History Taking in Musculoskeletal Pain
During history taking in musculoskeletal pain, the nurse practitioner (NP) considers the demographic characteristics of the patient and history of illnesses such as arthritis and diabetes. The NP also considers features of pain such as location, severity, aggravating or relieving factors, onset, and duration. The traits to look for in joint assessments include stiffness, stability, swelling, and numbness. Stiffness in the morning suggests the presence of inflammatory arthritis. A patient’s involvement in sports also needs to be recorded since pain localization implies the involvement of superficial structures. Moreover, the NP ought to focus on systemic signs such as fever, chills, malaise, and weight loss.
Physical Examination
The nurse practitioner (NP) employs inspection and palpation techniques in the physical examination of musculoskeletal disorders. The NP inspects for inflammatory signs such as swelling, redness and skin abrasions. It is also vital to perform gait inspection, joint defects and dermatological changes around the ankle joint. The NP feels for soft tissue swellings and tenderness, which are pointers of inflammation.
The main regions of focus during palpation are posterior, medial and anterior aspects of the ankle joint (Porter & Kaplan, 2011). Evaluation of blood circulation around the joint is vital in the determination of vascular involvement, which is a key determinant of the healing process. Establishing a patient’s response to touch is critical in gauging nerve involvement and cause of pain (nerve compression or trauma). Physical examination includes motion assessment aspects such as active, passive and resistive motions (Smeltzer, Bare, Hinkle, & Cheever, 2010).
Important Diagnostic Tests
Diagnostic tests in musculoskeletal pain include the ankle’s range of motion tests, laboratory blood studies and imaging studies. Motion analysis involves a talar tilt test for ankle ligament function, which is positive if there is ankle pain with excess joint looseness over the calcaneofibular and anterior talofibular ligaments. The anterior drawer test is positive if the patient has joint laxity of the talofibular ligaments with visible depression during movement (Tierney, McPhee, & Papadakis, 2006). Compression tests assess distal tibiofibular joint strength. Lower leg pain indicates a fracture or syndesmotic sprain, whereas external rotation is helpful in the diagnosis of syndesmotic injuries. Crepitus sounds, conversely, indicate cartilage or tendon involvement (Smeltzer et al., 2010).
Laboratory diagnostic tests involve the analysis of synovial fluid composition and blood tests to investigate rheumatic disease, which is typified by leukocytosis and elevated erythrocyte sedimentation rate. Imaging tests for fractures and other bone malformations include plain ankle X-rays, computed tomography, ultrasonography, and magnetic resonance imaging (MRI). However, MRI is the best test for minute fractures that are invisible to plain X-rays (Smeltzer et al., 2010). Other helpful diagnostic tests include arthrography and bone scanning. Bone densitometry determines bone mass, which is important in the diagnosis of osteoporosis.
Differential Diagnoses
The patient’s first differential diagnosis is chronic ankle sprain that arises from overstretching. Chronic ankle pain causes excessive pain in the right ankle, which gets worse when supporting the weight of the body. Another diagnosis is likely to be a fracture because of the patient’s age. At 46 years, she is probably undergoing menopause and has low estrogen levels that cause bone wasting and loss of bone mass thereby increasing the risk of pathologic fractures. The probable fractures are talar dome fracture or osteochondral defects (OSD) (Bond & Barreto, 2014).
The third differential diagnosis is a subluxation. This diagnosis is possible because the injury involves flexor hallucis longus or peroneal tendon due to separation from their anatomical points of insertion. Additionally, there is excessive pain while stretching. The fourth differential diagnosis is mid-foot injury or Lisfranc injury, which is common in athletes because of their intense physical activity. Lisfranc injury presents with joint pain and stiffness while standing on the toes due to tearing of the ligaments.
The fifth differential diagnosis is a high ankle sprain, which involves the ankle ligaments that support the tibia and fibula. The injury frequently occurs in sports that involve external rotation of the foot (Bond & Barreto, 2014).
References
Barreto, J. E. & Bond, T. K. (2014). Patients with ankle pain. In A. D. Kaye & R. V. Shah (Eds.), Case studies in pain management (pp. 235-242). Cambridge, United Kingdom: Cambridge University Press.
Porter, R. S. & Kaplan, J. L. (2011). The Merck manual of diagnosis and therapy (19th ed.). White Station, NJ: Merck Sharp & Dohme Corp.
Smeltzer, S. C., Bare, B., Hinkle, J. L., & Cheever, K. H. (2010). Brunner and Suddarth textbook of medical surgical nursing (12th ed.) Philadelphia: Lippincott Williams & Wilkins.
Tierney, L. M., McPhee, S. J., & Papadakis, M. A. (2006). Current Medical diagnosis & treatment (45th ed.). New York: McGraw-Hill Medical.