Primary Care of Musculoskeletal Problems in the Outpatient Setting PDF
Preview Primary Care of Musculoskeletal Problems in the Outpatient Setting
Primary Care of Musculoskeletal Problems in the Outpatient Setting Edward J. Shahady, MD Tallahassee,FL,USA Editor Primary Care of Musculoskeletal Problems in the Outpatient Setting With 207 Illustrations Edward J.Shahady 3085 Obrien Drive Tallahassee,FL 32309 USA Library ofCongress Control Number:2006920784 ISBN-10:0-387-30646-3 ISBN-13:978-0387-30646-9 Printed on acid-free paper. © 2006 Springer Science+Business Media,LLC All rights reserved.This work may not be translated or copied in whole or in part without the written permission ofthe publisher (Springer Science+Business Media,LLC,233 Spring Street, New York,NY 10013,USA),except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation,computer software,or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication oftrade names,trademarks,service marks and similar terms,even if they are not identified as such,is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made.The publisher makes no warranty, express or implied,with respect to the material contained herein. Printed in the United State ofAmerica. (SPI/MV) 9 8 7 6 5 4 3 2 1 springer.com This book is dedicated to my lovely wife Sandra, our six beautiful and gifted children, their wonderful spouses and our ten lovely and talented grandchildren. Through them I have learned the real joy and meaning of life. Contents Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix PART I. GENERAL TOPICS 1 Key Principles of Outpatient Musculoskeletal Medicine . . . . . . . . . 3 Edward J.Shahady 2 Exercise as Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Edward J.Shahady 3 Nutrition for Active People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Eugene Trowers 4 Altitude,Heat,and Cold Problems . . . . . . . . . . . . . . . . . . . . . . . . 35 Edward J.Shahady PART II. UPPER EXTREMITY 5 Shoulder Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Edward J.Shahady,Jason Buseman,and Aaron Nordgren 6 Elbow Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Edward J.Shahady 7 Wrist Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Edward J.Shahady 8 Hand Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Edward J.Shahady PART III. SPINE 9 Neck Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Edward J.Shahady vii viii Contents 10 Back Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Edward J.Shahady PART IV. LOWER EXTREMITY 11 Hip and Thigh Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Edward J.Shahady 12 Knee Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Jocelyn R.Gravlee and Edward J.Shahady 13 Lower Leg Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268 Edward J.Shahady 14 Ankle Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Edward J.Shahady 15 Foot Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310 Mike Petrizzi and Edward J.Shahady Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 Contributors Jason Buseman,MS,BS Senior Medical Student, Florida State University College of Medicine, Tallahassee,FL,USA. Jocelyn R.Gravlee,MD Assistant Professor, Department of Family Medicine and Rural Health, Florida State University College of Medicine,Tallahassee,FL,USA. Aaron Nordgren,BS Fourth Year Medical Student,Florida State University College of Medicine, Tallahassee,FL,USA. Mike Petrizzi,MD Associate Clinical Professor, Department of Family Medicine, Virginia Commonwealth University School of Medicine,Richmond,VA,USA. Edward Shahady,MD Clinical Professor,Department of Family Medicine and Community Health, University of Miami; Adjunct Professor, Department of Family Medicine, University of North Carolina; Associate Faculty Family Practice Residency Tallahassee Memorial Hospital,Tallahassee,FL,USA. Eugene Trowers MD,MPH,FACP Assistant Dean, Department of Clinical Sciences, Florida State University College of Medicine,Tallahassee,FL,USA. ix Part I General Topics 1 Key Principles of Outpatient Musculoskeletal Medicine EDWARD J. SHAHADY Musculoskeletal (MS) problems are common in primary care.Up to 15% of diagnoses made in primary care are MS.These diagnoses may be the primary reason for the patients’visit or an associated diagnosis or complaint.The com- plaints are common in the physically active especially the weekend warriorwho is too busy during the week to be active and overextends himself or herself on the weekend.Unfortunately,many patients do not receive effective care for MS prob- lems.In order to provide effective care there are key principles that should be followed: 1.Knowledge of the anatomy of the area involved is critical to diagnoses and treatment.Devoting a few extra minutes to rediscovering the anatomy will facilitate a more accurate diagnosis and prescription of effective treatment. 2.A focused history and examination that includes the mechanism of injury is 95% accurate in making the diagnosis of MS problems. 3.Imaging for MS problems is sometimes overordered and used as a substi- tute for the physical examination and history. 4.Rehabilitation for an injury begins with rest,ice,compression,and elevation (RICE).The next phase of rehabilitation includes stretching,strengthening, heat,ultrasound,and stimulation.Medications have a role but only a tem- porary one.Medications should never be used alone with MS problems. 5.Treatment always includes a reduction of training errors and use of orthotics if needed. 6.Older patients,especially those with chronic disease,will have minor MS problems that will lead to major disability if not properly addressed. 7.Exercise is an excellent medication for many chronic diseases. Understanding how to motivate patients and yourself to prescribe exercise is difficult and may require a change in clinician and practice attitude. 8.Exercise can induce MS problems if the potential for training errors and anatomic risks are not properly accessed and addressed. 9.Medications for relief of pain and inflammation are helpful but can also have negative effects especially in the elderly. 10.The place where physical activity occurs can represent a risk. High and low altitudes as well as heat and cold are environments that can lead to 3 4 E.J.Shahady problems. The most important role for the primary care clinician is pre- vention and early recognition of these problems. 11.When does being sick limit physical activity? An upper respiratory infec- tion (URI) or infection of any type should not necessarily limit physical activity. Infectious mononucleosis (MONO) is not necessarily a con- traindication to physical activity. 1. Principle 1 Each chapter of this book stresses some aspect of the anatomy of the MS problems of that chapter. The anatomy stressed is not the total anatomy of the area but the key anatomy most often involved in the diagnosis and treatment of MS problems. For example, Chapter 5 describes the impor- tance of the difference between the shoulder joint and the hip joint.This dif- ference allows for more movement of the shoulder than the hip. The hip is not as movable because the head of the femur fits into a socket from the pelvis,so bone aids in preventing it from dislocation and excessive movement. The head of the humerus fits on a flat glenoid process that covers only 1/3 of the surface of the humerus.A rim of cartilage (labrum) ligaments and rota- tor cuff muscles provide the rest of the stability for the shoulder. This anatomical arrangement permits the shoulder to move the arm in multiple directions.Many of the activities of daily living are possible because of this flexibility. Unfortunately, this anatomical arrangement places the shoulder atgreater risk of dislocation,making it the most commonly dislocated joint in the body. Knowledge of the shoulder anatomy also helps with rehabilitation. The rotator cuff muscles originate on different parts of the scapula and insert on the humeral head in different sites.Knowledge of the origin and insertion aids in understanding the exercises that need to be prescribed.Review the shoulder exercises to help you understand this principle.For example,the infraspinatus muscle originates on the posterior scapula and inserts on the humeral head. Look at the exercise for strengthening this muscle and you will see the anatomy in action. 2. Principle 2 The history helps the clinician not only make the diagnosis but better under- stand the risks for injury and the mechanism that led to the injury.Many of the cases presented in the different chapters highlight this importance. For example,the boy with leg pain in Chapter 13 was not in shape over the sum- mer so he was not well conditioned at the start of practice. His shoes were 2years old and had been used by his brother for a full season.They provided
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