Causes include traumatic injury, degenerative changes, overuse, misuse, disuse
By David Spight, DO
From Minnesota Healthcare News
Musculoskeletal aches and pains are among the most common reasons patients visit their physicians. The causes can be complex, affecting joints, muscles, tendons, ligaments, or bursae. Treatment options for spine-related complaints include physical therapy, injections, and surgery.
Many musculoskeletal problems arise gradually as a result of degenerative changes that usually affect the joints, resulting in abnormal joint movement and function that can lead to pain and disability. Musculoskeletal problems can also result from overuse, misuse, disuse, or traumatic injury. While overuse and misuse injuries sometimes involve joints, they typically affect muscles, tendons, ligaments, and bursae.
Diagnosing the problem
Many people begin the diagnostic process with their family physician. Diagnosing musculoskeletal problems begins with a thorough patient history and neuromusculoskeletal evaluation. Imaging studies, including x-rays, CT scans, or MRIs, are ordered if a diagnosis cannot be made from these initial evaluations. Scans also are used to pinpoint the problem when conservative measures fail to improve symptoms, or if the pain is disabling and accompanied by limb pain or muscle weakness. Imaging studies of the spine must be interpreted with caution, as some imaging abnormalities do not necessarily relate to the patient’s symptoms.
Electrodiagnostic testing may also be conducted to help in diagnosis. Because nerves and muscles create electrical signals that carry messages to and from the brain, injuries that impact these nerves and muscles can affect the movement of these signals. Measuring the speed of a nerve and degree of electrical activity of a muscle can help a physician make a diagnosis. Two common forms of electrodiagnostic testing include electromyography (EMG) to record and analyze the electrical activity in the muscle and nerve conduction studies to determine if a nerve is functioning normally.
Neck and back pain
Neck and back pain can result from degenerative changes or traumatic injuries to the discs or facet joints of the spine. (Facet joints are the small, stabilizing joints located between and behind adjacent vertebrae.) Neck and back pain also can occur after traumatic or overuse injuries to the surrounding muscles and nerves. Fortunately, most spine-related complaints resolve spontaneously in a few days or a few weeks. Sometimes they can be helped with anti-inflammatory medication, physical therapy, or spinal manipulation. If history, physical exam, and imaging studies reveal nerve root impingement that has not responded to more conservative measures, a physician may use fluoroscopically guided epidural steroid injections to ease the pain. If there is profound muscle weakness associated with nerve root impingement, or if there is spinal cord compression, then surgery is warranted. Great advances have been made in spinal surgery. Physicians can replace damaged discs with bone grafts to fuse vertebrae together and stabilize the spine. In addition, a minimally invasive procedure called balloon kyphoplasty can now repair spinal fractures in an outpatient procedure.
For spine-related pain without nerve root or spinal cord compression, facet-joint injections with steroids or local facet-joint nerve block with anesthetic can be both diagnostic and therapeutic. The physician uses fluoroscopic imaging for guidance. When spinal facet joints are the source of pain radiofrequency ablation (using radio waves to destroy facet joint nerves), with raadiologic imaging for gui ance, can result in long-term benefit.
Because the shoulder is a very mobile joint, it is prone to degenerative changes and traumatic injuries. Shoulder pain usually involves the structures that surround the joint, including the bicep tendon, the rotator cuff tendons, and the bursa that separates the two major joints of the shoulder. Common problems include bicep tendinitis, rotator cuff tendinitis, and bursitis. Tendinitis is inflammation of a tendon; bursitis is inflammation of the bursa. The initial evaluation of shoulder-related complaints should include the cervical spine as well as the shoulder, because the cervical spine often refers pain to the shoulder.
Therapy for shoulder-related complaints is aimed at relieving pain and maintaining or restoring range of motion. Treatment begins with rest and a progressive program of stretching and strengthening exercises, which can be aided by non-steroidal antiinflammatory medications. Injections of steroids and local anesthetic into the subacromial bursa or into the shoulder joint with fluoroscopic guidance can also be helpful. If therapy is not successful, surgery can correct structural abnormalities.
Carpal tunnel syndrome
One of the more common complaints today is carpal tunnel syndrome, or compression of the median nerve at the wrist, often seen in patients who work at the computer all day or play video games to the extreme. Patients often complain of numbness, pain, or stiffness in the thumb, index, and middle fingers, sometimes awakening them from sleep. Electrodiagnostic tests, such as electromyography or nerve conduction studies, can confirm the diagnosis. Mild cases can be treated with splints, therapy, and local injections of steroids.More severe cases may require surgery.
The hip is one of the largest and most stable joints in the body, yet it can be affected by two common problems: trochanteric bursitis, or inflammation of the hip and thigh area, and hip fractures, often a result of osteoporosis in elderly individuals. If the hip is injured or has significant degenerative changes resulting in severe pain and impaired mobility, then replacement with a prosthesis is necessary, followed by post-operative rehabilitation.
The knee is the largest joint in the body and is susceptible to degenerative changes and traumatic injuries. Injuries to the knee can affect the meniscus (a disc of cartilage that serves as a cushion between bones) or some of the stabilizing ligaments, such as the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). Injury to the meniscus and ligaments can lead to pain, instability, and loss of function. Depending on the severity of the injury, treatment may range from physical therapy and rehabilitation to surgery and post-operative rehabilitation. Today, many traumatic injuries to the knee involving the ligaments and meniscus can be treated with minimally invasive arthroscopy. The small incisions lead to a quicker recovery. Severe degenerative changes of the knee often require open surgery with a prosthetic implant. Hip and knee replacements are the most common joint replacement surgeries performed today.
Ankle sprains are probably the most frequently reported sports-related musculoskeletal injury. Severe cases involving complete ligament rupture with significant functional loss and limited range of motion usually require surgery. Mild or moderate ankle sprains can be treated with rest, ice, compression, and elevation. Joint support may be provided with elastic wraps or braces.
Range-of-motion exercises and stretching of the calf muscles can begin during the acute phase, followed by full weight-bearing and strengthening exercises directed at the muscles that attach in and around the ankle. The majority of people with ankle sprains treated in this manner are ready to return to activity in one to three weeks.
While musculoskeletal injuries need to be evaluated by a physician, there are four things patients with mild or moderate injuries of the arms or legs can do to alleviate pain and swelling:
- Rest—Rest the injured limb.
- Ice—Apply ice wrapped in towels to reduce swelling.
- Compression—Use compression to reduce swelling and stabilize the joint.
- Elevate—Keep the arm or leg elevated.
All traumatic injuries or pain of gradual onset should be evaluated by a physician.
David Spight, DO, practices interventional physiatry at the Institute for Low Back and Neck Care in Minneapolis, Plymouth, Fridley, Waconia, and Faribault, and through the United Specialty Center at the Apple Valley Medical Center.