SIT DOWN, STAND UP, BEND OVER A Review of the Musculoskeletal Physical Examination Larry Collins, MPAS, PA-C, ATC, DFAAPA Assistant Professor, Physician Assistant Program Assistant Professor, Department of Orthopaedics & Sports Medicine USF Health, Morsani College of Medicine History You cannot overemphasize the importance of a thorough and detailed history. In most cases if you ask the appropriate questions you will have a very good idea of the diagnosis before you ever examine the patient. Questions must include: • Onset • ADL’s • Mechanism of injury • Work activities • Quality of symptoms • Precipitating factors • Persistence of symptoms • Alleviating factors • Previous injuries • Mechanical symptoms • Treatment to date • Training routines Physical Examination You should strive to perform a detailed and systematic physical examination that follows a similar pattern each time you evaluate a patient. Knowing appropriate anatomy is paramount to properly evaluating your patients. A typical routine might be: • Inspection • Palpation Don’t forget: • R.O.M. • Joint above/below • Strength • Neurological • Stability • Vascular • Special tests • Referred pain Anatomy - Vertebral Column • 7 Cervical vertebrae • 12 Thoracic vertebrae • 5 Lumbar vertebrae • Sacrum Anatomy • Vertebral column – Anterior Segment - weight bearing • Vertebral Bodies • Intervertebral Disc – Posterior Segment - regulates motion and protects spinal cord and nerve roots • Facet joints Thoracic – horizontal, allowing rotation, • Pedicles side-bending • Neural Foramina Lumbar – vertical, allowing flexion/extension • Spinous processes • Muscular insertions • Spinal Cord and nerve roots Anatomy Ligaments Muscles • Prevent extremes of • Superficial movement – Erector Spinae • Anterior and • Deep Posterior – Multifidis Longitudinal – Interspinalis Ligaments – Intertransversarii • Posterior Ligament • Psoas narrows near sacrum • Iliacus • Abdominals Anatomy - Nerves An unfortunate patient is diagnosed with having a lateral disc herniation at the C56 and L45 levels. • Which of the following dermatomes would you expect to be affected? a) C5 and L4 b) C6 and L5 c) C5 and L5 d) C6 and L4 Anatomy – Nerve Roots Anatomy - Nerves Cervical Spine Palpation Strength • Spinous process • C5 • Paravertebral muscles • C6 • C7 Range of Motion • C8 • Flexion • T1 • Extension • Rotation Reflexes • Lateral bending • C5 • C6 Sensation • C7 • C2 Special Tests • C3 • Spurling’s • C4 • Valsalva • C5 • Compression/Distraction • C6 • Vertebral Artery Test • C7 • C8 • T1 Cervical Sensory Reflexes Motor Lumbar Spine Palpation Strength • Spinous process • T12 – L3 • Paravertebral muscles • L2 – L4 • L4 Range of Motion • L5 • Flexion • S1 • Extension • Rotation Reflexes • Lateral bending • L4 • S1 Sensation • Babinski • L1 Special Tests • L2 • Straight leg raise • L3 • Gaenslen’s • L4 • Pelvic ‘rock’ • L5 • One-leg hyperextension • S1 • Patrick (Fabere) • S2-5 • Hoover’s • Kernig/ Brudzinkski Examination Of Patient With Low Back Pain Shoulder Anatomy Shoulder Anatomy Ligaments Shoulder Anatomy Muscles Shoulder Exam • Inspection – Atrophy – Scapular dyskinesis • ROM – Active vs. passive • Strength – Rotator cuff • Special Tests – Impingement – Stability Scapular Dyskinesis ©2003-2007 Dr. Lintner, MD. eMedWebs, Inc.® - TOS - Houston TX Atrophy Shoulder Palpation • Bones – SC – Clavicle – AC – Scapula – Coracoid process – Greater tubercle humerus – Biceps groove Shoulder Range of Motion - active/passive • Shoulder shrug – symmetry • Forward flexion – 180 degrees • Extension – 50 degrees • Abduction – 180 degrees • Adduction – 50 degrees • Internal rotation – 90 degrees • External rotation – 90 degrees Range of Motion Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med. 2002;30:136–151 Shoulder Strength • Shoulder shrug - CN XI • Forward flexion • Abduction • Internal/external rotation Strength • Supraspinatus – abduction • Infraspinatus – external rotation • Teres Minor – external rotation • Subscapularis – internal rotation Rotator Cuff Exam Empty can – supraspinatus External rotation – infraspinatus Hawkins impingement test Apprehension test Murrell GAC and Walton J. Clinical diagnosis of rotator cuff tears. The Lancet, 357 (2001): 769-770. Special Tests Neer’s test • Supraspinatus Impingement Stability Exam • Sulcus sign • Apprehension test • Apprehension-relocation test • Anterior/posterior drawer test Generalized Laxity SLAP Exam (Superior Labrum Anterior Posterior) • Compression rotation test • Obrien’s test • Biceps tension test (speed test) Nerve Injuries Suprascapular Nerve Nerve Injuries Long Thoracic Nerve Elbow • Carrying Angle • Surface Anatomy – Medial epicondyle – Lateral epicondyle – Olecranon – Ulnar groove – Radial head Elbow • ROM • Special Tests – Flexion, extension, – Varus/Valgus Stress pronation, supination – Lateral Epicondylitis • Manual muscle – Medial Epicondylitis strength – Tinel's Sign Wrist, Hand and Fingers • Surface Anatomy – Ulnar Styloid – Scaphoid – Pisiform – Hook of hamate – MCP joints – IP joints Wrist, Hand and Fingers • ROM • Special Tests – Flexion, extension, – Pinch Grip pronation, supination, – Finkelstein Test radial/ulnar deviation, – Phalen's excursion (MC rotation) – Tinel – Allen's • Manual Muscle Tests Hip • Injuries to hip & pelvis are often frustrating – Evaluation is difficult • May involve variety of soft tissues and bones • May be acute, sub-acute or chronic • Large differential diagnosis – Understand mechanism, natural history & physical findings – Accurate diagnosis is essential Hip • Inspection • Strength • Palpation – Flexors • ROM (passive/active) – Extensors – Lumbar spine – Abductors – Hip – Adductors • Flexion – 120 – Hamstrings • Extension – 10 – Quadriceps • Abduction – 40 • Adduction – 30 • Internal rotation – 50 • External rotation – 35 – Knee Hip • Neurovascular – Sensation – Pulses – DTR • Specific tests – Trendelenburg – Ober test – Patrick’s/Fabere test – Gaenslen's test – Compression/Distraction – Hernia/testicular Knee Anatomy Knee • Key factors in making diagnosis – Mechanism of injury – Onset of swelling – Ability to bear weight – Mechanical symptoms – Instability – Pre-existing conditions Knee • Inspection • Alignment – Lacerations/Contusions – Alignment/Deformity – Effusion/Hemarthrosis – Gait • Palpation – Joint line pain • Meniscus tear – Palpable defects • Quadriceps tendon, Patella ligament, Patella fracture Knee • ROM – Knee (0 - 140) • Strength – Quadriceps • Straight leg raise • Extensor lag – Hamstrings • Neurovascular Physical Examination • Special tests – Meniscus • Joint line pain • Squat • Steinmann • McMurray • Apley • Thessaly • Hip Differential Diagnosis Acute hemarthrosis – Peripheral meniscus tear – ACL/PCL tear – Dislocation • Patella, knee – Fractures – Bleeding disorders • Coumadin • PVNS vs. Prepatellar Bursitis Physical Examination Ligaments Injured Ligament Key Test Secondary Test ACL Lachman Pivot Shift MCL Valgus laxity at 30 Valgus laxity at 0 PCL Posterior drawer at 90 Posterior sag at 90 LCL Varus laxity at 30 Varus laxity at 0 Posterolateral corner ER at 30 Posterior drawer at 30 Ligament Injuries - ACL Examination – Hemarthrosis – Contralateral side – Anterior drawer – Lachman – Pivot Shift • Difficult to reproduce • Must be relaxed Ligament Injuries – MCL Examination – Pain to palpation – Little or no effusion/hemarthrosis – Valgus instability at 30 (@ 0 ACL) – In child consider growth plate injury Ligament Injuries – PCL Examination – Hemarthrosis – Posterior drawer – Posterior sag – Quadriceps active test Extensor Mechanism Injuries • Commonly misdiagnosed • Anatomy – Quadriceps muscle quadriceps tendon patella patella tendon Extensor Mechanism Injuries • History – Patella tendon • Younger patient • Athletics – Quadriceps tendon • Older patient • Systemic disease – Vigorous eccentric quadriceps contraction – Unable to straighten leg – Fluoroquinolones (Cipro, Levaquin, etc.) Extensor Mechanism Injuries • Examination – Palpable defect – Unable to do straight leg raise • Extensor lag – Hemarthrosis • Imaging – Radiographs • Patella alta • Peds – sleeve fracture, tibial tubercle avulsion – MRI/Ultrasound Anterior Knee Pain • Multifaceted – Mal-alignment – Weakness (VMO, hip extensors) – Decreased flexibility (quad, calf – Neuromuscular adaptations (increased reflex arc, decreased response times) – Generalized joint laxity Q – angle Pronated Foot PFPS – Exam • Observe and palpate tracking through active flexion and extension • Crepitus most noticeable with active motion • Patellar compression may increase pain • Translate patella laterally in extension and attempt to flex knee • Assess general laxity Popliteal Cyst – Exam • Between semimembranosus and medial head gastrocnemius • Most visible and palpable with the knee extended (standing) • Palpate for size, consistency, and tenderness • Examine the knee for signs of derangement (i.e. meniscal tears) Popliteal Cyst – Differential Diagnosis • Deep vein thrombosis (ultrasound) • Exertional compartment syndrome (compartment pressure measurement) • Inflammatory arthritis (serologic tests) • Medial gastrocnemius strain (H & P) • Soft-tissue tumor (MRI) • Superficial phlebitis (H & P, –US) Ankle Anatomy Ankle Anatomy Ankle • Inspection – Pronation, pes planus • Palpation – Medial malleolus, lateral malleolus, navicular, 5th metatarsal – ATFL, deltoid, peroneal, posterior tibialis • ROM / Strength – Dorsiflexion, plantarflexion, inversion, eversion, subtalar motion Inversion