8. | Manual of Rheumatology and Outpatient Orthopedic Disorders (LB Spiral Manuals)

Chapter 1 Musculoskeletal History and Physical Examination

Manual of Rheumatology and Outpatient Orthopedic Disorders

Chapter 1 Musculoskeletal History and Physical Examination

Stephen A. Paget, Charles N. Cornell, and John F. Beary, III

Musculoskeletal History
	Chief complaint
	Primary physician
	History of rheumatic diseases
	Past history
	Social history
	Family history
	Review of systems
Physical Examination with Emphasis on Rheumatic Disease
	Gait
	Standing position
	Seated position
	Supine position
	Systematic examination and joint chart
	Extraarticular features
Assessment of Joint Structure and Function
	Degree of joint inflammation
	Structural damage and deformity
	Function

The musculoskeletal or locomotor system, like other body systems, can be defined anatomically and assessed functionally. Lower extremities support the weight of the body and allow ambulation. They require proper alignment and stability. Upper extremities reach, grasp, and hold, thus allowing self-care, feeding, and work. They require mobility and strength. Diseases and disorders of the musculoskeletal system disturb anatomy and interfere with function.

Musculoskeletal History

A careful history is the most important and powerful of the information-gathering procedures used to define a patient's problems. In most musculoskeletal disorders, 80% of the diagnosis comes from this part of the clinical evaluation. The history of patients with rheumatic complaints should include the following: (a) reason for consultation and duration of complaints; (b) present medical care and medications; (c) chronologic review of present illness with emphasis on the locomotor system, consequences of time and disease, and present functional assessment; (d) past history of medical, surgical, and trauma; (e) social history, emotional and work impact of the disorder , and environmental and work site factors; (f) family history, especially as it relates to the musculoskeletal system; and (g) review of systems. These queries cover the spectrum of rheumatic complaints: pain, stiffness, joint swelling, lack of mobility, physical handicap, and fear of future disability and handicap. The interviewer should be flexible and tactful. Avoid interrupting the patient with too many questions; the interviewer should merely guide the flow of information. The objective is to define the patient's complaints and goals and to identify patterns of disease and areas of musculoskeletal involvement that can be further scrutinized on physical examination.

I. Chief complaint. Note duration.

II. Primary physician. Note name , telephone number, fax number, and e-mail address to assist in locating important data. A discussion with that physician may add greatly to your assessment, may avoid the need to repeat expensive tests already performed, and will better define the course and tempo of the disorder.

III. History of rheumatic diseases

Determine the mode of onset, inciting events, duration, and pattern and progression of the musculoskeletal complaints.
1. Acute onset is consistent with infectious, crystal-induced, or traumatic origin. It can also occur in the setting of a connective tissue disorder. Chronic complaints are seen with rheumatoid arthritis (RA), seronegative spondyloarthropathies, and osteoarthritis or the chronic sequelae of traumatic or degenerative back problems.
2. The pattern of joint involvement is very important in defining the type of joint disorder. Symmetric polyarthritis of the small joints of the hands and feet is characteristic of RA, whereas asymmetric involvement of the large joints of the lower extremities is most typical of the seronegative spondyloarthropathies. A migratory pattern of joint inflammation is seen in rheumatic fever and disseminated gonococcemia. A monarticular arthritis is consistent with osteoarthritis, infectious arthritis, crystal-induced synovitis, or one of the seronegative spondyloarthropathies (e.g., psoriatic arthritis, Reiter's syndrome). An intermittent joint inflammation of the knee with remissions and exacerbations is typical of the tertiary phase of Lyme disease.
3. Location, pain characteristics, and associated findings may all be important keys to the diagnosis. First, metatarsophalangeal joint inflammation of an acute and severe type is quite characteristic of gouty arthritis. Sudden onset of low back pain in the setting of lifting or bending with associated pain radiating down the lateral leg is a common presentation for a disk herniation with sciatica.
  Pain in the superolateral shoulder or upper arm occurring in the setting of tennis playing or painting a ceiling is typical of a supraspinatus tendinitis, or impingement syndrome.
Record the severity of disease, as revealed by a chronologic review of the following:
1. Ability to work during months or years .
2. Need for hospitalization or home confinement.
3. When applicable , ability to do household chores.
4. Activities of daily living and personal care.
5. Landmarks or significant functional change, such as retirement from work, need for household help, assistance for personal care, and use of cane, crutches, or wheelchair.
Assess current functional ability. This can be done in a question-and-answer format and quantified with the use of functional instruments such as the Health Assessment Questionnaire (HAQ) or the Arthritis Impact Measurement Scale (AIMS2), or functional ability can be measured with the use of a visual analog scale (0 representing no impact on function and 10 being the worst possible limitation in function).
1. At home: independence or reliance on help from family members and others.
2. At work: transportation and job requirements and limitations. Have the patient collect an hour-by- hour log of work activities, with an attempt to define actions that may cause or exacerbate musculoskeletal problems.
3. At recreational and social activities: limitations and extent to which patient is house-bound.
4. Review of a typical 24-hour period, with focus on abilities to transfer, ambulate, and perform personal care.
Obtain an overview of management for rheumatic disease.
1. Medications used in the past, with emphasis on dosages, duration of treatments , efficacy response, and possible adverse reactions . Record the present drug regimen and how well the patient complies with it, and also the patient's understanding of the reasons for and potential complications of the medication .
2. Instruction in and compliance with a therapeutic exercise program.
3. Surgical procedures on joints, including benefits and liabilities. Record the name of the surgeon, date of the surgery, and the hospital. Operative pathology reports may be helpful.
Determine the patient's understanding of the disease, therapeutic goals, and expectations.
Record psychosocial consequences of disease.
1. Anxiety, depression, insomnia. Obtain information about psychological/ psychiatric intervention and a listing of psychotropic medications.
2. Economic impact of handicap and present means of support.
3. Family interrelationships.
4. Use of community resources.

IV. Past history. Follow traditional lines of questioning, with attention to trauma and joint operations. Also question the patient about those specific medical disorders that could have a significant impact on or association with the joint disorder.

Specific associations include psoriasis with psoriatic arthritis or gout; ulcerative colitis or Crohn's disease with inflammatory disease of the spine or peripheral or sacroiliac joints; diabetes with neuropathic, septic joints, or osteomyelitis; hemochromatosis with severe osteoarthritis; endocrinopathies such as hypothyroidism (carpal tunnel syndrome, myopathy), hyperparathyroidism (pseudogout), and acromegaly (severe osteoarthritis). A complete medication list is essential, as well as an inquiry into prior medications. Important in this context is drug-induced lupus associated with the use of hydralazine and procainamide, Raynaud's phenomenon associated with the use of beta blockers, eosinophilia-myalgia syndrome associated with l-tryptophan, or myositis associated with the use of statin drugs for hypercholesterolemia.

V. Social history. The physician must consider the following associations between the social history and types of musculoskeletal disorders:

Work activities, including the possibility of joint or back trauma, exposure to toxins, or overuse syndromes. Specific examples include low-back syndromes, exposure to vinyl chloride leading to scleroderma-type skin changes, and carpal tunnel syndrome resulting from typing at a computer terminal.
Sexual history, including sexual preference, sexual promiscuity, and the most recent sexual experience. Musculoskeletal disorders related to acquired immunodeficiency syndrome (AIDS) and venereal disorders such as gonococcal disease should be considered .
Living site and conditions, including overcrowding (e.g., rheumatic fever), living in an area where Lyme disease is endemic, or a recent or distant history of tick bite.
Emotional or physical stress, which could have an impact on the development or exacerbation of musculoskeletal disorders.
The presence of medical problems within the family, including infectious disorders in children (e.g., fifth disease caused by parvovirus B19, rubella) and adults (e.g., hepatitis B and C, Lyme disease, tuberculosis).
Recent travel, with specific emphasis on the development of dysentery caused by Salmonella or Shigella (e.g., reactive arthritis or Reiter's syndrome) or travel to an area where Lyme disease is endemic.

VI. Family history. Inquiry about arthritis and rheumatic disease in parents and siblings may elicit vague and unreliable statements, but they are nonetheless important. The presence of severely handicapped relatives with RA or other severe rheumatic disease might result in a significant psychological impact on the patient and should be brought out in the interview. Such information may also be important in relation to the genetic background of arthritis in the family. The physician should inquire about the following musculoskeletal disorders, which clearly have a tendency to run in families: gout and uric acid kidney stones; RA and other connective tissue disorders; ankylosing spondylitis and other seronegative spondyloarthropathies; osteoarthritis, especially nodal disease in the fingers; and true connective tissue disorders, such as Marfan syndrome.

VII. Review of systems. Emphasize diseases and system disorders related to rheumatic complaints and diseases of connective tissue. Especially inquire about eye disease (iritis, uveitis, conjunctivitis, dryness), mouth disorders (dryness, mouth sores, tightness), gastrointestinal problems (problems with swallowing, reflux symptoms, abdominal pain, diarrhea with or without blood, constipation), genitourinary complaints (including dysuria, urethral discharge , hematuria), and skin disorders (rash with or without sun sensitivity, nodules, ulcers, Raynaud's phenomenon, ischemic changes). The presence of constitutional symptoms is also important, including complaints of weight loss, fatigue, fever, chills, night sweats, and weakness.

Physical Examination with Emphasis on Rheumatic Disease

Five aspects of the physical examination that should be recorded are (a) gait, (b) spine, (c) muscles , (d) upper extremities, and (e) lower extremities. The patient should be properly attired in a short gown, open at the back to allow examination of the entire spine. Examination should be methodic and start with observation of the patient's attitude, comfort , apparent state of nutrition, ease of undressing, and method of rising from a chair and sitting down. The patient is examined while standing, sitting, and supine. The examiner should rely mainly on inspection. When using palpation and manipulation, the examiner should be gentle and forewarn the patient of potentially painful maneuvers.

I. Gait. Describe the gait, and note a limp or use of cane or crutches. The normal gait is divided into the phases of stance (60%) and swing (40%). Clinically important gaits include the following:

Antalgic gait, characterized by a short stance phase on the painful side.
Short-leg gait, with signs of pelvic obliquity and flexion deformity of the opposite knee.
Coxalgic gait, an antalgic gait with a lurch toward the painful hip.
Metatarsalgic gait, in which the patient tries to avoid weight bearing on the forefoot.

II. Standing position

Examining front and back, note posture (cervical lordosis, scoliosis, dorsal kyphosis, lumbar lordosis). Check if the pelvis is level by putting one finger on each iliac crest and noting asymmetry. Pelvic obliquity suggests unequal leg lengths. Note also if a tilt of the trunk to one side is present.
Examine alignment of the lower extremities for flexion deformity of the knees, genu varum (bowlegs), or genu valgum (knock-knees).
Observe position of the ankles and feet (varus or valgus heels, flat feet, inversion or eversion of feet).
Check back motion on forward bending (with rounding of the normal thoracolumbar spine), lateral flexion to each side, and hyperextension (see also section IV.C ). The extent of spinal flexion can be assessed with a metal tape measure. One end of the tape is placed at the C-7 spinous process, and the other end is placed at S-1 with the patient standing erect. The patient is then asked to bend forward, flexing the spine maximally. The measuring tape will reveal an increase of 10 cm with normal spine flexion; 7.5 cm of the total increase results from lumbar spine (measured from spinous process T12-S1) mobility in normal adults. These measurements are useful for the serial evaluation of patients with spondyloarthropathy.

III. Seated position

Observe head and neck motion in all planes (Fig. 1-1).

FIG. 1-1. Neck motion. A: Flexion and extension. B: Lateral bending. C: Rotation.
Examine thoracolumbar spine motion with the pelvis fixed. Observe rounding and straightening of back, lateral flexion to each side, and rotation to right and left.
Check temporomandibular joints. Palpate, examine lower jaw motion, and measure the aperture between upper and lower teeth with the mouth fully open.
Proceed with the rest of the routine examination of the head and neck; describe eye, ear, nose, and throat findings.
Upper extremities
1. Shoulders
  1. Note normal contour or squaring caused by deltoid atrophy. Palpate anteriorly for soft-tissue swelling and laterally under the acromion for tendon insertion tenderness.
  2. Function of the entire shoulder complex is evaluated by elevating both arms from 0 degrees along the sides of body to 180 degrees straight above the head. Quantify internal rotation by having the patient reach with the dorsum of the hands the highest possible level of the back (Fig. 1-2); quantify external rotation by noting the position behind the neck or head that the hands can reach.
    
    FIG. 1-2. Internal rotation of shoulder, posterior view. Record range of reach: Dorsum of hand to specific vertebral bodies.
  3. Isolate the glenohumeral joint motion from the scapulothoracic motion by fixing the scapula . Holding both hands, assist the patient in abducting arms to the normal maximum of 90 degrees, and note restriction of motion on either side. To determine internal and external rotation of the glenohumeral joint on each side, the examiner places one hand on the shoulder to prevent scapular motion and, with the other hand, assists each arm to full external rotation of 90 degrees and full internal rotation of 80 degrees (Fig. 1-3).
    
    FIG. 1-3. Shoulder rotation (with arm in abduction).
2. Elbows
  1. Inspect each elbow for maximum extension to 0 degrees and full flexion to 150 degrees. Less than full extension is reported in degrees as flexion deformity or lack of extension.
  2. Inspection and palpation may reveal the presence of olecranon bursitis at the elbow tip or the soft-tissue swelling of synovitis , which is felt in the fossae between the olecranon and lateral epicondyle or between the olecranon and medial epicondyle.
  3. Subcutaneous nodules and tophi should be sought in the olecranon bursa and over the extensor surface of the elbow and forearm.
3. Wrist and hands
  1. Inspect and palpate wrists; metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints of fingers; and carpometacarpal (CMC), MCP, and interphalangeal (IP) joints of thumbs (Fig. 1-4). Note shape and deformities: boutonniere, swan neck, and ulnar deviation.
    
    FIG. 1-4. Finger and thumb joints. MCP, metacarpophalangeal; PIP, proximal interphalangeal; DIP, distal interphalangeal; CMC, carpometacarpal; IP, interphalangeal.
  2. Soft-tissue swelling has a spongy consistency and should be sought on the dorsum of the wrist distal to the ulna and over the radiocarpal joint. On the volar surface, the normal step-down from hand to forearm may be obliterated by soft-tissue swelling. Volar synovitis may be associated with carpal tunnel syndrome. Tapping on the volar aspect of the wrist may elicit paresthesias radiating into the radial three fingers, or even the forearm. This positive Tinel's sign is consistent with carpal tunnel syndrome. Thenar atrophy would further support this diagnosis.
  3. All finger joints should be examined by inspection and palpation for soft-tissue swelling, capsular thickening, and bony enlargement .
  4. Average wrist motion is dorsiflexion to 75 degrees, palmar flexion to 70 degrees, ulnar deviation of 45 degrees, and radial deviation of 20 degrees (Table 1-1).
    
    Table 1-1. Average joint motion
  5. The fist is described as 100% when all fingers reach the palm of the hand and the thumb closes over the fingers. Halfway fist closing is recorded as 50%; less than 50% and 75% are other possible intermediate measurements. The distance from fingertips to palm can also be recorded.
  6. Grip is quantified by noting the patient's maximum strength in grasping two fingers of the examiner. Pinch is assessed by the force necessary to break the patient's pinch between index finger and thumb.
  7. Pronation and supination are combined functions of the elbow and wrist and are determined by having the patient hold the forearm horizontal and the thumb up. Pronation and supination are measured in degrees from the neutral position with the hand turning palm up and palm down (Fig. 1-5).
    
    FIG. 1-5. Forearm pronation and supination.
While the patient is sitting, customary physical examination of the neck and chest should be performed; it should include examination of sternoclavicular joints and measurement of chest expansion, which should be greater than 5 cm in the nipple line.

IV. Supine position

Start with the standard physical examination of the abdomen, and then proceed to the examination of the lower extremities.
Alignment of the knees is compared with the alignment noted on weight bearing (see section II.B ). Palpate pedal pulses .
Low back
1. Inspection, palpation, and assessment of range of motion (see section II.D ).
2. Neurologic examination. Look for radicular signs and root signatures (see section I ).
3. Traction maneuvers
  1. Straight leg-raising test to screen for lumbosacral nerve root symptoms; note angle of elevation that induces back or buttock pain.
  2. Gaenslen maneuver to detect sacroiliac joint inflammation. Instruct the patient to lie supine on the examining table with knees flexed and one buttock over the edge. Ask the patient to drop the unsupported leg off the table. This maneuver will elicit pain in the sacroiliac joint ipsilateral to the extended hip. The maneuver exerts a traction force on the sacroiliac joint, which opens it up.
Hips
1. Hip function is screened by gently log-rolling each lower extremity and noting the freedom of motion of the ball-and-socket joint. Rolling also allows measurement of the internal and external rotation of the hip joint in extension.
2. With one hand fixing the pelvis, the other hand moves each hip to the normal 60 degrees of full abduction and to the normal 30 degrees of adduction while the hip is held in extension.
3. Each hip joint is then examined in flexion; both lower extremities are flexed at knees and hips and carried toward the chest, which gives the maximum angle (120 degrees) of flexion of each hip.
4. Normal hip extension is to minus 10 degrees. To avoid overlooking a hip flexion deformity for which accentuation of lumbar lordosis may compensate, the examiner keeps one lower extremity flexed over the chest, thus flattening the lumbar spine, while instructing the patient to extend fully the opposite leg.
5. With the hip in 90 degrees of flexion, the joint is evaluated for internal rotation (25 degrees), external rotation (35 degrees), abduction (45 degrees), and adduction (25 degrees) (Fig. 1-6).
  
  FIG. 1-6. Hip rotation in flexion.
Measurement of leg length (see Chapter 19).
Knees
1. By inspection and palpation, note position and mobility of patellae. Knee extension-flexion range is 0 to 130 degrees. Also palpate for the presence of osteophytes at tibiofemoral joint margin, which may also be tender.
2. Soft-tissue swelling is elicited by bimanual examination.
  1. Demonstrate intraarticular fluid by the patellar click sign . While compressing the suprapatellar pouch with one hand, push the patella against underlying fluid and the femoral condyle with the index finger of the other hand to elicit a click.
  2. For detection of a small amount of effusion, use the bulge sign. This maneuver is best executed by placing both hands on the knee so that the index fingers meet on the medial joint margin and the thumbs meet on the lateral aspect of the joint. Through a firm stroking motion of the fingers above and below the patella, fluid is milked into the interior of the joint, and the medial aspect of the joint becomes flat . The thumbs are then pushed suddenly and firmly into the lateral joint margin, thus producing a bulge of fluid on the medial side of the joint.
3. The popliteal area is examined for the presence of a synovial cyst. Standing makes the cyst more prominent.
4. Knee stability is evaluated by stressing medial and lateral collateral ligaments. Anteroposterior stability is assessed by holding the knee flexed with the foot firmly anchored on the bed and using both hands to pull and push the leg ( drawer sign) to test the cruciate ligaments.
Ankles and feet
1. Synovial soft-tissue swelling of the ankles at both malleoli should be distinguished from periarticular edema and fat pads.
2. Normal ankle motion is 15 degrees flexion and 35 degrees extension.
3. Subtalar motion, which allows inversion and eversion of the foot, is best reported as a percentage of normal, with 100% meaning full mediolateral motion.
Toes. By inspection and palpation, note the following:
1. Alignment and deformity: hammertoes, claw toes, and hallux valgus.
2. Soft-tissue swelling and presence of inflammation, which are best documented by mediolateral squeezing across the metatarsal joints; pain may be elicited.
Muscle examination. Proximally and distally, note the following:
1. On inspection, muscle wasting and muscle atrophy.
2. On palpation, muscle tenderness.
3. On testing motion, muscle strength (Table 1-2).
  
  Table 1-2. Gradations of muscle weakness
Neurologic examination
1. Standard evaluation of tendon reflexes.
2. Impairment of nerve root function must be sought with care, and motor and sensory deficits recorded (see Chapter 14 and Chapter 18).
3. Look for nerve entrapment secondary to joint pathology (e.g., carpal tunnel syndrome).

V. Systematic examination and joint chart

Inspection, palpation, and movement of joints may reveal swelling, tenderness, temperature and color changes over the joint, crepitation, and deformity.
1. Tenderness on direct pressure over the joint and stress pain produced when the joint, at the limit of its range of motion, is nudged a little farther are important findings of inflammation. The number of tender and swollen joints can be recorded and compared with future joint counts after the institution of therapy .
2. Crepitation is a palpable or audible sensation with joint motion caused by roughened articular or extraarticular surfaces rubbing each other. Popping sounds can also be heard and felt when tendons travel over bony prominences.
3. Bony enlargement, subluxation, and ankylosis in abnormal positions cause deformity.
Quantification of findings
1. Range of motion is reported in degrees and, when practical, in percentage of normal (i.e., fist and subtalar motions ). See Table 1-1 for average values.
2. Swelling and tenderness are arbitrarily reported in grades 1, 2, and 3, which indicate size and severity ranging from minimal to severe. Numbers of swollen and tender joints can be recorded (called a joint count) for future comparison after treatment has been instituted, and for use in controlled clinical trials.
3. Other physical signs of joint abnormality include warmth and erythema over the joint and should be expressed as grades 1, 2, or 3 (mild, moderate, or severe).

VI. Extraarticular features. Examination is completed by recording specific findings important in rheumatic diseases, such as subcutaneous nodules, nail changes, rash, abnormal eye findings, sicca (dryness) signs of the eyes and mouth, lymphadenopathy, leg ulcers, and visceral involvement such as splenomegaly, pleural or pericardial signs, and neurologic abnormalities.

Assessment of Joint Structure and Function

The rheumatic disease history and systematic examination allow assessment of the following:

I. Degree of joint inflammation. Number of acute joints (tender and swollen) and their location and degree of involvement.

II. Structural damage and deformity (malalignment, subluxation, and instability). Findings are reported by a count of joints deformed or limited in their motion.

III. Function. Assessment is based on the following:

Joint range of motion.
Muscle strength (grip strength, abduction of shoulders, straight leg raising, rising from squatting and sitting positions, and walking on toes). See Table 1-2.
Activities of daily living. Mobility, personal care, special hand functions, and work and play activities.
Function can be reported in four classes based on the American College of Rheumatology classification:
Class 1 Normal function without or despite symptoms

Class 2 Some disability but adequate for normal activity without special devices or assistance

Class 3 Activities restricted; special devices or assistance required

Class 4 Totally dependent

Other, more quantitative instruments are available for the evaluation and prospective assessment of function, performance of social activities, and emotional status. Specialized pain and function instruments are also available for clinical trials.

In conclusion, a comprehensive clinical evaluation (history plus physical examination) focused on the musculoskeletal system and psychosocial consequences of disease, followed by a complete physical examination with a detailed musculoskeletal and joint evaluation, is the clinical basis for the diagnosis and individualized management of rheumatic disease. Such an approach allows the professional to distill large amounts of information rapidly to reach a specific diagnosis and formulate an appropriate, focused, and effective therapeutic plan.

Bibliography

Hoppenfeld S. Physical examination of the spine and extremities. New York: Appleton- Century-Crofts, 1976.

Books@Ovid
Copyright 2000 by Lippincott Williams & Wilkins
Stephen A. Paget, M.D., Allan Gibofsky, M.D., J.D. and John F. Beary, III, M.D.
Manual of Rheumatology and Outpatient Orthopedic Disorders

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