Ultrasound Musculoskeletal

Musculoskeletal disorders are the commonest cause of disability in the UK. Each year 15 per cent of patients on a general practitioner’s list will consult their doctor with a locomotor problem, and such conditions form 20–25 per cent of a GP’s workload. About 30 per cent of those with any physical disability, and 60 percent of those with a severe disability, have a musculoskeletal disorder as the primary cause of their problems.

Clinical skills – i.e. competent history taking and examination – are the key to making an accurate diagnosis and assessment of a patient complaining of joint problems. This booklet aims to outline the methods you might use. It is not intended to replace clinical teaching and experience but to be used as an aid to learning.

‘Arthritis’ is a term that is frequently used to describe any joint disorder (and not infrequently any musculoskeletal problem). It could be argued that the term ‘arthritis’ should be used to describe inflammatory disorders of the joint whilst ‘arthropathy’ should be used to describe non-inflammatory disorders. Other musculoskeletal problems should similarly be described according to their anatomical site (e.g. muscle or tendon) and whether they are of inflammatory or noninflammatory aetiology. However, the term ‘arthritis’ is in such widespread general use to describe any disorder of the joint that, for the purpose of this guide, it will be used in that sense.

History taking is one of the most important skills for any doctor or practitioner to acquire and this can only be achieved through regular practice.

It is clearly important to identify those cases where pain may appear to arise from the joint but is in fact referred pain – for example, where the patient describes pain in the left shoulder, which might in fact be referred pain from the diaphragm, the neck, or perhaps ischaemic cardiac pain. In cases where examination reveals no abnormalities in the joint, other clues will be obtained by taking a full history.

Assuming the patient’s problems do arise from the joint(s), the aims of the history will be to differentiate between inflammatory and degenerative/mechanical problems, to identify patterns that may help with the diagnosis, and to assess the impact of the problem upon the patient. There are four important areas which need to be covered when taking a musculoskeletal history:

• The current symptoms

• The evolution of the problem (is it acute or chronic?)

• The involvement of other systems

• The impact of the disease on the person’s life

• Pain

As with all pain, it is important to record the site, character, radiation, and aggravating and relieving factors. Patients may localize their pain accurately to the affected joint, or they may feel it radiating from the joint or even into an adjacent joint. In the shoulder, for example, pain from the acromioclavicular joint is usually felt in that joint, whereas pain from the glenohumeral joint or rotator cuff is usually felt in the upper arm. Pain from the knee may be felt in the knee, but can sometimes be felt in the hip or the ankle. Pain due to irritation of a nerve will be felt in the distribution of the nerve – as in sciatica, for example. The pain may localize to a structure near rather than in the joint – for example, the pain from tennis elbow will usually be felt on the outside of the elbow joint.

• Stiffness

In general, inflammatory arthritis is associated with prolonged morning stiffness which is generalized and may last for several hours. The duration of the morning stiffness is a rough guide to the activity of the inflammation. Commonly, patients with inflammatory disease will also describe worse stiffness in the evening as part of a diurnal variation. With inflammatory diseases such as rheumatoid arthritis (RA), where joint destruction occurs over a prolonged period, the inflammatory component may eventually become less active and the patient may then only complain of brief stiffness in the morning. In contrast, osteoarthritis (OA) causes localized stiffness in the affected joints which is short-lasting (less than 30 minutes) but recurs after periods of inactivity. It is sometimes difficult for patients to distinguish between pain and stiffness, so your questions will need to be specific. It may help to remind the patient that stiffness means difficulty in moving the joint.

• Joint Swelling

A history of joint swelling, especially if it is intermittent, is normally a good indication of an inflammatory disease process – but there are exceptions. Nodal osteoarthritis, for example, causes bony, hard and non-tender swelling in the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the fingers. Swelling of the knee is also less suggestive of inflammatory disease as it can also occur with trauma and in OA. Ankle swelling is a common complaint, but this is more commonly due to oedema than to swelling of the joint.

A brief screening examination, which takes 1–2 minutes, has been devised for use in routine clinical assessment. This has been shown to be highly sensitive in detecting significant abnormalities of the musculoskeletal system. It involves inspecting carefully for joint swelling and abnormal posture, as well as assessing the joints for normal movement.

This screening examination is known by the acronym ‘GALS’, which stands for Gait, Arms, Legs and Spine. The sequence in which these four elements are assessed can be varied – in practice, it is usually more convenient to complete the elements for which the patient is weight bearing before asking the patient to climb onto the couch (this is the approach adopted in the accompanying DVD).