You’re assessing, assessing, assessing to arrive at a diagnosis. And then even when you think you have the diagnosis, you’re assessing, assessing, assessing to make sure you’re on the right track.
I want a plan that helps; that goes without saying. But when you’re figuring things out, you want to know about any and all effects - helpful, harmful, or indifferent. In order to get to the helpful plan, we need to understand what’s going on, which importantly includes knowing what tests and/or treatment strategies have no effect or which ones make you worse.
If a repeated movement has no effect, that might make me think there’s more likely a tissue problem instead of a joint problem. Or that we have a joint problem that needs more force, or a different direction. If repeated movement in a particular direction makes things worse, then it is more likely you have a joint derangement, and now we have information about which direction would be helpful. Knowing that something we test has a negative impact (on pain, movement, etc.) is just as powerful as knowing something has a helpful impact.
All of these pieces - all of these effects of repeated movement tests combined with the verbal history and physical baselines (as well as any other necessary diagnostic tests) - help us understand what’s going on. There are dozens of these puzzle pieces, by the way! And the faster we know what’s going on, the faster we can hone in on the treatment you need. -- Laura
Perhaps if people consider common “medical” problems, they can better understand musculoskeletal problems. While a cough may feel like it’s coming from the throat, plenty of things can cause a cough. It can be due to a problem in the stomach, lungs, sinuses, nose, mouth, or throat. A quality verbal history and evaluation will steer the clinician’s investigation into the cause (diagnosis).
While your knee may hurt, plenty of things other than your knee can cause your knee pain. While your hands may be tingling, plenty of problems other than hand problems can cause that tingly sensation. While your shoulder may not rotate, there may be a cause other than your shoulder. While your calf muscle may be weak, there could be a cause other than your calf muscle.
Signs and symptoms such as a cough, pain, paresthesia, decreased mobility, and weakness are pieces of data which help us understand the problem. The location of signs and symptoms is not necessarily the location of the diagnosis. -- Laura
Being intentional with asking patients questions is important for two reasons. One, it saves time, thus making the process more efficient. Two, my thinking won’t be distracted or misinformed by extraneous, non-useful information. Asking questions with purpose takes practice, but is absolutely essential for both diagnosis and treatment. (When I take a patient’s verbal history, I typically only have 2 potential diagnoses in mind by the end thanks to effective questions.)
If the purpose of a question is to show interest in the patient’s story or to foster rapport, that is a fine purpose. Doing so, however, may confer to the patient that those answers are significant (when they aren’t). What I see novice clinicians frequently do is ask irrelevant questions about symptoms. For instance, differentiating if the pain is burning, hot, achy, or sore. While that may matter, it almost certainly doesn’t matter in the evaluation. Or if a patient says his knee clicks, the clinician dives deep into when it clicks. Again, in 99% of cases that doesn’t give you helpful information. Knowing which answers one needs and which one doesn’t is not easy - and comes with expertise. Once that skill is achieved, the process is streamlined and clinicians become more efficient at helping patients.
One of the most important questions I ask patients is: "Is the pain consistent or variable?" It tells me a lot about what the problem could be.
Consistent pain (or other symptoms such as tingling or numbness) is brought on by the same motion or activity EACH AND EVERY TIME, IN THE SAME LOCATION. For example, every time I reach in the back seat of my car my shoulder kills me. Or, every time when I hit the 10-minute mark walking, my calves goes numb. Or, my neck hurts each time I turn to the left.
Variable pain is a different beast. The patient would report something like: sometimes my elbow hurts when I play tennis, and sometimes it doesn't. Or, on Monday I could walk 30 minutes before my knee started hurting, but on Tuesday I could barely make it 5 minutes. Or, usually I can sit without pain in the mornings, but other times when I sit I get sharp pain in my buttocks.
Constant pain can be consistent or variable. Constant pain that is always at a 4/10 pain level would be considered consistent. Constant pain that sometimes registers as 1/10 pain and other times feels like 8/10 pain would be considered variable for my diagnosing purposes.
When I understand that the pain is consistent, I start thinking about a few things. For one, tendon or muscle pathology will produce consistent symptoms because each and every time you stress that tendon (or muscle), it should hurt. Consistent pain also makes me think of bony changes such as arthritis; pain due to arthritis should be consistent since the bones don't change on a daily basis! Consistent pain can also be produced by dysfunctional tissue such as scar tissue; every time the scar is stretched, it hurts.
Variable pain is often produced by an obstruction in a joint, what I call a joint derangement. Sometimes the joint moves well and without pain, but sometimes (either due to the day's activities or a sleeping position, etc.), the joint gets stuck and therefore produces symptoms - either locally or referred away from the joint.
As far as constant pain, there could be an inflammatory process going on or a mechanical obstruction/derangement that is obstructing a joint at all times, to name two common examples.
Based on the patient's answer to this one question, I know a lot about what is going on. When combined with "the how" of the injury, presence or absence of obstruction to motion. length of symptoms, and where the symptoms are located, I have a solid diagnosis in mind before I start the manual testing. --Laura
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