MSK Medicine Flashcards
Define lower chronic back pain
More than 3 months
Define acute lower back pain
Less than 3 weeks.
Name a cause of Lower back pain
Mechanical back pain, INV disc herniation, sciatica, ankolysing spondolithesis, cauda equina.
Name two RFs for lower back pain
Obesity, sedentary lifestyle causing weakness of paraspinal muscles, poor posture, poorly designed seating, incorrect manual handling, age, vibrations from driving or operating machinery, excessive exercise.
What scoring tool is used for guiding management for lower back pain?
Keele STarT Back Screening Tool
How does mechanical back pain present?
Worse when spine is loaded. Relieved by rest.
How is mechanical back pain managed?
Self management, improve manual handling technique, improve posture, ensure good seating when sitting at desk. Exercise programme and physiotherapy.
How does a slipped disc present?
Depends on whether L4/5, L5/S1. Lower back pain, numbness and tingling, difficulty straightening back, muscle weakness.
What would your first line investigation be for suspected slipped disc?
MRI scan.
How is slipped disc managed?
Keep active, analgesia, steroid injection, physio, lumbar decompression surgery.
Describe the presentation of sciatica
Unilateral leg pain, lower back pain, parasthesia, muscle weakness.
What investigation would you do for suspected sciatica?
Positive straight leg raising test - raise leg when lying on back - this increases pain.
How is sciatica managed?
Self exercises, physio, analgesia - NSAIDs, paracetamol, codeine. NEED to rule out red flags and safety net.
How does ankolysing spondylitis present?
Chronic back pain and stiffness. Suggestive of inflammatory cause - e.g. worse in morning, improves with movement. Fatigue. Patient less than 45years.
What investigations would you do for suspected ankylosing spondylitis?
XRAY - sacroilitis, blood test for HLA-B27.
Define spinal stenosis
Abnormal narrowing of the spinal canal, which can result in compression of the spinal cord or nerve roots.
How does spinal stenosis present?
Elderly due to degenerative changes, discomfort when standing, pain in LL, bilateral symptoms in 70% of cases, numbness, neurogenic claudication.
What investigation would you do for suspected spinal stenosis?
MRI referral
What management would you advise for spinal stenosis?
Analgesia, exercise, weight loss and surgery.
Define spondyloithesis
Anterior displacement of the vertebra above relative to the vertebra below.
How does spondyloithesis present?
Very varied - asymptomatic, occasional lower back pain, sciatica, neurogenic claudication
What is seen on XRAY for spondyloithesis?
Scotty dog sign.
Define cauda equina
Compression of nerve roots in the cauda equina.
What are red flags for CES?
Bilateral sciatica, bilateral neurological deficit, urinary retention or incontinence, faecal incontinence, perianal numbness, erectile dysfunction.
What is management plan for CES?
Urgent referral for spinal decompression
How would malignancy of the lower back present?
Over 50yrs old, gradual onset of Sx, night pain, localised tenderness, so improvement of symptoms after 4-6weeks of conservative management. Hx of cancer.
What are RF for osteoarthiritis?
Obesity, occupation, previous surgery, female, exercise stresses, joint laxity/reduced muscle strength.
How does OA present?
Over 45yrs. Activity related joint pain. No morning stiffness (settles in 30mins). Joints worse after use.
What is seen on examination for OA?
Joint deformity, crepitus, joint instability, muscle wasting, joint warmth, joint effusions, reduced movement.
How is OA managed?
Analgesia - paracetamol, NSAIDs, exercise, weight loss, heat/cold packs, footwear, walking aids. Steriod injections. Joint replacement.
Name a RF for RA
Fhx
How does RA present?
Persistent synovitis, stiffness in morning lasting over an hour. Improves with use, bilateral symptoms, rheumatoid nodules. Extrarticular features: vasculitis, uveitis, chest pain if lungs and heart are affected, fatigue, fever, sweats, weight loss.
What investigations would you order for suspected RA?
blood test for rheumatoid factor x-ray features: joint narrowing periarticular osteopenia juxta-articular bony erosions sublaxation & gross deformity PIP and MCP of hand commonly affected positive 'squeeze test' - discomfort on squeezing across the metacarpal or metatarsal joints
Name a DMARD that could be prescribed for RA?
Methotrexate, Azathoprine, Sulfasalazine (Just some examples)
Name a cause of bursitis?
Trauma, overuse.
How does bursitis present?
Localised swelling over location of bursa. Appears over hrs-days. Tender and warm at site, moveable and compressible.
How may septic bursitis present?
Increased tenderness and hot swelling that gets worse. Local cellulitis. Fever.
How is bursitis managed?
rest, ice, reduce activity, Analgesic pain relief - NSAIDs, paracetamol, compressive bandage. Advise re worsening sx.
How is septic bursitis managed?
Aspirate bursal fluid. Flucloxacillin 500mg 4x a day.
Define plantar fasciitis
A condition of persistent pain associated with degeneration and repair processes that affect the origin of the plantar fascia.
How does plantar fascitis present?
Age 40-60yrs. Slow gradual onset. Intense pain during first steps of waking or after inactivity. Pain reduces with moderate activity, worsens later in the day. Worsens with prolonged periods of standing or walking.
What is seen on examination in plantar fascitis?
Tendereness on palpation of the heel area. Limited ankle dorsiflexion. Tight achilles tendon. Antalagic fair. Positive Windlass test - pain induced by extension of the first metatarophalangeal joint.
How is plantar fasciitis managed?
Complete recovery expected within a year. Supportive shoes, rest, weight loss, insoles and heel pads, regular stretching, ice pack use, pain relief.
What are RF of gout?
Hyperuracemia. Male. Postmenopausal women. Obesity. Excessive alcohol consumption. Renal disease. Certain meds - diuretics. Trauma. Genetics. Seafood.
How does gout present?
Affects big toe. Rapid pain, swelling, redness, warmth. Over 40yrs.
How is gout managed?
Rest and elevate. Ice pack. NSAIDs at max dose +PPI. OR can use colchicine 500mg 2-4x a day.
How is gout prevented?
Urate lowering therapy. Allopurinol (a xanthine oxidase inhibitor).
What are RF for osteoporosis?
Endocrine disease, Chron’s and UC, CKD< chronic liver disease, COPD, Menopause, Immobility, oral corticosteroids, BMI<18.5kg/m2, smoking, alcohol, previous fragility fractures, rheumatology conditions, FHx of hip fractures.
How does osteoporosis present?
Asymptomatic, found when fragility fracture occurs.
Where are fragility fractures common?
Vertebrae, collet of wrist, hip.
What would be your chosen investigations for suspected osteoporosis?
DEXA scan of bone mineral density (T score of -2.5 = osteoporosis). Assess fragility fracture risk.
How is osteoporosis managed?
Bisphosphonate alendronate 10mg 1x/day or 70mg 1x/wk or risedronate 5mg 1x/day or 35mg 1x/wk.
A postmenopausal woman is complaining of bone aches. What might you consider of prescribing?
HRT
Define Morton’s neuroma
A benign fibrotic thickening of the plantar interdigital nerve.
What are RF for Morton’s neuroma?
Ill fitting shoes, repetitive heavy impact on the feet. Being a woman
How does Morton’s neuroma present?
40-60 years old pt. Pain in forefoot in 3rd inter-metatarsophalangeal space. Pain when walking, exacerbated by increased activity or particular footwear. Sensation of pebble or lump under metatarsal region when walking. Sharp, stabbing, tingling or burning sensation in distribution of the affected nerve. Loss of sensation in affected toes.
How is Morton’s neuroma examined?
Pain when apply pressure to inter meratarsaopharnygeal space.
How is Morton’s neuroma managed?
Avoid high heels and shoes which constrict toes. Avoid thin soles to reduce pressure on forefoot. Use metatarsal pad. NSAIDs.
Referred lumbar spine pain possible presentation?
Hip pain
Test to check whether hip pain is referred from lumbar spine?
Femoral nerve stretch test (positive)
How to perform femoral nerve stretch test?
Lie patient prone
Extend hip joint with straight leg and then bend knee
Stretches femoral nerve and will cause pain
