Differential Diagnosis of Lower
Quarter Conditions
Marcie Swift, PT, PhD, FAAOMPT
Assistant Professor in Physical Therapy
Rockhurst University
What will I take away?
• New students: Introduce concepts related to
differential diagnosis through deliberate
practice.
• Seasoned students: Supplement and reinforce
importance of differential diagnosis through
deliberate practice.
Ultimately, I hope to…
Provide you with some tools to
practice confidently in a direct-access
setting!
Agenda
• Direct Access
• Body Chart
– Introduction to Julie
• Directed Inquiry
– Finish SE
• Objective Exam Tests and Measures
– Selected Tests and Measures
• Triage
Direct Access
• Unrestricted: 18 states AK, AZ, CO, HI, ID, IA, KY, MD, MA,
MT, NE, NV, ND, OR, SD, UT, VT, WV
• Restricted: 1 state MI (evaluation only)
• Provisions: 31 states +District of Columbia
AL, AR, CA, CT, DC, DE, FL, GA, IL, IN, KS, LA, ME, MN, MS, MO, OK, NH,
NJ, NM, NY, NC, OH, PA, RI, SC, TN, TX, VA, WA, WI, WY
– APTA--Advocacy http://www.apta.org/StateIssues/DirectAccess/
– Direct access by state
https://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/D
irect_Access/DirectAccessbyState.pdf
Missouri: Provisions
• Missouri Revised Statutes, Chapter 334
(Physicians and Surgeons--Therapists--Athletic
Trainers--Health Care), Section 334.506
– PTs must have RX to begin new course of treatment
BUT
– PTs can provide education, fitness/wellness
programs, and screening/consultation services
without a RX and
– PTs can evaluate and treat a patient previously
diagnosed by “an approved health care provider.”
Kansas: Provisions
• May evaluate and initiate treatment on a
patient without a referral.
• If providing treatment without a referral and
patient is not progressing toward documented
treatment goals within 10 visits or 15 business
days from the initial treatment visit following
the initial evaluation visit, the PT shall obtain a
referral from an appropriate licensed health
care practitioner.
Bottom Line
• A PT must “refer to an approved health care
provider any patient whose medical condition
at the time of examination or treatment is
determined to be beyond the scope of
practice of physical therapy” and
• “No person licensed to practice, or applicant
for licensure, as a physical therapist or
physical therapist assistant shall make a
medical diagnosis.”
Disorder Recognition
Body
Chart
Complete
SE
OE
Treatment
Plan
• Hypothesis 1, Hypothesis 2,
Hypothesis 3, Hypothesis 4
• Modify Hypotheses
• Further Hypotheses Modification
• Assess Response to Treatment
and/ or TRIAGE
(Maitland, Hengeveld, Banks, & English, 2011)
“Science”
“Practice”
 PowerPoint Presentation has flow of information
 Link to Google Doc for Case Study Application
https://docs.google.com/document/d/162T5E0Yv5_NG
QfJUJpOHz2e0nBVJf_9L5FokKlzoC1M/edit?usp=sharing
Disorder Recognition
Body
Chart
• Hypothesis 1, Hypothesis 2,
Hypothesis 3, Hypothesis 4
Complete
SE
• Modify Hypotheses
OE
• Further Hypotheses
Modification
Treatment
Plan
• Assess Response to Treatment
and/ or TRIAGE
(Maitland, Hengeveld, Banks, & English, 2011)
Julie
✓
✓
✓
✓
P2:sharp,
constant,
variable
✓
✓
✓
✓
P1: ache,
constant,
variable;
at its
worst:
8/10
✓
P1 = / ≠ P2
✓ ✓
✓ ✓
✓ ✓
✓ ✓
Go to the case!
https://docs.google.com/docum
ent/d/1yAotNgx4OLszKQkfAeCFb
AYqw5aJgAlrmaox71BchUE/edit?
usp=sharing
Disorder Recognition
Body
Chart
• Hypothesis 1, Hypothesis 2,
Hypothesis 3, Hypothesis 4
Complete
SE
• Modify Hypotheses
OE
• Further Hypotheses
Modification
Treatment
Plan
• Assess Response to Treatment
and/ or TRIAGE
(Maitland, Hengeveld, Banks, & English, 2011)
Disorder Recognition
Body
Chart
• Hypothesis 1, Hypothesis 2,
Hypothesis 3, Hypothesis 4
Complete
SE
• Modify Hypotheses
OE
• Further Hypotheses
Modification
Treatment
Plan
• Assess Response to Treatment
and/ or TRIAGE
(Maitland, Hengeveld, Banks, & English, 2011)
Remember to ask questions that will
not only rule in your hypothesis
(provisional diagnosis) but rule out
other diagnoses. This process is known
as differential diagnosis.
Possible Non-Musculoskeletal Sites Capable of
Referring Pain to the Low Back/ Pelvis-SI region
• liver, gallbladder, stomach (lower thoracic
referral as well as shoulder area)
• kidney/ureter/bladder/urethra
• pancreas
• abdominal aorta (abdominal aortic aneurysm)
• prostate gland
• uterus/ovaries
• testes
• small intestine/colon
Moore, p. 243, 305; Goodman, p. 148-151, 156, 175-6, D’Ambrosia, p. 300-1,
Boissonnault, p 68
Visceral Pain Referral Patterns
(Boissonnault, 2011, pp. 182–192)
Visceral Pain Referral Patterns
(Boissonnault, 2011)
Systemic Signs and Symptoms (Red Flags) Requiring
Referral to a Physician
• bloody diarrhea, light stools,
melena
• fecal incontinence or urinary
incontinence
• dark or foul-smelling urine
• pain that is boring/stabbing,
cutting/knifelike, or
gnawing/burning
• constant pain or pain unchanged
by movement/position
• dysphagia, odynophagia
• early satiety
• fever, chills
• jaundice
• positive McBurney’s point
•
•
•
•
•
•
•
•
•
•
•
•
migratory arthralgias
night pain or night sweats
skin lesions
sudden weight loss or gain
vomiting, nausea
Kehr’s sign (if unsupported by
other glenohumeral signs &/or
symptoms)
decreased pulses
intermittent claudication
fatigue
malaise
progressive sensory or motor loss
(especially “saddle” anesthesia)
change in mentation
(Goodman, p. 142, 153, 179)
Note to the Wise:
Any “red flag” can become a “yellow
flag” on further questioning;
conversely, a “yellow flag” can convert
to a “red flag” over time.
Directed Inquiry: Review of Systems
9 Great Questions
•
•
•
•
•
Fatigue
Malaise
Weakness
Fever/chills/sweats
Weight change
• Nausea / vomiting
• Dizziness /
lightheadedness
• Paresthesia / numbness
• Change in cognition
-General Health Component of Review of Systems
Boissonnault, 2011, Ch 9, p 122
Directed Inquiry: All parts of SE!
• Environmental Factors
MS
• Participation
Factors
------
Rule
– Aggravating
and Easing Factors Out
Non MS
– 24 hour
• History
– Current Condition (current and past)
– Medical History
Non MS
-----• Review of Systems
MS
Rule In
Back to the Case!!
https://docs.google.com/document/d
/162T5E0Yv5_NGQfJUJpOHz2e0nBVJf
_9L5FokKlzoC1M/edit?usp=sharing
Disorder Recognition
Body
Chart
• Hypothesis 1, Hypothesis 2,
Hypothesis 3, Hypothesis 4
Complete
SE
• Modify Hypotheses
OE
• Further Hypotheses
Modification
Treatment
Plan
• Assess Response to Treatment
and/ or TRIAGE
(Maitland, Hengeveld, Banks, & English, 2011)
Disorder Recognition
Body
Chart
• Hypothesis 1, Hypothesis 2,
Hypothesis 3, Hypothesis 4
Complete
SE
• Modify Hypotheses
OE
• Further Hypotheses
Modification
Treatment
Plan
• Assess Response to Treatment
and/ or TRIAGE
(Maitland, Hengeveld, Banks, & English, 2011)
Remember to perform tests and/or
measures that will not only
your
hypothesis (provisional diagnosis) but
other diagnoses. This process
is known as differential diagnosis.
Directed selection of Tests and Measures
**Assumption: the clinician is performing a
Lower Quarter OE sequence so we will highlight
non-musculoskeletal and musculoskeletal tests
and measures the clinician should consider to
perform depending on their clinical reasoning.
Examination: Sitting
Non-musculoskeletal
Tests and Measures
• Posture
• Observation/Inspection
Musculoskeletal
Tests and Measures
• Observation/Inspection
• Functional Test (squat, gait,
balance)
• LS ROM
• Balance
• Neurological
– S1 myotome
– Heel/Toe Walking
– Balance
(Boissonnault, 2011, Ch 13)
Examination: Sitting
Non-musculoskeletal
Tests and Measures
• Percussion of kidneys
(Boissonnault, 2011, Ch 13)
Musculoskeletal
Tests and Measures
• Posture/Observation
• Neurological Testing
– Segmental Neuro Exam
– Neurodynamic Testing
(Slump)
Examination: Supine
Non-musculoskeletal
Tests and Measures
• Abdominal Tests
–
–
–
–
–
–
Observation
Auscultation
Percussion
Palpation
Sensory Testing
Superficial Abdominal Reflex
• Lymph Node Palpation
(NAVeL)
• Arterial Pulses of Lower
Extremities
Musculoskeletal
Tests and Measures
• Muscle strength and length
tests
• Implicate/ Clear joints
above and below
– Pelvis-SIJ, Thoracic Spine
– Hip, Knee, Ankle, Feet/Toes
• Neurological Testing
– Segmental (myotomes,
dermatomes, reflexes)
– Central (Babinski, Clonus)
– Neurodynamic Testing (SLR,
PNF)
(Boissonnault, 2011, Ch 13; Magee, p.405)
Examination: Prone
Non-musculoskeletal
Tests and Measures
• None
Musculoskeletal
Tests and Measures
• Muscle strength and length
tests
• Implicate/ Clear joints above
and below
– Pelvis-SIJ, Thoracic Spine
– Hip, Knee, Ankle, Feet/Toes
• Neurological Testing
– Segmental
– PKB
• Palpation
• Prone Stability Test
• Repeated Extension in lying
Examination: Sidelying
Non-musculoskeletal
Tests and Measures
• None
Musculoskeletal
Tests and Measures
• Muscle strength and length
tests
• Implicate/ Clear joints above
and below
– Pelvis-SIJ
• Palpation (PPIVMs)
• Anterior Stability Test
Back to the Case!!
https://docs.google.com/document/d
/162T5E0Yv5_NGQfJUJpOHz2e0nBVJf
_9L5FokKlzoC1M/edit?usp=sharing
In addition to Non-MS tests…
Consider the following MS tests and measures
MS diagnosis
for differential
-----• Neurological
Testing
Non MS
– Central Neurological Exam
– Segmental Neurological Exam
– SLR
Rule
Out
• Implicate/ Clear Tests for joints above and
Non MS
below
Rule
In SI, Hip
– Lumbar
Spine, Pelvis/
• Stability Testing
-----MS
Back to the Case!!
https://docs.google.com/document/d
/162T5E0Yv5_NGQfJUJpOHz2e0nBVJf
_9L5FokKlzoC1M/edit?usp=sharing
Disorder Recognition
Body
Chart
• Hypothesis 1, Hypothesis 2,
Hypothesis 3, Hypothesis 4
Complete
SE
• Modify Hypotheses
OE
• Further Hypotheses
Modification
Treatment
Plan
• Assess Response to Treatment
and/ or TRIAGE
(Maitland, Hengeveld, Banks, & English, 2011)
Disorder Recognition
Body
Chart
• Hypothesis 1, Hypothesis 2,
Hypothesis 3, Hypothesis 4
Complete
SE
• What additional questions will
you ask to Rule IN/ OUT??
OE
• What tests and measures will
you perform to rule IN/ OUT??
Treatment
Plan
• Assess Response to Treatment
and/ or TRIAGE
(Maitland, Hengeveld, Banks, & English, 2011)
Triage Categories
• Serious: medical referral trumps PT Intervention
– Urgent: life- or limb-threatening condition; escort
client to emergency room
– Immediate: serious condition requiring medical
referral within 1-2 days; “urgent care clinic” referral
– Delayed: condition should be evaluated within a
week or two by primary care physician
• Minimal: treat presenting complaint but also
refer
• Expectant: unable to benefit from PT
Intevention
Back to the Case!!
https://docs.google.com/document/d
/162T5E0Yv5_NGQfJUJpOHz2e0nBVJf
_9L5FokKlzoC1M/edit?usp=sharing
Errors in Clinical Reasoning
• Over-emphasis on findings which support an existing
hypothesis
• Ignoring findings that do not support an existing
hypothesis
• Obtaining redundant information
• Misinterpretation
• Translation errors
– The clinician accepts the terminology used by the
patient as the diagnosis
Reminder:
If what you think is a musculoskeletal
condition does not respond to treatment in
a reasonable amount of time, consider a
non-musculoskeletal etiology and refer or
return to the primary care manager.
References
•
•
•
•
•
•
•
•
•
•
Bates B (1991). A Guide to Physical Examination and History Taking, 5th ed. JB Lippincott Company.
Chapter 11.
Boissonnault WG (2011). Primary Care for the Physical Therapist: Examination and Triage (2nd
ed). Saunders Elsevier. Chapter 13 (pp 182-192).
D’Ambrosia RD (1977). Musculoskeletal Disorders: Regional Examination and Differential
Diagnosis, Chapter 7.
Goodman CC, Snyder TEK (1990). Differential Diagnoses in Physical Therapy: Musculoskeletal and
Systemic Conditions, Chapters 6, 7.
Magee DJ (1997). Orthopedic Physical Assessment, 3rd ed. Chap 9.
Maitland, GD, Hengeveld, E, Banks, K, & English, K (2011). Maitland’s Vertebral Manipulation Text
and Evolve eBooks Package, 7e (7th ed.). Butterworth-Heinemann.
Moore KL, Dalley AF (1999). Clinically Oriented Anatomy, 4th ed. Chapter 2.
Oluwole O, Akinyemi R, Owolabi LF (2005). Superficial Abdominal Reflex Is Not Sensitive to
Direction of the Moving Stimulus. African Journal of Neurological Sciences, 24(1), letters.
http://medicine.ucsd.edu/clinicalmed/abdomen.htm
Critical findings on abdominal plain films: http://www.medscape.com/features/slideshow/nonintestinal-xray?src=mp&spon=17&uac=126254DT