MUSCULOSKELETAL EXAMINATION
Examination of the musculoskeletal (MS) system can be one of the most complex aspects of the
general physical exam. The extent of the examination must vary according to the problem(s)
being assessed and the time available to perform the exam. Levels of complexity of the exam can
be expressed as follows:
1.
Screening exam of MS system: performed on nearly all patients; detects abnormalities of
function not always apparent on history and may provide diagnostic clues to clinical
questions.
2.
Detailed examination of symptomatic region of the musculoskeletal system (e.g., the
patient complaining of knee pain).
3.
Examination of the patient with established systematic disorder affecting the
musculoskeletal system (e.g., rheumatoid arthritis) under treatment.
4.
Examination of the new patient with diffuse musculoskeletal complaints.
The “screening” exam can concentrate on inspection and observation of function. Pathology
involving the joints very rarely produces symptoms without effect on function. Thus, except in a
detailed exam, palpation can be dispensed with if function is normal.
Prior to specific examination of the musculoskeletal regions, the patient’s general appearance,
bodily proportions and ease of movement should be noted.
Required Equipment:
No additional equipment is required
Optional Equipment
Gonimeter (to measure angles)
Stethoscope
(to
auscultate
temporomandibular joint (TMJ))
Non-elastic
tape
measure
Examination Techniques:
Inspection – Visual examination, range of motion of joints (active and passive)
Palpation – Joint muscle examination, use finger tips and thumbs
Percussion – Use ulnar surface of fist for spine examination
Motor Examination – Neuromuscular testing for strength, sensation and reflexes.
(will be covered in neurology section of course)
Auscultation – Use stethoscope on TMJ and audible tendinous rubs
Special maneuvers – Techniques used to elicit otherwise occult findings
The following outline is one detailed approach for a fairly extensive musculoskeletal
examination:
Patient in gown seated on examination table. Examiner stands facing patient.
A. Hands
1. Inspect hands
Note: Swelling
Deformity
Redness
Muscular atrophy
Nodules Joint
symmetry
Ability to make fist (tests function)
2. Assess range of motion (active range of motion, done by the patient)
a. Instruct patient to flex and extend fingers of both hands; patient should attempt to
touch tips of fingers to palmar crease at level of metacarpophalangeal joints.
b. Have patient make fist with thumbs across the knuckles
3. Palpate the following interphalangeal joints
- Distal
- Proximal
- Metacarpophalangeal
Note: Swelling, bogginess (soft, water logged or swollen deeper tissues that hinder
function), tenderness, bony enlargement
B. Wrists
1. Inspect wrists
Note: Swelling
Deformity
Redness Muscular
atrophy
Nodules Joint
symmetry
2. Assess active range of motion (done by patient)
With arms extended palms turned down, instruct patient to:
a.
Flex wrist to 90
o
downward
b.
Extend wrist to 90
o
upward
With arms in neutral position (handshake position), instruct patient to:
a.
Supinate wrist to 90
o
b.
Pronate wrist to 90
o
Note: Supination and pronation are motions that originate from the elbow but are
demonstrated at the wrists.
3. Place thumb on dorsum of patient’s wrist with fingers beneath it. Palpate the following
joints:
- Metacarpocarpal
- Carporadial
- Carpoulnar
Note: Swelling
Synovial
Bogginess
Tenderness
4. Clinical correlate: Carpal tunnel syndrome – compression of the median nerve between
the flexor retinaculum and the deeper carpal bones. Neuropathic symptoms (pain and
paresthesias) are present along a median nerve distribution (affecting the thumb, index,
middle fingers and the lateral half of the ring finger).
Tinel’s sign – Hyperextend the wrist and tap the median nerve with your middle finger or
reflex hammer. A positive sign is pain or paresthesias radiating down the palm into the
index, middle, and lateral half of ring finger (median nerve distribution).
Phalen’s test – Flex the wrist to 90
o
and maintain it for at least 40-60 seconds. A positive
test would be pain or paresthesias in the median nerve distribution. Phalen’s test is more
sensitive than Tinel’s sign.
Median Nerve Compression test – The most accurate physical exam test for carpal tunnel
syndrome. Firmly compress the median nerve with your thumb at the flexor retinaculum
for about 40 seconds. A positive test would be pain or paresthesias in the median nerve
distribution. This test is also called the carpal compression test.
C. Elbows.
1. Assess active range of motion
a. Instruct patient to extend and flex elbow
b. With arms extended, have patient supinate and pronate each hand
2. With patient’s forearm supported and elbow flexed to about 70
o
palpate the following:
- Extensor surface of ulna
- Olecranon process
Note: Swelling
Nodules
- Groove on either side of olecranon process. Remember, the ulnar nerve runs through
the medial groove.
Note: Thickening
Swelling
Tenderness
3. Clinical correlate: ulnar nerve entrapment at ulnar groove leading to neuropathy and
distal muscle atrophy of hypothenar muscles (the digiti minimi muscles).
4. Press on the lateral epicondyles
Note: Tenderness
5. Clinical correlate: Tennis elbow or lateral epicondylitis – tenderness of extensor tendons
originating at the lateral epicondyle.
D. Shoulders and Environs
1. Inspect shoulders and shoulder girdle anteriorly
Note:
Swelling
Joint
symmetry
Deformity
Muscular
atrophy
2. Inspect scapula and related muscles posteriorly
3. Assess active range of motion
- Screen for shoulder abnormalities by having patient clasp hands behind head and
extend arms so that elbows are “up against the wall” parallel to coronal plane.
- With arms at sides, abduct arm to 90
o
(abduction)
- With scapular motion elevate arm to 180
o
(move arms to a vertical position near
head)
Note: Symmetry and rhythm of movement
With patient’s arm at side (0
o
)
a.
Flex shoulder forward to 180
o
b.
Flex shoulder backward to 60
o
(without scapular motion)
c.
Adduct shoulder to 30
o
d. Have patient place hands behind small of back (internal rotation to 90
o
)
f. Place hands behind neck with elbows out to side (external rotation to 90
o
)
4. Palpate the following:
- Acromioclavcular joint
- Greater tubercle of humerus
- Biceps groove
- Coracoid process
- Genohumeral joint
- Subdeltoid bursa
Note: Tenderness
Fluid
5. Clinical correlates: deltoid muscle atrophy and shoulder joint effusion. (see lecture slides)
6. Clinical Correlate: Hawkins impingement test for supraspinatus tendonosis. The
examiner gently but firmly, internally rotates the proximal humerus when the arm is
forward flexed to 90
o
and slightly adducted.
E. Head and Neck
1. Inspect Neck
Note: Deformities
Abnormal
posture
2. Assess active range of motion for cervical spine (head and neck)
Instruct patient to:
a. Touch chin to chest (flex neck) – Normal is 45
o
of flexion.
b. Touch chin to each shoulder (rotate neck) – Normal is 70
o
of rotation, each
side.
c. Touch ear to corresponding shoulder (lateral bending) – Normal is 40
o
of
lateral bending, each side.
d. Put head back (extend neck) – Normal is 45
o
of hyperextension of neck.
3. With index fingers, gently palpate the following joints:
a. Sternoclavicular
b. Manubriosternal
c. Costochondral
Note:
Fluid
Tenderness
Swelling
4. With finger pads, palpate the following structures:
a. Cervical spine
b. Paracervical muscles
c. Trapezius muscles
d. Rhomboids
Note: Tender nodules in muscles or specific tender areas.
5. Palpate temporomandibular joint (TMJ)
- Place first two fingers of each hand in front of tragus of ear and have patient open and
close mouth
- Instruct patient to open and close mouth; assess degree of maximal opening (patient
should be able to place 3 vertically-placed fingers in mouth).
- Also, with mouth open, mandible should move laterally to each side at least 1.5cm.
Note: Range
of
motion
Tenderness
Swelling
Crepitus
Pain
6. Ausculate TMJ, if crepitus suspected, while patient opens and closes mouth.
7. Spurling’s test or Vertex Compression test (for cervical radicular pain or paresthesia)
Forcibly press down vertically on top of the head to compress the cervical nerve
roots. Normally this is well tolerated. Avoid doing this test on elderly, frail
individuals or patients with serious spine disease or injury (also see k.4.)
Patient seated with legs hanging over table. Examiner sits in front of patient.
F. Feet
1. Inspect feet
Note: Swelling
Calluses
Deformity
Corns
Nodules Flat
feet
2. Have patient curl and extend toes, then “cup” the arch of the foot to screen for
abnormalities. This also assesses active range of motion. Note any deformity like claw
toe or hammer toe (see lecture slides).
3. Compress the forefoot between thumb and fingers at the level of the metatarsal
phalangeal joints. A painful interdigital neuroma (Morton’s neuroma) is usually found by
palpating between the 3
rd
and 4
th
metatarsal bones, using thumb and index finger.
4. With thumbs on sole of foot and fingers on top of foot, bilaterally palpate the following
joints and enthesis:
- Distal interphalangeal
- Proximal interphlangeal
- Metatarsophalangeal
- Origin of plantar fascia into calcaneus (plantar fasciitis leads to tenderness to
palpation at this site)
5. Bilaterally assess passive range of motion (done by examiner)
- Stabilize heel
- Rest heel in one hand and grip forefoot with other hand:
a. Invert foot
b. Evert foot
c. Flex toes on metatarsophalangeal joint
6. Palpation of the foot
- Palpate for any bony deformity
- Compress forefoot gently, then firmly
Note: Presence of metatarsal disease (tenderness)
G. Ankles
1. Inspect ankles
Note: Bogginess
Swelling
Nodules
2. To screen for abnormalities, have patient flex, extend, invert and evert the foot (active
range of motion).
3. Palpate anterior surface of ankle joint
Note: Bogginess
Swelling
Tenderness
4. Palpate Achilles (gastrocnemius) tendon assess for tendonitis
Note: Nodules
Tenderness (at insertion into calcaneus)
5. Assess passive range of motion (done by examiner)
With thumb on top of foot and four fingers underneath, grip foot
a. Dorsiflex the ankle
b. Plantar flex the ankle
Note: Subtibial
motion
To stabilize ankle, grip calcaneus and subtalar joint from behind with one hand and heel
with other hand:
a. Invert foot
b. Evert foot
Note: Subtalar
motion
Still stabalizing ankle:
c. supernate forefoot
d. pronate forefoot
Note: Transverse tarsal joint motion
Patient supine. Examiner stands at foot of table.
H. Knees
1. Inspect knees
Note: Alignment – valgus (lateral malalignment of lower leg) or varus (medial
malalignment deformity)
Deformity
Quadriceps
atrophy
Absence of normal hollows around patella (suggests fluid in joint or fat around
knee)
Knock knee (genu valgum)
Bowleg deformity (genu varum)
Popliteal fossa swelling (possible Baker’s cyst)
2. Bulge sign – indicates an abnormal but small amount of fluid (effusion) in knee. This test
Can detect as little as 4-6 ml of fluid. Thsi test is done when you suspect traum or
effusion:
a. massage the medial knee upwardly to remove fluid from the medial knee area
b. press or tap the lateral patella medially
c. observe for bulge of fluid appearing in the medial pouch
3. Palpate suprapatellar pouch on each side of quadriceps
e. use thumb and fingers
Note: Thickening
Synovial membrane tenderness Bogginess
Bony enlargement around knee
4. Compress suprapatellar pouch with one hand and palpate
f. each side of patella; note, if present, synovial plicae; assess for effusion (fluid in
joint) by bulge test or patellar tap
g. Tibiofemoral joint space
Note: Thickening Bogginess
Fluid Tenderness near femoral epicondyles
h. place thumbs on patella and first two finger pads into popliteal space
i. examine the space by moving fingers in a deep rotary motion
Note: Swelling
Cysts
5. Clinical correlate: Baker’s cyst (a fluid-filled popliteal bursa found in the posterior knee)
6. Clinical correlate: Anserine Bursitis – tenderness and swelling or bogginess on the medial
tibia just below joint line.
Patient supine. Examiner stands first to patient’s right then left.
7. Assess range of motion (passive or active)
a. Extend knee to 0
o
(leg straight out)
b. Flex knee to at least 120
o
Note: Degree of range of motion.
8. Assess degree of ligamentous laxity both medially and laterally.
a. With the knee slightly flexed (20
o
), place outer hand on the lateral side of knee,
grasp the medial foot or ankle with the opposite hand, and abduct the lower leg
(valgus stress).
Note: Medial collateral ligament motion or degree of “give” in joint.
b. With the knee slightly flexed (20
o
), place the inner hand on the medial side of the
knee, grasp the foot or ankle with the opposite hand, and adduct the lower leg (varus
stress)
Note: Lateral collateral ligament motion or degree of “give” in the joint
9. Lachman’s test: Flex knee slightly to about 20
o
and one hand stabilizes the lower femur
while the other holds the tibia above the tibial tuberosity and then pulls and pushes the
tibia to assess laxity of anterior and posterior cruciate ligaments.
10. Drawer test: Patient is supine, knee is flexed about 90
o
, examiner sits on patient’s foot,
grabs the upper leg and pulls it anteriorly and posteriorly to assess for laxity of the
respective cruciate ligaments. When done properly Lachman’s test is more sensitive.
Patient supine with legs straight together. Examiner begins standing to right of examination
table and then moves to the left.
I. Hips
1. Assess passive range of motion
a. Rotate each extended leg externally and internally and then return to original position.
Repeat maneuver with each knee and hip partially flexed at knee. Should have about
45
o
of internal and external range of motion.
b. Check for full extension of hip (0
o
) and active flexion (~110
o
) as well as passive
flexion (~130
o
).
c. Thomas test (to detect occult hip flexion contracture): Have patient flex right knee
and pull firmly against abdomen. This flattens the normal lumbar lordosis.
Note: Degree of flexion of left hip
Position of left hip (If hip remains on table, it’s a negative test, if hip flexes and
thigh is off the table, it’s a positive test.)
Repeat for left hip
d. With the leg extended
j. Abduct hip to 60
o
k. Adduct hip to 30
o
Repeat maneuver for other leg
e. With patient prone, straighten one leg on examination table to stabilize pelvis and
extend other leg to 15
o
. (Repeat for other leg) this tests for normal hyperextension.
2. Patrick’s or FABER test (flexion, abduction, external rotation of the hip) to test for hip or
sacroiliac joint disease.
a. Place patient’s left foot on the right distal quadriceps just above the patella. Gently
but firmly press the left knee to the exam table.
Note: Tenderness of posterior hip or back. Repeat the maneuver with the other leg.
3. See special maneuvers (k) for Trendelenburg test (k.1.a.)
Patient stands with back to examiner. Gown parted to allow adequate spine visualization.
J. Spine.
1. Inspect spinal profile
Note:
Cervical lordosis
Shoulder height symmetry
Dorsal
kyphosis
Iliac crest symmetry
Lumbar lordosis
Lateral curvature (concave or convex)–scoliosis
Skin creases below buttocks
2. Inspect patient’s gait
Note:
Smoothness
Uninterrupted
motion
Antalgic gait related to pain
Patient bends slowly forward as far as possible with back to examiner
3. Inspect dorsolumbar spine
Note: Symmetry of movement as patient flexes and extends
Smooth curve of spine
Range of motion (how far can patient bend); Normal is about 90
o
Compare convexity of lumbar curve
Rib hump (elevated shoulder) or lateral curvature of the spine (scoliosis)
Patient stands with back to examiner. Examiner seated and stabilizes patient’s pelvis with hands.
4. Assess active range of motion
Have patient perform the following maneuvers:
a. Bend to the right and then left (lateral bending, 35
o
)
b. Bend back towards examiner (extension, 35
o
)
c. Twist shoulders to right then left (rotation, 30
o
)
Patient stands with back to examiner. Examiner sits or stands behind patient.
5. Palpate spinous processes
Note: Tenderness
6. Palpate paravertebral muscles
Note: Spasm
Tenderness
Firmness or hypertonicity
7. Palpate intervertebral spaces
8. Percuss
spine
Use ulnar surface of fist
Note:
Pain
Tenderness
9. When patient is supine, can perform straight leg raising test (see k.1.b. below)
K. Special Maneuvers
1. Perform the following maneuvers on patients suspected of having sacroiliac disease,
herniated nucleus pulposus (disc), hip abnormality, or neurologic disease which may
involve the legs.
a. Trendelenburg sign (to detect gluteal weakness)
- Assess both hips
- Having patient stand on one leg and note if opposite hip remains parallel or
slightly elevated (normal or negative). A positive Trendelenberg sign occurs when
the opposite hip falls below the parallel plane. This indicates weak intrinsic
muscles of the hip opposite to the fallen one.
b. Straight leg raising test (to detect hip or sciatic disease)
- With patient supine, raise patient’s leg up to 70
o
from examination table, then
sharply dorsiflex the forefoot; this indicates a positive test if there is pain
radiating down the posterior leg to at least the popliteal fossa. Raising the leg
beyond 70
o
is not necessary.
- Increased pain down the affected leg when the opposite (contralateral) leg is
raised is a positive crossed straight leg raising sign.
c. Patrick’s Test (to detect hip or sacroiliac disease) or FABER test
- With patient supine, have patient place right ankle on left knee just proximal to
patella.
- Stabilize pelvis and sharply, externally rotate hip, with right knee approaching the
table.
- Repeat for other side.
d. Pelvic compression (to detect sacroiliac disease)
- With patient lying on side, apply pressure to hip joint.
- Repeat for other side.
e. Modified Shober’s test (to detect and quantify restrictions of lumbar flexion)
-
With patient standing, locate posterior iliac spines (indicated by “dimples of
venus”) and mark site over spine at their level.
- From this line, measure 10cm superiorly and make second mark.
- Holding 0-point of tape measure at first mark, have patient bend over and attempt
to touch toes.
- Note maximum excursion of second mark and record. Normal excursion is
5-7 cm.
2. Measure the length of each leg by placing tape measure at anterior iliac spine and
measuring to the medial malleolus.
3. McMurry’s Test (see Judge p.397) to test for meniscal tears in the knee. Can also
hyperextend and hyperflex the knee to assess for pain on the medial or lateral knee joint,
corresponding to the respective meniscus.
4. Vertex Compression test (to assess neck and arm pain from cervical nerve root
compression). Place both hands on top of head and press downward. Reproduction of the
pain is a positive test.
5. Adson’s test for thoracic outlet syndrome. Patient takes a deep breath, hyperextends
his/her head and rotates head to the affected side while examiner palpates the radial
pulse. A decrease pulse is a positive test. If negative, repeat maneuver with the head
rotated to opposite side.
6. If spondylitis (arthritis of the spine) is suspected, measure the patient’s chest expansion in
full inspiration and expiration. Use non-elastic tape measure and place at level of xiphoid
process. Measure the circumference.
10/03