Week 8: Assessment of the Musculoskeletal System

Week 8: Assessment of the Musculoskeletal System

A 15-year-old Caucasian male Justin Timberland presents to the clinic with reports of dull pain in both knees. He states sometimes one or both knees click, and he describes a catching sensation under the patella.

To begin my assessment of my patient’s knee pain, I’ll  approach the interview initially by utilizing “a useful framework to differentiate whether the limb pain involves symptoms that are caused by musculoskeletal injury, , or systemic disease, or a combination of factors. Pain can result from direct reaction in tissues,  secondary reaction in adjacent tissues, or reaction from a proximal or distal lesion, or from organs such as  the heart or kidney”.(Dains,2019.p.1.).knowing this information, I decided to start with a Focused history, where I would begin by asking the patient questions such as, does he have any of the common childhood bone diseases, that would make him prone to bone injury or pain, i.e. Osteogenesis Imperfecta or as commonly known as brittle bone disease, as it is usually diagnosed at birth as a bone is broke during the delivery process, from the fetus traveling down the bony structures of the birth canal. Next, I will ask him if the pain if from an injury? If it was an injury, how did the injury occur? Is this a new injury, or is this an old injury that has recurred? And finally, I will ask him to state his level of pain, on a scale from 0-10, with 0 being the least pain, and 10 being the worst pain?

Back Pain

Subjective Data

Back pain can appear in a variety of ways, including stinging, muscle spasms, and achy pain (Aish et al., 2021). Back pain is the most common musculoskeletal condition, and it is frequently associated with potential or actual tissue damage (Ball et al., 2015). The lumbar spine is a complex network of interconnected bones, nerves, ligaments, joints, and muscles that collaborate to provide strength, support, and flexibility. The complexity of the structure makes it more susceptible to repetitive injury, blunt impact, or sudden stress from lifting or pulling. Below is a list of subjective data points of interest.

Chief Complaint: Back pain

Location: Lower back

Onset: One month ago

Character: At times, the pain radiates to his left leg

Duration: Ongoing pain. the health care professional will assess  how long did the pain start

Associated Factors: Will enquire such as headache, chills, and dizziness.

Relieving Factors: Will enquire what alleviates the pain, such as position, or a massage

Severity: I will enquire how bad is the pain using the numeric tool assessment, with “0” being no pain and “10” being the worst pain

Family History: I will enquire; it is very important to ask about the family history. Doing this will help determine if genetics is involved.

Social history: Will inquire about drinking or smoking habits and assess if the patient is taking illicit drugs. Also, the nurse will ask about the kind of work the patient is doing.

Past surgical history: None; I will assess past surgical history

Timing: The healthcare professional will enquire specific time

Was the pain gradual or sudden: I will enquire how the pain started and also assess if the pain is sudden or gradual

Medications: as a nurse practitioner, its important to assess what kind of medication the patient has been taking for the pain and also assess if the medication is working

Endocrine: will enquire

Hematologic: I will assess if the pain has a history of blood clots, bleeding disorders, bone marrow, lymph node and spleen

Also Check Out:

Objective Data

Physical Assessment:

Vital signs: Key signs to consider in this context include blood pressure, respiration, heart rate, temperature, pulse oximetry, weight, and height.

Neurological: The key metrics to be assessed here entail clearness of speech, vision changes, patient alertness, judgment, and facial drooping.

Lungs/Chest: Examine tachypnea, clearness of bilateral breath sounds, and whether the lungs expand symmetrically.

Skin: Explore the skin paleness, ashen, or cyanosis. Also, look for tainting, tears, and whether the skin is dry/warm.

Musculoskeletal: Examine the evidence of trauma in the affected area, radiation of lower back pain, and the relationship between pain and flexion, twisting, and extension. It is also imperative to assess whether there is reduced mobility due to pain.

Abdomen: Examine key characteristics such as softness, tenderness, presence of bowel sound, and activeness in all four quadrants.

Peripheral vascular/Heart: Here, we shall look at whether the heart rate rhythm is regular, the rate at which capillary refill in all extremities, whether S1 and S2 sounds are heard, and finally, the palpable and strength of peripheral pulses.

Diagnostic Tests:

Assess inflammations makers or infections through blood count.

Check erythrocyte sedimentation rate

Perform HLA-B27 to examine the white blood cells.

Perform MRI of the lumbar spine.

Perform Computerized Tomography (CT) cervical spine.

Perform an X-Ray of the lumbar spine.

Assessment

Differential Diagnosis:

Lumbar Spinal Stenosis (LSS) is the narrowing of the spinal canal and imposes pressure on the nerve extending from the spinal cord to the muscles (AANS, 2022). It can either be due to congenital abnormalities, primary or acquired, secondary. It is often attributed to degenerative changes in older persons. Degenerative LSS can involve lateral recess, central canal, foramina, or a combination of these locations. Neurogenic claudication is the primary symptom of LSSS and refers to leg symptoms holding the groin, buttock, and anterior thigh. Leg symptoms can comprise heaviness, fatigue, and paresthesia. The symptoms are usually symmetrical, bilateral, or unilateral.

Lumbar Disc Herniation (LDH): It is often referenced in the context of low back pain. The Intervertebral disc comprises the outer Annulus Fibrosus (AF) and inner Nucleus Pulposus (NP). The NP comprises type II collagen, which makes up to 20% of its overall dry weight. It is maintained in the center of the disc by AF, whose concentric type 1 fiber makes up 70% of its dry components. The narrowing of the thecal sac’s space in LDH can be due to extrusion of NP through AF, protrusion of disc through AF, but maintaining continuity with disc space. However, there can also be a complete loss of continuity with the disc space or sequestration of a free fragment. LDH’s common signs and symptoms include sensory abnormalities and radicular pain (Al Qaraghli & De Jesus, 2021). Its predisposing factors include Axial Overloading and dehydration, while 75% is hereditary.

Sciatica: Entails the pain radiating through the sciatic nerve’s path. Sciatica, also known as radiculopathy, is primarily caused by undue pressing on the sciatic nerve. The pressing typically travels via the buttocks and extends to the back of the leg. Persons with sciatica often feel burning low back pain or shock-like impact combined with the pain through the buttocks and down the leg (Ropper & Zafonte, 2015).

Ankylosing Spondylitis (AS): It is a rare lifelong condition deemed a form of arthritis that induces stiffness and pain in the spine. It is also called Bechterew disease and originates from the lower back, and consequently, damage joins in other body parts or extends to the neck. It dominantly leads to inflammation between vertebrae and is more severe in men. Though its cause is unclear, it could be due to genetic and environmental factors (MedlinePlus, 2020).

Lumbar Strain/Sprain (LSS): Occurs when muscle fibers are torn or abnormally stretched. The separation of ligaments from their attachment could be due to gradual overuse or sudden injury. In other words, the lumbar spine relies on soft tissues/lower back muscles to support body weight and is readily torn by excessive stress. The most dominant symptom includes sudden lower back pain (Pilitsis, 2020).

Plan

There are five differential diagnoses for the patient in this context. The next step entails tailoring the effective and appropriate treatment to guarantee quick recovery and sustainable living. Suppose there is a need to treat sciatica; it can be intervened with anti-inflammatories such as narcotics, anti-seizure medication, muscle relaxants, and tricyclic antidepressants. Surgery is an option if there are no improvements after 6-8 weeks (Jensen et al., 2019).

References

Aish, M. A., Abu-Jamie, T. N., & Abu-Naser, S. S. (2021). Lower Back Pain Expert System

Using CLIPS. 

American Association of Neurological Surgeons (AANS), (2022). Lumbar Spinal Stenosis.

Al Qaraghli, M. I., & De Jesus, O. (2021). Lumbar Disc Herniation. In StatPearls 

Publishing. 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2014). Seidel’s

Guide to Physical Examination-E-Book. Elsevier Health Sciences.

Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of

sciatica. Bmj, 367. doi: 

Pilitsis, J.G, (2020). Low back strain and sprain. American Association of Neurological

Surgeonans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Low-Back-Strain-and-Sprain#:

Ropper, A. H., & Zafonte, R. D. (2015). Sciatica. New England Journal of

Medicine, 372(13), 1240-1248. DOI: 10.1056/NEJMra1410151

The body is continually letting us know how it is doing. Pain is one of the signals that is the easiest to identify. One of the main factors in patients’ severe, ongoing pain is musculoskeletal disorders. The complex network of connecting levers known as the musculoskeletal system gives the body stability and mobility. Finding the reasons of pain might be difficult due to the musculoskeletal system’s interconnectivity. An evaluation approach based on the patient’s medical history and physical examinations is necessary to determine the source of musculoskeletal pain accurately.

Consider case studies that detail unusual results in patients seen in a clinical context in this Discussion.

Note: By Day 1 of this week, your Instructor will have given you a specific case study from the list below to discuss. Also, rather of using the standard narrative style for Discussion postings, your Discussion post should be in the Episodic/Focused SOAP Note format. For guidance, use the Episodic/Focused SOAP Template in the Week 5 Learning Resources and Chapter 2 of the Sullivan text. Keep in mind that each patient case contains specific information that is contained in every Episodic/Focused SOAP note.

First Case: Back Pain

A 42-year-old man claims that for the past month, his lower back has been hurting. On sometimes, his left leg feels the agony as well. What nerve roots might be involved in pinpointing the origin of the back discomfort based on your understanding of anatomy? For each of them, how would you test? What more symptoms need to be investigated? What other medical conditions could cause sudden low back pain? Using the Agency for Healthcare Research and Quality (AHRQ) recommendations as a guide, think about the potential causes. Which physical exam will you conduct? What unique actions will you take?

Case 2: Painful ankle

Despite experiencing pain in both of her ankles, a 46-year-old woman is more concerned about her right ankle. Over the weekend, she was playing soccer when she heard a “pop.” Although she can support weight, it hurts. What components of the foot are most likely involved in identifying the source of the ankle pain, based on your understanding of anatomy? What more symptoms need to be investigated? What other medical conditions could cause discomfort in the ankle? Which physical exam will you conduct? What unique actions will you take? If you want to know if you need more testing, should you use the Ottowa ankle rules?

Third case: knee pain

Male teenager age 15 suffers nagging soreness in both knees. A catching sensation under the patella is sometimes described by the patient along with one or both knees clicking. What further background information is required to determine the reasons of the knee pain? What classifications are there for knee pain? What particular differential diagnosis do you have for knee pain? Which physical exam will you conduct? How are you evaluating the anatomical structures as part of the physical examination? What unique actions will you take?

Patient Information:

JD, 15, M, Caucasian

S.

CC: JD complains of dull pain in both knees

HPI: JD is a 15-year-old Caucasian male presents with dull pain in both knees bilaterally and occasional catching/clicking with ambulation. JD reports the pain started 3 weeks ago after he collided with a runner at home plate during a baseball game. JD reports the pain as dull and intermittent on a scale of 5/10. He has not taken anything for the pain at this point. Walking and physical activity make the pain worse and ice/elevation and resting the legs make the pain better. JD reports he has not been able to participate in his baseball games since the injury occurred.

Current Medications: no current medications

Allergies: NKDA, no environmental allergies, no food allergies

PMHx: No previous medical history or surgeries

Soc Hx: Denies the use of cigarettes, denies etoh use, denies use of marijuana and illicit drugs. Freshman in high school, drum major in the band and plays basketball and baseball.

Fam Hx: Mother is 38 y/o with hypertension, Father is 35 with diabetes, Maternal grandmother is living with hypertension and hyperlipidemia, Maternal grandfather is living with hypertension and BPH, Paternal grandmother is living with diabetes and hypertension, Paternal grandfather is living with hyperlipidemia, Sister is 7 years old with no medical issues.

ROS:

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat . Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough, or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY:  No burning on urination and denies urgency.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Reports clicking/catching sensation under bilateral knee caps during ambulation

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

General: JD presents alert and oriented, appropriate hygiene, and without gait disturbances

Cardio: S1/S2, no murmurs or adventitious heart sounds heard

Resp: Lung sounds clear throughout lobes bases bilaterally, respirations even and unlabored

Musculoskeletal: Popping sounds heard with flexion of knees bilaterally, ballottement positive bilaterally.

Diagnostic results: Xray of bilateral knees, MRI of knees bilaterally

A.

Differential Diagnoses:

Bursitis: Bursitis is common in individuals who are often in the kneeling or squatting position. The prolonged kneeling causes inflammation of the bursa sac. This patient is a catcher on his baseball team and is squatting for extended periods of time (LeManac et al., 2012). Bursitis presents as pain and swelling in the knee joints exacerbated by the kneeling position.

ACL tear: Due to this patient being active in sports he could have torn his ACL. An ACL tear can present with symptoms such as popping, pain, swelling, and discomfort while walking. ACL tears can happen with a sudden change in directions, quickly slowing down, jumping, and landing wrong (Orthoinfo, 2014).

Patellar Tendonitis: This is reported as pain at the tendon where the patella connects to the tibia. This is common in individuals who participate in jumping activities such as basketball and volleyball players. Also known as “jumper’s knee”. This is caused by tiny tears to the patella tendon from increased stress over time causing weakness and pain to the affected area (Mayo Clinic, 2019). This patient plays basketball in high school and is very active and has high probability of this injury

Patellar fracture: This injury can take place due to blunt force to the affected area. The patient could have fallen on the basketball court or been hit by another player during a baseball game causing trauma to the knee. This presents with the inability to walk or straighten the leg. Severe pain or swelling and oftentimes bruising to the area (Boston Medical Center, n.d.).

Meniscus tear: The meniscus is cartilage that absorbs the impact of fast movements and the shock of body movements. The cartilage can tear with sudden movements or changing of directions. This patient participates in sports that could cause injuries such as this especially basketball. Meniscus injuries present with pain, swelling, locking/catching at the knee joint (John Hopkins Medicine, n.d.).

 

References

Anterior cruciate Ligament (acl) injuries – OrthoInfo – AAOS. OrthoInfo. (2014). .

Le Manac, h, A. P., Ha, C., Descatha, A., Imbernon, E., & Roquelaure, Y. (2012). Prevalence of knee bursitis in the workforce. Occupational Medicine, 62(8), 658–660. https://doi-org.ezp.waldenulibrary.org/10.1093/occmed/kqs113

Mayo Foundation for Medical Education and Research. (2019, October 16). Patellar tendinitis. Mayo Clinic. .

Patellar (Kneecap) Fracture. Boston Medical Center. (n.d.). https://www.bmc.org/patient-care/conditions-we-treat/db/patellar-kneecap-fracture.

Torn meniscus. Johns Hopkins Medicine. (n.d.). https://www.hopkinsmedicine.org/health/conditions-and-diseases/torn-meniscus.

Week 8: Assessment of the Musculoskeletal System

A 46-year-old man walks into a doctor’s office complaining of tripping over doorways more frequently. He does not know why. What could be the causes of this condition?

Without the ability to use the complex structure and range of movement afforded by the musculoskeletal system, many of the physical activities individuals enjoy would be curtailed. Maintaining the health of the musculoskeletal system will ensure that patients live a life of full mobility. One of the most basic steps that can be taken to preserve the health of the musculoskeletal system is to perform an assessment.

This week, you will explore how to assess the musculoskeletal system.

Learning Objectives

Students will:

• Evaluate abnormal musculoskeletal findings
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the musculoskeletal system

Photo Credit: SCIEPRO/Science Photo Library/Getty Images

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Learning Resources-Week 8: Assessment of the Musculoskeletal System

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

• • Review of Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)

• Chapter 21, “Musculoskeletal System” (pp. 501-543)This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

• • Chapter 22, “Limb Pain” (pp. 356-374)This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.

• Chapter 24, “Low Back Pain (Acute)” (pp. 288-300)The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

• • Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”; p. 29)

• Chapter 4, “Pediatric Preventative Care Visits” (“Documentation of Important Components of Age Specific Physical Exams and Sports Pediatric Sports Participation Physical Exam”; pp. 106-107)

Note: Download this Adult Examination Checklist and Physical Exam Summary: Abdomen to use during your practice musculoskeletal examination.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for musculoskeletal assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. This Adult Examination Checklist: Guide for Musculoskeletal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Musculoskeletal system. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. This Musculoskeletal System Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., & …Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee

pain: A qualitative study. BMC Musculoskeletal Disorders, 12(1), 78–85. Retrieved from the Walden Library databases. This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.

University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved from http://www.med-ed.virginia.edu/courses/rad/index.html. This website provides an introduction to radiology and imaging. For this week, focus on skeletal trauma in musculoskeletal radiology.

Smuck, M., Kao, M., Brar, N., Martinez-Ith, A., Choi, J., & Tomkins-Lane, C. C. (2014). Does physical activity influence the relationship between low back pain and obesity? The Spine Journal, 14(2), 209–216. doi:10.1016/j.spinee.2013.11.010 Retrieved from the Walden Library Databases.

Shiri, R., Solovieva, S., Husgafvel-Pursiainen, K., Telama, R., Yang, X., Viikari, J., Raitakari, O. T., & Viikari-Juntura, E. (2013). The role of obesity and physical activity in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640–650. doi:10.1016/j.semarthrit.2012.09.002. Retrieved from the Walden Library Databases.

Episodic/Focused SOAP Note

 

Patient Information:

K.S, 15, Male, Caucasian

S.

CC : Dull aches in bilateral knees, sometimes one or both knees clicks.

HPI: Patient is a 15-year-old male with complaints of a dull pain in both knees. He describes that one or both knees click, and he feels a catching sensation under his patella. According to the patient, he has been feeling the dull pain in his knees for past three days. He states the pain is tolerable however it has stopped him from running track or doing anything strenuous. He run Pain is rated a 6 out of 10. At rest his pain level is 2. Running aggravates his pain. He denies nausea or vomiting. He denies fatigue. He wears bilateral knee braces for support. He has taken Ibuprofen for temporary relief. He uses ice packs on and off to help with occasional swelling on the knees.

Current Medications: OTC Ibuprofen 400mg 6-8 hours PRN

Allergies: NKDA. Shellfish: Nasal stuffiness and will break out in hives and irritated skin.

PMHx: No prior hospitalizations. No prior injuries. Recent flu vaccine. Up to date with Covid-19 vaccine.  Immunization up to date.

Soc Hx: Patient is a sophomore in high school. His favorite sport is track. He lives with his mother, father, and older brother. His older brother is a senior in high school. He does not use illicit drugs. He denies smoking cigarettes or consuming alcohol.  His brother drives him to school. Mother is a registered nurse and father is a physical therapist.

Fam Hx: Mother is 48; history of HTN and asthma. Father is 52; GERD, HTN, history of MI. Brother is 17; healthy no health issues. Maternal grandmother 72; HTN, asthma, hypothyroid, pacemaker, osteoporosis. Maternal grandfather 75; Bilateral hip replacements, HTN. Paternal grandmother 78; DM II, HLD, history of MI. Paternal grandfather 80; AFIB, TIA, CABG.

ROS:

GENERAL: Negative for fevers, chills, fatigue, night sweats. Reports no change in appetite, no intentional weight loss.

HEENT:  No history of head injuries or trauma. Denies headaches. Negative for vision changes, or blurred vision. + for corrective lenses. Negative for epistaxis. Denies difficulty swallowing. Negative for changes in hearing.

SKIN:  No rash or itching. No rash or hives.

CARDIOVASCULAR:  Denies chest discomfort or pain, no murmurs, or palpitations. No history of edema, or arrythmias.

RESPIRATORY:  Negative for SOB or DOE, Negative for cough or hemoptysis.

GASTROINTESTINAL:  Denies anorexia. Negative for nausea or vomiting; negative for diarrhea or abdominal pain.

GENITOURINARY:  Denies any change in urine. No difficulty urinating. Denies blood in urine.

NEUROLOGICAL:  Denies headache, dizziness, numbness or tingling in the extremities. No change in bowel or bladder.

MUSCULOSKELETAL:  No muscle or back pain. Denies pain or joint swelling in upper extremities. + for pain in bilateral knees. + for occasional swelling.

HEMATOLOGIC:  No anemia, abnormal bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes.

PSYCHIATRIC:  No history of depression or anxiety. No suicidal ideations.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

O.

Physical exam:

VS: BP 110/70; P 99; R 20; T 36.7; 02 99% Wt 130lbs; Ht 5’7

GENERAL: KS, 15-year-old Caucasian male. A&O x 4. Clear communications. Figure slim. Dressed accordingly. Follows appropriate commands. Sitting, in no distress.

CARDIOVASCULAR:  S1 and S2 audible. No extra heart sounds or mummers.

RESPIRATORY:  Lung sounds clear on auscultation. No wheezing or rhonchi.

MUSCULOSKELETAL:  No gross deformities in upper extremities. No gross deformities in lower extremities. + for tenderness and pain upon palpitation. + for pain when pressure is applied to knees. Slight loss of concavities on right and left knee.  Bilateral knees unable to bend fully at 130 degrees flexion. Patient able to perform full extension of knees. Patient unable to hyperextend fully at 15 degrees.

 

 

 

Diagnostic results: X-ray lower extremities, CT, MRI, McMurray test, anterior and posterior drawer test, Lachman test, Valgus stress test.

A.

1. Meniscal tear

Meniscal tear a is common knee injury often followed by extensive activity. Track often consists of running, hurdles, sprints, long jump, etc. Activities causing the knees to forcefully twist or rotate knees can lead to torn meniscus.  KM admits to clicking on occasions. A McMurray test is considered positive when a click is felt over the meniscus as the knee is brought from full flexion (Shekarchi, et al., 2020). Although X-rays cannot diagnose a meniscus tear, X-rays can help rule out other medical issues. X-rays are first-line imaging of the musculoskeletal structures and can be a contribution to MRI studies (Ashby, Adams, Shetty, 2022).

2. Patellar tendonitis

Tendonitis affecting the knees due to overuse. Adolescents in competitive sports such as track often perform frequent running jumping, and repetitive action. Bone growth is not fully completed until age 20 (Ball, et al., 2019). KM’s continued growth and overuse of his knees may lead him to be more prone to knee injury.

3. Ligament injury in knees

Musculoskeletal injuries are the most common injuries in youth sports (Lara Costa, et al., 2022). KS’s age can be a contributing factor in knee injury.  During adolescence, a decrease in coordination and balance may occur, which not only increases the risk of injury, but also influences sports performance. ACL tears can be diagnosed during physical examination (Lachman test) and imaging. An MRI is a diagnostic technique useful in producing soft tissue images, lesions, and masses. MRI can determine the extent of ligament injury and additional damage to knees.

4. Soft tissue injury

Soft tissue injury related to muscle strain or ligament injury. Patient complains of knee pain and clicking noise. He may possibly have a meniscus tear or muscle strain. KM’s temporary relief of pain is resolved with ice over injury. Ice will constrict blood flow and decrease swelling. Cold therapy can be used as an immediate treatment to induce analgesia following acute soft tissue injuries (Bolton, et al., 2022).

5. Knee sprain

KM’s knee pain can be related to other concerning factors. Collateral ligament knee injuries are the most common cause of knee ligament sprains. (Choufani, et al., 2022). MRI imaging can distinguish between grades of sprain.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Ashby K, Adams BN, Shetty M. (2022). Appropriate Magnetic Resonance Imaging Ordering. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.  

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Bolton, S., Bailey, M. E. A., Wei, R., & McConnell, J. S. (2022). Pediatric injuries around the knee: Soft tissue injuries. Injury, 53(2), 237–243.

Choufani, E., Pesenti, S., Launay, F., & Jouve, J.-L. (2022). Treatment of knee sprains in children. Orthopaedics & Traumatology: Surgery & Research, 108(1).

Lara Costa e Silva, Júlia Teles, & Isabel Fragoso. (2022). Sports injuries patterns in children and adolescents according to their sports participation level, age and maturation. BMC Sports Science, Medicine and Rehabilitation, 14(1), 1–9.

Shekarchi B, Panahi A, Raeissadat SA, Maleki N, Nayebabbas S, & Farhadi P. (2020). Comparison of Thessaly Test with Joint Line Tenderness and McMurray Test in the Diagnosis of Meniscal Tears. Malaysian Orthopaedic Journal, 14(2), 94–100.