Differential DiagnosisSystemic Origins of Musculoskeletal Pain

Musculoskeletal Pain The single most important element in the evaluation

of a patient with musculoskeletal pain of unknown origin/cause is a detailed medical history

Characteristics of the patient’s pain will assist the therapist in recognizing systemic vs. musculoskeletal presentation of signs and symptoms

Identification of associated signs and symptom is essential for the therapist to determine the origin of pain

Back Pain Effect of position

Systemic pain is not relieved by recumbency With systemic pain, patients tend to constantly

move Pain that is systemic in origin cannot be

reproduced, aggravated or altered in any way during the examination

Pain that does not fit the expected mechanical or neuromusculoskeletal pattern should be a red flag

Back Pain Presence of night pain

Systemic back pain is usually worse at night Long-standing night pain that is unaltered by positional

change suggests a space-occupying lesion, such as a tumor

Check for associated signs and symptoms Fever Fatigue Dyspnea Sweating GI symptoms

Back Pain - Sources Visceral

Likely to result from abdominal or pelvic disease Can be referred from GI, pulmonary, urologic or

gynecologic systems Neurogenic

Sciatica vs. HNP Spinal stenosis may produce neurogenic claudication

LBP, numbness and paresthesia develops after walking a few hundred yards; relieved with rest

Patient may flex forward to relieve neurogenic pain

Back Pain - Sources Vasculogenic

Described as throbbing Increased with activity that requires greater cardiac output

and is decreased or relieved when workload or activity is stopped

History often reveals significant CV risk factors Vascular intermittent claudication – characterized by

occurrence with walking or exercise, relief on rest, and change in spinal position does not alter symptoms

Back pain due to abdominal aortic aneurysm is accompanied by a palpable abdominal pulse

Back Pain - Sources Spondylogenic (Bone lesions)

Primary symptoms are bone tenderness and pain on weight bearing

Osteoporosis Compression fractures Thoracic or lumbar pain is intensified with prolonged

sitting, standing and Valsalva maneuver Pain with percussion over fractured vertebral bodies Paraspinal muscle spasm Kyphoscoliosis

Back Pain - Sources Spondylogenic (Bone lesions)

Osteomyelitis Bone infection, most commonly affects L1 and L2 Marked tenderness over the spinous process Movement is painful Marked paravertebral and hamstring ms guarding

Disc space infection Subacute osteomyelitis that involves the vertebral endplates and

the disk Worse with activity, but not relieved with rest SLR may be positive

Back Pain - Sources Spondylogenic (Bone lesions)

Rheumatic Diseases Morning pain and stiffness that improves with activity Limited ROM in all directions Tender Night pain Associated signs and symptoms of fever, skin lesions,

anorexia, and weight loss

Back Pain - Sources Psychogenic

Anxiety increases perception of pain Hysterical patients have inadequate defense

mechanisms (anxiety ms spasms anxiety…) Other bizarre signs:

Paraplegia with only stocking-glove anesthesia Reflexes inconsistent with symptoms Cogwheel motion with MMT SLR inconsistent SLR in supine with PF rather than DF reproduces

symptoms

Back Pain - Sources Cancer

Primary or secondary Lumbar spine more often involved than cervical Key signs:

Age > 50 Significant recent weight loss Previous malignancy Constant pain – not relieved by positional change or rest Night pain Pain that disturbs sleep

Back Pain - Location Cervical Pain

Anytime urinary incontinence occurs with cervical pain medical referral is needed to assess for possible spinal cord compression

Anterior cervical pain – Assess for signs and symptoms of GI dysfunction and difficulty swallowing

Angina can refer pain to the anterior neck and jaw Pancoast tumors of the lung may invade roots of the brachial plexus

at C8-T1. Associated s/s of atrophy of hand muscles and Horner’s syndrome

Neck pain reproduced or increased with inspiratory movement or accompanied by dyspnea, persistent cough, hemoptysis or constitutional symptoms is indicative of pulmonary origin

Esophageal varices can refer pain to anterior cervical region. Accompanied by burning, swallowing disorders, pain relieved with antacids, aggravated by eating

Back Pain - Location Thoracic Pain

Most common site for spinal tumor. Watch for rapid deterioration of neurologic status.

Aortic aneurysm, angina or acute MI can refer pain to the thoracic region. Associated s/s include weak, thready pulse, high or low BP, unexplained perspiration and pallor. (Pulsing sensation in abdomen with AAA)

If pulmonary in origin, pain is reproduced with respiratory movements; however, also see an increase in pleural, intercostal, costal and dural pain with cough or deep inspiration

Acute pyelonephritis and kidney problems refer pain posteriorly to T12-L1. Dull, constant pain with possible radiation to pelvic crest or groin. Associated s/s include febrile chills, frequent urination and hematuria. Check with Murphy’s percussion test.

Peptic ulcers – Refer pain T6-T10. Check for correlation of symptoms with timing of meals, relief with antacids, and/or presence of blood in the stools.

Acute cholecystitis or pancreatic disease causes intense sudden pain into the right upper quadrant. Check for fever, chills, nausea, indigestion, change in urine/stools and signs of jaundice.

Back Pain - Location Scapular pain

Usually along vertebral border Can be referred from cardiac, pulmonary, renal or GI

disorders If pulmonary in origin, usually have malaise, dyspnea,

cough, hemoptysis, tachypnea, cyanosis. Respiratory movements cause increased symptoms. If pneumothorax, sitting upright is only relief position.

GI – Gallbladder and biliary colic refer pain to interscapular or right subscapular area

Back Pain - Location Lumbar/LBP

Metastatic cancers most often from breast, lung, prostate, kidney or GI

Abdominal aortic aneurysm – Usually men, 60-70 years old. c/o deep, boring mid lumbar pain. Check for pulsing abdominal mass. Prompt attention is necessary. Rupture death.

Bacterial endocarditis – 1/3 have c/o LBP. Also present with decreased ROM and spinal tenderness. Radiates to one leg and may be increased with SLR or sneeze. Differentiate from HNP by lack of neurologic deficits.

Kidney disorders – Often present with a combination of systemic signs and symptoms as well as pelvic, flank or low back pain. May have history of recent trauma or PMH of UTI

Back Pain - Location Lumbar/LBP

Pancreatitis – May appear as epigastric pain radiating to L1 area. If pain is from the head of the pancreas, it is felt to the right of the spine; if from the body or tail, it is felt to the left of the spine. Associated symptoms of diarrhea, anorexia, pain after meals, and unexplained weight loss. Pain relieved by heat, leaning forward, sitting up or lying motionless.

Small intestine disorders have occasional LBP alternating with abdominal pain. Often the patient does not associate the two symptoms because they do not occur simultaneously. Almost always have accompanying GI symptoms

Gynecologic disorders can also refer pain to the low back region.

Back Pain - Location SI/Sacral Pain

Sacral pain of musculoskeletal origin almost always has a history of recent trauma.

Sacral pain without history of trauma or overuse needs to be screened for systemic origin.

Endocarditis, prostate cancer, gynecologic disorders, Rheumatoid disorders and Paget’s disease can refer pain to the SI/sacral region.

Disorders of the large intestine and colon can also refer pain to the SI/sacral region. Pain from these disorders is often relieved by bowel movement or passing gas.

Hip Pain Musculoskeletal pain can be referred to the hip from the low

back, SI, sacrum or knee Disorders affecting the organs within the pelvic and

abdominal cavities can also refer pain to the hip region Spinal metastasis to the femur or lower pelvis may refer pain

to the hip. Joint ROM is usually not affected Urologic disorder may refer pain to the hip. Distinguished by

history, pattern of pain and urologic symptoms. Use Murphy’s percussion test to rule out kidney involvement

Hip Pain Abdominal or peritoneal inflammation leads to

irritation of the psoas muscle and may cause a psoas abscess which presents as hip pain More common on right Pain may involve the medial thigh and femoral triangle Usually associated with loss of appetite or GI symptoms,

fever and night sweats Differentiate from psoas trigger point. Trigger point is

aggravated by weight bearing, relieved by rest or recumbency. Relief is greater with the hip flexed.

Pain on weight bearing made worse with MMT is a red flag for bone involvement

Pelvic Pain Any organ disease or systemic condition of the pelvic cavity

or abdominal cavity can cause pelvic pain Pelvic pain of musculoskeletal origin is worse with

exercise/WB and relieved by rest, stretching or trigger point release. Trunk and lumbar rotation will aggravate symptoms.

Anterior pelvic pain most often occurs as a result of disorders affecting the hip joint or upper lumbar vertebrae; pregnancy; rectus abdominus, rectus femoris or adductor muscle injury; femoral neuralgia; and psoas abscess

Posterior pelvic pain usually originates from the lumbosacral, SI, coccydynial or sacrococcygeal regions.

Pelvic Pain Vascular occlusion

If the iliac arteries are occluded, pelvic pain may result along with pain in the affected limb and buttock pain. Pain will gradually increase with exercise. The affected limb is cold and pale. Sometimes have a decrease in pinprick sensation.

Thrombosis can occur after surgery or spontaneously. This produces an enlarged, warm and painful leg with occasional pelvic discomfort.

Varicosities of the ovaries results in pelvic pain that worsens toward the end of the day or after standing for a long time, pain after intercourse, sensation of heaviness in the pelvis and prominent varicose veins in the buttocks and thighs.

Pelvic Pain Renal or urologic disorders such as bladder or

kidney infection, kidney stones, renal failure and renal tumors may cause pelvic pain. Therapist would need to ask about painful urination, changes in urination and constitutional symptoms such as fever, chills, sweats, and nausea or vomiting

Right sided abdominal or pelvic pain is often associated with appendicitis. Left sided abdominal or pelvic pain is more often due to diverticulitis. Bilateral abdominal or pelvic pain is more likely due to an infection.

Groin Pain Painless, progressive enlargement of lymph nodes >

4 weeks, and involving more than one area requires a medical referral. (Screen for Hodgkin’s disease). Lymph nodes may become enlarged due to infection. Question onset of symptoms and associated symptoms.

Systemic causes of groin pain include: Spinal cord tumors Uretral pain Ascitis Hemophilia Abdominal Aortic Aneurysm

Groin Pain Musculoskeletal origin

Adductor strain, especially adductor longus. History of specific trauma or injury. Pain with passive stretch or active contraction. May be followed by ecchymosis in several days.

Avulsion of internal oblique abdominal muscles, trauma (sexual assault), inguinal hernia, hip joint disease (slipped capital femoral epiphysis) and avulsion of rectus femoris or sartorius can also cause groin pain.

Stress fracture of the pelvis may cause hip/groin pain. May be painful to deep palpation or pain with translational or rotational force. Heel tapping or unilateral hopping will produce pain.

Pubalgia results from an abdominal muscle wall injury. Common in soccer players. Pain with active abdominal flexion (sit ups) and passive abdominal extension (prone lying extension).

Chest Pain Parietal chest pain

Most common type of chest pain of systemic origin seen in the PT clinic

Lower chest pain is usually indicative of local disease Upper chest pain may be caused by disease located deeper

in the chest Usually not reproduced by palpation May be aggravated by any respiratory movement

involving the diaphragm (sighing, deep breathing, coughing, sneezing, laughing or hiccups)

Chest Pain Tumors/Cancer

Most are metastatic Asymptomatic unless they compress mediastinal

structures or invade the chest wall Cardiac pain may be due to angina, MI, pericarditis,

endocarditis, MVP or aortic aneurysm If anginal or infarct pain are absent it may go unnoticed Minimal symptoms due to anastomoses and collateral

circulation, until challenged by physical exertion or ex.

Chest Pain Epigastric pain

Chest pain may be experienced with lower esophogeal lesions, and disorders of the liver, gallbladder, common bile duct and pancreas

Reflux esophagitis vs. angina pectoris – Both described as gripping, squeezing or burning. Both may be precipitated by recumbency or meals. Reflux is not precipitated by exercise and is relieved with antacids.

Ulcers – Occasionally cause lower chest pain. Antacids and food immediately relieve pain. Not produced by effort and lasts longer than angina pectoris

Cholecystitis – Causes chest pain with radiation to shoulders and back. Usually associated with nausea, vomiting and fever and chills.

Chest Pain Breast pain

Most commonly due to fibrocystic changes Jarring or movement of breasts aggravates pain Report any large, firm, hard or fixed nodules to

MD Trigger points of pectoralis major, pectoralis

minor or anterior scalenes can present as breast pain or tenderness

Resistance to isometric UE movement causes pain with pectoralis myalgia but does not aggravate pain from breast tissue

Chest Pain – Musculoskeletal origin Chest pain of a musculoskeletal origin lasts for seconds to

hours and is not relieved by eating or nitroglycerin Tietze’s Syndrome (inflammation of a rib and its cartilage)

Usually unknown cause Most common age of onset is 20-30 years old, can occur in children Usually only one rib level is affected, most commonly the 2nd or 3rd

rib Associated with increased BP and HR and pain radiating down the

left arm Pain is increased by sneezing, coughing, deep inspiration, trunk

rotation, shoulder horizontal ab/adduction and rooster crowing motion

Symptoms can be reproduced with palpation or pressure

Chest Pain – Musculoskeletal origin Costochondritis

More common than Tietze’s syndrome Pain at costochondral articulations without swelling Usually occurs in people >40 years old Most commonly affects the 3rd, 4th or 5th costochondral

joint Women > Men Anterior chest pain may be widely radiating Elicited by pressure over costochondral junctions May follow trauma or be associated with rheumatic

diseases Can persist for months

Chest Pain – Musculoskeletal origin Trigger points

Tender points, taut bands of muscle tissue, increased pain with palpation, increased pain with resisted ROM

Most common – Serratus anterior, Anterior Scalenes, Pectoralis muscles

Myalgia Recent history of repeated or prolonged movement or

recent upper respiratory infection Described as aching Reproduced with palpation or squeezing the muscle belly

Chest Pain – Musculoskeletal origin Rib Fractures

Occult or history of trauma Sharp, localized pain, increased with trunk motions and respiratory

movements C-Spine Arthritis

May produce chest pain. Increased with flexion or hyperextension of the C-Spine

Not related to exertion or exercise Rest may not alleviate the symptoms and prolonged recumbency

makes pain worse Diskogenic disease

Check for diskogenic symptoms Will have neurologic symptoms

Chest Pain – Musculoskeletal origin Intercostal Neuritis

Usually due to shingles (herpes zoster) Unrelated to effort and long lasting Pain may be constant or intermittent and varies from burning to deep

visceral pain May be associated with chills, fever, headache, malaise and skin rash Symptoms are confined to the somatic distribution of the involved

spinal nerve(s) Skin rash – Clusters of groups vesicles appear along the cranial or

spinal nerve dermatomes after 1-2 days of pain, itching and hyperesthesia

Unilateral - Symptoms do not cross midline, but bilateral nerves may be affected

Skin eruptions usually clear in about 2 weeks

Chest Pain – Musculoskeletal origin Dorsal nerve root irritation

Can be caused by infectious process More likely due to mechanical irritation caused

by spinal disease or deformity More superficial than cardiac pain Can be aggravated by exertion of only the UEs Exertion of LEs has no exacerbating effect Usually accompanied by muscle atrophy,

numbness and tingling

Chest Pain – Musculoskeletal origin Thoracic Outlet Syndrome

Usually affects the UE in an ulnar nerve distribution but can result in episodic chest pain

Paresthesias and hypoesthesia are common Anesthesia and motor weakness reported only 10% of the time If a vascular component is included, the pain may be more diffuse

and have associated fatigue and weakness With severe arterial compromise, the patient describes coolness,

pallor, cyanosis, etc. Differs from CAD because it only affects UEs Most commonly occurs in 30-40 year olds Women 3X > Men Should compare Adson’s maneuver, hyperabduction test and

costoclavicular test bilaterally to assess effect on circulation

Shoulder Pain Pulmonary disorders may refer pain to the shoulder.

Pain due to pulmonary dysfunction may be improved with autosplinting, if shoulder pain is musculoskeletal in origin, lying on the affected side usually increases pain

Bacterial endocarditis and Pericarditis may refer pain to the shoulder. Hepatic and biliary diseases may also refer pain to the right shoulder/scapular region. Shoulder motion is not compromised and local tenderness is not prominant. However, if patient has avoided medical treatment, biomechanical changes in muscle contraction and shoulder movement may occur.

Shoulder Pain RSD/CRPS

Shoulder tenderness is diffuse Shoulder may be “stiff” several months before hand becomes involved or

they may occur simultaneously Accompanying symptoms include edema, skin changes and temperature

changes Rheumatic diseases

Coincident c/o malaise and easy fatigability as well as c/o discomfort in other joints is common

Common rheumatic diseases with major shoulder involvement are polymyalgia rheumatica and polymyositis

Pancoast’s tumors Produces sharp pain in the axilla, shoulder and subscapular area Eventual UE atrophy Bone pain is achy, exacerbated at night and is cause of restlessness and

changes in musculoskeletal movement

Key Points to Remember Anyone with chest, back, hip or shoulder pain

without history of trauma should be screened for possible systemic origin of symptoms.

It is not the responsibility of the PT to diagnose what the specific systemic involvement is, but to identify when the client’s history, subjective and objective findings do not support presence of a musculoskeletal problem, thus requiring a medical follow up.

Key Points to Remember Clients often reveal information to a PT that

may be more appropriate for an MD. A knowledgeable PT needs to be able to guide the patient appropriately.

Exercise may be the precipitating or aggravating factor for onset of certain conditions

Constitutional symptoms that are characteristic of systemic problems should serve as “Red Flags” to PT