Download musculo-skeletal system clinical assessment

Postgraduate
Sport and Exercise Medicine
MUSCULO-SKELETAL SYSTEM CLINICAL ASSESSMENT FOR GP’S
INTRODUCTION
A. HISTORY-TAKING
As in all areas of medicine, a comprehensive history is the vital first step to
correct diagnosis of an injury. Many sport-related injuries are complex in
nature and the treating practitioner will need the skills to obtain as much
information as possible.
 Description of current symptoms- pain (site, nature, severity, irritability,
referral, associated symptoms), stiffness, mechanical symptoms
(locking, giving way, weakness, crepitus or clicking), neurological
symptoms.
 Aggravating and relieving factors.
 Level of sport played. Personal “goals” of the subject.
 Description of onset of symptoms – acute or insidious.
 What was the exact mechanism of injury? (as much detail as possible)
 Was the onset trauma-related?
 Was the injured subject able to continue exercising or play on?
 If lower limb, could the subject weight bear? – if not, for how long?
 Were there any associated symptoms? e.g. numbness, “pins and
needles”
 Did the injured area swell? – If yes, was the swelling immediate or
delayed and, if so, for how long?
 What was the playing surface?
 What equipment or footwear was being used?
 Past history of injury details.
 Exclude “red flags”
 Check for relevant family history
 Training regimen - document any alterations in type, surfaces used,
intensity or volume.
 Details of any treatment received and from whom?
B. EXAMINATION
SHOULDER
LOOK
 symmetry, posture, muscle wasting and scars
 from behind, look for winging of scapulae or lateral shift at rest.
FEEL
 skin temperature
 check the axilla for lymph nodes or masses
 for tenderness at bony landmarks – acromio-clavicular joint, sternoclavicular joint, clavicle, acromion, coraco-clavicular ligaments,
supraspinatus insertion (with shoulder held in internal rotation and
slight extension)
 palpate gleno-humeral joint line – anterior and posterior
 palpate muscle bulk of supraspinatus, infraspinatus, deltoid and
parascapular muscles for trigger points and wasting.
MOVE
 flexion, extension and abduction - observe from anterior and posterior
aspects, the latter to assess scapulo-thoracic movement – look for
abnormal muscle movement or winging of either scapula. Assess “endfeel” at limit of range (“hard”, “soft” or “springy”) and record degrees of
arc that are painful. If active abduction or flexion is painful, try to
passively move the shoulder to see if a greater or less painful range
can be achieved.
 external rotation – assess by asking subject to put his or her hands
behind their head (alternative start position: with subject’s elbows
flexed to 90o and tucked into the side).
 internal rotation – assess by asking subject to put their hands behind
their back and record the level that is reached by the hand on both
sides.
 assess resisted movements– abduction at 10o (supraspinatus) and 90o
(deltoid), adduction (use one hand to stabilise the trunk), flexion,
extension, external and internal rotation (use the “lift-test” with hands
behind the back), and elbow flexion with hand supinated (biceps
brachii).
 assess cervical spine movements
SPECIAL TESTS- SHOULDER
Sub-acromial impingement
 Hawkins-Kennedy Test
The patient is examined in sitting with their arm at 90° and their elbow
flexed to 90°, supported by the examiner to ensure maximal relaxation.
The examiner then stabilises proximal to the elbow with their outside hand
and with the other holds just proximal to the patient's wrist. The examiner
then quickly moves the arm into internal rotation. A positive test occurs
when the patient has pain in the sub-acromial space.
 “Empty Can Test”
This is also a test of supraspinatus muscle. The patient is tested at 90°
elevation in the scapula plane and full internal rotation. Patient resists
downward pressure exerted by examiner at patients elbow or wrist. A
positive result occurs when the patient experiences pain and/or muscle
weakness.
Acromio-clavicular joint
 Scarf Test
The patient horizontally flexes the shoulder. Positive test will provoke pain
at the acromio-clavicular joint.
Gleno-humeral instability tests
 Anterior Apprehension Test
In supine the patient is positioned
with the scapula supported by the edge of the examining table. The
arm is positioned in 90° abduction and external rotation. With
increasing external rotation the examiner watches for apprehension on
the part of the patient. Essentially this test must produce an
apprehension response from the patient. Pain alone does not equal a
positive test. In the case of a positive test then proceed to the
relocation test (see next). A positive test is usually correlated with a
labral lesion and/or bony lesion at the anterior inferior rim of the
glenoid.
 Jobe relocation Test
This test was originally devised to distinguish patients with anterior
instability (and possible secondary rotator cuff impingement symptoms)
from those with primary impingement. The examiner repeats the
apprehension test and notes the amount of external rotation before the
onset of apprehension. Return to the start position and apply a
posterior stress over the humeral head. Then repeat the external
rotation manoeuvre and again note amount of external rotation at onset
of apprehension. An increase in the external rotation range before
symptom/apprehension reproduction with application of the posterior
glide on the humeral head is a positive test. It is important to note that
pain alone is not nearly as reliable regarding instability as
apprehension.
Biceps
 Yergason’s Test
The patient's elbow is flexed and their forearm pronated. The examiner
holds their arm at the wrist. Patient actively supinates against resistance.
Pain located to bicipital groove area suggests pathology in the long head
of biceps in its sheath.
ELBOW
LOOK
 from in front – look at carrying angle
 from the side – flexion deformity
 scars, muscle wasting, nodules, psoriasis, swelling/bursitis.
FEEL
 temperature across joint and forearm.
 support elbow in flexion at 90O and palpate joint line, head of radius.
 palpate lateral and medial epicondyles and olecranon process.
 Palpate ulnar nerve.
MOVE
 flexion and extension both active and passive– assess “end-feel”.
 pronation and supination, active and passive.
 Assess resisted movements: flexion, extension, pronation and
supination (biceps). Assess resisted wrist and middle finger extension
(extensor carpi radialis brevis - ECRB) and wrist flexion.
HAND AND WRIST
LOOK
 swelling, deformity, muscle wasting, scars, skin thinning or rashes.
Look at palmar and dorsal aspects.
 psoriatic and other changes in nails.
FEEL
 palpate the bulk of the thenar and hypothenar eminences.
 assess sensation in median, ulnar and radial distributions.
 assess skin temperature and any bony swellings at MCP. PIP and
DIP joints.
 Systematically palpate the wrists – radial styloid, scaphoid, 1st CMC
joint, lunate, hook of hamate, capitate, pisiform, ulnar styloid.
 assess peripheral pulses.
MOVE
 ask subject to straighten fingers and make a fist.
 assess wrist flexion and extension (“the prayer sign”).
 assess ulnar and radial deviation.
 assess resisted movements – wrist extension (radial nerve) and
flexion, radial and ulnar deviation, 1st DIP flexion (median nerve),
thumb extension and abduction.5th digit abduction (ulnar nervealternative is Fromont’s sign). Finger flexion and extension.
SPECIAL TESTS- HAND AND WRIST
 Tinel’s test
repeated percussion of the examiner’s finger on the surface of the
carpal tunnel. A positive test will reproduce symptoms of
paraesthesiae in the radial two and a half digits (carpal tunnel
syndrome).
 Phalen’s test forced flexion of the wrist for 60 seconds. A
positive test will reproduce symptoms of paraesthesiae in the
radial two and a half digits (carpal tunnel syndrome).
 Finkelstein’s test
flex the thumb within a clenched fist and ulnar deviate wrist. A
positive test will reproduce pain in the region of the radial styloid
(de Quervain’s tenosynovitis).
.
HIP AND GROIN
LOOK
In standing, additional to screening examination already described:
 especially look for gluteal wasting.
 pelvic tilt (especially anterior)
 assess single-leg standing if possible and look for Trendelenberg’s sign
(weakness of hip abductors).
 observe gait.
 also see functional tests below (if appropriate)
In lying
 look for flexion deformity of hip joint.
 assess for leg length difference- real and apparent (as measured from
anterior superior iliac spines and xiphisternum to medial malleoli).
FEEL
 palpate over the greater trochanter for tenderness.
 palpate the pubic symphysis superiorly, adductor origins, ASIS, AIIS,
iliopsoas muscle, musculo-tendinous junction of adductor longus,
piriformis, sacro-iliac joints, ischial tuberosities.
 check for inguinal and femoral cough impulses.
 check for inguinal lymphadenopathy.
 Palpate over the conjoined tendon just medial to the attachment of the
inguinal ligament to the pubic tubercle.
 if indicated in male subject, perform “Gilmore’s test” to assess for
tenderness on pubis bone and laxity of superficial inguinal ring.
MOVE
 with knee flexed at 900, assess active hip flexion (check “end-feel”).
Assess for fixed flexion deformity using Thomas’s test (keep one hand
under the subject’s back to ensure that normal lumbar lordosis is
removed, fully flex one hip and observe the opposite leg.
 with hip and knee flexed at 900, assess active and passive internal and
external rotation at the hip joint.
 with the leg straight assess hip abduction and adduction.
 resisted hip adduction can be tested with the leg straight (hip neutraladd longus, hip externally rotated- add magnus or hip internally rotated
– pectineus).
 “hip quadrant test” (combined hip flexion, adduction and internal
rotation). This test is especially useful of the hip movements are normal
in single planes.
 perform FABER test to assess anterior hip structures and sacro-iliac
joint.
 assess resisted movements: hip flexion with knee bent (iliopsoas), hip
adduction (knee straight: adductor longus, knee bent: adductor
magnus), hip internal and external rotation, knee extension (rectus
femoris) and flexion (hamstrings). Check resisted abdominal “sit-up”.
 “squeeze test” – both knees and hips flexed with feet either resting on
the couch or in the air.
 examine lumbar spine and sacro-iliac joints
KNEE
LOOK
 biomechanical posture in standing as in screening examination.
 effusion, popliteal cyst or swelling present?
 any redness or rash?
 equal weight-bearing?
 observe gait.
FEEL
 feel for increased temperature.
 palpate along borders of the patella (medial and lateral retinaculum,
quadriceps and patellar tendons). Assess size, position, shape and
mobility of the patella and any retro-patellar crepitus.
 with knee flexed to 900, palpate the joint lines, medial and lateral
collateral ligaments, and medial and lateral femoral condyles, fat
pad and the patellar tendon.
 assess whether there is a joint effusion- fluid bulge/shift, patellar
fluctuation.
 palpate superior tibio-fibular joint
MOVE
 assess full active and passive extension (including hyperextension)
and flexion of the knee, including “end feel”.
 assess the hip joint.
 resisted movements – knee flexion and extension.
SPECIAL TESTS- KNEE
Collateral ligament tests
 Medial Collateral Ligament (MCL) test
In 300 of knee flexion, the MCL is the major constraint against valgus
stress. MCL is therefore tested by applying a valgus force in this
position, taking care to allow for any rotation of the femur as the stress
is applied. Assess for laxity and “end-feel” and always compare both
sides.
 Lateral Collateral Ligament (LCL) test
LCL is the primary restraint against varus force at the knee at 50 and
250 of knee flexion. Test LCL applying a varus force in approximately
250 of flexion, taking care to allow for any rotation of the femur as the
stress is applied. Assess for laxity and “end-feel” and always compare
both sides.
Anterior Cruciate Ligament (ACL) tests
 Anterior draw
With the knee flexed to approximately 80° verification of complete
relaxation of the hamstrings is achieved by hamstring palpation. With
the foot stabilized and in neutral rotation, a firm, but gentle, grip on the
proximal tibia is achieved. An anterior force is then applied to the
proximal tibia with a gentle to-and-fro motion to assess for increased
translation compared to the contralateral knee.
 Lachman’s test
With the knee held in 300 of flexion, one hand secures and stabilizes
the distal femur while the other firmly grasps the proximal tibia. A
gentle anterior translation force is applied to the proximal tibia. The
examiner assesses for a firm / solid or soft endpoint. (Grade I <10mm,
Grade II 10-15mm, Grade III >15mm)
Posterior Cruciate Ligament (PCL) tests
 Posterior draw
With the knee flexed to approximately 80°, verification of complete
relaxation of the hamstrings is achieved by hamstring palpation. With
the foot in neutral rotation and stabilized, a firm, but gentle posterior
translation force is applied to the proximal tibia. Application of a
posterior translation force results in posterior subluxation of the tibia
on the femur in a patient with a PCL-deficient knee.
NB In the PCL deficient knee a ‘false positive’ anterior draw’ test can
occur when the posteriorly subluxed tibia is reduced into an
anatomically normal position giving the sensation of primary anterior
laxity.
Meniscal tests
 Tibial rotation tests
These attempt to differentiate a torn meniscus from other knee
pathology by trapping the torn meniscus between the femoral condyle
and tibial plateau. A positive test is indicated by a palpable or audible
click.
McMurray’s manoeuvre is performed by externally rotating the leg
with the knee fully flexed. A varus stress is then applied as the knee is
extended. A positive test suggests possible tear of the posterior horn of
the medial meniscus. The manoeuvre is repeated with forcible internal
rotation while applying a valgus stress to attempt to detect a tear of the
posterior horn of the lateral meniscus.
Patello-femoral joint tests
 Patellar glide / apprehension
The patella glide test is performed by manually displacing the patella in
a lateral direction at 20-300 of flexion. Mobility of less that 50% of the
patellar width from the midline indicates a degree of tightness of the
medial constraints. If pressure is continued and the patient becomes
‘apprehensive’ a positive apprehension sign consistent with impending
dislocation is observed.
ANKLE AND FOOT
LOOK
 loaded posture in standing as in screening examination.
 hind and forefoot position
 talo-crural joint effusion or swelling present?
 equal weight-bearing?
 observe gait.
 functional tests in standing – full squat, single-leg standing and
single-leg squat. Repeated testing if appropriate.
 check flexion and extension of 1st MTP joints.
 check plantar surface – callouses, verrucas etc.
FEEL
 Systematic palpation of the medial and lateral collateral structures
and the Achilles tendon. Particular attention should be paid to
tenderness around the syndesmosis and to tenderness in the
region of the sinus tarsi.
Ottawa rules in acute injury
X-ray is indicated if pain is around the malleoli with bone tenderness
at either:
 the posterior edge or tip of lateral malleolus to 6cm
 the posterior edge or tip of medial malleolus to 6cm
or if pain around the mid-foot with bone tenderness at either:
 the base of 5th metatarsal
 dorsal aspect of the navicular bone
or inability to weight bear immediately or when seen at A & E.
MOVE
 active plantarflexion and dorsiflexion at talo-crural joint
 passive end-feel to assess anterior or posterior impingement
 passive inversion and eversion at mid-tarsal joints with ankle
mortise in full dorsiflexion
 flexion and extension movement at 1st MTP joint
 adduction and abduction at the sub-talar joint with ankle mortise
in full dorsiflexion
 resisted plantarflexion, dorsiflexion, inversion, eversion and
combined movements
SPECIAL TESTS- ANKLE
Lateral ligament tests
 Anterior draw test
An anteroposterior (AP) force is applied to the foot in relation to the
tibia with the foot in plantar flexion. An increase of 4mm without a
definite end point compared with the ‘normal’ side implies
disruption of the ATFL (anterior talo-fibular ligament). The test is
repeated with the foot in a plantigrade position. Persistence of this
AP laxity implies disruption of the calcaneo-fibular (CFL) and PTFL
(posterior talo-fibular ligament) in addition to the ATFL).
Inferior tibio-fibular ligament test

The ‘squeeze test’
Is performed by performing proximal third compression of the
tibia and fibula. Pain at the site of the syndesmosis implies
damage to the interosseous ligaments.
Neurovascular check
 Palpate dorsalis pedis and posterior tibial pulses and check
dermatomes (see lumbar spine)
CERVICAL SPINE
LOOK
 posture (protracted cervical spine, sway back, lordosis etc)
 pelvis (anterior/posterior tilt)
 alignment (scoliosis)
 deformity
 spasm
FEEL
 spasm, heat, tenderness,
 spinous process alignment
MOVE
 range of movement - quality
 shift or catch pain
 symptoms reproduced by movement?
 repeated movements (does pain worsen or ease?)
 flexion, extension, side flexion, rotation, combined movements
SPECIAL TESTS- CERVICAL SPINE
 upper limb neurology
myotomes: resisted testing:
C5
shoulder abduction
C5/6 elbow flexion
C6
pronation and supination.
C6/7 shoulder adduction and wrist flexion/extension.
C7/8 elbow extension and finger flexion/extension.
T1
abduction and adduction of fingers.
dermotomes:
test with light touch and blunt/sharp pin.
reflexes
LUMBAR SPINE AND SACRO-ILIAC JOINTS
LOOK
 posture (sway back, lordotic etc)
 pelvis (anterior/posterior tilt)
 alignment (scoliosis)
 deformity
 spasm/stretch marks
 gait (heel/toe)
 leg length discrepancy
FEEL
 spasm, heat, tenderness,
 spinous process alignment,
 sweating (autonomic response), thickening of tissue
MOVE
 range of movement - quality
 shift or catch pain
 symptoms reproduced by movement?
 centralisation of pain (from peripheries)
 repeated movements (does pain worsen or ease?)
 flexion, extension, side flexion, rotation, combined movements
 sacroiliac joint tests – see below
SPECIAL TESTS- LUMBAR SPINE
 Lower limb neurology
myotomes: resisted movements:
L1/2 hip flexors
L3/4 Knee extensors
L4/5 Ankle dorsiflexion
L4/5 Toe extensors
L5/S1 Plantar flexion toes
S1/2 Plantar flexion in standing
S1/2 Knee flexion
S1/2 Hip extensors
dermotomes: see below:
test with light touch and blunt/sharp pin.
SLR (Lasegue's test)
Lasegue's test is also referred to now as the Straight Leg Raise (SLR) test.
When the test is positive, it is generally suggestive of an inflammation of the
sciatic nerve. The subject may experience low back pain or may experience
an "increase in intensity of pain" along the back of the leg (sciatic nerve
distribution). Low back pain only, may suggest a low back strain or sprain as
compared to a disc lesion.
The subject lies supine. The leg is kept straight, and passively raised as far as
possible. Most patients can have the leg raised almost straight up (90 0)
without major pain. The patient with "sciatica" will experience pain early in the
movement of the leg. It is important that it is documented at what level the
patient's leg raise has caused pain.