Section R Musculoskeletal pain

Nov 18, 2025
4 min read

Index

Introduction
Understanding Musculoskeletal Pain
Comprehensive History-Taking
Focused Physical Examination
Appropriate Investigations
Formulating a Differential Diagnosis
Initial Management Strategies
Documentation and Clinical Recording
Key Clinical Insights and Reflections
Conclusion

Introduction

Musculoskeletal pain is one of the most common presentations in primary and urgent care settings, spanning a broad spectrum of causes—from acute injuries to chronic degenerative conditions. Effective management requires a systematic, patient-centred approach underpinned by strong clinical reasoning and thorough assessment.

At Kraken Medical, we emphasise high-quality, structured clinical practice that empowers clinicians to deliver safe, efficient, and compassionate care. This reflective piece outlines a robust approach to assessing and managing musculoskeletal pain, drawing on core clinical skills and practical insights relevant to daily practice.

Understanding Musculoskeletal Pain

Musculoskeletal pain can arise from bones, joints, muscles, ligaments, tendons, or associated soft tissues. It may be acute or chronic, localised or generalised, traumatic or insidious in onset. A clinician’s task is to identify the underlying cause, assess severity, and initiate management that promotes recovery while ensuring red-flag conditions are not missed.

Comprehensive History-Taking

A detailed history forms the cornerstone of accurate diagnosis. I begin with an open, patient-centred conversation to gain insight into:

Onset and duration: When the pain started and whether it was sudden, gradual, or related to a specific event.
Location and characteristics: Sharp, dull, radiating, throbbing, or burning pain, and whether it affects function.
Aggravating and relieving factors: Movement, rest, weight-bearing, medications, or specific activities.
Mechanism of injury: Where relevant, understanding the biomechanics provides critical diagnostic clues.
Associated symptoms: Swelling, stiffness, locking, instability, numbness, weakness, or systemic symptoms such as fever.
Relevant medical and family history: Including arthritis, autoimmune conditions, previous injuries, or surgery.
Impact on daily life: Mobility, sleep, work, and quality of life considerations.

A thorough history not only narrows diagnostic possibilities but also supports shared decision-making and builds rapport.

Focused Physical Examination

The examination aims to identify structural abnormalities, functional limitations, and signs of inflammation. Key components include:

Inspection: Swelling, deformity, bruising, muscle wasting, or asymmetry.
Range of motion (active and passive): Identifying restrictions, pain thresholds, and joint integrity.
Palpation: Localised tenderness, warmth, effusion, crepitus, or soft-tissue abnormalities.
Strength testing: Assessing muscle groups for weakness or pain-related inhibition.
Stability and special tests: Ligament integrity tests, impingement tests, or neurological assessments where indicated.
Neurovascular assessment: Particularly in cases involving trauma or severe pain.

A systematic approach ensures no aspect of the musculoskeletal system is overlooked.

Appropriate Investigations

Investigations are guided by clinical findings and the suspected diagnosis. Options include:

Imaging
- X-ray: Useful for fractures, osteoarthritis, or significant structural changes.
- MRI: Valuable for soft-tissue injuries, including ligament, tendon, or cartilage pathology.
- Ultrasound: Dynamic imaging for tendons, ligaments, and joint effusions.
Laboratory tests
- Indicated when systemic or inflammatory conditions are suspected (e.g., CRP, ESR, autoimmune markers).
Functional assessments
- Gait analysis, mobility tests, or physiotherapy evaluations where appropriate.

Investigations should complement—not replace—a thorough history and examination.

Formulating a Differential Diagnosis

Using the collected information, a structured differential diagnosis is developed, considering:

Acute injuries: Sprains, strains, fractures, dislocations, tendon ruptures.
Chronic conditions: Osteoarthritis, tendinopathy, bursitis.
Inflammatory diseases: Rheumatoid arthritis, gout, spondyloarthropathies.
Neurological causes: Nerve impingement, radiculopathy.
Referred pain: Cervical or lumbar spine, visceral organs.
Overuse injuries: Repetitive strain or biomechanical dysfunction.

Developing a clear differential helps guide initial management and identify red flags requiring urgent escalation.

Initial Management Strategies

Management must be individualised and aligned with the suspected diagnosis. Principles include:

1. Acute Musculoskeletal Injuries

RICE Protocol: Rest, Ice, Compression, Elevation.
Analgesia: Paracetamol, NSAIDs (if appropriate), or topical agents.
Immobilisation: Temporary splints or supports when instability or fracture is suspected.
Early referral: Fractures, severe soft tissue injuries, or neurovascular compromise require urgent imaging and multidisciplinary input.

2. Chronic or Non-acute Pain

Physical therapy: Strengthening, stretching, gait correction, and functional rehabilitation.
Activity modification: Reducing strain while promoting gradual return to normal activity.
Pain management: Analgesics, heat therapy, or supportive devices.
Lifestyle advice: Weight management, ergonomics, and injury prevention.

3. Referral Pathways

Orthopaedics for structural pathology.
Physiotherapy for rehabilitation.
Rheumatology for suspected inflammatory disease.

Effective early management promotes recovery, reduces complications, and supports long-term functional outcomes.

Documentation and Clinical Recording

Accurate clinical documentation is essential for continuity of care. This includes:

A detailed record of the history, examination, and red flag screening.
Clear rationale for investigations and working diagnoses.
A structured management plan, including safety netting and follow-up arrangements.
Timely use of clinical coding and standardised assessment tools where required.

High-quality documentation supports safe practice, facilitates communication between clinicians, and enhances medicolegal protection.

Key Clinical Insights and Reflections

A structured assessment allows clinicians to differentiate minor injuries from significant pathology confidently.
Listening to the patient’s lived experience often reveals diagnostic clues not evident on examination.
Early mobilisation and functional rehabilitation can significantly improve long-term outcomes.
Recognising red flags and escalating appropriately remains critical in musculoskeletal medicine.
Consistent clinical reasoning and meticulous documentation are central to delivering safe, effective care.

Conclusion

Musculoskeletal pain is a complex but highly manageable presentation with the right clinical approach. By combining thorough history-taking, structured examination, appropriate investigations, and evidence-based management strategies, clinicians can ensure patients receive effective, timely, and compassionate care.