MSK Flashcards
What is ‘synovitis’ and what does it indicate?
Synovitis is inflammation (swelling, pain, and warmth) of a synovial membrane. It can be a feature of arthritis in which there is active inflammation. Common causes include rheumatoid arthritis and gout. It can sometimes occur in osteoarthritis where the degenerative process has caused some inflammation.
Define ‘stiffness’ and explain the clinical significance of ‘early morning stiffness’?
Stiffness is slowness or difficulty moving one or more joints. Early morning stiffness is used to describe stiffness on getting out of bed or staying in one position. It is an indicator of inflammatory arthritis. Stiffness which is generalised and lasts > 30 mins on waking is a feature of rheumatoid arthritis.
What are the likely causes of limited or painful active movement but with full, pain-free passive movement?
The range of passive movement of a joint (when the practitioner moves the joint with the person relaxed) is usually higher than what the person can achieve themselves through active movement.
As passive movement does not require the person to use their own nerves, muscles and tendons to produce movement, a reduction in passive range or pain on passive movement indicates a problem with the joint itself (e.g. foreign body, bony deformity, inflammation, contracture).
In active movement (when the patient moves the joint), muscles and tendons to be functioning. Therefore, a problem with the muscles and tendons would cause reduced range of active movement and/or pain on active movement only.
What is the WHO pain ladder? What cautions are needed in applying this to chronic MSK pain?
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 such as locking or catching of the knee on movement were traditionally thought to indicate a ‘mechanical’ problem with the knee such as a loose body or meniscal tear obstructing movement. More recently, this view has been challenged and it appears that these symptoms are quite common in knee disease, even without any obvious obstruction.
What is bursitis of the knee and how would you differentiate this from a knee effusion?
Like other joints, the knee is surrounded by small fluid-filled sacs (called bursae) which reduce friction between moving tendons and provide cushioning for the joint. By contrast, a knee effusion is swelling due to excess synovial fluid in the joint capsule itself. In a knee effusion, fluid can be moved across the knee (the ‘bulge’ test) and pressure over the patella causes the fluid to move (causing a ‘patellar tap’). In bursitis, the swelling is localised to the bursa that is affected – for example, an infra-patellar swelling in prepatellar or infrapatellar bursitis.
Which causes of hip pain would tend to produce pain in the anterior, lateral and posterior hip area?
Certain locations of hip pain are more typically associated with particular pathology. For example:
- ‘True’ hip pain (e.g. from osteoarthritis) - anterior to the groin. - ‘Trochanteric bursitis) – laterally in the hip. - Posterior/posterolateral pain - lumbosacral spine or gluteal muscles.
This can be useful in guiding further questions and clinical examination to identify the anatomical source of the patient’s symptoms.
What are the clinical features of plantar fasciitis and metatarsalgia? In metatarsagia, what would make you suspect a Morton’s neuroma?
Plantar fasciitis typically causes pain at the insertion of the plantar fascia into the calcaneum. It tends to occur in people who spend a lot of time on their feet; often the pain is marked with the first few steps on getting out of bed and then worsens again to the end of the day.
Metatarsalgia is pain in the mid-foot and has a wide range of causes. In Morton’s neuroma, the classic finding is tenderness in the inter-digital space where the neuroma is located.
What are the clinical features of gout? Which joint(s) are most often affected? What are the management options for an acute episode? What preventative treatment may be given?
Gout is a form of inflammatory arthritis due to uric acid crystal deposition in the joint. It most commonly affects the great toe (but can affect other joints). It is often recurrent. Quite rapid onset of severe pain, often with quite marked swelling and evidence of inflammation of the joint.
What features on history and examination help identify ‘radicular’ back pain?
Radicular back pain is caused by irritation or impingement of a nerve root. It is typically felt in the dermatomal area supplied by the foot. For example, in sciatica (the commonest pattern) the pain radiates to the buttock and posterior leg; and is often worse when the sciatic nerve is stretched (e.g. in a straight leg raise test). The pain is often described as ‘shooting’ or ‘numb’ and there may be other neurological symptoms (e.g. weakness, ankle hyporeflexia).
What is a ‘painful arc’ in the shoulder and what does this indicate?
Painful arc is pain in the mid-range (45 – 120 degrees) of abduction of the shoulder (I.e. movement in the scapular plane) which eases at greater range of abduction. It indicates impingement of the shoulder (catching of rotator cuff tendons or shoulder bursae) in the sub-acromial space with movement. The pain tends to be more pronounced on active than passive movement.
Besides shoulder pathology, what other problems might present with pain in one or both shoulders?
A wide range of conditions including: referred pain from the neck (e.g. cervical spine radiculopathy), cardiac problems (e.g. MI, angina); lung problems (e.g. Pancoast’s tumour); diaphragmatic pain (e.g. right shoulder pain from liver enlargement); polymyalgia rheumatica (bilateral).
How do the typical appearances of osteo- and rheumatoid arthritis in the hands differ?
Osteoarthritis: commonest sign in the hands is Heberden’s Nodes (on distal IP joints). Bouchard’s nodes (on proximal IP joints are less oommon).
Rheumatoid: in acute episodes, the proximal IP, metacarphalangeal and wrist are commonly affected. In chronic disease, you may see ulnar deviation of the fingers, “swan neck” and “boutonniere” deformities.
In the elbow, when would you diagnose tennis elbow, golfer’s elbow and olecranon bursitis?
Tennis elbow is lateral epicondylitis. Suspect if pain in lateral elbow with tenderness over the common extensor origin.
Golfer’s elbow is medial epicondylitis. Suspect if pain in medial elbow with tenderness over the common flexor origin.
Olecranon bursitis: suspect if fluctuant (usually non-painful) swelling over the olecranon process of the elbow.
