Table of Contents
Lower back pain
Exploring symptom
- Pain
- Site
- Onset
- Character
- Radiation
- Associated symptoms
- Timing
- Exacerbating/relieving factors
- Severity
- Associations
- Sciatica, stiffness/deformity, incontinence, neurological symptoms
- Red flags
- Cauda equina: urinary incontinence/retention, faecal incontinence/constipation, bilateral leg pain, severe/progressive neurological deficit, saddle anaesthesia, sexual dysfunction
- Infection or cancer: age <20 or >55 years at onset, cancer Hx, night pain, weight loss, fever, night sweats, injecting drugs, immunosuppression
- Fracture: trauma, severe central spinal pain
- Spondyloarthropathy: early morning stiffness, worse with rest
Relevant system reviews
- General
- Fever, night sweats, weight loss
- Neuro (lower limbs)
- Motor: weakness/wasting, incontinence
- Sensory: pain, numbness, tingling
Differential diagnoses and clues
Orthopaedic:
| Muscular | -Acute onset lower back pain -Paraspinal muscles affected, not central |
| Lumbar spondylosis and facet joint syndrome (lumbar arthritis) | -Chronic episodic mechanical lower back pain -Backache related to standing/walking a lot/sitting in one place -Progressive stiffening |
| Lumbar disc prolapse | -Acute onset while lifting / bending / sneezing / coughing -Severe pain -Sciatica, leg pain often worse than back pain -Neurological symptoms, e.g. weakness, numbness (usually L4/L5/S1 distribution) |
| Discitis | -Fever and systemic upset -Risk factors, e.g. injecting drug user |
| Spinal fracture | -History of trauma -Sudden onset |
| Cauda equina syndrome | -Urinary incontinence/retention -Faecal incontinence/constipation -Saddle anaesthesia or paraesthesia -Bilateral leg pain and weakness |
Rheumatological:
| Ankylosing spondylitis | -Morning stiffness >30 minutes -Pain worse on rest |
Others:
| Other differentials | Myeloma bone lesions, Bony metastasis, Paget’s disease, Spondylolisthesis, Osteoporotic vertebral collapse, Pyelonephritis, PID, Pancreatitis, AAA |
Joint pain / stiffness / swelling
Exploring symptom
- Pain
- Site(s)
- Onset
- Character
- Radiation
- Associated symptoms
- Timing
- Exacerbating/relieving factors
- Severity
- Stiffness/swelling
- Worse in morning?, how long for (>30 mins = inflammatory; <30 mins = osteoarthritis)
- Better or worse after exercise
- Sleep disturbance
- Loss of function
Relevant system reviews
- General
- Fever, rashes, weight loss
- Rheumatological
- Joints: pain, stiffness, swelling
- Work down body: skin (rashes, ulcers, Raynaud’s), hair loss, eyes (redness, dryness), mouth (dryness), chest (breathlessness, SOB), GI (IBD symptoms), genitourinary (discharge
Differential diagnoses and clues
Rheumatological:
| Rheumatoid arthritis | -Slowly progressive symmetrical polyarthropathy -Small joints (commonly of hand) -Deforming -Early morning stiffness |
| Gout | -First MTP joint most commonly affected -Isolated swollen, hot, painful joint -Hyperuricaemia risk factors, e.g. diuretics, alcohol excess (esp. beer), renal disease |
| Psoriatic arthritis | -Associated skin plaques and nail changes -Early morning stiffness -Many patterns of joint involvement |
| SLE | -Systemic illness with intermittent fevers -Photosensitive rash -Generalised myalgia and arthralgia -Other systemic symptoms (e.g. psychiatric, pleurisy, ulcers) |
| Enteropathic arthritis | -Symmetrical arthritis of lower limb joints and sacroiliac joints -Early morning stiffness -Symptoms/diagnosis of Crohn’s or UC |
Orthopaedic:
| Osteoarthritis | -Elderly -Worse on movement (rest helps) and at end of day, night pain common |
| Septic arthritis | -Isolated hot, red, swollen joint -Agonizingly painful -Systemically unwell with fever |
Others:
| Single joint | – Traumatic (dislocation/fracture/ligament injury) – Haemophilia (haemarthrosis) – Pseudogout – Joint specific problems (e.g. knee – chondromalacia patellae, Osgood-Schlatter’s disease, patellar tendonitis; hip – avascular necrosis) – Adhesive capsulitis – Transient synovitis – Bursitis – Reiter’s syndrome |
| Multiple joints | – Viral polyarthritis (e.g. flu, HIV, hepatitis, rubella) – Other connective tissue disorders (e.g. systemic sclerosis, polymyositis, polyarteritis nodosa) – Other spondyloarthropathies (e.g. ankylosing spondylitis, Reiter’s syndrome, Behçet’s disease, juvenile chronic arthritis, rheumatic fever) |
