Term
| know the definitions of directional movements of the head/neck used during the MSK exam |
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Definition
"flex and extend, rotate right and left, and sidebend right and left note any pain or restrictions of movement.
" |
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Term
| know the definitions of directional movements of the shoulder used during the MSK exam |
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Definition
| Flexion, Extension, Abduction, Internal rotation, and external rotation |
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Term
| know the definitions of directional movements of the spine used during the MSK exam |
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Definition
| Same as neck. Bend over (flexion), bend backwards (extension), rotate right, rotate left, side bend left, and side bend. Also, look for lumbar lordosis, thoracic kyphosis and cervical lordosis. |
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Term
| know the definitions of directional movemens of the extremities used during the MSK exam |
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Definition
"Shoulder
Flexion at shoulder (Arms forward). Extension (Arms Backward). Abduction (Arm away from the body). Adduction (Arm toward the body). Internal Rotation (of the humerus, arms behind back). External rotation (arms rotating out as if opening a coat to flash someone)
Elbow, knee
Flexion and Extension
Hip
Flexion, Extension
Internal hip rotation (move femur medially and feet go OUT)
External hip rotation (move femur laterally and feet go IN)
" |
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Term
| know the defintions of common terms used to describe movement for the MSK exam (e.g. abduction, adduciton, inversion, eversion, etc.) |
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Definition
"Abduction- movement away from body
Adduction- movement toward body
Inversion- Movement of the sole toward the middle plane
Eversion- Movement of the sole away from the middle of the plane
" |
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Term
| know the correct physical exam technique to examine a patient's shoulder |
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Definition
"Inspect: anteriorly, look for symmetry of shoulder height, bulk of trapezius and deltoids
posteriorly, look for scapular winging and bulk of spinatii
Palpate the following points for tenderness and deformity:
- Coracoid process
- greater tubercle of humerus
- bicipital groove
- subdeltoid bursa
- the acromioclavicula joint
- glenohumeral joints
Active range of motion
- Screen for shoulder abnormalities by having patient clasp hands behind head and extend arms so that elbows are “up against the wall” parallel to coronal plane.
- With arms at sides, abduct arm to 90o (abduction)
- With scapular motion elevate arm to 180o (move arms to a vertical position near head)
Look for symmetry and rhythm of movement
With patient’s arm at side (0o)
- Flex shoulder forward to 180o
- Flex shoulder backward to 60o (without scapular motion)
- Adduct shoulder to 30o
- Place hands behind small of back (internal rotation to 90o)
- Place hands behind neck with elbows out to side (external rotation to 90o) |
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Term
| know the physical exam technique for the evaluation of patients with shoulder injuries |
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Definition
"3 Special Tests for Shoulder Impingement:
1. Neer's Impingement sign: pain with shoulder flexion to 180º and internal rotation.
2. Hawkin's supraspinatus Impingement test: flexion, abduction, and internal rotation of the shoulder.
3. “Empty Can” Test for Supraspinatus impingement: Shoulders flexed to 90º, abducted slightly, humerus internally rotated, and examiner places a slight downward force on the arms.
Drop Arm Test for Rotator Cuff Insufficiency: Have patient slowly lower arm from 180º abduction to 0º abduction. |
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Term
| know the physical exam findings in patients with medial/lateral epicondylitis |
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Definition
| Lateral epicondylitis (tennis elbow) follows repetitive extension of the wrist or pronation–supination of the forearm. Pain and tenderness develop at the lateral epicondyle and possibly in the extensor muscles close to it. When the patient tries to extend the wrist against resistance, pain increases. Medial epicondylitis (pitcher’s, golfer’s, or Little League elbow) follows repetitive wrist flexion, as in throwing. Tenderness is maximal at the medial epicondyle. Wrist flexion against resistance increases the pain. |
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Term
| know the physical exam technique for the evaluatino of patients with humerus injuries |
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Definition
| check the patient for wrist drop |
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Term
| know the physical exam findings in patients with axillary, median, radial, and ulnar neuropathies |
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Definition
"AXILLARY: 1. Paralysis of the teres minor muscle and deltoid muscle , resulting in loss of abduction of arm (from 15-90 degrees), weak flexion, extension, and rotation of shoulder. Paralysis of deltoid & teres minor results in Flat shoulder deformity. 2. Loss of sensation in the skin over a small part of the lateral upper arm.
MEDIAN: Above the elbow, Injury of this nerve at a level above the elbow results in loss of pronation and a reduction in flexion of the hand at the wrist. At the elbow, Entrapment at the level of the elbow or the proximal forearm could be due to the pronator teres syndrome. Lesions of compression of the Median Nerve can also leads to Median Nerve Palsy
Within the forearm, Injury to the anterior interosseous branch in the forearm causes the anterior interosseous syndrome. At the wrist, Injury by compression at the carpal tunnel causes carpal tunnel syndrome. Severing the median nerve causes median claw hand (also called the ""Benedictine hand""). In the hand, thenar muscles are paralyzed and will atrophy over time. Opposition and flexion of the thumb are lost. Sensory is lost:Palm - 3 1/2 Fingers, Dorsal - Finger tips. The thumb and index finger are arrested in adduction and hyperextension. This appearance of the hand is collectively referred as 'ape hand deformity'
RADIAL: Wrist drop, also known as radial nerve palsy, or Saturday night palsy, is a condition where a person cannot extend their wrist and it hangs flaccidly. To demonstrate wrist drop, hold your arm out in front of you with your forearm parallel to the floor. With the back of your hand facing the ceiling (i.e. pronated), let your hand hang limply so that your fingers point downward. A person with wrist drop would be unable to move from this position to one in which the fingers are pointing up towards the ceiling.
ULNAR: Guyon's Canal Compression-Symptoms include a feeling of pins and needles in the ring and little fingers, and may progress to a burning pain in the wrist and hand followed by decreased sensation in the ring and little fingers." |
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Term
| know the physical exam findings in patients with olecranon bursiits |
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Definition
| Synovial inflammation or fluid is felt best in the grooves between the olecranon process and the epicondyles on either side. Palpate for a boggy, soft, or fluctuant swelling and for tenderness. |
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Term
| know the physical exam findings in carpal tunnel syndomre |
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Definition
"**Pain and numbness on the ventral surface of the thumb, index finger, middle finger, and part of the ring finger (ie. the distribution of the median nerve) and weak abduction of the thumb on muscle strength testing are the most helpful for making the diagnosis.
~Thumb abduction tests the strength of the abductor pollicis brevis, which is innervated solely by the median nerve.
*Weak opposition of the thumb can also be a finding.
*Thenar atrophy may be present.
*A positive Tinel’s sign (tingling or electric sensations develop in the distribution of the median nerve after percussing lightly over the wrist) is suggestive of carpal tunnel.
*A positive Phalen’s test (numbness and tingling develop after holding the patient’s wrists in acute flexion for 60 seconds or having the patient press the backs of both hands together to form right angles) is also suggestive of carpal tunnel.
" |
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Term
| know the physical exam findings in patients with a normal hip exam |
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Definition
"*Normal gait is observed with a negative Trendelenberg sign.
*Iliac crests, iliac tubercles, Anterior superior iliac spines, Posterior superior iliac spines, and greater trochanters are palpated & non-tender bilaterally.
*Iliac crests are at the same height.
*Passive ROM allows for hip flexion and extension (during hip flexion of one leg, the other leg stays down in extension= negative Thomas test)
*With the leg extended, passive abduction to 60° and adduction to 30° is achieved bilaterally.
*With the knee and hip flexed, hip is passively rotated internally (40°) and externally (45°)
*FABER test is negative bilaterally for sacroiliac or hip pain |
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Term
| know the physical exam findings in patients with femoral and sciatic neuropathies |
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Definition
" Femoral neuropathy- findings include weakness of knee extension and/or hip flexion, paresthesias (numbness, tingling, burning, pain, etc.) on the front of the thigh or inner calf; the patellar reflex may be decreased or absent; the quadriceps muscle on the affected side may be atrophied
Sciatic neuropathy- findings include possible tenderness or pain upon palpation of the sciatic nerve, weakness in knee flexion, weakness in movements of the foot (ex. Inversion and plantar flexion), weak or absent reflexes of the patellar or especially the Achilles tendons, pain on straight leg raising, tingling/numbness/paresthesias of the affected leg, and often shooting pain in the affected leg that radiates below the knee
" |
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Term
| know the physical exam findings in a patient with a normal knee exam |
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Definition
"*Knees are aligned bilaterally with hips (negative for genu varum/valgum)
*The patella and patellar tendon are palpable, non-tender
*No effusions are observed or palpated around the knee joints or in the suprapatellar pouches
*Passive and active flexion and extension of each leg is intact
*Stressing medial and lateral collateral ligaments demonstrates bilateral Mediolateral Stability (upon stressing, there is not much “give”)
*Bilateral Anterior and Posterior Stability are intact (the Lachman’s test and the anterior and posterior drawer tests do not demonstrate significant amount of tibial movement relative to the femur)
*There are no extra sounds, catches, or pain with McMurray’s test (varus/external rotation and valgus/internal rotation stresses to assess for meniscal injury)
" |
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Term
| know the physical exam technique and findings to identify patients with injries to the anterior cruciate ligament of the knee |
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Definition
"Anterior Drawer Test- with knees at 90° flexion, stabilize patient’s foot, place both hands around calf and pull forward, observing tibial plateau movement relative to the patella/femur
~A few degrees of forward movement are normal if equally present on the opposite side
~A significant, unilateral forward jerk which shows the contours of the upper tibia is a positive anterior drawer sign and suggests an ACL tear
Lachman’s Test (more sensitive for ACL assessment)- with patient supine and knees at 20-30° of flexion, place one hand around distal thigh and the other around the proximal calf; pull the hand around the calf forward and push the hand around the thigh backward, observing for tibial plateau movement relative to the patella/femur
~same results as anterior drawer test apply to Lachman’s
" |
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Term
| know the physical exam technique to identify patients with meniscal injuries of the knee |
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Definition
"McMurray Test. If a click is felt or heard at the joint line during flexion and extension of the knee, or if tenderness is noted along the joint line, further assess the meniscus for a posterior tear.
With the patient supine, grasp the heel and flex the knee. Cup your other hand over the knee joint with fingers and thumb along the medial and lateral joint line. From the heel, rotate the lower leg internally and externally. Then push on the lateral side to apply a valgus stress on the medial side of the joint. At the same time, rotate the leg externally and slowly extend it." |
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Term
| know the physical exam technique to identify patients with medial/lateral collateral ligaments of the knee |
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Definition
| Medial collateral ligament (MCL): Abduction Stress Test. With the patient supine and the knee slightly flexed, move the thigh about 30° laterally to the side of the table. Place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle. Push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side (valgus stress). Lateral collateral ligament (LCL): Adduction Stress Test. Now, with the thigh and knee in the same position, change your position so you can place one hand against the medial surface of the knee and the other around the lateral ankle. Push medially against the knee and pull laterally at the ankle to open the knee joint on the lateral side (varus stress). |
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Term
| know the physical exam techniques for evaluation of patients with knee injuries |
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Definition
"Check the alignment and contours of the knees. Observe any atrophy of the quadriceps muscles. Stumbling or pushing the knee into extension with the hand during heel strike suggests quadriceps weakness.
Check the alignment and contours of the knees. Bowlegs (genu varum) and knock- knees (genu valgum) are common; flexion contracture (inability to extend fully) in limb paralysis. Observe any atrophy of the quadriceps muscles.
Look for loss of the normal hollows around the patella, a sign of swelling in the knee joint and suprapatellar pouch; note any other swelling in or around the knee. Swelling over the patella suggests prepatellar bursaitis. Swelling over the tibial tubercle suggests infrapatellar or, if more medial, pes anserine bursitis.
Tenderness over the tendon or inability to extend the leg suggests a partial or complete tear of the patellar tendon.
Pain and crepitus suggest roughening of the patellar undersurface that articulates with the femur. Similar pain may occur with climbing stairs or getting up from a chair.
Pain with patellar movement during quadriceps contraction suggests chondromalacia, or degenerative patella.
MCL tenderness after injury is suspicious for an MCL tear. (The LCL is less subject to injury.)
Tenderness from tears following injury are more common in the medial than in the lateral meniscus.
Bony ridges along the joint margins may be felt in osteoarthritis.
Swelling above and adjacent to the patella suggests synovial thickening or effusion in the knee joint.
Thickening, bogginess, or warmth in these areas indicates synovitis or nontender effusions from osteoarthritis.
Prepatellar bursitis (“housemaid’s knee”) from excessive kneeling. Anserine bursitis from running, valgus knee deformity, fibromyalgias, osteoarthritis. A popliteal or “baker’s” cyst from distention of the gastrocnemius semimembranosus bursa.
A fluid wave or bulge on the medial side between the patella and the femur is considered a positive bulge sign consistent with an effusion." |
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Term
| know the physical exam findings in patients with genu valus and genu varus abnormalities |
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Definition
"Bowlegs (genu varum) and knock- knees (genu valgum) are common.
Severe bowing of the legs (genu varum) may still be physiologic bowing and will spontaneously resolve. Extreme bowing or unilateral bowing may be due to pathologic causes such as rickets or tibia vara (Blount’s disease)." |
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Term
| know the physical exam findings and significance of a Baker's cyst |
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Definition
| On the posterior surface, with the leg extended, check the medial aspect of the popliteal fossa. A popliteal or “baker’s” cyst from distention of the gastrocnemius semimembranosus bursa. Although an infrequent occurrence, a Baker's cyst can compress vascular structures and cause leg edema and a true DVT. |
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Term
| know the function and innervations of the gastrocnemius, peroneus longus, tibialis anterior, tibialis posterior, peroneus tertius |
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Definition
"Gastrocnemius: largest and most superficial of the calf muscles
**Function = plantar flexing the foot at the ankle joint and flexing the leg at the knee joint (involved in walking, running, standing, and jumping)
*Innervation = Tibial nerve
Peroneus Longus: superficial muscle in lateral compartment of the leg
*Function = eversion; plantarflexion of ankle
*Innervation = Superficial peroneal (fibular) nerve
Tibialis Anterior : lateral side of the tibia ; in anterior compartment
*Function = dorsiflex and invert the foot
*Innvervation = deep peroneal (fibular) nerve
Tibialis Posterior: most central of all leg muscles; in posterior compartment
*Function = key stabilizing muscle of lower leg; also contracts to produce inversion of the foot and assists in the plantar flexion of the foot at the ankle.
*Innervation = tibial nerve
Peroneus tertius: anterior compartment
*Function = weak dorsiflexion of the ankle joint and to evert the foot at the ankle joint
*Innervation = deep peroneal (fibular) nerve |
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Term
| know the physical exam findings in a ptient with a normal ankle/foot exam |
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Definition
"Inspection: observe all surfaces; there should not be any deformities, nodules, or swellings, and any calluses or corns
Palpation: *palpate anterior aspect of ankle joint--there should be no bogginess, swelling or tenderness;*feel along achilles tendon: there should be no nodules or tenderness; *heel (especially posterior and inferior calcaneus and plantar fascia)- should have no tenderness; *metatarsophalangeal joints: palpate and compress- no tenderness
Range of Motion: flexion and extension at the ankle (tibiotalar) joint and, in the foot, inversion and eversion at the subtalar and transverse tarsal joints-- should have no pain
(Bates 517-519)" |
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Term
| know the physical exam findings in patients with hallux valgus and hallus varus |
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Definition
"*Hallux Valgus: great toe is abnormally abducted in relationship to the first metatarsal, which itself is deviated medially. The head of the first metatarsal may enlarge on its medial side, and a bursa may form at the pressure point. This bursa may become inflamed. (bates 532)
*Hallux Varus: deformity of the great toe joint where the hallux is deviated medially (towards the midline of the body) away from the first metatarsal bone. The hallux usually moves in the transverse plane." |
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Term
| know the physical exam techniques for the evaluation of patient with ankle injuries |
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Definition
"General principles when assessing joint injury:
* Inspection for joint symmetry, alignment, bony deformities
* Inspection and palpation of surrounding tissues for skin changes, nodules,muscle atrophy, crepitus
* Range of motion and maneuvers to test joint function and stability,integrity of ligaments, tendons, bursae, especially if pain or trauma
* Assessment of inflammation or arthritis, especially swelling, warmth, tenderness, redness
See the general techniques for inspection palpation, etc in ""normal"" exam above...more specifics on ROM maneuvers include:
*The Ankle (Tibiotalar) Joint: Dorsiflex and plantar flex the foot at the ankle.
*The Subtalar (Talocalcaneal) Joint. Stabilize the ankle with one hand, grasp the heel with the other, and invert and evert the foot.
*The Transverse Tarsal Joint: Stabilize the heel and invert and evert the forefoot.
*The Metatarsophalangeal joints: flex the toes in relation to the feet.
in general, ligament spains produce maximal pain when ligament is stretched; three lateral ligaments have higher rates of injury" |
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Term
| know the physical exam fidings in patients with pes planus and pes cavus |
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Definition
"1. pes planus = flat feet/fallen arch: most apparent when patient
stands. The longitudinal arch flattens so that the sole
approaches or touches the floor. The normal
concavity on the medial side of the foot becomes
convex. Palpate to check for tenderness at medial malleolus. Inspect the shoes for excess wear
on the inner side of the soles and heels.
2. pes cavus = high arch: may have tenderness at metatarsals (increased pressure on the ball of foot)
"Extra info: pes planus is due to laxity of the soft tissue structures
Pes Cavus: does not flatten with weight bearing; can be located in the forefoot, midfoot, hindfoot, or a combination of these sites." |
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Term
| know the physical exam findings in patients with scoliosis |
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Definition
"Asymmetry: use visual inspection to check for asymmetry of shoulder blades or gluteal folds, in addition to elevation of one shoulder.
Curvature: Assess for lateral and rotary curvature of the spine
Pelvic tilt: Unequal height of the iliac crests, aka pelvic tilt, suggests unequal lengths of the leg and disappears when a block is put underneath the short leg and foot
Adam's Bend Test: Deformity of the thorax on forward bending: use “Adam’s bend test”- bend forward with knee straight.
(+) if asymmetry of shoulder blades or prominence of
posterior ribs
Right sided prominence most common; also more common in girls |
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Term
| know the physical exam and radiographic findings in patients with ankylosing spondylitis |
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Definition
"Physical Exam Findings:
1. Tenderness over the sacroiliac joint
2. Persistence of lumbar lordosis with forward flexion of the spine
3. limitation of anterior and lateral flexion
4. Decreased spinal mobility with extension (leaning back) and rotation of the spine.
Radiographic Findings:
1. Enhancement or indistinctness of the sacroiliac joint, indicating sacroilitis. bilateral sacroiliac joint erosions and iliac side subchondral sclerosis may be seen
2. Bamboo spine: early erosions of the corners of vertebral bodies and the development of syndesmophytes, lead to fusion of the vertebral spine
3. Fractures in the thoracolumbar and cervicothoracic junctions
4. enthesopathy (inflammation where ligaments, tendons, and joint capsules attach to bone) appears as erosions at the sites of attachments. Lesions typically develop bilaterally (on both sides) and are symmetric in distribution. Enthesopathic changes are particularly prominent around the pelvis.
5. hip involvement is generally bilateral and symmetric, with uniform joint space narrowing,
6. hands are generally involved asymmetrically, with smaller, shallower erosions and marginal periostitis.
"PE Findings: muscle spasm also possible (typical patient is young male)
X-Ray: AS can also affect the lungs (usually years after it does the joints)--might see TB like lesions at top of lungs" |
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Term
| know the physical exam findings in patients in osteoarthritis and rheumatoid arthritis |
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Definition
"Both:
-insidious onset of diffuse swelling of joints and limited ROM
Osteoarthritis
-Hand with bony overgrowths of Heberden’s nodes at DIPs (hard dorsolateral nodules), Bouchard’s nodes at PIPs. MCPs uninvolved
-Mild pain/decreased ROM of hips, knees. Other common locations include knees, hips, hands
(DIPs and PIPs, first carpometacarpal joint), cervical and lumbar spine; also joints previously injured or diseased
-crepitus heard with ROM of involved joints
Rheumatoid Arthritis:
- In rheumatoid arthritis, symmetric tenderness and stiffening, and deformity in the PIP, MCP, and wrist joints, with ulnar deviation
- fusiform or spindle-shaped swelling of the PIPs in acute disease
- chronic swelling and thickening of the MCPs and PIPs in chronic disease.
- Rheumatoid nodules may accompany either the acute or the chronic stage
- MCPs boggy and tender (rare in OA)
- The interosseous muscles atrophy. The fingers may show “swan neck” deformities (i.e., hyperextension of the proximal interphalangeal joints withfixed flexion of the distal interphalangeal joints). Less common is a boutonnière deformity (i.e., persistent flexion of the proximal interphalangeal joint with hyperextension of the distalinterphalangeal joint).
- Bilateral subacute swelling of the wrist is especially indicative of RA
- Other common locations include feet (metatarsophalangeal joints), knees, elbows, ankles
- A popliteal or “baker’s” cyst from distention of the gastrocnemius semimembranosus bursa
"OA: bony ridges along joint margins may be also be felt in involved joints; thickening, bogginess or warmth in joint is also seen with OA (indicates synovitis); ""additive"" pattern of spread (only one joint may be involved, however)
Helpful Case example from Bates for OA:
“Good range of motion in all joints. Hand with degenerative changes of Heberden’s nodes at the distal interphalangeal joints, Bouchard’s nodes at proximal interphalangeal joints. Mild pain with flexion, extension, and rotation of both hips. Good range of motion in the knees, with moderate crepitus; no effusion but boggy synovium and osteophytes along the tibiofemoral joint line bilaterally. Both feet with hallux valgus at the first metatarsophalangeal joints.”
RA: pattern in ""symmetrically additive"" ; stiffness lasts >30 minutes ; more generalized/systemic symptoms are also common ; may also cause tenderness of the intervertebral joints; tenderness on compression of the metatarsophalangeal joints is an early sign of RA" |
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