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Examination of the
Joints and
Extremities
Evelyn O. Salido, MD, FPCP, FPRA
Internal Medicine and Rheumatology
January 2009
Objectives in doing MSS PE

To screen for MSS problems among
asymptomatic and symptomatic individuals

To determine if complaint in the back or limb is
due to a MSS problem

To localize the MSS problem- intra or
periarticular

To diagnose
Who should be examined?

Musculoskeletal complaints
 Pain
 Deformity
 Disability

(loss of function)
Individuals consulting for other complaints
What should be examined?
Scope of the examination

Back

Upper Extremities

Lower Extremities

Systemic PE
Physical Examination will tell us …



Source of pain
Inflammatory or not
Pattern and extent of
joint involvement

single, few, multiple
 axial, appendicular
 distal vs proximal,
small vs large

Localized or systemic
Requirements for a good PE
Enough room and light
 Sufficient exposure of parts to be
examined while considering privacy
 Relaxed and comfortable patient and
examiner
 Good working knowledge of anatomy
 Adequate medical history

Physical Exam
MUST REMEMBER!!!




Examine each joint, not only the source of
complaint.
Assess each joint separately.
Perform an orderly exam including the spine,
the upper and lower extremities.
Proper positioning- as appropriate to the
examination being done
Maneuvers in the PE
 Inspection
 Palpation
 Range
of motion
 Measurements
Inspection: still & in motion






Posture
Contours
Symmetry
Deformities
Atrophy/hypertrophy
Masses or nodules





Swelling
Redness
Skin lesions
Instability
Abnormal movements
Posture, Contour, Symmetry
Deformity
Swelling and Redness
Redness, Skin Lesion
Masses & Nodules
Discrepancies e.g. Atrophy
Localized
 Generalized
 Document by
measuring limb
circumference

Instability





Diseased joints are able to move into abnormal
positions
due to joint surface damage or to laxity of
ligaments
passive maneuver by examiner
observation of active movement during
weightbearing and walking
wobbling, “movement” of bones, “giving-way”
Maneuvers in the PE
Inspection
 Palpation
 Range of motion
 Measurements

Palpate the joint, surrounding
tissues and the muscles of the
limbs and back
Palpation

Increased Warmth

Tenderness

Swelling- bony, soft tissue, effusion
Tenderness

Unusual sensitivity to touch or pressure

Grade I- pain only
II- pain and wincing
III- wincing and withdrawal
IV- palpation not tolerated
Swelling

Bony swelling- osteophyte
& new bone formation

Synovitis- edematous
synovium, boggy swelling,
usually tender

Effusion- excessive fluid in
joint cavity, bulge sign
Swelling

Localized periarticular swelling


does not communicate with main joint cavity
infrapatellar bursitis
Pitting edema of tissues over a joint
Maneuvers in the PE
Inspection
 Palpation
 Range of motion
 Measurements

Range of motion
 Requires
knowledge of normal motion
of particular joints
 Active or Passive
 When should ROM test be deferred
Limitation of Motion





Comparison with an unaffected joint of the
opposite extremity to evaluate individual
variations
Increased muscle tension may result in what
appears to be significant decreased ROM
May be due to limitation in the joint itself or the
periarticular structures
Active motion limited- joint or periarticular
problem
Only active motion limited-periarticular problem
Crepitus




palpable &/or audible grating or crunching
sensation produced by motion.
arises when roughened articular or extraarticular surfaces are rubbed together by
active motion or by manual compression
fine or coarse – depending on rough the
opposing cartilage surfaces are
differentiate from cracking sounds caused by
the slipping of ligaments or tendons over
bony surfaces- normal joints
Doing the Actual PE
Rapid Screen- GALS
Extensive PE
GALS Step 1- Ask 3 basic questions
Have you any pain or stiffness in your
muscles, joints, or back?
 Can you dress yourself completely without
any difficulty?
 Can you walk up and down stairs without
any difficulty?

GALS Step 2- Gait





Symmetry
Smoothness of
movement
Normal stride length
Normal heel strike,
stance, toe-off, swing
through
Able to turn quickly
Heel Strike, Stance, Toe Off, Swing
width of the base should be 2-4 in from heel to heel
flexion of the knee during toe off and swing
GALS Step 3- Inspection from Behind






Straight spine
Normal & symmetric paraspinal
muscles
Normal shoulder & gluteal
muscle bulk
Level iliac crests
No popliteal cysts nor swelling
No hindfoot swelling or
abnormality
GALS Step 4: Inspection from the side


Normal cervical & lumbar
lordosis
Normal thoracic kyphosis
GALS Step 5. “Touch your toes.”

Normal lumbar spine
(and hip) flexion
GALS step 6: Inspection from the
front- Arms
Place your hands
 behind your head (elbows out)- normal glenohumeral,
sternoclavicular, & acromioclavicular joint movement
 by your side (elbows straight)- full elbow extension
 In front (palms down)- no wrist/finger swelling or
deformity; able to fully extend fingers
Turn your hands over- normal supination/pronation; normal
palms
Make a fist- normal grip power
Place the tip of each finger on the tip of the thumb- normal
fine precision, pinch
GALS step 6: Inspection from the
front
Spine
Legs
 Normal quadricep
bulk/symmetry
 No knee swelling or
deformity
 No forefoot/midfoot
deformity
 Normal arches
 No abnormal
callous formation
“Place your ear on your
shoulder.”
Normal cervical lateral
flexion

Regional Examination
Back
Upper Extremities
Lower Extremities
Back



Look: Contour, Deformity,
Mass, Skin lesion
Feel: spinous processes,
paravertebral muscles, SI
joint
Move: cervical, lumbar;
Schober’s test for spine
flexibility
Back: Look
1="Vertebra
prominens"
Spinous process
of C7
2= 2nd Lumbar
vertebra
3= L4-5 inter
vertebral space
4= Iliac crests
5= Dimples of
Venus / Sacroiliac
joints
1= Cervical
lordosis
2=Thoracic
kyphosis
3= Lumbar
lordosis
4= Sacral
kyphosis
Back: Feel & Move
Back flexibility: Schober’s test
TMJ



Look
Feel
Move

Put picture here
Shoulder
Inspection
 Look for symmetry
between both shoulders
 Check the skin for any
signs of current or past
pathology
 Identify the clavicle,
deltoid & biceps muscles,
bicipital groove, scapula
Shoulder

Palpation
 Assess
the soft tissue tone, consistency, size
and shape of muscles, and tenderness
 Check the axilla for lymph nodes
Shoulder
Look- swelling,
redness
Feel- tenderness
Movecircumduction
Elbow
Humero-ulnar joint (hinge) is main articulation,
radio-ulnar & humero radial
In a bent arm,
the triangle is
quite
pronounced.
In a staight arm, the
"elbow bump" can be
at, and sometimes
even above, the
condyles.
Elbow joint
Inspection
 With palms facing anterior or in
anatomic position, note the
valgus angle made by the
forearm and the upper arm
Palpation
 Palpate the bony structures:
Medial and lateral epicondyles,
Medial and lateral supracondylar
line of the humerus, Olecranon &
Radial head
 Palpate the soft tissue structures

Medial aspect: ulnar nerve, wrist
flexors and pronators
 Posterior aspect: olecranon
bursa, triceps muscles
 Lateral aspect: wrist extensors,
lateral collateral ligament,
annular ligament
 Anterior aspect: cubital fossa

Range of motion:

flexion, extension at humeroulnar
articulation
 forearm supination, pronation at
proximal and distal radioulnar
joints
 passive
Wrist and Hand
•True wrist/radiocarpal
articulation- biaxial ellipsoidal
joint (radius, triangular
fibrocartilage, 3 carpal bones)
Palmar flexion & dorsiflexion
•Distal RU joint is a pivot joint
Pronation & supination
Radial & ulnar deviation
Wrist
Keep in mind that there are 6 dorsal
passageways and 2 palm tunnels through
which pass nerves, arteries, veins and
tendons.
 Some anatomic structures worth
mentioning are the carpal tunnel and the
median nerve

Wrist

Palpation

Bone palpation includes
the following:



Radial and ulnar styloid
processes
Tubercle of the radius
Bones of the wrist: eight
carpal bones

Scaphoid, navicular,
lunate, triguetrum
pisiform, trapezium,
trapezoid, capitate,
hamate

Range of motion



Flexion (80 degrees from
neutral)
Extension (70 degrees
from neutral
Ulnar and radial deviation
Hand

Inspection
 Ventral
surface:
creases, thenar and
hypothenar
eminences, MCP joint
area
 Dorsal surface: MCP
and soft tissue
“valleys,” DIP’s and
PIP’s, fingernails
MCPs
Hand

Palpation





Thenar and hypothenar
eminences
Palm aponeurosis
Flexor and extensor
tendons
Fingers: dorsal and palm
surfaces of MCP, PIP and
DIP joints
Fingernails and nail fold
capillaries
Range of motion
 MCPs- hinge joints


Fingers: Abd 20°, Flex
(make a fist to touch palm
crease), Add, Ext
1st CMC joint- saddleshaped

Thumb: opposition,
flexion/extension,
abduction and adduction
Hip
Inspection: pelvic tilt,
rotational deformity, muscle
wasting, leg length
Palpation: anterior joint line,
greater trochanter, ischial
tuberosity
Range of motion (ball &
socket joint)- F,E,Ab,Ad,R
Knee
10 Quadriceps
femoris tendon
1 Patella
4 Fibular head
11 Patellar
ligament
5 Anterior tibeal
tuberosity
Look- swelling, bulges
Feel- including bulge test
Move- flexion-extension only
Ligaments
18 Hamstring muscle
group
19 Calf muscle
What is wrong here?
Test for effusions: Bulge test & Patellar ballotment
Ankle and Feet
True Ankle joint- distal ends of tibia
& fibula and proximal part of body
of the talus
- hinge joint; dorsi & plantar flexion
Subtalar joint- inversion & eversion
Toes
Maneuvers in the PE
 Inspection
 Palpation
 Range
of motion
 Measurements
Measurement
Reporting Your Findings
Inspection
 Palpation
 Range of Motion
 Measurements

Objectives in doing MSS PE

To screen for MSS problems among
asymptomatic and symptomatic individuals

To determine if complaint in the back or limb is
due to a MSS problem

To localize the MSS problem- intra or
periarticular

To diagnose
Articular vs Non-articular
Disease ARTICULAR
EXTRA-ARTICULAR
ROM
Tender
ness
Pain
pain on active &
passive motion
jt surface
circumference
generalized,
poorly localized
more on active &
specific motion
over bony
prominences
along tendons
well-localized
superficial
Evaluation of patient with
musculoskeletal complaint
Logical differentials
 Accurate diagnosis
 Performance of necessary diagnostic
tests
 Timely provision of appropriate
therapy
