Possible Causes

Possible Physical Signs

Mechanical Low Back Pain

Acute, often recurrent, or possibly chronic aching pain in the lumbosacral area, possibly radiating into the posterior thighs but not below the knees. The pain is often precipitated or aggravated by moving, lifting, or twisting motions and is relieved by rest. Spinal movements are typically limited by pain. This is the back pain common from the teenage years through the 40s.

Radicular Low Back Pain

A radicular (nerve root) pain, usually superimposed on low back pain. The sciatic pain is shooting and radiates down one or both legs, usually to below the knee(s) in a dermatomal distribution, often with associated numbness and tingling and possibly local weakness. The pain is usually worsened by spinal movement such as bending and by sneezing, coughing, or straining.

Back and Leg Pain From Lumbar Stenosis

Pseudoclaudication is a pain in the back or legs that worsens with walking and improves with flexing of the spine, as by sitting or bending forward.

Chronic Persistent Low Back Stiffness

Aching Nocturnal Back Pain, Unrelieved by Rest

Back Pain Referred From the Abdomen or Pelvis

Usually a deep, aching pain, the level of which varies with the source

The exact cause cannot usually be proven. Intervertebral disc disease is probably involved in many cases. Congenital disorders of the spine, such as spondylolisthesis, may be present in a small percentage. In older women or in persons on long-term corticosteroid therapy, consider osteoporosis complicated by a collapsed vertebra.

A herniated intervertebral disc with compression or traction of nerve root(s) is the most common cause in persons under age 50. The nerve roots of L5 or S1 are most often affected. Spinal cord tumors or abscesses are much less common causes. Compared to a disc, they tend to affect more nerve roots and to produce more neurologic deficits.

Lumbar stenosis, which is a combination of degenerative disc disease and osteoarthritis that narrows the spinal canal and impinges on the spinal nerves. It is a common cause of pain after age 60.

Ankylosing spondylitis, a chronic inflammatory polyarthritis, most common in young men

Diffuse idiopathic skeletal hyperostosis (DISH), which affects middle-aged and older men

Consider metastatic malignancy in the spine, as from cancer of the prostate, breast, lung, thyroid, and kidney, and multiple myeloma.

Peptic ulcer, pancreatitis, pancreatic cancer, chronic prostatitis, endometriosis, dissecting aortic aneurysm, retroperitoneal tumor, and other causes

Local tenderness, muscle spasm, pain on movement of the back, and loss of the normal lumbar lordosis, but no motor or sensory loss or reflex abnormalities. In osteoporosis there may be a thoracic kyphosis, percussion tenderness over a spinous process, or fractures elsewhere such as in the thoracic spine or in a hip.

Pain on straight leg raising (see pp. 520), tenderness of the sciatic nerve, loss of sensation in a dermatomal distribution, local muscular weakness and atrophy, and decreased to absent reflex(es), especially affecting the ankle jerks. Dermatomal signs and reflex changes may be absent when only a single root is affected.

The posture may become flexed forward. Motor weakness and hyporeflexia in the lower extremities may be present.

Loss of the normal lumbar lordosis, muscle spasm, and limitation of anterior and lateral flexion

Flexion and immobility of the spine

Variable with the source. Local bone tenderness may be present.

Spinal movements are not painful and range of motion is not affected. Look for signs of the primary disorder.


Possible Causes

Possible Physical Signs

"Simple Stiff Neck"

Acute, episodic, localized pain in the neck, often appearing on awakening and lasting 1-4 days. No dermatomal radiation

Aching Neck

A persistent dull aching in the back of the neck, often spreading to the occiput. This is common with postural strain, as with prolonged typing or studying, and may also accompany tension and depression.

"Cervical Sprain"

Acute and often recurrent neck pains that are often more severe and last longer than simple stiff neck. There may be a precipitating factor such as a whiplash injury, heavy lifting, or a sudden movement, but there is no dermatomal radiation.

Neck Pain With Dermatomal Radiation

Neck pain as in cervical sprain, but with radiation of the pain to the shoulder, back, or arm in a dermatomal distribution. This radicular pain is typically sharp, burning, or tingling in quality.

Neck Pain From Possible Compression of the Cervical Spinal Cord

Associated here is weakness or paralysis of the legs, often with a decrease in or loss of sensation. These symptoms may occur in addition to the radicular symptoms or by themselves. The neck pain may be mild or even absent.

The mechanisms are not understood.

Poorly understood; may be related to sustained muscle contraction

Poorly understood

Compression of one or more nerve roots caused by either a herniated cervical disc or degenerative disease of the intervertebral discs with bony spurring*

Compression of the spinal cord in the neck caused by either a herniated cervical disc or degenerative disease of the intervertebral discs with bony spurring. Trauma may also be the

Local muscular tenderness and pain on certain movements

Local muscular tenderness. When areas of pain and tenderness are also present elsewhere in the body, consider the fibromyalgia syndrome (see Table 15-3, Patterns of Pain In and Around the Joints).

Local tenderness and pain on movement

Muscle tenderness and spasm, a limited range of neck motion, increase in the pain on coughing or straining, and possible sensory loss, weakness, muscular atrophy, and decreased reflexes in the areas involved

Limited range of motion in the neck, weakness or paralysis in the legs of the central nervous system type, Babinski responses, loss of position and vibration sense in the legs, and, less commonly, loss of pain and temperature sensation. Radicular signs in the arms may also be present.

* Tumors or abscesses of the cervical spinal cord, though less common, should also be considered.

TABLE 15-3 ■ Patterns of Pain In and Around the Joints



Common Locations

Pattern of Spread


Progression and Duration

Rheumatoid Arthritis


(degenerative joint disease)

Gouty Arthritis Acute Gout




Polymyalgia Rheumatica

Fibromyalgia Syndrome

Chronic inflammation of synovial membranes with secondary erosion of adjacent cartilage and bone, and damage to ligaments and tendons

Degeneration and progressive loss of cartilage within the joints, damage to underlying bone, and formation of new bone at the margins of the cartilage

An inflammatory reaction to microcrystals of sodium urate

Multiple local accumulations of sodium urate in the joints and other tissues (tophi), with or without inflammation

A disease of unclear nature seen in people over age 50, especially women; may be associated with giant cell arteritis

Widespread musculoskeletal pain and tender points. May accompany other diseases. Mechanisms unclear

Hands (proximal interphalangeal and metacarpophalangeal joints), feet (metatarsopha-langeal joints), wrists, knees, elbows, ankles

Knees, hips, hands (distal, sometimes proximal inter-phalangeal joints), cervical and lumbar spine, and wrists (first carpometacarpal joint); also joints previously injured or diseased

Base of the big toe (the first metatarso-phalangeal joint), the instep or dorsum of feet, the ankles, knees, and elbows

Feet, ankles, wrists, fingers, and elbows

Muscles of the hip girdle and shoulder girdle; symmetric

"All over," but especially in the neck, shoulders, hands, low back, and knees

Symmetrically additive: progresses to other joints while persisting in the initial ones

Additive; however, only one joint may be involved.

Early attacks are usually confined to one joint.

Additive, not so symmetric as rheumatoid arthritis

Usually insidious

Usually insidious

Sudden, often at night, often after injury, surgery, fasting, or excessive food or alcohol intake

Gradual development of chronicity with repeated attacks

Often chronic, with remissions and exacerbations

Slowly progressive, with temporary exacerbations after periods of overuse

Occasional isolated attacks lasting days up to 2 weeks; they may get more frequent and severe, with persisting symptoms.

Chronic symptoms with acute exacerbations

Insidious or abrupt, Chronic but even appearing ultimately self-

overnight limiting

Shifts unpredictably or worsens in response to immobility, excessive use, or chilling


Chronic, with and downs"

The vagueness of these characteristics is in itself a clue to the fibromyalgia syndrome.

Associated Symptoms


Redness, Warmth, and Tenderness


Limitation of Motion

Generalized Symptoms

Frequent swelling of synovial tissue in joints or tendon sheaths; also subcutaneous nodules

Tender, often warm, but seldom red

Prominent, often for an hour or more in the mornings, also after inactivity

Often develops

Weakness, fatigue, weight loss, and low fever are common.

Small effusions in the joints may be present, especially in the knees; also bony enlargement.

Possibly tender, seldom warm, and rarely red

Frequent but brief (usually 5-10 min), in the morning and after inactivity

Often develops

Usually absent

Present, within and around the involved joint

Exquisitely tender, hot, and red

Not evident

Motion is limited primarily by pain.

Fever may be present.

Present, as tophi, in joints, bursae, and subcutaneous tissues

Tenderness, warmth, and redness may be present during exacerbations.



Possibly fever; patient may also develop symptoms of renal failure and renal stones.

None Muscles often tender, Prominent, especially in Usually none Malaise, a sense of but not warm or red the morning depression, possibly anorexia, weight loss, and fever, but no true weakness


Multiple specific and symmetric tender "trigger points," often not recognized until the examination

Present, especially in the morning

Absent, though stiffness is greater at the extremes of movement

A disturbance of sleep, usually associated with morning fatigue en to o\

TABLE 15-4 ■ Painful Shoulders

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