COMMON REGIONAL MUSCULOSKELETAL PROBLEMS

Inflammatory arthritis or osteoarthritis causes pain in one or more joints. This section describes specific regional problems. The diagnosis of most of these conditions is usually clinical and initial treatment is with painkillers, e.g. paracetamol and NSAIDs. Physiotherapy and local steroid injections are used in some cases.

Pain in the neck and shoulder is often due to muscular spasm. There is unilateral or bilateral pain which may radiate upwards to the occiput and often is associated with tension headaches. Nerve root compression by cervical disc prolapse or spondylotic osteophytes causes unilateral neck pain radiating to interscapular and shoulder regions (see below). It is associated with pins and needles and neurological signs in the arms. Pain in the neck may also be caused by RA, ankylosing spondylitis or fibromyalgia (chronic widespread muscle pain often in young women with no underlying cause; large psychological overlay in some patients). Polymyalgia rheumatica (p. 307) causes pain and stiffness in the shoulder girdle.

Rotator cuff injury and inflammation is one of the most common causes of shoulder pain. The rotator cuff muscles (supraspinatus, infraspinatus, subscapularis, teres minor) are positioned around the shoulder joint and stabilize the joint and help with movement. The muscular tendons join to form the rotator cuff tendon which inserts into humerus. Rotator cuff tendinitis, impingement and tears cause shoulder pain with a painful arc (between 70 and 120°) on shoulder abduction in the former two and preven-tion of active abduction (in the first 90°) in the latter. Adhesive capsulitis (‘frozen' shoulder) causes severe shoulder pain with all movements. Ultra-sound examination is the best investigation to differentiate between these causes.

Elbow pain occurs due to inflammation of the insertion site of the wrist extensor tendon into the lateral epicondyle (tennis elbow) or wrist flexor tendon into the medial epicondyle (golfer's elbow). There is local tenderness and pain radiates into the forearm on using the affected muscles.

Hip problems Fracture of the femoral neck (pain in the hip, usually after a fall, leg shortened and externally rotated) or avascular necrosis of the femoral head (severe hip pain in a patient with risk factors, p. 314) will often be suspected from the history and examination. Pain over the trochanter which is worse going up stairs and when abducting the hip can be due to trochanteric bursitis or a tear of the gluteus medius tendon at its insertion into the trochanter. Magnetic resonance imaging (MRI) will differentiate the two. Meralgia paraesthetica (lateral cutaneous nerve of thigh compression) causes numbness and increased sensitivity to light touch over the antero-lateral thigh. It is usually self-limiting.

The knee is a frequent site of sports injuries leading to torn menisci and cruciate ligaments. These injuries may be associated with bleeding into the joint (haemarthrosis). The knee is also frequently involved in inflammatory arthritides, osteoarthritis and pseudogout. An associated effusion causes swelling, stiffness and pain with the ‘bulge sign' and ‘patellar tap' on exami-nation. In a few patients with an effusion there is a connection to a bursa, forming a cyst (Baker’s cyst) in the popliteal fossa. This may rupture (ruptured popliteal or Baker’s cyst) and the escape of fluid into the soft tissue of the popliteal fossa and upper calf causes sudden and severe pain, swelling and tenderness. It may be confused with a deep vein thrombosis (DVT) and is diagnosed on ultrasonography. Treatment is with analgesics, rest with the leg elevated and aspiration and injection of corticosteroids into the knee joint.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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