MSK - done

Question 1

What is osteochondritis dissecans

Answer 1

Joint condition where piece of bone underneath cartilage dies due to lack of blood supply. Often knees but can be elbow ankle or other joints. Associated with repeated minor trauma. Pain after activity.

Question 2

UMN features

Answer 2

Increased tone (spasticity, reduced power, spastic paresis, little or no muscle wasting, hyperreflexia with clonus, up going babinski

Question 3

LMN features

Answer 3

Reduced tone, reduced power flaccid paralysis, muscle wasting, may have fasciculations. Reduced or absent deep tendon reflexes. Downgoing babinski

Question 4

Common cancers to cause bony mets

Answer 4

breast lung prostate renal and gastric

Question 5

How does back pain present when caused by a cancer?

Answer 5

Unremitting, worse at night or lying down, worse on straining, midline tenderness over spine, weight loss, age more than 50YO.

Question 6

What might back pain be like if due to infection (discitis, osteomyelitis, abscess)

Answer 6

fever. risk factors such as diabetes, IV drug use, TB HIV recent UTI.

Question 7

What might back pain due to a fracture present with?

Answer 7

History of trauma, may be major or minor especially if known OP. Pain is sudden onset, midline pain eased when lying down. Rarely may feel step deformity in spine. Point tenderness over bone usually.

Question 8

What might bilateral sciatica be?

Answer 8

Bilateral sciatica may suggest cauda equina. If sudden onset bilateral radicular pain or unilateral sciatica which progresses to bilateral (even without CES symptoms).

Question 9

Causes of spinal cord compression

Answer 9

Cancer, trauma, degenerative spondylosis with myelopathy, central disc herniation, infection (spinal epidural abscess, or spinal TB).

Cancer is most common cause in the UK

Question 10

Pattern of disc herniations

Answer 10

Cervical disc herniate centrally, lumbar discs herniate laterally. Central disc herniations are rare but if they occur they can compress the cord or cauda equina, serious. By comparison a lateral disc herniation may cause radicular pain in arm or leg but little other neurology.

Question 11

Signs and symptoms of spinal cord compression

Answer 11

Bladder or bowel dysfunction, gait disturbance (or heavy legs), limb weakness, UMN features, numbness paraesthesia or sensory loss, radicular pain.

Will have LMN pattern at the level of the lesion and UMN pattern below the level of the lesion.

May have history of cancer.

Question 12

Mx of SCC

Answer 12

should be a local pathway
give 16mg oral dexamethasone
immobilise patient if signs/symptoms of instability.
pain assessment
aim for MRI within 24hrs.

Question 13

Mx of suspected spinal mets

Answer 13

ensure no signs/symptoms of SCC
discuss with cancer team
consider immobilisation if mod severe pain on movement
pain assessment and give pain relief.
MRI within 1 week or CT if CI.
Consider steroids (this is likely secondary care decision).

Further mx may include RT, or surgical stabilisation.

Question 14

What is the most common cause of cauda equina

Answer 14

Central disc prolapse at L4/5 or L5/S1.
But can also be due to cancer, trauma, or infection (all the same causes as SCC just at a different place)

Question 15

Early signs of cauda equina

Answer 15

Altered saddle sensation, altered sense of micturition, delay or difficulty opening bowels or initiating micturition, change in erections or vaginal sensation, back pain with or without sciatic pain, bilateral sciatica may be present but may not be

Question 16

Later signs of cauda equina

Answer 16

Saddle anaesthesia, overflow incontinence, severe progressive bilateral neurological deficit in the lower limbs, LMN signs, loss of anal tone.

Question 17

Investigation of choice in cauda equina

Answer 17

MRI (or CT if MRI CI).
No role for any drug treatments for cauda equina.

Question 18

Referral for suspected cauda equina (CES)

Answer 18

New or deteriorating CES symptoms <2 weeks or severe or progressive neurological deficit in both legs - A&E

Stable CES symptoms >2 weeks or bilateral sciatica without CES symptoms - urgent referal to MSK services within 2 weeks.

If in doubt, speak to senior A&E clinician or on call radiologist.

Question 19

Common tendinopathies

Answer 19

Tennis elbow - extensor origin tendinopathy, lateral
Golfers elbow - flexor origin tendinopathy
Patellar tendinopathy - anterior knee pain
Achilles tendinopathy - posterior ankle pain.

Question 20

Presentation of greater trochanteric pain syndrome

Answer 20

Lateral hip pain that is exacerbated by prolonged sitting, climbing stairs, high impact physical activity, or lying on the affected side.
The cause is a trochanteric bursitis associated with tendinopathy of gluteus medius or minimus

Presents with lateral hip pain and focal point tenderness over greater trochanter.

Question 21

What causes tendinopathies

Answer 21

multifactorial, age, genetic predisposition, metabolic factors, structural factors (eg of foot or knee), overuse, or trauma. Extrinsic factors can play role, for example, equipment, technique of exercising, drugs such as ciprofloxicin.

Overuse is the big trigger!
Always ask about sports history and occupation history. Crucially what has changed.

Question 22

Presentation of a tendinopathy

Answer 22

Localised tendon pain during activity.
Pain rarely occurs at rest or with low load.
tenderness to palpate the tendon
tendon swelling
impaired function (weakness)
pain often eases during an activity but worsens afterwards.

Pain from tendinopathy tends to increase over weeks to months rather than starting suddenly. They are difficult to treat and may take months to resolve.

When you have a tendinopathy that puts you at risk of tendon rupture.

Question 23

Achilles tendon rupture

Answer 23

Simmonds triad - calf squeeze fails to move the foot, palpable gap, altered angle of dangle.

May have sudden pop. Often cannot walk but some can!

Fluoroquinolone antibiotics and corticosteroids increase risk of tendon rupture.

Mx by same day referal to orthopedics.

Question 24

Management of tendinopathies

Answer 24

NSAIDs - can be used short term for pain but not long term. Tendinopathies are degenerative rather than inflammatory so NSAIDs do not help with healing.

Eccentric exercises
Counterforce brace for tennis elbow
Explanation, education, relative rest and activity modification.

Steroid injections have little benefit and are CI for lower limb tendinopathies due to risk of tendon rupture.

No evidence of any benefit of surgery with tendinopathies.

Question 25

Diagnosing osteoarthritis

Answer 25

Diagnose without imaging if - age more than 45YO - activity related joint pain - any morning stiffness lasts less than 30 minutes Imaging may be used if atypical features or if an alternative or additional diagnosis is likely. Management guided by symptoms and function. Core treatment is exercise and optimising BMI.

Question 26

Management of OA

Answer 26

Exercise - offer for all. consider supervised exercise sessions. Advise that joint pain may increase when starting sessions but that regular consistent exercise is beneficial and long term exercise reduces pain and increases function. Weight loss - will reduce pain, improve function and WOL. Aim for 10% weight loss. Any weight loss is a good thing. Walking aids - if lower limb. Drugs - see other card

Question 27

Drugs for OA

Answer 27

First line - topical NSAIDs Second line - Oral NSAIDs if not CI. Intra articular steroid injections if other drug treatments ineffective or unsuitable or to support exercise. Not paracetamol (no benefit), not opioids (harmful)

Question 28

When to refer OA for joint replacement

Answer 28

Need to first establish that symptoms are substantially impacting QOL and non-surgical management is ineffective or unsuitable. No exclusion criteria but explain to patients would be good to stop smoking, lose weight etc.

Question 29

What type of OA does obesity increase risk of

Answer 29

All OA! even the non load bearing type. because of inflammatory component, adipose tissue.

Question 30

What to say to people with OA

Answer 30

Diagnosis can be made without imaging provide information that offers hope for the future explain core treatments to help people understand that drug treatments are not the answer teach patients to recognise flares and how OA pain can vary over time.

Question 31

What happens in an OA flare

Answer 31

Flares last on average 3-8 days imaging is not requires unless features are atypical differentials would be a crystal arthropathy, septic arthritis, RA, trauma, malignancy. trigger may include - knee giving way - increased physical activity - psychosocial factors - mood, poor sleep - environmental factors - cold damp weather. tell patients early about flares to help them self manage. management of flares - relative rest short term then return to activity as symptoms settle - analgesia to reduce impact of flare - this can be as for chronic OA plus can involve weak opioid. If flare does not return to baseline may be progression of the OA.

Question 32

What about IA steroid injections for OA

Answer 32

Can be done if - other treatments have not helped - patient understands that benefit likely to be short lived (2-10 weeks) - injection supports people to participate in therapeutic exercise where possible! May result in a small risk of cartilage thinning, and worsening symptoms over long term - try to avoid in young people with knee OA, but ok if older person who cannot have surgery. IA steroid injection of hip found to be very beneficial - could be used for people who dont want surgery or have been told they are too young for surgery.

Question 33

What is a bakers cyst

Answer 33

It is a posterior bulging knee effusion, distension of the bursa in the poplitela fossa. Usually secondary to OA or IA disturbance such as degenerative meniscal tear. Can cause posterior knee discomfort, fullness or tightness. if suspected clinically, imaging is not required.

Question 34

Management of bakers cyst

Answer 34

Nothing if asymp NSAIDs Physio Aspiration and steroid injection of the KNEE JOINT Surgical excision is occasionally performed. Complications - rupture spilling contents into surrounding tissues - occlusion of the popliteal artery and neuropathies.

Question 35

When does hip OA count as a prescribed occupational disease?

Answer 35

For long term employees in agriculture (>10yrs). This means it is classed as an industrial injury and sufferers may be eligible for industrial injuries disability benefit

Question 36

True or false, hip OA is less common than knee or hand OA

Answer 36

True.

Question 37

Presentation of hip OA

Answer 37

achy groin pain, activity related, worse towards the end of day. rest or night pain is more common as the disease progresses. hip OA can present with knee pain so important to check both joints. Key examiantion findings are joint stiffness, painful limited ROM. Limited internal rotation is most sensitive indicator of hip OA.

Question 38

Differentials of hip OA

Answer 38

GTPS, spinal (neuropathic pain/numbness, neuro signs, straight leg raise), femoro-acetabular impingement (younger, activity related pain, worse on hip flexion), RA (morning stiffness, better with activity).

Question 39

Interventions for hip OA

Answer 39

steroid injection very impressive NNTs total hip replacement is one of most successful surgical procedures.

Question 40

How would an inflammatory arthritis of the hand present

Answer 40

Hot tender erythematous joints, bilateral, symmetrical polyarthropathy, significant morning stiffness and relieved by activity. Likely to also have systemic features, fairly rapid onset, otehr joints usually affected.

Question 41

Presenttation of hand OA

Answer 41

hand or thumb pain, weakness especially in grip strength, limited stiffness (<1hr), often difficulties in functioning. gradual onset. usually systemically well. Heberdens nodes and bouchards nodes may be present. May be isolated hand OA or part of generalised OA picture.

Question 42

What haematological condition can present with hand joint pain and stiffness

Answer 42

Haemochromatosis Also have fatigue (commonest symptom), arthralgia, abdominal pain, weight loss, erectile dysfunction,

Question 43

Management of hand OA

Answer 43

Topical NSaids oral nsaids occupational therapy - hand exercises, joint protectors, functional support. steroid injections should not generally be used in hands. surgery - occasionally arthrodesis or arthroplasty for IPJ OA.

Question 44

Management of base of thumb OA

Answer 44

topical NSAIds oral nsaids occupatinal therapy - hand exercises, orthoses. surgery may include osteotomy, trapeziectomy, and joint fusion - may help if significant pain and functional impairment despite conservative mx.

Question 45

What is another name for OA 1st metatarsophalangeal joint

Answer 45

hallux limitus if joint is stiff hallux rigidus if joint is physiologically fused

Question 46

Polymyalgia rheumatica

Answer 46

Affects the muscles rather than the joints, is symmetrical, most common in the seventh or eight decade of life and afflicts women more often than men. linked to GCA.

Question 47

What respiratory condition can shoulder pain be the presenting feature of

Answer 47

Pneumothorax. NB - breathlessness is seldom severe unless the pneumothorax is a tension pneumothorax.

Question 48

What findings on straight leg raise test would indicate lumbar disc herniation

Answer 48

Pain in the leg and lower back between 30-70 degrees of straight leg raising.

Question 49

What findings on straight leg raise testing would indicate hip pathology

Answer 49

Pain at more than 70 degrees.

Question 50

blood testing in polymyalgia rheumatica

Answer 50

almost always assocaited with ESR >40. CRP often raised too. May have associated normochromic normocytic anaemia. Clasically condition responds dramatically to steroids within a few days. Review diagnosis if good response does not occur.

Question 51

At what age should you do a fragility fracture risk assessment, in patients with no other risk factors

Answer 51

From age 65 in women From age 75 in men.

Question 52

Plantar fasciitis common presentation

Answer 52

pain in the heals, worse with the first steps of the day, or after a period of inactivity. Pain typically lessens with activity. Worsens towards the end of the day. Manage with simple analgesics, rest, orthoses such as heel pads or arch supports, optimise BMI, ice packs and plantar fascia stretching exercises. Podietry and physio support if condition fails to improve with conservative treatment.

Question 53

Lumbar spinal stenosis presentation

Answer 53

Common cause of low back pain that radiates to the legs. more common in those over 50Yo. Presents as back or leg pain, with associated tingling and numbness, worse on walking and after periods of prolonged standing, eased by sitting down or stooping forwards. No bladder or bowel involvement. Normal neurological assessment of lower limbs. Management can be surgical or non surgical. If suspected, refer to spinal surgeon who can do imaging and discuss treatment options.

Question 54

referal criteria bone cancer and sarcoma

Answer 54

Urgent direct access USS within 2 weeks for adults or 48hrs for children and young people if unexplained soft tissue lump that is enlarging. Then suspected cancer pathway referral for adults or refer for specialist appointment within 48 hours for children if USS findings suggestive of soft tissue sarcoma or uncertain findings. For bone sarcoma - urgent direct access XR if unexplained bone swelling or unexplained bone pain. Then refer using USC pathway for adults or within 48hrs for children if XR suggestive of possible bone sarcoma.

Question 55

Risk factors for bone or soft tissue sarcoma

Answer 55

genetics - li fraumeni, gardners, inherited RB, neurofibromatosis. radiotherapy - often after breast ca or lymphoma. around 10 years later. exposure to phenoxy herbicides, dioxins, or poisons. viral infections - EBV and herpes virus 8. But most cases no obvious cause.

Question 56

How common is soft tissue sarcoma?

Answer 56

Less than 1% cancers in adults but 10% of all cancers in children. Lipomas (main differential in adults) are 100 times more common than sarcomas so sarcomas are easily missed. Delayed presentation, the bigger they are the worse prognosis.

Question 57

Red flags for possible sarcoma

Answer 57

Unexplained lump that is 1. bigger than a golf ball OR 2. Increasing in size OR 3. deep to fascia (less obvious when muscle contracted) OR 4. painful OR 5. recurrence of previously excised benign tumour. Do USS for all of these (urgent if 2 or more). If 3 of these features - 80% chance of malignancy. Diagnosis is MRI and core biopsy, then staging CT.

Question 58

Management of sarcoma

Answer 58

Usually surgery and RT Sometimes amputation. usually not chemo Recurrence occurs in 50% those with sarcoma, mostly in first 2 years.

Question 59

Presentation of reactive arthritis

Answer 59

classic triad of urethritis, conjunctivitis and arthritis. (cant see cant pee cant climb a tree). Affects men and women, mostly in young people between 20-40YO. Autoimmune response. Arthritis typically acute asymmetrical oligoarthritis, five or fewer joints, usually lower extremities.

Question 60

What is fibromyalgia?

Answer 60

Chronic widespread MSK pain and fatigue for no apparent reason. Red flags for other pathology include - involvement of other joints, systemic malaise especially if weight loss (this should not happen with FM alone). Or evidence of thyroid dysfunction.

Question 61

Typical presentation of rheumatoid arthritis

Answer 61

Symmetrical, large and small joints such as both hands, both wrists, both elbows.

Question 62

Typical presentation of OA

Answer 62

Gradual presentation, often limited to one set of joints, such as distal finger joints, or thumbs, or large weight bearing joints such as the hips/knees or spine.

Question 63

Adductor tear vs adductor tendinopathy

Answer 63

Adductor injury common in athletes who sprint, kick, turn and twist (think taekwondo). Tear more likely if sudden onset. Tendinopathy more likely if chronic gradually increasing pain.

Question 64

What is slipped upper femoris capitus

Answer 64

Commonly affects teenage boys, left more common. May present as knee pain rather than hip pain, and limping. Child may be overweight.

Question 65

When to suspected septic arthritis

Answer 65

Fever pain and limp

Question 66

What is osgood schlatter disease

Answer 66

Inflammation of patellar ligament causing irritation. Common cause of knee pain in teenagers, often at growth spurts. Athletes at increased risk due to extra stress on tendon. Tibial tubercle usually enlarged and inflammed and tender OE. Management is RICE.

Question 67

Management of acute gout

Answer 67

First line colchicine, NSAIDs and prednisolone.

Question 68

what is transient synovitis

Answer 68

also called irritable hip. Is the most common cause of hip pain in children. boys twice as affected as girls age 2-12 years. clinically presents as hip pain and limp. generally well, often preceeded by viral infection. May also have fever but tends to be low grade. diagnosis of exclusion. 90% settle within 7 days, some recur.

Question 69

What is perthes disease

Answer 69

This is avascular necrosis of the femoral head. Affects 1 in 2000 children, 80% boys. Age range 4-9YO. Bilateral in 15% so always check both hips. Clinically presents with hip thigh knee pain and a limp. Diagnosis on XR. Treatment includes bed rest, traction in abduction, femoral osteotomy and hip replacement as a definitive treatment once the disease is inactive.

Question 70

What is slipper upper femoral epiphysis

Answer 70

This is uncommon. Age range 10-20YO especially around growth spurt. Bilateral in 25%. Presents with gradual onset hip pain and restricted abduction. XR diagnostic, widening and irregularities of the physis. Surgical correction is required to prevent avascular necrosis.

Question 71

What does 3Ns of back pain mean?

Answer 71

Nasty red flag back pain Nerve pain including sciatica Non specific low back pain (sometimes called mechanical back pain). No benefit for imaging if non specific LBP or sciatica - only if red flag back pain. (in practice, this means if patient with lumbar back pain for more than 6 weeks with no clinical or serological indicators of infection or neoplasia, only XR if presentation suggests OP collapse.

Question 72

What is the STarT back tool used for?

Answer 72

Stratify patients into those at low medium and high risk of chronic pain in order to be able to adopt a biopsychosocial approach for these people. Treatment strategy depends on the results of this.

Question 73

What would be red flags for low back pain

Answer 73

TUNAFISH trauma unexplained weight loss neurological symptoms (progressive or new bladder/bowel involvement) age <20 or >55. fever IVDU or Inflammatory pain Steroid use History of cancer - prostate kidney thyroid breast. Do full neuro exam. But refer based on history if worrying. Possible cause of above red flags include - fracture, malignanncy, infection, cauda equina, spinal stenosis, or inflammatory back pain.

Question 74

How to manage back pain with red flags

Answer 74

Refer to secondary care urgency depends on symptoms - A&E or MSCC coordinator OR suspected cancer pathway OR urgent MSK referal.

Question 75

Presentation of sciatica or radicular pain

Answer 75

No red flags Leg pain will be more severe than back pain Usually unilateral Pain radiates to back of leg/below knee. Neuropathic sounding pain - shooting/burning. Numbness/parasthesia of lower leg. positive neural tension test. Neurological deficit corresponding to nerve root affected. Do neuro exam and straight leg raise.

Question 76

What is straight leg raise test

Answer 76

Pain on the affected side when the opposite side lifted. It is very specific for disc prolapse.

Question 77

Management of sciatica pain

Answer 77

Risk assess, analgesia, safety net. Risk stratfy with STarT back tool. Refer urgently if any red flags or progressive neurological symptoms develop. Most are managed conservatively. Consider referral for intervention depending on local pathways.

Question 78

What should you examine if non specific low back pain

Answer 78

If no features of radicular pain and no red flags, dont need to do full neuro. So examine hip joints and for muscle tenderness.

Question 79

Management of non specific LBP

Answer 79

Advice education and reassurance Risk stratify with STart back tool. Clear explanation giving. Promote active treatment and self care. Safety neg, give cauda equina leaflet. Do not image.

Question 80

Presentation of infection with back pain?

Answer 80

Can be discitis / osteomyelitis/abscess. Uncommon Consider in IVDU, long term immunosuppression, TB, recent surgery or recent systemic infection. Will present as fever/malaise/systemically unwell. Increasing and unremitting back pain. Aggravated by straining. Focal bony tenderness. Neuro signs symptoms only present in 15%

Question 80

What to

Question 81

When to suspect inflammatory back pain

Answer 81

low back pain lasting more than 3 months starting before the age of 45YO with 4 or mroe of - onset before 35YO - waking in second half of night with symptoms - buttock pain - improves with movement - improves with 48hrs of nsaids - first deg relative with spondyloarthritis - current or past arthritis or enthesitis. - current or past psoriasis. If 4 or more present, refer to rheum, no need for imaging. If 3 present, do HLA-B27 then refer to rheum if positive. If less than 3 present, ask patients to re present if new symptoms.

Question 82

Differential diagnosis for sciatica.

Answer 82

Disc prolapse at L4S1- nearly all! Lumbar spinal stenosis especially if bilateral and over 60YO. Nerve root may also be compressed by soft tissue structure such as tumour, infection, cyst. Sacroiliac joint pain can mimic symptoms of sciatica. Risk factors for sciatica are smoking, obesity, manual work.

Question 83

Investigation of sciatica in primary care

Answer 83

NO imaging! This is because imaging findings do not correlate with symptoms. Consider referral if symptoms don't improve and are impacting function. Severe or progressive neuro deficit. Suspicion of cauda equina or bilateral sciatica Other red flags such as history of trauma, suspicion of cancer, previous cancer or suspected infection.

Question 84

Management of sciatica

Answer 84

Risk stratify with start back tool Safety net with cauda equina card Self care, keep active, avoid bed rest. Physiotherapy Analgesia - NSAID or mild opiates (only in first 12w). Few people get epidural LA or steroid injection - limited evidence of benefit. Surgery - may do microdiscectomy - if symptoms persist and consistent with radiological findings, some evidence sooner is better for this.

Question 85

Neuropathic pain agents for sciatica?

Answer 85

NICE advised to avoid gabapentinoids, oral steroids or benzos. No opioids for chronic sciatica. Duloxetine and amitriptyline - stated not enough evidence- but consensus is it may help.

Question 86

Management of NSLBP

Answer 86

Safety net and document all for CES. Low risk - reassurance in primary care, information leaflet, guided self help. Medium risk - refer to physio, reassurance, information, guided self help and 6-8 sessions of physiotherapy. High risk - refer to physio or pain clinic for combined supported exercise/physiotherapy and psychological approach.

Question 87

Drug treatments for NSLBP

Answer 87

NSAIDS with gastroprotection if no CI at lowest dose shortest duration possible. Not paracetamol alone! (not effective). Consider weak opioid if NSAID CI/ineffective (as acute script only with clear discussion of goals of treatment and plan to stop). NOT neuropathic pain agents. No role for spinal injection, bed rest, US or TENS or acupuncture.

Question 88

Specific causes of low back pain in over 65s

Answer 88

Can include vertebral fracture, malignancy, infection, aortic aneurysm, spinal canal stenosis, radicular pain and cauda equina syndrome. Have higher index of suspicion in these patients.

Question 89

What is the usual presentation and mx of peripheral meniscal tear

Answer 89

Located in most vascular portion of menisci and are most common type of meniscal tear. Younger people especially males with knee instability are most commonly affected by this type of tear. Mx initially with rehab and conservative therapy. But if still symptoms at 6 weeks refer for ortho assessment and arthroscopy.

Question 90

First line managemetn for patella tendinopathy not settled by 3 months

Answer 90

Physiotherapy

Question 91

Presetnation of carpal tunnel syndrome

Answer 91

Median nerve entrapment at the wrist. Pain paresthesia, worse at night. Usually in hand but can extend proximally to the elbow and shoulder.