Approach to a Patient Presenting With Pain

Pain is the most common symptom that brings a patient to a physician’s attention.
Management depends on determining its cause, alleviating triggering and potentiating factors, and providing rapid relief whenever possible.

Pain may be of somatic (skin, joints, muscles), visceral, or neuropathic (injury to nerves, spinal cord pathways, or thalamus) origin. Characteristics of each of the types are summarized below:

Somatic pain

• Nociceptive stimulus usually evident
• Usually well localized
• Similar to other somatic pains in pt’s experience
• Relieved by anti-inflammatory or narcotic analgesics

Visceral pain

• Most commonly activated by inflammation
• Pain poorly localized and usually referred
• Associated with diffuse discomfort, e.g., nausea, bloating
• Relieved by narcotic analgesics

Neuropathic pain

• No obvious nociceptive stimulus
• Associated evidence of nerve damage, e.g., sensory impairment, weakness
• Unusual, dissimilar from somatic pain, often shooting or electrical quality
• Only partially relieved by narcotic analgesics; may respond to antidepressants or anticonvulsants.

Introduction to Septic Arthritis

A medical emergency, septic (infectious) arthritis is caused by bacterial invasion of a joint, resulting in inflammation of the synovial lining. If the organisms enter the joint cavity, effusion and pyogenesis follow, with eventual destruction of bone and cartilage.
Septic arthritis can lead to ankylosis and even fatal septicemia. However, prompt antibiotic therapy and joint aspiration or drainage cures most patients.

Pathophysiology
In most cases of septic arthritis, bacteria spread from a primary site of infection, usually in adjacent bone or soft tissue, through the bloodstream to the joint.
Common infecting organisms include four strains of gram-positive cocci—Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Streptococcus viridans—and two strains of gram-negative cocci—Neisseria gonorrhoeae and Haemophilus influenzae. Various gram-negative bacilli—Escherichia coli, Salmonella, and Pseudomonas, for example—also cause infection.
Anaerobic organisms such as gram-positive cocci usually infect adults and children older than age 2. H. influenzae most often infects children younger than age 2.

Risk factors
Various factors can predispose a person to septic arthritis. Any concurrent bacterial infection (of the genitourinary or the upper respiratory tract, for example) or serious chronic illness (such as cancer, renal failure, rheumatoid arthritis, systemic lupus erythematosus, diabetes, or cirrhosis) heightens susceptibility. Consequently, alcoholics and elderly people run a higher risk of developing septic arthritis.
Of course, susceptibility increases with diseases that depress the autoimmune system or with prior immunosuppressant therapy. I.V. drug abuse (by heroin addicts, for example) can also cause septic arthritis.
Other predisposing factors include recent articular trauma, joint surgery, intra-articular injections, and local joint abnormalities.

Introduction to Osteoporosis

Introduction

In osteoporosis, a metabolic bone disorder, the rate of bone resorption accelerates while the rate of bone formation slows down, causing a loss of bone mass. Bones affected by this disease lose calcium and phosphate salts and thus become porous, brittle, and abnormally vulnerable to fracture.

Osteoporosis may be primary or secondary to an underlying disease. Primary osteoporosis is commonly called senile or postmenopausal osteoporosis because it’s most common in elderly, postmenopausal women.

Causes
The cause of primary osteoporosis is unknown; however, a mild but prolonged negative calcium balance, resulting from an inadequate dietary intake of calcium, may be an important contributing factor—as may declining gonadal adrenal function, faulty protein metabolism due to estrogen deficiency, and a sedentary lifestyle.

Causes of secondary osteoporosis include 

• prolonged therapy with steroids or heparin, 
• total immobilization or disuse of a bone (as with hemiplegia, for example), 
• alcoholism, 
• malnutrition,
•  malabsorption,
•  scurvy, 
• lactose intolerance, 
• hyperthyroidism, 
• osteogenesis imperfecta, and 
• Sudeck’s atrophy (localized to hands and feet, with recurring attacks).

Signs and symptoms
Osteoporosis is usually discovered when an elderly person bends to lift something, hears a snapping sound, and then feels a sudden pain in the lower back. Vertebral collapse, producing a backache with pain that radiates around the trunk, is the most common presenting feature. Any movement or jarring aggravates the backache.

Tendinitis and Bursitis

A painful inflammation of tendons and of tendon-muscle attachments to bone, tendinitis usually occurs in the shoulder rotator cuff, hip, Achilles tendon, or hamstring.
Bursitis is a painful inflammation of one or more of the bursae—closed sacs that are lubricated with small amounts of synovial fluid that facilitate the motion of muscles and tendons over bony prominences. Bursitis usually occurs in the subdeltoid, olecranon, trochanteric, calcaneal, or prepatellar bursae.

Causes
Tendinitis commonly results from trauma (such as strain during sports activity), another musculoskeletal disorder (rheumatic diseases, congenital defects), postural misalignment, abnormal body development, or hypermobility.

Bursitis usually occurs in middle age from recurring trauma that stresses or pressures a joint or from an inflammatory joint disease (rheumatoid arthritis, gout). Chronic bursitis follows attacks of acute bursitis or repeated trauma and infection. Septic bursitis may result from wound infection or from bacterial invasion of skin over the bursa.

Signs and symptoms
Tendinitis and bursitis have characteristic signs and symptoms.

Laboratory Workup For Children Who Present With Extremity Pain

Laboratory studies are unnecessary for most extremity pain. However, if the history and physical examination do not lead to a definitive diagnosis, if they raise suspicion of a systemic or an infectious disease, or if the pain persists longer than anticipated, then screening laboratory
tests are in order.

A basic evaluation should include

• a complete blood cell count (CBC),
• a sedimentation rate, 
• a C-reactive protein, and 
• a sickle cell preparation or
• hemoglobin electrophoresis when indicated. 

Appropriate serologies should be considered if features of the physical examination are consistent with rheumatologic disease.

•  An elevated sedimentation rate raises suspicion of an infectious or inflammatory disorder or, occasionally, of a neoplasm.
• A CBC may reveal anemia or may suggest an infectious disease. 
• With leukemia, the white blood cell (WBC) count varies, but immature forms may be present in the differential WBC count or thrombocytopenia may be present. 
• A creatine phosphokinase determination is occasionally indicated if muscular pain or weakness is suspected.

Imaging

Radiologic studies are often unnecessary in evaluating limb pain. However, because of the plasticity of children’s bones, traumatic injury that would ordinarily cause only a sprain in an adult is more likely to result in a greenstick or buckle fracture in a child. 

The presence of point tenderness or gross deformity in an extremity or pain on motion of the involved limb increases the likelihood of fracture. 

In an effort to minimize the use of radiographic studies after traumatic injury to the knee and ankle, The Ottawa Criteria have been developed for use in adults. These criteria have also now been validated for use in children older than 5 years. 

Introduction to Osteoarthritis

Osteoarthritis, also known as hypertrophic osteoarthritis, osteoarthrosis, and degenerative joint disease, is the most common form of arthritis. A chronic disease, it causes deterioration of the joint cartilage and formation of reactive new bone at the margins and subchondral areas of the joints. This degeneration results from a breakdown of chondrocytes, usually in the hips and knees.

Causes
Osteoarthritis is widespread, occurring equally in both sexes until age 55. After age 55, incidence is higher in women. Incidence is after age 40; its earliest symptoms generally begin in middle age and may progress with advancing age.
The degree of disability depends on the site and severity of involvement; it can range from minor limitation of the fingers to severe disability in persons with hip or knee involvement. The rate of progression varies, and joints may remain stable for years in an early stage of deterioration.
Primary osteoarthritis, a normal part of aging, results from many things, including metabolic, genetic, chemical, and mechanical factors. Secondary osteoarthritis usually follows an identifiable predisposing event—most commonly trauma, congenital deformity, or obesity—and leads to degenerative changes.

Signs and symptoms
The most common symptom of osteoarthritis is a deep, aching joint pain, particularly after exercise or weight bearing, usually relieved by rest. Other symptoms include:

• stiffness in the morning and after exercise (relieved by rest)
• aching during changes in weather (joint pain in rainy weather)
• “grating” of the joint during motion
• altered gait contractures
• limited movement.

These symptoms increase with poor posture, obesity, and occupational stress.
Osteoarthritis of the interphalangeal joints produces irreversible changes in the distal joints (Heberden’s nodes) and proximal joints (Bouchard’s nodes). These nodes may be painless at first but eventually become red, swollen, and tender, causing numbness and loss of dexterity.

Carpal Tunnel Syndrome

The most common of the nerve entrapment syndromes, carpal tunnel syndrome results from compression of the median nerve at the wrist, within the carpal tunnel. This nerve passes through, along with blood vessels and flexor tendons, to the fingers and thumb. Compression neuropathy causes sensory and motor changes in the median distribution of the hand.
Carpal tunnel syndrome usually occurs in women between ages 30 and 60 and poses a serious occupational health problem. Assembly-line workers and packers, secretary-typists, and persons who repeatedly use poorly designed tools are most likely to develop this disorder. Any strenuous use of the hands—ustained grasping, twisting, or flexing—aggravates this condition.

Causes
The carpal tunnel is formed by the carpal bones and the transverse carpal ligament. Inflammation or fibrosis of the tendon sheaths that pass through the carpal tunnel can cause edema and compression of the median nerve.
Many conditions can cause the contents or structure of the carpal tunnel to swell and press the median nerve against the transverse carpal ligament. Such conditions include rheumatoid arthritis, flexor tenosynovitis (commonly associated with rheumatic disease), nerve compression, pregnancy, renal failure, menopause, diabetes mellitus, acromegaly, edema following Colles’ fracture, hypothyroidism, amyloidosis, myxedema, benign tumors, tuberculosis, and other granulomatous diseases. Another source of damage to the median nerve is dislocation or acute sprain of the wrist.

Signs and symptoms
The patient with carpal tunnel syndrome usually complains of weakness, pain, burning, numbness, or tingling in the involved hands. This paresthesia affects the thumb, forefinger, middle finger, and half of the fourth finger. The patient is unable to clench his hand into a fist. The nails may be atrophic; the skin, dry and shiny.
Because of vasodilation and venous stasis, symptoms are usually worse at night and in the morning. The pain may spread to the forearm and, in severe cases, as far as the shoulder. The patient can usually relieve such pain by shaking his hands vigorously or dangling his arms at his side.

Sprains and Strains

 Definitions: 

Sprain: A sprain is a complete or incomplete tear in the supporting ligaments surrounding a joint that usually follows a sharp twist. 

Strain: A strain is an injury to a muscle or tendinous attachment. 

Both usually heal without surgical repair.

Causes

• Sprains occur when there is trauma to the joint, causing the joint to move in a position it wasn’t intended to move. 
• Strains may be caused by excessive physical effort or activity, improper warming up before an activity, or poor flexibility.

Signs and symptoms
Sprains and strains cause varying signs and symptoms.

Sprains
A sprain causes local pain (especially during joint movement), swelling, loss of mobility (which may not occur until several hours after the injury), and a black-and-blue discoloration from blood extravasating into surrounding tissues. A sprained ankle is the most common joint injury.

Strains
A strain may be acute (an immediate result of vigorous muscle overuse or overstress) or chronic (a result of repeated overuse).
An acute strain causes a sharp, transient pain (the patient may say he heard a snapping noise) and rapid swelling. When severe pain subsides, the muscle is tender; after several days, ecchymoses appear.
A chronic strain causes stiffness, soreness, and generalized tenderness. These conditions appear several hours after the injury.

Fibromyalgia Syndrome

Introduction

A diffuse pain syndrome, fibromyalgia syndrome (FMS, previously called fibrositis) is one of the most common causes of chronic musculoskeletal pain; it’s observed in up to 15% of patients seen in a general rheumatology practice and 5% of general medicine clinic patients. Symptoms of FMS include diffuse musculoskeletal pain, daily fatigue, and sleep disturbances. Multiple tender points in specific areas on examination are the characteristic feature. Women are affected much more commonly than men, and although FMS can affect all age-groups, its peak incidence is between ages 20 and 60. It may occur as a primary disorder or in association with an underlying disease, such as systemic lupus erythematosus, rheumatoid arthritis, osteoarthritis, sleep apnea syndromes, and neck trauma.

Causes
The cause of FMS is unknown, but many theories exist regarding its pathophysiology. Although the pain is located primarily in muscle areas, no distinct abnormalities have been documented on microscopic evaluation of biopsies of tender points when compared to normal muscle. Other theories suggest decreased blood flow to muscle tissue (due to poor muscle aerobic conditioning versus other physiologic abnormalities); decreased blood flow in the thalamus and caudate nucleus, leading to a lowering of the pain threshold; endocrine dysfunction such as abnormal pituitary-adrenal axis responses; and abnormal levels of the neurotransmitter serotonin in brain centers, which affect pain and sleep. Abnormal functioning of other pain-processing pathways may also be involved. Considerable overlap of symptoms with other pain syndromes, such as chronic fatigue syndrome, raises the question of an association with an infection such as with parvovirus B19. Human immunodeficiency virus (HIV) infection and Lyme disease have also been associated with FMS.
It’s possible that the development of FMS is multifactorial and is influenced by stress (physical and mental), physical conditioning, and quality of sleep as well as by neuroendocrine, psychiatric and, possibly, hormonal factors (because of the female predominance).

Signs and symptoms
The primary symptom of FMS is diffuse, dull, aching pain that’s typically concentrated across the neck, shoulders, lower back, and proximal limbs. It can involve all four body quadrants— bilateral upper trunk and arms and bilateral lower trunk and legs. The pain is typically worse in the morning and sometimes accompanied by stiffness. It can vary from day to day and be exacerbated by stress, lack of sleep, weather changes, and inactivity.

Introduction to Osteomyelitis

Introduction

A pyogenic bone infection, osteomyelitis may be chronic or acute. It commonly results from a combination of local trauma—usually quite trivial but resulting in hematoma formation—and an acute infection originating elsewhere in the body. Although osteomyelitis may remain localized, it can spread through the bone to the marrow, cortex, and periosteum.

Acute osteomyelitis is typically a blood-borne disease that usually affects rapidly growing children. Chronic osteomyelitis, although rare, is characterized by multiple draining sinus tracts and metastatic lesions.

Incidence

The incidence of both chronic and acute osteomyelitis is declining, except in drug abusers. With prompt treatment, the prognosis for acute osteomyelitis is good; for chronic osteomyelitis, which is more prevalent in adults, the prognosis is still poor.

Causes
The most common pyogenic organism in osteomyelitis is Staphylococcus aureus; others include Streptococcus pyogenes, Pneumococcus, Pseudomonas aeruginosa, Escherichia coli, and Proteus vulgaris. Typically, these organisms find a culture site in a hematoma from recent trauma or in a weakened area, such as the site of local infection (for example, furunculosis), and spread directly to bone.
As the organisms grow and form pus within the bone, tension builds within the rigid medullary cavity, forcing pus through the haversian canals. This forms a subperiosteal abscess that deprives the bone of its blood supply and eventually may cause necrosis. In turn, necrosis stimulates the periosteum to create new bone (involucrum); the old bone (sequestrum) detaches and works its way out through an abscess or the sinuses. By the time sequestrum forms, osteomyelitis is chronic.

Plantar Heel Pain

Plantar heel pain is a commonly encountered orthopedic problem that can cause significant discomfort and a limp because of the difficulty in bearing weight. The etiologies of this condition are multiple; therefore, a careful clinical evaluation is necessary for its appropriate management. Nonsurgical or conservative care is successful in most cases.

Pathology
The specialized soft tissue at the heel functions as a shock absorber. The subcutaneous structure consists of fibrous lamellae arranged in a complex whorl containing adipose tissues that attach with vertical fibers to the dermis and the plantar aponeurosis.

An inflammatory response and reparative process can double the thickness of the plantar fascia, which is normally approximately 3 mm. Biopsy specimens reveal collagen necrosis, angiofibroblastic hyperplasia, chondroid metaplasia, and calcification.

The heel pain can also have a neurologic basis. The tibial nerve, with nerve roots from L4-5 and S2-4, courses in the medial aspect of the hindfoot, through the tarsal tunnel, under the flexor retinaculum, and over the medial surface of the calcaneus. The calcaneal branch, arising directly from the tibial nerve, carries sensation from the medial and plantar heel dermis. The tibial nerve and its branches in the hindfoot can be involved with compressive neuropathies. A valgus heel can stretch in the tibial nerve.

Clinical Presentation
A careful history and physical examination is valuable in identifying the etiology of heel pain. Taking a comprehensive medical and general history is important in order to distinguish between various causes.
The most common cause of plantar heel pain in both athletic and nonathletic populations is proximal plantar fasciitis.

• The discomfort commonly manifests spontaneously and insidiously without an antecedent trauma or fever. Occasionally, some patients state they might have stepped on a small object such as a pebble or they may have recently started an exercise regimen involving walking or running.
• The pain is localized to the plantar and medial aspects of the heel. It is worse typically with the first few steps in the morning. The pain causes patients to limp for approximately half an hour. It is also worse after a period of rest, such as after standing up from a chair or getting out of a car.
• An acute onset of pain, especially after a vigorous or sudden athletic activity, can be indicative of traumatic rupture of the plantar fascia.
• Fat pad atrophy in elderly patients and in persons who have received multiple steroid injections manifests with pain under the heel that is more diffuse, involving most of the weight-bearing surface.
• Pain radiating from the heel distally or proximally and associated with numbness, paresthesia, or a burning sensation after activity and continuing even after rest is likely to be neurologic in origin.
• Significant loss of appetite and weight or pain at night can be indicative of a neoplasm.

A Brief Discussion On Paget’s disease

Paget’s disease is the disease of the bone caused by a high bone turnover and disorganized osteoid formation. Involved bone is deformed and weak.

How common is paget’s disease
Radiographic evidence is seen in around 2.5% of men over 55 years of age and a little less in women. Less than 10% of those have symptoms. It occurs predominately in people of English origin, including those in North America and Australia. It may be declining in prevalence.

Pathology of bone in paget’s disease.
Paget’s disease is caused by focal or multifocal areas of bone resorption by large osteoclasts, followed by increased bone formation, but the new bone is abnormal with a mosaic appearance on microscopy. It is expanded in size, deforms and fractures more easily and is highly vascularised.

Serum and urine biochemical changes seen in paget’s disease

• Raised alkaline phosphatase.
• Raised serum osteocalcin ( not routinely used )
• Raised urinary hydroxyproline and pyridinolone.

Some other causes of raised alkaline phospahtase

Introduction To Ankylosing Spondylitis

Introduction: This is a chronic inflammatory arthritis especially affecting sacroiliac joints and spine and characterized by progressive stiffening and fusion of the axial skeleton. It is one of the seronegative spondyloarthropathies.

Incidence:  It is most commonly seen in the age range of 20 to 30 years and male to female ratio is   4: 1 . More than 90% of affected persons carry the histocompatibilty antigenHLA B27

Clinical Signs and Symptoms
Onset is usually insidious. There are recurring episodes of low back pain and stiffness sometimes radiating to the buttocks or thigh. Pain is worse in early morning and after inactivity.

Some patients complian of chest pain aggravated by breathing that is due to involvement of costovertebral joints. There is occasionally heel pain due to plantar fasciitis .

On examination there is failure to obliterate lumbar lordosis on forward flexion. There is pain on sacroilliac compression and tenderness over bony prominenece such as illiac crest, ischial tuberosity and greater trochanter.

There is restriction of movement of lumbar spines in all directions. As the disease progresses stiffness increases throughout the spine.

Associated Clinical findings

• Iritis occurs in about 25% of patients.
• Aortic regurgitation, heart blocks and anterior uveitis
• Pulmonary fibrosis of the upper lobes with progression to cavitation mimicking tuberculosis.

Investigations

• ESR is often raised.
• RA factor is absent.
• HLA B 27 seen in 90% of cases

X Ray Lumbar spine

Sciatica - Definition, Causes , Symptoms, Diagnosis And Treatment.

Definition:
The term Sciatica is used for a condition with symptoms of leg pain and may be tingling and numbness along the path of the sciatic nerve. It originates in the lower back, travels through the hip and buttock down to the back of the leg. It typically affects only one side of the body. This term sciatica describes a symptom rather than a specific disease.

Characteristic symptoms of Sciatica:

Sciatica is characterized by one or more of the following symptoms:

• Pain in the leg which is worse when sitting.
• Pain most often occurs only on one side.
• Burning or tingling sensation down the leg.
• Sometimes the pain may be felt like a jolt or an electric shock.
• Weakness, numbness or difficulty moving the leg or the foot.
• A sharp pain that may sometimes make it difficult to walk or move.
• The symptoms may vary widely depending on the underlying cause leading to sciatica

Causes:
Sciatica is caused by irritation of the nerve roots in the lower lumbar and the lumbosacral spine. The conditions that can cause sciatica includes:

• Herniation of the lumbar disc that compresses on one of the lumbar or sacral nerve roots
• Spinal stenosis
• Pelvic injury or fracture
• Pregnancy when the weight of the fetus compresses the sciatic nerve
• Tumors that may impinge on the spinal cord or the nerve roots
• Piriform syndrome- a condition in which the piriform muscle in the buttock region becomes tight and causes irritation of the sciatic nerve.
• Trauma to the spine irritating the nerve roots.
• Bone spurs on the spine

Back Pain- A Brief Overview

Introduction:
Back pain is one of the most common reasons that adults see their physician. Most cases of acute back pain are a result of mechanical causes. Only a few cases have an underlying serious pathology Acute back pain is usually treated with reassurance, returning to activities, and acetaminophen
with or without an NSAID. Psychological factors increase the risk of development of chronic pain. Chronic back pain is difficult to treat and the best outcomes are typically achieved by a multidisciplinary approach.

1. Acute: Back pain that comes on suddenly and lasts less than 6 weeks is classified as Acute Back pain.
2. Chronic: Back pain that lasts for more than 3 months is classified as chronic and is relatively less common as compared to acute back pain.

Causes And Risk factors: The back pain may originate from the muscles, nerves, bones, joints or other structures in the spine. Sometimes it may also be referred from internal structures like pancreas and gallbladder. A few causes and risk factors are listed below:

• Old age.
• Manual labor or excessive back strain.
• Osteoarthritis of the spine.
• Lack of physical exercise.
• Obesity.
• Psychological conditions like depression and anxiety.
• Bulging or rupture vertebral disc.
• Osteoporosis.
• Skeletal irregularities
• Ankylosing spondylitis.
• Underlying malignancy.
• Pregnancy
• Kidney stones or infection
• Cauda equina syndrome

Clinical features: The episodes of back pain may be acute, sub acute on chronic depending upon the underlying cause. The pain be characterized as a dull ache, shooting or piercing pain or a burning sensation. The pain may radiate into the legs and feet. 

The most common area of pain is the lower back or the lumbar region.