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.
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 seronegativespondarthritis • 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 joint Damaged joint • Pseudogout in association with osteoarthritis • Bone pathology • Secondary avascular necrosis • Subchondral collapse or fracture • Cartilage damage • Fibrocartilage tear, cartilage debris • Haemarthrosis • Septic arthritis Existing 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 villonodularsynovitis • Synovial chondromatosis • Synovial sarcoma • Monoarticular presentation of oligo-/polyarticular disease • Rheumatoid arthritis • Seronegativespondarthritis • Juvenile idiopathic arthritis
Oligoarthritis (Affecting 2-4 joint groups) Causes of inflammatory oligoarthritis • Seronegativespondyloarthritis • Reactive arthritis • Psoriatic arthritis • Ankylosingspondylitis • Enteropathic arthritis • Erythema nodosum • Juvenile idiopathic arthritis • Oligoarticular presentation of polyarthritis • Infection, including • Infective endocarditis • Neisseria • Mycobacteria
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 possible • pain 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
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.
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 bursitis Inflammation 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
Complications Occasionally, 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 • Drainage • Steorid injections • Rest ( Brief immobilisation) • Pain killers
Hand and wrist pain • Causes • Tenosynovitis • Median nerve compression • Raynaud’s phenomenon • C8/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 tenosynovitis Also known as washerwoman's sprain, radial styloidtenosynovitis, de Quervaindisease,deQuervain'ssyndromme, de Quervain'sstenosingtenosynovitis, 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 testis 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.
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[