MSK Physical Exam

    Table of contents

    .

    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

    kneeAnatomy.jpg

     

    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  
      lachman.gif McMurray.gif  

    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
        neers.jpg hawkins.jpg
      • Sulcus sign (inferior apprehension) Spurling's Test (C-spine pain)
        sulcus sign.jpg spurlingsTest.jpg

    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
        • 1st 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?
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