Musculoskeletal: Acute Lower Back Pain

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1 Musculoskeletal: Acute Lower Back Pain Acute Lower Back Pain Back Pain only Sciatica / Radiculopathy Possible Cord or Cauda Equina Compression Possible Spinal Canal Stenosis Red Flags Initial conservative treatment is usually reasonable Urgent Imaging Imaging indicated No Red Flag Conservative treatment Not improved Cause found Bone scan + Spect CT Red Flag present Cause uncertain If pain not improving or progressive neurological deficit MRI is most appropriate CT guided nerve root block if nerve compression identified MRI If MRI not available CT MRI is most appropriate CT guided epidural steriod injection if caudaequina compression identified Musculoskeletal: Acute Lower Back Pain Treat If suspected stress fracture If suspected infection If suspected bony metastases Red Flags Age of onset < 20 years or > 55 years Recent history of violent trauma Constant progressive, non mechanical pain (no relief with bed rest) Thoracic pain Past medical history of malignant tumour Prolonged use of corticosteroids Bone Scan or CT MRI Bone Scan Drug/alcohol abuse, immunosuppression, HIV Systemically unwell Unexplained weight loss Widespread neurological symptoms (including cauda equina syndrome) Structural deformity Fever MRI +/- other imaging for metastatic disease

2 Musculoskeletal: Non Traumatic Hip or Knee Pain Non-Traumatic Hip or Knee Pain Clinical Assessment Musculoskeletal: Non Traumatic Hip or Knee Pain Mild Arthritis Conservative management If conservative management fails consider intra-articular steroid/local anaesthetic injection Cause for pain found Further investigation as indicated by severity of symptoms and fitness for potential surgery Initial conservative treatment is appropriate X-Ray of affected joint(s) Mod-Severe Arthritis Referral to orthopaedics, if patient fit for and requests surgery Cause for pain still uncertain MRI knee or MRI hip

3 Musculoskeletal: Post Traumatic Knee Pain Post Traumatic Knee Pain Fracture Treat (may need CT for Treatment Plan) Ottawa Rules - Clinical decision rules for X-Ray in acute knee injury Knee X-Rays are indicated when any of the following are present: Age 55 years or older Tenderness at head of the fibula Isolated tenderness of the patella Inability to flex knee to 90 degrees Inability to walk four weight-bearing steps immediately after the injury and in emergency department X-Rays indicated Fracture not seen on X-Ray Ongoing suspicion of fracture CT/MRI X-Rays not indicated Likely soft tissue injury MRI when available (or arthrography/ arthroscopy) Musculoskeletal: Post Traumatic Knee Pain Normal with high clinical suspicion Bone scan

4 Musculoskeletal: Shoulder Problems Shoulder Problem (Pain, Instability, Stiffness) Clinical Examination Musculoskeletal: Shoulder Problems Decreased external rotation Frozen shoulder Osteoarthritis X-Ray Include: True glenohumeral, AP axillary and lateral views Frozen shoulder confirmed Fracture detected Consider CT Osteoarthritis not visible and decreased external rotation Shoulder trauma including dislocation X-Ray Include: AC joint and axillary lateral views (Do not accept standard lateral) No fracture but painful movements Inject bursa (under ultrasound). If no improvement, MRI 1) Pain with elevation and/or internal rotation 2) Weak elevation and external rotation Impingement syndrome Rotator cuff tear X-Ray (+ impingement views) and Ultrasound bursa injection No improvement Consider MRI arthrogram Inject bursa & hydrodilatate glenohumeral joint/ physiotherapy Inject bursa (under ultrasound - guidance). If no improvement, MRI

5 Musculoskeletal: Ultrasound Medicare Rebate Guide Medicare has restricted rebates for shoulder and knee ultrasound. A Medicare rebate is claimable only when one or more of the following clinical indicators is applicable and noted on the referral. Shoulder Ultrasound Evaluation of injury to tendon, muscle or muscle tendon junction Rotator (biceps, subscapular, supraspinatus, infraspinatus) Biceps subluxation Capsulitis and bursitis Evaluation of mass including ganglion Occult fracture Acromioclavicular joint pathology Knee Ultrasound Abnormality of tendons or bursae about the knee Meniscal cyst, popliteal fossa cysts, mass or pseudomass Nerve entrapment, nerve or nerve sheath tumour Injury of collateral ligaments NB Non specific pain alone is not an accepted Medicare indication. Musculoskeletal: Ultrasound Medicare Rebate Guide

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