Primary Care of Musculoskeletal Problems in the Outpatient Setting - part 6 pot

C. Neck side bend (Figure 9.10): Place the palm of your hand on your temple and press into the hand while exerting some resistance. Hold for 5 s and repeat five times in one set. D. Neck lateral rotation (Figure 9.11): With the neck in a neutral position rotate the head to each side against the resistance of a clinched fist against the mandible. Hold for 5 s and repeat five times in one set. E. Shoulder shrugs (Figure 9.12): Stand with your neck in a neutral position and shoulders thrown back. Shrug your shoulders up and then relax. Do three sets of 10. 9. Neck Problems 175 FIGURE 9.9. Neck backward extension exercise. 176 E.J. Shahady FIGURE 9.10. Neck sidebend exercise. FIGURE 9.11. Neck lateral rotation exercise. Suggested Readings Slipman C, et al. Chronic neck pain: mapping out diagnosis and management. J Musculoskelet Med. 2002;19:242–255. Rao R. Neck pain, cervical radiculopathy, and cervical myelopathy: pathophysiology, natural history, and clinical evaluation. J Bone Joint Surg Am. 2002;84:1872–1881. 9. Neck Problems 177 FIGURE 9.12. Shoulder shrug exercise. 10 Back Problems EDWARD J. SHAHADY Low back pain (LBP) is the fifth most common reason for outpatient visits in the primary care setting. It is also a leading cause of lost work time, dis- ability, and is responsible for direct health care expenditures of more than $20 billion annually. Back pain can be a straightforward mechanical problem or it can be one of the most challenging problems seen by the primary care clinician. Studies of satisfaction with back pain care indicate 50% to 70% dissatisfaction with the care received. Chiropractors receive the highest satis- faction ratings and primary clinicians and orthopedist receive lower ratings. Lack of recognition and/or treatment of the behavioral or psychosocial issues account for most of the dissatisfaction. Almost everyone experiences back pain at some time during his or her life and up to 50% of working adults have one bout of back pain each year. On average, 60% recover by 6 weeks and 90% by 12 weeks. Lifetime recurrence rates of back pain may be as high as 80%. Recovery and prognosis are influ- enced by the presence of depression, previous history of back trouble, reim- bursement issues, and ongoing litigation. If the back pain is work-related and/or a lawyer is involved, recovery is delayed. Each year, about 2% of the American workforce has back injuries covered by workmen’s compensation. The injuries covered by workmen’s compensation usually take longer to recover, involve more nonspecific symptoms, and are a source of frustration for clinicians. Low back pain secondary to serious pathology is rare. Mechanical prob- lems are the usual diagnosis. It is most often a self-limited process lasting 6 weeks or less and complete recovery is the rule. Satisfaction derived by patients with the care they receive for back prob- lems is related to how well clinicians validate the patients’ suffering, help them return to normal functioning, and act like they care. Keep the follow- ing words of wisdom in mind: The patient does not care how much you know until they know how much you care. Simply stated, caring for the patient with LBP is exactly that: caring. The prudent clinician must realize that the psychosocial aspect of LBP is as impor- tant if not more important than looking for a biological cause of the pain. As 178 the history and physical is performed, equal emphasis must be placed on col- lecting information that facilitates making the biological as well as the psy- chosocial diagnosis. It is not unusual to find data that indicate both types of diagnosis are present. This chapter, like others, will use epidemiology and anatomy to aid discovery of an anatomical cause of the problem as well as describe methods of data collection that will enhance making a psychosocial diagnosis (Table 10.1). Effective treatment addresses both diagnoses. 1. Focused History Ask about any preceding events like lifting, bending over, twisting, or trauma. Many patients with an acute onset of back pain can remember an event within the past 24 h like repeated lifting that is not their usual activity or a significant twisting activity like dancing the twist the night before. The lifting may be with a heavy item or it may just be the way the lift was performed. Healthy ways to lift are described in the last part of the chapter. Acute onset of severe debilitating pain with no trauma or minimal activity suggests a frac- ture that may be seen with a malignancy or a compression fracture of osteo- porosis. Radiation of the pain to the buttocks and/or down the legs is significant. This radiation is called “sciatica or lumbago.” It does not always mean nerve impingement. In fact, the most common cause of radiation is hamstring tightness that usually accompanies back pain. Hamstring tight- ness pain is usually described as discomfort rather than the burning pain of nerve compression. Nerve compression pain usually radiates down to the lower leg and foot but it may not. The burning or stinging quality of the pain usually signifies nerve compression. What relieves the pain and what makes the pain worse is a helpful piece of history. Mechanical pain is relieved by bed rest and sitting and increased with rising from a chair and standing. The pain 10. Back Problems 179 TABLE 10.1. Classification of low back pain problems. (1) Low back pain syndrome ● Mechanical back pain ● Psychogenic back pain (2) Low back pain associated with loss of neurologic function ● Herniated disk ● Spinal stenosis ● Cauda equina syndrome (3) Low back pain associated with red flags ● Pathological fractures ● Compression fractures ● Infections (4) Other causes ● Ankylosing spondylitis ● Spondylolysis of a herniated lumbar disk is better with lying down, worse with sitting, and better with standing. Spinal stenosis pain is worse with walking and bending backward and relieved by bending forward. The pain of a fracture or metastatic bone pain is characteristically worse at night and when lying down whereas almost all other types of back pain are relieved by lying down. Asking about weakness or loss of strength and numbness in the legs is important. Herniated lumbar disks with nerve compression can lead to pro- gressive leg weakness and numbness. These symptoms can also be present with spinal stenosis. The symptoms of stenosis are usually brought on by walking and relieved by stopping and bending over. The cauda equina (CE) syndrome is a rare but devastating complication of disk herniation. The symptoms are inability to void and involuntary loss of stool. All patients with back pain should be asked questions about inabil- ity or difficulty voiding and involuntary loss of stool. Warn patients with any type of back pain to report any signs of bowel or bladder problems. The window of opportunity to prevent permanent loss of bladder or bowel func- tion is 24 h or less. Loss of bladder or bowel function constitutes a surgical emergency. Infections like tuberculosis (TB) or osteomyelitis rarely may be the cause of back pain. If signs of systemic illness like fever or weight loss are present, consider an infectious process. Ask about past problems with back pain, how long it took to recover, satis- faction with the care for that episode, and similarity of this episode to the past episode. Recurrent back pain usually has some psychosocial issues involved. Depression may be present so a few questions about inability to concentrate, not sleeping well, crying easily, guilt, and depressive mood are indicated. If depression is present, the back pain will not get better unless the depression is also addressed. Both can be treated at the same time. Most primary care prac- titioners are well versed in the treatment of depression and this book is not intended to cover therapy for depression. The emphasis here is on the impor- tance of recognizing it as a comorbid condition with back pain. Always ask if the back pain is work-related. If workmen’s compensation is involved some but not all of these patients may take longer to recover. Quick follow-up and use of a physical therapist helps hasten recovery with this group. Progressive back pain for at least 3 months in a male under 40 that involves the sacroiliac (SI) and gluteal regions, and is accompanied by decreased mobility, should alert the clinician to the possibility of ankylosing spondylitis (AS). This is a rare but important cause of back pain in younger men. 2. Focused Examination First obtain the vital signs to be sure the patient is not febrile and also eval- uate the blood pressure (BP). Pain elevates BP and the patient (especially males who avoid seeking health care) may not be aware they are hypertensive. 180 E.J. Shahady The BP may be greater than 180/110 and require treatment or at least appro- priate follow-up. The history will be pointing you to a more specific diagnosis but here are some general tips for a focused examination. The position of the patient when you walk into the room may be diagnostic. If they are standing and even pacing the room this is characteristic of a herniated disk. Patients with mechanical back pain are sitting in a chair and when you ask them to get up they struggle and grimace because of the pain. Next have the patient walk on their tiptoes and then their heels (Figure 10.1A and 10.1B). This is a good screening test for L5 and S1 nerve root compression. Weakness of toe walking is indicative of S1 root compression and heel walking of L5 root compression. If heel and toe walking are normal and there is nothing else to suggest root compression from the history or physical, no other tests for lower leg strength need be performed. Range of back motion is a very helpful part of the examination. With the patient standing in front of you, have him/her perform forward flexion (Figure 10.2). If the patient can achieve 90° of forward flexion, it is unlikely 10. Back Problems 181 FIGURE 10.1. (A) Walk on toes. that a disk or mechanical back problem is present. Backward extension (Figure 10.3) should now be performed. The patient can usually reach 30° to 40°. Limited or painful backward extension is characteristic of spinal steno- sis. Left and right lateral movement (Figure 10.4) should now be attempted. Pain on one side or the other is usually associated with mechanical back problems. Twisting movement, discomfort or stiffness may also be indicative of mechanical strain or SI problems. Be sure to stabilize the pelvis when ask- ing the patient to twist. Stand behind the patient and place your hands on both iliac crests to assure that the patient is not moving the pelvis but the back. Marked stiffness of all movements may be indicative of AS. The patient should now be asked to lie on the examination table. Observe the patient’s ability to get on the table. Patients who have no problems with the above movements and smoothly get on the examination table may have more of a psychosocial problem than an anatomic problem. Perform a straight leg raise as demonstrated in Figure 10.5. Be sure the opposite knee is flexed to 90°. If pain is present between 30° and 70°, be sure to ask where it radiates and what type of pain it is. Nerve compression pain is burning and goes in to the foot. Most patients will have pain in the posterior thigh, indicating hamstring tightness that is common with back problems. If pain is 182 E.J. Shahady FIGURE 10.1. (B) Walk on heels. FIGURE 10.2. Forward flexion. FIGURE 10.3. Backward extension. 184 E.J. Shahady FIGURE 10.4. Lateral movement. FIGURE 10.5. Straight leg raise. [...]... disease of the lumbar spine that occurs with aging: 1 Vertebral height decreasing because of the shrinkage of the intervertebral disks 2 Disks becoming weaker and beginning to bulge into the spinal canal 3 Other osteoarthritic changes that produce osteophytes and spurs that further increase compromise of the spinal canal The accumulation of these degenerative changes produces gradual narrowing of the cervical... period of time The next question would depend on the answer to the first If the onset is acute then ask patients what they were doing when the pain occurred and the location of the pain Pain in the back of the leg that occurred immediately after the patient started running is probably a hamstring muscle tear Age also helps with the diagnosis Hip pain in older patients is most likely OA but in a 13-year-old,... Thigh Problems FIGURE 11.5 Internal rotation FIGURE 11 .6 External rotation 207 208 E.J Shahady the other Use a goniometer to assess degrees of motion The focused history will guide the content of the remaining examination 3 Case 3.1 History A 22-year-old female runner comes to your office with complaints of right groin and thigh pain for the past 3 weeks The pain first began after 25 min of running but... into the foot In some patients, the initial presentation may not include radiation but if a herniated disk is present, radiation of the pain will usually appear Other complaints may include numbness and/or weakness in the lower extremity and aggravation of the pain by sitting, coughing, sneezing, straining, and defecation Difficulty voiding and involuntary loss of stool are indications of central disk... lying in bed and/or sleeping If the pain is worse at night or when the patient is reclining or lying in bed, a fracture, a malignancy, or an infection should be considered the cause Reclining, sleeping, and nighttime pain are an indication for an X-ray and further evaluation 8.2 Localized Tenderness over the Spine Acute onset of pain that is moderately severe and located in a specific area over the spine... overlying the femoral neck The above factors of (1) increased risk for osteoporosis (eating disorder), (2) history of recent increase in running mileage, (3) pain in the groin and thigh, (4) pain and limitation of motion with hip flexion and internal and external rotation are suggestive of a femoral neck stress fracture The negative X-ray is not surprising in the early stages of stress fractures Obtain... within minutes of beginning her run The pain stops when she stops running and the pain is not present with walking or at rest She has increased her running time recently in preparation for a marathon She has no history of hip or thigh problems in the past She denies taking any chronic medicines or using alcohol excessively Over the past few years, you have also evaluated her for inability to gain weight... symptoms of a femoral neck stress fracture include an aching sensation in the groin, anterior thigh, or knee The pain is frequently 11 Hip and Thigh Problems 209 associated with weight-bearing activity and stops shortly after cessation of activity Physical findings include a limp and limitation of hip motion, particularly internal rotation Tenderness by palpation is often minimal owing to the depth of soft... clinicians argue that they obtain the films for medical or legal reasons The data reviewing the reason why most physicians obtain unneeded X-rays and laboratory tests reveal that clinician ignorance 190 E.J Shahady about the clinical aspects of the presenting problem is more predictive of obtaining unneeded studies than their fear of malpractice Another problem with diagnostic imaging is the high incidence... bone grafting Recent weight gain is a predisposing factor The common symptom is pain and/or numbness in the anterolateral thigh in the distribution of the lateral femoral cutaneous nerve (Figure 11.7) Hyperextending the hip and bending backwards at the back may make the symptoms worse Tinel’s sign (tapping on the area and reproducing the pain) is usually present 1 cm medial and inferior to the anterior . of the lum- bar spine that occurs with aging: 1. Vertebral height decreasing because of the shrinkage of the intervertebral disks. 2. Disks becoming weaker and beginning to bulge into the spinal. weakness in the lower extremity and aggravation of the pain by sitting, coughing, sneezing, straining, and defecation. Difficulty void- ing and involuntary loss of stool are indications of central. prob- lems is related to how well clinicians validate the patients’ suffering, help them return to normal functioning, and act like they care. Keep the follow- ing words of wisdom in mind: The