MSK Flashcards
MSK ‘site’ question examples?
Pattern of involvement, which joints, small/ large, one/ more, speed of onset, bilateral, symmetrical/ asymmetrical
‘Onset’ questions?
When did it start, acute/ chronic, constant since onset, episodic- frequency, regularity and duration of episodes
‘Character’?
Ache, sharp, throbbing
‘Radiation’?
Neck–> upper limb, lower back pain to buttocks/ lower limb, hip pain to knee
Associated symptoms?
Stiffness/ swelling, crepitus, erythema/ increased local temp, fatigue/ malaise/ depression, systemic temp, rashes/ skin conditions, nodules, fever, abdo pain, weight loss- vasculitis, CND, IBD, dry mouth and gritty eyes
Timing questions?
Feel like on rising/ at end of the day/ how do you sleep
Exacerbatin factors?
Exercise in mechanical/ degenerative; rest in inflammatory
Alleviating factors?
NSAIDs, exercise/ rest
Severity?
Very- acute gout +/ sepsis, less= RA/OA, any movements painful? Function limited by pain
Completing the MSK HPC Qs?
Anything similar previous? Tests, Ix, Tx- response? Previous meds- SEs, why was it changed?, history of trauma? Recent infective episodes- dental/ pharyngeal? Diabetes–> infection? Psoriasis, IBD/ coeliac? TB? AI conditions? RFs for gout?
Drug, social and family Hx?
Drug- current med for presenting condition, other meds, over the counter meds- do they work?
Social- occupation, hobbies, home circumstances, ADLs, smoking, alcohol consumption
Family- RA/OA, psoriasis, gout, UC, Crohn’s, CND/ other AI disease
Intro for a GALS exam?
Wash hands, intro, confirm patient ID, explain, consent and expose arms: “screen for any joint problems, general inspection, watch you walk, do some head, arms and legs movement, need to remove top, trousers, socks and shoes, chaperone, any pain?”
Screening Qs for GALS exam?
Any pain/ stiffness in muscles, joints/ back, able to completely dress and undress yourself without any difficulty? Able to climb up and down stairs without difficulty?
What do you inspect for from the front in GALS?
Posture- asymmetry/ scoliosis
Body habitus- obesity can be ass w/ joint path like OA in knees
Skin rashes
Shoulders- bulk, asymmetry
Elbows- joint contractures can result in inability to extend elbow at rest
Leg length and alignment- valgus/ varus deformity
Quadriceps- bulk+ symmetry
Knees- swelling and erythema= inflammatory/ joint sepsis, valgus/ varus deformity, asymmetry from joint effusion, any hyperextension of knee joints
Ankles- swelling and erythema
Feet- mid/ forefoot deformity(flat feet), asymmetry- bunion
From the side in GALS?
Cervical spine- hyperlordosis(slipped vertebra)
Thoracic spine- kyphosis(normal= 20-40) Lumbar spine- lordosis(loss= sacroiliac disease)
Knee joints- degree of flexion(hyperextension= hypermobility)
From back in GALS?
Shoulder muscles
Spinal alignment
Iliac crest alignment
Gluteal muscle bulk- reduced mobility
Popliteal swellings- Baker’s cyst, popliteal aneurysms
Hind-foot abnormalities- thickening of achilles tendon= tendonitis
Inspect for in gait in GALS?
Walk to end of room, turn around and come bacl Gait cycle- heel strike, toe-off+ coordination Antalgic (painful) gait Normal arm swing Pelvic tilt Able to turn quickly Normal foot arches/ absent Painful/ painless walking
Inspect for what in spine of GALS?
Flexion of lumbar spine- put fingers on two adjacent lumbar vertebrae, ask patient to bend forward to touch their toes, observe fingers moving apart and together
Put hands on floor= joint hypermobility
Question to assess shoulders in GALS?
Can you place hands behind your head and push your elbows back as far as you can- abduction and external rotation and elbow flexion
Question for wrists and hands in GALS? Inspect for what and assess what?
Hands out in front with palms down
Shoulder flexion, elbow extension, wrist extension and extension of small joints of fingers
Asymmetry, swelling and deformity
Nails- pitting (psoriasis)
Turn hands over
Wrist and elbow supination
Muscle bulk of palms
Feel for what in wrists/ hands in GALS?
Lateral squeeze of MTC joints- non-verbal signs discomfort (active inflammatory arthropathy)
Questions, assess for what in ‘moving’ wrists/hands in GALS?
Can you make a fist- flexion of small joints and hand function (swelling/ deformities)
Can you squeeze my fingers- grip strength(swelling/ nerve pathology)
Can you touch each finger to your thumb?- precision grip, coordination and manual dexterity(inflammation/ contractures)
How position patient for legs in GALS? Question for hips and knees, assess for what?
Lying down
Bring foot to bum and straighten again whilst I hold your knee- one at time, feel for crepitus over patella, ROM and symmetry
Passive internal rotation- flex knee and hip to 90 degrees, use ankle to move leg(first to be lost in hip pathology)
Patellar tap- slide left hand down thigh, press down on patella with right hand fingertips
Inspect feet in GALS for what? Do what?
Swelling, deformity, callosities
Lateral squeeze of MTT joints- tenderness= inflammatory arthropathy
Presenting a GALS exam?
Performed x on x a x y/o patient General inspection, comfortable at rest Normal appearance in gait, arms, legs and spine Full ROM in all modalities tested Consistent with normal exam
Further= regional exam of MSK system
Starting a hip exam?
Wash hands, intro, confirm patient, explain, consent and expose: “General inspection, feeling and moving your joints and perform a few special test, chaperone, any pain?”
In hip exam, what to inspect from the front? From side? From behind?
Pelvic tilt, joint deformities(fixed flexion,) wasting of quadricep muscles
Exaggerated lumbar lordosis- fixed flexion deformity
Wasting of gluteal muscles, scoliosis of the spine- can be primary or secondary to pelvic tilt
How to assess gait in hip exam and what to assess? Ask patient to do what?
From various angles
Footwear
Speed/ smoothness/ turning(waddling- hip pain/ proximal muscle weakness, antalgic- pain on weight-baring, stance phase abnormally shortened relative to swing phase
Lay down on exam cough
Assess what two things when patient laid down in hip exam?
Apparent leg length- xiphisternum to medial malleolus(influenced by pelvic tilt)
True leg length- from ASIS to medial malleolus, if discrepancy- in tibia or femur–> bend knees to right angle and heels flat, inspect from side, hand across both tibial tuberosities, femoral= hand dip down towards shortened side, both suprapatellar regions, tibial= dip down towards shortened side
Ask what in ‘feel’ of hip exam?
Any pain/ tenderness in hips, temp using dorsum of hand in upper thigh and greater trochanter
Palpate greater trochanter or trochanteric bursitis
3 hip movements for active ROM?
Abduction- keep legs straight and move them outwards(normal= 45 degrees)
Adduction- move inwards(normal= 30 degrees)
Flexion- bring knees towards chest (normal= 120 degrees)
3 hip movements for passive ROM?
Flexion- stabilising ASIS
Abduction- stabilise contralateral iliac crest and use other hand to abduct hip until feel tilt (normal= 45 degrees)
Adduction- stabilise contralateral iliac crest and use other hand to adduct hip across midline as far as possible (normal ROM= 30 degrees)
Internal and external rotation in extension
Internal= flex hip and knee to 90 degrees and rotate foot laterally(normal= 40 degrees)
External= flex hip and knee, rotate foot medially(normal= 45 degrees)
2 special tests for hip exam?
Thomas’ test- hand under lumbar spine, passively flex unaffected leg, hand should detect lumbar lordosis flattened, contralateral leg should be flat on bed
Repeat on other hip joint (raises off= loss of extension, fixed flexion deformity)
Trendelenburg’s sign- hands on iliac crests on either side, stand on one leg for 30 seconds, observe hands up/down,(normal= side with foot off ground should rise, +ve= pelvis falls on side with foot off ground= weak hip abductors on contralateral side)
Presenting hip exam?
General inspection= comfortable at rest No abnormalities on inspection Normal gait Palpation= no tenderness Full ROM in all modalities tested Special tests= -ve Consistent with normal hip exam
Further= lumbar spine, ipsilateral knee joint, full neurological and vascular exam of patient’s lower limb
Starting a spine exam?
Wash hands, introduce, confirm patient ID, explain, consent and expose: “General inspection, feel, some movements and some special tests, remove top, chaperone, any pain?”
What to look for from bedside, front, side and behind for spine exam?
Aids/ adaptations; walking stick/ wheelchair
Posture of head and neck
Symmetry of shoulders
Cervical hyperlordosis(spondylolisthesis, spondylosis) Thoracic hyperkyphosis>45 degrees= vertebral fracture Lumbar hyperlordosis- obesity/ tight lower back muscles
Scars
Wasting of paraspinal/ back muscles; chronic immobility
Scoliosis
Cafe-au-lait spots; neurofibromatosis
Sacral dimple/ naevus/ hairy patch; spina bifida
Assessing gait in spine exam?
Normal heel-strike/ toe off gait, normal height, smooth and symmetrical, obvious abnormalities
Place supine on couch with hips and knee extended and inspect
What would you feel in spine exam?
Spinal processes, sacroiliac joints and paraspinal muscles
Thyroid, supraclavicular fossae and cervical lymph nodes for masses- cervical rib, lymph glands, tumours
Testing flexion in cervical spine? Extension? Lateral flexion? Rotation? What if reduced ROM on active movements?
Touch chin to chest
Schober’s test- posterior superior iliac spine, 5cm below and 10cm above, touch toes, normally= increases by >5cm(reduced=AS)
Look up to ceiling- 50 degrees
Ear to shoulder- restricted= cervical spondylosis
Turn head left to right, restricted= cervical spondylosis
Perform passively with one hand on neck for crepitus and other on top of head for movement
Testing flexion in lumbar spine, spine exam? Extension? Lateral flexion?
Touch toes with legs straight- normal= <7cm from ground
Lean backwards as far as possible- thoracic= 25 and lumbar= 35 degrees (restricted in prolapsed IV disc)
Stand straight, hands by sides, feet 30cm apart
Measure distance tips to floor
“Slide hand down as far as you can”- difference= should be 10cm
What movement for thorax in spine exam?
Rotation(45 degrees)- arms crossed, sat, turn side to side
Last step of spine exam?
Percuss- bend forward and lightly percuss spine from root of neck of sacrum(infection, fractures and neoplasia)
Special tests for spine exam?
Straight leg raise/ sciatic stretch test(disc prolapse)- place supine on bed, hold ankle and raise leg while knee straight(+ve= buttock pain, indicates sciatica, back pain= central disc prolapse), lower leg until pain gone and dorsiflex foot to increase tension
Bowstring test- flex hip, if pain, flex knee slightly and apply pressure to pop fossa(radiating pain= nerve root irritation)
Femoral nerve stretch- position prone, flex knee and extend hip, plantarflex foot(+ve= anterior thigh pain)
Suspected AS= chest expansion at 4th IC space(normal= 3-5cm), can be reduced in AS
Presenting spine exam?
General inspection= comfortable at rest No abnormalities on inspection Normal gait Palpation= no tenderness Full ROM in all modalities Special tests= -ve Consistent with normal exam
Further= full neuro and vasc exam of upper and lower limbs, hip and shoulder joints, peripheral pulses and lower back pain= abdo exam and rectal exam
Intro to a knee exam?
Wash hands, confirm patient ID, explain, consent and remove patient’s trousers, shoes and socks: “General inspection, feeling and moving your joints and then perform a few special tests, chaperone, any pain”
Look for around bedside, anteriorly, from side and behind in knee exam?
Mobility aids/ adaptations
Scars, swelling, asymmetry, valgus/ varus knee, quadriceps wasting
Knee hyperextension, flexion deformity
Scars, asymmetry, popliteal swellings
Gait in knee exam?
Normal heel strike/ toe off gait, normal height?- high-stepping gait in foot drop, smooth and symmetrical, obvious abnormalities, position supine with hips and knee extended and inspect
Feel for what in knee exam?
Temperature- mid-thigh, patella and upper tibia- normally feels cooler than surrounding
Palpate knee and surrounding structures when extended-
quadriceps tendon; tenderness in tendonitis, patella; medial and lateral patella facets whilst stabilising one side of the patella and palpate with fingertip of other
Patellar tap
Palpate when flexed to 90 degrees- patella tendon, tibial tuberosity, joint line, head of fibula, medial and lateral collateral ligaments, popliteal fossa
Active movements in knee exam?
Flexion- move heel to bottom(normal= 135 degrees), extension- now straighten(normal= 0 degrees)
Passive movements in knee exam?
Flexion and extension whilst feeling for crepitus
Hyperextension; elevate both by heels, <10 degrees= normal
Anterior draw test in knee exam?
Knee flexed to 90 degrees and foot flat on bed, stabilise leg with forearm across, position fingers behind knee, thumb on tibial tuberosity, forward pull
positive= significant movement, anterior cruciate ligament damage
Posterior sag test?
Flex knee to 90 degrees and foot flat, inspect from side, posterior sag of upper tibia with ‘step’ visible below the patella= posterior cruciate ligament damage
Lateral CL test?
Flex knee to 20 degrees, grasp heel with one hand and exert pressure against medial knee with other
LCL damaged= hand detect lateral aspect of joint opening up
Medial collateral ligament test?
Flex knee to 20 degrees, exert pressure against lateral knee with other, grasp heel with one hand
MCL damage= feel medial aspect opening up
McMurray’s test?
Flex hip to 90 degrees and maximally flex knee, externally rotate knee and maintaining, move knee gradually from fully flexed position to fully extended
Repeat using internal rotation
Presenting a knee exam?
“Today I performed a knee examination on [name] a [age] year old
[gender].”
o On general inspection, [name] appeared comfortable at rest.
o No abnormalities were detected on inspection.
o There was normal gait.
o On palpation, there was no tenderness.
o Full range of movement in all modalities tested.
o Special tests were negative.
o To conclude, this is consistent with [diagnosis/a normal knee
examination]”.
o “To complete my examination, I’d like to examine the patients ipsilateral hip
and ankle and perform a full neurological and vascular examination of the
patient’s lower limb”.
Intro for shoulder exam?
Wash hands, introduce, confirm patient, explain, consent and expose: “general inspection, feel, some movements and some special tests, chaperone, pain?”
Look for what around bedside, anteriorly, laterally, posteriorly in shoulder exam?
Aids/ adaptations
Scars, asymmetry- scoliosis, arthritis, trauma, bony prominence, swelling, muscle wasting
Scars
Scars, asymmetry/ deformity- winged scapula(hands against wall- long thoracic nerve injury, scoliosis), paravertebral muscles- swelling/wasting, in supra/ infraspinatus fossa
Feel what in shoulder exam?
Temperature
SC joint, clavicle, AC joint, GH joint, coracoid process, head of humerus, greater tuberosity of humerus, spine of scapula
Muscle bulk of- deltoid, supraspinatus, infraspinatus, trapezius
Screening examination in shoulder exam?
Put hands behind head and push elbows back- external rotation and abduction, behind back and push back(internal rotation, abduction)- difficulty, limitation/ pain
Active movements of shoulder exam?
External rotation- flex to 90 degrees, tuck into side and rotate outwards- lost in frozen shoulder
Internal- above but inwards
Flexion and extension- raise arms in front and behind them
Ab/ adduction- to side palm downwards and lower(normal= 180 degrees), across each other for adduction, observe front and behind for symmetrical scapula
Assess glenohumeral and scapulothoracic movement
(Rotator cuff pathology often pain from 60-120 degrees, may be alleviated by repeating with palm facing upwards, only at end may be ACJ arthritis)
Passive movements in shoulder exam? Function Qs?
External/ internal rotation, flexion/ extension, abduction/ adduction
Feel for crepitus
Dress themselves without difficulty, wash their own hair?
Motions of rotator cuff muscles?
Supraspinatus= resisted abduction first 15 degrees, deltoid= up to 90 degrees, trapezius/ serratus anterior= scapular rotation for abduction> 90 degrees
Infraspinatus, teres minor= resisted active external rotation
Subscap= resisted internal rotation
Special tests for shoulder exam?
“Lift-off test”- place dorsum behind lower back, apply light resistance to hand, ask to move hand off back (loss of power= subscapularis pathology)
“Scarf test”- put arm across chest to opposite shoulder- any pain/ tenderness over ACJ?
Presenting a shoulder exam?
Further tests= examine cervical spine, elbow joints and full neurological and vascular exam of patient’s upper limbs
Look for what local and global issues in nails of hand exam?
Local= pitting/ nail ridges- psoriasis, onycholysis- psoriasis/ fungal infection/ hyperthyroidism, hypertrophic- post-traumatic/ PVD
Global= splinter haemorrhages, clubbing
Look for what on dorsum of hands?
Skin- colour(Raynaud’s,) changes(sclerodactyly, ulceration due to neuropathies,) psoriasis, scars, muscle wasting, deformity
Deformities on dorsum of hand?
Focal swelling- dactylitis(psoriatic arthritis, arthropathies ass w/ AS/IBD,) nodular, swan neck+ Boutonniere, ulnar deviation, clawing, wrist swelling
Look for what on palms?
Skin, scars, muscle wasting- thenar and hypothenar, Dupuytren’s, elbow- nodules/ psoriatic plaques
Feel for what 4 things in hand exam?
Temperature- both sides, over redness areas
Joints- 4 fingers for joints, 2 hands for palm, joints from wrist to metacarpals by sliding thumb distally, lateral squeeze of MCPJs, anatomical snuffbox
Neuro- C6-8 dermatomes, median, ulnar and radial nerve distributions
Vascular- ulnar, radial pulses, Allen’s test
What movements in hand exam?
Fingers= flexion/ extension(full fist and straighten,) abduction/ adduction- spread fingers apart and bring back together
Thumb- flexion/ extension(to side and back together,) abduction/ adduction- point to ceiling, opposition- thumb to little finger
Wrist- dorsiflexion; prayers sign keeping elbows straight
Palmar flexion; reverse and keep elbows straight
Function tests in hand exam?
Grip strength:
Lateral pinch grip- hold key/ pen
Power grip- clench pen and pull out
Precision grip- can you undo and do up buttons
Tests for median nerve(Carpal tunnel syndrome)?
Sensation- light touch
Motor- thumb palmar abduction against resistance
Tinel’s test- tap strongly(+ve= pain/ tingling over area)
Phalen’s test= reverse prayer sign for one minute
Compression test- direct pressure over carpal tunnel can reproduce symptoms
Ulnar nerve tests?
Sensation- light touch
Motor- cross index and middle fingers, grip paper between thumb and index finger without flexing thumb IP joint
Finger abduction against resistance
Radial nerve tests?
Sensation- light touch in radial nerve distribution, motor= wrist and finger dorsiflexion against resistance
Presenting a hand exam?
“Today I performed a shoulder examination on [name] a [age] year old
[gender].”
o On general inspection, [name] appeared comfortable at rest.
o No abnormalities were detected on inspection.
o On palpation, there was no tenderness.
o Full range of movement in all modalities tested.
o Sensation was intact.
o Special tests were negative.
o To conclude, this is consistent with [diagnosis/a normal hand
examination]”.
FURTHER= observe elbow joint if pain/ restricted movement at wrist joint and perform full neurological and vascular examination of patient’s upper limbs
