Musculoskeletal Examination

Musculoskeletal Examination Scott A. Paluska, MD Oak Orthopedics Overview • • • • • • • Neck / Back Hand / Wrist Elbow Shoulder Hip Knee Foot / Ankle Spine Examination Cervical Spine Inspection • • • • • • Posture Movement Comfort level Lordosis Trauma Surgical scars Palpation • Expose both shoulders and neck • Spinous processes • Lateral processes • Paraspinal / regional muscles • Alignment Range of Motion • • • • Flexion (< 3cm) Extension (> 70°) Side bend (45°) Rotation (> 70°) C5 Motor Strength Deltoid C6 Motor Strength Biceps C7 Motor Strength Triceps C8 Motor Strength Finger Flexion Upper Extremity Reflexes Biceps C5 Upper Extremity Reflexes Brachioradialis C6 Upper Extremity Reflexes Triceps C7 Special Tests • Isometric muscle reinforcement • Jendrassik maneuver Special Tests Spurling’s Maneuver Special Tests Lhermitte's Sign Spine Examination Lumbar Spine Inspection • • • • • • Posture Movement Comfort level Lordosis Trauma Surgical scars Palpation • Expose both legs and feet • Spinous processes • Lateral processes • Paraspinal / regional muscles • Alignment • Gait Range of Motion • • • • Flexion Extension Side bend Rotation L4 Motor Strength Tibialis Anterior L5 Motor Strength Extensor Hallucis Longus S1 Motor Strength Gastocnemius / Soleus S1/S2 Motor Strength Extensor Digitorum Brevis Lower Extremity Reflexes Quadriceps L4 Lower Extremity Reflexes Achilles S1 Herniated Disc • Common cause of back pain • Bulging v. rupture • Acute v. chronic • 95% idiopathic • ? Best treatment • Radiculopathy Special Tests • Seated straight leg raise test • Supine straight leg test • Hamstring flexibility (popliteal angle) Special Tests • Babinski response • Toe dorsiflexion suggests UMN lesion in corticospinal tract Special Tests • Ankle Clonus • Rhythmic oscillations with foot maintained dorsiflexion • May occur with hyperactive reflexes (3+, 4+) • Sustained clonus suggests central nervous system process Spondylolysis / listhesis • Disorder of pars interarticularis • Often during adolescent growth • Variably progressive • Acute v. chronic • Imaging helpful • ? Bracing Special Tests One-legged hyper extension maneuver Upper Extremity Examination • Hand / Wrist • Elbow • Shoulder Upper Extremity Examination Hand / Wrist Inspection • • • • • • Swelling Bruising/erythema Deformity Asymmetry Atrophy Surgical scars Palpation • • • • • • • Phalanges IP joints MCP joints Basilar joint Metacarpal shafts Carpal bones Radius / Ulna Palpation 1. Ulnar 2. Median 3. Radial Palpation 1. Ulnar 2. Median 3. Radial Hand Fractures • Common injuries • Some serious • Location important • Acute vs. chronic • Hand dominance Mallet Finger • Rupture of extensor tendon at its insertion on distal phalanx Mallet Finger • Forced flexion • Unable to extend DIP joint • PIP joint normal extension Jersey Finger • Avulsion of FDP tendon at insertion on the distal phalanx Jersey Finger • Forced flexion against resistance • Ring and long fingers • Unable to flex DIP joint • PIP joint flexion preserved MCP Joint Sprain • Gamekeeper’s or skier’s thumb • Ulnar collateral ligament • Usually hyperabduction, extension MCP Joint Sprain • Grade I-III by valgus stress test • UCL proper tight at 30º thumb MCPJ flexion • UCL accessory tight at 0º thumb MCPJ flexion • Compare to contralateral side • Abnormal: 15º more than opposite or 35º absolute Adductor aponeurosis Torn UCL proper Scaphoid Fracture • Most common carpal fracture • 70% of carpal fractures • Position susceptible to injury • Crucial role in bridging carpal rows EPL APL / EPB Scaphoid Fracture • Fall on outstretched hand with wrist extended (FOOSH) Scaphoid Fracture • Snuffbox tenderness • X-rays • Clinical suspicion • Bone scan or MRI Upper Extremity Examination Elbow Inspection • • • • • • Swelling Bruising / erythema Deformity Asymmetry Position of arm Surgical scars Inspection Carrying angle: 9 and 14° when extended and supinated. Palpation The epicondyles and olecranon apex form an equilateral triangle when the elbow is at 90° and a straight line when the elbow extended Palpation The radial head is palpated with one thumb, while the pronating and supinating the forearm Range of Motion • • • • Flexion: 135º Extension: 0º Pronation: 90º Supination: 90º Epicondylitis • Common cause of elbow pain • Lateral or Medial • Lateral 7x more common Epicondylitis • Aching pain, worse with activity • Localized peicondylar tenderness and 1-2 cm distal • Swelling and erythema uncommon • X-rays normal Epicondylitis • Extensor carpi radialis brevis resistance test • Tennis elbow test Radial deviation and wrist extension Forearm pronation Nursemaid’s Elbow • 2-3 yo, rare > 7 yo • Head of radius subluxes from annular ligament • Older sibling pulls or lifts child by arm • Associated with joint laxity Nursemaid’s Elbow • History essential • Arm at side, elbow flexed and pronated • Pain initially but subsides • Reluctant to use arm • Tenderness over radial head • Resistance to forearm supination • Normal X-rays Cubital Tunnel Syndrome • Ulnar nerve compression and entrapment • Trucker’s Elbow • Postero-medial elbow pain • Forearm numbness • Positive Tinel’s Sign Medial Collateral Ligament Injury • Injury to medial elbow stabilizer • Dominant arm • Throwing sports • Pain, swelling, instability Medial Collateral Ligament Injury • Valgus stress test • Milking maneuver • Modified milking maneuver Upper Extremity Examination Shoulder Inspection • • • • • • Swelling, bony prominence Bruising / lacerations Position of arm Asymmetry Atrophy Surgical scars Palpation • Expose both shoulders • Palpate bony prominences • Soft tissue palpation, least tender areas first • Compare to contralateral side Range of Motion Forward Flexion: 180° Range of Motion Abduction: 180° Range of Motion External Rotation: 40-45° Range of Motion Internal Rotation: 55° Range of Motion Internal Rotation at 90° Forward Flexion: 90° Range of Motion Extension: 45° Crossed Adduction: 130° AC Joint AC Joint arthritis Crossed Adduction Test GH Joint Laxity Sulcus Sign GH Joint Laxity Load and Shift Test GH Joint Laxity •Apprehension Test •Augmentation •Relocation Rotator Cuff Injury • Tendonopathy or tear • Partial or complete • Acute or chronic Rotator Cuff Injury External Rotation: Teres minor Infraspinatus Rotator Cuff Injury Abduction: Supraspinatus Middle deltoid Rotator Cuff Injury Internal Rotation: Subscapularis Pectoralis major Latissimus dorsi Rotator Cuff Injury • Drop Arm Test: Unable to resist pressure at 90° abduction • Painful Arc: Between 45 ° and 120° abduction 24 yo with shoulder pain Osteomyelitis • • • • • • History essential Vague, progressive symptoms Non-specific clinical findings Mimics many conditions Pain out of proportion Obtain imaging studies Impingement • Usually subacromial space • Irritation between AC joint, RC tendons and bursae Impingement Neer’s Test Impingement Hawkin’s Test Biceps tendonitis • • • • • Usually long head Related to overuse/activity Anterior shoulder pain Acute or chronic Weakness with resisted flexion/supination Biceps Tendon Biceps tendonitis Yergason’s Test Biceps tendonitis Speed’s Test Lower Extremity Examination • Hip • Knee • Foot/Ankle Lower Extremity Examination Hip Inspection • • • • • • Swelling Asymmetry Limping Leg position Atrophy Surgical scars Palpation • Expose both legs • Palpate bony prominences • Soft tissue palpation, least tender areas first • Assess femoral pulses and lymph nodes • Compare to contralateral side Range of Motion: Adult • • • • • • Flexion: 115-137º Extension: 16-23º IR: 27-38º ER: 27-43º Abduction: 38-45º Adduction: 27-29º Osteoarthritis • Common disorder • Progressive pain • Start and end of day pain • Age, genetics, trauma, weight • ? Activity worsens Osteoarthritis • • • • • Radiating pain into leg Limping Regional weakness Loss of internal rotation Positive log-rolling Slipped Capital Femoral Epiphysis • • • • • • Serious condition Boys: 10-17 yo Girls: 8-15 yo Blacks, overweight Growth spurt Active Slipped Capital Femoral Epiphysis • • • • • • • Hip, thigh, groin or knee pain Limping, foot ER Loss of flexed hip IR 1-3 cm limb shortening Crutches if suspicious Radiographs essential MRI or bone scan Legges-Calve-Perthes Disease • Serious condition • Femoral head osteonecrosis • 4-8 yo • Boys 4x girls • 90% unilateral Legges-Calvé-Perthes Disease • • • • • Limping 2-3 weeks Worse end of day Groin, thigh ache Loss of hip abduction Abduct thighs simultaneously to prevent pelvic tilt • Use hand to stabilize pelvis Lower Extremity Examination Knee Inspection • • • • • • • Swelling Bruising Asymmetry Alignment Atrophy Braces Surgical scars Palpation • Expose both legs • Palpate bony prominences, joint lines • Soft tissues, least tender areas first • Compare to contralateral side Palpation Range of Motion • Flexion: 135º • Extension: 0º • IR: 10º • ER: 10º Anterior Cruciate Ligament Anterior Cruciate Ligament • Essential ligament • Limits anterior motion • Frequently injured • Arthritis or intra-articular abnormalities • Chronic instability Anterior Cruciate Ligament • Rapid stopping, landing, cutting or changing direction • Intrinsic and extrinsic factors • Women > men ACL Injury -- Physical Exam • Limping • Effusion • Joint-line tenderness • Decreased ROM • Quadriceps atrophy • Anterior drawer test • Lachman test ACL Injury -- Lachman Test • Flex the knee 30º • Stabilize femur • Place hand behind the proximal tibia and gently pull forward ACL Injury -- Lachman Test • Grade 1: < 0.5 cm translation • Grade 2: 0.5-1.0 cm translation • Grade 3: > 1.0 cm translation • End point: Soft or firm? • Compare to the opposite knee ACL Injury -- Diagnostic Tests • Segund sign: lateral capsule bony avulsion 32 yo with hyperextension injury Patellofemoral Pain Syndrome Patellofemoral Pain Syndrome (PFPS) • Various names:  Chondromalacia patellae  Anterior knee pain syndrome  Patellofemoral dysfunction • Young female athletes PFPS -- History • Diffuse anterior pain • Worse with:  Stairs or hills  Prolonged sitting or squatting (Theater sign)  Recent change in activity PFPS -- Physical Exam • • • • Q angle Pes planus No effusion No joint line tenderness PFPS -- Physical Exam • Ligament laxity uncommon • Normal ROM • Medial/lateral patellar facet tenderness • Patellar compression • Distal patellar push Meniscal Tear Meniscal Tear • Acute or degenerative • Rotational or compression injury • Associated with ligament injuries • Blood supply important Meniscal Tear -- Physical Exam • Localized joint line tenderness • Effusion • Apley’s load and grind • McMurray’s maneuver Osgood-Schlater’s Disease • Patellar tendon attachment on tibial tubercle apophysitis • Boys: 10-15 yo • Girls: 8-13 yo • Jumping, cutting sports • Unilateral or bilateral (20%) Osgood-Schlater’s Disease • • • • • • • Persistent pain Worse with knee flexion Improves with rest No catch, lock, giveway Swelling or prominence Localized tenderness Exam othewise normal Osteoarthritis • • • • • • Typically older individual Insidious, persistent Obesity, trauma, surgery Altered alignment Swelling, little inflammation Loss of motion Lower Extremity Examination Foot / Ankle Inspection • • • • • • • Swelling Bruising Asymmetry Alignment Arches Weight-bearing Surgical scars Palpation • Expose both legs • Palpate bony prominences • Soft tissues, least tender areas first • Compare to contralateral side Range of Motion • • • • Plantar flexion: 50º Dorsiflexion: 20º Inversion: 5º Eversion: 5º Lateral Ankle Sprain • Plantar flexion / inversion injury • Acute or chronic Deltoid Ligament Lateral Ankle Sprain • Pain, swelling, limping • Pop or snap • Instability • Tender over involved ligaments/bones Lateral Ankle Sprain • Talar tilt • Anterior drawer • Syndesmosis compression • Fibular head Sever’s Disease • • • • • • • Apophysitis at insertion of Achilles Vertical shear stress on calcaneus Active 9-10 yo, bilateral 60% Posterior pain with run/jump Gradual, improved with rest Tenderness to palpation, swelling Toe raise, forced dorsiflexion Jones’ Fracture • Base of 5th metatarsal • Diaphyseal / metaphyseal junction • Localized pain • Limp • Mimics styloid Fx