STI

Question 1

articular joint pain

Answer 1

• maximal tenderness on palpation at joint line
• pain regardless of active/passive movement

Question 2

when to refer for STI?

Answer 2

1) serious injury
2) ligament rupture
3) infection-related causes to prevent sepsis
4) malignancy, metastasis
5) if visceral condition (gal stone, pancreatitis)

Question 3

tldr phases of inflammation (immune cells part)

Answer 3

1) initial immune response
2) impaired healing, scarring, fibrosis
3) regeneration

Question 4

phases of inflammation - initial immune response

Answer 4

1) neutrophil activation and recruitment

• rapid recruitment to site of injury or inflammation for pathogen containment and neutralisation

2) monocyte - macrophage activation

• differentiation of monocyte into pro-inflammatory macrophage
• enhance inflammatory response through phagocytosis and release of pro-inflammatory cytokines (TNF-alpha, IL-1b)

3) adaptive immune function

• activation of T and B cells for more targeted response to pathogen

Question 5

phases of inflammation - impaired healing, scarring, fibrosis

Answer 5

1) tissue damage and inflammation

• DAMPS trigger prolonged inflammation -> further activate pro-inflammatory macrophage and cytokine release

2) Scar formation and fibrosis

• pro-inflammatory macrophages promote extracellular matrix deposition via MMP -> Scarring and fibrosis

3) regeneration inhibition

• excessive scarring impair normal tissue function

Question 6

phases of inflammation - regeneration

Answer 6

1) Resolution of inflammation

• transition from pro-inflammatory to anti-inflammatory macrophages

2) tissue repair and regeneration

• anti-inflammatory macrophages release growth factors -> stimulate angiogenesis and cell proliferation for tissue regeneration

3) scar prevention

• anti-inflammatory cytokine IL-10 secreted by anti-inflammatory macrophages inhibit excessive scarring

Question 7

standard non pharmaco for all STI

Answer 7

1) PRICE

• protection, rest, ice, compression, elevation

2) no HARM

• heat, alcohol, re-injury, massage

Question 8

sprains general

Answer 8

bone to bone connective tissue

Question 9

lateral ankle sprain

Answer 9

• most common
• affect anterior talofibular ligament
• caused by inversion of foot
• sudden onset of pain on side of foot after ‘pop’ sound

Question 10

severities of ankle sprain

Answer 10

1) Grade I

• mild stretching of ligament with microscopic tears
• mild swelling and tenderness
• able to bear weight and ambulate w minimal pain
• treatment: PRICE, X HARM

2) Grade II

• incomplete tear of ligament
• moderate pain, swelling, tenderness, ecchymosis
• painful weight bearing and ambulation
• restriction in range of motion and function
• treatment: non pharmaco + topical NSAIDS -> PO NSAID/celecoxib -> paracetamol

3) Grade III

• complete tear of ligament
• severe pain, swelling, tenderness, ecchymosis
• cannot bear weight or ambulate
• significant instability, loss of motion and function
• refer to A&E

Question 11

tendonitis general

Answer 11

• tendon inflammation
• muscle to bone connective tissue
• tendinosis: persistent tendinopathy

Question 12

clinical presentation of tendonitis

Answer 12

1) local pain and dysfunction on active use
2) unlikely to be painful on passive movement
3) inflammation but unlikely visible swelling
4) degeneration

Question 13

possible causes of tendonitis

Answer 13

1) overuse
2) sports injury
3) inflammatory rheumatoid disease
4) calcium apatite deposition from metabolic disturbances
5) drug induced: fluoroquinolone antibiotics (ciproflox) or statin

Question 14

common locations of tendonitis

Answer 14

1) shoulder: rotator cuff tendinopathy
2) elbow: tennis/golf elbow
3) wrist
4) hip (lateral)
5) ankle: Achilles tendinopathy (pain on back of heel)

Question 15

treatment of tendonitis

Answer 15

1) Standard non pharmaco
2) topical NSAID -> PO NSAID/celecoxib -> paracetamol

Question 16

bursitis general

Answer 16

• inflammation of bursae
• bursae: fluid filled sac like structure around joints that cushion tendons/muscles from adjacent bones

Question 17

acute bursitis causes

Answer 17

• trauma/injury
• crystal induced processes (gouty arthritis)
• infection (septic bursitis)

Question 18

clinical presentation of acute bursitis

Answer 18

• pain when joints fully flexed (active and passive)
• adjacent bursa compressed -> increased intra-bursal pressure -> pain

Question 19

treatment of acute bursitis

Answer 19

1) Standard non pharmaco
2) topical NSAIDs -> PO NSAID/celecoxib -> paracetamol

Question 20

chronic bursitis causes

Answer 20

• overuse
• prolonged pressure
• inflammatory arthritis

Question 21

chronic bursitis clinical presentation

Answer 21

• more swelling and thickening
• minimal pain
• secondary changes to contracture and muscle atrophy related to immobility

Question 22

chronic bursitis treatment

Answer 22

refer to doctor

Question 23

location of bursitis

Answer 23

1) superficial locations

• elbow, kneecap, posterior upper thigh region
• cushions skin and bones

2) Deep locations

• hip, shoulder
• reduce friction of muscles as they glide over each other
• consider giving intra-bursal glucocorticoid

Question 24

general plantar fasciitis

Answer 24

• injury and inflammation of plantar fascia
• fibrous attachment connecting heel bone to base of toes
• most common cause of heel pain

Question 25

aetiology of plantar fasciitis

Answer 25

- prolonged standing, jumping, running on hard surfaces - flat feet/high arched feet - tight hamstring -> decreased knee extension -> increased loading on forefoot -> increased stress on plantar and stretches it - higher risk in runners

Question 26

clinical presentation of plantar fasciitis

Answer 26

- pain that worsen when walking/running esp in early morning or after periods of inactivity - pain lessens w increased activity but will be worse at the end of the day due to prolonged weight bearing

Question 27

treatment of plantar fasciitis

Answer 27

1) standard non pharmaco 2) topical NSAID -> PO NSAID/celecoxib -> paracetamol

Question 28

differential diagnosis of plantar fasciitis

Answer 28

1) neurologic cause - nerve entrapment: paraesthesia and numbness - neuropathic pain: nocturnal pain - S1 radiculopathy: radiating pain from posterior aspect of leg to heel 2) skeletal causes - calcaneal stress fracture, bone contusion: prior trauma or excessive weight bearing - osteomyelitis: Fever, constant pain - neoplasm: nocturnal pain 3) soft tissue causes - Achilles tendinopathy, bursitis - fat-pad atrophy: old, pain, absent in morning but develop and worsen as day goes by - plantar fascia rupture: sudden onset, visible swelling and ecchymosis 4) inflammatory disorders - reactive arthritis: PH/FH of inflammatory disease - sarcoidosis: erythematous nodosum

Question 29

when to refer for plantar fasciitis

Answer 29

numbing pain, nocturnal pain, fever, sudden onset of pain, constant pain regardless of movement, PMH of inflammatory systemic conditions

Question 30

adhesive capsulitis (frozen shoulder) - clinical presentation

Answer 30

1) unilateral (non-dominant side) 2) limited reaching overhead, to the side, across chest

Question 31

adhesive capsulitis (frozen shoulder) - phases

Answer 31

self limiting 1) initial phase (2-9 months) - diffuse, severe, disabling shoulder pain - worse at night - increasing stiffness 2) intermediate phase (4-12 months) - stiffness and severe loss of shoulder motion - pain gradually lessens - refer to physiotherapist if very debilitating 3) recovery phase (5-24 months) - gradual return in range of motion

Question 32

when to refer for adhesive capsulitis (frozen shoulder)

Answer 32

- marked loss of motion - assess systemic symptoms of infection, malignancy, associated chronic illness

Question 33

adhesive capsulitis (frozen shoulder) - management

Answer 33

1) topical NSAIDs -> PO NSAIDs/celecoxib -> paracetamol 2) Range of motion exercises 3) intraarticular glucocorticoid + physical therapy

Question 34

lower back pain classification

Answer 34

1) Acute < 4 wks 2) subacute 4 - 12 wks 3) chronic > 12 wks

Question 35

causes of lower back pain

Answer 35

overuse, injury

Question 36

when to refer for lower back pain

Answer 36

1) neurologic symptoms - motor weakness, fall, gait instability, numbness, loss of bowel/bladder function 2) chronic glucocorticoid use, old, trauma, PMH of osteoporotic/trauma 3) unintended weight loss, PMH of malignancy 4) fever, malaise, recent spinal infection/epidural catheter placement, immunocompromised, haemodialysis, recent endocarditis/bacteraemia 5) constant pain, symptoms pointing to underlying cause (severe abdominal pain)

Question 37

pharmaco for back pain

Answer 37

1) acute and subacute - topical NSAID -> PO NSAID/celecoxib -> paracetamol - skeletal muscle relaxants (arcoxia) 2) chronic - topical NSAID -> PO NSAID/celecoxib -> paracetamol - weak opioids

Question 38

non pharmaco for back pain

Answer 38

1) RICE no HARM 2) refer to physio for back stretching exercises 3) maintain correct posture while sitting/standing 4) use correct lifting/moving techniques 5) engage in low impact core strengthening exercises to improve spine (swim, brisk walk) 6) avoid smoking and stressful situations 7) X lie down to rest cuz worsen muscle stiffness 8) maintain healthy diet cuz extra weight can add strain

Question 39

terminologies for myalgia

Answer 39

1) myalgia: muscle pain, soreness, stiffness 2) myopathy: muscle disease 3) myositis: muscle inflammation

Question 40

aetiology of myalgia

Answer 40

overuse, exercise

Question 41

differential diagnosis for myalgia

Answer 41

- infections: dengue, influenza, covid, endocarditis, impending sepsis - drug induced 1) ciprofloxacin, bisphosphonates, aromatase inhibitors 2) statin-induced rhabdomyolysis - symptoms: proximal symmetric muscle weakness, nocturnal cramping, stiffness, tendon pain, fatigue - discontinue statin if CK > 10X ULN w/wo unexplained weight loss - drink large quantities of water to facilitate renal excretion of myoglobin to prevent renal failure

Question 42

management of myalgia

Answer 42

1) standard non pharmaco 2) warm up before exercising