Musculoskeletal history

Musculoskeletal disorders are often multi-system that requires a wide range of questioning in the history.

A musculoskeletal (MSK) history focuses primarily on presentations affecting the musculoskeletal system including bones, joints, tendons, ligaments, and muscles. Remember that many musculoskeletal disorders are multi-system meaning a wide range of inquiry is required during the consultation to determine the involvement of other organ systems.

Presentations may be acute and obvious (e.g. fractured bone after fall) or more chronic with vague extending over months to years. Be patient and listen to the patient. Finally, it is essential to ask what the functional and psychological impact of the musculoskeletal disease is on the patient (e.g. can they dress, can they work, etc).

Many rheumatological diseases will manifest as joint pain, swelling, and/or stiffness.

There are several important aspects to determine in an MSK history:

• Timing of onset: acute, subacute, chronic
• Pattern of symptoms: monoarthropathy (single joint), polyarthropathy (multiple joints), axial involvement (spine)
• History of injury: any trauma? Any trivial injury?
• Associated symptoms: fever, rash, weight loss, bowel symptoms

Try putting these features together in your presentation:

“This 58 y/o man has presented with a 3-month history of a symmetrical polyarthropathy affecting the small joints of the hands.”

The key symptoms to determine in the MSK history include:

• Joint pain
• Joint swelling
• Joint stiffness
• Muscle pain
• Weakness and loss of function
• Locking and triggering: incomplete range of movement (i.e. broken fragments of cartilage)
• Deformity

Joint pain

A very common MSK complaint. It is important to take a good pain history using SOCRATES and make sure you determine the pattern of symptoms (i.e. symmetrical or asymmetrical / small or large joints).

• Site: which joints are affected? Is it restricted to large or small joints?
• Onset: when did the pain start? Was there initially a traumatic event?
• Character: is the pain severe and deep (e.g. osteomyelitis)? Or does it just ache when moved (e.g. tendonitis)?
• Radiation: does the pain move anywhere else (alternating buttock pain in ankylosing spondylitis)? Is there referred pain (groin pain may be suggestive of disease in the hip)?
• Associated symptoms: are there features of an inflammatory arthropathy or systemic disorder (fever, night sweats, rashes)?
• Timing: determine when the pain is better and when the pain is worse (pain worse at the end of the day in osteoarthritis)? Are the symptoms persistent or fleeting?
• Exaggerating and relieving factors: what is the pain like during exercise? Does it get better with rest? Is the patient taking analgesia? Have they seen a physiotherapist?
• Severity: grade the pain on a scale of 1-10

Joint swelling

Joint swelling usually accompanies joint pain. Swelling is suggestive of joint effusion that is caused by the underlying disease. May be difficult to differentiate from an inflamed bursa.

Joint stiffness

Joint stiffness refers to the feeling of a joint being limited or difficult to use. You should differentiate this from weakness (i.e. secondary to neuropathy or muscular atrophy from disuse) and movement should not be limited by pain.

Clarify the nature of the stiffness – is it worse in the mornings or evenings? For example, back stiffness is typically worse in the middle of the night and early morning in patients with ankylosing spondylitis.

Muscle pain

Muscle pain may be due to a primary myopathy, injury (e.g. tear), or as part of systemic disease. Determine the pattern and severity of muscle pain.

Is this a proximal myopathy suggestive of polymyalgia rheumatica or a generalised myalgia due to medications (e.g. statins)? Are there specific tender points suggestive of fibromyalgia?

Ensure that any weakness is not simply because pain is limiting function.

These refer to systemic signs and symptoms involving numerous organ systems.

Extra-articular manifestations are systemic clinical manifestations that can occur in many inflammatory MSK conditions.

Like a systems review, ask a number of short, closed questions relating to each organ system from head-to-toe. If any abnormalities are found, then explore these in more detail.

• Head & neck: any headaches? Any scalp tenderness?
• Eyes: any ocular pain? Any red eyes? Any visual changes?
• Chest: any breathing difficulty?
• Heart: any chest pain? Any palpitations?
• Gastrointestinal: any change in bowel habit? Any bleeding? Any swallowing problems?
• Genitourinary: any dysuria? Any haematuria? Any abnormal vaginal bleeding?
• Skin: any skin rashes? Any hair loss?

Ask specifically about any history of arthritis and ensure to differentiate this between osteoarthritis and rheumatoid arthritis.

Ask about any pre-existing MSK disease such as osteoarthritis, crystal arthropathy (e.g. gout, pseudogout), or inflammatory arthritis (e.g. rheumatoid, systemic lupus erythematosus). Ensure you enquire about any joint operations (e.g. joint replacement) and whether any conditions are still active.

For example, is osteoarthritis still causing significant symptoms? Are they awaiting joint replacement surgery?

Also ask about any risk factors for joint disease such as prior trauma, weight (i.e. obesity), recent infections (e.g. STIs), and diabetes mellitus.

When discussing previous MSK problems always establish:

• Age of diagnosis (e.g. lupus at 23 years old)
• Treatment for condition (e.g. hydroxychloroquine)
• Any complications (e.g. alopecia)
• Last follow-up & recommendations (e.g. annual review by rheumatology)

Patients with musculoskeletal disorders are commonly taking NSAIDs and/or corticosteroids.

Like with any history, make sure you take a full comprehensive drug history including:

• Prescribed medications
• Over-the-counter medications
• Herbal remedies

With musculoskeletal disorders, it is important that you ask specifically about analgesia including paracetamol, NSAIDs, and opioid-based medications. Patients will commonly be taking NSAIDs that are associated with a number of side-effects including renal, gastric and cardiac. Ask specifically about any GI bleeding or gastritis.

The same applies to the use of corticosteroids and other immunosuppressive agents that are commonly prescribed in a range of musculoskeletal disorders. Focus on:

• Current steroid or immunosuppressive regimen (e.g. prednisolone 15 mg once daily)
• Number of steroids courses (e.g. continuous steroids over last year)
• Previous treatments (e.g. azathioprine and methotrexate)
• Side-effects (e.g. Cataracts in both eyes)
• Bone and GI protection (e.g. usually on omeprazole 20 mg once daily and AdCal D3 two tablets once daily)

There may be a history of autoimmune disease or inflammatory arthritis.

Determine any relevant medical conditions in the immediate family. Ensure to ask specifically about any musculoskeletal conditions such as rheumatoid arthritis, osteoarthritis, or osteoporosis.

It is invaluable to establish how their condition is affecting their activities of daily living (e.g. washing, shopping).

A full social history is required, but ensure you take time to focus on activities of daily living (ADLs). This refers to what the patient can do for themselves and how their illness(es) may be affecting them. Try to establish what is limiting them. Is it pain or is it loss of mobility? Make sure you enquire about whether it has affected their ability to work (e.g. their occupation) and how it has affected their mental health.

Some useful questions:

“During your normal day, what are you able to do for yourself?”

“Does your condition interrupt your ability to do your normal activities?”

“Does anyone from your family need to help with cooking, shopping or dressing?”

“Do you have any carers coming into your home?”

“Could you describe what the carers do for you when they come (i.e. personal care, medications, and/or meal preparation)?

Always end by discussing the patient’s ideas, concerns & expectations.

1. Do you have an idea about what could be going on?
2. Is there anything that is worrying/concerning you at the moment?
3. Is there anything you were hoping for from this consultation?
4. Do you have any further questions today?