Introduction to the Musculoskeletal Exam
The essential approach to examining the musculoskeletal system is the same no matter what joint or limb is being examined. The affected and contralateral side should both be examined carefully, observing for side-to-side differences.
Inspect
- Observe alignment and relative sizes of the areas of interest, at rest and in motion
- Observe any erythema, swelling, ecchymosis, deformity, or skin lesions
Palpate
Use a systematic approach to palpation, assessing the same structures each time you perform a regional exam.
- 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
- Of muscles that move the joint, and in some cases, muscles that move the joint above or below it.
Stability and special tests, as directed by the differential diagnosis
For all orthopedic exams, there are many potential special tests that could be performed. In general, these the sensitivity and specificity of these tests is highly variable based on examiner skill. These may include:
- Joint specific maneuvers to test stability of major structures.
- Hypothesis driven maneuvers to support or argue against diagnoses on your differential.
In Immersion, the lower extremity exam will also include checking for edema and palpation of foot pulses.
Peripheral Circulation & Edema
Note the presence and severity of leg edema
Palpate the following pulses on each side:
- Dorsalis pedis
- Posterior tibialis
Cardinal signs of musculoskeletal disease
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.
Tenderness
Evaluate for tenderness over different anatomical structures including bones, joints, tendons and bursa.
- Tenderness over joint lines may suggest arthritis.
- Tenderness of a bony structure suggests traumatic injury, inflammation, or infection.
- Tenderness of tendon palpation suggests tendinitis. Other signs include pain with resisted motion of the tendon or with passive stretch of the tendon.
- Tenderness at a bursa suggests bursitis.
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 follows for each muscle group tested:
0/5 = No contraction.
1/5 = Visible/palpable muscle contraction but no movement.
2/5 = Movement with gravity eliminated.
3/5 = Movement against gravity only.
4/5 = Movement against gravity with some resistance.
5/5 = Movement against gravity with full resistance.
When weakness is present it is important to consider the cause. Could it be due to “give-way” weakness triggered by pain with strength testing rather than true weakness? When true weakness is present one must consider that it could be due to a tendon, muscle or neurologic problem.
Special Maneuvers
Special maneuvers should be performed dependent upon the area of injury and the clinical scenario. Not every special maneuver is performed every time but rather to support or refute your clinical suspicion.
Example: Lumbar Spine Exam
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.