Overview of musculoskeletal pain
Introduction
Related conditions
Chronic fibrosing condition characterised by insidious, progressive, and severe restriction of both active and passive shoulder range of motion. Many patients experience shoulder pain, but shoulder pain is not an essential component of adhesive capsulitis.
Although other fractures around and including the ankle can occur (such as distal tibial plafond fractures), the term 'ankle fracture' most commonly refers to fracture types in which one or more of either the medial, lateral, or posterior malleolus is broken.
A seronegative spondyloarthropathy predominantly affecting the sacroiliac joints and axial spine. Inflammatory back pain is the hallmark clinical feature. This is defined as back pain that is of insidious onset, worse in the morning and improves with exercise.
Injury typified by sudden, painful, audible 'pop' noise. Patient typically presents with inability to return to activity, joint instability, and rapid development of effusion (haemarthrosis). Often tender at lateral femoral condyle, lateral tibial plateau, and tibiofemoral joint lines.
Various spinal structures including ligaments, facet joints, paravertebral musculature and fascia, intervertebral discs, and spinal nerve roots have been implicated as pain generators. [8] The aetiologies can be subdivided into 3 groups: mechanical, systemic, and referred. By far the most common cause is mechanical (97%).[9][10] However, most low back pain is non-specific and the cause cannot be identified.[8][11]
Most commonly results from motor vehicle accidents, gunshot or stab wounds, contact sport accidents, or workplace accidents during heavy physical labour. The effects of the injury include paralysis, loss of sensation, and pain. The specific clinical presentation will depend on the nerve roots involved and the degree of injury to each root.
A bursa is a sac containing a small amount of synovial fluid that lies between a tendon and either skin or bone to act as a friction buffer. In bursitis, there is thickening and proliferation of the synovial lining, bursal adhesions, villus formation, tags, and deposition of chalky deposits. This may result from repetitive stress, infection, autoimmune disease, or trauma. Key diagnostic findings are localised pain and tenderness over a bursa and swelling if superficially sited.
Calcium pyrophosphate arthritis is caused by deposition of calcium pyrophosphate (CPP) crystals. It can be difficult to diagnose. CPP crystals in synovial fluids can be small, sparse, and difficult to find. It typically occurs in older patients. In patients aged <60 years, underlying metabolic conditions associated with calcium pyrophosphate deposition, such as hyperparathyroidism or haemochromatosis, should be investigated.
Most common entrapment neuropathy. Symptoms include numbness and/or tingling of the thumb and radial fingers, aching wrist, and clumsiness.
Encompasses a wide range of potential injuries to ligaments, muscles, bones, and spinal cord that follow acute incidents ranging from a seemingly innocuous fall to a high-energy motor vehicle accident. In all cases, careful investigation is required to ensure that the stability of the cervical spine has not been compromised. In extreme cases, cervical spine instability can lead to progressive neurological deficit, quadriplegia, and even death.
Osteoarthritis of the spine, including the spontaneous degeneration of either disc or facet joints. Presenting symptoms include axial neck pain and neurological complications.
Sudden or gradual onset of persistent disabling fatigue, post-exertional malaise/exertional exhaustion, unrefreshing sleep, cognitive and autonomic dysfunction, myalgia, arthralgia, headaches, and sore throat and tender lymph nodes (without palpable lymphadenopathy), with symptoms lasting at least 6 months.[12] The fatigue is not related to other medical or psychiatric conditions, and symptoms do not improve with sleep or rest.
Chronic pain is one of the most common reasons for seeing a primary care physician. There are many causes of chronic pain, and these may be attributed to musculoskeletal (mechanical) causes, neurological causes, causes of headaches, psychological causes or localised disease, or as part of a generalised disease process. The prevalence of chronic pain increases with age, affecting nearly 30% of older people.[13] Typical aetiologies in this population are arthritis, osteoporosis with fractures, and lumbar stenosis. These conditions are treatable and should not be considered part of the normal ageing process. Untreated chronic pain in older adults can result in depression, poor quality of life, and loss of independence.
Disabling pain in the coccyx, usually provoked by sitting or rising from sitting. May be post-traumatic (e.g., a fall or childbirth), non-traumatic, or idiopathic in origin.
Characterised by elevated interstitial pressure in a closed osteofascial compartment that results in microvascular compromise. Can be caused by fracture, compartment haemorrhage, direct soft-tissue injury, or direct muscular injury.
Prolonged pain, disproportionate to the initiating event, most frequently a minor trauma and most commonly affecting the distal aspect of an extremity. Pain is often described as spontaneous, burning, lancinating, sharp, shooting, or electric. Characteristically develops dull, boring, and aching qualities with chronicity.
Presents with insidious onset of anterior chest wall pain exacerbated by certain movements of the chest and deep inspiration. Key sign is pain on palpation of costochondral joints (particularly the second to the fifth).
A complex, multi-factorial, clinical condition characterised by low back pain with or without the concurrence of radicular lower limb symptoms in the presence of radiologically-confirmed degenerative disc disease. Red flags including night pain, unexplained weight loss, fever, or symptoms of the gastrointestinal, urinary, and cardiorespiratory systems should always be part of the clinical assessment, as their presence may suggest an alternative diagnosis for back pain.
Typically occurs during the fourth and fifth decades of life. Patients describe a history of activities contributing to overuse of the forearm muscles that originate at the elbow. Patients with epicondylitis report pain during or following elbow flexion and extension.
Patients (usually women) present with chronic, widespread body pain and often also have fatigue, memory problems, and sleep and mood disturbances. Criteria consist of adding up the number of body sites of pain, as well as the presence and severity of frequent comorbid symptoms such as fatigue, memory problems, and sleep disturbances.
Smooth, soft, benign masses that are usually located on the wrist. Patients may experience occasional aching discomfort secondary to compression of surrounding structures. In some patients, this aching is only present after activity. Occult ganglia are usually undetectable by physical examination but may be a cause of vague wrist pain.
Acute onset of severe joint pain, with swelling, effusion, warmth, erythema, and/or tenderness of the involved joint(s). The disease most commonly affects the first toe (podagra), foot, ankle, knee, fingers, wrist, and elbow; however, it can affect any joint.
Most common presentation for intra-articular pathology of the hip joint; however, referred pain from other sources is not uncommon. Signs and symptoms typically include activity-related pain, pain with movement of the hip, and antalgic gait.
Associated most commonly with low-energy injury (e.g., fall from standing height) and osteoporosis or osteopenia. The risk increases significantly with age. Treatment is most commonly surgical.
Iliotibial band syndrome is the most common cause of lateral knee pain in runners, related to repetitive friction of the iliotibial band sliding over the lateral femoral epicondyle. Runners predisposed to this injury are typically in a phase of overtraining and often have underlying weakness of the hip abductor muscle.
Complete separation of 2 articulating bony surfaces, often caused by a sudden impact to the joint. Typically, patients have significant pain when attempting motion and are significantly apprehensive about moving the affected joint. Diagnosis is usually confirmed with plain x-rays.
Inflammatory arthritis is a common term for several conditions that manifest as joint pain, swelling, and stiffness with varying degrees of functional impairment. In patients with pain and swelling in a single joint, acute infection is a relatively common cause - one that can result in rapid and irreversible damage. In contrast, the majority of patients with involvement of multiple joints tend to have disorders of chronic duration.
Most common chronic arthropathy of children and includes several subtypes. Affected joints can be painful, especially during motion and on palpation. Objective arthritis in joints for at least 6 weeks is necessary for diagnosis.[14]
By most definitions, acute knee injuries are defined as being diagnosed within the first 30 to 42 days of the injury or onset of symptoms. Chronic knee injuries are due to residual old trauma or surgery, existing degenerative diseases, or previous conditions not resolved within the first 30 to 42 days after the onset.
Occurs when excessive valgus stresses or external rotation forces are placed on the knee joint. Most common symptom is medial-sided knee pain above or below the joint line. Patients are usually able to walk. Diagnosis and grading is primarily made with history taking and physical examination.
Menisci can tear due to traumatic injury or degenerative wear (e.g., in knee joint arthritis), and can compromise force distribution across the knee joint. Tears can cause knee pain, swelling, limited range of motion, and catching, locking, and buckling of the knee joint.
Although mostly benign and self-limited, muscle cramps may also be indicative of a wide variety of potentially serious systemic disorders. The diagnostic approach for idiopathic muscle cramps is one of exclusion.
Pain, stiffness, and/or soreness of the lumbosacral region. Diagnosis is made by eliminating specific causes of low back pain arising from neurological compromise, neoplasia, inflammatory arthritis, fracture, or referred pain from other locations or organ systems.
Strain is an injury to the muscle or musculotendinous junction, whereas a sprain is an injury to the ligament. History and physical examination are key in diagnosis and grading of the injury as grade 1 (mild), 2 (moderate), or 3 (severe with complete rupture).
Patients may present acutely, particularly in the setting of trauma, or with more chronic pain. The estimated lifetime prevalence of a significant episode of neck pain is 40% to 70%, and the global point prevalence of neck pain is 4.9%.[15][16] It is important to detect neck pain caused by significant causes (e.g., primary or metastatic cancer) and pain associated with neurological compromise.
Repetitive tasks in the workplace can cause a variety of overuse syndromes as diverse as the occupations that may cause them. A patient's occupational history is vital in diagnosing the injury. Pain from these disorders can persist and cause work disabilities if left unchecked, and without secondary prevention strategies in place.
Overuse syndrome of the paediatric population that results in traction apophysitis of the tibial tubercle. Typically occurs during an adolescent growth spurt in young athletes who participate in sports that involve repeated knee flexion and forced extension. Males are affected more often than females. Diagnosis is clinical; patients typically present with pain, swelling, warmth, and localised tenderness to palpation over the tibial tubercle.
A degenerative joint disorder; prevalence increases with age. The most commonly affected joints are the knee, hip, hands, and lumbar and cervical spine. Patients present with joint pain and stiffness that is typically worse with activity. Radiographs show loss of joint space, subchondral sclerosis, and osteophytes.
An acquired, potentially reversible idiopathic lesion of subchondral bone resulting in delamination and sequestration with or without articular cartilage involvement and instability. Majority of patients are adolescent or young adult athletes. Main joints involved include the knee, ankle, and radiocapitellar joint of the elbow. Variable presentation: traumatic or atraumatic, insidious onset, non-specific joint pain, exacerbation of symptoms with exercise (especially stair or hill climbing), recurrent effusion, catching, or locking.
Vitamin D deficiency is the most common cause. Patients frequently complain of diffuse bony pain with a history of limited sunlight exposure. Proximal muscle weakness, spinal tenderness to percussion, pseudofractures, and skeletal deformities are found commonly.
An inflammatory condition of bone caused by an infecting organism, most commonly Staphylococcus aureus. Severity can be staged depending on the aetiology of the infection, its pathogenesis, extent of bone involvement, duration, and host factors particular to the individual patient. Broadly, bone infection is either haematogenous or contiguous-focus.
Asymptomatic until fracture occurs. Diagnosis based on history of prior fragility fracture or low bone mineral density, which is defined as a T-score ≤-2.5. Screening is based on individual risk factors, including female sex, maternal history of fragility fracture/osteoporosis, older age, low body mass index (<20 to 25 kg/m²), body weight <58 kg, weight loss of >10% of body weight, androgen deprivation treatment (in males), aromatase inhibitor treatment (in females), corticosteroid use, tobacco use, and kidney stone disease.
Patients may report sudden back pain from atraumatic activities such as standing from a seated position, bending forward, or coughing and sneezing. Pain is characteristically exacerbated by movement.
Worsening pain over weeks to months is the first and most common symptom. Pain is usually mild initially, becoming more severe. It is often reported as more severe at rest and at night. The pain is often described as deep, dull, boring, and relentless.
Chronic localised bone remodelling disorder characterised by increased bone resorption, bone formation, and remodelling, which may lead to major long bone and skull deformities. Majority of patients are asymptomatic, but may present with severe pain in long bones and, rarely, in some facial areas.
Patellofemoral pain syndrome is one of the most common disorders of the knee seen in a sports medicine clinic. The causes of patellofemoral problems are multifactorial, including abnormal patellofemoral joint mechanics, lower kinetic chain alterations, and overuse.
Most commonly affects people between 40 and 60 years of age who are overweight or obese. Also occurs in 10% of runners.[17] Pain may radiate to the lateral heel. To make a diagnosis of plantar fasciitis, the pain must be relieved with rest.
Manifests as pain and morning stiffness involving the neck, shoulder girdle, and/or pelvic girdle in individuals older than age 50 years. Patients complain of difficulty rising from seated or prone positions, varying degrees of muscle tenderness, shoulder/hip bursitis, and/or oligoarthritis. More common in women.[18] 15% to 20% of patients with polymyalgia rheumatica (PMR) have giant cell arteritis (GCA); 40% to 60% of GCA patients have PMR.[19]
Usually the result of pathology of the knee joint, such as arthritis or a cartilage tear. May present with swelling or pain behind the knee, but most cases are asymptomatic. A popliteal cyst may rupture, leading to severe pain and swelling in the calf.
Chronic inflammatory joint disease associated with psoriasis. Psoriatic arthritis frequently presents with a pattern of monoarticular or oligoarticular joint involvement. In patients with multiple joints involved, the pattern lacks the symmetry of rheumatoid arthritis.
An inflammatory condition that occurs after exposure to certain gastrointestinal and genitourinary infections, particularly Chlamydia species, Campylobacter jejuni, and Salmonella enteritidis. Patients may give a history of an antecedent genitourinary or dysenteric infection 1 to 4 weeks before onset. Presenting features include systemic symptoms such as fever, peripheral and axial arthritis, enthesitis (inflammation where tendons insert into bone), dactylitis (swelling of an entire finger or toe), conjunctivitis and iritis, and skin lesions including circinate balanitis and keratoderma blennorrhagicum.
The most common inflammatory arthritis, characterised by symmetric arthritis of the small joints of the hands and feet. A chronic, erosive arthritis that requires aggressive treatment.
May be due to blunt force injury, falls, non-accidental injury, aggressive CPR, severe coughing, athletic activities, or metastatic lesions and primary bone tumours. Rib fractures can be relatively benign, but often may be a marker of concomitant injuries such as pneumothorax, haemopneumothorax, and/or pulmonary contusions.
Deficient mineralisation at the growth plate of long bones, resulting in growth retardation. If the underlying condition is not treated, bone deformity occurs, typically causing bowed legs and thickening of the ends of long bones. Only occurs in growing children before fusion of the epiphyses, and typically affects wrists, knees, and costochondral junctions. Occurs primarily because of a nutritional deficiency of vitamin D, but can be associated with deficiencies of calcium or phosphorus.
Common shoulder condition, especially in older and active patients. Tears can be symptomatic or asymptomatic. Cause of tear can be traumatic or attritional.
Adolescent idiopathic scoliosis is a structural spinal deformity characterised by decompensation of the normal vertebral alignment during rapid skeletal growth in otherwise healthy children. Back pain is usually minimal or absent at presentation. Significant pain at presentation warrants a careful evaluation for other causes of the spinal deformity.
Typically seen in the adolescent age group. May present with an acute/insidious onset of pain and limp. Obligatory external rotation on hip flexion is a key examination finding.
Can occur as a result of spine trauma, vertebral compression fracture, intervertebral disc herniation, primary or metastatic spinal tumour, or infection.
Condition typically resulting from degenerative changes in the lumbar spine. Neurogenic claudication characterised by back and leg pain and lower-extremity paraesthesia, brought on by ambulation and relieved by sitting.
Sport-related injuries may be generally categorised as acute or chronic; the range of medical conditions potentially resulting from sport- or exercise-related injuries is wide. More than 90% of all sport-related injuries are either contusions or strains.[20]
A self-limiting inflammatory disorder of the hip that commonly affects young children between 2 and 12 years of age. Presents acutely with mild to moderate hip pain and limp.
Describes several painful disorders of the mandibular joint, including myofascial pain and dysfunction, internal derangement, and osteoarthritis. Typically presents with 4 characteristic features: temporomandibular joint pain, noise in the joint, masticatory muscle tenderness, and limited mandibular movement.
General term that describes tendon degeneration characterised by a combination of pain, swelling, and impaired performance. Common sites include the rotator cuff (supraspinatus tendon), wrist extensors (lateral epicondyle) and pronators (medial epicondyle), patellar and quadriceps tendons, and Achilles' tendon.
Tenosynovitis of the hand and wrist is a group of entities with a common pathology involving the extrinsic tendons of the hand and wrist and their corresponding retinacular sheaths. They usually start as tendon irritation manifesting as pain, and can progress into catching and locking when tendon gliding fails.
Usually occurs as a result of high-energy trauma (e.g., road traffic accidents, falls from heights). May occur spontaneously in patients with osteoporotic, neoplastic, or metabolic disorders of the spine.
Lower-extremity torsional abnormalities are common in children. Commonly attributed to femoral or tibial torsion, soft-tissue contractures, abnormal muscle tone, hindfoot varus/valgus, forefoot adduction/abduction, or a combination of these.
Fractures of the distal radius are the most common fracture in adults. Typically caused by a fall on the outstretched hand. May be accompanied by fractures of the ulnar styloid, distal ulna, and scaphoid. Isolated scaphoid fractures can also occur.
Contributors
Authors
Editorial Team
BMJ Publishing Group
Disclosures
This overview has been compiled using the information in existing sub-topics.
Patient leaflets
Ankle sprain
Back pain (lower back)
More Patient leaflets
Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer