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Chapter14
Musculoskeletalproblems
Symptoms of musculoskeletal disease 446
Neck pain 448
Low back pain 450
Shoulder problems 454
Elbow problems 456
Wrist and hand problems 458
Hip and pelvis problems 462
Knee problems 466
Ankle and foot problems 470
Sports medicine 474
Management of sporting injuries 476
Bone disorders 478
Rickets and osteomalacia 480
Osteoporosis 482
Treatment options for osteoporosis 484
Osteoarthritis 486
Rheumatoid arthritis 488
The spondyloarthropathies 492
Crystal- induced arthritis 494
Connective tissue diseases 496
Polymyalgia and giant cell arteritis 498
Vasculitis 500
Tiredness and chronic fatigue syndrome 502
Miscellaneous conditions 504
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CHAPTER14 Musculoskeletalproblems
Symptoms ofmusculoskeletaldisease
Bone pain Consider:
• Fracture— due to injury, stress fracture, or pathological fracture
• Arthritis— referred pain from aected joints
• Malignancy— primary bone malignancy, haematological malignancy, e.g.
multiple myeloma, or secondaries (usually from breast, prostate, lung,
thyroid, kidney— more rarely bowel, melanoma)
• Benign bone tumour
• Infection— osteomyelitis or joint infection
• Metabolic causes e.g. hypercalcaemia
Pain inone joint Common. Ask:
Is theproblem articular or periarticular?
• Articular disease (e.g. osteoarthritis) is suggested by joint line
tenderness and pain at the end of the range of movement in any
direction
• Periarticular problems (e.g. ligamentous injury)— point tenderness over
the involved structure, and pain exacerbated by movements
If articular Is the problem inammatory or mechanical? Look for:
• Signs of inammation— warmth, redness, eusions— may indicate joint
infection or inammatory arthritis
• Features of a mechanical problem— locking/ catching, e.g. cartilage tear
If periarticular Which structure is causing pain? Options: bursa; tendon;
tendon sheath; ligament; soft tissue; bony epiphysis/ metaphysis
• Red ags Features which should prompt early/ urgent referral:
• Inamed joint with associated fever or constitutional disturbance—
beware of septic arthritis
• Any joint which is ‘locked’ or so painful that movement is impossible
• Severe pain at rest or at night
• Pain that gets relentlessly worse over a period of days or weeks
Pain inmultiple joints Dierentiate between articular or periarticular
disease, and whether the condition is inammatory or not. Screening with
blood tests (ESR or CRP, FBC, ± autoimmune prole) may help. Look for
the pattern of disease, e.g. joint sites involved; other symptoms/ signs.
Common arthropathies E pp. 486–99
• Osteoarthritis
• Rheumatoid arthritis
• Ankylosing spondylitis
• SLE
• Reactive arthritis
• Red ags Features which should prompt early/ urgent referral:
• Severe systemic symptoms— high fevers, signicant weight loss, or a
very ill patient (suggests rheumatoid arthritis, sepsis, or malignancy)
• Focal systemic signs, e.g. rashes, nodules, or GI disturbances
• Severe pain and/ or inability to function
• Psoriatic arthritis
• Enteropathic arthropathy
• Gout or pseudogout
• Sjögren’s syndrome
• Malignancy
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SYMPTOMS OFMUSCULOSKELETALDISEASE
Back pain E p. 450 Neck pain E p. 448
Joint stiness Clarify what the patient means— stiness may refer to ei-
ther a loss of range of movement ± pain and/ or pain on movement (e.g.
following unaccustomed exercise). Morning stiness is pain that eases on
movement and is characteristic of inammatory arthritis, particularly RA.
Joint swelling Common. Ask:what does the swelling feel like?
• Hard/ bony swelling or deformity— usually osteoarthritis (e.g.
osteophytes) but may result from destructive arthropathy (e.g.
inammatory arthritis, Charcot’s joint), injury, or heterotopic
calcication
• Soft and uctuant— suggests joint eusion as a result of inammation or
infection within the joint
• Soft and non- uctuant— soft tissue swelling resulting from injury,
infection, or inammation
• Firm and non- uctuant— suggests synovial thickening resulting from
inammatory arthritis
Deformity Abnormal shape. May be temporary (e.g. soft tissue swelling
after injury, new fracture) or permanent (e.g. congenital malformation,
Paget’s disease, osteoarthritis). Look for the underlying cause.
Dystonia E p. 522
Short stature E p. 870
Chest deformity E p. 268
Excess height E p. 871
Myalgia Isolated myalgia can be a result of overuse or soft tissue injury.
Generalized myalgia is associated with many diseases including:
• Infection
• Fibromyalgia
• Chronic fatigue syndrome
• Myositis associated with statin
• PAN
• Granulomatosis with polyangiitis
Children withmusculoskeletal pain of unknown cause
Take a history and examine carefully to exclude other causes.
Investigate further with FBC, blood lm, ESR, ± X- ray if bone pain,
rest pain, or persistent or unexplained back painN. If no cause is
found, treatment is with analgesia and reassurance. Advise to return for
reassessment ± orthopaedic referral if pain worsens, continues >6wk,
changes in nature, or other symptoms develop.
Nocturnal musculoskeletal pains (growing pains) Episodic,
muscular pains, usually in the legs, lasting 730min and waking the child
from sleep. Rubbing the limb brings rapid relief. There is no pain or
disability in the morning. Diagnosis can be made on history if there are no
associated symptoms and examination is normal. If in doubt, check FBC
and ESR— which should be normal. In most cases reassurance ± analgesia
are all that is needed. In resistant cases, physiotherapy may help.
The limping child E p. 465
Further information
NICE (2015, updated 2017)Suspected cancer:recognition and referral.
M www.nice.org.uk/ guidance/ ng12
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CHAPTER14 Musculoskeletalproblems
Neckpain
• Neck trauma Any signicant cervical trauma requires neck immobilization with a hard collar and referral to A&E for cervical spine X- rays to
exclude vertebral fracture/ instability that could threaten the spinal cord.
Neck pain is common (lifetime incidence 50%) and contributes to 2% of
GP consultations. Prevalence is highest in middle age. Most neck pain is
acute and self- limiting (within days/ weeks) but 1 in 3 have symptoms lasting
>6mo or recurring pain.
History
• Pain Onset, site, radiation, aggravating and relieving factors, timing
• Stiness Timing— continuous? worse in the mornings?
• Deformity e.g. torticollis. Onset, changes
• Neurological symptoms Numbness, paraesthesiae, weakness
• Other symptoms Weight d, sweats, bowel/ bladder dysfunction
(consider spinal cord compression)
0 Pain is often poorly localized and neck problems commonly present with
shoulder pain and/ or headache (cervicogenic headache).
Examination
• Look Posture; deformity, e.g. torticollis, asymmetry of scapulae; arms
and hands— wasting, fasciculation? leg weakness?
• Feel Tenderness? Midline tenderness may be due to supraspinous
or spinous process damage following a whiplash injury. Paraspinal
tenderness ± spasm radiating into the trapezius ± crepitation is
common with cervical spondylosis
• Move/ measure Normal ranges:exion/ extension— 130° total range;
lateral exion— 45° in each direction from a neutral position; rotation—
80° in each direction from a neutral position
• Neurology Weakness in the upper limbs in a segmental distribution,
with loss of dermatomal sensation and altered reexes indicates a root
lesion (Table 14.1). If cervical cord compression is suspected, examine
the lower limbs looking for upgoing planters and hyperreexia
Cervical spondylosis Degenerative disease of the cervical spine.
May cause pain but minor changes are normal (especially >40y) and usually asymptomatic. Pain is generally intermittent and related to activity.
Examination reveals d neck mobility. Severe degeneration can cause nerve
root signs. Treat with analgesia. X- ray only if conservative measures fail,
troublesome pain, nerve root signs, or psoriasis (?psoriatic arthropathy).
Nerve root irritation or entrapment 2° to degeneration, verte-
bral displacement/ collapse, disc prolapse, local tumour, or abscess. Causes
neck stiness, pain in arms or ngers, d reexes, sensory loss, and d power.
Spurling’s test (neck extension + rotation to the aected side followed by
downwards, axial pressure) reproduces symptoms. Determine level of entrapment clinically (Table 14.1). Treat with analgesia. X- ray cervical spine—
lateral/ views. Refer for physiotherapy ± further investigations (e.g. MRI) if
conservative management fails and there is objective evidence of a root lesion
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NECK PAIN
Table14.1 Neurology associated withcervical nerve root entrapment
Root Sensory changes Motor weakness Reex changes
C5 Lateral arm Shoulder abduction/ exion
C6 Lateral forearm
Thumb
Index nger
C7 Middle nger Elbow extension
C8 Medial side of lower forearm
Ring and little ngers
T1 Medial side of upper forearm Finger abduction/ adduction None
Elbow exion
Elbow exion
Wrist extension
Wrist exion
Finger extension
Finger exion None
Biceps
Biceps
Supinator
Triceps
• Red ags Refer as an emergency if signs of spinal cord compression:
• Root pain and lower motor neurone signs at the level of the
lesion and
• Spastic weakness, brisk reexes, upgoing plantars, loss of coordination
and sensation below the lesion
Spasmodic torticollis (wry neck) Common. Sudden- onset, painful
sti neck due to spasm of trapezius and sternocleidomastoid muscles. Selflimiting. Heat, gentle mobilization, muscle relaxants, and analgesia can speed
recovery. Often caused by poor posture— e.g. computer- seating position;
carrying heavy uneven loads.
Thoracic outlet syndrome (TOS) Caused by neurovascular com-
pression as nerves/ blood vessels pass through the thoracic outlet (ring
formed by the scalene muscles, rst rib, and clavicle). May present with
shoulder/ arm pain, weakness/ paraesthesia ± thenar/ hypothenar wasting.
Radial pulse may be weak. Refer to upper limb orthopaedic surgeon for
assessment if suspected.
Cervical rib Congenital C7 costal process enlargement. Usually asymp-
tomatic but can cause TOS. X- ray may show cervical rib— but symptoms
are sometimes due to brous bands not seen on X- ray.
Whiplash injuries Neck pain caused by stretching/ tearing of cervical
muscles and ligaments due to sudden extension of the neck— often due to
a RTA. Pain and d neck mobility typically starts several hours or days after
injury. Pain may radiate to shoulders, arms, and head.
Management Examine to exclude bony tenderness requiring X- ray. Treat
with analgesia and early mobilization. A soft collar may help initially but
avoid long- term use. Recovery is often slow; 40% suer long- lasting symptoms. As a general rule, the quicker symptoms develop, the longer they take
to disappear. Early physiotherapy, if available, i recovery rate. Psychological
problems and medico- legal issues may aect progress.
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CHAPTER14 Musculoskeletalproblems
Low backpain
Denitions
• Acute low back pain New episode of low back pain of <6wk duration.
Common— lifetime prevalence 58%
• Chronic low back pain Back pain lasting >3mo
Causes ofback pain Table 14.2
History Ask about:
• Circumstances of pain— history of injury; duration
• Nature/ severity of pain— pain/ stiness mainly at rest/ at night, easing
with movement suggests inammation (e.g. discitis, spondyloarthropathy)
• Associated symptoms— numbness, weakness, bowel/ bladder symptoms
• PMH— past illnesses (e.g. cancer), previous back problems
• Exclude pain not coming from the back (e.g. GI/ GU pain; AAA)
Examination
• Deformity, e.g. kyphosis (typical of ankylosing spondylitis), loss of
lumbar lordosis (common in acute mechanical back pain), scoliosis
• Palpate for tenderness, step deformity, and muscle spasm
• Assess exion, extension, lateral exion, and rotation while standing
• Ask to lie down— this gives a good indication of severity of symptoms
• In lower limbs look for muscle wasting and check power, sensory loss,
and reexes (knee jerk and ankle jerk)— Table 14.3. Assess straight leg
raise (SLR)— sciatica is present if SLR on one side elicits back/ buttock
pain (usually ipsilateral) compared to SLR on the other side
• Red ags
• <20 or >55y
• Non- mechanical pain
• Pain that worsens
when supine
• Night- time pain
• Thoracic pain
• Past history of cancer
• AAA
• HIV
• Immune suppression
• IV drug use
• Taking steroids
• Unwell
• Weight d
• Widespread
• Structural
neurology
deformity
Management ofacute back pain inthe community Triage ac-
cording to history and examination— Figure 14.1, E p. 452
For patients who do not require immediate referral Consider analgesia, e.g.
NSAIDs (for short time + consider gastroprotection); weak opioids (±
paracetamol). Use Keele STarT Back screening tool (Box 14.1):
• If total score ≤3, explain likely natural history of the pain and advise to
avoid bed rest and maintain normal activities as far as possible (d chance
of chronic pain). Suggest self- help exercises
• If total score is ≥4, check question 5– 9 sub- score:
• If ≤3— if not resolved in 4wk, refer for physical therapy. Options
include: back exercise classes, physiotherapy, chiropractic, osteopathy
or acupuncture, if available
• If ≥4— if not resolved in 4wk, refer directly for specialist
intervention— sooner if worsening or severe pain
• In all cases, challenge any ‘yellow ag’ factors (Figure 14.1, E p. 452)
that may inhibit recovery and delay return to normal functioning
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LOW BACKPAIN
Table14.2 Causes ofback pain:age suggests themost likely cause
Age (y) Causes
15– 30 • Postural
• Mechanical
• Prolapsed disc
30– 50 • Postural
• Prolapsed disc
>50 • Postural
• Degenerative
• Paget’s disease
Other
• Spinal stenosis
causes
• Cauda equina tumour
• Trauma
• Fracture
• Ankylosing spondylosis
• Spondyloarthropathies
• Discitis
• Malignancy (lung, breast,
prostate, thyroid, kidney)
• Myeloma
• Abdominal aortic
aneurysm
• Spondylolisthesis
• Pregnancy
• Degenerative
joint disease
• Osteoporotic
collapse
• Spinal infection
• Referred pain
Table14.3 Neurology withlumbosacral nerve root entrapment
Root Sensory changes Motor weakness Reex changes
L2 Front of thigh Hip exion/ adduction None
L3 Inner thigh Knee extension Knee
L4 Inner shin Knee extension
L5 Outer shin
Dorsum of foot
S1 Lateral side of foot/ sole Knee exion
Foot dorsiexion
Knee exion
Foot inversion
Big toe dorsiexion
Foot plantarexion
Knee
None
Ankle
Box 14.1 Keele STarT Back Pain ScoringTool
Ask patients to consider the following statements and state whether they
agree or disagree with them. Thinking about the past 2wk:
1. My back pain has spread down my leg(s) at some time in the last 2wk
2. Ihave had pain in the shoulder or neck at some time in the last 2wk
3. Ihave only walked short distances because of my back pain
4. In the last 2wk, Ihave dressed more slowly than usual because of
back pain
5. It’s not really safe for a person with a condition like mine to be
physically active
6. Worrying thoughts have been going through my mind a lot of
the time
7. Ifeel that my back pain is terrible and it’s never going to get
any better
8. In general Ihave not enjoyed all the things Iused to enjoy
If the patient agrees with a statement, score 1; if disagrees, score 0.
9. Overall, how bothersome has your back pain been in the last 2wk?
• Not at all, slightly or moderately— score 0
• Very much or extremely— score 1
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CHAPTER14 Musculoskeletalproblems
Figure14.1 Triage of acute back pain
0 Do not X- ray routinely X- rays require a high radiation dose and clinically
meaningful ndings are rare. Exceptions:
• Young (<25y)— X- ray sacroiliac joints to exclude ankylosing spondylitis
• Elderly— if vertebral collapse/ malignancy suspected
• History of trauma
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LOW BACKPAIN
H Cauda equina syndrome Compression of the cauda equina
below L2, e.g. by disc protrusion at L4/ 5. Presents with:
• Numbness of the buttocks and backs of thighs
• Urinary/ faecal incontinence
• Lower motor neurone weakness:
• L4— loss of dorsiexion of the foot (and toes— L4/ 5)
• S1— loss of ankle reex, plantarexion and eversion of the foot
Management Refer/ admit as a neurological emergency. Rapid surgical
intervention i the chance of full motor and sphincter recovery.
H Spinal cord compression Aects 5% of cancer patients— 70% in
the thoracic region. Maintain a high level of suspicion if history of cancer
and new back pain— especially if known bony metastases or tumour likely
to metastasize to bone. Presents with:
• Back pain, worse on movement— often appears before neurology
• Neurological symptoms/ signs— can be non- specic, e.g. constipation,
weak legs, urinary hesitancy. Lesions above L1 (lower end of spinal
cord) produce upper motor neurone signs (e.g. i tone/ reexes) and
a sensory level; lesions below L1 produce lower motor neurone signs
(d tone/ reexes) and peri- anal numbness (cauda equina syndrome)
Management Prompt treatment (<24– 48h from rst neurological symptoms) is needed; once paralysed, <5% walk again. Treat with oral dexamethasone 16mg/ d and refer for same day assessment and surgery/
radiotherapy unless in nal stages of disease.
Osteoporotic vertebral collapse E p. 482
Scoliosis Lateral curvature of the spine associated with rotation of verte-
brae ± ribs or wedging of vertebrae. Early treatment prevents progression
and complications, e.g. cardiopulmonary disturbance. Causes:
• Idiopathic
• Congenital (buttery vertebra)
• Neuromuscular problems, e.g. cerebral palsy, neurobromatosis,
Friedreich’s ataxia, muscular dystrophy, polio
• Trauma l damage in vertebral growth plate and uneven growth
• Neoplasm 1°, 2°, or as a result of radiotherapy
Clinical features Dierence in shoulder height; spinal curvature; dierence in
the space between the trunk and upper limbs. 0 Scoliosis which disappears
on bending is postural and of no clinical signicance.
Management In all cases where structural scoliosis is suspected, refer to
orthopaedics— urgently if associated with pain, especially at night.
• Infection— TB of spine
• Metabolic, e.g. bone dysplasias
Further information
NICE (2016) Low back pain and sciatica in over 16s. M www.nice.org.uk/
guidance/ ng59
Patient information and support
Arthritis Research UK F 0800 5200 520 M www.arthritisresearchuk.org
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