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 Medicine 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 joints, 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 pathology (eg. osteoarthritis, fracture) ○ Soft end-feel suggests soft-tissue pathology (joint 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. ● Pulses, 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 ● Trendelenburg gait (Weakened abductor muscles) ○ During the stance phase, if the hip 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 McMaster Musculoskeletal Clinical Skills Manual S. Adiga, J. Rebelo, C. Lees, R. Carmona 3 HIP EXAMINATION If the hip examination is unremarkable or you suspect referred pain, consider examining the back and knee. 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 contracture 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) McMaster Musculoskeletal Clinical Skills Manual S. Adiga, J. Rebelo, C. Lees, R. Carmona 4 PALPATION ● Pubic symphysis ● Inguinal ligament ● Femoral pulse ● 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 femur 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 knees 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 McMaster Musculoskeletal Clinical Skills Manual S. Adiga, J. Rebelo, C. Lees, R. Carmona 5 SPECIAL TESTS ● Thomas Test (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 hips) ○ 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 McMaster Musculoskeletal Clinical Skills Manual S. Adiga, J. Rebelo, C. Lees, R. Carmona 6 ● 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. McMaster Musculoskeletal Clinical Skills Manual S. Adiga, J. Rebelo, C. Lees, R. Carmona 7 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) McMaster Musculoskeletal Clinical Skills Manual S. Adiga, J. Rebelo, C. Lees, R. Carmona 8 INSPECTION ● While standing: ○ Swelling o Popliteal fossa for Baker’s cysts ○ Erythema ○ Atrophy o Calves o Quadriceps o Hamstrings ○ Deformities o Genu recurvatum (hyperextension) o Genu procurvatum (flexion deformity, always abnormal) o Genu varum (bow-legged) o