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RheumatologyMain11-20Q1A35-year-oldmancomestotheofficeforfoilow-upoflowbackpain.Hehasachingpainintheleftlumbarparaspinalareathatisworseattheendofthedayandrelievedovernightwithrest.Thepainbegan3monthsagowithoutanyprecipitatingtrauma.Thepatientwasinitiallytreatedwithintermittentdosesofacetaminophenandnaproxenbutcontinuestohavemoderateresidualpain.Thereisnoassociatedfeverweightloss:radicularpain,lowerextremityweakness,orurinarysymptoms.Hismedicalhistoryisunremarkable.Thepatientisemployedasafactorylineworker,whichrequireshimtolift5-7kg(11-15lb)severaltimesdaily.Onphysicalexamination,vitalsignsarenormalandthepatientappearscomfortable.Cervicalandthoracicspinerangeofmotionisnormal,butflexionandextensionofthelumbarspineelicitspain.Straightlegraisingtestisnormal.Thereismildtendernessintheleftlumbarparaspinaltissuesbutnomidlinetenderness.Upperandlowerextremitystrengthanddeeptendonreflexesarenormal.Whichofthefollowingisthebestrecommendationformanagementofthispatient'spain?A.DiscontinueworkinguntilthepainisresolvedB.EpiduralglucocorticoidinjectionC.ExercisetherapyD.LumbarsupportbraceE.SpinalmanipulationtherapyA1Correctanswer:CThispatienthasuncomplicatedchronic(≧12weeks)lowbackpain(LBP).Patientswithacute(4weeks)LEPshouldbeadvisedtomaintainmoderateactivitywithshortcoursesofacetaminophenornonsteroidalanti-inflammatorydrugs(NSAIDs)toprovidepainrelief.Mostpatientswillhaveresolutionwithoutanyadditionalintervention.However,thosewithsubacute(4-12weeks)orchronicLBParemorelikelytocontinuetohaverecurrentorpersistentpain.InpatientswithchronicLBP,exercisehasproventobebeneficialinreducingpainandimprovingfunction.Patientsoftenstartwithasupervisedexerciseprogramthatemphasizesstretchingandstrengtheningofthebackmuscles.Aerobicexerciseisalsohelpfui.Subsequently,patientscantransitiontoahomeexerciseprogram,whichshouldbecontinuedonalong-termbasis.ShortcoursesofacetaminophenorNSAIDscanbeusedintermittently.Somepatientsalsomaybenefitfromtricyclicantidepressantsorduloxetine,butopioids,benzodiazepines,andmusclerelaxantsarenotadvisedforroutineuse.(ChoiceA)ProlongedactivityrestrictioninpatientswithuncomplicatedLBPisassociatedwithincreasedlong-termpainandstiffness.Patientsshouldbecounseledtomaintainnormalactivity.(ChoiceB)Epiduralglucocorticoidinjectionscanbeconsideredforpatientswithlumbosacralradiculopathywhohavenotrespondedtoinitialtreatment.TheyarenothelpfulfornonradicularLBP.(ChoiceD)BackbracesarenoteffectiveforpreventionortreatmentofLBP.(ChoiceE)SpinalmanipulationcanprovidesmallbenefitsforLBPthathasfailedotherinterventions.However,thebenefitsaretransient,andpatientsshouldfirstoptimizetheirexerciseregimen.Educationalobjective:Managementofchronicbackpainshouldincludeanexerciseprogramemphasizingstretchingandstrengtheningofthebackmusclesandaerobicconditioning.Acetaminophenornonsteroidalanti-inflammatorydrugscanbeusedintermittently.Somepatientsmaybenefitfromtricyclicantidepressantsorduloxetine,butopioids,benzodiazepines,andmusclerelaxantsarenotadvised.Q2A62-year-oldwomancomestotheemergencydepartmentduetoacutelegpain.Thepatient,whorecentlystartedanexerciseprogramforweightloss,feltpainattherightkneeandposteriorcalfwhilewalkingonatreadmill.Shesubsequentlydevelopedswellingatthecalfandrightankle.MedicalhistoryIsnotablefortype2diabetesmellitus,hypertension,andhypercholesterolemia.Thepatientdoesnotusetobaccooralcohol.Temperatureis36.5℃(97.7℉),bloodpressureis166/88mmHg,andpulseis90/min.BMIis41kg/㎡.Examinationshowstendernessandindurationatthemedia!headofthegastrocnemius.Thereismoderatepittingedemaattheankleandacrescent-shapedpatchofecchymosisatthemedialmalleolus.Whichofthefollowingisthemostlikelycauseofthispatient'ssymptoms?A.AnserinebursitisB.RupturedpoplitealcystC.StressfractureoftibiaD.TearofmedialcollateralligamentE.TearofmedialmeniscusFVenousthrombosisA2Correctanswer:BThispatientlikelyhasarupturedpopliteal(Baker)cyst.Apoplitealcystisduetoextrusionofsynovialfluidfromthekneejointintothegastrocnemiusorsemimembranosusbursathroughacommunicationbetweenthejointandthebursa.Excessivesynovialfluidformation(eg;duetoosteoarthritisorrheumatoidarthritis)andpositivepressureinthekneeduringextensioncancausepassageoffluidintothebursaandgradualenlargementofthecyst.Poplitealcystsareoftenasymptomaticandpresentasachronic,painlessbulgebehindtheknee.Thediagnosisisusuallyapparentonexamination,withasoftmassinthemedialpoplitealspacethatismostnoticeablewithkneeextensionandlessprominentwithflexion.Ruptureofapoplitealcyst(eg，followingstrenuousexercise)cancauseposteriorkneeandcalfpain,withtendernessandswellingofthecalfresemblingdeepvenousthrombosis(DVT).Anarcofecchymosisisoftenvisibledistaltothemedialmalleolus(crescentsign).UltrasoundcanruleoutDVTandconfirmthepoplitealcyst.(ChoiceA)Pesanserinuspainsyndrome(anserinebursitis)presentswithsubacutemedia!kneepain.Examinationshowsawell-definedareaoftendernessoverthemedialtibialplateaubelowthejointline.(ChoiceC)Stressfracturesofthetibiapresentwithprogressivepainattheshinandfocaltendernessoverthefracturesite.(ChoiceD)Tearsofthemedialcollate