Musculoskeletal Masqueraders

‘Behind every mask is a face and behind that a story…’

#therapyexpo

Marty Rubin

Musculoskeletal Masqueraders

Seeing through the mist during clinical assessment can be a challenge…!

#therapyexpo

Rolling the ‘Clinical Dice..’

#therapyexpo

‘Many diagnoses are missed as not considered to be likely or not considered at all..’ [Jackson, 2011]

• Imaging

• Injecting

• Prescribing

• Minor Surgery

• FCP Roles

Physiotherapy has moved on

#therapyexpo

Safety in LARGE numbers..!

#therapyexpo

• Leadership• Accountability• Risk• Governance• Education

‘The line between failure and success is so fine that we scarcely know when we pass it…’

Elbert Hubbard

Mistakes Happen

#therapyexpo

Consider the impact on person, family, clinician & service

‘The man of science has learned to believe in justification, not by faith, but by verification…” [Thomas Henry Huxley]

Clinical Reasoning

‘Clinical reasoning is only as good as the information on which it is based …’ [Jones 1992]

Three types of error can occur in clinical reasoning:

1.Faulty perception or elicitation of cues

2.Incomplete factual knowledge

3.Misapplication of known facts to a specific problem

[Scott, 2000]

#therapyexpo

Terminology

Masquerader

‘Appears in disguise or assumes a false appearance…’

Red Herring

‘Misleading biomedical or psychosocial factor that

can deflect clinical reasoning..’

Red Flag

‘Possible indicator of serious pathology…’

Serious Pathology

‘Fracture, Cancer, Infection, CES,

Inflammatory disorder…’

[Greenhalgh & Selfe, 2006; Clinical Standards Advisory Group 1994, Sykes, 1978]

#therapyexpo

Dear Team,

Thank you for the reviewing this 65 yr old male who has a history of LBP, however more recently he has had some unilateral leg pain which I believe coincides with a groin injury following gardening. Neurologically he is intact and I would be grateful of your physiotherapy assessment.

• Pain during gardening 3/52• LBP now worse in sitting• Lying on ® side causes rib pain• Intermittent ® leg pain• No neuro reported• Hypertensive

Clinical Scenario

#therapyexpo

• Alcohol 70 units per week• Testicular, Hip & Groin Pain• Syncope x 3 episodes 3/52• Ribs feel bruised• Leg feels heavy• Family history of PVD

Differential Diagnosis

• Low Back Pain• Degenerative Hip• Arterio Venous Malformation (AVM)• Abdominal Aortic Aneurysm• Acute Pancreatitis

#therapyexpo

Abdominal Aortic Aneurysm (AAA)

• Syncope may be the chief complaint, however, ć pain less prominent

• Expanding AAA causes sudden, severe, LBP, flank, abdominal, or groin pain

• Normal vital signs (?) ć ruptured AAA as a consequence of retroperitoneal containment of hematoma

• Common & life-threatening• 65 years > (M)• History of PVD• Usually asymptomatic until they expand or rupture• Grey Turners Sign • Grey Turners sign can be associated ć Cullen’s Sign

‘62 %chance that an AAA is present with a popliteal aneurysm and an 85 % chance it is present with a femoral artery aneurysm; 14 %of patients with a known AAA will have a femoral or popliteal artery aneurysm…’

[Bosmann et al, 2009; Von Allmen et al;2012]

Grey Turners Sign Cullens Sign

#therapyexpo

Things to watch & tune into….!

Unusual but worth noting..!

‘73-year-old man with a ruptured AAA presenting with isolated acute right hip pain without any classical features…’ [Validyanathan et al, 2008]

#therapyexpo

Or….how about this…!

#therapyexpo

‘Every physician seems to recall a case of a missed aneurysm with catastrophic outcomes where, in retrospect, warnings may have been overlooked. Because of frequent visits, she had been labeled as a “frequent flyer", and back pain is

an extremely common and nonspecific symptom…’

[Helliker & Burton, 2003]

Cauda Equina Syndrome (CES) – ‘Understand the horses tail’

#therapyexpo

Cauda Equina Syndrome

‘Narrowing of the spinal canal that compresses the nerve roots below the level of the spinal cord…’

[Todd, 2009]

‘Classic Triad - Saddle anesthesia, bowel and/or bladder dysfunction, and lower extremity weakness…’

[Gautschi et al. 2008]

‘Average compensation ć missed or delayed diagnosis £336,000 UK. 1000 operations per year ć 30-40 cases in UK…’

[Gardner et al, 2011]

‘Challenge of notes, under- recording of the actual presentation, failure to examine properly, act on red flags, refer on or investigate with sufficient urgency…’

[The CSP 2014; Greenhalgh, Selfe, 2006; Macfarlane, 2014]

#therapyexpo

‘The most common cause of CES is lumbar disc herniation at the L4-L5 and L5-S1 levels and then in decreasing order, tumour, infection, stenosis, haematoma, inflammatory and vascular..’ [Fraser et al, 2009]

Bladder Confusion & CES

#therapyexpo

Not uncommon for patients with severe back and leg pain to complain of difficulty

passing urine

• Severe back and leg pain can lead to Inhibition of bladder functioning

• Opiates (Morphine based) - Affect the bladder sphincters -

• Anxiety – Affect on bladder function

Urinary Retention…!

• Vaginal childbirth, Infections, Diabetes, Stroke, MS, Prostrate

• Surgery- Post-Op anaesthetic nerve block

• Medication - Antihistamines & Tricyclic antidepressants (e.g. Amitriptyline)

• Bladder Stone - urinary tract blockage

• Prolapse of anterior vaginal wall

• Constipation – Hard stool in the rectum can pinch shut the urethra

CES (Incomplete)

• Uni or bilateral sciatica may be present & >• Deteriorating neuro• Uni or patchy perineal / perianal numbness• Anal sphincter tone reduced• < desire to void, poor stream flow, strain to

micturate but with sensation of a full bladder

CES (Complete)

• May have NO leg pain OR • Uni/bi lateral sciatica• Widespread perineal sensory deficit• NO anal sphincter tone• Painless urinary retention with full bladder and

overflow incontinence

Sexual Dysfunction Associated ć CES

• Vaginal anesthesia and numbness• Incontinence during intercourse• < intensity and/or inability to achieve orgasm• Inability to achieve erection• Inability to achieve ejaculation

#therapyexpo

Cauda Equina Syndrome

Difficult Questions

‘Fine tune your message..’

#therapyexpo

Cauda Equina Syndrome

Endocrine Osteoporotic Collapse

Biochemical Paget’s Disease

Inflammatory Rheumatoid Arthritis, Ankylosing Spondylitis

HaemorrhagicEpidural/Subdural Haematoma

Thrombotic Inferior Vena Cava Thrombosis

Neoplastic Ependymoma, Neurofibroma, Meningioma,, Schwannoma, Lymphoma,Metastases

Congenital Spinal Dysraphism, Dwarfing Syndromes, Tumours, Dermoid, Epidermoid, Teratoma & Lipoma

Infective Bacterial abscess, TB, Schistosomiasis

Traumatic Spinal Fractures or dislocations

Degenerative Spondylolisthesis, Lumbar Spinal Stenosis, Herniated IV Disc

Vascular Ateriovenous Malformation (AVM), Aortic dissection

Iatrogenic Secondary to surgery, Spinal or epidural anasthesia, Spinal Manipulation

#therapyexpo

‘Multiple other pathologies can damage the anatomical structures involved…’ [Yuan et al, 2009]

#therapyexpo

• Qualify

• Quantify

• Index of suspicion

Go back in time & understand the history in more detail if needed..!

‘History is a vast early warning system…’ Norman Cousin

‘Dear Sir, I am now required to remove my MSK Hat and I will need to change tact

during assessment to ensure we have clarity. Please bear with me..!’

#therapyexpo

Removing the MSK Hat

‘Questions are great, but only if you know the answers’ Laurell Hamilton

#therapyexpo

It just sounds and looks a bit odd…!

• Masqueraders are rare• Coexistence of conditions• Pattern recognition obscured• Generally unwell• Co morbidities• Gut feeling

#therapyexpo

Dear Team,

Thank you for reviewing this 72yr old female who describes a 6-month history of left sided hip pain, which has progressively worsened in the last 8 weeks. The patient is now complaining of what I presume is Greater Trochanteric Bursitis on the left hip, which is affecting her walking. Iwonder if they may benefit from an injection.

• Fall 8 months ago in garden• > Hip and back pain since• Weird walking 12months• Clumsiness• Legs feel funny

Clinical Scenario

#therapyexpo

• Hyper-reflexia LL• B&B, Saddle Anesthesia clear• No Hx of Cancer• Weight stable• Cant lie on left hip due to pain

Differential Diagnosis

• Osteoporotic fracture

• Myelopathy

• Space Occupying Lesion

• Stenotic progression

#therapyexpo

Myelopathy

#therapyexpo

‘Can be a Slow burner.!’

Myelopathy

‘Neurologic deficit related to the spinal cord, usually due to compression of the spinal cord…’

• Osteophytes

• Discogenic

• Carcinoma

• Trauma

• Infection

• Cysts

[Kent; Rapport; Rothman; Tartaglino et al, 1994]

Basically we are looking at a Space Occupying Lesion (SOL) to various degrees…!

#therapyexpo

Metastatic Spinal Cord Compression (MSCC)

‘Metastatic spinal cord compression is defined radiographically as an epidural metastatic lesion causing true displacement of the spinal cord from its normal position in the spinal canal…’

[Loblaw et al, 2003]

#therapyexpo

63 year-old man with metastatic melanoma to the C5 vertebral body

8 Item Identification Tool for MSCC

• Referred back pain that is multi segmental or Band Like• Escalating pain which is poorly responsive to Rx (Including meds)• Different character of site to previous symptoms• Funny feelings, odd sensations or heavy legs (Multi Seg)• Lying flat increase back pain• Agonising pain causes anguish an despair• Gait disturbance, unsteadiness, especially on stairs (not just a limp)• Sleep grossly disturbed due to pain being worse at might

#therapyexpo

[The Greater Manchester and Cheshire Network UK]

Vigilance and awareness can be helpful..!

#therapyexpo

• Identify early

• Gain clarity

• Calm approach

• Methodical

•

•Altered facial sensation (L)•Light-headedness ć (L) UL 90°•Nausea ć (L) UL > 90 °•Exercise induced ‘heaviness’ of (L) UL•Recent > SOB ć UL activity & inclines

Clinical Scenario

#therapyexpo

Dear Team,

Thank you for the reviewing this 52yr old female who describes cervical spine pain which radiates into the left with an associated tension related headache. I wonder if some physiotherapy may be of some benefit. I enclose a copy of a recent x-ray that highlighted Spondylosis at the C4-5, which wont be helping symptoms.

•Handwriting <•Hypotensive•Temporal headache•Intermittent blurred vision (L)• Capsualr pattern – left shoulder

Differential Diagnosis

• Pancoast Tumour

• Upper Limb DVT

• Giant Cell Arteritis (GCA)

• Subclavian Steal Syndrome

• Thoracic Outlet Syndrome

• Adhesive Capsulitis

#therapyexpo

#therapyexpo

Clinically evident ć symptoms of the ‘Pancoast-Tobias Syndrome’ which includes ‘Claude-Bernard-Horner syndrome’

• <5% of Bronchogenic Cancer = Apex of the lung

• Severe pain in the shoulder radiating toward axilla and/or scapula & along the ulnar distribution of the upper arm

• Atrophy of hand and arm muscles and obstruction of the subclavian vein resulting in oedema of the upper arm

• Subclavian vein swelling

• Involvement of the Thoracic Outlet

• Horner Syndrome - Miosis (a constricted pupil), Ptosis (a weak, droopy eyelid), Anhidrosis (decreased sweating) with or without enophthalmus (inset eyeball).

T1W Coronal ć mass arising from right lung apex , involving the 1st

2nd ribs and the lower root & trunks

Pancoast Tumour

Giant Cell Arteritis (GCA) ‘ A headache not too miss..!

• >70yrs & rare <50yrs

• Most common form of Vasculitis in adults

• 3 x more common in (F)*

• Abrupt onset of headache ‘Head Pain’ (75%)

• Scalp pain (difficulty in combing hair)*

• Jaw & tongue claudication Cramping pain occurring after prolonged chewing or talking (DD ć TMJ)

• Limb claudication – ? large-vessel GCA (i.e. outside the cranial vessels).

• Visual disturbance - Transient

• Systemic symptoms ( low-grade - fever, anorexia and fatigue – 50%)

• Appetite, depression, fatigue*

• Polymyalgia symptoms (40-60%)

• Upper Cranial Nerve Palsies

#therapyexpo

Competency with Cranial & Haemodynamic Testing!

Differential Diagnosis in GCA

#therapyexpo

• Shingles

• Migraine

• Orbital or base of skull lesions

• Ischaemic attack

• Cluster headache

• Cervical spondylosis

• TMJ

• Ear problems

GCA & Bloods

• C-reactive protein (CRP)

• Erythrocyte sedimentation rate (ESR)

• ESR & CRP are no longer routinely requested together for most conditions, either marker (or both) can be raised in GCA

• If both CRP and ESR are normal, the likelihood of giant cell arteritis being present is reduced, but cannot be ruled out.

• Full blood count (FBC)

• Liver function tests (LFTs)

#therapyexpo

Thoracic Outlet Syndrome (TOS)

#therapyexpo

Neurogenic (TOS) Upper (C5-7)

• Radiating neck pain to ear, face & occiput causing headaches

• Mimics a C5-6 nerve root can be caused by hypertrophies scalene, elongated C7 TP, presence of Csx rib

• Paresthesias fingers & hands*

Neurogenic (TOS ) Lower (C8-T1)

• Median & ulnar distribution ć or without neck/shoulder pain

• Overhead activity can cause weakness

• Loss of grip and fine motor control

• No limited to a specific dermatome

[Nichols, 2009 ; Brantigan & Roos, 2004]

Vascular (TOS)

• Paget-Schroetter syndrome or Effort Thrombosis

• Underlying anatomical abnormality

• Concomitant repetitive arm raising exercises, such as swimming or throwing a ball

[De Leon et al, 2009]

Dear team,

Thank you for reviewing this 46 year old female who was very fit up until last year. Could you please advise for exercises due to weakness in both feet. I have attached an MRI of the foot for your records which has come back negative, as have a recent setof full bloods. I wonder whether an orthotic may be of use.

Clinical Scenario

#therapyexpo#therapyexpo

• No trauma• Antalgic gait• NO B&B, SA, night pain• 2 hr ‘Siesta’ required to function• No PMhx• Memory

• Hyperreflexia LL• No radicular S&S• First line analgesia no effect• Sub 4hr Marathon 18/12• Weakness L4/5 L5/S1• Hair loss

Family History of Myotonic Dystrophy

• Muscle weakness

• Inward & upward-turning foot

• Breathing

• Balding

• Cardiac

#therapyexpo

Dear team,

Thank you for reviewing this 61 yr old female who has a 3-month history of insidious right sided shoulder pain, which presents more as stiffness and wonder whether they may benefit from some exercise advice and an injection. I enclose a copy of a recent x-ray which is unremarkable.

Clinical Scenario

#therapyexpo

• Diagnosed ć (L) Breast Ca Jan 2015• Chemotherapy• Breast Surgery• Radiotherapy• Hormone Therapy

• Still under Consultant• No neuro, B&B or SA• Mid thoracic night Pain• Lateral rotation < AROM & PROM• Sympathetic response on ROM

Consideration for the medication

‘The MSK system has a high metabolic rate & blood flow, therefore high exposure to circulating medications..’

• Muscle Pain

• B&B Dysfunction

• Osteoporosis

• Fractures

• Tendon Ruptures

#therapyexpo

Medication

Clinical Presentation Considered Medication

Mild Aches and Pains Oral contraceptive (e.g: Microgynon) and Statins (e.g: Atorvastatin)

Muscle Cramps Diuretics (e.g. Bendroflumethiazide- Calcium Channel Blockers (e.g.: Verapamil) - Beta Agonists (e.g.: Salbutamol)

Proximal muscle weakness, atrophy Oral Corticosteroids (e.g. Prednisolone), >10mg dose, for at least 30 days

Severe Pain, myopathy, malaise, fever, dark urine statins, 0.1-0.2% of pets in clinical trials have side effects

Osteoporosis Fracture Oral corticosteroids, i.e.. Doses > 5mg daily lead to significant and rapid bone loss. A cumulative dose of >30g associated with high incidence of fracture 53%.

Avascular Necrosis -Corticosteroids 5-40% of pets on long term therapy

#therapyexpo

Adapted ~ Grieves Modern MSK Physiotherapy 2015

Medication

Clinical Presentation Considered Medication

Tendinopathy, tendon rupture , myopathy Injected corticosteroids , oral corticosteroids Glucocorticoids, direct catabolic effect on skeletal muscle tissue

Myalgia, arthralgia, arthritis, tendinitis Quinalones (synthetic broad spectrum antibiotics - e.g.: ciprofloxacin) World wide incidence of side effects estimated as 15-20 per 100,000 patients treated

Bladder & Bowel Dysfunction Opioid salts; constipation (e.g.: Tramadol, codeine) Anticonvulsants: urinary incontinence (Gabapentin, Pregablin). Antidepressants = retention, sexual dysfunction (Amitriptyline, Nortriptyline)

Muscle Cramp, muscle weakness Thyroid hormones (e.g: levothyroxine sodium… at excessive dosage

Joint aches and pain (Arthralgia) Antithyroid drugs used to treat hyperthyroidism – e.g.: Carbimazole

#therapyexpo

Adapted ~ Grieves Modern MSK Physiotherapy 2015

Systems Thinking

#therapyexpo

• General Health

• Musculosjeltal

• Nervous

• Cardiovascular

• Vasucular

• Respiratory

• Men Vs Women

Foot Drop Friday….!

‘You can not be serious…!’

Light Bulb Moments..!

‘To know what you know and what you do not know, that is true knowledge...’

[Confucius]

#therapyexpo

Brining it all together isn't easy..!

#therapyexpo

• Knowledge & exposure

• Ongoing competency

• Structure & support

• Qualify & quantify

• Index of suspicion

• Pathways

#therapyexpo

References

• Boden SD, et al. JBJS 1990; 72-A: 403-408

• Bosmann M, Schreiner O, Galle PR (April 2009). "Coexistence of Cullen's and Grey Turner's signs in acute pancreatitis". Am. J. Med. 122 (4): 333–4.

• Brantigan CO, Roos DB. Diagnosing thoracic outlet syndrome. Hand Clin. 2004;20:27–36.

• Fraser S, Roberts L, Murphy E. Cauda equina syndrome: a literature review of its definition and clinical presentation. Arch Phys Med Rehabil. 2009;90(11):1964–68

• Gautschi OP, Cadosch D, Hildebrandt G. Emergency scenario: cauda equina syndrome--assessment and management. Praxis (Bern 1994) 2008;97:305–12

• Gitelman A, Hishmeh S, Morelli BN, Joseph SA, Casden A, Kuflik P, et al. Cauda equina syndrome: a comprehensive review. Am J Orthop. 2008;37(11):556–62

• Greenhalgh S, Selfe J. Red flags: a guide to identifying serious pathology of the spine. Edinburgh: Churchill Livingstone; 2006.

• Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur Spine J. 2011 May;20(5):690-7

• Helliker K, Burton TM. Medical ignorance contributes to toll from aortic illness. Wall Street Journal; Nov 4, 2003.

References

• Jackson J . ‘ Musculoskeletal Pathway Information’. West Sussex NHS Trust (2011)

• Jones, M.A. Clinical reasoning in manual therapy. Phys. Ther. 1992; 72: 875–884\

• Loblaw DA, Laperriere NJ, Mackillop WJ. A population based study of malignant spinal cord compression in Ontario. Clin Oncol 2003;14:472-80

• Mooney V. Differential diagnosis of low back disorders: principles of classification. In: Frymore JW, editor. The adult spine: principles and practice. New York: Raven Press; 1991. pp. 1559–60.

• Macfarlane R. Cauda equina syndrome: key issues. London: Kennedys. 2014.

• Ma B, Wu H, Jia LS, Yuan W, Shi GD, Shi JG. Cauda equina syndrome: a review of clinical progress. Chin Med J. 2009;122(10):1214–22

• Nichols AW. Diagnosis and management of thoracic outlet syndrome. Curr Sports Med Rep. 2009;8:240–9.

• The Chartered Society of Physiotherapy. Professional and public liability insurance. London: The Chartered Society of Physiotherapy. [Accessed: 29 May 2014]

• Scott I. Teaching clinical reasoning: a case based approach. In: Jones MA, Higgs J, editors. Clinical reasoning in the healthprofessions, 2nd ed. Oxford: Butterworth Heineman; 2000 [chapter 34]

• Todd NV. An algorithm for suspected cauda equina syndrome. Ann R Coll Surg Engl. 2009 May. 91(4):358-9; author reply 359-60.

• Von Allmen RS, Powell JT. The management of ruptured abdominal aortic aneurysms: screening for abdominal aortic aneurysm and incidence of rupture. J Cardiovasc Surg (Torino). 2012 Feb. 53(1):69-76