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INTRODUCTION TOMSK EXAMINATION
27 March 2013
DR CLIVE SUNChair MSK SIG
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MSK problems
• Degenerative• Injury – trauma / overuse / unaccustomed use• Deconditioning – disuse / underuse
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MSK examination
• is part of clinical work up
• Based on history• Details of injury• Onset / frequency / duration• Aggravating factor• Relieving factor
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Aim of MSK examination
• Confirm or exclude MSK lesion/ abnormality• Should have a reasonable idea of the likely
diagnosis before ordering any imaging• Tests such as plain x-rays, ultrasound, CT,
nuclear scans or MRI to confirm diagnosis
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MSK lesions include:
• Strain• Sprain• Tear / rupture
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Structures involved:
• Muscle / tendon• Ligament• Joint / capsule• Bone • Nerve• Bursa
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MSK examination
• Look• Move • Feel• Stress / provocation• Other special tests
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LOOK
• Signs of distress / pain behaviour• Aids / appliances• Scars • Skin - rash / colour / trophic changes• Swelling / bruising• Deformity / contracture• Wasting / fasciculation• Alignment / posture / asymmetry
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• Gait• Active movements• Functional activities• Compare with contralateral side
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MOVE
• Active movements• Passive movements• Resisted range of movements / weakness• Pain provocation• Muscle tone / spasticity• crepitus
• Instability• Impingement
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FEEL
• Temperature• Tenderness - Allodynia / hyperalgesia• Sensation• Swelling / mass• Deformity• Muscle tone – splinting
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Looking for
• Pain• Restricted range• Instability• Loss of function
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Aim of MSK examination is
• Diagnose problem• Manage, treat or correct abnormality
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Aim of MSK examination is not
• Just to pass module 2 or fellowship exam
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MSK skills
• Need to practise in daily clinical work• To appreciate normal• To allow detection of abnormality
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GAIT
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Gait examination
Know the normal gaitSwing phaseStance phase (5 stages)
Normal stance CadenceStep / stride
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Head to toe
• Or start in the foot and work upwards
• Look from front• From side• From back
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Head
• Head position• Head posture• Neck splinting
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Shoulder / trunk
• Shoulder symmetry• Shoulder dipping• Arm swing
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Pelvic excursion
• Rotation• Lateral displacement• Tilting
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Hips
• Flexion• Extension• Loading on each hip• symmetry
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Knees
• Flexion • Extension
• Patella orientation• Tibial rotation -> Foot orientation at start and
at end of swing phase• Loading on each knee
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Ankles
• Loading on each ankle• Any unsteadiness on loading• Any abnormal movements on loading
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Foot
• Foot control during stance phase• Foot posture• Deformity • Sideway / rotational movements
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UPPER LIMB MSK
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Shoulder - LOOK
• Introduce. Establish rapport. Expose• Principal examining position: standing then sitting ( or
stay standing)• Either start off or finish with a quick upper limb screen• Start by saying ‘Can I have a LOOK at your shoulder?’• Ask if the patient has any pain of difficulty anywhere• Inspect patient from front, side and back• Look for muscle wasting, asymmetry, scars, swelling,
winging
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Shoulder - MOVE
• Ask if you can move their shoulders about• Guide patient to perform bilateral functional active
movements• Starting with arms by the side, raise (Abd) arms high above
head to clap• Reach down behind head and down between shoulders (E
rot)• Reach behind back and up as high as you can (I rot & Add)• Reach across chest to touch opposite shoulder (AC scarf
test)
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• Put arms straight up in front (Flex)• Lower arms and go as far back (Ext)• Push against wall (winging)• Retest external & internal rotation with
elbows by side• Distinguish between glenohumeral (1st 120
deg) and scapulothoracic movements (last 60 deg)
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Shoulder - MOVE
• Consider need for passive movements ( if active movements are full and normal there is little to gain testing passive movements)
• But useful to test passive movements while feeling for crepitus and end-feel of the joint
• Abduct arm to 90 deg then rotate arm into external & internal rotation feeling for crepitus with other hand over shoulder
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Test muscle strength
• Resisted isometric abduction at 15 deg for deltoid
• Resisted empty can test fro supraspinatus• Resisted Ext & Int rotation• Scapular lift-off test fro subscapularis• Resisted flexion for anterior deltoid &
pectorals• Resisted extension for Lat Dorsi & Teres Maj
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Shoulder - FEEL
• First feel for temperature• Start palpate from SC joint and move laterally
to clavicle, supraclavicular fossa, peactoral area, coracoid process, AC joint ,glenohumeral jointline, lesser tuberosity, bicipital groove/long head of biceps, subacromial bursa, subdeltoid bursa, greater tuberosity, deltoid
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• Move from lateral to posterior, acromion, deltoid, triceps, lateral scapular border, posterior glenohumeral jointline, spine of scapula, supraspinatus, infraspinatus, medial scapular border, lev scapulae, rhomboids
• Check axilla and lateral thoracic wall
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Shoulder special test
• Rotator cuff integrityDrop arm test for supraspinatus tear
• Labral tearO’Brien test
• ImpingementNeer’sHawkin’s
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• AC provocationScarf testForced adduction of fully elevated arm
• Biceps tendinitisSpeed’s test (resisted shoulder flexion
with extended elbow)Yergason’s test (resisted supination of
flexed elbow)
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• Instability Sulcus sign for inferior instabilityAnterior/posterior drawerApprehension & relocation test
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• Neuro• Vascular – pulses• Cervical spine• Upper limb screen
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Elbow LOOK
• Introduce. Expose • Principal examining position – standing• Upper limb screen• Ask if pain of difficulty with arm• Inspect front, side, back, medial• Front – carrying angle Valgus/varus• Side – flexion deformity, scars, swelling• Posterior – scars, psoriasis, nodules, bursitis• Medial – scars for ulnar nerve decompression
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Elbow - MOVE
• Guide active elbow into flexion and extension• Forearm pronation and supination• Check passive range, end-feel • Place thumb on radial head and fingers over
medial jointline for crepitus during passive movements
• Test function: hand to mouth, hand behind neck and reach for opposite shoulder
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Elbow - FEEL
• Ask about tender area• Feel for temperature• Palpate each compartment• Medial – medial epicondyle• Posterior – ulnar nerve, olecranon, bursa• Lateral – lateral epicondyle, head of radius• Anterior – biceps tendon, brachial artery
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Elbow – Special test
• Lateral epicondyle testsresisted wrist extension with extended elbowresisted finger extension
• Medial epicondyle testsresisted wrist flexion with clenched fist
• Tinel’s sign – ulnar nerve• Varus & valgus stress test
varus for lateral collateral ligamentvalgus for medial collateral ligament
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Hand & Wrist - LOOK
• Introduce. Expose• Principal examining position – seated with
both hands on pillow• Start or finish with upper limb screen. Think
function• Ask if they have pain or difficulty• Look for splints or orthotic device• Look for swelling, deformity, wasting, scars
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• Nailsvasculitis, splinter haemorrhage, periungual telangiectasia, pitting, hyperkeratosis, onycholysis, discoloration, ridges, pallor, dilated capillaries
• Fingersredness, sausage shape, tobacco stain, arthritis mutilans, tophi, swan neck, boutonniere, z-deformity, bouchard’s nodes, herbeden’s nodes, ulnar deviation, calcinosis, telangiectasia, skin tightness
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• Dorsum hand & wristscars, rash, erythema, ulnar deviation, interosseous wasting
• Palm operation scar, erythema, wasting, pallor, flexor nodules, contractures
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Hand & wrist MOVE
• Guide active movements• Make a fist. Open, extend and spread fingers• Flex fingers to distal palm crease• Thumb abduct and opposition to 5th MC head• Supine & pronate both hands• Ulnar & radial deviation• Extend both wrist palm to palm in prayer
position, elbows up, then flex wrists (back to back)
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Test strength
• Test strength of finger extension (radial)• Test finger abduction (ulnar)• Test thumb abduction (median)
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Test function
• Power grip• Precision grip• Function test – buttoning, use key, pick up
coin, hold cup
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Hand & wrist FEEL
• Feel for temperature• Palpate for localised tenderness, effusion,
synovitis, bone enlargement• Palpate each IP joint between thumb and
index.• Squeeze MCP, palpate each MCP bimanually• Palpate wrist, ulnar styloid and snuffbox• Feel for nodules along ulnar forearm to elbow
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• Palpate fingers for tenderness, synovitis, tendon thickening or nodules and digital triggering
• Test sensation at thenar, hypothenar and dorsal 1st web
• Vascular – radial pulse, capillary refill, brachial pulse
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Hand & wrist special test
• Phalen’s test (median n)• Tinel’s ( median or ulnar)• Froment’s sign (ulnar)• Finkelstein’s test (de Quervain’s tenosynovitis)• Flexor digitorum superficialis (flex PIP)• Flex dig profundus (flex DIP)• Flex Policis Longus (flex thumb IP)• Extensor Pol Long (lift thumb up palm down)
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LOWER LIMB MSK examination
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Hip LOOK
• Introduce. Expose• Principal examining position is standing
including gait then supine• Start or finish with quick lower limb screen• Ask for presence of pain or difficulty walking• Any aids or orthotics or other assistive device
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• Inspect standing – front, side, back• Note scars, asymmetry, swelling, wasting, contracture,
posture, leg length discrepancy, pelvic tilt, scoliosis, knees and feet for alignment and deformity
• Ask patient to bend over, walk up and down, squat, walk on heels, toes
• Gait – antalgic, extension lurch, waddling• Trendelenberg test• Hop on one spot• Stairs
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Hip FEEL
• Lie supine• Note posture, scar, wasting, shortening,
deformity• Palpate femoral head (lat to femoral pulse),
groin for tenderness• Check leg length difference Wilson-Barstow
manoeuver, measure ASIS to medial malleolus• Palpate pubic rami, trochanteric region
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Hip MOVE
Supine position• Test active movements and check for muscle tightness• Active leg elevation each side• Assess hip flexion and note tight hamstrings• Thomas test for flexion contracture• Check passive int & ext rotation of each hip• Perform FABER and FADIR test• Hip abduct and adduct (note tight add/ITB)• Test hip flexion strength
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Lie on side
Ask patient to turn on their side• Test strength of hip abductors and adductors
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Lie prone
• Ask patient to lie face down• Test range of hip extension and test strength• Palpate ischial tuberosity• Palpate gluteal muscles, sacroiliac joint and
lumbar spine for tenderness
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Hip special test
• Thomas• FABER / FADIR• IROP: internal rotation with overpressure for
femoro-acetabular impingement• Ober’s test: for ITB tightness
• To complete – neuro and peripheral vascular
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Knee LOOK
• Introduce. Expose• Principal examining position: standing then
sitting then supine• Start or finish with lower limb screen• Ask for presence of pain or difficulty walking• Look around for walking aids or appliance
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LOOK: Standing
• Anterior inspect – Scars, swelling, atrophy, patella, medial and lateral peripatellar groove, suprapatellar pouch, anserine bursa, patellar tendon, quadriceps
• Posterior – popliteal fossa, Bakers’s cyst• Knee alignment – valgus(knock knee), varus(bow
knee) hyperextension (recurvatum)
Examine gait – antalgicsquatting
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Knee MOVE
• Lie supine• Active range• Passive range • Place hand over anterior of knee for crepitus
while testing full flexion and full extension• Any hyperextension
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Knee FEEL
• Temperature• Small effusion - milking test / bulge sign (up
medially & down laterally)• Large effusion – patellar tap (squeeze & ballot)• Feel behind knee for popliteal swelling
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Palpate knee in flexion
• Palpate quadriceps• suprapatellar bursa• Patella/sides• Patellar tendon to tibial tubercle• Along tibia• Fibular to tibiofibular joint• Lateral collateral ligament• Lateral joint line
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• Medial collateral ligament• Anserine bursa (insertion of adductors)• Behind knee over hamstrings attachments• Baker’s cyst, popliteal pulse• Calf muscles
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Knee special tests
Test cruciate ligaments (supine, knees flexed)• Look for tibial sag (PCL) + posterior drawer• Anterior Drawer test (sit on patients forefoot,
relax hamstrings)• Lachman test (examiner’s knee underneath
patient’s distal thigh)• Lateral pivot shift
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Test menisci• McMurray’s test (repetitive full flexion full
extension):medial meniscus (cup heel IR tibia varus stress)lateral meniscus (cup heel ER tibia valgus stress)
• Appley’s grind (lie prone, knee flexed, press down on heel and rotate foot)
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Test medial and collateral ligament• LCL (varus stress)• MCL (valgus stress)
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Test patellofemoral joint• Patellar grind• Patellar apprehension test
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Foot & ankle LOOK
• Principal examining position: standing then supine
• Look: standing and walking then supine• Supine: skin, sensory, vascular, ROM, motor,
palpation
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• Standing • look from front and side• Look at alignment of whole leg, from hips to toes• Look for clawing, hammer toes, heel valgus, foot
arches, pes planus, pes cavus
• Look from behind• Calf wasting, achilles swelling, hindfoot alignment
(calcaneal varus/valgus)
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• Walk up and down• Antalgic, spastic, foot drop• Walk on heels and tiptoes, heel raises with
support (pain or restriction on max plantaflexion maybe posterior impingement)
• Roll feet into inversion and eversion• Squat fully a few times (pain or restriction
maybe anterior impingement)• Examine footwear for wear pattern
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• Supine position• Inspect soles for pressure area(corn callus)
deformities, H valgus, clawing, wasting, • Skin for trophic changes, rash, nail changes• Sensory• Vascular(dorsalis pedis, posterior tibial)
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Foot & ankle MOVE
• Active / Passive ROM – DF/PF• Grasp all toes in palm of hand and passive
flex/ext note restriction localised tenderness• Transverse tarsal movements• TMT movements – each ray individually• Subtalar – inversion / eversion
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Motor function
• Anterior compartment (Tib Ant, EHL)• Resisted ankle dorsiflex, palpate Tib Ant to
insertion at 1st cuneiform• Resisted big toe dorsiflex palpate EHL
• Posterior compartment (FHL, Tib Post, FDL)• Resisted plantar flex + invert, palpate Tib Post
to insertion at navicular
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• Everters • Resisted PF + eversion, palpate Peroneus Brev
to insertion at base of MT5• Locate Peroneus Longus behind P Brev to
insetion at MT1
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Foot & ankle FEEL
• Regional palpation• Achilles tendon (Thompson’s test for TA
rupture), bursa• Calcaneum (Calcaneal Squeeze for stress #)• palpate behind talus (posterior impingement
confirm with PF + axial compression of calcaneum)
• Plantar fascia & attachments, heel fat pad• Palpate tarsal tunnel, post tibial nerve (Tinel’s)
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Palpate ankle from medial to lateral• Medial malleolus, deltoid ligament• Perform eversion stress• Subtalar and talonavicular joint• Anterior ankle jointline• Inferior syndesmosis and squeeze test• Distal fibula, lateral malleolus, lateral collateral ligament
( ant talofib, calcaneofib, post talofib)• Anterior drawer• Inversion stress
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• Palpate midfoot and forefoot• mid tarsal bones – navicular tubercle, 1st
cuneiform, cuboid• Joints – talonavicular, calcaneocuboid• Base MT 5, Peroneus Brevis insertion• IP, big toe• MT heads, MTP• Metatarsal compression
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Cervical spine examination
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Neck LOOK
• Standing, sitting then lying• Aids, collar, brace• Inspect neck and trunk from all sides• Note body build, muscular development,
wasting, posture, spinal alignment, deformity, scoliosis (Normal spinal curvatures – Cx & Lx lordosis, Th kyphosis)
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Neck MOVE
• Stand or sit (supine for muscular relaxation)• Active ROM• Rotate (chin to shoulder)• Flex / Ext• Lat flexion (ear to shoulder)
• Quick screen for shoulder (hand behind neck, hand behind back)
• Neuro screen
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• Resisted neck flexion (C1-2)• Shoulder shrug (C3-4)• Shoulder abduction (C5)• Wrist ext(C6)• Elbow extension (C7)• Finger flex ( C8)
• Reflexes – biceps(5), brachioradialis (6), triceps(7)• Sensation – lateral deltoid(5), thenar (6), middle finger
(7), hypothenar (8)
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Neck FEEL
• Note temperature, skin changes
Palpate from behind (posterior, side then anterior structures)
• Paravertebral muscles• Spinous processes • Suboccipital• Articular pillar
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Neck special test
• Spurling test – cervical foraminal compression• Quadrant test – facet provocation• Thoracic outlet test• Vertebral artery test• Upper limb neural tension test
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Thoraco-lumbar spine examination
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Back LOOK
• Standing, sitting then lying• Look for corset, brace, walking aids and appliances• Inspect trunk while standing from back and all
sides• Note bodybuild, posture, spinal alignment,
deformity, spinal curves, pelvic tilt and leg length• Gait, heel & toe walking, squats, single leg stance
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Back MOVE
• Standing• Active trunk movements• Forward flexion• Extension• Lateral flexion• Rotation• Quadrant test
• Check hips
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• Sit patient• Neurological lower limbs• Sitting SLR• Slump test
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• Lie supine• SLR – with ankle DF manoeuvre, well leg SLR• Hamstrings length• Abdominal strength• Hip ROM• FABER / FADIR• Pelvic ring compression / distraction• Hip flexor length (iliopsoas, rectus femoris)• Adductor length• Abductor length (ITB)
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Back FEEL
• Prone position - palpate posterior trunk structures up to neck
• Paravertebrals• Spinous processes, ligaments• Springing intervertebral joints• Sacrum• SIJ• Iliolumbar angle• Iliac crest
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• Gluteal muscles• Piriformis• Trochanters• ischia
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• Femoral nerve stretch test• Hip flexor tightness (Ely’s test)• Extensor muscle testing
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Back special tests
• Passive intervertebral mobility• Gaenslen test• Hip abductor adductor strength• Ober test
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• Waddell’s non-organic tests (superficial tenderness, sensory loss in non-anatomical distribution, simulated axial loading, simulated rotation, distracted SLR, regional weakness, hyperreactivity)
(Mention you want to complete the examination with PR)
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MSK examination
• Look• Move• Feel• Special test
• To diagnose MSK problem – structures involved, stability & function
• To allow specific physical treatment and rehabilitation management
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acknowledgement
• Dr Alex Ganora• Dr Attila Gyory