MSK week 4 Flashcards
What is mechanical back pain?
Recurrent relapsing and remitting back pain with no neurological symptoms.
Back pain that is relieved by rest and worsened by activity.
What are the causes of mechanical back pain?
Obesity, lack of physical activity, spondylosis, OA, poor posture, poor lifting technique.
What is spondylosis?
As you age, the water content in your intervertebral discs decreasing meaning they lose some of their cushioning properties. This puts an increased pressure on the facet joints.
Treatment for mechanical back pain
NSAIDs and simple analgesia, physiotherapy
NO BED REST.
When would spinal stabilisation surgery be appropriate in mechanical back pain?
If two adjacent vertebrae are affected- spinal fusion of the two may benefit them. Tends to be a minority of patients since most of the time they have multilevel disease.
Conservative management has to have failed first.
When does an acute disc tear occur?
Classicly after lifting a heavy object.
Why do you feel pain in an acute disc tear?
What makes the pain worse?
The outer annulus fibrosis is richly innervated so you feel pain.
Coughing makes the pain worse because it increases the pressure on the disc.
Treatment of an acute disc tear?
Usually resolves itself in 2-3 months however in the meantime physiotherapy and analgesia.
What is sciatic/lumbar radiculopathy?
Disc material can impinge on exiting nerve roots causing altered sensation in a dermatomal distribution and weakness in a myotomal distribution
Where does radiculopathy most commonly occur?
In the lumbar spine- L4, L5 and S1 nerve roots which contribute to the sciatic nerve.
What does radiculopathy feel like?
Neuralgic burning or severe tingling pain- which radiates down the thigh to below the knee.
If a L3/L4 disc prolapse occured- which nerve root would be entrapped and what consequences would this have?
L4 nerve root would be entrapped. It would cause pain down to the medial ankle, loss of quadriceps power and a reduced knee jerk.
If a L4/L5 disc prolapse occurred- which nerve root would be entrapped and what consequences would this have?
L5 nerve root would be entrapped. It would cause pain down to the dorsum of the foot, reduced power in extensor hallicus longs and tibias anterior.
If a L5/S1 disc prolapse occured- which nerve root would be entrapped and what consequences would this have?
S1 would be entrapped. It would cause pain to the sole of the foot and reduced power plantarflexion and reduced ankle jerk.
Describe the anatomy of the transversing nerve root and the exiting nerve root. Which is more likely to be affected by a discogenic tear and why?
At each level (e.g. lumbar 4) there is an exiting nerve root that exits at that same level and a transversing nerve root that passes to the level below. The transversing nerve root is more likely to become trapped by a discogenic tear however a very lateral tear may affect the exiting nerve root.
What is bony nerve root entrapment? What is the treatment for it?
OA on the facet joints creates osteophytes that can impinge on the exiting nerve root. Treatment involves trimming of osteophytes.
What is spinal stenosis?
In conditions such as bulging discs, the disc can compress the spinal cord (or cauda equina).
It characteristically presents as claudication.
How can you tell between vascular claudication and neurogenic claudication?
Neurogenic claudication distance is inconsistent. The pain is burning rather than a cramping sensation. Pain is less walking uphill (spinal flexion offers more space) and pedal pulses are preserved.
Management of spinal stenosis
Conservative management - physio and weight loss.
Surgical management- if there is MRI evidence of stenosis- decompression surgery may be performed.
What is cauda equina syndrome?
When a disc prolapse (or other cause) compresses all the nerve roots of the cauda equina.
Affected nerve roots include S4 and S5 which control defecation and urination.
Symptoms of cauda equina syndrome?
Parathesia or numbness around the sitting area.
Bilateral leg pain
Urinary retention (sometimes incontinence)
Faecal incontinence and/or constipation.
What are the consequences of prolonged compression in cauda equina syndrome?
Prolonged compression can potentially cause permanent nerve damage. Even with quick intervention- patients may still have bladder and bowel dysfunction.
What are the red flag symptoms in spinal presentations?
New back pain in young people (<20)- young people are more susceptible to infection, as well as some malignant and benign tumours.
New back pain in older people (>60)- Neoplasia
Nature of the pain is constant, severe pain and worse at night. This indicates pain from tumour.
Systemic upset- fever, night sweats, fatigue may indicate presence of infection or tumour.
What are osteoporotic crush fractures?
In severe osteoporosis- spontaneous fractures can occur leading to acute pain and kyphosis.
What is the treatment of osteoporotic crush fractures?
generally conservative-
Patients with chronic pain- vertebroplasty (inserting a balloon into the vertebral body and filling it with cement)- has had some good results.
What is cervical spondylosis?
Loss of water from the intervertebral discs leads to accelerated OA.
How will patients present with cervical spondylosis?
They will have slow onset of stiffness and pain in the neck that can radiate locally to the shoulder and occiput.
Treatment of cervical spondylosis? What are complications of untreated CS?
Physiotherapy and analgesics are the mainstay.
Osteophytes that may form may start to impinge on exiting nerve roots causing radiculopathy.
Presentation of a cervical disc prolapse?
Shooting neuralgic pain down a dermatomal distribution with weakness and loss of reflexes.
Investigation and treatment of cervical disc prolapses?
Investigations include MRI to find the affected level. Treatment is conservative however persistent cases may have surgery considered.
What diseases may be related to spinal instability?
Can occur in Downs syndrome and rheumatoid arthritis.
What are children with Downs syndrome at risk of developing (in terms of the spine)? How would you prevent this from happening?
Atlanta-axial instability potentially causing subluxation and spinal cord compression.
Screening with flexion-extension X-rays will show abnormal motion. Children with minor degrees of injury- no contact sports. Severe instability may require surgery.
What are patients with RA spinal instability at risk of?
How is this prevented?
Atlanto-axial subluxation can occur due to destruction of the synovial joint between the atlas and the dens.
Subluxation can result in cord compression
Mild cases- wear a collar to prevent flexion. More severe cases will need surgical fusion.
What is the treatment of sciatic/lumbar radiculopathy?
Analgesia, maintaining mobility and physiotherapy.
Occasionally drugs for neuropathic pain can be used (gabapentin).
Very occasionally- discectomy is indicated when physio isn’t helping, localising signs suggesting a specific nerve root and positive MRI present.
What is impingement syndrome?
Syndrome where the tendons of the rotator cuff (predominantly supraspinatous) are compressed into the tight subacromial space during movement which produces pain.
Presentation of the patient with impingement syndrome?
Painful arc from 60-120 degrees
Pain characteristically radiates to the deltoid and upper arm.
Tenderness may be felt below the lateral edge of the acromion.
Causes of impingement syndrome
Tendonitis
Subacromial bursitis
Acromioclavicular OA with inferior osteophytes
A hooked acromion rotator cuff tear.
Treatment of impingement syndrome?
Conservative- majority of cases will heal with NSAIDs, analgesics, physio and subacromial steroid injection
If these don’t work- subacromial decompression surgery which creates more space for the tendon to pass through.
What is a rotator cuff tear? How does it occur?
A tear in the tendon of one of the rotator cuff muscles (usually supraspinatous). Can be due to degenerative changes to the tendon meaning little or no trauma causes the tear.
Typical history of a rotator cuff tear
A sudden jerk in a patient that is older than 40 with subsequent pain and weakness.
If there is a tear in the supraspinatous tendon, what will the patient not be able to do
Weakness in initiation of abduction.
If there is a tear in the infraspinatous tendon, what will the patient not be able to do
Weakness externally rotating.
If there is a tear in the subscapularis tendon, what will the patient not be able to do
Weakness internally rotating
If there is a tear in the teres minor tendon, what will the patient not be able to do
Weakness externally rotating also.
How would you confirm a rotator cuff tear?
Ultrasound or MRI.
Treatment of rotator cuff tears?
Surgical- rotator cuff repair (open or arthroscopic) with subacromial decompression can be performed in an attempt to improve/maintain strength. However failure occurs in a third of patients and very large tears may be irreparable.
Non-operative- physio to strengthen remaining muscles and subacromial injection to reduce symptoms.
What is adhesive capsulitis?
Frozen shoulder- disorder characterised by progressive pain and stiffness of the shoulder in patients between 40 and 60, resolving after 18-24 months.
Presentation of adhesive capsulitis
Patients usually complain of pain for the first 2-9 months. This then subsides and stiffness ensues for about 4-12 months. The stiffness gradually ‘thaws’ out over time- usually with good recovery of shoulder motion.
What is the principle clinical sign of adhesive capsulitis?
Loss of external rotation.
Causes of adhesive capsulitis?
The capsule and glenohumeral ligaments become inflamed and then contract. This is sometimes after shoulder surgery. Diabetics are particularly prone to it. It is associated with hypercholestronaemia and Dupuytrens contracture.
Treatment of adhesive capsulitis
Non-operative- aim to prevent pain and further stiffening while the condition resolves naturally. Physio and analgesics help. Intra-articular (not subacromial) injections can help
Operative- Once the pain has subsided but the patient cannot tolerate loss of function-manipulation under anaesthetic can occur (involves tearing the capsule) to increase ROM.
What is acute calcific tendonitis?
Calcium deposits in the supraspinatous tendon causing acute onset of severe shoulder pain.
Where can the calcium deposits be seen on Xray
Just proximal to the greater tuberosity of the humerus.
Treatment of acute calcific tendonitis
Subacromial steroid injection offers great relief. Along with subacromial anaesthetic.
Condition is self limiting as the calcium will eventually be reabsorbed.
What is instability of the shoulder?
Recurrent dislocations or subluxation or painful abnormal translation movements of the shoulder joint.
Two types of instability
Traumatic- after a previous anterior dislocation-the shoulder does not stabilise and recurrent dislocations with minimal force occur.
Atraumatic- ligamentous laxity
Treatment of traumatic instability
Bankurt repair can stabilise the shoulder by reattaching the labrum and capsule to the anterior glenoid.
Treatment of atraumatic instability
Treatment difficult as soft tissue procedures don’t work.
What is carpal tunnel syndrome?
Pressure increase between the flexor retinaculum and the the carpal bones (the carpal tunnel) compressing the median nerve.
What runs through the carpal tunnel?
The median nerve
9 flexor tendons and their synovial coverings.
What occurs to produce pain in carpal tunnel syndrome?
The compression of the nerve causes pain to be felt- tendons are not as sensitive to pressure whereas nerves are extremely sensitive.
What are the causes of carpal tunnel syndrome?
Most idiopathic Pregnancy Secondary to RA Conditions resulting in fluid retention e.g. diabetes, renal failure, hypothyroidism Consequence of fractures.
Presentation of carpal tunnel syndrome
Parathesia in the median nerve innervated digits (thumb and radial 2 and a half digits.
Worse at night
Loss of sensation and weakness in the thumb.
On examination of carpal tunnel syndrome- what would you expect to see (and what tests would you perform)?
Demonstateable loss of sensation and/or muscle wasting in the thenar eminence.
Symptoms reproduced by Tinels test (percussing over the median nerve) or Phalens test (holding the wrist hyper flexed to decrease space in the carpal tunnel).
Treatment of carpal tunnel syndrome?
Non-operative- use of wrist splints at night to prevent flexion. Injection of corticosteroid.
Surgical- carpal tunnel decompression- involves division of the flexor retinaculum. Highly successful op (small risk of damage to the median nerve).
What aids your diagnosis of carpal tunnel syndrome?
Nerve conduction studies with slowing of conduction across the wrist.
What is cubital tunnel syndrome?
Compression of the ulnar nerve at the elbow behind the medial epicondyle.
What would the patient complain of with cubital tunnel syndrome?
Parathesia in the ulnar 1 and a half fingers. Tinels test over the cubital tunnel is positive.
Weakness of the ulnar innervated muscles may be present- including 1st dorsal interosseous (abduct index finger) and the adductor pollicus.
Tested with froments test.
Causes of cubital tunnel syndrome?
Tight band of fascia forming the roof of the cubital tunnel (Osbornes fascia).
Tightness at the inter muscular septum as the nerve passes through.
How would you confirm the diagnosis of cubital tunnel syndrome? Treatment?
Nerve conduction studies confirm the diagnosis. Surgical release may be needed.
What is tennis elbow also known as?
Lateral epicondylitis. T in laTeral and T for tennis.
What causes tennis elbow?
Repetitive strain injury in tennis players who regularly perform who regularly perform resisted extension of the wrist.
It can also be due to degenerative enthesopathy (inflammation of the origin or insertion of a tendon or ligament onto a bone)
Pathology of tennis elbow?
Micro-tears in the common extensor origin.
Clinical features of tennis elbow?
Painful and tender lateral epicondyle.
Pain on resisted middle finger and wrist extension.
Treatment of tennis elbow?
Self limiting condition. Improves with rest from activities that exacerbate the pain. Physio, NSAIDs, steroid injections, use of brace.
Rarely cases may be offered surgery which involves division and/or excision of the common extensor origin.
What is golfers elbow also known as?
Medial epicondylitis
What causes golfers elbow?
Repeated strain or degeneration at the common flexor origin. Less common that lateral.
Treatment of golfers elbow?
Self limiting
Physio, NSAIDs
Not injection- carries risk of damage to the ulnar nerve.
What type of arthritis is the elbow likely to get?
Most commonly RA.
OA isn’t doesn’t normally occur here- only after trauma.
How can arthritis at the radio-capetellar joint be treated?
If conservative management has failed-can be treated with surgical excision of the radial head which affords good pain relief with minimal functional limitation.
How can arthritis at the humero-ulnar joint be treated?
If conservative management has failed- can be treated with total elbow replacement.
Only downside is that after the replacement you are only allowed to lift 2.5kg.
What is dupuytrens contracture?
Proliferative connective tissue disorder where the specialised palmar fascia undergoes hyperplasia with normal fascial bands forming nodules and cords progressing to contractures at the MCP and PIP joints.
