Musculoskeletal Examination: General Principles …

1 Musculoskeletal examination : General Principles and Detailed Evaluation Of the knee & ShoulderCharlie Goldberg, of Medicine, UCSD Principles Musculoskeletal exam performed if symptoms( injury, pain, decreased function) Different from screening exam Focusedon symptomatic area Musculoskeletal complaints common frequently examinedHistorical Clues What s functional limitation? Symptoms in singlev multiplejoints? Acutev slowlyprogressive? If injury mechanism? Prior problemsw/area?

2 Systemicsymptoms? examination Keys To Evaluating Any Joint Area well exposed-no shirts, pants, etc gowns Inspect joint(s)in question. Signs inflammation, injury (swelling, redness, warmth)? Deformity? Compare w/opposite side Understandnormal functional anatomy Observe normal activity what can t they do? Specific limitations? Discrete event ( trauma)? Mechanism of injury? Palpate joint warmth? Point tenderness? Over what structure(s)? Range of motion, active (patient moves it) and passive (you move it).

3 Strength, neuro-vascularassessment. Specific provocative maneuvers If acute injury& pain difficultto assessas patient protects limiting movement, examination examine unaffected side first(gain confidence, develop sense of theirnormal)Wrist ExtensionFlexionElbow FlexionExtensionShoulder AbductionAdductionHip FlexionHip ExtensionHip AbducitionHip AdductionKneeExtensionKneeFlexionPlantar flexionDorsiflexionTerminology: Flexion/Extension, Abduction/Adduction Anatomic Position & Planes Of The Body Flexion.

4 Moving forward out of the frontal plane of the body (except knee and foot) Extension:Movement in direction opposite to flexion Abduction:movement that brings a structure away from the body (along frontal plane) Adduction:movement that brings a structure towards the body (along frontal plane) knee Anatomy:Observation & Identification of Landmarks Hinge-type joint - tolerates sig force, weight Anatomy straight forward Exam make sense! Fully expose take off pants, use gown or shorts! Surface land marks: patella( knee cap), patellar tendon, medial joint line, lateral joint line, quadricepsmuscle, hamstringmuscle group, tibia, anterior tibial tuberosity(insertion of patellar tendon), knee AnatomyObservation (cont) Obvious pain w/walking?

5 Landmarks Scars past surgery? Swelling fluid in the joint (aka effusion)? Atrophic muscles ( from chronic disuse)? Bowing of legs (inward =s Valgus, outward =s Varus)?Varus Deformity (bowing outward)SurgicalScarsObvious right knee effusionRange of Motion (ROM) then passive (you move the joint) on patella w/extens. & flex osteoarthritis, may feel grinding sensation (crepitus)Normal range of motion:Full Flexion: 140 Full Extension: 0 Assessment For A Large Effusion - BallotmentAn effusion =s fluid w/in joint space Large effusions obviousTo knee on supra-pateallar pouch above patella, communicates w/joint space.

6 Down & towards patella fluid center of joint. down on patella w/thumb. large effusion patella floats & "bounces" back up when pushed Normal Function and AnatomyFemur(articular cartilage covers bone)FibulaTibiaMedialMeniscusLateral Meniscus Medial & lateral menisci on top of tibia cushioned articulating surface betwn femur & tibia Provides joint stability, distributes force, & protects underlying articular cartilage (covers bone, allows smooth movement) Menisci damaged by trauma or degenerative changes w/age.

7 Symptoms if torn piece interrupts normal smooth movement of joint pain, instability ("giving out"), locking &/or for Meniscal Injury Joint Line PalpationJoint Line Tenderness medial or lateral meniscal injury (& OA) flex knee . joint space along lateral & medial margins. Joint line perpendicular to long axix tibia. along medial, then lateral margins. suggest underlying meniscus damage or InjuriesAdditional Tests For Meniscal Injury McMurray s Test Medial MeniscusMcMurray s manipulates knee torn meniscus pinched SymptomsMedial hand w/middle, index, & ring fingers on medial joint line.

8 Heel w/right hand, fully flex knee . ankle foot pointed outward (everted). Direct knee pointed outward. foot in everted position, extend & flex medial meniscal injury, feel "click" w/hand on knee w/extension. May also elicit pain. Simulated McMurray s Note pressure placed on medial meniscusMcMurray s Test Lateral knee to fully flexed position, turn foot inwards (inverted). knee so pointed inward. on knee , fingers along joint and flex knee . lateral meniscal injury feel "click" w/fingers on joint line; May also elicit : McMurray s Test for medial and lateral meniscus injuries are performed togetherAdditional Assessment For Meniscal Injury Appley Grind lies on stomach.

9 Ankle & foot w/both hand, flex knee to ninety leg down w/your leg on back of thigh down while rotating ankle. direct pressure on menisci ifinjured pain. opposite legSimulated Appley Note how downward pressure pinches menisciLigaments Normal Anatomy and Function 4 bands tissue, connecting femur tibia provide stability Ligamentous injury (requires significant force eg leg struck from side w/foot planted) acute pain, swelling & often report hearing a "pop" (sound of ligament tearing).

10 After acute swelling & pain, patient may report pain & instability (sensation of knee giving out) w/maneuver exposing deficiency assoc w/damaged ligamentFemur(articular cartilage covers bone) AnatomyFibulaTibiaMedialMeniscusLateral MeniscusSpecifics of Testing Medial Collateral Ligament (MCL) knee ~ 30 degrees. hand on lateral aspect knee . hand on ankle or calf. inward w/left hand while supplying opposite force w/ right. MCL torn, joint "opens up" along medial aspect. also elicit pain w/direct palpation over ligamentCompare w/non-affected side normal laxity varies from patient to patientDirection of Collateral Ligament InjuriesLateral Collateral Ligament (LCL) knee ~ 30 degrees.