Musculoskeletal Pain Mnemonic – Best USMLE CS mnemonics

Musculoskeletal Pain Mnemonic:

Musculoskeletal pain is one of the most common reason for patients to see a doctor specially by their primary care providers, which makes it super high yield and a very common patient encounter for USMLE Step 2 CS. Having trouble remembering all the important questions to ask during your patient encounter? Then try this Musculoskeletal Pain Mnemonic for USMLE Step 2 CS.

PHYSICAL EXAMINATION for Musculoskeletal Pain Mnemonic

NOTE: Make sure to wash your hands or wear gloves before you start physical examination. Make sure to ask for permission before you start each physical exam. Make sure to use proper draping (don’t forget to tie back patient’s gown). Make sure to explain each physical examination in layman’s term to your patient. Do NOT repeat painful maneuvers.

1) Shoulder Pain:

• Head and neck exam: Checked for bruises, neck movements and signs of head trauma
• Exam of the arms: Compared both arms in terms of strength, range of motion (shoulder, elbow, wrist), sensation, DTRs, pulses

2) Lower back pain:

• Back exam:Inspection, palpation, range of motion
• Extremities: Inspection, palpation of peripheral pulses, hip exam
• Neuro exam: Motor, DTRs, Babinski sign, Gait (including toe and  heel walking), passive straight leg raising, sensory exam

3) Calf Pain:

• Extremities: Inspection, palpation; checked for Homans’ sign
• Joint exam:  Inspection, palpation, range of motion (knee, ankle, hip joint on both sides)
• Neuro exam: Sensory and motor reflexes (knee, ankle)

4) Heel Pain:

• Extremities: Palpation of medial calcaneal tuberosity, Achilles tendon, plantar fascia, retrocalcaneal bursa.  Passive range of motion and general strength of ipsilateral knee and hip.  Ankle dorsi flexion and great toe extension and passive range of motion; strength testing of ankle dorsi flexion and plantar flexion
• Neuro: Checked sensation to light touch for dermatomes of foot and ankle; assessed Achilles tendon reflex

DIFFERENTIAL DIAGNOSIS for Musculoskeletal Pain Mnemonic

1) Shoulder Pain:

• Shoulder dislocation
• Arthritis [eg. glenohumeral joint arthritis or acromioclavicular joint or AC joint arthritis]
• Rotator cuff tear
• Clavicular fracture
• Humeral fracture 
• Elder abuse

2) Lower Back Pain:

• Lumbar muscle strain
• Disk herniation
• Lumbar spinal stenosis
• Metastatic prostate cancer
• Tumor in the vertebral canal
• Vertebral compression fracture
• Multiple Myeloma
• Malingering 
• Ankylosing spondylitis

3) Calf Pain:

• Deep venous thrombosis
• Cellulitis
• Myositis
• Rupture of Baker’s cyst 
• Hematoma
• Spasm due to injury or sprain

4) Heel Pain:

• Plantar fasciitis
• Haglund’s deformity
• Calcaneal stress fracture
• Achilles tendonitis
• Retrocalcaneal bursitis
• Tarsal tunnel syndrome
• Foreign body
• Ankle sprain

DIAGNOSTIC WORK-UP for Musculoskeletal Pain Mnemonic

1) Shoulder pain:

• XR of the shoulder and arm: To look for signs of joint arthritis [eg. the glenohumeral joint or the acromioclavicular joint or AC joint], fractures, calcifications or dislocation
• MRI of the shoulder: for soft tissue evaluation including the rotator cuff tendons [to rule out partial or complete tear] and to rule out glenoid labrum tear
  • NOTE: MRI with contrast (eg. MRI arthrogram) is more sensitive for ruling out soft tissue pathology than MRI without contrast. 

2) Lower back pain:

• Digital rectal exam to check the anal sphincter tone and rule out cauda equina syndrome.
• X-ray of Lumbar Spine: To rule out arthritis, fractures or dislocations.
• MRI—Lower spine
• PSA: specially in men who also have urinary complaints such as urinary incontinence.
• CBC, calcium, BUN/Cr
• Serum and urine protein electrophoresis

3) Calf pain:

• Doppler U/S of the lower extremities
• D-dimer: is highly sensitive but not very specific. It may be falsely elevated in some patient [eg. patients with chronic kidney disease]. In the real world it is a good test to obtain if there is LOW suspicion for DVT. If the suspicions are high, then Doppler U/S of the lower extremities is recommended.
  • NOTE: Spiral CT scan with contrast is for ruling out pulmonary embolism and not DVT.
• Doppler U/S of the lower extremities
• Hypercoagulability testing: it is a great test to obtain specially if patient has recurrent history of clotting or family history of clotting disorder.
• CBC with differential
• CPK and myoglobin level: to rule out rhabdomyolysis
• CT venography
• MRI

4) Heel pain:

• X-Ray of foot and ankle: To rule out heel spur, arthritis, fractures and or dislocations. 
• Bone scan
• MRI: Usually obtained if initial x-ray is non-diagnostic and patient continues to have symptoms.

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