Clinical Diagnosis
Overview
The lecture on clinical diagnosis reviews:
• The essential steps in making a diagnosis • The distribution and location of pain • The quality and occurrence of pain • Acute and chronic inflammation
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Clinical Diagnosis
Clinical Diagnosis of MSK Disorders
• Family physician’s office • Symptomatology • Locomotor system examination • Laboratory investigations
An accurate clinical diagnosis of most common locomotor disorders can easily be undertaken in a family physician’s office. Making an accurate diagnosis necessitates paying careful attention to key elements of the patient’s symptomatology and having confidence and experience in completing a thorough examination of the locomotor system. Over-reliance on laboratory investigations is often unhelpful and can be misleading.
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Clinical Diagnosis
Factors in a Diagnosis
• Pain • Severity • Location • Distribution • Occurrence of symptoms
• Stiffness
• Inflammation When all these factors in a patient’s history are taken into consideration, the clinician can achieve a fairly accurate differential diagnosis.
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Clinical Diagnosis
Help in Making a Diagnosis
• Distribution of pain
• Location of pain
• Pain from joint or periarticular structures
Since most patients with locomotor disorders will present with pain, much can be learnt through careful assessment of its distribution, exact location, diurnal variation and quality.
Local pain syndromes are common and determining the exact distribution and localization will help in arriving at an accurate diagnosis. It is extremely important to determine whether the pain is truly emanating from the joint, from periarticular structures, or from distant structures such as lumbar spondylosis, the latter representing referred pain. As well, the patient presenting with hip girdle pain may have lateral thigh pain due to trochanteric bursitis as opposed to the characteristic groin pain of true hip joint disease.
A patient presenting with knee pain may not readily volunteer the local pain distal to the medial joint line associated with anserine bursitis as opposed to the more diffuse pain associated with true knee joint disease. Similar principles apply to patients presenting with shoulder and elbow pain when the symptoms may be emanating from periarticular tissues such as bursitis and tendinitis rather than the joint itself.
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Clinical Diagnosis
Regional Pain
• Confusion
• Precipitating factors • Careful clinical examination
Regional pain as seen in myofascial pain syndrome can lead to confusion. When taking the patient’s history, precipitating factors such as trauma and the localization of pain in structures distant from the articulations may alert one to its cause. More diffuse pain relating to the joints frequently indicates a more significant form of arthropathy such as rheumatoid disease. It is key to distinguish the pain of this distribution from the diffuse pain syndromes such as fibromyalgia. Here, the symptoms are more diffuse and usually associated with pain in periarticular and muscular structures rather than the joints. Pain involving the axial skeleton should alert one to the possibility of either a degenerative or inflammatory axial arthropathy. A careful clinical examination will often clarify these issues.
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Clinical Diagnosis
Pain Analysis
• Limited mono or oligoarticular arthralgia
• Symmetrical arthralgia
• Monoarthritis
If pain is originating from the joint, a limited mono or oligoarticular arthralgia can often help distinguish the underlying cause from those presenting with diffuse joint pain. For example, monoarthralgias particularly of the hip, knee and the DIP joints of the hands, are frequently a feature of degenerative joint disease as opposed to the more diffuse symmetrical arthralgia frequently seen in association with other types of inflammatory arthritis such as rheumatoid arthritis. Septic and crystal arthropathies are usually a monoarthritis.
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Clinical Diagnosis
Quality of Pain
• Regional pain syndromes
• Progressive inflammatory arthritis • Nocturnal pain • Location of pain
The quality of a patient’s pain can be helpful. In regional pain syndromes such as frozen shoulder or oligoarthritis, severe pain is not unusual particularly with oligoarthritis due to an acute inflammatory process such as a crystal or septic arthritis. The pain associated with less acute progressive inflammatory arthritis such as rheumatoid arthritis is often “relatively” mild.
The severity of the pain expressed by the patient is not necessarily a reflection of the severity of the underlying cause. Severe pain and particularly pain occurring at night is often an indicator of a more significant form of arthropathy or neurogenic pain. However, this must be distinguished from the night pain experienced by many patients with fibromyalgia and regional pain syndromes. The exact location of the pain in association with the other features of the clinical history should be helpful in making the differentiation.
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Clinical Diagnosis
Occurrence of Pain
• Morning • End of the day • Precipitating and relieving factors
Pain present on movement first thing in the morning is often a feature of inflammatory arthropathy, both of the peripheral joints or the axial skeleton. Pain occurring towards the end of the day, particularly after manual activities, is more suggestive of a degenerative cause. Precipitating and relieving factors can occasionally be helpful in distinguishing the cause of the locomotor symptoms. Many patients with degenerative arthritis will have a previous history of trauma. Relieving factors such as heat, cold and rest are relatively non-specific features of locomotor pain. A patient with “severe” pain that interferes with sleep which tends to be unremitting, without specific precipitating and relieving factors, may mean a patient is suffering from a diffuse pain syndrome such as fibromyalgia, or if localized, bursitis and tendinitis.
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Clinical Diagnosis
Stiffness
• Severity
• Occurrence • Limb girdle stiffness
Stiffness is another symptom that may be helpful in making a diagnosis.
Mild stiffness of short duration is relatively non-specific. More severe stiffness, however, lasting an hour or more, usually first thing in the morning or when rising from a sedentary position is frequently associated with an inflammatory arthropathy. Marked morning limb girdle stiffness in the absence of other symptoms and in an elderly patient is highly suggestive of polymyalgia rheumatica.
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Clinical Diagnosis
Acute or Chronic Inflammation
• Heat
• Redness • Tenderness • Degree of swelling
One of the key symptoms important to elucidate in detail is evidence of either acute or chronic inflammation. In acute inflammation, as seen in patients with gout or a septic arthritis, there may be heat, redness, exquisite tenderness and significant swelling. In many other forms of inflammatory arthritis, however, particularly rheumatoid arthritis, the degree of swelling may be mild. Do not be put off if the patient does not exhibit other symptoms of inflammation characteristically seen in those with an acute arthropathy. Low grade swelling without heat and redness, of a symmetrical distribution involving the hands, feet and smaller joints is a frequent indicator of a significant arthropathy such as rheumatoid arthritis.
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Clinical Diagnosis
Clinical Examination (1)
• Detection of joint swelling • Inflammation within a joint • Synovitis • Distribution
The key feature in the clinical examination is the confidence to enable detection of joint swelling and particularly evidence of inflammation within the joint itself i.e. synovitis. There are no easy ways to learn this skill other than through the regular and careful assessment of patients with both normal and abnormal joints. The acutely swollen, painful and inflamed joints of septic arthritis or crystal arthritis are usually easily detected, even by those with limited experience. The most important component of the physical examination is to achieve the skill and confidence to detect the early subtle changes of synovitis, a manifestation of more progressive inflammatory arthropathies. Remember, stress pain and joint line tenderness may be signs of early or mild synovitis. In many cases, the progressive inflammatory arthropathies may be insidious in onset and slow to progress. As a consequence, missing early synovitis can result in the withholding of important therapies at a time when many people now believe they are likely to be their most effective. Patients with symptoms and signs of an acute or chronic peripheral arthropathy must always be taken seriously with respect to their symptoms and require very careful examination. After determining the presence of synovitis, either by detection of joint swelling/effusion or stress pain/joint line tenderness, assess for distribution, e.g. mono, oligo, polyarticular and symmetrical. These points will often lead to a diagnosis of degenerative arthritis/osteoarthritis versus inflammatory (symmetrical polyarthritis = rheumatoid arthritis; asymmetrical oligoarteritis = seronegative arthritis, e.g. psoriatic arthritis.)
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Clinical Diagnosis
Clinical Examination (2)
• Localized tenderness • Diffuse pain • Hard, bony swelling
If there is no evidence of soft tissue swelling, careful examination of the symptomatic area may reveal areas of localized tenderness, which will help define the cause of the patient’s symptoms. This is especially true for regional pain syndromes such as myofascial pain syndrome and those patients presenting with a localized form of bursitis and tendinitis. Areas of local tenderness and particularly pain and tenderness on stressing the affected area will often help define a specific etiology for the local pain. Diffuse pain associated with specific areas of tenderness in the absence of swelling is highly suggestive of a chronic pain syndrome such as fibromyalgia. Hard bony swelling involving either isolated or diffuse joints is usually readily distinguished from the soft tissue swelling of active synovitis, and is usually a manifestation of local or diffuse degenerative joint disease.
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Clinical Diagnosis
Summary
• History taking • Examination • Diagnosis
Given that most patients presenting with locomotor pain will have either a regional or diffuse chronic pain syndrome, or degenerative arthritis, adopting the principles of history taking and examination should help in making a definitive diagnosis. It is also important to be able to clearly distinguish the less common but in many ways more important inflammatory arthropathies where delay in treatment can often be critical to successful long-term outcomes. Other rare conditions such as connective tissue diseases, e.g. systemic lupus erythematosus, can usually be readily distinguished from the more common locomotor disorders by the presence or absence of more diffuse symptomatology and physical findings of a multisystem disease. Do not forget the importance of a complete history for extra-articular features, not just for rare diseases (SLE), but also seronegative variants, e.g. psoriatic arthritis, reactive arthritis or Reiter’s syndrome, enteropathic arthropathy, etc.
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Clinical Diagnosis
References
Haslock I. Common perarticular syndromes. Med North Am 1996:49-58. Hitchon C, El-Gabalawy H. An approach to diffuse musculoskeletal pain. Can J CME 1997;9:95-106. Jones AC, Doherty M. How to do a rapid rheumatology screen. Med North Am 1995:991-998.
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