| Musculoskeletal Exam Session Handout
|
- MUSCULOSKELETAL DISEASE
- Magnitude: Over 3 7 million people in the United States suffer from one or another form of arthritis or related condition. It represents one of the five leading problems in patients presenting to the primary care physician.
- Rheumatology: This is the branch of medicine dealing with
arthritis and related disorders of the musculoskeletal system including the multi system autoimmune diseases. Rheumatologists are medical specialists in musculoskeletal disease.
- Value of the History and Physical: The history and physical are critical to arriving at an accurate diagnosis of musculoskeletal disorders. Although the same might be said for all systems, it is
particularly true in this area. In the diagnosis of musculoskeletal disease, 60% of the weight might be placed on the history, 3 0% on the physical and 10% on laboratory data.
TERMS-YOU SHOULD BE FAMILIAR WITH - Arthralgia: Pain in the joint.
- Arthritis: Inflammation of the joint. Implies presence of warmth,
swelling, heat, tenderness and possibly erythema.
- Baker's cyst: A synovial cyst found in the popliteal space which may occasionally rupture into the calf and mimic thrombophlebitis.
- Bouchard's nodes: Bony enlargement of the proximal interphalangeal joints found in osteoarthritis.
- Boutonniere deformity: A characteristic deformity found in
rheumatoid arthritis which includes a flexion contracture of the proximal phalangeal joint associated with hyperextension of the distal interphalangeal joint.
- Bursitis: Inflammation of a bursa which is a synovial lined sac which may or may not be in communication with a joint cavity.
- Crepitation: A palpable or audible grating or crunching sensation produced by
motion of a joint or tendon.
- Diarthrodial joint: A freely movable joint lined by synovium.
- Flat feet: Feet in which the longitudinal arch is flattened and the normal concavity on the medial side of the foot becomes convex.
- Ganglion: Cystic enlargement arising from joint capsules and tendon sheaths, most common* located
on the dorsum of the wrist
- Hallux vagus: Abnormal abduction of the great toe in relation to the first metatarsal. When the head of the first metatarsal subsequently enlarges on its medial side, a bunion deformity is created.
- Hammer toe: A common toe deformity characterized by hyperextension at the metatarsophalangeal joint, flexion at the proximal interphalangeal joint.
-
`Heberden's node: Bony enlargements of the distal interphalangeal joint of the hand secondaryto osteoarthritis. Kyphosis: Rounded thoracic convexity of the spine often seen in older women. Myalgia: Pain in muscle. Podagra: Acute of the first metatarsal phalangeal joint and often the calling cardof gout. Rheumatoid nodule: A
subcutaneous or subperiostial nodule with a characteristic histology often found on the extensor surface of the forearm and elbow and seen in about 20% of patients with rheumatoid arthritis. Scoliosis: A lateral curvature of the spine. Synovitis: Inflammation of the lining tissue of a diarthrodial joint. It results in the palpable swelling of joints found in diseases like rheumatoid arthritis. An examiner will
properly note the presence or absence of "palpable synovitis". Swan neck deformity: A characteristic hand deformity in rheumatoid arthritis in which there is a flexion contracture of the metacarpalphalangeal joint, hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint. It may be found in other types of arthritis. Tophus: A collection of monosodium urate crystals which may be palpated beneath the skin. Ulnar deviation: Another common deformity in rheumatoid arthritis in which the fingers drift inward at the MCP joints.
RECORDING THE MUSCULOSKELETAL EXAM A musculoskeletal exam nearly exclusively relies on inspection and palpation of the joints and some specialized tests
involving those techniques. Rarely do percussion and auscultation play a role in the musculoskeletal exam. The key features to note and record on the examination of the joints are Swelling, Tenderness and Loss of motion. Other important physical signs including temperature and color changes over the joint, crepitation and deformity can be added to complement the basic STL data Rating: Swelling, tenderness and loss of
motion can be graded conveniently on a scale of 0-4. In general terms, 0 means normal, I a mild abnormality, 2 moderate, 3 marked and 4 maximum abnormality. A more detailed explanation of the grading system is presented in the following table. THE MUSCULOSKELETAL EXAM
| SO
| S1
| S2
| S3
| S4
| 1. Swelling (S)
| No Swelling
| Join swelling which may not be apparent on casual inspection, but should be recognizable to an experienced examiner
| Joint swelling obvious even on casual observation
| Markedly abnormal swelling
| Joint swelling to a maximally abnormal degree
|
| TO
| T1
| T2
| T3
| T4
| 2. Tenderness (T)
| No tenderness
| Slight or mild tolerable discomfort on palpation
| More severe pain on ordinary palpation, which the patient prefers not to tolerate
| More intolerable pain even with light palpation or pressure
| Pain which may be caused by even a mild stimulus such as a sheet touching the joint often characteristic of acute gout
|
| L0
| L1
| L2
| L3
| L4
| 3. Limitation of motion (L)
| Normal joint motion
| About 25% loss of motion
| About 50% loss of motion
| About 75% loss of motion
| 100% loss of motion or complete ankyloses of the joint
|
Fist grading: Motion in small joints of the fingers can be specifically measured in each case, but this represents a time consuming exercise that is usually not critical to patient management. A good global assessment of joint motion in the hands can be achieved by asking the patient to make a fist and assessing the degree to which that functional activity is
impaired. A normal complete fist produced by complete flexion of all the fingers is described as 100% fist and a flat hand with no flexion is a 0%. In between these two extremes, one can estimate 25, -50 and 75% fists. A rheumatologist caring for a patient with polyarticular joint disease can benefit from the use of this semi-quantitative shorthand in following the course of the patient. The
following example of a recorded examination of a patient with rheumatoid arthritis demonstrates the usefulness of this method in providing an easy to read summary of the joint exam. EXAMPLE: Rheumatoid Arthritis Patient
| RIGHT
| LEFT
| TMJ
| 0
| 0
| Shoulder
| S0T1L70�abd
| S0T1L0
| Elbow
| S0T0L10-100
| S1T1L0
| Wrist
| S1T1L1
| S1T2L1
| MCP
| 2, 3S1T1
| 2, 4S1T1
| PIP
| 3, 4S1T1
| 3, 4S1T1
| DIP
| 0
| 0
| Fist
| 75%
| 75%
| Hip
| L0
| L0
| Knee
| S1T1L0-95
| S1T0L0-100
| Ankle
| 0
| 0
| MTP
| 2, 3S1T2
| 2, 3, 4S1T2
| EXAMINATION OF THE JOINTS - Specific information regarding joint anatomy, technique and range of motion can be found in Chapter 17 of Bates entitled, "The Musculoskeletal System".
- In general, all joints above the waist are examined with the patient in the sitting position while joints below the waist are
examined with the patient supine. Consistency in performance of the joint exam is more important than any specific method.
- If you forget range of motion for a given joint, you can refresh yourself by performing active range of motion on your own joints (presuming that range of motion of your joints is normal.)
- When noting swelling about the joints, always attempt to delineate periarticular
and bursal swelling from synovitis.
- Minor joint abnormalities may be more apparent when compared to the same joint on the contralateral side.
- COMMON SYNDROMES TO KNOW ABOUT AND SPECIAL SIGNS
- Carpal Tunnel Syndrome
(compression of median nerve within the carpal canal) - Phalen's Test - Tinel's
Sign
- Low Back Pain with Radiation to the Leg
Straight Leg Raising Sign (SLR) - Impingement Syndrome (Rotator Cuff Tendinitis)
- Lateral Epicondylitis (Tennis Elbow)
- Medial Epicondylitis (Golf Elbow)
- Patello-femoral syndrome--clicking on extension of lower leg
- Fibromyalgia--trigger
points
- Ruptured Baker's Cyst---mimics DVT
What is the significance of range of motion in the assessment and examination of the musculoskeletal system?
Passive range of motion is examiner-initiated movement of the joint, and tests only joint mobility. The combined use of passive as well as active range of motion minimizes the need for patient instruction and thus maximizes the speed and efficiency of the examination (Fig. 2–1B).
What is musculoskeletal system physical examination?
The musculoskeletal (MSK) examination confirms the diagnostic impression and lays the foundation for the physiatric treatment plan. It incorporates inspection, palpation, passive and active ROM, assessment of joint stability, manual muscle testing, joint-specific provocative maneuvers, and special tests (Table 1.8).
What is the main assessment technique used for the musculoskeletal system?
The techniques for the assessment of the musculoskeletal system are inspection, palpation, and observing the range of motion of the joints.
How do you assess musculoskeletal dysfunction?
Rolling of the skin (Kibler test) can be performed. The examiner observes for surface temperature, hypesthesia, hyperhidrosis, and muscle splinting. Tenderness of muscles and tendons and their attachments is assessed in both the anatomic resting position and through various ranges of motion.
|