Correspondence *Peninsula Medical School and Duke of Cornwall Department of Rheumatology, Royal Cornwall Hospital, Truro, Cornwall TR1 3LJ, UK

Email anthony.woolf@rcht.cornwall.nhs.uk

Introduction

The importance of gaining a clear description of a clinical problem has long been recognized. Reasoning and rational practice based on clinical observation was taught by Hippocrates in the 4th century BC, but was discarded from the 5th century AD until the revolution of medical science and practice in the 17th century, when Thomas Sydenham, the 'English Hippocrates', was a major proponent of clinical medicine. He described the clinical features and differences between conditions such as gout and rheumatism. The value of clinical observation was further promoted by physicians such as William Heberden, eponymously known for his observation of 'digitorum nodi' (Heberden's nodes) in osteoarthritis of the distal interphalangeal joints. Good clinical observation remains central to the management of musculoskeletal problems.

Musculoskeletal problems are very common,¹ and all clinicians should be able to assess, by appropriate history and examination, a patient with musculoskeletal symptoms.² Some musculoskeletal conditions can be managed in primary care, whereas other more complex or progressive conditions will require secondary care by a multidisciplinary team.³ Further competencies will be required at these different levels of care and by the different disciplines.⁴

Identification of the earliest signs of musculoskeletal conditions is crucial for improving their management,⁵ but the musculoskeletal system is seldom appropriately assessed in everyday clinical practice.^{6, 7} There is a lack of ability in this core competency;⁸ primary care physicians do not always have adequate musculoskeletal knowledge and confidence,⁹ and patients are often dissatisfied following consultations, with their expectations not being met.¹⁰ Inadequate priority is given to musculoskeletal health in the curricula of many medical schools,¹¹ and a further issue is that the assessment of the musculoskeletal system is often taught differently by the various specialties involved in the management of musculoskeletal conditions.¹²

In this article, we aim to provide a standardized approach to the clinical assessment of a musculoskeletal problem—whether presenting to primary care, rheumatology or orthopedics—that gives a benchmark for this competency. Teaching and assessing clinical skills are also considered. The described approach can also be used as a teaching aid. It is aimed, therefore, as a guide for any physician to whom someone will present with a musculoskeletal problem. As doctors become increasingly competent in clinical assessment and reach into training programs within musculoskeletal specialities, more detailed information will be required from the medical history, in addition to the use of special tests on examination; this level is not considered here.

Importance of history and examination

The aim of clinical assessment is to characterize the problem, establish the cause (if possible), and to assess the impact of the problem on the patient, family and care-givers. From this assessment, a plan for further investigation and management can be logically developed in partnership with the patient.

The clinician must be alert to identifying potentially serious conditions, although most consultations will concern less serious, common problems; however, any problem is important to the patient, who would not otherwise have consulted the physician. About 20% of adults in Europe with a musculoskeletal problem fail to consult a physician, and another 20% take a year before they do so.¹⁰ The patient's concerns and expectations of the consultation need to be established, and the physician must address these and explain what they think is wrong and the proposed management plan so that the patient is engaged as an active partner in any decision making. Such communication between patient and physician is essential for a satisfactory consultation, as well as concordance with any treatment recommendations. Good communication is a core competency for all doctors and is key to patient-centered care.¹³ There are certain additional core competencies that all doctors who manage musculoskeletal problems should attain (Box 1). Clinical assessment is also needed to monitor the response to treatments, and various scoring systems are often used.^{14, 15}

Clinical assessment and its interpretation require core knowledge about the structure and function of, and the effects of aging, injury and specific diseases on, the musculoskeletal system. The symptoms and signs of different conditions, especially those that are common and potentially serious, need to be known.² The interpretation of examination findings requires knowledge of surface and functional anatomy, which is often lacking amongst modern medical graduates.

The interpretation of clinical findings is largely based on experience over many generations; many findings are sufficiently sensitive to identify an abnormality but not specific as to the cause. Additional investigations might be needed to confirm clinical suspicions of diagnosis or to assess disease activity, prognosis, and to help decide on treatment.

History

During the consultation, the physician must initially observe the patient well and listen to what he or she has to say about their problem and concerns before asking specific questions to characterize their problem (Box 2). After this, the nature of the problem has to be clarified—the physician must establish the symptoms and their characteristics, other clues to diagnosis (such as preceding injuries, other illnesses or family history), the response to any previous treatment, and the impact on activities and participation. Is it a joint condition and, if so, is it inflammatory or osteoarthritic? If it is back pain, is it nonspecific, is it an inflammatory condition, or is it the result of vertebral fracture? Is it related to a systemic condition—is there weight loss, fever or other organ involvement? Could it be a potentially serious condition that needs urgent management—are there any 'red flags'?

Examination

The medical examination complements the history in characterizing the problem. It is an exercise in applied anatomy, and requires knowledge of surface and functional anatomy, such as the normal ranges of movement and function. The key questions of examination aim to identify and characterize the abnormality; to look for any pattern and any other abnormalities that will contribute to making a diagnosis, and to identify the structures that are abnormal, and the possible reasons. There are various signs of abnormality. A core set of clinical skills has been established for medical students.¹² In particular, it is important to be able to differentiate an abnormal joint that has arisen from inflammation from one that is the result of osteoarthritis, and to know when the features are indicative of infection. Musculoskeletal conditions are common and they can occur simultaneously or in combination.

A screening assessment to identify any musculoskeletal problems

Musculoskeletal conditions are common, but are often not identified if the person presents with other health problems.⁶ A simple screening assessment, the GALS (gait, arms, legs and spine; Box 7),¹⁷ has been developed to enable the identification and documentation of any musculoskeletal problem, which all doctors should be able to undertake.² It is very sensitive at identifying any abnormality of the musculoskeletal system. Any such problems will then need to be fully assessed, as proposed above.

Box 7 A rapid screening assessment.

 

Screening questions

• "Do you suffer from any pain or stiffness in your arms, legs, neck or back?"
• "Do you have any swelling of your joints?"
• "Do you have any difficulty with washing and dressing?"
• "Do you have any difficulty with going up or down stairs or steps?"

Screening examination

Gait: observe the patient walking forwards for a few meters, turning and walking back again. Recognize abnormalities of the different phases—heel strike, stance phase, toe-off and swing phases. Look for abnormalities of the movement of arms, pelvis, hips, knees, ankles and feet.

 

Inspection of standing patient: view the patient from the front, side and back, looking for any abnormalities, particularly of posture and symmetry. Apply pressure in the midpoint of each supraspinatus and roll an overlying skin fold to examine for tenderness.

 

Spine: ask the patient to flex the neck laterally to each side. Place several fingers on the lumbar spinous processes and ask the patient to bend forward and attempt to touch their toes whilst standing with legs fully extended, observing for normal movement and feeling for expansion of space between spinous processes.

 

Arms: ask the patient to place both hands behind their head and then move elbows right back, then straighten the arms down the side of the body and bend elbows to 90° with palms down and fingers straight. Turn hands palms up and make a tight fist with each hand, then place, in turn, the tip of each finger onto the tip of the thumb. Squeeze the metacarpals from second to fifth cautiously for tenderness.

 

Legs: get the patient to recline on a couch, then flex, in turn, each hip and knee while holding and feeling the knee. Passively rotate the hip internally. With the leg extended and resting on the couch, press down on the patella while cupping it proximally to examine for tenderness or swelling of the knee. Squeeze all metatarsals and then inspect the soles of the feet for callosities.

 

Documentation

An example of associated documentation:

Teaching clinical skills

Taking a history and performing a clinical examination are core skills that are taught at an early stage of undergraduate medical education, but the practical skills of musculoskeletal examination are often lacking when the student participates in a clinical attachment to a rheumatology or orthopedics department. When teaching clinical skills of the musculoskeletal system, it is essential that students acquire a standardized approach to physical examination. This will improve their ability to assess a patient, as examination of the musculoskeletal system is often regarded as complex in comparison with other organ systems. An integrated musculoskeletal disease course for medical students, bringing together orthopedics, rheumatology, and physical medicine and rehabilitation has been found to be effective.¹⁸

It is best for one tutor to teach the basic skills to small groups (maximum 10 students).¹⁹ The primary goal of the initial sessions, which should be completed in the first few days of a rotation, is for the students to be aware of the structure of the clinical examination and to be able to examine a normal person, preferably coupled with a student-directed session that reviews the anatomy of the musculoskeletal system. History-taking is an integrated part of these initial sessions but, as history is related to knowledge of the conditions, it needs to be highlighted in the context of the teaching session for each specific problem.

With these basic generic skills, and skills in regional examination, the students can move on to examine patients in the clinical setting, and learn to recognize and characterize abnormalities. This can be done by attending outpatient clinics, by serving in the emergency room or at the admission of patients for elective procedures. Patient educators, such as the Patient Partner Program, in which people with arthritis are trained to teach students about taking a history and performing a clinical examination, have also been shown to be an effective method of teaching clinical skills.^{20, 21, 22, 23}

The clinical teacher or tutor is a most important person in instructing the students; however, to ensure consistency of education, all other doctors in the department should be aware of how the students are taught, and have agreed on the content and structure for all regions of the examination. Towards the end of the rotation, each student should be able to examine one patient adequately while being observed as part of the formative assessment.

Conclusions

Musculoskeletal problems are common, but many clinicians lack the competencies that are needed for their assessment and management. Barriers include inadequate teaching as well as a lack of a simple, standardized approach. Such an approach is proposed, along with ways of teaching and assessing it. Improving the competency of all doctors in the clinical assessment of musculoskeletal problems, as well as improving communication skills, will improve the management of these common conditions.

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Subject areas under which this article appears: Miscellaneous rheumatic diseases | Diagnosis, imaging and screening