3. Main complaints
PAIN
• Determine whether the pain originates
Arthralgia (pain from a joint)
Myalgia (pain in muscle)
• Character of the pain
• Radiation
• Intensity
• Duration
• Conditions when pain occurs and intensifes (including
connections with movements in the joint)
• Conditions for cessation or reduction of pain
4.
5.
6. Main complaints
PAIN
• Pain can be detected by palpation, while the
patient himself does not feel it
• The site of pain can suggest diagnosis
• The nature of pain can be aching, pulling,
pressing, cutting or stabbing
7. Main complaints
PAIN
• Bone pain is penetrating, deep or boring and is
characteristically worse at night
• Localised pain suggests tumour, osteomyelitis (infection),
osteonecrosis or osteoid osteoma (benign bone tumour)
• Generalised bony conditions, such as osteomalacia, usually
cause diffuse pain
• Muscle pain is described as ‘stiffness’ and is poorly localised,
deep and aggravated by use of the affected muscle(s). It is
associated with muscle weakness e.g. polymyositis
• Fracture pain is sharp and stabbing, aggravated by attempted
movement or use, and relieved by rest and splintage
8. Main complaints
PAIN
• ‘Shooting’ pain is often caused by mechanical impingement of a
peripheral nerve or nerve root e.g. pain ‘shoots down the back
of the leg’, caused by lumbar intervertebral disc protrusion
• Chronic joint pain in patients >40 years with progression over
years is commonly caused by osteoarthritis
• Neurological involvement in diabetes mellitus, syringomyelia
and syphilis may cause loss of joint sensation, so pain is less
than expected from examination
• Chronic pain syndrome (fibromyalgia) causes widespread,
unremitting pain with little diurnal variation that is poorly
controlled by conventional analgesic/ anti-inflammatory drugs
10. Main complaints
PAIN
• Acute attacks of pain in muscles that last for
several days (often after exposure to cold)
suggest myositis
• Pain in the calf muscle during walking (usually
in the presence of marked atherosclerosis of
the arterial vessels in various organs, in frost-
bitten legs, in heavy smokers) is characteristic
of stenosing arteries of the lower extremities
and pain discontinues when the patient stops
walking (the syndrome of intermittent
claudication)
11. Main complaints
PAIN
• Pain from nerve compression radiates to the
distribution of that nerve, e.g. lower leg pain in
prolapsed intervertebral disc or hand pain in
carpal tunnel syndrome
• Neck pain radiates to the shoulder or over the
top of the head
• Hip pain is usually felt in the groin, but may
radiate to the thigh or knee
12. Main complaints
PAIN
• Pain caused by a mechanical problem is worse
on movement and eases with rest
• Pain due to inflammation is worse first thing in
the morning and eases with movement
• Pain from a septic joint is present both at rest
and with movement
13. Main complaints
PAIN
• A history of several years of pain with a normal
examination suggests chronic pain syndrome
• 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 fever and gonococcal arthritis
• If intermittent with resolution between episodes
it is likely to be palindromic rheumatism.
14. Main complaints
PAIN
• When one joint is involved – monoarthritis
• When 2–4 joints are involved – oligoarthritis
• When >4 joints are involved - polyarthritis
15. Main complaints
STIFFNESS
Establish what the patient means by stiffness. Is it:
• restricted range of movement?
• difficulty moving, but with a normal range?
• painful movement?
• ocalised to a particular joint or more generalised?
Inflammatory arthritis presents with early-morning
stiffness that takes at least 30 minutes to wear off with
activity
Non-inflammatory, mechanical arthritis has stiff ness
after rest which lasts only a few minutes on movement
16. Main complaints
SWELLING
• Establish the site, extent and time course of
any swelling
• Active inflammatory arthritis from any cause
results in swelling
• When vascular structures, e.g. bone and
ligament, are injured, bleeding into the joint or
soft tissues produces tense swelling within
minutes
• If avascular structures, e.g. the menisci, are
torn or articular cartilage is abraded, it can take
hours or days to produce a significant effusion
17. Main complaints
WEAKNESS
Develops not only in prolonged rest (immobilized patients
with grave diseases) but also in some neurological
diseases (myatonia, myasthenia, progressive muscular
dystrophy)
• Myasthenia is characterized by pathological muscular
fatigue - contractions of a muscle may first be quite
normal, but in repeated movements the muscular
force decreases to complete loss of contractile power
- after a short rest, the muscle again becomes capable
of contracting
• Weakening of active muscular movements is called
paresis
• Complete loss of power to perform movements is
known as paralysis
18. Main complaints
ERYTHEMA AND WARMTH
• is common in infective and traumatic conditions
and may be mildly present in inflammatory
arthritis
• all joints with an inflammatory or infective
component will be warm
19. Anamnesis
• Information concerning the onset and
development of the disease should be collected
• Many chronic diseases of bones and muscles
develop insidiously and progress slowly
• The disease becomes apparent only at later
periods
20. Anamnesis
Degenerative joint diseases develop in elderly and
senile people
Risk factors for osteoarthritis are:
• Female sex
• Overweight and obesity
• Working conditions characterized by overload
of the musculoskeletal system (carrying or
lifting weights, monotonous repetitive
movements with a long load on certain joints,
activities associated with a long stay in a static
vertical position)
21. Anamnesis
• Infectious arthritis involves finding out the
source of infection
e.g.
• Brucellosis arthritis is more common in rural
areas engaged in animal husbandry, where
there is direct contact with livestock infected
with brucellosis, including the consumption of
raw milk and dairy products that have not
undergone heat treatment, undercooked meat
• Gonorrheal arthritis usually developes in young
people after casual sex with sick partners
22. Anamnesis
Family history
• It is necessary to ask about the history of
osteoarthritis, rheumatoid arthritis,
osteoporosis, ankylosing spondylitis in relatives
• Ask about use of medications, NSAIDs,
diuretics, anticonvulsants
23. Anamnesis
Social history
• It is important to clarify the use of alcohol and
smoking
• It is necessary to clarify the characteristics of
the patient’s occupational history (e.g. heavy
workload of dancers, athletes)
24. Physical examination of the musculoskeletal
system: examination, palpation, determination of
the range of motion in the joints of the limbs
Practical skills training
