MSK - Level 3 Flashcards
Description of seronegative arthritis?
- Group of conditions that present with inflammatory arthritis without a positive RF
- Include Ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis, Behcet’s disease, JIA
Risk factors of seronegative arthritis?
o HLAB27
o FHx
Mean onset and symptoms of seronegative arthritis?
- Mean onset 20-40 o Back pain o Sacroilitis o Peripheral arthritis o Enthesitis o Dactylitis o Non-gonococcal urethritis o Psoriasis o Anterior Uveitis o IBD
What is psoriatic arthritis?
o 35-45, any joints
o Psoriasis, enthesitis, dactylitis
o Occasional uveitis, aortic regurgitation
What is enteropathic arthritis?
o Any age
o Asymmetrical lower extremities and symmetrical sacriliitis
o Erythema nodosum, pyoderma gangrenosum
o Aortic regurgitation
Investigations in seronegative arthritis?
- Bloods
o ESR and CRP raised
o Urate, RF, ANA normal - X-ray
Management of seronegative arthritis?
- Treat the type of spondylopathy
- Exercise, physiotherapy
- NSAIDs
- DMARDs
- Surgery – joint replacements
Physiology of vitamin D?
- Vitamin D is fat soluable vitamin that regulates calcium and phosphate homeostasis
- Promotes absorption of calcium and phosphorus from bowel to mineralise newly formed osteoid bone tissue
Forms of vitamin D?
o Vitamin D3 (cholecalciferol) – synthesised from 7-dehydrocholesterol in skin by UVB radiation (sunlight)
o Both D3 and D2 (ergocalciferol) are obtained from foods
Cod liver oil, oily fish and fortified cereals/spreads
o D2 and D3 are inactive – converted to 25-hydroxyvitamin D in liver and then to 1, 25(OH)2D in kidneys
Regulation of vitamin D?
o Production regulated by PTH on kidneys
Definition of osteomalacia and Ricket’s?
- Osteomalacia – normal bone amount but mineral content low, occurs after fusion of epiphysis
- Rickets = if this process occurs during period of growth
Causes of osteomalacia?
o Insufficient sunlight exposure
Depends on latitude, season and habit of dressing
Age
Darker skin need more sunlight
o Inadequate dietary intake
o Intestinal malabsorption – coeliac, CF, Crohn’s
o Obesity
o Liver failure
o CKD
o Drugs – antiepileptics, corticosteroids, rifampicin, HAART
Risk factors of osteomalacia?
o Muslim women o Housebound patients o Dark skin (African, Afro-Caribbean, Asian) o Vegans o Pregnancy o >65 o Obese o FHx
Symptoms of Ricket’s?
o Growth retardation
o Hypotonia
o Apathy
o Once walking: knock knee, bow legs, rachitic rosary
o Painful wrist swelling
o Craniotabes (skull softening with frontal bossing
o Delayed tooth eruption
Symptoms of osteomalacia?
o Bone pain – lower back, pelvis
o Fractures (esp femoral neck)
o Muscles aches
o Proximal myopathy (waddling gait)
Investigations in child with suspected Ricket’s?
o XR of long bone – cupping, splaying, fraying of metaphysis (champagne glass wrist) o Bone profile Vitamin D if low calcium o U&E o LFT o TFT o PTH o FBC, ferritin o RA o CRP/ESR
Investigations must be done in osteomalacia?
o Test serum 25(OH)D levels if present with symptoms
Diagnosis if <25nmol/L
25-50 may be inadequate for some people
Investigations considered if underlying cause suspected in osteomalacia?
Bone profile U&E LFT TFT PTH FBC, ferritin RA CRP/ESR
Prevention management of osteomalacia?
o Take daily 400IU (10mcg) supplement daily throughout year
If pregnant – can get free Healthy Start vitamins (has vitamin D, 400mcg folic acid and 70mg VitC)
If <1 years old – 340-400IU of vitamin D
o Advise to intake 700mg of calcium a day
If unable – combined calcium supplementation (Calcichew D3)
• Check Ca levels 1 months after
If child, recommended levels are different
o Lifestyle advice
Sun exposure – safely
Diet – supplements, cod liver oil, oily fish, egg yolk, meat
Management of osteomalacia - who to treat?
Serum 25(OH)D <25
Serum 25(OH)D 25-50 if:
• Fragility fracture, osteoporosis, on antiresorptive drug treatment, symptoms, raised PTH, CKD, coeliac, Crohn’s
Management of osteomalacia - how to treat?
Refer if cancer, Crohn’s to specialist
Drug treatment
Vitamin D2 – for strict vegans (from plant sources)
Vitamin D3 (cholecalciferol) for everyone else
• Loading dose of 300000 IU (50,000 IU once a week for 6 weeks) then daily 800IU maintenance
Management of osteomalacia - follow up?
1 month of high-dose Vitamin D treatment
• Serum calcium levels
3-6 months of high-dose Vitamin D treatment
• Serum 25(OH)D levels:
o IF <50 – refer to secondary care
o IF >50 and no symptoms of hypercalcaemia – maintenance dose of 800IU daily
Management of child with Ricket’s?
o Refer is underlying cause
o Refer to paediatrician if symptoms of Ricket’s
o Drug Treatment
Age 1-6 months – 3,000 IU daily for 8-12 weeks
Age 6 months-12 years – 6,000IU daily for 8-12 weeks
Age 12-18 years – 10,000IU daily for 8-12 weeks
Prognosis of osteomalacia?
o Correct management – restores levels and reduces risks
Complications of osteomalacia?
o Hypocalcaemia o 20 hyperparathyroidism o Bone loss o Muscle weakness o Fragility fractures
Description of Paget’s disease of the bone?
- Also called osteitis deformans
- Increased bone turnover, increased osteoblasts and osteoclasts which results in:
o Remodelling
o Bone Enlargement
o Deformity
o Weakness
Epidemiology of Paget’s disease of the bone?
- Incidence rises with age
- Commoner in temperate climates = England, USA
Risk factors of Paget’s disease of the bone?
- Risk Factors
- FHx
- Paramyxoviruses
- Male
Symptoms of Paget’s disease of the bone?
- Aymptomatic 70%
- Deep, boring pain
- Bony deformity and enlargement – typically pelvis, lumbar spine, skull, femur and tibia (classical bowed sabre tibia)
X-ray findings of Paget’s disease of the bone - Skull?
o Enlargement of bone
o Patchy cortical thickening with sclerosis, osteolysis and deformity (osteoporosis circumscripta of skull)
Osteoporosis circumscripta – large, well-defined lytic lesions
Cotton wool appearance – mixed lytic and sclerotic lesions
Tam o-shanter sign – frontal bone enlargement
X-ray findings of Paget’s disease of the bone - spine?
Picture frame sign – cortical thickening and sclerosis encasing margins
X-ray findings of Paget’s disease of the bone - long bone?
Blade of grass/candle flame – advancing tip of V-shaped osteolysis to diaphysis
Other tests to perform in Paget’s disease of the bone?
- Bone scintigraphy
o Hot spots of bone - Bloods
o Ca and PO4 normal
o ALP markedly raised
Management of Paget’s disease of the bone?
- Analgesia – NSAIDs + paracetamol
- Bisphosphonates
o Salmon Calcitonin 2nd line - Monitor Ca & Vitmain D levels
- Surgery – deformity, osteoarthritis, nerve compression
Complications of Paget’s disease of the bone?
o Pathological fractures o Osteoarthritis o High Calcium o Nerve compression o Osteosarcoma
Types of bone tumours - benign?
Osteoid osteoma Chondroma, osteochondroma Fibroma Haemangioma Giant cell tumour
Types of bone tumours - malignant?
Osteosarcoma Chondrosarcoma Fibrosarcoma Ewing’s sarcoma, myeloma Angiosarcoma
Description and management of osteoid osteoma?
o Usually <1cm in diameter and surrounded by dense osteoid
o Young adults
o Most common sites – tibia, femur, vertebrae
o Present with pain, worse at night, and relieved by NSAIDs
o X-ray – radiolucency surrounded by dense bone
o Management – local excision
Description and management of osteochondroma?
o Sessile or pedunculated lesions arising from cortex of long bone adjacent to epiphyseal plate
o Often present in adolescence as cartilaginous overgrowth at epiphyseal plate
o Symptoms – painless lump, joint pain
o Management – excision
Description and management of chondroma?
o Appears in tubular bones of hands and feet
o X-ray – well-defined osteopenic area in medulla
o Management – excision and bone graft
Description and management of giant cell tumour?
o Aggressive, locally recurrent tumour with low metastatic potential
o Sub-articular cancellous region of lone bone – mostly in closed epiphyses around knee and distal radius
o Symptoms – 20-40 females
o X-ray – asymmetric rarefied area at end of long bone
o Management – wide excision and joint replacement, amputation if malignant or recurrent
Description and management of chondroblastoma?
o Rare, in epiphysis of long bones
o Symptoms – joint pain, muscle atrophy, tenderness
o Management – curettage and bone grafting
Description and management of osteoblastoma?
o Locally destructive progressive lesion found in vertebrae
o Presents with dull aching pain
o Needs biopsy to exclude malignancy
o Management – curettage/bone graft
Description and management of osteosarcoma?
o Most common bone malignancy in children
o Occurs in metaphyses of long bone, around knee or proximal humerus
o Symptoms – painless mass, destroys bone and rapidly metastasises to lung
o X-ray – bone destruction and formation, soft-tissue calcification produces ‘sun-burst’ appearance
o Management – Surgical excision and mifamurtide and chemo
Description, symptoms, investigations, staging and management of Ewing’s sarcoma?
Common in white Caucasian <25, usually males
Symptoms – mass or swelling in long bones of arms, legs, pelvis, chest, pain in area, redness, anorexia, malaise, weight loss, paralysis, numbness, tingling if nerve affected
Investigations
X-ray – Bone destruction with overlying onion-skin layers of periosteal bone formation
Biopsy needed for diagnosis
FBC and LDH prognostic markers
CT/MRI
Management
Chemotherapy (Vincristine, ifosfamide, doxorubicin, etoposide)
Radiotherapy
Surgery to remove tumour (limb saving or amputation)
Symptoms of bone tumours?
- Pain, swelling and localised tenderness
- Rapid growth and erythema suggest malignancy
Referral from primary care if suspected bone sarcoma?
2-week (48 hours if child) X-ray if unexplained bone swelling or pain, then 2-week (48 hours if child) appointment if X-ray suggest possibility
Referral from primary care if suspected soft tissue sarcoma?
urgent US (48 hours if child) if unexplained lump increasing in size, then 2-week (48 hours if child) appointment if US suggestive of soft tissue sarcoma
Description of SLE?
- Multisystem autoimmune disease where autoantibodies are made against a variety of autoantigens (e.g. ANA)
- Polyclonal B-cell secretion of autoantibodies causing tissue damage via immune complexes, deposition and complement activation
Epidemiology of SLE?
- Women 9x, typically of child-bearing age
- More common in Afro-Caribbean, Asians
Risk factors of SLE?
o HLA- DR3/2 o EBV o Drugs Isoniazid, hydralazine, procainamide, quinidine, chlorpromazine, minocycline, phenytoin Disease remits if drugs stopped
Symptoms of SLE?
- Remitting and relapsing pattern
o Non-Specific - Malaise, fatigue, myalgia, fever, lymphadenopathy, weight loss, alopecia, non-infective endocarditis, Raynaud’s, migraine, stroke
Criteria for diagnosis of SLE?
o If 4 or more/11 criteria: Malar Rash (butterfly rash) - Fixed, erythema, flat or raised over malar eminences sparing nasolabial folds
Discoid Rash - Erythematous raised patches with keratotic scales and follicular plugging +/- atrophic scarring - Affects ears, cheeks, scalp, forehead
Photosensitivity - On exposed skin, may also cause disease to flare
Oral Ulcers
Serositis - Pleuritis OR Pericarditis
Non-Erosive Arthritis - Involving 2 or more peripheral joints, reversible deforming arthropathy may occur due to capsular laxity (Jaccoud’s arthropathy) - Joint and muscle pain – early morning stiffness - Non-erosive
Renal Disorder - Persistent proteinuria OR Cellular casts
CNS disorders - Seizures OR Psychosis
Haematological disorders - Haemolytic Anaemias with reticulocytosis OR Leukopenia OR lymphopenia OR thrombocytopenia
Immunological disorders - Anti-dsDNA OR anti-Sm OR antiphospholipid antibody positive
Antinuclear antibody (ANA)
Screening tests used in SLE?
o FBC
o ESR
o Plasma viscosity
o ANA
Further tests performed in SLE?
Antibodies ANA Anti-dsDNA Anti-Sm Anti-SSA/SSB Antiphospholipid syndrome Complement – low C3 and C4 ESR raised BP Urinalysis and urine M, C & S FBC (normochromic, normocytic anaemia), U&E, LFT, CRP
Management of SLE - flare ups?
o IV cyclophosphamide + high-dose prednisolone
Management of SLE - maintenance - general measures?
Smoking Cessation
Sun protection
Exercise
Management of SLE - maintenance - joint symptoms?
NSAIDs and hydroxychloroquine
Low-dose prednisolone
Steroid sparing - Azathioprine, methotrexate and mycophenolate
Cyclophosphamide reserved for life-threatening disease
Management of SLE - maintenance - mucocutaneous disease?
Sun protection
Chlorhexadine, basic oral hygiene and dental appointments
Artificial saliva preparations for dry mouth
Hypromellose eye drops
Hydroxychloroquine
Low-dose prednisolone
Steroid sparing - Azathioprine, methotrexate and mycophenolate
Management of SLE - maintenance - lupus nephritis?
Induction phase - prednisolone, cyclophosphamide or hydroxychloroquine
Maintenance – azathioprine/mycophenolate + prednisolone
BP control - ACEi, A-blockers or CCB
Renal replacement therapy if disease progresses
Management of SLE - maintenance - B-cell depletion?
Belimumab if autoantibody positive SLE
Prognosis of SLE?
o 5-year survival 95%
Complications of SLE?
o Anaemia o Leucopenia o Thrombocytopenia o Steroid-related problems o Amenorrhoea or infertility due to cyclophosphamide o Pericarditis o Myocarditis o Endocarditis o Pleuritis o Pleural Effusion
Description of systemic sclerosis?
- Systemic sclerosis is multisystem autoimmune disease where there is increased fibroblast activity resulting in abnormal growth of connective tissue
o Causes vascular damage and fibrosis in skin, GI, heart, lungs, other organs
o Vascular manifestations unclude secondary Raynaud’s phenomenon, ischaemia of extremities, pulmonary arterial hypertension and renal disease
Description of scleroderma?
o Scleroderma refers to dermatological component of systemic sclerosis
o Localised scleroderma called morphoea – excessive collagen deposition leading to thickening of dermis
Symptoms of scleroderma?
Plaques thickened, usually oval patches
Mauve colour then change to ivory white in middles with lilac edges
Surface is smooth and shiny
Investigations of scleroderma?
Deep punch biopsy
Management of scleroderma?
UVB phototherapy
UVA phototherapy
Methotrexate +/- prednisolone
Topical tacrolimus, imiquimod
Peak age for systemic sclerosis?
40-50
Risk factors of systemic sclerosis?
o FHx
o CMV, parvovirus B19, HepB, EBV, Toxoplasma, H.pylori, chlamydia
o Pesticides, hair dye, silica
o Cocaine, bleomycin, penicillamine, vitamin K
o Vitamin D deficiency
Types of systemic sclerosis?
o Limited cutaneous systemic sclerosis
Areas of skin affected include only face, hands and feet
Older term is CREST (calcinosis, Raynaud’s, oesophageal and gut dysmotility, sclerodactyly and telangiectasia)
Associated with anticentromere antibodies
o Diffuse cutaneous systemic sclerosis
Whole body and early organ fibrosis (lung, GI, cardiac and renal)
Antitopoisomerase-1 & anti-RNA polymerase antibodies
Symptoms of systemic sclerosis - the two types?
- LcSSc
o Milder disease, slow onset and slow progression - DcSSc
o Rapid onset, skin thickening and Raynaud’s phenomenon occurring together and skin changes spread rapidly
o Symptoms worse in first 3-5 years
General features of systemic sclerosis?
o Fatigue
o Weight Loss
Skin features of systemic sclerosis?
o Swelling of fingers and toes – sclerodactyly o Skin hard and thickened o Raynaud’s phenomenon o Calcinosis – nodules or lumps of chalky material o Tight facial skin and tight lips o Telangiectasia o Salt and Pepper appearance of skin o Dry skin
MSK features of systemic sclerosis?
o Joint pain and swelling
o Myalgia
o Restricted joint movements
GI features of systemic sclerosis?
o GORD o Oesophageal scarring o Fullness after meals o Reduced bowel motility o Constipation
Pulmonary features of systemic sclerosis?
o Fibrosis (ILD) – exertional SOB, cough and crackles o Pulmonary arterial hypertension – exertional SOB, syncope, RV strain
Cardiac features of systemic sclerosis?
o Microvascular CAD o Myocardial fibrosis o LV failure o Pericarditis o Arrhythmias
Renal features of systemic sclerosis?
o Glomerulonephritis
o Reduced renal function
GU features of systemic sclerosis?
o Erectile dysfunction
o Dysparenunia
Investigations done in systemic sclerosis?
- Bloods o FBC o ESR and CRP o U&E - Antibodies o Anti-topoisomerase 1 (anti-Scl 70) o Anti-centromere antibody (ACA) o Anti-RNA polymerase 3 antibody - Urine protein
Management of acute systemic sclerosis?
Scleroderma Renal Crisis
BP control – ACEi or CCB
Renal dialysis or transplant
Chronic management of systemic sclerosis - non-pharmacological?
Physiotherapy Exercise Stop smoking Emollients for skin dryness Maintain healthy weight
Chronic management of systemic sclerosis - Pharmacological?
Methotrexate, mycophenolate or cyclophosphamide
Chronic management of systemic sclerosis - Raynaud’s Phenomenon?
Avoid cold weather, stop smoking
CCB (nifedipine)
Aspirin
If ulcers – PDE-5 inhibitors
Chronic management of systemic sclerosis - skin?
Topical emollient
Topical/Oral prednisolone
Antihistamine
If thickening - Methotrexate, mycophenolate or cyclophosphamide
Chronic management of systemic sclerosis - GI involvement?
GORD – PPI
Gastroparesis – Prokinetic agents (erythromycin, domperidone)
Chronic management of systemic sclerosis - ILD?
Prednisolone
Azathioprine
Continuous Oxygen therapy
Lung transplant
Chronic management of systemic sclerosis - pulmonary arterial hypertension?
PDE-5 inhibitor
Oxygen
Lung transplant
Monitoring in systemic sclerosis?
o Annual LFTs, Echos
o Monitor U&Es and BP closely
Description of rotator cuff disorders?
o Subacromial pain which is felt in top and lateral side of shoulder
o Most common cause of shoulder pain, typically 35-75 and history of repetitive movements at shoulder height or heavy lifting
o Include:
Tendinopathy
• Shoulder impingement – between acromion and rotator cuff tendons
Partial rotator cuff tears
Diagnosis of rotator cuff injury?
Pain in top and lateral side of shoulder made worse by lifting arm or overhead activities
Night pain
Painful and restricted active movements
Painful passive movements
Painful arc syndrome – 70-120o of abduction
Description of frozen shoulder?
o Stiffness and disability of shoulder
o Progressive restriction of both active and passive shoulder movement
o Typically 40-60, women
o Primary or secondary (trauma, rotator cuff tear, CVD, hemiparesis, diabetes, thyroid disease)
Phases of frozen shoulder?
Painful phase – lasts 2-9 months, pain on movement, severe and can disturb sleep
Stiffness phase – lasts 4-12 months, less severe and reduced ROM
Resolution phase – lases 12-42 months, improvement gradually
Diagnosis of frozen shoulder?
Gradual onset pain in deltoid region, worsening shoulder stiffness
Restricted active and passive external rotation
Description of shoulder instability?
o Abnormal movement of head of humerus
o Typically, <35 years, shoulder feeling out of joint or moves
o Causes pain, subluxation or dislocation
Diagnosis of shoulder instability?
Shoulder moves partly or feeling out of joint
Ache or clicking
Arm weakness, tingling
Shoulder dislocation
• Anterior – fall onto outstretched hand, <20 years have 90% of further dislocation
• Posterior
When to XR shoulder?
- Anteroposterior and lateral shoulder XR:
o History of trauma
o Person not improving with conservative treatments
o Movement restricted
o Severe pain
o Arthritis suspected
Management of shoulder pain - when to refer urgently?
Trauma, pain and weakness, or sudden loss of ability to actively raise the arm Any shoulder mass or swelling Red skin, painful joint, fever Trauma leading to abnormal shape New inflammatory symptoms Systemic symptoms Acute rotator cuff tear
Management of shoulder pain - initial management?
Analgesia • Paracetamol 1st line • Oral NSAIDs or codeine added on Encourage carrying out normal daily activities if they are able Refer to physiotherapy
Management of shoulder pain - when to refer to secondary care?
Recurrent shoudler instability
Post-traumatic pain
Not improving after 3 months
Management of rotator cuff disorders - general management?
o Rest in acute phase – avoid reaching overhead
o Resume normal activities when feel able to do so
o Analgesia
Paracetamol 1st line
Oral NSAIDs or codeine added on
o Exercises/Physio (6 weeks)
o Corticosteroid injection
Give another after 6 weeks if improvement
Management of rotator cuff disorders - referral?
Not benefitted after 6 weeks of non-surgical treatment
Management of rotator cuff disorders - surgery?
Arthroscopic rotator cuff tendon repair if large
Management of frozen shoulder?
o Avoid movements that worsen pain but continue to use to avoid stiffness o Heat packs o In bed, support arm with pillow o Analgesia • Paracetamol 1st line • Oral NSAIDs or codeine added on o Physiotherapy (6 weeks) o Referral to secondary care: Pain or stiffness for 3 months and not benefitting from conservative measures
Description of lateral epicondylitis (Tennis Elbow)?
- Tendonosis affects attachment of tendons of extensor muscles of forearm to lateral epicondyle of humerus
Epidemiology of lateral epicondylitis (Tennis Elbow)?
- Prevalence of 1-3%, peak 35-55 years
- Most commonly affected muscle is extensor carpi radialis brevis
- Dominant arms in 75%
Causes of lateral epicondylitis (Tennis Elbow)?
o Minor trauma – repetitive overuse causes micro-tears near origin of common extensor tendon which initiates degenerative process
Activities associated of lateral epicondylitis (Tennis Elbow)?
o Tennis
o Plumbing
o Grip-tensive activities involving repetitive forceful elbow movements
Symptoms of lateral epicondylitis (Tennis Elbow)?
- Pain in lateral elbow, with wrist extension and reduced grip strength
o Radiates down extensor aspect of forearm
o Worsened by excessive and repetitive use of extensor muscles of forearm (strong gripping, repetitive wrist movements)
o Occupations using vibratory machines worsen symptoms - Impacts on ADLs
What is Mill’s Test?
o Straighten patients arm and palpate lateral epicondyle
o Fully flex wrist
o Pronate patients’ forearm
o If painful – positive test
What is Cozen’s Test?
o Elbow 90 degree of flexion, patient makes a fist and deviates wrist radially with forearm pronated
o Resisted extension of wrist
o Pain in lateral epicondyle is positive result
General management of lateral epicondylitis (Tennis Elbow)?
o Avoid heavy lifting, forceful gripping or twisting actions that may aggravate it
o Discuss with OH if work-related
May mix work patterns, take more rest breaks, change handling procedures
Further management of lateral epicondylitis (Tennis Elbow)?
- Analgesia
o Paracetamol and Ibuprofen gel 1st line
o Oral if symptoms ongoing
o Corticosteroid injection (may be repeated 2-3 times at 3-6 months intervals) - Physiotherapy
When to refer to orthopaedics in lateral epicondylitis (Tennis Elbow)?
o Uncertain diagnosis
o Refractory pain
o Pain >12 months despite optimal treatment
Prognosis of lateral epicondylitis (Tennis Elbow)?
Self-limiting and improves in about 80% of cases over 1-2 years
Description of medial epicondylitis (Golfer’s elbow)?
- Tendonosis of flexor forearm muscles which insert into medial epicondyle, causing medial elbow pain
Causes of medial epicondylitis (Golfer’s elbow)?
o Golf and other sports o DIY o Computer use o Climbing o Use of vibrating tools
Symptoms of medial epicondylitis (Golfer’s elbow)?
- Pain and tenderness over medial epicondyle, radiating into forearm
o Aggravated by wrist flexion and pronation
o Gradual onset
Tests done in medial epicondylitis (Golfer’s elbow)?
- Golfer’s elbow test
o Pronate and flex wrist and forearm at same time
o Pain over medial epicondyle is positive test
General measures of medial epicondylitis (Golfer’s elbow)?
o Avoid heavy lifting, forceful gripping or twisting actions that may aggravate it
o Discuss with OH if work-related
May mix work patterns, take more rest breaks, change handling procedures
Further management of medial epicondylitis (Golfer’s elbow)?
- Analgesia
o Paracetamol and Ibuprofen gel 1st line
o Oral if symptoms ongoing
o Corticosteroid injection (may be repeated 2-3 times at 3-6 months intervals) - Physiotherapy
Referral to orthopaedics in medial epicondylitis (Golfer’s elbow)?
o Uncertain diagnosis
o Refractory pain
o Pain >12 months despite optimal treatment
