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Musculoskeletal System

Taking a History and

Conducting an Examination

Objectives: History

You should be able to

-Distinguish inflammatory vs non inflammatory symptoms

-Take relevant histories for bone/joint/muscle/nerve problems

-Assess acute and chronic pain

-Understand the impact of chronic musculoskeletal condition on everyday activities

Objectives: Examination

You should be able to

-identify normality vs abnormality

-Examine joints/bones in a systematic manner

-Recognise common Musculoskeletal conditions

-perform GALS Screening

IntroductionMusculoskeletal problems are common

-Commonest cause of long term pain

-Second most common reason for consulting a Dr

-Up to 20% primary care consultations

-Predicted to increase with ageing population/obesity/lack of physical fitness

-Bone and Joint Decade (2000-2010)

Inflammation: Key features

Joints

Warm

Painful

SwollenErythema

Lack of function = ROM restricted

“Synovitis”

Joints: history

Which joints? Any precipitating event?

When? (before or during/after use?)

How long?-intermittent?

Swollen?

Stiff ?(partic. mornings/immobility)

Any associated features? E.g. rashes, eye problems etc

Joints: history

PMH: Any past history of joint problems?

DH: What has been tried..any side effects?

FH: Any FH of joint problems?

SH: Important to understand impact on ADL

Features in history to distinguish between inflammatory vs non inflam. symps

Mechanical Inflammatory

Pain Using joint Mornings

After use Improves with use

Stiffness Minimal Marked

Swelling None or Bony/fixed Fluid/soft tissues

Variable

Other

Weight bearing joints

Characteristic Distribution

History

• I.e Inflammatory Joint Pain = Synovitis• = RA/ Crystalline/ Spondyloarthropathies

• Spondlyoarthropathies also termed seronegative arthritis

• Seronegative means Rheumatoid Factor Negative• Spondylo= Spine

GALS Screening Questions(Gait, Arms/Legs/Spine)

Do you have pain or stiffness in your joints?

Can you dress without difficulty?

Can you walk up and down stairs?

If all negative, unlikely to be significant musculoskeletal problem.

These questions are helpful to an extent…

Examination: JointsLOOK, FEEL, MOVE

Inspect Compare with other side

Different shape? Swollen?

Alignment, muscle wasting?

Palpate Temperature

Swollen? Bony or fluctuant?

Move Full ROM?

Active (patient does) first

then passive (Dr does)

Examination

Systematic

Start with hands- Heberden’s Nodes?

Psoriasis/nail changes

Tophi?

Wrists

Elbows Nodules? Tophi?

Shoulders

Look At the Patient and Around the BedHands Behind your BackSticks/drugs/Drips/inhalers/sputum/OT aids etc

ExaminationHips Difficult to inspect and feel as deep

Knees Patellar tap, ligamentous instability?

Ankles Hinge/sub talar

Feet MTP Squeeze

Standing: Alignment-knees, ankles valgus/varus?

Spine Cervical/Thoracic/Lumbar

…Finally observe gait

GALS

• Gait

• Arms

• Legs

• Spine

Arms (shoulder elbow wrist hands)

• Pinch

• Grip

• Moving your hands to where you need them

• If you can reach behind your head…

LOOK FEEL MOVE FUNCTION

• Scars Rashes Swelling Wasting

• Nodules• RA (Seropositive)/ Gouty Tophi

• Rashes• Heliotropic+Gotrons Papules=

Dermatomyositis• Psoriasis= PsA• “Vasculitis”

• Purpura/splinters

Feel

• Warmth

• Remember hot swollen tender= SYNOVITIS

• Pain

• Joint Lines

• Nodules

MOVE

• Active vs Passive

• Restriction of Movement

Function

• Pick up a coin off a flat surface

• Button Shirt

• Write their name

Presenting Your Findings

• Symetrical Vs Asymetical

• Poly(>4) vs Oligo (2-4) vs Mono (1)

• Inflammatory / non inflammatory

• Upper / Lower limb

• Large / Small joint

• Spine involved

Summary

We have covered important points in History and Examination of Musculoskeletal system

Introduced GALS System

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