Musculoskeletal Injuries Case File

Musculoskeletal Injuries Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 12

A 25-year-old man presents to your office on a Monday morning with ankle pain. He was playing in his usual Saturday afternoon basketball game when he injured his right ankle. He says that he jumped for a rebound and landed on another player's foot. His right ankle "rolled over:' he fell to the floor, and his ankle immediately started to hurt. He did not hear or feel a pop. He was able to stand and walk with a limp, but was unable to continue playing. His ankle swelled over the next day in spite of rest, icing, and elevation. He suffered no other injury from the fall. On examination, he is a healthy appearing man with normal vital signs. The lateral aspect of the right ankle is swollen. The right ankle has normal dorsiflexion and plantar flexion and there is no focal tenderness to palpation of the fibula, malleoli, or foot. No ligamentous laxity is noted on testing. He can bear weight with minimal pain. There is normal sensation and capillary refill in the foot. The remainder of his examination is normal.

⯈ What is the most likely diagnosis of this injury?

⯈ What further diagnostic testing is needed at this time?

⯈ What is the most appropriate therapy?

ANSWER TO CASE 12:

Musculoskeletal Injuries

Summary: A 25-year-old man presents with an inversion injury of his right ankle that occurred during a basketball game. His ankle is swollen, but he is able to bear weight, and has no focal tenderness and no ligament laxity.

• Most likely diagnosis: Sprain of the right ankle
• Further diagnostic testing needed: None at this time
• Most appropriate initial therapy: "PRICE" therapy: Protection, Rest, Ice, Compression, and Elevation; a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen as needed for pain and early mobilization

ANALYSIS

Objectives

1. Learn an approach to the diagnosis of musculoskeletal injuries.
2. Know when to order imaging tests and which test to order to evaluate musculoskeletal complaints.
3. Be able to manage common joint sprains and strains.

Considerations

Ankle sprains are the most common acute, sports-related injury, and are a common reason for visits to primary care physicians, urgent care centers, and emergency rooms. As in this case, most ankle sprains are the result of landing on an inverted foot that is plantar flexed, such as landing on another player's foot in basketball, stepping in a hole or on uneven ground when running, missing a curb while walking. More than 20,000 people sprain their ankles every day in the United States. The lateral ankle is injured much more commonly than the medial ankle, with around 85% of all sprains involving the lateral structures. This is because the bony anatomy of the tibiotalar joint and the very strong deltoid ligament complex protect the medial ankle from injury. The lateral ligaments responsible for resistance against inversion and internal rotation-anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL)-are relatively weaker and more commonly injured. The ATFL is the most commonly injured ligament, followed by the CFL. Some common risk factors include previous ankle fracture, excess body weight, and an unconditioned body.

Ankle sprains are graded as grade 1, 2, or 3 injuries according to degree of severity. A grade 1 sprain is characterized by a stretch of a single ligament, most commonly the ATFL, but with minor swelling, no mechanical instability, and without significant loss of function. The patient can usually bear weight with, at most, mild pain. The history and examination of the patient in the case presented is consistent with a grade 1 ankle sprain. A grade 2 sprain represents a partial ligamentous tear. This injury causes more severe pain, swelling, and bruising. There is mild to moderate joint instability, significant pain with weight bearing, and loss of range of motion. A grade 3 sprain is a complete ligamentous tear. This injury causes significant joint instability, swelling, loss of function, and inability to bear weight.

The Ottawa Ankle Rules are a decision model designed to aid a phy sician in determining which patients with ankle injuries need an x-ray. These decision rules have been validated for nonpregnant adults who have a normal mental status, no other significant concurrent injury, and who are evaluated within 10 day s of the injury. When properly applied, the Ottawa Ankle Rules have a sensitivity approaching 100% in ruling out significant malleolar and midfoot fractures. These rules state that x-rays of the ankle should be performed if there is bony tenderness of the posterior edge or tip of the distal 6 cm of either the medial or lateral malleolus; tenderness in the midfoot coupled with point tenderness over the bony aspects of base on fifth metatarsal or the navicular; or if the patient is unable to bear weight immediately or when examined. Negative findings on Ottawa ankle rules safely eliminate the need for an x-ray. The patient presented, who has no bony tenderness, no limitation in weight bearing, and no contraindication to the application of the decision rules, does not need imaging of his ankle or foot. These rules, however, have a specificity of 30% to 50%, indicating that positive findings do not necessarily confirm a fracture, but confirms the need for x-ray to evaluate the possibility of a fracture.

Management of ankle sprains is geared toward decreasing pain and swelling, speed recovery, providing appropriate ankle support, and protecting against a recurrence of the sprain in the future. An easy way to remember the cornerstone of management of ankle sprains is by the mnemonic "PRICE."

Protection by appropriate splinting or casting can help to prevent further injury. Although initial rest during the acute phase marked by maximal pain and swelling is common sense, evidence has shown that prolonged rest is in fact inferior to early functional mobilization. Additionally range-of-motion exercises started early in the recovery period allow for a quicker recovery and return to activities than otherwise.

Ice applied as soon as possible after the injury helps to minimize swelling and relieve pain. Cryotherapy is now recommended in the first 3 to 7 days for shortterm pain relief and improved functionality.

Compression and elevation with an air stirrup brace with an elastic compression wrap also promote reduction of swelling. In most cases, NSAIDs or acetaminophen are adequate for pain relief. Surgery is rarely needed for ankle sprains, and its use is controversial even in the presence of chronic pain or persistent functional instability. Surgery for ankle sprains has been shown to increase stiffness in the joint, lead to longer recovery times, and result in impaired mobility when compared to conservative treatment only. Therefore, surgical consideration should be a last resort when all else has failed and should be discussed in a case by case manner.

Approach To:

Sprains and Strains

DEFINITIONS

SPRAIN: A stretching or tearing injury of a ligament.

STRAIN: A stretching or tearing injury of a muscle or tendon.

CLINICAL APPROACH

History

As in all areas of medicine, the history of the presenting illness will guide the diagnostic workup. In the history of a patient with musculoskeletal complaints, important information to gather includes whether the primary symptom is pain, limited movement, weakness, instability, or a combination of symptoms. The onset of the symptoms-whether acute, chronic, or an acute worsening of a chronic problemcan be significant. The location, severity, and pattern of radiation of pain should be delineated. Associated symptoms, such as numbness, should be identified. Efforts should be made to identify as specifically as possible the mechanism of any injury that led to the complaint. Interventions that have already been made, such as ice or heat, medications, splinting, and whether or not the interventions helped, should be noted.

Joint Examination

Examination of the musculoskeletal system should include documentation of inspection, palpation, range of motion, strength, neurovascular status, and, where appropriate, testing specific for the involved joint. Inspection should note the presence of swelling, bruising, deformity, and the use of any supports or assistive devices (eg, splints, crutches, bandages) that the patient is already using. Examination of the unaffected limb can provide a good comparison and allow for subtle changes to be more easily identified. Documentation should also be made of the patient's general functioning and mobility-does the patient walk with a limp, can the patient easily rise from a chair, is there difficulty getting on the examining table, is the patient's arm moving freely or held tightly to the patient's chest, and so on.

Palpation of the affected and surrounding areas can help to localize and confirm the presence of a specific injury. A focal area of bony tenderness may lead to the consideration of a fracture, whereas a tender, tight muscle may be more suggestive of a strain. The presence of joint effusions or soft-tissue swelling should be documented and may lead to consideration of specific injuries. Notation should be made of sensation, peripheral pulses, and capillary refill in the involved extremity. Absent pulses and delayed capillary refill, especially if the extremity is cool or cold, should prompt emergent evaluation and management of vascular insufficiency.

Range of motion should be tested both passively and actively. Active range of motion tests the patient's ability to move a joint. It tests the structural integrity of the joint, muscles, tendons, and neurologic impulses to the area and can be limited by problems with any of them or by the presence of pain. Passive range of motion tests the movement that an examiner can elicit in a relaxed patient. The presence of a dislocated joint or significant joint effusion may lead to limitations in both passive and active range of motion, where a torn tendon or muscle injury may have limited active, but preserved passive, range of motion.

Each joint or body area has specific examination maneuvers that can help to identify injury to specific structures. Reexamination 3 to 5 days after acute injury, when pain and swelling have improved, may help with diagnosis. Table 12-1 lists some common maneuvers that are used to examine the shoulder, knee, and ankle.

Imaging

Following the history and examination, the physician must decide when it is necessary to perform x-rays or other imaging tests. Validated decision rules are available to aid in some of these decisions. The Ottawa Ankle Rules for the determination of when an x-ray is necessary in an ankle injury were discussed earlier in this case. Similarly, the Ottawa Knee Rules can aid in the determination of when to perform an x-ray in a knee injury. The Ottawa Knee Rules recommend performing a knee x-ray on patients with a knee injury who have any one of the following five criteria: ( 1) age 5 5 or older, ( 2) isolated patella tenderness, ( 3) tenderness of the head of the fibula, ( 4) inability to flex the knee to 90°, and ( 5) inability to bear weight for four steps immediately and in the examination room (regardless of limping).

These rules were validated for, and should only be applied to, adults older than 18 years, although further study suggests that they may be valid in younger ages.

When a decision is made to perform an imaging test, whether to acutely rule out a fracture or to evaluate an injury that is failing to improve, the initial imaging study of choice is the plain x-ray. At minimum, an x-ray series should include at least two views at 90° angles to each other. In patients with normal x-rays and continued symptoms, or with suspected ligament or tendon injuries of the shoulder, ankle, knee, or hip, magnetic resonance imaging (MRI) has largely supplanted other modalities as the imaging method of choice. MRI is highly sensitive and specific for articular or soft-tissue abnormalities, including ligament, tendon, and cartilage tears.

Management Principles

The initial management of most acute sprains and strains is "PRICE" -Protection from further injury, relative Rest, Ice to reduce swelling and pain, Compression, and Elevation to reduce edema. In most cases, NSAIDs or acetaminophen are adequate for pain control, with narcotics used only when necessary.

Numerous studies show that early mobilization of injured ligaments actually promotes healing and recovery. Range-of-motion exercises should be started at 48 to 72 hours after injury in patients with sprains and strains. For lower-extremity injuries, protected weight bearing with orthotics is allowable, with advancement to unsupported weight bearing as tolerated. Crutches may be necessary initially because of painful weight bearing. Lace-up or semirigid ankle supports have been shown to be superior to tape and elastic bandages and provide stability to the injured ankle.

The most common cause of persistently stiff, painful, or unstable joints following sprains is inadequate rehabilitation. All patients with sprain or strain injuries should be educated on the importance of rehabilitative exercises. When possible, handouts with a specific exercise program should be given to the patient when the patient is evaluated. If the patient is unsuccessful in accomplishing this on his own, referral for a formal physical therapy program can be beneficial.

CASE CORRELATION

• See also Case 3 (Joint Pain, Gout).

COMPREHENSION QUESTIONS

12.1 Based on the Ottawa Ankle Rules, which of the following examination findings would make obtaining a radiograph most appropriate?

A. An 18-year-old athlete who injures his ankle during basketball but continues to play until the end of the game

B. A 33-year-old overweight woman who has multiple injuries, including ankle pain, following a motor vehicle accident

C. A 43-year-old man injured his ankle yesterday while playing volleyball and was unable to walk on it immediately afterwards

D. A 22-year-old woman seen in the emergency room (ER) immediately after falling while drunk and who falls asleep repeatedly during the examination

12.2 A 32-year-old man comes for evaluation of right shoulder pain that he has had for the past 3 weeks. He thinks that he injured it playing softball but does not remember a specific injury. There is no bruising or swelling. He gets pain in the joint on external rotation and abduction, but has preserved range of motion. Which of the following is the initial imaging test of choice?

A. X-ray

B. MRI

C. CT scan

D. Arthrogram

12.3 A 45-year-old woman comes in for follow-up of an ankle sprain that occurred while she was jogging 2 weeks ago. X-rays done at your initial visit were negative for fracture. She has been unable to run because of persistent stiffuess. She is frustrated as she states she has tried everything including ice, NSAIDs, bracing, and weight bearing as tolerated. Examination reveals no joint instability or focal tenderness. Which of the following is the most appropriate management at this time?

A. Referral for therapeutic ultrasound as this has shown to benefit patients who have failed conservative treatment.

B. Referral to chiropractor for soft-tissue techniques to loosen up the stiff muscles.

C. Change to another NSAID as the current one may not be strong enough.

D. Urge immobilization of the ankle as she may be doing too much too soon.

E. Discuss importance of rehabilitative stretching, strengthening, and range-of-motion exercises to gain functionality.

ANSWERS

12.1 C. The Ottawa Ankle Rules state that radiography should be obtained if there is pain in the malleolar area with point tenderness over the tip of lateral or medial malleolus, bony tenderness over area of base of fifth metatarsal or navicular bone, or an inability to bear weight for four steps immediately after the injury (answer choice C). These decision rules are not validated in patients with multiple painful injuries or with an altered mental status.

12.2 A. Plain film x-rays are the diagnostic imaging test of choice for the initial evaluation of the painful joint. In patients who have normal x-rays and who have a suspected soft-tissue (ligament, tendon, or cartilage) injury, MRI scanning is usually the next most appropriate imaging study to perform.

12.3 E. The most common cause of a stiff or painful joint following a sprain is inadequate rehabilitation. At 2 weeks postinjury, the patient is considered to be out of the acute phase and the focus should be on regaining range of motion and strength instead of NSAIDs, immobilization, or alternative

treatments (choices A, B, or C). Studies have not shown any benefit with therapeutic ultrasound or hyperbaric oxygen therapy for the treatment of acute ankle sprains.

CLINICAL PEARLS

⯈ A complete history and physical is essential in diagnosing and treating musculoskeletal injuries.

⯈ If you suspect that a patient's limited active range of motion is primarily a result of pain, you can numb the joint by injecting lidocaine into it and then reexamine the joint.

⯈ Use the uninjured, contralateral extremity as a comparison for your examination of an injured extremity.

⯈ An adequate x-ray series must include at least two views at 90° to each other.

REFERENCES

Brigham and Women's Hospital: Dept ofR ehabilitation Services. Standard of Care: Ankle Sprain. 2010. 

Burbank KM, StevensonJH, Czarnecki GR, DorfinanJ. Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008:77:453-460. 

Burbank KM, StevensonJH, Czarnecki GR, DorfinanJ. Chronic shoulder pain: part II. Treatment. Am Fam Physician. 2008;77:493-497. 

Hockenberry RT, Sammarco GJ. Evaluation and treatment of ankle sprains. Phys Sports Med. 2001:29(2):57-64. 

TiemstraJD. Update on acute ankle sprains. Am Fam Physician. 2012 Jun 15; 85(12):1170-1176. 

Trojian TH, McKeag DB. Ankle sprains: expedient diagnosis and management. Phys Sports Med. 1998:26(10):29-40.

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