Musculoskeletal pain is very common, may be acute or chronic, and is a major cause of morbidity and occupational sickness absence. Studies have found a prevalence of chronic musculoskeletal pain in approximately 13% of the adult Danish population, 16% of adults in the UK, and 40% to 67% of women in New Zealand. Over 20% of adults in Sweden report having back pain or shoulder pain. Back pain is the second most common cause of loss of productive work time in US adults (after headache), accounting for a mean loss of over 5 hours' work time each week in those affected. Sickness absence and reduced productivity while at work caused by common pain conditions have been estimated to cost US businesses $61.2 billion per year.
Chronic fibrosing condition characterised by insidious, progressive, and severe restriction of both active and passive shoulder range of motion. Many patients experience shoulder pain, but shoulder pain is not an essential component of adhesive capsulitis.
Although other fractures around and including the ankle can occur (such as distal tibial plafond fractures), the term 'ankle fracture' generally refers to the medial, lateral, or posterior malleolus.
An inflammatory arthritis predominantly affecting the sacroiliac joints and axial spine. Inflammatory back pain is the hallmark clinical feature. This is defined as back pain/stiffness, which is worse in the morning and improves with exercise.
Injury typified by sudden, painful, audible 'pop' noise. Patient typically presents with inability to return to activity, joint instability, and rapid development of effusion (haemarthrosis). Often tender at lateral femoral condyle, lateral tibial plateau, and tibiofemoral joint lines.
Various spinal structures including ligaments, facet joints, paravertebral musculature and fascia, intervertebral discs, and spinal nerve roots have been implicated as pain generators.  The aetiologies can be subdivided into 3 groups: mechanical, systemic, and referred. By far the most common cause is mechanical (97%).However, the majority of patients (85% or more) who present to primary care have low back pain that cannot reliably be attributed to any specific cause (non-specific low back pain).
Most commonly results from motor vehicle accidents, gunshot or stab wounds, contact sports, or workplace accidents during heavy physical labour. The effects of the injury include paralysis, loss of sensation, and pain. The specific clinical presentation will depend on the nerve roots involved and the degree of injury to each root.
A bursa is a sac containing a small amount of synovial fluid that lies between a tendon and either skin or bone to act as a friction buffer. In bursitis, there is thickening and proliferation of the synovial lining, bursal adhesions, villus formation, tags, and deposition of chalky deposits. This may result from repetitive stress, infection, autoimmune disease, or trauma. Key diagnostic findings are localised pain and tenderness over a bursa and swelling if superficially sited.
Calcium pyrophosphate arthritis is caused by deposition of articular calcium pyrophosphate (CPP) crystals. It can be difficult to diagnose. CPP crystals in synovial fluids can be small, sparse, and difficult to find. It typically occurs in older patients. In patients under the age of 60 years, underlying metabolic conditions associated with calcium pyrophosphate deposition, such as hyperparathyroidism or haemochromatosis, should be investigated.
Most common entrapment neuropathy. Symptoms include numbness and/or tingling of the thumb and radial fingers, aching wrist, and clumsiness.
Acute spinal cord trauma is a medical emergency that requires swift diagnosis and treatment to prevent irreversible spinal cord injury and long-term disability.
Osteoarthritis of the spine, including the spontaneous degeneration of either disc or facet joints. Presenting symptoms include axial neck pain and neurological complications.
Sudden or gradual onset of significant impairing fatigue not explained by known biological agents or disease processes. The syndrome is associated with progressive functional impairment, depression, fragmented sleep, and medication intolerance.
Chronic pain is one of the most common reasons for seeing a primary care physician. There are many causes of chronic pain, and these may be attributed to musculoskeletal causes, neurological causes, causes of headaches, psychological causes, or as part of a generalised systemic disease process. The prevalence of chronic pain increases with age, affecting nearly 30% of older people. Typical aetiologies in this population are arthritis, osteoporosis with fractures, and lumbar stenosis. These conditions are treatable and should not be considered part of the normal ageing process. Untreated chronic pain in older patients can result in depression, poor quality of life, and loss of independence.
Disabling pain in the coccyx, usually provoked by sitting or rising from sitting. May be traumatic (e.g., a fall or childbirth) or idiopathic in origin.
A pathological condition characterised by an elevation of the interstitial pressure in a closed osseofascial compartment that results in microvascular compromise. Can be caused by fracture, compartment haemorrhage, or direct soft-tissue or direct muscular injury.
Prolonged pain, disproportionate to the initiating event, most frequently a minor trauma and most commonly affecting the distal aspect of an extremity. Pain is often described as spontaneous, burning, lancinating, sharp, shooting, or electric. Characteristically develops dull, boring, and aching qualities with chronicity.
Presents with insidious onset of anterior chest wall pain exacerbated by certain movements of the chest and deep inspiration. Key sign is pain on palpation of costochondral joints (particularly the second to the fifth).
Lumbar discogenic back pain is the presence of low back pain, with or without radicular symptoms, with a chronic progressive pattern. Red flags including night pain, unexplained weight loss, fever, or symptoms of the gastrointestinal, urinary, and cardiorespiratory systems should always be part of the clinical assessment, as their presence may suggest an alternative diagnosis for back pain.
Typically occurs during the fourth and fifth decades of life. Patients describe a history of activities contributing to overuse of the forearm muscles that originate at the elbow. Patients with epicondylitis report pain during or following elbow flexion and extension.
Patients (usually women) present with chronic, widespread body pain and often also have fatigue, stiffness, and unrefreshing sleep. Criteria consist of adding up the number of body sites of pain, as well as the presence and severity of frequent comorbid symptoms such as fatigue, memory problems, and sleep disturbances.
Smooth, soft, benign masses that are usually located on the wrist. Patients may experience occasional aching discomfort secondary to compression of surrounding structures. In some patients, this aching is only present after activity. Occult ganglia are usually undetectable by physical examination but may be a cause of vague wrist pain.
Acute onset of severe joint pain. Swelling, effusion, warmth, erythema, and/or tenderness of the involved joint(s). The disease most commonly affects the first toe (podagra), foot, ankle, knee, fingers, wrist, and elbow; however, it can affect any joint.
Most common presentation for intra-articular pathology of the hip joint; however, referred pain from other sources is not uncommon. Signs and symptoms typically include activity-related pain, pain with movement of the hip, and antalgic gait.
Associated most commonly with low-energy injury (e.g., fall from standing height) and osteoporosis or osteopenia. The risk increases significantly with age.
Iliotibial band syndrome is the most common cause of lateral knee pain in runners, related to repetitive friction of the iliotibial band sliding over the lateral femoral epicondyle. Runners predisposed to this injury are typically in a phase of overtraining and often have underlying weakness of the hip abductor muscle.
Complete separation of 2 articulating bony surfaces, often caused by a sudden impact to the joint. Typically, patients have significant pain on movement and are significantly apprehensive about motion of the affected joint. Diagnosis is usually confirmed with plain x-rays.
Inflammatory arthritis is a common term for several conditions that manifest as joint pain, swelling, and stiffness with varying degrees of functional impairment. In cases of pain and swelling in a single joint, acute infection is a relatively common cause - one that can result in rapid and irreversible damage. In contrast, the majority of patients with involvement of multiple joints tend to have disorders of chronic duration.
Most common chronic arthropathy of children and includes several subtypes. Affected joints can be painful, especially during motion and on palpation. Objective arthritis in joints for at least 6 weeks is necessary for diagnosis.
Acute knee injuries are a new-onset disease process or new injury. By most definitions, acute knee injuries are defined as being diagnosed within the first 30 to 45 days of the injury or onset of symptoms. Chronic knee injuries are due to residual old trauma or surgery, existing degenerative diseases, or previous conditions not resolved within the first 30 to 45 days after the onset.
Occurs when excessive valgus stresses or external rotation forces are placed on the knee joint. Most common symptom is medial-sided knee pain above or below the joint line. Patients are usually able to walk. Diagnosis and grading is primarily done with history taking and physical examination.
An injury of 1 or both menisci, which are located in the knee joint between the femoral and tibial articulating surfaces. A meniscal tear can occur suddenly through a traumatic incident, or it can develop gradually within the course of age-related wear of the knee. It usually causes pain in the knee joint.
Although the majority of cases of muscle cramps are of a benign, self-limiting nature, muscle cramps can also be symptomatic of a wide variety of potentially serious systemic disorders.
Pain, stiffness, and/or soreness of the lumbosacral region lasting less than 12 weeks. Diagnosis made by eliminating specific low back pain caused by neurological compromise, neoplasia, inflammatory arthritis, fracture, or referred pain from other locations or organ systems.
A strain is an injury to the muscle or musculotendinous junction, whereas a sprain is an injury to the ligament. History and physical examination are key in diagnosis and grading of the injury as grade 1 (mild), 2 (moderate), or 3 (severe with complete rupture).
Neck pain is one of the most common presenting symptoms of cervical spine disease. Patients may present acutely, particularly in the setting of trauma, or with more chronic pain. The estimated lifetime prevalence of a significant episode of neck pain is 40% to 70%. When assessing a patient with neck pain, it is important to consider the possibility of neck pain caused by significant secondary causes (e.g., primary or metastatic cancer) and to detect neck pain associated with neurological compromise.
Repetitive tasks in the workplace can cause a variety of overuse syndromes as diverse as the occupations that may cause them. A patient's occupational history is vital in diagnosing the injury. Pain from these disorders can persist and cause work disabilities if left unchecked, and without secondary prevention strategies in place.
Overuse syndrome of the paediatric population, which results in traction apophysitis of the tibial tubercle. Typically occurs during an adolescent growth spurt in young athletes who participate in sports that involve repeated knee flexion and forced extension. Males are affected more often than females. Diagnosis is clinical; patients typically present with pain, swelling, warmth, and localised tenderness to palpation over the tibial tubercle.
Degenerative joint disorder. The prevalence increases with age. The most commonly affected joints are the knee, hip, hands, and lumbar and cervical spine. Patients present with joint pain and stiffness that is typically worse with activity. Radiographs show loss of joint space, subchondral sclerosis, and osteophytes.
Majority of patients are adolescent or young adult athletes. Main joints involved include the knee, ankle, and radiocapitellar joint of the elbow. Variable presentation: traumatic or atraumatic, insidious onset, non-specific joint pain, exacerbation of symptoms with exercise (especially stair or hill climbing), recurrent effusion, catching, or locking.
Vitamin D deficiency is the most common cause. Patients frequently complain of diffuse bony pain with a history of limited sunlight exposure. Proximal muscle weakness, spinal tenderness to percussion, pseudofractures, and skeletal deformities are found commonly.
An infection of the bone that presents a variety of challenges to the physician. The severity of the disease is staged depending upon the infection's aetiology, pathogenesis, extent of bone involvement and duration, and host factors particular to the individual patient. Osteomyelitis may be either haematogenous or caused by a contiguous spread of infection. Staphylococcus aureus is the most common organism isolated.
Asymptomatic until fracture occurs. Diagnosis based on history of prior fragility fracture or low bone-mass density, which is defined as a T-score <-2.5. Screening is based on individual risk factors, including older age, female sex, maternal history of fragility fractures/osteoporosis, post-menopausal, low BMI, and tobacco use.
Patients may report sudden back pain from atraumatic activities such as standing from a seated position, bending forward, or coughing and sneezing. Pain is characteristically exacerbated by movement.
Worsening pain over weeks to months is the first and most common symptom. Pain is usually mild initially, becoming more severe. It is often reported as more severe at rest and at night. The pain is often described as deep, dull, boring, and relentless.
Chronic localised bone remodelling disorder characterised by increased bone resorption, bone formation, and remodelling, which may lead to major long bone and skull deformities. Majority of patients are asymptomatic, but may present with severe pain in long bones and, rarely, in some facial areas.
Patellofemoral pain syndrome is one of the most common disorders of the knee seen in a sports medicine clinic. The causes of patellofemoral problems are multifactorial, including abnormal patellofemoral joint mechanics, lower kinetic chain alterations, and overuse.
Most commonly affects people between 40 and 60 years of age who are overweight or obese. Also occurs in 10% of runners. Pain may radiate to the lateral heel. To make a diagnosis of plantar fasciitis, the pain must be relieved with rest.
Typically a history of neck, shoulder girdle, and/or hip girdle stiffness and pain, occurring in patients aged 50 or older. Patients complain of difficulty rising from seated or prone positions, varying degrees of muscle tenderness, shoulder/hip bursitis, and/or oligoarthritis. More common in women. 15% to 20% of patients with polymyalgia rheumatica (PMR) have giant cell arteritis (GCA); 40% to 60% of GCA patients have PMR.
Usually the result of pathology of the knee joint, such as arthritis or a cartilage tear. Patients may present with swelling behind the knee or pain, but in most cases there will be no symptoms. A popliteal cyst may rupture, leading to severe pain and swelling in the calf.
Chronic inflammatory joint disease associated with psoriasis. Psoriatic arthritis frequently presents in a pattern of monoarticular or oligoarticular joint involvement. In patients with multiple joints involved, the pattern lacks the symmetry of rheumatoid arthritis.
An inflammatory condition that occurs after exposure to certain gastrointestinal and genitourinary infections, particularly Chlamydia species, Campylobacter jejuni, and Salmonella enteritidis. Patients may give a history of an antecedent genitourinary or dysenteric infection 1 to 4 weeks before the onset of arthritis. Presenting features include systemic symptoms such as fever, peripheral and axial arthritis, enthesitis (inflammation where tendons insert into bone), dactylitis (swelling of an entire finger or toe), conjunctivitis and iritis, and skin lesions including circinate balanitis and keratoderma blennorrhagicum.
The most common inflammatory arthritis, characterised by symmetric arthritis of the small joints of the hands and feet. A chronic, erosive arthritis that requires aggressive treatment.
Middle ribs are most commonly fractured. The lower rib can injure the diaphragm if fractured. The first rib is the least commonly fractured but can result in brachial plexus injury.
Deficient mineralisation at the growth plate of long bones results in growth retardation. If the underlying condition is not treated, bone deformity occurs, typically causing bowed legs and thickening of the ends of long bones. Only occurs in growing children before fusion of the epiphyses, typically affecting wrists, knees, and costochondral junctions. Occurs primarily because of a nutritional deficiency of vitamin D, but can be associated with deficiencies of calcium or phosphorus.
Common shoulder condition, especially in older and active patients. Tears can be symptomatic or asymptomatic. Cause of tear can be traumatic or attritional.
Adolescent idiopathic scoliosis is a structural spinal deformity characterised by decompensation of the normal vertebral alignment during rapid skeletal growth in otherwise healthy children. Back pain is usually minimal or absent at presentation. Significant pain at presentation should warrant a careful evaluation for other causes of the spinal deformity.
The disorder is typically seen in the adolescent age group. May present with an acute/insidious onset of pain and limp. Obligatory external rotation on hip flexion is a key examination finding.
Can occur as a result of spine trauma, vertebral compression fracture, intervertebral disc herniation, primary or metastatic spinal tumour, or infection.
Condition typically resulting from degenerative changes in the lumbar spine. Neurogenic claudication characterised by back and leg pain and lower-extremity paraesthesia brought on by ambulation and relieved by sitting.
Sport-related injuries may be generally categorised as acute or chronic; the range of medical conditions potentially resulting from sport- or exercise-related injuries is wide. More than 90% of all sport-related injuries are either contusions or strains.
A self-limiting inflammatory disorder of the hip that commonly affects young children. Presents acutely with mild to moderate hip pain and limp.
Includes several disorders of the mandibular joint, including myofascial pain and dysfunction, internal derangement, and osteoarthritis. Typically presents with 3 characteristic features: temporomandibular joint pain, noise in the joint, and limited mandibular movement.
General term that describes tendon degeneration characterised by a combination of pain, swelling, and impaired performance. Common sites include the rotator cuff (supraspinatus tendon), wrist extensors (lateral epicondyle) and pronators (medial epicondyle), patellar and quadriceps tendons, and Achilles' tendon.
Tenosynovitis of the hand and wrist is a group of entities with a common pathology involving the extrinsic tendons of the hand and wrist and their corresponding retinacular sheaths. It usually starts as tendon irritation manifesting as pain, and can progress into catching and locking when tendon gliding fails because of tendon entrapment.
Usually occurs as a result of high-energy trauma (e.g., road traffic accidents, falls from heights). May occur spontaneously in patients with osteoporotic, neoplastic, or metabolic disorders of the spine.
Lower-extremity torsional abnormalities are a commonly seen clinical entity in the paediatric population. These are commonly attributed to one or more of the following: femoral or tibial torsion, soft-tissue contractures, abnormal muscle tone, hindfoot varus/valgus, and forefoot adduction/abduction.
Fractures of the distal radius are the most common fracture in adults. Typically caused by a fall on the outstretched hand. May be accompanied by fractures of the ulnar styloid or the distal ulna and of the scaphoid. Isolated scaphoid fractures may also occur.
BMJ Publishing Group
This overview has been compiled using the information in existing sub-topics.
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