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Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
Causes of Thigh Pain • Neuromusculoskeletal: strains, bursitis, peripheral neuropathy, contusions, nerve compression, femoral shaft or subtrochanteric stress reaction or fracture, hip disease, si joint dysfunction, upper lumbar spine dysfunction; spondylolisthesis, herniated disk, inguinal hernia • Systemic: retroperitoneal or intraabdominal tumor or abscess, peripheral neuropathy, urethral, chronic alcohol use, thrombosis Symptoms and Differentiation of Leg Pain Vascular Claudication: Pain is usually bilateral with no burning or dysesthesia • Aggravating factors: Pain is brought on by physical exertion; increased by climbing stairs or walking uphill (increased metabolic demand) • Relieving factors: Relieved promptly by standing still, sitting down, or resting (1–5 minutes) Neurogenic Claudication: Pain is usually bilateral but may be unilateral with burning and dysesthesia in the back, buttocks, and/or leg • Aggravating factors: Increased in spinal extension ; walking—increased by walking downhill (increased lumbar lordosis), less painful when walking uphill • Relieving factors: Pain decreased by sitting, bending forward, or flexion exercises Peripheral Neuropathy: Pain, aching, and numbness of feet with motor, sensory, and autonomic changes: burning, prickling, or tingling may be present; hyperesthesia • Aggravating factors: Depends on underlying cause (e.g., uncontrolled glucose levels with diabetes; progressive alcoholism) • Relieving factors: Pain medications and relaxation techniques; treatment of underlying cause Restless Legs Syndrome: Crawling, creeping sensation in legs with involuntary contractions of calf muscles, occurring especially at night.
Pain can be mild to severe, lasting seconds, minutes, or hours • Aggravating factors: Caffeine, pregnancy, iron deficiency • Relieving factors: Eliminating caffeine; increasing exercise; medications; stretching; maintain hydration; heat or cold Trauma Cases of Lower Quadrant Pain Stress Reaction or Fracture: Undiagnosed stress fracture is a possible cause of hip, thigh, groin, knee, shin, heel, or foot pain. Exercise— induced groin, tibial, or heel pain are the most common stress fractures. • Two types of stress fractures ○ Insufficiency fractures: Breaks in abnormal bone under normal force, more common in older adults ○ Fatigue fractures: Breaks in normal bone that has been put under extreme force, usually caused by new, strenuous, very repetitive activities such as marching, jumping, or distance running • Depending on age, look for a history of high- energy trauma, prolonged activity, or abrupt increase in training intensity • Other risk factors: ○ Changes in running surface ○ Inadequately cushioned footwear ○ Female athlete triad ○ Radiation/chemotherapy ○ Prolonged use of corticosteroids ○ Metabolic disorders affecting bone • Clinical Signs and Symptoms: Stress Reaction/Stress Fracture ○ Aching pain in hip /groin area; may radiate to knee ○ Increases with activity /improves with rest ○ Compensatory gluteus medius gait ○ Localized tenderness ○ Positive Patrick’s or Faber’s test ○ Thigh pain reproduced by the fulcrum test (femoral shaft fracture) ○ Pain reproduced by weight bearing, heel strike ○ Possible local swelling ○ Night pain (femoral neck stress fracture)
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