Musculoskeletal Examination

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To examine range of motion of the wrist, ask the patient to assume an attitude with the elbows flexed and the forearms parallel to the floor, and then press the palms of the hands and the dorsum of the hands as closely together as possible, producing angulation of the wrist.

Category: Musculoskeletal

The wrist can normally be dorsiflexed to 70 degrees and palmar flexions should be possible to approximately 80 or 90 degrees. Ask the patient to deviate the hand ulnarward; this should be possible to 50 to 60 degrees. Finally, ask the patient to deviate both hands radialward; this should be possible to approximately 20 degrees. Observe and palpate both elbows and over the olecranon process, again noting areas of color change and enlargement. Be careful to observe for synovial thickening or effusion both in the joint itself and in the area of the olecranon bursa. Observe for subcutaneous nodules over the olecranon process.

Ask the patient to extend both elbows fully and to flex them fully. The position of full extension is designated as 0 degrees, and flexion should be performed well to degrees in the normal state. The range of motion in the radiohumeral joints is then tested by asking the patient to pronate and supinate both hands fully. In the normal state the palm of the hand should be able to be placed flat on a table in pronation and the dorsum of the hand flat on the table in supination. The examination of the shoulder is best performed with the patient sitting or standing in such a position that the examiner can move freely about the patient's body.

Range of motion of the shoulder should be examined with and without manual fixation of the shoulder. The shoulder mechanism is a complicated system where several joints act in concert. The physician should be familiar with the anatomy of the shoulder and of the contiguous structures that act together.

These include the glenohumeral joint, the acromioclavicular joint, the sternoclavicular joint, the gliding tissue space between the scapula and thorax, the shoulder capsule or rotator cuff, and the subacromial bursa. The sternoclavicular joint, the acromioclavicular joint, the scapulae, and shoulders are inspected for enlargement, wasting, and color changes.

Carefully palpate these areas, then the shoulder joints around the margin of the shoulder capsule. If swelling or tenderness is encountered, it is important to attempt to localize the responsible structure. This is most easily done by referring to an atlas on the anatomy of the shoulder. Forward flexion is then checked by asking the patient to flex the shoulders fully frontward. This should be possible to 90 degrees or parallel to the floor when the patient is standing or sitting erect.

Ask the patient to rotate and to continue to flex the shoulders, placing both hands together over the head with arms parallel to and against the ears. This should be possible in the normal state to degrees.

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Ask the patient to abduct both shoulders, which should again be possible to 90 degrees, and to rotate and further abduct the shoulders touching both hands together over the head with the upper arms tightly pressed against the ears. Ask the patient to clasp both hands behind the occiput to check for external rotation. Ask the patient to spread both elbows wide apart, then to release the handclasp but maintain the flexion of the elbows and touch the elbows together in front of the head. The patient is then asked to elevate both shoulders as if shrugging them.

In this instance it is difficult to describe specific angles and motion, but the examiner will gain experience in detecting abnormalities. The temporomandibular joints are inspected and palpated as described previously for other joints.

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Continue to palpate the temporomandibular joints while asking the patient to open and close the mouth and to move the jaw from side to side. Again, it is very difficult to describe a specific range of motion, but experience will help in detecting abnormalities.

Palpate and listen for crepitation while the motion is being performed. Inspect the cervical spine for loss of the normal lordotic curve. Palpate for local areas of tenderness and crepitation.

Musculoskeletal Physical Exam: Knee

Next, ask the patient to put the chin on the chest to check flexion, to put first the right ear on the right shoulder and the left ear on the left shoulder for lateral flexion, and to extend the neck as far as possible by looking back over the ceiling as far as possible. Rotation is then checked by asking the patient to put the chin on the right shoulder and then the left shoulder. Examine the thoracic and lumbar spine together. Examine the back and palpate for areas of muscle spasm and tenderness.

Lightly percuss over the spinous processes throughout the spine to check further for tenderness. Observe the patient both standing and sitting from behind and from the side to check for kyphosis an abnormal forward flexed position and scoliosis an abnormal curvature of the spine on one side or the other. The presence of scoliosis can best be judged by determining if a list is present.

If the first thoracic vertebra is not centered over the sacrum, the patient is said to have a list. This can easily be measured by dropping a perpendicular from the first thoracic vertebra and measuring how far to the right or left of the gluteal fold it falls. If a list is demonstrated, scoliosis must be present. Also observe whether the lumbar lordosis is present in increased amount or abnormally absent. Check for forward flexion in the sitting position by asking the patient to place the nose on the knee, and in the standing position by asking the patient to touch the toes.

To check for lateral flexion, ask the patient to hyperextend the spine as much as possible and then to pass the hand straight down the thigh, first on the right and then on the left, keeping the hips straight. Ask the patient to maintain the pelvic girdle in a flexed position and rotate the shoulders first to the right and then to the left to check for rotation. With the patient standing, check for a pelvic tilt by placing your hands on the iliac crests and observing if these are parallel.

Angles of motion can be estimated from an imaginary line passing straight up through the spine, perpendicular to the floor or to the table. It is very difficult to measure these accurately or to list accurate normal measurements. The most accurate parameter of measurement is the amount of lengthening of the spine in forward flexion. The normal spine should lengthen more than 5 cm in the thoracic area and more than 7. Costovertebral joint motion can be measured by placing the hands with fingers spread on the thorax and having the patient inspire and expire fully.

If there is an abnormality, an accurate measurement of chest expansion at the nipple line should be recorded as a baseline. For straight leg raising tests , ask the patient to lie with the spine on the table and to relax completely. With the knee fully extended, first one leg and then the other is slowly lifted and flexed at the hip. This produces stretch on the sciatic nerve, at which point sciatic pain is produced. If this maneuver produces pain in the hip or low back with radiation in the sciatic area, the test is considered positive for nerve root irritation.

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The angle of elevation of the leg from the table at the point where pain is produced should be recorded. The sacroiliac joints are examined by palpation and by light fist percussion for tenderness. Other maneuvers that might produce pain in a sacroiliac joint when inflammation is present are:. The feet are inspected for abnormal coloration and localized areas of swelling. Note should be taken of skin lesions about the feet and toes. Palpate and record arterial pulsations dorsalis pedis and posterior tibial.

In addition, observe for lowering of the longitudinal arch pes planus, or flat foot , abnormal elevation of the longitudinal arch pes cavus , abnormal angulation of the first metatarsophalangeal joint hallux valgus , hammertoe or cock-up deformities of the toes, and the formation of callouses or bursae over the pressure areas. Ask the patient to perform flexion and extension of the toes actively. If there appears to be an abnormality, each toe must be passively put through a range of motion. Mobility of the midtarsal joints is measured by grasping the foot with both hands and gently rotating the hands in opposite directions.

Examine the ankle for discoloration and swelling and palpate for tenderness, swelling, effusion, and crepitus on range of motion. Ask the patient to dorsiflex the ankles this should be possible to approximately 20 degrees and to plantar-flex the ankles this should be possible to approximately 45 degrees. Then ask the patient to invert supinate the ankle, which should be possible to 30 degrees, and to evert pronate the ankle, which should be possible to 20 degrees. Ask the patient to stand and walk. Note attitudes of pronation or supination and toeing in and toeing out with walking. The knee , the largest joint in the body, is a compound condylar joint.

The specific anatomy of the knee should be reviewed. Inspect the knees for discoloration, swelling, and deformities and note whether they are laterally angulated genu varum or medially angulated genu valgum.

source url In addition, note a backward bowing of the knee genu recurvatum and lack of full extension of the knee flexion contracture. The abnormalities mentioned on inspection up to this point are best noted with the patient standing and weight-bearing. P Patellar tap Phalen maneuver Pivot-shift test.

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S Schober's test Shoulder examination Simmonds' test Straight leg raise. T Thomas test Thompson test Tinel's sign. V Valgus stress test. W Waddell's signs Watson's test. Categories : Physical examination Musculoskeletal system.