Musculoskeletal Exam

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

2. 10/26/2011 Clinical Skills Resource Centre, University of Liverpool, UK 2
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)

3. 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
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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

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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

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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

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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.

8. Other structures
Symptoms/signs may not always be caused
by the jointitself, 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.
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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)

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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

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Main anatomical movements
Measurement
of joint
movement
can be
subjective and
can be more
reliably
measured by
use of a
goniometer

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Main anatomical movements
Adduction -
movement of the
part distal to the
joint towards the
midline
Abduction -
movement away
from the midline

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Main anatomical movements
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

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Main anatomical movements
Pronation-rotation
of the forearm so
that the palm faces
backwards
Supination-
rotation of the
forearm so that the
palm faces forwards

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Examination of upper
limb joints

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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

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Interphalangeal joints (IP‟s)
Palpate the
interphalangeal
joints individually
between finger
and thumb
DIP = distal
interphalangeal
joint
PIP = proximal
interphalangeal

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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

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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.

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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)

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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

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Thumb opposition
The thumb is used to
touch the base of the
little finger
This movement is
important for fine
manipulative skills

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Wrist joints
With patient palms
facing down,
support palmar
aspect of wrist with
fingers
place thumbs on
dorsal wrist surface
and gently palpate

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Movement of the wrist
Palmar flexion
Dorsiflexion (extension)
Ulnar flexion
Radial flexion
Compare one wrist with the other

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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

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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 positionSupination
Pronation

27. Inspection and palpation of elbow
joints
Inspect the elbow joint
from the front, sides
and behind
With the elbow flexed
at around 70
o
palpate:
Epicondyles
Olecranon process and
grove on either side
Extensor surface of
ulna
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Elbow movements
Flexion-is possible to
approx. 150 degrees
Extension-returns the joint to the
neutral position of 0 degrees

29. Inspection and palpation of the
shoulder
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B
D
A
D
B
F
C
E
G
Inspect from the front, side
and back
Palpate
A.Sternoclavicularjoint
B.Clavicle
C.Acromioclavicularjoint
D.Acromialprocess
E.Head of humerus
F.Coracoidprocess
G.Greater tuberosistyof humerus
H.Spine of scapular (situated on
the back of the scapula)

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Shoulder Movement
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation

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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

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Abduction and Adduction
Adduction -
movement of the
distal part of the
joint towards the
midline
Abduction -
movement away
from the midline

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Shoulder movements
Abduction consists of
two parts
The initial part is
glenohumeral joint
movement
The second part is
principally due to
scapular rotation
1st
2nd

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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)

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Examination of the spine

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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)

37. 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
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Movements of the spine
Observe movements
Flexion
Extension
Lateral Flexion right and left
Lateral Rotation right and left

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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

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Cervical spine movements
Lateral flexion -ask the
patient to touch their
ears to their shoulders,
without raising the
shoulders. Normal
approx. 45 degrees

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Cervical spine movements
Rotation -ask the
patient to look back
over each shoulder in
turn -normal approx.
70 degrees

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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

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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
Rotationis 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

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Examination of lower
limb joints

45. 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)
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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

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Movement of the Hip Joint
Flexion
Extension
Abduction
Adduction
Internal and external rotation

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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)

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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

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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)

51. 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
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Movements of knee and ligaments
Flexion
Extension
Hyperextension
Lateral and medial collateral ligaments
Anterior and posterior cruciate ligaments

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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

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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

55. 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
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56. Palpate
Heel (calcaneus)
Lateral malleoli
Medial malleoli
Metatarsal heads
Metatarsophalangeal joints
Interphalangeal joints
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Movement of the ankle and foot
Ankle
Dorsiflexion
Plantar flexion
Inversion
Eversion
Toes
Extension
Flexion
Abduction and adduction

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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

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Eversion and Inversion
Isolate the heel by
holding it firmly
Attempt inversion
and eversion by
twisting the mid-
foot medially and
laterally.

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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.

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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

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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