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:
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:
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).
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 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 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.
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:
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:
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:
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.
Have comments about these notes? Leave us feedback