Physical exam: MSK exam

Question 1

Inspection: SEADS

Answer 1

• S: Swelling
• E: Erythema
• A: Atrophy/Asymmetry
• D: Deformity
• S: Skin changes

Question 2

Common concerns for MSK exam

Answer 2

1. Neck pain
2. Low back pain
3. Monoarticular or polyarticular joint pain
4. Inflammatory or infectious joint pain
5. Joint pain with systemic features:
   
   • Fever, chills, rash, anorexia, weight loss, weakness
6. Joint pain with symptoms from other organs systems

Question 3

Shoulder exam

Answer 3

• Inspection: SEADS
  Ask patient to stand up and place their hands behind their head and behind their back and observe for any deformity.
• Palpation:
  -Temperature: “No local rise in T”
  
  1. Sternoclavicular joint for tenderness
  2. Trace clavicles
  3. Posteriorly: Follow the bony spine of the scapula until reaches the acromion. From there, palpate the acromio-clavicular joint, and from there down to the coracoid process of the scapula.
  4. Greater tubercule and the biceps ligament
  5. Lift humurus posteriorly: Palpate the subacromial bursa and the subdeltoid bursa. Also SITS muscles
     *Supraspinatus
     *Infraspinatus
     *Teres minor
     *Subscapularis
• Range of motion:
  -Flexion (in front and overhead), extension (arm behind), abduction (out of the side and overhead), adduction (cross arm in front of the body), internal rotation (arm behind back to touch shoulder blade), external rotation (rotate arm towards the ceiling-classroom).
  -Then passively (second hand feeling joint for crepitus)

Question 4

Shoulder: Special tests!!

Answer 4

• Acromioclavicular joint: Cross-over test
• Shoulder rotation: Appley scratch test
• Rotator cuff: Neer’s impingement-in front overhead-suggests sprain. Hawkin’s impingement-cross arm in front of body and beyond-suggests sprain or tear, drop arm test.
  - SITS muscles:
  - Supraspinatus: Empty can test; Job’s test; Resistance isometric aBduction
  - Teres minor and infraspinatus: Resistance isometric external rotation
  - Infraspinatus: Thumbs up and pushes outside, fighting resistance against hands of examiner.
  - Subscapularis: Lift off test
  
  • Four arm supination?: PX is asked to turn hands from pronation to supination like holding a bowl of soup.
• Long Serratus anterior: Apprehension test (pushing against wall) ->Winged scapula

Question 5

Elbox exam

Answer 5

1. Grab arm with left hand to create flexure of 70 degrees.
2. Palpate components with right arm and name them!
   -Temperature
   -Medial and lateral epicondyle
   -Olecranon process
   -Cubital fossa
   -Extensors and flexors of ulnar
3. Range of motion
   -Flexion and extension
   -Sup and pronation
   -Then passively (second hand feeling joint for crepitus)
4. Special tests:
   -Tennis elbow: Pain over lateral epicondyle on active extension of the wrist with elbow bent
   -Golfer’s elbow: Pain to the medial epicondyle by flexing wrist.
5. End:
   You look at the examiner and say “to complete my examination, I would like to examine the other elbow. I would also like to examine one joint above and one joint below.”

Question 6

Wrists and hands exam

Answer 6

1. Inspection: Position, wrists and hands for swelling and deformities; contours (thenar and hypothenar)
2. Palpation:
   
   • Temperature
   • Start proximal and end distal
     
     • Radial pulse
     • Distal radius and ulnar;
     • radial styloid bone and anatomical snuffbox (pain suggests scaphoid fracture).
     • Eight carpal bones and each MCP joint.
       
       • Medial and lateral aspects of each PIP joints (Bouchard’s nodes are common in OA) and DIP (Heberden’s nodules in OA).
   • Compress MCP joint (squeezing hand).
   • BOTH HANDS!
3. Range of motion:
   
   • Ask patient to copy you:
     
     • Make a fist
     • Pronate wrist
     • Extend little finger
     • Extend all fingers
     • Abduction and adduction
     • Turn away and towards px.
4. Assess function:
   
   • Opposition
   • Pinch grip
   • Undo button/Write something
5. Assess power:
   
   • Ulnar nerve: Finger aBduction
   • Median nerve: Thumb aBduction
   • Radial nerve: Wrist extension
6. Sensation:
   
   • Ulnar nerve: 5th finger
   • Median nerve: Index and medium finger
   • Radial nerve: Dorsal Web
7. Other tests:
   
   • Handgrip strength:
     
     • Decrease: De Quervain’s tenosynovitis; arthritis, cervical radiculopathy
   • Finkelstein test: Grab thumb in palm, squeeze, and extension wrist. Pain in De Quervain’s tenosynovitis
   • Carpal tunnel: Tinel’s sign (percuss nerve-TIN TIN) and Phalen’s (pray downwards-FALLIN’- and inverse)

Question 7

Back exam

Answer 7

1. Inspection: Head, neck (sternocleidal muscle) and back (expose back standing)
   * “Mr is sitting comfortably and doesn’t appear to be in distress”
   * Then, ask px to stand up
   * Observe:
   
   • From behind: Pelvic and shoulder symmetry. Scoliosis
   • From the side: Kyphosis, increased lumbar lordosis
   • SEADS
2. Palpate
   
   • Spinal process for tenderness (with thumb)
   • Sacroiliac joints!!! Identified by dimples
   • Paravertebral muscles for spasm
   • Sciatic nerve: Lying on one side, one leg extended and the other flexed (upper), palpate nerve midway greater trochanter
   • Spinus processes of the cervical spine
   • Trapezius muscles
3. Range of movement lower spine: Make sure to stand next to patient to protect!
   
   • Flexion: Touch your toes
   • Extension: Bend backwards
   • Rotation: Can you please cross your arms and turn to the right, now to the left
   • Lateral flexion: Slide your hand down the tight while keeping the hips straight

Question 8

Hip exam (not tested in NAC)

Answer 8

1. Inspection:
   
   • Gait back and forth
2. Palpate:
   
   • Anterior: Iliac crest, then iliac tubercle, find the anterior superior iliac spine, and then greater trocanther.
   • Posterior: Posterior superior iliac spine (dimples, right above line), then greater trochanter and ischial tuberosity
   • If painful:
     
     • Upper leg flexed, palpate trochanteric and ischiotuberal bursa (not palpable unless inflamed)
3. Assess mobility:
   
   • Flexion: Patient supine, place your hand below px’s dorsal spine and ask to bend knee up to chest and firmly against chest.
   • Extension
   • Abduction: With left hand feeling contralateral hip joint
   • Adduction: With left hand feeling contralateral hip joint
   • Internal and external rotation: Bend knee in 45 degrees and move it like meditation (inwards) and the opposite.

Question 9

Knee exam

Answer 9

Ligaments that stabilize knee: Medial collateral ligament (MCL), Lateral collateral ligament (LCL), anterior cruciate (ACL), and posterior cruciate (PCL).

1. Inspection
2. Palpation:
   
   • Temperature
   • Suprapatellar pouch
   • TIbial femoral joint
   • Medial and lateral meniscus (knees flexed 90 degrees-planta del pie in bed)
   • Medial femoral condyle and MCL
   • Lateral femoral condyle and LCL
3. Range of motion
   
   • Extension and flexion
   • Internal and external rotation (point with toe to midline and outside)
4. Special tests:
   
   • MCL and medial meniscus: Valgus (abduction) stress test-Move thigh about 30 degrees laterally, push medially in knee and pull laterally in ankle.
   • LCL and lateral meniscus: Varus (adduction) stress test-Push laterally against knee and pull medially at the ankle to open knee joint on lateral side.
   • ACL: Anterior drawer sign-draw tibia forward
   • PCL: Posterior drawer sign-push tibia posteriorly
   • Extend leg to touch hand: TO check the integrity of patellar tendon.
   • McMurray’s test: Meniscal tear

Question 10

Ankles and feet

Answer 10

Tibiotalar joint and subtalar joint

1. Inspection
   
   • Gait: Ask if they can bear weight (show empathy!). Ask px to take a few steps
   • Patient standing: Check for pes cavus (high arches) or pes planus.
   • SEADS
   • Look at the patient’s shoes!
2. Palpation
   
   • Temperature
   • Distal pulses
   • Anterior aspect of each ankle
   • Akilles for nodules
   • Heel (posterior and anterior calcaneous)
   • Fascia
   • Lateral and medial malleolus
   • Compress forefoot
   • Heads of 5 metatarsals
3. Range of motion:
   
   • Flexion and extension
   • Inversion and eversion of ankle
   • Stabilize heel and evert invert
   • Move each finger to assess limitation or pain.
4. Special tests
   
   • Ankle anterior drawer test
   • Talar tilt test
   • Thompson’s test
   • Plantar fasciitis test

Question 11

Neck exam

Answer 11

1. Inspection:
   -From the back: SEADS
   -From the side: “Normal cervical and thoracic curvatures”
   -Can you cough, please? Any pain?: “No pain with Valsalva” (If pain, herniation).
2. Palpation
   *I would like to feel your back please:
   -Temperature
   -Tenderness: Spinal processes (tip of thumb) and para-vertebral muscles (tip of fingers), trapezius and sternomastoid
   *Thyroid: Can you swallow for me, please?
   -Lymph nodes: “No enlarged LNs”
3. ROM
   -Flexion and extension of the head
   -To the sides
   -Tilting to sides
   “Normal flexion, extension, rotation, and lateral flexion”
4. Assess power:
   -Test against resistance: “Neck pain is not associated with muscle contractures”
5. Special tests:
   -Spurling test (lateral flexion and manual pressure downwards): Radiculopathy

Part of my exam is to check your upper extremities, can you roll up your sleeves, please?
*Upper extremity examination

Question 12

Neck: Post encounter probes

Answer 12

What is the level of the lesion?

• C6 nerve lesion (C5-C6): Weak biceps reflex
• C7 nerve lesion (C6-C7): Weak triceps reflex
• Dx: Osteoarthritis of the cervical spine at …. level