Assessing The Musculoskeletal Pain Essay

Assessing Musculoskeletal Pain Essay

Assessing Musculoskeletal Pain Essay

A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?Assessing Musculoskeletal Pain Essa

With regard to the case study you were assigned:

Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Note: Before you submit your initial post, replace the subject line (“Discussion – Week 8”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.Assessing Musculoskeletal Pain Essay

Musculoskeletal (MSK) pain has a major impact on people’s quality of life. Chronic MSK pain causes sleep interruption, fatigue, depressed mood, activity limitations and participation restrictions. The impact of MSK pain is influenced by contextual factors, including comorbidity, arthritis coping efficacy and access to MSK care. Thus, MSK pain assessment warrants a bio-psychosocial perspective that includes pain, its downstream effects and contextual factors. Such an approach should incorporate elicitation of symptoms using patient-report questionnaires and physical examination to help localize the pain and assess for signs of inflammation, tenderness on palpation, pain on motion, joint instability and malalignment. Using such an approach to the assess chronic pain in MSK conditions has potential to improve our ability to target the right treatment to the right patient, resulting in improved outcomes.

Patient medical information
K.A, a 17years old high school gymnast, fall and fracture his left femur several weeks ago. He has been on bed rest in skeletal traction since then, because of painful muscle spasms ,He often refuses to be turn or to move voluntarily.
1) Create a nursing care plan for KA with the above medical conditions.
2) Nursing Diagnosis?Assessing Musculoskeletal Pain Essay

Goals/Expected Outcomes?
Nursing Orders?
3) Define terms of assessment of the musculoskeletal system.

Nursing care plan for patient K. A
The nursing care plan is targeted at managing the muscle spasm and pain experienced by the patient.
Nursing diagnosis for this patient is that of Acute Pain. This may be related to muscle spasms, movement of bone fragments, edema and injury to the soft tissue, traction/immobility device, stress and anxiety. The possible evidence that helped to make this musculoskeletal assessment is that which relates to the reports of pain, distraction, self-focusing/narrowed focus, facial mask of pain, Guarding, protective behavior, alteration of the muscle tone and autonomic responses.
There is a desired outcome for the nursing care plan; This relates to verbalizing the relief of pain, display relaxed manner, able to participate in activities, acceptance of turning around and movement voluntarily, state of relaxation and sleeping properly.

Nursing diagnosis, goals and expected outcomes for patient K.A
– The increased risk of bone inflammation related to open fracture; in cases like this, the best nursing plan and intervention is to provide fixation of the fracture so as to help prevent the injury to the tissues hence reduce the risk of inflammation.
– Increased risk of fat embolism related to fracture of the long bones; when there are signs like this on the patient, such signs would have to observe continuously during the first 48 hours of patient fracture and admission.Assessing Musculoskeletal Pain Essay
– Increased risk of severe fluid, electrolyte, and metabolic imbalances related to injury or inflammation. The required nursing plan and intervention for this patient is to ensure that the fluid input and output is being monitored continuously while the insertion of IV catheter and urinary catheter are being done very carefully.
– Pain and immobility , related to diagnosis of fracture. As regards to this diagnosis which seems to be the most important regarding to the patient, the patient vital signs and responses need to be monitored to understand the response to the pain management. The required IV therapies, analgesics, antibiotic and other medications need to be administered appropriately to ensure that the patient is managed well as indicated.
– Increased risk of respiratory, cardiovascular, bowel, and skin complications related to a long period of immobility. The nursing plan and intervention for this nursing diagnosis is just to ensure that the required laboratory test is done and test evaluated appropriately to check any case of abnormalities.
– Anxiety related to the symptoms of disease and fear of the unknown. This is usually due to several factors. One important factor is that which relates to the fear of the intended surgical procedures. In cases of this, the patient and the family need to be prepared emotionally and physically for the intended surgical procedures.

Goals/expected outcome
There are several goals/expected outcome that need to be achieved while managing patient K.A. Such goals include the following listed below;
– Prevent all forms of avoidable injury common to such kind of patients.
– Prevent complications of immobility which could lead to some other problems.
– Provide optimal bone and wound healing to help reduce the patient hospital stay.
– Then surgical intervention prescribed, prevent postoperative complications.
– Decreased anxiety with increased knowledge and adequate emotional preparation.Assessing Musculoskeletal Pain Essay

In order to achieve the goals and expected outcomes for this patient, certain important steps are essential. These include;
– Care for the traction by checking the weights (if hanging properly and freely), check the skin (to avoid any form of irritation), site of the skeletal traction for the prevention of any form of infection. This can be done by ensuring aseptic technique for all procedures.
– Respiratory exercises are needed to prevent any form of lung infection in cases of associated risks.
– Checking for signs of thrombophlebitis often and report immediately when noticed.
– Risk of pressure sores should be avoided using appropriate skin care method.

Definition of terms of musculoskeletal assessment
– Atrophy : This described the state of muscle wasting with subsequent reduction in the size of the muscle.
– Hypertrophy: Simply describes the state of increased in muscle mass
– Contracture: Simply described the state of shortening in the length of muscle
– Fasciculation: means there is an involuntary muscle movement

Read more at: Musculoskeletal Pain Essay

Musculoskeletal problems account for an estimated 3.5 million emergency department (ED) attendances each year. More patients will consult their general practitioner (GP) or treat the problem themselves. Most of these conditions (sprains, bruises, and aches) will be self limiting, requiring clinical diagnosis, and straightforward treatment and advice. However, there are diagnostic dilemmas facing the practitioner on the “front line”. Even simple injuries often need hospital assessment, usually for radiographs. Some problems are rare but important to diagnose if life threatening or limb threatening problems are to be avoided. The skill is to recognise those conditions where urgent referral and treatment are required. The aim of this series is to arm the practitioner with these skills (see box 1). Major trauma is not covered in this article.Assessing Musculoskeletal Pain Essay

Box 1 Objectives of this article
The recognition of life threatening or limb threatening problems

The identification of those patients requiring obvious hospital transfer

The principles of a secondary survey relevant to musculoskeletal problems

Differentiation between injury and non-injury presentations

Differential diagnoses in non-injury musculoskeletal problems including pitfalls

Follow up arrangements

An overview of the following will be included

Functional anatomy

Forces causing injury and the injury spectrum

Indications/regulations for radiographs

Specific conditions to be covered

Back pain

Neck pain

Rib injury

Degenerative disease/osteoarthritis

Hot joints


Primary survey positive patients
Musculoskeletal injuries will rarely lead to a primary survey positive patient, except in major trauma. There are however immediately life threatening problems that might mimic a musculoskeletal condition. These pose a trap for the unwary and are listed below.

Leaking abdominal aortic aneurysm (AAA) presenting as back pain

Aortic dissection presenting as inter-scapular pain

Perforation/peritonitis presenting as shoulder tip pain

Acute myocardial infarction (MI) presenting as shoulder or arm pain

A high index of suspicion and assessment of the ABCs can help identify these important conditions. A careful history will usually disclose no episode of trauma and a very acute onset of pain.Assessing Musculoskeletal Pain Essay

A leaking AAA presents acutely with abdominal and lower back pain with or without collapse and features of hypotension. The pain of an aortic dissection pain is described as tearing. Ischaemic chest pain is classically tight or band-like. Diaphragmatic irritation from a ruptured hollow viscus can cause shoulder pain, particularly on lying flat. Patients with these suspected conditions need urgent transport to a facility with the capabilities to fully manage these problems.

Immediate management will consist of essential interventions only. Administer oxygen, obtain intravenous access, and give analgesia and possibly cautious fluid resuscitation en route. Do not delay transport to perform these procedures.

Certain conditions pose a serious threat to life or limb and must not be missed when considering a “wait and see” approach. The conditions listed in table 1 are the “red flag” conditions of the musculoskeletal system.Assessing Musculoskeletal Pain Essay


Table 1
“Red flag” conditions requiring immediate hospital treatment

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For further details on all these conditions, their presentations, and treatment look under the emergency medicine section at

A major joint dislocation should be reduced as soon as possible particularly if there is no distal circulation or sensation to the limb. Acutely ischaemic limbs for whatever cause have about four hours to be revascularised before irreversible muscle and nerve damage occurs. Therefore make one gentle effort at relocation. Otherwise the limb needs to be splinted in its current position and urgent transfer arranged.

Compartment syndrome is caused by swelling in a myofascial compartment leading to a critically impaired circulation to the enclosed muscles in that compartment and possible distal ischaemia. There will usually be a good history of trauma. The hallmark of this condition is pain out of all proportion to the examination findings and exquisite pain on passive stretch of the muscles in the affected compartment. These patients require urgent transfer because surgical decompression is necessary as soon as possible, but certainly within four hours.Assessing Musculoskeletal Pain Essay

A septic joint is usually hot, swollen, and very tender. All movements are restricted and it may be virtually impossible to move the joint because of pain. Typically the patient is systemically unwell and complains of the pain keeping them awake at night and being of a throbbing nature. These patients require urgent transfer to hospital because they need early surgery to remove the infection and preserve the joint.

Patients with objective neurological deficit due to nerve root compression or due to other spinal pathology should be referred immediately. Consider the diagnosis of a cauda equina syndrome. The lumbar and sacral nerve roots lie in the spinal canal below the level of L1/2. A central disc prolapse between the levels of L3 to S1 can compress these nerve roots causing retention of urine and weakness of the legs. The patient will present with lower back pain and neurological symptoms and signs. These include saddle area sensory loss and a reduced or absent anal tone on rectal examination. Depending on the level of the injury there will also be obvious neurological deficits in the motor assessment of the lower limbs.

The minimum necessary interventions should be carried out on these patients but could include administration of oxygen or entonox, splinting, dressing open wounds, intravenous analgesia, and controlled traction or reduction of neurovascularly compromised extremities. These procedures should not delay transfer arrangements.Assessing Musculoskeletal Pain Essay

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For further information on the treatment of compartment syndrome and crush syndrome see the ATLS manual,1 Wardrope,2 or the eMedicine web site ( For dislocations, septic joints and neurovascular compromise see Wardrope,2 Apley,3 and McRae.4

Assessment of the stable patient
The assessment is carried out according to a recognised system (SOAPC) now familiar to readers of this series. The first step is to decide if the problem is attributable to trauma or one of the many causes of non-traumatic limb or spinal pain. The range of diagnoses is very different in these two groups.

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The first step in the assessment of musculoskeletal symptoms is to decide if the problem is attributable to an episode of trauma or a non-traumatic problem.Assessing Musculoskeletal Pain Essay

Trauma compared with no history of trauma
Patients who present with no history of trauma should alert the clinician to the possibility of missing Referred pain, Ischaemic syndromes, Sepsis, and Kids problems such as epiphyseal abnormalities. Remember the mnemonic “RISK”. These are the conditions commonly overlooked and can indicate limb threatening or even life threatening problems such as cardiac pain, a slipped upper femoral epiphysis, or a septic joint.

Definite trauma
Acute trauma is caused by a single, clear event. This can lead to a wide range of injury from minor self limiting sprains to fractures and/or dislocations of joints. The features of a fracture are pain, swelling, loss of function, and bony tenderness. Dislocations are usually more obvious with similar features to fractures plus an abnormal joint morphology with deformity. In the absence of these features then a soft tissue injury is more likely but consider damage to other structures such as ligaments, tendons, nerves, and vessels.Assessing Musculoskeletal Pain Essay

Mechanism of injury
A clear history of the mechanism of injury is essential to accurate diagnosis in trauma. Elicit the magnitude and direction of the forces causing the injury. Simple errors are made by a failure to follow this advice. For example, if the only history obtained was “hurt neck in road traffic accident” the clinician might jump to the conclusion the injury was likely to be a simple neck sprain. However, consider how different your actions might be if a full history were to be obtained such as “hurt neck in road traffic accident, was unrestrained front seat passenger in car which overturned at speed” (see fig 1).

Figure 1
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Figure 1
A history of “hurt neck in road traffic accident” can mean anything from the injury being sustained in a minor rear end shunt to a major high speed and high risk impact. Always try to gain a clear mental picture of the mechanics of the injury.Assessing Musculoskeletal Pain Essay

Box 2 Elements of history taking in acute trauma
Mechanism of injury

Symptoms and progress of symptoms over time

Previous episodes of injury

Past history/drugs/allergy

Level of activity in job or sport

Symptoms and progress
Pain, swelling, and loss of function are the main symptoms after injury. Ask if these symptoms have progressed since the incident. A sudden and complete loss of function at time of impact increases the risk for a more severe injury. Ask about associated symptoms such as paraesthesia and trauma elsewhere.

History and previous injuries
Ask the patient if they have any other significant medical conditions or are taking any medication. Most injuries are acute, but some are an acute episode complicating a chronic problem. The investigation and treatment of an “acute on chronic” injury may be slightly different.

Level of activity
Patient expectations are an important consideration in the management of musculoskeletal injuries. A professional athlete will demand as near 100% function as is possible after injury but most patients will manage very well with minor ligament instability as long as they have good protective neuromuscular function. Nevertheless it is important to consider occupation, hobbies, and handedness so that expectations and needs can be identified.Assessing Musculoskeletal Pain Essay

No definite trauma
Patients who present with a limb or spinal pain but with no history of trauma can present diagnostic problems. In most patients the illness will be minor and self limiting or of a chronic nature not needing urgent treatment or investigation. However, a few patients with these “minor” symptoms may be suffering from life or limb threatening pathology. The mnemonic “RISK” highlights the categories of serious diagnoses that may require exclusion, Referred pain, Ischaemic or vascular problems, Sepsis, and Kids or childhood problems (see box 3)

Box 3 “RISK” diagnoses in non-traumatic limb and spinal pain
R—Referred pain from chest/abdomen/spine*

I—Ischaemia/vascular problems/DVT


K—Kids problems such as an epiphyseal injury

Consider the RISK diagnoses. Failure to even consider them WILL lead to them being missed.Assessing Musculoskeletal Pain Essay

History in non-traumatic limb and spinal pain
The most common symptom is pain. PQRST is a good mnemonic to help remember the questions that should be asked about pain (see below). Many serious pathologies cause severe pain with few findings on examination. Pain at night that keeps the patient awake is of special significance. It usually indicates a severe inflammatory process and should always be taken seriously.

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Severe pain at night—consider severe pathology

The “PQRST” of pain
P—provoking or palliative factors
Ask if the patient has participated in any unusual activity in the period leading up to the onset of symptoms, or has recently significantly increased the level of an activity (for example, doubling their running distance) that would be unusual for that patient. Note other aggravating or relieving factors.

Q—quality of pain
Is the pain throbbing in nature, toothache-like, or sharp and associated with certain movements? How severe is the pain?

R—radiation and site
Ask if the pain radiates either proximally or distally in the limb. This may be an indication that the problem lies more centrally. Common examples are arm pain radiating from the neck or heart. Shoulder pain from irritation of the diaphragm. Knee pain from the hip and leg pain from the lumbar spine.Assessing Musculoskeletal Pain Essay

S—systemic symptoms/associated symptoms/history
Does the patient have markers of a systemic illness such as fever, chills, loss of appetite, or weight loss?

Joint problems are sometimes associated with systemic illnesses. Ask if there are any other symptoms such as back problems (ankylosing spondylitis), eye problems, inflammatory bowel symptoms, genitourinary symptoms, recent illnesses, and respiratory tract infection. Some types of acute arthritis are part of complex syndromes, for example, Reiter’s syndrome

Note medical history, especially if there have been similar problems in the past. Exclude problems with other joints or a history of arthritis. Exclude many of the more common diseases such as diabetes. Does the patient take warfarin or have any coagulopathy?

Does the pain keep the patient awake at night? Is it worse first thing in the morning or after exercise?

Objective information gathering—the examination
Develop a systematic method of musculoskeletal examination:

Box 4 “PQRST” history taking of the symptom of pain
P—provoking and palliative factors


R—referred pain

S–systemic symptoms/associate symptoms Assessing Musculoskeletal Pain Essay


Joint above





Nerves and vessels

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See article 2 of this series on examination, including the musculoskeletal system. See also Wardrope,2 Cyriax,5 and McRae6 for a fuller examination description of anatomical regions.

Have the patient in a relaxed position. Start by examining the joint proximal to the injury (or spine if indicated). Follow standard orthopaedic practice, using the “look, feel, move, function” system. Finish by checking the circulation to the limbs and test neural function distal to the injury.

Where there is no history of trauma, follow the same system but check vital signs and look for other clinical signs as summarised in box 5.

Box 5 Summary of vital signs and clinical signs
Vital signs—particularly temperature and pulse rate

Stigmata of systemic disease or of systemic arthritis


Proximal joints

Neurovascular examination


(Chest and abdomen if indicated)Assessing Musculoskeletal Pain Essay

Objective information—tests
If a fracture or dislocation is suspected then the patient needs referral to hospital. Many will need immediate referral, but if there is no deformity, no neurovascular compromise, and the injured limb can be effectively immobilised (including non-weight bearing for the lower limb) the patient might be referred for radiography at a more convenient time. Outpatient referral to the radiology department of the local hospital allows non-urgent radiographs to be performed. Many departments have a system of “hot reporting” so that radiographs are reviewed immediately. If abnormalities are seen the patient is referred to the appropriate hospital team. If radiographs are normal the patient may return to their GP for further treatment.

Use local guidelines and policy to decide when a radiograph is indicated. The definite fractures are easy to diagnose but unfortunately many fractures are undisplaced and it is difficult to confidently exclude a fracture without a radiograph. Many experienced clinicians would advise “radiography when in doubt”. Other indications include suspected foreign body within a wound, for example, glass or metal. For further information see the Royal College of Radiologists guidance ( and guidelines for doctors. Assessing Musculoskeletal Pain Essay