Hot Musculoskeletal Topics

1. Hot Musculoskeletal Topics

2. Neck Pain • Non-specific - or mechanical - neck pain is very common affecting 15% of the adult population per year.  More than a third go on to have persistent symptoms and recurrence rates are high.  The evidence shows that patients benefit from simple interventions that promote mobility, activity • Neck pain that radiates into the arm – cervical radiculopathy – is less common than  non-specific neck pain but is more disabling and the acute pain can be excruciating.1  It is generally caused by irritation or entrapment of the lower cervical roots (C5-T1 are most common2) from a herniated disc or degenerative disc disease.1  

3. Red Flags

4. Features suggesting spinal cord compression • Insidious progression • Bladder/bowel dysfunction, gait disturbance, clumsy/weak hands • Lower motor neurone signs in upper limbs (e.g. hyporeflexia, atrophy) • Upper motor neurone signs in lower limbs (e.g. spasticity, up-going plantars)

5. Features suggesting infection/cancer/inflammation • Fever, malaise, unexplained weight loss, lymphadenopathy • History of cancer, inflammatory arthritis, infection (e.g. tuberculosis, HIV), immunosuppression • Exquisite localised tenderness over vertebral body (could also be fracture)

6. Features suggesting severe trauma/skeletal injury • History of high impact trauma or fall from height, or minor trauma with osteoporosis • Previous neck surgery • Risk factors for osteoporosis

7. Features suggesting vascular insufficiency • Dizziness or blackouts (vertebral artery insufficiency) on movement, especially when neck extended • Drop attacks

8. How should cervical radiculopathy be managed? • Degenerative cervical radiculopathy with a subacute onset has a favourable prognosis and a wait-and-see policy is recommended for the first 6 weeks.3  NHS Clinical Knowledge Summaries recommends referring for MRI and/or specialist interventions if symptoms persist after this. • immobilisation with a semi-hard collar v physiotherapy v a simple wait-and-see strategy • First two better at six weeks but no different at six months. Best advice for us being relative rest • Drugs paracetamol NSAID opioids ? TCA after four weeks

9. Joint Hypermobility Syndrome • Joint hypermobility syndrome (JHS) is a heritable disorder of connective tissue leading to symptomatic joint hypermobility which predisposes to arthralgia, joint instability and soft tissue injury.  It is associated with premature osteoarthiritis.  • It can be a multisystem disorder and non-articular complications include: • Autonomic dysfunction – for example urinary incontinence • Intestinal dysmotility – irritable bowel syndrome is common • Proprioceptive impairment • Laxity in other tissues causing skin problems, hernias or prolapses • Obstetric complications, including premature rupture of membranes, precipitate delivery and perineal injury

10. Beighton Score • Can you put your hands flat on the floor with your knees straight (1) • Can you bend your elbow backwards? L(1) R(1) • Can you bend your knee backwards? L(1) R(1) • Can you bend your thumb back on to the front of your forearm? L(1) R(1) • Can you bend your little finger up at right angles to the back of your hand? L(1) R(1) • TOTAL SCORE (max. 9): ≥4 is suggestive

11. Brighton Criteria • Major criteria • Beighton score ≥4 • Arthralgia for >3 months in ≥4 joints • Minor criteria • Beighton score of 1-3 • Arthralgia in 1-3 joints, or back pain, or spondylosis or spondylolisthesis • Joint dislocation , more than once • ≥3 soft tissues lesions e.g. epicondylitis, bursitis, tenosynovitis • Marfanoid habitus (tall, slim, arachnodactyly but Marfan’s itself is excluded) • Skin: striae, hyper-extensibility, thin • Eyes: drooping eyelids, myopia • Varicose veins, hernias, uterine or rectal prolapse • Two major/ One major two minor/ Four minor

12. Management • Exclude potentially more serious, heritable connective tissue disorders such as Marfan’s syndrome or the vascular type of Ehlers-Danlos - which are suggested by positive family history, including premature death from ruptured aneurysms or spontaneous arterial or uterine ruptures. • Physiotherapy needs to be adapted to the patient’s lax and fragile tissues and have a greater emphasis on core strengthening, joint proprioception and fitness training.

13. Leg Cramps • Involuntary leg cramps have a prevalence of 56% in elderly people and half of these have cramps at least once a week.  They are, of course, most prominent at night, affecting the lower calf and foot muscles.  They become more common when the motor system is stressed, for example by dehydration, excessive exercise or by neuromuscular disease.  Other causes include: • Renal and liver dysfunction • Hypothyroidism • Electrolyte imbalances, hypocalcaemia, hypomagnesaemia • Idiopathic

14. Non pharmacological treatment • Adequate hydration - common sense advice but no formal studies • Muscle stretching exercises - one study suggested calf-stretching exercises three times a day may reduce cramps

15. Pharmacological treatment • Quinine • Over-used, but two class 1 studies show some efficacy • Studies suggest a 25-37% reduction in the number of cramps compared to placebo • Equivalent to one less cramp per week on average • Potentially serious side effects and serious risk in overdose

16. Non Licenced • Natridrofuryl (300mg bd) • Diltiazem hydrochloride (30mg) • Vitamin B complex

17. Quinine • There are a number of significant adverse effects with quinine use which both patient and doctor can misinterpret as simple ageing. The include tinnitus, impaired hearing, headache, nausea, disturbed vision, confusion, flushing and abdominal pain. • There are also rarer but potentially very serious side effects, reported in 2-4% of patients according to the review in Neurology. 8 These include thrombocytopenia, with a small number of linked deaths. • Quinine is toxic in overdose, leading to blindness and death. It also has a number of significant interactions with other medications, including digoxin and warfarin. • So routine use is not recommended - but the advice if we do use it (mirrored in the BNF) is to trial for four weeks and stop if no benefit.  If treatment continues, it should be stopped every three months and the benefits reassessed.