Differential Diagnosis

1
Chapter 9

• Differential Diagnosis

2
Overview

• Differential diagnosis involves the ability to
  quickly differentiate those problems of a serious
  nature from those that are not
• Problems of a serious nature include, but are not
  limited to visceral diseases, cancer, infections,
  fractures and vascular disorders

3
Referred Pain

• The term referred pain is used to describe those
  symptoms that have their origin at a site other
  than where the patient feels the pain

4
Referred pain

• Referred pain can be generated by
• Convergence of sensory input from separate parts
  of the body to the same dorsal horn neuron via
  primary sensory fibers
• Secondary pain resulting from a myofascial
  trigger point
• Sympathetic activity elicited by a spinal reflex
• Pain-generating substances

5
Referred Pain

• Macnab recommends the following classification
  for referred pain
• Viscerogenic
• Vasculogenic
• Neurogenic
• Psychogenic
• Spondylogenic

6
Viscerogenic Pain

• Viscerogenic pain may be produced when the
  nociceptive fibers from the viscera, synapse in
  the spinal cord, with some of the same neurons
  that receive pain from the skin.

7
Viscerogenic Pain

• Visceral pain has five important clinical
  characteristics
• It is not evoked from all viscera
• It is not always linked to visceral injury
• It is diffuse and poorly localized
• It is referred to other locations
• It is accompanied with autonomic reflexes, such
  as the nausea, and vomiting

8
Vasculogenic Pain

• Vasculogenic pain tends to result from venous
  congestion or arterial deprivation to the
  musculoskeletal areas
• Tends to mimic a wide variety of musculoskeletal,
  neurologic, and arthritic disorders, as this type
  of pain is often worsened by activity

9
Neurogenic Pain

• Neurogenic pain is pain that is referred from a
  neurological structure.
• Neurogenic causes of pain may include
• A tumor compressing and irritating a neural
  structure of the spinal cord, meninges
• A spinal nerve root irritation
• Peripheral nerve entrapment
• Neuritis

10
Scanning Examination

• The tests of the Cyriax upper or lower quarter
  scanning examination can be used to
• Examine the patients neurological status
• Highlight the presence of a lesion to the central
  or peripheral nervous systems
• Help rule out any serious pathology such as a
  fracture or tumor

11
Scanning Examination

• The upper quarter scanning examination is
  appropriate for upper thoracic, upper extremity,
  and cervical problems
• The lower quarter scanning examination is
  typically used for thoracic, lower extremity, and
  lumbosacral problems

12
Scanning Examination

• The tests included in the scanning examination
  include strength testing, sensation testing
  (light touch and pin-prick), deep tendon
  reflexes, and the pathological reflexes

13
Scanning Examination

• At the end of each of the scanning examinations,
  either a medical diagnosis (disc protrusion,
  prolapse, or extrusion, acute arthritis, specific
  tendonitis, or muscle belly tear,
  spondylolisthesis or stenosis) can be made, or
  the scanning examination is considered negative

14
Psychogenic Pain

• Psychogenic (non-organic) pain is characterized
  by abnormal illness behaviors
• Commonly exhibited by patients suffering from
  depression, emotional disturbance, or anxiety
  states
• All patients should be given the benefit of the
  doubt until the clinician, with a high degree of
  confidence, can rule out an organic cause for the
  pain

15
Spondylogenic Pain

• Spondylogenic pain is pain referred from a
  vertebral lesion
• Characteristics of a spondylogenic lesion
  include
• Severe and unrelenting pain
• The presence of a fever
• Bone tenderness
• Unexplained weight loss

16
Generalized Body Pain

• Two conditions that can cause generalized body
  pain
• Fibromyalgia
• Myofascial pain syndrome (MPS)

17
Fibromyalgia

• Poorly understood complex of generalized body
  aches that can cause pain or paresthesias, or
  both, in a non-radicular pattern
• Not a disease, but rather a syndrome with a
  common set of characteristic symptoms, including
  widespread pain and the presence of a defined
  number of tender points

18
Fibromyalgia

• A positive tender point count of 11 or more of 18
  standardized sites, when present in combination
  with the history of widespread pain, yields a
  sensitivity of 88.4 and a specificity of 81.1
  in the diagnosis of fibromyalgia

19
Myofascial Pain Syndrome

• Characterized by the presence of myofascial
  trigger points (MTrPs)
• A MTrP is a hyperirritable location,
  approximately 2 to 5 cm in diameter, 86within a
  taut band of muscle fibers, that is painful when
  compressed and that can give rise to
  characteristic referred pain, tenderness, and
  tightness

20
Causes of Head and Facial Pain

• Trauma
• Headaches
• Migraine
• Two types of migraine headaches migraine without
  aura (common migraine), and migraine with aura
• Migraine without aura Symptoms are typically
  unilateral with a pulsating quality of moderate
  or severe intensity. Aggravated by routine
  physical activity, and is associated with nausea,
  auras, photophobia, and phonophobia
• Migraine with aura Characterized by reversible
  aura symptoms, which typically develop gradually
  over more than 4 minutes, but last no longer than
  60 minutes

21
Causes of Head and Facial Pain

• Headaches
• Cluster
• Severe unilateral retro-orbital headaches
• Often accompanied by nasal congestion, eye-lid
  edema, rhinorrhea, miosis, lacrimation, and
  ptosis (drooping eyelid) on the symptomatic side
• Patients feel better during a headache by
  remaining in an erect posture and moving about
• Tension-type
• Those associated with a disorder of the
  pericranial muscles, and those not associated
  with this type of disorder
• Characterized by a bilateral non-throbbing ache
  in the frontal or temporal areas, and spasm, or
  hypertonus of the neck muscles

22
Causes of Head and Facial Pain

• Headaches
• Benign exertional
• Headache is specifically brought on by physical
  exercise, particularly with straining and
  valsalva type maneuvers such as those seen in
  weightlifting
• Bilateral, throbbing in nature at onset and may
  develop migrainous features in those patients
  susceptible to migraine
• Effort induced
• Differ from the exertional headaches in that they
  are not necessarily associated with a power or
  straining type of exercise
• Occur more frequently in hot weather

23
Causes of Head and Facial Pain

• Headaches
• Occipital
• Likely referred from a cervical disorder
• The underlying musculoskeletal mechanism for this
  type of headache is often structural, including
  cervical hypomobility or hypermobility, joint
  subluxation, degenerative bony changes, or poor
  posture
• Hypertensive
• Occurs in individuals with diastolic readings
  above 120 mm Hg, although the intensity of these
  headaches does not necessarily parallel the
  height of the blood pressure levels

24
Causes of Head and Facial Pain

• Headaches
• External compression headache
• This entity, formerly known as swim-goggle
  headache, presents with pain in the facial and
  temporal areas produced from wearing excessively
  tight face masks or swimming goggles
• Idiopathic carotidynia
• Unilateral facial or orbital pain in half of the
  patients with this condition
• Most commonly located in the frontotemporal area,
  but it occasionally involves the entire
  hemicranium or the occipital area
• Chronic daily
• Follows trauma to the head or neck

25
Causes of Head and Facial Pain

• Headaches
• Post-traumatic
• More prolonged and enduring headache than chronic
  daily
• May be associated with subdural hematoma, an
  epidural hematoma, an intracerebral hematoma, an
  aneurysm, a subarachnoid hemorrhage or a cerebral
  contusion

26
Causes of Head and Facial Pain

• Occipital neuralgia
• A rare neuralgic disorder involving the greater
  occipital nerve
• Glossopharyngeal neuralgia
• Characterized by intense unilateral attacks of
  pain in the retrolingual area radiating to the
  depth of the ear
• The pain is typically aggravated by movement or
  contact with the pharynx, especially with
  swallowing

27
Causes of Head and Facial Pain

• Trigeminal neuralgia
• Chronic pain syndrome characterized by dramatic,
  brief stabbing or electric shock-like pain
  paroxysms felt in one or more divisions of the
  trigeminal distribution, either spontaneously or
  on gentle tactile stimulation of a trigger point
  on the face or in the oral cavity
• Bells palsy
• A lower motor neuron disease of the facial nerve
  characterized by a wide range of facial muscle
  movement dysfunction from mild paresis to total
  paralysis

28
Causes of Head and Facial Pain

• Ramsay Hunt syndrome
• A herpetic inflammation of the geniculate and/or
  facial nerve ganglia, manifests as a peripheral
  facial nerve palsy accompanied by an erythematous
  vesicular rash on the ear (zoster oticus) or in
  the mouth
• Arteriovenous malformation
• Congenital malformation

29
Causes of Head and Facial Pain

• Meningitis
• An infection of the meninges and subarachnoid
  space
• Classic triad of fever, neck stiffness, and an
  altered mental status
• Cerebrovascular disease
• Dependent on the size and location of the
  hemorrhage
• Intracranial bleed
• Dependent on the rate of arterial or venous
  bleeding

30
Causes of Head and Facial Pain

• Tumor
• Tumors, benign or otherwise are space-occupying
  lesions that may increase to a size that
  compresses nearby structures or increases
  intracranial pressure
• Encephalitis
• An inflammation of the brain

31
Causes of Head and Facial Pain

• Systemic infections
• Rocky Mountain Spotted Fever
• Lyme disease
• Pneumonia
• Pyelonephritis
• Multiple sclerosis
• Optic neuritis

32
Causes of Head and Facial Pain

• Miscellaneous
• Temporal arteritis
• Acute sinusitis
• Eclampsia
• Cerebrospinal fluid (CSF) hypotension
• Temporomandibular joint dysfunction
• Peridontal disease
• Thyroiditis
• Fracture of the facial bones or skull
• Trochleitis

33
Causes of Cervical Pain

• Thyroid disease
• Widespread manifestations including cervical pain
  
• Subarachnoid hemorrhage
• Retropharyngeal abscess
• Infection of the space anterior to the
  prevertebral layer of the deep cervical fascia
• Carotodynia

34
Causes of Cervical Pain

• Cardiac disease
• Trauma
• Tumor
• Tumors of the adult cervical spine may be
  primary, arising from the bone, or secondary
• Temporomandibular Joint Dysfunction
• Meningitis

35
Causes of Cervical Pain

• Cervical disk disease
• Vertebral artery disorder
• Torticollis
• Rheumatoid arthritis
• Cervical spine involvement is common in
  rheumatoid arthritis
• Ankylosing spondylitis
• Ankylosing spondylitis commonly affects the C 1-2
  segment

36
Causes of Cervical Pain

• Gout
• Although the occurrence of gout in the neck is
  distinctly uncommon, the medications used to
  treat it can have serious side-effects in this
  region
• Osteoarthritis
• Occipital neuralgia

37
Causes of Thoracic Pain

• Gastrointestinal conditions
• Pancreatic carcinoma
• Mediastinal tumors
• Although primary tumors of the thoracic spine are
  rare, the thoracic spine is the most common site
  for metastases
• Myocardial infarction
• Pleuropulmonary conditions
• Thoracic disk
• Vertebral or rib fracture
• Intercostal neuralgia

38
Causes of Thoracic Pain

• Epidemic myalgia
• Costochondritis
• Osteoarthritis
• Rheumatoid arthritis
• Ankylosing spondylitis
• Diffuse Idiopathic Skeletal Hyperostosis (DISH)
• Characterized by an ossification of the anterior
  longitudinal ligaments and all related,
  anatomically similar ligaments
• Manubrium-sternal dislocations

39
Causes of Lumbar Pain

• Strain or sprain
• Renal disorder
• Epidural abscess
• Prostatitis
• Pleural dysfunction
• Aortic aneurysm
• Metastasis
• Ankylosing spondylitis
• Stiff-person syndrome

40
Causes of Buttock and Upper and Lower Leg Pain

• Lumbar disc herniation
• Femoral nerve neuropathy
• Piriformis syndrome
• Sacral plexopathy
• Intermittent claudication
• Conus medullaris syndrome
• Severe low back and buttock pain, lower limb
  weakness, saddle hypesthesia or anesthesia.
  Bowel and bladder changes are also frequently
  reported
• Meralgia paresthetica

41
Causes of Buttock and Upper and Lower Leg Pain

• Iliofemoral thrombophlebitis
• Mononeuritis multiplex
• May occur in association with a number of other
  medical conditions including rheumatoid arthritis
  (RA), vasculitis, polyarteritis nodosa, diabetes
  mellitus, sarcoidosis, and amyloidosis
• Ischial apophysitis and avulsion
• Gluteal compartment syndrome
• Genital herpes
• Vascular Disorders

42
Causes of Pelvic Pain

• Sacroiliac arthritis
• Acute appendicitis
• Iliopsoas abscess
• Iliopsoas hematoma
• Sign of the buttock
• Gynecologic disorders
• Prostate cancer

43
Causes of Trochanteric, Pubic, and Thigh pain

• Dislocation and fracture dislocation of the
  hip
• Labral tear
• Hip or pelvis fracture
• Pubic fracture
• Femoral neck stress fracture
• Osteoarthritis of the hip
• Septic arthritis of the hip
• Osteoid osteoma
• Reiters syndrome

44
Causes of Trochanteric, Pubic, and Thigh pain

• Synovitis of the hip in children or adolescents
• Avascular necrosis of the femoral head
• Iliopsoas abscess
• Iliofemoral venous thrombosis
• Obturator, femoral or inguinal hernia
• Osteomyelitis of the pubis

45
Causes of Trochanteric, Pubic, and Thigh pain

• Compartment syndrome
• Myoneural anoxia results from a prolonged
  increase in tissue pressure within a closed
  osseofascial space. This compromises local blood
  flow of skeletal muscle, resulting in ischemia
  and necrosis
• Sexually transmitted disease

46
Causes of shoulder pain

• Tendinous and capsular lesions
• Traumatic synovitis
• Subluxation/dislocation
• Spondyloarthropy
• Acute arthritis
• Infections/tumors
• Clay shovelers fracture
• A traction fracture of the lower cervical or
  upper thoracic spine due to an excessive pull of
  the trapezius, rhomboid muscles during heavy work

47
Causes of shoulder pain

• Degenerative conditions
• Vascular conditions
• Metabolic conditions
• Osseous lesions
• Muscular lesions
• Cerebrovascular disease
• Multiple sclerosis
• Amyotrophic lateral sclerosis
• Guillian-Barre

48
Causes of shoulder pain

• Syringomyelia
• Cervical radicular pain
• Elbow dysfunction
• Myofascial pain syndrome
• Peripheral nerve entrapment

49
Causes of shoulder pain

• Brachial plexopathy
• Herpes Zoster
• Gallbladder dysfunction
• Cardiac dysfunction
• Pulmonary dysfunction
• Visceral
• Diaphragm
• Spleen

50
Causes of elbow and forearm pain

• Fracture
• Dislocation
• Osteochondritis
• Ligament sprain
• Arthrosis
• Peripheral nerve entrapment

51
Causes of elbow and forearm pain

• Soft tissue injury or tendinitis (lateral
  epicondylitis, medial epicondylitis, triceps
  tendinitis, bicipital tendinitis, brachialis
  tendinitis and Little League elbow)
• Infective arthritis
• Polyarthritis
• Gout
• Bursitis
• Vascular disorder
• Referred pain from shoulder/neck

52
Causes of wrist, hand and finger pain

• Fracture
• Sprains and dislocations
• Triangular fibrocartilage complex (TFCC) lesions
• Tenosynovitis
• Tendinitis
• Carpal instability
• Gout

53
Causes of wrist, hand and finger pain

• Rheumatoid arthritis
• Psoriatic Arthritis
• Osteoarthritis
• Carpal tunnel syndrome
• Infection
• Kienböcks disease
• Ganglia

54
Causes of wrist, hand and finger pain

• Tumor
• Peripheral nerve entrapment
• Complex regional pain syndrome
• Vascular occlusion
• Scleroderma
• Mononeuritis multiplex
• Viscerogenic

55
Causes of generalized Knee Pain

• Fracture (supracondylar, patellar, proximal
  tibia)
• Acute dislocation of the knee
• Acute dislocation of the patella
• Intra-articular ligament injury
• Mono- and polyarthritis
• Complex Regional Pain Syndrome
• Referred pain from the hip or lumbar spine

56
Causes of anterior knee pain

• Musculoskeletal causes
• Osgood Schlatters disease
• Jumpers knee
• Bipartite patella
• Trauma-related causes
• Osteochondritis dissicans
• Bone contusion

57
Causes of anterior knee pain

• Miscellaneous causes
• Tumor
• Plical irritation
• Hoffas syndrome
• Osteomyelitis of the patella
• Bursitis
• Excessive lateral pressure syndrome
• Maltracking of the patella
• Iatrogenic causes
• Infrapatellar contracture syndrome

58
Causes of medial knee Pain

• Medial meniscus tear
• Medial collateral ligament sprain
• Medial collateral bursitis
• Hoffas disease
• Pes anserine bursitis
• Semimembranosus tendinitis

59
Causes of lateral knee pain

• Iliotibial band friction syndrome
• Popliteus tenosynovitis
• Popliteus tendon rupture
• Lateral meniscal tear
• Lateral collateral ligament sprain
• Tibiofibular disorder
• Biceps femoris tendinitis
• Osteochondral fracture of the lateral femoral
  condyle

60
Causes of posterior knee pain

• Gastrocnemius muscle strain or rupture
• Plantaris muscle strain or rupture
• Hamstring muscle and tendon disorder
• Rupture of a popliteal artery aneurysm
• PCL/posterior capsule tear
• Bakers cyst

61
Causes of lower leg pain

• Anterolateral lower leg pain
• Anterior compartment syndrome
• The clinical signs of compartment syndrome are
  often remembered by using the mnemonic of the 5
  Ps pain, paresthesia, paresis, pallor, and
  pulses
• Lateral compartment syndrome
• Often misdiagnosed as tenosynovitis of the
  tibialis anterior and flexor hallucis longus,
  fibular stress fracture, or a lateral
  gastrocnemius strain
• Irritation of the superficial peroneal nerve
• Muscle strain

62
Causes of lower leg pain

• Calf pain
• Pyomyositis
• Spontaneous muscle abscess of skeletal muscle
• Fibula shaft fracture
• Deep vein thrombosis
• Hematoma
• Rupture of Achilles tendon
• Soleus muscle strain
• Acute posterior compartment syndrome
• Causes include a deep vein thrombosis, rupture of
  a Bakers cyst, and a spontaneous rupture of the
  medial head of the gastrocnemius

63
Causes of lower leg pain

• Anteromedial lower leg pain
• Stress fracture of the tibia
• Medial tibial stress syndrome
• Saphenous neuritis
• Osteomyelitis of the tibia

64
Causes of generalized ankle pain

• Crystal-induced arthropathies
• Gout and pseudogout
• Ligament sprain
• Tendinitis
• Fracture
• Bursitis
• Os trigonum
• Failure of the lateral tubercle, of the posterior
  process, to unite with the body of the talus
  during ossification, producing an impingement
  with extreme plantar flexion

65
Causes of generalized ankle pain

• Osteochondritis dissecans (OCD)
• Actually a "transchondral fracture" secondary to
  trauma
• Onset of pain is usually insidious, but there may
  be some prior macrotrauma

66
Causes of generalized foot pain

• Infection
• Necrotizing fasciitis
• Osteomyelitis
• Rheumatoid Arthritis
• Gout and pseudogout
• Systemic lupus erythematosus (SLE)
• Sickle cell disease
• Complex regional pain syndrome
• Peripheral vascular disease
• Peripheral polyneuropathy

67
Causes of generalized foot pain

• Systemic causes
• Carcinoma
• Leukemia
• Lymphoma
• Myeloma
• Amyloidosis
• Connective tissue diseases (polyarteritis nodosa,
  SLE)
• Renal failure
• AIDS
• Sarcoidosis
• Cutaneous disorders

68
Causes of forefoot pain

• Metatarsalgia
• Freibergs disease
• Mortons neuroma
• Arthritis
• Fracture
• Forefoot sprain
• Bursitis

69
Causes of plantar hindfoot pain

• Fat pad disorders
• Calcaneus stress fracture
• Plantar fasciitis
• Entrapment neuropathy of first branch of lateral
  plantar nerve
• Flexor tendinitis

70
Causes of posterior hindfoot pain

• Superficial Achilles bursitis
• Retrocalcaneal bursitis
• Haglunds syndrome
• Achilles tendinitis/Achilles tendon rupture
• Calcaneal osteomyelitis

71
Causes of medial hindfoot pain

• Tibialis posterior tendinitis
• Flexor hallucis longus tendinitis
• Tarsal tunnel syndrome
• Calcaneal fracture
• Medial ankle sprain

72
Causes of lateral hindfoot pain

• Peroneal muscle strain/tendinitis
• Lateral ankle sprain
• Osteochondral fracture of talar dome
• Sural nerve entrapment
• Stress fracture of lateral malleolus

73
Causes of medial forefoot and great toe pain

• Nail lesions
• Hallux valgus
• Hallux rigidus
• Arthritis of 1st MTP

74
Causes of midfoot pain

• Longitudinal arch strain
• Aseptic necrosis of the navicular
• Tendinitis of flexor hallucis longus or peroneal
  tendinitis
• Subtalar osteochondral fracture
• Accessory navicular
• Köhlers Bone disease

75
Causes of midfoot pain

• Stress fracture of navicular
• Acquired flatfoot
• Osteoarthritis
• Plantar fascial pain
• Cuboid subluxation syndrome

76
Causes of dorsal foot pain

• Tendinitis of
• Extensor hallucis longus
• Extensor digitorum longus
• Tibialis anterior