Discussion: Assessing Musculoskeletal Pain

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Discussion: Assessing Musculoskeletal Pain

Discussion Assessing Musculoskeletal Pain

   Thank you for sharing your discussion with us. Your assessment and outlining of the patient’s signs and symptoms indicate an assessment of patellar tendinitis. This is the most likely diagnosis for the patient based on the patient’s history of being an athlete and prior involvement in long jumping, which could have put excessive and repetitive strain on the knee and led to inflammation. Additionally, jumps and movements from basketball could also put additional stress on the knee resulting in pain complaints.

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Bursitis is also a condition secondary to tendinitis that has a similar presentation to that of the patient and is associated with overuse and trauma, leading to inflammation (Dains et al., 2019). It, therefore, is an appropriate diagnosis to examine and assess the patient to provide appropriate treatment. It is important to include it as a differential diagnosis as the location of the inflammation can differ. Therefore, treatment can be specifically directed to the inflamed location once a diagnosis is confirmed or ruled out.

   The diagnosis that is least likely for the patient from the assessment would be juvenile arthritis (JA). While JA is also an inflammation of the joint that can present as pain, the characteristics of the presenting complaint are not in line with the patient’s presentation. According to Dains et al.(2019), JA can also present with fatigue, low-grade fever, and weight loss. As outlined in your discussion, the patient does not present with these findings.

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The diagnosis is further less likely due to the differences in aggravation of symptoms. The patient reports worsening pain with intensive training, and after playing in games while in JA, the pain and stiffness are mostly noted in the night and morning and get better with activity. Swelling at the joint is also a common factor and was not present in this patient. JA is, therefore, the least likely assessment for this patient and the differential diagnosis I would reject.

The patient’s history of sporting activity and athletic training does justify the inclusion of chondromalacia of the patella as a differential diagnosis. According to Habusta et al.(2022), patients with chondromalacia patella do present with pain as the most common presentation and is frequently seen in patients that experience post-traumatic injuries, wear and tear to the hyaline cartilage.

The pain worsens with activities that increase stress on the patellofemoral joint, such as running and jumping, as outlined by the patient. Pain is a common symptom for most musculoskeletal conditions; therefore, it’s important to perform tests and diagnostics to rule out the possible cause of the pain to prevent misdiagnosis. Additionally, including the chondromalacia patella is important as it is sometimes diagnosed via the method of elimination.

 

References

 

Dains, J., Baumann, L., & Scheibel, P. (2019). Advanced health assessment & clinical diagnosis in primary care (6th ed.). St. Louis MO: Elsevier Mosby.

Habusta, S., Coffey, R., Ponnarasu, S., Mabrouk, A., & Griffin, E. (2022). Chondromalacia patella. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459195/

A 15-year-old Caucasian male Justin Timberland presents to the clinic with reports of dull pain in both knees. He states sometimes one or both knees click, and he describes a catching sensation under the patella.

To begin my assessment of my patient’s knee pain, I’ll  approach the interview initially by utilizing “a useful framework to differentiate whether the limb pain involves symptoms that are caused by musculoskeletal injury, musculoskeletal or joint disease, or systemic disease, or a combination of factors. Pain can result from direct reaction in tissues,  secondary reaction in adjacent tissues, or reaction from a proximal or distal lesion, or from organs such as  the heart or kidney”.(Dains,2019.p.1.).knowing this information, I decided to start with a Focused history, where I would begin by asking the patient questions such as, does he have any of the common childhood bone diseases, that would make him prone to bone injury or pain, i.e. Osteogenesis Imperfecta or as commonly known as brittle bone disease, as it is usually diagnosed at birth as a bone is broke during the delivery process, from the fetus traveling down the bony structures of the birth canal. Next, I will ask him if the pain if from an injury? If it was an injury, how did the injury occur? Is this a new injury, or is this an old injury that has recurred? And finally, I will ask him to state his level of pain, on a scale from 0-10, with 0 being the least pain, and 10 being the worst pain?

According to research, the location of  pain, has a strong influence on a patient’s functional status, my next step will be to differentiate his knee pain, corresponding to a research article based on elderly and knee pain, “the most common knee patterns are tibiofemoral only pain (62%), followed by patellofemoral only pain(23%), and combined pain (15%). The combined pain pattern was associated with odds of reporting pain, symptoms, sports or recreational activity limitations and lower knee-related quality of life compared to either isolated knee pain patterns, after adjusting for demographics and radiographic disease severity.

The research article also mentioned using a “knee map” on the participants, so the participants can classify their pain  into three categories of localized, regional, or diffuse.”.(Farrokhi,2016.p.).The medical assessment is a vital means to correctly diagnose and treat knee pain and problems “ many maneuvers are available to rule out the type of stability and test the knee structures involved. All tests can be divided in 4 groups: stress tests, slide tests, pivot shift(jerk) tests, and rotational tests.

1.Stress Tests- the standard stress tests include valgus (abduction), and varus (adduction) tests; additionally, Cabot maneuver is a commonly used stress test. The key point in performing these tests is taking care not to perform them carelessly. The test should be conducted at 30 degree flexion, rather than in full knee extension: by flexing the knee all tendinous structures and posterior capsule are released allowing to evaluate the MCL and LCL isolated.

2.Bohler’s test- a varus and a valgus stress are applied to the knee: pain is elicited by compression, of the  tear.

3. Squat test, duck walking test Thessaly test consist in several repetitions of full weightbearing flexions on the knee, in various positions (squatting, walking in full flexion, and at a 5 and 20 degree flexion, respectively).

4.Merke’s test is like Thessaly test performed in a weightbearing position: pain with internal rotation of the body produces an external rotation of the tibia and medial joint line pain when medial meniscus is torn. The opposite occurs when lateral meniscus is torn.

5. Helfet’s test, in this test, the knee is locked and cannot c externally while extending, and the Q angle cannot reach normality with extension.

6.In  test, the patient is asked to sit in Turkish position, thus stressing the medial joint line: if the position raises pain, the test is positive for a medial meniscal lesion.

7.In Steinmann’s first test, the knee is held flexed at 90 degree, and forced to external rotation, then internal rotation: the test is positive for medial meniscal tear if raises pain upon externally rotating, while it is positive for lateral meniscal tears in case of pain during internal rotation.

8.Apley’s (grinding) test is conducted with the patient prone, and the knees flexed to 90 degrees, then the leg is twisted and pulled, then pushed. If pain is only felt while pushing, a meniscal lesion is diagnosed, while if no difference between distraction and compression is detected, a chondral lesion is more likely”.(Rossi,2011.p.5.). In addition to the physical exams, there are some diagnostic tests physicians use to gather  information about the patient’s condition.

Some of the tests that may be ordered are a Computed Tomography scan,  as the scanner circles the body, and the cross-sectional images of the knee, will allow the physician to better pinpoint the place of injury, a Magnetic Resonance Image MRI, uses a powerful magnetic field, radio waves, and a computer to create in-depth images of the structures inside the knee joint, an Arthroscopy, is a surgical procedure, where a small camera is inserted into the knee joint through tiny cuts to look for problems within the knee joint,  or a knee x-ray, that can locate the origin of pain, deformity, swelling of the knee, it can also display dislocated joints or broken bones.

(DDX)

1.Rheumatoid arthritis.

2. Gout.

3. Baker’s cyst.

4. Meniscal tear

5.Patellofemoral pain syndrome.

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby Retrieved August 1,2022 from

Farrokhi S, Chen YF, Piva SR, Fitzgerald GK, Jeong JH, Kwoh CK. The Influence of Knee Pain Location on Symptoms, Functional Status, and Knee-related Quality of Life in Older Adults with Chronic Knee Pain: Data from the Osteoarthritis Initiative. Clin J Pain. Retrieved August 2,2022 from  doi: 10.1097/AJP.0000000000000291. PMID: 26308705; PMCID: PMC4766069.

Rossi R, Dettoni F, Bruzzone M, Cottino U, D’Elicio DG, Bonasia DE. Clinical examination of the knee: know your tools for diagnosis of knee injuries. Sports Med Arthrosc Rehabil Ther Technol. Retrieved August 4, 2022, from  doi: 10.1186/1758-2555-3-25. PMID: 22035381; PMCID: PMC3213012.

Case # 2 Ankle Pain:

A 46-year-old female expresses pain in both of her ankles, but her right ankle is more concerned. Over the weekend, she was playing soccer when she heard a “pop.” She can bear weight, although it is painful for her. What foot structures are likely to be involved in diagnosing the source of ankle pain based on your knowledge of anatomy? What other symptoms should be investigated? What are your possible diagnoses for ankle pain? What kind of physical examination will you conduct? What particular moves are you planning? Should you use the Ottawa ankle rules to see if you need more testing?

Assignment:

Using the episodic/focused note, write an episodic/focused note about the patient in the case study to whom you were assigned. Provide literary evidence to support diagnostic testing that would be appropriate in each scenario. Explain why you chose each of the five probable conditions for the patient’s differential diagnosis.

Information for Patients:

A 42-year-old man experiences lower back ache for the previous month. The pain occasionally spreads to his left leg. What nerve roots might be involved in establishing the cause of back discomfort based on your knowledge of anatomy? How would you put each of them to the test? What other symptoms should be investigated? What are the possible diagnoses for acute low back pain? Using the Agency for Healthcare Research and Quality (AHRQ) recommendations as a framework, consider the various origins. What kind of physical examination will you conduct? What particular moves are you planning?

S.

CC  Back pain

HPI: SK, a 42-year-old Caucasian man, has been complaining of lower back pain for the past two months and has undergone a

physical examination. His left leg is giving him sporadic radiating discomfort, he claims. An episode of severe leg discomfort that lasts for many hours has been described. SK’s discomfort has made it difficult for him to move around as he goes about his daily activities (ADLs) and at work. Pt says, “My back hurts, and it throbs.” The discomfort in my leg is like a “burning sensation” when it is inflamed. There’s a lot of pain. Lifting large objects is said to exacerbate the pain. A good night’s sleep helps to ease the discomfort. For the previous two weeks, the patient has been applying ice to her lower back and taking Ibuprofen 800 mg PO BID. Denies that back pain is accompanied by any other symptoms.

Medications in Use Today:

Back pain: ibuprofen 500 mg once daily

Taking atorvastatin 20mg PO once a day for high cholesterol levels.

There are no allergies to foods or latex, and there aren’t any to the environment.

Atorvastatin 20 mg PO once a day was prescribed to PMHx with a diagnosis of HLD in 2016. Up-to-date on all required vaccines. Immunization against influenza within a year of the visit. There is no prior surgical history to speak of. There are no prior hospitalizations on record. Until now, I haven’t had an annual physical.

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As a construction worker, Soc Hx: SK maintains an active lifestyle. Has been married to his wife for three years and is currently having sex. They define themselves as “social drinkers” and can’t remember the last time they had a drink. Denies the use of any tobacco product, including cigarettes. Denies he has ever used drugs. She works out at least once a day. The diet changes regularly and does not keep track of how much food is consumed. Driving a corporate car and a personal automobile, he always buckles up. All homes have smoke detectors. His neighborhood is safe, according to his neighbors.

Fam Hx:

Father: Alive, age 67, Hx HTN

Mother: Alive, age 69, Hx HTN, HLD, Mitral Valve Prolapse

Maternal Grandmother: Alive, age 87, Hx HTN, HLD

Maternal Grandfather: Deceased at age 89; GI Bleed.

Paternal Grandmother: Deceased at age 61; Melanoma

Paternal Grandfather: Deceased at age 48; Lung CA

ROS:

GENERAL:  Denies fever, fatigue, sob, or recent illness.

SKIN:  Denies pruritus, rash, or areas of hyperpigmentation.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema. HX of HLD

RESPIRATORY:  No sob, dyspnea, cough, or hemoptysis.

MUSCULOSKELETAL:  Pain in lumbar region of back. Episodic pain that radiates from back down left leg impairing gait. Range of motion impaired.

O.

VS: BP: 145/90, RR: 16, HR: 84, T: 98.0 F, O2: 97% on RA; Ht. 5’10” wt. 220 lbs BMI: 31.75

GENERAL: Pt is calm and cooperative while sitting upright on the examination table. Pt appears to be in NAD at this time. Appears to have good hygiene maintenance. Answers all questions without contradiction. Speech is clear and coherent.

SKIN: No breakdown, lesions, abrasions, or rashes noted. No tenting.

CARDIOVASCULAR:  S1, S2 heard with no murmur. S3 audible in mitral landmark. No edema noted in upper and lower extremities.

RESPIRATORY: Respirations even and unlabored. Equal chest rise and fall. Lung sounds clear throughout anterior and posterior landmarks.

MUSCULOSKELETAL:  Pain in lumbar region of back. No deformity noted throughout lumbar region. Episodic pain that radiates from back down to left leg impairing gait. Range of motion impaired when attempting hyperextension of spine.

Diagnostic results: X Ray of Lumbar Spine, CT cervical and lumbar spine. MRI lumbar spine.

Plain radiographs, standing anteroposterior and lateral spine views, bone scan, electromyography, as well as a CT scan or an MRI scan, may be recommended to confirm the presence of the suspected cause of the patient’s pain (Dains, Baumann, & Scheibel, 2016).

A.

1.Sciatica- A herniated disc causes nerve root irritation and acute lower back pain that radiates down the buttock to below the knee. Acute lower back pain is characterized by pain and burning that radiates down the lateral thigh, leg, and foot, and is occasionally accompanied by numbness in the dermatomal areas. Sciatica is a classic symptom of nerve root irritation caused by disk displacement that causes sharp and burning pain to radiate down the lateral and posterior aspect of the leg to the lateral ankle or foot (Dains, Baumann, & Scheibel, 2016). I will assess the patient’s muscle strength and reflexes during the physical exam. For example, will instruct the patient to walk on their toes or heels, rise from a squatting position, and lift their legs one at a time while lying supine. The pain caused by sciatica usually worsens during these activities. The primary diagnosis is sciatica, which is based on clinical symptoms, physical examination results, and diagnostics.

2. Herniated lumbar disc-A herniated disk is a problem with one of the disks that connect the vertebrae that make up the spine (Lama et al., 2014). A herniated disk can irritate nearby nerves, resulting in arm or leg pain, numbness, or weakness (Lama et al., 2014). A CT lumbar spine, X-ray, and an MRI are usually used to make a diagnosis.

3. Muscle strain- Muscle strain is defined as damage to a muscle or its tendons (Benjamin, 2014). This can happen when putting extreme pressure on muscles during normal daily activities, such as sudden heavy lifting, sports, or work tasks (Benjamin, 2012). To rule out other diagnoses, a physical exam and possibly an X-ray are performed. The most common course of treatment is rest with the use of NSAIDs (Benjamin, 2014).

4. Lumbar Stenosis- When combined with the word spinal, it defines a narrowing of the bone channel occupied by the spinal nerves or the spinal cord, lumbar stenosis affects the lower back, and cervical stenosis affects the neck. Spinal stenosis is most commonly caused by osteoarthritic wear-and-tear changes in the spine. Spinal stenosis is the most common cause of acute lower back pain in adults over the age of 50. The cause of lumbar spinal stenosis is commonly associated with aging (Ullrich, 2017).

Facet joints (small stabilizing joints located between and behind vertebrae) degenerate and can compress the spinal nerve roots in the lower back, causing lumbar stenosis symptoms of pain, particularly with activity (Ullrich, 2017). Pain is associated with lumbosacral radiculopathy, and relief occurs with sitting or forward flexion of the spine, most commonly in the lower back and neck. Dains et al., 2016; Baumann et al., 2016; Scheibel et al., Based on the nature of the disease, including symptoms, this is not a likely diagnosis.

5. Ankylosing Spondylitis is a systemic inflammatory condition affecting the vertebral column and sacroiliac joints. Ankylosing Spondylitis (AS) is a type of arthritis that affects the hips, knees, and shoulders. AS, according to Dains, Baumann, and Scheibel (2016), can cause weak, brittle bones (osteoporosis). The most common symptom is hip and lower back pain and stiffness (Dains, Baumann, & Scheibel, 2016).

This condition is typically described as chronic lower back pain that worsens in the morning and improves throughout the day. Physical examination reveals thoracic kyphosis and posterior thoracic spine rounding, as well as forward flexion of the head, neck, and lower back (Dains, Baumann, & Scheibel, 2016). Because of the inflammatory nature of the disease and the symptoms as presented, this condition is ruled out.

Initial post-Case 3: Knee Pain

Template for Episodic/Focused SOAP Notes

KD, 15, Male, Hispanic, S. CC (Patient Identification Number: “Knee pain on both sides”
A Hispanic male, age 15, presents to the clinic with complaints of knee pain. He experiences dull, throbbing discomfort in both knees, along with “clicking” and “catching” sensations behind the patella while walking. Two weeks ago, the soreness began when he ran in his athletics class. He recalls limping when he experiences catching in the knees, but denies numbness and edema. He adds that running exacerbates his pain, while rest, ice, and Tylenol ease it. The patient’s current pain level is 3/10, but it increases to 7/10 after running.

Current Treatments:

Tylenol 500 mg 1 tablet orally every 6 hours as needed for pain, for one week.
Refuses to acknowledge pharmaceutical, food, and environmental sensitivities.
PMHx: TDap- 04/2019 Flu shot- 10/2021 Covid series- 01/021, 03/2021 Current on all essential childhood vaccinations
 Denies past illness or surgery.

Soc Hx: The patient reports playing football for his high school. His hobbies include running and socializing with pals. He lives with his mother, father, and sister in a single-family dwelling and claims that the smoke detectors are operational. He denies the use of tobacco, ethanol, and illicit drugs, and he states that he is not exposed to secondhand smoke. He adds that he does not have a driver’s license but has a permission and is authorized to drive with a parent in the car. He also denies using a cell phone while driving and states that he always wears a seat belt.
Mother- hypertension and asthma
Patriarch- HTN
 Sister- Asthma
Maternal grandmother passed away at age 56 due to breast cancer.
Grandfather of the mother- HTN, CAD
Grandmother of the Father- DM2
Paternal Grandfather with Hypertension and Polio at Age 11

ROS:
 GENERAL: Denies weight modifications. Denies fever, chills, tiredness, and weakness.
CARDIOVASCULAR: Denies angina, palpitations, and cardiac problems in the past.
Denies dyspnea, orthopnea, tussis, and sputum production.
MUSCULOSKELETAL: Refuses to acknowledge significant edema, myalgia, spinal discomfort, or stiffness.
Denies the presence of erythema, puritus, or rash.
Denies symptoms of vertigo, headache, syncope, paralysis, ataxia, and paresthesia. No change in bowel or urinary continence.
PSYCHIATRIC: Denial of depression or anxiety in the past
O. Physical exam:
GENERAL: BP 112/66 P 70 T 98.6 R 16 O2 100 percent Weight 140 Height 66 inches BMI 22.6
CARDIOVASCULAR: audible S1 and S2; strong and equal bilateral peripheral pulses 3+; cap refill 2 seconds.
RESPIRATORY: chest rise and fall are uniform and effortless. CTA of the lungs to all lobes.
MUSCULOSKELETAL: Both lower extremities are symmetrical, and there are no abnormalities, redness, or lumps present. Knees on both sides show little edema. Negative knee resistance test, with a strength rating of 5/5 and complete ROM in the upper and lower extremities.
Test results for McMurrays were negative. Positive results for Clarke’s test. Upon palpation, bilateral patella-patellar tendon junction sensitivity without crepitus.
SKIN: Free of erythema, tenting, lesions, and rashes.
 NEUROLOGICAL: CN intact x 12, intact deep tendon reflexes. Complies with directives; movements are coordinated and directed; gait

PSYCHIATRIC: Aware and attentive to person, place, and time; responds properly; no depression or anxiety signs.

Discussion: Assessing Musculoskeletal Pain

Knee X-rays are recommended to determine the presence of a patellar tendon ossicle, tibial tubercle fragmentation, or other fracture (Patel & Villalobos, 2017.).
Knee MRI is recommended for viewing knee structures and diagnosing emerging lesions and skeletal immaturity in young individuals (Patel & Villalobos, 2017.).

A. Differential Diagnoses

1. Osgood-Schlatter disease was chosen as the major diagnosis due to the clinical presentation of bilateral knee discomfort in roughly 30% of teenage males who participate in sports, with localized pain that is relieved by rest (Patel & Villalobos, 2017).
2. Sinding-Larsen-Johansson syndrome is a differential diagnosis for a runner with bilateral knee discomfort, tenderness, and trace edema (Patel & Villalobos, 2017).
Patello-femoral pain syndrome is a differential diagnosis due to the presence of anterior localized pain as a symptom (Patel & Villalobos, 2017.).

Pes anserine bursitis is a differential diagnosis because its causes are overuse, working out without stretching, or improperly lifting weights, and its symptoms are knee discomfort that is exacerbated by exercise and is felt within the knee (Cleveland Clinic, 2019.).
5. Plica syndrome is a differential diagnosis since joint pain caused by direct injury or overuse may be accompanied with palpitations and localized swelling (Patel & Villalobos, 2017.).
This part is not necessary for this course’s (NURS 6512) assignments, but it will be for future courses.

To diagnose the origin of the knee pain the patient is experiencing, a thorough medical and surgical history, damage, edema, precise location, and mechanical symptoms are required (Bunt, et al., 2018.). Inflammatory, acute, and chronic mechanical are the classifications utilized to classify knee pain in patients (Bunt, et al., 2018.). During the physical examination, the knee will be inspected for bruises, edema, and abnormalities.

Knee palpation to evaluate for warmth and localized pain in soft tissues and bony prominences. Patella, femur, quadriceps, patellofemoral joint, hamstrings, MCL, ACL, tibial tuberosity, lateral and medial tibial plateau and spine, femoral condyle, intercondylar notch, tibia, and fibula are evaluated.

References

Bunt, C., Chang, J., Jonas, C. (2018). Initial assessment of knee discomfort in adults and adolescents.
Retrieved from https://www.aafp.org/afp/2018/1101/p576.html

Clinic in Cleveland, Ohio (2019). Frontal knee discomfort (pes anserinus bursitis). bursitis information obtained from https://my.clevelandclinic.org/health/diseases/21620-anterior-knee-pain-pes-anserinus.

Patel, D. R., & Villalobos, A. (2017). Evaluation and treatment of knee discomfort in young athletes: overuse knee injuries Pediatric translational research, 6, 190–198.
https://doi.org/10.21037/tp.2017.04.05

First Repsonse

Thank you for your contribution, I truly appreciate it. I observe that the patient is a fifteen-year-old male who is experiencing pain in both knees. Pain is exacerbated by exercise. According to his interview, the patient appears athletic and active in sports. His passions include running and football. Therefore, he does not appear to find exercise unusual. This patient began having a new ache two weeks ago. Osgood Schlatter disease typically affects males aged 11 to 14. Typically, edema is linked with this problem as a hard lump would. Typically, this pain occurs just below the kneecap and is accompanied by a hard lump. (clevelandclinic.org)

This patient is 15 years old and is experiencing bilateral knee pain. The patient describes the discomfort as intensifying with physical exertion and having a “catching sensation.”
The sensation of catching is forcing him to limp. Rest, ice, and Tylenol have been aiding with his pain alleviation. The patient does not mention a hard mass under the kneecaps in addition to the swelling.

In addition, the patient reports no shin pain. I feel the patient exhibits some symptoms of Osgood

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