Examination of the Joints and Extremities

Evelyn O. Salido, MD, FPCP, FPRA

Internal Medicine and RheumatologyJanuary 2009

Objectives in doing MSS PE

To screen for MSS problems among asymptomatic and symptomatic individuals

To determine if complaint in the back or limb is due to a MSS problem

To localize the MSS problem- intra or periarticular

To diagnose

Who should be examined?

Musculoskeletal complaints

Pain

Deformity

Disability (loss of function)

Individuals consulting for other complaints

What should be examined?

Scope of the examination

Back

Upper Extremities

Lower Extremities

Systemic PE

Physical Examination will tell us …

Source of pain Inflammatory or not Pattern and extent of

joint involvement single, few, multiple axial, appendicular distal vs proximal,

small vs large Localized or systemic

Requirements for a good PE

Enough room and light Sufficient exposure of parts to be

examined while considering privacy Relaxed and comfortable patient and

examiner Good working knowledge of anatomy Adequate medical history

Physical ExamMUST REMEMBER!!! Examine each joint, not only the source of

complaint. Assess each joint separately. Perform an orderly exam including the spine,

the upper and lower extremities. Proper positioning- as appropriate to the

examination being done

Maneuvers in the PE

Inspection Palpation Range of motion Measurements

Inspection: still & in motion

Posture Contours Symmetry Deformities Atrophy/hypertrophy Masses or nodules

Swelling Redness Skin lesions Instability Abnormal movements

Posture, Contour, Symmetry

Deformity

Swelling and Redness

Redness, Skin Lesion

Masses & Nodules

Discrepancies e.g. Atrophy

Localized Generalized Document by

measuring limb circumference

Instability

Diseased joints are able to move into abnormal positions

due to joint surface damage or to laxity of ligaments

passive maneuver by examiner observation of active movement during

weightbearing and walking wobbling, “movement” of bones, “giving-way”

Maneuvers in the PE

Inspection Palpation Range of motion Measurements

Palpate the joint, surrounding tissues and the muscles of the limbs and back

Palpation

Increased Warmth

Tenderness

Swelling- bony, soft tissue, effusion

Tenderness

Unusual sensitivity to touch or pressure

Grade I- pain only

II- pain and wincing

III- wincing and withdrawal

IV- palpation not tolerated

Swelling Bony swelling- osteophyte

& new bone formation

Synovitis- edematous

synovium, boggy swelling,

usually tender

Effusion- excessive fluid in

joint cavity, bulge sign

Swelling

Localized periarticular swelling does not communicate with main joint

cavity infrapatellar bursitis Pitting edema of tissues over a joint

Maneuvers in the PE

Inspection Palpation Range of motion Measurements

Range of motion

Requires knowledge of normal motion of particular joints

Active or Passive When should ROM test be deferred

Limitation of Motion

Comparison with an unaffected joint of the opposite extremity to evaluate individual variations

Increased muscle tension may result in what appears to be significant decreased ROM

May be due to limitation in the joint itself or the periarticular structures

Active motion limited- joint or periarticular problem

Only active motion limited-periarticular problem

Crepitus palpable &/or audible grating or crunching

sensation produced by motion. arises when roughened articular or extra-

articular surfaces are rubbed together by active motion or by manual compression

fine or coarse – depending on rough the opposing cartilage surfaces are

differentiate from cracking sounds caused by the slipping of ligaments or tendons over bony surfaces- normal joints

Doing the Actual PE

Rapid Screen- GALS

Extensive PE

GALS Step 1- Ask 3 basic questions

Have you any pain or stiffness in your muscles, joints, or back?

Can you dress yourself completely without any difficulty?

Can you walk up and down stairs without any difficulty?

GALS Step 2- Gait

Symmetry Smoothness of

movement Normal stride length Normal heel strike,

stance, toe-off, swing through

Able to turn quickly

Heel Strike, Stance, Toe Off, Swingwidth of the base should be 2-4 in from heel to heel flexion of the knee during toe off and swing

GALS Step 3- Inspection from Behind

Straight spine Normal & symmetric paraspinal

muscles Normal shoulder & gluteal

muscle bulk Level iliac crests No popliteal cysts nor swelling No hindfoot swelling or

abnormality

GALS Step 4: Inspection from the side

Normal cervical & lumbar lordosis

Normal thoracic kyphosis

GALS Step 5. “Touch your toes.”

Normal lumbar spine (and hip) flexion

GALS step 6: Inspection from the front- ArmsPlace your hands behind your head (elbows out)- normal glenohumeral,

sternoclavicular, & acromioclavicular joint movement by your side (elbows straight)- full elbow extension In front (palms down)- no wrist/finger swelling or

deformity; able to fully extend fingersTurn your hands over- normal supination/pronation; normal

palmsMake a fist- normal grip powerPlace the tip of each finger on the tip of the thumb- normal

fine precision, pinch

GALS step 6: Inspection from the frontLegs Normal quadricep

bulk/symmetry No knee swelling or

deformity No forefoot/midfoot

deformity Normal arches No abnormal callous formation

Spine “Place your ear on your

shoulder.”Normal cervical lateral

flexion

Regional Examination

BackUpper ExtremitiesLower Extremities

Back

Look: Contour, Deformity, Mass, Skin lesion

Feel: spinous processes, paravertebral muscles, SI joint

Move: cervical, lumbar; Schober’s test for spine flexibility

Back: Look1="Vertebra prominens" Spinous process of C7

2= 2nd Lumbar vertebra

3= L4-5 inter vertebral space

4= Iliac crests

5= Dimples of Venus / Sacroiliac joints

1= Cervical lordosis

2=Thoracic kyphosis

3= Lumbar lordosis

4= Sacral kyphosis

Back: Feel & Move

Back flexibility: Schober’s test

TMJ

Look Feel Move

Put picture here

Shoulder

Inspection Look for symmetry

between both shoulders Check the skin for any

signs of current or past pathology

Identify the clavicle, deltoid & biceps muscles, bicipital groove, scapula

Shoulder

PalpationAssess the soft tissue tone, consistency, size

and shape of muscles, and tendernessCheck the axilla for lymph nodes

Shoulder

Look- swelling, redness

Feel- tenderness

Move- circumduction

Elbow

In a staight arm, the "elbow bump" can be at, and sometimes even above, the condyles.

In a bent arm, the triangle is quite pronounced.

Humero-ulnar joint (hinge) is main articulation, radio-ulnar & humero radial

Elbow jointInspection With palms facing anterior or in

anatomic position, note the valgus angle made by the forearm and the upper arm

Palpation Palpate the bony structures:

Medial and lateral epicondyles, Medial and lateral supracondylar line of the humerus, Olecranon & Radial head

Palpate the soft tissue structures Medial aspect: ulnar nerve, wrist

flexors and pronators Posterior aspect: olecranon

bursa, triceps muscles Lateral aspect: wrist extensors,

lateral collateral ligament, annular ligament

Anterior aspect: cubital fossa

Range of motion: flexion, extension at humeroulnar

articulation forearm supination, pronation at

proximal and distal radioulnar joints

passive

Wrist and Hand

•True wrist/radiocarpal articulation- biaxial ellipsoidal joint (radius, triangular fibrocartilage, 3 carpal bones)

•Distal RU joint is a pivot joint

Palmar flexion & dorsiflexion

Radial & ulnar deviation

Pronation & supination

Wrist

Keep in mind that there are 6 dorsal passageways and 2 palm tunnels through which pass nerves, arteries, veins and tendons.

Some anatomic structures worth mentioning are the carpal tunnel and the median nerve

Wrist

Palpation Bone palpation includes

the following: Radial and ulnar styloid

processes Tubercle of the radius Bones of the wrist: eight

carpal bones Scaphoid, navicular,

lunate, triguetrum pisiform, trapezium, trapezoid, capitate, hamate

Range of motion Flexion (80 degrees from

neutral) Extension (70 degrees

from neutral Ulnar and radial deviation

Hand

Inspection Ventral surface:

creases, thenar and hypothenar eminences, MCP joint area

Dorsal surface: MCP and soft tissue “valleys,” DIP’s and PIP’s, fingernails

MCPs

Hand

Palpation Thenar and hypothenar

eminences Palm aponeurosis Flexor and extensor

tendons Fingers: dorsal and palm

surfaces of MCP, PIP and DIP joints

Fingernails and nail fold capillaries

Range of motion MCPs- hinge joints

Fingers: Abd 20°, Flex (make a fist to touch palm crease), Add, Ext

1st CMC joint- saddle-shaped Thumb: opposition,

flexion/extension, abduction and adduction

Hip

Inspection: pelvic tilt, rotational deformity, muscle wasting, leg lengthPalpation: anterior joint line, greater trochanter, ischial tuberosityRange of motion (ball & socket joint)- F,E,Ab,Ad,R

Knee10 Quadriceps femoris tendon

1 Patella4 Fibular head

11 Patellar ligament

5 Anterior tibeal tuberosity

18 Hamstring muscle group19 Calf muscle

Look- swelling, bulgesFeel- including bulge testMove- flexion-extension only

Ligaments

What is wrong here?

Test for effusions: Bulge test & Patellar ballotment

Ankle and Feet

True Ankle joint- distal ends of tibia & fibula and proximal part of body of the talus

- hinge joint; dorsi & plantar flexion

Subtalar joint- inversion & eversion

Toes

Maneuvers in the PE

Inspection Palpation Range of motion Measurements

Measurement

Reporting Your Findings

Inspection Palpation Range of Motion Measurements

Objectives in doing MSS PE

To screen for MSS problems among asymptomatic and symptomatic individuals

To determine if complaint in the back or limb is due to a MSS problem

To localize the MSS problem- intra or periarticular

To diagnose

Articular vs Non-articular Disease ARTICULAR EXTRA-ARTICULAR

ROM pain on active & more on active &

passive motion specific motion

Tender jt surface over bony

ness circumference prominences

along tendons

Pain generalized, well-localized

poorly localized superficial

Evaluation of patient with musculoskeletal complaint

Logical differentials Accurate diagnosis Performance of necessary diagnostic

tests Timely provision of appropriate

therapy