Musculoskeletal Assessment

Patrick Cotter
 Overview
• History taking
• Basic musculoskeletal anatomy
• Basic core principles of musculskeletal
assessment
• Basic musculoskeletal assessment with
practice
 History
• The most important aspect of musculoskel
assessment
• Important to direct examination
• Significant in deciding on differential diagnosis
• Presenting problem
• History of presenting problem
• What/mechanism (exact)/subsequent
activity/symptoms
 Group Work
What questions would you ask this patient?
 SOCRATES
• Site of the problem
• Onset – When did it start?
• Cause of injury
• Relief
• Aggravating factors
• Treatment
• Exacerbation
• Specific condition related Qs e.g. Swelling,
radiation, paraesthesia, numbness
 History
• Presenting Complaint
• History of Presenting Complaint
• Social history (occupation, dependents etc)
• Hand dominance
• Medications History including allergies and
tetanus status
• Past Medical and Surgical History
• PC: Right wrist injury X 1 day (RHD)
• HPC: Slipped on ice falling on outstretched
right hand, painful right wrist since injury, pain
exacerbated by movement, minimal relief
from ibuprofen
• Soc Hx: Self employed carpenter, living with
wife and 3 children, also assisting in care of
disabled brother
• Right hand dominant
• Medications: None
• Past Med/Surg Hx: None relevant
 History: Some Pointers
• Location of pain
• Type of pain
• Severity of pain
• Pain radiation
• Other symptoms (systemic)
• Exacerbating or relieving factors
• Impact on activities
• Past injury or problems with same area
• Patient’s opinion
 Group Work
Now.......What would you ask this patient?
 Be Wary!
• Symptoms in absence of trauma
• Non weight bearing (unable to take 4 steps)
• Immediate swelling following injury
• Neuro signs present
• Symptoms that are deteriorating rather than
improving
 Major Components
• Bones
• Joints
• Muscles
• Tendons
• Ligaments
• Bursae
• Nerves
The Key to Physical Exam of
Musculoskeletal System........

KNOWLEDGE OF
ANATOMY
 Prepare Patient for Examination
• Introduction
• Explanation and consent
• Privacy
• Clothing
• Comfort
• Hand hygiene
 Musculoskeletal Examination

• Look (Inspect)

• Feel (Palpate)

• Move
 Look
• Symmetry
• Deformity
• Atrophy
• Oedema, Erythema, Bruising, Wounds

• Always compare both sides

 Feel
• Palpate area
• Note:
Temperature
Tenderness (what structures)
Masses
Sensation
 Move
• Assess range of motion (ROM)
• Active ROM
• Passive ROM
• Normal ranges of active and passive ROM
should be the same
• Note abnormality in relation to history
 Movement
• Extension – straightening a joint
• Flexion- Bending a joint
• Abduction – moving away from midline
• Adduction – moving towards midline
• Circumduction – moving in a circular motion
• Retraction – moving backward
• Protraction – moving forward
• Pronation – turn downwards
• Supination – turn upwards
• Internal rotation – turning towards midline
• External rotation – turning away from midline
• Inversion – turning inwards
• Eversion - turning outwards
The Shoulder – Anterior View
The Shoulder – Posterior View
 Shoulder Exam - Look
• Inspect shoulder anteriorly and posteriorly
• Observe bones and joint
• Assess symmetry
• Note deformity, swelling, bruising, erythema,
wounds/scars or fasciculations (tremors)
 Shoulder Exam -Feel
• Ask patient to point out area of pain
• Feel all bony areas noting tenderness or
crepitus
• Palpate muscles for firmness and symmetry
• Note temperature
• Axillary Nerve sensation
• Distal Neurovasc status
 Move

6 Shoulder Movements

•Abduction
•Adduction
•Internal Rotation
•External Rotation
•Flexion
•Extension
Assess Muscle Strength

Abduction to resistance - Supraspinatous

External rotation and

Internal rotation to
resistence – Infraspinatous
and Subscapularis
The Elbow
Elbow
 Elbow Exam - Look
• Deformity – Bone and Muscle
• Oedema – Localised or Generalised
• Erythema
• Bruising
• Wounds/scars
 Elbow Exam - Feel
• Palpate olecranon
• Medial and lateral epicondyles
• Radial head (pronation/supination)
• Note tenderness, heat, crepitus
• Distal Neurovasc status
 Elbow Exam - Move
• ROM of elbow –
 Extension,
 Flexion,
 Supination,
 Pronation
• Assess strength
Wrist and Hand

UCL

NB
 Wrist and Hand Exam - Look
• Hand at rest - fingers slightly flexed
• Observe deformity
• Wrist deformity – dorsal displacement, volar
displacement, radial or ulnar deviation
• Hand – loss of knuckle, mallet deformity,
boutonniere deformity, swan neck deformity,
rotational deformity
• Note oedema, bruising, erythema, nodules,
wounds, scars
 Mallet Deformity

Boutonniere Deformity

Swan Neck
Deformity

Rotational Deformity of Digit

 Wrist and Hand - Feel
• Palpate distal radius and ulna
• Palpate carpals
• NB Scaphoid (Anatomical Snuff Box)
• Palpate metacarpals and phalanges of
individual digits
• Note temperature
• Neurovasc status
(sensation, muscle tone, sweat)
 Wrist Exam - Move
• Note any pain or crepitus on movement
 Hand Exam - Move
• Movement of thumb – abduction, adduction,
opposition, circumduction
• Palmar grip strength
• Flexion and extension to resistance at all joints
• Pincer strength thumb and index
 Hip Examination - Look
• Observe patient’s gait
• Observe lumbar spine and leg length for
symmetry
• Redness, swelling
• Deformity
• Scars or wounds
 Hip Examination - Feel
• Palpate surface anatomy of hip
• Anterior illiac crest
• Greater trochanter
• Ischial tuborosity
• Note calor
Hip Examination - Move

Flexion Extension

Abduction/
Adduction

Internal External
Rotation Rotation
 Assess Hip Strength
Assess strength with resistance:
• Hip flexion
• Hip extension
• Hip abduction
• Hip adduction
The Knee
 The Knee
• Function:
• To maintain stability of the lower limb
• Active stability is maintained by the muscles
surrounding the lower limb e.g. Quadriceps
and hamstrings
• Passive stability is maintained by the collateral
and cruciate ligaments and meniscii
 Examination of Knee - Look
• Observe:
 Oedema (mild/moderate/ severe & location)
 Bruising
 Erythema
 Deformity (esp patella)
 Scars
 Baker’s cyst
 Examination of Knee - Feel
• Flex knee to 30 degrees
• Palpate into joint and tibial margins
• Feel collatreral ligaments
• Patella for tenderness and crepitus
• Palpate popliteal fossa
• Note callor
Bulge or Pattellar Tap Test
 Knee Examination - Move

Flexion (up to 135˚)

Extension

Note Weight Straight Leg Raise

Bearing Ability
 Stress Structures (Demonstrate)
• Medial Collateral Ligament
• Lateral Collateral Ligament
• Anterior Cruciate (Lachman’s)
• Anterior and Posterior Cruciate (Drawer tests)
• Meniscus (Apley’s and McMurray’s)
Ankle and Foot
 Assessment of Ankle and Foot - Look
• Observe
• Bruising
• Oedema
• Erythema
• Tinea pedis
• Wounds
• Deformity
• Blistering
• Calluses
 Assessment of Ankle and Foot - Feel
• Note heat or cold • Palpate navicular,
• Pedal pulse/cap refill cuboid, proximal end
• Sensation 5th metatarsal and
midfoot
• Palpate calf muscle
• Palpate calcaneus
• Palpate posterior edges
of lateral and medial • Palpate matatarsals and
malleoli MTPJs
• Palpate achilles tendon • Palapate toes
 Ankle and Foot - Move
• Weight bearing
• Plantarflex foot
• Dorsiflex foot
• Drawer test
• Talar tilt
Simmond’s Test
Ottawa Ankle Rules
 Documentation
• Good Accurate History
• Document what you see
• Document what you feel
• Document range of motion and strength