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 Programme
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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
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.
 History
 Look
 Feel
 Move
 History
of trauma
 Nature of symptoms/ Effect on activities
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Pain, instability, swelling
 Duration
of symptoms
 History of arthropathy
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Gout, rheumatoid, psoriatic
 History
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of immunocompromise
Steroids, diabetes
 Scars
of surgery
 Deformity
 Swelling
 Muscle wasting
 Skin changes erythema/psoriasis/eczema
 Bone/muscle contours
 Comparison to unaffected side
 Joint
temperature
 Effusion
 Bony prominences
 Area of tenderness along joint margin
 Crepitus
 Pulses
 Range
of movement
 Active and Passive
 Stress tests
 Special tests
 Neurological Examination
 Anatomy
 Case
study
 Differential
Diagnosis
 Examination
 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).
 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
 slim
tall, good quads definition
 Trauma-
bony
soft tissue
 Degenerative
 Inflammatory
 Tumour
 Infection
 Referred
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
 Look
 Feel
 Move
 Special
Tests
3 Bones
Humerus
Scapula
Clavicle
3 Joints
Glenohumeral
Acromioclavicular
Sternoclavicular
1 “Articulation”
Scapulothoracic
BREAK
 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.
 Agg:
nothing in particular
 Ease: nothing
 24h: worse during the night
 Sleep: disturbed
 DH: meds for gout
 SH: lorry driver
 barrel
chest, rounded shoulders
 What
is the differential diagnosis?
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Rotator cuff disorders
cuff tendinopathy, calcific
tendonitis, subacromial
bursitis, impingement, cuff
tears
Glenohumeral jt. Problems
adhesive capsulitis,
osteoarthritis
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ACJ Problems
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Traumatic Dislocation
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Infections
Pain arising from the shoulder jt
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Referred Pain
Neck pain, myocardial
pain, referred diaphragmatic
pain
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Polymyalgia Rheumatica
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Malignancy
Apical lung tumors,
metastases
Pain arising from elsewhere
 Answer:
Cx radiculopathy + neural tension
pain. Amitriptyline for sleep, rehab involved
posture, Tx extension exc, Cx traction and
retraction
 Look
 Feel
 Move
 Special
Tests
 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
slouched posture
 SH:
married, 3 children at home, part-time
work, main carer for mum
 What
is the differential diagnosis?
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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%)
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Nonmechanical spinal conditions (1%)
Neoplasia (0.7%)
Inflammatory arthritis (0.3%)
Infection (0.01%)
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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
 Answer:
Disc degenerative changes, back
exc, core work
 Look
 Feel
 Move
 Special
tests
 Other
examinations...
Cancer
Age > 50
History of Cancer
Weight loss
Unrelenting night
pain
Failure to improve
Infection
IVDU
Steroid use
Fever
Unrelenting night
pain
Failure to improve
Fracture
Age >50
Trauma
Steroid use
Osteoporosis
Cauda Equina Syndrome
Saddle anesthesia
Sphincter
dysfunction
Loss of sphincter
control
Major motor
weakness