- History is most important in diagnosing musculoskeletal problems.
- The mechanism of injury can explain the pathology and symptoms.
- Determine whether the injury is traumatic or atraumatic, acute
or chronic, high or low velocity (greater velocity suggests more structural
damage), or whether any movement aggravates or relieves pain associated with
Musculoskeletal problems account for about 10-20% of
outpatient primary care clinical visits. Orthopedic problems can
be classified as traumatic (ie, injury-related) or atraumatic (ie,
degenerative or overuse syndromes) as well as acute or chronic.
The mechanism of injury is usually the most helpful part of the
history in determining the diagnosis.
The onset of symptoms should be elicited. With acute traumatic
injuries, patients typically seek medical attention within 1–6 weeks
of onset. The patient should describe the exact location of symptoms,
which helps determine anatomic structures that may be damaged. If
the patient is vague, the clinician can ask the patient to point
with one finger only to the point of maximal tenderness.
The chief musculoskeletal complaints are typically pain (most common), instability or dysfunction around the joints. Since symptoms and signs are often nonspecific, recognizing the expected combination of symptoms and physical examination signs can help facilitate the clinical diagnosis. Patients may describe symptoms of “locking” or “catching,” suggesting internal derangement in joints. Symptoms of “instability” or “giving way” suggest ligamentous injury; however, these symptoms may also be due to pain causing muscular inhibition. Constitutional symptoms of fever or weight loss, swelling with no injury, or systemic illness suggest medical conditions (such as infection, cancer, or rheumatologic disease).
Initial evaluation should follow routine trauma guidelines to
rule out serious joint injury. However, typical evaluations in the clinic
follow the traditional components of the physical examination and
should include inspection, palpation, and assessment of range of
motion and neurovascular status.
Inspection includes observation of swelling, erythema, atrophy, deformity, and (surgical) scars (remembered by the mnemonic, “SEADS”).
The patient should be asked to move joints of concern (For example, see Table 41–1). If motion is asymmetric,
the clinician should assess the passive range of motion for any
Table 41–1. Shoulder Examination.
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Table 41–1. Shoulder Examination.
Check the patient's posture and “SEADS” (swelling, erythema, atrophy, deformity,
Include important landmarks: acromioclavicular (AC) joint,
long head of biceps tendon, coracoid, and greater tuberosity (supraspinatus insertion).
Range of motion testing
Check range of motion actively (patient performs) and
passively (clinician performs).
Move the arm forward as high as possible in the sagittal
Check with the patient's elbow touching their body so that external
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