Pearls in the Musculoskeletal Exam Frank Caruso MPS, PA-C, EMT-P Skin, Bones, Hearts & Private Parts 2019 Examination Key Points • Area that needs to be examined, gown your patients - well exposed • Understand normal functional anatomy • Observe normal activity • Palpation • Range of Motion • Strength/neuro-vascular assessment • Special Tests General Exam Musculoskeletal Overview Physical Exam Preview Watch Your Patients Walk!! Inspection • Posture – Erectness – Symmetry – Alignment • Skin and subcutaneous tissues – Swelling – Redness – Masses Inspection • Extremities – Size – Deformities – Enlargement – Alignment – Contour – Symmetry Inspection • Muscles – Bilateral symmetry – Hypertrophy – Atrophy – Fasciculations – Spasms Palpation • Palpate bones, joints, and surrounding muscles for the following: – Heat – Tenderness – Swelling – Fluctuation – Crepitus – Resistance to pressure – Muscle tone Muscles • Size and strength affected by the following: – Genetics – Exercise – Nutrition • Muscles move joints through range of motion (ROM). Muscle Strength • Compare bilateral muscles – Strength – Symmetry – Equality – Resistance End Feel Think About It!! • The sensation the examiner feels in the joint as it reaches the end of the range of motion of each passive movement • Bone to bone: This is hard, unyielding – normal would be elbow extension. • Soft–tissue approximation: yielding compression that stops further movement – elbow and knee flexion. End Feel • Tissue stretch: hard – springy type of movement with a slight give – toward the end of range of motion – most common type of normal end feel : knee extension and metacarpophalangeal joint extension. Abnormal End Feel • Muscle spasm: invoked by movement with a sudden dramatic arrest of movement often accompanied by pain - sudden hard – “vibrant twang” • Capsular: Similar to tissue stretch but it does not occur where one would expect – range of motion usually reduced. Abnormal End Feel • Bone to bone: similar to normal bone – to bone but the restriction or sensation of restriction occurs before the normal end of range of movement • Empty: detected when considerable pain is produced by movement - - no real mechanical resistance – acute bursitis – neoplasm. Abnormal End Feel • Springy block: similar to a tissue stretch – occurs where one would not expect it to occur – usually found in joints with menisci. There is a rebound effect – example: would feel a springy block end feel with a torn meniscus of a knee when it is locked or unable to go into full extension (usually no muscle spasm). Range of Motion • Active ROM and passive ROM for each joint and related muscle group • Note – Pain – Limited or spastic movement – Joint instability – Deformity – Contracture Range of Motion • Passive ROM may exceed active ROM by 5 degrees. • Active ROM and passive ROM should be equal in contralateral joints. • Discrepancies may indicate muscle weakness or disorder. • Use goniometer where there is increased or limited ROM. Examination and Findings Equipment • Marking pencil • Goniometer • Tape measure • Reflex hammer • Inclinometer • Mono-filament Goniometry • Is most appropriate for the measurement of medium and small appendicular joints • The examination procedure and techniques used must be consistent Lets Put It All Together!! Joint by Joint My Shoulder Hurts!! Shoulder ICD-9 ICD 10 • Shoulder pain – 719.41 • Shoulder pain – M25.51 • Rotator cuff sprain - • Rotator cuff sprain - 840.4 S43.4 • Rotator cuff tendonitis • Rotator cuff tendonitis – 726.10 – M75.1 Shoulder/Scapula 34 36 Supraspinatus 37 38 Infraspinatus 39 Teres Minor 40 Subscapularis 41 Exam & Findings: Shoulders • Inspect – Shoulder girdle, Clavicle, and Scapula for: – Size – Symmetry – Contour – Dislocation/winging of scapula • Palpate – Sterno-clavicular joint – Acromioclavicular joint – Shoulder muscles – Biceps Groove Exam & Findings: Shoulders • Assess Active and Passive ROM – Forward flexion • The arm is kept straightened and brought upward through the frontal plane, and moved as far as the patient can go above his head. Note: for recording purposes, 0 degrees is defined as straight down at the patient's side, and 180 degrees is straight up Exam & Findings: Shoulders • Assess Active and Passive ROM – External rotation (hands behind head) – The patient is positioned sitting and the elbow is flexed 90 degrees – While the elbow is held against the patient's side, the examiner externally rotates the arm as permitted Exam & Findings: Shoulders • Assess Active and Passive ROM – Extension Exam & Findings: Shoulders • Assess Active and Passive ROM – Abduction Adduction Shoulder Assessment • Several procedures are used to evaluate rotator cuff for impingement or tear―increased pain associated with inflammation or tear • Neer test – Internally rotate and forward flex arm at the shoulder: presses supraspinatus muscle against anteroinferior acromion Shoulder Assessment • Hawkins test – Forward flexing shoulder to 90 degrees, flexing elbow to 90 degrees, and then internally rotating arm to its limit Apley scratch test. The patient attempts to touch the opposite scapula to test range of motion of the shoulder. (Left) Testing abduction and external rotation. (Right) Testing adduction and internal rotation. Supraspinatus examination ("empty can" test). The patient attempts to elevate the arms against resistance while the elbows are extended, the arms are abducted and the thumbs are pointing downward. Infraspinatus/teres minor examination. The patient attempts to externally rotate the arms against resistance while the arms are at the sides and the elbows are flexed to 90 degrees. Subscapular Muscle Testing • Push off • Largest part of the rotator cuff 52 Test Maneuver Diagnosis suggested by positive result Apley scratch Patient touches superior and inferior aspects of opposite Loss of range of motion: rotator cuff test scapula problem Neer's sign Arm in full flexion Subacromial impingement Hawkins' test Forward flexion of the shoulder to 90 degrees and internal Supraspinatus tendon impingement rotation Drop-arm test Arm lowered slowly to waist Rotator cuff tear Cross-arm Forward elevation to 90 degrees and active adduction Acromioclavicular joint arthritis test Apprehension Anterior pressure on the humerus with external rotation Anterior glenohumeral instability test Relocation Posterior force on humerus while externally rotating the arm Anterior glenohumeral instability test Sulcus sign Pulling downward on elbow or wrist Inferior glenohumeral instability Yergason test Elbow flexed to 90 degrees with forearm pronated Biceps tendon instability or tendonitis Speed's Elbow flexed 20 to 30 degrees and forearm supinated Biceps tendon instability or tendonitis maneuver "Clunk" sign Rotation of loaded shoulder from extension to forward flexion Labral disorder Probable Finding diagnosis Scapular winging, trauma, recent viral illness Serratus anterior or trapezius dysfunction Seizure and inability to passively or actively rotate Posterior shoulder dislocation affected arm externally Supraspinatus/infraspinatus wasting Rotator cuff tear; suprascapular nerve entrapment Pain radiating below elbow; decreased cervical range Cervical disc disease of motion Shoulder pain in throwing athletes; anterior Glenohumeral joint instability glenohumeral joint pain and impingement Pain or "clunking" sound with overhead motion Labral disorder Nighttime shoulder pain Impingement Generalized ligamentous laxity Multidirectional instability IMPINGEMENT 55 Patient Symptoms: Impingement • I can’t sleep at night, my shoulder is killing me • It is too painful to raise up my arm • It feels like my bones are rubbing together • My arm is painful and weak • My shoulder, neck and arm are hurting me 56 Exam Summary: • Pain with painful arc maneuver – subacromial impingement • Focal subacromial tenderness • Painless testing of resisted abduction (supraspinatus), external rotation (infraspinatus), adduction ( subscapularis), and elbow flexion (Biceps) • Normal range of motion of the glenohumeral joint • Preserved strength in all directions 57 ROTATOR CUFF TENDONITIS 62 Patient Symptoms: Rotator Cuff Tendonitis • I can’t reach up my back anymore • Whenever I move in certain directions I get a sharp deep pain in my shoulder • My arm feels better by hanging it over the bed 63 Exam Findings: • Focal subacromial tenderness • Subacromial impingement, a positive painful arc test • Positive Flexion Abduction Resistance (FAR) • Normal range of motion of glenohumeral joint • Preserved rotator cuff strength – no gross weakness 64 ADHESIVE CAPSULITIS – FROZEN SHOULDER 65 Patient Symptoms: Adhesive Capsulitis • My shoulder is stiffening up • I can’t reach up over my head • Its getting harder and harder to put my coat on • My shoulder used to be painful, pain has improved by I can’t move it now 66 Exam Summary • Loss of external rotation with elbow at side • Restricted abduction • My shoulder makes this terrible clunking noise • No radiographic evidence of glenohumeral osteoarthritis 67 ROTATOR CUFF TENDON TEAR 69 Patient Symptoms: Rotator Cuff Tear • I have no strength in my shoulder any more • Every time I roll my shoulder , it pops • I can’t sleep on my back any more, There’s this spot of pain over my shoulder blade 70 Exam Summary: • Weakness in testing of rotator cuff muscles • Rule out central lesion • Positive drop arm test • High riding humeral head (older patients) 71 ACROMIO-CLAVICULAR STRAIN/OSTEOARTHRITIS 78 Acromioclavicular Joint(AC) ICD-9 ICD-10 • AC joint pain: 719.41 • AC joint