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Back pain and regional disorders 

Back pain and regional disorders

Chapter:
Back pain and regional disorders
Author(s):

Simon Carette

and Carlo Ammendolia

DOI:
10.1093/med/9780199204854.003.1904_update_001

November 28, 2012: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

Update:

Diagnostic criteria for neurogenic claudication—enhanced based on recent evidence reviews.

Intervention recommendations for nonspecific low back pain—based on review of national guidelines for management of low back pain published in 2010.

Prevalence, risk factors, classification, and intervention recommendations for neck pain—based on findings from the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders, published in 2008.

Updated on 30 Nov 2011. The previous version of this content can be found here.
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Essentials

Low back pain

Over 70% of people in industrialized countries suffer from low back pain at some time, and it is one of the leading reasons for visits to physicians. Risk factors include heavy physical work, smoking, stress, depression, and job dissatisfaction. In more than 90% of cases the exact anatomical source of back pain cannot be determined, and the preferred diagnostic label is ‘nonspecific low back pain’.

‘Red flags’ is the term used for the presence on history of any of the following: age over 50, fever, weight loss, significant trauma, previous history of neoplasia, use of corticosteroids, drug or alcohol abuse, neurological symptoms and signs, night pain, morning stiffness, and the persistence of pain after 1 month of conservative therapy. Such red flags suggest the possibility of serious disorders, e.g. neoplasia, infection, fracture, or inflammatory spinal disease.

Investigation and management: investigation should be restricted to patients with red flags, with MRI the best imaging modality for the diagnosis of lumbar disorders. In the absence of red flags, patients with acute low back pain should be reassured and encouraged to remain active: simple analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and spinal manipulation may help for pain relief.

The early recognition of psychosocial risk factors, or ‘yellow flags’, is important to identify patients who are at higher risk of progressing towards chronic low back pain. Cognitive behavioural therapy, supervised exercise therapy, brief educational interventions, multidisciplinary treatment, and short courses of manipulation/mobilization can each be recommended in patients with nonspecific chronic low back pain, but the condition is often refractory.

Other regional disorders

Neck pain—the clinical approach should follow the same principles as described for low back pain.

Regional musculoskeletal pain disorders—painful conditions affecting a specific region of the body are extremely common. Various pains have been described affecting the shoulder, elbow, wrist and hand, hip, knee, ankle, and foot regions. Most of these can usually be identified by a careful history and directed physical examination. The principles of management include temporary rest, analgesics or NSAIDs, local corticosteroid injections, thermal modalities, orthotics, and graded flexibility and strengthening exercises.

Low back pain

Low back pain is one of the commonest symptoms and was the fifth leading reason for all visits to doctors’ surgeries in the United States of America in 2002. Between 60 and 80% of adults suffer from at least one episode of back pain during their lifetime. Acute back pain is usually self-limiting, and most sufferers do not seek medical advice. Of those who do, more than 90% are back to work within 2 months, independent of the treatment received, including those in whom the acute episode results from a work-related injury for which compensation might be available. The 5 to 10% of patients who remain disabled after this time are a difficult therapeutic challenge, owing to the influence of psychological and social factors on the continuation of pain. These few patients are responsible for more than 75% of the total costs of low back pain to society, estimated to be between 1 and 2% of the gross national product in most industrialized countries.

Significant risk factors for the occurrence of back pain include older age, heavy labour (in particular jobs requiring lifting in an awkward position), lower education and income, smoking, high birth rate (in males), and obesity. Twin studies suggest that genetic factors have an important influence on the lifetime prevalence of back pain, with heritability ranging from 52 to 68%. Long-distance driving and whole-body vibration such as experienced by truck drivers are well-known risk factors for disc herniation. Previous episodes of back pain are strong predictors of recurrence. A number of psychosocial risk factors, or so-called ‘yellow flags’, predict poor outcomes. These include beliefs that back pain is harmful or potentially severely disabling, resulting in fear/avoidance behaviour and reduced activity levels, excessive reliance on aids and appliances, depressed mood, withdrawal from social interaction, and job dissatisfaction.

Many structures of the back, including the muscles, ligaments, discs, bones and zygapophyseal and sacroiliac joints are innervated and can therefore be a source of pain. However, in more than 90% of patients presenting with low back pain it is extremely difficult—if not impossible—to identify precisely the anatomical source of the pain on the basis of history and physical examination. These patients should be diagnosed as suffering from ‘nonspecific low back pain’. A host of clinical entities such as muscle strain, degenerative disc disease, facet syndrome, myofascial pain syndrome, segmental instability, minor intervertebral displacement, iliolumbar syndrome, piriformis syndrome, etc. have been described within this broad category based on the localization of pain and tenderness, reproduction of symptoms by specific manoeuvres, radiological features, or pathophysiological hypotheses. Unfortunately, the signs and manoeuvres described for each of these clinical syndromes lack sensitivity and specificity and are not reproducible, even by experienced clinicians. Moreover, the claim that any of these entities is responsible for the pain in a given patient can very rarely be validated. For example, it is hazardous to ascribe pain to degenerative disc disease or zygapophyseal joint osteoarthritis when it has been shown that individuals with similar radiological changes can be completely asymptomatic. The only way to determine if the discs or zygapophyseal or sacroiliac joints are the source of pain in a given patient is through injection studies done under stringent, controlled conditions (see below).

Clinical approach to the diagnosis of low back pain

In evaluating a patient presenting with low back pain, the physician should not try to differentiate between the various elusive entities responsible for nonspecific back pain, but rather should focus on determining if the patient needs emergency surgery, has sciatica with signs of nerve root compression, or has an underlying medical cause of back pain (infectious, inflammatory, metabolic, tumoural or visceral) (Table 19.4.1).

Table 19.4.1 Causes of back pain

Surgical emergencies

Cauda equina syndrome (disc, tumour mass, abscess)

Aortic aneurysm (ruptured, dissected)

Sciatica with neurological signs

Ruptured intervertebral disc

Spinal stenosis (the neurological examination is often normal)

Spinal cord tumours (extradural, intradural–extramedullary/intramedullary)

Medical conditions

Neoplastic

Benign: osteoid osteoma

Malignant: primary (multiple myeloma), secondary (metastasis)

Infectious

Acute: pyogenic discitis, osteomyelitis

Chronic: tuberculosis

Inflammatory

Ankylosing spondylitis

Psoriatic arthritis

Reactive arthritis

Inflammatory bowel diseases

Metabolic

Osteoporosis (with fractures)

Osteomalacia

Paget’s disease of bone

Visceral

Pelvic organs (endometriosis, prostatitis)

Renal disease (pyelonephritis, renal colic)

Gastrointestinal (pancreatitis)

Aortic aneurysm

Nonspecific low back pain

Muscle

Ligaments

Discs

Zygapophyseal joints

Sacroiliac joints

Spondylolisthesis

Is this a surgical emergency?

Cauda equina syndrome and an expanding vascular aneurysm are two extremely rare but important conditions to recognize, because both are surgical emergencies. In the first instance, the patient will usually present with low back and/or buttock pain, associated with bilateral sciatica, neurological symptoms in the lower extremities, and urinary and/or bowel incontinence. Physical examination may show bilateral weakness, sensory losses, saddle anaesthesia, decreased reflexes in the legs, and decreased rectal tone. Diagnostic procedures (MRI, CT, or myelogram) should be performed on an emergency basis if bowel and bladder control are to be preserved. Central disc herniation is the most common cause of the syndrome, followed by tumours and epidural abscesses.

An aortic aneurysm can be responsible for a dull, gnawing back pain due to direct compression of the aneurysm on the lumbar vertebrae. They are typically seen in elderly patients, especially white men, and physical examination may reveal a pulsating abdominal mass and decreased pulses in the legs. Diagnosis is most important because rupture or dissection of the aneurysm is often fatal, the patient presenting with sudden, excruciating, tearing abdominal or back pain radiating to the groin, buttocks, or thighs along with haemodynamic compromise (hypotension, tachycardia, and shock). Up to 30% of ruptured aneurysms are initially misdiagnosed. Preventive surgery (before rupture or dissection) is the optimal treatment.

Does the patient have sciatica and/or neurological signs?

Sciatica can be defined as pain radiating below the knee. It is a rare symptom, being reported by only 1% of patients with back pain, but its presence is usually associated with an identifiable aetiology. It typically results from compression of the spinal nerve originating between L4 and L5 (L5 nerve root) and/or L5 and S1 (S1 nerve root) by a herniated disc, bone, or a combination of the two (spinal stenosis). Tumours, infections, or epidural haemorrhage can very rarely produce similar symptoms and signs. The pain in a patient with a herniated disc tends to be aggravated by prolonged sitting as well as any manoeuvre that increases intrathecal pressure, such as sneezing, coughing, or defecation. It is often associated with paraesthesias and weakness in the distribution of the involved nerve.

Back pain and regional disordersPatients with spinal stenosis are usually older and typically complain of pain and/or paraesthesias in one or both buttocks, thighs, and/or legs that develop on standing or walking and are relieved by sitting (neurological claudication). These patients often walk with the trunk flexed, as extension aggravates their symptoms by worsening nerve impingement. The neurological examination is most often normal or shows nonspecific abnormalities, such as reduced or absent ankle reflexes. Differentiating neurological from vascular claudication can be difficult, as both problems occur in the same age category, but pain from vascular claudication is typically not influenced by changing trunk posture.

Does the patient have an underlying medical cause for their back pain?

The history is by far the most important diagnostic step in the search for potential medical causes of low back pain. A number of clues or ‘red flags’ should be looked for systematically. These include the presence of fever, chills, night sweats, weight loss, and nocturnal pain, which should direct the clinician towards the possibility of neoplasia or infection. An insidious onset of back pain accompanied by significant early morning stiffness in a young patient suggests a spondyloarthropathy and should prompt the clinician to enquire about the family history and undertake a detailed review of the ocular (conjunctivitis, iritis), cutaneous (psoriasis, mouth ulcers, balanitis, keratoderma blennorrhagica), gastrointestinal (diarrhoea, haematochezia, abdominal pain), genitourinary (urethritis), and musculoskeletal (peripheral arthritis, dactylitis, enthesitis, heel pain) systems. Risk factors for neoplasia (previous or current history of malignancy), infection (history of tuberculosis, AIDS, intravenous drug abuse, or recent genitourinary procedures), and metabolic bone diseases (previous fractures, menopause, corticosteroid intake, history of anorexia nervosa) should also be sought in patients suspected of having a medical problem underlying their back pain.

What are the key signs to look for in the physical examination?

A good examination of the lumbar spine and relevant nerves can be accomplished in less than 3 min if it is done systematically (Table 19.4.2). A full physical examination must be completed in patients suspected of having a medical cause for their back pain. The diagnostic utility of the many physical manoeuvres described to identify zygapophyseal and sacroiliac joint pain has been refuted when validated against diagnostic blocks with local anaesthetic. Waddell has described a number of nonorganic physical signs (Box 19.4.1): psychological factors or secondary gains may be involved when a patient has three or more of these.

Table 19.4.2 Physical examination of the patient with back pain

Patient standing

Posture (protruding abdomen, hyperlordosis, loss of lordosis, scoliosis)

Spinal motion (flexion–extension–lateral flexion)

Walking on heels (L4–L5) and toes (S1)

Squatting (L2–L3–L4)

Patient sitting

Straight leg-raising test (tripod sign)

Knee (L4) and ankle (S1) reflexes

Patient supine

Abdominal examination (mass, bruit)

Vascular examination

Sensory examination:

L4: anteromedial knee and leg

L5: lateral leg, web space between first and second toes

S1: lateral aspect of the foot, heel

Motor examination (if abnormalities are noted in the standing position):

L4: quadriceps

L5: dorsiflexion of first toe

S1: plantar flexion of foot and toes

Hip examination

Patient prone

Palpation (spinous processes, paraspinal muscles)

Sensory examination:

S2–S4: saddle anaesthesia

Motor examination:

S1: contraction of gluteus maximus

Femoral stretch test (L2 to L4)

Sphincter tone

a A positive test results in aggravation of low back pain.

Who should be investigated and how?

There is a general agreement that the initial assessment should focus on the detection of ‘red flags’ suggestive of a medical aetiology, and that the vast majority of patients with back pain do not need any investigations. Recommendations for ordering a plain radiograph in a patient presenting with back pain include the following: age over 50, fever, weight loss, significant trauma, previous history of neoplasia, use of corticosteroids, drug or alcohol abuse, neurological symptoms and signs (particularly if widespread), night pain, morning stiffness (in which case a pelvic rather than a lumbar radiograph is recommended to detect sacroiliitis), and the persistence of pain after 1  month of conservative therapy.

All other tests should be restricted to patients in whom a medical aetiology is suspected from the history and physical examination, and patients with abnormalities on neurological examination who do not improve with conservative management. Ordering blood tests and imaging in any other situation can not be justified, as not only are these tests unhelpful but they contribute significantly to medical costs. In addition, as many as 25 to 50% of asymptomatic individuals have been shown to have abnormalities such as disc herniation on CT and MRI.

The erythrocyte sedimentation rate (ESR) is the most useful blood test in patients suspected of having spinal infection, as it is elevated in up to 80% of cases. Neutrophilia and anaemia are also commonly seen in patients with neoplasia and infection. Laboratory evaluation of patients with osteoporosis and/or pathological fractures should include serum calcium, phosphate and alkaline phosphatase, as well as serum and urine immunoelectrophoresis (to detect myeloma), particularly if the ESR is elevated.

MRI is the imaging modality of choice for the diagnosis of lumbar disorders. It provides a unique noninvasive means of studying the spine and is unsurpassed for imaging soft tissues. It is particularly helpful in the evaluation of spinal cord tumours, as well as infections of the spine, including discitis and epidural and paraspinal abscesses. CT is superior to MRI for the evaluation of bony structures and therefore is a good choice for spinal stenosis, particularly when combined with myelography. Plain myelography is rarely used today, except in patients who have contraindications to MRI or CT (claustrophobia in particular). The diagnostic accuracy of MRI, plain CT and CT myelography is comparable for the assessment of nerve root compression due to disc herniation. Although MRI is noninvasive and involves no radiation to the patient, the much lower cost of plain CT makes it an excellent choice in this context. CT-guided percutaneous biopsy is commonly used to obtain histological material from patients with tumour mass or infection.

As mentioned previously, injection studies done under fluoroscopic guidance are the only means of diagnosing back pain of discal, zygapophyseal, or sacroiliac joint origin. When normal discs are injected with contrast material, the individual does not experience pain. A provocative discography should be considered positive only if the injection reproduces the patient’s pain and no pain is experienced during the injection of adjacent discs. In a recent report, 40% of patients with chronic low back pain attending a large specialist spinal centre satisfied this strict definition and demonstrated a radial fissure on CT. Similarly, between 10 and 15% report a significant improvement in their pain when their zygapophyseal joints or their sacroiliac joints are injected with a local anaesthetic, but not with isotonic saline. Taken together, these figures suggest that the anatomical source of pain can be established in as many as 70% of patients with nonspecific back pain by using these invasive techniques. However, the impact of this approach on patient management is unclear, as no specific treatment has yet been demonstrated to be effective for these conditions.

Radionuclide bone scintigraphy with technetium-99m is helpful in conditions characterized by increased bone turnover. These include bone metastases, fracture, Paget’s disease, and infections. Gallium-67 binds to polymorphonuclear leucocytes and can be helpful in the evaluation of vertebral osteomyelitis and sacroiliac septic arthritis. Typically, bone scans are negative in patients with multiple myeloma, which is characterized by lytic lesions.

Neurophysiological studies are rarely indicated, except in patients in whom it is difficult to distinguish between a neuropathy, radiculopathy, or plexopathy. Fibrillations in the paraspinous muscles are the most common and earliest findings seen in radiculopathy. Their presence indicates a lesion proximal to the vertebral foramen and excludes a plexopathy.

How are patients with low back pain best managed?

Surgical emergencies

As mentioned earlier, cauda equina syndrome and a ruptured vascular aneurysm are the only two conditions that must be managed surgically on an emergency basis.

Sciatica and neurological deficits

About 90% of patients with a herniated lumbar disc will improve significantly with limited rest, analgesics and anti-inflammatory drugs. The role of epidural steroids remains unclear: they may afford short-term improvement in leg pain, but they do not reduce the need for surgery. Indications for surgery include persistent disabling buttock and/or leg pain despite 2 to 3 months of conservative management, and/or severe or progressive worsening neurological deficit while on treatment. Surgery may also be indicated in patients with neurological claudication due to spinal stenosis, but only after all attempts with conservative management have failed. Patients with spinal stenosis who are more incapacitated by back pain than by neurological claudication should probably not be operated on, because surgery is rarely effective and may even worsen back pain.

Medical back pain

Primary and secondary tumours of the spine can be treated by surgery, radiotherapy, or chemotherapy, whereas antibiotics with or without surgical drainage are the treatment for discitis and osteomyelitis. Postural exercises and nonsteroidal anti-inflammatory drugs (NSAIDs) remain the cornerstone of treatment for patients with spondyloarthropathies. Sulfasalazine and methotrexate are helpful for the peripheral arthritis associated with these conditions, but they have no role in the treatment of the spinal disease. Biological agents—including etanercept, infliximab, and adalimumab—are the drugs of choice in patients with spinal disease associated with spondyloarthropathies who fail NSAIDs. The treatment of metabolic bone diseases is discussed in Chapters 20.1 and 20.4.

Nonspecific low back pain

A number of systematic reviews of randomized controlled trials of the most common interventions have been published and form the basis of the recommendations found in the over 15 national guidelines published in the past two decades. These were developed with the main objectives of improving prevention and management of acute and chronic nonspecific low back pain, and their recommendations are generally consistent.

Patients with acute back pain should be reassured and advised to stay active and continue normal daily activities, including work if possible. If necessary, medications for pain relief, including paracetamol and NSAIDs, should be prescribed and preferably taken at regular intervals. A short course of muscle relaxants to reduce pain may be tried in patients failing paracetamol or NSAIDs, and referral for spinal manipulation should be considered in patients failing to return to normal activities. Exercise therapy is ineffective in the acute phase but should be recommended for prevention of recurrence.

An important objective in managing acute low back pain is to reduce the likelihood of patients progressing to chronicity, not least because there are only a few modalities that have been shown to be beneficial in chronic back pain. The early identification of psychosocial risk factors, or ‘yellow flags’, should lead to appropriate cognitive and behavioural management in an attempt to influence positively some of these factors, although convincing evidence of the effectiveness of this approach or of other psychosocial interventions at this stage is currently lacking.

Back pain and regional disordersIn patients with chronic low back pain, cognitive behavioural therapy, supervised exercise therapy, brief educational interventions and multidisciplinary (biopsychosocial) treatment can each be recommended, and so can the short-term use of NSAIDs and weak opioids for pain relief. Noradrenergic or noradrenergic–serotoninergic antidepressants may also be considered for pain relief. Invasive treatments, including epidural corticosteroids, intra-articular steroid injections and local facet nerve blocks, intradiscal injections, and prolotherapy are not recommended. Surgery should be considered only in carefully selected patients with a maximum of two level degenerative disc disease who have failed 2 years of all previously recommended treatments.

Neck pain

Back pain and regional disordersNeck pain is a very common symptom, with the 12-month prevalence of neck pain among adults in the general population varying between 30% and 50% and the 1-month prevalence between 15% and 45%. As for low back pain, neck pain can rarely be attributed to a specific anatomical source, and most patients presenting with this symptom should be diagnosed as suffering from ‘nonspecific neck pain’ or ‘cervical spinal pain of unknown origin’, rather than applying nonvalidated diagnostic labels. Trauma, in particular acceleration–deceleration (whiplash) injuries, younger age, female gender, and previous history of neck pain are the most common risk factors associated with seeking care for neck pain.

The clinical approach to the patient with neck pain should follow the same principles as described for low back pain. Signs of nerve root and/or spinal cord compression should always be looked for, particularly in patients complaining of associated pain, numbness, or weakness in their arms or legs. Older patients with cervical spinal stenosis due to severe osteoarthritis may present with wasting and lower motor neuron weakness in the arms or hands and spastic weakness and sensory disturbance in the legs.

A number of diseases of the pharynx (pharyngitis, retropharyngeal abscess), larynx (laryngitis), trachea (tracheitis), thyroid (acute thyroiditis), lymph nodes (lymphadenitis), carotids (carotidynia), lungs (Pancoast tumour), heart (myocardial infarction), pericardium (pericarditis), aorta (dissecting aneurysm), and diaphragm (subphrenic abscess) can refer pain to the neck and should be considered. These conditions will usually have other clinical manifestations to alert the physician to the proper diagnosis. The neoplastic, infectious, inflammatory, and metabolic conditions enumerated in Table 19.4.1 can also affect the cervical spine. In addition, rheumatoid arthritis and diffuse idiopathic skeletal hyperostosis should be considered in the differential diagnosis, as both can involve the cervical spine and cause spinal cord compression.

Back pain and regional disordersA special task force proposed a classification of neck pain and associated disorders that takes into account presenting signs and symptoms and impact on activities of daily living (Table 19.4.3). This classification can be very useful in guiding management of patients presenting with neck pain.

Back pain and regional disordersTable 19.4.3 Classification of neck pain and associated disorders

Grade

Clinical presentation

I

Neck pain and associated disorders with no signs or symptoms suggestive of major structural pathologya and no or minor interference with activities of daily living

II

Neck pain and associated disorders with no signs or symptoms of major structural pathology, but major interference with activities of daily livinga

III

Neck pain and associated disorders with no signs or symptoms of major structural pathology, but presence of neurological signsb

IV

Neck pain and associated disorders with signs and symptoms suggestive of major structural pathology

Symptoms and disorders that can manifest in all grades include deafness, dizziness, tinnitus, headache, memory loss, dysphagia, and temporomandibular joint pain.

a Major structural pathologies include (but are not limited to) fracture, vertebral dislocation, injury to spinal cord, infection, neoplasm, or systemic disease including the inflammatory arthropathies.

b Neurological signs include decreased or absent deep tendon reflexes, weakness, and sensory deficits. Adapted from Haldeman et al. A best evidence synthesis on neck pain: findings from the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008. 33 (supp) pS1-220, with permission from Lippincott Williams and Wilkins.

Investigation of patients with neck pain—who and how?

Back pain and regional disordersPatients with grade I or grade II neck pain (nonspecific neck pain) do not usually require radiographic evaluation. Those with grade III and grade IV neck pain and associated disorders may require a baseline radiological examination, particularly if there is associated trauma. This should consist of plain films with anteroposterior, lateral, and open-mouth views. Degenerative changes in the discs and zygapophyseal joints increase with age and do not correlate with symptoms of neck pain. CT is helpful for evaluating the bony structures of the neck, but it must be combined with myelography to adequately visualize the neural tissues. MRI is therefore preferred in most cases with spinal cord or nerve root compromise. Fifty per cent of patients with chronic neck pain after motor vehicle collisions respond to diagnostic zygapophyseal joint injection, suggesting that these joints are responsible for their pain.

Management of patients with neck pain

Most treatments recommended for the management of patients with neck pain have not been evaluated in a scientifically rigorous manner. Those that have been have shown very little, if any, evidence of efficacy. These include soft cervical collars, zygapophyseal joint injections and acupuncture. Patients with acute neck pain should be encouraged to maintain their usual level of activity. There is evidence that non-narcotic analgesics, NSAIDs, exercise, mobilization, and manipulation are effective, whereas the promotion of rest and soft collars tends to prolong disability. Surgery is indicated only for patients with severe radiculopathy not responsive to 6 to 12 weeks of conservative management.

There is no consensus as to how best to manage patients with chronic neck pain.

Regional pain disorders

Regional musculoskeletal pain disorders, defined as painful conditions in a specific region of the body, are extremely common. A number of clinical entities have been described for the shoulder, elbow, wrist and hand, hip, knee, ankle, and foot regions (Table 19.4.4). Most of these can usually be identified by a careful history and directed physical examination, although recent research indicates that interobserver diagnostic agreement is only moderate for the conditions related to the shoulder region, particularly in patients complaining of severe or chronic pain, and those with bilateral involvement. Investigations are not usually required for the diagnosis of most regional pain disorders.

Table 19.4.4 Regional pain disorders

Diagnosis

Epidemiology

Clinical symptoms

Physical examination

Associations

Investigations

Treatment

Shoulder region

Rotator cuff tendinitis

Any age

Pain maximum in the deltoid region; increased at night and by specific movements

Painful arc of abduction 60–120 degrees. Full passive movements; pain aggravated by resisted movement of the involved tendon. Positive impingement signs

DM, repetitive movements

Radiograph in chronic cases may show cysts and sclerosis of greater tuberosity

NSAIDs, steroid injection, physio

Calcific tendinitis

Age 20–60

Acute severe pain on the tip of the shoulder

Limitation of both active and passive movements by pain. Occasional swelling when bursa involved

Calcification on radiograph

Rest in sling, NSAIDs, ?steroid injection

Adhesive capsulitis

Age > 40

Diffuse pain in the shoulder area. Progressive restriction of movements

Limitation of both active and passive movements in all directions (external rotation-abduction internal rotation)

DM, MI stroke, thyroid and pulmonary diseases

Arthrography

NSAIDs, steroid injection, physiotherapy, ?distension

Bicipital tendinitis

Very rare in isolation

Pain anterior aspect of the shoulder and deltoid region

Speed’s* and Yerganson’s manoeuvres non-specific

Rotator cuff tendinitis

None

NSAIDs, steroid injection

Rotator cuff rupture

Age > 40

Sudden pain deltoid area

Weakness of abduction if complete tear

US, arthrography, MRI

Surgery if acute and patient <65, NSAIDs physio otherwise

Elbow region

Lateral epicondylitis

Age 40–60

Pain lateral epicondyle; may spread up and down the arm

Tenderness lateral epicondyle; increased by resisted extension of the wrist

Over use

NSAIDs, physio, steroid injection

Medial epicondyltiis

15 times rarer than lateral epicondylitis

Pain medial epicondyle

Tenderness medial epicondyle; increased by resisted flexion of the wrist

Over use

NSAIDs, physio, steroid injection

Olecranon bursitis

Swelling ± pain olecranon bursa

Swelling ± erythema ± tenderness

Trauma, RA, gout

Bursal aspiration: cell count, Gram stain, culture, crystals

NSAIDs, steroid injection, antibiotics if septic

Wrist and hand region

DeQuervain tenosynovitis

Women, age 30–50

Pain radial aspect of wrist and thumb base during pinching

Tenderness ± swelling abd.pol.longus. Finkelstein manoeuvre +

NSAIDs, splinting, steroid injection

Trigger finger

Any age

Pain palm of hand; snapping finger

Tenderness ± swelling ± nodule flexor tendon

Diabetes, RA

NSAIDs, steroid injection

Dupuytren’s contracture

Males, age 40–80

Flexion contracture of 4th and 5th fingers

Thickening palmar aponeurosis

Alcohol, liver disease, DM

?Steroid injection

Hip region

Trochanteric bursitis

Women, age 40–70

Pain lateral aspect of hip and thigh; worse at night; increased by lateral decubitus

Tenderness greater trochanter

Hip OA, obesity

NSAIDs, steroid injection

Knee region

Prepatellar bursitis

Women

Swelling ± pain anterior aspect of knee

Tenderness greater trochanter

Kneeling

Synovial fluid aspiration

NSAIDs, steroid injection

Patello-femoral syndrome

Age 15–40

Pain anterior knee, increased in stairs and by squatting

Tenderness patella ± patellofemoral crepitus

?NSAIDs, exercises

Anserine bursitis

Women, age 40–60

Pain medial aspect upper tibia

Tenderness medial aspect of tibia

Knee OA, obesity

Rest, NSAIDs, steroid injection

Popliteal cyst

Any age

Pain, stiffness, swelling posterior knee

Swelling posterior knee. Leg swelling if rupture

Inflammatory arthritis

Steroid injection

Ankle and feet

Achilles tendinitis

Age 20–50

Pain over Achilles tendon

Tenderness ± swelling ± crepitus over Achilles tendon

Spondylarthropathies

Rest, NSAIDs

Plantar fasciitis

Pain plantar aspect foot

Tenderness heel, increased by passive flexion of the toes

Spondylarthropathies

Orthotics; weight reduction; steroid injection

Morton’s neuroma

Women, age 40–60

Burning pain interdigital clefts increased by walking

Tenderness interdigital cleft; rarely sensory alteration, cleft 4th toe

Pes planus, pes cavus, tight shoes

Proper shoes, surgery

* Speed’s manoeuvre: the examiner resists shoulder forward flexion while the patient’s arm is held in extension and supination. A positive test causes pain in the biccipital groove.

† Yergason’s test: the patient’s elbow is flexed to 90 degrees and the forearm pronated. The examiner resists the patient’s attempts to flex and supinate the forearm. A positive test causes pain in the biccipital groove.

‡ Finkelestein’s manoeuvre: the patient’s thumb is flexed inside the fingers and the wrist is passively deviated in an ulnar direction. A positive test results in pain over the abductor pollicis longus and extensor pollicis brevis tendons at the wrist.

Abbreviations: DM, diabetes mellitus; NSAIDs, non-steroidal anti-inflammatory drugs; physio, physiotherapy; MI, myocardial infarction; US, ultrasonography; MRI, magnetic resonance imaging; RA, rheumatoid arthritis; OA, osteoarthritis.

Adapted from Spitzer et al. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders (WAD): Redefining “whiplash” and its management. Spine 1995. 20 (supp) pS1-73. With permission from Lippincott Williams and Wilkins.

NB: For internet usage, a link must be included to the LWW website: http://lww.com

In a patient presenting with regional pain, one should aim to determine whether the pain has its origin in the bones and joints, periarticular soft tissues (tendons, bursa, and fascia), nerve roots and peripheral nerves, or blood vessels, or if it is referred from distant musculoskeletal or visceral structures. Lesions of the periarticular soft tissues account for most causes of regional pain disorders. Plain radiographs are helpful in delineating soft tissue calcification that may or may not be related to the pain presented by the patient. Ultrasonography and MRI are of equal value in confirming a diagnosis of tendon rupture in the shoulder, knee, or ankle regions.

The principles of management include temporary rest, analgesics or NSAIDs, local corticosteroid injections, thermal modalities, orthotics, and graded flexibility and strengthening exercises.

Diffuse musculoskeletal pain

Between 8 and 10% of adults report suffering from chronic diffuse musculoskeletal pain, and about half of these satisfy the classification criteria for fibromyalgia. The aetiology of fibromyalgia is unknown, but recent data indicate that psychological distress is a strong predictor of the development of this condition. Although the pain is felt primarily in the muscles, the muscles show no histological or metabolic abnormalities other than those associated with physical deconditioning. Management that includes patient education, cognitive-behavioural approaches, regular aerobic training, and low-dose tricyclic agents generally provides benefit only to few patients. For further discussion see Chapters 19.2 and 26.5.3.

Further reading

Airaksinen O, et al. (2006). Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J, 15 (Suppl. 2), S192–300.Find this resource:

Burton AK, et al. (2006). Chapter 2. European guidelines for prevention in low back pain. Eur Spine J, 15 (Suppl. 2), S136–68.Find this resource:

Carette S, Fehlings MG (2005). Cervical radiculopathy. New Engl J Med, 353, 392–9.Find this resource:

Gupta A, et al. (2006). The role of psychosocial factors in predicting the onset of chronic widespread pain: results from a prospective population-based study. Rheumatology, 46, 666–71.Find this resource:

Haldeman S, et al. (2008). Best evidence synthesis on neck pain: findings from the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 33(4 Suppl), S1–220.Find this resource:

    Koes BW, et al. (2010). An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J, 19, 2075–94.Find this resource:

    Lawry G, et al. (2010). Fam’s musculoskeletal examination and joint injection techniques, 2nd edition, Mosby Elsevier, St Louis.Find this resource:

      Linton SJ, Halldén K (1998). Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain. Clin J Pain, 14, 209–15.Find this resource:

      Loney PL, Stratford PW (1999). The prevalence of low back pain in adults: a methodological review of the literature. Phys Ther, 79, 384–96.Find this resource:

      MacGregor AJ, et al. (2004). Structural, psychological, and genetic influences on low back and neck pain: a study of adult female twins. Arthritis Rheum, 51, 160–7.Find this resource:

      Mease P (2005). Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures and treatment. J Rheumatol Suppl 75, 6–21.Find this resource:

      Manek NJ, MacGregor AJ (2005). Epidemiology of back disorders: prevalence, risk factors, and prognosis. Curr Opin Rheumatol, 17, 134–40.Find this resource:

      Schwarzer AC, et al. (1994). The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine, 19, 801–6.Find this resource:

      Schwarzer AC, et al. (1995). The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 20, 1878–83.Find this resource:

      Schwarzer AC, Aprill CN, Bogduk N (1995). The sacroiliac joint in chronic low back pain. Spine 20, 31–7.Find this resource:

      Suri P, et al. (2010). Does this older adult with lower extremity pain have the clinical syndrome of lumbar spinal stenosis? JAMA, 304, 2628–36.Find this resource:

      Winters ME, Kluetz P, Zilberstein J (2006). Back pain emergencies. Med Clin North Am, 90, 505–23.Find this resource: