Non-Traumatic MSK Injuries Module

One of the main priorities in patients presenting with atraumatic MSK pain is to seek out red flag symptoms and signs in order to rule out sinister diagnosis.

Red flag symptoms and signs include:

• Weight loss
• Night sweats
• Pyrexia
• Nocturnal pain
• Non weightbearing
• Rash
• Eye pain

A standardised assessment should be performed depending on the body area/areas involved.  Look for any swelling, bruising, erythema or cellulitis.  Determine if there is any point tenderness which may give indicate a possible fracture.  Assess joint function for range of motion (passive / active / resisted), weight bearing status, additional stiffness and stability.

Always ask yourself, is the story really atraumatic?  Has there been any possibility of non-accidental injury?

Some level of investigation is required for each of the potential diagnoses. You may make the diagnosis of apophysitis based on an accurate history and exam alone but even then, one study found that 5% of management plans were altered following baseline x-ray in patients with Sever’s disease (apophysitis of the calcaneus).

A low threshold for a baseline x-ray is sensible in all paediatric patients presenting to secondary care with atraumatic MSK pain.  They can be helpful to identify bony lesions, signs of osteomyelitis and unexpected fractures.

Inflammatory markers are useful when the patient’s presentation is concerning an infective or inflammatory process.

Apophysitis: https://dontforgetthebubbles.com/apophysitis/

JIA http://www.pmmonline.org/doctor/child-with-a-swollen-joint/diagnosis-of-jia

Osteochondrosis: https://dontforgetthebubbles.com/osteochondrosis/

Avulsion fractures: https://dontforgetthebubbles.com/pelvic-avulsion-injuries/

Osteomyelitis and septic arthritis: https://www.rch.org.au/clinicalguide/guideline_index/Osteomyelitis_and_septic_arthritis/

Patellofemoral pain: https://pedemmorsels.com/patellofemoral-pain-syndrome-anterior-knee-pain/

• Patello-femoral pain
• Apophysitis of tibial tuberosity (Osgood Schlatter disease) or inferior pole of patella (Sinding-Larsen-Johansson)
• Osteochondritis dissecans
• Arthritis
• Malignancy
• Osteomyelitis
• Hip pathology

Apophysitis has a typical history of gradual onset localised pain in a child from 10-16 years of age.  Pain is exacerbated by activity and initially improves with rest.  The typical patient is highly active and may be overtraining.  Examination will typically reveal point tenderness over the area involved with possibly some mild swelling.

Important factors to exclude are pyrexia, trauma, weight loss and systemic symptoms.

An apophysis is an area of bony growth in children separate to ossification centres.  It is the site of tendon or ligament attachment and fuses with the bone as the body matures. Rapid growth and repetitive movements combined with relative bone weakness, cause increased traction forces at the point of tendon attachment.  This leads to micro-separation and bone fragmentation which is known as apophysitis.  This clinically presents as an insidious onset focal pain, worsened by activity and eased by rest.  There may be point tenderness and swelling on exam. 

Apophysitis commonly affects:

• Tibial tuberosity: Osgood Schlatter disease
• Inferior pole of the patella: Sinding-Larsen-Johansson disease
• Calcaneal tuberosity: Sever’s disease
• Medial vondyle of elbow: Little leaguers’ elbow

Apophysitis is described as a clinical diagnosis and as such patients do not require any investigations.

Despite this, it is reasonable with the above differentials in mind to perform a baseline x-ray in all patients presenting with possible apophysitis.  This is especially important if the patient presentation or clinical course is atypical.

One study found that 5% of management plans were altered following baseline x-ray in patients with Sever’s disease.

Knee x-ray of a 12-year-old female volleyball player.  She is presenting with progressive pain over her tibial tuberosity.  Her pain is exacerbated by jumping.  The x-ray shows fragmentation of apophysis with overlying soft tissue swelling.  Some isolated fragmentation can be normal at the tibial tuberosity.

Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 9740

https://radiopaedia.org/articles/osgood-schlatter-disease?lang=gb

Plain ankle radiograph of an 11-year-old male basketball player complaining of heel pain. There is increased density of the calcaneal apophysis, typical for ages between 7 and 14 years. There is loss of fat/soft tissue planes in the region of the retrocalcaneal bursa in keeping with acute inflammation. This may be seen in the context of the clinical diagnosis of Sever’s disease.

https://radiopaedia.org/cases/sever-disease-5

Case courtesy of Dr Dinesh Brand, Radiopaedia.org, rID: 60324

• There is sparse evidence looking at appropriate type and length of treatment for apophysitis. This has led to guidance on treatment being expert opinion only.
• Traditional treatment plans have involved activity cessation until symptoms free with a gradual return.
• Most of the research that is available focuses on Osgood Schlatter and Severs disease. 
• One RCT looking at management of Osgood Schlatter disease looked at the effectiveness of dextrose injections vs steroids injection vs normal therapy.  This study showed small benefits of dextrose injections.  But this is unlikely to be a sensible treatment plan due to possible adverse effects in a self-limiting condition
• There have been recent developments looking at active treatment pathways.  These are moving away from total rest and sport cessation. Instead the aim is to move towards active and monitored treatment plans. Rathleff et al (2020) have a good infographic describing different treatment options for Osgood Schlatter’s.
• There is some weak evidence that treatment of Sever’s disease with heel raises can improve symptoms when compared to physiotherapy or doing nothing.
• The type of heel raise does not need to be customised, but whatever is comfortable and available to the patient.
• Principles can be adopted to all forms of apophysitis with the main aims of treatment being
  1. Altering current activity to prevent worsening symptoms
  2. Stretching and strengthening programmes as appropriate
  3. Cross training
  4. Graduated return to sporting activity
  5. Prevention of recurrence

• Although apophysitis is self-limiting.  One study found that up to 40% of patients will continue to suffer from intermittent pain even 2 years after diagnosis.  This pain might not necessarily prevent a return to sporting activities.

• Stress fracture
• Arthritis
• Osteochondrosis
• Apophysitis
• Arthritis
• Osteomyelitis
• Malignancy
• Retained foreign body

Flattening and sclerosis of the navicular bone. Mild soft tissue swelling. No fracture seen.

Kohler disease: osteochondrosis of the navicular bone.

Typical x-ray Findings of osteochondrosis:

Early: Potentially normal

Initial radiological findings

• Irregular epiphyseal growth
• Flattening of the epiphysis
• Soft tissue swelling

Radiological findings as disease progresses

• Sclerosis
• Fragmentation
• Joint destruction

• Osteochondrosis is often described as idiopathic osteonecrosis.
• It is a disorder of bone growth primarily involving the ossification centres at the epiphysis.
• It leads to altered bone and cartilage formation beyond the growth plate.
• There are some links showing genetic factors and high activity levels can increase a person’s risk of developing osteochondrosis.
• You should always ensure the osteonecrosis is not from a secondary cause such as sickle cell disease or leukaemia.

Treatment in this case will involve activity modification.  This will entail reduced overall activity but and specifically avoiding activity which stresses the foot.  Immobilisation in a walking boot may be beneficial if there is significant pain or inability to weight bear comfortably.

• Osteochondrosis is self-limiting and the bone will eventually revascularise. 
• The goal of therapy is to facilitate maximal revascularisation while minimising long term affects.

Three broad treatment strategies exist for osteochondrosis

Conservative: This will involve modified activity to ensure no further stress is placed on the area involved. A physio programme can help to strengthen the area and improve joint function.  This approach is suitable for patients with minimal symptoms and early changes of disease progression on x-ray.

Immobilisation:  Immobilisation can be beneficial for patients with significant pain or more advanced changes on x-ray.  This may be in the form of a cast, walking boot or splint depending on the area involved.  This needs to be weighed up against the risk of worsening joint stiffness.

Surgery:  It is very rare, if ever, that patients will require surgery.  When used it is only in advanced stages of disease and when appropriate conservative management has proved ineffective. Surgical options include osteotomy, arthroplasty and physeal drilling.

Largely normal knee x-ray. Subtle lucency to chondral surface of medial femoral condyle. Findings consistent with osteochondritis dissecans. 

• Osteochondritis Dissecans is a focal injury disruption of articular cartilage and subchondral bone.
• It is largely idiopathic, but some theoretical causes are genetics, trauma or vascular phenomenon.
• There is a juvenile and adult form.  The juvenile version is most common and present in patients between 10 and 16 with open physis.
• The knee is the most common joint involved with >70% of knee lesions being in the posterolateral aspect of the medial femoral condyle.  The ankle and elbow are other joints that are regularly affected.

Presentation depends on the stage of lesion.  Initially nonspecific pain with or without swelling.  As the process progresses, patients can develop mechanical symptoms such as reduced range of movement (ROM) and locking of joints.

Osteochondritis dessicans grading system:

Clanton Classification of Osteochondritis (Clanton and DeLee)

• Bilateral x-rays should be obtained as up to 30% of patients can have bilateral lesions.
• An additional notch view x-ray can help to get a better image of the femoral intercondylar spaces.  This is taken with the patient supine and knee flexed to 40 degrees.
• MRI is widely used in patients with high suspicion for osteochondritis dissecans or to assess stability of a lesion diagnosed on x-ray. 
• MRI has superior capabilities for assessing stability of cartilage and subchondral bone when compared to standard radiographs.
• Arthroscopy is the gold standard for assessing stability and may be used if questions marks remain following MRI

There is a lack of consensus on appropriate type and length of treatment.

The latest American Academy of Orthopaedic surgeons’ guidelines were unable to recommend any conservative treatment regime.

Masquijo and Kothari (2019) illustrate their preferred treatment algorithm in a flowchart 

Modern protocols recommend patients should have a three to 6 months trial of conservative management. 

Conservative management involves

• Immobilisation phase with minimal weight bearing followed by
• A phase of partial weightbearing and
• Lastly a gradual supervised return to activity.

Favourable prognostic factors are:

• Younger age
• Open distal femoral physis

Poor prognostic factors include

• Lesions involving the patella
• Sclerosis on x-ray

Approximately 50-75% of lesions will heal in 6-12 months following conservative management.

Conservative management is not suitable for displaced or loose fragments.

Surgical treatment

Surgical treatment is preserved for large or unstable lesions, displaced fragments and those not responding to conservative therapy

Three broad surgical options

• Stimulate growth by retroarticular drilling,
• Reducing and fixing displaced fragments
• Osteochondral grafts

Drilling and fixation are usually successful surgical options with minimal complications.  Up to 90% of patients can expect radiographic resolution of lesions.  Unfortunately, grafts are usually seen as salvaging surgeries and outcomes can be variable.

Length of symptoms: This is important as JIA can only be diagnosed once the patient has had symptoms for over 6 weeks without any other cause found.

Effect on activities: Has the patient stopped playing a sport they previously enjoyed.  Is the patient regressing at physical activity or schoolwork such as handwriting?

Pattern of symptoms: Important to elicit if any stiffness or worsening of symptoms in the morning.  Ask about symptoms associated with malignancy such as leukaemia.

Illicit any associated symptoms which may help discover a cause such as multisystem condition (Lupus/Vasculitis/psoriasis) or a reactive arthritis from a satellite infection (UTI/STI)

You should also enquire about symptoms which may indicate complications such as eye pain caused by uveitis or tendon pain caused by enthesitis.

Pattern of joint involvement.

Monoarthropathy: Single joint. Can still be JIA but infection, trauma and malignancy would be higher on your list and need to be consciously out ruled.

Oligoarthritis: Four or fewer joints involved

Polyarthritis: Over four joints involved.

Typical patterns include:

• Asymmetric, small and large joints and distal interphalangeal joint involvement is typical of psoriatic arthritis.
• Symmetric, small and large joints is typical of polyarticular JIA.
• Hip involvement and enthesitis is typical of Enthesitis-Related Arthritis. 
• Large joint and intermittent / flitting involvement is typical of acute rheumatic fever. 
• Fever, rash and serositis and later symmetrical involvement of small and large joints (including distal small joints of the hands, ankle or wrist involvement) are typical of systemic JIA.

Examination: 

• Trauma: Bruising, wound, bleeding, deformity.
• Infection: Guarding joint and refusing to move/weight bear.  Hot red and swollen.  Temperature
• Malignancy: Secondary signs of anaemia, thrombocytopenia.  Cachexia in advanced stages.  Unusual swelling i.e. not involving a joint and not in an area typically injured.
• Rashes: look for signs of psoriasis, vasculitis rashes, rheumatological rashes as seen in lupus, skin changes produced by Kawasaki.
• Joints: As previously mentioned look for patterns of swelling, record joints involved, assess range of motion and function of joints.
• Review of systems: Assess for any other signs of systemic disease, distant infection or complications which may give you a clue to the aetiology of the arthropathy.

The most likely diagnosis is JIA but there are also some other reasonable differentials.

• Psoriatic arthritis
• Post viral arthritis
• Rheumatic fever
• Malignancy
• Metabolic disease (rickets/osteomalacia)

JIA comprises a group of inflammatory disorders that begins before the 18th birthday and persists for at least 6 weeks and other known conditions are excluded.

There are six main disorders of JIA with their own individual diagnostic criteria

• Systemic JIA
• RF-Positive JIA
• Enthesitis/Spondylitis-related JIA
• Early onset ANA positive JIA
• Other JIA: does not meet

For further background on the individual criteria. http://www.jrheum.org/content/46/2/190

No blood or radiological test can definitively make a diagnosis of JIA.  The diagnosis is based on careful clinical assessment, exclusion of other possible causes and aided by blood and radiology.

pGALS screen has the benefit of quickly assessing all joints. pGALS is a standardised musculoskeletal (MSK) basic examination. Free educational resources to demonstrate pGALS are available online. (www.pmmonline.org).

• CRP and ESR give an indication of total body inflammation.  But you cannot rule out the diagnosis if inflammatory markers are normal.  These markers are more useful in disease monitoring.
• Antinuclear antibodies (ANA) are positive in roughly 50% of oligoarticular JIA, however positive ANA can be seen in healthy children also.  A positive ANA can indicate a higher risk of uveitis once JIA is diagnosed.
• HLA-B27 is positive in 27% of patients with JIA and up to 80% of patients with enthesitis related arthropathy.
• Rheumatoid factor can help with diagnosis of RF-positive JIA.  It also provides a worse prognosis if positive.
• Radiographs are useful for investigating alternative causes.  They rarely show any changes in the early stages of arthropathy but are important to get a baseline condition of the joints.

Refer early. Treatment should be initiated by a specialist. If you have concerns about JIA, you should discuss with rheumatology.  The dawn of biologic treatment has ensured reduced symptoms, chronic complications and minimised need for systemic steroids.

Ophthalmology.  JIA patients are at risk of losing their eyesight from chronic uveitis and may be asymptomatic despite having eye changes.

Which of these conditions and age of onset do not match?

A: Apophysitis 10-14 F 12-16 M

B: Osteochondrosis 12-18

C: SUFE 10-16

D: Osteochondritis dissecans >10

E: Septic arthritis Any age

B: Osteochondrosis, the usual age of onset is anywhere between 4 and 18.  There have even been some Kohler diseases documented as young as 3.

Which of these anatomical areas do you not commonly see apophysitis?

A: Capitellum

B: Inferior pole of patella

C: Tibial tuberosity

D: Medial condyle of elbow

E: Calcaneal tuberosity

A: Capitellum.  Apophysitis only occurs at sight of apophysis formation.

Which of these statements about osteochondritis dissecans is not true?

A: Osteochondritis is a focal disruption of articular cartilage and subchondral bone

B: Most commonly seen on the medial femoral condyle

C: The aetiology is largely unknown

D: Recovery can take 6-12 months

E: A closed physis is a good prognostic factor

E: An open physis is seen as a good prognostic factor

Which of these is not a radiological finding of osteochondrosis?

A: Sclerosis

B: Fragmentation

C: Flattening of epiphysis 

D: Lytic lesion

E: Irregular epiphyseal growth

D: Lytic lesions.  There may be no radiographic changes in the initial stages of osteochondrosis.  You will then begin to see epiphyseal changes, soft tissue swelling, fragmentation and sclerosis. 

Lytic lesions would help point you towards another possible differential diagnosis depending on its location and characteristics.  Lesions can be caused by infections, malignancy or simple cysts.