History
Key features of the history in a patient with musculoskeletal disease are shown in Table 8.1.
Table 8.1 Key Features of the History in a Patient with Musculoskeletal Disease
| Feature | Details | Rationale |
| Basic details | Age, sex, height, weight | Establish body mass index; musculoskeletal disorders more common in the elderly and in women |
| Symptoms | Pain – may be worse on usage (mechanical), after rest (inflammatory) or at night | Identify significant symptom patterns including site, duration and aggravating/relieving factors |
| Stiffness – early morning or disuse stiffness (inflammation); may be associated weakness and deformity | ||
| Swelling, deformity | ||
| Symptoms of systemic illness – weight loss, fatigue | ||
| Past medical history | Previous episodes of similar symptoms; autoimmune disease; dermatological disease | Consider associated autoimmunity |
| Social and family history | Occupation; hobbies – sport, gardening; household environment; activities of daily living | Potential causes of injury; inability to cope at home |
| Medication | Review all medication including complementary therapies | Side effects – NSAIDs, corticosteroids |
Examination
Before examining the musculoskeletal system it is essential to enquire about painful joints and to examine with care so as not to exacerbate pre-existing pain. Position the relevant joints or region carefully, observe the patient’s face during the examination and keep checking for pain.
A rapid, general assessment of the musculoskeletal system is shown in Table 8.2 – the GALS screen. The GALS screen aims to establish:
- if there are any abnormal joints
- the nature of the joint abnormality
- the distribution of joint abnormalities
- whether or not there are associated diagnostic features.
If the GALS screen is normal then further examination is not required during a general medical assessment. Any abnormalities identified should lead to detailed examination of the musculoskeletal system.
Table 8.2 The GALS Screen
| Preliminary questions | |
| Have you any pain or stiffness in your muscles, joints or back? | |
| Can you dress yourself completely without difficulty? | |
| Can you walk up and down stairs without difficulty? | |
| Gait | Symmetry and smoothness of movement |
| Normal stride length | |
| Ability to turn normally | |
| Arms (sitting) | Inspect for wrist/finger swelling/deformity |
| Hands | Squeeze across 2nd–5th metacarpals (tenderness indicates synovitis of MCP joints) |
| Grip strength | Turn hands over (inspect for muscle wasting, normal forearm supination/pronation) |
| Elbows | Power grip (‘Make a tight fist’) |
| Shoulders | Precision grip (‘Touch your thumb to individual fingers in turn’) |
| Full extension (‘Put your arms out straight’) | |
| Abduction and external rotation (‘Put your hands behind your head’) | |
| Legs (lying) | |
| Knees | Inspect for swelling/deformity/quadriceps bulk |
| Check for knee effusion | |
| Check for knee crepitus whilst passively flexing the knee | |
| Hips | Check internal rotation of hips |
| Feet | Squeeze across metatarsals (tenderness indicates synovitis of MTP joints) |
| Inspect for callosities on soles of feet | |
| Spine (standing) | |
| Inspection from behind | Scoliosis |
| Symmetrical muscle bulk | |
| Level iliac crest | |
| No popliteal swelling | |
| Normal hind foot alignment | |
| Trigger points | Pressure over mid-supraspinatus |
| Inspection from in side | Kyphosis |
| Inspection from in front | Normal flexion (‘Lean down and touch your toes’) |
| Lateral cervical flexion (‘Touch your ear on your shoulder’) | |
| Adapted from Doherty M, Dacre J, Dieppe P and Snaith M. (1992) The ‘GALS’ locomotor screen. Annals of the Rheumatic Diseases 51: 1165–1169. | |
Detailed examination of the musculoskeletal system should be performed regionally, involving observation, palpation and manipulation (‘Look, Feel and Move’). Always make a quick survey of the patient and their surroundings prior to starting a regional examination routine. Look for obvious clues including evidence of joint replacements, mobility aids and hand warmers.
For each region or affected joint(s):
Observe at rest
- skin changes
- swelling
- muscle wasting
- deformity
Palpate for
- tenderness
joint line, periarticular
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