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Musculoskeletal Pain

By

Alexandra Villa-Forte

, MD, MPH, Cleveland Clinic

Last full review/revision Feb 2021| Content last modified Feb 2021
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Pain is the most common symptom of most musculoskeletal disorders. Pain ranges from mild to severe and from acute and short-lived to chronic and of long duration and may be local or widespread (diffuse).

Causes of Musculoskeletal Pain

Muscle pain (known as myalgia) is often less intense than bone pain but can be very unpleasant. For example, a muscle spasm or cramp (a sustained painful muscle contraction) in the calf is an intense pain that is commonly called a charley horse. Pain can occur when a muscle is affected by an injury, loss of blood flow to the muscle, infection, or a tumor. Polymyalgia rheumatica Polymyalgia Rheumatica Polymyalgia rheumatica involves inflammation of the lining of joints, causing severe pain and stiffness in the muscles of the neck, back, shoulders, and hips. The cause is unknown. The neck... read more is a disorder that causes severe pain and stiffness in the neck, shoulders, upper and lower back, and hips.

Tendon and ligament pain is often less intense than bone pain. It is often described as "sharp" and is worse when the affected tendon or ligament is stretched or moved and is usually relieved by rest. Common causes of tendon pain include tendinitis Tendinitis and Tenosynovitis Tendinitis is inflammation of a tendon. Tenosynovitis is tendinitis accompanied by inflammation of the protective covering around the tendon (tendon sheath). The cause is not always known. Tendons... read more , tenosynovitis Tendinitis and Tenosynovitis Tendinitis is inflammation of a tendon. Tenosynovitis is tendinitis accompanied by inflammation of the protective covering around the tendon (tendon sheath). The cause is not always known. Tendons... read more , lateral epicondylitis Lateral Epicondylitis Lateral epicondylitis is inflammation of the tendons of muscles that extend the hand backward and away from the palm. (See also Overview of Sports Injuries.) Pain develops in the outer aspect... read more or medial epicondylitis Medial Epicondylitis Medial epicondylitis is inflammation of the tendons of the muscles that flex or bend the palm toward the wrist, causing pain on the inner aspect of the elbow and forearm. (See also Overview... read more , and tendon injuries. The most common cause of ligament pain is injury (sprains Overview of Sprains and Other Soft-Tissue Injuries Sprains are tears in ligaments (tissues that connect one bone to another). Other soft-tissue injuries include tears in muscles (strains) and tears (ruptures) in tendons (tissues that connect... read more Overview of Sprains and Other Soft-Tissue Injuries ).

Bursae pain can be caused by trauma, overuse, gout, or infection. Bursae are small fluid-filled sacs that provide a protective cushion around joints. Usually, pain is worse with movement involving the bursa and is relieved by rest. The affected bursa may swell.

Joint pain (called arthralgia) may or may not be related to joint inflammation (called arthritis). Arthritis may cause swelling as well as pain. A wide variety of disorders can cause arthritis, including inflammatory arthritis (such as rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints.... read more Rheumatoid Arthritis (RA) ), osteoarthritis Osteoarthritis (OA) Osteoarthritis is a chronic disorder that causes damage to the cartilage and surrounding tissues and is characterized by pain, stiffness, and loss of function. Arthritis due to damage of joint... read more Osteoarthritis (OA) , infectious arthritis Infectious Arthritis Infectious arthritis is infection in the fluid and tissues of a joint usually caused by bacteria but occasionally by viruses or fungi. Bacteria, viruses, or fungi may spread through the bloodstream... read more , gout Gout Gout is a disorder in which deposits of uric acid crystals accumulate in the joints because of high blood levels of uric acid (hyperuricemia). The accumulations of crystals cause flare-ups ... read more Gout and related disorders, autoimmune disorders (such as systemic lupus erythematosus Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic autoimmune inflammatory connective tissue disorder that can involve joints, kidneys, skin, mucous membranes, and blood vessel walls. Problems in the... read more Systemic Lupus Erythematosus (SLE) ) and vasculitic disorders (such as immunoglobulin A–associated vasculitis Immunoglobulin A–Associated Vasculitis Immunoglobulin A–associated vasculitis (formerly called Henoch-Schönlein purpura) is inflammation of mainly small blood vessels that most often occurs in children. A rash of reddish purple bumps... read more Immunoglobulin A–Associated Vasculitis ), osteonecrosis Osteonecrosis Osteonecrosis is the death of a segment of bone caused by an impaired blood supply. Osteonecrosis can be caused by an injury or can occur spontaneously. Typical symptoms include pain, limited... read more , and injuries affecting the part of a bone inside a joint. Arthritic pain can be new (acute, for example, when caused by infections, injuries, or gout), or longstanding (chronic, for example, when caused by rheumatoid arthritis or osteoarthritis). Pain resulting from arthritis is typically worse when the joint is moved but usually is present even when the joint is not being moved. Sometimes pain originating in structures near the joint, such as ligaments, tendons, and bursae, seems to be coming from the joint.

Fibromyalgia Fibromyalgia Fibromyalgia is characterized by poor sleep, fatigue, mental cloudiness, and widespread aching and stiffness in soft tissues, including muscles, tendons, and ligaments. Poor sleep, stress, strains... read more may cause pain in the muscles, tendons, or ligaments. The pain is usually felt or causes tenderness in multiple locations and may be difficult to describe precisely but is usually not coming from the joints. Affected people usually have other symptoms, such as fatigue and poor sleep.

Evaluation of Musculoskeletal Pain

In trying to establish the cause of joint pain, doctors first determine

  • How many and which joints are involved

  • Whether the central part of the skeleton (such as the spine and pelvis) is involved

  • Whether the joint pain is acute or chronic

  • What factors relieve or worsen the pain

  • Whether there are other symptoms affecting other organs (for example, rash, fever, or dry eyes)

Determining these factors gives important clues to what disorder is likely causing the pain. Doctors do a physical examination to help determine these factors and detect other important findings that could help determine the cause of the pain.

Sometimes, the type of pain suggests where the pain has originated. For example, pain that worsens with movement suggests a musculoskeletal disorder. Pain with muscle spasm suggests that pain is caused by a muscle disorder (sometimes a chronic spinal cord injury). The site of swelling or the location of tenderness when the doctor feels (palpates) the area (for example, a joint, ligament, or bursa) or passively moves a joint often indicates the source of pain. However, often these characteristics of pain do not indicate its origin or cause. Thus, doctors usually base a specific diagnosis on the presence of other symptoms, physical examination findings, and often the results of laboratory tests and x-rays. For example, Lyme disease often causes joint pain with swelling and a bull's eye-like rash, and blood tests show antibodies to the bacteria that cause Lyme disease. Gout is characterized by a sudden attack of pain, swelling, and redness in the joint at the base of the big toe or other joints. Tests of the joint fluid generally show the presence of uric acid crystals.

Testing

Blood tests Laboratory Tests A doctor can often diagnose a musculoskeletal disorder based on the history and the results of a physical examination. Laboratory tests, imaging tests, or other diagnostic procedures are sometimes... read more Laboratory Tests are useful only in supporting the diagnosis made by the doctor after an examination. A diagnosis is not made or confirmed by a blood test alone. Examples of such blood tests include rheumatoid factor and antinuclear antibodies, which are used to help diagnose common causes of arthritis, such as rheumatoid arthritis and systemic lupus erythematosus. Usually, such tests are recommended only if symptoms specifically suggest such a disorder.

X-rays X-rays A doctor can often diagnose a musculoskeletal disorder based on the history and the results of a physical examination. Laboratory tests, imaging tests, or other diagnostic procedures are sometimes... read more X-rays are primarily used to take images of bones, but they do not show muscles, tendons, and ligaments. X-rays are usually taken if the doctor suspects a fracture or, less commonly, a bone tumor or infection or to look for changes that confirm a person has a certain kind of arthritis (for example, rheumatoid arthritis or osteoarthritis).

Magnetic resonance imaging (MRI) Computed tomography (CT) and magnetic resonance imaging (MRI) A doctor can often diagnose a musculoskeletal disorder based on the history and the results of a physical examination. Laboratory tests, imaging tests, or other diagnostic procedures are sometimes... read more Computed tomography (CT) and magnetic resonance imaging (MRI) , unlike plain x-rays, can identify abnormalities of soft tissues, such as muscles, bursae, ligaments, and tendons. Thus, MRI may be used when the doctor suspects damage to a major ligament or tendon or damage to important structures inside a joint; it may not be better than a standard x-ray in the evaluation of many painful conditions. MRI can detect fractures that are not visible on x-rays.

Computed tomography (CT) Computed tomography (CT) and magnetic resonance imaging (MRI) A doctor can often diagnose a musculoskeletal disorder based on the history and the results of a physical examination. Laboratory tests, imaging tests, or other diagnostic procedures are sometimes... read more Computed tomography (CT) and magnetic resonance imaging (MRI) is more sensitive than an x-ray and is often used to obtain more detail about a fracture or bone problem that was found with plain x-rays. A CT scan is useful if MRI cannot be done or is unavailable.

Other imaging tests include ultrasonography Ultrasonography A doctor can often diagnose a musculoskeletal disorder based on the history and the results of a physical examination. Laboratory tests, imaging tests, or other diagnostic procedures are sometimes... read more Ultrasonography , arthrography (an x-ray procedure in which a radiopaque dye is injected into a joint space to outline the structures, such as ligaments inside the joint), and bone scanning Bone scanning A doctor can often diagnose a musculoskeletal disorder based on the history and the results of a physical examination. Laboratory tests, imaging tests, or other diagnostic procedures are sometimes... read more Bone scanning . These tests may help doctors diagnose certain conditions. Doctors may remove a sample of bone, the lining of the joint (synovium), or other tissues for examination under a microscope (biopsy).

Joint fluid testing is often done if the joint is swollen. Doctors extract the fluid from the joint by first sterilizing the area with an antiseptic solution and then numbing the skin with an anesthetic. Then a needle is inserted into the joint and joint fluid is withdrawn (a procedure called joint aspiration Joint aspiration (arthrocentesis) A doctor can often diagnose a musculoskeletal disorder based on the history and the results of a physical examination. Laboratory tests, imaging tests, or other diagnostic procedures are sometimes... read more Joint aspiration (arthrocentesis) or arthrocentesis). This procedure causes little or no pain. The fluid is usually tested for, among other things, bacteria that can cause infection and is examined under a microscope for crystals that cause gout and related disorders.

Treatment of Musculoskeletal Pain

  • Pain relievers

  • Other measures to relieve pain

Pain is usually best relieved by treating its cause. The doctor may recommend pain relievers (see Treatment of Pain Treatment of Pain In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more ) such as acetaminophen Acetaminophen In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more , nonsteroidal anti-inflammatory drugs Nonsteroidal Anti-Inflammatory Drugs In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more (NSAIDs), or, if pain is severe, opioids Opioid Analgesics In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more . Depending on the cause, applying cold Cold therapy (cryotherapy) Professional rehabilitation therapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include... read more or heat Heat therapy Professional rehabilitation therapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include... read more or immobilizing the joint may help relieve musculoskeletal pain.

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Musculoskeletal Pain
The most common symptom in musculoskeletal disorders is pain. Pain varies widely from mild to severe, and from short-lived and acute to long-term and chronic. Pain may affect a small or large area of the body. Which of the following is the most common cause of musculoskeletal pain?
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