Neck, Shoulder, Arm and Low back Flashcards
What should nocturnal neck pain raise suspicion of? x3
Nerve root pain, bony pathology or underlying malignancy
What does radiation of pain distally from upper arm or elbow suggest?
Neck or peripheral neurological problem
What is neck pain usually due to?
Poorly defined mechanical influences
Red flags for malignancy with neck pain?
Hx of cancer, signs of cancer, unexplained deformity, mass or swelling
Red flags for infective cause of neck pain
Fever, systemically unwell, redness and swelling
Signs of unreduced shoulder dislocation
Hx of trauma, epileptic fit, electric shock, loss of rotation and normal shape
Drop arm sign indicates what?
Rotator cuff tear
What is normally the cause of bilateral shoulder pain with or without neck pain and with early morning stiffness?
PMR, RA or GCA
Cause of rapid shoulder swelling after trauma
Haemarthrosis of shoulder
What happens with radicular pain? (from nerve root)
Neck pain that radiates into shoulder girdle and/or arm
with paraesthesia or numbness in root distribution
What are signs of cervical myelopathy? (compression of spinal cord) due to herniated disc and is emergency
hx of difficulty walking, lower limb symptoms or bladder and bowel dysfunction
Also increased reflexes and tone, sensation losses
Treatment of neck pain
Generally favourable diagnosis and usually responds to simple analgesia, mobilisation and physiotherapy
What is essential for treating neck pain
Mobilisation
Especially mobilisation in whiplash injuries
Gentle exercises can help
Medication for neck pain
Limited evidence for use of paracetamol, opioids, NSAIDs and antidepressants
When do you do surgery for neck pain
Radiculopathy or myelopathy
Causes of shoulder pain x5
Rotator cuff problems Adhesive capsulitis GHJ problems Referred pain from elsewhere Regional or diffuse pain syndromes
What are most shoulder complaints due to?
Rotator-cuff complaints (60-70%)
What is common with the rotator cuff?
Asymptomatic cuff tears found on scanning - increasing incidence with age - implies might be a part of aging
Who are rotator cuff disorders common in?
Young people playing sports involving overhead activities
Middle and older age
Symptoms of rotator cuff disease
Pain in shoulder or lateral aspect of upper arm
Worse with overhead activities and at night
Especially worse when lying on affected side
Examination signs of rotator cuff disease
Pain in mid-range of shoulder abduction and on resisted shoulder abduction
Passive motion is normal
What is sign of rotator cuff impingement
Pain when patient places hand on their contralateral shoulder and push up against resistance
Sign of large or complete rotator cuff tear
Drop arm test
Can’t lower arm slowly and controlled
Will drop when reach a certain point
What is a rotator cuff problem in women aged 30-50 years and how does it present?
Calcific tendinitis - formation and resorption of calcium deposits in the cuff
Acute onset of severe pain - occasionally with fever and severe limitation of movement due to pain
Diagnosis of rotator cuff disease
Usually made clinically
Limited diagnostic utility of scanning because of the amount of asymptomatic rotator cuff tears
Treatment aims of rotator cuff disease
Control pain with analgesics
Restore movement and function
Analgesia in rotator cuff disease
Paracetamol with mild opiates - codeine phosphate - if needed
NSAIDs can be good short-term
Steroid injections provide rapid relief but not maintained
Physiotherapy in rotator cuff disease
Combination of mobilisation techniques and strengthening exercises
What can be needed if physio and analgesia don’t work in rotator cuff disease
Surgery - decompression of subacromial space, with or without rotator cuff repair
Treatment of calcific tendinitis? x4
Subacromial steroid injections
Needling of calcific deposits
Percutaneous needle aspiration and lavage by US guidance
What is adhesive capsulitis?
Frozen shoulder
Incidence of adhesive capsulitis and in whom is it more common?
2-5% of population
Slightly more common in women
Much more common in diabetes patients and it is also more severe
What age does frozen shoulder usually occur?
5th and 6th decades
Rare before 40 years old
Phases of frozen shoulder?
Initial gradual development of diffuse severe pain - 2-9months
Stiff phase with less severe pain but global stiffness and severe loss of shoulder movement 4-12 months
Recovery phase with gradual return to movement over 5-24months
Diagnosis of frozen shoulder
Clinically
Restriction of both active and passive movement in all planes of movement
Treatment of frozen shoulder
Analgesia - same as for rotator cuff disease
Steroid injections again provide rapid but not sustained pain relief
Physiotherapy can be helpful after the painful stage
Interventional management of frozen shoulder
Arthrographic distention of GHJ or hydrodilatation performed under radiological guidance - using anaesthetic, saline and corticosteroid
Can have sustained benefit on pain, function and ROM
Other possible pain reliefs in frozen shoulder x3
Short course of oral steroids
Suprascapular nerve blocks
Manipulation under anaesthesia with possible debridement of adhesions - if all other options have failed (associated risks)
Where in shoulder does OA affect?
Acromioclavicular joint
Rare in GHJ but can occur if previous trauma
Where in shoulder is affected by RA
Sternoclavicular joint (can be presenting site of RA) GHJ in connection with PMR
What is Milwaukee shoulder?
Severe destructive apatite-associated arthropathy - presents with shoulder pain, limited movements and large joint effusion
Aspiration shows blood-tinged synovial fluid
Mainly effects elderly women
What is tennis elbow?
Lateral epicondylitis
Incidence of Lateral epicondylitis?
4-7 per 1000 patients in GP
Most common age for Lateral epicondylitis?
40-50
Cause of Lateral epicondylitis?
Thought to be overload injury at origin of common extensors from lat.epicondyle
Tennis is only the cause in 5%
Risk factors for Lateral epicondylitis?
Wrist turning or hand gripping
What is Golfer’s elbow?
Medial epicondylitis
Symptoms of epicondylitises?
Pain and tenderness over epicondyle
Aggravated by repetitive movement and lifting
May be night pain and early morning stiffness
Stiffness after periods of inactivity
Diagnostic test for epicondylitis
Pain on resisted movement (eg. resisted dorsiflexion of wrist or middle finger or both in Lateral epicondylitis)
Prognosis of Lateral and medial epicondylitis?
Self-limiting normally, recover within a year or so
Treatment of Lateral and medial epicondylitis?
Rest in acute phase and Splinting can help
Topical and oral NSAIDs
Corticosteroid injections for short relief
Physiotherapy (US, deep friction massage and exercise)
Arthritis which affects elbow
RA, Seronegative arthritis, gout or pseudogout - rarely septic arthritis
OA only really if trauma
Symptoms and cause of olecranon bursitis?
“students elbow” - acute or repetitive trauma
Discrete swellng, pain and inflammation at posterior point of elbow
Inflammatory arthritis signs in elbow
Pain when try to extend the arm - if effusion
DDX in olecranon bursitis
Exclude septic arthritis
Treatment of olecranon bursitis due to inflammatory or crystal arthritis
Steroid injection
Treatment of infective olecranon bursitis
Broad-spectrum antibiotics and possibly open drainage and lavage
What is a sclerotome?
Deep somatic track innervated by the same spinal nerve - when tissue is irritated in this sclerotome - it is experienced as originating from all the tissues innervated by the same nerve
Difference between sciatica low back pain and sclerotomal low back pain?
Sclerotomal pain is non-dermatomal in distribution and also radiates to lower extremities but not below the knee (whereas sciatica goes below the knee)
Also no paraesthesia with sclerotomal pain as in sciatica
What causes the majority of lower back pain?
Mechanical pain which is from anatomical abnormality, increases with physical activity and decreases with rest
Most common cause of mechanical low back pain
Degenerative change - eg. lumbar spondylosis (lumbar OA) - degenerative changes in IV disc and facet joint
What can disc herniation result in occasionally?
Nerve root impingment causing sciatica
Which are the most common clinically significant herniations?
L4-L5 and L5-S1 - 95% are these two
Which nerve root is commonly impinged in herniations? eg. with L4-L5
The caudal nerve root therefore will be L5 root in L4-5 herniation
What is a rare surgical emergency with disc herniation
Cauda equina syndrome with a large midline herniation
- altered saddle section, rectal/perineal pain, reduced bladder sensations, difficulty walking, urinary retention with overflow incontinence and faecal incontinence
What is spondylolisthesis?
Anterior displacement of a vertebra on the one beneath it
Usually due to secondary degenerative changes but may result from developmental defect in pars interarticularis of vertebral arch
Symptoms of spondylolisthesis?
Can be asymptomatic if mild - can have mechanical low back pain
If larger displacement that can have sciatica or spinal stenosis
What is spinal stenosis?
Narrowing of spinal canal and its lateral recesses and neural foramina
What are symptoms of spinal stenosis?
Can cause compression of lumbosacral nerve roots
Results in pseudoclaudication (neurogenic claudication), - bilateral pain, weakness and sometimes paraesthesiae in buttocks thighs and legs
Symptoms induced by standing and walking - unsteadiness of gait is common
What causes spinal stenosis?
Normally occur due to degenerative changes
What stature can result from spinal stenosis?
Simian stance because forward flexion increases the canal diameter
Signs of low back pain being due to infection or neoplasm
Non-mechanical
Especially when accompanied by nocturnal pain
Signs of low back pain being due to spondyloarthropathy
Night-time waking with pain and stiffness
Prolonged morning stiffness that improves with exercise but not with rest
What are functional and structural scoliosis
Structural scoliosis is secondary to structural changes of vertebral column. Functional scoliosis is usually the result of paravertebral muscle spasm or leg-length discrepancy
Examination to differentiate between functional and structural scoliosis?
Functional disappears with spinal flexion but structural does not
Examination sign of spondylolisthesis?
Palpable step off between adjacent spinous processes
What sort of pain does hip arthritis usually cause?
Groin pain and occasionally referred back pain
What does the straight leg raise test do?
Places tension on sciatic nerve and stretches nerve roots - patients with existing nerve root irritation eg. impingement will experience radicular pain that extends below the knee
Problem with investigations in LBP
Many of the causes are present in asymptomatic patients - some are equally present in patients with LBP as they are in patients without LBP
General treatment for LBP
Analgesia, education, back exercises, aerobic conditioning and weight control
Different classifications of LBP for treatment purposes
Patients either have acute LBP (3 months) or chronic or nerve root compression syndrome
Treatment of acute LBP
Activity is encouraged - bed rest discouraged
Paracetamol and NSAIDs
Muscle relaxants may help
Treatment once acute LBP episode has resolved
Regular back exercises, aerobic conditioning and loss of excess weight to prevent recurrences
Treatment of chronic LBP
Pain relief - complete relief is unrealistic goal - paracetamol and NSAIDs may provide analgesia, low dose tricyclics may help some
Exercises, aerobic conditioning and weight loss
Back surgery not helpful
Treatment of nerve root compression syndromes - disc herniation
Treat conservatively as for acute LBP - for the first 6 weeks unless severe or progressive neurological defect and 90% will improve
Surgery may be considered if neurological defect = laminotomy with limited discectomy
Treatment of nerve root compression syndromes -spinal stenosis
Symptoms remain stable in most patients - analgesics, loss of excess weight and exercises - also epidural glucocorticoids may help with symptoms
Surgery to decompress neural elements if disabling symptoms
Type of pain presentation with disc prolapse
Seized by severe pain on coughing, sneezing or twisting - a few days after back strain
Signs of disc prolapse
Forward flexion and extension are limited
Lateral flexion may also be limited unilaterally
L5/s1 prolapse get calf pain and weak foot plantar flexion
L4/l5 hallux is weak
Causes of rotator cuff tears
Trauma or degenerative changes
What joints are ACJ and GHJ?
GHJ - synovial
ACJ - fibrous
Fluid on shoulder MRI
White - due to a tear - can be partial/complete
Conservative management of cuff tear
Analgesia, steroids, physio
Impingement treatment
Conservative (physio, analgesia, rest)
Steroid injections
Decompression - bursectomy, acromioplasty
Association of frozen shoulder
Diabetes
Hypo and hyperthyroidism
Autoimmune
Posterior dislocation position
Internally rotated and abducted
What should you examine for in posterior shoulder dislocation
Hyper laxity and other collagen problems
