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Orthopaedic History Taking: Back Pain, Knee Pain & Other Chief Complaints

General Framework for Any Orthopaedic Complaint

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1. BACK PAIN - Detailed History Taking

Pain Character & Location

• Axial (localised to back): points to muscular, ligamentous, vertebral, disc, or facet origin
• Radiation to buttocks/thighs only: often referred from disc or SI joint
• True sciatica (below knee, dermatomal): nerve root involvement - ask specifically if it goes below the knee
• L4-L5 disc: radiates to dorsum of foot / big toe (L5 dermatome)
• L5-S1 disc: radiates to lateral foot / small toe (S1 dermatome)

Critical Pain Features to Ask

RED FLAGS in Spine (Goldman-Cecil Medicine)

Rule these out in every patient with back pain:

• History of malignancy (back pain is the initial symptom in majority of spinal mets; 20% have undiagnosed primary)
• Unexplained weight loss
• Unexplained fever / rigors
• Immunosuppression (HIV, steroids, transplant, chemotherapy)
• Intravenous drug use (spinal epidural abscess)
• Osteoporosis + even minor trauma (compression fracture - especially elderly women, steroid users)
• Age < 20 or > 50 years
• History of recent surgery / GI / GU procedure (haematogenous seeding)
• Progressive neurological deficit (weakness, sensory loss worsening)
• Myelopathy signs (bilateral leg weakness, spasticity, clumsiness)
• Possible cauda equina syndrome (see below)
• Duration > 6 weeks without improvement
• Uncontrollable / unrelenting pain despite analgesics and rest
• Trauma (any mechanism raising fracture concern)

CAUDA EQUINA SYNDROME - Emergency History (Do Not Miss)

• Bladder: retention (inability to void) or incontinence?
• Bowel: incontinence or loss of anal tone sensation?
• Saddle anaesthesia: numbness in perineum, inner thighs, genitalia?
• Progressive bilateral leg weakness or numbness?

Bowel or bladder incontinence combined with back pain is a surgical emergency until proven otherwise. Measure post-void residual (>100 mL is significant). - Tintinalli's Emergency Medicine

Spinal Infection (Discitis/Epidural Abscess) Predictors

1. Fever or rigors
2. Recent antibiotic use (past 30 days - may mask)
3. Significant spinal pain
4. IV drug use
5. Advanced age
6. Diabetes mellitus
7. Renal failure, alcoholism, recent skin abscess/UTI/pneumonia

Positive & Negative Likelihood Ratios - Cancer as Cause of LBP

Functional History (Mandatory)

• How far can you walk before pain stops you? (claudication distance - neurogenic vs vascular)
• Can you ride a bike without pain? (neurogenic claudication: flexed posture = relief; vascular claudication: cycling also hurts)
• Effect on sleep, work, ADLs

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2. KNEE PAIN - Detailed History Taking

Core Symptoms to Ask About

• Pain - location (anterior, medial, lateral, posterior, diffuse)
• Locking - true locking (cannot fully extend, springy block) vs. pseudo-locking (pain inhibition)
• Activity-related change
• Night pain
• Clicking / Clunking
• Limp / gait change
• Oedema (swelling - acute vs. chronic; intra-articular vs. extra-articular)
• Giving way
• Stiffness (morning stiffness duration)

Anterior Knee Pain

• Worse going up/down stairs or sitting for prolonged periods ("cinema sign"): patellofemoral syndrome / OA
• Young active patient: patellar tendinopathy, Osgood-Schlatter (tibial tubercle pain in adolescents)

Medial Knee Pain

• After awkward twisting: medial meniscus tear
• Tender on anteromedial proximal tibia: pes anserine bursitis (common in obese patients, OA, fibromyalgia - often missed)
• MCL strain: after valgus stress, lateral blow

Lateral Knee Pain

• Lateral meniscus tear, IT band friction syndrome (runners)

Posterior Knee Pain

• Baker's cyst (popliteal cyst) - fluctuant swelling behind knee, worse with extension

Mechanical Symptoms

• True locking (cannot fully extend, springy block at a fixed angle) = meniscal tear (bucket-handle) until proven otherwise
• Giving way = ligamentous instability (ACL most common), patellofemoral maltracking, or quadriceps weakness
• Clicking / snapping = may be meniscal, or plica syndrome

"A sensation of giving way or snaps, clicks, catches, or jerks in the knee may be described, or the history may be even more indefinite, with recurrent episodes of pain" - Campbell's Operative Orthopaedics, 15th Ed

Swelling Pattern

Inflammatory vs. Mechanical History

Don't Miss

• Referred pain from the hip - always examine the hip in every patient presenting with knee pain. Hip OA / fracture frequently refers to the knee. "Very often a patient with pathology in the hip will complain of pain in the knee" - S Das Clinical Surgery
• Gout/pseudogout - acute monoarthritis, warm, erythematous knee
• Septic arthritis - fever, hot swollen joint, inability to bear weight - EMERGENCY
• DVT - posterior knee / calf swelling, risk factors (immobility, recent surgery)

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3. HIP PAIN

• Groin pain = intra-articular (OA, AVN, labral tear, fracture)
• Greater trochanter pain = trochanteric bursitis / gluteus medius tendinopathy
• Posterior buttock pain = piriformis syndrome, SI joint, referred lumbar
• FABER test pain = hip / SI joint pathology
• Night pain / rest pain = AVN, malignancy
• Leg length discrepancy = ask about shoe wear, pelvic tilt
• Groin pain radiating down anterior thigh = femoral nerve / L2-L3 involvement

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4. SHOULDER PAIN

• Painful arc (60-120° of abduction) = rotator cuff / subacromial impingement
• Full arc pain = AC joint pathology
• Night pain, unable to lie on shoulder = rotator cuff tear, frozen shoulder
• Unable to raise arm, dropping arm test = full-thickness rotator cuff tear
• Instability / apprehension = glenohumeral instability
• Stiffness in all planes = adhesive capsulitis (frozen shoulder)
• Occupation: overhead work, throwing athletes
• Age: RCT tears commoner > 50 years; instability commoner < 30 years

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5. FOOT & ANKLE PAIN

• First step pain in the morning, heel pain = plantar fasciitis
• Lateral ankle pain after inversion injury = lateral ligament complex sprain
• Bony prominence dorsal foot = exostosis
• Numbness in toes = tarsal tunnel syndrome, peripheral neuropathy - check diabetes history
• Gradual flat foot deformity = tibialis posterior tendon dysfunction

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6. General Positive & Negative History Points in Orthopaedics

Positive History Points (Increase Suspicion for Serious Pathology)

• History of malignancy anywhere (LR+ 14.7 for spinal mets)
• Constitutional symptoms: fever, weight loss, night sweats (infection / malignancy)
• Night pain that awakens from sleep (tumour until proven otherwise)
• Bilateral neurological symptoms (myelopathy, cauda equina)
• Bowel/bladder dysfunction with back pain (CES - surgical emergency)
• Trauma mechanism (fracture, ligament injury)
• Acute swelling / haemarthrosis (ACL, fracture)
• Vascular risk factors + claudication distance (PAD vs. neurogenic)
• Immunosuppression / IV drug use / recent instrumentation (infection)

Negative History Points (Reassuring / Mechanical Nature)

• Young patient, no systemic symptoms
• Clear precipitating activity (injury mechanism consistent with diagnosis)
• Pain improves with rest
• No night pain
• No neurological symptoms
• Responds to NSAIDS / physiotherapy within 4-6 weeks
• Duration < 6 weeks

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Key Diagnoses NOT to Miss in Orthopaedics

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