01-08 differential diagnosis - expanded systemic causes

1 – DDx Back Pain Cervical Spine Thoracic Spine Lumbar Spine

NMS Bone Persistent, excruciating , often worse at night; ONSET: #=immediate

O/A: -Spondylosis→ altered alignment of facets→↑risk of strain or

lock

- may lead to hypermobility (esp initially), more often hypomobility

-Cervical bar Lhermitte’s sign (flexn –extn → ‘electric’ shock);

ΔΔ MS

- NRI ← osteophytosis (mechanical irritation)

Osteoporosis - #? – greatly ↑ risk of #, most commonly in

hip, wrist, spine. Contra to forceful TTT. Ca & Mg, Vit C & Vit D supplements, wt. bearing Exx, esp outside (vit D aids Ca absorption). Oestrogen also aids Ca absorb, prevents urinary excretion; progesterone MAY encourage new bone growth (tofu, sesame seeds etc have high progesterone content). Fosamax (alendronic acid) may be Pxx. Alendronic acid inhibits osteoclastic bone resorption. Controversial: may be a link ĉ osteonecrosis of jaw. Also systemic bioavailability after oral ingestion extremely low (~0.6%), affected by ingestion of food/fluids before or after (have to fast). Has also been argued that osteoclastic activity is natural/necessary, and alendronic acid may prevent breakdown of old bone (→ ↑ bone density) but the bone thus preserved is not necessarily stronger.

Spinal stenosis - see Neuro/Referred below

Cervical Rib (rare) ∞ TOS? Often incomplete, may be fibrous

→ will not show on x-ray (need MRI)

C2 # Klippel Feil Syndrome Dens #? Whiplash/rugby

Rib # - exquisitely ful, AGG deep breathing, tuning fork,

percussion, A-P & latl rib compression. NOTE: may not show on xray immed after injury Osteochondritis/Scheurmann’s (35% of pop,

although only 5% ∑atic); low TSp and T/L region, also affects LSp Kyphotic (/kypholordotic) posture – stretching

& weakening of TES, may cause hypoxic ; ↑ stress on C/T and ↑CSp lordosis →facet irritation, ↑wear and tear A/S – bamboo spine, a.m. stiffness(>30 mins), improve ĉ

exercise; on sacral springing, ankylosis evident on S/B; cervical hyperextn, thoracic kyphosis, ↓ LSp lordosis, hip & knee flexn contractures. Night , ↓ rib expansion. Slow onset (starts <40 yoa)

Scoliosis – This is a can of worms... MYTH: if a scoliosis

disappears when Pt sits, it is functional (that is a compensatory/acquired scoliosis, i.e. compensation for short LEx). Scolioses may be DEXTROscoliosis (CONVEXITY R) or LEVOscoliosis (CONVEXITY L); Functional vs. structural (following Ward et al 2002:619): Assess degree of functionality of scoliosis by standing postr to pt.” Pt bends forward until maximal rib hump on horizon. Pt then swings upper body right, then left, while clinician observes functional ability of rib hump to reduce. Amt of rib hump remaining indicates assoc structural scoliotic component. Functional scoliotic curves reduce ĉ S/B, rotn or forward bending”

Myeloma }

2° Ca } see p.2

TB }

Spondylolysis – narrowing of neuroforaminae →

radiculopathy? AGG Exx and bending

Spondylolisthesis – often a∑atic. More common LLSp (retro

more common ULSp ← shape of lordosis). Extn ful, prob from ligs and Nn. May be palpable step on WB gone in NWB, skin feels ‘anchored’ to spine; AGG standing, walking; REL lying down, sitting. Difficulty getting OOB. “Hitching Sx” – 2 step process moving from flexn to extn: 1st extend LSp into lordosis, then extending hip. May be Sx & ∑ of spinal stenosis: neurogenic claud, NRI, poss cauda equina. QL works against psoas →may affect ilio-hyp, ilio-ing & gen-fem Nn→groin (mimcs hip/SI referral)

Osteochondritis Spinal Stenosis – may be ass ĉ LBP, and/or paraesthesiae

unilatl/bilatl LExx, loss of B/B control. Neurogenic claudication: classically relieved by bending forward for a few seconds (leaning against wall etc). Dull ache across L/S when standing/walking. LMNL Sx at level, UMNL Sx below level of lesion (ataxia, hyperreflexia, proprioceptive deficits). SLRT & femoral n stretch will be –ive. ↓ LSp lordosis. °Δ pulses.

Osteoporotic Crush # - characteristic gibbus or acute

angle, formed when vert body collapses (‘Dowager’s hump’); loss of height (2-4cm / #). Ac regional back (usually low thoracic/high lumbar) rad → antr along costal margins. RISK FACTORS: post-menopausal (↓oestr & progest), low body fat, low Ca &/or Mg intake, high caffeine intake, bed rest, alcoholism, steroid use, (HIV) CD4 <200, liver disease

2° Ca } see p.2

Hemi-Vertebra Spina Bifida – may be: dimple, patch of hair, pigmented area,

haemangioma, ↓lordosis, mild LBP, SLRT +ive. Often a∑atic.

Joint AGG compression/loading REL Txx

Facet lock – unlike inflamm, little/° on rest; sharp on slight

movement, AGG S/B, occ. refers to UExx; often affects relatively hypERmobile jt.

Apophysitis – Often NAR (wake up ĉ...); tender & often

palpable capsule; often refers to appropriate derm/myo/sclerotome (sclera via ligs inflamm ← capsular inflamm) Spondylosis – C4-6 most common (apex); ↑ onset ĉ aging

but may be accel by cumulative trauma (RTA/whiplash), poor body mechanics, postural Δs, previous disc injury. ↑ on activity, stiffness at rest. ↓ A & PRoM, crepitus.

Spondylarthrosis – C2-4; C5-T1 (lower) ĉ spondylosis - ∞ ĉ

whiplash? Stiff after rest, REL activity; night rel by getting up and movement; AGG extn & rotn CSp, paraesthesiae but °Δ DTRs

TMJ dysfunction – click on opening = postr capsule; click on

closing = latl pterygoid; three-finger test, deviation/deflection on depression (contralatl pterygoids or TMJ restrict; 90% is S/T)

R/A (early CSp involve common) – contra to HVLAT, controversial

as to whether should TTT affected jts at all

Rib lesion (insp/exp): Costotransverse/vertebral - on palpation, often

worse at angle; on DEEP inspiration/coughing, tend to have ass. stretched ligs, therefore may recur

- Costochondral (antr) : Tietze’s – 50% at 2nd rib;

tender ful perichondral swelling over single(?) costal cart, often 2° to postr lesion

Facet irritation – less common than CSp or LSp, if

occurs will usually be assoc ĉ rib dysfunction.

Scapulo-costal syndrome – & tenderness medl

border scap, snapping/crepitus; possibly overlying rib lesion, old #, thinning of serr antr or subscap, hypotrophy subscap bursa

Spondylosis – stiffness, local uniform kyphosis/scoliosis.

Periodic, intermittent, dull , ass. Myofascial , poss rib lesions. Occasional acute ligamentous

Facet irritation/strain/lock: small injury, great ; stiff am,

eases quickly (mins); ° neuro Sx; AGG Δ position, standing from sitting, roll over in bed → wake up, rotn

Spondylosis – L4/5, usually > 60 yoa; slow onset, unilatl , ↑ĉ

prolonged postures, ↑ on extn, usually does not radiate.

Spondylarthrosis Disc herniation (ĉ or ŝ sequestration) /overstrain/ fissure/endplate compaction: ♂ > ♀; 30-45yoa;

L/S>L4/5>L3/4; AGG standing, sitting(wt bearing) flexn, REL lying, eases on move, DP worse a.m. (imbibition during night). LBP may slowly diminish while LEx worsens; =ive SLRT; ↓ LSp lordosis. NOTE: LATERAL HNP → ° LBP, LEx Σs consistent with level of hermiation, AGG walking, standing, REL sitting; SLRT will likely be –ive.

Ligament & Capsule AGG EoR, Tx; ONSET delay of 30-60mins post-trauma; LIG: deep aching

Strain/hypermobility from e.g. whiplash (WAD: also

ĉ micro# in lower facets, will NOT show on xray; from inflamm, lig damage, postr

facet compression, muscle trauma

Transverse lig (∞ ĉ R/A? Contra to HVLAT)

PLL – pressure on lig sys may give LBP as well as neck

Costovertebral/costotransverse ligament strain – often ass ĉ rib lesion as above

PLL - ↑ kyphosis, poor posture while sitting,

Supr & inf

r sternopericardial ligs

Antr & post

r diaphragm-pericardial ligs

Supr & inf

r vertebra-pericardial ligs (C4 &

T4) – esp in WAD

Sphenopericardial & thyropericardial ligs

Strain: PLL Iliolumbar lig. from posture/parturition/hyperflexn

NOTE: Bogduk thinks ILL unlikely source of LBP → more likely tendinopathy of lumbar intermuscular aponeurosis (common tendon of longissimus/iliocostalis)

Muscle AGG Stretching, A-R; ONSET: immediate

Postural fatigue: (muscle hypoxia, REL activity) -suboccipitals (do not TTT O/A , short MM pull on periosteum →

H/A)

-CES -accessory breathing MM

Scalene hypertonicity may → TOS

Torticollis – seven forms of congenital; other causes include

hemivertebra, cervical pharyngitis (major cause in 5-10 yo), JRA, trauma. ↓ c-latl rotn & i-latl S/B; firm, nontender swelling appx size of adult thumbnail. Σs appear 6-8/52 of age

Myasthenia Gravis - see Systemic Causes

Postural fatigue: (MM hypoxia) -Hypomobility ∞ shortening – ch contracture of MM →

relative hypoxia of tissues (poor blood supply) → buildup of metabolites and inflammatory mediators (prostaglandins, Subs P, cytokines etc); move will relieve as pumps and flushes tissues – DO NOT TALK ABOUT ISCHAEMIA UNLESS THERE IS E.G. TOTAL OCCLUSION OF BLOOD SUPPLY (NECROSIS WILL SWIFTLY FOLLOW) – NOT A CH CONDITION!

Exaggerated kyphosis → TES

Breathing issues: - Intercostals - Diaphragm (esp around T/L)

Myasthenia Gravis - see Systemic Causes

Postural fatigue: -LES hypertonia ∞ hip extensor hypertonia -Link ĉ exaggerated A-P curves

Hypermobility – be careful with use of this term, either

assess (Beighton etc.) or use ‘relative hypermobility’ (i.e. to c-lat

l side, rest of spine etc)

Psoas spasm (see below) (ΔΔ: Psoas abscess)

QL overstrain ∞ pelvic function

Neurological /Referred

NOTE: triceps may be only neuro Sx in CSp dysfunc, pt may be unaware, so always test power + reflex NRI - Commonest: C5,6,7,8,(T1)

NRC - 2° to spondylosis, cervical bar, OA/,disc herniation etc.

Cervical bar ∞ ĉ spinal stenosis (below) Spinal stenosis – unilatl or bilatl symptoms that usually span

several dermatomes; ↑ ĉ cervical flexn and ↓ ĉ extn; loss of hand dexterity (difficulty writing/doing up buttons), LOB and unsteady gait; LMNL Sx at level of stenosis and UMNL Sx below level of stenosis; xray reveals spondylitic bars & osteophytes, ossification of PLL & ligamentum flavum

T4 Syndrome – Hypomobility at T4 (+/- a few

segments), vague UExx or discomfort ĉ/ŝ paresthesiae that do not follow dermatomal patterns; ĉ/ŝ H/As; hand considered integral to $; thought to be autonomic in aetiology.

Intercostobrachial n - up thorax, across scapula,

axilla, postr/medl arm

NRI – sharp, linear, dermatomal distr; worse distally; theory: P+Ns

← compression, ← inflamm; tingling ŝ ← chemical (not mechanical) irritation. Commonest: L4, 5, S1

NRC – cf. Horland, Freemont et al 1989 cadaveric study: disc bulges

do not co-exist ĉ NRC; rather: compression & distortion of large venous plexus within IVFG →congestion, venous stasis, ischaemia → peri- & intraneural fibrosis, NR oedema, focal demyelination →improve venous drainage → improve Σs

O/A Hip Psoas n. entrapment – e.g. in Ch hyperlordosis → tension

hypoxia → femoral and/or obturator Nn Dorsal sacral plexus – quite often compressed. Possible

sciatic referral

Cauda Equina - Triad of Σs: saddle anaesthesia, loss of

sphincter control, urinary retention (parasymp damage →sphincter cannot relax →fills to capacity→overflow incontinence). DO NOT TREAT ŝ ANAL SENSORY TEST (‘ANAL WINKING’). SURGICAL EMERGENCY

FUNCTIONAL Kypholordotic posture PC-based work posture Osteochondrosis

Diaphragmatic dysfunction Costovertebral dysfunction

Short LEx – ass ĉ SIJ dysf, compensatory scoliosis, PSIS/ASIS/iliac

crest not level

Pelvic torsion/imbalance Lateral curve – i.e. functional scoliosis

A-P curves

2 – DDx – UEx

Shoulder Elbow Wrist/Hand

Bone Clavicular # - nearly always occurs in middle third (80%), then

latl 1/3 (15%), then medl (5%), one of most commonly #ed bone in body (5% of total in casualty depts.). TTT coldpacking and support (sling). Rarely operated even in case of misunion.

Humeral # - Proximal (surgical neck) most common (75%),

average 65 yoa, axillary n. most likely to be damaged; mid-shaft (diaphyseal) (~20%) average 50 yoa, radial n. at risk; distal Ň ass. ĉ ipsilatl proximal forearm #s, ulnar n. at risk. 80% of humeral #s do not require surgical intervention. Elevated Scapula

Olecranon # or hyperextension injury – ass ĉ antr

capsular strain; for # assess on active extn vs. resisted extn: resisted extn will localise & intensify

Olecranon impingement – forced extn → ; often some

degree of valgus instability (↑medl gapping); caused by repetitive extn ĉ valgus component (e.g. overhead throwing/tennis strokes)

Avulsion/stress # [medl] epicondyle Radiocapitellar chondromalacia ← repetitive valgus

stress (throwing athletes, racquet sports) → compresses radial head into capitellum. May result in periosteal bruising, osteochondral injury or even loose body formation. PPW latl elbow ĉ swelling & locking; passive pronation-supination applied with an axial load → & crepitus, TTP latlly over radiocapitellar jt.

Osteochondritis dessicans – affects convex jt surface –

capitulum. Often affects knee first. Loose bodies, ful locking. Often bilatl (inherited vascular anatomy) or sequelae of throwing (jamming radial head). 8-16 yoa, f>m 4:1 Bone cyst Radial head dislocation - paediatric Pts more likely

NOTE: Carpal bone probs tend to have well-localised (helps ΔΔ against e.g. tendonitis)

Scaphoid # - classic: fall onto outstretched hand.Local .

Hamate # - 2% of carpal #s. Those involving hook are more

common (30% ← repetitive swinging by golfers/bats racquets → stress #). Direct #s lso ass ĉ fall onto outstretched hand. PPW palmar AGG grasping, dorsoulnar deviation, flexn 4th & 5th digits .Exam: discrete point tenderness over hook, ↓ grip, also (2° to proximityof # to ulnar n) paraesthesiae 4th & 5th digits. A-R DIP flexn in ulnar deviation → (° in radial deviation)

Lunate/capitate sublux/dislocation – all carpal bones

dislocate dorsally except lunate (which may → CTS)

Met-Phal dislocation – met may ‘button-hole’ in palmar

direction

Stener’s lesion – valgus rupture of MCL of 1st met-phal →

thumb ‘flops out’

Avascular necrosis of head of scaphoid (post-#) - may be a∑atic for some time

Joint A/C, S/C, G/H dislocation/subluxation – Sulcus Sx for

infrG/H instability (Tx humerus, observe for depression latl or infr to acromion)

Bursitis (esp. subacromial)

Painful arc (subacromial impingement) – 60-120°

SLAP lesion/other labral tear – SLAP = labral detachment

originating postr to LHB insertion and extending antrly. Traumatic onset SLAP lesions often ass ĉ other intra-articular injuries → if suspected, consider likelihood of co-existing pathology. PPW non-specific shoulder ĉ overhead/cross-body activities, deep, vague in nature, often ass ĉ popping/clicking/catching, possible weakness and/or stiffness. Pt supine, flex UEx to 120° ĉ max ER, elbow flexed to 90°. +ve = on A-R elbow flexn. Kim et al (2003) state sensitivity of 89.7% & specificity 96.9% in detecting SLAP lesions

O/A (A/C - 90° abdn, then addt → localised , G/H – thought to

be very rare, S/C)

O/A ∞ intra-articular loose body - 2° to trauma, heavy labour Olecranon bursitis – TTP locally, on extn or resting wt on

elbows (possibly PC work) Posterolat

l Rotatory instability – TEST: RCL (spec

portion that attaches to ulna) Extd UEx over Pts head, ER at shoulder. Supinate forearm, axially load & apply valgus force. +ive = apprehension/sublux as extend elbow ĉ valgus stress.

R/A – uncommon in elbow Radial/ulnar dislocation – radial sublux: children <4yoa; in

adults = housemaid’s elbow, due to axial Txx of extended, pronated forearm. May involve torn annular lig.

O/A – mainly DIPJs (swelling, ), Heberden’s nodes (DIP),

sometimes Bouchard’s nodes (PIP)

R/A (swan-neck deformity) – esp PIPJs, swollen; MM wasting

Triangular Fibrocartilage Complex dysfunction –

TFCC describes the ligamentous & cartilaginous structures that suspend the distal radius & ulnar carpus from distal ulna (improves functional wrist stability, cushions forces translated through ulnocarpal axis, and allows 6° of freedom of move). Differentiates humans from lower primates (Palmer 1981). PPW ulnar sided wrist , freq ĉ clicking. Caused: falls onto pronated extended wrist, power drill injuries (drill locks and rotates wrist instead of drill bit), disTxx force applied to volar forearm/wrist, distal radius #s. Test: axial load down 4th & 5th mets ĉ wrist in ulnar deviation.

Distal radioulnar jt subluxation Carpal instability – commonly scapholunate

instability/separation. TEST: Watson’s (compress through scaphoid tuberosity while moving wrist from ulnar → radial deviation. +ive = ful click/pop)

Ligament/Capsule

Adhesive capsulitis - ↓ abdn & ER (“hand on belt”), each

phase 6-8/12 (freezing/frozen/thawing); NSAIDs, mobilise/MUA, corticosteroids

Capsular instability - Ň ass. ĉ rotator cuff dysfunction → may

be PC

Coracoclavicular ligament strain Haematoma - Traumatic onset

Medl/Lat

l Collateral ligament instability –

Reinforced gapping to test. Assess for laxity, , ↓ RoM, or apprehension.

Antr capsule strain – ass ĉ hyperextn injury; ful swelling in

antecubital fossa; ΔΔ vascular compromise or n. injury.

Annular lig. Rupture - ↑gapping of radial head (latl);

will prob be ass ĉ p-latl rotatory instability

Radial collatl ligament instability – test ĉ latl gapping

Ulnar collatl ligament instability – test ĉ medl gapping

Trigger finger – Ň digit 3 or 4, locks in flexn. Passive re-extn

possible (clicks). Trigger thumb may be flexn or extn

Skier’s thumb - damaged palmar lig

Muscle Long head of biceps tendonitis/tear – YERGASON’S

TEST: Pt’s elbow flexed 90°, passively ER. Pt. attempts to supinate & flex elbow. +ive = repro Σs.

Supraspinatus tendinitis – critical zone hypoxic all day,

when recumbent → hyperaemia→ tendon swells → ; + calcification → A-R + ↓ power

Rotator cuff tear/strain – supraspinatus minor tear → A-R

but power almost Ň; major tear → +ive empry can test. LIFT-OFF TEST: Pt places dorsum of hand on small of back. Inability to move hand further against resistance (by IR) due to → subscapularis prob.

Painful arc – following Neer (1972) impingement of rotator cuff

tendons (commonly supraspinatus) under coracoacromial arch. Stage 1: <25yoa, charac by ac inflamm, oedema, microhaemorrhage in rotator cuff. Stage 2: 25-40 yoa, sequel of St 1, charac by tendonitis & fibrosis. Stage 3: >40 yoa, mech disruption of tendon, Δs in coracoacromial arch e.g. osteophytosis along antr acromion. 2° impingement: occurs 2° to functional ↓ in supraspinatus outlet space ← underlying instability of G/H. HAWKIN’S TEST: Elevate Pts UEx to 90° while forcibly IR shoulder. = subacromial impinge/rotator cuff tendonitis. Bak & Fauno (1997) found Hawkin’s more sensitive for impingement than Neer’s test (IR upper humerus & forcibly flex → 180°).

Latl epicondylitis – often ECRB (small insertion); sometimes

ECRL. Peak 30-40 yoa; 40% have other UExx probs. TEST: Get Pt to make fist, pronate, extd wrist, radlly deviate. Resist. +ive = at medl epicondyle (Cozen’s Sx). TTT: rest, NSAIDs, analgesics, avoid AGG & PRECIP, strapping, deep friction may be ful. Med

l epicondylitis – pronator teres, FCU, FCR. → local ,

rads → forearm, weak grip. TEST: Extd wrist ĉ supination/A-R pronation + flexn. +ive = at medl epicondyle

Shortened biceps tendon[itis] Triceps tendonitis – focal tenderness over triceps tendon,

AGG A-R elbow extn

Extensor/Flexor strain – ass. ĉ latl/medl epicondylitis.

RSI – see wrist

Myositis ossificans - elbow injuries →↑liklihood of

ossification of S/T.

RSI - ↑ stimulation of somatosensory cortex → neuroplasticity →

↑ activity motor cortex → ↑MM tension in wrist & hand. TTT: stimulate lots of areas of hand (not just the few involved in repetitive activity) e.g. partner draws figures on hand, “blind dominoes” etc.

Ulnar/median/radial lesion

Volkmann’s ischaemic contracture - ↓ blood to

forearm flexors → contracture → Volkmann’s Sx: fingers flex if extend wrist

Tenosynovitis – inflamed sheaths, possible crepitus. De

Quervain’s: AbdPL, EPB (snuffbox tendons) e.g. waiters holding plates ĉ thumb, mothers holding babies. Finkelstein’s test: fist ĉ thumb, flex & ulnar deviate

Myasthenia gravis

Neuro/ Referred/ Systemic

C5/axillary n. referral – to acromion, deltoid distr, may go

as far as elbow TrP referral – e.g. deltoid, supra- & infraspin, biceps, pectorales

R/A – Jt’s ĉ ↑ synovium more susceptible e.g. UCSp, hip, shoulder.

Link ĉ CTS

PMR - quite common, 50+ yoa. f>m 3:1. Usually symmetrical,

shoulder & pelvic girdles, axial MM, a.m. , malaise, night sweats/difficulty turning in bed, ↑ ESR. Linked ĉ GCA (temoral arteritis) – ALWAYS ask about H/As ĉ any bilatl shoulder prob. TTT ĉ corticosteroids (most common reason for L/T use) – risk factor for osteoporosis – ask about menopause, nulliparity, Exx, FHx etc.

Heart (e.g. MI) → L - ask about: sweating, nausea, chest

discomfort, mouth/jaw/tooth when getting shoulder . Does shoulder increase with exertion that should not involve shoulder (climbing stairs, exercise bicycle)?

Liver → L - e.g. hepatitis, cirrhosis, metastatic Ca

Gallbladder, pancreatitis, perforated duodenal ulcer → R - ask about relnship with meals: eating REL

duodenal/pyloric ulcer; AGG gastric ulcer, gallbladder inflamm; 1-3 hrs after eating/between meals = duodenal/pyloric ulcer, gallstones; ask about effect of antacids (ulcers in general), NSAIDs Note: any structure contacting diaphragm may refer via PHRENIC N.

NRI – C5/6/7/8/T1 all possible (although unlikely)

Shoulder referral – refers to elbow (as hip → knee) Pronator teres syndrome - antr interosseus n. (← median

n.) medn n Σs ĉ –ve Tinel’s & Phalen’s implicates, ↑ ĉ resisted pronation, Tinel’s over proximal forearm. Often head of pronator is hypertrophied (palpably) Cubital tunnel syndrome – ulnar n. entrap in fribro-osseus

arcade of Struthers; 2 heads of FCU & FDP. Tinel’s between olecranon & medl epicondyle Tumour – e.g. metastasis to bone (night and other

constitutional Σs) Osteomyelitis – infection spreads (a) from bloodstream (b)

contiguously from adjacent infected area or (c) penetrating trauma/iatrogenically. Tibia, humerus, vertebrae, maxilla & mandibular bodies most prone to bloodborne infection due to anatomy of blood supply.

NRI – C6 (latl, thumb)/C7 (middle)/C8 (medl)

Carpal Tunnel Syndrome (Median n.) – more likely if

‘double crush’ e.g. combined ĉ pronator teres syndrome. Phalen’s test: must hold for at least one min. TInel’s: have to hit quite briskly (patella hammer is best)

Radial Tunnel Syndrome – postr interosseus n. night

may be present; ΔΔ latl epicondylitis, but is distal to epicondyle & rads →dorsum of forearm; perform Tinel’s 3” distal to epicondyle (repro Σs); A-R supination ĉ wrist flexn & elbow extn → . Entrapment most often occurs in arcade of Frohse, but can also occur distally at supinator m, or (rarely) margin of ECRB or under fibrous band in front of radial head

Canal of Guyon – Ulnar n. Diabetic neuropathy (glove/stocking) - bilatl, feet

and LExx likely to be affeted before hands and UExx. Numbness, P+Ns, causalgia, sharp /cramps and loss of balance (Charcot’s, loss of proprioception) are all possible ∑s

Radial/ulnar Aa. Occlusion – weak MM in appropriate

distribution, weak/absent pulses; cold/colour Δ in distal extremity, numbness/P+Ns in non-dermatomal distribution

Complex Regional Pain Syndrome aka reflex sympathetic dystrophy – f>m 3:1; Δ of exclusion. NOT A GOOD

IDEA TO MENTION IN THE CCA UNLESS YOU WANT TO GET INVOLVED IN A DISCUSSION ABOUT CNS SENSITISATION & N-methyl-D-aspartamate RECEPTORS...!

METABOLIC e.g. acromegaly, hypothyroidism, gout,

hypocalcaemia, Paget’s disease, hyperparathyroidism

FUNCTIONAL Rotator cuff imbalance – likely to be a

contributing/maintaining factor in any shoulder problem

Scapulothoracic rhythm disturbance – ass ĉ rotator

cuff (∞)

Calcium deposits i.e Myositis ossificans (e.g.

supraspinatus tendon)

Kyphotic posture with protracted shoulders and contracted

antr structures ∞ ĉ shoulder, chest, thoracic & cervical pain, & breathing probs

Compensatory mechanism – CNS will compromise

shoulder to maintain dexterity of the hand

Cubitus valgus/varus – Tardy ulnar n. palsy ass. ĉ excess

valgus

Loose body – ass. ĉ O/A, radiocapitellar chondromalacia Wrist/Shoulder dysfunction (compensatory mechanism)

(cf. shoulder): e.g. poor shoulder posture (protracted, tightened antr structures) → humerus held in IR → shortening of supinators (inc biceps brachii) → at EoR extn supinators taut → imbalance of elbow/wrist flexors/extensors → PDF epicondylitis.

Ganglion - common cause of ulnar n. compression in canal of

Guyon

Dupuytren’s contracture (possible ∞ ĉ diabetes &

alcoholism)

RSI – controversial Δ (in osteopathy) – be careful whether you mean

strain of MM or true RSI (strain in the brain, as above)

3 – DDx – LEx Hip/Pelvis Knee Ankle/Foot

NMS

Bone # of femoral head – can be surprisingly aΣatic.

Pelvic # Osteoporosis – greatly ↑ risk of #, most commonly in hip,

wrist, spine. Contra to forceful TTT. Ca & Mg, Vit C & Vit D supplements, wt. bearing Exx, esp outside (vit D aids Ca absorption). Oestrogen also aids Ca absorb, prevents urinary excretion; progesterone MAY encourage new bone growth (tofu, sesame seeds etc have high progesterone content). Fosamax (alendronic acid) may be Pxx. Alendronic acid inhibits osteoclastic bone resorption. Controversial: may be a link ĉ osteonecrosis of jaw. Also systemic bioavailability after oral ingestion extremely low (~0.6%), affected by ingestion of food/fluids before or after (have to fast). Has also been argued that osteoclastic activity is natural/necessary, and alendronic acid may prevent breakdown of old bone (→ ↑ bone density) but the bone thus preserved is not necessarily stronger.

Slipped capital femoral epiphysis - rare, but

accurate Δ & immed TTT critical. ♂ 10-16 yoa ♀ 12-14 yoa; ♂>♀2.4:1. Femoral head is displaced post

rly & inf

Rly in rel

n to

femoral neck. PPW hip, medl thigh, and/or knee . Pts often hold hip in passive ER. L hip affected > R. Often bilatl. PDF obesity (↑ shear forces through proximal growth plate).

Osgood-Schlatter’s - tibial Tx epiphysitis; affects 20%

athletic adolescents, ♂>♀ 3:1. , tenderness, lump on tibial tubercle (of Gerdy). AGG activity. TTT complete cessation

sport/activity for 6/12, gradual return afterwards. Chondromalacia patellae - Patellofemoral

syndrome; ∞ weak hip ERs. on going up stairs, weak/tight quads, genu valgus, patella alta. TEST: compression → medl

& latl retinacula & patellar lig

Patellar # Sinding-Larsen-Johnson - patellar epiphysitis

Osteochondritis dessicans

Ankle # Tarsal # Calcaneal spur (Tx exostosis: plantar fasciitis, Achilles tendonitis) Cuneiform sublux (→ sup

r)

Styloid # (proximal 5th

met #, aka tennis or dancer ‘)

Joint O/A– characteristic gait: flexed, addd, ER (‘charlie chaplin

waddle’). Pt will have difficulty walking backwards (can’t extend hip). on wt-bearing, a.m. eased by gently activity. antr groin, a-latl thigh, knee. Gluteii weaken → limping gait, likely +ive Trendelenburg. ΔΔ fixed flexn may be ← psoas spasm ← abscess, appendicitis etc – RULE OUT 1st. Thomas’ Test: Pt supine, c-latl hip/knee flexed (flatten out lumbars). +ve = Σatic LEx lifts off plinth (fixed flexn deformity). TTT: analgesics, NSAIDs, walking stick (c-latl side), work on glutei (strengthening exx, stretches), Wt loss advice if pt visceroptosic.

Otto’s pelvis – protrusion acetabuli. ∞ ĉ osteomalacia, stress

#. Often unnoticed until later in life (start of O/A). May be 2° ← R/A, A/S, O/A, Paget’s etc. ↓ RoM in abdn, ER, extn.

CHD – dysplasia (esp postr acetabular rim) ♂>. ♀ 7:1. Short LEx,

waddling gait, ↓ RoM in abdn

Calve-Perthes - epiphyseal osteonecrosis . 4-10

yoa.

Pubic symphysis dysfunction – ‘the pelvis as a ring’,

often ass ĉ SIJ dysf.

R/A – Jt’s ĉ ↑ synovium more susceptible e.g. UCSp, hip, shoulder.

Link ĉ CTS

O/A – most commonly affected jt by O/A, esp patellofemoral

jt.(esp latl facet of patella). Varus deformity common, but may be valgus.

Meniscal damage/tear – on compression, wt.

bearing rotational injury

Patellofemoral disloc/sublux Patellofemoral Pain Syndrome – PPW on

active flexn extn. on direct pressure to patella, esp during movement of jt. AGG descending stairs (retropatellar pressure is 10x greater descending than ascending), prolonged sitting (‘moviegoers Sx’). Often inflamm. Palpate for crepitus on active movement. TTT ITB (tight?), VMO (weak?), hams (hypertonic?), adductors (hypo?), hip MM imbalances, foot pronation? (→tibial IR). Advice: relative rest, non-impact activities (swimming?), coldpacking esp post-activity, tell Pt could take up to 6/52 to resolve. If no resolution → imaging, possible surgery

Tibiofemoral disloc – traumatic onset, will nearly

always be ligamentous damage (strain/rupture), severe swelling

Loose bodies (→ locking) R/A

O/A (esp. talocrural, DIPJs) – Heberden’s nodes, crepitus, on

activity & end of day; eased by rest, severe on resuming activity (stiff a.m. getting up, rising from sitting); stiffness, jt swelling, tenderness,

Osteochondritis: Kohler’s (navicular); Freiberg’s (2nd

met);

Sever’s (calcaneal)

Hallux valgus Tibial Stress # - after exx, localised tenderness, A-R –ive.

Ligament & Capsule

‘Snapping hip’ - ITB/TFL/glut med tendon over greater

trochanter, iliopsoas/rectus femoris on AIIS/lesser trochanter/iliopectineal line; ∞ ĉ bursitis; can be ligamentum teres tear

LCL, MCL, ACL PCL or coronary lig. Damage – controversial as to whether or not can effectively work on

coronary ligs (some osteos say yes, others no...) ‘Unhappy Triad’ = MCL, ACL, medl meniscus: valgus strain → MCL strain, if severe → ACL & meniscal damage also.

Bursitis - supra/infra/prepatellar/pes anserine

Popliteal cysts (Baker’s) – up to 50% children.

Bursae communicate.. In adults, often ass ĉ meniscal tear or O/A. Usually aΣatic, but may rupture → sever bruising.

Plica syndrome - presence of medl plica is more

common than a latl plica

Inversion/eversion injury (LCL/MCL) – consider that c-latl side will

be compacted e.g. if inversion injury, fluid/pumping work on latl ankle, also decompact medl side...

Achilles strain/rupture – TEST: Pt prone, squeeze gastrocsoleus

complex, if rupture → ° plantarflexn at ankle.

Achilles tendonitis - : postr heel , AGG A-R plantarflexn. TTT S/T, deep

friction, coldpacking. Plantar fasciitis – inflamm of plantar aponeurosis at attach → heel, worst

on getting up a.m., AGG walking. Usually ← overuse/unaccustomed Exx. TTT lose wt., moderate Exx, better footwear, S/T gastrocsoleus, deep friction plantar fascia to stretch, self-massage of plantar fascia (tennis ball, small frozen bottle of water), hams & gastrocs stretches.

Muscle Piriformis Syndrome C

h lat

l hip rotators/gluts/TFL - ∞ ĉ ITB syndrome &

snapping hip

Trochanteric bursitis – under glut max

Ischiogluteal bursitis (‘Weaver’s bottom) – under psoas

Iliopectineal bursitis – may irritate femoral n. Obturator internus enthesopathy Rec-fem tendonitis – link ĉ snapping hip.

VMO dysfunction – causes latl tracking of patella, also

linked ĉ tight ITB

ITB friction syndrome (Runner’s knee) - ∞ LCL and hip, synovium inflamed ←ITT rubbing over latl

femoral condyle; TTT rest, NSAIDs, incremental increase of Exx – no more than 10% increase per week.

Popliteus tendonitis Patellar tendonitis (Jumper’s knee) – often

sports players, swelling, tenderness infrapatellar region. TTT rest, NSAIDs, corticosteroid injection?

Myositis ossificans (post-haematoma?)

Compartment syndrome - antr/postr/latl. Oedema → ↑ pressure in

compart → ↓ blood flow → hypoxic . Antr compart most often affected (least ‘spare room’). TA & EHL first affected. on activity; A-R may be –ive (requires prolonged activity)

Shin splints - postr or ant;: various theories/mechs: overuse syndrome,

interosseus membrane strain, tendonitis, periostitis, micro# . as soon as start exx, diffuse tenderness, A-R +ive, MM TTP.. ΔΔ stress #

Neurological/Referred /Systemic

SIJ dysfunction → antr groin, hip, knee

LSp referral (L2-5) Meralgia paraesthetica – entrapment of latl cutaneous n.

of thigh under inguinal lig. AGG bending forwards, tight clothes.

Appendicitis - preceding nausea, Ň begins in umbilical

region then localises LRQ. Groin and/or testicular may be only Σs. Assess for rebound tenderness, abd MM rigidity, McBurney’s. ΔΔ

iliopsoas or obturator abscess

Femoral hernia - Indirect or direct:

PID Reiter’s (arthritis, urethritis, uveitis) - See p7, SNAs A/S – See p7, SNAs AAA - NOTE: AA’s are often a∑atic as nociceptors do not

respond well to slow Δs. Palpate latl to rectus sheath for ‘pulsatile’ AA pulse. LBP may be only Σ on presenting. Ask about throbbing or burning . Check for radiofemoral delay.

Kidney stones

Charcot’s joints – sensorimotor loss, esp the loss of

proprioception, ass ĉ diabetic neuropathy → severe degenerative arthritis. Common in ankle & knee, also in shoulder (∞ ĉ periarthritis and adhesive capsulitis, 5x more common in diabetic population)

L3/4 referral – facet strain/apophysitis/lock; disc annular

strain/herniation/bulge

Hip referral – Pubofemoral lig →medl knee (via obturator

n); Iliofemoral lig →antr knee (occ. medl ankle) (via femoral n); Ischiofemoral lig →heel (via sciatic n)

TrP referral Gout - ↑ uric acid (either ↑ production or ↓ excretion).

PDF alcohol, game meat, shellfish (high in purines). 2° to hypothyroidism, drug therapies, hormonal disorders. 75% cases 1st MTPJ, but any small joints of hands and feet (gravity role?). Jt hot, shiny, swollen, tender. Uric acid deposits in jts, kidneys, and “tophi” in skin of hands, elbows, ears. TTT allopurinol; avoid aspirin (affects renal excretion of uric acid)

Infective arthritis - cartilage v. Sensitive to bacteria,

will cause damage that cannot heal. Surgical emergency- arthroscopy, ABx

Tabes dorsalis - slow degeneration of fibres in dorsal

columns (JPS, vibration, discriminative touch → test as necessary) due to demyelination as a result of untreated syphilis infection

Popliteal aneurysm - hot, pulsating, swollen.

Intermittent claudication, at rest. EoR flexn orextn → ↑ and/or heat. Absent/decreased dorsalis pedis pulse.

DVT - Homan’s Sx: ĉ knee in extn forcibly dorsiflex ankle

→ in calf. Controversial (chance of dislodging and causing e.g. PE; plus only about 50% DVT Pts are +ive). May be: tenderness/leg ; swelling (>1.2cm (f) or >1.4cm (m) diff in leg circ); warmth; subcut venous distension; discolouration, palpable cord

L5/S1 referral Diabetic peripheral neuropathy – foot and LExx ∑stend to appear

before UExx. Check regularly in diabetic pts. May be trophic Δs to skin, loss pinprick/soft touch, P+Ns, numbness, sharp & cramps, causalgia & loss of balance possible.

Ganglion/ Morton’s neuroma - Morton’s most often between 3rd and

4th MTPJs (where latl plantar n. combines ĉ part of medl planter n. PDF pes planus, high heels/tight toe boxes (e.g. female footwear). Entrapment neuropathy. Neuralgic on pressure. May also be P+Ns/numbness.

Foot drop (∞ cauda equina ) – Pt cannot heel-walk. May notice on

greeting Pt (while walking, high step). May be caused by L5 NRC (e.g. herniation), sciatic n. compression (direct trauma, iatrogenic), peroneal/fibular n. palsy (esp at fibular head), lumbosacral plexus (cauda equina), spinal cord compression (poliomyelitis, SOL, cervical bar), stroke/TIA/brain tumour, MS

Intermittent claudication – Neurogenic: ↓ blood flow to Nn in

spinal foraminae, spinal stenosis. Probably some at rest (i.e. is not relieved as swiftly as vascular claud, may persist for hours). Walk further when flexed (shopping trolley, uphill, mowing grass), Pulses NAD, ° LExx skin Δs. May be ° neuro

Sx or ∑s. Vascular: stops immediately when Pt stops walking/sits. May be

abŇ pulses (HOWEVER may not be apparent at rest), sin cold, dry flaky (poor perfusion)

Gout – see under KNEE

FUNCTIONAL LEx length discrepancy Snapping hip – see above

Patellar mal-tracking – quads imbalance, rotn from

hip/foot. ∞ ĉ VMO dysfunction – VM Ň prevents maltracking in last 15° of extn, latl retinaculum contracts, ITB shortens → patellar compaction latl to femoral groove. TTT: terminal extn exx, retinacular stretch, ITB work (also TFL, glutei), lat’l reinforced gapping.

Pes planus - ∑s likely in antr leg & calf (rather than foot); tibialis antr tends

to tire on walking . Arches maintained by MM of plantar fascia while standing; while walking also TA, TP (esp under sustentaculum tali), PL, EDL, EHL

Pronation - be careful to distinguish from pes planus. Pronation → IR of

tibia → more pressure on medl knee Pes cavus – ass ĉ spina bifida, poor shoes

4 - Systemic Causes of Back Pain Cervical Spine

CVS May refer to neck, shoulder, arm

Angina - ask about: sweating, nausea, chest discomfort, mouth/jaw/tooth when getting chest /discomfort. Does

neck/jaw increase with exertion that should not involve shoulder (climbing stairs, exercise bicycle)? Dyspnoea: nausea; belching MI – as angina, plus crushing band/tightness around chest, , prolonged/sever substernal chest or squeezing

pressure; feeling of indigestion; nausea; sudden dimness/loss of vision or loss of speech; pallor; diaphoresis (heavy perspiration); SOB; weakness, numbness; feelings of faintness

Aortic aneurysm – as angina

Pericarditis – substernal that rads → upper back, UFT, L supraclavicular area, down L UEx to costal margins,

neck; dysphagia; AGG deep breathing (laughing, coughing etc), trunk movements (S/B or rotn), lying down; REL holding

breath, leaning forward, sitting down; LExx oedema; cough

Vasculitis (esp. If ass ĉ H/As) TIA – Vertebral Arterial Dysfunction –

V vertigo, vomiting, CNV Σs (facial), visual Σs A ataxia D drop attack, diplopia, dysphonia, dysarthria, dysphagia, dissociated sensory loss

Embolism

Respiratory May refer to neck, UFT, costal margins, TSp, scapulae, shoulder (and along med

l arm)

Lung Ca (Pancoast’s) – look for Horner’s syndrome ( Ptosis, Enophthalmos, Anhydrosis,Meiosis) Σs:.

Haemoptysis; persistent cough; dyspnoea. Ask about: constant, intense , esp unrelieved by Δ in position/bone/night; unexplained wt loss (10% in 10-14/7) – most Pts in are inactive → wt gain; excessive fatigue; Δ bowel/bladder habits; rapid onset of clubbing (10-14/7); (proximal) MM weakness, esp accompanied by Δ in 1+ DTR; unusual/prolonged bleeding/discharge; Δ voice/c

h cough/hoarseness (recurrent laryngeal n)

Tracheobronchial irritation - dyspnoea, wheezing, chest

Ch bronchitis – persistent productive cough (worse a.m. & p.m. than midday), ↓ chest expansion; wheezing; fever;

dyspnoea; central cyanosis; ↓ exercise tolerance

Pneumothorax – may be spontaneous, ruptured bulla on pleura. Σs: fall in BP, weak and rapid pulse, ↓ in

respiratory moves on affected side. NOTE: Pt may present with shoulder NOT breathing probs

GIT Oesoph →mid-back, also to level of lesion postr CSp Stomach/Duo → back at level of lesion, R shoulder /UFT, latl border R

scapula Liver →R T7-10, R shoulder Gallbladder →R interscap (T4-8), R shoulder (phrenic n) Sm-Int →low-back L-Int →sacrum (rectum) Pancreas →mid/low back, (rarely) interscapular, L shoulder

Oesophagitis Oesophageal varices – dysphagia, odynophagia

Oesophageal Ca – hoarseness/voice Δs, dysphagia, odynophagia

GU May refer to flank, low back, or pelvis

OBGYN

Neoplastic Metastatic lesions (leukaemia, Hodgkin’s disease) Bone & cord Ca – LMNL Sx at level of lesion, UMNL Sx below Lung Ca (esp. Pancoast’s) - look for Horner’s syndrome ( Ptosis, Enophthalmos, Anhydrosis,Meiosis) Σs:.

Haemoptysis; persistent cough; dyspnoea. Ask about: constant, intense , esp unrelieved by Δ in position/bone/night; unexplained wt loss (10% in 10-14/7) – most Pts in are inactive → wt gain; excessive fatigue; Δ bowel/bladder habits; rapid onset of clubbing (10-14/7); (proximal) MM weakness, esp accompanied by Δ in 1+ DTR; unusual/prolonged bleeding/discharge; Δ voice/c

h cough/hoarseness (recurrent laryngeal n)

Oesophageal Ca - hoarseness/voice Δs, dysphagia, odynophagia Thyroid Ca – may be euthyroid/hypothyroid/hyperthyroid. Relatively uncommon. Slow growing. Rarely

metastasizes. Palpable nodule/mass; hoarseness; haemoptysis; dyspnoea; hypertension

Metabolic/Endocrine

Myasthenia gravis – auto-immune, circulating antibodies block acetylcholine receptors at post-synaptic NMJ →

weakness. V. rare (200-400 cases/million). Main Σ: fatigue, improves ĉ rest. MM that control eye/eyelid, facial expression, chewing, talking & swallowing esp susceptible. Σs may be intermittent. Ptosis, diplopia, dysphagia, SOB & dysarthria most common PCs.

Other INFECTION: Osteomyelitis – infection spreads (a) from bloodstream (b) contiguously from adjacent infected area or (c)

penetrating trauma/iatrogenically. Tibia, humerus, vertebrae, maxilla & mandibular bodies most prone due to anatomy of blood supply.

Meningitis – nuchal rigidity, photophobia, H/A, pyrexia

Lyme disease Retropharyngeal abscess

Fibromyalgia - widespread & tenderness, presence of characteristic TrPs (esp in shoulders, back, elbows, knees)

HOWEVER: the “eleven out of eighteen” tender points “test” is intended to be used to identify FM pts for inclusion in research studies; it was never intended to be used in clinical settings (Scudds 1998); there are neurohormonal Δs that can diminish repair of MM tissues (Neeck & Riedel 1994). It involves a disrupted hypothalamic-pituitary-adrenal (HPA) axis, and studies indicate there may be biochemical abnormalities requiring metabolic adjustment (e.g. Eisenger et al 1994, Samborski et al 1996), and may be ass ĉ IBS and or migraines – stress linkage. ° Sx of inflammation; jts tender but not swollen; a.m. stiffness, eases quickly on movement. Depression, malaise, fatigue; ♀ > ♂, peak incidence middle years, sometimes triggered by bereavement/stress. Often Δ of exclusion (although FM sufferers and experts dispute this).

4 - Systemic Causes of Back Pain Thoracic Spine


Angina - ask about: sweating, nausea, chest discomfort, mouth/jaw/tooth when getting TSp ? Does TSp increase with

exertion that should not involve shoulder (climbing stairs, exercise bicycle)? Dyspnoea: nausea; belching MI – as angina, plus crushing band/tightness around chest, prolonged/sever substernal chest or squeezing pressure; feeling

of indigestion; nausea; sudden dimness/loss of vision or loss of speech; pallor; diaphoresis (heavy perspiration); SOB; weakness, numbness; feelings of faintness

Pericarditis – substernal that rads → upper back, UFT, L supraclavicular area, down L UEx to costal margins, neck;

dysphagia; AGG deep breathing (laughing, coughing etc), trunk movements (S/B or rotn), lying down; REL holding breath, leaning

forward, sitting down; LExx oedema; cough

Endocarditis – easy fatigue; dyspnoea; palpitations; pitting oedema; orthopnoea/paroxysmal dyspnoea; dizziness; syncope;

arthralgias/arthritis; low back/SI (1/3 of cases; NOTE: will be accompanied by ↓ RoM and spinal tenderness) , myalgias; cold and painful Exx

Aortic aneurysm – Pulsating chest , often aΣatic until ruptured: sudden severe chest ĉ tearing/ripping sensation; may

rad → neck, shoulders, interscapular area, low back or abdomen - rad → postr thighs may help distinguish from MI;

lightheadedness; nausea; NOT REL by Δ in position


l arm)

Respiratory infection – pyrexia, malaise, dyspnoea, chest

Empyema C

h bronchitis – persistent productive cough (worse a.m. & p.m. than midday), ↓ chest expansion; wheezing; fever; dyspnoea;

central cyanosis; ↓ exercise tolerance Pleurisy – chest AGG breathing, coughing, laughing (deep inspiration); cough; fever, chills; tachypnoea

Pneumothorax - see CSp Pneumonia – sudden sharp pleuritic AGG chest movement, shoulder ; hacking, productive cough (rust/green purulent

sputum); dyspnoea; cyanosis; H/A; pyrexia, chills; fatigue; confusion in older adult

Pulmonary Embolism (PE) TB – fatigue; malaise; anorexia; wt loss; low-grade pyrexia (esp in afternoon); night sweats; frequent prod cough; dull chest

/tightness/discomfort; dyspnoea

GIT Oesoph →mid-back Stomach/Duo → back at level of lesion, R shoulder /UFT, latl border

R scapula Liver →R T7-10, R shoulder Gallbladder →R interscap (T4-8), R shoulder (phrenic n) Sm-Int →low-back L-Int →sacrum (rectum) Pancreas →mid/low back, (rarely) interscapular, L shoulder

Oesophagitis (severe) Oesophageal spasm Peptic ulcer (esp. penetrating duodenal) – steady near midline of back T6-10 (perforating); nausea, emesis,

anorexia, wt loss; melaena; R shoulder

Ac cholecystitis Biliary colic Pancreatic Disease – AGG sitting up/leaning forward,


Ac pyelonephritis/glomerulonephritis (upper UTI) – unilat

l costovertebral tenderness; flank ; ipsilat

l shoulder

; pyrexia & chills; haematuria; nocturia

Cystitis/urethritis (lower UTI) – urinary frequency, urgency; dysuria; haematuria; LBP; dyspareunia ( ful intercourse);

pelvic/lower abd

Kidney disease

OBGYN

Neoplastic Mediastinal Ca Metastatic extension Pancreatic Ca Breast Ca

Metabolic/Endocrine

Asthma Kidney problems (∞ rennin-angiotensin system) → T/L region

Hyperthyroidism Myasthenia gravis – auto-immune, circulating antibodies block acetylcholine receptors at post-synaptic NMJ → weakness.

V. rare (200-400 cases/million). Main Σ: fatigue, improves ĉ rest. MM that control eye/eyelid, facial expression, chewing, talking & swallowing esp susceptible. Σs may be intermittent. Ptosis, diplopia, dysphagia, SOB & dysarthria most common PCs. Cushing’s Syndrome (hypercortisolism)

Other INFECTION: Osteomyelitis – infection spreads (a) from bloodstream (b) contiguously from adjacent infected area or (c) penetrating

trauma/iatrogenically. Tibia, humerus, vertebrae, maxilla & mandibular bodies most prone due to anatomy of blood supply H. zoster HIV – CD4 <200 at any point in Hx = ↑ risk of osteoporosis (contra HVLAT), healthy indiv = 1000; 500 =’ok’; viral load

<40(copies/ml) = undetectable, 100,000 = need to start ARV. Side effects of meds = lipodystrophy → need to be careful ĉ soft tissue Fibromyalgia - widespread & tenderness, presence of characteristic TrPs (esp in shoulders, back, elbows, knees) HOWEVER:

the “eleven out of eighteen” tender points “test” is intended to be used to identify FM pts for inclusion in research studies; it was never intended to be used in clinical settings (Scudds 1998); there are neurohormonal Δs that can diminish repair of MM tissues (Neeck & Riedel 1994). It involves a disrupted hypothalamic-pituitary-adrenal (HPA) axis, and studies indicate there may be biochemical abnormalities requiring metabolic adjustment (e.g. Eisenger et al 1994, Samborski et al 1996), and may be ass ĉ IBS and or migraines – stress linkage. ° Sx of inflammation; jts tender but not swollen; a.m. stiffness, eases quickly on movement. Depression, malaise, fatigue; ♀ > ♂, peak incidence middle years, sometimes triggered by bereavement/stress. Often Δ of exclusion (although FM sufferers and experts dispute this). Acromegaly

4 - Systemic Causes of Back Pain Lumbar Spine


AAA / Arterial occlusion – AAAs occur appx 4x more often than thoracic aneurysms. Most common site is just below the

kidney, with referred to the T/L. Sx & Σs: Abdominal ‘heartbeat’ felt by Pt when lying down; dull ache midabdominal L flank or LB; groin and/or LEx ; weakness or transient paralysis of LExx.

Myocarditis Endocarditis – easy fatigue; dyspnoea; palpitations; pitting oedema; orthopnoea/paroxysmal dyspnoea; dizziness; syncope;

arthralgias/arthritis; low back/SI (1/3 of cases; NOTE: will be accompanied by ↓ RoM and spinal tenderness) , myalgias; cold and painful Exx

Peripheral vascular - e.g. post-op bleed from antr spine surgery, occlusive disease (thrombus, embolism, trauma,

arteriosclerosis obliterans, Raynaud’s). Diabetes is a risk factor. 1st

Sx may be loss of hair on the toes. Also: intermittent claudication, ischaemic rest , AGG by elevating extremity, REL hanging foot over side of bed/chair. Colour, temp, skin & nail bed Δs


l arm)

--------------------------------

GIT Oesoph →mid-back Stomach/Duo → back at level of lesion, R shoulder /UFT, latl border R scapula Liver →R T7-10, R shoulder Gallbladder →R interscap (T4-8), R shoulder (phrenic n) Sm-Int →low-back L-Int →sacrum (rectum) Pancreas →mid/low back, (rarely) interscapular, L shoulder

SMALL INT: Obstruction (e.g. neoplasm) IBS Crohn’s disease COLON: Diverticular disease – L lower abd & tenderness; L pelvic ; bloody stools; pyrexia

Pancreatitis – epigastric rad→ back; nausea; emesis; pyrexia, sweating; tachycardia; malaise; weakness; jaundice; bluish

discolouration of abdomen/flanks (ac haemorrhagic pancreatitis)

Appendicitis – R lower quadrant or flank , periumbilical and/or epigastric , rebound tenderness, =ive McBurney’s point

Gall bladder


KIDNEY: A

c pyelonephritis/glomerulonephritis (upper UTI) – unilat

l costovertebral tenderness; flank ; ipsilat

l shoulder ;

pyrexia & chills; haematuria; nocturia

Cystitis/urethritis (lower UTI) – urinary frequency, urgency; dysuria; haematuria; LBP; dyspareunia ( ful intercourse);

pelvic/lower abd

Perinephrine Abscess Upper UT obstruction –nephrolithiasis (calculi) - sudden, sharp, severe ; Uretal colic rads → genitalia & thighs;

renal colic deep in lumbar area rads → around side & down to testicle in male, bladder in female; haematuria; nausea/emesis; ↑ frequency (unless stone blocks flow → hydronephrosis)

Dialysis (first-use syndrome) Upper UT obstruction e.g. renal tumours – slow onset – mild & dull flank ; palpable flank mass; hyperaesthesia

dermatomes T10-L1; nausea/emesis; haematuria; abd. MM spasm

OBGYN Uterine fibroids Ovarian cysts Endometriosis Pelvic Inflammatory Disease (PID) Retroversion of uterus Rectocele/Cystocele Uterine prolapsed ALSO: Ň pregnancy; multiparity

Neoplastic Metastasis - commonly from: breast, lung, GIT, kidney, prostate. Ask about: constant, intense , esp unrelieved by Δ in

position/bone/night; unexplained wt loss (10% in 10-14/7) – most Pts in are inactive → wt gain; excessive fatigue; Δ bowel/bladder habits; rapid onset of clubbing (10-14/7); (proximal) MM weakness, esp accompanied by Δ in 1+ DTR; unusual/prolonged bleeding/discharge; Prostate, testicular, pancreatic, colorectal Ca’s Multiple myeloma Lymphoma

Metabolic/Endocrine

Hyperthyroidism Adrenal dysfunction (e.g. phaeochromocytoma) → osteomalacia Paget’s Myasthenia gravis – auto-immune, circulating antibodies block acetylcholine receptors at post-synaptic NMJ → weakness. V.

rare (200-400 cases/million). Main Σ: fatigue, improves ĉ rest. MM that control eye/eyelid, facial expression, chewing, talking & swallowing esp susceptible. Σs may be intermittent. Ptosis, diplopia, dysphagia, SOB & dysarthria most common PCs. Cushing’s Syndrome – as TSp

Other INFECTION: Osteomyelitis – infection spreads (a) from bloodstream (b) contiguously from adjacent infected area or (c) penetrating

trauma/iatrogenically. Tibia, humerus, vertebrae, maxilla & mandibular bodies most prone due to anatomy of blood supplyH. Zoster Spinal TB Psoas abscess HIV - CD4 <200 at any point in Hx = ↑ risk of osteoporosis (contra HVLAT), healthy indiv = 1000; 500 =’ok’; viral load <40(copies/ml) =

undetectable, 100,000 = need to start ARV. Side effects of meds = lipodystrophy → need to be careful ĉ soft tissue Fibromyalgia – widespread & tenderness, presence of characteristic TrPs (esp in shoulders, back, elbows, knees) HOWEVER:

the “eleven out of eighteen” tender points “test” is intended to be used to identify FM pts for inclusion in research studies; it was never intended to be used in clinical settings (Scudds 1998); there are neurohormonal Δs that can diminish repair of MM tissues (Neeck & Riedel 1994). It involves a disrupted hypothalamic-pituitary-adrenal (HPA) axis, and studies indicate there may be biochemical abnormalities requiring metabolic adjustment (e.g. Eisenger et al 1994, Samborski et al 1996), and may be ass ĉ IBS and or migraines – stress linkage. ° Sx of inflammation; jts tender but not swollen; a.m. stiffness, eases quickly on movement. Depression, malaise, fatigue; ♀ > ♂, peak incidence middle years, sometimes triggered by bereavement/stress. Often Δ of exclusion (although FM sufferers and experts dispute this). Type III hypersensitivity disorder (back/flank pain) Post-regional anaesthesia

Roots C5 C6 C7 C8 T1

Sensory Supply Latl arm Lat

l forearm, inc. Pollux &

index finger Mid-forearm, middle finger

Medl forearm, little finger Axilla, med

l forearm

Sensory Loss Over deltoid Thumb, radial border of hand

Middle fingers, front & back of hand

Little finger, heel of hand → above wrist

Axilla

Area of Pain As above, + medl border of

scapula Esp. thumb and index finger

As above, + medl border

of scapula As above Deep ache in shoulder and axilla

Reflex Arc Biceps jerk Supinator jerk Triceps jerk Finger jerk None

Motor Deficit Deltoid supraspinatus infraspinatus rhomboids

Pronators & supinators of forearm

Triceps wrist extensors and flexors lat dorsi pec. major

Finger flexors and extensors FCU

Intrinsic MM of hand

Causative Lesions

Brachial neuritis Cervical Spondylosis Upper plexus avulsion

Cervical Spondylosis Ac disc lesions Cervical Spondylosis

Disc lesions Spondylosis (rare)

Cervical rib/1st

rib Pancoast’s tumour Metastatic Ca in deep cervical lymph nodes TOS

Nerves Axillary (C5) Musculocutaneous (C5,C6)

Radial (C5,C6,C7,C8)

Median (C6,C7,C8,T1)

Ulnar (C8,T1)

Sensory Supply

Over deltoid Latl forearm → wrist Lat

l dorsal forearm, back of

thumb & index finger

Latl palm, index, middle and

latl ½ ring finger Med

l palm, 5

th and med

l ½ ring

finger

Sensory Loss Over deltoid Latl forearm Dorsum of thumb & index

(rare) Thumb, index & middle finger, lat

l palm

As above, but often none

Area of Pain Tip of shoulder Latl forearm Dorsum of thumb & index Thumb, index, middle finger As above

Reflex Arc None Biceps jerk Triceps jerk Supinator jerk

Finger jerk None

Motor Deficit Deltoid –usually obvious

Biceps, brachialis Triceps Wrist extensors Finger extensors Brachioradialis Supinator

Wrist flexors Long finger flexors (1,2) APB

All intrinsic MM of hand (except APB) Long fingers flexors (3,4) FCU

Causative Lesions

# neck of humerus RARE Crutch palsy Saturday night palsy # humerus (radial groove) Entrap within supinator Radial tunnel syndrome (postr interosseus branch)

CTS Direct trauma → wrist Pronator teres syndrome (antr interosseus branch) Falling on glass Palmar space infection

ELBOW: trauma Bed rest # olecranon WRIST (canal of Guyon): Trauma Gangion

5 – Differential Diagnosis of Peripheral Nn vs. Nerve Root – Upper Extremity

Roots L2 L3 L4 L5 S1

Sensory Supply

Across upper thigh to postr

axial line

Across lower thigh to postr

axial line

Across knee to medl malleolus Lat

l leg to dorsum and sole of

foot & hallux

Behind latl malleolus to

latl foot and little toe

Sensory Loss Often none, latl area if any Often none, lat

l area if any Med

l leg below knee to medl

malleolus

Dorsum of foot to hallux Behind latl malleolus &

latl border of foot

Area of Pain Across thigh (diagonally) Across thigh (diagonally) Down to medl malleolus. Often

severe at knee around patella

Postr thigh, latl calf, dorsum of

foot , hallux

Postr thigh, post

r calf,

latl foot to little toe

Reflex Arc None Adductor reflex Knee jerk None Ankle jerk

Hamstring jerk

Motor Deficit

Hip flexn

Thigh addn

Knee extn

Thigh addn

Inversion of foot Dorsiflexn of toes & foot

(latter L4 also)

Plantarflexn

Eversion of foot

Causative Lesions

L2/3/4: (in order of frequency)

Facet insult

Neurofibroma

Meningioma

Neoplastic disease

Disc lesions (very rare: except L4, <5% of all disc lesions)

L5/S1: (in order of frequency)

Disc lesions

Facet

Metastatic malignancy

Neurofibromas

Meningiomas

Congenital cauda equina lesions

Nerves Obturator (L2,L3,L4) Femoral (L2,L3,L4) Sciatic nerve (L4,L5,S1,S2,S3)

Peroneal/Fibular Tibial

Sensory Supply

Medl surface of thigh to post

r axial

line

Anteromedl surface of thigh & leg

down to medl malleolus

Antr leg, dorsum of ankle & foot Post

r leg, sole & lat

l border of foot

Sensory Loss Often none Usually anatomical Often only detectable on dorsum of foot Sole & latl border of foot

Area of Pain Medl thigh Ant

r thigh & medl leg → ankle Often painless; dull ache anterolat

l leg &

foot

Often painless, very uncommon

Reflex Arc Adductor jerk Knee jerk Latl hamstring jerk Ankle jerk

Medl hamstring jerk

Motor Deficit

Addn of thigh Ext

n of knee Dorsiflex

n, inversion (TA) & eversion of

foot, latl hamstrings

Plantarflexn & inversion of foot (TP),

medl hamstrings

Causative Lesions

Pelvic neoplasm

Pregnancy

Pelvic surgery

Diabetes

Femoral hernia

Femoral a. Aneurysm

Postr abdominal neoplasm

Psoas sbscess

Pressure palsy at fibular head

Hip # or dislocation

Penetrating trauma to buttock

Iatrogenic (misplaced injection in

buttock)

Very rarely injured, even in buttock

- peroneal division more prone to

injury (reason unknown)

6 – Differential Diagnosis of Peripheral Nn vs. Nerve Root – Lower Extremity

7 – Osteoarthritis vs. Rheumatoid Arthritis

Osteoarthritis Rheumatoid Arthritis Definition Non-inflammatory disorder of synovial joints, charac. by articular surface wear &

formation of new bone

Auto-immune inflammatory multi-systemic connective tissue disorder

Epidemiology 80% m. & 89% f. over the age of 75yrs, ♀ > ♂ 3:1

1-2 % general population. , ♀ > ♂ 3:1. Onset any time 10-70 yoa, but peak: 30-40 yoa.

Aetiology Primary O/A = idiopathic (many factors, but cause unknown) Secondary O/A = consequent to trauma, congenital abnormalities, infection, functional problems, avascular necrosis, neuropathy, metabolic/endocrine diseases, crystal arthropathies, or iatrogenesis.

Unknown – sex hormones may be involved (often 1st

appears after pregnancy, or remits during, contraceptive pill appears to have mild protective influence), also genetic/immunological component likely

Pathophysiology Stage 1: Breakdown of articular surface Stage 2: Synovial irritation Stage 3: Chondral remodelling Stage 4: Eburnation of bone & cyst formation Stage 5: Disorganization

Ch inflammatory synovitis: proliferation of villi that contain infiltrates of lymphocytes,

macrophages & plasma cells. Synoviocytes secrete cytokines → stimulate further synoviocyte prod, cartilage resorption, further cytokine production (may →progressive nature of disease). In established disease these mild inflammatory lesions develop into RHEUMATOID NODULES (pathognomic of R/A) in many tissues – heart/pericardium, lungs, blood Vv, skin/subcut tissue, eye, salivary/lacrimal glands etc. Synovium devs tumour-like mass – PANNUS that extends from synovial margin eroding articular cartilage & invading bone. Exudate within jt → swollen S/Ts

Clinical Features Affects mainly: 1st

CMCJ, 1st

MTPJ, knee & hip (joints that have undergone most recent evolutionary Δ?) AGG wt. bearing/use; worse after activity/at end of day REL by rest Stiffness, weakness (usually 2° to disuse) Crepitus/clicking Swelling – may be bony, cold, hard. Often ĉ additional effusion (←synovitis?) Locking/unsteadiness ← loose bodies/irregular jt surface MM weakness/wasting ↓ RoM Jt deformities – e.g. fixed flex

n, Heberden’s/Bouchard’s nodes

NRI/impingement - 2° to Spondylosis

Commonly affected initially: PIPJs, MCPJs, MTPJs, wrist, CSp Knee common in later stages, along ĉ hip, ankle. Likely to be symmetrical BUT 20% Pts present initially as monartrhitis, usually knee or wrist Jt & stiffness, esp a.m. Low-grade pyrexia, malaise, fatigue, wt loss ass ĉ anorexia Sjögren’s Syndrome in up to 40% of Pts (dry, sore eyes, nose & mouth). Uveitis & scleritis important ocular manifestations RESP: nodules, interstitial fibrosis, obstruction small bronchi → wheeze, exertional dyspnoea CVS: pericarditis, vasculitis (esp fingers & nail beds), mitral valve disease, Raynaud’s, anaemia NERVOUS: cervical myelopathy (most common rheum cause of death in R/A), CTS

DDx

Depends on whether mono-, oligo- or polyarthritic on presentation... SLE, allergic/viral onset polyarthritis, psoriatic arthritis, 1° generalised O/A

Medical Management

NSAIDs, intra-articular steroid injections, glucosamine & chondroitin supplement (may ↓ Σs, unlikely to promote regrowth of cart), artificial synovial fluid (M/T, lasts appx 6/12); osteotomy, arthrodesis, debridement, jt. resurfacing, total joint replacement

NSAIDs, DMARDs (disease-modifying anti-rheumatic drugs, a group of otherwise unrelated compounds e.g. methotrexate, sulphasalazine, anti-malarials, gold) steroids

Osteopathic Management

Advice: explanation of condition and reassurance; keep active but modify causing activities: low-impact exercise (swimming, exercise bikes), wt. loss if viscerotopic, walking stick c-lat

l side if hip/knee affected etc. Disuse (not just overuse) can → Δ in

function and levels – if any given jt not used through full RoM → poorer health of that joint (and those surrounding it). Bony remodelling is an ongoing process → maintain function through manual therapy & Exx.

Exx to maintain RoM, MM bulk around affected joints, and general fitness. Avoid TTT of neck (synovitis around C1/2 may → excess move or vertical subluxation of C1 relative to C2; both may lead to progressive spastic quadraparesis or transient episodes of medullary dysfunction; also transverse ligament likely to be affected – CONTRA TO HVLAT), do not TTT during active phase/flare-up. Controversial: only treat unaffected joints?

SERONEGATIVE ARTHROPATHIES (SNAs)

Group of overlapping forms of INFLAMMATORY JOINT DISEASE COMMON FEATURES: Tendency to affect the SPINE RhF negative ↑ incidence of HLA-B27 FAMILY HISTORY of single/multiple SLAs PPW: Back pain AGG prolonged inactivity/sitting/lying REL activity

When Pts present ĉ back AGG prolonged sitting/lying down, REL activity, suspect SNA... Enthesopathy is responsible for many of the features: inflammation, fibrosis, ossification/reactive bone formation at the enthesis

8 - Seronegative Spondyloarthropathies

Condition Epidemiology Pathophysiology Clinical Features Management

Ankylosing Spondylitis C

h inflammatory condition

affecting spine & SIJs

Uncommon, m > f, 3:1 15-30 yoa, rarely after 45 Women tend to have more peripheral jt involvement Men have more severe spinal disease

Inflamm at entheses → reactive new bone formation in adj ligs & sclerosis of underlying bone → vertebral fusion

- Insidious onset LBP - Stiffness, esp T/L - Peripheral arthropathy - Pelvic & Back Pain, intermittent - Enthesopathy: plantar fasciitis, costochondritis, Achilles tendinitis etc. - Antr uveitis

- ↓ Pain & inflamm - MOBILISING EXX for SPINAL MOBILITY: Spinal extn, spinal strength & mob, deep breathing, swimming - ADVICE: postural (e.g. no/low pillow); avoidance of prolonged immobility

Reiter’s/Reactive Arthritis Triad of Σs: Conjunctivitis Urethritis Arthritis

Peak incidence age 30 yoa, following enteric infection distr much wider – children & elderly may be affected

Follows intestinal/dysenteric or genital infection (major identifiable cause inflamm arthritis in young adults in West)

- PERIPHERAL ARTHRITIS: starts 2/52 after infect; asymmetrical, additive - UVEITIS/CONJUNCTIVITIS - URETHRITIS: dysuria/urethral discharge, polyuria, prostatitis, balanitis, cystitis

Treat infection (ABx); for arthritis: NSAIDs, rest. If spondylitis is present, TTT as per A/S (above). In a

c stages jt

aspiration and corticosteroid injections may be performed.

Psoriatic Arthritis

Psoriasis affects 1-2% [Caucasian] population. 5-10% of these will have PsA. m=f; 30% of cases have FHx Peak onset 36-46 yoa Most Pts ĉ PsA have pre-existing skin/nail psoriasis, but jt inflamm precedes psoriasis in c. 15% of cases.

Aetiology unknown; trauma, stress, infection all implicated. Hormonal factors also seem to be involved - PsA usually improves during pregnancy and there is often post-partum flare.

DIPJ DISEASE: m>f, sausage digits ARTHRITIS MUTILANS: <5%. Small jts hands & feet ĉ osteolysis of phalanges PERIPHERAL OLIGO/POLYARTHRITIS: most common subgroup; affects large/small jts. Sausage digits SPONDYLITIS: mainly SPINAL involve. >half Pts have CSp involve.

- Diet: rich in polyunsaturated fats may help psoriasis, ↓ need for NSAIDs - EDUCATION: re pattern of disease & good rest-exx balance - PHARM: S/T NSAIDs; L/T sulfasalzine, low dose methotrexate - CORTICOSTEROIDS - UV LIGHT for skin lesions

ENTEROPATHIC ARTHROPATHIES Crohn’s & UC (together: IBD)

20% of Crohn’s Pts → peripheral arthritis 10% of UC Pts → peripheral arthritis m=f Axial involvement in up to 25% Pts.

55% of Crohn’s & 70% UC are HLA-B27 positive

PERIPHERAL: asymmetrical, mainly knees & ankles SACRO-ILIITIS: axial involve in >25%. 4% progress to A/S

EDUCATION:

Whipple’s Disease Very rare; m>f NOTE: in 50% of cases, arthritis precedes bowel disease

← T. whippelii. In 50% of cases, arthritis precedes bowel disease. Bacterial infection often involves Sm-Int

Steatorrhoea Arthritis: ankle & knee, elbow & fingers Abdominal pain Enlarged lymph nodes

Rest, NSAIDs may agg bowel problem; steroids help both arthritis & bowel

Behçet’s Disease Triad

Rare Aetiology unknown; some familial link Oro-genital ulceration Uveitis Skin rashes Asymmetrical arthritis, often LExx 75% cases is KNEE; intermittent, severe, may involve effusion

As other types of ac arthritis

01-08 differential diagnosis - expanded systemic causes

Documents