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Mobilization. Numerous studies showed that early mobilization of injured ligaments actually promotes healing and recovery. ROM exercises should be started at
48 to 72 hours after injury in patients with sprains and strains. For lower extremity
injuries, protected weight-bearing with orthotics is allowable, with advancement
to unsupported weight-bearing as tolerated. Crutches may be necessary initially
because of painful weight-bearing. Lace-up or semirigid ankle supports have been
shown to be superior to tape and elastic bandages and provide stability to the
injured ankle.
The most common cause of persistently stiff, painful, or unstable joints follow-
ing sprains is inadequate rehabilitation. All patients with musculoskeletal injuries
should be educated on the importance of rehabilitative exercises and avoiding bed
rest. When possible, handouts with a specific exercise program should be given to
the patient when the patient is evaluated. If the patient is unsuccessful in accomplishing this on his own, referral for a formal physical therapy program can be
beneficial.
Surgery. Surgery is rarely needed for sprains, and its use is controversial even in the
presence of chronic pain or persistent functional instability. Surgery for ankle sprains
has been shown to increase stiffness in the joint, lead to longer recovery times, and
result in impaired mobility when compared to conservative treatment only; however,
it is the joint that may require surgery after conservative therapy if there is persistent
instability, for example. In general, surgical consideration should be a last resort when
all else has failed and should be discussed in a case-by-case manner.
CASE CORRELATION
See also Case 37 (Limping in Children) and Case 58 (Osteoporosis).
COMPREHENSION QUESTIONS
12.1 A 57-year-old man with well-controlled diabetes presents to the office with
more than 3 months of right shoulder pain. He notes that he stopped moving it
because it hurt to do so after he hit his shoulder. He can no longer raise his arm.
You are the first health care provider he has told about this. On examination,
he can actively forward flex his left shoulder to 180 degrees but cannot abduct
right arm past 110 degrees. With passive ROM, you cannot abduct his right
shoulder past 135 degrees, as you meet strong resistance. He is also restricted
in internal rotation. He has pain when you flex his shoulder to 90 degrees
with internal rotation and has decreased strength with arm abduction against
resistance. The rest of the examination is unremarkable. A shoulder x-ray in
your office is normal. What would you recommend as initial therapy?
A. Ibuprofen taken regularly for 6 weeks
B. Glenohumeral steroid joint injection followed by 3 weeks in a sling
C. Glenohumeral steroid joint injection followed by physical therapy
D. MRI and manipulation of shoulder under anesthesia
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12.2 A 38-year-old woman who works as a cashier on her feet all day has gradually developed pain in the medial aspect of her left knee. She says the knee
sometimes buckles or locks up on her, and the medial side of the knee swells
by the end of the day. On examination, she has a slight limp, medial joint
line tenderness, and a positive McMurray sign. Her examination is otherwise
unremarkable, with normal Lachman and varus/valgus testing. What is her
most likely diagnosis?
A. Medial collateral ligament (MCL) injury
B. Anterior cruciate ligament (ACL) injury
C. Medial meniscus tear
D. Lateral meniscus tear
12.3 A 45-year-old pipe fitter complains of severe back pain after heavy lifting this
morning. Sharp, shooting pain radiates down his right leg, especially when he
is sitting. He has no loss of bowel or bladder function and no saddle anesthesia. On examination, he has a significant right-sided limp, tenderness at the
L4/L5 intervertebral disk at the level of the iliac crest on the right side, and
lumbar flexion limited to 45 degrees secondary to pain. Extension is normal.
Muscle strength is 5/5 on the left and 4/5 on the right secondary to pain;
reflexes are 2+ and equal bilaterally. Sensation is decreased on the lateral calf
of the right leg. The supine straight leg raise (SLR) is positive at 30 degrees
for re-creating the radiculopathy down his right leg. What is your initial
management?
A. Since the pain is severe, start an oral narcotic and order a lumbar x-ray.
B. Start NSAIDs and physical therapy.
C. Complete bed rest for 6 weeks until pain free.
D. Stat MRI and referral for emergent surgical intervention.
ANSWERS
12.1 C. This patient has a frozen shoulder (adhesive capsulitis) with the underlying cause related to an injury that stopped him from moving his shoulder.
He may have an underlying rotator cuff impingement, as evidenced by a positive Hawkins maneuver. The goal in management is to improve pain and
restore motion. Glenohumeral steroid injection will help pain but is not adequate by itself. It should be followed by immediate mobilization and physical
therapy. The joint should not be immobilized in a sling (answer B). MRI and
surgical manipulation (answer D) may be appropriate options later if he does
not improve with the initial management. Ibuprofen (answer A) is not sufficient treatment for this condition.
12.2 C. Medial joint line tenderness with a positive McMurray test is consistent
with a diagnosis of medial meniscus tear, which can be a chronic or acute
injury. It is unlikely that the patient had an ACL tear (answer B), as she did
not have acute injury with immediate large swelling at her anterior knee.
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MCL injury (answer A) is less likely since valgus stress testing is negative.
MCL injury will also not cause the locking up of the knee, which is caused as
a flap of torn cartilage from the meniscus flips inside the patellofemoral joint.
Lateral meniscus tears (answer D) are less common than medial meniscus
tears and would present with pain or tenderness at the lateral aspect.
12.3 B. This patient likely has a herniated lumbar disk secondary to a heavy lifting
injury, as evidenced by aggravated pain with lumbar flexion as occurs with
sitting or during supine SLR. First-line management is NSAIDs or acetaminophen and physical therapy exercises. NSAIDs are used if there are no contraindications, such as a peptic ulcer. Complete bed rest (answer C) will
worsen back pain and increase risks of deep venous thrombosis. There are no
red flags for emergent MRI or surgery (answer D). In the absence of red flag
signs, conservative management for 6 weeks with physical therapy is warranted before obtaining imaging studies. Answer A (oral narcotic and lumbar
x-ray) is not warranted and can lead to a patient becoming habituated on
opioids; nonopioid anti-inflammatory agents should be tried first.
CLINICAL PEARLS
» A complete history and physical examination is essential in diagnosing
and treating musculoskeletal injuries.
» Use the uninjured, contralateral extremity as a comparison for your
examination of an injured extremity.
» Always be sure to examine the joint above and below the site of injury.
» Order x-rays with at least two views at 90 degrees to each other; other-
wise, you may miss a fracture.
» The mainstay of treatment is early remobilization and therapy to improve
muscle strength, flexibility, endurance, and proprioception.
» PRICE is a mnemonic to remember how to treat musculoskeletal injuries
and stands for protection from further injury, relative rest, ice to reduce
swelling and pain, compression, and elevation to reduce edema.
REFERENCES
Brigham and Women’s Hospital, Department of Rehabilitation Services. Standard of care: ankle sprain.
2010. https://www.brighamandwomens.org/assets/BWH/patients-and-families/rehabilitation-
services/pdfs/ankle-sprain-bwh.pdf. Accessed April 30, 2020.
Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part I. Evaluation and
diagnosis. Am Fam Physician. 2008;77:453-460.
Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part II. Treatment.
Am Fam Physician. 2008;77:493-497.
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Childress MA, Beutler A. Management of chronic tendon injuries. Am Fam Physician. 2013:
87(7):486-490.
Hockenberry RT, Sammarco GJ. Evaluation and treatment of ankle sprains. Phys Sports Med.
2001;29(2):57-64.
Jones BQ, Covey CJ, Sineath MH, Nonsurgical management of knee pain in adults. Am Fam Physician.
2015:92(10):875-883.
Monica J, Vredenburgh Z, Korsh J, Gatt C. Acute shoulder injuries in adults. Am Fam Physician.
2016;94(2):119-127.
Ramirez J. Adhesive capsulitis: diagnosis and management. Am Fam Physician. 2019;99(5):297-300.
Tiemstra JD. Update on acute ankle sprains. Am Fam Physician. 2012;85(12):1170-1176.
Trojian TH, McKeag DB. Ankle sprains: expedient diagnosis and management. Phys Sports Med.
1998;26(10):29-40.
Will JS, Bury DC, Miller JA. Mechanical low back pain. Am Fam Physician. 2018;98(7):421-428.
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CASE 13
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A 45-year-old woman presents to your office concerned about a “mole” on her
face. She says that it has been present for years, but her husband has been urging
her to have it checked. She denies any pain, itching, or bleeding from the site,
and the mole has not changed in size. She has no significant past medical history,
takes no medications, and has no allergies. She has no history of skin cancer in her
family. She is an accountant by occupation.
On examination, the patient is normotensive, afebrile, and in no distress.
The physical examination reveals a nontender, symmetric, 4-mm papule that is
uniformly reddish-brown in color and located in the right nasolabial fold region.
The lesion is well circumscribed, and the surrounding skin is normal in appearance.
There are no other lesions in the area.
▶ What is the most likely diagnosis?
▶ What features indicate a benign versus malignant condition?
▶ What is your next step?
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ANSWERS TO CASE 13:
Skin Lesions
Summary: A 45-year-old healthy woman presents with
No significant past medical history
A skin lesion that is symmetric, with well-defined borders, relatively small (< 6 mm),
and with uniform coloration
No obvious growth of the skin lesion and no history of itching or bleeding at the site
No family history of skin cancer
Most likely diagnosis: Benign nevus.
Features indicating benign versus malignant condition: Signs that are reassuring of a
benign condition include:
Size less than 6 mm
Symmetric, uniform color
Well-defined borders
Malignancy would be indicated by larger size, asymmetric appearance and irregular
borders.
Next step: Reassurance and surveillance.
ANALYSIS
Objectives
1. Describe an approach to the evaluation of skin lesions. (EPA 1, 2)
2. Describe the features of a skin lesion in dermatologic terms. (EPA 1)
3. Describe which features of a lesion are typically benign and which are concerning
for malignancy or potential malignancy. (EPA 1, 10)
Considerations
This case represents a typical scenario seen in primary care medicine: “I have this
mole. Is it cancer?” Although simplified, this is what the patient is most concerned
about and wants to know. The role of the provider is to determine the likelihood of
malignancy or premalignancy and to define a course of action that is appropriate. In
this particular case, there are several features that reassure a benign condition that
can be monitored without the need for a biopsy. There was neither a family medical
history of skin cancer nor a history of skin cancer in the patient. She has an occupation that does not expose her to harmful chemicals or the sun on a regular basis.
On examination, the lesion has typically benign features (size < 6 mm, symmetric,
uniform color, well-defined borders).
In this case, it would be appropriate to make a note (or possibly even a photo-
graph) in the patient’s chart describing the characteristic features of the lesion and
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monitor for changes in the lesion at periodic health evaluations. The patient should
also be educated in self-examination of the skin, with an emphasis on what to look
for and when to come to the clinician’s office for an evaluation of a new or changing
skin lesion. Finally, it should be understood that many otherwise benign-appearing
moles might have an atypical characteristic that warrants further investigation.
The criteria that are used to predict the likelihood of a benign versus malignant
lesion are only guidelines; to be sure, not all malignant skin lesions present in the
same manner, and a malignant melanoma is not always visibly pigmented. The bottom line is that all tools available should be used—the history of present illness,
medical history of the patient, the family medical history, social and occupational
history, and a pertinent review of systems—to arrive at a conclusion that is consistent with the physical examination.
APPROACH TO:
Skin Lesions
DEFINITIONS
ABSCESS: A closed pocket containing pus.
BULLA: A blister greater than 0.5 cm in diameter (plural: bullae).
CYST: A closed, saclike, membranous capsule containing a liquid or semisolid material.
MACULE: A discoloration on the skin that is neither raised nor depressed.
NODULE: An elevated mass of rounded or irregular shape that is greater than
1cm in diameter.
PAPULE: A small, circumscribed elevated lesion of the skin that is less than 1 cm
in diameter.
PLAQUE: A plateau-like, raised, solid area on the skin that covers a large surface
area in relation to its height above the skin.
ULCER: A lesion through the skin or mucous membrane resulting from loss
of tissue.
VESICLE: A small blister less than 0.5 cm in diameter.
CLINICAL APPROACH
Epidemiology
There has been an increase in the morbidity and mortality of skin cancer in the past
few decades in the United States. The American Academy of Dermatology estimated that almost 192,000 new cases of melanoma would be diagnosed in 2019,
and the incidence is increasing. When considering nonmelanoma skin cancers,
including basal cell carcinoma (BCC) or squamous cell carcinoma, approximately
5.5 million new cases of skin cancer are diagnosed annually.
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The single most important risk factor for the development of skin cancer is expo-
sure to natural and artificial ultraviolet (UV) radiation. It is also one of the only risk
factors that can be avoided, and avoiding it can potentially prevent millions of new
cases of skin cancer every year. Other risk factors include a prior history of skin
cancer; a family history of skin cancer; fair skin; red or blonde hair; a propensity
to burn easily; chronic exposure to toxic compounds such as creosote, arsenic, or
radium; and a suppressed immune system.
Pathophysiology
Melanoma In Situ. No invasion has occurred in this type of melanoma, as the malignant melanocytes are localized to the epidermis. If diagnosed early, this type of
lesion should be excised with 5- to 10-mm borders.
Superficial Spreading Melanoma. This is the most common type of melanoma in
both sexes. As its name implies, this lesion spreads superficially along the top layers of
skin before penetrating into the deep layers. The superficial, or radial, growth phase
is slower than the vertical phase, which is when the lesion grows into the dermis
and can invade other tissues or metastasize. Men are more commonly affected on
the upper torso, whereas women are affected mostly on the legs. Common clinical
features include raised borders, comprised of dark and light brown color, and also
sometimes pinks, whites, grays, or blues.
Lentigo Maligna. Similar to the superficial spreading type, this lesion is most
often found in the elderly (commonly diagnosed in the seventh decade of life), usually
on chronic sun-damaged skin such as the face, ears, arms, and upper trunk. It is
the least common of the four types of melanoma. Clinically, they are characterized as
tan-to-brown lesions with very irregular borders.
Amelanotic Melanoma. This is an uncommon (less than 5%) melanoma that is
nonpigmented and can clinically present as many other types of noncancerous conditions, including eczema, fungal infections, or basal or squamous cell carcinoma.
Because of its lack of pigmentation, this type of melanoma usually remains undiagnosed until a more invasive stage as compared to other melanomas.
Acral Lentiginous Melanoma. This lesion is similar to the other two superficial
melanomas in that it begins in situ, but it differs in many ways. This is the most
common melanoma found in African Americans and Asians. This melanoma is usually found under the nails, on the soles of the feet, and on the palms of the hands;
common clinical features include flat, irregular lesions that are dark brown to black.
Nodular Melanoma. This melanoma, unlike the others, is usually invasive at the
time of diagnosis. This is the most aggressive and second most common type of mela-
noma (Figure 13–1). It is clinically characterized as mostly black, but occasionally
brown, blue, gray, red, or tan, lesions that arise from nevi or normal skin.
Clinical Presentation
In 1985, it was noted by clinicians studying melanoma that there were several characteristic features of skin lesions that correlated with melanoma. Specifically, color
variegation, border irregularity, asymmetry, and size greater than 6 mm in diameter
were consistently observed with melanoma. This led to the ABCD acronym, which
has been used extensively to determine the likelihood of a cancerous skin lesion
(Table 13–1).
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A
C
Figure 13–1. Examples of nodular melanoma. Reproduced with permission, from Wolff K, Johnson
R, Saavedra AP, et al., eds. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 8th ed. 2017.
Copyright © McGraw Hill LLC. All rights reserved.
B
D
Table 13–1 • CLASSIC ABCDE CRITERIA FOR SUSPICIOUS SKIN LESIONS
Acronym Characteristic More Likely Benign More Likely Malignant
A Asymmetry Symmetric (right half looks like
left half)
B Borders Well defined Ragged or blurred
C Color Uniform color Variegated (2 or more colors)
D Diameter < 6 mm (6 mm = size of pencil
eraser)
E Elevation Flat surface Raised surface
Evolving Stable in size and appearance Enlargement, changes in
Asymmetric (in > 2 axes)
> 6 mm
thickness, or bleeding
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