: Assessing Musculoskeletal Pain

The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.To prepare:By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.Review the following case studies:BELOW IS THE CASE STUDY——————Case 2: Ankle PainPhoto Credit: University of Virginia. (n.d.). Lateral view of ankle showing Boehler’s angle [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/8ankle/01anatomy.html. Used with permission of University of Virginia.A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing?BELOW IS THE QUESTION——————–Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.With regard to the case study you were assigned:Review this week’s Learning Resources, and consider the insights they provide about the case study.Consider what history would be necessary to collect from the patient in the case study you were assigned.Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.BELOW IS THE REQUIRED READING————————Learning ResourcesRequired Readings (click to expand/reduce)Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)Chapter 22, “Musculoskeletal System”This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.Chapter 22, “Lower Extremity Limb Pain”This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.Chapter 24, “Low Back Pain (Acute)”The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”) (Previously read in Weeks 1, 2, 3, 4, and 5)Chapter 3, “SOAP Notes”This section explains the procedural knowledge needed to perform musculoskeletal procedures.Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Ferreira, P. H., Fritz, J. M., Koes, B. W., Peul, W., Turner, J. A., Maher, C. G., Buchbinder, R., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., van Tulder, M., . . . Woolf, A. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet, 391(10137), 2368-2383. https://doi.org/10.1016/s0140-6736(18)30489-6Hicks, C., Levinger, P., Menant, J. C., Lord, S. R., Sachdev, P. S., Brodaty, H., & Sturnieks, D. L. (2020). Reduced strength, poor balance and concern about falls mediate the relationship between knee pain and fall risk in older people. BMC Geriatrics, 20(1), 94. https://doi.org/10.1186/s12877-020-1487-2————————————————————————You should create missing information in the episodic note to support your case. CORE SKILL: building a musculoskeletal differential from the pattern of joint involvement. The PATTERN is the diagnosis — count the joints, note the symmetry, and time the stiffness.
THE THREE QUESTIONS THAT DO MOST OF THE WORK:
1. HOW MANY JOINTS? Monoarticular (think septic arthritis, gout, trauma, hemarthrosis) vs. oligoarticular (2–4) vs. polyarticular (≥5 — think RA, SLE, viral).
2. SYMMETRIC OR ASYMMETRIC? RA is symmetric and involves the small joints (MCP, PIP — and characteristically SPARES the DIP). Osteoarthritis is asymmetric, weight-bearing, and involves the DIP (Heberden’s nodes) and PIP (Bouchard’s nodes). That DIP/MCP distinction alone separates the two most common arthritides.
3. INFLAMMATORY OR MECHANICAL? INFLAMMATORY: morning stiffness lasting >60 minutes, IMPROVES with use, worse with rest, warmth/swelling/erythema, systemic symptoms, elevated ESR/CRP. MECHANICAL/DEGENERATIVE: stiffness <30 minutes, WORSENS with use, improves with rest, minimal systemic features. This is the single most useful discriminator in rheumatology and it comes entirely from the history.
THE ONE YOU CANNOT MISS: SEPTIC ARTHRITIS — acute monoarticular, hot, exquisitely painful joint with fever and refusal to move it. It destroys cartilage within days. ARTHROCENTESIS IS MANDATORY before starting antibiotics. Know synovial fluid analysis: non-inflammatory WBC 50,000 with >90% PMNs; and crystal analysis under polarized light — GOUT = needle-shaped, NEGATIVELY birefringent (yellow when parallel); PSEUDOGOUT (CPPD) = rhomboid, POSITIVELY birefringent. Note that gout and septic arthritis can COEXIST, so a positive crystal finding does not exclude infection.
OTHER KEY ENTITIES: gout (podagra — first MTP joint, purine/alcohol/diuretic triggers, hyperuricemia — though serum urate can be NORMAL during an acute flare, a classic exam trap); polymyalgia rheumatica (age >50, proximal shoulder/hip girdle pain and stiffness, markedly elevated ESR, dramatic steroid response — and always ask about temporal headache/jaw claudication/visual change because of its association with GIANT CELL ARTERITIS, which threatens vision and is treated emergently); fibromyalgia (widespread pain, fatigue, non-restorative sleep, NORMAL inflammatory markers — a diagnosis of central sensitization, not inflammation); ankylosing spondylitis (young male, inflammatory back pain, HLA-B27).
EXAM: inspect, palpate for warmth/effusion/tenderness, active then passive ROM, joint-specific special tests (McMurray, Lachman, drawer, Phalen, Tinel, Finkelstein).
DIAGNOSTICS: know what each test actually adds — RF is neither sensitive nor specific; ANTI-CCP is far more SPECIFIC for RA; ANA is sensitive but poorly specific for SLE (a good screen, a bad confirmation).

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