(16) Musculoskeletal Flashcards
Joint structures: Articular
includes:
- the joint capsule
- articular cartilage (composed of a collagen matrix containing charged ions and water, allowing the cartilage to change shape in response to pressure or load, acting as a cushion for underlying bone)
- synovium
- synovial fluid (provides nutrition to the adjacent relatively avascular articular cartilage)
- intra-articular ligaments
- juxta-articular bone
Joint structures: Extra-articular
include:
- periarticular ligaments
- tendons
- bursae
- muscle
- fascia
- bone
- nerve
- overlying skin
Age provides clues to causes of joint pain:
<60 years old consider:
repetitive strain or overuse syndromes like tendinitis or bursitis
crystalline arthritis (gout; crystalline pyrophosphate deposition disease [CPPD]) (males)
rheumatoid arthritis (RA)
psoriatic arthritis and reactive (Reiter) arthritis (in inflammatory bowel disease [IBD])
infectious arthritis from gonorrhea, Lyme disease, or viral or bacterial infections.
Age provides clues to causes of joint pain:
>60 years old consider:
OA gout and pseudogout polymyalgia rheumatica (PMR) osteoporotic fracture septic bacterial arthritis
3 types of joints (w/ extent of movement and example)
- Synoval - freely moveable (knee, shoulder)
- Cartilaginous - slightly moveable (vertebral bodies of the spine)
- Fibrous - immovable (skull structures)
Synovial Joints
h other, and the
joint articulations are freely movable within
the limits of the surrounding ligaments
(Fig. 16-3). The bones are covered by
articular cartilage and separated by a
synovial cavity that cushions joint
movement. A synovial membrane lines the
synovial cavity and secretes a small amount
of viscous lubricating fluid, the synovial
fluid. The membrane is attached at the
margins of the articular cartilage and
pouched or folded to accommodate joint
movement. Surrounding the joint is a
fibrous joint capsule, which is strengthened
by ligaments extending from bone to bone.
Cartilaginous Joints
ex: intervertebral joints, symphysis pubis
slightly movable
Fibrocartilaginous discs separate the bony surfaces. At the center of each disc is the nucleus pulposus, somewhat gelatinous fibrocartilaginous material that serves as a cushion or shock absorber between bony surfaces.
Fibrous Joints
ex: sutures of the skull
intervening layers of fibrous tissue or cartilage hold the bones together
The bones are almost in direct contact, which allows no appreciable movement.
3 type of synovial joints w/ articular shape, movement, and example
- Spheroidal (ball and socket) - convex surface in concave cavity
- wide-ranging flexion, extension, abduction, adduction, rotation, circumduction
ex: shoulder, hip - Hinge - flat, plantar
- motion in one plane; flexion, extension
ex: interphalangeal joints of hand and foot; elbow - Condylar - convex or concave
- movement of 2 articulating surfaces not dissociable
ex: knee, TMJ
Spheroidal Joints.
ball-and-socket configuration—a rounded, convex surface articulating with a concave cuplike cavity, allowing a wide range of rotatory movement, as in the shoulder and hip
Hinge Joints
flat, planar, or slightly curved, allowing only a gliding motion in a single plane, as in flexion and extension of the digits
Condylar Joints.
ex: knee
have articulating surfaces that are
convex or concave
allow flexion, extension, rotation, and motion in the coronal plane
Bursae.
roughly disc-shaped synovial sacs that ease joint action and allow adjacent muscles or muscles and tendons to
glide over each other during movement
lie between the skin and the convex surface of a bone or joint, as in the prepatellar bursa of the knee or in areas where tendons or muscles rub against bone, ligaments, or other tendons or muscles, as in the subacromial bursa of the shoulder
Joint Pain: common/concerning symptoms
● Joint pain: articular or extra-articular, acute or chronic, inflammatory or
noninflammatory, localized or diffuse
● Joint pain: associated constitutional symptoms and systemic manifestations
from other organ systems
● Neck pain
● Low back pain
Tips for Assessing Joint Pain
Ask the patient to “point to the pain.” This may save considerable time
because many patients have trouble pinpointing pain location in words.
● Clarify and record when the pain started and the mechanism of injury, particularly
if there is a history of trauma.
● Determine whether the pain is articular or extra-articular, acute or chronic,
inflammatory or noninflammatory, and localized (monoarticular) or diffuse
(polyarticular).
types of joint pain
- monoarticular - one joint
- polyarticular - several joints (usually 4 or more)
- extra-articular - involving bones, muscles, tissues around joints sun as tendons, bursae, overlying skin
4 cardinal features of joint inflammation
swelling, warmth, and
redness, in addition to pain
acute vs chronic joint pain
Acute joint pain typically lasts up to 6 weeks
chronicpain lasts >12 weeks.
2 tools to establish cervical spine injury
NEXUS
Canadian C-spine Rule
3 categories of low back pain
There are numerous clinical guidelines, but most categorize low back pain into three groups:
nonspecific (>90%)
nerve root entrapment with radiculopathy or spinal stenosis (∼5%)
pain from a specific underlying disease (1% to 2%)
Red Flags for Low Back Pain from
Underlying Systemic Disease
- Age <20 years or >50 years
- History of cancer
- Unexplained weight loss, fever, or decline in general health
- Pain lasting more than 1 month or not responding to treatment
- Pain at night or present at rest
- History of intravenous drug use, addiction, or immunosuppression
- Presence of active infection or human immunodeficiency virus (HIV) infection
- Long-term steroid therapy
- Saddle anesthesia, bladder or bowel incontinence
- Neurologic symptoms or progressive neurologic deficit
Physical Activity Guidelines for Americans
At least 2 hours and 30 minutes a week of moderate-intensity, or 1 hour and 15 minutes a week of vigorous-intensity, aerobic physical activity, or an equivalent combination
● Moderate- or high-intensity muscle-strengthening activity that involves all
major muscle groups on 2 or more days a week
Risk Factors for Osteoporosis
● Postmenopausal status in women
● Age ≥50 years
● Prior fragility fracture
● Low body mass index
● Low dietary calcium
● Vitamin D deficiency
● Tobacco and excessive alcohol use
● Immobilization
● Inadequate physical activity
● Osteoporosis in a first-degree relative, particularly with history of fragility
fracture
● Clinical conditions such as thyrotoxicosis, celiac sprue, IBD, cirrhosis, chronic
renal disease, organ transplantation, diabetes, HIV, hypogonadism, multiple
myeloma, anorexia nervosa, and rheumatologic and autoimmune disorders
● Medications such as oral and high-dose inhaled corticosteroids, anticoagulants
(long-term use), aromatase inhibitors for breast cancer, methotrexate,
selected antiseizure medications, immunosuppressive agents, proton-pump
inhibitors (long-term use), and antigonadal therapy for prostate cancer
osteoporosis screening recommendations
The U.S. Preventive Services Task Force
(USPSTF) gives a grade B recommendation supporting osteoporosis screening
for women age ≥65 years and for younger women whose 10-year fracture risk
equals or exceeds that of an average-risk 65-year-old white woman.34 The USPSTF
finds that evidence about risks and benefits for men is insufficient (I statement)
for recommending routine screening. However, the American College of
Physicians recommends that clinicians periodically assess older men for osteoporosis
risk and measure bone density for those at increased risk who are candidates
for drug therapy.37 Screen your patients for the many risk factors listed on
the preceding page, and proceed to further assessment.
bone strength depends on:
bone quality, bone
density, and overall bone size.
best predictor of hip fracture
DEXA measurement of bone density at the femoral neck
read:
- calcium and vitamin d recommendations
- antiresportive and anabolic agents
- preventing falls
p.640-1
Steps for Examining the Joints
- Inspect for joint symmetry, alignment, bony deformities, and swelling
- Inspect and palpate surrounding tissues for skin changes, nodules, muscle
atrophy, tenderness - Assess range of motion and maneuvers to test joint function and stability
and the integrity of ligaments, tendons, bursae, especially if pain or trauma - Assess any areas of inflammation, especially tenderness, swelling, warmth,
redness
Your examination should be systematic. Include inspection, palpation of bony
structures and related joint and soft tissue structures, assessment of range of
motion, and special maneuvers to test specific movements. Recall that the anatomical
shape of each joint determines its range of motion.
Tips for Successful Examination of the
Musculoskeletal System
● During inspection, look for symmetry of involvement. Is the change in joints
symmetric on both sides of the body, or is the change only in one or two joints?
Note any deformities or malalignment of bones or joints.
● Use inspection and palpation to assess the surrounding tissues, noting skin
changes, subcutaneous nodules, and muscle atrophy. Note any crepitus, an
audible or palpable crunching during movement of tendons or ligaments over
bone or areas of cartilage loss. This may occur in joints without pain but is
more significant when associated with symptoms or signs.
● Test range of motion and maneuvers (described for each joint) to demonstrate
limitations in range of motion or joint instability from excess mobility of
joint ligaments, called ligamentous laxity.
● Finally, test muscle strength to aid in the assessment of joint function (for
these techniques, see Chapter 17, pp. 743–748).
Assessing the Four Signs of Inflammation
● Swelling. Palpable swelling may involve: (1) the synovial membrane, which can
feel boggy or doughy; (2) effusion from excess synovial fluid within the joint
space; or (3) soft tissue structures, such as bursae, tendons, and tendon
sheaths.
● Warmth. Use the backs of your fingers to compare the involved joint with
its unaffected contralateral joint, or with nearby tissues if both joints are
involved.
● Redness. Redness of the overlying skin is the least common sign of inflammation
near the joints and is usually seen in more superficial joints like fingers,
toes, and knees.
● Pain or tenderness. Try to identify the specific anatomic structure that is
tender.
Temporomandibular Joint
Overview, Bony Structures, and Joints. The temporomandibular joint (TMJ) is the most active joint in the body, opening and closing up to 2,000 times a day (Figs. 16-10 and 16-11). It is formed by the fossa and articular tubercle of the temporal bone and the condyle of the mandible. It lies midway between the external acoustic meatus and the zygomatic arch. A fibrocartilaginous disc cushions the action of the condyle of the mandible against the synovial membrane and capsule of the articulating surfaces of the temporal bone. Therefore, it is a condylar synovial joint. Muscle Groups and Additional Structures. The principal muscles opening the mouth are the external pterygoids (Fig. 16-12). Closing the mouth are the muscles innervated by cranial nerve V, the trigeminal nerve— the masseter, the temporalis, and the internal pterygoids
TMJ swelling may appear as:
rounded bulge approximately
0.5 cm anterior to the external auditory meatus.
TMJ: inpection and palpation
Inspect the face for symmetry. Inspect the
TMJ for swelling or redness. Swelling may appear as a rounded bulge approximately
0.5 cm anterior to the external auditory meatus.
To locate and palpate the joint, place
the tips of your index fingers just in
front of the tragus of each ear and ask
the patient to open his or her mouth
(Fig. 16-13). The fingertips should
drop into the joint spaces as the mouth
opens. Check for smooth range of
motion; note any swelling or tenderness.
Snapping or clicking may be felt
or heard in normal people.
Palpate the muscles of mastication:
■ The masseters, externally at the angle of the mandible
■ The temporal muscles, externally during clenching and relaxation of the jaw
■ The pterygoid muscles, internally between the tonsillar pillars at the mandible
TMJ: ROM and maneuvers
The TMJ has glide and hinge motions
in its upper and lower portions, respectively. Grinding or chewing consists primarily
of gliding movements in the upper compartments.
Range of motion is threefold: ask the patient to demonstrate opening and closing,
protrusion and retraction (by jutting the mandible forward), and lateral, or sideto-
side, motion. Normally, as the mouth is opened wide, three fingers can be
inserted between the incisors. During normal protrusion of the jaw, the bottom
teeth can be placed in front of the upper teeth.
Shoulder
The glenohumeral joint of the shoulder is distinguished by wideranging
movement in all directions. This joint is largely uninhibited by bony
structures. The humeral head contacts less than one third of the surface area of
the glenoid fossa and essentially dangles from the scapula, attached by the joint capsule, the intra-articular capsular ligaments, the glenoid labrum, and a
meshwork of muscles and tendons.
The shoulder derives its mobility from a complex interconnected structure of
three joints, three large bones, and three principal muscle groups, often referred
to as the shoulder girdle. These structures are viewed as dynamic stabilizers, which
are capable of movement, or static stabilizers, which are incapable of movement.
■ Dynamic stabilizers: These consist of the SITS muscles of the rotator cuff (Supraspinatus,
Infraspinatus, Teres minor, and Subscapularis), which move the
humerus and compress and stabilize the humeral head within the glenoid
cavity.
■ Static stabilizers: These are the bony structures of the shoulder girdle, the
labrum, the articular capsule, and the glenohumeral ligaments. The labrum
is a fibrocartilaginous ring that surrounds the glenoid and deepens its socket,
providing greater stability to the humeral head. The joint capsule is strengthened
by tendons of the rotator cuff and glenohumeral ligaments, adding to
joint stability
Shoulder: Bony structures
The bony structures of the shoulder include the
humerus, the clavicle, and the scapula (Fig. 16-14). The scapula is anchored to
the axial skeleton only by the sternoclavicular joint and inserting muscles, often
called the scapulothoracic articulation because it is not a true joint.
Identify the manubrium, the sternoclavicular joint, and the clavicle. Also identify
the tip of the acromion, the greater tubercle of the humerus, and the coracoid process,
which are important landmarks of shoulder anatomy
Shoulder: Joints
The glenohumeral joint. In this joint, the head of the humerus articulates with
the shallow glenoid fossa of the scapula. This joint is deeply situated and
normally not palpable. It is a ball-and-socket joint, allowing the arm its wide
arc of movement—flexion, extension, abduction (movement away from the
trunk), adduction (movement toward the trunk), rotation, and circumduction.
■ The sternoclavicular joint. The convex medial end of the clavicle articulates
with the concave hollow in the upper sternum.
■ The acromioclavicular joint. The lateral end of the clavicle articulates with the
acromion process of the scapula.
Shoulder: Muscle Groups
The Scapulohumeral Group. This group extends from the scapula to the
humerus and includes the muscles inserting directly on the humerus, namely the
SITS muscles of the rotator cuff:
■ Supraspinatus—runs above the glenohumeral joint; inserts on the greater
tubercle
■ Infraspinatus and teres minor—cross the glenohumeral joint posteriorly; insert
on the greater tubercle
■ Subscapularis (not illustrated)—originates on the anterior surface of the
scapula and crosses the joint anteriorly; inserts on the lesser tubercle
The scapulohumeral
group rotates the shoulder
laterally (the rotator
cuff ) and depresses and
rotates the head of the
humerus (Fig. 16-15).
See pp. 653–654 for discussion
of rotator cuff
injuries.
The Axioscapular Group. This group attaches the scapula to the trunk
and includes the trapezius, rhomboids, serratus anterior, and levator scapulae
(Fig. 16-15). These muscles rotate the scapula and pull the shoulder posteriorly.
The Axiohumeral Group. This group attaches
the humerus to the trunk and includes the pectoralis
major and minor and the latissimus dorsi (Fig. 16-16).
These muscles rotate the shoulder internally.
The biceps and triceps, which connect the scapula to
the bones of the forearm, are also involved in shoulder
movement, especially forward flexion (biceps) and
extension (triceps).
Shoulder: additional structures
Also important to
shoulder movement are the articular capsule and bursae.
Surrounding the glenohumeral joint is a fibrous
articular capsule formed by the tendon insertions of the
rotator cuff and other capsular structures. The loose fit
of the capsule allows the shoulder bones to separate,
and contributes to the shoulder’s wide range of
movement. The capsule is lined by a synovial membrane
with two outpouchings—the subscapular bursa and the
synovial sheath of the tendon of the long head of the biceps.
To locate the biceps tendon, rotate your arm externally and
find the tendinous cord that runs just medial to the greater
tubercle (Fig. 16-17). Roll it under your fingers. This is the
tendon of the long head of the biceps. It runs in the bicipital
groove between the greater and lesser tubercles.
The principal bursa of the shoulder is the subacromial
bursa, positioned between the acromion and the head of
the humerus and overlying the supraspinatus tendon.
Abduction of the shoulder compresses this bursa. Normally,
the supraspinatus tendon and the subacromial
bursa are not palpable. However, if the bursal surfaces
are inflamed (subacromial bursitis), there may be tenderness
just below the tip of the acromion, pain with
abduction and rotation, and loss of smooth movement
shoulder: insepction
Inspect the shoulder and shoulder girdle anteriorly, then the
scapulae and related muscles posteriorly.
Note any swelling, deformity, muscle atrophy or fasciculations (fine tremors of the
muscles), or abnormal positioning.
Look for swelling of the joint capsule anteriorly or a bulge in the subacromial
bursa under the deltoid muscle. Survey the entire upper extremity for color
change, skin alteration, or unusual bony contours.
shoulder: palpation
Begin by palpating the bony contours and structures of the
shoulder, then palpate any area of pain.
■ Beginning medially, at the sternoclavicular joint, trace the clavicle laterally
with your fingers.
■ From behind, follow the bony spine
of the scapula laterally and upward
until it becomes the acromion (A), the
summit of the shoulder (Fig. 16-18).
Its upper surface is rough and slightly
convex. Identify the anterior tip of the
acromion.
■ With your index finger on top of the acromion, just behind its tip, press
medially with your thumb to find the slightly elevated ridge that marks the
distal end of the clavicle at the acromioclavicular joint (shown by the arrow).
Move your thumb medially and down a short step to the next bony prominence,
the coracoid process (B) of the scapula.
■ With your thumb on the coracoid process, allow your fingers to fall on and
grasp the lateral aspect of the humerus to palpate the greater tubercle (C),
where the SITS muscles insert.
Next, to palpate the biceps tendon in the intertubercular bicipital groove, keep
your thumb on the coracoid process and your fingers on the lateral aspect of
the humerus (Fig. 16-19). Remove
your index finger and place it halfway
between the coracoid process and the
greater tubercle on the anterior surface
of the arm. As you check for tendon
tenderness, rolling the tendon
under the fingertips may be helpful.
You can also rotate the glenohumeral
joint externally, locate the muscle distally
near the elbow, and track the
muscle and its tendon proximally
into the intertubercular groove.
■ To examine the subacromial and subdeltoid bursae and the SITS muscles, first
passively extend the humerus by lifting the elbow posteriorly, which rotates
these structures so that they are anterior to the acromion. Palpate carefully
over the subacromial and subdeltoid bursae (Figs. 16-20 and 16-21). The
underlying palpable SITS muscles are:
Supraspinatus—directly under the acromion
■ Infraspinatus—posterior to supraspinatus
■ Teres minor—posterior and inferior to the supraspinatus
■ Subscapularis—inserts anteriorly and is not palpable
■ The fibrous articular capsule and the broad flat tendons of the rotator cuff are
so closely associated that they must be examined simultaneously. Swelling in
the capsule and synovial membrane is often best detected by looking down
on the shoulder from above. Palpate the capsule and synovial membrane
beneath the anterior and posterior acromion to check for injury or arthritis
Shoulder: ROM
(1) Flexion
Principal Muscles Affecting Movement Anterior deltoid, pectoralis major (clavicular
head), coracobrachialis, biceps brachii
Patient Instructions
“Raise your arms in front of you and overhead.”
(2) Extension Principal Muscles Affecting Movement Latissimus dorsi, teres major, posterior deltoid, triceps brachii (long head) Patient Instructions “Raise your arms behind you.”
(3) Abduction Principal Muscles Affecting Movement Supraspinatus, middle deltoid, serratus anterior (via upward rotation of the scapula) Patient Instructions “Raise your arms out to the side and overhead.”
(4) Adduction Principal Muscles Affecting Movement Pectoralis major, coracobrachialis, latissimus dorsi, teres major, subscapularis Patient Instructions “Cross your arm in front of your body.”
(5) Internal Rotation Principal Muscles Affecting Movement Subscapularis, anterior deltoid, pectoralis major, teres major, latissimus dorsi Patient Instructions “Place one hand behind your back and touch your shoulder blade.” Identify the highest midline spinous process the patient is able to reach
(6) External Rotation Principal Muscles Affecting Movement Infraspinatus, teres minor, posterior deltoid Patient Instructions “Raise your arm to shoulder level; bend your elbow and rotate your forearm toward the ceiling.” OR “Place one hand behind your neck or head as if you are brushing your hair.”
Shoulder: Maneuvers
Acromiocalvicular Joint - Crossover or crossed body
adduction test. Adduct
the patient’s arm
across the chest.
Overall Shoulder Rotation - Apley scratch test. Ask the patient to touch the opposite
scapula using the two motions shown below.
Tests abduction and
external rotation.
Tests adduction and internal
rotation.
Rotator Cuff: Pain Provocation Tests - Painful arc test. Fully adduct the patient’s arm from 0° to 180°. Neer impingement sign. Press on the scapula to prevent scapular motion with one hand, and raise the patient’s arm with the other. This compresses the greater tuberosity of the humerus against the acromion. Hawkins impingement sign. Flex the patient’s shoulder and elbow to 90° with the palm facing down. Then, with one hand on the forearm and one on the arm, rotate the arm internally. This compresses the greater tuberosity against the supraspinatus tendon and coracoacromial ligament.
Strength Tests: External rotation lag test. With the patient’s arm flexed to 90° with palm up, rotate the arm into full external rotation Internal rotation lag test. Ask the patient to place the dorsum of the hand on the low back with the elbow flexed to 90°. Then you lift the hand off the back, which further internally rotates the shoulder. Ask the patient to keep the hand in this position. 90º flexion Drop-arm test. Ask the patient to fully abduct the arm to shoulder level, up to 90°, and lower it slowly. Note that abduction above shoulder level, from 90° to 120°, reflects action of the deltoid muscle.
Composite Tests: External rotation resistance test. Ask the patient to adduct and flex the arm to 90°, with the thumbs turned up. Stabilize the elbow with one hand and apply pressure proximal to the patient’s wrist as the patient presses the wrist outward in external rotation. Empty can test. Elevate the arms to 90° and internally rotate the arms with the thumbs pointing down, as if emptying a can. Ask the patient to resist as you place downward pressure on the arms
Shoulder: Tests
Pain provocation test: painful arc test (subacromial bursa and rotator cuff). This test
has a positive LR of 3.7, which is the highest of all the rotator cuff maneuvers.
It also has the best negative LR, 0.36, for ruling out rotator cuff disorders. Other
common pain provocation tests are the Neer and Hawkins tests, also included
in the box on next page, although their positive LRs are <2, so they are less
diagnostic
Strength tests: internal rotation lag test (subscapularis), external rotation lag test
(supraspinatus and infraspinatus), and drop arm test (supraspinatus). These tests
have positive LRs of 7.2, 5.6, and 3.3, respectively.
■ Composite test: external rotation resistance test (infraspinatus). This test has
a positive LR of 2.6. Another common composite test is the empty can
test.
Elbow: Bony Structures and Joints
The elbow helps position the hand in
space and stabilizes the lever action of the forearm.
The elbow joint is formed by the humerus and the
two bones of the forearm, the radius and the ulna
(Fig. 16-22). Identify the medial and lateral
epicondyles of the humerus and the olecranon
process of the ulna.
These bones have three articulations: the humeroulnar
joint, the radiohumeral joint, and the
radioulnar joint. All three share a large common
articular cavity and an extensive synovial lining.
Elbow: Muscle Groups and Additional Structures
Muscles traversing the elbow
include the biceps and brachioradialis (flexion),
the brachialis, the triceps (extension), the pronator
teres (pronation), and the supinator (supination).
Note the location of the olecranon bursa between
the olecranon process and the skin (Fig. 16-23).
The bursa is not normally palpable but swells
and becomes tender when inflamed. The ulnar
nerve runs posteriorly in the ulnar groove
between the medial epicondyle and the olecranon
process. The radial nerve is adjacent to the
lateral epicondyle. On the ventral forearm, the
median nerve is just medial to the brachial artery
in the antecubital fossa.
Elbow: inspection
Support the patient’s forearm with your opposite hand so
that the elbow is flexed to about 70°. Identify the medial and lateral epicondyles
and the olecranon process of the ulna. Inspect the contours of the elbow,
including the extensor surface of the ulna and the olecranon process. Note any
nodules or swelling.
Elbow: Palpation
Palpate the olecranon
process and press over the epicondyles for
tenderness (Fig. 16-24).
Palpate the grooves between the epicondyles
and the olecranon process, where the
synovium is most easily examined. Normally
the synovium and olecranon bursae
are not palpable.
The sensitive ulnar nerve can be palpated
posteriorly between the olecranon process
and the medial epicondyle.
Note any displacement of the olecranon process (Figs. 16-25 and 16-26).
Elbow: ROM (primary muscles affecting movement, patient instructions)
Flexion:Biceps brachii, brachialis,
brachioradialis
PI: “Bend your elbow”
Extension: Triceps brachii, anconeus
PI: “straighten your elbow”
Supination: Biceps brachii, supinator
PI: “Turn your palms up, as if
carrying a bowl of soup.”
Pronation: Pronator teres, pronator quadratus
PI: “Turn your palms down.”
Wrist and Hands: Bony Structures
The wrist includes
the distal radius and ulna and eight small
carpal bones (Fig. 16-28). At the wrist,
identify the bony tips of the radius and the
ulna.
Identify the carpal bones distal to the wrist
joint, each of the five metacarpals, and the
proximal, middle, and distal phalanges.
Note that the thumb has only two phalanges.
Wrist and Hands: Joints
Wrist joints. The wrist joints include the radiocarpal or wrist joint, the distal radioulnar joint, and the intercarpal joints (Fig. 16-29). The joint capsule, articular disc, and synovial membrane of the wrist join the radius to the ulna and to the proximal carpal bones. On the dorsum of the wrist, locate the groove of the radiocarpal joint. This joint provides most of the flexion and extension at the wrist because the ulna does not articulate directly with the carpal bones. ■ Hand joints. The joints of the hand include the metacarpophalangeal joints (MCPs), the proximal interphalangeal joints (PIPs), and the distal interphalangeal joints (DIPs). Flex the hand and find the groove marking the MCP joint of each finger (Fig. 16-30). It is distal to the knuckle and is best felt on either side of the extensor tendon
Wrist and Hands: Muscle Groups
Wrist flexion arises from the two carpal muscles, located
on the radial and ulnar surfaces. Two radial and one ulnar muscle provide wrist
extension. Supination and pronation are powered by muscle contraction in the
forearm.
The thumb is powered by three muscles that form the thenar eminence and
provide flexion, abduction, and opposition. The muscles of extension are at the
base of the thumb along the radial margin. Movement in the digits depends on
action of the flexor and extensor tendons of muscles in the forearm and wrist.
The intrinsic muscles of the hand attaching to the metacarpal bones are involved
in flexion (lumbricals), abduction (dorsal interossei), and adduction (palmar interossei)
of the fingers.
Wrist and Hands: Additional Structures
Soft tissue structures, especially tendons and tendon sheaths, are especially important to movement of the wrist and hand. Six extensor tendons and two flexor tendons pass across the wrist and hand to insert on the fingers. Through much of their course these tendons travel in tunnel-like sheaths, generally palpable only when swollen or inflamed. Be familiar with the structures of the carpal tunnel, a channel beneath the palmar surface of the wrist and proximal hand (Fig. 16-31). The channel contains the sheath and flexor tendons of the forearm muscles and the median nerve. Holding the tendons and tendon sheath in place is a transverse ligament, the flexor retinaculum. The median nerve lies between the flexor retinaculum and the tendon sheath. The median nerve provides sensation to the palm and the palmar surface of most of the thumb, the second and third digits, and half of the fourth digit. It also innervates the thumb muscles of flexion, abduction, and opposition.
Wrist and Hands: inspection
Inspect the position of the hands in motion for smooth natural
movement. When the fingers are relaxed they should be slightly flexed; the
fingernail edges should be in parallel
Wrist and Hands: inspection
Inspect the position of the hands in motion for smooth natural
movement. When the fingers are relaxed they should be slightly flexed; the
fingernail edges should be in parallel
Inspect the palmar and dorsal surfaces of the wrist and hand carefully for swelling
over the joints or signs of trauma.
Note any deformities of the wrist, hand, or finger bones, as well as any angulation.
Observe the contours of the palm, namely the thenar and hypothenar eminences.
Note any thickening of the flexor tendons or flexion contractures in the fingers.
Wrist and Hands: Palpation
At the wrist, palpate
the distal radius and ulna on the lateral
and medial surfaces (Fig. 16-32).
Palpate the groove of each wrist joint
with your thumbs on the dorsum of
the wrist, your fingers beneath it. Note
any swelling, bogginess, or tenderness
Palpate the radial styloid bone and the
anatomic snuffbox, a hollowed depression
just distal to the radial styloid process
formed by the abductor and extensor
muscles of the thumb (Fig. 16-33). The
“snuffbox” is more visible with lateral
extension of the thumb away from the
hand (abduction).
Palpate the eight carpal bones lying distal
to the wrist joint, and then each of the
five metacarpals and the proximal, middle,
and distal phalanges (Fig. 16-34).
Palpate any other area where you suspect
an abnormality.
Compress the MCP joints by squeezing
the hand from each side between
the thumb and fingers. Alternatively,
use your thumb to palpate each MCP
joint just distal to and on each side of
the extensor tendons as your index finger
feels the head of the metacarpal in
the palm. Note any swelling, bogginess, or tenderness.
Now examine the fingers and thumb. Palpate the medial and lateral aspects of
each PIP joint between your thumb and index finger, again checking for swelling,
bogginess, bony enlargement, or tenderness.
Using the same techniques, examine
the DIP joints (Fig. 16-36).
In any area of swelling or inflammation, palpate along the tendons inserting on
the thumb and fingers.
Wrist ROM (primary muscles affecting movement & patient instructions)
Flexion: Flexor carpi radialis, flexor
carpi ulnaris
“With palms down, point your
fingers toward the floor.”
Extension: Extensor carpi ulnaris, extensor carpi radialis longus, extensor carpi radialis brevis “With palms down, point your fingers toward the ceiling.”
Adduction (radial deviation): Flexor carpi ulnaris
“With palms down, bring your
fingers toward the midline.”
Abduction (ulnar deviation): Flexor carpi radialis
“With palms down, bring your
fingers away from the
midline.”
Hand and Wrist Maneuvers
Maneuvers for assessing conditions at the wrist are listed on
the next page. For complaints of nocturnal hand or arm numbness (paresthesias),
dropping objects, inability to twist lids off jars, aching at the wrist or
even the forearm, and numbness of the first three digits, test for carpal tunnel
syndrome, the most common entrapment neuropathy, involving compression
of the median nerve. Learn the distribution of the median, radial, and ulnar
nerve innervations of the wrist and hand (Figs. 16-39 and 16-40). Remember
to assess more proximal causes of wrist and hand pain arising from cervical
radiculopathy.
Ulnar
nerve
Median nerve
Radial nerve
F I G U R E 1 6 - 3 9 . Dorsal surface.
Radial nerve
Ulnar
nerve
Median nerve
F I G U R E 1 6 - 4 0 . Volar surface.
Forceful repetitive handwork with
wrist flexion such as keyboarding or
mail sorting, vibration, cold environments,
wrist anatomy, pregnancy, RA,
diabetes, and hypothyroidism are risk
factors for carpal tunnel syndrome.
You can test sensation as follows:
■ Pulp of the index finger—median nerve
■ Pulp of the fifth finger—ulnar nerve
■ Dorsal web space of the thumb and index finger—radial nerve
Hand Grip. Test hand grip strength by asking
the patient to grasp your second and third
fingers (Fig. 16-41). This tests function of wrist
joints, the finger flexors, and the intrinsic muscles
and joints of the hand
EXAMINATION OF SPECIFIC JOINTS
Thumb Movement. To test thumb
function, ask the patient to grasp the
thumb against the palm and then move
the wrist toward the midline in ulnar deviation
(sometimes called the Finkelstein
test), as shown in Figure 16-42.
Carpal Tunnel Syndrome—Thumb Abduction,
Tinel Test, and Phalen Test for Median
Nerve Compression. To test thumb
abduction, ask the patient to raise the
thumb straight up as you apply downward
resistance (Fig. 16-43).
Test Tinel sign by tapping lightly over the
course of the median nerve in the carpal
tunnel as shown in Figure 16-44.
To test Phalen sign, ask the patient to hold
the wrists in flexion for 60 seconds with the
elbows fully extended (Fig. 16-45). Alternatively,
ask the patient to press the backs
of both hands together to form right angles.
These maneuvers compress the median
nerve.
Fingers: ROM
Assess flexion, extension, abduction, and adduction
of the fingers.
■ Flexion and extension (Fig. 16-46). For flexion,
to test the lumbricals and finger flexor muscles,
ask the patient to “Make a tight fist with
each hand, thumb across the knuckles.” For extension,
to test the finger extensor muscles,
ask the patient to “Extend and spread the fingers.”
At the MCPs, the fingers may extend
beyond the neutral position.
Test the flexion and extension of the PIP and
DIP joints (lumbrical muscles). The fingers
should open and close easily.
■ Abduction and adduction (Fig. 16-47). Ask the
patient to spread the fingers apart (abduction
from dorsal interossei) and back together (adduction
from palmar interossei). Check for
smooth, coordinated movement.
Thumbs: ROM
At the thumb, assess flexion, extension, abduction, adduction, and
opposition (Figs. 16-48 to 16-51). Each of these movements is powered by a
related muscle of the thumb
Ask the patient to move the thumb across the palm and touch the base of the fifth
finger to test flexion, and then to move the thumb back across the palm and away
from the fingers to test extension.
Next, ask the patient to place the fingers and thumb in the neutral position with
the palm up, then have the patient move the thumb anteriorly away from the
palm to assess abduction and back down for adduction. To test opposition, or
movements of the thumb across the palm, ask the patient to touch the thumb to
each of the other fingertips.
A full examination of the wrist and hand involves detailed testing of muscle
strength and sensation,
Spine: overview
The vertebral column, or spine, is the central supporting structure
of the trunk and back. The concave curves of the cervical and lumbar spine and
the convex curves of the thoracic and sacrococcygeal spine help distribute upper
body weight to the pelvis and lower extremities and cushion the concussive
impact of walking or running.
The complex mechanics of the back reflect the coordinated action of:
■ The vertebrae and intervertebral discs
■ An interconnecting system of ligaments between anterior vertebrae and posterior
vertebrae, ligaments between the spinous processes, and ligaments
between the lamina of two adjacent vertebrae
■ Large superficial muscles, deeper intrinsic muscles, and muscles of the abdominal
wall
Spine: Bony Structures
The vertebral column contains 24 vertebrae stacked on the sacrum and coccyx. A typical vertebra contains sites for joint articulations, weight bearing, and muscle attachments, as well as foramina for the spinal nerve roots and peripheral nerves. Anteriorly, the vertebral body supports weight bearing. The posterior vertebral arch encloses the spinal cord. Review the location of the vertebral processes and foramina, with particular attention to: ■ The spinous process projecting posteriorly in the midline and the two transverse processes at the junction of the pedicle and the lamina. Muscles attach at these processes. ■ The articular processes—two on each side of the vertebra, one facing up and one facing down, at the junction of the pedicles and laminae, often called articular facets. ■ The vertebral foramen, which encloses the spinal cord, the intervertebral foramen, formed by the inferior and superior articulating process of adjacent vertebrae, creating a channel for the spinal nerve roots; and in the cervical vertebrae, the transverse foramen for the vertebral artery The proximity of the spinal cord and spinal nerve roots to their bony vertebral casing and the intervertebral discs makes them especially vulnerable to disc herniation, impingement from degenerative changes in the vertebrae and facets, and trauma.
Spine: Joints
The spine has slightly movable cartilaginous joints between the
vertebral bodies and between the articular facets. Between the vertebral bodies
are the intervertebral discs, each consisting of a soft mucoid central core, the
nucleus pulposus, rimmed by the tough fibrous tissue of the annulus fibrosis. The
intervertebral discs cushion movement between vertebrae and allow the vertebral
column to curve, flex, and bend. The flexibility of the spine is largely determined
by the angle of the articular facet joints relative to the plane of the vertebral body,
and varies at different levels of the spine. Note that the vertebral column angles
sharply posterior at the lumbosacral junction and becomes immovable. The
mechanical stress at this angulation contributes to the risk for disc herniation
and subluxation, or slippage (spondylolisthesis), of L5 on S1.
Spine: Muscle Groups
The trapezius and latissimus dorsi form the large outer layer of muscles attaching to each side of the spine (Fig. 16-52). They overlie two deeper muscle layers—a layer attaching to the head, neck, and spinous processes (splenius capitis, splenius cervicis, and sacrospinalis) and a layer of smaller intrinsic muscles between vertebrae. Muscles attaching to the anterior surface of the vertebrae, including the psoas muscle and muscles of the abdominal wall, assist with flexion. Muscles moving the neck and lower vertebral column are summarized in the table on p. 670.
Spine: Inspection
Inspect the
patient’s posture when entering the
room, including the position of both
the neck and trunk.
Assess the patient for erect position of the head, neck, and back; for smooth,
coordinated neck movement; and for ease of gait.
Drape or gown the patient to expose the entire back for complete inspection.
If possible, the patient should be upright in the natural standing position, with
feet together and arms at the sides. The head should be midline in the same plane
as the sacrum, and the shoulders and pelvis should be level.
Viewing the patient from behind,
identify the following (Fig. 16-53):
■ Spinous processes, usually more
prominent at C7 and T1 and
more evident on forward flexion
■ Paravertebral muscles on either
side of the midline
■ Iliac crests
■ Posterior superior iliac spines,
usually marked by skin dimples.
A line drawn above the posterior iliac
crests crosses the spinous process of
L4.
Inspect the patient from the side and
from behind. Evaluate the spinal curvatures
and the features in the display
on the next page.
Spine: Palpation
From a sitting or standing position, palpate the spinous processes
of each vertebra with your thumb.
In the neck, palpate the facet joints that lie between the cervical vertebrae 1 to
2 cm lateral to the spinous processes of C2 to C7. These joints lie deep to the
trapezius muscle and may not be palpable unless the neck muscles are relaxed.
In the lower lumbar area, palpate carefully for vertebral “step-offs” to see if one
spinous process seems unusually prominent (or recessed) in relation to the one
above it. Identify any tenderness.
Palpate over the sacroiliac joint, often identified by the dimple overlying the posterior
superior iliac spine.
You may wish to percuss the spine for tenderness by thumping, but not too
roughly, with the ulnar surface of your fist.
Inspect and palpate the paravertebral muscles for tenderness and spasm. Muscles
in spasm feel firm and knotted and may be visible.
With the patient’s hip flexed and
the patient lying on the opposite
side, palpate the sciatic nerve, the
largest nerve in the body, consisting
of nerve roots from L4, L5, S1,
S2, and S3 (Fig. 16-54). The sciatic
nerve lies midway between the
greater trochanter and the ischial
tuberosity as it runs through the
sciatic notch. It is difficult to palpate
in most patients.
Palpate for tenderness in any other areas suggested by the patient’s symptoms.
Check for pain radiation into the buttocks, perineum, or legs.
Assess all low back pain for possible cauda equina compression, the most serious
cause of pain, due to risk of limb paralysis or bladder/bowel dysfunction
Neck: ROM
- Flexion - Sternocleidomastoid, scalene,
prevertebral muscles
“Bring your chin to your
chest.” - Extension - Splenius capitis and cervicis,
small intrinsic neck muscles
“Look up at the ceiling.” - Rotation - Sternocleidomastoid, small
intrinsic neck muscles
“Look over one shoulder,
and then the other.” - Lateral Bending - Scalenes and small intrinsic
neck muscles
“Bring your ear to your
shoulder.”
Spinal Column: ROM
Flexion - Psoas major, psoas minor, quadratus lumborum; abdominal muscles attaching to the anterior vertebrae, such as the internal and external obliques and rectus abdominis “Bend forward and try to touch your toes.” Note the smoothness and symmetry of movement, the range of motion, and the curve in the lumbar area. As flexion proceeds, the lumbar concavity should flatten out
2. Extension - Deep intrinsic muscles of the back, such as the erector spinae and transversospinalis groups “Bend back as far as possible.” Support the patient by placing your hand on the posterior superior iliac spine, with your fingers pointing toward the midline
3. Rotation - Abdominal muscles, intrinsic muscles of the back “Rotate from side to side.” Stabilize the patient’s pelvis by placing one hand on the patient’s hip and the other on the opposite shoulder. Then rotate the trunk by pulling the shoulder anteriorly and then the hip posteriorly. Repeat these maneuvers for the opposite side.
4. Lateral Bending - Abdominal muscles, intrinsic muscles of the back “Bend to the side from the waist.” Stabilize the patient’s pelvis by placing your hand on the patient’s hip. Repeat for the opposite side
Hip: overview
The hip joint is deeply embedded in the pelvis and is notable for
its strength, stability, and wide range of motion. The stability of the hip joint,
essential for weight bearing, arises from the deep fit of the head of the femur into
the acetabulum, its strong fibrous articular capsule, and the powerful muscles
crossing the joint and inserting below the femoral head, providing leverage for
movement of the femur.
Ligaments
rope-like bundles of collagen fibrils that connect bone to bone
Tendons
collagen fibers connecting muscle to bone
Bursae
pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures
Hip: Bony Structures and Joints
The hip joint lies below the middle third
of the inguinal ligament but in a deeper plane. It is a ball-and-socket joint; note
how the rounded head of the femur articulates with the cup-like cavity of the
acetabulum. Because of its overlying muscles and depth, the hip joint is not
readily palpable. Review the bones of the pelvis—the acetabulum, the ilium, and
the ischium—and the connection inferiorly at the symphysis pubis and posteriorly
with the sacroiliac bone.
On the anterior surface of the hip, locate the following
bony structures (Fig. 16-56):
■ The iliac crest at the level of L4
■ The iliac tubercle
■ The anterior superior iliac spine
■ The greater trochanter
■ The pubic tubercle
On the posterior surface of the hip, locate the following
(Fig. 16-57):
■ The posterior superior iliac spine
■ The greater trochanter
■ The ischial tuberosity
■ The sacroiliac joint
Note that you can locate S2 by envisioning an
imaginary line across the posterior superior iliac
spines
Hip: Muscle Groups
Four powerful muscle groups move the hip. Picture these
groups as you examine patients, and remember that to move the femur or any
bone in a given direction, the muscle must cross the joint line.
The flexor group lies anteriorly and
flexes the thigh (Fig. 16-58). The primary
hip flexor is the iliopsoas, extending
from above the iliac crest to the
lesser trochanter. The extensor group
lies posteriorly and extends the thigh
(Fig. 16-59). The gluteus maximus is
the primary extensor of the hip. It
forms a band crossing from its origin
along the medial pelvis to its insertion
below the trochanter
The adductor group is medial and swings
the thigh toward the body (Fig. 16-60).
The muscles in this group arise from the
rami of the pubis and ischium and insert
on the posteromedial aspect of the femur.
The abductor group is lateral, extending
from the iliac crest to the greater trochanter,
and moves the thigh away from the body
(Fig. 16-61). This group includes the gluteus
medius and minimus. These muscles
help stabilize the pelvis during the stance
phase of gait
Hip: Additional Structures
A strong, dense articular capsule, extending
from the acetabulum to the femoral neck, encases and strengthens the hip
joint. The capsule is reinforced by three overlying ligaments and lined with
synovial membrane. There are three principal bursae at the hip. Anterior to the
joint is the psoas (also termed iliopectineal or iliopsoas) bursa, overlying the
articular capsule and the psoas muscle. Find the bony prominence lateral to the hip
joint—the greater trochanter of the femur. The large multilocular trochanteric bursa
lies on its posterior surface. The ischial (or ischiogluteal) bursa, not always present,
lies under the ischial tuberosity, and accommodates the weight of the sitting position.
Note its proximity to the sciatic nerve, as shown on p. 679.
Hip: Inspection
Inspection of the hip begins with careful observation of the
patient’s gait when entering the room. Observe the two phases of gait:
1. Stance—when the foot is on the ground and bears weight (60% of the walking
cycle) (Fig. 16-62)
2. Swing—when the foot moves forward and does not bear weight (40% of the
cycle)
Inspect the gait for the width of the base,
the shift of the pelvis, and flexion of the
knee (Fig. 16-63). The width of the base
should be 2 to 4 inches from heel to heel.
Normal gait has a smooth, continuous
rhythm, achieved in part by contraction of
the abductors of the weight-bearing limb.
Abductor contraction stabilizes the pelvis
and helps maintain balance, raising the
opposite hip. The knee should be flexed
throughout the stance phase, except when
the heel strikes the ground to counteract
motion at the ankle.
Inspect the lumbar portion of the spine for the degree of lordosis and, with the
patient supine, assess the length of the legs for symmetry. (To measure leg length,
see Special Techniques, p. 694.)
Inspect the anterior and posterior surfaces of the hip for any areas of muscle
atrophy or bruising. The joint is too deeply situated to detect swelling.
Hip: Anterior Landmark Palpation
● Identify the iliac crest at the upper margin of the pelvis at the level of L4.
● Follow the downward anterior curve and locate the iliac tubercle, marking the
widest point of the crest, and continue tracking downward to the anterior–
superior iliac spine.
● Place your thumbs on the anterior–superior spines and move your fingers
downward and laterally from the iliac tubercles to the greater trochanter of
the femur.
● Then move your thumbs medially and obliquely to the pubic tubercle, which
lies at the same level as the greater trochanter.
Hip: Posterior Landmark Palpation
● Palpate the posterior–superior iliac spine directly underneath the visible dimples
just above the buttocks.
● Placing your left thumb and index finger over the posterior superior iliac
spine, next locate the greater trochanter laterally with your fingers at the level
of the gluteal fold, and place your thumb medially on the ischial tuberosity. The
sacroiliac joint is not always palpable but may be tender. Note that an imaginary
Hip: Inguinal Structures
With the patient
supine, ask the patient to place the
heel of the leg being examined on the opposite
knee. Then palpate along the inguinal
ligament, which extends from the
anterior–superior iliac spine to the pubic
tubercle (Fig. 16-64).
The femoral nerve, artery, and vein bisect the overlying inguinal ligament; lymph
nodes lie medially. The mnemonic NAVEL may help you remember the lateralto-
medial sequence of Nerve–Artery–Vein–Empty space–Lymph node.
Anterior or inguinal pain, typically deep within the hip joint and radiating to the
knee, points to intra-articular pathology; pain radiating to the buttocks or posterior
trochanteric region points to extra-articular causes.75
Hip: Bursae
If the hip is painful, palpate the (psoas) bursa, below the inguinal
ligament but on a deeper plane.
With the patient resting on one side and the hip flexed and internally rotated,
palpate the trochanteric bursa lying over the greater trochanter (Fig. 16-65). Normally,
the ischiogluteal bursa, over the ischial tuberosity, is not palpable unless
inflamed (Fig. 16-66).
Hip: ROM
primary muscles affected, patient instructions
- Flexion - Iliopsoas
“Bend your knee to your chest
and pull it against your
abdomen.”
2. Extension (actually hyperextension) - Gluteus maximus “Lie face down, then bend your knee and lift it up.” OR “Lying flat, move your lower leg away from the midline and down over the side of the table.”
- Abduction - Gluteus medius and minimus
“Lying flat, move your lower
leg away from the midline.”
4. Adduction - Adductor brevis, adductor longus, adductor magnus, pectineus, gracilis “Lying flat, bend your knee and move your lower leg toward the midline.”
5. External Rotation - Internal and external obturators, quadratus femoris, superior and inferior gemelli “Lying flat, bend your knee and turn your lower leg and foot across the midline.”
- Internal Rotation - Iliopsoas
“Lying flat, bend your knee and
turn your lower leg and foot
away from the midline.”
Hips: Maneuvers
Often, the examiner must assist the patient with movements
of the hip, so further detail is provided below for flexion, abduction, adduction,
and external and internal rotation. Meta-analyses suggest that no single test discriminates
specific hip pathology.75,77,78
■ Flexion. With the patient supine, place your hand under the patient’s lumbar
spine. Ask the patient to bend each knee in turn up to the chest and pull it
firmly against the abdomen (Fig. 16-67). Note that the hip can flex further
when the knee is flexed because the hamstrings are relaxed. When the back
touches your hand, indicating normal flattening of the lumbar lordosis, further
flexion must arise from the hip joint itself
As the thigh is held against the abdomen, inspect the degree of flexion at the
hip and knee. Normally, the anterior portion of the thigh can almost touch
the chest wall. Note whether the opposite thigh remains fully extended, resting
on the table.
■ Extension. With the patient lying face down, extend the thigh toward you in
a posterior direction. Alternatively, carefully position the supine patient near
the edge of the table and extend the leg posteriorly.
■ Abduction. Stabilize the pelvis by pressing down on the opposite anterior–
superior iliac spine with one hand. With the other hand, grasp the ankle and
abduct the extended leg until you feel the iliac spine move (Fig. 16-69). This
movement marks the limit of hip abduction
Adduction. With the patient supine, stabilize the pelvis, hold one ankle, and
move the leg medially across the body and over the opposite extremity
(Fig. 16-70).
External and internal rotation. Flex the
leg to 90° at hip and knee, stabilize the
thigh with one hand, grasp the ankle
with the other, and swing the lower
leg—medially for external rotation at
the hip, and laterally for internal rotation
(Fig. 16-71). Although confusing
at first, it is the motion of the head of
the femur in the acetabulum that identifies
these movements
Knee: Overview
The knee joint is the largest joint in the body. It is a hinge joint
involving three bones: the femur, the tibia, and the patella (or knee cap), with
three articular surfaces, two between the femur and the tibia and one between
the femur and the patella. Note how the two rounded condyles of the femur rest
on the relatively flat tibial plateau. There is no inherent stability in the knee
joint itself, making it dependent on four ligaments to hold its articulating
femur and tibia in place. This feature, in addition to the lever action of the
femur on the tibia and the lack of padding from overlying fat or muscle, makes
the knee highly vulnerable to injury.
Knee: Bony Structures
Learn the bony landmarks in and around the knee. These will guide your examination of this complicated joint (Fig. 16-72). ■ On the medial surface, identify the adductor tubercle, the medial epicondyle of the femur, and the medial condyle of the tibia. ■ On the anterior surface, identify the patella, which rests on the anterior articulating surface of the femur midway between the epicondyles, embedded in the tendon of the quadriceps muscle. This tendon continues below the knee joint as the patellar tendon, which inserts distally on the tibial tuberosity. ■ On the lateral surface, find the lateral epicondyle of the femur, the lateral condyle of the tibia, and the head of the fibula
Knee: Joints
Two condylar tibiofemoral joints are formed by the convex curves of
the medial and lateral condyles of the femur as they articulate with the concave
condyles of the tibia. The third articular surface is the patellofemoral joint. The
patella slides on the groove of the anterior aspect of the distal femur, called the
trochlear groove, during flexion and extension of the knee.
Knee: Muscle Groups
Powerful muscles move and support the knee. The
quadriceps femoris extends the knee, covering the anterior, medial, and lateral
aspects of the thigh (Figs. 16-73 and 16-74). The hamstring muscles lie on the
posterior aspect of the thigh and flex the knee
Knee: Menisci and Ligaments
The menisci and two important pairs of ligaments,
the collaterals and the cruciates, are crucial to stability of the knee.
Learn the location of these structures from the illustrations on p. 682 and below
(Fig. 16-75).
■ The medial and lateral menisci cushion
the action of the femur on the
tibia. These crescent-shaped fibrocartilaginous
discs add a cup-like
surface to the otherwise flat tibial
plateau.
■ The medial collateral ligament (MCL),
not easily palpable, is a broad, flat
ligament connecting the medial femoral
epicondyle to the medial condyle
of the tibia. The medial portion
of the MCL also attaches to the medial
meniscus.
■ The lateral collateral ligament (LCL) connects the lateral femoral epicondyle
and the head of the fibula. The MCL and LCL provide medial and lateral
stability to the knee joint.
■ The ACL crosses obliquely from the anterior medial tibia to the lateral femoral
condyle, preventing the tibia from sliding forward on the femur.
■ The posterior cruciate ligament (PCL) crosses from the posterior tibia and lateral
meniscus to the medial femoral condyle, preventing the tibia from slipping
backward on the femur. Although the ACL and PCL lie within the knee
joint so are not palpable, they are nonetheless crucial to the anteroposterior
stability of the knee.
Knee: Negative Infrapatellar Space and Suprapatellar Pouch
Inspect the
concavities that are usually evident adjacent and superior to each side of the patella,
known as the “negative infrapatellar space” (Fig. 16-76). Occupying these areas is
the synovial cavity of the knee, one of the largest joint cavities in the body. This cavity
includes an extension 6 cm above the upper border of the patella, lying upward
and deep to the quadriceps muscle, called the suprapatellar pouch. The joint cavity
covers the anterior, medial, and lateral surfaces of the knee, as well as the condyles
of the femur and tibia posteriorly. Although the synovium is not normally palpable,
these areas may become swollen and tender when the joint is inflamed or injured
Knee: Bursae
Several bursae lie near the knee. The prepatellar bursa lies between
the patella and the overlying skin. The anserine bursa lies 1 to 2 cm below the knee
joint on the medial surface, proximal and medial to the attachments of the medial
hamstring muscles on the proximal tibia. It cannot be palpated due to these overlying
tendons. Now identify the large semimembranosus bursa that communicates
with the joint cavity, also on the posterior and medial surfaces of the knee.
Knee: Inspection
Learn to examine “the seven structures
of the knee”: the medial and lateral menisci, the LCL and MCL, the ACL and
PCL, and the patellar tendon. The ACL and PCL are not palpable but are tested
by specific maneuvers. Palpation and maneuvers of these structures are especially
helpful in primary care diagnosis.
Inspection. Inspect the gait for a smooth rhythmic flow as the patient enters
the room. The knee should be extended at heel strike and flexed at all other phases
of swing and stance.
Check the alignment and contours of the knees. Observe any atrophy of the
quadriceps muscles.
Inspect for any loss of the normal hollows around the patella, a sign of swelling
in the knee joint and suprapatellar pouch; note any other swelling in or around
the knee.
Knee: Palpation
Ask the patient to sit on the edge of the examining table with
the knees in flexion. In this position, bony landmarks are more visible, and the
muscles, tendons, and ligaments are more relaxed, making them easier to palpate.
Pay special attention to any areas of tenderness. Pain is a common complaint in
knee problems, and localizing the structure causing pain is important for accurate
evaluation.
Knee: Tibiofemoral Joint Palpation
Palpate the tibiofemoral joint. Facing the knee, place
your thumbs in the soft tissue depressions on either side of the patellar tendon.
Identify the groove of the tibiofemoral joint. Note that the inferior pole of the
patella lies at the tibiofemoral joint line. As you press your thumbs downward,
you can feel the edge of the tibial plateau. Follow it medially, then laterally, until
you are stopped by the converging femur and tibia. By moving your thumbs upward
toward the midline to the top of the patella, you can follow the articulating
surface of the femur and identify the margins of the joint.
Note any irregular bony ridges along the joint margins.
Knee: Medial and lateral menisci palpation
Palpate the medial meniscus. Press on the medial
soft tissue depression along the upper edge of the tibial plateau with the tibia
slightly internally rotated. Place the knee in slight flexion and palpate the
lateral meniscus along the lateral joint line
Knee: medial and lateral joint compartments ( MCL and LCL) palpation
Palpate the medial and lateral joint
compartments of the tibiofemoral joint
with the knee flexed on the examining
table to approximately 90°. Pay special attention
to any areas of pain or tenderness.
■ Medial compartment (Fig. 16-77). Medially,
move your thumbs upward to palpate
the medial femoral condyle. The
adductor tubercle is posterior to the medial
femoral condyle. Move your
thumbs downward to palpate the medial
tibial plateau.
Also medially, palpate along the joint
line and identify the MCL, which connects
the medial epicondyle of the
femur to the medial condyle and superior
medial surface of the tibia. Palpate
along this broad, flat ligament from its
origin to insertion
■ Lateral compartment. Lateral to the patellar tendon, move your thumbs
upward to palpate the lateral femoral condyle and downward to palpate the
lateral tibial plateau. When the knee is flexed, the femoral epicondyles are
lateral to the femoral condyles.
■ Also on the lateral surface, ask the patient to cross one leg so that the ankle
rests on the opposite knee and find the LCL, a firm cord that runs from
the lateral femoral epicondyle to the head of the fibula.
Knee: patellofemoral compartment: patellar tendon palpation
Palpate the patellofemoral compartment.
Locate the patella and trace the patellar tendon distally until you
palpate the tibial tuberosity. Ask the patient to extend the knee to make sure
the patellar tendon is intact.
With the patient supine and the knee extended, compress the patella against
the underlying femur, and gently move it medially and laterally, assessing for
crepitus and pain. Ask the patient to tighten the quadriceps as the patella
moves distally in the trochlear groove. Check for a smooth sliding motion
(the patellofemoral grinding test).
Knee: suprapetellar pouch, pre patellar bursa, and anemone bursa palpation
Palpate for
any thickening or swelling in the suprapatellar
pouch and along the margins of the
patella (Fig. 16-78). Start 10 cm above
the superior border of the patella, well
above the pouch, and feel the soft tissues
between your thumb and fingers. Move
your hand distally in progressive steps,
trying to identify the pouch. Continue
your palpation along the sides of the patella.
Note any tenderness or increased
warmth.
Check three other bursae for bogginess or swelling. Palpate the prepatellar bursa.
Palpate over the anserine bursa on the posteromedial side of the knee between
the MCL and the tendons inserting on the medial tibial and plateau. On the
posterior surface, with the leg extended, check the medial aspect of the popliteal
fossa.
Knee: palpation tests for joint effusion
Learn to apply three tests for detecting
fluid in the knee joint: the bulge sign, the balloon sign, and balloting
the patella.
■ The bulge sign (for minor effusions). With the knee extended, place the left hand
above the knee and apply pressure on the suprapatellar pouch, displacing or “milking”
fluid downward (Fig. 16-80). Stroke downward on the medial aspect of the
knee and apply pressure to force fluid into the lateral area (Fig. 16-81). Tap the
knee just behind the lateral margin of the patella with the right hand (Fig. 16-82).
■ The balloon sign (for major
effusions). Place the thumb
and index finger of your
right hand on each side of
the patella; with the left
hand, compress the suprapatellar
pouch against the
femur (Fig. 16-83). Palpate
for fluid ejected or “ballooning”
into the spaces next to
the patella under your right
thumb and index finger
■ Balloting the patella (for major effusions).
To assess large effusions, you can also
compress the suprapatellar pouch and
“ballotte” or push the patella sharply
against the femur (Fig. 16-84). Watch for
fluid returning to the suprapatellar
pouch.
Knee: Gastrocnemius and Soleus Muscles, Achiles Tendon palpation
Palpate the gastrocnemius
and soleus muscles on the posterior lower leg. Their common tendon,
the Achilles, is palpable from about the lower third of the calf to its insertion on
the calcaneus.
To test the integrity of the Achilles tendon, place the patient prone with the knee
and ankle flexed at 90°, or alternatively, ask the patient to kneel on a chair.
Squeeze the calf and watch for plantar flexion at the ankle.
Knee: ROM
primary muscles affecting movement and patient instructions
1. Flexion - Hamstring group: biceps femoris, semitendinosus, and semimembranosus “Bend or flex your knee.” OR “Squat down to the floor.”
2. Extension - Quadriceps: rectus femoris, vastus medialis, lateralis, and intermedius “Straighten your leg.” OR “After you squat down to the floor, stand up.”
- Internal Rotation - Sartorius, gracilis, semitendinosus,
semimembranosus
“While sitting, swing your lower
leg toward the midline.” - External Rotation - Biceps femoris
“While sitting, swing your lower
leg away from the midline.”
Knee: Maneuvers
1. Medial Meniscus and Lateral Meniscus: McMurray Test. With the patient supine, grasp the heel and flex the knee. Cup your other hand over the knee joint with fingers and thumb along the medial joint line. From the heel, externally rotate the lower leg, then push on the lateral side to apply a valgus stress on the medial side of the joint. At the same time, slowly extend the lower leg in external rotation. The same maneuver with internal rotation of the foot stresses the lateral meniscus. If a click is felt or heard at the joint line during flexion and extension of the knee, or if tenderness is noted along the joint line, further assess the meniscus for a posterior tear.
2. Medial Collateral Ligament (MCL): Abduction (or Valgus) Stress Test. With the patient supine and the knee slightly flexed, move the thigh about 30° laterally to the side of the table. Place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle. Push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side (valgus stress).
3. Lateral Collateral Ligament (LCL): Adduction (or Varus) Stress Test. With the thigh and knee in the same position, change your position so that you can place one hand against the medial surface of the knee and the other around the lateral ankle. Push laterally against the knee and pull medially at the ankle to open the knee joint on the lateral side (varus stress).
4. Anterior Cruciate Legament (ACL): Anterior Drawer Sign. With the patient supine, hips flexed and knees flexed to 90° and feet flat on the table, cup your hands around the knee with the thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstrings. Draw the tibia forward and observe if it slides forward (like a drawer) from under the femur. Compare the degree of forward movement with that of the opposite knee. Lachman Test. Place the knee in 15° of flexion and external rotation. Grasp the distal femur on the lateral side with one hand and the proximal tibia on the medial side with the other. With the thumb of the tibial hand on the joint line, simultaneously pull the tibia forward and the femur back. Estimate the degree of forward excursion.
5. Posterior Cruciate Ligament (PCL): Posterior Drawer Sign. Position the patient and place your hands in the positions described for the anterior drawer test. Push the tibia posteriorly and observe the degree of backward movement in the femur.
Ankle/Foot: Overview
The total weight of the body is transmitted through the ankle to
the foot. The ankle and foot must balance the body and absorb the impact of the
heel strike and gait. Despite thick padding along the toes, sole, and heel and
stabilizing ligaments at the ankles, the ankle and foot are frequent sites of sprain
and bony injury.
Ankle/Foot: Bony Structures and Joints
The ankle is a hinge joint formed by the
tibia, the fibula, and the talus. The tibia and fibula act as a mortise, stabilizing the
joint while bracing the talus like an inverted cup
The principal joints of the ankle are the
tibiotalar joint, between the tibia and the
talus, and the subtalar (talocalcaneal) joint
(Fig. 16-85).
Note the principal landmarks of the
ankle: the medial malleolus, the bony
prominence at the distal end of the tibia,
and the lateral malleolus, at the distal end
of the fibula. Lodged under the talus and
jutting posteriorly is the calcaneus, or heel
bone.
An imaginary line, the longitudinal arch,
spans the foot, extending from the calcaneus
of the hind foot along the tarsal
bones of the midfoot (see cuneiform,
navicular, and cuboid bones in Fig. 16-86)
to the forefoot metatarsals and toes. The
heads of the metatarsals are palpable in the
ball of the foot. In the forefoot, identify
the metatarsophalangeal joints, proximal to
the webs of the toes, and the PIP and DIP
joints of the toes.
Ankle/Foot: Muscle Groups and Additional Structures
Movement at the ankle
(tibiotalar) joint is limited to dorsiflexion and plantar flexion. Plantar flexion is
powered by the gastrocnemius, the posterior tibial muscle, and the toe flexors.
Their tendons run behind the malleoli. The dorsiflexors include the anterior tibial
muscle and the toe extensors. They lie prominently on the anterior surface, or
dorsum, of the ankle, anterior to the malleoli.
Ligaments extend from each malleolus onto the foot.
■ Medially, the triangle-shaped deltoid ligament fans out from the inferior surface
of the medial malleolus to the talus and proximal tarsal bones, protecting
against stress from eversion (heel bows outward).
■ Laterally, the three ligaments are less substantial, with higher risk for injury:
the anterior talofibular ligament, most at risk in injury from inversion (heel
bows inward) injuries; the calcaneofibular ligament; and the posterior talofibular
ligament (Fig. 16-86). The strong Achilles tendon attaches the gastrocnemius
and soleus muscles to the posterior calcaneus. The plantar fascia inserts
on the medial tubercle of the calcaneus.
Ankle/Foot: Inspection
Observe all surfaces of the ankles and feet, noting any deformities,
nodules, swelling, calluses, or corns
Ankle/Foot: Palpation
With your thumbs,
palpate the anterior aspect of each ankle
joint, noting any bogginess, swelling, or
tenderness (Fig. 16-87).
Feel along the Achilles tendon for nodules
and tenderness.
Palpate the heel, especially the posterior
and inferior calcaneus, and the
plantar fascia for tenderness. Bone
spurs are common on the calcaneus.
Palpate for tenderness over the medial and lateral ankle ligaments and the medial
and lateral malleolus, especially in cases of trauma. In trauma, the distal tip of
the tibia and fibula should also be palpated.
Palpate the metatarsophalangeal (MTP)
joints for tenderness (Fig. 16-88).
Compress the forefoot between the
thumb and fingers. Exert pressure just
proximal to the heads of the first and
fifth metatarsals.
Palpate the heads of the five metatarsals and the
grooves between them with your thumb and
index finger (Fig. 16-89). Place your thumb on
the dorsum of the foot and your index finger on
the plantar surface.
Ankle/Foot: ROM
primary muscles and patient instructions
- Ankle Flexion (Plantar Flexion): Gastrocnemius, soleus,
plantaris, tibialis posterior
“Point your foot toward the
floor.”
2. Ankle Extension (Dorsiflexion): Tibialis anterior, extensor digitorum longus, and extensor hallucis longus “Point your foot toward the ceiling.”
- Inversion: Tibialis posterior and anterior
“Bend your heel inward.” - Eversion: Peroneus longus and brevis
“Bend your heel outward.”
Ankle/Foot: Maneuvers
■ The ankle (tibiotalar) joint. Dorsiflex and plantar flex the foot at the ankle. ■ The subtalar (talocalcaneal) joint. Stabilize the ankle with one hand, grasp the heel with the other, and invert and evert the foot by turning the heel inward then outward (Figs. 16-90 and 16-91). ■ The transverse tarsal joint. Stabilize the heel and invert and evert the forefoot ■ The metatarsophalangeal joints. Move the proximal phalanx of each toe up and down.
Measuring the Length of Legs.
To measure leg length, the patient
should be relaxed in the supine position and symmetrically aligned with legs
extended. With a tape, measure the distance between the anterior superior iliac
spine and the medial malleolus (Fig. 16-94). The tape should cross the knee on
its medial side.
Describing Limited Motion of a Joint.
Use a goniometer to
measure range of motion in degrees. In Figures 16-95 and 16-96, the red
lines show the range of the patient’s range of motion, and the black lines
show the normal range.
Observations may be described in several ways. The numbers in parentheses
show abbreviated descriptions.
