musculoskeletal exam

10/26/2011 Clinical Skills Resource Centre, University of Liverpool, UK 1

Musculoskeletal

Examination


General principles of joint examination

Ensure that the joints to be examined are fully exposed and the patient is resting comfortably.

The routine for joint examination is:

Inspection

Palpation

Movement of joint(s)

Which joints to examine

If examination of all the joints is required, use a systematic approach. The patient may have to be in underwear only.

The GALS (Gait, arms legs and spine) locomotor screen developed by Doherty et al, is commonly used.

Alternatively if the patient presents with one affected joint – then examine that joint, and the joint above and below



Inspection of joint

Swellings

Skin changes

colour - redness - inflammation or infection

scars, previous surgery

rashes

Adjacent structures

muscles - wasting of muscles above and below a joint often

accompanies joint disease

compare to opposite side

Deformity misalignment of bones making up the joint

valgus - distal part displaced laterally

varus - distal part displaced medially


Palpation of joint

Feel for any swelling and its nature

hard suggests bone

spongy or boggy suggests synovial thickening

fluctuance suggests an effusion (fluid)

position - joint or periarticular (e.g. bursa)

Tenderness

assess joint margin, related ligaments, tendons

and adjacent bony structures


Palpation of joint

Temperature

compare with opposite side

if bilateral joint involvement compare tissues

above and below the joint for comparison

Joint crepitus

a palpable grating sensation appreciated by a

hand placed on the joint during movement

Tendon crepitus

a dry, friction rub palpable when tendons move


Joint movement

Range of joint movement

Active movement

movement undertaken by the patient alone

Passive movement

movement undertaken by the examiner

The spine should not be moved passively

If a full range of movement is demonstrated actively

then passive is not required. If movement is

impeded or painful passive movement can help

identify if the cause.

Other structures

Symptoms/signs may not always be caused

by the joint itself, but may be due to

problems with bone, soft tissues, muscles or

nerves.

A summary of the examination of muscles is

included on the following slide.

The assessment of nerves is covered in your

„Motor Power and Tone‟ study guide.



Examination of muscles

Evidence of wasting - compare sides (measure limb

circumferences)

muscle disuse

lower motor neurone lesions / joint disease

primary muscle disease

Abnormal bulk body builders / muscular dystrophies

Spontaneous contractions muscle spasms / abnormal movements / fasciculation

Palpate Tenderness (acute injury / some myopathies)


The neutral position

The range of most

movements are

described with the

neutral position in mind

In the neutral position

the limbs are extended

with the feet dorsiflexed

at 90 degrees and the

forearms in mid-

pronation


Main anatomical movements

Measurement

of joint

movement

can be

subjective and

can be more

reliably

measured by

use of a

goniometer



Adduction -

movement of the

part distal to the

joint towards the

midline

Abduction -

movement away

from the midline



Flexion - bending of joint

away from neutral

position

Extension - movement to

straighten a joint towards

the neutral position

Hyperextension - occurs

when the joint can be

extended beyond the

neutral position



Pronation - rotation

of the forearm so

that the palm faces

backwards

Supination -

rotation of the

forearm so that the

palm faces forwards


Examination of upper

limb joints


Inspection and palpation of the

hand and wrist joints

Inspect both hands and wrists as one

Inspect the front, back and sides of all joints

Compare sides

Palpate joints between finger and thumb

Support the joint whilst palpating

Taking the weight of the patients limb where

possible


Interphalangeal joints (IP‟s)

Palpate the interphalangeal joints individually between finger and thumb

DIP = distal interphalangeal joint

PIP = proximal interphalangeal


Metacarpo-phalangeal joints (MCP‟s)

Use a similar technique to palpate metacarpo-phalangeal joints

With patient palms facing down, support palms with

fingers

place thumbs on dorsal metacarpo-phalangeal surface and gently palpate


Finger movements

Ask the patient to make a fist (= flexion of distal

and proximal interphalangeal and metocarpophalangeal

joints)

Then ask the patient to open their hand (=extension of interphalangeal and metocarpophalangeal

joints)

Metacarpophalangeal and interphalangeal

joints flex to 90 degrees

Metacarpophalangeal joints may hyperextend

to approx. 10 degrees

Abduction, ask the patient to spread their

fingers apart. Adduction ask them to put them

back together.


Thumb flexion and extension

Movement of flexion

occurs across the palm

Extension takes the

thumb away from the

lateral aspect of the

palm

Occurs at the MCP

joint (Metacarpo-

phalangeal joint)


Thumb abduction and adduction

Abduction occurs at

90° to the palm

Adduction returns the

thumb to the palm

Occurs at CMC joint,

carpo-metacarpal joint


Thumb opposition

The thumb is used to

touch the base of the

little finger

This movement is

important for fine

manipulative skills


Wrist joints

With patient palms facing down,

support palmar aspect of wrist with fingers

place thumbs on dorsal wrist surface and gently palpate


Movement of the wrist

Palmar flexion

Dorsiflexion (extension)

Ulnar flexion

Radial flexion

Compare one wrist with the other


Wrist movement

Dorsiflexion - normal

approx. 75 degrees

Palmar flexion - normal

approx. 75 degrees

Ulnar flexion - normal

approx. 20 degrees

Radial flexion - normal

approx. 20 degrees


Movement of the forearm

Isolate the forearm by putting the arm against the body with the elbow bent

Pronation - rotates the arm through 90 degrees so that the palm faces downwards

Supination - rotates the forearm so that the palm faces upwards

Neutral positionSupinationPronation

Inspection and palpation of elbow

joints

Inspect the elbow joint

from the front, sides

and behind

With the elbow flexed

at around 70o palpate:

Epicondyles

Olecranon process and

grove on either side

Extensor surface of

ulna



Elbow movements

Flexion - is possible to

approx. 150 degrees

Extension - returns the joint to the

neutral position of 0 degrees

Inspection and palpation of the

shoulder


B

D

A

DB

F

C

EG

Inspect from the front, side

and back

Palpate

A. Sternoclavicular joint

B. Clavicle

C. Acromioclavicular joint

D. Acromial process

E. Head of humerus

F. Coracoid process

G. Greater tuberosisty of humerus

H. Spine of scapular (situated on

the back of the scapula)


Shoulder Movement

Flexion

Extension

Abduction

Adduction

Internal rotation

External rotation


Shoulder movements

Inspect the shoulder contour

Feel for tenderness and

swelling and crepitus during

motion

Flexion - 180 degrees

approximately 90 degrees is

attributable to the glenohumeral

joint

Extension - approx. 65

degrees


Abduction and Adduction

Adduction -

movement of the

distal part of the

joint towards the

midline

Abduction -

movement away

from the midline


Shoulder movements

Abduction consists of

two parts

The initial part is

glenohumeral joint

movement

The second part is

principally due to

scapular rotation1st

2nd


Shoulder movements

Internal rotation -involves

moving the flexed forearm

across the front of the body.

The movement is limited by the

chest wall

External rotation - the flexed

forearm is moved outwards

Alternatively, ask patient to put

hands together behind the head

(external) and then together

behind small of back (internal

rotation)


Examination of the spine


Inspection of the spine

Ask patient to undress down to their underwear

Inspect from the front, sides and behind ideally

with patient sitting and standing. In particular for:

Pigmentations, abnormal hair growth or unusual skin

creases

Alignment of the neck and shoulder symmetry

Kyphosis (thoracic spine curves giving a round

shouldered or hunched appearance)

Lordosis (lumber spine curves pushing abdomen out,

seen in late stages of pregnancy)

Scoliosis (thoracic and or lumbar spine curve laterally

forming a S or C shaped)

Palpation of the spine

Palpate the shoulder and

neck muscles for tenderness

Palpate each of the spinal

processes noting any

prominence or steps

Palpate the paraspinal

muscles for tenderness or

spasm (feels firmer)

Palpate the sacroiliac joints



Movements of the spine

Observe movements

Flexion

Extension

Lateral Flexion right and left

Lateral Rotation right and left


Cervical spine movements

Flexion - ask the

patient to touch their

chin to their chest -

normal about 45

degrees

Extension - ask the

patient to look upwards

and back - normal

about 45 degrees



Lateral flexion - ask the

patient to touch their

ears to their shoulders,

without raising the

shoulders. Normal

approx. 45 degrees



Rotation - ask the

patient to look back

over each shoulder in

turn - normal approx.

70 degrees


Thoracolumbar spine

Flexion - the patient is

asked to touch their toes

whilst keeping their knees

straight (ask the patient to

slide hands down the

anterior aspect of the

thighs)

Extension is assessed by

asking the patient to bend

back as far as possible


Thoracolumbar spine

Lateral flexion - ask the

patient to place a hand on

the outer thigh and to run

the hand down that side

without bending forwards

Rotation is assessed with

the patient seated on a low

stool (to fix the pelvis) and

viewed from above. The

patient is asked to turn to

one side as far as possible

and then the other


Examination of lower

limb joints

Inspection of the lower limb

The lower limbs bares the weight of the entire body.

It is common for patients to present with problems

with a joint when it is an entirely different joint which

is the route of the cause.

It is imperative that the lower limb is inspected as a

whole and compared to the other leg, looking for:

The position of the joints (the knee may externally rotate

when a hip joint is broken or diseased for example)

Pelvic tilting (can occur if the patient is trying to avoid

weight baring on the affected side)



Inspection and palpation of the hip

joint

The hip joint is not visible externally,

but inspect (ideally with patient

standing) for any obvious deformities

Palpation for joint tenderness is only

possible just distal to the midpoint of

the inguinal ligament also palpate

soft tissues around the area for

tenderness

Palpate bony prominences such as

anterior superior iliac spine and iliac

crest to ensure they are anatomically

where they should be


Movement of the Hip Joint

Flexion

Extension

Abduction

Adduction

Internal and external rotation


Hip movements - flexion and extension

Flexion - with the patient

lying supine and the knee

flexed passively flex the

hip joint - normal approx.

115 degrees

Extension - with the

patient lying prone,

support the knee and with

a hand on the buttock

passively extend the joint

(normal approx. 30

degrees)


Hip movements - abduction and adduction

Abduction -

normal approx. 45

degrees

Adduction -

judged by

carrying limb

immediately in

front of the other -

normal approx. 30

degrees


Hip movements - rotation

The person flexes the knee

and hip

The knee is held in one hand

and the foot in the other

External rotation is achieved

by passively moving the foot

medially (normal approx. 45

degrees)

Internal rotation is tested by

moving the foot laterally

(normal approx. 45 degrees)

Inspection and palpation of the knee

Inspect, comparing knees with patient supine

Swellings may be detected by a loss of the medial and

or lateral dimples suggestive of an effusion

Palpate for:

presence / absence of patella and its mobility

collateral ligaments

the joint line for tenderness

10/26/2011 lSkills Resource Centre, University of Liverpool, UK 51


Movements of knee and ligaments

Flexion

Extension

Hyperextension

Lateral and medial collateral ligaments

Anterior and posterior cruciate ligaments


Flexion: the knee is

flexed with one hand

resting on the patella -

normal approx. 135

degrees

Extension: the leg is

straightened to its fullest

extent - normal 5

degrees of

hyperextension

Knee movements


Testing knee ligaments

Anterior and posterior cruciate

ligaments are tested with the

knee in 90 degrees of flexion

The foot is fixed (examiner can

sit on it) and anterior and

posterior movements are

attempted (“Drawer sign”)

Medial and lateral ligaments are tested with the

knee in 20 degrees of flexion

With the upper leg supported, lateral and medial

movements are attempted - normal < 5 degrees

Inspection and palpation of the ankle

and foot

Inspect foot and ankles ideally with patient

standing and more carefully with the patient

supine

Look at the shoes for abnormal wear or stretching

Palpate for tenderness particularly over bony

prominences placing thumbs on sole of foot and

finger tips on dorsum

Assess the metatarsophalangeal joints by gently

squeezing between index finger and thumb


Palpate

Heel (calcaneus)

Lateral malleoli

Medial malleoli

Metatarsal heads

Metatarsophalangeal joints

Interphalangeal joints



Movement of the ankle and foot

Ankle

Dorsiflexion

Plantar flexion

Inversion

Eversion

Toes

Extension

Flexion

Abduction and adduction


Dorsiflexion and plantar flexion

Ask the person to bend

their foot down into

plantar flexion - normal

approx. 50 degrees

Ask the person to bend

the foot upwards into

dorsiflexion - normal

approx. 20 degrees

Plantar surface


Eversion and Inversion

Isolate the heel by

holding it firmly

Attempt inversion

and eversion by

twisting the mid-

foot medially and

laterally.


Movement of the Toes

Ask the patient to flex and extend the toes

Ask the patient to abduct and adduct the toes

Remember the big toe can usually move

independently of the others.


Trendelenburg test

The person is asked to

stand on one leg then the

other

Normally the non-weight

bearing limb is elevated

In joint or muscle disease

the non-weight bearing

side sags

„Negative‟ test is normal

Normal


Measurement of leg length

True leg length - measured

from anterior superior iliac

spine to medial malleolus

True leg length differences due

to hip disease on the shorter

side. 1-1.5cm difference

classed as normal, anything

greater would be abnormal

musculoskeletal exam

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