How To Approach A Patient With Musculoskeletal Problems

This article highlights the process and protocol that a physician goes through when he faces a patient with musculoskeletal disorder. Individuals with musculoskeletal complaints should be evaluated in uniform, logical manner by means of a thorough history, a comprehensive physical examination, and if appropriate, laboratory testing.

What are Goals of Initial Encounter?
The goals of the initial encounter are to determine whether the musculoskeletal complaints is

• Articular or non articular in origin
• Inflammatory or noninflammatory in nature
• Acute or chronic
• Localized, widespread, or systemic

With such an approach and a understanding of the pathophysiologic processes that underline musculoskeletal complaints, an adequate diagnosis can be made in the vast majority of individuals.

Many musculoskeletal disorders resemble each other at the outset, and some take months to evolve into a readily recognizable diagnostic entity. Therefore it may always be not possible to fix the diagnosis in first meeting.

Articular Versus Nonarticular

The musculoskeletal evaluation must pin point the anatomic site(s) of origin of the patient’s complaints. For example, pain in the knee can result from a variety of pathologic conditions involving different anatomic structures, including osteoarthritis, rheumatoid arthritis, gonococcal arthritis, fractures around knee, arthritis resulting from infection, cellulitis etc.

Articular structures include the synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule, and juxtaarticular bone.

Nonarticular (or periarticular) structures, such as supportive extraaricular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin may be involved.

Pain from these structures may mimic true articular pain.

Distinguishing between articular and nonarticular disease requires a careful and detailed examination.

Articular disorders may be characterized by pain and limited range of motion on active and passive movement, swelling caused by synovial proliferation or effusion or bony enlargement, crepitation, instability, locking, or deformity.

In contrast, nonarticular disorders tend to be painful on active but not passive range of motion, demonstrate point or focal tenderness in regions distinct from articular structures, and have physical findings remote from the joint capsule.
Nonarticular disorders seldom demonstrate crepitus, instability, or deformity.

Inflammatory Versus Noninflammatory

The primary objective is to identify the nature of the underlying pathologic process. Musculoskeletal disorders are generally classified as inflammatory or noninflammatory.
Inflammatory disorders are those which involve an ongoing inflammation and reparitive proces.

Inflammatory cause may be infection, crystal-induced (gout, pseudogout), immune related [rheumatoid arthritis (RA), systemic lupus erythematosus (SLE)], reactive (rheumatic fever, Reiter’s syndrome), or idiopathic.

Inflammatory disorders may be identified by

• The presence of some or all of the four cardinal signs of inflammation
  • Erythema
  • Warmth
  • Pain
  • Swelling
• By systemic symptoms
  • Prolonged morning stiffness
  • Fatigue
  • Fever
  • Weight loss
• By laboratory evidence of inflammation
  • Elevated erythrocyte sedimentation rate
  • Elevated C-reactive protein level
  • Thrombocytosis.

Articular stiffness is common in chronic musculoskeletal disorders. However, the chronology and magnitude of stiffness may be diagnostically important. Morning stiffness related to inflammatory disorders is precipitated by prolonged rest, often lasts several hours, and may improve with activity and anti-inflammatory medications. By contrast, intermittent stiffness associated with noninflammatory conditions, such as osteoarthritis, is precipitated by brief periods of rest, usually lasts less than 60 min, and is exacerbated by activity.

Noninflammatory disorders may be related to trauma (rotator cuff tear), ineffective repair (osteoarthritis), cellular overgrowth (pigmented villonodular synovitis), or pain amplification (fibromyalgia).

They are often characterized by

• Pain without swelling
• Warmth
• The absence of inflammatory or systemic features
• Little or no morning stiffness
• Normal laboratory findings.

Chronology and nature of disorder can be delineated in history and examination.The main purpose of the examiner is to narrow the diagnostic consideration and to assess the need for immediate diagnostic or therapeutic intervention or for continued observation.

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