Musculoskeletal Physical Exam Patrick Foye, MD Physical Medicine & Rehab.

(PM&R)

Musculoskeletal Physical Exam:

Upper Limb and Lower Limb

Patrick M. Foye, M.D.

Associate Professor,
Physical Medicine &
Rehabilitation (PM&R)
New Jersey Medical School, Newark
(973) 972-2802
UMDNJ - NJMS, Newark

Applications of this Lecture: Musculoskeletal Exam: Outline

• General Principles
• Regardless of your field or specialty:
– Most physicians will have patients with acute • UPPER LIMB
and chronic musculoskeletal conditions, and – Shoulder
associated disabilities.
• PMD’s: These patients often present to their internist, – Elbow
family practitioner, pediatrician, – Wrist and hand
• Other: emergency room doctors, surgeons, OB/GYN,
radiologists, etc. • LOWER LIMB
– Most Mskl conditions non-surgical treatment.
– Hip
– Family/Friends will often ask you…
– Knee
• To empower you to provide appropriate
care, with efficiency and confidence. – Ankle and foot

A few general principles:

Broaden you differential diagnosis
Relax… • Whenever evaluating a symptom at one
body region, always assess whether those
symptoms are being referred from
elsewhere.

– Always evaluate at least 1 joint above + below.

• Don’t let the # of slides (>90) or maneuvers alarm
you.
– Remember internal organs as sources of pain
• We are breaking it down to just a few maneuvers
• heart, lung, liver, kidneys, etc.
for the most common conditions that you will see
at each joint/ body region. • consider cancer, infections, kidney stones, etc.

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 Musculoskeletal Physical Exam Patrick Foye, MD Physical Medicine & Rehab.
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A few general principles: Pain

Assessing for Tendinitis Referred to
the Shoulder
In general, pain at an inflamed
tendon will be exacerbated by:

1. direct palpation

2. actively using the muscle

against resistance

3. passively stretching the

muscle. and vice versa

The Shoulder “Joint” is really a Glenohumeral Joint vs. Hip Joint

“Shoulder Complex”

Great shoulder mobility, comes at what expense?

Note difference in how deep the “ball” is within the “socket”.

Shoulder ROM: “Frozen Shoulder”:

Apley Scratch Test “Adhesive Capsulitis”
Shown assessing combined at the Glenohumeral Joint.
shoulder abduction
and external rotation.

Also can combine

shoulder adduction
and internal rotation.

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Demonstration: Acromion limits shoulder abduction

with your arms straight out to the side… to about 120 degrees
• Point your thumb all the way DOWN and back
(internal rotation at the shoulder)…
– How far up can you elevate/abduct your arm?
– What limits you from going further?

• Now point your thumb all the way UP towards

the ceiling (external rotation of the shoulder)…
– Try again. What happens now? Why?

Below the acromion: the rotator cuff Rotator cuff tendinitis/impingement

and the subacromial bursa
• Rotator cuff muscles are commonly
impinged below the acromion,
becoming painful and inflamed.
• Various tests for rotator cuff
tendinitis/impingement:
– Neer’s
– Hawkin’s
– Empty-can sign (thumbs down)
– Pain while testing supraspinatus strength

Neers test Hawkins

Ouch!
test
• With rotator cuff
impingement: • With rotator cuff
impingement:
+ shoulder pain
during forced + pain during
shoulder combined
flexion. humeral
abduction and
internal rotation.

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Drop Arm Test: (for complete

Two separate tests rotator cuff tear, but can also
are shown here. seem ‘positive’ just from pain):

patient is unable to
1: Empty can sign: Thumbs-down slowly lower the arm
from an abducted
2: Supraspinatus strength testing position.
(done in the plane of the scapula)

Apprehension Test: Shoulder Pain:

Anterior You make the diagnosis.
Instability
• Positive Neers, Hawkins, and empty can
signs, and pain with supraspinatus
testing,

• but negative anterior apprehension test

and negative drop arm tests.
Abduction and
external rotation.
• What is the diagnosis?
•“Quarterback position”

Pain Referred to Tinels

the Elbow at
ulnar
groove

Is the term “Tinel’s” specific to one site/nerve?

Is focal tenderness considered “positive”?

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Olecranon Bursitis Testing for Lateral Epicondylitis

• “Tennis Elbow”
• Based on the general principles and basic
knowledge of the anatomy….
• with lateral epicondylitis, you expect to
reproduce the lateral elbow pain by:
Also known as – direct palpation
“student’s elbow” or – wrist extension (and forearm supination)
“draftsman’s elbow”, against resistance
due to elbow rubbing
while writing. – stretching the wrist extensors and forearm
supinators by passively putting the patient
into wrist flexion (and forearm pronation).

Testing for Wrist

Tennis Flexors-
Elbow: Pronators
PT
wrist
FCR
extension
PL Originate at the
against medial epicondyle,
FCU
resistance
reproduces the site of medial
lateral elbow epicondylitis
(Golfer’s Elbow)
pain (Swimmer’s Elbow).

Testing for Medial Epicondylitis Pain Referred

to the
• “Golfer’s Elbow” or “Swimmer’s Elbow”
Wrist and Hand
• Based on the general principle and basic
knowledge of the anatomy….
• with medial epicondylitis, you expect to
reproduce the medial elbow pain by:
– palpation
– wrist flexion (and forearm pronation)
against resistance
– stretching the wrist flexors and forearm
pronators by passively putting the patient
into wrist extension (& forearm supination)

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 Musculoskeletal Physical Exam Patrick Foye, MD Physical Medicine & Rehab.
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Thumb Pain/Dysesthesias (tingling): Borders of the “Snuffbox”:

you make the diagnosis... (EPB + APL, together) & EPL
How would you differentiate the following:
EPL
• cervical radiculopathy
• carpal tunnel syndrome
• radial nerve lesion
• deQuervain’s tenosynovitis
• 1st CMC joint arthritis
• trigger finger (i.e., trigger thumb)
• Dupuytren’s contracture

Pain at the base of the thumb… Finkelstein’s Thumb

in fist
test
Why is it important to further localize the for
source of pain? DeQuervain’s
tenosynovitis
On palpation, how do you localize these:
• deQuervain’s tenosynovitis
• 1st CMC joint arthritis
• Scaphoid fracture or AVN

• How close together are they?

Scaphoid = Navicular
Trapezium 1st CMC Mallet Finger:
Joint EDC has torn away from the distal phalanx,
1st CMC thus you can not extend that DIP joint.
Joint

(1st MC)

CMC = CarpoMetaCarpal

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Rupture of finger flexor

Trigger
The “Jersey Finger” Finger

Flexor tendon
stuck in
Flexion,
then painfully
SNAPS into
extension

Dupuytren’s The Carpal Tunnel

contracture

• Palmar
aponeurosis
contracture

• usually digits 4-5

• usually painless.

Carpal tunnel syndrome: Tinel’s sign Carpal tunnel syndrome: Phalen’s test

Phalen’s: “Phlexion”
1 minute. + = hand/finger dysesthesias
Only called “positive” if symptoms occur in fingers.

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 Musculoskeletal Physical Exam Patrick Foye, MD Physical Medicine & Rehab.
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UPPER LIMB RECAP: Questions??? Pain referred to the “Hip”

Also:
Where does a
patient mean when
they say they have
pain at their “hip”?

FAbER’s Patrick’s “Hip” - Greater Trochanter

Test Test,
“Figure 4”

• FAbER: hip is passively put into:

Flexion, Abduction, External Rotation.

• Groin pain ~ hip joint (femoro-acetabular) • Especially important in trochanteric bursitis,

• Buttock pain ~ sacroiliac joint a fairly common cause of lateral hip pain.

Ober Test for Tight ITB/TFL Ober Test: Positive

• Start with combination of hip abduction and extension. • Tight ITB/TFL prevents the
• Let the hip “drop” to the table. limb from dropping fully.
• ITB: iliotibial band • important in snapping hip,
• TFL: tensor fascia lata snapping knee,
trochanteric bursitis,
patello-femoral pain.

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Referred pain to the Knee • Medial

– pes anserine bursitis Knee Pain:
– MCL tear or sprain where is it?
– medial meniscal injury
• Lateral
– lateral meniscal injury
– LCL tear or sprain
– iliotibial band snapping over the femoral condyle
• Anterior
– patello-femoral pain (tracking dysfunction)
– ACL tear or sprain
– injury to the patellar tendon
– patellar dislocation

Knee: anterior-medial view Knee: Osgood-Schlatter Syndrome

Pain and tenderness
where the
infrapatellar tendon
inserts at the tibial
tubercle.

Knee: Pes Anserine tendons Knee: anterior-lateral view

Sartorius,
Gracilis
SemiTendinosus

Tendons Insert
at the site of
Pes Anserine All these are
Bursitis palpable

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Knee Effusion: Ballottement Knee effusion: “milk it”

Knee: Bounce-Home Test: Negative Knee: Bounce-Home Test: Positive

Assessing Ligaments: Knee: Valgus/Varus Stressing

Stability vs. Laxity

General principles:
• How much “joint play” is there?
– Compare with the contralateral side.
• Is the “endpoint” solid/crisp?

• Knee: 4 ligaments:
– MCL, LCL
– ACL, PCL
Valgus stress tests MCL Varus stress tests LCL

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Lachman’s test • “Sit” on patient’s foot to stabilize Knee:

• Tests ACL stability
the distal lower limb, freeing both Anterior
hands to check for anterior
translation of the tibia relative to Drawer
the femur. tests
• Assess both quantitatively (how ACL
much excursion) as well as
qualitatively (e.g. is the end-feel
firm or soft).
• Compare!

• assess for anterior translation of the tibia relative to the femur.

Knee: Posterior Drawer tests PCL McMurray’s Test for Meniscal Injury
• Opposite of anterior drawer. • McMurray’s test can be performed in a few ways.
• Assess for posterior
• Essentially, with a meniscal tear, certain knee
translation of the tibia in
relationship to the femur.
movements may produce a palpable click + pain.
• With the patient supine, completely flex the knee.
NJMS
• Then do the following:
• Simple method: tibial internal and external rotation.

• Further: tibial internal and external rotation may be

done in various degrees of knee flexion, or may be
•Who gets PCL injuries??
followed by knee extension.

McMurray’s test for Meniscal Injury McMurray’s test for Meniscal Injury
• Tibial external rotation tests the medial meniscus • Tibial internal rotation tests the lateral meniscus

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 Musculoskeletal Physical Exam Patrick Foye, MD Physical Medicine & Rehab.
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Pain referred to the foot/ankle

Medial Ankle

2
Medial Ankle Deltoid Ligament:
Test via Eversion/Varus
1 3

Deltoid Ligament 4

Mnemonic:
“Tom 1
Dick 2
AN’ 3,4
Harry” 5

Lateral ankle Lateral Ankle ligaments

PTFL ATFL **

CFL

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 Musculoskeletal Physical Exam Patrick Foye, MD Physical Medicine & Rehab.
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Ankle: Anterior Drawer tests ATFL

ATFL and
Sinus Tarsus

ATFL

Positive Anterior Drawer: Talar Tilt:

anterior translation of the foot
Varus to test
ATFL and CFL

Posterior View

Positive Talar Tilt: Achilles' tendon and calcaneal bursa

excessive movement
with varus stress

“Heel” pain: ask posterior vs. plantar

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Plantar Fasciitis Plantar Fasciitis

• painful 1st
step in the
morning.

Pain on
Palpation

Heel Spur Plantar Fasciitis

• Commonly seen on X-rays
• Wolf’s Law (bone remodeling):
calcaneal spur due to tension, e.g.
from plantar fascia.

When should
they stretch?

Styloid Process of 5th Metatarsal

1st MTP

Common site of:

gout attacks A common
(podagra), fracture site
valgus deformities,
bunions, etc.

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 Musculoskeletal Physical Exam Patrick Foye, MD Physical Medicine & Rehab.
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Metatarsal “Stress” Fracture Morton’s Neuroma vs. MT Fx

If tender at MT head: think stress Fracture Pain: Usually between the 3rd + 4th Metatarsal Heads.
(If tender at MT head: think stress Fracture)

Final Points to Remember….

• Location, Location, Location
– during both the history and physical exam Thank
• Reproduce the symptoms You.
• Think at least one joint above and below - Patrick Foye, MD
• Basic principles for tendonitis apply, PM&R,
regardless of the site of tendonitis New Jersey
Medical School
• Know at least a few maneuvers per major joint,
– especially maneuvers that will test for the most
commonly seen diagnoses for that joint.
Patrick.Foye@umdnj.edu

Credit to Hoppenfeld for Images

Thank
You.
- Patrick Foye, MD
PM&R,
New Jersey
Medical School
• If you own the copyright to any images used in this lecture,
please contact me if you would like to be listed as a source. Patrick.Foye@umdnj.edu

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