MUSCULOSKELETAL EXAMINATION 2012-2013 Examination of the musculoskeletal (MS) system can be one of the most complex aspects of the

general physical exam. The extent of the examination must vary according to the problem(s) being assessed and the time available to perform the exam. Levels of complexity of the exam can be expressed as follo s! ". Screening exam of MS system! performed on nearly all patients# detects abnormalities of function not al ays apparent on history and may provide diagnostic clues to clinical $uestions. &etailed examination of symptomatic region of the musculoskeletal system (e.g.' the patient complaining of knee pain). Examination of the patient ith established systematic disorder affecting the musculoskeletal system (e.g.' rheumatoid arthritis) under treatment. Examination of the ne patient ith diffuse musculoskeletal complaints.

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The *screening+ exam can concentrate on inspection and observation of function. ,athology involving the -oints very rarely produces symptoms ithout effect on function. ,rior to specific examination of the musculoskeletal regions' the patient.s general appearance' bodily proportions and ease of movement should be noted. Required Equipment: /o additional e$uipment is re$uired Opti n!" Equipment 0onimeter (to measure angles) Stethoscope (to auscultate temporomandibular -oint (TM1)) /on2elastic tape measure E#!min!ti n Te$%nique&: 3nspection 4 5isual examination' range of motion of -oints (active and passive) ,alpation 4 1oint muscle examination' use finger tips and thumbs ,ercussion 4 6se ulnar surface of fist for spine examination Motor Examination 4 /euromuscular testing for strength' sensation and reflexes. ( ill be covered in neurology section of course) 7uscultation 4 6se stethoscope on TM1 and audible tendinous rubs Special maneuvers 4 Techni$ues used to elicit other ise occult findings

S$reenin' Appr !$% t t%e (!tient )it% ut ! T!r'eted C mp"!int*

7ny abnormal findings should be follo ed up ith a detailed exam. (!tient Se!ted n E#!min!ti n t!+"e ,!$in' t%e e#!miner. 8ands9:rists! ". 7ssess ;ange of Motion (7ctively' done by patient) a. <inger flexion' extension' abduction and adduction b. Thumb flexion' extension' abduction' and adduction c. :rist flexion' extension' radial deviation (adduction) and ulnar deviation (abduction). %. 3nspect digits for -oint enlargement or deformity (. 3nspect dorsum of the hands for intrinsic atrophy (prominence of extensor tendons) ). 3nspect palms of hands for palmar nodules' hypthenar' or thenar muscle atrophy Elbo s! ". 7ssess ;ange of Motion (7ctively' done by patient) a. 3nstruct patient to flex and fully extend elbo s b. :ith Elbo s flexed to =>?' have patient supinate and pronate each hand %. 3nspect the humeral epicondyles' olecranon for deformity (. ,alpate the lateral and medial humeral epicondyles for tenderness (Tennis elbo ' 0olf Elbo ) Shoulders! ". 7ssess 7ctive ;ange of Motion. 3nstruct patient to! a. ;aise (7bduct) both arms above the head b. ,lace hands behind the neck to assess abduction and external rotation c. ,lace hands behind the small of the back to assess internal rotation %. 3nspect the shoulders for 7symmetry (height' muscle bulk' position' bony prominences) @ervical Spine! ". /ote position of cervical spine' kyphosis' posture %. 7sk patient to flex and extend' rotate right and left' and sidebend right and left' note any pain or restrictions of movement.

(!tient L-in' Supine n E#!min!ti n T!+"e 8ips! ". 7ssess ,assive ;ange of motion 4 flexion' internal and external rotation %. 0ently palpate the 0reater Trochanters of both femurs for tenderness Anees! ". 3nspect for valgus or varus deformities' -oint line hypertrophy' effusion %. ,assively flex and extend knees hile palpating for crepitus (!tient St!ndin' <eet! ". 3nspect for foot and ankle deformities! a. pes planus' pes cavus b. 8allux 5algus c. 8ammertoes' @la Toes %. 3nstruct patient to alk' inspect for internal or external rotation of feet during gait (!tient St!ndin'. )it% %i&/%er 0!$1 t t%e e#!miner Thoracolumbar Spine ". 3nspect for scoliosis' rib asymmetry' thoracic kyphosis' lumbar lordosis %. 7sk patient to flex for ard' extend back ard' rotate to the right and left ( hile stabiliBing the pelvis)' and sidebend right and left' note any restrictions of movement. Scapular ,osition ". inspect for any scapular inging

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Patient in gown seated on examination table. Examiner stands facing patient. " A* 3!nd& % ". 3nspect hands /ote! S elling &eformity ;edness Muscular atrophy /odules 1oint symmetry 7bility to make fist (tests function) " % %. 7ssess range of motion (active range of motion' done by the patient) a. 3nstruct patient to flex and extend fingers of both hands# patient should attempt to touch tips of fingers to palmar crease at level of metacarpophalangeal -oints. b. 8ave patient make fist ith thumbs across the knuckles ( (. ,alpate the follo ing interphalangeal -oints ) 2 &istal C 2 ,roximal D 2 Metacarpophalangeal /ote! S elling' bogginess (soft' ater logged or s ollen deeper tissues that hinder function)' tenderness' bony enlargement

0* 4ri&t& ( ". 3nspect rists /ote! S elling ;edness /odules

&eformity Muscular atrophy 1oint symmetry

%. 7ssess active range of motion (done by patient) :ith arms extended palms turned do n' instruct patient to! " a. <lex rist to =>o do n ard % b. Extend rist to =>o up ard :ith arms in neutral position (handshake position)' instruct patient to! ( a. Supinate rist to =>o b. ,ronate rist to =>o /ote! Supination and pronation are motions that originate from the elbo but are demonstrated at the rists.

(. ,lace thumb on dorsum of patient.s rist ith fingers beneath it. ,alpate the follo ing -oints! " 2 Metacarpocarpal % 2 @arporadial ( 2 @arpoulnar /ote! S elling Synovial Eogginess Tenderness ). @linical correlate! @arpal tunnel syndrome 4 compression of the median nerve bet een the flexor retinaculum and the deeper carpal bones. /europathic symptoms (pain and paresthesias) are present along a median nerve distribution (affecting the thumb' index' middle fingers and the lateral half of the ring finger). Tinel.s sign 4 8yperextend the rist and tap the median nerve ith your middle finger or reflex hammer. 7 positive sign is pain or paresthesias radiating do n the palm into the index' middle' and lateral half of ring finger (median nerve distribution). ,halen.s test 4 <lex the rist to =>o and maintain it for at least )>2D> seconds. 7 positive test ould be pain or paresthesias in the median nerve distribution. ,halen.s test is more sensitive than Tinel.s sign. Median /erve @ompression test 4 The most accurate physical exam test for carpal tunnel syndrome. <irmly compress the median nerve ith your thumb at the flexor retinaculum for about )> seconds. 7 positive test ould be pain or paresthesias in the median nerve distribution. This test is also called the carpal compression test. C* E"+ )& % ". 7ssess active range of motion " a. 3nstruct patient to extend and flex elbo % b. :ith arms extended' have patient supinate and pronate each hand ( %. :ith patient.s forearm supported and elbo flexed to about F>o palpate the follo ing! ) 2 Extensor surface of ulna C 2 Glecranon process D /ote! S elling /odules F 2 0roove on either side of olecranon process. ;emember' the ulnar nerve ;uns through the medial groove. /ote! Thickening S elling Tenderness

(. @linical correlate! ulnar nerve entrapment at ulnar groove leading to neuropathy and distal muscle atrophy of hypothenar muscles (the digiti minimi muscles). " ). ,ress on the lateral epicondyles /ote! Tenderness C. @linical correlate! Tennis elbo or lateral epicondylitis 4 tenderness of extensor tendons originating at the lateral epicondyle. % 2* S% u"der& !nd En5ir n& ". 3nspect shoulders and shoulder girdle anteriorly /ote! S elling 1oint symmetry &eformity Muscular atrophy %. 3nspect scapula and related muscles posteriorly % (. 7ssess active range of motion 2 Screen for shoulder abnormalities by having patient clasp hands behind head and extend arms so that elbo s are *up against the all+ parallel to coronal plane. ( 2 :ith arms at sides' abduct arm to =>o (abduction) ) 2 :ith scapular motion elevate arm to "H>o (move arms to a vertical position near head) /ote! Symmetry and rhythm of movement :ith patient.s arm at side (>o) a. <lex shoulder for ard to "H>o " b. <lex shoulder back ard to D>o ( ithout scapular motion) % c. 7dduct shoulder to (>o d. 8ave patient place hands behind small of back (internal rotation to =>o) e. ,lace hands behind neck ith elbo s out to side (external rotation to =>o) ). ,alpate the follo ing! 2 7cromioclavcular -oint ( 2 0reater tubercle of humerus ) 2 Eiceps groove C 2 @oracoid process D 2 0enohumeral -oint F 2 Subdeltoid bursa /ote! Tenderness <luid C. @linical correlates! deltoid muscle atrophy and shoulder -oint effusion. D. @linical @orrelate! 8a kins impingement test for supraspinatus tendonosis. The examiner gently but firmly' internally rotates the proximal humerus hen the arm is for ard flexed to =>o and slightly adducted.

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E* 3e!d !nd Ne$1 ". 3nspect /eck /ote! &eformities 7bnormal posture

%. 7ssess active range of motion for cervical spine (head and neck) 3nstruct patient to! % a. Touch chin to chest (flex neck) 4 /ormal is )Co of flexion. ( b. Touch chin to each shoulder (rotate neck) 4 /ormal is F>o of rotation' each side. ) c. Touch ear to corresponding shoulder (lateral bending) 4 /ormal is )>o of lateral bending' each side d. ,ut head back (extend neck) 4 /ormal is )Co of hyperextension of neck. C (. :ith index fingers' gently palpate the follo ing -oints! a. Sternoclavicular D b. Manubriosternal F c. @ostochondral /ote! <luid Tenderness S elling ). :ith finger pads' palpate the follo ing structures! H a. @ervical spine = b. ,aracervical muscles "> c. TrapeBius muscles "" d. ;homboids /ote! Tender nodules in muscles or specific tender areas. "% C. ,alpate temporomandibular -oint (TM1) 2 ,lace first t o fingers of each hand in front of tragus of ear and have patient open and close mouth 2 3nstruct patient to open and close mouth# assess degree of maximal opening (patient should be able to place ( vertically2placed fingers in mouth). 2 7lso' ith mouth open' mandible should move laterally to each side at least ".Ccm. /ote! ;ange of motion Tenderness S elling @repitus ,ain D. 7usculate TM1' if crepitus suspected' hile patient opens and closes mouth. F. Spurling.s test or 5ertex @ompression test (for cervical radicular pain or paresthesia) <orcibly press do n vertically on top of the head to compress the cervical nerve roots. /ormally this is ell tolerated. 7void doing this test on elderly' frail individuals or patients ith serious spine disease or in-ury (also see k.).)

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Patient seated with legs hanging over table. Examiner sits in front of patient. 1 % " 6* 6eet ". 3nspect feet /ote! S elling &eformity /odules @alluses @orns <lat feet

%. 8ave patient curl and extend toes' then *cup+ the arch of the foot to screen for abnormalities. This also assesses active range of motion. /ote any deformity like cla toe or hammer toe (see lecture slides). (. @ompress the forefoot bet een thumb and fingers at the level of the metatarsal phalangeal -oints. 7 painful interdigital neuroma (Morton.s neuroma) is usually found by palpating bet een the (rd and )th metatarsal bones' using thumb and index finger. ). :ith thumbs on sole of foot and fingers on top of foot' bilaterally palpate the follo ing -oints and enthesis! 2 &istal interphalangeal 2 ,roximal interphlangeal 2 Metatarsophalangeal 2 Grigin of plantar fascia into calcaneus (plantar fasciitis leads to tenderness to palpation at this site)

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C. Eilaterally assess passive range of motion (done by examiner) F 2 StabiliBe heel 2 ;est heel in one hand and grip forefoot ith other hand! H a. 3nvert foot = b. Evert foot "> c. <lex toes on metatarsophalangeal -oint "" D. ,alpation of the foot 2 ,alpate for any bony deformity 2 @ompress forefoot gently' then firmly /ote! ,resence of metatarsal disease (tenderness)

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7* An1"e& ". 3nspect ankles %. To screen for abnormalities' have patient flex' extend' invert and evert the foot (active range of motion). (. ,alpate anterior surface of ankle -oint ). ,alpate 7chilles (gastrocnemius) tendon assess for tendonitis /ote! /odules Tenderness (at insertion into calcaneus)

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C. 7ssess passive range of motion (done by examiner) :ith thumb on top of foot and four fingers underneath' grip foot a. &orsiflex the ankle b. ,lantar flex the ankle /ote! Subtibial motion To stabiliBe ankle' grip calcaneus and subtalar -oint from behind ith one hand and heel ith other hand! a. 3nvert foot b. Evert foot /ote! Subtalar motion Still stabaliBing ankle! c. supernate forefoot d. pronate forefoot /ote! Transverse tarsal -oint motion

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Patient supine. Examiner stands at foot of table. 3* Knee& > " ". 3nspect knees /ote! 7lignment 4 valgus (lateral malalignment of lo er leg) or varus (medial malalignment deformity) &eformity Iuadriceps atrophy 7bsence of normal hollo s around patella (suggests fluid in -oint or fat around knee) Anock knee (genu valgum) Eo leg deformity (genu varum) ,opliteal fossa s elling (possible Eaker.s cyst)

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%. Eulge sign 4 indicates an abnormal but small amount of fluid (effusion) in knee. This test can detect as little as )2D ml of fluid. This test is done hen you suspect trauma or effusion! a. massage the medial knee up ardly to remove fluid from the medial knee area b. press or tap the lateral patella medially c. observe for bulge of fluid appearing in the medial pouch (. ,alpate suprapatellar pouch on each side of $uadriceps d. use thumb and fingers /ote! Thickening Synovial membrane tenderness Eony enlargement around knee

Eogginess

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). @ompress suprapatellar pouch ith one hand and palpate e. each side of patella# note' if present' synovial plicae# assess for effusion (fluid in -oint) by bulge test or patellar tap f. Tibiofemoral -oint space /ote! Thickening Eogginess <luid Tenderness near femoral epicondyles g. place thumbs on patella and first t o finger pads into popliteal space h. examine the space by moving fingers in a deep rotary motion /ote! S elling @ysts C C. @linical correlate! Eaker.s cyst (a fluid2filled popliteal bursa found in the posterior knee) D. @linical correlate! 7nserine Eursitis 4 tenderness and s elling or bogginess on the medial tibia -ust belo -oint line. 2 Patient supine. Examiner stands first to patients right then left. ( F. 7ssess range of motion (passive or active) a. Extend knee to >o (leg straight out) b. <lex knee to at least "%>o % /ote! &egree of range of motion. ( H. 7ssess degree of ligamentous laxity both medially and laterally. a. :ith the knee slightly flexed (%>o)' place outer hand on the lateral side of knee' grasp the medial foot or ankle ith the opposite hand' and abduct the lo er leg (valgus stress). /ote! Medial collateral ligament motion or degree of *give+ in -oint. b. :ith the knee slightly flexed (%>o)' place the inner hand on the medial side of the knee' grasp the foot or ankle ith the opposite hand' and adduct the lo er leg (varus stress) /ote! Lateral collateral ligament motion or degree of *give+ in the -oint

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=. Lachman.s test! <lex knee slightly to about %>o and one hand stabiliBes the lo er femur hile the other holds the tibia above the tibial tuberosity and then pulls and pushes the tibia to assess laxity of anterior and posterior cruciate ligaments. ">. &ra er test! ,atient is supine' knee is flexed about =>o' examiner sits on patient.s foot' grabs the upper leg and pulls it anteriorly and posteriorly to assess for laxity of the respective cruciate ligaments. :hen done properly Lachman.s test is more sensitive. Patient supine with legs straight together. Examiner begins standing to right of examination table and then moves to the left. " I* 3ip& " % ( ) C D F ". 7ssess passive range of motion a. ;otate each extended leg externally and internally and then return to original position. ;epeat maneuver ith each knee and hip partially flexed at knee. Should have about )Co of internal and external range of motion. b. @heck for full extension of hip (>o) and active flexion (J"">o) as ell as passive flexion (J"(>o). c. Thomas test (to detect occult hip flexion contracture)! 8ave patient flex right knee and pull firmly against abdomen. This flattens the normal lumbar lordosis. /ote! &egree of flexion of left hip ,osition of left hip (3f hip remains on table' it.s a negative test' if hip flexes and thigh is off the table' it.s a positive test.) ;epeat for left hip d. :ith the leg extended 2 7bduct hip to D>o 2 7dduct hip to (>o ;epeat maneuver for other leg e. :ith patient prone' straighten one leg on examination table to stabiliBe pelvis and extend other leg to "Co. (;epeat for other leg) this tests for normal hyperextension. " > %. ,atrick.s or <7EE; test (flexion' abduction' external rotation of the hip) to test for hip or sacroiliac -oint disease. a. ,lace patient.s left foot on the right distal $uadriceps -ust above the patella. 0ently but firmly press the left knee to the exam table. /ote! Tenderness of posterior hip or back. ;epeat the maneuver ith the other leg. (. See special maneuvers (k) for Trendelenburg test (k.".a.)

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Patient stands with back to examiner. Gown parted to allow adequate spine visualization. " 8* Spine " ". 3nspect spinal profile /ote! @ervical lordosis Shoulder height symmetry &orsal kyphosis 3liac crest symmetry Lumbar lordosis Lateral curvature (concave or convex)4scoliosis Skin creases belo buttocks %. 3nspect patient.s gait /ote! Smoothness 6ninterrupted motion 7ntalgic gait related to pain Patient bends slowl forward as far as possible with back to examiner (. 3nspect dorsolumbar spine /ote! Symmetry of movement as patient flexes and extends Smooth curve of spine ;ange of motion (ho far can patient bend)# /ormal is about => o @ompare convexity of lumbar curve ;ib hump (elevated shoulder) or lateral curvature of the spine (scoliosis) Patient stands with back to examiner. Examiner seated and stabilizes patients pelvis with hands. ). 7ssess active range of motion 8ave patient perform the follo ing maneuvers! > a. Eend to the right and then left (lateral bending' (Co) " b. Eend back to ards examiner (extension' (Co) % c. T ist shoulders to right then left (rotation' (>o) Patient stands with back to examiner. Examiner sits or stands behind patient. " C. ,alpate spinous processes /ote! Tenderness

D. ,alpate paravertebral muscles /ote! Spasm Tenderness <irmness or hypertonicity F. ,alpate intervertebral spaces H. ,ercuss spine 6se ulnar surface of fist /ote! ,ain Tenderness =. :hen patient is supine' can perform straight leg raising test (see k.".b. belo ) K* Spe$i!" M!neu5er& ". ,erform the follo ing maneuvers on patients suspected of having sacroiliac disease' herniated nucleus pulposus (disc)' hip abnormality' or neurologic disease hich may involve the legs. " % ( a. Trendelenburg sign (to detect gluteal eakness) 2 7ssess both hips 2 8aving patient stand on one leg and note if opposite hip remains parallel or slightly elevated (normal or negative). 7 positive Trendelenberg sign occurs hen the opposite hip falls belo the parallel plane. This indicates eak intrinsic muscles of the hip opposite to the fallen one. b. Straight leg raising test (to detect hip or sciatic disease) 2 :ith patient supine' raise patient.s leg up to F>o from examination table' then sharply dorsiflex the forefoot# this indicates a positive test if there is pain radiating do n the posterior leg to at least the popliteal fossa. ;aising the leg beyond F>o is not necessary. 2 3ncreased pain do n the affected leg hen the opposite (contralateral) leg is raised is a positive crossed straight leg raising sign. C c. ,atrick.s Test (to detect hip or sacroiliac disease) or <7EE; test 2 :ith patient supine' have patient place right ankle on left knee -ust proximal to patella. 2 StabiliBe pelvis and sharply' externally rotate hip' ith right knee approaching the table. 2 ;epeat for other side. H d. ,elvic compression (to detect sacroiliac disease) 2 :ith patient lying on side' apply pressure to hip -oint. 2 ;epeat for other side.

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e. Modified Shober.s test (to detect and $uantify restrictions of lumbar flexion) 2 :ith patient standing' locate posterior iliac spines (indicated by *dimples of venus+) and mark site over spine at their level. 2 <rom this line' measure ">cm superiorly and make second mark. 2 8olding >2point of tape measure at first mark' have patient bend over and attempt to touch toes. 2 /ote maximum excursion of second mark and record. /ormal excursion is C2F cm.

"% "( %. Measure the length of each leg by placing tape measure at anterior iliac spine and measuring to the medial malleolus. > " % ( ) (. McMurry.s Test (see 1udge p.(=F) to test for meniscal tears in the knee. @an also hyperextend and hyperflex the knee to assess for pain on the medial or lateral knee -oint' corresponding to the respective meniscus. ). 5ertex @ompression test (to assess neck and arm pain from cervical nerve root compression). ,lace both hands on top of head and press do n ard. ;eproduction of the pain is a positive test. C. 7dson.s test for thoracic outlet syndrome. ,atient takes a deep breath' hyperextends his9her head and rotates head to the affected side hile examiner palpates the radial pulse. 7 decrease pulse is a positive test. 3f negative' repeat maneuver ith the head rotated to opposite side. D. 3f spondylitis (arthritis of the spine) is suspected' measure the patient.s chest expansion in full inspiration and expiration. 6se non2elastic tape measure and place at level of xiphoid process. Measure the circumference.

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