The Musculoskeletal Examination Flashcards
(31 cards)
What are the 9 steps (in the correct order) to be followed during a musculoskeletal examination?
1 - Assess blood pressure
2 - ± Clinical examinations (e.g. neurological examination, cardiovascular examination)
3 - Observation and regional screening examination
4 - Active range of motion
5 - Passive range of motion
6 - Joint play / segmental definition
7 - ± Resisted isometric muscle testing
8 - Palpation of musculoskeletal structures
9 - ± Orthopaedic and musculoskeletal testing
Why are clinical examinations performed during a musculoskeletal examination?
Provide examples of clinical examinations of the lower limb.
To:
- determine if treatment is contraindicated
- determine if referral is necessary
- provide baseline for monitoring aspects of patient’s presenting complaint
E.g. Extremity neurological Extremity vascular Cranial nerve Cardiovascular Respiratory Abdominal
Identify the 10 steps to be followed (in the correct order) when performing an observation, regional and functional screening of the lower limb.
1 - Observation (e.g. swelling, redness, bruising) 2 - Functional movements/ADLs 3 - Gait 4 - Posture 5 - Cervical spine motion 6 - Upper extremity screen 7 - Lumbar / Thoracic motion 8 - Thoracic cage 9 - Pelvis 10 - Lower extremity screen
What are the 6 characteristics of skin to palpate and how are they tested?
1 - temperature (dorsal side of hand)
2 - thickness (roll between fingers)
3 - drag (lightly drag finger pads)
4 - vitality (gently pinch skin and watch recoil)
5 - roughness/smoothness (lightly brush fingers along skin surface)
6 - mobility (circles on superficial tissues)
What are the normal degrees of motion for hip mobility?
Flexion - 120-130 degrees
Extension - 15-20 degrees
Abduction - 40-45 degrees
Adduction - 25-30 degrees
Internal Rotation - (at 0 and 90 degrees flexion) 25-35 degrees
External Rotation - (at 0 and 90 degrees flexion) 45 degrees
What barriers are being tested during AROM and PROM? Define these barriers.
AROM - limited by physiological barrier (the normal ROM a joint moves through during everyday life)
PROM - limited by elastic barrier; point of end feel of a movement (i.e. where some resistance to movement is first felt)
Anatomical barrier - end range; ROM is limited by bone contours/ligaments within an articulation (exceeding the anatomical barrier may cause damage to tissues e.g. fracture)
Define joint play.
What structures are tested during joint play? What are you looking for when testing joint play?
A movement that is essential for normal joint functioning, that the patient cannot perform themselves.
Tests all joint structures - e.g. capsule, ligaments, joint surfaces
Identifies any pain or change in movement quality
What 3 movements of joint play are performed at the hip? Demonstrate how these are performed.
1 - circumduction
2 - traction
3 - compression
Define resisted isometric testing.
Why is resisted isometric testing performed?
The practitioner provides a force to counter the patient’s movement, however, no change in joint angle or muscle length occurs during muscle activation.
Performed with the purpose of reproducing pain/similar symptoms by applying stress to muscle belly/surrounding connective tissues/tendon/musculotendinous junction
How is muscular strength graded during R.I.T?
0 - zero = no evidence of muscle contraction
1 - trace = slight muscle contraction; no evidence of joint motion
2 - poor = complete ROM with assistance and gravity eliminated
3 - fair = active ROM = full ROM against gravity with no resistance
4 - good = full ROM against gravity with some resistance
5 - normal = full ROM against gravity with full resistance
How long should a resisted muscle test be held for? How many reps? What position should the joint be placed in?
Resistance should be applied for at least 5 seconds.
2-5 repetitions are necessary.
The joint should be placed in mid-range.
During resisted isometric testing of the hip, what muscles (and nerve roots) are activated performing the following movements: Flexion Abduction Adduction External rotation Internal rotation Extension
Flexion = L1-4
- iliopsoas
- rectus fem.
Abduction = L4-S2
- gluteus med/min/max
- TFL
Adduction = L2-4
- adductors
Ext. rot. = L5-S2
- glute max
- deep hip ERs
Int. rot. = L2-S1
- adductors
- ant glute med/min
Extension = L5-S2
- glute max
- hamstring muscle group
During palpation, what are we looking for?
Reproduction of pain/symptoms, tissue texture change (change in temp/swelling/redness) that may be associated with acute injury or inflammation.
What is an orthopaedic test?
A biomedical stress test designed to place functional stress on isolated tissue structures believed to be responsible for patient’s pain or dysfunction. Aims to reproduce symptoms in order to assist with accurate diagnosis.
What is the difference of sensitivity and specificity in orthopaedic testing?
Sensitivity = probability of patient having the condition after receiving a positive test result
Specificity = probability of patient not having the condition after receiving a negative test result
A perfect test would have 100% sensitivity and 100% specificity.
Where would a patient feel pain with femoroacetabular impingement (FAI)? What are 2 orthopaedic tests for FAI? How are these tests performed and what would be a positive result?
FAI presents as anterior hip/groin pain.
FADDIR test = patient supine, passive flexion to 90 degrees and end range adduction + internal rot. of hip with over-pressure.
Impingement sign test = patient supine, passive flexion to 90 degrees and end range internal rot. Also tests for labral tear.
+ive result for both tests = pain due to femur abutting acetabular rim/tear
When would you suspect a femoral fracture? What orthopaedic test is suitable for a traumatic/acute, radiologically occult hip fracture? How is this test performed? What is a +/- result for this test?
Patient presents with acute hip pain, mostly after a trauma.
Patellar-pubic percussion test = patient supine, stethoscope over lat. pubic tubercle whilst tapping patellar on same side.
-ive result = sharp, distinct sound
+tive result = not sharp, indistinct/fuzzy
When would you suspect a hip tendinopathy? What are 3 tests for osteoarthritis/tendinopathy of the hip joint? How are these performed? What is a +/- result for these tests?
Patient reports lateral hip pain.
Trendelenberg test = patient stands on one leg, practitioner monitors hip levels during single-legged stance
+ result = pelvis drops away from stance leg indicating gluteus med weakness and/or OA pain and/or gluteal tendinopathy.
FABER/Patrick’s test = patient supine with one knee bent so foot is placed above knee of resting (straight) leg. Practitioner presses down on iliac crest and medial aspect of bent knee.
+ result = pain or loss of ROM; may indicate OA, labral tear or psoas spasm
Resisted hip abduction test
What orthopaedic test is suitable for reported pubic and adductor-related groin pain (osteitis pubis)? What is the sensitivity/specificity of this test? How is this test performed? What is a +/- result for this test?
How can this test be used as a screening tool?
Adductor squeeze test.
Sensitivity = 43% Specificity = 91%
Patient supine with hips at 45 degrees and knees bent so feet are planted. Patient squeezes knees together against practitioners closed fist, slowly building force.
+ result = pain, weakness, resistance to movement; may indicate presence of or risk of osteitis pubis.
Can be used as a screening/rehab tool
- tested with hips at 0, 45, 90 degrees
- use a sphygmomanometer/dynamometer
- test 1-2 times per week at same time
- look for loss in adductor strength >15%
- look for strength gains without pain
- return to sport when strength returns to baseline
List all active movements (AROM) to be tested at the hip joint. Demonstrate how these are to be performed.
Flexion (supine and 90 degrees knee flexion)
Extension (prone and 90 degrees knee flexion)
Abduction (supine and practitioner supporting pelvis)
Adduction (supine and patient cradling opposite leg)
Internal rotation (at zero and 90 degrees hip flexion; practitioner cradles patellar at 90)
External rotation (at zero and 90 degrees hip flexion; practitioner cradles the patellar at 90)
List all passive movements (PROM) to be tested at the hip joint. Demonstrate how these are performed.
Same as AROM
Flexion (supine and 90 degrees knee flexion)
Extension (prone and 90 degrees knee flexion)
Abduction (supine and practitioner supporting pelvis)
Adduction (supine and patient cradling opposite leg)
Internal rotation (at zero and 90 degrees hip flexion; practitioner cradles patellar at 90)
External rotation (at zero and 90 degrees hip flexion; practitioner cradles the patellar at 90)
List all joint play movements to be tested at the hip joint.
Traction (supine, foot planted, practitioner seated on foot, fingers interlocked and pull GH joint downwards)
Compression (supine, hip at 90 degrees, hand on lateral hip and around knee, press down towards table)
Circumduction (supine, practitioner grasps knee and has chest against patient’s shin, move in circles)
List all resisted isometric movements to be tested at the hip joint.
Flexion (supine, leg supported with hip in mid-range, practitioner hand on calf and quad)
Extension (same as flexion but practitioner hand on calf and hamstring)
Internal rotation (at zero degrees; same as extension; at 90 degrees swap hamstring hand to over top of knee)
External rotation (at zero degrees; same as extension; at 90 degrees swap hamstring hand to top of knee)
Adduction (same as extension, but with hamstring hand more medial)
Abduction (same as extension, but with hamstring hand more lateral)
Also need to test: Knee extension (supine, practitioner arm goes under patient leg and rests over quad of relaxed leg; patient working leg's heel can rest on table; practitioner resisting hand over distal shin) Knee flexion (same as knee extension, but swap shin hand to distal calf and lift patient foot off table)
When performing the observation, regional and functional screening component of a musculoskeletal examination, what are some good e.g’s of ADLs?
Getting in/out of bed, putting on shoes, walking up/down stairs.
