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Describe three features of mechanical back pain?
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Describe three features of mechanical back pain?
• Typically results from abnormal strain being placed on the supporting structures of the spine including vertebral joints (e.g. ZA joints), discs, muscles and ligaments.
• Varies with time and activity
• Is rarely constant or severe at rest or nocturnally and
• The person is well with no red flags. (Definition NHS review, Prof Gordon Wardell).
• It is usually a deep ache of variable severity that can grab with movement.
• Often improves with therapy i.e. drug/medication and physical therapy.
• Mechanical or somatic pain (not simple or nonspecific pain) 85-90% of presentations
Describe three features of disc or radicular back pain?
• Varies less with time and activity compared to mechanical back pain
• Tends to be more constant, severe at rest and nocturnally.
• Radicular pain may be associated with limb numbness, paraesthesia and positive neurological findings.
• The pain is usually a burning or stabbing pain and has poor response to simple drug therapy and physical therapy. 5% of presentations are radicular. Incidence of discogenic pain is unclear.
• Discogenic = arising from damaged/ degenerative intervertebral discs without nerve root involvement, back pain with no leg pain.
• Radicular = disc injury with prolapse or marked inflammatory response causing pressure on nerve root, leg pain +/- back pain (e.g. sciatica, foraminal stenosis, spinal stenosis.)
What vertebral level usually is at:
• Base of skull - C2
• Vertebrae prominens - C7 (It is the vertebra to become most prominent with flexion.
• N.B. that C6 vertebra disappears with extension but C7 remains palpable.)
• Inferior angle of scapula - T7 but varies with scapula movt
• Line of iliac crests - L4-5
• Line of posterior superior iliac spines - S2
What are four red flag symptoms in the musculoskeletal history?
• >50 yrs old and <20 years old
• History of Osteoporosis (fracture with minimal trauma)
• Trauma significant for age (minor in elderly, severe in young)
• History of malignancy (possible metastatic bone pain)
• Pain that is constant and night pain severe enough to significantly disturb sleep
ddf
• Use of intravenous (IV) drugs
• Immunocompromised patient and steroid use
• Neurological compromise involving more than 1 level (e.g. MS)
• Constitutional symptoms: night sweats, associated fever (e.g. septic joint, myeloma, osteomyelitis, spinal abscess), unintentional weight loss.
• Red, hot, painful, swollen joint with very limited ROM - think septic arthritis or acute inflammatory arthropathy.
Name two possible sources of referred knee pain?
• Knee pain can be referred from the spine e.g. disc prolapse with a radiculopathy.
• Hip pathology can refer pain to the knee and may or may not have anterolateral hip and groin pain as well.
Describe Ege's test and explain which meniscus is being tested with the hips in external rotation and internal rotation.
• Squatting with the feet turned outward (hips in External Rotation) tests the medial meniscus and feet turned inwards (hips in Internal Rotation) tests the lateral meniscus. Ensure adequate exposure from quadriceps to bare feet (no shoes/ socks)
• Ask the patient if there was any pain and where it was located
• An easy way to remember this is that the feet point AWAY from the meniscus being tested
e.g. when the feet are pointed laterally (in external rotation) the medial meniscus in the one being tested.
Does the patella usually dislocate medially or laterally?
Lateral dislocation is much more common than medial dislocation of the patella.
Why should you check for Sag Sign at the knee before doing the Anterior Drawer and Lachman's test?
If Sag Sign is positive, you will see that the tibial plateau on the affected side sags when the knee is flexed at 90 degrees, suggesting that the posterior cruciate ligament (PCL) is ruptured. As the tibia is posteriorly subluxed it may produce a false positive Anterior Draw or Lachman's test.
Why is the Anterior Drawer test not very useful in the acute setting? Which other test can assess the anterior cruciate ligament (ACL) and why might it be more useful in the acute context?
• In an acute injury, the Anterior Drawer test has low sensitivity and specificity probably due to effusion, pain and secondary muscle spasm, especially of hamstrings, and inability to draw an already tight knee due to haemarthrosis.
• Lachman's Test, like the Anterior Drawer test, assesses the ACL. The knee is held at 20-30 degrees flexion, which reduces any tension along the line of the tibial plateau, by having the hamstring tendons nearly perpendicular to the direction of movement and with minimal flexion is not affected as much by haemarthrosis as in the Anterior Draw test. The tibia is again drawn forward in the line of joint. This is the most accurate test for ACL injury in acute or chronic cases.
Explain the difference between the terms valgus and varus deformity at the knee andgive a clinical example.
• A valgus deformity is a condition in which the bone segment distal to a joint is angled outward (or laterally) away from the midline. An example at the knee would be genu valgum or "knock-knee".
• A varus deformity is a condition in which the bone segment distal to a joint is angled inwards (or medially) towards the midline. An example at the knee would be genu varus or "bow-legged'.
• A useful way to remember this is vaLgus - segment distal to the joint moves Lateral to the midline (note the L).
What would indicate a "positive" McMurray's test? What is McMurray's testing for?• Any "pop", "click" or pain under the finger on the joint line while straightening the leg during the McMurray's test. • McMurray's Test is looking for problems with the medial or the lateral meniscus.Where does pain from the glenohumeral joint tend to refer?• Pain from the glenohumeral joint tends to refer to the deltoid or biceps area and occasionally the posterior shoulder. Pain in trapezius/ proximal shoulder may be from cervical spine. • Shoulder pain rarely goes below the elbow or to the neck. This suggests radicular causes from cervical spine.Which shoulder pathologies are expected if there is pain in the 60-120 degree range of abduction? What about if the pain occurred in abduction beyond 120 degrees?• Watch for painful arc (60‐120 degrees), suggesting supraspinatus tendinitis and/or impingement syndrome (Subacromial Pain Syndrome) • Watch for pain above 120 degrees, suggesting acromioclavicular pathology or referred cervicothoracic pain.What can cause winging of the scapula?• This is caused by pathology of the Serratus Anterior Muscle, which is supplied by the Long Thoracic Nerve (of Bell) - C5, C6 +/- C7. This nerve has a superficial course and is particularly susceptible to sport-related trauma to the ribs, below an outstretched arm.If both active and passive abduction are restricted what kind of pathology might this suggest?This might indicate glenohumeral (intra-articular) pathology, such as adhesive capsulitis, severe osteoarthritis, or rheumatoid arthritis.For the Empty Can Test and the Full Can Test how much abduction and forward flexion should the arms be in?The patients' arm should be in 90 degrees of abduction and 30 degrees of forward flexion.What is the main rotator cuff muscle being tested by the abduction strength testing (i.e. the full and empty can tests?) Is this the only muscle being activated?• Generally, we think of these tests assessing mainly supraspinatus, BUT It is difficult for any test to "isolate" supraspinatus.What rotator cuff muscles does the External Rotation Strength Testing primarily assess?• Infraspinatus and Teres Minor.What rotator cuff muscle does the Gerber's Test (Lift-Off Test) assess?• Subscapularis as this test assesses internal rotation strength.What two tests are used for impingement testing?• Neer's test • Hawkins-Kennedy TestWhat direction should the palm be facing for Neer's test?• The palm should be facing down (pronation)In Hawkins-Kennedy Test how much passive internal rotation do you expect? If you go beyond this range how do most patients try to compensate for this?You would normally only expect 20-30 degrees of internal rotation at the shoulder and if you force it further the patient is likely to try to compensate by raising the shoulder up.What two tests assess the biceps tendon?• Speed's test • Resisted elbow flexion testIn Speed's Test where must the pain be located for it to be a positive test result?In the bicipital groove.If there has been a rupture of the long head of the biceps tendon, what will you notice in the Resisted Elbow Flexion Test?A muscle "lump" will appear over the anterior humerus (a "Popeye" bulge).What internal organs might be the cause of back pain and give some examples of conditions that might present this way?Dissecting Aortic Aneurysm, pancreatic inflammation and malignancy, posterior perforating duodenal ulcer, renal calculi, pyelonephritis, pelvic pathology.What are you looking for in forward flexion to assess for scoliosis?Scoliosis can give an uneven height in the left and right hemi thoraces (the domes of each half of the thorax).Why do we ask the patient to sit on the bed when we assess rotation of the spine?To keep the hips in a fixed position so they don't contribute to the rotational movement.What is the Femoral Nerve Stretch Test Testing for? What nerve root level is the Femoral nerve and where would the patient feel pain if the Femoral Nerve Stretch Test is positive?• It tests for impingement of the Femoral Nerve. Impingement of this nerve is likely to be caused by intervertebral disc prolapse at L2-L3 or L3-L4, and less likely L4-L5. • Reproduction of the patient's neuropathic pain (qualities include "burning, shooting, tingling, numbness, electricity") in the anterior thigh is positive for Femoral Nerve Stretch.What does the Straight Leg Raise (SLR) test assess for? What nerve root level is the Sciatic nerve and where would the patient feel pain if the SLR Test is positive?• SLR test for impingement of the Sciatic Nerve. Impingement of this nerve is likely to be caused by intervertebral disc prolapse at L5 or S1. • Reproduction of the patient's neuropathic pain in the back of the leg, not the back (qualities include "burning, shooting, tingling, numbness, electricity") is positive.With the Fabre Test, if the patient describes the pain posteriorly what is the likely origin of the pain? What if they describe anterior pain?• Posterior pain suggests sacroiliac or lumbar origin. • Anterior pain: suggests joint pathology e.g. arthropathy, labral tears, loose body or femoroacetabular impingement. It can also be positive in iliopsoas tendonitis/bursitis