Likely and differential diagnoses (NMSKP)

Question 1

Hip 1:
A 65 year old man and has had a (R) sided Total hip replacement (THR) 2 weeks ago. He had mild Congenital Dislocation of the hip (CDH) as a baby but has always tried to remain fairly active. He has made reasonable progress and is now walking with one stick, but he is currently walking with a limp and has reduced weight-bearing on the (R) side.

Answer 1

Likely:
soft tissue injury due to incision

Differentials:
THR fracture healing
congenital hip dysplasia
osteoarthritis

Question 2

Hip 2:
A 55 year old teacher has been complaining of pain and clicking in her right hip since she fell earlier in the year whilst running. She described twisting her hip at the time and has noticed some clicking and occasional giving way every time she has tried to run since. She is very frustrated as running is her way of managing her stress.

Answer 2

Likely:
Labral tear

Diffs:
FAI
Ligament tear

Question 3

Hip 3:
An amateur Taekwondo athlete injured her left leg during a competition 5 days ago. She experienced a sudden sharp pain in the groin area whilst doing a high kick against her opponent. She was unable continue fighting and applied ice immediately. Slight bruising has started to appear along the inside of her thigh and it is painful on movement.

Answer 3

Likely:
Adductor tear

Diffs:
Hip flexor tear
tendon rupture
labral tear

Question 4

Knee 1:
A 23 year old male patient has suffered a valgus injury to his left knee 1 week ago. The knee swelled within 10 minutes of the injury. The knee remains slightly swollen although this has almost settled. He has some restriction to knee joint flexion. There is little pain present. He hopes to return to playing squash and tennis as soon as possible.

Answer 4

Likely:
ACL

Diffs:
MCL
Meniscus

Question 5

Knee 2:
A 76 year old lady presents with difficulty walking. She complains of difficulty balancing and has nearly fallen on a couple of occasions. In addition the knees feel stiff especially following periods of rest. She also complains of constant pain in her knees which worsens immediately when weight bearing (standing/ walking). X-rays organised by her General Practitioner (GP) show that she has moderate osteoarthritis in the joint.

Answer 5

Likely:
Osteoarthritis

Diffs:
Rheumatoid
Meniscal tear
weakened/shortened muscle

Question 6

Knee 3:
A 16 year old female patient is complaining of bilateral anterior knee pain. She is a keen cross country runner. Pain (moderate intensity) developed after a fell race which involved a lot of uphill and downhill running and is now present when going up or down stairs or hills. She denies any injury at the time of onset. There is no obvious swelling present and the knee does not ‘lock’ or ‘give way’. She has noticed some clicking/crepitus in the knee.

Answer 6

Likely:
Patellofemoral pain syndrome

Diffs:
Patella tendinopathy
Stress/avulsion fracture
osgood schlatters

Question 7

Ankle 1:
An amateur basketball player ‘went over’ on her ankle when landing from shooting a basket 2 days ago. She went to A&E but was diagnosed as having NBI (no bony injury) but a severe sprain. She was given a tubigrip and crutches and advised to rest and referred to physio clinic. O/E the right ankle is extremely swollen, hot and red with bruising appearing along the posterior aspect of the calf and lateral border of the foot. She is struggling to even walk and worried about having time off work. She works on the shop floor at a packing warehouse.

Answer 7

likely:
ATFL sprain

Diffs:
avulsion fracture
peroneal tendon tear/rupture
compartment syndrome
Calcaneofibular/PTFL ligs

Question 8

Ankle 2:
A 45 year old club distance runner C/O worsening pain in his right Achilles. The pain has come on gradually over a period of several months. The pain was mild initially when running but is getting worse and is now tender on a morning when he gets out of bed. On palpation the tendon feels thickened. He has a big race coming up in a month.

Answer 8

likely:
achilles tendinopathy

diffs:
severs apophysitis

Question 9

Foot 1:
A mother brings her 8 year old son to see you as he is complaining of pain at the back of his heels when he gets out of bed on a morning and also when running and playing rugby. It started in his left foot but is now starting in his right. O/E he is slightly ‘flat footed’ and both calcaneal apophysis are painful on palpation and pain is reproduced on squeezing the heels.

Answer 9

Likely:
severs apophysitis

diffs:
achilles tendinopathy
calcaneal fracture
plantar fasciopathy

Question 10

Foot 2:
A professional footballer is C/O lateral mid foot pain of several weeks duration They describe this as an aching feeling and can feel a click when stepping O/E there is evidence of moderate swelling forming over the lateral aspect of the foot and there is marked tenderness along the 5th metatarsal. The patient is now struggling to train and play.

Answer 10

likely:
stress fracture/ jones

diffs:
avulsion facture
ligament tear

Question 11

Shoulder 1:
An amateur rugby player has been complaining of localised pain on the top of his left shoulder after sustaining an injury during a tackle 1 week ago. He has pain on shoulder flexion, which gets worse the higher he lifts his arm, and when rolling over onto the left side in bed. He is also unable to do any press ups due to the pain.

Answer 11

likely:
ac sprain/dysfunction/fracture

diffs:
clavicle fracture
sublaxation
dislocation
rc tear

Question 12

Shoulder 2:
A 50 year old woman is complaining of severe pain around the anterior and superior aspect of her right shoulder. She had a gradual onset of pain 1 week ago, 24 hours after repeatedly throwing a ball for her dog for about 1 hour. She is now unable to lift her arm more than 30 degrees away from her body into flexion or abduction or extension, and is struggling to sleep. The GP has suggested painkillers and rest but this is not helping. Sue does not work but is normally very fit and well. She is keen to return to the gym

Answer 12

likely:
rc tear/SA impingment

diffs:
bursitis
subacromial impingement 
tendinopathy
SLAP tear
deltoid tear/strain

Question 13

Shoulder 3:
An 18 year old skateboarder who fell and dislocated his left shoulder 4 weeks ago. This is the second time he has sustained this injury in the last 2 years. He failed to attend his outpatient physiotherapy appointments after the initial injury. This time he reports that he removed the sling he was given after 1 week. He now has little pain and has regained full flexion abduction and medial rotation. However he reports some clicking in the joint when lowering from full elevation, and it feels unstable at the end of medial and lateral rotation.

Answer 13

likely:
instability due to dislocation assoc labral tear or RC instability

diffs:
labral tear
rc tear
ligament tear

Question 14

Elbow 1:
A 24 year secretary has come to see you C/O a gradual onset of pain over the lateral aspect of her left elbow, over the last 6 months. She doesn’t remember doing anything to injure her elbow, but is having increasing difficulty typing. She is left handed and is finding gripping activities increasingly painful and weak. She is worried about needing time off work.

Answer 14

likely:
lateral (tennis) epicondylitis

diffs:
RSI
ligament?

Question 15

Elbow 2:
Your next patient is a 55 year old horse rider who has had ORIF (Open Reduction Internal Fixation) of her fractured right olecranon 6 weeks ago. Her pain levels are 3/10 at worst, but she is struggling to regain the last 30’ of full extension, which feels “very stiff and blocked”. She has returned to her job in an office, but is wary of carrying any bags in the right hand, and is keen to return to horse riding.

Answer 15

likely
ORIF fracture healing - joint stiffness/ muscle tightness

diffs:
muscle weakness
osteoarthritis?
bone spurs?

Question 16

Elbow 3:
A 65 year old man has managed his Rheumatoid Arthritis (RA) for 30 years. He walks with 2 sticks normally, but recently he has had a flare up of his symptoms, which is making it difficult to use his sticks. He complains of 7/10 pain, which is worse following movement, and the elbow joint is swollen and hot. He is losing ROM of both flexion and extension, and activities of daily living are becoming increasingly difficult.

Answer 16

likely:
rheumatoid symptoms

diffs:
?
muscle length and strength issues?

Question 17

Wrist/Hand 1:
A 70 year old lady sustained a fractured right distal radius and ulna following a fall 6 weeks ago. She has been conservatively managed in a cast for 4 weeks and has now been referred to you with pain and dysfunction. She is the main carer for her 77 year old husband who has chronic lung disease. She is normally fit and active, enjoying baking and gardening.

Answer 17

likely:
muscle weakness/tightness? traumatic soft tissue?/nerve damage?

diffs:
osteoporosis 
traumatic soft tissue
scaphoid injury 
TFCC
carpal tunnel

Question 18

Wrist/Hand 2:
A 24 year old male complains of right sided wrist pain following a FOOSH injury whilst Snowboarding in France 2 weeks ago. They explain their symptoms to be on the central, anterior wrist crease extending to the ulnar aspect. They report painful weight-bearing through the R upper limb and also report some painful crepitus on the palmar/ulnar aspect. Went to A&E on holiday. X ray showed NBI. Advised to rest and take painkillers by A&E. Stiff first thing in the morning.

Answer 18

likely:
tfcc

diffs:
scapholunate instability
tendon/ lig injury
carpal tunnel

Question 19

Wrist/Hand 3:
A 73 year old widower is complaining of pain in the base of his Right thumb. He is very fit and active and has always participated in hiking and walking. He doesn’t remember doing anything to bring on the pain, but now rates it as between 4 – 7/10 most of the time. He is struggling to pull his rucksack on to his shoulder and turn his key in the lock.

Answer 19

likely:
de quervains

diffs:
scaphoid fracture
cmc OA

Question 20

Wrist/Hand 4:
Your next patient works as a joiner and had a fasciotomy for dupuytren’s contracture of his right ring finger 3 weeks ago. He has been apprehensive about moving his hand since the surgery, and is still unable to make a full fist. He has been wearing his resting splint for 24 hours a day, and the consultant has now told him to remove it during the day. He is keen to return to work.

Answer 20

likely:
dupuytrens soft tissue healing

diffs:
nerve/tendon?