Clinical Pearl Series Sports and Chronic Injuries

--From [Yale-G First Aid: Crush USMLE Step 2CK and Step 3] By Dr. Yale Gong, USMLE-Certified, Sr. Advisor of www.medicine.net

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Sports and chronic injuries and their differentiations are common problems in our daily life and worth learning.

Bursitis

It’s an inflammation of the bursae secondary to trauma, repetitive use, infection, or systemic diseases (gout, rheumatoid arthritis, osteoarthritis, etc.). Common sites are subacromial (subdeltoid, the No.1 site), olecranon, trochanteric, and prepatellar bursa. Infection can cause septic bursitis (more often with superficial bursa).

Essentials of diagnosis

1. History of trauma, repetitive use, or infection followed by localized tenderness, erythema, edema, and decreased range of motion. Diagnosis is clinical and aspiration analysis is only needed if septic bursitis is suspected.

2. Subacromial bursitis: Common in athletes with repeated, improper use of the shoulder; pain on overhead actions (arm abduction, flexion, or rotation) and limited shoulder movement; Neer sign (+) (shoulder pain on passive rotation internally).

3. Olecranon bursitis: Swelling and pain at point of elbow; spongy “bag of fluid” over the extensor surface of elbow.

4. Iliopsoas bursitis: Overlies the capsule; an enlarging inguinal mass (should be differentiated from a hernia, hydrocele, and abscess).

5. Trochanteric bursitis: A common cause of lateral hip pain; with obvious pain on palpation of the greater trochanter.

6. Ischial bursitis: Inflamed bursa overlying the ischial tuberosity; pain in the buttocks, especially when sitting and flexing the hip.

7. Retrocalcaneal bursitis: Between the calcaneus and the Achilles.

Treatment

1. Combined therapies: Immobilization (except for subacromial bursitis with the risk of “frozen” shoulder) and rest; physical therapy—ice during acute phase; moist heat during chronic phase; exercise modification; NSAIDs as indicated.

2. Intrabursal steroid injection is saved for severe cases (pain), except for septic bursitis, which requires antibiotics for 7-10 days.

Differential diagnosis

Frozen shoulder:

(1) Glenohumoral joint stiffness causing limited motion of shoulder in all directions, passively and actively; no local warm, red, swollen, or tender signs. (2) Diagnosis: Arthroscopy is confirmative, showing decrease in joint space and loss of normal auxiliary pouch. (3) Treatment: NSAIDs, triamcinolone, focal injection of steroid/lidocaine, plus physical therapy.

Rotator Cuff Injury

I. Rotator cuff tear

It’s the damage to the rotator cuff of the muscles, tendons, and the bursae around the shoulder leading to the inability to reflex or abduct the shoulder, due to acute or chronic trauma.

(1) Shoulder abduction decreases accompanied by pain with both passive and active arm lift to the shoulder level; drop arm sign is positive. The shoulder pain is worse at night when lying on the affected shoulder. Mild cases may only cause pain without dysfunction.

(2) Diagnosis: Based on clinical manifestations or confirmed by arthroscopy or MRI.

(3) Diagnostic treatment: Lidocaine injection is not effective.

Treatment

NSAIDs, rest and physical therapy are helpful. If ineffective, focal injection of steroids and surgery are indicated.

II. Rotator cuff tendinitis

See below.

Tendinopathy (Tendinitis and Tendinosis)

Tendinopathy is a clinical syndrome characterized by inflammation, swelling, tendon thickening and pain at tendinous insertions into the bone end due to overuse or occupational use. Common sites include the biceps, supraspinatus, wrist extensor, patellar, and Achilles tendons.

The common term tendinitis/tendonitis, which usually involves inflammatory injury, is confusing because inflammation is often not seen on histopathology. Tendinopathy is preferred to refer to acute and chronic pain associated with a tendon injury other than tendon tear or rupture. Tendinosis usually refers to chronic, degenerative change, mostly as overuse tendinopathy and with minimal inflammatory reaction.

Diagnosis and differentiation

Most cases are based on clinical manifestations.

1. Rotator cuff tendinopathy and supraspinatus tendinopathy:

(1) Shoulder abduction decreases; patient cannot actively raise arm above the shoulder level because of pain, which is usually on the lateral aspect of the shoulder but may be poorly localized and weaker than that of subacromial bursitis; drop arm sign is (+).

(2) It’s commonly seen in elderly patients (degeneration of tendons) and in young patients with frequent overhand lifting or throwing.

(3) Diagnostic treatment: Focal injection of steroid/lidocaine is effective. Diagnosis is best initiated by ultrasound and may be confirmed by arthroscopy or MRI. Other helpful therapies include NSAIDs, rest, and physical therapy.

2. Biciptal tendinitis:

Anterior shoulder pain and pain on flexion with forearm supinated and elbow extended (against resistance). Treatment: Rest, ice, tendon support, and NSAIDs.

3. “Tennis elbow”Lateral/extensional epicondylitis at the elbow:

(1) Caused by inflammation or degeneration of the extensor tendons of the forearm due to excessive supination/pronation.

(2) Pain worsens with resisted dorsiflexion of the wrist.

(3) Treatment: Splinting the forearm (not the elbow) is the initial treatment.

4. “Golfer elbow”Medial (flexors of forearm) epicondylitis:

(1) Caused by overuse of the flexor pronator muscle group.

(2) Pain distal to medial epicondyle; exacerbated by wrist flexion.

(3) Treatment: Rest, ice, tendon support, and NSAIDs. If pain persists > 6 months, surgery may be indicated.

5. Achilles tendinopathy:

This can affect both competitive athletes and recreational people. Acute tendon pain generally develops when athletes abruptly increase their training intensity. Chronic tendon pain (> 3 months) may result from sustained stress, poor running mechanics, or improper footwear. Rupture occurs when a sudden shear stress is applied to an already weakened or degenerative tendon.

Treatment: Rest, ice, tendon support, and NSAIDs. For chronic midportion tendinopathy (> 3-month symptoms), a rehabilitation program is recommended to emphasize resistance exercise using heavy loads. Tendon rupture is treated with surgical repair.

6. De Quervain tenosynovitis:

In the chronic stage, it is also characterized by a lack of inflammation and widespread degenerative and fibrotic changes affecting the sheath and the tendon itself.

(1) Inflammation of the abductor pollicis longus and extensor pollicis brevis tendons.

(2) Commonly seen in postpartum women and similar patients due to repeated baby-lifting, causing wrist pain/tenderness on the radial side (especially with pinch gripping). Finkelstein sign is usually positive (pain produced by ulnarly deviating the wrist with clenched thumb).

(3) Treatment: 1) Combined therapies of rest, splinting or immobilization, physical therapy (heat and ice), exercise modification, and NSAIDs. 2) If the above treatment fails, focal injections of lidocaine and long-active steroid are used. Repetitive focal injections should be avoided due to risk of rupture.

Pain Syndromes

Fibromyalgia

It’s a chronic non-inflammatory musculoskeletal pain syndrome with multiple tender points and weakness of the connective tissue. It’s very common in middle-aged women, and perhaps associated with depression, anxiety, or IBS (irritable bowel syndrome).

Essentials of diagnosis

1. Chronic multiple myalgias with more than 10 diffuse tender “trigger sites” that reproduce the pain at palpation, together with body stiffness, aches, numbness, fatigue, and insomnia.

2. Objective signs of inflammation are absent and lab tests are normal. Diagnosis is based on clinical manifestations and by exclusion.

Differential diagnosis

Myofascial pain syndrome:

There are “trigger points (small hard knots under skin) and less than 10 tender points in a regional area (whereas it’s widespread tender points with fibromyalgia), with shorter period of pain, and less other symptoms. Treatment: Trigger-point injection, acupuncture, physical therapy, topical capsaicin or lidocaine, and NSAIDs.

Chronic fatigue syndrome:

(1) It may be associated with EBV or mycoplasma infections. (2) Persistent fatigue, +/- low fever, pharyngitis, body aches, and depression. (3) EEG shows non-restoring sleep (alpha- and delta-wave). It’s diagnosed by excluding other similar disease. Treatment: 1) Psychological support. 2) Medications: Antidepressants (TCAs, amytriptyline), tryptophan (increasing 5-HT and sleep), and/or anti-mycoplasma drugs may be helpful.

Treatment

1. Supportive and physical therapy (stretching, heating, electrical nerve stimulation).

2. Medications: Low-dose TCAs (amytriptyline or cyclobenzapine) may be effective, especially with coexisting depression. Other medications are milnacipran (inhibitor of the reuptake of 5-HT and NE) and pregabalin (analgesic and anticonvulsant). NSAIDs are not effective because the disease is non-inflammatory. Prognosis varies.

Carpal Tunnel Syndrome

It results from compression of the median nerve within the tight confines of the carpal tunnel at the wrist, causing pain and paresthesia in median nerve distribution. It’s more common in people with risk factors: repeated wrist use (as with computer, music instrument), pregnancy, obesity, diabetes, wrist osteoarthritis/trauma, rheumatoid arthritis, acromegaly, hypothyroidism, amyloidosis, etc.

Essentials of diagnosis

1. Thenar and wrist pain or tingling radiating up the arm and exacerbated by flexing the wrist, and difficulty holding an ordinary object; usually worse at night.

2. P/E: (1) Weak grip and decreased thumb opposition with numb and tingling sense in the thumb and first-third digits. (2) Decreased 2-point sensation in the whole palm (except the radial part). (3) Possible thenar muscle weakness and atrophy.

3. Diagnosis is clinical, and can be confirmed by: (1) Abnormal EMG or reduced neurological conduction (#1 reliable test); or (2) Phalen’s sign (+): wrist flexing at 90o for 1 min causes numbness or pain (highly specific but lowly sensitive). Tinel’s sign is lowly sensitive and specific, and only for reference. Tinel’s sign (+): tapping on the wrist causes numbness/pain.

Treatment

1. Behavior modification of wrist motions (reduced use) is fundamental. The best initial treatment is to use wrist splints to immobilize the hand and relieve pressure.

2. Medicines: NSAIDs can reduce pain and inflammation. If it fails, focal steroids can be injected.

3. If symptoms persist, the effective therapy is surgical decompression or diversion of the transverse carpal ligament.

Complications

Permanent loss of sensation, strength, and fine motor skills of the hand can happen.

(Acute) Compartment Syndrome

It’s defined as acutely increased pressure within a confined space that decreases the perfusion and functions of the nerve, muscle, and soft tissue. It mostly occurs in the forearm and anterior compartment of the lower leg secondary to trauma with fracture or muscle injury.

Essentials of diagnosis

1. Typical pain out of proportion to the P/E findings: Obvious swelling after injury, severe pain with passive motion of the fingers and toes; “5P” featuresparesthesia, pallor, poikilothermia, paralysis, and pulselessness (late stage).

2. Diagnosis is usually clinical and can be confirmed by measurement of the compartment pressures (mostly > 30 mmHg).

Treatment

1. Immediately remove all external pressure on the compartment—any dressing, splint, cast, or other restrictive covering. The limb should be kept level with the torso, not elevated or lowered. Analgesics should be given and supplementary oxygen provided. Hypotension should be treated.

2. Urgent surgical fasciotomy to decrease the pressure and increase the tissue perfusion.

Dupuytren Contracture

It is a relatively common, benign, slowly progressive fibroproliferative disease of the palmar fascia, a hand deformity that usually develops over years.

Clinical features and diagnosis

1. Initial fascial thickening is painless and often goes unnoticed. As the disorder progresses, nodules form on the palmar fascia, and the finger gradually loses its flexibility, with contractures that draw one or more fingers into flexion. It is the hyperplasia of the palmar fascia that leads to nodule formation and contracture of the 4th and 5th fingers. Patient typically loses the ability to extend the fingers and feels embarrassed about it.

2. Pathologically, Dupuytren contracture is characterized by fibroblastic proliferation and disorderly collagen deposition with fascial thickening. There is a genetic tendency and association with alcoholism, cirrhosis, and systemic fibrosing syndrome.

Treatment

1. The goals of treatment are to improve flexibility of the fingers and to evaluate the need for surgery. Initial treatment is focal injection of glucocorticoids with triamcinolone, collagenase, or lidocaine.

2. If the function is impaired, surgical correction (open fasciectomy) is indicated. All patients should receive post-treatment exercises of range of motion stretching, with or without night splinting. Prognosis varies.