General Principles of Physical & Radiological Evaluation

Question 1

Components of Musculoskeletal Exam

Answer 1

1) GENERAL SURVEY:
2) INSPECTION/OBSERVATION:
3) PALPATION:
4) RANGE OF MOTION:
5) NEUROLOGIC & VASULAR TESTING
6) SPECIAL TESTS

Question 2

GENERAL SURVEY:

Answer 2

record the pt’s general appearance, body proportions and ease of movement (preferably even before they enter the exam room, to get a more candid picture)

Question 3

INSPECTION/OBSERVATION:

Answer 3

Look for symmetry, joint deformities or malalignment of bones, muscle atrophy and fasciculations, pigmentation/skin texture changes, bruising, scars, and swelling.

Question 4

PALPATION:

Answer 4

be systematic, know anatomy (know what palpating), have pt point w/ one finger to area of pain. Palpate the bony landmarks and joint spaces when accessible, as well as the surrounding soft tissue structures. Palpate for crepitus, masses, swelling, warmth and tenderness. Always palpate joint above and below

Question 5

RANGE OF MOTION:

Answer 5

Bilateral comparison is essential!! Assess for ROM limitation and joint instability. (This requires that you know the normal ranges of motion for each joint!) Ask the patient to actively move the joint; if pt cannot, then test passive ROM. Either way, don’t neglect to compare one side to the other.

Question 6

NEUROLOGIC & VASULAR TESTING:

Answer 6

(Motor and neuro exam); includes MSE, CN exam, dermatomal sensation tests, vibratory sensation, joint position sense, discriminative sensation, muscle tone, muscle strength, DTRs, Ankle clonus, Plantar response (Babinski) and the coordinaton tests (Gait, heel-to-toe walk, station, Romberg, point to point movements, Rapid alternating movements, and pronator drift) and peripheral pulses.

Question 7

L5 innervation

Answer 7

top of foot

Question 8

S1 innervation

Answer 8

lateral mallelous

Question 9

Upper limb nerves:

Answer 9

Axillary, Musculocutaneous, Radial, Median, and Ulnar

Question 10

Lower limb nerves:

Answer 10

Femoral – Obturator, Sciatic - Fibular (peroneal) or Tibial

Question 11

L4 innervation

Answer 11

med malleolus

Question 12

C6 innervation

Answer 12

thumb

Question 13

C7 innervation

Answer 13

middle finger

Question 14

C8 innervation

Answer 14

little finger

Question 15

Muscle grading: 5

Answer 15

5 = Normal- Complete ROM against gravity w/ full resistance

Question 16

Muscle grading: 4

Answer 16

4 = Decreased- Good- Complete ROM against gravity w/ some resistance

Question 17

Muscle grading: 3

Answer 17

3 = Fair- Complete range of motion against gravity (no weight)

Question 18

Muscle grading: 2

Answer 18

2 = Poor- Complete ROM with gravity eliminated

Question 19

Muscle grading: 1

Answer 19

1 = Twitch/Trace- Muscle contraction but no or very limited joint motion

Question 20

Muscle grading: 0

Answer 20

0 = Zero- No evidence of muscle function

Question 21

Articular structures:

Answer 21

Joint capsule, articular cartilage, synovium, synovial fluid, intra-articular ligaments and juxta-articular bone

Question 22

Articular disease:

Answer 22

Involves swelling and tenderness of the entire joint. Joint “locking” and deformity may be present. Both active AND passive ROM are limited

Question 23

Extra-articular structures:

Answer 23

Periarticular ligaments, tendons, bursae, muscle, fascia, bone nerve and overlying skin.

Question 24

Extra-articular disease:

Answer 24

Typically involves selected region(s) of the joint and certain types of movement. There is classically a loss of active but NOT passive ROM. Compared to intra-articular dz, the pain and swelling of extra-articular dz is more focal. Examples- bursitis, tendonitis, tenosynovitis, (ligament) sprains.

Question 25

“Gelling”:

Answer 25

Stiffness and limited motion after inactivity.

Question 26

Dermatome:

Answer 26

An area of skin supplied by a single nerve root.

Question 27

Myotomes:

Answer 27

Groups of muscles supplied by a single nerve root.

Question 28

Monoarticular pain:

Answer 28

the pain is localized and involves only one joint. Potential causes include: trauma, monoarticular arthritis, tendinitis or bursitis

Question 29

Polyarticular pain:

Answer 29

the pain involves many joints, and should be further described regarding the joints’ pattern of involvement. For example, a migratory spread is seen in rheumatic fever and gonococcal arthritis; but rheumatoid arthritis has a progressively additive and symmetric joint involvement.

Question 30

Sprain:

Answer 30

stretching or tearing of a ligament

Question 31

Grade I Sprain:

Answer 31

Grade I sprains cause stretching of the ligament. The symptoms tend to be limited to pain and swelling. Most patients can walk without crutches, but may not be able to jog or jump.

Question 32

Grade II Sprain:

Answer 32

A grade II sprain is more severe partial tearing of the ligament. There is usually more significant swelling and bruising caused by bleeding under the skin. Patients often have pain with walking, but can take a few steps.

Question 33

Grade III Sprain:

Answer 33

Grade III sprains are complete tears of the ligaments. The joint is usually quite painful, and walking can be difficult. Patients may complain of instability, or a giving-way sensation in the joint.

Question 34

Radicular pain or radiculitis:

Answer 34

Pain “radiated” along the dermatome of a nerve due to inflammation or other irritation of the nerve root (radiculopathy) at its connection to the spinal column. A common form of radiculitis is sciatica,

Question 35

Osteomyelitis:

Answer 35

an infection of the bone or bone marrow. In general, microorganisms may infect bone through one or more of three basic methods: via the bloodstream, contiguously from local areas of infection (as in cellulitis), or penetrating trauma, including iatrogenic causes such as joint replacements or internal fixation of fractures or root canal procedures

Question 36

Arthroscopy:

Answer 36

aka arthroscopic surgery, is a minimally invasive surgical procedure in which an examination and sometimes treatment of damage of the interior of a joint is performed using an arthroscope, a type of endoscope inserted into the joint through a small incision.

Question 37

Arthrography:

Answer 37

Contrast media is injected into the joint and then imaged using Xray, CT or MRI

Question 38

Myelography:

Answer 38

Contrast media is used to study the spinal cord, nerve roots and dura mater

Question 39

Osteopenia:

Answer 39

bone density 1.0-2.5 standard deviations below the mean of the bone density of a young, adult white woman (in other words, a T score between -2.5 and -1.0)

Question 40

Osteoporosis:

Answer 40

bone density 2.5 or more standard deviations below the mean bone density for a young, adult white woman (T score less than -2.5)

Question 41

Crepitus:

Answer 41

an audible or palpable crunching, grating, crackling or popping that occurs during movement of tendon or ligaments over bone.

Question 42

Ankylosis:

Answer 42

bony fixation of a joint, caused by disease or injury

Question 43

Ligamentous laxity:

Answer 43

joint instability from excess mobility of the joint’s ligaments

Question 44

Synovitis:

Answer 44

inflammation of the synovial membrane, indicated by palpable bogginess or doughiness of the synovial membrane

Question 45

Tendinitis:

Answer 45

inflammation of a tendon, indicated by tenderness over the tendon sheath. Generally tendinitis is referred to by the body part involved, such as Achilles tendinitis (affecting the Achilles tendon), or patellar tendinitis (jumper’s knee, affecting the patellar tendon).

Question 46

Dynamic stabilizers:

Answer 46

Supportive structures that are capable of movement. For example, the dynamic stabilizers of the shoulder are the SITS muscles of the rotatof cuff, which move the humerus and stabilize the humeral head within the glenoid fossa.

Question 47

Static stabilizers:

Answer 47

supportive structures incapable of movement. For example, the static stabilizers of the shoulder are bones of the shoulder girdle, the labrum, the articular capsule and glenohumeral ligaments.

Question 48

Stance:

Answer 48

when the foot is on the ground and bears weight (60% of the walking cycle). Most problems appear during this phase.

Question 49

Swing:

Answer 49

when the foot moves forward and does not bear weight (40% of the walking cycle)

Question 50

The stance phases of gait:

Answer 50

Heelstrike, Foot flat, Midstance, Push-off (see diagram Bates p 619)

Question 51

Etiologies of swelling

Answer 51

1) Swelling of the synovial membrane, which may feel boggy or doughy;
2) Effusion from excess synovial fluid in the joint space;
3) Swelling of soft tissue structures around the joint, like bursae, tendons and tendon sheaths