Introduction

Musculoskeletal problems are very common, and can be encountered in hospital emergency departments, orthopaedics, and out-patient physiotherapy (Carter & Rizzo 2007). It is not uncommon for in-patients who are admitted for another problem to be referred and treated in the ward or in the out-patient department for a musculoskeletal problem. The prevalence of specific conditions can vary between the different groups in the community. For example, sporting injuries are more likely to occur in the younger groups, whereas degenerative conditions such as osteoarthritis are more likely to occur as people progress in years.

Musculoskeletal problems can result in pain and functional limitations (disability), and represent a major burden to the society due to associated health care costs and loss of productivity (National Health Priority Action Council 2004). Musculoskeletal conditions, including arthritis, cause more disability than any other medical condition and affect one-third of all people with disability. Since part of the chronic disease burden is attributed to risk factors such as physical inactivity (Bauman 2004) people with musculoskeletal conditions are often referred to physiotherapy out-patients for management of their conditions.

As in other areas of physiotherapy practice, musculoskeletal assessment and treatment requires a systematic clinical reasoning approach (Edwards et al 2004). The clinical reasoning approach used in this chapter considers: (i) differential diagnoses based on assessment and clinical presentation; (ii) intervention based on the best evidence available; (iii) constant evaluation of therapy outcomes; (iv) adjustment of intervention programme in line with diagnosis and stage of progress; and (v) referring to or working together with other disciplines to exclude and or address confounding problems. In assessing and treating common musculoskeletal conditions and measuring progress it is important to use outcome measures that are valid and reliable, and that consideration must be given to impairments of body structure and function as well as activity limitation and participation restriction, such as ability to return to work. The World Health Organization’s International Classification of Functioning, Disability and Health (ICF) provides a useful framework for physiotherapists in out-patients to assess patient functioning (Jette 2006). Referral to or working with other disciplines may involve tests such as X-rays or dynamic ultrasound scans, or the provision of orthotics to improve biomechanics. In addition to specific techniques, treatment may require education, ergonomic advice and the instruction of a home exercise programme to improve outcomes on function and pain.

There is an emerging and increasing body of research on the effectiveness of physiotherapy that provides the clinician in out-patients with an evidence base for their practice (Herbert et al 2001). For example, there is high level evidence that therapeutic exercise can benefit clients across broad areas of physiotherapy practice (Morris & Schoo 2004, Taylor et al 2007). In prescribing exercises it can be important to know whether the exercise programme is performed correctly and adhered to by the client. Conditions such as back problems or tendinopathies may be negatively affected by incorrect activity performance. Additional problems that can affect health outcomes are incorrect belief systems and mental health problems. For instance, people with osteoarthritis may think that movement harms the joint, but by not moving they put themselves at risk of developing problems associated with physical inactivity (e.g. increased morbidity and mortality due to cardiovascular problems or falls) (Philbin et al 1996). Also, people with chronic pain may be depressed and are, therefore, less likely to be interested in performing exercises, and may benefit from counselling (e.g. motivational interviewing). Screening patients for problems such as fear-avoidance behaviour and anxiety (Andrews & Slade 2001), asking about past and current exercise performance, motivating them if needed (Friedrich et al 1998) and demonstrating the prescribed exercises can assist in determining the likelihood of correct and consistent programme performance (Friedrich et al 1996b, Schneiders et al 1998).

We have selected common musculoskeletal conditions that are likely to be encountered in hospital out-patient departments. The different cases relate to younger and older people, females as well as males. A multitude of physical tests and outcome measures have been included together with clinical reasoning and evidence-based treatment options.

CASE STUDY 1 Jaw pain

CASE STUDY 2 Headache

Subjective examination

Subject

29-year-old male working on Help Desk in Information and Computer Technology

HPC

Gradual onset of headaches and cervical pain about 3/52 ago

Cannot recall precipitating incident

Headaches becoming more frequent (now daily) and lasting longer (up to 3 hours)

Has deep ache (non-throbbing) radiating from the back of the occiput to the right frontal region. Also complaining of stiffness like pain in the right side of the cervical spine. Neck pain and headache seem related (see Figure 8.1)

FIGURE 8.1 Body chart – Case Study 2.

PMH

Car accident 10 years ago which led to cervical pain for about 3/52. No problems since apart from an occasional stiff neck

Aggravating factors

Prolonged work at the computer (if more than 2 hours brings on headache)

Reversing the car reproduces slight cervical stiffness

Easing factors

Analgesia dulls the headache

Night

Sleep undisturbed

Daily pattern

Seems to depend on how long he has spent at the computer

General health

In good health, no weight loss

No complaints of dizziness, no nausea or vomiting

Assessed as being depressed, has been taking antidepressants over the last 3/12

Investigations

No X-rays or other investigations at this stage

Attitude/expectations

At the moment headache is not affecting him a lot but wanted to get it checked out in case it is something serious

Keen not to miss any work

Intends to continue normal recreation of sail boarding this weekend

Pain and dysfunction scores

Neck Disability Index: 14% Disability

VAS level of pain when headache is most severe (after working at the computer for 2 hours) = 6

CASE STUDY 3 Neck pain – case one

Subjective examination

Subject

32-year-old male accountant

HPC

Prolonged sitting (all day) at a conference 3/52 previously

Noticed onset of left lower cervical and interscapular pain at the end of the day

On waking the next morning pain had spread to the posterior aspect of the arm and forearm as far as the middle three fingers (see Figure 8.2)

FIGURE 8.2 Body chart – Case Study 3.

Seen by doctor 1/52 ago. Doctor ordered plain X-rays including oblique views that did not show any abnormality

Has not improved at all since onset of symptoms

Medical history

High cholesterol, overweight, sedentary lifestyle

Minor neck complaints that usually settled within 2 or 3 days

Aggravating factors

Sitting for more than 10 minutes increases neck pain. More than 30 minutes increases arm pain

Looking up or to the left increases neck and arm pain

Lifting briefcase with left hand aggravates neck and interscapular pain

Easing factors

Neck pain relieved by lying supine

Arm pain relieved by lying supine with left arm above head

Night

Can sleep 2–3 hours at a time before being woken by increased neck and interscapular pain

Changing position helps to decrease the pain

Daily pattern

Increased symptoms with increased amounts of sitting, particularly if using computer

Medication

Was prescribed non-steroidal anti-inflammatory medication (Meloxicam) which helps take the edge off the neck pain

Attitude/expectations

Wants to know what the problem is, particularly as the X-rays did not show any abnormality

Feels that something might be ‘out’ in his neck. If it could be ‘put back in’ the symptoms should resolve

CASE STUDY 4 Neck pain – case two

Subjective examination

Subject

23-year-old female personal assistant

HPC

Rear end motor car accident 2/7 ago

Immediate onset of cervical pain and stiffness (left and right). Both pain and stiffness have been increasing. Pain is now constant

Vague headache started today (see Figure 8.3)

FIGURE 8.3 Body chart – Case Study 4.

Seen by doctor yesterday who organised an X-ray (no abnormality detected) and referred patient to physiotherapy

PMH

Left knee reconstruction 3 years ago with good return of function since

No past history of neck complaints

Aggravating factors

Turning head to either side, especially if movement is quick

Travelling in car – took 20 minutes to settle after 30-minute car trip

Easing factors

Supine with head supported on one pillow

Felt a bit easier under hot shower

Night

Wakes often due to discomfort

Sleeps on 3 pillows

Difficulty turning in bed due to pain

Daily pattern

Constant pain that gradually worsens during the day

General health

Taking non-prescription analgesics every 4 hours on advice of doctor. No other medications

Not seeing the doctor for any other health problems

Attitude/expectations

Anxious about prognosis

Worried about how much work she will have to miss as she only started in her current position 3/12 ago

Pain and dysfunction scores

VAS current pain at rest = 5

VAS level of pain after 30 minute car trip = 8.5

CASE STUDY 5 Thoracic pain

Subjective examination

Subject

60-year-old male lawyer

Presents with bilateral lower thoracic pain with radiation of symptoms anteriorly to the lower sternal area (see Figure 8.4)

FIGURE 8.4 Body chart – Case Study 5.

Had a similar problem 5 years previously that settled with physiotherapy which resolved after three sessions of passive mobilisation directed to the thoracic spine

HPC

Noticed onset of symptoms 4/52 previously after lifting pots while gardening. Pain initially felt in sternal area, then onset of thoracic pain over the course of the day

Pain initially intermittent, now constant at a level of VAS 2/10 at best and VAS 7/10 at worst

Medical history

Noticed 5 kg of weight loss in previous 4/52 that could not be explained by other factors

Had noticed intermittent, generalised, mild (VAS 1–2/10), aches and pains in trunk, arms and legs over the previous 3/12 that had worsened slightly over the previous 4/52

Aggravating factors

Prolonged sitting for greater than 20 minutes at work would increase posterior and anterior chest pains to VAS 6/10

Easing factors

Standing and walking for 10 minutes decreases all symptoms to VAS 2/10

Night

Wakes 3–4 times each night with increased symptoms in thoracic and sternal areas. Has to get out of bed and walk around to ease pain. Tends to notice generalised aches and pains associated with increased sweating at night

Daily pattern

Dependent on amount of sitting during the day. More thoracic and sternal pain at end of day when sitting a lot

Medication

Nil

Attitude/expectations

Expects that physiotherapy will ease symptoms as they did for a past episode of similar pain

CASE STUDY 6 Low back pain – case one

Subjective examination

Subject

44-year-old male bank manager

HPC

4/7 ago bent to reach into boot of car and felt slight backache. Thought it would settle so played golf anyway.

Next morning severe low back pain with aching pain radiating down the back of the right leg to just below the knee. Has no pins and needles or numbness (see Figure 8.5)

FIGURE 8.5 Body chart – Case Study 6.

PMH

Has had four or five episodes of low back pain over the last 8 years, usually settles quickly in 2 or 3 days

Has not required treatment with previous episodes

Aggravating factors

Finds it difficult to put shoes and socks on in the morning

After driving to work (about 40 minutes) found leg pain had worsened

Can only sit for about 15 to 20 minutes at a time at work

Has noticed that sneezing increased back and leg pain

Easing factors

Lying on back eventually relieves the leg pain

Standing and walking seem to help a little

Night

Pain gradually eases after initial discomfort

Is waking at night but finds can get back to sleep quite quickly when changes position

Daily pattern

Back stiff and aches getting out of bed first thing in the morning but eases after shower

Back pain is worse by the end of the day, and leg pain is more constant by the end of the day

General health

Taking non-steroidal anti-inflammatories (NSAIDs) with slight improvement

At recent annual review doctor advised to increase physical activity to reduce weight (BMI 26.4) and adjust diet (cholesterol 6.4). Otherwise fit and well

Attitude/expectations

Very keen not to miss club Stableford golf competition this weekend (in 3/7)

Intending to cope with work as best he can. Very busy at work so reluctant to take time off

Pain and dysfunction scores

Oswestry Disability Score: 36% Disability

VAS level of pain after 40 minute car trip: back = 8, leg = 6

Physical examination

Observation

Slight left-sided contralateral list (when observed from behind in standing shoulders are to the left relative to the hips)

Changes position regularly when in sitting position

Palpation

Increased tone, right erector spinae in the lumbar region

Central postero-anterior pressures over the lumbar spine reproduced back pain (but not leg pain) at L4 and L5

Unilateral pressures were painful on the right at L4 and L5

Movements

Active movements

Lumbar flexion in standing limited (2 cm below the knee)

Lumbar extension in standing markedly limited

Left and right rotation (assessed in sitting) both more than 60°

Attempt to correct contralateral list led to increased back pain

Repeated active movements

Flexion in standing repeated 10 times led to increased back pain and increase of leg pain

Extension in standing repeated 15 times abolished leg pain, and increased range – back pain remained

Repeated correction of contralateral list (side gliding to the right) led to reduced central back pain and slightly increased range

Neurodynamic tests

Straight leg raise: right = 70° left = 70°

Slump test not evaluated

Neurological tests (tests of nerve conduction)

Muscle strength in myotomes L3 to S1, left = right

Sensation in dermatomes L2 to S1, left = right

Reflexes (patella tendon and Achilles), brisk left = right

CASE STUDY 7 Low back pain – case two

Subjective examination

Subject

49-year-female assembly worker at automotive manufacturer

HPC

Complaining of increasing back pain over the last 14/12. Back pain is in the central low back region and radiates into both gluteal regions – no leg pain (see Figure 8.6). Has been off work for the last 6/12 with no improvement in pain

FIGURE 8.6 Body chart – Case Study 7.

Injured back when installing car upholstery 14/12 ago. Initially had 3/7 off work and experienced some slow improvement over the first 3/12

Has had manipulative physiotherapy involving manipulation, mobilisation and traction with no benefit. Also tried chiropractic without benefit

PMH

15-year history of intermittent low back pain usually no more than a few days off work

Cholecystectomy 6 years ago

Aggravating factors

Prolonged walking or standing (more than 15 minutes) increases ache

Prolonged sitting (more than 15 minutes) increases ache

Unable to do weekly shopping or housework as these activities aggravate the ache

Easing factors

Lying down but only for about 30 minutes, as gets stiff when lying in one position for too long

Night

Finds it difficult to get comfortable, wakes when turning

Not getting good-quality sleep any more

Daily pattern

Gradually worse by the end of the day

General health

Has gained weight over the last 14/12 (about 6 kg)

Assessed as being depressed, has been taking antidepressants over the last 3/12

Investigations

X-ray shows mild bilateral degeneration of the L4–5 facets

CT scan shows a minor disc bulge at L4–5 and L5–S1 with no nerve root involvement

Attitude/expectations

Has reduced activity level to avoid aggravating back

Believes that if she can find the right practitioner then they will fix her

Very concerned with the CT scan report and the diagnosis of disc pathology

Has been more short-tempered with family and friends since her back problem began

Her spouse has been very supportive and has willingly taken over tasks such as housework and shopping

Pain and dysfunction scores

Oswestry Disability Score: 72% Disability

VAS level of pain after 15 minutes of standing or sitting = 7.5

Physical examination

Observation

Exhibits pain behaviours including grimacing, and placing hand on back

Changes position regularly when sitting and standing

Walking pattern is slow and guarded

Palpation

Central palpation of the lumbar spine at L1, L2, L3, L4 and L5 painful

Unilateral pressures are painful left and right at L1, L2, L3, L4 and L5

Movements

Active movements

Lumbar flexion in standing limited (2 cm above the knee)

Lumbar extension in standing moderately limited (estimated half of expected range)

Left and right rotation (assessed in sitting) both about 40°

Neural mobility tests

Straight leg raise on right = 50° left = 50°

Able to fully extend knee in upright sitting

Slump test not evaluated

Neurological tests (tests of nerve conduction)

• Normal no abnormality detected

CASE STUDY 8 Shoulder pain

Subjective examination

Subject

47-year-old female factory worker

Right arm dominant

HPC

Right shoulder pain which started 1/52 ago when dragging a heavy item onto the conveyor belt. Routinely she has to pull, lift, and reach overhead

PMH

Low back pain episodes since work-related lifting injury

Asthma and frequent coughing

Aggravating factors

At work: Overhead work, lifting and carrying boxes

In transit: Driving car, riding a bike with wide handlebars.

At home: Preparing meals, working at the computer, knitting

Easing factors

Rest

Avoiding overhead work or holding elbows out when lifting or carrying items

Night

Wakes frequently because of pain, particularly when sleeping on the painful shoulder

Daily pattern

Constant nagging pain that worsens during activities as mentioned above (see aggravating factors)

General health

Asthma attacks. Smokes. Using bronchodilatators as needed

Attitude/expectations

Is afraid that she may need to look for another job due to experiencing increasing shoulder problems at work

Wants better duties within the factory as some of her colleagues have managed to do

Pain and dysfunction scores

VAS current pain at rest = 3

VAS usual level of pain during aggravating activity in the last week = 7

VAS worst level of pain in the last week = 9

Shoulder Pain and Disability Index (SPADI): Pain score = 60%, Disability score = 45%, Total score = 50.8% (Roach et al 1991)

CASE STUDY 9 Elbow pain

CASE STUDY 10 Hand weakness and pain

CASE STUDY 11 Groin pain

Physical examination

Observation

In standing, no obvious wasting or pelvic asymmetry

With walking, observed excessive pelvic tilting (obliquity) in the frontal plane

Palpation

Tender to palpation at tendon attaching to right medial inferior pubic ramus

Trigger point tenderness to muscle belly distal to medial inferior pubic ramus

Tender at right side of pubic symphysis

Movement

Right hip flexion = 130°, no pain = left

Right hip extension = 25°, no pain = left

Right hip abduction = 45°, pain (VAS = 3), left = 55°

Right hip internal/external rotation = left

Functional testing

Squeeze test (patient supine with hip flexed 45°, examiner places fist between patient knees, and asks patient to bilaterally adduct) reproduced right groin pain (VAS = 4)

Resisted straight-leg right hip adduction reproduced right groin pain (VAS = 4)

Right hip quadrant (passive hip flexion, adduction and internal rotation) only very slight pain, similar to discomfort when tested on the left side

Thomas test (slight restriction on right compared to left with only slight reproduction of pain (VAS = 0.5) when hip flexion resisted)

Abdominal muscle testing:

1. global muscles, only slight pain (VAS = 1) on resisted abdominal flexion

2. stabilising muscles, assessed in supine with a pressure cuff biofeedback unit placed in the small of the back. He could increase the pressure in the cuff from 40 to 43 mmHg for 3 seconds 4 times before unwanted activity from global muscles was observed

Standing on one leg (Trendelenburg test), only slight drop of pelvis observed, within normal limits (<10°)

Investigations (completed 1/52 ago)

X-ray: no abnormality detected

Bone scan: indicated some increased uptake in the right inferior pubic region

CASE STUDY 12 Hip and thigh pain

Objective examination

Standing

Visibly overweight

Wide hips, but knees are touching each other

Valgus position of knees and ankles

Pronated feet with reasonable longitudinal arches

Palpation

Although skin temperature (Tsk) around hip and along the thigh appeared normal, that of the posterior aspect of the trochanter may have been a little elevated

Tenderness of the iliotibial tract and the bony posterior aspect of the greater trochanter, with a boggy feeling around the location of the bursa (Hoppenfield 1986)

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