Muscle, bone, and pain conditions

Myofascial pain syndrome

• Chronic pain condition that affects muscles and the tissue that surrounds them. Characterized by trigger points in muscles that cause pain when pressed

  • Can be caused by sudden overload, overstretching, and increased repetition
  • Types of trigger points
    • Active trigger points are tender to palpation and can cause referred pain
    • Latent trigger points are taut bands that can be transitioned to active trigger points

• Symptoms

  • Deep, aching, or throbbing pain that can be localized or widespread.
  • Tender knots (trigger points) that reproduce pain when pressed.
  • Pain that radiates to other areas, such as from the neck to the head or shoulder.
  • Headaches

• Diagnosis

  • Clinical presentation

• Medical management

  • Dry needling
  • Corticosteroid injections
  • Analgesic injections

• Physical therapy management

  • Soft tissue techniques to reduce pain and inflammation
  • Progressive resistance training
  • Modalities for managing pain and inflammation
  • Functional mobility training

Scope of practice: dry needling and spinal and peripheral joint mobilization/manipulation (thrust and non-thrust) are performed only by the physical therapist, not the PTA. As the PTA, you carry out the soft tissue techniques and exercise progressions assigned in the plan of care and report the patient’s response back to the PT.

Complex regional pain syndrome (CRPS)

• Chronic pain condition characterized by persistent, severe pain; presentation of symptoms is disproportionate to the initial injury, thought to be caused by an abnormal response of the sympathetic nervous system to an injury.

  • Can be caused by trauma or have an unknown etiology
  • Types of complex pain syndrome
    • CRPS I- tissue injury with no nerve involvement
    • CRPS II- tissue injury with known nerve involvement

• Symptoms

  • Intense, burning, or throbbing pain disproportionate to the initial injury, worsening with movement or touch
  • Allodynia (pain from normally non-painful stimuli) and hyperalgesia (increased sensitivity to pain)
  • Changes in skin color, temperature, or sweating; swelling and joint stiffness
  • Numbness, tingling, or prickling sensation

• Radiographs in CRPS may show bone demineralization, but this finding is nonspecific because bone can also look abnormal after trauma without CRPS

• Diagnosis

  • Clinical presentation

• Medical management

  • Sympathetic nerve block
  • Spinal cord stimulation
  • Intrathecal drug pumps
  • Antiseizure medications
  • Antidepressants
  • Corticosteroid medications
  • Opioid medications

• Physical therapy management

  • Patient education on diagnosis and prevention of exacerbating activities
  • Desensitization activities for return to normal function
  • Modalities for pain relief, such as TENS, avoid heat and cold therapies.
  • Graded motor imagery (left/right limb recognition, then imagined movement, then mirror therapy) and stress loading (scrubbing and carrying while bearing weight through the limb), with edema control and gentle active range of motion progressed toward functional use

Muscle strains

• Injury to the muscle or tendon, the fibrous tissue that connects muscles to bones, causing an inflammatory response

  • Typically due to overuse or overstretching caused by forceful movement

• Symptoms

  • Sudden, sharp pain at the time of injury, worsening with movement or stretch
  • Inflammation, swelling, and bruising (ecchymosis) in the affected area
  • Difficulty or inability to use the injured muscle, with restricted movement
  • Pain when the injured muscle is touched or pressed

• Diagnosis

  • Clinical presentation
  • MRI, possibly

• Medical management

  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)

• Physical therapy management

  • Soft tissue techniques, progressive resistance training, modalities for pain and inflammation, and functional mobility training, progressing according to the phase of tissue healing.

Grades

Grade 1 (Mild)

• What it is: Minor overstretching or microscopic tearing of muscle fibers with no appreciable structural damage.
• Symptoms: Mild soreness, tenderness, and slight stiffness.
• Function: Less than 5% loss of strength; strength and movement remain mostly intact.
• Healing time: A few weeks.

Grade 2 (Moderate)

• What it is: Partial tearing of the muscle or musculotendinous junction.
• Symptoms: Significant pain, moderate to severe swelling, and localized bruising (ecchymosis).
• Function: Moderate loss of function and strength (usually a 25% to 50% reduction).
• Healing time: Two weeks to a few months.

Grade 3 (Severe)

• What it is: A complete rupture of the muscle or tendon.
• Symptoms: Immediate, intense, sharp pain, severe swelling, and sometimes a visible gap or deformity in the muscle.
• Function: Essentially complete loss of strength and function at the site of rupture.
• Healing time: Several months (often 4 to 6 months), with intensive rehabilitation. Surgical repair may be needed, mainly for a tendon rupture or an avulsion from bone; tears at the muscle-tendon junction are usually managed without surgery.

Myositis ossificans

• Abnormal calcification within the muscle belly

  • Can be caused by direct trauma- hematoma causes calcification
  • Frequently located in the quadriceps or brachialis

• Symptoms

  • Persistent, localized pain that worsens with activity
  • A firm, palpable lump or mass in the injured muscle
  • Limited range of motion
  • Warmth
  • Redness

• Diagnosis

  • Clinical presentation
  • X-ray imaging
  • CT scan
  • MRI

• Medical management

  • Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs)

• Physical therapy management

  • Gentle, pain-free active range of motion and progressive strengthening as tolerated.
  • Avoid deep massage/soft tissue mobilization and aggressive or forceful passive stretching over the mass - these can increase bleeding and calcification.
  • Report increasing pain, swelling, or loss of range of motion to the supervising PT.

Myositis ossificans, osteomyelitis, and an acute muscle strain can all present with a painful, warm, swollen area, but they’re managed very differently:

Paget’s disease

• Chronic bone disorder characterized by abnormal bone remodeling

  • May be linked to viral infections

• Symptoms

  • Deep, aching pain in the affected bones, often worse at night or with activity.
  • Bowing of the legs or arms
  • Enlargement of the skull or jaw
  • Thickening of the bones in the spine or pelvis
  • Numbness, tingling, or weakness in the arms or legs
  • Headaches
  • Hearing loss

• Diagnosis

  • Clinical presentation
  • X-ray
  • Lab tests
    • Serum alkaline phosphatase and urinary hydroxyproline

• Medical management

  • Bisphosphonates (first-line, e.g., zoledronic acid)
  • Calcitonin (second-line)
  • Acetaminophen for pain
  • Surgery for bone deformities or joint replacements

• Physical therapy management

  • Joint protection strategies
  • Improve joint biomechanics
  • Aerobic capacity/conditioning

Osteoporosis

• Bones become brittle and fragile from loss of tissue due to metabolic changes, resulting in bone mineral density loss

  • Affects women about four times more than men
    • Can be related to menopause (reduction in estrogen)
  • Common sites are the thoracic and lumbar spine, the proximal humerus, the proximal femur (hip), the pelvis, distal radius

• Symptoms

  • Often asymptomatic until a fragility fracture occurs
  • Bone fractures (especially hip, spine, and wrist)
  • Back pain and loss of height
  • Kyphosis (dowager’s hump)

• Diagnosis

  • Clinical presentation
  • CT scan
  • DEXA scan T-score (bone density scan)
    • -1.0 or higher: Normal bone density
    • Below -1.0 but above -2.5: Osteopenia (low bone mass)
    • -2.5 or lower: Osteoporosis (weak bones)

• Medical management

  • Calcium supplement
  • Vitamin D supplement
  • Estrogen - hormone replacement therapy
  • Calcitonin medication
  • Bisphosphonate medication

• Physical therapy management

  • Joint protection strategies
  • Improve joint biomechanics
  • Aerobic capacity/conditioning
  • Emphasize weight-bearing activities, such as walking, to help maintain bone density.
  • Aquatic therapy is not effective in maintaining bone density due to buoyancy.
  • Immobilization and extended sedentary periods cause bone loss, so bed rest should be minimized and weight-bearing exercise encouraged.

Exercise precautions for osteoporosis:

• Contraindicated: loaded spinal flexion (e.g., sit-ups, toe touches) and combined flexion with rotation; high-impact loading or activities with a high fall risk.
• Recommended: favor extension-biased strengthening, weight-bearing and resistance exercise, and balance/fall-prevention training to reduce fracture risk.
• Precaution: progress resistance and balance challenges gradually (start lower in patients at high fracture risk or new to resistance training), and guard against falls with a support surface nearby and non-slip footwear.
• Stop and notify the PT for sudden, severe back pain or a new spinal deformity - these can signal a vertebral compression fracture.

Osteomyelitis

• Inflammation of the bone caused by infection

• Symptoms

  • Pain and tenderness in the affected bone, with swelling, redness, and warmth
  • Drainage of pus from a wound or abscess
  • Limited range of motion in the affected joint
  • Fever, chills, and other systemic signs (fatigue, malaise, loss of appetite, weight loss)

• Diagnosis

  • Clinical presentation
  • Bone biopsy
  • Lab tests
  • Radiographs become abnormal only after 2 to 4 weeks, so if films are equivocal or symptoms are acute, CT and MRI are the imaging techniques of choice

• Medical management

  • Antibiotics
  • Surgical debridement if necessary

• Physical therapy management

  • Joint protection strategies
  • Improve joint biomechanics

Medication effects on physical therapy

Medication considerations for PT:

• NSAIDs/analgesics (e.g., acetaminophen): can mask pain, so monitor the patient’s response to exercise rather than relying on reported pain alone to judge progression.
• Long-term corticosteroids: weaken tendons and bone, raising the risk of tendon rupture and fracture - progress loading cautiously.
• Opioids, antidepressants, and antiseizure medications: can cause sedation and dizziness, increasing fall risk.
• Oral bisphosphonates: require the patient to remain upright for 30 minutes after dosing.

Somatic dysfunction

Somatic dysfunction is an impaired or altered function of the body’s framework, including muscles, joints, and fascia. It is commonly associated with pain, restricted movement, and abnormal tissue texture.

A physical therapist diagnoses somatic dysfunction using the TART criteria. As the PTA, you document these findings as objective data and report any changes to the supervising PT - diagnosing the dysfunction is outside the PTA’s scope.

Definitions

Tissue texture changes

Palpable differences in the texture of the skin, fascia, or muscle over the dysfunctional segment.

Asymmetry

Structural or positional asymmetry observed in the segment.

Restriction of motion

A decrease in active or passive range of motion at the segment.

Tenderness

Pain elicited on palpation of the segment.

Below is a description of somatic dysfunction within each segment type:

Cervical somatic dysfunction

• Location: Affects the neck (C1-C7).
• Common causes:
  • Poor posture, whiplash, prolonged screen time, stress-related muscle tension.
• Symptoms:
  • Neck pain, stiffness, headaches, dizziness, reduced range of motion, and possible radiating pain to the shoulders or arms.
• Treatment:
  • Soft tissue mobilization, joint mobilization (performed by the PT), stretching, and postural correction exercises.

Thoracic somatic dysfunction

• Location: Affects the mid-back (T1-T12).
• Common causes:
  • Poor posture, kyphotic spine patterns, prolonged sitting, rib dysfunction, and respiratory issues.
• Symptoms:
  • Mid-back stiffness, difficulty taking deep breaths, rib pain, referred pain to the chest or upper back, and limited spinal rotation.
• Treatment:
  • Thoracic and rib mobilization (performed by the PT), breathing exercises, and spinal extension exercises.

Lumbar somatic dysfunction

• Location: Affects the lower back (L1-L5).
• Common causes:
  • Heavy lifting, poor body mechanics, prolonged sitting, muscle imbalances, disc pathology.
• Symptoms:
  • Lower back pain, stiffness, restricted forward bending, muscle spasms, pain radiating to the hips or legs, and possible sciatic nerve involvement.
• Treatment:
  • Joint mobilization (performed by the PT), core strengthening, stretching, and movement retraining.