Week 2: MSK examination and history

Question 1

how to start thinking about an MSK examination

Answer 1

• SOCRATES framework
• is the condition acute or chronic
• are the symptoms from the joint or the soft tissue?
• is the symptoms inflammation or non-inflammatory

Question 2

SOCRATES

Answer 2

to establish

• onset
• pattern of affected areas
• aggravating factors eg exercise/rest,
• relieving factors eg NSAIDS/exercise/rest and
• other associated symptoms
• RED FLAG
  
  • SYMPTOMS, swelling, stiffness, fatigue.

Question 3

Are the symptoms from the joint or the soft tissue?

Answer 3

• Is the pain from the joint e.g. arthritis or is it referred pain e.g. pain in the left shoulder may be referred pain from the diaphragm, neck or ischaemic cardiac pain
• Common cause of widespread pain with normal joint examination is fibromyalgia

Question 4

Is the condition cute or chronic: chronic

Answer 4

• >6 weeks= chronic
  
  • May start insidiously and have a variable course with remissions and exacerbations influenced by therapy an other factors

Question 5

Is the condition acute or chronic: acute

Answer 5

• Was the onset associated with a particular event e.g. trauma or infection

Question 6

Main symptoms of MSK conditions are

Answer 6

pain, stiffness and joint swelling

Question 7

presentation of inflammatory

Answer 7

e.g. RA, are associated with prolonged early morning stiffness that eases with activity

Question 8

presentation of non-inflammatory

Answer 8

e.g. OA, are associated with pain more than stiffness, exacerbated by activity

Question 9

Pain history

Answer 9

Site, character, radiation and aggravating and relieving factors

• Site
  
  • Pt may localise pain to a joint or may feel it radiating from an adjacent joint
    
    • E.g. pains in the knee may be felt in the hip or ankle
  • Pain felt due to irritation of nerve will be felt in the distribution of the nerve e.g. sciatica
• Character
  
  • Sharp, deep, achy, burning or stabbing
  • Pain due to pressure on a nerve tends to be numb and tingling
• Aggravating and relieving factors
  
  • Non-inflammatory pain is more directly related to use –. i.e. the more you do the worse it gets
  • Inflammatory pain is present at rest as well as on use and varies from day to day
    
    • Flares up and settles down
    • Tender to touch
    • Worse in the morning
  • Severe bone pain (suggestive of underlying malignancy) is often unremitting and persists through the night, disturbing sleep

Question 10

stiffness history : inflammatory

Answer 10

• Prolonged morning stiffness which is generalised and lasts a few hours
• Duration of stiffness = activity of inflammation
  
  • With inflammatory diseases such as rheumatoid arthritis, where joint destruction occurs over a prolonged period, the inflammatory component may eventually become less active and give way to secondary mechanical pain as a result of the damage. It is therefore sometimes difficult for patients to distinguish between pain and stiffness, so your questions will need to be specific.

Question 11

stiffness history : non-inflammatory

Answer 11

• Localised stiffness e.g. OA, which may be short lasting but can recur after sitting for short periods

Question 12

joint swelling history

Answer 12

• A history of joint swelling, especially if it is intermittent, is normally a good indication of an inflammatory disease process.
  
  • Patients often describe rings becoming tight or a sensation of walking on pebbles.
• There are exceptions however. Nodal osteoarthritis, for example, causes bony, hard and non-tender swelling in the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the fingers.
• Swelling of the knee is also less suggestive of inflammatory disease as it can also occur with trauma and in OA.
• Ankle swelling is a common complaint, but this is more commonly due to oedema than to swelling of the joint.

Question 13

monoarticular

Answer 13

only one joint affected e.g. septic arthritis

Question 14

Oligoarticular

Answer 14

only a few joints affected e.g. psoriatic arthritis

Question 15

polyarticular

Answer 15

many joints e.g. RA

Question 16

axial

Answer 16

spine is predominantly affected e.g. ankylosing spondylitis

Question 17

which joints?

Answer 17

small or large joints affected

symmetrical or asymmetrical

Question 18

example of joint involvement i.e. RA

Answer 18

for example, is a polyarthritis (it affects lots of joints) that tends to be symmetrical (if it affects one joint, it will affect the same joint on the other side), and if it affects one of a group of joints it will often affect them all, for example, the metacarpophalangeal (MCP) joints

Question 19

example of joint involvement i.e. spondyloarthritides (is the name for a family of inflammatory rheumatic diseases that cause arthritis)

Answer 19

such as psoriatic arthritis, are more likely to be asymmetrical and may be associated with inflammatory symptoms, such as early morning stiffness involving the spine.

Question 20

example of joint involvement i.e. osteoarthritis

Answer 20

tends to affect weight-bearing joints and the parts of the spine that move most (lumbar and cervical).

Question 21

other system involvement

Answer 21

• Inflammatory arthritis
  
  • Often involves other systems inc skin eyes, lungs and kidneys
  • General symptoms: malaise, weight loss, mild fevers and night sweat
• Non-inflammatory
  
  • Limited to MSK and not associated with immune activation
• Fatigue and depression common in any arthritis where there is functional loss or chronic pain

Question 22

Impact of condition on patients life

Answer 22

• Ask open ended questions
  
  • Functional issues
  • Difficulty with day to day activities
  • Get patient to describe typical day e.g. washing, dressing etc
• Impact on employment
• Patients needs and aspirations are important to understand
• Ideas concerns expectations

Question 23

with an MSK exam

Answer 23

LOOK FEEL MOVE

Question 24

hand and wrist assessment overview

Answer 24

• LOOK
• FEEL
• MOVEMENTS
  
  • active
  • pass
• Neurovascular assessment
• Special tests

Question 25

what does RASH stand for

Answer 25

rash/ erythema

atrophy

swelling/scars

hyperaemia

Question 26

Hand and wrist exam: LOOK

Answer 26

• RASH
  
  • Rash
  • Atrophy
  • Swelling/ scars
  • Hyperaemia
• Start at dorsum of the hands
  
  • Nail plates
    
    • Pitting, onycholysis
  • DIP
    
    • Nodes / swellings
  • PIP
    
    • Nodes/swellings
  • MJP
  • Wrists
    
    • Carpal tunnel surgery
• Palms
  
  • Look for thenar wasting
  • Hyperaemia e.g. alcoholism
• Elbow à rheumatoid nodules and psoriasis

Question 27

hand and wrist exam: FEEL

Answer 27

• Using your thumb and index, feel each of the joints in the hand whilst looking at the patients face
• MCP test- squeeze enough to blanch
• Wrist squeeze
• Elbow squeeze
• Ask patient to make a fistà mountain signs

Question 28

hand and wrist exam: MOVE

Answer 28

Movement

• Active movements
  
  • Make fist
  • Fan-out
  • Flex and extend at risk
  • Rotate from wrist
  • Bend elbows
• Passive movements- copy movements done in active
• function of the hands

Question 29

Function of the hands

Answer 29

1. Grip- squeeze finger tight
2. Write name with both hands
3. Pick a coin up with both hands
4. Pinch against each finger with thumb

Question 30

hand and wrist exam: neurovascular assessment

Answer 30

• Radial pulse (rate and character)
• Sensory- light touch
  
  • Radial- outer border of thumb
  • Ulnar- outer border of little finger
  • Median – outer border of the index finger
• Motor

Question 31

special tests

Answer 31

Tinels test

Phalens test

Question 32

Tinels test

Answer 32

tap on carpal tunnel- check for pins and needles

Question 33

Phalens test

Answer 33

• Downwards prayer signs à parasthesisa in lateral 3.5 digits

Question 34

Elbow exam overview

Answer 34

LOOK

FEEL

MOVE

Function

Question 35

elbow exam LOOK

Answer 35

• Look from the front for the carrying angle, and from the side for flexion deformity
• RASH
  
  • Rashes
  • Muscle wasting
  • Scars
  • Rheumatoid nodules
  • Psoriatic plaques
  • Swellings of the olecranon bursa

Question 36

elbow exam FEEL

Answer 36

• Using the back of your hand, feel the temp across the joint and the forearm
• Hold the forearm with one hand and, with the elbow flexed to 90°, palpate the elbow, feeling the head of the radius and the joint line with your thumb. If there is swelling, is it fluctuant? Synovitis is usually felt as a fullness between the olecranon and the lateral epicondyle.
• Palpate the medial and lateral epicondyles (for golfer’s and tennis elbow respectively) and the olecranon process for tenderness and evidence of bursitis.

Question 37

elbow exam MOVE

Answer 37

• Does the elbow extend fully and flex fully? Assess both actively and passively and compare one side with the other. If there is limitation, note how severe it is.
• Assess pronation and supination, both actively and passively, feeling for crepitus.

Question 38

elbow exam function

Answer 38

An important function of the elbow is to allow the hand to reach the mouth. Other functionally important movements (such as hands behind head) will have been assessed during the screening examination (GALS).

Question 39

shoulder exam overview

Answer 39

LOOK

FEEL

MOVE

FUNCTIOn

Question 40

shoulder exam LOOK

Answer 40

• RASH
  With the shoulder fully exposed, inspect the patient in stance from the front, from the side and from behind, checking for symmetry, posture, muscle wasting and scars.

Question 41

shoulder exam fEEL

Answer 41

• Assess the temperature over the front of the shoulder (the glenohumeral joint).
• Palpate the bony landmarks for tenderness, starting at the sternoclavicular joint, then the clavicle, acromioclavicular joint, acromion process and around the scapula.
• Palpate the glenohumeral joint line – anterior and posterior.
• Palpate the muscle bulk of the supraspinatus, infraspinatus and deltoid muscles.

Question 42

shoulder exam MOVE

Answer 42

• Ask the patient to put their hands behind their head to assess external rotation, and then behind their back to assess internal rotation, comparing one side with the other. If there is a restriction in the latter movement, describe how far the patient can reach – for example, to the lumbar, lower thoracic or mid-thoracic level.
• With the elbow flexed at 90° and tucked into the patient’s side, assess external rotation of the shoulder. Loss of external rotation may indicate adhesive capsulitis (‘frozen shoulder’) or other glenohumeral joint problems.
• Ask the patient to raise their arms behind them and to the front. Assess flexion and extension.
• Ask the patient to abduct the arm to assess for a painful arc (between 10° and 120°) (see image below). Can you passively take the arm further? Be sure to assess abduction from behind the patient and observe scapular movement. Restricted glenohumeral movement can be compensated for by scapular/thoracic movements.

Question 43

shoulder exam function

Answer 43

• Function of the shoulder includes getting the hands behind the head and back. This is important in washing, toileting and other selfcare. If this has not been assessed during the screening examination, it should be done now.

Question 44

spine examination overview

Answer 44

LOOK

FEEL

MOVE

function

Question 45

spine exam LOOK

Answer 45

• Observe the patient standing. Look initially from behind the patient for any obvious muscle wasting, asymmetry, or scoliosis of the spine.
• Look from the side for normal cervical lordosis, thoracic kyphosis, and lumbar lordosis.

Question 46

spine exam FEEL

Answer 46

• Feel down the spinal processes from the top of the neck to the sacrum and over the sacroiliac joints for alignment and tenderness.

Palpate the paraspinal muscles for tenderness

Question 47

spine exam MOVE

Answer 47

• Assess lumbar flexion and extension by placing two or three fingers over the lumbar spine. Ask the patient to bend to touch their toes. Your fingers should move apart during flexion and back together during extension (see images below).
• Ask the patient to run each hand in turn down the outside of the adjacent leg to assess lateral flexion of the spine.
• Next, assess the cervical spine movements. Ask the patient to: tilt their head to each side, bringing the ear towards the adjacent shoulder (lateral flexion); turn their head to look over each shoulder (rotation); bring their chin towards their chest (flexion); and tilt their head backwards (extension). As highlighted in the GALS screen, lateral flexion is usually the first movement to be restricted.
• With the patient sitting on the edge of the couch to fix their pelvis and their arms crossed in front of them, assess thoracic rotation (with your hands on the patient’s shoulders to guide the movement) (see image below).
• With the patient lying as flat as possible, perform straight leg raising (see image below). Dorsiflexion of the foot with the leg raised may exacerbate the pain from a nerve root entrapment or irritation such as that caused by a prolapsed intervertebral disc.

Question 48

Hip exam overview

Answer 48

LOOK

FEEL

MOVE

function

Question 49

Hip exam LOOK

Answer 49

• With the patient standing, assess for muscle wasting (gluteal muscle bulk in particular).
• With the patient lying flat and face up, observe the legs, comparing one side with the other – is there an obvious flexion deformity of the hip suggesting osteoarthritis?
• If there is a suggestion of leg length disparity, assess true leg lengths using a tape measure. Measurements are taken from the anterior superior iliac crest to the medial malleolus of the ankle on the same side. Compare the measurements. In a fractured neck of femur, the leg is shortened and externally rotated. There may also be an indication of this on the patient’s footwear with excessive wear on one heel.
• Check for scars overlying the hip.

Question 50

hip exam FEEL

Answer 50

• Palpate over the greater trochanter for tenderness (suggestive of trochanteric bursitis) and in the groin for true hip joint problems.

Question 51

hip exam MOVE

Answer 51

• With the knee flexed at 90°, assess full hip flexion, comparing one side with the other and watching the patient’s face for signs of pain.
• Assess for a fixed flexion deformity of the hip by performing the Thomas test. Keep one hand under the patient’s back to ensure that normal lumbar lordosis is removed. Fully flex one hip and observe the opposite leg (see image below). If it lifts off the couch, then there is a fixed flexion deformity in that hip. (As the pelvis is forced to tilt a normal hip would extend allowing the leg to remain on the couch.)
• With the hip and knee flexed at 90°, assess internal and external rotation of both hips. This is often limited in hip disease and internal rotation is frequently the first movement affected (see GALS screen).
• Assess the hip and proximal (gluteal) muscle strength by performing the Trendelenburg test. This involves the patient alternately standing on each leg alone. In a negative test, the pelvis remains level or even rises. In an abnormal test, the pelvis will dip on the contralateral side (see image below).

Question 52

hip exam function

Answer 52

Ask the patient to walk – look for an antalgic or Trendelenburg gait. An antalgic gait simply means a painful gait, normally resulting in a limp. A Trendelenburg gait results from proximal muscle weakness and commonly results in a ‘waddling’ walk.

gluteus medius and gluteus minimus muscles

Question 53

knee exam overview

Answer 53

LOOK

FEEL

MOVE

function

Question 54

knee exam LOOK

Answer 54

• Look from the end of the couch with the patients leg straight, compare each knee to each other for symmetry and alignment
• RASH
  
  • Rashes suggesting psoriasis
  • Atrophy (muscle)
  • Scars/swelling
  • Hyperaemia/redness
• Look for valgus deformity (where the knee is medially deviated) and for varus deformity (where the leg below the knee is deviated laterally)

Question 55

knee exam FEEL

Answer 55

• Using the back of your hands, feel the skin temp, starting with the mid thigh and comparing it to the temp over the knee. Compare each knee to eachother
• Palpate for tenderness along the borders of the patella
• With the knee flexed, palpate for tenderness and swelling along the joint line from the femoral condyles to the inferior poles of the patella, then down the inferior patella tendon to the tibial tuberosity
• Feel behind knee for popliteal cyst (backers cysts)
• Assess for effusion by performing a patellar tap

Question 56

knee exam MOVE

Answer 56

• Ask patient to flex the knee as far as possible to assess active movement
• Then assess passive movement. This is done by placing one hand on the knee and flexing the knee as far as possible , noting the range of movement. Assess for full flexion and extension of the knees, comparing one to the other
• With the knee flexed, check the stability of the knee ligaments
• Perform an anterior draw test
  
  • Place both hands round the upper tibia, with your thumbs on the tibial tuberosity and index finger tucked under the hamstrings to make sure these are relaxed.
  • Stabilise the lower tibia with your forearm and gently pull the upper tibia forward.
  • In a relaxed, normal patient there is normally a small degree of movement
  • More significant movement suggest anterior cruciate ligament laxity

Question 57

knee exam function

Answer 57

Function

Ask the patient to stand and then walk a few steps, looking again for a varus or valgus deformity

(vaLgus- distal part more lateral)

Question 58

ankle and foot overview

Answer 58

LOOK

FEEL

MOVE

function

Question 59

ankle and foot exam LOOK

Answer 59

With the patient sitting on the couch, their feet overhanging the end of it:

• Observe the feet, comparing one with the other for symmetry.
• Look specifically at the forefoot for nail changes or skin rashes, such as psoriasis.
• Look for alignment of the toes, evidence of hallux valgus of the big toe or subluxation (partial dislocation) of the joints.
• Look for clawing of the toes, joint swelling and callus formation which typically occurs over the metatarsophalangeal joints on the plantar aspect and over the dorsum and/or apex of the toes.
• Look at the underside or plantar surface for callus formation.
• Look at the patient’s footwear. Check for abnormal or asymmetrical wearing of the sole or upper, for evidence of poor fit or the presence of special insoles.

With the patient weight-bearing:

• Look again at the forefoot for toe alignment and whether they are in contact with the ground.
• Look at the midfoot for foot arch position (a low arch profile in a patient with normal joint movement should resolve when standing on tip toes).
• From behind, look at the hindfoot for Achilles tendon thickening or swelling.
• Look for normal alignment of the hindfoot (see image below). Disease of the ankle or subtalar joint may lead to a varus or valgus deformity.

Question 60

ankle and foot exam FEEL

Answer 60

• Assess the temperature over the forefoot, midfoot and ankle.
• Check for the presence of a peripheral pulse palpating the dorsalis pedis on the dorsum of the foot.
• Gently squeeze across the MTP joints, watching the patient’s face for signs of pain or discomfort.
• Palpate the midfoot, the ankle and subtalar joints for tenderness.

Question 61

ankle and foot exam MOVE

Answer 61

• Assess, both actively and passively, movements of inversion and eversion at the subtalar joint, plus dorsi- and plantar flexion at the big toe and ankle joint checking for any restrictions and/or crepitus.
• Movement of the mid-tarsal joints can also be performed by fixing the heel with one hand and, with the other hand, passively inverting and everting the forefoot.

Question 62

ankle and foot exam function

Answer 62

• If not already done, assess the patient’s gait, watching for the normal cycle of heel strike, stance, and toe-off, speed of walking and turning.

Question 63

what is GALS?

Answer 63

What is GALS?

The GALS screen is used to identify significant musculoskeletal problems.

The mnemonic stands for:

• Gait
• Arms
• Legs
• Spine

It involves some ‘screening’ questions and examinations which test the composite function of different joints. It is often used to identify problems that require more focused assessment: if you identify a problem with a particular joint, this would prompt more detailed assessment.

Initial assessment

• Do you have any pain, swelling or stiffness in your muscles, joints or back?
• Can you dress yourself completely without any difficulty?
  
  • Upper limb function
• Can you walk up and down stairs without any difficulty?
  
  • Focuses on lower limb function