Advanced Musculoskeletal Examination

Advanced Musculoskeletal Examination

• This module is titled "Advanced Musculoskeletal Examination" and the module code is PDIII PAS3038C.

Learning Objectives

• Distinguish the anatomy of the major joints (TMJ, Vertebral column, shoulder, elbow, wrist, hand, fingers, hip, knee and ankle).
• Demonstrate the proper techniques for a musculoskeletal examination.
• Analyze appropriate questions used to evaluate problems involving the temporomandibular joint (TMJ); cervical, thoracic and lumbar spines; shoulder, elbow, wrist, fingers, thumbs, hip, knee, ankle and toes.
• Differentiate important anatomic landmarks in each of these joints and understand their clinical significance.
• Distinguish the anatomical composition and demonstrate the examination for the following joints with special exam techniques needed to effectively diagnose problems:

Special Joint Exam Techniques

• Shoulder tests include Painful arc (screening test), Apley's Scratch test, Crossover test, Neer's impingement sign, Hawkin's impingement sign, Full can test, Empty can test, and Infraspinatus test.
• Wrist tests include Froment's Sign (ulnar nerve), Tinel's Sign (median nerve, carpal tunnel syndrome), Phalen's Sign (median nerve, carpal tunnel syndrome), and Finkelstein's Test (De Quervain's Tenosynovitis).
• Knee tests include Bulge Sign (Effusion), Patellar Tap Test AKA “Ballotable Patella", Abduction stress test (MCL), Adduction stress test (LCL), Anterior drawer sign (ACL), Posterior drawer sign (PCL), Lachman Test, and McMurray's (Medial and lateral menisci).
• Ankle and foot tests include Testing Integrity of the Subtalar (Talocalcaneal) Joint (talar tilt test), integrity of talocrural joint, transverse tarsal joint, test for plantar fasciitis and Morton neuroma.
• Apply the findings from a focused history, physical examination, differential diagnosis, and diagnostic testing to attain an appropriate treatment and patient education plan for a given simulation/OSCE case.

Joint Structures

• Articular structures include joint capsule, articular cartilage, synovium and synovial fluid, intra-articular ligaments, and juxtaarticular bone.
• Extra-articular structures include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve and overlying skin
• Ligaments are ropelike bundles of collagen fibrils that connect bone to bone.
• Tendons are collagen fibers connecting muscle to bone.
• Cartilage is a collagen matrix overlying bony surfaces.
• Bursae are disc-shaped synovial sacs that facilitate joint action and allow adjacent muscles or muscles and tendons to glide over each other during movement with reduced friction.

Joint Pathology

• Pathology of articular structures involves swelling and tenderness of the joint, crepitus, instability, "locking,” or deformity and limits both active and passive range of motion (ROM) due to stiffness, mechanical blockage, or pain.
• Pathology involving extraarticular structures rarely causes intraarticular joint swelling, instability, or joint deformity.
• Extraarticular pathology typically involves “point or focal tenderness in regions adjacent to articular structures," and limits active ROM only.

Common Symptoms

• Joint pain is the leading complaint of patients seeking treatment, thus attributes of each symptom, including context, associations, and chronology, should be clarified.
• Understanding summary of essential characteristics, summarize as the seven attributes of a symptom, is critical.
• It's essential to discern neck pain requiring immediate stabilization from pain resulting from more common musculoskeletal causes.
• If the patient reports neck trauma (e.g., motor vehicle accident), ask about neck tenderness and consider clinical decision rules that identify risk of cervical spine injury.
• Persistent pain after blunt trauma or a collision warrants further evaluation.
• At least 60% of adults experience low back pain at least once, with prevalence and related disability peaking between ages 35 and 55.

Joint Pain

• First goal is to characterize the patient complaint
• Assess if the join problem is articular or extraarticular by asking the patient to point to the pain.
• Differentiate if the pain is localized (monoarticular) or diffuse (polyarticular), inflammatory or non-inflammatory (cardinal signs and symptoms).
• Establish whether the pain is acute (usually <6 weeks) or chronic (usually >12 weeks).
• Focus can save time since patient descriptions of the location of the pain may be vague.
• Important to clarify and record the mechanism of injury, particularly if the joint pain is caused by trauma

Joint pain location characteristics

• Pain in a single joint suggests injury, monoarticular arthritis, or extraarticular causes like tendinitis, bursitis, or soft tissues injury.
• Oligoarticular (pauciarticular) arthritis can result from infection (e.g., gonorrhea or rheumatic fever, connective tissue disease, and OA) among other causes.
• Causes of polyarthritis include viral or inflammatory from RA, systemic lupus erythematosus (SLE), or psoriasis.
• Spondyloarthropathies (e.g., psoriatic arthritis) often involve the spine, including sacroiliac joints and medium-to-large joints, such as the shoulders, hips, knees, and ankles.
• Smaller joint involvement, such as the wrists, fingers, and toes, is more consistent with RA and SLE.

Assessment of Joint Pain

• Ask Does the pain radiate or travel anywhere else; pain in the smaller joints (hands, feet) are localized than larger joints.
• Hip joint pain can be particularly deceptive since true pain from the hip joint typically radiates to the groin, although it can also cause knee pain.
• Sacral/sacroiliac pain is often in the buttock, and trochanteric pain from bursitis or tendinitis can occur on the lateral thigh.
• How bad is the pain? Ask for the severity rating on a scale of 1 to 10.
• Ask about the setting in which the pain occurs and how the pain arose.
• Include environmental factors, personal activities, emotional reactions, and other circumstances that may have contributed to the occurrence of the pain.
• Acute injury or overuse from repetitive motion of the same part of the body must be considered.
• Determine in detail the mechanism of injury or the specific series of events that caused the joint pain.

Inflammatory vs Non-inflammatory Joint Pain

• Inflammatory causes of joint pain tend to be more painful than noninflammatory types
• Examples of causes of inflammatory disorders include infectious, where N. gonorrhoeae, M. tuberculosis are responsible, crystal-induced where gout and pseudo-gout, are responsible.
• Immune-related inflammatory causing disorders include: Rheumatoid arthritis, Systemic lupus erythematosus, and reactive causes of inflammatory disorders include Rheumatic fever, or reactive arthritis
• Causes of non-inflammatory disorders include trauma like rotator cuff tear, overuse like bursitis or tendinitis, and degenerative changes like osteoarthritis, or fibromyalgia

Joint Pain Considerations

• Ask what aggravates or relieves pain
• Ask about the effects of exercise or physical activity, rest, medications and physical therapy, quantify the change, if any, using a rating scale of 1 to 10
• In inflammatory joint disorders (e.g., RA), rest tends to worsen pain while activity improves the symptoms
• In mechanical joint disorders (e.g., OA), activity tends to increase pain and stiffness, rest improves symptoms.

Associated Symptoms

• Four cardinal features of inflammation include swelling, warmth, redness, in addition to pain
• Inquire about fever and chills
• High-grade fever and chills typically seen in septic arthritis
• Low-grade fever can be present in crystal-induced arthritis or inflammatory arthritis, like RA
• Extraarticular pain occurs in inflammation of bursae (bursitis), tendons (tendinitis), or tendon sheaths (tenosynovitis), as well as in sprains from stretching or tearing of ligaments
• Symptoms of decreased joint movement and stiffness indicate pain is articular

Joint Stiffness

• Musculoskeletal stiffness refers to a perceived tightness or resistance to movement
• Pattern of stiffness: worse in morning, gradually better with activity
• Intermittent "gel phenomenon namely brief periods of daytime stiffness following inactivity lasting from 30 to 60 minutes then get worse again with movement?
• Stiffness lasting more than 1 hour represents severe inflammation in rheumatoid arthritis or polymyalgia rheumatica
• Morning stiffness gradually improves with activity being more common in inflammatory disorders like RA and PMR
• Intermittent stiffness or gelling worsening over the day is commonly seen in osteoarthritis

Assessing Joint Pain

• When assessing decreased or limited movement, ask about activity changes due to problems with the involved joint
• Articular joint pain generally involves decreased active (joint movement performed by the patient) and passive (joint movement performed on the patient by the examiner) ROM with morning stiffness or "gelling."
• Periarticular joint pain involves periarticular tenderness and pain with active ROM, while passive ROM remains intact

Constitutional Symptoms

• Joint problems associated with constitutional symptoms like fever, chills, rash, fatigue, anorexia, weight loss, and weakness
• Joint disorders have systemic manifestations in other organ systems, which can provide clues to diagnosis.
• Watch for the symptoms, signs, and disorders associated with these disorders
• Ask about family history of joint or muscle disorders
• Constitutional symptoms are common in inflammatory arthrites such as RA, SLE, and PMR
• High fever and chills suggest an infectious cause
• Rapid or gradual onset of pain should be assessed

Rapid Onset

• Rapid onset of severe pain in adults suggests acute septic arthritis or crystalline arthritis (Gout).
• Osteomyelitis should be considered in a bone contiguous to a joint of children exhibiting joint pain.

Assessing Neck Pain history

• Neck pain is a common complaint, but it is essential to discern neck pain requiring immediate stabilization from pain resulting from the more common musculoskeletal causes.
• Trauma is common in MVA, identify risk of cervical spine injury, and persistent pain after blunt trauma or collision requires further evaluation
• Radiation into the arm, hand, scapular area, weakness, numbness, or paresthesias (could indicate impingement of the spinal cord or one of the spinal nerves)
• Radicular pain signals spinal nerve compression and/or irritation
• Any level can be affected, but the C6 and C7 levels are most common
• Foraminal impingement from degenerative joint changes is more common (70% to 75%) than disc herniation (20% to 25%).

Assessing Low Back Pain

• Most guidelines categorize low back pain (Nonspecific >90%, Nerve root entrapment with radiculopathy or spinal stenosis ~5%, and pain from specific underlying disease 1-2%) into 3 groups.
• Nonspecific low back pain (“low back sprain or strain”) is usually from musculoligamentous injuries and age-related degenerative processes of the intervertebral discs and facet joints.
• Ask about each of the following Location, Radiation, History of trauma,Midline pain.
• Assess if there is any bladder or bowel dysfunction

Midline vs Off the Midline LBP

• Midline pain signifies disc herniation, musculoligamentous injury, degenerative disease of the facet joints of the spine, vertebral collapse, spinal cord metastases, or epidural abscess
• Off the midline signifies muscle strain, myofascial pain (trigger points), sacroiliitis, trochanteric bursitis, hip arthritis, sciatica, pyelonephritis, or kidney stones
• Radicular gluteal and posterior leg pain is usually caused by impingement nerve roots at the L4–S1 root levels.
• Leg pain that improves with lumbar forward flexion occurs in spinal stenosis

Lumbar Radicular Pain

• Sciatic pain is sensitive (~95%) and specific (~88%) for disc herniation; up to 85% of the cases are associated with a disc disorder, usually at L4-L5 or L5-S1 levels.
• Shooting pain often below the knee, commonly into the lateral leg (L5) or posterior calf (S1).
• Often with associated paresthesias and weakness, worsened by bending, sneezing, coughing, straining during bowel movements
• When the sciatic nerve is irritated by the piriformis muscle, it is termed piriformis syndrome, with symptoms reproduced with FAIR or sometimes FADIR tests
• FAIR = Flexion, ADduction, Internal Rotation
• Pain associated with forward flexion, straight-leg raise/slump maneuvers, valsalva or sneezing indicates disc disease

Low Back Pain Red Flags

• Age <20 years or >50 years
• History of cancer
• Unexplained weight loss, fever or decline in general health
• Pain lasting more than 1 month or not responding to treatment
• Pain at night or present at rest
• History of intravenous drug use, addiction or Immunosuppression
• Presence of active infection or HIV infection
• Long-term steroids therapy
• Saddle anesthesia, bladder or bowel incontinence
• Neurologic symptoms or progressive neurologic deficit

Physical Examination

• Keep the patient's baseline level of function in mind during exam.
• Visualize anatomy of joints and pertinent points of history and time course
• Inspection is important, palpation of bony structures, assess ROM and also special tests.
• Inspect for joint symmetry, signs of deformity, swelling scars, and atrophy.

Physical Exam: Assess for...

• Palpate for surface anatomy landmarks to localize points of tenderness, fluid collection, crepitus or nodules
• For ROM the patient should actively move the involved joint, then have them move passively.
• Decreased ROM points to arthritis, effusion, tissue inflammation or fibrosis.
• Special move to assess tendon, bursae, and ligament integrity.
• Assess for infection, tenderness, warmth and redness.
• Evaluate neurovascular, strength, and pulses.

Shoulder Examination

• Inspect for symmetry, bony deformities, inflammation, and muscle atrophy of the sternoclavicular joint, clavicle, acromioclavicular joint, & glenohumeral joint.
• Palpate bony landmarks and any places of tenderness.
• Check the range of motion, including flexion, extension, abduction, adduction, internal and external rotation.
• Perform maneuvers to assess the AC joint, bursae, overall shoulder rotation, and rotator cuff

Scapulohumeral group Examination

• Abducts, rotates internally and externally, depresses, rotates humeral head
• Includes supraspinatus, infraspinatus, deltoid, teres minor and latissimus dorsi

Axioscapular group Examination

• Trapezius, rhomboid, serratus anterior, levator scapula
• Muslces rotate and pull the shoulder posteriorly

Joint Stability Examination

• Static stabilizers are from bony and soft tissue, capsule and gh ligaments that add stability.
• Static stabilizers include the labrum (fibrocartilaginous ring around glenoid)
• The rotator cuff and gleno-humeral ligaments strengthen the joint capsule and add to stability
• Dynamic stabilizers are from the SITS and the biceps and triceps

Bicipital Groove Evaluation

• Capsules lined by synovial membrane with 2 bursae; (subscapular bursa and synovial sheath of tendon of the long head of the biceps
• Tendon of the long head of biceps in bicipital groove between greater and lesser tubercles
• Principle bursa of shoulder is subacromial subdeltoid bursa
• Lies betwe rotator cuff tendons acromion of scapula, acromioclavicular joint, bicipital groove, and deltoid muscle
• Abduction of shoulder compresses this bursa but is usually not tender
• If inflamed (subacromial, subdeltoid bursitis) then there may be tenderness just below the tip of acromion, pain with abduction and rotation with loss of movement