This should be thorough. It is important that the physician is confident with the diagnosis and is not concerned about other disease processes as a cause of the pain. Time spent at this stage may prevent repetition and unnecessary, distressing investigations at a later date. The list of differential diagnoses with any pain condition is long. An example of differential diagnoses of musculoskeletal pain is given in Table 3. A good history and examination will exclude most of these. If, however, there is concern, this is the time to order all investigations and ensure that these are followed up. Undue delay leads to catastrophization and often a worsening of pain symptoms and associated disability.
Table 3 Diagnostic Possibilities for Musculoskeletal Pain in Adolescents (Not Exhaustive!)
Localized idiopathic pain syndrome
Chronic regional pain syndrome type 1 (reflex sympathetic dystrophy) Chronic regional pain syndrome type 2
Slipped femoral epiphysis Transient synovitis Spondyloarthropathy Knee
Arthritis (knee or radiating from hip) Osgood-Schlatter disease Chondromalacia Discoid meniscus Osteochondritis Ankle and foot Enthesitis Arthritis
Osteochondritis dissecans of talus Sever's disease Tarsal coalition Upper limb
Localized idiopathic pain syndrome Chronic regional pain syndrome type 1 Chronic regional pain syndrome type 2 Shoulder
Dislocation Transient synovitis Rotator cuff injury Elbow
"Pulled elbow" Arthritis Wrist and hand Arthritis
Raynaud's disease Erythromelalgia Back
Ankylosing spondylitis Spondylolysis Scheuermann's disease Osteomyelitis
Hyperlordosis (with hypermobility) Fractures, malignancies, and systemic illnesses can also present with localized musculoskeletal pain
Source: Adapted from Ref. 79.
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