Musculoskeletal History and Physical Examination
Stephen A. Paget
Charles N. Cornell
John F. Beary III
The musculoskeletal or locomotor system, like other body systems, can be defined anatomically and assessed functionally. Lower extremities support the weight of the body and allow ambulation. They require proper alignment and stability. Upper extremities reach, grasp, and hold, thereby allowing self-care, feeding, and work. They require mobility and strength. Diseases and disorders of the musculoskeletal system disturb anatomy and interfere with function.
MUSCULOSKELETAL HISTORYA careful history is the most important and powerful of the information-gathering procedures used to define a patient’s problems. In most musculoskeletal disorders, 80% of the diagnosis comes from this part of the clinical evaluation. The history of patients with rheumatic complaints should include the following: (a) reason for consultation and duration of complaints; (b) present medical care and medications; (c) chronologic review of present illness with emphasis on the locomotor system, consequences of time and disease, and present functional assessment; (d) past history—medical, surgical, and of trauma; (e) social history, emotional and work impact of the disorder, and environmental and work site factors; (f) family history, especially as it relates to the musculoskeletal system; and (g) review of systems. These queries cover the spectrum of rheumatic complaints: pain, stiffness, joint swelling, lack of mobility, physical handicap, and fear of future disability and handicap. The interviewer should be flexible and tactful and should avoid interrupting the patient with too many questions and merely guiding the flow of information. The objective of the interview is to define the patient’s complaints and to identify patterns of disease and areas of musculoskeletal involvement that can be further scrutinized on physical examination.
I. CHIEF COMPLAINT
Note duration.
II. PRIMARY PHYSICIAN
III. HISTORY OF RHEUMATIC DISEASES
Determine the mode of onset, inciting events, duration, and pattern and progression of the musculoskeletal complaints.
Acute onset is consistent with infectious, crystal-induced, or traumatic origin. It can also occur in the setting of a connective tissue disorder. Chronic complaints are seen with rheumatoid arthritis (RA), spondyloarthropathies, and osteoarthritis, or the chronic sequelae of traumatic or degenerative back problems.
The pattern of joint involvement is very important in defining the type of joint disorder. Symmetric polyarthritis of the small joints of the hands and feet is characteristic of RA, whereas asymmetric involvement of the large joints of the lower extremities is most typical of spondyloarthropathies. A migratory pattern of joint inflammation is seen in rheumatic fever and disseminated gonococcemia. A monarticular arthritis is consistent with osteoarthritis, infectious arthritis, crystal-induced synovitis, or one of the spondyloarthropathies (e.g., psoriatic arthritis, reactive arthritis). An intermittent joint inflammation of the knee with remissions and exacerbations is typical of the tertiary phase of Lyme disease.
Location, pain characteristics, and associated findings may all be important keys to the diagnosis. First, metatarsophalangeal joint inflammation of an acute and severe type is quite characteristic of gouty arthritis. Sudden onset of low back pain in the setting of lifting or bending with associated pain radiating down the lateral leg is a common presentation for a disk herniation with sciatica.
Pain in the superolateral shoulder or upper arm occurring in the setting of playing tennis or painting a ceiling is typical of supraspinatus tendinitis or impingement syndrome.
Record the severity of disease, as revealed by a chronologic review of the following:
Ability to work during months or years.
Need for hospitalization or home confinement.
When applicable, ability to do household chores.
Activities of daily living and personal care.
Landmarks or significant functional change, such as retirement from work, need for household help, assistance for personal care, and the use of a cane, crutches, or a wheelchair.
Assess current functional ability. This can be done in a question-and-answer format and quantified with the use of functional instruments such as the Health Assessment Questionnaire (HAQ) or the Arthritis Impact Measurement Scale (AIMS2), or functional ability can be measured with the use of a visual analog scale (0 representing no impact on function and 10 being the worst possible limitation in function).
At home: independence or reliance on help from family members and others.
At work: transportation and job requirements and limitations. Have the patient collect an hour-by-hour log of work activities, with an attempt to define actions that may cause or exacerbate musculoskeletal problems.
At recreational and social activities: limitations and extent to which patient is house-bound.
Review of a typical 24-hour period, with focus on abilities to transfer, ambulate, and perform personal care.
Obtain an overview of management for rheumatic disease.
Medications used in the past, with emphasis on dosages, duration of treatments, efficacy response, and possible adverse reactions. Record the present drug regimen and how well the patient complies with it, and also the patient’s understanding of the reasons for and potential complications of the medication.
Instruction in and compliance with a therapeutic exercise program.
Surgical procedures on joints, including benefits and liabilities. Record the name of the surgeon, date of the surgery, and the hospital. Operative pathology reports may be helpful.
Determine the patient’s understanding of the disease, therapeutic goals, and expectations.
Record psychosocial consequences of disease.
Anxiety, depression, insomnia. Obtain information about psychological/ psychiatric intervention and a listing of psychotropic medications.
Economic impact of handicap and present means of support.
Family inter-relationships.
Use of community resources.
IV. PAST HISTORY
Follow traditional lines of questioning, with attention to trauma and joint operations. Also question the patient about those specific medical disorders that could have a significant impact on, or association with, the joint disorder.
Specific associations include psoriasis with psoriatic arthritis; ulcerative colitis or Crohn’s disease with inflammatory disease of the spine or peripheral or sacroiliac joints; diabetes with neuropathic or septic joints, or osteomyelitis; hemochromatosis with severe osteoarthritis; endocrinopathies such as hypothyroidism with carpal tunnel syndrome or myopathy, hyperparathyroidism with pseudogout, and acromegaly with severe osteoarthritis. A complete medication list of the patient is essential, as well as an inquiry into prior medications. In this context, think about agents associated with drug-induced lupus, Raynaud’s phenomenon associated with the use of β-blockers eosinophilia-myalgia syndrome associated with L-tryptophan, or myositis associated with the use of “statin” drugs for hypercholesterolemia.
V. SOCIAL HISTORY
The physician must consider the following associations between the social history and types of musculoskeletal disorders:
Work activities, including the possibility of joint or back trauma, exposure to toxins, or overuse syndromes. Specific examples include low-back syndromes, exposure to vinyl chloride leading to scleroderma-type skin changes, and carpal tunnel syndrome resulting from typing at a computer terminal.
Sexual history, including sexual preference, sexual promiscuity, and the most recent sexual experience. Musculoskeletal disorders related to acquired immunodeficiency syndrome (AIDS) and venereal disorders such as gonococcal disease should be considered.
Living site and conditions, including overcrowding (e.g., rheumatic fever), living in an area where Lyme disease is endemic, or a recent or distant history of tick bite.
Emotional or physical stress, which could have an impact on the development or exacerbation of musculoskeletal disorders.
The presence of medical problems within the family, including infectious disorders in children (e.g., fifth disease caused by parvovirus B19, rubella) and adults (e.g., hepatitis B and C, Lyme disease, tuberculosis).
Recent travel, with specific emphasis on the development of dysentery caused by Salmonella or Shigella (e.g., reactive arthritis), or travel to an area where Lyme disease is endemic.
VI. FAMILY HISTORY
Inquiry about arthritis and rheumatic disease in parents and siblings may elicit vague and unreliable statements, but they are nonetheless important. The presence of severely handicapped relatives with RA or other severe rheumatic disease might result in a significant psychological impact on the patient and should be brought out in the interview. Such information may also be important in relation to the genetic background of arthritis in the family. The physician should inquire about the following musculoskeletal disorders, which clearly have a tendency to run in families: gout and uric acid kidney stones; RA and other connective tissue disorders; ankylosing spondylitis and other spondyloarthropathies; osteoarthritis, especially nodal disease in the fingers; and classic, heritable connective tissue disorders, such as Marfan’s syndrome.
VII. REVIEW OF SYSTEMS
Emphasize diseases and systemic disorders related to rheumatic complaints and diseases of connective tissue. Especially inquire about eye disease (iritis, uveitis, conjunctivitis, dryness), mouth disorders (dryness, mouth sores, tightness), gastrointestinal problems (problems with swallowing, reflux symptoms, abdominal pain, diarrhea with or without blood, constipation), genitourinary complaints (including dysuria, urethral discharge, hematuria), and skin disorders (rash with or without sun sensitivity, nodules, ulcers, Raynaud’s phenomenon, ischemic
changes). The presence of constitutional symptoms is also important, including complaints of weight loss, fatigue, fever, chills, night sweats, and weakness.
changes). The presence of constitutional symptoms is also important, including complaints of weight loss, fatigue, fever, chills, night sweats, and weakness.
PHYSICAL EXAMINATION WITH EMPHASIS ON RHEUMATIC DISEASESFive aspects of the physical examination that should be recorded are (a) gait, (b) spine, (c) muscles, (d) upper extremities, and (e) lower extremities. The patient should be properly attired in a short gown, open at the back to allow examination of the entire spine. Examination should be methodic and start with observation of the patient’s attitude, comfort levels, ease of undressing, method of rising from a chair and sitting down, and apparent state of nutrition. The patient is examined while standing, sitting, and supine. The examiner should rely mainly on inspection. When using palpation and manipulation, the examiner should be gentle and forewarn the patient of potentially painful maneuvers.
I. GAIT
Describe the gait, and note a limp or use of a cane or crutches. The normal gait is divided into the phases of stance (60%) and swing (40%). Clinically important gaits include the following:
Antalgic gait, characterized by a short stance phase on the painful side.
Short-leg gait, with signs of pelvic obliquity and flexion deformity of the opposite knee.
Coxalgic gait, an antalgic gait with a lurch toward the painful hip.
Metatarsalgic gait, in which the patient tries to avoid weight bearing on the forefoot.
II. STANDING POSITION
Examining front and back, note posture (cervical lordosis, scoliosis, dorsal kyphosis, lumbar lordosis). Check if the pelvis is level by putting one finger on each iliac crest and noting asymmetry. Pelvic obliquity suggests unequal leg lengths. Note also if a tilt of the trunk to one side is present.
Examine alignment of the lower extremities for flexion deformity of the knees, genu varum (bowlegs), or genu valgum (knock-knees).
Observe position of the ankles and feet (varus or valgus heels, flat feet, inversion or eversion of feet).
Check back motion on forward bending (with rounding of the normal thoracolumbar spine), lateral flexion to each side, and hyperextension. The extent of overall spinal flexion can be assessed with a metal tape measure. One end of the tape is placed at the C7 spinous process, and the other end is placed at S1 with the patient standing erect. The patient is then asked to bend forward, flexing the spine maximally. The measuring tape will reveal an increase of 10 cm with normal spine flexion; 7.5 cm of the total increase results from lumbar spine (measured from spinous process T12–S1) mobility in normal adults. The lumbar spine motion can be assessed by the Schober’s test in an erect patient, wherein the examiner makes an ink mark at the lumbosacral junction and at a point 10 cm above. The patient is then instructed to maximally anterior flex, and the distance between the marks is recorded. Less than 5 cm of distraction is abnormal. These measurements are useful for the serial evaluation of patients with spondyloarthropathy.Related posts:
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