TDP: 1st Practical (MSK)

What are the 8 steps to performing MSK exams?

• Inspect

• Palpate

• ROM

• Special maneuvers

• Sensation

• Motor tests

• Deep tendon reflexes

• Gait (& Coordination)

  • not included in Upper/Lower Extremity

Inspect the patient’s spine standing up

Look for swelling, deformity, atrophy, muscle spasm, and signs of discomfort (in addition to the following)

Front: Alignment & Symmetry

• Head position

• Shoulders

• Trunk

• Pelvic

• Muscle bulk

Back: Spinal Alignment & Musculature

• Spine

• Shoulder & Scapula

• Pelvic

• Muscle bulk

• Muscle spasm (tightness, contracted)

• Skin & Soft tissue (scars, swelling, deformities)

Side: Posture & Spinal Curvature

• Head posture

• Cervical lordosis

• Thoracic kyphosis

• Lumbar lordosis

• Overall

Palpate and percuss the patient’s spine

Look for warmth, swelling, masses, nodules, or erythema (in addition to the following)

• Spinous processes

  • tenderness, alignment, step-offs, deformity, pain

• Interspinous spaces

  • tenderness, widening, narrowing

• Paravertebral muscles bilaterally

  • tenderness, muscle spasm, hypertonia, asymmetry, or atrophy

• Posterior ribs bilaterally

  • tenderness, asymmetry, deformity, crepitus (popping)

• Sacrum and sacroiliac

  • tenderness, asymmetry, deformity, or pain

Check patient’s ROM of neck and spine

Neck (active > passive if needed)

• Flexion

• Extension

• Rotation

• Side bending

Spinal column (active > passive if needed)

• Flexion

• Extension

• Rotation

• Side bending

Perform the cervical compression test (Spurling)

• Patient: sits, looks over shoulder and up at ceiling

• You: press down on head behind patient

  • ask pain?

Positive test: cervical radiculopathy

Perform the cervical distraction test

• Patient: supine

• You: ask pain?

  • place both hands on the occiput

  • pull

  • ask pain relieved?

Positive test: cervical radiculopathy

Perform the Lhermitte sign/Barber chair phenomenon

• Patient: flex neck down

• You: ask shock sensation (extending down spine and/or limbs)

Positive test: cervical affected (multiple sclerosis, spinal cord compression, radiculopathy)

Perform the Adson test

• Patient: extend elbow

• You: palpate radial pulse

  • while palpating, abduct and laterally rotate

  • ask take deep breath and hold

  • check pulse

Positive test: decreased vigor of pulse; Thoracic Outlet syndrome (compression b/t anterior and middle scalene muscles)

Perform Adam’s forward bend test

• Patient: expose back and stand straight

• You: stand behind at eye level

  • ask slowly bend forward to touch toes

  • inspect any asymmetry

Positive test: rib or paraspinal hump; scoliosis

Perform the straight leg raise test

• Patient: supine

• You: place one hand on ankle and other above knee

  • flex the extended leg

  • ask pain (shooting down leg)

  • dorsiflex and ask pain again

Positive test: sciatica

Perform sitting knee extension test

• Patient: sit at side of bed

  • flex neck (chin to chest)

• You: fix thigh on bed while extending leg with other hand

  • ask pain?

  • dorsiflex and ask pain again

Positive test: sciatica

Inspect the patient’s gait

Ask patient to walk barefoot. Instruct them to 1) walk away, 2) return on tiptoes, 3) away on heels, and 4) return walking heel-to-toe

Inspect from all sides

• Arm swing (symmetrical, hands relaxed, joint position)

• Head and trunk (midline, smooth, vertical excursion of head)

• Pelvis (level, anterior/posterior rotation bilaterally)

• Hip motion (flexion/extension, shifts, lateral excursion from hip)

• Knee (flexion/extension, genu valgus or varus)

• Ankle and foot (plantar/dorsiflexion, alignment/position, calcaneal varus/valgus)

• Overall gait (stride length, frequency)

  • width heel-to-heel (2-4 in)

  • Shift of pelvis

  • Flexion of knee

Inspect the patient’s upper extremities

Ask for all parts of upper extremities to be exposed. Compare both sides.

• Symmetry and positioning (shoulder, arm, elbow, wrist, finger, posture)

• Scapulae and shoulder girdle (asymmetry, positioning, prominence, scapular winging)

  • Arms relaxed at sides and slowly raising/lowering both

  • Wall push-up test:

    • Hands on wall at shoulder height

    • Perform push-up

    • Positive test: 1 scapula protrudes away from chest wall

• Muscle bulk and contour (asymmetry, atrophy, muscle wasting, prominence)

• Skin and soft tissues (scars, lesions, rashes, bruising, discoloration, swelling, edema)

• Joint contours and alignment (swelling, enlargement, deformity, position, prominence)

• Hands and fingers (ulnar, swan neck deformity, boutonniere deformity, mallet finger, trigger finger, or Dupuytren contracture, Janeway or Osler lesions)

• Nails (clubbing, koilonychia, pitting, splinter hemorrhages, Beau lines, Terry nails, Muehrcke lines, paronychia, subungual hematoma)

Palpate the patient’s bony landmarks and joints

For joints, compare both sides. Palpate 1 joint above/below the affected joint.

• Palpate area of concern last. Identify location of max tenderness

While palpating, note: tenderness, swelling, temperature (use back of hand), crepitus (cracking), effusion (fluid buildup), nodules, spasms, and step-offs

Using fingers, identify and assess

• Clavicle

• Acromion

• Scapula

• Humerus

• Medial and lateral epicondyles

• Radius

• Ulna

• Shoulder

• Elbow

• Wrist

• Carpals

• Metacarpals

• Phalanges

Palpate the patient’s muscles and tendons

Compare both sides.

• Palpate area of concern last. Identify location of max tenderness

While palpating, note: tenderness, swelling, temperature (use back of hand), crepitus (cracking), effusion (fluid buildup), nodules, spasms, and step-offs

• and tightness, atrophy, tendon thickening

Using fingers, identify and assess muscles and tendons of

• Shoulder

• Arm

• Forearm

• Wrist

• Hand

Palpate the patient’s soft tissues

Compare both sides.

• Palpate area of concern last. Identify location of max tenderness

While palpating, note: tenderness, swelling, temperature (use back of hand), crepitus (cracking), effusion (fluid buildup), nodules, spasms, and step-offs

• and edema, erythema, cysts

Using fingers, identify and assess

• surrounding soft tissues

Perform range of motion tests on the patient

Active > Passive (if needed)

• Shoulder (flexion, extension, AB/ADduction, I/E rotation)

• Elbow (flexion, extension, supination, pronation)

• Wrist (flexion, extension, ulnar deviation, radial deviation)

• Fingers (flexion, extension, AB/ADduction)

• Thumb (flexion, extension, AB/ADduction, opposition)

Perform subacromial palpation

• You: find acromion (by following spine of scapula)

  • palpate

  • ask pain?

Positive test: inflammation of tendon/bursa

• Pain provocation test

Perform the Neer impingement sign

• You: one hand on scapula, other on forearm

  • internally rotate forearm (thumb down)

  • flex shoulder

  • position hand over head

  • ask pain?

Positive test: Rotator cuff (subacromial impingement or tendinitis)

• Pain provocation test

Perform the Hawkin’s impingement sign

You: elevate arm, and forward flex 90 degrees

• rotate internally (thumb down)

• ask pain?

Positive test: Rotator cuff (subacromial impingement or tendinitis)

• Pain provocation test

Perform the empty can/Jobe’s test

• You: elevate arm, and forward flex 90 degrees

  • internally rotate

  • ask to resist as you press down on arms

  • ask pain or weakness?

Positive test: supraspinatus muscle problem

• Composite test

Perform the drop arm test

• Patient: fully abduct arm at shoulder level

  • lower slowly

Positive test: Arm drops suddenly (supraspinatus muscle tear)

Perform the external rotation resistance test

• Patient: abduct shoulders slightly

  • flex elbows at 90 degrees

  • lateral rotation (thumbs up)

• You: place hands on outside forearm

  • ask push arms out

  • ask pain?

Positive test: Infraspinatus or teres minor problem

• Composite test

Perform the external rotation lag test

• Patient: flex arm 90 degrees

  • palm up

• You: rotate into full external rotation

  • ask to hold it

Positive test: inability (supraspinatus, infraspinatus disorder)

• Strength test

Perform the internal rotation lag test (Gerbers’ lift off test)

• You: place dorsum of hand to their lower back (elbow at 90 degrees)

  • grip wrist and lift hand off back (internal rotation)

  • release hand and ask hold it

Positive test: inability (subscapularis problem)

• strength test

Perform the Apley scratch test

• Patient: touch opposite scapula from above and below

• You: ask pain?

Positive test: shoulder rotation problem (rotator cuff disorder or adhesive capsulitis)

• Pain provocation test

Perform the crossover or crossed body adduction test

• Patient: adduct arm across chest

• You: ask pain?

Positive test: problem with acromioclavicular joint

• Pain provocation test

Perform the shoulder apprehension test or anterior apprehension test

• Patient: supine

• You: abduct arm to 90 degrees

  • flex elbow to 90 degrees

  • one hand to support elbow, and the other with wrist

  • slowly externally rotate humerus

  • any reluctance?

Positive test: problem with anterior shoulder instability

• Apprehension test

Perform the thumb movement (Finkelstein) test

• Patient: grasp thumb against palm

  • adduct wrist

• You: ask pain?

Positive test: de Quervain tenosynovitis

• Pain provocation test

Perform the carpal tunnel tests

• Thumb abduction: pt raise thumb up as you press down

  • Positive test = median nerve (thenar) weakness

• Tinel sign: hold patient’s hand and tap firmly over median nerve

  • Positive test = aching, tingling, numbness (median)

• Phalen sign: hold both wrists and elbows in flexion for 60 sec

  • Positive test = pain, numbness, or tingling (median)

Perform sensation test on patient

• Touch patient’s chest wall to let pt know how it feels = baseline

• Patient’s eyes closed

• Lightly touch extremities and trunk (and immediately compare opposite side)

  • Ask if sensation felt?

  • If sensation feels like baseline?

  • Bilateral sensation the same?

• For any abnormalities, perform a focused exam for those

• Test all/multiple dermatomes

What are you assessing in the muscle groups of upper and lower extremities?

• Bulk (size, contour)

  • atrophy, hypertrophy, asymmetry, fasciculations/fibrillations

• Tone (resistance)

  • patient relaxes

  • hold extremity and move through ROM

  • check resistance (normal, spasticity, rigidity, flaccid)

• Muscle strength

  • 0: no contraction

  • 1: slight

  • 2: complete w/o gravity

  • 3: complete against gravity

  • 4: (3 but with some resistance)

  • 5: (4 but with full resistance)

Perform the deep tendon reflexes

Check biceps (C5/6), brachioradialis (C5/6), triceps, (C6/7), patellar (L2-4), ankle (S1)

Grading

• 4+: hyperactive

• 3+: slightly hyper-reflexive

• 2+: normal

• 1+: lower

• 0: none