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Chapter 22 • Lower Extremity Limb Pain
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269
EVIDENCE-BASED PRACTICE
How Good is the McMurray Test to Evaluate Meniscal
Pathology of the Knee?
Clinical assessment of meniscal pathology in the knee is difficult because of the number of tests available and variations
in their interpretation and application. This paper assessed
the literature to investigate the validity and diagnostic accuracy of the McMurray test to determine its clinical usefulness. Studies that compared the McMurray test to the gold
standard of knee arthroscopy or MRI were included. Eleven
studies met the criteria. Results showed little consensus in
Data from Hing W, White S, Reid D, Marshall R: Validity of the McMurray’s test and modified version of the test: A systematic literature review,
J Man Manip Ther
17:22, 2009.
knee focuses on assessment of a change in consistency
of the mass on extension (hardening) and exion (softening), called Foucher sign. Foucher sign is negative
with a Baker cyst and positive with a tumor or popliteal
aneurysm. The cyst can rupture and cause edema
and tenderness of the lower extremity with a positive
Homans sign. Ultrasound will detect the cyst or
recently ruptured cyst.
Ankle and Foot
Ankle sprain (inversion or eversion). The most
common mechanism of ankle injury is an inversion
force that stresses the lateral ligamentous support of
the joint. The lateral ligaments are of greater length
than the medial ligaments and are more predisposed to
injury. An audible pop or tear implies a rupture or tear
of the ligament. Swelling of the ankle within minutes
of injury indicates bleeding and soft tissue trauma.
Patients with a ligamentous injury will generally be
able to walk and bear weight on the injured foot even
though it may be uncomfortable. Examine the injured
joint by palpating the course and attachment points
of the ligaments and perform joint ROM to test for
ligamentous integrity.
Shin splints (medial tibial stress syndrome). Shin
splints are an inammation of the origin of muscles
on the shaft of the tibia caused by overuse, often by
running athletes. Patients report achy pain and tenderness over the medial tibia that increases with
exercise, especially running, and improves with rest.
A radiograph of the tibia will exclude fracture.
Achilles tendinitis. The gastrocnemius and so-
leus muscles conjoin to form the Achilles tendon.
Inammation of this tendon creates pain and swelling
where the tendon inserts into the calcaneus, and a
patient will report a tightness of the tendon that
the reported measures of validity of the McMurray test,
mostly caused by methodologic limitations of the studies.
Scores on the STARD (Standards for Reporting Diagnostic
Accuracy) yielded scores from 10/25 to 20/25. The authors
conclude that the McMurray test is of limited clinical value
because of the relatively low sensitivity (although high speci-
ficity), with modified tests having higher diagnostic accuracy
and thus more clinically useful.
makes walking or running difcult. Tendinitis may be
caused by overuse, especially running, or by de-
creased vascularity to the tendon sheath. Examination
reveals tenderness over the Achilles tendon with pal-
pation and ankle ROM, especially with dorsiexion,
crepitus over the tendon with motion, and weakness
of the calf muscles.
Plantar fasciitis. Plantar fasciitis, which affects
women twice as often as men, is caused by chronic
weight-bearing stress when laxity of foot structures
allows the talus to slide forward and medially, the
calcaneus to drop, and plantar ligaments and fascia to
stretch. People who are obese or who engage in exces-
sive standing are at greatest risk. Pain is worse
on awakening and is relieved with non-weightbearing
activity. Tendons and joints become inamed, and
muscles spasm because of the misalignment of struc-
tures. Patients often complain of heel pain.
Muscle Pain (Myalgia)
Viral Infections
Viral infections can produce diffuse myalgias that are
usually associated with fever, chills, upper respiratory
tract symptoms, and malaise. A patient with inuenza
will have intense myalgia and high fever and appear
quite ill. Because viral illnesses are highly contagious,
epidemics in both children and adults in a community
may be a useful clue to diagnosis. A paraviral immuno-
globulin M (IgM) titer is diagnostic of an acute parvo-
virus B19 infection.
Psychogenic
Pain that is diffuse, varies in pattern, and is unaffected
by activity or rest may be psychogenic in origin. A care-
ful history may reveal any secondary gain the patient
may derive from the pain and suggest the presence of
an anxiety or depression disorder. On examination, the
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Chapter 22 • Lower Extremity Limb Pain
patient may display facial expressions and descriptions
of discomfort to palpation and movement that are inconsistent. This diagnosis involves excluding other causes.
Fibromyalgia
Fibromyalgia is a syndrome characterized by chronic
fatigue, generalized musculoskeletal pain, and multiple
trigger points of pain on physical examination. It primarily affects women between 20 and 50 years of age
and the symptoms are worse in the morning. Other
symptoms associated with this syndrome include stage
IV sleep disturbance, anxiety or depression, obsessivecompulsive behavior, and irritable bowel syndrome.
Symptoms are exacerbated by stress. Physical examination shows focal tenderness without signs of synovitis. Diagnostic criteria for bromyalgia include diffuse
pain present for 3 months and tenderness at 11 or more
of 18 trigger points.
Systemic Disorders
Acute Leukemia
Leukemia is the most common cancer in children, and
bone and joint pain is the most common presenting
complaint. The bone pain is diffuse and nonspecic
and may extend to adjacent joints. Laboratory ndings
may show the WBC count as elevated, depressed, or
normal. Severe anemia is common as is a depressed
platelet count. Radiographs of the limb at the distal end
of the femur and the proximal end of the tibia show
abnormal areas of radiolucency.
Sickle Cell Disease
Sickle cell disease is a genetic disorder characterized by
production of hemoglobin S, an anemia secondary to
short erythrocyte survival, and sickle-shaped erythrocytes. It affects mainly African American, Mediterranean, and Southeast Asian population groups. Sickle cell
disease manifests itself after the rst 6 months of life.
The child presents with painful or vaso-occlusive crises
characterized by symmetrical, painful swelling of the
hands and feet. Older people report pain in long bones
and joints, abdominal pain, decreased appetite, fever,
and malaise. The laboratory ndings reveal a hemoglobin S genotype and anemia, but ndings can vary depending on the hemoglobin genotype, age, gender, and
presence of other organ involvement. Sickle cell disease
is associated with osteonecrosis of the hip.
Systemic Lupus Erythematosus
Systemic lupus erythematosus (SLE) is a systemic
inammatory condition that occurs most often in
women. It is characterized by arthritis that commonly
involves the small joints of the hands, wrists, ankles,
knees, and hips as well as malar rash, oral ulcers, glomerulonephritis, hematological disorders, and psychological symptoms. The pain is transient but severe.
Laboratory ndings show leukopenia with neutrophils
predominating the peripheral count, and the ANA is
positive.
Lyme Arthritis
The bite of the deer tick may transmit the spirochete
B. burgdorferi. Patients may not recall a tick bite but
will have been in an endemic area. The presenting
complaints in Lyme disease are diffuse joint pain and
swelling, a target like skin rash (erythema migrans),
fever, and chills. These symptoms may be present for
weeks before the spirochete spreads via blood and
lymph tissue to the myocardium and central nervous
system. A chronic arthritis may appear months after
the initial infection. The arthritis is asymmetrical and
occurs in the large joints. The knee is a commonly
affected joint. The patient has an antalgic limp with
diffuse swelling and warmth of the knee joint anteriorly, as well as local synovial thickening. Laboratory
diagnosis reveals elevation of IgM titers and immunoglobulin G (IgG) antibodies against the spirochete.
The ESR is elevated.
Neuroblastoma
Neuroblastoma is a malignant tumor that usually occurs in children under 5 years of age. It originates from
cells in the sympathetic ganglia and adrenal medulla
but can arise from any part of the sympathetic nervous
system and metastasize to the bone. The presenting
complaint may be varied, but bone pain, limp, pallor,
and fatigue may be present. Computed tomography
(CT) or magnetic resonance imaging (MRI) is used to
identify the primary location of the tumor. In the urine,
3-methoxy-4-hydroxymandelic acid and homovanillic
acid levels are elevated.
Osteogenic Sarcoma
Osteogenic sarcoma occurs in people 10 to 25 years
old, with the most common site being the distal femur
or the proximal tibia. The patient initially complains
of local intermittent pain that quickly progresses to a
constant and severe pain, and an antalgic limp may
develop. Palpation reveals tenderness over the area
affected. Laboratory ndings show an increase in serum alkaline phosphatase level; radiograph shows a
“sunburst” image.
Chapter 22 • Lower Extremity Limb Pain
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271
Nerve Entrapment Syndromes
Peroneal Nerve Compression
Peroneal nerve compression can be caused by a cast,
sports injury, or trauma. Pain is felt across the head of
the bula and can result in footdrop.
Neuritis
Vascular metabolism affected by systemic disorders,
such as diabetes mellitus, can cause a nerve to become
ischemic, producing toxins that can directly damage
the nerve. Inammation can be of the nerve axon, my-
elin sheath, or both. Soft tissue inammation contribut-
Tarsal Tunnel Syndrome
Tarsal tunnel syndrome is occasionally associated
with motor weakness of the proximal toe exors. The
posterior tibial nerve is involved, and the pain is felt
across the ankle and proximal foot. Patients may not
remember a specic onset but report pain and weakness of the foot muscles. Tapping the posterior tibial
nerve posterior and inferior to the medial malleolus
elicits pain. Ask the patient about shoe t and use of
ing to neuropathy can be caused by collagen disorders
(e.g., SLE, scleroderma).
Diabetes mellitus is commonly associated with
sensory peripheral neuropathy and results in pain
and sensory loss that is more intense in the lower
extremities.
Alcoholism is associated with distal, demyelinating
neuropathy that may resolve with cessation of alcohol
ingestion.
any orthotic devices.
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
MUSCULOSKELETAL INFLAMMATION
Tenosynovitis (tendinitis) Repetitive trauma activities;
Bursitis History of overuse; aching pain
Osteomyelitis
Presentation depends on age, lo-
Common Causes of Lower Extremity Limb Pain
Swelling over tendon, crepitus None
pain with movement
over affected bursae that
radiates along limb
cation of infection; history of
infection, trauma, penetration,
invasive procedure; refusal to
bear weight (hip); constant pain
Local tenderness, swelling;
limited joint motion;
muscle weakness
Fever, chills, vomiting; pain
localized over affected area
but progressively worsens;
soft tissue injury or abscess
None
Increased WBCs,
ESR, C-reactive
protein; radiographs
JOINT INFLAMMATION
Osteoarthritis
Rheumatoid arthritis Morning stiffness of small joints;
Juvenile rheumatoid
arthritis
Septic arthritis History of systemic infection,
Gout Acute pain of large joint, asym-
Older adults; asymmetrical joint
pain and stiffness that improves
throughout day; history of repetitive joint trauma; obesity
symmetrical involvement;
anorexia, weight loss
Fatigue, weight loss, failure to
thrive, refusal to walk, joint
pain and stiffness
malaise, diaphoresis, refusal
to bear weight (hip), acute
joint pain
metrical; males over 30 yr,
history of gout
DIP, PIP joints enlarged;
Heberden nodes; limited
cervical spine ROM
Fever, rheumatoid nodules,
ulnar deviation of wrists
Fever, rash, guarding of joints,
limited ROM; joint swelling,
nodules
Fever; red, swollen joint;
limited range of motion
Inflamed, swollen joint; tophi;
sodium urate crystals
ESR; radiograph may
reveal osteophytes,
loss of joint space
Increased ESR, positive
rheumatoid factor,
anemia on CBC;
radiograph shows
bony erosion
Elevated WBCs, ESR;
positive rheumatoid
factor and antinuclear
antibody
WBCs, culture of joint
aspirate, ESR,
C-reactive protein,
ultrasound of joint
Increased serum uric
acid level, ESR, WBCs
Continued
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Chapter 22 • Lower Extremity Limb Pain
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Lower Extremity Limb Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
MUSCULOSKELETAL PAIN RELATED TO TRAUMA OR OVERUSE
Slipped capital femoral
epiphysis
Transient synovitis of
hip
Legg-Calvé-Perthes
disease (LCPD)
Iliopsoas tendinitis History of repetitive flexion
Proximal fibular fracture History of direct trauma to the
Stress fracture Younger age, history of overuse
Chondromalacia patellae Adolescent females; history of
Patellar tendinitis History of overuse, especially
Medial collateral liga-
ment sprain
Medial meniscus tear History of twisting injury to the
Anterior cruciate
ligament tear
Osgood-Schlatter
disease
Baker cyst Fullness or swelling of posterior
Ankle sprain History of inversion stress with
Children: During rapid growth
spurts; knee pain worse with
activity
Children less than 10 yr; history
of upper respiratory tract infection; limp, pain in anteromedial thigh and knee
Boys age 3-11 yr; groin or
medial thigh pain, limp
of hip; pain worse with
movement
fibula or ankle
of lower extremities
knee trauma or misalignment,
knee pain worse with activity
running or jumping; dull, achy
knee pain; click
History of valgus stress to knee;
limp; pain
knee, pain, difficulty flexing,
bearing weight, clicking
or catching of knee with
movement
History of twisting or extension
knee injury; audible “pop”
Adolescent males; knee pain and
swelling aggravated by activity,
limp
knee, aggravated by walking
audible “pop,” immediate
swelling
Limitation of medial hip
rotation, limp
Tenderness on palpation over
anterior hip; hip movement
increases pain and is limited; low-grade fever
Decreased hip ROM AP and frog lateral
With patient sitting, place
heel of affected leg on knee
of other; test is positive if
pain is elicited
Pain on weight bearing,
edema and tenderness to
palpation over fracture
Pain with activity Radiography, MRI
Tenderness to palpation
over knee
Q angle .10 degrees in males,
15 degrees in females;
clicking or popping with
knee movement
Effusion and point tenderness
over knee; valgus and
varus pressure to assess
instability
Positive McMurray test, click-
ing or locking during joint
movement
Swelling; positive Lachman
test
Tenderness, warmth, swelling
over anterior tibial tubercle
Negative Foucher sign; normal
joint examination; positive
Homans sign in ruptured
cyst
Swelling, soft tissue trauma,
able to perform active ROM
with ligament sprain
Radiograph of epiphyseal
plate
Ultrasound, ESR
radiographs of hip;
LCPD may show
increased density
of femoral head
None
Radiography, CT
if soft tissue injury
is suspected
Four-view radiographs
of knees to rule out
arthritis
None
AP and lateral radio-
graphs may reveal a
ligament avulsion of
femoral origin
Four-knee view radio-
graphs to rule out
bony abnormality; MRI
Radiograph to rule out
fracture; MRI
Radiograph with knee
rotated inward may
show soft tissue
swelling
None
Radiograph needed only
with tenderness over
the lateral malleolus
to rule out fracture
Chapter 22 • Lower Extremity Limb Pain
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273
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Lower Extremity Limb Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Shin splints Ache or pain over medial tibia
that is worse with exercise,
history of running
Achilles tendinitis Pain and tightness over Achilles
tendon, especially with walking or running
Plantar fasciitis History of chronic weight
bearing; aching feet,
muscle spasms, obesity
MUSCLE PAIN (MYALGIA)
Viral infections History of upper respiratory
tract infection; malaise,
chills, cold symptoms,
general muscle aches
Psychogenic Pain is diffuse; varies in pattern
of activity, setting; history of
depression or anxiety
Fibromyalgia Female 20-50 yr; history of de-
pression, sleep disturbance,
chronic fatigue, general
muscle and joint aches
Tenderness over medial tibia AP and lateral radio-
graphs may show a
stress fracture; a bone
scan will be positive
with increased uptake
Tenderness over Achilles
tendon; pain worse with
dorsiflexion ankle; calf
weakness
Misalignment of foot
structures, especially
talus, calcaneus, and
plantar ligaments
Fever, ill-appearing adult or
child
Normal examination or patient
response to examination
maneuvers disproportionate
to physical findings or
subjective complaints
Palpation of trigger points
will produce pain; normal
physical examination
along the medial tibia
Lateral ankle radiograph
reveals enlarged posterosuperior tuberosity
of the calcaneus
None
Viral serum titer
None
None
SYSTEMIC DISORDERS
Acute leukemia Hip pain in children, refusal
Sickle cell disease African American, family history;
Systemic lupus erythe-
matosus
Lyme arthritis History of exposure to endemic
Neuroblastoma Under age 5 yr; pain in bones Unexplained fever Urine for vanillylman-
Osteogenic sarcoma Age 10-25 yr; intermittent pain
to walk
appears after 6 mo of age;
acute pain with swelling of
hands and feet, abdominal
pain, decreased appetite,
malaise
Female; transient arthritis of
small joints, malar rash
areas of deer tick; chills, diffuse joint pain and swelling;
often knee is affected
of lower femur, upper tibia;
limp
Fever, hepatosplenomegaly,
bruising
Normal examination Hemoglobin S genotype
Normal examination may
have joint tenderness on
palpation
Asymmetrical swelling,
warmth of joint; erythema
migrans; may have
myocardial involvement
Tenderness over affected area Radiograph, serum
CBC
Kidney function tests,
antinuclear antibody,
CBC
Serum IgM and IgG
antibodies, ESR
delic or homovanillic
acid; CT scan
alkaline phosphatase
Continued
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Chapter 22 • Lower Extremity Limb Pain
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Lower Extremity Limb Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
NERVE ENTRAPMENT SYNDROMES
Peroneal compression History of pressure to knee
from a cast, sports injury, or
trauma; pain over head of
Tarsal tunnel syndrome Pain in ankle and proximal
Neuritis
AP, Anteroposterior; CBC, complete blood cell count; CT, computed tomography; DIP, distal interphalangeal; ESR, erythrocyte sedimentation rate;
MRI, magnetic resonance imaging; PA, posteroanterior; PIP, proximal interphalangeal; ROM, range of motion; WBC, white blood cell.
fibula; clumsy gait
foot; weakness of toe flexors;
ill-fitting shoes
Pain and sensory loss, usually of
lower extremities; history of
alcohol ingestion, diabetes
mellitus
References and Readings
Edwards Jr PH, Wright ML, Hartman JF: A practical approach for
the differential diagnosis of chronic leg pain in the athlete, Am J
Sports Med 33:1241, 2005.
Fagan H: Approach to the patient with acute swollen/painful joint,
Clin Fam Pract 7:305, 2005.
Garbez R, Puntillo K: Acute musculoskeletal pain in the emergency
department: A review of the literature and implications for the
advanced practice nurse, AACN Clin Issues 16:310, 2005.
Gutierrez K: Bone and joint infections in children, Ped Clin North
Am 52:779, 2005.
Leung AK, Lemay JF: The limping child, J Pediatr Health Care
18:219, 2004.
Unilateral footdrop None
Tapping posterior tibial nerve
elicits pain
Decreased sensory and pain
sensation
Logan K: Stress fracture in the adolescent athlete, Pediatr Ann
36:738, 2007.
Lowe R, Hashkes P: Growing pains a noninammatory pain syn-
drome in early childhood, Nat Clin Pract Rheumatol 4:542, 2008.
Roberts DM, Stallard TC: Emergency department evaluation and
treatment of knee and leg injuries, Emerg Med Clin North Am
18:67, 2000.
Solomon DH, Simel DL, Bates DW, et al: The rational clinical ex-
amination: Does this patient have a torn meniscus or ligament of
the knee? Value of the physical examination, JAMA 286:1610,
2001.
Wilson JJ, Furukawa M: Evaluation of the patient with hip pain, Am
Fam Physician 89:27, 2014.
None
Liver function tests,
hemoglobin A1c to
rule out diabetes
mellitus
CHAPTER
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23
eports of pain in a limb present a diagnostic chal-
R
lenge because of the many possible pathophysiological causes. It is helpful to distinguish between limb
pain that affects the bones, muscles, and tendons. Injury or inammation of a joint can affect surrounding
musculature, nerves, and blood vessels. Pain may also
involve upper extremity peripheral vascular disease.
Upper Extremity Limb Pain
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Is the pain related to a problem that needs immediate
treatment to avoid disability or death?
Key Questions
l
Have you had a recent injury?
l
Can you describe exactly how the injury occurred?
l
Do you have any other symptoms, such as fatigue,
fever, or swollen joints?
l
What is the severity of the pain? Does it occur with
exercise or rest?
Injury
If the injury does not warrant urgent attention, obtain
further history related to it (see Chapter 22).
related to myocardial ischemia indicates immediate
referral for evaluation.
What does the location of the pain tell me?
Key Questions
l
Where does it hurt?
l
Is the pain local or generalized?
Location
Pain localized at the top of the shoulder suggests
arthritis or acromioclavicular joint separation. Pain
from an inamed bursa or torn rotator cuff begins in
the deltoid region and radiates to the lateral upper arm.
Pain at the base of the thumb that occurs with grip or
pinching moving suggests arthritis.
Could this be caused by a sprain or strain?
Key Questions
l
Describe how the injury occurred.
l
Did you hear a noise with the injury, such as a ripping
or cracking sound?
l
Were you able to use the limb after the injury?
Constitutional Symptoms
The presence of generalized symptoms, such as fever,
weight loss, general malaise, or hot, swollen joints,
suggests the presence of a systemic disorder such as
infection or rheumatic disease.
Other systemic infections associated with polyarthritis include bacterial endocarditis, Lyme disease,
syphilis, and such viruses as hepatitis B, rubella, cytomegalovirus, human immunodeciency virus, EpsteinBarr virus, and varicella zoster.
Severity of Pain
Unrelenting diffuse pain, often occurring at night, is an
indication of bone involvement, either through bone
cancer or an infection such as osteomyelitis. Pain
Strain
A strain is an injury to a muscle or tendon (brous
cords that connect muscles to bone). Strains usually
involve repetitive trauma. The most common wrist/
hand complaint is pain caused by inammation of any
of the tendons that cross the wrist (tendonitis). Treatment usually consists of rest, splinting, ice, and nonsteroidal antiinammatory medicines. Golfers will often
have wrist and elbow strain.
Sprain
A sprain is a stretch or tear of a ligament (brous bands
that connect bone to bone across a joint). Sprains of the
ngers are common. Patients almost always report a
history of trauma.
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Chapter 23 • Upper Extremity Limb Pain
Fracture
A Bennett fracture of the wrist is an oblique fracture at
the base of the thumb metacarpal often after a blow to
the thumb. Humeral fracture is fairly common after a
blow to the arm. A displaced fracture is characterized
by severe arm pain, swelling, and deformity.
If there is no history of trauma or a precipitating event,
what else is causing the pain?
Key Questions
l
Can you describe your usual daily activities at home
and at work and your hobbies?
l
How does the pain affect your activities?
Overuse
Cumulative injury or overuse is a problem caused
by repetitive microtrauma, which most often affects
the ngers, wrists, and upper extremities. People
who work on keyboards for long periods of time
may complain of paresthesia of the ngers and pain
and soreness of the wrists and ngers. Weekend
hobbies or participation in sports may result in overuse of certain muscle groups associated with those
activities.
EVIDENCE-BASED PRACTICE
Is Childhood Obesity a Risk Factor
for the Type and Severity of Humeral
Fracture?
Obese children have an increased risk of sustaining musculoskeletal injuries compared with normal-weight peers
and are at greater risk of sustaining forearm fractures,
particularly from low-energy mechanisms. This study explored whether children who sustain lateral condyle (LC)
fractures have a higher body mass index (BMI) than those
with supracondyle (SC) humerus fractures and if children
with higher BMI sustain more severe fractures. The retrospective review involved 992 patients, 230 with LC injuries and 762 with SC fractures. Age-appropriate BMI and
BMI-for-age percentiles were calculated. Results showed
that the LC group had a higher mean BMI than the SC
group as well as more obese patients (37% versus 19%).
Among patients with SC fractures, there was no difference
in the BMI or percentage of obese children when analyzed
by fracture subtype. The authors concluded that obesity
places a child at greater risk for sustaining an LC fracture
and that these fractures are often more severe compared
with those in nonobese children.
Data from Fornari ED, Suszter M, Roocroft J, et al: Childhood obesity
as a risk factor for lateral condyle fractures over supracondyle fractures,
Clin Orthop Relat Res 417:1193, 2013.
Activities
A person may adapt to chronic musculoskeletal problems by limiting activities. Inammatory disorders produce symmetrical discomfort and pain with inactivity
while noninammatory conditions are often associated
with asymmetrical pain.
In upper extremity (shoulder, wrist, elbow) joint pain
with injury, what do I need to know about the specic
joints involved?
Key Questions
l
Is the pain in your dominant limb?
l
Did you fall on an outstretched hand or arm?
l
Did you engage in any activities that required over-
use of one or more joints?
Pain in the dominant hand may indicate repetitive microtrauma caused by overuse. Breaking a fall with an
outstretched arm is a common mechanism of injury for
a fracture or dislocation of the hand or wrist.
Could this be musculoskeletal or joint disease?
Key Question
l
Can you describe the pain?
Pain associated with fracture is often severe. Older
adults often report chronic joint pain. Bursitis pain is
often associated with swelling and limited joint motion
(see Chapter 22).
What does the history of swelling tell me?
Key Questions
l
Is there any swelling?
l
When did the swelling begin?
Swelling
Generally, swelling secondary to trauma such as a
strain develops immediately or within 2 hours after an
injury. Swelling 6 to 24 hours after an injury is usually
of synovial origin, such as a subluxation, dislocation,
or ligamentous damage (sprain). Swelling after 24 hours
suggests an inammatory response.
Is this an acute or a chronic problem?
Key Questions
l
When did the pain rst occur?
l
When did you rst notice a problem?
Chapter 23 • Upper Extremity Limb Pain
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277
Severe ligament sprain is manifested as an immediately disabling pain at the moment of the injury. Pain
experienced hours after an injury or physical activity is
usually caused by acute extensor injury or overuse.
How is activity affected?
Key Questions
l
What are your usual activities?
l
What activity makes the pain worse?
l
What movements make the pain worse?
Patients may report noticing pain, weakness, or difculty in activities of daily living, such as using a hair
dryer, opening jars, holding a pen, or handling eating
utensils.
A large percentage of musculoskeletal injuries are
caused by repetitive motion that leads to microtrauma
and eventually cumulative damage.
What does joint stiffness tell me?
Key Questions
l
Have you had any joint stiffness?
l
Does activity make the stiffness worse or better?
Joint Stiffness
Stiffness is a common feature of any inammatory arthropathy. It is important to know whether it is localized or generalized. The length of time the stiffness
lasts in the morning is a useful index of active synovitis in disease states such as rheumatoid arthritis (RA)
or systemic lupus erythematosus (SLE). With most inammatory arthropathies, stiffness and pain are alleviated by activity; in contrast, mechanical problems are
aggravated by activity. Musculoskeletal tumors commonly present with mild joint stiffness because of
muscle involvement but rarely demonstrate instability.
Could this be caused by systemic disease?
Key Questions
l
Have you been treated with antibiotics recently?
l
Have you had any recent immunizations?
l
Does the pain awaken you at night?
l
Is the pain worse at night?
Medications
Transient arthralgia may occur 6 to 8 weeks after receiving immunizations. Recurrent or permanent arthritis may
follow rubella vaccination, especially in adult women.
Night Pain
Rotator cuff tears can cause shoulder pain and upper
extremity numbness when sleeping on one’s affected
side.
What does the health history tell me?
Key Questions
l
Do you have a chronic disease?
l
Could you have been exposed to any sexually trans-
mitted infection?
l
Have you been treated with cortisone?
Chronic diseases, such as sickle cell anemia, inammatory bowel disease, Crohn disease, hypothyroidism
and hyperthyroidism, and collagen vascular diseases,
are frequently associated with skin rashes, psoriasis,
and limb and joint pain.
Gonorrhea disseminates to the musculoskeletal
system in 1% to 3% of infected individuals. One form
involves skin rashes and many joints, usually large
joints such as the knee, wrist, and ankle. Exposure to
other infectious agents, such as Chlamydia trachoma-
tis (sexually transmitted) and Chlamydia pneumonia
(respiratory tract), can trigger an autoimmune response when these organisms migrate through the
blood to joint tissue; this is called reactive arthritis.
Viral infections may cause diffuse myalgia.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Figures 23-1 to 23-3 depict anatomic landmarks of the
shoulder, elbow, hand, and wrist.
Observe Patient Walking, Removing Coat/Jacket
People who have septic joints appear ill, and movement of the joint will increase pain. Inspect the patient
with minimal clothing obstructing your view of movements.
Have Patient Locate the Pain
Have the patient point to the area of pain. Location of
pain and actual area of pathology may not be the same
because of referred pain.
Shoulder pain from rotator cuff tendinitis is felt
over the lateral aspect of the deltoid.
Swelling of the elbow may compress the ulnar
nerve, producing a tingling sensation in the fourth and
fth ngers.
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Chapter 23 • Upper Extremity Limb Pain
Subacromial
(subdeltoid) bursa
Greater tuberosity
of humerus
Lesser tuberosity
Deltoid muscle
Bicipital
(intertubercular)
groove
Humerus
FIGURE 23-1 Anterior view of bones and ligaments of the right shoulder. (From Fam A, Lawry G, Kreder H:
Musculoskeletal examination and joint injection techniques, Philadelphia, 2005, Mosby.)
Acromioclavicular joint
Acromion
Joint capsule
Clavicle
Supraspinatus muscle
and tendon
Glenoid fossa and
labrum glenoidale
Glenohumeral synovial
joint space
Axillary recess
Synovial membrane
Note Any Deformities
Fractures generally produce unilateral deformities or
swelling in the extremities. Inammatory and degenerative joint diseases produce observable joint swelling
and deformity that usually occurs bilaterally.
Osteoarthritis typically involves the distal interphalangeal (DIP) and proximal interphalangeal (PIP)
joints, spine, hips, knees, and rst metatarsophalangeal (MTP) joints. Joints are enlarged with Heberden
(DIP joints) and Bouchard (PIP joints) nodes. (See
Figure 23-4.)
Joints affected by RA include PIPs, metacarpophalangeal (MCP) joints, wrists, knees, elbows, cervical
spine, and MTPs. Joints are swollen with a fusiformshaped swelling of the PIP joints. Subluxation, ankylosis, and ulnar deviation may be observed as a result of
joint destruction from chronic inammation.
Assess Vital Signs
Elevated temperatures are seen with neoplastic, systemic, and infectious processes such as osteomyelitis,
septic arthritis and septic hip in children, and rheumatic disease. Palpate for quality and presence of
pulses in any injured limb and compare with the opposite side. Assess peripheral pulses for presence, rate,
regularity, strength, and symmetry.
Inspect the Skin and Nails
Inspect the skin for redness and inammation.
Look for a puncture or an abscess that could be the
source of infection and seeding if a septic joint or osteomyelitis is suspected. Look for ecchymosis and
bruising. These indicate trauma as a source for pain as
well as raise a suspicion of abuse. Swelling and redness of a joint indicate underlying infection or inammation. Effusion, or uid in the joint capsule, always
distends the joint in a smooth, symmetrical manner.
Observe the muscles around the painful limb area.
Decreased muscle tone or atrophy from disuse begins
immediately after injury; however, it will not be clinically apparent for approximately 1 week.
Measure Limb Circumference and Length
Use a tape measure to locate points at which to measure and compare limb circumference. Differences
may be the result of muscle atrophy or edema.
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