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CHAPTER14 Musculoskeletalproblems
Sportsmedicine
Fitness toperform sporting activities GPs are commonly asked
to certify tness to perform sports. Normally the patient will come with
a medical form. If there is a form, request to see it before the medical. If
there is no form and you are unsure what to check, telephone the sport’s
governing body or the event organizer. Afee is payable by the patient.
Many gyms/ sports clubs also ask older patients/ patients with pre- existing
conditions or disabilities to check with their GP before they will sign them
on. Assuming that a suitable regime is undertaken, most people can participate. Consider the patient’s baseline tness, check BP and medications, and
recommend gradual introduction to new forms of exercise.
0 Remember— signing a form may result in legal action against you should
the patient NOT be t to undertake an activity. Where possible include a
caveat, e.g. ‘Based on information available in the medical notes the patient
appears to be t to ... although it is impossible to guarantee this’. If unsure,
consult your local LMC/ medical indemnity organization.
• Hypertrophic obstructive cardiomyopathy Can cause sudden death
during sport. It is dicult to exclude on clinical examination— if there is
a FH or systolic murmur refer to cardiology before recommending new
intense activity.
Benets ofexercise E p. 154
Children and sport
• Exercise is good for children— it stimulates development of the
musculoskeletal and cardiovascular systems
• It should be fun and not physically or emotionally
over- demanding
• Children are more prone to sports injuries due to continuing growth
(bone growth plates are prone to damage) but are more exible so
have d injury rate
• Children’s temperature control is not as good as adults
• Equipment must be checked regularly to ensure it ts
• Encourage warm- up and stretching exercises before sport
• Refer children with suspected overuse or sports injuries, which do not
recover rapidly with simple analgesia, for specialist assessment
Nutrition Recommend a normal varied diet (E p. 148).
• Special circumstances Particular sports have special requirements (e.g. i
protein for strength athletes); i muscle glycogen stores before exercise
can d fatigue during prolonged heavy exercise, e.g. ‘carbohydrate
loading’— 3– 4d of i carbohydrate (8– 10g/ kg body weight) and a
carbohydrate meal 3– 4h before competing
• Fluids Sucient uid during exercise is vital to good performance
and health, especially in hot conditions. Rehydration uids containing
carbohydrate and electrolytes are absorbed faster than plain water
• Supplements e.g. vitamins, minerals, amino acids, carnitine, creatine.
Agood diet generally supplies sucient nutrients
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SPORTSMEDICINE
Drugs and sport Most regulating bodies have strict codes regarding
drug use. Regulations may dier between dierent sports. Status of a particular medicine may be checked in the Global Drug Reference Online
(Mwww.globaldro.com).
Prohibited classes ofdrugs
• Stimulants e.g. amphetamine, caeine (above 12 mcg/ mL), ephedrine,
certain β2 agonists (inhaled medication for asthma is allowed)
• Narcotics e.g. morphine, diamorphine, pethidine, methadone (codeine
is allowed)
• Anabolic agents e.g. nandrolone, DHEA, testosterone
• Diuretics e.g. furosemide, bendroumethiazide
• Hormones, hormone antagonists, and related substances e.g. growth
hormone, erythropoietin
• Cannabinoids
Classes ofdrugs subjected torestrictions
• Alcohol and marijuana— restricted in certain sports
• Local anaesthetics— local or intra- articular injection only are allowed
(provide written notication of administration)
• Corticosteroids— topical, inhaled, or local/ intra- articular injection only
are allowed (provide written notication of administration)
• β- blockers— restricted in certain sports
Drugs forpain relief Generally paracetamol, all NSAIDs, and codeine are
allowed for pain relief. Stronger opioids and drugs containing caeine are
banned. If in doubt, check on the Global Drug Reference before prescribing.
Anabolic steroid misuse Signicant problem in the UK (5% in gyms and tness
clubs). Drugs are often used in complicated regimens at high doses to i lean
muscle mass and d body fat. Side eects include:
• i cholesterol
• i BP
• Gynaecomastia
0 Other drugs may be taken in conjunction with anabolic steroids to
dthese side eects.
• Abnormal LFTs
• Testicular atrophy
• Baldness
• Acne
• Mood changes
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• Doctors who prescribe or collude in the provision of drugs or treatment with the intention of improperly enhancing an individual’s performance in sport risk losing their GMC registration. This does not preclude
the provision of any care or treatment where the doctor’s intention is to
protect or improve the patient’s health.
Further information
British Association of Sport and Exercise Medicine M www.basem.co.uk
Global Drug Reference Online M www.globaldro.com
MacAuley D (2012) Oxford Handbook of Sports and Exercise Medicine (2nd
edn). Oxford:Oxford University Press. ISBN:9780199660155
UKAD Antidoping in Sport. M www.ukad.org.uk
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CHAPTER14 Musculoskeletalproblems
Management ofsportinginjuries
Principles ofmanaging sportinginjuries
• First aid (Airway, Breathing, Circulation), refer severe injuries to A&E
• RICE
• Rest Relative rest of aected part while continuing other activities
to maintain overall tness
• Ice and analgesia Use immediately after injury (wrap ice in a towel
and use for maximum 10min at a time to prevent acute cold injury)
• Compression Taping or strapping can be used to treat (d swelling)
and also to prevent acute sprains and strains
• Elevation d local swelling and dependent oedema enabling quicker
recovery
• Conrm the diagnosis Clinical examination, X- ray
• Early treatment According to cause. Do not delay
• Liaise With sports physician, sports physio, and coach if elite athlete
• Rehabilitation Regaining tness, strength, and exibility; examine and
correct the cause of the injury (e.g. poor technique, equipment)
• Graded return to activity Discuss with coach
• Prevention Suitable preparation and training (e.g. suitable footwear,
warm- up and warm- down exercises, safety equipment) can d
likelihood of injuries
Muscleinjuries
• Haematoma within or between muscles can l dramatic whole limb
bruising (due to tracking of blood) and stiness. Treat with RICE regime,
encourage movement in pain- free range
• Strain (e.g. hamstring injury) Refer to physiotherapy. Asecondary injury
is likely if the patient returns to sport too soon
Ligament injuries (sprains)
• Grade 1 Local tenderness, normal joint movement. Give NSAIDs,
support strain, encourage mobilization
• Grade 2 Slightly abnormal joint movement. More joint protection,
NSAIDs, elevate limb, encourage middle of the range movement
• Grade 3 Abnormal joint movement. Refer to orthopaedics
Groin pain inathletes Consider:
• Conjoint tendon pathology (Gilmore’s groin)
• Symphysitis (footballers notably)
• Adductor tendonitis
Liaise with a sports medicine physician or physiotherapist early.
Overuse injuries Incidence is increasing due to increasingly intensive
training regimes, especially in young adults— even among amateurs.
• Causes Load too great for conditions, poor technique or posture, faulty
or poor quality equipment
• Types of injury Stress fractures, joint tenderness or eusion, ligament
and tendon strains, muscle stiness
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MANAGEMENT OFSPORTINGINJURIES
• Management Rest, NSAIDs, physiotherapy, improved training regime
• Prevention Recognize and correct poor posture or technique, check
equipment is appropriate and ts, warm up and stretching before
exercise, gradually i intensity and duration of training
Shin splints Exercise- related shin pain may be due to a stress fracture of
the tibia, compartment syndrome, or periostitis. Fractures are not always
seen on X- ray— bone scan is more sensitive and shows periostitis. Treat
with rest and analgesia. Consider referral to sports physiotherapist.
Iliotibial band syndrome Pain due to inammation of the synovium
under the iliotibial tract from rubbing of the tract on the lateral femoral
condyle. Seen in runners. Treat with rest, NSAIDs, specialist physiotherapy
± steroid injection.
Over- training syndrome Poor performance, fatigue, heavy muscles,
and depression due to excessive sports training or competing without sufcient rest. Usually diagnosed from history. Exclude other causes of fatigue (E p. 502). Manage with rest, reassurance, and alteration of training
programme.
‘Scrumpox’ (herpes gladiatorum) Herpes simplex virus is very con-
tagious and outbreaks among sporting teams are common, e.g. spread by
close contact and facial stubble grazes while scrumming. Treatment:aciclovir
(cream or tablets) and exclusion of infected players. Impetigo, erysipelas,
and tinea barbae can be transmitted in the same way.
Environmentalfactors
• Heat cramps Painful spasm of heavily exercised muscles (calves and
feet)— due to salt depletion. Treatment:rest, massage of aected
muscle, and uid and salt replacement (e.g. Dioralyte®)
• Heat stroke/ exhaustion Exercising in excessive heat l salt and water
depletion, dehydration, and metabolite accumulation. Signs:headache,
nausea, confusion, incoordination, cramps, weakness, dizziness, and
malaise. Eventually thermoregulatory mechanisms fail l seizures and
coma. Signs:ushing, sweating, and dehydration. Temperature may be
normal (mild cases) or i. Treatment:Rest, uid and salt replacement
(e.g. Dioralyte®). Admission for IV uids and supportive measures in
severe cases
• Hypothermia Ensure appropriate clothing and limit time in the cold.
Signs:behaviour change, incoordination, clouding of consciousness.
Treatment:remove from cold environment, wrap in blankets (including
the head), and transfer to hospital. Do not use direct heat
• Frost bite Freezing of the peripheries (usually feet, hands, ears, or
nose). Tissues become hard, insensitive, and white. Treatment:gentle
rewarming, Refer if signicant dead tissue. Debridement is usually
delayed to allow natural recovery
• Diving Decompression illness is due to rapid ascent causing nitrogen
dissolved in blood to form gas bubbles. Usually <1– 36h after surfacing.
Presentation:deep muscle aches, joint pains, skin pain, paraesthesia,
itching and burning, retrosternal pain, cough and breathlessness,
neurological symptoms. Refer suspected cases urgently to A&E
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CHAPTER14 Musculoskeletalproblems
Bonedisorders
Osteogenesis imperfecta Inherited condition with auto-
somal dominant inheritance (rarely recessive). Several types but
all have an underlying problem with collagen metabolism resulting
in fragile bones that break easily. Other features include lax joints,
thin skin, blue sclerae, hypoplastic teeth, and deafness. Presentation
varies according to severity. May be obvious at birth or present early with
fractures. Less severe cases present later and may be mistaken for NAI.
Mild cases may not present until adolescence with thin bones on X- ray.
Treatment is supportive.
Osteopetrosis (marble bone disease) Inherited condition with
autosomal dominant or recessive inheritance. Dominant form presents in
childhood with fractures, osteomyelitis ± facial paralysis. Recessive form
is more severe causing bone marrow failure and death. Bone marrow
transplantation has been tried but is of limited success.
Paget’s disease ofbone Abnormal osteoclast activity causes acceler-
ated, disorganized bone remodelling. Aects 1– 2% of UK adults; 15% have
a FH. ♂:♀ 83:1. Most common in the elderly— only a minority are symptomatic. Aects just one bone in 1 in 3 cases.
Presentation Pain— dull ache aggravated by weight bearing, often remains at
rest; deformity— bowing of weight- bearing bones especially tibia (sabre),
femur, and forearm— usually asymmetrical; frontal bossing of the forehead;
distinctive changes on X- ray; i bone- specic alk phos; normal Ca2+, PO4,
and PTH.
Management Refer to rheumatology. Give analgesia. Oral/ IV
bisphosphonates d pain and long- term complications. Complications:patho-
logical fracture; OA of adjacent joints; high- output CCF; hydrocephalus
and/ or cranial nerve compression l neurological symptoms, e.g. deafness;
spinal stenosis; bone sarcoma (rare:0.1– 1.15%).
Osteomyelitis Infection of bone. May spread from abscesses or follow
surgery. Often no primary site is found. More common in those with
DM, sickle cell disease, impaired immunity, and/ or poor living standards.
Organisms involved:S.aureus, streptococci, E.coli, Salmonella, Proteus, and
Pseudomonas species, TB. Presents with pain, unwillingness to move af-
fected part, warmth, eusions in neighbouring joints, fever, and malaise.
Blood cultures are +ve in 60%; i ESR/ CRP; i WCC.
Management Refer suspected cases for same- day orthopaedic opinion.
Diagnosis is conrmed with imaging, e.g. MRI or bone scan (X- ray changes
can take days to appear). Treatment:is with IV then PO antibiotics (≥6wk)
and surgery to drain abscesses. Complications:septic arthritis, pathological
fracture, deformity of growing bone, chronic infection.
Chronic osteomyelitis Occurs after delayed/ inadequate treatment of acute
osteomyelitis. Signs:pain, fever, and discharge of pus from sinuses. Follows a
relapsing/ remitting course over years. Needs specialist management.
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BONEDISORDERS
H Referral guidelines for suspected sarcoma
Refer forimmediate X- ray Any patient with suspected spontaneous fracture. If the X- ray:
• Indicates possible bone cancer, refer urgently
• Is normal but symptoms persist, follow- up and/ or request repeat X-
ray, bone function tests, or referral
Refer urgently If a patient presents with a palpable lump that is:
• >5cm in diameter
• Deep to fascia, xed, or immobile
• Arecurrence after previous excision
0 If a patient has HIV, consider Kaposi sarcoma and make an urgent
referral if suspected.
Urgently investigate Increasing, unexplained, or persistent bone pain or
tenderness, particularly pain at rest (and especially if not in the joint), or
an unexplained limp. In older people metastases, myeloma, or lymphoma,
as well as sarcoma, should be considered.
• Increasing in size
• Painful
N
Sarcoma Cancer of the bone or connective tissue. 72300 patients/ y are
diagnosed with sarcoma in the UK, and it causes 71000 deaths. There are
2 peaks of incidence— one in teenagers, and another in old age. 5 types of
sarcoma account for >80% of tumours.
Osteosarcoma and theEwing’s family oftumours Present with aching bone
pain, swelling, ± pathological fracture. If X- ray is normal but symptoms
persist, consider checking bone function tests, re- X- raying, discussing the
patient with a specialist or referral. Treatment involves surgery and chemotherapy. Overall 5y survival is 50– 80%.
Adult soft tissue sarcoma oflimb or trunk Usually presents with a palpable
lump. The most common tumours are leiomyosarcoma, liposarcoma, and
synovial sarcoma. Treated with surgery ± radiotherapy (high- grade tumours). Chemotherapy is reserved for palliation.
Kaposi sarcoma E p. 722
Intra- abdominal sarcoma Usually presents late. Often arises in the
retroperitoneum. If possible, surgery is the main treatment. Local relapse is
common and often not responsive to cytotoxic therapy.
Rhabdomyosarcoma Originates from striated muscle. Presents usually in children <2y with a lump. Responds to intensive multimodal
therapy; outlook is generally good (>60% long- term survival).
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Further information
NICE (2015, updated 2017)Suspected cancer:recognition and referral. M
www.nice.org.uk/ guidance/ ng12
Patient information and support
Brittle Bone Society F 01382 204446 M www.brittlebone.org
Paget’s Association F 0161 799 4646 M www.paget.org.uk
Sarcoma UK F 0808 801 0401 M www.sarcoma.org.uk
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CHAPTER14 Musculoskeletalproblems
Rickets andosteomalacia
Vitamin D deciency causes rickets in children and osteomalacia in adults.
The body needs 710 micrograms of vitamin D per day to maintain healthy
bones. The body makes its own vitamin D when sunlight falls on the skin in
the summer months but a diet with adequate vitamin D is needed to maintain the supply in the winter— especially for people who do not get out or
for cultural or religious reasons are completely shielded from the sun by
their clothing.
Clinical features ofrickets
• Bone pain/ tenderness:arms, legs, spine, pelvis
• Skeletal deformity:bow legs, pigeon chest (forward projection of
the sternum), rachitic rosary (enlarged ends of ribs), asymmetrical/
odd- shaped skull due to soft skull bones, spinal deformity (kyphosis,
scoliosis), pelvic deformities
• Pathological fracture
• Dental deformities— delayed formation of teeth, holes in enamel,
icavities
• Muscular problems— progressive weakness, d muscle tone,
muscle cramps
• Impaired growth l short stature (can be permanent)
Clinical features ofosteomalacia
• Bone pain— diuse, particularly in hips
• Muscle weakness
• Pathological fractures
• Low calcium l perioral numbness, numbness of extremities, hand and
feet spasms, and/ or arrhythmias
Causes andmanagement
Dietary deciency (<30nmol/ L) Particularly in children with pigmented skin
in Northern climes. Give vitamin D and Ca2+ supplements.
Age- related deciency (<30nmol/ L) Vitamin D metabolism deteriorates with
age and many >80y are decient. Consider giving vitamin D (800IU/ d) to
all elderly >80y.
Secondary rickets/ osteomalacia Due to other disease, e.g. malabsorption, liver disease, renal tubular disorders, or chronic renal failure. Treat
underlying cause and supplement Ca2+ and vitamin D as needed.
Vitamin D- dependent rickets Rare autosomal recessive inherited disorder
resulting in an enzyme decit in the metabolism of vitamin D.Refer for specialist care. Treated with vitamin D and Ca2+ supplements.
Hypophosphataemic rickets (vitamin D- resistant rickets) X- linked dominant trait resulting in d proximal renal tubular resorption of phosphate.
Parathyroid hormone and vitamin D levels are normal. Specialist management is needed. Treatment is with phosphate replacement ± calcitriol.
Dietary sources ofcalcium and vitamin D Tables 14.6 and 14.7
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RICKETS ANDOSTEOMALACIA
Table14.6 Approximate vitamin D content ofcommon foods
Food Serving Vitamin D (mcg)
Margarine 10g (½ oz) 0.8
Eggs 1 size 3 1.1
Cheese 60g (2oz) 0.2
Milk 0.15l (¼ pint) 0.05
Butter 10g (½ oz) 0.1
Fortied cereals 30g (1oz) 0.5
Herring 100g (3½ oz) 16.5
Mackerel 100g (3½ oz) 8
Sardines 100g (3½ oz) 7.5
Tinned tuna 100g (3½ oz) 4
Tinned salmon 100g (3½ oz) 12.5
Kipper 100g (3½ oz) 13.5
a
Recommended daily intakes:birth to 50y, 5mcg; 50– 70y, 10mcg; >70y, 15mcg.
a
Table14.7 Approximate calcium content ofcommon foods
Food Serving Calcium (mg)
Whole milk 0.2l (⅓ pint) 220
Semi- skimmed milk 0.2l (⅓ pint) 230
Hard cheese 30g (1oz) 190
Cottage cheese 115g (4oz) 80
Low- fat yoghurt 150g (5oz) 225
Sardines (including bones) 60g (2oz) 310
Brown or white bread 3 large slices 100
Wholemeal bread 3 large slices 55
Baked beans 115g (4oz) 60
Boiled cabbage 115g (4oz 40
a
Recommended daily intakes:birth to 6mo, 210mg; 7mo– 1y, 270mg; 1– 3y, 500mg; 4– 8y, 800mg;
9– 18y, 1300mg; 19– 50y, 1000mg; >50y, 1200mg.
a
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Patient information and support
Arthritis Research UK F 0800 5200 520 M www.arthritisresearchuk.org
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CHAPTER14 Musculoskeletalproblems
Osteoporosis
Lifetime risk of osteoporotic fracture is 1:3 in ♀ and 1:5 in ♂ (>200,000
fractures/ y in the UK). The main morbidity and nancial costs of osteoporosis relate to hip fracture where incidence i steeply >70y. Treatment aims
to prevent fracture.
Denitions
• T- score Compares bone mineral density (BMD) of the subject with the
young adult mean (age 30y)
• Osteoporosis Dened as BMD >2.5 standard deviations (SD) below
the young adult mean (i.e. T score of <−2.5). There is 2– 3× i relative
risk of fracture for each SD d in BMD
• Osteopenia Diagnosed if T- score is between −1 and −2.5
• Z- score Compares BMD of the subject to an age- matched normal
control, i.e. measures whether BMD is normal for the patient’s age.
Cannot be used to diagnose osteoporosis or osteopenia, but may be
useful in young patients to predict osteoporosis risk for the future
Causes Osteoporosis may be 1° or 2° to other medical conditions:
• Endocrine Hypogonadism (e.g. premature menopause, anorexia,
androgen blockade, taking aromatase inhibitors), hyperthyroidism,
hyperparathyroidism, hyperprolactinaemia, Cushing’s disease,
type 1 DM
• GI Coeliac disease or other causes of malabsorption, inammatory
bowel disease, chronic liver disease, chronic pancreatitis
• Rheumatological RA, other inammatory arthropathies
• Other Immobility, multiple myeloma, haemoglobinopathy, systemic
mastocytosis, CF, COPD, CKD, homocystinuria
Fragility fracture Fracture sustained falling from ≤ standing height—
includes vertebral collapse (may not be as a result of a fall). Previous fracture is a risk for future fracture. Common fractures:
• Hip Associated with i mortality • Wrist Colles’ fracture
• Osteoporotic vertebral collapse Causes pain, d height, and kyphosis.
Pain can take 3– 6mo to settle and requires strong analgesia. Calcitonin is
useful for pain relief for 3mo after vertebral fracture if other analgesics
are ineective
Predicting fracture risk
available:FRAX® (available from M www.shef.ac.uk/ FRAX) and Qfracture®
(available from M www.qfracture.org). Qfracture does not require BMD
measurement; FRAX can be performed without BMD measurement. Both
provide information on 10y probability of hip or other osteoporotic fracture. Case- nding and further actions— Figure 14.6.
Bone mineral density (BMD) measurement X- rays cannot be
used to measure BMD, but are useful if vertebral fracture or metastases is
suspected. Hip and lumbar spine BMD is measured using dual energy X- ray
absorptiometry (DXA). Do not request without prior use of a risk prediction tool, e.g. FRAX® (without BMD measurement) or Qfracture®.
N
2 validated fracture risk prediction tools are
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OSTEOPOROSIS
Glucocorticoid use Steroid use is a risk factor for osteoporosis.
Minimize steroid dose. For patients taking oral/ high- dose inhaled steroids
for >3mo or frequent courses of steroids, in addition:
• Add bone protection agent (e.g. bisphosphonate) for patients >65y or
with history of fragility fracture or
• Refer patients <65y without history of fragility fracture for DXA scan
and add a bone protection agent if T score is ≤−1.5
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Figure14.6 Use of fracture risk prediction tools
Further information
National Osteoporosis Guideline Group Clinical guideline for the prevention and treatment of osteoporosis. M www.shef.ac.uk/ NOGG
NICE (2012, updated 2017)Assessing the risk of fragility fracture. M
www.nice.org.uk/ guidance/ cg146
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