A Practical Guide to Clinical

Medicine
A comprehensive physical examination and clinical education site for medical
students and other health care professionals

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Medicine; Content and Photographs by Charlie Goldberg, M.D., UCSD School of
Medicine and VA Medical Center, San Diego, California 92093-0611.

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The Rest of the History The Upper Extremities
Vital Signs The Lower Extremities
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Musculo-Skeletal Examination
Detailed examination of the joints is usually not included in the routine medical
examination. However, joint related complaints are rather common, and
understanding anatomy and physiology of both normal function and pathologic
conditions is critically important when evaluating the symptomatic patient. By
gaining an appreciation for the basic structures and functioning of the joint, you'll be
able to "logic" your way thru the exam, even if you can't remember the eponym
attached to each specific test!

I have included detailed descriptions of the shoulder, knee, and low back
examinations as these are the most commonly affected areas. In addition, a review of
relevant anatomy, function, and common disorders are described for most of the other
major joints. This is not meant to be an all-inclusive list.

A few general comments about the musculoskeletal exam

Historical clues when evaluating any joint related complaint:

 What is the functional limitation?

 Symptoms within a single region or affecting multiple joints?
  Acute or slowly progressive?
 If injury, what was the mechanism?
 Prior problems with the affected area?
 Systemic symptoms?

Common approach to the examination of all joints:

 Make sure the area is well exposed - no shirts, pants, etc covering either side -
gowns come in handy
 Carefully inspect the joint(s) in question. Are there signs of inflammation or
injury (swelling, redness, warmth)? Deformity? As many joints are symmetric,
compare with the opposite side
 Must understand normal functional anatomy - what does this joint normally
do?
 Observe the joint while patient attempts to perform normal activity - what
can't they do? What specifically limits them? Was there a discrete event (e.g.
trauma) that caused this? If so, what was the mechanism of injury?
 Palpate the joint in question. Is there warmth? Point tenderness? If so, over
what anatomic strucutres?
 Assess the range of motion, both active (patient moves it) and passive (you
move it) if active is limited/causes pain.
 Strength, neuro-vascular assessment.
 Specific provocative maneuvers related to pathology occurring in that joint
(see descriptions under each joint).
 In the setting of acute injury and pain, it's often very difficult to assess a joint
as patient "protects" the affected area, limiting movement and thus your
examination. It helps to examine the unaffected side first (gain patient's
confidence, develop sense of their normal).

Lower
Knee Shoulder Hand Hip
Elbow Back
Exam Exam Exam Exam
Exam

The Knee Exam

Observation:

1. Make sure that both knees are fully exposed. The patient should be in either a
gown or shorts. Rolled up pant legs do not provide good exposure!
2. Watch the patient walk. Do they limp or appear to be in pain? When standing,
is there evidence of bowing (verus) or knock-kneed (valgus) deformity? There
is a predilection for degenerative joint disease to affect the medical aspect of
the knee, a common cause of bowing.
 Verus Knee Deformity, more marked on the left leg.

3. Make note of any scars or asymmetry. Chronic/progressive damage, as in

degenerative joint disease, may lead to abnormal contours and appearance. Is
there obvious swelling as would occur in an effusion? Redness suggesting
inflammation?
4. Is there evidence of atrophy of the quadriceps, hamstring, or calf muscle
groups? Knee problems/pain can limit the use of the affected leg, leading to
wasting of the muscles.

While both legs have well developed musculature,

the left calf and hamstring are bulkier than the right.

5. Look at the external anatomy, noting structures above and below the knee
itself:
a. Patella
b. Patellar tendon
 c. Quadriceps/Hamstring/Calf muscles
d. Medial and lateral joint lines.
e. Femur and Tibia
f. Tibial tuberosity

 
Palpation and Examination for Degenerative Joint Disease:

1. If the knee is injured, start by examining the unaffected side. This allows for
comparison and relaxes the patient as you are not performing maneuvers that
cause discomfort from the outset.
2. Ask the patient to bend the knee, gauging whether they can fully extend and
flex. This is referred to as their active range of motion. Full extension is 0
degrees, full flexion ~ 140.

3. Knee Flexion (Left) and Extension (Right)

4. Place one hand on the patella. Note any warmth, which if present, would
suggest inflammation. Grasp the ankle or calf with your other hand and gently
flex the knee. Note the extent to which you can flex and extend the knee,
referred to as its passive range of motion. Also, using the hand on the patella,
feel for crepitus. This is a crackling/grinding sensation that occurs with
movement. If present, it's suggestive, but not diagnostic, of degenerative joint
disease (DJD). It reflects a loss of the normal smooth movement between the
articulating structures (femur, tibia, and patella). DJD is suggested by the
presence of pain with activity that gets progressively more limiting over time.
There may be a history of antecedent injury, which caused the inciting damage
to the articulating surface. And co-existent damage to ligaments or menisci
may also be present (see below). When defining the extent of DJD, the knee is
broken into 3 compartments: Medial, central, and lateral. DJD can occur in
any or all regions. The precise location of the DJD can be hard to determine on
examination and is more accurately defined via x-rays.
 5. X-Ray of Normal Knee (Left) and Knee With DJD (Right)
6. If any of the above maneuvers elicits pain, stop and note at what point in the
range of motion this occurs.
7. It's important to note that many patients report noises (e.g., creaking, popping,
cracking) associated with joint movement. The vast majority of these sounds
are not clinically significant. Rather, pain or functional limitation are the
subjective complaints which carry clinical relevance.

Tests for an effusion:

An effusion is the accumulation of fluid within the joint space. If there is a large
collection, the knee will look swollen. Lesser amounts of fluid can be a bit more
subtle. Patient's symptoms are often related to whatever caused the fluid to
accumulate in the first place. The effusion itself makes the knee feel as if it's
somewhat unstable or floating and may limit range of motion. Effusions resulting
from inflammatory arthritis (e.g. infection, gout, rheumatoid arthritis) are associated
with other signs of inflammation, including: warmth, redness, pain with any
movement.
 Large Effusion, Right Knee.

Ballotment (helpful if the effusion is large)

1. Slightly flex the knee which is to be examined.

2. Place one hand on the supra-pateallar pouch, which is above the patella and
communicates with the joint space. Gently push down and towards the patella,
forcing any fluid to accumulate in the central part of the joint.
3. Gently push down on the patella with your thumb.
4. If there is a sizable effusion, the patella will feel as if it's floating and "bounce"
back up when pushed down.

Balloting the Left Knee.

Milking (helpful for detecting small effusions)

 1. Gently stroke upwards along the medial aspect of the patella, pushing fluid
towards the top and lateral aspects of the joint.
2. Gently push on the lateral aspect of the joint. If there's a small effusion, the
fluid which was milked to the lateral aspect will be pushed back towards the
medial area of the joint, causing the medial skin to bulge out slightly.

Video demonstrating technique for

milking an effusion.

Inflammatory Arthritis and Effusions:

Intense inflammatory processes within the joint space can also cause an effusion.
Infection, gout, and rheumatoid arthritis are a few of the conditions that can lead to an
inflammatory arthritis (IA) and effusion. The joint and overlying skin is usually warm
and red. In addition, there is significant pain with any active or passive movement.
The more intense the inflammation, the more severe the pain and the more limited the
range of motion. Identifying the precise cause of IA is critical as it directs the
clinician towards the best treatment, limiting permanent damage to the joint. This
usually requires aspiration and examination of the joint fluid. Inflammatory fluid has
a high white cell count and should contain other clues as to its origin (e.g. gout -->
crystals on microscopy; infection --> bacteria on gram stain and culture; etc). Fluid
from those with degenerative effusions has relatively few white cells. Clinically,
patients with DJD have few signs of inflammation and some degree of preserved
range of motion (ROM). Historical information also helps distinguish DJD from IA.
DJD is usually slowly progressive while those with IA more often have an acute
presentation. Additionally, those with IA may have characteristic patterns of
recurrence (e.g. great toe MTP in gout, MCPs of hands in RA), systemic symptoms,
suggestive joint deformities (e.g. ulnar deviation of the hands in RA), and particular
radiographic changes. Of course, it's possible to have element of both IA and DJD.
DJD, for example, can result from joint damage that occurred secondary to past
episodes of gout or infection.
 Gouty Inflammation of Metatarsal-Phalangeal Joint, Left Great Toe

Specific Maneuvers for the Knee Exam

Tests for Meniscal Injury

Normal anatomy and function: The menisci sit on top of the tibia and provide a
cushioned articulating surface between the femur and tibia. Symptoms occur when a
torn piece interrupts normal smooth movement of the joint. This can cause a sensation
of pain, instability ("giving out") or locking in position. Injury may also cause
swelling. If the meniscus has been injured and no longer adequately covers the tibia,
damage can occur to the underlying bone, leading to degenerative arthritis.

Anatomy of Menisci, Right Knee (patella has been removed).

Joint Line Tenderness:

1. Have the patient slightly flex their knee. The knee is slightly flexed when
performing all of the functional tests that are described below. This positions
the joint such that other stabilizing elements do not interfere with the structure
that is being tested.
2. Define the joint space along its lateral and medial margins. The joint line is
perpendicular to the long axis of the tibia.
3. Gently palpate along first the medial and then the lateral margins. Pain
suggests that the underlying meniscus is damaged. Osteoarthritis can also
cause joint line tenderness
 4. Palpation Along Lateral (picture on left) and Medial (picture on right)
Joint Lines. The Joint Line is Marked by Purple Line.
5. Note that only a portion of the meniscus lies near the joint line. The remainder
of the meniscus cannot be assessed with this technique.

Video Demonstrating Assessment of

Medial Joint Line Tenderness.
Video Demonstratinag Assessment of
Lateral Joint Line Tenderness..

McMurray's Test

1. When examining the right knee, place your left hand so that your middle,
index, and ring fingers are aligned along the medial joint line.
2. Grasp the foot with your right hand and fully flex the knee.
3. Gently turn the ankle so that the foot is pointed outward (everted). Then direct
the knee so that it is pointed outward as well (valgus stress).
4. While holding the foot in this everted position, gently extend and flex the
knee. If there is medial meniscal injury, you will feel a "click" with the hand
on the knee as it is extended. This may also elicit pain.
5. Simulated McMurray's Test With Foot Everted (picture on left). Close-up
(picture on right) Reveals How This Maneuver Streeses The Medial
Meniscus.

6.
7. McMurray's Test: Assessment Of Medial Meniscus Demonstrated In
Picture On Left, Lateral Meniscus In Picture On Right.
8. Now, return the knee to the fully flexed position, and turn the foot inwards
(inversion). Then direct the knee so that it is pointed inward as well (varus
stress).
9. Place the index, middle, and ring fingers of your left hand along the lateral
joint line.
10. Gently extend and flex the knee. If the lateral meniscus has been injured, you
may feel a "click" with the hand palpating the joint line. You may also elicit
pain.
 Video showing McMurray's Test.

Appley Grind Test

1. Have the patient lie on their stomach.

2. Grasp one ankle and foot with both of your hands and gently flex the knee to
ninety degrees. Hold the patients leg down by gently placing your leg over the
back of their thigh.

3. Appley Grind Test

4. Push down gently while rotating the ankle back and forth.
5. This maneuver places direct pressure on the menisci. If injured, it will cause
pain.
6. Test the opposite leg in the same fashion.

Tests for Injury to the Ligaments

Normal anatomy and function

The ligaments are very strong tissues that connect bone to bone. In the knee, they
assure stability and correct alignment. There are 4 main ligaments in the knee: Medial
collateral (MCL), lateral collateral (LCL), anterior cruciate (ACL) and posterior
cruciate (PCL). The medial and lateral ligaments provide stability in response to
medial and lateral joint stress. The cruciate ligaments limit anterior and posterior
movement of the femur on the tibia and limit the degree to which the knee can rotate.
Injury usually requires significant force. Following a ligamentous injury, there is
generally acute pain, swelling and the injured person will often report hearing a "pop"
(the sound of the ligament tearing). After the acute swelling and pain have dissipated,
the patient may report pain and instability (sensation of the knee giving out) during
any maneuver that would expose the deficiency created by the damaged ligament (e.g.
rotation, during which there is nothing to "check" the movement of the femur on the
tibia).
 Anatomy of Ligaments, Right Knee (Patella Has Been Removed).

The following are common mechanisms of injury for each of the major ligaments:

1. ACL: Most commonly injured when the foot is planted while extreme
rotational force is applied (e.g. a cleated foot caught in the turf while an athlete
attempts to rotate towards that side). The ACL may also be injured from a
direct force on the lateral knee while the foot is planted.
2. PCL: Much less commonly injured then the ACL. Posterior force on the tibia
(e.g. the tibia striking against the dashboard in a motor vehicle accident) can
lead to disruption.
3. LCL: Direct force on the medial aspect of the knee while the foot is planted.
4. MCL: Direct force on the lateral aspect of the knee while the foot is planted.

Given the forces required to tear a ligament, menisci are often damaged at the same
time. It is also possible to tear more then one ligament at once. When testing any
ligament, remember the following:
1. Always begin your exam with the asymptomatic knee. This gives you some
sense of the individual normal degree of laxity. That is, the "tightness" of
everyone's ligaments varies somewhat. By working on their unaffected side,
you will define "normal." It also helps to generate a sense of trust between you
and the patient.
2. If you're unsure as to whether there is really an abnormality, check back and
forth between the normal and abnormal sides. This will enhance your ability to
identify differences.
3. It can be difficult to examine patients with large joints, particularly if you have
small hands!
 4. Detecting subtle abnormalities takes lots of practice, particularly if you don't
have a great sense for the range of normal.
5. It can be extremely difficult to examine the acutely injured knee. Movement
often causes significant pain. The patient is understandably apprehensive and
will use surrounding muscles to prevent movement. This inability to relax is a
normal response and may limit the extent of your exam. It may be necessary to
simply wait until the acute inflammation resolves (with rest, elevation, anti-
inflammatory medications, and time) before being able to perform an accurate
exam.

Specifics of Ligament Testing

Medial Collateral Ligament

1. Slightly flex the right knee (~30 degrees).

2. Place your left hand along the lateral aspect of the knee.
3. Place your right hand on the ankle or calf.
4. Push steadily inward with your left hand while supplying an opposite force
with the right.

5. Stressing the MCL

6. If the MCL is completely torn, the joint will "open up" along the medial
aspect.
 Simmulated Torn MCL--Note How Joint Line Opens Up Along Medial
Aspect

7. Reverse hand position to assess the left knee.

8. Additionally, palpation along the course of the ligament may also elicit pain if
it has been injured.

Video Demonstrating Medial

Collateral Ligament Testing.

Lateral Collateral Ligament

1. Slightly flex the right knee (~30 degrees).

2. Place your right hand along the medial aspect of the knee.
3. Place your left hand on the ankle or calf.
4. Push steadily outward with your right hand while supplying an opposite force
with the left.
 5. Stressing the LCL
6. If the LCL is completely torn, the joint will "open up" along the lateral aspect.

Simmulated Torn LCL--Note How Joint Line Opens Up Along Lateral

Aspect

7. Reverse hand position to assess the left knee.

8. Additionally, palpation along the course of the ligament may also elicit pain if
it has been injured.

Video Demonstrating Lateral

Collateral Ligament Testing.

Alternative method for stressing the medial lateral collateral ligaments:

1. Extend the patient's knee and cradle the heel between your arm and body. The
knee should be slightly flexed.
2. Place your index fingers across the medial and lateral joint lines.
3. Using your body and index fingers, gently provide first medial and then lateral
stress to the joint.
 Stressing the MCL and LCL

Video demonstrating technique

stressing the MCL and LCL .

Anterior Cruciate Ligament

Lachman's Test

1. For testing the right leg, grasp the femur just above the knee with your left
hand and the tibia with your right.
2. Flex the knee slightly.
3. Pull up sharply (towards your belly button) with your right hand while
stabilizing the femur with the left. The intact ACL will limit the amount of
distraction that you can achieve. The intact ACL is described as providing a
firm end point during Lachman testing.
 4. Stressing the ACL
5. If the ACL is completely torn, the tibia will feel unrestrained in the degree to
which it can move forward (see above for image of simulated ACL tear).
6. Compare this to the other leg, reversing your hand position.
7. The patient must be able to relax their leg for this test to work. If they cant,
then compensatory muscles will limit the degree of motion, making it very
difficult to assess the integrity of the ACL.
8. If the thigh is too big in circumference (or your hand too small) to stabilize,
you can perform the Lachman's test with the leg hanging off the side of the
table (see picture below). It may also help to further stabilize the leg by
holding their ankle between your legs.

Variation On Lachman's Test For Patients With Large Legs.

Video Demonstrating Lachman's Test.

Video Demonstrating Positive

Lachman's Test.

Anterior Drawer Test (Note: This test has largely fallen out of favor. It is included for
the sake of completeness).

1. Have the patient lie down, with the right knee flexed such that their foot is flat
on the table.
2. Gently sit on the foot. Grasp below the knee with both hands, with your
thumbs meeting along the front of the tibia.
3. Gently pull forward, gauging how much the tibia moves forward in relation to
the femur. The ACL, if intact, will provide a discrete end point.
 4. Stressing the ACL
5. If the ACL is completely torn, the tibia will feel unrestrained in the degree to
which it can move forward.

Simmulated Torn ACL--Note How Far The Tibia Is Distracted Relative

To The Femur

6. Compare this to the other side by simply shifting your hands to the same
position on the opposite leg and repeating.

Video Demonstrating Anterior Drawer

Test.
Video Demonstrating Positive
Anterior Drawer Test.
Posterior Cruciate (PCL)

Posterior Drawer Test

1. Have the patient lie down, the right knee flexed to 90 degrees, foot flat on the
table.
2. Gently sit on the foot. Grasp below the knee with both hands, with your
thumbs meeting along the front of the tibia.
3. Gently push backward, gauging how much the tibia moves in that direction in
relation to the femur. The intact PCL will give a discrete end point.

4. Stressing the PCL (Because Of Its Posterior Location, The Actual

Ligament Cannot Be Seen In Picture On Right)
5. Compare this to the other side by simply shifting your hands to the same
position on the opposite leg and repeating.
6. If the PCL is completely torn, the tibia will feel unrestrained in the degree to
which it moves backwards.
 Simmulated Torn PCL--Note How Far Back The Tibia Moves Relative
To The Femur

7. If the PCL is completely torn, the tibia may appear to "sag" backwards even
before you apply any force.

Video Demonstrating Posterior

Drawer Test.

Assorted Other Testing

Patello-Femoral Syndrome: A problem with the way in which the patellar articulates
with the femur and moves (tracks) during flexion and extension. As a result, cartilage
lining the undersurface of the patella becomes irritated and worn down. Known as
Chondromalacia, this process causes anterior knee pain with activity and often after
prolonged sitting. Several ways of assessing for this condition are described below:

1. Have the patient slightly flex the leg to be tested.

2. Gently push down on the patella with both thumbs, which may elicit pain in
the setting of Chondromalacia.
3. Now, gently move the patella from side to side and try to palpate its
undersurface. This may elicit pain in the setting of Chondromalacia.
4. Hold the patella in place with your hand and ask the patient to contract their
quadriceps muscle. This will force the inferior surface of the patella onto the
femur, eliciting pain in the setting of Chondromalacia.
 5. Assessing For Chondromalacia

Bursitis

Bursa are small pouches of fluid that lie between bony prominences and the tendons
that surround joints. Their presence allows the tendons to move without generating a
lot of friction. The bursa do not communicate with the joint space itself. Inflammation
of the bursa, most commonly due to overuse of the tendon or direct trauma, can cause
pain and swelling. Examination of the affected area reveals focal pain. Swelling,
warmth, and redness may be prominent if there is concurrent infection, another cause
of bursitis. Bursitis can be distinguished from an intra-articular process because of the
location of the pain and the fact that movement of the joint itself does not cause
discomfort. The major bursa surrounding the knee include:

1. Pre-patella: Located directly on top of the patella. Most frequently affected

due to direct trauma, as may occur with people who spend a lot of time on
their knees (e.g. carpet layers, carepenters).
2. Infrapatella (a.k.a. anserine): Below the knee. Also affected by direct trauma,
as with the prepatella bursa.
 Location Of Bursa Is Shown On Model (Left). Picture On Right Demonstrates
Septic Prepatellar Bursitis Of The Left Knee.

Lower
Knee Shoulder Hand Hip
Elbow Back
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