Musculoskeletal and Soft Tissue Disorders - Mayo … and... · Musculoskeletal and Soft Tissue...
Transcript of Musculoskeletal and Soft Tissue Disorders - Mayo … and... · Musculoskeletal and Soft Tissue...
©2015 MFMER | slide-1
Musculoskeletal and Soft Tissue Disorders
• Brian Grogg, MD is a Consultant in the Department of Physical Medicine and Rehabilitation at the Mayo Clinic in Rochester, MN
• Dr. Grogg is an Assistant Professor in the College of Medicine
• He is board certified in PM&R • Clinical interests include utilizing ultrasound in
musculoskeletal medicine
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-2
Musculoskeletal and Soft Tissue Disorders Online Curriculum Brian Grogg, MD
Physical Medicine and Rehabilitation Board Review
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-3
Disclosures • Financial-None • Off Label Use-None
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-4
Objectives • Identify common musculoskeletal disorders • Know the management options for common
musculoskeletal disorders
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-5
Outline • Spine • Upper Extremity • Lower Extremity • Myofascial Pain • Arthroplasty Rehabilitation
©2015 MFMER | slide-6
Spine Disorders-General Principles • Anatomy
©2015 MFMER | slide-7
Spine Disorders-General Principles
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-8
Spine Disorders-General Principles • Red Flags
• gait disorder • weakness • bowel/bladder changes • night pain • unintentional weight loss • fever/chills • night sweats
Mayo Clinic Physical Medicine and Rehabilitation Board Review
Cuccurullo, S. 2004
©2015 MFMER | slide-9
Spine Disorders-General Principles • “Yellow Flags”—indicators of potential disability
• Fear-avoidance behavior • Medico-legal issues • Waddell’s (TORDS) • Mood disorder • History of abuse • Work-related disability—unhappy with
supervisor or job, missed time from work
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-10
Spine Disorders-Cervical Radiculopathy • Pain radiating from the neck into upper limb or
medial scapula region • Paresthesias and/or weakness • C6, C7 • Etiology: disc herniation, degenerative changes
resulting in foraminal narrowing • Management: medications, physical therapy,
epidural corticosteroid injections, surgery
Mayo Clinic Physical Medicine and Rehabilitation Board Review
Radharkrishnan, 1994
©2015 MFMER | slide-11
Spine Disorders-Cervical Stenosis
• Most common cervical cord lesion after middle age (Wilkinson, 1960)
• Degenerative changes narrow the spinal canal diameter (> 1/3) (Penning, 1986)
• Insidious weakness (LE>UE), gait disorder, bowel/bladder changes, may have UE radicular symptoms
• UMN findings on exam • Treatment: monitor/education, maximize
balance, surgery
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-12
Spine Disorders- Cervical Facet Syndrome • Facet joints are true
synovial joints
• Pain from arthritis, injury
• Clinical: primarily axial pain, exacerbated by extension, tenderness, decreased ROM
• (Cooper, 2007)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-13
Spine Disorders-Cervical Facet Syndrome • Imaging: degenerative changes, MRI with
periarticular edema or fluid within joint • Treatment:
• Medications • Manual medicine • Exercise program to promote proper posture • Injections • MBB/RFA
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-14
Spine Disorders-Scheuermann’s Kyphosis • Progressive thoracic kyphosis in adolescents • Disorder of vertebral endplates and apophysis • Kyphosis is fixed on exam • X-rays: Schmorl’s nodes and anterior wedging
of vertebral bodies • Treatment: spine stabilization, symptom
management • (Brown, 2004)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-15
Spine Disorders-Vertebral Body Fractures • Compression fractures, typically thoracic
• Etiology: osteoporosis, trauma, neoplasm
• Severe localized pain, often sudden
• Focal tenderness on exam
• X-ray: vertebral body compression
• MRI: vertebral body compression +/- edema
• Treatment: pain medications, bracing, hyperextension exercises, vertebroplasty/kyphoplasty, rarely surgery
• (Brown, 2004)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-16
Spine Disorders-Lumbar Facet Syndrome • Facet joints are true synovial joints • Pain from arthritis, injury • Clinical: primarily axial pain, exacerbated by
extension, tenderness, decreased ROM • Referral patterns vary
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-17
Spine Disorders-Lumbar Facet Syndrome • Imaging: degenerative changes, MRI with
periarticular edema or fluid within joint • Treatment:
• Medications • manual medicine • lumbar stabilization program • Injections • MBB/RFA
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-18
Spine Disorders-Lumbar Disc Disorders • Discogenic Pain: internal disc disruption, disc
degeneration
• Lumbosacral pain, may radiate to buttock or proximal LE
• Exacerbated by increasing disc pressure • sitting • cough/strain/sneeze • flexion
• Treatment: medications, lumbar stabilization, epidural?
• Controversial treatments: disc replacement, lumbar fusion, IDET
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-19
Spine Disorders-Lumbar Radiculopathy • Nerve root pain related to the lumbar spine • Mechanical compression or chemical irritation • Rare causes: infection, malignancy, fracture • L5 and S1 radiculopathies most common • Treatments: time, medications, relative rest,
exercise, epidural corticosteroid injections, surgery
• (Vad, 2002)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-20
Spine Disorders-Lumbar Stenosis • Central canal narrowing + neurologic symptoms • Neurogenic claudication: Lower extremity pain,
paresthesias, and/or weakness with standing/walking/extension
• Majority remain stable (Johnsson, 1992)
• Neurologic decline rare, no harm waiting for surgery (Amundson, 2000)
• Treatments: walker w/ seat, medications, ESI, surgery Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-21
Spine Disorders-Cauda Equina Syndrome • Rare condition affecting the nerve roots of the
cauda equina • Usually due to large disc herniation • Less likely caused by trauma, infection, tumor,
hematoma • Saddle anesthesia, bowel/bladder dysfunction,
LE pain/paresthesias/weakness • Treatment: Emergent surgery
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-22
Spine Disorders-Sacroiliac Joint Pain • Low back, buttock, or LE pain • No consistent history or exam findings • Etiology: degenerative, traumatic, hypermobile,
hypomobile, pregnancy, spondyloarthropathy • Treatment: Manual medicine, medications,
physical therapy, injections • Surgery is controversial
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-23
Spine Disorders-Infections • Osteomyelitis, discitis, epidural space, facet joint
• Typically presents with insidious back pain
• Risks: immunocompromised, IV drug use, DM, hemodialysis
• “Rule of 50” (Tali, 2004) • >50 y/o • 50% have nl WBC, fever, sx > 3 months • 50% lumbar • 50% originate in urinary tract
• Treatments: IV antibiotics 4-6 weeks
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-24
Shoulder Disorders-Glenohumeral Joint Osteoarthritis • Painful and reduced ROM • Risks: prior dislocations, trauma, fractures • ROM globally reduced and pain with movement
in all directions • Diagnosis: imaging and clinical • Treatments: medications, injections, TSA,
reverse arthroplasty with RTC deficiency
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-25
Shoulder Disorders-Rotator Cuff Disorders • Supraspinatus • Infraspinatus • Teres minor • Subscapularis
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-26
Shoulder Disorders-Rotator Cuff Disorders • Tendinopathy, SA/SD bursopathy, partial tendon
tears, complete tears, calcific tendonitis
• Etiology: trauma, repetitive microtrauma, external impingement, internal impingement
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-27
Shoulder Disorders-Rotator Cuff Disorders • Acromion Types
• Type I: flat • Type II: curved • Type III: hooked
• Risk of RTC tendon tears increases from I-III
• (Bigliani, 1986)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-28
Shoulder Disorders-Rotator Cuff Disorders • Anterolateral shoulder pain at night, with
abduction, internal rotation, overhead activities • PE: painful arc, Hawkin’s, Neer’s, Drop Arm
Test • Xrays, MRI • Treatments: medications, activity modifications,
subacromial corticosteroid injection, physical therapy, surgery
• Acute, full-thickness tears should receive surgery consult
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-29
Shoulder Disorders-Adhesive Capsulitis • “Frozen Shoulder”
• Painful restriction of shoulder ROM, fibrocartilaginous proliferation
• Decreased internal/external rotation on exam
• 2-5% of general population
• 2-4 x more likely in females
• DM
• 40-60 y/o
(Bunker 1995, Connolly 1998)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-30
Shoulder Disorders-Adhesive Capsulitis • Four Stages
• I: 1-3 months, painful movement but minimally restricted
• II: 3-9 months, painful movement with loss of motion
• III: 9-15 months, reduced pain but severely limited motion
• IV: 15-24 months, minimal pain and gradual improvement in ROM
• (Hannafin 2000)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-31
Shoulder Disorders-Adhesive Capsulitis • Treatment:
• Medications • Intraarticular Corticosteroid Injection • AAROM • Surgery
• Manipulation under anesthesia • Arthroscopic capsular release • Open release
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-32
Elbow Disorders-Olecranon Bursopathy • Swollen olecranon bursa • Etiology: trauma, inflammatory disorder • Redness, warmth may suggest infection • Treatment: protection, ice, aspiration to r/o
infection if clinically indicated
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-33
Elbow Disorders-Osteoarthritis • Painful, decreased ROM • H/o trauma • Osteoarthritis on xray • Treatment:
• Physical therapy • Medication • Injections • Surgical referral
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-34
Hand and Wrist Disorders-Ganglion Cysts • Cystic structure arising from synovium • Often painless • Dorsum of the wrist, “snuff box” • Treatment:
• monitor • aspiration (recurrence common) • surgical resection
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-35
Hand and Wrist Disorders-DeQuervain’s Tenosynovitis • Stenosing tenosynovitis of the first dorsal
compartment (APL, EPB) • Most common tenosynovitis of the wrist • Repetitive gripping • Tenderness to palpation, edema, Finkelstein’s
test • (Conklin et al, 1960)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-36
Hand and Wrist Disorders-DeQuervain’s Tenosynovitis • Finkelstein’s test
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-37
Hand and Wrist Disorders-DeQuervain’s Tenosynovitis • Treatment: activity modification, ice, NSAIDS,
physical therapy, corticosteroid injection • Injections 62-100% improved
• (Wood, 1986)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-38
Hand and Wrist Disorders-Osteonecrosis of the Lunate • Kienbock disease
• Vascular compromise of the lunate progressing to avascular necrosis
• Pain and stiffness • Diagnose:
• X-ray—scleroiscollapse • Bone scan, MRI
• Treatment: immoblization early, surgical referral
• (Stahl, 1947)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-39
Hand and Wrist Disorders-Stenosing Tenosynovitis • “Trigger Finger” • Catching/locking of the finger in flexion • Repetitive trauma, DM, inflammatory arthritis • Nodule forms on flexor tendonnodule passes
under A1 pulley upon flexioncaught upon extensionfinger locked in flexion
• Treatment: corticosteroid injection, surgery
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-40
Hand and Wrist Disorders-Carpal Tunnel Syndrome DoPhotoShop/Wikimedia Commons
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-41
Hand and Wrist Disorders-Carpal Tunnel Syndrome • Pain • Paresthesias in median innervated digits • Associations: pregnancy, DM, inflammatory
arthritis • Symptoms worse at night, wrist flexion • PE: Tinel’s, Phalen’s, Carpal Compression,
weakness/atrophy in advanced cases
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-42
Hand and Wrist Disorders-Carpal Tunnel Syndrome • Diagnose: Clinically, EMG, US
• Treatment: wrist splints, corticosteroid injection,
surgery
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-43
Hand and Wrist Disorders-Osteoarthritis • 1st CMC joint
• Common • Female • Pain, stiffness, tenderness • Diagnose: xray • Treatment: NSAIDs, acetaminophen, thumb
spica, corticosteroid injection, surgical referral
• (Peter, 1968)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-44
Hip Disorders-General Principles • Location
• Buttock, groin, anterior thigh
• Gait • Compensated Trendelenburg
• Aggravators • Crossing legs
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-45
Hip Disorders-Trochanteric Pain Syndrome • Gluteus medius syndrome, Trochanteric bursitis • History:
• Pain in lateral thigh with hip flexion and lying on the affected side
• Location: greater trochanter, ITB • Causes: trauma, weakness, pes planus
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-46
Hip Disorders-Trochanteric Pain Syndrome • Physical Examination
• Tenderness to palpation • Pain with ER>IR of the hip • Tight ITB • Pain associated weakness; compensated
trendelenburg • Pes planus
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-47
Hip Disorders-Trochanteric Pain Syndrome • Management
• US • Stretch ITB • Ice • Arch supports • Cane • NSAIDS • Injection
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-48
Hip Disorders-Avascular Necrosis of the Femoral Head • 15000-20000 new cases in U.S. per year • 10% of THA • 40-60% bilateral • Late 30s to 50s • Not likely in the elderly due to marrow changes-
--gelatinous marrow • (Lavernia, 1999)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-49
Hip Disorders-Avascular Necrosis of the Femoral Head
• Hemodialysis • Gaucher disease • Hemophilia • Hemoglobinopathies • Hypercoaguable state • Collagen vascular
disease/SLE • Smoking • Pregnancy
• (Mont, 1995)
• Etiology: • Trauma • Alcoholism • Corticosteroid • Caisson Disease • Pancreatic Disease • Radiation • Dialysis • Hyperlipidemia
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-50
Hip Disorders-Avascular Necrosis of the Femoral Head • Radiography
• Femoral head lucency, subchondral sclerosis
• Subchondral collapse (crescent sign), femoral head flattening
• Femoral head collapse, joint space narrowing
• MRI • Most sensitive, most
specific • Diffuse edema early (low
T1, high T2) • Edema becomes more
focal • Serpiginous line of low
signal intensity • SE T2: peripheral band of
low signal, inner aspect of band with high signal; “double-line sign”
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-51
Hip Disorders-Avascular Necrosis of the Femoral Head • Management
• Non-weight bearing • Core decompression
• Bone grafting • Vascularized fibular graft
• Resurfacing, bipolar arthroplasty • Total Hip Arthroplasty
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-52
Hip Disorders-Osteoarthritis History • pain in groin, buttock, lateral thigh and/or
anterior thigh • pain worse with weight bearing and rotation
(crossing legs, donning/doffing shoes)
• <15 minute stiffness after immobilization • Risks: age, trauma, developmental
abnormalities, repetitive heavy lifting/farming, obesity Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-53
Hip Disorders-Osteoarthritis • Physical Examination
• Compensated Trendelenburg gait
• Pain reproduced with IR>ER
• Positive Stinchfield and FABER
• Reduced ROM • Weak hip abductors
• Imaging • Osteophytes • Subchondral sclerosis • Subchondral cysts • Intra-articular loose
bodies
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-54
Hip Disorders-Osteoarthritis • Management:
• Education • Cane • Medications • Physical therapy • Injection
• Corticosteroid • Decrease pain, stiffness, and impairment up to 3
months • Viscosupplementation
• Studies suggest variable, modest outcomes • Surgery
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-55
Hip Disorders-Fractures • History
• Repetitive stress/overuse
• Osteoporosis • Groin and or thigh pain
with weight bearing
• Physical Examination • Hip joint provocative
tests positive • Fulcrum test • Pound test
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-56
Hip Disorders-Fractures • Compression type
• Most common • Inferior neck of femur • Can treat with non-
weightbearing (4-6 weeks) and progress weightbearing as tolerated
• Tension Type • Superior neck of femur • Treated with internal
fixation
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-57
Hip Disorders-Piriformis Syndrome • History
• Buttock and/or posterior thigh pain
• +/- paresthesias • Symptoms usually
worse with sitting; +/- walking and standing
• Physical Examination • Palpatory tenderness
over the piriformis, sciatic notch
• Pain with stretching
• Imaging
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-58
Hip Disorders-Piriformis Syndrome • Management
• Stretch piriformis • US • Myofascial release • Manual medicine • Injections
• Corticosteroid • Botulinum toxin
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-59
Knee Disorders-Patellofemoral Pain • History
• Anterior knee pain • Squatting, kneeling
• Physical Exam • Patellofemoral grind • patella alta, tight ITB,
increased Q angle
• Risk Factors: female, tight lateral retinaculum, VMO dysfunction, hip abductor weakness
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-60
Knee Disorders-Patellofemoral pain • Treatment:
• Medications • Taping • Bracing • Strengthen VMO and hip abductors • Stretch ITB, hip adductors, hamstring
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-61
Knee Disorders-Patellofemoral Pain • Chondromalacia patella
• Cartilage damage • Longstanding mal-tracking? Trauma? • Treatment:
• patellofemoral pain plus: • corticosteroid injections • viscosupplementation
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-62
Knee Disorders-Osteoarthritis • History
• Pain • Swelling • Stiffness • Exacerbated by weight
bearing and after prolonged immobilization
• Exam • Joint line tenderness • Effusion • Pseudo-laxity • Varus/valgus
deformities
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-63
Knee Disorders-Osteoarthritis • Risk Factor
• Age • Weight • Female gender • Trauma • Infection • Genetic • Metabolic disorders
• Ex. Hemosiderosis, acromegaly
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-64
Knee Disorders-Osteoarthritis • Treatment
• Weight loss • Exercise • Acetaminophen • NSAIDs • Capsaicin • Glucosamine • Injections
• Corticosteroid, viscosupplementation, PRP, stem cells
• Surgery Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-65
Foot and Ankle Disorders-Plantar Fasciitis • History
• Medial plantar heel pain
• Morning • After immobilization
• Exam • Tenderness-medial
plantar calcaneous • Pain with plantar fascia
stretching • Pes planus? • Pes cavus? • Tight GS complex?
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-66
Foot and Ankle Disorders-Plantar Fasciitis • Treatment
• Ice • NSAIDS • Modalities • Orthotic • Stretch GS complex and plantar fascia • Night splint • Injection • Surgery
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-67
Foot and Ankle Disorders-Osteoarthritis • Tibiotalar, subtalar, midfoot, forefoot • Pain, swelling, tenderness • Risks: trauma • Diagnose: clinically, x-ray • Treatment: acetaminophen, NSAIDS, bracing,
injections, surgery
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-68
Foot and Ankle Disorders-Morton’s Neuroma • Interdigital nerve irritation in the foot
• Most common—between 3rd-4th MT
• Insidious pain in MT head region
• Paresthesias
• Exam: tenderness, “click”
• Treatment: • unload the forefoot • distribute forces via orthotics • shoes with wide toe box • injection • surgery (Fitzgibbons, 1996)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-69
Myofascial Pain • Localized vs Diffuse • Diffuse, muscular pain, and tenderness
• Trigger Points • Fibromyalgia • Central Sensitization Syndrome
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-70
Myofascial Pain • Fibromyalgia
• 2-4% of population • 80-90% female • Diagnostic criteria, modified ACR 2010
• 19 painful/tender areas in the last week plus a patient reported score for—difficulty sleeping, fatigue, poor cognition, headaches, abdominal pain, depression
• > 3 months duration • No other explanation for symptoms
• (Bennett, 2014)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-71
Myofascial Pain • Fibromyalgia
• Treatment • Behavioral • Exercise • Tai Chi • Yoga • Antidepressants • Acupuncture • Gabapentin • Pregabalin • Duloxetine
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-72
Myofascial Pain • Central Sensitization Syndrome
• Appears to play role in FM and other chronic pain syndromes
• Repeated noxious stimuli in the dorsal horn of spinal cord sensitization or increased responsiveness hyperalgesia & allodynia
• Altered function of pain inhibitory/facilitory centers in the brainstem
• (Staud R, 2002 and Eriksen, 2004)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-73
Joint Arthroplasty Rehabilitation • Knee
• Rehabilitation protocols vary • Rehabilitation Effectiveness
• Improves early function and ROM • Does not improve early QOL or walking • No difference in therapy vs no-therapy for
any category at one year • (Minns Lowe, 2007)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-74
Joint Arthroplasty Rehabilitation • Knee
• Complications • Thromboembolic
• 2.1% • (White, 1998)
• Aseptic loosening • Knee stiffness • Neurologic injury (7.7%)
• peroneal, tibial • longer tourniquet time
• (Horlocker, 2006)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-75
Joint Arthroplasty Rehabilitation • Knee
• Long term exercise • Recommended: cycling, golfing, swimming,
walking, hiking, bowling • Allowed with experience: low-impact aerobics,
horseback riding, cross-country skiing, doubles tennis
• Not recommended: basketball, jogging, soccer, volleyball
• (Healey, 2008)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-76
Joint Arthroplasty Rehabilitation • Hip
• Rehabilitation protocols vary • Complications
• Dislocation 3-10% • Avoid flexion, adduction, IR
• Infection 0.2% • Thromboembolic • Nerve injury 0-3%
• Peroneal division of sciatic • Leg-length discrepancy
• Most often functional and resolves • (Barrack, 2004) (Soong, 2004)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-77
Joint Arthroplasty Rehabilitation • Hip
• Long term exercise • Hip group musculature weaker on involved side
• Recommended: cycling, golfing, swimming, walking, hiking, bowling
• Allowed with experience: low-impact aerobics, horseback riding, cross-country skiing, downhill skiing, doubles tennis
• Not recommended: basketball, jogging, soccer, volleyball
• (Healey, 2008)
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-78
References • Amundson T, Weber H, Nordal HJ, et al. Lumbar spinal stenosis:
conservative or surgical management? A prospective 10 year study. Spine 2000; 25(11):1424-35.
• Barrack RL. Neurovascular injury: avoiding catastrophe. J Arthroplasty 2004; 19(Supp 1):104-107.
• Bennett RM, Friend R, Marcus D, et al. Criteria for the diagnosis of fibromyalgia: validation of the modified 2010 preliminary American College of Rheumatology criteria and the development of alternative criteria. Arthritis Care Res 2014; 66(9):1364-73.
• Bigliani L, Morrison DS, April EW. The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans 1986;10:228.
• Brown DP, Freeman ED, Cuccurullo S. Musculoskeletal Medicine in Cucurrullo S ed. Physical Medicine and Rehabilitation Board Review. Demos Medical Publishing NY, NY 2004, pg 284-5.
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-79
References • Bunker R, Anthony PP. The pathology of frozen shoulder: a
Dupuytren-like disease. JBJS Br 1995;77:677-683.
• Conklin J, White W. Stenosing tenosynovitis and its possible relation to the carpal tunnel syndrome. Surg Clin N Am 1960; 40:531-40.
• Connolly J. Unfreezing the frozen shoulder. J Musculoskel Med 1998;Nov:47-58.
• Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Medicine 2007;8(4):344-53.
• Della-Giustina DA. Emergency department evaluation and treatment of back pain. Emerg Med Clin N Am. 1999; 17(4):vi-vii, 877-93.
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-80
References • Eiff M, Hatch RL, Calmbach WL. Carpal fractures. In Eiff M, Hatch
RL, Calmbach WL, eds. Fracture management for primary care. Philadelphia: Saunders; 1998:65-77.
• Eriksen HR, Ursin H. Subjective health complaints, sensitization, and sustained cognitive activation. J. Psychosom Res 2004;56:445-8.
• Fitzgibbons T, Keown B, Sampson C, et al. Foot Problems in Athletes. In: Mellion M ed. Office Sports Medicine 2nd Ed. Philadelphia: Hanley and Belfus; 1996:318-36.
• Hannafin J, Chiaia TA. Adhesive capsulitis. Clin Orthop 2000; 372:95-109.
• Healey WL, et al. Athletic activity after total joint arthroplasty. JBJS 2008; 90:2245-52.
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-81
References • Horlocker TT, et al. Anesthetic, patient, and surgical risk factors for
neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Anesthesia & Analgesia. March 2006; 102(3):950-55.
• Johnsson KE, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Clin Orthop 1992; Jun(279):82-6.
• Lavernia CJ, Sierra RJ, Grieco FR. Osteonecrosis of the femoral head. J of the Am Acad Orthop Surg 1999; 7(4):250-61.
• Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of phsyiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ 2007; 335:812.
• Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. JBJS Am 1995; 77(3):459-74.
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-82
References • Penning L, Wilmink JT, Van Woerden HH, et al. CT myelographic
findings in degenerative disorders of the cervical spine: clinical significance. AJR 1986; 7:119-27.
• Peter JB, Marmor L. Osteoarthritis of the first carpometacarpal joint. California Medicine 1968; 109(2): 116-20.
• Radharkrishnan K, et al. Epidemiology of Cervical Radiculopathy. A population-based study from Rochester, MN 1976-1990. Brain 1994; 117(pt 2):325-335.
• Soong M, Rubash HE, Macualy W. Dislocation after total hip arthroplasty. J Am Acad Orthop Surg 2004; 12(15):314-21.
• Stahl F. On lunatomalacia (Kienbock’s disease), a clinical and roentgenological study, especially on its pathogenesis and the late results of immobilization treatment. Acta Chir Scand (Suppl) 1947; 126:1-133.
Mayo Clinic Physical Medicine and Rehabilitation Board Review
©2015 MFMER | slide-83
References • Staud R, Simtherman ML. Peripheral and central sensitization in
FM: pathogenic role. Curr Pain Headache Rep 2002; 6:259-66.
• Tali ET. Spinal Infections. Eur J Rad 2004; 50(2):120-33.
• Vad VB, Bhat AL, Lutz GE, et al. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine 2002; 27(1):11-16.
• Wilkinson M. The morbid anatomy of cervical spondylosis and myelopathy. Brain 1960; 83:589-616.
• Wood M, Dobyns J. Sports-related articular wrist syndromes. Clin Orthop 1986; 262:93-102.
Mayo Clinic Physical Medicine and Rehabilitation Board Review