MSK Physical Exam

Hip Exam

Inspection

GALS Screening

• Do you have any pain or stiffness in your muscles joints or back?
• Can you dress yourself completely without difficulty?
• Can you walk up down stairs without difficulty?
  • Gait
  • Observe shoulders, iliac crests, gluteal, popliteas, foot abnormalities varus/valgus
  • Observe: Antaglic gait (limp), Trendelenburg gait, heel strike, toe off, arm swings, alignment of back and shoulders.
  • Side: cervical lordosis, thoracic kyphosis, lumbar lordosis
  • Front: swelling deformity foot archers, forefoot deformity
  • Movement:
    • Lateral flecture - touch ear to shoulder
    • TM joints - move mouth side to side
    • Shoulder abduction + ext rotation: put hands behind head
    • Inspect wrists: swelling deformity
    • Fist, Power Grip (squeeze fingers)
    • Thumb to fingers for joint mobility
    • Squeeze MCP joints (inflammatory?)

Non-GALS Inspection

• Symmetry
• Alignment
• Swelling
• Muscle Atrophy
• Trendelenburg Test
• Antalgic gait/Trendelenberg gait

Supine:

• Symmetry, Alignment,

Landmark

• Greater trochanter
• ASIS
•  iliac crest,
• IT band
• Lymph nodes + pulse
• Leg Length (true Asis- Med malleolus, apparent, umbilicus – med malleolus)

Palpation

ROM

• Hip Flexion
• Hip Extension (active/passive)
• Hip External Rotation
• Hip Internal Rotation
• Hip Adduction (stabilize contralateral pelvis)
• Hip Abduction

Special Test

• Faber Test: malleolus on left knee, move knee out (Flection, abduction, external rotation)
• Flexion Contraction: Flex knee, see if other knee flexes, support contralateral side or put hand under back.

KNEE Exam

History

• Mechanical
  • Locking? (meniscal tear)
  • Pop during injury? (ligament injury)
  • Knee giving way? (patellar subluxation or ligamentous rupture)
• Effusion:
  • Rapid onset: within 2h? (hemarthrosis: rupture of ACL or fracture of tibial plateau, peripheral 1/3 of meniscus torn [vascular part])
  • Slow onset (consistent with meniscal injury or ligamentous sprain).
• Mechanism of injury
  • Acceleration + deceleration (stopping suddenly): ACL tear
  • Twisting component of injury: meniscus
  • Direct blow to planted knee: collateral ligament injury
  • Hyperextension: ACL or PCL

KNEE

Inspection

• Front/side/back
• SEADS
• Alignment: Varus/valgus deformity/genu recurvatum (hyperextension)
• Symmetry
• Swelling
• Color
• Atrophy
• GAIT:
  • full extension flexion of knee while walking
  • antalgic gait?

Palpate

• Temperature
• Check Effusion:
  • 1.  Bulge Sign
  • 2.  Ballottement Test: Push down on one side, feel fluid with other
  • 3.  Patellar Tap Test
  • 4.  Joint Line Tenderness (flexed knee)
• Range of Motion
  • Flex/Extend knee look for ROM (touch knee to buttocks)
  • Flex/Extend palpate crepitus
• Ligamentous Tests:
  • LCL: varus stress @ 30° flexion (also do in full extension: ACL and bone articulation stabilizes it in full ext.).
  • MCL: valgus stress @ 30° flexion (also full ext.)
  • ACL:
    • Drawer Test (recent data not favourable)
    • Lachman test: knee 30° flexion: one hand on femur, another on tibia, try ant. displacement of tibia
  • PCL
    • Posterior Drawer Test
• McMurray’s Tests:  (Pain or clicking/catching = positive)
  • MCL: flexed knee, int rotation, valgus strain ... then move to extended
  • LCL : flexed knee, ext rotated, varus strain...then move to extended.
• Images:

• Lachman Test	McMurray's Test

Back

• Pattern 1: disk problem, worse with flexion
• Pattern 2: stenosis/post joint, worse with extension
• Pattern 3: Sciatica – L4, L5, S1, S2, leg dominant affected by back movement
• Pattern 4: Neurogenic Claudication – leg pain, worse with activity immediately better with rest (vascular >5min rest needed)
• Inspection (undrape upper body, females tie gown at neck)
  • Scars/masses/lesions
  • Deformities (kyphosis, scoliosis)
  • Posture
  • Symmetry
• Palpation:
  • Along the spine (swelling, bony/soft tissue abnormalities, masses, tender)
• ROM
  • 1.  Forward Flexion (“Bend forward touch your toes”)
  • 2.  Extension (“arch your back”)
  • 3.  Side flexions (“slide your hand down your leg”)
  • 4.  Rotation (“twist toward each side”) (w/o moving pelvis)
  • 5.  Chest Expansion
    • Tape measure around chest, take deep breath (full insp – rest)
  • 6.  Schober’s Test (ank. Spond., seronegative)
    • Mark midline 5cm below PSIS and 10cm above, ask to flex and measure length (5cm incr or more is normal)
  • 7.  Check neuro system of legs.
  • 8.  Straight leg raise – supine raise straight leg (pain at 30-60deg if radiculopathy)
  • 9.  Femoral stretch test - prone, bend knee to buttocks (pain = tight quads, irritated femoral nerve?)
  • Another way to approach it:
    • Inspect back
    • Palpate back
    • Check ROM
    • Chest expansion, schrober’s test
    • Sit down in chair
      • Ankle reflex
      • Dorsiflex + extend toes
    • Sit in bed:
      • Knee jerk, banbinski
    • Lie supine
      • Straight leg raise
      • ROM thigh
      • Dorsalis pedis (claudication can present)
      • Check abdo sometimes abdo pain can masquerade as back pain
    • Lie prone
      • Saddle sensation (S1, S2, S3)
      • Clench buttocks (S1)
      • Femoral stretch test

Shoulder

• Pain, weakness, ROM, function, radiating?
• Inspection:  (sitting on edge of bed or standing)
  • Skin (scars/masses/lesions)
  • Soft Tissue (swelling/asymmetry/atrophy)
  • Bone (deformity, asymmetry, winging of scapula - serratus anterior and trapezeus problem)
• Palpation: (watch face for pain)
  • Joints (both hands, symmetrically joints)
    • SC joint
    • Along clavicle
    • AC joint
    • GH joint
    • Scapula
    • Cervical spine
  • Extra-articular
    • Biceps groove, subdeltoid bursa, rotator cuff tendons
  • Crepitus (over GH joint), hand on shoulder,  circumduct the arm
  • Sensation (light touch over deltoids both sides..same? – axillary nerve)
• ROM
  • Neck ROM
    • Flexion “look down”
    • Extension “look up”
    • Rotation “turn head side to side”
    • Later flexion “ear to shoulder”
  • Shoulder ROM
    • Trace an arch focus on up/forward (forward flexion/Elevation) [can also test "drop arm test"]
    • Reverse arc and focus backwards (extension)
    • Raise arms from sides over the head (abduction)
    • Apley Scratch test (Adduction + internal rotation) reach up the back (normal ~T7)
    • Put hands on head, reach back with elbows (Abduction and External rot.)
  • Special tests (if pathology suspected)
    • Rotator cuff tear
      • Supraspinatus – shoulder abduction
        • "Drop arm test".  Abduct arm completely, and slowly adduct.  Deltoid helps until 90°, then if arms drop to sides = supraspinatus tear or dysfunction.
      • Infraspinatus + Teres Minor (ext rot) - bend elbow ask to ext. rotate against resistance
      • Subscapularis - hand on back, ask to push backwards against resistance OR pat the abdomen.  (NOTE: internal rotation is subscap + pectoralis)
      • Drop Arm (suprasp.+ deltoid) à abduct shoulder completely, ask to lower smoothly (if drops pos test)
    • Impingement tests
      • "empty can" abduct shoulders to 90deg thumbs down, examiner pushes down against resistance
      • Neer’s test: The arm is fully pronated and placed in forced flexion (Pinch tendons under coracoacromial arch)
      • Hawkin’s-Kenedy Test – 90° flexion, internally rotate (push down)…pain?
    • AC Joint disorder
      • AC joint stress – arm 90° frwd flexion, move arm across chest
    • Tests of shoulder instability
      • Anterior Apprehension – one hand on shoulder joint, other hand on wrist, arm 90° lat abducted and elbow bent 90° up.  Ext rotate arm and push forward shoulder to sublux.
      • Post Apprehension – fwd flex arm 90°, push on elbow post. While applying forward pressure to scapula
      • Inferior stability – stand arms down, grab below elbow and pull distally
  • Images:

  • Neers	Hawking-Kenedy

  • Sulcus sign (inferior apprehension)	Spurling's Test (C-spine pain)

Wrist/Hand

• Pain
• Numbness tingling (carpal tunnel?)
• Stiffness? Weakness?
• Inspection
• Inspect front/back of hand
• Nails (pitting, hemorrhages)
• Swelling contractures, atrophy
• Joints – Misalignments, deformity
  • Tuck sign – make fist and extend slowly (look for fluid on dorsum)
  • MCP
  • PIP
  • DIP
• Palpation
  • Joints (Joint line tenderness? Effusion? Bony sructures? Joint pain? Crepitus?)
    • Radial-Ulnar joint
    • Radial-Carpal joint
    • MCP joints
    • PIP and DIP joints
    • 1^st carpal metacarpal joint
  • Palm of hand
    • Compress palm between thumb and fingers feel tendons (thickening? Tenderness? Nodules?)
• Range of Motion
  • Supination
  • Pronation
  • Wrist flexion (check stress pain?)
  • Wrist extension (check stress pain?)
  • Ulnar deviation
  • Radial deviation
  • Fist, and then extend all joints
  • Thumb
• Carpal tunnel test
  • Tinnel’s test (Tap on median nerve in wrist, numbness/tingling positive)
  • Phelan’s test (Flex wrists against each other dorsal side in for 60s, numbness/tingling positive
• DeQuervain’s Disease test (Finklestein Test)
  • Make fist with thumb inside + ulnar deviation..pain?