Regional Pain Disorders

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
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.