The Examination of the Musculoskeletal System

A.D. Woolf, Royal Cornwall Hospital, Truro, UK, TR1 3LJ SCREENING ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM
Screening History The common symptoms of any musculoskeletal condition are pain, stiffness and limitation of function. Joint disease is often associated with swelling. Function is frequently affected and the ability to dress without difficulty, including socks and shoes, is a complex activity that utilises upper and lower limbs and is a sensitive functional test. The ability to ascend and descend stairs without difficulty is sensitive to detecting abnormality in the lower limbs. If the only need is to establish quickly the presence or absence of major musculoskeletal problems, then these screening questions will suffice. Do you suffer from any pain or stiffness in your arms or legs, neck or back? Do you have any swelling of your joints? Do you have any difficulty with washing and dressing? Do you have any difficulty with going up or down stairs or steps? Musculoskeletal conditions are often associated with systemic features and should not be considered is isolation. General inquiry about their health should be made. These questions should identify if there are any problems that might relate to the musculoskeletal system that needs further evaluation.
Screening Examination Any significant abnormality in the spine, arms or legs should be identified by inspection at rest and during certain movements with brief palpation and stress tests of selected joints. Good observation is essential. Normality is looked for in appearance, posture and resting position of the joints and in smooth movement through the expected normal range. When any joint is affected by a musculoskeletal condition, then there is usually one movement that is nearly always affected and it is these movements that are assessed in this screen. For such a screen to be part of the routine examination of all patients, it has to be quick, simple and easy to annotate. This screen was developed to meet these criteria. The gait, arms, legs and spine (G, A, L, S) should be assessed. Gait. The patient should be observed walking forwards for a few metres, turning and walking back again. Abnormalities of the different phases should be recognised heel strike, stance phase, toe off and swing phases. Look for abnormalities of movements of the arms, pelvis, hips, knees, ankles and feet during these phases. Inspection of standing patient. The patient should be viewed from the back, side and front looking for any abnormalities in particular of posture and symmetry. Examine for tenderness by applying pressure in the midpoint of each supraspinatus and rolling an overlying skin fold. Spine. Ask the patient to flex the neck laterally to each side. Place several fingers on lumbar spinous processes and ask them to bend forward and attempt to touch their toes whilst standing with the legs fully extended, observing and feeling for normal movement. Arms. Ask the patient to place both hands behind their head with elbows right back. This is a sensitive test of many components of the shoulder apparatus. Straighten the arms down the side of the body and then inspect with elbows bent to 90o with palms down and fingers straight. Turn hands over and make a tight fist with each hand. Place in turn the tip of each finger onto the tip of the thumb. Squeeze the metacarpals from 2nd to 5th. Legs. With the patient reclining on a couch, flex in turn each hip and knee while holding and feeling the knee. Then passively rotate the hip internally. With the leg extended resting on the couch, examine for tenderness or swelling of the knee by pressing down on the patella while cupping it proximally. Squeeze all the metatarsals and finally inspect the soles of the feet for callosities. Such a screening examination should take a few minutes. Identify abnormalities that then need to be fully assessed.

History & Examination (Woolf)

December 2002

FULL ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM The Examination of the Musculoskeletal System Watch the patient walk and undress Look at the posture with the patient standing undressed to their underwear Examine the Neck Spine and pelvis Shoulders Arms Hands Hips Knees Ankles and feet System for examination Look o At rest for swelling deformity wasting attitude skin During movement

o Feel for o tenderness o swelling o movement crepitus o temperature Move o active o passive o resistance o listen Stress o stability Special tests

Cervical spine Look Look for hyperextension due to a thoracic kyphosis, or loss of normal lordosis. Feel Palpate the paraspinal muscles for spasm or tenderness. Move Actively turn head to right, left, flexion, extension, rotation to left and right and lateral flexion to left and right with examiner gently guiding the head to ensure maximum range is reached. Additional Percussion of the vertebrae may elicit the presence of tenderness. Information Problems related to the cervical spine are often associated with neurological symptoms and signs, which should be elicited. Temporomandibular joint Feel Palpate over the joint line for tenderness, crepitus or clicking. The joint can be palpated anterior to the tragus or from within the external auditory meatus. Feel for crepitus or clicking on movement. Move Open mouth wide. Deviate lower jaw side to side. Dorsal spine Look Look for any kyphosis or scoliosis Look for any asymmetry of scapulae. Feel Percuss the vertebrae for tenderness. Palpate the paraspinal muscles for spasm or tenderness. Move Fix the pelvis by sitting and rotate the upper body to right and left with examiner gently guiding the shoulders to ensure maximum range is reached.

Lumbar spine Look Look for normal lordosis or any scoliosis. Feel Percuss the vertebrae for tenderness. Palpate the paraspinal muscles for spasm or tenderness. Move Whilst standing in an erect posture, bend forward as if trying to touch the toes, bend backwards to arch the back, and bend from side to side. Stress Tests for tension of the lumbar roots should be performed. Femoral nerve stretch test With the person lying prone, hold their ankle and passively flex the knee as far as it will go. It is positive if pain is felt in the ipsilateral anterior thigh. Sciatic nerve stretch test With the person lying supine, gently raise the straight leg to the maximum angle achievable without significant pain and then dorsiflex the ankle. An increase in pain indicates sciatic nerve root tension. Additional Flexion can be more formally assessed by the Schober test with measurement of the extension of Information a line drawn when upright between 10 cm above and 5 cm below the level of the posterior iliac spines identified by the dimples of Venus. The lumbar spine houses the lumbar spinal nerve roots and neurological symptoms and signs should be elicited. Pelvis and sacroiliac joints Look Look for asymmetry of the pelvic brim and of the lower part of buttock. Feel Palpate for tenderness in the buttocks. Palpate the sacroiliac joints for tenderness. Stress Stress the sacroiliac joints for tenderness. There are various methods to compress or distract the joint to elicit tenderness such as pushing on both iliac wings when the person is lying on their back on the couch. Shoulder Look Feel Move

Look for any asymmetry of scapulae, posture or muscle wasting. Palpate over the midpoint of each trapezius and the supraspinatus to identify tender spots. Palpate over the acromioclavicular joint line, glenohumeral joint line and bicipital groove. Actively elevate arms into air. Actively place hands behind head then behind back. Steady scapula and with the elbow at 90o passively abduct, flex, internally and externally rotate the shoulder.

Elbow Look Feel Move Additional Information Wrist Look

Look for any swelling or deformity. Joint swelling is first apparent in the para-olecranon groove.

Palpate over the para-olecranon groove for synovial swelling or tenderness. Palpate over the medial and lateral epicodyles for tenderness.
Passively extend and flex the elbow and look for hyperextension. With the elbow at 900 flexion, pronate and supinate the forearm. The olecranon is a common site for bursitis and rheumatoid nodules. Assess the laxity of the skin if considering hypermobility.

Feel Move

Look for any swelling or deformity. Look for squaring of the palm base because of swelling of the carpo-metacarpal joint seen in osteoarthritis. Typical deformities in established rheumatoid arthritis are volar subluxation and radial deviation at the wrist with dorsal subluxation of the ulnar styloid. Palpate over the joint line for tenderness or synovial swelling. Passively flex and extend the wrist. Assess for hypermobility by passively moving the thumb towards the volar aspect of the forearm

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with the wrist in full flexion. Swelling over the dorsum is of the joint or extensor tendon sheath. With active extension of the fingers, swelling of the extensor tendon sheath moves the tuck sign. Resisted flexion, extension or pronation of the wrist may be done if assessing for epicondylitis at the elbow. Assess stability of the inferior radio-ulnar joint by demonstrating movement with pressing down on the radial head the piano key sign

Hand Look

Feel

Move Additional Information

Look for any swelling or deformity. Is the swelling specific to joints or tendons or is it diffuse? Look for wasting of the small muscles, inspect the skin, nails and nail beds. Typical deformities in established rheumatoid arthritis are ulnar deviation of the fingers at the metacarpal-phalangeal joints, hyperextension at the proximal interphalangeal with flexion at the distal interphalangeal (swan-neck deformity) or flexion at the PIP with hyperextension at the DIP (Boutonnire deformity). Palpate over each joint line for tenderness, bony or synovial swelling. Squeezing across all the knuckles together can be used as a composite assessment for tenderness of the MCPJs. Palpate the tendon sheaths during movement to detect crepitus or tendon nodules. Feel the quality of the skin for induration, thickening or laxity. Actively make a tight fist with palmar aspect uppermost to see if all fingers fully flex. Actively make a firm pinch grip between the thumb and the fingers individually. A Z-deformity of the thumb may be seen in SLE. Estimate strength of grip by observing the blanching of the palmar surface of the hand on release of the fist. Passive extension of the fifth finger may be done to assess for hypermobility

Lower extremity Observing the gait is an important part of assessing the lower limbs. Examination should be done with the person lying on the couch. Measure leg length if a pelvic tilt when standing suggests shortening. Pain in the hindquarter is often called hip pain but can have many origins that need elucidating by examination. Hip Look Feel Move

Observation of the person walking will have given some information about the hips. There may be wasting of the buttock or thigh muscles from disuse. Palpation should be used to clarify the origin of any symptoms. The hip is used to describe symptoms anywhere in the hindquarter. Tenderness is usually related to tendinitis or busitis. With the person supine, passively flex the hip as far as possible with the knee in flexion. With the hip passively flexed to 90o, rotate it internally and externally by holding the foot, supporting the thigh and moving the lower leg inwards and outwards, careful to not inflict pain. Internal rotation is often affected first in diorders of the hip joint. With the person lying supine with the leg fully extended, hold the contralateral anterior superior iliac spine to prevent movement of the pelvis and passively abduct and adduct the leg. With the person lying prone or on their side, passively extend the straightened leg.

Knee Look

Feel Move

Observation of the person walking will have given some information about the knees. There may be wasting of the thigh muscles from disuse. There may be instability. Look for any swelling and its exact site as it may relate to the joint or peri-articular structures. Look for any deformity. Typical deformities are fixed flexion, valgus or varus. Palpate for tenderness or swelling and establish the affected structures. Palpate the joint line for tenderness. Assess for articular swelling and effusion by the bulge sign or patella tap. Palpate for a popliteal cyst. With the person supine, passively flex the knee as far as possible with the hip in flexion. If the

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hip is also abnormal, hang the leg over the side of the couch to examine flexion of the knee without hip flexion. With the person lying supine, fully extended the leg in an attempt to touch the back of the knee onto the couch. Assess passively if the knee will hyperextend. Anterior and posterior stability can be tested to assess the cruciate ligaments. Medial & lateral stability should be tested to assess the collateral ligaments.

Foot and ankle Look Observe the feet when standing and during walking. Look for a normal longitudinal arch and during the gait cycle, look for normal heel strike and take off from the forefoot. Look for any callosities beneath the metatarsal heads and for any swelling and redness of the toes. Swelling of the metatarsophalangeal joints can separate the toes. Look for any deformities. Deformities include pes planus (flattening of the longitudinal arch), pronation of the foot, valgus deformity of the hindfoot (eversion of the sub-talar joint, pes cavus (high longitudinal arch), talipes equinovarus, hallux valgus, subluxation of the metatarsophalangeal joints, and claw, hammer and mallet deformities of the toes. Feel Symptoms may relate to the joint, the periarticular bone, the tendons including their sheaths and insertions, or bursae. Palpate for tenderness or swelling and establish the affected structures. Squeeze across the metatarsus and if there is tenderness, examine the metatarsophalangeal joints individually. Move Passively flex and extend the ankle. Passively deviate the heel medially (inversion) and laterally (eversion) by grasping the heel between the examiners thumb and index finger of one hand and moving it whilst anchoring the lower leg with the other hand. Passively rotate the forefoot on the hindfoot by grasping the forefoot between the examiners thumb and fingers whilst anchoring the heel with the other hand to assess the midtarsal joint. See if they are able to stand on their toes, which requires an intact posterior tibialis tendon. History & Examination (Woolf) December 2002

modified for osi locomotion module/jun 2005 and jan 2006