Musculoskeletal Exam
last written: Oct 2009, David LaPierre and Susan Tyler
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
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.
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