Differential Diagnosis: Sacrum, Sacroiliac, Pelvis/Screening Lower Quadrant
Terms in this set (47)
SI Joint Pain usually associated with:
Unexpected step off a curb or in a hole
Fall on the buttocks or hip
Lifting a heavy object in an awkward position
Pain Referral to the SI Region from Systemic Diseases:
Prostate cancer or other cancers
Large intestine and colon-ulcerative colitis, carcinoma, IBD
NORMAL pain pattern of SI Joint Problems:
Pain over the posterior SI joint and buttock
No pain above the level of L-5
May or may not have referral into the L/E
May have pain with weight bearing and when getting up from sitting
Most commonly in men over 70 years. Slowly progressive enlargement and deformity of bones associated with unexplained acceleration of bone deposition and absorption
GI Causes of Sacral Pain:
Referred from the small or large intestine.
Referred pain from the viscera- autonomic nerves (T-11 to S-3), sensory nerves (S2, 3) from the pudental
Pelvic disease may cause primary pelvic pain and may refer pain to...
The low back, thigh, groin, or rectum
The most common tumor is one that has metastasized from the...
breast, lung, intestine, or prostate
Deep pain in the pelvis may indicate spread of rectal tumors into the..
Sacral nerve plexus
Pelvic cancer usually causes back, sacral, or pelvic pain described as:
Constant with crescendo waves of pain that come and go, or diffuse pain (usually the patient can not point to a specific source of the pain)
Uterine Cancer is the most common gynecologic cancer usually occurring in women between...
50 and 70 years of age
Most common symptom of uterine cancer is...
Pelvic pain with vaginal bleeding or discharge. May have unexpected weight loss, and fatigue
Ovarian cancer is 2nd most comon reproductive cancer in women. Early symptoms are non-specific and most women do not seek medical attention until the disease is advanced:
Persistent vague GI complaints
Abdominal discomfort, bloating
Changes in bowel or bladder habits
Pelvic or back pain or discomfort
Has no symptoms!
Painful intercourse may be first sign.
The cancer can spread through the retroperitoneal lymph nodes
Coccydynia (coccyx pain):
most common cause of pain is a direct fall on the "tailbone", or trauma during childbirth.
Bowel or rectal problems could refer pain to the coccyx
painful cramping during menstruation caused by an assortment of gynecologic problems.
Characterized by spasmodic cramp-like pain that comes and goes in waves and radiates over the lower abdomen and pelvis, thighs, and low back
Ectopic pregnancy symptoms:
Unexplained vaginal spotting, bursts of bleeding, and sudden lower abdominal and pelvic cramping.
Gradual hemorrhage causes pelvic, and sometimes shoulder and low back pain. Rapid hemorrhage may result in hypotension and shock-This is a medical emergency!
Retrograde menstruation. T
issue resembling the mucous membrane lining the uterus occurs outside of the uterus and may line the ovaries, peritoneum, bowel, and diaphragm.
Pain can be referred to the low back, rectum, and lower sacral or coccygeal region
Peripheral Vascular Disease
Usually from occlusion of the iliac arteries
which leads to ischemia.
The pain is aggravated by exercise
Typically symptoms start 5 to 10 minutes after starting exercise.
Affected limb becomes colder and paler, with diminished pulse, and sometimes paresthesia occurs
Can cause unilateral or bilateral low back, hip, buttock, groin, or leg pain, and intermittent claudication, and trophic changes of the affected lower extremities
With true hip joint disease (e.g.osteoarthritis), pain will be...
Re-produced with active or passive motion of the hip joint, and the pain usually increases with weight bearing. The patient often demonstrates an antalgic gait
If true hip joint pathology, the patient should have pain with...
Log-rolling, active or passive ROM, and special tests such as the Patrick's Test or scour (quadrant) test
Cyriax's Signs of the Buttock that indicate serious pathology of the hip:
Passive hip flexion more limited and more painful than straight leg raise (straight leg raise is still limited)
Painful weakness of hip extension.
Non-capsular pattern of limitation-limited in only flexion
Swelling in the buttock region
Empty end feel (ROM is limited by pain well before ROM limit is reached)with hip flexion
Musculoskeletal causes may be adductor muscle strain, stress fractures of the neck of the femur, labral tears, or osteoarthritis.
Common for patients with osteoarthritis to have groin pain and radiating pain to the knee.
Femoral shaft stress fractures:
Most common in distance runners and military recruits (vague anterior thigh pain that radiates to the hip or knee especially with weight bearing).
Strike or percussion test to the heel of the patient may elicit pain or fulcrum test
Femoral Neck or Inter-trochanteric Fractures
Usually in older adults or post-menopausal women
If not displaced the patient may still be able to bear weight, but most likely will be painful.
ROM will be very limited due to pain
Painless, progressive enlargement of lymph nodes is a red flag!
Tender may be present with an infection
Neuralgia of the lateral femoral cutaneous nerve either from disk problem (L-2 or 3 nerve roots) or from entrapment in the inguinal area
Most common causes are dehydration, arterial occlusion from PVD, neurogenic claudication from spinal stenosis, neuropathy, medications, or nutritional deficiencies (vitamins, calcium)
Restless Leg Syndrome:
pain at night or at rest in the lower legs. "Creepy, crawling feeling".
Need to move the legs
Pain in the sciatic nerve distribution
Nerve root irritation usually from a herniated disk.
Severe pain and progressive worsening of neurological deficits are red flags and need physician referral
Damage to the peripheral nerve outside of the spine.
Causes may include ischemia (PVD, diabetes, high use of tobacco), direct trauma to the nerve, compression by neoplasm or from the piriformis muscle
THA (total hip arthroplasty)
Direct trauma during surgery, infarction, hemorrhage, or dislocation of the prosthetic device
Arises in the lymph glands, most commonly on a single side of the neck or groin.
The presence of painless, hard lymph nodes that are similarly present at other sites is always a red flag
Spinal Cord Tumors:
Can refer pain to the hip, groin, or legs
small, benign but painful tumor of bone. May occur in the pelvis or proximal femur causing hip pain with weight bearing and restricted hip ROM.
Pain is usually worse at night.
One distinguishing factor is that the pain is relieved by aspirin
Begins posteriorly in the costovertebral angle, but may radiate anteriorly to the upper thigh and groin
pain in the flank that radiates to the scrotum (male) or labia (female).
PT can perform Murphy's percussion test to rule out kidney involvement.
A positive test may be from kidney infection or inflammation
Any infectious or inflammatory process affecting the abdominal or pelvic region
An infection can seed itself to the psoas muscle by direct extension, resulting in a psoas abscess with a local collection of pus.
Patient may have constitutional signs and symptoms.
Pain will be referred to the femoral triangle area and medial thigh
GI causes of pain-Red Flags
Alternating back pain and abdominal pain, or alternating hip pain and abdominal pain are red flag symptoms.
Symptoms that are unrelieved by PT interventions
Symptoms that improve with PT but then get worse again
In anyone with hip or groin pain of unknown cause, look for a known history of pelvic inflammatory disease (PID), Crohn's disease (regional enteritis), ulcerative colitis, irritable bowel syndrome, diverticulitis, or bowel obstruction.
Look for skin rashes
Joint infections of the L/E can be secondary to abdominal infections
Risk factors for vascular causes of pain:
Older age, hyperlipidemia, tobacco use, diatbets
Most common after surgical procedures of the abdomen or orthopedic surgery of the hip or knee
Leg (calf) pain with swelling of the calf or ankle.
Pain with squeezing or stretching the calf (Homan's Sign).
Could lead to venous embolus that could travel to the lung causing a stroke or death.
Abdominal Aortic Aneurysm
Most common symptom is awareness of a pulsating mass in the abdomen, with or without pain, progressively leading to abdominal and back pain.
Flank and groin pain may also occur.
Symptoms of impending rupture: rapid onset of severe groin pain or back pain, radiation of pain to abdomen, pain not relieved by change in position, pain described as "tearing" or "ripping", and cold and pulseless L/E's
Avascular Osteonecrosis of Femoral Head:
Pain with weight bearing, and capsular pattern of restricted hip ROM. The presentation would be similar to patients with osteoarthritis of the hip
Causes of Avascular Osteonecrosis of Femoral Head:
Femoral neck fractures
chronic use/abuse of alcohol
diabetes (decreased circulation) corticosteroid use (rheumatoid arthritis) other immunosuppressant medication (organ transplant, cancer meds)
Affects children from the age of 3-10 from poor blood supply development to the head of the femur
Slipped Capital Epiphysis:
Experienced in the adolescent years during bone growth.
Occurs more often in boys than girls. Often in teens that are over-weight.
May compromise blood supply to the head of the femur
May lead to femoral neck or inter-trochanteric fractures.
Most often in post-menopausal women or older men
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