programme for today: 13.30 intros: us, you, specialities? 13.45 knees 14.15 shoulder /1 14.30...
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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
Look
Feel
Move
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
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?
• 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
Look
Feel
Move
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
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