By: Nabil Ebraheim and Scott Huff
A proper diagnostic work-up in orthopaedics involves a number of well-defined steps. These include a history, physical exam, preliminary tests, and definitive tests. Physicians are expected to proceed through these steps in proper order, to generate and narrow a list of differential diagnoses before more expensive and invasive tests are ordered. The physical exam aspect of this sequence may include tests known as provocative tests. These tests are meant to recreate the patients’ symptoms. In cases where the patient’s primary symptom is pain, this may cause apprehension. In medicine, these provocative tests constitute an important role in the work-up of a patient.
What brings a patient into the office? This is known as the chief complaint and within the field of orthopedics, it generally involves pain or loss of function; for example, “knee pain” or “shoulder weakness”. Collecting the chief complaint is the very first step in generating a differential and working up a patient. After eliciting the chief complaint, a physician will move into the History of Present Illness (HPI). This step in meant to flesh out as many details as possible pertaining to the current chief complaint. When did it start? Was it sudden onset or did it develop slowly? How severe is it? Any other symptoms? What makes it worse/better? What have you tried in the past to make it better? These are all questions a patient can expect. Being prepared with answers to these questions will facilitate the interaction with the physician, creating a smoother and more streamlined interview.
After the history is complete, a Review of Systems (ROS) is conducted. The physician will ask about all organ systems in the body, including the cardiovascular system, gastrointestinal system, endocrine system, etc. The purpose of this step is to note any other possibly connected symptoms that are not otherwise obvious, but may help explain what is going on.
Following the ROS, a Past Medical History (PMH) is obtained. This includes information such as a history of smoking, diabetes, or other surgeries. Both smoking and diabetes can increase the risk of infection or failure of a surgery, so they are important details for the surgeon to know. The physician may also inquire about the patient’s family history. This is less important for conditions such as acute fractures, but very important in conditions such as cancer or osteoporosis. The PMH wraps up the interview portion of the patient encounter and the physician can proceed to the physical exam.
During the physical exam the physician will attempt to gain further insight into the chief complaint. This includes testing objective measurements of function, range of motion, strength, and stability of joints, in addition to inspection and palpation. Additional aspects of the physical exam include provocative tests, meant to recreate the patients’ symptoms. These types of tests involve a certain maneuver that is meant to exacerbate the patient’s symptoms, typically pain. Generally, a test is considered positive if the patient’s pain is acutely worsened during the maneuver. Patients typically do not enjoy these tests. Provocative tests are aptly named; they provoke the patient’s pain, however they are vital components of the diagnostic workup. Recreating symptoms helps the clinician home in on what diagnostic tests to order, therefore minimizing the patient’s exposure to tests and minimizing cost. Additionally, some of these tests are required in the patient note by insurance companies before they will pay for certain expensive tests such as an MRI.
A common sports injury is a meniscal tear of the knee. The meniscus acts as a sort of cushion between the femur and tibia, dispersing weight and decreasing friction during movement. A meniscal tear is a soft-tissue injury, and as such, MRI scans are extremely useful in confirming the diagnosis. MRIs also aid in planning if a surgical intervention is required. Many insurance companies require specific documentation of a positive provocative McMurray test before granting the patient an MRI. The McMurray test involves placing stress on either the medial or lateral meniscus while the knee is flexed (Figure 1), and then maintaining the stress as the knee is extended. An agreed upon definition of a positive result differs, but the test is generally considered positive if the patient experiences pain or pain plus clicking of the knee. Other provocative tests assessing meniscal damage (Figure 2) include the Apley compression test and Thessaly test. The Thessaly test involves the patient standing on the affected leg and twisting back-and-forth.
Other provocative tests are used to assess a variety of other musculoskeletal conditions. A common source of thumb-sided wrist pain is tendinitis of the 1st extensor compartment. This is called De Quervain’s Tenosynovitis and can be very bothersome, especially when patients are lifting heavy items. Several diagnostic tools in an astute clinicians pocket include the Finkelstein and Eichoff maneuvers. The Finkelstein test involves the patient clasping their own thumb in their palm. The physician will then quickly apply an ulnar force to stretch the affected tendons. A positive test is characterized by sharp pain over the radial side of the wrist.
It is important for patients to understand that their physician is not trying to harm them or torture them. In reality, performing these tests is important in moving along the diagnostic trail which eventually leads to a definitive diagnosis and treatment. The end goal when evaluating a patient is always to help them, even if short-term pain or irritation is required to make a proper diagnosis.
Following the physical exam, patients are sent for preliminary testing and eventually confirmatory testing. Preliminary testing includes blood work and possibly x-rays. Definitive tests may include a CT scan, MRI, or biopsy, among many others. Exposing a patient to radiation is not a benign test, so clinicians want to make sure they are ordering the proper tests. For example, if a doctor suspects a meniscal tear in a patient, ordering a knee X-ray, CT scan, and MRI would expose the patient to undue radiation. Why? The meniscus is a ligament and a tear would be considered soft-tissue damage. MRI scans are great for imaging soft-tissue damage; CT scans and X-rays not as informative. The later tests have great use in diagnosing bone fractures and damage, but limited ability to visualize soft-tissue. If the physician has obtained a proper HPI, ROS, and conducted a thorough physical including provocative tests, they should have a strong suspicion of meniscal pathology rather than bony pathology. Limiting confirmatory testing to an MRI eliminates radiation to the patient and additionally limits medical costs.
Only when a diagnosis has been confirmed will a physician initiate a discussion of treatment with the patient. Treatment options should be a joint decision-making process between the doctor and patient. The physician can provide their expert level of knowledge and make suggestions, but the treatment plan needs to be a joint decision involving the patient. All the above aspects are crucial to arriving at a stage where the patient can be successfully treated. As a patient, be prepared to engage in the diagnostic workup with your physician as described above. And even if you don’t enjoy them, remember that provocative tests are important to keep you moving in the right direction.