1

A colleague asks you for advice. He tells you about a 63-year-old woman with a 1-week history of
anterior neck pain. The pain came on suddenly and is a constant dull ache on the left side of her neck
just lateral to the trachea and under the line of the jaw. The neck moves freely, and there is no pain with
any evocative maneuver or radiation of the discomfiture to the shoulder, arm, or back. The thyroid is
not tender. He feels a pulsatile area that is uncomfortable. The patient notes no weakness, dizziness, or
changes in vision.

Which of the following would be an alarm symptom?

Gait instability

A pulsatile and tender carotid artery

Asymmetric thyroid

Temporomandibular joint (TMJ) pain

Asymmetric neck pain

Ans

Carotid artery dissection is an unusual complication of neck manipulation and can cause a variety of
neurologic symptoms in the distribution of the involved carotid artery. In this case, with the absence of
any antecedent injury, carotidynia is the most likely diagnosis. This would produce the physical finding of
a tender carotid artery. Pain in the thyroid would not radiate to the upper anterior neck. TMJ pain would
not radiate below the jaw. Carotidynia is typically on one side only.

An 85-year-old woman sees you for intense pain in the right shoulder and arm. The pain began slowly
over a few days and then intensified. She has never had any previous neck pain; she has not had any
injury or trauma. She describes a burning sensation and a cluster of red bumps on her forearm.
What findings would you immediately look for on physical examination?

Hyperreflexia in her extremities

Pain with evocative maneuvers

Weakness in the biceps

A vesicular eruption on her right forearm

A diffuse eczematous rash on her torso

Ans

This is a common presentation for shingles or herpes zoster. The pain is in a dermatomal distribution, in
this case the C7 nerve root. The pain of shingles can precede the rash by a few days. The case does not
suggest cervical spinal cord compression because there is no trauma and no history of chronic neck pain.
Although there might be pain with evocative maneuver (she is 85 years old, after all), the presence of
the typical rash of shingles makes a concurrent cervical radiculopathy unlikely. For the same reason,
there would be no expectation of weakness. Shingles does not affect the motor neurons. A diffuse
eczematous rash would not fit with any cause of radicular neck pain.

A 45-year-old man is seen in the emergency room following a motor vehicle accident. His car was struck
from behind while he was waiting at a stop light. He was thrown forward and then backward toward his
headrest. There was no head trauma, he was wearing a seatbelt, and the airbag did not deploy. He
complains only of a stiff neck.

What specific question would you ask?

How severe was the accident?

What sort of work do you do?

Have you had a prior history of neck pain?

Does the pain radiate?

Point to the area on my neck where you have pain?

All of the above.

Ans

The severity of injury, monotonous work, and prior history of neck pain are all associated with a more
protracted course. After determining that the spinal cord is not at risk, the next step is to classify the
neck pain as axial or radicular. Finally, using your own body as a diagnostic tool can help you to get a
better sense of what structures are involved.

A 45-year-old man is seen in the emergency room following a motor vehicle accident. His car was struck
from behind while he was waiting at a stop light. He was thrown forward and then backward toward his
headrest. There was no head trauma, he was wearing a seatbelt, and the airbag did not deploy. He
complains only of a stiff neck.

What specific question would you ask?

How severe was the accident?

What sort of work do you do?

Have you had a prior history of neck pain?

Does the pain radiate?

Point to the area on my neck where you have pain?

All of the above.

Ans
The severity of injury, monotonous work, and prior history of neck pain are all associated with a more
protracted course. After determining that the spinal cord is not at risk, the next step is to classify the
neck pain as axial or radicular. Finally, using your own body as a diagnostic tool can help you to get a
better sense of what structures are involved.

A 67-year-old postal supervisor comes to your office saying, "Doctor, I think I have arthritis." He reports
intermittent left shoulder pain gradually worsening over the past 6 months. The pain occurs when he
walks up the hill to the bus stop in the morning and has been occurring earlier on the ascent over time
and more frequently with cold weather. It is unaffected by arm movement and relieved by resting for 5
minutes.

What is the most likely diagnosis?

Rotator cuff tendinopathy

Frozen shoulder

Referred pain

Osteoarthritis

Ans

The absence of pain with movement signifies that this is not "moving parts pain" from the articulations,
muscles, or tendons of the shoulder complex. This is likely referred pain. Pain with exertion that is
relieved by rest and worsened with cold suggests angina (see Chapter 27).

A 50-year-old chief financial officer comes in with a refractory shoulder pain that has worsened
gradually over the past year. He points to his anterior shoulder to localize the pain. He is an avid
weightlifter, and the pain occurs with any motion of the shoulder.

Which of the following is most compatible with a diagnosis of acromioclavicular osteoarthritis?

Pain exacerbated by horizontal cross-body adduction

Pain when lifting his arm above his head

Fear the shoulder will "pop" on external rotation and abduction of the shoulder

Pain radiating into the neck

Unrelenting pain all day and night

Ans

Pain exacerbated by cross-body adduction—reaching across the body to grab the opposite shoulder—
suggests acromioclavicular (AC) joint disease. Pain when lifting arms above the head would suggest
impingement syndrome. A fear of the shoulder popping would suggest intermittent shoulder
dislocation, usually in persons with prior shoulder dislocations. Pain radiating from the neck suggests
cervical disk disease. Unrelenting pain all day and night suggests an inflammatory arthritis, infection, or
malignancy. On his examination, the AC joint was visibly stepped off, and bony enlargement was
observed. Stressing the AC joint on examination exacerbated the pain, and radiography confirmed the
diagnosis of AC joint osteoarthritis.

A 50-year-old chief financial officer comes in with a refractory shoulder pain that has worsened
gradually over the past year. He points to his anterior shoulder to localize the pain. He is an avid
weightlifter, and the pain occurs with any motion of the shoulder.

Which of the following is most compatible with a diagnosis of acromioclavicular osteoarthritis?

Pain exacerbated by horizontal cross-body adduction

Pain when lifting his arm above his head

Fear the shoulder will "pop" on external rotation and abduction of the shoulder

Pain radiating into the neck

Unrelenting pain all day and night

Pain exacerbated by cross-body adduction—reaching across the body to grab the opposite shoulder—
suggests acromioclavicular (AC) joint disease. Pain when lifting arms above the head would suggest
impingement syndrome. A fear of the shoulder popping would suggest intermittent shoulder
dislocation, usually in persons with prior shoulder dislocations. Pain radiating from the neck suggests
cervical disk disease. Unrelenting pain all day and night suggests an inflammatory arthritis, infection, or
malignancy. On his examination, the AC joint was visibly stepped off, and bony enlargement was
observed. Stressing the AC joint on examination exacerbated the pain, and radiography confirmed the
diagnosis of AC joint osteoarthritis.

A 42-year-old woman presents to your clinic with 1 year of progressive weakness and numbness in the
hand and wrist. The pain has progressed to include her forearm, elbow, and upper arm. She was in a car
accident about 18 months ago. She describes the pain as burning, and touching the arm makes the pain
much worse.

What is the most likely cause of her upper extremity pain?

Cubital tunnel syndrome

Carpal tunnel syndrome

Intersection syndrome

Olecranon bursitis

Reflex sympathetic dystrophy

This patient has reflex sympathetic dystrophy (RSD), also known as chronic regional pain syndrome
(CRPS). Key features include a burning sensation that progresses over time, usually following trauma.
Carpal and cubital tunnel syndromes are unlikely because they do not progress to include the entire
arm. Intersection syndrome is pain localized to the wrist and is more common in Alpine skiers.
Olecranon bursitis presents as pain and erythema over the olecranon process.

9
A 35-year-old woman describes periodic pain in her fingers and hands. The pain has been present for
more than 3 years and is worse in the winter. She notes that when the pain is present, her fingers turn
white, then blue, and then red.

What is the most likely diagnosis?

Thoracic outlet syndrome

Cubital tunnel syndrome

de Quervain tenosynovitis

Carpel tunnel syndrome

Raynaud's disorder

This patient has Raynaud's disorder. Classic features include 3-color changes of the digits exacerbated by
cold exposure. Thoracic outlet syndrome presents as pain, weakness, and swelling of the arm and hand.
Cubital tunnel syndrome is isolated to the elbow or first 2 or 3 digits, whereas Raynaud's disorder occurs
in all fingers. de Quervain tenosynovitis causes soreness on the thumb side of the forearm. Carpal tunnel
syndrome is isolated to the first 2 or 3 digits, similar to cubital tunnel syndrome.

10

A 55-year-old man presents to your clinic with elbow pain. He recently retired and has started to play
golf more frequently. The pain improves with rest. There is no swelling or erythema of the elbow. The
pain is worse with wrist flexion.

What is the most likely diagnosis?

Medial epicondylitis

Lateral epicondylitis
Referred pain from chest structures

Reflex sympathetic dystrophy

Olecranon bursitis

The patient has medial epicondylitis, also known as golfer's elbow. Lateral epicondylitis is not correct
because it worsens with repeated wrist extension. There is nothing in this patient's history to suggest
that chest pathology is the cause of his elbow pain. Reflex sympathetic dystrophy usually occurs after a
trauma and will progress. Olecranon bursitis presents as pain and erythema over the olecranon process.

11

A 72-year-old male smoker with chronic obstructive pulmonary disease presents to your clinic with
severe low back pain. The pain began acutely yesterday after moving furniture in his living room. It is
located in the central aspect of the upper lumbar spine and is described as sharp and intermittent. It is
aggravated by walking, standing, and moving from a sitting to a standing position. It is relieved with rest.
He used the clinic wheelchair to come to your office because the pain is limiting ambulation. On
examination, he is a thin male having sharp bursts of pain with movement, although he is comfortable
while sitting still between these episodes. He has severe tenderness to palpation over the L1 spinal
process with milder pain to palpation over the paraspinous muscles.

What is your leading diagnosis?

Nonspecific low back pain (LBP)

Compression fracture

Spinal stenosis

Abdominal aortic aneurysm

Disk herniation
The acute onset, localized distribution, and intermittent nature of the pain strongly suggest a vertebral
compression fracture. Patients with chronic obstructive pulmonary disease often require intermittent
treatment with corticosteroids, which increases his likelihood of compression fracture. One must also
consider abdominal aortic aneurysm in a male patient older than 65 with a smoking history, but the lack
of abdominal symptoms and localized mechanical nature make this diagnosis less likely. The next
diagnostic step would be plain radiographic imaging with a lumbar posterior-anterior view and lateral x-
ray.

12

A 34-year-old female real estate agent presents to your office with low back pain that began 6 days ago
when she slipped in the foyer of a new condominium building. She fell onto her buttocks and
experienced immediate pain over her tailbone. She was able to get up independently, but the following
day, she awakened with increased pain and stiffness. She states that she is barely able to move and has
spent the last 5 days either in bed or lying on her couch. Her pain is located across her low back and
radiates into her buttock bilaterally. It is described as constant sharp pain of variable intensity. She
states that every movement aggravates it and nothing seems to help.

What is your leading diagnosis?

Nonspecific low back pain (LBP)

Compression fracture

Spinal stenosis

Abdominal aortic aneurysm

Disk herniation

This patient has nonspecific LBP. Her young age and ability to move immediately after the fall, the low
impact of the fall, and the fact that stiffness was not apparent until the following day all go against a
diagnosis of fracture. The localized distribution of her pain and lack of symptoms suggesting
radiculopathy are also reassuring. Of utmost concern for this woman is the lack of activity over the past
week and her high avoidance of movement for fear of causing greater symptoms. These are both
worrisome predictors for developing a chronic condition. She would benefit from close follow-up,
reassurance, and possibly early physical therapy
13.

A 72-year-old man with a history of emphysema presents to your outpatient clinic with left hip pain. The
pain radiates to the groin and has been present for greater than a year. His emphysema is poorly
controlled, and he has had multiple exacerbations in the past 5 years. An x-ray of the hip shows
avascular necrosis of the femoral head.

Which medication put this patient at increased risk for this condition?

Ibuprofen (a nonsteroidal anti-inflammatory drug [NSAID])

Prednisone (a corticosteroid)

Salmeterol inhaler (a long-acting β-agonist)

Aspirin

Simvastatin (an HMG-CoA reductase inhibitor)

This patient has avascular necrosis of the femoral head. Risk factors for this condition include sickle cell
anemia, fracture, corticosteroid therapy, alcohol, gout, diabetes, and Gaucher disease. Avascular
necrosis has been associated with prednisone (a corticosteroid) and not ibuprofen, salmeterol, aspirin,
or simvastatin.

14.

A 24-year-old woman presents to your clinic 4 weeks after delivering a healthy, 9 lb, 4 oz baby boy. She
reports feeling well except for pain in her lower back, which she describes as an aching sensation in the
midline.

What is the most likely diagnosis?

Sciatica

Piriformis syndrome
Meralgia paresthetica

Reflex sympathetic dystrophy

Coccydynia

The patient has coccydynia, which is present in up to 20% of women after difficult deliveries. Coccydynia
usually presents as midline pain at the end of the spinal column. Sciatica and piriformis syndrome are
usually unilateral and cause pain in the distribution of the sciatic nerve. Meralgia paresthetica is caused
by damage to the lateral femoral cutaneous nerve and usually presents with bilateral lateral thigh pain.
Reflex sympathetic dystrophy is characterized by a burning pain that is progressive. It usually has a
predisposing event such as injury.

15.

A 21-year-old man presents to your clinic with pain in his thighs. He describes the pain as a burning
sensation localized to the lateral aspect of both thighs. He is on the college wrestling team and
frequently lifts weights.

What is the most likely cause of his pain?

Trochanteric bursitis

Hamstring strain

Quadriceps muscle strain

Meralgia paresthetica

Sciatica

Meralgia paresthetica is caused by damage or injury to the lateral femoral cutaneous nerves by surgery,
diabetic neuropathy, restrictive clothing, or weightlifting belts. Trochanteric bursitis usually causes
unilateral pain in the upper lateral thigh. Quadriceps and hamstring strains are usually precipitated by
activity. Sciatica usually presents with deep posterior buttock pain with radiation down the posterior
thigh and leg.

A 25-year-old woman presents to an urgent care center with a swollen, painful right knee. The patient
was playing soccer and ran into another player, causing her to twist and fall. She reports immediate
swelling of her knee.

What is the most likely diagnosis?

Fracture

Ligamentous tear

Meniscal tear

Septic joint

Ligamentous tear is most likely because the patient had injury by external force and immediate swelling
of her knee. Fracture may occur with ligamentous tear, but the immediate swelling strongly suggests
ligamentous tear. Meniscal tears usually do not cause immediate swelling (but rather swelling over
several hours). Septic joint is unlikely because the symptoms were precipitated by trauma.

16:

A 65-year-old retired male bricklayer presents with bilateral anterior knee pain that has worsened over
the past month. He reports intermittent knee pain for the past 5 years. He denies swelling, warmth,
fever, or erythema. There is no history of trauma. The pain worsens with climbing stairs and when
standing from a seated position.

What is the most likely diagnosis?

Ligamentous tear

Patellar fracture
Patellofemoral syndrome

Septic arthritis

Patellofemoral syndrome is most likely because he has chronic anterior knee pain aggravated by
climbing stairs and rising from a chair. There is no swelling or trauma, making fracture and ligamentous
tear unlikely. Septic joint is unlikely given the chronic nature of the pain and absence of fever, swelling,
or other risk factors..

17

A 50-year-old woman presents with calf pain and swelling for 1 day. She had a cholecystectomy 3 weeks
ago. On examination, she has a swollen left calf with 2+ pitting edema.

What diagnosis must be urgently excluded?

Baker cyst

Deep venous thrombosis

Muscle strain

Intermittent claudication

The patient has ≥ 3 points per the Wells criteria (1 for recent major surgery, 1 for calf swelling, and 1 for
pitting edema) and thus is at high risk for deep venous thrombosis.

18

A 69-year-old woman comes to see you for worsening ankle pain. She underwent an open reduction,
internal fixation with hardware insertion for a right ankle fracture 3 weeks earlier and reports the ankle
has become increasingly red, warm, and swollen. This morning, she developed a temperature of 102°F.

What is the most important diagnosis that must be considered?

Ligamentous strain

Osteoarthritis

Plantar fasciitis

Septic arthritis

You must not miss a septic arthritis. Although fever is not always present, a painful, red, swollen joint
should be considered septic until proven otherwise. A joint with hardware is especially susceptible to
septic arthritis. Osteoarthritis and ligamentous strain may cause painful swollen joints, but typically not
redness or fever. Plantar fasciitis causes pain without swelling, and the pain is not near the joint.

19:

A 32-year-old man comes to the office complaining of heel pain. He does not recall injuring himself or
stepping on anything. The pain is greatest in the morning when he first gets out of bed and is most
intense at the medial plantar edge of his heel. He is not an athlete.

What is the most likely diagnosis?

Bunion

Calcaneal fracture

Callus

Plantar fasciitis

The history of pain worse in the morning with the first step is typical of plantar fasciitis. Calcaneal
fractures are usually seen after trauma or in long-distance runners. Bunions cause pain at the first MTP
joint. Although calluses can occur anywhere on the foot, the pain would not abate with walking in the
morning.
20 ;A 45-year-old man presents with 2 days of intense pain in his first metatarsophalangeal (MTP) joint.
The pain began suddenly, without any previous trauma. He has never played sports. His toe feels hot
and very tender to touch. He mentions that he cannot even sleep with the sheets on his foot.

What is the most likely diagnosis?

Bunion

Gout

Osteoarthritis

Plantar warts

This history is typical for gout, in which the pain is exquisite. The first MTP joint is a common site for
gout, known as podagra. Arthritis pain is less severe and tends to be more of an aching pain that comes
on slowly over time. Plantar warts can cause pain with weight bearing and walking but are not red or
swollen unless infected. Bunions also occur at the first MTP joint and may become red with rubbing
from a shoe but do not typically cause acute, severe pain.