Cookie policy notice

By continuing to use this site you agree to our cookies policy below:
Since 26 May 2011, the law now states that cookies on websites can ony be used with your specific consent. Cookies allow us to ensure that you enjoy the best browsing experience.

This site is intended for health professionals only

At the heart of general practice since 1960

Key learning points on musculoskeletal medicine



Key questions on muscle disorder page 15

+ In patients with fibromyalgia or chronic fatigue syndrome, depression is present in about one-third of cases, and anxiety in about one-third.

+ Because these mental health problems overlap, about 50% of patients with CFS and fibromyalgia do not have diagnosable anxiety or depression.

+ Both fibromyalgia and CFS are positive diagnoses with strongly suggestive features, but both should be diagnosed when appropriate differential diagnoses have been excluded.

+ Some patients with fibromyalgia have a good initial response to medium-strength opiates such as tramadol and cocodamol.

+ Muscular dystrophy is often suggested by a positive family medical history, and confirmed on tests – typically electromyography, muscle biopsy and DNA testing.

+ Myotonic muscular dystrophy is the most common form of muscular dystrophy in adults.

+ The incidence of new cases

of dermatomyositis and polymyositis is 5.5 cases per million people per year.

+ Dermatomyositis is often paraneoplastic and the most common associated cancers are ovarian, lung and breast.

+ Weight loss of 3-4kg is common at presentation in patients with polymyalgia rheumatica (PMR).

+ Not all cases of PMR will have inflammatory markers – 15% are normal.

+ A third of patients on statins may report muscle symptoms.

+ Statin myalgia is far more common than myositis and is not accompanied by any rise in creatine kinase levels.

+ Patients with PMR typically take steroids for one to three years, although some will require small doses of steroids (5mg or less) indefinitely.

+ If individuals are stuck on high doses of analgesics, you can try to cycle through a variety of equivalent-level analgesics.

Ten top tips on diagnosing inflammatory arthritis page 19

+ Patients with osteoarthritis stiffen up after exercise.

+ It's helpful to discuss with patients how far they can walk now and how far could they walk before.

+ In typical rheumatoid arthritis, the metacarpophalangeal joints tend to be involved.

+ There is a clear ‘window of opportunity' during which starting therapy has a very good chance of preventing or even aborting the inflammatory arthritis.

+ Joint erosions do not appear until 12 months after the disease starts.

+ Even if inflammatory markers are normal, the patient may still have inflammatory arthritis.

+ Some infections can give false positive results on rheumatoid factor tests.

+ Gout can masquerade as inflammatory arthritis, so if the patient is overweight, hypertensive and drinks alcohol, check their uric acid.

Acute knee injuries page 20

+ Most acute anterior cruciate ligament (ACL) injuries are very painful, and often the patient is unable to weight-bear.

+ In all cases where the knee is swollen and the patient cannot weight-bear, an X-ray is required to exclude fracture.

+ Joint-line tenderness is one of the signs of a meniscal injury.

+ The Lachman test and the anterior drawer test are specific ACL injury tests.

+ If symptoms of an acute injury persist beyond six to eight weeks, consider referral.

+ Medial or lateral collateral ligament injury can be treated with protection in a brace and physiotherapy.

+ A posterior cruciate ligament injury will need bracing and physiotherapy – surgical reconstruction is rarely required.

Paediatric musculoskeletal problems page 21

+ An age-based approach might aid diagnosis in a limping child.

+ Septic arthritis, non-accidental injury and neoplasia – including leukaemia – are paediatric emergencies.

+ For chronic disease, differentiate between inflammatory and mechanical causes.

+ Juvenile idiopathic arthritis (JIA) and connective tissue diseases need prompt referral to a paediatric rheumatology service.

+ Key features of rheumatic disease are joint swelling, muscle weakness, erythematous rash and multisystem inflammatory disease.

+ Toe walking may be normal but if it is persistent, consider Duchenne's muscular dystrophy in boys and cerebral palsy.

+ Chondromalacia patellae typically occurs in adolescent females, especially if the pain is exacerbated by rising from a sitting position or walking up stairs.

+ Widespread bone pain at night with anaemia, bruising and poor general health could indicate leukaemia in a child or neuroblastoma in an infant.

+ Consider referral when symptoms of JIA have persisted for four weeks or more.

+ Multisystem inflammatory disease is rare in adolescents.

+ Hip pain may be caused by transient synovitis of the hip, Perthe's disease or avascular necrosis of the femoral head, or slipped upper femoral epiphysis.

Musculoskeletal hot topics page 22-23

+ The increase in cardiovascular risk in patients with inflammatory arthritis has been estimated at being 1.5- to 3-fold.

+ Last year, a UK study suggested an increased risk of oesophageal cancer over five years in women aged 60-79 from one in 1,000 to two in 1,000 after five years' use of oral bisphosphonates.

+ It is reasonable to conclude that glucosamine sulphate as a single daily dose of 1,500mg shows a small benefit over placebo for treatment of knee osteoarthritis.

+ The most common activities which can trigger work-related upper limb disorder are any kind of repetitive movements, where the upper limb must be kept in an abnormal position or tools are awkward to hold or use.

+ NICE guidance on low back pain suggests a course of manual therapy, including spinal manipulation, of up to a maximum of nine sessions over a period of up to 12 weeks.

Click here to start the assessment 3 CPD hours

Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say