MSK tutorial - solo learning

Question 1

What three questions are asked in GALS?

Answer 1

1. Do you have any pain or stiffness in any of your joints, muscles or back?
2. Are you able to dress yourself without any difficulty?
3. Can you walk up and down the stairs without any difficulty?

Question 2

What is involved in gait?

Answer 2

Smoothness, symmetry and ability to turn quickly

Question 3

What else to assess when patient stood up?

Answer 3

• Muscle bulk - trapezius, shoulder girdle
• Spine straight?
• Iliac crests level?
• Gluteal muscle bulk and size?
• Popliteal fossa swelling?
• Hindfoot deformities

Question 4

What to assess in spine?

Answer 4

• From side of patient
• Normal cervical lordosis?
• Normal thoracic kyphosis?
• Normal lumbar lordosis?
• Bend forward and touch toes, assess lumbar spine movement with fingers, fingers should come together when pt comes up

Question 5

What to check in arms?

Answer 5

• Normal anatomical position - normal elbow exension
• Symmetry
• Muscle bulk - pectoralis and shoulder
• Jaw side to side - TMJ related to RA
• Elbows back and behind head - glenohumoural, elbow flexion, function assessment
• Hands out infront - pronate
• Inspect hands - swelling, skin changes, deformity
• Palms - muscle bulk, tendon thickening
• Fist -
• Touch each finger together
• Grip strength
• Squeeze MCPJ

Question 6

What is involved in leg assessment?

Answer 6

• Knee flexion
• Hip flexion
• Internal rotation hip - push leg outwards
• Both sides
• Patella tap - fluid?
• Sweep test?
• Inspect feet - callous? squeeze MTPJ and look for pain

Question 7

If no problem with gals…

Answer 7

Record GALS NAD

Question 8

What does GALS stand for?

Answer 8

• Gait
• Arm
• Legs
• Spine

Question 9

Function of GALS

Answer 9

• Screening for function of joints
• Used to identify problems which require more focused assessment

Question 10

OA of the knee exam findings

Answer 10

• Complain of - pain on walking, grinding sensation
• Muscle wasting
• Inability to fully extend knee
• Normal temp joint
• Normal patella tap
• Positive sweep test?
• Limited knee flexion
• Crepitus felt on full ROM
• Tenderness when flexed knee palpated
• Normal anterior drawer test
• Normal collateral ligament tests - maybe uncomfy
• Varus deformity on standing?
• Stick to mobilise?
• Slow walk - antalgic?

Question 11

Inflammatory arthiritis of feet findings

Answer 11

• Antalgic gait
• Symmetrical deformities feet
• Clawing toes
• Normal temp and foot pulses
• Squeeze MTPJ - some tenderness
• Palpate painful joints - tender
• Normal midfoot, ankle and subtalar palpation
• Normal dorsi/plantar flexion, inversion and eversion
• Stiffness on individual IPJ
• Loss ROM ankle joint and toes
• Flat foot walk - inability to stand on toes

Question 12

Rheumatoid arthirits findings - hands

Answer 12

• Bilateral, symmetrical
• Polyartropathy
• Ulnar deviation
• Subluxation
• Z deformity thumb
• Boutonierre deformity
• Good power and pincer grip
• If no pain/tenderness - disease may be inactive currrently

Question 13

What is synovitis?

Answer 13

• Inflammation (swelling, pain and warmth) of synvoial membrane
• Feature of arthirits when there ois active inflammation
• Causes inc RA and gout
• Can occur in OA if degen process causes inflammation

Question 14

What is stiffness and early morning stiffness?

Answer 14

• Difficulty moving one or more joints
• Early morning = stiffness on getting out of bed/staying in one position
• Indicates inflammatory arthritis
• Usually lasts more than 30 mins on waking to be RA

Question 15

Likely causes of limited or painful active movement but with full, pain free passive movement

Answer 15

• Passive movement does not require pt to use own nerves, muscles and tendons to produce movement
• Reduction in passive range/pain on passive indicates joint problem (foreign body, deformity, inflam)
• Problem with muscles, tendons etc would cause pain on active movement but not passive

Question 16

What is WHO pain ladder?

Answer 16

• Developed for acute pain
• Stepwise
• Simple analgesia (eg paracetamol)
• NSAIDs
• Stronger analgesics eg opioids
• Also used for cancer pain

Question 17

When can pain ladder be problematic?

Answer 17

• Chronic pain - risk of side effects and habituation with prolonged regular use of analgesics
• Addiction to opiates can occur
• Risk of neglecting non-pharmacological options eg physio/psychological pain management

Question 18

Mechanical symptoms of knee

Answer 18

• Locking/catching of the knee
• Suggest loose body/meniscal tear
• But they are quite common in knee disease even without obvious obstruction

Question 19

What is bursitis? How to differentiate from effusion of knee?

Answer 19

• Bursa reduce friction between tendons and cushion joint, surround joint
• Knee effusion is swelling due to excess synovial fluid within joint capsule
• Knee effusion fluid can be moved across knee - bulge test and patella tap causes fluid to move
• In bursitis, swelling is localised to bursa

Question 20

What causes of hip pain would produce pain in anterior, lateral and posterior hip area?

Answer 20

• True hip pain from OA - anterior to the groin
• Trochanteric bursitis - laterally to hip
• Posterior/posterolateral - lumbosacral spine/gluteal muscles

Question 21

Clinical features of plantar fasciitis

Answer 21

• Pain at insertion of plantar fascia into the calcaneum
• Occurs in people who spend a lot of time on their feet
• Pain is marked with first few steps on getting out of bed, worsens again to the end of the day

Question 22

In metatarsalgia, what would make you suspect Mortons neuroma?

Answer 22

• Pain in midfoot = metatarsalgia
• Mortons neuroma = inter-digital space tenderness where neuroma is located

Question 23

Clinical features of gout

Answer 23

• Quite rapid onset
• Severe pain
• Marked swelling and evidence of inflammation of joint
• Recurrent

Question 24

Which joints most affected by gout?

Answer 24

• Great toe - first MTPJ

Question 25

Preventative measures for gout

Answer 25

* Allopurinol - lowers uric acid levels

Question 26

Acute treatment of episode of gout

Answer 26

* NSAIDs eg naproxen * Colchicine * Consider oral steroids eg prednisolone or intra-articular injection of steroid if NSAIDs and colchicine not worked/not tolerated

Question 27

What features in history and exam identify radicular back pain?

Answer 27

* Radicular = impingement/irritation of nerve root * Felt in dermatomal area * Shooting/numb and can have other neurological signs eg weakness, ankle hyporeflexia

Question 28

Sciatica radicular pain

Answer 28

* Pain radiates from buttock and posterior leg * Worse when nerve is stretched - eg straight leg raise test

Question 29

What is painful arc in shoulder?

Answer 29

* Pain in mid range of abduction of shoulder - 45 to 120 degress * Eases at greater range of abduction * Pain more pronounced on active than passive movement

Question 30

What does painful arc indicate?

Answer 30

Indicates impingement of shoulder - catching of rotator cuff tendons or shoulder bursae in subacromial space with movement

Question 31

Besides shoulder pathology, what other problems may present with pain in one/both shoulders?

Answer 31

* Referred pain from neck - cervical spine radiculopathy * Cardiac problems - MI, angina * Lung problems - pancoast tumour * Diaphragm pain - right shoulder from liver enlargement * Polymyalgia rheuemtica - bilateral

Question 32

Appearance of OA vs RA hands

Answer 32

* OA - Herberdens nodes - on distal IP joints, Bouchards less common (on proximal) * RA - proximal IPJ, MCPJ and wrist are commonly affected, may see ulnar deviation, swan neck and boutonierre

Question 33

Tennis elbow, golfers elbow and olecranon bursitis

Answer 33

* **Tennis elbow** - lateral epicondylitis, suspect if pain in lateral elbow with tenderness over common extensor origin * **Golfers elbow** - medial epicondylitis - pain in medial elbow, tenderness over common flexor origin * **Olecranon bursitis** - fluctuant, non painful swelling over olecranon process of elbow