musculoskeletal injuries (sprains,strains)

muscle injury

1. M USCULOSKELETAL INJURIES tendonitis, bursitis, sprains, and strains

2. Introduction to musculoskeletal injuries (tendonitis, bursitis, sprains, and strains) Describe the general epidemiology, including prevalence, risk factors, and affected populations Explain the etiology and pathological processes Identify the clinical manifestations Outline criteria for referral to a healthcare provider Discuss treatment goals Explore various management strategies Provide key patient counselling points for prevention and recovery Illustrate a simple treatment algorithm for clinical decision-making. OBJECTIVES

3. EPIDEMIOLOGY • Tendonitis & Bursitis : More common in athletes, manual laborers, and older adults. • Sprains & Strains : Common in physically active individuals, sports players, and those with poor conditioning or improper movement. Risk Factors : Overuse Poor biomechanics sudden injury Repetitive movements Aging

4. ETIOLOGY Tendonitis: Inflammation of tendons due to overuse or excessive strain. Several factors contribute to the development of tendonitis: Mechanical Overload and Repetitive Stress Aging and Degeneration Poor Biomechanics and Muscle Imbalance Trauma or Direct Injury Inflammatory and Systemic Conditions Medication-Induced Tendonitis

5. The pathological process of tendonitis involves: Inflammatory Response: Initial injury triggers an inflammatory reaction, leading to localized swelling, pain, and redness. Inflammatory cells, including macrophages and neutrophils, infiltrate the damaged tissue. Tendons are composed of Type I collagen; inflammation leads to collagen breakdown and disorganization. A shift from Type I to Type III collagen occurs, resulting in weaker tendon fibers. In chronic cases, abnormal blood vessel growth (neovascularization) occurs but fails to provide effective healing. Scar tissue formation may replace normal tendon tissue, reducing elasticity and increasing stiffness. Chronic Tendon Pathology (Tendinosis): Prolonged inflammation leads to degeneration rather than repair, characterized by thickened, fibrotic tendons. Tendinosis is marked by collagen disarray, tenocyte apoptosis, and loss of normal tendon architecture. Khan, K. M., Cook, J. L., Bonar, F., Harcourt, P., & Astrom, M. (1999). Histopathology of common tendinopathies. Sports Medicine, 27 (6), 393-408.

6. BURSITIS Bursitis is the inflammation of a bursa, a fluid-filled sac that reduces friction between tissues such as tendons, muscles, and bones. The condition can be acute or chronic and is caused by various factors: 1. Repetitive Motion and Overuse 2. Trauma or Direct Pressure 3. Infection (Septic Bursitis) 4. Inflammatory Conditions 5. Aging and Degenerative Changes 6. Poor Posture and Biomechanics

7. Acute Inflammatory Response can occur due to: I rritation which can later lead to an increase in synovial lining cells and cell infiltration by the macrophages and neutophils.This would then lead to an excess in synovial fluid causing swelling, pain and restricted movement. Chronic bursitis leads to fibrosis, inflammation, and thickening of the bursal wall, causing persistent pain and limited function. Over time, calcium deposits may form, restricting mobility. In septic bursitis, infection results in pus, necrotic tissue, and bacterial growth, which can spread to surrounding areas if untreated. Morrey, B. F., & Sanchez-Sotelo, J. (2017). Bursitis: Pathophysiology, Diagnosis, and Treatment. Journal of Bone and Joint Surgery, 99 (2), 123-134.

8. SPRAINS/STRAINS Ligament injury due to overstretching or tearing (e.g., twisting an ankle). The common causes of sprains include: Sudden Trauma or Overstretching Excessive Joint Motion or Improper Landing Muscle Weakness and Fatigue Inadequate Footwear and Equipment Structural Abnormalities and Previous Injuries External Forces and Contact Injuries Woo, S. L., Abramowitch, S. D., Kilger, R., & Liang, R. (2006). Biomechanics of ligament healing, repair, and reconstruction. Journal of Biomechanics, 39 (1), 1-20. doi:10.1016/j.jbiomech .2005.04.01

9. The severity of sprains is categorized into three grades: • Grade I (Mild): Slight stretching with minimal fiber damage. • Grade II (Moderate): Partial ligament tear with some instability. • Grade III (Severe): Complete ligament rupture leading to significant instability.

10. Pathological Process of Sprains and Strains: Acute Inflammatory Phase (0–72 hours): Ligament damage causes vascular disruption, bleeding, and swelling. Release of inflammatory mediators (histamine, prostaglandins, cytokines). Pain, redness, and warmth; neutrophils and macrophages clear debris. Proliferative Phase (4 days – 6 weeks): Fibroblasts synthesize Type III collagen (weaker, less organized). Neovascularization occurs to support healing. Ligament remains fragile and prone to reinjury. Remodelling and Maturation Phase (6 weeks – 12 months): Type III collagen is replaced by Type I collagen (stronger). Collagen fibers cross-link, improving tensile strength. Incomplete healing can lead to ligament laxity and chronic instability.

11. C linical manifestations Bursitis : Swelling, warmth, pain in the affected joint, reduced range of motion Tendonitis : Localized pain, tenderness, swelling worsened by movement. Sprains/strains : Bruising, swelling, pain, instability in the joint, Muscle weakness, spasms, swelling.

12. DIFFERENTIAL DIAGNOSIS Fractures Osteoarthritis Rheumatoid arthritis Soft tissue knee injury Gout Infections (e.g., septic arthritis) Deep venous thrombosis Cellulitis

13. WHEN TO REFER TO A DOCTOR Severe pain/swelling not improving even after treatment for more than a week Suspected fracture or dislocation Significant loss of function or mobility Signs of infection (fever, redness, warmth) American Academy of Orthopaedic Surgeons (AAOS). (2022). Recognizing Emergency Symptoms: When to Seek Medical Help for Musculoskeletal Injuries. AAOS . Retrieved from https://www.aaos.org

14. GOAL OF TREATMENT Minimize pain and discomfort to allow for optimal healing and functional recovery. Control swelling and inflammation to prevent further tissue damage and improve the healing environment. Stimulate the natural healing processes of the affected tissues (muscles, tendons, ligaments, or bursa). Avoid re-injury or aggravation of the current injury. Improve the strength of muscles, tendons, and ligaments around the injured area to prevent future injuries and support long-term recovery. Educate the patient on how to prevent future injuries and manage any contributing factors that led to the current injury. American Academy of Orthopaedic Surgeons (AAOS). (2022). Principles of Musculoskeletal Injury Management. AAOS . Retrieved from https://www.aaos.org

15. MANAGEMENT Non-Pharmacological: A Physical therapy exercise program tailored to the patient’s injury, aimed at improving strength, mobility, flexibility, and overall function. Benefits: • Restores strength and function • Reduces pain • Prevents future injuries • Speeds up recovery P roper Hydration is crucial for muscle function, recovery, and overall performance 1. Cella, D., & Harris, M. (2021). Physical Therapy and Non-Pharmacological Interventions in Musculoskeletal Injury Recovery. Journal of Rehabilitation Research and Development . 2. Mayo Clinic. (2022). RICE: Rest, Ice, Compression, and Elevation for Acute Injuries. 3. American Academy of Orthopedic Surgeons (AAOS). (2020). Bracing and Splints in Orthopedic Recovery. 4. National Institute for Occupational Safety and Health (NIOSH). (2022). Ergonomic Interventions for Musculoskeletal Injury Prevention.

16. RICE (Rest, Ice, Compression, Elevation) RICE is a well-established protocol used for the initial management of acute musculoskeletal injuries such as sprains, strains, and soft tissue damage. It consists of four key components Benefits: • Reduces inflammation and swelling, which are common responses to injury Pain relief is achieved through ice application R educing nerve activity in the injured area Promotes faster healing and Prevents further injury by reducing movement and providing initial support. RICE THERAPY

17. Rest: Rest the injured area for the first 24-48 hours after the injury. Avoid activities that put strain on the affected part. Ice: Apply ice for 20-30 minutes every 1-2 hours during the first 48 hours to control swelling and pain. Never apply ice directly to the skin; use a cloth or towel. Compression: Use an elastic bandage to wrap the injured area snugly but not too tight to avoid cutting off circulation. E levation: Elevate the injured limb above the heart level whenever possible, especially when sitting or lying down.

18. PHARMACOLOGICAL NSAIDs Common examples : Ibuprofen (Advil, Motrin), Naproxen (Aleve), Diclofenac (Voltaren) MOA: NSAIDs block both COX-1 and COX-2, thereby reducing inflammation and alleviating pain. Side effects : GI upset, ulcers, renal issues Dosage : Ibuprofen: 400-800 mg q6-8h PRN Naproxen: 250-500mg q12h Diclofenac: 50mg q8h daily American College of Rheumatology (ACR). (2022). Pharmacological Management of Inflammatory Musculoskeletal Diseases. 2. MedlinePlus, U.S. National Library of Medicine. (2023). Drugs and Supplements: Medications for Musculoskeletal Pain. 3. Mayo Clinic. (2022). NSAIDs: Uses, Side Effects, and Precautions.  

19. ACETAMINOPHEN MOA: Act primarily in the central nervous system (CNS) by inhibiting the enzyme cyclooxygenase (COX) in the brain, thus reducing the perception of pain and lowering fever. Side effects: Overuse or high doses of acetaminophen can lead to liver damage. Dosage: Adults: 325-1000 mg every 4-6 hours as needed (maximum 4000 mg/day). Patients with liver impairment should use lower doses (max 2000-3000 mg/day). • For children: Dosage varies by weight and age, typically 10-15 mg/kg every 4-6 hours (maximum 5 doses per day).

20. TOPICAL ANALGESICS Common Examples: Diclofenac gel ( Voltaren ), Menthol, Capsaicin MOA: Diclofenac gel works by inhibiting COX enzymes at the local site of application, providing targeted relief from pain and inflammation. Menthol and capsaicin produce a cooling or warming sensation, respectively, which distracts the nervous system from pain and may help alleviate discomfort. Side Effects: • Skin irritation Burning or stinging sensation Allergic reactions Dosage: • Voltaren gel (Diclofenac): Apply a thin layer to the affected area 3-4 times daily. Menthol or Capsaicin creams: Apply a small amount to the painful area up to 4 times daily.

21. Corticosteroids (Oral and Injectable) Common Examples: Prednisone, Methylprednisolone (Medrol), Triamcinolone (Kenalog) MOA: W ork by mimicking the action of cortisol, a hormone produced by the adrenal glands. They suppress immune system activity and inflammation by inhibiting the release of inflammatory cytokines, prostaglandins, and other mediators. Side Effects: Chronic use can lead to more serious side effects such as osteoporosis, weight gain, high blood sugar, increased risk of infections, Cushing's syndrome and gastric ulcers. Dosage: • Oral Prednisone: Typically, 5-60 mg daily depending on the severity of the condition. A tapering schedule is usually required to prevent withdrawal symptoms. • Injectable Methylprednisolone (Medrol): 10-40 mg in a single injection, depending on the injury’s severity, with follow-up injections spaced several weeks apart. • Triamcinolone (Kenalog) injections: Typically, 10-40 mg per injection for tendonitis or bursitis.  

22. MUSCLE RELAXANTS Common Example: Methocarbamol (Robaxin ) MOA: Muscle relaxants act on the central nervous system (CNS) to reduce muscle spasm and alleviate pain. Side Effects: • Sedation and drowsiness • Dry mouth and blurred vision • Addiction potential:(carisoprodol) • Nausea and headache   Dosage: • Methocarbamol (Robaxin): 1500 mg 3-4 times daily for the first 2-3 days, then reduced to 750-1500 mg 3-4 times daily.

23. S UPPLEMENTATION Collagen (Type I & III) Supports the repair of tendons, ligaments, and cartilage. Dosage : 10-15 grams per day (typically in powder or liquid form). Side Effects : Some may experience mild digestive upset or bloating. Glucosamine and Chondroitin Supports joint health, reduces pain, and may slow cartilage deterioration. Dosage : Glucosamine: 1,500 mg per day (divided into 2-3 doses). Chondroitin: 1,200 mg per day. Side Effects : May cause mild gastrointestinal discomfort, bloating,or stomach cramps. People allergic to shellfish should avoid glucosamine derived from shellfish. Vitamin C Benefits : Crucial for collagen production and tissue repair, reduces inflammation. Dosage : 500-1,000 mg per day. Side Effects : high doses (above 2,000 mg) can lead to digestive issues, including diarrhoea and stomach cramps.

24. Vitamin D Benefits : Supports bone health and calcium absorption. Dosage : 1,000-2,000 IU per day (may vary based on individual vitamin D levels). Side Effects : Toxicity can cause hypercalcemia (high calcium levels), leading to kidney stones, nausea, or weakness. Toxicity typically occurs at doses above 4,000 IU per day. Omega-3 Fatty Acids (Fish Oil) Benefits : Reduces inflammation, joint pain, and muscle soreness. Dosage : 1,000-3,000 mg of EPA and DHA combined per day. Side Effects : Can cause fishy aftertaste, belching, or indigestion. High doses may increase bleeding risk, especially if on blood thinners. 1. Möller, H. J., & Smith, M. L. (2021). Collagen and Vitamin C Supplementation in Musculoskeletal Injury Recovery. Journal of Orthopedic Research and Rehabilitation . 2. Horne, L., & Wheeler, M. (2020). Glucosamine and Chondroitin for Osteoarthritis: Evidence and Safety Profile. Arthritis & Rheumatism Journal . 3. Calder, P. C. (2022). Omega-3 Fatty Acids and Inflammation in Musculoskeletal Health. Nutritional Research Reviews . 4. National Institutes of Health (NIH), Office of Dietary Supplements. (2023). Omega-3 Fatty Acids: Benefits and Risks.

25. P ATIENT COUNSELING Importance of proper warm-up and stretching Limiting repetitive strain and overuse Adhering to medication guidelines and monitoring side effects When to seek medical attention Listen to your body

26. Emergent Situation (Open fracture, Neurovascular Compromise, Severe Bleeding) Primary Assessment (ABCDEs - Airway, Breathing, Circulation, Disability, Exposure) No → Proceed to Secondary Assessment Yes → Immediate Emergency Care (Hospital, Surgery, Advanced Imaging) Secondary Assessment (History & Physical Examination) Cause of Injury (Trauma, Overuse, Degenerative) Pain, Swelling, Deformity, Range of Motion, Tenderness Neurological & Vascular Examination Imaging & Diagnostic Tests X-ray → Suspected Fracture, Dislocation MRI → Soft Tissue, Ligament, or Tendon Injury CT Scan → Complex Fractures Ultrasound → Tendon, Muscle, Ligament Injuries Injury Classification • Sprains/Strains • Mild-Moderate → RICE (Rest, Ice, Compression, Elevation) + NSAIDs • Severe → Surgery (e.g., ACL Tear, Rotator Cuff) • Tendinitis/ Bursitis → Activity Modification, PT, NSAIDs Rehabilitation & Follow-up • Physical Therapy • Pain Management • Preventive Measures ALGORITHM FOR MUSCULOSKELETAL INJURIES INJURY OCCURS

27. R EFERENCES Khan, K. M., Cook, J. L., Bonar, F., Harcourt, P., & Astrom, M. (1999). Histopathology of common tendinopathies. Sports Medicine, 27 (6), 393-408. Morrey, B. F., & Sanchez-Sotelo, J. (2017). Bursitis: Pathophysiology, Diagnosis, and Treatment. Journal of Bone and Joint Surgery, 99 (2), 123-134. Woo, S. L., Abramowitch, S. D., Kilger, R., & Liang, R. (2006). Biomechanics of ligament healing, repair, and reconstruction. Journal of Biomechanics, 39 (1), 1-20. Khan, K. M., & Cook, J. L. (2000). Overuse tendon injuries: Where does the pain come from? British Journal of Sports Medicine, 34 (2), 81-84. doi:10.1136/bjsm.34.2.81 American Academy of Orthopaedic Surgeons (AAOS). (2022). Recognizing Emergency Symptoms: When to Seek Medical Help for Musculoskeletal Injuries. AAOS . Retrieved from https://www.aaos.org American Academy of Orthopaedic Surgeons (AAOS). (2022). Principles of Musculoskeletal Injury Management. AAOS . Retrieved from https://www.aaos.org

28. Cella, D., & Harris, M. (2021). Physical Therapy and Non-Pharmacological Interventions in Musculoskeletal Injury Recovery. Journal of Rehabilitation Research and Development . Mayo Clinic. (2022). RICE: Rest, Ice, Compression, and Elevation for Acute Injuries. American Academy of Orthopedic Surgeons (AAOS). (2020). Bracing and Splints in Orthopedic Recovery. National Institute for Occupational Safety and Health (NIOSH). (2022). Ergonomic Interventions for Musculoskeletal Injury Prevention. Möller, H. J., & Smith, M. L. (2021). Collagen and Vitamin C Supplementation in Musculoskeletal Injury Recovery. Journal of Orthopedic Research and Rehabilitation . Horne, L., & Wheeler, M. (2020). Glucosamine and Chondroitin for Osteoarthritis: Evidence and Safety Profile. Arthritis & Rheumatism Journal . Calder, P. C. (2022). Omega-3 Fatty Acids and Inflammation in Musculoskeletal Health. Nutritional Research Reviews . National Institutes of Health (NIH), Office of Dietary Supplements. (2023). Omega-3 Fatty Acids: Benefits and Risks. American College of Rheumatology (ACR). (2022). Pharmacological Management of Inflammatory Musculoskeletal Diseases. MedlinePlus, U.S. National Library of Medicine. (2023). Drugs and Supplements: Medications for Musculoskeletal Pain. Mayo Clinic. (2022). NSAIDs: Uses, Side Effects, and Precautions.  Mayo Clinic. (2022). Tendonitis and Bursitis: Prevention and Treatment Tips. American Academy of Orthopaedic Surgeons (AAOS). (2023). Sprain and Strain Management and Prevention. National Institute for Health and Care Excellence (NICE). (2021). Musculoskeletal Injury Rehabilitation Guidelines.