Virginia Research Day 2021

EXPAND YOUR DIFFERENTIAL FOR ABDOMINAL PAIN Don’t Forget Musculoskeletal Etiologies John C. Biery, Jr., DO, CAQSM, Albert J Kozar DO, FAOASM, R-MSK Edward Via College of Osteopathic Medicine, VCOM Sports and Osteopathic Medicine, Blacksburg, VA. Introduction/Background Case Discussion

Abdominal pain is a top reason people present to the emergency department 1 . The evaluation of abdominal pain is a complex task. Many variables must be considered. All the requirements of a good history and physical exam, to include consideration of imaging, must be included in the initial evaluation of the patient. Even in the most recent UpToDate 2 , the extensive differential diagnosis list of non-traumatic abdominal pain sparsely includes the musculoskeletal (MSK) system, an etiology (Figure 1). As one of the largest systems in the body and fully intertwined with the other systems, this is unfortunately a frequently overlooked source of pain in the initial and even follow up evaluation. This case is an example of a common musculoskeletal problem, psoas syndrome , presenting as abdominal pain , and demonstrating the need to consider the MSK system in the differential diagnosis of abdominal pain.

- Psoas syndrome is a well-known and described etiology of chronic low back pain taught extensively in Osteopathic education 3 . The classic psoas syndrome starts as a bilateral psoas spasm that then concentrates to one side. A non- neutral L1 or L2, then sacral rotation on an oblique axis, sidebending to the same side as the spasm and hip shift, piriformis spasm and sciatic pain contralateral to the psoas spasm 3 . The current case does not purely fit this classic model. She had some findings on physical exam that were suggestive of a psoas etiology (RLQ pain with resisted hip flexion and knee extension), but with specific evaluation of trigger points the diagnosis was more certain. Then relief of the pain with treatment of the somatic dysfunction confirmed the diagnosis. - Most psoas trigger points refer to the

Initial Exam : Knowing the extent of the previous work up, the patient was approached from a more global perspective using tissue texture and the area of greatest restriction (AGR) to guide further evaluation. - Key Physical Exam & Somatic Dysfunction Findings: • Positive Right Standing Flexion Test • RLQ pain with resisted right knee extension and resisted right hip flexion. • First lumbar non-neutral, flexed, sidebent right (L1 FRSr). • Tenderness to palpation at the cephalad psoas tenderpoint and the lesser tubercle attachment of the iliopsoas, otherwise unremarkable abdominal exam.

- Diagnosis: Right Psoas Syndrome.

ipsilateral paraspinals and to the ipsilateral upper quad 6 . However, when looking into the specifics of the psoas syndrome a lesser know psoas minor syndrome has been described with referred pain into the right lower quadrant and would be easily mistaken for an appendicitis. Initially

Right lower Quadrant Pain Differential Diagnosis

Treatment Plan: Osteopathic Manipulative treatment (OMT) consisting of muscle energy treatment of the L1 somatic dysfunction (SD) and Counterstrain of the tender psoas muscle with 95% resolution of her index pain. Results : Two week follow up: pain free unless she was very active, but the RLQ pain resolved with rest. The lumbar and psoas SD returned, but less severe, easier to treat and better relief of pain with the second treatment .

Colonic: appendicitis, colitis, diverticulitis, IBD, IBS Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID Renal: nephrolithiasis, pyelonephritis

Figure 1

described in young girls, 15-17 years of age. This was treated with surgical tenotomy with resolution of pain.

Ten principal reasons for emergency department visits, 2017 1. Stomach and abdominal pain, cramps, and spasms 2. Chest pain and related symptoms 3-10. Fever, Cough, Shortness of breath, Pain, specified site not refer- able to a specific body system, Headache, pain in head, Back symptoms. Vomiting, Symptoms referable to throat Adapted from National Hospital Ambulatory Medical Care Survey: 2017 Emergency Department Summary Tables

Psoas Syndrome Findings Figure 4

- While abdominal pain is a complex, complicated evaluation and treatment complaint, knowledge of musculoskeletal causes of pain would increase the physician’s ability to treat pain when the initial work up for acute, surgical pathology is negative.

Psoas Trigger Points 6 Figure 3

Figure 2

Psoas Minor Figure 5

Case

Discussion Abdominal pain is a challenging patient complaint. Appropriate evaluation to diagnose and treat or rule out life threatening conditions is necessary 2 . The above case exemplifies the need for expanding the differential diagnosis to include MSK etiologies. Using a more global MSK screening method to guide additional specific physical exam for MSK and visceral etiologies will help the clinician determine what imaging and labs are necessary to fully evaluate the broadened differential diagnosis. This approach gets the clinician closer to a focused evaluation of actual findings rather than using a protocolized lab and radiologic screening approach. In this case, had a musculoskeletal etiology been considered, a trial of OMT could have been performed in the ED as part of a thorough evaluation for life threatening etiologies and likely would have decreased the time to an actionable diagnosis and significantly reduced the total cost of care.

- Hx CC : A 22-year-old woman presents to the VSOM office referred from OB/Gyn for evaluation of eight-week history of sharp, intermittent right lower quadrant (RLQ) pain with radiation to the ipsilateral posterior iliac crest. The pain was of insidious onset following binge eating “junk food.” Urgent care visit in August, led to an emergency department evaluation including a CT scan, ultrasound, and blood work, but no diagnosis. - An acute episode of pain at work again led to a second ED evaluation and a four-day hospitalization to rule out an appendicitis, but again no actionable diagnosis was made. - Social Hx : sedentary, student lifestyle. Started a retail job in August that requires extensive walking and lifting up-to 50-pounds. Nicotine use vaping. - Trauma Hx : she fell in January 2020 descending a set of stairs at her Univ., slipping on ice, landing flat on her back while wearing a full backpack. - PMHx : migraine headache, anxiety, chronic neck pain, frequent ankle sprains anaphylactic reaction to amoxicillin/clavulanic acid. No surgical history or significant family history.

References

1. National Hospital Ambulatory Medical Care Survey: 2017 Emergency Department Summary Tables. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf 2. Penner RM. Evaluation of the adult with abdominal pain. In UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on Dec 1, 2020.) 3 Diagnosis and manipulative treatment: Lumbopelvic region. In: Kuchera WA, Kuchera ML. Osteopathic Principles in Practice. 2nd ed. Columbus, OH: Greyden Press; 1994:481-490. 4. Tufo A, Desai GJ, Cox WJ. Psoas Syndrome: A Frequently Missed Diagnosis. J Am Osteopath Assoc. 2012;112(8):522-528. 5. Zhu Z, Zhang J, Sheng J, Zhang C, Xie Z. Low Back Pain Caused by Iliopsoas Tendinopathy Treated with Ultrasound-Guided Local Injection of Anesthetic and Steroid: A Retrospective Study. J Pain Res 2020:13 3023 – 3029. 6. Simons,D.G.,Travell , J.G., 1999.Travell&Simons’Myofascial pain and dysfunction. Trigger Point Manual. In: Upper Half of Body, second ed., vol. 1. Williams & Wilkins, Baltimore, pp. 89-109.

Acknowledgements

I thank the Edward Via College of Osteopathic Medicine for the opportunity to present our case presentation..

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