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Introduction

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There is no more difficult art to acquire than the art of observation.

William Osler

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The importance of making an accurate, pathological diagnosis cannot be overemphasized. This chapter addresses what physicians call the history and physical examination and what physiotherapists/physical therapists consider the subjective and objective assessment. Chapter 12 addresses investigations.

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Far too often, sporting injuries are given descriptive labels such as “swimmer’s shoulder” or “tennis elbow.” These terms do not represent diagnoses. Accurate pathological diagnosis is essential for several reasons:

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  1. It enables the clinician to explain the problem and the natural history of the condition to the athlete, who will want to know precisely for how long he or she will be affected. A patient may present with an acute knee injury, but the diagnosis of anterior cruciate ligament tear has markedly different implications from the diagnosis of minor meniscal injury.

  2. It enables optimum treatment. Numerous conditions have similar presentations but markedly different treatments. For example, consider the differences in treatment between lateral ligament sprain of the ankle and osteochondral fracture of the talus, patellofemoral joint syndrome and meniscal tear, hamstring tear and hamstring pain referred from the lumbar spine.

  3. It enables optimum rehabilitation prescription. For example, rehabilitation after shin pain due to stress fracture will be more gradual than that after identical shin pain due to chronic compartment syndrome.

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Practice Pearl

When a patient presents with an overuse injury, an accurate pathological diagnosis must be supplemented by assessment of the etiologic factors underlying the condition, otherwise the injury is likely to be slow to recover and highly likely to recur.

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Etiologic factors include training error, malalignment, faulty technique, and inappropriate equipment. An important etiologic factor can sometimes be identified by examining the entire “kinetic chain.”

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Occasionally, it may be impossible to make a precise pathological diagnosis. For example, in a patient with low back pain, the exact source of the pain is often difficult to isolate. In such cases, it is still possible to exclude certain causes of low back pain (e.g. spondylolysis) and identify abnormalities such as areas of focal tenderness, altered soft tissue consistency, or abnormalities of range of motion. Treatment then aims to correct these abnormalities. How treatment affects symptoms and signs can help determine how each particular abnormality contributes to the overall picture.

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Making a diagnosis

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Diagnosis relies on taking a careful history, performing a thorough physical examination, and using appropriate investigations. There is a tendency for clinicians to rely too heavily on sophisticated investigations and to neglect their clinical skills.1

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Keys to accurate diagnosis in patients presenting with apparent musculoskeletal pain include:

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  • whether the symptoms are of musculoskeletal origin (Chapter 7)

  • possible local causes of the patient’s symptoms

  • sites that could be referring pain to the site of the symptoms (...

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