Optimising Function - MSK

Question 1

What are some lower limb red flags?

Answer 1

Sudden onset without obvious cause
Night pain
History of malignancy
Unplanned/unexpected weight loss
Night sweats
Appetite loss
Malaise
Fever without cause
Inability to weight bear
Fractures/Acute trauma
Dislocation/Tendon ruptures
Pins and needles/Altered sensation (Cauda Equina)
DVT (Wells Score)
Infection

Question 2

What are the key myotomes for the lower limb?

Answer 2

L2 Hip flexion
L3 Knee extension
L4 Ankle dorsiflexion
L5 Big toe extension
S1 Ankle plantarflexion
S2 Knee flexion

Reflexes: L2/3/4 for patella and S1 for Achilles

Question 3

What is the slump test?

Answer 3

Once in a slumped position, actively extend leg and complete extension passively
Positive only if pain shoots beyond the knee

Tightness behind the knee is normal
If severe or back pain increases, muscular de-conditioning is likely

When the knee is extended, flexion at the neck exacerbates sciatic pain, while extension relieves it

Question 4

What are the warning symptoms for cauda equina?

Answer 4

Loss of feeling/pins and needles between inner thighs or genitals
Numbness in or around back passage and buttocks
Altered feeling when using toilet paper to wipe
Increased difficulty when trying to urinate
Increasing difficulty in controlling urine flow
Leaking urine
Not knowing when your bladder is full or empty
Inability to stop bowel movement
Loss of sensation when bowels open
Loss or change in sensation during sex
Change in ability to achieve an erection or ejaculation

Question 5

What are the warning symptoms for cauda equina?

Answer 5

Loss of feeling/pins and needles between inner thighs or genitals
Numbness in or around back passage and buttocks
Altered feeling when using toilet paper to wipe
Increased difficulty when trying to urinate
Increasing difficulty in controlling urine flow
Leaking urine
Not knowing when your bladder is full or empty
Inability to stop bowel movement
Loss of sensation when bowels open
Loss or change in sensation during sex
Change in ability to achieve an erection or ejaculation

Question 6

What is lateral hip pain - Greater Trochanteric Pain Syndome 0 GTPS?

Answer 6

Overuse/mechanical overload due to bursitis often caused by tendonopathy of the glute med/min

Presentation: lateral hip pain, tender on palpation, specifically near the greater trochanter . Pain on resisted abduction.

Aggregating: prolonged sitting, climbing stairs, lying on affected side, high impact activity, crossed leg sitting, pain on non painful side of leg falls into adduction

Gluteal tendonopathy is the main cause of pain and leads to inflammation at the bursa

Diagnosis: FADER, OBER and FABER, trendelburg sign, Single leg stand 30s produces pain

Management:
Strengthening of weak hip abductors
Education
Local corticosteroid injection
Medication
Weight reduction
Surgery only if the management has failed

Question 7

What is a hip flexor tendonopathy?

Answer 7

Pain usually come on with increase in load/training regime

Microtrauma caused to the associated tendon due to chronic overuse or injury.

Presentation: increasing pain at the site of the affected tendon. Reduced function/range of motion usually into hip extension and decreased exercise tolerance. Often localised pain - severe or sharp but can become dull. Intermittent groin pain described as a deep ache

Usually pain is load dependant/worsens with activity. Symptoms often worse with kicking or deep hip flexion. Can lead onto hip bursitis.

Diagnosis: increase tenderness with deep palpation of iliopsoas muscle - particularly around the insertion onto the lesser trochanter . Passive hip extension pain. Active/resisted hip flexion is painful. Thomas Test.

Management: eccentric exercises to promote collagen fibre cross-link formation and tendon remodelling/repair . Isometric exercises for pain modulation. Corticosteroid injections only for short term outcome/pain management.

Question 8

Discuss hip fractures? Neck of femur (NOF) fracture.

Answer 8

Onset: usually trauma - fall
Eitiology: classed as an intrascapular fracture. Can have extracapular too (outside of capsule so better outcomes as less affects blood supply)

Presentation: dull ache in groin or hip. External rotation of affected leg. Stiffness, bruising and swelling around the affected leg. Shortening of affected leg. Inability to weight bear.

Diagnosis: history, physical exam, X0ray/MRI/CT.

Management: surgery, weight bearing/walking on the day after surgery. Regular PT review (daily), rehab (strength, balance, ROM).

Question 9

Discuss knee osteoarthritis.

Answer 9

Usually chronic/long term (gradual onset)

Eitiology: change in shape/structure of the joint. Cartilage thins and becomes rougher. Not all patients with OA are symptomatic.

Presentations: pain and stiffness within the joint. Morning stiffness lasts less than 30 minutes. Swelling. Pain with prolonged sitting/resting. Pain when going down the stairs/walking. Knee can lock or give way. Loss of ROM.

Features: Bakers cyst (fluid filled swelling - small tear in the joint capsule)

Diagnosis: X ray and blood tests. Pain on joint line and palpation. Joint enlargement/swelling. Grade 0-4.

Management: exercises. Education, weight loss, steroid injections, NSAIDs, analgesia, surgical intervention.

Question 10

Discuss ligamentous injuries/meiscus tears

Answer 10

Onset - trauma, twisting. Usually after cutting manoeuvres/ SLS or jump and land

Eitiology - ACL stops anterior translation of the tibia over the femur

Presentation: audible crack/pop. Initially feeling of instability. Episodes of giving way. Extreme pain (ititially). Reduced ROM (extension). Muscle weakness.

Diagnosis: MRI, Anterior Draw/Lachman test/Pivot Shift, Subjective history

Management: Conservative vs surgical, strength and conditioning, ROM, advice and education

Question 11

Discuss anterior knee pain/patella tendinopathy/ Recurrent patella dislocations (patella alta).

Answer 11

Gradual or acute onset

Presentations: varying array of symptoms, crepitus, pain, instability, worsens with stairs, squatting, running

Diagnosis: subjective and objective (rarely pain at rest). Instant pain with loading. Dose dependant pain (load/range).

Management: strengthening program. ISOMETRIC then ECCENTRIC then CONCENTRIC. Not NSAIDs as negative effect on soft tissue healing.

Patella alta is a high riding patella.

Question 12

Discuss stress fractures of the ankle

Answer 12

Usually due to repetitive loading such as running and marching or a sudden change in activity demands

Due to an imbalance of bone remodelling. Fatigue vs insufficiency. Stress reaction and fracture.

Presentation: pain tends to develop and worsen over weeks. Localised pain and tenderness. Worse on weight bearing. Swelling and present.

Other features: vitamin D deficiency, diet and recovery.

Diagnosis: MRI - acute. Bone scan - X-ray secondary

Management:
Initial phase of off loading (6/52)
Maintain fitness (cross training)
Pacing and strengthening

Question 13

Discuss plantar fascia patchy/plantar heel pain

Answer 13

Can present as an overuse injury due to micro tears (runners)

Primarily a degenerative process, micro tears, chronic degermation of the fascia

Presentation: sharp localised heel pain that worsens with load/weight bearing. Initial pain on loading and then eases. Pain reduces with moderate activity but then worsens later in the day due to prolonged activity. At its worst pain can present at night and rest.

Diagnosis: tenderness around the plantar feel area (sometimes around the medial calcaneal tuberosity). Reduced dorsiflexion. Subjective history (antalgic gait). Positive windlass test.

Management: ice massage/elevation. Cushioned shoes/Arch support. Stretching. Analgesia. Weight loss. Cross training/load management.

Question 14

Discuss Achilles tendonopathy

Answer 14

Gradual onset. Repetitive stress/loading. Weakened/deconditioned tendon

Eitiology: repetitive micro trauma active — inflammatory
Tendon disrepair if not offloaded and allowed to recover
Degenerative tendinopathy — poor prognosis

Presentations: pain in the back of heel
Warmth and tenderness along TA. Swollen and thickened TA. Clicking/rubbing of tendon on movement. Morning pain - stretch through range.

Diagnosis: rupture - Thompson test. TA tears grades 1-3.

Management: supportive helped shoes/heel lift. Pacing. Strengthening. Pain activity ladder.

Question 15

Discuss ankle sprains

Answer 15

Onset: inversion (lateral) sprain. Rapid shift in center of mass - ankle goes out forth goes in

Ethology - healing process - 3 phases: inflammatory, proliferation, remodelling

Presentation - pain of WBing. Tenderness over palpation of joint/ligaments. Bruising/swelling. Limited ROM/instability.

Diagnosis - grading 1-3. Anterior draw, posterior draw and Tatar tilt special tests

Management: decrease pain and swelling (analgesia/PRICE). Strengthening/ROM. PEACE and LOVE.

Question 16

What are some common ligaments on the lateral aspect of the ankle?

Answer 16

Posterior talofibular ligament
Anterior talfibular ligament
Calcaneofibular ligament

Question 17

Discuss the stages of a hip assessment

Answer 17

Objective assessment
Postural exam, hip height
Back extension, flexion, lateral flexion
PROM and ACROM Knee flexion
PROM and AROM External and internal rotation of hip, over pressure
PROM and AROM Abduction and abduction, over pressure

Strength for knee flexion, abduction, internal and external rotation

Palpate in and around the hips

Move patient onto front and then perform hip extension, apply over pressure. AROM and PROM.

Question 18

Discuss a full assessment of the knee

Answer 18

Observation
Palpation of the knee In extension and flexion
Knee flex, extension - and hip, with int and external rotation
Anterior draw for ACL
Test for MCL and LCL
Knee strength

Question 19

Discuss the steps of an ankle assessment

Answer 19

Observation
Palpate the ankle, and up the calves too - with bent and straight leg
Toe extension and flexion, over pressure
Internal rotation, over pressure
External rotation, over pressure

Strength for these movements

Question 20

What is the anterior draw test of the ankle?

Answer 20

Detect laxity for anterior talo-crural joint laxity after inversion trauma
Knee joint slightly flexed in supine
Fixate tibia and draw the food anteriorly under the ankle

Or slightly flexed foot and fixate. Push tibia posteriorly.

Question 21

Describe the Talar tilt test

Answer 21

To assess integrity of anterior and posterior talo fibulae ligament, calcaneofibular ligament and deltoid ligaments

Sitting, knee off the table
Foot into plantar flexion
Grab calcaneous and perform inversion

To test calcaneo-fibular ligament, bring foot into anatomical position, then bring foot into inversion and eversion (stresses deltoid ligament)

To stress posterior talo-fibular ligament bring foot into dorsiflexion and perform the same movement again.

Question 22

What is the Thompson squeeze test?

Answer 22

For achillies tendon rupture
Prone, feels off of the bed
Squeeze the calf and observe plantar flexion at the ankle

Question 23

Discuss Tinel’s Sign for ankles?

Answer 23

For peripheral nerve injury
Tap anterior to medial malleolus
Tap behind the medial melleleous

Tingling and parenthesis felt dismally is a positive sign

Question 24

Describe the management for osteoarthritis

Answer 24

Exercise - therapeutic exercise. Advise that it may initially cause pain but long term adherence will benefit the joints, reduce pain and improve function

Weight management - improve function and decrease pain

Information and support

Only consider manual therapy for hip and knee, alongside therapeutic exercise.

Do not offer: acupuncture, dry needling, electrotherapy, treatments, insoles, braces, tape, splints or supports routinely.

Question 25

What are the Ottawa ankle rules?

Answer 25

Ankle: X-ray only required if: - bone tenderness at Posterior edge or top of lateral melleolus OR - bone tenderness at posterior edge or tip of medial malleolus OR - inability to weight bear both immediately and in ED (4 steps) Foot: X-ray only required if: - bone tenderness at base of 5th metatarsal OR - bone tenderness at navicular OR - inability to weight bear both immediately and in ED (4 steps)

Question 26

What is the McMurrays test?

Answer 26

Physical exam to help diagnose a torn meniscus Patient lies on their back with knee and hip fully bent Practitioner rotates the patients leg whilst extending the knee. Positive test indicated by a thud or click.

Question 27

What is the anterior draw test for the knee?

Answer 27

Assesses the stability of the knee’s anterior cruciate ligament (ACL). Patient supine and bends knee to 90 degrees. Practitioner sits on the patients foot Practitioner wraps their hands around the back of the patients knee, places their thumbs on the front of the kneecap, and pulls the knee forward. Practitioner rotates the patients foot to a different direction and pulls forward again.

Question 28

What is the posterior draw test for the knee?

Answer 28

Assess for posterior cruciate ligament tears Supine. Practitioner applies a force in the posterior direction to the proximal tibia. Looks similar to anterior (force in the opposite direction).

Question 29

What is the thesseleys test for the knee?

Answer 29

Can help to diagnose a torn meniscus in the knee. Patient stands on one leg with their foot flat on the ground. Examiner supports them. The patient then rotates their knee and body internally and externally three times. Positive test result is indicated by pain or a feeling of catching or locking in the knee, or a popping sound.

Question 30

What is the Thompson test for the ankle?

Answer 30

Physical exam to help diagnose an Achilles tendon rupture Calf squeeze test

Question 31

What is the syndesmosis test?

Answer 31

A physical exam that helps diagnose a syndesmosis sprain in the ankle. The examiner squeezes the tibia and fibula together above the injury. Pain in the area of the distal tibia fibulas and interosseous ligaments indicates a positive test. Test for high ankle sprain.

Question 32

What is FABERS test?

Answer 32

Asseses pathologies at the hip Flexion, abduction, external rotation Test is positive if it reproduces the patients pain or limits their range of movement. Low back pain indicates SI joint pathology, while pain in the anterior groin indicates intraarticular hip pathology.

Question 33

What is FARDIRS test?

Answer 33

For the hip. Helps diagnose hip joint issues, such as femoroacetabular impingement (FAI) or labral tears. Flexion, abduction, internal rotation Positive test is when the patient experiences pain in the groin or anterolateral hip during the test.

Question 34

Describe the 5 tests for the sacroiliac joint?

Answer 34

Gaenslen - looks like Thomas test. Apply pressure to extended hip and flexed hip. Positive = reproduction of their symptoms Thigh thrust - hip flexed and pressure down Distraction - posterior directed force to both anterior superior iliac spines Compression - patient in side, hip and knees flexed to approximately right angles. Apply force vertically downward on uppermost iliac crest. Sacral thrust - force is vertically downward on center of sacrum

Question 35

What are upper limb tension tests?

Answer 35

Used for suspected cervical radicular syndrome. ULTT A: median nerve, anterior interosseous nerve, nerve roots C5-C7 - depress shoulder, laterally rotate shoulder, supinate forearm, extend fingers and extend elbow until symptoms provoked (can laterally flex neck to the opposite side too). ULTT 2/B: stresses median nerve, ancillary nerve, musculocutaneous nerve - depress shoulder, abduction arm to 10 degrees, flex elbow, extended fingers (same as above except elbow stays next to waist). To confirm findings, you can create slack by flexing elbow and laterally flex neck. ULTT 3/C: stresses radial nerve. Depress shoulder, bring arm to 10 degrees of flexion, 10 degrees abduction, pronate forearm, flex fingers and the extend the elbow. Until symptoms are provoked. ULTT4: stresses the ulnar nerve and nerve roots C8 - T1. Bring arm into 90 degrees of abduction, pronate forearm, extend fingers and go into lateral rotation, and bring fingers towards ear. Until symptoms provoked. All considered positive if reproduce patient symptoms. Marked differences between each side.

Question 36

What is the straight leg test?

Answer 36

Test for lumbar radicular syndrome Hip flexion in supine whilst maintaining full knee extension Positive test = shorting pain down the leg is reproduced, usually below 60 degrees. Test places tension on the sciatic nerve.

Question 37

What are whiplash associated disorders?

Answer 37

Rapid/excessive hyperflexion or hyperextension of the neck causing damage to spinal structures Presentation: acute/sharp pain, excessive movement aggravating, ice/heat/.rest eases Patients can be very protective and guarding. Severe causes may struggle with dizziness, double vision, loss of balance, and nausea. Management: Education/Reassurance. Exercises - ROM and/or strengthening (isometrics). Ice/heat. TENS. Manual therapy. CBT is appropriate.

Question 38

What is cervical spondylosis?

Answer 38

Degenerative changes to the spinal structures (most typically the intervertebral discs and facet joints). Presentations: dull, fairly constant spine. Aggravated by excessive movement. Imaging is not neccessary. More severe cases can progress to radiculopathy and/or myelopathy. Management: education/reassurance. Exercises. Ice/heat. Manual therapy.

Question 39

What is cervical radiculopathy?

Answer 39

Compression of a nerve root caused by a herniated disc or degenerative change feature such as an osteophyte. Presentations: Referred symptoms: shoulder/arm pain. Typically unilaterally and reflecting the level of compromise. Pins and needles, numbness, burning described. Can be an absence of neck pain. Management: education/reassurance. Exercises - nerve glides. Ice/heat. Manual therapy. More severe cases can progress to stenosis/myelopathy.

Question 40

What is thoracic outlet syndrome?

Answer 40

The TOS is formed of the scalenes, clavicle, and first rib. Occurs when structures (nerves, arteries and veins) within the thoracic outlet are compressed and become injured. Presentation: neck/shoulder pain, referring down the army. Unilateral. Other features: dependant on the structures being compressed. Neurological (numbness, burning, weakness) Vascular (skin changes - pallor/cyanosis, swelling, heaviness in the arm/hand - claudication) Combination Management: education/reassurance. Exercises - AROM, Nerve glides, strengthening (scalenes). Posture re0education and cues. Manual therapy.

Question 41

What is non-specific mechanical lower back pain?

Answer 41

Back pain that presents mechanically but lacks a clear attributeable cause. May relate to spondylosis (degenerative changes) Crucial to diagnosis is ruling out red flags If stenosis deteriorates to the point of causing notable compression on the spinal cord, it can become myelopathy.

Question 42

What is a lumbar radiculopathy?

Answer 42

Same physiology of cervical radiculopathy. Stenosis. Similar changes causing narrowing of IV foramen. Sciatica is a radiculopathy.

Question 43

What are some indications to perform a neurological exam?

Answer 43

Burning Traction or crush Reports of weakness Referred symptoms Throbbing Electric shock Tingling Fizzing Repetitive movements Reports of numbness

Question 44

What are upper motor neurone lesions?

Answer 44

UMN lesions are designated as any damage to the motor neurones that reside above the nulcei of cranial nerves of the anterior horn cells of the spinal cord. Damage to UMNs leads to a characteristic set of clinical symptoms known as the upper motor neuron syndrome. - Hoffmann sign positive for upper limb - Babinski sign for lower limb

Question 45

What is a myelopathy?

Answer 45

Symptoms arising from compression of the spinal cord caused by degenerative changes, inflammatory pathology, or space occupying lesions. Can display red flag symptoms and become a medical emergency. Cluster of tests for examination: 1, Gait deviation (focus on control) 2, Poaitive Hoffmann test 3, Inverted supination sign 4, Positive Babinski test 5, 45+ years of age

Question 46

What are some spinal red flags for cancer?

Answer 46

Unremitting pain (particularly at night) History of cancer Unexplained weight loss No improvement with therapy input

Question 47

What are some spinal red flags for infection?

Answer 47

Pain at night Fever Immunocompromised History of diabetes

Question 48

What are some spinal red flags for infection?

Answer 48

Pain at night Fever Immunocompromised History of diabetes

Question 49

What are some spinal red flags for fracture?

Answer 49

Age (under 18 or over 60) Osteoporosis Major trauma

Question 50

What are red flag specific questions for the lumbar spine?

Answer 50

Bilateral symptoms Gait disturbance/difficulty walking Bladder changes - urinary retention and or compromised sensation Bowel changes - not feeling full/empty, loss of control Saddle anaesthesia Erectile dysfunction

Question 51

What are red flag questions for cervical spine pathologies?

Answer 51

Diplopia - double/blurred vision Dizziness Dysphasia - Difficulty swallowing Drop attacks Dysarthria/Dysphasia - Speech or articulation difficulties Nausea Facial Numbness Nystagmus - involuntary eye movements

Question 52

What are the cauda equina syndrome warning signs?

Answer 52

Loss of feeling / pins and needles between your inner thighs or genitals Numbness in or around your back passage or buttocks Altered feeling when using toilet paper to wipe yourself Increasing difficulty when you try to urinate Difficulty controlling flow of urine Loss of sensation when passing urine Leaking urine Not knowing whether bladder os full or empty Inability to stop bowel movement or leaking Loss of sensation when bowels open Change in ability to ejaculate Loss of sensation in genitalia during sexual intercourse

Question 53

What are some red flags for axial spondyloarthropathy?

Answer 53

Inflammatory changes in the spine Age 20-40 Notable morning stiffness Family history of inflammatory pathology History of recurrent tendinopathy History of IBS Skin Colitis and Chron’s Relatives Eyes Early morning stiffness Nails Dactylitis Enthesitis Movement and medication effect

Question 54

What is Hoffman test?

Answer 54

For myleopathy Flick finger nail of middle finger in flexion Positive test is indicated by abduction of the thumb and flexion of the index finger.

Question 55

What is the babinski test?

Answer 55

Neurological test that assesses the function of the CNS. Sharp objects firmly strokes the sole of the foot, starting at the heel and moving to the big toe. Abnormal response is when the big toe moves upward and the other toes fan outwards.

Question 56

What is a radiculopathy?

Answer 56

A pinching of the nerves at the root, which can produce pain, weakness and numbness in the wrist and hand.

Question 57

What are neurodynamic tests?

Answer 57

Putting nerves under more tension Eg slump test is a lower limb nerve tension test Eg straight leg raise for sciatic nerve Upper limb nerve tension tests

Question 58

What is the Oppenheimer test?

Answer 58

To test for the presence of an upper motor neurone lesion Patient in supine and practionier runs a fingernail along the crest of the tibia. Sign present if toes extend and fan out (similar to Babinski).

Question 59

How do you differentiate between an upper and lower motor neurone lesion?

Answer 59

Upper is the brain or spinal cord (CNS) Lower involves the anterior horn cell, motor nerve roots or peripheral motor nerve

Question 60

What are some signs of an upper motor lesion upon neurological examination?

Answer 60

Disuse atrophy or contractures Increased tone (spasticity/rigidity) and or ankle clonus Pyramidal pattern of weakness (extensors weaker than flexors in the arms and vice versa in the legs) Hypereflexia Upgoing plantars (Babinski sign) Hypertonic and spastic paralysis

Question 61

What are some signs of lower motor neurons lesions upon neurological examination?

Answer 61

Marked atrophy Fasiculations Reduced tone Variable patterns of weakness Reduced or absent reflexes Downgoing plantar or absent response Hypotonia and flaccid paralysis

Question 62

What are some red flags for the cervical spine?

Answer 62

Eye sight, swallowing, speech, vision, double vision, nausea Severe headache Facial symptoms eg paresthesia Cough, shortness of breath, chest pain Neurological symptoms: tingling, numbness, pins and needles (centrally). Gait, balance, coordination, gripping, bladder and bowel movement.

Question 63

What is the cluster of Wainner?

Answer 63

A set of 4 clinical tests used to help diagnose cervical radiculopathy: Spurlings test Distraction test Upper limb nerve tension test ULTT1

Question 64

When should you perform a neurological exam for peripheral spinal nerves when assessing the cervical spine?

Answer 64

When a patient has altered sensations, heavy/weak/radiation of pain. Change in coordination. Neck symptoms radiating below the acronym/down the arm (Same for into buttock for lumbar spine)

Question 65

What are cord signs?

Answer 65

Clinical findings that can indicate spinal cord compression or injury: Pain Numbness Weakness Coordination issues Sensation changes Bowel or bladder issues Spasticity Differing tone

Question 66

What is a myleopathy?

Answer 66

Caused by compression of the spinal cord, which can affect the entire spinal cord. Symptoms include loss of coordination, dexterity, numbness in the hands, difficulty walking.

Question 67

What is a myleopathy?

Answer 67

Caused by compression of the spinal cord, which can affect the entire spinal cord. Symptoms include loss of coordination, dexterity, numbness in the hands, difficulty walking.

Question 68

What is a myopathy?

Answer 68

A disease of the muscles that causes muscle fibres to malfunction. Symptoms include cramping, stiffness, soreness, difficulty lifting the arms, rising from a chair, or climbing the stairs. It can affect muscles in the hands, feet, face, eyes, heart and breathing muscles.

Question 69

What is the passive straight leg raise test?

Answer 69

A neurological exam that is used to commonly identify disc pathology or nerve root irritation, as it mechanically stresses lumbosacral nerve roots. A neurodynamic test to detect excessive nerve root tension or compression. Stresses the sciatic nerve primarily from L4 to S2. A true positive test should include: Radicular leg pain (symptoms below the knee) Pain occurs when the hip is flexed at 30 and 60 or 70 degrees from horizontal. Neurological pain which is reproduced in the leg and lower back between 30 and 70 degrees of hip flexion is suggestive of lumbar disc herniation at the L4-S1 nerve roots.

Question 70

What is rotator cuff related pain?

Answer 70

Subacromial pain, cuff tendonopathy, bursitis, impingement Pain typically to the top of the shoulder and lateral side of the shoulder Typically aggravated by overhead activity and lying on the affected side (often a history of overhead use or increase in loading). Differential diagnosis: ACJ, frozen shoulder, OA, bicep tendinitis

Question 71

What is calcific tendinitis?

Answer 71

Formation of deposits of calcium phosphate crystals in the cuff Often self-limiting Typically SUDDEN, acute onset of shoulder/upper arm pain and reduced movement Pain, reduced movement, stiffness, weakness

Question 72

What is frozen shoulder?

Answer 72

Deep joint pain and restriction in activities Pain can extend down the arm and paraesthesia is also possible Loss of passive range, especially external rotation Self-limiting Stages: Freezing, Frozen, thawing

Question 73

What is acromioclavicular joint pain?

Answer 73

Pain locally over the ACJ/superior shoulder Usually due to trauma or OA but can be overuse ACJ pain and localised tenderness, high arc pain, painful cross body/scarf. Natural changes occur in the shoulder over 40 which may show up on X-rays

Question 74

What is lateral epicondyalgia?

Answer 74

Pain over the lateral elbow which can radiate to forearm Tendinopathy of the extensor tendon, typically ECRB Mostly dominant arm Differential diagnosis: C spine, OA, radial tunnel syndrome Mills/Cozens test: resisted wrist flexion and extension

Question 75

What is cubital tunnel syndrome?

Answer 75

Compression of the ulnar nerve at the elbow causing medial elbow pain, parenthesis down the medial forearm and hand, snapping around the elbow Aggravated by elbow flexion Diff diagnosis: golfers elbow, carpel tunnel, C spine T1

Question 76

What is Olecronon bursitis

Answer 76

There is a bursa overlying the olecronon to reduce friction Bursas irritation causes the characteristic of swelling Septic - from seeding by bacteria - required medical input Non-septic - sterile swelling usually from trauma/overload Trauma includes minor/repeated, prior infiltration, immune compression Large swelling over olecronon Differential diagnosis: septic arthritis, gout, tumour

Question 77

What is carpel tunnel syndrome?

Answer 77

Occurs at the wrist in the space between carpels and flexor retinaculum Pain and parenthesia in the median nerve, disruption of hand Often worse at night Repetitive movements, vibrating machine use, obesity, pregnancy, diabetes ?wasting ?loss of strength Arm elevation, Tinels, Phalenes Differential diagnosis: CuTS, C spine

Question 78

What is DeQuervain’s syndrome?

Answer 78

Radial sided wrist pain as two tendons run through the tendon sheath Repetitive loading, recent mothers Pain on lifting thumb, using scissors etc Pain on resisted thumb movements Positive Finkelsteins, swelling, snapping

Question 79

What is stenosing tenosynovitis?

Answer 79

Trigger finger Pain in the palm and affected finger which can progress to clocking/locking Increased risk with diabetes Mid finger, ring finger, then thumb Friction between tendon and A1 pulley can cause thickening of the sheath and of the tendon causing a nodule. Nodule can get stuck in flexed position causing the classic trigger presentation Triggering/locking, nodule in palm Diff dx: Dupuytrens

Question 80

What is OA 1st CMC (base of thumb)?

Answer 80

Pain at the base of thumb, aggravated by use of Functional issues with gripping, pinching Stiffness and difficulty moving thumb away from the hand Objective - ‘squaring’, wasting of thenar muscles, tenderness on palpation at base of thumb, loss of range, positive grip test Diff Dx: DeQuervains

Question 81

What are the principles of tendinopathy management?

Answer 81

Gradually increase load and monitor - VAS during activity - Symptom response over next 24-48 hours - Pain during tendon load tests Progressive loading Isometrics are very useful to introduce load and help with pain. 30-45 seconds, 4-5 reps Progress to heavy/slow as pain allows Slight increase in pain okay as long as it settles 6-8 reps, 3-4 sets Dynamic load/energy storage Sport specific plyometrics

Question 82

What are some useful tests to monitor tendon pain?

Answer 82

Achilles - single leg heel raise or hop Patellar tendon - decline squat or high single leg jump, landing from height Hamstring tendon - single leg bent knee bridge or single leg deadlift Gluteal tendon - single leg stance or hop

Question 83

What are some management strategies for RCRSP?Sub acromial shoulder pain?

Answer 83

Advise relative rest and modification of activities which exacerbate symptoms Usual activities within acceptable levels of pain should be restarted asap Physio may include: postural correction, motor control retraining, stretching and strengthening of the rotator cuff and scapula muscles, manual therapy Can consider subacromial injection Management usually taking at least 12 weeks, a long process

Question 84

What are some management strategies for frozen shoulder?

Answer 84

Analgesics Corticosteroid injection Home exercise programme Supervised physiotherapy Education/advice Exercise - ROM or strength Manual therapy Imaging

Question 85

What are some treatments for calcific tendinitis?

Answer 85

Dependant on symptoms/severity If severe, simple ROM to avoid stiffness If less severe, progressive loading as per RCRSP to restore shoulder/scapula strength and function Timely corticosteroid also indicated in acute phase Imaging - X-ray best to ascertain presence of calcification.

Question 86

What are some management strategies for acromioclavicular joint pain?

Answer 86

Acute injury/trauma - A and E or fracture clinic Non-traumatic/OA Avoid cross body activity Physiotherapy: - range of movement - progressive shoulder and scapula strength - manual therapy - corticosteroid injection

Question 87

What are some management strategies for lateral epicpndylitis?

Answer 87

Analgesics/NSAIDS oral/topical Orthotics/clasp Reassurance - often self limiting Activity modification Avoid corticosteroid injection Physiotherapy: Progressive loading of the extensor tendons

Question 88

What are some management strategies for cubital tunnel syndrome?

Answer 88

Avoid or modify provocative activity, typically prolonged flexion Splinting (at night) Physiotherapy: - nerve gliding/flossing - ROM/stretching - Manual therapy If persistent, nerve conduction? Corticosteroid injection

Question 89

What are some management strategies for carpal tunnel syndrome?

Answer 89

Activity modification Splinting (at night) to maintain neutral position Physiotherapy: - nerve gliding - ROM - Manual therapy Corticosteroid injection

Question 90

What are some management strategies for DeQuervains tenosynovitis?

Answer 90

Activity modification/avoiding overuse Splinting (functional) Physiotherapy: ROM to maintain mobility Gradual loading of the thumb General wrist strength Corticosteroid injection

Question 91

What are some management strategies for trigger finger?

Answer 91

Activity modification Avoid gripping!! Splinting 8-12 weeks Corticosteroid injection

Question 92

What are some management strategies for 1st CMC OA?

Answer 92

Activity modification - Pinch change Splinting Physiotherapy OTTER exercises - To maintain/restore C shape - Avoid hyperextension

Question 93

What are steroids?

Answer 93

Powerful, anti-inflammatory aimed to reduce pain, swelling and stiffness caused by inflammation Primary mechanism is the down-regulation of pro-inflammatory mediators Also upregulates some anti-inflammatory enzyme production Influences inflammatory cascade higher up than NSAIDs.

Question 94

What are some metabolic effects of steroids?

Answer 94

Affects carbohydrate and protein metabolism Stimulates glucose formation in the brain Reduced peripheral utilisation of glucose Increased gluconeogenesis Inhibits immune function: decreased production of WBC and B and T lymphocyte function

Question 95

What are some contraindications for steroid injections?

Answer 95

Allergy, infection, immunosuppression, live vaccine, uncontrolled anti-coagulation, fracture, haemarthrosis, prosthesis Precautions: Metabolic - diabetes Anti-coag Pregnancy/breastfeeding Upcoming surgery Unstable cardiac/BP Recent oral corticosteroids