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Hi, everyone. It's nice to meet you. We'll get started in a few minutes, I think. Um, just while we're waiting, could someone in the chart let me know if they can see and hear? Fine, please. Ok, cool. So nice. Um, nice to meet you. So NIA and I today are going to be covering joint pain. Um, and I'm sure you'll know the drill by now, but we are teaching things which are weekly tutorials run by medical students. Everything is reviewed by doctors and before we present it to all of you, um, please follow us on me. So we're going to start with osteoarthritis and before I begin, just wanna get a quick overview of how you feel about this topic. So I'm just going to start Paul, if you could all answer, that would be great. Ok, so most of us are pretty much in the middle. Um, hopefully by the end of the session, we're all a bit more confident. So we're going to start this with the case of Missus Smith who is a 72 year old woman. She presents to her GP with severe pain in her buttocks. How should the GP, proceed. Does anyone have any ideas to begin with? What would we initially do when a patient presents pretty much anywhere in a hospital setting? Ok. We'll just keep going. So the first thing is of course to always take a good history and the GP has taken this history, the history reveals that she's been feeling pain mostly on her right side. It started around six months ago and it's been progressively getting worse. She feels like it's a little stiff in the mornings, but there's, but um, there's no pain, just the stiffness, it comes on after she takes her dog for a walk. And this is when it's at its worst. The pain is mostly in her buttocks, but sometimes it radiates to her groin and her outer thigh as well. And by the end of the day, the pain is usually at its worst. So from the history, the first things we're trying to pick out is the features of osteoarthritis. So we can see that there's a gradual onset for the pain. We know that for hip arthritis, usually that pain is going to be felt in the bum and groin and outer thigh kind of area. It's worse after exercise, which is the case for this lady. She says that it's worse at night, it's usually relieved by rest. And so consequently, there's the least amount of pain in the mornings and there are very little sensory changes if there were sensory changes you would then have to start thinking about sciatica and other kind of pathologies to do with the spine, especially in the case of hip osteoarthritis. So after the history of presenting complaint, we would then take a full history. Can anyone think of any risk factors that would support a diagnosis of osteoarthritis? What would we be wanting to ask during the history? Any ideas in the chat, if possible? Good. Raised BM. I recurrent um history of recurrent fractures or trauma? Good. Anything else? Yeah, good. Ok. So the kind of things we'd be looking out for is obesity is a big one injury as Amelia mentioned previously. So previous trauma to the area increasing age is a huge one. female gender increasing age in females, structural abnormalities. So by this, we mean things like when the joint doesn't fit together properly and because of that, the bone just starts rubbing against each other kind of precipitating osteoarthritis. Um So for example, Perthes disease, which is like a like developmental kind of like dysplasia of the hip. What people are born with like your axis is a little misaligned and this can precipitate osteoarthritis because like I said, the bone prematurely starts rubbing against bone. Um Other things from the social history you'd want to know are smoking and alcohol. These generally it's good to always ask about these because most pathologies no matter what they are smoking and alcohol is not good for them. So, yeah, joint overuse is another one. So her occupation would be very relevant here and what she does and whether, how impactful it is on her job as well. We'd want to know all of those things. Ok. Moving on. So investigations, we kind of split investigations into at the bedside, imaging bloods and then sorry, at the bedside bloods and then imaging for osteoarthritis, all like arthritis, joint pain, anything musculoskeletal in general. The most important thing is always, always the investigation of actually examining the hip and the joints. So in hip examination, what you would find is an antalgic gait. So this would present as a shorter stride length with the affected leg. And if you think about it, it kind of makes sense why? Because obviously that joint is in so much pain that this person or the person who has osteoarthritis can't do too much with it. So they'll try and relieve any pain felt by taking shorter strides, resting, it, taking another short stride, resting it. Um, there'll also be weakness on movement which is worsened with resistance. So this is when you're pushing against the joint and the person will most likely be in pain or it will be weak crepitus. So you'll hear that kind of clicking sound, muscle wasting around the joint. Again, this goes back to the antalgic gait because the stride length is shorter, the muscle is being used less. And in general, if you're in pain, you're going to use that muscle less as well. Um And also stiffness. So that's going to make it difficult to move and to rotate the leg in um, orthopedics and orthopedic examinations. The general rule is to examine the joint below and the joint above with the hip, the joint above is a little bit difficult but the spine is kind of the most adjacent joint. Um in an osk situation, of course, you're not going to get time to do all of this. So as long as you examine the joint, that's got the presenting complaint, just mention that you will also examine the joint below and the joint above. And in addition, a neurological examination always just mention you will do one because you always want to rule out some kind of neurological cause before treating it as a musculoskeletal issue. And then we'd move on to imaging for arthritis, which is quite evidently presenting as osteoarthritis bloods are useful, but the imaging is kind of the mainstay of orthopedics and in this kind of arthritis, the main things we're looking for is symbolized by the acronym lost. So I hope the picture is clear enough, but it's always helpful to compare it with a normal X ray. So you can see what's going on and that's for chest x rays for bone x-rays, joint x-rays all of it. So in this, we're looking for loss of joint space which you can very clearly see on the image on the right, there's a lot less distance between the two bones, um osteophyte formation as well. So this will come as some kind of bone spurs that form and they usually result from the bone rubbing against each other. Subchondral sclerosis is another thing you're looking for. And that kind of refers to kind of, it's like if you kind of think of it as scar tissue for the bone, that's how I usually make the most sense of it. So you'll see that the area around the bone.