MSK

Question 1

When should you consider ulnar nerve compression at elbow?

Answer 1

Also called cubital tunnel syndrome
Pain at the medial elbow, with numbness and tingling in the little and ring fingers.
grip weakness.
loss of hand dexterity.
Can occur from prolonger elbow flexion but also distal humeral fracture
Chronic: 4th 5th finger clawing, hypothenar muscle wasting

Question 2

Tennis vs golfer’s elbow

Answer 2

Tendonopathy
Tennis: lateral epicondylitis, pain resisted wrist extension
Golfers: medial epicondylitis, pain resisted wrist flexion

Question 3

Management of tendinopathy (golfers, tennis, achilles)

Answer 3

Progressive loading >12 weeks physio, isometric first,
Modify activity
Ice
Pain relief
Steroid injection 6 weeks pain relief but doesn’t fix problem

Question 4

Management ulnar nerve compression

Answer 4

If muscle wasting/progressive neurological signs- urgent T+O

Otherwise:
Modify activities
Keep the elbow extended with a soft pad or towel in the antecubital fossa overnight
Neural glides/slides, physio

If persistent paraesthesia, routine T+O ?surgery

Question 5

Features of carpal tunnel

Answer 5

Median nerve compression
Pain/paraesthesia wrist/hand, worse at night
The patient often shakes their hand or dangles it out of bed to ease the symptoms.
Provoked by flexing (Phalen) or extending wrist, or tapping (Tinel)
May have weakness of hand grip, specifically with thumb abduction and pincer grip.
If severe, thenar muscle wasting

Question 6

Management carpal tunnel

Answer 6

Modify activities
Wrist splinting at night
Exercises, neural glides
Consider steroid injection

Routine ref T+O ?surgery if:
-Permanent sensory loss
-Motor weakness
-Muscle wasting
-Failure conservative treatment 3 months

Question 7

What is DeQuervian’s tenosynovitis?

Answer 7

radial-sided wrist pain on flexing and extending the thumb, especially with radial or ulnar deviation.
Abductor pollicis longus and extensor pollicis brevis
Women, age 30-55, esp lifting young baby

Question 8

Test for DeQuervian’s

Answer 8

Finklesteins Test-
In neutral sup/pronation, adduct the thumb across the patient’s palm and place the wrist into ulnar deviation.

Question 9

Management DeQuervian’s

Answer 9

NSAIDs
Strengthening exercises
Modify activity
Wrist thumb splint
Consider steroid injection

Question 10

What are Dupytrens contractors associated with?

Answer 10

Smoking
Alcohol excess
Diabetes
Hypercholesterolaemia
FHx
Peyronies disease

Question 11

Management Dupytrens

Answer 11

Physiotherapy, splints, exercises, and steroid injections do not appear to alter the course of the problem.
Routine T+O for surgery if impacting job/ADLs/function

Question 12

When should you consider hand therapy for base of thumb CMCJ OA?

Answer 12

Simple measures and splints not helping and:
Experiencing barriers to recovery.
Loss of strength, range of movement, proprioception, or function.
Pain is a key feature.
Can also consider steroid injection

Question 13

Referral criteria for ganglion

Answer 13

Ganglion should transilluminate

Routine hand clinic if:
significant pain.
functional impairment affecting ADLs
Pressing on neighbouring structures, e.g. nerves.
Diagnostic uncertainty (USS not usually needed)

Question 14

What underlying diagnosis could there be with trigger finger?

Answer 14

Usually none
RA, amyloidosis, diabetes, carpal tunnel syndrome, and in patients on dialysis

Question 15

Referral criteria trigger finger

Answer 15

Urgent hand clinic if:
Finger is locked

Routine hand clinic ?surgery if:
Diabetes
Severe symptoms.
Preference for surgery
Steroid injections fails/not available in GP

Question 16

Features and management of ACJ pain

Answer 16

Pain over ACJ on scarf test

Rest, NSAIDs
Steroid injection
Physio

Question 17

Risk factors and phases of frozen shoulder

Answer 17

Age 40-60
Diabetes
Severe pain, esp at night, can radiate down arm
Painful freezing pahse, 3-9m, can’t lie on affected side, stiff, global loss of ROM, steroid injection helps pain
Stiff frozen phase, 3-18m, stiff, pain improves, exercise helps
Recovery thaw phase, stretching pain only, gradual return of function, 12-36m

Question 18

Examination features of frozen shoulder

Answer 18

Global reductions active and passive movement, pain, external rotation most obvious

Question 19

Describe 4 step shoulder examination

Answer 19

-Check neck movement, looking for stiffness or pain in the neck or down the arm.
-Identify the acromioclavicular joint and look for tenderness over the joint.
-Identify the glenohumeral joint and check external rotation. Asymmetrical external rotation suggests a glenohumeral joint problem.
-Identify the subacromial space and look for pain on elevation of arm or on resistance. Pain on internal rotation at 90° or a painful arc suggests a subacromial space problem.

Question 20

What features would suggest glenohumeral joint OA

Answer 20

Age>60
Insidious
Pain variable, related to movement, pain free at rest
Internal and external rotation limited
Crepitus

Question 21

Features of rotator cuff pathology

Answer 21

Age>35
Limited active but full passive movement
Pain tip of shoulder/lateral deltoid.
Gradual onset.
Painful arc from 70 to 120 degrees of active abduction

Question 22

Management rotator cuff pathology

Answer 22

Activity modification, self help
Physio 6 weeks
if no improvement steroid injection
Refer routine T+O if no improvement 12w physio/steroid injection or full thickness rotator cuff tear>1 cm

Question 23

What’s Thompson’s test?

Answer 23

Lie pt prone.
Resting position of injured foot is more dorsiflexed than other side,
Squeeze the calf of the affected leg, looking for normal plantar flexion. Absence of plantar flexion indicates a tendon rupture- admit

Question 24

Ottowa ankle rules that signify need to do ankle X-ray

Answer 24

Ankle X‑ray series is indicated if there is pain near either of the malleoli and either of the following:
Inability to weight bear both immediately after the injury and when examined acutely (4 steps)
Bone tenderness at the posterior edge or tip of either malleolus

Question 25

Ottowa ankle rules that signify need to do foot X-ray

Answer 25

Pain in the midfoot and either of the following findings: Inability to weight bear after the injury and when examined acutely (4 steps) Bone tenderness at the navicular or the base of the fifth metatarsal

Question 26

Advice after a sprain

Answer 26

Modify activities according to pain- early mobilisation is important. Apply ice for 20m every 2hrs for the first 2-3 days after injury. OTC analgesia. Avoid ibuprofen in the first 48hrs Elevate ankle when resting. Use elasticated tubular bandage doubled over to provide compression, and remove at night. Rehab exercises (If grade 3 sprain ankle, ED assessment + moon boot)

Question 27

Risk factors for achilles tendinopathy

Answer 27

Overuse injury Recreational athletes aged 30-50 Poor running technique vascular disease, T2DM, inflammatory arthritis ciprofloxacin, steroids

Question 28

Features of gout

Answer 28

deposition of monosodium urate crystals within and around joints, acute + chronic inflammation-> joint damage Pain sudden in onset, peaking 24- 72 hours, resolving over 1-2 weeks May see gouty tophi joints/ears

Question 29

Prevention gout

Answer 29

Allopurinol 100–200 mg daily, after food, increase by 100mg increments every 4 weeks, aim urate<360 until tophi and or symptoms resolve. Co‑prescribe colchicine 500mcg OD-BD for 3-6 months on initiation allopurinol to prevent acute attacks.

Question 30

Features fibromyalgia

Answer 30

widespread chronic MSK pain, associated with somatic symptoms- poor sleep, cognitive disturbance, headache, fatigue, and stiffness 'central sensitisation' Pain processing disorder

Question 31

Ix for fibromyalgia

Answer 31

FBC, CRP, ferritin, B12, folate, tTG, RF, TFTs, CK, calcium, ANA, anti‑CCP ACR diagnostic criteria

Question 32

Management fibromyalgia

Answer 32

Explanation, pain processing disorder not joint disorder Exercise CBT OT/PT Support groups Amitriptyline/duloxetine ?chronic pain management clinic

Question 33

Features inflammatory arthritis

Answer 33

Joint pain, tenderness, and soft tissue swelling Early morning and inactivity pain and stiffness lasting>30 mins Improves with activity Worse at night Constitutional symptoms (fever, weight loss, fatigue)

Question 34

Name 4 examples of seronegative spondyloarthropathy

Answer 34

Inflammatory back pain and ankylosing spondylitis (HLA-B27) Psoriasis and psoriatic arthritis Inflammatory bowel disease and enteropathic arthritis Recent enteric or genitourinary infection and reactive arthritis

Question 35

Referral criteria inflammatory arthritis

Answer 35

Urgent rheumatology if: Hx + examination strongly suggestive of inflammatory arthritis. Less suggestive of new inflammatory arthritis, but with positive anti‑CCP Ab result or raised inflammatory markers. Diagnostic uncertainty + symptoms>6 weeks. If NSAIDs are contraindicated or not tolerated, or if poor response, seek rheumatology advice to consider prednisolone to manage acute symptoms.

Question 36

Features PMR

Answer 36

Pain bilateral shoulders, neck, pelvic girdle, on active and passive movements morning stiffness>45 minutes. systemic symptoms- anorexia, weight loss, low-grade fever, fatigue GCA features Patient aged >50 Symptom duration>2 weeks Evidence of an acute phase response

Question 37

Features GCA

Answer 37

New or changed headaches Scalp tenderness Jaw claudication Visual symptoms

Question 38

Conditions that mimic PMR

Answer 38

Fibromyalgia Statin induced myalgia Polymyositis (raised CK, muscle weakness) RA Lymphoma/myeloma Hypothyroidism

Question 39

Management PMR

Answer 39

Routine ref if age<50 or diagnostic uncertainty or relapses at 10mg Seek advice if inflammatory markers normal Prednisolone 15mg/day for 3 weeks, should be dramatic response Wean: 12.5 mg a day for 3 weeks, then 10 mg a day for 4 to 6 weeks, then reduce by 1 mg every 4 to 8 weeks Review regularly incl BP, glucose, U+E, FBC, CRP Consider bone protection + PPI Steroid alert card Optometry yearly Postpone live vaccines

Question 40

Features of spondyloarthritis

Answer 40

Plantar fasciitis Achilles tendinitis Uveitis (iritis) Peripheral oligoarthritis (<4 joints) affecting large lower limb joints, especially knees and ankles Dactylitis (sausage finger/toe) IBD Recent (within 2 weeks) chlamydia or acute gastroenteritis (Campylobacter, Salmonella, Shigella) infection

Question 41

When should HLA-B27 be done?

Answer 41

Back pain>3 months age<45 and 3 of: onset< age 35 waking in the second half of the night with symptoms. buttock pain. improvement with movement. improvement within 48 hours of taking NSAIDs. first‑degree relative with spondyloarthritis. current or past enthesitis. current or past psoriasis. Urgent ref if 4 of above, or 3 + HLAB27 positive, or dactylitis

Question 42

Referral criteria bunions

Answer 42

Routine podiatry if interfere with shoe fitting, cause significant pain, or impairment of activities. Routine T+O ?surgery if: Co‑existing OA 1st MTP Impending/actual skin compromise. Lesser toe pain and deformity. Inability to wear work specific footwear (metal toed work boots).

Question 43

Referral criteria hallux rigidus

Answer 43

Routine podiatry if gross foot deformity/rigid sole footwear not enough, ?steroid injection Routine T+O ?surgery if: severe or intractable pain interfering with mobility or sleep. significant functional impairment impacting on ability to work or ADLs

Question 44

Management ingrown toenail

Answer 44

cut the nail straight across Drying after bathing Change socks regularly. Push the skin away from the nail using a cotton bud. Tight footwear places pressure on the toenail, which may pierce the skin. Surgical removal of a section of the nail, under local anaesthetic ring block if significant infection + overgrowth soft tissues. Phenol to ablate the nail fold

Question 45

Management curly toes in children

Answer 45

Will likely grow out of it Routine T+O ?surgery if: Persists after age 4 + concern to parents. The toe cannot be moved into a normal position by hand. There are nail changes or callus formation. The child is unable to wear footwear because of skin breakdown, nail changes, and pain.

Question 46

Define tarsal coalition

Answer 46

Congenital foot deformity in which 2 or more tarsal bones are joined together or fail to separate in fetal development. Painful stiff foot usually develops in early adolescence. Often present with recurrent ankle sprain and a flat foot. Progressive lateral ankle pain and a mildly stiff hindfoot. On examination, there is limited subtalar movement, and on tiptoes the arch does not reconstitute Routine T+O

Question 47

Referral criteria flat feet

Answer 47

Routine podiatry: ↓ level of activity Unable to keep up with peers Unstable gait/tendency to trip + fall Effect on postural development Routine podiatry if flat, flexible feet and is in pain with no other abnormalities. Routine T+O if: the foot is rigid there is significant functional impairment or unilateral deformity. marked bony abnormality, e.g. rocker bottom foot.

Question 48

Referral criteria intoeing

Answer 48

Routine paeds: ?cerebral palsy Routine T+O if: Asymmetrical intoeing Intoeing and limp Foot deformity Reduced hip abduction or pain in the hip Normal until age 12 in mild femoral anteversion

Question 49

Red flags limp in child

Answer 49

Osteomyelitis or septic arthritis (fever, swollen joint, erythema, unwell child). Non‑accidental injury, especially age<5 Slipped upper femoral epiphysis Obligatory external rotation of the hip, overweight, Down syndrome, renal disease Malignancy – night sweats, bruising, weight loss, night pain. Abdominal or scrotal pathology presenting as a limp – undescended testes, hernia, appendicitis. Child is not weight‑bearing.

Question 50

Differentials limp age<3

Answer 50

Non‑accidental injury Musculoskeletal infection Injuries including toddler's fracture Developmental dysplasia of the hip (DDH) Malignancy Metabolic disease, JIA Neuromuscular disease Fracture or soft tissue injury Abdominal or scrotal pathology

Question 51

Differentials limp age 3-10

Answer 51

Transient synovitis: Diagnosis of exclusion, septic arthritis must be ruled out, systemically well Boys>girls, preceded by viral infection Perthes disease: Avascular necrosis femoral head Infection, Malignancy Metabolic disease, JIA Neuromuscular disease Fracture or soft tissue injury Abdominal or scrotal pathology

Question 52

Differentials limp age>10

Answer 52

SUFE Perthes disease Infection, Malignancy Metabolic disease, JIA Neuromuscular disease Fracture or soft tissue injury Abdominal or scrotal pathology

Question 53

Describe perthes

Answer 53

Avascular necrosis femoral head of Boys>girls, age 4-8 Insidious onset, worsens with exercise, and can be bilateral Restricted internal rotation and abduction is found on hip examination Urgent T+O

Question 54

Describe SUFE

Answer 54

Vague knee pain or a gradually developing limp Can be acute, presents like fracture Male, overweight, and some endocrine abnormalities including hypothyroidism, age 8-15 Shortened and externally rotated leg and reduced ROM at hip Admit T+O/ED

Question 55

Features morton's neuroma

Answer 55

Interdigital neuroma between metatarsals Often aggravated by tight-fitting shoes Burning pain, parasthesia, or numbness Radiates to lateral side of one toe and the medial side of its neighbour Pain reproduced by pressure into the webspace Usually third interspace, sometimes second interspace Nature of pain changes on shoe removal

Question 56

Differentials for Morton's neuroma

Answer 56

OA Inflammatory arthritis (esp if nail changes/dactylitis) Malignancy Stress fracture Charcot foot T2DM Systemic sclerosis (raynauds)

Question 57

Features plantar fasciitis

Answer 57

Gradual onset heel pain, worst putting foot down in morning Repetitive microtears of the fascial substance, common in runners Acute injury/tear or partial tear/or inflammation. Age 40-60

Question 58

Management plantar fasciitis

Answer 58

Supportive slightly heeled footwear Stretched Ice 20mins, rolling motion Routine podiatry if >12 weeks self management ongoing symptoms

Question 59

Describe 4 most common knee ligament linjuries

Answer 59

ACL: valgus twisting mechanism- forcefully landing on the leg and suddenly turning to the opposite side. PCL: direct blow to the flexed knee Collateral: varus or valgus strain and direct blow to the knee. Meniscal acute tears: rotation + compressive forces on a bent knee leads to joint effusion after several hours -> urgent physio

Question 60

Features and management hip OA

Answer 60

Groin pain on internal rotation (foot outward) Stiffness and reduced function Exercises, paracetamol + ibuprofen gel, ESCAPE pain classes Xray, if mod/severe OA-> routine T+O ?surgery, otherwise physio

Question 61

Management knee OA

Answer 61

Oak Knee, ESCAPE pain Exercises, lose weight, analgesia Steroid injection to: manage acute flare manage symptoms if surgery not an option only if >3m til joint replacement (incr risk infection with surgery)

Question 62

Features greater trochanteric pain syndrome

Answer 62

Lateral hip/thigh/buttock pain on movement Tendinopathy of the gluteal insertions/greater trochanteric bursitis

Question 63

Management greater trochanteric pain syndrome

Answer 63

Graded loading and exercises, ice, analgesia Physio-> shockwave? Steroid injection at point of max tenderness

Question 64

USC criteria soft tissue lump

Answer 64

USC sarcoma referral if soft tissue lump: >5 cm in diameter. deep to fascia (fixed) and any size. growing (especially observed rapid growth). painful. recurring after a previous sarcoma excision.

Question 65

Red flags in back pain

Answer 65

Cancer – Hx cancer, unexplained weight loss, no improvement 1 month, >50 years, unremitting pain, increasing severity pain. Spinal infection – fever, IV drug use, spinal/epidural anaesthesia Vertebral compression fracture – older age, osteoporosis, steroid use, menopause, or post‑chemotherapy. Inflammatory- ankylosing spondylitis, younger, morning stiffness, improvement with exercise, alternating buttock pain, awakening during the 2nd half of the night, marked improvement with NSAIDs. Cauda equina

Question 66

Symptoms cauda equina

Answer 66

Bilateral sciatica Severe or progressive weakness of the legs. Difficulty passing or controlling urine – retention, incontinence, or palpable bladder. Saddle anaesthesia/paraesthesia or unable to feel rectal fullness. Lax anal sphincter.

Question 67

Neuro exam features for radiculopathy L4, L5, S1

Answer 67

L4- knee extension, foot drop, reduced knee jerk with sensory loss in the medial shin L5- great toe extension and ankle dorsiflexion with sensory loss in the big toe and inside of the foot S1- ankle plantar flexion, reduced ankle jerk with sensory loss in the sole and lateral foot

Question 68

Features spinal stenosis

Answer 68

Age>60 Pain worse on walking and standing, and relieved by sitting or lying down, or walking flexed with a trolley or walking uphill. Bilateral, involves the whole leg, mild low back pain. Sensory loss and weakness may be present.

Question 69

Stages of lymphoedema

Answer 69

Stage 0 – subclinical. Heaviness or aching. Stage 1 – early onset. Swelling which subsides with elevation. Stage 2 – swelling which is rarely reduced by limb elevation. Loss of anatomical contour of the limb. May have pronounced pitting – pitting may then reduce as tissue fibrosis increases. Stage 3 – fibrosis is present and pitting absent. Skin changes may occur, including hyperpigmentation, wart-like growths, fat deposits, thickening.

Question 70

Management lymphoedema

Answer 70

Limb elevation Weight management Skin care Compression garments, bandaging and taping Exercises- activate muscle pump and preserve mobility Lymphatic drainage and massage

Question 71

Recurrent cellulitis management in lymphoedema

Answer 71

14 days+ abx If> 2 episodes in 12 months, refer lymphoedema clinic re abx prophylaxis. Rescue pack abx at home Staphylococcus aureus eradication measures- intranasal mupirocin and chlorhexidine wash.

Question 72

Features dermatomyositis

Answer 72

Proximal muscle weakness Heliotrope rash — bilateral lilac discolouration of the eyelids, swelling of the eyelids and skin around the eyes Shawl sign- fixed redness affecting the back, shoulders, chest, and neck Photosensitivity Gottron papules extensor surfaces joints Thinning of hair Prominent blood vessels in the proximal nailfolds Calcinosis finger skin Raynauds Triggered by malignancy/silica exposure/viral infection