Comprehensive Guide to Musculoskeletal Problems and Differential Diagnosis

1. Chapter 15Musculoskeletal Problems

2. Initial Considerations • Acute versus chronic • Traumatic injury or overuse syndrome • Age of patient • Pediatric—epiphyseal growth plates • Geriatric—degenerative process • “Weekend warrior” or athletically fit • Self-care measures • Prior history of musculoskeletal problems

3. Common Musculoskeletal Complaints • Duration: acute or chronic • Origin: articular or nonarticular • Nature: inflammatory or noninflammatory • Distribution: localized or systemic

4. Differential Diagnosis of Musculoskeletal Problems • Trauma • Metabolic or circulatory disorders • Degenerative disorders • Systemic problems • Infection • Tumors • Synovial conditions • Developmental problems • Congenital problems

5. Keys to Diagnosis • Careful, thorough history is critical—use OLDCART or PQRST mnemonic as a guide • Physical examination: compare sides for symmetry; have patient undress if needed • Have patient perform all range of motion (ROM) possible without assistance • Use special maneuvers that are related to potential difficulty to refine physical exam

6. Minimal laboratory testing; primarily to rule out systemic illness Reserve imaging studies for cases with persistent symptoms >4–6 weeks or “red flags” Red flags: radicular symptoms >4–6 weeks; increasing symptoms, osteomyelitis, cauda equina, herniation of disc, epidural abcess Role of Laboratory Diagnostics

7. Neck Pain: Differential Diagnosis • Muscle spasm • Cervical radiculopathy • Torticollis • Myofascial pain • Whiplash • Cervical spondylosis • Cervical strain • Referred pain

8. Neck Pain: Assessment • Precipitating event • Active ROM • Presence of palpable muscle spasm • Character of pain—numbness, tingling, radiation or localized • Age of patient; history of degenerative arthritis • Red flags: fever, loss of function, erythema, systemic symptoms

9. Neck Pain: Cervical Compression Test

10. 14 and 29?

11. Neck Pain: Management • Refer to orthopedist or neurologist if emergent symptoms • Conservative treatment • Rest followed by gentle ROM as tolerated • NSAIDs if no contraindications for inflammation • Short-term muscle relaxant if no contraindication • Ice or heat, physical therapy if indicated

12. Shoulder Pain: Differential Diagnosis • Adhesive capsulitis • Rotator cuff tear • Subacromial bursitis • Tendonitis • Impingement • Fractures: humerus, clavicle, acromion • Degenerative arthritis: glenohumeral, acromioclavicular • Glenohumeral dislocation • Nerve compression • Thoracic outlet syndrome • Shoulder-hand syndrome

13. Arm (Elbow, Wrist, Hand) Pain: Differential Diagnosis • Lateral epicondylitis • Medial epicondylitis • Olecranon bursitis • Carpal Tunnel syndrome • Ganglion • Fractured wrist • Gout • De Quervain’s tenosynovitis • Osteoarthritis • Rheumatoid arthritis • Trigger finger • Dupuytren’s contracture • Boutonniere deformity

14. Low Back Pain: Differential Diagnosis • Musculoskeletal strain • Sciatica • Spinal stenosis • Infection • Pyelonephritis • Prostatitis • Ankylosing spondylitis • Cauda equina syndrome • Cholelithiasis • Herniated disc • Aortic aneurysm • Spondylolithesis

15. Knee Pain: Differential Diagnosis • Fractures • Meniscal injuries • Contusions • Ligamentous injuries • Tumors • Patellofemoral syndrome • Arthritis • Sepsis • Chondromalacia patella • Overuse syndromes • Bursitis • Tendonitis • Anterior knee pain

25. Ankle and Foot Pain: Differential Diagnosis • Sprains • Hallus valgus (bunion) • Neuromas • Pes planus • Stress fractures • Hammer toe deformity • Arthritis • Achilles tendonitis • Plantar fasciitis • Infracalcaneal bursitis • Heel spurs • Corns and calluses

26. Osteoarthritis (OA) • Multifaceted; “degenerative joint” disease • Typical joints affected are hands, knees, hips • Early morning stiffness, interfering with usual activities, usually improves with activity • Clinical diagnosis; functional assessment is important • X-ray findings do not correlate well with clinical symptoms

27. OA: Differential Diagnosis • Bursitis • Tendonitis • Avascular necrosis of femoral head • Lyme disease • Rheumatoid arthritis • Vasculitis • Lupus erythematosus • Neuropathy • Osteopenia • Bone malignancy

28. OA: Management • Non-narcotic analgesics are the first step. • NSAIDs are used with more caution due to cardiovascular concerns; COX-2 selective preferred • Intra-articular corticosteroids may be used • Referral to pain management for intractable pain when surgery is not a consideration

29. OA: Management (cont’d) • Arthritis Society patient support resources • Counseling on living with a chronic illness • Activity modifications • Exercise as tolerated—water exercise • Heat/cold • Physical therapy or self-help groups • Surgical consult if indicated

30. Osteoporosis: Risk Factors • Age • Caucasian • Eating disorder • Dietary deficiencies in calcium • Chronic glucocorticoid use • Hyperthyroid or parathyroid problem • Tobacco use • Alcohol use • Sedentary lifestyle • Epilepsy • Family history • Excess caffeine • Rheumatoid arthritis • Prior history of fracture

31. Osteoporosis: Screening • Dexa-scan is the gold standard • FRAX questionnaire: http://www.sheffield.ac.uk/FRAX/tool.jsp • Incidental finding on plain film

32. Osteoporosis: Management • Weight-bearing exercise; home safety • Calcium and vitamin D • Bisphosphonate if tolerated; newer parenteral options but prohibitively expensive • Selective estrogen receptor modulator • Newer pharmacologic options are emerging • Repeat Dexa 2 to 3 years into therapy

33. Fibromyalgia Syndrome • Recent proposed change in diagnostic criteria by the American College of Rheumatology • Symptoms include pain, stiffness, fatigue, disrupted or poor sleep, cognitive difficulties, anxiety, and depression • Use of tender points for diagnosis is under question due to impracticality in primary care

34. Fibromyalgia Syndrome: Differential Diagnosis • AIDS • Bursitis or tendinitis • Polymyositis • Myofascial pain • Temporal arteritis • Complex regional pain syndrome • Polymyalgia rheumatica • Rheumatoid arthritis • Lyme disease • Multiple sclerosis • Hypothyroidism • Chronic fatigue syndrome

35. Fibromyalgia Syndrome: Diagnostics • Diagnostic testing is indicated only to the extent that it is necessary to rule out other causes of symptoms.

36. Fibromyalgia: Management • Pain and symptom management are priorities • Lyrica and Cymbalta have proven most effective • Gentle exercise, nonrepetitive • Support groups, individual counseling and education on self-management with a chronic condition

37. Fibromyalgia: Management (cont’d) • SSRIs or SNRIs are also effective • Tricyclic antidepressant or sleep agent may be prescribed at bedtime • Some patients may need to be evaluated for obstructive sleep apnea or restless leg syndrome as these are common comorbidities