joint/limb pain differential diagnosis

 


 PE:
1) Shoulder Pain:

• Head and neck exam: Checked for bruises, neck movements and signs of head trauma
• Exam of the arms: Compared both arms in terms of strength, range of motion (shoulder, elbow, wrist), sensation, DTRs, pulses

2) Lower back pain:

• Back exam:Inspection, palpation, range of motion
• Extremities: Inspection, palpation of peripheral pulses, hip exam
• Neuro exam: Motor, DTRs, Babinski sign, Gait (including toe and heel walking), passive straight leg raising, sensory exam

3) Calf Pain:

• Extremities: Inspection, palpation; checked for Homans’ sign
• Joint exam:  Inspection, palpation, range of motion (knee, ankle, hip joint on both sides)
• Neuro exam: Sensory and motor reflexes (knee, ankle)

4) HeelPain:

• Extremities: Palpation of medial calcaneal tuberosity, Achilles tendon, plantar fascia, retrocalcaneal bursa.  Passive range of motion and general strength of ipsilateral knee and hip.  Ankle dorsifl exion and great toe extension and passive range of motion; strength testing of ankle dorsifl exion and plantarflexion
• Neuro: Checked sensation to light touch for dermatomes of foot and ankle; assessed Achilles tendon reflex

DIFFERENTIAL DIAGNOSIS for Musculoskeletal Pain Mnemonic

1) Shoulder Pain:

• Shoulder dislocation
• Rotator cuff tear
• Clavicular fracture
• Humeral fracture 
• Osteoporosis
• Elder abusE

2) Lower Back Pain:

• Lumbar muscle strain
• Disk herniation
• Lumbar spinal stenosis
• Metastatic prostate cancer
• Tumor in the vertebral canal
• Vertebral compression fracture
• Multiple Myeloma
• Malingering 
• Ankylosing spondylitis

3) Calf Pain:

• Deep venous thrombosis
• Cellulitis
• Myositis
• Rupture of Baker’s cyst 
• Hematoma
• Spasm due to injury or sprain

4) Heel Pain:

• Plantar fasciitis 
• Calcaneal stress fracture
• Achilles tendinitis
• Retrocalcaneal bursitis
• Tarsal tunnel syndrome
• Foreign body
• Ankle sprain
•  

KNEE PAIN - SPORTS
S - Septic arthritis
P - Pseudogout, Psoriatic arthritis, Patela-femoral pain syndrome
O- Osteoarthritis
R - Rheumatoid arthritis, Reactive arthritis
T - Tophi (Gout), Trauma (fall, elderly abuse, sports)
S- Sac inflammation (Bursitis)

FOOT PAINS
Fat atrophy ( age related) + foreign body , 

osteomyelitis ,

osteoporosis, 

tarsal tunnel syndrome , tendonitis, tumor, 

plantar facitis , periostitis, 

apophysitis ,arthritis ( rheumatoid , reactive,)

 ischemic ( peripheral vascular disease) , 

nerve entrapment ,

 stress fracture in athletes and spur in bones

 

DIAGNOSTIC WORKUP for Musculoskeletal Pain Mnemonic

1) Shoulder pain:

• XR of the shoulder and arm
• MRI—shoulder
• Bone density scan (DEXA)

2) Lower back pain:

• Rectal exam
• XR—Lower spine
• MRI—Lower spine
• PSA
• CBC, calcium, BUN/Cr
• Serum and urine protein electrophoresis

3) Calf pain:

• Doppler U/S of the lower extremities
• D -dimer
• Hypercoagulability testing
• CBC with differential
• CPK and myoglobin level
• CT venography
• MRI

4) Heel pain:

• XR—right ankle
• Bone scan
• MRI

case 1 
30y F w wrist pain and black eye after tripping, falling, hitting head on edge of table. Looks anxious and gives inconsistent story.

ddx :

• Domestic violence

• factitious d/o

•  substance abuse)

W/U:

 XR-wrist, CT-head, urine tox

case 2

30y F secretary w/ wrist pain and numbness/burning in palm and 1st, 2nd, 3rd R phalanges. Pain worse at night, relieved by loose shaking of hand. +Sensory loss on affected digits. PE: +Tinel sign.

ddx:

• Carpal tunnel syndrome
• (median nerve compression in forearm/arm,
•  C6/C7 radiculopathy)

W/U:

•  nerve conduction study, 
• EMG

case 3

28y F w/ pain in interphalangeal joints a/w hair loss and rash on face.

ddx 

• SLE
• (RA, 
• psoriatic arthritis,
•  parvovirus B19)

W/U: 

• ANA,
•  anti-dsDNA, 
• ESR, 
• C3/C4, 
• RF, 
• CBC, 
• XR-hands,
•  U/A

case 4

28y F w/ pain in metacarpophlanageal joints. Left knee painful and red. +Morning stiffness x1hr. FHx RA.

ddx

• RA
• (SLE,
•  disseminated gonorrhea, I
• BD-associated arthritis,
•  osteoarthritis)

W/U: 

• ANA, 
• anti-dsDNA,
•  CCP, 
• ESR,
• RF,
•  CBC, 
• XR-hands/L knee, 
• cervical culture, 
• arthrocentesis w/ synovial fluid analysis
•  

case 5

18y M w/ pain in intraphalangeal joints bilaterally. +Scaly, salmon-pink lesions on extensor surface of elbows/knees.

ddx

• Psoriatic arthritis
• RA, 
• SLE

W/U:

•  RF,
•  ANA,
• ESR,
•  CBC, 
• XR-hands/pelvis/sacroiliac, 
• uric acid

case 6

65y F w/ inability to use L leg or bear weight s/p tripping on carpet. Menopause x20yrs ago, no hx of HRT or Ca supplements. PE: L leg is externally rotated, shortened, adducted, tenderness in L groin.

ddx 

• Hip fracture
• (hip dislocation, 
• pelvic fracture)

W/U:

•  XR-hip/pelvis,
•  CT-hip, 
• MRI-hip,
•  CBC, 
• serum Ca, 
• serum VitD, 
• DEXA scan

case 7

40y M w/ R groin pain s/p motor vehicle accident. PE: R leg flexed at hip, adducted, internally rotated.

ddx

• Hip dislocation 2/2 trauma
• (hip fracture)

W/U:

•  XR-hip, 
• CT-hip, 
• MRI-hip, 
• CBC, 
• PT/PTT, 
• Blood type and cross/match, 
• Urine tox,
•  blood EtOH level

 case 8

56y obese F w/ R knee stiffness and pain worse w/ movement. Sx worsened x10yrs. +Swelling and deformity of joint, difficulty walking.

ddx

• Osteoarthritis
•  (pseudogout, 
• gout, 
• meniscal/ligamental damage)

W/U:

•  XR-knee, 
• CBC,
•  ESR,
•  knee arthrocentesis &
•  synovial fluid analysis [cell cout, Gram stain, culture, crystals], 
• MRI-knee

case 9

45y M w/ fevers and R knee pain w/ swelling and redness.

ddx 

• Septic arthritis
• (gout, 
• pseudogout, 
• lyme arthritis,
•  trauma,
•  reactive arthritis)

W/U: 

• CBC, 
• knee arthrocentesis and 
• synovial fluid analysis [cell count, Gram stain, culture, crystals], 
• blood cx, 
• urethral cx, 
• XR-knee, 
• uric acid,
•  lyme Ab

case 10

65y M w/ R foot pain. Training for marathon.

ddx

• Stress fracture
• (plantar fasciitis,
• foot sprain/strain)

W/U: 

• XR-foot, 
• bone scan-foot, 
• MRI-foot

case11 

65y M w/ pain in R heel most notable in first few steps then improves w/ walking. No hx trauma.

ddx

• Plantar fasciitis
• (heel fracture, 
• splinter/foreign body)

W/U: 

• XR-heel, 
• bone scan

case 12

55y M w/ pain in elbow playing tennis. Grip impaired due to pain. PE: tenderness on lateral epicondyle, pain on resisted wrist dorsiflexion w/ elbow extended (Cozen test) 

DDX:

• Lateral epicondylitis (Tennis elbow)
• (stress fracture)

W/U:

•  XR-arm,
•  bone scan, 
• MRI-elbow

case 13

27y F w/ painful wrists & elbows, swollen/hot knee joint painful on flexion, rash on limbs, vaginal discharge. Sexually active w/ multiple partners w/ occasional condom use.

DDX

• Disseminated gonorrhea
• (RA, 
• SLE, 
• psoriatic arthritis, 
• reactive arthritis)

W/U: 

• knee arthrocentesis & 
• synovial fluid analysis [cell count, Gram stain, culture], 
• ANA,
•  anti-dsDNA, 
• ESR,
•  RF
• , CBC,
• blood cx, 
• cervical cx, 
• XR-knee

CASE 14

60y F w/ pain in both legs induced by walking, relieved by rest. Hx CABG x6mo, current smoker.

DDX

• PVD (intermittent claudication)
• (Leriche syndrome [aortoiliac occlusive disease], 
• lumbar spinal stenosis [pseudoclaudication], 
• osteoarthritis

W/U: 

• ankle-brachial index,
•  doppler U/S-LE, angiography, 
• MRI-lumbar spine

CASE 15

45y F w/ R calf pain. Started on OCPs 2mo ago for dysfunctional uterine bleeding. PE: tender, warm, swollen R calf.

DDX

• DVT
• (Baker cyst rupture, 
• myositis, 
• cellulitis, 
• superficial venous thrombosis)

W/U: 

• doppler U/S - R leg,
• CBC, 
• CPK,
•  D-dimer, 
• PT/PTT/fibrinogen,
•  XR-R leg

 CASE 16

60y F w/ L arm pain started when swimming, relieved by rest.

DDX

• Angina/MI
• (tendonitis, 
• osteoarthritis, 
• shoulder dislocation)

W/U: 

• CPK-MB, 
• troponin
• , EKG,
•  CBC,
•  ESR, 
• XR-shoulder, 
• CXR, 
• echocardiography, 
• stress test

 CASE 17

50y M w/ R shoulder pain s/p falling on outstretched hand while skiing. PE: deformity of shoulder, holding R arm.

DDX

• houlder dislocation
• (humerus fracture, 
• rotator cuff injury)

W/U:

•  XR-shoulder, 
• XR-arm, 
• MRI-shoulder

CASE 18

55y M w/ crampy b/l thigh and calf pain, fatigue, dark urine. Hx simvastatin and clofibrate for HLD.

DDX

• Rhabdomyolysis 2/2 simvastain or clofibrate
• (polymyositis,
•  inclusion body myositis, 
• thyroid disease)

W/U: 

• CBC, 
• electrolytes,
•  CPK,
•  aldolase,
•  U/A,
• urine myoglobin, 
• TSH