Clinical Nuggets Flashcards
What is ‘synovitis’and what does it indicate?
Synovitis is when the synovium (connective tissue that lines the joint capsule) of a joint becomes inflamed (swollen).
Causes: overuse of the joint, inflammatory arthritis - more common with RA than OA.
Define ‘stiffness’ and explain the clinical significance of ‘early morning stiffness’?
Joint stiffness is the sensation of difficulty moving a joint or the apparent loss of range of motion of a joint
Morning stiffness is a cardinal sign of inflammatory arthritis that can appear even before pain and may be related to the accumulation of edema fluid within inflamed tissues during sleep.
Morning stiffness is a very common complaint of patients with RA and is experienced as soreness and restricted movement upon awakening. This feeling is generalized in distribution and does not simply affect the joints. Although it is a form of pain, patients may not describe it as such.
What are the likely causes of limited or painful active movement but with full, pain-free passive movement?
Active - reduced if there is pain, muscular weakness and altered nerve pathways or a foreign object blocking the movement
Passive - This would eliminate the cause being due to structures which produce the movement such as muscle action.
Passive range of movement may be decreased due structures and which to swelling, bony abnormalities and foreign objects within the joint.
What is the WHO pain ladder?
What cautions are needed in applying this to chronic MSK pain?
WHO analgesic ladder proposes that treatment of pain should begin with a nonopioid medication. If the pain is not properly controlled, one should then introduce a weak opioid. If the use of this medication is insufficient to treat the pain, one can begin a more powerful opioid.
Often longer term use of NSAID’s can cause gastric, renal and anti-platelet side-effects. There is a move to weaker opioids but this brings the problem of addiction.
What are ‘mechanical’ symptoms’ of the knee?
What have they traditionally been thought to represent and is there any evidence to contradict this view?
Symptoms of ‘catching’ and/or ‘locking’ of the knee are typically considered to be of mechanical origin, caused by something being trapped or stuck inside the knee that can be removed with surgery. Preoperative mechanical knee symptoms are defined as self-reported catching/locking or self-reported inability to straighten knee fully.
If mechanical symptoms are present in combination with a meniscal tear confirmed on MRI the symptoms are generally considered to originate from the tear, providing a strong rationale for meniscal surgery. However, surgery does not relieve these symptoms better than placebo surgery or result in larger improvements in pain and function compared to patients without mechanical symptoms and degenerative meniscal tears.
What is bursitis of the knee and how would you differentiate this from a knee effusion
Knee bursitis is inflammation of a small fluid-filled sac situated near your knee joint.
Bursitis tends to be more painful. Bursitis may not show a positive patella sweep test
Which causes of hip pain would tend to produce pain in the anterior, lateral and posterior hip area?
Posterior- referral from the lumbar spine and sacroiliac joint (SIJ), proximal hamstring tendinopathy, sacral stress fractures, piriformis syndrome
Lateral - tendinosis of the gluteus medius and minimus and thickening of the iliotibial band
Considerable overlap exists between sources of posterior and lateral hip pain.
Anterior - OA of the femoroacetabular joint - elderly, acetabular labral tears in a young patient with anterior hip pain, iliopsoas impingement and internal snapping hip; stress fractures of the femoral neck, pubic rami, or acetabulum
Plantar Fasciitis
Symptoms?
Metatarsagia
Symptoms?
In metatarsagia, what would make you suspect a Morton’s neuroma?
Plantar fasciitis typically causes a stabbing pain in the bottom of your foot near the heel. The pain is usually the worst with the first few steps after awakening, although it can also be triggered by long periods of standing or when you get up after sitting. The pain is usually worse after exercise, not during it.
Metatarsagia typically causes a burning or aching sensation or a shooting pain, tingling or numbness in the toes or a feeling like there’s a small stone stuck under the foot.
Neuroma - There is no pain with range of motion of the metatarsophalangeal joints or with palpation of the plantar metatarsal heads.
You have successfully ruled out toe joint disorders. Palpation into the third intermetatarsal space. If there is any pain, then this is consistent with a joint problem.
Gout
What? Which joints? Symptoms? Diagnosis? Managment?
Inflammatory arthritis – monosodium urate crystals because of hyperuricemia.
1st MTP, elbows, knees, wrists, fingers.
Episodic, flares for days or weeks bought on by triggers like stress, illness, or dehydration, purine rich foods. Main cause is alcohol and weight
Joint aspiration and microscopy showing the crystals in synovial fluid. X-ray may show swelling.
NSAID’s. If present with extra-articular features (like in gouty tophi or uric acid nephropathy), prescribe prophylactic agents like allopurinol (urate lowering therapy) for prevention.
Colchacine given with allopurinol for the first 6mnths. Once daily and is a lifelong medication. Monitor every 4 weeks until target serum uric acid level is reached.
Don’t stop if acute attacks, allopurinol can make the acute attacks more frequent to start with but can be controlled wit NSAID’s.
Stop smoking, control alcohol, weight loss, avoid sweetners, avoid purine rich foods, low fat yoghurts, Vit C supplements
What features on history and examination help differentiate ‘mechanical’ and ‘radicular’ back pain?
Mechanical pain is confined to one spot or region. It may be described a number of ways, such as sharp or dull, comes and goes, constant, or throbbing. A muscle strain is a common cause of axial back pain as are facet joints and annular tears in discs.
Radicular pain is commonly described as electric shock-like or searing, radicular pain follows the path of the spinal nerve as it exits the spinal canal. This type of pain is caused by compression and/or inflammation to a spinal nerve root. In the lower back (lumbar spine), radicular pain may travel into the leg. Other terms for radicular pain are sciatica or radiculopathy (when accompanied by weakness and/or numbness). It can be caused by conditions such as a herniated disc, spinal stenosis, or spondylolisthesis.
Tennis elbow
What?
Age?
Cause?
Symptoms?
Tennis elbow is a condition in which the tendons that attach the extensor muscles to the lateral epicondyle become painful.
Anybody can develop tennis elbow, but it’s most common between the ages of 40–60.
It’s an over-use injury linked with activities that involve repetitive extension of the wrist and hand
Pain on the lateral epicondyle, increased tenderness when pressure is applied on the outside of the elbow, pain when gripping.
Golfer’s Elbow
What?
Cause?
Symptoms?
Golfer’s elbow affects the medial epicondyle and it doesn’t affect the elbow joint.
Wear and tear in the tendon that attaches the flexor muscles to the medial epicondyle. It isi often caused by repeatedly flexing and twisting your forearm, wrist and hand and a tight grip can make the condition worse.
Pain on the medial epicondyle, pain when gripping
Olecranon bursitis
What?
Cause?
Symptoms?
Olecranon bursitis occurs when the bursa at the back of the elbow becomes swollen and inflamed. When they become inflamed or infected they can become swollen and painful.
Most commonly occurs in people who get repetitive friction over the back of their elbow, for example if you often lean your elbows on a chair or table. Some people who have gout or rheumatoid arthritis can get inflammation of the bursa without any external pressure.
Swelling, pain and warmth over the bony part at the back of the elbow, restricted movement of the elbow.
