Treatment of Musculoskeletal Injuries

Initial Management

The American Academy of Orthopaedic Surgeons recommends exercise therapy and NSAIDs as first-line treatments for musculoskeletal injuries, such as supraspinatus tendinitis and partial infraspinatus tears, with significant improvements in pain and function with structured exercise programs 1, 2, 3
Exercise programs should focus on rotator cuff strengthening, scapular stabilization, and range of motion exercises, and should be structured and progressive, including supervised physical therapy and targeted physical therapy with eccentric strengthening exercises 1, 4
NSAIDs are effective for pain management in musculoskeletal injuries and should be recommended at maximum tolerated dosage for 2-4 weeks, as supported by the American Academy of Orthopaedic Surgeons 1, 5, 6

Reducing activities that cause repetitive loading of the affected muscles and avoiding complete immobilization to prevent muscle atrophy are recommended, as well as activity modification to reduce repetitive loading and avoid complete immobilization 7, 5, 6
Orthotics and braces may help reinforce and protect tendons during activity, but have limited evidence for effectiveness, and are generally safe 7
Heat/ice application is recommended as part of conservative management for patients with reproducible paraspinal muscle pain 5, 6

Corticosteroid injections have conflicting evidence for effectiveness, and may weaken tendon tissue and predispose to rupture, with caution advised, and may also weaken muscles if used for paraspinal muscle pain 1, 7, 2, 5, 6
Other modalities with inconclusive evidence include pulsed electromagnetic field therapy (PEMF), therapeutic ultrasound, extracorporeal shock wave therapy (ESWT), iontophoresis, phonophoresis, and TENS 1, 7

A focused physical examination should include assessment for point tenderness, muscle spasm, and range of motion limitations, followed by a neurological examination to rule out radicular involvement, including motor strength testing, sensory testing in dermatomes, deep tendon reflexes, and straight leg raise test (for lumbar involvement) 5
The American College of Radiology recommends plain radiographs as the first-line imaging to rule out structural abnormalities, rated 9/9 (usually appropriate) for mechanical back pain, to help exclude other causes of back pain such as fractures, tumors, or inflammatory conditions 5
The American College of Radiology also recommends MRI without contrast if symptoms persist beyond 4 weeks or if red flags are present, rated 7/9 (usually appropriate) for chronic mechanical back pain, to identify muscle edema, atrophy, or fatty infiltration 5, 6
Red flags for paraspinal muscle pain include night pain, constant pain unrelated to activity, neurological deficits, pain lasting >4 weeks without improvement, and abnormal neurological examination, according to the American College of Radiology 5

Consider surgical options only after failure of conservative management for at least 6 months, with arthroscopic removal of calcific deposits and débridement or repair for high-grade partial-thickness tears as possible options, as recommended by the American Academy of Orthopaedic Surgeons 7, 2
For high-grade partial-thickness tears that have failed physical therapy, both débridement and repair are options, though repair may improve outcomes, according to the American Academy of Orthopaedic Surgeons 2

Overreliance on corticosteroid injections may inhibit healing and reduce tendon tensile strength, and can predispose to spontaneous rupture, and multiple steroid injections may compromise the integrity of the rotator cuff and affect subsequent repair attempts, as warned by the American Academy of Orthopaedic Surgeons 7, 2
Immediate surgical intervention should be avoided, with conservative management tried for at least 6 months before considering surgery, as recommended by the American Academy of Orthopaedic Surgeons 7, 2
Inadequate exercise programs and failure to address biomechanical issues can permit humeral head migration, resulting in continued impingement, and supervised physical therapy is more appropriate than unsupervised home exercise for most patients with musculoskeletal injuries 7, 2, 3