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McMaster Musculoskeletal Clinical Skills Manual

Authors Samyuktha Adiga Dr. Raj Carmona, MBBS, FRCPC

Illustrator Jenna Rebelo

Editors Caitlin Lees Dr. Raj Carmona, MBBS, FRCPC

In association with the Medical Education Interest Group Narendra Singh and Jacqueline Ho (co-chairs)

FOREWORD AND ACKNOWLEDGEMENTS

The McMaster Musculoskeletal Clinical Skills Manual was produced by members of the Medical Education Interest Group (co-chairs Jacqueline Ho and Narendra Singh), and Dr. Raj Carmona, Assistant Professor of at McMaster University. Samyuktha Adiga and Dr. Carmona wrote the manual. Illustrations were done by Jenna Rebelo. Editing was performed by Caitlin Lees and Dr. Carmona.

The Manual, completed in August 2012, is a supplement to the McMaster MSK Examination Video Series created by Dr. Carmona, and closely follows the format and content of these videos. The videos are available on Medportal (McMaster students), and also publicly accessible at RheumTutor.com and fhs.mcmaster.ca/medicine/rheumatology.

McMaster Musculoskeletal Clinical Skills Manual S. Adiga, J. Rebelo, C. Lees, R. Carmona

McMaster Musculoskeletal Clinical Skills Manual

TABLE OF CONTENTS

General Guide 1

Hip Examination 3

Knee Examination 6

Ankle and Foot Examination 12

Examination of the Back 15

Shoulder Examination 19

Elbow Examination 24

Hand and Wrist Examination 26

Appendix: Neurological Assessment 29 1

GENERAL GUIDE (Please see videos for detailed demonstration of examinations)

Always wash your hands and then introduce yourself to the patient. As with any other exam, ensure adequate exposure while respecting patient's modesty. Remember to assess gait whenever doing an examination of the back or any part of the lower limbs.

Inspection follows the format: ● S welling ● E rythema ● A trophy ● D eformities ● S cars, skin changes, etc.

Palpation assesses: ● Tenderness ● Effusion ● Swelling ● Temperature ● Crepitus ● Atrophy

Range of Motion (ROM) ● Always compare (or comment that you would compare) both sides ● During ROM, check for crepitus, clicking, and locking ● Start with active ROM ● If active ROM is limited, do passive ROM. For some , it may be best to integrate this with active ROM, rather than doing them as 2 separate "sections" ● If doing passive ROM, assess end-feel ○ Bony end-feel suggests bony (eg. , fracture) ○ Soft end-feel suggests soft-tissue pathology ( capsule, ligaments, tendons, muscles)

Power Assessment ● Best to do resisted isometric testing ● Position the joint as required, then apply force while the patient resists

Score Description

5 Movement against gravity with full resistance

4 Movement of the body part against gravity and some resistance

3 Movement of the body part against gravity only

2 Movement of the body part with gravity eliminated (supported)

1 Muscle contraction, but no joint movement

0 No muscle contraction

McMaster Musculoskeletal Clinical Skills Manual S. Adiga, J. Rebelo, C. Lees, R. Carmona 2

Neurological and Vascular Assessment (see Appendix for details) Depending on the clinical scenario, you should be prepared to perform a neurological and vascular assessment. ● , capillary refill ● Tone ● Power (above) ● Sensation according to dermatomes ● Reflexes

Gait Assessment Observe gait whenever asked to examine back or any part of the lower limb ● Symmetry, smoothness of movement (legs, arm swing, pelvic tilting) ● Normal stride length ● Ability to turn quickly ● Stance phase ○ Heel strike, to mid-stance, to toe-off ○ 60% of gait cycle ● Swing phase ○ Toe-off, to mid-swing, to heel strike ○ 40% of gait cycle ● Antalgic gait ○ Stance phase is shortened on affected side, typically indicating pain on weight- bearing ● (Weakened abductor muscles) ○ During the stance phase, if the abductors are weak on the standing side, the pelvis will drop on the opposite side ○ The trunk compensates by lurching towards the side of the weakened abductor muscles ○ Bilateral hip abductor weakness produces a waddling gait

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HIP EXAMINATION If the hip examination is unremarkable or you suspect referred pain, consider examining the back and .

GAIT ● Stance phase (heel strike → mid-stance → toe-off) ● Swing phase and stride length ● Smoothness, symmetry, ability to turn quickly ● Antalgic gait (identify point at which pain occurs) ● Trendelenburg gait ● Weak hip abductors

INSPECTION Ensure adequate but respectful exposure ● Swelling ○ Unlikely to see effusion, but massive swelling may present as a prominence in groin ● Erythema ● Atrophy ○ Pelvic girdle ○ Gluteal muscles ○ Hamstrings ○ Quadriceps ○ Lower back ● Deformity ○ Posture o Scoliosis o Exaggerated lumbar lordosis ● May suggest flexion of the hip ○ Pelvic tilt (inspect or palpate level of iliac crests) o Possible hip adduction deformity on higher side, or hip abduction deformity on lower side ○ External or internal rotation of hip at rest (look at feet) o Possible rotational deformity of the hip o External rotation also found in hip fracture. ○ Trendelenberg Sign o Patient stands on one leg at a time - if the unsupported side drops, this indicates weakness of the hip abductors on the standing side. ● Swelling and skin changes ○ Rashes ○ Scars from surgery (on lateral aspect of hip)

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PALPATION ● Pubic symphysis ● Inguinal ligament ● Femoral ● ASIS ● Iliac crest ● PSIS (dimples of Venus) ● Ischial tuberosity(bony prominence that you sit on) ● Greater trochanter(tender in trochanteric bursitis) ● Iliotibial band

RANGE OF MOVEMENT Generally perform active ROM first, followed by passive ROM if active ROM is limited. These may be integrated at terminal range of movement. ● Active ROM ○ Flexion (knee to chest): 120° ○ Abduction: 45° ○ Adduction: 30° o Abduct other leg out of the way so that leg can be brought in as far as possible without lifting (which will flex hip) ○ Extension (best done with patient lying prone): 20° o If patient on side, stabilize hemipelvis with one hand ○ Internal rotation at hip: 35-40° o Flex knee to 90° and stabilize knee with one hand, bringing lower leg outwards with the as the axis of rotation ○ External rotation at hip: 45° o As above, except moving lower leg inwards ● Passive ROM(performed with each step above as needed) ○ Assess end-feel

POWER ASSESSMENT This is best done by resisted isometric testing, with patient resisting examiner's force ● Flex hip and to 90° ○ Flexion strength: examiner pushes thigh in direction away from head ○ Extension strength: examiner pushes thigh in direction of patient's head ● Extend hip and knee (flat on bed), slightly abducted ○ Abduction: examiner presses thigh together ○ Adduction: examiner pushes thighs apart

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SPECIAL TESTS

● (hip contracture) ○ With the patient supine, place a hand under the lumbar spine ○ Patient pulls one knee to the chest with his/her hands ○ If the contralateral thigh raises off the bed, this is suggestive of a contralateral hip contracture

● Ober Test (Tight iliotibial band) ○ Decubitus position, upper leg is extended backwards with knee bent, then released and allowed to fall into bed ○ Failure of knee to touch bed indicates a tight iliotibial band

● Patrick Test/FABER Test/Figure-Of-4 Test (sacroiliac joints, also stresses ) ○ This is primarily a test of the sacroiliac joints, but is included in multiple sources as part of the hip exam ○ FABER: Flexion, ABduction, External Rotation ○ In supine position, patient places heel of one leg on the knee of the other leg ○ Apply applies downward pressure on the flexed knee and contralateral hemipelvis ○ Pain in anterior or lateral aspects may indicate hip joint pathology ○ Pain in lower back or gluteal region may indicate sacroiliac joint pathology

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● Leg Length Discrepancy ○ True/Actual Leg Length o Measured from the ASIS to the medial malleolus on each side o If different, then a true length leg discrepancy is present ○ Apparent Leg Length Discrepancy o An apparent leg length discrepancy occurs when the actual lengths are the same, but there appears to be a difference in length visually o First measure the true leg length on each side (above) o Then measure from the umbilicus to the each medial malleolus o If the umbilicus-to-malleolus lengths are not equal, but true leg length measurements are the same, this indicates an apparent leg length discrepancy. This may be due to pelvic tilt or abduction/adduction deformities of the hips.

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KNEE EXAMINATION If the knee examination is unremarkable or you suspect referred pain, consider examining the hip, ankle, and foot

GAIT ● Stance phase (heel strike → mid-stance → toe-off) ● Swing phase, stride length ● Smoothness, symmetry, ability to turn quickly ● Antalgic gait (identify point at which pain occurs)

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INSPECTION ● While standing: ○ Swelling o Popliteal fossa for Baker’s cysts ○ Erythema ○ Atrophy o Calves o Quadriceps o Hamstrings ○ Deformities o (hyperextension) o Genu procurvatum (flexion deformity, always abnormal) o Genu varum (bow-legged) o Genu valgum (knock-kneed) ○ Skin changes and scars ● While supine: ○ Swelling o Loss of parapatellar grooves/fossae or swelling extending to the supra- patellar area ● May occur with ○ Localized swelling may indicate bursitis, tendon, or ligament pathology

PALPATION ● With knee extended ○ Temperature (use back of hand) o Patella should be cooler than the thigh and tibia o Warmth can occur with septic bursitis or inflammatory or septic ○ Palpate patella o Feel undersides by tilting to one side and feeling with or thumb ○ Quadriceps, suprapatellar tendon, patellar ligament, tibial tuberosity ○ Popliteal fossa ○ Pulse ○ Swelling (may be Baker’s cysts) ○ Bursae o Pre-patellar bursa (just in front of the patella) o Superficial infra-patellar bursa (just inferior to the patella, overlying the patellar ligament and under the skin) o Deep infra-patellar bursa (behind patellar ligament) o Anserine bursa (anteromedial aspect of knee, near medial tibial plateau, composed of Sartorius, gracilis, and semitendinosus tendons) ● With knee flexed to 90° ○ Medial and lateral tibial plateaus ○ Femoral condyles ○ Medial and lateral joint line

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○ Medial collateral ligament ● In the figure-of-4 Position (heel resting on opposite knee) ○ Lateral collateral ligament is easily felt as accord on the lateral aspect of the knee ● Palpation for Effusion ○ Fluid Wave/Bulge Sign/Milking Test o Empty the medial fossa by sweeping hand superiorly and laterally, followed immediately by sweeping down the lateral side o A bulge forming in the medial fossa indicating an effusion ○ Fluid Ballotment test o With leg extended, grasp the knee just above the patella and apply pressure while squeezing o With the other hand, grasp the medial and lateral parapatellar fossae o If ballotable fluid is felt, indicates an effusion ○ o With leg extended, grasp the knee just above the patella and apply pressure while squeezing, pushing any fluid under the patella o Push the patella towards the femur (posteriorly) with the index of the other hand o If the patellar taps the femur and bounces back up, this is a positive test (best felt in moderate to large effusions)

RANGE OF MOTION Generally perform active ROM first, followed by passive ROM if active ROM is limited. These may be integrated at terminal range of movement. ● Active and Passive ○ Flexion (135°) ○ Extension (more than 10°is abnormal hypermobility) ○ Internal and external rotation (best done with knee flexed at 90°) o Point toes in (internal rotation, normally 30°) o Point toes out (external rotation, normally 20°) ○ Patellar movement o Push medially and laterally on patella o Look for hypermobility, or pain or apprehension from dislocation o Assess patellar crepitus during ROM by placing one hand on patella

POWER ASSESSMENT Best done by resisted isometric testing with the knee flexed to 90°, with patient resisting examiner's force ● Extension ○ Push against lower leg toward buttocks with patient resisting force ● Flexion ○ Pull lower leg away from buttocks with patient resisting force

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SPECIAL TESTS ● Anterior and Posterior Cruciate Evidence-Based Medicine: Anterior Cruciate Ligaments Ligament Tear ○ Anterior (ACL tear) Anterior Drawer Test LR+ 3.8 o Patient supine, knee Diagnostic Value: Ruling in anterior cruciate ligament flexed at 90° tear

o Stabilize the tibia with forearms while grasping LR+ 42 the upper part with Diagnostic Value: Ruling in anterior cruciate ligament tear thumbs on either side,

and pull the upper tibia Solomon DH et. al. JAMA. 2001;286(13):1610-1620. forward o Excess anterior displacement of the tibia compared with the contralateral knee indicates an ACL tear

○ Posterior Drawer Test (PCL tear) o In the same position as the Anterior Drawer Test, push backwards on the upper tibia o Excess posterior displacement of the tibia compared with the contralateral knee indicates PCL tear

○ Lachman Test (ACL tear) o Patient supine, knee flexed at 30° o Stabilize the femur with one hand and grasp the upper tibia with the other hand and try to pull tibia forward o If there is notable anterior movement of the tibia or no discrete end point, this indicates possible ACL tear

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● Medial and Lateral Collateral Ligaments

○ Medial Collateral Stress Test (MCL Tear) o Patient supine, knee flexed 30° o Stabilize the knee and apply a valgus (lateral) force to the lower leg o Increased laxity and pain at the MCL indicates torn MCL

○ Lateral Collateral Stress Test (LCL Tear) o Patient supine, knee flexed 30° o Stabilize the knee and apply a varus (medial) force to the lower leg o Increased laxity and pain at the LCL indicates a torn LCL

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● Menisci ○ McMurray’s Test (Meniscal Tear) o Attempt to elicit pain or a "clunking" sensation by trapping between femur and tibia o Ideally done in one smooth movement o Medial Meniscus ● With the patient supine, flex the knee and place one hand over the knee and the other under the foot ● Externally rotate the foot and apply a varus (medial) force on the lower leg and extend the knee ● If pain or a palpable or audible click occurs, this indicates a tear of the medial meniscus o Lateral Meniscus ● With the patient supine, flex the knee and place one hand over the knee and the other under the foot ● Internally rotate the foot and apply a valgus (lateral) force on the lower leg and extend the knee ● If pain or a palpable or audible click occurs, this indicates a tear of the lateral meniscus

○ Apley’s Compression Test (Meniscal Tear) o Attempt to elicit pain by trapping meniscus between femur and tibia o With the patient supine and the knee flexed to 90°, stabilize the femur with one hand and grasp the heel with the other o Using the patient’s foot, apply downward pressure while Evidence-Based Medicine: Meniscal Tear rotating the lower leg internally McMurray’s Test and externally Sensitivity 71%, Specificity 71% o Apply a varus force/tilt for Diagnostic Value: Ruling in meniscal tears

medial meniscus, and a lateral Apley’s Test force/tilt for the lateral Sensitivity 61%, Specificity 70.2% meniscus Diagnostic Value: Ruling in meniscal tears

o Pain or popping/clicking Hegedus EJ et. Al. 2007. J Orthop Sports Phys indicates a meniscal tear Ther 37(9):541-550.

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ANKLE AND FOOT EXAMINATION

FOOTWEAR ● Abnormal wear may indicate gait abnormalities

GAIT ● Stance phase (heel strike → mid- stance → toe-off) ● Swing phase and stride length ● Smoothness, symmetry, ability to turn quickly ● Antalgic gait (identify point at which pain occurs) ● Ask patient to walk on the heels, toes, and medial and lateral borders of the feet

NSPECTION ● Briefly observe spine, hip and knee for misalignment ● Feet should be inspected in weight-bearing and at rest ● Standing ○ Splaying of the toes (suggest collapse of transverse arch) ○ Pes planus or “” (collapsed longitudinal arch) ○ Pes cavus (high longitudinal arch) ○ Hindfoot valgus (normally 5-10°) ○ "Too many toes sign" o More than 2 toes visible when looking from the back o Seen in severe pes planus or posterior tibialis dysunction ● Swelling ○ True ankle swelling causes loss of normal depressions anterior to malleoli ○ Peroneal : swelling posterior to lateral malleolus ○ Posterior tibial tenosynovitis: swelling posterior to medial malleolus ○ Swelling at the back of the heel: retrocalcaneal bursitis, retroachilleal bursitis ○ Swelling of the forefoot: can be seen

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in inflammatory arthritis ● Erythema ● Atrophy ● Deformities ○ Hallux valgus, , or bunionettes ○ Hammer toes ○ Claw toes ○ Mallet toes ● Skin changes or scars ○ Callous formation (may indicate abnormal gait or stance) ○ Remember to inspect sole of the foot

PALPTION (tenderness or temperature changes) ● Palpate and soft tissue structures in a systematic manner ● , lateral malleolus, lateral malleolar bursa, lateral ligaments, peroneal tendons ● Shin, extensor tendons, tarsal bones, metatarsals ● Medial malleolus, deltoid ligament, posterior tibialis ● Gastrocnemius, musculotendinous junction, Achilles tendon, enthesis, calcaneus ● Plantar fasciitis ○ Apply pressure to medial calcaneus tuberosity (insertion of plantar fascia) ○ Tense plantar fascia by passively dorsiflexing toes ● Painful Heel Pad Syndrome ○ Centre of heel is painful ● True ankle (tibiotalar) joint swelling ○ Cup hands around the ankle, palpate tibiotalar joint space anteriorly for fullness, try to ballot fluid between thumbs ● MTP Squeeze (metatarsal compression test) ○ Painful with inflammatory arthritis, intermetatarsal bursitis ● MTP joint swelling ○ Four-finger technique: palpate with tips of thumbs on top and fingers stabilizing underneath. Remember: MTP joint is 1-2 cm proximal to the webspace. ● PIPs and DIPs ○ Palpate with two fingers stabilizing at sides, index finger and thumb of other hand pressing from top and bottom

RANGE OF MOVEMENT ● Assess ROM with knee flexed and foot in neutral position (90° flexion) ● True ankle (tibiotalar) joint ○ Ankle dorsiflexion (15-25°) ○ Ankle plantar flexion (40-50°) ○ Ankle inversion and eversion (subtalar joint) ● Subtalar joint (between talus and calcaneum) ○ Ankle inversion (up to 30°) ○ Ankle eversion (up to 20°) ● Midtarsal joint ○ Stabilize heel, grasp and rotate the mid and forefoot ○ Inversion (30°) ○ Eversion (20°) ○ Adduction ○ Abduction ● Toes: flexion and extension

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SPECIAL TESTS ● Stability Testing ○ Deltoid Ligament o Stabilize lower leg, grasp hindfoot and apply eversion force checking for excessive movement ○ Lateral Ligaments o Stabilize lower leg, grasp hindfoot and apply inversion force checking for excessive movement ○ Anterior Drawer Test (anterior talofibular ligament) o With the foot in 20 ° of plantar flexion, stabilize the leg, grasp the calcaneus, and pull the heel forward (normally < 5 mm movement) o A positive test indicates an anterior talofibular ligament tear

● Tarsal Tunnel Syndrome ○ Tinel’s Test o Tap over the tarsal tunnel (just posterior to medial malleolus) o Paresthesias radiating to the first three toes indicates possible tarsal tunnel syndrome

● Torn Achilles Tendon ○ Thompson Calf-Squeeze Test o With the patient supine or kneeling and foot hanging off chair, squeeze the calf o Failure of the foot to plantarflex indicates a torn Achilles tendon

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EXAMINATION OF THE BACK

GAIT ● Stance phase (heel strike → mid-stance → toe-off) ● Swing phase, stride length ● Smoothness, symmetry, ability to turn quickly ● Antalgic gait (identify point at which pain occurs) ● Trendelenberg gait (weak hip abductors) ● Transition from sitting to standing (useful to find source of pain)

INSPECTION Ensure adequate exposure while preserving patient's modesty ● Swelling ● Erythema ● Atrophy ○ Sternocleidomastoid, girdle, chest wall, intercostals ○ Paraspinals, gluteal muscles ○ Abdominal obesity or muscle laxity ● Deformities ○ Posture and alignment: expect 4 normal curvatures o Cervical lordosis o Thoracic kyphosis ● Increased in ankylosing spondylitis (AS) and fractures from osteoporosis o Lumbar lordosis ● Increased in flexion contracture of hip ● Flattened in AS o Sacrococcygeal kyphosis ○ Scoliosis (asymmetric shoulder height) o Adam’s Forward Bend Test Evidence-Based Medicine: Scoliosis

● Patient bends forward Adam’s Forward Bend Test with knees in full Sensitivity 92%, Specificity 60% extension Diagnostic Value: Ruling out thoracic spine curvature ● Inspect from behind, Côté P, Cassidy JD. Spine (Phila Pa 1976). 1999 Nov scapula will be elevated 15;24(22):2411-2.

on the side of convexity ● Skin ○ Scars or skin changes ○ Sinus or hair tuft in keeping with spina bifida

PALPATION ● Systematic approach from the occiput down (stabilize the patient - don't push over!) ● Assess for muscle bulk/tenderness and bony tenderness ● Spinous processes and interspinous ligaments ○ C7: bony prominence at base of neck ○ T3: corresponds to spine of scapula ○ T7: corresponds to angle of scapula ○ L3-L4: corresponds to iliac crests (useful for landmarking lumbar puncture) ○ S2: posterior superior iliac spine ● Space between ribs and iliac crest (normal is 4 fingers, decreased in kyphosis)

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RANGE OF MOVEMENT ● Cervical Spine ○ Flexion o Chin should touch chest ○ Extension (look up) o Chin should pass level of ear ○ Lateral flexion o Ear to shoulder ○ Rotation o Normal ≥ 70° to each side (can estimate but best to measure with a goniometer)

● Thoracolumbar Spine ○ Chest expansion (see "Special Tests") ○ Flexion (touch toes while keeping knees straight) o Finger to Floor distance ● Not specific - can be limited by hip, tight hamstrings, abdominal obesity, etc. May be useful as a tracking measurement. ● Observe rhythm: lumbar lordosis should transition to a kyphosis o Modified Schober's test (see "Special Tests") ○ Extension (ensure legs are kept straight) o Best done with patient against a surface (eg. bed) while leaning backwards ○ Lateral Flexion o Finger-fibula distance (normal 0 cm) on each side o Measure finger-floor before and after bending to side (normal > 10 cm) o Useful in following patient over time ○ Rotation (patient sitting, arms crossed across chest) o May apply overpressure while observing for pain

SPECIAL TESTS ● Occiput-to-Wall (cervical or thoracic kyphosis) Evidence-Based Medicine: Vertebral Fractures

○ Patient stands with back to wall, Occiput-wall distance of >4.0 cm: nose and ear must be at same Sensitivity 41%, Specificity 92% horizontal level to ensure patient is Diagnostic Value: Ruling in thoracic vertebral fracture not hyperextending neck J Musculoskelet Neuronal Interact. 2011 Sep;11(3):249-56. ○ Occiput-to-wall should be 0 cm Rib-pelvis distance of <2 finger breadths: ○ Increased in abnormal cervical or Sensitivity 88%, Specificity 46% thoracic kyphosis (eg. ankylosing Diagnostic Value: Ruling out lumbar vertebral fractures spondylitis, thoracic fractures in Siminoski K et. al. 2003. Am J Med 115(3):233-236. osteoporosis)

● Chest expansion ○ Quick screen o Hands on back at 10th rib level; thumbs should move apart 4 cm with inspiration ○ Measure at level of xiphisternum: normal ≥ 4 cm ○ May be reduced in thoracic scoliosis, ankylosing spondylitis, or COPD

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● Modified Schober's Test (restricted lumbar flexion) ○ Place mark in midline between Dimples of Venus, then mark 10 cm above and 5 cm below ○ Patient then bends forward trying to touch floor (knees straight) ○ Normal ≥ 5 cm increase

● (for sciatic nerve root irritation: L4, L5, S1, S2)) Evidence-Based Medicine: Lumbar Disc Herniation ○ With patient lying supine, passively raise straight leg (knee extended) Straight Leg Raise ○ Pain radiating down the back of the Sensitivity 91%, Specificity 32% Diagnostic Value: Ruling out lumbar disc herniation leg into the foot is a positive test Vroomen PC et. al. 1999. J Neurol 246(10):899-906 (usually between 30-70°) ○ Pain in thigh only may be due to Crossed Straight Leg Raise hamstring muscles. Sensitivity 32%, Specificity 98% ○ If positive test, slowly lower leg just Diagnostic Value: Ruling in lumbar disc herniation Vroomen PC et. al. 1999. J Neurol 246(10):899-906 until the pain stops, then dorsiflex ankle ○ Return of pain is a positive Lasegue's sign

● Crossed Straight Leg Raise (sciatic nerve root irritation) ○ With patient lying supine, passively raise asymptomatic leg (with knee extended) ○ Pain radiating down the symptomatic leg is a positive test (good specificity for sciatica, but poor sensitivity) ○ ● Femoral Nerve Stretch (for femoral nerve Evidence-Based Medicine: Nerve Impingement root irritation: L2, L3, L4) ○ With patient lying prone, passively flex Femoral Nerve Stretch Sensitivity 50%, Specificity 100% knee and extend hip lifting thigh off Diagnostic Value: Ruling in mid-lumbar nerve bed impingement ○ Positive if the patient experiences pain Spine (Phila Pa 1976). 2011 Jan 1;36(1):63-73. in the anterior thigh

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● Sacroiliac Joints ○ FAbER Test o With patient supine: Flex, ABduct, Externally Rotate one hip (by placing heel on the opposite knee) o Then push down on knee, while stabilizing the opposite hemipelvis o Lower back or sacroiliac joint pain is a positive test

○ Gaenslen’s Test o Patient lies supine at the edge of bed with one leg hanging off bed, while using his/her hands to bring the other knee to the chest o Pain in back or buttock is a positive test

NEUROLOGIC EXAM ● Tone ○ Hip, knee, ankle ○ Look for ankle clonus ● Power Nerve Root Action L1, L2, L3 Hip flexion S1, S2 Hip extension L2, L3, L4 Knee extension L5, S1, S2 Knee flexion L4, L5 Ankle dorsiflexion S1, S2 Ankle plantar flexion L5, S1 Great toe dorsiflexion

● Reflexes ○ Patellar: L2-L4 (mainly L4) ○ Achilles: S1-S2 (mainly S1) ○ Plantar response (upgoing toes with upper motor neuron lesion) ● Dermatomes of lower limb Nerve Area of sensation Root L1 Groin L2 Just below L1 L3 Medial aspect of knee L4 Lateral aspect of knee L5 Dorsum of foot S1 Lateral border of foot

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SHOULDER EXAMINATION Depending upon the clinical scenario, you may need to examine the cervical spine and .

INSPECTION ● Swelling (especially joints) ○ Sternoclavicular ○ Acromioclavicular ○ Glenohumeral (bulge at delto-pectoral groove may occur in very large effusions) ● Erythema ● Atrophy ○ Pectoralis major ○ Deltoid (causing squaring of shoulder) ○ Supraspinatus and infraspinatus ○ Trapezius ● Deformities ○ Step-deformity of the clavicle (prior fracture) ○ Step-deformity of acromioclavicular joint (AC ligament disruption) ○ Asymmetrical height of o May be from scoliosis or Sprengel’s deformity (high riding scapula) ○ Shoulder elevation, depression, protraction, or retraction ○ Winging of scapula o Ask the patient to “do a push up against wall” o Winging is caused by injury of long thoracic nerve and paralysis of serratus anterior muscle

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PALPATION ● Palpate the sternoclavicular, acromioclavicular and glenohumeral joints for warmth ● Then systematically palpate the bones and soft-tissue structures for tenderness ● SC joint, clavicle, coracoid process, AC joint, acromion, spine of scapula ● Trapezius, supraspinatus, infraspinatus, deltoid, triceps, biceps muscles ● Long and short head of biceps ● insertion on greater tuberosity of humerus (extend arm backwards to bring humerus out from under the acromion) ● Palpate for crepitus during shoulder movement

RANGE OF MOVEMENT Generally perform active ROM first, followed by passive ROM if active ROM is limited. These may be integrated at terminal range of movement. ● Active ROM ○ Abduction (180°) o Look for painful arc (pain typically between 60-120°) o Found in subacromial impingement, , supraspinatus tendonitis o If pain begins beyond 120°, this may indicate AC joint pathology ○ Scapulothoracic Rhythm o First 30°: movement at glenohumeral joint o Beyond 30°, scapula engages with a 2:1 ratio of glenohumeral to scapulothoracic movement o With adhesive capsulitis, the humerus and scapula move together as one complex ○ Adduction o Cross arms in front of body ○ Flexion (180°) ○ Extension (60°) ○ External Rotation o Arms at sides, flex to 90°, rotate forearms away from body o Normal is 45-90° in this position ○ Internal Rotation o Arms at sides, flex elbows to 90°, rotate forearms into body and behind back o Normal up to 120° ○ Apley Scratch Test o Ask patient to touch tip of opposite scapula ● Passive ROM ○ Perform if active range of motion is restricted ○ Adhesive capsulitis will result in global restriction in all fields of movement ○ Check for crepitus (hand over shoulder, move arm around)

POWER ASSESSMENT Best done by resisted isometric testing, with patient resisting examiner's force

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● With arms at side, elbow flexed to 90° ○ Flexion ○ Extension ● Arms abducted from sides at approximately 20° ○ Abduction ○ Adduction

SPECIAL TESTS ● Supraspinatus tear ○ Drop Arm Test o Assessed during abduction, as the patient actively brings arms back to sides from an overhead abducted position o If the arm suddenly drops to side, this indicates a torn supraspinatus o Alternatively, with the arm abducted to 90°, quickly “chop” down on the arm o If arm suddenly drops to side, this indicates a torn Evidence-Based Medicine: Subacromial Impingement (SIS), including subacromial supraspinatus bursitis and supraspinatus/rotator cuff tendonitis

Neer’s Test ● Subacromial Impingement Syndrome (or Sensitivity 78%, Specificity 58% Supraspinatus tendonitis, or Subacromial Diagnostic Value: Ruling out SIS bursitis) Hawkins-Kennedy Test ○ Painful Arc Sensitivity 74%, Specificity 58% o Look for painful arc (pain Diagnostic Value: Ruling out SIS

typically between 60-120°) Empty Can Test ○ Neer’s Test (done passively) Sensitivity 69%, Specificity 62% o With elbow in full extension, Diagnostic Value: Ruling in SIS

stabilize the shoulder and lift Arch Phys Med Rehabil. 2012 Feb;93(2):229-36. the arm to the ear (Neer’s to the ear) o Pain is a positive test ○ Hawkins-Kennedy Test o Shoulder flexed forward to 90° ad elbow flexed 90° with forearm parallel to floor o Passively rotates the forearm clockwise (causing internal rotation at the shoulder) o Pain indicates a positive test ○ Empty Can Test o Arms abducted 45° and

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flexed forward 45° (as if emptying a can), thumbs pointing down o Patient resists examiner’s downward pressure on arms o Pain at the tip of the shoulder is a positive test

● Bicipital Tendonitis ○ Speed’s Test Evidence-Based Medicine: Bicipital Tendinitis

o Elbow extended, arm supinated Speed’s Test and forward at 45° Sensitivity 90%, Specificity 113.8% o Patient resists downward Diagnostic Value: Ruling out bicipital tendinitis Bennett, 1998 Nov-Dec;14(8):789-96 pressure from the examiner o Pain at the biceps tendon indicates bicipital tendonitis ○ Yergason’s Test (resisted supination) o Patient’s arm at side, elbow flexed at 90°, and hand in neutral position o Hold the patient's wrist and attempt to pronate the forearm, with the patient resisting by trying to supinate o Pain at the biceps tendon indicates bicipital tendonitis

● AC Joint Pathology ○ Scarf Test (AC Joint Compression Test) o Patient places hand on the opposite shoulder o Examiner then pushes arm into the body, while stabilizing the opposite shoulder o Pain around the acromioclavicular joint suggests acromioclavicular pathology e.g. osteoarthritis

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○ AC Joint Distraction Test o Patient adducts the arm behind the back, with the dorsum of their hand resting on the opposite buttock o Apply additional adduction force while stabilizing at the opposite shoulder o Pain at the acromioclavicular joint suggests acromioclavicular pathology

● Shoulder Instability ○ Sulcus Sign (inferior instability) o With the opposite shoulder Evidence-Based Medicine: Shoulder Instability stabilized, apply downward Sulcus Sign pressure on the arm by Sensitivity 31%, Specificity 89% grasping just above the elbow Diagnostic Value: Ruling in inferior shoulder instability o Appearance of a sulcus at the T’Jonck et. al. Geneeskunde Sport 2001;3415-24

tip of shoulder indicates inferior Anterior Relocation Test instability LR+ 6.5, LR- 0.18 Diagnostic Value: Ruling in anterior shoulder instability ○ Anterior and posterior instability Luime JJ et al. 2004. JAMA 292(16): 1989-1999 o Attempt to move the head of the humerus backwards and Anterior Release Sign LR+ 8.3, LR- 0.09 forwards Diagnostic Value: Ruling in anterior shoulder instability o Excessive movement indicates Luime JJ et al. 2004. JAMA 292(16): 1989-1999 anterior (movement forwards) or posterior (movement backwards) instability ○ Apprehension Test (anterior subluxation) o With the patient lying supine, passively abduct and externally rotate the arm at 90° o With one hand holding the wrist, apply upwards pressure against the head of the humerus in an anterior direction to pull the humeral head forward o If the patient becomes apprehensive and complains of pain, this is indicative of recurrent anterior subluxation ○ Relocation Test (anterior subluxation) o Continuing from the Apprehension Test, apply downward pressure on the head of humerus o If the patient becomes relaxed and looks relieved, this is a positive relocation test for recurrent anterior subluxation ○ Anterior Release Sign (anterior subluxation) o Continuing from the Relocation Test, suddenly remove the posterior force o If the patient again looks apprehensive and complains of pain, this is a positive anterior release sign for recurrent anterior subluxation

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ELBOW EXAMINATION If referred pain is suspected, or elbow examination is unremarkable, consider examining the shoulder and hand/wrist

INSPECTION ● Swelling ○ Joint swelling: loss of para-olecranon groove ○ Olecranon bursitis: swelling on posterior aspect of olecranon ● Erythema ● Atrophy ○ Biceps ○ Triceps ○ Brachioradialis ○ Wrist flexors (attached to medial epicondyle) ○ Wrist extensors (attached to lateral epicondyle) ● Deformities ○ Carrying angle o Observe with patient standing, arms at side, elbows extended, palms facing forwards o Angle that the forearm makes with a line drawn straight down through the humerus o Normally 5-10o in men, 10-20 o in women. ○ Flexion ● Skin changes or scars ○ Rheumatoid nodules (rubbery nodules overlying olecranon) ○ Gouty tophi (hard nodules overlying olecranon)

PALPATION (tenderness, warmth) ● Triceps, olecranon and olecranon bursa ● Biceps, biceps tendon in antecubital fossa, brachial artery pulsation ● Wrist flexors (attached to medial epicondyle) ● Wrist extensors (attached to lateral epicondyle) ● Supra-trochlear lymph nodes (above medial epicondyle) ● Elbow effusion ○ Palpate lateral para-olecranon betrween the lateral epicondyle and the olecranon ○ With thumb and index fingers in the para-olecranon groove, flex and extend the elbow checking for a bulge forming ● Medial epicondylitis ○ Tenderness at medial epicondyle and common flexor tendon ● Lateral epicondylitis ○ Tenderness at lateral epicondyle and common extensor tendon ● Radial head ○ Felt by pronating and supinating forearm/hand with elbow flexed 90° and examiner's thumb just distal to the lateral epicondyle ● Bony crepitus

RANGE OF MOVEMENT ● Flexion (140 o +/- 10o) ● Extension: full extension defined as 0 o, up to 10o of hyperextension especially women

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● Pronation and supination ○ Arms at side, elbows flexed, thumbs up ○ Turn palms down: pronation (75-90 o) ○ Turn palms up: supination (8-90 o) ● Assess passive ROM and note end-feel if active is limited

POWER ASSESSMENT ● Resisted isometric testing ● Flexion, extension, pronation, and supination with humerus stabilised

SPECIAL TESTS ● Stability ○ Medial (Ulnar) Collateral Ligament o Hold the elbow to stabilize while keeping it flexed at 30° o Apply a valgus (outward) force against the forearm, while stabilizing the elbow o Excess laxity with valgus force may indicate medial collateral ligament injury ○ Lateral (Radial) Collateral Ligament o Hold the elbow to stabilize while keeping it flexed at 30° o Apply a varus (inward) force against the forearm, while stabilizing the elbow o Excess laxity with varus force may indicate lateral collateral ligament injury ○ Antero-posterior stability o With the elbow flexed 90o, push and pull the humerus: there should be no movement

● Lateral Epicondylitis (Tennis Elbow) ○ Palpate for tenderness at lateral epicondyle and common extensor tendon ○ Resisted wrist extension: with elbow extended and wrist cocked backwards, examiner then tries to pull the hand down while patient resists ○ A positive test is pain at the lateral epicondyle

● Medial Epicondylitis (Golfer's Elbow) ○ Palpate for tenderness at medial epicondyle and common flexor tendon ○ Resisted wrist flexion: with elbow extended and wrist flexed (fingers pointing down), examiner then tries to pull the hand up while patient resists ○ A positive test is pain at the medial epicondyle

● Cubital Tunnel Syndrome ○ Caused by irritation or entrapment of the ulnar nerve in the cubital tunnel (groove between the medial epicondyle and olecranon) ○ Tinel’s Sign o With the elbow flexed at 90o, tap over the ulnar nerve o A positive test positive test is pain or paresthesia radiating to 4th/5th fingers. ○ Elbow Flexion Test o Patient maximally flexes elbow with the wrist extended o Hold this position for 60 seconds to see if paresthesias (radiating to 4th/5th fingers) develop

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HAND AND WRIST EXAMINATION

INSPECTION ● Swelling ● Erythema ○ Palmar erythema associated with portal hypertension, chronic liver disease, pregnancy, , thyrotoxicosis, etc. ● Atrophy ○ Thenar and hypothenar ○ Interossei muscles ○ Dupuytren’s contracture o Caused by thickening and puckering of the palmar fascia o Non-specific, but associated with diabetes, epilepsy, alcoholism, liver disease or cirrhosis ● Deformities ○ Osteoarthritis o Squaring of the wrist o Bouchard's nodes (PIP) o Heberden's nodes (DIP) ○ Rheumatoid arthritis o Joint swelling (DIPs are spared) o Prominent ulnar head o Radial deviation of wrist o Ulnar deviation and subluxation of the MCPs o (PIP hyperextension with DIP flexion) o Boutonniere's deformity (PIP flexion with DIP extension) ○ Psoriatic arthritis o Any joint involved including DIPs o Dactylitis (sausage digits) ● Scars and skin changes ○ ○ Psoriatic nail changes: pitting, onycholysis ○ Gouty tophi ○ Vasculitis: splinter hemorrhages (nail beds), peri-ungal infarcts ○ Scars (such as from a median nerve release procedure)

PALPATION ● Check for warmth and systematically palpate bones and soft-tissues for tenderness ● Ulnar head, ulnar styloid ● Triangular fibrocartilaginous complex (TFCC) (between ulnar head and carpal ) ● Abductor pollicis longus and extensor pollicis brevis (DeQuervain's tenosynovitis) ● Anatomical snuffbox ○ Floor of snuff box formed by scaphoid ○ Tenderness may suggest fracture ● Pisiform, Hook of hamate ● Metacarpals (swelling and point tenderness can be found with a fracture) ● Wrist effusion ○ Using one's thumbs, palpate radiocarpal joint space ○ Check for tense or boggy sensation (effusion) and slide thumbs over radial joint line (if indistinct, this suggest synovitis or effusion)

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○ Try to ballot fluid between one's thumbs ● MCP Effusion ○ Joint line is 1 cm distal to tip of knuckle with MCP flexed ○ Use 4-finger technique: middle fingers to support the underside, tip of thumbs to palpate joint line ○ Check for tenderness, fullness; try to ballot fluid between thumbs ● PIP and DIP Effusion ○ 4-finger technique: thumb and index of one hand on the dorsal and volar aspect, while using the thumb/index of the other hand to feel the sides of the joint ○ Check for tenderness, fullness; try to ballot fluid between fingers ● Flexor tendonitis ○ Palpate flexor tendons in palm for tenderness, check for nodules or crepitus while passively flexing and extending each finger

RANGE OF MOVEMENT ● Quick screen: make a fist with thumb out, then extend all fingers ● PIPs: finger tuck (DIPs flex 0-80°, PIPs flex 100-120°) ● MCPs: extension (10-20°), flexion (90-100°), abduction and adduction ● Thumb ○ Flexion, extension, adduction, abduction, circumduction ○ Opposition (touch thumb to tip of each finger) ● Wrists ○ Flexion (70-90°) ○ Extension 70-90°) ○ Radial and ulnar deviation ○ Supination, pronation, circumduction ○ Tuck sign o During active wrist/finger extension, look for a bulge forming on the dorsal aspect of the wrist o This is found with extensor tenosynovitis

SPECIAL TESTS ● Stability Testing ○ Wrist o Stabilize forearm, grasp hand and gently try to sublux wrist up and down ○ Piano key sign o Hold patient's hand while gently pressing down the ulnar head o If it depresses and comes back up like a piano key, this indicates disruption of the (distal) radioulnar ligament (found in rheumatoid arthritis) ○ MCPs o With MCPs flexed, try to sublux proximal phalanx anteriorly and posteriorly (similar to anterior-posterior drawer test of the knee; small amount of movement normal) o Collateral ligaments at the MCPs ● With the MCPs flexed try move the finger to each side (varus and valgus stress) ● There should be little or no movement ○ IPs o Apply varus and valgus stress to assess collaterals

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● Carpal Tunnel Syndrome ○ Phalen's sign o Patient holds wrist in complete flexion by holding dorsal surfaces of hands together for approximately one minute o If burning or paresthesias over the first, second, third or fourth fingers occurs, this suggests carpal tunnel syndrome ○ Tinel's sign o Tap at the median nerve at the inside of the wrist o If burning or paresthesias occur over the thumb, index, and middle finger, this may indicate carpal tunnel syndrome ● DeQuervain's tenosynovitis ○ Finkelstein’s test o This is caused by inflammation of the sheaths of the abductor pollicis longus and extensor pollicis brevis tendons o Patient makes a fist with the thumb in, then examiner passively moves the wrist into ulnar deviation o Sharp pain along the radial aspect of the wrist indicates DeQuervain’s tenosynovitis

NEUROLOGICAL SCREEN ● Power assessment ○ Grip strength: power across MCPs, PIPs, DIPs ○ Finger extension, flexion ○ Dorsal interossei (abduct fingers against resistance): Ulnar nerve ○ Palmar interossei (adduct fingers against resistance): Ulnar nerve ○ Thumb abduction, flexion, opposition: Median nerve ○ Thumb extension: Radial nerve ○ Wrist flexion: Median nerve ○ Wrist extension: Radial nerve

● Reflexes ○ Biceps (C6) ○ Triceps (C7) ○ Brachioradialis

● Sensory and Motor Assessment

Nerve Motor Sensory

Median nerve “Okay” sign Palmar aspect of the index finger

Radial Nerve “Thumbs up” Dorsal side of the radial half of hand or 1st web space

Ulnar Nerve Finger abduction Fifth finger

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APPENDIX: NEUROLOGICAL ASSESSMENT Depending on the , a neurologic assessment may be required as part of a complete musculoskeletal exam.

INSPECTION ● Inspection can generally be done throughout the examination beginning as the patient enters the room ● Posture and gait ○ Abnormal position may indicate neurologic deficits ● Involuntary movements ○ Tremors, tics, or fasciculations ● Muscle bulk ○ Assess for any signs of muscle atrophy

TONE ● With the patient relaxed, support the limb and put the muscle group through their full range of movement ● Decreased Tone (Hypotonia) ○ Seen in lower motor neuron lesions (nerve root, peripheral nerve) ● Increased Tone ○ Spasticity o Increased resistance that varies and is often worse at the extreme of the range of motion ○ Cog-Wheel Rigidity o Intermittent increased resistance and tremor, felt as jerky, “cog-wheeling” resistance on passive motion o May indicate Parkinson’s Disease ○ Lead-Pipe Rigidity o Increased resistance that persists throughout the entire range of motion o May indicate Parkinson’s Disease

POWER Best to do resisted isometric testing: position the joint as required and then apply force while having the patient resist

Score Description

5 Movement against gravity with full resistance

4 Movement of the body part against gravity and some resistance

3 Movement of the body part against gravity only

2 Movement of the body part with gravity eliminated (supported)

1 Muscle contraction, but no joint movement

0 No muscle contraction

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REFLEXES ● Response depends partly on the force of stimulus ● Hyperactive reflects and sustained suggest upper motor neuron lesions Grade Description ● Diminished or absent reflexes suggest damage to the spine (specifically the level 0 Absent at which the tested nerve originates), peripheral nerves, muscle pathology, or 1+ Diminished neuromuscular junction disorders ○ If reflexes are diminished or 2+ Normal absent bilaterally, reinforcement may increase reflexes 3+ Hyperactive without clonus ○ Ask the patient to clench his teeth or to lock his/her fingers and pull 4+ Hyperactive with clonus

SENSATION For the purposes of a musculoskeletal exam, a quick check of light touch sensation in relevant dermatomes suffices  If a spinal cord lesion is suspected: o Meticulous detailing of the location of altered sensation o Testing of light touch, pain and temperature (spinothalamic tract), and position and vibration (posterior column)  Patient closes their eyes, and indicates when they feel touch from the examiner o Sensation should be compared to the other side of the body o Ensure that the pace is varied so that patients do not merely respond to a pattern o A cotton ball or tongue depressor are commonly used

NEUROLOGIC ASSESSMENT OF THE UPPER BODY May be used to assess and isolate a potential cause of pathology in the cervical spine or upper limbs

Nerve Spinal Muscle Movement Sensation Reflex

Axillary C5,6 Deltoid Arm abduction Deltoid

Radial C6,7,8 Triceps Elbow extension Anatomic snuff Triceps box Brachioradialis

C7,8 Wrist Wrist extension Dorsal side of extensors "Thumbs up" sign radial 1/2 of hand

Musculocuta C5,6 Biceps Elbow flexion Lateral forearm Biceps neous

Median C6,7 Flexor Thumb IP flexion Palmar side of pollicis "Okay sign" first 3 1/2 fingers longus

Ulnar C8,T1 Interossei Finger abduction / 5th finger of hands adduction

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NEUROLOGIC ASSESSMENT OF THE LOWER BODY May be used to assess and isolate a potential cause of pathology in the hip, leg, ankle, or foot

Nerve Spinal Muscle Movement Sensation Reflex

Femoral L1,2,3 Iliopsoas Hip flexion

L2,3,4 Quadriceps Knee extension Anterior thigh Patellar

Obturator L2,3,4 Hip adductors Hip adduction Innermost thigh

Superior L4,5,S1 Hip abductors Hip abduction gluteal

Sciatic L5,S1,2 Hamstrings Knee flexion Outer thigh, calf Achilles

Deep L4,5 Tibialis anterior Ankle dorsiflexion peroneal

L5,S1 Extensor Great toe Space between hallucis longus dorsiflexion the great toe and second toe

Tibial S1,2 Gastrocnemius, Ankle plantar Plantar aspect Achilles soleus flexion of the arch of the foot

Posterior L4,L5 Tibialis Posterior foot tibial inversion

Superficial L5,S1 Peroneus Foot eversion Dorsum of foot peroneal longus, brevis

McMaster Musculoskeletal Clinical Skills Manual S. Adiga, J. Rebelo, C. Lees, R. Carmona