MSK1 Flashcards
What examination findings might you expect with a tendonopathy?
- Pain on resisted movement or stretching of the tendon.
- Tenderness on palpation of the tendon or its attachment.
- Crepitations felt with movement when palpating the area over the tendon.
What is the general management of any tendonopathy?
- Rest from offending activity or activity modification.
- Trial of NSAID.
- Physiotherapy referral for rehabilitation with graduated activity.
- FEET - use a heel raise.
- LIGAMENTOUS injury - Use lace up shoes.
- ACUTE PAIN - RICE
- Splint - eg. CTS and posterior interosseus nerve entrapment.
- Steroid injection - (not for all tendonapthies - for some bursitis/tendonitis/nerve entrapment).
- Correct Biomechanical issues.
Name the ‘red flags’ which point to serious back conditions?
Age over 50 or less than 20
History of cancer
Temp - greater than 37.8
Pain that is constant (day and night) esp. SEVERE NIGHT PAIN
Unexplained weight loss
Symptoms in other systems (eg. cough/breast mass).
Significant trauma
Features of spondyloarthropathy (age less than 40, night time waking)
Neurological deficit
ETOH/IV drug abuse
Use of Anticoagulants
Use of GCS
Lack of improvement after 1 month
Possible cauda equina syndrome - saddle anaesthesia, recent onset bladder dysfunction/overflow incontinence, bilateral or progressive neurological deficit.
What symptom pattern do you expect in inflammatory back pain?
Insidious onset, Aching, throbbing, Prolonged morning stiffness Exacerbated by rest and relieved by activity More localised, bilateral or alternating Most intense at night or early morning
What symptom pattern do you expect in mechanical back pain?
A precipitating injury/ previous episodes
Deep dull ache, sharp if nerve root compression
Moderate, transient stiffness
Relieved by Rest
Exacerbated by Activity
Diffuse, unilateral
More intense at the end of the day, following activity
How would you manage back pain without any red flags, lasting less than six weeks? Would you image or investigate?
Imaging/pathology is not required for back pain without red flags lasting less than six weeks duration.
Management:
Regular paracetamol 1g orally qid is first line
If muscle spasm - add ibuprofen 400mg three times a day orally
Use heat pack or ice pack
Structured exercise program with graduated activity
Avoid total bed rest
Trial of deep tissue massage, yoga, acupuncture (less than 12 weeks of acupuncture).
What are the common causes of lower back pain?
- Muscular spasm
- Interspinous ligament damage
- Facet joint arthritis
- Disc damage/disruption (with or without radiculopathy)
- Spondylolisthesis and spinal canal stenosis
- Lumbar spondylosis (OA) leading ultimately to spinal canal stenosis.
What is the pathophysiology of spondylolisthesis?
Spondylolisthesis occurs where one vertebra shifts forward over another.
Usually there is a preceding stress fracture of the pars interarticularis.
Pain is often caused by extreme stretching of the interspinous ligaments and/or the nerve roots themselves.
What are the clinical examination findings in spondylolisthesis?
Stiff waddling gait, INCREASE in lumbar lordosis, Decreased flexion, hamstring tightness, Flexed knee stance, tender prominent spinous processes of slipped vertebrae
What are the history findings of spondylolisthesis
Affects 5% of population. Not all are symptomatic.
Those that are there’s often intercurrent disc damage.
Mechanical back pain - worse with activity. Prolonged standing, walking.
Diagnostic physical exam.
How do you definitively diagnose spondylolisthesis?
A Lateral Xray (Standing)
How would you manage a patient with spondylolisthesis?
Refer to physiotherapy for a strict flexion exercise program for at least 3 months. (objective is to splint their own spine with abdominal and spinal muscle strengthening).
Avoid extension, especially hyperextension of the lower back.
Surgery in intractable cases (Also lumbar corsets in refractory)
IF PATIENT DEVELOPS new LUMBOSACRAL RADICULOPATHY or acute neurological deficit - IMMEDIATE neurosurgical review is needed.
A child presents with spondylolisthesis? How would you manage them?
Most children presenting with spondylolisthesis or spondylosis do well with rest and symptom management. Avoid agressive interventions if possible.
What is the pathophysiology of lumbar spondylosis?
Degenerative osteoarthritis of lumbar spine. Can follow vertebral dysfunction eg severe disc disruption/degeneration.
MAIN FEATURE IS LOWER BACK STIFFNESS
Progressive deterioration can occur leading to stress fractures in facet joints and subluxation of facet joints which can lead to spinal canal stenosis
How would you manage a patient who presents with stiff back secondary to lumbar spondylosis.
- Oral paracetamol 1g up to four times daily
- Oral Ibuprofen 400mg three times daily as needed.
- Appropriate balance between rest and graduated light activity.
- An exercise program under physiotherapy supervision
- Consider hydrotherapy
- Regular mobilisation therapy may assist
- Consider a trial of electrotherapy eg TENS
- Consider acupuncture.
- If spinal canal stenosis occurs - referral to neurosurgery for consideration of neurosurgical decompression.
A young endurance athlete presents with calf pain which occurs during exercise. Pain is described as ache, squeeze tightness. Symptoms gradually subside with rest (After 20 minutes) and are minimal during normal daily activities. What is the most likely diagnosis? What is the pathophysiology?Ix? Management?
Chronic exertional compartment syndrome.
CECS.
Can be associated (after months/years) with tibial stress fracture.
A stiff/non compliant fascial compartment may underlie symptoms.
If not improving with conservative management for orhtopaedic review for pressure testing of fascial compartments and for consideration of fasciectomy/fasciotomy.
What is an acute compartment syndrome?
Occurs when tissue pressure within a closed compartment exceeds the perfusion pressure. Leading to muscle and nerve ischaemia. Commonly after trauma/fracture.
