MSK history and examination Flashcards
What do you need to ask about the site of pain?
What is the pattern of joints involved?
- Which joints?
- Small or large?
- Single/multiple?
- Bilateral?
- Symmetrical/asymmetrical?
What are some associated symptoms of MSK pain?
Stiffness and/or swelling Crepitus Erythema Increased local temperature Fatigue Malaise Depression Systemic temperature Rashes/skin conditions Nodules Abdominal pain Weight loss Systemic symptoms Dry mouth and gritty eyes
What do you need to ask about timing?
Relationship to time of day?
- How do they feel in the morning/evening?
- How do you sleep?
What do exacerbating factors have to do with the type of condition?
Exercise - mechanical/degenerative conditions
Rest - inflammatory conditions
What do you ask in a MSK PMH?
Anything similar previously? Tests/diagnoses/treatments? Did they work? S/E? Hx of trauma? Recent infective episodes? Diabetes? Psoriasis? IBD? Coeliac disease? TB? Autoimmune conditions? Risk factors for gout?
What do you ask in a drug Hx?
Current medications for presenting condition
Other current medications
OTC? Do they work?
What should you ask in a social Hx?
Occupation - does it affect their employment? Sports and hobbies? Home circumstances AODL Smoking Alcohol
What should you ask in a FHx?
FHx of RA, OA, psoriasis, gout, UC, Crohn’s, connective tissue disease or any other autoimmune diseases?
What are the initial questions to ask in a GALS examination?
Do you have any pain or stiffness in your muscles, joints or back?
Are you able to completely dress or undress yourself without difficulty?
Are you able to climb up and down stairs without any difficulty?
What are the main steps in a GALS examination?
Inspection Gait Arms Legs Spine
What do you look for in the inspection and how do you do it? GALS
Look from front - abnormalities in shoulders, elbows, wrists, hands, chest, hips, knees, thighs and feet
Look from side - presence of normal spine curvatures, hip and knee flexion deformities or knee hyperextension
Look from back - abnormalities in shoulders, spine, and paraspinal muscles, level of iliac crests, gluteal regions, popliteal fossae, calves, achilles tendons nad hind feet
What do you look for in their gait and how do you do it? GALS
Ask patient to walk a few steps, turn and walk back
Comment on arm swing, pelvic tilt, stride length, ability to turn quickly and any painful gait on walking
Ask whether walking is painful/painless
What do you assess in the spine? GALS
Assess flexion of lumbar spine
Assess lateral flexion of neck
What should you observe in the arms? GALS
Shoulders
Wrists and hands
What movements do you need to do when assessing the shoulders? GALS
Ask patient to put their hands behind their head and push their elbows back
Observe abnormalities in ROM of shoulder abduction and external rotation and elbow flexion
What do you need to do when assessing the hands and wrists? GALS
Look
Feel
Move
What should you look for in the wrists and hands? GALS
Hands out in front of them palms down
Ask them to turn hands over palms up
Observe any joint swelling, deformity, loss of contours, muscle wasting, skin/nail changes and nodules in wrists and hands
Observe ability to supinate and pronate at elbow
Observe ability to fully straighten elbow
What do you feel for in the hands? GALS
Assess tenderness by performing lateral squeeze of MCPs
What do you look for when you move the hands? GALS
Check ability to make a full fist covering the nails
Ask patient to squeeze fingers to assess grip strength
Ask patient to bring each finger to meet the thumb
What do you look at in the legs? GALS
Hips and knees
Feet
What do you look for in the hips? GALS
Ask the patient to fully flex and extend their knee placing hand over knee to assess for crepitus
Bend knee and hip to 90 degrees
Hold knee and use ankle to move leg assessing external and internal rotation of the hip
Patellar tap test/bulge test
What do you look for in the feet? GALS
Inspect soles for swelling, deformity or callosities
Squeeze across MTP joints checking for tenderness
What are the steps in a joint examination?
Look
Feel
Move
Special tests
What do you look for in a hip examination and how do you do it?
With patient standing
- Inspect from front for pelvic tilt, joint deformities, wasting of quadriceps
- Inspect from side for exaggerated lumbar lordosis
- Inspect from behind for wasting of gluteal muscles and scoliosis
- Look at stance
With patient supine
- Inspect for scars in groin, anterior and lateral thighs
- Roll patient onto side to inspect gluteal region
Assess symmetry - leg length discrepancy?
How do you measure leg length?
Apparent leg length - from xiphisternum to medial malleolus
True leg length - from ASIS to medial malleolus
If true leg length discrepancy then assess whether originates in tibia/femur
Position patient with knees bent up to right angle and heels flat on bed
Inspect from side
Place hand on both tibial tuberosities - if femoral shortening then hand will dip down towards shortened side
Place hand on suprapatellar regions, if tibial shortening then hand will dip down towards shortened side
What do you feel for in a hip examination?
Ask patient if they have tenderness in hip
Assess temperature in upper thigh and greater trochanter
Palpate greater trochanter for trochateric bursitis
How do you move the joint in a hip examination?
Check active ROM in flexion, abduction and adduction
Check passive ROM in the same + internal and external rotation
What is the normal active ROM in hip flexion?
115-125
What is the normal active ROM in hip abduction?
40-50
What is the normal active ROM in hip adduction?
15-25
What is the normal passive ROM for internal rotation in extension?
30-40
What is the normal passive ROM for external rotation in flexion?
25-50
What is the normal passive ROM for internal rotation in flexion?
25-40
What special tests do you do in a hip examination?
Thomas’ test
Assess gait
Trendelenburg’s test
What is Thomas’ test?
Assessing for fixed flexion deformity of contralateral hip
Place hand under patients lumbar spine to check for fill correction of lumbar lordosis then observe contralateral hip as flex hip fully
If fixed flexion deformity then raise leg off bed
What is Trendelenburg’s test?
Ask patient to stand on one leg to assess the abductor muscle strength of that hip
In a negative (normal) test, pelvis remains level or rises on contralateral side as contracts abductors
In positive test, pelvis will dip on contralateral side
How should you complete a hip examination?
Examine patients lumbar spine and ipsilateral knee joint
Perform a neurological and vascular examination of lower limb
What do you look for in a knee examination and how do you do this?
With patient standing inspect from front, side and back for... - Valgus deformity - Varus deformity - Genu recurvatum - Flexion deformity - Swellings in popliteal fossa - Comment on patients stance With patient supine with hips and knees extended inspect for... - Symmetry - Valgus and varus deformities - Rashes - Scars - Swelling - Muscle wasting - Displacement of patella - Fixed-flexion deformity
What do you feel for in a knee examination?
Assess temperature
Palpate around borders of patella for tenderness at full extension and 90 flexion
Palpate behind the knee for popliteal swellings or cysts
Assess for effusion by either - bulge test or patellar tap
What is the bulge test?
Sweep hand firmly up medial fossa, over suprapatellar pouch and down lateral fossa
Medial fossa may refill producing a bulge of fluid
What is the patellar tap test?
Compress suprapatellar pouch to empty it
Press down on patellar
How do you move the joint in a knee examination?
Actively flex and extend knee
Passively flex and extend knee
Palpate for crepitus
What special tests do you do in a knee examination?
Posterior sag test Anterior draw test Lateral collateral ligament test Medial collateral ligament test Gait
How do you do a posterior sag test?
Position patient with knee flexed to 90 and foot flat on bed
Inspect from side
Posterior sag of upper tibia with step visible below patellar suggestive of PCL damage
How do you do an anterior draw test?
Position patient with knee flexed to 90 and foot flat on bed
Stabilise leg using forearm
With fingers of both hands behind knee and patients hamstrings relaxed, place thumbs over tibial tuberosity and apply a forward pull
Significant movement indicates positive draw test and suggests ACL damage
How do you do a lateral collateral ligament test?
Flex knee to 20
Grasp patients heel with one hand whilst exerting pressure against inside of knee with other hand
Varus stress applied causes lateral gaping in laterally unstable knee
Small amount of lateral joint gaping is physiological and is asymmetry of gaping that constitutes abnormal finding
How do you do a medial collateral ligament test?
Flex knee to 20
Grasp patients heel with one hand whilst exerting pressure against outside of knee with other hand
Valgus stress applied causes medial gaping in medially unstable knee
Small amount o medial lateral joint gaping is physiological and is asymmetry of gaping that constitutes abnormal finding
How should you complete a knee examination?
Examine ipsilateral hip and ankle
Assess neurological and vascular status of limb
How do you inspect the spine in a spinal examination?
Inspect from front, side and behind
Inspect skin, cervical spine and thoracolumbar spine
What do you look for in the skin in a spinal examination?
Cafe-au-lait spots (neurofibromatosis) Sacral dimples Naevus Hairy patch suggestive of spina bifida Scarring suggestive of previous thoractomy or spinal surgery
What do you look for in the cervical spine in a spinal examination?
Deformity - cervical spondylosis, acute torticollis
Abnormal head posture
Asymmetry of the clavicles, scapulae and shoulders
What do you look for in the thoracolumbar spine in a spinal examination?
Kyphosis or scoliosis
What do you feel for in a spinal examination and how do you do it?
Palpate cervical spine posteriorly in midline, laterally and anteriorly
Palpate supraclavicular fossae for any masses
Palpate thoracolumbar spine and sacrum for tenderness
Palpate paraspinal muscles
Palpate for tenderness over sacroiliac joints
How do you assess the active ROM in the cervical spine?
Flexion
Extension
Lateral flexion
Lateral rotation
What is the normal active ROM for flexion of the cervical spine?
80 - chin able to touch sternoclavicular joint
What is the normal active ROM for extension of cervical spine?
50
What is the normal active ROM for lateral flexion of the cervical spine?
45 from midline
What is the normal active ROM for lateral rotation of the cervical spine?
80 to each side
How do you assess the ROM of the thoracolumbar spine?
Flexion
Extension
Lateral flexion
Rotation
How do you assess flexion of the thoracolumbar spine?
Combination of thoracic, lumbar and hip movements
Composite movement recorded as distance between patient’s fingers and ground
Modified Schober’s test
How do you do the modified Shoeber’s test?
15cm length of lumbar spine with patient erect
Measure 10cm above and 5cm below PSIS
Instruct patient to flex spine maximally
Remeasure distance between marks
Normally increases distance by at least 5cm
How do you assess extension of the thoracolumbar spine and what is normal?
Arch back
Thoracic 25
Lumbar 35
How do you assess lateral flexion of the thoracolumbar spine?
Stand erect with hands at sides and feet 30cm apart
Measure distance from finger tips to floor
Flex maximally and remeasure distance from finger tips to floor
Normally > 10cm
How do you assess rotation of the thoracolumbar spine?
Seated
Fold arms across chest and twist round to each side
Mostly thoracic - 40
Lumbar contribution < 5
How do you percuss the spine in a spinal exam?
Bend forwards slightly and percuss spine from root of neck to sacrum
Significant percussion tenderness is feature of infection, fractures and neoplasia
What special tests should you do in a spinal exam?
Gait
Full neurological examination of upper and lower limbs
Abdominal examination if lower back pain
Peripheral pulses
Shoulder joints if neck pain
Lower back pain examine hips
If suspected prolapsed intervertebral disc - bowstring test/femoral stretch test
Test for ankylosing spondylitis if suspected
How do you test for a suspected prolapsed intervertebral disc?
Straight leg raise - lie flat on couch and passively flex thigh with leg extended - if complains of back or leg pain test is positive
Lower leg gradually until pain disappears then dorsiflex foot which should increase tension in nerve roots aggravating pain
What is Bowstring test?
Straight leg raise
If patient experiences pain, flex knee slightly and apply firm pressure with thumb in popliteal fossa to stretch tibial nerve radiating pain and paresthesiae suggest nerve root irritation
What is the femoral stretch test?
With patient prone and anterior thigh fixed to couch, flex each knee in turn
Causes pain in skin overlying anterior compartment of thigh by stretching the femoral nerve roots in L2-4
Pain produced normally aggravated by extension of the hip
How do you test for suspected ankylosing spondylitis?
Assess chest expansion at level of 4th intercostal space
Normal 3-5cm
How do you examine a patient in a shoulder examination?
Standing
From the front, side and back
What should you inspect for from the front in a shoulder examination?
Symmetry Posture Swelling Deformity Bony prominence Muscle wasting Scars Skin changes
What should you inspect for from the back in a shoulder examination?
Muscle bulk
Abnormalities in the scapula
Scars/skin changes
What should you palpate in a shoulder examination?
Assess temperature
Palpate from the front, work from medial to lateral - look for joint tenderness, swelling and crepitus
Palpate muscle bulk of deltoid, supraspinatus, infraspinatus, trapezius
What is the screening examination for ROM in a shoulder examination?
Ask patient to put hands behind head and push elbows back as far as they can (external rotation and abduction)
Ask the patient to put their hands behind their back (internal rotation and abduction)
How do you assess the active ROM in a shoulder examination?
External rotation - flex elbow to 90 and tuck into patients side, turn arm outwards
Internal rotation
Flexion and extension
Abduction (checking painful arc)
How do you assess passive ROM in a shoulder examination?
Internal and external rotation Flexion Extension Abduction Palpate shoulder for creptius
What questions should you ask the patient in shoulder examination?
Can they dress themselves without difficulty?
Can they wash their own hair?
What special tests should you do in a shoulder examination?
Test rotator cuff
Acromioclavicular joint pathology
How do you test the rotator cuff?
Resisted active abduction (supraspinatus)
Resisted active external rotation (infraspinatus and teres minor)
Resisted active internal rotation (subscapularis)
How do you test for acromioclavicular joint pathology?
Place arm into forced adduction (scarf test)
How should you complete a shoulder examination?
Examine cervical spine and elbow
Assess neurological and vascular status of limb
What should you inspect in a hand exam?
Hands - nails, palm and dorsum
Elbow
What should you look for in the nails in a hand exam?
Pitting and/or nail reidges Onycholysis Onychogryphosis Splinter haemorrahes Clubbing
What should you look for on the palm and dorsum of the hand in a hand exam?
Skin - colour, changes, psoriasis
Scars
Muscle wasting
Deformities
What deformities might you see in the hands?
Dactylitis Bouchards/Herbeden's nodes Swan neck and Boutonniere deformities Squaring of the hand Windswept deformity Clawing Wrist swelling Dupuytren's contracture
What should you look for on the elbow in a hand exam?
Rheumatoid nodules
Psoriatic plaques
What should you palpate for in a hand exam?
Temperature
Tenderness, swelling or bony deformities
Squeeze test of MCPJs
Palpate along dorsal and volar aspect of metacarpals and phalanges
Palpate radial and ulnar aspects of phalanges
Check sensation in dermatomes and peripheral nerve (median, ulnar and radial distribution)
Check ulnar and radial pulses
Allen’s test
How do you test range of motion in a hand exam?
Fingers - flexion/extension, abduction/adduction
Thumb - flexion/extension, palmar abduction, adduction and opposition
Wrist - dorsiflexion and palmar flexion, radial and ulnar deviation with elbows by side
How do you test function in a hand exam?
Assess grip strength - power grip, lateral pinch grip and precision
What special tests do you do in a hand exam?
Carpal tunnel tests (median nerve tests)
Ulnar nerve tests
Radial nerve tests
How do you test the median nerve?
Sensory - test light touch in median nerve distribution
Motor - test palmar abduction against resistance
Provocation - Tinel’s, Phalen’s and compression test
How do you perform Tinel’s test?
Tap over median nerve as it goes through the carpal tunnel
Reproduction of pain, numbness or tingling in the cutaneous distribution of the medial nerve is a positive test
How do you perform Phalen’s test?
Hold both wrists in palmar flexion for one minute
Reproduction of pain, numbness or tingling in the cutaneous distribution of the median nerve is a positive test
How do you perform a compression test?
Direct pressure of carpal tunnel
How do you test ulnar nerve sensation and motor function?
Sensory - test sensation in ulnar nerve distribution
Motor - ask patient to cross index and middle fingers
Grip a piece of paper between thumb and index finger without flexing thumb IP joint
Abduct fingers against resistance
How do you test radial nerve sensation and motor function?
Sensation - test sensation in the anatomical snuff box
Motor - test wrist and finger dorsiflexion against resistance
How should you complete a hand exam?
Examine ipsilateral elbow if abnormal exam
