MUSCULOSKELETAL SYSTEM EXAMINATION NOTES

Musculoskeletal History:

• PC – Injury/Pain/Stiffness/Movement Limitation.
• HxPC:
  • Acute or Chronic problem?
  • Mech of injury – Utmost Importance!!
  • Problems experienced:
    • Pain Vs Tenderness. (+ Be mindful of referred pain)
      • NILDOCARF
    • Movement limitation
      • Pain:
        • Tendinopathy
        • Impingement
        • Sprain
        • Labral
      • Mechanical Block:
        • Stiffness/Creakiness + Time of day & Duration
        • Labral
        • Frozen shoulder
    • Instability (clicking/clunking)
    • Joint swelling
    • Night pain? (Lying on affected joint)
      • Eg. Rotator cuff
      • Eg. AC joint injury
      • Eg. Collateral Knee Ligaments
      • Eg. Bone Cancers
  • Associated Rheumatologic Symptoms:
    • Fever, Weakness, Faituge, Weight Loss, Conjunctivitis/Iritis.
  • Progression with time (Trending Better/worse/same)
• Pmh, Meds, Famhx, Sochx, Systems Review
• Red Flags? (Ie. Things that if you miss ➔ mortality/morbidity)
  • Open fractures
  • Neurovascular compromise
  • Cauda equina syndrome
  • Infections (Joints/Bones)
  • Acute Compartment Syndrome
  • Cancer
  • Temporal arteritis (high risk in pts with PMR – poly something rheumatica)
  • Serious/life-threatening conditions that present with sx mimicking msk pain (eg. MI)
• Yellow Flags – Conditions ‘masquerading’ as msk conditions:
  • Eg. Psychological – depression & back pain.

GALS Screen (Gait, Arms, Legs, Spine):

• Introduction, Wash Hands, Consent,
• Adequate Exposure!!! (Remove Shirt, Pants & Shoes)
• Gait – (Observe for Fluidity, Symmetry, Limp, Compensation, Foot Drop[L4,L5]):
  • Walk to the other side of the room, Turn around, and walk back to me.
• Arms:
  • Shoulder & Elbow:
    • Raise hands up to the ceiling, then down behind your head. Push your shoulders backwards.
    • Touch your fingers on your shoulders, and raise your elbows as high as you can.
    • Lock your elbows into your side, and turn your arms outward as far as you can. (Ext.Rotation)
    • Run your thumb up the middle of your back. (Internal Rotation)
    • Push your hands as far back behind you as you can. (Extension)
    • Touch your left thigh with your right hand (and Vice Versa) (Adduction)
    • Supinate & Pronate your Hands
  • Hands & Fingers:
    • Splay your fingers wide + Resist me squeezing them.
    • Fingers together + Resist me pulling them apart.
    • Grip my fingers as hard as you can + Assess Grip Strength
    • Make a fist
    • Touch each of your fingers with your thumb.
    • + Metacarpophalyngeal Sqeeze Test (For Tenderness)

• Legs:
  • 3x Half Squats (Patellofemoral Joint)
  • 1x Full Squat (Knee Joint Proper)
  • Ankle Eversion & Inversion
  • Dorsiflexion & Plantarflexion
  • Splay Toes & Scrunch Toes.
• Spine:
  • (Feet shoulder-width apart)
  • Observe for Lordosis, Kyphosis, Scholiosis.
  • Bend from Lumbar Spine and reach for your toes
  • Bend from Lumbar Spine and look at the ceiling
  • Bend Sideways & Slide your hand down your thigh
  • Neck Flexion (Chin on chest)
  • Neck Extension (look at ceiling)
  • Lateral Neck Flexion (Ear on Shoulder)
  • Neck Rotation (Look to the side)
• Reporting on a GALS Screening.
  • G – Normal/Abnormal + Comments on Findings
  • A – Normal/Abnormal + Comments on Findings
  • L– Normal/Abnormal + Comments on Findings
  • S– Normal/Abnormal + Comments on Findings
  • (Eg. Abnormal Arm (limited abduction of the shoulder to ?degrees))
• “Thankyou that concludes my examination”

Focused Joint Exam Algorithm (Shoulder or Knee):

• Look (Visual Inspection)
  • Symmetry? (Size, Shape, Position, Height)
  • Scars
  • Redness
  • Bruising
  • Lumps
  • Atrophy
  • Swelling
• Feel (Palpate Relevant Anatomy for Tenderness, Heat, Swelling, Crepitus):
  • Objective Findings:
    • Tenderness
  • Subjective Findings:
    • Warm (Inflammation, Trauma, Infection, Tumour)
    • Swelling (Effusion, Tumour)
    • Crepitus (Osteoarthritis, Tendinopathy, Fracture)
• Move (Active +/- Passive if Required):
  • Symmetry?
  • Active Movement in All Planes:
    • Range of Movement
    • Fluidity
    • Pain with Movement
  • If a pt can’t do something, ask them why? (Blockage/weakness/Neuro)
  • (Passive – Only for Movements that were Limited)
• Measure (Range of Movement):
  • Done at the same time as “Move”
  • Compare with opposite side (ballpark – doesn’t have to be objective)

– +/- Special Tests:

• • Shoulder:
    • Empy Can Test (Supraspinatus Tear)
    • Drop Arm Test (Supraspinatus Tear)
    • Hawkin’s Kennedy Test (Impingement)
    • Apprehension & Relocation Test (Instability)

• • Knee:
    • Lachman’s Test (Anterior Cruciate Ligament)
    • Thessaley Test (Meniscal Tear)
    • Apley’s Grind Test (Meniscal Tear)
    • Varus & Valgus Stress Tests (Collateral Ligament Tears)
    • Half Squats (For Patellofemoral Maltracking Syndrome)

Focused Shoulder Examination:

• 1. EXPOSE THE PATIENT FULLY!!
• Look (Visual Inspection)
  • Symmetry? (Size, Shape, Position, Height)
  • Scars
  • Redness, Bruising
  • Lumps, Swelling
  • Atrophy
• Feel (Palpate Relevant Anatomy for Tenderness, Heat, Swelling, Crepitus):
  • Palpate BOTH joints (Say you’d like to examine the other side)
  • Palpate Definite Anatomical Structures for Tenderness:
    • Sterno-clavicular Joint
    • Clavicle
    • Acromio-clavicular Joint
    • Gleno-humoral Joint Line
    • Spine of Scapula
    • Edges of the Scapula
  • Feel for Heat, Swelling, & Crepitus
  • Eg. “Non tender to firm palpation”
• Move (Active +/- Passive if Required):
  • Symmetry?
  • Active Movement in All Planes:
    • Range of Movement
    • Fluidity
    • Pain with Movement
  • If a pt can’t do something, ask them why? (Blockage/weakness/Neuro)
  • (Passive – Only for Movements that were Limited)
  • Eg. “Symmetrical and full ROM in all planes”
• Measure (Range of Movement):
  • Done at the same time as “Move”
  • Compare with opposite side (ballpark – doesn’t have to be objective)
  • “Limited active extension of l-elbow to 150deg”
• (Clinical Presentations Requiring Special Tests):
  • Tears – Eg. Supraspinatus Tear:
    • Special Tests:
      • “Drop Arm Test” – Passive abduction of pt’s arm ➔ let go and get them to lower arm as slow as possible. Arm Drops at around Parallel = Positive.
      • “Empty Can Test” – Passive abduction of Pt’s arm with full internal rotation (ie. Emptying can). Push down and get them to resist your movement. Pain &/or Weakness = Positive.
  • Impingement – Eg. Of Subacromial Contents:
    • Subacromial contents get squashed between the humoral head and the acromion. (eg. Supraspinitis, Subacromial Bursa)
    • Special test:
      • “Hawkins test” – Pain = Positive, No Pain = Negative
        • Passive Internal Rotation of Shoulder with elbow in 90deg and humerus at parallel to the ground.
  • Instability – Eg. Anterior Instability of Shoulder (ie. Post dislocation)
    • Eg. Dislocation/Post Dislocation/Stretch of Anterior Capsule of the Shoulder
    • Special Test:
      • “Apprehension & Relocation Test” – Apprehension (not pain) in 1. Less apprehension in 2. = Positive
        • 1. Patient lies on bed while you Abduct & Externally Rotate their arm to precipitate apprehension (Ie. High five position)
        • 2. Same thing, but with pressure on the anterior capsule. (This should be much more bearable for the patient.)

Focused Knee Examination:

• 1. EXPOSE THE PATIENT FULLY!!
• Look (Visual Inspection)
  • Symmetry? (Size, Shape, Position)
  • Scars
  • Redness, Bruising
  • Lumps, Swelling
  • Atrophy/Wasting
• Feel (Palpate Relevant Anatomy for Tenderness, Heat, Swelling, Crepitus):
  • Palpate BOTH Knees (Say you’d like to examine the other side)
  • Palpate Definite Anatomical Structures for Tenderness:
    • Quadriceps Tendon
    • Patella (+ Patella “Tap” test for Effusion)
    • Patella Tendon
    • Tibial Tuberosity
    • Joint Line
    • Collateral Ligament Attachments.
  • Feel for Heat, Swelling, & Crepitus
  • Eg. “Non tender to firm palpation”
• Move (Active +/- Passive if Required):
  • Symmetry?
  • 3x Half Squats (Patellofemoral Joint)
  • 1x Full Squat (Knee Joint Proper)
    • Range of Movement
    • Fluidity
    • Pain with Movement
  • If a pt can’t do something, ask them why? (Blockage/weakness/Neuro)
  • (Passive – Only for Movements that were Limited)
  • Eg. “Symmetrical and full ROM in all planes”
• Measure (Range of Movement):
  • Done at the same time as “Move”
  • Compare with opposite side (ballpark – doesn’t have to be objective)
  • “Limited active extension of l-elbow to 150deg”
• (Clinical Presentations Requiring Special Tests):
  • Acute Knee pain:
    • Cruciate Ligament Tear (“went to change direction, felt something pop, and was swollen within hours” = ACL)
      • Lachman’s Test – Pt supine, examiner’s knee under pt’s knee, stabilise femur with one hand, move tibia ant-&-post firmly. Positive if displacement > other side.
      • Anterior Drawer – (NB: Only really useful in an anaesthetised, paralysed pt. NB. A conscious pt will guard). Pt supine, knee bent to 90deg. Sit on pt’s foot. With 2 hands apply anterior force to the tibial head. Positive if Anterior Displacement is > than other side.
    • Meniscal Tear
      • **Thessaly Test (For Meniscal Tear) – Hold hands standing. Stand on 1 foot. Bend the weight-bearing leg 20^o. Do the Twist. Pain = Positive. (NB: Pt must point to source of pain – same place both times)
    • Collateral Ligament Sprains/Tears
      • Valgus & Varus Stress Tests –Pt supine, support knee from below, 30deg flexion & apply valgus & varus stresses. (Positive = Laxity/gaping.)
    • Patellofemoral Mal-Tracking Syndrome. Tracking of the Patella through it’s groove isn’t right; or groove isn’t straight; or vastus medialis isn’t working properly.

• • • • ➔ Pain with stairs/squatting
      • Half squats – Good indication of patella-femoral function

Thank You so Much. Happy Learning!!