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125 Cards in this Set
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Case: 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.
What is the most likely diagnosis? |
Sprain of the right ankle |
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Case: 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.
What further diagnostic testing is needed at this time? |
None |
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Case: 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.
What is the most appropriate initial therapy? |
"PRICE" therapy: - Protection - Rest - Ice - Compression - Elevation
NSAIDs or Tylenol as needed for pain Early mobilization |
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What is the most common acute, sports-related injury? |
Ankle sprains |
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What is the most common cause of ankle sprains? |
Ankle inversion while plantar flexed (e.g., landing on another player's foot in basketball, stepping gin a hole or on uneven ground when running, missing a curb while walking) |
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Which side of the ankle is more likely to be sprained? |
The lateral side because the bony anatomy of the tibiotalar joint and the very strong deltoid ligament complex protect the medial portion from injury |
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What are the ligaments of the lateral ankle? |
- Anterior Talofibular Ligament (ATFL) - Calcaneofibular Ligament (CFL) - Posterior Talofibular Ligament (PTFL) |
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What is the most commonly injured ligament of the ankle? |
Anterior Talofibular Ligament (ATFL) >> Calaneofibular Ligament (CFL) |
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How do you evaluate the severity of an ankle sprain? |
Grade: 1, 2, or 3 injuries
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What are the characteristics of a grade 1 ankle sprain? |
- Stretching of ATFL - Pain and swelling - No mechanical instability - Little to no functional loss - Patient can usually bear weight with at most mild pain |
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What are the characteristics of a grade 2 ankle sprain? |
- Partial tear of the ATFL and stretching of the CFL - More severe pain, swelling, and bruising - Mild to moderate joint instability - Significant pain with weight bearing - Loss of range of motion |
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What are the characteristics of a grade 3 ankle sprain? |
- Complete tear of ATFL and CFL with partial tearing of the PTFL - Significant joint instability - Loss of function - Inability to bear weight |
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How can you determine whether a patient with an ankle injury needs an x-ray? Criteria for use? |
Ottawa Ankle Rules (can be used on non-pregnant adults who have a normal mental status, no other significant concurrent injury, and who are evaluated within 10 days of injury) |
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How effective are the Ottawa Ankle Rules? Function? |
They have a sensitivity of near 100% in ruling out significant malleolar and midfoot fractures |
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What are the Ottawa Ankle Rules? |
X-rays of the ankles should be performed if: - Bony tenderness of the posterior edge or tip of the distal 6 cm of either the medial or lateral malleolus - Bony tenderness over the navicular bone (medial midfoot), the base of the fifth metatarsal (lateral midfoot) - Patient is unable to bear weight immediately or when examined
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What is the "PRICE" mnemonic for? |
Management of ankle sprains: - Protection by appropriate splinting or casting can help prevent further injury - Rest from activity helps promote ligamental healing, although weight bearing can be allowed as tolerated and early, functional rehab exercises are crucial - Ice applied ASAP after injury minimizes swelling and relieves pain - Compression also promotes reduction of swelling - Elevation also promotes reduction of swelling |
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What is the difference between a strain and a sprain? |
- sPrain: stretching/tearing of a LIGAMENT - sTrain: stretching/tearing of a MUSCLE or TENDON |
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What history should you assess in a patient with musculoskeletal complaints? |
- Whether the primary symptom is pain, limited movement, weakness, instability, or combination - Onset of symptoms - acute, chronic, acute worsening of chronic problem - Location - Severity - Pattern of radiation of pain - Associated symptoms: numbness, tingling - Identify mechanism of injury - Interventions that have already been used, e.g., ice, heat, meds, splinting; whether these have helped |
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What are the general components of a musculoskeletal physical exam? |
- Inspection - Palpation - Range of motion - Strength - Neurovascular status - Testing specific to the involved joint - General function an mobility - do they walk with a limp, can they rise from their chair, is there difficulty getting on the exam table, are their arms moving freely or held tightly to their chest, etc |
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What should you look for on inspection for the musculoskeletal exam? |
- Swelling - Bruising - Deformity - Use of any supports or assistive devices (e.g., splints, crutches, bandages)
Compare to unaffected limb! |
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What should you look for on palpation during the musculoskeletal exam? |
Palpate the affected and surrounding ares to help localize and confirm the presence of a specific injury - A focal area of bony tenderness may lead to the consideration of a fracture - A tender, tight muscle may suggest a strain - A joint effusion or soft-tissue swelling should be documented |
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How can you assess for deeper injuries? |
Check for normal sensation, peripheral pulses, and capillary refill |
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What should you think of in a patient with a focal area of bony tenderness? |
Fracture |
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What should you think of in a patient with a tender, tight muscle? |
Muscle strain |
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What should you think of in a patient with absent peripheral pulses and delayed capillary refill, especially if the extremity is cool or cold? |
Vascular insufficiency |
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How should you test range of motion? |
Both passively and actively |
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What does active ROM test? |
Patient's ability to move a joint - 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 |
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What does passive ROM test? |
Movement than an examiner can elicit in a relaxed patient - presence of a dislocated joint or significant joint effusion may lead to limitations in both passive and active ROM whereas a torn tendon or muscle injury may only limit active ROM |
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Should you re-examine a patient after the injury? When? Why? |
Re-examination 3-5 days after acute injury when pain and swelling have improved may help with diagnosis |
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What are the types of specific tests for evaluating the shoulder / rotator cuff? |
- Empty can test - External rotation - Lift-off test - Internal rotation - Hawkins impingement - Drop-arm rotator cuff |
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What do you do in the "empty can test"? What structure are you testing? What do the results mean? |
- With arms abducted, elbow extended, and thumb pointing down, patient elevates the arm against resistance - Tests the SUPRASPINATUS - If painful, indicates rotator cuff injury or tear |
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What do you do in the "external rotation test"? What structure are you testing? What do the results mean? |
- With elbows at sides and flexed at 90 degrees, patient external rotates against resistance - Tests the INFRASPINATUS and TERES MINOR - If painful, indicates rotator cuff injury or tear |
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What do you do in the "lift-off test"? What structure are you testing? What do the results mean? |
- Patient places dorm of hand on lumbar back and attempts to lift hand off of back - Tests the SUBSCAPULARIS - If painful, indicates a rotator cuff injury or tear |
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What do you do in the "internal rotation test"? What structure are you testing? What do the results mean? |
- With elbows at sides and flexed at 90 degrees, patient internally rotates against resistance - Tests the SUBSCAPULARIS - If painful, indicates a rotator cuff injury or tear |
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What do you do in the "Hawkins impingement test"? What structure are you testing? What do the results mean? |
- Pain with internal rotation when the arm is flexed to 90 degrees with the elbow bent to 90 degrees - Tests SUBACROMIAL IMPINGEMENT of the SUPRASPINATUS TENDON - If painful, indicates a rotator cuff injury or tear |
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What do you do in the "drop-arm rotator cuff test"? What do the results mean? |
- Patient is unable to lower his arm slowly from a raised position - Indicates a large rotator cuff tear |
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What does this test evaluate? |
Empty can test: - Tests for injury / tear of the supraspinatus |
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What does this test evaluate (when pushing arm laterally)? |
External rotation test: - Tests for injury / tear of the infraspinatus and teres major |
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What does this test evaluate? |
Lift-off test: - Tests for injury / tear of the subscapularis |
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What does this test evaluate (when pushing arm medially)? |
Internal rotation test: - Tests for injury / tear of the subscapularis |
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What does this test evaluate? |
Hawkins impingement: - Pain with internal rotation indicates impingement of the supraspinatus tendon subacromially |
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What does this test evaluate? |
Drop arm rotator cuff test: - Indicates a large rotator cuff tear |
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What are the specific tests for examining the ankle? |
- Anterior drawer test - Inversion stress test - Squeeze test |
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What do you do in the "anterior drawer test"? What structure are you testing? What do the results mean? |
- Examiner pulls forward on patient's heel while stabilizing the lower leg with other hand - Tests the Anterior Talofibular Ligament (ATFL) - Excessive translation of joint suggests ATFL tear |
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What do you do in the "inversion stress test"? What structure are you testing? What do the results mean? |
- Examiner inverts ankle with one hand while stabilizing lower leg with other hand - Tests the Calcaneofibular Ligament (CFL) - Excessive translation or palpable "clunk" of talus on tibia suggests ligament tear |
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What do you do in the "squeeze test"? What structure are you testing? What do the results mean? |
- Examiner compresses tibia / fibula at midcalf - Tests the Syndesmosis - Pain at anterior ankle joint (below where examiner is squeezing) suggests syndesmotic ("high ankle") injury |
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What does this test evaluate? |
Anterior drawer test: - Excessive translation of joint suggests ATFL tear |
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What does this test evaluate? |
Inversion stress test: - Excessive translation of palpable "clunk" of talus on tibia suggests CFL tear |
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What does this test evaluate? |
Squeeze test: - Pain at anterior ankle joint (below where examiner is squeezing) suggests syndesmotic ("high ankle") injury |
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What are the tests to evaluate for knee injuries? |
- Lachman test - Anterior drawer - Valgus stress - Varus stress |
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What do you do in the "Lachman test"? What structure are you testing? What do the results mean? |
- Knee in 20 degree flexion, examiner pulls forward on upper tibia while stabilizing upper leg - Tests ACL - Excessive translation with no solid end point suggests ACL tear |
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What do you do in the "Anterior drawer test"? What structure are you testing? What do the results mean? |
- Knee in 90 degree flexion, examiner pulls forward on upper tibia while stabilizing upper leg - Tests ACL - Excessive translation with no solid end point suggests tear |
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What do you do in the "Valgus test"? What structure are you testing? What do the results mean? |
- In full extension and at 30 degree flexion, medial directed force on knee, lateral directed force on ankle - Tests medial collateral ligament (MCL) - Excessive translation suggests MCL tear |
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What do you do in the "Varus test"? What structure are you testing? What do the results mean? |
- In full extension and at 30 degree flexion, lateral directed force on knee and medial directed force on ankle - Tests lateral collateral ligament (LCL) - Excessive translation suggests LCL tear |
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What does this test evaluate? |
Lachman test (20 degree flexion) - Excessive translation with no solid end point suggests ACL tear |
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What does this test evaluate? |
Anterior drawer test (90 degree flexion) - Excessive translation with no solid end point suggests ACL tear |
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What does this test evaluate? |
Valgus stress test: - Excessive translation suggests MCL tear |
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What does this test evaluate? |
Varus stress test: - Excessive translation suggests LCL tear |
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How can you determine whether to do an x-ray for a knee injury? |
Ottawa Knee Rules say to order an x-ray for any of the following reasons: (1) age >55 (2) isolated patella tenderness (3) tenderness of the head of the fibula (4) inability to flex the knee to 90 degrees (5) inability to bear weight for four steps immediately and in the exam room (regardless of limping) |
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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, what modality should be used? |
Plain x-ray - at least 2 views at 90 degree angles to each other |
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What should you do for a patient with normal x-rays and continued symptoms? |
Get an MRI |
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What should you do for a patient with a suspected ligament or tendon injury of the shoulder, ankle, knee, or hip? |
MRI - highly specific for articular or soft-tissue abnormalities including ligaments, tendons, and cartilage tears |
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What kind of therapy should be implemented for injured ligaments? |
Early mobilization; ROM should be started within 48-72 hours |
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For lower extremity injuries what should be done in terms of bearing weight? |
- Protected weight bearing with orthotics is allowable with advancement to unsupported weight bearing as tolerated - Crutches may be necessary initially due to pain - Lace-up or semi-rigid ankle supports have been shown to be superior to tape and elastic bandages and provide stability to the injured ankle |
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What is the most common cause of persistently stiff, painful, or unstable joints following sprains? |
Inadequate rehabilitation |
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How should patients be instructed to treat their ankle following a sprain? |
They should be given specific exercises to do for rehabilitation; if unsuccessful in doing this alone they should be referred to physical therapy |
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Based on the Ottawa Ankle Rules, which of the following situations is most appropriate to have radiographs of the involved bones? a) 6-year old boy injures his ankle riding a scooter b) 33-year old woman injures both ankles and knees in a motor vehicle accident c) 43-year old man injured his ankle yesterday while playing volleyball d) 22-year old woman injures her ankle after falling while drunk |
C) 43-year old man who injured his ankle playing volleyball
The Ottawa Ankle Rules apply to non-pregnant adult patients who have a normal mental status, who don't have other painful injuries, and who are seen within 10 days of their injury. The only setting in which all of these criteria apply is C. According to the rules, 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, or if the patient is unable to bear weight immediately when examined. |
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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 ROM.
What is the initial imaging test of choice? |
X-rays - plain x-rays are the diagnostic imaging test of choice for initial evaluation of a painful joint. In patients who have normal x-rays and who have a suspected soft-tissue (ligament, tendon, cartilage) injury, MRI scanning is the NEXT most appropriate imaging study to perform. |
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A 45-year old woman comes in for follow-up of an ankle sprain that occurred while she was jogging. X-rays done at your initial visit were negative for fracture. She has been unable to run because of persistent stiffness. Exam reveals no joint instability or focal tenderness.
What is the most appropriate management at this time? |
Refer to PT
The most common cause of a stiff or painful joint following a sprain is inadequate self-rehabilitation. When a patient is unable to adequately self-rehab an injury, a PT referral can be beneficial. If they continue to have symptoms after that, consider advanced imaging or refer to orthopedic surgery. |
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What can you do if you suspect a patient's limited ROM is primarily a result of pain? |
You can numb the joint by injecting lidocaine into it and then reexamine the joint |
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Case: A previously healthy 48-year old man presents with acute onset of low back pain after strenuous activity. His neuro exam is normal and he denies any systemic complaints.
What is the most likely diagnosis? |
Acute low back pain also known as lower back strain |
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Case: A previously healthy 48-year old man presents with acute onset of low back pain after strenuous activity. His neuro exam is normal and he denies any systemic complaints.
How should this patient be worked-up? |
Nothing more needed until after conservative treatment for at least one month |
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Case: A previously healthy 48-year old man presents with acute onset of low back pain after strenuous activity. His neuro exam is normal and he denies any systemic complaints.
How should this patient be treated? |
4-6 weeks of: - Rest - NSAIDs - Muscle relaxants |
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How often do patients who present with low back pain leaving without a specific anatomical reason for their pain? |
85% |
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How often do patients with acute low back pain recover within 2 weeks of diagnosis? |
90% |
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What happens when you herniate a disc? |
Rupture of the fibrocartilage between the vertebrae leading to leakage of the nucleus pulposus that may impinge on the nerve roots causing pain |
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What is sciatica? |
Sharp or burning pain along the path of the sciatic nerve usually caused by a herniated disk of the lumbar region of the spine, which typically will radiate to the buttocks and to the back of the thigh |
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What is the first step in managing acute low back pain? |
Form a differential diagnosis followed by history and physical without missing any red flag symptoms |
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What are the red flag symptoms in low back pain? |
- Unrelenting night pain - Unrelenting pain at rest - Neuromotor deficit - Unexplained fever - Greater than 6 weeks duration - Age >70 - Loss of bowel or bladder control - Progressive focal neurologic deficits - Suspicion of ankylosing spondylitis - Trauma - History or suspicion of cancer - Osteoporosis - Chronic corticosteroid use - Immunosuppression - Alcohol abuse - IV drug use |
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What are the symptoms of cauda equina syndrome? |
Present with increasing neurologic deficits and leg weakness, bowel and urinary incontinence, anesthesia or paresthesia in a saddle distribution, and bilateral sciatica |
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What are the signs of cauda equina syndrome on exam? |
- Pain elicited by straight leg raise test - Reduction in anal sphincter tone - Decreased ankle reflexes |
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How should you further evaluate a patient you suspect of having cauda equina syndrome? |
Needs immediate evaluation with lumbar MRI, surgical decompression of the entrapped cauda equina to prevent further neurological deterioration |
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What should you consider in a patient with fevers, direct vertebral tenderness, recent infections, and a history of IV drug use? |
Infectious process --> osteomyelitis, septic discitis, paraspinous abscess, epidural abscess |
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How do you evaluate a patient with fevers, direct vertebral tenderness, recent infections, and a history of IV drug use? |
- CBC - ESR - Blood cultures - Abscess content cultures (if applicable) - CSF - MRI |
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How should you treat a patient with fevers, direct vertebral tenderness, recent infections, and a history of IV drug use? |
Long course of IV antibiotics and sometimes surgical drainage |
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What should you consider in a patient with a history of cancer (up to 9% chance), unexplained weight loss, worsening pain at night, failure to improve after 1 month of therapy, or an age >50 years? |
Underlying cancer in the bone - multiple myeloma; metastatic prostate / breast / lung / etc cancer |
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How should you further evaluate a patient with a history of cancer (up to 9% chance), unexplained weight loss, worsening pain at night, failure to improve after 1 month of therapy, or an age >50 years? |
MRI and / or bone scan |
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What is the classic sign of a herniated disc? |
Sciatica - sharp or burning back pain that radiates down the back and side of the lung and distal to the knee |
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What are the symptoms of a herniated disc? |
- Classically sciatica (sharp burning back pain radiating down back, side of leg, and distal to knee) - Improves with laying down - Increases with valsalva, sneezing, coughing - Anesthesia, dysesthesia, hyperesthesia, and paresthesia --> specific lumbosacral dermatome |
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How can you examine for sciatica? |
Straight-leg raise (91% sensitive, 26% specific) and contralateral leg raise test (29% sensitive, 88% specific)
Sensory, strength, and reflex testing of lower extremities |
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What are the reflexes / strength testing of the lower extremity that help to evaluate for a herniated disc? |
- L4 - knee strength / reflex - L5 - great toe and foot dorsiflexion - S1 - plantar flexion and ankle reflexes |
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Where do most lunbar disc compressions occur? |
90% at L4/L5 and L5/S1 |
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When is an MRI indicated for sciatica? |
Only if symptoms last >1 month or if the patient is not a candidate for surgery or epidural injection |
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What is the conservative management of a herniated disc with sciatica? |
NSAIDs or acetaminophen, possibly short-course steroids, and activity modifications
Opioids have a lack of proven efficacy and potential adverse drug reactions, so they are reserved for those with severe pain who have exhausted non-narcotic treatment options |
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When is PT recommended for patients with herniated disc? |
Patients with persistent mild to moderate symptoms of 3 weeks or more since majority of patients are likely to experience spontaneous improvement in the first 2 weeks |
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When can surgery be considered for herniated disc? |
If patient suffers from disabling radicular pain of 6 weeks or more |
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What happens in spinal stenosis? |
Congenital or acquired spinal canal narrowing that puts pressure on the spinal cord |
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What are the most common acquired causes of lumbar spinal stenosis? |
Degenerative arthritis and spondylolisthesis |
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What are the most common congenital causes of lumbar spinal stenosis? |
- Dwarfism - Spina bifida - Myelomeningocele |
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How does spinal stenosis present? |
- Lower back and leg pain - Leg weakness - Pseudoclaudication that occurs after walking different distances while the vascularity of the legs remains intact - Majority are only symptomatic when active |
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How can patients with spinal stenosis reduce their pain? |
- Bending over - Squatting - Lying - Sitting |
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When is spinal stenosis more common? |
In those over 60 years |
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When should you evaluate for spinal stenosis? |
The same as for herniated disc - MRI is not recommended unless the symptoms are greater than 1 month or if the patient is not a candidate for surgery or epidural injection |
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How do you treat spinal stenosis? |
- Initially with NSAIDs and analgesics - PT - Epidural corticosteroids - Surgical therapy is reserved for those who have failed conservative management or those with progressive neurological deficits |
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When can you consider surgery for spinal stenosis? |
When they fail conservative management or for those with progressive neurologic deficits |
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In whom are vertebral compression fractures more common? |
- Older patients - Those with osteoporosis - Those with chronic steroid use |
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When do vertebral compression fractures occur? Presentation? |
- Presents after low-impact trauma or no trauma history at all - May present with acute onset of back pain after certain sudden movements such as lifting, bending, or coughing - Pain follows distribution of contiguous nerve and radiates bilaterally into anterior abdomen, aka "girdle of pain" |
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Where are vertebral compression fractures more likely? |
Well localized to thoracolumbar segment (T12-L2) of spine |
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How should you evaluate a patient you suspect of having vertebral compression fractures? |
Plain x-rays of the spine |
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How do you treat vertebral compression fractures? |
- Pain control - PT - Calcitonin and bisphosphonates for underlying osteoporosis - Surgical management with balloon kyphoplasty can be considered and may have better outcomes than medical management in those with severe pain |
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When can you consider surgery for a patient with vertebral compression fractures? What procedure? |
If they have severe pain --> balloon kyphoplasty |
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What are predictors of slow recovery from acute low back pain, and increase risk for chronic low back pain? |
Psychosocial factors / emotional distress: - Depression - Fear avoidance (fear that activity will cause permanent damage) - Job dissatisfaction - Current involvement in litigation - Reliance on passive treatments - Somatization |
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What do the majority of patients presenting for acute low back pain get diagnosed with? |
Lumbar strain / sprain (70%) - exact anatomical cause of pain is often unknown, but hypothesis that there may be an incomplete tear of the annulus fibrosus |
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What can an incomplete tear of the annulus fibrosus lead to? |
Unclear etiology of acute low back pain - May leak fluids that create local inflammation or it may bulge posteriorly irritating certain lumbar roots - Irritation of surrounding muscles, tendons, ligaments, or joint capsule may be coconspirators in this painful process |
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What are the categories of causes of low back pain? Incidence? |
- Mechanical low back pain (~97%) - Non-mechanical spinal condition (~1%) - Visceral disease (~2%) |
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What are the potential causes of mechanical low back pain? Incidence? |
- Lumbar strain, sprain (70%) - Degenerative facets or discs (10%) - Herniated disc (4%) - Compression fracture (4%) - Spinal stenosis (3%) - Spondylolisthesis (2%) - Spondylolysis (<1%) |
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What are the potential causes of non-mechanical spinal conditions / low back pain? Incidence? |
- Cancer (primary or metastatic) (0.7%) - Inflammatory arthritis (0.3%) - Infection (0.01%)
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What are the potential causes of visceral disease / low back pain? Incidence? |
Overall 2%: - Pelvic organs: prostatitis, PID, endometriosis - Renal disease: nephrolithiasis, pyelonephritis, perinephric abscess - Aortic aneurysm - GI disease: pancreatitis, cholecystitis, peptic ulcer |
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How should you treat acute mechanical back pain (<4 weeks)? |
- NSAIDs - Acetaminophen - Muscle relaxants - Heat - Early mobility - For those with moderate to severe pain, combination therapy of muscle relaxant and NSAID may be more effective than monotherapy
- No significant benefit with use of opioids, systemic corticosteroids, or >2 days of bed rest
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When should muscle relaxants be taken? Why? |
Night time - may cause sedation |
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What non-pharmaceutical therapies may be helpful in treating acute low back pain? |
- Resume normal daily activities as tolerated - Specific exercises have not been proven to be helpful - Massage therapy and spinal manipulation may be of some benefit - PT has some benefit for short-term pain relief, but studies do not show long-term benefit - Acupuncture and yoga may be reasonable for chronic back pain, their effectiveness in acute back pain remains unproven - Traction has not been shown to be helpful |
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How can you prevent recurrences of acute low back pain? |
- Exercise
- Lumbar support braces do NOT prevent back pain |
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A 45-year old man without significant PMH presents with severe back pain after lifting boxes at work 2 days ago. Other than his back pain, his ROS is negative. Pain radiates from his lower back down his posterior thigh to his great toe when you perform both a straight leg raise test and contralateral leg raise. His strength, sensation, and reflexes are preserved.
What imaging studies should be done immediately? |
No imaging indicated - this patient has signs of a herniated disc. No evidence that imaging in the first month has any morbidity benefit. If symptoms persist after 1 month, then MRI would be correct. X-rays do not show discs or nerve roots, and CT has poorer visualization of soft tissue than MRI. |
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A 50-year old woman comes to her doctor complaining of low back pain for exactly 1 month after a fall. She has no history of fever, unexplained weight loss, diabetes, and cancer. She had a hysterectomy for fibroids at age 40. Which of the following characteristics would prompt further evaluation? a) history of frequent steroid use for asthma b) caucasian race c) time course of back pain d) history of prior cocaine use e) premenopausal age |
History of frequent steroid use for asthma
The patient's history is suspicious for a vertebral compression fracture that could be secondary to osteoporosis. This can be initiated by use of steroids, which in this case was used to control her asthma. Time course of pain is 4 weeks. >6 weeks is a red flag symptom for further evaluation. While osteoporosis is more common in Caucasian women, it is not considered a "red flag". Postmenopausal women are at greater risk for osteoporosis than premenopausal women. |
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A 67-year old man with CAD, dyslipidemia, and eczema comes to you complaining of lower back pain and leg pain. It is worse when he stands for long periods of time, but is better when he stoops to push his shopping cart around the store. He indicates that his feet "burn" and "ache" after walking different distances every day. Your exam of his nervous and muscular systems is normal.
What is the best treatment for this patient? |
Steroid epidural injection
His history is classic for spinal stenosis. Often they find relief by sitting or stooping. NSAIDs, PT, and epidural steroid injections are used to relieve pain. Decompression is used in cauda equina syndrome and kyphoplasty is useful in vertebral fractures. Bed rest for more than 2 days is not used in conservative treatment of back pain for any cause! |
