Diagnostics

Medical History

Taking a precise medical history is important in the diagnosis of orthopedic pain. Acute pain originating from the musculoskeletal system demonstrates certain characteristics:

It is position-dependent, i.e., pain increases or decreases according to posture or positioning.
It is load-dependent, i. e., pain generally increases when pressure is exerted on the affected body part, e.g., when walking, standing, lifting, or carrying.
It is limited to a specific area, i. e., the patient is able to describe where the pain comes from and the area of spread.

The possible locations of source pain in the shoulder, anterior knee, neck, and lumbosacral region are densely packed together. Each location exhibits special clinical symptoms which require a special type of pain therapy. Diagnoses such as knee, shoulder, or back pain are too general and allow general pain therapy at the most.

When diagnosing orthopedic pain, the physician should ask specific questions if the patient does not spontaneously offer information. The four “-ions” have been tried and tested for this purpose:

NOTE

The four “-ions”:Location—Duration—Provocation—Description

Location: Where exactly is the pain located when it occurs? It is best to let the patient show where the pain is coming from, or where it radiates to, by pointing with their finger. Nonspecific information about inconsistent, diffuse, or sock-like spread and cramp-like pain is less characteristic of musculoskeletal disorders.

Duration: How long has the pain been present? Days, weeks, years? How did it start? How has it been treated previously?

Provocation: When does the pain appear? The patient should be asked about the effects of position and weight-bearing, and also about when the pain appears: during the day, at night, mainly when sitting, standing, when walking, etc. Special clinical symptoms require special questions, such as the abduction phenomena in the shoulder or crouching low with posterior meniscal horn damage. What can be done to relieve the pain? Warmth, cold, flexion, extension, sitting, walking? How does the patient react when the pain occurs?

Examples

Patients with back pain and sciatica prefer to walk around.

Patients with lumbar spinal canal stenoses flex when standing or sitting down.

Patients with neck symptoms caused by a cervical syndrome prefer a warm shower.

Description: This relates to the quality and quantity of the pain. The use of a visual analogue scale to assess the quantity of pain has been tried and tested. It ranges from pain free = 0 to worst pain imaginable = 10, see Chapter 4, “Multimodal Medication Concomitant Therapy” (Fig. 4.16a–c).

Words are suggested to the patient to assess the quality of the pain. Musculoskeletal pain is most likely to be

stabbing
shooting
burning.

Patients suffering from the usual acute orthopedic disorders tend to be in good general condition. Apartfromthe local problem, e. g., in the lower lumbar region, they are usually physically and psychologically healthy, provided they have not already taken too much medication. Symptoms such as nausea, vomiting, loss of weight, loss of appetite, or general feelings of weakness are not characteristic of disorders or injuries of the musculoskeletal system. If the patient reports symptoms of this nature in the subjective assessment, differential diagnoses should be kept in mind.

Patients suffering from chronic pain should be questioned about how and when it started. Many patients can specify the exact day and hour when their pain began. When the primary opportunity for treatment has been missed and the pain has been present for weeks or months, the characteristics of the pain may change. Localized pain becomes diffuse; the intensity of the pain is no longer position-dependent but rather becomes a permanent fixture; and the patient’s general condition increasingly suffers from lack of sleep, intoxication from medication, and psychosocial stress. For these reasons the details of all previous therapy have to be ascertained, including which physician has been consulted and why the treatment was discontinued. In order to treat patients appropriately, all details of their previous and current pain have to be established. The physician has to become a medical history fanatic when dealing with musculoskeletal pain.

Clinical Examination

NOTE

The clinical examination used to diagnose musculoskeletal pain always looks at the entire orthopedic picture. It includes a neurological assessment and specialized manual medicine techniques.

Examination of the entire body is always required, even when pain is concentrated in a specific part of the body (Table. 2.1).

Example

Persistent symptoms coming from the inferior zygapophyseal and sacroiliac joints (summarized as treatment-resistant low back pain) may originate from the first metatarsophalangeal joint. A hallux rigidus is found during the examination of the entire body. This movement disorder affects the gait pattern and is suspected of causing the pain. It is therefore the primary area to be treated.

Assessment of the entire orthopedic picture consists of

visual assessment
palpation
assessment of movement.

Visual Assessment

Musculoskeletal pain causes characteristic postural and behavioral changes. Patients suffering from hip and knee pain limp when walking, and patients suffering from sacroiliac joint pain or sciatica tend to have a typical asymmetrical gait. It is important to observe patients when they walk around the examination room, while dressing and undressing, and also when they climb up onto the examination couch.

**Table 2.1** Orthopedic Pain Diagnostics (Clinical Examination Findings)
Entire orthopedic picture
Neurological examination
Manual medical assessment

Palpation

The typical painful pressure points are assessed during palpation. These points do not always correspond to the source of pain. It is best to let the patient point to the main location of pain, e. g., a specific spinous process. In case it is helpful for further diagnostics, the point is immediately marked with a pen and infiltrated with a local anesthetic following the clinical examination. When this trial treatment results in freedom from pain, the approach required for orthopedic pain therapy has been found.

Example

A localized cervical syndrome with a pressure point on the superomedial edge of the scapula.

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