Week 2 - Safeguarding & MSK

Question 1

MSK History Taking

Joint vs Soft Tissues
Non-Inflammatory Conditions
Inflammatory Conditions
Impact on Life

Answer 1

1. ) Joint vs Soft Tissues - joint pain w/ normal joint examination suggests referred pain from soft tissues
   - sprains, strains, bruises, contusions
2. ) Non-Inflammatory Conditions - OA, fibromyalgia
   - pain is worse in use and relieved by rest
   - localised, short lasting (30mins) stiffness
   - joint swelling is less common unless knee related
3. ) Inflammatory Conditions - RA, gout, psoriatic/reactive arthritis, polymyalgia rheumatica
   - pain is not relieved by rest
   - generalised, prolonged morning stiffness
   - joint swelling is also very common
4. ) Impact on Life
   - daily acitivities, work, social, mood, ICE

Question 2

Management of Soft Tissue Injuries

Rest
Ice
Compression and Elevation
Painkillers

Answer 2

1. ) Rest - avoid strenuous activity
   - need to move regularly to prevent stiffness
   - most resolve in 2-3 weeks
2. ) Ice - reduces pain and limits swelling
   - wrap ice around damp cloth
   - hold on affected area for 5/10 mins, repeating as often as possible for first 48hrs after the injury
3. ) Compression & Elevation
   - buy compression bandages from pharmacy
   - if lower limb, use a stool, if upper limb use a sling
4. ) Painkillers
   - paracetamol x2 up to 4 times a day
   - ibuprofen taken only w/ food

Question 3

Sciatica

Symptoms
Examinations
Management
Amitriptyline

Answer 3

1. ) Symptoms - pain, numbness, tingling
   - buttocks, back of thigh, outer calf, feet and toes
   - pain can present in any location but often radiates
   - often relieved on sitting and worse on standing
   - needs to rule out cauda equina syndrome
2. ) Examinations
   - pain on 90-degree straight leg raises
   - pain on palpation of sciatic nerve in pelvis
   - hip examination to rule out hip dislocation or fracture
   - knee exam to rule out referred pain of the knee
3. ) Management - can take at least 4-6 weeks
   - stretching exercises, apply heat, staying active
   - paracetamol + naproxen + PPI
   - cocodamol + senna if naproxen is contraindicated
   - amitriptyline (for chronic sciatica)
4. ) Amitriptyline - used for neuropathic pain
   - anticholinergic drug so side-effects: dry eyes/mouth, hypotension, delirium
   - other side effects: constipation, urinary retention, arrhythmias (↑QT interval), hypothermia

Question 4

Red Flag Symptoms for MSK

General 
Cauda Equina Syndrome
Infection x2
Cancer
Other Urgent Conditions x5

Answer 4

1. ) General
   - worsening symptoms not responding to conservative management or medication as expected
   - systemically unwell, night pain preventing sleep
2. ) Cauda Equina Syndrome - low back pain w/:
   - bilateral sciatica, severe muscle weakness
   - perianal numbness, urinary/faecal incontinence
   - erectile dysfunction
   - causes: disc prolapse, bony mets, myeloma, epidural haematoma/abscess, primary sacral tumour
3. ) Infection - spinal infection, septic arthritis
   - spinal infection: discitis (disc), osteomyelitis (bone)
   - bone pain and systemically unwell
   - hot, swollen, painful joint suggest septic arthritis
4. ) Cancer - often metastatic bone pain
   - >50, gradual onset, unexplained weight loss
   - severe pain remains when supine, disturbs sleep
   - pain aggravated by straining (e.g. coughing etc.)
   - conservative management ineffective after 4-6wks
   - PH (esp): breast, lung, GI, prostate, renal, thyroid
5. ) Other Urgent Conditions
   - metastatic bone pain, insufficiency fracture
   - cervical spondylotic myelopathy
   - major spinal related neurological deficit
   - rheumatological conditions often require referral to a rheumatologist

Question 5

Morton’s Neuroma

What is it?
Presentation
Clinical Features
Management
Differentiating between Intermetartarsal Bursitis

Answer 5

1. ) What is it? - benign fibrotic thickening of a plantar interdigital nerve that is a response to irritation
   - irritated by nerve entrapment, stretching, ischaemia
2. ) Presentation
   - around 55yrs, more common in women
3. ) Clinical Features
   - pain commonly between 3rd and 4th metatarsal
   - patients describe like walking on a pebble
   - occurs while walking, worsens with increased activity and certain footwear
   - sharp, stabbing, burning or tingling sensation in the distribution of the affected nerve
4. ) Management
   - footwear: orthotics (metatarsal pad), avoid thin soles, high heels, constricting toe pad
   - NSAIDs if necessary for pain
   - if >3 months, refer to specialist (orthopedics)
5. ) Differentiating between Intermetartarsal Bursitis
   - bursitis due to inflammation, similar symptoms
   - imaging (ultrasound) needed to differentiate

Question 6

Carpal Tunnel Syndrome

Risk Factors
Clinical Features
Diagnostics Tests
Management

Answer 6

1. ) Risk Factors - cause is often unknown
   - high hand/wrist repetition rate, obesity
   - hypothyroidism, diabetes, B12 deficiency
2. ) Clinical Features
   - sensory loss, dry skin in median nerve distribution
   - atrophy of thenar eminence, reduced strength of thumb abduction
   - positive diagnostic tests
3. ) Diagnostic Tests - produce pain and paraesthesia
   - Phalen’s: wrist flexion for up to 60 seconds
   - Tinel’s: tapping over transverse carpal ligament
   - compression test: applying firm pressure over carpal tunnel for up to 30 seconds
4. ) Management
   - assess potential underlying risk factors/causes
   - avoiding repetitive movements, if work-related, arrange an assessment with their employer
   - carpal tunnel splint (in a neutral position).
   - corticosteroid injection
   - referral to specialist services if symptoms worsen
   - surgery: division of the flexor retinaculum to decompress the median nerve

Question 7

Plantar Fasciitis

Clinical Features
Management

Answer 7

1. ) Clinical Features
   - intense pain on onset of walking
   - pain reduces w/ moderate activity but worsens later during the day
   - tenderness on palpation of plantar heel area
   - limited ankle dorsiflexion range
2. ) Management
   - rest, avoid tight shoes, insoles, stretching exercises
   - paracetamol/ibuprofen, ice pack to ↓inflammation
   - most have complete recovery within a year
   - steroid injection if severe pain persists