Chapter 5: Differential Diagnosis

CHAPTER OBJECTIVES

At the completion of this chapter, the reader will be able to:

1. Understand the importance of differential diagnosis.

2. Recognize some of the signs and symptoms that indicate the presence of a serious pathology.

3. Discuss the concept of malingering.

4. Describe why certain signs and symptoms (red flags) require medical referral.

5. Describe the various infective diseases and inflammatory disorders that the orthopaedic clinician may encounter.

6. Describe the various neoplastic and metabolic diseases that can impact the orthopaedic patient.

7. Discuss the differences between fibromyalgia (FM) and myofascial pain syndrome (MPS).

8. List the various systemic or medical pathologies that can mimic musculoskeletal pathology in the various body regions.

OVERVIEW

The American Physical Therapy Association Vision Statement for the American Physical Therapy Association (APTA) is “transforming society by optimizing movement to improve the human experience.”¹ With the majority of US states now permitting direct access to physical therapists, many physical therapists now have the primary responsibility for being the gatekeepers of health care and for making medical referrals. In light of the APTA’s movement toward realizing “Vision 2020,” the APTA’s Board provides the following guiding principles:

• Identity. The physical therapy profession will define and promote the movement system as the foundation for optimizing movement to improve the health of society. Recognition and validation of the movement system are essential to understand the structure, function, and potential of the human body.

• Quality. The physical therapy profession will commit to establishing and adopting best practice standards across the domains of practice, education, and research as the individuals in these domains strive to be flexible, prepared, and responsive in a dynamic and ever-changing world. As independent practitioners, doctors of physical therapy in clinical practice will embrace best practice standards in the examination, diagnosis/classification, intervention, and outcome measurement.”

• Collaboration. The physical therapy profession will demonstrate the value of collaboration with other healthcare providers, consumers, community organizations, and other disciplines to solve the health-related challenges that society faces. In clinical practice, doctors of physical therapy, who collaborate across the continuum of care, will ensure that services are coordinated, of value, and consumer-centered by referring, comanaging, engaging consultants, and directing and supervising care.

Through the history and physical examination, physical therapists diagnose and classify different types of information for use in their clinical reasoning and intervention.² The Guide clearly articulates the physical therapist’s responsibility to recognize when a consultation with, or referral to, another healthcare provider is necessary.³ This responsibility requires that the clinician have a high level of knowledge, including an understanding of the concepts of medical screening and differential diagnosis. This is because a patient can present with multiple symptomatic areas that can pose a diagnostic challenge for the physical therapist. Though musculoskeletal and nonmusculoskeletal symptoms typically present separately, they can occur together, mimicking each other, making the ability to differentiate between musculoskeletal and nonmusculoskeletal symptoms a critical skill for the physical therapist. Thus, when ...