DR. Müge BıçakçıgilYÜH. Romatoloji BD.

The patient should be undressed and gowned as needed for this examination.

The examination may not be appropriate (e.g. performing ROM on a fractured leg).

The musculoskeletal exam is all about anatomy.

Think of the underlying anatomy as you obtain the history and examine the patient.

General Considerations

General ConsiderationsWhen taking a history for an acute

problem ;always inquire about ; mechanism of injury, loss of function, onset of swelling (< 24 hours), and initial treatment.

General ConsiderationsWhen taking a history for a chronic

problem always inquire about ;past injuries, past treatments, effect on function, and current symptoms.

General ConsiderationsThe cardinal signs of musculoskeletal

disease are: pain, redness (erythema), swelling, increased warmth, deformity, and loss of function.

General Considerations

Always begin with ;inspection, palpation and range of motion,

regardless of the region you are examining.

General ConsiderationsSpecialized tests are often omitted unless

a specific abnormality is suspected.

A complete evaluation will include a focused neurologic exam of the effected area.

VascularPulses

Check the radial pulses on both sides. If the radial pulse is absent or weak, check the brachial pulses.

Check the posterior tibial and dorsalis pedis pulses on both sides. If these pulses are absent or weak, check the popliteal and femoral pulses.

Capillary Refill

Press down firmly on the patient's finger or toe nail so it blanches.

Release the pressure and observe how long it takes the nail bed to "pink" up.

Capillary refill times greater than 2 to 3 seconds suggest peripheral vascular disease, arterial blockage, heart failure, or shock.

Edema, Cyanosis, and Clubbing

Check for the presence of edema (swelling) of the feet and lower legs.

Check for the presence of cyanosis (blue color) of the feet or hands.

Check for the presence of clubbing of the fingers.

Lymphatics

Check for the presence of axillary lymph nodes.

Check for the presence of inguinal lymph nodes.

Inspection

Look for scars, rashes, or other lesions.

Look for asymmetry, deformity, discoloration, or atrophy.

Always compare with the other side.

Varus - distal extremity deviates medially from the joint (bow-legged)

Valgus - distal extremity deviates laterally from the joint

Often in a fracture or disclocation there is an obvious deformity about the joint or bone.

Swelling - suspect if normal landmarks about the joint are not apparent, or the normal contour of the extremity is altered.

Wasting - muscle wasting can result from neurologic or muscular disease or injury. Bony landmarks often more prominent.

Discoloration:•  Erythema, or redness, is a sign of

inflammation. •  Ecchymosis, or bruising, can be secondary to

superficial bruising, or may indicate damage to the underlying muscle, ligament, or bony structure.

 

The examination of the patient begins when tha patient first enters the room. How is the patient's posture? Does the patient appear uncomfortable? Are there any obvious joint deformities? How is the patient's gait?

PalpationExamine each major joint and muscle

group in turn. Identify any areas of tenderness.

Identify any areas of deformity.

Always compare with the other side.

During palpation, changes in temperature, palpable deformities, crepitus and tenderness.

Temperature   Use the back of your hand

  Deformities   Palpate using your finger pads. Is there a palpable deformity? Any dislocation. An irregular enlargement- due to

arthritis, deposition of inflammatory material, an old injury, or more rarely a tumor.

Crepitus   Grinding or rubbing sensation or sound. Due to bony or cartilaginous structures

moving across each other, or due to tendons moving across each other.

Tenderness Pain with palpation is usually an indicator of

injury or inflammation. The severity of the pain is usually a marker of

the severity of the underlying condition.

Fractures, dislocations and complete tears of ligaments or tendons are usually very painful.

Acute inflammatory arthritis due to gout or infection is also exquisitely painful.

Mild sprains or contusions tend to be less painful.

Pain from chronic conditions such as rheumatoid arthritis or osteoarthritis, while sometimes severe, is usually less painful

Range of Motion

Start by asking the patient to move through an active range of motion (joints moved by patient).

Proceed to passive range of motion (joints moved by examiner) if active range of motion is abnormal.

Active ROM

Ask the patient to move each joint through a full range of motion.

Note the degree and type (pain, weakness, etc.) of any limitations.

Note any increased range of motion or instability.

Always compare with the other side. Proceed to passive range of motion if

abnormalities are found. If there is injury or pain, begin with

normal side first. Assess one joint at a time. Observe the patient for pain, smoothness

of motion, and any unusual movements.

Passive ROMAsk the patient to relax and allow you to

support the extremity to be examined.Gently move each joint through its full

range of motion. Note the degree and type (pain or

mechanical) of any limitation. If increased range of motion is detected,

perform special tests for instability as appropriate.

Always compare with the other side.

  Palpation during passive (or active) ROM

may reveal crepitus.   Be sure to have the patient tell you if the

ROM becomes painful.   Discrepancies between active and passive

ROM may be due to weakness, pain or joint disorder.

STRENGTH TESTING

  If pain or injury, begin with normal side.   Isolate the joint about which you are testing

strength.   Compare one side to other.

SPECIAL MANEUVERS Clinicians perform special maneuvers when

they are hypothesis testing, i.e., they are concerned about a specific condition or injury.

Some common special maneuvers for the upper extremity include:

Shoulder Impingement test Drop test

Hand and wrist Tinel and phalen's (for carpal tunnel) Finkelstein's maneuver (for deQuervain's

tenosynovitis)

SHOULDER JOINT

It has an incredibly wide range of motion, due to the complex structures of the shoulder girdle.

PALPATION : Palpate the acriomoclavicular joint, the

acromion, the scapular spine, and the bicipital groove.

Palpate the muscles about the shoulder.

STRENGTH TESTING Routinely test flexion, extension and

abduction. If indicated (pain, other complaints), check

internal and external rotation, and adduction.

ACTIVE AND PASSIVE RANGE OF MOTIONObserve the patient abducting, flexing and

extending their shoulder. Evaluate external rotation by having the

patient place their hand behind the head. Evaluate internal rotation by asking the

person to touch his fingers at the back.

Range of MotionAbduction (150 degrees) Forward flexion (180 degrees) Extension (45 degrees) External Rotation (90 degrees), elbow at

90 degrees With arm comfortably at side With arm at 90 degrees abduction

Internal rotation (90)

SPECIAL MANEUVERSThe Neer

impingement sign: This maneuver

narrows the space between the acromion and the humeral head. If a patient has impingement of a rotator cuff tendon (or a tear), they will usually have increased pain with this test.

The drop test: Gently abduct the arm above ninety degrees,

if pain allows. Ask the patient to maintain the arm in the this position, warn the patient and then drop the arm. In a patient with a rotator cuff tear, they will often not be able to maintain the arm's position and it will fall.

ELBOW JOINT

A - Olecranon B - Lateral

Epicondyle

INSPECTIONInspect the elbows with the arm in a neutral,

anatomic position  PALPATION Be able to palpate the lateral and medial

epicondyles, and the olecranon process.

RANGE OF MOTION Flex and extend, and supinate and pronate. Normal elbow range of motion Extension: 0 degrees Flexion: 150 degrees Pronation: 70 degrees Supination: 90 degrees

HAND AND WRIST

Palmar Hand

A - Distal wrist crease

B - Thenar eminence

C - Hypothenar eminence  

Dorsal Hand A - Carpometacarpal

joint B -  

Metacarpophalangeal joints

C   - Proximal interphalangeal joints

D - Distal interphalangeal joints

E -   Interphalangeal joint of thumb

INSPECTION At rest, the fingers will be slightly flexed and

almost in parallel. Inspect the dorsum of the hand and wrist for

swelling. Inspect the palmar expect for thenar or

hypthenar wasting. Inspect each joint for swelling, discoloration

and deformity.

PALPATION Palpate the radial and ulnar styloid, and the

radiocarpal and radioulnar joints. Palpate the CMC joint, and the lateral and

medial aspects of each MCP, PIP and DIP joint. The joints of the wrist and hand are commonly

affected in osteoarthritis and rheumatoid arthritis. Other common conditions affecting the hand and wrist are ganglion cysts and Dupuytren's contractures

In osteoarthritis palpation will reveal tenderness and bony growths (osteophytes) that enlarge the joints - particularly the DIP and PIP joints. These are called Heberden's nodes and Bouchard's nodes, respectively

In rheumatoid arthritis the synovium of the joint is inflamed, leading to tenderness and bogginess about the joint, in addition to warmth and redness.

Later in the course of the disease, the bony and ligamentous structures supporting the joint are damaged, and joint deformity results.

Ganglion cysts are common, and arise from the synovium. There are frequently found on the dorsum of the wrist, but can arise from the MCP and other joints as well. They only require treatment if they are painful.

Dupuytren's contracture is a localized thickening of the palmar fascia, most frequently affecting the fascia overlying the 4 th and 5 th metacarpals. It can lead to hand contracture, deformity and decreased function.

RANGE OF MOTION Assess pronation and supination of the forearm Assess flexion, extension, abduction and

adduction of the wrist. Assess flexion of the MCP joints with the PIP

joints extended, and have the patient make a fist to assess flexion of the PIP and DIP joints, and spread the hand out to assess extension of the PIP, DIP and MCP joints.

Have the patient oppose the thumb to the small finger

Normal wrist range of motion •  Extension - 70 degrees •  Flexion-   90 degrees •  Radial deviation (abduction) - 20 degrees •  Ulnar deviation (adduction) - 55 degrees

Normal hand range of motion •  MCP hyperextension - 30 degrees •  MCP flexion - 90 degrees •  PIP and DIP extension - 0 degrees •  PIP and DIP flexion - 90 degrees •  Oppostion - thumb should touch the 5 th

MCP. Passive ROM of the hand is frequently not

performed.

STRENGTH TESTING Test wrist flexion and extension Grip strength Opposition - have the patient touch thumb to

small finger, and try to pull your finger through. (median nerve)

Key grip strength - have patient grip a thin object (piece of paper) between his thumb and the proximal phalanx of index finger,   and resist you as you try to pull the object from his grasp. (median nerve, collateral ligament)

Finger abduction - have patient spread fingers out against resistance.(ulnar nerve)

Special Tests-Snuffbox Tenderness

(Scaphoid)Identify the "anatomic snuffbox"

between the extensor pollicis longus and brevis (extending the thumb makes these structures more prominent).

Press firmly straight down with your index finger or thumb.

Any tenderness in this area is highly suggestive of scaphoid fracture.

Flexor Digitorum Superficialis Test

Hold the fingers in extension except the finger being tested.

Ask the patient to flex the finger at the proximal interphalangeal joint.

If the patient cannot flex the finger, the flexor digitorum superficialis tendon is cut or non-functional.

Flexor Digitorum Profundus Test

Hold the metacarpophalangeal and proximal interphalangeal joints of the finger being tested in extension.

Ask the patient to flex the finger at the distal interphalangeal joint.

If the patient cannot flex the finger, the flexor digitorum profundus tendon is cut or non-functional.

Neurologic TestsPhalen's Test (Median

Nerve)Ask the patient to press the

backs of the hands together with the wrists fully flexed (backward praying).

Have the patient hold this position for 60 seconds and then comment on how the hands feel.

Pain, tingling, or other abnormal sensations in the thumb, index, or middle fingers strongly suggest carpal tunnel syndrome.

Neurologic Tests

Tinel's Sign (Median Nerve)Use your middle finger or a reflex hammer to

tap over the carpal tunnel. Pain, tingling, or electric sensations strongly

suggest carpal tunnel syndrome.

EXAMINATION OF SPINE

Landmarks helpful in identifying spinal levels include:

•  C7 and T1 - prominent spinous processes

•  T7 to T8 - inferior angle of scapula typically located at this level

•  L4 - an imaginary line across the tops of the iliac crests crosses L4

PHYSICAL EXAMINATION Examination of the spine includes inspection,

palpation and range of motion. Strength testing of the spine is not a part of the typical physical examination.

Observe the patient from the back, with the back exposed. The patient could either be wearing only undergarments, or a gown that is not tied in the back.  Normal Findings

Shoulders (left and right should be equal height) Scapulae   (left and right should be equal height) Iliac crests (left and right should be equal height) Hands at equal height.

Unequal heights of any of these structures might indicate scoliosis (congenital or acquired),   leg-length discrepancy or spinal pathology.

Observe the patient from the side, identifying the normal cervical and lumbar concave curves, and the convex curves of the thoracic and sacral spine.

Scoliosis - curvature of spine - congenital, developmental, acquired Note the slight curvature to this patient's spine, and note that the right

scapula is raised relative to the left. The curvature is seen more clearly on the X-ray:

Lordosis - increased or "swayback" curve in lumbar area Pregnancy, muscle imbalance, obesity

Kyphosis - increased or "humback" curve in thoracic area Osteoporosis, posture, congenital

Palpation: Palpate the spinous processes and the

paraspinous musculature, assessing for tenderness, swelling, warmth, and muscle tone.

Range of motion The examiner asks the patient to flex, extend,

laterally bend and rotate (or turn) the cervical spine and the "back" (primarily the lumbar, thoracic and sacral spine). Begin from the neutral position, with the patient standing up straight (can assess range of motion of the cervical spine with the patient seated).

Cervical spine range of motion: Flexion - 45°     "Touch chin to chest" Extension - 55°     "Tilt your head back as far

as you can" Lateral bending (right and left) - 40°   "Try to

touch your ear to your shoulder without moving your shoulder"

Rotation (right and left) - 70°    "Turn your head towards your shoulder"

Back range of motion: Flexion - 90° "Try to touch your toes without

bending your knees" Extension - 30°     "Lean back as far as you

can" Lateral bending (right and left) - 35° "Lean to

your side" Rotation (right and and left) - 30°    "Twist to

your side" Examiner may need to stabilize patients

pelvis to prevent rotation at the pelvis.

Extension

Lateral bending

Left-right rotation

Special Maneuvers: Straight leg raise (SLR)

Purpose: Used to evaluate back pain that radiates into leg (sciatica). Places tension on sciatic nerve and inflamed nerve root

Technique:   Patient supine, legs straight. Hold heel, and passively lift affected leg with knee straight. Talk with patient to be sure their leg muscles remain relaxed. Repeat with other leg.

.

Findings: Positive test is reproduction of sciatic-type pain when hip is flexed between 30° and 70°. Dorsiflexion of foot may aggravate pain. If SLR of leg opposite the affected leg causes pain in the affected leg, patient is very likely to have a ruptured disc

LOWER EXTREMITIES

HIPCan assess entire lower extremity,

observing the hips, knees, ankles and feet. Observe for symmetry, deformity and

discoloration. Can assess hip strength by watching

patient rise from a chair. Individuals needing to use their arms to push

up from the chair, or who have to "rock" themselves out of the chair have muscle weakness of the proximal hip musculature.

Palpation: Palpate the iliac crest and greater

trochanter. In the patient with hip pain, palpate the gluteal

musculature as well as the hip and thigh musculature.

In the patient with pelvic pain, palpate the symphysis pubis, ischial tuberosities, the posterior superior iliac crest.

Range of motion: Either active or passive. In patient with

pain, active should precede passive ROM. Flexion (with knee bent) -   120° Flexion (with leg straight) - 90° Extension - with patient lying on side, lying

prone or standing - 15° Abduction - 45° Adduction - 30° Rotation - with knee flexed to 90°

Internal 40° External 45°

KNEEInspection: Evaluate for swelling, discoloration,

deformity. Identify the landmarks about the knee.

Inspect the quadriceps muscle for atrophy. Atrophy is common in chronic knee conditions.

Palpation: Evaluate for warmth, tenderness, crepitus

and fluid. Identify the tibial and femoral condyles in

order to palpate the tibiofemoral joint space medially and laterally.

Palpate the patella Palpate the popliteal space (swelling may

indicate Baker's cyst )

Range of motion: Passive or active. If   patient has pain,

active should proceed passive. Expected ROM:

Flexion - 130° Extension - 0° (neutral) to 15° (hyperextension)

Special Manuevers: The knee is a commonly injured joint, due to

its lack of inherent bony stability, reliance on ligamentous structures for structural stability, and extreme forces it is subject to. There are a number of tests used to evaluate specific cartilaginous and ligamentous structures.

Presence of fluid: Ballotement: With knee extended, apply

downward pressure on the suprapatellar pouch with one hand, and with the other hand push the patella firmly down against the femur. A tapping or clicking will be felt if an effusion is present, and as you slowly release pressure, you will feel the patella "floating" upwards

Bulge sign: With knee extended, "milk" the medial aspect of the knee upward several times, then tap the lateral side of the knee, between the patella and the femoral condyle. Watch for a bulge on the medial knee as fluid returns to this region.

Mediolateral instability Purpose: evaluate the medial and collateral

ligaments. Technique:

Medial collateral ligament: with the knee flexed at 30° (or in neutral position), apply a valgus stress to the knee.

Lateral collateral ligament: with the knee flexed at 30° (or in neutral position), apply a varus stress to the knee.

Compare injured to normal side.

Positive finding - pain, with evidence of joint space widening in comparison to normal side. Pain alone suggests possible strain of ligament, without disruption of the fibers.

FOOT and ANKLE Inspection: Evaluate for symmetry, deformity,

discoloration. In patients with diabetes, assess for ulcers,

which can often lead to osteomyelitis (bone infection).  

It is often helpful to observe the foot and ankle during weight-bearing

Palpation: Evaluate for warmth, tenderness and

crepitus. Palpate the achilles tendon, medial and lateral malleoli

The anterior tibiofibular ligament, along with the posterior tibiofibular ligament and the transverse tibiofibular ligamen are the structures injured in high ankle sprains

.

Range of Motion: Expected ROM - neutral position of foot

and ankle is with foot at 90° to leg. Dorsiflexion - 20°     "Point your toes towards

nose" Ankle joint: Plantarflexion - 45   "Point toes

towards floor." Inversion (sole points "in") - 30° Eversion (sole points "out") - 20° Flex and extend toes.

Strength:Dorsiflexion - patient flexes up against your

hand. Plantarflexion - patient flexes down against

your hand

FABER Test (Hips/Sacroiliac Joints)FABER stands for Flexion, ABduction, and

External Rotation of the hip. This test is used to distinguish hip or sacroiliac

joint pathology from spine problems. Ask the patient to lie supine on the exam table. Place the foot of the effected side on the

opposite knee (this flexes, abducts, and externally rotates the hip).

Pain in the groin area indicates a problem with the hip and not the spine.

Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest.

Pain in the sacroiliac area indicates a problem with the sacroiliac joints.

FADIR TEST(Hips/Sacroiliac Joints)

FADIR stands for Flexion, ADduction, and Internal Rotation of the hip.

Schober test

10 cm 15 cm