Principles

The consultation

When  a person  experiences an illness they look to health  professionals to provide  a solution.  Ideally, a partnership between patient  and  doctor should  be  established that  allows  the  best  possible  outcome for  the patient.

The starting point of the whole  process  is the medical consultation. The purpose  of the consultation is to assess the impact  that the condition is having on the patient,  establish the nature  of the underlying  cause of the problem, make  a  diagnosis,   decide   –  between both the  doctor   and patient   –  on  a  suitable   course   of  treatment   and  then  monitor   how effective this treatment  is being.

You,  as  the  patient,   are  the  main  source   of  information   about   your problem, and  the  information   you  give  is crucial  to  help  the doctor understand the  nature  and  impact  of the  problem  and  to  arrive  at  a diagnosis  and a course  of treatment.

It has been  shown  that musculoskeletal problems  (problems  that affect the joints, ligaments,  tendons  or muscles) are often not fully assessed  by doctors  and  that as a result many  of the problems  are not managed as well  as they might be.  It is known  that  the earlier  in the course  of the disease  that the problem  is identified  and treatment  started the better the outcome for the patient.  So a good consultation is really important.

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Patient Partners have an important  role in giving health  professionals  insight into how musculoskeletal problems affect individuals’ lives and how the professionals need  to ask the right questions  to gain the information  they require to make a diagnosis.

Your role as a Patient Partner is helping  health professionals  understand how to assess musculoskeletal problems effectively and efficiently by using history and examination. You will learn about  a screening  history and examination that enables  the doctor  to identify if someone has any musculoskeletal problems and also learn the assessment  by full history and examination of those problem  joints identified. You will learn about  the assessment of some of those joints that do or have affected you.

It is clear that if the doctor has had specific training in performing  a complete assessment  of a musculoskeletal problem, with the added advantage of working with a Patient Partner, this process  will be more efficient and will produce benefits for both doctor  and patient  alike.

This is what makes the Patient Partner programme so valuable.

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Matching expectations

A medical  consultation is a two-way  process.  Information  must flow in both directions  between doctor  and patient. This is best achieved if both parties  understand each  other’s expectations and  if both  know  how  to ask the right questions  to get the information  they need. The doctor  will be interested  in the disease  but the patient  is more concerned about  the illness  and  problems  that  the  disease  produces. So let  us  just  take  a moment  to consider:  what  is the  purpose  of the  consultation from the patient’s point of view? And, what is the purpose of the consultation from the doctor’s point of view?

The consultation from the patient’s perspective

Musculoskeletal  problems   may  arise  quite  quickly,   or  may  develop gradually  over time. When  the patient  sees the doctor  for the first time with  this  particular   problem  the  sort  of questions  that  may  be  going through  his or her mind is:

  • What is wrong?
  • What will happen to me?
  • What can you (the doctor) do about it?
  • What can I do about it?
  • Will I get better?
  • Will I get worse?

At later consultations, people  will be asking questions  such as:

  • Am I getting better?
  • Am I receiving the best treatment?
  • Are there any other treatments available?
  • Why am I not improving? Or: am I improving quickly enough?
  • Will my symptoms get worse?
  • Will I become permanently disabled and lose my job or independence?

It is the role of the doctor  to answer  these questions  as best as he or she is able and to work with the patient to resolve the issues. Patients will be seeking information  and also reassurance.

The consultation from the doctor’s perspective

The doctor will have many questions  that need  to be answered either by asking the patient  or by carefully observing  and examining  the person.

There are many different types of conditions that the doctor  will have to consider  during  the consultation. These are listed in Part 2 and  will be discussed  as we encounter them in the manual.

The questions  a doctor  will wish to be answered include:

  • What is the problem?
  • Is there an abnormality? And if there is,
    • What is the nature  of the abnormality?
    • What is the effect of the abnormality?
    • What is the cause  of the abnormality?
  • Are there any predisposing risk factors? (Predisposing risk factors are features that  make  a person  more  likely than  the  average to get a disease.  For arthritis,  these  factors include  obesity,  lack of exercise, smoking,  a family history of the condition or other illnesses  such as psoriasis (a skin condition).
  • Are there any  complications? (e.g.  some  diseases  can  affect  other parts of the body, or treatments  may have side effects)
  • What is the course of the disease?
  • What is the response to treatment?
  • What are the physical and psychosocial impacts  of this condition on my patient.

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Special note

The terms “abnormality” or “abnormal” are used medically  to describe something  that is outside what is seen in the majority of the population, such as swelling or loss of movement of a joint or a laboratory  investigation result. These terms are not judgemental or pejorative in nature and are not suggesting that the patient is “abnormal”, but knowing  that something about  a joint or a

laboratory  test is unusual  or abnormal gives the doctor crucial  information.  It is important  that Patient Partners appreciate this and understand how these terms are used both in this manual  and in clinical situations.

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The consultation process

There are two parts of a consultation from the doctor’s viewpoint  – taking a history and performing an examination. This may be followed by some special  tests, such as blood  tests or x-rays. When  the doctor  is confident about   the  diagnosis   he  or  she  will  work  out a management  plan in  partnership  with  the  patient.   The  doctor   also  needs   to  tell  the patient  about:

  • What is known about  the cause  of their problem.
  • What, relying  on  their  clinical  experience, the  doctor  expects  the course  and  pattern  of the condition will be (although  it is important to remember that people  are unique  and no-one  has the crystal ball that will predict  exactly what will happen to each  individual).
  • What treatments  are available.
  • What  the   likely  benefits   and   possible   side-effects   of  treatment will be.
  • What support  will be available  from the Healthcare Provider (in the UK this is the NHS) and from local Social Services.

Taking a history describes  the  interview  process  in which  the  patient, with  guidance from the  doctor,  describes  the  problem  and  gives other information  that will help the doctor  understand that problem. From the patient   perspective  it  is  better  described  as  giving  the history.  This training  manual, along  with  your  own  experience, will enable  you  to give your history in a way which  will teach  the doctor and  improve  his or her ability to take a history for other patients.

The other important  component of a consultation is the examination  of the  musculoskeletal system  – the  bones,  joints  and  muscles. That is a systematic  assessment  of the  condition of the  patient’s joints  and  how well they are functioning  and possible  problems  with the other tissues of the musculoskeletal system.

These  may  be  done  first as a screening  assessment  to rapidly  identify whether  there is a musculoskeletal problem  and where  it is located  and is  then  followed   by  a  full  history  and  examination  to  evaluate   the problem  identified.

If the person  is already  very specific about  the problem, then the doctor may just take a full history and perform an examination of that problem. For example,   if the  person  is just  complaining of shoulder   pain,  the doctor  may just assess the neck and shoulder. However, he may also do a screening  examination to check  quickly  whether  there  are any  other joints affected or other musculoskeletal problems.

 

When   you   are   demonstrating  how to  assess your musculoskeletal problem at a Patient Partner meeting, such as a problem  with your knee, you will need  to be able to describe  the problem  in a way that provides all the  information  that doctors  will need  to know  to help them  fully understand your  problem. By taking  them  through  your  history  in this way, and  guiding  them  if they do not seem  to know what  questions  to ask, you will be helping  them  assess such  problems more effectively in the future. It will be much easier for you to do this if you first understand what  sort of information  they need  to know  and  why. You also need  to know  the  purpose   and  principles   of  examining   the  musculoskeletal system so you can demonstrate the examination effectively. The aim of the  next  section   is  to  explain   this background  and   the  principles involved.

Giving your history

As a Patient Partner you will be able to draw on your own experience to give a personal  history to the doctor or other health professional. It is not the role of a Patient Partner to formally teach history taking, but it is quite appropriate for you  to guide  and  prompt  doctors  if they  do not  know what  to ask, forget to ask about  certain  items,  or ask the wrong  sort of question  that  will miss significant  information.  They will then  learn  by experience.

You may find this process  easier if you have some understanding of how the ideal consultation can be structured.  This will also help you develop the script that describes  the history of your problem.

The doctor  should  initially have a general  conversation with the patient, with open  remarks  such  as, “Tell me about  your problem”. The doctor should  be listening  to the patient’s description of his or her problem  in his or her own words and at the same time observing the patient’s overall appearance  and  demeanour; that  is  assessing  whether   the  patient  is troubled  or depressed by the condition. The doctor should  be watching the patient walk and sit down and seeing whether  he or she has problems with movement.

The doctor  should  then try to explore  the  patient’s problem  by asking about  the following:

  • What  are  the  symptoms   that  the  patient   is  experiencing  (pain, stiffness, deformity, loss of function  etc)?
  • The characteristics of these symptoms?
  • The site(s), and pattern of these symptoms?
  • The time scale over which the symptoms developed and the order in which  the symptoms  appeared?
  • Whether there  are  any  associated symptoms,  such  as fever, loss of energy, weight loss, rashes etc?
  • If there  are  any  interventions,  including   medicines, that  alleviate these symptoms?
  • If any factors came before or triggered off these symptoms?
  • The impact of these symptoms  on the patient’s quality of life?

In addition, the doctor  will ask questions  about:

  • The person’s lifestyle.
  • The person’s general health  and  any other  medical  conditions they have.
  • The person’s past history.
  • His or her family history.

Before  we  consider   the  history  taking  further,  it is worth  spending   a few minutes to consider  just what the symptoms of arthritis or musculoskeletal conditions are.

Symptoms of musculoskeletal conditions

Musculoskeletal conditions have  a number  of profound  effects on  the individual  – each  affecting different people  in different ways.

Common  symptoms  are:

  • Pain, often chronic.
  • Loss or limitation of function.
  • Stiffness in the spine or limbs.
  • Weakness.
  • Swelling of a joint.
  • Deformity of a joint (see special note).
  • Instability (giving way) of a joint.
  • Fatigue and malaise (general feeling of being unwell).

As a result the person may have:

  • Depression and fear.
  • Sleep disturbance.

There may also be other symptoms  such as:

  • Numbness or tingling in the fingers or toes.
  • Mouth ulcers.
  • Dry mouth.
  • Dry or red eyes.
  • Rashes, including psoriasis and sensitivity to sunlight.
  • Nodules.
  • Indigestion, often related  to treatment  with anti-inflammatory drugs.
  • Unusual or excessive  diarrhoea.
  • Pain or difficulty with urination.
  • Weight loss.
  • Fever.

A sample  of the  type  of questions  that  will be  asked  when  the  doctor takes  a detailed  history  is summarised in the  tables.  These  tables  also include  a brief summary  of what sort of information  the doctor  will gain from  these   questions,  which   may   help   you   understand  why   these questions  are  necessary.  These  lists are  not  comprehensive, the  doctor will not necessarily  ask every one of these questions, and may ask others. These tables  are just a guide  to help  understand the types of questions and their aims.

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Special note

As with the terms “abnormality” or “abnormal”, “deformity” has a specific technical meaning  in relation  to joints or bones.  A joint deformity refers to misalignment of the two bones  that move against each  other in a joint.

A bone  deformity suggests an abnormal shape  of a bone  or bones.  It is preferable  that the term “finding”  is used rather than “abnormality” but many doctors  will use the term deformity. As with abnormality, the patient should  not be upset or distressed  by this term.

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 Question about Pain  What this tells the doctor
Where is the pain  and  where does  it spread to? Ideally the patients should indicate with their hands exactly  where on their bodies the pain  is felt and  where it is most intense. The site of the pain  tells a lot about what is causing it. Pain may be clearly localised to an anatomical structure, such  as the knee,  but sometimes it is more  diffuse and can be referred from another structure, so that the pain  appears a long way from where it originates. For example a problem with the hip sometimes causes pain  to be felt in the knee. Generalised pain (pain all over) is usually  due  to a different set of diseases to those  that cause  localised pain.
What  is the pain  like? For example, is it sharp,  stabbing, shooting, throbbing or dull and  aching? How  severe  is it? Is it an ache  or agony? Pains have  different qualities depending on their cause. Shooting pains  are usually associated with nerves,  aching pains  with joints,  while  throbbing pains  may be due to inflammation.
Is there  a pattern to how  the pain has developed or spread?

The doctor needs  to know  how the patient  has arrived  at the present situation.

Some diseases have  a specific pattern of pain.  For example, gout pain  starts as a pricking  in the big toe which builds  into a severe  burning pain over a day or two. Rheumatoid arthritis follows a gradual course, starting typically  in both  hands and  wrists, and  then  both  feet.
Was there  any injury or change of use (repetitive or unusual) before  the onset of pain?  Many episodes of musculoskeletal pain follow an injury,  such  as whiplash strain and  neck  pain.  Suddenly doing  repetitive activities  can also cause  musculoskeletal pain.
Do you have  pain  when  you are at rest or at night? Conditions such  as osteoarthritis are more painful  when  the joint is used, whereas inflammatory joint pain, such as that of rheumatoid arthritis, is present at rest and  is usually  worse in the morning and/or evening. Back pain  due  to mechanical problems is better  when resting but inflammatory problems cause pain  at night.
Does  anything make  the pain  worse? Mechanical pain  and  the pain

of osteoarthritis are often worse  with physical activity.

Being able  to move  a joint without pain may show  that there  is not a problem of the joint itself and  the pain  may be referred.

Does  anything improve the pain? Do any activities  or interventions, including medication, relieve  the pain? Rest may relieve  osteoarthritis pain but has little effect on inflammatory pain. Exercise improves inflammatory low back pain.  Inflammatory pain  responds well to anti-inflammatory drugs
Does  any other  problem accompany the pain? Pain may prevent sleep  or may be causing depression.

 

How  does  the pain  affect your life?For example, does  the pain  prevent you doing  anything? Pain may prevent people carrying out normal daily activities  and  affect their quality  of life.

 

Questions about loss of function What this tells the doctor
Are you having any difficulties with any activities that you could previously do quite easily? Difficulty with specific activities can point to which joint is affected by the patient’s condition.
Do you have any difficulties washing and dressing? This is a good measure of function of the lower limbs.
Do you have any difficulties going up and down stairs? This is a good measure of function of the lower limbs.
Do you have any difficulties with activities in the home because of this problem? Musculoskeletal problems often affect the ability to carry out domestic activities.
Do you have any difficulties with your work because of this problem? Musculoskeletal problems often affect the ability to carry out employment activities.
Do you have any difficulty with leisure activities because of this problem? Musculoskeletal problems often prevent people participating in activities such as walking for pleasure or playing sports.

 

Questions about stiffness What this tells the doctor
Are you stiff at all? Which parts are affected? Is it the joints, muscles, back or generalised? Stiffness also means different things to different people and what is being described needs to be clarified.

Generalised stiffness can occur after a long car journey or the day after exercise. This is quite normal and occurs more often as people age. Some musculoskeletal conditions can also cause stiffness. Stiffness of joints and marked morning stiffness of the back point to a specific problem.

When during the day is the joint most stiff? Inflammatory joint disorders cause prolonged morning stiffness and osteoarthritis is associated with short-lived stiffness after inactivity such as sitting in a chair for a few hours.
How long does the stiffness last? The time the stiffness lasts can tell a lot about the severity of the arthritis.
Does anything make the stiffness worse? Short-lasting, but severe, stiffness after inactivity is typical of osteoarthritis.
Does anything make the stiffness better? The stiffness of osteoarthritis may be overcome by gentle use of the joint but this is often not the case for rheumatoid arthritis. Stiffness of the back due to inflammation improves with exercise.

 

Questions about swelling and joint deformity What this tells the doctor
Do you have any swelling of the joints or elsewhere? Swelling can be of the joint or periarticular structures such as a bursa or tendon sheaths. Hard swellings called nodules can develop in RA.
Did the swelling or changes appear rapidly or slowly? Is it painful? This will tell the doctor something about how severe the condition is and how it is progressing.
Did the joint swelling or changes follow an injury? The doctor needs to know whether the swelling is a short-term response to a recent injury which is not an arthritic condition or whether arthritis is developing after an injury.
Do the problems come and go? Rheumatoid arthritis and similar conditions can have flare-ups and quiet periods, while other types of arthritis may be progressive.
Is the joint gradually getting bigger? Gradual enlargement of a joint suggests a progressive condition.

 

Questions about the timeframe of the disorder and other relevant questions What this tells the doctor
When did the problem start and the pattern that has developed and over what time? All these questions help the doctor differentiate between the different causes of musculoskeletal problems.
Where and how has the problem spread?
What associated symptoms have developed and when did they occur?
Did you have an injury sprain or strain of the affected joint or region in the past?
Do you have loss of strength? This is asking about a loss of muscle power, not loss of energy. Generalised weakness may be a sign of muscle disorders such as polymyositis. Weakness in specific limbs will have a specific cause, maybe a nerve problem that needs identifying.
How do you feel generally? Inflammatory conditions such as RA are often accompanied by feelings of malaise. Generalised illness that can affect bones and joints may cause people to feel unwell.
Do you suffer from tiredness or fatigue? Fatigue accompanies many rheumatic disorders, such as RA, systemic lupus erythematosus (SLE) and fibromyalgia. People with these conditions are often able to function for several hours but then become overwhelmed by fatigue.
Is your sleep disturbed? Pain or discomfort can affect sleep, contributing to fatigue and depression. Pain at night is an important clue for certain types of arthritis.
How do you feel upon waking in the morning? Morning stiffness is indicative of certain types of arthritis. Waking unrefreshed may point to fibromyalgia.

It is well recognised that some of these symptoms are difficult to describe clearly.

For example, what is an unacceptable degree of pain to one person may be perceived as a slight pain to another  and some perceive  admitting to pain  as “making  a fuss”. To overcome this problem  the  doctor  should always  watch  patients  for signs of pain  (wincing  or grimacing) during examination and ask the patient  to mention  any pain felt. It also helps if the  doctors   ask  questions   that  suggest  words   to describe   the  pain (see table) and  they may also suggest to the patient  activities  that make the pain  worse  or better. Another  way of conveying  the severity of pain is to ask a patient  what it stops him or her doing.

If a person  reports  “fatigue”,  it is important  that the doctor  understands the nature of the tiredness. The patient may be feeling tired because pain is stopping  him or her sleep,  or maybe  the patient  is depressed by the illness; on the other hand,  fatigue may be a feature of the illness which points  to inflammatory  (rheumatoid arthritis  type) diseases  rather  than the “wear  and tear” (osteoarthritis  type) illness.

If a person  reports  “fatigue”,  it is important  that the doctor  understands the nature of the tiredness. The patient may be feeling tired because pain is stopping  him or her sleep,  or maybe  the patient  is depressed by the illness; on the other hand,  fatigue may be a feature of the illness which points  to inflammatory  (rheumatoid arthritis  type) diseases  rather  than the “wear  and tear” (osteoarthritis  type) illness.

The detailed  questions  are  also  necessary  to make  quite  sure  that  the patient’s problem  is truly musculoskeletal. There are illnesses  that may look  similar  to  a  musculoskeletal  condition  but  which   need   quite different treatment.

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Special note

Many doctors  are not fully aware  how pervasive arthritis and other chronic musculoskeletal conditions can be on a person’s everyday  life. For some people  their condition impacts  constantly throughout the day.

As a Patient Partner you have the direct experience of the impact  of a musculoskeletal condition that can help inform the healthcare professionals  in a way that no text book can.

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Impact of symptoms

It is important  that the doctor  knows  how  the symptoms  are impacting on the patient’s daily life.

The  doctor  should  ask  several  questions   about  how  the  condition is affecting the patient  and their quality of life. The doctor  should  also ask questions  so as to understand the situation  of the patient,  such as his or her support by family and friends, the home environment, their work and the everyday  activities they need  or are expected to be able to carry out. The information  will be  clearer  and  more  useful  if it is gathered  in an organised  rather  than  a haphazard way.  It is important  that  the  doctor understands  how   the  musculoskeletal  problem limits  activities   and restricts participation.

The activities affected can be considered under  four headings:

  • Self care e.g. washing, dressing, going to the toilet, feeding.
  • Domestic care e.g. cooking, cleaning,  laundry,  shopping.
  • Work e.g. standing, sitting, typing.
  • Leisure e.g. playing sports, walking the dog, going out for meals.

People   with   musculoskeletal  conditions  may   also   find  that   (when relevant)  their  problem  is affecting  their  sexual  relationship with  their partner.  This could  also  be  mentioned if you  feel  comfortable  talking about  this in your demonstration.

You should  therefore  describe  the impact  your condition has on you in these  terms  to ensure  the  health  professional  fully appreciates how  it affects you.

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Many doctors  are not fully aware  how pervasive arthritis and other chronic musculoskeletal conditions can be on a person’s everyday  life. For some people  their condition impacts  constantly throughout the day.

As a Patient Partner you have the direct experience of the impact  of a musculoskeletal condition that can help inform the healthcare professionals  in a way that no text book can.

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Principles of examination

The examination of the musculoskeletal system is to answer  important questions  that, together  with the history, should enable  a diagnosis  to be made.

These questions  are:

  • Is the patient’s musculoskeletal system normal?
  • If there is an abnormality?
    • What structures  are involved?
  • What is the cause?
    • Inflammation?
    • Damage?
    • Mechanical problems?
  • What is the pattern of distribution?
    • Is it one-sided or does it affect both sides of the body
  • What other features are there that may help assess the problem?

In  order  to  define  the  nature  of  the  abnormality the  doctor will  be looking for:

Inflammation of the joint. It is important  to distinguish  between inflammatory   types  of  arthritis  and   non-inflammatory conditions.  In general  terms the signs of inflammation are: warmth,  swelling, and tenderness.

Warmth which  can  be elicited  by lightly stroking the back  of the hand starting  at  a  normal  area  and  moving  over  the  joint.  This method is suitable  for testing medium  and large joints such as knee, ankle or wrist, but you cannot  feel the temperature of deep  seated joints like the hip.

Fig 1

Swelling of a joint. This may be due  to swelling  of bone,  swelling  soft tissue such  as the lining of the joint (synovitis)  or the accumulation of fluid (an effusion) in a joint, or a combination of these.  One  purpose  of examining  the swelling  is to determine what  is the cause  and there  are ways of doing this which you will learn about.  Sometimes x-rays or other tests are also done  to establish  the cause.

Fig 2

Tenderness. This is assessed  by  gentle  palpation or  squeezing to  test which  structures  are tender.  Any structure  of the musculoskeletal system can be tender. Tenderness  can be a feature of inflammation but muscles which  are in spasm for other reasons  can be tender.

Fig 3

Redness can  be seen  over very inflamed  joints such  as in gout or with infection.

Crepitus, which  is an  audible   sensation  that  can  also  be  felt by  the examiner, results from the movement of one rough surface over another. The roughness  may  arise  from OA when  it makes  a sound  that  differs from that of a normal  joint.

Damage may be irreversible damage  from past inflammation, recognised by  deformity   of  the  joint  and   permanent  loss  of  normal range   of movement.

Mechanical problems can include  tears of ligaments,  or prolapsed discs in the spine (slipped disc). These are identified  by a painful restriction  of movement of the joint in the absence of inflammation.

The range of joint motion  (ROM) will reveal  problems. Joints that  can move  further than  the average  show  hypermobility (hyper- means  more than usual; hypo means less than usual). Joint movement is usually diminished  by  inflammation  or  by  irreversible   damage  to the  joint structures by disease. Progressive diseases are accompanied by progressive loss of movement. If movement is lost completely it is known as ankylosis.

Other features are signs of systemic illness and skin signs. Skin signs can include  nodules  that suggest RA.

All these observations are vital to diagnosis and there is a systematic way of  obtaining   this  information.   The  following   sections   will consider different joints and  will all use this system for examining  a joint and  its surrounding tissue. This system may be summarised as:

Look (inspect) – looking at the patient and the joint at rest and during movement Many abnormalities can be noted by careful observation. The doctor should look at the way the person moves, performs activities and the posture adopted.

Any deformity or swelling should be noted. The skin overlying the affected region should be looked at. The muscle bulk should be looked at to see if there is any loss (wasting).

Feel (palpate) – feeling the joint The joint should be felt for warmth and tenderness. Any swelling should be characterised – exactly where is it, is it tender, is it fluid, soft tissue or bone?
Move – establishing the range of motion of the joint by both active, passive and resisted movement and looking at how the function of the joint is affected Abnormality of movement can be assessed, if the problem only affects one side, by comparing the abnormal joint with the other side. The pattern of loss of movement or the effect that movements have on pain can help identify the cause.
Stress – carry out physical tests on the joint by getting the patient to move against a resistance (often the examiner’s hand) Testing if stressing a joint causes pain or if it is unstable can help identify the problem.
Listen Listen for sounds of crepitus when the joint is moving.
Special tests – consider any other investigations that allow diagnosis of specific conditions There are many special tests used when examining the musculoskeletal system but only the most important ones will be considered here.

These concepts are outlined in greater detail in the joint examination script.

Screening assessment

As we have  said already,  a screening  assessment  can  establish  whether there  is  actually   a  musculoskeletal problem,  and   locate where   this problem  is before a more detailed  assessment. There is no point wasting time fully examining  a person’s  legs if the only problem is pain  in his or her  hand.  It is also  important  to differentiate  local  from generalised problems.

This  screening   assessment   is  based   on  a  validated   and  widely  used method  which  assesses a person’s

  • Gait
  • Arms
  • Legs
  • Spine.

The doctor needs to ask questions  related to, and then examine,  all these aspects  of the patient.

The doctor  will ask:

  • Do you  suffer any  pain  or stiffness in your  arms,  or legs, neck,  or back?
  • Do you  have  any  difficulty  with  activities  such  as  washing   and dressing or in going up or down  stairs?
  • Do you have any swelling of your joints?
  • How is your general health  (i.e. is there any systemic illness)?

Dressing  without  difficulty  – including  putting  on  tights or  socks  and shoes, doing up buttons or tying a tie – is a complex  use of the joints and utilises  subtle  movements of both  the  upper  limbs  (shoulders,  elbows wrists and  hands) and  lower limbs (hip, knee,  ankle  and  feet). Washing also  needs  good  function  of the  arms  and  hands.  Coping  with  stairs needs  good function  of the legs. These questions therefore  give a good, simple and quick indicator  of musculoskeletal health.

The doctor  will then perform a rapid screen  of all joints to locate the site of  the   problems.  These   are   given   in   the   examination  script. The movements used in the GALS are the first to show evidence of disease so it is a sensitive test of early problems.

A  musculoskeletal  problem   is  very  unlikely   if  the   person   has   no symptoms and if the appearance of the muscles  and joints is normal and the joints move normally.

Table 1 Table 2