MSK conditions Flashcards
Describe Achilles tendinopathy
Pain, swelling and impaired function of the Achilles tendon
Common in active people
List complications of Achilles tendon injury
Tendon rupture
Negative impact on a person’s ability to work and carry out their usual activities
Limitation in sporting activity
Describe the signs and symptoms of Achilles tendinopathy
Aching pain in the heel
-pain is aggravated by activity or pressure to the area
Stiffness in the tendon
-may occur in the morning or after a period of prolonged sitting
Tenderness, swelling & crepitus along the tendon
Describe the diagnosis of Achilles tendinopathy
Usually a clinical diagnosis (imaging is not routinely recommended)
Examination – exclude Achilles tendon rupture:
1) Tenderness on palpation
2) Evaluate the range of motion of the ankle, pain worsens with passive dorsiflexion of the ankle
List differentials for Achilles tendinopathy
Retrocalcaneal bursitis
Plantaris tendinopathy
Dislocation of the peroneal/other plantar flexor tendons
Posterior ankle impingement
Describe the management of Achilles tendinopathy
Arrange admission/same-day referral to orthopaedics if Achilles tendon rupture is suspected
Most common causes:
1) Fluoroquinolone antibiotics – discontinue
2) Hypercholesterolemia
3) Diabetes mellitus
Advice: cold packs, paracetamol, rest, can weight bear
Refer to physio for assessment if their symptoms fail to improve within 7-10 days
DO NOT INJECT CORTICOSTEROIDS INTO/AROUND THE TENDON
Describe ankylosing spondylitis
Axial spondyloarthritis characterised by sacroiliitis (inflammation of the sacroiliac joints) on x-ray
List the signs and symptoms of ankylosing spondylitis
Chronic back pain and stiffness that improves with exercise, not rest
Sacroiliac joint and spinal fusion
Arthritis and enthesitis
Dactylitis
Fatigue
Extra-articular manifestations – anterior uveitis, psoriasis, IBD
List complications of ankylosing spondylitis
Spinal fractures
Hip involvement
Osteoporosis
Anterior uveitis
Describe the diagnosis of ankylosing spondylitis
Chronic or recurrent low back pain, fatigue and stiffness:
-45 years or younger
- > 3 months
-worse in the morning, improving with movement
Refer to a rheumatologist for confirmation of the diagnosis
Describe the criteria for diagnosing ankylosing spondylitis
Modified New York criteria:
Clinical criteria:
-low back pain: present for more than 3 months, improvement by exercise but not relieved by rest
-limitation of lumbar spine motion in both the sagittal and frontal planes
-limitation of chest expansion relative to normal values for age and sex
Radiological criteria: sacroiliitis on x-ray
Diagnose: if the radiological criterion is present & at least one clinical criterion
Other: ASAS classification criteria for axial spondyloarthritis
List differential diagnosis for ankylosing spondylitis
Degenerative/mechanical problems eg. degenerative disc disease, spondylosis, congenital vertebral anomalies
Fractures
Infectious sacroiitis
Bone metastasis
Describe the management of ankylosing spondylitis
NSAIDs, if contraindicated standard analgesic
Confirmed diagnosis: flare management plan, NSAIDs, TNF-alpha inhibitors (may be greater risk of skin cancer)
Describe Baker’s cysts
Not true cysts
Distension of the gastrocneumius-semimembranosus bursa behind the knee
Primary cysts: not associated with underlying disease of the knee joint & found mainly in children
Secondary cysts: associated with underlying disease of the knee joint
Describe the diagnosis of a Baker’s cyst
Swelling and pain, may be aggravated by walking
Present with acute symptoms – if the cyst dissects/ruptures, history of a sudden ‘pop’
Examine the person standing and in the supine position – inspect and palpate the popliteal fossa for masses (bulge in medial popliteal fossa)
List differential diagnosis for a Baker’s cyst
DVT
Superficial thrombophlebitis
Popliteal artery aneurysm
Lipoma
Describe the management of a Baker’s cyst
Arrange a same-day assessment in secondary care if any red flags are identified
Identify & optimise management of any underlying condition
Asymptomatic – no treatment
Simple analgesia
Describe bunions
A toe deformity when the great toe laterally deviates away from the midline towards the lesser toes
Causes medial prominence of the first metatarsal head & overlying bursa may also become inflamed
Describe the diagnosis of bunions
Progressive pain at the medial aspect of the first MTP and/or medial aspect of the forefoot
Difficulty wearing shoes
Lateral deviation of the hallux at the first MTP joint
Medial prominence of the first metatarsal head
List complications of bunion deformity
MTP joint pain
Difficulty finding comfortable footwear
OA of the first MTP joint
Impaired balance and increased risk of falls
List differential diagnosis for bunions
Hallux rigidus
Gout
Fracture
Inflammatory joint disease
Osteomyelitis
Describe the management of bunions
Self-care: wear low-heeled, wide-fitting shoes with a soft sole
Offer referral to podiatry for a footwear assessment
Consider referral to the local MSK service
Describe carpal tunnel syndrome
Entrapment neuropathy caused by compression of the median nerve in the carpal tunnel at the wrist
Majority of cases are idiopathic
Describe the diagnosis of carpal tunnel syndrome
Intermittent paraesthesia
Numbness
Altered sensation
Burning/pain
All in the distribution of the median nerve
Examination – wasting of the thenar eminence muscles, weakness of median nerve movements, positive Phalen’s & Tinel’s test
List differentials for carpal tunnel syndrome
Cubital tunnel syndrome
Cervical nerve root entrapment
De Quervains tenosynovitis
Osteoarthritis
Describe the management of carpal tunnel syndrome
6-week trial of conservative treatment in primary care:
1) Use of wrist splint in a neutral position at night
2) A single corticosteroid injection into the carpal tunnel
3) Hand exercises and median nerve mobilisation techniques
Review after 6 weeks, arrange referral if seems appropriate
Describe giant cell arteritis
Chronic vasculitis characterised by granulomatous inflammation in the walls of medium and large arteries
Usually affects people over 50 years of age
List complications of giant cell arteritis
Vision loss
Large artery complications – aortic aneurysm, aortic dissection & large artery stenosis
Cardiovascular disease
Describe the diagnosis of giant cell arteritis
Age > 50 and one of the following:
1) New-onset headache, usually in the temporal region
2) Temporal artery abnormality, occasionally the overlying skin is red & pulsation may be reduced/absent
Other symptoms include: visual disturbances, scalp tenderness, intermittent jaw claudication
List differentials for giant cell arteritis
Herpes zoster
Cluster headache or migraine
Acute angle closure glaucoma
Describe the management of giant cell arteritis
Medical emergency – early treatment with effective doses of glucocorticoids may prevent serious complications
If new visual loss -> urgent same day assessment by an ophthalmologist
Urgently discuss with a specialist & refer using a fast track local GCA pathway (diagnosis will be confirmed in secondary care)
Describe gout
Type of arthritis caused by monosodium urate crystals forming inside and around joints
Causes sudden flares of severe pain, heat & swelling
List risk factors for gout
Hyperuricaemia
Increasing age
Excess body weight or obesity
Male sex
Diet – excess alcohol, sugary drinks, meat & seafood
List complications of gout
CVS disease
Chronic arthritis
CKD
Joint damage
Renal stones
Tophi
Describe the diagnosis of gout
Rapid onset of severe pain together with redness and swelling in one or both MTPJs
Tophi
History of previous self-limiting attacks supports the diagnosis
Examination – warm, red and swollen joints, tophi
List differentials for gout
Bursitis
Haemochromatosis
Pseudogout
Osteoarthritis
Describe the management of gout
Acute flare-ups: NSAID at the maximum dose, colchicine, short course of oral corticosteroid
Prevention: urate-lowering therapy, offer allopurinol or febuxostat first-line, colchicine
Describe Lyme disease
Infection caused by bacteria called Borrelia burgdorferi which are transmitted to humans following a bite from an infected tick
List complications of Lyme disease
Severe neurological symptoms
Lyme arthritis
Describe the diagnosis of Lyme disease
Clinical diagnosis of Lyme disease in people with erythema migrans (at the site of a tick bite, round or oval in shape, pinkish in colour, usually flat, expands over days to weeks)
Without erythema migrans -> clinical presentation & laboratory testing is used to guide diagnosis and treatment
List differentials for Lyme disease
Tick bite hypersensitivity reaction
Cellulitis
Erythema multiforme
Describe the management of Lyme disease
Prescribe oral antibiotics – doxycycline first line, amoxicillin & azithromycin second line
NB: a Jarisch-Herxheimer reaction may develop in the first 24 hours of treatment with any abx for Lyme disease
What is Morton’s neuroma?
Compression neuropathy of the common digital plantar nerve
Occurs mostly in the third intermetatarsal space
Not a true neuroma, but a benign fibrotic thickening of the nerve due to constant irritation
Describe the diagnosis of Morton’s neuroma
Pain in the forefoot, most commonly in the third intermetatarsal space -> sharp, stabbing, burning, shooting
Altered sensations & feeling a ‘lump’ in the show on weight bearing
Pain is intermittent as episodes occur with long intervals between attacks
Examination – pain is elicited on applying pressure to the involved inter-metatarsophalangeal space
List differentials for Morton’s neuroma
Biomechanical problems – anomalies of the forefoot bone structure, instability issues, obesity
Soft tissue problems – focal plantar keratosis, plantar fibromatosis, plantar fat pad atrophy
Bone and joint disease – stress fractures, OA
Describe the management of Morton’s neuroma
Advice: avoid high heels & shoes with a constricting tow box/thin soles, use a metatarsal pad, avoid impact activities
Consider NSAIDs if necessary
Consider referral if symptoms persist
Describe olecranon bursitis
Occurs when the bursa is irritated and inflamed:
1) Non-septic: sterile inflammation resulting from various causes including trauma or overuse
2) Septic: infection resulting from seeding of the bursal sac with micro-organisms
Describe the diagnosis of olecranon bursitis
Swelling over the olecranon process thar appears over several hours to several days, may be tender of warm, is fluctuant
Movement at elbow is painless except on full flexion
History of preceding trauma or bursal disease
List differentials of olecranon bursitis
Rheumatoid arthritis
Septic arthritis
Gout
Cellulitis
Describe the management of olecranon bursitis
Rest, ice and reduced activity
Compressive bandaging
Consider aspiration to improve function and comfort
If none of the above works = corticosteroid injection
Give oral abx if aspiration not possible in septic bursitis
Describe Osgood-Schlatter disease
Apophysitis of the tibial tuberosity that causes anterior knee pain during adolescence and is usually self-limiting
-result of repetitive strain from the patella tendon at its insertion on the ossification centre of the tibial tuberosity
Describe the diagnosis of Osgood-Schlatter disease
If there are no features suggestive of another cause of knee pain, OSD may be diagnosed clinically
Pain starts in adolescence and is:
1) Localised to tibial tuberosity
2) Gradual in onset & initially mild and intermittent
3) Unilateral (bilateral in 30%)
4) Relieved by rest
Examination – tenderness over the tibial tuberosity, pain provoked by resisted knee extension
List the differentials of Osgood-Schlatter disease
Tumour
Inflammatory arthritis
Trauma
Infection
Describe the management of Osgood-Schlatter disease
Symptoms usually resolve over time
Pain relief
Reduction in activity may be sufficient to control pain
Describe osteoporosis
Disease characterised by low bone mass and structural deterioration of bone tissue -> increase in bone fragility and susceptibility
Asymptomatic, often remains undiagnosed until a fragility fracture occurs
Describe plantar fasciitis
Condition in which there is persistent pain associated with degeneration of the plantar fascia as a result of repetitive microtears in the contracted fascia
Common condition, especially in people aged 40-60 years
Describe the diagnosis of plantar fasciitis
Usually diagnosed by the history and physical examination findings alone
History – initial insidious onset of heel pain, intense heel pain during the first steps after waking/after a period of inactivity; pain reduces with moderate activity
Examination – tenderness on palpation of the plantar heel area, limited ankle dorsiflexion range, positive ‘windlass test’ (pain by extension of the first MTPJ)
List differentials of plantar fasciitis
Achilles tendonitis
Flexor hallucis longus tendinopathy
Calcaneal stress fracture
Describe the management of plantar fasciitis
Most people will make a complete recovery within a year
Self-care advice: rest the foot, wear shoes with good arch support & cushioned heels
Simple analgesics to provide symptom relief
Describe polymyalgia rheumatica
Chronic, systemic rheumatic inflammatory disease characterised by aching and morning stiffness in the neck, shoulder and pelvic girdle
Cause of PMR is unknown
List complications of polymyalgia rheumatica
Giant cell arteritis
Complications of long-term corticosteroid treatment
Describe the diagnosis of polymyalgia rheumatica
Age > 50 years presenting with at least 2 weeks of:
1) Bilateral shoulder and/or pelvic girdle pain
2) Stiffness lasting for at least 45 minutes after waking or periods of rest
Other features: low-grade fever, fatigue, anorexia, weight loss & depression, peripheral musculoskeletal signs: carpal tunnel syndrome, peripheral arthritis, swelling with pitting oedema
List differentials of polymyalgia rheumatica
Cervical and lumbar spondylosis
Osteoarthritis
Bilateral adhesive capsulitis and rotator cuff disorders
Thyroid disease
Describe the management of polymyalgia rheumatica
Reduce the dose of prednisolone slowly when symptoms are fully controlled (typically treatment is required for between 1-2 years)
Ensure the person is provided with a blue steroid card
Arrange routine reviews one week after any change in dose and at least every 3 months in the first year following diagnosis
Ask about symptoms of GCA
What is tennis elbow?
Tendinosis (chronic symptomatic degeneration of the tendon) that affects the common attachment of the tendons of the extensor muscles of the forearm to the lateral epicondyle of the humerus
Women and men are affected equally, peak incidence between 35-54 years of age
Describe the diagnosis of tennis elbow
History – pain present in the dominant arm in the region of the lateral epicondyle with radiation down the extensor aspect of the forearm, symptoms exacerbated by wrist extension
Examination – localised point tenderness on palpation over and/or distal to the lateral epicondyle & along the common extensor tendon, resisted middle finger extension may be painful (Maudsley’s test), grip strength may be reduced
List differentials of tennis elbow
Rheumatoid arthritis
Septic arthritis
Cervical radiculopathy
Elbow osteoarthritis
Describe the management of tennis elbow
Advice: heat/ice, rest the arm, analgesia
No response to initial treatment after 6 weeks = consider arranging referral to physio, do not routinely offer corticosteroid injection
No response to treatment 6-12 months after initial presentation, consider referral to an orthopaedic surgeon for evaluation
