Chapter 9 Differential Diagnosis. Overview Differential diagnosis involves the ability to quickly differentiate those problems of a serious nature from

Chapter 9Chapter 9

Differential 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 following classification for referred pain:referred 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 It is not always linked to visceral

injuryinjury3.3. 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


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


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


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 be spondylolisthesis or stenosis) can be made, or the scanning examination made, or the scanning examination is considered negative 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, from depression, emotional disturbance, or anxiety statesor anxiety 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 approximately 2 to 5 cm in diameter, [86]within a taut band of diameter, [86]within a taut band of muscle fibers, that is painful when muscle fibers, that is painful when compressed and that can give rise compressed and that can give rise to characteristic referred pain, to 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 rhinorrhea, miosis, lacrimation, and ptosis (drooping eyelid) on the symptomatic sideeyelid) on the symptomatic side

Patient’s feel better during a headache by remaining in Patient’s feel better during a headache by remaining in an erect posture and moving about an erect posture and moving about

– Tension-typeTension-type Those associated with a disorder of the pericranial Those associated with a disorder of the pericranial

muscles, and those not associated with this type of muscles, and those not associated with this type of disorderdisorder

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 frontal or temporal areas, and spasm, or hypertonus of the neck musclesthe neck muscles


– 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


– 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


– External compression headacheExternal compression headache This entity, formerly known as ‘swim-goggle This entity, formerly known as ‘swim-goggle

headache’, presents with pain in the facial and headache’, presents with pain in the facial and temporal areas produced from wearing excessively temporal areas produced from wearing excessively tight face masks or swimming gogglestight face masks or swimming goggles

– Idiopathic carotidyniaIdiopathic carotidynia Unilateral facial or orbital pain in half of the patients Unilateral facial or orbital pain in half of the patients

with this conditionwith this condition Most commonly located in the frontotemporal area, Most commonly located in the frontotemporal area,

but it occasionally involves the entire hemicranium or but it occasionally involves the entire hemicranium or the occipital area the occipital area

– Chronic dailyChronic daily Follows trauma to the head or neckFollows trauma to the head or neck


– 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


Cardiac diseaseCardiac disease TraumaTrauma TumorTumor

– Tumors of the adult cervical spine Tumors of the adult cervical spine may be primary, arising from the may be primary, arising from the bone, or secondarybone, or secondary

Temporomandibular Joint Temporomandibular Joint DysfunctionDysfunction

MeningitisMeningitis


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


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 rare, the thoracic spine is the most common site for metastases for 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 A traction fracture of the lower cervical or upper thoracic spine due to an excessive pull upper thoracic spine due to an excessive pull of the trapezius, rhomboid muscles during of the trapezius, rhomboid muscles during heavy workheavy 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


Rheumatoid arthritis Rheumatoid arthritis Psoriatic ArthritisPsoriatic Arthritis OsteoarthritisOsteoarthritis Carpal tunnel syndrome Carpal tunnel syndrome InfectionInfection Kienböck’s diseaseKienböck’s disease GangliaGanglia


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, Fracture (supracondylar, patellar,

proximal tibia)proximal 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 Referred pain from the hip or lumbar

spinespine

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 Baker’s cyst, and a spontaneous rupture of the medial head of the gastrocnemiusmedial head 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

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Chapter 9 Differential Diagnosis. Overview Differential diagnosis involves the ability to quickly differentiate those problems of a serious nature from