If the patient’s baker’s cyst is asymptomatic, there is no need for any treatment such as aspiration, excision, or antibiotics. The use of low molecular weight heparin is not appropriate for managing Baker’s cysts, as it is typically used for preventing and treating DVT.

Baker’s cysts, also known as popliteal cysts, are not true cysts but rather a distension of the gastrocnemius-semimembranosus bursa. They can be classified as primary or secondary. Primary Baker’s cysts are not associated with any underlying pathology and are typically seen in children. On the other hand, secondary Baker’s cysts are caused by an underlying condition such as osteoarthritis and are typically seen in adults. These cysts present as swellings in the popliteal fossa behind the knee.

In some cases, Baker’s cysts may rupture, resulting in symptoms similar to those of a deep vein thrombosis, such as pain, redness, and swelling in the calf. However, most ruptures are asymptomatic. In children, Baker’s cysts usually resolve on their own and do not require any treatment. In adults, the underlying cause of the cyst should be treated where appropriate. Overall, Baker’s cysts are a common condition that can be managed effectively with proper diagnosis and treatment.

The Beighton score is a valuable method for evaluating hypermobility, with a positive result indicating at least 5 out of 9 criteria met in adults or at least 6 out of 9 in children. In contrast, Schirmer’s test is commonly employed to diagnose Sjogren syndrome, while plain radiographs and MRI scans are not effective for assessing hypermobility.

Ehler-Danlos syndrome is a genetic disorder that affects the connective tissue, specifically type III collagen. This causes the tissue to be more elastic than usual, resulting in increased skin elasticity and joint hypermobility. Common symptoms include fragile skin, easy bruising, and recurrent joint dislocation. Additionally, individuals with Ehler-Danlos syndrome may be at risk for serious complications such as aortic regurgitation, mitral valve prolapse, aortic dissection, subarachnoid hemorrhage, and angioid retinal streaks.

When spinal stenosis is suspected in a patient, the preferred imaging method is an MRI. It is important to differentiate between spinal stenosis and peripheral vascular disease, such as intermittent claudication. The absence of normal foot pulses suggests that peripheral vascular disease is not the cause of the patient’s symptoms. The fact that the patient experiences relief when leaning forward is a characteristic symptom of spinal stenosis. Nerve conduction studies are not used to diagnose spinal stenosis, but rather peripheral neuropathy. To diagnose peripheral vascular disease, possible investigations include an arterial duplex scan, ankle brachial pressure index, and angiogram.

Treatment for Lumbar Spinal Stenosis

Laminectomy is a surgical procedure that is commonly used to treat lumbar spinal stenosis. It involves the removal of the lamina, which is the bony arch that covers the spinal canal. This procedure is done to relieve pressure on the spinal cord and nerves, which can help to alleviate the symptoms of lumbar spinal stenosis.

Laminectomy is typically reserved for patients who have severe symptoms that do not respond to conservative treatments such as physical therapy, medication, and epidural injections. The procedure is performed under general anesthesia and involves making an incision in the back to access the affected area of the spine. The lamina is then removed, and any other structures that are compressing the spinal cord or nerves are also removed.

After the procedure, patients may need to stay in the hospital for a few days to recover. They will be given pain medication and will be encouraged to walk as soon as possible to prevent blood clots and promote healing. Physical therapy may also be recommended to help patients regain strength and mobility.

Overall, laminectomy is a safe and effective treatment for lumbar spinal stenosis. However, as with any surgery, there are risks involved, including infection, bleeding, and nerve damage. Patients should discuss the risks and benefits of the procedure with their doctor before making a decision.

Common Upper Limb Injuries

Medial epicondylitis, also known as golfer’s elbow, is caused by inflammation at the common flexor origin at the medial epicondyle of the elbow. Patients with this condition experience pain when performing resisted wrist flexion and resisted pronation of the forearm.

Bicipital tendonitis is inflammation of the long head of biceps tendon, which causes anterior shoulder pain. Pain is also experienced when flexing the elbow against resistance.

Carpal tunnel syndrome affects the hand in the median nerve distribution. Symptoms can be reproduced by forced wrist flexion (Phalen’s sign) and tapping over the median nerve at the wrist (Tinel’s sign).

Lateral epicondylitis, or tennis elbow, is more common than golfer’s elbow. It is characterized by tenderness at the lateral epicondyle of the elbow and pain when performing resisted wrist extension.

Ulnar neuritis is caused by a compressive neuropathy at the elbow. It can lead to wasting and weakness of the small muscles of the hand supplied by the ulnar nerve.

Distinguishing Sciatica from Other Causes of Leg Pain

Leg pain can be caused by a variety of conditions, and it is important to accurately diagnose the underlying issue in order to provide appropriate treatment. Sciatica is a common cause of leg pain, but it is not a diagnosis in itself. Rather, it is a description of symptoms that can be caused by pressure on the sciatic nerve. Other conditions that can cause leg pain include osteoarthritis of the hip, polymyalgia rheumatica, sacroiliitis, and trochanteric bursitis. Each of these conditions presents with unique symptoms and requires a different approach to treatment. By carefully evaluating a patient’s symptoms and conducting appropriate diagnostic tests, healthcare providers can accurately diagnose the underlying cause of leg pain and provide effective treatment.

Differentiating Pseudogout from Gout and Septic Arthritis

Pseudogout is a joint inflammation caused by the deposition of calcium pyrophosphate crystals. It is often idiopathic but can also be associated with metabolic abnormalities such as hyperparathyroidism and haemochromatosis. Symptoms can last for days to weeks and commonly affect the knees, wrists, and hips. Radiographs may show chondrocalcinosis or osteoarthrosis. Urate crystals in gout are shaped like needles with pointed ends and exhibit negative birefringence. Septic arthritis requires cues such as exposure to gonorrhoea, a recent puncture wound over the joint, or systemic signs of disseminated infection. Synovial fluid examination can exclude infection. Anticoagulant therapy is not a cause of pseudogout.

Common Causes of Ocular Vasculitis: A Brief Overview

Ocular vasculitis is a group of disorders that affect the blood vessels in the eye. Here are some common causes of ocular vasculitis and their clinical features:

Giant-cell arteritis: This large-vessel vasculitis mainly affects the temporal and ophthalmic arteries. It typically presents with headache, scalp tenderness, jaw pain, and visual disturbance. The erythrocyte sedimentation rate (ESR) is usually elevated, and skip lesions are common.

Central retinal vein occlusion: This condition may occur in chronic simple glaucoma, arteriosclerosis, hypertension, and polycythaemia. The fundus appears like a ‘stormy sunset’ with red haemorrhagic areas and engorged veins.

Diabetic retinopathy: This is the most common cause of blindness in adults between 30 and 65 years of age in developed countries. It is characterised by microaneurysms, retinal haemorrhages, exudates, cotton-wool spots, neovascularisation, and venous changes.

Polyarteritis nodosa: This necrotising vasculitis affects multiple systems and has variable manifestations, although it most commonly affects the skin, joints, peripheral nerves, the gut, and the kidney. Ocular involvement is rare.

Sjögren syndrome: This autoimmune disorder is characterised by dry mouth and dry eyes with variable lacrimal or salivary gland enlargement due to lymphocytic infiltration.

Understanding the clinical features of these common causes of ocular vasculitis can aid in early diagnosis and prompt treatment.

Recommended Levels of Homocysteine

Homocysteine is a naturally occurring amino acid in the body that can be harmful in high levels. The upper limit of normal for homocysteine was previously set at 0.42 µmol/L, with reducing levels below that considered acceptable. However, recent guidelines have recommended even lower levels, with most sources suggesting levels below 0.36 µmol/L and the latest guidelines aiming for 0.30 µmol/L. It is important to monitor homocysteine levels and take steps to reduce them if they are too high, as elevated levels have been linked to an increased risk of cardiovascular disease and other health issues.

A useful test to rule out SLE is ANA positivity, as the majority of patients with SLE are ANA positive. While CRP and ESR may rise during an acute flare of SLE, they are not specific to autoimmune conditions. ANCA is an antibody associated with autoimmune vasculitis, not SLE.

Systemic lupus erythematosus (SLE) can be investigated through various tests, including antibody tests. ANA testing is highly sensitive and useful for ruling out SLE, but it has low specificity. About 99% of SLE patients are ANA positive. Rheumatoid factor testing is positive in 20% of SLE patients. Anti-dsDNA testing is highly specific (>99%) but less sensitive (70%). Anti-Smith testing is also highly specific (>99%) but has a lower sensitivity (30%). Other antibody tests that can be used include anti-U1 RNP, SS-A (anti-Ro), and SS-B (anti-La).

Monitoring of SLE can be done through various markers, including inflammatory markers such as ESR. During active disease, CRP levels may be normal, and a raised CRP may indicate an underlying infection. Complement levels (C3, C4) are low during active disease due to the formation of complexes that lead to the consumption of complement. Anti-dsDNA titres can also be used for disease monitoring, but it is important to note that they are not present in all SLE patients. Overall, these investigations can help diagnose and monitor SLE, allowing for appropriate management and treatment.

Referring Patients for Joint Replacement Surgery

Referring patients for joint replacement surgery can be a challenging decision. With the increasing demand for this procedure, healthcare professionals must consider various factors before making a referral. These factors include the severity of the patient’s symptoms, their overall health and any comorbidities, their functional abilities and expectations, and the effectiveness of non-surgical treatments.

Orthopaedic assessment tools such as the Oxford hip and knee scores can be helpful in evaluating the impact of osteoarthritis on daily activities. However, they should not be the sole basis for referral decisions. Similarly, x-rays may provide additional information, but they should not be relied upon as the only factor in making a referral decision.

It is important to note that factors such as smoking status, age, and comorbidities should not be used as obstacles to referral. While they may increase postoperative risks and affect long-term outcomes, some patients may still benefit greatly from joint replacement surgery.

In summary, joint replacement surgery should be considered for patients with osteoarthritis who experience significant symptoms that do not respond to non-surgical treatments. Referral should occur before functional limitations and severe pain develop, and the decision should be made collaboratively between the healthcare professional and the patient. Scoring tools and x-rays can be helpful adjuncts, but they should not be the sole basis for referral decisions.

Achilles Tendon Rupture and Fluoroquinolones

This is a typical history of an Achilles tendon rupture – sudden and severe pain at the back of the leg. Patients often hear an audible snap and feel as if something hit them at the back of the leg. To confirm the diagnosis, doctors use the Simmonds’ test, which involves squeezing the calf while the patient is kneeling on a bench.

Fluoroquinolones, such as ciprofloxacin, have been found to cause tendinopathies, although this is rare. Patients taking these medications should be advised to stop treatment at the first signs of tendon discomfort and seek medical attention. It is important to be aware of this potential side effect when prescribing fluoroquinolones to patients.

Patients with cervical myelopathy require ongoing follow-up after surgery as the pathology can recur at adjacent spinal levels that were not treated during the initial decompressive surgery. Recurrent symptoms should be treated with suspicion, and peripheral neuropathy should not be the primary diagnosis as delays in diagnosing and treating DCM can negatively impact outcomes. Urgent evaluation by specialist spinal services is necessary for all patients with recurrent symptoms, and axial spine imaging, such as an MRI scan, is the first line of investigation. AP and lateral radiographs are of limited use when myelopathy is suspected. Therefore, statements A and E are false, and statement C is also false.

Degenerative cervical myelopathy (DCM) is a condition that has several risk factors, including smoking, genetics, and certain occupations that expose individuals to high axial loading. The symptoms of DCM can vary in severity and may include pain, loss of motor function, loss of sensory function, and loss of autonomic function. Early symptoms may be subtle and difficult to detect, but as the condition progresses, symptoms may worsen or new symptoms may appear. An MRI of the cervical spine is the gold standard test for diagnosing cervical myelopathy. All patients with DCM should be urgently referred to specialist spinal services for assessment and treatment. Decompressive surgery is currently the only effective treatment for DCM, and early treatment offers the best chance of a full recovery. Physiotherapy should only be initiated by specialist services to prevent further spinal cord damage.

Radiological Features of Joint Diseases

Osteoarthritis is a joint disease that can be identified through four core features on plain x-ray examination. These features include loss of joint space, osteophyte formation, subchondral sclerosis, and subchondral cyst formation. All of these features are present on the x-ray, making osteoarthritis the correct diagnosis.

Chondrocalcinosis, on the other hand, is characterized by calcium deposition in structures such as the cartilage. In gout, x-rays may only show soft tissue swelling, but chronic inflammation can lead to punched out lesions in juxta-articular bone. Late-stage gout is characterized by tophi formation and joint space narrowing.

In rheumatoid arthritis, plain films can show soft tissue swelling, juxta-articular osteoporosis, and loss of joint space. As the disease progresses, the destructive nature of the disease can lead to bony erosions, subluxation, and massive deformity. Septic arthritis, an infective process, can be identified through early plain film radiographic findings of soft tissue swelling around the joint and a widened joint space from joint effusion. With the progression of the disease, joint space narrowing can occur as articular cartilage is destroyed.

Treatment Options for Carpal Tunnel Syndrome

Carpal tunnel syndrome is a condition that affects many people, and it can be quite debilitating. However, there are several treatment options available to help manage the symptoms. It is important to note that anti-inflammatories may exacerbate symptoms, and there is no significant evidence behind using a diuretic or amitriptyline as a treatment option. Instead, treatment options include avoiding precipitating causes, simple advice about minimizing activities that trigger symptoms, nocturnal wrist splintage, and corticosteroid injection. Referral for nerve conduction studies is appropriate in some cases where there is diagnostic doubt, but if there is a clear clinical diagnosis, further investigation is not needed, and treatment can be initiated. Corticosteroid injection is a first-line treatment option and can be performed based on a clinical diagnosis in primary care by an adequately trained and competent clinician. Surgery, which would not be an appropriate initial management, would clearly need referral to secondary care. By understanding these treatment options, individuals with carpal tunnel syndrome can work with their healthcare provider to find the best approach for managing their symptoms.

Osteomalacia may be indicated by bone pain, tenderness, and proximal myopathy (resulting in a waddling gait), as evidenced by low levels of calcium and phosphate and elevated alkaline phosphatase.

Understanding Osteomalacia: Causes, Features, Investigation, and Treatment

Osteomalacia is a condition characterized by the softening of bones due to low levels of vitamin D, which leads to a decrease in bone mineral content. While rickets is the term used for this condition in growing children, osteomalacia is the preferred term for adults. The causes of osteomalacia include vitamin D deficiency, malabsorption, lack of sunlight, diet, chronic kidney disease, drug-induced factors, inherited factors, liver disease, and coeliac disease.

The features of osteomalacia include bone pain, bone/muscle tenderness, fractures (especially femoral neck), proximal myopathy, and a waddling gait. To investigate this condition, blood tests are conducted to check for low vitamin D levels, low calcium and phosphate levels (in around 30% of patients), and raised alkaline phosphatase (in 95-100% of patients). X-rays may also show translucent bands known as Looser’s zones or pseudofractures.

The treatment for osteomalacia involves vitamin D supplementation, with a loading dose often needed initially. Calcium supplementation may also be necessary if dietary calcium is inadequate. By understanding the causes, features, investigation, and treatment of osteomalacia, individuals can take steps to prevent and manage this condition.

Allopurinol should not be started until the inflammation has subsided and the patient is no longer experiencing pain. Immediate treatment for acute gout should involve the use of colchicine, as starting allopurinol too soon can lead to a recurrence or prolongation of acute attacks. The current recommendation is to base treatment on symptoms rather than a specific time frame, and joint aspiration is not typically necessary for diagnosis. Tophi, which are crystal deposits that form from untreated gout over a long period of time, may indicate the need for allopurinol treatment. However, joint aspiration may be necessary to differentiate between gout and septic arthritis.

Allopurinol can interact with other medications such as azathioprine, cyclophosphamide, and theophylline. It can lead to high levels of 6-mercaptopurine when used with azathioprine, reduced renal clearance when used with cyclophosphamide, and an increase in plasma concentration of theophylline. Patients at a high risk of severe cutaneous adverse reaction should be screened for the HLA-B *5801 allele.

Maximum Oral Morphine Use and Tapering Off

The Faculty of Pain Management has established a maximum threshold for oral morphine use to prevent harm without additional benefits. The maximum dose should not exceed 120mg/day of oral morphine equivalent. In cases where patients report no benefit from the medication, it is sensible to taper them off completely. This approach is unlikely to lead to increased pain and can free the patient from opioid-related side effects. Switching to a different opioid or route of administration is also unlikely to be beneficial if the patient has reported no benefit from the current dose. Immediate-release preparations can provide flexibility in dosing, and patients can be encouraged to avoid taking opioids whenever possible.

Treatment Options for Ankylosing Spondylitis

Ankylosing spondylitis is a type of inflammatory arthritis that primarily affects the spine and sacroiliac joints. The following are some of the treatment options available for managing this condition:

Oral Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs are the first-line medication recommended by the National Institute for Health and Care Excellence (NICE) for managing ankylosing spondylitis. They help to reduce pain and stiffness in the affected joints.

Corticosteroid Injection
Intra-articular steroid injections can be used to treat a flare of ankylosing spondylitis that has not responded to oral NSAIDs or other oral treatments. However, repeated injections are associated with risks such as joint infection.

Oral Corticosteroids
Oral corticosteroids can be used to treat symptoms that are not responding to other oral treatments. However, their use is limited due to the multiple complications and side effects associated with long-term use.

Paracetamol and Codeine
If patients have an allergy, severe asthma, or a high risk for gastrointestinal bleeding, alternative analgesia should be considered, such as paracetamol and codeine.

Tumour Necrosis Factor (TNF)-Alpha Inhibitor
TNF-alpha inhibitors are used to treat ankylosing spondylitis in patients whose symptoms are not controlled on other treatments. However, they must be prescribed and monitored in secondary care.

Managing Ankylosing Spondylitis: Treatment Options

Patients aged 75 years or older who have experienced a fragility fracture should be initiated on oral alendronate 70mg once weekly without the need for a DEXA scan, as they are presumed to have osteoporosis.

Osteoporosis is a condition that weakens bones, making them more prone to fractures. When a patient experiences a fragility fracture, which is a fracture that occurs from a low-impact injury or fall, it is important to assess their risk for osteoporosis and subsequent fractures. The management of patients following a fragility fracture depends on their age.

For patients who are 75 years of age or older, they are presumed to have underlying osteoporosis and should be started on first-line therapy, such as an oral bisphosphonate, without the need for a DEXA scan. However, the 2014 NOGG guidelines suggest that treatment should be started in all women over the age of 50 years who’ve had a fragility fracture, although BMD measurement may sometimes be appropriate, particularly in younger postmenopausal women.

For patients who are under the age of 75 years, a DEXA scan should be arranged to assess their bone mineral density. These results can then be entered into a FRAX assessment, along with the fact that they’ve had a fracture, to determine their ongoing fracture risk. Based on this assessment, appropriate treatment can be initiated to prevent future fractures.

NSAIDs and COX-2 Inhibitors: Balancing Thrombotic and GI Risks

Cyclo-oxygenase-2 selective inhibitors (COX-2 inhibitors) and non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for pain relief, but they carry different risks. COX-2 inhibitors have an increased risk of thrombotic events, while all NSAIDs are associated with potential serious gastrointestinal (GI) problems. However, there is variation in risk among different NSAIDs.

Diclofenac at high doses and high dose ibuprofen are linked with an increased thrombotic risk, while naproxen and lower doses of ibuprofen have not been shown to increase the risk of myocardial infarction. In terms of GI toxicity, azapropazone has the highest risk, ibuprofen the lowest, and naproxen and diclofenac are intermediate. Selective COX-2 inhibitors provide the lowest risk of serious GI toxicity.

When choosing a pain reliever, the specific indication and patient factors should be considered. Etoricoxib, a selective COX-2 inhibitor, should only be used if a specific indication to avoid a traditional NSAID is present. Ketorolac is licensed for short-term management of postoperative pain. The doses of diclofenac given in the options increase the risk of thrombotic events. The naproxen and ibuprofen doses given provide the lowest thrombotic risk, but ibuprofen has a better GI safety profile and is the cheapest option. Gastroprotection, such as proton-pump inhibitors, should also be considered based on patient factors.

Patients with an acute flare of gout who are already on allopurinol treatment should not discontinue it during the attack, as per the current NICE CKS guidance. Colchicine is a suitable option for acute gout treatment, and oral steroids can be used if colchicine or NSAIDs are not tolerated. Hospital review on the same day is not necessary unless there are red flag features or evidence of a septic joint. Aspirin is not recommended for gout treatment.

Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with a delayed start recommended until inflammation has settled. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Other options for refractory cases include febuxostat, uricase, and pegloticase.

When an adolescent experiences persistent night time pain and has a palpable bony mass, it is important to consider the possibility of a bone tumour until proven otherwise. The NICE guidelines for childhood cancer recommend obtaining an urgent X-ray within 48 hours for suspected sarcoma. Referring the patient to physiotherapy or providing reassurance is not appropriate as it doesn’t address the concerning symptoms. Ultrasound is not the most suitable imaging modality for bone pain and swelling. Urgent outpatient orthopaedic referral is also not the correct answer as it may cause delays in further investigation and management.

Types of Bone Tumours

Benign and malignant bone tumours are two types of bone tumours. Benign bone tumours are non-cancerous and do not spread to other parts of the body. Osteoma is a benign overgrowth of bone that usually occurs on the skull and is associated with Gardner’s syndrome. Osteochondroma, the most common benign bone tumour, is a cartilage-capped bony projection on the external surface of a bone. Giant cell tumour is a tumour of multinucleated giant cells within a fibrous stroma that occurs most frequently in the epiphyses of long bones.

Malignant bone tumours are cancerous and can spread to other parts of the body. Osteosarcoma is the most common primary malignant bone tumour that mainly affects children and adolescents. It occurs most frequently in the metaphyseal region of long bones prior to epiphyseal closure. Ewing’s sarcoma is a small round blue cell tumour that mainly affects children and adolescents. It occurs most frequently in the pelvis and long bones and is associated with t(11;22) translocation. Chondrosarcoma is a malignant tumour of cartilage that most commonly affects the axial skeleton and is more common in middle-age.

Pharmacological Management of Osteoarthritis

Here we have a patient with knee and hand osteoarthritis who is currently taking oral paracetamol and a topical anti-inflammatory but still experiences symptoms. The next step in treatment options would be an oral NSAID, COX-2 inhibitor, or opioid analgesic. However, since the patient has a cardiac history and is already taking aspirin, an opioid analgesic would be the safest option. It is important to consider the potential risks and benefits of NSAID use, particularly their potential gastrointestinal, liver, and cardio-renal toxicity.

To add an opioid analgesic, oral codeine can be prescribed and combined with paracetamol in a co-codamol. It is recommended to initiate patients on separate products, starting at a low dose and titrating as needed. This allows for determining what works best for the patient and avoiding unnecessary medication with increased side-effect risk. Dose reduction of paracetamol is also gaining momentum in patients aged 70 or over, which should be considered when using co-products.

In summary, the pharmacological management of osteoarthritis should be carefully considered, taking into account the patient’s medical history and potential risks and benefits of different treatment options.

Assessing Ligamentous Integrity in the Knee: Tests for Excessive Movement and Sagging

The knee joint is stabilized by four major ligaments: the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL). Injuries to these ligaments can result in instability and pain in the knee. Here are some tests to assess the integrity of these ligaments.

Excessive forward movement of the tibia is prevented by the ACL. To test for ACL disruption, flex the knee to 90° with the hip flexed to 45° and pull the tibia forward (anterior drawer test). Excessive movement may indicate ACL injury, although ligamentous laxity may be difficult to detect in the acute situation.

Excessive backward movement of the tibia is prevented by the PCL. To test for PCL integrity, push backwards in relation to the tibia instead of pulling forwards.

Excessive valgus movement of the tibia is prevented by the MCL, while excessive varus movement is prevented by the LCL. These ligaments can be tested by applying pressure to the inside or outside of the knee joint, respectively.

Sagging of the tibia when the knee is flexed can indicate PCL injury. To test for this, perform the posterior sag test (gravity drawer test) by flexing the hip and knee to 90° while supporting the leg and looking for posterior sag of the tibia relative to the patella caused by gravitational pull.

By performing these tests, healthcare professionals can better diagnose and treat knee injuries related to ligamentous instability.

Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. This can cause pain and pins and needles sensations in the thumb, index, and middle fingers. In some cases, the symptoms may even travel up the arm. Patients may shake their hand to alleviate the discomfort, especially at night. During an examination, weakness in thumb abduction and wasting of the thenar eminence may be observed. Tapping on the affected area may also cause paraesthesia, and flexing the wrist can trigger symptoms.

There are several potential causes of carpal tunnel syndrome, including idiopathic factors, pregnancy, oedema, lunate fractures, and rheumatoid arthritis. Electrophysiology tests may reveal prolongation of the action potential in both motor and sensory nerves. Treatment options may include a six-week trial of conservative measures such as wrist splints at night or corticosteroid injections. If symptoms persist or are severe, surgical decompression may be necessary, which involves dividing the flexor retinaculum.

Supplementation of vitamin D and calcium along with oral bisphosphonate.

Managing Osteoporosis Risk in Patients on Corticosteroids

Osteoporosis is a significant risk for patients taking corticosteroids, which are commonly used in clinical practice. To manage this risk appropriately, the 2002 Royal College of Physicians (RCP) guidelines provide a concise guide to prevention and treatment. According to these guidelines, the risk of osteoporosis increases significantly once a patient takes the equivalent of prednisolone 7.5mg a day for three or more months. Therefore, it is crucial to manage patients in an anticipatory manner, starting bone protection immediately if it is likely that the patient will need to take steroids for at least three months.

The RCP guidelines divide patients into two groups based on age and fragility fracture history. Patients over the age of 65 years or those who have previously had a fragility fracture should be offered bone protection. For patients under the age of 65 years, a bone density scan should be offered, and further management depends on the T score. If the T score is greater than 0, patients can be reassured. If the T score is between 0 and -1.5, a repeat bone density scan should be done in 1-3 years. If the T score is less than -1.5, bone protection should be offered.

The first-line treatment for corticosteroid-induced osteoporosis is alendronate. Patients should also be replete in calcium and vitamin D. By following these guidelines, healthcare providers can effectively manage the risk of osteoporosis in patients taking corticosteroids.

Trochanteric bursitis is characterized by pain in the lateral hip/thigh area, accompanied by tenderness specifically over the greater trochanter. This condition, also known as greater trochanteric pain syndrome, typically presents as a localized issue and doesn’t affect the patient’s overall health.

Iliotibial band syndrome, on the other hand, primarily affects the knee and is unlikely to cause nighttime symptoms. Additionally, it is not common in patients of this age group.

Meralgia paresthetica is caused by compression of the lateral femoral cutaneous nerve and typically results in numbness or tingling sensations, rather than pain.

Osteoarthritis is not typically associated with pain upon direct pressure over the greater trochanter.

Understanding Greater Trochanteric Pain Syndrome

Greater trochanteric pain syndrome, also known as trochanteric bursitis, is a condition that results from the repetitive movement of the fibroelastic iliotibial band. This condition is more prevalent in women aged between 50 and 70 years. The primary symptom of this condition is pain on the lateral side of the hip and thigh. Additionally, tenderness can be felt when the greater trochanter is palpated.

Greater trochanteric pain syndrome, also known as trochanteric bursitis, was previously thought to be caused by an inflamed bursa over the greater trochanter. However, it is now understood to be due to minor tears or damage to nearby muscles, tendons, or fascia, with an inflamed bursa being a less common cause. Common causes include injury, repetitive movements, or prolonged excessive pressure. Diagnosis is typically made through history and examination, with a positive Trendelenburg test indicating a dip in the pelvis when lifting the unaffected leg. Treatment options include analgesics, physiotherapy to strengthen muscles, and corticosteroid injection. Other potential causes of hip pain include entrapment of the lateral femoral cutaneous nerve, fracture of the neck of the femur, osteoarthritis of the hip, and sciatica, each with their own distinct symptoms and diagnostic tests.

Assessing Risk for Osteoporosis

Osteoporosis is a concern due to the increased risk of fragility fractures. To determine which patients are at risk and require further investigation, NICE produced guidelines in 2012. They recommend assessing all women aged 65 years and above and all men aged 75 years and above. Younger patients should be assessed if they have risk factors such as previous fragility fracture, current or frequent use of oral or systemic glucocorticoid, history of falls, family history of hip fracture, other causes of secondary osteoporosis, low BMI, smoking, and alcohol intake.

NICE suggests using a clinical prediction tool such as FRAX or QFracture to assess a patient’s 10-year risk of developing a fracture. FRAX estimates the 10-year risk of fragility fracture and is valid for patients aged 40-90 years. QFracture estimates the 10-year risk of fragility fracture and includes a larger group of risk factors. BMD assessment is recommended in some situations, such as before starting treatments that may have a rapid adverse effect on bone density or in people aged under 40 years who have a major risk factor.

Interpreting the results of FRAX involves categorizing the results into low, intermediate, or high risk. If the assessment was done without a BMD measurement, an intermediate risk result will prompt a BMD test. If the assessment was done with a BMD measurement, the results will be categorized into reassurance, consider treatment, or strongly recommend treatment. QFracture doesn’t automatically categorize patients into low, intermediate, or high risk, and the raw data needs to be interpreted alongside local or national guidelines.

NICE recommends reassessing a patient’s risk if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years or when there has been a change in the person’s risk factors.

The risk of breast cancer may be reduced by Raloxifene.

Osteoporosis is a condition that weakens bones, making them more prone to fractures. The National Institute for Health and Care Excellence (NICE) has updated its guidelines on the management of osteoporosis in postmenopausal women. Treatment is recommended for women who have confirmed osteoporosis following fragility fractures. Vitamin D and calcium supplements should be offered to all women unless they have adequate intake. Alendronate is the first-line treatment, but if patients cannot tolerate it, risedronate or etidronate may be given. Strontium ranelate and raloxifene are recommended if bisphosphonates cannot be taken. Treatment criteria for patients not taking alendronate are complex and based on age, T-score, and risk factors. Bisphosphonates have been shown to reduce the risk of fractures, while vitamin D and calcium supplements have a poor evidence base. Raloxifene, strontium ranelate, and denosumab are other treatment options, but they have potential side effects and should only be prescribed by specialists. Hormone replacement therapy is no longer recommended for osteoporosis prevention due to concerns about increased rates of cardiovascular disease and breast cancer. Hip protectors and falls risk assessments may also be considered in the management of high-risk patients.