Differential Diagnosis for Back Injury

Given the symptoms and history provided, the following differential diagnoses are considered:

• Single most likely diagnosis

  • Muscle strain or ligament sprain: The description of a 'crunch' sound upon landing and the location of pain between the shoulder blades (T5 to T6 area) could indicate a strain or sprain of the muscles or ligaments in the thoracic spine region. The absence of findings on MRI and X-ray, along with the persistence of symptoms despite rest and physical therapy, suggests a soft tissue injury that may not be visible on these imaging modalities.

• Other Likely diagnoses

  • Thoracic facet joint pain: The pain location and the mechanism of injury could also suggest facet joint pain in the thoracic spine. Facet joints are small stabilizing joints located between and behind adjacent vertebrae, and their injury can cause localized pain and stiffness.
  • Costovertebral joint dysfunction: Given the location of pain and the symptoms, dysfunction of the costovertebral joints (joints between the ribs and the vertebrae) could be another possible diagnosis. This condition can cause pain in the thoracic region and between the shoulder blades.
  • Myofascial pain syndrome: This condition involves pain and inflammation of the fascia (the connective tissue surrounding muscles) and could explain the persistent pain and numbness, especially if there are trigger points in the muscles of the thoracic region.

• Do Not Miss diagnoses

  • Spinal cord injury or compression: Although the MRI was inconclusive, any injury to the spine warrants careful consideration of potential spinal cord involvement, especially with symptoms of numbness. It's crucial to ensure there's no compression or injury to the spinal cord that could lead to more severe neurological deficits.
  • Osteoporotic compression fracture: Despite the lack of findings on X-ray, osteoporotic compression fractures can sometimes be subtle and require further imaging like a bone density scan or a more detailed MRI to diagnose. This is particularly important in individuals with risk factors for osteoporosis.
  • Infection (e.g., osteomyelitis, discitis): Infections of the spine are rare but can present with persistent back pain and may not always show up on initial imaging. A high index of suspicion is necessary, especially if there are systemic symptoms like fever or if the pain is worsening over time.

• Rare diagnoses

  • Scheuermann's disease: A rare condition that affects the thoracic spine, causing curvature and potentially pain in the area between the shoulder blades. It's more common in adolescents but can be considered in adults with persistent thoracic back pain.
  • Tumor (primary or metastatic): Although rare, spinal tumors can cause back pain and neurological symptoms. The persistence of symptoms despite conservative management warrants consideration of this diagnosis, potentially requiring further imaging or referral to a specialist.