MSK Physical Exams

Question 1

Inspection Hip Exam

Answer 1

• Gait Assessment
• Swellings? Erythema? Skin changes/scarring?
• Atrophy: Pelvic girdle, gluteal muscles, hamstrings, quadriceps, lower back.
• Deformity:
  
  • Posture- scoliosis, exaggerated lumbar lordosis
  • Pelvic tilt - look at level of iliac crests.
  • Feet valgus or varus
• Trendelenburg sign

Question 2

Palpation Hip Exam

Answer 2

• With patient supine palpate along - pubic symphysis, inguinal ligament, femoral pulse, ASIS.
• With patient sitting up - PSIS, dimples of venus, SI joint (superior to dimples), ischial tuberosity (lateral to dimples), greater trochanters, IT band.

Question 3

ROM and Power Hip Exam

Answer 3

Perform active and then possive if active is limited.

• Flexion (120^o): Knee to chest
• Extension (20^o)
• Internal rotation (30^o)
• External rotation (45^o)
• Abduction (45^o)
• Adduction (30^o)

Do power assessment after for all of the above motions

Question 4

Special Tests Hip Exam

Answer 4

• Thomas Test - check for signs of hip contracture. Place one hand under patients lumbar spine and get patient to hold their knee to their chest. Look to see if contralateral thigh rises off the bed.
• Ober test - check for signs of illiotibial band. Place patient in decubitus position with knees bent. Brace upper leg and extend it backwards. Knee should touch the bed.
• FABER - check for sacroilliac joint of hip joint pathology. Make figure 4 position with leg and apply pressure stabilizing contralateral hemipelvis from other hand. See if their is pain.
• Leg length discrepancy
  
  • True leg length - from ASIS to medial mallelous
  • Apparent leg lenth - from umbilicus to medial mallelous

Question 5

Gait Assessment

Answer 5

• Gait Assessment
  
  • Stance phase/swing phase
  • Quailty of gait - smoothness, symmetry, ability to turn quickly.
  • Antalgic gait? (Painfult gait)
  • Trendelenburg gait (weak hip abductors on opposite side)

Question 6

Inspection Knee Exam

Answer 6

Standing Position:

• Swelling (bakers cysts)
• Erythema
• Atrophy -calves, quadriceps, hamstrings
• Deformity - knee hyperextension, flexion deformity, varus, valgus
• Skin changes and scarring

Supine:

• Swelling - loss of parapatellar grooves/fossa, localized swelling

Question 7

Palpation Knee exam

Answer 7

With knee extended:

• Temperature
• Patella palpation
• Anterior from superior to inferior: quadriceps, suprapatellar tendon, patellar ligament, tibial tuberosity.
• Posterior from superior to inferior: Popliteal fossa, popliteal pulse.
• Palpate 4 bursa - pre-patellar, superficial and deep infra-patellar, anserine bursa

With knee flexed to 90⁰

• Palplate joint line: Medial and lateral tibial plateaus, femoral condyles, medial and lateral joint line, MCL
• In figure 4 position palpate LCL

Palpation for effusion:

• Fluid wave/milking: empty medial fossa by sweeping hand in superior lateral direction, then immediately sweep down.
• Fluid ballottement test: Grasp knee just above patella and apply pressure while squeezing with one hand. With other hand, grasp medial and lateral parapatellar fossa to palpate for effusion.
• Patellar trap: Grasp knee just above patella and apply ressure while squeezing with one hand. With other hand push patella down.

Question 8

ROM and Power Knee exam

Answer 8

ROM

• Flexion (135^o)
• Extension (180^o)
• Internal rotation (30^o)
• External rotation (20^o)
• Patellar movement

Power

• Just flexion and extension

Question 9

Special Tests Knee Exam

Answer 9

• Anterior and Posterior Drawer test (ACL and PCL tear)
• Lachmans (ACL tear) - flex to 30⁰. Stabilize femur with one hand, while you grasp the upper tibia with other hand. Try to pull tibia forward.
• Medial and lateral collateral stress test - flex to 30⁰. Stabilize knee posteriorly with one hand, and stabilize ipsilateral shin posteriorly with other hand. Apply varus force (MCL) and valgus force (LCL)
• McMurray (menisca tear) - externally rotate foot with varus force (medial) while extending knee; internally rotate foot with calgus force (lateral) while extending knee.
• Apley’s compression - with patient prone flex knee to 90⁰. Push down while applying a varus and lateral force.

Question 10

Shoulder Exam Inspection

Answer 10

• Swelling (especially of joints) - sternoclavicular, acromioclavicular, and glenohumeral
• Erythema
• Atrophy - pectoralis major, deltoid, supraspinatus, infraspinatus, and trapezius
• Deformities - alignment, step deformity of clavicle (prior fracture), wing of scapula (get patient to push against wall).

Question 11

Palpation Shoulder Exam

Answer 11

• Palpate sternoclavicular joint, acrominocalvicular joint, and gelnohumeral joint for warmth
• Palpate SC joint, clavicle, coracoid process, AC joint, acromion, spine of scapula
• Palpate - trapezius, supraspinatus, infraspinatus, deltoid, triceps, biceps
• Palpate rotator cuff insertion on greater tuberosity of humerus - extend arm backwards to bring humerus out from under acromion. Also palpate for crepitus.

Question 12

ROM Shoulder Exam

Answer 12

• Apley scratch test - have patient touch tip of their contralateral scapula.
• Crepitus - With hand over shoulder, move shoulder in all directions around.
• Shoulder abduction (180⁰)
  
  • Painful arch - tends to occur between 60-120⁰ during abduction, indicative of subacrominal impingement, subacrominal bursitings, or supraspinatus tendonitis.
  • Scapulothoracic rhythm - if abnormal, you would see kink in rhythm.
• Shoulder adduction
• Shoulder flexion (180⁰)
• Shoulder extension (60⁰)
• Shoulder external rotation - rotate forearm away from body
• Shoulder internal rotation - rotate forearm towards body and then behind the back.
• Power - shoulder flexion, extension, abduction, adduction, internal and external rotation.

Question 13

Special Testes Shoulder Exam

Answer 13

Supraspinatus tear

• Drop arm test - have patient abduct arms to overhead position and bring arm back to side actively. If an arm suddenly drops to the side test is positive.

Subacrominal impingement syndrome

• Painful arc - have patient abduct arms and look for signs of pain (between 60-120⁰)
• Neer’s test - Stabilize shoulder and passively lift arm to the ear.
• Hawkins Kennedy test - place arm as if it were holding a Hawk and internally rotate. Look for signs of pain.
• Empty can test - Arms abducted 45⁰ and flexed forward 45⁰ with thumbs pointed down apply downward pressure.

Bicipital Tendonitis

• Speed’s test - Patients elbow extended, arm supinated and forward at 45⁰ apply downward pressure.
• Yergasons test - with patients arm flexed to 90⁰ pronate arm while patient is resisting.

Acromioclavicular joint pathology

• Patient places their hand on contralateral shoulder. Stabilize ipsilateral shoulder. Apply a posterior force to push arm into body while stabilizing the ipsilateral joint.

Question 14

Elbow exam General

Answer 14

• Inspection:
  
  • Swelling (look at para-olecranon grooves (joint swelling); posterior aspect of olecranon (bursitis)).
  • Erythema
  • Atrophy - biceps, triceps, brachioradialis, wrist flexors (medial epicondyle), wrist extensors (lateral epicondyle).
  • Deformities - carrying angle, flexion contractures
  • Skin changes or scars
• Palpation
  
  • Posteriorly - humerus, triceps, olecranon process, olecranon bursa, para-olecranon grooves, extensor surface of arm
  • Medially - medial triceps border, epitrochlear lumph nodes, medial epicondyle, common flexor tendon
  • Anteriorly - biceps, biceps tendon, brachial pulse
  • Laterally - lateral epicondyle, common extensor tendon, radial head
• ROM: Flexion, extension, prontation, supination
• Power: Flexion, extension, prontation, supination

Question 15

Elbow Exam Special Tests

Answer 15

• MCL (ulnar) an and LCL (radial) collateral ligaments - hold elbow to stabilize with on hand, and glex elbow at 30^0. Grasp foreamrm with other hand. Apply a valgus force (MCL) and a varus (LCL) force
• Antero-posterior stability - elbow flexion to 90⁰ and grasp at humerus. Push and pull humerus anteriorly and posteriorly, there should be no movement.
• Tennis Elbow Test - Elbow extended with wrist extended. Palpate for tenderness at lateral epicondyle. Then apply a flexion force at wrist while patient resists. Look for signs of pain.
• Golfers Elbow Test - Elbow extended with wrist flexion. Palpate for tenderness at medial epicondyle. The apply extension force at wrist while patient resists. Look for signs of pain.
• Tinels Sign
• Elbow flexion test - Have patient hold position with elbow flexed and wrists extended for 60seconds.

Question 16

Back Examination General

Answer 16

• Gait assessment - stance, swing, quality of gait, antalgic gait, trendelenburg gait, sitting to standing
• Inspection - Swelling, erythemia, atrophy (sternocleidomasteroids, shoudler girdle, chest wall, intercostsals, paraspinal, gluteal, abdominal
• Palpation - Palpate spinous processes and paravertebral muscles
• ROM
  
  • Cervical Spine - flexion, extension, lateral flexion, rotation
  • Thoracolumbar spine - flexion (measure finger to floor distance), extension (get patient to lean against bed), lateral flexion, rotation (sitting on bed)

Question 17

Back Examination Special Tests

Answer 17

• Adams forward bend test
• Occiput wall distance
• Chest expansion
• Rib-pelvis distance
• Schober test - measure 10cm above and 5cm below dimples of venus. Have patient bend over and remeasure - distance should now be 20cm or more
• Straight leg raise and lasegue sign (sciatica) - raise leg that is symptomatic and look for pain radiating down leg. If pain occurs lower leg until pain stops and dorsiflex the ankle, if pain occurs lasegues is positive.
• Crossed straight leg raise (sciatica) - Raise leg that is asymptomatic, and patient may experience pain radiating down symptomatic leg.
• Femoral nerve stretch - Patient prone with knees extended. Passively flex the knee and extend the hip lifting thigh off the bed. Patient may experience pain in anterior thigh.
• FABER

Question 18

Ankle exam general

Answer 18

• Gait assessment - stance; swing; smoothness; symmetry; ability to turn quickly; antalgic gait; walk on toes, heels, medial border, lateral border
• Inspection:
  
  • Splaying of toes
  • Too many toes sign
  • Sweeling
  • Erythemia
  • Atrophy
  • Deformity - valgus, bunions, hammer toes, claw toes, mallet toes
  • Skin changes
  • Shoe inspection
• Palpation
  
  • Lateral, dorso-medially, medially, posteriorly
  • Planter fasciitis - medial calcanous tuberosity
  • Painful heel pad syndrome - centre of heel
  • True ankle joint swelling - cup hands around ankle, and palpate tibiotalaer joint space anteriorly for fullness, try to ballot fluid between thumbs
  • MTP squeeze
  • Palpate MTP, PIPs, and DIPs,
• ROM
  
  • True ankle - dorsiflexion, plantarflexion
  • Subtalar - inversion, eversion
  • Midtarsal (stabilize heel, grasp and rotate mid and forefoot) - inversion, eversion, adduction, abduction
  • Toes - flexion, extension

Question 19

Special Tests

Answer 19

• Stability testing - stabilize lower leg with one hand anteriorly and grasp the hindfoot
  
  • Deltoid ligaments - apply eversion force to foot
  • Lateral ligament - apply inversion force to foot
  • Anterior talofibular ligament - put foot in 20⁰ plantarflexion, and then perform an anterior drawer test
• Tinel’s sign - tape just posteriorly to medial malleolus for 30 seconds (first 3 toes)
• Thompson calf-squeeze test (torn achilles tendon) - have patient supine or kneeling in a chair with foot handing off chair. Squeeze calf, calf should plantarflex

Question 20

Hands exam general

Answer 20

• Inspection: swelling, erythemia, atrophy (thenar, hypothenar, interossei muscles, dupuytrens contractures), deformities (OA: bouchards (PIP), heberdens (DIP); RA: joint swelling MCPs, PIPs; prominent ulnar head, radial deviation of wrist, ulnar deviation of fingers, psoractic changes), prayer sign, scars and skin changes (psoriatic, gout, vasculities, scar).
• Palpation: Warmth; MCP squeeze; snuffbox; carpal bones; metacarpals; wrist effusion; MCP, PIP, DIP effusion; flexor tendons
• ROM
  
  • Wrist: flexion, extension, radial deviation, ulnar deviation, tuck sign
  • Thumb: Flexion, extension, adduction, abduction, opposition
  • PIPs and DIPs - finger tuck
• Power: grip strength; wrist extension; wrist flexion; MCP flexion; finger adduction and abduction; thumb abduction, flexion, extension
• Neurological - OK signs, thumbs up

Question 21

Special Tests Wrist

Answer 21

• Wrist stability
• Paino key sign
• MCP stability
• IP stability
• Tinels
• Phalens
• Finkelsteins