Programme for today:13.30 Intros: Us, You, specialities?13.45 Knees14.15 Shoulder /114.30 Break14.45 Shoulder /215.00 Back15.30 Q&A, other examinations16.00 Close

MSK consult common in primary care

Accurate dx is therapeutically important

Possible with careful history and clinical examination

A referred cause is common

Accurate diagnosis and physiotherapy will prevent chronic pain, prolonged symptoms and functional disability.

History

Look

Feel

Move

History of trauma Nature of symptoms/ Effect on activities

Pain, instability, swelling Duration of symptoms History of arthropathy

Gout, rheumatoid, psoriatic History of immunocompromise

Steroids, diabetes

Scars of surgery Deformity Swelling Muscle wasting Skin changes

erythema/psoriasis/eczema Bone/muscle contours Comparison to unaffected side

Joint temperature Effusion Bony prominences Area of tenderness along joint margin Crepitus Pulses

Range of movement Active and Passive Stress tests Special tests Neurological Examination

Anatomy

Case study

Differential Diagnosis

Examination

28 Year old, football injury 4/12 ago, heard pop/snap in R knee and immediate swelling/pain. Eased with ice and rest within a week. Improved by 75% at first appointment and after full compliance with rehab, better but unable to fully extend knee (-10 degree).

Agg: nothing really, just “discomfort” when getting into a car and occasional “weak” knee when playing football

Ease: short-term discomfort 24: activity dependent Sleep: OK DH: nil SH: computer programmer, football

5xweek

slim tall, good quads definition

Trauma- bony

soft tissue Degenerative Inflammatory Tumour Infection Referred

Answer: full ACL rupture. Was fully functional apart from his high level sports. Was given the option for surgical intervention - age+sporting interest key factors, surgery not for everyone

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Special Tests

3 BonesHumerusScapulaClavicle

3 JointsGlenohumeralAcromioclavicularSternoclavicular

1 “Articulation”Scapulothoracic

BREAK

54 Year old male chopping wood in Jan, felt ache in L shoulder a few days later. The heaviness/achiness has not fully resolved. Symptoms ISQ 5/12 down the line.

Agg: nothing in particular Ease: nothing 24h: worse during the night Sleep: disturbed DH: meds for gout SH: lorry driver

barrel chest, rounded shoulders

What is the differential diagnosis?

Pain arising from the shoulder jt Pain arising from elsewhere

Rotator cuff disorders cuff tendinopathy, calcific

tendonitis, subacromial bursitis, impingement, cuff tears

Glenohumeral jt. Problems

adhesive capsulitis, osteoarthritis

ACJ Problems

Traumatic Dislocation

Infections

Referred Pain

Neck pain, myocardial pain, referred diaphragmatic pain

Polymyalgia Rheumatica

Malignancy

Apical lung tumors, metastases

Answer: Cx radiculopathy + neural tension pain. Amitriptyline for sleep, rehab involved posture, Tx extension exc, Cx traction and retraction

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Special Tests

61 Year old cashier I/M LBP over many years, constant in the last 3/12. CE, B+B, SA , bilat P+N/numbness clear

Agg: working at till, walking to town Ease: movement if stationery, rest if

mobile 24h: stiff in morning, eases with

movement Sleep: aware of pain if awake

slouched posture

SH: married, 3 children at home, part-time work, main carer for mum

What is the differential diagnosis?

• Mechanical low back pain (97%)• Lumbar strain or sprain (≥ 70%)• Degenerative disk or facet process (10%)• Herniated disk (4%)• Osteoporotic compression fracture (4%)• Spinal stenosis (3%) Pain better when spine is

flexed or when seated, • Spondylolisthesis (2%)

• Nonmechanical spinal conditions (1%)• Neoplasia (0.7%)• Inflammatory arthritis (0.3%)• Infection (0.01%)

• Nonspinal/visceral disease (2%)• Pelvic organs—prostatitis, pelvic

inflammatory disease,• endometriosis• Lower abdominal symptoms common• Renal organs—nephrolithiasis,

pyelonephritis• Aortic aneurysm - pulsatile abdominal

mass• Gastrointestinal system—pancreatitis,

cholecystitis, • Shingles - Unilateral, dermatomal pain;

distinctive rash

Answer: Disc degenerative changes, back exc, core work

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Special tests

Other examinations...

Cancer Infection

Age > 50History of

CancerWeight lossUnrelenting

night painFailure to

improve

IVDUSteroid useFeverUnrelenting

night painFailure to

improve

Fracture Cauda Equina Syndrome

Age >50Trauma Steroid useOsteoporosis

Saddle anesthesia

Sphincter dysfunction

Loss of sphincter control

Major motor weakness