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The universal GP Training website for everyone, not just Bradford.   Created in 2002 by Dr Ramesh Mehay

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Musculoskeletal Medicine, Orthopaedics & Rheumatology

Bradford VTS Clinical Resources

  • by Dr Ramesh Mehay
  • Last modified: 30th January 2024
  • No Comments

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path: MSK, ORTHO & RHEUM

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Information provided on this medical website is intended for educational purposes only and may contain errors or inaccuracies. We do not assume responsibility for any actions taken based on the information presented here. Users are strongly advised to consult reliable medical sources and healthcare professionals for accurate and personalised guidance – especially with protocols, guidelines and doses. 

COME AND WORK WITH ME… If you’d like to contribute or enhance this resource, simply send an email to  rameshmehay@googlemail.co.uk. We welcome collaboration to improve GP training on the UK’s leading website, Bradford VTS. If you’re interested in a more active role with www.bradfordvts.co.uk (and get your name published), please feel free to reach out. We love hearing from people who want to give.

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Knee Pain at a Glance

HISTORY TAKING TIPS

  • 3 Important things
      1. Injury – especially if twisting involved – high chance of damage (go into mechanism of the injury)
      2. Swelling – was it immediate or after 24 h, or more gradual than that?  (immediate/within 24h = worrying)
      3. Pain – going up stairs, downstairs, extending the knee, bending the knee
  • xx

 

EXAMINATION TIPS

  • Feel for joint line tenderness – easy thing to do – indicated knee damage
  • Knee Popping When Extending: Knee popping when you straighten your knee is usually due to gas bubbles (not usually painful), plica syndrome or patellofemoral pain syndrome.
  • Knee Popping and Pain When Bending: If you get knee popping and pain when bending your knee e.g. squatting down, it is most likely due to a problem with the knee cartilage such as a meniscus tear or chondromalacia patella.
  • Knee Popping When Extending And Bending: If you get knee pain and popping with both knee flexion and extension, it is likely that there is damage to the joint surface such as cartilage damage or knee arthritis. If there is no pain, it is likely to be gas bubbles popping.
  • Knee Popping With Twisting: Sudden knee pain and popping when you twist is usually doe to a knee ligament injury, most often an ACL injury and/or MCL tear. If the knee swells up or feels unstable after hearing a pop as you twisted, seek medical attention immediately.
  • Knee Popping When Walking: Almost all the possible causes of knee popping that we’ve looked at here can cause knee pain and popping when walking, be it arthritis, runners knee, cartilage tear or ligament injury. There will usually be other symptoms associated here that will lead to a clearer knee pain diagnosis.
  • Knee Popping No Pain: If there is no pain with your knee popping, chances are it is a simple case of gas bubbles bursting inside the joint which is completely harmless. Keeping active and strengthening the knee muscles can sometimes help to reduce the frequency of knee popping.
  • Sudden onset of swelling within 24h – send to A&E – haemarthrosis?
  • Warm, red, tender knee – inflammatory or infective?   Septic arthritis (infective) is serious – needs immediate admission.   Is the patient pyrexial?  Any overt injury marks to knee?

Back Pain at a Glance

HISTORY TAKING TIPS

Categorise back pain into four groups based on history: non-specific low back pain, radicular symptoms, inflammatory back pain, red flags (trauma, tumour, infection, cauda equina). This will help guide management in primary care and onward referral.

Exclude red flags: more than just cauda equina syndrome. Also think TTI – trauma, tumour, and infection (remember TB).

    • Cauda equina things
        1. Sciatica on both sides,
        2. Weakness or numbness in both legs that is severe or getting worse,
        3. Numbness around or under your genitals, or around your anus,
        4. Finding it hard to start peeing, can’t pee or can’t control when you pee – and this isn’t normal for you
        5. You don’t notice when you need to poo or can’t control when you poo – and this isn’t normal for you
    • TTI things
        • Trauma (may be minimal in osteoporotic wedge fracture).
        • Tumour – ask about history of malignancy, weight loss
        • Infection – fevers, systemic upset, weight loss and night sweats. 

EXAMINATION TIPS

  • Special Tests:
  • straight leg raise test for sciatica
  • FABER test (Flexion, ABduction, and External Rotation) for sacroiliac joint dysfunction
  • Schober’s test for ankylosing spondylitis (see ank spond section

*DE-MEDICALISE*

**DON’T CALL IT ARTHRITIS **

  • Most patients presenting in primary care will have non-specific low back pain and can be reassured there is no serious spinal pathology. Pain is frequently isolated to the lower back. Often there is a
    prior history of similar self-limiting episodes.
  • Expect to settle spontaneously over WEEKS not days. Give realistic timeframes for recovery.   
  • Do not do imaging like x-rays or MRIs. 
  • Analgesia  – do not use strong opiates/opioids, neuropathic agents or benzodiazepines.
  • Instead, advise patients to start self-directed physiotherapy as the acute pain settles. Obesity and inactivity are frequently the elephant in the room and should be clearly addressed. Do not image.
  • Urgent action is required if serious spinal pathology is suspected – do not refer to an MSK service.
  • Nature of urgent action depends on suspected pathology.   Cauda equina – speak to on-call neurology urgently. 

Sciatica

    • Usually presents acutely with low back pain radiating (most commonly unilaterally) into the leg.
    • Lower lumbar segments most commonly affected hence neuropathic symptoms are frequently (but not exclusively) below knee (don’t get confused with radiated pain).
    • Cause is commonly a herniated lumbar disc impinging on lumbosacral nerves, but tumour and abscess can also cause nerve impingement so ALWAYS SCREEN FOR RED FLAGS.

Sciatica Management – for those with radicular symptoms

  • Most cases will settle spontaneously in 2-3 months – reassure and refer to physio.
  • Do not use strong opiates/opioids, gabapentinoids or benzodiazepines. Do not do imaging like x-rays or MRIs.
  • Obesity and inactivity are frequently the elephant in the room and should be addressed.
  • Refer cases that haven’t resolved by 2-3 months to an MSK service.
  • Document you have screened for and discussed emergency action in case of cauda equina syndrome
  • CONSIDER IT > EXAMINE IT > RECORD IT (reduce your chance of a claim)

Inflammatory Back Pain

    • Less common presentation in primary care.  Usually lumbar pain and prolonged (>30mins) morning stiffness. Pain often wakes patient in the second half of the night. Pain gets better with activity and NSAIDs. Can alternate from buttock to buttock. Younger age of onset (<35) usually.
    • Check family history for others with IBP.
    • Screen for associated conditions (uveitis, enthesitis, psoriasis, inflammatory bowel disease, history of peripheral joint inflammation, recent gastrointestinal or genitourinary infection).
    • Absence of sacroiliitis on plain film xray does not exclude the diagnosis. Refer rheumatology if suspected IBP.

Ankylosing spondylitis can lead to a decrease in spinal mobility, particularly in the sagittal plane (forward and backward movement). Over time, this can result in a characteristic stooped posture due to spinal fusion. Schober’s test is designed to measure the range of motion of the lumbar spine as a means to assess for this decreased flexibility.

It’s important to note that Schober’s test is just one part of a comprehensive clinical evaluation for ankylosing spondylitis. The diagnosis of AS typically involves a combination of clinical assessment, imaging studies (like X-rays or MRI), and laboratory tests. Reduced spinal mobility as detected by Schober’s test can also be seen in other conditions, so it’s not specific to AS. Nevertheless, it’s a valuable tool for monitoring disease progression and response to treatment in patients with known AS.

Schober’s Test

Here’s how Schober’s test is typically performed:

  1. Initial Marking: With the patient standing upright, a mark is made over the lumbar spine at the level of the fifth lumbar vertebra (L5), which is usually in line with the top of the iliac crests (hip bones).

  2. Second Marking: A second mark is made 10 cm above the first mark along the spine.

  3. Patient Flexion: The patient is then asked to bend forward as far as possible without bending their knees.

  4. Measurement: The distance between the two marks is measured again while the patient is in maximum forward flexion.

  5. Interpreting Results: In a normal spine, the distance between these two points should increase by at least 5 cm upon flexion. An increase of less than 5 cm indicates reduced lumbar spine flexibility, which is a common finding in patients with ankylosing spondylitis.

It’s important to note that Schober’s test is just one part of a comprehensive clinical evaluation for ankylosing spondylitis. The diagnosis of AS typically involves a combination of clinical assessment, imaging studies (like X-rays or MRI), and laboratory tests. Reduced spinal mobility as detected by Schober’s test can also be seen in other conditions, so it’s not specific to AS. Nevertheless, it’s a valuable tool for monitoring disease progression and response to treatment in patients with known AS.

Rheumatological problems at a Glance

Giant cell arteritis is a medical emergency, because prompt identification can prevent sight loss. Patients are sick and require long-term, high-dose oral steroids, a treatment that is not without risks of its own.  It is therefore important to have a high index of suspicion.

  • If you think GCA is highly probablye, you should take bloods that same day, start steroids and pick up the phone to speak to a rheumatologist.
  • If there is visual disturbance, you should arrange IMMEDIATE ophthalmology assessment.
  • If you think GCA is one of a number of possibilities, we should still pick up the phone and speak to rheumatology to agree a plan for further investigation and whether to start steroids.
  • GCA patients will end up on high doses of steroids
      • They need regular shared care follow-up to monitor comorbidities, e.g. hypertension, diabetes, and for side-effects.
      • All will need a steroid treatment and a steroid emergency card.
      • Nearly all will need bone and gastro-protection.

Smythe’s points, often referred to in the context of fibromyalgia, are actually a misnomer. The correct term is “tender points,” and these are specific areas on the body that are used to diagnose fibromyalgia. The term is frequently confused with “trigger points” used in myofascial pain syndrome, which is a different condition.

In the diagnosis of fibromyalgia, doctors use a set of criteria established by the American College of Rheumatology (ACR). Originally in 1990, the ACR specified 18 tender points. These points are symmetrically distributed across the body and are considered positive if pain is felt when firm pressure is applied. According to the original criteria, a patient needed to have pain in at least 11 of these 18 points to be diagnosed with fibromyalgia.

However, it’s important to note that the diagnostic criteria for fibromyalgia have evolved over time. In 2010, the ACR moved away from the exclusive focus on tender points. The newer criteria consider a wider range of symptoms, including widespread pain index (WPI) and symptom severity scale (SSS). This change reflects a broader understanding of fibromyalgia as not just a condition of localized pain but a more complex syndrome involving symptoms like fatigue, sleep disturbances, cognitive difficulties, and other somatic symptoms.

The shift in diagnostic criteria is significant because it acknowledges the variability in how fibromyalgia presents and affects individuals. Tender points, while still a tool in understanding the condition, are no longer the sole focus in diagnosing fibromyalgia.

Ramadan & Fasting Advice for Rheumatological Disease

Fasting is an obligation for competent, healthy adult Muslims although there are exemptions. Many of those who could seek exemption might still want to fast. It is important to respect this but it is advisable to start planning 6-8 weeks before Ramadan to avoid adverse outcomes e.g. patient self-adjustment of medication.

The fast of Ramadan lasts from dawn to sunset for a period of 29 or 30 days. It follows the lunar calendar so is brought forward by about 10 days each year.   Fasting people generally eat two meals a day: often a smaller meal before dawn (Suhoor) and a larger one after sunset (Iftar).  No fluids or food are taken during daylight hours. This includes water and most medication.

Who is exempt from fasting?

  • Acute or chronic illness
  • Travellers
  • Pregnant/breastfeeding*
  • Menstruating/postpartum bleeding
  • Children
  • Mentally unwell/lacks capacity

*Consensus by Islamic scholars that it is permissible not to fast if there is threat of harm to mother/child

Permissible interventions/medications

  • Blood tests
  • Vaccinations
  • Asthma inhalers*
  • Ear drops*
  • Eye drops
  • Transdermal patches

*Difference of opinions exist. Encourage patients to contact their local imam, or BIMA for advice.

Should I advise my patient NOT to fast?

BIMA have an interactive traffic light tool that help to classify patients into low/moderate risk, high risk, and very high risk at 

Patients in the two higher tiers should be advised that they ‘must not fast’ and ‘should not fast’ respectively. Consider advising these patients to fast in the shorter winter months. If they insist to fast, monitor regularly and ask that they should be prepared to break the fast in case of adverse events. Below is a shortened summary of the advice:

MUST NOT FAST
V. HIGH RISK

  • Active SLE with renal involvement

SHOULD NOT FAST
HIGH RISK

  • Uncontrolled gout
  • Steroids >20mg a day

INDIVIDUAL DECISION - WHAT IS THEIR ABILITY TO TOLERATE IT - LOW RISK

  • Controlled gout
  • Steroids <20mg a day

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How IT ALL STARTED
WHAT WE'RE ABOUT
WHO ARE WE FOR?

Bradford VTS was created by Dr. Ramesh Mehay, a Programme Director for Bradford GP Training Scheme back in 2001. Over the years, it has seen many permutations.  At the time, there were very few resources for GP trainees and their trainers so Bradford decided to create one FOR EVERYONE. 

So, we see Bradford VTS as  the INDEPENDENT vocational training scheme website providing a wealth of free medical resources for GP trainees, their trainers and TPDs everywhere and anywhere.  We also welcome other health professionals – as we know the site is used by both those qualified and in training – such as Associate Physicians, ANPs, Medical & Nursing Students. 

Our fundamental belief is to openly and freely share knowledge to help learn and develop with each other.  Feel free to use the information – as long as it is not for a commercial purpose.   

We have a wealth of downloadable resources and we also welcome copyright-free educational material from all our users to help build our rich resource (send to bradfordvts@gmail.com).

Our sections on (medical) COMMUNICATION SKILLS and (medical) TEACHING & LEARNING are perhaps the best and most comprehensive on the world wide web (see white-on-black menu header section on the homepage).

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