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Examination of musculoskeletal system it is important to keep the concept of function in mind. Note any gross abnormalities of mechanical function beginning with the initial introduction to the patient. Continue to observe for such problems throughout the interview and the examination.
On a screening examination of a patient who has no musculoskeletal complaints and in whom no gross abnormalities have been noted in the interview and general physical examination, it is adequate to inspect the extremities and trunk for observable abnormalities and to ask the patient to perform a complete active range of motion with each joint or set of joints.
If the patient presents complaints in the musculoskeletal system or if any abnormality has been observed, it is important to do a thorough musculoskeletal examination, not only to delineate the extent of gross abnormalities but also to look closely for subtle anomalies.
To perform an examination of the muscles, bones, and joints, use the classic techniques of inspection, palpation, and manipulation. Start by dividing the musculoskeletal system into functional parts. With practice the examiner will establish an order of approach, but for the beginner it is perhaps better to begin distally with the upper extremity, working proximally through the shoulder. Then, beginning with the temporomandibular joint, pass on to the cervical spine, the thoracic spine, the lumbar and sacral spine, and the sacroiliac joints. Finally, in the lower extremity, again begin distally with the foot and proceed proximally through the hip.
Use the opposite side for comparisons: it is easier to spot subtle differences as well as identify symmetrical problems. If there is any question, use your own anatomy as a control.
Glean the maximum information from observation. Concentrating on one area at a time, inspect the area for discoloration (e.g., ecchymoses, redness), soft tissue swelling, bony enlargement, wasting, and deformity (abnormal angulation, subluxation). While noting these changes, attempt to determine whether they are limited to the joint or whether they involve the surrounding structures (e.g., tendons, muscles, bursae).
The aim of examination in patients with a musculoskeletal swelling is to identify the exact location, size, anatomical extent, biological nature and the effects of the swelling and to plan its treatment. Method of treatment depends on the nature of swelling, its anatomic location, its relation to adjacent anatomic structures and its effects on the patient and adjacent tissues.
Swellings may either be due to normal variants (muscle hernias, anomalous muscle), normal tissue (rupture of long head of biceps), non-neoplastic (ganglions, bursa, infection, hematoma or cysts) or neoplastic. Neoplastic swellings may be benign or malignant. An important aim of examination is to rule out malignancy and to rule out any limb threatening or life threatening complications. Malignant swellings generally have a short duration, grow rapidly and show features of invasion either locally or distantly. Once the clinical examination is over; the examiner should be able to answer the following questions.
- Is there a swelling or is it just an anatomical variant?
- Is it a neoplastic or non-neoplastic swelling?
- If neoplastic; is it benign or malignant?
- If malignant; is there any local infiltration and is there any metastasis?
- What is the site of the swelling?
- What is the plane of the swelling?
- What is its relation to nearby anatomic structures?
- Are there any complications due to the swelling?
- What is the probable tissue diagnosis?
- How long since the swelling was found?
- How was it found?
It might be noticed accidently, detected by someone else or detected because of pain.
- What has happened to the swelling since it was detected?
It may change in size, shape, consistency or associated symptoms. So it is better to ask whether there was any change in the size, shape or symptoms after the swelling was first noted.
- Is the swelling enlarging?
- How rapidly is it enlarging?
- Is the any associated pain?
- Duration of pain?
- How pain started? It may start suddenly or gradually.
- How did it progress?
- Is the pain remaining the same, worsening, improving or fluctuating.
- Site of pain? This is the most valuable factor. The exact site should be noted. Ask the patient to point it out with a single finger. Also note the patient’s perception of the depth of pain; whether superficial or deep.
- Severity of pain? As the tolerance to pain vary between individuals, it is better to note the effect of pain on the patient. Ask for any interference to daily routine, recreational activities, work, sleep and need for analgesics.
- Character of pain?
- Any radiation?
- Is there rest pain?
- Is the pain interfering with sleep?
- Which came first; pain or swelling? Pain appears before the swelling in malignant swellings as rapid growth increases the tissue pressure.
- What are the aggravating factors and relieving factors?
- Any other swellings in the body?
- Is there any history of trauma?
- Is there any history of recent loss of weight and appetite?
- Is there any associated fever?
- Is there any numbness or weakness in the distal part of the limb?
- Is there any swelling of the distal part of the limb?
- Previous illnesses, operations, accidents and hospital admissions.
- Hypertension, diabetes mellitus, coronary artery disease.
- Tuberculosis, bronchial asthma, allergies.
- Bleeding disorders.
- Sexually transmitted disease.
- Marital status.
- Sexual habits.
- Eating habits.
- Recreational habits.
- Smoking, drinking, substance abuse.
- Occupation. Occupational exposure to industrial toxins.
- Travel abroad.
- Family tree.
- Age and health status of close relatives and companions.
- Similar illness in the family.
- Cause of death of close relatives.
- Any drugs taken regularly; particularly steroids, antidiabetics, antihypertensives, antipsychotics, blood thinners, contraceptives.
- What was the treatment taken for the swelling so far?
- What all investigations were done?
Inspection of the limb.
Inspection of swelling.
The site of swelling should be noted in exact anatomic terms. It’s relation to adjacent joint or bony landmarks should be identified. Identify whether the swelling is at a joint, proximal or distal juxta-articular region or the middle of a limb segment. Identify which aspect of the limb it is located such as anterior, posterior, medial or lateral.
Remember that the swelling is three dimensional; it has a length, width and depth. Often the swelling size may be discernible only in 2 dimensions and the third dimension especially the depth may not be identifiable on inspection; then it should be clearly mentioned.
As a swelling is three dimensional, it cannot be round, square or oval. It may be described as hemispherical, spherical or ovoid.
Surface on inspection may be smooth, irregular or mixed. Irregular surface may be bosselated, lobulated or rough. Smooth surface on inspection is seen in deep seated swellings and fluid filled swellings such as bursa or ganglion.
5. Skin over the swelling.
It may be normal, inflamed, ulcerated, infected, adherent, infiltrated with peau de orange appearance or perforated by the tumor tissue.
Borders may be well defined or indistinct. In deep seated swellings, margins may be indistinct on inspection but may be clearly defined on palpation.
Swelling may be solitary or multiple. Multiple swellings may be either within the same anatomic region or in other anatomic regions. Multiple swellings may be identical or dissimilar.
Manipulation consists of different techniques to access the range of motion (ROM), strength, sensations, reflexes, and gait. The proper evaluation consists mainly of testing strength (evaluate individually the muscle capacity and integrity), range of motion (evaluate the joint independently, it’s restrictions, and hypo or hypermobility), reflex and sensory function (evaluate dermatomes, reflex and sensory function, to identify possibles correlations and dysfunctions between musculoskeletal and neural system), gait analysis (evaluate the integrated functions of locomotion), and trigger points (to evaluate myofascial pain, presence of trigger points and association with patient symptoms).
Range of Motion (ROM)
ROM could be either active or passive. An active ROM is patient-initiated, which can access not only joint mobility but also an intact musculoskeletal and nervous system. Passive ROM examination is by initiating manipulation of the joint. ROM depends on the type of joint, and also it is important to know whether ROM is limited due to pain or guarding, weakness, or muscle or joint disease. Comparing to the unaffected side is indispensable. The assessment of a range of motion needs to be quantified (to avoid subjectivity bias), and for this, the use of a goniometer is indispensable. There are two types of goniometers; the first one is to use the universal goniometer and manually scale the ROM.[rx] The second is to use the smartphone goniometric application. It has indications for greater precision metrics then the universal goniometer.[rx]
To evaluate strength, the Medical Research Council scale of muscle strength (MCR-scale) is commonly used that grades the strength into 0 to 5[rx]:
- 0 – No contraction
- 1 – Flicker or trace of contraction
- 2 – Full range of active movement, with gravity eliminated
- 3 – Active movement against gravity
- 4 – Active movement against gravity and resistance
- 5 – Normal power
The bias of this scale is subjectivity depending on the experience, sensibility, and judgment of the health care professional. To avoid this bias, it is suggested to use a dynamometer.[rx] Another way to evaluate the strength in more conditioned patients is by doing the 1RM (maximum load capacity for one repetition) strength test.[rx]
Reflexes and Sensory Examination
The neuropathy impairment score (NIS) is one of the most direct scales to evaluate the correlations between the nervous system and the musculoskeletal system. It is possible to enhance the NIS by adding the dermatomal knowledge to the sensation test.[rx] It scores the reflexes and sensation (touch-pressure, pin-prick, and vibration) as[rx]:
- 0 – Normal
- 1 – Decreased
- 2 – Absent
The most important human locomotion method is gait; it provides independence and allows functionality, being the basis of daily living activities. Clinical gait analysis is the evaluation and measurement of the biomechanical walking function, the relation between the upper body and the lower body, and the dislocation of the gravity center. The gait analysis can support and enhance clinical diagnosis, decision making, and patient clinical case follow-up.[rx]
Myofascial trigger points (MTrP) are common in individuals with musculoskeletal pain. A palpable taut band characterizes the trigger point with a hypersensitive spot in the muscle. There are active and latent trigger points; the difference between them is that the active trigger point causes spontaneous and referred pain when palpated, the latent trigger point causes local, and not spontaneous pain. The evaluation of the trigger points is based on the clinical exam, but the provider can use thermography and ultrasound images to avoid clinical misinterpretations and clarify the diagnosis. The clinical palpation exam should identify the following criteria:
- Palpable taut band in skeletal muscle
- Hypersensitive tender spot within the taut band
- Reproduction of referred pain in response to MTrP compression
|Type of the gait||Physical findings and observations||Possible cause|
|Antalgic gait||Short stance phase of the affected side Decrease of the swing phase of the normal side||Pain on weight bearing could be any reason from Back pathology to toe problem, e.g., degenerative hip joint|
|Ataxic (stamping) gait||Unsteady and uncoordinated walk with a wide base||Cerebral cause Tabes dorsalis|
|Equinus (tiptoes) gait||Walking on tiptoes||Weak dorsiflexion and/or plantar contractures|
|Equinovarous gait||Walking on the out border of the foot||CETV|
|Hemiplegic (circumductory) gait||Moving the whole leg in a half circle path||Spastic muscle|
|Rocking horse (gluteus maximum) gait||The body shift backward at heel strike then move forward||Weak or hypotonic gluteus maximum|
|Quadriceps gait||The body leans forward with hyperextension of the knee in the affected side||Radiculopathy or spinal cord pathology|
|Scissoring gait||One leg crosses over the other||Bilateral spastic adductors|
|Short leg (Equinus) gait (more than 3 cm)||Minimum: Dropping the pelvis on the affected side Moderate: Walks on forefoot of the short limb Severe: Combination of both||Leg length discrepancy|
|Steppage gait (high stepping – slapping – foot drop)||No heel strike The foot lands on the floor with a sound like a slap||Foot drop Polio Tibialis anterior dysfunction|
|Trendelenburg (lurching) gait||Trunk deviation towards the normal side When the foot of the affected side leaves the floor, the pelvis on this side drops||Weak gluteus medius|
|Waddling gait||Lateral deviation of the trunk with an exaggerated elevation of the hip||Muscular dystrophy|
|Name of the test||Purpose of the test||Manoeuvre|
|Silfverskiold test||Differentiate between a tight gastrocnemius and a tight soleus muscle||The leg hangs loosely off the table – knee flexed Dorsiflex the ankle to the maximum Patient should then extend their knee Repeat the ankle dorsiflexion If there was more ankle dorsiflexion with the knee flexed then there is gastrocnemius tightness|
|Thompson’s test||Achilles’ tendon rupture||Patient lies is prone on the bed or kneel on a chair The examiner gently squeeze the gastrocsoleus muscle (calf) If the tendon is intact, then the foot passively plantar flexes when the calf is squeezed|
|Test for tarsal tunnel syndrome||Compressions of the posterior tibial nerve underneath the flexor retinaculum at the tarsal tunnel||Tap inferior to the inferior to the medial malleolus to produce Tinel’s sign|
|Test for flat foot||Differentiate between flexible vs rigid||Ask patient to stand on tiptoes If the medial arch forms and heel going into varus then it is flexible flat foot Beware of rupture tibialis posterior tendon or tarsal coalition|
|Test for stress fractures||Stress fractures||Place a tuning fork onto the painful area If it increases the pain, then it is positive Other test: One spot tenderness on palpation with finger|
|Babinski’s response||Upper motor neuron disease||Scratch the lateral border of the sole of the foot A positive response is dorsiflexion of the great toe|
|Oppenheim’s test||Upper motor neuron disease||Run a knuckle or fingernail up the anterior tibial surface A positive response is dorsiflexion of the great toe|
|Mulder’s test||Morton’s neuroma||A mass felt or audible Click is elicited by palpating (grasping) the forefoot (web space) with the index finger and thumb of the examiner|
|Muscle||Ankle position||Manoeuvre of the test|
|Tibialis Anterior||Maximum Dorsiflexion and inversion||Try to plantar flex the ankle with your hand and ask the patient to resist, use your second hand on the tendon to feel the contraction.|
|Tibialis posterior||Plantar flexion and inversion||Patient inverts the foot in full plantar flexion whilst the examiner pushes laterally against the medial border of the patient’s foot (in an attempt to evert the foot). The examiner needs to use second hand on the tendon to feel the contraction|
|Peroneal longus and peroneal brevis||Plantar flexion and eversion||Patient everts the foot in full plantar flexion and the examiner pushes medially against the lateral border of the patient’s foot (in an attempt to invert the foot)|
|Extensor hallucis longus||Neutral||Patient extends the great toe and the examiner try to planter flex it (Figure |
|Extensor digitorum longus||Neutral||Patient extends the lesser toes toe and the examiner try to planter flex it|
|Flexor hallucis longus and flexor digitorum longus||Neutral||Patient curls the toes downward and the examiner tries to dorsiflex them1|
|Name of the test||Purpose of the test||Maneuver|
|Anterior drawer test||Lateral ligament complex||The leg hangs loosely off the table The examiner hold the patient’s leg just above the ankle joint with one hand The examiner uses the other hand to hold the ankle in plantar flexion and try to gently to pull the ankle forward – anterior translation Look at the skin over the anterolateral dome of the talus to watch for anterior motion of the talus with this maneuver – sulcus sign|
|Inversion stress test||Stability of the lateral ankle ligaments (ATFL)||The knee is flexed 90 degree With one hand perform inversion stress by pushing the calcaneus and talus into inversion while holding the leg form the medial side with the other hand The test is positive when there is excessive inversion and/or pain|
|Calf compression or “squeeze” test||Syndesmotic injury||The leg hangs loosely off the table – knee flexed The examiner uses both hand to squeeze at midpoint of the tibia and fibula Pain caused by this maneuver indicates Syndesmotic injury|
|External rotation stress||Syndesmotic injury||The leg hangs loosely off the table – knee flexed and foot fully dorsiflexed The examiner uses one hand to stabilize the lower leg With the other hand they externally rotate the foot Pain caused by this maneuver indicates Syndesmotic injury|
|Coleman block test||To assess the flexibility of the hindfoot, i.e., whether the cavus foot is caused by the forefoot or the hindfoot||A block is placed under the lateral border of the patients foot The medial forefoot is allowed to hang over the side The first metatarsal will be able to drop below the level of the block, i.e., eliminate the contribution by the first ray With a flexible hindfoot, the heel will fall into valgus or neutral termed forefoot-driven hindfoot varus In case of rigid hindfoot or hindfoot-driven hindfoot varus the heel will remain in varus, and no correction will be happen|
|Semmes-weinstein monofilament test||To assess the degree of sensory deficit||Pressure testing using a 10 g Semmes-Weinstein mono- filament. Especially useful in diabetic charcot feet|