PCM: Musculoskeletal Exam

=Musculoskeletal Exam Skills=

General Order for any joint test

 * Inspection
 * Palpation
 * Range of motion
 * Muscle strength
 * Joint Specific Tests

Describe normal range of motion for the movements of the shoulder, elbow, hip, knee, ankle, and spine
Refers to active ROM unless noted otherwise.


 * Shoulder
 * Forward flexion (over head): 180°
 * Adduction (across body): 50°
 * External & internal rotation: 90°


 * Elbow
 * Supination & pronation (w/elbow flexed at 90°, thumb up): 90°
 * Full extension to flexion: 0° to 160°


 * Wrist
 * Flexion: 90°
 * Extension: 70°
 * Adduction (ulnar): 55°
 * Abduction (radial): 20°


 * Hip
 * Flexion (knee extended): 90°
 * Flexion (knee flexed): 120°
 * Abduction: 45°
 * Adduction: 30°
 * Internal rotation (flexed knee): 40°
 * External rotation (flexed knee): 45°


 * Knee
 * Hyperextension: 15°
 * Flexion (standing): 130°


 * Ankle (sitting):
 * Dorsiflexion: 20°
 * Plantarflexion: 45°
 * Inversion (passive): 30°
 * Eversion (passive): 20°


 * Spine
 * Flexion: 70°
 * Hyperextension: 30°
 * Lateral: 35°

Demonstrate an examination of any joint
Joint tenderness – Palpate joint to determine if there is any discomfort with pressure

Active ROM – ask patient to move particular joint through its complete range of motion, compare bilaterally

Passive ROM – move the same joint through same range of motion with patient relaxed, joint range should be about 5 degrees more with passive ROM, compare bilaterally

0 – No evidence of contractibility 1 – slight contraction, no movement 2 – full passive ROM (no gravity) 3 – full active ROM (with gravity) 4 – full ROM against some resistance 5 – full ROM against full resistance
 * Muscle strength testing – 0-5 Assessment Grades

Describe a complete knee exam
Evaluation for joint effusion, swelling, or deformity – Check for effusion and/swelling by inspection, and also by using the: Bulge sign – with knee extended, milk medial aspect of knee upward two or three times, then tap lateral patella (see Mosby’s pocket guide pg 221)
 * Ballottement procedure – (French, from ballotter, to toss - A palpatory technique for detecting or examining a floating object in the body) With knee extended, apply downward pressure on suprapatellar pouch with thumb and finger of one hand, then push patella sharply against femur with fingers of other hand. Suddenly release pressure on patella, while keeping fingers lightly on knee. Unexpected – tapping or clicking is sensed when patella is pushed against femur. Patella then floats out as if a fluid wave were pushing it.


 * Check for deformity by inspecting knees, popliteal spaces, in both the flexed and extended positions


 * Palpation for tenderness – self-explanatory

Passive – Test flexion and extension with patient relaxing muscles, should be 135 degrees flexion, and full extension
 * Range of motion (active and passive) – Active – ask patient to bend each knee, expected ROM 130 degrees, ask patient to straighten leg, full extension expected up to 15 degrees hyperextension


 * Muscle strength testing – Ask patient to maintain flexion and extension of knee, while you apply opposing force, expected bilaterally symmetric with full resistance (5) to opposition.


 * Joint specific tests – MCL/LCL tests – to check the medial collateral ligament, ask patient to extend knee to full extension. With one hand on medial knee, and the other on the lower leg near the ankle, pull the lower leg lateral to see if there is any discomfort on the medial side of the knee. For the lateral collateral ligament, do the same except push the lower leg medially to check for discomfort on the lateral side of the knee. Remember that the most common place of injury is the MCL, since it is weaker than the LCL, and is also attached to the medial meniscus.

Valgus stress test


 * Ligament stability – ACL test – Anterior drawer sign – ask patient, while supine, to flex knee 45 – 90 degrees, placing foot flat on table. Place hands on lower leg with thumbs on ridge of anterior tibia near tibial tuberosity. Pull tibia, sliding it forward on femur. Any movement beyond 5 mm is NOT expected. PCL test – same as above, except push tibia backward, sliding it on femur. Again, any movement beyond 5 mm is NOT expected.


 * Meniscus tear – McMurry Test – ask patient to lie supine and flex one knee completely with foot flat on table near buttocks. Maintain that flexion with your thumb and index finger on either side of the joint space while stabilizing knee. Hold heel with other hand, rotate foot and lower leg to lateral position. Return knee to full flexion; then repeat procedure rotating foot and lower leg to medial position. Not Expected – palpable or audible click or limited extension of knee with either lateral or medial movements.

Describe a complete shoulder exam

 * Inspection for joint effusion, swelling, or deformity – check for bilateral symmetry


 * Palpation for tenderness – palpate A/C joint, and acromial area for possible sub-acromial bursitis, palpate intertubercular groove for bicep tendonitis

First active, then passive for each of the above.
 * Range of motion (active and passive) –
 * 1) Ask patient to shrug shoulders (should be symmetric)
 * 2) Forward flexion - raise both arms forward and straight up overhead (should be 180 degrees)
 * 3) Hyperextension - extend and stretch both arms behind back (should be 50 degrees)
 * 4) Abduction - life both arms laterally and straight overhead (should be 180 degrees)
 * 5) Adduction - swing each arm across front of body (should be 50 degrees)
 * 6) Internal/medial rotation - place both arms behind hips, elbows out (should have 90 degrees rotation)
 * 7) External/lateral rotation - place both arms behind head, elbows out (should have 90 degrees rotation)


 * Muscle strength testing – test strength against resistance for each of the movements above (0-5 strength scale)


 * Joint specific tests – Hawkins Test (Impingement Sign) – Forward flex the shoulder to 90 degrees, flexing the elbow to 90 degrees, and then internally rotation the arm to its limit. Pain NOT expected; indicative of superspinatus tendon impingement.


 * Rotator cuff tendonitis – Neer test – Have the patient internally rotate and forward flex the arm at the shoulder, pressing the supraspinatus muscle against the anterior inferior acromion. Pain NOT expected.

Describe a complete spine exam including

 * Inspection for alignment – straight alignment cervical, thoracic, and lumbar spinal processes. Concave curves (excess curve = lordosis) for cervical and lumbar areas, and convex curves (excess curves = kyphosis) for thoracic and sacral areas.


 * Palpation for tenderness – palpate muscles - posterior neck, cervical/thoracic/lumbar spine, paravertebral muscles, and spinal processes.


 * Range of motion (active) – ask patient to:
 * 1) forward flex head, chin to chest (expected 45 degrees)
 * 2) hyperextend neck backward, chin to ceiling (expected 45 degrees)
 * 3) lateral bending neck to each side, ear to shoulder (40 degrees expected)
 * 4) rotation of head to each side, chin to shoulder (70 degrees expected)
 * 5) forward flexion at waist, trying to touch toes, check curvature from behind (expected 75-90 degrees flexion)
 * 6) hyperextend at waist as far as possible (expected 30 degree with reversal of lumbar curve)
 * 7) lateral bending of waist from side to side as far as possible (expected 35 degrees)
 * 8) rotation of waist, front to both sides, while you stabilize pelvis (expected 30 degrees)


 * Tests for nerve root compression – Straight Leg Raising Test – to test for lumbar nerve root irritation or disk herniation at L4, L5, or S1 – ask patient to raise leg with knee extended, and repeat on other side (Pain below knee NOT expected) – Braggard Stretch Test – Hold patient’s lower leg with knee extended, and raise it slowly until pain is felt. Lower leg slightly, briskly dorsiflex foot, and internally rotate the hip (Pain when let is raised less than 70 degrees is NOT expected, or any aggravation by dorsiflexion or internal rotation of hip.

= Demonstrate proficiency in Musculoskeletal Exam using DVD checklist.= a. Hip Flexion – grasp heel and move thigh up towards trunk b. Hip internal/external rotation – return thigh to perpendicular position while holding the shin parallel to table. Move the ankle medially and laterally. c. Flex and extend knee – noted above d. inspect the feet, toes, plantar surfaces, plantar flex and dorsiflex ankles (45 degrees plantar flexion, 20 degrees dorsiflexion expected) e. inspect palms and back of hands f. finger extension and flexion (spread the fingers and then make a fist) g. inspect fists and wrists while supinating and pronating the forearm. h. extend and flex the wrist (90 degrees flexion and 70 degrees hyperextension expected) i. flex and extend the elbow (160 degrees flexion from full extension expected) k. Shoulder flexion/extension/internal/external rotation (as noted above) l. Spinal flexion/extension/rotation/lateral bending (as noted above)

Vocabulary
•Arthralgia-pain in the joint •Arthritis-inflammation of the joint •Myalgia-pain in a muscle •Bursa-synovial lined sac •Bursitis-inflammation of a bursa •Synovitis-inflammation of a joint’s lining tissue •Varus-distal segment deviates medially •Valgus-distal segment deviates laterally

The musculoskeletal exam is important because:
 * 280 visits/1000 people
 * 20 million visits/year
 * Low back pain= $25 billion/year (1991)

Video Demonstrations
McMurray Test - Meniscus

Lachmann Test



University of Chicago Muscoloskeletal    