Phys Di - MSK System Flashcards
What are the keys to a good ortho history?
- location
- PMT: point of maximal tenderness
- unilateral vs. bilateral
- acute description of associated sx: pain, swelling, loss of ROM, weakness, clicking/locking, etc.
- insidious onset: progression, change
- acute onset: if known injury, ask the mechanism, sensation at time of injury
- **above and below rule: knee pain can be d/t hip, etc.
Instead of using a 1-10 scale for severity, what questions should you ask to grade severity?
- does the complaint interrupt daily life?
- what does your (e.g. knee pain) keep you from doing that you enjoy?
- does your (e.g. shoulder pain) disrupt your sleep?
- can you transfer yourself from bed to toilet?
- do you require an assistive device?
- is it affecting your ability to work?
What should you ask about aggravating/alleviating factors?
-Aggravating Factors?
Weight bearing, exercise, stair climbing, sleeping position, carrying their baby, new job, sitting in a car, getting up from chair
-Alleviating Factors?
Rest, moving around, NSAIDs, bracing, toddler holding arm, sleeping position, stretching, massage, ice/heat
Pertinent questions to ask about pain complaint
- character: dull vs. sharp, aching, radiating
- location: uni- or bilateral, get the PMT
- associated sxs: fatigue weakness?
- timing: frequency, time of day, worse in am, progressive, constant or intermittent, injury, related to activity
Pertinent questions to ask about joint complaint
- swelling
- subjective stiffness vs. true ↓ROM,
- warmth/erythema
- instability or “giving way”
- mechanical sx (click, catching, locking, etc)
- morning or activity related pain
- loss of function
- crepitus
- deformity
Pertinent questions to ask about back complaint
-onset: abrupt or gradual
-location:
Midline vs. paravertebral
Unilateral vs. bilateral
Radiation to leg
-associated/aggravating:
Worse with cough/strain
Postural changes?
Night pain?
Paresthesias
Bowel or bladder changes
MSK ROS
-joint
- Joint Pain/Stiffness
- Joint Swelling/Redness
- Joint Instability
- Decreased ROM
MSK ROS
-muscle
- Muscle Pain
- Muscle Weakness
- Muscle Atrophy
MSK ROS
-miscellaneous
- Gait changes
- Use of Assistive Devices
- Back Pain
MSK ROS
-history of
- History of Arthritis
12. History of Gout
What PMG and surgeries should you ask about?
- prior orthopedic surgeries
- history of prior fractures
- history of osteoporosis
- childhood MSK issues
- any issues with healing
- risks for falling
- hypercoaguable states
Importance of social history
- employment: lifting, standing, how long have you been at your current job?
- exercise
- functional abilities: housework, bathing, toileting, etc.
- recent weight gain/loss
- nutrition: calcium, vitamin D, calories, protein
- cigarette smoking delays healing
- ETOH use can contribute to accidents and injuries
Family history
- osteoarthritis
- rheumatoid arthritis
- family member with history of total joint replacements
- fractured hips
- osteoporosis
- congenital abnormalities of hip or foot
- scoliosis or back problems
- ankylosing spondylitis, gout
- genetic disorders: osteogenesis imperfecta, Ehlers-Danlos, Charcot
What comprises a good MSK Exam?
- inspection
- palpation
- ROM testing
- muscle strength testing
- quick sensory and vascular check
- special tests
Physical exam - inspection
- standing posture, sitting posture
- compare the extremities visually: look for atrophy, asymmetry, gross deformity
- spinal deformities, check symmetry (look from anterior or posterior), check contour (look from lateral)
- watch the gait
- inspect the PMT, ask patient to use 1 finger to localize it
- note the skin: swelling? redness?
Physical exam - palpation
- tenderness
- abnormal masses
- effusion
- temperature changes
- crepitus
- alignment
Physical exam - ROM testing
- parameters for rating MSK disability are based on the degree of motion impairment
- can be guesstimated visually, but a goniometer enhances accuracy
- documented in degrees of whatever motion you are evaluating
- active vs. passive ROM
- Know the ACCEPTED ZERO STARTING POSITIONS for each joint: for most joints it is anatomical position
Should you start with active or passive ROM? What is the difference?
- if the joint is injured or painful, observe ACTIVE motion first
- active motion is the patient physically moving the joint
- passive motion is you moving the joint
What is the key to quantifying muscle strength?
- **testing bilaterally
- you are looking for a gross weakness on one side
- place the muscle being tested in a shortened position
- ask patient to perform a motion that lengthens the muscle as the examiner resists the movement
Muscle strength scale
5 - Normal - Complete ROM against gravity with full resistance
4 - Good - Complete ROM against gravity with some resistance
3 - Fair - Complete ROM against gravity
2 - Poor - Complete ROM with gravity eliminated
1 - Trace - Muscle contraction but limited joint motion
0 - Zero - No evidence of muscle function
Testing muscle strength also indirectly assesses…
the function of that nerve or nerve root that innervates it
Physical Exam – Motor and Sensory Evaluation
- if patient presents with a neck or back complaint, MUST assess nerve root function
- if patient presents with an extremity complaint, MUST assess peripheral nerve function
- evaluate ONE muscle and ONE area of sensation for each nerve in question
On physical exam, how to you perform the vascular check?
**a quick vascular check is vital, especially if s/p injury or s/p surgery
Ask…
- is capillary refill present and normal?
- are pulses present in the limb being evaluated?
- is there pallor in extremities?
- what is the temperature of skin, “cool to touch” or “warmth”?
Shoulder inspection
- symmetry
- deformity
- effusion
- warmth
Shoulder palpation
- AC joint
- proximal humerus
- insertion of biceps tendon
Shoulder ROM and strength
- forward flexion
- abduction
- internal/external rotation
Shoulder special tests (4)
- Neer Impingement Sign
- Jobe Test
- Crossover Test
- Apprehension Test
Shoulder
-Neer Impingement Sign
**to test for rotator cuff tear, tendonitis, or impingement
- grasp patient’s extended arm at the wrist, internally rotate the arm
- use other hand to stabilize the scapula
- lift the arm into full flexion
- positive test = pain
Shoulder
-Jobe “empty can” test
***tests for pain or weakness in the
supraspinatus muscle of the rotator cuff
- abduct arm to 90°
- angle forward 30° (bringing it into the scapular plane)
- and internally rotate (empty the can)
- press down on arm while patient resists
- positive test = pain or inability to rotate shoulder
Shoulder
-crossover test
***evaluates for AC joint pathology
- forward flex the arm to 90⁰
- horizontally adduct the arm across the body
- positive test = pain
“the scarf test”
Shoulder
-apprehension test
***tests for anterior shoulder instability
- correct technique is pt supine
- elbow flexed to 90⁰
- arm abducted to 90⁰
- slowly apply external rotation and watch for apprehension in patient’s face, some may ask you to stop
Shoulder
-other special tests
- Speed’s Test for proximal biceps
- Hawkin’s Impingement Sign for RTC
- lift elbow to 90 degrees, try to impinge the shoulder - lift off test for subscapularis MM
- place back of hand on small of back then lift off
The elbow
-inspection
- identify PMT
- look for deformity
- bruising
- note carrying angle
The elbow
-palpation
- for tenderness, crepitus, warmth, effusion
- palpate the radial head, olecranon (ulna), distal humerus, the epicondyles
in a non-verbal kid with a negative x-ray who protects elbow, gently palpate the radial head, the distal humerus
What are the different carrying angles of the elbow?
- normal
- excessive cubilus valgus
- cubilus varus
- gunstock deformity
The elbow
-ROM and strength
- check pronation/supination for radius injury
- extension/flexion for olecranon or humerus injury
What are the special tests for the elbow?
- elbow flexion test
- stability testing
How should you document ROM of the elbow?
***by amount of
flexion
“Right elbow with full
flexion from 0-140 degrees” or
“Right elbow flexes from 0-150 degrees.”
How do you document hyperextension in the elbow?
“full elbow
ROM with 10 degrees of hyperextension
present” or “full flexion of right elbow
present from -10 to 150 degrees”
**common in children
How do you document an elbow without full ROM?
“lacks the last 10⁰ of extension” or “flexion from 10-150 degrees”
Inspection of the hand and wrist
- know the nodes: Bouchard and Heberden (common in OA)
- look for ulnar deviation (common in RA)
- look for thenar atrophy
Hand and wrist
-palpation
- MP
- PIP
- DIP
- first CMC joints
- radiocarpal joint
- ulna styloid
- distal radius
- anatomical snuffbox
You’re looking for tenderness, temperature, crepitus, effusion.
Hand and wrist
-ROM and strength
- fingers
- hand grip
- wrist flexion
- extension
- supination
- pronation
Why do you palpate the anatomical snuffbox?
A scaphoid fracture can result in avascular necrosis d/t damage to the radial A.
Radial N also runs here.
Instead of using anterior/posterior to describe the hand, use…
Volar/dorsal
Instead of using medial/lateral to describe the hand, use…
Ulnar/radial
What parts of the hand are innervated by median N?
Thumb, index, long, and 1/2 of ring.
What parts of the hand are innervated by ulnar N?
other 1/2 of ring and pinky.
Special tests for hand and wrist (4)
- Durkan’s Compression Test
- Phalen’s Test
- Tinel’s Sign
- Finkelstein’s Test
Hand and wrist
-Durkan’s compression test
***evaluation of median N for carpal tunnel syndrome (better than Phalen’s)
-hold compression over the CT for 30 sec
Hand and wrist
-Phalen’s test
***evaluates CTS also by impinging median N
- hold wrists in flexion (reverse prayer) for 60 seconds
- not as sensitive as a good compression test
Hand and wrist
-Tinel’s Sign
***evaluates median N
-lightly tap the median N at the wrist flexion crease in line with long finger
Hand and wrist
-Finkelstein’s test
***to evaluate wrist pain for DeQuervain’s tenosynovitis
- have patient make a fist with thumb inside the fingers
- then apply ulnar deviation
- positive test = pain elicited at the radial wrist (1st dorsal compartment)
- reproduces their pain complaint
Inspection of the hip
- is PMT anterior or lateral?
- symmetry of limb length
- look at iliac crest height
- note any muscle atrophy
Palpation of the hip
- tenderness
- masses
- greater trochanter
- anterior superior iliac spine (ASIS)
The hip
-ROM and strength
- test with patient supine
- flexion (normal = 0-130⁰)
- abduction (normal is up to 35⁰ to 50⁰) *away
- adduction (normal is up to 25⁰ to 35⁰) *toward
- internal and external rotation (with patient in hip flexion)
The hip
-special tests
TRENDELENBURG TEST:
- tests for ABductor strength, examiner behind
- patient stands on one leg
- a positive test = pelvic tilts/drops on contralateral side = weak hip abductors on stance leg
What 3 joints/articulations are you evaluating in the knee?
- knee (tibiofemoral) joint
- patellofemoral joint
- tibiofibular articulation
What is full motion of the knee? Hyperextension?
- full motion is 0-150⁰
- hyperextension to -10⁰ is considered normal, called recurvatum
What are the special tests for stability?
- Lachman’s
- anterior drawer
- posterior drawer
What are the special tests for the meniscus?
McMurray’s
Inspection of the knee
- effusion
- erythema
- deformities
- muscle atrophy
- patellar position/tracking
- gait
Palpation of the knee
- for effusion (milk it down)
- tenderness (patella, joint line)
- crepitus
- patellar tracking
- temperature
What are valgus knees commonly called?
knock-kneed
What are varus knees commonly called?
bow-legged
Name the special tests for the knee (5)
- McMurray Test
- Valgus/Varus Stress Test
- Lachman Test
- Anterior Drawer Test
- Posterior Drawer Test
Knee special test
-McMurray
- flex knee to maximum pain free position (must be >90⁰ for test to work)
- hold that flexed position
- and stress meniscus by…
- externally rotate tibia to evaluate medial meniscus
- internally rotate tibia to evaluate lateral meniscus
-then gradually extend knee and feel/watch for localized click and/or pain
Knee specialty test
-valgus/varus stress test
knee must be flexed to 30⁰, tests collateral ligaments
Knee specialty test
-Lachman test
- flex knee to 30⁰, stabilize femur from lateral side
- attempt to translate the tibia anteriorly with other hand
- abnormal test if NO firm end point and increased tibial “translation” compared to the contralateral knee
Knee specialty test
-anterior drawer test
- not as sensitive as Lachman’s but easier to do
- flex knee to 90⁰
- stabilize tibia by sitting on patient’s foot
- grasp to proximal tibia with both hands
- attempt to translate the tibia anteriorly
Knee specialty test
-posterior drawer test
- same position as above
- inspect for gravity sag sign
- attempt to push tibia posteriorly
- “flush” is abnormal (the anterior tibial plateaus sit 10mm anterior to the femoral condyle in a normal position)
- abnormal posterior drawer test can cause a false + anterior drawer test
Inspection of foot and ankle
-deformities
- Pes planus (flat feed)
- hammer toes
- hallux valgus (bunion)
Inspection of foot and ankle
-location
- FOREFOOT (metatarsals, phalanges, sesamoids)
- MIDFOOT (navicular, cuboid, cuneiforms)
- HINDFOOT (talus, calcaneous)
- BONES and JOINTS: Hallux, First MTP joint, Navicular, and Calcaneous…
Palpation of anterior ankle
- bones/joints
- soft tissue structures
- ankle (tibiotalar) joint
- anterior talofibular ligament (ATFL)
Palpation of medial ankle
- bones/joints
- soft tissue structures
- medial malleolus (tibia)
- deltoid ligament
Palpation of lateral ankle
- bones/joints
- soft tissue structures
- lateral malleolus (fibula)
- calcaneofibular ligament
Palpation of posterior ankle
-soft tissue structures
achilles tendon
Palpation of forefoot
-bones/joints
-metacarpalphalangeal (MP) joints
Ankle and foot
-ROM testing and strength
- dorsiflexion
- plantar flexion
- inversion
- eversion
- great toe extension
What are the special tests focused on stability for the ankle? (3)
-name the ligament
- anterior drawer test (tests ATFL)
- inversion stress test (tests CFL)
- eversion stress test (tests deltoid ligament)
Thompson test for foot and ankle
- tests Achilles tendon function
- have patient prone
- flex knee to 90⁰, make sure muscles relaxed
- squeeze the calf to make the foot plantar flex
- positive test = NO plantar flexion = ruptured Achilles
Overview of the spine
-patient standing
- inspection/palpation: feel spinous processes to help determine alignment
- evaluate for scoliosis
- check thoracolumbar ROM (flexion, extension, rotation, lateral bending)
Overview of the spine
-patient seated
- inspection/palpation:
- cervical Spinous processes
- muscles (sternocleidomastoid, trapezius, paraspinal muscles)
cervical spine ROM and strength:
-special test = SPURLING TEST
Overview of the spine
-patient seated
Watch for discomfort as you lay patient back.
2 special tests in supine position:
- -straight leg raise
- -FABER Test
Evaluating for scoliosis
- inspect/palpate spinous processes of thoracolumbar spine for alignment
- if lateral deviation noted, have patient forward flex the spine and look for one side of the back higher than the other
- check from behind the patient
In scoliosis, a slight posterior asymmetry becomes ______ with forward flexion.
A very slight posterior asymmetry becomes VERY apparent with the forward flexion.
**asymmetry due to muscle spasm goes away with forward flexion
The spine
-cervical ROM and strength testing
- flexion (chin to chest)
- extension (look up)
- lateral flexion (ear to shoulder)
- rotation (look left, look right)
the spine – special tests
- straight leg raise: to determine if back pain is due to nerve root irritation
- FABER test: use to check if “back” pain is truly hip or SI pain
Straight leg raise test
- common provocative test to evaluate low back pain
- patient supine, passively elevate the fully extended leg of the affected side to 30-60⁰; you will usually need to extend >60⁰
- positive test = pain in the region of the original complaint of back pain, often with radiation down the leg
- test contralateral leg too, if nerve root irritation is severe enough this will cause pain on the affected side as well
How do you elicit the tripod sign?
- with pt seated (don’t announce that you are checking the back pain), extend the leg on affected side
- a positive sign = pain in the back (again often radiating down the leg) accompanied by the patient’s natural tendency to ↓ the pain by leaning back and resting both arms on the table for support, creating a tripod
The tripod sign is a good test for…
- malingering!
- failure to lean back and rest both arms on the table may suggest the pain is NOT present or NOT related to irritation of a nerve root
What are the other 2 tests for malingering patients?
Nonorganic tenderness: lightly touch lower lumbar spine - this should NOT cause pain. A positive test is marked pain behavior.
Axial stimulation: apply light downward pressure on top of head which should not cause pain in the lower back. A positive test is the patient grimacing or reporting pain in the back.
