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 nonarticular in origin
- Inflammatory or noninflammatory in nature
- Acute or chronic
- Localized, widespread, or systemic
Many musculoskeletal disorders resemble each other at the outset, and some take weeks to months to evolve into a readily recognizable diagnostic entity. Therefore it may always be not possible to fix the diagnosis in the first meeting.
Articular or nonarticular origin of the symptoms should be determined. For example, pain in the knee can result from conditions involving different articular structures [like synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule, and juxta-articular bone etc] or nonarticular (or periarticular) structures [extraaricular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin] may be involved.
The presenting symptoms could overlap but evaluation can differentiate.
Articular disorders have articular tenderness and other physical findings located in joint structures. There would be a pain on active as well as passive joint motion.
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.
Inflammatory disorders are those which involve an ongoing inflammation and reparative process.
The inflammatory cause may be an infection, crystal-induced (gout, pseudogout), immune-related [rheumatoid arthritis, 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.
Morning stiffness related to inflammatory disorders is precipitated by prolonged rest and lasts for more than hour and may improve with activity.
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 prior 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.
Acute and chronic conditions can be determined by the duration of symptoms.
Localized or widespread symptoms can be differentiated by the number of the regions involved.
History
History and clinical examination of the patient help the physician to identify the nature of the problem and narrow down the possibilities of differential diagnoses.
Apart from presenting complaint, duration of symptoms and the progression of symptoms many other parameters are important in clinical evaluation.
Age
Certain diagnoses 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.
Sex
Some diseases are more common in a particular gender or race.
For example, gout and the spondyloarthropathies like ankylosing spondylitis are more common in men, whereas rheumatoid arthritis and fibromyalgia are more common in women.
Race
Polymyalgia rheumatica, giant cell arteritis, and Wegener’s granulomatosis preferentially affect whites, whereas sarcoidosis and systemic lupus erythematosus are more common in blacks.
Family History
Familial aggregation occurs in some disorders, such as ankylosing spondylitis, gout, RA, and Heberden’s nodes of osteoarthritis.
Onset and Duration
The onset of disorders such as septic arthritis and gout tends to be abrupt, whereas osteoarthritis, rheumatoid arthritis, and fibromyalgia may develop more insidiously.
Involvement
Whether the disease is localized to one site or involves multiple sites.
Articular disorders are classified as monoarticular (one joint involved), oligoarticular (two to three joints involved), or polyarticular (more than three joints involved).
Nonarticular disorders can be classified as either focal or widespread. In some cases such as fibrous dysplasia, the condition if involves single bone is called mono-ostatic and if multiple, poly-ostotic.
Past History
Precipitating events, such as trauma, drug administration, or antecedent or intercurrent illnesses should be looked for and identified.
A thorough rheumatic review of systems may disclose associated features outside the musculoskeletal system and provide useful diagnostic information.
Physical Examination
Physical examination ascertains the structures involved, verify the nature of pathology, assess the extent and function of the part involved.
The physical examination consists mainly of
- Inspection – looking at the problem without touching the patient
- Palpation– Feel the problem, correlate and add upon the findings
- Movements– To note any loss of movement in the involved or neighboring joint.
- Measurements-To look for any lengthening or shortening in case of limb involvement.
- Special Tests and Maneuvers depending upon the area involved.
In extremities, a comparison to the opposite uninvolvled side helps to gauge better in cases of unilateral involvement.
Inspection looks at the swelling, skin changes, wound if present, any deformity, muscle wasting etc. Limb position may indicate the underlying diagnosis [as in dislocations] . In lower limb and back complaints, gait examination is important.
Palpation would feel the swelling, warmth, elicit, tenderness, paplpable landmarks and their relation, evaluate the neighboring structures, evalaute the deformity and compares with opposite side if possible. Exact sequence would depend on the region involved.
Active and passive range of motion should be assessed in all planes and compared with the 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 lateral deviation or bending).
Measurements are extrmely important in lower limb affections as limb length discrepancies needs to be addressed.
Special tests and maneuvers vary with the region. For example impingement test in shoulder and Mcmurray test in knee.
Further Work-Up
X-rays and lab tests are mcommon investigations
Routine investigations include
- Complete blood count including a white blood cell and differential count,
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
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 antistreptolysin O (ASO) titer should be carried out only when there is substantive clinical evidence.
Aspiration and analysis of synovial fluid is always indicated in acute monoarthritis or when an infectious or crystal-induced arthropathy is suspected.
X-rays of the region are done with at least two perpendicular view, mostly AP and lateral.
