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  • Goal of section: The reader will understand common causes of acute ankle, knee, shoulder, back injuries, and chronic back pathology injuries, their diagnoses and management.
  • 1%–19% of musculoskeletal injuries evaluated in the ED receive proper discharge instructions for optimal management and rehabilitation.
    • The mnemonic PRICEMMMS (see treatment section) includes the necessary components for proper care of acute musculoskeletal pain and swelling.




  • Sprain: Stretch or tear of a ligament that connects two or more bones (localized tenderness, swelling, ± joint instability over injured ligament)
  • Strain: Inflammation and injury to a muscle or tendon
  • Acute: Pain less than 3 mo
  • Chronic: Pain greater than 3 mo
  • Valgus: A force or alignment that results in the joint opening medially
  • Varus: A force or alignment that results in the joint opening laterally (opposite of valgus)
  • Apophysitis: Inflammation of growth plate (epiphysis under tension at site of tendon insertion)
  • Spondylolysis: Stress injury or fracture of pars interarticularis
  • Spondylolisthesis: Anterior movement of one vertebrae in relation to adjacent vertebrae




  • History: (1) mechanism of injury; (2) degree of functional impairment immediately after injury; (3) a “pop”, snap, or tear (→ fracture or ligament tear); (4) painful locking or catching sensation (→ cartilage tear, loose body, Osteochondritis dissecans (OCD); (5) feeling of instability (→ dislocation or ligament injury); (6) onset and timing of swelling; (7) pain assessment (where, pain scale 0–10, what makes it worse, what makes it better)
  • Physical exam
    • Inspection: Surface anatomy (alignment, swelling, ecchymoses, or deformity)
    • Neurovascular: Document pulses, and determine sensation
    • Palpation: Provoke complaint by pressing with fingertips to elicit tenderness
    • Range of motion: Active, passive (flexibility), resisted (strength)
    • Provocative tests: Special maneuvers or manipulation techniques unique to each body segment (see Tables 1–6; a video demonstration of each exam is available at
    • Function: Assess patient's ability to bear weight, stand, walk, toe raise, hop, broad jump, throw
  • Red flags: Fever; sweating; age <5 yo; local tenderness/warmth/redness; no history of injury; night pain; weight loss; migratory joint pain (SLE, rheumatic fever, HSP, subacute endocarditis, Lyme disease, gonococcal arthritis, viral or Mycoplasma infection, sepsis); elevated WBC, ESR, or CRP (evaluate for septic arthritis or osteomyelitis).
  • Radiographic studies
    • Two views minimum of entire bone. Add oblique view for foot, ankle, and elbow injuries (foot injuries require weight-bearing views so that a Lisfranc injury is not missed).
    • Normal X-ray does not rule out fracture: Consider other views if exam strongly suggests fracture (if in doubt, splint and order follow-up radiographs in 5–10 d).

Table Graphic Jump Location
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Potential Injury

Additional Testing/Management


Lateral malleolus

  • Fractured fibula; ligament tear
  • Ankle X-ray (three views) if point tenderness OR unable to bear weight
  • Initial talus fracture X-ray may be (-)
  • See section on fractures and splinting

Length of fibula

  • Maisonneuve fracture

Medial malleolus

  • Fractured tibia; ligament tear

Base fifth MT

  • Fracture

Navicular bone

  • Fracture

Medial joint line

  • Eversion ankle sprain
  • Deltoid ligament injury
  • Posterior tibialis tendon injury
  • Ankle stirrup brace
  • Confirm ligament injury with corresponding provocative ...

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