Musculoskeletal Aging

Dorothy D. Sherwood, MD, FACP4/19/2012

Overview

Pathobiology Clinical Presentation and Treatment of:

Cervical Spine Lumbar Spine Hip Knee

Pathobiology of DJD Degeneration of Cartilage

Chondrocyte: Normal function to create and break down matrix

Proinflammatory cytokines ( IL 1, 6,7,8 and TNF alpha) cause chondrocytes to stop making healthy matrix and increase the breakdown of cartilage

Thickening of subchondral bone,osteophyte formation, hypertrophy, ligamental injuries.

Risk Factors AGE! 50 to 80% of people over 60 have

symptomatic DJD Obesity Genetics Injuries Crystal arthopathies Vitamin D deficiency

Cervical Spine Disease Anatomy:

8 cervical nerves with ventral and dorsal roots Spinal nerve spits into the dorsal ramus and the

ventral ramus Dorsal ramus – posterior neck pain Ventral ramus – Brachial plexus as well as

paraverterbral neck pain Myotome- group of muscles innervated by a spinal

nerve Dermatome- sensory innervation.

Cervical 80 to 90 % of non-traumatic cervical pain is

due to DJD – but DD included Rheumatoid Arthritis Spondyloarthritis Polymyagia Rheumatica Bone Mets/Cord Tumor Infection Multiple Sclerosis

Cervical DJD Stiff neck/cervical strain: c/o neck pain, restricted

ROM, para-spinal muscle tenderness – may or may not have trigger points; no weakness, no sensory symptoms, will have LROM of the neck on exam. Neurological exam normal.

Management: NSAID if tolerated in elderly; low dose hydrocodone if needed for further relief of pain ( sleep interuption ) ; avoid muscle relaxers – don’t work and are very anticholinergic.

Cervical DJD Cervical Spondylosis – DJD

Cervical Spondylitic myelopathy: weakness, impaired coordination, gait impairment, bowel or bladder incontinece, babinsky

Due to cord compression by arthritic changes. Think of it as squeezing the cord

Cervical Radiculopathy: pain, weakness, sensory changes and reflex changes due to pinching the nerve at the cervical foramen

Cervical DJD Physical Exam:

Cervical ROM Muscle palpation Strength, reflexes, sensory, gait, upper motor neuron signs Maneuvers: Spurling, Elvey, Upward Traction

Imaging: X ray Cervical spine: shows curvature, shows position of

vertebra, shows arthritic changes that can be causing pain, metastatic lesion, osteomylitis

MRI Cervical Spine: age >50, immunocompromised, h/o cancer, neurological findings, fever – non-contrast if just looking for DJD changes. Gadolinium in patietns with GFR < 30 causes Nephrogenic Systemic Fibrosis

CT Cervical Spine: looking more for boney problems

Cervical DJD Treatment:

Motor findings: refer to Neurosurgeon of choice Sensory findings: respond well to time…

Steroid taper TCA Gabapentin Narcotics

If safe, NSAID is always indicated ( but not if you are using a steroid taper )

NSAID and Elderly Renal Toxicity

Age is major risk factor after known CKD CHF Hypertension with chronic meds Volume Depletion

GI Toxicity Age H. pylori Steroid use Anticoagulant use Prior h/o bleeding ulcer

Choice: lowest dose, shortest duration, monitor every 3 months for GI and or Renal Toxicity

Use PPI in all patients over age 70

Lumbar Spine Disease Pathophysiology

Loss of Interverterbral disc with degeneration Loat on the Facets Facet hypertrophy Ligament hypertrophy

Lumbar DJD Terminology:

Spondylosis: arthritis Spondylolisthesis: slippage – Grade 1 to 4 Sondylolysis: fracture of the pars interarticularis Spinal Stenosis; squeezing the cord Radiculopathy: nerve root compression

Lumbar Clinical Presentation:

Pain Sensory Loss Weakness Neruogenic Claudication Bowel, Bladder incontinece, Erectile Dysfunction

– Cauda Equina or Conus Medullaris Syndrome ( compression at T11)

Lumbar DJD DD:

Vascular Distal polyneuropathy DJD hip and knee SI Joint pain Inflammatory conditions

Arachnoiditis Chronic Demylinating Polyneuropathy Sarcoidosis Carcinomatous meiningitis Lymes, HSV, HZV< EBV, mycoplasma, TB

Lumbar DJD Exam:

Palpate back Observe movment Neurological Exam

Lumbar DJD Evaluation:

Back pain alone of recent onset: NSAID, opiate, follow up in 4 weeks – if still present X ray and ESR – if abnormal MRI

Back pain with neruo findings in patient >50: pain relief – opiate, NSAID not as helpful: if pain only – treat and if not better in 4 weeks – MRI: If weakness – MRI and refer.

Bowel, bladder, ED, sensory level – MRI H/O fever, cancer, weight loss - MRI

Lumbar Treatment modalities

Physical Therapy : No proven benefit, no standard treatment protocol, but everyone does it and patients like it

Injections: may give short term benefit Surgery: depends on the problem – helps in a

young back, dicy at best in an old back

Hip DJD DD: Trochanteric Bursitis, Gluteusmedius Bursitis, DJD,

fracture There are 18 bursas in the hip joint and they can all hurt

Take Home: Hip Joint Pain is anterior groin pain Trochanteric Bursitis is lateral thigh pain Lateral Cutaneous Femoral Nerve Pain – not influenced by

movement Anterior hip or groin pain – usually DJD but r/o osteonecrosis,

abdominal pathology such as hernia, or L2-3 nerve root Posterior pain is almost never the hip – lumbar, SI Joint or

Leriche’s syndrome (vascular disease causing buttock, hip, thigh claudication)

Hip DJD Exam:

FABERE Test Flex Abduct Externally Rotate Extend

Internal and External Rotation Palpation

Hip DJD Treatment:

Injections can be your best friend

Knee Pain Medial: meniscal, medial ligament,

Anserine bursitis Lateral: meniscal, lateral ligament, iliotibial

band syndrome Anterior: Patellofemoral syndrome, Patellar

bursitis, Patellar tendonopathy ( jumpers leg ) Osgood Schlutter – tibial pain

Posterior:Arthritis, Bakers Cyst,

Valgus Movement testing Medial Collateral Ligament

Varus movement, testing lateral collateral ligament