Musculoskeletal examination of the individuals with musculoskeletal complaints involves a thorough history, a comprehensive physical examination, and if appropriate, laboratory testing.
Goals of Musculoskeletal Examination
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
- By systemic symptoms
- Prolonged morning stiffness
- Weight loss
- By laboratory evidence of inflammation
- Elevated erythrocyte sedimentation rate
- Elevated C-reactive protein level
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
- 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.
History and clinical examination of the patient helps the physician to identify the nature of problem and narrow down the possibilities of differential diagnoses.
Certain diagnosis are more frequent in specific age groups. SLE, rheumatic fever, and Reiter’s syndrome are more common the young, whereas fibromyalgia is most common in middle age, and osteoarthritis and polymyalgia rheumatica in old age.
Some diseases are more common in a particular gender or race.
Gout and the spondyloarthropathies like ankylosing spondylitis, Reiter’s syndrome are more common in men, whereas rheumatoid arthritis and fibromyalgia are more common in women.
Polymyalgia rheumatica, giant cell arteritis, and Wegener’s granulomatosis preferentially affect whites, whereas sarcoidosis and systemic lupus erythematosus are more common in blacks.
Familial aggregation occurs in some disorders, such as ankylosing spondylitis, gout, RA, and Heberden’s nodes of osteoarthritis.
Onset of The Disease
The onset of disorders such as septic arthritis and gout tends to be abrupt, whereas osteoarthritis, rheumatoid arthritis, and fibromyalgia may develop more indolently. In terms of evolution, disorders are classified as chronic i.e slow but present for a duration (e.g., osteoarthritis) and acute i.e abrupt.
Musculoskeletal disorders typically are called acute if they last less than 6 weeks and chronic if they last longer.
Acute arthroplathies tend to be infectious, crystal-induced, or reactive. Noninflammatory and immune-related arthritides, such as osteoarthritis and RA, respectively, are often chronic.
The duration of the patient’s complaints may alter the diagnostic considerations. For example, the musculoskeletal signs and symptoms of hepatitis B virus infection may be identical with those of early RA at the onset but rarely persist beyond 3 weeks.
Distribution of The Disease
The number and distribution of involved articulations should noted. Articular disorders are classified as
monarticular (one joint involved), oligoarticular or pauciarticular (two to three joints involved), or polyarticular (more than three joints involved).
Nonarticular disorders can be classified as either focal or widespread.
The clinical history should also identify precipitating events, such as trauma, drug administration, or antecedent or intercurrent illnesses, that may have contributed to the patient’s complaints. A thorough rheumatic review of systems may disclose associated features outside the musculoskeletal system and provide useful diagnostic information.
- The goal of the physical examination is
- To ascertain the structures involved
- The nature of the underlying pathology
- The extent and functional consequences of the process
- The presence of systemic or extraarticular manifestations.
A knowledge of anatomy is necessary to identify the primary site(s) of involvement and differentiate articular from nonarticular disorders.
The musculoskeletal examination depends largely follows as
- Inspection or looking at the problem without touching the patient
- Palpation- Feel the problem and correlate and add upon the findings with findings in inspection
- Movements- To note any loss of movement in the involved or neighbouring joint.
- Measurments-To look for any lengthening or shortening in case of limb involvement.
- Special Tests and Maneuvers depending upon the area involved.
Examination of involved and uninvolved joints will determine whether warmth, erythema, or swelling is present.
The examination should distinguish true articular swelling caused by synovial effusion or synovial proliferation from nonarticular or periarticular involvement, which usually extends beyond the normal joint margins or the full extent of the synovial space.
Synovial effusion can be distinguished from synovial hypertrophy by palpation or specific maneuvers.
Joints stability can be assessed by palpation and by the application of manual stress.
Subluxation or dislocation, which may be secondary to traumatic, mechanical, or inflammatory causes, can be assessed by inspection and palpation.
Joint volume can be assessed by palpation. Distention of the articular capsule usually causes pain. The patient will attempt to minimize the pain by keeping the joint in the position of least intraarticular pressure and greatest volume, usually partial flexion.
Clinically, joint distention may be detected as
- Voluntary or fixed flexion deformities
- Diminished range of motion-especially on extension, which decreases joint volume.
Active and passive range of motion should be assessed in all planes and compared with contralateral side.
Serial evaluations of joint motion may be made using a goniometer to quantify the arc of movement. Each joint should be passively manipulated through its full range of motion (including, as appropriate, flexion, extension, rotation, abduction, adduction, inversion, eversion, supination, pronation, and medial or lataral deviation or bending).
Limitation of motion is frequently caused by effusion, pain, deformity, or contracture.
Contractures may reflect antecedent synovial inflammation or trauma. Joint crepitus may be felt during palpation or maneuvers and may be prominent in osteoarthritis.
Joint deformity usually indicates a long-standing or aggressive pathologic process. Deformities may result from ligamentous destruction, soft tissue contracture, bony enlargement, ankylosis, erosive disease or subluxation.
Examination of the musculature will permit assessment of strength and reveal atrophy, pain, or spasm. The examiner should look carefully for nonarticular or periarticular involvement, especially when articular complaints are not supported by objective findings referable to the joint capsule.
The identification of nonarticular pain will prevent unwarranted and often expensive additional evaluations.
Majority of musculoskeletal disorders can be diagnosed easily by a complete history and physical examination.
Clinical evaluation helps to determine whether additional investigations are needed.
Monarticular conditions require additional evaluation, as do traumatic of inflammatory conditions and conditions accompanied by neurologic changes or systemic manifestations of serious disease.
Individuals with chronic symptoms are candidates for additional evaluation.
The extent and nature of the additional investigation should be dictated by the clinical features and suspected pathologic process.
Routine investigations include
- Complete blood count including a white blood cell and differential count,
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Both tests are inexpensive and easily performed
The CRP and ESR values may be elevated with infections, inflammatory arthritis, autoimmune disorders, neoplasia, pregnancy, and advanced age.
Serologic tests for rheumatoid factor, antinuclear antibodies, complement levels, Lyme disease antibodies, or antistreptolysim O (ASO) titer should be carried out only when there is substantive clinical evidence suggesting a relevant diagnosis.
IgM rheumatoid factor (autoantibodies against the Fc portion of IgG) is found in 80 percent of patients with RA and may also be seen in low titers in patients of
- chronic infectionsi.e.tuberculosis, leprosy
- Autoimmune disease i.e. SLE, Sjogren’s syndrome
- Chronic pulmonary, hepatic, or renal disease.
Antinuclear antibodies are found in nearly all patients with SLE and may also be seen in patients with other autoimmune diseases, drug-induced lupus or chronic hepatitic or renal disorders.
Aspiration and analysis of synovial fluid is always indicated in acute monoarthritis or when an infectious or crystal-induced arthropathy is suspected.
Synovial fluid analysis
Synovial fluid analysis may be crucial in distinguishing between noninflammatory and inflammatory processes. This distinction can be made on the basis of the appearance, viscosity, and cell count of the synovial fluid.
Tests for synovial fluid glucose, protein, lactate dehydrogenase, lactic acid, or autoantibodies are not recommended, as they are insensitive or have little discriminatory value.
Noninflammatory synovial fluid is clear, viscous, and amber-colored, with a white blood cell count of <2000/µL and a predominance of mononuclear cells. The viscosity of synovial fluid is assessed by expressing fluid from the syringe one drop at a time. Normally there is a stringing effect, with a long tail behind each drop. Effusions due to osteoarthritis or trauma usually have this typical viscosity.
Inflammatory fluid is turbid and yellow, with an increased white cell count and a predominance of polymorphonuclear leukocytes. Inflammatory fluid has a reduced viscosity, with little or no tail following each drop of synovial fluid. Such effusion are found in RA, gout, other inflammatory arthritis, and septic arthritis.
Infectious fluid is turbid and opaque, with a white cell count usually >50,000/µL, a predominace of polymorphonuclear leukocytes (>75%), and low viscosity. Such effusions are typical of septic arthritis, but they occur rarely with sterile inflammatory arthritides such as RA or gout.
Hemorrhagic synovial fluid may be seen with hemarthrosis or trauma. Synovial fluid should be analyzed immediately for appearance, viscosity, and cell count. Cellularity and the presence of crystals may be assessed by light or polarizing microscopy, respectively.
Get more stuff on Musculoskeltal Health
Subscribe to our Newsletter and get latest publications on Musculoskeletal Health your email inbox.
Thank you for subscribing.