MSK Flashcards
When should you consider ulnar nerve compression at elbow?
Also called cubital tunnel syndrome
Pain at the medial elbow, with numbness and tingling in the little and ring fingers.
grip weakness.
loss of hand dexterity.
Can occur from prolonger elbow flexion but also distal humeral fracture
Chronic: 4th 5th finger clawing, hypothenar muscle wasting
Tennis vs golfer’s elbow
Tendonopathy
Tennis: lateral epicondylitis, pain resisted wrist extension
Golfers: medial epicondylitis, pain resisted wrist flexion
Management of tendinopathy (golfers, tennis, achilles)
Progressive loading >12 weeks physio, isometric first,
Modify activity
Ice
Pain relief
Steroid injection 6 weeks pain relief but doesn’t fix problem
Management ulnar nerve compression
If muscle wasting/progressive neurological signs- urgent T+O
Otherwise:
Modify activities
Keep the elbow extended with a soft pad or towel in the antecubital fossa overnight
Neural glides/slides, physio
If persistent paraesthesia, routine T+O ?surgery
Features of carpal tunnel
Median nerve compression
Pain/paraesthesia wrist/hand, worse at night
The patient often shakes their hand or dangles it out of bed to ease the symptoms.
Provoked by flexing (Phalen) or extending wrist, or tapping (Tinel)
May have weakness of hand grip, specifically with thumb abduction and pincer grip.
If severe, thenar muscle wasting
Management carpal tunnel
Modify activities
Wrist splinting at night
Exercises, neural glides
Consider steroid injection
Routine ref T+O ?surgery if:
-Permanent sensory loss
-Motor weakness
-Muscle wasting
-Failure conservative treatment 3 months
What is DeQuervian’s tenosynovitis?
radial-sided wrist pain on flexing and extending the thumb, especially with radial or ulnar deviation.
Abductor pollicis longus and extensor pollicis brevis
Women, age 30-55, esp lifting young baby
Test for DeQuervian’s
Finklesteins Test-
In neutral sup/pronation, adduct the thumb across the patient’s palm and place the wrist into ulnar deviation.
Management DeQuervian’s
NSAIDs
Strengthening exercises
Modify activity
Wrist thumb splint
Consider steroid injection
What are Dupytrens contractors associated with?
Smoking
Alcohol excess
Diabetes
Hypercholesterolaemia
FHx
Peyronies disease
Management Dupytrens
Physiotherapy, splints, exercises, and steroid injections do not appear to alter the course of the problem.
Routine T+O for surgery if impacting job/ADLs/function
When should you consider hand therapy for base of thumb CMCJ OA?
Simple measures and splints not helping and:
Experiencing barriers to recovery.
Loss of strength, range of movement, proprioception, or function.
Pain is a key feature.
Can also consider steroid injection
Referral criteria for ganglion
Ganglion should transilluminate
Routine hand clinic if:
significant pain.
functional impairment affecting ADLs
Pressing on neighbouring structures, e.g. nerves.
Diagnostic uncertainty (USS not usually needed)
What underlying diagnosis could there be with trigger finger?
Usually none
RA, amyloidosis, diabetes, carpal tunnel syndrome, and in patients on dialysis
Referral criteria trigger finger
Urgent hand clinic if:
Finger is locked
Routine hand clinic ?surgery if:
Diabetes
Severe symptoms.
Preference for surgery
Steroid injections fails/not available in GP
Features and management of ACJ pain
Pain over ACJ on scarf test
Rest, NSAIDs
Steroid injection
Physio
Risk factors and phases of frozen shoulder
Age 40-60
Diabetes
Severe pain, esp at night, can radiate down arm
Painful freezing pahse, 3-9m, can’t lie on affected side, stiff, global loss of ROM, steroid injection helps pain
Stiff frozen phase, 3-18m, stiff, pain improves, exercise helps
Recovery thaw phase, stretching pain only, gradual return of function, 12-36m
Examination features of frozen shoulder
Global reductions active and passive movement, pain, external rotation most obvious
Describe 4 step shoulder examination
-Check neck movement, looking for stiffness or pain in the neck or down the arm.
-Identify the acromioclavicular joint and look for tenderness over the joint.
-Identify the glenohumeral joint and check external rotation. Asymmetrical external rotation suggests a glenohumeral joint problem.
-Identify the subacromial space and look for pain on elevation of arm or on resistance. Pain on internal rotation at 90° or a painful arc suggests a subacromial space problem.
What features would suggest glenohumeral joint OA
Age>60
Insidious
Pain variable, related to movement, pain free at rest
Internal and external rotation limited
Crepitus
Features of rotator cuff pathology
Age>35
Limited active but full passive movement
Pain tip of shoulder/lateral deltoid.
Gradual onset.
Painful arc from 70 to 120 degrees of active abduction
Management rotator cuff pathology
Activity modification, self help
Physio 6 weeks
if no improvement steroid injection
Refer routine T+O if no improvement 12w physio/steroid injection or full thickness rotator cuff tear>1 cm
What’s Thompson’s test?
Lie pt prone.
Resting position of injured foot is more dorsiflexed than other side,
Squeeze the calf of the affected leg, looking for normal plantar flexion. Absence of plantar flexion indicates a tendon rupture- admit
Ottowa ankle rules that signify need to do ankle X-ray
Ankle X‑ray series is indicated if there is pain near either of the malleoli and either of the following:
Inability to weight bear both immediately after the injury and when examined acutely (4 steps)
Bone tenderness at the posterior edge or tip of either malleolus
Ottowa ankle rules that signify need to do foot X-ray
Pain in the midfoot and either of the following findings:
Inability to weight bear after the injury and when examined acutely (4 steps)
Bone tenderness at the navicular or the base of the fifth metatarsal
Advice after a sprain
Modify activities according to pain- early mobilisation is important.
Apply ice for 20m every 2hrs for the first 2-3 days after injury.
OTC analgesia. Avoid ibuprofen in the first 48hrs
Elevate ankle when resting.
Use elasticated tubular bandage doubled over to provide compression, and remove at night.
Rehab exercises
(If grade 3 sprain ankle, ED assessment + moon boot)
Risk factors for achilles tendinopathy
Overuse injury
Recreational athletes aged 30-50
Poor running technique
vascular disease, T2DM, inflammatory arthritis
ciprofloxacin, steroids
Features of gout
deposition of monosodium urate crystals within and around joints, acute + chronic inflammation-> joint damage
Pain sudden in onset, peaking 24- 72 hours, resolving over 1-2 weeks
May see gouty tophi joints/ears
Prevention gout
Allopurinol 100–200 mg daily, after food, increase by 100mg increments every 4 weeks, aim urate<360
until tophi and or symptoms resolve.
Co‑prescribe colchicine 500mcg OD-BD for 3-6 months on initiation allopurinol to prevent acute attacks.
Features fibromyalgia
widespread chronic MSK pain, associated with somatic symptoms- poor sleep, cognitive disturbance, headache, fatigue, and stiffness
‘central sensitisation’
Pain processing disorder
Ix for fibromyalgia
FBC, CRP, ferritin, B12, folate, tTG, RF, TFTs, CK, calcium, ANA, anti‑CCP
ACR diagnostic criteria
Management fibromyalgia
Explanation, pain processing disorder not joint disorder
Exercise
CBT
OT/PT
Support groups
Amitriptyline/duloxetine
?chronic pain management clinic
Features inflammatory arthritis
Joint pain, tenderness, and soft tissue swelling
Early morning and inactivity pain and stiffness lasting>30 mins
Improves with activity
Worse at night
Constitutional symptoms (fever, weight loss, fatigue)
Name 4 examples of seronegative spondyloarthropathy
Inflammatory back pain and ankylosing spondylitis (HLA-B27)
Psoriasis and psoriatic arthritis
Inflammatory bowel disease and enteropathic arthritis
Recent enteric or genitourinary infection and reactive arthritis
Referral criteria inflammatory arthritis
Urgent rheumatology if:
Hx + examination strongly suggestive of inflammatory arthritis.
Less suggestive of new inflammatory arthritis, but with positive anti‑CCP Ab result or raised inflammatory markers.
Diagnostic uncertainty + symptoms>6 weeks.
If NSAIDs are contraindicated or not tolerated, or if poor response, seek rheumatology advice to consider prednisolone to manage acute symptoms.
Features PMR
Pain bilateral shoulders, neck, pelvic girdle, on active and passive movements
morning stiffness>45 minutes.
systemic symptoms- anorexia, weight loss, low-grade fever, fatigue
GCA features
Patient aged >50
Symptom duration>2 weeks
Evidence of an acute phase response
Features GCA
New or changed headaches
Scalp tenderness
Jaw claudication
Visual symptoms
Conditions that mimic PMR
Fibromyalgia
Statin induced myalgia
Polymyositis (raised CK, muscle weakness)
RA
Lymphoma/myeloma
Hypothyroidism
Management PMR
Routine ref if age<50 or diagnostic uncertainty or relapses at 10mg
Seek advice if inflammatory markers normal
Prednisolone 15mg/day for 3 weeks, should be dramatic response
Wean: 12.5 mg a day for 3 weeks, then
10 mg a day for 4 to 6 weeks, then
reduce by 1 mg every 4 to 8 weeks
Review regularly incl BP, glucose, U+E, FBC, CRP
Consider bone protection + PPI
Steroid alert card
Optometry yearly
Postpone live vaccines
Features of spondyloarthritis
Plantar fasciitis
Achilles tendinitis
Uveitis (iritis)
Peripheral oligoarthritis (<4 joints) affecting large lower limb joints, especially knees and ankles
Dactylitis (sausage finger/toe)
IBD
Recent (within 2 weeks) chlamydia or acute gastroenteritis (Campylobacter, Salmonella, Shigella) infection
When should HLA-B27 be done?
Back pain>3 months age<45 and 3 of:
onset< age 35
waking in the second half of the night with symptoms.
buttock pain.
improvement with movement.
improvement within 48 hours of taking NSAIDs.
first‑degree relative with spondyloarthritis.
current or past enthesitis.
current or past psoriasis.
Urgent ref if 4 of above, or 3 + HLAB27 positive, or dactylitis
Referral criteria bunions
Routine podiatry if interfere with shoe fitting, cause significant pain, or impairment of activities.
Routine T+O ?surgery if:
Co‑existing OA 1st MTP
Impending/actual skin compromise.
Lesser toe pain and deformity.
Inability to wear work specific footwear (metal toed work boots).
Referral criteria hallux rigidus
Routine podiatry if gross foot deformity/rigid sole footwear not enough, ?steroid injection
Routine T+O ?surgery if:
severe or intractable pain interfering with mobility or sleep.
significant functional impairment impacting on ability to work or ADLs
Management ingrown toenail
cut the nail straight across
Drying after bathing
Change socks regularly.
Push the skin away from the nail using a cotton bud.
Tight footwear places pressure on the toenail, which may pierce the skin.
Surgical removal of a section of the nail, under local anaesthetic ring block if significant infection + overgrowth soft tissues.
Phenol to ablate the nail fold
Management curly toes in children
Will likely grow out of it
Routine T+O ?surgery if:
Persists after age 4 + concern to parents.
The toe cannot be moved into a normal position by hand.
There are nail changes or callus formation.
The child is unable to wear footwear because of skin breakdown, nail changes, and pain.
Define tarsal coalition
Congenital foot deformity in which 2 or more tarsal bones are joined together or fail to separate in fetal development.
Painful stiff foot usually develops in early adolescence.
Often present with recurrent ankle sprain and a flat foot.
Progressive lateral ankle pain and a mildly stiff hindfoot.
On examination, there is limited subtalar movement, and on tiptoes the arch does not reconstitute
Routine T+O
Referral criteria flat feet
Routine podiatry:
↓ level of activity
Unable to keep up with peers
Unstable gait/tendency to trip + fall
Effect on postural development
Routine podiatry if flat, flexible feet and is in pain with no other abnormalities.
Routine T+O if:
the foot is rigid
there is significant functional impairment or unilateral deformity.
marked bony abnormality, e.g. rocker bottom foot.
Referral criteria intoeing
Routine paeds:
?cerebral palsy
Routine T+O if:
Asymmetrical intoeing
Intoeing and limp
Foot deformity
Reduced hip abduction or pain in the hip
Normal until age 12 in mild femoral anteversion
Red flags limp in child
Osteomyelitis or septic arthritis (fever, swollen joint, erythema, unwell child).
Non‑accidental injury, especially age<5
Slipped upper femoral epiphysis
Obligatory external rotation of the hip, overweight, Down syndrome, renal disease
Malignancy – night sweats, bruising, weight loss, night pain.
Abdominal or scrotal pathology presenting as a limp – undescended testes, hernia, appendicitis.
Child is not weight‑bearing.
Differentials limp age<3
Non‑accidental injury
Musculoskeletal infection
Injuries including toddler’s fracture
Developmental dysplasia of the hip (DDH)
Malignancy
Metabolic disease, JIA
Neuromuscular disease
Fracture or soft tissue injury
Abdominal or scrotal pathology
Differentials limp age 3-10
Transient synovitis:
Diagnosis of exclusion, septic arthritis must be ruled out, systemically well
Boys>girls, preceded by viral infection
Perthes disease:
Avascular necrosis femoral head
Infection, Malignancy
Metabolic disease, JIA
Neuromuscular disease
Fracture or soft tissue injury
Abdominal or scrotal pathology
Differentials limp age>10
SUFE
Perthes disease
Infection, Malignancy
Metabolic disease, JIA
Neuromuscular disease
Fracture or soft tissue injury
Abdominal or scrotal pathology
Describe perthes
Avascular necrosis femoral head of
Boys>girls, age 4-8
Insidious onset, worsens with exercise, and can be bilateral
Restricted internal rotation and abduction is found on hip examination
Urgent T+O
Describe SUFE
Vague knee pain or a gradually developing limp
Can be acute, presents like fracture
Male, overweight, and some endocrine abnormalities including hypothyroidism, age 8-15
Shortened and externally rotated leg and reduced ROM at hip
Admit T+O/ED
Features morton’s neuroma
Interdigital neuroma between metatarsals
Often aggravated by tight-fitting shoes
Burning pain, parasthesia, or numbness
Radiates to lateral side of one toe and the medial side of its neighbour
Pain reproduced by pressure into the webspace
Usually third interspace, sometimes second interspace
Nature of pain changes on shoe removal
Differentials for Morton’s neuroma
OA
Inflammatory arthritis (esp if nail changes/dactylitis)
Malignancy
Stress fracture
Charcot foot T2DM
Systemic sclerosis (raynauds)
Features plantar fasciitis
Gradual onset heel pain, worst putting foot down in morning
Repetitive microtears of the fascial substance, common in runners
Acute injury/tear or partial tear/or inflammation.
Age 40-60
Management plantar fasciitis
Supportive slightly heeled footwear
Stretched
Ice 20mins, rolling motion
Routine podiatry if >12 weeks self management ongoing symptoms
Describe 4 most common knee ligament linjuries
ACL: valgus twisting mechanism- forcefully landing on the leg and suddenly turning to the opposite side.
PCL: direct blow to the flexed knee
Collateral: varus or valgus strain and direct blow to the knee.
Meniscal acute tears: rotation + compressive forces on a bent knee leads to joint effusion after several hours
-> urgent physio
Features and management hip OA
Groin pain on internal rotation (foot outward)
Stiffness and reduced function
Exercises, paracetamol + ibuprofen gel, ESCAPE pain classes
Xray, if mod/severe OA-> routine T+O ?surgery, otherwise physio
Management knee OA
Oak Knee, ESCAPE pain
Exercises, lose weight, analgesia
Steroid injection to:
manage acute flare
manage symptoms if surgery not an option
only if >3m til joint replacement (incr risk infection with surgery)
Features greater trochanteric pain syndrome
Lateral hip/thigh/buttock pain on movement
Tendinopathy of the gluteal insertions/greater trochanteric bursitis
Management greater trochanteric pain syndrome
Graded loading and exercises, ice, analgesia
Physio-> shockwave?
Steroid injection at point of max tenderness
USC criteria soft tissue lump
USC sarcoma referral if soft tissue lump:
>5 cm in diameter.
deep to fascia (fixed) and any size.
growing (especially observed rapid growth).
painful.
recurring after a previous sarcoma excision.
Red flags in back pain
Cancer – Hx cancer, unexplained weight loss, no improvement 1 month, >50 years, unremitting pain, increasing severity pain.
Spinal infection – fever, IV drug use, spinal/epidural anaesthesia
Vertebral compression fracture – older age, osteoporosis, steroid use, menopause, or post‑chemotherapy.
Inflammatory- ankylosing spondylitis, younger, morning stiffness, improvement with exercise, alternating buttock pain, awakening during the 2nd half of the night, marked improvement with NSAIDs.
Cauda equina
Symptoms cauda equina
Bilateral sciatica
Severe or progressive weakness of the legs.
Difficulty passing or controlling urine – retention, incontinence, or palpable bladder.
Saddle anaesthesia/paraesthesia or unable to feel rectal fullness.
Lax anal sphincter.
Neuro exam features for radiculopathy L4, L5, S1
L4- knee extension, foot drop, reduced knee jerk with sensory loss in the medial shin
L5- great toe extension and ankle dorsiflexion with sensory loss in the big toe and inside of the foot
S1- ankle plantar flexion, reduced ankle jerk with sensory loss in the sole and lateral foot
Features spinal stenosis
Age>60
Pain worse on walking and standing, and relieved by sitting or lying down, or walking flexed with a trolley or walking uphill.
Bilateral, involves the whole leg, mild low back pain.
Sensory loss and weakness may be present.
Stages of lymphoedema
Stage 0 – subclinical. Heaviness or aching.
Stage 1 – early onset. Swelling which subsides with elevation.
Stage 2 – swelling which is rarely reduced by limb elevation. Loss of anatomical contour of the limb. May have pronounced pitting – pitting may then reduce as tissue fibrosis increases.
Stage 3 – fibrosis is present and pitting absent. Skin changes may occur, including hyperpigmentation, wart-like growths, fat deposits, thickening.
Management lymphoedema
Limb elevation
Weight management
Skin care
Compression garments, bandaging and taping
Exercises- activate muscle pump and preserve mobility
Lymphatic drainage and massage
Recurrent cellulitis management in lymphoedema
14 days+ abx
If> 2 episodes in 12 months, refer lymphoedema clinic re abx prophylaxis.
Rescue pack abx at home
Staphylococcus aureus eradication measures- intranasal mupirocin and chlorhexidine wash.
Features dermatomyositis
Proximal muscle weakness
Heliotrope rash — bilateral lilac discolouration of the eyelids, swelling of the eyelids and skin around the eyes
Shawl sign- fixed redness affecting the back, shoulders, chest, and neck
Photosensitivity
Gottron papules extensor surfaces joints
Thinning of hair
Prominent blood vessels in the proximal nailfolds
Calcinosis finger skin
Raynauds
Triggered by malignancy/silica exposure/viral infection
