Table 9: Musculoskeletal Exam
| Physical Sign / Manoeuvre | Rationale | Technique(s) | Interpretation | Evidence | Pre-Clerkship | Clerkship |
|---|---|---|---|---|---|---|
| Inspection of joints | Reveals deformity, swelling , changes in colour, extra-articular abnormalities | Direct, organized, systematic observation Compare the affected joint with the symmetric and healthy one, when possible. | Define location, distinguish normal from abnormal – deformity, valgus/varus, swelling, erythema, patterns | Primary screening approach for most MSK conditions General screen sensitive Carek, 2003. Hand OA: Heberden’s nodes helpful Jones, 2001. Shoulder muscle wasting helpful Litaker, 2000. | 3 | 4 |
| Inspection of gait | Screen and locate MSK abnormality | Observation of patient standing and walking time | Normal/abnormal Trendeleburg , antalgic | Establishes functional impairment Helps rule out MSK disease in a general screen Carek, 2003. Valuable as part of knee exam. Jackson, 2003. | 3 | 4 |
| ROM Active/passive range of motion | Screen for joint abnormalities, pain, and function | Spine (active only)– C- flex, ext, lateral flex and rotation,T-rotation, chest expansion, L-flex/ext, lateral flex TM – active range, open mouth Shoulder – Active – abduction, external/internal rotation, (hands over head, hands behind head, hands behind back) Passive- stabilize scapula, check abduction of GH joint Elbow – flex, ext, supination/pronation Wrist – flex, ext, sup/pron Hand – grip Thumb – opposition, Hip – abduction, internal rotation, ? flexion/extension Knee – flex/ext Ankle – flex/ext Toe – dorsiflexion | Active – good screen, low specificity Passive – Differentiates joint from tendon, muscle and nerve | General screen using these is sensitive for young athletes Carek, 2003. Grip strength correlates with other measures for hand OA Jones, 2001. Shoulder movement (restriction, arc) reliable and valid for diagnosis of rotator cuff pathology Litaker, 2000. ROM of knee helps screen for fracture, OA. Jackson, 2003. Reliable and valid for ankylosing spondylitis Haywood, 2004. | 3 | 4 |
| Palpation | Elicit tenderness, effusions, crepitus, nodules | Small joint – apply pressure at right angles to examining fingers Knee – wipe test, ballotment, patellar tap Crepitus – knee, shoulder Degree of firmness of abnormality – bone/soft tissue/fluid Joint line tenderness-knee, small joints | Inflammatory vs mechanical joint disease Joint vs soft tissue disease | Most reliable to follow RA van der Heijde, 1992. Ultrasound more sensitive for effusions Wakefield,2004. Value of effusion and tenderness for knee # Bauer, 1995. Tests for effusions specific, not sensitive Kane, 2003. Tenderness, crepitus for knee pathology Jackson, 2003. | 3 | 4 |
| Trendelburg Test | Hip disease – tests abductor muscle strength | Stand supported by affected leg, unaffected hip drops | Positive sign is a lower buttock on the non-weight bearing side-suggesting dislocating of hip or paradigm of gluteus medius | Hardcastle, 1985. | 2 | 4 |
| Anterior/Posterior Stability drawer | Detection of tears of cruciate ligaments | Knee flexed with foot on examining table, pressure applied on knee post or ant. | Common traumatic injury | Evidence for Lachman test for anterior cruciate: sensitive. Malanga, 2003. | 1 | 3 |
| lateral and medial collateral stability | Detection of instability or tear of collateral ligament or detection of cartilage loss | Knee flexed, lateral or medial pressure applied to distal leg | Common injury Sign of osteoarthritis | 1 | 3 | |
| Straight leg raising | Tension on Sciatic nerve | Leg lifted straight upwards while patient supine | Sign of acute nerve root compression | SLR and Lesague correlate with outcome for spinal surgery Kohlboeck, 2004. Rebain, 2002. | 2 | 4 |
| Schober’ Test and other mobility tests in ankylosing spondylitis | Changes in gait and flexibility in axial arthritis | Measurement of expansion of ten centimetre segment in lower spine.Also, chest expansion, finger floor distance, wall occiput | Signs of common inflammatory arthritis | Validated and used as part of disease indices in research and clinical settings
Haywood, 2004. Maksymowych, 2006. | 2 | 4 |
| Meniscal tests | Detection of torn meniscus | Several described | Signs of common acute knee trauma | Highly variable evidence: Most reliable in hands of experts: If done, in clerkship Ryzewicz, 2007. Scholton, 2001. Malanga, 2003. | 1 | 3 |
| Carpal Tunnel tests | Irritability of compressed nerve, findings of sensory or motor loss in nerve distribution | Tinel, Phalen and examination of sensory and motor loss | Signs of common form of nerve compression | Reliable testing for carpal tunnel requires a complex combination of history and exam: No single test is reliable, but Tinel’s is certainly not. Massey-Westrop, 2000. Wainner, 2005. | 1 | 3 |
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