Musculoskeletal Disease

Examination of the MSK system

• Inspection at rest– Skin changes– Swelling– Wasting– Attitude– Deformity

• Inspection during movement– Restriction– Increased rane– Pain on usage

• Palpation with movement– Tenderness– Increased warmth– Swelling– Crepitus– Stability– Resisted active movements– Stress tests

Important MSK symptoms

Pain• Usage pain: worse on use, relieved by rest

(mechanical strain, damage)• Rest pain: worse after rest, improved by

movement (inflammation)• Night or 'bone' pain: mostly at night, poorly

related to movement (bone origin)

Stiffness • Subjective feeling of inability to move freely• Duration and severity of early morning and

inactivity stiffness that can be 'worn off' suggest degree of inflammation

Weakness • Consider primary or secondary muscle

abnormality

Swelling • Fluid• Soft tissue• Bone

Deformity • Joint• Bone

Non-specific symptoms of systemic illness

• Weight loss ± reduction in appetite

• Fatigability, poor concentration

• Sweats and chills, particularly at night

• Feeling ill, low, irritable

• Example of 'stress pain' at the wrist. Pain worsens as the wrist moves towards the 'tight-pack' positions (flexion and extension) because of increased intracapsular pressure from inflammatory swelling and effusion. In the mid 'loose-pack' position, when the capsule is at its slackest, there is no pain. Stress pain is the earliest and most sensitive sign of synovitis, occurring before visible swelling or reduction of movement. With joint damage, pain is more evenly spread throughout the range.

Example of resisted active movement. Attempted external rotation reproduces upper arm pain resulting from an infraspinatus/teres minor rotator cuff lesion.

Example of a stress test. Passive ulnar flexion reproduces pain from de Quervain's tenosynovitis.

Epidemiology

Presenting problems in MSK diseases

Monoarthritis Almost always it’s due to crystals or sepsis.

Principal causes of acute monoarthritis in a previously normal joint• Septic arthritis• Crystal synovitis: gout, pseudogout• Monoarticular presentation of oligo- or polyarthritis

– Reactive, psoriatic or other seronegative spondarthritis– Erythema nodosum– Rheumatoid arthritis– Juvenile idiopathic arthritis*

• Trauma: especially if associated with haemarthrosis• Haemarthrosis associated with clotting abnormality• Foreign body reaction (e.g. plant thorn)

Common causes of acute arthritis in a previously abnormal jointDamaged joint• Pseudogout in association with osteoarthritis• Bone pathology

– Secondary avascular necrosis– Subchondral collapse or fracture

• Cartilage damage– Fibrocartilage tear, cartilage debris

• Haemarthrosis• Septic arthritisExisting inflammatory disease • Septic arthritis• Exacerbation of underlying disease

Causes of chronic single site synovitis• Foreign body (e.g. plant thorn)• Infection, including tuberculosis, fungi• Chronic sarcoidosis• Enteropathic arthritis (mainly Crohn's)• Amyloidosis• Pigmented villonodular synovitis• Synovial chondromatosis• Synovial sarcoma• Monoarticular presentation of oligo-/polyarticular

disease– Rheumatoid arthritis– Seronegative spondarthritis– Juvenile idiopathic arthritis

Oligoarthritis (Affecting 2-4 joint groups)

Causes of inflammatory oligoarthritis• Seronegative spondyloarthritis

– Reactive arthritis– Psoriatic arthritis– Ankylosing spondylitis– Enteropathic arthritis

• Erythema nodosum• Juvenile idiopathic arthritis• Oligoarticular presentation of polyarthritis• Infection, including

– Infective endocarditis– Neisseria– Mycobacteria

Polyarthritis - >4 joints

Single regional pain

• Usually results from an over-usage strain or injury affecting a periarticular structure

• The patient can often identify an obvious provoking event or injury

• The pain is non-progressive and reproduced by just one or a few movements; the patient is otherwise well

• Muscle injuries usually settle within days, whereas fibrous structures such as tendons and ligaments can take weeks or months to return to normal.

Single regional pain

• The diagnosis is usually made clinically, although imaging, especially ultrasound and MRI, may confirm.

• Management is aimed towards: identifying and avoiding predisposing or adverse

mechanical factors if possiblepain relief (topical and/or oral analgesics, local

injection for severe pain)appropriate exercise and rehabilitation to restore

movement and function.Surgery is only occasionally required for very

resistant or disabling lesions.

Single regional pain

E.g.:• Shoulder pain• Elbow pain• Hand and wrist pain• Hip pain• Knee pain• Foot and ankle pain

Shoulder painExamination findings in common periarticular lesions at the shoulder

Rotator cuff lesionPain reproduced by resisted active movement:

Abduction: supraspinatusExternal rotation: infraspinatus, teres minorInternal rotation: subscapularis

Subacromial bursitisNo pain on resisted active abduction (cf. supraspinatus lesion, the other cause of a painful middle arc)

Bicipital (long head) tendinitisTender over bicipital groovePain reproduced by resisted active wrist supination or elbow flexion

Rotator cuff tendinitis/ adhesive capsulitis/ frozen shoulder

Over use or minor tears of the rotator cuff initiate a chronic inflammation of the tendon. Impingement of the supraspinatus tendon against the coracoacromial ligament may play a role in its pathogenesis.

Rotator cuff tendinitis/ adhesive capsulitis/ frozen shoulder

• Presents with shoulder pain which will peak in 4-10wks before subsiding over similar time course.

• Restriction of movement also manifest progressively and reaches maximum when pain subsides.

PainRange

Rotator cuff tendinitis - Triggers

• Diabetes mellitus• Rotator cuff tear• Local trauma• Myocardial infarction or • Hemiplegia

Rotator cuff tendinitis - treatment

Treatment in the early stage is with analgesia, intra- and extracapsular steroid injection, and regular 'pendulum' exercises of the arm to prevent the capsule from over-tightening.

Mobilising and strengthening exercises are the sole treatment in the painless 'frozen' stage. The natural history is for slow but complete recovery, sometimes taking up to 2 years.

Elbow pain

Tennis elbow (Lateral epicondylitis)A condition where the outer part of the elbow becomes sore and tender. It is commonly associated with playing tennis and other racquet sports, though the injury can happen to almost anyone.

• Golfer's elbow, or medial epicondylitis, is an inflammatory condition of the elbow which in some ways is similar to tennis elbow in pathology.

Treatment• Non-specific palliative treatments include:• Non-steroidal anti-inflammatory

drugs(NSAIDs): ibuprofen, naproxen or aspirin• Rest, ice, compression and elevation (R.I.C.E.) • A counter-force brace or "elbow strap" to reduce

strain at the elbow epicondyle, to limit pain provocation and to protect against further damage.

Olecrenon bursitisInflammation of the olecrenon bursa.

Triggers– Idiopathic– Trauma

The common symptoms of elbow bursitis include:– Pain around the back of the elbow– Swelling directly over the bony prominence of the tip of

the elbow– Slightly limited motion of the elbow

ComplicationsOccasionally, the swelling and inflammation can be the result of an infection within the bursa, this is called infected elbow bursitis. Patients with systemic inflammatory conditions, such as gout and rheumatoid arthritis, are also at increased risk of developing infected elbow bursitis.

Treatment of olecrenon bursitis

DrainageSteorid injectionsRest ( Brief immobilisation)Pain killers

Hand and wrist pain

• CausesTenosynovitisMedian nerve compressionRaynaud’s phenomenonC8/T1 radiculopathy

Tenosynovitis

Tenosynovitis is inflammation of the lining of the sheath that surrounds a tendon.• Causes, incidence, and risk factors Infection Injury Overuse Strain

Tenosynovitis

• The wrists, hands, and feet are commonly affected. However, the condition may occur with any tendon sheath.

• Note: An infected cut to the hands or wrists that causes tenosynovitis may be an emergency requiring surgery.

Tenosynovitis

Symptoms• Difficulty moving a joint• Joint swelling in the affected area• Pain and tenderness around a joint, especially

the hand, wrist, foot, or ankle• Pain when moving a joint• Redness along the length of the tendon

Tenosynovitis

Signs and tests• A physical examination shows swelling over

the involved tendon. • Crepitus• Pain when the muscle or tendon is stretched.

Treatment• Rest• splint or a removable brace • Applying heat or cold to the affected area• NSAIDs• Steroid injection• After recovery, do strengthening exercises

using the muscles around the affected tendon.

prognosis• Most fully recover with treatment. However, if

the condition is caused by overuse and the activity is not stopped, tenosynovitis is likely to come back. In chronic conditions, the tendon may be damaged and recovery may be slow or incomplete.

Varieties of tenosynovitis

• DeQuervain's tenosynovitis (affecting the first dorsal compartment of the wrist)

• Trigger finger (affecting the digital flexor tendons)

DeQuervain's tenosynovitisAlso known as washerwoman's sprain, radial styloid tenosynovitis, de Quervain disease,de Quervain's syndromme, de Quervain's stenosing tenosynovitis, mother's wrist, or mommy thumb)

Pathology

• It’s tenosynovitis involving the tendons of the extensor pollicis brevis and abductor pollicis longus muscles. These two muscles, which run side by side, have almost the same function: the movement of the thumb away from the hand in the plane of the hand—so called radial abduction (as opposed to movement of the thumb away from the hand, out of the plane of the hand (palmar abduction)

Signs and symptoms• Symptoms are pain, tenderness, and swelling

over the thumb side of the wrist, and difficulty gripping.

• Finkelstein's test is used to diagnose de Quervain syndrome. To perform the test, the examining physician grasps the thumb and the hand is ulnar deviated sharply, as shown in the image. If sharp pain occurs along the distal radius DeQuervain's syndrome is likely.

Trigger finger

Trigger finger (or thumb) arises either from thickening of the flexor tendon sheath (which occurs following tenosynovitis of infective, traumatic or rheumatolgical origin) or from nodular thickening of the flexor tendon itself which may be congenital.

Carpal Tunnel Syndrome

• The wrist, or carpus, consists of eight small bones known as the carpals, which are joined by bands called ligaments.

• A nerve called the median nerve passes through the space between the carpal bones and the ligaments in the wrists.

• Thickening of the ligaments causes pressure on the median nerve, and this can cause irreversible nerve damage.

• The nerve damage will cause the muscle at the base of the thumb to waste away and will make it hard for the person with CTS to use his or her thumb for grasping objects.

Symptoms and signs

• Numbness, tingling, or burning sensations in the thumb and fingers, particularly the index, middle fingers, and radial half of the ring fingers which are innervated by the median nerve. Less specific symptoms may include pain in the hands or wrists and loss of grip strength[

Surgical treatment

EXERCISES

Hip pain

• Pain from the hip joint is usually maximal deep in the anterior groin, with variable radiation to the buttock, anterolateral thigh, knee or shin.

• Trochanteric bursitis is the most common periarticular lesion, typically affecting obese women, and occurring in isolation or secondary to an abnormal gait, such as in hip or knee OA.

Hip pain may be referred from other structures. Back pain commonly radiates to the buttock and posterior thigh but the site of maximal pain is close to the spine or pelvic brim. Root entrapment can cause pain in the lateral thigh (T12-L1) or the inguinal region and lateral thigh (L2-4) but is worsened by coughing and straining more than by movement and is often accompanied by sensory disturbance.

Hip pain

• A psoas abscess, retroperitoneal haemorrhage or pelvic inflammation can cause inguinal and lateral thigh pain that is aggravated by resisted hip flexion.

• Sacroiliac pain is maximal in the buttock, with radiation down the posterior thigh, worse on standing on that leg.

Knee pain

• Pain arising from the patello-femoral or medial and lateral tibio-femoral compartments is anterior and well localised to the involved compartment.

• Patello-femoral pain is worse going up and down stairs or inclines. Locking-sudden painful inability to extend fully that often spontaneously unlocks, followed by aching-is usually due to mechanical derangement such as a meniscal tear or osteochondritis dissecans.

• Referred pain from the hip may present at the knee but is more diffuse and often relieved by rubbing; on examination, it is reproduced by hip not knee movement.

Knee pain

• Pain from periarticular lesions is well localised to the involved structure.

• Inflammation of any of the three bursae around the patella usually results from repetitive occupational kneeling, but also infection and gout.

Knee pain

• Anterior knee pain syndrome is common, especially in adolescent girls. The pain has patello-femoral characteristics and is often aggravated by sports. In a small proportion, there is evidence of non-progressive fibrillation of the retropatellar cartilage ('chondromalacia patellae'). It is usually self-limiting and treatment is conservative.

Knee pain

• Anterior tibial compartment syndrome is characterised by severe pain in the front of the lower leg, aggravated by exercise and relieved by rest. Symptoms result from fascial compression of the muscles in the anterior tibial compartment and may be associated with foot drop. Treatment is urgent surgical decompression.

Knee pain

Foot and ankle pain

• Pain from the ankle joint is felt anteriorly between the two malleoli and is worse on standing or walking.

• Subtalar pain is mainly posterior between the malleoli and is particularly aggravated by walking on uneven surfaces, requiring eversion/inversion.

Foot and ankle pain

• Periarticular lesions that cause hindfoot pain are:

Foot and ankle pain

• Midtarsal disease causes pain in the 'bootlace' area, mainly during the late stance and toe-off phase of walking.

• Loss of the normal arches-pes planus ('flat foot')-may cause pain in the mid-sole. This is often congenital, but acquired causes include trauma, constitutional hyper-mobility, RA and neuropathic arthropathy.

Foot and ankle pain

• Medial arch supports in well-fitting shoes and/or intrinsic muscle-strengthening exercises usually relieve symptoms, but rigid splints may be required for hyperpronated feet, provided the foot is not rigid from fusion of the tarsal bones (tarsal coalition).

Foot and ankle pain

• MTP joint pain is felt below the metatarsal heads (metatarsalgia) and is often described as 'like walking on marbles'.

• Hallux valgus deformity with secondary bursitis (bunions) and OA of the first MTP joint is often associated with flattening of the transverse metatarsal arch and is a common cause of forefoot pain. It predominates in women as a consequence of wearing narrow high-heeled shoes.

Foot and ankle pain

• Severe restriction of first MTP joint extension (hallux rigidus), usually due to OA, may cause marked pain during attempted toe-off.

• For both hallux problems, conservative treatment and appropriate footwear usually suffice, although surgery is required in a minority.

Foot and ankle pain

• Pes cavus ('claw foot') is characterised by a high medial arch, secondary clawing of toes and metatarsal callosities.

• It can be caused by neurological disorders such as Friedreich's ataxia, spina bifida or poliomyelitis.

• Associated pain is often helped by medial arch supports and metatarsal insoles, and fasciotomy or osteotomy is rarely indicated.

• Morton's neuroma is an entrapment neuropathy of the interdigital nerves, mostly between the third and fourth metatarsal heads in middle-aged women with ill-fitting shoes.

• lancinating pain occurs mainly when the patient is wearing shoes and may associate with local sensory loss and a palpable tender swelling between the metatarsal heads.

• Footwear adjustment, with or without a local corticosteroid injection, is often sufficient but excision is occasionally required.

Mechanical back painFeatures of simple mechanical low back pain• Pain varies with physical activity (improved

with rest)• Sudden onset, precipitated by lifting or

bending• Recurrent episodes• Pain limited to back or upper leg• No clear-cut nerve root distribution• No systemic features• Prognosis good (90% recovery at 6 wks)

Mechanical back pain

• Mechanical pain accounts for more than 90% of episodes, usually affecting patients aged 20-55 years.

• The onset is often acute and associated with lifting or bending. It is related to activity and is generally relieved by rest.

• It is usually confined to the lumbosacral region, buttock or thigh, is asymmetrical, and does not radiate beyond the knee (this implies nerve root irritation)

Mechanical back pain

• On examination, there may be asymmetric local paraspinal muscle spasm and tenderness, and painful restriction of some but not all movements.

• Back pain precipitated by extension may relate to facet joint hypertrophy or spinal stenosis.

• Low back pain is more common in heavy manual workers, particularly those in occupations that involve heavy lifting and twisting.

Mechanical back pain

• Psychological factors (e.g. job dissatisfaction, depression, anxiety) are important risk factors for both acute back pain and the transition to chronic pain and disability.

Non-mechanical pain

• This is constant and often progressive, and has little variation in intensity or with activity.

• Anorexia, dyspepsia, change in bowel habit, prostatism or abnormal vaginal bleeding may indicate specific malignancies.

• Other 'red flags' for possible serious spinal pathology are :

Non-mechanical pain

Red flags for possible spinal pathology• Age: presentation < 20 yrs or > 55 yrs• Character: constant, progressive pain unrelieved by

rest• Location: thoracic pain• Past medical history: carcinoma, tuberculosis, HIV,

systemic corticosteroid use• Constitutional: systemic upset, sweats, weight loss• Major trauma

Red flags Contd…

On Examination • Painful spinal deformity• Severe/symmetrical spinal deformity• Saddle anaesthesia• Progressive neurological signs/muscle-wasting• Multiple levels of root signs

Non-mechanical pain

• If there is evidence of a spinal cord or cauda equina lesion, urgent neurosurgical assessment is required.

Non-mechanical pain

Features of radicular pain/ Nerve root pain• Unilateral leg pain worse than low back pain• Pain radiates beyond knee• Paraesthesia in same distribution• Nerve irritation signs (reduced straight leg

raising which reproduces leg pain)• Motor, sensory or reflex signs (limited to one

nerve root)• Prognosis reasonable (50% recovery at 6 wks)

Non-mechanical pain

Cauda equina syndrome• Difficulty with micturition• Loss of anal sphincter tone or faecal

incontinence• Saddle anaesthesia• Gait disturbance• Pain, numbness or weakness affecting one or

both legs

Inflammatory pain• Inflammatory pain due to spondylitis ('inflamed

vertebrae/spine') has a more gradual onset and often occurs before the age of 30.

• It is usually axial, symmetrical and spread over many segments which may include the thoracic region.

• Pain from sacroiliitis is maximal in the buttock, with radiation down the posterior thigh.

• Inflammatory pain associates with marked morning and inactivity stiffness, and improves rather than worsens with activity.

Other specific causes of low back pain

• Spondylolysis • Spondylolisthesis• Spinal stenosis• Prolapsed intervertebral disc• Arachnoiditis• Scheuermann's disease• Vertebral fracture

Spondylolysis

• It’s a stress fracture in the pars intercularis of the vertebrae.

• The pars interarticularis is especially vulnerable when the spine is in an extended position, and a force suddenly presses the vertebrae together, such as when landing on one's feet after a hop.

• This pressure acts like a nut-cracker on the pars interarticularis and can fracture it in susceptible individuals

Diagnosis

• Oblique view of the lumbar spine has a scotty dog appearance.

Spondylolisthesis

• Anterior or posterior displacement of a vertebra or the vertebral column in relation to the vertebrae below.

spondylolisthesis

• Spondylolysis is the most common cause of spondylolisthesis in pediatric patients.

• In the older population, degenerative disc disease commonly leads to spondylolisthesis without spondylolysis.

• the spinal canal narrows because the spino-laminar arch at one level slides forward on the lower level effectively flattening the canal.

Spinal stenosis• Spinal stenosis occurs when there is narrowing

of the vertebral canal.• The most common presentation is

'pseudoclaudication' with discomfort in the legs on walking that is relieved by rest, bending forwards or walking uphill.

• Common causes include Paget's disease where enlargement of the vertebrae may encroach on the spinal canal, and spondylosis of the spine where osteophytes can have the same effect.

Spinal stenosis

• Patients may adopt a characteristic simian posture, with a forward stoop and slight flexion at the hips and knees.

• Decompression is indicated if mobility or quality of life is significantly impaired.

Prolapsed intervertebral disc

• Age-related reductions in proteoglycans within the nucleus pulposus diminish its viscoelasticity, leading to focal damage and disc herniation.

• These changes occur most frequently at L4 and L5 due to the increased mechanical forces across this area.

Prolapsed intervertebral disc• Most patients have their first episode between

the ages of 20 and 30 years.• Presentation is with radicular pain (invariably

felt below the knee) in combination with evidence of root involvement (sensory deficit, motor weakness, asymmetrical reflexes) and a positive sciatic or femoral stretch test.

• About 70% of patients improve by 4 weeks. Persistent neurological deficit at 6 weeks is an indication for surgery.

Arachnoiditis

• Chronic inflammation of nerve root sheaths in the spinal canal can cause severe low back pain, sometimes combined with nerve root symptoms.

• Arachnoiditis can complicate meningitis or spinal surgery.

Management of low back pain• Reassure patients (favourable prognosis)• Advise patients to stay active• Prescribe medication if necessary (preferably at fixed time

intervals)– Paracetamol– NSAID– Consider opioids, muscle relaxants

• Discourage bed rest• Consider spinal manipulation for pain relief• Do not advise lumbar supports, back-specific exercises,

traction, acupuncture, epidural or facet injections

Neck pain

• Neck pain is usually due to mechanical or degenerative problems, although serious spinal disease needs to be excluded using the same principles as for back pain.

• Most episodes of transient mechanical neck pain are not associated with demonstrable spinal pathology

Causes of neck painMechanical Inflammator

yReferred pain

Metabolic Neoplasia Other

Postural Infections Pharynx Osteoporosis Myeloma Fibromyalgia

Whiplash injury

JIA Teeth Osteomalacia

Matastasis Torticolis

Cervical Spondylosis

RA MI Lymphoma

Principles of management of MSK diseases

The aims of management of MSK disorders are to:

• educate the patient• control pain• optimize function• modify the disease process where possible.

Core interventions

EducationInform patients about the nature of their

condition and its investigation, treatment and prognosis, as education can improve outcome.

Information and therapist contact can reduce pain and disability, improve self-efficacy and reduce the health-care costs of many MSK conditions, including osteoarthritis and RA.

Core interventions - Exercise

Two types of exercise should be prescribed • Aerobic fitness training can produce long-term reduction in

pain and disability. It improves well-being, encourages restorative sleep and benefits common comorbidity such as obesity, diabetes, chronic heart failure and hypertension.

• Local strengthening exercise for muscles that act over compromised joints also reduces pain and disability, with improvements in the reduced muscle strength, proprioception, coordination and balance that associate with chronic arthritis. 'Small amounts often' of strengthening exercise are better than protracted sessions performed infrequently.

Core interventions – Joint protection

• Excessive impact-loading and adverse repetitive use of a compromised joint or periarticular tissue can often be reduced: for example, cessation of contact sports, or altered use of machinery or tools at the workplace. Simple 'pacing' of activities-dividing physically onerous tasks into shorter segments with brief breaks in between-is helpful. Use of shock-absorbing footwear with thick soft soles can reduce impact-loading through feet, knees, hips and back, and improve symptoms at these sites. A walking stick held on the contralateral side takes weight off a painful hip, knee or foot.

Core interventions - Weight loss

• Obesity aggravates pain at most sites of the body through increased mechanical strain and is a risk factor for more rapid progression of joint damage in patients with arthritis. Obese patients should receive an explanation of this and be offered strategies on how to lose and then maintain an appropriate weight

Core interventions – Pharmacological

• Simple analgesics – paracetamol• NSAIDS• Topical analgesics• DMARDS• Corticosteroids

Core interventions – non Pharmacological

• Physical therapy/ heat• Surgery• Self help techniques/ Coping strategies