Musculoskeletal Problems in the Elderly
Kim Edward LeBlanc
CLINICAL PEARLS
Between age 20 and 40, both men and women attain their highest level of muscular strength. Strength loss in the elderly is directly related to their decreasing mobility and declining fitness level.
The mechanism of injury will provide the clinician with the critical information needed to proceed in making the diagnosis and formulating a treatment plan.
The Spurling maneuver is helpful in assessing encroachment on a cervical nerve root by disc pathology.
Impingement syndrome of the shoulder is diagnosed by positive Neer and/or Hawkins signs and a painful arc.
Nighttime shoulder pain is characteristic of rotator cuff pathology.
The sudden appearance of a bulge in the lower arm on strenuous use, causing the arm to have a “Popeye” appearance, is usually diagnostic of biceps tendon rupture.
Symptomatic or markedly swollen olecranon bursitis may be aspirated, followed by corticosteroid instillation and a 48-hour compression dressing.
Dupuytren contracture will cause flexion contractures of fingers, which must be surgically treated if the disease significantly impairs the function of the hand.
When evaluating osteoarthritis of the knee, anteroposterior radiographs are much more valuable when accompanied by weight-bearing views.
One of the historic hallmarks of the diagnosis of plantar fasciitis is the severe pain on taking the first few steps in the morning.
Musculoskeletal problems are one of the most common complaints in the aging population. Although these problems are often thought of as part and parcel of the normal aging process, musculoskeletal disease is not necessarily part of the inevitable consequences of increasing birthdays. The proper management of these injuries is critical. Seemingly minor injuries, if neglected or improperly treated, will result in significantly negative effects on the quality of life or, worse, significant disability that will only worsen with time.
Perhaps a bit surprisingly, age does not appear to affect the incidence of injury, even in those who exercise.1 Therefore, fear of injury should not deter anyone from exercising at any age. Furthermore, although all measures of physiologic performance typically decline with age, this decline does not occur at a uniform rate. For example, aerobic capacity declines at a faster rate than nerve-conduction velocities. Continued activity will slow decline significantly and afford an improved quality of life and maintenance of independence.
This chapter begins with a discussion on changes in connective tissues, followed by patterns of injury common to the elderly. The remainder of the chapter covers the common musculoskeletal problems and how to manage them.
CHANGES IN MUSCULOSKELETAL TISSUE WITH AGING
Connective tissue becomes stiffer as we age as a result of the thickening of the basement membrane and a decrease in elastin. Collagen stiffens as a consequence of an increase in the number of cross-links within its framework. Because collagen is the major component of tendons and ligaments, these structures become weaker and stiffer with age. These microscopic structural alterations may be manifested on a macroscopic level by a decrease in the range of motion. This would only be worsened by injury or decreased use.
There are many factors that influence the degenerative changes. Some of them are related to genetics but much is related to activity. It has been demonstrated that the range of motion of a joint and musculotendinous flexibility may be maintained and/or increased by activity and stretching.2 Simply stated, an individual’s tissues may stiffen with time, but the deterioration may be attenuated by activity regardless of the genetic background.
Generally speaking, between the age of 20 and 40, both men and women attain their highest level of muscular strength. Subsequently, muscle strength begins to decline, slowly at first, but more rapidly after middle age. Strength loss in the elderly is directly related to their decreasing mobility and declining fitness level. Decreased activity coupled with the aging process results in loss of muscle motor units and in muscle fiber atrophy, culminating in the reduction of strength. However, the elderly maintain remarkable plasticity in structural, physiologic, and performance characteristics. Muscles have the ability to respond to training and conditioning with marked improvements in strength, even into the ninth decade of life.3,4 Consequently, continued activity will allow strength maintenance and/or gains. This will allow improved function such that the ability to rise out of a chair, maintain balance, and climb stairs will be preserved.
Articular cartilage lines the bony ends of the joints. It is a thin layer of deformable tissue with the ability to support and distribute forces that are generated during the loading of the joint. In addition, it provides a lubricating surface that assists in preventing the wear and tear of the joint surface. Although cartilage is a metabolically active tissue, it has a limited capacity for self-restoration. Injuries to this tissue due to trauma or degenerative joint disease will impair the mechanical properties of the cartilage, leading to loss of joint function and pain. With aging and as a consequence of erosive loss, the thickness of the joint cartilage will decrease. In addition, water content decreases while collagen content and cross-linking increases. Changes in the pattern of glycosylation of the protein, sulfation of chondroitin, alteration of proteoglycan components, and decreases in chondroitin concentration contribute to the processes occurring in the aging cartilage.
GENERAL AREAS OF INJURY
Although there are a multitude of examples of injury, any discussion of injury patterns may be divided into four basic categories: Tendon injuries, ligamentous sprains, injuries to the articular cartilage, and muscle strains, which are the most common of these maladies. It should always
be remembered that, regardless of the pattern of injury, prolonged immobility will lead to a lengthy recovery and great difficulty in returning to the previous level of functioning. A gradual return to activity should be initiated as soon as feasible to avoid disabling or other negative ramifications from a relatively minor problem.
be remembered that, regardless of the pattern of injury, prolonged immobility will lead to a lengthy recovery and great difficulty in returning to the previous level of functioning. A gradual return to activity should be initiated as soon as feasible to avoid disabling or other negative ramifications from a relatively minor problem.
Tendon Injuries
Nearly all clinicians are familiar with tendinitis, but as commonly used to imply symptomatic inflammation of a tendon, the term is a misnomer. Most of these conditions are truly tendinosis. Tendinitis refers specifically to symptomatic degeneration with vascular disruption and an inflammatory response. Tendinosis, on the other hand, refers to intratendinous degeneration commonly due to aging, microtrauma, and/or vascular compromise. Furthermore, tendinosis implies tendon degeneration without clinical or histologic signs of intratendinous inflammation and is not necessarily symptomatic.5,6 The use of the term tendinosis appropriately suggests the chronicity of the condition, which is much more common in the elderly patient.
Elderly patients with a chronic tendinosis are particularly prone to eventual rupture of the affected tendon. Therefore, a proper diagnosis and treatment plan must be initiated to effect proper recovery and avoid tendon rupture. The most commonly affected tendons in this population are the Achilles and rotator cuff tendons. Other less commonly affected tendons are the wrist extensors of the elbow and adductor muscles of the thigh, particularly in very active individuals. The Achilles and rotator cuff tendons are particularly prone to weakening and tendon rupture.
Ligamentous Sprains
Ligamentous sprains are injuries that are usually seen as a result of repetitive overuse or in the early phases of a new activity. It may also occur in someone who is physically active but forgets to do proper warm-up or begins the activity too vigorously. These scenarios may result in ligamentous injury or injury to the joint capsule. Differentiating between the two may be difficult, but joint capsular injuries usually hurt at the extremes of motion, and the tenderness is located directly over the joint capsule as opposed to the specific ligament. Many of these injuries are related to a decreased range of motion of the joint due to stiffness of the surrounding supporting structures, regardless of whether it is due to aging or previous injury or surgery. Lack of flexibility of a joint, for example, the ankle, will not allow compensation for a misstep. As a result, the person will “roll the ankle” and cause subsequent sprain of the lateral ankle ligaments.
Articular Cartilage Injuries
The knee joint is the most commonly affected when speaking of cartilaginous problems. Because of all the weight bearing in a lifetime, it is not surprising that degeneration of this cartilage surface would ensue. When joints are subjected to activity, problems may occur even in someone without previous injury because of the normal cartilage aging process. It should be noted that there is no direct correlation between the extent of radiographic evidence of cartilaginous degeneration and osteoarthritis and the amount of pain that the individual patient may experience. Some patients with extensive osteoarthritic changes on radiographs will have only minimal discomfort, whereas others with minimal changes have significant pain. Furthermore, it should be noted that osteoarthritic changes may begin to appear after the age of 30 in many individuals, so clinical correlation must always be considered.
Muscle Strains
Any muscle group may be affected by muscle strains, the most common musculoskeletal problem. These injuries may be a consequence of a single traumatic event (e.g., straining to move a heavy sofa) or a result of chronic use (e.g., daily working in the garden). In active older individuals, the most commonly affected muscles are the back, abdomen, hamstrings, and quadriceps. In less active individuals, it may also be the back, but upper extremity muscles will be affected frequently as well. Muscle strains may be seen in someone who is beginning an activity for the first time. Muscles that are unaccustomed to such an endeavor will fatigue quickly and be prone to injury. In addition, even muscles that are used frequently for a specific activity may become injured by repetitive overuse or increased intensity or duration of use. Generally speaking, the treatment of these strains is similar to that in the younger population. However, prolonged rest or immobilization in the elderly is detrimental. Rest should be relative, and alternative activity should be encouraged. Gentle stretching and gradual return to activity is critical in the recovery of muscle injuries.
HISTORY
It is not unusual for the patient to present with a known event that has resulted in his or her discomfort or problem. The patient may be able to specifically identify the offending activity that led to the injury. Determination of the mechanism of injury is crucial to making the proper diagnosis. By knowing the mechanism of injury, the practitioner is better able to determine what structure is most likely injured, which is critical in formulating the appropriate treatment plan.
Certain questions should be asked to elicit the best information. If it can be identified, the offending activity should be described. How often is the activity performed? How intense is the patient’s participation in this activity? Is this a new activity? Is it being done more often? Has there been a sudden increase in the level of activity? What specific
movement was the patient doing when the injury occurred? When was the problem first noted? Was it a single event or has it developed gradually over time? Has it been present for some time and then suddenly worsened (implying that this is an acute event superimposed on a chronic condition)? What makes the pain worse? Have there been any similar problems in the past? What medications are you taking? What is the past medical and surgical history?
movement was the patient doing when the injury occurred? When was the problem first noted? Was it a single event or has it developed gradually over time? Has it been present for some time and then suddenly worsened (implying that this is an acute event superimposed on a chronic condition)? What makes the pain worse? Have there been any similar problems in the past? What medications are you taking? What is the past medical and surgical history?
Because of the potential to harbor an occult malignancy, this possibility should always be considered. If there is unexplained weight loss or fever, pain that is suddenly severe with no apparent reason, or an unusual presentation of a particular complaint, more immediate diagnostic studies should be performed.
CERVICAL SPRAIN—ICD-9 CODE 847.0
CASE ONE
A 78-year-old woman presents to your office complaining of a gradual onset of posterior neck pain for the past 3 days. She can relate no specific trauma but states that the pain began when she was going to sit in her easy chair and fell “heavily” into the chair in the sitting position when her grandson unexpectedly jumped into her lap. She denies any previous problems with her neck. There is no headache or dizziness and no numbness or radiation of the pain. The discomfort is made worse by motion of the neck and is causing sleep difficulties. She is also having difficulty performing some of her usual activities because of her discomfort and reduced neck mobility.
A sprain refers to an injury to a ligamentous structure. A cervical strain should refer to an injury to the paraspinal muscles. However, in neck injuries these terms are commonly used interchangeably because of the deep location of the soft tissues of the cervical region. It is not uncommon that rendering a precise location of the problem is very difficult. As long as one does not suspect serious cervical injuries, such as an unstable fracture or potentially damaging neurologic problems, these soft tissue injuries are diagnosed and managed in a similar manner.
Workup/Keys to Diagnosis
Physical Examination
There will usually be areas of tenderness such as the paraspinal muscles, interspinous ligaments, or spinous processes of the vertebrae. At times, depending on the severity, there may be tenderness along the medial aspects of the scapulas. Range of motion should be assessed in all directions, including rotation, lateral bending, flexion, and extension. Not infrequently, pain may be noted at the extremes of motion. Limited motion is a very common occurrence with this entity. It is helpful to know whether there was limited motion before this event. Decreased cervical range of motion is not uncommon in the elderly, particularly extension. In addition, symmetry of rotation (left compared to right) should be assessed because this may be decreased even in the healthy older individual, but it should be fairly close to symmetrical. Flexion is usually fairly well maintained. There is no deformity noted on visual inspection. Neurologic examination is normal. The differential diagnosis (see Table 22.1) includes cervical sprain, cervical spondylosis, cervical disc herniation, arthritic conditions of the spine, vertebral spinal fracture, tumor, and infection.
Imaging
No specific studies are warranted initially. It is reasonable to treat this patient with conservative management and reevaluate in 2 weeks. If the pain has not improved or has worsened by this point, radiographs should be obtained.
If warranted, three standard radiographs should be ordered: Anteroposterior, lateral, and odontoid views. All seven vertebrae should be clearly seen. Although cervical fracture is unlikely in this patient, it should be noted that the width of the prevertebral soft tissue at C3 should not exceed 7 mm in healthy adults. If there is significant spasm, the normal lordotic curve may be straightened or reversed; however, this may not be readily apparent in the elderly patient with significant degenerative changes. Degenerative changes will usually be noted that would predate the diagnosis of a simple cervical sprain. These are age related and most are commonly seen at levels C5-6 and C6-7.
Management
The use of a soft cervical collar will aid the patient significantly, although there are no randomized outcome studies of this approach. However, this device should be used for no longer than 1 to 2 weeks (Evidence Level C). Beyond this period, muscular atrophy will begin to occur and further stiffness of the ligamentous structures will follow. The use of heat, either dry or moist, may be of benefit but should not be used for an extended period (20 to 30 minutes) nor should it be too hot (Evidence Level B). If a heating pad is used, it should not be placed higher than medium heat. The use of balms that provide warmth combined with wet or dry heat should be disallowed because burns may result if left on for too long. The use of heat may provide relief from symptoms but does not speed recovery.
Acetaminophen and/or nonsteroidal anti-inflammatory agents may be used as analgesics (Evidence Level A). If necessary, mild narcotic analgesics may be used during the first week or so. Activity should be allowed but in a limited manner. Gentle stretches that could be suggested include trying to touch the chin to the chest, extending the head backward, and trying to touch the ear to the shoulder on each side, as well as trying to place the chin on each shoulder. These stretches should be done without pain and each held for approximately 15 to 30 seconds at first. This
should be gradually increased to 60 seconds as flexibility increases. Physical modalities may be added if the patient is in severe discomfort; these would include massage, ultrasound, and/or phonophoresis (Evidence Level B). Manipulation of the spine is contraindicated.
should be gradually increased to 60 seconds as flexibility increases. Physical modalities may be added if the patient is in severe discomfort; these would include massage, ultrasound, and/or phonophoresis (Evidence Level B). Manipulation of the spine is contraindicated.
TABLE 22.1 DIFFERENTIAL DIAGNOSES FOR MUSCULOSKELETAL/SOFT TISSUE CONDITIONS (ICD-9) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Follow-up
This is a self-limited condition; however, it is not unusual for discomfort to persist for up to 6 weeks. The patient may be seen within 2 weeks if necessary. If the patient is worsening, radicular symptoms have developed, or the patient has not substantially improved within 6 weeks, further studies may be ordered such as computed tomography (CT) scan or magnetic resonance imaging (MRI). Subsequently, referral may be considered, but this is rarely, if ever, necessary.
CERVICAL SPONDYLOSIS (WITHOUT MYELOPATHY)—ICD-9 CODE 721.0
CASE TWO
An active 83-year-old man presents complaining of stiffness of his neck. He states that he has been having neck pain for at least 3 years, which worsens with upright activity. It has been affecting his ability to tend his garden and sleep. His wife says this discomfort makes him irritable as well. He further states that he can frequently hear a grinding or popping noise in his neck when he looks from side to side. He also indicates that, at times, he may have some tingling and weakness of the upper arms, particularly the left one.
The term cervical spondylosis is synonymous with cervical arthritis and degenerative disc disease of the cervical spine. It may cause cervical pain, radiculopathy (encroachment on the nerve root), and/or myelopathy (bony encroachment on the spinal cord). Cervical stiffness and chronic neck pain that is exacerbated by upright activity are the most common symptoms of cervical spondylosis. Often patients will complain of grinding or popping with motion of the neck. Headaches, muscle spasms, impaired tolerance to activity, irritability, and sleep disturbances may also be described. As the disease worsens over time, there may be pain in the upper extremities and radicular symptoms such as aching or burning pain following a dermatomal pattern, particularly with lateral stenosis and/or compromise of a particular nerve root. Most commonly this involves the C5-6 and C6-7 disc spaces, which leads to entrapment of the C6 (pain and sensory changes in the thumb and index finger) and/or C7 (pain and sensory changes in the index and middle fingers) nerve roots, respectively.
TABLE 22.2 EVALUATIONS OF THE SENSORY AND MOTOR FUNCTIONS OF THE NERVE ROOTS | |||||||||||||||||||||
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