Conducting a musculoskeletal examination


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Conducting a musculoskeletal examination

  1. 1. Musculoskeletal System Taking a History and Conducting an Examination
  2. 2. Objectives: History You should be able to -Distinguish inflammatory vs non inflammatory symptoms -Take relevant histories for bone/joint/muscle/nerve problems -Assess acute and chronic pain -Understand the impact of chronic musculoskeletal condition on everyday activities
  3. 3. Objectives: Examination You should be able to -identify normality vs abnormality -Examine joints/bones in a systematic manner -Recognise common Musculoskeletal conditions -perform GALS Screening
  4. 4. Introduction Musculoskeletal problems are common -Commonest cause of long term pain -Second most common reason for consulting a Dr -Up to 20% primary care consultations -Predicted to increase with ageing population/obesity/lack of physical fitness -Bone and Joint Decade (2000-2010)
  5. 5. Inflammation: Key features Joints Warm Painful Swollen Erythema Lack of function = ROM restricted “ Synovitis”
  6. 6. Joints: history Which joints? Any precipitating event? When? (before or during/after use?) How long?-intermittent? Swollen? Stiff ?(partic. mornings/immobility) Any associated features? E.g. rashes, eye problems etc
  7. 7. Joints: history PMH: Any past history of joint problems? DH: What has been tried..any side effects? FH: Any FH of joint problems? SH: Important to understand impact on ADL
  8. 8. Features in history to distinguish between inflammatory vs non inflam. symps Mechanical Inflammatory Pain Using joint Mornings After use Improves with use Stiffness Minimal Marked Swelling None or Bony/fixed Fluid/soft tissues Variable Other Weight bearing joints Characteristic Distribution
  9. 9. History <ul><li>I.e Inflammatory Joint Pain = Synovitis </li></ul><ul><ul><li>= RA/ Crystalline/ Spondyloarthropathies </li></ul></ul><ul><ul><ul><li>Spondlyoarthropathies also termed seronegative arthritis </li></ul></ul></ul><ul><ul><ul><li>Seronegative means Rheumatoid Factor Negative </li></ul></ul></ul><ul><ul><ul><li>Spondylo= Spine </li></ul></ul></ul>
  10. 10. GALS Screening Questions (Gait, Arms/Legs/Spine) Do you have pain or stiffness in your joints? Can you dress without difficulty? Can you walk up and down stairs? If all negative, unlikely to be significant musculoskeletal problem. These questions are helpful to an extent…
  11. 11. Examination: Joints LOOK, FEEL, MOVE Inspect Compare with other side Different shape? Swollen? Alignment, muscle wasting? Palpate Temperature Swollen? Bony or fluctuant? Move Full ROM? Active (patient does) first then passive (Dr does)
  12. 12. Examination Systematic Start with hands- Heberden’s Nodes? Psoriasis/nail changes Tophi? Wrists Elbows Nodules? Tophi? Shoulders Look At the Patient and Around the Bed Hands Behind your Back Sticks/drugs/Drips/inhalers/sputum/OT aids etc
  13. 13. Examination Hips Difficult to inspect and feel as deep Knees Patellar tap, ligamentous instability? Ankles Hinge/sub talar Feet MTP Squeeze Standing: Alignment-knees, ankles valgus/varus? Spine Cervical/Thoracic/Lumbar … Finally observe gait
  14. 14. GALS <ul><li>Gait </li></ul><ul><li>Arms </li></ul><ul><li>Legs </li></ul><ul><li>Spine </li></ul>
  15. 15. Arms (shoulder elbow wrist hands) <ul><li>Pinch </li></ul><ul><li>Grip </li></ul><ul><li>Moving your hands to where you need them </li></ul><ul><li>If you can reach behind your head… </li></ul>
  16. 16. LOOK FEEL MOVE FUNCTION <ul><li>Scars Rashes Swelling Wasting </li></ul><ul><li>Nodules </li></ul><ul><ul><li>RA (Seropositive)/ Gouty Tophi </li></ul></ul><ul><li>Rashes </li></ul><ul><ul><li>Heliotropic+Gotrons Papules= Dermatomyositis </li></ul></ul><ul><ul><li>Psoriasis= PsA </li></ul></ul><ul><ul><li>“ Vasculitis” </li></ul></ul><ul><ul><ul><li>Purpura/splinters </li></ul></ul></ul>
  17. 17. Feel <ul><li>Warmth </li></ul><ul><li>Remember hot swollen tender= SYNOVITIS </li></ul><ul><li>Pain </li></ul><ul><li>Joint Lines </li></ul><ul><li>Nodules </li></ul>
  18. 18. MOVE <ul><li>Active vs Passive </li></ul><ul><li>Restriction of Movement </li></ul>
  19. 19. Function <ul><li>Pick up a coin off a flat surface </li></ul><ul><li>Button Shirt </li></ul><ul><li>Write their name </li></ul>
  20. 20. Presenting Your Findings <ul><li>Symetrical Vs Asymetical </li></ul><ul><li>Poly(>4) vs Oligo (2-4) vs Mono (1) </li></ul><ul><li>Inflammatory / non inflammatory </li></ul><ul><li>Upper / Lower limb </li></ul><ul><li>Large / Small joint </li></ul><ul><li>Spine involved </li></ul>
  21. 21. Summary We have covered important points in History and Examination of Musculoskeletal system Introduced GALS System
  22. 22. More free resources <ul><li>More help and advice </li></ul><ul><li>MCQs </li></ul><ul><li>Videos </li></ul><ul><li>OSCEs </li></ul><ul><li>Podcasts </li></ul><ul><li>Visit Medical Educator </li></ul>