Document Title: Overuse Syndrome Joseph H. Hartmann, DO ...€¦ · • Passively dorsi-flex toes...
Transcript of Document Title: Overuse Syndrome Joseph H. Hartmann, DO ...€¦ · • Passively dorsi-flex toes...
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Project: Ghana Emergency Medicine Collaborative Document Title: Overuse Syndrome Author(s): Joseph H. Hartmann, DO License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
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Overuse Syndrome
Joseph H. Hartmann, DO
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A rose is a rose…
• Overuse syndrome • Repetitive stress disorder / injury • Repetitive motion disorder / injury • Repetitive strain disorder / injury • Cumulative trauma disorder • Musculoskeletal disorder
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What is it?
• Repetitive activity over a variable course of time resulting in damage to tissue, usually muscular or ligamentous / tendinous (nerve entrapment also included).
• Repetitive activities – Occupational – Recreational (sport-related) – Habitual (Nintendo thumb, Nintendinits,
gamer’s thumb, PlayStation thumb)
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Literary Digest, Wikimedia Commons
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Unknown, Wikimedia Commons
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Unknown, Wikimedia Commons
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Bart, Flickr
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Pathophysiology
• Tissue adaptation can not occur preventing healing
• Persistent trauma causes escalating injury – Mechanical effects – Biochemical effects
• Free radicals, prostaglandins, proinflammatory interleukins
– ? Genetic effects
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Clinical Presentation - Hx
• Begin with PQRST questions • More specific detailing of suspected
offending activity – Repetitive activity (mechanism) – Technique employed
• Limbs malpositioned from neutral position
– Equipment used / worn
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Clinical Presentation – P.E.
• Tenderness • Diminished ROM (active / passive) • Diminished strength • Tissue edema (?)
– Swelling of bursae, synovial sheaths • Evidence of musculoskeletal compensation • Classically recognized presentations
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Laboratory Studies
• May or may not be indicated • General metabolic
– CBC, comprehensive medical panel with liver function testing, TSH
• Rheumatologic – ESR, CRP, ANA, RPR
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Imaging Studies
• May or may not be indicated
– Acute on chronic injury – Significant worsening changes (unexplainable) – Mechanism of injury questioned
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Radiographs
• Bony avulsions • Stress fractures • Chronic tendonitis
– Calcification of tendons • Myositis ossificans
• Bone scan / CT – Stress fractures
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Source Undetermined
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Source Undetermined
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Source Undetermined
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Ultrasound
• Ligament and tendon pathology – Opportunity for dynamic examination
• Higher resolution transducers provide higher spatial resolution rivaling MRI
• Procedural and professional costs are 20% that of comparable MRI study
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Magnetic Resonance Imaging
• Historically more effective with acute injury than with more subtle findings associated with chronic injury
• Newer generation units, increasing experience, use of gandolinium enhance-ment with fat saturation (identifies inflamma-tion) has provided excellent soft-tissue resolution
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Electrodiagnostic Studies
• EMG - NCT – Peripheral nerve compression / injury
• Location • Severity
• MRI ?
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Treatment • Rest • Analgesics • Immobilization (?) • Physical therapy
– Supervised • To more carefully plan tx program • Use of modalities • Patient education
– Home exercise program
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Treatment
• Occupational therapy – Tailor physical therapy – Identify workplace modifications
• Sports medicine therapy – Sport specific physical therapy – More knowledgably address
• Training issues • Technique flaws • Ill-fitting equipment
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Treatment
• Steroid injections – Ligaments and tendons can undergo structural weakening leading to potential rupture
• Surgery – Failed conservative management
• Nerve decompression • Ligament repair (laxity)
– Dismal outcomes if performed for subjective pain relief without objective findings
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Shoulder
• Impingement syndrome – Compression of supraspinatus tendon and
subacromial bursa – Pain with abduction (Neer maneuver) and
flexion / internal rotation (Hawkins maneuver) – Subacromial tenderness – Normal ROM – Normal strength
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National Institute Of Arthritis And Musculoskeletal And Skin Diseases, Wikimedia Commons
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Elbow • Epicondylitis
– Lateral epicondylitis • Extensor carpi radialis brevis and longus • “tennis elbow”
– Medial epicondylitis • Flexor carpi radialis • “golfer’s elbow”
– Pain with strong gripping – Decreased grip strength – Normal ROM
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Gray’s Anatomy, Wikimedia Commons
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Wrist and Hand
• Carpal tunnel syndrome – Median nerve entrapment – Symptoms typically worse at night – Typical sensory distribution – Flattening of thenar eminence – Thumb adduction weakness – Hoffman-Tinel test – tapping – Phalen maneuver - flexion
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Gray’s Anatomy, Wikimedia Commons
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Wrist and Hand
• deQuervain’s tenosynovitis – Involves abductor pollicus longus and brevis – Repetitive gripping / grasping motions – Local tenderness over radial styloid region – Pain with resisted thumb extension/abduction – Pain with passive ulnar deviation with thumb
adducted in palm – Finkelstein maneuver
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PhilippN, Wikimedia Commons
Gray’s Anatomy, Wikimedia Commons
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Hip
• Snapping hip syndrome – Usually from “iliotibial band snap”
• Snapping of thick,wide iliotibial tendon over greater trochanter with hip extension
– Snapping sensation – Audible “pop” – Commonly seen in runners – May cause a trochanter bursitis
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Beth Ohara, Wikimedia Commons
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Gray’s Anatomy, Wikimedia Commons
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Knee
• Patellofemoral pain syndrome (chondromalacia patella) – “runner’s
knee” – Pain posterior to patella / anterior knee – Pain with compression of patella or with resisted
knee extension – Repetitive irritation – increased lateral forces on
patella – More commonly seen in women (anatomy)
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Kari Stammen, Wikimedia Commons
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Medial Tibial Stress Syndrome
• “shin splints” • Posteromedial margin of tibia • Dull aching discomfort relieved by rest • Progresses to worsening discomfort not
relieved by rest • ? Hyposthesia over fourth toe • r/o stress fx – “female athlete triad”
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en:Anatomography, Wikimedia Commons
Gray’s Anatomy, Wikimedia Commons
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Chronic Compartment Syndrome • Masquerades as other pain syndromes • Aching pain or cramping within 10-30 min in region of particular compartment • Exaggeration of normal exercise response
– Increased blood flow = increased muscle volume = decreased blood flow = compartment pressures above 20 mmHg
• Return to normal function between episodes • Non-urgent fasciotomy (?)
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Sarte, Wikimedia Commons
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Ankle / Foot
• Achilles tendonitis – Heel pain – Worse with dorsi-flexion – Retrocalcaneal bursa involvement
• Swelling, erythema, warmth
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Gray’s Anatomy, Wikimedia Commons
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Posterior Tibial Tendonitis
• Pain over medial ankle – Worse with inversion – Inability to stand on toes – Tenderness over tendon sheath – Often pronated flat foot found = overly-inverted
• Tarsal Tunnel Syndrome – Nerve entrapment of posterior tibial nerve
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Plantar Fasciitis
• Involves plantar aponeurosis • Plantar heel and / or mid-foot pain • Passively dorsi-flex toes and palpate sole • Bilateral presentation 1/3 of patients
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Wikimedia Commons
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Lucien Monfils, Wikimedia Commons
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Davius, Wikimedia Commons
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Finally • Lengthy recovery times
– 4 – 6 weeks common – 6 months possible
• Return to pre-injury activities – Complete resolution on pain – Full range of motion – At least 90% recovered strength
• Prevention – Education – Modification