AFMC National Clinical Skills Working Group Evidence-Based Clinical Skills Document

Table 9: Musculoskeletal Exam

Physical Sign / ManoeuvreRationaleTechnique(s)InterpretationEvidencePre-ClerkshipClerkship
Inspection of jointsReveals deformity, swelling , changes in colour, extra-articular abnormalitiesDirect, 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.

Inspection of gaitScreen 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.
ROM Active/passive range of motionScreen 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.
PalpationElicit tenderness, effusions, crepitus, nodulesSmall 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

Value of effusion and tenderness for knee #
Bauer, 1995.

Tests for effusions specific, not sensitive
Kane, 2003.

Tenderness, crepitus for knee pathology
Jackson, 2003.
Trendelburg TestHip disease – tests abductor muscle strengthStand 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 mediusHardcastle, 1985.24

Stability drawer
Detection of tears of cruciate ligamentsKnee flexed with foot on examining table, pressure applied on knee post or ant.Common traumatic injuryEvidence for Lachman test for anterior cruciate: sensitive.

Malanga, 2003.

lateral and medial collateral stabilityDetection of instability or tear of collateral ligament or detection of cartilage lossKnee flexed, lateral or medial pressure applied to distal legCommon injury

Sign of osteoarthritis
Straight leg raising Tension on Sciatic nerveLeg lifted straight upwards while patient supineSign of acute nerve root compressionSLR and Lesague correlate with outcome for spinal surgery

Kohlboeck, 2004.
Rebain, 2002.

Schober’ Test and other mobility tests in ankylosing spondylitisChanges in gait and flexibility in axial arthritisMeasurement of expansion of ten centimetre segment in lower spine.Also, chest expansion, finger floor distance, wall occiputSigns of common inflammatory arthritisValidated and used as part of disease indices in research and clinical settings

Haywood, 2004.
Maksymowych, 2006.

Meniscal testsDetection of torn meniscusSeveral describedSigns of common acute knee traumaHighly variable evidence: Most reliable in hands of experts: If done, in clerkship

Ryzewicz, 2007.
Scholton, 2001.
Malanga, 2003.

Carpal Tunnel testsIrritability of compressed nerve, findings of sensory or motor loss in nerve distributionTinel, Phalen and examination of sensory and motor lossSigns of common form of nerve compressionReliable 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.