GP: MUSCULOSKELETAL/ORTHO/NEURO ISSUES

*POLYMYOSITIS* "mad cries" mnemonic

"M(2)AD CRI(2)ES(2)" - *M*uscle weakness (proximal), weakness and tenderness: e.g. difficulty rising from a chair. - *M*alignancy (10-20% cases are non-Hodgkin's, lung or bladder ca) - *A*rthralgia (50%): small hand joints commonly - *D*ysphagia (50%) - *C*K levels are 50x more raised!!! - *R*aynaud's phenomenon - *I*nflammatory markers raised + ILD related - *E*MG reguired for confirmation - *Seropositive disease + *S*teroid treatment required)

*REACTIVE ARTHRITIS*

acute asymmetrical *lower limb arthritis*; a few days to weeks after GI/GU infection. - triad of *conjunctivitis, arthritis and urethritis*. - other possible s/s include skin changes. It has an association with HLAB27. Can present with arthritis anywhere including the back but the lower limbs are most common.

*OSTEOPOROSIS* a bone disease; "porous bones". It is characterised by decreased bone mass and strength as a result of reduced bone quantity and quality. A person with osteoporosis has an increased risk of fracturing a bone. Osteoporosis usually progresses without symptoms until a broken bone occurs.

usually asymptomatic until bone fracture: *elderly and post-menopausal women* are more at risk. The most common sites affected are the => *HIP* - e.g. femoral neck => *VERTEBRAE* compression fractures - thoracic and upper lumbar with severe pain and deformity leading to kyphosis => *WRIST* e.g. Colles fracture (distal radial fracture) from FOOSH - other risk factors: low BMI (such as in anorexia nervosa), excess steroids, Cushings syndrome, immobilisation, hyperthyroidism, long term heparin, vitamin D deficiency investigations (1) *DEXA is gold standard* - it measures bone density and can range from normal to osteopaenia to osteoporosis. Graded based on T-score below -2.5 (2) rule out secondary causes: check *FBC, electrolytes (Ca2+, phosphorous for hyperparathyroidism), creatinine/BUN, LFT, TSH, vitamin D, free PTA, coeliac disease work up (TTG antibodies), myeloma and monoclonal gammopathy (urine Bence-Jones protein) and hypogonadism* management - *diet*: daily calcitonin (1200mg/day), vitamin D - *weight bearing exercise* 3x/week to stimulate bone formation, - *smoking and alcohol cessation* - *oral biphosphonates* (alendronate 70mg once weekly or risedronate) reduce osteoclastic activity and thus the risks of fractures. A/E - reflux, oesophageal irritation, ulceration - zoledroninic acid IV or denosumab are alternatives - 2nd line - *PTH therapy (teriparatide)* if 1st line failed or severe spinal osteoporosis - max 24 months.

*ACUTE SWOLLEN/PAINFUL JOINT PAIN* anyone presenting with joint pain should always have *SEPTIC ARTHRITIS* ruled out. Look for swelling, redness, tenderness, warmth of the area; hips and knees are particularly at risk. Look for risk factors; elderly, child, diabetics, HIV+, IVDU, prosthetic implant, metalwork in joint, previous surgery, joint injections, traumatic event

⚠️ *SEPTIC ARTHRITIS* - most commonly affects the large joints: knee > hip and has a subacute onset 1-2 weeks. In children, the hip is the most common source. *risk factors*: immunocompromised (elderly, IVDU, diabetes, HIV, steroid use), prosthetic joint, recent trauma/intra-articular injection, arthritis, sepsis. *s/s*: acutely swollen, red, tender, warm joint. A child would be unwillingness to bear weight on the affected joint. Kocher criteria used in children *investigate*: hip may be flexed, abducted and externally rotated, poor ROM. Bloods: raised inflammatory markers. Joint aspiration is gold standard. X-ray will not show joint destruction/narrowing until 2-3 weeks after onset of attack. *treatment*: with analgesia, high dose co-amoxiclav 1.2g/8hr IV for >6 weeks after positive diagnostic joint aspiration test. May need repeated aspiration/surgical washout. ⚠️ *OSTEOMYELITIS* - doesn't affect the joint itself; but the bone marrow. It may look like a swollen joint so important to keep in differential. *GOUT - typically rapid onset <24hrs with exquisite tenderness. 1st attack 1st MTPJ in 50-70%. - risks: previous attacks, male, >30, diet: ETOH, meats or seafood, obesity, diuretics and renal impairment. Joint aspiration is gold standard. - manage with rest, elevation, ice packs, NSAIDs +./- PPI cover or colchicine 500mcg 2-4x daily or taper down prednisolone 20mg OD. - advise to return if symptoms worsen/do not resolve in 1-2 days for gout/pseudogout. Follow up with GP in 4-6 weeks after acute attack has resolved with review of starting allopurinol. Do not stop allopurinol if already on it. Do not start allopurinol if not on it. *PSEUDOGOUT* - calcium pyrophosphate; knee most common site of attack. *HAEMARTHROSIS* *REACTIVE ARTHRITIS*: will have prior GI symptoms. *SLE/RA exacerbation*: ask about systemic symptoms *TRAUMATIC SYNOVITIS*: commonly associated with arthritis; particularly RA *TRANSIENT SYNOVITIS/IRRITABLE HIP*: self-limiting condition with unknown cause; typically occurs in children

WHEN TO REFER A PATIENT WITH BACK PAIN?

**** they have neurological features of cauda equina syndrome or cord compression *** they develop progressive neurological deficit (weakness, anaesthesia) *** nerve root pain not resolving after 6 weeks: perform routine bloods including U&E, haematinics and Mg2+. ** suspected underlying inflammatory disorder such as ankylosing spondylitis ** simple back pain and have not resumed their normal activities in 3 months. The effects of pain will vary and could include reduced quality of life, functional capacity, independence or psychological well-being. Where possible, referral should be to a multidisciplinary back pain team + they develop a serious unwanted effect from drug therapy **** immediate referral (within a day) *** urgent referral ** soon * routine

*BACK PAIN CLASSED BASED ON AGE*

*15-30 years* - mechanical: muscular strain/overuse - slipped disc (IV disc bulges outward) - kyphosis (excessive outward curve of the spine results in an abnormal rounding of the upper back): can be due to OA, Scheuermann's disease (genetic). - ankylosing spondylitis - bone cancer *30-50 years* - spondylosis (general term referring to degenerative changes in the spine e.g. bone spurs, degenerated IV discs, OA) can result in sciatica, spinal stenosis, kyphosis, slipped disc and spondylolisthesis ==> spondylolisthesis (anterior slipped vertebrae): caused as a result of spondylosis ==> prolapsed disc: most common cause of lumbar radiculopathy in young adults - discitis - metastatic disease *>50 years* ⚠️- cauda equina tumors ⚠️- metastatic malignancy: lung, breast, prostate, myeloma ⚠️- referred pain: cardiac pain, aortic aneurysm, pancreatitis ⚠️- spinal infarction - degenerative - vertebral compression fracture (secondary to osteoporosis, trauma or cancer). - Paget's disease: raised ALP, sacrolumbar pain and tenderness. deafness, high cardiac output - spinal stenosis - metastatic disease always consider rule out: - AAA - acute pancreatitis - acute MI - pyelonephritis non-specific back pain is common in all age groups

*KNEE LIGAMENT INJURY* - ACL: sports injury - PCL: motor vehicle accident - MCL: direct blow to outside - LCL: direct blow to inside (rare)

*ACL*: sudden deceleration, twisting, pivoting, turning causing *audible pop*, *immediate swelling, "giving way" and inability to continue activity* - diagnosis: positive anterior drawer test (easiest and has good 90% sensitivity and specificity - see picture), pivot shift sign and Lachmann test (more accurate) <anterior draw test: see picture: patient in supine; flex the hip and knee to 45 and 90 degrees respectively. Sit on the patient's foot (for grip), hold onto the upper part of the tibia and quickly pull it toward yourself. Positive if pain (sprain) or excessive movement (tear)> *PCL*: sudden posterior displacement of tibia when knee is flexed or hyperextended for example in a MVC. Symptoms as above. - diagnosis: positive posterior drawer test, reverse pivot shift sign management for ACL or PCL 1) *immobilise with knee brace for 2-4 weeks with early ROM and strengthening* 2) if complete tear or a very active individual: refer for ligament reconstruction *MENISCAL TEARS* - MCL more common with direct blow to outside of knee causes valgus deformity: pain, instability, difficulty weight-bearing, locking. LCL is due to a blow from the inside (rare). - diagnosis: MRI or arthroscopy - management: surgical repair if there is locking or non-operative has failed

*ANKLE AND FOOT* - ankle ligament damage - achilles tendonitis - achilles tendon rupture - plantar fasciitis

*ANKLE LIGAMENT* - >90% lateral ligaments from eversion injury - swelling, tenderness, bruising anterior to the lateral malleolus - conservatively: rest, ice, compression, elevation +/- strap ankle in dorsiflexion and eversion for 4-6 week + physio - if complete tear: below knee walking cast for 4-6 weeks. *ACHILLES TENDONITIS* - chronic inflammation from poor activity/incorrect footing wear. *Haglund deformity*: heel bumps: enlargement of posterior superior tuberosity of the calcaneus - *pain, stiffness, thickened tendon, palpable bump* - manage: rest, NSAIDs, shoe wear modifications, heel sleeves/pads, insoles for proper support. If chronic problem; offer shockwave therapy <warning: never inject steroids> *ACHILLES TENDON RUPTURE* - "stop and go" sport: audible pop, sudden pain, *inability to plantar flex* - cast foot in plantar flexion for 2 weeks then use a walking boot (wean off for the next 4 weeks) with physiotherapy - surgery indicated after 6-8 weeks if high athletic demand. *PLANTAR FASCIITIS* - the most common cause of heel pain secondary to repetitive strain injury causing microtears and inflammation of plantar fascia *- risk factors*: increased periods of standing, flat soled shoes, obese, women, joggers *- symptoms*: sharp pain in the heel/anterior calcaneus whilst taking first several steps in the morning or after long periods of inactivity. There is *pain when palpating the plantar medial calcaneal tubercle or dorsiflexing the toes*. *- management*: rest, NSAIDs, ice, prefabricated shoe inserts that provide arch support, stretching of the achilles tendon. Surgery (fasciotomy) reserved only for those with 6-12 months of uninterrupted failed conservative therapy. *- differential*: rule out calcaneal stress fracture by squeezing the heel with your palm on examination; if it elicits pain; perform x-ray. *FAT PAD ATROPHY* - common cause of heel pain in the elderly: in contrast to plantar fasciitis: *causes pain as the day goes on* *MORTON'S NEUROMA*: benign tumour of the 3rd intermetatarsal plantar nerve, most commonly of the second and third intermetatarsal spaces. Entrapment of the nerve causes pain and/or numbness. - W>M, mid-age, terrible shoes. - variable localised tenderness, pain +/- numbness. - management: appropriate footwear/orthoses, steroid injection, cryotherapy. surgical excision. *BUNION/HALLUX VALGUS* - secondary to wearing poor fitting footwear, can be hereditary, F>M - management: *low heel fitted shoes with toe spacer*. - osteotomy indicated if very painful despite orthoses, inflammation not resolving, toe drifting in/crossing over, toe stiffness/inability to straighten the big toe. *TOE JOINT DEFORMITIES*: => *claw toe*: flexion of the IP joint and hyperextension of the MTP joint,. Special footwear or arthrodesis for management. => *hammer toe* (PIP hyperflexed) often 2nd toe: When the shoe rubs against a hammer toe, corns, blisters or calluses may form. Prescribe *custom made shoes and a protective shield* for the hammer toe. Surgery is inflexible. => *mallet toe*: hyperflexion of the DIP. *LOWER LIMB STRESS FRACTURES*: localised tenderness and swelling in superficial bones. Caused by repetitive minor stress e.g. running with a history of recent increased intensity. Pain can be reproduced when jumping on the affected leg. See below for more details.

*ARM NERVE PATHOLOGY*

*AXILLARY* - around surgical neck of humerus - reduced sensation and power of the shoulder - common with anterior shoulder dislocation *MUSCULOCUTANEOUS* - unable to flex arm +/- tingling/reduced sensation over the lateral side of the forearm. - test by flexing arm against resistance +/- (result of pain) and/or feel under coracoid process *RADIAL*: - unable to extend wrist/wrist drop, cannot extend fingers, dorsal paraesthesia in the first 3 and half fingers. - "Saturday night palsy" often refers to when a person falls asleep whilst sedated (e.g. alcohol) with the underside of their arm compressed against a hard object e.g. bench. *MEDIAN* - unable to flex wrist - ape hand (thenar wasting, poor thumb flexion, unable to oppose thumb), hand of Benediction (2nd/3rd metacarpals) - paraesthesia in the first 3 and half fingers (carpal tunnel syndrome). *ULNA* - poor grip/thumb flexion, clawing and paraesthesia o the of ring and little fingers

*CERVICAL SPINE* - *cervical spondylosis*: degenerative changes of the cervical spine through wear and tear ==> *cervical disc syndrome*: nucleus pulposus herniates through annulus fibrosus and impinges upon nerve root, most commonly at C6-C7 ==> *cervical stenosis*: commonly due to spondylosis (progressive degeneration), bone spurs, herniated discs, or swollen ligaments. Typically begins at age 40-50, M>F, most commonly at the C5-C6 region - *cervical myelopathy*: an injury to the spinal cord due to severe compression that may result from trauma, congenital stenosis, degenerative disease or disc herniation

*CERVICAL SPONDYLOSIS* - also known as cervical osteoarthritis with risk factors being occupation (e.g. painters/carpenters), previous trauma, family history and increasing age. - s/s: can be asymptomatic otherwise neck pain (improving with rest), stiffness, crepitations, headaches, pain down shoulders (cervical disc syndrome) - general management (assuming no red flags): include physiotherapy, muscle relaxants, steroid injections. In severe cases, surgical options are also available. - can lead to disc herniation, bone spurs, compression fractures: all of which can lead to devastating stenosis or cord compression. *VERTEBRAL COMPRESSION FRACTURE* defined as a vertebral bone in the spine that has decreased at least 15 to 20% in height due to fracture. Usually associated with *osteoporosis* (most common), *trauma* or *spinal metastases*. Can occur anywhere in the spinal vertebrae. => initially: conservative management with bed rest (till pain lessens) then follow up in a week. => *percutaneous vertebroplasty, and balloon kyphoplasty* without stenting are recommended as options for treating osteoporotic vertebral compression fractures only in people who have severe ongoing pain >2 weeks despite optimal pain management and in whom the pain has been confirmed to be at the level of the fracture by physical examination and imaging. *CERVICAL DISC SYNDROME* - nucleus pulposus herniates through annulus fibrosus and impinges upon nerve root, *most commonly at C6-C7* (positive Spurling test). - s/s: pain in arm in a dermatomal distribution, worse with neck extension, rotation and flexion (due to compression of ipsilateral neural foramen). LMN signs, sensory/motor deficit and radiculopathy. - management: activity modification, physiotherapy, NSAIDs + re-assure that 95% improve within 4-8 weeks - MRI imaging of choice if s/s do not improve within 4-8 weeks - surgery involves *anterior cervical discectomy* reserved only for intractable pain >3 months despite analgesia or progressive neurological deficit. *CERVICAL STENOSIS* - mechanical neck pain worse with movement including positive Spurling sign (examiner turns the patient's head to the affected side while extending and applying downward pressure to the top of the patient's head -> radicular pain secondary to nerve root compression) *CERVICAL MYELOPATHY* ■ weakness (upper > lower extremity), lower extremity weakness (corticospinal tracts) is most worrisome complaint ■ decreased dexterity, loss of fine motor control ■ sensory changes ■ UMN findings such as hyperreflexia, clonus, and Babinski reflex ■ funicular pain, characterised by burning and stinging ± Lhermitte's sign (lightning-like sensation down the back with neck flexion) management - analgesia, muscle relaxants - rigid neck collar (for <1 week): beneficial in 50% - refer to A&E immediately if history of trauma and spine tenderness. - surgery: cervical root decompression. Referral to neurosurgery required if: ==> symptoms of spinal cord compression ==> signs and symptoms of myelopathy ==> spinal tenderness and previous trauma/surgery indicates immediate immobilisation, A&E referral and imaging. ==> dizziness/dropouts/blackouts: suggest vascular insufficiency ==> new symptoms below age 20 or above age 55 years ==> history of cancer, unexplained weight loss, fever, history of infections (e.g. TB, HIV), history of inflammatory arthritis

*TORTICOLLIS* - congenital - acquired

*CONGENITAL CAUSES* usually in newborns 6-8 weeks old with tilted neck and sternocleidomastoid muscle mass. U/S confirms mass/diagnosis. - managed with physiotherapy; passive positioning of the head is essential to strengthen neck muscles, develop active and passive positioning, and improve the cervical range of motion. - re-assure parents that the majority of SCM masses resolve after 2-6 months of stretching therapy and positioning. If no improvement after a year; refer for myotomy. *ACQUIRED* causes can be due to antipsychotics, posterior fossa tumours or ENT infections.

*HIP PAIN IN CHILDREN* ⚠️ always rule out septic arthritis or osteomyelitis in children! ➖ developmental dysplasia of the hip: painless limp when starting to walk @ 9-12 months ➖ transient synovitis of the hip: 2-10yrs common after an URTI ➖ Perthes' disease: 4-10yrs, reduced internal rotation/abduction painful, antalgic gait ➖ slipped upper femoral epiphysis: similar to Perthes disease with reduced internal rotation only and child is older @ 6-10yrs ➖ sickle cell disease (avascular necrosis) ➖ femoroacetabular impingement (anterolateral hip pain with painful internal rotation) ➖ trochanteric bursitis (lateral hip pain worse with standing and abduction) if 12-13 month old infant who is still unable to walk, rule out global delay and/or assess if a hip problem - can they respond their own name/cry when parent not around (social), follow 1-step commands and say 2 words (S&L), near pincer grasp (fine motor): all of which are relevant to 12-13 month old infants workup for older infants and children 1) ask about red flags: - pain out of proportion to degree of inflammation - pain worse at night/@rest - fever, night sweats, weight loss - erythema, pinpoint pain/tenderness 2) ask if any history trauma, previous surgeries, previous episodes? 3) examine: able to weightbear? is the joint red, hot, swelling and/or tender? assess ROM, limb weakness, sensation and pulses.

*DEVELOPMENTAL DYSPLASIA OF THE HIP* - *presents @ birth* - risks: *F*rank breech (most important), *F*emale (8x more!!) *F*amily history, *F*irst born, left hip, oligohydramnios - painless limp when starting to walk (9-12 months). Parents may notice leg length discrepancy, limp, trouble crawling/walking, waddling, and restricted ROM. - s/s: assessment of child at 6 weeks; affected leg shortened (results in asymmetry in skin folds), limited abduction angle of the flexed hip - examination: *Barlow's test*: checks if hips are dislocatable. *Ortolani test*: checks if hips are dislocated aiming to relocate hip back into position: palpable clunk will be felt if hip successfully reduced - if suspected, U/S to confirm. - management depends on the age => @ <6 months: pavlik harness in abduction and flexion => @ >6 months: closed reduction with GA, hip spica cast => @ > 2 years: open reduction *TRANSIENT SYNOVITIS OF THE HIP* - *2-10 years* of age with M>F commonly occurring after an URTI with the R>L - hip +/- knee pain, difficulty weight bearing, externally rotated/abducted. There is *full ROM*, no erythema or tenderness and patient looks well. - x-ray: normal, bloods may show mildly elevated inflammatory markers - U/S may show transient effusion. - typically resolves in 7-10 days *PERTHES' DISEASE* - peaks *4-10yrs* with M>F - *antalgic gait* (on weight bearing leg), pain in the hip, *restricted ROM internal rotation and abduction*. Bilateral involvement in ∼15% of cases. - due to *idiopathic avascular necrosis* of the femoral head - XR (only appears late): joint space narrowing, flattened head of femur, osteonecrosis. If negative but clinically suspected; request MRI. - management: mild cases and younger children <6yrs: *limited weight bearing, physical therapy*. If ROM worsens; *cast and brace* before surgery (*femoral osteotomy*) which aims to ensure the femoral head remains well seated in socket. - usually heals in 2-3 years *SLIPPED UPPER FEMORAL EPIPHYSIS* - v.similar to Perthes disease but this one *occurs in older children peaking in puberty teenage years*: M>F, typically in obese, tall and underdeveloped children - chronic pain in the the *groin and anterior hip +/- knee pain* progressing to a *limp*. Bilateral in 20% with L>R - examination: *positive Trendelenburg sign*. tenderness over joint capsule with *reduced ROM particularly internal rotation*. - XR shows "frog leg", *posterior inferior displacement of the femoral head in relation to the neck*. - management: surgery - complications: avascular necrosis, premature OA *SICKLE CELL DISEASE* - avascular necrosis is a common complication of Perthes' disease (4-10yrs) and *sickle cell disease* (pubertal/teenage years of life). - always suspect sickle cell disease in an African-American child presenting with groin pain and bone tenderness with no systemic symptoms. - s/s: subacute hip pain with lack of systemic symptoms are signs for avascular osteonecrosis, which occurs due to trabecular bone infarction from RBC sickling and vaso-occlusion. The femoral head is commonly affected as a result of poor collateral blood supply. *FEMOROACETABULAR IMPINGEMENT* extra bone grows (bone spurs) along the hip joint causing friction eventually leading to pain and limited activity. - S/S: gradual *anterolateral hip joint pain* exacerbated by pivoting laterally and sitting from standing. ==> physical exam: "FADIR test": flex, adduct then internally rotating the hip will reproduce the pain. *TROCHANTERIC BURSITIS* - lateral thigh pain and tenderness with no radiation down the leg. Worse when standing up and with abducting the hip against resistance.

*LOWER LIMB STRESS FRACTURES* - femoral neck stress # - tibia stress # - navicular stress # - 2nd metatarsal # - 5th metatarsal # - sesamoid bone #

*FEMORAL NECK stress #* sports associated: distance running. - distraction side (superior) requires urgent surgical review - compression (inferior) side can be managed with non-weight bearing (NWB) and relative rest *TIBIA stress #* sports associated: distance running. - anterior tibial (distraction) and medial (compression) can be managed with Aircast® brace followed by gradual reintroduction of weight bearing (WB). - distraction fractures usually require prolonged treatment (6-12 months) *NAVICULAR stress #* sports associated: athletics, football, rugby. - treatment includes NWB plaster cast immobilisation for 6-8 weeks *2ND METATARSAL STRESS #* e.g. ballet dancing. - treatment: NWB immobilisation (Aircast®) for 2 weeks with partial WB for further 2 weeks *5TH METATARSAL stress #* e.g. ballet, endurance WB, tennis. - treatment: NWB plaster cast immobilisation for 6-8 weeks or surgical fixation *SESAMOID stress #* e.g. ballet, dancing, running. - treatment: NWB immobilisation (Aircast®) for up to 6 weeks

*HIP PROBLEMS*

*FEMOROACETABULAR IMPINGEMENT* - extra bone grows (bone spurs) along the hip joint causing friction eventually leading to pain and limited activity. S/S: gradual *anterolateral hip joint pain* exacerbated by pivoting laterally and sitting from standing. ==> physical exam: "FADIR test": flex, adduct then internally rotating the hip will reproduce the pain. *TROCHANTERIC BURSITIS* - lateral thigh pain and tenderness with no radiation down the leg. Worse when standing up and with abducting the hip against resistance.

*EPICONDYLITIS* - golfer's elbow - tennis elbow

*GOLFER'S ELBOW* medial epicondylitis: inflammation of the wrist flexor tendon at the site of the medial epicondyle. Patients may report pain with wrist flexion. - treat with rest, NSAIDs, splint, physio. Steroid injections if severe. - re-assure: the pain should settle on its own. If >6 months; refer for surgery *TENNIS ELBOW* lateral epicondylitis; most common at mid-age. Not all the time is it due to overuse during sport but from painting/crafting/building jobs. - physical: localised tenderness on the lateral epicondyle, pain with resisted wrist extension/passive wrist flexion. - treat with rest, NSAIDs, splint, physio. Steroid injections if severe. The pain should settle on its own. If >6 months, refer for surgery.

*LUMBAR SPINE PATHOLOGY* - *lumbar disc herniation*: more likely in a young person secondary to degenerative - spondylotic - disc changes and following an awkward lift or other strain. Lateral disc herniation typically only affects nerve roots leading to sciatica - *lumbar stenosis*: usually presents in the 6th-7th decade - *cauda equina syndrome*: decreased space in the vertebral canal below L2 secondary to: CENTRAL lumbar disc herniation, spinal stenosis, tumour, epidural abscess, haematoma or trauma - *spinal cord compression*:

*LUMBAR DISC HERNIATION* / SLIPPED DISC - radiculopathy with nerve root compression: straight leg raise precipitates symptoms in leg - usually precipitated by some form of trauma - may present with a neurological deficit (to indicate a nerve compression). 💡 <straight leg raise + foot dorsiflexion: lie flat and raise leg until pain is felt: A 30-70-degree angle is considered a sign of lumbar disc herniation. If raising the unaffected leg hurts the affected leg, it also indicates that a nerve root is impinged or irritated> - lumbar MRI/myelogram CT usually not required *unless s/s persist >6 weeks* - management: *strict 1-2 days only of bed rest* to calm down severe back pain. It should NOT exceed 48 hours. Firm bed base is advisable, *keep active and to exercise regularly if painless*. Give *analgesia*, (NSAID and diazepam), consider *epidural, physiotherapy, chiropractice* - *discectomy* indicated only if pain is disabling, persistent >6 weeks despite conservative measures and there is progressive neurological deficit - 9/10 people would have their pain resolved by 6 weeks). - progressive neurological deficit e.g. leg weakness, foot drop, numbness in the limb; if found on examination; discuss further management with the neurosurgeons. *VERTEBRAL COMPRESSION FRACTURE*: - defined as a vertebral bone in the spine that has decreased at least 15-20% in height due to fracture. - usually associated with *osteoporosis, trauma or spinal metastases* - can occur anywhere in the spinal vertebrae. - s/s: *abrupt onset of back pain with position changes, coughing, sneezing, or lifting*. Midline spinal tenderness may be present. - request *lumbar x-ray* for confirmation => initially: conservative management with bed rest (till pain lessens), regular analgesia, bracing, physical therapy, nerve root blocks or epidurals. Follow up the case in a week. => if severe ongoing pain after a recent, unhealed vertebral fracture despite optimal pain management *percutaneous vertebroplasty, and balloon kyphoplasty* without stenting. *LUMBAR STENOSIS* - usually progressive symptoms ==> neurogenic claudication (*leg pain upon walking*) is the cardinal symptom present in patients with central LSS: progressive onset of pain numbness, weakness and paraesthesia in low back, buttocks and legs *worse with walking* (mainly extension which occurs walking downhill). Note that the opposite would indicate vascular claudication). - back pain is *relieved with sitting and forward flexion.* - management: analgesia (NSAIDs, gabapentin), antidepressants, oral or epidural steroids (only if he had a herniated disc), physiotherapy. - surgical options include decompression and interspinous spacer devices. *ANKYLOSING SPONDYLITIS* - chronic back pain (often inflammatory in nature) and stiffness that improves with exercise, not rest, sacroiliac joint and spinal fusion - arthritis and enthesitis — the most common peripheral manifestations (predominantly in the lower limbs with asymmetrical distribution). - other s/s: dactylitis (swelling of a finger or toe), fatigue, extra-articular manifestations (for example anterior uveitis, psoriasis, inflammatory bowel disease)

*MECHANICAL BACK PAIN*

- often arises from a known injury - pain usually relieves with bed-rest - increases with activities that load the disk (sitting, getting up from bed or a chair), lumbar flexion with or without rotation, lifting, vibration (eg, riding in a car), coughing, sneezing, laughing, and the Valsalva manoeuvre - most commonly focal to the lumbosacral junction, the lumbar muscles, and the buttocks. - typically begins to subside after 4-6 weeks and responds to heat, NSAIDs, acetaminophen, massage and physiotherapy.

*ANTERIOR KNEE PAIN IN CHILDREN* - patellofemoral overload - patellofemoral syndrome/chondromalacia patellae (antero-medial pain) - osgood-schlatter disease workup for knee pain in a child 1) ⚠️ rule out septic arthritis and osteomyelitis with history (SOCRATES) and examination (fever, acute hot, painful, swollen, tenderness, inability to weight bear, poor↓ROM). Immediately call orthopaedic registrar and ambulance if septic observations. 2) ⚠️ rule out tumours: any fevers, night sweats, weight loss or pain @ night? 3) any recent history of trauma? consider ligament or meniscal damage 4) if all above are ok; consider other differential with specific examination - feel for tender lump over tibial tuberosity; obtain x-ray if suspected Osgood-Schlatter disease - have child sitting; compress patella into medial femoral groove and observe for J-sign to rule out patellofemoral syndrome = obtain MRI if this is the case

*PATELLOFEMORAL OVERLOAD* - common in teenagers, young athletics due to damaged cartilage - pain with walking up and down stairs and with prolonged sitting *PATELLOFEMORAL SYNDROME - CHONDROMALACIA PATELLAE* - softening of the cartilage of the underside the kneecap - risks: young athlete females, excessive knee strain causing articular cartilage damage *predominantly in the medial aspect of the patella* - s/s: deep aching anterior knee pain *worse with prolonged sitting, stair climbing or strenuous athletic activity*, "popping", catching, stiffness may also accompany clinically features - physical examination: ==> pain with firm compression of the patella into the medial femoral groove. ==> *J sign*: ask patient to sit with legs hanging; then extend knee from baseline 90 to 180 degrees. Observe for patellar deviation laterally in the shape of the letter "J" . - *MRI is best to assess cartilage*. X-ray may be non-conclusive - management: exercise and strengthening via physio is the mainstay of treatment, surgery if all else fails <note: there should be NO swelling or locking as this indicates an intra-articular pathology> *OSGOOD-SCHLATTER DISEASE* - inflammation of the patellar ligament at the insertion point on the tibial tuberosity due to repetitive stress - puberty, athletic boys>girls - s/s: *tender lump over tibial tuberosity, pain on resisted leg extension*. There are no effusions, instability or loss of ROM. - x-ray: lateral: shows fragmentation of tibial tubercle - management: restrict high intensity exercises, pain relief, physiotherapy. - most cases completely resolve in 18-24 months.

*ORTHOPAEDICS: UPPER LIMB DISORDERS*

*SHOULDER DISLOCATION* anterior most common (posterior for seizures): pain, reduced ROM, extremity shortness. Axillary nerve damage reported to be as high as 40%! - anterior: slight abduction, external rotation - posterior: slight adduction, internal rotation management: closed reduction with Kocher's method or Stimson method. Post reduction x-ray, NV check, sling for 3 weeks followed by shoulder rehab. Surgery if there is recurrent instability. *CLAVICLE FRACTURE* middle 1/3 most common secondary to FOOSH. - obtain AP XR of both clavicles. - figure of eight sling for 1-2 weeks, early ROM and repeat XR. - ORIF indicated only if open fracture, NV compromise, floating shoulder, >2cm shortening, non-union for several months, fracture of the distal 1/3 of clavicle. *PROXIMAL HUMERUS FRACTURE* risk factors: osteoporotic, F>M, elderly. <axillary nerve damage at risk> - 1 part: sling, slab - 2 part: ORIF - 3 part: of poor bone stock: hemiarthroplasty *HUMERAL SHAFT FRACTURE* requires high energy trauma or FOOSH from osteoporotic person. <radial nerve is at risk> - non-displaced: hanging cast, U-slab or orthosis with sling for 4-6 weeks. Radial nerve heals in 3-6 months - displaced: long splint cast + functional brace or ORIF or external fixation (if open fracture). *DISTAL HUMERUS FRACTURE* - transcondylar: elderly - supracondylar: children <median nerve at risk> - if non-displaced, immobilise elbow in splint at 90 degrees for 3 weeks. - elderly with poor bone quality may require total elbow arthroplasty. - complications: stiffness, median nerve damage, Volkmann's contracture, cubitus varus. *ELBOW DISLOCATION* - 90% posterior from FOOSH - manage with closed reduction, long arm splint with forearm neutral and elbow at 90 degrees; early ROM within 2 weeks. *LATERAL EPICONDYLITIS* tennis elbow related to *excessive wrist extension*. Tenderness just distal to the lateral epicondyle with increased pain with resisted wrist extension. - about 89% recover within a year with non-operative management: rest, ice, NSAIDs, physical therapy, short acting steroid injections (provide 6 week symptomatic relief), GTN patches over painful area. - surgery only if refractory after 1 year. *MEDIAL EPICONDYLITIS* golfers elbow: inflammation of the *wrist flexor tendon* at the site of the medial epicondyle - pain with wrist flexion e.g. carpenters, DIY jobs. *NURSEMAID'S ELBOW/RADIAL HEAD SUBLUXATION* - most common upper extremity injury in children <6yrs caused by a pulling mechanism - affected arm is semi flexed, adducted and in pronation. - closed reduction with either the supination-flexion technique or hyperpronation technique. *OLECRANON FRACTURE* direct trauma leading to loss of active extension. - management if undisplaced: immobilisation with above elbow cast, 40 degree flexion for 2 weeks; then early ROM *RADIAL HEAD FRACTURE* !! most common elbow fracture - pain on lateral elbow aggravated by pronation/supination with point tenderness of the radial head - X-Ray: "sail sign" of anterior and posterior fat pads. Management based on Mason classification - type I: undisplaced: elbow slab, sling for 3-5 days, early ROM with physiotherapy - type 2: displaced: ORIF then cast elbow at 90 degrees flexion for 2 weeks changing to hinged brace - type 3 and 4: comminuted/posterior dislocation: excision of radial head + prosthesis *MONTEGGIA FRACTURE* fracture of proximal 1/3 of ulna with dislocation of the head of the radius - common in children secondary to direct blow, FOOSH. *COLLES' FRACTURE* distal radius fracture with dorsal displacement "dinner fork deformity". ==> aim to reduce (traction with extension, ulnar deviation, pronation and flexion of the distal fragment), immobilise with short arm cast (for 6 weeks) in 20 degrees palmar flexion and ulnar deviation => then follow up in fracture clinic. - if articular involvement; orthopaedic referral. *SMITH'S FRACTURE* reverse Colles' fracture with palmar displacement of the distal fragment. *GALLEAZI FRACTURE* distal radius fracture with dislocation of the distal radio-ulnar joint *BARTON'S FRACTURE* distal radius fracture with dislocation of the radio-carpal joint *NIGHTSTICK FRACTURE*: => if non-displaced: place in distal 2/3 forearm cast for 10 days, brace for 8 weeks ==> displaced: ORIF *SCAPHOID FRACTURE* tenderness in the anatomical snuffbox <radial artery at risk> ==> immobilising both the wrist and the thumb *(short arm thumb spica splint) for 2 weeks* reduces the risk of non-union or AVN. Follow up with a repeat XR. *THUMB FRACTURE* either transverse across the base of the metacarpal or Bennett's fracture subluxation (intra-articular) ==> most cases will require *surgical intervention*: K-wire placement to fixate thumb followed later by a *short arm thumb spica splint* for 2-6 weeks *DE QUERVAIN'S DISEASE* idiopathic inflammation of the 1st extensor compartment; secondary to overuse or RA. - pain and tenderness over radial styloid aggravated by wrist movement - *Finkelstein's test is positive* (pain over radial styloid when fist made and thumb is within palm moving the wrist toward the little finger) - manage: NSAIDs, splinting, steroid injections (most effective), surgery if severe. *BOXER'S FRACTURE* 5th metacarpal transverse neck fracture. - reduce with *Jahss maneuver* & maintain with splint - non-displaced fractures should be splinted using an *ulna gutter splint for 4-6 weeks* then gentle 2-3 week finger joint physiotherapy required. *TRIGGER FINGER* locked finger in flexion due to thickening of the flexor tendon sheath. - can be associated with RA, diabetes, gout. - treatment as above (De Quervain's disease). *PIP EXTENSOR TENDON INJURY* mechanism similar to mallet finger (see below) ==> management: aluminium splint PIP joint in full extension for 6 weeks. Delay can lead to Boutonniere's deformity *MALLET FINGER* injury to the extensor tendon at the DIP joint commonly due to an object e.g. a ball striking and forcefully flexing an extended DIP. - s/s include pain, flexion deformity and inability to actively extend the joint. - *surgical indications include: inability to passively extend the DIP joint* and bony avulsions involving >30% of the joint space. *DUPYTREN'S CONTRACTURE* thickening of the palmar fascia resulting in painless nodule: initially asymptomatic but can later interrupt with hand function. - can be bilateral, R>L, 4th MCP most commonly affected resulting in irreversible flexure. - risk factors: family history, northern European, type I diabetes, use of oral hypoglycaemic medication and insulin. Those with Dupytren's have 4x more likely to develop microalbuminuria than diabetics. => management: if moderate: try needle fasciotomy for MCP joint contractures or collagenase injections. Surgical fasciectomy required if MCP joint contracture of 30° and/or any degree of PIP contracture. *ULNAR COLLATERAL LIGAMENT INJURY OF THE THUMB/SKIER'S THUMB* caused by avulsion of the attachment of the ulnar collateral ligament. - weakened ability to grasp objects or perform such tasks as tying shoes and tearing a piece of paper. Other complaints include intense pain experienced upon catching the thumb on an object, such as when reaching into a pants pocket

*JUVENILE IDIOPATHIC ARTHRITIS* - arthritis in >1 joint lasting >6 weeks in a child aged <16

*STILL'S DISEASE*: joint pain and swelling, muscle pain, and a salmon-pink maculopapular rash. Inflammatory markers raised *OLIGOARTICULAR ARTHRITIS*: the most common type of JIA. It affects up to 4 joints in the body - most commonly in the knees, ankles and wrists. Usually *girls>boys (80%), age <4 years*, affects *large joints* and can be associated with *uveitis in 20%* *POLYARTICULAR JIA*: second most common type of JIA and affects 5 or more joints; s/s similar to RA. *ENTHESITIS RELATED ARTHRITIS* is a type of juvenile arthritis that often affects weight bearing joints with inflammation at the site where tendons or ligaments attach to the bone. Stiffness can occur in the neck and lower back in the teenage years. It's also linked to acute uveitis

*ROTATOR CUFF INJURIES* normal actions of each muscle - supraspinatus - abduction (impingement syndrome): the most common of all. - infraspinatus - external rotation - teres minor - external rotation - subscapularis - internal rotation and adduction

*aetiology*: - acute trauma e.g. FOOSH or lifting heavy things with jerking - chronic: increasing age, bone spurs, previous trauma, repetitive overhead activity (e.g. baseball, tennis) or heavy lifting over a prolonged period of time, occupation (painters, carpenters, etc). *symptoms*: - deep pain with active and passive motions (*especially overhead motions!!*), - weakness of arm - others: night pain, tender over greater tuberosity *investigate* - physical will show pain against resistance with the following: - supraspinatus - abduction or try Hawkins impingement test: flex arm and elbow at 90 degrees then internally rotate; produces pain. The most common problem (impingement syndrome) seen by GPs. - infraspinatus - external rotation - teres minor - external rotation - subscapularis - internal rotation and adduction *diagnosis* - MRI has very good specificity and sensitivity *management*: - in acute, traumatic complete tears: surgical intervention necessary within 6 weeks of injury particularly in young and active patients. If mild tear: broad arm sling for several days, analgesia and once pain free: isometric rehab exercises with weights - in chronic tears: conservative measurements: rest, ice, physiotherapy, corticosteroid injections. Surgical correction if symptoms have not improved with 2-3 months of physiotherapy and 1-2 steroid injections.

*CARPAL TUNNEL SYNDROME*

*causes*: mnemonic: ID CRAMPS *i*atrogenic, *d*iabetes, *c*ushing's syndrome, *R*A, *a*cromegaly/*a*myloidosis, *m*enopausal, *p*regnancy, *s*arcoidosis - s/s: paraesthesia in first 3 and half fingers +/- thenar wasting, poor thumb flexion therefore poor grip +/- hand of benediction *hx*: W>M 3x more likely, arthritis, occupational (e.g. typist). Can also occur in those with hypothyroidism, diabetes, rheumatoid disease, 3rd trimester of pregnancy, obesity, acromegaly *test*: *phalen's test*: hold for 1 minute until tingling felt, *tinel's test* may be positive, *trial splints* if symptoms persist; refer for *nerve conduction test* and consider for surgery: carpal tunnel decompression. ways to remember tests: Phalen's (prayer) while Tinel (tap)

*APPROACH TO BACK PAIN*

*history*: - duration, SOCRATES, location cervical: rule out recent trauma and in particular; spinal fracture. With whiplash; there is not much you can do aside from physiotherapy. thoracic: rule out acute pancreatitis, acute MI, AAA rupture, aortic dissection, PUD as well as cord compression lumbar pain: red flags: cord compression, cauda equina, abscess/infection, cancer optional to ask: occupation/hobbies. Others: hx of PVD, cardiac hx ❗️*history of trauma*: - if yes and major; call ambulance, send to A&E with immobilisation and x-ray. - If minor; rule out fracture (hx of trauma, osteoporosis, aged>55, c-spine midline tenderness) --> send to A&E for x-ray. Otherwise; whiplash injury. - rule out cord compression/cauda equina: bilateral limb weakness/bladder bowel dysfunction/difficulty walking. ❗️*inflammatory* cause? - pain that is severe/unrelenting worse at night and with rest. Improves with exercise - usually no hx of trauma; though for an abscess, may have previous spinal surgery, IVDU, hx of inflammatory arthritis etc. - fever/chills, night sweats - positive Lhermitte's sign; consider myelopathy such as MS. ❗️rule out *cancer* - unintentional weight loss, hx of cancer: if so; consider lung (CXR), prostate, (PSA), thyroid (TFTs), breast (hx and physical) and myeloma (bloods). if all above negative; most likely mechanical especially if aged 20-55, pain easing with bed rest and worsening with exercise and occupation involves repetitive stress. If physical identifies radiculopathy; mechanical compression of the nerve root secondary to: (1) disc herniation (90%) (2) spinal stenosis (3) spondylolisthesis examination includes (A) spurling test: cervical (B) straight leg raise and foot dorsiflexion for lumbar management: re-assure mechanical pain resolves within 1-2 weeks. Avoid heavy lifting, remain active, exercise, analgesia. Sciatica symptoms should settle within 4-6 weeks.

*GROWING PAINS* M=F, age 2-12yrs

- diagnosis of exclusion with physical findings normal - intermittent, non-articular pain night pain, often bilateral limited the calf or shin, relief with heat/massage - child is well, asymptomatic during the day with no loss of function

*OSTEOARTHRITIS*

- joint pain (dull/sharp) - *morning stiffness* <30 minutes - *worse with movement and progresses moreso later in the day*, and *improves with rest* commonly *knees, hips and wrists* are affected - risk factors:↑age, genetics (50-60%), obesity (for knee OA), female, previous trauma of the joint -- promote appropriate footwear, exercise -- paracetamol +/- NSAIDs +/- codeine -- physiotherapy to improve mobility and ADLs -- topical therapies: *rosehip*; anti-inflammatory oil *diclofenac/ibuprofen gel* *capsaicin cream*: particularly useful for knee and hand osteoarthritis but it is expensive -- if severe osteoarthritis: intra-articular steroid injections. -- surgery: e.g. total hip/knee replacement candidates for THR or TKR only if: - severe pain, swelling and stiffness in the joint with reduced mobility - pain is so severe that it interferes with quality of life and sleep - everyday tasks, such as shopping or getting out of the bath, are difficult or impossible - feeling depressed because of the pain and lack of mobility - impairment on work/social life

*KNEE PAIN* - medial knee pain: OA, MCL injury, medial meniscus tear and fractures of the tibial plateau - lateral knee pain: iliotibial band syndrome, lateral meniscus injury - anterior knee pain: ACL injury, pre-patellar bursitis, chondromalacia patellae, patella instability, osgood-schlatter disease. *OTTAWA RULES FOR X-RAY*: only applies to those with an *acute* knee injury + >1 of: - >55 years or older - Tenderness at head of fibula - Isolated tenderness of patella - Inability to flex the knee greater than 90° - Inability to bear weight both immediately and in the emergency department (4 steps)

- ligament injury: see below - septic arthritis - osteoarthritis - disorders in children: anterior knee pain: chondromalacia patellae, patella instability, osgood-schlatter disease - pre-patellar bursitis: anterior knee pain and swelling - anserine bursitis: medial knee, night pain. 2-3cm below medial joint line; can be bilateral with localised tenderness. - iliotibial band syndrome: lateral knee and thigh pain: one of the most common overuse injuries among runners. Can be tender in this area and s/s worse with knee flexed to 30 degrees. WORKUP 1) ask *S*ite (anterior, medial, below, etc), *O*nset (when and how long?, *C*haracter (sharp/dull/aching?), *R*adiation (any pain in the hip or foot?), *A*ssociated (any numbness/tingling/limb weakness and ask systemic s/s like weight loss, fever, night sweats), *T*iming (how long it lasts?), *E*xacerbates (worse with rest or exercise? - rule out inflammatory causes e.g. RA, SLE). *S*everity (on a scale of 10) 2) *history*: previous episodes? (can determine if systemic disease) history of any trauma? previous surgeries? => helps rule out ligament injury, meniscal tear and fractures 3) *examination*: - is the joint red/hot/swollen/tender? rule out gout, pseudogout, septic or other infectious arthritis and check basic observations - can the patient weightbear? can they move their knee actively and/or passively (if not at all; ?septic) - check knee power, sensation, pulses and reflexes if necessary 4) *tests*: joint aspiration + c&s: if suspected septic arthritis or pseudogout or gout (rarer) otherwise x-ray (Ottawa rules) or MRI.

*POLYMYALGIA RHEUMATICA*

- very rare if under 50yrs, more common in those older than 70 - profound pain and stiffness in proximal extremities (worse with exercise) + tenderness, malaise and fever for at least 1 month. - associated in 10% with giant cell arteritis - may linked with increased risk of malignancy - ESR >40, CK levels normal, seronegative disease (RF negative). - does NOT respond to NSAIDs

*KAWASAKI DISEASE* - multi-systemic acute vasculitis usually affecting Asian children less that 5 years of age

1) fever persisting for >5 days or more 2) 4 or more of the following - bilateral non-exudative conjunctivitis - diffuse mucous membrane erythema (strawberry tongue) also; fissuring of the lips is unique and differentiates it from scarlet fever or toxic shock syndrome. - polymorphous rash (primarily on the trunk) - cervical lymphadenopathy <1.5cm - changes in peripheral extremities: oedema, desquamation "CRASH" and Burn *C*onjunctivitis - non exudative, bilateral (>90%) *R*ash - polymorphous (>90%) *A*denopathy >1.5cm. typically cervical and unilateral. (<50%) *S*trawberry tongue- Redness of oral mucosa or lips or dry peeling lips. (>90%) *H*and - swelling/erythema or hands/feet. progresses to peeling but this is late. (>90%) and *Burn*... >5 days of fevers. main goal of treatment is to prevent coronary artery disease (common complication is coronary artery aneurysms) by administering IV immunoglobulin and aspirin - baseline ECHO is required with periodic follow up at 6 weeks - children with aneurysms may require chronic anticoagulation

*PAEDIATRICS MINI QUIZ* 1) 6 year old girl presents with a 5 day history of limp and pain in one hip with restriction of all hip movements. She was recently treated for acute otitis media. All investigations are normal and the girl recovers after 3 days. 2) 12 year old presents with gradually increasing pain in the right hip with a limp. There is reduced range of movement in the hip. Sclerotic femoral head with widened joint space; observed on x-ray. 3) 7 year old boy from Ghana presents with a history of pain in his left knee worse on walking. He is pyrexial and has a warm upper shin and small knee effusion

1) irritable hip 2) avascular necrosis 3) osteomyelitis

*ADULTS MINI QUIZ* 1) 20 year old man soon after playing football suffers from pain, instability, difficulty weight-bearing in his right knee 2) 40 year old lady presents with sharp pain in the heel; particular after walking out from bed in the morning 3) 25 year old presents with ankle pain. On examination; there is swelling, tenderness and bruising anterior to the lateral malleolus. There is no bony tenderness and patient is able to weight bear. Advice? 4) 32 year old sprint runner felt an an audible pop with severe pain when he started to run. What is the best finding of physical examination? and how would you manage this? 5) 22 year old man feels his knee "giving way" whilst playing football; he is unable to continue with the activity. Describe the most common physical examination used to diagnose this disorder? 6) 40 year old lady with a bunion presents with ongoing pain that limits their everyday activities, including walking and wearing reasonable shoes. Management? 7) 55 year old lady presents with heel pain that tends to get worse as the day goes on. There is no pain when dorsiflexing the toes. 8)

1) most likely this is *MCL* (more common); blow to lateral part of knee. Confirm with MRI/arthroscopy 2) *plantar fasciitis*: confirm with palpating the plantar medial calcaneal tubercle or dorsiflexing the toes which produces pain. 3) *lateral ankle ligament injury*: but first; be sure to rule out ankle fracture with Ottawa rules. Advise rest, ice, compression sleeve, elevation; should resolve within the week; otherwise 4) *achilles tendon rupture*: unable to feel tendon on palpation, patient unable to plantar flex. U/S can confirm. Cast foot in plantar flexion for 2 weeks then use a walking boot (wean off for the next 4 weeks) with physiotherapy - surgery indicated after 6-8 weeks if high athletic demand. 5) *ACL damage*: anterior draw test: see picture: patient in supine; flex the hip and knee to 45 and 90 degrees respectively. Sit on the patient's foot (for grip), hold onto the upper part of the tibia and quickly pull it toward yourself. Positive if pain (sprain) or excessive movement (tear)> 6) refer for bunion surgery: osteotomy 7) fat pad atrophy: common cause of heel pain in the elderly: as opposed to plantar fasciitis: it causes pain as the day goes on 8)

*PERIPHERAL MUSCLE CRAMPS* causes - after surgical procedures/trauma - dehydration, electrolyte abnormalities, medications (statins), vigorous exercise. - claudication: vascular or neurological

MANAGEMENT - Most cramps can be stopped with muscle stretching; simple physiotherapy exercises, *massaging* the muscle will help as well as applying a *heating pad* - *treat any underlying causes* such as dehydration, electrolyte deficit, calcium levels etc. Review medications. - *quinine* ONLY if cramps have no cause, are nocturnal and affecting one's ability to sleep. It is a drug that carries many adverse effects and to be used with caution. It can take 4 weeks to work; if no effect; then stop the treatment. The licensed dose for the treatment and prevention of nocturnal leg cramps in adults is 200-300 mg at night for quinine sulphate (recommended starting dose 200 mg).

*NECK PAIN CAUSES* - mechanical - systemic key things to ask - any history of trauma? - worse with rest? better with movement? - associated with fever or photophobia? - any night sweats/unintentional weight loss? - ask about occupation - ask and examine for limb weakness/sensory symptoms/neurological deficits: rule out cervical cord compression and myelopathy of which would need neurosurgical review. examine - observe for any masses or rash - spinal cord tenderness: if fracture suspected; call an ambulance for neck collar and assessment in A&E - neck ROM active (unless suspected fracture) - Spurling test: assess for spondylosis - nuchal rigidity - examine arm/leg weakness and sensation

MECHANICAL - acute torticollis (muscle spasm): caused mostly by poor posture - whiplash injury: history of trauma - cervical spondylosis*: degenerative changes secondary to age, OA, repetitive trauma; causing bone spurs leading to disc prolapse, stenosis ligament hypertrophy and radiculopathy. Radiculopathy can be detected with the *Spurling test*. <Spurling test: extend the neck then laterally bend to one side; if s/s not reproduced, apply downward pressure> symptoms of cervical spondylosis - neck stiffness and pain. - headache that may originate in the neck. - shoulder/arm pain - inability to fully turn the head or bend the neck, sometimes interfering with driving. - grinding/crepitus noise or sensation when the neck is turned SYSTEMIC CAUSES *- inflammatory*: ankylosing spondylitis, RA, polymyalgia rheumatica *- infection*; meningitis, abscess *- malignancy*: myeloma or metastatic *- metabolic*: osteomalacia *- fibromyalgia*

*SERIOUS CAUSES OF LUMBAR BACK PAIN* red flags - cord compression - cauda equina - infection - cancer

cancer, cord compression/cauda equina, infection and trauma ⚠️ *SPINAL CORD COMPRESSION* - back pain worse on exertion/cough/sneezing/walking/lying down (similar to compression fractures). - spinal cord tenderness - bladder/bowel dysfunction - bilateral leg weakness/numbness - UMN signs: rigidity, increased tone, brisk reflexes (e.g. Babinski's). - history of cancer if strongly suspected; strict bed rest for the patient then discuss with neurosurgeons in regards to starting dexamethasone 16mg stat with PPI +/- radiotherapy +/- decompression. Obtain an MRI whole spine scan. ⚠️ *CAUDA EQUINA* - numbness/tingling around buttocks and genitals - bilateral leg pain, weakness, numbness, tingling associated with sharp shooting pains - bladder/bowel/erectile dysfunction - LMN signs: flaccid, reduced tone, weak reflexes, atrophy - reduced perianal sensation and anal tone (late sign) - management: urgent MRI with aim to perform surgical decompression <48hrs to preserve bowel, bladder and sexual function, and/or to prevent progression to paraplegia discuss case with neurosurgeons for further management re; decompression. If in hospital, d/w radiologist for urgent MRI spine. ⚠️ *CANCER* e.g. prostate, breast, lung, thyroid, kidney, myeloma - unintentional weight loss, night pain, fevers, sweats, - ask/examine for: breast lumps, urinary frequency/urgency/haematuria, haemoptysis, dysphagia, hoarseness, swellings in neck. - ask if any family or personal history of cancer ⚠️*INFECTION*: e.g. osteomyelitis, abscess, meningitis - fevers, chills, headaches, stiff neck, nausea/vomiting - risk factors: immunosuppression, previous spinal cord injury/surgery - if suspected: refer to neurosurgeons immediately. Lower limb neurological examination is vital in all cases - power, tone, reflexes, sensation

*FIBROMYALGIA*

chronic condition with *widespread aching and pain in the muscles* and fibrous soft tissue; neck, back and thighs with s/s persisting for >3 months - on examination: *multiple tender points* - risk factors: W>M, poor socioeconomic background, divorced, depression. - while ANA may be positive; other specific antibodies for other rheumatological diseases are all negative. *Anti-polymer antibodies* however are positive in 50%. - other s/s: headache, fatigue and sleep disturbance - management: *CBT and amitriptyline*. Others include duloxetine, gabapentin, pregabalin, tramadol and SSRIs.

*PHYSICAL EXAMINATION: ASSESSING MUSCLE STRENGTH*

grade 0 - inability contract grade 1 - contract without movement grade 2 - moves with gravity neutralised grade 3 - moves against gravity only grade 4 - moves against gravity and resistance grade 5 - moves against substantial resistance

*SHOULDER PAIN* - rotator cuff injury - instability/dislocations - arthritis - fracture *pain exacerbated by overhead activity/abduction* - *rotator cuff tear*: painless weakness, painful active abduction, normal passive ROM. Unresponsive to lidocaine injections - *subacromial impingement*: does not cause weakness but does cause night pain. Can progress to rotator cuff tendinopathy. - *rotator cuff tendinopathy*: abduction/internal rotation and night pain: similar presentation to subacromial impingement.

↳ *ROTATOR CUFF INJURY* (see below/separate card for more details) - *acute tendonitis*: painful limitation of motion in one plane. Supraspinatus most commonly affected with pain on both active and passive abduction - *rotator cuff tear*: painless weakness, painful active motion especially with overhead movements. *Normal passive ROM* - *subacromial impingement*: pain on arm abduction and/or internal rotation, night pain. 👨‍🏭 if age <40; moreso associated with *glenohumeral instability*. 👴 in older patients; *chronic rotator cuff tendinitis*. Mostly treated with NSAIDs and physiotherapy. Pain can be controlled with steroid injections and surgical correction ↳ *INSTABILITY/DISLOCATIONS* - history of trauma *anterior shoulder dislocation* - most common; look for a visibly deformed or out-of-place shoulder, slight abduction and with limb shortening, swelling/bruising, intense pain and inability to move the joint. - Apprehension test will be positive: patient supine; *abduct arm to 90 degrees then externally rotate; patient will feel apprehensive with fear of subluxation* - management: closed reduction with Kocher's method or Stimson method. Post reduction x-ray, NV check, sling for 3 weeks followed by shoulder rehab. Delay contact sports for 2-3 months. Surgery if recurrent instability. ↳ *FRACTURE*: - severe, pain, swelling and bruising with a history of acute trauma. ↳ *BURSITIS*: e.g. subacromial bursitis - precipitated by traumatic injury, overuse and impingement with calcium deposits - pain tends to be at the top of the shoulder - poor ROM when with abduction >90 degrees. ↳ *ARTHRITIS*: - OA: pain and stiffness relieved with rest and worsened with exercise - RA: usually affects the small joints only and improved with exercise. - psoriatic. Ask about slow, growing pain and stiffness. ↳ *FROZEN SHOULDER* (adhesive capsulitis): - idiopathic disorder occurring @ mid-age - s/s can last >18 months - *diabetes* being the most common risk factor. - stiffness, *loss of passive and active ROM* - severe pain particularly at night - bloods and XR are normal - self-limiting condition. Aim to manage diabetes alongside analgesia and physiotherapy. ↳ *POLYMYALGIA RHEUMATICA* - >50yrs, profound bilateral pain, morning stiffness and tenderness in proximal extremities worse with activity, ↑ESR, normal CK, associated with GCA, may also be linked to malignancy. - treat with low dose prednisolone. ↳ *POLYMYOSITIS*: "mad cries" - proximal *M*uscle weakness and tenderness - *M*alignancy associated (10-20% Non-Hodgkin's, lung or bladder ca) - *A*rthralgia (50%) - *D*ysphagia (50%) - ⇈⇈*C*K levels - *R*aynaud's phenomenon - *I*nflammatory markers raised - *E*MG confirmation - *S*eropositive (anti-Jo and anti-Mi-2) - *S*teroid responsive. Consider *DERMATOMYOSITIS* if there is a heliotrope rash around the eyes; it is more associated with malignancy. ↳ *FIBROMYALGIA* - widespread aching pain in the muscles and fibrous soft tissue; neck, back and thighs - *s/s persist for >3 months* - multiple tender points - headache, fatigue and sleep disturbances - management with CBT and amitriptyline other rarer causes of shoulder pain; tumours, infection, and nerve-related problems.