1. Common Musculoskeletal (MSK) Presentations in Primary Care
Common Musculoskeletal (MSK) Presentations in Primary Care. Dr Neil Langridge MSc MMACP Consultant Physiotherapist

2. Aims.
To introduce the most common MSK conditions seen in primary care.
To introduce the common signs/symptoms of these conditions.
To introduce the relevancy of physical testing.
To introduce the relevance of investigations.

3. Low back pain Common benign condition. 85% Mechanical
5%-15% Associated with radiculopathy (Sciatica)
< 5% serious

4. The most challenging patient!

6. What are the key features of disability in LBP?
History
Clinical Exam
Depression
Poor sleep
Anxiety
Catastrophizing
Maladaption
Previous LBP
Work/social issues assoc with LBP
Widespread hyperalgesia
Non-mechanical features
Allodynia
Dysaesthesia
Latent response

7. Use of imaging for LBP X- ray – unhelpful (unless ? Fracture)
MRI - Unless ? Serious pathology
CT – For Surgical opinions (or non-MRI)
Early use of MRI increases chances of disability, reduces a return to work and increases chances of surgery.
Surgery for LBP – outcome no different than rehab

8. What are the key red flags?
History of Ca – Breast, prostate, Lung
Severe night pain
New onset LBP over 55
Young spine
CES – poorly interpreted.
Weight loss, night sweats, constant

9. Useful Tests Observation – deformity ROM Clear the HIP
Neurological testing
Palpation

10. Management Advice to stay active. Simple analgesia – taken regularly.
Try to remain at work.
No need to seek medical support unless increased analgesia needed.
Use STarTBack to inform.

11. Sciatica
Leg pain – generally below the knee, with potentially Pins and Needles/Numbness.
Average time – 6-8 weeks
Highly disabling
Can be recurrent
Most treated conservatively

12. Leg pain worse than back pain – in many cases no LBP
Not always dermatomal
Cross over sign
Slump if SLR less reactive

13. Imaging for sciatica MRI helpful Worsening neurological compromise
Severe leg pain at 6 weeks.

14. Management Analgesics
Neuropathic mediators if after 2 weeks symptoms unchanging and sleep is disturbed
Seek investigation with motor loss/worsening leg pain
Injections/surgery

15. The Neck
Whiplash
Referred pain
Neurological compromise
Myelopathy

16. Myelopathy UMN tests Babinski Hoffmans Roos Hyper-reflexia
If suspect – needs specialist assessment

17. Whiplash Advice Gentle exercise Appropriate pain medication
Clear any neurological loss
Physio is helpful
Can take many months to resolve

18. Radicular pain As per sciatica Tends to resolve Injections are risky
Do well with neuropathic medication

19. Management
Physiotherapy
Analgesia
Injections
Surgery

20. The Shoulder - Osteoarthritis
Age
Pain, stiffness and crepitus
Observation
Loss of range of motion – active & passive
+/- cuff weakness
Xray 20

21. Frozen Shoulder Age: Normally >45yrs
Typical onset – pain & stiffness
Natural history -9/12 to 2yrs +
Loss of active & passive ROM
No true loss of power
Normal X-ray 21

22. Management Physiotherapy – in some cases It has a natural history
Injections for night pain
V rare need surgery

23. Rotator Cuff Age and vascularity of the tendon
Natural history –Repetitive movement of the arm
Presentation
Management options 23

24. Impingement Loss of ROM Painful arc
No massive loss of External Rotation
Passive Rom improves
Rest/NSAIDs
Physiotherapy
Time
X-ray
Injection
Refer

25. Knee OA
Trauma – soft tissue
Degenerative meniscal
Patella-femoral

26. OA knee

27. Management Physiotherapy – lifestyle Weight loss Exercise – therapies
Injections
If all fails - surgery

28. Patella-femoral Young Tends to affect females more than males
Worse up and down stairs
Pain at front of knee
No obvious swelling

29. Soft tissue Locked knee – immediate referral
Trauma – 2 weeks if not improving RICEM – needs assessment
Degenerative meniscal after 50
Tendonitis/bursitis

30. Hip OA
Bursitis
Labral Tear
Dysplasia

32. OA Groin Buttock Anterior thigh pain – referral pattern
Loss of rotation
Putting shoes on/etc

33. Bursitis Lateral or posterior thigh pain Biomechanical
Worse at night and after sitting
Rest, ICE etc
Can be injected

34. Labral Tear
Catching/after actvity
Younger/sporting
FABER/FADIR/Scoop
Modify activity
X-ray – Cam/Pincer lesion/impingement
Ortho Consultant opinion

35. Elbow Tennis/golfers elbow Natural resolution in most cases
Inflammatory/chronic tendon changes
Physio/relative rest
Injections
Surgery

36. Foot/Ankle
Sprain – lateral
Plantar Fascia
Hallux valgus

37. Inversion injuries
This patient decided to play on for 30 minutes after serious tendon injury!

40. Thank you for your attention.