Discussion: Assessing Musculoskeletal Pain NURS 6512N-32

Discussion: Assessing Musculoskeletal Pain NURS 6512N-32

Discussion: Assessing Musculoskeletal

Pain

Photo Credit: Getty Images/Fotosearch RF
The body is constantly sending signals about its health. One of the most easily
recognized signals is pain. Musculoskeletal conditions comprise one of the leading

causes of severe long-term pain in patients. The musculoskeletal system is an
elaborate system of interconnected levers that provides the body with support and
mobility. Because of the interconnectedness of the musculoskeletal system, identifying
the causes of pain can be challenging. Accurately interpreting the cause of
musculoskeletal pain requires an assessment process informed by patient history and
physical exams.
In this Discussion, you will consider case studies that describe abnormal findings in
patients seen in a clinical setting.
To prepare:
 By Day 1 of this week, you will be assigned to one of the following specific case studies
for this Discussion. Please see the “Course Announcements” section of the classroom
for your assignment from your Instructor.
 Your Discussion post should be in the Episodic/Focused SOAP Note format rather than
the traditional narrative style Discussion posting format. Refer to Chapter 2 of the
Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning
Resources for guidance. Remember that all Episodic/Focused SOAP notes have
specific data included in every patient case.
 Review the following case studies:
Case 1: Back Pain
Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-
ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.
A 42-year-old male reports pain in his lower back for the past month. The pain
sometimes radiates to his left leg. In determining the cause of the back pain, based on
your knowledge of anatomy, what nerve roots might be involved? How would you test
for each of them? What other symptoms need to be explored? What are your differential
diagnoses for acute low back pain? Consider the possible origins using the Agency for
Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical
examination will you perform? What special maneuvers will you perform?
Case 2: Ankle Pain
Photo Credit: University of Virginia. (n.d.). Lateral view of ankle showing Boehler's angle [Photograph]. Retrieved from http://www.med-
ed.virginia.edu/courses/rad/ext/8ankle/01anatomy.html. Used with permission of University of Virginia.
A 46-year-old female reports pain in both of her ankles, but she is more concerned
about her right ankle. She was playing soccer over the weekend and heard a "pop." She
is able to bear weight, but it is uncomfortable. In determining the cause of the ankle
pain, based on your knowledge of anatomy, what foot structures are likely involved?
What other symptoms need to be explored? What are your differential diagnoses for
ankle pain? What physical examination will you perform? What special maneuvers will
you perform? Should you apply the Ottawa ankle rules to determine if you need
additional testing?
Case 3: Knee Pain
Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved from http://www.med-
ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission of University of Virginia.

A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click,
and the patient describes a catching sensation under the patella. In determining the
causes of the knee pain, what additional history do you need? What categories can you
use to differentiate knee pain? What are your specific differential diagnoses for knee
pain? What physical examination will you perform? What anatomic structures are you
assessing as part of the physical examination? What special maneuvers will you
perform?
With regard to the case study you were assigned:
 Review this week's Learning Resources, and consider the insights they provide about
the case study.
 Consider what history would be necessary to collect from the patient in the case study
you were assigned.
 Consider what physical exams and diagnostic tests would be appropriate to gather
more information about the patient's condition. How would the results be used to make
a diagnosis?
 Identify at least five possible conditions that may be considered in a differential
diagnosis for the patient.
Note: Before you submit your initial post, replace the subject line ("Discussion – Week
8") with "Review of Case Study ___." Fill in the blank with the number of the case study
you were assigned.
By Day 3 of Week 8
Post an episodic/focused note about the patient in the case study to which you were
assigned using the episodic/focused note template provided in the Week 5 resources.
Provide evidence from the literature to support diagnostic tests that would be
appropriate for each case. List five different possible conditions for the patient's
differential diagnosis, and justify why you selected each.
Note: For this Discussion, you are required to complete your initial post before you will
be able to view and respond to your colleagues’ postings. Begin by clicking on the  “Post
to Discussion Question” link, and then select " Create Thread" to complete your initial
post. Remember, once you click on Submit, you cannot delete or edit your own posts,
and you cannot post anonymously. Please check your post carefully before clicking
on Submit!
Read a selection of your colleagues' responses.
By Day 6 of Week 8
Respond to at least two of your colleagues on 2 different days who were assigned
different case studies than you. Analyze the possible conditions from your colleagues'
differential diagnoses. Determine which of the conditions you would reject and why.
Identify the most likely condition, and justify your reasoning.
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 8 Discussion Rubric
Post by Day 3 of Week 8 and Respond by Day 6 of Week 8

To Participate in this Discussion:
Week 8 Discussion

Review Case

The history needed for knee pain will include characteristic of patient pain, mechanical symptoms (locking, popping, giving away), joint effusion (timing, amount, recurrence) and mechanism of injury. Furthermore, is important to clarify the characteristics of the pain, including the onset, location (anterior, posterior, medial or lateral) duration, severity, and quality (dull, sharp, achy). Aggravating and alleviating factors need to be identified.

Nevertheless, knee pain can be divided into three major categories:

Acute injury: such as a broken bone, torn ligament, or meniscal tear.

Medical conditions: Rheumatoid Arthritis, Osteoarthritis, Infections

Chronic use/overuse conditions: Osteoarthritis, Chondromalacia, IT band syndrome, Patellar syndrome, Tendinitis, and Bursitis.

The differential diagnosis for knee pain consisted of Patellofemoral pain syndrome includes knee pain, stiffness.

Chondromalacia due to symptoms such as knee pain, crackling joints.

Torn meniscus include symptoms like knee pain, limited range of motion.

Jumper’s knee as part of the main symptoms involve knee pain, stiffness

Osgood-Schlatter disease includes symptoms for instance knee pain, pain below knee.

Moreover, the physical examination includes inspection of knee for erythema, swelling, bruising and discoloration. Also, check the quadriceps muscle in the anterior thigh for atrophy. Because it is the prime mover of knee extension, this muscle is important for joint stability during weight bearing palpation for point starting high on the anterior thigh, above the patella. Palpate with left thumb and fingers in grasping fashion. Proceed down toward the knee, exploring the region of suprapatellar [pouch. The muscles and soft tissues should feel solid, and the joint should feel smooth, with no warmth, tenderness, thickening, or nodularity. Assessment of joint effusion, range of motion testing by extending and flexing the knee as far as possible, evaluation of ligaments for injury, and assessment of menisci.

The anatomic structures assess lateral epicondyle of femur, lateral collateral ligament, lateral meniscus, lateral condyle of tibia, fibula, quadriceps muscle, patella, patellar ligament, medial condyle of tibia, anterior cruciate ligament, tibial tuberosity.

The special maneuvers include with fingers placed at the medial aspect of the patella, the professional attempt to subluxed patella laterally. If this maneuver reproduces the patient’s pain or giving-way sensation, patellar subluxation is the likely cause of patient’s symptoms.  Anterior drawer test: the patient assumes a supine position with the injured knee flexed to 90 degrees. The professional fixes the patient’s foot in slight external rotation and then places thumbs at the tibial tubercle and fingers at the posterior calf. With the patient’s hamstring muscles relaxed, the physician pulls anteriorly and assesses anterior displacement of tibia.

Lachman test: to assess the integrity of anterior cruciate ligament. The patient is in a supine position and the injured knee flexed to 30 degrees. The professional stabilizes the distal femur with one hand, and then attempts to sublux the tibia anteriorly. Lack of clear end point indicates a positive Lachman test.

McMurray test to assess medial meniscus. The test is performed with the patient supine and the knee flexed to 90 degrees. The examiner grasps the patient’s heel with one hand to hold the tibia in external rotation, with the thumb at the lateral joint line, the fingers at the medial joint line. The examiner flexes the patient’s knee maximally to impinge the posterior horn of the meniscus against the medial femoral condyle. To summarize, externally rotate the leg and push valgus stress on knee. Then slowly extend the knee. Normally the leg extends smoothly with no pain.

References:

Akbas, E., Atay, A.O. and Yuksel, I. (2011) The effects of additional kinesio taping over exercise in the treatment of patellofemoral pain syndrome. Acta Orthopaedical et Traumatological Turcica45, 335-341

Corso, M., & Howitt, S. (2018). Adolescent knee pain: fracture or normal? A case reports. Journal of the Canadian Chiropractic Association62(2), 105–110

Jarvis, C. (2014) Physical Examination & Health Assessment. Saunders Elsevier, 624-626

Iwamoto J, Takeda T, Sato Y, Matsumoto H. (2009) Radiographic abnormalities of the inferior pole of the patella in juvenile athletes. Keio J Med. 58(1):50-53

Vaishya R, Azizi AT, Agarwal AK, Vijay V. (2016) Apophysitis of the tibial tuberosity (Osgood-Schlatter Disease): a review. Cureus. 8(9)

 

Learning Resources

Required Readings (click to expand/reduce)
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.

 Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)
 Chapter 22, “Musculoskeletal System”
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. (2019). Advanced health
assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., &
Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 22, “Lower Extremity Limb Pain”
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)”

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") (Previously read in Weeks 1, 2, 3, 4, and 5)
 Chapter 3, "SOAP Notes"
This section explains the procedural knowledge needed to perform
musculoskeletal procedures.
Note: Download this Student Checklist and Abdomen Key Points to use
during your practice abdominal examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Musculoskeletal system: Student checklist. In Seidel's guide to
physical examination: An interprofessional approach (9th ed.). St. Louis,
MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Musculoskeletal system: Key points. In Seidel's guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.

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.

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.

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

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

Document: Episodic/Focused SOAP Note Exemplar (Word document)

Document: Episodic/Focused SOAP Note Template (Word document)

Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s
diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

 Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)
In this chapter, the authors explain the physiology of the spine, pelvis, and
extremities. The chapter also describes how to examine the spine, pelvis,
and extremities.
Required Media (click to expand/reduce)
Online media for Seidel's Guide to Physical Examination
In addition to this week's resources, it is highly recommended that you access
and view the resources included with the course text, Seidel's Guide to Physical
Examination. Focus on the videos and animations in Chapter 21 that relate to the
assessment of the musculoskeletal system. Refer to the Week 4 Learning
Resources area for access instructions on https://evolve.elsevier.com/

Rubric Detail

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Name: NURS_6512_Week_8_Discussion_Rubric
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Main Posting
45 (45%) – 50 (50%)
“Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.
40 (40%) – 44 (44%)
“Responds to the Discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.
35 (35%) – 39 (39%)
“Responds to some of the Discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors.
0 (0%) – 34 (34%)
“Does not respond to the Discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Post: Timeliness
10 (10%) – 10 (10%)
Posts main post by Day 3.
0 (0%) – 0 (0%)
N/A
0 (0%) – 0 (0%)
N/A
0 (0%) – 0 (0%)
Does not post main post by Day 3.
First Response
17 (17%) – 18 (18%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.
15 (15%) – 16 (16%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.
13 (13%) – 14 (14%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.
0 (0%) – 12 (12%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Second Response
16 (16%) – 17 (17%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.
14 (14%) – 15 (15%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.
12 (12%) – 13 (13%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.
0 (0%) – 11 (11%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Participation
5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days.
0 (0%) – 0 (0%)
N/A
0 (0%) – 0 (0%)
N/A
0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on three different days.
Total Points: 100
Name: NURS_6512_Week_8_Discussion_Rubric

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