MSK Flashcards
Differential diagnosis for lower back pain?
✔️ muscle strain ✔️ herniated disk ✔️ osteoarthritis ✔️ osteoporosis (crush fracture) ✔️ ankylosing spondylitis ✔️ cauda equina syndrome ✔️ metastatic cancer (e.g. prostate) ✔️ psychological / depression
What are some red flag symptoms for lower back pain?
✔️ patient > 50 years or < 20 years of age
✔️ personal Hx of cancer, particularly prostate cancer
✔️ unexplained fever
✔️ associated B symptoms (e.g. night sweats, weight loss)
✔️ changes to urinary or bowel habits
✔️ abnormal sensation (e.g. saddle parasthesia)
✔️ constant pain; night pain
✔️ anticoagulant use (suggestive of retroperitoneal hematoma)
What are some yellow flag symptoms for lower back pain?
✔️ unable / refusal to return to work ✔️ not responding to treatment ✔️ abnormal illness behaviour ✔️ compensation issues ✔️ atypical pain
Differentiate between INFLAMMATORY / MECHANICAL causes for lower back pain.
INFLAMMATORY CAUSES ✔️ insidious / chronic onset ✔️ aching / throbbing ✔️ prolonged stiffness ✔️ relieves with movement; exacerbated with rest ✔️ morning stiffness
MECHANICAL CAUSES
✔️ acute onset; known precipitant
✔️ deep, dull ache; sharp if compression a nerve
✔️ moderate / transient stiffness
✔️ exacerbated with movement; alleviated with rest
✔️ most intense @ end of day / after movement
Outline key components of history for lower back pain.
- History of presenting complaint –> SOCRATES
- Red flag features
- PMHx and PSHx
- Medications
- Family Hx
- Social Hx –> SNAP
Outline the key components of examination for lower back pain.
- Inspection
- Passive movement –> forward flexion, extension, lateral flexion
- Provocative tests –> femoral nerve stretch, straight leg raise
- Palpation –> spine, paravertebral muscles
- Neurological Examination –> L3, L4, L5, S1
✔️ L3 –> extension of the knee
✔️ L4 –> flexion of the knee
✔️ L5 –> dorsiflexion
✔️ S1 –> plantar flexion
Outline key investigations for management of lower back pain?
✔️ FBC + WCC ✔️ Inflammatory markers ✔️ UECs + eLFTs (to check ALP) ✔️ coagulation studies ✔️ Vitamin D levels (25-hydroxy Vitamin D) ✔️ CMP ✔️ androgen levels ✔️ bone mineral density (Z Score) ✔️ Plain X Ray (not always indicated)
Indications for ordering a plain X ray for investigation of lower back pain?
✔️ history of cancer
✔️ significant trauma
✔️ unexplained weight loss (4.5kg in < 6 months)
✔️ temperature > 37.8°C
✔️ risk factors for infection
✔️ neurological deficit
✔️ minor trauma in patients (a). < 50 years of age (b). osteoporosis (c). taking corticosteroids
✔️ no improvement / response to treatment for one month
Risk factors for OSTEOPOROSIS?
✔️ female ✔️ post-menopausal / no oestrogen ✔️ low BMI ✔️ physical inactivity ✔️ poor nutrition / malabsorption ✔️ low Ca++ and Vitamin D levels ✔️ hypogonadism ✔️ corticosteroid use (e.g. prednisolone) ✔️ family Hx of osteoporosis
What is OSTEOPOROSIS?
Osteoporosis is clinically defined as a T score of < -2.5 based on DEXA / bone mineral density test and / or a fragility fracture is present.
T score < -1.5 is called osteopenia
Signs / symptoms of osteoporosis?
✔️ mainly asymptomatic
✔️ may develop pathological fragility fractures (e.g. crush fractures of the spine)
Outline appropriate investigations for OSTEOPOROSIS.
✔️ FBC + WCC ✔️ Inflammatory markers ✔️ UECs + eLFTs (particularly ALP) ✔️ CMP ✔️ 25-hydroxy vitamin D levels ✔️ TFTs ✔️ PTH levels ✔️ Plain X Ray ✔️ DEXA scan (bone mineral density)
Outline appropriate management (conservative and medical) for OSTEOPOROSIS.
- Confirm diagnosis with appropriate investigations.
- Adjust medications. Cease medications that may exacerbate condition (e.g. glucocorticoids).
- Calcium and Vitamin D supplementation.
- Bisphosphonate therapy (oral)
- Androgen therapy (oestrogen for women, testosterone for men)
- Monoclonal antibody infections (denosumab)
- Encourage moderate physical activity.
- Analgesia as appropriate.
When would it be appropriate to refer a patient with lower back pain?
✔️ suspicious for malignancy ✔️ Paget's disease ✔️ undiagnosed back pain ✔️ neoplasm or infection ✔️ spinal fractures ✔️ myopathy ✔️ Cauda equina syndrome
Differential diagnoses for SHOULDER PAIN?
✔️ rotator cuff tear ✔️ rotator cuff impingement ✔️ bursitis ✔️ osteoarthritis ✔️ rheumatoid arthritis ✔️ polymyalgia rheumatica (bilateral shoulder pain + temporal arteritis) ✔️ gout / pseudo gout
