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Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
Coccygodynia: Most cases of coccygodynia occur as a result of trauma, such as a fall directly on the tailbone, or events associated with childbirth. • Symptoms: Localized pain in the tailbone that is aggravated by direct pressure such as that caused by sitting, passing gas, or having bowel movement
2. Compression Test : In side-lying position, apply downward pressure with bilateral hands through the anterior portion of the ilium, spreading the SI joint ○ Stresses posterior SI joint ligament 3. Gaenslen’s test: Patient actively flexes opposite LE to chest and holds it. Examiner applies pressure to opposite leg into hip extension ○ Test indicates presence or absence of a SI joint lesion, pubic symphysis instability, hip pathology, or an L4 nerve root lesion 4. Sacral thrust test: The patient is prone, and the examiner applies an anterior pressure through the sacrum 5. Thigh thrust: Patient supine, hip is flexed to 90 degrees to stretch posterior structures. Examiner applies axial pressure, and the femur is used as lever to push the ilium posteriorly Red Flags: Sacral Pain • History ○ Sacroiliac/sacral pain without a history of trauma or overuse ○ Previous history of cancer ○ Previous history of gastrointestinal (GI) disease ○ Previous history of infection (skin, genitourinary tract, heart) • Risk factors ○ Osteoporosis ○ Sexually transmitted infection or other organ system infection ○ Long-term use of antibiotics (colitis) • Clinical presentation ○ Insidious onset/unknown cause ○ Lack of objective findings ○ Anterior pelvic, suprapubic, or low abdominal pain at the same level as the sacrum • Associated signs and symptoms ○ Pain relieved by passing gas or having a bowel movement ○ Presence of GI, gynecologic, or urologic signs and symptoms ○ Fever (septic sacroiliitis); other constitutional symptoms
LEARNING TIP! Causes of coccygeal pain: • Discogenic disease • Degenerative spondylolysis/ spondylolisthesis • Lumbar spinal stenosis • Anal fissures • Inflammatory cysts • Prostatitis • Thrombosed hemorrhoids
Pelvic Pain Chronic pelvic pain is most commonly associated with endometriosis, adhesion, irritable bowel syndrome, and interstitial cystitis. Infectious disease is the most common systemic cause of pelvic pain. Pain can be referred to the pelvis from the hip, sacrum, SI area, or lumbar spine. • Causes of pelvic pain ○ Musculoskeletal/neuromuscular ○ Gynecologic ○ Infectious ○ Vascular ○ Cancer ○ GI Red Flags Associated with Pelvic Pain or Symptoms • Clinical presentation ○ Insidious onset; unknown cause ○ Poorly localized, diffuse; client unable to point to one spot ○ Aggravated by increased intra-abdominal pressure
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