1 DDx Back Pain NMS

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

Cervical Spine
O/A: -Spondylosis altered alignment of facetsrisk of strain or
lock - may lead to hypermobility (esp initially), more often

Thoracic Spine
Rib # - exquisitely ful, AGG deep breathing, tuning fork,
percussion, A-P & latl rib compression. NOTE: may not show on xray immed after injury

Lumbar Spine
Spondylolysis narrowing of neuroforaminae
radiculopathy? AGG Exx and bending

Osteochondritis/Scheurmanns (35% of pop,

although only 5% atic); low TSp and T/L region, also affects LSp

Spondylolisthesis often aatic. More common LLSp (retro

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

hypomobility

-Cervical bar
MS

Lhermittes sign (flexn extn electric shock);

Kyphotic (/kypholordotic) posture stretching

& weakening of TES, may cause hypoxic ; stress on C/T and CSp lordosis facet irritation, wear and tear

- NRI osteophytosis (mechanical irritation)

Osteoporosis - #?

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

A/S bamboo spine, a.m. stiffness(>30 mins), improve

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

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

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

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

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

Osteoporotic Crush #

Spinal stenosis - see Neuro/Referred below Cervical Rib (rare) TOS? Often incomplete, may be fibrous
will not show on x-ray (need MRI)

- characteristic gibbus or acute angle, formed when vert body collapses (Dowagers hump); loss of height (2-4cm / #). Ac regional back (usually low thoracic/high lumbar) rad antr along costal margins. RISK FACTORS: postmenopausal (oestr & progest), low body fat, low Ca &/or Mg intake, high caffeine intake, bed rest, alcoholism, steroid use, (HIV) CD4 <200, liver disease 2 Ca } see p.2 Hemi-Vertebra Spina Bifida may be: dimple, patch of hair, pigmented area,
haemangioma, lordosis, mild LBP, SLRT +ive. Often aatic.

C2 # Klippel Feil Syndrome Dens #? Whiplash/rugby

Myeloma 2 Ca TB

} } see p.2

Joint
AGG compression/loa ding REL Txx

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

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

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

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

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

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

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

palpable capsule; often refers to appropriate derm/myo/sclerotome (sclera via ligs inflamm capsular inflamm)

Costochondral (ant ) : Tietzes 50% at 2nd rib;

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

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

prolonged postures, on extn, usually does not radiate.

Spondylosis C4-6 most common (apex); onset aging

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

Facet irritation less common than CSp or LSp, if

occurs will usually be assoc rib dysfunction.

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

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

Spondylarthrosis C2-4; C5-T1 (lower) spondylosis -

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

Scapulo-costal syndrome & tenderness medl

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

TMJ dysfunction click on opening = postr capsule; click on

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

Spondylosis stiffness, local uniform kyphosis/scoliosis.

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

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

as to whether should TTT affected jts at all

Ligament & Capsule

AGG EoR, Tx; ONSET delay of 30-60mins posttrauma; LIG: deep aching

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

micro# in lower facets, will NOT show on xray; from inflamm, lig damage, post r facet compression, muscle trauma

Transverse lig ( R/A? Contra to HVLAT) PLL pressure on lig sys may give LBP as well as neck

Muscle
AGG Stretching, A-R; ONSET: immediate

Postural fatigue: (muscle hypoxia, REL activity)

-suboccipitals (do not TTT O/A , short MM pull on periosteum
H/A)

Costovertebral/costotransverse ligament strain often ass rib lesion as above PLL - kyphosis, poor posture while sitting, r r Sup & inf sternopericardial ligs r r Ant & post diaphragm-pericardial ligs r r Sup & inf vertebra-pericardial ligs (C4 & T4) esp in WAD Sphenopericardial & thyropericardial ligs Postural fatigue: (MM hypoxia)
-Hypomobility shortening ch contracture of MM
relative hypoxia of tissues (poor blood supply) buildup of metabolites and inflammatory mediators (prostaglandins, Subs P, cytokines etc); move will relieve as pumps and flushes tissues DO NOT TALK ABOUT ISCHAEMIA UNLESS THERE IS E.G. TOTAL OCCLUSION OF BLOOD SUPPLY (NECROSIS WILL SWIFTLY FOLLOW) NOT A CH CONDITION!

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

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

Postural fatigue:
-LES hypertonia hip extensor hypertonia -Link exaggerated A-P curves Hypermobility be careful with use of this term, either assess (Beighton etc.) or use relative hypermobility (i.e. l to c-lat side, rest of spine etc) Psoas spasm (see below) (: Psoas abscess) QL overstrain pelvic function

-CES -accessory breathing MM

Scalene hypertonicity may TOS Torticollis seven forms of congenital; other causes include
hemivertebra, cervical pharyngitis (major cause in 5-10 yo), JRA, trauma. c-latl rotn & i-latl S/B; firm, nontender swelling appx size of adult thumbnail. s appear 6-8/52 of age

Exaggerated kyphosis TES Breathing issues:

- Intercostals - Diaphragm (esp around T/L) Myasthenia Gravis - see Systemic Causes

Myasthenia Gravis

- see Systemic Causes

Neurological /Referred

NOTE: triceps may be only neuro Sx in CSp dysfunc, pt may be unaware, so always test power + reflex NRI - Commonest: C5,6,7,8,(T1) NRC - 2 to spondylosis, cervical bar, OA/,disc herniation etc. Cervical bar spinal stenosis (below) Spinal stenosis unilatl or bilatl symptoms that usually span
several dermatomes; cervical flexn and extn; loss of hand dexterity (difficulty writing/doing up buttons), LOB and unsteady gait; LMNL Sx at level of stenosis and UMNL Sx below level of stenosis; xray reveals spondylitic bars & osteophytes, ossification of PLL & ligamentum flavum

T4 Syndrome Hypomobility at T4 (+/- a few

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

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

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

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

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

Intercostobrachial n -
axilla, postr/medl arm

up thorax, across scapula,

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

hypoxia femoral and/or obturator Nn

Dorsal sacral plexus quite often compressed. Possible

sciatic referral

Cauda Equina

- Triad of s: saddle anaesthesia, loss of sphincter control, urinary retention (parasymp damage sphincter cannot relax fills to capacityoverflow incontinence). DO NOT TREAT ANAL SENSORY TEST (ANAL WINKING). SURGICAL EMERGENCY

FUNCTIONAL

Kypholordotic posture PC-based work posture Osteochondrosis

Diaphragmatic dysfunction Costovertebral dysfunction

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

crest not level

Pelvic torsion/imbalance Lateral curve i.e. functional scoliosis A-P curves

2 DDx UEx
Bone

Shoulder
Clavicular # - nearly always occurs in middle third (80%), then
latl 1/3 (15%), then medl (5%), one of most commonly #ed bone in body (5% of total in casualty depts.). TTT coldpacking and support (sling). Rarely operated even in case of misunion.

Elbow
Olecranon # or hyperextension injury ass antr

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

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

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

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

Olecranon impingement forced extn ; often some

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

Scaphoid # - classic: fall onto outstretched hand.Local . Hamate # - 2% of carpal #s. Those involving hook are more
common (30% repetitive swinging by golfers/bats racquets stress #). Direct #s lso ass fall onto outstretched hand. PPW palmar AGG grasping, dorsoulnar deviation, flexn 4th & 5th digits .Exam: discrete point tenderness over hook, grip, also (2 to proximityof # to ulnar n) paraesthesiae 4 th & 5th digits. A-R DIP flexn in ulnar deviation ( in radial deviation)

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

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

Elevated Scapula

Lunate/capitate sublux/dislocation all carpal bones

dislocate dorsally except lunate (which may CTS)

Met-Phal dislocation met may button-hole in palmar

direction

Osteochondritis dessicans affects convex jt surface

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

Steners lesion valgus rupture of MCL of 1st met-phal

thumb flops out

Bone cyst Radial head dislocation - paediatric Pts more likely

Avascular necrosis of head of scaphoid (post-#)

- may be aatic for some time

Joint

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

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

O/A intra-articular loose body - 2 to trauma, heavy labour

O/A

Olecranon bursitis TTP locally, on extn or resting wt on

elbows (possibly PC work)

mainly DIPJs (swelling, ), Heberdens nodes (DIP), sometimes Bouchards nodes (PIP)

Bursitis (esp. subacromial)

Painful arc (subacromial impingement) 60-120 SLAP lesion/other labral tear SLAP = labral detachment
originating postr to LHB insertion and extending ant ly. Traumatic onset SLAP lesions often ass other intra-articular injuries if suspected, consider likelihood of co-existing pathology. PPW nonspecific shoulder overhead/cross-body activities, deep, vague in nature, often ass popping/clicking/catching, possible weakness and/or stiffness. Pt supine, flex UEx to 120 max ER, elbow flexed to 90. +ve = on A-R elbow flexn. Kim et al (2003) state sensitivity of 89.7% & specificity 96.9% in detecting SLAP lesions
r

Posterolat Rotatory instability TEST: RCL (spec

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

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

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

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

O/A (A/C - 90 abdn, then addt localised , G/H thought to be very rare, S/C)

Distal radioulnar jt subluxation Carpal instability commonly scapholunate

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

Ligament/Cap sule

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

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

Med /Lat Collateral ligament instability

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

Capsular instability - ass. rotator cuff dysfunction may

be PC

Ant capsule strain ass hyperextn injury; ful swelling in

antecubital fossa; vascular compromise or n. injury.

Radial collat ligament instability test latl gapping l Ulnar collat ligament instability test medl gapping Trigger finger digit 3 or 4, locks in flexn. Passive re-extn
possible (clicks). Trigger thumb may be flexn or extn

Muscle

Coracoclavicular ligament strain Haematoma - Traumatic onset Long head of biceps tendonitis/tear YERGASONS
TEST: Pts elbow flexed 90, passively ER. Pt. attempts to supinate & flex elbow. +ive = repro s.

Annular lig. Rupture

l

- gapping of radial head (latl); will prob be ass p-latl rotatory instability

Skiers thumb - damaged palmar lig RSI - stimulation of somatosensory cortex neuroplasticity
activity motor cortex MM tension in wrist & hand. TTT: stimulate lots of areas of hand (not just the few involved in repetitive activity) e.g. partner draws figures on hand, blind dominoes etc.

Lat epicondylitis often ECRB (small insertion); sometimes

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

Supraspinatus tendinitis critical zone hypoxic all day,

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

Med epicondylitis pronator teres, FCU, FCR. local ,

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

Rotator cuff tear/strain supraspinatus minor tear A-R

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

Ulnar/median/radial lesion Volkmanns ischaemic contracture - blood to

forearm flexors contracture Volkmanns Sx: fingers flex if extend wrist

Painful arc following Neer (1972) impingement of rotator cuff

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

Shortened biceps tendon[itis] Triceps tendonitis focal tenderness over triceps tendon,
AGG A-R elbow extn

Tenosynovitis inflamed sheaths, possible crepitus.

Extensor/Flexor strain ass. latl/medl epicondylitis. RSI see wrist Myositis ossificans - elbow injuries liklihood of
ossification of S/T.

De Quervains: AbdPL, EPB (snuffbox tendons) e.g. waiters holding plates thumb, mothers holding babies. Finkelsteins test: fist thumb, flex & ulnar deviate

Myasthenia gravis

Neuro/ Referred/ Systemic

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

as far as elbow

TrP referral e.g. deltoid, supra- & infraspin, biceps, pectorales R/A Jts synovium more susceptible e.g. UCSp, hip, shoulder.
Link CTS

NRI C5/6/7/8/T1 all possible (although unlikely) Shoulder referral refers to elbow (as hip knee) Pronator teres syndrome - antr interosseus n. ( median
n.) medn n s ve Tinels & Phalens implicates, resisted pronation, Tinels over proximal forearm. Often head of pronator is hypertrophied (palpably)

NRI C6 (latl, thumb)/C7 (middle)/C8 (medl) Carpal Tunnel Syndrome (Median n.) more likely if
double crush e.g. combined pronator teres syndrome. Phalens test: must hold for at least one min. TInels: have to hit quite briskly (patella hammer is best)

PMR

- quite common, 50+ yoa. f>m 3:1. Usually symmetrical, shoulder & pelvic girdles, axial MM, a.m. , malaise, night sweats/difficulty turning in bed, ESR. Linked GCA (temoral arteritis) ALWAYS ask about H/As any bilatl shoulder prob. TTT corticosteroids (most common reason for L/T use) risk factor for osteoporosis ask about menopause, nulliparity, Exx, FHx etc.

Radial Tunnel Syndrome postr interosseus n. night

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

Cubital tunnel syndrome ulnar n. entrap in fribro-osseus

arcade of Struthers; 2 heads of FCU & FDP. Tinels between olecranon & medl epicondyle

Tumour e.g. metastasis to bone (night and other

constitutional s)

Heart (e.g. MI) L

- ask about: sweating, nausea, chest

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

Osteomyelitis infection spreads (a) from bloodstream (b)

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

Canal of Guyon Ulnar n. Diabetic neuropathy (glove/stocking)

Liver L - e.g. hepatitis, cirrhosis, metastatic Ca Gallbladder, pancreatitis, perforated duodenal ulcer R - ask about relnship with meals: eating REL
duodenal/pyloric ulcer; AGG gastric ulcer, gallbladder inflamm; 1-3 hrs after eating/between meals = duodenal/pyloric ulcer, gallstones; ask about effect of antacids (ulcers in general), NSAIDs

- bilatl, feet and LExx likely to be affeted before hands and UExx. Numbness, P+Ns, causalgia, sharp /cramps and loss of balance (Charcots, loss of proprioception) are all possible s Radial/ulnar Aa. Occlusion weak MM in appropriate
distribution, weak/absent pulses; cold/colour in distal extremity, numbness/P+Ns in non-dermatomal distribution

Note: any structure contacting diaphragm may refer via PHRENIC N.

Complex Regional Pain Syndrome aka reflex sympathetic dystrophy f>m 3:1; of exclusion. NOT A GOOD
IDEA TO MENTION IN THE CCA UNLESS YOU WANT TO GET INVOLVED IN A DISCUSSION ABOUT CNS SENSITISATION & N-methyl-D-aspartamate RECEPTORS...!

e.g. acromegaly, hypothyroidism, gout, hypocalcaemia, Pagets disease, hyperparathyroidism

METABOLIC

FUNCTIONAL

Rotator cuff imbalance likely to be a

contributing/maintaining factor in any shoulder problem

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

valgus

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

Guyon

Scapulothoracic rhythm disturbance ass rotator

cuff ()

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

supraspinatus tendon)

Loose body ass. O/A, radiocapitellar chondromalacia Wrist/Shoulder dysfunction (compensatory mechanism)
(cf. shoulder): e.g. poor shoulder posture (protracted, tightened ant structures) humerus held in IR shortening of supinators (inc biceps brachii) at EoR extn supinators taut imbalance of elbow/wrist flexors/extensors PDF epicondylitis.
r

Dupuytrens contracture (possible diabetes &

alcoholism)

RSI controversial (in osteopathy) be careful whether you mean

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

Kyphotic posture with protracted shoulders and contracted

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

Compensatory mechanism CNS will compromise

shoulder to maintain dexterity of the hand

3 DDx LEx N M S
Bone

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

Knee
Osgood-Schlatters - tibial Tx epiphysitis; affects 20%
athletic adolescents, > 3:1. , tenderness, lump on tibial tubercle (of Gerdy). AGG activity. TTT complete cessation sport/activity for 6/12, gradual return afterwards.

Ankle/Foot
Ankle # Tarsal # Calcaneal spur (Tx exostosis: plantar fasciitis, Achilles tendonitis) r Cuneiform sublux ( sup ) th Styloid # (proximal 5 met #, aka tennis or dancer )

Chondromalacia patellae - Patellofemoral

syndrome; weak hip ERs. on going up stairs, weak/tight quads, genu valgus, patella alta. TEST: compression medl & latl retinacula & patellar lig

Patellar # Sinding-Larsen-Johnson - patellar epiphysitis Osteochondritis dessicans

Slipped capital femoral epiphysis

- rare, but accurate & immed TTT critical. 10-16 yoa 12-14 yoa; >2.4:1. Femoral head is displaced postrly & infRly in reln to femoral neck. PPW hip, medl thigh, and/or knee . Pts often hold hip in passive ER. L hip affected > R. Often bilatl. PDF obesity ( shear forces through proximal growth plate).

Joint

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

waddle). Pt will have difficulty walking backwards (cant extend hip). on wt-bearing, a.m. eased by gently activity. antr groin, a-latl thigh, knee. Gluteii weaken limping gait, likely +ive Trendelenburg. fixed flexn may be psoas spasm abscess, appendicitis etc RULE OUT 1st. Thomas Test: Pt supine, c-latl hip/knee flexed (flatten out lumbars). +ve = atic LEx lifts off plinth (fixed flexn deformity). TTT: analgesics, NSAIDs, walking stick (c-latl side), work on glutei (strengthening exx, stretches), Wt loss advice if pt visceroptosic.

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

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

O/A (esp. talocrural, DIPJs) Heberdens nodes, crepitus,

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

Meniscal damage/tear
bearing rotational injury

on compression, wt.

Osteochondritis: Kohlers (navicular); Freibergs (2nd met);

Severs (calcaneal)

Patellofemoral disloc/sublux Patellofemoral Pain Syndrome PPW

n n

Ottos pelvis protrusion acetabuli. osteomalacia, stress

#. Often unnoticed until later in life (start of O/A). May be 2 R/A, A/S, O/A, Pagets etc. RoM in abdn, ER, extn.

CHD dysplasia (esp postr acetabular rim) >. 7:1. Short LEx,
waddling gait, RoM in abd n

Calve-Perthes - epiphyseal osteonecrosis

yoa.
often ass SIJ dysf.

. 4-10

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

Hallux valgus Tibial Stress # -

after exx, localised tenderness, A-R ive.

Pubic symphysis dysfunction the pelvis as a ring, R/A Jts synovium more susceptible e.g. UCSp, hip, shoulder.
Link CTS

Tibiofemoral disloc traumatic onset, will nearly

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

Loose bodies ( locking) R/A LCL, MCL, ACL PCL or coronary lig. Damage controversial as to whether or not can effectively work on
coronary ligs (some osteos say yes, others no...) Unhappy Triad = MCL, ACL, medl meniscus: valgus strain MCL strain, if severe ACL & meniscal damage also.

Ligament & Capsule

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

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

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

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

Achilles strain/rupture TEST: Pt prone, squeeze gastrocsoleus

complex, if rupture plantarflexn at ankle.

Bursitis - supra/infra/prepatellar/pes anserine Popliteal cysts (Bakers) up to 50% children.

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

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

Plantar fasciitis inflamm of plantar aponeurosis at attach heel, worst

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

Plica syndrome - presence of med plica is more

l

common than a latl plica

Muscle

Piriformis Syndrome h l C lat hip rotators/gluts/TFL

snapping hip

VMO dysfunction causes latl tracking of patella, also

-

Compartment syndrome - antr/postr/latl.

ITB syndrome &

linked tight ITB

Trochanteric bursitis under glut max Ischiogluteal bursitis (Weavers bottom)

under psoas

ITB friction syndrome (Runners knee) - LCL and hip, synovium inflamed ITT rubbing over latl
femoral condyle; TTT rest, NSAIDs, incremental increase of Exx no more than 10% increase per week .

Oedema pressure in compart blood flow hypoxic . Antr compart most often affected (least spare room). TA & EHL first affected. on activity; A-R may be ive (requires prolonged activity)

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

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

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

Popliteus tendonitis Patellar tendonitis (Jumpers knee) often

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

Neurological/Re ferred /Systemic

SIJ dysfunction antr groin, hip, knee LSp referral (L2-5) Meralgia paraesthetica entrapment of latl cutaneous n.
of thigh under inguinal lig. AGG bending forwards, tight clothes.

Myositis ossificans (post-haematoma?) Charcots joints sensorimotor loss, esp the loss of
proprioception, ass diabetic neuropathy severe degenerative arthritis. Common in ankle & knee, also in shoulder ( periarthritis and adhesive capsulitis, 5x more common in diabetic population)

L5/S1 referral Diabetic peripheral neuropathy foot and LExx stend to appear
before UExx. Check regularly in diabetic pts. May be trophic s to skin, loss pinprick/soft touch, P+Ns, numbness, sharp & cramps, causalgia & loss of balance possible.

Appendicitis

- preceding nausea, begins in umbilical region then localises LRQ. Groin and/or testicular may be only s. Assess for rebound tenderness, abd MM rigidity, McBurneys. iliopsoas or obturator abscess Femoral hernia - Indirect or direct: PID Reiters (arthritis, urethritis, uveitis) - See p7, SNAs A/S See p7, SNAs AAA - NOTE: AAs are often aatic as nociceptors do not
respond well to slow s. Palpate latl to rectus sheath for pulsatile AA pulse. LBP may be only on presenting. Ask about throbbing or burning . Check for radiofemoral delay.

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

strain/herniation/bulge

Ganglion/ Mortons neuroma - Mortons most often between 3rd and

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

Hip referral Pubofemoral lig medl knee (via obturator

n); Iliofemoral lig ant knee (occ. med ankle) (via femoral n); Ischiofemoral lig heel (via sciatic n)
r l

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

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

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

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

Intermittent claudication Neurogenic: blood flow to Nn in

spinal foraminae, spinal stenosis. Probably some at rest (i.e. is not relieved as swiftly as vascular claud, may persist for hours). Walk further when flexed (shopping trolley, uphill, mowing grass), Pulses NAD, LExx skin s. May be neuro Sx or s. Vascular: stops immediately when Pt stops walking/sits. May be ab pulses (HOWEVER may not be apparent at rest), sin cold, dry flaky (poor perfusion)

Infective arthritis Tabes dorsalis

Kidney stones

- cartilage v. Sensitive to bacteria, will cause damage that cannot heal. Surgical emergencyarthroscopy, ABx - slow degeneration of fibres in dorsal columns (JPS, vibration, discriminative touch test as necessary) due to demyelination as a result of untreated syphilis infection

Gout see under KNEE

Popliteal aneurysm DVT

- hot, pulsating, swollen. Intermittent claudication, at rest. EoR flexn orextn and/or heat. Absent/decreased dorsalis pedis pulse.

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

FUNCTIONAL

LEx length discrepancy Snapping hip see above

Patellar mal-tracking quads imbalance, rotn from

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

Pes planus - s likely in antr leg & calf (rather than foot); tibialis antr tends
to tire on walking . Arches maintained by MM of plantar fascia while standing; while walking also TA, TP (esp under sustentaculum tali), PL, EDL, EHL

Pronation

- be careful to distinguish from pes planus. Pronation IR of tibia more pressure on medl knee

Pes cavus ass spina bifida, poor shoes

4 - Systemic Causes of Back Pain

CVS
May refer to neck, shoulder, arm

Cervical Spine
Angina - ask about: sweating, nausea, chest discomfort, mouth/jaw/tooth
when getting chest /discomfort. Does neck/jaw increase with exertion that should not involve shoulder (climbing stairs, exercise bicycle)? Dyspnoea: nausea; belching

MI as angina, plus crushing band/tightness around chest, , prolonged/sever substernal chest

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

Aortic aneurysm as angina Pericarditis substernal that rads upper back, UFT, L supraclavicular area, down L UEx to costal margins,
neck; dysphagia; AGG deep breathing (laughing, coughing etc), trunk movements (S/B or rot ), lying down; REL holding breath, leaning forward, sitting down; LExx oedema; cough
n

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

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

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

Embolism Lung Ca (Pancoasts) look for Horners syndrome ( Ptosis, Enophthalmos, Anhydrosis,Meiosis)

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

Tracheobronchial irritation - dyspnoea, wheezing, chest h C bronchitis persistent productive cough (worse a.m. & p.m. than midday), chest expansion; wheezing; fever;
dyspnoea; central cyanosis; exercise tolerance

Pneumothorax may be spontaneous, ruptured bulla on pleura. s: fall in BP, weak and rapid pulse, in
respiratory moves on affected side. NOTE: Pt may present with shoulder NOT breathing probs

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

Oesophagitis Oesophageal varices dysphagia, odynophagia Oesophageal Ca hoarseness/voice s, dysphagia, odynophagia

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

GU
May refer to flank, low back, or pelvis

OBGYN Neoplastic Metastatic lesions (leukaemia, Hodgkins disease) Bone & cord Ca LMNL Sx at level of lesion, UMNL Sx below Lung Ca (esp. Pancoasts) - look for Horners syndrome ( Ptosis, Enophthalmos, Anhydrosis,Meiosis)

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

Oesophageal Ca - hoarseness/voice s, dysphagia, odynophagia Thyroid Ca may be euthyroid/hypothyroid/hyperthyroid. Relatively uncommon. Metabolic/Endocrine

Slow growing. Rarely metastasizes. Palpable nodule/mass; hoarseness; haemoptysis; dyspnoea; hypertension

Myasthenia gravis auto-immune, circulating antibodies block acetylcholine receptors at post-synaptic NMJ
weakness. V. rare (200-400 cases/million). Main : fatigue, improves rest. MM that control eye/eyelid, facial expression, chewing, talking & swallowing esp susceptible. s may be intermittent. Ptosis, diplopia, dysphagia, SOB & dysarthria most common PCs.

Other

INFECTION:
Osteomyelitis infection spreads (a) from bloodstream (b) contiguously from adjacent infected area or (c)
penetrating trauma/iatrogenically. Tibia, humerus, vertebrae, maxilla & mandibular bodies most prone due to anatomy of blood supply.

Meningitis nuchal rigidity, photophobia, H/A, pyrexia Lyme disease Retropharyngeal abscess Fibromyalgia - widespread & tenderness, presence of characteristic TrPs (esp in shoulders, back, elbows, knees)
HOWEVER: the eleven out of eighteen tender points test is intended to be used to identify FM pts for inclusion in research studies; it was never intended to be used in clinical settings (Scudds 1998); there are neurohormonal s that can diminish repair of MM tissues (Neeck & Riedel 1994). It involves a disrupted hypothalamic-pituitary-adrenal (HPA) axis, and studies indicate there may be biochemical abnormalities requiring metabolic adjustment (e.g. Eisenger et al 1994, Samborski et al 1996), and may be ass IBS and or migraines stress linkage. Sx of inflammation; jts tender but not swollen; a.m. stiffness, eases quickly on movement. Depression, malaise, fatigue; > , peak incidence middle years, sometimes triggered by bereavement/stress. Often of exclusion (although FM sufferers and experts dispute this).

4 - Systemic Causes of Back Pain

CVS
May refer to neck, shoulder, arm

Thoracic Spine
Angina - ask about: sweating, nausea, chest discomfort, mouth/jaw/tooth
when getting TSp ? Does TSp increase with exertion that should not involve shoulder (climbing stairs, exercise bicycle)? Dyspnoea: nausea; belching

MI as angina, plus crushing band/tightness around chest, prolonged/sever substernal chest Pericarditis substernal

or squeezing pressure; feeling of indigestion; nausea; sudden dimness/loss of vision or loss of speech; pallor; diaphoresis (heavy perspiration); SOB; weakness, numbness; feelings of faintness that rads upper back, UFT, L supraclavicular area, down L UE x to costal margins, neck; n dysphagia; AGG deep breathing (laughing, coughing etc), trunk movements (S/B or rot ), lying down; REL holding breath, leaning forward, sitting down; LExx oedema; cough

Endocarditis easy fatigue; dyspnoea; palpitations; pitting oedema; orthopnoea/paroxysmal dyspnoea; dizziness; syncope;
arthralgias/arthritis; low back/SI (1/3 of cases; NOTE: will be accompanied by RoM and spinal tenderness) , myalgias; cold and painful Exx

Aortic aneurysm Pulsating chest Respiratory

May refer to neck, UFT, costal margins, TSp, scapulae, l shoulder (and along med arm)

, often aatic until ruptured: sudden severe chest tearing/ripping sensation; may r rad neck, shoulders, interscapular area, low back or abdomen - rad post thighs may help distinguish from MI; lightheadedness; nausea; NOT REL by in position

Respiratory infection pyrexia, malaise, dyspnoea, chest Empyema h C bronchitis persistent productive cough (worse a.m. & p.m. than midday), chest expansion; wheezing; fever; dyspnoea;
central cyanosis; exercise tolerance

Pleurisy chest AGG breathing, coughing, laughing (deep inspiration); cough; fever, chills; tachypnoea Pneumothorax - see CSp Pneumonia sudden sharp pleuritic AGG chest movement, shoulder ; hacking, productive cough (rust/green purulent
sputum); dyspnoea; cyanosis; H/A; pyrexia, chills; fatigue; confusion in older adult

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

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

Oesophagitis (severe) Oesophageal spasm Peptic ulcer (esp. penetrating duodenal) steady
anorexia, wt loss; melaena; R shoulder

near midline of back T6-10 (perforating); nausea, emesis,

Ac cholecystitis Biliary colic Pancreatic Disease AGG sitting up/leaning forward, A pyelonephritis/glomerulonephritis (upper UTI) unilatl costovertebral tenderness; flank
; pyrexia & chills; haematuria; nocturia pelvic/lower abd
c

GU
May refer to flank, low back, or pelvis

; ipsilat shoulder ful intercourse);

Cystitis/urethritis (lower UTI) urinary frequency, urgency; dysuria; haematuria; LBP; dyspareunia ( Kidney disease OBGYN Neoplastic

Metabolic/Endocrine

Mediastinal Ca Metastatic extension Pancreatic Ca Breast Ca Asthma Kidney problems ( rennin-angiotensin system) T/L region Hyperthyroidism Myasthenia gravis auto-immune, circulating antibodies block acetylcholine receptors at post-synaptic NMJ weakness.
V. rare (200-400 cases/million). Main : fatigue, improves rest. MM that control eye/eyelid, facial expression, chewing, talking & swallowing esp susceptible. s may be intermittent. Ptosis, diplopia, dysphagia, SOB & dysarthria most common PCs.

Cushings Syndrome (hypercortisolism) Other

INFECTION:
Osteomyelitis infection spreads (a) from bloodstream (b) contiguously from adjacent infected area or (c) penetrating
trauma/iatrogenically. Tibia, humerus, vertebrae, maxilla & mandibular bodies most prone due to anatomy of blood supply

H. zoster HIV CD4 <200 at any point in Hx = risk of osteoporosis (contra HVLAT), healthy indiv = 1000; 500 =ok; viral load
<40(copies/ml) = undetectable, 100,000 = need to start ARV. Side effects of meds = lipodystrophy need to be careful soft tissue

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

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

Acromegaly

4 - Systemic Causes of Back Pain

CVS
May refer to neck, shoulder, arm

Lumbar Spine
AAA / Arterial occlusion AAAs occur appx 4x more often than thoracic aneurysms.
Most common site is just below the kidney, with referred to the T/L. Sx & s: Abdominal heartbeat felt by Pt when lying down; dull ache midabdominal L flank or LB; groin and/or LEx ; weakness or transient paralysis of LExx.

Myocarditis Endocarditis easy fatigue; dyspnoea; palpitations; pitting oedema; orthopnoea/paroxysmal dyspnoea; dizziness; syncope;
arthralgias/arthritis; low back/SI (1/3 of cases; NOTE: will be accompanied by RoM and spinal tenderness) , myalgias; cold and painful Exx

Peripheral vascular - e.g. post-op bleed from antr spine surgery, occlusive disease (thrombus, embolism, trauma,
arteriosclerosis obliterans, Raynauds). Diabetes is a risk factor. 1 Sx may be loss of hair on the toes. Also: intermittent claudication, ischaemic rest , AGG by elevating extremity, REL hanging foot over side of bed/chair. Colour, temp, skin & nail bed s
st

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

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

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

SMALL INT: Obstruction (e.g. neoplasm) IBS Crohns disease COLON: Diverticular disease L lower abd & tenderness; L pelvic ; bloody stools; pyrexia Pancreatitis epigastric rad back; nausea; emesis; pyrexia, sweating; tachycardia; malaise; weakness; jaundice; bluish
discolouration of abdomen/flanks (a haemorrhagic pancreatitis)
c

GU
May refer to flank, low back, or pelvis

Appendicitis R lower quadrant or flank , periumbilical and/or epigastric , rebound tenderness, =ive McBurneys point Gall bladder KIDNEY: c A pyelonephritis/glomerulonephritis (upper UTI) unilatl costovertebral tenderness; flank ; ipsilatl shoulder
pyrexia & chills; haematuria; nocturia

Cystitis/urethritis (lower UTI) urinary frequency, urgency; dysuria; haematuria; LBP; dyspareunia (
pelvic/lower abd

ful intercourse);

Perinephrine Abscess Upper UT obstruction nephrolithiasis (calculi)

frequency (unless stone blocks flow hydronephrosis)

- sudden, sharp, severe ; Uretal colic rads genitalia & thighs; renal colic deep in lumbar area rads around side & down to testicle in male, bladder in female; haematuria; nausea/emesis;

Dialysis (first-use syndrome) Upper UT obstruction e.g. renal tumours slow onset mild & dull flank
dermatomes T10-L1; nausea/emesis; haematuria; abd. MM spasm

; palpable flank mass; hyperaesthesia

OBGYN

Neoplastic

Uterine fibroids Ovarian cysts Endometriosis Pelvic Inflammatory Disease (PID) Retroversion of uterus Rectocele/Cystocele Uterine prolapsed ALSO: pregnancy; multiparity Metastasis - commonly from: breast, lung, GIT, kidney, prostate. Ask about: constant, intense , esp unrelieved by in
position/bone/night; unexplained wt loss (10% in 10-14/7) most Pts in are inactive wt gain; excessive fatigue; bowel/bladder habits; rapid onset of clubbing (10-14/7); (proximal) MM weakness, esp accompanied by in 1+ DTR; unusual/prolonged bleeding/discharge;

Metabolic/Endocrine

Prostate, testicular, pancreatic, colorectal Cas Multiple myeloma Lymphoma Hyperthyroidism Adrenal dysfunction (e.g. phaeochromocytoma) osteomalacia Pagets Myasthenia gravis auto-immune, circulating antibodies block acetylcholine receptors at post-synaptic NMJ weakness.
rare (200-400 cases/million). Main : fatigue, improves rest. MM that control eye/eyelid, facial expression, chewing, talking & swallowing esp susceptible. s may be intermittent. Ptosis, diplopia, dysphagia, SOB & dysarthria most common PCs.

V.

Cushings Syndrome as TSp Other

INFECTION:
Osteomyelitis infection spreads (a) from bloodstream (b) contiguously from adjacent infected area or (c) penetrating trauma/iatrogenically. Tibia, humerus, vertebrae, maxilla & mandibular bodies most prone due to anatomy of blood supply H. Zoster Spinal TB Psoas abscess HIV - CD4 <200 at any point in Hx = risk of osteoporosis (contra HVLAT), healthy indiv = 1000; 500 =ok; viral load <40(copies/ml) =
undetectable, 100,000 = need to start ARV. Side effects of meds = lipodystrophy need to be careful soft tissue

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

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

Type III hypersensitivity disorder (back/flank pain) Post-regional anaesthesia

Roots Sensory Supply Sensory Loss Area of Pain Reflex Arc Motor Deficit

C5
Lat arm Over deltoid As above, + med border of scapula Biceps jerk Deltoid supraspinatus infraspinatus rhomboids Brachial neuritis Cervical Spondylosis Upper plexus avulsion
l l

C6
Lat forearm, inc. Pollux & index finger Thumb, radial border of hand Esp. thumb and index finger Supinator jerk Pronators & supinators of forearm
l

C7
Mid-forearm, middle finger Middle fingers, front & back of hand l As above, + med border of scapula Triceps jerk Triceps wrist extensors and flexors lat dorsi pec. major Ac disc lesions Cervical Spondylosis

C8
Med forearm, little finger Little finger, heel of hand above wrist As above Finger jerk Finger flexors and extensors FCU
l

T1
Axilla, med forearm Axilla Deep ache in shoulder and axilla None Intrinsic MM of hand
l

Causative Lesions

Cervical Spondylosis

Disc lesions Spondylosis (rare)

Cervical rib/1 rib Pancoasts tumour Metastatic Ca in deep cervical lymph nodes TOS

st

Nerves Sensory Supply Sensory Loss Area of Pain Reflex Arc Motor Deficit

Axillary (C5)
Over deltoid

Musculocutaneous (C5,C6)
Lat forearm wrist
l

Radial (C5,C6,C7,C8)
Lat dorsal forearm, back of thumb & index finger Dorsum of thumb & index (rare) Dorsum of thumb & index Triceps jerk Supinator jerk Triceps Wrist extensors Finger extensors Brachioradialis Supinator Crutch palsy Saturday night palsy # humerus (radial groove) Entrap within supinator Radial tunnel syndrome (postr interosseus branch)
l

Median (C6,C7,C8,T1)
Lat palm, index, middle and latl ring finger Thumb, index & middle l finger, lat palm Thumb, index, middle finger Finger jerk Wrist flexors Long finger flexors (1,2) APB
l

Ulnar (C8,T1)
Med palm, 5 and med ring finger As above, but often none
l th l

Over deltoid

Lat forearm

Tip of shoulder None Deltoid usually obvious

Lat forearm Biceps jerk Biceps, brachialis

As above None All intrinsic MM of hand (except APB) Long fingers flexors (3,4) FCU ELBOW: trauma Bed rest # olecranon WRIST (canal of Guyon): Trauma Gangion

Causative Lesions

# neck of humerus

RARE

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

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

Roots Sensory Supply Sensory Loss Area of Pain Reflex Arc Motor Deficit Causative Lesions

L2
Across upper thigh to post axial line Often none, lat area if any Across thigh (diagonally) None Hip flex n Thigh add
n l r

L3
Across lower thigh to post axial line
l r

L4
Across knee to med malleolus
l

L5
Lat leg to dorsum and sole of foot & hallux Dorsum of foot to hallux Postr thigh, latl calf, dorsum of foot , hallux None Dorsiflex of toes & foot (latter L4 also) L5/S1: (in order of frequency) Disc lesions Facet Metastatic malignancy Neurofibromas Meningiomas Congenital cauda equina lesions
n l

S1
Behind lat malleolus to l lat foot and little toe Behind lat malleolus & l lat border of foot Post thigh, post calf, l lat foot to little toe Ankle jerk Hamstring jerk Plantarflex Eversion of foot
n r r l l

Often none, lat area if any Across thigh (diagonally) Adductor reflex Knee ext n Thigh add
n

Med leg below knee to medl malleolus Down to med malleolus. Often severe at knee around patella Knee jerk Inversion of foot
l

L2/3/4: (in order of frequency) Facet insult Neurofibroma Meningioma Neoplastic disease Disc lesions (very rare: except L4, <5% of all disc lesions)

Nerves Sensory Supply Sensory Loss Area of Pain Reflex Arc Motor Deficit Causative Lesions

Obturator (L2,L3,L4)
Med surface of thigh to post axial line Often none Med thigh Adductor jerk Add of thigh
n l l r

Femoral (L2,L3,L4)
Anteromed surface of thigh & leg l down to med malleolus Usually anatomical Ant thigh & medl leg ankle Knee jerk Ext of knee
n r l r

Sciatic nerve (L4,L5,S1,S2,S3) Peroneal/Fibular Tibial

Ant leg, dorsum of ankle & foot Post leg, sole & lat border of foot
r l

Often only detectable on dorsum of foot Often painless; dull ache anterolat leg & foot Lat hamstring jerk Dorsiflex , inversion (TA) & eversion of l foot, lat hamstrings Pressure palsy at fibular head Hip # or dislocation Penetrating trauma to buttock Iatrogenic (misplaced injection in buttock)
n l l

Sole & lat border of foot Often painless, very uncommon Ankle jerk l Med hamstring jerk Plantarflex & inversion of foot (TP), l med hamstrings Very rarely injured, even in buttock - peroneal division more prone to injury (reason unknown)
n

Pelvic neoplasm Pregnancy Pelvic surgery

Diabetes Femoral hernia Femoral a. Aneurysm Postr abdominal neoplasm Psoas sbscess

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

Osteoarthritis
Definition Epidemiology Aetiology Pathophysiology
Non-inflammatory disorder of synovial joints, charac. by articular surface wear & formation of new bone 80% m. & 89% f. over the age of 75yrs, > 3:1 Primary O/A = idiopathic (many factors, but cause unknown) Secondary O/A = consequent to trauma, congenital abnormalities, infection, functional problems, avascular necrosis, neuropathy, metabolic/endocrine diseases, crystal arthropathies, or iatrogenesis. Stage 1: Breakdown of articular surface Stage 2: Synovial irritation Stage 3: Chondral remodelling Stage 4: Eburnation of bone & cyst formation Stage 5: Disorganization

Rheumatoid Arthritis
Auto-immune inflammatory multi-systemic connective tissue disorder 1-2 % general population. , > 3:1. Onset any time 10-70 yoa, but peak: 30-40 yoa. Unknown sex hormones may be involved (often 1 appears after pregnancy, or remits during, contraceptive pill appears to have mild protective influence), also genetic/immunological component likely
st

C inflammatory synovitis: proliferation of villi that contain infiltrates of lymphocytes, macrophages & plasma cells. Synoviocytes secrete cytokines stimulate further synoviocyte prod, cartilage resorption, further cytokine production (may progressive nature of disease). In established disease these mild inflammatory lesions develop into RHEUMATOID NODULES (pathognomic of R/A) in many tissues heart/pericardium, lungs, blood Vv, skin/subcut tissue, eye, salivary/lacrimal glands etc. Synovium devs tumour-like mass PANNUS that extends from synovial margin eroding articular cartilage & invading bone. Exudate within jt swollen S/Ts Commonly affected initially: PIPJs, MCPJs, MTPJs, wrist, CSp Knee common in later stages, along hip, ankle. Likely to be symmetrical BUT 20% Pts present initially as monartrhitis, usually knee or wrist Jt & stiffness, esp a.m. Low-grade pyrexia, malaise, fatigue, wt loss ass anorexia Sjgrens Syndrome in up to 40% of Pts (dry, sore eyes, nose & mouth). Uveitis & scleritis important ocular manifestations RESP: nodules, interstitial fibrosis, obstruction small bronchi wheeze, exertional dyspnoea CVS: pericarditis, vasculitis (esp fingers & nail beds), mitral valve disease, Raynauds, anaemia NERVOUS: cervical myelopathy (most common rheum cause of death in R/A), CTS SLE, allergic/viral onset polyarthritis, psoriatic arthritis, 1 generalised O/A

Clinical Features

Affects mainly: 1 CMCJ, 1 MTPJ, knee & hip (joints that have undergone most recent evolutionary ?) AGG wt. bearing/use; worse after activity/at end of day REL by rest Stiffness, weakness (usually 2 to disuse) Crepitus/clicking Swelling may be bony, cold, hard. Often additional effusion (synovitis?) Locking/unsteadiness loose bodies/irregular jt surface MM weakness/wasting RoM n Jt deformities e.g. fixed flex , Heberdens/Bouchards nodes NRI/impingement - 2 to Spondylosis

st

st

DDx Medical Management Osteopathic Management

Depends on whether mono-, oligo- or polyarthritic on presentation...

NSAIDs, intra-articular steroid injections, glucosamine & chondroitin supplement (may s, unlikely to promote regrowth of cart), artificial synovial fluid (M/T, lasts appx 6/12); osteotomy, arthrodesis, debridement, jt. resurfacing, total joint replacement Advice: explanation of condition and reassurance; keep active but modify causing activities: low-impact exercise (swimming, exercise bikes), wt. loss if viscerotopic, l walking stick c-lat side if hip/knee affected etc. Disuse (not just overuse) can in function and levels if any given jt not used through full RoM poorer health of that joint (and those surrounding it). Bony remodelling is an ongoing process maintain function through manual therapy & Exx.

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

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

7 Osteoarthritis vs. Rheumatoid Arthritis

SERONEGATIVE ARTHROPATHIES (SNAs)

Group of overlapping forms of INFLAMMATORY JOINT DISEASE COMMON FEATURES: Tendency to affect the SPINE RhF negative incidence of HLA-B27 FAMILY HISTORY of single/multiple SLAs PPW: Back pain AGG prolonged inactivity/sitting/lying REL activity When Pts present back AGG prolonged sitting/lying down, REL activity, suspect SNA... Enthesopathy is responsible for many of the features: inflammation, fibrosis, ossification/reactive bone formation at the enthesis

Condition

Epidemiology

Pathophysiology

Clinical Features

Management

Ankylosing Spondylitis
C inflammatory condition affecting spine & SIJs
h

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

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

- Insidious onset LBP - Stiffness, esp T/L - Peripheral arthropathy - Pelvic & Back Pain, intermittent - Enthesopathy: plantar fasciitis, costochondritis, Achilles tendinitis etc. - Antr uveitis - PERIPHERAL ARTHRITIS: starts 2/52 after infect; asymmetrical, additive - UVEITIS/CONJUNCTIVITIS - URETHRITIS: dysuria/urethral discharge, polyuria, prostatitis, balanitis, cystitis

Reiters/Reactive Arthritis
Triad of s: Conjunctivitis Urethritis Arthritis

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

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

- Pain & inflamm - MOBILISING EXX for SPINAL MOBILITY: Spinal extn, spinal strength & mob, deep breathing, swimming - ADVICE: postural (e.g. no/low pillow); avoidance of prolonged immobility Treat infection (ABx); for arthritis: NSAIDs, rest. If spondylitis is present, c TTT as per A/S (above). In a stages jt aspiration and corticosteroid injections may be performed.

Psoriatic Arthritis

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

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

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

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

ENTEROPATHIC ARTHROPATHIES Crohns & UC (together: IBD) Whipples Disease Behets Disease
Triad

20% of Crohns Pts peripheral arthritis 10% of UC Pts peripheral arthritis m=f Axial involvement in up to 25% Pts. Very rare; m>f NOTE: in 50% of cases, arthritis precedes bowel disease

55% of Crohns & 70% UC are HLA-B27 positive

PERIPHERAL: asymmetrical, mainly knees & ankles SACRO-ILIITIS: axial involve in >25%. 4% progress to A/S Steatorrhoea Arthritis: ankle & knee, elbow & fingers Abdominal pain Enlarged lymph nodes Oro-genital ulceration Uveitis Skin rashes Asymmetrical arthritis, often LExx 75% cases is KNEE; intermittent, severe, may involve effusion

EDUCATION:

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

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

Rare

Aetiology unknown; some familial link

As other types of a arthritis

8 - Seronegative Spondyloarthropathies