Musculoskeletal Examination

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1 Musculoskeletal Examination Statement of Goals Know how to perform a complete musculoskeletal examination. Learning Objectives A. Describe the anatomy of the musculoskeletal system including the bony structures, muscle groups, and joints of the shoulders, elbow, wrists, hands, hips, knees, ankles and feet. B. Describe the techniques (inspection, palpation, and range of motion) used to evaluate the joints and the surrounding tissues/muscles. C. List and describe the following characteristics assessed during a musculoskeletal exam: range of motion signs of inflammation crepitus deformities condition of the surrounding tissues muscular strength symmetry of involvement D. Describe and demonstrate the examination (inspection, palpation and range of motion) of normal joints, including: hands wrists elbows shoulders ankles and feet knees hips E. Perform a complete shoulder examination including inspection, palpation and range of motion. Include evaluation of the following: acromioclavicular joint (including "crossover test") subacromial and subdeltoid bursae rotator cuff (including "drop arm" sign) bicipital groove and tendon articular capsule and synovial membrane of glenohumeral joint ability to document in medical record

2 F. Perform a complete knee examination including inspection, palpation and range of motion. Perform and explain the significance of the following tests: Lachman Test posterior drawer sign adduction stress test/varus stress test abduction stress test/valgus stress test bulge and balloon signs palpation of patellofemoral compartment McMurray Test G. List usual biological changes of the aging process and how they affect physical finding for the musculoskeletal exam. H. Know aspects of the musculoskeletal exam unique to infants and children. I. Document the musculoskeletal examination in the format of a medical record. Student s Preparation for the Unit Your Small Group Leader will ask you to dress appropriately to practice the musculoskeletal exam on your classmates, so you may want to bring your gym clothes to change into if you want to volunteer for this, but remember to dress professionally for the Geriatric Assessment with the Standardized Patients. Curriculum Comments Objective C: When evaluating a joint, it is helpful to assess the bulk and strength of the muscles that move that joint. For example, evaluating the bulk and strength of the quadriceps and hamstrings aids in the overall assessment of the knee. The evaluation of muscle bulk, tone and strength will be covered in more detail with the neurologic examination next semester. Objective F The McMurray test tests the integrity of the medial meniscus. It is specific (an abnormal test is highly predictive of a torn meniscus) but not very sensitive (many people with a torn meniscus will still have a normal McMurray test.) Note that an abnormal test requires both a palpable click and the patient s perception that you have reproduced the symptom.

3 Objective G In older adults muscles may atrophy with loss of both bulk and strength. This is particularly evident in the hands. Some decrease in muscle mass may be attributed to decreasing testosterone in men. Much is simply due to decreased activity. Evaluate range of motion, strength, and coordination of the shoulders and hands when assessing functional status. Objective H At birth, the normal newborn may have feet that appear deformed secondary to their position inside the uterus. Such a deformity usually resolves spontaneously. Infants are usually bow legged (genu varum) until about 18 months of age, when a knock kneed (genu valgum) growth pattern occurs. Children are knock kneed until 6 to 10 years of age. Most of these children do not require any intervention. All newborn infants should have their hips examined to ensure there are no signs of subluxation or dislocation. Know the Ortolani and Barlow tests. All children who can stand should be screened for scoliosis. Bates pp ; (Scoliosis) Objective I Examples of the documentation of the musculoskeletal examination can be found in Bates on pages 20 and 558. Your documentation will vary based on the patient's physical exam findings. Apply Your Skills Observe your preceptor performing aspects of a musculoskeletal examination. If possible, perform joint examinations under your preceptor s supervision and then independently. Examine as many different joints as possible. If possible, describe a musculoskeletal examination in your next patient encounter note.

4 Musculoskeletal Examination Checklist Appropriate draping for all aspects of the exam Appropriate guidance given to the patient throughout the exam Sitting Position Temporomandibular Joint (see Head and Neck Exam) Hands each DIP and each PIP squeeze hand compressing all MCPs each MCP make fist extend and spread fingers flexion, extension, abduction, adduction & opposition of the thumb Wrists flex and extend ulnar and radial deviation Elbows olecranon, epicondyles and grooves bend and straighten supinate and pronate Shoulders sternoclavicular joint acromioclavicular joint subacromial and subdeltoid area

5 "SITS" muscle insertions bicipital groove articular capsule and synovial membrane of glenohumeral joint arms above head hands behind neck, elbows out hands behind small of back Special Tests "crossover test" (acromioclavicular joint) "drop arm" sign (rotator cuff) abduction against resistance (supraspinatus) medial rotation against resistance (subscapularis) lateral rotation against resistance (infraspinatus, teres minor) adduction against resistance (thoracohumeral group) Supine Position Ankles/feet ankle joint Achilles tendon compress forefoot each metatarsophalangeal joint (optional) dorsiflex and plantarflex (tibiotalar) invert and evert at heel (subtalar) invert & evert forefoot (transverse tarsal) flex toes (metatarsophalangeal joints) Knees patellofemoral compartment tibiofemoral joint tibial tuberosity

6 flexion and extension Special Tests (if indicated) bulge and balloon signs Lachman (anterior cruciate ligament) posterior drawer (posterior cruciate ligament) adduction stress/varus stress ( lateral collateral ligament) abduction stress/valgus stress (medial collateral ligament) McMurray (medial meniscus) Hips hip joint ischial tuberosity greater trochanter flexion and extension internal and external rotation abduction and adduction Straight leg raise (done for back pain) Measure leg length (if indicated) Standing Position Legs/Feet Spine (See Back Exam) Gait (See Neuro Exam) for knee deformities popliteal fossa popliteal fossa (if indicated) for foot deformities

7 Study Questions: 1. Do you remember the basic anatomy of the musculoskeletal system? Types of joints? Names of joints and landmarks? 2. What three techniques are used to evaluate most joints? 3. What types of characteristics should a physician make note of when examining joints and surrounding tissues? 4. Can you demonstrate an exam of the areas in the checklist? 5. What additional evaluation would you include for a patient with a painful shoulder? What are the SITS muscles? How do you evaluate a rotator cuff? How do you check the biceps tendon? 6. What additional evaluation would you include for a patient with an injured knee? Which ligaments/menisci are you testing with the Lachman Posterior Drawer Test? Adduction (Varus) Stress Test? Abduction (Valgus) Stress Test? McMurray Test? What are the Ortolani and Barlow tests?

SMALL GROUP SESSION 16 January 8 th or 10 th Shoulder pain case/ Touch workshop/ Upper and Lower Extremity Examination

SMALL GROUP SESSION 16 January 8 th or 10 th Shoulder pain case/ Touch workshop/ Upper and Lower Extremity Examination Suggested Readings: Opatrny L. The Healing Touch. Ann Int Med 2002; 137:1003. http://www.annals.org/cgi/reprint/137/12/1003.pdf