Jerry O. Ciocon MD
Diana J. Galindo MD
Daisy G. Ciocon PhD, ARNP
Patients with pain often seek immediate relief and alleviation of discomfort. Success of treatment depends on the accuracy of the diagnosis and provision of the most appropriate medications. Prescription drugs (eg, analgesics, anti-inflammatory agents, and muscle relaxants) may be helpful, but appropriate trigger point injections might provide more effective treatment.
In many instances in this chapter, we recommend injections as a therapeutic modality. The amount of corticosteroid (Depo-Medrol) used should be ~40 mg for small areas and 80 mg for larger areas. Long-acting local anesthetics (eg, bupivacaine) are preferred and are mixed with the corticosteroid before injection. Complicated pain syndromes may benefit from evaluation and treatment by a physiatrist or anesthetist who specializes in pain management.
TEMPOROMANDIBULAR JOINT PAIN
ESSENTIALS OF DIAGNOSIS
Whiplash injury, head, neck, and facial trauma (direct and indirect) are common preceding events.
External stress, including dental malocclusion and external head and neck injuries, causes internal derangement of the synovial articular disk of the temporomandibular joint (TMJ), resulting in pain and joint dysfunction. The muscles of mastication, namely, the temporalis, masseter, pterygoids, trapezius, and sternocleidomastoids, tighten into spasm during joint injury, causing facial pain.
Regular dental maintenance, immediate medical attention after head and neck trauma, especially after a vehicular accident with whiplash injury, might help prevent muscle spasm that leads to myofascial pain.
Headache with pain in the ear and neck, with point tenderness in the internal and external portions of the TMJ, are the common findings.
Sedimentation rate may reflect inflammation of the joint (a nonspecific finding).
Radiographic imaging of the TMJ may not show any abnormalities, except perhaps for malalignment. Magnetic resonance imaging (MRI) may show irregularities of the synovial disk.
Injection of the joint with a small amount of anesthetic may serve as a diagnostic test to determine whether the TMJ is the source of pain.
The internal portion of the TMJ must be palpated, and the pain should be reproduced to give a definite diagnosis.
Cervicalgia, cervical degenerative disk disease, tooth abscess, otitis media, otitis externa, and temporal arteritis
must be differentiated from TMJ disease. Nocturnal bruxism can also cause pain in the TMJ area.
Chronic headache, depression, weight loss as a result of trouble chewing, insomnia, tinnitus, dizziness, altered taste, and decline in function may result from untreated TMJ pain.
Timely correction of dental occlusion with acrylic bite appliances will prevent worsening of malocclusion. Myofascial massage of the tender muscles of mastication may alleviate the pain. Trigger point injection (Table 43-1) with long-acting anesthetics around the joint may also relieve discomfort. The joint space between the mandibular condyle and the glenoid fossa of the zygoma may be injected with a small amount of local anesthetic and steroid. Narcotic analgesics and benzodiazepines should be avoided.
Kropmans TJ et al: Repeated assessment of temporomandibular joint pain: reasoned decision-making with use of unidimensional and multidimensional pain scales. Clin J Pain 2002; 18:107. [PMID: 11882774]
Greene CS: The etiology of temporomandibular disorders: implications for treatment. J Orofacial Pain 2001;15:93. [PMID: 11443830]
RELEVANT WORLD WIDE WEB SITES
American Academy of Orofacial Pain: http://www.aaop.org/TMD/info_factors.htm
American Academy of Orofacial Pain: http://www.aaop.org/guidelines.htm
Table 43-1. Suggested dosage of corticosteroids (methylprednisolone) & local anesthetic agent (bupivacaine 0.5%).
TRAPEZIUS MYOFASCIAL PAIN SYNDROME
ESSENTIALS OF DIAGNOSIS
This common condition may not be clinically recognized, and pain is often thought to be due to cervical spine arthritis or even angina pectoris. Poor posture while doing desk work, computer work, watching television, and engaging in unaccustomed physical activity are predisposing factors.
Flexion and extension injuries to the neck area secondary to pressure from the straps of purses, backpacks, or laptop computer cases may result in trapezius myofascial pain syndrome. Taut bands of muscle fibers resulting from repeated muscular contractions lead to microtrauma of the affected muscle, causing still more muscle deformity and pain. This often leads to chronic deconditioning of the agonist and antagonist muscle unit. The trapezius muscle is also very vulnerable to stress-induced tension, leading to muscle spasm and pain.
Patients should be advised to balance the weight distribution of purses, golf bags, and other items when carried on the shoulders. Regular exercise with proper stretching before and after any activity will condition the trapezius muscle and prevent taut bands from forming.
Pain in the neck, mastoid region, angle of the jaw, and upper extremity and neck stiffness are the common manifestations. Patients may believe the symptoms are of cardiac origin. Point tenderness in these areas and the jump test (involuntary withdrawal of the stimulated muscle) are characteristic clinical findings.
Blood tests are typically not helpful.
Computed tomography (CT) or MRI may reveal other causes of neck pain (eg, cervical spondylosis, cervical disk herniation) that may mimic this syndrome.
Liquid crystal contact thermography may demonstrate a higher than normal temperature in the trapezius muscles. Electromyographic (EMG) increases in electrical activity of the trapezius can provide objective evidence for this disorder; when pain is relieved, EMG activity decreases.
Localizing a defined trigger point and a positive jump test support the diagnosis of trapezius myofascial syndrome.
Angina pectoris, cervical spondylosis, cervical radiculopathy, occipital neuralgia, and tension headache can mimic the symptoms of trapezius myofascial syndrome.
Chronic and unrecognized conditions may lead to chronic pain, fatigue, anxiety and depression, and functional decline caused by pain with simple motions such as hair combing, fastening of brassieres, or reaching overhead. Inactivity caused by pain may result in muscle wasting and frozen shoulder.
Heat and cold compress therapy accompanied by proper trapezius muscle stretching may help prevent repeated muscle spasm. Anti-inflammatory medications may relieve some discomfort. Injections (see Table 43-1) directed at the primary trigger point with long-acting anesthetics and methylprednisolone may provide benefit, although multiple administrations may be necessary.
Carlson CR et al: Reduction of pain and EMG activity in the masseter region by trapezius trigger point injection. Pain 1993;55:397. [PMID: 8121703]
RELEVANT WORLD WIDE WEB SITES
SHOULDER PAIN SYNDROMES
ACROMIOCLAVICULAR JOINT PAIN; SUPRASPINATUS, INFRASPINATUS, SUBSCAPULARIS TENDINITIS; BICIPITAL TENDINITIS, & ROTATOR CUFF TEAR
ESSENTIALS OF DIAGNOSIS
Shoulder pain may be mistakenly attributed to osteoarthritis when insufficient historical information is obtained and inadequate examination is performed. Acromioclavicular (AC) joint pain is aggravated by stretching the affected arm across the chest. With subdeltoid bursitis and supraspinatus, infraspinatus, subscapularis (SIS) tendinitis, shoulder pain is exacerbated by abduction.
The AC joint is vulnerable to injury from both acute trauma and repeated microtrauma. Falls, breaking a fall with the arm outstretched, repeated strain from throwing injuries, or working with the arm raised across the body may result in injury to the AC joint, causing inflammation and pain. Overuse or misuse of the shoulder,
such as carrying heavy loads in front of and away from the body, and vigorous exercise without adequate stretching may also precipitate injury. When not treated, calcium deposits may form and cause permanent changes in the lining of the joint, leading to the development of chronic arthritis. This may further limit movement of the shoulder.
Recognition of the disorder may prevent further injury. Patients can avoid carrying heavy objects with an outstretched arm, avoid heavy handbags, maintain improved posture, and implement fall prevention strategies (see Chapter 12: Falls & Mobility Disorders).
Pain is experienced in the shoulder with specific movements. Point tenderness may be appreciated over the acromion (AC bursitis), rotator cuff area (SIS), and subdeltoid areas. Pain may be reproduced with resisted abduction and lateral rotation of the shoulder joint. Sudden release of resistance during this maneuver will markedly increase the pain.
Complete blood count, sedimentation rate, and antinuclear antibody may be indicated if an inflammatory or infectious cause is suspected.
Plain radiographs of the shoulder may reveal calcification of the bursa and associated structures consistent with chronic inflammation. In acute conditions, the radiograph will be normal. MRI may reveal tendinitis, partial disruption of the ligaments, or rotator cuff tear. Radionucleotide bone scan is indicated if metastatic diseases or primary bone tumor is suspected.
EMG studies (ordered rarely) in patients with shoulder bursitis may reveal decreases in electrical activity of the deltoid muscle compared with the supraspinatus muscle. This reflects inhibition of the deltoid as a compensatory mechanism for inflamed rotator cuff ligaments.
Trigger point tenderness at a specific site in the shoulder and reproduction of pain with shoulder passive and active maneuvers will often define the specific site of shoulder inflammation. In rotator cuff tear, there is weakness on external rotation of the shoulder if the infraspinatus is involved and weakness in abduction above the level of the shoulder if supraspinatus is involved. A positive drop-arm test (inability to hold the arm abducted at the level of the shoulder after the supported arm is released) is often present with complete rotator cuff tears. Moseley's test is performed by having the patient actively abduct the arm to 80; and then adding gentle resistance, which will force the arm to drop if complete rotator cuff tear is present. A positive Yergason's sign, or production of pain on active supination of the forearm against resistance with the elbow flexed at a right angle, is characteristic of bicipital tendinitis.
Polymyalgia rheumatica, rheumatoid arthritis, rotator cuff tear, osteoarthritis of the shoulder, and Lyme disease may mimic symptoms of this disorder. Rotator cuff tear is often the result of ongoing tendinitis of the shoulder.
Frozen shoulder, chronic pain, handicap resulting from limitations of upper extremity function, and interrupted sleep are common complications.
Range of motion (ROM) and stretching exercises may be beneficial after acute flares subside. Trigger point injections (see Table 43-1) at the specific site (AC, supraspinatus, infraspinatus, bicipital, or subscapularis tendon) may alleviate the pain.
Short-term (2–4 weeks) immobilization of shoulder with sling and swath is recommended when there is significant trauma to the shoulder joint.
Glockner SM: Shoulder pain: a diagnostic dilemma. Am Fam Physician 1995;51:1677. [PMID: 7754927]
Turnbull JR: Acromioclavicular joint disorders. Med Sci Sports Exerc 1998;30(suppl):S26. [PMID: 9565953]
RELEVANT WORLD WIDE WEB SITES
E-Medicine: Acromioclavicular Injury: http://www.emedicine.com/emerg/topic14.htm
North Wales Sports Physiotherapy Clinic: http://www.north-wales-sports-physiotherapy-clinic.co.uk/shoulder2.htm
E-Medicine: Rotator Cuff Injury: http://www.emedicine.com/aaem/byname/rotator-cuff-injury.htm
ELBOW PAIN SYNDROMES
ARTHRITIS OF THE ELBOW, TENNIS ELBOW, GOLFER'S ELBOW, OLECRANON BURSITIS
ESSENTIALS OF DIAGNOSIS
True elbow arthritis is uncommon. Frequently, tendinitis and bursitis will coexist with arthritis pain of the elbow. The olecranon bursa lies in the posterior aspect of the elbow joint and may become inflamed as a result of direct trauma or overuse of the joint.
Recurrent microtrauma to the extensor tendons of the forearm with microtearing at the origin of the extensor carpi radialis and extensor carpi ulnaris leads to lateral epicondylitis (tennis elbow). Secondary inflammation from continued overuse or misuse of the extensors of the forearm can become chronic. Coexistent bursitis, arthritis, and gout may also perpetuate the pain and disability of tennis elbow. Similarly, microtrauma of the flexor tendons of the forearm and microtearing at the origin of the pronator teres, flexor carpi radialis and flexor carpi ulnaris, and palmaris longus leads to medial epicondylitis (golfer's elbow). Repeated irritation, acute trauma, and infection of the olecranon bursa lead to bursitis.
Proper stretching of the elbow before and after any sports or regular activity that subjects the elbow to repeated trauma (eg, golf, tennis, hockey, repeated hand shaking, scooping of ice cream) may prevent microtrauma to tendons. Proper positioning of the arm when engaged in sports activities and use of elbow support may also prevent unnecessary trauma and irritation.
Pain in the elbow worsened by movement and relieved by rest and heat are characteristic of elbow pain syndrome. Pain may interfere with sleep. Specific symptoms depend on the location of the inflammation. In elbow arthritis, the pain is felt deep inside the joint, and crepitus may be present. In tennis elbow, elbow pain in the lateral epicondyle is constant and made worse with active contraction of the wrist, leading to diminished grip strength, difficulty holding items such as a coffee cup or a hammer, and sleep disturbance. On physical examination, there will be tenderness along the extensor tendons or just below the lateral epicondyle. Forcing the clenched fist into flexion further aggravates the elbow pain.
In golfer's elbow, pain is constant in the medial epicondyle and is made worse with active contraction of the wrist. Forcing the clenched fist into extension aggravates the elbow pain. In olecranon bursitis, pain and swelling of the olecranon bursa occur.
In infectious olecranon bursitis, leukocytosis may be found, and Gram's stain and culture of aspirates from the bursa may reveal an infectious cause. Sedimentation rate, antinuclear antibody testing, and examination of joint fluid for uric acid crystals are indicated if collagen vascular disease or gout is suspected.
Plain radiographs of the elbow may reveal calcification of the tendons, bursa, or elbow joint. MRI is indicated if there is joint instability or failure to respond to conservative treatment and surgical procedure is contemplated.
If ulnar nerve entrapment of the elbow is suspected, electromyography and nerve conduction velocity studies (EMG/NCS) may be used; these tests are extremely sensitive. EMG/NCS can sort out other causes of pain that may mimic ulnar nerve entrapment at the elbow, including cervical radiculopathy and plexopathy.
A diagnostic trial with trigger point injection using a local anesthetic and corticosteroid may prove revealing.
Septic arthritis, collagen vascular disease, gout, and pseudogout are common disorders that may present with elbow pain and may have similar clinical findings to the elbow pain syndrome. Ulnar nerve entrapment at the elbow is one of the most common entrapment neuropathies
encountered in clinical practice. Nerve irritation may mimic elbow pain syndrome.
Flexion contractures, chronic pain, upper extremity disability, sleep disturbance, and depression may complicate elbow pain syndrome if it is not treated aggressively.
Trigger point injection (see Table 43-1) with anesthetic or corticosteroids, acupuncture, shock wave therapy, use of orthotic devices, physiotherapy, and antibiotics (if infection is identified) are common treatment modalities for elbow pain syndrome.
Buchbinder R et al: Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev 2002;1:CD003524. [PMID: 11869669]
Fink M et al: Acupuncture in chronic epicondylitis: a randomized controlled trial. Rheumatology 2002;41:205. [PMID: 11886971]
Pienimaki TT et al: Chronic medial and lateral epicondylitis: a comparison of pain, disability and function. Arch Phys Med Rehabil 2002;83:317. [PMID: 11887110]
Sevier TL, Wilson JK: Treating lateral epicondylitis. Sports Med 1999;28:375. [PMID: 10593647]
RELEVANT WORLD WIDE WEB SITES
Sports Injury Clinic: http://www.sportsinjuryclinic.net/cybertherapist/front/elbow/tenniselbow.htm
WRIST PAIN SYNDROMES
ARTHRITIS, CARPAL TUNNEL SYNDROME, DE QUERVAIN'S TENOSYNOVITIS, DUPUYTREN'S CONTRACTURE, TRIGGER FINGER OR THUMB
ESSENTIALS OF DIAGNOSIS
The hands and wrists are vulnerable to trauma or inflammation because of the presence of multiple joints and the repeated motion with activities of daily living (ADLs) or work. Pain is often aggravated by motion and relieved by rest or heat therapy.
Recurrent and frequent repetitive movement of the joints in the hands and wrists leads to wear and tear, resulting in inflammation and possible arthritis. Rheumatoid arthritis may affect the wrists and hands even in the absence of trauma. Posttraumatic arthritis is commonly observed in athletes, in those who fall, and in those who perform strenuous manual work or operate heavy equipment.
Compression of the median nerve is commonly due to flexor tenosynovitis, rheumatoid arthritis, myxedema, amyloidosis, and other space-occupying lesions. This leads to carpal tunnel syndrome. Repeated twisting motions of the hands (eg, using a screwdriver, frequent hand shaking) and high-torque wrist turning (eg, scooping ice cream) may lead to inflammation and swelling of the abductor pollicis longus and extensor pollicis brevis at the level of the radial styloid process, resulting in de Quervain's tenosynovitis. Compression and repeated trauma to the tendon of the flexor pollicis longus lead to trigger thumb, and repeated trauma to the tendons of the flexor digitorum superficialis resulting from compression against the heads of the metacarpal bones lead to trigger finger.
Use of protective gloves, proper hand positioning with use of computers and keyboards, and frequent rest from strenuous and repetitive hand and wrist movements reduce risk of wrist injury.
Wrist and hand pain made worse by activities and relieved by rest and heat are characteristic of wrist and hand pain syndromes. When severe, sleep interruption is common. Grating and popping sensation with use of the joint and crepitus may be present on physical examination. Rheumatoid arthritis commonly causes swelling and tenderness of the metacarpophalangeal joints with deformities. With continued disuse, muscle wasting may occur and joint stiffness will be observed.
Rheumatoid factor, sedimentation rate, and antinuclear antibody are useful if inflammatory rheumatological disease is suspected. Complete blood count, Gram's stain, and culture of aspirated synovial fluid may reveal an infectious cause of inflammation and pain.
Plain radiography may reveal bony displacement, joint instability, and occult bony disease. MRI may reveal joint deformity, space-occupying lesion, and inflammation of the tendons involved, although clinical examination with proper anatomic correlation may obviate the need for such studies.
EMG/NCS may reveal objective evidence of nerve irritation in carpal tunnel syndrome.
The injection of anesthetics to the site of pain may serve as a diagnostic maneuver to identify the cause of the pain. In suspected carpal tunnel syndrome, Tinel's or Phalen's signs and the application of pressure over the median nerve (by inflating a sphygmomanometer over the wrist) support the diagnosis. Tinel's sign is the induction of paresthesias by tapping over the site of the median nerve at the wrist. Phalen's sign is positive if symptoms are reproduced by maximum flexion of the wrist for 60 s.
Rheumatoid arthritis, septic arthritis, Lyme disease, and posttraumatic arthritis may mimic the symptoms of hand and wrist pain syndromes.
Muscular atrophy of the thenars and hypothenars, decreased joint ROM, chronic pain, insomnia, depression, and a decrease in functional level, including work-related disabilities, are common complications.
Use of specific splints to reduce compression and irritation of the tendons and nerves, trigger point injections (see Table 43-1) with corticosteroids and anesthetics, and surgical release or removal of structures that cause mechanical compression are common treatment modalities. Infection requires aggressive treatment with appropriate antibiotics. If carpal tunnel syndrome is diagnosed (positive Tinel's or Phalen's signs) or significant osteoarthritis is noted, referral to a hand surgeon for operative treatment may be warranted, if symptoms are severe and the patient is a surgical candidate.
D'Arcy CA, McGee S: The rational clinical examination. Does this patient have carpal tunnel syndrome? JAMA 2000;283:3110. [PMID: 10865306]
Hayward AC et al: Primary care referral protocol for carpal tunnel syndrome. Postgrad Med J 2002;78:149. [PMID: 11884696]
CHEST PAIN SYNDROMES
COSTOSTERNAL SYNDROME, INTERCOSTAL NEURALGIA, DIABETIC TRUNCAL NEUROPATHY, TIETZE'S SYNDROME, FRACTURED RIBS, POSTTHORACOTOMY PAIN, ACUTE HERPES ZOSTER OF THE THORACIC DERMATOME, XIPHODYNIA SYNDROME, SLIPPING RIB SYNDROME, THORACIC VERTEBRAL COMPRESSION FRACTURE
ESSENTIALS OF DIAGNOSIS
Because of concerns about potentially life-threatening thoracic disease, chest pain is a serious matter and one of the most common reasons for urgent medical attention. A clear history of trauma may clarify the diagnosis, especially when specific clinical findings (eg, point tenderness that reproduces the pain) are present.
Inflammation of chest wall structures is caused by overuse or misuse or trauma secondary to acceleration or deceleration injuries or blunt impact. Costal joints are susceptible to the development of arthritis, spondylitis,
Reiter's syndrome, and psoriatic arthritis, even without any history of trauma. With severe trauma, chest wall joints may sublux or dislocate. The chest wall joints are also subject to tumor invasion from malignancies, including thymoma and metastatic disease.
Use of seat belts when driving, attention to fall prevention, conscious effort to avoid excessive and repeated use of chest wall muscles, and stretching before strenuous sports or physical activities may prevent these injuries.
Patients suffering from either costosternal syndrome or Tietze's syndrome (second or third costochondral joint inflammation) show vigorous splinting by keeping the shoulders stiffly in neutral position. Pain is reproduced with active protraction or retraction of the shoulder, deep inspiration, and full elevation of the shoulder. Coughing and shrugging of the shoulder also reproduce the pain. Patients may also complain of a clicking sensation with movement of the costal joints or ribs (slipping rib syndrome). Physical examination findings in intercostal neuralgia are minimal unless there is a history of thoracic or subcostal surgery or cutaneous findings of herpes zoster involving the thoracic dermatomes. Motor involvement of the subcostal nerve (eg, from diabetic neuropathy) leads to weakening and bulging of the abdominal muscles.
Complete blood count, sedimentation rate, antinuclear antibody, and prostate-specific antigen laboratory tests may provide further information about the degree of inflammation, presence of infection, and metastatic bone deposits from prostate carcinoma.
Plain radiographs of the ribs and sternocostal region are indicated for chest wall pain resulting from trauma and to rule out suspected bony disease, including tumors.
MRI of the costosternal joints is indicated if joint instability or occult mass is suspected. Radionuclide bone scanning may also confirm the presence of fractures of the ribs or sternum and detect inflammatory disease.
Direct trigger point injection of local anesthetics with subsequent alleviation of pain may identify a specific cause of the chest wall pain syndrome. The hooking maneuver is performed by having the patient lie in the supine position with the abdominal muscles relaxed while the examiner hooks the fingers under the lower rib cage and pulls gently outward. The presence of clicking, or a snapping sensation, of the affected ribs and cartilage indicates the slipping rib syndrome.
The costochondral and sternocostal joints are susceptible to trauma, osteoarthritis, ankylosing spondylitis, rheumatoid arthritis, Reiter's syndrome, and psoriatic arthritis. These joints are also subject to invasion by tumor either from direct extension of primary malignancies (eg, thymoma) or from metastatic disease. Infectious agents (eg, herpes zoster, Candida albicans, and bacterial infection in the case of open chest wall injuries) or surgical trauma may also cause chest wall pain syndromes.
Chronic pain may develop with insufficient therapy and inadequate preventive measures for recurrent injuries. Subsequently, patients may experience functional decline, sleep disturbance, or depression. Pneumothorax may result from rib fractures or attempted therapeutic injections.
Proper recognition of the specific cause of the chest wall pain syndrome must precede appropriate therapy. Once potentially serious diseases are ruled out, reassurance should be provided. Nonsteroidal anti-inflammatory drugs (NSAIDs), cyclo-oxygenase-2 (COX-2) inhibitors, local application of heat followed by cold packs, elastic rib belt, and localized trigger point injection (see Table 43-1) using local anesthetic and corticosteroids are reasonable therapeutic options. Intercostal nerve block may be beneficial for postthoracotomy syndrome and postherpetic neuralgia. Narcotic analgesics, adjuvant analgesics (such as anticonvulsants), and antidepressants are often used for chronic pain.
Aeschlimann A, Kahn MF: Tietze's syndrome: a critical review. Clin Exp Rheumatol 1990;8:407. [PMID: 1697801]
Wise CM et al: Musculoskeletal chest wall syndromes with noncardiac chest pains: a study of 100 patients. Arch Phys Med Rehab 1992;73:147. [PMID: 1543409]
RELEVANT WORLD WIDE WEB SITES
ABDOMINAL & GROIN PAIN SYNDROMES
ILIOINGUINAL NEURALGIA, GENITOFEMORAL NEURALGIA
ESSENTIALS OF DIAGNOSIS
Potentially fatal diseases causing abdominal pain, such as pancreatitis, ruptured viscus, ischemic bowel, sigmoid volvulus, and intra-abdominal abscess, should be ruled out before considering the possibility of myofascial pain or specific neuralgia. Thorough abdominal examination will often reveal deep intra-abdominal disease. With support of laboratory data, these conditions can be ruled out.
Ilioinguinal neuralgia is caused by compression of the ilioinguinal nerve as it passes through the transverse abdominis muscle at the level of the anterior superior iliac spine. Genitofemoral neuralgia is caused by compression of the genitofemoral nerve as it arises from L1 and L2 nerve roots and passes the psoas muscles or from either the inguinal or genital branches of the nerve as they pass beneath the inguinal ligament. Direct injury, blunt trauma after inguinal herniorrhaphy, and pelvic surgery are the most common causes of this injury.
Stretching of the leg and lower abdominal muscles before anticipated physical activities and early therapy using heat and gentle massage at the inguinal areas after inguinal surgery may prevent irritation and inflammation of nerves.
In ilioinguinal and genitofemoral neuralgia, paresthesias, burning pain, and numbness over the lower abdomen radiating to the legs, scrotum, or labia and occasionally the inner thigh are common. The patient often assumes a bent-forward “novice skier's position” to relieve pressure on the nerve. Chronic pain leads to bulging of the abdominal muscle wall and may be confused with inguinal hernia.
Sedimentation rate and antinuclear antibody may be helpful for the neuralgias to rule out secondary causes.
In an evaluation of abdominal pain, a plain radiograph of the abdomen may reveal calcification in the pancreas, calcified gallstones, or evidence of ileus. Plain radiographs of the hip and pelvis help to rule out occult bony disease. MRI of the lumbar plexus is indicated if tumor or hematoma is suspected and may also define inflammation around the specific nerve affected.
EMG will help distinguish ilioinguinal or genitofemoral neuralgia from lumbar plexopathy, lumbar radiculopathy, and diabetic polyneuropathy.
Tinel's sign elicited by tapping over the ilioinguinal nerve where it pierces the transverse abdominal muscle or the genitofemoral nerve where it passes beneath the inguinal ligament helps identify respective neuralgia syndromes.
Other causes of abdominal pain (see also Chapter 23: Abdominal Complaints & Gastrointestinal Disorders) include cholecystitis, bowel obstruction, renal calculi, myocardial infarction, diabetic ketoacidosis, pneumonia, perforated bowel, ischemic bowel, and irritable bowel syndrome. Clinical and laboratory information as well as history will often provide clues to the diagnosis. Acute herpes zoster may present with abdominal pain before the appearance of skin rash. Lesions of the lumbar plexus from trauma, hematoma, tumor, diabetic neuropathy, or inflammation can mimic pain, numbness, and weakness of genitofemoral or ilioinguinal neuralgia.
Ilioinguinal and genitofemoral neuralgia are often missed; when recognized, and if nerve blocks are given, ecchymosis and hematoma formation are common.
Initial treatment of the neuralgias consists of treatment with NSAIDs or COX-2 inhibitors and avoidance of repetitive activities that cause pain. Nerve block to the ilioinguinal or genitofemoral area may also alleviate discomfort; when not effective, epidural block may be considered. A home program for sustained stretch of myofascial trigger points has also been shown to reduce pain.
Hanten WP et al: Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial trigger points. Phys Ther 2000;80:997. [PMID: 11002435]
RELEVANT WORLD WIDE WEB SITES
LUMBAR SPINE & RELATED SYNDROMES
LUMBAR RADICULOPATHY, SPINAL STENOSIS, ARACHNOIDITIS, SACROILIAC JOINT PAIN, PIRIFORMIS SYNDROME, ISCHIOGLUTEAL BURSITIS, COCCYDYNIA, TROCHANTERIC BURSITIS
ESSENTIALS OF DIAGNOSIS
Back pain and leg pain are often disabling and may affect daily function, work, and safety with ambulation. Lumbar radiculopathy often affects the lower extremities. Other inflammatory conditions in the hip, pelvic, and lower back area may present with similar symptoms but may be differentiated by specific tender trigger point areas.
Lumbar radiculopathy can be due to herniated disk, foraminal stenosis, tumor, osteophyte formation, and, rarely, infection. Most of these processes are due to wear and tear, especially in overweight and underactive persons. Sacroiliac joint pain is often caused by poor posture, but other causes include ankylosing spondylitis, rheumatoid arthritis and other collagen vascular diseases, and overaggressive bone graft.
Proper posture and avoidance of excessive bending prevent worsening of the pain and repeat injuries. Professionally guided exercise programs designed to strengthen back and leg muscles may help with pain control and mobility.
Pain, numbness, tingling, and paresthesias in the distribution of the affected lumbar nerve root or roots and lack of coordination of the affected extremities may cause difficulty with ambulation and even falls. Continuous irritation to the nerve roots may lead to urinary and fecal incontinence. Patients suffering from lumbar stenosis or lumbar radiculopathy often stoop forward to walk or may shift their body weight onto a shopping cart to relieve pressure on the affected nerve root of the lumbar spine. Calf pain with ambulation (pseudoclaudication) is also a common presentation of lumbar stenosis or radiculopathy.
Complete blood count and blood cultures may be indicated if an infectious cause (eg, abscess) is suspected. Sedimentation rate, antinuclear antibody, and human leukocyte B-27 antigen screening help to differentiate other rheumatological diseases.
MRI of the lumbar spine, sacroiliac area, and other specific areas may help identify abnormalities and provide
guidance for further therapy. Computed tomography complemented by myelography is a reasonable second choice to MRI. Radionucleotide bone scanning and plain radiography are indicated when fracture or other bony abnormalities such metastatic disease are suspected.
EMG/NCS provides the neurophysiological information that can delineate the actual status of individual nerve roots and the lumbar plexus.
Identifying trigger tender points and performing the straight-leg test to document nerve root irritation and the pelvic rock test for sacroiliac joint pain may help in locating the cause of lower back and leg pain. The pelvic rock test is performed by placing the hands on the iliac crests and the thumbs on the anterior superior iliac spines and then forcibly compressing the pelvis toward the midline. A positive test is indicated by the production of pain around the sacroiliac joint.
Low back strain, lumbar bursitis, lumbar fibromyositis, lumbar disk herniation, and spinal stenosis can mimic lumbar radiculopathy.
Failure to accurately diagnose lumbar radiculopathy can lead to lumbar myelopathy, which, if untreated, may progress to paraparesis, paraplegia, cauda equina syndrome, and gait disorders, resulting in falls.
Physical therapy, heat modalities, deep sedative massage, NSAIDs, and skeletal muscle relaxants are reasonable initial therapeutic options for lumbar radiculopathy and spinal stenosis. Caudal epidural blocks with local anesthetic and corticosteroids may alleviate pain temporarily. Use of an antidepressant (eg, nortriptyline) may help depression and sleep disturbance. Trigger point injections (see Table 43-1) at the specific tender location sacroiliac joint, ischiogluteal bursa, sacrococcyx junction, trochanteric bursa, and sciatic nerve at the level of the piriformis muscle in piriformis syndrome may alleviate pain and improve function and gait. Referral to a physiatrist or anesthetist (pain clinic) may be necessary for trigger point injections.
Maigne JY et al: Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma. Spine 2002;25:3072. [PMID: 11145819]
RELEVANT WORLD WIDE WEB SITES
E-Medicine: Piriformis Syndrome: http://www.emedicine.com/sports/topic102.htm
E-Medicine: Coccygodynia: http://www.emedicine.com/orthoped/topic383.htm
KNEE PAIN SYNDROMES
ARTHRITIS OF THE KNEE, MEDIAL COLLATERAL LIGAMENT SYNDROME, SUPRAPATELLAR BURSITIS, PREPATELLAR BURSITIS, BAKER'S CYST
ESSENTIALS OF DIAGNOSIS
Osteoarthritis of the knee is the most common cause of knee pain. Movement of the knee results in more pain; pain may be relieved by rest and application of heat therapy. Coexisting bursitis, tendinitis, and internal derangement of the knee may make the clinical diagnosis of arthritis difficult unless detailed imaging is performed.
Excessive weight and repeated movement lead to wear and tear of the lining of the knee, causing inflammation, fluid accumulation, prostaglandin production, and further inflammation. Soft tissues around the knee may also be subjected to strain and become irritated and inflamed, resulting in bursitis or tendinitis. Baker's cyst is due to excess synovial fluid accumulation in the knee.
Proper knee support and adequate stretching before and immediately after any strenuous sports or physical
activity are important. Use of knee guards may minimize direct irritation of knee structures by a hard floor surface and prevent myofascial inflammation.
In osteoarthritis of the knee, pain is felt around the knee and distal femur. Pain is constant and achy. Pain may interfere with sleep. Grating and popping sensations and crepitus are often observed. Later, ROM is diminished and ADLs become difficult. Ultimately, muscle wasting and stiff “frozen knee” may develop.
Synovial fluid cell count and culture (along with complete blood count and blood cultures) are essential when septic arthritis is a consideration. In addition, crystal analysis should be performed if gout or pseudogout is suspected.
Plain radiographs are indicated for most patients who complain of knee pain. MRI of the knee is indicated if aseptic necrosis or occult mass or tumor is suspected.
EMG will help distinguish patellar bursitis from femoral neuropathy, lumbar radiculopathy, and plexopathy. Sonography of the patellar tendon and adjacent structures may confirm patellar bursitis syndrome.
Knee manipulation is used to assess joint instability or appreciate joint stiffness as in “frozen knee” resulting from adhesive capsulitis. Pain with passive and active resisted extension of the knee will reproduce pain in patellar bursitis, and sudden release during this maneuver will markedly increase the pain. On palpation of the patellar bursa, a boggy sensation, erythematous appearance, and warm skin surface may also be found.
Lumbar radiculopathy may mimic pain and associated symptoms of knee arthritis. Bursitis and other soft tissue inflammatory processes can cause pain around the knee. Primary and metastatic tumors of the femur and spine may also present with symptoms similar to knee osteoarthritis. Dysfunction of the quadriceps tendon can mimic symptoms of patellar bursitis.
Failure to identify neoplasm and septic arthritis may result in venous thrombosis, pulmonary embolism, joint destruction, and sepsis. Intra-articular or trigger point injections may lead to infection.
Weight reduction, use of NSAIDs, and physical therapy are the initial therapeutic modalities. Aseptic intra-articular injection (see Table 43-1) with corticosteroids and local anesthetic may reduce inflammation and pain. Trigger point injection of corticosteroids at the tender myofascial area or specific knee bursa (suprapatellar or prepatellar), followed by knee muscle strengthening exercise, may alleviate pain. Baker's cysts must be drained.
Dawn B et al: Prepatellar bursitis. J Rheumatol 1997;24:976. [PMID: 9150094]
RELEVANT WORLD WIDE WEB SITES
Clinical Sports Medicine: http://www.clinicalsportsmedicine.com/chapters/24f.htm
E-Medicine: Myofascial Pain in Athletes: http://www.emedicine.com/sports/topic158.htm
ANKLE & FOOT PAIN SYNDROMES
ARTHRITIS OF THE ANKLE & MIDTARSAL JOINTS, TARSAL TUNNEL SYNDROME, ACHILLES TENDINITIS, MORTON'S NEUROMA, PLANTAR FASCIITIS
ESSENTIALS OF DIAGNOSIS
Osteoarthritis and tendinitis of the soft tissue around the ankle and feet may cause disabling discomfort. Detailed history and comprehensive examination of the foot and ankle joints often lead to a specific diagnosis.
Excessive strain and frequent use of the ankle joint leads to inflammation and pain. Compression of the tarsal ligaments is commonly due to repeated trauma with daily use of high-heel shoes. Inflammation from rheumatoid arthritis results in a higher incidence of tarsal tunnel syndrome. Repeated trauma to the plantar aspect of the foot leads to plantar fasciitis. Perineural fibrosis of the interdigital nerves is the cause of Morton's neuroma.
Use of comfortable shoes when taking long walks and avoidance of sudden ankle and foot motion without proper stretching may prevent trauma to joints and supporting structures.
Osteoarthritis of the ankle and feet presents with pain localized to the ankle and foot, which is made worse by walking and relieved by rest and heat. Plantar fasciitis is characterized by pain localized to the hindfoot and is most painful on awakening in the morning. Muscle atrophy resulting from disuse and “frozen ankle” may be seen in patients with ankle or foot pain syndromes.
Complete blood count and synovial fluid analysis (cell count, culture) are essential when septic arthritis is a consideration. Crystal analysis of synovial fluid is helpful in suspected gout or pseudogout.
Plain radiographs are indicated in most patients with ankle pain to rule out fractures, occult mass, and tumors. MRI may show aseptic necrosis, osteomyelitis (a consideration if there is an open wound), and tumors.
Bone scan may be helpful if an acute inflammation or metastatic bone lesion is suspected. EMG will help distinguish lumbar radiculopathy and diabetic polyneuropathy from tarsal tunnel compression symptoms.
A positive Tinel's sign an electric shock sensation when the deep peroneal nerve (just medial to the dorsalis pedis artery) is palpated is often observed in anterior tarsal tunnel syndrome (ATSS). Active plantar flexion will often reproduce the symptoms of ATTS. Weakness of the extensor digitorum brevis may also be observed. Tinel's sign just below and behind the medial malleolus over the posterior tibial nerve is seen in posterior tibial tunnel syndrome (PTTS). In PTTS weakness of the flexor digitorum brevis and the lumbrical muscles may also be present.
Lumbar radiculopathy, diabetic polyneuropathy, stress fracture of the ankle or feet, and primary bony or metastatic bony tumors present with symptoms similar to other foot and ankle pain syndromes.
Failure to adequately treat or recognize these disorders may lead to gait disorder, falls, depression, and disability.
Weight reduction, proper use of foot orthotics, use of comfortable shoes, NSAIDs therapy, and trigger point injections (see Table 43-1) with corticosteroids and local anesthetics are the treatment modalities for patients with this pain syndrome.
Barrett SJ, O'Malley R: Plantar fasciitis and other causes of heel pain. Am Fam Physician 1999;59:2200. [PMID: 10221305]
Coughlin MJ: Common causes of pain the forefoot in adults. J Bone Joint Surg 2000;82:781. [PMID: 10990297]
Wu KK: Morton neuroma and metatarsalgia. Curr Opin Rheumatol 2000;12:131. [PMID: 10751016]