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:
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Palpation
Range of Motion
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
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
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
CHLORIDE FPP
Character- What is the pain like?
Location- Where does it start? Ask specifically.
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?
Events associated
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?
past infections: strep throat, Parvovirus, gonorrhea
Ask about
NSAIDs, Tylenol, narcotics, ASA, steroids, immunosuppressants
Minocycline can lead to SLE exacerbations
Allergies
occupation
hobbies
smoking
EtOH
IVDU
sex hx
mobility aid use (very important for elderly population)
arthritis, OA, osteoporosis, connective tissue disease
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.
(SEADS)
S: Swelling
E: Erythema, ecchymosis
A: Atrophy/asymmetry (muscle bulk)
D: Deformity
S: Skin changes/scars/bruising
Also, gait, posture, position of comfort
(TEST CA)
T: Tenderness
E: Effusion
S: Swelling (edema)
T: Temperature
C: Crepitus
A: Atrophy (muscle bulk)
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.
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:
Power (MRC Scale)
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!
maneuver for babies hip
put fingers over trochanter, then lift the
Ortolani's maneuver:stars out goes in
Barlow: starts in, goes out.
University of Sasketchewan physical exam resources