Download Introduction to MSK Examination

INTRODUCTION TO
MSK EXAMINATION
27 March 2013
DR CLIVE SUN
Chair MSK SIG
MSK problems
• Degenerative
• Injury – trauma / overuse / unaccustomed use
• Deconditioning – disuse / underuse
MSK examination
• is part of clinical work up
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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:
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Muscle / tendon
Ligament
Joint / capsule
Bone
Nerve
Bursa
MSK examination
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Look
Move
Feel
Stress / provocation
Other special tests
LOOK
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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
MOVE
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Active movements
Passive movements
Resisted range of movements / weakness
Pain provocation
Muscle tone / spasticity
crepitus
• Instability
• Impingement
FEEL
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Temperature
Tenderness - Allodynia / hyperalgesia
Sensation
Swelling / mass
Deformity
Muscle tone – splinting
Looking for
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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 gait
Swing phase
Stance phase (5 stages)
Normal stance
Cadence
Step / 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
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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
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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)
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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)
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 integrity
Drop arm test for supraspinatus tear
• Labral tear
O’Brien test
• Impingement
Neer’s
Hawkin’s
• AC provocation
Scarf test
Forced adduction of fully elevated arm
• Biceps tendinitis
Speed’s test (resisted shoulder flexion with
extended elbow)
Yergason’s test (resisted supination of
flexed
elbow)
• Instability
Sulcus sign for inferior instability
Anterior/posterior drawer
Apprehension & relocation test
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Neuro
Vascular – pulses
Cervical spine
Upper limb screen
Elbow LOOK
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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
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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
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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 tests
resisted wrist extension with extended elbow
resisted finger extension
• Medial epicondyle tests
resisted wrist flexion with clenched fist
• Tinel’s sign – ulnar nerve
• Varus & valgus stress test
varus for lateral collateral ligament
valgus 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
• Nails
vasculitis, splinter haemorrhage, periungual
telangiectasia, pitting, hyperkeratosis,
onycholysis, discoloration, ridges, pallor, dilated
capillaries
• Fingers
redness, sausage shape, tobacco stain, arthritis
mutilans, tophi, swan neck, boutonniere, zdeformity, bouchard’s nodes, herbeden’s nodes,
ulnar deviation, calcinosis, telangiectasia, skin
tightness
• Dorsum hand & wrist
scars, rash, erythema, ulnar deviation,
interosseous wasting
• Palm
operation scar, erythema, wasting, pallor,
flexor nodules, contractures
Hand & wrist MOVE
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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
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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
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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 – antalgic
squatting
Knee MOVE
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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
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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
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
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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)
• 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
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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
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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)
Neck FEEL
• Note temperature, skin changes
Palpate from behind (posterior, side then
anterior structures)
• Paravertebral muscles
• Spinous processes
• Suboccipital
• Articular pillar
Neck special test
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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
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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)
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
• Femoral nerve stretch test
• Hip flexor tightness (Ely’s test)
• Extensor muscle testing
Back special tests
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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
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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