Management of Painful Palpation
Begin analgesic management immediately when painful palpation is identified, as diagnosis should not delay pain relief, and initiate a systematic evaluation to determine the underlying cause while treating the pain. 1
Immediate Pain Management
Administer appropriate analgesics as soon as possible without waiting for a definitive diagnosis, as the American College of Emergency Physicians emphasizes that analgesic management should begin immediately when indicated. 1
Use evidence-based assessment techniques including the patient's self-report of pain as a critical component, recognizing that pediatric patients, the elderly, and cognitively impaired individuals are at highest risk for inadequate pain management. 1
Consider both pharmacologic agents and non-pharmacologic interventions, which should be readily available in the clinical setting. 1
Systematic Physical Examination for Painful Palpation
The location and characteristics of tenderness on palpation guide the differential diagnosis:
For Musculoskeletal/Tendon Pain
Well-localized tenderness that reproduces the patient's activity-related pain suggests tendinopathy, which is the most common cause of painful palpation in load-bearing structures. 1
Examine for muscle atrophy, asymmetry, swelling, and erythema, as atrophy indicates chronicity while swelling and erythema suggest active pathology. 1
Assess range of motion, which is typically limited on the symptomatic side in tendinopathy. 1
Perform physical maneuvers that simulate tendon loading to confirm the diagnosis if they predictably reproduce the patient's pain. 1
For Vascular Causes (Critical to Not Miss)
If painful palpation involves extremities, immediately assess pulses bilaterally using both palpation and handheld continuous-wave Doppler, as pulse palpation alone is inaccurate. 1
Check for the "5 Ps plus temperature" (Pain, Paralysis, Paresthesias, Pulselessness, Pallor, and Poikilothermia) to identify acute limb ischemia, which requires revascularization within 4-6 hours. 1, 2, 3
Obtain ankle-brachial index (ABI) testing immediately if bilateral lower extremity symptoms are present, as peripheral artery disease may present with atypical symptoms including painful palpation rather than classic claudication. 2, 4
Measure bilateral arm blood pressures to identify subclavian artery stenosis, with differences >15-20 mmHg considered abnormal. 2
Treatment Algorithm Based on Etiology
For Confirmed Tendinopathy
Initiate relative rest by reducing activity to decrease repetitive loading of the damaged tendon, as this is the cornerstone of conservative management. 1
Reserve imaging (plain radiography, ultrasonography, or MRI) for cases where diagnosis remains unclear after thorough history and physical examination, for recalcitrant pain despite adequate conservative management, or for preoperative evaluation. 1
Plain radiography may reveal bony abnormalities such as loose bodies or osteoarthritis but typically cannot demonstrate soft-tissue changes of tendinopathy. 1
For Suspected Vascular Pathology
Administer systemic anticoagulation with unfractionated heparin immediately unless contraindicated, as this stops thrombus propagation and may provide anti-inflammatory effects. 1
Arrange emergent evaluation by a vascular specialist (vascular surgeon, interventional radiologist, or cardiologist with vascular expertise) if acute limb ischemia is suspected. 1
For Category IIa or IIb acute limb ischemia (marginally or immediately threatened limbs), perform revascularization emergently within 6 hours. 1
Critical Pitfalls to Avoid
Do not delay analgesic administration while pursuing diagnostic workup, as pain relief should begin immediately when indicated regardless of diagnostic certainty. 1
Do not dismiss painful palpation of extremities as "just musculoskeletal" without vascular assessment, as peripheral artery disease often presents with atypical symptoms including painful palpation rather than classic claudication. 2, 4
Do not miss acute limb ischemia, which presents with painful palpation accompanied by the other "Ps" and requires immediate revascularization to prevent permanent damage and limb loss. 1, 3
Do not assume joint effusions indicate tendinopathy, as effusions are uncommon with tendinopathy and suggest intra-articular pathology requiring different management. 1
If multiple tendons are symptomatic with painful palpation, evaluate for rheumatic disease and consider rheumatologic referral rather than treating as isolated tendinopathy. 1
Recognize that aberrant pain behaviors do not equate with addictive disease and may indicate under-treatment of pain; all patients should be treated appropriately for reports of pain. 1