Lekcja 3: Badanie i Ocena Stanu Pacjenta | Patient Examination and Assessment

Musculoskeletal History

Taking a thorough and structured musculoskeletal history is crucial in identifying the root causes of symptoms related to bones, joints, muscles, and connective tissues. A comprehensive history helps in pinpointing the nature and progression of the disorder, providing insights into trauma, inflammatory conditions, degenerative diseases, and congenital abnormalities. The history should be patient-focused, assessing the presenting complaint, associated symptoms, and relevant medical background.

Primary Complaint

The musculoskeletal history begins with identifying the patient’s primary complaint. Common complaints related to the skeletal system include:

  • Joint pain (arthralgia)
  • Muscle pain (myalgia)
  • Bone pain
  • Swelling
  • Stiffness
  • Weakness
  • Deformity
  • Limited range of motion
  • Functional impairment

History of Present Illness

A detailed history of present illness focuses on the characteristics, onset, progression, and aggravating or relieving factors associated with the patient’s symptoms.

Pain

Pain is one of the most common symptoms in musculoskeletal disorders. It’s essential to assess:

  • Location: Identifying the exact location of the pain helps determine whether it’s localized to a joint, bone, muscle, or generalized across multiple areas.
  • Quality: Descriptive terms like “sharp,” “dull,” “aching,” or “burning” can indicate different pathologies. Sharp pain is often related to fractures or acute trauma, while dull or aching pain suggests inflammatory or degenerative causes.
  • Onset: Did the pain develop suddenly (as in trauma) or gradually (as seen in conditions like osteoarthritis or tendinitis)?
  • Duration: Chronic pain lasting for months suggests a degenerative or systemic condition, while acute pain points to trauma or infection.
  • Pattern: Is the pain worse in the morning (indicative of inflammatory arthritis) or after activity (suggesting osteoarthritis or overuse injury)?
  • Associated symptoms: Is there swelling, redness, or warmth over the joint or area of pain? These may indicate inflammatory conditions like rheumatoid arthritis or infections. Mechanical symptoms like locking or instability often suggest ligament or meniscal injuries in joints.

Swelling

Swelling may be localized to a single joint or muscle group or generalized. It is important to assess:

  • Timing: Acute swelling often suggests trauma, infection, or gout, whereas chronic swelling is more likely due to arthritis or a chronic overuse condition.
  • Accompanying symptoms: Redness, warmth, and tenderness over the swollen area can point to infection or inflammatory arthritis. Pain-free swelling may suggest fluid accumulation, such as in a joint effusion or bursitis.

Stiffness

Joint stiffness is often a key feature in musculoskeletal diseases:

  • Morning stiffness: If stiffness lasts more than 30 minutes in the morning, it suggests an inflammatory arthritis (e.g., rheumatoid arthritis or ankylosing spondylitis). Short-lived stiffness after rest, often seen in osteoarthritis, typically resolves quickly with movement.
  • Movement-related stiffness: Stiffness that worsens with movement may indicate degenerative conditions like osteoarthritis.

Weakness

Muscle weakness can be indicative of neuromuscular or musculoskeletal disorders:

  • Location: Weakness may be generalized (as seen in myopathies) or localized to a specific muscle group (as in nerve compression or muscular dystrophy).
  • Duration: Progressive weakness over time may suggest chronic conditions such as muscular dystrophies or neuropathies, while sudden weakness can occur with traumatic injuries like muscle tears or nerve injuries.
  • Associated symptoms: Numbness, tingling, or muscle wasting associated with weakness may suggest nerve entrapment or peripheral neuropathy.

Deformity

Deformities can be congenital or acquired, and understanding their characteristics helps guide diagnosis:

  • Congenital vs. acquired: Congenital deformities, such as scoliosis, may present early in life, while acquired deformities like kyphosis or joint misalignment develop over time due to trauma, degenerative changes, or infection.
  • Progression: Is the deformity worsening over time, as seen in progressive scoliosis or arthritis-related joint destruction?

Limited Range of Motion

Range of motion limitations often accompany pain, stiffness, or swelling. It’s essential to determine:

  • Active vs. passive limitation: Active range of motion is what the patient can do voluntarily, while passive range is what the examiner can achieve for the patient. Limited active range with normal passive range often suggests muscular issues, while limitations in both can indicate joint or structural problems.
  • Pain during movement: Pain with movement may be due to mechanical issues like osteoarthritis, while pain at rest could point to inflammatory causes.

Functional Impairment

The impact of musculoskeletal symptoms on the patient’s daily activities is critical to assess:

  • Activities of daily living (ADLs): How do the symptoms affect the patient’s ability to perform everyday tasks such as walking, climbing stairs, or dressing?
  • Gait abnormalities: Limping, inability to bear weight, or altered gait can be due to joint, muscle, or nerve conditions.
  • Assistive devices: Ask whether the patient uses a cane, walker, or other aids to help with movement.

Past Medical History

A review of the patient’s past medical history can reveal underlying risk factors for musculoskeletal conditions:

  • Osteoarthritis: A history of previous joint trauma or repetitive use injuries increases the likelihood of developing osteoarthritis.
  • Rheumatoid Arthritis (RA): A past diagnosis of RA or other autoimmune diseases may explain symptoms related to inflammatory joint disease.
  • Osteoporosis: A history of osteoporosis predisposes patients to fractures, particularly in the elderly or those on long-term corticosteroids.
  • Trauma or Surgery: Previous fractures, joint replacements, or surgeries can lead to post-traumatic arthritis or biomechanical changes affecting joint function.
  • Congenital disorders: Conditions such as scoliosis, hip dysplasia, or Marfan syndrome may have lifelong musculoskeletal implications.

Family History

Musculoskeletal conditions often have hereditary components, and a detailed family history helps identify potential genetic predispositions:

  • Osteoarthritis: A family history of osteoarthritis increases the likelihood of the condition developing earlier or more severely.
  • Rheumatoid Arthritis: There is a genetic component to RA and other autoimmune conditions like lupus, making family history important in these cases.
  • Muscle dystrophies: Conditions like Duchenne or Becker muscular dystrophy are inherited, and a family history of muscle disease or early weakness in relatives is significant.
  • Bone diseases: Family history of osteoporosis or Paget’s disease can provide clues to the patient’s susceptibility to bone conditions.

Social History

Social history is essential in understanding lifestyle factors contributing to musculoskeletal health:

  • Occupation: Physical jobs involving repetitive movements, heavy lifting, or prolonged standing can predispose patients to joint or muscle strain, osteoarthritis, or overuse injuries.
  • Physical Activity: Engaging in sports or high-impact activities can lead to specific injuries such as stress fractures, tendinitis, or ligament tears. Conversely, a sedentary lifestyle may contribute to obesity, joint stress, or muscle deconditioning.
  • Smoking: Smoking negatively impacts bone healing, increases the risk of osteoporosis, and contributes to poor outcomes in joint surgeries.
  • Alcohol Use: Excessive alcohol consumption is linked to muscle wasting, gout, and an increased risk of fractures.
  • Diet: Poor nutrition, particularly low calcium and vitamin D intake, can predispose individuals to osteoporosis and fractures.

Environmental and Occupational Exposures

Chronic musculoskeletal problems can be associated with environmental or occupational exposures:

  • Repetitive Strain Injuries (RSIs): Jobs requiring repetitive motion, such as typing, factory work, or manual labor, increase the risk of tendinitis or carpal tunnel syndrome.
  • Vibration Exposure: Prolonged exposure to vibrating tools, such as jackhammers, can lead to conditions like hand-arm vibration syndrome, causing pain, numbness, and loss of function in the hands and wrists.

Observation

Observation is a crucial initial step in a musculoskeletal examination. It offers immediate visual information about the patient’s condition, guiding the subsequent steps of the physical exam. Through observation, clinicians can identify abnormalities in posture, muscle bulk, symmetry, and joint alignment.

Skin Conditions

Observing the condition of the skin overlying the musculoskeletal structures is essential because skin changes can reflect underlying systemic diseases, local trauma, or infections.

  • Erythema (Redness): This may suggest inflammation of underlying tissues, such as in the case of arthritis, cellulitis, or bursitis. In autoimmune diseases like lupus, erythema can be widespread, especially over sun-exposed areas.
  • Ecchymosis (Bruising): Bruising may indicate recent trauma or bleeding disorders. For example, a large bruise around the knee might suggest ligamentous injury, such as in an anterior cruciate ligament (ACL) tear.
  • Ulceration and Rash: Open sores or persistent rashes may suggest systemic diseases like diabetes or vasculitis, which can impair circulation and lead to delayed wound healing. Rashes in specific patterns can also suggest dermatomyositis, a condition involving both muscle inflammation and skin involvement.
  • Skin Atrophy and Sclerosis: Thinning of the skin can indicate chronic disuse or vascular insufficiency, while thickening and hardening (sclerosis) may suggest conditions like scleroderma, which involves the skin, connective tissues, and often the musculoskeletal system.

Joint Deformities

Assessing joint alignment and structure provides insight into the integrity of the skeletal system. Common deformities to look for include:

  • Subluxation or Dislocation: Joint subluxation is a partial dislocation where the joint surfaces have lost their normal alignment. Complete dislocation indicates that the joint surfaces are completely displaced. These findings are common in traumatic injuries, rheumatoid arthritis, or connective tissue disorders like Ehlers-Danlos syndrome.
  • Swelling and Effusion: Swelling in the joint may be caused by fluid accumulation (effusion), which can be seen in conditions such as osteoarthritis, rheumatoid arthritis, or gout. Observation of unilateral or bilateral swelling should raise suspicion of systemic inflammatory conditions or localized joint pathology.
  • Misalignment: Deformities like genu valgum (knock knees) or genu varum (bow legs) suggest congenital or acquired bone deformities. Observation of hip dysplasia, scoliosis (lateral curvature of the spine), or kyphosis (hunched posture) can indicate structural abnormalities that require further evaluation.

Muscle Abnormalities

Abnormalities in muscle size, contour, and symmetry are essential diagnostic clues.

  • Atrophy: Muscle wasting is a key indicator of disuse, nerve damage, or systemic muscle disease. It may be localized, such as in quadriceps atrophy following knee injury, or generalized, as seen in conditions like muscular dystrophy.
  • Hypertrophy: Increased muscle size, which may be compensatory due to overuse or pseudohypertrophy, where muscle is replaced by fibrotic tissue or fat, is observed in conditions like Duchenne muscular dystrophy.
  • Fasciculations: Involuntary muscle twitches, often seen in the hands, arms, or legs, can be a sign of lower motor neuron pathology, such as in amyotrophic lateral sclerosis (ALS) or peripheral neuropathies.
  • Involuntary Movements: Tremors (rhythmic shaking), chorea (jerky, involuntary movements), and myoclonus (shock-like contractions) may indicate neurological disorders such as Parkinson’s disease, Huntington’s disease, or epilepsy.

Postural Abnormalities

The overall posture of the patient is critical in evaluating musculoskeletal health.

  • Scoliosis: The presence of an abnormal lateral curvature of the spine can suggest scoliosis, which may be congenital or idiopathic.
  • Kyphosis: A hunched upper back can indicate thoracic vertebral collapse, often associated with osteoporosis or degenerative disc disease.
  • Lordosis: Exaggerated lumbar curvature is common in individuals with weak core muscles, obesity, or conditions like pregnancy.

Palpation

Palpation involves using the hands to feel specific musculoskeletal structures, allowing for the detection of tenderness, warmth, swelling, and abnormalities in texture.

Tenderness

Palpation of muscles, bones, and joints for tenderness can localize pain and help differentiate between musculoskeletal and systemic causes of discomfort.

  • Localized tenderness may suggest tendinitis, muscle strain, or localized trauma. For instance, tenderness over the lateral epicondyle of the elbow is characteristic of lateral epicondylitis (tennis elbow).
  • Diffuse tenderness could indicate systemic inflammatory conditions, such as polymyalgia rheumatica or fibromyalgia.

Swelling

  • Edema or effusion around joints is often a sign of inflammation or trauma. Palpation helps determine whether swelling is caused by fluid within the joint (joint effusion), a soft tissue injury (sprain), or inflammatory disease (rheumatoid arthritis).
  • Pitting edema indicates fluid retention, often due to systemic conditions like heart failure or venous insufficiency, while non-pitting edema may indicate lymphatic blockage or infection.

Trigger Points

  • Trigger points are focal areas of muscle spasm or hyperirritability, typically found in patients with myofascial pain syndrome. Applying pressure to these points often reproduces pain in a specific pattern or referred area.

Joint Abnormalities

  • Crepitus: A palpable grating sensation during joint movement may indicate cartilage degeneration or damage, such as in osteoarthritis.
  • Effusion: Fluid in the joint, detected as a spongy or fluctuating sensation, is often due to inflammatory conditions like septic arthritis, hemarthrosis, or crystal-induced arthropathy (e.g., gout).
  • Bony prominences: Enlargement of bony structures may indicate osteophytes (bone spurs) commonly found in osteoarthritis, or fractures in trauma cases.

Range of Motion (ROM) Testing

Evaluating both active and passive range of motion is essential in determining joint functionality, muscle flexibility, and the integrity of soft tissues like tendons and ligaments.

Active ROM

This involves the patient voluntarily moving their joints. It assesses muscle strength, joint mobility, and the patient’s willingness or ability to move the joint through its normal range.

  • Clinical significance: Reduced active ROM may indicate muscle weakness, pain, mechanical restriction due to joint pathology, or neurological impairment.
  • Example: Limited active shoulder abduction may indicate rotator cuff pathology, adhesive capsulitis (frozen shoulder), or nerve impingement.

Passive ROM

Here, the clinician moves the joint without patient effort, providing an indication of the full potential range of movement, independent of muscle strength.

  • Clinical significance: If passive ROM is preserved but active ROM is restricted, it often suggests muscle weakness or a mechanical issue, such as tendon pathology. Conversely, reduced passive ROM may indicate joint stiffness due to arthritis, capsulitis, or ligamentous contracture.
  • Example: A discrepancy between active and passive ROM in the hip joint may suggest conditions like hip osteoarthritis or ligamentous injury.

Abnormal Findings in ROM

  • Hyperflexibility or hypermobility: Excessive movement beyond the normal range, often due to ligamentous laxity or connective tissue disorders like Marfan syndrome or Ehlers-Danlos syndrome.
  • Hypomobility: Restricted movement due to conditions such as osteoarthritis, rheumatoid arthritis, or joint contracture following injury.

Muscle Strength Testing

Muscle strength testing helps assess the integrity of the muscles, nerves, and tendons responsible for movement. The Lovett scale is commonly used to evaluate muscle strength:

  • Grade 0: No muscle contraction observed.
  • Grade 1: Flicker of muscle contraction, but no movement.
  • Grade 2: Full ROM without gravity (gravity eliminated).
  • Grade 3: Full ROM against gravity, but without resistance.
  • Grade 4: Full ROM against some resistance, but weaker than normal.
  • Grade 5: Full ROM against full resistance (normal strength).

Techniques

  • Isotonic Contraction: Muscle changes length during contraction, such as lifting a weight (concentric contraction) or lowering it (eccentric contraction).
  • Isometric Contraction: Muscle length remains constant, such as holding a plank position, where the muscle generates force without moving.
  • Isokinetic Contraction: Muscle contracts at a constant speed, often using specialized equipment in rehabilitation settings.

Common Muscle Strength Tests

Upper Extremities

  • Shoulder Abduction: Test the deltoid muscles by having the patient raise their arms out to the sides against resistance. Weakness may indicate a rotator cuff injury, nerve impingement, or brachial plexus injury.
  • Elbow Flexion and Extension: The biceps and triceps are tested by having the patient flex (bend) and extend (straighten) the elbow against resistance. Weakness here could indicate nerve injury, such as damage to the radial or musculocutaneous nerves, or localized muscle injury.
  • Wrist Flexion and Extension: Test wrist flexor and extensor muscles by asking the patient to bend and straighten the wrist against resistance. Weakness can point to tendon or nerve injuries, such as carpal tunnel syndrome (median nerve compression).

Lower Extremities

  • Hip Flexion and Extension: Assess the iliopsoas (hip flexors) and gluteus maximus (hip extensors) by having the patient lift and extend their leg while supine, respectively. Weakness may indicate lumbar radiculopathy or hip pathology.
  • Knee Extension and Flexion: The quadriceps are tested by resisting knee extension, while hamstring strength is tested by resisting knee flexion. Weakness in these muscles can suggest injury to the femoral or sciatic nerves or direct muscle pathology.
  • Ankle Dorsiflexion and Plantarflexion: The tibialis anterior (dorsiflexion) and gastrocnemius/soleus complex (plantarflexion) are tested by resisting upward or downward foot movement. Weakness here might indicate sciatic nerve involvement or compartment syndrome

Diagnostic Tests and Procedures

Electromyography (EMG)

Electromyography assesses the electrical activity of muscles and is used to diagnose muscle and nerve disorders. It helps determine whether muscle weakness is caused by nerve dysfunction or a primary muscle disease.

How is it Performed?

A thin needle electrode is inserted into the muscle, and the patient is asked to contract the muscle. The electrical activity is recorded and analyzed to assess muscle and nerve function.

Diagnoses:

  • Peripheral neuropathy
  • Muscular dystrophy
  • Amyotrophic lateral sclerosis (ALS)
  • Carpal tunnel syndrome
  • Radiculopathy

Nerve Conduction Study (NCS)

Nerve conduction studies measure how quickly electrical impulses travel through a nerve. It is used to evaluate nerve function and diagnose conditions that affect nerve and muscle communication.

How is it Performed?

Electrodes are placed on the skin along the nerve pathway. Mild electrical pulses are delivered to the nerve, and the response time is recorded to assess the nerve’s function.

Diagnoses:

  • Carpal tunnel syndrome
  • Peripheral neuropathy
  • Myasthenia gravis
  • Guillain-Barré syndrome
  • Radiculopathy

Muscle Biopsy

A muscle biopsy involves removing a small sample of muscle tissue for examination under a microscope. It is used to diagnose various muscle diseases, including muscular dystrophy and inflammatory conditions.

How is it Performed?

After local anesthesia, a small incision is made, and a sample of muscle is taken using a biopsy needle or scalpel. The sample is sent to a laboratory for microscopic analysis.

Diagnoses:

  • Muscular dystrophy
  • Polymyositis
  • Dermatomyositis
  • Mitochondrial myopathies
  • Inclusion body myositis

Creatine Kinase (CK) Blood Test

A creatine kinase (CK) blood test measures the level of CK, an enzyme released when muscle tissue is damaged. Elevated CK levels indicate muscle injury or disease.

How is it Performed?

A blood sample is drawn and analyzed in a laboratory to measure CK levels. Elevated levels suggest muscle damage or inflammation.

Diagnoses:

  • Rhabdomyolysis
  • Muscular dystrophy
  • Polymyositis
  • Heart attack
  • Muscle injury from trauma

Magnetic Resonance Imaging (MRI) of the Muscles

MRI is an imaging test that provides detailed images of muscles and soft tissues. It is often used to diagnose muscle injuries, inflammation, or degenerative conditions.

How is it Performed?

The patient lies inside an MRI machine, which uses a magnetic field and radio waves to create images of muscles and surrounding tissues. Contrast agents may be used to enhance the images.

Diagnoses:

  • Muscle tears
  • Tendinitis
  • Muscular dystrophy
  • Soft tissue tumors
  • Inflammatory myopathies

Ultrasound of the Muscles

Muscle ultrasound uses sound waves to create real-time images of muscles, tendons, and soft tissues. It is useful for diagnosing muscle injuries and monitoring muscle conditions.

How is it Performed?

A handheld transducer is moved over the skin after applying a gel. The transducer emits sound waves, which bounce back to produce images of the muscles.

Diagnoses:

  • Muscle strains
  • Tendon injuries
  • Hematomas
  • Muscle degeneration
  • Soft tissue masses

Genetic Testing

Genetic testing is used to identify specific mutations that cause hereditary muscle disorders. It confirms the diagnosis of inherited muscle diseases.

How is it Performed?

A blood or saliva sample is collected and analyzed in a lab to detect mutations in genes related to muscle disorders.

Diagnoses:

  • Duchenne muscular dystrophy
  • Becker muscular dystrophy
  • Limb-girdle muscular dystrophy
  • Myotonic dystrophy
  • Facioscapulohumeral muscular dystrophy

Exercise Stress Test

The exercise stress test evaluates how muscles and the cardiovascular system respond to physical activity. It is used to diagnose conditions that cause muscle weakness or fatigue during exercise.

How is it Performed?

The patient performs physical exercise, such as walking on a treadmill, while heart rate, blood pressure, and oxygen levels are monitored.

Diagnoses:

  • Exercise-induced muscle weakness
  • Myasthenia gravis
  • Mitochondrial myopathies
  • Metabolic muscle disorders

Lactate and Ammonia Blood Test

This blood test measures levels of lactate and ammonia, which can be elevated in certain muscle metabolic disorders. It helps diagnose conditions that affect how muscles produce energy.

How is it Performed?

Blood samples are collected during rest and sometimes after exercise. The levels of lactate and ammonia are measured to assess muscle energy metabolism.

Diagnoses:

  • Mitochondrial myopathies
  • McArdle disease
  • Metabolic muscle disorders