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The musculoskeletal history

Issue 11-2 (Clinical assessment of the musculoskeletal system)

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History taking is one of the most important skills for any doctor or practitioner to acquire and this can only be achieved through regular practice. This handbook is primarily concerned with problems arising from the joints – that is from the articular and periarticular structures. (These structures are shown in Figure 2, while Figure 3 represents diagrammatically the changes which occur in the two main types of arthritis.) However, it is clearly important to identify those cases where pain may appear to arise from the joint but is in fact referred pain – for example, where the patient describes pain in the left shoulder, which might in fact be referred pain from the diaphragm, the neck, or perhaps ischaemic cardiac pain. In cases where examination reveals no abnormalities in the joint, other clues will be obtained by taking a full history.

Assuming the patient’s problems do arise from the joint(s), the aims of the history will be to differentiate between inflammatory and degenerative/mechanical problems, to identify patterns that may help with the diagnosis, and to assess the impact of the problem upon the patient. There are four important areas which need to be covered when taking a musculoskeletal history:

  • the current symptoms
  • the evolution of the problem (is it acute or chronic?)
  • the involvement of other systems
  • the impact of the disease on the person’s life.

The assessment of these four areas is discussed in the sections which follow.

Current symptoms

The main symptoms of musculoskeletal conditions are pain, stiffness and joint swelling affecting one or more joints. Assessment of the patient’s current symptoms may allow differentiation to be made between inflammatory and non-inflammatory conditions. Inflammatory joint conditions are frequently associated with prolonged early morning stiffness that eases with activity, whilst non-inflammatory conditions are associated with pain more than stiffness, and the symptoms are usually exacerbated by activity.

Pain

As with all pain, it is important to record the site, character, radiation, and aggravating and relieving factors. Patients may localize their pain accurately to the affected joint, or they may feel it radiating from the joint or even into an adjacent joint. In the shoulder, for example, pain from the acromioclavicular joint is usually felt in that joint, whereas pain from the glenohumeral joint or rotator cuff is usually felt in the upper arm. Pain from the knee may be felt in the knee, but can sometimes be felt in the hip or the ankle. Pain due to irritation of a nerve will be felt in the distribution of the nerve – as in sciatica, for example. The pain may localize to a structure near rather than in the joint – for example, the pain from tennis elbow will usually be felt on the outside of the elbow joint.

The character of the pain is sometimes helpful. Pain due to pressure on nerves often has a combination of numbness and tingling associated with it. However, the character of musculoskeletal pain can be very variable and is not always helpful in making a diagnosis.

Pain of a non-inflammatory origin is more directly related to use: the more you do the worse it gets. Pain caused by inflammation is often present at rest as well as on use, and tends to vary from day to day and from week to week in an unpredictable fashion. It flares up and then it settles down. Severe bone pain is often unremitting and persists through the night, disturbing the patient’s sleep.

Stiffness

In general, inflammatory arthritis is associated with prolonged morning stiffness which is generalized and may last for several hours. The duration of the morning stiffness is a rough guide to the activity of the inflammation. Commonly, patients with inflammatory disease will also describe worse stiffness in the evening as part of a diurnal variation. With inflammatory diseases such as rheumatoid arthritis (RA), where joint destruction occurs over a prolonged period, the inflammatory component may eventually become less active and the patient may then only complain of brief stiffness in the morning. In contrast, osteoarthritis (OA) causes localized stiffness in the affected joints which is short-lasting (less than 30 minutes) but recurs after periods of inactivity. It is sometimes difficult for patients to distinguish between pain and stiffness, so your questions will need to be specific. It may help to remind the patient that stiffness means difficulty in moving the joint.

Joint swelling

A history of joint swelling, especially if it is intermittent, is normally a good indication of an inflammatory disease process – but there are exceptions. Nodal osteoarthritis, for example, causes bony, hard and non-tender swelling in the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the fingers. Swelling of the knee is also less suggestive of inflammatory disease as it can also occur with trauma and in OA. Ankle swelling is a common complaint, but this is more commonly due to oedema than to swelling of the joint.

Pattern of joint involvement

The pattern of joint involvement is very helpful in defining the type of arthritis, as different patterns are associated with different diseases. Common patterns of joint involvement include:

Monoarticular – only one joint affected

Pauciarticular (or oligoarticular) – less than four joints affected

Polyarticular – a number of joints affected

Axial – the spine is predominantly affected

As well as the number of joints affected, it is useful to consider whether the large or small joints are involved, and whether the pattern is symmetrical or asymmetrical. Rheumatoid arthritis, for example, is a polyarthritis (it affects lots of joints) which tends to be symmetrical (if it affects one joint it will affect the same joint on the other side), and if it affects one of a group of joints it will often affect them all, for example, the MCP joints. Note, however, that this describes established disease and early RA can affect any pattern of joints. Spondyloarthritides, such as psoriatic arthritis, are more likely to be asymmetrical and may be associated with inflammatory symptoms, such as early morning stiffness, involving the spine. Osteoarthritis tends to affect weight-bearing joints and the parts of the spine that move most (lumbar and cervical).

Evolution of the problem: is it acute or chronic?

You will need to listen to the patient’s history to find out:

  • When did the symptoms start and how have they evolved? Was the onset sudden or gradual?
  • Was the onset associated with a particular event, e.g. trauma or infection?
  • Which treatments has the condition responded to?

The way in which symptoms evolve and respond to treatment can be an important guide in making a diagnosis. Gout, for example, is characterized by acute attacks – these often start in the middle of the night, become excruciatingly painful within a few hours, and respond well to non-steroidal anti-inflammatory drugs (NSAIDs).

Musculoskeletal symptoms lasting more than 6 weeks are generally described as chronic. Chronic diseases may start insidiously and may have a variable course with remissions and exacerbations influenced by therapy and other factors. It may be helpful to represent the chronology of a condition graphically (see Figure 4).

Involvement of other systems

Inflammatory arthropathies often involve other systems including the skin, eyes, lungs and kidneys. In addition, patients with inflammatory disease often suffer from general symptoms such as malaise, weight loss, mild fevers and night sweats. Fatigue and depression are also common. Osteoarthritis in contrast is limited to the musculoskeletal system. A comprehensive history must include the usual screening questions for all systems as well as specific enquiries relating to known complications of specific musculoskeletal disorders.

The presence of an arthritis does not exclude other diseases, and these other conditions may affect both the patient and their arthritis. A combination of two disabling diseases will be worse than either one alone, and the impact on the patient will therefore be greater. In addition, other conditions may be affected by the treatments prescribed for the arthritis – for example, the presence of liver disease may limit the use of disease-modifying drugs for inflammatory arthritis, because most of these drugs can upset the liver.

Impact of the condition on the patient

Understanding the impact of the disease on the patient is crucial to negotiating a suitable management plan. Ask open questions about functional problems and difficulty in doing things. It may be easiest to get the patient to describe a typical day, from getting out of bed to washing, dressing, toileting etc. Potentially sensitive areas, such as hygiene or sexual activity, should be approached with simple, direct, open questions. The impact of the disease on the patient’s employment will be important.

A patient’s needs and aspirations are an important part of the equation and will influence their ability to adapt to the condition. Questions concerning the things a person would like to do, but is currently unable to, may pinpoint key problems. Later negotiations with the patient on balancing the risks and benefits of an intervention will be greatly affected by the patient’s priorities for treatment.

Medical students, doctors and practitioners should have an awareness of the relationship between functional loss, limitation of activity, and restriction of participation. Being unable to fully flex a finger (loss of function) might lead to difficulty, for example, with fastening buttons (activity) which might have a fairly minor impact on general life (participation). The same loss of function, however, might prevent a pianist from playing (activity) which, for a professional musician, might have a significant impact on his/her way of life (participation) (see Figure 5).

Screening questions for musculoskeletal disorders

These screening questions should be incorporated into the routine systemic enquiry of every patient. The main symptoms arising from disorders of the mus- culoskeletal system are pain, stiffness, swelling, and associated functional problems. The screening questions directly address these aspects:

  • ‘Do you have any pain or stiffness in your muscles, joints or back?’
  • ‘Can you dress yourself completely without any difficulty?’
  • ‘Can you walk up and down stairs without any difficulty?’

A patient who has no pain or stiffness, and no difficulty with dressing or with climbing stairs is unlikely to be suffering from any significant musculoskeletal disorder. If the patient does have pain or stiffness, or difficulty with either of these activities, then a more detailed history should be taken (as described above).

History taking: revision checklist

Current symptoms

  • Pain
  • Stiffness
  • Swelling
  • Pattern of joint involvement

Evolution

  • Acute or chronic?
  • Associated events
  • Response to treatment

Involvement of other systems

  • Skin, eye, lung or kidney symptoms?
  • Malaise, weight loss, fevers, night sweats?

Impact on patient's lifestyle

  • Patient's needs/aspirations
  • Ability to adapt to functional loss

Screening questions:

  • Do you have any pain or stiffness in your muscles, joints or back?
  • Can you dress yourself completely without any difficulty?
  • Can you walk up and down stairs without any difficulty?
For more information, go to www.arthritisresearchuk.org.
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