History and Examination

The history often establishes the leading differential and directs the examination that follows. For pain, a structured approach such as site, onset, character, radiation, associated features, timing, exacerbating and relieving factors and severity keeps the account complete. In a sports context the mechanism is central: was the injury contact or non-contact, acute or gradual in onset. Gradual-onset problems commonly follow changes in training exposure, recovery, surface, equipment or tissue capacity, rather than a single event, so the clinician should record the sport and level, the training and competition schedule and any recent change, and the effect on both daily function and performance.

Two threads run through every SEM history. The first is the search for features that raise concern about a cause other than a simple musculoskeletal one. These are context-dependent rather than a checklist, since night pain or weight loss do not automatically indicate serious disease, but concern rises with unremitting pain unrelieved by position change, fever, unexplained weight loss, progressive neurological deficit, and a background of possible infection or malignancy. For suspected cauda equina syndrome the features that matter most are new urinary retention or altered urinary sensation or flow, saddle or perineal sensory change, and bilateral or progressive neurological deficit. The second thread is the athlete's own context: previous injury, general health, psychosocial factors and their goals and deadlines, along with a medication and supplement history that includes anti-doping considerations, since what an athlete takes can matter both clinically and for compliance with the rules of their sport.

The musculoskeletal examination follows a repeatable sequence that works for any region: look, feel, move and test function, followed by special tests when relevant. Inspection at rest looks for swelling, deformity, muscle wasting and skin change, always comparing one side with the other. Palpation assesses temperature, tenderness, swelling and the character of any lump. Movement is examined actively, where the patient moves the joint, and passively, where the examiner does. Reduced active movement with relatively preserved passive movement suggests weakness, tendon injury, neurological impairment or pain inhibition, rather than proving that the joint itself is normal. Function then asks whether the range that remains is useful, and a neurovascular assessment is added where indicated.

Two standard routines organise this in UK practice. The gait, arms, legs and spine (GALS) screen is a rapid one to two minute assessment, built around three screening questions and a brief examination, that detects whether a musculoskeletal problem is present without saying what it is. When GALS or the history flags an area, the regional examination of the musculoskeletal system (REMS) provides the detailed, joint-by-joint examination of that region using the same look, feel, move and function structure. Together they give a consistent, teachable approach that scales from a quick screen to a focused regional workup.

Special tests are targeted manoeuvres that load a region and provoke symptoms. Familiar examples include the Lachman and anterior drawer tests used to assess anterior cruciate ligament integrity, the Neer and Hawkins-Kennedy tests which provoke subacromial-region symptoms, empty can testing which loads the rotator cuff but does not independently diagnose a supraspinatus lesion, McMurray and Thessaly tests for the meniscus which have limited accuracy individually, and the anterior apprehension test for shoulder instability. It is a common error to describe these tests as isolating one anatomical structure; most load several tissues at once, and each has useful but imperfect sensitivity and specificity.

The practical rules follow from that. A validated combination of findings may shift diagnostic probability more usefully than one isolated test, but an arbitrary count of positive tests does not constitute a valid cluster. Special tests refine a diagnosis already suggested by the history and basic examination rather than replacing them, and the setting changes what is possible. A pitchside assessment is a rapid, focused examination aimed at excluding serious injury and making a safe removal decision, and return-to-play clearance should not rest on a rushed pitchside structural diagnosis. Recording both positive and negative findings, and comparing with the uninjured side, keeps the examination interpretable when the athlete is reviewed again.

The value of the history and examination is that they converge on a working diagnosis and a short differential, which then decide what happens next. Investigation should be chosen to answer a specific question rather than ordered by reflex: targeted blood tests where a systemic or inflammatory cause is suspected, and imaging, from plain radiographs to magnetic resonance imaging (MRI), where it will change management. A normal examination is itself useful information and, with clear safety-netting, often supports a period of active management rather than immediate imaging, with imaging reconsidered if symptoms fail to improve, the working diagnosis changes, or new concerning features develop.

Good documentation closes the loop. Recording the mechanism, the positive and negative findings, the working diagnosis and the plan allows meaningful comparison at review and safe handover between clinicians. Refer when concerning features are present, when the condition falls outside the clinician's competence, when specialist treatment may be required, or when uncertainty remains despite an appropriate assessment. Throughout, the athlete's goals and timeline shape how the plan is delivered, but they must not lower safety standards or the biological criteria for return to sport, because the same injury may be managed differently in a recreational runner and a professional facing a fixture list without either being returned to play before it is safe.

• •The history often establishes the leading differential; mechanism and change in training exposure are the key sports questions.
• •The examination sequence is look, feel, move and test function, then special tests, always comparing sides.
• •Reduced active with preserved passive movement suggests weakness, tendon injury, neurological impairment or pain inhibition.
• •The gait, arms, legs and spine (GALS) screen detects a problem; the regional examination of the musculoskeletal system (REMS) characterises it.
• •Special tests rarely isolate one structure; a validated combination beats an arbitrary count of positives.
• •For suspected cauda equina, new urinary retention or altered flow, saddle sensory change and bilateral deficit are the features that matter.