Regional and Musculoskeletal Pain Syndromes
Distinguish regional from systemic
Most musculoskeletal pain is regional and mechanical. Key features: pain localised to a structure, reproduced by specific movement, absence of systemic features, and normal inflammatory markers. Recognise the common patterns so you do not over-investigate.
Important regional syndromes
- Rotator cuff disease and subacromial pain: painful arc, worse on overhead activity and at night lying on the affected side.
- Adhesive capsulitis (frozen shoulder): global restriction, especially external rotation; associated with diabetes.
- Lateral epicondylitis: pain at the common extensor origin, worse on gripping.
- Carpal tunnel syndrome: nocturnal median-nerve symptoms, thenar wasting; associated with pregnancy, diabetes and hypothyroidism.
- Plantar fasciitis: first-step heel pain.
- Trochanteric and gluteal pain syndromes: focal tenderness, worse lying on the side.
- Fibromyalgia: widespread pain, fatigue, unrefreshing sleep and cognitive symptoms; a clinical diagnosis without inflammatory markers, requiring exclusion of mimics such as hypothyroidism, polymyalgia rheumatica and vitamin D deficiency.
Polymyalgia rheumatica
Consider in patients over 50 with bilateral shoulder and hip girdle pain and stiffness, raised inflammatory markers, and rapid response to low-dose steroids. Always ask about giant cell arteritis symptoms.
Traps
- Do not label widespread pain as fibromyalgia without excluding inflammatory and endocrine mimics.
- Regional pain with red flags (fever, weight loss, night pain unrelieved by rest, neurological deficit) needs investigation.
- Radiographs are often normal in early inflammatory disease; normal imaging does not exclude pathology.
Rule of thumb
If a regional pain syndrome does not fit a mechanical pattern, or has systemic features, broaden the differential rather than repeating local treatments.