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Chapter 9
Differential Diagnosis
Overview


Differential diagnosis involves the
ability to quickly differentiate those
problems of a serious nature from
those that are not
Problems of a serious nature include,
but are not limited to visceral diseases,
cancer, infections, fractures and
vascular disorders
Referred Pain

The term referred pain is used to
describe those symptoms that have
their origin at a site other than where
the patient feels the pain
Referred pain

Referred pain can be generated by:
Convergence of sensory input from separate
parts of the body to the same dorsal horn
neuron via primary sensory fibers
 Secondary pain resulting from a myofascial
trigger point
 Sympathetic activity elicited by a spinal reflex
 Pain-generating substances

Referred Pain

Macnab recommends the following
classification for referred pain:
– Viscerogenic
– Vasculogenic
– Neurogenic
– Psychogenic
– Spondylogenic
Viscerogenic Pain

Viscerogenic pain may be produced
when the nociceptive fibers from the
viscera, synapse in the spinal cord,
with some of the same neurons that
receive pain from the skin.
Viscerogenic Pain

Visceral pain has five important
clinical characteristics:
1.
2.
3.
4.
5.
It is not evoked from all viscera
It is not always linked to visceral injury
It is diffuse and poorly localized
It is referred to other locations
It is accompanied with autonomic
reflexes, such as the nausea, and
vomiting
Vasculogenic Pain


Vasculogenic pain tends to result from
venous congestion or arterial
deprivation to the musculoskeletal
areas
Tends to mimic a wide variety of
musculoskeletal, neurologic, and
arthritic disorders, as this type of pain
is often worsened by activity
Neurogenic Pain


Neurogenic pain is pain that is referred from
a neurological structure.
Neurogenic causes of pain may include:
– A tumor compressing and irritating a neural
structure of the spinal cord, meninges
– A spinal nerve root irritation
– Peripheral nerve entrapment
– Neuritis
Scanning Examination

The tests of the Cyriax upper or lower
quarter scanning examination can be
used to:
Examine the patient’s neurological status
 Highlight the presence of a lesion to the
central or peripheral nervous systems
 Help rule out any serious pathology such as a
fracture or tumor

Scanning Examination


The upper quarter scanning
examination is appropriate for upper
thoracic, upper extremity, and cervical
problems
The lower quarter scanning
examination is typically used for
thoracic, lower extremity, and
lumbosacral problems
Scanning Examination

The tests included in the scanning
examination include strength testing,
sensation testing (light touch and pinprick), deep tendon reflexes, and the
pathological reflexes
Scanning Examination

At the end of each of the scanning
examinations, either a medical
diagnosis (disc protrusion, prolapse, or
extrusion, acute arthritis, specific
tendonitis, or muscle belly tear,
spondylolisthesis or stenosis) can be
made, or the scanning examination is
considered negative
Psychogenic Pain
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

Psychogenic (non-organic) pain is
characterized by abnormal illness behaviors
Commonly exhibited by patient’s suffering
from depression, emotional disturbance, or
anxiety states
All patients should be given the benefit of
the doubt until the clinician, with a high
degree of confidence, can rule out an
organic cause for the pain
Spondylogenic Pain


Spondylogenic pain is pain referred
from a vertebral lesion
Characteristics of a spondylogenic
lesion include:
– Severe and unrelenting pain
– The presence of a fever
– Bone tenderness
– Unexplained weight loss
Generalized Body Pain

Two conditions that can cause
generalized body pain:
– Fibromyalgia
– Myofascial pain syndrome (MPS)
Fibromyalgia


Poorly understood complex of generalized
body aches that can cause pain or
paresthesias, or both, in a non-radicular
pattern
Not a disease, but rather a syndrome with a
common set of characteristic symptoms,
including widespread pain and the presence
of a defined number of tender points
Fibromyalgia

A positive tender point count of 11 or
more of 18 standardized sites, when
present in combination with the
history of widespread pain, yields a
sensitivity of 88.4% and a specificity
of 81.1% in the diagnosis of
fibromyalgia
Myofascial Pain
Syndrome

Characterized by the presence of
myofascial trigger points (MTrPs)
– A MTrP is a hyperirritable location,
approximately 2 to 5 cm in diameter,
[86]within a taut band of muscle fibers,
that is painful when compressed and that
can give rise to characteristic referred
pain, tenderness, and tightness
Causes of Head and Facial
Pain


Trauma
Headaches
– Migraine

Two types of migraine headaches: migraine without
aura (common migraine), and migraine with aura
– Migraine without aura: Symptoms are typically unilateral
with a pulsating quality of moderate or severe intensity.
Aggravated by routine physical activity, and is associated
with nausea, auras, photophobia, and phonophobia
– Migraine with aura: Characterized by reversible aura
symptoms, which typically develop gradually over more
than 4 minutes, but last no longer than 60 minutes
Causes of Head and Facial
Pain

Headaches
– Cluster


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Severe unilateral retro-orbital headaches
Often accompanied by nasal congestion, eye-lid
edema, rhinorrhea, miosis, lacrimation, and ptosis
(drooping eyelid) on the symptomatic side
Patient’s feel better during a headache by remaining in
an erect posture and moving about
– Tension-type


Those associated with a disorder of the pericranial
muscles, and those not associated with this type of
disorder
Characterized by a bilateral non-throbbing ache in the
frontal or temporal areas, and spasm, or hypertonus of
the neck muscles
Causes of Head and Facial
Pain

Headaches
– Benign exertional


Headache is specifically brought on by physical
exercise, particularly with straining and valsalva type
maneuvers such as those seen in weightlifting
Bilateral, throbbing in nature at onset and may develop
migrainous features in those patients susceptible to
migraine
– Effort induced


Differ from the exertional headaches in that they are
not necessarily associated with a power or straining
type of exercise
Occur more frequently in hot weather
Causes of Head and Facial
Pain

Headaches
– Occipital

Likely referred from a cervical disorder
– The underlying musculoskeletal mechanism for this type
of headache is often structural, including cervical
hypomobility or hypermobility, joint subluxation,
degenerative bony changes, or poor posture
– Hypertensive

Occurs in individuals with diastolic readings above 120
mm Hg, although the intensity of these headaches
does not necessarily parallel the height of the blood
pressure levels
Causes of Head and Facial
Pain

Headaches
– External compression headache

This entity, formerly known as ‘swim-goggle headache’,
presents with pain in the facial and temporal areas
produced from wearing excessively tight face masks or
swimming goggles
– Idiopathic carotidynia


Unilateral facial or orbital pain in half of the patients
with this condition
Most commonly located in the frontotemporal area, but
it occasionally involves the entire hemicranium or the
occipital area
– Chronic daily

Follows trauma to the head or neck
Causes of Head and Facial
Pain

Headaches
– Post-traumatic
More prolonged and enduring headache than
chronic daily
 May be associated with subdural hematoma,
an epidural hematoma, an intracerebral
hematoma, an aneurysm, a subarachnoid
hemorrhage or a cerebral contusion

Causes of Head and Facial
Pain

Occipital neuralgia
– A rare neuralgic disorder involving the greater
occipital nerve

Glossopharyngeal neuralgia
– Characterized by intense unilateral attacks of
pain in the retrolingual area radiating to the
depth of the ear
– The pain is typically aggravated by movement or
contact with the pharynx, especially with
swallowing
Causes of Head and Facial
Pain

Trigeminal neuralgia
– Chronic pain syndrome characterized by
dramatic, brief stabbing or electric shock-like
pain paroxysms felt in one or more divisions of
the trigeminal distribution, either spontaneously
or on gentle tactile stimulation of a trigger point
on the face or in the oral cavity

Bell’s palsy
– A lower motor neuron disease of the facial nerve
characterized by a wide range of facial muscle
movement dysfunction from mild paresis to total
paralysis
Causes of Head and Facial
Pain

Ramsay Hunt syndrome
– A herpetic inflammation of the geniculate
and/or facial nerve ganglia, manifests as
a peripheral facial nerve palsy
accompanied by an erythematous
vesicular rash on the ear (zoster oticus)
or in the mouth

Arteriovenous malformation
– Congenital malformation
Causes of Head and Facial
Pain

Meningitis
– An infection of the meninges and subarachnoid
space
– Classic triad of fever, neck stiffness, and an
altered mental status

Cerebrovascular disease
– Dependent on the size and location of the
hemorrhage

Intracranial bleed
– Dependent on the rate of arterial or venous
bleeding
Causes of Head and Facial
Pain

Tumor
– Tumors, benign or otherwise are spaceoccupying lesions that may increase to a
size that compresses nearby structures or
increases intracranial pressure

Encephalitis
– An inflammation of the brain
Causes of Head and Facial
Pain

Systemic infections
– Rocky Mountain Spotted Fever
– Lyme disease
– Pneumonia
– Pyelonephritis

Multiple sclerosis
– Optic neuritis
Causes of Head and Facial
Pain

Miscellaneous
–
–
–
–
–
–
–
–
–
Temporal arteritis
Acute sinusitis
Eclampsia
Cerebrospinal fluid (CSF) hypotension
Temporomandibular joint dysfunction
Peridontal disease
Thyroiditis
Fracture of the facial bones or skull
Trochleitis
Causes of Cervical Pain

Thyroid disease
– Widespread manifestations including cervical
pain


Subarachnoid hemorrhage
Retropharyngeal abscess
– Infection of the space anterior to the
prevertebral layer of the deep cervical fascia

Carotodynia
Causes of Cervical Pain
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
Cardiac disease
Trauma
Tumor
– Tumors of the adult cervical spine may be
primary, arising from the bone, or
secondary


Temporomandibular Joint Dysfunction
Meningitis
Causes of Cervical Pain
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Cervical disk disease
Vertebral artery disorder
Torticollis
Rheumatoid arthritis
– Cervical spine involvement is common in
rheumatoid arthritis

Ankylosing spondylitis
– Ankylosing spondylitis commonly affects the C 12 segment
Causes of Cervical Pain

Gout
– Although the occurrence of gout in the
neck is distinctly uncommon, the
medications used to treat it can have
serious side-effects in this region


Osteoarthritis
Occipital neuralgia
Causes of Thoracic Pain
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
Gastrointestinal conditions
Pancreatic carcinoma
Mediastinal tumors
– Although primary tumors of the thoracic spine
are rare, the thoracic spine is the most common
site for metastases

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Myocardial infarction
Pleuropulmonary conditions
Thoracic disk
Vertebral or rib fracture
Intercostal neuralgia
Causes of Thoracic Pain
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Epidemic myalgia
Costochondritis
Osteoarthritis
Rheumatoid arthritis
Ankylosing spondylitis
Diffuse Idiopathic Skeletal Hyperostosis
(DISH)
– Characterized by an ossification of the anterior
longitudinal ligaments and all related,
anatomically similar ligaments

Manubrium-sternal dislocations
Causes of Lumbar Pain
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Strain or sprain
Renal disorder
Epidural abscess
Prostatitis
Pleural dysfunction
Aortic aneurysm
Metastasis
Ankylosing spondylitis
Stiff-person syndrome
Causes of Buttock and
Upper and Lower Leg Pain
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Lumbar disc herniation
Femoral nerve neuropathy
Piriformis syndrome
Sacral plexopathy
Intermittent claudication
Conus medullaris syndrome
– Severe low back and buttock pain, lower limb
weakness, saddle hypesthesia or anesthesia.
Bowel and bladder changes are also frequently
reported

Meralgia paresthetica
Causes of Buttock and
Upper and Lower Leg Pain
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
Iliofemoral thrombophlebitis
Mononeuritis multiplex
– May occur in association with a number of other
medical conditions including rheumatoid arthritis
(RA), vasculitis, polyarteritis nodosa, diabetes
mellitus, sarcoidosis, and amyloidosis
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Ischial apophysitis and avulsion
Gluteal compartment syndrome
Genital herpes
Vascular Disorders
Causes of Pelvic Pain
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Sacroiliac arthritis
Acute appendicitis
Iliopsoas abscess
Iliopsoas hematoma
Sign of the buttock
Gynecologic disorders
Prostate cancer
Causes of Trochanteric,
Pubic, and Thigh pain
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Dislocation and fracture dislocation of the
hip
Labral tear
Hip or pelvis fracture
Pubic fracture
Femoral neck stress fracture
Osteoarthritis of the hip
Septic arthritis of the hip
Osteoid osteoma
Reiter’s syndrome
Causes of Trochanteric,
Pubic, and Thigh pain
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Synovitis of the hip in children or
adolescents
Avascular necrosis of the femoral
head
Iliopsoas abscess
Iliofemoral venous thrombosis
Obturator, femoral or inguinal hernia
Osteomyelitis of the pubis
Causes of Trochanteric,
Pubic, and Thigh pain

Compartment syndrome
 Myoneural anoxia results from a
prolonged increase in tissue pressure
within a closed osseofascial space. This
compromises local blood flow of skeletal
muscle, resulting in ischemia and
necrosis

Sexually transmitted disease
Causes of shoulder pain
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Tendinous and capsular lesions
Traumatic synovitis
Subluxation/dislocation
Spondyloarthropy
Acute arthritis
Infections/tumors
Clay shoveler’s fracture
 A traction fracture of the lower cervical or
upper thoracic spine due to an excessive pull
of the trapezius, rhomboid muscles during
heavy work
Causes of shoulder pain
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Degenerative conditions
Vascular conditions
Metabolic conditions
Osseous lesions
Muscular lesions
Cerebrovascular disease
Multiple sclerosis
Amyotrophic lateral sclerosis
Guillian-Barre
Causes of shoulder pain
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Syringomyelia
Cervical radicular pain
Elbow dysfunction
Myofascial pain syndrome
Peripheral nerve entrapment
Causes of shoulder pain
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Brachial plexopathy
Herpes Zoster
Gallbladder dysfunction
Cardiac dysfunction
Pulmonary dysfunction
Visceral
 Diaphragm
 Spleen
Causes of elbow and
forearm pain
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Fracture
Dislocation
Osteochondritis
Ligament sprain
Arthrosis
Peripheral nerve entrapment
Causes of elbow and
forearm pain
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Soft tissue injury or tendinitis (lateral
epicondylitis, medial epicondylitis, triceps
tendinitis, bicipital tendinitis, brachialis
tendinitis and Little League elbow)
Infective arthritis
Polyarthritis
Gout
Bursitis
Vascular disorder
Referred pain from shoulder/neck
Causes of wrist, hand and
finger pain
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Fracture
Sprains and dislocations
Triangular fibrocartilage complex (TFCC)
lesions
Tenosynovitis
Tendinitis
Carpal instability
Gout
Causes of wrist, hand and
finger pain
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Rheumatoid arthritis
Psoriatic Arthritis
Osteoarthritis
Carpal tunnel syndrome
Infection
Kienböck’s disease
Ganglia
Causes of wrist, hand and
finger pain
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Tumor
Peripheral nerve entrapment
Complex regional pain syndrome
Vascular occlusion
Scleroderma
Mononeuritis multiplex
Viscerogenic
Causes of generalized
Knee Pain
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Fracture (supracondylar, patellar, proximal
tibia)
Acute dislocation of the knee
Acute dislocation of the patella
Intra-articular ligament injury
Mono- and polyarthritis
Complex Regional Pain Syndrome
Referred pain from the hip or lumbar spine
Causes of anterior knee
pain

Musculoskeletal causes
– Osgood Schlatter’s disease
– Jumper’s knee
– Bipartite patella

Trauma-related causes
– Osteochondritis dissicans
– Bone contusion
Causes of anterior knee
pain

Miscellaneous causes
–
–
–
–
–
–
–

Tumor
Plical irritation
Hoffa’s syndrome
Osteomyelitis of the patella
Bursitis
Excessive lateral pressure syndrome
Maltracking of the patella
Iatrogenic causes
– Infrapatellar contracture syndrome
Causes of medial knee
Pain
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Medial meniscus tear
Medial collateral ligament sprain
Medial collateral bursitis
Hoffa’s disease
Pes anserine bursitis
Semimembranosus tendinitis
Causes of lateral knee
pain
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Iliotibial band friction syndrome
Popliteus tenosynovitis
Popliteus tendon rupture
Lateral meniscal tear
Lateral collateral ligament sprain
Tibiofibular disorder
Biceps femoris tendinitis
Osteochondral fracture of the lateral femoral
condyle
Causes of posterior knee
pain
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Gastrocnemius muscle strain or
rupture
Plantaris muscle strain or rupture
Hamstring muscle and tendon disorder
Rupture of a popliteal artery aneurysm
PCL/posterior capsule tear
Baker’s cyst
Causes of lower leg pain

Anterolateral lower leg pain
– Anterior compartment syndrome

The clinical signs of compartment syndrome are often
remembered by using the mnemonic of the 5 Ps: pain,
paresthesia, paresis, pallor, and pulses
– Lateral compartment syndrome

Often misdiagnosed as tenosynovitis of the tibialis
anterior and flexor hallucis longus, fibular stress
fracture, or a lateral gastrocnemius strain
– Irritation of the superficial peroneal nerve
– Muscle strain
Causes of lower leg pain

Calf pain
– Pyomyositis

–
–
–
–
–
–
Spontaneous muscle abscess of skeletal muscle
Fibula shaft fracture
Deep vein thrombosis
Hematoma
Rupture of Achilles tendon
Soleus muscle strain
Acute posterior compartment syndrome

Causes include a deep vein thrombosis, rupture of a
Baker’s cyst, and a spontaneous rupture of the medial
head of the gastrocnemius
Causes of lower leg pain

Anteromedial lower leg pain
– Stress fracture of the tibia
– Medial tibial stress syndrome
– Saphenous neuritis
– Osteomyelitis of the tibia
Causes of generalized
ankle pain

Crystal-induced arthropathies
– Gout and pseudogout

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Ligament sprain
Tendinitis
Fracture
Bursitis
Os trigonum
– Failure of the lateral tubercle, of the posterior
process, to unite with the body of the talus
during ossification, producing an impingement
with extreme plantar flexion
Causes of generalized
ankle pain

Osteochondritis dissecans (OCD)
– Actually a "transchondral fracture"
secondary to trauma
– Onset of pain is usually insidious, but
there may be some prior macrotrauma
Causes of generalized
foot pain
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Infection
Necrotizing fasciitis
Osteomyelitis
Rheumatoid Arthritis
Gout and pseudogout
Systemic lupus erythematosus (SLE)
Sickle cell disease
Complex regional pain syndrome
Peripheral vascular disease
Peripheral polyneuropathy
Causes of generalized
foot pain

Systemic causes:
–
–
–
–
–
–
–
–
–
–
Carcinoma
Leukemia
Lymphoma
Myeloma
Amyloidosis
Connective tissue diseases (polyarteritis nodosa,
SLE)
Renal failure
AIDS
Sarcoidosis
Cutaneous disorders
Causes of forefoot pain
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Metatarsalgia
Freiberg’s disease
Morton’s neuroma
Arthritis
Fracture
Forefoot sprain
Bursitis
Causes of plantar
hindfoot pain
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Fat pad disorders
Calcaneus stress fracture
Plantar fasciitis
Entrapment neuropathy of first branch
of lateral plantar nerve
Flexor tendinitis
Causes of posterior
hindfoot pain
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Superficial Achilles bursitis
Retrocalcaneal bursitis
Haglund’s syndrome
Achilles tendinitis/Achilles tendon
rupture
Calcaneal osteomyelitis
Causes of medial hindfoot
pain
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
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
Tibialis posterior tendinitis
Flexor hallucis longus tendinitis
Tarsal tunnel syndrome
Calcaneal fracture
Medial ankle sprain
Causes of lateral hindfoot
pain
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Peroneal muscle strain/tendinitis
Lateral ankle sprain
Osteochondral fracture of talar dome
Sural nerve entrapment
Stress fracture of lateral malleolus
Causes of medial forefoot
and great toe pain
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Nail lesions
Hallux valgus
Hallux rigidus
Arthritis of 1st MTP
Causes of midfoot pain
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Longitudinal arch strain
Aseptic necrosis of the navicular
Tendinitis of flexor hallucis longus or
peroneal tendinitis
Subtalar osteochondral fracture
Accessory navicular
Köhler’s Bone disease
Causes of midfoot pain
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Stress fracture of navicular
Acquired flatfoot
Osteoarthritis
Plantar fascial pain
Cuboid subluxation syndrome
Causes of dorsal foot pain

Tendinitis of:
– Extensor hallucis longus
– Extensor digitorum longus
– Tibialis anterior