Musculoskeletal system: History & examination
Mr. Harish Kurup
Consultant in Orthopaedics
PilgrimHospital, Boston
1. Spine
History
Back pain: where(leg versus back),radiation,when,type,nocturnal pain,aggravating and relievingfactors, increase with cough or sneeze
Othersymptoms: stiffness,deformity,numbness,weakness,bladder or bowel symptoms
Function: walking,limp,supports,distance, stairs, symptom change when going up or down slopes (canal stenosis)
Past history: treatment,injury,surgery,similar episodes
Examination
Standing
Look: shoes,sticks,spine,scars,waist, abnormal hair,deformity (scoliosis, kyphosis,kyphos,and lordosis)
Feel: Limb lengths,pelvic obliquity, step on palpating spine ( spondylolisthesis)
Move: Spine flexion: Distance from hands to floor or Schober’s test.
Spine extension:hands sliding down thigh
Lateral flexion, rotation
Supine
Look: asymmetry,wasting,deformity, scars
Feel: pulses
Move: Straight leg raising (SLR) – leg passively raised, less than 45 degrees suggestive of disc prolapse, crossed-SLR(pain felt on opposite side)
Neurology: sensation,power,tone,coordination,abdominal reflex,tendon reflex
By Side
Femoral stretch test: For high lumbar disc prolapses
Prone
Look:bony tendernesssteps, soft tissue
Move: hip internal and external rotation and hip extension power
Waddel signs suggestive of non-organic back pain
Tenderness: superficial or non anatomic
Simulation tests: axial load & pelvic rotation
Distraction tests: SLR with patient seated normal
Non anatomical distribution of neurological findings
Over reaction
2. Hip
History
Pain: where (groin suggestive of hip joint per se, buttock suggestive of lower back pathology or lateral side suggestive of trochanteric bursitis), radiation,when,type, nocturnal,start up pain in loose hip replacements
Other symptoms:stiffness,deformity,give way,locking (loose body)
Function:walkingdistance,limp,supports,stairs,socks
Past history:treatment,injury,surgery,similar episodes
Examination
Standing
Look:shoes,sticks,spine,scars,waist,and deformity
Feel: Limb length discrepancy, Trendelenberg test
Move:spine,gait
Supine
Look: asymmetry,wasting,deformity
Feel: pulses & crepitus
Move: Thomas' test for flexion deformity,flexion,extension,abduction,adduction,internal rotation,external rotation
Neurovascular examination
By the Side
Gluteus medius power
3. Knee
History
Pain:where,radiation,type,when, night pain is suggestive of arthritis
Other symptoms:locking,swelling,giveway,stiffness,deformity
Function:walking,limp,support,squat,kneel, stairs
Past history:treatment,injury,surgery,similar episodes
Examination
Standing
Look:spine,scars,swelling,deformity,wasting,and redness
Move: gait,squatting (pain on joint line suggestive of meniscal tear)
Supine
Look:swelling,wasting,deformity,fixed flexion deformity
Feel:pulses, Look for effusion (Patellar tap),temperature,posteriorlyfor baker’s cyst, tenderness along joint line is suggestive of meniscal tear or arthritis.
Move:crepitation,extension,flexion, quadriceps power
Ligaments:
Varus/ valgus testing: for medial and lateral collateral ligaments.
Lachmann or anterior drawer for ACL
Posterior drawer test for PCL
Menisci:McMurray’s test (for meniscal Tears) – joint line tenderness is as reliable as this test
Distal neurovascular status: sensation and power in toes, Pedal pulses
4. Foot and Ankle
History
Pain: where,radiation,type,when,aggravating and relieving factors
Other symptoms:stability,giveway,swelling,deformity,cosmesis, stiffness
Function: walking,limp,shoes,sticks,sports,work
Past history: treatment,injury,surgery,injections,similar episodes
Examination
Standing
Look: shoes,calipers, Look from front,side,back,single toe rise shows tibialis posterior function
Feel: spine
Move: gait,toe walk,heel walk
Supine
Look:sole of footwear(for abnormal wear pattern),dorsal corns (soft & hard), swelling, deformity, redness, scars
Feel: pulses, sole of foot, Metatarsal heads,MTP joints
Move:anklejoint, subtalar joint,midtarsal joint, MTP joint, IP joint
Ligaments:Ankle: AP drawer test
Muscle power: (Tibialis posterior, Tibialis anterior, peroneals, tendoachilles etc.)
5. Shoulder
History
Pain: where,radiation,type,when
Other symptoms: stiffness,deformity,clunk,give way / instability
Function: putting coat on,wash back,bra,toilet,combing hair,feeding, taking things from high shelf, lifting weight,throw,pull,work,sport,recreation
Past history: neck problems,treatment,injury,surgery,similar episodes
Examine neck first
Examination of shoulder
Look: swelling,wasting,deformity,scars,biceps,undressing
Feel: Sternoclavicular joint,clavicle, Acromioclavicular joint,acromion,tuberosities & groove,scapula,rotator cuff,deltoid,biceps tendon
Move: Crepitation, Stabilize scapula to check gleno-humeral movements alone; elevation, abduction, flexion,internal rotation,cross body adduction
Resisted: abduction,abduction at 90,external rotation,Gerber's lift off test
Special tests:
Impingement:passive & active with varying rotation
Biceps:Speed's & Yergason's
Instability: anterior apprehension
Deltoid power, Rotator cuff power, neurovascular status
6. Elbow
History
Pain: where,radiation,type, when
Other symptoms: stiffness,locking,deformity, give way
Function: coat,wash back,bra,toilet,comb,feed,high shelf, lift weight,throw,pull,work,sport,recreation.
Past history:neck,treatment,injury,surgery,similar episodes
Examine Neck and Shoulder
Examination
Look: swelling (olecranon bursa or rheumatoid nodule), wasting, deformity,scars,biceps,undressing
Feel: temperature,nodules,synovial thickening,fluid,tenderness, bony landmarks
Move: crepitus,active & passive ROM (flexion /extension/ pronation /supination)
Ligaments: varus and valgus stress
Power,neurovascular examination
7. Wrist
History
Pain: where,radiation,type, when
Other symptoms: stiffness,deformity,numbness,click,clunk,catch,giveway
Function: back pocket,toilet,eat,comb,rise from chair,dress,pull,throw,work,sport,recreation
Past history:neck,treatment,injury,surgery,similarepisodes
Exam Neck, Shoulder and Elbow first
Examination
Look:swelling,wasting,deformity,scars,redness
Feel:warmth,tenderness,bony landmarks
Move:crepiations,active & passive movements (dorsiflexion, palmarflexion,radial and ulnar deviation, supination and pronation)
Phalens test and Tinel sign for carpal tunnel syndrome
Power (including grip strength) and neurovascular examination
8. Hand
History
Pain: where,type, when
Other symptoms:stiffness,swelling, paresthesia,deformity,weakness
Function:washing,feeding,hygiene, turning taps, opening jars, using keys,pens,buttons
Past history:neck,treatment,injury,surgery,similar episodes
Exam Neck, Shoulder, Elbow and wrist first
Examination
Look:swelling, wasting, deformity, scars
Feel:temperature, nodules, tenderness
Move:crepitus, active & passive movements of individual joints (flexion/extension)
Function: pinch(pen), power (grip stregth), key, large object, hook grip
Power, neurovascular examination