Severe interscapular pain and increased creatine kinase activity: the answer was in the ankles

Severe thoracic back pain with increased creatine kinase activity is a clinical presentation that suggests a variety of life threatening conditions. If initial examination is unrevealing, multiple diagnostic tests are usually performed attempting to identify the origin of the problem, sometimes neglecting apparently unrelated subtle physical findings. A patient is described in whom this was the initial presentation of a sensory demyelinating neuropathy, resulting in a diagnostic challenge. This case expands the differential diagnosis of severe thoracic back pain and increased creatine kinase activity, and illustrates the importance of physical examination in reaching a final diagnosis.