The musculoskeletal system is not an independent, isolated entity. It is generally understood to include a collection of limbs, joints, muscles and nerves and their functional interaction. The inseparable cohesion between the different organ systems makes it difficult to make a primary distinction between an orthopaedic, neurological, vascular, psychogenic or internal medicine-based causes of a complaint. Consequently, the diagnosis established is often no more than guesswork packaged in an impressive sounding name (PHS, lumbago), which covers a complex of poorly-understood complaints. Therefore, systematic and conscientious history-taking often provides the key to the mechanisms that ultimately lie behind the complaint.
Although this program is intended as a manual for practical skills, we certainly do not wish to ignore the history-taking. In the majority of cases, pain is the symptom which causes the patient to visit their GP. Ideally, during the process of clarifying the problem the patient should be given the opportunity to clearly state the nature of the pain, how this is experienced, the extent to which the symptom affects daily living and what the patient expects from the doctor.
The specific history-taking is the phase in which questions are posed about the modalities of the symptom (aetiology, provocation, course of the problem over time, triggers improvement or deterioration, associated symptoms, radiation). In addition, the musculoskeletal system is assessed in more detail. Associated symptoms such as paresthesia and loss of strength, require further neurological and vascular examinations. Symptoms such as swelling, redness and limited movement are indicative of an inflammatory process and necessitate additional laboratory tests.
Note that the concomitant occurrence of symptoms that may initially appear to be unrelated (such as joint complaints and urethritis and/or eye complaints), might point towards the existence of a specific syndrome and can form a reason for further exploration by an internal medicine specialist.
There does not always have to be a direct relationship between the site where the pain is experienced and the location of the pain-inducing process (referred pain). Sometimes there are good reasons for enquiring about certain organ systems in further detail during the history-taking due to the possible presence of, for example, bone metastases, intermittent claudication, miction disorders, genital pathology etc.
The examination of the musculoskeletal system is divided into several subsidiary examinations. These will be discussed below in an order based on two premises.
1. The examination should be performed systematically based on functional anatomical insights.
The examination covers the following elements, listed in the order in which they should be carried out:
- General inspection.
- Basic functional examination:
- Active movement (function) examination.
- Passive movement (function) examination.
- Muscle tests.
- Palpation.
- Specific tests.
- Circumference measurement.
- Neurological and vascular examinations.
2. The inconvenience caused to the patient should be minimised by making full use of the patient’s initial posture (standing, sitting, or lying).
If the sequence of the examination is adhered to too strictly, it may disrupt the relaxed nature of the examination and place additional burden on the patient. Not all of the subsidiary examinations stated are always indicated. The local and/or general condition of the patient can form an important guiding principle.