CHAPTER 1

Approach to the Patient With a Musculoskeletal Problem

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT

Common chief complaints in outpatient musculoskeletal (MSK) clinic

Pain

•  Nociceptive (somatic, MSK) and neuropathic pain

•  Combined: common (eg, chronic MSK pain with neuropathic components involved)

•  Nonorganic cause of pain: underrecognized

Loss of function

•  Disability: restriction or lack of ability to perform an activity (1)

•  Neurologic causes or secondary to pain (with MSK causes)

Characteristics of Pain

•  Important clues for differential diagnosis and approach to the plan

•  Many different ways available to characterize the pain

•  Systematic approach recommended to decrease missing information

P—provoke and palliate

•  Specify the etiology or contributing factors

•  Identify provoking (aggravating) or alleviating (palliating) factors

      Therapeutic implication by modifying abnormal biomechanics (provoking factors) especially in overuse injury

Q—quality (characteristics)

•  Nociceptive (MSK), neuropathic pain or mixed pattern

•  Nociceptive, neuropathic (non-nociceptive), mixed, and psychogenic

N, nerve.

•  Mixed pattern: chronic nociceptive (MSK) pain has neuropathic pain components

•  Psychosomatic pain: no typical presentation or distribution of involvement

      Complaints are more impressive than the clinical evaluation; do not be judgmental, often responsive to the treatment

R—regional (local) versus diffuse versus referred pain

•  Indentify typical pain patterns: the dermatomal pattern (root), peripheral nerve distribution, or sclerotome (frequently overlooked; Figure 1.1)

•  Regional/local pain

      Explains acute/subacute lesions of local MSK structures better

      Knowledge of the regional/surface anatomy: especially superficial structure (hand and foot) leading to localization of pathology

      Joint structures as pain generator; different structures have different pain thresholds (contribution)

OA, osteoarthritis.

FIGURE 1.1

Typical pain distribution from sclerotome, dermatome, and peripheral nerves.

Source: Adapted from Ref. (3). Werner C, Boos N. History and physical examination spinal disorders. In: Boos N, Aebi M, ed. Springer, Berlin and Heidelberg; 2008:201–225.

N, nerve/nervous.

      Periarticular soft tissue structures as pain generator: often presents with distinct localization

  Ligament (sprain, tear), bursa (bursitis), muscle/tendon (contusion, strain/tear, rarely myopathy/myositis), subcutaneous tissue (cutaneous nerve, lipoma, etc) and skin (cellulitis)

  Intra-articular structures (eg, cruciate ligament); not as distinct localization as periarticular structure

•  Referred pain

      Peripheral nerve pathologies

  Radiculopathy: radiating pain typically in dermatomal distribution (±neuropathic pain)

  Entrapment neuropathy: in peripheral nerve distribution typically

      MSK pathologies: less common (sclerotome)

  Joint pathologies (facet arthropathy, sacroiliac joint complex pathology) and muscle fascia (6) (with trigger point) can present with referred pain (7)

•  Diffuse pain

      MSK pathologies: fibromyalgia most common (MC), polymyalgia rheumatica, metabolic muscle disorders, systematic inflammatory disease (polyarthralgia), and so on

      Chronic neuropathic pathologies: central nervous system (CNS); central (thalamic) pain, neuropathic pain from spinal cord lesion, complex regional pain syndrome, and so on

•  More details are provided in Chapter 11.

S—severity

•  Often not as objective as desired

•  Useful in the follow-up (FU) of the response to treatment and deciding for initial treatment plan, many different scales available

•  Visual analogue scale (most validated, 10 cm), numeric rating scale (0–10, MC used)

      Numeric rating scale often categorized as mild (1–3), moderate (4–6), or severe (7–10) (8)

      Minimal meaningful change: 2 to 3 in numeric scale (varies depending on the condition)

•  Other scales available: patient’s global impression of change, verbal description scale, African palliative outcome scale (APCA), or pain assessment in advanced dementia scale (9) and so on

      Global impression of change: 1 (very much improved) to 7 (very much worse) (10)

      Scales for subjective improvement: 0% to 100% improvement (easier for patients to report) on FU or after intervention (procedure)

  Placebo effect varies depending on the disease and method of placebo; upto 30% (11)

T—temporal, acute, or chronic

^aImportant to recognize stressful life events, depression, and other psychiatric problems, and take history in nonjudgmental fashion.

Source: From Ref. (12). Marx JA, Hockberger RS, Walls RM, Adams J, Rosen P. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby/Elsevier; 2010.

Differential Diagnosis Based on Symptoms (13)

Different approaches

•  Based on location of pain, mechanism of injury, etiologies, and so on.

Common versus uncommon etiologies (diagnosis)

•  Initially focus on the common conditions, then less common etiology if not responsive to treatment for the common diagnosis

Serious versus nonthreatening etiologies

•  Serous etiologies: tumor, infection, progressive neurologic, systematic inflammatory arthropathy, or vascular

      Should not be missed in the differential diagnoses although it is not common or likely considering the related significance of morbidity or mortality

      Check red flags: unexplained constitutional symptoms (fever, chills, night sweats, unintentional weight loss), rapidly progressive progress, unclear mechanisms, and so on

Valid versus less valid etiologies

•  First, focus on the valid (well-accepted) causes of pain, then investigate unusual causes of the pain if you rule out the valid diagnosis explaining the presentation/pain

NEUROLOGICAL IMPAIRMENT

Weakness

Secondary to neurologic versus MSK disorder

•  Neurological disorders

      Categorized into upper (brain, spinal cord) and lower motor neuron disease

      Upper motor neuron disease: more prominent dysfunction than weakness with coordination (cortical/subcortical/extrapyramidal)

Dz, disease.

      Increased tone/spasticity/rigidity in upper motor neuron disease; can be confused with joint contracture or stiffness (can coexist)

  Often difficult to distinguish from spasticity (high grade): diagnostic motor block can be helpful

Psychogenic (functional) weakness (14)

•  Underrecognized.

      Functional weakness or functional movement disorder: ~5% of neurology patients in Scotland (15)

•  Common features

      Multiple symptoms, including pain and fatigue (very common)

      A history of other poorly explained chronic symptoms or syndromes: common

  Irritable bowel syndrome, chronic fatigue syndrome, menorrhagia, or fibromyalgia

      Mood dysfunction (depressed or anxious): common but not exclusive

      Only 20% of patients believe that stress is relevant (lower than patients with disease)

      Common panic symptoms before acute functional weakness (not exclusive)

Sensory Dysfunction

Symptoms

•  Can be divided into positive sensory symptoms (paresthesia, dysesthesia, allodynia) and negative symptoms (hypo/anesthesia)

•  Positive symptoms

      Frequently reported by patients with MSK pathologies

  Often difficult to differentiate from MSK pain (eg, chronic heel pain; Baxter’s entrapment neuropathy versus plantar fasciitis or concomitant)

      Respond better to the intervention than negative sensory symptoms (in entrapment neuropathy)

•  Negative symptoms

      Prominent in hereditary conditions (eg, hereditary sensorimotor neuropathy [Charcot Marie tooth disease]) or severe nerve injuries (complete anesthesia)

      Patient may not complain about it so much but more functional impact

  Related to impaired activities of daily living (ADL)/safety (burn), deformity (Charcot neuroarthropathy), and mobility disability (ataxic gait)

      Difficult to manage

Impaired Function

Disability

•  Umbrella term covering loss of function (self-care, ADL)/I (instrumental) ADL, work/occupation, leisure activity (hobby/sports, etc), and restriction of participation (definition from World Health Organization)

•  Traditional model: pathology impairment functional limitation physical disability (16)

•  Disability often not correlating with impairment

Differential diagnosis

•  Onset of impaired function, preceding event, progression, accompanying symptoms (significant pain or no pain), and comorbidities (diabetes, vascular risk factors, family history of neuromuscular disease, etc): important for differential diagnosis

      Onset: acute (vascular or traumatic > acute inflammatory) versus chronic (slowly progressive or overuse)

      Progression: monophasic versus stepwise or slowly progressive

      Comorbidities: elderly patients with multiple vascular risk factors (hypertension, diabetes, increased cholesterol, smoking) high risk for vascular events (eg, unrecognized stroke)

      Neurological lesions: related to self-care and mobility disability

  Subtle neurological dysfunction and nonorganic causes often underrecognized

  Fine/gross motor dysfunction, coordination, sensation, ataxia: common cause of disability

•  Common presentations

      Difficulty with dressing, showering, feeding, grooming, and instrumental ADL

  Upper extremity dysfunction (shoulder, elbow, especially hand with impaired dexterity): pain, decreased range, and weakness

  Differential diagnosis: rotator cuff tear, cervical (C5–6) radiculopathy, brachial plexopathy, muscle disease (myositis [poly or dermatomyositis] or polymyalgia rheumatica), and so on

      Difficulty with toileting, bathing, and tub transfer: lower extremity dysfunction (hip, knee, and ankle), upper extremity dysfunction and neurological diseases

      Difficulty negotiating stairs and standing from sitting

  Proximal (hip/gluteal/thigh) muscle weakness and pain: hip and knee joint pathologies, tendon/bursal pathologies (painful range/blocking with disuse atrophy)

  Differential diagnosis: lumbar plexopathy/radiculopathy, or muscle disorder (myopathy, polymyalgia rheumatica, etc)

      Gait dysfunction: check biomechanics section

      Fall

  Joint instability: ligament/tendon/muscle pathologies (massive tear/avulsion pain inhibited, instability, weakness), joint pathologies (synovitis/effusion, etc pain, stiffness, contracture/adhesion)

  Knee buckling or “giving out”: lumbar radiculopathy, plexopathy, myopathy, and so on, in addition to knee pain and instability

  Foot drop/slap: L4–5 radiculopathy, peroneal/sciatic neuropathy, myopathy, tendon rupture, stroke (spasticity, with vascular risk factors) and other neuromuscular disorders, and so on

  Ataxia: especially recurrent falls; more common; central (especially in recurrent) or peripheral

  Others: syncope, cardiac, and CNS lesions

      Sphincter control (bladder and bowel) dysfunction

  Peripheral nerve (autonomic dysfunction), lumbosacral (LS) radiculopathy (cauda equina syndrome), spinal cord lesion (including conus medullaris), or medication induced and other neurological dysfunction

•  Evaluation and FU regarding the progression of impaired function: important for treatment/rehabilitation plan

      Scales available: Disability of the Arm, Shoulder, and Hand (DASH), Oswestry low back disability scale, Western Ontario and McMaster Universities Osteoarthritis Scales (WOMAC) for knee and hip osteoarthritis (OA), American Orthopaedic (AO) foot and ankle surgery scale, and so on, based on the anatomical region

      Can integrate the functional activities into the therapy program and for FU of response to treatment

OTHER HISTORY

Flowchart 1.1

•  Obtain historical information that can help in differential diagnosis

FLOWCHART 1.1

Etiology of musculoskeletal disorder.

MSK, musculoskeletal.

Source: From Ref. (1). Harper JD. Determining foot and ankle impairments by the AMA fifth edition guides. Foot Ankle Clin. 2002;7(2):291–303.

Relevant histories for MSK disorders (17,18)

MSK, musculoskeletal.

Common MSK Disorders Related to Specific Sport/Recreational Activity (21)

AC, acromioclavicular; Dx, diagnosis; F, female; Fx, fracture; M, male; MC, most common.

Relationship between OA and sports/recreational activity

•  Intensity and duration of exposure: a risk factor for hip and knee OA in high level athletes

•  The risk of OA associated with sport: lesser than that associated with a history of trauma and overweight

•  Joint trauma is a greater risk factor than the practice of sport

•  No firm conclusion about the possible protective role of sports, such as cycling, swimming, or golf

Common Sports-Related Peripheral Nerve Lesions (23)

Occupational Risk for MSK Pain (24)

Job title: higher incidence in strenuous and manually intensive work tasks

Physical load (ergonomic stressor): forceful activity, higher repetition, and awkward posture

•  The precise nature of biomechanical stresses leading to OA remains unclear

•  High loads on the joint, unnatural body position, heavy lifting, climbing, and jumping may contribute to knee and hip OA

Psychosocial factors: low social support at work, and low job control. Less job satisfaction and depressive symptoms. Patients receiving worker’s compensation with chronic low back pain have longer length of time to return to work (25).

PAST MEDICAL HISTORY (LIMITED TO MSK PROBLEMS)

Systemic Conditions

•  Local pain/presentation can be presentation of systematic conditions, referred pain (from neighboring body part), or regional MSK conditions

•  Systematic conditions (rheumatologic, tumor, infection, vascular, inflammatory, etc): review involvement of other joint and other system (neurologic, hematologic, dermatologic, and others)

      For example, rheumatoid disease or inflammatory disease: frequent involvement of multiple joints

•  Diabetes mellitus (DM): adhesive capsulitis, peripheral neuropathy (length-dependent, dying-back phenomenon: MC pattern) and diabetic amyotrophy (radiculoplexus neuropathy), entrapment neuropathy (more common), Charcot neuroarthropathy (in foot)

•  Cardiovascular history/stroke: shoulder–hand syndrome (complex regional pain syndrome) and immobility-related conditions (tight iliopsoas, tight hamstring, tight gastrocnemius, etc)

History of cancer

•  Metastatic lesion to bone (spine, femur, and others) and paraneoplastic syndrome (sensory neuropathy, neuronopathy, neuromuscular dysfunction, etc), chemotherapy-related problem, or radiation plexopathy

•  Timely (urgent) work up if red flags exist or systematic treatment required

History of pediatric MSK issues

•  OA: for example, hip OA with past medical history of (H/O) hip dysplasia and slipped femoral epiphysis for early onset hip OA

•  Tendinopathy with H/O enthesopathy (eg, patellar tendinopathy with H/O Osgood–Schlatter disease, Achilles tendinopathy with h/o Sever’s disease)

•  Tardy ulnar nerve palsy with H/O elbow fracture/dislocation during childhood

History of trauma or injury

•  Late sequels related to fracture/dislocation: posttraumatic arthritis (especially in arthritis resilient joints, such as ulnar-trochlear (elbow) or ankle joint), local nerve irritation (radial neuropathy in humeral shaft fracture or tardy ulnar nerve palsy after elbow fracture), or underrecognized compartment syndrome

•  Secondary MSK condition related to iatrogenic nerve injury

      For example, accessory nerve injury with scapular depressed and protracted scapula with myofascial pain syndrome, shoulder impingement syndrome

REVIEW OF SYSTEMS

Constitutional

•  Weight loss, night sweat, fever: red flags for cancer, infection, and other systematic disease

CNS

•  Headache (cervicogenic; chronic neck pain or Chiari malformation in the context of spinal malformation)

Head, ears, eyes, nose, and throat (HEENT)

•  Vision (uveitis; inflammatory arthropathy—rheumatoid arthritis, ankylosing spondylosis, psoriasis, etc.; or visual disturbance—optic neuritis in multiple sclerosis)

•  Dry mouth (Sjögren, small fiber neuropathy), and others

Respiratory and cardiovascular

•  Chest discomfort/tightness, cough, shortness of breath: shoulder/scapular girdle pain from cardiac/pleural pathologies or myofascial pain syndrome (after cardiac/pleural pathologies ruled out)

•  Claudication in the leg and nonspecific abdominal pain: aortic or arterial disease especially with smoking or family history

Gastrointestinal (GI) and renal

•  Diarrhea (inflammatory bowel disease: often related to inflammatory arthropathy), medication (Metronidazole: sensory neuropathy)

•  Gastritis/ulcer: in nonsteroidal anti inflammatory drug (NSAID) users (or contraindication for NSAID)

•  Abdominal pain (upper): rarely referred pain from thoracic (or thoracolumbar) spine pathologies

•  Dysuria, frequency (urinary tract infection), can mimic the lower back pain, an etiology of vertebral osteomyelitis

•  Renal insufficiency: contraindication for NSAIDs or adjust the dose of the medication

Bowel/bladder dysfunction/saddle anesthesia

•  Cauda equina (especially in patients with chronic low back pain) or conus medullaris syndrome

•  Pain medication (opioid): more common cause of incontinence (from constipation/fecal impaction)

•  Unless specifically asked, can be missed

•  Must be evaluated in chronic low back pain, severe back pain (large disc herniation), or any red flags

Skin

•  Psoriasis or dry skin (Sjögren’s disease) related to arthropathy or small fiber neuropathy

OTHER MSK SYMPTOMS

Joint and Limb Swelling

•  Acute-subacute onset

      Joint effusion (immediate onset hemarthrosis: associated with intra-articular injury, synovitis, OA flare up) versus periarthrial swelling: focal, bursal effusion or tenosynovitis (26)

•  Chronic: often confused with bone osteophyte or deformity and rarely bony tumor

Unilateral limb swelling (27)

•  Acute: deep vein thrombosis, ruptured Baker cyst, compartment syndrome, cellulites

•  Chronic:

      Venous insufficiency (MC cause): common with varicosities, hyperpigmentation from hemosiderin deposits

      Reflex sympathetic dystrophy: rarely bilateral (BL)

      Pelvic tumor, lymphoma (external pressure on veins), abdominal tumor or radiation; subacute, can be BL

      Secondary lymphedema (tumor, surgery, infection), congenital venous malformations

      May–Thurner syndrome (iliac vein compression syndrome)

      Arterial entrapment syndrome

BL limb swelling

•  Subcutaneous/skin

      Pitting or nonpitting edema

  Lymphedema: typically painless (secondary: tumor, radiation, infection, filariasis), nonpitting

  Chronic venous insufficiency: pitting ± low-grade pain

      Classification based on etiology

  Idiopathic (adolescent, female <50 years, no signs of systemic or venous insufficiency): cyclic edema (premenstrual), pregnancy related (preeclampsia)

  Medication (common secondary cause): calcium channel blocker/others anti hypertension medications (HTN meds), prednisone/hormone, NSAID, gabapentin, Lyrica, and others

  Systematic: heart (heart failure, restrictive cardiomyopathy, pericarditis), pulmonary hypertension (sleep apnea: underrecognized, >45 years), liver/GI (protein losing enteropathy) and kidney (nephrotic syndrome, glomerulonephritis), beri beri (vitamin B1 deficiency), and so on

•  Muscle edema

      Myopathy (28), diabetic muscle infarct (29,30), and myxedema (hypothyroidism)

      Mimicker

  Muscle tear with retraction; tendon rupture in the wrist (31), and medial gastrocnemius rupture in the calf

  Tenosynovitis (eg, extensor tendon in the wrist): inflammatory arthropathy

Joint Stiffness and Contracture (32)

Snapping (33)

•  Differential diagnosis

•  Calcification on the muscle and bursa: calcific tendinopathy or bursitis over bony prominence

      Subcoracoid bursopathy under the coracoid process

      Rectus femoris calcific tendinopathy (near the origin at anterior inferior iliac spine or reflected head to acetabulum)

•  Periarticular soft tissue over the joint: labral tears, intra-articular loose bodies, indirect head of the rectus femoris rubbing with hip joint capsule

•  Tendon over benign bony tumor: chondral or osteochondral lesion; osteochondroma

Mechanical Locking of Joint

•  Common causes: ectopic materials interposed between the articular surfaces

•  Loose body

•  Chondral or osteochondral fragments

•  Torn meniscus, ligament or rarely tendon swelling (the long head of biceps) or torn tendon

PHYSICAL EXAMINATION

Inspection

Gait and posture

•  Quickly evaluate as the patient walks in

•  Visually examine the location of interest

Standing posture

•  Frontal plane (from the front or back): pelvic obliquity, asymmetric skin fold (in frontal plane, observation from the back) for scoliosis, knee (genu varum/valgum/recurvatum), hindfoot (calcaneus) eversion/inversion, and forefoot abduction/adduction

•  Sagittal plane (observation from the side): lumbar/cervical lordosis and thoracic kyphosis. Knee (genu recurvatum) and patellar location from tibial tuberosity (patellar alta or baja)

Sitting posture

•  Head posture (anterior tilted head or dropped head), cervical spine (kyphosis or straight in sagittal plane), and scapular posture (protracted, symmetric), and so on

•  Coronal balance in scoliosis (difference from standing posture) can be evaluated

Inspection of individual part (head to toe)

•  See individual chapters

•  Quick limb and joint inspection for atrophy, masses, edema/fullness, scars/wounds, involuntary movement (tremor, myokymia, or fasciculation, etc), erythema, and so on

•  Periarticular swelling

      Focal (part of joint, often superficial structure like bursal effusion) versus general (joint effusion)

      Often difficult to recognize in obese person

Palpation

Area of Maximal Pain/Tenderness

•  Ask the patient to indicate; if unable, try to palpate locations for common pathologies or specific pathologies suggested by history followed by systemic palpation

•  Be aware of bony landmark (surface anatomy in individual chapter) then palpate and describe based on the bony landmark (more consistent)

•  Try to be consistent in the pressure of palpation

      May provide rough idea of severity (or nonorganic: less or no pain on the same amount of palpation on the same location after distraction; may indicate psychological component involvement)

•  Soft tissue: tenderness, spasm, guarding, trigger point (with referred pain) or tone

•  Joint: swelling/edema, warmth, masses, crepitus, snapping, or mechanical locking

Vascular

•  Pulse examination; often misleading; a low reliability

•  If suspicious of vascular compromise, consider objective tests

Palpation of cutaneous nerve

•  Particularly useful on the dorsum of the hand and foot in the lean person

•  In suspected focal nerve entrapment syndrome, palpation can reproduce pain with radiation proximally or distally (Valleix’s phenomenon, Tinel sign) ± sensory symptoms

•  For example, superficial radial nerve, dorsal ulnar cutaneous and superficial peroneal, or saphenous nerves palpable: useful for nerve conduction study (NCS)

Range of Motion

Difference exists between the normal and functional range of motion (ROM) (less than normal ROM)

•  Impaired range required for ADLs can cause increased energy expenditure or compensation from other joints in the proximity

Clinical evaluation

•  Goniometer using consistent surface landmark and test positions (increased reliability). Check the joint in the plane of movement. Compare it with the opposite side

•  0° defined as anatomic position

•  Normal range of movement: check individual chapter

Variations

•  Based on age, gender, conditioning, obesity, and genetics; generally more flexible in younger than in older population and occurs more in females than in males

Limited range in the neighboring joint

•  Can be underlying culprit/contributing factor for the pathology (especially overuse syndrome)

•  Limitation of wrist joint can be contributing factor for elbow overuse syndrome

Spasticity versus contracture

•  Range the joint passively at very low speed additional ROM is achieved in spasticity versus no difference in contracture

      Frequently both components exist

•  Nerve block can give a further diagnostic value for high-grade spasticity from joint contracture

Common muscle tightness in patients with MSK problems

•  Scapular protractor tightness (round shoulder) in shoulder pain: pectoralis major, minor, and subscapularis muscles

      Distance between midline to medial scapular border: rough idea of progress in FU or dynamic evaluation to ask patient retract, evaluate the distance from resting to contracted position

•  Scapular girdle muscle tightness: trapezius (lateral neck flexion), levator scapular (flex the neck toward axilla), and latissimus dorsi/teres major muscles (internal rotator, adductor and extensor), and so on

•  Glenohumeral internal rotator tightness: evaluation by sidearm external rotation (with the elbow on the trunk)

•  Hip flexor (iliopsoas, and rectus femoris) affecting anterior tilting of the pelvis (therefore increase lumbar lordosis): Ely test

•  Hip extensor (hamstring muscle) tightness: loss of lordosis; flat back affecting sagittal balance (stooped posture): popliteal angle for hamstring tightness

•  Hip external rotator tightness (tight piriformis, gluteus medius) affecting buttock pain, hip external rotation (promoting pronation response on standing/walking): check side-to-side difference

•  Hip abductor (Ober test) and adductor tightness

      Hip adductor tightness: causing pain in the medial knee (adductor tubercle) as well as groin pain with hip abduction (FABER position)

•  Ankle plantar flexor: gastrocnemius (two joint muscle) tighter than soleus

      Due to subtalar, midtarsal joint compensation, the deficit underrecognized commonly

      To check ankle tightness, subtalar/midtarsal joint movement should be minimal. Subtalar neutral or slight hindfoot inversion (lock subtalar and midtarsal joint) while dorsiflexing the ankle joint

      Silfverskiold test for gastrocnemius tightness (34)

Check the details of the examination in individual chapters.

Generalized ligament laxity

•  Beighton score (Figure 1.2)

FIGURE 1.2

The Beighton score for generalized ligament laxity.

MCP, metacarpophalangeal.

      Fifth finger dorsiflexion, thumb to the forearm, elbow hyperextension, knee hyperextension (one for each limb), palm rest on the floor (1)

      Positive if greater than or equal to 4/9

      The Brighton criteria (major) for joint hypermobility syndrome

  Joint pain >3 months in ≥4 joints and Beighton score ≥4/9

PROVOCATIVE TEST

•  Special test may not be specific for one pathology

•  Often positive for multiple different pathologies (low specificity); therefore, needs some precautions for interpretation

General principles

•  Helpful to understand underlying mechanisms

      Shoulder impingement test: for example, Hawkins Kennedy tests: bursa or rotator cuff tendon impingement between greater tuberosity and coracoid-acromial arch by abduction and internal rotation of humerus (by engaging greater tuberosity under the coracoacromial arch)

      Ankle impingement: impingement of the soft tissue between the tibia and talus or calcaneus

  Aggravation of pain of anterior impingement by dorsiflexion and posterior impingement by plantarflexion

  Therapeutic implication

           –  Avoid dorsiflexion in anterior impingement (heel lift), plantarflexion in posterior impingement (avoid provoking activity: toe walking, eg, Ballet dancer and wearing high heels)

•  Be proficient in three to four special tests in common pathologies for time efficiency

Sensitivity and specificity

•  Predictive value varies from study to study

•  Be aware of different study population, slightly different techniques (with modification) and definition of the test and different gold standards

•  Typically, multiple positive tests may provide higher predictive value and specificity

Specific tests: See in the individual chapter

Focused Neurological Examination

Sensory examination

•  To find the pattern of abnormality

      Peripheral nerve (individual or multiple) distribution

      Root/plexus distribution: different peripheral nerve of same root or plexus

  Plexus lesion: often patch involvement

  Root: dermatomal distribution

      Spinal cord (distal to the level of injury with variation of involvement depending on the location and sensory modality) or brain (contralateral side typically)

•  Test different sensory modalities for the nerve fiber of the different size

      Smaller fiber: pins/needle/temperature, lateral spinothalamic tract in the spinal cord

      Larger fiber: proprioception and vibration, posterior column in spinal cord

      Clinical implications

  Entrapment neuropathy: large fiber usually first involved

           –  Two-point discrimination often used before and after the peripheral nerve procedure. Different threshold for normal; palm: 10 mm, foot: 20 mm)

  Smaller fiber neuropathy can spare larger fiber (usually assessed by NCS and needle electrodiagnosis [EMG]; therefore normal in isolated small fiber neuropathy)

•  Occasionally, patient’s interpretation is different from the objective examination: hyperesthesia in ipsilateral side may indicate decreased sensation in the opposite side

      Often challenging to interpret

Motor examination

•  First, differentiate pain inhibited (usually mild in the area of MSK pathologies) versus true muscle weakness

•  True muscle weakness: follows patterns of neuromuscular abnormality similar to sensory examination

      Upper motor neuron syndrome (hemi, di, quadriparesis/plegia), peripheral nerve (root, peripheral nerve), neuromuscular junction (diurnal variation, fatigue), or muscle (commonly proximal and symmetric but can be distal)

•  Evaluate key myotomes

      Most muscles innervated by multiple roots; therefore, single-level radiculopathy often causes mild/subtle weakness

•  Localize the peripheral nerve lesion: root versus peripheral nerve (root lesion; multiple peripheral nerve of same root and not length dependent)

      Example: mild weakness in ankle dorsiflexion (often presenting as foot slapping)

  Differential diagnoses: distal peripheral neuropathy (eg, diabetic peripheral neuro­pathy), peroneal neuropathy, compartment syndrome, lumbar plexopathy or L5 radiculo­pathy, motor neuron disease, upper motor neuron disease (stroke)

           –  If hip abductor (gluteus muscle, tensor fascia lata) is also weak, then differential diagnosis narrowed down to proximal lesion (plexopathy, L5 radiculopathy, and motor neuron disease, etc)

•  Pain-inhibited weakness typically shows less severe weakness than neuromuscular dysfunction

      Quicker response to the treatment: pain relief can improve weakness dramatically but takes longer to improve subtle weakness (or disuse atrophy)

DTR, deep tendon reflex; Dz, disease; N, nerve; ROM, range of motion.

Functional weakness (35)

•  Hoover’s sign

      With the patient seated, weakness of hip extension returns to normal with contralateral hip flexion against resistance

•  Dragging gait: patients with acute functional weakness may drag their whole leg behind them with the hip externally or internally rotated (unlike patients with hemiparesis who tend to swing or circumduct their legs)

Deep tendon reflex

•  Grading

      0: absent, 1: trace or only with facilitation/reinforcement; 2: normal; 3: brisk; 4: sustained clonus (other scales available)

•  Facilitation/reinforcement

      Jendrassik maneuver for knee or ankle jerk: The patient’s fingers of each hand are hooked together so each arm can forcefully pull against the other. Pull for a second before tapping

      Priming: slight ankle plantarflexion (touch the examiner’s hand on neutral ankle dorsiflexion) before tapping

•  Asymmetric pattern (decreased DTR) often helpful in localizing the specific root lesion. However, MSK injury to the muscle/tendon can also compromise the reflex.

•  Difficult to obtain in some patients (in obese or big persons)

      Needs good hammer (with some weight and soft rubber)

      Palpation of muscle/tendon contraction also useful for grading

Upper motor neuron signs

•  Hoffman reflex: may be more sensitive than Babinski sign for cervical myelopathy (36)

•  Can be used in peripheral nerve disorder

      Presence of Babinski in patient with difficulty dorsiflexing ankle indicates intact peroneal nerve, extensor hallucis longus muscle (in addition to presence of upper motor neuron disease)

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