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 1). 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.
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.
|Table 1 Regional pain disorders|
|Diagnosis||Epidemiology||Clinical symptoms||Physical examination||Associations||Investigations||Treatment|
|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|
|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|
|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|
|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.