Important Aspects of Physical Examination

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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!)

Lower limb

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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