MUSCULOSKELETAL SYSTEM

PART 1
NAME- PURUSHOTHAMAN
SABARIGIRI
1ST YEAR SEC- I
 OBJECTIVES
By the end of the presentation, participants
would be able to know and understand the:
1. Abnormalities of temporomandibular joint,
2. Abnormalities of shoulder joint,
3. Abnormalities of elbow.
 CONCEPT MAP
• Abnormalities of temporo-mandibular joint:
– During inspection,
– During palpation.
• Abnormalities of shoulder joint:
– During inspection,
– During palpation,
– During manuevers.
• Abnormalities of elbow:
– During inspection,
– During palpation,
– During maneuvers.
Abnormalities of temporomandibular joint

• During inspection:
– Facial asymmetry with unilateral chronic pain with
chewing, jaw clenching or teeth grinding
accompanied by headache suggests of TMJ
disorders.
– Swelling in TMJ would also suggests of TMJ
inflammation or arthiritis.
 During palpation
– A dislocation of
temporomandibular joint during
palpation may be due to any
trauma,
– Palpable crepitus would suggests
of synovial fluid accumilation in
the TMJ.
– Temporomandibular joint
syndrome is also been presented
with pain and tenderness during
palpation.
 Abnormalities of shoulder joint
Abnormalities seen during inspection
• Scoliosis:
– Elevation of one shoulder,

• Swelling:
– the synovial fluid accumilation in the glenohumeral joint
capsule is significant and may cause its distension,
– The same with the acromioclavicular joint is easier to
detect as it is more superficially present.
Abnormalities seen during palpation
– Tenderness over the muscles of the rotator cuff
suggests of sprains, tears and tendon rupture of
those muscles, mainly of supraspinatus.
– Tenderness and effusion in the palpation of
glenohumeral joint would be due to humeral joint
synovitis.
 Abnormalities seen during maneuvers
• Rotator cuff tendinitis:
– Acute, recurrent/chronic pain
aggravating by activity.
– Pain, grating and weakness
when lifting the arm
overhead.
– When supraspinatus tendon is
involved, tenderness is
maximal just below the tip of
the acromion.
• Rotator cuff tears
– Chronic shoulder pain,
night pain, grating when
rising arm above the head.
– Palpate anterior greater
tuberosity for muscle
attachments and in below
the acromion for crepitus
during arm rotation.
– In complete tear, active
abducted and forward
flexion are severely
impaired producing a shrug
and a positive drop arm
test.
• Calcific tendinitis:
– As the arm is held closer to
the side of the body, all the
motions are severely
limited by pain,
– Tenderness is maximal in
below the tip of acromion,
– Inflammation of
subacromial bursa may be
occurred with chronic less
severe pain.
• Bicipital tendinitis:
– Tenderness is maximal in
the bicipital groove.
– Increased pain in the
bicipital groove during the
forceful supination of the
patient’s forearm against
your resistance when the
elbow is flexed at 90
degrees.
– Also pain during resisted
forward flexion when the
elbow extended.
• Adhesive capsulitis:
– Localized tenderness,
– Diffuse, dull aching pain
and progressive
restriction of active and
passive range of motion
during external rotation.
• Acromioclavicular
arthritis
– Localized tenderness
over acromioclavicular
joint,
– Pain with movements
of the scapula and arm
abduction.
• Anterior dislocation of
the humerus:
– Shoulder seems to be slip
out of the joint during the
abduction and external
rotation of the arm,
– Causing positive
apprehension sign for
ant. Instability when the
examiner places the arm
in this position,
– Pain in any shoulder
movement,
– Rounded lateral aspect
appears flatened.
 Maneuvers in shoulder examination and its
related abnormalities
• Crossover adduction test:
– Adduction of arm across the
chest,
– Pain with adduction suggest
positive for adduction test.
• Apley scratch test:
– To touch the opposite scapula,
using a combination of abduction
& external rotation and
adduction & internal rotation.
– Pain - rotator cuff disorder or
adhesive capsulitis.
• Painful arc test:
– Full adduction of arm from 0
degree to 180 degree,
– Shoulder pain from 60 to
120 degree - subacromial
impingement/ rotator cuff
tendinitis.
• Near impingement test:
– Raising the arm with one
hand while pressing the
scapula on another,
– Pain - subacromial
impingement/ rotator cuff
tendinitis.
• Hawkins impingement sign:
– With one hand on forearm and
another on the arm, rotate the arm
internally after flexing the
shoulder and elbow to 90 degree
with palm facing down,
– Pain - supraspinatus impingement/
rotator cuff tendinitis.
• External rotation lag test:
– With arm flexed to 90 degree with
palm facing up, rotate it into full
external rotation,
– Inability to maintain external
rotation- supraspinatus and
infraspinatus disorders
• Internal rotation lag test:
– Placing the dorsum of the hand on
low back with the elbow flexed to
90 degree. With lifting the hand
off the back, ask the patient to
keep the hand in this position,
– Inability to hold the hand in this
position is positive for
subscapularis disorder.
• Drop arm test:
– With abducting the arm to
shoulder level, up to 90 degree,
ask to lower it slowly.
– Weakness – supraspinatus rotator
cuff/ bicipital tendinitis.
• External rotation resistance
test:
– With adducting and flexing
the arm to 90 degree and with
thumbs turned up, stabilize
the elbow with one hand and
apply pressure proximal to
the patients wrist as the
patient presses the wrist
outward in external rotation,
– Pain or weakness-
infraspinatus disorder,
– Limited external rotation-
glenohumeral disease or
adhesive capsulitis.
• Empty can test:
– Wirth elevating the arms to 90-
degree and internally rotate the
arms with the thumbs pointing
down, ask the patient to resist
as you place downward
pressure on the arms.
– Inability to hold the arm fully
abducted at shoulder level or
control lowering the arm is
positive for supraspinatus
rotator cuff tear.
 Abnormalities of elbow
• Abnormalities seen during inspection:
• Olecranon bursitis:
– Swelling that is superficial to the
olecranon process which may reach 6 cm
in diameter,
– Consider aspiration for diagnosing.
• Rheumatoid nodules:
– Subcutaneous nodules,
– Along the extensor surface of the ulna,
– Firm and non-tender,
– May develop in the area of olecranon
bursa.
 Abnormalities seen during palpation
• Arthritis of elbow:
– Synovial inflammation or fluid,
– Felt best in the grooves between
the olecranon process and the
epicondyles on each side,
– Boggy, soft or fluctuant
swelling and tendinitis,
– May report pain, stiffness and
restricted motion.
 Abnormalities seen during maneuvers
• Epicondylitis:
• Lateral epicondylitis:
– Pain and tenderness 1cm distally to lateral
epicondyle,
– Pain increases when extending the wrist against
resistance.
• Medial epicondylitis:
– Pain lateral and distal to the medial epicondyle,
– Pain increases when flexing the wrist against
resistance.

• Full extension of elbow makes intra-articular

effusion or hemoarthiritis and allow fracture
unlikely.
 Clinical corelation
A 42-year old patient presents with complaints of right
shoulder joint, while lifting an outboard motor out of the
water while at work. On that incident he felt a pop and a
sharp pain in his right shoulder. Since that time, he reports
not been able to use his shoulder as previously, and his right
arm feels pain, stiff and weak when attempting to elevate it
overhead. The pain is localized too right shoulder.

• with the given information and the lecture taken, the

students are encouraged to find the abnormality seen in this
patient.
 references
• Bates guide to physical examination and history
taking, 12th edition,
• http://accessphysiotheraphy.mhmedical.com/conte
nt.aspx?bookid=591&sectionid=43777679
.

• For better understanding of the topic, please refer

to the bates for the pathology of the abnormalities
before studying how we can diagnose it in PE.