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Differential Diagnosis in Physical Therapy of Upper Extremity and Lower Quadrant: Summary
Guidelines for Physician Referral • Hip, thigh, or buttock pain with a total hip arthroplasty that is brought on by activity but resolves with continued activity (loose prosthesis), or who has persistent pain that is unrelieved by rest (Implant infection) • Sciatica accompanied by extreme motor weakness, numbness in the groin or
rectum, or difficulty controlling bowel or bladder function • One or more of Cyriax’s signs of the buttock • New onset of joint pain in a client with a known history of Crohn’s disease, requiring careful screening and possible referral based on examination results
CASE STUDY
Patient is 49-year-old African American female. Patient with diagnosis of bilateral trochanteric bursitis and referred for pain reduction and strengthening. Patient states that she has diffuse muscle and joint pain that is worse in the morning and gets better during the day. She states that her bilateral hip pain started in 2014 and is dull and continual. She states that she also has bouts of fatigue that have made her unable to be compliant with exercising. Additionally, she reports she cannot take anti-inflammatories because she is allergic. She has tried Lyrica in the past, but it didn’t help her pain.
Examination Findings • Past medical history: Various food allergies, allergy to NSAIDS, asthma, cervical dystonia, migraines, OA • Previous therapy: N/A • Medications: Albuterol, Advair, Zyrtec, Benadryl. Botox every 3 months for migraines • Clinical presentation ○ Vitals: BP: 120/72; HR: 82 bpm ○ Integumentary—intact • PROM: Bilateral LE/UE: WNL • Pain (NPS score): Left UE: 5/10 in shoulder and bilateral LE: 3/10 hips • Strength ○ Bilateral UE: 4+/5 ○ Right LE: Knee extension/adduction/ plantar flexion—4/5; dorsiflexion—3+/5; abduction—3+/5 ○ Left LE grossly 5/5 • 5x sit to stand: 10.2 seconds • Sensation: Grossly intact • Reflexes: 2+ bilateral UE/LE • Ober’s: Negative • Thomas Test: Negative • FABER/FADIR: Negative • Jump: Negative • Endurance: 6 minute walk test—1,400 feet with Borg of 6 • Timed up and go: 10 seconds • Participation: LEFS – 70
Evaluation Patient presents with impairments in strength and complaint of pain in B hips and L shoulder. Also complaint of fatigue. Yellow/red flags • Bilateral pain distribution
• Fatigue Treatment • Pain reduction • Endurance training • Strengthening Re-evaluation (2 weeks)
Patient states that she feels stronger. Pain remains unchanged but patient presents with increased endurance and strength. Differential Diagnosis: • Fibromylagia Result Patient seen by physician. After testing, patient diagnosed with RA.
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