![Page 1: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/1.jpg)
Mastering Your Musculoskeletal Exam
Laurel Short, DNP, MSN, FNP-C
![Page 2: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/2.jpg)
Disclosure
I have no current affiliation or financial interest with any grantor or commercial interests that may have direct interest in the subject matter of the CE Program.
![Page 3: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/3.jpg)
Here’s what we’ll cover
• Review key components of a comprehensive musculoskeletal exam
• Describe an organized approach to exam techniques
• Identify history questions used to assess patients presenting with problems for the upper and lower extremity
• Identify functional anatomy with clinical significance
• Discuss pharmacologic and non-pharmacologic treatment options for common musculoskeletal conditions
![Page 4: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/4.jpg)
Preparing for a Comprehensive MSK
Workshop
So many topics to cover!
![Page 5: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/5.jpg)
![Page 6: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/6.jpg)
![Page 7: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/7.jpg)
MSK Exam and Primary Care
Musculoskeletal problems are in the top reasons for PCP visits
Over half of chronic medical conditions in the U.S. are related to
MSK diagnoses
![Page 8: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/8.jpg)
Components of MSK Exam
•Observation
• Palpation
• Active & Passive range of motion (ROM)
• Strength
• Reflexes and Sensation
•Gait
![Page 9: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/9.jpg)
Helpful Terms
•Abduction
•Adduction
•Proximal
•Distal
•Origin
• Insertion
•Volar
•Dorsal
•Valgus
•Varus
![Page 10: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/10.jpg)
Observation
• Skin appearance-breakdown, color, scar
• Swelling, edema, erythema
• Symmetry or asymmetry
• Posture
• Patient affect
![Page 11: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/11.jpg)
![Page 12: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/12.jpg)
![Page 13: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/13.jpg)
Palpation
Pressure level: light prior to firm
Identify location: tendon attachment, muscle, joint?
Type of pain provoked
Focal vs. radiating pain
![Page 14: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/14.jpg)
Range of Motion
![Page 15: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/15.jpg)
Range of Motion
• Passive vs. Active
• Types of joints
• Is range limited due to pain/guarding, weakness, or muscle/joint issue?
• Always check the unaffected side first for comparison
• Is there pain associated with the reduced range of motion?
![Page 16: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/16.jpg)
![Page 17: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/17.jpg)
American Spinal Injury Association Strength Grading
0 Total paralysis
1 Palpable or visible contraction
2 Active Movement
3 Active movement against gravity
4 Active movement against gravity with some degree of resistance
5 Active movement with full resistance (normal)
![Page 18: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/18.jpg)
Reflex Grading
0 No response
1+ Slight by definite response (may or may not be normal)
2+ Brisk response (normal)
3+ Very brisk (may or may not be normal)
4+ Repeating response/clonus (always abnormal)
![Page 19: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/19.jpg)
Dermatome Review!
![Page 20: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/20.jpg)
Type of Pain
Somatic Neurogenic
![Page 21: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/21.jpg)
Consistent Physical Exam!
ROM & Strength
Focused Area(s)
Special Tests
![Page 22: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/22.jpg)
Make friends with a physical therapist!
![Page 23: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/23.jpg)
Upper Limb
![Page 24: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/24.jpg)
Shoulder Anatomy
3 Bones
•scapula
•clavicle
•humerus
Rotator cuff muscles (SITS)
•Supraspinatus
•Infraspinatus
•Teres Minor
•Subscapularis
![Page 25: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/25.jpg)
Shoulder
• Very mobile joint with shallow glenoid fossa
• Stability depends on muscles and connective tissue
• Assess posture!
• Inspection, palpation, muscle testing, special tests
![Page 26: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/26.jpg)
Special Shoulder Tests
• Impingement signs: Neer, Hawkins, Empty Can
• Cross body adduction
• Apprehension sign
•Drop arm test
•Wall push-up
![Page 27: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/27.jpg)
Shoulder Diagnostic TestingWill the test change your treatment plan?
• X-ray
•MRI
• EMG (especially if numbness/tingling, weakness)
• http://www.abemexam.org/Verify-Certification/ABEM-Directory
• Consider visceral causes (e.g. cardiac, gallbladder, etc)
• Always assess for cervical spine symptoms
![Page 28: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/28.jpg)
![Page 29: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/29.jpg)
Shoulder Case Study
o History of intermittent impingement syndrome
o Patient enjoys cycling, fell while on a summer ride
o Began physical therapy ~1 month after symptoms began
o MRI completed due to lack of progress RTC tear
o Surgery completed in January, started post-op rehab when cleared by surgeon
![Page 30: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/30.jpg)
Common Shoulder Diagnoses
• Impingement syndrome- also referred to as separate diagnoses of bursitis, rotator cuff tendinosis
•Osteoarthritis (glenohumeral and/or acromioclavicular joint)
• Biceps tendinosis (tendon rupture less common)
• Rotator Cuff Tear (partial or complete)
![Page 31: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/31.jpg)
“Universal” Conservative Treatment
• NSAIDs- oral and/or topical
• Ice/HEAT
• Physical Therapy
• Home Exercises
• Cortisone injection
• Refer if significant weakness of RC or lack of progress with 2-3 months of rehab
![Page 32: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/32.jpg)
![Page 33: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/33.jpg)
Elbow
•Hinge joint
• Stable with firm bone support
• Joint articulations include the humerus, radius, and ulna
• Special tests: Resisted supination/pronation, resisted middle finger, Resisted wrist extension/flexion, Tinel at the ulnar groove
![Page 34: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/34.jpg)
Common Elbow Diagnoses
• Lateral-Tennis Elbow
• Tendonitis of extensor carpi radialis brevis
• extensor – supinator group
• Medial- Golf Elbow
• flexor – pronator group
• Bursitis
• Cubital tunnel syndrome (ulnar neuropathy)
• Fracture of radial head
• Osteoarthritis of elbow
• Radial tunnel syndrome (posterior interosseous nerve)
• Triceps tendinosis
![Page 35: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/35.jpg)
![Page 36: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/36.jpg)
![Page 37: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/37.jpg)
Wrist/Hand
• Bilateral comparison to look for asymmetry
• Inspect for atrophy, joint swelling, triggering of finger
• Special Tests: Tinel (wrist AND elbow), Phalen, Median nerve compression, Finkelstein, CMC grind
• Include exam of shoulder and elbow to determine etiology (e.g. cervical radiculopathy vs. carpal tunnel syndrome)
![Page 38: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/38.jpg)
Common Wrist/Hand Diagnoses
• Carpal tunnel syndrome
•Osteoarthritis (especially CMC joint)
•DeQuervain’s Tenosynovitis (“texting thumb”)
• Ice, thumb spica splint, injection, avoid aggravating activity
•Ganglion cyst
• Trigger Finger
•Dupuytren’s contracture
![Page 39: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/39.jpg)
• Snapping or triggering at the MCP (A1 pulley)
-Tender, swollen nodule at the A1 pulley
-Often history of repetitive grasping or pinching
-Triggering transmitted to DIP, locking• NSAIDs, injection, mixed
results with splinting• Often requires surgical
release if persistent
Trigger Finger
![Page 40: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/40.jpg)
Carpal Tunnel Syndrome Treatment
• Splinting (nighttime)
• Injection – can be diagnostic and used prior to surgery
• Surgical intervention for median nerve release• EMG can assess severity
• Refer patient for consult if symptoms are progressive and/or if exam shows weakness, sensory changes
![Page 41: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/41.jpg)
Thenar atrophy
Dupytren’s contracturePrayer sign
![Page 42: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/42.jpg)
“Universal” Conservative Treatment
• NSAIDs- oral and/or topical
• Ice/HEAT
• Physical Therapy and Home Exercises
• Cortisone injection
• PRP and newer therapies (?)
• Refer if significant weakness, neurologic findings, or lack of progress with 2-3 months of rehab
![Page 43: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/43.jpg)
Lower Limb
![Page 44: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/44.jpg)
Hip
Pelvic Girdle: 3 joints
Hip joint
Sacroiliac joint
Pubic symphysis
![Page 45: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/45.jpg)
![Page 46: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/46.jpg)
![Page 47: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/47.jpg)
Diagnosing Hip Pain:Often Challenging
• BACK PAIN
• GLUTEAL PAIN
• LATERAL HIP PAIN
• ANTERIOR HIP PAIN
• GROIN PAIN
• LEG PAIN OR TINGLING
• SCIATICA
• WEAKNESS
• GAIT DIFFICULTY
• SPASM
Common Chief Complaints
![Page 48: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/48.jpg)
Diagnostic TestingWill the test change your treatment plan?
• X-ray
•MRI
• EMG (especially if numbness/tingling, weakness)
• http://www.abemexam.org/Verify-Certification/ABEM-Directory
• Consider visceral causes
• Always assess for lumbar spine symptoms
![Page 49: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/49.jpg)
Observation example: Different approaches for hip replacement
incisions
![Page 50: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/50.jpg)
Hip
• Key point: Identify if pain is from hip joint, a surrounding area, or lumbar spine
• Assess anterior, lateral, and posterior hip
• Good lumbar spine exam
• Special tests: Stinchfield (resisted flexion with extended knee), Faber, Gaenslon, Ober
![Page 51: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/51.jpg)
Common Hip Diagnoses
• Osteoarthritis
• Trochanteric bursitis (Greater trochanteric pain syndrome)
• Hip flexor tendinosis, Psoas tendinosis
• Sacroiliac Joint Dysfunction/Pain
• Piriformis Syndrome
• Meralgia Paresthetica
• Lumbar Spine etiology
![Page 52: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/52.jpg)
Meralgia Paresthetica
![Page 53: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/53.jpg)
Trochanteric Pain Syndrome
Key Point: Often a secondary issue/symptom of gluteal weakness, gait
abnormality, and/or iliotibial band syndrome
![Page 54: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/54.jpg)
Piriformis Syndrome
![Page 55: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/55.jpg)
Trendelenburg Sign
Testing the STANDING leg
Dropping the opposite side indicates gluteal
weakness
+ For Right gluteal weakness
![Page 56: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/56.jpg)
![Page 57: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/57.jpg)
Knee
• Largest joint in the body
• Modified hinge joint
• Greatest range of motion is flexion
• More exposed joint, therefore higher risk of injury
• Is pain intra-articular or extra-articular?
• Meniscal tear testing (McMurray, Apley)
• Ligament stability testing:
Anterior and posterior cruciate ligaments (Anterior & Posterior Drawer, Lachman)
Medial and lateral collateral ligaments (Varus/Valgus test)
![Page 58: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/58.jpg)
Knee X-ray Views: Include Weight Bearing
& Sunrise View
![Page 59: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/59.jpg)
![Page 60: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/60.jpg)
Common Knee Diagnoses
• Osteoarthritis
• Effusion (secondary to trauma or OA)
• Tendinosis: Patellar, Quadriceps
• Pes Anserine Bursitis
• Iliotibial band syndrome
• Patellofemoral syndrome (aka “runner’s knee”)
• Ligament strain or tear
• Meniscal tear
![Page 61: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/61.jpg)
Managing knee pain can be integral for
patient quality of life!
![Page 62: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/62.jpg)
![Page 63: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/63.jpg)
Peroneal Neuropathy
![Page 64: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/64.jpg)
P.R.I.C.E. NSAID
Hinged Brace (OA)
Physical Therapy
Aspiration,
Injection
Knee Treatment
![Page 65: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/65.jpg)
Foot/Ankle
• Foot and ankle are focal points of support for the body to weight bear and ambulate
• Heel and toe pads act as shock absorbers for walking and activity
• Complex joints allow for balance on variable terrain
• Morton’s Neuroma: Squeeze test- usually between 3rd and 4th metatarsal heads
![Page 66: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/66.jpg)
Common Foot & Ankle Diagnoses
• Achilles Tendinosis (complete rupture less common)
• Gastroc strain
• Peroneal and Posterior Tibial tendinosis
• Ankle Sprain- ATF, CF, PTF
• Anterior Tibial Stress Syndrome (Shin splints)
• Plantar Fasciitis
• Morton’s Neuroma
• Metatarsalgia
• Hallux Valgus
• Pes Planus
![Page 67: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/67.jpg)
Foot and Ankle
• Include inspection of shoes
• Sensation
• Proprioception
• Arches
• Add visual of foot
Deformed Joint Pes Planus
Charcot Joint
![Page 68: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/68.jpg)
Injury may effect all 3! ATF, PTF, CFL (CFL least common)
![Page 69: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/69.jpg)
Plantar fasciitis
Tenderness over the medial tuberosity of the
calcaneus, tightness with dorsiflexion
Assess for gastric tightness, arches
![Page 70: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/70.jpg)
Metatarsalgia & Morton’s Neuroma
![Page 71: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/71.jpg)
Foot Fractures
May occur with low impact/no trauma
Assess for swelling
Key: Pain with percussion?
Think about osteoporosis
![Page 72: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/72.jpg)
“Universal” Conservative Treatment
• NSAIDs- oral and/or topical
• Ice/HEAT
• Physical Therapy and Home Exercises
• Cortisone injection
• PRP and newer therapies (?)
• Refer if significant weakness, neurologic findings, or lack of progress with 2-3 months of rehab
![Page 73: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/73.jpg)
SHOULDER EXAM: No atrophy. Normal strength of rotator cuff and shoulder girdle. Special tests are negative.
Range of Motion: Pain with Internal Rotation, External Rotation, Abduction. Painful arc of motion 80-120 degrees (supraspinatus/impingement).
Special Tests: Positive impingement testing.
ELBOW EXAM: No atrophy, no effusion, redness or warmth. ROM is pain-free and within functional limits, normal strength. Inspection/Palpation:
Tenderness at: lateral epicondyle.
Special Tests: Positive resisted middle finger extension, resisted supination.
WRIST/HAND EXAM: No swelling, redness or warmth. No skin breakdown or nail abnormalities. No palmar or dorsal atrophy. Range of motion is pain free and within functional limits, normal strength.
Inspection: thenar atrophy.
Special Tests: Positive Phalen's, Tinel's, Median nerve compression.
HIP EXAM: No atrophy.Inspection/Palpation:
Tenderness at: trochanteric bursa, piriformis, SI joint.
Special Tests: Negative FABER's, Stinchfield's (resisted hip flexion).
KNEE EXAM: No atrophy, no effusion, redness or warmth. ROM is pain-free and within functional limits, normal strength. Good ligamentous stability.
ANKLE/FOOT EXAM: No swelling, redness or warmth. No skin breakdown or gross deformity. No atrophy. Range of motion is pain free and within functional limits, normal strength. Special tests are negative.
![Page 74: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/74.jpg)
Thorough Exam PT/OT
Modify Activity NSAID/Ice/Injection
![Page 75: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/75.jpg)
Challenge Yourself, Practice These
Skills, &Achieve Confidence
with MSK Issues!
✓ Functional Anatomy
✓ Good Exam
✓ Partner with the Patient
✓ Reassess
![Page 76: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/76.jpg)
ReferencesAkhtar S, Bradley MJ, Quinton DN, Burke FD. Management and referral for trigger finger/thumb. BMJ 2005, 331:30-3.
Brown, K.,L. & Merrill, E. (2015). Musculoskeletal management matters: principles of assessment and triage for the nurse practitioner. The Journal for Nurse Practitioners, 11(10), 929-939. http://dx.doi.org/10.1016/j.nurpra.2015.08.036
Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Annual Incidence of Common Musculoskeletal Procedures and Treatment. http://www.aaos.org/research/stats/CommonProceduresTreatments-March2014.pdf Published March 2014. Accessed [09/01/2017].
Holm, G. (2015). Musculoskeletal assessment and treatment of the upper extremities (Powerpoint slides).
Hoppenfeld, S., & Hutton, R. (1976). Physical examination of the spine and extremities. New York: Appleton-Century-Crofts.
Musculoskeletal Medicine. PM&R Knowledge Now. Retrieved on 09/01/2017 from https://now.aapmr.org/category/musculoskeletal-medicine/
Sallis, R. (n.d.) Examination skills of the musculoskeletal system. American Academy of Family Physicians. Retrieved on 09/01/2017 from http://www.ucdenver.edu/academics/colleges/medicalschool/departments/familymed/education/fellowship/sportsmedfellow/Documents/MS%20exam.pdf
Sarwark, J. F., & Carl, R. L. (2010). Essentials of musculoskeletal care. Rosemont, IL: American Academy of Orthopaedic Surgeons.
Silva MB, Skare TL.(2012). Musuloskeletal disorders in diabetes mellitus. Rev Bras Rheumatoly, 52(4), 594-609.
![Page 77: Mastering Your Musculoskeletal Exam · Identify history questions used to assess patients presenting with problems for the upper and lower extremity • Identify functional anatomy](https://reader033.vdocument.in/reader033/viewer/2022042100/5e7d27c778fce80a62643d7e/html5/thumbnails/77.jpg)
Contact Info: Laurel Short, DNP, MSN, FNP-CKansas City Bone & Joint Clinic
@Laurelontherun