HISTORY NOTES

THE MUSCULOSKELETAL SYSTEM

COMMON PRESENTING SYMPTOMS

Pain
¡ In musculoskeletal pain, the acronym SOCRATES prompts questions that reveal useful diagnostic clues.
Site
¡ illustrates the anatomy of a typical joint. Determine which component is painful: the joint (arthralgia), muscle
(myalgia) or other soft tissue.
¡ Pain may be localized and suggest the diagnosis, such as a red, hot, tender first metatarsophalangeal joint in gout
or swelling of several joints suggesting an inflammatory arthritis.
Onset
¡ Pain from traumatic injury is usually immediate and exacerbated by movement or hemarthrosis (bleeding into
the joint).
¡ Inflammatory arthritis can develop over 24 hours, or more insidiously.

¡ Crystal arthritis (gout and pseudogout) causes acute, severe pain that develops quickly, often overnight.

¡ Joint sepsis causes pain that develops over 1–2 days.

WHAT ARE POSSIBLE SYMPTOMS FOR SUCH JOINT PROBLEM ?

Acute gout of the first metatarsophalangeal joint. This

causes swelling, erythema, and extreme pain and
tenderness (podagra)
¡ Character of the pain
¡ Describe the significance of pain character in the diagnosis of the disease of musculoskeletal
system
¡ Radiation
Pain from nerve compression radiates to the distribution of that nerve or nerve root , such as lower leg pain in
intervertebral disc prolapse, or hand pain in carpal tunnel syndrome.
Neck pain radiates to the shoulder or scalp. Hip pain is usually felt in the groin but may radiate to the thigh or knee
¡ Associated symptoms
Swelling and redness of a joint indicate inflammatory arthritis.
¡ Timing (frequency, duration and periodicity of symptoms)
A history of several years of pain with a normal examination suggests fibromyalgia . A history of several weeks of
pain, early-morning stiffness and loss of function is likely to be an inflammatory arthritis. ‘Flitting’ pain starting in one
joint and moving to others over a period of days is a feature of rheumatic ever and gonococcal arthritis. If
intermittent, with resolution between episodes, it may be palindromic rheumatism.
¡ Exacerbating/relieving factors Inflammatory arthritis the pain is mostly severe and apparent in the morning

Pain from joints damaged by intra-articular derangement or osteoarthritic degeneration worsens with exercise. Pain
from inflammatory arthritis worsens with rest. Pain from a septic joint is present both at rest and with movement.
¡ Severity
Apart from trauma, the most severe joint pain occurs in septic and crystal arthritis. Disproportionately severe pain is
seen acutely in compartment syndrome (increased pressure in a fascial compartment, compromising perfusion and
viability of compartmental structures) and chronically in complex regional pain syndrome. Neurological involvement
in diabetes mellitus, leprosy (Hansen’s disease), syringomyelia and syphilis (tabes dorsalis) may impair joint sensation,
reducing pain despite obvious pathology on examination. Grossly abnormal joints may even be pain-free (Charcot
joints). Partial muscle tears are painful; complete rupture may be less so
PATTERNS OF JOINT INVOLVEMENT

Different patterns of joint involvement aid the differential diagnosis.

¡ Are the small or large joints of the arms or legs affected?
¡ How many joints are involved? 4 or less mono arthritis
And symmetry
Mention the difference between monoarthritic and polyarthritis
¡ Predominant involvement of the small joints of the hands and feet suggests an inflammatory arthritis, such as
rheumatoid arthritis or systemic lupus erythematosus (SLE)
¡ Medium- or large-joint swelling is more likely to be degenerative (osteoarthritis) or a seronegative arthritis (such
as psoriatic arthritis).
¡ Nodal osteoarthritis has a predilection for the distal interphalangeal (DIP) joints of the hands and the
carpometacarpal (CMC) joint of the thumb.
STIFFNESS

¡ Ask what the patient means by stiffness.

Is it:
• restricted range of movement?
• difficulty moving, but with a normal range?
• painful movement?
• localised to a particular joint or more generalised?
¡ There are characteristic differences between inflammatory and non-inflammatory presentations of joint stiffness.
Inflammatory arthritis causes early-morning stiffness that takes at least 30 minutes to wear off with activity.
¡ Non-inflammatory, mechanical arthritis causes stiffness after rest that eases rapidly on movement. Disease of the soft
tissues, rather than the joint itself, may cause stiffness.
¡ In polymyalgia rheumatica, stiffness commonly affects the shoulder and pelvic areas.
SWELLING

¡ Ask about the site, extent and time course of the swelling.

¡ The speed of onset of swelling is a clue to the diagnosis: HOW ?

Olecranon bursitis.
Right-knee haemarthrosis.
ERYTHEMA AND WARMTH

¡ Erythema (redness) occurs in infective, traumatic and crystal-induced conditions, and mild erythema may be
present in inflammatory arthritis. All affected joints will be warm.
¡ Erythema associated with DIP joint swelling helps to distinguish DIP joint psoriatic arthritis from the Heberden’s
nodes of osteoarthritis
WEAKNESS

¡ Weakness suggests joint, neurological or muscle disease.

¡ The problem may be focal or generalised. Joint disorders cause weakness, either through inhibition of function by
pain, or by disruption of the joint or its supporting structures.
¡ Nerve entrapment may be the cause: for example, carpal tunnel syndrome at the wrist.
¡ Muscle disorders can produce widespread weakness associated with pain and fatigue, such as in myositis, and
with a rash, as in dermatomyositis.
¡ Proximal muscle weakness can occur in endocrine disorders: for example, hypothyroidism or excess of
glucocorticoids
LOCKING AND TRIGGERING

¡ ‘Locking’ is an incomplete range of movement at a joint because of an anatomical block. It may be associated with
pain.
¡ Patients use ‘locking’ to describe various problems, so clarify exactly what they mean.
¡ True locking is a block to the normal range of movement caused by mechanical obstruction, such as a loose body
or torn meniscus, within the joint. The patient is characteristically able to ‘unlock’ the joint by trick manœuvres.
¡ Pseudolocking is a loss of the range of movement due to pain.
DEFINE TRIGGERING AND WHAT ARE ITS POSSIBLE CAUSES?
 EXTRA-ARTICULAR SYMPTOMS

¡ Patients may present with extra-articular features of disease that they may not connect with musculoskeletal
problems
¡ WHAT ARE IMPORTANT POINTS THAT SHOULD BE ASKED REGARDING EXTRA
ARTICULAR SYMPTOMS IN MUSCULOSKELETAL DISEASES?
EXTRA-ARTICULAR SIGNS IN RHEUMATIC CONDITIONS
Past medical history
¡ Note past episodes of musculoskeletal involvement, extra-articular diseases as listed in the previous section,
fractures and possible complicating comorbidities such as diabetes or obesity.
Drug history
¡ Many drugs have side effects that may either worsen or precipitate musculoskeletal conditions , GIVE
EXAMPLES
DRUGS ASSOCIATED WITH ADVERSE MUSCULOSKELETAL EFFECTS
Family history
¡ Inflammatory arthritis is more common if a first-degree relative is affected.
¡ Osteoarthritis, osteoporosis and gout are heritable in a variable polygenic fashion.
¡ Spondyloarthritis is more common in patients with human leucocyte antigen B27.
¡ A single-gene defect (monogenic inheritance) is found in hereditary sensorimotor neuropathy (Charcot–Marie–
Tooth disease), osteogenesis imperfecta, Ehlers–Danlos syndrome, Marfan’s syndrome and the muscular
dystrophies
Social, environmental and occupational histories
¡ Identify functional difficulties, including the ability to use pens, tools and cutlery.
¡ How does the condition affect the patient’s activities of daily living, such as washing, dressing and toileting?
¡ Can they use the stairs and do they need walking aids?
¡ Ask about functional independence, especially cooking, housework and shopping. Ask about current and previous
occupations.
¡ Is the patient working full- or part-time, on sick leave or receiving benefits?
¡ Has the patient had to take time off work because of the condition and is their job at risk?
¡ Litigation may be pending following injury and in occupational disorders, such as repetitive strain disorder, hand
vibration syndrome and fatigue fractures.
¡ Smoking is a risk factor for rheumatoid arthritis and possibly other inflammatory arthritides.
¡ High alcohol intake contributes to gout and falls that may result in fracture. It can also cause myopathy,
neuropathy and rhabdomyolysis.
¡ Some conditions are seen in certain ethnic groups; for example, sickle cell disease may present with bone and
joint pain in African patients.
¡ Osteomalacia is more common in Asian patients. Bone and joint tuberculosis is more common in African and
Asian patients.
¡ A sexual history may be relevant , since sexually transmitted disease is associated with musculoskeletal problems,
such as reactive arthritis, gonococcal arthritis, human immunodeficiency virus infection and hepatitis B
THANK YOU