DR. Müge Bıçakçıgil KalaycıYÜH. 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.

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? An increased joint space - 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.

  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.

  0 - No active movement   1 -   Muscle contraction, no movement   2 -  Full active ROM   with gravity eliminated   3 -   Full active ROM Movement against gravity   4 - Full active ROM against partial resistance   5 - Full active ROM overcome full resistance Reported, for example as "Strength in the upper

extremity was 5/5"

SPECIAL MANEUVERS Clinicians perform special maneuvers when

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

LookLook for any asymmetry of scapulae, posture, or muscle wasting.

FeelPalpate over the midpoint of each trapezius and the supraspinatus to identify tender spots.Palpate over the acromioclavicular joint line, glenohumeral joint line, and bicipital groove.

Move Actively elevate arms into air.Actively place hands behind head.Actively place hands behind back.Steady scapula and with the elbow at 90 degrees rotate internally and externally; then passively abduct, flex, and internally and externally rotate the shoulder.

TestsThere are several methods to establish if there is impingement

r

Adduction, extension and internal rotation. Abduction and external rotation.

External rotation

Internal rotation.

Flexion.

Elevation.

Extension.

Abduction.

Adduction.

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)

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)

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

Look

Look for any swelling or deformity. Joint swelling is first apparent in the para-olecranon groove. The olecranon is a common site for bursitis and rheumatoid nodules.

Feel

Palpate over the para-olecranon groove for synovial swelling or tenderness. Palpate over the medial and lateral epicondyles for tenderness.Assess the laxity of the skin if considering hypermobility.

MovePassively extend and flex the elbow and look for hyperextension.

Palpate over the medial and lateral epicondyles for tenderness.

Elbow flexion. Elbow extension

Assess for elbow hyperextensibility.

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

Look Look for any swelling or deformity.

Swelling over the dorsum is of the joint or extensor tendon sheath.

Look for squaring of the palm base because of swelling of the carpometacarpal joint seen in osteoarthritis. Typical deformities in established rheumatoid arthritis are volar subluxation and radial deviation at the wrist with dorsal subluxation of the ulnar styloid.

FeelPalpate over the joint line for tenderness or synovial swelling.

Move Passively flex and extend the wrist.

Assess for hypermobility by passively moving the thumb toward the volar aspect of the forearm with the wrist in full flexion.

Use resisted flexion, extension, or pronation if assessing epicondylitis at the elbow.

Stress

Assess stability of the inferior radioulnar joint by demonstrating movement with pressing down on the radial head—the piano key sign.

Wrist flexion. Wrist extension.

Wrist ulnar movement. Wrist radial movement.

Resisted active wrist extension to test for lateral epicondylitis.

Resisted active wrist flexion to test for medial epicondylitis.

LookLook for any swelling or deformity. Is the swelling specific to joints or tendons or is it diffuse?

Look for any associated clues. Much can be learned from the hand. Look for wasting of the small muscles; inspect the skin, nails, and nail beds.

Typical deformities in established rheumatoid arthritis are ulnar deviation of the fingers at the metacarpophalangeal joints, hyperextension at the proximal interphalangeal joint with flexion at the distal interphalangeal (swan-neck deformity) joint or flexion at the proximal interphalangeal joint with hyperextension at the distal interphalangeal joint (boutonniere deformity). A Z-deformity of the thumb can be seen in systemic lupus erythematosus.

Feel

Palpate over each joint line for tenderness or bony or synovial swelling. Squeezing across all the knuckles together can be used as a composite assessment for tenderness of the metacarpophalangeal joints.Palpate the tendon sheaths during movement to detect crepitus or tendon nodules. Feel the quality of the skin for induration, thickening, or laxity.

Move

Actively make a tight fist with palmar aspect uppermost to see if all fingers fully flex and estimate strength of grip by observing the blanching of the palmar surface of the hand on release of the fist.Actively make a firm pinch grip between the thumb and the fingers individually.Passively extend the fifth finger to assess for hypermobility.

Assess supination.

Assess pronation.

Actively make a fist. Release grip and observe palm for blanching.

Palpate the metacarpophalangeal joints.

Palpate the proximal interphalangeal joints.

Squeeze across the metacarpophalangeal joints.

Palpate the tendon sheaths.

Assess grip strength.

Assess pinch grip.

Assess for hypermobility of the thumb and wrist.

Assess hyperextensibility of fifth 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.

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.

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

• Observing the gait is an important part of assessing the lower limbs.

• Examination should be done with the person lying on a bench.

• Measure leg length if a pelvic tilt when standing suggests shortening or if there is a discrepancy in position of medial malleoli with straightened pelvis.

Assess leg length by relative position of medial malleoli with straightened pelvis.

Look

Observation of the person walking will have given some information about the hips. There may be wasting of the buttock or thigh muscles from disuse.

FeelPalpation should be used to clarify the origin of any symptoms. The “hip” is used to describe symptoms anywhere in the hindquarter.

Tenderness is usually related to tendinitis or bursitis.

MoveWith the person supine, actively and then passively flex the hip as far as possible with the knee in flexion looking for contralateral movement.

With the hip passively flexed to 90 degrees, rotate it internally and externally by holding the foot, supporting the thigh, and moving the lower leg inward and outward, careful to not inflict pain. Internal rotation is often affected first in disorders of the hip joint.

With the person lying supine with the leg fully extended, hold the contralateral anterior superior iliac spine to prevent movement of the pelvis and passively abduct and adduct the leg.

With the person lying prone or on the side, passively extend the straightened leg.

Hip flexion—active.

Hip flexion—passive, looking for contralateral movement.

Internal rotation.

External rotation.

Abduction.

Adduction.

Patrick's test-FABERFlexion, ABduction, and External Rotation of the hip.

FADIR test- Flexion-ADduction-Internal Rotation

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°

Look

Observation of the person walking will have given some information about the knees. There may be wasting of the thigh muscles from disuse. There may be instability. Look for any swelling and its exact site because it may relate to the joint or periarticular structures. Look for any deformity. Typical deformities are fixed flexion, valgus, or varus.

Feel

Palpate for tenderness or swelling and establish the affected structures. Palpate the joint line for tenderness. Assess for articular swelling and effusion by the bulge sign or patella tap .Palpate for a popliteal cyst.

Move

With the person supine, passively flex the knee as far as possible with the hip in flexion. If the hip is also abnormal, hang the leg over the side of the bench to examine flexion of the knee without hip flexion.With the person lying supine, fully extend the leg in an attempt to touch the back of the knee onto the bench. Assess passively if the knee will hyperextend.

StressAnterior and posterior stability should be tested to assess the cruciate ligaments.Medial and lateral stability should be tested to assess the collateral ligaments and for loss of joint space.

The bulge sign in the knee. The back of the hand gently pushes the fluid from one side of the knee to the other, filling out the “dimples” on either side of the patella. This is most helpful in detecting small knee effusions.

The patellar tap. One hand is used to cup the patella and compress the suprapatellar pouch, and the fingers of the other hand press down on the patella to feel for cross-fluctuation.

Knee flexion. Knee extension.

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

active should proceed passive. Expected ROM:

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

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.

Stress the cruciate ligaments. (anterior and posterior drawer test)

Stress the collateral ligaments.

Look

Observe the feet when standing and during walking. Look for a normal longitudinal arch and during the gait cycle look for normal heel strike and take off from the forefoot. Look for any callosities beneath the metatarsal heads and for any swelling and redness of the toes.

Swelling of the metatarsophalangeal joints can separate the toes and daylight becomes visible between them. Look for any deformities.

Deformities include pes planus (flattening of the longitudinal arch), pronation of the foot, valgus deformity of the hindfoot (eversion of the subtalar joint, pes cavus (high longitudinal arch), talipes equinovarus, hallux valgus, subluxation of the metatarsophalangeal joints, and “claw,” “hammer,” and “mallet” deformities of the toes.

Feel

Symptoms may relate to the joint; the periarticular bone; the tendons, their sheaths and insertions; or bursae. Palpate for tenderness or swelling and establish the affected structures. Squeeze across the metatarsus, and if there is tenderness, examine the metatarsophalangeal joints individually.

Move Actively flex and extend the ankle.

Actively invert and supinate and then evert and pronate the foot.Passively deviate the heel medially (inversion) and laterally (eversion) by grasping the heel between the examiner's thumb and index finger of one hand and moving it while anchoring the lower leg with the other hand.

Passively rotate the forefoot on the hindfoot by grasping the forefoot between the examiner's thumb and fingers while anchoring the heel with the other hand to assess the midtarsal joint.

See if the patient is able to stand on the toes, which requires an intact posterior tibialis tendon.

Move

Metatarsal squeeze.

Ankle flexion.

Ankle extension.

Subtalar inversion.

Inversion and supination.Eversion and pronation.

Subtalar eversion.

Midtarsal rotation.

Assessing the first metatarsophalangeal joint.

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

Schober test

10 cm 15 cm