INTRODUCTION TOMSK EXAMINATION

27 March 2013

DR CLIVE SUNChair MSK SIG

MSK problems

• Degenerative• Injury – trauma / overuse / unaccustomed use• Deconditioning – disuse / underuse

MSK examination

• is part of clinical work up

• Based on history• Details of injury• Onset / frequency / duration• Aggravating factor• Relieving factor

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

MSK lesions include:

• Strain• Sprain• Tear / rupture

Structures involved:

• Muscle / tendon• Ligament• Joint / capsule• Bone • Nerve• Bursa

MSK examination

• Look• Move • Feel• Stress / provocation• Other special tests

LOOK

• Signs of distress / pain behaviour• Aids / appliances• Scars • Skin - rash / colour / trophic changes• Swelling / bruising• Deformity / contracture• Wasting / fasciculation• Alignment / posture / asymmetry

• Gait• Active movements• Functional activities• Compare with contralateral side

MOVE

• Active movements• Passive movements• Resisted range of movements / weakness• Pain provocation• Muscle tone / spasticity• crepitus

• Instability• Impingement

FEEL

• Temperature• Tenderness - Allodynia / hyperalgesia• Sensation• Swelling / mass• Deformity• Muscle tone – splinting

Looking for

• Pain• Restricted range• Instability• Loss of function

Aim of MSK examination is

• Diagnose problem• Manage, treat or correct abnormality

Aim of MSK examination is not

• Just to pass module 2 or fellowship exam

MSK skills

• Need to practise in daily clinical work• To appreciate normal• To allow detection of abnormality

GAIT

Gait examination

Know the normal gaitSwing phaseStance phase (5 stages)

Normal stance CadenceStep / stride

Head to toe

• Or start in the foot and work upwards

• Look from front• From side• From back

Head

• Head position• Head posture• Neck splinting

Shoulder / trunk

• Shoulder symmetry• Shoulder dipping• Arm swing

Pelvic excursion

• Rotation• Lateral displacement• Tilting

Hips

• Flexion• Extension• Loading on each hip• symmetry

Knees

• Flexion • Extension

• Patella orientation• Tibial rotation -> Foot orientation at start and

at end of swing phase• Loading on each knee

Ankles

• Loading on each ankle• Any unsteadiness on loading• Any abnormal movements on loading

Foot

• Foot control during stance phase• Foot posture• Deformity • Sideway / rotational movements

UPPER LIMB MSK

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

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)

• 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)

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

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

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

• 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

Shoulder special test

• Rotator cuff integrityDrop arm test for supraspinatus tear

• Labral tearO’Brien test

• ImpingementNeer’sHawkin’s

• 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)

• Instability Sulcus sign for inferior instabilityAnterior/posterior drawerApprehension & relocation test

• Neuro• Vascular – pulses• Cervical spine• Upper limb screen

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

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

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

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

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

• 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

• Dorsum hand & wristscars, rash, erythema, ulnar deviation, interosseous wasting

• Palm operation scar, erythema, wasting, pallor, flexor nodules, contractures

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)

Test strength

• Test strength of finger extension (radial)• Test finger abduction (ulnar)• Test thumb abduction (median)

Test function

• Power grip• Precision grip• Function test – buttoning, use key, pick up

coin, hold cup

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

• 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

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)

LOWER LIMB MSK examination

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

• 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

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

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

Lie on side

Ask patient to turn on their side• Test strength of hip abductors and adductors

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

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

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

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

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

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

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

• Medial collateral ligament• Anserine bursa (insertion of adductors)• Behind knee over hamstrings attachments• Baker’s cyst, popliteal pulse• Calf muscles

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

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)

Test medial and collateral ligament• LCL (varus stress)• MCL (valgus stress)

Test patellofemoral joint• Patellar grind• Patellar apprehension test

Foot & ankle LOOK

• Principal examining position: standing then supine

• Look: standing and walking then supine• Supine: skin, sensory, vascular, ROM, motor,

palpation

• 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)

• 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

• 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)

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

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

• Everters • Resisted PF + eversion, palpate Peroneus Brev

to insertion at base of MT5• Locate Peroneus Longus behind P Brev to

insetion at MT1

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)

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

• 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

Cervical spine examination

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)

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

• 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)

Neck FEEL

• Note temperature, skin changes

Palpate from behind (posterior, side then anterior structures)

• Paravertebral muscles• Spinous processes • Suboccipital• Articular pillar

Neck special test

• Spurling test – cervical foraminal compression• Quadrant test – facet provocation• Thoracic outlet test• Vertebral artery test• Upper limb neural tension test

Thoraco-lumbar spine examination

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

Back MOVE

• Standing• Active trunk movements• Forward flexion• Extension• Lateral flexion• Rotation• Quadrant test

• Check hips

• Sit patient• Neurological lower limbs• Sitting SLR• Slump test

• 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)

Back FEEL

• Prone position - palpate posterior trunk structures up to neck

• Paravertebrals• Spinous processes, ligaments• Springing intervertebral joints• Sacrum• SIJ• Iliolumbar angle• Iliac crest

• Gluteal muscles• Piriformis• Trochanters• ischia

• Femoral nerve stretch test• Hip flexor tightness (Ely’s test)• Extensor muscle testing

Back special tests

• Passive intervertebral mobility• Gaenslen test• Hip abductor adductor strength• Ober test

• 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)

MSK examination

• Look• Move• Feel• Special test

• To diagnose MSK problem – structures involved, stability & function

• To allow specific physical treatment and rehabilitation management

acknowledgement

• Dr Alex Ganora• Dr Attila Gyory