History and physical examination

Best Practice & Research Clinical Rheumatology Vol. 17, No. 3, pp. 381 –402, 2003 doi:10.1016/S1521-6942(03)00027-5, www.elsevier.com/locate/jnlabr/yberh

2 History and physical examination Anthony D. Woolf *

BSc , MBBS , FRCP

Professor of Rheumatology, Peninsula Medical School Duke of Cornwall Department of Rheumatology, Royal Cornwall Hospital, Truro TR1 3LJ, UK

Musculoskeletal conditions are common, their impact is pervasive and they are a major burden on health and social care. However, they are poorly managed because of lack of priority and inadequate competencies due to limited medical education in this spectrum of conditions. The ability to take a clear history and perform a competent examination are core skills to the appropriate management of musculoskeletal problems. This chapter outlines an approach that is followed by most specialists in rheumatology, orthopaedics or rehabilitation that can be used to teach other clinicians going into primary care or at the beginning of specialist training. Key words: history; examination; musculoskeletal system.

Musculoskeletal conditions are the most common cause of severe long-term pain and physical disability affecting hundreds of millions of people around the world. They significantly affect the psychosocial status of individuals with the condition as well as their families and carers.1 These conditions are responsible for the utilization of a sizeable amount of health and social care resources. At any one time, 30% of adults in the USA are affected by joint pain, swelling or limitation of movement.2 Using disabilityadjusted life years, osteoarthritits is the fourth most frequent predicted cause of problems world-wide in women, and the eighth in men.3 There is a 40% lifetime risk of fracture for women over 50 years in Westernized countries and the burden of osteoporosis is increasing rapidly in developing countries with increased life expectancy and increases in risk factors.4 Roughly 42% of persons with musculoskeletal conditions are limited in their activities. They are the most common cause of health problems limiting work in developed countries. The cost of these conditions in the UK is 7.8% of all health service and personal social services expenditure. In the USA, the limitation of activity translates to 2.5% of the gross national product5 and these conditions represent 28% of disability compensation schemes.5 Musculoskeletal complaints are the second most common reason for consulting a doctor, and in most countries they constitute up to 10– 20% of the primary care practice.6 The prevalence of many of these conditions increases markedly with age and many are affected by lifestyle changes such as obesity and lack of physical activity. With the increasing number of older people and the changes in lifestyle occurring throughout the world, the burden on the individual and * Tel.: þ 44-1872-253792; Fax: þ44-1872-222857. E-mail address: [email protected] (A. D. Woolf). 1521-6942/03/$ - see front matter Q 2003 Elsevier Science Ltd. All rights reserved.

382 A. D. Woolf

society will increase dramatically. This has been recognized by the UN and WHO with the endorsement of the Bone and Joint Decade.7 Despite their high prevalence and the impact they have on the individual and society, musculoskeletal conditions are under-recognized and poorly treated. Undergraduate education in musculoskeletal health and conditions is underdeveloped in most of the universities worldwide. As a consequence, there is inadequate experience gained by students and trainee GPs in relation to these conditions. Students are seldom assessed in examinations for their competency to take an appropriate history and examine the musculoskeletal system. Practising clinicians are not confident in their musculoskeletal examination skills8 and many wish they had had more training.9 It is therefore not surprising that, in clinical practice, musculoskeletal symptoms are often minimized and ignored in both hospital and ambulatory care settings10,11 and the system not examined. Of patients admitted to internal medicine wards of a teaching hospital, it was found that more than 50% had musculoskeletal symptoms and 20% had significant rheumatological disorders but that the symptoms were recorded in only 40% of the cases and examination documented in only 14% of cases.11 Another study showed that only 20% of nearly 400 Australian interns were competent at assessing disability and handicap.12 There is also a lack of appreciation of the importance of psychological factors in chronic musculoskeletal disease. Reducing disability is a WHO ‘Health For All’ target13, but this inadequate education and experience in rheumatic disorders will inevitably result in poor management and outcome. This lack of competency not only impairs the provision of good-quality care and the achievement of health gain that is possible with modern management, it also perpetuates negative attitudes about what can be done. Most musculoskeletal conditions are being managed in primary care or seen as a co-morbid condition by other specialists. There is therefore a clear need to improve the competencies of all doctors in the assessment and management of musculoskeletal conditions. In many medical schools, and in primary care training programmes, the education of medical students in these conditions warrants careful reconsideration because the level of competency in the assessment and management of musculoskeletal conditions needs to be improved; recommendations are being developed for core curricula for undergraduates and primary care physicians by the Bone and Joint Decade Education Task Force. This chapter considers the ideal clinical assessment for identifying and characterizing a musculoskeletal problem. It outlines an approach that is followed by most specialists in rheumatology, orthopaedics or rehabilitation. This approach can be used for teaching other clinicians who are going into primacy care or who are at the beginning of specialist training. The role of further investigations and the assessment for monitoring musculoskeletal conditions, in particular in the research setting, is considered separately. The recommendations are based largely on expert opinion and tradition as there is little literature looking at the sensitivity and specificity of various features in the history and examination to enable a diagnosis to be made. It is possible that imaging techniques, such as ultrasound or magnetic resonance imaging, are far more specific for characterizing an abnormality but the history and examination are probably a sensitive screening tool for identifying the situations that warrant further assessment.

WHAT ARE THE AIMS OF THE CLINICAL EVALUATION OF A PATIENT? The purpose of assessing an individual is three-fold. First, to identify and characterize their problem to enable a diagnosis of the cause to be made. Second, to identify

History and physical examination 383

the effect of the problem and targets for treatment. Third, to monitor response to treatment. The subsequent actions of investigation and management should follow logically from the findings of the clinical evaluation. The role of special investigations when dealing with a musculoskeletal problem is usually to confirm clinical suspicions regarding diagnosis, or to help gauge disease activity, prognosis and choice of treatment. The performance of unnecessary investigations may be avoided by this thoughtful sequence, ensuring that investigations are performed only if the results will influence decision making. The communication of the process, findings, conclusions and management plan is central to ensuring that the person with the problem is an active participant in their own management. The clinical evaluation should be in the context of identifying and evaluating the symptoms and structural changes and their causes, any functional abnormality and the impact on the person in terms of limitation of activities and restriction of participation. This follows the philosophy of the World Health Organization International Classification of Functioning, Disability and Health (WHO ICF).14 The cause of the problem should be considered in some framework. It is simplest to consider the structure affected and the mechanism of the problem. Is the cause related to the spine, joints, muscle, periarticular structures or bone? Is it a local or generalized musculoskeletal problem or a systemic condition? What is the underlying mechanism— is it vascular/ischaemic; infectious; traumatic; autoimmune or immune-mediated; metabolic/toxic; inherited; neoplastic; congenital/developmental or degenerative. The characteristics of the symptoms can give major clues to this. It should not be assumed that each symptom relates to a single diagnosis as musculoskeletal conditions are common and often co-exist. Each symptom should be evaluated individually and interpreted only after all the findings have been collated. The management of musculoskeletal conditions requires an understanding of the impact of these conditions on the person and identification of the cause. Musculoskeletal conditions can affect the individual in a variety of ways, and these must be identified; as well as the usual features of chronic pain, stiffness and physical disability, there is frequently depression, fatigue and loss of vitality. The person may be unable to do their work in the home or in employment. There is fear of the future. Their interpersonal relationships with family, carers and friends may be affected. A multidisciplinary assessment is necessary to identify this broad range of problems to be able to develop an appropriate plan of management. There are many standardized assessments of musculoskeletal conditions for measuring impact15 and for monitoring response to treatment16 which are considered elsewhere in this issue. Finally, clinical assessment requires good clinical skills, combined with experience and knowledge, to be able to recognize what is abnormal, make a diagnosis, develop a plan of management and give a prognosis. The clinician therefore needs background knowledge of surface and functional anatomy; of the features of common musculoskeletal conditions; of their differential diagnosis, risk factors and complications; and of their likely prognosis.

PROBLEMS WITH INTERPRETATION OF CLINICAL FINDINGS Any clinical finding is like a test and must meet certain criteria of validity, sensitivity and specificity to be of value. If it is a screening test, it is important that it has a high sensitivity, that is, few false negatives, but if it is a diagnostic test, it must have good construct validity with a high specificity for the condition within the population in which

384 A. D. Woolf

it is being used. For example, a test for rheumatoid factor, if used in the population without characteristic clinical features of rheumatoid arthritis, will have a sensitivity and specificity which differs from that in a population with joint symptoms and signs. A ‘test’ being used to monitor a person will also need different characteristics, such as discriminant validity with good reproducibility and sensitivity to change. The problem is that few aspects of history and routine clinical examination have been subjected to such formal evaluation of their construct validity and where this has been done, many of the traditional clinical examination tests have been found wanting. A difficulty in validating features in the history or findings on examination is agreeing on the diagnostic gold standard. Testing reproducibility and sensitivity to change is easier and has been done for various tests.

THE PRINCIPLES OF CLINICAL ASSESSMENT The history and clinical examination are the most important steps in the evaluation of a person with a musculoskeletal problem. The whole person must be evaluated as many musculoskeletal conditions present with, or develop, symptoms and findings in other systems, and other conditions or therapy may be associated with manifestations in the musculoskeletal system. It is also important to gain the confidence of the person and establish a partnership between doctor and patient and a relationship of trust. Many of these conditions are chronic and there is a dependency on the physician for the person’s ongoing health and future quality of life. A satisfactory outcome of the consultation requires the patient’s expectation of their condition, and of the consultation, to be identified early and to be met as far as possible. This may not be the same as the clinician’s expectations (Table 1). Lack of communication is a common complaint of people after their consultation and therefore any consultation should close with a full discussion of the findings and conclusions so that the person understands the cause, the treatment, what they can do to help themselves and what is

Table 1. What is the purpose of the consultation? Expectation of the patient What is wrong? What will happen? What can you do about it? What can I do about it? Am I getting better?

Expectation of the clinician

Is there an abnormality? What is the abnormality? What effect is it having? What is the cause? Are there any predisposing or risk factors? Am I receiving the best treatment Are there any complications? as I am not improving? What treatment is indicated? What has been the response to previous treatment? Is there a response to current treatment? What is the prognosis?

History and physical examination 385

the prognosis. At the end of the consultation the person should have a realistic expectation of the likely outcome of their condition to avoid future dissatisfaction and difficulty in accepting their problem. The chronic or recurrent musculoskeletal conditions require more detailed explanation to enable the person to participate actively in their own care. Further support can be given by other health professionals, written material, the Internet and patient-support groups.

THE PROCESS OF CLINICAL ASSESSMENT—THE CONSULTATION The person may present with a specific musculoskeletal complaint that will need a detailed assessment to facilitate appropriate management of that problem (Table 2). This may just require a detailed assessment of the specific problem and the structure affected, but musculoskeletal problems frequently involve various components of the musculoskeletal or other systems and a more comprehensive assessment is necessary. In addition, musculoskeletal conditions are very common and should be sought as part of any general history and examination of all patients by a routine screen; any problems identified will require more detailed assessment. A scheme is therefore proposed for a screening assessment that can be used in routine medical practice to ensure the identification of musculoskeletal problems, and for a more comprehensive approach that can be used to characterize and facilitate the appropriate management of a musculoskeletal problem once identified. A wide range of examination techniques can be used in an attempt to characterize a problem more fully. Screening assessment The aim of a minimum screening assessment of the musculoskeletal system is that it should be sensitive to identifying the presence of any significant abnormality and be feasible to perform as part of any general examination. Different schemes have been developed but the GALS (gait, arms, legs and spine) screen is one of the most popular17 – 19, a slight modification of which is proposed here. It is composed of questions and examination techniques that have been chosen for their sensitivity for identifying any abnormality, but the cause of that abnormality will require further evaluation. The scheme proposed is a guidance that can be adapted, and the different components can be done at various stages of a general medical clerking. It takes only a few minutes and is easily annotated. It has been validated in a general medical setting and within undergraduate training.19 Screening history The common symptoms of any musculoskeletal condition are pain, stiffness and limitation of function. Joint disease is often associated with swelling. Function is frequently affected, and the ability to dress without difficulty, including socks and shoes, is a complex activity that utilizes the upper and lower limbs and is a sensitive functional test. The ability to go up and down stairs without difficulty is sensitive to detecting abnormality in the lower limbs. The presence or absence of major musculoskeletal problems can therefore be quickly established by these screening questions: † Do you suffer from any pain or stiffness in your arms or legs, neck or back? † Do you have any swelling of your joints?

386 A. D. Woolf

Table 2. A system for the assessment of a person with a musculoskeletal problem.

Screening assessment determine whether there is a problem or physical signs Is there a problem?

OR Person presents with a symptom related to the musculoskeletal system

What is the problem?

Detailed history and examination to identify symptoms and structural abnormalities

What is the effect of the problem?

Establishing from consultation the impact of the problem on function, activities and participation

What is the cause of the problem?

Combining findings from the consultation with subsequent investigations in the context of knowledge of the possible causes

What are the targets for treatment?

Multidisciplinary assessment to consider all aspects of the effect of the problem on the person

Intervention

What is the response to treatment?

Re-assessment using clinical features, laboratory investigations or health assessment instruments that are sensitive and specific to change related to the condition being monitored

and

Meeting the needs of the person with the musculoskeletal problem

Ensuring that the person with the problem is an active participant in their own management is essential; this is achieved by having the appropriate attitude and by good communication of the process, findings, conclusions and management plan

History and physical examination 387

† Do you have any difficulty with washing and dressing? † Do you have any difficulty with going up or down stairs or steps? Musculoskeletal conditions should not be considered in isolation as they are often associated with systemic features, and general enquiry about their health should be made. Screening examination Any significant abnormalities in the spine, arms or legs can be identified by inspection at rest and during certain movements with brief palpation and stress tests of selected joints. Good observation and familiarity with what is normal and abnormal is essential. Abnormality is recognized by observing appearance, posture and resting position of the joints and loss of smooth movement through the expected normal range. There is usually one movement that is nearly always abnormal when any joint is affected by a musculoskeletal condition and it is these movements that are assessed in this screen. The gait, arms, legs and spine should be assessed routinely. Gait The patient should be observed walking forwards for a few metres, turning and walking back again. Abnormalities of the different phases should be looked for—heel strike, stance phase, toe off and swing phases. Abnormalities of movement of the arms, pelvis, hips, knees, ankles and feet can also be observed during these phases. The standing patient The patient should be viewed from the back, side and front looking for any abnormalities, in particular of posture and symmetry. Examine for tender myofascial spots by applying pressure in the midpoint of each supraspinatus and rolling an overlying skin fold. Spine Lateral flexion of the neck to each side is a sensitive movement. Ask them to bend forward and attempt to touch their toes while standing with the legs fully extended. Observe and feel for normal movement by placing several fingers on lumbar spinous processes. Arms Placing both hands behind the head with elbows right back is a sensitive test of many components of the shoulder apparatus. Straighten the arms down the side of the body and then inspect with elbows bent to 908 with palms down and fingers straight. Turn hands over and make a tight fist with each hand. Place in turn the tip of each finger onto the tip of the thumb. Squeeze the metacarpals from 2nd to 5th. Legs With the patient reclining on a couch, flex in turn each hip and knee while holding and feeling the knee. Then passively rotate the hip internally. With the leg extended, resting on the couch, examine for tenderness or swelling of the knee by pressing down on the patella while cupping it proximally. Squeeze all the metatarsals and finally inspect the soles of the feet for callosities.

388 A. D. Woolf

Such a screening examination should take a few minutes and should identify abnormalities that then need fully assessing and can be easily documented. Musculoskeletal clinical evaluation The person either presents with a musculoskeletal problem or it has been identified by a screening assessment. A full clinical evaluation is required. This can be divided into several phases which, in practice, overlap throughout the consultation process: Open phase † Listen and observe History † † † †

Symptoms Chronology—temporal and anatomical pattern Impact Other aspects

Examination † Musculoskeletal system † Systemic examination Investigations † Diagnostic † Monitoring Conclusion † Analysis and interpretation † Management plan † Explanation and reassurance: tell the patient what is wrong, the cause, the prognosis, the treatment and its likely benefits and risks History taking is by far the most important part of this evaluative process, to which examination and investigations are complimentary. However, it has not been formally evaluated as to how much each contributes to problem solving. The key information to be established is: what has brought the person to the consultation, the characteristics of their problem, and their concerns and expectations. In addition, the impact of the problem is central to developing a plan of management. The examination is used to complement the history in order to confirm the cause and effect of the musculoskeletal problem. The role of investigation in the assessment of the musculoskeletal system is usually to confirm suspicions from the history and examination. Investigations should be performed only if the results will influence decision making. It may be appropriate to concentrate the clinical evaluation relatively quickly and exclusively on the specific localized problem with which the person presents, but in the majority of cases it is necessary to make a full assessment, particularly as an apparently

History and physical examination 389

simple local problem may be the manifestation of a more generalized condition or the symptoms may be referred from a distant site. The initial phase of a consultation should be open and should allow the patient to be listened to and observed—and allow the patient to appreciate the caring attitude of the physician. Open questions allow the patient to tell their story and will avoid their frustration after the consultation of not feeling listened to. With a little guidance, the person can express the problems that really bother them. Careful observation should include the overall appearance of the patient (biological age, gender, body height, body shape, obesity, skeletal deformity, appearance ‘spell’ illness, anaemia, depression or emotional distress); their movements (hesitant, laboured, inhibited, painful, restricted, gait, use of walking aid, ability to sit down and get up again, ability to dress, especially footwear); and their manner (resentful, aggressive, unduly demanding, manipulative, argumentative, frustrated, their effect).

HISTORY The purpose of taking the history is to clarify what has brought the patient to the consultation and what their expectations are; to characterize fully the nature of the condition and its impact—the current symptoms, the chronology of the condition, including the influence of any therapy, and the impact of the disorder in both physical and psychological terms; and to explore other factors that might influence this—such as clues to diagnosis from family or present and past general history, risk factors related to lifestyle or occupation, and factors that may influence impact, such as their expectation and socio-economic environment. This requires background knowledge of the possible diagnosis, associated risk factors, expected effects of the condition and options for intervention to guide the interview. Symptoms of musculoskeletal conditions Musculoskeletal conditions affect the individual in a variety of ways. They are the most common causes of chronic pain. There may be stiffness of the spine or limbs, and weakness and deformity are often described. In addition, there is frequently loss of vitality, poor-quality sleep, fatigue and depression. There is fear for the future. These symptoms are frequently accompanied by loss of function and mobility, limitation of activities and restriction of participation. Their interpersonal relationships may be affected. These features are the core domains when formally assessing the impact of musculoskeletal conditions. The symptoms need to be characterized in terms of their quality, onset, site and pattern, including chronology and the factors that influence them. Clinical experience suggests that this helps to differentiate a rheumatic complaint into six main types: † † † † † †

inflammatory musculoskeletal disease mechanical joint or periarticular disorder bone disorders non-rheumatic disease causing musculoskeletal symptoms a functional disorder or another of unknown cause However, the sensitivity and specificity of these characteristics are poorly evaluated.

390 A. D. Woolf

Pain Pain needs to be characterized by its site and distribution; characteristics and pattern; preceding and precipitating factors; factors which worsen or improve symptoms; associated symptoms; symptom response to health interventions and impact. These characteristics are considered important in identifying its cause and effect but there is little evidence for the sensitivity and specificity or positive predictive power of this approach. The typical patterns of pain are listed below: † Bone pain—pain at rest and at night Tumour Paget’s disease Fracture † Mechanical joint pain—pain related to joint use only Unstable joint † Osteoarthritic joint pain—pain on joint use, stiffness after inactivity, pain at end of day after use † Inflammatory joint pain—pain and stiffness in the joints in the morning, at rest and with use Inflammatory joint disease Infective † Neuralgic—diffuse pain and parasthesia in dermatome, worsened by specific activity Root or peripheral nerve compression † Referred—pain unaffected by local movement The site and distribution of pain should be established by description and by the patient demonstrating on themselves where the pain is felt, where it is most intense and where it radiates to. It is helpful to distinguish generalized pain, such as that due to fibromyalgia or polymyalgia rheumatica, localized pain such as that due to an arthropathy or a soft-tissue lesion, and referred pain. ‘Red flags’ need recognizing— for example, pain at multiple sites that is not just related to joints and which may be due to myeloma or metastatic malignancy. The full differentiation of the anatomical site of origin of pain usually requires examination of the patient. The features of the pain, the time and mode of onset, diurnal pattern and evolution contribute to diagnosis. Severity is subjective. Pattern recognition is important in identifying a likely cause of pain. A good example is gout which usually begins in the middle of the night with a pricking sensation in the great toe and quickly builds up into an intolerable persistent burning pain; whereas osteoarthritis is characterized by userelated pain and inactivity stiffness of the affected joints. Mechanical pain is generally related to use. Inflammatory joint pain is present at rest and with use and is usually worse at either end of the day. Neuralgic pain is diffuse, often worsened by a specific activity and associated with parasthesia in the dermatome. Bone pain is typically present at rest and at night. However, these descriptions are not diagnostic and their specificity is unknown. The pattern of evolution of the pain in conjunction with the development of any other symptoms can give further leads to diagnosis. For example, the pain may have the characteristics of an inflammatory polyarthropathy but rheumatoid arthritis typically

History and physical examination 391

follows a gradual additive course whereas a viral arthropathy is of acute onset, often with systemic features of malaise or rash. Factors that have precipitated pain, or which affect it, need to be established. Any preceding trauma, or repetitive or unusual use, should be identified. The differential response to rest and to exercise is a feature of sacroiliitis versus simple back pain and osteoarthritis versus inflamatory joint diseases. Response to treatment can provide clues. The response to anti-inflammatory analgesics compared with simple analgesics can help to distinguish an inflammatory cause of symptoms, such as ankylosing spondylitis compared with mechanical back pain, and the response of polymyalgia to glucocorticosteroids is characteristic. Pain is a subjective sensation that cannot be felt by others, cannot be remembered exactly and has psychological effects, including fear. Although it can be measured on various self-administered scales, it has different effects on different individuals for the same level of severity. The response to pain and the degree to which it disrupts the person’s life gives a more meaningful indication of severity, such as sleep disturbance, mood and effect on specific functions or activities.

Stiffness ‘Stiffness’ is a common symptom of musculoskeletal conditions and is used as a diagnostic criterion for rheumatoid arthritis and osteoarthritis. It means different things to different people and what it is being used to describe needs clarifying with the individual patient. ‘Stiffness’ is often described after prolonged rest—such as a long car journey, or the day after an unusual level of exercise; it is more common as people age. More specifically, patients often describe stiffness related to their symptomatic joints or back. An inflammatory joint disorder is generally associated with severe and prolonged morning and evening stiffness, whereas osteoarthritis is associated with short-lived but severe stiffness after inactivity. The stiffness following inactivity of the osteoarthritic joint is principally a difficulty in the initiation of movement, but morning stiffness in rheumatoid arthritis usually describes a more constant difficulty in moving the joints through any part of their range. Stiffness of movement of the fingers can relate to tenosynovitis, sometimes with triggering, joint disease or tightening of the soft tissues—such as in systemic sclerosis or with Dupreytren’s contracture. ‘Stiffness’ can also be used to describe pain or aching in joints with movement, to mean a reduced or limited range of movement, or used by the patient to describe the difficulty in movement associated with muscle disease such as myositis and motor neurone disease. One of the disorders most characterized by morning stiffness is polymyalgia rheumatica. The duration of morning stiffness can indicate the activity for several conditions such as rheumatoid arthritis or polymyalgia rheumatica, but it is an inconsistent symptom.

Weakness and instability Weakness may be used to describe a specific loss of strength, may describe the sensation of ‘giving way’ due to joint instability, or may describe general fatigue. True muscle weakness may be due to pain, to local muscle wasting that can accompany joint damage, or may be a result of limited range of joint movement. It can also result from a muscle disorder such as polymyositis or from a neuropathy. The pattern of muscle weakness and its central or peripheral distribution should be established. Regional weakness is more likely to have a specific cause that needs identifying.

392 A. D. Woolf

Swelling Swelling is an important symptom that needs characterization by both the history of its evolution and related symptoms, as well as by careful examination. Examination is necessary to confirm whether it is related to the joint or to a periarticular structure, and to establish whether it is due to an effusion or synovial proliferation or is bony. It may be necessary to carry out imaging of the soft tissues, the joint or bone. Loss of function The major impact of musculoskeletal conditions is the difficulty in performing various activities and this may be the presenting complaint. It is uncommon for these limitations to arise in the absence of a complaint of pain and/or stiffness but the painless loss of movement suggests a tendon rupture or a neurological cause. The impact of musculoskeletal conditions should be fully explored in how it affects activities and participation. Fatigue, loss of vitality, malaise and emotional lability Fatigue and loss of vitality is a manifestation of most generalized rheumatic disorders, including rheumatoid arthritis, systemic lupus erythematosus and, most notably, fibromyalgia. Fatigue may also be the consequence of poor sleep often related to pain or depression. It may be severely disabling and the major complaint. The fatigue of rheumatoid arthritis or systemic lupus erythematosus is a good indicator of the systemic activity of the disease. The time at which fatigue becomes a problem is sometimes used, along with the duration of morning stiffness, as one of the monitors of disease activity. Anxiety and depression are common accompaniments of chronic painful or disabling musculoskeltal conditions, although they are not often severe. Emotional lability, depression and other psychiatric disturbances can also be the direct result of a rheumatic disease, such as systemic lupus erythematosus. What is the pattern and chronology of symptoms The pattern of distribution and chronological development of the symptoms need to be established. Different patterns are characteristic of different conditions and, if articular, it is of value to establish whether it affects peripheral small joints, large joints or the axial skeleton, whether it has followed an additive, intermittent or flitting course or whether it is symmetric or asymmetric. The early recognition of inflammatory arthritis that is likely to progress to rheumatoid arthritis is central to strategies for early treatment. The development and timing of any non-musculoskeletal symptoms or signs, the influence of drug therapy or any other interventions, and the relationship of the symptoms to activities and life events are also relevant. Other clues to the diagnosis Musculoskeletal conditions must be assessed in the context of the general health of the person as these conditions often have systemic features, and systemic disorders often have musculoskeletal symptoms. This must be done in the context of knowledge, and specific questions should be directed by knowledge of the differential diagnosis under consideration. The diagnosis of connective tissue diseases, reactive arthritis and psoriatic arthritis is often delayed because of a failure to do this. Clues to the present problem may also be gained from preceding events, such as a previous attack of unexplained epilepsy in someone with lupus or fetal loss in

History and physical examination 393

antiphospholipid syndrome—or a story of a swollen ankle in childhood in a young man with back pain who has now developed ankylosing spondylitis. The family history can help towards the differential diagnosis in some situations, although almost everyone has a relative with arthritis and familial associations are seldom predictive. Importantly, a family history gives personal experience of the potential impact of a rheumatic condition and affects the person’s anxieties about their own diagnosis and prognosis. Useful clues include a recent flu-like illness in the family or other close contacts, raising the possibility of a viral arthritis; nodal arthritis affecting the mother when deciding whether the small joint polyarthralgia of the hands is early rheumatoid arthritis or nodal osteoarthritis (NOA); a family history of ankylosing spondylitis, iritis or psoriasis in a young man presenting with back pain; or a history of gout in the family. Hypermobility may also be familial. Occupation may have a causal role or an effect on the symptoms, such as back pain and regional pain syndromes. Life-style risk factors, such as smoking and alcohol intake, can be important in a few cases: smoking may be of great relevance in someone with rheumatoid arthritis who develops fibrosing alveolitis, for example, and alcohol can be an important factor in the pathogenesis of gout. There are recognized risk factors for osteoporosis. Sexual history is of relevance to reactive arthritis, gonococcal arthritis and acquired immunodeficiency syndrome. Previous health interventions Previous and present management should be reviewed. This includes the patient’s understanding of their condition and what explanations have been given as well as the specific management and their response to this, both beneficial as well as adverse effects. Many patients take ‘alternative’, ‘complementary’ or other over-the-counter medicines in addition to prescribed drugs, or have sought the help of an ‘alternative’ practitioner and their responses to this should also be noted. Many may be taking nonsteroidal anti-inflammatory drugs (NSAIDs) over the counter in addition to prescribed NSAIDs without being aware of it. What is the impact of a musculoskeletal condition? The impact of the musculoskeletal condition must be assessed to understand the problems of the individual and their carers and to develop a plan of management that will try and address these problems. This impact will be affected by their aspirations and expectations. Psychosocial issues are just as important as the physical ones when considering the impact of a rheumatic disorder on a person. This can be explored in the context of a framework such as the WHO ICF which looks at the effect of any health condition on the functioning of an individual in terms of loss of function, limitation of activities and restriction of participation within the context of their life (see Chapter 6 in this issue). There are two aspects to the context of an individual’s life— environmental and personal. Environmental factors refer to all aspects of the extrinsic world that may have an impact on that person’s functioning. Personal factors relate to the individual, such as age, gender, social status, life experiences and so on. The context of the person’s life will interact with and affect the impact and progression of the disabling process at each stage. Clearly, identifying what contributes to the impact at all these different levels is essential to developing an effective plan for management. There are certain domains that are most important to those with musculoskeletal conditions— pain related to the musculoskeletal system, bones and joints; energy/vitality and anxiety; mobility; the ability to perform activities of daily living and to be able to participate in

394 A. D. Woolf

society. The effect on health-related quality of life can be formally assessed using various validated generic and disease-specific questionnaires, such as the Health Assessment Questionnaire (HAQ).15

EXAMINATION The recognition of abnormality and its characterization is the goal of a good examination. This requires careful observation of structure, movement and function and also establishing consistency with the history. The reproducible assessment of clinical abnormalities for the monitoring of the course of a condition, such as scoring joints for swelling and tenderness in rheumatoid arthritis or measuring spinal movement in ankylosing spondylitis, requires standardization of techniques. Careful training is necessary to achieve reasonable reproducibility of these tests, without which their usefulness is greatly limited. The aim of the examination—as well as the limitation of what information can be gained from the examination—must be considered before performing various examination techniques that are difficult to interpret because of the lack of construct validation. The principle of whether the findings will alter management should be applied to clinical examination tests just as much as to laboratory tests or imaging. Aims of examination The aim of the clinical examination of the musculoskeletal system is to answer three questions which, in combination with the history, should establish the differential diagnosis: † Is it normal? † What is the abnormality, its nature, the structures involved and the pattern of distribution? † What other features of clinical importance are there? The purpose of the examination must also be remembered along with the limitation of what can be interpreted from the findings. For example, is the purpose to establish whether the presenting problem relates to the lumbar spine and to exclude a specific cause, or is the aim to try to establish the exact nature of the mechanical abnormality in order to guide therapy—in which case, special examination techniques are used, although their validity is unclear. Is the purpose to decide whether knee pain relates to a meniscal lesion that requires further assessment? Is it to identify whether the cause of joint symptoms relates to osteoarthritis or inflammatory arthritis—in which case, examination plays an important part, although imaging techniques such as ultrasound and magnetic resonance imaging are more sensitive. In many cases, the clinical findings are a guide to the nature of the abnormality and further assessment is required to confirm diagnosis and establish plan of management. Is it normal? There must be sufficient familiarity with normality for recognition of the expected appearance and ranges of movement of the musculoskeletal system. What is the abnormality? A careful examination within the knowledge of surface and functional anatomy should enable the identification of the structure that is involved. The nature of the abnormality needs to be established. Is there evidence of inflammation, damage, mechanical defects and/or biomechanical abnormalities? These

History and physical examination 395

are not mutually exclusive, and a combination of them may be found. Are there any ‘red flags’ suggesting a significant or urgent underlying problem such as bony tenderness due to a metastasis or buttock pain with perineal sensory deficit suggesting cauda equina compression. An inflamed joint is characterized by pain and tenderness, warmth, redness and swelling. Swelling of an inflamed joint is characterized by its articular origin, is fluctuant due to synovial proliferation or effusion, and is tender, whereas there may be bony swelling along the joint line in osteoarthritis. There are a number of specific techniques for detection of synovitis and effusion at different joints (Figure 1). The ability to detect this is central to assessing disease activity in rheumatoid arthritis. Synovitis of the joint must be carefully distinguished from inflammation of periarticular structures such as tendon sheaths or bursae. Joint damage is characterized by deformity, crepitus, movement in an abnormal plane and loss of joint range of movement in the absence of features of active inflammation. There may be painful restriction of movement in a certain plane in the absence of inflammation due to mechanical defects, such as a knee with an impacted meniscal tear; or ‘locking’ of the spine in lumbar intervertebral disc prolapse. Joint deformity usually describes malalignment or subluxation and is identified by abnormal posture. There may be movement in an abnormal plane of a joint severely damaged from rheumatoid arthritis or osteoarthritis. For example, the elbow is a simple hinge joint; its normal range is only flexion/extension, and any other movement, such as elbow abduction, is abnormal and is likely to indicate gross joint disruption. Hypermobility describes a range of joint motion in excess of that expected for age, gender, genetic kit and ethnic origin. The joint range is reduced by joint inflammation or by irreversible damage to the joint structures; complete loss of movement with ankylosis of the joint can occur, in particular in ankylosing spondylitis or following joint infection. The distribution of involvement of the musculoskeletal structures is important in the diagnosis of musculoskeletal conditions became certain patterns are characteristic. A careful examination is needed to confirm the pattern of distribution established by the history and to ascertain whether the various problems relate to a single diagnosis or to several coincident problems. What other features of diagnostic importance are there? Many musculoskeletal conditions are associated with systemic features, which may be important for diagnosis or to assess severity. These include their general appearance and easily visible skin signs such as skin laxity, rashes, nodules or vasculitic lesions. Identification of other features, such as neuropathy, will need a careful general examination. Method of examination It is important to look at the whole person, their posture and movement, and then to examine—region by region—comparing one side with the other. A full examination of the musculoskeletal system is usually necessary for a correct assessment of the problem, but emphasis should be placed on the likely origins of the symptoms, remembering that pain is frequently referred and that any examination must consider all possible causes. It is important that there is greatest competency in assessing common or serious problems. The key elements of the examination of the musculoskeletal system are to inspect (look), to palpate (feel), to assess both passive and active movement and movement against resistance (move) and finally to assess stability (stress). These elements of

396 A. D. Woolf

the examination are usually performed in an integrated way. Special tests may be necessary to identify specific problems. The examination of the musculoskeletal system should be part of a general examination to identify related and unrelated abnormalities. A

B

Figure 1. (A) Testing for swelling and fluctuation of the small joints of the hand. Detect cross fluctuation at the joint line with the index fingers and thumbs, with the examiner’s fingers squeezing and feeling each side of the joint (as illustrated) or one index finger/thumb squeezing and feeling from side to side and the other from palmar to dorsal aspects (‘interlocking C’). (B) The bulge sign in the knee. The back of the hand gently pushes the fluid from one side of the knee to the other, filling out the ‘dimples’ either side of the patella. This is most helpful in detecting small knee effusions. (C) The patella tap. One hand is used to cup the patella and compress the suprapatellar pouch, and the fingers of the other hand press down on the patella to feel for cross fluctuation. Adapted with permission from JH Klippel & PA Dieppe (Eds) Rheumatology, 2nd edn 1998, Mosby and R Mc Rae Clinical Orthopaedic Examination, 4th edn 1997, Churchill Livingstone, Edinburgh.

History and physical examination 397

C

Figure 1 (continued )

Look Many of the abnormalities associated with musculoskeletal conditions can be identified by careful observation of the person undertaking various functional movements during the consultation. Note the way the person moves, performs activities and the attitude in which they hold the affected region. Joint and spinal deformities are usually more apparent on weight-bearing or with use. They should be recorded—but attempting to measure them accurately is of limited value because of poor reproducibility. Examination is necessary to determine whether they are correctable. Swelling can be observed, but palpation is necessary to characterize it. There may be skin changes, such as redness, overlying a joint indicating marked inflammation, or other skin changes such as psoriasis, ulceration, livedo reticularis and nodules. There are characteristic changes in the nail fold capillaries in certain connective tissue diseases that should be looked for. Muscle wasting can usually be detected by careful inspection. Impaired circulation may be apparent by discoloration of the skin. Feel First feel gently for warmth, which is best elicited by using the back of the fingers and comparing with a normal structure. Ensure that sensation to a light touch is normal. The presence and localization of tenderness is important in identifying the cause of the problem; it is necessary to examine carefully to establish whether it is the joint line, periarticular, or muscular, either generalized, such as in myositis, or localized such

398 A. D. Woolf

as the characteristic tender spots of fibromyalgia. Gradually increase pressure while watching the person for any reaction and releasing as soon as the presence of tenderness is established. Use pressure only until blanching of the nail of the examining fingers. Bone tenderness, such as that of the vertebrae, can be elicited by percussion. Any swelling should be characterized to determine its precise location and anatomical associations, whether it is tender, and whether it is fluid, soft tissue or bone. Fluid and soft tissue is ballotable and this is the principle of joint palpation such as the patellar tap and the interlocking-C examination of the interphalangeal joints (Figure 1). Swelling of the joint originates from the joint line and this should be identified and palpated. Feeling the joint and periarticular structures while moving it can give information about pain and tenderness as well as helping to detect crepitus from the joint or tendon sheaths. Move There are three methods for assessing joint movement: active, passive and against resistance. The recognition of abnormality requires familiarity with the normal ranges and planes of movement relevant to that particular joint. If the problem is unilateral, comparing the affected with the unaffected side can best assess the range of movement and establish whether there is a loss. Formal measurement is of limited value. Involvement of the joint, in particular synovitis, usually affects all movements, although some movements are more sensitive than others. Restriction of movement in one plane is characteristic of periarticular lesions, tenosynovitis and internal derangement of the joint. The characteristics of joint pain on movement indicate the cause. An increase in pain towards the extremes of restricted movement—with none, or little pain, in the midrange—is described as stress pain. Its presence in all directions is a good indicator of synovitis. Its presence in just one plane of movement indicates a localized articular or periarticular problem. Pain throughout the range of movement is more characteristic of mechanical problems such as osteoarthritis. Movement against resistance measures power, although this is difficult to assess fully in the presence of pain. Resisted active movement is more valuable in identifying problems that relate to the muscle tendon or enthesis. This should be performed with the joint in a neutral position; the reproduction of pain indicates that it is originating from the muscle, tendon or tendon insertion relevant to that movement. Passively stretching the tendon or ligament may also reproduce the pain. Stress Stability should be established by stressing the joint to see whether there is any movement in abnormal planes for that joint. Instability can be due to generalized hypermobility, ligament rupture subsequent to trauma or inflammation, capsular inflammation, or loss of articular cartilage and bony changes due to osteoarthritis or rheumatoid arthritis. Special tests There are various special tests for specific diagnoses but these are not considered here.

History and physical examination 399

Regional examination of the musculoskeletal system A systematic approach to examination should be taken but be sure to address any questions raised by the history. It is easiest to look at the patient as a whole walking, standing and undressing. Then work from the head downwards and compare one side with the other for each limb. In summary: † Watch the patient walk and undress † Look at the posture with the patient standing undressed to their underwear † Examine the: Neck Shoulders Arms Hands Spine and pelvis Hips Knees Ankles and feet Gait Observation of the full gait cycle demonstrates the integrated function of the lower limbs and will reveal abnormalities of the neuromusculoskeletal system. Further assessment of the lower limbs will be necessary to identify the specific cause of any abnormality of gait. Certain abnormal patterns of gait are well recognized. An antalgic gait describes when pain in one limb causes the avoidance of weight-bearing by that limb, with shortening of that phase of the gait cycle and shorter steps on the painful limb. A Trendelenburg gait results from dipping of the pelvis to the other side when weightbearing on the affected limb due to weakness of the hip adductors. During the gait cycle, the person leans their upper body over the weak hip to compensate for this to keep their balance and there is side-to-side movement of the shoulders when walking. Sideto-side movement of the shoulders is also seen if there is an inequality of leg length leading to tilting of the pelvis during the gait cycle. An alternative gait—with leg length inequality—involves flexing the knee of the longer leg to clear the ground during the swing phase, with consequent dipping of the person up and down. A drop foot results in a high-stepping gait to avoid tripping on the toes during the swing phase. Posture The normal symmetry of the body helps to identify abnormalities of posture. The whole person should be observed standing undressed to their underwear, and equality of height of landmarks—the shoulder tips, the scapulae, the pelvic brim, the crease of the buttock and normal curvature of the spine standing and on flexion—should be looked for. The posture of the feet should be observed for their normality when weightbearing. Regional examination There are various techniques for examining the different regions of the musculoskeletal system. Different techniques are used by different experts—rheumatologists,

400 A. D. Woolf

orthopaedic surgeons, physiotherapists and those specializing in manipulative medicine. Which techniques are used in practice depends on the purpose of the examination and largely varies by the extent of examination and use of special tests. The identification of abnormality and its characterization is the first level but then there are various techniques to try and further establish the exact nature or cause of the abnormality that will influence the management of the problem. This level is more difficult for many potential abnormalities and is more dependent on investigations for confirmation. The methods suggested for examining different regions are well documented and should be referred to.20 – 22 These follow the previously outlined principles of look, feel and stress and the special tests where appropriate. Although there is a move towards agreement of what is taught to give a minimum level of competency23,24, the debate is about how far one should go with the use of various traditional clinical tests when their construct validity is unclear and better methods of imaging are increasingly accessible.

DOCUMENTATION The history and examination need to be documented. The history should form a clear story which another clinician can read, assess and interpret. The examination is documented most easily on a homunculus. A standardized approach is recommended to denote deformities, restricted movement, joint swelling and joint tenderness similar to that used for the formal documentation of joint scores.16

CONCLUDING THE CONSULTATION Interpretation The consultation should result in the identification of the cause of the person’s problems, assessment of the severity and response to any treatment, and the formulation of a management plan; this, and the expected outcome, should be fully discussed with the patient. The history and findings on examination—with knowledge of the possible causes and results of appropriate investigations—must be integrated to make a diagnosis. Knowing what is likely at different stages of life in different individuals, looking for clues throughout the consultation and pattern recognition are all important. A specific diagnosis, together with the identification of other determinants of outcome, enable a prognosis to be given. The assessment of disease activity and severity is also essential for good management and this is based on a combination of symptoms, signs and disease markers such as the acute-phase response or radiological changes. Treatment needs to be adjusted accordingly, and any assessment must separate out these factors to ensure that the right target is being treated. Poor pain control due to depression will not respond well to disease-modifying therapy for rheumatoid arthritis. Communicating the findings The most important part of the consultation, especially for the patient, is communication of the findings and conclusions. This can lead to the greatest dissatisfaction by the patient. This part of the consultation must very much focus on

History and physical examination 401

the patient’s expectations and concerns. It is sometimes difficult to explain the reason for all musculoskeletal symptoms with precise tissue-based causes, and this can result in loss of confidence in the physician. Concepts of mechanical back pain and fibromyalgia can be difficult for the patient to grasp. This part of the consultation needs the most time, and a specialist nurse can supplement the information required by the patient. There is also a lot of material available about musculoskeletal conditions from support organizations, such as the Arthritis Foundation or Arthritis Care, and from the Internet, although the latter is also a source of misinformation.

SUMMARY This chapter considers the ideal clinical assessment for identifying and characterizing a musculoskeletal problem. It outlines an approach that is followed by most specialists in rheumatology, orthopaedics or rehabilitation—an approach that can be used for teaching other clinicians going into primary care or at the beginning of specialist training.

Practice points † the history and clinical examination are the most important steps in the evaluation of a person with a musculoskeletal problem † the purpose of assessing an individual is to identify and characterize their problem to enable a diagnosis to be made, to identify the effect of the problem and targets for treatment and to monitor response to treatment † the clinical evaluation should be in the context of identifying and evaluating the symptoms and structural changes and their causes, any functional abnormality and the impact on the person in terms of limitation of activities and restriction of participation † a screening assessment can be used in routine medical practice to ensure the identification of musculoskeletal problems † a comprehensive approach can be used to characterize and facilitate the appropriate management of a musculoskeletal problem once identified † the history should clarify what has brought the patient to the consultation and what their expectations are, and should characterize the nature of the condition and its impact † the recognition of abnormality and its characterization is the goal of a good examination † the consultation should identify the cause of the person’s problems, the assessment of severity and their response to any treatment † the most important part of the consultation is the communication of the findings and conclusions to the patient

Research agenda † there is a need to evaluate the construct validity, sensitivity and specificity of many traditional aspects of the history and features on clinical examination

402 A. D. Woolf

REFERENCES ˚ kesson K. Editorial. Understanding the burden of musculoskeletal conditions. British 1. Woolf AD & A Medical Journal 2001; 322: 1079–1080. 2. The consensus document. The Bone and Joint Decade 2000–2010. Inaugural Meeting 17 and 18 April, 1998, Lund, Sweden. Acta Orthopaedica Scandinavica, 69 (supplement 281) 67–86. 3. Murray CJL & Lopez AD (eds) The Global Burden of Disease. A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Published by the Harvard School of Public Health on behalf of the WHO and the World Bank, distributed by Harvard University Press, 1996. 4. Genant HK, Cooper C, Poor G et al. Interim report and recommendations of the World Health Organisation Taskforce for Osteoporosis. Osteoporosis International 1999; 10: 259– 264. 5. Yelin E & Callahan LF. The economic cost and social and psychological impact of musculoskeletal conditions. Arthritis and Rheumatism 1995; 38: 1351–1362. 6. Rasker JJ. Rheumatology in general practice. British Journal of Rheumatology 1995; 34: 494–497. 7. Woolf AD. The Bone and Joint Decade 2000–2010 (editorial). Annals of the Rheumatic Diseases 2000; 59: 81–82. 8. Glazier RH, Dalby DM, Badley EM et al. Determinants of physician confidence in the primary care management of musculoskeletal disorders. Journal of Rheumatology 1996; 23: 351– 356. 9. Moorhead RG & Lawrence CO. Continuing medical education needs for local general practitioners. Australian Family Physician 1994; 23: 1929–1933. 10. Brooks PM. Undergraduate education in rheumatology. British Journal of Rheumatology 1996; 35: 203–206. 11. Ahern MJ, Soden M, Schultz D & Clarck M. The musculoskeletal examination: a neglected clinical skill. Australian and New Zealand Journal of Medicine 1991; 21: 303 –306. 12. Crotty M, Ahern MJ, McFarlane AC et al. Clinical rheumatology training of Australian medical students. Medical Journal of Australia 1993; 158: 119–120. 13. World Health Organisation/Europe. Health 21—The Health for All Policy for the WHO European Region—21 Targets for the 21st Century. Copenhagen: WHO Regional Office for Europe, 1988. 14. WHO International Classification of Functioning, Disability and Health. Available at: http://www3.who. int/icf/icftemplate.cfm. 15. Fries JF, Spitz P, Kraines RG & Holman HR. Measurement of patient outcome in arthritis. Arthritis and Rheumatism 1980; 23: 137–145. 16. van Riel PLCM, van Gestel AM, Scott DL on behalf of the EULAR Standing Committee for International Clinical Studies Including Therapeutic Trials. The EULAR Handbook of Clinical Assessments in Rheumatoid Arthritis. Alpen an den Rijn, The Netherlands: van Zuiden Communications, 2000. 17. Doherty M, Dacre J, Dieppe P & Snaith M. The ‘Gals’ locomotor screen. Annals of the Rheumatic Diseases 1992; 51: 1165– 1169. 18. Plant MJ, Linton S, Dodd E et al. The GALS locomotor screen and disability. Annals of the Rheumatic Diseases 1993; 52: 886–890. 19. Fox RA, Dacre JE, Clark CL & Scotland AD. Impact on medical students of incorporating GALS screen teaching into the medical school curriculum. Annals of the Rheumatic Diseases 2000; 59: 668–671. 20. Woolf AD. History and examination. In Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME & Weisman MH (eds) Rheumatology, 3rd edn. Mosby, 2003. 21. Doherty M, Hazleman BL, Hutton CW et al. Rheumatology Examination and Injection Techniques, 2nd edn. London: W.B. Saunders, 1999. 22. McRae R. Clinical Orthopaedic Examination, 4th edn. Edinburgh: Churchill Livingstone, 1997. 23. Walker DJ & Kay LJ. Musculoskeletal examination for medical students: the need to agree what we teach. Rheumatology 2002; 41: 1221–1223. 24. Woolf AD, A˚kesson K, Walsh N. Core recommendations for a musculoskeletal undergraduate curriculum. Submitted for publication.