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?
Passive movement, where the practitioner moves the joint while the person is relaxed, often shows a wider range than what the person can do on their own (active movement). This is because passive movement doesn’t rely on the person’s own muscles and nerves. If there’s a problem during passive movement, like reduced range or pain, it likely points to an issue with the joint itself, such as inflammation, bony deformity, or a foreign body.
On the other hand, active movement involves the person using their muscles and tendons. So, if there’s a problem during active movement, like reduced range or pain, it’s more likely related to an issue with the muscles or tendons. This distinction helps healthcare professionals pinpoint whether the problem lies within the joint or the surrounding muscles and tendons, guiding further assessment and treatment.
What is the WHO pain ladder? What cautions are needed in applying this to chronic MSK pain?
The WHO pain ladder was originally developed for acute pain and advocates stepwise use of simple analgesia (e.g.
paracetamol), non-steroidal drugs (e.g. ibuprofen) and stronger analgesics (e.g. opiates). It has also been used to
manage cancer pain.
It can be problematic in chronic pain due to (i) risks of side-effects and habituation with prolonged regular use of
analgesics; (ii) risk of addiction to opiates; (iii) risk of neglecting non-pharmacological options in treatment and
rehabilitation (e.g. physiotherapy) and psychological/pain management approaches.
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 metatarsalgia, what would make you
suspect a Morton’s neuroma?
Plantar Fasciitis:
Symptoms:
- Heel pain, typically worse in the morning or after periods of rest.
- Pain that improves with activity but worsens again after prolonged standing or walking.
Typical Patient:
- Middle-aged adults, especially those who are overweight or have jobs requiring prolonged standing or walking.
Risk Factors:
- Obesity or sudden weight gain.
- Overuse or repetitive stress on the feet, such as running or standing for long periods.
- Flat feet or high arches.
Morton’s Neuroma:
Symptoms:
- Morton’s neuroma – patient presenting with typical pain and pain
distribution expected in Morton’s neuroma (sharp pain + pebble feeling in the 3rd intermetatarsal space) which is aggravated by walking.
- Pain worsens with walking or wearing tight shoes and improves with rest.
Typical Patient:
- Women, particularly those who wear high heels or narrow-toed shoes.
Risk Factors:
Wearing tight or high-heeled shoes that compress the toes.
Activities that involve repetitive pressure on the forefoot, such as running or jumping.
Certain foot deformities, such as bunions or hammertoes, which can increase pressure on the nerves.
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?
Certainly! Here are the key features on history and examination that help identify radicular back pain:
History:
Pain radiating down one leg (unilateral)
Described as sharp, shooting, or electric shock-like
May be worsened by certain movements or positions, such as bending forward, coughing, or sneezing
Associated with back pain, which may or may not be as severe as the leg pain
May have a history of previous back injury or trauma
Examination:
Observation: May note antalgic gait (limping) due to pain
Palpation: Tenderness along the spine, especially at the level of nerve root involvement
Neurological examination:
Sensory deficits: Reduced sensation or abnormal sensations (e.g., tingling, numbness) along the affected nerve distribution
Motor deficits: Weakness in specific muscle groups supplied by the affected nerve
Reflexes: Diminished or absent deep tendon reflexes corresponding to the affected nerve root
Special tests: Positive findings on tests such as straight leg raise (Lasegue’s sign) or crossed straight leg raise, which reproduce or exacerbate leg pain when the leg is raised while the person is lying down
These features collectively suggest radicular back pain, indicating compression or irritation of a spinal nerve root.
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.
How long do you use steroids for in polymyalgia rheumatica?
1-2 years
