15 Musculoskeletal problems

Consider:

Common. Ask:

Is the problem inflammatory or mechanical? Look for:

Which structure is causing pain? Options: bursa; tendon; tendon sheath; ligament; soft tissue.

pp. 512–523

Isolated myalgia can be a result of overuse or soft tissue injury. Generalized myalgia is associated with many diseases including:

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Neck pain is common (lifetime incidence 50%) and contributes to 2% of GP consultations. Prevalence is highest in middle age. Most neck pain is acute and self-limiting (within days/weeks) but 1 in 3 have symptoms lasting >6mo or recurring pain.

Pain is often poorly localized and neck problems commonly present with shoulder pain and/or headache (cervicogenic headache).

Degenerative disease of the cervical spine can cause pain, but minor changes are normal (especially >40y) and usually asymptomatic. Pain is generally intermittent and related to activity. Examination reveals ↓ neck mobility. Severe degeneration can cause nerve root signs. Treat with analgesia ± cervical collar. X-ray only if conservative measures fail, troublesome pain, nerve root signs, or the patient has psoriasis (? psoriatic arthropathy).

Secondary to degeneration, vertebral displacement/collapse, disc prolapse, local tumour, or abscess. Causes neck stiffness, pain in arms or fingers, ↓ reflexes, sensory loss, and ↓ power. The level of entrapment can usually be determined clinically (see Table 15.1). Treat with analgesia ± cervical collar. X-ray cervical spine—lateral or oblique views. Refer for physiotherapy. Refer for further investigations (e.g. MRI) if conservative management fails and there is objective evidence of a root lesion.

Common. Sudden onset of painful stiff neck due to spasm of trapezius and sternocleidomastoid muscles. Self-limiting. Heat, gentle mobilization, muscle relaxants, and analgesia can speed recovery. A cervical collar may help in the short term but can prolong symptoms. Often caused by poor posture, e.g. computer-seating position; carrying heavy, uneven loads.

Congenital condition of C7 vertebra costal process enlargement. Usually asymptomatic but can cause thoracic outlet compression → hand or forearm pain, weakness or numbness, and thenar or hypothenar wasting. Radial pulse may be weak. X-ray of thoracic outlet may show cervical rib—but symptoms are sometimes due to fibrous bands that are not seen on X-ray. Refer to upper limb orthopaedic surgeon for further assessment.

Neck pain resulting from stretching or tearing of cervical muscles and ligaments due to sudden extension of the neck—often due to a RTA. Pain and ↓ neck mobility typically starts several hours or days after injury. Pain may radiate to shoulders, arms, and head.

Examine carefully to exclude bony tenderness requiring X-ray. Treat with analgesia and early mobilization—collar may help initially but avoid long-term use. Recovery is often slow and 40% patients suffer long-lasting symptoms. As a general rule of thumb, the quicker the symptoms develop, the longer they will take to disappear. Early physiotherapy, if available, can improve recovery rate. Psychological problems and medicolegal issues can affect progress.

See Table 15.2.

Ask:

Triage according to history and examination—see Figure 15.1, p. 479.

Prescribe analgesia, e.g. paracetamol ± NSAIDs ± amitriptyline (10–25mg nocte) and use the Keele STarT back screening tool (see Box 15.1):

X-rays require a high radiation dose, and clinically meaningful findings are rare. Exceptions:

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Lateral curvature of the spine associated with rotation of vertebrae ± ribs or wedging of vertebrae. Early treatment prevents progression and complications, e.g. cardiopulmonary disturbance. Causes:

Difference in shoulder height; spinal curvature; difference in the space between the trunk and upper limbs. Scoliosis which disappears on bending is postural and of no clinical significance.

In all cases where structural scoliosis is suspected, refer for an orthopaedic opinion. If associated with pain, especially at night, consider spinal tumour and refer urgently.

Intra-articular disease—painful limitation of movement in all directions; tendonitis—painful limitation of movement in one plane only; tendon rupture or neurological lesions—painless weakness.

Often occurs after a history of trauma. Less common than knee or hip OA. Often associated with crystal-induced inflammation and 2° causes of OA (e.g. gout, haemochromatosis). Imaging for synovitis (USS/MRI) is important to rule out disease that may benefit from steroid injection. Shoulder replacement may be considered in severe cases.

Overdiagnosed in primary care. Affects patients aged 40–60y. Painful, stiff shoulder with global limitation of movement—notably external rotation. Pain is often worse at night. Cause unknown, but ↑ in diabetics and those with intrathoracic pathology (MI, lung disease) or neck disease.

If not known to be diabetic, check fasting blood glucose. NSAIDs, physiotherapy, and local steroid injection can all be helpful. May take >1y to recover and long-term outcome is uncertain. If restricted movements are slow to return consider orthopaedic referral.

The shoulder is the most mobile joint in the body and relies on the musculo-tendinous rotator cuff to maintain stability. Disorders of the rotator cuff account for most shoulder pain.

X-ray may show calcification of the supraspinatus tendon in acute tendinitis and irregularities/cysts at the humeral greater tuberosity if chronic cuff tendinitis.

Rest followed by mobilization and physiotherapy, NSAIDs, and/or subacromial steroid injection ( p. 166). If conservative measures fail refer for imaging, arthroscopy, and consideration for surgery.

Usually due to fall on arm or shoulder—anterior dislocation is most common. Shoulder contour is lost (flattening of deltoid) and the head of the humerus is seen as an anterior bulge. Axillary nerve may be damaged → absent sensation on a patch below the shoulder. Refer to A&E for X-ray and reduction. In young patients, ~30% have recurrent dislocations afterwards due to labral tear. Dislocation is associated with rotator cuff tear in ~25% of elderly patients.

Usually anterior and follows trauma—but 5% recurrent dislocations are in teenagers with no trauma but general joint laxity. Refer for specialist physiotherapy and consideration of surgery.

Pain on the top of the shoulder or in the suprascapular area suggests a problem with the acromioclavicular (AC) joint or neck. AC joint pain is usually due to trauma or OA—joint tenderness and pain are present on palpation and passive horizontal adduction. Management: NSAIDs ± local steroid injection.

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Inherited autosomal dominant condition. Part/all of the clavicle is missing and ossification of the skull is delayed—sutures remain open. Associated with short stature. No treatment.

Discomfort in the arm on lifting and a feeling of ‘something going’. A lump appears in the body of biceps muscle on elbow flexion. May be associated with other shoulder pathology. Management: exclude distal rupture of the tendon at the elbow. Reassure. No treatment necessary.

Common extensor tendon inflammation at the epicondyle. Cause: repeated strain.

Stop trigger movements if possible. Often settles with time ± NSAIDs. Recovery is speeded by local steroid injection ( p. 166), although relapse is more common after injection. Physiotherapy may help, as may an epicondylar clasp. Rarely referral for autologous blood injection or surgical release is indicated.

Usually due to fall on outstretched hand with flexed elbow. Ulna is displaced backwards, elbow is swollen and held in fixed flexion. May have associated fracture. Refer to A&E for reduction.

Traumatic bursitis due to repeated pressure on the elbow. Pain and swelling over olecranon. Aspirate fluid from bursa—send for microscopy to exclude sepsis and gout (request polarized light microscopy). Fluid may reaccumulate—if sepsis has been excluded, inject hydrocortisone to help settle. Refer septic bursitis for surgical drainage.

Narrowing of the ulnar grove (from OA, RA, or post-fracture) causes pressure on the ulnar nerve → ulnar neuropathy. Clumsiness with the hand is often the first symptom, then weakness ± wasting of hand muscles innervated by the ulnar nerve and ↓ sensation in the little finger and medial half of the ring finger. Rule out metabolic and autoimmune causes of a mononeuritis and refer for consideration of surgical decompression ± nerve conduction studies if entrapment is likely.

p. 1111.

Smooth, firm, painless swelling—usually around the wrist. No treatment is needed unless causing local problems. May resolve spontaneously; can be drained (large-bore needle)/excised but often recurs.

Work-related pain in the arm ± wrist, e.g. due to keyboard use. Overuse syndrome. Often termed repetitive strain injury (RSI). Diagnosis of exclusion—no physical signs. Exclude other conditions, e.g. carpal tunnel syndrome (CTS), tennis elbow.

Reassure—condition is curable, continue work, but avoid the aggravating activity, liaise with work to ensure evaluation of workstation ergonomics. Gradually reintroduce activity. Physiotherapy may help. Explore psychological and work-related issues. A multidisciplinary approach is needed. Work-related upper limb pain is a notifiable industrial disease.

Existence of RSI has been challenged—rigorous assessment often reveals undiagnosed causes of pain.

(also known as reflex sympathetic dystrophy or algodystrophy). Pain ± vasomotor changes in a limb → loss of function. Most common in the hand and wrist. Usually follows trauma—but the trauma may be trivial and signs may appear weeks/months later. Signs: pain at rest exacerbated by movement and light touch, swelling, discoloration, temperature changes, abnormal sensitivity, sweating, and loss of function. X-ray may show osteopenia.

Physiotherapy improves prognosis if started early; analgesia (NSAIDs, opioids, and/or nerve painkillers). Refer to pain clinic or rheumatology for specialist treatments, e.g. nerve block, spinal cord stimulation, CBT, and/or graded motor imagery.

Inflammation of the tendon sheath—often due to unaccustomed activity (e.g. gardening). May affect extensor or flexor tendons. Pain is often worse in the morning. Presents with swelling and tenderness over the tendon sheath and pain on using the tendon. Treat with rest and NSAIDs. If not settling, an injection of steroid into the tendon sheath may help. Notifiable industrial disease if work-related.

Tenosynovitis of thumb extensor and abductor tendon sheaths. Pain over radial styloid and on forced adduction/flexion of the thumb. Treat with thumb splint ± local steroid injection. Refer if not settling. F. de Quervain (1868–1940)—Swiss surgeon.

Pain in the radial 3½ digits of the hand ± numbness, pins and needles, and thenar wasting. Due to compression of the median nerve as it passes under the flexor retinaculum. Worse at night. Symptoms are improved by shaking the wrist. Associations: pregnancy, hypothyroidism, DM, obesity, and carpal arthritis.

Phalen’s test—hyperflexion of wrist for 1min triggers symptoms; Tinel’s test—tapping over the carpal tunnel causes paraesthesiae; request nerve conduction studies if diagnosis is in doubt.

GP treatment—night splints may help ± carpal tunnel steroid injection ( p. 166). Less likely to help if age >50y or symptoms >10mo. If GP treatment fails, constant paraesthesiae and/or triggering of fingers, refer to orthopaedics for division of the flexor retinaculum.

The lunate bone develops patchy necrosis after acute or chronic injury. The patient is usually a young adult complaining of aching and stiffness of one wrist. Examination: tenderness in the centre of the back of the wrist ± limitation of wrist extension. X-ray is normal at first but later shows ↑ density of the lunate ± deformity. Refer for orthopaedic opinion. R. Kienböck (1871–1953)—Austrian radiologist.

Pain and swelling at the base of the thumb. Thumb becomes stiff. A splint or steroid injection can be helpful. If pain persists surgery (trapeziectomy) may help.

Palmar fascia contracts so that the fingers (typically the right fifth finger) cannot extend. Prevalence: 10% ♂ > 65y (more if family history). Less common in women. Associations: smoking; alcohol; heavy manual labour; trauma; DM; phenytoin; Peyronie’s disease; AIDS. Often simple reassurance suffices. Consider referral for surgery (fasciotomy or fasciectomy) if MCP joint contracture >30° or PIP/DIP joint contracture >10°. G. Dupuytren (1777–1835)—French surgeon.

Nodules on the tendon can occur spontaneously and in RA and DM. Most common in ring and middle fingers. The nodule can be palpated moving with the tendon. Pain and triggering (the finger is in fixed flexion and needs to be flicked straight by the other hand) occur because the nodule jams in the tendon sheath. Management: local steroid injection or refer for surgical release.

The fingertip droops due to avulsion of the extensor tendon attachment to the terminal phalanx (see Figure 15.2). Refer for X-ray. Management: a plastic splint which holds the terminal phalanx in extension is worn for 6wk to help union (must not be removed). Arthrodesis may be needed if healing does not occur.

Forced thumb abduction causes rupture of the ulnar collateral ligament. Can occur on wringing a pheasant’s neck—hence the name, or, more commonly, by catching the thumb in the matting on a dry ski slope. The thumb is very painful and pincer grip weak. Refer—open surgical repair is the most effective treatment.

Protect the nail bed of an avulsed nail with soft paraffin and gauze, check tetanus status, and give antibiotic prophylaxis (e.g. flucloxacillin 500mg qds for 7d). Partially avulsed nails need removing under ring block to exclude an underlying nail bed injury—the nail is replaced to act as a splint to the nail matrix.

A blow to the finger can cause bleeding under the nail—very painful due to pressure build-up. Relieve by trephining a hole through the nail using a 19 gauge needle (no force required; just twist the needle as it rests vertically on the nail) or a heated point (e.g. of a paper clip or cautery instrument). Of benefit up to 2d after injury.

Pain on walking? Pain at rest? Hip joint pain is usually felt in the groin (see Table 15.4). Referred pain is often felt in the knee. Hip disease results in ↓ walking distance, difficulty climbing stairs and getting out of low chairs.

Hip and pelvis are common sites for 2° malignancy. Pain is severe and unremitting, day and night. Often accompanied by weight loss. X-ray may show no abnormalities or reveal lytic or sclerotic deposits. Bone scan is diagnostic but may miss myeloma. Depending on clinical circumstances either refer for specialist advice (oncologist, radiotherapist) or to palliative care. Treat with analgesia meanwhile. High risk of pathological fracture.

Major cause of hip pain and disability. Incidence ↑ with age; ♂ ≈ ♀. Predisposing factors: past hip disease (e.g. Perthes’) or trauma; unequal leg length.

Pain may be diffuse and felt in hip region, thigh, or knee. Relieved by rest in early stages of disease. Signs: ↓ internal rotation and abduction of hip, with pain at extremes of movement; antalgic gait; eventually fixed flexion of the hip. Investigation: X-ray may confirm diagnosis but is often not needed. There is poor correlation between X-ray changes and pain felt. Perform Oxford Hip Score (see Table 15.5).

Analgesia (e.g. regular paracetamol, NSAIDs), education, weight ↓, exercise, correction of unequal leg length. Walking stick ± shock-absorbing shoe insoles can help. Consider referral for physiotherapy (muscle strengthening exercises may ↓ pain) or, if significant impairment in functioning (e.g. Oxford Hip Score ≤20) to orthopaedics for hip resurfacing or replacement.

>90% achieve good result. Most last >15y. Post-op care: risk of dislocation in the first 6wk—advise to avoid crossing legs; take care with transfers; use a walking stick; no driving for 6wk. Physiotherapy is usually arranged via secondary care.

Occurs in front seat passengers in car accidents as the knee strikes the dashboard. Reduction under anaesthetic is required.

Can mimic ± coexist with hip OA. May be associated with muscle weakness around the hip. Diagnosis: point tenderness over the greater trochanter.

Consider local steroid injection if trochanteric bursitis is likely. Refer to physiotherapy for exercises to strengthen hip musculature to prevent recurrence.

Burning/numbness in the upper lateral aspect of the thigh due to compression of the lateral cutaneous nerve of the thigh. Risk factors: pregnancy, obesity, DM. Examination: extension of the hip or deep palpation just below the anterior superior iliac spine provokes symptoms. Treatment: analgesia (including neuropathic painkillers), TENS ± local steroid injection. Rarely surgical decompression is needed.

Inflammation of the fascia lata causing pain in the lateral thigh. Often due to overuse or weak musculature around the hip. Treatment is with rest ± referral to physiotherapy.

Presents with hip pain, ↓ weight, night sweats, and rigors. Be aware of infection in patients with RA, hip prosthesis, or immunocompromise. Refer for investigation. X-rays are often unhelpful—bone scan is non-specific. Admit for USS-guided drainage, bed rest, and IV antibiotics.

May present with hip pain. Have a high level of suspicion in patients with risk factors—SLE, sickle cell disease, high alcohol consumption, pregnancy, or corticosteroids. X-ray or bone scan may confirm diagnosis but MRI is most sensitive. Specialist management is needed. Usually progresses to cause OA.

Painful condition occuring in late pregnancy that may persist after delivery. The pubic symphysis separates resulting in low abdominal pain which may be accompanied by low back pain and radiate down both thighs. Pain is constant and worse on movement. It resolves on rest. Examination reveals a soft abdomen and obstetric examination is normal. Advise simple analgesia (paracetamol 1g qds). Rest in a semi-recumbent position when in pain. Refer for physiotherapy, especially if still a problem in the puerperium. Most resolve spontaneously within several months of delivery. Some persist and need specialist referral.

Always compare the two knees.

Knee pain can be referred from the hip so examine the hip as well.

Very common; X-ray evidence of OA is even more common. Treatment: education; glucosamine; analgesia (paracetamol ± NSAIDs); exercise (refer to physiotherapy). Suggest using a walking stick. Steroid injection can be helpful in some patients. If pain and disability are severe (e.g. Oxford Knee Score ≤16), refer to orthopaedics for consideration of total or partial knee replacement. Knee replacement is a very successful procedure resulting in ↓ pain and ↑ mobility. 95% prostheses last >10y.

Most commonly infected joint. Signs: hot, red, swollen, painful knee. Differential diagnosis: Reiter’s disease, gout, pseudogout, traumatic effusion, RA. If infection is suspected refer as an emergency to rheumatology or orthopaedics for investigation. Do not give antibiotics until the joint has been aspirated.

Common causes: gout, RA, calcium pyrophosphate dehydrate disease (pseudogout), spondylarthropathies (including reactive arthritis). Consider FBC, ESR, rheumatoid factor, anti-nuclear antibody, LFTs, bone biochemistry, and thyroid function tests. Drain effusion (or refer to rheumatology to drain) and send fluid for polarized light miscroscopy (for crystals) and microbiology (?infection).

If no infection, inject with long-acting steroid ( p. 164). If recurrent and no cause found, refer to rheumatology.

Detected on X-ray. Usually asymptomatic incidental finding but can cause pain due to excessive mobility of a patella fragment. If troublesome refer for fragment excision.

Lateral dislocation of the patella and tearing of the medial capsule/quadriceps can occur due to trauma. More common in young people and if joint hypermobility syndrome. Patient is in pain and unable to flex knee. Refer via A&E or orthopaedics for reduction.

Medial knee pain + knee ‘gives way’ due to lateral subluxation of the patella. Most common in girls with valgus knees. Associations: familial, hypermobility, high-riding patella. Signs:↑ lateral patella movement and +ve apprehension test (pain and reflex contraction of quadriceps on lateral patella pressure). Refer to physiotherapy for vastus medialis exercises. If that is unhelpful, refer to rheumatology to exclude a hereditary connective tissue disorder and/or to orthopaedics for consideration of lateral retinacular release.

Small tear in the patella tendon causes pain. Most commonly seen in athletes. Differential includes inferior patellar pole enthesitis (spondylarthropathies), fat-pad syndrome, anterior cartilage lesion, and bursitis. Diagnosis is with USS. Treatment is with rest, NSAIDs ± steroid injection around (not into) the tendon.

Prepatellar bursitis (housemaid’s knee) is associated with excess kneeling. Vicar’s knee (infrapatellar bursitis) is associated with upright kneeling. Avoid aggravating activity, aspirate ± steroid injection (↓ recurrence). If infected treat with antibiotics ± refer for drainage.

Popliteal cyst (herniation of joint synovium) can cause swelling and discomfort behind the knee. Usually caused by a degenerative knee. Rupture may result in pain and swelling in the calf mimicking DVT. Treat underlying knee synovitis. Surgical cyst removal may be necessary if persistent problems. W.M. Baker (1839–96)—English surgeon.

Common in contact sports. Causes knee effusion if severe ± tenderness over the injured ligament. Collateral ligaments provide lateral stability to the knee. Normally there is <5° of movement—if >5° the ligament may be ruptured. Treat with rest, knee support, analgesia. Refer to orthopaedics if rupture is suspected.

Cruciate ligaments provide anterior/posterior knee stability. Assessment can be difficult.

Refer to orthopaedics if suspected. Splinting and then physiotherapy helps most (60%) but some require reconstructive surgery—consider urgent referral if keen sportsman.

May result in locking of the joint and/or effusion. Causes: OA, chip fractures, osteochondritis dissecans, synovial chondromatosis. If problematic refer for removal.

Necrosis of articular cartilage and underlying bone. Can cause loose body formation. Cause unknown. Seen in young adults → pain after exercise and intermittent knee swelling ± locking. Predisposes to arthritis. Refer for expert management.

Twisting with the knee flexed can cause medial (bucket handle) meniscal tears and adduction with internal rotation can cause lateral cartilage tears. Symptoms/signs:

Refer for MRI ± arthroscopy. Treated by removal of the torn meniscal fragment.

Pain + swelling over the joint line due to a meniscal tear. Lateral cysts are more common than medial. The knee may click and give way. Refer for arthroscopy—removal of damaged meniscus relieves pain.

Trauma; ↑ activity, e.g. walking or running a long way for the patient; feeling of instability; pain/stiffness (relation to weight-bearing; localized/diffuse); deformity (problems getting shoes, shoes wear in odd places, or shoes are always uncomfortable); interference with activities.

Compare one foot with the other:

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Inflammation of the Achilles tendon may be related to overuse or a spondylarthropathy. Presents as a painful local swelling of the tendon. Advise rest. NSAIDs, heel padding, physiotherapy ± steroid injection may help (never inject into the tendon). If persistent refer to rheumatology.

Presents with a sudden pain in the back of the ankle during activity (felt as a ‘kick’). The patient walks with a limp. There is some plantar flexion, but the patient cannot raise the affected heel from the floor when standing on tiptoe. A ‘gap’ can usually be felt in the tendon. Calf squeeze test is −ve (squeezing the calf muscles results in movement of the foot if the Achilles tendon is intact). Refer immediately for consideration of repair. The alternative is immobilization in a splint with the foot plantar flexed.

High foot arches may be idiopathic, due to polio, spina bifida, or other neurological conditions. Toes may claw. Padding under the metatarsal heads relieves pressure. Operative treatment—soft tissue release or arthrodesis—straightens toes. Can lead to tarsal bone OA causing pain—refer for fusion.

Patients trip frequently or walk with a high stepping gait. On examination, patients are unable to walk on their heels and cannot dorsiflex their foot. Check ankle jerk. Causes:

Dull throbbing pain under the heel. Develops a few months after heel trauma. May be due to plantar fasciitis, bursitis, or tendinitis. Treat with rest and heel padding. Refer to physiotherapy—ultrasound treatment can help. Blind steroid injections into the fat pad are not recommended. In persistent cases refer to rheumatology.

Common cause of inferior heel pain, especially amongst runners. Pain is worst when taking the first few steps after getting out of bed. Usually unilateral and generally settles in <6wk. Advise shoes with arch support, soft heels, and heel padding (e.g. trainers). Achilles tendon-stretching exercises can help; NSAIDs and steroid injection are also helpful. In persistent cases refer to podiatry (for fitting of an insole) ± orthopaedics.

May be due to synovitis, stress fractures, sesamoid fracture, injury or ↑ pressure on the metatarsal heads due to mechanical dysfunction (e.g. in RA). Treat with insoles and padding under the metatarsal heads. Surgery may be helpful in RA—discuss with rheumatologist.

Pain due to entrapment of the interdigital nerve between the third/fourth metatarsal heads (usually). Gradual onset of sudden attacks of pain or paraesthesia during walking. Refer to orthopaedics. Treatment is with steroid injection and advice on footwear. Some need surgical excision of the neuroma. T.G. Morton (1835–1903)—US surgeon.

See Figure 15.2.

If causing pain or difficulty with walking/footwear, refer for surgery.

Lateral deviation of the big toe at the MTP joint exacerbated by wearing pointed shoes ± high heels. A bunion develops where the MTP joint rubs on footwear. Arthritis at the MTP joint is common. Bunion pads can help but severe deformity requires surgery.

Arthritis at first MTP joint causes a stiff, painful big toe. Refer severe cases to podiatrist or orthotist for offloading or custom-made rocker-bottom foot orthoses. Resistant pain requires surgery.

Most common in the big toe. Ill-fitting shoes and poor nail cutting predispose to the nail growing into the toe skin → pain. The inflamed tissue is prone to infection. Advise about cutting nails (cut straight with edges beyond the flesh). Refer to podiatry. Treat infection with antibiotics (e.g. flucloxacillin 250–500mg qds). If recurrent infection, consider referral for surgery (e.g. wedge resection of the nail).

British Orthopaedic Foot and Ankle Society    www.bofas.org.uk

GPs are commonly asked to certify fitness to perform sports. Normally the patient will come with a medical form. If there is a form, request to see it before the medical. If there is no form and you are unsure what to check, telephone the sport’s governing body or the event organizer. A fee is payable by the patient. Many gyms/sports clubs also ask older patients/patients with pre-existing conditions or disabilities to check with their GP before they will sign them on. Assuming that a suitable regime is undertaken most people can participate. Consider the patient’s baseline fitness, check BP and medications and recommend gradual introduction to new forms of exercise.

Remember—signing a form may result in legal action against you should the patient NOT be fit to undertake an activity. Where possible, include a caveat, e.g. ‘based on information available in the medical notes the patient appears to be fit to … although it is impossible to guarantee this.’ If unsure, consult your local LMC/medical defence organization.

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Recommend a normal varied diet ( p. 174).

Most regulating bodies have strict codes regarding drug use. Regulations may differ between different sports. Status of a particular medicine may be checked in the Global Drug Reference Online (  www.globaldro.com).

Generally paracetamol, all NSAIDs, and codeine are allowed for pain relief. Stronger opioids and drugs containing caffeine are banned. If in doubt, check on the Global Drug Reference before prescribing.

Significant problem in the UK (5% in gyms and fitness clubs). Drugs are often used in complicated regimes at high doses to ↑ lean muscle mass and ↓ body fat. Side effects include:

Other drugs may be taken in conjunction with anabolic steroids to ↓ these side effects.

Consider:

Liaise with a sports medicine physician or physiotherapist early.

Incidence is increasing due to increasingly intensive training regimes, especially in young adults—even amongst amateurs.

Exercise-related shin pain may be due to a stress fracture of the tibia, compartment syndrome, or periostitis. Fractures are not always seen on X-ray—bone scan is more sensitive and shows periostitis. Treat with rest and analgesia. Consider referral to sports physiotherapist.

Pain due to inflammation of the synovium under the iliotibial tract from rubbing of the tract on the lateral femoral condyle. Seen in runners. Treat with rest, NSAIDs, specialist physiotherapy ± steroid injection.

Poor performance, fatigue, heavy muscles, and depression due to excessive sports training or competing without sufficient rest. Usually diagnosed from history. Exclude other causes of fatigue ( p. 528). Manage with rest, reassurance, and alteration of training programme.

Herpes simplex virus is very contagious and outbreaks among sporting teams are common, e.g. spread by close contact and facial stubble grazes whilst scrumming. Treatment: aciclovir (cream or tablets) and exclusion of infected players. Impetigo, erysipelas, and tinea barbae can be transmitted in the same way.

Abnormal osteoclast activity causes accelerated disorganized bone remodelling. Affects 1–2% of UK adults; 15% have a FH. ♂:♀≈ 3:1. Most common in the elderly—only a minority are symptomatic. Affects just one bone in 1 in 3 cases.

Pain—dull ache aggravated by weight-bearing often remains at rest; deformity—bowing of weight-bearing bones, especially tibia (sabre), femur, and forearm usually asymmetrical; frontal bossing of the forehead; distinctive changes on X-ray; ↑ bone-specific alk phos; normal Ca²⁺, PO₄  ^3–, and PTH.

Refer to rheumatology. Give analgesia. Oral/IV bisphosphonates ↓ pain and long-term complications. Complications: pathological fracture; OA of adjacent joints; high-output CCF; hydrocephalus and/or cranial nerve compression → neurological symptoms, e.g. deafness; spinal stenosis; bone sarcoma (rare—0.1–1.15%).

Infection of bone. May spread from abscesses or follow surgery. Often no primary site is found. More common in those with DM, sickle cell disease, impaired immunity, and/or poor living standards. Organisms involved: S. aureus, streptococci, E. coli, Salmonella, Proteus, and Pseudomonas species, TB. Presents with pain, unwillingness to move affected part, warmth, effusions in neighbouring joints, fever, and malaise. Blood cultures are +ve in 60%; ↑ ESR/CRP; ↑ WCC.

Refer suspected cases for same-day orthopaedic opinion. Diagnosis is confirmed with imaging, e.g. MRI or bone scan (X-ray changes can take days to appear). Treatment: is with IV then po antibiotics (≥6wk) and surgery to drain abscesses. Complications: septic arthritis, pathological fracture, deformity of growing bone, chronic infection.

Occurs after delayed/inadequate treatment of acute osteomyelitis. Signs: pain, fever, and discharge of pus from sinuses. Follows a relapsing/remitting course over years. Needs specialist management.

Is cancer of the bone or connective tissue. 2,300 patients/y are diagnosed with sarcoma in the UK, and it causes 1,000 deaths. There are 2 peaks of incidence—1 in teenagers and another in old age. 5 types of sarcoma account for >80% of tumours:

Present with aching bone pain, swelling ± pathological fracture. If X-ray is normal, but symptoms persist, consider checking bone function tests, re-X-raying, discussing the patient with a specialist or referral. Treatment involves surgery and chemotherapy. Overall 5y survival is 50–80%.

Usually presents with a palpable lump. The most common tumours are leiomyosarcoma, liposarcoma, and synovial sarcoma. Treated with surgery ± radiotherapy (high-grade tumours). Chemotherapy is reserved for palliation.

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Usually presents late. Often arises in the retroperitoneum. If possible, surgery is the main treatment. Local relapse is common and often not responsive to cytotoxic therapy.