GENERAL APPROACH TO MUSCULOSKELETAL INJURIES
ESSENTIALS OF DIAGNOSIS
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 the injury.
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 see (Table 8–1). If motion is asymmetric, the clinician should assess the passive range of motion for any physical limitation.
Table 8–1.Shoulder examination. |Favorite Table|Download (.pdf) Table 8–1. Shoulder examination.
|Maneuver ||Description |
|Inspection ||Check the patient's posture and “SEADS” (swelling, erythema, atrophy, deformity, surgical scars). |
|Palpation ||Include important landmarks: acromioclavicular (AC) joint, long head of biceps tendon, coracoid, ...|