Kuliah PANUM FKUB

Diagnosing
Muskuloskeletal Pain

Dr.B.P.Putra Suryana, SpPD-KR

Rheumatology, Internal Medicine
Brawijaya University – Dr.Saiful Anwar Hospital
Why musculoskeletal disease is
important?
 Classification of pain

Currently, 4 different pain states are recognized : nociceptive, neuropathic,

neuroplastic and idiopathic pain.

Bruce L Kidd et al. Arthritis Research and Therapy 2007;9.

FISIOLOGI NYERI
Nociceptive (inflammatory) pain

SP=substance P ; BK=bradikinine ; PLs=phospholipids ; PGs=prostaglandins ; 5HT=5-

hydroxytryptamine
Neuropathic pain
 Pain in gouty attack

Phagocytosis of crystals lead to rupture of leukocytes and followed by releases of

cytokines and enzymes
 Pain in OA

Cartilage Trauma
Joint abnormalities in OA
degeneration
 History taking
and physical examination
• Pain information : onset, duration, location,
severity or intensity, quality or character,
aggravation and alleviating factor, previous
treatment and their effect.
• Physical examination : vital signs, a thorough
physical and neurological examination, the
pain area (with gentle palpation).

Current diagnosis and treatment of pain. McGraw-Hill,2006.

Pain assessment tool
 Screening
Musculoskeletal
Examination
G ait
A rms
L egs
S pine
Clinical Skill sessions (MBBS 5 Year 2)
at St George’s University of London
 Screening Questions

Screening questions for musculoskeletal disorders

1. Do you have any pain or stiffness in your arms,

legs or back?

2. Can you walk up and down stairs without

difficulty?

3. Can you dress yourself in everyday clothes without

any difficulty?
 Gait

Ask the patient to walk Observe the patients gait for symmetry,
a few steps, turn & smoothness and the ability to turn quickly.
walk back.

With the patient in the

anatomical position Observe for any abnormalities in the muscles
inspect from the (e.g. reduced muscle bulk), spine (e.g.
posterior, lateral and abnormal spinal curvature such as scolosis),
anterior aspects. limbs or joints (e.g. a red swollen knee)
 Arm
Ask the patient to place their hands behind their head,
Shoulder movements with their elbows back This movement assesses
  abduction, external rotation of the shoulder and elbow
flexion.

Ask the patient to extend their arms fully and turn their
hands over so palms are down.
Elbow movements & hands
Following this ask the patient to turn their hands over.
 
Observe the hands for any joint swelling or deformities
 

Ask the patient to make a fist. Observe the hand and

Grip strength finger movements
  Ask the patient to grip your fingers and assess the degree
of grip strength

Ask the patient in turn to bring each finger in turn to

Precision pinch
meet the thumb
 
 
Squeeze across the metacarpalphalangeal joints
(tenderness here may indicates synovitis of
Metacarpalphalangeal squeeze test
metacarpalphalangeal joints)
Click here to see some interesting clinical cases
Hand joints palpation
Squeeze Test
Small joint palpation technique
 Leg

With the patient lying on the couch

Knee movements assess flexion and extension of both
  knees. Make sure to palpate the knee
for crepitus

Hold the knee & hip flexed to 90

Hip movement degrees. Now assess the degree of
  internal rotation in each hip

Perform a patellar tap in each knee for

Patellar tap test
the presence of an effusion

Inspect the feet for any swelling,

Inspection of feet
Metacarpalphalangeal squeeze test
deformity or any callosities
Squeeze across the
metatarsophalangeal joints for any
tenderness
Patellar Tap Test
Drawer Test
Straight Leg Raising (SLR) Test
 Spine
Inspect the spine for any abnormalities including
Inspection abnormal kyphosis, scolosis or loss of lordosis.

Ask the patient to tilt their head to each side,

Neck movements
brining the ear towards their shoulder. Assess the
 
degree of lateral neck flexion.

Ask the patient to bend forward and touch their

toes. During this movement the patient may
depend partly on good hip flexion to bend
Lumbar spine movement forwards. So it is always a good idea to palpate
  for the range of lumbar movement. Place two
fingers over the lumbar vertebra. As the patient
bends forward your fingers should move apart
(assuming the patient has a good range of
lumbar spine movement)
 Spinal mobility test

Slide collection of Rheumatology Clinic RSSA Malang

Recording GALS
 Case
“ Severe leg pain “
Data 1
Mrs. US, 57 yo
Admitted at ER with
severe right leg pain
for 5 days.

Diabetes for 3 years,

BS controlled with
metformin.
 Question
• History taking : what more information
needed?
• What are the differential diagnosis of her leg
pain?
• What physical examination to do?
Data 2
Vital signs normal.

Knee :
Crepitation both
knees, no
inflammation.

Leg :
Right SLR test +
at 45 degrees.
 Question

• What are differential diagnosis for leg pain?

• What tests to plan?
• What results may support your diagnosis?
Data 3A
Data
3B
 Question

• What is most likely pain diagnosis?

• How is the mechanism (pathophysiology) ?
• How do you treat?
 Take Home Message
• Most causes of muskuloskeletal pain are
diagnosed by history and physical
examination, occasionally with the use of
laboratory and radiology tests.
• GALS examination is a simple screening
muskuloskeletal examination to identify joint
problems.