Body Pain Flashcards
Body Pain Cases
- Neck Pain - Cervical Spondylosis
- Shoulder Pain - Polymyalgia Rheumatica
- Back Pain - Sciatica
- Back Pain - Mechanical Back Pain
- Back Pain - Osteoporosis
- Hip Pain - Trochanteric Bursitis
- Knee Pain - Meniscal Injury
- Hand Pain - Rheumatoid Arthritis
Differential diagnoses of Hand/ Arm Pain
- Hand pain - Rheumatoid Arthtritis
Probability diagnosis
Dysfunction of the cervical spine (lower)
Disorders of the shoulder
Medial or lateral epicondylitis
Overuse tendonopathy of the wrist
Carpal tunnel syndrome
Osteoarthritis of the thumb and DIP joints
Serious disorders not to be missed Cardiovascular: •angina (referred) •myocardial infarction •axillary vein thrombosis •arm claudication (left arm)
Infection: •septic arthritis (shoulder/elbow) •osteomyelitis •infections of tendon sheath and fascial spaces of hand •sporotrichosis (‘gardener’s arm’)
Neoplasia/cancer:
•Pancoast tumour
•bone tumours (rare)
Pitfalls (often missed) Entrapment neuropathies (e.g. median nerve, ulnar nerve) Pulled elbow (children) Foreign body (e.g. elbow)
Rarities: •polymyalgia rheumatica (for arm pain) •complex regional pain syndrome I •thoracic outlet syndrome •erythromelalgia •Kienböck disorder
Masquerades checklist
Depression
Diabetes
Spinal dysfunction
Is the patient trying to tell me something?
Highly likely, especially with the so-called RSI syndromes.
Hand and Arm Pain - Key History
Key history
Include an analysis of the pain and a history of trauma, particularly unaccustomed activity. In children ask about pulling the child up by the arms or a fall on an outstretched arm. Ask for relationship of pain to any sleep disturbance.
Hand and Arm Pain - Key PE
Key examination
Inspect the arm as a whole with both arms free of clothing and compare both sides. It may be necessary to examine a variety of joints including the cervical spine, shoulder, elbow, wrist and various joints of the hand
Hand and Arm Pain - Key Investigation
Key investigations
•FBE
•ESR/CRP
•Consider ECG, nerve conduction studies, plain X-ray according to rule ‘if in doubt, X-ray and compare both sides’, ultrasound for soft tissue injuries (e.g. tendonopathy)
Hand and Arm Pain - Diagnostic tips
Diagnostic tips
The working rule for arm pain causing sleep disturbance:
- thoracic outlet: patient cannot fall asleep
- carpal tunnel syndrome: wake in middle of night then settles
- cervical spondylosis: wakes patient with pain that persists.
Always keep regional pain syndrome in mind for persistent burning pain in hand following injury, trivial or severe
Differential Diagnoses of Back Pain - Lower
- Back Pain - Sciatica
- Back Pain - Mechanical Back Pain
- Back Pain - Osteoporosis
Probability diagnosis
Vertebral dysfunction especially facet joint and disc (mechanical pain)
Musculoligamentous strain/sprain
Spondylosis (degenerative OA)
Serious disorders not to be missed
Cardiovascular:
•ruptured aortic aneurysm
•retroperitoneal haemorrhage (anticoagulants)
Neoplasia/cancer:
•myeloma
•pancreas
•metastases (e.g. lung, breast, prostate)
Infection: •vertebral osteomyelitis •epidural/subdural abscess •septic discitis •tuberculosis •pelvic abscess/PID •pyelonephritis
Other:
•osteoporotic compression fracture
•cauda equina compression
Pitfalls (often missed) Spondyloarthropathies: •ankylosing spondylitis •reactive arthritis •psoriasis •bowel inflammation
Sacroiliac dysfunction Spondylolisthesis Spinal canal stenosis Claudication: •vascular •neurogenic
Paget disease
Prostatitis
Endometriosis
Masquerades checklist
Depression
Spinal dysfunction
UTI
Is the patient trying to tell me something?
Quite likely. Consider lifestyle, stress, work problems, malingering, conversion reaction.
Back Pain Lower - Key History
Key history
Routine analysis of pain (SOCRATES approach), especially intensity of pain and its relation to rest and activity and also diurnal variation.
Ask about pain on standing, sitting and walking with types of claudication (if any).
Review family history, occupational history, drug history, psychosocial history and ask questions about red flags that are alarm symptoms of serious disease.
Back Pain Lower - Key PE
Key examination
Follow the LOOK, FEEL, MOVE, MEASURE clinical approach with an emphasis on palpation—central and lateral.
The movements with normal ranges are:
•extension 20°–30°
•forward flexion 75°–90°
•lateral flexion (left and right) 30°.
Perform a neurological and vascular examination of the lower limb/s with pain.
Back Pain Lower - Key Investigation
Key investigations
This should be conservative, especially in the absence of red flags. Basic screening is:
•FBE
•ESR/CRP
•urinalysis
•serum alkaline phosphatase
•PSA in males 50–75 years
•plain X-ray if chronic pain and red flags.
Reserve CT scan, MRI or radionuclide scan for suspected serious disease (malignancy and infection).
Back Pain Lower - Diagnostic tips
Diagnostic tips
•Continuous pain (day and night) points to neoplasm (esp. malignancy) or infection.
•Pain (and stiffness) at rest, relief with activity indicates inflammation (e.g. spondyloarthropathy).
•Pain provoked by activity with relief at rest indicates mechanical (vertebral) dysfunction.
•Pain in the periphery of the limb can be discogenic causing radicular pain or spinal cord stenosis causing neurogenic claudication or vascular causing intermittent claudication.
Differential diagnoses of Shoulder Pain
Shoulder Pain - Polymyalgia Rheumatica *
Probability diagnosis Cervical spine dysfunction (referred pain) Rotator cuff tendonopathy ± a tear Adhesive capsulitis (glenohumeral joint) Glenoid labral tears Bicipital tendonopathy
Serious disorders not to be missed
Cardiovascular:
•angina
•myocardial infarction
Neoplasia/cancer:
•Pancoast tumour
•primary or secondary in humerus
Infection:
•septic arthritis (especially children)
•osteomyelitis
Axillary vein thrombosis
Rheumatoid arthritisIntra-abdominal pathology, e.g. bleeding
Pitfalls (often missed) Polymyalgia rheumatica Cervical dysfunction Gout/pseudogout (uncommon) Osteoarthritis of acromioclavicular joint Winged scapula--muscular fatigue pain Masquerades checklist Depression Diabetes esp. adhesive capsulitis Drugs, e.g. steroids, anabolic steroids Thyroid disorder (rarely) Spinal dysfunction
Is the patient trying to tell me something?
Shoulder is prone to (uncommonly) psychological fixation for secondary gains, depression and conversion reaction.
Shoulder Pain - Key History
Key history
A careful history should generally indicate whether the neck or the shoulder (or both) is responsible for the patient’s pain. Enquire about features of movement: - stiffness and restriction - excessive movement/instability - weakness - rough versus smooth.
Shoulder Pain - Key PE
Key examination
•Examine the cervical spine then the affected shoulder
•Follow the protocol of inspection, palpation, movement, special tests for tendonopathies
•Look for impingement and a painful arc with adduction
•Undertake resisted movements for each tendon:
o- adduction for supraspinatus
o- internal rotation for subscapularis
o- external rotation for infraspinatus
o- elbow flexion for biceps
Shoulder Pain - Key investigations
Key investigations
Consider:
•ESR (polymyalgia rheumatica)
•rheumatoid factor and anti-CCP
•ECG (if ischaemic heart disease suspected)
•imaging according to history and examination (e.g. high resolution ultrasound).
