Osteoathritis Geoff McColl and Andrea Bendrups

Doctor of Medicine Mrs Carmela Ierino Mrs Ierino is a 55 year old woman with increasing pain in the right buttock and groin on walking. The pain began about 2 years ago but was intermittent and not severe. In the last few months the pain is present when walking and limits her ability to climb stairs. The pain radiates to the lateral thigh.

Doctor of Medicine Interactive exercise 1 Form yourselves into groups of 3-5 people Identify a spokesperson for the group Discuss the following questions – What are the key points in history? – What are your initial hypotheses for Mrs Ierino’s problems? Could this be a red flag condition? – What other information on the medical interview would be helpful to clarify the diagnosis?

What are the key points in the history? Age Time frame – chronic Distribution of the pain Presence of any low back pain Presence of neurological symptoms eg paraesthesia or numbness Previous injury, family history of arthritis Comorbidities

Could this be a red flag condition? What is a red flag condition? Infection Fracture Malignancy

Doctor of Medicine Mrs Ierino Mrs Ierino’s groin and thigh pain is worse with walking and better with rest There is some associated lower back pain She has stopped walking any distance due to the pain Paracetamol is helpful She is reluctant to take an NSAID as she had a gastric ulcer 2 years ago after taking diclofenac for back pain

Doctor of Medicine Mrs Ierino Previous history – Hypertension for 10 years treated with indapamide 2.5mg daily – Diabetes mellitus type 2 diagnosed 6 years ago treated with Metformin 500mg bd – Bleeding gastric ulcer 2 years ago after using diclofenac Family history – Mother had a myocardial infarct at 62 years of age Social history – Married with 2 children and 1 grandchild, husband works fulltime in the family dry cleaning business

Doctor of Medicine Interactive exercise 2 On the basis of this further information refine your diagnostic hypotheses What are the possible sources of her pain? What features on physical examination would assist you in further refining you diagnostic hypotheses?

Doctor of Medicine Mrs Ierino Physical examination – Cardiovascular Normal – Respiratory Normal – Abdominal Normal – Neurological No evidence of right leg weakness, reflex loss or sensory change

Doctor of Medicine Mrs Ierino Physical examination Right hip examination Look - gait - Trendelenberg test negative (Revise) Feel - no back or soft tissue tenderness Move - both hips move painlessly through a full ROM Back examination Look - Posture/curvatures (scoliosis) Feel - for vertebral or paravertebral (muscle spasm) tenderness Move - Flexion, extension, lateral flexion (left and right), rotation (left and right) Special tests eg Schober’s test (How is this performed?)

Doctor of Medicine

Doctor of Medicine Anatomy Revision 1.Many complexly-oriented muscles over many layers 2.Overlapping spinal innervation levels 3.Small cortical homunculus representation All of the above leads to poor pain localisation and complex patterns of referred pain

Doctor of Medicine Scoliosis Surface anatomy

Doctor of Medicine Scoliosis: radiology

Doctor of Medicine Interactive exercise Form yourselves into a new group of 3-5 people Identify a spokesperson for the group Discuss the following questions – What are your initial hypotheses for Mrs Ierino’s problems? – What other information on the medical interview would be helpful to clarify the diagnosis?

Low Back Pain What are some causes of LBP?

Doctor of Medicine Causes of low back pain 1 Facet joint osteoarthritis Disc degeneration Disc herniation – central (can cause canal stenosis) or – posterolateral (can cause radicular impingement)

Doctor of Medicine Inflammatory back pain – Ankylosing spondylitis, Psoriatic arthritis, Reactive arthritis / Reiter’s syndrome Fractures – Osteoporosis, malignancy, trauma Malignancy – Eg. breast, lung, prostate Infection – Discitis, osteomyelitis, epidural abscess Intra-abdominal pathology – AAA, renal, pelvic Causes of low back pain 2

Doctor of Medicine

The summation shadows of 2 overlapping lumbar vertebrae in the oblique view plain Xray are said to resemble the outline of a “scotty dog”. This example shows some facet joint OA (aka degenerative) changes – joint space narrowing and sclerosis. radiologysigns.tumblr.com

Doctor of Medicine

Possible cause of Mrs Ierino’s pain Spinal canal stenosis  Anatomically is usually caused by a combination of facet joint OA + ligamentum flavum hypertrophy + disc herniation  May cause the clinical syndrome of lumbar claudication, ie. Lumbar, buttock or thigh pain usually uni- but may be bilateral that is NOT present at rest but comes on with exercise, at a reproducible walking distance  Nerve roots become compressed

Doctor of Medicine Mr Mohamed Mr Mohamed is a 25 year old refugee from Iraq who presents with 2 days of lumbar back pain after lifting a heavy box

Doctor of Medicine Interactive exercise Form yourselves into a new group of 3-5 people Identify a spokesperson for the group Discuss the following questions – What are your initial hypotheses for Mr Mohamed’s problems? – What other information on the medical interview would be helpful to clarify the diagnosis?

Additional information Previous history of LBP Site, radiation, mechanical pattern? How soon after the event did the pain start? Why is this important? Acute = fracture, acute disc injury or muscular Other medical history: ?use of oral steroids for asthma, ?IVDU, ?immunosuppressive d/o

Doctor of Medicine Mr Mohamed Mr Mohamed’s pain is in the centre of his lumbar spine and radiates to both buttocks but not to the legs The pain is worse standing and walking but is better lying down Pain is rated 5/10 at rest, 8/10 movement Paracetamol is not helpful

Can you suggest some possible causes for Mr Mohamed’s back pain? Indicate why you think your suggestion is a likely diagnosis.

Doctor of Medicine Mr Mohamed Previous history – Refugee from Iraq – Arrived in Australia 3 years ago – Married with 2 children – No previous back pain – Smoker – 5-10 per day

Doctor of Medicine Interactive exercise On the basis of this further information refine your diagnostic hypotheses What features on physical examination would assist you in further refining you diagnostic hypotheses?

Doctor of Medicine Mr Mohamed Vital signs – BP – 115/70, Pulse 72, Temperature – 37.2 Back examination – Look – slight loss of lumbar lordosis – no scoliosis – Feel – exquisite tenderness in the mid paravertebral lumbar spine – Move – reduction of all back movements – Special tests – no abnormal neurological signs

Doctor of Medicine Interactive exercise On the basis of this further information refine your diagnostic hypotheses What investigations would assist you in further refining you diagnostic hypotheses?

Doctor of Medicine Australia Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain – a guide for clinicians. Bowen Hills: Australian Academic Press; 2004.

Doctor of Medicine MRI Changes in the Lumbar Spine Jensen MC, et al. “MRI imaging of the lumbar spine in people without back pain.” N Engl J Med – 1994; 331:

Doctor of Medicine Australia Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain – a guide for clinicians. Bowen Hills: Australian Academic Press; 2004.

Doctor of Medicine Interactive exercise No X-ray or other investigation is requested What is the likely outcome of Mr Mohamed’s back pain? What treatment would you recommend?

Doctor of Medicine Australia Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain – a guide for clinicians. Bowen Hills: Australian Academic Press; 2004.

Doctor of Medicine Australia Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain – a guide for clinicians. Bowen Hills: Australian Academic Press; 2004.

Doctor of Medicine Australia Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain – a guide for clinicians. Bowen Hills: Australian Academic Press; 2004.

Doctor of Medicine Australia Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain – a guide for clinicians. Bowen Hills: Australian Academic Press; 2004.

Doctor of Medicine Paracetamol First line treatment for simple back pain as well as OA hip and knee RACGP osteoarthritis working group. Clinical Guideline for the Non-surgical management of hip and knee osteoarthritis. South Melbourne: RACGP; July 2009.

Doctor of Medicine NSAIDs Short term use in acute back pain may be useful. Early in its natural history OA is often inflammatory (sometimes very!) Late OA is usually not! RACGP osteoarthritis working group. Clinical Guideline for the Non-surgical management of hip and knee osteoarthritis. South Melbourne: RACGP; July 2009.

Interactive exercise 5 Q. What is the mechanism by which oral NSAIDs cause serious side effects? A.Cyclo-oxygenase 1 and 2 inhibition Consider the gut, kidney, blood vessels for negative and positive clinical benefits

Doctor of Medicine Mr Mohamed You recommend ongoing activity and a heat pillow (eg. wheat bag) for treatment You provide Mr Mohamed with written material about acute back pain On review in 2 days his pain has improved by 50% and one week later has resolved completely Diagnosis – acute muscle spasm

Back Pain History Checklist Site: localised or diffuse. Radiation :consider 1.referred pain – MSK, visceral 2.radicular pain – nerve root irritation Timing: Onset, progression, exacerbators, relievers Remember red flag conditions – infection, malignancy

Doctor of Medicine What have we learned? Back pain is a common complaint in all age groups Most recent onset MSK pain is self-limiting and is musculoligamentous in origin Appropriate acute management and accurate patient education will modify the long-term outcome Degenerative disc disease with secondary facet joint OA is a common condition with a significant impact on the patient Diagnosis is generally made on the medical interview and physical examination Investigations are often not necessary Treatment of osteoarthritis includes pharmacological and non- pharmacological approaches considered in the context of the patient’s other medical conditions

© Copyright The University of Melbourne 2015 Updated and revised: January 2014