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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.

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