Assessing Musculoskeletal Pain Discussion Paper

Assessing Musculoskeletal Pain Discussion Paper

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Respond ONLY to POST ONE and POST TWO separately and each response should have two references. My POST ABOVE is my own discussion post that will serve as a guide to respond to POST ONE and POST TWO.

Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.


Respond To Post One


You did a great work in your discussion on assessing musculoskeletal pain, particularly on your 42-year-old male patient, who was an African American. From the discussion, it is clear that the patient was suffering from lower back pain that developed within a month. The pain is associated with tingling, numbness, and a sharp shooting pain down the left leg. Thus, I will identify the possible conditions based on your discussion, which I would reject or justify, and give reasons why I would do that.

You did a great job identifying the differential diagnoses for this condition. However, based on the patient’s presentation, I would support your primary diagnosis. What needs to be considered when carrying out examinations and tests is that the patient’s pain is located at the lumber region, as well as the frequent tingling, numbness, and pain that runs down the left leg. According to Al Qaraghli & De Jesus (2020), lumbar disc herniation is a lower back herniated disc that frequently causes sciatica or radiating pain. Pain, burning, tingling, and numbness can travel from the buttock into the leg and occasionally into the foot when one or more of the nerves that make up the sciatic nerve are compressed. However, the symptoms and signs of this condition are similar to those of anterior tibial tunnel syndrome. The region of pain is what brings distinction in.

I would reject lumbar strain and spinal stenosis because, for instance, Lumbar strain causes strained and aching muscles and tendons to become injured. This condition is not associated with our cue, which is “tingling, numbness and pain in the lumbar region.” Additionally, I will rule out spinal stenosis based on the patient’s movements, particularly bending forward. Lumbar herniation disc and spinal stenosis have similar symptoms and signs; however, the primary distinction between disc herniations and spinal stenosis is that whereas disc herniations usually hurt worse when you bend forward, spinal stenosis can be relieved by doing so (Kreiner et al., 2020).


Al Qaraghli, M. I., & De Jesus, O. (2020). Lumbar disc herniation.

Kreiner, D. S., Matz, P., Bono, C. M., Cho, C. H., Easa, J. E., Ghiselli, G., … & Yahiro, A. M. (2020). Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. The Spine Journal20(7), 998-1024.

Respond to Post Two


Thank you for sharing your discussion, which you completed involving a 15-year-old Caucasian who presents at the healthcare facility with complaints of bilateral knee pain. You identified a number of differential diagnoses. I would justify the diagnosis that I believe is most likely based on the patient’s presentations and examination.

I agree that the primary diagnosis for this case is patellofemoral pain syndrome, which is prevalent in teens and athletes. When all other potential causes of anterior knee pain have been ruled out, patellofemoral pain refers to anterior knee pain involving the patella and retinaculum (Sigmund et al., 2021). running, climbing stairs, prolonged sitting, and crouching frequently cause more knee pain. Easy remedies like ice and relaxation frequently work.

I would rule out patellar tendinopathy, plica syndrome, Osgood-Schlatter disease, and Osteochondritis dissecans because, for instance, I rule out Patellar Tendinopathy since its pathophysiology is mostly proximal when the patient has a bilateral ankle pain (Golman et al., 2020). Also, I rule out Plica Syndrome because it is associated with a synovial plica that becomes a source of discomfort due to increased volume and decreased flexibility, which is the cause of the painful knee condition.


Golman, M., Wright, M. L., Wong, T. T., Lynch, T. S., Ahmad, C. S., Thomopoulos, S., & Popkin, C. A. (2020). Rethinking patellar tendinopathy and partial patellar tendon tears: a novel classification system. The American Journal of Sports Medicine48(2), 359-369.

Sigmund, K. J., Bement, M. K. H., & Earl-Boehm, J. E. (2021). Exploring the pain in patellofemoral pain: a systematic review and meta-analysis examining signs of central sensitization. Journal of Athletic Training56(8), 887-901.

Assessing Musculoskeletal Pain Discussion Paper





Please, DO NOT respond to this post (INITIAL POST/MY POST). It is just a guide)

Assessing Musculoskeletal Pain

Chief Complain (CC): “My ankles hurt.”

History of Presenting Illness (HPI): L. S., is an African American who presented with complaints of bilateral ankle pain for two days. She stated that the pain started over the weekend while playing soccer. She is concerned with the right ankle which produced a ‘pop’ sound while playing soccer and she felt uncomfortable despite being able to bear weight on the leg. L.S. described the pain as achy and throbbing with an intensity of 6 out of 10 at rest while standing or walking, the pain on the right lateral ankle scored 8 out of 10. The pain was relieved on elevation, ice packing, and ibuprofen although it only attained moderate efficacy with the pain in the left ankle scoring 2-3 out of 10 with insignificant impact felt on the right ankle.



Oral Ibuprofen for pain management

Oral contraceptive (Did not remember the name).

Allergies: No known allergies

Medical and Surgical History: L.S. has a history of sprain to the right ankle in 2016. She is compliant with all immunizations with her last flu shot received three months ago. She has no surgical history.

Social History: L. S. is married to a Caucasian male and has a nine-year-old son. She is a high school teacher and enjoys playing soccer on weekends. She denied substance use, drinking, or smoking. She engages in gymnastics and plays soccer to keep fit.

Family History: L.S.’s father died in 2017 of kidney failure. The mother is alive with a history of rheumatoid arthritis, type 2 diabetes mellitus, and hypertension. She also has a healthy older brother. Her son is also healthy with no chronic condition reported.

Review of Systems:

General: No fever, chills, body fatigue, weakness or weight loss.

HEENT: Denies headache, hearing, vision, or olfactory impairment.

Skin: No rashes, itching, or easy bruising

Cardiovascular: No palpitations, chest pain, exercise intolerance, or difficulty breathing while lying.

Respiratory: No chest pain, exercise intolerance, or difficulty breathing.

Gastrointestinal: No nausea, diarrhoea, vomiting, or constipation

Musculoskeletal: Confirms swelling of the right lateral ankle, bilateral ankle pain mainly on the right side. Denies joint stiffness or reduced range of motion.

Neurological: No dizziness, headaches, numbness, tingling sensation, or history of concussion.

Objective Data

Physical Exam:

Vitals: Blood pressure: 128/74, Heart rate: 78, Respiratory rate: 17, SpO2: 97% at room air, Height: 5’4’’ Weight: 127lbs

General: A well-dressed and nourished female in a fair general condition. She is pleasant and cooperative in the interaction.

HEENT: Normocephalic head, PERRLA, anicteric eyes with intact extra-ocular motion.  

Skin: Dry and warm with no rashes or wounds. There is slight bruising on the right lateral ankle.

Cardiovascular: S1 and S2 heard. No edema, murmurs, clicks, gallops or jugular venous distention

Respiratory: Vesicular sounds with bilateral and symmetrical chest expansion. No wheeze or crackles.

Gastrointestinal: Seven bowel sounds per minute. No scars, striae, distention or shifting dullness.

Neurological: Cranial nerves intact

Musculoskeletal: Swollen and slightly bruised right lateral ankle with reduced range of movement. On palpation, the ankle is tender at the lateral malleolus, anterior and posterior talofibular, tibiofibular and calcaneofibular ligaments. The medial aspect is not swollen with no evidence of bone deformity. The left ankle is not swollen and does not exhibit tenderness on palpation. It exhibits a full range of motion. The patient can bear weight on both limbs although feels some pain in the right ankle. There is altered gait due to the ankle pain.

Diagnostics Results: Right ankle X-ray indicated a normal Boehler’s angle.



Right Lateral Ankle Sprain: Can occur as a result of foot inversion or eversion. Patient assessment of walking under the Ottawa rules evaluates the ability of the patient to minimize incidences of unwarranted radiographs (Gomes et al., 2022). According to the Ottawa Ankle Rules, the need for radiographic imaging is eliminated if the patient can walk four steps after injury (Gomes et al., 2022). Halabchi and Hassabi (2020) stated that incidences of ankle sprains are common in lateral ligaments such as the talofibular.  The patient reported lateral ankle pain that started two days prior and could bear weight with bearable pain. This can confirm the right lateral ankle sprain as the diagnosis. However, the evidence of bilateral pain is indicative of an underlying condition accounting for the pain.

Calcaneal fracture: Assessing Boehler’s angle confirms the possibility of displaced intra-articular calcaneal fracture. The patient’s X-ray radiograph exhibited a normal Boehler’s angle thus ruling out calcaneal fracture. According to Dains et al. (2019), ankle fracture is marked by acute pain and a reduction in the range of motion. The patient used the ankle for two days before reporting, could bear weight and walk, and there was no indication of association with the bone, thus there was no relevance of radiographic imaging.

Osteoarthritis: The patient reported with bilateral joint pain. It is characterized by joint pain, stiffness and reduced range of motion (Smith et al., 2021). However, the patient denied joint stiffness thus along with the unilateral ankle swelling and tenderness on the right lateral ankle rule out the diagnosis.

Right Ankle Instability: This is linked to ankle pain, swelling, and multiple ankle sprains in the span of six months (Hertel & Corbett, 2019). However, the patient started experiencing the pain the past two days and had the last ankle sprain in 2016 thus ruling out the diagnosis.



Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Gomes, Y. E., Chau, M., Banwell, H. A., & Causby, R. S. (2022). Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis. BMC Musculoskeletal Disorders23(1), 1-11.

Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World Journal of Orthopedics, 11(12), 534-558.

Hertel, J., & Corbett, R. O. (2019). An updated model of chronic ankle instability. Journal of Athletic Training54(6), 572-588.

Smith, M. D., Rhodes, J., Al Mahrouqi, M., MacDonald, D. A., & Vicenzino, B. (2021). Balance is impaired in symptomatic ankle osteoarthritis: A cross-sectional study. Gait & Posture90, 61-66.



Patient Information: Initials: JM, Age: 42, Sex: Male, Race: African American


CC (chief complaint): “I have lower back pain that sometimes radiates to my left leg.”

HPI: J.M., a 42-year-old African American male, presents with lower back pain that began a month ago. Sometimes the pain might be felt in the left leg as well as the lumbar area. Without a particular trigger event, onset is slow. is characterized by a shooting pain down the left leg and a dull discomfort in the lower back. Frequent tingling and numbness in the left leg are among the accompanying symptoms. Excessive sitting or standing makes the ache worse.

Location: The pain is primarily located in the lumbar region (lower back) and occasionally radiates to the left leg.

Onset: The pain began gradually about a month ago.

Character: The pain is described as a dull ache in the lower back and a shooting pain down the left leg.

Associated signs and symptoms: Numbness and tingling in the left leg accompany the pain.

Timing: The pain worsens with prolonged sitting or standing.

Exacerbating/Relieving factors: The pain is exacerbated by certain activities such as prolonged sitting or standing, and no specific relieving factors have been identified.

Severity: The pain is moderate, scoring 6/10 on the pain scale.

Current Medications: None reported.

Allergies: No known allergies.

PMHx: No significant past illnesses or surgeries reported. The patient reports to be up-to-date on his immunization history with COVID-19 vaccine shot taken 6 months ago.

Soc Hx: The patient is an office worker who engages in regular exercise as part of their hobbies. He reports no tobacco or alcohol use. Additionally, the patient adheres to safety measures by using seat belts regularly and ensuring the presence of working smoke detectors in their home.

Fam Hx: A possible genetic susceptibility is suggested by the family history, which shows a noticeable trend of hypertension on both sides of the patient’s family. There are no other documented chronic or communicable illnesses involving parents, grandparents, siblings, or children. Because the patient’s maternal grandfather had type 2 diabetes, it is crucial to keep an eye on blood sugar levels. The deceased father of the patient passed away due to cardiac arrest at the age of sixty.


GENERAL: No weight loss, fever, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision. Ears: No hearing loss. Nose/Throat: No sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC/LYMPHATICS: No anemia, bleeding, or bruising. No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema, or rhinitis.


Vital signs:

Blood Pressure (BP): 120/80 mm

HgHeart Rate (HR): 72 beats per minute

Respiratory Rate (RR): 16 breaths per minute

Temperature (T): 98.6°F (37°C)

Oxygen Saturation (SpO2): 98%

Physical exam:

GENERAL: The patient is alert and oriented with a normal posture.

RESPIRATORY: No signs of respiratory distress. Clear breath sounds bilaterally.No cough or abnormal respiratory patterns noted.

CARDIOVASCULAR: Regular heart rate with no palpable irregularities. Normal blood pressure. No chest pain, discomfort, or edema. Capillary refill is within normal limits.

MUSCULOSKELETAL: Limited lumbar range of motion noted. Tenderness over the lumbar spine is observed. No obvious deformities or abnormalities detected.

NEUROLOGICAL: Diminished sensation in the left leg. Weakness in dorsiflexion of the left foot.

Diagnostic results:

Lumbar Spine MRI: Lumbar spine MRI reveals a posterior disc herniation at the L4-L5 level, causing compression on the left L5 nerve root. The herniated disc measures 8 mm in diameter, contributing to the patient’s lower back pain and left leg radiation.

X-ray of Lumbar Spine: X-ray shows mild degenerative changes in the lumbar spine, with a measured intervertebral disc height reduction of 10% at the L4-L5 level. No fractures or significant abnormalities are identified.

Complete Blood Count (CBC): CBC results indicate a normal white blood cell count (WBC) of 8,000 cells/mm³, a red blood cell count (RBC) of 4.5 million cells/mm³, and a platelet count of 250,000 cells/mm³, ruling out systemic infections or hematologic disorders.

Basic Metabolic Panel (BMP): BMP values are within normal limits, including sodium (Na) 140 mEq/L, potassium (K) 4.0 mEq/L, blood urea nitrogen (BUN) 15 mg/dL, and creatinine 1.0 mg/dL, ruling out metabolic imbalances or renal dysfunction.


Differential Diagnoses

  1. Lumbar Disc Herniation: A lumbar disc herniation, which has a progressive onset, radiates pain down the leg, and causes neurological symptoms including numbness, is a relevant differential diagnosis for the patient’s lower back pain with radiation in the left leg. A physical examination reveals limited lumbar range of motion and soreness, which further supports the clinical presentation of disc herniation, and the worsening of pain with particular activities (Popescu & Lee, 2020). Further helpful in the diagnosis process are imaging investigations, especially MRIs, which may show signs of disc herniation. Taking into account the possibility of lumbar disc herniation facilitates a thorough assessment of all possible pathologies that could be causing the patient’s symptoms, hence directing suitable treatment plans.
  2. Lumbar Strain: Based on a number of variables, lumbar strain is regarded as a differential diagnosis for lower back pain radiating to the left leg. The patient’s description of a gradual beginning of pain that worsens with specific activities fits the profile of lumbar strain, which is frequently brought on by overuse or injury to the muscles (Ball et al., 2023). A musculoskeletal etiology is supported by the physical examination’s observation of soreness over the lumbar spine in addition to the lack of particular neurological symptoms like tingling and numbness. In addition, the absence of noteworthy results from imaging tests such as MRI helps rule out other structural problems, supporting the diagnosis of lumbar strain. When lumbar strain is included in the differential diagnosis, it facilitates a thorough investigation of possible causes, which helps with focused therapy and management choices.
  3. Spinal Stenosis: Due to a number of important characteristics, spinal stenosis is a pertinent differential diagnosis for the patient’s lower back discomfort and radiation in the left leg. The patient’s age, along with the progressive onset of symptoms and worsening with extended standing, are consistent with the typical presentation of spinal stenosis. Aging and degenerative changes in the spine are frequently associated with spinal stenosis (Wu et al., 2020). The possibility of a structural problem such as spinal stenosis is supported by the lack of particular neurological abnormalities in the lower limbs, as well as by the physical examination findings of limited lumbar range of motion and soreness over the lumbar spine. This diagnostic approach is further supported by the possible existence of degenerative alterations that are detectable on imaging examinations like MRI.


Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.

Popescu, A., & Lee, H. (2020). Neck pain and lower back pain. Medical Clinics, 104(2), 279-292.

Wu, A., March, L., Zheng, X., Huang, J., Wang, X., Zhao, J., … & Hoy, D. (2020). Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Annals of Translational Medicine, 8(6).



CC: Knee pain

HPI: A.B. is a 15-year-old Caucasian male who presents to the clinic with complaints of dull bilateral knee pain that started 2 weeks ago. He reports recent “clicking” in his knees, especially during squat exercises and track practice. He also describes a “catching sensation” under the patella while running. He rates the severity of his pain 0/10 at rest and 6/10 with physical activity. He states that “other than resting,” he has not done anything to treat his symptoms. Denies recent injuries or trauma.


Current Medications: None

Allergies: No known allergies

PMHx: No medical history

Past Surgical Hx: Circumcision at birth, no complications

Soc Hx: He lives with his mother, father, and younger sister. He is a sophomore in high school and takes a weightlifting class on Tuesdays and Thursdays. He runs track in the spring and plays football in the fall. He works as a lifeguard at a community pool in the summer. Denies smoking, vaping, alcohol, or drug use. No exposure to secondhand smoke.

Fam Hx:

Mother – hyperthyroidism

Father – no medical hx

Maternal grandmother – HTN, high cholesterol

Maternal grandfather – heart disease, MI at age 42

Paternal grandmother – no medical hx

Paternal grandfather – colon cancer, diabetes



GENERAL: Denies weight loss, fever, chills, or fatigue.

SKIN: Denies rashes or lesions.

CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. Denies palpitations, arrhythmias, or claudication.

RESPIRATORY: Denies shortness of breath, cough, or sputum.

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities.

MUSCULOSKELETAL: + bilateral anterior knee pain and clicking with loaded flexion, no pain with extension. Denies joint swelling and posterior knee pain. No hx of fractures or joint pain.

HEMATOLOGIC: Denies bleeding or bruising. No hx anemia.



Physical exam:

General: A.B. is a well-developed, well-nourished Caucasian adolescent male. He is a good historian and answers questions appropriately.

Vital Signs: BP 108/62, P 64 and regular, R 16, O2 sat 100%, Temp 98.6 orally; Height 5’6, Weight 130 lbs; BMI is 21.

Skin: Warm, dry, and intact; no rashes, lesions, cyanosis, or swelling.

Lymph nodes: No palpable lymph nodes.

Cardiovascular/Peripheral vascular: RRR, no murmurs, gallops, or rubs; +2 radial and pedal pulses bilaterally.

Respiratory: Breathing even and non-labored, chest expansion symmetrical; upper and lower lung sounds clear bilaterally.

Musculoskeletal: Muscles and extremities symmetric; spine is straight and smooth with no lateral curvature or rib hump; full passive knee flexion and extension bilaterally, + patellofemoral crepitation with no masses or tenderness on palpation; strength 5/5 in foot plantar flexion and dorsiflexion, 4/5 in bilateral quadriceps, no atrophy; no joint effusions, clubbing, cyanosis, or edema; negative ballottement sign; negative McMurray and Lachman tests; gait is smooth and coordinated with walking.

Neurologic: Alert and oriented x 3, cooperative; mood and affect appropriate to situation; CN II – XII grossly intact, DTRs intact; 5/5 upper and lower extremities.


Diagnostic results:

Diagnostic imaging such as x-rays, CT scans, MRIs, and arthography are used if severe injuries are suspected, such as fractures and soft tissue tears (Habusta et al., 2023). Ultrasound may be used to facilitate a diagnosis of tendon pathology, such as patellar tendinopathy (Santana et al., 2023). A diagnosis of patellofemoral syndrome (PFS) is often made through physical exam findings and by excluding all other potential diagnoses (Bump and Lewis, 2023). Based on the patient’s symptoms in this case study, the differential diagnosis would most likely be developed through a thorough history and physical examination.


Differential Diagnoses

  1. Patellofemoral syndrome, also known as “runner’s knee,” is prevalent among adolescent athletes and results from overuse or overload of the hyaline cartilage located behind the patella (Bump and Lewis 2023). It is characterized by dull, anterior knee pain that is unilateral or bilateral and worsens with loading activities such as running, squatting, and climbing stairs (Bump and Lewis, 2023). The patient complains of clicking in both knees and a catching sensation under the patella which are characteristic symptoms of PFS. He is at risk for developing PFS due to his age, activity level, and year-round sports participation.
  2. Patellar tendinopathy, or “jumper’s knee,” causes anterior knee pain due to damage or tears of the patellar ligament (Santana et al., 2023).
  3. Osgood-Schlatter disease is associated with increased physical activity, particularly in adolescence, and causes unilateral or bilateral knee pain (Ball et al., 2019).
  4. Plica syndrome is caused by overuse or injury of the knee joint and results in tenderness, tight muscles, joint effusion, and a popping sound during range of motion (Casadei and Kiel, 2023).
  5. Osteochondritis dissecans affects bone and cartilage in the joint and often manifests in childhood or adolescence (Wood et al., 2023). Patients may be asymptomatic, or they may experience joint tenderness, swelling, and reduced range of motion.



Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Elsevier Mosby.

Bump, J. M., & Lewis, L. (2023). Patellofemoral syndrome. StatPearls. to an external site.

Casadei, K., & Kiel, J. (2023). Plica syndrome. StatPearls. to an external site.

Habusta, S. F., Coffey, R., & Ponnarasu, S. (2023). Chondromalacia patella. StatPearls. to an external site.

Santana, J. A., Mabrouk, A., & Sherman, A. I. (2023). Jumpers knee. StatPearls. to an external site.

Wood, D., Davis, D. D., & Carter, K. R. (2023). Osteochondritis dissecans. StatPearls. to an external site.


Respond ONLY to POST ONE and POST TWO separately and each response should have two references. My POST ABOVE is my own discussion post that will serve as a guide to respond to POST ONE and POST TWO.


 Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning

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