Musculoskeletal Pain Assessment: Key Questions

• Differential Diagnosis in Physical Therapy Practice
• Michael Garrison, PT, DSC, Board-Certified Clinical Specialist in Sports Physical Therapy and Orthopedic Physical Therapy, Clinical Associate Professor

Agenda

• Introduction to the topic
• Examination of the relevance to Physical Therapists (PTs)
• Identification of emergent and urgent conditions
• Discussion of red flags and screening
• Recognition of constitutional signs and symptoms
• Understanding common systemic symptoms and questions
• Overview of axial spondyloarthropathy (ankylosing spondylitis)
• Consideration of clinical realities

Introduction

• Back pain is a pervasive condition, often benign and self-limiting.
• Most cases of back pain are related to musculoskeletal issues like DDD, sprains, facet joint problems, or nonspecific pain in the lower back or neck.
• Some back pain originates from sources other than the spine.
• It's vital to recognize and refer when appropriate to avoid delays in diagnosis and treatment and to ensure appropriateness for PT.
• Approximately 2% of cases of lower back pain (LBP) are due to non-musculoskeletal issues.
• Response to musculoskeletal interventions can be useful.
• Defensible documentation is critical to align with MSK etiology.
• Monitor and document rehab progress, and define patient goals using the SMART format.

Importance to PT

• Direct access providers, Physical Therapists are often the first point of contact for patients.
• The primary care physician (PCP) may conduct a limited examination during telephone encounters, possibly leading to quick referrals based on previous conditions.
• Patients may present with multiple complaints at a primary care visit.
• There is limited time for primary care physicians to perform thorough examinations and limited MSK training.
• Patients may reveal new symptoms during physical therapy sessions.
• Symptoms can evolve or worsen after the primary care physician visit.

Physical Examination

• History and physical examination are critical components.
• Perform a systematic examination to identify different diagnoses.
• Differentiate between musculoskeletal and non-musculoskeletal presentations by age, onset, aggravating/easing factors, and positional night pain.
• History should be documented- a crucial element of differential diagnosis.
• In the differential diagnosis process, each possibility needs to be either ruled in or ruled out.
• Refer the patient to PCPs if there is still concern following an examination.

Compare and Contrast

• MSK related pain often begins suddenly due to trauma or overuse.
• Non-MSK pain starts spontaneously and happens without trauma
• MSK pain presents with local tenderness to palpation, stiffness, and relief with movement.
• Non-MSK pain presents as stabbing, throbbing, deep, and aching.
• MSK pain occurs with activity or in specific positions.
• Non-MSK pain is constant and can wake a person from sleep.

Flag System

• Red flags indicate potential serious pathology like Cauda Equina Syndrome (CES).
• Orange flags indicate psychiatric issues such as depression and anxiety; be thoughtful in questioning and documenting.
• Yellow flags indicate beliefs and pain behavior.
• Blue flags indicate work-related issues, boss-employee dynamics, and job tasks.
• Black flags indicate systemic or contextual barriers like insurance, workers' compensation legislation, or family dynamics that are either helpful or unhelpful.

Red Flags

• Age over 50 with traumatic incidents.
• History of cancer.
• Fever, chills, and night sweats.
• Unexplained weight loss of 10 pounds or more within 3 months.
• Recent infection or immunosuppression.
• Resting pain or non-positional night pain.
• Saddle anesthesia (cauda equina syndrome).
• New bowel or bladder dysfunction.
• It's essential to address symptoms documented and to document the negative.
• Can't reliably rule in a condition due to lack of specificity.
• Can't reliably rule out a condition due to lack of sensitivity.

Constitutional Symptoms

• Constitutional symptoms can indicate systemic disease and should be evaluated by a primary care physician (PCM).
• These include fever, diaphoresis, night sweats, nausea, vomiting, diarrhea, pallor, dizziness, syncope, fatigue, and weight loss.

Example Scenario involving a constitutional symptom

• A 14-year-old male soccer player comes for PT because of left shoulder pain, with no MOI and no primary care visit.
• The pain is in his left scapula.
• Movement of either upper extremity induces pain.
• There are no pain reducers.
• The patient feels nauseous, and vomited yesterday after taking a knee to the abdomen.
• If a patient has been struck in the abdomen and reports vomiting, this is concerning.

Example Scenario Outcome

• Question a patient reporting with shoulder pain further.
• See if they have dizziness or left abdominal pain.
• Assess bruising in the left upper quadrant and if possible, a light abdominal palpation.
• As a result, the patient may be diagnosed with a lacerated spleen.

Kehr's Sign

• Ruptured spleen symptom
• Discovered by German surgeon Hans Kehr
• Is actually referred pain from phrenic nerve irritation
• Irritation of the diaphragm from a spleen injury may result in this.
• Left shoulder indicates spleen issues when the patient is supine and upper left quadrant palpated.
• Right shoulder indicates potential gallbladder or liver problems.
• Consult a physician if Kehr's sign is present.
• C3-5 keeps you alive

Example

• A 59-year-old male office worker was referred to PCN for LBP.
• The patient reports 2 months of lower lumbar pain with no MOI, or imaging of the area.
• The patient has a 20 year history of lower back pain usually relieved with time and exercise.
• There's no relief with change of position or time of day.
• The patient reports a throbbing pain in the stomach that happens at night.
• An exam of his abdomen should be performed.

Emergent Conditions

• It is possible for medical emergencies can present.
• Some patients may be walking in the clinic talking.
• However, initial symptoms can involve back or shoulder pain.
• Abdominal Aortic Aneurysm (AAA) is 4x more common in men.
• Risk factors can include CVD, HTN, and atherosclerosis.
• Patients with these conditions may show pulsatile abdominal mass.
• Myocardial Infarction involves mid-back pain radiating to the shoulder.
• Nausea, vomiting, and diaphoresis are also symptoms.

Abdominal Aortic Aneurysms

• Majority of cases are in patients aged 65 and older
• It's a frequent cause of death for elderly patients.
• The condition is discovered 75% of the time.
• Look for radiologic workups of certain symptoms.
• Note common symptoms like back, groin, and buttock pain.
• Other symptoms: Early satiety, nausea, weight loss
• Throbbing or pulse-like pain
• Abdominal palpation for pulsatile mass

Lung Cancer

• The PT recommends patient receive a shoulder X-Ray
• Apical opacity is on their right lung
• Imaging has metastatized to their brain
• Delayed diagnosis can impact treatment options.
• MSK issues respond to MSK interventions
• Continuing PT without progress is not indicated
• It is important to know smoker guidelines
• X-rays are typically easy, and inexpensive to obtain
• If a patient smokes, and is elderly, get them an X-Ray

Lung Cancer Screening

• The 50-20-15 Rule is based on the following items:
  • 50 years old or older
  • 20 pack years or greater
  • Smoked within the last 15 years
• Pack years is calculated by PPD x Years of smoking
• 1 PPD for 30 years = 30 pack years
• 2 PPD for 10 years = 20 pack years
• New guidelines eliminate recency of cessation

Example

• 56-year-old male returns to PT with acute mid-back pain.
• Pain is improving, however he still feels weak, and fatigued.
• The patient has a history of tobacco use, so calculating back years with a chest X-Ray may be needed.
• Asks if you can look at a finger issue.
• Reports being able to flex IPJs 4 and 5, and extended MCPs.
• A positive Froment's test is present along with EDM, EDC, and EDI weakness.

Further Scenario

• Further identify a patient with a claw hand deformity, which may involve a nerve issue, root level problems, brachial plexopathy, lower brachial plexopathy, or Pancoast tumor, superior lobe lung cancer.

Gastrointestinal Symptoms

• Watch for back pain, and abdominal pain at the same level of the body.
• Pain might be associated with meals for gastrointestinal problems
• Pains may also be present with heartburn
• The patient might also report Dysphagia (difficulty swallowing), or unintended weight loss.
• Consider abdominal palpation near McBurney's Point; if there's tenderness, the patient might have appendicitis.
• You may observe Sacral pain with the Valsalva maneuver.

Pulmonary Symptoms

• Signs include persistent fevers, chills
• Inspiration may aggravate their pain
• Back pain may be relieved with holding breath Rehabilitating back issues may require auto splinting (relief laying on painful side) Spinal movement wouldn't change rehabilitation.
• Finally, observe the patient to see if they have Tachycardia to observe changes in their arterial blood pressure.

Cardiovascular Symptoms

• Consider back pain, that is more throbbing
• Also consider vascular claudication which is relieved by rest.
• Look for pulsatile abdominal changes.
• Changes in temperature in one leg. One leg may be warmer, suggesting DVT. One leg may also be cooler, indicating arterial occlusion.
• With weight training there may be known CVDs. As such, the patient should avoid cardiovascular exercise.

Renal/Urologic Symptoms

• Dermatomal pain over T9-L1 dermatomal pain
• Back pain at the level of their kidney/costovertebral
• Back/Shoulder pain
• Associated signs/symptoms
  • Blood in urine, fever, chills
  • Increase urinary frequency
  • Difficulty starting/maintain the stream of urine
  • Testicular pain with history of traumatic fall, blow, or lift.

Example

• A 28 year old male works as an electrician, and presents with low back pain
• Has intermittent flares over past several years
• Referred from PCM, no MOI, normal x-rays
• Feels better with activity and NSAIDs
• Pain happens in the morning, or during periods of prolonged driving.
• Recent medical history includes chronic GI issues that is treated with NSAIDs, has flares of psoriasis.
• Intermittent bilateral achilles tendonitis

Axial Spondyloarthritis

• The patient also reports LBP, without a specific injurym and falls under the care of their health provider.
• It's a chronic Inflammatory & Rheumatic disease
• Can result in spine fusion/disability
• Types of AxSpA:
  • AS is a structural changes on the x-ray
  • Non radiographic spondyloarthritis can lead to structural changes, which makes it harder to treat
• Observe extra Articular Manifestations
• Observe Uveitis, Enthesitis (calcaneus)
• Observe if the patient has Psoriasis or irritable bowel disorder
• Delay in diagnosis results in worse outcomes.

Axial Spondyloarthritis (cont.)

• Key sign is LBP, which often attributed to MSK cause; especially in absence of radiographic AS findings.
• Often a 10 delay in diagnosis
• Rx may help stop progression.
• Can also refer to a rheumatologist.
• Age of onset is <45 and one of the following
• IBP, (+) HLA-B27, sacroiliitis on MRI, EAMS
• Liap finding with ankying spondyviris
• Good response to NSAIDs

Inflammatory Back Pain

• Insidious onset of pain.
• Duration of >3 months
• Relieved by exercise
• No Relief to the body with rest
• If morning stiffness is present for > 30 min:
• Alternating buttock
• Good response to NSAIDs
• Pt reports positional night pain, it might be appropriate to order a MRI
• Patient may require a new MRI due to signal changes on the I joint.
• Note: If the patient meets 3/5 criteria, they should be more concerned about inflammation.

Identifying AxSpA w/ PT

• ID patient's needing referral
• Often see LBP patient's
• PCN may not be aware of the importance of IBP signs
• Early treatment can prevent patient's condition.
• Progression is more common in men, and smokers.
• Look for + lab findings (HLA-B27, ESR, CRP)
• PT can treat specific symptoms, but Rheumatology referrals is the most important action.

Clinical Reality

• Real textbook cases are rare.
• PT can manage with suspected non-MSK cases.
• Response to MD interventions can be helpful
• Urgent/emergent cases that require immediate referral.
• Always err on the side of caution!
• Documentation reflects patient's appropriateness.
• Review records for centrical events that may need definable documentation.

Explore key questions for assessing musculoskeletal pain. Identify systemic causes, Cauda Equina Syndrome, and abdominal trauma. Understand the importance of documenting negative findings and smoking history.