensitive or nonspecific for the presence pain, promoting self-management, addressing misconcep- of a particular underlying disorder. tions, and encouraging physical activity as appropriate. In all

disease, such as nephrolithiasis, pyelonephritis, and abdomi- Imaging is clearly indicated when severe or progressive nal aortic aneurysm, may also cause low back pain. neurologic compromise or a life- or function-threatening cause is suspected. Plain radiography can be helpful for the History and Physical Examination initial evaluation of suspected fracture, sacroiliitis, or cancer, Evaluation of patients with low back pain includes a detailed although MRI should be obtained if clinical suspicion remains history directed toward factors that increase the likelihood of high. Measurement of inflammatory markers may be helpful specific causes of pain (Table 33). Psychosocial factors may also for suspected cancer or infection, but normal results do not affect the course of low back pain and should be assessed. rule out their presence. MRI is otherwise the preferred test for Psychosocial distress, comorbid psychiatric conditions, soma- suspected spinal infection, cancer, cord compression, or cauda tization, and maladaptive coping strategies (e.g., avoiding equina syndrome. work) are associated with poor clinical outcomes. Nonurgent imaging may be considered in patients with The physical examination should similarly include a pain persisting for longer than 6 weeks in the absence of red search for evidence of an underlying disorder (see Table 33). flags; persistent or progressive symptoms despite conservative Specific attention should be paid to “red flag” findings on therapies; or neurologic symptoms, such as radiculopathy or examination, including fever and neurologic signs. A thorough neurogenic claudication. Patients who are otherwise unfit for neurologic examination that includes strength, sensory, and invasive procedures, such as surgical laminectomy, are unlikely reflex testing of the legs, in addition to performing both the to benefit from imaging. ipsilateral and contralateral straight leg raise test (Figure 10), can identify patterns of deficits that point to lesions (most Treatment commonly disk herniation) at specific levels (Table 34). Patient education is a key component of the treatment of low Decreased anal sphincter tone and perianal sensation raise back pain regardless of pain duration. Education includes concern for cauda equina syndrome. Many examination find- providing information on the expected course of the back ings, however, are insensitive or nonspecific for the presence pain, promoting self-management, addressing misconcep- of a particular underlying disorder. tions, and encouraging physical activity as appropriate. In all 51

Common Musculoskeletal Problems TABLE 33. History and Examination Features and Suggested Diagnoses in Low Back Pain Suggested Diagnosis History Features Examination Features | Cancer Personal history of cancer Vertebral tenderness Unexplained weight loss Failure to improve after 1 mo No relief at night Infection Fever Fever Injection drug use Vertebral tenderness Urinary tract infection Skin infection Sacroiliitis Onset before age 40 y Positive FABER maneuver Gradual onset Morning stiffness >30-60 min Pain not relieved when supine Pain persisting for >3 mo Return of stiffness after rest (“gelling”) Nerve rootirritation Sciatica (pain that radiates from the back through the buttocks Positive ipsilateral SLR (LR+, 3.7) (radiculopathy) down into one or both legs) Positive contralateral SLR (LR+, 4.4) Increased pain with cough, sneeze, or the Valsalva maneuver Spinal stenosis Severe leg pain No pain when seated Improvement in pain when bending forward Pseudoclaudication? (worsened pain with walking or standing and relief with sitting) Compression fracture Advanced age Vertebral tenderness Osteoporosis Trauma Glucocorticoid use

Improvement in pain when bending forward Pseudoclaudication? (worsened pain with walking or standing and relief with sitting) Compression fracture Advanced age Vertebral tenderness Osteoporosis Trauma Glucocorticoid use Cauda equina Bowel or bladder dysfunction Decreased anal sphincter tone syndrome? Perineal (saddle) sensory loss Decreased perineal/perianal sensation Rapidly progressive neurologic deficits Diminished or loss of one or both Achilles reflexes Back pain with radiation into one or both legs FABER = Flexion, ABduction, and External Rotation; LR+ = positive likelihood ratio; SLR = straight leg raise. “Lower extremity symptoms caused by lumbar spinal stenosis mimicking vascular ischemia; also termed neurogenic claudication. | Compression of the lumbar and sacral nerves below the termination of the spinal cord (conus medullaris). TABLE 34. Patterns of Neurologic Deficits in Patients with Low Back Pain Nerve Root Level Motor Deficit Sensory Deficit Involved Reflex L3 Hip flexion Anteromedial thigh Patella L4 Knee extension Anterior leg/medial foot Patella L5 Great toe dorsiflexion Lateral leg/dorsal foot NA S1 Plantar flexion of foot Posterior leg/lateral foot Achilles NA = not applicable.

L4 Knee extension Anterior leg/medial foot Patella L5 Great toe dorsiflexion Lateral leg/dorsal foot NA S1 Plantar flexion of foot Posterior leg/lateral foot Achilles NA = not applicable. Adapted with permission from Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Phys. 2012;85:346. [PMID: 22335313] © 2012, American Academy of Family Physicians. All rights reserved. 52

Common Musculoskeletal Problems patients with low back pain, bed rest should be avoided, and recommend nonpharmacologic and nonopioid therapies over depressive symptoms should be appropriately assessed and opioids.

Common Musculoskeletal Problems patients with low back pain, bed rest should be avoided, and recommend nonpharmacologic and nonopioid therapies over depressive symptoms should be appropriately assessed and opioids. managed. In addition to education, treatment modalities for patients Interventional and Surgical Treatment with low back pain may include nonpharmacologic and/or Most patients with low back pain do not require surgery. pharmacologic therapies and, rarely, surgery. The interven- Immediate surgery is indicated for patients with suspected tions should be chosen on the basis of the patient’s signs, cord compression or cauda equina syndrome. Nonurgent sur- symptoms, and comorbid conditions. gery may be considered in patients with neurologic deficits, progressively worsening spinal stenosis, or chronic pain with Nonpharmacologic Treatment corresponding abnormalities on imaging that has been refrac- Nonpharmacologic therapies are a cornerstone of treatment of tory to conservative measures and has the potential to respond acute and chronic low back pain. For acute low back pain, to surgery. Typical surgical approaches include diskectomy for potentially useful nonpharmacologic therapies include physi- disk herniation and posterior decompressive laminectomy for cal therapy, local heat, massage, and acupuncture, although spinal stenosis. the evidence supporting these approaches is generally weak. Epidural glucocorticoid injections are frequently per- Spinal manipulation therapy has moderate evidence for mod- formed in patients with radiculopathy; however, available est pain reduction and improvement in function. The type of evidence suggests they offer only small, short-term benefits. performing provider (physical therapist, physician, or chiro- practor) does not affect outcomes. ¢ Most patients with nonspecific low back pain do not HVC Multiple nonpharmacologic options are available for require imaging or other diagnostic testing. chronic low back pain, including exercise therapy, manual and massage therapy, acupuncture, yoga, intensive interdiscipli- e Patient education for low back pain includes providing nary therapy, and cognitive behavioral therapy, with varying information on the expected course of the back pain, levels of predominantly weak evidence supporting these promoting self-management, addressing misconcep- approaches. Multidisciplinary approaches have produced tions, and encouraging physical activity as appropriate. greater magnitudes of improvement in long-term pain and ¢ Nonpharmacologic therapies are considered a corner- HVC disability compared with individual interventions. The 2016 stone of treatment for acute and chronic low back pain; National Institute for Health and Care Excellence guidelines opioid therapy should be avoided. endorse self-management, exercise, manual therapy, psycho- logical therapy, and return-to-work programs.

managed. In addition to education, treatment modalities for patients Interventional and Surgical Treatment with low back pain may include nonpharmacologic and/or Most patients with low back pain do not require surgery. pharmacologic therapies and, rarely, surgery. The interven- Immediate surgery is indicated for patients with suspected tions should be chosen on the basis of the patient’s signs, cord compression or cauda equina syndrome. Nonurgent sur- symptoms, and comorbid conditions. gery may be considered in patients with neurologic deficits, progressively worsening spinal stenosis, or chronic pain with Nonpharmacologic Treatment corresponding abnormalities on imaging that has been refrac- Nonpharmacologic therapies are a cornerstone of treatment of tory to conservative measures and has the potential to respond acute and chronic low back pain. For acute low back pain, to surgery. Typical surgical approaches include diskectomy for potentially useful nonpharmacologic therapies include physi- disk herniation and posterior decompressive laminectomy for cal therapy, local heat, massage, and acupuncture, although spinal stenosis. the evidence supporting these approaches is generally weak. Epidural glucocorticoid injections are frequently per- Spinal manipulation therapy has moderate evidence for mod- formed in patients with radiculopathy; however, available est pain reduction and improvement in function. The type of evidence suggests they offer only small, short-term benefits. performing provider (physical therapist, physician, or chiro- practor) does not affect outcomes. ¢ Most patients with nonspecific low back pain do not HVC Multiple nonpharmacologic options are available for require imaging or other diagnostic testing. chronic low back pain, including exercise therapy, manual and massage therapy, acupuncture, yoga, intensive interdiscipli- e Patient education for low back pain includes providing nary therapy, and cognitive behavioral therapy, with varying information on the expected course of the back pain, levels of predominantly weak evidence supporting these promoting self-management, addressing misconcep- approaches. Multidisciplinary approaches have produced tions, and encouraging physical activity as appropriate. greater magnitudes of improvement in long-term pain and ¢ Nonpharmacologic therapies are considered a corner- HVC disability compared with individual interventions. The 2016 stone of treatment for acute and chronic low back pain; National Institute for Health and Care Excellence guidelines opioid therapy should be avoided. endorse self-management, exercise, manual therapy, psycho- logical therapy, and return-to-work programs. Pharmacologic Treatment Neck Pain NSAIDs reduce pain and disability in patients with acute low Diagnosis and Evaluation back pain. They are considered first-line pharmacologic ther- Neck pain has an annual prevalence of 30% in the U.S. adult apy and should be used at the lowest effective dose for the population, making it the fourth leading cause of disability. A shortest duration needed. Notably, acetaminophen is ineffec- priority in evaluating neck pain is differentiating musculo- tive for acute low back pain. Second-line agents include non- skeletal neck pain from other conditions that may cause seri- benzodiazepine muscle relaxants. Opioids and tramadol ous complications or be amenable to therapy. Evaluation should be avoided if possible. Evidence on oral glucocorticoids begins with a thorough history, including circumstances of the for pain management is weak. onset, presence of antecedent trauma, duration, progression, A similar approach is appropriate in patients with chronic impact on daily activities, and accompanying symptoms. low back pain. NSAIDs remain first-line pharmacologic ther- Examination includes inspection and palpation of the cervical apy, and nonbenzodiazepine muscle relaxants may be used as spine and muscles; range-of-motion testing; and comprehen- second-line therapy. The serotonin-norepinephrine reuptake sive neurologic assessment, including sensory, motor, and inhibitor duloxetine is FDA approved to treat chronic low back reflex testing. pain and may be useful in select patients. Systemic glucocorti- The most common causes of neck pain are musculoskel- coids, tricyclic antidepressants, selective serotonin reuptake etal (e.g., cervical strain, spondylosis, cervical facet osteoar- inhibitors, and neuromodulators (gabapentin and pregabalin) thritis). Whiplash injury develops after trauma involving have not demonstrated benefit for nonradicular chronic pain. abrupt acceleration and deceleration, leading to sudden neck A 2018 randomized controlled trial demonstrated that flexion and extension. Patients with musculoskeletal causes opioids were not superior to nonopioid medications for present with pain and stiffness with neck movement along improving pain-related function for chronic back pain; pain with decreased cervical range of motion and absence of neu- intensity was significantly improved in the nonopioid group, rologic abnormalities. Myofascial pain may be differentiated and side effects were less common. Multiple organizations, from other musculoskeletal causes by localized tenderness or including the American College of Physicians and the CDC, “trigger points” on palpation of the neck and shoulder. Often,

Pharmacologic Treatment Neck Pain NSAIDs reduce pain and disability in patients with acute low Diagnosis and Evaluation back pain. They are considered first-line pharmacologic ther- Neck pain has an annual prevalence of 30% in the U.S. adult apy and should be used at the lowest effective dose for the population, making it the fourth leading cause of disability. A shortest duration needed. Notably, acetaminophen is ineffec- priority in evaluating neck pain is differentiating musculo- tive for acute low back pain. Second-line agents include non- skeletal neck pain from other conditions that may cause seri- benzodiazepine muscle relaxants. Opioids and tramadol ous complications or be amenable to therapy. Evaluation should be avoided if possible. Evidence on oral glucocorticoids begins with a thorough history, including circumstances of the for pain management is weak. onset, presence of antecedent trauma, duration, progression, A similar approach is appropriate in patients with chronic impact on daily activities, and accompanying symptoms. low back pain. NSAIDs remain first-line pharmacologic ther- Examination includes inspection and palpation of the cervical apy, and nonbenzodiazepine muscle relaxants may be used as spine and muscles; range-of-motion testing; and comprehen- second-line therapy. The serotonin-norepinephrine reuptake sive neurologic assessment, including sensory, motor, and inhibitor duloxetine is FDA approved to treat chronic low back reflex testing. pain and may be useful in select patients. Systemic glucocorti- The most common causes of neck pain are musculoskel- coids, tricyclic antidepressants, selective serotonin reuptake etal (e.g., cervical strain, spondylosis, cervical facet osteoar- inhibitors, and neuromodulators (gabapentin and pregabalin) thritis). Whiplash injury develops after trauma involving have not demonstrated benefit for nonradicular chronic pain. abrupt acceleration and deceleration, leading to sudden neck A 2018 randomized controlled trial demonstrated that flexion and extension. Patients with musculoskeletal causes opioids were not superior to nonopioid medications for present with pain and stiffness with neck movement along improving pain-related function for chronic back pain; pain with decreased cervical range of motion and absence of neu- intensity was significantly improved in the nonopioid group, rologic abnormalities. Myofascial pain may be differentiated and side effects were less common. Multiple organizations, from other musculoskeletal causes by localized tenderness or including the American College of Physicians and the CDC, “trigger points” on palpation of the neck and shoulder. Often, 53

Common Musculoskeletal Problems multiple musculoskeletal conditions occur in tandem, making rheumatologic conditions (polymyalgia rheumatica, giant cell it difficult to determine a sole etiology of pain. arteritis) may present with a constellation of symptoms, Radiculopathy and myelopathy are the most common including neck pain; these conditions are discussed in MKSAP neurologic causes of neck pain. Cervical radiculopathy is 19 Neurology and MKSAP 19 Rheumatology, respectively. caused by spinal nerve root compression resulting from degen- Red flag findings in patients with neck pain are listed in erative spinal changes or disk herniation. Radiculopathy leads Table 35. In the absence of red flags, imaging is not necessary to neck pain accompanied by radiating arm pain, paresthesia for mild pain that does not interfere with activities of daily in a dermatomal distribution, decreased deep tendon reflexes, living. Plain radiography should be performed when evalua- and diminished strength in the affected extremity. In some tion suggests fracture, infection, or cancer and can be consid- cases, pain may be limited to the shoulder girdle. On examina- ered in patients with cervical strain that has been unresponsive tion, the patient’s symptoms may be reproduced with the to 6 to 8 weeks of conservative therapy. MRI is recommended Spurling test (sensitivity, 30%; specificity, 94%) (Figure 11) and when suspicion for cancer or infection remains high despite improved by holding the patient’s hand above the head (shoul- normal radiographs, when myelopathy is suspected, or if pro- der abduction test: sensitivity, 17%-78%; specificity, 75%-92%). gressive neurologic symptoms are present. In patients who Compressive cervical myelopathy can cause neck pain cannot undergo MRI, CT myelography can be considered. with associated leg weakness, gait and coordination distur- Electromyography and nerve conduction velocity are often bances, and bladder and bowel dysfunction. On examination, used to confirm the presence of radiculopathy. there are upper motor neuron signs, such as increased muscle tone, hyperreflexia, and clonus, in the upper and lower Treatment extremities, but lower motor neuron signs (atrophy, hypore- Most patients have resolution or near-resolution of their flexia) may occur near the level of compression or after acute symptoms within 8 to 12 weeks of onset by using conservative injury. The Lhermitte sign, an electric shock-like pain radiat- measures. Although multiple treatments exist for musculo- ing from the neck to the spine or the arms, can be produced by skeletal neck pain, no one treatment or combination of treat- forward flexion of the neck, but it is insensitive for the pres- ments has demonstrated superiority. A multimodal approach ence of cervical cord disease. that is tailored to the individual patient appears to work best Cancer should be considered in patients with a history of and may include range-of-motion exercise, physical therapy, cancer or suggestive systemic symptoms, such as weight loss. ice or heat applications, and analgesic agents. Stretching and Infectious causes, such as an epidural abscess, diskitis, or strengthening exercises appear to provide intermediate-term osteomyelitis, should be considered in patients with fever and relief of symptoms. Regular use of a cervical collar may delay chills, a history of injection drug use, or a history of recent improvement. bacteremia. Neurologic conditions (tension headache) and Oral and topical NSAIDs are considered first-line phar- macologic therapy for neck pain. Because of its favorable side-effect profile, acetaminophen is also frequently used, although its effectiveness is not clearly established. Muscle relaxants are more effective than placebo for treatment of acute neck pain associated with muscle spasm. For patients with chronic radicular symptoms, venlafaxine and neuro- modulators (e.g., gabapentin, tricyclic antidepressants) may provide some pain relief. Because of abuse potential, opioids are generally avoided. No evidence supports the use of oral glucocorticoids.

multiple musculoskeletal conditions occur in tandem, making rheumatologic conditions (polymyalgia rheumatica, giant cell it difficult to determine a sole etiology of pain. arteritis) may present with a constellation of symptoms, Radiculopathy and myelopathy are the most common including neck pain; these conditions are discussed in MKSAP neurologic causes of neck pain. Cervical radiculopathy is 19 Neurology and MKSAP 19 Rheumatology, respectively. caused by spinal nerve root compression resulting from degen- Red flag findings in patients with neck pain are listed in erative spinal changes or disk herniation. Radiculopathy leads Table 35. In the absence of red flags, imaging is not necessary to neck pain accompanied by radiating arm pain, paresthesia for mild pain that does not interfere with activities of daily in a dermatomal distribution, decreased deep tendon reflexes, living. Plain radiography should be performed when evalua- and diminished strength in the affected extremity. In some tion suggests fracture, infection, or cancer and can be consid- cases, pain may be limited to the shoulder girdle. On examina- ered in patients with cervical strain that has been unresponsive tion, the patient’s symptoms may be reproduced with the to 6 to 8 weeks of conservative therapy. MRI is recommended Spurling test (sensitivity, 30%; specificity, 94%) (Figure 11) and when suspicion for cancer or infection remains high despite improved by holding the patient’s hand above the head (shoul- normal radiographs, when myelopathy is suspected, or if pro- der abduction test: sensitivity, 17%-78%; specificity, 75%-92%). gressive neurologic symptoms are present. In patients who Compressive cervical myelopathy can cause neck pain cannot undergo MRI, CT myelography can be considered. with associated leg weakness, gait and coordination distur- Electromyography and nerve conduction velocity are often bances, and bladder and bowel dysfunction. On examination, used to confirm the presence of radiculopathy. there are upper motor neuron signs, such as increased muscle tone, hyperreflexia, and clonus, in the upper and lower Treatment extremities, but lower motor neuron signs (atrophy, hypore- Most patients have resolution or near-resolution of their flexia) may occur near the level of compression or after acute symptoms within 8 to 12 weeks of onset by using conservative injury. The Lhermitte sign, an electric shock-like pain radiat- measures. Although multiple treatments exist for musculo- ing from the neck to the spine or the arms, can be produced by skeletal neck pain, no one treatment or combination of treat- forward flexion of the neck, but it is insensitive for the pres- ments has demonstrated superiority. A multimodal approach ence of cervical cord disease. that is tailored to the individual patient appears to work best Cancer should be considered in patients with a history of and may include range-of-motion exercise, physical therapy, cancer or suggestive systemic symptoms, such as weight loss. ice or heat applications, and analgesic agents. Stretching and Infectious causes, such as an epidural abscess, diskitis, or strengthening exercises appear to provide intermediate-term osteomyelitis, should be considered in patients with fever and relief of symptoms. Regular use of a cervical collar may delay chills, a history of injection drug use, or a history of recent improvement. bacteremia. Neurologic conditions (tension headache) and Oral and topical NSAIDs are considered first-line phar- macologic therapy for neck pain. Because of its favorable side-effect profile, acetaminophen is also frequently used, although its effectiveness is not clearly established. Muscle relaxants are more effective than placebo for treatment of acute neck pain associated with muscle spasm. For patients with chronic radicular symptoms, venlafaxine and neuro- modulators (e.g., gabapentin, tricyclic antidepressants) may provide some pain relief. Because of abuse potential, opioids are generally avoided. No evidence supports the use of oral glucocorticoids. TABLE 35. Red Flag Findings in Patients with Neck Pain

multiple musculoskeletal conditions occur in tandem, making rheumatologic conditions (polymyalgia rheumatica, giant cell it difficult to determine a sole etiology of pain. arteritis) may present with a constellation of symptoms, Radiculopathy and myelopathy are the most common including neck pain; these conditions are discussed in MKSAP neurologic causes of neck pain. Cervical radiculopathy is 19 Neurology and MKSAP 19 Rheumatology, respectively. caused by spinal nerve root compression resulting from degen- Red flag findings in patients with neck pain are listed in erative spinal changes or disk herniation. Radiculopathy leads Table 35. In the absence of red flags, imaging is not necessary to neck pain accompanied by radiating arm pain, paresthesia for mild pain that does not interfere with activities of daily in a dermatomal distribution, decreased deep tendon reflexes, living. Plain radiography should be performed when evalua- and diminished strength in the affected extremity. In some tion suggests fracture, infection, or cancer and can be consid- cases, pain may be limited to the shoulder girdle. On examina- ered in patients with cervical strain that has been unresponsive tion, the patient’s symptoms may be reproduced with the to 6 to 8 weeks of conservative therapy. MRI is recommended Spurling test (sensitivity, 30%; specificity, 94%) (Figure 11) and when suspicion for cancer or infection remains high despite improved by holding the patient’s hand above the head (shoul- normal radiographs, when myelopathy is suspected, or if pro- der abduction test: sensitivity, 17%-78%; specificity, 75%-92%). gressive neurologic symptoms are present. In patients who Compressive cervical myelopathy can cause neck pain cannot undergo MRI, CT myelography can be considered. with associated leg weakness, gait and coordination distur- Electromyography and nerve conduction velocity are often bances, and bladder and bowel dysfunction. On examination, used to confirm the presence of radiculopathy. there are upper motor neuron signs, such as increased muscle tone, hyperreflexia, and clonus, in the upper and lower Treatment extremities, but lower motor neuron signs (atrophy, hypore- Most patients have resolution or near-resolution of their flexia) may occur near the level of compression or after acute symptoms within 8 to 12 weeks of onset by using conservative injury. The Lhermitte sign, an electric shock-like pain radiat- measures. Although multiple treatments exist for musculo- ing from the neck to the spine or the arms, can be produced by skeletal neck pain, no one treatment or combination of treat- forward flexion of the neck, but it is insensitive for the pres- ments has demonstrated superiority. A multimodal approach ence of cervical cord disease. that is tailored to the individual patient appears to work best Cancer should be considered in patients with a history of and may include range-of-motion exercise, physical therapy, cancer or suggestive systemic symptoms, such as weight loss. ice or heat applications, and analgesic agents. Stretching and Infectious causes, such as an epidural abscess, diskitis, or strengthening exercises appear to provide intermediate-term osteomyelitis, should be considered in patients with fever and relief of symptoms. Regular use of a cervical collar may delay chills, a history of injection drug use, or a history of recent improvement. bacteremia. Neurologic conditions (tension headache) and Oral and topical NSAIDs are considered first-line phar- macologic therapy for neck pain. Because of its favorable side-effect profile, acetaminophen is also frequently used, although its effectiveness is not clearly established. Muscle relaxants are more effective than placebo for treatment of acute neck pain associated with muscle spasm. For patients with chronic radicular symptoms, venlafaxine and neuro- modulators (e.g., gabapentin, tricyclic antidepressants) may provide some pain relief. Because of abuse potential, opioids are generally avoided. No evidence supports the use of oral glucocorticoids. TABLE 35. Red Flag Findings in Patients with Neck Pain Recent trauma

multiple musculoskeletal conditions occur in tandem, making rheumatologic conditions (polymyalgia rheumatica, giant cell it difficult to determine a sole etiology of pain. arteritis) may present with a constellation of symptoms, Radiculopathy and myelopathy are the most common including neck pain; these conditions are discussed in MKSAP neurologic causes of neck pain. Cervical radiculopathy is 19 Neurology and MKSAP 19 Rheumatology, respectively. caused by spinal nerve root compression resulting from degen- Red flag findings in patients with neck pain are listed in erative spinal changes or disk herniation. Radiculopathy leads Table 35. In the absence of red flags, imaging is not necessary to neck pain accompanied by radiating arm pain, paresthesia for mild pain that does not interfere with activities of daily in a dermatomal distribution, decreased deep tendon reflexes, living. Plain radiography should be performed when evalua- and diminished strength in the affected extremity. In some tion suggests fracture, infection, or cancer and can be consid- cases, pain may be limited to the shoulder girdle. On examina- ered in patients with cervical strain that has been unresponsive tion, the patient’s symptoms may be reproduced with the to 6 to 8 weeks of conservative therapy. MRI is recommended Spurling test (sensitivity, 30%; specificity, 94%) (Figure 11) and when suspicion for cancer or infection remains high despite improved by holding the patient’s hand above the head (shoul- normal radiographs, when myelopathy is suspected, or if pro- der abduction test: sensitivity, 17%-78%; specificity, 75%-92%). gressive neurologic symptoms are present. In patients who Compressive cervical myelopathy can cause neck pain cannot undergo MRI, CT myelography can be considered. with associated leg weakness, gait and coordination distur- Electromyography and nerve conduction velocity are often bances, and bladder and bowel dysfunction. On examination, used to confirm the presence of radiculopathy. there are upper motor neuron signs, such as increased muscle tone, hyperreflexia, and clonus, in the upper and lower Treatment extremities, but lower motor neuron signs (atrophy, hypore- Most patients have resolution or near-resolution of their flexia) may occur near the level of compression or after acute symptoms within 8 to 12 weeks of onset by using conservative injury. The Lhermitte sign, an electric shock-like pain radiat- measures. Although multiple treatments exist for musculo- ing from the neck to the spine or the arms, can be produced by skeletal neck pain, no one treatment or combination of treat- forward flexion of the neck, but it is insensitive for the pres- ments has demonstrated superiority. A multimodal approach ence of cervical cord disease. that is tailored to the individual patient appears to work best Cancer should be considered in patients with a history of and may include range-of-motion exercise, physical therapy, cancer or suggestive systemic symptoms, such as weight loss. ice or heat applications, and analgesic agents. Stretching and Infectious causes, such as an epidural abscess, diskitis, or strengthening exercises appear to provide intermediate-term osteomyelitis, should be considered in patients with fever and relief of symptoms. Regular use of a cervical collar may delay chills, a history of injection drug use, or a history of recent improvement. bacteremia. Neurologic conditions (tension headache) and Oral and topical NSAIDs are considered first-line phar- macologic therapy for neck pain. Because of its favorable side-effect profile, acetaminophen is also frequently used, although its effectiveness is not clearly established. Muscle relaxants are more effective than placebo for treatment of acute neck pain associated with muscle spasm. For patients with chronic radicular symptoms, venlafaxine and neuro- modulators (e.g., gabapentin, tricyclic antidepressants) may provide some pain relief. Because of abuse potential, opioids are generally avoided. No evidence supports the use of oral glucocorticoids. TABLE 35. Red Flag Findings in Patients with Neck Pain Recent trauma | Lower extremity weakness

multiple musculoskeletal conditions occur in tandem, making rheumatologic conditions (polymyalgia rheumatica, giant cell it difficult to determine a sole etiology of pain. arteritis) may present with a constellation of symptoms, Radiculopathy and myelopathy are the most common including neck pain; these conditions are discussed in MKSAP neurologic causes of neck pain. Cervical radiculopathy is 19 Neurology and MKSAP 19 Rheumatology, respectively. caused by spinal nerve root compression resulting from degen- Red flag findings in patients with neck pain are listed in erative spinal changes or disk herniation. Radiculopathy leads Table 35. In the absence of red flags, imaging is not necessary to neck pain accompanied by radiating arm pain, paresthesia for mild pain that does not interfere with activities of daily in a dermatomal distribution, decreased deep tendon reflexes, living. Plain radiography should be performed when evalua- and diminished strength in the affected extremity. In some tion suggests fracture, infection, or cancer and can be consid- cases, pain may be limited to the shoulder girdle. On examina- ered in patients with cervical strain that has been unresponsive tion, the patient’s symptoms may be reproduced with the to 6 to 8 weeks of conservative therapy. MRI is recommended Spurling test (sensitivity, 30%; specificity, 94%) (Figure 11) and when suspicion for cancer or infection remains high despite improved by holding the patient’s hand above the head (shoul- normal radiographs, when myelopathy is suspected, or if pro- der abduction test: sensitivity, 17%-78%; specificity, 75%-92%). gressive neurologic symptoms are present. In patients who Compressive cervical myelopathy can cause neck pain cannot undergo MRI, CT myelography can be considered. with associated leg weakness, gait and coordination distur- Electromyography and nerve conduction velocity are often bances, and bladder and bowel dysfunction. On examination, used to confirm the presence of radiculopathy. there are upper motor neuron signs, such as increased muscle tone, hyperreflexia, and clonus, in the upper and lower Treatment extremities, but lower motor neuron signs (atrophy, hypore- Most patients have resolution or near-resolution of their flexia) may occur near the level of compression or after acute symptoms within 8 to 12 weeks of onset by using conservative injury. The Lhermitte sign, an electric shock-like pain radiat- measures. Although multiple treatments exist for musculo- ing from the neck to the spine or the arms, can be produced by skeletal neck pain, no one treatment or combination of treat- forward flexion of the neck, but it is insensitive for the pres- ments has demonstrated superiority. A multimodal approach ence of cervical cord disease. that is tailored to the individual patient appears to work best Cancer should be considered in patients with a history of and may include range-of-motion exercise, physical therapy, cancer or suggestive systemic symptoms, such as weight loss. ice or heat applications, and analgesic agents. Stretching and Infectious causes, such as an epidural abscess, diskitis, or strengthening exercises appear to provide intermediate-term osteomyelitis, should be considered in patients with fever and relief of symptoms. Regular use of a cervical collar may delay chills, a history of injection drug use, or a history of recent improvement. bacteremia. Neurologic conditions (tension headache) and Oral and topical NSAIDs are considered first-line phar- macologic therapy for neck pain. Because of its favorable side-effect profile, acetaminophen is also frequently used, although its effectiveness is not clearly established. Muscle relaxants are more effective than placebo for treatment of acute neck pain associated with muscle spasm. For patients with chronic radicular symptoms, venlafaxine and neuro- modulators (e.g., gabapentin, tricyclic antidepressants) may provide some pain relief. Because of abuse potential, opioids are generally avoided. No evidence supports the use of oral glucocorticoids. TABLE 35. Red Flag Findings in Patients with Neck Pain Recent trauma | Lower extremity weakness Coordination or gait disturbances

multiple musculoskeletal conditions occur in tandem, making rheumatologic conditions (polymyalgia rheumatica, giant cell it difficult to determine a sole etiology of pain. arteritis) may present with a constellation of symptoms, Radiculopathy and myelopathy are the most common including neck pain; these conditions are discussed in MKSAP neurologic causes of neck pain. Cervical radiculopathy is 19 Neurology and MKSAP 19 Rheumatology, respectively. caused by spinal nerve root compression resulting from degen- Red flag findings in patients with neck pain are listed in erative spinal changes or disk herniation. Radiculopathy leads Table 35. In the absence of red flags, imaging is not necessary to neck pain accompanied by radiating arm pain, paresthesia for mild pain that does not interfere with activities of daily in a dermatomal distribution, decreased deep tendon reflexes, living. Plain radiography should be performed when evalua- and diminished strength in the affected extremity. In some tion suggests fracture, infection, or cancer and can be consid- cases, pain may be limited to the shoulder girdle. On examina- ered in patients with cervical strain that has been unresponsive tion, the patient’s symptoms may be reproduced with the to 6 to 8 weeks of conservative therapy. MRI is recommended Spurling test (sensitivity, 30%; specificity, 94%) (Figure 11) and when suspicion for cancer or infection remains high despite improved by holding the patient’s hand above the head (shoul- normal radiographs, when myelopathy is suspected, or if pro- der abduction test: sensitivity, 17%-78%; specificity, 75%-92%). gressive neurologic symptoms are present. In patients who Compressive cervical myelopathy can cause neck pain cannot undergo MRI, CT myelography can be considered. with associated leg weakness, gait and coordination distur- Electromyography and nerve conduction velocity are often bances, and bladder and bowel dysfunction. On examination, used to confirm the presence of radiculopathy. there are upper motor neuron signs, such as increased muscle tone, hyperreflexia, and clonus, in the upper and lower Treatment extremities, but lower motor neuron signs (atrophy, hypore- Most patients have resolution or near-resolution of their flexia) may occur near the level of compression or after acute symptoms within 8 to 12 weeks of onset by using conservative injury. The Lhermitte sign, an electric shock-like pain radiat- measures. Although multiple treatments exist for musculo- ing from the neck to the spine or the arms, can be produced by skeletal neck pain, no one treatment or combination of treat- forward flexion of the neck, but it is insensitive for the pres- ments has demonstrated superiority. A multimodal approach ence of cervical cord disease. that is tailored to the individual patient appears to work best Cancer should be considered in patients with a history of and may include range-of-motion exercise, physical therapy, cancer or suggestive systemic symptoms, such as weight loss. ice or heat applications, and analgesic agents. Stretching and Infectious causes, such as an epidural abscess, diskitis, or strengthening exercises appear to provide intermediate-term osteomyelitis, should be considered in patients with fever and relief of symptoms. Regular use of a cervical collar may delay chills, a history of injection drug use, or a history of recent improvement. bacteremia. Neurologic conditions (tension headache) and Oral and topical NSAIDs are considered first-line phar- macologic therapy for neck pain. Because of its favorable side-effect profile, acetaminophen is also frequently used, although its effectiveness is not clearly established. Muscle relaxants are more effective than placebo for treatment of acute neck pain associated with muscle spasm. For patients with chronic radicular symptoms, venlafaxine and neuro- modulators (e.g., gabapentin, tricyclic antidepressants) may provide some pain relief. Because of abuse potential, opioids are generally avoided. No evidence supports the use of oral glucocorticoids. TABLE 35. Red Flag Findings in Patients with Neck Pain Recent trauma | Lower extremity weakness Coordination or gait disturbances Bladder or bowel dysfunction FIGURE 11. Spurling test for cervical nerve root compression. With the patient in a sitting position, the examiner extends the patient's head and then laterally Fever or chills flexes the neck. Downward pressure is then applied to the head in this position.A | History of injection drug use positive result reproduces the patient's pain, which radiates into the ipsilateral arm Chronic glucocorticoid use or immunosuppression ina dermatomal distribution and supports the diagnosis of cervical radiculopathy (sensitivity, 30%; specificity, 94%). History of cancer or unexplained weight loss

Bladder or bowel dysfunction FIGURE 11. Spurling test for cervical nerve root compression. With the patient in a sitting position, the examiner extends the patient's head and then laterally Fever or chills flexes the neck. Downward pressure is then applied to the head in this position.A | History of injection drug use positive result reproduces the patient's pain, which radiates into the ipsilateral arm Chronic glucocorticoid use or immunosuppression ina dermatomal distribution and supports the diagnosis of cervical radiculopathy (sensitivity, 30%; specificity, 94%). History of cancer or unexplained weight loss Reproduced with permission from Davis MF, Davis PF, Ross DS. Expert Guide to Sports Medicine. Philadelphia, PA: Unrelenting headache American College of Physicians, 2005:271. ©2005, American College of Physicians. 54

Common Musculoskeletal Problems Patients with cervical radiculopathy presenting with catheter-directed thrombolysis when thrombosis is present, nonprogressive paresthesia and numbness should also be followed by prompt surgical decompression of the thoracic treated conservatively for 6 to 8 weeks as long as myelopathy outlet. is not suspected. The data supporting epidural glucocorticoid injections in patients with significant refractory symptoms are ¢ Neurogenic thoracic outlet syndrome (TOS), the most unconvincing. common type of TOS, results from compression of the Surgery is generally reserved for patients with confirmed brachial plexus; arm paresthesia, pain, and weakness cervical nerve root compression and either progressive motor worsen with repetitive arm use, especially overhead weakness or persistent radicular pain for more than 6 to activities. 12 weeks. For those with neck pain with a systemic cause, the underlying disorder should be appropriately treated. Shoulder Pain Diagnosis and Evaluation HVC e Most patients with neck pain do not require imaging Shoulder pain assessment involves a detailed history with studies; plain radiography should be performed when attention to the presence of antecedent trauma and relevant evaluation suggests fracture, infection, or cancer and occupational or recreational activities. A comprehensive can be considered for cervical sprain that is unrespon- shoulder examination, performed with both shoulders fully sive to 6 to 8 weeks of conservative therapy. exposed, includes inspection, palpation, range-of-motion HVC ¢ Neck pain usually resolves with conservative measures, assessment, and specialized maneuvers. including range-of-motion exercise, physical therapy, Shoulder pain with acute onset after trauma should be ice or heat application, and analgesic agents. evaluated with appropriate imaging to rule out injury, such as fracture and dislocation, which may require urgent treatment. The initial step in evaluating atraumatic shoulder pain is to Upper Extremity Disorders determine whether the pain arises from the shoulder (intrin- Thoracic Outlet Syndrome sic) or is referred from another site (extrinsic), such as the Diagnosis and Evaluation cervical spine. Extrinsic pain is suggested by the inability to Thoracic outlet syndrome (TOS) refers to signs and symptoms reproduce pain with shoulder movement, pain extending due to compression of the upper extremity neurovascular beyond the elbow, and pain with neck movement. bundle, located posterior to the clavicle above the first rib. The Anterolateral shoulder pain is the most common shoulder three subtypes of TOS may be distinguished by the affected pain and may be caused by impingement syndrome, rotator structure. Neurogenic TOS, the most common type (>90% of cuff tendinopathy, adhesive capsulitis, or labral tears. Biceps cases), results from compression of the brachial plexus. tendinitis of the long head results in anterior shoulder pain Symptoms (arm paresthesia, pain, and weakness) worsen with that is aggravated by lifting and carrying. Posterior shoulder repetitive arm use, especially overhead activities. Venous TOS pain may result from tendinopathy of the external rotators of (3%-5% of cases) is caused by axillary vein compression within the rotator cuff or may be referred pain from the spine. the thoracic outlet, often resulting in thrombosis. Symptoms Acromioclavicular pathology should be suspected when pain (arm pain/fatigue, swelling, and cyanosis) occur with repeti- is localized to the end of the clavicle. Glenohumeral joint tive arm use, particularly activities with elevation of the arm pathology should be considered when examination results are above the shoulder. Arterial TOS (1%-3% of cases), due to sub- equivocal and pain occurs with movement in any direction. clavian artery compression (with or without thrombosis), Plain film radiographs should be obtained in patients with usually occurs in the presence of an anomalous cervical rib. recent trauma and those with loss of range of motion. Symptoms include arm or hand pain (which may be exer- tional), weakness, paresthesia, coolness, and pallor. Rotator Cuff Disease Neurogenic TOS is a clinical diagnosis, although electro- Rotator cuff disease, the most common cause of shoulder pain, diagnostic testing may be helpful in some patients. Vascular encompasses all symptomatic rotator cuff disorders, including causes require imaging of the affected vessel; ultrasonography rotator cuff tendinopathy, rotator cuff tears, subacromial bur- is the most useful initial test. Cervical rib anomalies are usually sitis, and impingement syndrome (impingement of the shoul- present in patients with arterial TOS and may be identified der tendons or bursa by the shoulder bones that can lead to through chest radiography. rotator cuff tendinopathy, bursitis, or tears). Pain from rotator cuff disease is frequently localized to the upper arm near the Treatment deltoid insertion, is worsened with overhead activities, and is First-line therapy for neurogenic TOS includes improving pos- often worse when lying on the affected side. A rotator cuff tear ture and strengthening the shoulder girdle muscles. Surgical should be suspected when the pain is complicated by weak- decompression is reserved for progressive or disabling symp- ness in external rotation or abduction. Except for acute toms. Treatment of both arterial and venous TOS involves traumatic rotator cuff tears, onset of symptoms is usually

Patients with cervical radiculopathy presenting with catheter-directed thrombolysis when thrombosis is present, nonprogressive paresthesia and numbness should also be followed by prompt surgical decompression of the thoracic treated conservatively for 6 to 8 weeks as long as myelopathy outlet. is not suspected. The data supporting epidural glucocorticoid injections in patients with significant refractory symptoms are ¢ Neurogenic thoracic outlet syndrome (TOS), the most unconvincing. common type of TOS, results from compression of the Surgery is generally reserved for patients with confirmed brachial plexus; arm paresthesia, pain, and weakness cervical nerve root compression and either progressive motor worsen with repetitive arm use, especially overhead weakness or persistent radicular pain for more than 6 to activities. 12 weeks. For those with neck pain with a systemic cause, the underlying disorder should be appropriately treated. Shoulder Pain Diagnosis and Evaluation HVC e Most patients with neck pain do not require imaging Shoulder pain assessment involves a detailed history with studies; plain radiography should be performed when attention to the presence of antecedent trauma and relevant evaluation suggests fracture, infection, or cancer and occupational or recreational activities. A comprehensive can be considered for cervical sprain that is unrespon- shoulder examination, performed with both shoulders fully sive to 6 to 8 weeks of conservative therapy. exposed, includes inspection, palpation, range-of-motion HVC ¢ Neck pain usually resolves with conservative measures, assessment, and specialized maneuvers. including range-of-motion exercise, physical therapy, Shoulder pain with acute onset after trauma should be ice or heat application, and analgesic agents. evaluated with appropriate imaging to rule out injury, such as fracture and dislocation, which may require urgent treatment. The initial step in evaluating atraumatic shoulder pain is to Upper Extremity Disorders determine whether the pain arises from the shoulder (intrin- Thoracic Outlet Syndrome sic) or is referred from another site (extrinsic), such as the Diagnosis and Evaluation cervical spine. Extrinsic pain is suggested by the inability to Thoracic outlet syndrome (TOS) refers to signs and symptoms reproduce pain with shoulder movement, pain extending due to compression of the upper extremity neurovascular beyond the elbow, and pain with neck movement. bundle, located posterior to the clavicle above the first rib. The Anterolateral shoulder pain is the most common shoulder three subtypes of TOS may be distinguished by the affected pain and may be caused by impingement syndrome, rotator structure. Neurogenic TOS, the most common type (>90% of cuff tendinopathy, adhesive capsulitis, or labral tears. Biceps cases), results from compression of the brachial plexus. tendinitis of the long head results in anterior shoulder pain Symptoms (arm paresthesia, pain, and weakness) worsen with that is aggravated by lifting and carrying. Posterior shoulder repetitive arm use, especially overhead activities. Venous TOS pain may result from tendinopathy of the external rotators of (3%-5% of cases) is caused by axillary vein compression within the rotator cuff or may be referred pain from the spine. the thoracic outlet, often resulting in thrombosis. Symptoms Acromioclavicular pathology should be suspected when pain (arm pain/fatigue, swelling, and cyanosis) occur with repeti- is localized to the end of the clavicle. Glenohumeral joint tive arm use, particularly activities with elevation of the arm pathology should be considered when examination results are above the shoulder. Arterial TOS (1%-3% of cases), due to sub- equivocal and pain occurs with movement in any direction. clavian artery compression (with or without thrombosis), Plain film radiographs should be obtained in patients with usually occurs in the presence of an anomalous cervical rib. recent trauma and those with loss of range of motion. Symptoms include arm or hand pain (which may be exer- tional), weakness, paresthesia, coolness, and pallor. Rotator Cuff Disease Neurogenic TOS is a clinical diagnosis, although electro- Rotator cuff disease, the most common cause of shoulder pain, diagnostic testing may be helpful in some patients. Vascular encompasses all symptomatic rotator cuff disorders, including causes require imaging of the affected vessel; ultrasonography rotator cuff tendinopathy, rotator cuff tears, subacromial bur- is the most useful initial test. Cervical rib anomalies are usually sitis, and impingement syndrome (impingement of the shoul- present in patients with arterial TOS and may be identified der tendons or bursa by the shoulder bones that can lead to through chest radiography. rotator cuff tendinopathy, bursitis, or tears). Pain from rotator cuff disease is frequently localized to the upper arm near the Treatment deltoid insertion, is worsened with overhead activities, and is First-line therapy for neurogenic TOS includes improving pos- often worse when lying on the affected side. A rotator cuff tear ture and strengthening the shoulder girdle muscles. Surgical should be suspected when the pain is complicated by weak- decompression is reserved for progressive or disabling symp- ness in external rotation or abduction. Except for acute toms. Treatment of both arterial and venous TOS involves traumatic rotator cuff tears, onset of symptoms is usually 55

Common Musculoskeletal Problems insidious. Risk factors for rotator cuff disease include increas- MRI is most commonly performed, ultrasonography is as ing age and participation in activities that require repetitive accurate as and less expensive than MRI, and patients prefer overhead arm use. ultrasonography. Many examination maneuvers are available for rotator Patients with acute full-thickness tears should be consid- cuff disease assessment; they are most useful in combination ered for immediate repair. Treatment of other rotator cuff (Table 36). Positive results on both the painful arc test and the disorders includes education about the expected course, drop arm test in the setting of weakness in external rotation is avoidance or modification of aggravating activities, and physi- particularly suggestive of a rotator cuff tear. cal therapy. Immobilization with a sling should be avoided to Imaging should be performed immediately in patients prevent development of adhesive capsulitis. Pharmacologic with suspected acute rotator cuff tears. Chronic or slowly pro- treatment should begin with acetaminophen and, if ineffec- gressive rotator cuff disease does not require imaging in most tive, progress to oral or topical NSAIDs. Subacromial glucocor- cases, but imaging may be considered if the diagnosis is in ticoid injections may provide short-term pain relief in patients doubt or if surgical treatment is being considered. Although with subacromial bursitis in whom other measures have failed TABLE 36. Physical Examination Maneuvers in Rotator Cuff Disease

Many examination maneuvers are available for rotator Patients with acute full-thickness tears should be consid- cuff disease assessment; they are most useful in combination ered for immediate repair. Treatment of other rotator cuff (Table 36). Positive results on both the painful arc test and the disorders includes education about the expected course, drop arm test in the setting of weakness in external rotation is avoidance or modification of aggravating activities, and physi- particularly suggestive of a rotator cuff tear. cal therapy. Immobilization with a sling should be avoided to Imaging should be performed immediately in patients prevent development of adhesive capsulitis. Pharmacologic with suspected acute rotator cuff tears. Chronic or slowly pro- treatment should begin with acetaminophen and, if ineffec- gressive rotator cuff disease does not require imaging in most tive, progress to oral or topical NSAIDs. Subacromial glucocor- cases, but imaging may be considered if the diagnosis is in ticoid injections may provide short-term pain relief in patients doubt or if surgical treatment is being considered. Although with subacromial bursitis in whom other measures have failed TABLE 36. Physical Examination Maneuvers in Rotator Cuff Disease | Maneuver Technique Positive LR? Negative LR? Notes (95% Cl) (95% Cl) | Painful arc test During full passive abduction of the 3.7 (1.9-7.0) 0.36 (0.23-0.54) Highest positive LR of all special affected arm, pain occurs between 60 rotator cuff maneuvers and 120 degrees.

Painful arc test During full passive abduction of the 3.7 (1.9-7.0) 0.36 (0.23-0.54) Highest positive LR of all special affected arm, pain occurs between 60 rotator cuff maneuvers and 120 degrees. | Drop arm test The affected arm is fully passively 3.3 (1.0-11) 0.82 (0.7-0.97) An uncontrolled drop of the arm abducted, and the patient is asked to suggests a full tear of the | slowly lower the arm. A sudden drop supraspinatus of the arm with reproduction of the | patient's pain is a positive result. Hawkins test The arm is passively flexed to 1.5 (1.1-2.0) 0.51 (0.39-0.66) Believed to maximize impingement 90 degrees with the elbow in of the supraspinatus tendon; if the 90 degrees of flexion, and the painful arc test, Hawkins test, and | examiner then internally rotates the resisted external rotation are | shoulder. Reproduction of pain during positive, the positive LR for a full- internal rotation is a positive result. thickness rotator cuff tear is 16.4

Hawkins test The arm is passively flexed to 1.5 (1.1-2.0) 0.51 (0.39-0.66) Believed to maximize impingement 90 degrees with the elbow in of the supraspinatus tendon; if the 90 degrees of flexion, and the painful arc test, Hawkins test, and | examiner then internally rotates the resisted external rotation are | shoulder. Reproduction of pain during positive, the positive LR for a full- internal rotation is a positive result. thickness rotator cuff tear is 16.4 Empty can test The extended arm is passively 1.3 (0.97-1.6) 0.64 (0.33-1.3) Inability to maintain the position | abducted to 90 degrees in the plane before resistance is applied of the supraspinatus (30 degrees suggests a full tear of the anterior to the coronal plane) and supraspinatus | internally rotated (as though pouring a glass of water onto the floor). The | patient is asked to maintain the | position while the examiner exerts | downward force on the arm. Weakness or reproduction of pain is a positive result.

Empty can test The extended arm is passively 1.3 (0.97-1.6) 0.64 (0.33-1.3) Inability to maintain the position | abducted to 90 degrees in the plane before resistance is applied of the supraspinatus (30 degrees suggests a full tear of the anterior to the coronal plane) and supraspinatus | internally rotated (as though pouring a glass of water onto the floor). The | patient is asked to maintain the | position while the examiner exerts | downward force on the arm. Weakness or reproduction of pain is a positive result. Resisted external | The arm is abducted to 0 degrees 2.6 (1.8-3.6) 0.49 (0.33-0.72) Pain or weakness suggests rotation with the elbow flexed to 90 degrees infraspinatus pathology; limitation in and the thumb pointing upward. The external rotation range of motion examiner exerts an internal rotation suggests glenohumeral disease or force proximal to the wrist, which the adhesive capsulitis patient is asked to resist. Weakness or reproduction of pain is a positive result.

Resisted external | The arm is abducted to 0 degrees 2.6 (1.8-3.6) 0.49 (0.33-0.72) Pain or weakness suggests rotation with the elbow flexed to 90 degrees infraspinatus pathology; limitation in and the thumb pointing upward. The external rotation range of motion examiner exerts an internal rotation suggests glenohumeral disease or force proximal to the wrist, which the adhesive capsulitis patient is asked to resist. Weakness or reproduction of pain is a positive result. | Internal rotation The patient places the dorsum of the 6.2 (1.9-12) 0.04 (0.0-0.58) Subscapularis is the primary muscle lag sign hand on the lower back with the of internal rotation; LRs are for a full elbow flexed to 90 degrees. The tear of the subscapularis examiner lifts the hand off the back, further internally rotating the shoulder. Inability to maintain the hand away from the back is a positive result. LR = likelihood ratio. @LRs relate to the diagnosis of rotator cuff disease unless otherwise indicated. Reproduced with permission from Whittle S, Buchbinder R. In the clinic. Rotator cuff disease. Ann Intern Med. 2015;162:ITC1-15. [PMID: 25560729] doi:10.7326/AITC201501060. © 2015, American College of Physicians. 56

Common Musculoskeletal Problems but should be limited to one or two courses to limit complica- Acromioclavicular Joint Degeneration tions (tendon rupture or tear). Surgery in patients with a Acromioclavicular joint degeneration is typically character- chronic rotator cuff tear is reserved for those in whom 3 to ized by poorly localized pain on the superior shoulder, 6 months of conservative therapy has failed or for physically although pain may be present throughout the shoulder region. active patients with functionally significant tears. Subacromial On examination, pain is usually elicited with palpation of the decompression surgery is ineffective for pain relief and is not acromioclavicular joint. The crossed-arm adduction test often indicated for patients with chronic shoulder pain attributed to reproduces the pain, as does shoulder abduction beyond rotator cuff disease. 120 degrees, but neither test is specific for acromioclavicular joint disease. Plain radiography is often completed to assess for Adhesive Capsulitis other structural disease and usually reveals degenerative Adhesive capsulitis (frozen shoulder) is the most likely diagno- changes of the acromioclavicular joint (Figure 12). sis when anterolateral shoulder pain is associated with stiff- First-line therapy consists of NSAIDs and activity modifi- ness that is often worse at night and in cold weather. It usually cation. Glucocorticoid injections may provide short-term pain occurs in patients older than 40 years. Examination reveals relief. loss of abduction or external rotation, and both passive and active range of motion are decreased. Adhesive capsulitis can Labral Tears be idiopathic but is also associated with prolonged immobili- Repetitive overhead stress, especially stress that puts weight zation, antecedent shoulder surgery or injury, diabetes melli- on the shoulder, may produce a labral tear. Superior labrum tus, hypothyroidism, and autoimmune disorders. anterior and posterior (SLAP) tears are common in athletes Treatment focuses on pain control and improved range of and laborers. Labral tears often present with deep anterolateral motion. Intra-articular glucocorticoid injections appear to be pain that worsens with abduction and external rotation, more effective than physical therapy, although combining although pain may be generalized. Patients report a catching modalities may be most effective. Acetaminophen and NSAIDs sensation with movement, crepitus, and instability of the joint. can be used as an adjunct for analgesia. Surgery is reserved for Labral tears may be difficult to diagnose, and early referral to patients who do not respond to 3 to 6 months of conservative an orthopedic surgeon with experience in treating shoulder measures. injuries is recommended.

but should be limited to one or two courses to limit complica- Acromioclavicular Joint Degeneration tions (tendon rupture or tear). Surgery in patients with a Acromioclavicular joint degeneration is typically character- chronic rotator cuff tear is reserved for those in whom 3 to ized by poorly localized pain on the superior shoulder, 6 months of conservative therapy has failed or for physically although pain may be present throughout the shoulder region. active patients with functionally significant tears. Subacromial On examination, pain is usually elicited with palpation of the decompression surgery is ineffective for pain relief and is not acromioclavicular joint. The crossed-arm adduction test often indicated for patients with chronic shoulder pain attributed to reproduces the pain, as does shoulder abduction beyond rotator cuff disease. 120 degrees, but neither test is specific for acromioclavicular joint disease. Plain radiography is often completed to assess for Adhesive Capsulitis other structural disease and usually reveals degenerative Adhesive capsulitis (frozen shoulder) is the most likely diagno- changes of the acromioclavicular joint (Figure 12). sis when anterolateral shoulder pain is associated with stiff- First-line therapy consists of NSAIDs and activity modifi- ness that is often worse at night and in cold weather. It usually cation. Glucocorticoid injections may provide short-term pain occurs in patients older than 40 years. Examination reveals relief. loss of abduction or external rotation, and both passive and active range of motion are decreased. Adhesive capsulitis can Labral Tears be idiopathic but is also associated with prolonged immobili- Repetitive overhead stress, especially stress that puts weight zation, antecedent shoulder surgery or injury, diabetes melli- on the shoulder, may produce a labral tear. Superior labrum tus, hypothyroidism, and autoimmune disorders. anterior and posterior (SLAP) tears are common in athletes Treatment focuses on pain control and improved range of and laborers. Labral tears often present with deep anterolateral motion. Intra-articular glucocorticoid injections appear to be pain that worsens with abduction and external rotation, more effective than physical therapy, although combining although pain may be generalized. Patients report a catching modalities may be most effective. Acetaminophen and NSAIDs sensation with movement, crepitus, and instability of the joint. can be used as an adjunct for analgesia. Surgery is reserved for Labral tears may be difficult to diagnose, and early referral to patients who do not respond to 3 to 6 months of conservative an orthopedic surgeon with experience in treating shoulder measures. injuries is recommended. FIGURE 12. Radiograph showing evidence of degenerative changes of the left acromioclavicular joint consistent with acromioclavicular arthritis (/eft). As a synovial joint, the acromioclavicularjoint may show the typical findings of osteoarthritis, including joint-space narrowing (white arrow), subchondral sclerosis (red arrow), and osteophyte formation (orange arrow), compared with a normal shoulder radiograph (right).

FIGURE 12. Radiograph showing evidence of degenerative changes of the left acromioclavicular joint consistent with acromioclavicular arthritis (/eft). As a synovial joint, the acromioclavicularjoint may show the typical findings of osteoarthritis, including joint-space narrowing (white arrow), subchondral sclerosis (red arrow), and osteophyte formation (orange arrow), compared with a normal shoulder radiograph (right). 57

Common Musculoskeletal Problems Initial treatment consists of avoidance of elbow trauma and nocturnal splinting. NSAIDs can be beneficial for short- e Rotator cuff disease pain is frequently localized to the term pain relief. Surgery is an option when conservative meas- upper arm near the deltoid insertion, is worsened with ures fail in the setting of significant or progressive symptoms. overhead activities, and is often worse when lying on the affected side. Olecranon Bursitis and Synovitis HVC ¢ Most patients with rotator cuff disease do not require Olecranon bursitis is the most common cause of swelling at imaging studies; treatment may include education, the elbow and is usually secondary to trauma, crystal disease, avoidance or modification of aggravating activities, or infection. Normal elbow range of motion and posterior physical therapy, and acetaminophen or NSAIDs. elbow swelling and tenderness are typical (Figure 13). Swelling e Treatment of adhesive capsulitis focuses on pain control with pain on elbow extension and reduced range of motion and improved range of motion; treatment includes suggest synovitis. Causes of synovitis include infection (septic intra-articular glucocorticoid injections and physical arthritis) and rheumatologic conditions (rheumatoid, reac- therapy. tive, or psoriatic arthritis; gout; or seronegative spondyloar- thropathies). Elbow Problems Bursa or joint aspiration with culture and fluid analysis Diagnosis and Evaluation should be performed for severe pain, when there is any suspi- Elbow problems may be caused by pathology within the elbow cion of infection, or when crystal disease is suspected. joint, surrounding tissues, or nerves. Evaluation focuses on the Noninfectious bursitis is treated with joint rest, ice, elbow patient history and physical examination. protection, and as-needed NSAID therapy. Glucocorticoid injections should be avoided because evidence shows no ben- Epicondylitis efit and there is an increased risk for infection or development Lateral epicondylitis (tennis elbow), or inflammation of the of a draining sinus tract. Surgery may be necessary for infec- tendon at the lateral epicondyle, is caused by repetitive strain tious or refractory bursitis. of extensor tendons, such as with computer use or tennis. Pain and tenderness are located over the lateral epicondyle and increase with resisted wrist extension. Medial epicondylitis e Epicondylitis is generally managed with avoidance of HVC (golfer’s elbow) is caused by repetitive flexion of the wrist. trauma and pain-inducing activities; NSAIDs may be Pain occurs over the medial elbow and ventral forearm and effective for analgesia. worsens with resisted wrist flexion. Diagnostic imaging is ¢ Olecranon bursitis is characterized by normal elbow usually unnecessary if the clinical picture is consistent with range of motion with posterior elbow swelling and ten- medial or lateral epicondylitis. derness; swelling and pain on elbow extension suggest Initial management of epicondylitis includes avoidance of synovitis. pain-inducing activities and NSAIDs for analgesia. Physical therapy and counterforce braces may improve symptoms and prevent future exacerbations. Glucocorticoid injections may reduce pain in the short term but provide no long-term benefit.

Initial treatment consists of avoidance of elbow trauma and nocturnal splinting. NSAIDs can be beneficial for short- e Rotator cuff disease pain is frequently localized to the term pain relief. Surgery is an option when conservative meas- upper arm near the deltoid insertion, is worsened with ures fail in the setting of significant or progressive symptoms. overhead activities, and is often worse when lying on the affected side. Olecranon Bursitis and Synovitis HVC ¢ Most patients with rotator cuff disease do not require Olecranon bursitis is the most common cause of swelling at imaging studies; treatment may include education, the elbow and is usually secondary to trauma, crystal disease, avoidance or modification of aggravating activities, or infection. Normal elbow range of motion and posterior physical therapy, and acetaminophen or NSAIDs. elbow swelling and tenderness are typical (Figure 13). Swelling e Treatment of adhesive capsulitis focuses on pain control with pain on elbow extension and reduced range of motion and improved range of motion; treatment includes suggest synovitis. Causes of synovitis include infection (septic intra-articular glucocorticoid injections and physical arthritis) and rheumatologic conditions (rheumatoid, reac- therapy. tive, or psoriatic arthritis; gout; or seronegative spondyloar- thropathies). Elbow Problems Bursa or joint aspiration with culture and fluid analysis Diagnosis and Evaluation should be performed for severe pain, when there is any suspi- Elbow problems may be caused by pathology within the elbow cion of infection, or when crystal disease is suspected. joint, surrounding tissues, or nerves. Evaluation focuses on the Noninfectious bursitis is treated with joint rest, ice, elbow patient history and physical examination. protection, and as-needed NSAID therapy. Glucocorticoid injections should be avoided because evidence shows no ben- Epicondylitis efit and there is an increased risk for infection or development Lateral epicondylitis (tennis elbow), or inflammation of the of a draining sinus tract. Surgery may be necessary for infec- tendon at the lateral epicondyle, is caused by repetitive strain tious or refractory bursitis. of extensor tendons, such as with computer use or tennis. Pain and tenderness are located over the lateral epicondyle and increase with resisted wrist extension. Medial epicondylitis e Epicondylitis is generally managed with avoidance of HVC (golfer’s elbow) is caused by repetitive flexion of the wrist. trauma and pain-inducing activities; NSAIDs may be Pain occurs over the medial elbow and ventral forearm and effective for analgesia. worsens with resisted wrist flexion. Diagnostic imaging is ¢ Olecranon bursitis is characterized by normal elbow usually unnecessary if the clinical picture is consistent with range of motion with posterior elbow swelling and ten- medial or lateral epicondylitis. derness; swelling and pain on elbow extension suggest Initial management of epicondylitis includes avoidance of synovitis. pain-inducing activities and NSAIDs for analgesia. Physical therapy and counterforce braces may improve symptoms and prevent future exacerbations. Glucocorticoid injections may reduce pain in the short term but provide no long-term benefit. Radial or Ulnar Nerve Entrapment The radial nerve is susceptible to compression where it is in close proximity to the humerus in the spiral groove. Sustained pressure on the nerve, such as may occur with prolonged unconsciousness, results in weakness of the wrist extensors (wrist drop) and sensory loss on the dorsum of the first three fingers. Entrapment of the posterior interosseous branch of the radial nerve at the elbow (radial tunnel syndrome) should be considered in patients with lateral elbow pain initially diag- nosed as tennis elbow that has not responded to conservative therapy. Ulnar nerve impingement at the elbow (cubital tunnel syndrome) presents as elbow pain that worsens with flexion FIGURE 13. Olecranon bursitis, characterized by warmth, redness, and and is associated with paresthesia, numbness of the fourth swelling. The ability to extend and flex the elbow generally excludes an intra- and fifth fingers, and weakness of the interosseous muscles. articular process. Diagnosis is usually clinical, but electromyography is often Reproduced with permission from Moore G. Atlas of the Musculoskeletal Examination. Philadelphia, PA: American used for diagnostic confirmation. College of Physicians; 2003:24. ©2003, American College of Physicians.

Radial or Ulnar Nerve Entrapment The radial nerve is susceptible to compression where it is in close proximity to the humerus in the spiral groove. Sustained pressure on the nerve, such as may occur with prolonged unconsciousness, results in weakness of the wrist extensors (wrist drop) and sensory loss on the dorsum of the first three fingers. Entrapment of the posterior interosseous branch of the radial nerve at the elbow (radial tunnel syndrome) should be considered in patients with lateral elbow pain initially diag- nosed as tennis elbow that has not responded to conservative therapy. Ulnar nerve impingement at the elbow (cubital tunnel syndrome) presents as elbow pain that worsens with flexion FIGURE 13. Olecranon bursitis, characterized by warmth, redness, and and is associated with paresthesia, numbness of the fourth swelling. The ability to extend and flex the elbow generally excludes an intra- and fifth fingers, and weakness of the interosseous muscles. articular process. Diagnosis is usually clinical, but electromyography is often Reproduced with permission from Moore G. Atlas of the Musculoskeletal Examination. Philadelphia, PA: American used for diagnostic confirmation. College of Physicians; 2003:24. ©2003, American College of Physicians. 58

Common Musculoskeletal Problems the lower leg. Patients report throbbing pain during exercise. The pain gradually resolves with rest. Diffuse tenderness of the affected muscle bed may be present but only during exercise. Diagnosis is confirmed by measuring compartment pressures. Treatment includes modification of the exercise regimen and occasionally surgical fasciotomy.

the lower leg. Patients report throbbing pain during exercise. The pain gradually resolves with rest. Diffuse tenderness of the affected muscle bed may be present but only during exercise. Diagnosis is confirmed by measuring compartment pressures. Treatment includes modification of the exercise regimen and occasionally surgical fasciotomy. lliotibial Band Syndrome lliotibial band syndrome is characterized by poorly localized lateral knee and distal thigh pain. Pain is initially present at the end of exercise that involves knee flexion and extension, but it may occur earlier in exercise or with rest as the condition progresses. Running outdoors or downhill may worsen symptoms. On examination, there is often tenderness FIGURE 18. Location of the anserine bursa on the medial aspect of the leg and approximately 2 to 3 cm proximal to the lateral femoral con- pain associated with pes anserine bursitis. dyle. Patients frequently have a positive result on the Noble test Reproduced with permission from Moore G. Atlas of the Musculoskeletal ination. Philadelphia, PA: American College of Physicians; 2003:87. ©2003, American College of ea and weakness with hip abduction (see Table 38). Imaging is not usually required. Initial treatment of iliotibial band syndrome involves therapy includes quadriceps strengthening, local cryotherapy, abstaining from the inciting activity and using ice, followed by activity modification, and NSAIDs. a gradual return to activity, stretching, strengthening, and local massage. NSAIDs appear to be effective when used as Tendinopathies and Tears part of a multimodal approach. Local glucocorticoid injections Tendinopathy of the quadriceps or patellar tendon causes knee may provide at least short-term relief. pain with movement, such as jumping, running, or squatting. Pain occurs superior to the patella (quadriceps tendinopathy) Popliteal Cysts or distal to the patella (patellar tendinopathy) and can be A popliteal (Baker) cyst is an enlargement of the gastrocne- reproduced with palpation of the affected area. Treatment mius-semimembranosus bursa behind and communicating involves conservative measures, including strengthening and with the knee joint. Popliteal cysts most commonly develop in stretching exercises and NSAIDs. the setting of knee trauma, osteoarthritis, or inflammatory A patellar tendon tear causes acute knee pain with effu- arthritis. They are frequently asymptomatic but can present sion after low-impact trauma, such as occurs with sports. It with posterior knee pain and swelling. Ruptured cysts may can also occur in the setting of fluoroquinolone or glucocorti- mimic deep venous thromboses and may be associated with coid use. Pain is located inferior to the patella, where there is ecchymosis from the popliteal fossa to the ankle. The “crescent often swelling and ecchymosis. Treatment frequently involves sign” may be present with rupture, recognized as an ecchy- surgery. motic area below the medial malleolus (Figure 19). In patients with asymptomatic popliteal cysts, no treatment is necessary. Osteochondral Injury Symptomatic patients with unruptured cysts often experience Injury to the articular cartilage (osteochondral injury) can occur relief with joint aspiration and intra-articular glucocorticoid when there is significant trauma to the knee or as an overuse injury. Patients describe diffuse knee pain. Osteochondral injury often requires MRI or arthroscopy for diagnosis. Treatment is surgical.

lliotibial Band Syndrome lliotibial band syndrome is characterized by poorly localized lateral knee and distal thigh pain. Pain is initially present at the end of exercise that involves knee flexion and extension, but it may occur earlier in exercise or with rest as the condition progresses. Running outdoors or downhill may worsen symptoms. On examination, there is often tenderness FIGURE 18. Location of the anserine bursa on the medial aspect of the leg and approximately 2 to 3 cm proximal to the lateral femoral con- pain associated with pes anserine bursitis. dyle. Patients frequently have a positive result on the Noble test Reproduced with permission from Moore G. Atlas of the Musculoskeletal ination. Philadelphia, PA: American College of Physicians; 2003:87. ©2003, American College of ea and weakness with hip abduction (see Table 38). Imaging is not usually required. Initial treatment of iliotibial band syndrome involves therapy includes quadriceps strengthening, local cryotherapy, abstaining from the inciting activity and using ice, followed by activity modification, and NSAIDs. a gradual return to activity, stretching, strengthening, and local massage. NSAIDs appear to be effective when used as Tendinopathies and Tears part of a multimodal approach. Local glucocorticoid injections Tendinopathy of the quadriceps or patellar tendon causes knee may provide at least short-term relief. pain with movement, such as jumping, running, or squatting. Pain occurs superior to the patella (quadriceps tendinopathy) Popliteal Cysts or distal to the patella (patellar tendinopathy) and can be A popliteal (Baker) cyst is an enlargement of the gastrocne- reproduced with palpation of the affected area. Treatment mius-semimembranosus bursa behind and communicating involves conservative measures, including strengthening and with the knee joint. Popliteal cysts most commonly develop in stretching exercises and NSAIDs. the setting of knee trauma, osteoarthritis, or inflammatory A patellar tendon tear causes acute knee pain with effu- arthritis. They are frequently asymptomatic but can present sion after low-impact trauma, such as occurs with sports. It with posterior knee pain and swelling. Ruptured cysts may can also occur in the setting of fluoroquinolone or glucocorti- mimic deep venous thromboses and may be associated with coid use. Pain is located inferior to the patella, where there is ecchymosis from the popliteal fossa to the ankle. The “crescent often swelling and ecchymosis. Treatment frequently involves sign” may be present with rupture, recognized as an ecchy- surgery. motic area below the medial malleolus (Figure 19). In patients with asymptomatic popliteal cysts, no treatment is necessary. Osteochondral Injury Symptomatic patients with unruptured cysts often experience Injury to the articular cartilage (osteochondral injury) can occur relief with joint aspiration and intra-articular glucocorticoid when there is significant trauma to the knee or as an overuse injury. Patients describe diffuse knee pain. Osteochondral injury often requires MRI or arthroscopy for diagnosis. Treatment is surgical. Medial Tibial Stress Syndrome Medial tibial stress syndrome (shin splints) presents as pain in the mid to distal shins, usually after activity. Diffuse tender- ness is often found over the affected area. Diagnosis is clinical, although imaging may be required to rule out stress fracture. Treatment includes avoidance of high-impact activities (e.g., running) and using shock-absorbing insoles.

Medial Tibial Stress Syndrome Medial tibial stress syndrome (shin splints) presents as pain in the mid to distal shins, usually after activity. Diffuse tender- ness is often found over the affected area. Diagnosis is clinical, although imaging may be required to rule out stress fracture. Treatment includes avoidance of high-impact activities (e.g., running) and using shock-absorbing insoles. Chronic Exertional Compartment Syndrome Chronic exertional compartment syndrome is exertion- provoked swelling of a specific muscle bed, most commonly in FIGURE 19. Ruptured Baker cyst with hemorrhagic crescent sign. 64

Common Musculoskeletal Problems injection. Ruptured cysts can be treated with rest, elevation, (dorsiflexion-external rotation test). Treatment is similar to and NSAIDs. Surgical excision is reserved for severely sympto- that for other ankle sprains, although recovery is usually matic and functionally limited patients in whom conservative delayed. measures fail or serious complications develop. Stress Fracture The metatarsals, tarsals, and calcaneus are the most common e All patients with prepatellar bursitis regardless of dura- sites of stress fracture in the foot. Physical examination may tion should undergo fluid aspiration and analysis. reveal bony tenderness, pain with percussion, or pain with e [liotibial band syndrome is characterized by lateral knee hopping on a single leg. The calcaneal squeeze test may elicit and distal thigh pain at the end of exercise involving knee pain in patients with calcaneal fracture. Radiography is first- flexion and extension; treatment is typically nonsurgical. line diagnostic testing but may fail to reveal a fracture line. MRI HVC e No treatment is necessary for asymptomatic popliteal has greater sensitivity and provides prognostic information (Baker) cysts; joint aspiration and intra-articular gluco- about the risk for nonunion; it should be performed when

HVC e No treatment is necessary for asymptomatic popliteal has greater sensitivity and provides prognostic information (Baker) cysts; joint aspiration and intra-articular gluco- about the risk for nonunion; it should be performed when corticoid injection may provide relief for those with plain films are unrevealing but clinical probability is high.

(Baker) cysts; joint aspiration and intra-articular gluco- about the risk for nonunion; it should be performed when corticoid injection may provide relief for those with plain films are unrevealing but clinical probability is high. symptoms. Patients should be screened for factors affecting bone health, including the athletic triad in females (low caloric intake, menstrual dysfunction, and low bone mineral density). Ankle and Foot Pain Management varies according to the risk for nonunion Ankle Sprains (Table 39). High-risk fractures can be treated with immobili- Acute ankle sprains are usually caused by excessive ankle inver- zation and serial imaging or surgical fixation; specialist sion. Common examination findings include overlying ecchy- involvement should be considered. Low-risk fractures are mosis and swelling with tenderness of involved ankle ligaments. treated with rest, crutches, a walking boot, and/or footwear Weight-bearing ability and bony tenderness are components of padding to achieve pain-free ambulation. Follow-up radiogra- the Ottawa ankle rules, which help determine the necessity of phy 4 weeks after the injury can help document healing. Once obtaining radiographs to exclude fracture (Figure 20). Treatment the patient can ambulate without pain and has no pain on includes intermittent cryotherapy and a lace-up support or air examination with provocative maneuvers, nonimpact activity stirrup brace combined with elastic compression wrapping. can be resumed gradually. Most patients with low-risk injuries Early mobilization should be encouraged with weight bearing as can resume running in 8 to 12 weeks; resumption of running tolerated. Acetaminophen and NSAIDs can be used for pain con- in patients with high-risk injuries should be individualized. trol. Patients with persistent ligamentous laxity 4 to 6 weeks after injury should be referred for proprioceptive training and Hindfoot Pain strengthening therapy. Achilles tendinopathy typically develops in persons who initi- High ankle sprains (distal tibiofibular syndesmosis liga- ate or abruptly increase activity. Patients report activity-related ment injuries) occur when an externally rotated force is applied to a dorsiflexed ankle. Pain may be elicited by squeez- ing the leg at mid-calf (squeeze test) and by dorsiflexing TABLE 39. Nonunion Risk in Foot and Ankle Stress and externally rotating the foot with the knee flexed Fractures, by Anatomic Location

symptoms. Patients should be screened for factors affecting bone health, including the athletic triad in females (low caloric intake, menstrual dysfunction, and low bone mineral density). Ankle and Foot Pain Management varies according to the risk for nonunion Ankle Sprains (Table 39). High-risk fractures can be treated with immobili- Acute ankle sprains are usually caused by excessive ankle inver- zation and serial imaging or surgical fixation; specialist sion. Common examination findings include overlying ecchy- involvement should be considered. Low-risk fractures are mosis and swelling with tenderness of involved ankle ligaments. treated with rest, crutches, a walking boot, and/or footwear Weight-bearing ability and bony tenderness are components of padding to achieve pain-free ambulation. Follow-up radiogra- the Ottawa ankle rules, which help determine the necessity of phy 4 weeks after the injury can help document healing. Once obtaining radiographs to exclude fracture (Figure 20). Treatment the patient can ambulate without pain and has no pain on includes intermittent cryotherapy and a lace-up support or air examination with provocative maneuvers, nonimpact activity stirrup brace combined with elastic compression wrapping. can be resumed gradually. Most patients with low-risk injuries Early mobilization should be encouraged with weight bearing as can resume running in 8 to 12 weeks; resumption of running tolerated. Acetaminophen and NSAIDs can be used for pain con- in patients with high-risk injuries should be individualized. trol. Patients with persistent ligamentous laxity 4 to 6 weeks after injury should be referred for proprioceptive training and Hindfoot Pain strengthening therapy. Achilles tendinopathy typically develops in persons who initi- High ankle sprains (distal tibiofibular syndesmosis liga- ate or abruptly increase activity. Patients report activity-related ment injuries) occur when an externally rotated force is applied to a dorsiflexed ankle. Pain may be elicited by squeez- ing the leg at mid-calf (squeeze test) and by dorsiflexing TABLE 39. Nonunion Risk in Foot and Ankle Stress and externally rotating the foot with the knee flexed Fractures, by Anatomic Location | High Risk

symptoms. Patients should be screened for factors affecting bone health, including the athletic triad in females (low caloric intake, menstrual dysfunction, and low bone mineral density). Ankle and Foot Pain Management varies according to the risk for nonunion Ankle Sprains (Table 39). High-risk fractures can be treated with immobili- Acute ankle sprains are usually caused by excessive ankle inver- zation and serial imaging or surgical fixation; specialist sion. Common examination findings include overlying ecchy- involvement should be considered. Low-risk fractures are mosis and swelling with tenderness of involved ankle ligaments. treated with rest, crutches, a walking boot, and/or footwear Weight-bearing ability and bony tenderness are components of padding to achieve pain-free ambulation. Follow-up radiogra- the Ottawa ankle rules, which help determine the necessity of phy 4 weeks after the injury can help document healing. Once obtaining radiographs to exclude fracture (Figure 20). Treatment the patient can ambulate without pain and has no pain on includes intermittent cryotherapy and a lace-up support or air examination with provocative maneuvers, nonimpact activity stirrup brace combined with elastic compression wrapping. can be resumed gradually. Most patients with low-risk injuries Early mobilization should be encouraged with weight bearing as can resume running in 8 to 12 weeks; resumption of running tolerated. Acetaminophen and NSAIDs can be used for pain con- in patients with high-risk injuries should be individualized. trol. Patients with persistent ligamentous laxity 4 to 6 weeks after injury should be referred for proprioceptive training and Hindfoot Pain strengthening therapy. Achilles tendinopathy typically develops in persons who initi- High ankle sprains (distal tibiofibular syndesmosis liga- ate or abruptly increase activity. Patients report activity-related ment injuries) occur when an externally rotated force is applied to a dorsiflexed ankle. Pain may be elicited by squeez- ing the leg at mid-calf (squeeze test) and by dorsiflexing TABLE 39. Nonunion Risk in Foot and Ankle Stress and externally rotating the foot with the knee flexed Fractures, by Anatomic Location | High Risk Lateral view Medial view Base of second metatarsal

symptoms. Patients should be screened for factors affecting bone health, including the athletic triad in females (low caloric intake, menstrual dysfunction, and low bone mineral density). Ankle and Foot Pain Management varies according to the risk for nonunion Ankle Sprains (Table 39). High-risk fractures can be treated with immobili- Acute ankle sprains are usually caused by excessive ankle inver- zation and serial imaging or surgical fixation; specialist sion. Common examination findings include overlying ecchy- involvement should be considered. Low-risk fractures are mosis and swelling with tenderness of involved ankle ligaments. treated with rest, crutches, a walking boot, and/or footwear Weight-bearing ability and bony tenderness are components of padding to achieve pain-free ambulation. Follow-up radiogra- the Ottawa ankle rules, which help determine the necessity of phy 4 weeks after the injury can help document healing. Once obtaining radiographs to exclude fracture (Figure 20). Treatment the patient can ambulate without pain and has no pain on includes intermittent cryotherapy and a lace-up support or air examination with provocative maneuvers, nonimpact activity stirrup brace combined with elastic compression wrapping. can be resumed gradually. Most patients with low-risk injuries Early mobilization should be encouraged with weight bearing as can resume running in 8 to 12 weeks; resumption of running tolerated. Acetaminophen and NSAIDs can be used for pain con- in patients with high-risk injuries should be individualized. trol. Patients with persistent ligamentous laxity 4 to 6 weeks after injury should be referred for proprioceptive training and Hindfoot Pain strengthening therapy. Achilles tendinopathy typically develops in persons who initi- High ankle sprains (distal tibiofibular syndesmosis liga- ate or abruptly increase activity. Patients report activity-related ment injuries) occur when an externally rotated force is applied to a dorsiflexed ankle. Pain may be elicited by squeez- ing the leg at mid-calf (squeeze test) and by dorsiflexing TABLE 39. Nonunion Risk in Foot and Ankle Stress and externally rotating the foot with the knee flexed Fractures, by Anatomic Location | High Risk Lateral view Medial view Base of second metatarsal A Malleolar zone B | Fifth metatarsal diaphysis Posterior edge Midfoot zone hog | Posterior edge | Medial malleolus or tip of dae * \_ or tip of lateral malleolus = / | \ medial malleolus | Anterior tibial cortex | (6-cm length) / Boe u mS: \\_(6-cm length) | Navicular Fibular and tibial sesamoid Base of fifth Navicular metatarsal bone | Moderate Risk Cc D Cuboid FIGURE 20. Ottawa ankle and foot rules. An ankle radiographic series is Cuneiform indicated if a patient has pain in the malleolar zone and any of the following findings: bone tenderness at A, bone tenderness at B, or inability to bear weight Low Risk |

A Malleolar zone B | Fifth metatarsal diaphysis Posterior edge Midfoot zone hog | Posterior edge | Medial malleolus or tip of dae * \_ or tip of lateral malleolus = / | \ medial malleolus | Anterior tibial cortex | (6-cm length) / Boe u mS: \\_(6-cm length) | Navicular Fibular and tibial sesamoid Base of fifth Navicular metatarsal bone | Moderate Risk Cc D Cuboid FIGURE 20. Ottawa ankle and foot rules. An ankle radiographic series is Cuneiform indicated if a patient has pain in the malleolar zone and any of the following findings: bone tenderness at A, bone tenderness at B, or inability to bear weight Low Risk | immediately and in the emergency department or physician's office. A foot Posterior tibia radiographic series is indicated ifa patient has pain in the midfoot zone and any of Fibula the following findings: bone tenderness at C, bone tenderness at D, or inability to bear weight immediately and in the emergency department or physician's office. Calcaneus

immediately and in the emergency department or physician's office. A foot Posterior tibia radiographic series is indicated ifa patient has pain in the midfoot zone and any of Fibula the following findings: bone tenderness at C, bone tenderness at D, or inability to bear weight immediately and in the emergency department or physician's office. Calcaneus Reproduced with permission from Davis MF, Davis PF, Ross DS. Expert Guide to Sports Medicine. Philadelphia, PA: Metatarsals (other than second and fifth) American College of Physicians, 2005:404. ©2005, American College of Physicians. 65