MSK in Primary Care 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 > active movement (usually)
As passive movement does not require the person to use their own nerves, muscles and tendons to produce
movement, a reduction in passive range or pain on passive movement indicates a problem with the joint itself.
(e.g. foreign body, bony deformity, inflammation, contracture).
In active movement (when the patient moves the joint), muscles and tendons are functioning. Therefore, a
problem with the muscles and tendons would cause a reduced range of active movement and/or pain on active
movement only.
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 the ‘mechanical symptoms’ of the knee? What do these tend to indicate?
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.
What is bursitis of the knee and how would you differentiate this from a knee effusion?
Bursitis = infection and swelling of the bursae.
Knee effusion = excess synovial fluid in the joint causing swelling.
In knee effusion the fluid can be moved (patellar tap test), in bursitis the swelling is localised to one area of the knee and doesn’t move.
Which causes of hip pain would tend to produce pain in the anterior, lateral and posterior hip area?
‘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.
What are the clinical features of plantar fasciitis and metatarsalgia? In metatarsalgia, what would make you suspect
a Morton’s neuroma?
Plantar fasciitis typically causes pain at the insertion of the plantar fascia into the calcaneum. It tends to occur in
people who spend a lot of time on their feet; often the pain is marked with the first few steps of getting out of
bed and then worsens again at the end of the day.
Metatarsalgia is a pain in the mid-foot and has a wide range of causes. In Morton’s neuroma, the classic finding is
tenderness in the inter-digital space where the neuroma is located.
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.
Acute: colchicine, NSAIDs or glucocorticoids.
Preventative: Allopurinol.
What features on history and examination help identify ‘radicular’ back pain?
Radicular back pain is caused by irritation or impingement of a nerve root. It is typically felt in the dermatomal
area supplied by the foot. For example, in sciatica (the commonest pattern) the pain radiates to the buttock and
posterior leg; and is often worse when the sciatic nerve is stretched (e.g. in a straight leg raise test). The pain is
often described as ‘shooting’ or ‘numb’ and there may be other neurological symptoms (e.g. weakness, ankle
hyporeflexia).
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 common).
Rheumatoid: in acute episodes, the proximal IP, metacarpophalangeal 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 the pain in the lateral elbow with tenderness over the common extensor
origin.
Golfer’s elbow is medial epicondylitis. Suspect if the pain in the 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.
What are the red flags for people with sciatica?
Bowel/bladder dysfunction (most commonly urinary retention).
Progressive neurological weakness.
Saddle anaesthesia.
Bilateral radiculopathy.
Incapacitating pain.
Unrelenting night pain.
Use of steroids or intravenous drugs.
What are the red flags that could indicate cauda equina syndrome?
Bilateral sciatica.
Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.
Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible urinary retention with overflow urinary incontinence.
Loss of sensation of rectal fullness, if untreated may lead to irreversible faecal incontinence.
Perianal, perineal, or genital sensory loss (saddle anaesthesia or paraesthesia).
Laxity of the anal sphincter.
Consider an assessment of anal tone but note that this does not need to be performed in primary care.
Erectile dysfunction.
