Transcript Slide 1
Programme
for today:
13.30 Intros: Us, You, specialities?
13.45 Knees
14.15 Shoulder /1
14.30 Break
14.45 Shoulder /2
15.00 Back
15.30 Q&A, other examinations
16.00 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
Look
Feel
Move
Special
Tests
3 Bones
Humerus
Scapula
Clavicle
3 Joints
Glenohumeral
Acromioclavicular
Sternoclavicular
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?
Rotator cuff disorders
cuff tendinopathy, calcific
tendonitis, subacromial
bursitis, impingement, cuff
tears
Glenohumeral jt. Problems
adhesive capsulitis,
osteoarthritis
ACJ Problems
Traumatic Dislocation
Infections
Pain arising from the shoulder jt
Referred Pain
Neck pain, myocardial
pain, referred diaphragmatic
pain
Polymyalgia Rheumatica
Malignancy
Apical lung tumors,
metastases
Pain arising from elsewhere
Answer:
Cx radiculopathy + neural tension
pain. Amitriptyline for sleep, rehab involved
posture, Tx extension exc, Cx traction and
retraction
Look
Feel
Move
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?
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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%)
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Nonmechanical spinal conditions (1%)
Neoplasia (0.7%)
Inflammatory arthritis (0.3%)
Infection (0.01%)
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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
Look
Feel
Move
Special
tests
Other
examinations...
Cancer
Age > 50
History of Cancer
Weight loss
Unrelenting night
pain
Failure to improve
Infection
IVDU
Steroid use
Fever
Unrelenting night
pain
Failure to improve
Fracture
Age >50
Trauma
Steroid use
Osteoporosis
Cauda Equina Syndrome
Saddle anesthesia
Sphincter
dysfunction
Loss of sphincter
control
Major motor
weakness