Musculoskeletal 1

What is the diagnostic approach to a warehouse worker who develops heel pain within several weeks of starting a job that involves prolonged walking and standing on concrete floors?

• Midfoot: navicular, cuboid, and 3 cuneiform bones
• Hindfoot: talus and calcaneus
• Major soft tissue regions: calcaneal fat pad, plantar fascia, Achilles insertion
• Tendons under medial flexor retinaculum: PT, FDL, FHL
• Tendons under lateral retinaculum: peroneal tendons
• Plantar fasciitis: most common 40-70 yrs, in runners, obese. 90% of patients achieve resolution w/o surgery. Pain loc in anteromedial or central heel, gradual onset, exacerbated by toe walking, worse in AM. History may include change in footwear. Risks include pes cavus/planus, decr subtalar motion, and a tight Achilles tendon. PE shows limited ankle DF with max tenderness at anteromedial aspect of inf heel, palpate for gap (sign of rupture)
• Imaging: limited role, used to assess for calcaneal stress fx or other bony lesion. Heel spur is often noted, but of no value. Bone scan if stress fx suspected. MRI can be used for suspected AVN. Ultrasound rarely used.
• DDx: fracture, infection, malignancy, rheum d/o.
• Calcanial stress fx: 2nd most common stress fx in foot, after metatarsals. Vague pain worsens with WB. Calcaneal squeeze may reproduce pain. Plain rads may be normal initially.
• Heel fat pad atrophy: similar sx to plantar fasciitis but more diffuse, commonly in elderly. Pain does not radiate anteriorly or worsen with toe DF and is not worse in AM.
• Achilles tendonitis: from overuse, jumping, running.
• Retrocalcaneal bursitis: Achilles tendon insertional pain, caused by abrasion and resulting in inflammation of the burse between the Achilles insertion and the calcaneus, from shoes. Associated with Haglund’s disease, bony protuberance of calc tuberosity.
• Peroneal tendon ruptures occur prox to insertion or just distal to lat malleolus, associated with swelling and tenderness after multiple ankle sprains
• Tarsal tunnel: numbness, tingling or burning pain, worsened with prolonged WBing and ambulation. Foot DF and eversion stretches nerve and can reproduce symptoms
• Other causes of neurogenic heel pain: medial calcaneal neuroma, S1 radic, neuropathy of nerve to abductor digiti quinti.



What is the diagnostic assessment of a transportation worker who p/w neck pain after a rear end collision while stopped at the side of the road?

• Most people involved in collisions have symptoms resolve in 4-6 weeks, but up to 1/3 have chronic symptoms
• Symptoms assoc with whiplash: neck pain and stiffness, arm pain, paresthesias, TMJ, HA, dizziness, visual disturbance, difficulty with memory/concentration
• Controlled diagnostic blocks show facet pain generators in 60% of patients
• Center of headrest should be at ear level and not reclined
• Symptoms may be mild after the accident but increase in the following 2-3 days
• Neurologic deficits are rare
• Imaging: flexion and extension films to r/o instability, plain rad may show decr lodosis. MRI usually unnecessary


What is the pathogenesis of job-related wrist and elbow pain?

• Risks: old age, obesity, DM, smoking, pregnancy, rheum arthritis, psych stress
• History should assess high repetitive nature of work and prolonged abnormal postures, pain at insertion of muscle or tendon
• Tx: PT/OT with work modifications
• DeQuervain’s: pain in 1st dorsal compartment (APL, EPB). Finkelstein’s test positive.
• CTS: pain, numbness, and tingling in first three digits


What is a diagnostic plan for a loading dock worker with LBP?

• History: determine if injury related to work, possible litigation
• Exclude fx, infection, cauda equina syndrome (ask about B/B symptoms). Ask about cancer history, IV drug use, fever, night sweats
• PE: Assess symmetry of muscle bulk and tone, kyphosis or lordosis, scoliosis, L-spine ROM to flexion, ext, bending and rotation. Strength testing, sensation, reflexes. Peripheral pulses.
• Schober’s test: line drawn between PSIS at S2 and draw line to 5 cm below and 10 cm above. And increase of more than 5 cm is normal.
• Check hamstring and gluteus maximus flexibility: Ely test, Thomas test
• Femoral stretch test: L4 nerve root pathology
• SLR: positive if pain below knee at 30-70 degrees of hip flexion
• SIJ pain: No tests sensitive or specific. FABER test, Gaenslen test, Gillet test.
• 5 Waddell signs: nonanatomic regional tenderness, overreaction, nonanatomic regionalization, distraction, and simulation (axial loading)  3/5 must be positive
• If no red flags, imaging may not be necessary
• Early X-rays if: age > 50, significant trauma, neurologic deficits, unplanned wt loss, assess ank spondylosis, drug/alcohol abuse, cancer history, steroid use, fever, no improvement with conservative care, pain > 7 weeks
• CT useful for assessing bones: foraminal bony narrowing and lateral recess stenosis, assess for fx if pt cannot get MRI
• MRI: useful for bone and soft-tissues, disk degen, endplate changes, neoplastic conditions. Gad contrast helps detect fracture, neoplasms, demyelination.
• 35% prevalence of DDD in young people < 40, 100% in age > 60yrs. 36% prev of herniated disk in >60 yrs.
• Bone scans for neoplasm or infection
• EMG to ID objective weakness, r/o neuropathy or neuromusc disease, localize lesion, assist in prognosis