MSK Flashcards
Discuss some key aspects of a good MSK history
- Assess severity of symptoms
- What’s impact on every day life?
- If injured, what was mechanism?
- Distinguish inflammatory vs non-inflammatory causes of joint pain (e.g. when is stiffness)
- Identify mechanical symptoms
- Identify any red flags
- Identify potentially significant problems e.g. cancer, psoriasis, gout etc…
- Identify FH of any MSK conditions
- Identify occupation triggers e.g. repetitive movements, lifting, posture etc..
- ICE
… and of course usual questions such as timing, aggrevating factors, relieving factors etc…
State some MSK pathologies that require urgent admission to A&E
- Cauda equina syndrome
- Metastatic spinal cord compression
- Spinal infection
- Septic arthritis
State some MSK pathologies that require urgent referral to appropriate specialists
- Primary or secondary cancers
- Insufficiency fracture
- Major spinal relaed neurologial defiit
- Cervical spondylotic myelopathy (CSM)
- Myositis (refer urgently to rheumatology)
- Giant cell arteritis (urgent referral to rheumatologist on same day if possible, if not in 3 working days. Commence steroid therapy if have to wait)
State some red flags of cauda equina syndrome
- Bilateral sciatica
- Perianal numbness
- Bowel or bladder dysfunction
- Uni- or bi-lateral lower limb motor and/or sensory abnormality
- Erectile dysfunction
Remind yourself:
- What cauda equina syndrome is
- Why it is an emergency
- Cauda equina is compressed
- Complications if untreated:
- Paralysis
- Sensory abnormalities
- Bladder and bowel dysfunction
- Sexual dysfunction
What can you give to patients who are at risk of cauda equina syndrome?
CES cards (highlights symptoms that pt should be concerned about and advises them when to seek medical attention)
State some red flags of metastatic spinal cord compression
- Spine pain with band like referral
- Escalating pain
- Gait disturbance (not just a limp, unsteadiness that is even worse on stairs)
- Pain worse on lying flat
- Sleep disturbance due to pain
- Funny feelings/odd sensations or heavy legs
- Past medical history of cancer
State some red flags of a spinal infection?
- Spinal pain
- Fever
- Worsening neurological symptoms
- Risk factors e.g. immunosupression, primary soure of infection, personal or family history of TB
State some red flags of septic arthritis
- Sudden onset of a hot, swollen joint
- Multidirectional restriction in movement
- Fever
*NOTE: septic arthritis may present as painful limp or loss of function in upper limb- don’t necessarily have hot swollen joint
State some red flags of primary or secondary cancers affecting the MSK system
- History of cancer (breast, prostrate, lung, kidney, thyroid are most likely to metastasise to bone)
- Escalating pain
- Night pain
State some red flags of an insufficiency fracture of the spine
- Sudden onset of pain (usually in thoraco-lumbar region)
- Pain varies (usually severe and localised to area of fracture)
- History of low impact trauma
- Risk factors e.g. osteoporosis
What is a stress fracture?
Insufficiency fractures are a type of stress fracture (fracture caused by repeated stress over time) in abnormal bone e.g. weakened bone due to osteoporosis.
State some red flags/criteria for major spinal related neurological deficit
- Spinal pain
- Associated limb symptoms (e.g. new onset or progressively worsening limb weakness present for days/weeks)
- Less than grade 4 on Oxford muscle grading system and associated with >1 myotome
What is the Oxford Scale for muscle grading?
Quick method of assessing and grading muscle power. Scale is from 0-5 (note: may see +/- signs to indicate more or less power but not enough of a change to alter the number).
State some red flags for cervical spondylotic myelopathy (CSM)
- History of cervical spondylosis
- Pain getting worse
- Lack of coordiation
- Heaviness or weakness in arms
- Pins & needles in arms
- Problems walking
- Loss of bladder or bowel control
You should consider serious pathology as a differential diagnosis when a patient presents with any of what 3 criteria?
- Escalating pain & progressively worsening symptoms that do not respond to conservative management or medication as expected
- Systemically unwell (e.g. fever, weight loss)
- Night pain that prevents sleep due to escalating pain and/or difficulty lying flat
State some situations in which you would refer a patient to rheumatology
Wouldnt’ learn whole list; idea that anyone with a rheumatological condition that needs long term managment e.g. RA, psoriatic arthritis, autoimmune, spondyloarthritis, GCA (although this is urgent referral)
- Suspected rheumatoid or psoriatic arthritis: persistent synovitis (i.e. hot, swollen joints), early morning stiffness >30 mins, +/- increased CRP/ESR, +/- RF/anti-CCP
- Suspected new onset of autoimmune connective tissue disease
- Myalgia not secondary to viral infection or fibromyaglia that is worse proximally, worse in morning, >30 mins stiffness… could have polymyalgia rheumatica or myositis
- Temporal arteritis
- Suspected spondyloarthritis
What are the likely causes of limited or painful active movement but full, pain-free passive movement?
If active movement is painful or limited but passive movement is pain-free and has full range of motion this would suggest pathology is with the mechanisms that produce injury e.g. muscles, nerves. If there is e.g. a foreign object in joint obstructing movement, movement would be reduced and painful on both active and passive movement.
Describe the WHO pain ladder
The three main principles of the WHO analgesic ladder are: “By the clock, by the mouth, by the ladder”
Define stiffness
Inability to move with ease and without pain
Discuss the use of the WHO analgesic ladder in chronic MSK pain
If opiods are used for chronic pain, patient can become both tolerant and dependent on the opioids; opioids then no longer help the pain but the pt is addicted
What are mechanical symptoms of knee?
What have they traditionally ben thought to represent and is there evidence to contradict this view?
- Mechanical symptoms inlcude locking (inability to bend or straighten knee), catching, popping and feeling of ‘giving way’ in knee
- Traditionally they were thought to represent meniscal tears however recent studies show that mechanical knee symptoms are equally as common among patients with and without meniscal tears.
Remind yourself of the bursa in the knee (6)
**Suprapatellar bursa is extension of synovial cavity
Which bursa of the knee are most commonly inflamed?
- Suprapetallar: extension of synovial cavity therefore suprapatellar bursitis is not a sign of localised irritation but a sign of a knee effusion which indicates knee pathology. Causes include: RA, OA, infection, gout, repetitive microtrauma
- Pre-patellar: “housemaids knee” history of repeitive trauma (usually) or blunt trauma
- Infra-patellar: “clergyman’s knee” caused by repetitive trauma in more upright position than housemaids knee
- Semi-membranous bursa: attached to posterior capsule of knee and may communicate with knee joint via small opening; therefore in a knee effusion you may get swelling of this bursa- presents as Baker’s/popliteal cyst
- Pes anserinus/subsartorial:
Explain how you can differentiate between bursitis and knee effusion
Not sure… ask
- Position?
- Does swelling move?
State some causes of pain in the anterior hip
Intraarticular pathology e.g.:
- OA
- Labral tears
- Septic arthritis
- Femoral neck fracture
- SCFE
- Femeroacetabular syndrome
State some causes of pain in the lateral hip
- Greater trohanteric bursitits
- Gluteal muscle tear
- Iliotibial tract syndrome
- Meralgia parasthetica
State some causes of pain in the posterior hip
- Piriformis syndrome
- Ischiofemoral impingement
- Hamstring strain/avulsion
- SI joint dysfunction
For plantar fasciitis, describe:
- What it is
- Risk factors
- Clinical features
- Examination findings
- Management
- Inflammation of plantar fascia (fascia on sole of foot)
- Risk factors:
- Over pronatin
- Leg length discrepancies
- Overweight
- Recently increased amount of exercise
- Clinical features:
- Sharp pain across plantar aspect of foot
- Felt most severly at heel but can radiate down foot
- Pain aggravated by stretchin sole of foot e.g. walking upstairs
- Worst in morning/after rest
- Examination findings: tenderness on palpation of infracalcaneal region (and soemtimes medical calcaneal tubercle)
- Management:
- Rest, ice and raise foot
- Activity modification
- Soft insoles
- Phsyiotherapy- heel stretching exercises
- Paracetamol
- Exercises that don’t put pressure on feet
- Podiatrist referral e.g. for insoles
For metatarsalgia, discuss:
- What it is
- Risk factors
- Clinical features
- Examination findings
- Management
- Pain in the ball of the foot
- Risk factors:
- Wearing high heels
- On feet for long periods of time
- ‘Pointy shoes’
- Deformities such as hallux valgus, hammer or claw toe, pes cavus
- Clinical features:
- Sharp, aching or burning pain (may start as dull and progress to sharp)
- Aggrevated by standing, walking etc…
- Examination findings:
- Tender on palpation
- Signs of risk factors
- Management:
- Rest, ice and raise foot
- Paracetamol
- Soft insoles
- Gentle stretching exercises
- Weight loss if overweight
When would you suspect it in a pt presenting with metatarsalgia? Describe Morton’s neuroma, include:
- What it is
- Who common in
- Symptoms
- Management
- Morton’s neuroma is a benign fibrotic thickening of a plantar interdigital nerve that is a response to irritation. Mechanisms thought to cause irritation of the nerve include: compression or entrapment of the nerve, stretching of the nerve & nerve ischaemia.
- Mean age= 55yrs, women > men
- Symptoms:
- Pain most commonly felt in the 3rd inter-metatarsophalangeal space
- Exacerbated by incresed activity and footwear
- Sensation of pebble or lump when walking
- Sharp, stabbing, tingling sensation
- Management:
- Avoid shoes with thin soles, high heels or constriction around toes
- Consider NSAIDs
- If symptoms persist after 3 months refer to orthotist, orthopaedic surgeon with interest in foot
- or podiatric surgeon
What’s the difference between mechanical and radicular back pain?
Mechancial back pain = source of the pain may be in the spinal joints, discs, vertebrae, or soft tissues.
Radicular back pain = radicular pain occurs when pain radiates from an inflamed or compressed nerve root.
Compare mechanical and radicular back pain in terms of:
- Site
- Quality
- Aggrevating/relieving factors
- Radiation
- Parasthesia
- Reflexed
- Motor strength
What is painful arc?
- Pain on abduction of arm between 60-120 degrees
- Inflammation of supraspinatous tendon e.g. due to impingement syndrome
State some potential causes of referred shoulder pain
- Irriation of diaphragm e.g. from peritonitis
- ACS
- Gallstones
- Pancreatitis
- Pneumonia
- Shingles
- Polymyalgia rheumatica
- Lung cancers
Compare tennis elbow, golfers elbow and bursitis
Tennis Elbow
- History of repeated use of extensor muscles e.g. tennis, construction work, piano
- Pain over lateral epicondyle with pain radiatin gdown extensor aspect of arm and pain during wrist extension
Golfers Elbow
- History of repeated valgus stress on arms which causes weakening of muscles & microscopic tears e.g. golf, weightlifting, arching
- Pain over medial elbow often associated with accelarated phase of throwing. Pain on resisted pronation of wrist. May have ulnar nerve symptoms.
Olecranon Bursitis
- Repeated minor trauma
- Swelling over elbow: soft, cystic, transilluminates, tender
What is tendonitis?
Symptoms?
Discuss how you would manage tendonitis
- Inflammation of tendon after injury
- Symptoms:
- Joint pain, stiffness
- Reduced ROM (painful, restricted active but painless, full passive)
- Swelling
- Sometimes heat or redness
- Management:
- Manage at home with:
- Rest, ice & wear a support (e.g. bandage or soft brace. Remove before going to bed)
- Keep it as mobile as possible
- Avoid heavy lifting and sport
- Paracetamol & NSAIDs (oral or topical)
- If above doesn’t work- physiotherapy
- If above doesn’t work- referral to orthopaedic specialist
- Manage at home with:
Which joints can be replaced in OA?
Common ones include:
- Shoulder
- Hip
- Knee
Which OA patients should you refer for surgery?
Patient has tried non-surgical options and these haven’t worked/condition still having a substantial impact on quality of life
What do we mean by yellow flags for back pain?
Give some examples
Yellow flags for back pain are pyschosocial factors shown to be indicative of long term chronicity and disability, examples include:
- A negative attitude that back pain is harmful or potentially severely disabling
- Fear avoidance behaviour and reduced activity levels
- An expectation that passive, rather than active, treatment will be beneficial
- A tendency to depression, low morale, and social withdrawal
- Social or financial problems
State some differentials for back pain
- Mechanical lower back pain or leg pain
- Lumbar strain
- Age related disc/facets degeneration
- Herniated disc
- Inflammatory arthritis e.g. ankylosing spondylitis
- Infection
- Malignancy
- Aortic aneuryseum
- GI disease
- Diseases of pelvic organs..
State some risk factors for mechanical lower back pain
- Age
- Occupational hazards e.g. heavy lifting
- Poor posture
- Excess weight
- Sedentary lifesyle
- Trauma
- Conditions e.g. ankylosing spondylitis
Discuss the possible management of mechanical lower back pain, include:
- Conservative
- Pharmacological
- Surgical (depends on problem therefore don’t answer but be aware it may be an option)
Obviously if red flags are present then manage differently. Management depends on cause however some options are:
Conservative
- Exercises
- Education
- Referral to physiotherapy
- Group exercise programme
- Reduce risk factors e.g. weight loss
Pharmacological
- NSAIDS
- If not working, work up WHO analgesia ladder and consider e.g. co-codamol or codeine
- Diazepam if paraspinal muscles in spasm
Surgical
- Depends on problem
For sciatica, remind yourself of:
- Pathophysiology
- Risk factors
- Example causes
- Symptoms
*
- Irritation or compression of either the sciatic nerve or one or more of nerve roots that contribute to the sciatic nerve (L4-S3)
- Risk factors:
- Strenuous physical activity
- Whole body vibration e.g. drilling
- Smoking
- Obesity
- General health
- Causes can include marginal osteophytosis, slipped disc etc…
- Symptoms:
- Pain in back and buttock which radiates to dermatome(s) supplied by affected nerve root(s)
- Parasthesia in teh dermatome(s) suppplied by affected nerve root(s)
What does a positive straight leg test indicate?
Disc herniation causing back pain/sciatica
Discuss the management of sciatica
-
Self management advice:
- Symptoms usually settle on own in 4-6weeks
- Heat pillows
- Sleeping positions: pillow between legs on side, prop up with pillows
- Information leaflets on back exercises
- Encourage to keep as active as possible and return to work asap
-
Analgesia
- NSAIDS (but be aware there is limited evidence regarding use in back pain)
- DO NOT offer opiods, benzodiazepines, steroids etc..
-
Safety netting
- Advise to seek help if no improvement in 2 weeks
- Warn of red flags e.g. of cauda equina
- Referral to surgery if necessary
YOU MUST LOOK AT YR3 MEDICINE RHEUMATOLOGY FLASHCARDS FOR REST OF NOTES ON CONDITIONS SUCH AS OA, RA ETC..
