Musculoskeletal Exam

last written: Oct 2009, David LaPierre and Susan Tyler

 

 

Standard techniques of history and physical exam are useful for exploring musculoskeletal concerns, and while each joint is unique there are also aspects of the physical exam common to them all.

 

Inspection:

  • swelling
  • redness
  • atrophy
  • deformity
  • scars
  • nodules
  • bruising

Palpation

  • bony landmarks
  • soft tissue
  • joints: warmth, tenderness, swelling

Range of Motion

  • active before passive

Special Tests

 

Musculoskeletal injuries or conditions fall into a few broad categories. Common signs and symptoms for each include:

mechanical/degenerative: pain worse at end of day, better with rest/worse with increased use (also are ligamentous or meniscal sx: instability, locking, clicking, joint giving away suddenly).

inflammatory: pain, erythema, warmth, swelling, AM stiffness for greater than 30 mins.

neoplastic/infectious: weakness, fatigue, anorexia, wt loss, fevers/chills/night sweats, night pain, constant pain
neurological: paresthesias (numbness, tingling), bowel/bladder problems, weakness, headache

 

 

Approach

Articular or soft tissue?

inflammatory or non-inflammatiory

acute or chronic?

what joints involved?

extra-articular features

findings of synovitis on exam (if considering inflammatory)

labs, imaging

 

Pediatric examination

Be respectful of age, gender, and physical/cognitive capabilities

Look at the patient's face when examining

look at people's whole body when they're walking

 

Look, feel, move

 

 

 

History

  • history of presenting complaint
  • past medical history
  • medications
  • social history
  • family history

History of Presenting Complaint

 

CHLORIDE FPP

Character- What is the pain like?

Location- Where does it start? Ask specifically.

  • joint distribution

Onset- When and how did it come on? (acute vs. gradual/insidious)

Radiation- Does the pain move/travel anywhere? Deep pain can be poorly localized.

Intensity- Scale of 1 to 10; effect on ADL and IADLs. Is it getting better, worse, the same?

Duration- How long as it been there?

  • Pattern: intermittent, migratory, or additive

Events associated

  • Falls (frail elderly!)
  • morning stiffness/swelling/redness (less or more than ½ hr helps differentiate inflammatory vs mechanical arthritides)
  • joint clicking or locking (think meniscal tears in the knee)
  • muscle pain/cramping
  • wasting
  • limitation of movement/weakness
  • numbness/tingling (neurological sequelae)
  • fevers/chills/night sweats/wt loss
  • trauma (always describe how injury happened!)
  • job vs sports vs repetitive movements?

Frequency- New vs recurrent pain (intermittent vs. constant)

Palliative factors- What makes the pain better? (rest/activity/pain meds/heat or cold?)

Provocative factors- As above, but what makes pain worse?

PMHx

  • arthritis
  • gout
  • OA
  • osteoporosis
  • connective tissue diseases
  • past injuries or surgeries

past infections: strep throat, Parvovirus, gonorrhea

Medications

Ask about

NSAIDs, Tylenol, narcotics, ASA, steroids, immunosuppressants

Minocycline can lead to SLE exacerbations

Allergies

Social History

occupation

hobbies

smoking

EtOH

IVDU

sex hx

mobility aid use (very important for elderly population)

 

Family history

arthritis, OA, osteoporosis, connective tissue disease

 

 

 


Physical Exam

Always compare the joint in question with the one above and the one below, as well as left to right.

A good way to remember approach: look, feel, move, function.

  • inspection
  • palpation
  • range of motion
  • power
  • gait
  • other
  • pediatric testing

Inspection

(SEADS)

S: Swelling

E: Erythema, ecchymosis

A: Atrophy/asymmetry (muscle bulk)

D: Deformity

S: Skin changes/scars/bruising


Also, gait, posture, position of comfort

Palpation

(TEST CA)

T: Tenderness

E: Effusion

S: Swelling (edema)

T: Temperature

C: Crepitus

A: Atrophy (muscle bulk)

Range of Motion

 

Range and quality of motion

Stability and gait

 

If the problem is articular, both active and passive causes pain. If para-articular, then passive ROM is much better than active. Muscle/tendon stretch can also do this.

Power

Test both active and passive ranges of motion. Muscle weakness can result from UMN, NMJ pathology, injury to peripheral nerve, muscle pathology.

 

Helpful hints for patient cooperation:

  • "let me take your arm" - move it
  • "now keep it there"

 

Power (MRC Scale)

  • 5: Normal
  • 4: Completely moves body part against gravity and with some resistance (not full strength)
  • 3: Completely moves body part against gravity, but not at all against resistance
  • 2: Moves body part with gravity eliminated (partial movement)
  • 1: Flicker, trace of movement without gross joint motion
  • 0: Nada

 

 

Gait

walking normally, heel-to-toe, heels only, toes only. Important to look for Trendelenburg gait, high stepping, foot drop, antalgic gait

 

Special Tests (specific for each joint)

Neurological Testing (DTRs, sensation) (specific for each joint)

Neurovascular ax:distal pulses, cap refill, skin color, Tm, sensation, and always watch for a possible compartment syndrome!

Pediatric

maneuver for babies hip

put fingers over trochanter, then lift the

Ortolani's maneuver:stars out goes in

Barlow: starts in, goes out.

 

 

 

Resources and References

University of Sasketchewan physical exam resources