Immune System Regulation of Muscle Injury
Immune System Regulation of Muscle Injury
Immune System Regulation of Muscle Injury

What type of history will you obtain for this visit?
Presenting complain
History of presenting complaint
Past medical history (Sataloff, 2019)
Drug history
Family history
Social history
What additional history would you obtain from the family that is significant to A.J.’s situation
Family history e.g. Cardiac and diabetes history
Presence of genetic conditions in the family
Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided
Muscle or tendon injury
Medial tibial stress syndrome
Stress fracture,
Exertional compartment syndrome
Nerve entrapment Immune System Regulation of Muscle Injury
For each of the following:
Medical Diagnosis: Muscle or tendon injury:
Pathophysiology
Muscle strain occurs from overstretched muscles and is common among sporting people. Symptoms include leg pain and mobility difficulties among others.
Muscle strains cause excessive fiber stretching due to exertion of tensile force at the muscle. The pathophysiological process is characterized by destruction, repair and remodeling. Destruction involves tearing and myofibrils necrosis, creation of hematoma and division of inflammatory cells (Bengtsson, Ekstrand, Waldén & Hägglund, 2017). Repair and remodeling phases involve necrotic tissue phagocytosis, myofibrils regeneration and concomitant development of connective scar tissue, neoformation of vessels and growth of neurons also occur (Hamilton et al., 2020)
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ICD 10 code: ICD-10-CM Code S86
Diagnosis 2: Medial tibial stress syndrome
Pathophysiology:
Clinical exercise induced pain caused by repetitive loading stress during running and jumping and triggered on palpation over a length of ≥5consecutive centimeters. It occurs along the posteromedial tibial border.
Foot inversion by dorsiflexes of the tibialis anterior is followed by extension of the great toe. Other toes extend causing pain and dysfuctions.
ICD-10-CM Diagnosis Code S83.132A
Differential diagnosis, 3-5 Differentials
Stress fracture
Tiny cracks in bones caused by repetitive force, often from overuse — such as repeatedly jumping up and down or running long distances. Stress fractures can also develop from normal use of a bone that’s weakened by a condition such as osteoporosis.
ICD-10-CM Diagnosis Code M84.35

Exertional compartment syndrome
It is associated with pain and pressure on the leg due to failure of muscle expansion on the affected tissues. It causes inflammation, pain and disability of arms and legs. It is nerve condition or exercise induced.
ICD-10-CM Diagnosis Code M79.A22 (ICD10data, 2018).
Nerve entrapment
It is characterized by pain, tingling, numbness and muscle weakness. It is a medical condition resulting from direct exertion of pressure on the nerves (Black, Brindle & Honaker, 2016). Localized structural changes and microvascular function interferences cause dysfunction of peripheral-nerves (Kastenschmidt, Mannaa, Muñoz & Villalta, 2019).
ICD-10-CM Diagnosis Code S84.02XD Immune System Regulation of Muscle Injury
Pertinent positives
muscle injury;
pain
Pertinent negatives
Broken bone
References

Kastenschmidt, J. M., Mannaa, A. H., Muñoz, K. J., & Villalta, S. A. (2019). Immune System Regulation of Muscle Injury and Disease. In Muscle Gene Therapy (pp. 121-139). Springer, Cham.

Hamilton, B., Pollock, N., Reurink, G., de Vos, R. J., Purdam, C., & Thorborg, K. (2020). Muscle Injury Classification and Grading Systems. In Prevention and Rehabilitation of Hamstring Injuries (pp. 189-198). Springer, Cham.

Bengtsson, H., Ekstrand, J., Waldén, M., & Hägglund, M. (2017). No difference in muscle injury rates during professional football matches preceded by three to five days of recovery. British Journal of Sports Medicine, 51(4), 294-294.

Black, J. M., Brindle, C. T., & Honaker, J. S. (2016). Differential diagnosis of suspected deep tissue injury. International wound journal, 13(4), 531-539.

ICD10data. (2018). The Web’s Free 2019/2020 ICD-10-CM/PCS Medical Coding Reference. Retrieved from https://www.icd10data.com/

Sataloff, R. T. (2019). Patient history. Obesity and Voice, 65.

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Immune System Regulation of Muscle Injury