Semester 1 Physical Examination Skills Labs Handout

Musculoskeletal Examination

General Concepts
Synovial joints are points of connection or articulation between two bones with a synovial or joint
cavity lined by a synovial membrane and filled with synovial or joint fluid. Ligaments attach bone to
bone and provide stability to the joint. Tendons attach muscle to bone to provide movement.
Adequate exposure for any musculoskeletal exam requires visualization of the muscles that move the
joint being examined. Have your patient undress and drape your patient to allow an adequate
examination AND protect his/her modesty. Begin with inspection and remember that symmetry is an
important concept. Acute inflammation presents with erythema (redness) and/or swelling and is
usually caused by trauma, infection or acute arthritis (arth=joint + itis=inflammation). Chronic
arthritis causes deformity from bony overgrowth or erosion which can also cause limitation of motion.
Extra fluid within the joint capsule is called an effusion. (This is not to be confused with edema,
which is swelling caused by accumulation of fluid in the intercellular tissue spaces surrounding the
body’s tissues and organs.) Inspect for muscle atrophy since joint problems or pain can limit the use
of the joint and lead to muscle wasting called disuse atrophy. Another type of muscle atrophy is
neurogenic atrophy which occurs when there is damage to the nerve supplying the muscle.

In the musculoskeletal examination, palpation is used to find surface landmarks and increased
warmth associated with acute inflammation, tenderness and effusion.

Assess range of motion (ROM). Active range of motion is tested when the patient moves the joint. If
there are no limitations or pain associated with movement active range of motion is “full”. If it is not
full and painless passive range of motion should be checked by the examiner attempting to move the
joint through its range. If passive ROM is full the joint itself is not causing the limited motion; likely
the patient stopped moving the joint during active ROM testing due to muscle weakness or pain from
a periarticular structure (such as a muscle, ligament or tendon). If passive ROM is also limited or
painful the joint itself is likely abnormal (deformity from chronic inflammation or prior trauma).

Provocative test(s) are performed to find joint instability or to provoke symptoms from an injury. If
the joint “opens up” upon provocative testing it suggests ligamentous laxity or rupture and the joint
is considered unstable. Note that at the time of initial injury there may be an effusion and significant
pain making provocative testing impractical. If the acute injury is allowed to heal and the patient has
ongoing complaints suggesting joint instability, provocative testing is very useful and can be done
without evoking pain. In contrast musculotendinous injuries usually produce chronic pain and
diminished function and the provocative tests for these injuries are designed to elicit pain or reveal
diminished active ROM.

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Hand Exam

Inspect for muscle wasting of the thenar muscles (median nerve), hypothenar and interosseus
muscles (ulnar nerve). Atrophy of the thenar eminence is often present with arthritic joint changes, as
well as nerve damage or impingement in the hand. Interosseous muscle wasting is seen between the
metacarpals of the hand (see pictures, below).

Thenar atrophy Interosseous muscle wasting (note first web space)

If there are joint abnormalities in the hands the distribution is important. Bony nodules on the DIP
joints (Heberden’s nodes) and PIP joints (Bouchard’s nodes) are caused by bony enlargement
(osteophytes) seen in osteoarthritis.
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 Bouchard’s nodes Heberden’s nodes

Swelling, pain and deformity at the MCP joints of both hands (including ulnar deviation) is consistent
with a systemic inflammatory process such as rheumatoid arthritis (RA). RA is a chronic inflammatory
disease characterized by progressive damage of synovial-lined joints, and joint destruction, with
variable extra-articular manifestations. In the hand, it is usually found in the MCP joints and wrists
(the PIP joints may also be involved). There may be “Swan neck” deformities of the DIP joints (due to
tenosynovitis of the flexor tendon sheath) and “Boutonierre” deformities of the PIP joints (due to
destruction of the central tendon slip) in advanced disease.

RA: Note ulnar deviation at MCP

joints and swelling of MCP joints and
wrist due to marked joint destruction
in advanced disease.

The anatomic snuffbox is the indentation between the tendons at the base of the thumb when the
thumb is held in full extension. Tenderness in the snuffbox after a fall on an outstretched hand
indicates trauma to the scaphoid bone which is at the floor of the snuffbox. Scaphoid fractures are
notorious for difficult healing due to blood supply disruption from a fracture.

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Shoulder Exam
With the patient adequately exposed in the sitting position inspect for scars from previous surgeries
and for asymmetry which could be from a new or old injury.
Palpate the clavicle beginning at the sternoclavicular (SC) joint and ending at the acromioclavicular
(AC) joint. A shoulder separation results from injury to the AC ligaments; a prominence of the AC joint
is often apparent due to upward displacement of the clavicle.

Assess active range of motion in the following manner. Flexion: Ask the patient to reach forward
with the elbows straight and raise her arms in an arc overhead. Extension: Ask the patient to reverse
directions and trace an arc backwards with the elbows straight. Abduction and external rotation:
Ask the patient to place one hand behind her head and reach as far down the spine as possible.
Notice how far the patient can reach and compare to the other side. Adduction and internal
rotation: Ask the patient to place one hand behind her back and reach as far up the spine as possible.
Notice how far she can reach and compare to the other side.

Shoulder Extension

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Shoulder pain related to impingement is common. The rotator cuff tendons pass under the acromion
en route to their insertions on the humerus. The supraspinatus tendon is particularly susceptible to
inflammation from friction on the acromion with overhead motions such as swimming, reaching
overhead repeatedly or sleeping with arms overhead. This tendinous friction on the acromion is
impingement. Assess for impingement by placing one hand over the shoulder and forward flexing
(elevating) the arm while holding it in internal rotation (complete pronation of the hand with the
thumb facing backwards). This is called the Neer sign and it is positive if there is pain at the shoulder
with the passive motion.

Neer test: note the positioning of the hand and the FLEXION of the arm

Knee Exam
In the sitting or supine position with the patient adequately exposed to well above the knees inspect
for scars from previous surgeries or injuries and for asymmetry which could be from an old deformity
or acute inflammation (swelling or effusion). Quadriceps muscle atrophy suggests a chronic problem
with the knee(s).

Palpate for warmth. Palpate the patellar tendon down to the tibial tuberosity. Palpate the joint line
by placing your thumbs in the soft tissue depressions on either side of the patellar tendon and feeling
the groove between the tibia and the femur. Finally palpate the collateral ligament attachments as
you progress posteriorly along the joint.

Assess for effusion by placing the patient in the supine position and “milking” the fluid from the
suprapatellar pouch into the joint space since the suprapatellar bursa communicates with the synovial
cavity of the knee. Start above the knee and use the first web space of your hand to milk any fluid
downward. A bulge in the skin indicates fluid in the joint. If there is a large amount of fluid in the
joint space it may be possible to ballotte the patella by pushing it downward briskly with the thumb or
index finger of your other hand.

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Assess active range of motion. Flexion: In the supine position ask the patient to bend the knee and
assess how close the heel comes to the buttocks or simply look at the knee itself. Compare to the
other side. Extension: Ask the patient to straighten the leg. Then, holding your hand a few inches
above his toes, ask him to lift the leg off the table to touch your hand with his toes while you observe
knee extension.

Assess ligaments. The anterior cruciate ligament (ACL) is in the notch of the knee connecting the
posterior portion of the lateral femoral condyle to the anterior portion of the tibial plateau. This
crosses (cruciate=cross) the posterior cruciate ligament (PCL) which connects the anterior part of the
medial femoral condyle to the posterior tibial plateau. The cruciate ligaments stabilize the knee in the
anteroposterior direction by preventing movement of the femur on the tibia. The provocative tests
used to assess the anterior cruciate ligament (ACL) are called the Lachman test and the anterior
drawer test. The Lachman test is the more sensitive test for detecting anterior cruciate injuries.

Perform the Lachman test with your patient in the supine position. With the knee slightly flexed
grasp the tibia just below the knee with one hand and the femur just above the knee with the other
hand. Pull briskly toward the ceiling on the tibia while stabilizing the femur. Notice how far the tibia
moves forward relative to the femur. The intact ACL will limit motion of the tibia on the femur and a
firm endpoint is achieved. If there is no firm endpoint it is evidence of damage to the ACL.

The collateral ligaments provide medial and lateral stabilization to the knee joint. Test the medial
collateral ligament (MCL) by flexing the knee slightly and placing one hand on the outside of the knee
and the other hand on the ankle. Provide a valgus stress (angulation is away from the midline of the
body) by pushing inward (medially) on the knee while pulling outward (laterally) on the ankle. If the
MCL is completely torn the joint line will “open up” with the valgus stress; if the MCL is stretched, or
lax, there will be a lesser degree of opening.

Repeat the above to test the LCL by placing one hand on the inside of the knee and the other hand on
the ankle. Provide a varus (angulation of the part is toward the midline of the body) stress by pulling
outward (laterally) on the knee while pushing inward (medially) on the ankle.

The drawings and explanations below provide additional quidance.

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Ankle Sprain Exam
This very limited exam is intended to familiarize you with the most common ankle sprain injury, a
lateral ankle sprain, also called an inversion injury to the ankle. A sprain is damage to the ligaments;
in a mild sprain the ligaments are stretched and in a severe sprain they can be torn. A sprained ankle
is usually associated with swelling and when more severe also with ecchymosis, or bruising.
Locate the lateral ankle joint by palpating below the anterior border of the lateral malleolus (distal
fibula) in the groove between the fibula and the talus. This is the location of the anterior talofibular
ligament. Palpate posteriorly along the lower edge of the lateral malleolus to the calcaneofibular
ligament. You may not be able to distinguish the actual ligaments but should be familiar with their
locations.

In the sitting position inversion is the ankle motion when the patient turns the inside or medial border
of the foot toward the ceiling. To passively invert the ankle hold the distal leg above the ankle to
stabilize it while grasping the calcaneus with the other hand. Rock the calcaneus medially. This is the
mechanism of injury when the patient “twists” their ankle in a lateral ankle sprain. In a severe sprain
with complete disruption of the lateral ligaments the joint would “open up” similar to the knee joint
when the collateral ligaments are damaged. Eversion is when the patient turns the outside or lateral
border of the foot toward the ceiling. Passively evert the ankle by repeating the above and rocking
the calcaneus laterally instead of medially.

Spine Exam
This exam focuses on the musculoskeletal components of the spine rather than the neurologic
evaluation for sciatica or nerve root compression. Additional aspects of the back examination will be
covered in Semester 2 in the “Scenarios/Chronic Diseases” PE Skills Lab.

The normal spinal curves include cervical and lumbar lordosis (convexity of curve anteriorly) and
thoracic kyphosis (convexity of curve posteriorly). A loss of cervical and lumbar lordosis occurs in
paraspinous muscle spasm which is often seen in stress related muscle tension, after trauma, and
sometimes after a surgical fusion has been performed. An exaggerated thoracic kyphosis is abnormal
and a patient who has this is referred to as being “kyphotic”. An “S curve” in the spine is called
scoliosis, is an abnormal finding, and is best examined with the patient bending forward so that the
spine is parallel to the floor. In early scoliosis before the curve is noticeable it is sometimes possible
to see only a rotatory component. This presents with asymmetry of the rib cage with one side or one
scapula higher than the other. An exam for scoliosis is particularly important in children as scoliosis
may progress rapidly at the beginning of puberty, especially in girls, because of an increase in the rate
of linear growth. While most cases are mild, and many do not require treatment, progressive scoliosis
can lead to heart and lung problems, chronic back pain, and unwelcome changes in appearance and
body symmetry.

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Active range of motion will be tested separately in the neck and back. Start with forward flexion in
the back as the patient is in that position for evaluation of scoliosis. Assess back extension by noting
the motion in the spine as the patient bends backwards toward you. You may stabilize the hips if
desired. Test back rotation by having the patient twist around to look at you while keeping her hips
facing forward. Note the symmetry of how far she can turn. Test lateral flexion by having the patient
side bend and again note symmetry. Test neck flexion by having the patient attempt to touch her
chin to her chest and extension by having her look up toward the ceiling. Lateral flexion is tested by
having the patient attempt to touch her ear to her shoulder. Rotation is tested by having her turn her
chin toward the same-side (ipsilateral) shoulder.

With the patient standing upright sit behind her and put your hands on the iliac crests noting whether
they are level. Observe the posterior superior iliac spines, the “dimples” at the sacral level, for
symmetry. Asymmetry may indicate a leg-length discrepancy or a misalignment of the pelvis. Either
can be a cause of back pain and can cause an abnormal gait.

Palpate the spine and paraspinous muscles for any localized areas of tenderness if the patient is
complaining of pain. Paraspinous muscle spasm and compression fractures may be tender upon
palpation. Compression fractures are not uncommon in the elderly and may occur in the face of
spinal osteoporosis and without history of trauma. Under such circumstances, localized tenderness
over the lumbar spine and decreased range of motion may be found on physical examination.

If there is no palpable tenderness you can percuss the spine lightly with your fist to further localize
any tenderness which might be due to osteomyelitis or metastatic disease. Note the location of the
kidneys below the rib cage. In a patient with suspected pyelonephritis (infection of the kidney)
tenderness would be present in the costovertebral angle which is formed by the 12th rib and the
vertebral column. Although you may see other resources recommending it, percussing here in a
patient with pyelonephritis would be extremely painful; light palpation is all that is needed to confirm
tenderness.

Resources:

Bickley L. Bates Guide to Physical Examination and Medical History Taking, 12th ed., 2017.

A Practical Guide to Clinical Medicine http://meded.ucsd.edu/clinicalmed/joints.htm

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