Immersion: General Approach Video

Immersion: Lumbar Spine Video

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. Please watch this video overview – we’ll practice the low back exam in class to cement the approach to the MSK exam.

Term 2: 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.

Term 2: Cervical Spine

Inspection

Inspect the neck and shoulders posteriorly, observing for symmetry of shoulder height and musculature, especially the trapezius.

Palpation

Palpate rom the occipital protuberance to C7, observing for pain or tenderness of the spinal column or paraspinous muscles.

Range of motion:

Assess active range of motion

• Flexion (normal is 80 to 90 degrees)
• Extension (normal is 70 degrees)
• Lateral rotation (normal is 90 degrees)
• Side bending (normal is 20 to 40 degrees)

Strength and neurovascular testing:

Cervical radiculopathy can affect one or more levels of the cervical spine, with characteristic patterns of weakness, numbness and reflex changes based on the levels that are affected.

To assess for compression of nerve roots or spinal cord, test

• Strength: Abduction of the shoulder, flexion and extension of the elbow, flexion and extension of the wrist, flexion, abduction and adduction of the fingers.
• Reflexes: Biceps, triceps, and brachioradialis
• Sensation: Key sensor points below

Spurling’s test. If you are concerned about cervical radiculopathy, perform Spurling’s Test The patient’s neck is extended and laterally rotated slightly, then an axial load is placed on the head by the examiner.Pain, numbness or tingling recreated in the upper extremity is considered a positive test and supports a diagnosis of a cervical radiculopathy

Term 2: Shoulder Benchmarks

Inspection

Identify each of the following landmarks, moving from anterior to lateral to posterior shoulder.

Right Shoulder– Anterior view	Right Shoulder– Lateral view	Right Shoulder– Posterior view

Palpation

Palpate the shoulder systematically, starting with the sternoclavicular joint and moving systematically, from anterior to lateral to posterior.

• • Sternoclavicular joint
  • Clavicle
  • Acromioclavicular (AC) joint
  • Biceps tendon in the bicipital groove
  • Coracoid process is the origin of the short head of the biceps
  • Subacromial space and rotator cuff:
    • supraspinatus tendon lies just below the anterior lateral acromion
    • infraspinatus tendon lies just below posterolateral acromion
    • teres minor lies just inferior to the infraspinatus
    • subscapularis insertion lies just lateral to coracoid at the anterior shoulder
  • Scapula:
    • spine of the scapula  is the origin of the infraspinatus

Range of motion

Assess active and passive ROM in each plane: flexion, abduction, internal and external rotation.  If range of motion is limited, note whether it is limited by pain or “true” restriction.  Adhesive capsulitis, glenohumeral osteoarthritis and dislocation limit or cause pain with both active and passive ROM.  Injury of muscles or ligaments such as rotator cuff tendonitis affect active more than passive ROM. Increased ROM of the shoulder suggests ligamentous laxity or prior dislocations.

You can also assess the shoulder with simple functional tests.

• Internal rotation and adduction:  Ask your patient to reach up behind the back to touch the highest point on the spine that they can.  This tests internal rotation and adduction. Normal shoulder ROM is to reach up to T10 (count down from T7 at the lower border of the scapula or up from L4 at the level of the iliac crest).
• External rotation and abduction:  Ask your patient to reach as far down behind their head as they can to touch the spine.  This tests external rotation and abduction. Normal shoulder ROM is to reach down to T1 (below C7, the prominent bump at the base of the neck)

Strength testing

With your patient seated, test strength of shoulder flexion, extension, abduction, adduction, internal and external rotation, grading each movement on the 0-5 scale. If you suspect long thoracic nerve injury, you can test subscapularis strength by asking your patient to perform a ‘mini-push up’ against the wall and observing for scapular winging.

Stability & special testing

Targeted testing of rotator cuff muscles

Rotator cuff disorders include tendinitis, tear, subacromial bursitis, and impingement syndromes.  Different examiners prefer different special tests when rotator cuff pathology is suspected. You will practice those with the strongest evidence base in FCM.

The rotator cuff is made up of the 4 ‘SITS’ muscles. Targeted strength testing of these muscles may reveal pain, which suggests tendinitis, or weakness, which supports a rotator cuff tear.

• Supraspinatus: abduction from 0 to 90 degrees
• Infraspinatus: external rotation
• Teres Minor: external rotation
• Subscapularis: internal rotation

Special tests are used to target specific muscles. The empty can test isolates the supraspinatus and the lift off test isolates the subscapularis muscle. Weakness or pain with these maneuvers supports a tear or tendinitis of the targeted muscle.

Special tests for rotator cuff impingement

The rotator cuff tendons occupy a narrow space between the acromion and the head of the humerus. Impingement, or pinching, of the tendons between these two structures is a common cause of shoulder pain. Pain with the Neer or Hawkins/Kennedy test, both of which narrow the space even further, support a diagnosis of rotator cuff impingement, which is usually caused by swelling of the tendons or bursa.

Term 2: Elbow

Inspect: Dorsal, lateral and ventral elbow

Palpate: affected area, observing for tenderness and swelling.

Range of motion: Flexion (140°)​, extension (10°), supination (80°) , p​ronation (80°)

Strength testing: Extension, flexion, supination, pronation

Term 2: Wrist & Hand

Inspect and palpate the dorsal and palmer wrist and hand, focusing on the symptomatic area.

Right wrist and hand – Dorsal view	Right wrist and hand– Palmar view

Range of motion of the wrist:

• Flexion: 75°
• Extension: 75°
• Ulnar deviation: 40°
• Radial deviation: 20°

Range of motion of the hand:

• DIP/PIP Flexion: 90 °
• DIP/PIP Extension: 0°
• MCP Flexion: 90°
• MCP Extension: 5 to -10 °

Stability and Special tests

Stability testing of the ulnar collateral ligament of the thumb.

Each metacarpophalangeal and interphalangeal joint has both ulnar and radial collateral ligaments. The UCL of the thumb is commonly injured (skier’s or gamekeeper’s thumb) which can lead to significant morbidity if not treated properly. To assess UCL stability, hold the thumb flexed 45 degrees towards the palm and apply valgus stress to the proximal phalanx. Compare the degree of laxity and firmness of the endpoint to the opposite side.

Finkelstein’s test for DeQuervain’s tenosynovitis

The thumb is held in patient’s palm and the examiner moves the hand and wrist into ulnar deviation, which stresses the first dorsal compartment of the wrist.

Pain with ulnar deviation is considered a positive test

Tests for Carpal Tunnel Syndrome

Phalen’s test

• Hands are pressed together forcing both wrists into flexion and compressing the carpal tunnel
• Pain, numbness, tingling the distribution of the median nerve indicates a positive test for carpal tunnel syndrome

Tinel’s test

• Examiner uses the thumb to compress the carpal tunnel
• An alternative method is to tap the middle finger repeatedly over the carpal tunnel
• Pain, numbness, tingling the distribution of the median nerve indicates a positive test for carpal tunnel syndrome

MSK Workshop 1. Knowledge Check

Term 2. Lumbar Spine Benchmarks

Key landmarks & structures:

Term 2: Hip Exam

Key Landmarks & structures

Identify each of the anatomic landmarks.

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Inspection

Standing inspection should be performed for the anterior, lateral and posterior hip, noting swelling, erythema, ecchymoses, alignment and muscle bulk.  Then, have the patient walk, observing for antalgia and functional range of motion.

Palpation

Palpate systematically, from the anterior to the lateral to the posterior structures of the hip above, noting any tenderness

Range of motion

Evaluate active and passive ROM.  Normal ROM of the hip:

• Flexion (knee extended): 80-90 degrees
• Flexion (knee flexed): 110-120 degrees
• Extension: 10-20 degrees
• Adduction: 20-30 degrees
• Abduction: 30-50 degrees
• Internal rotation: 20-30 degrees
• External rotation: 40-50 degrees

Strength testing.

With the patient supine test:

• Extension
• Flexion
• Adduction

With the patient in the lateral decubitus position test:

• Abduction
• Internal rotation
• External rotation

Stability and special tests

FABER is an acronym for Flexion, Abduction, External Rotation and tests for pathology of the ipsilateral hip and contralateral SI joint. The patient flexes the leg at the hip and knee and abducts and externally rotates the hip. The examiner applies additional pressure to further externally rotate.

Term 2: Knee Benchmarks

Key landmarks & structures

Identify each of the following anatomic landmarks, which will guide your exam and your documentation.

Right Knee – Anterior views		Right Knee – Posterior view

Inspection

Inspect the knees in the standing position, first anteriorly and then posteriorly, observing leg length and alignment.   Next inspect the knees in the seated or supine position, observing for asymmetry, redness, swelling, bruising or deformity.

Differences in alignment may be described as:

• Varus or genu varum (historically referred to as “bow legs”)
• Valgus or genu valgum (historically referred to as “knock knees”)

Palpation

Systematically palpate the structures of the knee, comparing one side to the other.  Carefully note any warmth, deformity, swelling or tenderness and attempt to identify any structures that are tender.

• Patella, quadriceps tendon and prepatellar bursa
• Proximal tibia (including tibial plateau area, patellar tendon, tibial tuberosity and Gerdy’s tubercle)
• Proximal fibula (including head and neck)
• Medial & lateral femoral epicondyles
• Popliteal fossa
• Joint Line: medial & lateral

Range of Motion

Evaluate active and passive range of motion, comparing the affected to the unaffected knee. If range of motion is limited note the following:

• Is motion limited by pain or “true” restriction?
• Is the end point “soft” or “firm”?

Motion of the patellofemoral joint should also be assessed. This is done passively primarily through medial and lateral motion of the patella.
Make not of the following:

• Amount of motion (see quadrants in image), including restriction of motion.  1-2 quadrants is considered normal.
• Pain
• Apprehension sign (sign of prior dislocation/subluxation of the patella)

Strength testing

With the patient in the seated position, test knee extension and flexion.

Strength testing can also help differentiate some causes of knee pain.

• Hip flexion can help to distinguish between quadriceps muscles that may be causing pain.  Only the rectus femoris crosses both the knee and the hip – pain with hip flexion suggests that it may be causing knee pain.
• Hip adduction can bring out pain localized to the pes anserine.
• The Squat Test, where you ask patients to squat with the goal of reaching the “gluts to the floor,”  tests flexion of the knee as well as pain with compression of the intra-articular structures such as the meniscus.

Hypothesis Driven Physical Exam

Ligamentous injuries

Most ligamentous injuries of the knee will be related to a traumatic event.  They most frequently occur in athletes especially those involved in sports that require sudden changes in direction and speed.  Injuries involving the medial collateral ligament (MCL) and the anterior cruciate ligament (ACL) are the most common.  Patients may complain of hearing a “pop” at the time of injury, swelling, locking (especially if the meniscus is also injured), giving out of the joint or a sense of knee instability.

• MCL injuries occur when knee is struck from the outside (valgus stress)
• LCL injuries occur when knee is struck from the inside (varus stress)
• ACL injuries can occur from a direct blow causing hyperextension or valgus deformation of the knee or from jumping or changing direction and causing rotation and lateral bending (valgus stress) to the knee.
• PCL injuries are the least common isolated ligament injury. Usually due to high-energy trauma such as motor vehicle accident with posteriorly directed force applied to flexed knee “dashboard injury.”  Can also occur in low-energy trauma with direct blow to anterior knee or falling on flexed knee with foot plantar flexed.
• “Terrible triad” involves injury to MCL, ACL and the medial meniscus.

MCL and LCL stability testing

With your patient supine, apply varus and valgus stress to the knee at 0° and 30° of flexion, noting any laxity or pain.  Pain may suggest a ligamentous strain.  Laxity may suggest a tear of the ligament.

ACL and PCL stability testing

Next assess the stability of the anterior and posterior cruciate ligaments.  The two most commonly used tests for the ACL are the anterior drawer and Lachmann’s test. For the PCL, perform the posterior drawer.  For each, note the amount of laxity and the presence or absence of a clear ‘endpoint’.

Meniscal injuries

Meniscal injuries are common.  Acute meniscal tears usually occur from twisting injuries.  Chronic degenerative tears can occur in older individuals with minimal twisting or stress.  Meniscal injuries can occur in isolation or in association with collateral or cruciate ligament injuries/tears.  Depending on the severity of the injury patients may present differently.  Common complaints may include swelling, pain with twisting or pivoting, a sensation of popping, locking (inability to extend the knee fully), catching or the knee “giving out.”

McMurray’s test

This is a fundamental component of the knee exam, performed to evaluate for tears of the medial and lateral meniscus.

• Examiner holds foot in one arm/hand.  The other hand wraps over anterior knee with thumb and pointer/middle finger over joint lines.
• Knee is then run through flexion and extension with internal and external rotation of the tibia
• Positive test is indicated by a palpable clunk. Also note pain as this may indicate a non-displaced meniscal tear
• Pain and clicking in the patellofemoral joint are common and important to distinguish from the medial and lateral joint lines

Assessment for joint effusions

There are many ways to assess for an effusion in the knee joint.  One method is:

• Position the patient supine, with the knee extended.
• Place the thumb and finger of one hand on both sides of the patella.
• With the other hand compress the suprapatellar pouch against the femur, pushing fluid downwards if it is present.
• Feel for fluid with your thumb and finger

Term 2: Ankle and Foot Exam

Although this exam isn’t an FCM benchmark, foot and ankle concerns are common in primary care and emergency departments.  As with any musculoskeletal exam remember the approach of inspection, palpation, range of motion, strength testing and special maneuvers.

The original version of this chapter contained H5P content. You may want to remove or replace this element.

Key landmarks & structures

Inspection

Inspect the foot and ankle, observing carefully for swelling, erythma or ecchymosis. Also note:

• Alignment
• Muscle bulk
• Arch structure
• Appearance of first MTP joint

Palpation

Palpate the above structures systematically, noting any tenderness or swelling.

Range of motion

Tibiotalar Joint:

• Plantarflexion: 0 to -10 degrees
• Dorsiflexion: 30 to 40 degrees

Subtalar Joint

• Inversion: 30 degrees
• Eversion: 20 degrees

First MTP joint

• Flexion: 45 degrees
• Extension: 70 degrees

Strength testing

With the patient seated test:

• Plantar flexion of ankle
• Dorsiflexion of ankle
• Inversion of ankle
• Eversion of ankle

Stability and special tests

Thompson squeeze test

– Tests for the integrity of the Achilles tendon
– Pictures and drawing show two different versions of test
– The foot should rest in slight plantarflexion
– Compare to contralateral side
– Squeeze the gastroc muscles and foot should plantarflex
– Lack of plantarflexion with squeeze suggests Achilles tear

Anterior drawer test

Tests for stability of the ATFL
– One hand placed on tibia, held for stability.
– Opposite hand grips heel and distracts distally
– Note should be made of laxity and presence of clear end point

Lunge test

– Stresses tibiotalar joint and support structures
– Foot/heel kept on the floor
– Knee pushed forward to create dorsiflexion of the ankle
– Note should be made of pain and restricted motion

MSK Workshop 2. Knowledge Check