2 Diagnostics
2.1 Medical History
Taking a precise medical history is important in the diagnosis of orthopedic pain. Acute pain originating from the musculoskeletal system demonstrates certain characteristics:
It is position-dependent, i.e., pain increases or decreases according to posture or positioning.
It is load-dependent, i.e., pain generally increases when pressure is exerted on the affected body part, e.g., when walking, standing, lifting, or carrying.
It is limited to a specific area, i.e., the patient is able to describe where the pain comes from and the area of spread.
The possible locations of source pain in the shoulder, anterior knee, neck, and lumbosacral region are densely packed together. Each location exhibits special clinical symptoms which require a special type of pain therapy. Diagnoses such as knee, shoulder, or back pain are too general and allow general pain therapy at the most.
When diagnosing orthopedic pain, the physician should ask specific questions if the patient does not spontaneously offer information. The four “-ions” have been tried and tested for this purpose:
Note
The four “-ions”: location—duration—provocation—description.
Location: Where exactly is the pain located when it occurs? It is best to let the patient show where the pain is coming from, or where it radiates to, by pointing with their finger. Nonspecific information about inconsistent, diffuse, or sock-like spread and cramp-like pain is less characteristic of musculoskeletal disorders.
Duration: How long has the pain been present? Days, weeks, years? How did it start? How has it been treated previously?
Provocation: When does the pain appear? The patient should be asked about the effects of position and weight-bearing, and also about when the pain appears: during the day, at night, mainly when sitting, standing, when walking, etc. Special clinical symptoms require special questions, such as the abduction phenomena in the shoulder or crouching low with posterior meniscal horn damage.
What can be done to relieve the pain? Warmth, cold, flexion, extension, sitting, walking? How does the patient react when the pain occurs?
Examples
Patients with back pain and sciatica prefer to walk around.
Patients with lumbar spinal canal stenoses flex when standing or sitting down.
Patients with neck symptoms caused by a cervical syndrome prefer a warm shower.
Description: This relates to the quality and quantity of the pain. The use of a visual analogue scale to assess the quantity of pain has been tried and tested. It ranges from pain-free = 0 to worst pain imaginable = 10 (see Chapter 4, “Multimodal Medication Concomitant Therapy”; Fig. 4‑20).
Words are suggested to the patient to assess the quality of the pain. Musculoskeletal pain is most likely to be:
Stabbing.
Shooting.
Burning.
Patients suffering from the usual acute orthopedic disorders tend to be in good general condition. Apart from the local problem, e.g., in the lower lumbar region, they are usually physically and psychologically healthy, provided they have not already taken too much medication. Symptoms such as nausea, vomiting, loss of weight, loss of appetite, or general feelings of weakness are not characteristic of disorders or injuries of the musculoskeletal system. If the patient reports symptoms of this nature in the subjective assessment, differential diagnoses should be kept in mind. For example, to diagnose peripheral arterial disease, the foot pulse should be palpated.
Patients suffering from chronic pain should be questioned about how and when it started. Many patients can specify the exact day and hour when their pain began. When the primary opportunity for treatment has been missed and the pain has been present for weeks or months, the characteristics of the pain may change. Localized pain becomes diffuse; the intensity of the pain is no longer position-dependent but rather becomes a permanent fixture; and the patient increasingly suffers from lack of sleep, intoxication from medication, and psychosocial stress. For these reasons, the details of all previous therapy have to be ascertained, including which physician has been consulted and why the treatment was discontinued. In order to treat patients appropriately, all details of their previous and current pain have to be established. The physician has to become a medical history fanatic when dealing with musculoskeletal pain.
2.2 Clinical Examination
Note
The clinical examination used to diagnose musculoskeletal pain always looks at the entire orthopedic picture. It includes a neurological assessment and specialized manual medicine techniques.
Examination of the entire body is always required, even when pain is concentrated in a specific part of the body.
Example
Persistent symptoms coming from the inferior zygapophyseal and sacroiliac joints (summarized as treatment-resistant low back pain) may originate from the first metatarsophalangeal joint. A hallux rigidus is found during the examination of the entire body. This movement disorder affects the gait pattern and is suspected of causing the pain. It is therefore the primary area to be treated.
Assessment of the entire orthopedic picture consists of:
Visual assessment.
Palpation.
Assessment of movement.
2.2.1 Visual Assessment
Musculoskeletal pain causes characteristic postural and behavioral changes. Patients suffering from hip and knee pain limp when walking, and patients suffering from sacroiliac joint (SIJ) pain or sciatica tend to have a typical asymmetrical gait. It is important to observe patients when they walk around the examination room, while dressing and undressing, and also when they climb up onto the examination couch.
Orthopedic pain diagnostics (clinical examination findings):
Orthopedic overall status.
Neurological examination.
Manual medical diagnostics.
2.2.2 Palpation
The typical painful pressure points are assessed during palpation. These points do not always correspond to the source of pain. It is best to let the patient point to the main location of pain, e.g., a specific spinous process. In case it is helpful for further diagnostics, the point is immediately marked with a pen and infiltrated with a local anesthetic following the clinical examination. When this trial treatment results in freedom from pain, the approach required for orthopedic pain therapy has been found.
Example
A localized cervical syndrome with a pressure point on the superomedial edge of the scapula.
Example
Baastrup’s disease with a pressure point between the inferior lumbar spinous processes.
2.2.3 Assessment of Movement
The range of motion in the musculoskeletal system is assessed and documented using the neutral-zero method. Chronic pain in a spinal segment or in a joint leads to permanent adaptive changes in posture, joint capsule contraction, and muscle contractures, and always leads to a limitation in range of motion. In order to document the pain situation objectively, these changes must be identified. Manual medicine techniques are applied to the spine to diagnose limitations in mobility or complete blockage in individual segments. On the lower cervical spine and the thoracic and lumbar spine, the segmental mobility is checked using the movement patterns of the spinous processes relative to each other. All six movement directions (kyphosis, lordosis, right and left lateral flexion, right and left rotation) must be checked. It is most reliable to perform segmental testing with the patient seated (Bischoff 1997), because a corotation of the pelvis is prevented during the examination (Fig. 2‑1, Fig. 2‑2).
Assessing the “overtake” (Vorlauf) phenomenon enables the examiner to easily determine a segmental disturbance in the lumbar spine area. With the patient standing, the examiner places his or her thumbs approximately 1 cm paraspinal at the level of the individual vertebral bodies. The examiner presses the thumbs so firmly so that when the patient is asked to bend forward slowly, the thumbs follow the muscles rather than the skin. According to Bischoff (1997), this “overtake” is interpreted to mean that the relative additional mobility on the unaffected side is responsible for the “overtake.” However, a hypomobile disturbance located cranial in the vertebral joint should be ruled out (Fig. 2‑3, Fig. 2‑4).
The overtake phenomenon can also be used to check the mobility of the SIJs. Other tests for the SIJs include the spine test and the leg length discrepancy test (Fig. 2‑5, Fig. 2‑6, Fig. 2‑7, Fig. 2‑8).
Patrick’s test or FABER test is another functional test that can indicate a disturbance in the SIJ. The patient lies supine with one leg flexed and the ankle resting on the opposite knee, making the shape of the numeral 4 (explaining the name “Vierertest”/“Viererzeichen” in German—“Maigne’s test”). When the examiner pushes down the flexed knee joint, the lumbar spine is placed in lordosis and torqued. Vertebral joint pain intensifies or is triggered if the joint capsule is irritated (Fig. 2‑9).
If the examiner immobilizes the patient’s pelvis on the examining table with the other hand, further pathological changes may be determined (Fig. 2‑10).
In addition to range of motion, the location of pain occurring during the test (adductors, trochanter, hip joint, SIJs) and the end-feel of the movement are evaluated as an indication of the location and nature of the disturbance (Bischoff 1997).
In patients with cervical syndrome, functional testing of the cervical spine nearly always shows limited mobility. Usually, only certain segments are affected.
The movement patterns of the transverse process of the atlas are considered to be an indicator for evaluating the joints of the head (C0–C1). In this area, lateral bending testing and rotation testing are required (Fig. 2‑11, Fig. 2‑12). Basic testing of the cervical spine also includes testing of extension (Glisson’s test/extension test) and compression.
The assessment of entire spinal segments is performed using the neutral-zero method.
To diagnose and monitor the progression of chronic spinal pain disorders, it is extremely important to examine and document range of motion during the pain therapy. This especially applies in the evaluation of individual pain therapy measures. The assessment of movement shows us which directions of movement are pain-free and which directions provoke pain within a spinal segment, indicating the approach that should be used in causal orthopedic pain therapy. For example, when treating limitations in mobility, pain therapy should always treat in the pain-free range of motion (Dietrich 2003).
Example
Chronically recurring cervical syndrome. Cervical lateral flexion and rotation in a certain direction is usually found to be less painful during the manual medical assessment. This should be used as the starting position for Glisson’s kyphosis traction and movement therapy.
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