CHAPTER TWO ASSESSING CARDINAL MUSCULOSKELETAL SYMPTOMS AND SIGNS
INTRODUCTION
The part or region under evaluation must be adequately exposed and in good lighting. Many mistakes are made simply because the examiner does not insist on removing enough of the patient’s clothing to allow proper evaluation and inspection (Fig. 2-1). When examining the involved extremity, the uninvolved extremity is always used for comparison.
ORTHOPEDIC GAMUT 2-1 VISUAL INSPECTION
Systematically, visual inspection focuses on four areas:
ORTHOPEDIC GAMUT 2-2 PALPATION
Four elements are the focus of palpation:
CARDINAL SYMPTOMS
Pain and Sensibility
Among presenting symptoms, pain is usually most important for the patient. Among presenting signs, swelling of a joint or periarticular tissue is important. With regard to pain, the examiner must be certain of the site of origin and distribution. The patient’s verbal description may be misleading. The patient should be able to point to or define the site of maximal intensity and map out the area over which pain is experienced.
Factors that exacerbate or ameliorate the pain are important. Pain during an activity suggests a mechanical problem, particularly if it worsens during use and quickly improves when resting. Pain while at rest, and pain that is worse at the beginning rather than at the end of use, implies a marked inflammatory component. Night pain is a distressing symptom that reflects intraosseous hypertension and accompanies serious problems, such as avascular necrosis, bone neoplastic activity, or bone collapse adjacent to a severely arthritic joint. Persistent bony pain is characteristic of neoplastic invasion. The activities that create a mechanical pain may provide clues as to the appropriate diagnosis. Periarticular problems are often induced by a specific type of activity but are also divided by region (Table 2-1).
| Region | Periarticular Syndrome |
|---|---|
| Jaw | Temporomandibular joint dysfunction (myofascial pain syndrome) |
| Shoulder |
Adapted from Kelley WN, et al: Textbook of rheumatology, ed 5, Philadelphia, 1997, WB Saunders.
Disability and Handicap
Disability is present when a tissue, organ, or system cannot function adequately. A handicap exists when disability interferes with a patient’s daily activities or social or occupational performance. A marked disability does not necessarily cause a handicap. Conversely, minor disability may produce a major handicap. Both states of disability and handicap require separate assessment, with the evaluation of disability being a purely medical activity, whereas handicap assessment is often a medicolegal function. Patients’ perceptions of their problems is a product of their adaptation to the depreciated tissue, as well as aspirations for recovery (Box 2-1).
BOX 2-1 ABILITY DEPRECIATION ASSESSMENT
Adapted from Demeter SL: Disability evaluation, St Louis, 1996, Mosby.
ORTHOPEDIC GAMUT 2-5 SPECIFIC ELEMENTS TO CONSIDER IN ACTIVITIES OF DAILY LIVING ASSESSMENT
