MEDICAL SCHOOLFOR CLAIMS EXAMINERS & ATTORNEYS

DWC 2020

• MUSCULOSKELETAL & NERVE COMPRESSION DISORDERS• MYOFASCIAL PAIN SYNDROME & FIBROMYALGIA• OSTEOARTHRITIS• THORACIC OUTLET SYNDROME (TOS)• SHOULDER PAIN & INJURIES• ELBOW & FOREARM PAIN & INJURIES• ULNAR NERVE COMPROMISE AT THE ELBOW• CARPAL TUNNEL SYNDROME• HAND INJURIES• LOW BACK PAIN & INJURIES• LUMBAR SPINAL STENOSIS• HIP PAIN & INJURIES• KNEE PAIN & INJURIES• ANKLE & FOOT INJURIES

• CHRONIC PAIN DISORDERS• NEUROPATHIC PAIN• COMPLEX REGIONAL PAIN SYNDROME (CRPS)• HEADACHES: EVALUATION & TREATMENT

Summary of Topics

Musculoskeletal System

• Musculoskeletal system– Bones– Joints– Supporting soft tissue structures

• Muscles• Ligaments• Tendons• Bursa

Nerve Compression Disorders

• Nerve Compression Disorders– Spinal cord – Nerve roots– Brachial & lumbar plexus– Peripheral nerves

What are tendons? Tendons are rope-like

structures attaching muscleto bone.

Stretched Tendon

Stretched Muscle

What are ligaments? Ligaments are rope-like

structures attaching bone to bone.

Stretched/Tearingligament

Misaligned joint

Irritated nerve

Defined as Sprain: Injury to a ligament

(bone to bone fibers) Strain: Injury to muscle or

tendon (muscle to bone fibers) Graded according to the

extent of injury Causes pain, swelling &

bruising

Generally graded by level of damage and instability of involved joints:

Grade 1 sprain: Stretching and some damage to the fibers of the ligaments.

Grade 2 sprain: Partial tearing of the ligaments. If the joint is examined, abnormal looseness (laxity) of the joint can be felt.

Grade 3 sprain: Complete tear of the ligaments. Pulling or pushing on the joint produces gross instability.

Muscle injuries can be categorized into three grades, as follows:

• Grade 1: Mild damage to individual muscle fibers (less than 5% of fibers) that causes minimal loss of strength and motion.

• Grade 2: More extensive damage with more muscle fibers involved.

• Grade 3: Complete rupture of a muscle or tendon.

Muscle guarding is defined as: The hypertonic reaction of muscles

to localized pain, usually associated with movement that aggravates the pain.

Muscle guarding is defined as: The hypertonic reaction of muscles

to localized pain, usually associated with movement that aggravates the pain

Usually associated with injury. A protective mechanism post injury.

Muscle spasm is defined as: Sudden, involuntary contraction of a

muscle or a group of muscles. Usually after acute injury or due to

overuse, dehydration or electrolyte imbalance.

Causes:

Repetitive motion resulting in accumulation of micro-injuries without recovery time.

Long, uninterrupted hours of activities, using computers, manual labor, professional athletes.

Symptoms are burning, stinging, aching, tenderness to touch, stiffness, tingling and numbness.

Direct causes may include:

Disuse atrophy, due to lack of physical exercise.

Bedridden patient can have significant muscle wasting

Neurogenic atrophy as a resultof injury or disease of nerve thatsupplies trophic function to the affected muscle(s)

May not be evident when there is spasticity (i.e., from Brain or SCI)

Normal Atrophic

Myofascial Pain Syndrome& Fibromyalgia

Myofascial Pain Syndrome (MPS)

• MPS refers to soft tissue tenderness and pain with a specific zone of discomfort or pain ("trigger point") within the muscle that triggers pain that refers away from the trigger point to contiguous areas

• Muscle spasm, tenderness, stiffness, limitation of motion, and weakness

Fibromyalgia (FM)

• 80 to 90% women, usual ages 20 to 55 years• Widespread musculoskeletal pain

– Myalgias and fatigue in more than 90% + tender points• Cognitive disturbances• Psychiatric symptoms

– Depression and/or anxiety 30–50% of patients• Headaches• Paresthesias

– Numbness, tingling, burning or creeping/crawling sensations• Sleep disturbances• No identifiable cause

MPS & FM

• No objective tests• Treatment

– Passive therapies• Heat, cold, acupuncture• Trigger (MPS) or tender (FMS) point injections

– Active therapies• Stretching, strengthening and conditioning, aerobic exercise

– Medications (non-opioid)• Acetaminophen, NSAIDs, antidepressants

– Psychological approaches• biofeedback, psychotherapy, cognitive-behavioral therapy

DEGENERATIVE JOINT DISEASE (DJD) OSTEOARTHRITIS (OA)

• Common– Normal finding after age 40 often w/o symptoms– 25% of population symptomatic after age 50

• Cause– Mostly unknown– Genetic component– Secondary to normal wear-and-tear, prior

trauma, joint misalignment, infection

DEGENERATIVE JOINT DISEASE (DJD) OSTEOARTHRITIS (OA)

• Spine & Joints• Presentation

– Pain with motion or weight bearing– Stiffness with rest, somewhat relieved with use– Swelling– Crepitus (grinding and popping of the joint with

motion) is caused by motion of the irregular joint surface

NECK PAIN

• Ubiquitous in society• So common that the expression "a pain in

the neck" has become a figure of speech• Causes for cervical problems include

– disc degenerative disease (spondylosis)– damage to the spinal cord (myelopathy) or nerve roots

(radiculopathy)– muscular or myofascial syndromes– other more ominous spinal and non-spinal conditions

NECK PAIN

• Cervical (Degenerative) Spondylosis– occurs over time due to cumulative

and specific trauma– normal aging process and a common

x-ray finding in older individuals– While in the majority of cases,

cervical spondylosis is not associated with significant symptoms, it can be associated with muscular and neurologic dysfunction along with pain and disability

NECK PAIN

• Cervical Myelopathy– Compression and injury to the

spinal cord secondary to trauma or degenerative changes

– Typically after the 5th decade– Slow progressive history of

neurologic deterioration with remissions and exacerbations

– Gait disturbance with lower extremity increased reflexes and tone

– May be bowel and bladder dysfunction

NECK PAIN

• Cervical Radiculopathy– Compromise and damage of the

nerve root arising from compression secondary to disc herniation, cervical spondylosis or stenosis, tumor or trauma

– The symptoms of cervical radiculopathy can include pain, abnormal sensations (paresthesias) and weakness

– Complaints may involve the neck and upper back and/or the upper extremity

Thoracic Outlet SyndromeCompression of the nerves (brachial plexus) and/or the vessels (subclavian artery and vein) to the upper limb

TOS Symptoms

• Tingling, numbness, weakness and discomfort particularly down the inside of the arm going into the hand

• Swelling, paleness and coldness of the arm and hand

• Related symptoms may include headaches in the back of the head and pain in the neck, shoulder and arm

TOS Symptoms

• Symptoms elicited by overhead activities such as hair combing or sleeping on one side which can put pressure on the structures within the thoracic outlet

• Each of these maneuvers/positions causes a tightening or compression of the thoracic space and thus the nerves and/or blood vessels may be compromised and produce the associated symptoms

TOS Diagnosis & Treatment

• Diagnosis– Physical exam– X-ray and specialized MRI– Electrodiagnostic testing of limited value

• Treatment (Edgelow Protocol)– Education – Alleviation or reduction of compression– Postural training & weight loss– Gentle stretching and strengthening– Avoid surgery if possible

The shoulder joint is the most movable joint in the body.

This mobility is responsible for the shoulder’s instability, making it the most often dislocated joint in the body.

SHOULDER INJURIES

• Shoulder injuries may result from– specific acute– traumatic events– repetitive overuse

activities

Intrinsic Shoulder Disorders

• Two types: Overuse & Traumatic– Impingement syndrome– Bicipital & calcific tendinitis– Glenohumeral instability– Degenerative arthritis– Adhesive capsulitis

One of the most common causes of pain in the adult shoulder

Results from pressure on the rotator cuff due to misalignment of bony structures, often due to trauma

Extrinsic Shoulder Disorders

• Extrinsic disorders originating outside the shoulder may refer pain to the shoulder and present a diagnostic challenge

• Pathology involving the cervical spine, brachial plexus, visceral disease (e.g., gallbladder disease) or neoplastic disease may be culprits

Elbow Anatomy

• A hinge and pivotal joint that has the primary function of positioning the hand

• Movements include:– flexion and extension– Rotation

• pronation (palm downward)

• supination (palm upward)

ELBOW AREA INJURIES

• Typically pain, stiffness and/or swelling• Pain and swelling soon after injury may be

due to a fracture or tendon dislocation• Olecranon bursitis suspected with a

bulbous swelling with redness and warmth• When sudden swelling and pain are

present, consider infection or an inflammatory condition such as gout or rheumatoid arthritis

Epicondylitis

• An epicondylitis involves tissue degenerative or tendinosis

• Common and develops from overuse of the forearm muscles in motions that require rotation of the forearm and movements of the wrist

Epicondylitis

• Lateral epicondylitis or "tennis elbow" describes a condition characterized by lateral elbow pain

• Medial epicondylitis or "golfer’s elbow" occurs on the inside of the elbow and is usually seen in occupations that require repeated contractions of the flexor and pronator muscles

Ulnar Nerve Compromiseat the Elbow

• Medial elbow and forearm pain• Tenderness and/or nerve

enlargement• Numbness, tingling and coldness

in the region innervated by the ulnar nerve

• Weakness and atrophy in the muscles supplied by the ulnar nerve

• There can also be a burning, hypersensitivity type of pain

Differential Diagnoses

• C8 and/or T1 cervical radiculopathy• Brachial plexus compromise

– Thoracic outlet syndrome– Pancoast tumor– Space occupying lesion

• Ulnar nerve compromise at the wrist or elsewhere

One of the most common injuries. Often occurs as a result of fall on an

outstretched hand Symptoms

Swelling in the wrist Pain at the time of the injury Persistent pain with wrist movement Bruising or discoloration of the skin Tenderness at the injury site A warm or feverish feeling to the skin

around the wrist

Palmar wrist ligaments

Wrist: Carpal Tunnel

Defined as

Entrapment leading to pressure on the median nerve

Related to repetitive trauma

Signs are median nerve numbness, tingling, weakness

Often bilateral Causes early morning awakening Symptoms worse with use

Causes of CTS

• Medical Conditions– Diabetes, neuropathy, pregnancy, etc.

• Job-related Factors– Stressful postures, vibration, cold exposure, excessive

strength requirements, poor gripping surfaces, and repetitive movements of the fingers and wrists

• Avocational activities– such as home-building projects, gardening, sewing,

crocheting, knitting, racket sports and throwing, etc.

Low Back Pain

• Although back pain is among the most common of human conditions, fortunately the majority of causes are benign

• Commonly related to musculoligamentous injuries and age-related degenerative changes followed by disk herniation and spinal and foraminal stenosis

• Some 60% of patients recover in a week, and about 90% in 6 weeks

Defined as: Narrowing of the spinal

canal or neuroforamina, as a result of advanced degenerative disease of the disc, bone and ligaments

Grade II SpondylolisthesisAt L5 on Sacrum

CAUDAEQUINA

Manifested by Bowel and/or

bladder dysfunction Saddle anesthesia Variable loss of leg

motor and sensory function

Sphincter tone loss Diminished or

absent leg reflexes

Hip Pain & Injuries

• Determining source of hip pain often challenging as may occur as a result of – direct injury– cumulative trauma– lighting up an underlying

degenerative process• Hip dysfunction presents

both with localized and referred pain complaints– Groin– Knee

Hip Pain Musculoskeletal Causes

• Osteoarthritis • Bursitis • Avascular Necrosis (Osteonecrosis) • Inflammatory Arthritis • Stress Fractures • Traumatic Fracture • Pathologic Fracture • Post-Surgical • Metabolic Conditions

Mimickers of Hip Pain

• Degenerative Disk Disease • Spinal Stenosis • Facet Joint Arthropathy • Knee Osteoarthritis• Hernias • Aneurysms• Atherosclerosis • Meralgia Paresthetica • Thrombophlebitis • Cellulitis • Abdominal Disease & Retroperitoneal Pathology

The KNEE

• Largest joint in the body• Functions as a hinge joint • Provides a fairly wide range of motion• Knee susceptible to trauma - not protected

by layers of muscle or fat and is located at the end of two long lever arms

The KNEE

Knee Injuries

• History often of a twisting episode followed by swelling, clicking, popping, grinding, giving way (buckling) or locking

• Many areas around the knee can be injured, but the most common are the cartilage (menisci) and ligaments

Defined as: Stretching or tearing of

the ligaments supporting the knee.

Most commonly involved are the MCL, the LCL and the ACL

Knee Bursitis

• Bones, ligaments, tendons and muscles are kept from rubbing each other by four small fluid filled sacs call bursae

• Bursae susceptible to an inflammatory response from direct/indirect trauma

• Prepatellar bursa most commonly affected area and may present with a significant swelling

Menisci made of tough cartilage. Primary Functions: Shock absorbers Stabilizers in the knee Distributes body weight across knee

Cause of meniscal tears: Trauma Degenerative aging processes Medial > Lateral meniscus tears

Common symptoms: Knee pain, tenderness & swelling Popping or clicking within the knee Limited motion of the knee joint

Patellofemoral Pain

• Accounts for 25% of all knee injuries

• Nearly all patellofemoral disorders can be traced to knee malalignment

• Wear and tear leads to cartilage softening (chondromalacia)

Knee Osteoarthritis (DJD)

• Most common joint to be involved in DJD

• May result from early life injury or prior surgery

• Develops over many years• Abnormal knee wear from:

– Fractures involving the joint– Instability from ligament tears, and

meniscal injuries• Obesity a causative risk factor• SX = pain, swelling & stiffness• TKR = end treatment

Sprained or twisted ankle, common cause of ankle pain

Inversion sprain most common damaging outside ligaments

Swelling & bruising common symptoms

Can cause lateral malleolus Fx Eversion injuries less common

and cause medial malleolus Fx

Neuropathic Pain

• Pain related to the nervous system• Central (brain and spinal cord)

• Multiple sclerosis, poststroke pain, spinal cord injury–related pain, postherpetic neuralgia, etc.

• Peripheral (nerves)• Polyneuropathy (diabetes; chemotherapy)• Radicular pain (from injury to a nerve root)• Postsurgical chronic neuropathic pain.

Neuropathic Pain

• Pain related to nervous system injury or disease

• Clinical presentation includes descriptions of burning, pins and needles (paresthesia), tingling, numbness, electric shocks/shooting, crawling, itching, and intolerance to temperature

Complex Regional Pain Syndrome

Reflex Sympathetic Dystrophy & Causalgia

What is CRPS?

• Term CRPS is meant as a descriptor– no assumptions about pathophysiology

• CRPS is a syndrome– Symptoms and signs match criteria

• CRPS is Uncommon– most patients with widespread pain in an

extremity do NOT have CRPS– more appropriate to describe a patient as

having "regional pain of undetermined origin"

CRPS Etiology

• Cause: why some and not others?• No obvious etiology• Nerve injury or minor trauma• Limb surgery post-operatively

CRPS

• CRPS describes an array of painful conditions that are characterized by a continuing (spontaneous and/or evoked) regional (not in a specific nerve territory or dermatome) pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or other lesion

R. Norman Harden, et. al.: Proposed New Diagnostic Criteria for Complex Regional Pain Syndrome, in Pain Medicine, Volume 8, Number 8, 2007.

CRPS Presentation

• Gradual or abrupt onset of severe aching,throbbing and burning pain at the injury site

• Increased sensitivity to touch, swelling,muscle spasm, stiffness and limited mobility

CRPS Presentation

• Skin initially usually warm, red and dry & changes to cyanotic, cold and sweaty

• There may be accelerated hair & nail growth and the nails may become cracked, grooved or ridged

CRPS Presentation

• Osteopenia• Pain increased by dependency of the

affected limb, physical contact (the touch of clothes or bed sheets) or emotional upset

• Visual & auditory stimuli may aggravate pain

• Muscles spasm progressing to wasting• Increasing loss or ROM

CRPS Presentation• Pain may spread proximally or to other

limbs• Pain may become intractable in some or

may lessen or stabilize• Dystrophic changes become more distinct

and irreversible tissue damage occurs– muscles atrophy, contractures develop, and

the skin becomes thin and shiny– The nails are increasingly brittle and ridged– There is marked, diffuse osteoporosis

Treatment Approach

• Early diagnosis should be followed by a multi-faceted program involving:– blockade of sympathetic hyperactivity– physical rehabilitation– psychological care– Education– medication optimization– functional restoration