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CASE 12
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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 he 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?
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ANSWERS 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
A swollen ankle but with the ability to bear weight
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 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. Describe the diagnostic approach to musculoskeletal injuries. (EPA 1, 2)
2. Describe when to order imaging tests and which test to order to evaluate musculoskeletal complaints. (EPA 3)
3. Describe how to manage common musculoskeletal injuries and scenarios.
(EPA 4)
Considerations
Ankle sprains are the most common acute, sports-related injury, and they are a
common reason for visits to primary care providers, urgent care centers, and emergency departments. 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, or missing a curb
while walking. Management of ankle sprains are geared toward decreasing pain
and swelling, speeding 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.
APPROACH TO:
Musculoskeletal Injuries
DEFINITIONS
OTTAWA ANKLE RULES: A decision model designed to aid a provider in determining which patients with ankle injuries need an x-ray.
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PRICE: A mnemonic to remember how to treat musculoskeletal injuries. The letters stand for the following: Protection from further injury, relative Rest, Ice to
reduce swelling and pain, Compression, and Elevation to reduce edema.
SPRAIN: A stretching or tearing injury of a ligament.
STRAIN: A stretching or tearing injury of a muscle or tendon.
CLINICAL APPROACH
Pathophysiology
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 liga-
ment, 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 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
(ROM). A grade 3 sprain is a complete ligamentous tear. This injury causes significant joint instability, swelling, loss of function, and inability to bear weight.
Clinical Presentation
As in all areas of medicine, the history of the presenting illness will guide the diagnostic workup. Examination of the musculoskeletal system should include documentation of inspection, palpation, ROM, strength, neurovascular status, and,
where appropriate, testing specific for the involved joint.
History. 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 problem—
can 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.
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Physical Exam. 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. 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. Range of motion should be tested both passively and actively.
Active ROM 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 ROM
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 ROM, where a torn tendon or muscle injury may have limited
active, but preserved passive, ROM. Tables 12–1, 12–2, and 12–3 list differential
diagnosis, physical examination findings, and management for common musculoskeletal complaints.
Imaging. Following the history and examination, the provider must decide when
it is necessary to perform x-rays or other imaging tests. Validated decision rules
include the Ottawa ankle rules for the determination of when an x-ray is necessary
in an ankle injury. The Ottawa ankle rules have been validated for nonpregnant
adults who have a normal mental status, no other significant concurrent injury,
and are evaluated within 10 days 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 confirm the need for x-ray to
evaluate the possibility of a fracture. In general, bony tenderness and severe restric-
tion in motion after injury are signs that an x-ray would be helpful in diagnosis.
Table 12–1 • LOWER EXTREMITY PAIN
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Differential
Diagnosis Pertinent Historical Clues Physical Examination Diagnostic/Treatment Plan
Ligament sprain ACL injury associated with loud
pop and acute swelling of anterior
knee
Meniscus tear acute from twisting
injury or chronic from repetitive
motion; report knee “locking up”
(as part of torn cartilage flips into
knee joint during ambulation)
135
Anterior knee swelling for ACL and joint line tenderness for meniscus injury, tender on collaterals if MCL
or LCL tear
Special tests for increased ligament laxity. Laxity of
ligament when compared to contralateral joint
can be a sign of a torn ligament:
Lachman’s—ACL: flex knee to 20 degrees,
stabilize upper leg, and pull forward on tibia
Anterior drawer—ACL: flex knee to 90 degrees,
pull forward on upper tibia while stabilizing
upper leg
McMurray—Menisci: flex knee past 90 degrees,
abduct and externally rotate lower leg, feeling for
palpable clunk on medial meniscus as you fully
extend the leg from initial position; for lateral
meniscus, start with knee adducted and internal
rotated
Valgus—MCL: 30-degree knee flexion, medial-
directed force on knee, lateral-directed force on
ankle
Varus—LCL: 30-degree knee flexion, lateral-
directed force on knee, medial-directed force on
ankle
Anterior drawer for ATFL of ankle: stabilize ankle
with one hand and pull forward on heel with
other hand
Short term: PRICE (protection, rest, ice,
compression, and elevation)/NSAIDs
Protect (air stirrup brace for ankle, knee
immobilizer)
X-ray: Follow Ottawa rules for ankle and knee
Long term: Stabilization, strengthening, PT;
consider MRI if not improved in 6 weeks of
conservative care
Ligament tears frequently require
surgical repair
(Continued)
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Table 12–1 • LOWER EXTREMITY PAIN
(continued)
Differential
Diagnosis Pertinent Historical Clues Physical Examination Diagnostic/Treatment Plan
Tendon rupture or
muscle strain
Septic joint
(emergency)
Osteoarthritis of
knee and hip
Abbreviations: ACL, anterior cruciate ligament; LCL, lateral collateral ligament; MCL, medial collateral ligament; MRI, magnetic resonance imaging; NSAIDs, nonsteroidal anti-inflammatory drugs;
PT, physical therapy; ROM, range of motion; WBC, white blood cell.
Acute injury Ecchymosis, edema, erythema, tenderness
Lack of movement of associated muscle: patellar
tendon rupture—lack of quadriceps extension
Achilles tendon rupture associated with lack of
plantar flexion (Thompson test)
Acute timeline, fever, joint pain
and swelling, and decreased
mobility; recent skin infection or
joint surgery
Chronic pain Knee crepitus, restricted ROM
Edema, erythema, tenderness, warmth to palpation Ultrasound
Hip examination elicits groin pain on Flexion,
ABduction, and External Rotation (FABER test)
Short term: RICE (rest, ice to reduce swelling
and pain, compression, and elevation)
NSAIDs; consider x-ray. Tendon rupture often
requires surgical repair
Long term: Stabilization, strengthening, PT; MRI
if not improved in 6 weeks of conservative care
Joint aspiration and fluid analysis for WBCs,
Gram stain and culture, crystal analysis, intravenous antibiotics, and surgical debridement
Acetaminophen, NSAIDs, weight loss if
overweight
Joint steroid or hyaluronic acid injections
PT with straight leg raises for quad
strengthening
Joint replacement for lifestyle-limiting
chronic pain
Table 12–2 • SHOULDER PAIN
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Pertinent
Differential
Diagnosis
Rotator
cuff tear or
tendinopathy, which
can cause
impingement
syndrome
when involving supraspinatus muscle
Impingement
syndrome
refers to narrowing of
the space
between the
head of the
humerus and
the acromion,
which then
causes pain
Bicipital
tendonitis
Osteoarthritis Chronic swell-
Frozen shoulder (adhesive
capsulitis):
fibrous adhesions form
in the joint
capsule due
to lack of
motion, further impeding
motion
Historical
Clues Physical Examination
Acute injury:
hurts to sleep
on shoulder,
especially with
acute rotator
cuff tears
Acute or chronic
injury
ing, pain,
stiffness
Chronic shoul-
der pain and
severe restric-
tion in motion,
especially
abduction and
internal rota-
tion; predispos-
ing history may
include underly-
ing rotator cuff
injury or severe
osteoarthritis
limiting motion
Swelling and tenderness
Passive maneuvers to check for
impingement:
Hawkins test: pain with passive
Neers test: abduct and internally
Empty can test: resisted abduc-
Speeds test: pain with resisted biceps
flexion—patient palm up and elbow
flexed 20 degrees and arm forward
flexed to 60 degrees; provider
pushes down on forearm as patient
forward flexes
Crepitus, grinding, with or without
edema
Even passive motion is met with
restriction and pain—restriction in
active motion, especially forward
flexion and internal rotation, which
cannot be corrected with passive
motion
SECTION II: CLINICAL CASES 137
flexion of shoulder to 90 degrees
and internal rotation (brings the
head of the humerus closer to the
acromion to exacerbate impingement syndrome)
rotate shoulder to elicit pain;
Hawkins is more sensitive and specific than Neers
tion of both arms with thumbs
pointed down; arms are placed
in 90-degree abduction and
30-degree forward flexion prior
to testing muscle strength; weakness suggests supraspinatous
tendinopathy
Diagnostic/
Treatment Plan
Therapy includes steroid injection into the
subacromial space or
glenohumeral joint to
decrease the effect of
the subacromial bursitis and supraspinatus
tendonopathy
PT may be required
Consider MRI if not
improved with conservative care in 6 weeks
Surgery is saved for
recalcitrant cases and
involves decompression of the narrowed
space by cutting part
of the acromion
NSAIDs, PT, avoid
steroid injection into
tendons
Acetaminophen/
NSAIDs
Joint steroid injection
PT with rotator cuff
strengthening
Joint steroid injections followed by PT
and strengthening
exercises
Osteopathic manipulation also helps
increase range of
motion
Recalcitrant cases may
require surgery involving manipulation of
the shoulder under
anesthesia to break up
the fibrous adhesions
Abbreviations: MRI, magnetic resonance imaging; NSAIDs, nonsteroidal anti-inflammatory drugs; PT, physical therapy.
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Table 12–3 • LUMBAR PAIN
Differential
Diagnosis Pertinent History
Spondylolisthesis:
slippage of the vertebral body posterior
to the vertebral body
above it
Osteoarthritis of lumbar spine (degenerative disk disease)
Spinal stenosis: narrowing of the spinal
canal as occurs with
facet arthropathy,
hypertrophy, spondylosis associated with
advanced arthritis
Herniated lumbar
disk with or without
radiculopathy
Thoracic or lumbar
strain
Cauda equina
syndrome
Repetitive backward bending as in
gymnastics
Older age or early
arthritis as a consequence of motor
vehicle accident
or other trauma to
back
Pain improves with
bending forward
(lumbar flexion) as
this action opens
the spinal canal
Pain worsens with
lumbar flexion
(bending forward,
sitting, lifting leg
up from sitting or
supine position)
Acute injury:
patient felt “pull on
back” when lifting
or pulling object
History of herniated
disk or back injury
with sudden onset
of bowel or bladder incontinence,
saddle anesthesia,
and severe limp
Physical
Examination
Mild-to-moderate tenderness on palpation
of spinous process
Stiffness in lumbar
flexion and sometimes
decreased ROM to less
than 75 degrees of
lumbar flexion
Pain improves with
bending forward (lumbar flexion)
Perform SLR: provider
raises straightened leg
of patient to increase
lumbar flexion; positive SLR is pain shooting down leg to below
the knee; SLR test has
high sensitivity for
herniated disk
Tenderness to palpation; muscle spasms
with overlying edema
and warmth during
acute phase
Palpation reveals
muscle spasms with
texture of a tight rope
down the back and
is often cool to touch
when pain becomes
chronic
Loss of rectal tone,
decreased sensation in
the groin and perianal
area (saddle anesthesia); severe limp
Diagnostic/
Treatment Plan
Lumbar x-ray, avoid bed
rest and overexertion
Stabilization, strengthening via home exercises
or PT
Consider imaging if not
improved in 6 weeks
Stabilization, strengthening, PT
MRI if not improved in
6 weeks of conservative
care
Consider surgical decompression of lumbar spine
if severe pain
Avoid overexertion, but
avoid extended bed
rest as this worsens
condition; NSAIDs, stabilization, PT (McKenzie
exercises)
Consider imaging if not
improved in 6 weeks of
conservative care
Consider surgical diskectomy if severe
Avoid overexertion, but
avoid extended bed
rest as this worsens
condition; NSAIDs, stabilization, strengthening,
home exercises, or PT
Imaging if not improved
in 6 weeks of conservative care
Emergent MRI and
emergent neurosurgical
consultation to prevent
paralysis from occurring
(Continued)
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Table 12–3 • LUMBAR PAIN
Differential
Diagnosis Pertinent History
Malignancy: may be
primary (eg, multiple myeloma) OR
metastatic
Infectious etiology (diskitis: spinal
disk infection or
osteomyelitis)
Abbreviations: ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging; MVA, motor vehicle accident;
NSAID, non-steroidal anti-inflammatory drug; PT, physical therapy; ROM, range of motion; SLR, straight leg raise;
WBC, white blood cell.
Weight loss,
advanced age,
severe back pain,
possible history
of pathological
fractures
Fever and severe
pain
Direct or hematogenous spread from
infectious source
(wound, ulcer, etc)
(continued)
Physical
Examination
Severe bony tenderness in spine (which
may be present due
to bony lytic lesions or
pathologic fractures)
Fever, bony tenderness at site of infection
Diagnostic/
Treatment Plan
Blood work: elevated
protein
X-ray/MRI/bone scan
Multimodal treatment
for the malignancy
Blood work: elevated
WBCs and ESR
X-ray and/or MRI of
involved area with or
without biopsy and
culture
Intravenous antibiotics;
consider diskectomy or
surgical debridement
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-degree angles to each other. In patients with normal x-rays and continued symptoms despite an adequate trial of conservative management or who have
suspected disk, ligament, or tendon injuries, 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.
Treatment
PRICE. 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. 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,
ROM 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 3–7 days for short-term pain relief and improved functionality. Compres-
sion 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 control, with narcotics used only if intolerance or contraindication
to other medications exists.
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