Subjective Exam

Subjective Examination for Musculoskeletal/Neuromuscular Disorders of the Upper Extremity

Overview

The subjective examination is a crucial aspect of patient assessment, primarily focusing on comprehensively understanding the patient's medical history, presenting symptoms, and potential contributing factors that may influence their condition. This examination is conducted by Cathy Schmidt, PT, PhD, emphasizing a systematic approach to gather thorough information.

1. Patient Profile

Risk Factors:

• Adhesive Capsulitis: It predominantly occurs in individuals aged 40-65 years, with a higher prevalence noted in females. This condition is frequently associated with systemic conditions, including diabetes and thyroid disease, which may predispose individuals to adhesive capsulitis, significantly impacting shoulder mobility and overall quality of life.

• Shoulder Fracture: The incidence of shoulder fractures notably increases in older female adults, especially post-menopausal women, due to factors related to bone density and osteoporosis.

• Acromioclavicular Sprain/Separation: This injury is more commonly seen in males under 40 years, particularly among athletes who participate in high-impact sports, as they are at an increased risk due to the physical demands of their activities.

• Labral Tear: Occurs primarily in individuals aged 30-50 years, often resulting from acute injury or chronic overuse, affecting the stability of the shoulder joint and functionality.

• DeQuervain’s Synovitis: This condition has a higher incidence among females and individuals who frequently use smartphones or engage in repetitive wrist movements, leading to inflammation of the tendons along the radial side of the wrist.

• Lateral Epicondylitis: Commonly emerging in individuals aged 40-50 years, especially among tennis players, it is generally associated with overuse injuries that occur in the dominant arm.

• Wrist Fracture: The risk of wrist fractures rises significantly with advanced age, often due to falls or accidents among elderly populations.

2. Symptoms

Mechanism of Onset

• Understand whether the symptoms represented are new occurrences or a recurrence of previous episodes.

• New symptoms may indicate acute injuries, while gradual onset often results from chronic conditions or repetitive stresses.

• Conditions such as rheumatoid arthritis may present with patterns of flares and remissions, wherein symptoms can vary in intensity over time.

Type/Description/Location

• Types of Symptoms: Patients may report various sensations including:

  • Clicking, popping, or clunking sounds during movement.

  • Heaviness, weakness, or a sensation of a "dead-arm," indicating possible nerve involvement.

  • Joint locking or instability during specific ranges of motion.

  • Apprehension or fear during shoulder movements, often linked to past traumatic experiences.

  • Painful arc of motion, where specific movements aggravate the pain.

  • Parasthesias, including abnormal sensations like tingling or numbness, which may indicate nerve compression or irritation.

• Location of Symptoms: Assess whether pain is localized to a particular structure or if it radiates above or below the joint, potentially signifying broader involvement of surrounding tissues or underlying conditions.

3. Behavior of Symptoms

Aggravating Factors

• Identify specific activities or positions that worsen symptoms, such as:

  • Reaching overhead, across the body, or behind which may exacerbate conditions like impingement syndrome.

  • Lifting, carrying, or throwing movements that can aggravate injuries related to shoulder instability.

  • Sleep positions that put pressure on the shoulder or exacerbate symptoms, affecting overall sleep quality.

  • Movements of the cervical spine which can indicate referred pain or cervical radiculopathy.

Easing Factors

• Determine what provides symptom relief, including:

  • Rest, which may temporarily alleviate symptoms.

  • Movement that could gently mobilize the joint and lessen discomfort.

  • Use of supportive devices such as pillows, braces, or slings that provide stability.

  • Application of medication, heat, and cold modalities.

24-Hour Behavior

• Explore the impact of symptoms on nighttime rest, including:

• Disturbances during sleep due to pain, leading to sleep deprivation.

• Variations in symptom intensity between morning and evening, which may inform the stage and nature of the condition.

4. Framework for Examination: SINS

SINS Model

• The SINS model serves as a structured approach to assessing patient symptoms:

  • S = Severity: Assess pain intensity on a 0-10 scale and frequency of discomfort.

  • I = Irritability: Evaluate how quickly symptoms are provoked or eased by activity.

  • N = Nature: Determine whether the underlying issue is musculoskeletal or involves non-musculoskeletal origins.

  • S = Stage: Identify the staging of the condition (acute, subacute, chronic), critical for treatment planning.

SINS Severity Details

• Assessing pain severity on a scale can help in understanding the impact on daily activities and quality of life, ranging from mild discomfort to maximal pain that could limit mobility and function.

SINS Irritability Characteristics

• Classifying irritability into categories such as Max, Mod-Max, Mod, Min-Mod, and Min helps to gauge how aggressive the treatment needs to be.

SINS Nature Identification

• Differentiating between musculoskeletal and non-musculoskeletal conditions (e.g., neurological issues) allows for targeted interventions that consider all underlying factors.

• The mechanical nature of complaints is often revealed through observation of movement/posture-related symptoms.

SINS Stage Guidance

• By assessing how symptoms have progressed or stabilized, practitioners can formulate a treatment plan that is responsive to past episodes and current presentations.

Practice Scenario

A patient presents with a history of slipping and falling 5 days ago, now reporting constant pain in the right upper arm with a pain rating oscillating between 4/10 and 9/10. Symptoms aggravate with movement away from the body, resulting in functional limitations. The patient has taken medication with only partial relief.

SINS Summary Application

• Regular evaluations of the SINS framework during physical therapy visits are essential for dynamically tailoring examinations and treatments, ensuring optimal outcomes for the patient.

Origin of Symptoms Assessment

• A strong emphasis is placed on a patient-centric approach, considering not only local issues but also other potential musculoskeletal and non-musculoskeletal origins that could complicate diagnosis and treatment.

Common Symptom Referrals

• Awareness of referral patterns is crucial, as symptoms from cervical spine injuries or peripheral nerve conditions can often mimic shoulder pain, necessitating a comprehensive examination.

Review of Systems: Special Questions

• Conduct a thorough assessment of the patient's overall health, including inquiries about systemic symptoms such as changes in appetite, weight fluctuations, and any cardiovascular or gastrointestinal symptoms that might influence treatment decisions.

Diagnostic Tests Consideration

• Consider recommending diagnostic imaging (e.g., X-ray, MRI, CT scans) and specialized tests such as nerve conduction velocity (NCV) and electromyography (EMG) to gain a clearer understanding of the underlying pathology.

Patient-Reported Outcome Measures

• Utilizing standardized questionnaires like the SPADI (Shoulder Pain and Disability Index), DASH (Disabilities of the Arm, Shoulder, and Hand), and Quick-DASH provides quantifiable metrics on upper extremity functional status.

Conclusion

Conducting a systematic subjective examination is vital in accurately identifying musculoskeletal and neuromuscular disorders of the upper extremity and establishing an effective plan for clinical evaluation and patient care.