Show Summary Details
Page of

Joint, limb, and back symptoms and physical signs 

Joint, limb, and back symptoms and physical signs
Chapter:
Joint, limb, and back symptoms and physical signs
Author(s):

Huw Llewelyn

, Hock Aun Ang

, Keir Lewis

, and Anees Al-Abdullah

DOI:
10.1093/med/9780199679867.003.0009
Page of

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy).

Subscriber: null; date: 21 October 2017

Muscle stiffness or pain

Usually worse in the early morning, often with pain and stiffness. Initial investigations (others in bold below): FBC, ESR, or CRP.

Main differential diagnoses and typical outline evidence, etc.

Normal response to strenuous exercise

  • Suggested by: fit, healthy, unaccustomed exercise 1–2d before.

  • Confirmed by: spontaneous resolution.

  • Finalized by the predictable outcome of management, e.g. rest improves symptoms.

Polymyalgia rheumatica

  • Suggested by: abrupt onset of symptoms, severe morning stiffness and limb girdle pain, tender proximal muscles. Fatigue, night sweats, and fever in elderly person.

  • Confirmed by:↑↑ESR and CRP, ↓Hb, rheumatoid factor –ve, prompt response to prednisolone, no other cause (e.g. infection on follow-up).

  • Finalized by the predictable outcome of management, e.g. NSAIDs if not contraindicated, analgesics, advise exercises, low dose prednisolone, e.g. 20–30mg daily—reduced gradually over a period of weeks or months. Can resolve spontaneously, even without treatment.

Rheumatoid arthritis

  • Suggested by: early morning stiffness, fatigue, and joint pain, and swelling. Fingers showing ‘swan neck’ or ‘boutonnière’ deformities. Thumbs show Z-deformities. Metacarpophalangeal (MCP) joints and wrists—subluxed giving ulnar deviation. Knees—valgus or varus deformity and popliteal ‘Baker’s’ cysts. Feet—subluxation of metatarsal heads with hallux valgus, clawed toes.

  • Confirmed by: rheumatoid factor +ve, anti-IgG auto-antibody, cryoglobulins. FBC: normochromic anaemia, ↑ESR and ↑CRP when active.

  • Finalized by the predictable outcome of management, e.g. supportive physiotherapy and occupational therapy, NSAIDs with gastric protection, analgesics. Disease-modifying drugs, e.g. methotrexate. Immunotherapy, e.g. infliximab.

Ankylosing spondylitis

  • Suggested by: onset over months or years. Spinal pain and stiffness with progressive loss of spinal movement. Kyphosis and spinal extension.

  • Confirmed by: ‘bamboo’ spine on back X-ray and loss of sacroileal joint space. Rheumatoid factor –ve, HLA-B27 +ve. ↑IgA.

  • Finalized by the predictable outcome of management, e.g. exercise, physiotherapy, NSAIDs, and analgesics. Dramatic response to immunotherapy using anti-tumour necrosis factor (TNF) drugs, e.g. infliximab.

1° muscle disease

  • Suggested by: onset over weeks to years. Predominant weakness of proximal muscles mainly, seasonal variation of symptoms ± symptoms of an associated malignancy.

  • Confirmed by:CPK, electromyography (EMG), MRI scan, and muscle biopsy.

  • Finalized by the predictable outcome of management, e.g. possible diagnosis of an underlying malignancy. Physiotherapy, high-dose steroids, immunosuppressants, e.g. methotrexate.

1° hypothyroidism

  • Suggested by: onset over weeks to months. Predominant fatigue. Also cold intolerance, depression.

  • Confirmed by:TSH, ↓FT4.

  • Finalized by the predictable outcome of management, e.g. thyroid replacement treatment.

Early manifestation of occult malignancy

  • Suggested by: onset over weeks or months. Weight loss, anorexia.

  • Confirmed by: subsequent appearance of malignancy, especially spinal 2° deposits.

Fibromyalgia

  • Suggested by: variable onset—weeks to years. Fatigue, diffuse pain, muscles stiffness, and tender points, but no features of specific diagnosis.

  • Confirmed by: no ‘subsequent’ development of features of another diagnosis, normal ESR, rheumatoid factor –ve, CPK normal, TSH and FT4 normal.

  • Finalized by the predictable outcome of management, e.g. education and reassurance, exercise, relaxation techniques, tricyclic antidepressants (e.g. amitriptyline), selective serotonin reuptake inhibitors—SSRIs (e.g. fluoxetine), muscle relaxants (e.g. tizanidine).

Monoarthritis

One joint affected by pain, swelling, overlying erythema, stiffness, and local heat (± fever). Initial investigations (others in bold below): FBC, ESR or CRP, rheumatoid factor.

Main differential diagnoses and typical outline evidence, etc.

Acute septic arthritis

  • Suggested by: extremely painful, red hot joint, high fever.

  • Confirmed by:↑↑WCC. Joint aspiration: synovial fluid turbid. Culture growing Staphylococcus or Streptococcus or Pseudomonas or gonococci or TB, etc.

  • Finalized by the predictable outcome of management, e.g. aspiration of joint, culture, and sensitivity, analgesics, NSAIDs, antimicrobial according to culture and sensitivity results, urgent orthopaedic referral for possible washout.

Gout

  • Suggested by: one acutely inflamed joint (usually small, esp. big toe) at a time, but other joints in hands, arms, legs, and feet deformed. Tophi on ears and tendon sheaths.

  • Confirmed by:serum urate (not always). Urate crystals (negatively birefringent in plane-polarized light) present on joint aspiration. X-rays show damage to cartilage and bones.

  • Finalized by the predictable outcome of management, e.g. appropriate diet, avoid food high in purines, plenty of fluids, reduce alcohol consumption, lose weight, analgesics, NSAIDs, colchicine. Allopurinol to prevent future attacks.

Pseudogout (Ca2+ pyrophosphate arthropathy/chondrocalcinosis) hyperparathyroidism, myxoedema, osteoarthritis, dialysis or trauma, haemochromatosis, acromegaly

  • Suggested by: one painful joint (usually knee), especially in elderly or history of associated condition. Occasionally, family history of the condition.

  • Confirmed by: X-rays of joint show chondrocalcinosis. Joint aspiration: synovial calcium pyrophosphate crystal deposits, positively birefringent in plane-polarized light.

  • Finalized by the predictable outcome of management, e.g. joint aspiration to ease pain, analgesics, NSAIDs, intra-articular joint injection, colchicine, and in severe cases, systemic steroids.

Reiter’s disease

  • Suggested by: monoarthritis, urethritis, conjunctivitis—especially in a young man—or a history of diarrhoea (dysentery). Also suggested by associated iritis, keratoderma blenorrhagica (brown, aseptic abscesses on soles and palms), mouth ulcers, circinate balanitis (painless, serpiginous penile rash), plantar fasciitis, Achilles’ tendonitis, and aortic incompetence.

  • Confirmed by: rheumatoid factor –ve (i e. ‘seronegative’), ↑ESR, +ve culture for Chlamydia. X-rays show spondylitis and sacroiliitis. Urinalysis: first glass of a 2-glass urine test shows debris in urethritis.

  • Finalized by the predictable outcome of management, e.g. bed rest, exercise, analgesics, NSAIDs, local intra-articular steroid injections, antibiotics for proved infections, e.g. Chlamydia. Immunosuppression in severe cases.

Psoriasis

  • Suggested by: acutely inflamed terminal interphalangeal (IP) joint, but other joints deformed, especially terminal IP joints, and pitting and thickening of fingernails.

  • Confirmed by: psoriatic plaques on elbows and extensor surfaces of limbs, scalp, behind ears, and around navel. Rheumatoid factor –ve (i.e. ‘seronegative’).

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, and in intractable cases, immunosuppressants, e.g. methotrexate.

Rheumatoid arthritis

  • Suggested by: early morning stiffness. Fingers: ‘swan neck’ or ‘boutonnière’ deformities. Thumbs have Z-deformities. MCP joints and wrists: subluxation acquiring ulnar deviation. Knees: valgus or varus deformity and popliteal ‘Baker’s’ cysts. Feet: subluxation of metatarsal heads with hallux valgus, clawed toes, and calluses.

  • Confirmed by: rheumatoid factor +ve (i. e. ‘seropositive’), ↑anti-IgG autoantibody. FBC: normochromic anaemia, ↑ESR when active.

  • Finalized by the predictable outcome of management, e.g. supportive physiotherapy and occupational therapy, NSAIDs with stomach protection, analgesics. Disease-modifying drugs, e.g. methotrexate. Immunotherapy, e.g. infliximab.

Traumatic haemarthrosis

  • Suggested by: acutely inflamed joint after trauma.

  • Confirmed by: joint aspiration: aspiration of blood from joint.

  • Finalized by the predictable outcome of management, e.g. analgesia ± joint aspiration.

Leukaemic joint deposits

  • Suggested by: acutely inflamed joint.

  • Confirmed by: leukaemic picture on peripheral film and bone marrow.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, and treatment of the original problem.

Reactive arthritis (aseptic) due to venereal or enteric infection, Yersinia, Chlamydia trachomatis, Campylobacter, Salmonella/Shigella, and Chlamydia pneumoniae, HIV, Vibrio parahaemolyticus, Borrelia burgdorferi, Clostridium difficile

  • Suggested by: asymmetric mono- or oligoarthritis developing about 1wk after infection elsewhere. Previous history of food poisoning or another intestinal illness.

  • Confirmed by: ↑ESR, HLA-B27 +ve, microbiological investigations.

  • Finalized by the predictable outcome of management, e.g. heat–cold application for temporary easing of pain, analgesics, NSAIDs, appropriate antibiotics, exercise, and in severe cases, DMARDs.

Polyarthritis

Several joints affected by pain, swelling, overlying redness, stiffness, and local heat (± fever). Initial investigations (others in bold below): FBC, ESR or CRP, rheumatoid factor.

Main differential diagnoses and typical outline evidence, etc.

Viruses

  • Suggested by: several acutely inflamed joints. History of recent rubella or mumps or hepatitis A or Epstein–Barr viral infection or Parvovirus B19 infection, etc.

  • Confirmed by:viral titres, rheumatoid factor –ve (‘seronegative’).

  • Finalized by the predictable outcome of management, e.g. analgesia and reassurance.

Rheumatoid arthritis

  • Suggested by: history of early morning stiffness. Fingers: ‘swan neck’ or ‘boutonnière’ deformities. Thumbs have Z-deformities. MCP joints and wrists: subluxation acquiring ulnar deviation. Knees: valgus or varus deformity and popliteal ‘Baker’s’ cysts. Feet: subluxation of metatarsal heads with hallux valgus, clawed toes, and calluses.

  • Confirmed by: rheumatoid factor +ve, ↑anti-IgG autoantibody. ↑ESR when active.

  • Finalized by the predictable outcome of management, e.g. supportive physiotherapy and occupational therapy, NSAIDs with stomach protection, analgesics. DMARDs, e.g. methotrexate. Immunotherapy, e.g. infliximab.

Sjögren’s syndrome associated diabetes mellitus, hypothyroidism

  • Suggested by: several acutely inflamed joints and diminished lacrimation, causing dry eyes and dry mouth. Enlarged salivary glands.

  • Confirmed by: Schirmer’s test +ve (ability to wet a small test strip put under the eye), rheumatoid factor +ve, and anti-Ro (SS-A) and anti-La (SS-B) antibodies present. Salivary gland biopsy.

  • Finalized by the predictable outcome of management, e.g. symptomatic. For dry eyes, artificial tears, eye lubricants, or ciclosporin eye drops. For dry mouth, artificial saliva, lemon drops, and salivary gland stimulants, e.g. pilocarpine—if not contraindicated ± hydroxychloroquine. For severe cases with vasculitis, immunosuppressants, e.g. prednisolone or azathioprine.

Rheumatic fever (reactive arthritis to earlier infection with Lancefield Group A β- haemolytic streptococci)

  • Suggested by: flitting polyarthritis (a major ‘Jones criterion’).

  • Confirmed by: evidence of recent streptococcal infection plus 1 more major revised Jones criterion or 2 more minor criteria. Evidence of streptococcal infection = scarlet fever or positive throat swab or increase in ASOT >200 or ↑DNase B titre. (Major criteria = carditis or flitting polyarthritis or subcutaneous nodules or erythema marginatum or Sydenham’s chorea. Minor criteria = fever or ↑ESR/CRP, arthralgia (but not if arthritis is one of the major criteria), prolonged PR interval on ECG (but not if carditis is a major criterion), previous rheumatic fever.) Rheumatoid factor –ve.

  • Finalized by the predictable outcome of management, e.g. bed rest, penicillin to eradicate streptococcal infection, NSAIDs. Treat chorea with benzodiazepines or haloperidol.

Systemic lupus erythematosus

  • Suggested by: polyarthritis with periarticular and tendon involvement, muscle pain, proximal myopathy.

  • Confirmed by:↑↑double-stranded DNA antibodies titre. ANA +ve and rheumatoid factor +ve.

  • Initial management: analgesics and NSAIDs, sunscreens to protect skin, oral steroids for acute exacerbations, hydroxychloroquine to improve joint and skin symptoms, immunosuppressants, e.g. methotrexate, for resistant cases.

Ulcerative colitis

  • Suggested by: large joint polyarthritis, sacroiliitis, ankylosing spondylitis, background of gradual onset of diarrhoea with blood and mucus, and crampy abdominal discomfort.

  • Confirmed by: rheumatoid factor –ve. FBC: ↓Hb and ↑ESR. Inflamed, friable mucosa on sigmoidoscopy and biopsy shows inflammatory infiltrate, goblet cell depletion, etc.

  • Finalized by the predictable outcome of management, e.g. analgesics and antidiarrhoeic agents, topical anti-inflammatory agents (e.g. mesalazine), systemic anti-inflammatory agents (e.g. oral steroids), and immunosuppressants (e.g. azathioprine and methotrexate) for the more severe cases. Surgical intervention after many years when risk of colon cancer increases.

Crohn’s disease

  • Suggested by: large joint polyarthritis, sacroiliitis, ankylosing spondylitis, background of gradual onset of diarrhoea, abdominal pain, weight loss.

  • Confirmed by: rheumatoid factor –ve. Contrast studies showing ileal strictures, proximal dilatation, inflammatory mass or fistula, e.g. barium enema: ‘cobblestoning’, ‘rose thorn’ ulcers, colonic strictures with rectal sparing.

  • Finalized by the predictable outcome of management, e.g. advise healthy, balanced and high-fibre content diet. Analgesics and antidiarrhoeic agents, oral anti-inflammatory agents (e.g. mesalazine, oral prednisolone) or immunosuppressants (e.g. azathioprine) in more severe cases. Surgical intervention for intractable symptoms not controlled medically.

Drug reaction

  • Suggested by: several acutely inflamed joints. History of suspicious drug.

  • Confirmed by: rheumatoid factor –ve and improvement on withdrawing drug.

  • Finalized by the predictable outcome of management, e.g. withdrawing suspect drug(s).

Reiter’s syndrome

  • Suggested by: polyarthritis, urethritis, conjunctivitis—especially in a young man—or a history of diarrhoea (dysentery). Also suggested by associated iritis, keratoderma blenorrhagica (brown, aseptic abscesses on soles and palms), mouth ulcers, circinate balanitis (painless, serpiginous penile rash), plantar fasciitis, Achilles’ tendonitis, and aortic incompetence.

  • Confirmed by: rheumatoid factor –ve. Urinalysis: first glass of a 2-glass urine test shows debris in urethritis.

  • Finalized by the predictable outcome of management, e.g. bed rest, exercise, analgesics, NSAIDs, local intra-articular steroid injections, antibiotics for proved infections, e.g. Chlamydia. Immunosuppression in severe cases.

Psoriasis

  • Suggested by: several acutely inflamed joints (usually terminal IP and other joints deformed, especially terminal IP joints, with pitting and thickening of fingernails.

  • Confirmed by: psoriatic plaques on elbows and extensor surfaces of limbs, scalp, behind ears, and around navel. Rheumatoid factor –ve.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, or immunosuppressants, e.g. methotrexate.

Pain or limitation of movement in the hand

Ask patient to flex and extend fingers, and then wrists. Observe opening and closing of buttons, range of movement, any limitation, or pain. Initial investigations (others in bold below): X-ray hand and wrist.

Main differential diagnoses and typical outline evidence, etc.

Carpal tunnel syndrome associated hypothyroidism, acromegaly, or pregnancy.

  • Suggested by: pain, numbness, and weakness of hand. Symptoms worse early hours of morning, waking up patient from sleep. Shaking the hand eases symptoms.

  • Confirmed by: nerve conduction studies showing a delay at the wrist.

  • Finalized by the predictable outcome of management, e.g. analgesics, night splints, local injection of steroids, or surgery.

Dupuytren’s contracture usually familial or associated with alcohol, anti-epileptic therapy, or diabetes mellitus

  • Suggested by: progressive flexion deformity of ring and little fingers, mainly with palmar fibrosis (often bilateral, familial).

  • Confirmed by: fixed flexion at MCP joints first, then IP joints (inability to place hand on flat surface = severe).

  • Finalized by the predictable outcome of management, e.g. wait and see if the palm only is affected. Surgical intervention if fingers affected.

Ganglion

  • Suggested by: painless, spherical swelling around wrist.

  • Confirmed by: fluctuant, soft sphere. Disappears spontaneously leave alone, if persists or after blow, e.g. from a book.

  • Finalized by the predictable outcome of management, e.g. aspiration and local steroid injection.

Rheumatoid arthritis

  • Suggested by: ‘swan neck’ or ‘boutonnière’ deformities of fingers. Thumbs have Z-deformities. MCP joints and wrists: subluxation acquiring ulnar deviation. Nodules on elbows and extensor tendons.

  • Confirmed by: rheumatoid factor +ve. ↑anti-IgG autoantibody.

  • Finalized by the predictable outcome of management, e.g. supportive physiotherapy and occupational therapy, NSAIDs with stomach protection, analgesics. DMARDs, e.g. methotrexate. Immunotherapy, e.g. infliximab.

Psoriasis

  • Suggested by: several acutely inflamed joints (usually terminal IP) and other joints deformed, especially terminal IP joints with pitting and thickening of fingernails.

  • Confirmed by: psoriatic plaques on extensor surfaces of limbs, scalp, behind ears, and around navel. Rheumatoid factor –ve.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs or immunosuppressants, e.g. methotrexate.

Trigger finger due to nodule sticking in tendon sheath

  • Suggested by: fixed flexion at the ring or little finger with no fibrosis in palm. Patient unable to extend finger spontaneously.

  • Confirmed by: ‘click’ as fingers passively extended. Nodule, then palpable on flexor surface of finger.

  • Finalized by the predictable outcome of management, e.g. orthopaedic intervention, e.g. division of the sheath at the level of MP joint.

De Quervain’s syndrome—stenosing tenosynovitis

  • Suggested by: pain at the wrist, e.g. when lifting teapot. History of forceful hand use, e.g. wringing clothes. Weakness of grip.

  • Confirmed by: pain over radial styloid process, made worse by forced adduction and flexion of thumb into palm.

  • Finalized by the predictable outcome of management, e.g. orthopaedic intervention, e.g. dividing of lateral wall of tendon sheath.

Volkmann’s ischaemic contracture due to ischaemia flexor muscles of thumb and fingers (supplied by brachial artery)

  • Suggested by: flexion deformity at the thumb, fingers, wrist, and elbow with forearm pronation. History of trauma or surgery near to brachial artery, or plaster of Paris applied too tightly to forearm.

  • Confirmed by: cold, dark, ischaemic arm, no pulse at the wrist, and pain when fingers extended.

  • Finalized by the predictable outcome of management, e.g. surgical release of pressure.

Soft tissue injury or fracture

  • Suggested by: history of recent impact and acute pain and/or loss of function, tenderness, deformity, swelling, crepitus.

  • Confirmed by: acute pain and deformity clinically and on X-ray.

  • Finalized by the predictable outcome of management, e.g. analgesia; orthopaedic intervention if fracture ± physiotherapy.

Pain or limitation of movement at the elbow

Ask the patient to straighten arms, and compare for deformity and deviation from the normal valgus angle. Ask the patient to flex elbow, and to supinate and rotate normally over 90°. Note degree of bold movement, any limitation, or pain. Initial investigations (others in below): FBC, ESR, rheumatoid factor, X-ray elbow.

Main differential diagnoses and typical outline evidence, etc.

Epicondylitis: tennis elbow (tenoperiostitis)

  • Suggested by: preceding repetitive strain, e.g. use of screwdriver, tennis racquet. Pain worse when patient asked to flex fingers and wrist, and pronate hand. Difficulty in holding a heavy object at arm’s length. The arm feels stiff, heavy, and weak.

  • Confirmed by: pain when patient’s extended wrist pulled. Improvement after avoidance of preceding repetitive movement.

  • Finalized by the predictable outcome of management, e.g. avoid suspected triggering activity, analgesics, and NSAIDs. RICE (Rest, Ice, Compression, and Elevation), physiotherapy, arm brace or tape, or local injections.

Osteoarthritis

  • Suggested by: joint deformity, intermittent pain and swelling, past history of injury, e.g. fracture or dislocation. ‘Locking’ if loose bodies.

  • Confirmed by: impairment of flexion and extension, but rotation full. Elbow X-ray showing osteoarthritic changes and might show loose bodies.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, physiotherapy, local injections of steroids or hyaluronic acid. Arthroscopy to remove inflammatory tissues or loose bodies, and to smooth out irregular surfaces. Joint replacement if severe.

Old trauma

  • Suggested by: history of impact, fracture, deformity.

  • Confirmed by: deformity and related elbow X-ray.

  • Finalized by the predictable outcome of management, e.g. analgesia and physiotherapy.

Soft tissue injury or fracture

  • Suggested by: recent impact and acute pain and/or loss of function, tenderness, deformity, swelling, crepitus.

  • Confirmed by: X-ray appearance.

  • Finalized by the predictable outcome of management, e.g. analgesia; orthopaedic intervention if fracture ± physiotherapy.

Pain or limitation of movement at the shoulder

Ask patients to put their arms behind their head, and note angle at which any restriction and pain occurs. Initial investigations (others in bold below): FBC, ESR or CRP, X-ray shoulder.

Main differential diagnoses and typical outline evidence, etc.

Impingement syndrome

  • Suggested by: pain on shoulder abduction, e.g. when throwing. Pain worse at night.

  • Confirmed by: painful arc of movement between 70° and 120° abduction. Neer’s impingement test: pain is triggered when forcibly internally rotating the shoulder while flexed to 90°. MRI studies of shoulder joint.

  • Finalized by the predictable outcome of management, e.g. rest and reduced activities, analgesics and NSAIDs, physiotherapy, local injection of steroids. Surgery with decompression of subacromial space in non-responding cases.

Rotator cuff tears of the supraspinatus tendon or adjacent subscapularis or infraspinatus tendons

  • Suggested by: limitation and/or pain on abduction at the shoulder to the first 60° range (achieved by scapular rotation), the pain is recurrent for several months. History of trauma at the time of onset.

  • Confirmed by: passive movement pain-free and spontaneous above 90°. MRI showing connection between joint capsule and subacromial bursa.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, and physiotherapy. Surgical repair in selected cases.

Chronic supraspinatus inflammation ± calcification

  • Suggested and confirmed by: acute and continued limitation and/or pain on abduction at the shoulder in the final 60° to 90° range. Acutely painful, tender, swollen, and warm shoulder.

  • Further confirmation by: any calcification in muscle on shoulder X-ray.

  • Finalized by the predictable outcome of management, e.g. analgesics and NSAIDs. Joint aspiration and local injection.

Cervical spondylosis (pain is referred to shoulder), very common cause of shoulder pain

  • Suggested by: pain and tenderness on the same side of the neck, occipital headache.

  • Confirmed by: any positive neurological signs, e.g. absent arm reflexes, muscle weakness, and sensory impairment. Neck X-ray and MRI scan.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, cervical collar, and physiotherapy. Surgical decompression of nerve root if intractable pain.

Biceps tendonitis

  • Suggested by: repetitive overhead activity, pain in front of the shoulder aggravated by contraction of the biceps.

  • Confirmed by: above clinical findings.

  • Finalized by the predictable outcome of management, e.g. resting arm, change of activity or sport, NSAIDs, physiotherapy. Orthopaedic intervention, e.g. arthroscopic surgery.

Rupture of long head of biceps

  • Suggested by: sudden pain in front of the shoulder during an activity, a snapping sensation felt.

  • Confirmed by: pain aggravated by contraction of the biceps, and a lump (contracting muscle belly) appears between the shoulder and elbow, possibly with some bruising.

  • Finalized by the predictable outcome of management, e.g. a sling to rest shoulder, NSAIDs, occupational therapy and physiotherapy, surgical repair for patients who need arm strength.

Frozen shoulder—adhesive capsulitis

  • Suggested by: pain worse at night, marked reduction in active and passive movement with less than 90° abduction. Difficulty in brushing hair or putting on shirts or bra.

  • Confirmed by: above clinical findings and normal shoulder X-ray.

  • Finalized by the predictable outcome of management, e.g. NSAIDs, analgesics, exercises, physiotherapy, and intra-articular steroid injections. Surgical intervention, e.g. manipulation under anaesthesia and arthroscopic capsular release.

Osteoarthritis of acromio- clavicular (AC) joint

  • Suggested by: pain and swelling at the AC joint.

  • Confirmed by: very well localized tenderness to the AC joint. Positive X-ray and MRI appearance.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, physiotherapy. Surgical intervention if intractable.

Rheumatoid arthritis

  • Suggested by: history of early morning stiffness. Multiple joint involvement, small joints affected, ‘swan neck’ or ‘boutonnière’ deformities of fingers. Z-deformities of thumbs.

  • Confirmed by: rheumatoid factor +ve, ↑anti-IgG autoantibody. ↑ESR when active.

  • Finalized by the predictable outcome of management, e.g. supportive physiotherapy and occupational therapy, NSAIDs with gastric protection, e.g. PPI. DMARDs, e.g. methotrexate. Immunotherapy, e.g. infliximab.

Soft tissue injury or fracture

  • Suggested by: recent impact and acute pain and/or loss of function, tenderness, deformity, swelling, crepitus.

  • Confirmed by: X-ray appearance.

  • Finalized by the predictable outcome of management, e.g. analgesia; support and immobilize. Orthopaedic intervention if fractured ± physiotherapy.

Septic arthritis

  • Suggested by: acutely, painful, red hot joint, with very restricted movements. High temperature with sweats and shivering.

  • Confirmed by:WCC, ↑ESR, ↑CRP, joint aspirate positive for culture and sensitivity.

  • Finalized by the predictable outcome of management, e.g. antibiotics as per culture and sensitivity results.

Osteoarthritis of the glenohumeral joint. Very rare

  • Suggested by: history of avascular necrosis of head of humerus, following an injury to the proximal humerus.

  • Confirmed by: X-ray appearance, arthroscopy.

  • Finalized by the predictable outcome of management, e.g. analgesics, e.g. NSAIDs, local injection of steroids, joint replacement for severe cases.

Pain or limitation of movement at the neck

Look from the side to see if there is normal cervical (and lumbar) lordosis. Ask the patient to tilt head: move ear towards shoulder. Note angle at which any restriction and pain occurs. Initial investigations (others in bold below): FBC, ESR, X-ray of cervical spine.

Main differential diagnoses and typical outline evidence, etc.

Neck pain due to an abnormal posture

  • Suggested by: a sedentary job, long hours on computer or driving. Loss of normal neck curvature.

  • Confirmed by: history, full range of neck movements, and normal cervical X-rays.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, postural exercises for the neck, eliminating bad posture, and a good support neck pillow for sleeping.

Whiplash (rapid extension and flexion movement) and extension injuries

  • Suggested by: history of road traffic accident (RTA) (rear end car crashes) with rapid extension and flexion movement of neck. Pain and stiffness of neck and the arms.

  • Confirmed by: typical history.

  • Finalized by the predictable outcome of management, e.g. soft cervical collar, analgesics, NSAIDs, and physiotherapy. Encourage early return to work.

Spasmodic torticollis (cervical dystonia) anterocollis (tilts forwards), retrocollis (tilts backwards), laterocollis (tilts to one side)

  • Suggested by: recurrent involuntary contraction of neck muscles causing pain and the turning of the head to one side.

  • Confirmed by: presence of tremor, stiffness of neck muscles, and elevation of shoulder on the affected side. Absence of root compression pattern pain or paresis.

  • Finalized by the predictable outcome of management, e.g. analgesics for pain. GABA-regulating drugs (e.g. lorazepam or baclofen), dopamine agonists (e.g. bromocriptine), or anticonvulsants (e.g. carbamazepine), all used individually or in combination. Botulinum toxin or surgery for non-responding cases.

Infantile torticollis due to birth damage of sternomastoid

  • Suggested by: onset early childhood (up to 3y). Head tilted to shoulder with restricted neck movements, and retarded growth of the cranium or face on the affected muscle side (plagiocephaly). Presence of associated muscle or skeletal disorder, e.g. hip dysplasia.

  • Confirmed by: palpable nodule in muscle on affected side. Biopsy of nodule: fibrous only and no gangliocytoma.

  • Finalized by the predictable outcome of management, e.g. physiotherapy consisting of positioning, gentle range of movements, and strengthening by the stimulation of head and trunk muscles. Cervical collars and cranial remoulding orthosis in cases of plagiocephaly. Botulinum toxin and surgery for intractable cases.

Cervical rib with compression of lower brachial plexus affecting median and ulnar nerves, and brachial artery (thoracic outlet syndrome)

  • Suggested by: weakness and numbness in forearm and hand, usually on ulnar side. Wasting of the intrinsic hand muscles. Arm cyanosis and absent pulse.

  • Confirmed by: symptoms exacerbated by abduction and external rotation of shoulder. Cervical rib neck X-ray (may be no rib—fibrous band instead).

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, physiotherapy, and local injections of trigger points. Surgical intervention.

Cervical spondylosis

  • Suggested by: pain and stiffness of neck. Occipital headache, shoulder and arm pain due to radiation. Symptoms of nerve root or spinal cord involvement.

  • Confirmed by: X-ray and MRI appearances.

  • Finalized by the predictable outcome of management, e.g. analgesics and NSAIDs, physiotherapy, and local injections. Trial of traction. Surgical intervention for intractable symptoms.

Posterior prolapsed (cervical disc, usually C5/C6 disc and C6/C7 disc pressure on nerve roots)

  • Suggested by: torticollis, stiffness and pain in neck over side of disc lesion. Pain, numbness in arm and tip of little or middle finger or thumb.

  • Confirmed by: loss of biceps or supinator reflexes. Loss of sensation in medial or lateral borders of hand. MRI scan shows posterior protrusion.

  • Finalized by the predictable outcome of management, e.g. analgesics and NSAIDs, physiotherapy, and local injections. Trial of traction. Surgical intervention if weakness, severe pain, or suspected cord compression.

Anterior prolapsed cervical disc (usually C5/C6 disc and C6/C7 disc pressure on spinal cord)

  • Suggested by: torticollis, stiffness and pain in neck over side of disc lesion. Numbness and weakness in leg. Unsteadiness of gait, walking problems, and impaired bladder and bowel function.

  • Confirmed by: flaccid first, then spastic paresis of leg. Loss of knee, ankle reflexes, and extensor plantar response. Loss of vibration sense, touch and pain with sensory level. MRI scan shows protrusion.

  • Finalized by the predictable outcome of management, e.g. analgesics and NSAIDs, physiotherapy, and local injections. Trial of traction. Surgical intervention if weakness, severe pain, or suspected cord compression.

Pain or limitation of movement of the back: with sudden onset over seconds to hours originally

Look from the side to see if there is normal lumbar lordosis. Ask patients to touch their toes and watch for movement of spine and hips. Ask the patient to arch backwards, bend to each side, and rotate trunk from side to side. Lie patient down and measure length of legs. Raise each straight leg for any restriction before 45°. Initial investigations (others in bold below): FBC, ESR or CRP, rheumatoid factor.

Main differential diagnoses and typical outline evidence, etc.

Mechanical pain (strains, tear, or crushing of ligaments, discs, vertebrae with normal healing)

  • Suggested by: recent onset over minutes of pain and restriction of movement in lower back in a young person. History of lifting a heavy weight or a head-on impact RTA.

  • Confirmed by: recovery with minimal loss of function over days or weeks.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, and physiotherapy. Encourage back to work early.

Posterior lumbar disc prolapse

  • Suggested by: onset over seconds of severe back pain on coughing, sneezing, or twisting after earlier strain. Radiation to buttock, thigh, or calf if prolapse compresses posterior root.

  • Confirmed by: back flexed and extension restricted. Straight leg raising stopped before 45° by pain. Loss of sensation lateral foot (L4/5). Loss of ankle jerk and sensation sole of foot (S1). MRI scan.

  • Finalized by the predictable outcome of management, e.g. bed rest, analgesics, NSAIDs, muscle relaxants, and physiotherapy. If these fail, then surgical intervention.

Anterior lumbar disc prolapsed

  • Suggested by: onset over seconds of severe back pain on coughing, sneezing, or twisting after earlier strain (if large, prolapse compresses cauda equina, with leg weakness, incontinence, and numbness around perineum).

  • Confirmed by: flaccid paresis of leg(s). Loss of knee, ankle reflexes, and extensor plantar response. Loss of vibration sense, touch, and pain with sensory level. MRI scan shows protrusion.

  • Finalized by the predictable outcome of management, e.g. bed rest, analgesics, NSAIDs, muscle relaxants, and physiotherapy. If these fail, then surgical intervention.

Spondylolisthesis due to spondylolysis, congenital malformation of articular process, osteoarthritis of posterior facet joints

  • Suggested by: positive family history. Sudden onset over minutes of back pain with or without sciatica in adolescence.

  • Confirmed by: plain back X-ray shows forward displacement of vertebra over one below.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, avoidance of sports, and the use of a corset support. Surgical intervention if intractable symptoms.

Central disc protrusion

  • Suggested by: sudden onset over minutes or hours with bilateral sciatica, disturbance of bladder or bowel function. Saddle or perineal anaesthesia.

  • Confirmed by: history and compression of cord visible on MRI scan.

  • Finalized by the predictable outcome of management, e.g. pain control and neurosurgery.

Pain or limitation of movement of the back: with onset over days to months originally

Look from the side to see if there is normal lumbar lordosis. Ask the patient to touch toes, and watch for movement of spine and hips. Ask patient to arch backwards, bend to each side, and rotate trunk from side to side. Lie patient down and measure length of legs. Raise each straight leg for any restriction before 45°. Initial investigations (others in bold below): FBC, ESR, rheumatoid factor.

Main differential diagnoses and typical outline evidence, etc.

Lumbar spinal stenosis due to facet joint osteoarthrosis

  • Suggested by: onset of pain over months, worse on walking with ache and weakness in one leg.

  • Confirmed by: pain on extension of back. Straight leg raising normal. Few CNS signs (but may appear shortly after exercise). MRI scan.

  • Finalized by the predictable outcome of management, e.g. analgesics. Spinal decompression if intractable pain.

Spinal tumours (1° or 2° to carcinoma of lung, breast, prostate, thyroid, kidney, myeloma)

  • Suggested by: onset of back pain over months with progressive pain or paresis in one or both legs. (Physical signs depend on part of cord or nerve roots affected).

  • Confirmed by: ‘hot spot’ on bone scan with erosion or sclerosis on plain X-ray of ‘hot spot’. Space-occupying lesion on MRI or CT scan and histology on biopsy.

  • Finalized by the predictable outcome of management, e.g. effective analgesia and control of other symptoms, e.g. vomiting. Radiotherapy, chemotherapy, and surgery, individually or in combination.

Pyogenic spinal infection usually of disc space due to Staphylococcus, Salmonella typhi, etc.

  • Suggested by: onset of pain over days or weeks. Little or no fever, tenderness or ↑WCC. ↑ESR. Background debilitation, surgery, or diabetes.

  • Confirmed by: bone rarefaction or erosion with joint space narrowing on back X-ray. ‘Hot spot’ on isotope bone scan and space-occupying lesion on MRI or CT scan.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, and antibiotics.

Spinal TB with abscesses and cord compression (Pott’s paraplegia), psoas abscess

  • Suggested by: onset of weeks or months. Low-grade fever, tenderness or ↑WCC. ↑ESR. Background debilitation, diabetes.

  • Confirmed by: bone rarefaction or erosion with joint space narrowing, then wedging of vertebrae. Space-occupying lesion on MRI and CT scan. Tubercle baccilli on stains or culture of drainage material.

  • Finalized by the predictable outcome of management, e.g. standard anti-tuberculous treatment.

Pain or limitation of movement of the back: with onset over years

This is a notoriously poor lead. Look from the side to see if there is normal lumbar lordosis. Ask the patient to touch toes and watch for movement of spine (?rounded) and hips. Ask the patient to arch backwards, bend to each side, and rotate trunk from side to side. Lie patient down and measure length of legs. Raise each straight leg for any restriction before 45°. Initial investigations (others in bold below): FBC, ESR, rheumatoid factor, back X-ray (A–P and lateral).

Main differential diagnoses and typical outline evidence, etc.

Kyphotic pain

  • Suggested by: poor posture with a hump appearance of the back (hunchback). Onset over years usually, exacerbated over days with wedge fracture. Spinal curvature visible from the side. Associated neuromuscular disease.

  • Confirmed by: back X-ray appearance suggestive of congenital deformity, Scheuermann’s or Calve’s osteochondritis, wedge fracture from osteoporosis or carcinoma, ankylosing spondylitis.

  • Finalized by the predictable outcome of management, e.g. analgesics and OBAS (Observation, Bracing, And Surgery).

Scoliotic pain, poliomyelitis, syringomyelia, etc. (see under ‘Suggested by’, this Table)

  • Suggested by: lateral curvature visible from the back and associated rib prominence apparent from the front. Head appears off centre, and a hip or shoulder is higher than the other side. Known to have past poliomyelitis, syringomyelia, torsion dystonia, spinal tumours, spondylolisthesis, arthrogryphosis, enchondromatosis, osteogenesis imperfecta, neurofibromatosis, Chiari malformation, Duchenne muscular dystrophy, Friedreich’s ataxia, Marfan’s syndrome, Pompe’s disease.

  • Confirmed by: history and X-ray appearance of bony congenital anomaly.

  • Finalized by the predictable outcome of management, e.g. treat underlying causes. Otherwise analgesics and OBAS.

Idiopathic scoliosis of thoracic or lumbar spine

  • Suggested by: progressive loss over years of horizontal alignment of shoulders and hips with age, usually in adolescent girls more than boys.

  • Confirmed by: X-ray appearance. Increased scoliosis with growth.

  • Finalized by the predictable outcome of management, e.g. OBAS.

Pain or limitation of movement of the hip

Assess activity. Test flexion (normal >120°) by grasping ankle in one hand and iliac crest in the other to eliminate pelvic rotation. Test abduction (normal 30–40°), preventing pelvic tilt. Test abduction in flexion (normal >70°) and adduction (normal >30°) by moving one foot over the other, internal and external rotation (normal >30°). Measure true length of legs from anterior superior iliac spines to medial malleoli. Trendelenburg test is positive if hip drops when foot on that same side is lifted from ground. Initial investigations (others in bold below): FBC, ESR, X-ray (A–P and lateral).

Main differential diagnoses and typical outline evidence, etc.

Osteoarthritis

  • Suggested by: elderly, overweight, and overwork. Onset over months or years. Pain, often causing a disturbed sleep, with stiffness and limitation of movement, initially of internal rotation. Difficulties in putting on stockings and cutting the toenails.

  • Confirmed by: A–P and lateral X-rays of hips show loss of joint space, deformity of head and acetabulum with osteophytes and sclerosis.

  • Finalized by the predictable outcome of management, e.g. advise weight reduction, analgesics, NSAIDs, physiotherapy. Hip replacement/resurfacing in severe cases.

Coxa vara caused by congenital slipped upper femoral epiphyses, fracture with malunion or non-union, osteomalacia or Paget’s disease

  • Suggested by: pain and stiffness, limp with Trendelenburg ‘dip’ to affected side. True shortening of leg.

  • Confirmed by: angle between neck and femur <125° on X-ray.

  • Finalized by the predictable outcome of management, e.g. surgical correction.

Transient synovitis (most common cause of hip pain in children)

  • Suggested by: hip pain in a child, usually a boy, with a limp and sometimes history of a preceding minor trauma. Restricted extension and internal rotation of hip. Usually no temperature.

  • Confirmed by: X-ray and US scan showing synovitis.

  • Finalized by the predictable outcome of management, e.g. symptomatic treatment with analgesics and NSAIDs ± bed rest for up to 6wk. If slow to respond, check stool culture for Campylobacter, and treat accordingly.

Soft tissue injury or fracture

  • Suggested by: recent impact and acute pain and/or loss of function, tenderness, deformity, swelling, crepitus.

  • Confirmed by: A–P and lateral X-ray appearance.

  • Finalized by the predictable outcome of management, e.g. analgesia; surgical intervention if fracture ± physiotherapy.

Perthes’ disease

  • Suggested by: pain in hip or knee with limp with onset over months from age 3–11y. Limitation of hip movement in all ranges ± thin affected leg.

  • Confirmed by: A–P and lateral X-rays of hips show widening of joint space and ↓size of femoral head, patchy density and later, collapse. US scan shows capsular distension due to synovial thickening, usually bilateral.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, rest and traction + physiotherapy. If it is difficult to preserve mobility, then plaster casts, bracing, and surgery (to put the femoral head back in the socket).

Slipped femoral epiphysis sometimes associated with 1° hypothyroidism

  • Suggested by: typically an overweight boy with pain in groin, front of thigh or knee, and limping with onset over minutes (if acute) or weeks to months. Limitation of flexion, abduction, and medial rotation. Pain usually comes with exercise and sports. Affected leg turns outwards and might be shorter than other side. Both hips might be affected.

  • Confirmed by: displacement of growth plate visible on lateral X-ray view of hip (not A–P) or avascular necrosis and chondrolysis.

  • Finalized by the predictable outcome of management, e.g. exclude associated conditions, e.g. hypothyroidism. If suspected, admit straight away. Traction initially; early surgical intervention.

Tuberculous arthritis

  • Suggested by: fever and night sweats. Pain and limp in 2–5y old, especially from poor country. Pain at night. Pain and spasm in all directions of movement with progressive muscle wasting.

  • Confirmed by: rarefaction of bone on X-ray, then fuzziness of joint margin, then erosions. AFB in biopsy ± culture of synovial membrane (or in cultures from aspirates).

  • Finalized by the predictable outcome of management, e.g. rifampicin + isoniazid + pyrazinamide + ethambutol for 2mo, followed by rifampicin and isoniazid for another 4mo in addition to bed rest and traction. Surgical intervention if deformity.

Developmental dysplasia (still referred to as congenital dislocation of the hip)

  • Suggested by: pain, stiffness and ↓movement in childhood or adolescence; undiagnosed hip dislocation early in life. Waddling gait with hyperlordosis in bilateral hip involvement.

  • Confirmed by: positive Ortolani test (palpable clunk when hip is reduced in and out of acetabulum) or Barlow test (clunk is felt when gentle pressure is applied to the adducted hip) in the newborn. Shallow acetabulum with or without current dislocation on A–P and lateral X-ray of hips (ultrasound in neonate).

  • Finalized by the predictable outcome of management, e.g. bracing (Pavlick harness) if under 6y-old. Closed reduction preceded by traction for the ‘over 6y-old’. If >2y or failed previous treatment, open reduction or various procedures depending on age.

Post-total hip replacement problems (dislocation, prosthesis failure, prosthesis loosening, and infection)

  • Suggested by: pain, difficult or impossible weight-bearing. Limb shorter and externally rotated in the case of dislocation. General ill heath, high temperature, and night sweats in cases of infection.

  • Confirmed by: radiological appearances. +ve culture and sensitivity if infection.

  • Finalized by the predictable outcome of management, e.g. analgesia. Antibiotics. Re-replacement of hip if indicated.

Pain or limitation of movement of the knee

Look for quadriceps wasting, ability to weight bear, deformity of the knee, or swelling. Feel for swelling with palm of other hand pressing above patella. Compare flexion and extension on both sides. Abduct and adduct tibia with knee flexed at 30° to test medial and lateral ligaments. With knee flexed at 90°, pull and push tibia to test anterior and posterior cruciate ligaments. Initial investigations (others in bold below): FBC, ESR, or CRP, X-ray of knee (P–A and lateral).

Main differential diagnoses and typical outline evidence, etc.

Osteoarthritis

  • Suggested by: old age, overweight, or overwork. Onset of months or years, worse in cold and damp. Deformity (especially varus—bow-legged) and swelling. Crepitus on passive movement.

  • Confirmed by: above history and examination. Loss of joint space on X-ray with deformity, osteophytes, and sclerosis.

  • Finalized by the predictable outcome of management, e.g. weight reduction, analgesics, NSAIDs, physiotherapy. Orthopaedic intervention, e.g. for total knee replacement in advanced cases.

Chondromalacia patellae

  • Suggested by: patella aching after sitting or walking on slopes or stairs in a young adult, typically females. Patellar tenderness.

  • Confirmed by: above history and examination, and ‘fibrillation’ of patellar cartilage on arthroscopy or MRI.

  • Finalized by the predictable outcome of management, e.g. restrict activities that aggravate symptoms, analgesics, and physiotherapy. Surgical intervention if no response.

Recurrent patella subluxation

  • Suggested by: jumping-type sports, e.g. basketball or volleyball. Knee often giving way (especially in knock-kneed girls).

  • Confirmed by: increased lateral movement of patella.

  • Finalized by the predictable outcome of management, e.g. surgical intervention for joint stabilization.

Patella tendinopathy (jumper’s knee)

  • Suggested by: jumping-type sports. Pain on forceful movement of knee in sport.

  • Confirmed by: tenderness over patellar tendon. X-rays show normal bones.

  • Finalized by the predictable outcome of management, e.g. rest, NSAIDs, analgesics, physiotherapy to build up quadriceps, hamstrings, and calf muscles. Orthopaedic intervention if no response.

Iliotibial band syndrome

  • Suggested by: long distant runners and cyclists, pain when active. Rest eases the pain.

  • Confirmed by: tenderness over lateral femoral condyle.

  • Finalized by the predictable outcome of management, e.g. RICER regime (Rest, Ice, Compression, Elevation and Referral). If no response, advise different sporting activity.

Medial shelf syndrome

  • Suggested by: repetitive stress, single blunt trauma, anterior knee pain, knee clicking or brief locking. Symptoms made worse by activity, prolonged standing or stair climbing.

  • Confirmed by: inflamed synovial fold above medial meniscus on arthroscopy.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, and physiotherapy. If no response, possible arthroscopic resection of inflamed medial band.

Hoffa’s fat pad syndrome

  • Suggested by: history of major acute or chronic repetitive trauma. Brief locking of knee with pain and swelling under patella.

  • Confirmed by: hypertrophic pad between articular surfaces on MRI or arthroscopy.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, ice, and rest in the acute stage ± physiotherapy. If no response, arthroscopic resection of inflamed fat pad.

Acute arthritis due to sepsis, gout or rheumatoid arthritis

  • Suggested by: onset hours, days of pain and swelling.

  • Confirmed by: aspiration, microscopy, and culture. ↑urate in gout. Rheumatoid factor +ve in rheumatoid arthritis.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs; treat cause, e.g. antibiotics, and arthroscopic drainage if septic arthritis with no response to antibiotics.

Medial collateral ligament (MCL) tear

  • Suggested by: a blow on the outer surface of the knee or an injury forcing the leg outwards. Pain and swelling over the injured ligament. Pain triggered by stretching ligament. Unstable knee, feeling that the knee may give way or buckle.

  • Confirmed by: pain and excessive laxity when gentle pressure is applied to the outside of the knee. X-ray and MRI scan.

  • Finalized by the predictable outcome of management, e.g. rest, ice, compression, analgesics, and NSAIDs. Wearing knee immobilizer; avoid weight-bearing. Surgical repair for very severe injuries.

Lateral collateral ligament (LCL) tear

  • Suggested by: an injury causing a direct impact to the inner surface of the knee. Pain and swelling over the injured ligament. Pain is triggered or made worse by stretching the ligament. In severe injuries, the knee is very unstable.

  • Confirmed by: pain and laxity when gentle pressure is applied to the inside of the knee. X-ray and MRI scan.

  • Finalized by the predictable outcome of management, e.g. rest, ice, compression, analgesics, and NSAIDs. Wearing of a knee immobilizer and avoiding weight-bearing for about 2wk in more severe injuries. Surgical repair for very severe injuries with persisting instability.

Anterior cruciate ligament (ACL) tears

  • Suggested by: history of a posterior blow or a rotational force when foot fixed to ground. Sudden swelling and pain in the knee. Hearing a ‘pop’ at the time of the injury and/or a sensation that the knee will ‘give way’.

  • Confirmed by: tibia moves forward when pulled after effective analgesia or anaesthesia (Lachman’s test). X-ray and MRI scan.

  • Finalized by the predictable outcome of management, e.g. RICE, analgesics, and NSAIDs. Reconstruction of ACL if instability persists.

Posterior cruciate ligament (PCL) tears

  • Suggested by: history of a direct impact on the shin when the knee is bent. Pain and swelling with a feeling that the knee will ‘give way’.

  • Confirmed by: tibia moves backward when pulled after effective analgesia or anaesthesia (reverse Lachman’s test). X-ray and MRI scan.

  • Finalized by the predictable outcome of management, e.g. RICE, analgesics, and NSAIDs. Reconstruction of PCL if persistent instability.

Meniscal tears

  • Suggested by: history of twisting, pivoting, and decelerating of the knee. Stiffness, swelling, locking, and buckling of the knee. A popping sensation at the time of injury.

  • Confirmed by: X-ray and MRI scan.

  • Finalized by the predictable outcome of management, e.g. RICE, analgesics, and NSAIDs. Arthroscopic trimming of damaged meniscus.

Meniscal cyst

  • Suggested by: history of a blow on the side of the knee. Variable swelling, worse when knee flexed to 60°, less when flexed further. Knee clicking and giving way.

  • Confirmed by: cyst present on MRI scan.

  • Finalized by the predictable outcome of management, e.g. aspiration to give temporary relief. Definitive treatment is excision with or without meniscectomy.

Osteochondritis dessicans (juvenile and adult types)

  • Suggested by: history of repetitive stress as in competitive sports. Pain and swelling of knee. A snapping, catching feeling, or locking when the knee is moved.

  • Confirmed by: defect on articular surface with or without a loose body on X-ray.

  • Finalized by the predictable outcome of management, e.g. in the juvenile, suspending exercise and sports, using crutches, or wearing a cast for 2mo (until symptoms subside) followed by physiotherapy. Surgical correction if bone growth ceased.

Loose bodies due to osteochondritis dessicans, osteoarthritis, chip fractures, synovial chondromatosis

  • Suggested by: locking of knee during extension and flexion. Swelling and effusion.

  • Confirmed by: seeing loose bodies on arthroscopy.

  • Finalized by the predictable outcome of management, e.g. arthroscopic or open surgical removal if symptomatic.

Bursitis (without or with infection) due to prepatellar bursitis (housemaid’s knee), etc.

  • Suggested by: localized pain and swelling over site of bursa (e.g. below patella).

  • Confirmed by: localized pain and swelling over site of bursa. Improvement with rest, analgesia, and physiotherapy.

  • Finalized by the predictable outcome of management, e.g. analgesics and antibiotics if infected. Aspiration and local steroid injection if no infection. Surgical excision.

Pain or limitation of movement of the foot

Observe gait, examine wear on shoe sole and print on floor of damp foot. Ask to extend or dorsiflex (normal >25°), flex (normal 30°). Evert and invert. Ask to extend toes (normal >60°) and stand on tiptoe. Initial investigations (others in bold below): FBC, ESR, rheumatoid factor, X-ray.

Main differential diagnoses and typical outline evidence, etc.

Hallux valgus associated with bunion and osteoarthritis

  • Suggested by: the first metatarsal is deviated medially and the big toe deviated laterally. Painful motion of joint and/or difficulty with footwear.

  • Confirmed by: above clinical appearance (big toe deviated laterally). X-ray to assess joint pathology and measure angular deformity.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, adapting footwear, and functional orthotic therapy. Surgical correction of the deformity.

Pes planus

  • Suggested by: loss of medial foot arch (appearance of damp surface in contact with floor, normal in early childhood) causing the foot to roll inwards. Pain if foot and heel everted.

  • Confirmed by: above clinical appearance and response to exercises, and medial heel shoe wedges in some cases.

  • Finalized by the predictable outcome of management, e.g. use of orthotics (special insoles), combined with supportive footwear that fit the foot correctly and contains a firm low heel. Surgical correction if these measures fail.

Pes cavus normal variant, hereditary, idiopathic, or due to spina bifida, past polio

  • Suggested and confirmed by: accentuated foot arches and other neurological disorders, e.g. spina bifida. The ankle may be rolled out slightly and the toes may appear clawed.

  • Confirmed by: above clinical appearance.

  • Finalized by the predictable outcome of management, e.g. foot orthotics (insoles), pads to get pressure off painful areas, proper fitting of footwear, treatment of associated corns and calluses.

Hammer toes

  • Suggested by: tip of a lesser toe points downwards.

  • Confirmed by: toe extended at the metatarsophalangeal (MTP) joint, flexed at the proximal IP joint but extended at the distal IP joint.

  • Finalized by the predictable outcome of management, e.g. wide fitted, low-heeled shoes, non-medicated pads to take pressure off corns and hard skin, moisturizing creams to keep skin soft, silicon toe prop to prevent further contracture. In rigid deformities, surgical interventions, e.g. arthroplasty or arthrodesis.

Claw toes

  • Suggested by: tip of a lesser toe points down and back.

  • Confirmed by: toe extended at the MTP joint, flexed at the proximal IP and distal IP joint.

  • Finalized by the predictable outcome of management, e.g. same as in hammer toes.

Mallet toes

  • Suggested by: tip of a lesser toe points downwards.

  • Confirmed by: toe is extended at the MTP and proximal IP joints, and flexed at the distal IP joint.

  • Finalized by the predictable outcome of management, e.g. same as in hammer toes.

Trigger toe

  • Suggested by: tip of the big toe points downwards.

  • Confirmed by: big toe is extended at MTP joint and flexed at the IP joint.

  • Finalized by the predictable outcome of management, e.g. same as in hammer toes.

Hallux rigidus

  • Suggested by: pain and stiffness localized to big toe, aggravated by cold damp weather. Difficulties with running and squatting.

  • Confirmed by: tenderness and swelling of 1st MTP joint. X-ray may show a distal ring of osteophytes.

  • Finalized by the predictable outcome of management, e.g. shoe modifications, e.g. wide-fitting shoes, orthotic devices, analgesics, NSAIDs, physiotherapy, local steroid injections. Surgical intervention in advanced cases.

  • Metatarsalgia

  • due to shoe pressure, previous trauma, rheumatoid arthritis, sesamoid fracture, synovitis

  • Suggested by: pain in the ball of the foot, the part of the sole just behind the toes worse on standing or running. Feeling as if walking on pebbles. Patient typically does high impact sport or overweight.

  • Confirmed by: tenderness of heads of metatarsals. X-ray to exclude other conditions, e.g. stress fracture.

  • Finalized by the predictable outcome of management, e.g. rest, ice packs on the affected areas, analgesics, and NSAIDs, proper shoes, shock-absorbing insoles, metatarsal pads. Surgical intervention if these measures fail.

  • Morton’s metatarsalgia

  • due to interdigital neuroma

  • Suggested by: intermittent pain, burning sensation or numbness on the bottom of the foot radiating to the 3rd and 4th toes. A description of ‘as if walking on marbles’.

  • Confirmed by: tenderness on compression of site of neuroma between metatarsals (e.g. squeezing the forefoot together triggers pain) and massaging offers significant relief.

  • Finalized by the predictable outcome of management, e.g. soft-soled shoes with a wide toe box and low heel. Plantar pad to elevate metatarsal head adjacent to neuroma preventing compression. Surgical intervention if refractory case.

March fracture

  • Suggested by: localized foot pain after excessive walking.

  • Confirmed by: tenderness of 2nd or 3rd metatarsals. X-ray showing fracture.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs.

Calcaneum disease; arthritis of subtalar joint; tear of calcaneal tendon; post calcaneal bursitis; plantar fasciitis, etc.

  • Suggested by: localized heel pain.

  • Confirmed by: X-ray and MRI scan appearance.

  • Finalized by the predictable outcome of management, e.g. analgesics, NSAIDs, physiotherapy. Surgical intervention if refractory.

Soft tissue injury or fracture

  • Suggested by: recent impact and acute pain and/or loss of function, tenderness, deformity, swelling, crepitus.

  • Confirmed by: X-ray appearance.

  • Finalized by the predictable outcome of management, e.g. analgesia; surgical intervention if fracture ± physiotherapy.