MSK Flashcards
Anterior shoulder inspection
Scars: note the location of the scar as this may provide clues as to the patient’s previous surgical history or suggest previous joint trauma.
Bruising: suggestive of recent trauma or surgery.
Asymmetry of the shoulder girdle: may be caused by scoliosis, arthritis, fractures or dislocation.
Swelling: note any evidence of asymmetry in the size of the shoulder joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, dislocation).
Abnormal bony prominence: may indicate fracture (e.g. clavicular fracture) or anterior dislocation of the glenohumeral joint.
Deltoid wasting: note any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary nerve injury.
Lateral shoulder inspection
Scars: again look for scars indicative of previous trauma or surgery.
Deltoid wasting: note any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary nerve injury.
Posterior shoulder inspection
Scars: again look for scars indicative of previous trauma or surgery.
Trapezius muscle asymmetry: suggestive of muscle wasting secondary to disuse atrophy or a spinal accessory nerve lesion.
Supraspinatus and infraspinatus asymmetry: suggestive of muscle wasting secondary to chronic rotator cuff tear or a suprascapular nerve lesion.
Scoliosis: lateral curvature of the spine that may be congenital or acquired.
Winged scapula: ask the patient to push against a wall with both hands spaced shoulder-width apart whilst you inspect the back. The protrusion of a scapula (known as scapular winging) is suggestive of ipsilateral serratus anterior muscle weakness, typically secondary to a long thoracic nerve injury.
Increased joint temperature
particularly if also associated with swelling and tenderness may indicate septic arthritis or inflammatory arthritis.
Shoulder joint palpation
Sternoclavicular joint: the joint between the sternum and the clavicle.
Clavicle: extends between the sternum and the acromion of the scapula.
Acromioclavicular joint: the joint between the acromion and the clavicle.
Acromion: a continuation of the scapular spine and the most superolateral bony prominence of the shoulder.
Coracoid process of the scapula: a small hook-like bony prominence located 2cm inferior and medial to the clavicular tip.
Head of the humerus: located 1cm inferolateral to the coracoid process.
Greater tubercle of the humerus: located slightly anterolateral to the head of the humerus.
The spine of the scapula: easily palpable on the posterior aspect of the scapula, running from the acromion towards the thoracic vertebrae.
Adhesive capsulitis
stiffness and pain in the shoulder joint associated with a significant reduction in the range of both active and passive movement. Palpation of the joint does not typically cause pain and clinical examination reveals a significantly reduced range of active and passive movement. The underlying aetiology is unclear however risk factors include surgery, prolonged immobility and trauma.
associated with diabetes
Axillary nerve palsy
caused by shoulder dislocation. Clinical features include loss of sensation over the lateral deltoid region (known as the regimental patch) and deltoid muscle weakness (loss of shoulder abduction).
Empty can/Jobe’s test
tests function of supraspinatus muscle
abduction and internal rotations against resistance
weakness = tear in supraspinatus tendon or pain due to impingement
Painful arc
tests for impingement of supraspinatus
1. passively abduct arm to maximum point
2. ask patient to lower arm slowly
positive = pain between 60 and 120 degrees of abduction
Shoulder impingement syndrome
the inflammation of tendons of the rotator cuff muscles as they pass through the subacromial space.
most often associated with supraspinatus tendonitis. Symptoms include pain, weakness and a reduced range of active movement in the affected shoulder (normal passive range of motion is preserved). Symptoms are usually exacerbated by overhead movement of the limb, typically during abduction between 60-120°, which is referred to as a ‘painful arc’ of movement.
External rotation against resistance
assesses function of infraspinatus muscle and teres minor
pain = tendonitis
arm falls back to internal rotation or loss of power = tear
Internal rotation against resistance
(Gerber’s lift-off test)
assessed function of subscapularis muscle
patient pushes against you with hand on back
Scarf test
assesses function of acromioclavicular joint
passively flex and ask patient to put hand to contralateral shoulder while applying resistance to elbow
Anterior inspection of hip
Scars: note the location of scars as they may provide clues as to the patient’s previous surgical history or indicate previous joint trauma.
Bruising: suggestive of recent trauma or surgery.
Swelling: note any evidence of asymmetry in the size of the hip joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, septic arthritis).
Quadriceps wasting: note any asymmetry in the bulk of the quadriceps muscles which may be due to disuse atrophy or a lower motor neuron lesion.
Leg length discrepancy: may be congenital or acquired (e.g. fracture, degenerative joint disease, surgical removal of bone, trauma to the epiphyseal endplate prior to skeletal maturity).
Pelvic tilt: lateral pelvic tilt can be caused by scoliosis, leg length discrepancy or hip abductor weakness.
Lateral inspection of hip
Flexion abnormalities: fixed flexion deformity at the hip joint may suggest the presence of contractures secondary to previous trauma, inflammatory conditions or neurological disease.
Posterior inspection of hip
Scars: again look for scars indicative of previous trauma or surgery.
Muscle wasting: inspect for any asymmetry in the muscle bulk of the posterior compartment of the thigh and the gluteal region suggestive of disuse atrophy or a lower motor neuron lesion.
Gait assessment
Gait cycle: note any abnormalities of the gait cycle (e.g. abnormalities in toe-off or heel strike).
Range of movement: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, inflammatory arthritis).
Limping: may suggest joint pain (i.e. antalgic gait) or weakness.
Leg length: note any discrepancy which may be the cause or the result of joint pathology.
Turning: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
Trendelenburg’s gait: an abnormal gait caused by unilateral weakness of the hip abductor muscles secondary to a superior gluteal nerve lesion or L5 radiculopathy.
Waddling gait: an abnormal gait caused by bilateral weakness of the hip abductor muscles, typically associated with myopathies (e.g. muscular dystrophy).
Assess the patient’s footwear: unequal sole wearing is suggestive of an abnormal gait.
Trendelenburg gait
if a patient has unilateral hip abductor weakness, the pelvis will drop toward the contralateral side when the leg on that side leaves the ground (i.e. if there is left hip abductor weakness, the pelvis will drop towards the right whenever the right foot is lifted off the ground). It’s important to remember that the pelvis falls on the contralateral side to the weakness
caused by a superior gluteal nerve lesion or L5 radiculopathy
Waddling gait
bilateral hip abductor weakness
overuse of circumduction to compensate for gluteal weakness.
Bilateral hip abductor weakness is typically associated with myopathies (e.g. muscular dystrophy).
Hip joint palpation
Palpate the greater trochanter of each leg for evidence of tenderness, which may suggest trochanteric bursitis.
Femoral Pulse
True vs apparent leg length
To assess apparent leg length, measure and compare the distance between the umbilicus and the tip of the medial malleolus of each limb.
To assess true leg length, measure from the anterior superior iliac spine to the tip of the medial malleolus of each limb.
Hip movements tested passively
flexion
extension
internal rotation
external rotation
abduction
adduction
Thomas’s test
used to assess for a fixed flexion deformity
The test is positive (abnormal) if the affected thigh raises off the bed, indicating a loss of hip joint extension. This would suggest a fixed flexion deformity in the affected hip.
This test should not be performed on patients who have had a hip replacement as it can cause dislocation.
Trendelenburg test
used to screen for hip abductor weakness (gluteus medius and minimus)
If the patient’s hip abductors are functioning normally the pelvis should remain stable or rise slightly on the side of the raised leg.
If the pelvis drops on the side of the raised leg it suggests contralateral hip abductor weakness (this is known as Trendelenburg’s sign).
Anterior knee inspection
Scars: note the location of scars as they may provide clues as to the patient’s previous surgical history (e.g. arthroscopy port entry sites) or indicate previous joint trauma.
Bruising: suggestive of recent trauma or spontaneous haemarthrosis (e.g. patients on anticoagulants or with clotting disorders such as haemophilia).
Swelling: note any evidence of asymmetry in the size of the knee joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, septic arthritis, haemarthrosis).
Psoriasis plaques: typically present over extensor surfaces and important to note due to the increased risk of psoriatic arthritis.
Patellar position: the patella is normally located over the centre of the knee joint and any deviation from this central position may indicate patellar dislocation or subluxation (i.e. partial dislocation).
Valgus deformity of the knee: the tibia is turned outward in relation to the femur, resulting in the knees ‘knocking’ together.
Varus deformity of the knee: the tibia is turned inward in relation to the femur, resulting in a bowlegged appearance.
Quadriceps wasting: note any asymmetry in the bulk of the quadriceps muscles which may be due to disuse atrophy or a lower motor neuron lesion.
Lateral knee inspection
Extension abnormalities: knee hyperextension can occur secondary to cruciate ligament injury.
Flexion abnormalities: fixed flexion deformity at the knee joint may suggest the presence of contractures secondary to previous trauma, inflammatory conditions or neurological disease.
Posterior knee inspection
Scars: again look for scars indicative of previous trauma or surgery.
Muscle wasting: inspect for any asymmetry in the muscle bulk of the posterior compartment of the thigh or lower leg suggestive of disuse atrophy or a lower motor neuron lesion.
Popliteal swellings: possible causes include a Baker’s cyst or popliteal aneurysm (typically pulsatile).
Gait assessment in knee exam
Gait cycle: note any abnormalities of the gait cycle (e.g. abnormalities in toe-off or heel strike).
Range of movement: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, inflammatory arthritis).
Limping: may suggest joint pain (i.e. antalgic gait), weakness or joint instability (e.g. ligamentous injury).
Leg length: note any discrepancy which may be the cause or the result of joint pathology.
Turning: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
Height of steps: high-stepping gait is associated with foot drop, which can be caused by peroneal nerve palsy (e.g. trauma, surgery).
Closer knee inspection (on bed)
Scars
Swelling
Bruising
Quadriceps wasting
Knee joint asymmetry
Fixed flexion deformity
Abnormal patellar position
Knee palpation
Patella
Medial and lateral joint lines
quadriceps bulk
popliteal fossa
tibial tuberosity
(temperature)
Assessing for knee effusion
Patellar tap test
Sweep test
Osgood-Schlatter disease
inflammation of the patellar ligament at the tibial tuberosity (its insertion point) and most often affects males between the age of 10-15. Typical presenting features include a painful bony elevation over the tibial tuberosity which is worsened with activity. Risk factors include overuse, often due to sports that involve lots of running and jumping.
Popliteal fossa pathology
A popliteal cyst (also known as a Baker’s cyst) typically presents as a fluctuant swelling in the popliteal fossa. The swelling will feel tense when the patient’s knee is extended and soft when the knee is flexed (known as Foucher’s sign). The cyst may also transilluminate with a pen torch.
Popliteal aneurysms are rare, but if the popliteal pulse is visible and superficially palpable this should be considered. Typically the popliteal pulse is only palpable on deep palpation of the popliteal fossa.
Cruciate ligament assessment
posterior sag sign
anterior draw test
posterior draw test
lachman’s test (ACL)
Collateral ligament assessment
Varus stress test (LCL)
Valgus stress test (MCL)
(repeat with knee flexed at 30 degrees)
Dorsal hand inspection
Hand posture: note any abnormalities of hand posture which may indicate underlying pathology (e.g. Dupuytren’s contracture, ulnar deviation secondary to rheumatoid arthritis).
Scars: inspect for evidence of scars which may indicate previous surgery or trauma.
Swelling: note any areas of swelling, by comparing the hands and the wrists.
Skin colour: erythema of the soft tissue may indicate cellulitis or joint sepsis
Bouchard’s nodes: occur at the proximal interphalangeal joints (PIPJ) and are associated with osteoarthritis.
Heberden’s nodes: occur at the distal interphalangeal joints (DIPJ) and are associated with osteoarthritis.
Swan neck deformity: occurs at the distal interphalangeal joint (DIPJ) with clinical features including DIPJ flexion with PIPJ hyperextension. Swan neck deformity is typically associated with rheumatoid arthritis.
Z-thumb: hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the metacarpophalangeal joint (MCPJ). Z-thumb is associated with rheumatoid arthritis.
Boutonnières deformity: PIPJ flexion with DIPJ hyperextension associated with rheumatoid arthritis.
Skin thinning or bruising: can be associated with long-term steroid use (e.g. common in patients with active inflammatory arthritis).
Psoriatic plaques: salmon coloured plaques with a silvery scale. Patients who have psoriasis are at significantly increased risk of developing psoriatic arthritis.
Muscle wasting: can occur secondary to chronic joint pathology or lower motor neuron lesions (e.g. median nerve damage secondary to carpal tunnel syndrome).
Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
Nail pitting and onycholysis: associated with psoriasis and psoriatic arthritis.
Palmar hand inspection
Hand posture: note any evidence of abnormal hand posture (e.g. clawed hand secondary to Dupuytren’s contracture).
Scars: inspect for evidence of scars which may indicate previous surgery or trauma (e.g. carpal tunnel surgery).
Swelling: note any areas of swelling, by comparing the hands and the wrists.
Dupuytren’s contracture involves thickening of the palmar fascia, resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb.
Thenar/hypothenar wasting: isolated wasting of the thenar eminence is suggestive of median nerve damage (e.g. carpal tunnel syndrome).
Elbows: inspect for evidence of psoriatic plaques or rheumatoid nodules.
Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.
Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis.
Hand ‘feel’
Temperature
Radial and ulnar pulse
Thenar and hypothenar eminence bulk
Palmar thickening (Dupuytren’’s contracture)
Median nerve sensation (thenar eminence)
Ulnar nerve sensation (hypothenar eminence)
Radial nerve sensation (first dorsal webspace)
Hand joint palpation
MCP squeeze (tenderness = active inflammatory arthropathy)
Bimanual palpation: MCP, PIP, DIP, CMC of thumb
Anatomical snuffbox (scaphoid fracture)
Bimanual wrist palpation
Elbow palpation
ulnar border to elbow: tenderness, rheumatoid nodules, psoriatic plaques
Hand function screening
power grip (squeeze my fingers with hand)
pincer grip (squeeze my finger with your thumb and index finger)
pick up small object
Tinel’s test
used to identify median nerve compression and can be useful in the diagnosis of carpal tunnel syndrome.
To perform the test, simply tap over the carpal tunnel with your finger. Positive = tingling in thumb and radial 2 1/2 fingers
Phalen’s test
Carpal tunnel syndrome
Ask the patient to hold their wrist in maximum forced flexion (pushing the dorsal surfaces of both hands together) for 60 seconds.
Positive = reproduction of carpal tunnel symptoms (burning, tingling, numbness)
Finkelstein’s test
De Quervain’s tenosynovitis
pain radiating up arm on pushing thumb into palm
Anterior foot and ankle inspection
Scars: note the location of scars as they may provide clues as to the patient’s previous surgical history or indicate previous joint trauma.
Bruising: suggestive of recent trauma or spontaneous haemarthrosis (e.g. patients on anticoagulants or with clotting disorders such as haemophilia).
Swelling: note any evidence of asymmetry in the size of the ankle joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, septic arthritis, haemarthrosis, Charcot joint).
Psoriasis plaques: typically present over extensor surfaces and important to note due to the association with psoriatic arthritis.
Fixed flexion deformity of the toes: subtypes include hammer-toe and mallet-toe.
Big toe misalignment: note any evidence of lateral (hallux valgus/bunion) or medial (hallux varus) big toe angulation.
Calluses: thickened, hardened skin that develops as a result of repetitive friction which may be caused by poorly fitting footwear or a gait abnormality.
Lateral foot and ankle inspection
Foot arch: inspect for evidence of flat feet (pes planus) or an abnormally raised foot arch (pes cavus).
Posterior foot and ankle inspection
Scars: again look for scars indicative of previous trauma or surgery.
Muscle wasting: inspect for any asymmetry in the muscle bulk of the posterior compartment of the lower leg suggestive of disuse atrophy or a lower motor neuron lesion.
Heel misalignment: may be caused by a valgus or varus deformity of the ankle joint.
Achilles tendon: discontinuity and swelling may indicate tendonitis and/or rupture.
Ankle and Foot ‘feel’
temperature
posterior tibial pulse
dorsalis pedis pulse
MTP joint squeeze
joint palpation
achilles tendon and gastrocnemius
Ankle and foot joint palpation
Metatarsal and tarsal bones
Tarsal joint
Ankle joint
Subtalar joint
Calcaneum
Medial/lateral malleoli
Distal fibula
Simmond’s test
used to assess for clinical evidence of Achilles tendon rupture:
- Ask the patient to kneel on a chair with their feet hanging over the edge.
- Squeeze each of the patient’s calves in turn.
In healthy individuals, the foot should plantarflex when you squeeze the calf due to the contraction of the gastrocnemius muscle and the subsequent pulling force transmitted via the Achilles tendon.
There will be no movement of the foot if the Achilles tendon is ruptured due to loss of continuity between the gastrocnemius and the foot.
GALS exam
Gait, Arms, Legs, Spine
(screening)
GALS screening questions
- Do you have any pain or stiffness in any of your muscles, joints or back?
- Do you have any problem going up and down stairs?
- Do you have any difficulty getting dressed?
GALS anterior inspection
Posture: note any asymmetry which may indicate joint pathology or scoliosis.
Scars: note the location of any scars as they may provide clues as to the patient’s previous surgical history and/or indicate previous joint trauma.
Joint swelling: note any evidence of asymmetry in the size of joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, septic arthritis).
Joint erythema: suggestive of active inflammation (e.g. inflammatory arthropathy or septic arthritis).
Muscle bulk: note any asymmetry in upper and lower limb muscle bulk (e.g. deltoids, pectorals, biceps brachii, quadriceps femoris). Asymmetry may be caused by disuse atrophy (secondary to joint pathology) or lower motor neuron injury.
Elbow extension: inspect the patient’s carrying angle which should be between 5-15°. An increased carrying angle is known as cubitus valgus. Cubitus valgus is typically associated with previous elbow joint trauma or congenital deformity (e.g. Turner’s syndrome). A decreased carrying angle is known as cubitus varus or ‘gunstock deformity’. Cubitus varus typically develops after supracondylar fracture of the humerus.
Valgus joint deformity: the bone segment distal to the joint is angled laterally. In valgus deformity of the knee, the tibia is turned outward in relation to the femur, resulting in the knees ‘knocking’ together.
Varus joint deformity: the bone segment distal to the joint is angled medially. In varus deformity of the knee, the tibia is turned inward in relation to the femur, resulting in a bowlegged appearance.
Pelvic tilt: lateral pelvic tilt can be caused by scoliosis, leg length discrepancy or hip abductor weakness.
Fixed flexion deformity of the toes: subtypes include hammer-toe and mallet-toe.
Big toe: note any evidence of lateral (hallux valgus) or medial (hallux varus) angulation.
GALS lateral inspection
Cervical lordosis: hyperlordosis is associated with chronic degenerative joint disease (e.g. osteoarthritis).
Thoracic kyphosis: the normal amount of thoracic kyphosis is typically between 20-45º. Hyperkyphosis is associated with Scheuermann’s disease (congenital wedging of the vertebrae).
Lumbar lordosis: loss of normal lumbar lordosis suggests sacroiliac joint disease (e.g. ankylosing spondylitis).
Knee joint hyperextension: causes include ligamentous damage and hypermobility syndrome.
Foot arch: inspect for evidence of flat feet (pes planus) or an abnormally raised foot arch (pes cavus).
GALS posterior inspection
Muscle bulk: note any asymmetry in upper and lower limb muscle bulk (e.g. deltoid, trapezius, triceps brachii, gluteal muscles, hamstrings, calves). Asymmetry may be caused by disuse atrophy (secondary to joint pathology) or lower motor neuron injury.
Spinal alignment: inspect for lateral curvature of the spine suggestive of scoliosis.
Iliac crest alignment: misalignment may indicate a leg length discrepancy or hip abductor weakness.
Popliteal swellings: possible causes include a Baker’s cyst or popliteal aneurysm (typically pulsatile).
Achilles’ tendon thickening: associated with Achilles’ tendonitis.
Valgus joint deformity: the bone segment distal to the joint is angled laterally. In valgus deformity of the ankle, the foot is turned outward in relation to the tibia.
Varus joint deformity: the bone segment distal to the joint is angled medially. In varus deformity of the ankle, the foot is turned inward in relation to the tibia.
Arms in GALS
Hands behind head
Hands held out with palms down
Inspect dorsum and nails
Palms facing up
Inspect thenar and hypothenar eminence
Make a fist
Grip strength
Precision grip
MCP joint squeeze
Legs GALS
Passive knee flexion
Passive knee extension
Passive internal rotation of hip
MTP joint squeeze
Patellar tap/Sweep test
Spine GALS
Cervical lateral flexion (ear to shoulder)
Lumbar flexion & Schober’s
