Back Pain - Causes - 15 - 30
Back Pain - Causes - 30 - 50
degenerative joint disease,
Back Pain - Causes - >50
malignancy (lung, breast, prostate, thyroid, kidney), myeloma
cauda equina tumours,
Back Pain - Prevention of back pain
advice reposture, working environment, and lifting techniques;
correct uneven leg length of >2-3cm measured from pubis to medial malleolus.
GI - Back Pain - Red Flags
<20y. or >55y.
Past history of carcinoma
GI - Back Pain - Acute - Management
Explain the likely natural history - avoid bed rest
Don't X-ray routinely (unless < 25 or SI joints)
Consider referral for physiotherapy, chiropractic, or osteopathy
GI - Back Pain - Chronic - Management
Exclude spinal pathology and lesions amenable to surgery
Consider referral to a pain clinic.
Other approaches - back supports, heel raises, TENS
GI - Carpal Tunnel - Investigations
Phalen's test - hyperflexion of wrist for 1min. triggers symptoms
Tinnel's test - tapping over the carpal tunnel causes paraesthesiae
Nerve conduction studies
GI - Carpal Tunnel - Management
carpal tunnel steroid injection (p.192);
surgery to divide the flexor retinaculum is curative in mild/moderate disease
Hip Pain - Causes
Buttock pain - PMR, sacroilitis, vascular insufficiency, referred from back.
Groin pain - hip joint disease (OA, RA, Paget's, osteomalacia), fracture, osteitis pubis, hernia, psoas abscess.
Lateral thigh pain - trochanteric bursitis, referred pain from back, enthesitis (spondyloarthropathies), gluteus medius tear, meralgia paraesthetica, fascia lata syndrome.
OA of Hip -management
Analgesia (e.g. regular paracetamol, NSAIDs), education, weight â†", exercise, correction of unequal leg length. Walking stick Â± shock-absorbing shoe insoles can help. Consider referral for physiotherapy (muscle strengthening exercises may â†" pain) or to orthopaedics for consideration of hip resurfacing or replacement
Osteoporosis - Investigations
DEXA scan if <75y. Exclude other causes of pathological fracture (e.g. malignancy, osteomalacia, hyperparathyroidism). Check FBC, ESR, TSH, Cr, bone and liver function testsâ€"all should be normal. Consider checking serum paraproteins/urine Bence Jones protein, bone scan, and FSH/testosterone/LH (if hormonal status is unclear).
RA - Non articular features
Rheumatoid nodules (especially extensor surfaces of forearms).
Vasculitis - digital infarction, skin ulcers, mononeuritis.
Eye - SjÃ¶gren's syndrome, episcleritis, scleritits.
Lungs - pleural effusions, fibrosing alveolitis, nodules.
Heart - pericarditis, mitral valve disease, conduction defects.
Skin - palmar erythema, vasculitis, rashes.
Neurological - nerve entrapment e.g. Carpal tunnel, mononeuritis, and peripheral neuropathy.
RA, splenomegaly, and leucopenia.
persistent skin ulcers
Splenectomy may improve the neutropenia
HTN - Referral
Suspected 2Â° hypertensionâ€"S/R
Multiple risk factorsâ€"R
BP difficult to treatâ€"R
Pregnancyâ€"to obstetrician; urgency depends on stage of pregnancy and clinical features