15.4 Musculoskeletal Complaints: Low Back Pain, Osteoarthritis, Sprains, Strains & Common Conditions in Women
Key Takeaways
Most acute low back pain improves within 4–6 weeks; imaging is not recommended early unless red flags (cauda equina signs, cancer, infection, fracture, or progressive neurologic deficit) are present.
ACP recommends nondrug therapy first for low back pain (heat, massage, acupuncture, spinal manipulation, exercise), then NSAIDs or skeletal muscle relaxants if needed, and avoiding early opioids.
Osteoarthritis causes use-related joint pain with morning stiffness under 30 minutes, Heberden and Bouchard nodes, and no systemic inflammation; exercise, weight loss, and topical NSAIDs for knee and hand OA are first-line.
The Ottawa ankle rules call for radiographs only with malleolar or midfoot bone tenderness at specific points or inability to bear weight for four steps.
Postpartum wrist pain over the radial styloid with a positive Finkelstein test suggests de Quervain tenosynovitis, and carpal tunnel syndrome is common in pregnancy.
Low Back Pain
Low back pain is one of the most common reasons for primary care visits. About 90% of acute episodes are nonspecific (musculoligamentous) and improve within 4–6 weeks.
Red Flags Requiring Urgent Evaluation
| Red Flag | Concern | Action |
|---|---|---|
| Saddle anesthesia, new urinary retention or incontinence, bilateral leg weakness | Cauda equina syndrome | Emergency MRI and surgical referral |
| History of cancer, unexplained weight loss, pain at night or at rest, age over 50 with new pain | Metastatic disease | MRI and labs |
| Fever, injection drug use, immunosuppression, recent spinal procedure | Spinal epidural abscess or osteomyelitis | MRI, ESR/CRP, blood cultures |
| Significant trauma, osteoporosis, long-term glucocorticoids | Vertebral fracture | Radiographs or CT |
| Progressive or severe neurologic deficit | Severe nerve compression | Urgent MRI and referral |
Sciatica (lumbar radiculopathy): Pain radiating below the knee in a dermatomal pattern, usually from an L4–L5 or L5–S1 disc, with a positive straight-leg raise. Most cases improve with conservative care; MRI is reserved for persistent deficits after about 6 weeks or for surgical planning.
Treatment (American College of Physicians, 2017)
- Acute or subacute pain: Start with nondrug therapy: superficial heat, massage, acupuncture, and spinal manipulation, with advice to stay active (bed rest delays recovery). If medication is needed, use NSAIDs or skeletal muscle relaxants for short courses.
- Chronic pain (12 weeks or more): Exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, CBT, and spinal manipulation. NSAIDs are first-line drugs, with duloxetine or tramadol as second-line options. Opioids are a last resort.
- Imaging: Not recommended for nonspecific back pain without red flags, because it does not improve outcomes and leads to unnecessary procedures.
Osteoarthritis (OA)
OA is degenerative cartilage loss with bony remodeling. Risk rises with age, female sex (especially after menopause), obesity, prior joint injury, and occupational loading.
| Feature | Osteoarthritis | Rheumatoid Arthritis |
|---|---|---|
| Pain pattern | Worse with use, better with rest | Worse after rest, better with activity |
| Morning stiffness | Less than 30 minutes | More than 1 hour |
| Joints | Knees, hips, DIP (Heberden nodes), PIP (Bouchard nodes), first CMC, spine | MCP, PIP, wrists, MTP, symmetric; spares DIP |
| Exam | Bony enlargement, crepitus, no warmth | Boggy synovitis, warmth |
| Labs | Normal ESR, CRP, RF, and anti-CCP | Elevated inflammatory markers; RF and anti-CCP often positive |
| Radiographs | Asymmetric joint-space narrowing, osteophytes, subchondral sclerosis | Periarticular osteopenia, erosions |
OA is a clinical diagnosis; radiographs help when the picture is atypical.
Management (ACR/Arthritis Foundation, 2019)
- Strongly recommended: Exercise (strengthening, aerobic, aquatic), weight loss for knee and hip OA (5% or more helps), self-management education, tai chi, and canes or braces as appropriate.
- First-line drugs: Topical NSAIDs for knee and hand OA (fewer systemic effects), then oral NSAIDs at the lowest effective dose (consider GI, renal, and cardiovascular risk).
- Other options: Intra-articular corticosteroid injections for flares, duloxetine, and tramadol. Acetaminophen gives only modest benefit.
- Not recommended: Glucosamine and chondroitin (for knee and hip OA), bisphosphonates, hydroxychloroquine, and platelet-rich plasma or stem-cell injections.
- Joint replacement for severe pain and functional limitation despite conservative care.
Sprains and Strains
- A sprain injures a ligament; a strain injures a muscle or tendon.
- Ankle inversion sprain (anterior talofibular ligament first) is the most common sprain. Grade I is a stretch, grade II a partial tear with some instability, and grade III a complete tear.
- Ottawa ankle rules: Obtain radiographs only for pain in the malleolar zone and bone tenderness at the posterior edge or tip of either malleolus, or pain in the midfoot and tenderness at the base of the fifth metatarsal or the navicular, or inability to bear weight for four steps both right after the injury and at evaluation.
- Treatment: Protection, optimal loading, ice, compression, and elevation; NSAIDs; functional support with a lace-up or semi-rigid brace rather than casting; early weight bearing; and balance and proprioception exercises to prevent recurrence.
Musculoskeletal Problems Common in Women
| Condition | Key Features | Management |
|---|---|---|
| ACL tear | Female athletes have 2–8 times the risk of male athletes; pivoting injury, a "pop," rapid effusion, positive Lachman test | MRI and orthopedic referral; neuromuscular training programs prevent injury |
| Scaphoid fracture | Fall on an outstretched hand with anatomic snuffbox tenderness | Splint as a fracture even if the first radiograph is normal (avascular necrosis risk) |
| Carpal tunnel syndrome | Nocturnal numbness and tingling of the thumb, index, and middle fingers; positive Phalen and Tinel signs; common in pregnancy and hypothyroidism | Neutral wrist splint at night; often resolves after delivery; steroid injection or surgical release if persistent |
| De Quervain tenosynovitis | Radial wrist pain from repetitive lifting of an infant ("new mother's wrist"), positive Finkelstein test | Thumb spica splint, NSAIDs, corticosteroid injection |
| Relative Energy Deficiency in Sport (RED-S) | Low energy availability with menstrual dysfunction and low bone density, leading to stress fractures | Restore energy intake; evaluate for amenorrhea and bone health |
| Pregnancy pelvic girdle pain | Pain over the sacroiliac joints and symphysis pubis | Support belt, physical therapy, activity modification |
A 42-year-old woman has had low back pain for 5 days after moving furniture. The pain does not radiate below the knee, she has no fever, weight loss, cancer history, or bowel or bladder symptoms, and her neurologic examination is normal. What is the most appropriate initial management?
Order a lumbar spine MRI now to rule out a herniated disc before starting any treatment.
Prescribe oxycodone for pain control and recommend 1 week of strict bed rest at home.
Recommend heat and staying active, with an NSAID if needed, and reassess if not better in 4–6 weeks.
Refer her immediately for spinal surgery evaluation and a lumbar epidural steroid injection.
A 63-year-old woman reports bilateral knee pain that worsens with walking and improves with rest, with about 15 minutes of morning stiffness. Examination shows bony enlargement and crepitus without warmth or effusion, and she has bony nodules at several distal interphalangeal joints. Which first-line pharmacologic therapy is recommended by the ACR for her knees?
Daily oral glucosamine and chondroitin sulfate supplements
Oral prednisone 20 mg daily for 4 weeks, then a slow taper
Hydroxychloroquine 200 mg twice daily for disease control
Topical NSAID, such as diclofenac gel, applied to the knees
A 28-year-old woman 3 months postpartum reports pain at the radial side of her right wrist that worsens when she lifts her baby. Pain is reproduced when she makes a fist over her flexed thumb and the wrist is deviated toward the ulna. What is the most likely diagnosis?
De Quervain tenosynovitis
Carpal tunnel syndrome
Scaphoid fracture
Rheumatoid arthritis of the wrist
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