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Chapter 9. Differential Diagnosis. Overview. Differential diagnosis involves the ability to quickly differentiate those problems of a serious nature from those that are not - PowerPoint PPT Presentation
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Chapter 9Chapter 9Differential DiagnosisDifferential Diagnosis
OverviewOverview Differential diagnosis involves the Differential diagnosis involves the
ability to quickly differentiate those ability to quickly differentiate those problems of a serious nature from problems of a serious nature from those that are notthose that are not
Problems of a serious nature Problems of a serious nature include, but are not limited to include, but are not limited to visceral diseases, cancer, infections, visceral diseases, cancer, infections, fractures and vascular disorders fractures and vascular disorders
Referred PainReferred Pain The term The term referred painreferred pain is used to is used to
describe those symptoms that describe those symptoms that have their origin at a site other have their origin at a site other than where the patient feels the than where the patient feels the painpain
Referred painReferred pain Referred pain can be generated by:Referred pain can be generated by:
Convergence of sensory input from Convergence of sensory input from separate parts of the body to the same separate parts of the body to the same dorsal horn neuron via primary sensory dorsal horn neuron via primary sensory fibersfibers
Secondary pain resulting from a Secondary pain resulting from a myofascial trigger pointmyofascial trigger point
Sympathetic activity elicited by a spinal Sympathetic activity elicited by a spinal reflexreflex
Pain-generating substancesPain-generating substances
Referred PainReferred Pain Macnab recommends the Macnab recommends the
following classification for referred following classification for referred pain:pain:– ViscerogenicViscerogenic– VasculogenicVasculogenic– NeurogenicNeurogenic– PsychogenicPsychogenic– SpondylogenicSpondylogenic
Viscerogenic PainViscerogenic Pain Viscerogenic pain may be Viscerogenic pain may be
produced when the nociceptive produced when the nociceptive fibers from the viscera, synapse fibers from the viscera, synapse in the spinal cord, with some of in the spinal cord, with some of the same neurons that receive the same neurons that receive pain from the skin. pain from the skin.
Viscerogenic PainViscerogenic Pain Visceral pain has five important Visceral pain has five important
clinical characteristics:clinical characteristics:1.1. It is not evoked from all visceraIt is not evoked from all viscera 2.2. It is not always linked to visceral injuryIt is not always linked to visceral injury3.3. It is diffuse and poorly localizedIt is diffuse and poorly localized4.4. It is referred to other locationsIt is referred to other locations5.5. It is accompanied with autonomic It is accompanied with autonomic
reflexes, such as the nausea, and reflexes, such as the nausea, and vomitingvomiting
VasculogenicVasculogenic Pain Pain Vasculogenic pain tends to result Vasculogenic pain tends to result
from venous congestion or from venous congestion or arterial deprivation to the arterial deprivation to the musculoskeletal areasmusculoskeletal areas
Tends to mimic a wide variety of Tends to mimic a wide variety of musculoskeletal, neurologic, and musculoskeletal, neurologic, and arthritic disorders, as this type of arthritic disorders, as this type of pain is often worsened by activity pain is often worsened by activity
NeurogenicNeurogenic Pain Pain Neurogenic pain is pain that is referred Neurogenic pain is pain that is referred
from a neurological structure.from a neurological structure. Neurogenic causes of pain may include:Neurogenic causes of pain may include:
– A tumor compressing and irritating a neural A tumor compressing and irritating a neural structure of the spinal cord, meningesstructure of the spinal cord, meninges
– A spinal nerve root irritationA spinal nerve root irritation– Peripheral nerve entrapmentPeripheral nerve entrapment– NeuritisNeuritis
Scanning ExaminationScanning Examination The tests of the Cyriax upper or The tests of the Cyriax upper or
lower quarter scanning lower quarter scanning examination can be used to:examination can be used to:
Examine the patient’s neurological Examine the patient’s neurological statusstatus
Highlight the presence of a lesion to the Highlight the presence of a lesion to the central or peripheral nervous systemscentral or peripheral nervous systems
Help rule out any serious pathology Help rule out any serious pathology such as a fracture or tumorsuch as a fracture or tumor
Scanning ExaminationScanning Examination The upper quarter scanning The upper quarter scanning
examination is appropriate for examination is appropriate for upper thoracic, upper extremity, upper thoracic, upper extremity, and cervical problemsand cervical problems
The lower quarter scanning The lower quarter scanning examination is typically used for examination is typically used for thoracic, lower extremity, and thoracic, lower extremity, and lumbosacral problemslumbosacral problems
Scanning ExaminationScanning Examination The tests included in the scanning The tests included in the scanning
examination include strength examination include strength testing, sensation testing (light testing, sensation testing (light touch and pin-prick), deep tendon touch and pin-prick), deep tendon reflexes, and the pathological reflexes, and the pathological reflexesreflexes
Scanning ExaminationScanning Examination At the end of each of the scanning At the end of each of the scanning
examinations, either a medical examinations, either a medical diagnosis (disc protrusion, prolapse, diagnosis (disc protrusion, prolapse, or extrusion, acute arthritis, specific or extrusion, acute arthritis, specific tendonitis, or muscle belly tear, tendonitis, or muscle belly tear, spondylolisthesis or stenosis) can spondylolisthesis or stenosis) can be made, or the scanning be made, or the scanning examination is considered negative examination is considered negative
PsychogenicPsychogenic Pain Pain Psychogenic (non-organic) pain is Psychogenic (non-organic) pain is
characterized by characterized by abnormal illness abnormal illness behaviorsbehaviors
Commonly exhibited by patient’s suffering Commonly exhibited by patient’s suffering from depression, emotional disturbance, or from depression, emotional disturbance, or anxiety statesanxiety states
All patients should be given the benefit of All patients should be given the benefit of the doubt until the clinician, with a high the doubt until the clinician, with a high degree of confidence, can rule out an degree of confidence, can rule out an organic cause for the painorganic cause for the pain
SpondylogenicSpondylogenic Pain Pain Spondylogenic pain is pain Spondylogenic pain is pain
referred from a vertebral lesionreferred from a vertebral lesion Characteristics of a spondylogenic Characteristics of a spondylogenic
lesion include:lesion include:– Severe and unrelenting pain– The presence of a fever– Bone tenderness– Unexplained weight lossUnexplained weight loss
Generalized Body PainGeneralized Body Pain Two conditions that can cause Two conditions that can cause
generalized body pain:generalized body pain:– FibromyalgiaFibromyalgia– Myofascial pain syndromeMyofascial pain syndrome (MPS) (MPS)
FibromyalgiaFibromyalgia Poorly understood complex of Poorly understood complex of
generalized body aches that can cause generalized body aches that can cause pain or paresthesias, or both, in a non-pain or paresthesias, or both, in a non-radicular patternradicular pattern
Not a disease, but rather a syndrome Not a disease, but rather a syndrome with a common set of characteristic with a common set of characteristic symptoms, including widespread pain symptoms, including widespread pain and the presence of a defined number and the presence of a defined number of tender pointsof tender points
FibromyalgiaFibromyalgia A positive tender point count of A positive tender point count of
11 or more of 18 standardized 11 or more of 18 standardized sites, when present in sites, when present in combination with the history of combination with the history of widespread pain, yields a widespread pain, yields a sensitivity of 88.4% and a sensitivity of 88.4% and a specificity of 81.1% in the specificity of 81.1% in the diagnosis of fibromyalgiadiagnosis of fibromyalgia
Myofascial Pain Myofascial Pain SyndromeSyndrome Characterized by the presence of Characterized by the presence of
myofascial trigger points (MTrPs)myofascial trigger points (MTrPs)– A MTrP is a hyperirritable location, A MTrP is a hyperirritable location,
approximately 2 to 5 cm in diameter, approximately 2 to 5 cm in diameter, [86]within a taut band of muscle [86]within a taut band of muscle fibers, that is painful when fibers, that is painful when compressed and that can give rise to compressed and that can give rise to characteristic referred pain, characteristic referred pain, tenderness, and tightness tenderness, and tightness
Causes of Head and Causes of Head and Facial PainFacial Pain TraumaTrauma HeadachesHeadaches
– MigraineMigraine Two types of migraine headaches: migraine without Two types of migraine headaches: migraine without
aura (common migraine), and migraine with auraaura (common migraine), and migraine with aura– Migraine without aura: Symptoms are typically Migraine without aura: Symptoms are typically
unilateral with a pulsating quality of moderate or unilateral with a pulsating quality of moderate or severe intensity. Aggravated by routine physical severe intensity. Aggravated by routine physical activity, and is associated with nausea, auras, activity, and is associated with nausea, auras, photophobia, and phonophobia photophobia, and phonophobia
– Migraine with aura: Characterized by reversible aura Migraine with aura: Characterized by reversible aura symptoms, which typically develop gradually over symptoms, which typically develop gradually over more than 4 minutes, but last no longer than 60 more than 4 minutes, but last no longer than 60 minutes minutes
Causes of Head and Causes of Head and Facial PainFacial Pain HeadachesHeadaches
– ClusterCluster Severe unilateral retro‑orbital headachesSevere unilateral retro‑orbital headaches Often accompanied by nasal congestion, eye-lid edema, Often accompanied by nasal congestion, eye-lid edema,
rhinorrhea, miosis, lacrimation, and ptosis (drooping eyelid) rhinorrhea, miosis, lacrimation, and ptosis (drooping eyelid) on the symptomatic sideon the symptomatic side
Patient’s feel better during a headache by remaining in an Patient’s feel better during a headache by remaining in an erect posture and moving about erect posture and moving about
– Tension-typeTension-type Those associated with a disorder of the pericranial muscles, Those associated with a disorder of the pericranial muscles,
and those not associated with this type of disorderand those not associated with this type of disorder Characterized by a bilateral non-throbbing ache in the Characterized by a bilateral non-throbbing ache in the
frontal or temporal areas, and spasm, or hypertonus of the frontal or temporal areas, and spasm, or hypertonus of the neck musclesneck muscles
Causes of Head and Causes of Head and Facial PainFacial Pain HeadachesHeadaches
– Benign exertionalBenign exertional Headache is specifically brought on by physical Headache is specifically brought on by physical
exercise, particularly with straining and valsalva exercise, particularly with straining and valsalva type maneuvers such as those seen in weightliftingtype maneuvers such as those seen in weightlifting
Bilateral, throbbing in nature at onset and may Bilateral, throbbing in nature at onset and may develop migrainous features in those patients develop migrainous features in those patients susceptible to migrainesusceptible to migraine
– Effort inducedEffort induced Differ from the exertional headaches in that they Differ from the exertional headaches in that they
are not necessarily associated with a power or are not necessarily associated with a power or straining type of exercisestraining type of exercise
Occur more frequently in hot weatherOccur more frequently in hot weather
Causes of Head and Causes of Head and Facial PainFacial Pain HeadachesHeadaches
– OccipitalOccipital Likely referred from a cervical disorderLikely referred from a cervical disorder
– The underlying musculoskeletal mechanism for The underlying musculoskeletal mechanism for this type of headache is often structural, this type of headache is often structural, including cervical hypomobility or hypermobility, including cervical hypomobility or hypermobility, joint subluxation, degenerative bony changes, or joint subluxation, degenerative bony changes, or poor posturepoor posture
– HypertensiveHypertensive Occurs in individuals with diastolic readings Occurs in individuals with diastolic readings
above 120 mm Hg, although the intensity of above 120 mm Hg, although the intensity of these headaches does not necessarily parallel these headaches does not necessarily parallel the height of the blood pressure levelsthe height of the blood pressure levels
Causes of Head and Causes of Head and Facial PainFacial Pain HeadachesHeadaches
– External compression headacheExternal compression headache This entity, formerly known as ‘swim-goggle headache’, This entity, formerly known as ‘swim-goggle headache’,
presents with pain in the facial and temporal areas presents with pain in the facial and temporal areas produced from wearing excessively tight face masks or produced from wearing excessively tight face masks or swimming gogglesswimming goggles
– Idiopathic carotidyniaIdiopathic carotidynia Unilateral facial or orbital pain in half of the patients with Unilateral facial or orbital pain in half of the patients with
this conditionthis condition Most commonly located in the frontotemporal area, but Most commonly located in the frontotemporal area, but
it occasionally involves the entire hemicranium or the it occasionally involves the entire hemicranium or the occipital area occipital area
– Chronic dailyChronic daily Follows trauma to the head or neckFollows trauma to the head or neck
Causes of Head and Causes of Head and Facial PainFacial Pain HeadachesHeadaches
– Post-traumaticPost-traumatic More prolonged and enduring headacheMore prolonged and enduring headache
than chronic dailythan chronic daily May be associated with subdural May be associated with subdural
hematoma, an epidural hematoma, an hematoma, an epidural hematoma, an intracerebral hematoma, an aneurysm, intracerebral hematoma, an aneurysm, a subarachnoid hemorrhage or a a subarachnoid hemorrhage or a cerebral contusioncerebral contusion
Causes of Head and Causes of Head and Facial PainFacial Pain Occipital neuralgiaOccipital neuralgia
– A rare neuralgic disorder involving the A rare neuralgic disorder involving the greater occipital nervegreater occipital nerve
Glossopharyngeal neuralgiaGlossopharyngeal neuralgia– Characterized by intense unilateral attacks Characterized by intense unilateral attacks
of pain in the retrolingual area radiating to of pain in the retrolingual area radiating to the depth of the earthe depth of the ear
– The pain is typically aggravated by The pain is typically aggravated by movement or contact with the pharynx, movement or contact with the pharynx, especially with swallowingespecially with swallowing
Causes of Head and Causes of Head and Facial PainFacial Pain Trigeminal neuralgiaTrigeminal neuralgia
– Chronic pain syndrome characterized by Chronic pain syndrome characterized by dramatic, brief stabbing or electric shock-like dramatic, brief stabbing or electric shock-like pain paroxysms felt in one or more divisions of pain paroxysms felt in one or more divisions of the trigeminal distribution, either spontaneously the trigeminal distribution, either spontaneously or on gentle tactile stimulation of a trigger point or on gentle tactile stimulation of a trigger point on the face or in the oral cavityon the face or in the oral cavity
Bell’s palsyBell’s palsy– A lower motor neuron disease of the facial A lower motor neuron disease of the facial
nerve characterized by a wide range of facial nerve characterized by a wide range of facial muscle movement dysfunction from mild muscle movement dysfunction from mild paresis to total paralysis paresis to total paralysis
Causes of Head and Causes of Head and Facial PainFacial Pain Ramsay Hunt syndromeRamsay Hunt syndrome
– A herpetic inflammation of the A herpetic inflammation of the geniculate and/or facial nerve geniculate and/or facial nerve ganglia, manifests as a peripheral ganglia, manifests as a peripheral facial nerve palsy accompanied by an facial nerve palsy accompanied by an erythematous vesicular rash on the erythematous vesicular rash on the ear (zoster oticus) or in the mouthear (zoster oticus) or in the mouth
Arteriovenous malformationArteriovenous malformation– Congenital malformation Congenital malformation
Causes of Head and Causes of Head and Facial PainFacial Pain MeningitisMeningitis
– An An infection of the meninges and infection of the meninges and subarachnoid spacesubarachnoid space
– Classic triad of fever, neck stiffness, and an Classic triad of fever, neck stiffness, and an altered mental status altered mental status
Cerebrovascular diseaseCerebrovascular disease– Dependent on the size and location of the Dependent on the size and location of the
hemorrhagehemorrhage Intracranial bleedIntracranial bleed
– Dependent on the rate of arterial or venous Dependent on the rate of arterial or venous bleedingbleeding
Causes of Head and Causes of Head and Facial PainFacial Pain TumorTumor
– Tumors, benign or otherwise are Tumors, benign or otherwise are space-occupying lesions that may space-occupying lesions that may increase to a size that compresses increase to a size that compresses nearby structures or increases nearby structures or increases intracranial pressureintracranial pressure
EncephalitisEncephalitis– An inflammation of the brainAn inflammation of the brain
Causes of Head and Causes of Head and Facial PainFacial Pain Systemic infectionsSystemic infections
– Rocky Mountain Spotted FeverRocky Mountain Spotted Fever– Lyme diseaseLyme disease– PneumoniaPneumonia– PyelonephritisPyelonephritis
Multiple sclerosisMultiple sclerosis– Optic neuritisOptic neuritis
Causes of Head and Causes of Head and Facial PainFacial Pain MiscellaneousMiscellaneous
– Temporal arteritisTemporal arteritis– Acute sinusitisAcute sinusitis– EclampsiaEclampsia– Cerebrospinal fluid (CSF) hypotensionCerebrospinal fluid (CSF) hypotension– Temporomandibular joint dysfunctionTemporomandibular joint dysfunction– Peridontal diseasePeridontal disease– ThyroiditisThyroiditis– Fracture of the facial bones or skullFracture of the facial bones or skull– Trochleitis Trochleitis
Causes of Cervical PainCauses of Cervical Pain Thyroid diseaseThyroid disease
– Widespread manifestations including Widespread manifestations including cervical paincervical pain
Subarachnoid hemorrhageSubarachnoid hemorrhage Retropharyngeal abscessRetropharyngeal abscess
– Infection of the space anterior to the Infection of the space anterior to the prevertebral layer of the deep cervical prevertebral layer of the deep cervical fasciafascia
CarotodyniaCarotodynia
Causes of Cervical PainCauses of Cervical Pain Cardiac diseaseCardiac disease TraumaTrauma TumorTumor
– Tumors of the adult cervical spine may Tumors of the adult cervical spine may be primary, arising from the bone, or be primary, arising from the bone, or secondarysecondary
Temporomandibular Joint Temporomandibular Joint DysfunctionDysfunction
MeningitisMeningitis
Causes of Cervical PainCauses of Cervical Pain Cervical disk diseaseCervical disk disease Vertebral artery disorderVertebral artery disorder TorticollisTorticollis Rheumatoid arthritisRheumatoid arthritis
– Cervical spine involvement is common in Cervical spine involvement is common in rheumatoid arthritisrheumatoid arthritis
Ankylosing spondylitisAnkylosing spondylitis– Ankylosing spondylitis commonly affects Ankylosing spondylitis commonly affects
the C 1-2 segmentthe C 1-2 segment
Causes of Cervical PainCauses of Cervical Pain GoutGout
– Although the occurrence of gout in Although the occurrence of gout in the neck is distinctly uncommon, the the neck is distinctly uncommon, the medications used to treat it can medications used to treat it can have serious side-effects in this have serious side-effects in this regionregion
OsteoarthritisOsteoarthritis Occipital neuralgiaOccipital neuralgia
Causes of Thoracic Causes of Thoracic PainPain Gastrointestinal conditionsGastrointestinal conditions Pancreatic carcinomaPancreatic carcinoma Mediastinal tumorsMediastinal tumors
– Although primary tumors of the thoracic spine are Although primary tumors of the thoracic spine are rare, the thoracic spine is the most common site for rare, the thoracic spine is the most common site for metastases metastases
Myocardial infarctionMyocardial infarction Pleuropulmonary conditionsPleuropulmonary conditions Thoracic diskThoracic disk Vertebral or rib fractureVertebral or rib fracture Intercostal neuralgiaIntercostal neuralgia
Causes of Thoracic Causes of Thoracic PainPain Epidemic myalgiaEpidemic myalgia CostochondritisCostochondritis OsteoarthritisOsteoarthritis Rheumatoid arthritisRheumatoid arthritis Ankylosing spondylitisAnkylosing spondylitis Diffuse Idiopathic Skeletal Hyperostosis Diffuse Idiopathic Skeletal Hyperostosis
(DISH)(DISH)– Characterized by an ossification of the anterior Characterized by an ossification of the anterior
longitudinal ligaments and all related, longitudinal ligaments and all related, anatomically similar ligamentsanatomically similar ligaments
Manubrium-sternal dislocationsManubrium-sternal dislocations
Causes of Lumbar PainCauses of Lumbar Pain Strain or sprainStrain or sprain Renal disorderRenal disorder Epidural abscessEpidural abscess ProstatitisProstatitis Pleural dysfunctionPleural dysfunction Aortic aneurysmAortic aneurysm MetastasisMetastasis Ankylosing spondylitisAnkylosing spondylitis Stiff-person syndromeStiff-person syndrome
Causes of Buttock and Causes of Buttock and Upper and Lower Leg Upper and Lower Leg PainPain Lumbar disc herniationLumbar disc herniation Femoral nerve neuropathyFemoral nerve neuropathy Piriformis syndromePiriformis syndrome Sacral plexopathySacral plexopathy Intermittent claudicationIntermittent claudication Conus medullaris syndromeConus medullaris syndrome
– Severe low back and buttock pain, lower limb Severe low back and buttock pain, lower limb weakness, saddle hypesthesia or anesthesia. weakness, saddle hypesthesia or anesthesia. Bowel and bladder changes are also frequently Bowel and bladder changes are also frequently reportedreported
Meralgia parestheticaMeralgia paresthetica
Causes of Buttock and Causes of Buttock and Upper and Lower Leg Upper and Lower Leg PainPain Iliofemoral thrombophlebitisIliofemoral thrombophlebitis Mononeuritis multiplexMononeuritis multiplex
– May occur in association with a number of May occur in association with a number of other medical conditions including rheumatoid other medical conditions including rheumatoid arthritis (RA), vasculitis, polyarteritis nodosa, arthritis (RA), vasculitis, polyarteritis nodosa, diabetes mellitus, sarcoidosis, and amyloidosisdiabetes mellitus, sarcoidosis, and amyloidosis
Ischial apophysitis and avulsionIschial apophysitis and avulsion Gluteal compartment syndromeGluteal compartment syndrome Genital herpesGenital herpes Vascular DisordersVascular Disorders
Causes of Pelvic PainCauses of Pelvic Pain Sacroiliac arthritisSacroiliac arthritis Acute appendicitisAcute appendicitis Iliopsoas abscessIliopsoas abscess Iliopsoas hematomaIliopsoas hematoma Sign of the buttockSign of the buttock Gynecologic disordersGynecologic disorders Prostate cancerProstate cancer
Causes of Causes of Trochanteric, Pubic, Trochanteric, Pubic, and Thigh painand 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 Reiter’s syndrome
Causes of Causes of Trochanteric, Pubic, Trochanteric, Pubic, and Thigh painand 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
Causes of Causes of Trochanteric, Pubic, Trochanteric, Pubic, and Thigh painand 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
Causes of shoulder Causes of shoulder painpain
Tendinous and capsular lesions Traumatic synovitis Subluxation/dislocation Spondyloarthropy Acute arthritis Infections/tumors Clay shoveler’s fracture
A traction fracture of the lower cervical or upper A traction fracture of the lower cervical or upper thoracic spine due to an excessive pull of the thoracic spine due to an excessive pull of the trapezius, rhomboid muscles during heavy worktrapezius, rhomboid muscles during heavy work
Causes of shoulder Causes of shoulder painpain
Degenerative conditions Vascular conditions Metabolic conditions Osseous lesions Muscular lesions Cerebrovascular disease Multiple sclerosis Amyotrophic lateral sclerosis Guillian-Barre
Causes of shoulder Causes of shoulder painpain Syringomyelia Cervical radicular pain Elbow dysfunction Myofascial pain syndrome Peripheral nerve entrapment
Causes of shoulder Causes of shoulder painpain Brachial plexopathy Herpes Zoster Gallbladder dysfunction Cardiac dysfunction Pulmonary dysfunction Visceral
Diaphragm Spleen
Causes of elbow and Causes of elbow and forearm painforearm pain Fracture Dislocation Osteochondritis Ligament sprain Arthrosis Peripheral nerve entrapment
Causes of elbow and Causes of elbow and forearm painforearm 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 from shoulder/neck
Causes of wrist, hand Causes of wrist, hand and finger painand finger pain FractureFracture Sprains and dislocationsSprains and dislocations Triangular fibrocartilage complex (TFCC) Triangular fibrocartilage complex (TFCC)
lesionslesions TenosynovitisTenosynovitis TendinitisTendinitis Carpal instability Carpal instability Gout Gout
Causes of wrist, hand Causes of wrist, hand and finger painand finger pain Rheumatoid arthritis Rheumatoid arthritis Psoriatic ArthritisPsoriatic Arthritis OsteoarthritisOsteoarthritis Carpal tunnel syndrome Carpal tunnel syndrome InfectionInfection Kienböck’s diseaseKienböck’s disease GangliaGanglia
Causes of wrist, hand Causes of wrist, hand and finger painand finger pain TumorTumor Peripheral nerve entrapmentPeripheral nerve entrapment Complex regional pain syndromeComplex regional pain syndrome Vascular occlusion Vascular occlusion SclerodermaScleroderma Mononeuritis multiplexMononeuritis multiplex ViscerogenicViscerogenic
Causes of generalized Causes of generalized Knee PainKnee Pain Fracture (supracondylar, patellar, proximal Fracture (supracondylar, patellar, proximal
tibia)tibia) Acute dislocation of the kneeAcute dislocation of the knee Acute dislocation of the patellaAcute dislocation of the patella Intra-articular ligament injuryIntra-articular ligament injury Mono- and polyarthritis Mono- and polyarthritis Complex Regional Pain SyndromeComplex Regional Pain Syndrome Referred pain from the hip or lumbar spineReferred pain from the hip or lumbar spine
Causes of anterior Causes of anterior knee painknee pain Musculoskeletal causesMusculoskeletal causes
– Osgood Schlatter’s diseaseOsgood Schlatter’s disease– Jumper’s kneeJumper’s knee– Bipartite patellaBipartite patella
Trauma-relatedTrauma-related causes causes– Osteochondritis dissicansOsteochondritis dissicans– Bone contusionBone contusion
Causes of anterior Causes of anterior knee painknee pain MiscellaneousMiscellaneous causes causes
– TumorTumor– Plical irritationPlical irritation– Hoffa’s syndromeHoffa’s syndrome– Osteomyelitis of the patellaOsteomyelitis of the patella– Bursitis Bursitis – Excessive lateral pressure syndromeExcessive lateral pressure syndrome – Maltracking of the patellaMaltracking of the patella
IatrogenicIatrogenic causes causes– Infrapatellar contracture syndromeInfrapatellar contracture syndrome
Causes of Causes of medial knee medial knee PainPain Medial meniscus tearMedial meniscus tear Medial collateral ligament sprainMedial collateral ligament sprain Medial collateral bursitisMedial collateral bursitis Hoffa’s diseaseHoffa’s disease Pes anserine bursitisPes anserine bursitis Semimembranosus tendinitisSemimembranosus tendinitis
Causes of Causes of lateral knee lateral knee painpain Iliotibial band friction syndromeIliotibial band friction syndrome Popliteus tenosynovitisPopliteus tenosynovitis Popliteus tendon rupturePopliteus tendon rupture Lateral meniscal tearLateral meniscal tear Lateral collateral ligament sprainLateral collateral ligament sprain Tibiofibular disorderTibiofibular disorder Biceps femoris tendinitis Biceps femoris tendinitis Osteochondral fracture of the lateral Osteochondral fracture of the lateral
femoral condylefemoral condyle
Causes of posterior Causes of posterior knee pain knee pain Gastrocnemius muscle strain or ruptureGastrocnemius muscle strain or rupture Plantaris muscle strain or rupturePlantaris muscle strain or rupture Hamstring muscle and tendon disorderHamstring muscle and tendon disorder Rupture of a popliteal artery aneurysmRupture of a popliteal artery aneurysm PCL/posterior capsule tearPCL/posterior capsule tear Baker’s cystBaker’s cyst
Causes of lower leg Causes of lower leg painpain Anterolateral lower leg painAnterolateral lower leg pain
– Anterior compartment syndromeAnterior compartment syndrome The clinical signs of compartment syndrome are The clinical signs of compartment syndrome are
often remembered by using the mnemonic of the often remembered by using the mnemonic of the 5 Ps: 5 Ps: ppain, ain, pparesthesia, aresthesia, pparesis, aresis, ppallor, and allor, and ppulsesulses
– Lateral compartment syndromeLateral compartment syndrome Often misdiagnosed as tenosynovitis of the tibialis Often misdiagnosed as tenosynovitis of the tibialis
anterior and flexor hallucis longus, fibular stress anterior and flexor hallucis longus, fibular stress fracture, or a lateral gastrocnemius strainfracture, or a lateral gastrocnemius strain
– Irritation of the superficial peroneal nerveIrritation of the superficial peroneal nerve – Muscle strainMuscle strain
Causes of lower leg Causes of lower leg painpain Calf painCalf pain
– PyomyositisPyomyositis Spontaneous muscle abscess of skeletal muscleSpontaneous muscle abscess of skeletal muscle
– Fibula shaft fractureFibula shaft fracture– Deep vein thrombosisDeep vein thrombosis– HematomaHematoma– Rupture of Achilles tendonRupture of Achilles tendon– Soleus muscle strainSoleus muscle strain – Acute posterior compartment syndromeAcute posterior compartment syndrome
Causes include a deep vein thrombosis, rupture of a Causes include a deep vein thrombosis, rupture of a Baker’s cyst, and a spontaneous rupture of the medial Baker’s cyst, and a spontaneous rupture of the medial head of the gastrocnemiushead of the gastrocnemius
Causes of lower leg Causes of lower leg painpain Anteromedial lower leg painAnteromedial lower leg pain
– Stress fracture of the tibiaStress fracture of the tibia – Medial tibial stress syndromeMedial tibial stress syndrome– Saphenous neuritisSaphenous neuritis– Osteomyelitis of the tibiaOsteomyelitis of the tibia
Causes of generalized Causes of generalized ankle pain ankle pain Crystal-induced arthropathiesCrystal-induced arthropathies
– Gout and pseudogout Gout and pseudogout Ligament sprainLigament sprain TendinitisTendinitis FractureFracture BursitisBursitis Os trigonumOs trigonum
– Failure of the lateral tubercle, of the posterior Failure of the lateral tubercle, of the posterior process, to unite with the body of the talus process, to unite with the body of the talus during ossification, producing an impingement during ossification, producing an impingement with extreme plantar flexionwith extreme plantar flexion
Causes of generalized Causes of generalized ankle painankle pain Osteochondritis dissecans (OCD)Osteochondritis dissecans (OCD)
– Actually a "transchondral fracture" Actually a "transchondral fracture" secondary to traumasecondary to trauma
– Onset of pain is usually insidious, Onset of pain is usually insidious, but there may be some prior but there may be some prior macrotraumamacrotrauma
Causes of generalized Causes of generalized foot painfoot pain InfectionInfection Necrotizing fasciitisNecrotizing fasciitis OsteomyelitisOsteomyelitis Rheumatoid ArthritisRheumatoid Arthritis Gout and pseudogoutGout and pseudogout Systemic lupus erythematosus (SLE)Systemic lupus erythematosus (SLE) Sickle cell diseaseSickle cell disease Complex regional pain syndrome Complex regional pain syndrome Peripheral vascular diseasePeripheral vascular disease Peripheral polyneuropathyPeripheral polyneuropathy
Causes of generalized Causes of generalized foot painfoot pain Systemic causes:Systemic causes:
– Carcinoma– Leukemia– Lymphoma– Myeloma– Amyloidosis– Connective tissue diseases (polyarteritis nodosa,
SLE)– Renal failure– AIDS– Sarcoidosis– Cutaneous disorders
Causes of forefoot Causes of forefoot pain pain MetatarsalgiaMetatarsalgia Freiberg’s diseaseFreiberg’s disease Morton’s neuromaMorton’s neuroma ArthritisArthritis FractureFracture Forefoot sprainForefoot sprain BursitisBursitis
Causes of plantar Causes of plantar hindfoot painhindfoot pain Fat pad disordersFat pad disorders Calcaneus stress fractureCalcaneus stress fracture Plantar fasciitisPlantar fasciitis Entrapment neuropathy of first Entrapment neuropathy of first
branch of lateral plantar nervebranch of lateral plantar nerve Flexor tendinitisFlexor tendinitis
Causes of posterior Causes of posterior hindfoot painhindfoot pain Superficial Achilles bursitisSuperficial Achilles bursitis Retrocalcaneal bursitisRetrocalcaneal bursitis Haglund’s syndromeHaglund’s syndrome Achilles tendinitis/Achilles tendon Achilles tendinitis/Achilles tendon
rupturerupture Calcaneal osteomyelitisCalcaneal osteomyelitis
Causes of medial Causes of medial hindfoot painhindfoot pain Tibialis posterior tendinitisTibialis posterior tendinitis Flexor hallucis longus tendinitisFlexor hallucis longus tendinitis Tarsal tunnel syndromeTarsal tunnel syndrome Calcaneal fractureCalcaneal fracture Medial ankle sprainMedial ankle sprain
Causes of lateral Causes of lateral hindfoot painhindfoot pain Peroneal muscle strain/tendinitisPeroneal muscle strain/tendinitis Lateral ankle sprainLateral ankle sprain Osteochondral fracture of talar Osteochondral fracture of talar
domedome Sural nerve entrapmentSural nerve entrapment Stress fracture of lateral Stress fracture of lateral
malleolusmalleolus
Causes of medial Causes of medial forefoot and great toe forefoot and great toe pain pain Nail lesionsNail lesions Hallux valgusHallux valgus Hallux rigidusHallux rigidus Arthritis of 1Arthritis of 1stst MTP MTP
Causes of midfoot pain Causes of midfoot pain Longitudinal arch strainLongitudinal arch strain Aseptic necrosis of the navicularAseptic necrosis of the navicular Tendinitis of flexor hallucis longus Tendinitis of flexor hallucis longus
or peroneal tendinitisor peroneal tendinitis Subtalar osteochondral fractureSubtalar osteochondral fracture Accessory navicularAccessory navicular Köhler’s Bone diseaseKöhler’s Bone disease
Causes of midfoot painCauses of midfoot pain Stress fracture of navicularStress fracture of navicular Acquired flatfootAcquired flatfoot OsteoarthritisOsteoarthritis Plantar fascial painPlantar fascial pain Cuboid subluxation syndromeCuboid subluxation syndrome
Causes of dorsal foot Causes of dorsal foot painpain Tendinitis of:Tendinitis of:
– Extensor hallucis longusExtensor hallucis longus– Extensor digitorum longusExtensor digitorum longus– Tibialis anteriorTibialis anterior