Week 2: MSK examination and history Flashcards
how to start thinking about an MSK examination
- SOCRATES framework
- is the condition acute or chronic
- are the symptoms from the joint or the soft tissue?
- is the symptoms inflammation or non-inflammatory
SOCRATES
to establish
- onset
- pattern of affected areas
- aggravating factors eg exercise/rest,
- relieving factors eg NSAIDS/exercise/rest and
- other associated symptoms
- RED FLAG
- SYMPTOMS, swelling, stiffness, fatigue.
Are the symptoms from the joint or the soft tissue?
- Is the pain from the joint e.g. arthritis or is it referred pain e.g. pain in the left shoulder may be referred pain from the diaphragm, neck or ischaemic cardiac pain
- Common cause of widespread pain with normal joint examination is fibromyalgia
Is the condition cute or chronic: chronic
- >6 weeks= chronic
- May start insidiously and have a variable course with remissions and exacerbations influenced by therapy an other factors
Is the condition acute or chronic: acute
- Was the onset associated with a particular event e.g. trauma or infection
Main symptoms of MSK conditions are
pain, stiffness and joint swelling
presentation of inflammatory
e.g. RA, are associated with prolonged early morning stiffness that eases with activity
presentation of non-inflammatory
e.g. OA, are associated with pain more than stiffness, exacerbated by activity
Pain history
Site, character, radiation and aggravating and relieving factors
- Site
- Pt may localise pain to a joint or may feel it radiating from an adjacent joint
- E.g. pains in the knee may be felt in the hip or ankle
- Pain felt due to irritation of nerve will be felt in the distribution of the nerve e.g. sciatica
- Pt may localise pain to a joint or may feel it radiating from an adjacent joint
- Character
- Sharp, deep, achy, burning or stabbing
- Pain due to pressure on a nerve tends to be numb and tingling
- Aggravating and relieving factors
- Non-inflammatory pain is more directly related to use –. i.e. the more you do the worse it gets
-
Inflammatory pain is present at rest as well as on use and varies from day to day
- Flares up and settles down
- Tender to touch
- Worse in the morning
- Severe bone pain (suggestive of underlying malignancy) is often unremitting and persists through the night, disturbing sleep
stiffness history : inflammatory
- Prolonged morning stiffness which is generalised and lasts a few hours
- Duration of stiffness = activity of inflammation
- With inflammatory diseases such as rheumatoid arthritis, where joint destruction occurs over a prolonged period, the inflammatory component may eventually become less active and give way to secondary mechanical pain as a result of the damage. It is therefore sometimes difficult for patients to distinguish between pain and stiffness, so your questions will need to be specific.
stiffness history : non-inflammatory
- Localised stiffness e.g. OA, which may be short lasting but can recur after sitting for short periods
joint swelling history
- A history of joint swelling, especially if it is intermittent, is normally a good indication of an inflammatory disease process.
- Patients often describe rings becoming tight or a sensation of walking on pebbles.
- There are exceptions however. 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.
monoarticular
only one joint affected e.g. septic arthritis
Oligoarticular
only a few joints affected e.g. psoriatic arthritis
polyarticular
many joints e.g. RA
axial
spine is predominantly affected e.g. ankylosing spondylitis
which joints?
small or large joints affected
symmetrical or asymmetrical
example of joint involvement i.e. RA
for example, is a polyarthritis (it affects lots of joints) that 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 metacarpophalangeal (MCP) joints
example of joint involvement i.e. spondyloarthritides (is the name for a family of inflammatory rheumatic diseases that cause arthritis)
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.
example of joint involvement i.e. osteoarthritis
tends to affect weight-bearing joints and the parts of the spine that move most (lumbar and cervical).
other system involvement
-
Inflammatory arthritis
- Often involves other systems inc skin eyes, lungs and kidneys
- General symptoms: malaise, weight loss, mild fevers and night sweat
-
Non-inflammatory
- Limited to MSK and not associated with immune activation
- Fatigue and depression common in any arthritis where there is functional loss or chronic pain
Impact of condition on patients life
- Ask open ended questions
- Functional issues
- Difficulty with day to day activities
- Get patient to describe typical day e.g. washing, dressing etc
- Impact on employment
- Patients needs and aspirations are important to understand
- Ideas concerns expectations
with an MSK exam
LOOK FEEL MOVE
hand and wrist assessment overview
- LOOK
- FEEL
- MOVEMENTS
- active
- pass
- Neurovascular assessment
- Special tests
what does RASH stand for
rash/ erythema
atrophy
swelling/scars
hyperaemia