1 MUSCULOSKELETAL PAIN Suggestions for Lecturer -1-hour lecture-Use GRS slides alone or to supplement your own teaching materials. -Refer to GRS and Geriatrics at Your Fingertips for further content. -See GRS9 questions 49, 74, 87, 141, 149, 160, 228, 291, 323, 334 for additional case vignettes. -For strength of evidence (SOE) levels, please see the GRS Teaching Slides site or the GRS inside front cover.
2 OBJECTIVES Know and understand:What questions to ask to determine the potential cause of musculoskeletal pain Components of a thorough physical examination for investigating musculoskeletal issues Most common causes of neck, shoulder, elbow, hand and wrist, thigh, hip, knee, and back pain Evidence-based management of musculoskeletal problems
3 TOPICS COVERED General Principles for DiagnosisEvaluation and Management of Regional Complaints Neck pain Shoulder pain Elbow pain Hand and wrist pain Thigh and hip pain Knee pain Back pain
4 GENERAL PRINCIPLES FOR DIAGNOSISA musculoskeletal problem is treated most effectively if the specific cause can be identified The gold standard for determining the cause of musculoskeletal pain is the physical examination, complemented by a good history If an older adult reports pain in more than one joint, a systemic process may be considered; however, older adults often have multiple mechanical problems in different sites of the body
5 GENERAL PRINCIPLES FOR DIAGNOSIS: The HISTORYWhat symptoms accompany the pain? What brings on the pain? Is it exacerbated when going from lying to sitting, ascending or descending stairs, standing, or walking? Is the pain worse in the morning, midday, or night? Does the pain radiate? Does the pain cause the patient to cease the activity associated with the pain? Was the pain acute at onset? Or has it worsened over time? The pattern of the pain is important. Pain that is gradual at onset and progressively worsens raises concern for a systemic condition such as a tumor or infection. Pain that is relatively abrupt at onset and related to position is more typical of mechanical pain. Some mechanical pain, such as rotator cuff tendonitis, is worse at night, interrupting sleep. Many musculoskeletal conditions produce pain at sites quite distant from the structure involved. Neck conditions produce pain throughout the trapezius and retroscapular region. Shoulder and neck disease can cause pain throughout the arm. Lumbar spine disease can produce discomfort in the back and legs, whereas pain in the buttock, thigh, groin, and knee may originate from the hip.
6 GENERAL PRINCIPLES FOR DIAGNOSIS: The EXAMCarefully observe the patient’s mobility Manually examine joints and muscle groups, focusing on: Patterns of weakness Malalignment and swelling of joints (whether the swelling is soft tissue or bony enlargement) Decreased range of motion (ROM) Patterns of joint involvement consistent with specific conditions Order imaging and laboratory tests only after formulating a list of potential diagnoses Ordering imaging and laboratory tests before establishing the differential diagnosis is costly, may expose the patient to risks of radiation and contrast material, and can mislead the clinician, often directing the process down the wrong path. These tests are very often abnormal in asymptomatic patients. In one study, 50% of asymptomatic individuals >60 years old had abnormal MRIs of the lumbar spine. The incidence of abnormalities on cervical spine radiographs and MRIs in older adults without neck pain is also very high.
7 NECK PAIN (1 of 5) Four general causes: systemic disease, cervical myelopathy, cervical radiculopathy, mechanical neck disease Systemic disease Often associated with polymyalgia rheumatica, rheumatoid arthritis, and other inflammatory conditions Systemic symptoms and signs, other joint complaints, and prolonged morning stiffness are often present Typical: symmetric loss of ROM of the cervical spine Lab markers of inflammation, such as C-reactive protein and erythrocyte sedimentation rate, are often increased
8 NECK PAIN (2 of 5) Myelopathy produced by cervical stenosisDoes not always cause neck pain Often characterized by spastic gait disturbance and weakness in the lower extremities with upper motor neuron signs (eg, hyperreflexia, increased muscle tone, positive Babinski signs) Can also produce lower motor neuron findings in the upper extremities Bladder symptoms include urgency, frequency, or retention Cervical myelopathy should be identified as early as possible, because it is a potentially reversible cause of leg weakness and spasticity. The clinical course is quite variable. Of note, the same neurologic pattern is seen in amyotrophic lateral sclerosis.
9 NECK PAIN (3 of 5) Cervical radiculopathyCharacterized by pain in the neck and arm, sensory loss, loss of motor function, and reflex changes in the affected nerve-root distribution Usually due to encroachment of the neuroforamina of the cervical spine; the C7 nerve root is most frequently affected Suggested by pain that is reproduced by rotating the head or bending it toward the symptomatic side Most patients improve with symptomatic treatment, and only a relatively small number require surgery
10 NECK PAIN (4 of 5) Nonspecific mechanical disease of cervical spine: diagnosis Cervical disc displacement appears to be a frequent cause of neck pain in older adults Cervical spine disease can also produce local muscle spasm and tenderness, often mistaken for the “trigger points” of fibromyalgia Typical: asymmetric loss of ROM of the cervical spine and weakness of the muscles innervated by cervical nerve roots, such as elbow extension and finger abduction in patients with C7, C8, and T1 disease Nonspecific mechanical disease of the cervical spine is the most common cause of neck pain in older adults. Cervical disc disease can be referred into several regions. C2C3 disease is felt in the occiput; C3C4 and C4C5 problems are referred into the posterior and lateral aspects of the neck; C5C6 lesions are referred into the trapezius and upper cervical regions; C6C7 disease is felt in the retroscapular region, often as far down as the mid- to lower thoracic region.
11 NECK PAIN (5 of 5) Nonspecific mechanical disease of cervical spine: treatment Little hard data on the effectiveness of one therapy versus another Bone and Joint Decade 2000–2010 Task Force on Neck Pain: Manual therapy and exercise are more effective than alternative strategies Virtually all studies involved patients ≤65 years old Surgery should be considered only for significant, persistent, and worsening neurologic signs
12 EXAMINING THE SHOULDERAssess the passive ROM of the glenohumeral joint Place one hand on the superior spine of the scapula and passively abduct the arm The point at which the scapula starts to rise is the point of glenohumeral abduction, normally about 90 Check external or lateral rotation by rotating the arm in that direction until tightness is felt External rotation is usually about 90; internal rotation, about 80 At the same time, check for a “painful arc” (present if the patient has discomfort when the arm is passively abducted from 45 to 120)
13 SHOULDER PAIN (1 of 4) Common causes are acromioclavicular disease, adhesive capsulitis, biceps tendinopathy and tendon rupture, and rotator cuff tendinopathies and tears Acromioclavicular disease Often due to trauma or osteoarthritis Patients complain of anterior shoulder pain, usually referred directly to the acromioclavicular joint Adhesive capsulitis (frozen shoulder) Loss of passive ROM of the glenohumeral joint, often due to shoulder injury or tendonitis Radiographs are normal The natural history is good, but ROM may not be restored for up to a year
14 SHOULDER PAIN (2 of 4) Rotator cuff tendinopathies and tears: diagnosis Shoulder pain is aggravated by pulling, lifting, or holding the arm above the shoulder level, as well as by lying on the affected side Consider these conditions if the patient has a painful arc Tendonitis: Suggested if the pain can be reproduced by resisting the active ROM of the affected tendon (abduction for supraspinatus and external rotation for infraspinatus and teres minor) Pain is usually felt in the deltoid area and often as far down as the elbow The supraspinatus is the most common tendon involved, and it can be evaluated with the “empty can” sign. The patient places a straight arm in 90 of abduction and 30 of forward flexion and then internally rotates the arm until the thumb is pointing down. The patient resists the clinician’s attempts to push down the arm. Pain without weakness is consistent with tendinopathy, whereas weakness is consistent with a tendon tear.
15 SHOULDER PAIN (3 of 4) Rotator cuff tendinopathies: treatmentTypical: NSAIDs, physical therapy, and/or local subacromial corticosteroid injections In one study, no difference at 1 year between corticosteroid injections and physical therapy But all patients were <65 years old Because of the complications of NSAIDs in older adults, corticosteroid injections are often preferred Mobilizing exercises alone are a reasonable approach
16 SHOULDER PAIN (4 of 4) Rotator cuff tearsCommon in older adults; may be insidious in onset Recurring shoulder pain and loss of function Diagnosed if active ROM is less than passive ROM of the glenohumeral joint, there is a positive “drop arm” sign (patient is unable to hold the arm in the abducted position against gravity), or the patient has significant weakness when performing the “empty can” sign (see slide notes) MRI is the definitive method of diagnosis Consider surgery if patient has substantial functional loss or persistent pain that has not responded to conservative therapy To reiterate the “empty can” sign: The patient places a straight arm in 90 of abduction and 30 of forward flexion and then internally rotates the arm until the thumb is pointing down. The patient resists the clinician’s attempts to push down the arm. Pain without weakness is consistent with tendonopathy, whereas weakness is consistent with a tendon tear.
17 ELBOW PAIN (1 of 5) Can result from cervical radiculopathy or be referred from subacromial bursitis or rotator cuff tendonitis Can also be caused by: Arthritis of the elbow Olecranon bursitis “Tennis elbow” (lateral epicondylitis) “Golfer’s elbow” (medial epicondylitis) Involvement of the elbow joint usually limits flexion and extension of the elbow
18 ELBOW PAIN (2 of 5) Arthritis of the elbowUsing the thumb, follow the lateral aspect of the humerus down the forearm to locate the lateral epicondyle There should be an indentation below that epicondyle and a second bony structure below the indentation If that structure rotates when the patient’s wrist is rotated, it is the radial head Run a thumb between the radial head and the olecranonthis space is where the synovial outpouching of the true elbow joint is felt Swelling or induration of this region indicates an elbow joint process
19 ELBOW PAIN (3 of 5) Olecranon bursitisUsually, but not always, causes swelling over the tip of the olecranon Results from trauma, gout, pseudogout, or infection To determine the cause of either bursitis or arthritis, aspirate the bursa or joint and examine the fluid for white cells, infection, or crystals Treat any infection with oral antibiotics and drainage of the bursa (outpatient procedure) Local corticosteroid injections are often helpful for gout or pseudogout of this joint Infection of the bursa usually results from contiguous spread of infection from the skin, whereas infection of the elbow joint itself usually comes from an endovascular source.
20 ELBOW PAIN (4 of 5) “Tennis elbow” (lateral epicondylitis)Results from irritation of the wrist extensor tendons close to their insertion on the lateral epicondyle of the humerus Tenderness may be found over the lateral aspect of the elbow Diagnose if elbow pain is reproduced by resisting extension of the patient’s wrist Steroid injections are ineffective; although there are little controlled data, physical therapy and counterforce braces placed 6–10 cm distal to the elbow joint are often suggested
21 ELBOW PAIN (5 of 5) “Golfer’s elbow” (medial epicondylitis)Diagnosed if elbow pain is reproduced by resisting flexion of the wrist Often accompanied by tenderness over the medial epicondyle
22 HAND AND WRIST PAIN (1 of 5)Inflammatory arthritis is suggested by: Synovial thickening of the metacarpal phalangeal joints Symmetric decreased ROM of the wrists Monoarticular arthritis of the wrist is frequently caused by gout or calcium pyrophosphate deposition disease (pseudogout) Gout or pseudogout can be effectively treated with a local steroid injection into the wrist Gout frequently affects the distal and proximal interphalangeal joints already involved in generalized osteoarthritis Generalized osteoarthritis does not typically involve the metacarpal phalangeal joints and wrists.
23 HAND AND WRIST PAIN (2 of 5)De Quervain tenosynovitis Produces pain along the radial aspect of the wrist, increased when grasping objects Caused by stenosing inflammation of the tendon sheath located over the radial styloid Pain is produced when a clenched fist is deviated quickly in an ulnar direction Responds well to a corticosteroid injection into the tendon sheath
24 HAND AND WRIST PAIN (3 of 5)Carpal tunnel syndrome: diagnosis Numbness and pain over the palm, which may radiate up the arm Pain is often increased in the morning; patients often drop objects Tinel test: tap the medial aspect of the wrist with a reflex hammer; the test is positive if the hand has pain or paresthesias in the fingers innervated by the median nerve Phalen maneuver: patient hyperflexes wrists by placing the backs of the hands against each other with the elbows in a flexed position; the test is positive if pain or paresthesias in the fingers develop within 1 minute
25 HAND AND WRIST PAIN (4 of 5)Carpal tunnel syndrome: treatment Usual approach: splinting of the wrist If splinting is ineffective, try a corticosteroid injection into the carpal tunnel space If this therapy is ineffective, surgery is the next option Ulnar neuropathies Common in peripheral neuropathies and can also be caused by trauma at the elbow area Numbness and tingling on the lateral aspect of the hand Diagnosis is confirmed if the patient has weakness of finger abduction but not elbow extension
26 HAND AND WRIST PAIN (5 of 5)“Trigger finger” syndrome Causes difficulty opening up a flexed finger Due to a combination of a flexor tendon nodule and thickening or fibrosis of the sheath in which this tendon travelsthe tendon is caught in a flexed position Dupuytren contraction of the palm Produces painless deformities Causes thickening and fibrosis of the palmar fascia sheath, often with “puckering” of the skin over the flexor tendon Flexion contractures of the fingers may result
27 THIGH AND HIP PAIN (1 of 7) Hip diseaseCommon cause of pain in thigh, groin, buttock, knee Pain often comes on with walking, is relieved with sitting and lying If ROM is normal, hip unlikely to be causing pain With patient supine, place one hand on the pelvis and gently abduct the hip (abduction is reached when the pelvis starts to tilt, normally at about 40) Should be able to flex the hip beyond 110 With the hip flexed, move the foot toward the midline (external rotation) Normal external rotation should be 50–60; internal rotation, when the heel is moved away from the midline, is normally 15–20 Patients with thigh pain due to hip disease may complain of significant pain on the first few steps after getting up from a sitting position. If the pain is significant, the patient usually limps, spending less time bearing weight on the affected side. If the disease is severe, it produces a short stride, because the hip is the “hinge” joint that controls the length of the stride. If the patient develops a flexion contracture of the hip, he or she will bend forward while walking.
28 THIGH AND HIP PAIN (2 of 7) Hip disease, continuedMost common cause in older adults: osteoarthritis Plain radiographs of the hip may not display significant changes in patients with early osteoarthritis, and cartilage can be seen only on MRI If the patient has significant signs and symptoms of hip osteoarthritis with an unimpressive radiograph, MRI may be indicated Corticosteroid injections, given under fluoroscopic guidance, can be beneficial for up to 3 months The success rate of hip arthroplasty for osteoarthritis of the hip is high Medical therapies for osteoarthritis of the hip are limited. In one study, physical therapy did not result in better improvement in pain or function than sham treatment. Although NSAIDs are effective in the treatment of osteoarthritis, their adverse effects limit their use in older adults.
29 THIGH AND HIP PAIN (3 of 7) Lumbar spine diseaseCommonly causes thigh pain, usually with standing and walking Pain can be felt on the lateral aspect of the hip and into the thigh region The physical examination is key to diagnosis, because the straight leg raise test is often positive Many patients will have subtle weakness of the great toe extensor, hip abductor, and hip extensor, because the L4L5 and L5S1 regions are the most common regions involved
30 THIGH AND HIP PAIN (4 of 7) Trochanteric bursitisPain is felt in the lateral thigh and may radiate down the lateral aspect to the knee Pain is usually worse when rolling over on that side at night or after prolonged sitting, and it may be reproduced by resisting abduction of the hip Most characteristic physical feature: local tenderness, usually felt about 1.5 inches below the superior portion of the trochanter
31 THIGH AND HIP PAIN (5 of 7) Femoral nerve dysfunctionCan produce pain in the thigh area, particularly in patients with diabetes, retroperitoneal hemorrhage, or metastatic cancer Causes focal weakness of the hip flexor and knee extensor muscles, because both of these muscle groups are innervated by the femoral nerve Pain occurs over the anterior aspect of the thigh, unaffected by movement Patients may have altered sensation over the anterior aspect of the thigh and a decreased quadriceps reflex
32 THIGH AND HIP PAIN (6 of 7) Inguinal or femoral herniaDiscomfort is increased when intra-abdominal pressure is increased, which can occur with straining, prolonged standing, or heavy lifting Diagnosis is best made on physical examination: groin bulge or discrete groin impulse that increases with cough or a Valsalva maneuver Although incarceration and strangulation of these hernias are rare, this complication requires urgent attention and surgery
33 THIGH AND HIP PAIN (7 of 7) Other causesVisceral problems in the abdomen, including psoas abscess Peripheral arterial disease Bone disease of the pelvis or femur, including metastatic bone cancer
34 KNEE PAIN (1 of 8) Can be referred from the hip or backMost common cause: osteoarthritis In some cases, patients have radiographic findings of knee osteoarthritis, but pain may be caused by other conditions, such as gout, pseudogout, or anserine bursitis The patient can often localize the site of the pain over the anterior, medial, or posterior aspect of the knee
35 KNEE PAIN (2 of 8) Anterior knee painCan be due to prepatellar or infrapatellar bursitis or irritation of the patellofemoral compartment Patellofemoral pain can be reproduced by placing fingers firmly on the superior aspect of the patella, then asking the patient, lying supine, to press the knee into the bed Patellofemoral pain often radiates down to the anterior aspect of the lower leg and is usually worse on prolonged knee flexion (eg, sitting in a theater or airplane) or when descending stairs
36 KNEE PAIN (3 of 8) Medial knee painCan be caused by osteoarthritis of the medial knee compartment, medial meniscal disease, irritation at the attachment of the medial meniscus to the medial collateral ligament, or irritation of the anserine bursa Diagnose meniscal disease by reproducing pain with a combination of extension and rotation of the knee Patients with irritation at the attachment of the medial meniscus to the medial collateral ligament often have night pain in the medial aspect of the knee There is usually tenderness along the medial joint line, and patients frequently put a pillow between their knees at night Patients with a varus or “bow-legged” appearance have significant medial joint space narrowing due to osteoarthritis.
37 KNEE PAIN (4 of 8) Managing knee osteoarthritisFirst steps: quadriceps-strengthening exercises and weight reduction Interarticular injections of corticosteroids are effective but on average last only 4 weeks Hyaluronic acid (HA) injections are somewhat controversial, but adverse effects are limited and response may be more prolonged than with corticosteroid injections Consider HA injections for patients who are not candidates for surgery HA injections have fewer adverse effects than daily use of NSAIDs
38 KNEE PAIN (5 of 8) Managing knee osteoarthritis, continuedMany patients have evidence of meniscal disease, and caution is warranted when considering surgical interventions A study has demonstrated that arthroscopic partial meniscectomy was no more effective than physical therapy for meniscal tears in patients with knee osteoarthritis
39 KNEE PAIN (6 of 8) BursitisThe combined insertion of the 3 medial hamstring muscles on the tibia resembles a “goose’s foot”; this region is named “pes anserine” The anserine bursa is located directly over that combined insertion, approximately 2 finger breadths below the medial joint line on the medial aspect of the tibia Marked local tenderness at the region can indicate a bursitis This condition often responds to local injection of a corticosteroid and lidocaine
40 KNEE PAIN (7 of 8) Popliteal cyst (Baker cyst)Pain is often felt in the popliteal region if there is significant swelling or inflammation of synovial tissue Sometimes this swelling can produce an outpouching in the popliteal area, known as a popliteal cyst or Baker cyst These cysts sometimes rupture, causing swelling and pain in the calf, producing a “pseudo-thrombophlebitis” syndrome
41 KNEE PAIN (8 of 8) Knee effusionIt is important to determine whether the patient has knee effusion, signifying that the problem is likely to be intra-articular If there is pain and joint effusion, aspirate the joint fluid and have it analyzed, looking for white blood cells (WBCs), crystals, and infection Mechanical disease such as osteoarthritis and meniscal irritation: bland fluid with a WBC count of <2,000 cells/mL Any condition that produces inflammation of the joint, such as rheumatoid arthritis, gout, pseudogout, or infection: synovial fluid WBC count of ≥2,000 cells/mL
42 CONDITIONS CAUSING BACK PAIN (1 of 3)History Examination Lab Tests, Imaging Tumor Persistent, progressive pain at rest; systemic symptoms No focal abnormalities Anemia, increased ESR, abnormal bone scan or MRI Infection Persistent pain, fever; at-risk patient (eg, indwelling catheter) Tender spine Increased ESR, WBC count; positive bone scan or MRI Unstable lumbar spine Recurring episodes of pain on change of position Pain going from flexed to extended position MRI or CT showing one disc space narrowed and sclerotic spondylolisthesis ESR = erythrocyte sedimentation rate
43 CONDITIONS CAUSING BACK PAIN (2 of 3)History Examination Lab Tests, Imaging Lumbar spinal stenosis Pain on standing and walking relieved by sitting and lying Immobile spine; L4, L5, S1 weakness MRI or CT scan showing stenosis Sciatica Pain in posterior aspect of leg; may be incomplete Often positive straight leg raise; L4, L5, S1 weakness Variable findings Vertebral compression fracture Sudden onset of severe pain; resolves in 4–6 weeks Pain on any movement of spine; no neurologic deficits Vertebral end-plate collapse; compression fracture seen on plain film
44 CONDITIONS CAUSING BACK PAIN (3 of 3)History Examination Lab Tests, Imaging Osteoporotic sacral fracture Sudden lower back, buttock, or hip pain Sacral tenderness H-shaped uptake on bone scan Note that systemic causes of back pain have histories quite distinct from those of mechanical pain
45 ASSESSMENT OF LOWER BACK PAIN IN OLDER ADULTSSymptom Condition Acute pain Vertebral compression fracture Disc displacement Osteoporotic sacral fracture Visceral origin (eg, aortic aneurysm) Positional pain Increased with standing and walking and relieved with sitting Brought on by bending, lifting, or unguarded movements Lumbar spinal stenosis Unstable lumbar spine Persistent pain (gradually increasing, non-positional) Tumor Infection Low back pain is rarely associated with inflammatory arthritis. Although ankylosing spondylitis, psoriatic arthritis, and Reiter syndrome can produce back pain, this involvement is not seen with rheumatoid arthritis, systemic lupus, polymyalgia rheumatica, or other inflammatory conditions.
46 BACK PAIN: THE EXAM Evaluate the back, hips, legs, and gaitWith patient upright, move the back through the 4 planes of movement of the lumbar spine (flexion to the right, flexion to the left, forward flexion, extension) Straight leg raise tests can be helpful if positive The most helpful physical finding in patients with possible back disease is subtle weakness of the L4L5 and L5S1 muscles (see slide notes) Examination of the hips is important because many patients with back, buttock, and leg pain have hip disease. Gait evaluation should note whether the patient bends forward as he or she walks, has a short stride, or spends less time on one leg than the other (limp). The pain of lumbar spinal stenosis is often produced by spinal extension. Asymmetric limitation of the range of motion of the lumbar spine, or reproduction of the pain with these maneuvers, may indicate mechanical disease of the lumbar spine. L4L5 weakness is demonstrated by weakness of the great toe extensor and hip abductor. The ankle dorsiflexor is also innervated by L4L5, but this muscle is quite strong, and subtle weakness may be difficult to elicit. L5S1 weakness is demonstrated by involvement of the hip extensors. This is easily tested by attempting to pull up the leg at the ankle when the patient is trying to hold the leg on the bed. Normally, a patient can successfully resist this maneuver.
47 PHYSICAL EXAM OF OLDER ADULTS WITH LOWER BACK PAINSign Condition Paravertebral muscle spasm Mechanical disc disease* Asymmetric ROM of the lumbar spine Mechanical disc disease Unstable lumbar spine Spinal tenderness Vertebral compression fracture Infection Weakness of L4L5 and L5S1 muscles Lumbar spinal stenosis Normal examination of lumbar spine Osteoporotic sacral fracture Hip disease Tumor Referred visceral pain *Not caused by tumor, infection, spinal stenosis, or fracture
48 INNERVATION OF LOWER EXTREMITIESFunction Muscle Peripheral Nerve Nerve Root Great toe dorsiflexion Extensor hallucis longus Deep peroneal L5 Ankle dorsiflexion Tibialis anterior L4, L5 Ankle eversion Peroneus longus, brevis Superficial peroneal L5, S1 Ankle plantar flexion Gastrocnemius, soleus Tibial S1, S2 Knee extension Quadriceps Femoral L3, L4 Hip flexion Iliopsoas L2, L3 Hip adduction Adductor magnus, brevis, longus Obturator Hip abduction Gluteus medius Superior gluteal Hip extension Gluteus maximus Inferior gluteal
49 BACK PAIN: IMAGING Red flags that warrant imaging without delay:If the discovery of a vertebral compression fracture will change management, obtain a plain radiograph of the lumbar spine in older women, and in older men who have risk factors for osteoporosis Acute neurologic deficit Bowel or bladder dysfunction Fever History of cancer
50 CAUSES OF BACK PAIN: SYSTEMICPain due to tumor, infection, etc usually has insidious onset and becomes more persistent and severe The pain is usually non-positional, can occur at night, and may be linked to systemic symptoms or signs Risk of cancer as a cause of back pain increases in adults >50 years old, those with a previous history of cancer, and those with pain that persists >1 month Fever, discrete local vertebral tenderness, pain in the upper lumbar or thoracic area, and non-positional pain may indicate vertebral infection Evaluate infection as a source of back pain in patients at risk of endovascular infections A number of visceral problems, such as abdominal aortic aneurysm, bladder distention secondary to urinary retention, uterine fibroids, pancreatic cancer, or other intra-abdominal infections or tumors, can present with back pain. Referred pain from these conditions should be suggested by the historical pattern of the pain, the absence of positional changes, and a normal examination of the lumbosacral spine. Patients with a known cancer with likelihood of spread to the bones should be urgently evaluated if they develop back pain.
51 CAUSES OF BACK PAIN: LUMBAR SPINAL STENOSIS (1 of 2)Common cause of back pain in people in their late 80s and 90s, but frequently seen on spine imaging in patients without symptoms Characteristic symptom: back pain radiating into the buttocks or legs that is worse on standing and walking (particularly downhill), relieved with sitting A similar clinical syndrome can be seen in patients with osteoarthritis of the hips Other common symptoms: Sciatic pain with standing and walking Pain in the calf when walking, relieved only by sitting down (pseudoclaudication) Lumbar spinal stenosis results from a narrowing of either the central or lateral aspect of the lumbar spinal canal. Osteophytes of the facet joints often impinge on nerve roots of the lower lumbar region when they travel in the lateral recess of the canal. This space can also be compromised by lumbar disc displacement into the canal.
52 CAUSES OF BACK PAIN: LUMBAR SPINAL STENOSIS (2 of 2)Conservative therapy has limited benefit No clear evidence that physical therapy, exercise, or medications alter the natural history A study of epidural steroid injections for spinal stenosis demonstrated minimal or no short-term benefit compared with epidural injections of lidocaine alone Surgery was more effective than conservative therapy in a randomized multicenter study For patients ineligible for spinal surgery, a rolling walker with an attached seat can be very helpful
53 CAUSES OF BACK PAIN: SCIATICAOlder adults can develop a typical sciatica syndrome similar to that seen in younger individuals Acute sciatica usually occurs spontaneously, with no obvious causal event This pain can be felt in any position, is usually not relieved with sitting, and often causes a good deal of night discomfort The clinical course in younger people is quite variable No studies have specifically evaluated sciatica in older adults
54 CAUSES OF BACK PAIN: VERTEBRAL COMPRESSION FRACTURESOnly 1/3 of patients have symptoms Pain is typically abrupt, is felt deep in the site of the fracture, can be severe Pain is usually worse on standing and walking, is relieved with lying down, may radiate to flank or legs Diagnosis is usually made on a plain radiograph of the lumbar or thoracic spine General consensus: Analgesics are successful in about 2/3 of patients with these fractures; reserve vertebroplasty and kyphoplasty for nonresponders Most important intervention: treatment of osteoporosis In one study, analgesic use decreased by 16% at day 5 and by 33% at day 14. In another study, patients in the control group had a significant reduction in pain by 3 months. Patients with vertebral compression fractures are more likely to have further fractures, become more disabled, and have a higher mortality rate than those without fractures. It is hard to determine whether these fractures are markers of or actually causative of frailty. There is no clear evidence that vertebroplasty and kyphoplasty are better than sham procedures for patients with chronic pain secondary to vertebral compression fractures. A number of studies have shown that calcitonin has analgesic effect in management of vertebral compression fractures.
55 CAUSES OF BACK PAIN: SACRAL FRACTURESOsteoporotic sacral fractures in older women can cause spontaneous buttock, pelvic, and low back pain Sacral tenderness is usually present on physical exam Associated additional osteoporotic fractures are likely Imaging: Plain radiographs are usually negative Technetium bone scans: characteristic H-shaped uptake over the sacrum CT: displacement of the interior border of the sacrum The pain usually resolves over 4-8 weeks
56 CAUSES OF BACK PAIN: NONSPECIFIC LOW BACK PAINVery little is known about nonspecific mechanical low back pain, except that it is quite common and relatively short-lived History and physical exam are best ways to determine probable cause of pain Usually has a relatively sudden onset and is exacerbated by positions that stress the lumbar spine If there is weakness of the L4L5 and L5S1 innervated muscles, pain is probably due to a displacement of disc material In the Framingham study, 22% of patients ≥68 years old had back pain on most days. A 10-year study of 550 community-dwelling adults ≥70 years old documented 1,528 episodes of low back pain severe enough to restrict activity. Of these episodes, 80% lasted less than 1 month and only 6.4% lasted longer than 3 months. Examples of positions that stress the lumbar spine are going from supine to sitting, getting in and out of bed, bending, lifting, or putting on socks and shoes. Herniation of the nucleus pulposus is unlikely in older adults, because the water content of this structure decreases dramatically with age. It is no longer gel-like and, therefore, much less apt to herniate.
57 SUMMARY Musculoskeletal issues are the most common causes of pain in older adults The gold standard for determining the cause of musculoskeletal pain is the physical examination, complemented by a good history Order imaging and laboratory tests only after formulating a list of potential diagnoses Back problems are the third most common reason for clinician visits by older adults Nonspecific mechanical low back pain is typically relatively short-lived: pain of relatively sudden onset, exacerbated by positions that stress the lumbar spine
58 CHOOSING WISELY Recommendations based on the ABIM Foundation’s Choosing Wisely® Campaign: Avoid NSAIDs in individuals with hypertension, heart failure, or chronic kidney disease of all causes, including diabetes mellitus. Do not perform imaging for lower back pain within the first 6 weeks unless red flags are present (severe or progressive neurologic deficits or when serious underlying conditions are present). If there is a concern for a vertebral compression fracture, a plain lumbar spine x-ray should be done immediately after the patient is evaluated.
59 CASE 1 (1 of 4) An 80-year-old woman describes persistent pain over the top of her right shoulder. The pain began 3 weeks ago. It occasionally awakens her and is worse if she rolls onto her right side. It worsens when she carries more than a few pounds with her right arm. History: type 2 diabetes, coronary artery disease, hyperlipidemia, hypertension, osteoarthritis, stage 3 chronic kidney disease
60 CASE 1 (2 of 4) Medications: metformin, hydrochlorothiazide, pravastatin, acetaminophen, tramadol, vitamin D3, calcium carbonate Physical examination Normal temperature Blood pressure: 130/70 mmHg Heart rate: 76 bpm The patient appears to be in mild distress from shoulder pain.
61 CASE 1 (3 of 4) Which one of the following is the most likely cause of the shoulder pain? Glenohumeral joint arthritis Acromioclavicular joint arthritis Supraspinatus tendinosis Bicipital tendinosis Adhesive capsulitis
62 Glenohumeral joint arthritis Acromioclavicular joint arthritis CASE 1 (4 of 4) Which one of the following is the most likely cause of the shoulder pain? Glenohumeral joint arthritis Acromioclavicular joint arthritis Supraspinatus tendinosis Bicipital tendinosis Adhesive capsulitis Answer: B Osteoarthritis affects the acromioclavicular joint more commonly than the glenohumeral shoulder joint in those who are ≥50 years old. This patient has symptoms typical of acromioclavicular joint arthritis, including the location of the pain, night symptoms, and reproduction of pain by stressing the acromioclavicular joint through a cross-adduction maneuver. Patients also describe increased pain when they carry heavy objects, when the downward pulling motion can further stress the acromioclavicular joint. In glenohumeral joint arthritis, swelling is common in the anterior aspect of the shoulder, and active or passive movement of the shoulder will elicit pain. Rotator cuff disease is common in older adults, in part because of underlying arthritis, and because of physiologic changes, such as loss of water content, cross-linking of collagen fiber, and sarcopenia of the rotator cuff apparatus. This patient’s symptoms are much more indicative of acromioclavicular joint pathology. Adhesive capsulitis, or frozen shoulder, is characterized by global limitation of active and passive shoulder motion associated with severe shoulder pain. The classic presentation of bicipital tendinosis is anterior shoulder pain that radiates distally over the biceps tendon. Although the problem can present in isolation, more often it is associated with rotator cuff disease.
63 CASE 2 (1 of 3) A 79-year-old woman comes to the office because she has pain predominantly in the right buttock. The pain is worse when she stands or walks. She has a pronounced limp, because she is unable to bear weight on her right leg without significant pain. MRI of the lumbar spine 6 months ago showed diffuse degenerative changes throughout the lumbar area, with significant stenosis at L4-L5 and L5-S1. The patient has been treated by a pain specialist with a series of facet joint injections, without significant relief.
64 Which one of the following is the most appropriate next step?CASE 2 (2 of 3) Which one of the following is the most appropriate next step? Bone scan to exclude tumor of the spine Referral for decompression laminectomy of the lumbar spine Passive examination of the right hip Trial of tramadol 25 mg titrated to 4 times daily as needed Referral for intensive program of physical therapy
65 Which one of the following is the most appropriate next step?CASE 2 (3 of 3) Which one of the following is the most appropriate next step? Bone scan to exclude tumor of the spine Referral for decompression laminectomy of the lumbar spine Passive examination of the right hip Trial of tramadol 25 mg titrated to 4 times daily as needed Referral for intensive program of physical therapy Answer: C Buttock pain can be produced by both hip and lumbar spine disease. When back pain is caused by hip disease, patients are more likely to have a limp, groin pain, and decreased internal rotation of the hip. In the absence of sciatica, the presence of a significant limp in a patient with groin pain calls for a thorough evaluation of the hips, starting with passive physical examination. The patient should lie in the supine position. The hip should be abducted to 40 and flexed to over 90, and should have external rotation (heel toward midline) of 60 and internal rotation (heel away from midline) of approximately 20. Plain radiography of the hip should be obtained if there is any limitation in range of motion. The history and physical features of this case would be unusual for a tumor. Pain related to systemic disease is usually not positional, unless there is a metastatic lesion on a weight-bearing surface. Back surgery is not indicated unless there is clear evidence that mechanical disease of the spine is causing the pain. This patient’s presentation is not typical for lumbar spinal stenosis. Narcotic analgesics have a limited role in patients with positional pain. In a recent controlled study, physical therapy had no significant impact on pain and function in patients with osteoarthritis of the hip.
66 CASE 3 (1 of 4) A 78-year-old man comes to the office because he has pain radiating from his buttock to his right heel. The pain began suddenly 10 days ago. It bothers him in all positions, particularly at night. It limits his walking and his ability to climb stairs. He does not recall similar pain in the past, although he has had intermittent low back pain.
67 CASE 3 (2 of 4) Physical examinationRaising the right leg to 40º reproduces the leg pain. Mild weakness of right great toe extensor, right hip abductor, and right hip extensor Full ROM of both hips, with no pain MRI findings: stenosis at L4-L5 and L5-S1 and moderate disc displacement into right L4-L5 interspace
68 CASE 3 (3 of 4) Which one of the following statements is true?The pattern of pain is typical for sciatica due to lumbar spinal stenosis. Between 50% and 75% of patients report improvement of this pattern of pain within 4 weeks. The patient’s age is associated with poor prognosis for sciatica. The disc herniation indicates a need for surgical intervention.
69 CASE 3 (4 of 4) Which one of the following statements is true?The pattern of pain is typical for sciatica due to lumbar spinal stenosis. Between 50% and 75% of patients report improvement of this pattern of pain within 4 weeks. The patient’s age is associated with poor prognosis for sciatica. The disc herniation indicates a need for surgical intervention. Answer: B This patient’s history does not suggest sciatica associated with lumbar spinal stenosis. Lumbar spinal stenosis pseudoclaudication syndrome is characterized by leg pain with standing and walking that is relieved by sitting. The process usually develops gradually. The patient’s abrupt onset of pain, with pain in any position, is more typical of an acute attack of sciatica. No prognostic factors consistently predict outcome in patients with sciatica. According to 6 studies, age is not a significant predictor of its course. Four studies have examined the relationship between radiologic findings and prognosis. Although 1 study found that a larger ratio of disc material to the remaining canal was associated with poor outcome, 2 other studies found no association between radiologic findings and prognosis, and in a fourth study, broad-based disc protrusion was associated with good outcome. Pain associated with sciatica lasts longer than low back pain alone. Still, in 1 study, between 50% and 70% of patients in the placebo arm reported improvement at 4 weeks. In another study, 80% of patients in the nonsurgical arm had complete resolution of symptoms at 8 weeks. Surgery is a reasonable option for patients whose symptoms persist ≥8 weeks. It is associated with a shorter duration of pain but does not significantly affect outcome at 1 year.
70 Copyright © 2016 American Geriatrics SocietyGRS9 Slides Editor: Mandi Sehgal, MD GRS9 Chapter Author: Leo M. Cooney, Jr., MD GRS9 Question Writers: Leo M. Cooney, Jr., MD Raymond Yung, MD Medical Writers: Beverly A. Caley Faith Reidenbach Managing Editor: Andrea N. Sherman, MS Copyright © 2016 American Geriatrics Society Topic