A large proportion of the musculoskeletal
problems for which patients seek medical attention are related to periarticular structures and do not represent a true articular process or a more generalized systemic illness.[1] Knowledge of the common
nonarticular regional rheumatic disorders is
important because of their high prevalence in primary care practice, the
dependence on clinical findings for diagnosis, and the high cost that can
result from unnecessary laboratory evaluations. The ability to recognize
important patterns of pain and physical signs is essential to making a correct
diagnosis; in most cases, radiographic and laboratory studies are not needed.
Diagnostic studies should be utilized judiciously and must be interpreted in
the light of existing clinical findings and prestudy
suspicion for specific diagnoses.
Most regional rheumatic disorders respond to
local measures, such as application of heat or cold, splinting, and injection
of glucocorticoids. Nonsteroidal
anti-inflammatory drugs (NSAIDs) or mild analgesic
medications are often helpful therapeutic adjuncts. Referral for surgical
intervention may be indicated for patients with certain conditions. For
example, in cases of cervical or lumbar disk disease or spinal stenosis with
definite nerve entrapment or spinal cord compression, well-timed decompression
may be necessary to restore function or prevent further functional impairment.
Arthroscopic intervention is sometimes useful to better define and treat
refractory knee and shoulder pain syndromes. Surgical release is indicated for
entrapment neuropathies when there is evidence of motor dysfunction. Surgical
consultation may be useful for a variety of other syndromes when the response
to conservative measures proves to be less than optimal. Physical therapy and
occupational therapy are useful for many patients--particularly those patients
who have persistent back and shoulder pain--though these therapies may
constitute an important part of the treatment of almost any refractory regional
pain syndrome.
Common regional rheumatic disorders include
various types of bursitis, tendinitis, tenosynovitis, myofascial pain,
and entrapment neuropathies. Bursitis results from mechanical or inflammatory
changes of one of the many bursae in the body. Bursae are synovia-lined sacs
around the joints that serve to minimize friction between tendons, ligaments,
and bony structures. Tendinitis usually results from
trauma or overuse of tissues near sites where tendons attach to bone or at the musculotendinous junction. Myofascial
pain originates at sites within muscle groups and surrounding fascial tissues that become tender and painful as a result
of localized injury or overuse. Entrapment neuropathies occur at sites where
peripheral nerves are compressed as they traverse periarticular
areas that allow relatively little room for free movement of the affected
nerves.
Neck pain may result from degenerative changes
in the cervical disks and zygapophyseal (facet)
joints or from a variety of muscular, ligamentous,
and tendinous conditions. In whiplash injuries
occurring after rapid acceleration or deceleration and hyperextension of the head
in motor vehicle accidents, a number of structures may be injured.[2] Recovery from whiplash
injuries is often incomplete, and a combination of physical and psychosocial
factors may contribute to prolongation of pain.[3] Judicious use of
analgesics, muscle relaxants, and physiotherapy are useful in some patients.
Injection of the facet joints with glucocorticoids
appears to have no efficacy.[4] In some patients with
chronic neck pain after whiplash injury, the zygoapophyseal
joints may be the source of pain, and local nerve block with an anesthetic or
ablation often brings relief.[5]
The term cervical sprain denotes transient
neck pain associated with muscle tenderness and spasm. Cervical sprain usually
responds to heat, rest, and, occasionally, immobilization and traction. Manual
therapy or exercises may provide relief in some patients.[6] In cervical disk
herniation, nerve root impingement results in pain, paresthesia,
and sometimes muscle weakness in the distribution of the affected nerve
(usually at the C5 to C7 level). In such patients, radiographic documentation
and surgical decompression are sometimes needed if symptoms do not improve with
rest or traction or if significant neurologic deficit
is present.[7] In some patients with long-standing
cervical spondylosis, cervical stenosis may cause
chronic compression of the spinal cord (most often at the C3 to C5 level).
Surgical decompression is indicated in patients with evolving myelopathy.
Low back pain is the most common
musculoskeletal complaint requiring medical attention; it is the fifth most
common reason for all physician visits.[8,9] Over half of the
general population will seek medical attention for back pain at some point in
their lives. An increased risk of back pain is associated with male sex,
smoking, frequent lifting of children or heavy objects, poor general health and
conditioning, and certain occupational and sports activities.[10] In most patients, the
cause of pain cannot be determined with any degree of certainty and is usually
attributed to muscular or ligamentous strain, facet
joint arthritis, or disk pressure on the annulus fibrosus,
vertebral end plate, or nerve roots.
Diagnosis. For patients with
acute back pain, the initial history should be used to identify those who are
at increased risk for serious underlying conditions, such as fracture,
infection, tumor, or major neurologic deficit[8] [see Table 1].
The presence of such indicators in patients with acute back pain may indicate
the need for radiographic and laboratory studies earlier than in patients
without such indicators. The initial physical examination should include
evaluation for areas of localized bony tenderness and assessment of flexion and
straight leg raising. Because acute low back pain will
improve within a month in over 90% of patients, further evaluation is usually
unnecessary. Plain radiographs should be reserved for patients at high risk for
more serious underlying conditions [see Table 1], because abnormal
findings on plain films are common and do not correlate with back pain.
Treatment. A number of
therapeutic interventions are available for acute back pain, but data
supporting efficacy are minimal for most therapies.[11] Strict bed rest should
be kept to a minimum (no more than 2 to 4 days), and the continuation of normal
activities within the limits permitted by pain will lead to a more rapid
recovery than will either enforced rest or a back-mobilizing exercise program,
even in patients with sciatica.[12-14] Mild analgesics and NSAIDs may be useful for early symptom control; muscle
relaxants and opiates should be used sparingly. Spinal manipulation or specific
exercise programs may be effective in acute back pain, but most controlled
studies suggest little to no advantage of any particular regimen compared to
other measures.[15-17] Patient education
about the natural history of back pain may result in fewer demands for further
diagnostic tests and physician visits and should improve patient satisfaction.
However, a study of a preventive "back school" educational program in
the workplace did not find any reduction in the frequency or severity of
episodes of back pain.[18]
Diagnosis. Patients whose pain
persists after 4 to 6 weeks of conservative treatment measures should be
reassessed. Plain radiography and basic laboratory studies (e.g., complete
blood count, sedimentation rate, chemistry profile, and urinalysis) should be
considered to screen for systemic illnesses. A herniated lumbar disk should be
considered in patients with symptoms of radiculopathy,
as suggested by pain radiating down the leg with symptoms reproduced by
straight leg raising. Magnetic resonance imaging may
be necessary to confirm a herniated disk, but findings should be interpreted
with caution because many asymptomatic persons have disk abnormalities.[19] Electromyography may
be useful in differentiating lumbar radiculopathy
from other causes of radicular leg pain. Most lumbar disk herniations
producing sciatica occur at the L4-L5 and L5-S1 levels. Surgical intervention
is indicated in patients with persistent sciatica and clear-cut evidence of a
herniated disk on MRI or myelogram-computed tomographic scanning.[20]
Treatment. Patients with chronic
back pain should undergo physical therapy with local modalities, an exercise
program, and an education program emphasizing proper ergonomics for lifting and
other activities. Light normal activity and a regular walking program should be
encouraged. Judicious use of analgesics, NSAIDs, and tricyclic antidepressants may help the patient function
more fully and may improve outcome.[21] In some patients with
chronic low back pain that worsens with prolonged standing and extension, the
source of pain may be lumbar facet joint disease. Flexion exercises and NSAIDs may be useful, but facet joint injections with glucocorticoids do not appear to be effective.[22] Recent controlled
studies have suggested that therapeutic massage or low-impact aerobic exercise
provides more benefit than other strategies (e.g., acupuncuture,
standard physical therapy, or machine-based strengthening exercises).[23,24]
Lumbar Stenosis. Lumbar spinal
stenosis, usually a result of extensive degenerative disk disease and
osteophytes, should be suspected in elderly patients with chronic back pain
associated with sciatica.[25] Patients typically
complain of pain, numbness, and weakness in the buttocks that extends to one or
both legs. Symptoms are usually brought on by standing or walking and improve
when the patient assumes a flexed position or lies down (i.e., neurogenic claudication or pseudoclaudication). The diagnosis may be confirmed by MRI
or myelogram-CT scanning.[26] Although conservative
measures may be helpful in some patients, surgical decompression by multilevel laminectomy and fusion should be considered in patients
with progressive functional deterioration.[27,28]
|
Patient demographics |
Age > 70 yr |
|
Historical features |
Weight loss |
|
Neurologic symptoms |
Bowel or bladder dysfunction |
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