MSK Exams

Question 1

Describe the order of the MSK exam

Answer 1

Intro (WIPER)
Screening questions
Gait
Inspection
Arms
Legs
Spine
Other tests

Question 2

What are the screening questions for an MSK exam

Answer 2

Do you have any pain, swelling or stiffness in your joints, muscles or back?

Do you have any difficulty getting dressed without any help?

Do you have ay problem going up and down the stairs?

Question 3

How do you assess gait in an MSK exam

Answer 3

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying attention to:

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.

GRLLTTWF

Question 4

Give 6 things to look out for in the observation stage of an MSK exam

Answer 4

Body habitus: obesity is a significant risk factor for joint pathology due to increased mechanical load (e.g. osteoarthritis).

Scars: may provide clues regarding previous surgery.

Wasting of muscles: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron injury.

Psoriasis: typically presents with scaly salmon coloured plaques on extensor surfaces (associated with psoriatic arthritis).

Aids and adaptations: examples include support slings, splints, walking aids and wheelchairs.

Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications (e.g. analgesia).

Question 5

What does the question “Do you have any pain or stiffness in your muscles, joints or back?” screen for?

Answer 5

This question screens for common symptoms present in most forms of joint pathology (e.g. osteoarthritis, rheumatoid arthritis, ankylosing spondylitis).

Question 6

What does the question “Do you have any difficulty getting yourself dressed without any help?” screen for?

Answer 6

.This question screens for evidence of fine motor impairment and significant restriction joint range of movement.

Question 7

What does the question “Do you have any problem going up and down the stairs?” screen for?

Answer 7

This question screens for evidence of impaired gross motor function (e.g. muscle wasting, lower motor neuron lesions) and general mobility issues (e.g. restricted range of movement in the joints of the lower limb).

Question 8

What does the closer inspection screen for in an MSK exam

Answer 8

Ask the patient to stand in the anatomical position and turn in 90° increments as you inspect from each angle for evidence of pathology.

Question 9

What do you look for in an anterior inspection in an MSK exam

Answer 9

Posture

Scars

Joint swelling: unilateral swelling (e.g. effusion, inflammatory arthropathy, septic arthritis).

Joint erythema: suggestive of active inflammation (e.g. inflammatory arthropathy or septic arthritis).

Muscle bulk: 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=cubitus valgus. A decreased carrying angle is known as cubitus varus or ‘gunstock deformity’.

Valgus joint deformity: the bone segment distal to the joint is angled laterally.

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

Fixed flexion deformity of the toes: subtypes include hammer-toe and mallet-toe.

Big toe

Question 10

What is cubitus valgus and what does it suggest

Answer 10

the patient’s carrying angle which should be between 5-15°. An increased carrying angle=cubitus valgus.

Cubitus valgus is typically associated with previous elbow joint trauma or congenital deformity (e.g. Turner’s syndrome).

Question 11

What is cubitus varus

Answer 11

A decreased carrying angle is known as cubitus varus or ‘gunstock deformity’.

Cubitus varus typically develops after supracondylar fracture of the humerus.

Question 12

What is valgus deformity

Answer 12

In valgus deformity of the knee, the tibia is turned outward in relation to the femur, resulting in the knees ‘knocking’ together.

Question 13

What can cause a lateral pelvic tilt

Answer 13

lateral pelvic tilt can be caused by scoliosis, leg length discrepancy or hip abductor weakness.

Question 14

What are types of Fixed flexion deformity of the toes?

Answer 14

subtypes include hammer-toe and mallet-toe.

Question 15

What do you look for in the big toe during inspection the MSK exam

Answer 15

note any evidence of lateral (hallux valgus) or medial (hallux varus) angulation.

Question 16

What are you looking for in the lateral inspection in the MSK exam

Answer 16

Cervical lordosis

Thoracic kyphosis - the normal amount of thoracic kyphosis is typically between 20-45º.

Lumbar lordosis

Knee joint hyperextension

Foot arch

Question 17

What is cervical lordosis indicative of

Answer 17

hyperlordosis is associated with chronic degenerative joint disease (e.g. osteoarthritis).

Question 18

What is thoracic kyphosis indicative of

Answer 18

the normal amount of thoracic kyphosis is typically between 20-45º. Hyperkyphosis is associated with Scheuermann’s disease (congenital wedging of the vertebrae).

Question 19

What are you looking for in lumbar lordosis inspection

Answer 19

loss of normal lumbar lordosis suggests sacroiliac joint disease (e.g. ankylosing spondylitis).

Question 20

What does Knee joint hyperextension
cause

Answer 20

causes include ligamentous damage and hypermobility syndrome.

Question 21

What do you look for when inspecting the foot arch

Answer 21

inspect for evidence of flat feet (pes planus) or an abnormally raised foot arch (pes cavus).

Question 22

What are you looking for in the posterior inspection during a MSK exam

Answer 22

Muscle bulk: 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

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

Question 23

What are possible causes of popliteal swelling

Answer 23

possible causes include a Baker’s cyst or popliteal aneurysm (typically pulsatile).

Question 24

What do you assess in the Arms section of the MSK exam

Answer 24

Hands behind head
Hands held out in front with palms facing down
Hands held out in front with palms facing up
Making a fist
Grip strength
Precision grip
Metacarpophalangeal joint squeeze

Question 25

Why do you ask the patient to put their hands behind their head and point their elbows out to the side in an MSK exam

Answer 25

assesses shoulder abduction and external rotation in addition to elbow flexion. Restricted range of movement is suggestive of shoulder or elbow pathology (e.g. osteoarthritis). Excessive range of movement indicates hypermobility.

Question 26

What do you inspect when the patient has Hands held out in front with palms facing down (MSK)

Answer 26

assesses forward flexion of the shoulders, elbow extension, wrist extension and extension of the small joints of the fingers. Inspect the dorsum the hands for asymmetry, joint swelling and deformity. Inspect the nails for signs associated with psoriasis (e.g. nail pitting).

Question 27

What do you inspect when the patient has Hands held out in front with palms facing up (MSK)

Answer 27

assesses wrist and elbow supination. Restriction of supination is suggestive of wrist or elbow pathology (e.g. osteoarthritis). Inspect the thenar and hypothenar eminences for evidence of muscle wasting.

Question 28

Why ask the patient to make a fist whilst observing hand function? (MSK)

Answer 28

assesses flexion of the small joints of the fingers as well as overall hand function. The patient may be unable to make a fist if they have joint swelling (e.g. inflammatory arthritis or joint infection) or if they have other deformities of the small joints of the hands.

Question 29

How do you assess grip strength in MSK

Answer 29

Ask the patient to squeeze your fingers and assess grip strength (comparing the patient’s hands): Grip strength may be reduced due to pain (e.g. swelling of the small joints of the hand) or due to lower motor neuron lesions (e.g. median nerve damage secondary to carpal tunnel syndrome).

Question 30

How do you assess precision grip in MSK

Answer 30

Ask the patient to touch each finger in turn to their thumb (known as ‘precision grip’): This sequence of movements assesses co-ordination of the small joints of the fingers and thumbs. Reduced manual dexterity may suggest inflammation or joint contractures of the small joints of the hand.

Question 31

Describe the metacarpophalangeal joint squeeze (MSK)

Answer 31

Gently squeeze across the metacarpophalangeal (MCP) joints and observe for verbal and non-verbal signs of discomfort. Tenderness is suggestive of active inflammatory arthropathy.

Question 32

How should the patient be positioned when you are assessing their legs in the MSK exam

Answer 32

Position the patient lying down on the examination couch for further assessment of the lower limbs.

Question 33

What is passive movement and why is it important in the MSK exam

Answer 33

Passive movement refers to a movement of the patient, controlled by the examiner. This involves the patient relaxing and allowing you to move the joint freely to assess the full range of joint movement. It’s important to feel for crepitus as you move the joint (which can be associated with osteoarthritis) and observe any discomfort or restriction in the joint’s range of movement.

Question 34

What are the passive movements performed on the legs in the MSK exam

Answer 34

Passive knee flexion Passive knee extension Passive internal rotation of the hip

Question 35

Describe passive knee flexion assessment

Answer 35

Normal range of movement: 0-140° Instructions: Whilst supporting the patient’s leg, flex the knee as far as you are able, making sure to observe for signs of discomfort.

Question 36

Describe passive knee extension assessment

Answer 36

If the patient is able to lay their legs flat on the bed, they are already demonstrating a normal range of movement for knee extension. To assess for hyperextension: 1. On the leg being assessed, hold above the ankle joint and gently lift the leg upwards. 2. Inspect the knee joint for evidence of hyperextension, with less than 10° being considered normal. Excessive knee hyperextension may suggest pathology affecting the integrity of the knee joint’s ligaments or hypermobility.

Question 37

Describe passive internal rotation of the hip assessment

Answer 37

Normal range of movement: 40° Instructions: Flex the patient’s hip and knee joint to 90° and then rotate their foot laterally.

Question 38

What do you do after the passive movement assessment in an MSK exam

Answer 38

Patella tap Metatarsophalangeal joint squeeze

Question 39

Describe a Metatarsophalangeal joint squeeze

Answer 39

Gently squeeze across the metatarsophalangeal (MTP) joints and observe for verbal and non-verbal signs of discomfort. Tenderness is suggestive of active inflammatory arthropathy

Question 40

What is a patella tap

Answer 40

Joint effusion can be caused by ligament rupture (e.g. anterior cruciate ligament), septic arthritis, inflammatory arthritis and osteoarthritis. The patellar tap test can be used to screen for the presence of a moderate-to-large knee joint effusion. 1. With the patient’s knee fully extended, empty the suprapatellar pouch by sliding your left hand down the thigh to the upper border of the patella. 2. Keep your left hand in position and use your right hand to press downwards on the patella with your fingertips. 3. If there is fluid present you will feel a distinct tap as the patella bumps against the femur.

Question 41

How do you assess the spine in the MSK exam

Answer 41

look at: Cervical lateral flexion Lumbar flexion Temporomandibular joint

Question 42

How do you assess cervical lateral flexion in the MSK exam

Answer 42

Assess lateral flexion of the cervical spine by asking the patient to tilt their head to each side, moving their ear towards their shoulder: “Try and touch your shoulder to your ear on each side.”

Question 43

How do you assess lumbar flexion in the MSK exam

Answer 43

Assess the range of lumbar flexion using your fingers to palpate for a normal range of movement of the lumbar vertebrae (loss of lumbar flexion can be masked by good hip flexion, making inspection without palpation less reliable): 1. Place two of your fingers on the lumbar vertebrae approximately 5-10cm apart. 2. Ask the patient to bend forwards and touch their toes. 3. Observe your fingers as the patient’s lumbar spine flexes (they should move apart). 4. Observe your fingers as the patient extends their spine to return to a standing position (your fingers should move back together). If the patient is able to place their hands flat on the floor it suggests joint hypermobility.

Question 44

How do you assess the TMJ in the MSK exam

Answer 44

ask the patient to open their mouth wide and put three of their fingers into their mouth (demonstrate using your own fingers and mouth). This manoeuvre assesses the temporomandibular joint’s range of movement and screens for deviation of jaw movement. Restricted jaw opening may be due to temporomandibular joint disease.

Question 45

What are further assessments and investigations you could perform after an MSK exam

Answer 45

A focused examination of joints with suspected pathology. Further imaging if indicated (e.g. X-ray and MRI).

Question 46

What is different about assessing a child's gait in pGALS

Answer 46

Also assess heel and tiptoe walking The presence of flat feet (pes planus) is normal in young children, but the medial longitudinal arches of the foot should be visible when the child stands on their tiptoes. Assessing gait in this way screens for pathology in the ankles joints, subtalar joints, midtarsal joints and the smaller joints of the feet and toes.

Question 47

How do you assess the arms in pGALS?

Answer 47

Hands behind head Hands in front, palms down (inspect dorsum and nails here + MCP squeeze) Supinate Inspect and palpate palms Make a fist Precision grip ( touch each finger in turn to their thumb) Palms together Hands back to back Touch the sky and look up