Bone, joint and muscle

Chapter 10 Bone, joint and muscle



SYMPTOMS OF BONE, JOINT AND MUSCLE DISORDERS



Bone



PAIN



• Deep, boring quality

• May be focal (tumour, infection, fracture)

• May be diffuse (osteoporosis, osteomalacia).


Joint



PAIN



• Usually the most prominent complaint of arthritic disorders.

• Referred to segments (sclerotomes) which differ from dermatomes (Fig. 10.1).

• Hence joint pain can be felt at some distance from the affected structure.

• Osteoarthritis and rheumatoid arthritis typically result in chronic pain with periodic exacerbations.

• Septic arthritis or gout produces an acutely painful joint.

• Inflammatory joint disease tends to cause pain on waking, improving with activity but returning at rest.

image

Fig. 10.1 Distribution of pain arising from (a) the acromioclavicular or sternoclavicular joints, (b) the scapulohumeral joint, (c) the hip joint and (d) the knee joint.




imageDifferential diagnosis: Bone pain











Focal Diffuse

• Fracture or trauma

• Infection

• Malignancy

• Paget’s disease

• Osteoid osteoma
• Malignancy

• Paget’s disease

• Osteomalacia

• Osteoporosis

• Metabolic bone disease


• Mechanical joint disease (e.g. due to osteoarthritis) leads to pain that worsens during the course of the day, particularly with activity.


SWELLING AND CREPITUS



• Elicit the duration of any swelling, whether it is painful and whether it fluctuates.

• Crepitus is a grating noise or sensation.

• Fine crepitus is more readily felt than heard.

• Readily audible crepitus is associated with advanced degeneration in large joints.



imageDifferential diagnosis: Causes of joint pain



• Inflammatory
– rheumatoid arthritis

– ankylosing spondylitis

• Mechanical
– osteoarthritis

• Infective
– pyogenic

– tuberculosis

– brucellosis

• Traumatic


LOCKING



• Occurs when ectopic material becomes interposed between the articular surfaces.

• Particularly prevalent with knee cartilage damage.


Muscle


Muscle symptoms include pain, stiffness, spontaneous movements and cramps.




imageDifferential diagnosis: Causes of muscle pain



• Inflammatory
– polymyositis

– dermatomyositis

• Infective
– pyogenic

– cysticercosis

• Traumatic

• Polymyalgia rheumatica

• Neuropathic, e.g. Guillain–Barré syndrome


PAIN AND STIFFNESS



• Muscle pain tends to be deep, constant and poorly localised.

• Muscle stiffness is usually the consequence of unaccustomed activity. If it persists, suspect spasticity.


WEAKNESS



WASTING AND FASCICULATION



• Determine the duration of these symptoms and their distribution.


CRAMPS



• Usually physiological but can occur in metabolic myopathies.


GENERAL PRINCIPLES OF EXAMINATION



Bone



• Expose structure.

• Assess deformity and tenderness.

• Assess any altered temperature.


Joint



INSPECTION



Swelling



• Determine if within or adjacent to the joint.

• Causes include effusions, synovial thickening (e.g. rheumatoid arthritis) and bony deformity.


Deformity



• Results either from misalignment of the bones forming the joint or from alteration of the relationship between the articular surfaces.

• Valgus deformity – deviation of part distal to the joint away from the midline (Fig. 10.2).

• Varus deformity – deviation of part distal to the joint towards the midline (Fig. 10.2).

• Subluxation – partial loss of contact of the articulatory surfaces.

• Dislocation – complete loss of contact of the articulatory surfaces.

image

Fig. 10.2 Genu varum (left) and genu valgum (right).



Skin changes


Redness of the skin over a joint implies an underlying acute inflammatory process (e.g. gout or septic arthritis) (Fig. 10.3).


image

Fig. 10.3 Acute gout of the first metatarsophalangeal joint.



Changes of adjacent structure


The most striking change adjacent to a diseased joint is muscle wasting.



PALPATION


During palpation of a joint, assess the nature of any swelling, whether there is tenderness, and whether the joint is hot.



Swelling


Is the swelling:


• Hard? – suggesting bone deformities secondary to osteoarthritis.

• Spongy? – suggesting synovial thickening, e.g. rheumatoid arthritis.

• Fluctuant? – an effusion can be displaced from one part of the joint to another.


Tenderness


Determine whether any tenderness is focal or diffuse. In an acutely inflamed joint, the whole of the contour is tender. If there is derangement of a single knee cartilage, tenderness is confined to the cartilage margin.



Temperature



• For a small joint, assess temperature with the fingertips.

• For a larger joint, e.g. the knee, rub the back of your hand across the joint then compare it with its fellow.


MOVEMENT



• To define the range of joint movement, start with the joint in the neutral position:
– the lower limbs extended with the feet dorsiflexed to 90°

– the upper limbs midway between pronation and supination with the arms flexed to 90° at the elbows.

• Active joint movement is that initiated by the patient.

• Passive joint movement is that induced by the examiner.

• From the neutral position, record the degrees of flexion and extension.

• If extension does not normally occur at a joint (e.g. the knee) but is present, describe the movement as hyperextension and give its range in degrees.

• Restricted movement, say of knee extension, is recorded as X° flexion deformity or as X° lack of extension.

• For a ball-and-socket joint, record flexion, extension, abduction, and internal and external rotation.


Muscle


Initial assessment will include inspection, palpation then testing of muscle power.



INSPECTION


Look for evidence of muscle wasting, signs of abnormal muscle bulk and for spontaneous contractions.



Wasting


If not due to adjacent joint disease, or a global loss of body weight, wasting reflects either primary muscle disease or disease of its innervating neuron.



Increased muscle bulk


Rare.


• True hypertrophy – seen in some forms of congenital myotonia.

• Pseudohypertrophy – due to fatty infiltration. The muscle is actually weak. Seen in some forms of muscular dystrophy (e.g. Duchenne’s).


Spontaneous muscle contractions


Seen in both upper and lower motor neuron disorders.


• Flexor or extensor spasms – typically affecting the hips, knees or both. Seen with spinal disorders, e.g. multiple sclerosis.

• Fasciculation – episodic twitching due to contraction of muscle fibres supplied by a single motor unit. It is seen with motor neuron disease but can also occur in normal individuals.


PALPATION


Muscle palpation is of limited value. Look for tenderness. It is seen in muscle infection, inflammatory muscle disease (e.g. polymyositis) and in certain neuropathies (e.g. due to beriberi).



MUSCLE POWER


Use the Medical Research Council (MRC) classification of muscle power.


• Is the weakness global or focal?

• If focal, can it be explained by a root or peripheral nerve lesion?

• Is the weakness fluctuant?



imageSymptoms and signs: MRC classification of muscle power



5. Normal

4. Contracts against resistance but incomplete

3. Contracts against gravity but not resistance

2. Contracts with gravity eliminated

1. Flicker of contraction

0. Nil


REGIONAL EXAMINATION



Temporomandibular joints



• Assess the range of movement and whether there is local tenderness.

• The joints lie immediately in front of and below the tragus.


Spine



• Ask the patient to undress to his or her underwear.

• Inspect the whole spine.

• Palpate the spine for tenderness.

• Assess the range of movement.


CERVICAL SPINE



• Examine the patient sitting.

• Test flexion, extension, lateral flexion and rotation.

• Determine whether any movement causes pain, and whether that pain is referred to the arm or head.


THORACIC SPINE



• For movement, measure chest expansion.

• Then, with the patient’s arms folded across the chest, ask the patient, while sitting, to twist as far as possible to one side then the other.



imageSymptoms and signs: Spinal deformities (Fig. 10.4)



Kyphosis – increased flexion

Lordosis – increased extension

Scoliosis – increased lateral curvature

Gibbus – focal flexion deformity

image

Fig. 10.4 Spinal deformities.



LUMBAR SPINE



• Ask the patient to touch the toes.

• Then test extension and lateral flexion.


SACROILIAC JOINTS



• Palpate the joints (they lie under the dimples found in the lower lumbar region).

• To test whether movement is painful, first press firmly over the midline of the sacrum with the patient prone, then, with the patient supine, forcibly flex one hip while maintaining the other hip extended.



imageDifferential diagnosis: Back pain



• Muscle or ligamentous strain

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Apr 20, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Bone, joint and muscle

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