The most important job we do is screening for serious conditions that require referral. Much of our training revolves around the identification of serious pathologies and the case history, even more than the examination, is designed to spot them.
So, what clues are we looking for? We are looking for:
Onset - Was there a trauma, that makes a mechanical, musculoskeletal injury more likely, of course, if the trauma is severe, the patient may have fractures which are a contraindication to treatment, so judgement is still required
Progression - are the symptoms worsening for no apparent reason?
Location - Musculoskeletal problems don't tend to occur simultaneously in multiple places
Comorbidities - Are there other siulatneous symptoms which could suggest infection, neoplasm or another systemic disease process
Aggravating and relieving factors - most musculoskeletal pain is aggravated and relieved by position and/or movement. Inflammatory pain is helped by anti-inflammatory drugs
Nature and site of pain - Is there a musculoskeletal structure which causes pain in the right place and with the right characteristics?
It is with this in mind that I was presented with a 75 year old woman who spoke no English and whose daughter translated for her. She looked very unhappy and actually cried as she described her symptoms. She had pain in both arms and shoulders of two months duration, which was worst on waking and was progressing. She felt her grip was reduced and she couldn't raise her arms above the horizontal. She also described pain in b hips and down legs to feet. She was advised by the GP to have and x ray which showed some wear and tear in the neck. At this point I am thinking 'no way is this musculoskeletal' and I am wondering whether I should stop her there and send her for blood tests for, amongst other things, polymyalgia rheumatica (PMR), a not uncommon condition affecting mainly women over 50 and affecting the hip and shoulder girdles. We continue with the case history and it emerges that she had a fall a couple of months prior to the symptoms commencing, landing on her left outstretched hand, but was fine after a little physio. Critically the patient wasn't getting any headaches or visual disturbance (more of that later).
Upon examination the woman was very kyphotic and the shoulders were very protracted, her upper rib cage was hard and unyielding and some of the ribs were prominent and causing the shoulder blades to tip forward.
I explained that the onset of symptoms in multiple places suggested that there might be something systemic behind this and that blood tests might be required but that I would be happy to try a gentle treatment, if she was, to see if there was a musculoskeletal element. Crucially the lack of headaches made it very unlikely that, if the condition was PMR it was not yet accompanied by its dangerous bedfellow giant cell arteritis (GCA), which can cause blindness, and so urgent further investigation was not required.
I treated the patient using articulation techniques to get the upper back and ribs moving, bearing in mind that the patient was very kyphotic and of an age where I needed to treat her as though where she may have osteoporosis . This week I saw her again and she was all smiles. The left arm still hurts in some positions but she can raise both arms and feels her grip is returning, the right arm feels almost back to normal...and the legs? I don't know if it was mistranslation or just exaggeration born out of fear and pain, but it appears that the problems in the legs are just around the knees and are caused by varicose veins and that there is no problem in the hips.
I haven't ruled out something systemic, all diagnoses are provisional, but it looks like this was a case of a mechanical problem masquerading as something more serious. I'm glad I took the chance to treat and see.