History taking & physical assessment

History taking and physical assessment are essential first steps in any clinical encounter. Comprehensive and accurate history taking and physical assessment allow the “complete picture” of an individual presenting with possible osteoarthritis to be established. A person-centered approach is key, with active, open communication. Using techniques such as active listening, empathy, building rapport, open-ended questions, closed-ended probing questions, avoiding leading and “why” questions, allowing silence, and using nonverbal communication enable rich information to be elicited. A holistic approach to history taking ensures that all aspects of the individual are considered. Key components include systematically reviewing symptoms, participation, previous history, comorbidities, psychological factors, sleep and fatigue, support, attitudes and beliefs, red flag screening, using person-reported outcome measures, and setting goals. The physical assessment should be viewed as an extension of history taking. Adopting a systematic approach to physical assessment focusing on the four components: look (general and local observation), feel (palpation), move (range of movement), and measure (range of movement assessment, muscle strength and length, function, neurological features, and special tests) ensures comprehensive information is gained. Together, history taking and physical assessment form the foundation on which a personalized management plan can be built and to optimize engagement and adherence with management in long term.