SIT DOWN, STAND UP, BEND OVER
Larry Collins, MPAS, PA-C, ATC, DFAAPA
Assistant Professor, Physician Assistant ProgramAssistant Professor, Department of Orthopaedics & Sports MedicineUSF Health, Morsani College of Medicine
A Review of the
Musculoskeletal
Physical Examination
History
Questions must include:• Onset
• Mechanism of injury
• Quality of symptoms
• Persistence of symptoms
• Previous injuries
• Treatment to date
You cannot overemphasize the importance of a thorough
and detailed history. In most cases if you ask the
appropriate questions you will have a very good idea of
the diagnosis before you ever examine the patient.
• ADL’s
• Work activities
• Precipitating factors
• Alleviating factors
• Mechanical symptoms
• Training routines
Physical Examination
A typical routine might be:• Inspection
• Palpation
• R.O.M.
• Strength
• Stability
• Special tests
You should strive to perform a detailed and systematic
physical examination that follows a similar pattern each
time you evaluate a patient. Knowing appropriate anatomy
is paramount to properly evaluating your patients.
Don’t forget:• Joint above/below
• Neurological
• Vascular
• Referred pain
Anatomy - Vertebral
Column
• 7 Cervical
vertebrae
• 12 Thoracic
vertebrae
• 5 Lumbar
vertebrae
• Sacrum
Anatomy
• Vertebral column– Anterior Segment - weight bearing
• Vertebral Bodies
• Intervertebral Disc
– Posterior Segment - regulates motion and protects spinal cord and nerve roots
• Facet joints
• Pedicles
• Neural Foramina
• Spinous processes
• Muscular insertions
• Spinal Cord and nerve roots
Thoracic – horizontal, allowing rotation,
side-bending
Lumbar – vertical, allowing flexion/extension
Anatomy
Ligaments• Prevent extremes of
movement
• Anterior and
Posterior
Longitudinal
Ligaments
• Posterior Ligament
narrows near sacrum
Muscles• Superficial
– Erector Spinae
• Deep
– Multifidis
– Interspinalis
– Intertransversarii
• Psoas
• Iliacus
• Abdominals
Anatomy - Nerves
An unfortunate patient is diagnosed with having
a lateral disc herniation at the C56 and L45 levels.
• Which of the following dermatomes would you
expect to be affected?
a) C5 and L4
b) C6 and L5
c) C5 and L5
d) C6 and L4
Anatomy – Nerve Roots
Anatomy - Nerves
Cervical SpinePalpation• Spinous process
• Paravertebral muscles
Range of Motion• Flexion
• Extension
• Rotation
• Lateral bending
Sensation• C2
• C3
• C4
• C5
• C6
• C7
• C8
• T1
Strength• C5
• C6
• C7
• C8
• T1
Reflexes• C5
• C6
• C7
Special Tests• Spurling’s
• Valsalva
• Compression/Distraction
• Vertebral Artery Test
Motor
Reflexes
Sensory
Cervical
Lumbar SpinePalpation• Spinous process
• Paravertebral muscles
Range of Motion• Flexion
• Extension
• Rotation
• Lateral bending
Sensation• L1
• L2
• L3
• L4
• L5
• S1
• S2-5
Strength• T12 – L3
• L2 – L4
• L4
• L5
• S1
Reflexes• L4
• S1
• Babinski
Special Tests• Straight leg raise
• Gaenslen’s
• Pelvic ‘rock’
• One-leg hyperextension
• Patrick (Fabere)
• Hoover’s
• Kernig/ Brudzinkski
Examination Of Patient With Low Back Pain
Shoulder Anatomy
Shoulder AnatomyLigaments
Shoulder AnatomyMuscles
Shoulder Exam• Inspection
– Atrophy
– Scapular dyskinesis
• ROM
– Active vs. passive
• Strength
– Rotator cuff
• Special Tests
– Impingement
– Stability
©2003-2007 Dr. Lintner, MD. eMedWebs, Inc.® - TOS - Houston TX
Scapular Dyskinesis
Atrophy
ShoulderPalpation• Bones
– SC
– Clavicle
– AC
– Scapula
– Coracoid process
– Greater tubercle humerus
– Biceps groove
ShoulderRange of Motion - active/passive
• Shoulder shrug – symmetry
• Forward flexion – 180 degrees
• Extension – 50 degrees
• Abduction – 180 degrees
• Adduction – 50 degrees
• Internal rotation – 90 degrees
• External rotation – 90 degrees
Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med. 2002;30:136–151
Range of Motion
Shoulder
Strength
• Shoulder shrug - CN XI
• Forward flexion
• Abduction
• Internal/external rotation
Strength
• Supraspinatus – abduction
• Infraspinatus – external rotation
• Teres Minor – external rotation
• Subscapularis – internal rotation
Murrell GAC and Walton J. Clinical diagnosis of rotator cuff tears. The Lancet, 357 (2001): 769-770.
Empty can – supraspinatus External rotation – infraspinatus
Hawkins impingement test Apprehension test
Rotator Cuff Exam
Special Tests
Neer’s test• Supraspinatus
Impingement
Stability Exam• Sulcus sign
• Apprehension test
• Apprehension-relocation test
• Anterior/posterior drawer test
Generalized Laxity
SLAP Exam(Superior Labrum Anterior Posterior)
• Compression rotation test
• Obrien’s test
• Biceps tension test (speed test)
Nerve InjuriesSuprascapular Nerve
Nerve InjuriesLong Thoracic Nerve
Elbow
• Carrying Angle
• Surface Anatomy
– Medial epicondyle
– Lateral epicondyle
– Olecranon
– Ulnar groove
– Radial head
Elbow
• Special Tests
– Varus/Valgus Stress
– Lateral Epicondylitis
– Medial Epicondylitis
– Tinel's Sign
• ROM
– Flexion, extension,
pronation, supination
• Manual muscle
strength
Wrist, Hand and Fingers
• Surface Anatomy
– Ulnar Styloid
– Scaphoid
– Pisiform
– Hook of hamate
– MCP joints
– IP joints
Wrist, Hand and Fingers• Special Tests
– Pinch Grip
– Finkelstein Test
– Phalen's
– Tinel
– Allen's
• ROM
– Flexion, extension,
pronation, supination,
radial/ulnar deviation,
excursion (MC rotation)
• Manual Muscle Tests
Hip
• Injuries to hip & pelvis are often
frustrating
– Evaluation is difficult
• May involve variety of soft tissues and bones
• May be acute, sub-acute or chronic
• Large differential diagnosis
– Understand mechanism, natural history &
physical findings
– Accurate diagnosis is essential
Hip• Inspection
• Palpation
• ROM (passive/active)– Lumbar spine
– Hip• Flexion – 120
• Extension – 10
• Abduction – 40
• Adduction – 30
• Internal rotation – 50
• External rotation – 35
– Knee
• Strength
– Flexors
– Extensors
– Abductors
– Adductors
– Hamstrings
– Quadriceps
Hip
• Neurovascular– Sensation
– Pulses
– DTR
• Specific tests– Trendelenburg
– Ober test
– Patrick’s/Fabere test
– Gaenslen's test
– Compression/Distraction
– Hernia/testicular
Knee Anatomy
Knee• Key factors in making
diagnosis
– Mechanism of injury
– Onset of swelling
– Ability to bear weight
– Mechanical symptoms
– Instability
– Pre-existing conditions
• Inspection
– Lacerations/Contusions
– Alignment/Deformity
– Effusion/Hemarthrosis
– Gait
• Palpation
– Joint line pain
• Meniscus tear
– Palpable defects
• Quadriceps tendon,
Patella ligament, Patella
fracture
• Alignment
Knee
• ROM– Knee (0 - 140)
• Strength– Quadriceps
• Straight leg raise
• Extensor lag
– Hamstrings
• Neurovascular
Knee
Physical Examination
• Special tests– Meniscus
• Joint line pain
• Squat
• Steinmann
• McMurray
• Apley
• Thessaly
• Hip
Differential Diagnosis
Acute hemarthrosis– Peripheral meniscus tear
– ACL/PCL tear
– Dislocation
• Patella, knee
– Fractures
– Bleeding disorders
• Coumadin
• PVNS
vs.
Prepatellar Bursitis
Physical Examination
LigamentsInjured Ligament Key Test Secondary Test
ACL Lachman Pivot Shift
MCL Valgus laxity at 30 Valgus laxity at 0
PCL Posterior drawer at 90 Posterior sag at 90
LCL Varus laxity at 30 Varus laxity at 0
Posterolateral corner ER at 30 Posterior drawer at 30
Ligament Injuries - ACLExamination
– Hemarthrosis
– Contralateral side
– Anterior drawer
– Lachman
– Pivot Shift
• Difficult to reproduce
• Must be relaxed
Ligament Injuries – MCL
Examination
– Pain to palpation
– Little or no
effusion/hemarthrosis
– Valgus instability at
30 (@ 0 ACL)
– In child consider
growth plate injury
Ligament Injuries – PCL
Examination
– Hemarthrosis
– Posterior drawer
– Posterior sag
– Quadriceps active test
Extensor Mechanism Injuries• Commonly misdiagnosed
• Anatomy
– Quadriceps muscle quadriceps tendon patella patella tendon
• History– Patella tendon
• Younger patient
• Athletics
– Quadriceps tendon• Older patient
• Systemic disease
– Vigorous eccentric quadriceps contraction
– Unable to straighten leg
– Fluoroquinolones (Cipro, Levaquin, etc.)
Extensor Mechanism Injuries
• Examination
– Palpable defect
– Unable to do straight leg raise
• Extensor lag
– Hemarthrosis
• Imaging
– Radiographs
• Patella alta
• Peds – sleeve fracture, tibial tubercle avulsion
– MRI/Ultrasound
Extensor Mechanism Injuries
Anterior Knee Pain
• Multifaceted
– Mal-alignment
– Weakness (VMO, hip extensors)
– Decreased flexibility (quad, calf
– Neuromuscular adaptations (increased
reflex arc, decreased response times)
– Generalized joint laxity
Q – angle Pronated Foot
PFPS – Exam
• Observe and palpate tracking
through active flexion and
extension
• Crepitus most noticeable with
active motion
• Patellar compression may
increase pain
• Translate patella laterally in
extension and attempt to flex
knee
• Assess general laxity
Popliteal Cyst – Exam• Between
semimembranosus and medial head gastrocnemius
• Most visible and palpable with the knee extended (standing)
• Palpate for size, consistency, and tenderness
• Examine the knee for signs of derangement (i.e. meniscal tears)
Popliteal Cyst –
Differential Diagnosis
• Deep vein thrombosis (ultrasound)
• Exertional compartment syndrome
(compartment pressure measurement)
• Inflammatory arthritis (serologic tests)
• Medial gastrocnemius strain (H & P)
• Soft-tissue tumor (MRI)
• Superficial phlebitis (H & P, –US)
Ankle Anatomy
Ankle Anatomy
Ankle• Inspection
– Pronation, pes planus
• Palpation
– Medial malleolus, lateral malleolus, navicular, 5th
metatarsal
– ATFL, deltoid, peroneal, posterior tibialis
• ROM / Strength
– Dorsiflexion, plantarflexion, inversion, eversion, subtalar motion
With inversion sprains
the foot is forcefully
inverted or occurs when
the foot comes into
contact w/ uneven
surfaces
Inversion Injuries
Ankle Stability Tests• Anterior drawer test
– Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarily
– A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point
Talar tilt test• Performed to determine
extent of inversion or eversion injuries
• With foot at 90 degrees, calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments
• If the calcaneus is everted, the deltoid ligament is tested
Eversion Ankle Sprains
• Etiology
– Bony protection and
ligament strength
decreases likelihood of
injury
– Eversion force resulting
in damage to deltoid and
possibly fx of the fibula
– Deltoid can also be
impinged and contused
with inversion sprains Represent <5-10% of all ankle sprains
Syndesmosis Sprain‘High Ankle’ Sprain
• Mechanism of injury– External rotation force
– ‘Turf’ sports• Player prone and force applied to back of leg
• Fixed, planted foot with cutting or blow to leg
• Examination– Pain at distal syndesmosis
– Squeeze test
– Pain at syndesmosis with external rotation of foot
– Athlete walks on toes
• Diagnostic Studies– X-ray
– Stress test
– MRI
4 Ligaments
1
3
2
4
Ottawa Foot & Ankle RulesAn ankle x-ray is required only if there is any pain in malleolar zone and
any of these findings:•Bone tenderness at A
•Bone tenderness at B
•Inability to weight bear both immediately and in the ED
A foot x-ray is required if there is any pain in the midfoot zone and any of
these findings:•Bone tenderness at C
•Bone tenderness at D
•Inability to weight bear both immediately and in the ED
Questions?
Larry Collins, MPAS, PA-C, ATC, DFAAPA
Assistant Professor, Physician Assistant ProgramAssistant Professor, Department of Orthopaedics & Sports MedicineUSF Health, Morsani College of [email protected]
A Review of the Musculoskeletal
Physical Examination
Thank You