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LEARNING OBJECTIVES

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  1. Accurately identify the most likely etiology when patients present with a musculoskeletal symptom, through history, diagnostic tests, and appropriate patient findings on examination to enable the appropriate recommendation of effective treatment or referral to an appropriate provider.

  2. Use the knowledge of the pathophysiology, etiology, and common presentations of musculoskeletal complaints as a primary symptom to review prescription orders for appropriateness and to accurately educate patients about their disease and its treatment.

  3. Use the knowledge of the pathophysiology, etiology, and common presentation of diseases with musculoskeletal complaints as a primary symptom to accurately interpret the diagnostic process to advise regarding the most appropriate prescription therapy.

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ETIOLOGY

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Musculoskeletal complaints are among the most frequently encountered primary care visits. Trauma, either acute or overuse, to muscles, ligaments, tendons, bones, or joints is a common cause for symptoms involving the musculoskeletal system. Other diverse etiologies such as autoimmune diseases, vitamin deficiencies, infections, disordered metabolism or clearance, and medication also have to be considered when a patient presents with musculoskeletal symptoms.

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DIAGNOSIS

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The diagnosis of specific musculoskeletal complaints requires an organized approach. Eliciting a history of trauma is essential. A positive reply will send the diagnostic process toward traumatic injuries, such as overuse or sports injuries. A negative response directs the inquiries toward nontraumatic causes. Location is the second most important diagnostic clue. Many times different diseases are associated with different locations, e.g., rheumatoid arthritis occurs primarily in the metacarpophalangeal (MCP) joints and proximal interphalangeal (PIP) joints of the hands, whereas osteoarthritis (OA) is predominantly a disease of the weight bearing joints, such as the knee and hip. OA may also affect distal interphalangeal joints (DIP). Whether the pain is in the joint, over a bone, or in a muscular area also helps differentiate etiology. Numbness and tingling or blue, pale discoloration in an extremity are symptoms requiring immediate referral. Finally, physical examination helps confirm the diagnosis. Swelling, decreased or increased range of motion, increased pain on movement, redness, heat, and fever all help discriminate among specific problems.

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COMMON INJURIES RELATED TO TRAUMA/OVERUSE

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Plantar Fasciitis

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Plantar fasciitis is an overuse injury in runners and walkers; the pain is located on the medial aspect and bottom of the heel. Many times it becomes severe enough to prevent continuation of running for up to 12 months. To avoid the pain, patients tend to walk on the ball and lateral side of the foot. On physical examination, there is pain upon palpation of the medial calcaneal tubercle, passive dorsiflexion of the foot, eversion of the foot, and active dorsiflexion of the big toe. Patients complain of pain in the morning that is worse with the first few steps, or when starting activity with it getting better as they continue to walk or run. It needs to be aggressively treated at the first sign. Continued ...

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