PhysioEverywhere

Section 1 – Universal MSK Red Flag Framework

1.1 🔴 What are Red Flags?

Red flags are clinical indicators suggesting the presence of a serious underlying pathology requiring urgent or emergency medical attention.

In MSK practice, these include but are not limited to:

• Serious spinal pathology (e.g., cauda equina, myelopathy, fracture, infection, malignancy)
• Systemic inflammatory disease (e.g., AxSpA, RA)
• Vascular compromise (e.g., DVT, PE, cervical artery dysfunction, acute limb ischaemia)
• Infection (e.g., septic arthritis, osteomyelitis, discitis)
• Metastatic disease
• Other medical emergencies

1.2 Why do we ask about them?

• Early identification prevents life-threatening consequences (e.g., sepsis, paralysis, amputation, death)
• Protects the patient by ensuring urgent escalation rather than inappropriate physio management
• Protects the clinician legally — demonstrates due diligence and adherence to best-practice screening
• Guides decision-making:
  • Proceed with physiotherapy
  • Delay treatment pending investigations
  • Urgent same-day referral
  • Immediate emergency referral

1.3 How do we ask them? (framing principles + example questions)

General principles:

• Use neutral, non-leading language — avoids under-reporting or over-reporting
• Contextualise questions so patients understand relevance without becoming alarmed
• Ask one at a time and allow silence for recall
• Use time frames (“in the past few weeks”)
• Clarify severity, onset, progression

Example Phrasing Across Key Domains

1.4 What answers matter most?

• Any “first-ever” or “worst-ever” symptom (e.g., headache, neurological deficit)
• Rapid progression — from onset to functional loss in hours/days
• Combination of symptoms — e.g., night pain + weight loss + past cancer
• Symptoms unexplained by mechanical pattern — pain at rest, constant, severe, not eased by position
• Systemic features — fever, night sweats, unintentional weight loss, fatigue

1.5 How do we manage them? (Emergency vs urgent vs safe-to-proceed)

🚨 Immediate Emergency Referral (A&E / 999)

• Acute neurological deficit + bladder/bowel symptoms (suspected cauda equina)
• Acute limb ischaemia (cold, pale, pulseless limb)
• Suspected septic arthritis with systemic symptoms
• Stroke/TIA symptoms (5D/3N, facial droop, speech disturbance)

⚡ Urgent Same-Day Medical Referral (GP / Specialist)

• Suspicion of new cancer or metastasis
• Suspected vertebral/carotid artery dissection without stroke signs
• Signs of infection without systemic instability
• Inflammatory arthritis with rapid joint deterioration

✅ Proceed with Caution (Physio + Safety Net)

• No red flags identified
• Mechanical pattern clearly established
• Provide explicit safety-net advice (document exact wording)

Section 2 – Vascular Red Flags

Scope: clinician-facing reference for recognising and acting on vascular red flags in patients with neck pain and/or headache (and wider MSK presentations).

2.1 Cervical Artery Dysfunction (CAD)

What it is & why it matters. Cervical Artery Dysfunction (CAD) includes vertebral and carotid artery pathology that may lead to cervico-cranial ischaemia, TIA, or stroke. Early phases often mimic benign MSK neck pain/headache, so recognition relies on pattern-based risk screening rather than a single provocative test.

• Key risk in MSK practice: missing subtle pre-ischaemic patterns.
• Serious event during physiotherapy is very rare, but screening decisions should be driven by risk recognition, not rarity.

Clinical mantra: Intercept risk before classic neuro signs (the “5 D’s / 3 N’s”) appear.

🩺 Anatomical overview

🧬 Pathophysiology (umbrella)

• Dissection (spontaneous or micro/traumatic)
• Atherosclerosis / plaque narrowing
• Thrombosis / in-situ clot; Embolism (remote source)
• External compromise (major trauma)
• Less common: fibromuscular dysplasia, connective-tissue disorders, vasculitis

These can first present as neck pain or headache.

🧭 Clinical course & symptom phases

🩺 Risk factor stack

Key pattern: new neck/head pain + vascular risks ± subtle neuro features.

🧩 Focused subjective (C-spine vascular screen)

• “Is this pain mechanical (linked to movement/posture) or constant/non-mechanical?”
• “Any vision changes, double vision, speech or swallowing difficulty?”
• “Any imbalance, clumsy hands, or loss of coordination?”
• “Any new severe or unusual headache?”
• “Any history of stroke/heart disease/clotting problems or recent neck injury?”

Clarify: time course (sudden vs gradual), first-ever/worst-ever headache, precipitants (minor trauma/sport/illness), duration (TIA <1 hr; stroke >24 hrs), and progression.

🧪 Objective exam (MSK + neuro + vitals)

Avoid relying on vertebral artery positional/provocation tests (low diagnostic accuracy).

• Vitals: BP (consider both arms if suspicious), HR, SpO₂, temperature
• Cranial nerves (pupils/eye movements, facial symmetry, palate, tongue)
• Cerebellar/coordination: finger–nose, heel–shin, Romberg, tandem gait
• UMN signs where appropriate (Hoffmann’s, clonus, Babinski)
• Motor/sensory/reflexes for focal deficit; gait observation
• MSK screen to exclude a clear mechanical cause (avoid end-range cervical rotation)

🧪🧪 Differential diagnosis — pattern contrasts

🧭 Decision pathway

Manual therapy precautions: If AMBER/RED risk, avoid end-range rotation and thrust techniques; prioritise education, relative rest, and urgent medical referral.

🗣️ Safety netting — exact phrases

• “If you notice new dizziness, double vision, trouble speaking or swallowing, sudden weakness, or loss of coordination, call 999 or go to A&E immediately.”
• “If this headache becomes the worst you’ve had, or your symptoms change suddenly, seek urgent medical care.”
• “If any visual loss (like a curtain coming down) occurs, go straight to A&E.”

📝 Documentation checklist (clinician)

• Vascular risk factors reviewed (positives & negatives)
• 5D/3N/Ataxia asked (document wording + response)
• Onset/context incl. recent trauma/infection/pregnancy
• Vitals and relevant neuro findings
• Reasoning: AMBER/RED/GREEN rationale
• Advice given (safety-net) recorded verbatim
• Referral details (pathway, urgency) or plan + review date

2.2 Avascular Necrosis (AVN) / Osteonecrosis

🔍 What is it & why it matters

Avascular Necrosis (AVN) is death of bone tissue from interrupted blood supply. Without timely intervention it can progress to subchondral collapse, secondary osteoarthritis, and long-term disability. Early symptoms often mimic benign joint pain, so recognition before collapse is critical.

🧬 Pathophysiology

• Arterial inflow disruption → bone ischaemia → osteocyte death
• Venous outflow obstruction → marrow congestion
• Fat emboli / marrow fat hypertrophy → intravascular occlusion
• Steroid-related lipid changes → microvascular compromise
• Structural collapse when the subchondral plate loses support

📍 Common sites & vascular vulnerability

🧾 Risk factors

• Trauma (fracture, dislocation)
• Prolonged/high-dose corticosteroids
• Alcohol misuse
• Smoking
• Sickle cell disease
• Connective-tissue disorders (e.g., SLE)
• Gaucher disease
• Decompression sickness
• Radiotherapy / chemotherapy
• Post-transplant status

📋 Typical presentation

🧪 Imaging

• Plain radiographs: may be normal early; later show crescent sign, sclerosis, subchondral collapse.
• MRI: most sensitive for early disease; picks up marrow change before collapse.
• Bone scan: increased uptake; less specific than MRI.

📊 Staging – Ficat (Hip AVN)

🧩 Differential diagnosis

🧑‍⚕️ MSK management considerations

• Avoid high-impact/aggressive loading when suspected.
• Modify rehab to low-impact mobility & pain management pending imaging.
• Avoid end-range loading of the affected joint.
• Early orthopaedic input: core decompression in early stages can prevent collapse.

🧭 Referral pathway

📝 Documentation checklist

• Risk factors (steroids, alcohol, trauma, systemic conditions)
• Onset & progression
• Functional impact (e.g., walking distance, ADLs)
• Joint findings (ROM, tenderness, gait)
• Imaging results (if available)
• Advice given (activity modification, safety netting)
• Referral details (who, when, urgency)

🗣️ Safety-netting — exact phrases

• “If your pain worsens, becomes constant, or you lose movement in the joint, contact your GP or attend A&E immediately.”
• “Avoid high-impact activities until we have clear imaging and diagnosis.”

2.3 Deep Vein Thrombosis (DVT) & Pulmonary Embolism (PE)

Virchow’s triad

Wells score

urgent escalation

What it is & why it matters

DVT is thrombus formation within a deep vein (most often lower limb). The primary danger is embolisation to the lungs → Pulmonary Embolism (PE), which is life-threatening.
• Annual incidence ~1/1,000 adults (population).
• Physio relevance: DVT can mimic calf strain/post-op swelling; PE can present after immobilisation or surgery.
• Key role: early recognition and urgent medical referral to prevent death or permanent disability.

Pathophysiology — Virchow’s Triad

• Stasis: immobility, post-op recovery, long-haul travel, paralysis.
• Endothelial injury: trauma, surgery, central lines, vascular disease.
• Hypercoagulability: cancer, pregnancy, oestrogen therapy, thrombophilia, inflammatory disease (RA/SLE).

Risk factors — screen every patient

Subjective features (DVT)

• Calf/thigh pain (dull ache, tightness, heaviness), unilateral & evolving over hours–days.
• Often preceded by immobility/surgery or a risk-factor trigger.

Objective signs (DVT)

• Unilateral swelling: measure 10 cm below tibial tuberosity; >3 cm difference is concerning.
• Warmth/erythema, pitting oedema, tenderness along deep veins, distended superficial veins.
• Homan’s sign is unreliable and should not be used as a sole diagnostic.

Wells Clinical Prediction Rule (suspected DVT)

Risk stratification: ≥2 → DVT likely → urgent D-dimer & Doppler; <2 → unlikely → consider D-dimer/monitor.

Pulmonary Embolism (PE) — recognise immediately

• Sudden breathlessness, pleuritic chest pain, cough ± haemoptysis.
• Tachycardia/tachypnoea, dizziness, collapse/syncope, anxiety/“impending doom”.

Context: often days–weeks after DVT onset or triggering event.

Management pathway

• Suspected DVT: urgent same-day referral to GP/UCC/ED. Advise mobility as tolerated and hydration; avoid compression until diagnosis confirmed.
• Suspected PE: immediate ED (999 if unstable); oxygen if hypoxic; monitor vitals.
• Physio: document findings, risks, Wells score, and escalation route.

Safety netting — exact phrases

• “If you develop sudden breathlessness, chest pain, cough up blood, or collapse, call 999 immediately.”
• “If leg pain/swelling worsens or redness/heat develops, seek urgent medical care.”

Documentation checklist (clinician)

• Risk factors present/absent (full list).
• Wells score with criteria breakdown.
• Leg measurements (if taken).
• Vitals if PE suspected.
• Escalation pathway & who contacted.
• Safety-net wording recorded verbatim.

2.4 Acute Limb Ischaemia (ALI) / Arterial Occlusion

🔍 What it is & why it matters
ALI is a sudden decrease in limb perfusion that threatens viability — a vascular emergency.

• Time-critical: irreversible tissue damage within 6 hours.
• Causes: embolism, in-situ thrombosis (often on background of PAD), trauma, dissection.

🧠 Classic presentation — “The 6 Ps”

1. Pain – sudden, severe, distal to occlusion
2. Pallor – pale skin, may progress to mottling
3. Pulselessness – absent distal pulses
4. Paraesthesia – numbness, pins & needles
5. Paralysis – late, ominous sign of muscle necrosis
6. Poikilothermia – limb feels cold compared to other side

👥 Risk factors

• Atrial fibrillation (cardioembolic source)
• Previous MI or cardiac thrombus
• Peripheral arterial disease (PAD)
• Recent vascular surgery or angioplasty
• Hypercoagulable states (as per DVT risks)
• Trauma to limb or artery

🗣 Subjective clues

• Sudden onset compared to gradual claudication of chronic PAD
• “My leg went cold and dead”
• May have history of intermittent claudication suddenly worsening

🧑‍⚕️ Objective findings

• Cool, pale limb with well-defined demarcation from healthy tissue
• Absent pulses distal to occlusion
• Capillary refill > 2s
• Possible muscle tenderness if late presentation

🧭 Management pathway

🗣 Safety netting phrase (post-event or for at-risk patients)

📝 Documentation checklist (clinician)

• Onset time and trigger
• 6 Ps status (positive/negative for each)
• Pulses palpated (document site and findings)
• Sensory/motor exam results
• Escalation route (ambulance, ED)
• Advice given

Section 3 – Neurological Red Flags

This section covers multi-level neurology patterns, Cauda Equina Syndrome (CES), and Cervical Myelopathy (CM). See 3.1, 3.2, and 3.3 below.

3.1 Multi-level Neurology

Neurological changes affecting multiple spinal levels (sensory, motor, reflex) strongly suggest cord-level pathology (e.g. tumour, stenosis, transverse myelitis) rather than a single nerve root issue.

3.2 Cauda Equina Syndrome (CES)

🔍 What it is & why it matters

Cauda Equina Syndrome is compression of the nerve roots at the base of the spinal cord, affecting:

• Bowel
• Bladder
• Saddle sensation
• Sexual function
• Lower limb motor and sensory function

Main causes:

1. Central lumbar disc herniation (most common)
2. Tumour / Metastatic Spinal Cord Compression (MSCC) – see Oncology section
3. Infection (e.g., epidural abscess, discitis) – see Infections section
4. Spinal stenosis (bony overgrowth/osteophytes)
5. Haemorrhage (spontaneous or post-procedure)

Missed or delayed diagnosis can cause permanent disability. Progressive symptom worsening over hours to days is common and must be recognised early.

📈 Typical Symptom Evolution

“My back hurts” → “Now my leg hurts” → “My leg(s) feel weak” → “It’s harder to wee” → “I can’t feel when I wipe”

🗣️ Framing CES questions

Clinical introduction:
“I know these questions may sound strange, but they’re very important, and we ask every patient with back pain these questions.”

• “It was like asking what colour you paint your toe nails when you are in labour.”
• “Can’t even think about sex, why are you asking me that?”
• “What’s that got to do with the price of fish?”

🧠 CES nerve root functions

• ✅ Skin sensation around the saddle region
• ✅ Motor & sensory control for bowel & bladder
• ✅ Motor & sensory input for sexual function

Questions must target these domains directly.

📋 Structured screening questions

1. Lower limb neuro symptoms
   • Progressive unilateral or bilateral leg pain/paraesthesia (dermatomal/myotomal pattern)
   • Reflex or myotome changes
   • ⚠️ May be early sign before CES fully develops.
2. Saddle anaesthesia
   • “Can you feel when wiping yourself?”
   • “Have you found you had urinated and didn’t realise?”
3. Bowel dysfunction
   • “Are you going to the toilet as normal?”
   • “When you feel the need to go, can you actually go?” (Retention if not)
   • “Have you had any bowel accidents?”
4. Bladder dysfunction
   • “Are you able to urinate as normal?”
   • “Do you feel the urge to go but can’t pass anything?” (Retention)
   • “Are you going more often than usual?” (Early sign)
   • “Are you incontinent of urine?”
5. Sexual dysfunction
   • “Does it feel normal?”
   • Males: inability to get/maintain erection
   • Females: lack of sensation during sex, pain during intercourse (dyspareunia)

📊 CES progression stages

🧩 Subjective Clues Suggesting CES

• Pain is non-mechanical or worsening despite rest
• Symptoms progressing over hours/days
• Back pain with new bladder/bowel/sexual function change
• Bilateral or rapidly progressing neuro symptoms

🧑‍⚕️ Management & referral pathway

1. Step 1: Speak to a senior immediately (Senior Physio/ESP)
2. Step 2: Triage
   • Yes/Could be CES: 📤 Urgent A&E referral
   • No/Not yet: ⚠️ Monitor + safety net; arrange MRI if worsening
3. Step 3: Referral
   • Use CES Warning Card (if available)
   • Follow GIRFT CES Pathway (2023):
     • Suspected → A&E
     • Confirmed → Surgical decompression
     • Post-op → rehab pathway

📝 Clinician documentation checklist

• All CES screening questions asked and responses documented verbatim
• Presence or absence of saddle anaesthesia recorded
• Bowel, bladder, sexual function status clearly noted
• Any lower limb neuro deficits described (myotome, dermatome, reflex changes)
• CES stage classification (CESS/CESI/CESR/CESC) recorded if applicable
• Timeline of symptom onset and progression
• Details of escalation: who was contacted, when, and outcome
• Safety netting advice given (include exact wording)
• Copies of CES warning cards or written information provided to patient

🗣️ Safety netting phrases

3.3 Cervical Myelopathy (CM)

🔍 What it is & why it matters

Cervical Myelopathy is spinal cord compression within the cervical spine, most often due to degenerative changes, but also trauma, tumours, or inflammatory disease. It is a progressive neurological condition that can cause irreversible spinal cord damage if untreated. Early detection and referral for surgical decompression are critical.

🧬 Causes

• Degenerative cervical spondylosis (most common)
• Disc herniation
• Ossification of the posterior longitudinal ligament (OPLL)
• Tumours (primary or metastatic)
• Congenital spinal canal stenosis
• Rheumatoid arthritis with atlantoaxial instability
• Post-traumatic changes

🧠 Pathophysiology

Narrowing of the cervical spinal canal compresses the spinal cord, disrupting both ascending sensory and descending motor pathways. Chronic compression may cause demyelination and neuronal loss, leading to spasticity, weakness, and coordination deficits.

📋 Typical clinical presentation

Early symptoms (often subtle)

• Hand clumsiness (difficulty with buttons, handwriting changes)
• Mild balance issues or unsteadiness
• Changes in gait pattern (wide-based, slow)
• Upper limb paraesthesia without clear dermatomal pattern

Progressive / advanced symptoms

• Weakness in hands or legs
• Stiffness and spasticity in lower limbs
• Numbness or altered sensation in arms, hands, or legs
• Bladder or bowel urgency

Red flag signs

• Upper Motor Neuron (UMN) signs:
  • Hoffmann’s sign
  • Babinski reflex
  • Clonus (>3 beats)
  • Hyperreflexia (especially brisk patellar reflexes)
• Sensory changes:
  • Altered joint position sense
  • Loss of vibration sense in feet
• Lhermitte’s sign: electric shock sensation with neck flexion

🗣️ Screening questions

• “Have you noticed clumsiness in your hands or difficulty with buttons?”
• “Do you feel unsteady or off balance when walking?”
• “Have you had any changes in handwriting or fine motor skills?”
• “Any new urgency or changes in bladder or bowel habits?”
• “Do your symptoms worsen when you move your neck?”

🧪 Objective examination

• Observe gait (may be stiff, wide-based, or ataxic)
• Test coordination (finger–nose, heel–shin)
• Assess reflexes (biceps, triceps, patellar, Achilles)
• Check for UMN signs (Hoffmann’s, Babinski, clonus)
• Sensory exam: proprioception, vibration, light touch
• Assess for Lhermitte’s sign (with caution)

📊 Differential diagnosis

🧑‍⚕️ Management & referral pathway

1. Step 1: Suspect CM in presence of UMN signs or progressive neuro symptoms.
2. Step 2: Immediate actions
   • Avoid cervical manipulations or high-velocity techniques
   • Refer urgently to spinal/orthopaedic/neurosurgical team for assessment and imaging (MRI preferred)
3. Step 3: Document findings clearly, including:
   • Positive/negative UMN signs
   • Functional impairments
   • Onset and progression timeline
   • Safety netting advice

📝 Clinician documentation checklist

• All screening questions and patient responses recorded
• Detailed neuro exam findings (motor, sensory, reflexes, coordination)
• Positive/negative UMN signs clearly noted
• Functional impact described (e.g., hand function, gait stability)
• Symptom timeline and progression documented
• Escalation steps (who contacted, when, and outcome)
• Safety netting advice recorded verbatim

🗣️ Safety netting phrases

🔥 Section 4 – Inflammatory Pathologies

Scope: Clinician-facing reference for recognising and managing systemic inflammatory conditions that present in MSK settings. Early identification prevents irreversible joint damage, organ involvement, and limits systemic complications.

📋 Common inflammatory red flag conditions

• Rheumatoid Arthritis (RA)
• Psoriatic Arthritis (PsA)
• Polymyalgia Rheumatica (PMR)
• Axial Spondyloarthropathy (AxSpA)

🧬 4.1 Axial Spondyloarthropathy (AxSpA)

• Onset: 20–45 years
• Sex: Male > Female (3:1)
• Symptoms: Morning stiffness > 45 min; night pain (2nd half of night); worse with rest, improves with movement
• Risk factors: Family history of autoimmune disease, HLA-B27 positivity, history of IBD
• Extra-articular: GI symptoms, uveitis, psoriasis

🤲 4.2 Rheumatoid Arthritis (RA)

• Onset: Most common between 30–50 years; female > male (3:1)
• Pattern: Symmetrical small joint polyarthritis (MCP, PIP, wrists)
• Symptoms: Morning stiffness > 60 min, joint swelling, systemic fatigue, weight loss
• Extra-articular: Rheumatoid nodules, vasculitis, lung involvement, pericarditis, scleritis
• Risk factors: Female sex, smoking, family history, HLA-DR4/DR1 positivity
• Complications: Joint destruction, cervical spine instability, increased CV risk

🧴 4.3 Psoriatic Arthritis (PsA)

• Onset: 30–50 years; affects men and women equally
• Pattern: Asymmetrical oligoarthritis, symmetrical polyarthritis, spondylitis, or predominant DIP joint involvement
• Symptoms: Morning stiffness, joint swelling, pain, dactylitis (“sausage digits”)
• Extra-articular: Psoriasis (skin plaques), nail changes (pitting, onycholysis), uveitis
• Risk factors: Family history of psoriasis, HLA-B27 positivity
• Complications: Joint deformity, enthesitis, increased metabolic syndrome risk

👵 4.4 Polymyalgia Rheumatica (PMR)

• Onset: > 50 years; female > male (2:1)
• Pattern: Bilateral pain and stiffness in shoulders, neck, hips
• Symptoms: Morning stiffness > 45 min, difficulty rising from chair or lifting arms, fatigue, low-grade fever
• Risk factors: Northern European ancestry, history of autoimmune disease
• Complications: 20% develop temporal arteritis (GCA) — risk of vision loss; concurrent inflammatory arthritis

🔡 SCREEND-EM — Inflammatory disease screening (Kirwan, 2020)

🌙 Night pain in inflammatory disease

• Wakes patient in early morning hours
• Driven by increased parasympathetic tone at rest
• Relieved by movement; associated with prolonged stiffness

🧪 Investigations

• Bloods: ESR, CRP, WCC, HLA-B27 (AxSpA, PsA), Anti-CCP (RA), Rheumatoid Factor
• Imaging:
  • X-ray: sacroiliitis, joint space narrowing, erosions (later stages)
  • MRI: early inflammatory changes (bone marrow oedema, synovitis)
  • Ultrasound: synovial thickening, effusion, Doppler activity

🧭 Management pathway

• 🗣 Discuss with senior or rheumatology link
• 📄 Urgent referral if SCREEND-EM markers positive or red flag features present
• 💊 Early DMARDs/biologics initiated by rheumatology
• ⚠️ Check infection risk before starting immunosuppression

📝 Clinician documentation checklist

• SCREEND-EM responses
• Stiffness duration and timing
• Night pain presence/absence
• Extra-articular features documented
• Functional limitations
• Investigations ordered/results
• Referral details and urgency
• Safety netting advice

🦠 5. Infections

Scope: Clinician-facing reference for recognising and managing MSK infections that can progress rapidly and require urgent action.

• Why it matters: risk of irreversible cartilage/bone damage (e.g., septic arthritis) and systemic sepsis.
• Higher-risk groups: immunosuppressed, post-operative, IVDU, diabetics, those with indwelling devices.

🔎 Quick jump

5.1 Overview & risk screen
5.2 Discitis
5.3 Septic arthritis
5.4 Osteomyelitis

🦠 5.1 Overview & why they matter

📚 Overview

• Sites: bone, joints, intervertebral discs.
• Routes: haematogenous spread, direct inoculation (trauma/wounds/bites), post-surgical contamination.
• Why it matters: rapid cartilage/bone destruction (e.g. septic arthritis), risk of bacteraemia/sepsis, blunted signs in immunocompromised patients.

🧵 THREADSOCS — infection risk screen

❗ Additional infection red flags

• Fever, night sweats, unexplained fatigue
• Constant, progressive pain not mechanical
• Recent surgery, injections, wounds, dental work
• Immunosuppression: HIV, chemo, DMARDs, steroids
• Non-mechanical night pain
• Rapid functional decline
• Invasive procedures (catheterisation, endoscopy)
• Open wounds, ulcers, cellulitis
• IV drug use

🧪 Investigations

• Bloods: ESR/CRP, WCC, blood cultures (before antibiotics if possible).
• Imaging: MRI (gold standard for spine/early bone infection), US (joint effusion), X-ray (late bony change).
• Procedures: urgent joint aspiration (cell count, Gram, culture) — do not delay if septic arthritis suspected; consider HIV/TB tests if risk.

🧭 Management pathway

1. Escalate immediately to senior/medical team if suspected.
2. Same-day referral: GP/consultant physio/orthopaedics/rheumatology; A&E if systemic signs or sepsis.
3. Do not delay referral for imaging if unstable — early IV antibiotics are time-critical.
4. Document thoroughly (see checklist).

📝 Clinician documentation checklist

• THREADSOCS risk factors reviewed
• Onset, progression, duration
• Systemic signs present/absent
• Functional impact
• Site(s) & clinical findings
• Investigations & results
• Who escalated to, when, outcome
• Safety-netting advice

🗣️ Safety-netting phrase

“If you develop fever, chills, sweats, new swelling, redness, or worsening pain, seek urgent medical attention or attend A&E immediately.”

📌 Clinical pearls

• Immunosuppressed patients may lack fever — watch for functional decline and subtle change.
• Septic arthritis can destroy a joint in <24h — same-day referral.
• In diabetics, always inspect feet — ulcers may hide osteomyelitis.

🟢 5.2 Discitis

• Definition: infection of the intervertebral disc ± adjacent vertebrae (spondylodiscitis).
• Epidemiology: children and older adults; recent systemic infection, IVDU, or immunosuppression.
• Presentation: severe localised back pain, fever/malaise, reduced spinal mobility; pain worse with movement.
• Causes: Staph. aureus most common; TB in endemic/immigrant populations.
• Complications: epidural abscess, neuro deficits from cord/root compression.

🟢 5.3 Septic Arthritis

• Definition: infection of a joint and surrounding soft tissues (usually monoarthritis).
• Who: children, elderly, post-op arthroplasty, immunosuppressed.
• Presentation: hot, swollen, red, very tender joint; severely reduced ROM; fever/chills.
• Sites: knee > hip, shoulder, ankle.
• Causes: Staph. aureus, Strep spp., N. gonorrhoeae (sexually active adults).
• Complications: irreversible cartilage damage in 6–12h; osteomyelitis from spread.

🟢 5.4 Osteomyelitis

• Definition: infection of bone (acute or chronic).
• Epidemiology: long bones in children (haematogenous); vertebrae in adults; common with diabetic foot ulcers & post-trauma.
• Presentation: persistent localised bone pain, fever, swelling/redness; chronic: sinus tract, non-healing ulcers.
• Routes: blood-borne, post-surgical, direct trauma.
• Complications: chronic infection, pathological fracture, sepsis.

🧩 6. General Screening Acronyms & Systemic Red Flags

Scope: Hidden risks that sit outside pure MSK but drive serious pathology or alter management. Use as a fast screen and escalation guide.

🔎 Quick jump

6.1 #THREADSOCS – Hidden Red Flag Screening Tool (+ Alcohol & Smoking)
6.2 Other Important Pathologies — When to Think Outside MSK
6.3 Oncology-Specific Red Flags
6.4 Management Pathway

🔎 6.1 #THREADSOCS – Hidden Red Flag Screening Tool

➕ Also ask about: A/S – Alcohol & Smoking

Why it matters: Both have multi-system effects that impair recovery, increase surgical and rehab risk, and elevate the likelihood of serious pathology behind an MSK presentation.

• Combined effect of smoking + alcohol is synergistic in worsening CVR disease, cancer risk, and impaired healing.
• Alcohol excess → balance/gait disturbance → increased falls/fractures.
• Smoking → ↓ surgical success rates (esp. spinal fusion, joint replacements).
• Both reduce rehab tolerance due to fatigue, poor cardiorespiratory function, and systemic inflammation.

🧠 6.2 Other Important Pathologies — When to Think Outside MSK

⏳ First Presentation < 20 or > 55

• Back pain is uncommon in these age groups unless there’s serious pathology.
• High suspicion for cancer, fracture, infection in these cases.

🔁 Constant, Progressive, Non-Mechanical Pain

• Not eased or aggravated by rest/activity.
• Suggestive of tumour, fracture, infection, or systemic inflammation.

🟥 Thoracic Pain / Band-Like Pain

• Rarely purely mechanical; may indicate metastases or visceral referral.
• Always screen cancer history.
• Particularly if constant or progressive; may indicate metastatic disease, visceral referral (lungs, abdominal organs, breast), or spinal cord pathology.

⚡ Neurological Red Flags

🌡️ Systemically Unwell

• Fatigue, malaise, unintentional weight loss, night sweats, fever
• Suggestive of systemic inflammation, infection, or cancer

🧬 Relevant PMH

• Cancer (personal/family)
• Drug abuse
• HIV
• Long-term steroids

↑ recurrence risk, immune compromise → higher infection risk (discitis, septic arthritis, osteomyelitis)

🧬 6.3 Oncology-Specific Red Flags

5 Most Common Tumours to Metastasise (Mnemonic: Pierce Brosnan – Licence to Kill)

• Prostate – lumbar
• Breast – thoracic
• Lung – thoracic
• Thyroid – cervical/thoracic
• Kidney – lumbar

Typical cancer presentation

• PMH of cancer
• Progressive symptoms: “It’s getting worse”
• Night pain
• Unusual locations (thoracic, ribs, abdominal, band-like)
• Systemic signs: malaise, weight loss

🌙 Night Pain (Cancer Link)

• Pain worse at night, any position
• “Awake pacing”, “night sweats”, “sleeping in a chair”
• Supine position worsens symptoms (space-occupying lesion suspicion)

🧭 6.4 Management Pathway

• 🚨 Escalate to senior
• 📝 Urgent referral (GP, Consultant Physio, Oncology)
• 💉 Imaging + bloods

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