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CHAPTER 16 Musculoskeletal symptoms and signs
402
Pyogenic spinal
infection
usually of disc
space due to
Staphylococcus,
Salmonella typhi,
etc.
Suggested by: onset of pain over days or weeks. Little
or no fever, tenderness or raised WBC. ESR is raised.
Background of debilitation, surgery, or diabetes
Confirmed by: bone rarefaction or erosion with joint
space narrowing on back X-ray. “Hot spot” on
isotope bone scan and space-occupying lesion on MRI
or CT scan
Spinal TB
with abscesses
and cord
compression
(Pott’s para-
plegia), psoas
abscess
Suggested by: onset of weeks or months. Little fever,
tenderness, or iWBC. ESR i. Background of
debilitation, diabetes
Confirmed by: bone rarefaction or erosion with joint
space narrowing, then wedging of vertebrae. Space-
occupying lesion on MRI and CT scan. Tubercle bacilli
on stains or culture of drainage material
Spondylitis
(ankylosing
spondylitis and
associated
disorders)
Suggested by: onset over months. Usually presenting in
young adult, with morning stiffness of 1 hour. iCRP
or ESR; HLA-B27 positive
Confirmed by: early disease may only be evident by
sacroiliitis confirmed by X-ray or MRI. Late disease
confirmed by abnormal Schober, decreased thoracic
expansion, on X-ray: sacroiliac erosion or fusion with
bridging syndesmophytes leading to bamboo spine
Idiopathic
scoliosis
of thoracic or
lumbar spine
Suggested by: progressive loss over years of horizon
t
al
alignment of shoulders and hips with age, usually in
adolescent girls more than boys
Confirmed by: absence of evidence of specific or
treatable cause. Increased scoliosis with growth
Kyphotic pain Suggested by: history of previous vertebral fractures
with “Dowager’s hump” for years, with associated
protuberant abdomen and height loss
Confirmed by: X-ray appearance suggestive of
congenital deformity, Scheurmann’s or Calve’s
osteochondritis, wedge fracture from osteoporosis or
carcinoma
Scoliotic pain Suggested by: lateral curvature visible from the back
and associated rib prominence apparent from the
front
Confirmed by: history and X-ray appearance of bony
congenital anomaly, past poliomyelitis, syringomyelia,
torsion dystonia, spinal tumors, spondylolisthesis,
arthrogryphosis, enchondromatosis, osteogenesis
imperfecta, neurofibromatosis, Chiari malformation,
Duchenne muscular dystrophy, Freiderich’s ataxia,
Marfan syndrome, Pompe’s disease
PAIN OR LIMITATION OF MOVEMENT OF THE HIP1
403
Pain or limitation of movement
of the hip
Many of the arthritides listed previously can involve the hip. The most
common of these are osteoarthritis, rheumatoid arthritis, and the
spondyloarthropathies, including ankylosing spondylitis and psoriatic
arthritis. Other nonarthritic conditions are listed below.
Assess the patient’s activity. Test flexion (normal >120*) by grasping
ankle in one hand and iliac crest in the other to eliminate pelvic rotation.
Test abduction (normal 30*–40*) preventing pelvic tilt. Test abduction in
flexion (normal >70*) and adduction (normal >30*) by moving one foot
over the other, internal and external rotation (normal >30*). Measure
the true length of the legs from the anterior superior iliac spine to medial
malleoli. The Trendelenburg test is positive if the hip drops when the
foot on that same side is lifted from the ground. Look for a leg length
discrepancy that can exacerbate hip pain (usually on the shorter leg).
Some differential diagnoses and typical outline evidence
Osteoarthritis Suggested by: onset over months or years. Pain, stiff-
ness, and limitation of movement, initially of internal
rotation. Frequently unilateral
Confirmed by: A-P and lateral X-ray of hips shows loss
of joint space, deformity of head and acetabulum with
osteophytes and sclerosis
Inflammatory
arthritis
Suggested by: onset over months or years. Pain,
stiffness, and limitation of movement, initially of
internal rotation, more commonly bilateral in patients
with systemic inflammatory arthritis
Confirmed by: A-P and lateral X-ray of hips shows loss
of joint space, deformity of head and acetabulum,
eventually with secondary osteoarthritic changes
Osteonecrosis,
aka avascular
necrosis
Suggested by: onset over days to months. Pain,
stiffness, and limitation of movement, initially of
internal rotation. History of corticosteroid use or
excessive alcohol intake
Confirmed by: A-P and lateral X-ray of hips: early
disease may only be evident on MRI scan of hips;
within months, a crescent lucency within the superior
edge of femoral head will be evident, and eventually,
collapse of the femoral head and secondary
osteoarthritic changes
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CHAPTER 16 Musculoskeletal symptoms and signs
404
Coxa vara
(angle between
neck and femur
<125°) caused
by congenital
slipped upper
femoral
epiphyses,
fracture with
malunion or
non-union,
osteomalacia, or
Paget’s disease
Suggested by: limp with Trendelenburg “dip” to
affected side. True shortening of leg
Confirmed by: angle between neck and femur <125°
on X-ray
Perthes’ dis-
ease
Idiopathic
osteonecrosis
of the hip
Suggested by: pain in hip or knee with limp, with onset
over months from 3 to 11 years of age. Limitation of
hip movement in all ranges
Confirmed by: A-P and lateral X-ray of hips shows
widening of joint space and decrease in size of femoral
head, patchy density, and later collapse
Slipped femoral
epiphysis
Suggested by: pain in groin, front of thigh, or knee and
limping with onset over minutes if acute, or weeks to
months. Limitation of flexion, abduction, and medial
rotation
Confirmed by: displacement of growth plate visible on
lateral view of hip (not A-P)
Tuberculous
arthritis
Suggested by: pain and limp in a 2- to 5-year old, espe-
cially in endemic areas. Pain and spasm in all directions
of movement
Confirmed by: rarefaction of bone on X-ray then
fuzziness of joint margin, then erosions. AFB in biopsy
± culture of synovial membrane
Developmental
dysplasia with
dislocation
leading to
osteoarthritis
Suggested by: pain, stiffness, and restricted movement in
childhood or adolescence if undiagnosed (or noisy
reduction of dislocation in neonatal click test)
Confirmed by: shallow acetabulum with or without
current dislocation on A-P and lateral X-ray of hips
(or ultrasound in neonate)
PAIN OR LIMITATION OF MOVEMENT OF THE KNEE1
405
Pain or limitation of movement
of the knee
Many of the arthritides listed previously can involve the knee. The most common
of these are osteoarthritis, gout, pseudogout, rheumatoid arthritis, and the
spondyloarthropathies, including ankylosing spondylitis and psoriatic arthritis.
Look for quadriceps wasting, deformity of the knee, or swelling. Compare
flexion and extension on both sides. Abduct and adduct tibia with the knee
flexed at 30° to test medial and lateral ligaments. With the knee flexed at
90° pull and push tibia to test anterior and posterior cruciate ligaments.
Feel for warmth over the knee (the knee should be cooler than the
anterior lower leg). A small knee effusion can be detected by “milking”
the fluid into the superior patellar pouch medially, and then pressing on
the lateral patella to see a fluid wave. Look for leg length discrepancy
that can exacerbate pain in the shorter leg.
Some differential diagnoses and typical outline evidence
Osteoarthritis Suggested by: onset of months or years, worse in
cold and damp. Deformity (can be varus, bow-legged,
or valgus, knock-kneed) and swelling. Crepitus on
passive movement. More common in obese patients
or if there is a history of previous trauma to that joint
Confirmed by: above his
t
ory and examination. Loss of
joint space on X-ray with deformity (usually medial
compartment), osteophytes, and sclerosis
Chondromalacia
patellae
Suggested by: patella aching after sitting in young
adults. Patellar tenderness
Confirmed by: above history and examination or
softening or fibrillation of patellar cartilage on
arthroscopy or MRI scan
Recurrent
patellar
subluxation
Suggested by: knee often giving way (especially in
knock-kneed girls)
Confirmed by: above increased lateral movement of patella
Patella
tendinopathy
(jumper’s knee)
Suggested by: pain on forceful movement of knee in sport
Confirmed by: tenderness over patellar tendon
Ileotibial tract
syndrome
Suggested by: pain when running
Confirmed by: tenderness over lateral femoral condyle.
Medial shelf
syndrome
Suggested by: brief locking of knee
Confirmed by: inflamed synovial fold above medial
meniscus on arthroscopy
Hoffa’s fat pad
syndrome
Suggested by: brief locking of knee and pain under
patella, more common in obese woman with valgus
knee deformities
Confirmed by: hypertrophic pad between articular
surfaces on MRI scan or arthroscopy
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CHAPTER 16 Musculoskeletal symptoms and signs
406
Acute arthritis
due to sepsis,
crystal-induced
arthritis
Suggested by: onset over hours or days of pain, swell-
ing, warmth
Confirmed by: aspiration, microscopy and culture. Urate
i in gout
Meniscal cyst Suggested by: variable swelling, worse when knee
flexed to 60*, less when flexed further. Knee clicking
and giving way
Confirmed by: cyst present on MRI scan
Ligament tears Suggested by: sudden pain and swelling after forceful
abduction or adduction at knee
Confirmed by: above history, tenderness on
examination, appearance on MRI scan
Anterior
cruciate tears
Suggested by: history of posterior blow or rotational
force when foot fixed to ground
Confirmed by: tibia moves forward when pulled (after
effective analgesia or anesthesia), appearance on
MRI scan
Meniscal tear Suggested by: history of forceful twisting to a flexed
knee. Knee locks when extension attempted
Confirmed by: tear visible on MRI scan
Osgood-Schlatter
disease
Osteochondritis
Suggested by: 11- to 12-year-old girl or 13- to
14-year-old boy after rapid growth spurt, with pain
and swelling of the tibial tubercle, can occur after
exercise, occasionally locking
Confirmed by: tenderness and soft tissue or bony
prominence of the tibial tubercle
Osteoid osteoma Suggested by: pain and after exercise, intermittent
knee swelling and locking
Confirmed by: defect on articular surface on X-ray
Loose bodies
due to osteochon-
dritis dessicans,
osteoarthritis, chip
fractures, synovial
chondromatosis
Suggested by: locking of knee during extension and
flexion. Swelling and effusion
Confirmed by: seeing loose bodies on arthoscopy
Bursitis (with or
without infection)
due to prepatellar
bursitis (house-
maid’s knee), etc.
Suggested by: localized pain and swelling over site of
bursa (e.g., below patella)
Confirmed by: localized pain and swelling over site of
bursa. With infection, aspiration of the bursal fluid
and microscopy and culture. For repetitive injury,
improvement with rest, analgesia, and physiotherapy
PAIN OR LIMITATION OF MOVEMENT OF THE FOOT AND ANKLE1
407
Pain or limitation of movement
of the foot and ankle
Many of the arthritides listed previously can involve the feet. The most
common of these are osteoarthritis, gout, rheumatoid arthritis, and the
spondyloarthropathies, including ankylosing spondylitis and psoriatic arthritis.
Watch the patient’s gait and examine wear on the shoe sole and the
print on the floor from their damp foot. Ask the patient to extend or
dorsiflex (normal >25*), flex (normal 30*), evert and invert. Ask the
patient to extend the toes (normal >60*) and stand on tiptoe.
Some differential diagnoses and typical outline evidence
Hallux valgus
Associated with
bunion and
osteoarthritis
Suggested by: big toe deviated laterally. Frequently
causes pain especially with tight shoes
Confirmed by: above clinical appearance
Pes planus Suggested by: loss of medial foot arch (appearance of
damp surface in contact with floor, normal in early
childhood). Pain if foot and heel everted in some
Confirmed by: above clinical appearance and response
to exercises and medial heel shoe wedges in some
cases
Pes cavus
idiopathic, due to
spina bifida, past
polio
Suggested by: accentuated foot arches and other
neurological disorders, e.g., spina bifida
Confirmed by: above clinical appearance
Posterior ankle
tendinopathy
Suggested by: pain and/or swelling of the tendon
Confirmed by: MRI
Achilles tendon
rupture
Suggested by: audible snap with pain in the calf; has
been associated with fluoroquinolone antibiotics espe-
cially combined with corticosteroids
Confirmed by: inability to stand on toes, MRI
Hammer toes Suggested by: tip of toe points downward
Confirmed by: toe extended at the metatarsophalangeal
(MTP) joint, flexed at the proximal interphalangeal
(PIP) joint, but extended at the DIP joint
Claw toes Suggested by: tip of toe points down and back
Confirmed by: toe extended at the MTP joint, flexed at
the proximal (PIP) and distal (DIP) joints
Hallux rigidus Suggested by: pain localized proximal to big toe
Confirmed by: tenderness and swelling of first MTP
joint. X-ray may show a distal ring of osteophytes
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CHAPTER 16 Musculoskeletal symptoms and signs
408
Metatarsalgia
due to shoe
pressure,
previous trauma,
rheumatoid
arthritis,
sesamoid
fracture,
synovitis
Suggested by: pain in forefoot
Confirmed by: tenderness of heads of metatarsals
Morton’s
metatarsalgia
due to
interdigital
neuroma
Suggested by: localized sharp pain on dorsum of foot,
with radiation between 2 metatarsals down to toes
Confirmed by: tenderness on compression of site of
neuroma between metatarsals
March fracture Suggested by: localized foot pain after excessive walking
Confirmed by: tenderness of second or third metatarsal.
X-ray showing fracture
Calcaneum
disease; arthritis
of subtalar joint;
tear of calcaneal
tendon;
post-calcaneal
bursitis; plantar
fasciitis; etc.
Suggested by: localized heel pain
Confirmed by: MRI scan appearance
Chapter 17
409
Psychiatric symptoms
and signs
Psychiatric signs 410
General excessive anxiety 411
Anxiety in response to specific issues 412
Depression 414
Hallucinations, delusions, or thought disorder 415
Confusion (global cognitive deficit) 416
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CHAPTER 17 Psychiatric symptoms and signs
410
Psychiatric signs
Psychiatric symptoms and signs are noted to a large extent during the
history and examination. The patient may have complained of anxiety or
depression, but in order for these diagnoses to be accepted by others,
specific features should be present, some of which are observed, rather
than reported by the patient.
GENERAL EXCESSIVE ANXIETY1
411
General excessive anxiety
Some differential diagnoses and typical outline evidence
Generalized
anxiety disorder
Suggested by: long history of fearful anticipation,
irritability, sensitivity to noise, restlessness, poor
concentration, worrying thoughts, insomnia, night-
mares, depression, obsessions, depersonalization, dry
mouth, difficulty swallowing, tremor, dizziness, head-
ache, parasthesias, tinnitus, epigastric discomfort,
frequent or loose motions, constriction or discomfort
in the chest, difficulty breathing or hyperventilation,
palpitations and awareness of missed beats,
frequency or urgency of micturition, erectile dysfunc-
tion, menstrual problems. Panic attacks, depression,
and alcohol dependence
Confirmed by: no evidence of thyrotoxicosis, hypo-
glycemia, Cushing’s disease, or pheochromocytoma
Panic disorder Suggested by: intense feeling of apprehension or
impending disaster. Develops quickly and unexpect-
edly without a recognizable trigger. Shortness of
breath and smothering, nausea, abdominal pain,
depersonalization, choking, numbness, tingling,
palpitations, flushes, trembling, shaking, chest discom-
fort, fear of dying, sweating, dizziness, faintness
Confirmed by: Four symptoms of panic attack in one
episode and four attacks in a month, or a persistent
fear of attacks
Alcohol
withdrawal
Suggested by: recent decrease in alcohol intake,
usually superimposed on habitually high intake. Visual
and/or tactile hallucinations suggest delirium tremens.
Confirmed by: subsequent episodes in similar
circumstances
Thyrotoxicosis Suggested by: heat intolerance, tremor, nervousness,
palpitation, frequent bowel movements, goiter
Confirmed by: dTSH, iFT4
Hypoglycemia Suggested by: preceded by seconds or minutes by
anxiety, fear, chest tightness, sweating, hunger, and
darkening of vision. Usually in diabetic, usually on
insulin
Confirmed by: d blood glucose (<40 mg/dL)
Pheochromo-
cytoma
Suggested by: abrupt episodes of anxiety, fear, chest
tightness, sweating, headaches, and marked rises in BP
Confirmed by: catecholamines (iVMA, iHMMA) or
free metanephrine i in urine and blood soon after
episode
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