MF3 CRE Practice Questions MSK

1. MF3 CRE Practice QuestionsMSK Anne Dang, CCPA Orthopaedic Surgery Physician assistant McMaster University Physician Assistant Education Program Class of 2011 anneccpa@gmail.com Last Updated June 24, 2013 Special thanks To: Dr. Clark, physiatrist OhoodElzibak., Mcmasterpaep Class of 2010 Jacob eappen., mcmasterpaep Class of 2014

2. Disclaimer All of these names and cases are fictitious but based on clinical presentations that real patients may present with. Similarities to anyone in real life is coincidental and unintended. The opinions expressed on this PowerPoint are those of the author, and they do not reflect in any way those of the institutions to which they are affiliated. This PowerPoint is for educational purposes only. It is not intended as a substitute for the diagnosis, treatment and advice of a qualified licensed professional. In no way should anyone consider that this presentation represents the "practice of medicine." The author assumes no responsibility for how this material is used. Also note that the information is updated on occasion and due to a variety of reasons, therefore, some information may be out of date.

3. Obligatory Preamble Written in the style of CRE (was called CAE back in 2010) based on case studies that were given to the Class of 2011 in MF3 for the Orthopaedics section MSK is an enormous topic, in addition to typical cases you’d see in Orthopaedics, there is a lot of overlap with Rheumatology, Physiatry, Neurology… you name it! With that being said, do not limit your differential to just “Muscles and bones”, think metabolic, systemic, inflammatory, neoplastic just like you would in a real clinical scenario. This in no way reflects the kind of questions you will receive on the CRE, purpose is to have you practice answering the question style and to review important topics in MSK. I am open to feedback about the cases, please contact me (anneccpa@gmail.com) if you have any questions or concerns.

4. Study Tips Rather than memorizing a checklist of etiology, symptoms & investigations - try to understand the pathophysiology or why, the former then comes more easily As JC puts it “Broad Brush Strokes”! Don’t get bogged down by the nitty gritty details. Try to think about what is will be relevant in understanding what is going on with the patient, and how that affects your choice of management

5. Outline Case 1: Shoulder Pain Case 2: Knee Pain Case 3: Joint Pain Case 4: Developmental abnormality Case 5: Back Pain Outline Review

6. Case 1: Shoulder Pain Reference case MF3 : Case 16c Mike ChiassoN 45 year old male with shoulder pain

7. Case 1: Shoulder Pain John, a 62-year-old male electrician presents to your family doctor’s office with a 3 year history of right shoulder pain. He cannot recall any specific injury or inciting event, but notes the pain has been getting worse over time. He says the pain is aggravated at work, especially when he is lifting above the level of the shoulder or doing any work overhead for a long period of time and is better with rest. He localizes the pain to the anterolateral aspect of the shoulder with no radiation. He has tried ice and heat with no relief, and has not tried any other modalities of treatment. He denies any numbness or tingling. Review of systems is otherwise unremarkable. He is a non-smoker and non-drinker.

8. Based on this gentleman’s history, name three differential diagnosis and the reasoning for why you included each on your differential in the order of most likely to least likely. • What findings on physical exam would you expect to observe based on what you think is the most likely diagnosis? • What investigations would you order? What would you expect to find based on what you think is the likely diagnosis? • Briefly explain what treatment options are available to John. QuestionsCase 1: Shoulder Pain ________________ John, a 62 year old male electrician presents to your family doctor office with a 3 year history of right shoulder pain. He cannot recall any specific injury or inciting event, but notes the pain has been getting worse with time. He says the pain is aggravated at work, especially when he is lifting above the level of the shoulder or doing any work overhead for a long period of time and is better with rest. He localizes the pain to the anterolateral aspect of the shoulder with no radiation. He has tried ice and heat with no relief, and has not tried any other modalities of treatment. Review of systems is otherwise unremarkable. He is a non-smoker and non-drinker

9. At the top of your Differential: • Rotator Cuff Pathology (tear or impingement) • can be traumatic or atraumatic (chronic); • commonly aggravated by overhead activities; • pain typically localized to anterolateral aspect of shoulder; • AC joint osteoarthritis • pain usually presents over the AC joint (superolateral aspect of shoulder) • Shoulder Osteoarthritis (OA) • Usually presents in elderly or after an injury (post-traumatic OA) • Painful & stiff in the morning and gets better throughout the day • Patients often describe “grinding” in the shoulder (this is a result of ‘bone on bone’ arthritis) • Adhesive Capsulitis (“Frozen Shoulder”) • Can present very similarly to rotator cuff tears, except patients may explain “stiffness” is their most predominant complaint. • Risk factors including smoking and Diabetes, can be idiopathic • Biceps Tendinopathy/Tendon Partial Tear Answers to Case 1QUESTION 1 Concepts to Review: Rotator Cuff Tears Shoulder Anatomy/ Rotator Cuff Muscles Helpful (Quick) Reads American Family Physician: Management of Shoulder Impingement Syndrome & Rotator Cuff Tears Examples of Differential Diagnosis for Acute/traumatic presentations of shoulder pain: American Family Physician Diagnosing Rotator Cuff Tears: American Family Physician

10. Based on a Diagnosis of Rotator Cuff Tear/Impingement Inspection: • You may or may not see rotator cuff muscle wasting, depending on severity of the tear or chronicity of the problem Palpation • Tenderness over the superolateral aspect of shoulder Active Range of Motion • If its just impingement or rotator cuff tear alone, range of motion may be full, but painful • Forward flexion and abduction are either limited or painful above 90 degrees. Power • Should be at least 3+/4- on the Oxford power scale, and limited by pain; you may be dealing with something else if power is less than this. Neurovascular Status • Rotator cuff tears/impingement does NOT cause numbness or tingling on the affected extremity in most cases! If a patient presents with this, you must adjust your differential diagnosis! (e.g. Thoracic Outlet Syndrome, Brachial Plexus Neuropathies, etc.) Special/Provocative Tests • Positive Impingement Sign/Testing Answers to Case 1QUESTION 2 Concepts to Review: Shoulder Physical Exam (inspection, palpation, range of motion, power, neurovascular assessment) Shoulder Exam “Special Tests” Impingement Biceps testing – biceps pathology Labral testing – rule out SLAP/labral tears Apprehension test – rule out shoulder instability (e.g. recurrent shoulder dislocations) Helpful Resource: Physical exam of the shoulder: AAFP http://www.aafp.org/afp/2000/0515/p3079.html

11. Based on diagnosis of Rotator Cuff Tear/Impingement • X-Ray: Rule out any bony abnormalities. X-rays in rotator cuff tears may be normal or demonstrate narrowing of the subacromial space. • If the problem is chronic, there will be long term changes (extra details: superior migration of the humeral head, narrowing of the subacromial space, spurring on the undersurface of the acromion). • Ultrasound: Will often display tendinosis, partial or complete tearing of the supraspinatus tendon or other rotator cuff muscles. • MRI: Usually a more definitive test to determine more precisely the size & location of the rotator cuff tear/impingement/tendon inflammation. Useful if you plan on referring to a specialist for a surgical opinion (i.e. orthopaedic surgeon). In clinic: we usually order x-ray and ultrasound together first since they are the fastest and cheapest, MRI waiting list in Hamilton is 2-3 months) Other (extra knowledge) • CT Scan: If the x-ray comes back abnormal (e.g. bony lesions/depressions). Usually ordered in a specialist setting. • Bone Scan: If you suspect a fracture (e.g. proximal humeral fracture) that did not appear on x-ray • Blood work: If you are suspicious for a rheumatological cause of the pain (e.g. Rheumatoid Arthritis), inflammatory or neoplastic cause, etc. Answers to Case 1QUESTION 3 Question 3: What investigations would you order? What would you expect to find based on what you think is the likely diagnosis? Quick Reference about Imaging X-rays – evaluates bone Ultrasounds – evaluates soft tissue (e.g. muscles); but sound radar is blocked by bone – so you cannot see the entire anatomy of the shoulder. MRI – evaluates bone and muscle – can appreciate entirety of shoulder; used to evaluate muscle pathology in greater detail in Orthopaedics. CT scan – for evaluating bony anatomy in detail; usually ordered by Orthopaedic Surgeons for surgical planning for certain fractures, or presentations of arthritis.

12. Based on a diagnosis of Rotator Cuff Tear/impingement Non-Operative Management • Anti-inflammatories: for pain relief; John has no risk factors, but we would advise him to take any NSAIDs with food, issues with blood pressure, ensure he has no kidney disease or liver problems. • Physiotherapy (if you’re American – physical therapy): Specific exercises will help strengthen muscles at the front & back of the shoulder, to reduce impingement and offload the supraspinatus muscle • Modified Activities: John may benefit from reducing his overhead activities and work as an electrician. He may ask his employer to switch to a more administrative role which does not require lifting or overhead activities for several weeks. • Cortisone Injection: A steroid is injected into the subacromial space to reduce inflammation and provide temporary pain relief. Operative Management • Surgical Repair:if non-operative management fails, John may consider surgical repair of the torn rotator cuff, with debridement (cleanup) of the subacromial space. Surgery may be open or arthroscopic. Answers to Case 1QUESTION 4 Question 4: Briefly explain what treatment options are available to John.

13. Shoulder Case Study References Fongemie, A. Buss, D. Rolnick, S. Management of Shoulder Syndrome and Rotator Cuff Tears. Am Fam Physician. 1998 Feb 15; 57(4):667-674 Hide, G. Ultrasonography for Rotator Cuff Injury. Medscape. 2011 Jul 29 Accessed from http://emedicine.medscape.com/article/401595-overview#a22 Miller, M. 2008. Review of Orthopaedics 5th ed. Saunders Elseiver Philadelphia.

14. Case 2: Knee Pain Reference case MF3 : Case 17a Daniel gatto 41-year-old male with knee pain

15. Case 2: Knee Pain Alex is a 26-year-old male who presents to a family medicine practice two weeks after “twisting his knee” during a basketball game. He recalls the pain was “sharp” and “hard to forget”. He is currently taking Naproxen for pain and icing the knee. He feels the knee “gives way” sometimes while walking and especially going down stairs. He reports occasional locking of the knee. He has a history of Asthma and Tonsillectomy at age 5. He has no known drug allergies. He works at a desk job.On physical exam, you note he has antalgic gait. On inspection you notice decreased quadriceps muscle bulk on the left compared to the right. The left knee is slightly more swollen than the right but there is no redness. Range of motion is full. He knee has neutral alignment. Testing of his MCL and LCL are within normal limits. He has medial joint line tenderness to palpation. Posterior sag sign is negative. He has a positive Lachman’s and Anterior Drawer Test, and positive McMurray and Apley Test medially. He is distally neurovascularly intact.

16. Based on the Alex’s initial clinical presentation, what are your top three on your differential diagnosis? Give evidence for each. • How would you explain the decrease in quadriceps muscle bulk on physical exam? QuestionsCase 2: Knee Pain ________________ Alex is a 26-year-old male who presents to a family medicine practice two weeks after “twisting his knee” during a basketball game. He recalls the pain was “sharp” and “hard to forget”. He is currently taking Naproxen for pain and icing the knee. He feels the knee “gives way” sometimes while walking and especially going down stairs. He reports occasional locking of the knee. He has a history of Asthma and Tonsillectomy at age 5. He has no known drug allergies. He works at a desk job.On physical exam, you note he has antalgic gait. On inspection you notice decreased quadriceps muscle bulk on the left compared to the right. The left knee is slightly more swollen than the right but there is no redness. Range of motion is full. He knee has neutral alignment. Testing of his MCL and LCL are within normal limits. He has medial joint line tenderness to palpation. Posterior sag sign is negative. He has a positive Lachman’s and Anterior Drawer Test, and positive McMurray and ApleyTest medially. He is distally neurovascularly intact.

17. At the top of your Differential for Medial Knee Pain: • ACL Tear:tear of the anterior cruciate ligament is common in sudden deceleration or twisting injuries. Evidence: • Alex had a twisting injury • He has the sensation of “giving way” and swelling in the area • Positive anterior drawer and Lachman Test on physical exam • Meniscal Tear:meniscal tears common in twisting injuries, can happen in conjunction with ACL tears. • Locking of the knee is a common symptom, when tears of the meniscus protrude and obstruct the knee from extending and flexing • McMurray and Apley tests are positive for medial side. • Medial joint line pain • Medial Collateral Ligament (MCL) Tear or Strain • MCL injuries occur when there is a valgus force to the knee. You would have experienced laxity of the medial side when applying a valgus force on physical exam – this exam was normal on Alex’s exam. Answers to Case 2QUESTION 1 Question 1: Based on the Alex’s initial clinical presentation, what are your top three on your differential diagnosis? Give evidence for each Concepts Knee Anatomy ACL tear vs. PCL tear Meniscal Tear Osteoarthritis of the knee

18. Muscle wasting can be caused by various factors In Alex’s case, most likely: • Deconditioning/disuse of the muscledue to pain and guarding of the knee. This may happen even if he is neurovascularly intact. • Decrease in quadriceps muscle strength following his ACL injury may contribute to sensation of functional instability of the knee (i.e. “giving way”). Answers to Case 2QUESTION 2 Question 2: How would you explain the decrease in quadriceps muscle bulk on physical exam?

19. Knee Case Study References Calmbach, W. Hutchens, M. Evaluation of Patients Presenting with Knee Pain: Part I. History, Physical Examination, Radiographs, and Laboratory Tests. Am Fam Physician. 2003 Sept 1; 68(5): 907-912 Calmback, W. Hutchens, M. Evaluation of Patients Presenting with Knee Pain: Part II. Differential Diagnosis. Am Fam Physician. 2003 Sep 1;68(5):917-922.

20. Case 3: Joint Pain Reference case: Ann green

21. Case 3: Joint Pain Janice, a 52-year-old female comes to your office with bilateral shoulder pain worse on the right than the left for the past several months. She also notes the knees and hands have been bothering her recently. She notes stiffness in her joints in the morning, and trying to get up or move after driving or sitting for prolonged periods of time. She also reports a long-standing history of difficulty with opening jars, writing and computer work. She has not had any investigations or treatments done. Review of systems otherwise negative. Upon further questioning, Janice smokes 1 pack per day for the past 20 years. She used work as a project manager for an IT company but has had to discontinue due to her progressive joint pain, blaming it on “old age”. She is allergic to Penicillin. On physical exam, you note she has swelling on bilateral wrists which are soft and warm to touch, metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. You also note swan neck deformities in several finger PIP, ulnar deviation of the MCP, and Boutonniere deformity of thumb.

22. What two diagnoses are on the top of your differential after reviewing Janice’s History and Physical Exam? • What investigations would you order? What parameters are you looking for to confirm the most likely diagnosis? • What treatment options are available to Janice? • Why is Janice’s presentation unlikely to be osteoarthritis? QuestionsCase 3: Joint Pain ________________ Janice, a 52-year-old female comes to your office with bilateral shoulder pain worse on the right than the left for the past several months. She also notes the knees and hands have been bothering her recently. She notes stiffness in her joints in the morning, and trying to get up or move after driving or sitting for prolonged periods of time. She also reports a long-standing history of difficulty with opening jars, writing and computer work. She has not had any investigations or treatments done. Review of systems otherwise negative. Upon further questioning, Janice smokes 1 pack per day for the past 20 years. She works as a project manager for an IT company. She is allergic to Penicillin. On physical exam, you note she has swelling on bilateral wrists, metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. You also note swan neck deformities in several finger PIP, ulnar deviation of the MCP, and Boutonniere deformity of thumb.

23. Most likely diagnosis: • Rheumatoid Arthritis (RA): Based on Janice’s presentation, the clinical presentation that is consistent with rheumatoid arthritis include: • Bilateral presentation • Ulnar deviation at the MCPs, Boutonniere deformity and swan neck deformities are classic findings of RA. • Insidious onset / no history of trauma • Morning and startup stiffness • Multiple joints affected • Seronegative Polyarthritis • Reactive Arthritis (Reiter’s Syndrome) • Systemic Lupus Erythematous • Pseudogout Answers to Case 3QUESTION 1 Question 1: What two diagnoses are on the top of your differential after reviewing Janice’s History and Physical Exam? References: American College of Rheumatology 1987 revised classification material for rheumatoid arthritis

24. Based on the most likely diagnosis being Rheumatoid Arthritis: • Blood work: • Elevated ESR and C-reactive protein • Positive Rheumatoid Factor (RF) • Positive anti-CCP antibody • To rule out other rheumatologic disorders: Uric Acid (rule out pseudogout/CPPD) • Investigations: • X-ray: Bone erosions; ulnar deviation of MTPs, absence of Heberden’s Nodes, Swan Neck Deformity of PIPs. • MRI: may show synovitis of affected joints • Joint aspiration: rule out presence of CPPD crystals (pseudogout) Answers to Case 3QUESTION 2 Question 2: What investigations would you order? What parameters are you looking to confirm the most likely diagnosis? Image 1: UptoDate Image 2: http://ra-ss.blogspot.ca/p/30-years-of-ra.html

25. Referral to Rheumatologist • Early use of DMARD (Disease Modifying Antirheumatic Drug) e.g. Methotrexate; may take four to six weeks to take effect • Or use of Biologics if she does not respond to use of DMARDs include Etanercept, Adalimumab, infliximab, golimumab (TNF inhibitors); effects are more rapid than DMARD • NSAIDs (nonsteroidal anti-inflammatory drugs) as an adjunct for initiating DMARD therapy or controlling Janice’s flares. • Short term use of Glucocorticosteroid Prednisone, with caution against the risks of chronic use e.g. GI bleeding, risk for osteoporosis and fractures, diabetes mellitus, infections, cataracts and impaired HPA axis response, • Smoking cessation counseling for Janice Answers to Case 3QUESTION 3 Question 3: What treatment options are available to Janice?

26. Osteoarthritis may present very similarly to Rheumatoid Arthritis, however, there are important distinctions: Answers to Case 3QUESTION 4 Question 4: What reasons is this unlikely osteoarthritis? Image 1: http://www.bio.davidson.edu/courses/immunology/students/spring2006/dresser/ra.html Image 2: http://www.cedars-sinai.edu/Patients/Health-Conditions/Osteoarthritis.aspx Table from UptoDate

27. Case 3 References Lipsky P. Algorithms for the diagnosis and management of musculoskeletal complaints: A new tool for the primary-care provider. (See www.swmed.edu/home_pages/cme/endurmat/lipsky/index.html.) O’Dell, J. Use of glucocorticoids in the treatment of rheumatoid arthritis. UptoDate. 2012 Dec 17. Accessed April 12, 2013 from http://www.uptodate.com/contents/use-of-glucocorticoids-in-the-treatment-of-rheumatoid-arthritis?source=see_link Schur, P & Moreland, L. General Principles of management of rheumatoid arthritis in adults. UptoDate. 2013 Feb 4. Accessed April 12, 2013 from http://www.uptodate.com/contents/general-principles-of-management-of-rheumatoid-arthritis-in-adults?source=related_link Venables, P. Maini, R. Clinical features of rheumatoid arthritis. UptoDate. 2012 Oct 6. Accessed April 12, 2013 from http://www.uptodate.com/contents/clinical-features-of-rheumatoid-arthritis?source=see_link Venables, P. Maini, R. Diagnosis and differential diagnosis of rheumatoid arthritis. UptoDate. 2012 Mar 28. Accessed April 12, 2013 from http://www.uptodate.com/contents/diagnosis-and-differential-diagnosis-of-rheumatoid-arthritis?source=search_result&search=rheumatoid+arthritis&selectedTitle=1%7E150

28. Case 4: Developmental Abnormality Reference case: Ann green

29. Case 4: Joint Pain You are in your second year PA clerkship and have decided to do a rotation overseas with a supervisor who is looking to bring health care to underserviced areas. While doing home visits to administer vaccinations in one of the local villages, you meet Jane, a lovely 8-year-old female accompanied by her mother. Starvation and poverty are endemic in Jane’s village. Jane’s mother has explained food has been difficulty to come by, and Jane has had trouble growing as fast as some of her classmates. Upon further questioning, you learn that Jane is sick frequently with infections. On physical examination you note that Jane is small in stature for her age. You notice significant varus alignment of the knees, as well as bowing of the tibia and fibula.

30. What is the likely diagnosis? What other questions would you ask to clarify this diagnosis? • Explain the pathophysiology behind the disease. • How would the disease process present differently if Jane was an adult at the time of onset? When Jane was a neonate? • What investigations would you order to confirm the diagnosis and what specific findings would you expect? • What treatment options and education would you recommend for Jane and her mother? QuestionsCase 4: Developmental Abnormality ________________ You are in your second year PA clerkship and have decided to do a rotation overseas with a supervisor who is looking to bring health care to underserviced areas. While doing home visits to administer vaccinations in one of the local villages, you meet Jane, a lovely 8-year-old female accompanied by her mother. Starvation and poverty are endemic in Jane’s village. Jane’s mother has explained food has been difficulty to come by, and Jane has had trouble growing as fast as some of her classmates. Upon further questioning, you learn that Jane is sick frequently with infections. On physical examination you note that Jane is small in stature for her age. You notice significant varus alignment of the knees, as well as bowing of the tibia and fibula.

31. Most likely diagnosis is Rickets as a result of Vitamin D Deficiency (Calcipenic Rickets) • Rule out causes of Vitamin D Deficiency: • Decreased nutritional intake: Ask about diet, e.g. what a typical breakfast, lunch, and dinner consists of to understand over time what Jane’s nutritional picture looks like • Decreased synthesis: i.e. those with darker pigmented skin in low sunlight times of the year or clothing coverage • Constitutional symptoms to rule out neoplasms that may be causing hormonal imbalances • Maternal Factors: (1) Maternal Vitamin D deficiency; (2) Prematurity; (3) Exclusive breast feeding • Ask about family history (rule out inherited Vitamin D resistance) • Medications: Anticonvulsants, antiretroviral drug use for HIV, glucocorticosteroids, Antifungal agents such as Ketoconazole • Do a thorough review of systems to rule out kidney disorders, liver disorders parathyroid hormone problems • Rule out causes of malabsorption(e.g. Celiac’s Disease, inflammatory bowel disease, pancreatic insufficiency, cholesstasis, post-gut resection or bariatric surgery) Answers to Case 4QUESTION 1 Question 1: What is the likely diagnosis? What other questions would you ask to clarify this diagnosis?

32. Vitamin D Metabolism Overview: • Vitamin D3 (dietary and synthesized in skin from sunlight exposure) and Vitamin D2 • Carried to the liver by D-binding protein to the liver where it is converted into 25(OH)-D a storage form of Vitamin D • In the kidney, 25(OH)-D is converted to1-25(OH)2D regulated by PTH, serum Calcium & Phosphate. • Vitamin D increases calcium absorption from gut & reasborptionfrom kidney. • Pathophysiology: For Jane, there is likely a significant dietary role for her disease process. There are two subtypes of rickets: • Calcipneic Rickets: due to low intestinal absorption of calcium but not necessarily to hypocalcemia • Phosphophenic Answers to Case 4QUESTION 2 Question 2: Explain the pathophysiology behind the disease. Image from http://www.uptodate.com/contents/image?imageKey=ENDO/65360&topicKey=ENDO%2F2021&source=outline_link&utdPopup=true

33. Vitamin D Deficiency in a: • Neonate – delayed closure of the fontanelles • Adult –Presents as Osteomalacia • Presentation is difference since growth plates are closed including “bone pain”, and joint pain muscle weakness, difficult walking Answers to Case 4QUESTION 1 Question 3: How would the disease process present differently if Jane was an adult at the time of onset? When Jane was a neonate?

34. Blood work: • Serum Calcium, Vitamin D levels of 25(OH)D, Parathyroid Hormone (PTH), ALP, Phosphorus, Kidney Function Tests • X-raysto rule out pathologic fractures in areas of pain • Blood work Findings: Expected findings highlighted in red with Vitamin D deficiency with child who has normal kidney and liver function Answers to Case 4QUESTION 4 Question 4: What investigations would you order to confirm the diagnosis? Image from http://www.uptodate.com/contents/image?imageKey=PEDS/56687&topicKey=PEDS%2F14590&source=outline_link&search=rickets&utdPopup=true

35. Case 4 – Question 4: Supplementary Slide Image from: http://www.uptodate.com/contents/image?imageKey=PEDS/81032&topicKey=PEDS%2F5856&source=outline_link&search=search+rickets&utdPopup=true

36. Treatment: • Vitamin D Replacement (D3): for Jane’s age, it would be 2000 IU/day for six weeks, followed by maintenance of 600 to 1000 IU/day • Since Jane is also presenting with clinical manifestations of rickets, she should have Calcium along side her Vitamin D supplementation (10-20 mg/kg/day) Answers to Case 4QUESTION 5 Question 5: What treatment options and education would you recommend for Jane and her mother?

37. Resources Carpenter, T. Overview of rickets in children. UptoDate. 2013, Mar 28. Accessed April 19, 2013 from http://www.uptodate.com/contents/overview-of-rickets-in-children?source=search_result&search=vitamin+d+deficiency+neonate&selectedTitle=3%7E150 Menkes, CJ. Clinical Manifestations, diagnosis and treatment of osteomalacia. UptoDate. 2013, Apr 3. Accessed April 19, 2013 from http://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-treatment-of-osteomalacia?source=search_result&search=osteomalacia&selectedTitle=1%7E117

38. Case 5: Back Pain Reference: MF3 MSK Jack Gamble Case study Reviewed by Dr. Clark, MD, FRSCS(C) physical medicine and rehabilitation / physiatry MD

39. Case 5: Back Pain 50 year old male Donald presents to the Emergency room with an acute on chronic episode of low back pain. He has worked in construction for 30 years and despite “strains” in the past, has never sought treatment for his low back pain. He has had longstanding intermittent numbness and tingling down the lateral lower leg made worse with walking, and better with rest, sitting or lying in a supine position which you identify as “neurogenic claudication”. He does not take any medications, and has an otherwise benign past medical history. Inspection of spine curvature is normal. He has pain with forward flexion of the lower back. He is tender to palpation of his lumbar paraspinals and midline structures at the level of L5/S1. He can walk on his heels and perform a full squat. However, he was unable to stand up on his toes on the left side (weak plantarflexion). His hip, knee, and ankle exam is unremarkable. He reports decreased pinprick and light touch over the posterior calf and lateral foot, but also reports he has decreased sensation near the groin area bilaterally. Straight raise leg reproduces his symptoms at 30 degrees of elevation. Romberg testing is negative. Upper extremity testing was unremarkable. Muscle strength is 2+ at the hips, knees and ankles, with normal muscle stretch reflexes at the knees. Absent ankle reflex on the left. Peripheral pulses are palpable. Upon further questioning, he has noted urinary retention and difficulty with bowel movement in the past week. He also notes new onset erectile dysfunction within the past 24 hours. He denies any constitutional symptoms, hearing or vision changes.

40. a) What red flags appeared in Donald’s clinical presentation that would have you worried about a potential medical emergency? b)What other urgent conditions would you want to rule on your differential diagnosis in an ER setting? • What investigations would you order to rule out serious conditions? • a) What are the potential differential diagnosis if Donald presented without the red flags, in a primary care setting with chronic low back pain? b) What investigations would you order in that circumstance? • If the most likely serious condition is confirmed from your investigations, what treatment options are available to Donald? BONUS: Explain the various findings on Donald’s physical exam, and the rationale for performing those tests. BONUS 2: Explain a diagnostic approach to presentations of non-specific low back pain QuestionsCase 5: Back Pain

41. American College of Radiology: “Red Flags” for potentially serious underlying cause for low back pain: • Trauma (cumulative) • Underlying Systemic Diagnosis: (1) Age > 50 years; (2) Unexplained weight loss; (3) Duration longer than 6 weeks; (4) Night Pain; (5) History of Cancer • Unexplained fever, history of urinary or other infections • Immunosuppression/Diabetes Mellitus • IV Drug Use • Prolonged use of corticosteroids, osteoporosis • Focal neurologic deficits with progressive or disabling symptoms, caudaequina syndrome (bowel or bladder dysfunction) • New onset “bilateral groin pain” could represent saddle anesthesia • Prior Surgery • RULE OUT CAUDA EQUINA SYNDROME OR SPINAL CORD COMPRESSION • DDx: Spinal Cord Neoplasma, Diabetic Neuropathy, ALS, Traumatic Peripheral Nerve Lesions, Osteomyelitis, Perineural Cysts Answers to Case 5QUESTION 1 a) Question 1: a) What red flags appeared in Donald’s clinical presentation that would have you worried about a potential medical emergency? B) What would you want to rule out first on your differential diagnosis?

42. RULE OUT CAUDA EQUINA SYNDROME Other Urgent Differential Diagnosis for Low Back Pain: • Spinal Cord Neoplasma • Perineural Cysts • Aortic Aneurysm • Costochondritis • GI Disease: Pancreatitis, Cholecystitis, Penetrating Ulcer • Infection: Osteomyelitis, septic discitis, epidural abscess, bacterial endocarditis • Pelvis Organs: Prostatitis, Endometriosis, • *Renal Disease:Neophrolithiasis, Pyelonephritis Answers to Case 5QUESTION 1b) Question 1: a) What red flags appeared in Donald’s clinical presentation that would have you worried about a potential medical emergency? B) What would you want to rule out first on your differential diagnosis?

43. Investigations in a ER setting • Blood work: CBC, chemistries, fasting blood sugar (rule out anemia, infection, and kidney dysfunction) + ESR (rule out inflammatory pathology such as infection) • Catheterize bladder and measure post-void residual (> 50-100cc is abnormal): rule out urinary retention from other causes (e.g. atonic bladder from certain meds) Imaging: • Urgent MRI and/or CT scan • Lumbar spine x-ray to rule out trauma, fracture, disc space narrowing and spondylolysis • Bone Scan – may detect malignant tumor or metastases, infection and occult fractures Other Tests • Meningitis (causing spinal cord compression) workup unlikely necessary unless patients present with neck symptoms • Syphilis/Lyme serologies(rule out meningovascular syphilis) • Lumbar puncture to rule out meningitis (CSF Exam) Answers to Case 5QUESTION 2 Question 2: What investigations would you order to rule out serious conditions.

44. Mechanical Back Pain • Lumbar Strain • Herniated Disc • Osteoporosis • Fractures • Sciatica: numbness and tingling of sciatic nerve to foot or ankle • Piriformis Syndrome: the piriformis muscle compresses/irritates the sciatic nerve • S1 radiculopathy: impairment of a nerve root • Spondylosis(arthritis of spine) • Spondylolisthesis (anterior displacement of vertebra  90% degenerative) • Spondylolysis: fracture usually at L5 of the pars interarticularis • Spinal Stenosis: narrowing of the central spinal canal by bone or soft tissues • Congenital: Lordosis, kyphosis, scoliosis Neoplasia: multiple myeloma, metastatic carcinoma, lymphoma/leukemia, spinal cord tumors, retroperitoneal tumors. Inflammatory Arthritis: IBD, Ankylosing Spondylitis, Reiter’s Syndrome. Paget’s Disease Answers to Case 5QUESTION 3 a)_ Question 3: a) What are the potential differential diagnosis if Donald presented without the red flags, in a primary care setting with chronic low back pain? b) What investigations would you order in that circumstance?

45. Investigations (outpatient): • MRI of lumbar spine – r/o fracture, tumor, infection, structural abnormality of the spinal cord • X-ray of lumbar spine • Blood work (if systemic disease is suspected) with or without rheumatologic markers Outpatient setting: • EMG and nerve conduction studies: • not appropriate in an emergency setting, any nerve damage in arms takes 5-10 days before showing up on EMG, and 2 weeks for peripheral legs. • Any same day acute pain you are trying to investigate may appear normal on EMG and nerve conduction studies. Answers to Case 5QUESTION 3 b) Question 3: a) What are the potential differential diagnosis if Donald presented without the red flags, in a primary care setting with chronic low back pain? b) What investigations would you order in that circumstance?

46. Determine underlying cause of caudaequina syndrome • If Urgent Surgery Required: Admit patient to appropriate service from Emergency within 24 hours (Orthopaedic Surgery or Neurosurgery) Answers to Case 5QUESTION 4 Question 4: If the serious condition is confirmed from your investigations, what treatment options are available to Donald?

47. Assessing lumbar spine range of motion • Romberg Testing rule out dorsal column abnormalities • Lumbar Nerve Root Irritation tests • Straight Leg Raise: rule out sciatica • Femoral stretch test • Nerve Root Conduction Tests • L5 – hip abduction (Trendelenburg test), ankle dorsiflexion, great toe extension • S1 – hip extension, great toe flexion, ankle reflex • Upper Motor Neuron Test (absent Babinski is normal) • Lower sacral nerve root tests • Saddle sensation • Muscle strength testing • Muscle stretch reflexes Answers to Case 5BONUS QUESTION BONUS: Explain the various findings on Donald’s physical exam, and the rationale for performing those tests Image from: http://www.uptodate.com/contents/image?imageKey=PC%2F68791&topicKey=PC%2F7782&rank=1%7E132&source=see_link&search=low+back+pain&utdPopup=true

48. Back Predominant: more likely mechanical • Back • Buttock • Trochanteric (hip) • Groin (SI joint) • Leg Predominant: anywhere below gluteal fold • radicular pain • peripheral neuropathy • entrapment neuropathy Answers to Case 5BONUS Q 2 Approach to Non-Specific Back Pain

49. References Dawodu, S. CaudaEquina and ConusMedullaris Syndromes Treatment & Management. MedScape Reference: Drugs, Diseases and Procedures. 2013, Mar 6. Accessed April 19, 2013 from http://emedicine.medscape.com/article/1148690-overview Hall, H. Rampersaud, R. The Practical Management of Low Back Pain. Family Medicine Forum. Accessed April 23, 2013 from http://www.spinecanada.ca/assessing_tlb_web2011.pdf Wheeler, S. Wipf, J. Staiger, T. Deyo, R. Approach to the diagnosis and evaluation of low back in adults. UptoDate. 2012, Apr 5. Accessed April 19, 2013 from http://www.uptodate.com/contents/approach-to-the-diagnosis-and-evaluation-of-low-back-pain-in-adults?source=search_result&search=approach+to+low+back+pain&selectedTitle=1%7E150

50. Resources Larsen, Betty. The diagnosis and pharmacologic management of low back pain. JAAPA 2012 [PDF available] http://www.jaapa.com/the-diagnosis-and-pharmacologic-management-of-low-back-pain/article/229325/