THE MUSCULOSKELETAL SYSTEM.

EXAMINATION OF PARTICULAR
JOINTS. THE AMPLITUDE OF
MOVEMENT AND MANEUVERS.
SPECIAL METHODS OF EXAMINATIONS.
THE SYMPTOMATOLOGY AND
SYNDROMES OF MUSCULOSKELETAL
SYSTEM
TECHNIQUES OF EXAMINATION
Inspection. Begin by observing the patient’s
posture when entering the room, including the
position of both the neck and trunk.

Assess the patient for erect position of the head,

neck, and back; for smooth, coordinated neck
movement; and for ease of gait.
Inspect the entire back. If possible, the patient
should be upright in the natural standing
position , with feet together and arms hanging at
the sides. The head should be midline in the
same plane as the sacrum, and the shoulders and
pelvis should be the same level.
Inspect the patient from the side and from behind.
Evaluate the spinal curvatures
PALPATION.

From a sitting or standing position, palpate the

spinous processes of each vertebra with your
thumb.

In the lower lumbar area, check carefully for any

vertebral “step-offs” to determine whether one
spinous process seems unusually prominent (or
recessed) in relation to the one above it. Identify
any tenderness.

Palpate over the sacroiliac joint, often identified

by the dimple overlying the posterior superior
iliac spine.
INSPECTION OF THE SPINE

View of Patient
From the side

Focus of Inspection
Cervical, thoracic, and lumbar curves

Increased thoracic kyphosis occurs with aging. In

children, a correctable structural deformity
should be pursued.
From behind

inspect the spinal column, alignment of the

shoulders, the iliac crests, and the skin creases
below the buttocks

Skin markings, tags, or masses.

In scoliosis, there is lateral and rotatory

curvature of the spine to bring the head back to
midline. Scoliosis often becomes evident during
adolescence, before symptoms appear.
 Inspect and palpate the paravertebral muscles for
tenderness and spasm. Muscles in spasm feel firm and
knotted and may be visible.

Spasm occurs in degenerative and inflammatory processes of

muscles, overuse, prolonged contraction from abnormal
posture, or anxiety.
Palpate for tenderness in any other areas that
are suggested by the patient’s symptoms. Recall
that low back pain warrants careful assessment
for cauda equina compression, the most serious
cause of pain, because of risk of paralysis of the
affected limb or loss of bladder or bowel control.
Check for pain radiation into the buttock,
perineum, or legs.
Range of Motion and Maneuvers
Neck ,Movement, Rotation , Lateral Bending.

The neck is the most mobile portion of the spine.

Patient Instructions
“Bring your chin to your chest.”
“Look up at the ceiling.”
“Look over one shoulder, and then the other.”
“Bring your ear to your shoulder.”
RANGE OF MOTION: SPINAL COLUMN.

Now assess range of motion in the spinal column.

In the table below, note the specific muscles
responsible for each motion and the instructions
that prompt the requested patient response
Back Movement
Flexion

Patient Instructions
“Bend forward and try to
touch your toes.”
Note the smoothness and
symmetry of movement,
the range of motion, and
the curve in the lumbar
area.
Extension

“Bend back as far as possible.”

Support the patient by placing

your hand on the
posterior superior iliac
spine, with your fingers
pointing toward the
midline.
Rotation

“Rotate from side to side.”

Stabilize the patient’s pelvis

by placing one hand
on the patient’s hip and
the other on the opposite
shoulder.
Then rotate the trunk by
pulling the shoulder
anteriorly and then the
hip posteriorly. Repeat
these maneuvers for the
opposite side.
Lateral Bending

“Bend to the side from the

waist.”

Stabilize the patient’s pelvis

by placing your hand
on the patient’s hip.
Repeat for the opposite
side.

Note that arthritis, tumor, or infection

in the hip, rectum, or pelvis
may cause symptoms in the lumbar
spine.
TECHNIQUES OF EXAMINATION
Inspection. Inspection of the hip begins with
careful observation of the patient’s gait on
entering the room. Observe the two phases of
gait:

 Stance—when the foot is on the ground and bears

weight (60% of the walking cycle)

Swing – when the foot moves forward and does

not bear weight (40%of the cycle)
RANGE OF MOTION AND MANEUVERS

Range of Motion. Assess hip range of motion,

referring to the table below for specific muscles
responsible for each movement. Review the
instructions to the patient.

Hip Movement
Flexion
Extension (actually
hyperextension)
Abduction
Adduction
External Rotation
Internal Rotation
Patient Instructions

“Bend your knee to your chest

and pull it against your
abdomen.”
“Lie face down, then bend
your knee and lift it up.”
Or “Lying flat, move your
lower leg away from the
midline and down over the
side of the table.”
“Lying flat, move your lower
leg away from the midline.”
“Lying flat, bend your knee
and move your lower leg
toward the midline.”
“Lying flat, bend your knee
and turn your lower leg
and foot across the midline
“Lying flat, bend your knee and
turn your lower leg and
foot away from the midline
MANEUVERS

Often the examiner must assist the patient with

movements of the hip, so further detail is
provided below for knee flexion, abduction,
adduction, and external and internal rotation.
Flexion. With the patient supine, place your hand
under the patient’s lumbar spine. Ask the patient to
bend each knee in turn up to the chest and pull it
firmly against the abdomen. Note that the hip can
flex further when the knee is flexed because the
hamstrings are relaxed. When the back touches your
hand, indicating normal flattening of the lumbar
lordosis, further flexion must arise from the hip joint
itself.
As the thigh is held against the abdomen, observe the
degree of flexion at the hip and knee. Normally, the
anterior portion of the thigh can almost touch the
chest wall. Note whether the opposite thigh remains
fully extended, resting on the table.

Extension. With the patient lying face down, extend

the thigh toward you in a posterior direction.
Alternatively, carefully position the supine patient
near the edge of the table and extend the leg
posteriorly.

Abduction. Stabilize the pelvis by pressing down on

the opposite anterior– superior iliac spine with one
hand. With the other hand, grasp the ankle and
abduct the extended leg until you feel the iliac spine
move. This movement marks the limit of hip
abduction
Adduction. With the patient supine, stabilize the
pelvis, hold one ankle, and move the leg medially
across the body and over the opposite extremity.
External and internal rotation.
Flex the leg to 90 degrees at hip
and knee, stabilize the thigh with
one hand, grasp the ankle with the
other, and swing the lower leg—
medially for external rotation at
the hip, and laterally for internal
rotation. Although confusing at
first, it is the motion of the head
of the femur in the acetabulum
that identifies these movements.
Structure
Medial meniscus and lateral meniscus

Maneuver
McMurray Test. With the patient supine, grasp the heel and flex the knee.
Cup your other hand over the knee joint with fingers and thumb along the
medial joint line. From the heel, externally rotate the lower, then push on the
lateral side to apply a valgus stress on the medial side of the joint. At the
same time, slowly extend the lower leg in external rotation.

The same maneuver with internal rotation of the foot stresses the lateral
meniscus.

If a click is felt or heard at the joint line during flexion and extension of the
knee, or if tenderness is noted along the joint line, further assess the
meniscus for a posterior tear
Medial collateral ligament (MCL)

Abduction (or Valgus) Stress Test. With the

patient supine and the knee slightly flexed, move
the thigh about 30 degrees laterally to the side of
the table. Place one hand against the lateral knee
to stabilize the femur and the other hand around
the medial ankle. Push medially against the knee
and pull laterally at the ankle to open the knee
joint on the medial side (valgus stress).
Lateral collateral ligament (LCL)
Adduction (or Varus) Stress Test. With the
thigh and knee in the same position, change your
position so you can place one hand against the
medial surface of the knee and the other around
the lateral ankle. Push laterally against the knee
and pull medially at the ankle to open the knee
joint on the lateral side (varus stress).
Anterior cruciate ligament (ACL)

Anterior Drawer Sign. With the patient supine, hips

flexed and knees flexed to 90 degrees and feet flat on the
table, cup your hands around the knee with the thumbs
on the medial and lateral joint line and the fingers on the
medial and lateral insertions of the hamstrings. Draw the
tibia forward and observe if it slides forward (like a
drawer) from under the femur. Compare the degree of
forward movement with that of the opposite knee.
Lachman Test. Place the knee in 15 degrees
of flexion and external rotation. Grasp the distal
femur on the lateral side with one hand and the
proximal tibia on the medial side with the other.
With the thumb of the tibial hand on the joint
line, simultaneously pull the tibia forward and
the femur back. Estimate the degree of forward
excursion.
Posterior cruciate ligament (PCL)

Posterior Drawer Sign. Position the patient

and place your hands in the positions described
for the anterior drawer test. Push the tibia
posteriorly and observe the degree of backward
movement in the femur
THE ANKLE AND FOOT
TECHNIQUES OF EXAMINATION
Inspection. Observe all surfaces of the ankles and feet, noting any
deformities, nodules, swelling, calluses, or corns

Palpation. With your thumbs, palpate the anterior aspect of each

ankle joint, noting any bogginess, swelling, or tenderness.

Feel along the Achilles tendon for nodules and tenderness.

Palpate the heel, especially the posterior and inferior calcaneus,

and the plantar fascia for tenderness.
Check for rheumatoid nodules and tenderness,
commonly found in Achilles tendinitis, bursitis,
or partial tear from trauma.

Palpate for tenderness over the medial and

lateral malleolus, especially in cases of trauma
Palpate the metatarsophalangeal joints for
tenderness. Compress the forefoot between the
thumb and fingers. Exert pressure just proximal
to the heads of the first and fifth metatarsals.
Palpate the heads of the five metatarsals and the
grooves between them with your thumb and
index finger. Place your thumb on the dorsum of
the foot and your index finger on the plantar
surface.
RANGE OF MOTION AND MANEUVERS

Range of Motion. Assess flexion and

extension at the tibiotalar (ankle) joint. In
the foot, assess inversion and eversion at the
subtalar and transverse tarsal joints.
Ankle and Foot Movement
Ankle Flexion
(plantar flexion)
Ankle Extension
(dorsiflexion)
Inversion
Eversion

Patient Instructions
“Point your foot toward the floor.”
“Point your foot toward the ceiling.”
“Bend your heel inward.”
“Bend your heel outward.”
 MANEUVERS
 The Ankle (Tibiotalar) Joint. Dorsiflex and plantar
flex the foot at the ankle.

 The Subtalar (Talocalcaneal) Joint. Stabilize the

ankle with one hand, grasp the heel with the other,
and invert and evert the foot by turning the heel
inward then outward.
 The Transverse Tarsal Joint. Stabilize the heel
and invert and evert the forefoot.

 The Metatarsophalangeal Joints. Move the

proximal phalanx of each toe up and down.
SPECIAL TECHNIQUES
Measuring the Length of
Legs. If you suspect that the
patient’s legs are unequal
in length, measure them.
Get the patient relaxed in
the supine position and
symmetrically aligned with
legs extended. With a tape,
measure the distance
between the anterior
superior iliac spine and the
medial malleolus. The tape
should cross the knee on its
medial side
DESCRIBING LIMITED MOTION OF A JOINT
Measurement of motion can be described in degrees.
Pocket goniometers are available for this purpose. In
the two examples shown below, the red lines indicate
the range of the patient’s movement, and the black
lines suggest the normal range.

Observations may be described in several ways. The

numbers in parentheses show abbreviated
descriptions.