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CASE STUDY 1 : SHOULDER PAIN

Mrs. B is a 56 years old lady with underlying Hypothyroidism and Diabetes Mellitus, presented with a 9 week history of left sided shoulder pain and restricted movement.

What is your differential diagnoses?

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CAUSES OF SHOULDER PAIN

CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

Pain origin	Differential diagnosis
Pain arising from the shoulder	Rotator cuff disorders: rotator cuff tendinopathy, impingement, subacromial bursitis, rotator cuff tears Glenohumeral disorders: capsulitis (“frozen shoulder”), arthritis Acromioclavicular disease Traumatic dislocation
Pain arising from elsewhere	Referred pain: neck pain, myocardial ischaemia, referred diaphragmatic pain Polymyalgia rheumatic Malignancy: apical lung cancers, metastases

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What further history and physical examination would you like to do?

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HISTORY AND PHYSICAL EXAMINATION

CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

HISTORY	EXAMINATION
Onset and characteristics Functional impact Pain at rest /movement Night pain Any neck thoracic or upper limb pain? History of acute trauma, shoulder pain, or instability during certain movement? Systemic symptoms of illness Significant comorbidity (diabetes, stroke, cancer)	Examine neck, axilla and chest wall Assess range of movement of cervical spine Inspect shoulder for swelling, wasting and deformity Palpate sternoclavicular, acromioclavicular and glenohumeral joints for tenderness, warm, swelling and crepitus Assesss stability and range of movement (active, passive, resisted) Specific diagnostic tests Neurological examination of both upper limbs

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RED FLAGS IN SHOULDER PAIN

CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

Features	Possible diagnosis
History of cancer, symptoms and signs of cancer, unexplained deformity, mass or swelling	Tumor
Red skin, fever systemically unwell	Infection
Trauma, epileptic fit, electric shock, loss of rotation and normal shape	Shoulder Dislocation
Trauma, acute disabling pain, significant weakness, positive drop arm test	Acute Rotator Cuff Tear
Unexplained wasting, significant sensory or motor deficit	Neurological Lesion

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What special test would you perform on this patient?

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SPECIFIC DIAGNOSTIC TESTING

CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

Specific tests	Diagnosis
Drop arm test	Rotator Cuff Tear
Apprehension test	Test For Anterior Instability
Impingement test	Impingement Syndrome

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CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

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FINDINGS

Examination	Description
Inspection	No wasting, heat, redness or swelling
Palpation	Pain on all cuff and impingement tests
Range of movement	Reduced ROM in all directions of left shoulder- flexion 80°, abduction 80°, lateral rotation 10°. Unable to put her hand behind her back

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Diagnosis :

Frozen shoulder (Adhesive capsulitis)

How would you manage this patient?

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TREATMENT	REFERRAL CRITERIA
A holistic approach: nonpharmacological & pharmacological Adequate analgesia (paracetamol, NSAIDs drugs - regular / PRN basis) Self-motivation Encourage activity Give written patient information sheet.	Pain lasting more than 6 months with functional disability Diagnostic uncertainty Positive Red flags

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SHOULDER PAIN EXERCISE

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CASE 2: KNEE PAIN

Ms. AZ, 72 years old retired teacher.

Complaint of bilateral knee pain for 1 years.
Pain is aggravated by walking & climbing stairs, and relived by rest.
Pain increased to score of 7/10 for past two months. She also has morning stiffness over her knee for short duration less than 30 minutes & it improves on walking. At rest pain score is 2/10.
She is able to walk with walking stick. She is bADL independent and iADL-independent.

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What is your differential diagnoses?

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DIFFERENTIAL DIAGNOSES OF KNEE PAIN

CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

Ligament injuries
Meniscus injuries
Osteoarthritis

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What further history would you like to ask?

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CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

Red flags in knee pain:

Systemic complaints – fever, weight loss, pain at rest, night pain.

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What physical examination would you perform on this patient?

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PHYSICAL EXAMINATION & DIAGNOSIS

CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

Examination	Description:
Inspection	Attitude of the lower limbs ( genu varus / genu valgus) Skin changes ( scar/sinus/swelling/inflammation) Wasting of muscles
Walking ( gait)	Normal, antalgic, shuffling, short limb, and high stepping
Palpation	Temperature of the knee Patella tap to assess intraarticular fluid collection
Rang of movement	Lift both feet up ( with hips flexed and knee extended) Patient to flex the knee and hip actively & passively to assess the posible range of movement

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SPECIFIC TESTS FOR LIGAMENT INJURIES

CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

Specific tests	Diagnosis
Valgus stress	Medial collateral ligament
Varus stress	Lateral collateral ligament
Lachman test	Anterior cruciate ligament injury
Anterior drawer test	Anterior cruciate ligament injury
Posterior drawer test	posterior cruciate ligament injury

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What other investigation you want to do

next?

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KELLGREN-LAWRENCE CLASSIFICATION

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Diagnosis: Bilateral knee osteoarthritis (moderate).

What is your management plan for this patient?

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TREATMENT OPTIONS

CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

Non pharmacology treatment:

Physiotherapy
Occupational Therapy
knee brace
Self-motivation
Encourage activity
Give written patient information sheet

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KNEE EXERCISE

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CASE 3 : HIP PAIN

65 years old lady, with underlying Diabetes and Hypertension presented with right hip pain for 3 months. No history of trauma.

What is your differential diagnoses?

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CAUSES OF HIP PAIN

CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

	Anterior hip	Lateral	Posterior
Differential diagnosis	Osteoarthritis	Osteoarthritis	Sciatic nerve irritation secondary to spondyloarthritis / lumbar disc herniation
	Avascular Necrosis	Bone tumor	Muscle strain
	Hip fracture	Radiating lumbar disease
	Hip flexor muscle strains or tendonitis, and iliopsoas bursitis	Radiating lumbar disease

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What further history would you ask?

How would examine this patient?

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Integrating the history and physical examination to diagnose hip pain

	Disorder	Presentation and exam findings
Anterior pain	Osteoarthritis	Gradual onset anterior thigh/groin pain worsening with weight-bearing. Limited range of motion with pain, especially internal rotation
	Hip flexor muscle strain/tendonitis	History of overuse or sports injury. Tenderness over specific muscle or tendon
	Iliopsoas bursitis	Anterior pain and associated snapping sensation. Tenderness with deep palpation over femoral triangle. Etiology from overuse, acute trauma, or rheumatoid arthritis
	Hip fracture (proximal femur)	Fall or trauma followed by inability to walk. Limb externally rotated, abducted, and shortened. Pain with any movement
	Inflammatory arthritis	Morning stiffness or associated systemic symptoms. Previous history of inflammatory arthritis. Limited range of motion and pain with passive motion
	Avascular necrosis of femoral head	Dull ache in groin, thigh, and buttock usually with risk factors (corticosteroid exposure, alcohol abuse). Limited range of movement with pain.

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RED FLAG OF HIP PAIN

CHRONIC PAIN MANAGEMENT TRAINING MODULE FOR PRIMARY CARE MINISTRY OF HEALTH MALAYSIA

Fever, malaise
Night sweats, night pain, weight loss
Previous history of cancer
Trauma/assault (fall, blow, lifting)
Intravenous drug abuse
Long term use of immunosuppressants
Pain that is not relieved with rest and continues through the night

** An accumulation of multiple red flags requires immediate medical referral

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