Approach to MSK Pain Flashcards
How are (i) articular (ii) periarticular and (iii) non-articular cause of MSK pain differentiated?
1) Location
- A: in joint
- P: near joint
- N: “All over”
2) Pain on movement
- A: in all directions
- P: in some directions
- N: unrelated
3) Passive and active movement
- A: Active=Passive
- P: Active > Passive
- N: Unrelated
What are some characteristics of MSK pain that allude to a referred pain pathology?
1) Visceral
2) Colic
3) Joint above/below affected
What are some characteristics of MSK pain that allude to a vascular pathology?
1) Limb claudication
2) Ischaemic pain at rest
3) Features of peripheral vascular disease (eg. absent/weak pulse, ulcers)
What are some characteristics of MSK pain that allude to a neurological pathology?
1) Burning/electric shock in character
2) Numbness/weakness
3) Specific distribution (eg. hand in carpal tunnel syndrom, back in radiculopathies eg. PID, Cauda Equina)
What are 10 anatomical causes/sites of joint pain?
Ben & - Bone
Jerry’s - Joint
Makes - Muscle
Truly - Tendon
Luscious - Ligament
Beautiful - Bursa
Fancy - Fascia
Snacks - Skin and soft tissue
Really - Referred
Very - Vascular
Nice - Neurologic
What are 8 rheumatic causes of inflammatory articular MSK pain?
Inflammatory Arthritides:
1) RA
2) Crystal arthropathies (Gout, CPPD)
3) Spondyloarthropathies (eg. AS, PsA, IBD related, ReA)
Connective tissue diseases:
4) SLE
5) Sjogren’s syndrome
6) Systemic sclerosis
7) Idiopathic inflammatory myopathies
8) Mixed CTD
Others:
9) Vasculitis
10) Polymyalgia Rheumatica
11) Sarcoidosis
12) Adult Onset Still’s Disease
What are 4 infective causes of inflammatory articular MSK pain?
Direct infection (Septic arthritis):
1) Bacterial: SA, Gonococcus, GBS, TB
2) Fungal
Indirect infection:
3) Viral: Parvovirus B19, HIV, Hep B/C
4) Bacterial: TB, Whipple’s disease Lyme disease
What are 2 mechanical causes of articular MSK pain?
1) OA
2) Trauma (± hemarthrosis, fracture)
What is an endocrinological cause of articular MSK pain?
1) Haematochromatosis
2) Hyper/Hypocalcemia
What is a neuropathic cause of articular MSK pain?
Charcot’s joint
What are 3 tendon/ligament causes of periarticular MSK pain?
1) Tendonitis/Tenosynovitis
2) Ligamentous sprain
3) Tear/rupture
What are 2 bursae causes of periarticular MSK pain?
1) Bursitis
2) Rupture (eg. Baker’s cyst)
What are 2 soft tissue causes of periarticular MSK pain?
1) Cellulitis
2) Oedema
What are 4 bone causes of periarticular MSK pain?
1) Fracture
2) Tumour
3) Infection (Osteomyelitis)
4) Avascular necrosis
What are 3 muscular causes of periarticular MSK pain?
1) Contusion
2) Localised myositis
3) Myofascial pain syndrome
What are 2 vascular causes of non-articular MSK pain?
1) Peripheral vascular disease
2) Acute limb ischaemia
What are 3 neurological causes of non-articular MSK pain?
1) Compressive neuropathies
2) Spinal cord compression/Cauda Equina syndrome
3) Complex region pain syndrome
What are 3 systemic causes of diffuse pain?
1) Infection
2) Inflammatory
3) Malignancy
What are 3 endocrine/metabolic causes of diffuse pain?
1) Osteomalacia
2) Paget’s disease of bone
3) Hypo/Hyperthyroidism
4) Hyperparathyroidism
What are 2 pharmacological causes of diffuse pain?
1) Statins
2) Bisphosphonates
3) Aromatase inhibitors
What are 10 DDx for diffuse pain?
DIRECTION:
Degenerative
- Generalised OA
Infection
- Viral, bacterial, endocarditis
Rheumatic
- Crystal arthopathies
- RA
- CTDs
- PMR
- Vasculitides
Endocrine
- Hypothyroidism
- Hyperparathyroidism
- Hyper/hypocalcemia
- Paget’s
- Addison’s
Congenital
- Joint hypermobility syndrome
- Metabolic myopathies
Traumatic
Iatrogenic
- statins, bisphosphonates, aromatase inhibitors
Ouch (psych/neuro)
- Depression, Anxiety
- Multiple sclerosis, neuropathic pain
- Fibromyalgia, Myofascial pain syndrome
Neoplastic
- solid organ, haematological cancers
- bony metastases
What does a burning MSK pain indicate?
Inflammatory processes
Inflammatory or non-inflammatory?:
Pain worse in morning
Inflammatory
Inflammatory or non-inflammatory?:
Pain worse at end of day
Non-inflammatory
Inflammatory or non-inflammatory?:
Wakes up in middle of night due to pain
Unlikely non-inflammatory
Inflammatory or non-inflammatory?:
Pain worse after prolonged rest
Inflammatory
Inflammatory or non-inflammatory?:
Pain worse after activity
Non-inflammatory
How does the classic description of stiffness differ in inflammatory vs non-inflammatory causes?
Inflammatory
- >1hr
- better w activity
Non-inflammatory:
- <30min
- recurrent after rest
Which joint is most commonly affected in gouty podagra?
1st MTPJ
What are 2 distributive features of Spondyloarthropathies?
1) Enthesitis (eg. achilles tendonitis)
2) Dactylitis (Sausage-like swelling of digits)
What is a MSK disorder that is associated with the following extra-articular manifestations:
i) Raynaud’s
ii) Alopecia
iii) Oral ulcers
iv) Sicca symptoms (dry mouth and eyes)
v) Frothy urine
Connective tissue disease
eg. SLE
What is a MSK disorder that is associated with the following extra-articular manifestations:
i) Dry cough
ii) SOB
Interstitial lung disease
A/w: RA, Systemic sclerosis, Inflammatory myopathies
What is a MSK disorder that is associated with the following extra-articular manifestations:
i) Red eyes
ii) Photophobia
iii) Eye pain
iv) Vision blur
Uveitis
A/w: SpA
What is a MSK disorder that is associated with the following extra-articular manifestations:
i) Epistaxis
ii) Sinusitis
iii) Haematuria
iv) Haemoptysis
Vasculitis
In a patient with lower back pain, what is the most likely cause given:
1) Hx of preceding fall/trauma
2) Risk factor for osteoporosis including advanced age, corticosteroid use
Vertebral fracture
In a patient with lower back pain, what is the most likely cause given:
- pain is worse with bending forwards, coughing, sneezing
Discogenic pain
In a patient with lower back pain, what is the most likely cause given:
- constitutional symptoms
1) Infection
2) Malignancy
3) Inflammatory
In a patient with lower back pain, what is the most likely cause given:
- Hx of IVDU
Infection:
- spondylodiscitis/ osteomyelitis
In a patient with lower back pain, what is the most likely cause given:
- Hx of malignancy or symptoms suggestive of cancer?
Bony metastasis to the spine
In a patient with lower back pain, what is the most likely cause given:
- pain that radiates down leg
- numbness/tingling in legs
- positive straight leg raise test
L4/L5/S1 nerve root impingement (radiculopathy)
In a patient with lower back pain, what is the most likely cause given:
i) Weakness of lower limbs
ii) Difficulty walking/inability to walk
iii) Bladder/bowel incontinence/Urinary retention (LUTS)
iv) Reduced sensation around anal region
v) Reduced anal tone on DRE
Spinal cord compression / Cauda Equina syndrome
