Clinical Diagnosis

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Clinical Diagnosis
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
Family physicians office
Symptomatology
Locomotor system examination
Laboratory investigations
An accurate clinical diagnosis of most common
locomotor disorders can easily be undertaken in a
family physicians office. Making an accurate
diagnosis necessitates paying careful attention
to key elements of the patients 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
Pain
Severity
Location
Distribution
Occurrence of symptoms
Stiffness
Inflammation
When all these factors in a patients history are
taken into consideration, the clinician can
achieve a fairly accurate differential diagnosis.
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Clinical 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
Confusion
Precipitating factors
Careful clinical examination
Regional pain as seen in myofascial pain syndrome
can lead to confusion. When taking the patients
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
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
Regional pain syndromes
Progressive inflammatory arthritis
Nocturnal pain
Location of pain
The quality of a patients 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
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
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
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
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
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 patients 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
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
Reiters syndrome, enteropathic arthropathy, etc.
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Clinical Diagnosis
Haslock I. Common perarticular syndromes. Med
North Am 199649-58.   Hitchon C, El-Gabalawy H.
An approach to diffuse musculoskeletal pain. Can
J CME 1997995-106.   Jones AC, Doherty M. How
to do a rapid rheumatology screen. Med North Am
1995991-998.
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