Immersion MSK
The approach to examining the musculoskeletal system is similar across joints. The affected and contralateral side are inspected and palpated carefully, observing for side-to-side differences. Range of motion and strength testing may be followed by joint-specific exam maneuvers to differentiate between two possible causes of the problem. In FCM, we will introduce a few of these ‘stability and special tests’ but we don’t expect you to master them until you use them routinely in clerkships. Focus on developing a consistent approach to the basics.
Inspection
- Observe alignment and relative sizes of the areas of interest, at rest and in motion
- Observe any erythema, swelling, ecchymosis, deformity, or skin lesions
Palpation
Use a systematic approach to palpation of:
- Joint
- Soft tissue
- Bursae
- Tendons
- Muscles
- Ligaments
- Bony Prominences
Range of motion
- Active range of motion – the patient moves the joint
- Passive range of motion – the examiner moves the joint
Strength testing
- Muscles that move the joint, and in some cases, the joint above or below it.
Stability and special tests as directed by the differential diagnosis
For every joint, there are many stability and special tests that could be performed to differentiate between possible causes of your patient’s problem. Their sensitivity and specificity often varies based on examiner skill and different physicians often prefer and use different tests.
Neurovascular testing
In Immersion, you will apply the general approach to the musculoskeletal exam to the lumbar spine.
In Term 2, you will practice the exam of other joints commonly assessed in primary care. Only the Lumbar Spine, Shoulder and Knee exams are included in the FCM Benchmarks.
Cardinal signs of MSK disease
The cardinal findings of MSK disease may be identified on any regional exam. Inspect and palpate carefully and don’t forget to compare the symptomatic to the contralateral joint.
Swelling: Visible swelling of a joint suggests synovial inflammation or joint effusion. Maneuvers specific to each joint can help to further evaluate for subtle effusions especially in the knee.
Swelling of the surrounding soft tissue could be caused by infection or trauma. Sometimes swelling of these areas can be subtle. Loss of skin wrinkling or joint landmarks can be signs of swelling.
Warmth: Compare the temperature of one joint to the other and to the surrounding muscles. Joints should be cooler than the surrounding muscles. Warmth to palpation of a joint suggests inflammation which could be due to an inflammatory condition or infection.
Atrophy: Localized muscle atrophy suggest prolonged damage to that specific muscle group or the nerve supply.
Tenderness: Evaluate for tenderness over different anatomical structures including bones, joints, tendons and bursa.
- Joint line tenderness may suggest arthritis.
- Bony structure tenderness suggests traumatic injury, inflammation, or infection.
- Tenderness at a bursa suggests bursitis.
- Tenderness of a tendon suggests tendinitis. Pain with passive stretch or resisted motion of the tendon support tendonitis.
Decreased range of motion: Active range of motion refers to the patient moving the joint themselves, while passive range of motion refers to the examiner moving the joint. Intraarticular problems cause pain with both active and passive ROM – it hurts to move an injured joint whether the patient or examiner is moving it. Tendon and muscle problems typically cause more pain with active ROM, when the tendons and muscles are actively engaged in moving the joint.
Decreased ROM can also be caused by stiffness or prolonged disuse of any cause. Increased ROM may be due to joint laxity.
Weakness: It is important to test all muscle groups in the impacted area and compare to other side. Strength testing should be documented as for the neurologic exam.
Immersion MSK Exam: Lumbar Spine
Low back pain is one of the most common reasons for primary care visits and the exam of the back is the most straightforward regional MSK exam. We will practice this exam in Immersion although you do not need to demonstrate it on the Immersion PE checkoff. You will apply this exam in our Back Pain sim in a few weeks. We will re-visit it in the MSK block.
Please watch this video overview – we’ll practice the low back exam in class to cement the approach to the MSK exam.