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Common orthopaedic and rheumatological histories

Lower back pain

Exploring symptom

  • Pain
    • Site
    • Onset
    • Character
    • Radiation
    • Associated symptoms
    • Timing
    • Exacerbating/relieving factors
    • Severity
  • Associations
    • Sciatica, stiffness/deformity, incontinence, neurological symptoms
  • Red flags
    • Cauda equina: urinary incontinence/retention, faecal incontinence/constipation, bilateral leg pain, severe/progressive neurological deficit, saddle anaesthesia, sexual dysfunction
    • Infection or cancer: age <20 or >55 years at onset, cancer Hx, night pain, weight loss, fever, night sweats, injecting drugs, immunosuppression
    • Fracture: trauma, severe central spinal pain
    • Spondyloarthropathy: early morning stiffness, worse with rest

Relevant system reviews

  • General
    • Fever, night sweats, weight loss
  • Neuro (lower limbs)
    • Motor: weakness/wasting, incontinence 
    • Sensory: pain, numbness, tingling

Differential diagnoses and clues

Orthopaedic

Muscular

  • Acute onset lower back pain
  • Paraspinal muscles affected, not central

Lumbar spondylosis

Includes lumbar facet joint syndrome (lumbar arthritis)

  • Chronic episodic mechanical lower back pain
  • Backache related to standing/walking a lot/sitting in one place
  • Progressive stiffening

Lumbar disc prolapse

  • Acute onset while lifting / bending / sneezing / coughing
  • Severe pain
  • Sciatica, leg pain often worse than back pain
  • Neurological symptoms, e.g. weakness, numbness (usually L4/L5/S1 distribution)

Discitis

  • Fever and systemic upset
  • Risk factors, e.g. injecting drug user

Spinal fracture

  • History of trauma
  • Sudden onset

Cauda equina syndrome

  • Urinary incontinence/retention
  • Faecal incontinence/constipation
  • Saddle anaesthesia or paraesthesia
  • Bilateral leg pain and weakness

Rheumatological

Ankylosing spondylitis

  • Morning stiffness >30 minutes
  • Pain worse on rest

Others

Others

  • Bony

    • Myeloma bone lesions
    • Bony metastasis
    • Paget’s disease
    • Spondylolisthesis
    • Osteoporotic vertebral collapse

  • Abdominal

    • Pyelonephritis
    • PID
    • Pancreatitis
    • AAA

Joint pain / stiffness / swelling

Exploring symptom

  • Pain
    • Site(s)
    • Onset
    • Character
    • Radiation
    • Associated symptoms
    • Timing
    • Exacerbating/relieving factors
    • Severity
  • Stiffness/swelling
    • Worse in morning?, how long for (>30 mins = inflammatory; <30 mins = osteoarthritis)
    • Better or worse after exercise
    • Sleep disturbance
    • Loss of function

Relevant system reviews

  • General
    • Fever, rashes, weight loss
  • Rheumatological
    • Joints: pain, stiffness, swelling
    • Work down body: skin (rashes, ulcers, Raynaud’s), hair loss, eyes (redness, dryness), mouth (dryness), chest (breathlessness, SOB), GI (IBD symptoms), genitourinary (discharge

Differential diagnoses and clues

Rheumatological

Rheumatoid arthritis

  • Slowly progressive symmetrical polyarthropathy
  • Small joints (commonly of hand)
  • Deforming
  • Early morning stiffness

Gout

  • First MTP joint most commonly affected
  • Isolated swollen, hot, painful joint
  • Hyperuricaemia risk factors, e.g. diuretics, alcohol excess (esp. beer), renal disease

Psoriatic arthritis

  • Associated skin plaques and nail changes
  • Early morning stiffness
  • Many patterns of joint involvement

SLE

  • Systemic illness with intermittent fevers
  • Photosensitive rash
  • Generalised myalgia and arthralgia
  • Other systemic symptoms (e.g. psychiatric, pleurisy, ulcers)

Enteropathic arthritis

  • Symmetrical arthritis of lower limb joints and sacroiliac joints
  • Early morning stiffness
  • Symptoms/diagnosis of Crohn’s or UC

Orthopaedic

Osteoarthritis

  • Elderly
  • Worse on movement (rest helps) and at end of day, night pain common

Septic arthritis

  • Isolated hot, red, swollen joint
  • Agonizingly painful
  • Systemically unwell with fever

Others

Others

  • Single joint

    • Traumatic (dislocation/fracture/ligament injury)
    • Haemophilia (haemarthrosis)
    • Pseudogout
    • Joint specific problems (e.g. knee – chondromalacia patellae, Osgood-Schlatter’s disease, patellar tendonitis; hip – avascular necrosis)
    • Adhesive capsulitis
    • Transient synovitis
    • Bursitis
    • Reiter’s syndrome

  • Multiple joints

    • Viral polyarthritis (e.g. flu, HIV, hepatitis, rubella)
    • Other connective tissue disorders (e.g. systemic sclerosis, polymyositis, polyarteritis nodosa)
    • Other spondyloarthropathies (e.g. ankylosing spondylitis, Reiter’s syndrome, Behçet’s disease, juvenile chronic arthritis, rheumatic fever)

Try some viva questions

Please list some differentials for lower back pain

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What are the RED FLAGS of back pain?

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What treatment options are there for chronic nonspecific back pain?

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Which investigations may be used to help differentiate the causes of back pain?

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Name the three main causes of spinal disc pathology

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Now it’s your turn to shine! Here are some history stations…

  1. Back pain
  2. Joint pain
  3. And more joint pain!
  4. Time for a different joint
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