Windsor VTS MSK Half day

1. Windsor VTS MSK Half day • Programme for today: • 13.30 Intros: Us, You, specialities? • 13.45 Knees • 14.15 Shoulder /1 • 14.30 Break • 14.45 Shoulder /2 • 15.00 Back • 15.30 Q&A, other examinations • 16.00 Close

2. Introduction MSK in GP MSK consult common in primary care Accurate dx is therapeutically important Possible with careful history and clinical examination A referred cause is common Accurate diagnosis and physiotherapy will prevent chronic pain, prolonged symptoms and functional disability.

3. Common Denominator • History • Look • Feel • Move

4. History • History of trauma • Nature of symptoms/ Effect on activities • Pain, instability, swelling • Duration of symptoms • History of arthropathy • Gout, rheumatoid, psoriatic • History of immunocompromise • Steroids, diabetes

5. Look • Scars of surgery • Deformity • Swelling • Muscle wasting • Skin changes erythema/psoriasis/eczema • Bone/muscle contours • Comparison to unaffected side

6. Feel • Joint temperature • Effusion • Bony prominences • Area of tenderness along joint margin • Crepitus • Pulses

7. Move • Range of movement • Active and Passive • Stress tests • Special tests • Neurological Examination

8. Outline • Anatomy • Case study • Differential Diagnosis • Examination

9. Surface Anatomy

10. Bony Anatomy

11. Soft tissues

12. Soft tissues

13. Q-Angle

14. Knee CS /1 • 28 Year old, football injury 4/12 ago, heard pop/snap in R knee and immediate swelling/pain. Eased with ice and rest within a week. Improved by 75% at first appointment and after full compliance with rehab, better but unable to fully extend knee (-10 degree).

15. Agg: nothing really, just “discomfort” when getting into a car and occasional “weak” knee when playing football • Ease: short-term discomfort • 24: activity dependent • Sleep: OK • DH: nil • SH: computer programmer, football 5xweek

16. Obs • slim tall, good quads definition

17. Differential Diagnosis • Trauma- bony soft tissue • Degenerative • Inflammatory • Tumour • Infection • Referred

18. Answer: full ACL rupture. Was fully functional apart from his high level sports. Was given the option for surgical intervention - age+sporting interest key factors, surgery not for everyone

19. Examination • Look • Feel • Move • Special Tests

20. Anatomy 3 Bones Humerus Scapula Clavicle 3 Joints Glenohumeral Acromioclavicular Sternoclavicular 1 “Articulation” Scapulothoracic

21. Shoulder

22. BREAK

23. Shoulder CS /1 • 54 Year old male chopping wood in Jan, felt ache in L shoulder a few days later. The heaviness/achiness has not fully resolved. Symptoms ISQ 5/12 down the line.

24. Agg: nothing in particular • Ease: nothing • 24h: worse during the night • Sleep: disturbed • DH: meds for gout • SH: lorry driver

25. Obs • barrel chest, rounded shoulders

26. What is the differential diagnosis?

27. Causes of Shoulder Pain • Rotator cuff disorders cuff tendinopathy, calcific tendonitis, subacromial bursitis, impingement, cuff tears • Glenohumeral jt. Problems adhesive capsulitis, osteoarthritis • ACJ Problems • Traumatic Dislocation • Infections • Referred Pain Neck pain, myocardial pain, referred diaphragmatic pain • Polymyalgia Rheumatica • Malignancy Apical lung tumors, metastases Pain arising from the shoulder jt Pain arising from elsewhere

28. Answer: Cx radiculopathy + neural tension pain. Amitriptyline for sleep, rehab involved posture, Tx extension exc, Cx traction and retraction

29. Examination • Look • Feel • Move • Special Tests

30. Anatomy review

31. Anatomy

36. Back CS /1 • 61 Year old cashier I/M LBP over many years, constant in the last 3/12. CE, B+B, SA , bilat P+N/numbness clear • Agg: working at till, walking to town • Ease: movement if stationery, rest if mobile • 24h: stiff in morning, eases with movement • Sleep: aware of pain if awake

37. OBS slouched posture

38. Back CS • SH: married, 3 children at home, part-time work, main carer for mum • What is the differential diagnosis?

39. Causes of Back Pain • Mechanical low back pain (97%) • Lumbar strain or sprain (≥ 70%) • Degenerative disk or facet process (10%) • Herniated disk (4%) • Osteoporotic compression fracture (4%) • Spinal stenosis (3%) Pain better when spine is flexed or when seated, • Spondylolisthesis (2%) • Nonmechanical spinal conditions (1%) • Neoplasia (0.7%) • Inflammatory arthritis (0.3%) • Infection (0.01%)

40. Causes of Back Pain • Nonspinal/visceral disease (2%) • Pelvic organs—prostatitis, pelvic inflammatory disease, • endometriosis • Lower abdominal symptoms common • Renal organs—nephrolithiasis, pyelonephritis • Aortic aneurysm - pulsatile abdominal mass • Gastrointestinal system—pancreatitis, cholecystitis, • Shingles - Unilateral, dermatomal pain; distinctive rash

41. Answer: Disc degenerative changes, back exc, core work

42. Examination • Look • Feel • Move • Special tests

43. Keele Back STarT Tool

44. Q&A • Other examinations...

45. Thank You

46. History Age > 50 History of Cancer Weight loss Unrelenting night pain Failure to improve IVDU Steroid use Fever Unrelenting night pain Failure to improve Cancer Infection

47. History Age >50 Trauma Steroid use Osteoporosis Saddle anesthesia Sphincter dysfunction Loss of sphincter control Major motor weakness Fracture Cauda Equina Syndrome