Musculoskeletal Conditions Flashcards
Achilles tendinopathy (management)
Management:
● Supportive footwear and rest.
● Referral to physiotherapist or exercise physiologist for stretching and strengthening exercises (if symptoms
have not settled with 1-2 weeks of rest)
AC joint injury - dislocation/subluxation (mechanism, examination, grades, treatment)
Mechanism: Direct trauma to the superior or lateral aspect of the shoulder with the arm adducted.
Examination:
● Passive cross-body adduction (pain = positive)
● AC Paxinos shear test (one handed)
● AC shear test
○ Force applied posterior acromion and mid-clavicle
Grades: I partial, II complete tear, III complete tear with the coracoclavicular affected.
Treatment: Analgesia, St John’s high sling, mobilisation exercise when able.
● For Grade III compression, bandage with padding at pressure points.
AC joint injury - osteoarthritis (RF, presentation, examination, diagnostic test, management)
Risk factors: builders, sportspeople
Presentation: night pain
Examination: full ROM but pain on full elevation
Diagnostic test: Bell-van Riet.
Management: rest, support, analgesia; +/- intra-articular injections for resistant or severe cases.
44M, mathematics teacher, presents with an acutely painful right shoulder 3 hours after falling off his son’s
skateboard directly onto his shoulder. Unable to abduct and is in a significant amount of pain. No step-wise deformity.
Nil previous injuries.
(3 immediate management steps, timeframe for basketball, examination findings for clearance)
List 3 immediate management steps that you initiate today.
● Apply a broad-arm sling
● Analgesia - paracetamol 1g PO QID PRN
● Apply ice to the shoulder
Mark is keen to return to basketball. Within what timeframe can he safely return?
● 2-6 weeks
List 3 physical examination findings you would look for to confirm that Mark is ready to return to basketball.
● No pain to palpate at the acromio-clavicular joint
● No pain on abduction of the shoulder
● Full range of motion through the shoulder joint
● Ability to bear weight through the shoulder joint on outstretched hand without pain
ACL rupture (significance, mechanism, clinical features, management)
Significance: serious and disabling injury that may result in chronic instability.
Mechanism: sudden change in direction, marked valgus force (direct).
Clinical features: history of pain and ‘giving way’ of the knee.
Management: conservative management (physiotherapy), surgical (if conservative fails or due to occupation).
Acute blue finger syndrome/blue toe syndrome (presentation, prognosis, cause)
Presentation: sudden onset of pain and cyanosis.
Prognosis: lasts 2-3 days, can recur one or more times per year.
Cause: unknown (? emboli).
Adhesive capsulitis (prognosis, causes, phases, examination, diagnosis, management)
Prognosis: self-limiting that can last 2-3 years.
Causes: idiopathic, diabetes, trauma.
Phases:
● Initial: painful, lasting 2-9 months
● Intermediate: stiff, lasting 4-12 months
● Recovery: pain improving, lastis 5-24 months
Examination: severe global passive movement loss in all planes
Diagnosis: clinical.
Management: symptomatic.
● Initial: paracetamol 1g PO 4-6 hourly +/- ibuprofen 400mg PO TDS PRN +/- prednisolone 30mg PO daily for
three weeks then wean.
○ AVOID USE OF NSAID AND PREDNISOLONE CONCURRENTLY
● Intermediate and recovery: arthrographic distension (hydrodilation) may provide sustained relief and improve
function.
● Refer refractory for surgical evaluation.
Anterior ankle (anterior tibialis) tendinopathy (epidemiology, cause, presentation, examination, management)
Epidemiology: > 45 years, cyclists, runners (uphill), soccer players, hikers.
Cause: chronic overuse (dorsiflexion).
Presentation: insidious pain, swelling along the course of the tendon, difficulty walking.
Examination: pain on resisted ankle dorsiflexion, weakness compared to the other side.
Management: rest, structural support, physical therapy (inc eccentric strength exercises).
Baker’s cyst (pathophysiology, RF, Ix, presentation)
Pathophysiology: herniation of a chronic knee effusion between the heads of the gastrocnemius muscles.
Risk factors: OA, RA, internal derangement of the knee.
Investigation: indicated as there is likely intra-articular pathology.
Presentation: pain and swelling in the calf (similar to DVT).
Biceps tendon rupture (epidemiology, cause, presentation, examination, treatment)
Epidemiology: elderly
Cause: spontaneous, or after lifting or falling on outstretched hand
Presentation: preceding tearing or snapping sensation, pain and difficulty moving shoulder
Examination: bruised upper arm, rolled up lump on flexion of elbow.
Treatment: conservative in elderly, surgical considered in younger population.
Calcaneal apophysitis (epidemiology, location, treatment)
AKA: Sever disorder
Epidemiology: boy, 7-15 years.
Pain: heel at insertion of tendon achilles.
Treatment: shoes with slightly raised heels, calf stretching exercises. Restriction of strenuous sporting activity for 12
weeks then review.
Calcific tendinopathy (presentation, Ix, DDx, Mx)
Presentation:
● Pain similar to that experienced by patients with rotator cuff tendinopathy or shoulder impingement
● Gradual pain, top or lateral aspect of the shoulder
● Increased pain at night, inability to lay on affected shoulder
Investigation: Plain XR and ultrasound.
Differentials: rotator cuff tear, cervical radiculopathy, acromioclavicular OA, biceps tendinopathy, glenohumeral OA,
frozen shoulder.
Management:
● Conservative management with NSAIDs, corticosteroid injection (methylprednisolone 20 to 40mg) and
physical therapy.
Carpal tunnel syndrome (causes, management)
Causes: idiopathic, acromegaly, diabetes, hypothyroidism, multiple myeloma, occupational, Paget disease,
pregnancy (2nd-3rd trimester), premenstrual oedema, rheumatoid arthritis, tophi gout.
Management: ** diuretics have no role
● Treatment of underlying condition
● NSAID (do no use in pregnancy)
● Corticosteroid injection
● Splinting and elevation at night
● Surgical referral if progressive with motor deficits
Charcot neuropathy (risk factor, cause, pathophysiology, differentials, examination, treatment)
Risk factor: diabetes.
Cause: multifactorial (neuropathy, vasculopathy, metabolic abnormality of bone).
Pathophysiology: small muscle wasting, decreased sensation, maldistribution of weight bearing.
Differentials: septic arthritis, cellulitis, gout, osteoarthritis, idiopathic inflammatory diseases, osteomyelitis, and
complex regional pain syndrome.
Examination:
● Active phase - redness with intense oedema.
● Chronic (most common) - slow progressing with insidious swelling over months or years.
Treatment: individualised with MDT approach.
1. Offloading of foot until resolution of swelling
2. Podiatry and orthotics
Chilblains (erythema pernio)
precautions, treatment
Precautions: rule out Raynaud, protect from trauma, do not rub or massage area, do not apply heat or ice.
Treatment:
● Physical - elevate affected part, warm gradually
● Drug - betamethasone 0.05% BD
● Other - nifedipine SR 30 mg PO daily.
Chronic compartment syndrome
cause, RF, alleviation, aggravation, management
Cause: repetitive loading or exertional activities.
Risk factors: competitive athletes (long-distance runners, basketball, skiers, soccer).
Alleviation: rest.
Aggravated: exertional activity resumed.
Management: conservative for 2-3 months (NSAIDs, reducing activities, stretching), fasciotomy.
De Quervain tendonitis (mechanism, examination, diagnostic signs)
Mechanism: work-induced of the first dorsal extensor compartment.
Examination: pain at and proximal to wrist on radial border, pain during pinch grasp, pain on movement of thumb and
wrist.
Triad of diagnostic signs:
● Tenderness to palpate over and just proximal to radial styloid
● Firm tender localised swelling in the area of the radial styloid
● Positive Finkelstein sign (hand in fist, movement of wrist in ulnar direction)
Dupuytren’s contracture (pathophysiology, presentation, RF, Mx)
Pathophysiology: fibrous hyperplasia of palmar fascia.
Presentation: discomfort and dysfunction.
Risk factors: smoking, ETOH, liver cirrhosis, COPD, diabetes, heavy manual labour.
Management: corticosteroid injection (if rapidly growing), surgery (for severe deformity).
Erythromelalgia (trigger, presentation, cause, management)
Trigger: heat and exercise.
Presentation: redness, burning sensation and swelling of the hands
Cause: primary or secondary (diabetes, haematological disorders, connective tissue disease)
Management: aspirin.
Femoroacetabular impingement (key point, mechanism, types, treatment)
Key point: radiological findings have poor correlation to symptoms.
Mechanism: abnormal contact between the proximal femur and the acetabulum.
Types:
● Pincer - over covered acetabulum
● Cam - aspherical femoral head
Treatment: no proven effective treatment
Flexor hallucis longus tendonitis (epidemiology, examination, diagnosis, management)
Epidemiology: ballet dancers, jumping.
Examination: Pain on resisting great toe flexion when the foot is held in plantar flexion. If ruptured = unable to flex the
big toe.
Diagnosis: clinical.
Management: conservative; complete tear = surgical.
Glenoid labrum tear (key points, SLAP)
Key points
● Glenoid labrum is a ring of fibrous tissue attached to the rim of the glenoid.
● Injuries are divided into SLAP (superior labrum anterior to posterior) or non-SLAP + stable or unstable.
SLAP
● Risk factors: overhead throwing athletes and laborers with overhead throwing activities.
● Cause: forceful eccentric traction exerted on the biceps tendon, chronic stress placed on labrum when the
shoulder is forcefully abducted and externally rotated.
● History: anterior shoulder pain, clicking of the shoulder.
● Examination: O’Brien, Crank and Speed test.
● Investigation: MRI most specific.
