Symptoms and Signs of the Musculoskeletal System

Musculoskeletal Assessment Health History Subjective Data -Chief Complaints – pain, altered sensation, limited motion Family history, personal history, dietary history, socioeconomic status Medications (steroids); Current health problems Objective Data - Physical Exam Special Assessment Techniques Objective Data - Diagnostic Tests

History symptom onset, location, patterns of progression, severity, exacerbating and alleviating factors, associated symptoms. relationship of the symptoms to psychosocial stressors, impact of the symptoms on all aspects of the patient's functioning, effects of current or previous therapy on the course of the illness

Pain The most common symptom The distribution of the pain and determine if this fits with anatomic structures. Pain localized : articular disorder, bursae, tendons, ligaments, or nerves (superficial structures) deep structures: poorly localizing pain. Pain arising from small, peripheral joints is often more focal than pain arising from proximal, large joints, such as the shoulders and hips. Pain referring: from the joint, periarticular structures, distant structures such as lumbar spondylosis, Entrapting neuropathy, nerve root compression Visseral pathology

widespread, vaguely described pain, and not respecting anatomic distributions generally suggests a chronic pain syndrome, such as fibromyalgia or psychiatric disease.

The severity of pain: A common approach is to ask the patient to describe the level of pain on a numeric scale of intensity from 0 (no pain) to 10 (very severe pain). exacerbating and alleviating conditions: Joint pain present at rest but worse with movement suggests an inflammatory process, pain occurring primarily with activity and relieved by rest generally indicates a mechanical disorder, such as degenerative arthritis.

Timing of the pain symptoms: during the day and night Character of pain: Aching in a joint area suggests an arthritic disorder, whereas “burning” or “numbness” in an extremity may indicate a neuropathy. Duration of pain: Acute: DH, trauma, inflammatory Chronic: dejenerative Onset of pain Sudden: DH, infection, fracture Progressive: osteoarthritis, neuropathic pain Initiation: weight lifting, gastroenteritis, infection

STIFFNESS Discomfort and limitation on attempted movement of joints after a period of inactivity. Morning stiffness is an early feature of inflammatory arthropathies, in which morning stiffness may last for several hours. A useful question to assess morning stiffness is: “In the morning, how long does it take for your joints to limber up as good as they are going to get for the day?” Morning stiffness associated with noninflammatory joint diseases, such as degenerative arthritis, is generally of short duration (usually <30 minutes) and less severe than stiffness of inflammatory joint disease.

LIMITATION OF MOTION Determining the rapidity of onset of the limitation of motion may be helpful in the differential diagnosis; the abrupt onset of the limitation of motion suggests a structural derangement, such as a tendon rupture or torn knee cartilage, an insidious onset of restricted joint motion is more common with inflammatory joint disease.

SWELLING Determine if the swelling is related to joint synovitis or soft tissue conditions, Diffuse soft tissue swelling: venous or lymphatic obstruction, soft tissue injury, or obesity. Swelling of a joint resulting from synovitis or bursitis frequently is associated with discomfort with motion because of tension on the inflamed tissues. If the swollen tissues are periarticular, however, no discomfort may be present with joint motion because the inflamed tissues are not stressed. Swelling of a confined structure, such as a synovial cavity or bursa, is most painful when it has developed acutely, whereas a similar degree of swelling that has developed slowly is often much more tolerable.

WEAKNESS The temporal course of weakness is important to the differential diagnosis. Weakness of sudden onset without trauma: a neurologic disorder, ( acute cerebrovascular event) Weakness of insidious onset: a muscle disease, such as an inflammatory myopathy (i.e., polymyositis). Weakness that is intermittent: myasthenia gravis. the distribution of the weakness: Proximal weakness that is bilateral and symmetric suggests an inflammatory myopathy. The presence of a unilateral or isolated deficit generally indicates a neurogenic etiology. Many medications, including corticosteroids and lipid-lowering agents, can cause muscle injury. Taking a complete review of systems is helpful in evaluating a patient with weakness. Constitutional symptoms, such as weight loss and night sweats, may indicate the presence of a malignancy as the cause of generalized weakness.

FATIGUE Fatigue can be defined as an inclination to rest even though pain and weakness are not limiting factors. Fatigue after varying degrees of activity that is relieved by rest is normal. Patients with rheumatic diseases experience fatigue even without activity.

Other symptoms Parestehesia Deformity Gait variations and difficulty in mobility

Physical Exam Mental Status General inspection Head and neck: temporomandibular joint; crepitus Height, weight, nutritional status, skin, spine – lordosis, scoliosis, posture, joint function, upper and lower extremities Posture, gait, ROM ex., deep tendon reflexes, bone integrity, muscle strength and tone, neurovascular, MS injuries Goniometer, which provides a measure of ROM

Neurological examination: Inspection Palpation Range of motion Neurological examination: Muscle test Reflexes Sensory Special Tests Functional evaluation

SYSTEMATIC METHOD OF EXAMINATION SWELLING TENDERNESS LIMITATION OF MOTION CREPITATION DEFORMİTY INSTABILITY

SWELLING Swelling around a joint may be caused by intra-articular effusion, synovial proliferation, periarticular subcutaneous tissue inflammation, bursitis, tendinitis, bony enlargement, or extra-articular fat pads. Inspection: visible evidence of swelling, such as loss of normal landmarks or contours. Compare the same joints on both sides of the body visually to detect subtle evidence of swelling and to appreciate symmetry. Palpation

TENDERNESS In the musculoskeletal examination, tenderness indicates unusual discomfort on palpating and putting pressure on articular and periarticular tissues. Localizing the tenderness to palpation may assist the examiner in determining whether the pathology is in an articular or a periarticular structure, such as a fat pad, tendon attachment, ligament, bursa, muscle, or skin. It can be useful to palpate structures that are not involved to assess the importance of tenderness.

LIMITATION OF MOTION the examiner must know the normal type and range of motion of each joint. compare the passive range of motion with the active range of motion. If the passive range of motion is greater than the active range of motion, the restriction may be the result of pain, weakness, or the state of the articular and periarticular structures. It also is important to distinguish muscle tension from a true limitation of joint motion.

CREPITATION Crepitation is a palpable or audible grating or crunching sensation produced by motion. This sensation may or may not be accompanied by discomfort. Crepitation occurs when roughened articular or extra-articular surfaces are rubbed together by active motion or by manual compression. Fine crepitation Coarse crepitation Crepitation from within a joint should be differentiated from cracking or popping sounds caused by the slipping of ligaments or tendons over bony surfaces during motion. Fine crepitation is often palpable over joints involved by chronic inflammatory arthritis and usually indicates roughening of the opposing cartilage surfaces as a result of erosion or the presence of granulation tissue. Coarse crepitation may be caused by inflammatory or noninflammatory arthritis. Bone-on-bone crepitus produces a higher frequency, palpable, and audible squeak.

DEFORMITY Deformity of the joints may manifest as a bony enlargement, articular subluxation, contracture, or ankylosis in nonanatomic positions. Deformed joints usually do not function normally, frequently restrict activities, and may be associated with pain, especially with overuse.

INSTABILITY Joint instability is present when the joint has greater than normal movement in any plane. Subluxation refers to a joint in which there is partial displacement of the articular surfaces, but still some joint surface-to-surface contact. A dislocated joint has lost all cartilage surface-to-surface contact.