Mge B ak gil MD. Yeditepe University Rheumatology Division.

General Considerations
y The patient should be undressed and gowned as

needed for this examination.

y The examination may not be appropriate

(e.g. performing ROM on a fractured leg).

y The musculoskeletal exam is all about anatomy. y Think of the underlying anatomy as you obtain the

history and examine the patient.

General Considerations
y The cardinal signs of musculoskeletal disease are:

pain, y redness (erythema), y swelling, y increased warmth, y deformity, and y loss of function.

General Considerations
y Always begin with ;
y inspection, y palpation and y range of motion,

regardless of the region you are examining.

General Considerations
y Specialized tests are often omitted unless a specific

abnormality is suspected.
y A complete evaluation will include a focused

neurologic exam of the effected area.

Vascular
Pulses
y Check the radial pulses on both sides. If the radial

pulse is absent or weak, check the brachial pulses.

y 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

y Check for the presence of edema (swelling) of the

feet and lower legs.

y Check for the presence of cyanosis (blue color) of

the feet or hands.

y Check for the presence of clubbing of the fingers.

Lymphatics

y Check for the presence of axillary lymph nodes. y Check for the presence of inguinal lymph nodes.

Inspection
y Look for scars, rashes, or other lesions. y Look for asymmetry, deformity, discoloration, or

atrophy.
y Always compare with the other side.

y Varus - distal extremity deviates medially from the

joint (bow-legged)
y Valgus - distal extremity deviates laterally from the

joint
y Often in a fracture or disclocation there is an obvious

deformity about the joint or bone.

y Swelling - suspect if normal landmarks about the joint

are not apparent, or the normal contour of the extremity is altered.

y Wasting - muscle wasting can result from neurologic

or muscular disease or injury. Bony landmarks often more prominent.

y 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.

y The examination of the patient begins when the

patient first enters the room. y How is the patient's posture? y Does the patient appear uncomfortable? y Are there any obvious joint deformities? y How is the patient's gait?

Palpation
y Examine each major joint and muscle group in

turn. y Identify any areas of tenderness.

y Identify any areas of deformity. y Always compare with the other side.

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

y Temperature y Use the back of your hand y Deformities y Palpate using your finger pads. y Is there a palpable deformity? y An irregular enlargement- due to
y y y y

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

y Crepitus y Grinding or rubbing sensation or sound. y Due to bony or cartilaginous structures moving across each other, or due to y tendons moving across each other. y Tenderness y Pain with palpation is usually an indicator of injury or inflammation. y The severity of the pain is usually a marker of the severity of the underlying condition.

y Fractures, dislocations and complete tears of ligaments

or tendons are usually very painful. y Acute inflammatory arthritis due to gout or infection is also exquisitely painful. y Mild sprains or contusions tend to be less painful. y Pain from chronic conditions such as rheumatoid arthritis or osteoarthritis, while sometimes severe, is usually less painful

Range of Motion
y Start by asking the patient to move through an active

range of motion (joints moved by patient).

y Proceed to passive range of motion (joints moved by

examiner) if active range of motion is abnormal.

y Active ROM
y Ask the patient to move each joint through a full

range of motion. y Note the degree and type (pain, weakness, etc.) of any limitations. y Note any increased range of motion or instability.

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

abnormalities are found. y If there is injury or pain, begin with normal side first. y Assess one joint at a time. y Observe the patient for pain, smoothness of motion, and any unusual movements.

y Passive ROM
y Ask the patient to relax and allow you to support

the extremity to be examined. y Gently move each joint through its full range of motion. y Note the degree and type (pain or mechanical) of any limitation. y If increased range of motion is detected, perform special tests for instability as appropriate. y Always compare with the other side.

y Palpation during passive (or active) ROM may reveal

crepitus. y Be sure to have the patient tell you if the ROM becomes painful. y Discrepancies between active and passive ROM may be due to weakness, pain or joint disorder.

STRENGTH TESTING
y If pain or injury, begin with normal side. y Isolate the joint about which you are testing strength. y Compare one side to other.

y SPECIAL MANEUVERS y Clinicians perform special maneuvers when they are

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

y Some common special maneuvers for the upper

extremity include: y Shoulder

y Impingement test y Drop test

y Hand and wrist

y Tinel and phalen's (for carpal tunnel)

y SHOULDER JOINT y It has an incredibly

wide range of motion, due to the complex structures of the shoulder girdle.

y PALPATION : y Palpate the acriomoclavicular joint, the acromion, the

scapular spine, and the bicipital groove. y Palpate the muscles about the shoulder.

y STRENGTH TESTING y Routinely test flexion, extension and abduction. y If indicated (pain, other complaints), check internal

and external rotation, and adduction.

y ACTIVE AND PASSIVE RANGE OF MOTION y Observe the patient abducting, flexing and extending

their shoulder. y Evaluate external rotation by having the patient place their hand behind the head. y Evaluate internal rotation by asking the person to touch his fingers at the back.

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

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

y Internal rotation (90)

SPECIAL MANEUVERS
y The Neer

impingement sign: y 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.

y The drop test: y 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

y A - Olecranon y B - Lateral Epicondyle

y INSPECTION y Inspect the elbows with the arm in a neutral, anatomic

position y Observe the carrying angle (the angle of the forearm on the upperarm). y PALPATION y Be able to palpate the lateral and medial epicondyles, and the olecranon process.

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

HAND AND WRIST

y Palmar

Hand y A - Distal wrist crease y B - Thenar eminence y CHypothenar eminence

y Dorsal Hand y A - Carpometacarpal y

y y y

joint BMetacarpophalangeal joints C - Proximal interphalangeal joints D - Distal interphalangeal joints E - Interphalangeal joint of thumb

y INSPECTION y At rest, the fingers will be slightly flexed and almost in

parallel. y Inspect the dorsum of the hand and wrist for swelling. y Inspect the palmar expect for thenar or hypthenar wasting. y Inspect each joint for swelling, discoloration and deformity.

y PALPATION y Palpate the radial and ulnar styloid, and the

radiocarpal and radioulnar joints. y Palpate the anatomic snuffbox. y Palpate the CMC joint, and the lateral and medial aspects of each MCP, PIP and DIP joint. y 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

y 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

y In rheumatoid arthritis the synovium of the joint is

inflamed, leading to tenderness and bogginess about the joint, in addition to warmth and redness. y Later in the course of the disease, the bony and ligamentous structures supporting the joint are damaged, and joint deformity results.

y 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.

y 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.

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

the wrist. y 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. y Have the patient oppose the thumb to the small finger

y Normal wrist range of motion y y y y

Extension - 70 degrees Flexion- 90 degrees Radial deviation (abduction) - 20 degrees Ulnar deviation (adduction) - 55 degrees

y Normal hand range of motion

MCP hyperextension - 30 degrees y MCP flexion - 90 degrees y PIP and DIP extension - 0 degrees y PIP and DIP flexion - 90 degrees y Oppostion - thumb should touch the 5 th MCP. y Passive ROM of the hand is frequently not performed.
y

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

finger, and try to pull your finger through. (median nerve) y Key grip strength - have patient grip a thin object (piece of paper or name tag works well) 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) y Finger abduction - have patient spread fingers out against resistance.(ulnar nerve)

Special TestsSnuffbox Tenderness (Scaphoid) y Identify the "anatomic snuffbox" between the extensor pollicis longus and brevis (extending the thumb makes these structures more prominent). y Press firmly straight down with your index finger or thumb. y Any tenderness in this area is highly suggestive of scaphoid fracture.

y Neurologic Tests y Phalen's Test (Median Nerve) y Ask the patient to press the backs of the hands together with the wrists fully flexed (backward praying). y Have the patient hold this position for 60 seconds and then comment on how the hands feel. y Pain, tingling, or other abnormal sensations in the thumb, index, or middle fingers strongly suggest carpal tunnel syndrome.

Neurologic Tests
y Tinel's Sign (Median Nerve) y Use your middle finger or a reflex hammer to tap over

the carpal tunnel. y Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome.

EXAMINATION OF SPINE

y Landmarks helpful in identifying

spinal levels include: y C7 and T1 - prominent spinous processes y T7 to T8 - inferior angle of scapula typically located at this level y L4 - an imaginary line across the tops of the iliac crests crosses L4

y PHYSICAL EXAMINATION y 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.

y 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.
y Normal Findings
y y y y

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.

y Unequal heights of any of these structures might

indicate scoliosis (congenital or acquired), leg-length discrepancy or spinal pathology. y Observe the patient from the side, identifying the normal cervical and lumbar concave curves, and the convex curves of the thoracic and sacral spine.

y Scoliosis - curvature of spine - congenital, developmental, acquired y 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

y

Pregnancy, muscle imbalance, obesity

Kyphosis - increased or "humback" curve in thoracic area

y

Osteoporosis, posture, congenital

y Palpation: y Palpate the spinous processes and the paraspinous

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

y Range of motion y 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).

y Cervical spine range of motion:

y Flexion - 45

"Touch chin to chest" y Extension - 55 "Tilt your head back as far as you can" y Lateral bending (right and left) - 40 "Try to touch your ear to your shoulder without moving your shoulder" y Rotation (right and left) - 70 "Turn your head towards your shoulder"

y Back range of motion:

y Flexion - 90 "Try to touch your toes without bending

your knees" y Extension - 30 "Lean back as far as you can" y Lateral bending (right and left) - 35 "Lean to your side" y Rotation (right and and left) - 30 "Twist to your side" y Examiner may need to stabilize patients pelvis to prevent rotation at the pelvis.

Left-right rotation Extension

Lateral bending

y Special Maneuvers: y Straight leg raise (SLR)

y Purpose: Used to evaluate back pain that radiates into

leg (sciatica). Places tension on sciatic nerve and inflamed nerve root y 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.
y Findings: Positive test is reproduction of sciatic-type pain

when hip is flexed between 30 and 70. Dorsiflexion of foot may aggravate pain.

y.

y LOWER EXTREMITIES

HIP
y Can assess entire lower extremity, observing the

hips, knees, ankles and feet. y Observe for symmetry, deformity and discoloration. y Can assess hip strength by watching patient rise from a chair.
y 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.

y Palpation:

y Palpate the iliac crest and greater trochanter.

y In the patient with hip pain, palpate the gluteal

musculature as well as the hip and thigh musculature. y In the patient with pelvic pain, palpate the symphysis pubis, ischial tuberosities, the posterior superior iliac crest.

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

should precede passive ROM.

y Flexion (with knee bent) - 120 y Flexion (with leg straight) - 90 y Extension - with patient lying on side, lying prone or

standing - 15 y Abduction - 45 y Adduction - 30 y Rotation - with knee flexed to 90 y Internal 40 y External 45

y KNEE y Inspection: y Evaluate for swelling, discoloration, deformity. Identify

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

y Palpation: y Evaluate for warmth, tenderness, crepitus and fluid. y Identify the tibial and femoral condyles in order to

palpate the tibiofemoral joint space medially and laterally. y Palpate the patella y Palpate the popliteal space (swelling may indicate Baker's cyst )

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

proceed passive. y Expected ROM:

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

y Presence of fluid: y 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

y Mediolateral instability
y Purpose: evaluate the medial and collateral ligaments. y Technique:
y

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.

y 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.

y FOOT and ANKLE y Inspection: y Evaluate for symmetry, deformity, discoloration. y In patients with diabetes, assess for ulcers, which can

often lead to osteomyelitis (bone infection). y It is often helpful to observe the foot and ankle during weight-bearing

y Palpation: y Evaluate for warmth, tenderness and crepitus. Palpate

the achilles tendon, medial and lateral malleoli

y.

y Range of Motion: y Expected ROM - neutral position of foot and ankle

is with foot at 90 to leg.

y Dorsiflexion - 20 y y y y

"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.

y Strength: y Dorsiflexion - patient flexes up against your hand. y Plantarflexion - patient flexes down against your hand

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

Rotation of the hip. y This test is used to distinguish hip or sacroiliac joint pathology from spine problems. y Ask the patient to lie supine on the exam table. y Place the foot of the effected side on the opposite knee (this flexes, abducts, and externally rotates the hip).

y Pain in the groin area indicates a problem with the hip

and not the spine. y Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest. y Pain in the sacroiliac area indicates a problem with the sacroiliac joints.

FADIR TEST
y (Hips/Sacroiliac Joints) y FADIR stands for Flexion, ADduction, and Internal

Rotation of the hip.

Schober test

10 cm

15 cm