Macleod's Clinical Examination 15th Edition PDF

John Macleod (1915–2006) John Macleod was appointed consultant physician at the Western General Hos- pital, Edinburgh, in 1950. He had major interests in rheumatology and medical education. Medical students who attended his clinical teaching sessions remember him as an inspirational teacher with th...

John Macleod (1915–2006) John Macleod was appointed consultant physician at the Western General Hos- pital, Edinburgh, in 1950. He had major interests in rheumatology and medical education. Medical students who attended his clinical teaching sessions remember him as an inspirational teacher with the ability to present complex problems with great clarity. He was invariably courteous to his patients and students alike. He had an uncanny knack of involving all students equally in clinical discussions and used praise rather than criticism. He paid great attention to the value of history taking and, from this, expected students to identify what particular aspects of the physical examination should help to narrow the diagnostic options. His consultant colleagues at the Western welcomed the opportunity of contrib- uting when he suggested writing a textbook on clinical examination. The book was first published in 1964, and John Macleod edited seven editions. With character- istic modesty he was very embarrassed when the eighth edition was renamed Macleod’s Clinical Examination. This, however, was a small way of recognising his enormous contribution to medical education. He possessed the essential quality of a successful editor – the skill of changing disparate contributions from individual contributors into a uniform style and format without causing offence; everybody accepted his authority. He avoided being dogmatic or condescending. He was generous in teaching others his editorial skills, and these attributes were recognised when he was invited to edit Davidson’s Principles and Practice of Medicine. Macleod’s 15th Edition Examination Clinical Edited by Anna R Dover MB ChB, PhD, FRCP, SFHEA Consultant in Diabetes, Endocrinology and General Medicine, Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh; Honorary Senior Clinical Lecturer, University of Edinburgh, UK J Alastair Innes MB ChB, PhD, FRCPE Consultant Physician (retired), Respiratory Unit, Western General Hospital, Edinburgh; Honorary Reader in Respiratory Medicine, University of Edinburgh, UK Karen Fairhurst MB BS, PhD Senior Lecturer, Centre for Population Health Sciences, University of Edinburgh, UK Illustrations by Robert Britton, Ethan Danielson and Wendy Beth Jackelow London New York Oxford Philadelphia St Louis Sydney 2024 MACLEOD’S CLINICAL EXAMINATION, 15TH EDITION Copyright © 2024 Elsevier Ltd. All rights reserved. Previous editions copyrighted 2018, 2013, 2009, 2005, 2000, 1995, 1990, 1986, 1983, 1979, 1976, 1973, 1967 and 1964. ISBN 978-0-323-84770-4 International ISBN 978-0-323-84771-1 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Publisher: Jeremy Bowes Content Development Specialist: Laura Fisher Project Manager: Thoufiq Mohammed Design: Miles Hitchen Graphics Coordinator: Akshaya Mohan Marketing Manager: Deborah Watkins Printed in India Last digit is the print number: 9 8 7 6 5 4 3 2 1  Jane Gibson Phil Walmsley 13 The musculoskeletal system The history 288 Spine 297 Common presenting symptoms 288 Upper limb 302 Past medical history 292 Lower limb 309 Drug history 292 Fractures, dislocations and trauma 319 Family history 292 The history 319 Social history 293 The physical examination 319 The physical examination 293 Investigations 320 General principles 293 OSCE example 1: Right shoulder pain 322 General examination 293 OSCE example 2: Painful hands 322 Detailed examination of the musculoskeletal system 296 Integrated examination sequence for the locomotor system 323 Gait 296 288 THE MUSCULOSKELETAL SYSTEM several joints suggesting inflammatory arthritis. Causes of The history arthralgia and myalgia are shown in Boxes 13.1 and 13.2. Onset Common presenting symptoms Pain from traumatic injury is usually immediate and exacerbated by movement. An affected joint may develop haemarthrosis Pain (bleeding into the joint). Inflammatory arthritis can develop over In musculoskeletal pain, the acronym SOCRATES (see Box 2.2, p. 24 hours or more insidiously. Crystal arthritis (gout and pseu- 12) suggests questions that help reveal useful diagnostic clues. dogout) causes acute, severe pain that develops quickly, often overnight. Joint sepsis causes pain that develops over 1–2 days. Site Fig. 13.1 illustrates the anatomy of a typical joint. Determine Character which component is painful: the joint (arthralgia), muscle Bone pain can be described as a ‘deep ache’ or ‘penetrating’ (myalgia) or other soft tissue. Pain may be localised and may and is characteristically worse at night. Common causes of suggest the diagnosis, for example, a red, hot, tender first localised pain are tumours, osteomyelitis (infection), osteonec- metatarsophalangeal joint in gout (Fig. 13.2), or swelling of rosis or osteoid osteoma (a benign bone tumour). Generalised bony conditions, such as osteomalacia, more commonly cause diffuse pain. Skin and Pain from fractures is usually sharp and stabbing, aggravated subcutaneous by any movement and relieved by rest and splintage. tissue Muscle pain may be described as ‘stiffness’ or ‘aching’ and is Bone Bursa aggravated by use of the affected muscle(s). Capsule Tendon Synovium Tendon sheath 13.1 Common causes of arthralgia (joint pain) Fibrocartilage pad Ligamentous Infective thickening Viral (e.g. rubella, parvovirus B19, mumps, hepatitis B, chikungunya) Joint space of capsule Bacterial (e.g. staphylococci, Mycobacterium tuberculosis, Borrelia) Muscle Fungal Articular cartilage Postinfective Bursa Rheumatic fever Fig. 13.1 Structure of a joint and surrounding tissues. Reactive arthritis Inflammatory Rheumatoid Arthritis Degenerative Osteoarthritis Tumour Primary (e.g. osteosarcoma, chondrosarcoma) Metastatic (e.g. from lung, breast, prostate) Systemic tumour effects (e.g. hypertrophic pulmonary osteoarthropathy) Crystal formation Gout, pseudogout Trauma For example, Road traffic accidents Fig. 13.2 Acute gout of the first metatarsophalangeal joint. This causes Others swelling, erythema, and extreme pain and tenderness (podagra). From Col- Chronic pain disorders (e.g. fibromyalgia (usually diffuse pain)) ledge NR, Walker BR, Ralston SH, eds. Davidson’s Principles and Practice of Hypermobile Ehler’s Danlos syndrome Medicine. 21st ed. Edinburgh: Churchill Livingstone; 2010.  The history 289 13.2 Causes of muscle pain (myalgia) 13.3 Common patterns of referred and radicular musculoskeletal pain Infective Site where pain is perceived Site of pathology Viral: Coxsackie, cytomegalovirus, echovirus, dengue, SARS CoV2 Occiput C1, 2 Bacterial: Streptococcus pneumoniae, Mycoplasma Interscapular region C3, 4 Parasitic: schistosomiasis, toxoplasmosis Tip of shoulder, upper outer aspect of arm C5 Traumatic Interscapular region or radial fingers and thumb C6, 7 Tears Ulnar side of forearm, ring and little fingers C8 Haematoma Rhabdomyolysis Medial aspect of upper arm T1 Chest Thoracic spine Inflammatory Buttocks, knees, legs Lumbar spine Polymyalgia rheumatica Myositis Lateral aspect of upper arm Shoulder Dermatomyositis Forearm Elbow Drugs Anterior thigh, knee Hip Alcohol withdrawal Thigh, hip Knee Statins Triptans Metabolic pain, early-morning stiffness and loss of function is likely to be 13 Hypothyroidism inflammatory arthritis. ‘Flitting’ pain, starting in one joint and Hyperthyroidism moving to others over a period of days, is a feature of rheumatic Addison’s disease Vitamin D deficiency Neuropathic 13.4 Clinical vignette: arthralgia and fatigue A 34-year-old mother-of-two presents to her General Practitioner (GP) with a 1-year history of gradually worsening pain and persistent fatigue. ‘Shooting’ pain is often caused by impingement of a peripheral The pain moves around and involves the back, neck, shoulders, elbows, hands and knees. All joints are described as swollen, particularly her nerve or nerve root; for example, buttock pain, which ‘shoots hands, which swell ‘all over’. Further history reveals poor sleep, with the down the back of the leg’, is caused by lumbar disc protrusion. patient wakening every 2 hours and feeling unrefreshed in the morning. Progressive joint pain in patients over 40 years old is most She has a difficult social background and a past history of depression and commonly caused by osteoarthritis. irritable bowel syndrome. Examination shows no skin or joint abnormality Fibromyalgia, a chronic pain syndrome, causes widespread, but there is widespread tenderness, particularly across her shoulders, in constant pain with little diurnal variation, which is poorly her neck and down her back (see figure). Blood tests are all normal. controlled by conventional analgesic/anti-inflammatory drugs. She is diagnosed with fibromyalgia. Radiation Low cervical spine Pain from nerve compression radiates to the distribution of the Trapezius Occiput Medial affected nerve or nerve root (see Fig. 7.26), such as lower leg end of Medial pain in intervertebral disc prolapse or hand pain in carpal tunnel 2nd rib border of syndrome. Neck pain radiates to the shoulder or scalp. Hip pain scapula Lateral is commonly felt in the groin but may radiate to the thigh or knee. epicondyle Common patterns of radiation are summarised in Box 13.3. Associated symptoms Outer Medial gluteal For example, swelling and redness of a joint indicate inflamma- fat pad muscle tory arthritis. of knee Greater Timing (frequency, duration and periodicity of trochanter symptoms) A B A history of several years of pain with a normal examination Typical tender points in fibromyalgia. A Anterior view. B Posterior view. suggests fibromyalgia (Box 13.4). A history of several weeks of 290 THE MUSCULOSKELETAL SYSTEM fever and gonococcal arthritis. If intermittent, with resolution Predominant involvement of the small joints of the hands and between episodes, it may be palindromic rheumatism. feet suggests inflammatory arthritis, such as rheumatoid arthritis or systemic lupus erythematosus (SLE). Exacerbating/relieving factors Medium- or large-joint swelling is more likely to be degener- Pain from joints damaged by intra-articular derangement or ative (osteoarthritis) or seronegative arthritis (such as psoriatic osteoarthritic degeneration worsens with exercise. Pain from arthritis). inflammatory arthritis worsens with rest. Pain from a septic joint is Nodal osteoarthritis particularly affects the distal interpha- present both at rest and with movement. langeal (DIP) joints of the hands and the carpometacarpal (CMC) joint of the thumb. Severity Apart from trauma, the most severe joint pain occurs in septic and crystal arthritis. Disproportionately, severe pain is seen Stiffness acutely in compartment syndrome (increased pressure in a fascial compartment, compromising perfusion and viability of Ask what the patient means by stiffness. Is it: compartmental structures) and chronically in complex restricted range of movement? regional pain syndrome. Neurological involvement in diabetes difficulty moving, but with a normal range? mellitus, leprosy, syringomyelia and syphilis (tabes dorsalis) painful movement? may impair joint sensation, reducing pain despite obvious localised to a particular joint or more generalised? pathology on examination. Grossly abnormal joints may There are characteristic differences between inflammatory and even be pain-free (e.g. Charcot joints, Fig 10.14C, p. 237). non-inflammatory presentations of joint stiffness. Inflammatory Partial muscle tears are painful; a complete rupture may be arthritis causes early-morning stiffness that takes at least 30 mi- less so. nutes to wear off with activity. Non-inflammatory, mechanical Patterns of joint involvement arthritis causes stiffness after rest that eases rapidly on movement. Disease of the soft tissues rather than the joint itself may cause Different patterns of joint involvement aid the differential diag- stiffness. In polymyalgia rheumatica, stiffness commonly affects nosis (Fig. 13.3). Are the small or large joints of the arms or legs the shoulder and pelvic areas. affected? How many joints are involved? Involvement of one joint is called monoarthritis; 2–4 joints, oligoarthritis; and more than 4, polyarthritis. Swelling Ask about the site, extent and time course of the swelling. Rheumatoid arthritis Psoriatic arthritis Axial spondyloarthritis Osteoarthritis A B C D Fig. 13.3 Contrasting patterns of joint involvement in polyarthritis. A Rheumatoid arthritis (symmetrical, small and large joints, upper and lower limbs). B Psoriatic arthritis (asymmetrical, large > small joints, swelling of a whole digit – dactylitis, enthesitis). C Axial spondyloarthritis (spine and sacroiliac joints, asymmetrical peripheral arthritis, large > small joints, enthesitis). D Osteoarthritis (symmetrical, small and large joints, base of thumb, distal interphalangeal joints).  The history 291 The speed of onset of swelling is a clue to the diagnosis: Erythema and warmth Rapid (90 degrees, with the 1 point each side hand in a neutral position Ask the patient to walk barefoot in a straight line. Then repeat in shoes. Extend the elbow >10 degrees 1 point each side Observe the patient from behind, in front and from the side. Extend the knee >10 degrees 1 point each side Evaluate what happens at each level (foot, ankle, knee, hip and Touch the floor, with the palms of hands and 1 point pelvis, trunk and spine) during both stance and swing phases. the knees straight A score of "4 indicates hypermobility Pain Reproduced from Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973; 32(5):413, with An antalgic gait is one altered to reduce pain. Pain in a lower limb permission from BMJ Publishing Group. is usually aggravated by weight bearing, so minimal time is spent in the stance phase on that side. This results in a ‘dot–dash’ mode of walking. If the source of pain is in the spine, axial Stand behind the patient, hold their pelvis, and ask them to rotatory movements are decreased, resulting in a slow gait with turn from side to side without moving their feet. small paces. Patients with hip pain may lean towards the affected Ask them to slide their hand down the lateral aspect of their side, as this decreases the joint reaction force in the hip joint. leg towards their knee. Stand in front of the patient. Ask them to put their ear to each shoulder in turn. Structural change Ask the patient to look down to the floor and then up to the Patients with limb-length discrepancy may limp or walk on tiptoe ceiling. on the shorter side, with compensatory hip and knee flexion on Ask them to open their jaw wide and move it from side to side. the longer side. Assess for limb-length discrepancy (see Fig. 13.36). Other structural changes producing an abnormal gait include joint fusion, bone malunion and contracture. Hypermobility Some patients have a greater than normal range of joint move- ment. If this is severe, patients may present with recurrent dis- Weakness locations or sensations of instability. Milder cases may develop This may be due to nerve or muscle pathology or altered muscle arthralgia or be symptom-free. Mild hypermobility is normal, but tone. In a normal gait, the hip abductors of the stance leg raise Marfan’s and Hypermobile Ehler’s Danlos syndromes (Box 13.8) the contralateral hemipelvis. In Trendelenburg gait, abductor cause significant hypermobility. function is poor when weight-bearing on the affected side, so the contralateral hemipelvis falls (see Fig. 13.37). Common causes of a Trendelenburg gait are: Detailed examination of the painful hip joint problems, as in osteoarthritis musculoskeletal system weak hip abductors, as in poliomyelitis or after hip replacement The GALS screen provides a rapid but limited assessment. This structural hip joint problems, as in congenital dislocation. section describes the detailed examination required for thorough A high-stepping gait occurs in foot drop due to common evaluation. peroneal nerve palsy. The knee is raised high to bring the weak foot off the ground. Gait Gait is the cyclical pattern of musculoskeletal motion that carries Increased tone the body forwards. Normal gait is smooth, symmetrical and This occurs with upper motor neurone lesions, such as cere- ergonomically economical, with each leg 50% out of phase with brovascular accident (stroke) or cerebral palsy. The gait depends the other. It has two phases: stance and swing. The stance on the specific lesion, contractures and compensatory mecha- phase is from initial contact to toe-off, when the foot is on the nisms (see Box 7.7 on p. XXX). ground and load-bearing. The swing phase is from toe-off to  Detailed examination of the musculoskeletal system 297 Gibbus is a spinal deformity caused by an anterior wedge Spine deformity of a single vertebra, producing localised angular flexion (see Fig. 13.12D). The spine is divided into the cervical, thoracic, lumbar and sacral segments (Fig. 13.11). Most spinal diseases affect multiple seg- ments, causing altered posture or function of the whole spine. Cervical spine Spinal disease may occur without local symptoms, presenting with referred pain, neurological symptoms or signs in the trunk or limbs. Anatomy and physiology Common causes of spinal pain are shown in Box 13.9. Head nodding occurs at the atlanto-occipital joint, and rotational neck movements mainly at the atlantoaxial joint. Flexion, exten- sion and lateral flexion occur mainly at the mid-cervical level. The Definitions Scoliosis is the lateral curvature of the spine (Fig. 13.12A). Kyphosis is the curvature of the spine in the sagittal (anterior– posterior) plane, with the apex posterior (see Fig. 13.12B). The 13.9 Common spinal problems thoracic spine normally has a mild kyphosis. Mechanical back pain Lordosis is the curvature of the spine in the sagittal plane, with Prolapsed intervertebral disc the apex anterior (see Fig. 13.12C). Spinal stenosis Axial Spondyloarthritis C1 Compensatory scoliosis from leg-length discrepancy C1 1 Cervical myelopathy C2 C3 2 2 3 Cervical Pathological pain/deformity (e.g. osteomyelitis, tumour, myeloma) 13 3 4 lordosis C4 Osteoporotic vertebral fracture resulting in kyphosis (or rarely lordosis), C5, C6 – Arm abduction 4 5 C5 6 especially in the thoracic spine with loss of height Elbow flexion 5 C6 7 Cervical rib C6, C7 – Wrist extension 6 C7 8 Scoliosis C7, C8 – Elbow extension 7 1 C8 Spinal instability (e.g. spondylolisthesis) C8, T1 – Finger abduction T1 2 Hand grasp T1 2 3 T2 3 4 T3 4 5 Thoracic T4 6 kyphosis T2–T7 – Chest muscles 5 T5 7 6 T6 8 7 9 T7 8 10 Scoliosis T8 11 Kyphosis 9 T9 12 10 1 T10 2 T9–T12 – Abdominal muscles 11 3 4 T11 5 12 1 2 T12 3 L1, L2, L3 – Hip flexion L1 4 L1 5 2 A B L2 L1, L3, L4 – Knee extension Lumbar 3 lordosis L3 Cauda equina 4 L4, L5, S1, S2 – Knee flexion L4 Gibbus L4, L5 – Ankle dorsiflexion 5 L5, S1 – Great toe extension L5 S1, S2 – Ankle plantar flexion S1 S2 Increased S2, S3, S4 – Voluntary S3 lumbar rectal tone lordosis S4 S5 Co C D Fig. 13.11 The normal spinal curves and root innervations. Fig. 13.12 Spinal deformities. 298 THE MUSCULOSKELETAL SYSTEM neural canal contains the spinal cord and the emerging nerve Feel the paraspinal soft tissues. roots, which pass through the exit foramina bounded by the Feel the supraclavicular fossae for cervical ribs or enlarged facet joints posteriorly and the intervertebral discs and neuro- lymph nodes. central joints anteriorly. The nerve roots, particularly in the lower Feel the anterior neck structures, including the thyroid. cervical spine, may be compressed or irritated by lateral disc Note any tenderness in the spine, trapezius, interscapular protrusion or by osteophytes arising from the facet or neuro- and paraspinal muscles. central joints. Central disc protrusions may press directly on the cord (see Fig. 7.30 on p. 166). Move Assess active movements (Fig. 13.13). The history Ask the patient to: Look down to the floor so you can assess forward flexion. The most common symptoms are pain and difficulty turning the The normal range is 0 (neutral) to 80 degrees. Record the head and neck. Neck pain is usually felt posteriorly but may be decreased range as the chin–chest distance. referred to the head, shoulder, arm or interscapular region. Look upwards at the ceiling as far back as possible, to Cervical disc lesions cause radicular pain in one arm or the other, assess extension. The normal range is 0 (neutral) to 50 de- roughly following the dermatomes of the affected nerve roots grees. The combined flexion–extension arc is normally (see Box 13.3). If the spinal cord is compromised (cervical approximately 130 degrees. myelopathy), upper motor neurone leg weakness, altered Put their ear on to their shoulder so that you can assess sensation and sphincter disturbance may occur. lateral flexion. The normal range is 0 (neutral) to 45 degrees. Look over their right/left shoulder. The normal range of lateral The physical examination rotation is 0 (neutral) to 80 degrees. Be particularly careful when examining patients with rheumatoid arthritis, as atlantoaxial instability can lead to spinal cord damage If any of the active movements are reduced, gently perform when the neck is flexed. passive movements. Confirm whether the end of a range has a In patients with neck injury, never move the neck. Splint it and sudden or gradual resistance, plus whether it is pain or stiffness check for abnormal posture. Check for neurological function in that restricts movement. Pain or paraesthesiae in the arm on the limbs and x-ray or computed tomography (CT) to assess passive neck movement suggests nerve root involvement. bony injury. Thoracic spine Examination sequence (Video 25) Anatomy and physiology Ask the patient to remove enough clothing for you to see their This segment of the spine is the least mobile and maintains a neck and upper thorax, then direct them to sit on a chair. physiological kyphosis throughout life. Movement is mainly Look rotational with a very limited amount of flexion, extension and Face the patient. Observe the posture of their head and neck. lateral flexion. Note any abnormality (Box 13.10), such as loss of lordosis (usually due to muscle spasm). Feel Feel the midline spinous processes from the occiput to T1 (usually the most prominent). 13.10 Causes of abnormal neck posture Neutral Rotation Loss of lordosis or flexion deformity Acute lesions, rheumatoid arthritis, trauma Increased lordosis Axial Spondyloarthritis Torticollis (wry neck) Sternocleidomastoid spasm, contracture, trauma Pharyngeal/parapharyngeal infection Lateral flexion Flexion and extension Lateral flexion Erosion of lateral mass of atlas in rheumatoid arthritis Fig. 13.13 Movements of the cervical spine.  Detailed examination of the musculoskeletal system 299 The history The principal movements are flexion, extension, lateral flexion Presenting symptoms in the thoracic spine are: localised spinal and rotation. In flexion, the upper segments move first, followed pain (Box 13.11), pain radiating round the chest wall or, less by the lower segments, to produce a smooth lumbar curve. frequently, signs of cord compression – upper motor neurone leg However, even with a rigid lumbar spine, patients may be able to weakness (paraparesis), sensory loss, and loss of bladder or touch their toes if their hips are mobile. bowel control. Thoracic spine disc lesions are rare but may cause In an adult, the spinal cord ends at L2. Below this, only the pain radiating around the chest, mimicking cardiac or pleural spinal nerve roots may be injured by disc protrusion. disease. Osteoporotic vertebral fractures can present with acute The history pain or painless loss of height with increased kyphosis. Low back pain is an extremely common symptom. Most Vertebral collapse from malignancy may cause cord commonly this is ‘mechanical’ and caused by degenerative compression. Infection causes acute pain, often with systemic changes in discs and facet joints (spondylosis). upset or fever. With poorly localised thoracic pain, consider Analyse the symptoms using ‘SOCRATES’. For back pain, ask intrathoracic causes such as myocardial ischaemia or infarction, specifically about: oesophageal or pleural pain, and aortic aneurysm. occupational or recreational activity that may strain the back The physical examination additional clinical features suggesting significant spinal pa- thology (Box 13.12) Examination sequence (Video 26) prior treatment with glucocorticoids. Ask the patient to undress to expose their neck, chest and Radicular pain, caused by sciatic nerve root compression, back. radiates down the posterior aspect of the leg to the lower leg or Look ankle (sciatica). Groin and thigh pain in the absence of hip ab- 13 normality suggests referred pain from L1 to L2. With the patient standing, inspect their posture from behind, Consider also abdominal and retroperitoneal pathology, such from the side and the front, noting any deformity, such as a as abdominal aortic aneurysm. rib hump or abnormal curvature (see Fig. 13.12). Mechanical low back pain is common after standing for too Feel long or sitting in a poor position. Symptoms worsen as the day Palpate the midline spinous processes from T1 to T12. Feel progresses and improve after resting. for increased prominence of one or more posterior spinal processes, implying an anterior wedge-shaped collapse of the vertebral body. 13.12 Important features for history-taking in acute Feel the paraspinal soft tissues for tenderness. low back pain Move Features that may indicate serious pathology and require urgent Ask the patient to sit with their arms crossed. Ask them to referral twist round both ways and look behind. History Age 55 years Faecal incontinence Recent significant trauma Motor weakness (fracture) Sensory changes in the Lumbar spine Pain: perineum (saddle anaesthesia) Non-mechanical (infection/ Sexual dysfunction (e.g. erectile/ Anatomy and physiology tumour/pathological ejaculatory failure) The surface markings are the spinous process of L4, which is fracture) Gait change (cauda equina level with the pelvic brim, and the ‘dimples of Venus’, overlying Fever (infection) syndrome) the sacroiliac joints. The normal lordosis may be lost in disorders Difficulty in micturition Bilateral ‘sciatica’ such as axial spondyloarthritis and lumbar disc protrusion. Past medical history Cancer (metastases) Previous glucocorticoid use (osteoporotic collapse) 13.11 Causes of thoracic spine pain System review Weight loss/malaise without obvious cause (e.g. cancer) Adolescents and young adults Psychosocial factors associated with greater likelihood of long- Scheuermann’s disease Disc protrusion (rare) term chronicity and disability Axial spondyloarthritis A history of anxiety, depression, chronic pain, irritable bowel syndrome, Middle-aged and elderly chronic fatigue, social withdrawal Degenerative change Osteoporotic fracture A belief that the diagnosis is severe (e.g. cancer). Faulty beliefs can Dissecting aortic aneurysm lead to ‘catastrophisation’ and avoidance of activity Any age Lack of belief that the patient can improve leads to an expectation that Tumour Infection only passive, rather than active, treatment will be effective Ongoing litigation or compensation claims (e.g. work, road traffic accident) 300 THE MUSCULOSKELETAL SYSTEM Insidious onset of back or buttock ache and stiffness in an motor disturbance, including diminished perianal sensation and adolescent or young adult suggests inflammatory disease of the disturbance of bladder function. The motor disturbance may be sacroiliac joints and lumbar spine (axial spondyloarthritis, profound, as in paraplegia. Cauda equina syndrome and spinal Box 13.13). Symptoms are worse in the morning or after inac- cord compression are neurosurgical emergencies. tivity and ease with movement. Morning stiffness is more marked Acute back pain in the middle-aged, elderly or those with risk than in osteoarthritis or mechanical pain, lasting at least 30 mi- factors, such as glucocorticoid therapy, may be due to osteo- nutes. Other clues to the diagnosis are peripheral joint involve- porotic fracture. This is eased by lying, exacerbated by spinal ment, extra-articular features or a positive family history. flexion and not usually associated with neurological symptoms. Acute onset of low back pain in a young adult, often associ- Acute onset of severe progressive pain, especially when ated with bending or lifting, is typical of an acute disc protrusion associated with malaise, weight loss or night sweats, may indi- (slipped disc). Coughing or straining to open the bowels exac- cate pyogenic or tuberculous infection of the lumbar spine or erbates the pain. There may be symptoms of lumbar or sacral sacroiliac joint. The infection may involve the intervertebral discs nerve root compression. Cauda equina syndrome occurs when a and adjacent vertebrae and may track into the psoas muscle central disc prolapses or another space-occupying lesion com- sheath, presenting as a painful flexed hip or groin swelling. presses the cauda equina. There are features of sensory and Consider a malignant disease involving a vertebral body in patients with unremitting spinal pain of recent onset that disturbs sleep. Other clues are a previous history of cancer, and systemic 13.13 Clinical vignette: back pain symptoms or weight loss. Chronic intermittent pain in the lumbar spine is typical of A 34-year-old man attends his general practitioner’s surgery with back pain. degenerative disc disease. There is stiffness in the morning or He first developed pain in his late teens, but it improved for a few years. He has after immobility. Pain and stiffness are relieved by gentle activity had persistent pain in his lower back and sometimes in his buttocks for 5 years but recur with, or after, excessive activity. now. It wakes him from sleep, and he can be very stiff in the mornings, Diffuse pain in the buttocks or thighs brought on by standing although this eases as the morning progresses. There is no radiation to the leg. too long or walking is the presenting symptom of lumbosacral He is stiff after sitting or driving. He has always put it down to his occupation. spinal stenosis. This can be difficult to distinguish from intermit- He has used ibuprofen to good effect but has had diarrhoea and abdominal tent claudication (Chapter 4, p. 70). The pain may be accom- pain recently, which he attributes to this drug. Examination in the outpatient clinic shows a thin man with reduced lumbar mobility (modified Schober’s panied by tingling and numbness. Typically, it is relieved by rest index, reduced at 2 cm; see Fig. 13.15), pain on sacroiliac joint compression, or spinal flexion. Stooping or holding on to a supermarket trolley and tenderness at his Achilles insertion. Investigations show him to have a may increase exercise tolerance. raised C-reactive protein, an anaemia of chronic disease, a positive human leucocyte antigen B27 and a raised faecal calprotectin, suggesting inflam- The physical examination matory bowel disease. Magnetic resonance imaging confirms bilateral sac- roiliitis and inflammatory changes in the lumbar spine. Examination sequence A diagnosis of axial spondyloarthritis is made. Ask the patient to stand with their back fully exposed. Look Look for obvious deformity (decreased/increased lordosis, scoliosis) and soft-tissue abnormalities such as a hairy patch or lipoma that might overlie a congenital abnormality, for example, spina bifida. Feel Palpate the spinous processes and paraspinal tissues. Note overall alignment and focal tenderness. After warning the patient, lightly percuss the spine with your closed fist and note any tenderness. Move (Fig. 13.14) Flexion: ask the patient to try to touch their toes with their legs straight. Record how far down the legs they can reach. Some of this movement depends on hip flexion. Usually, the upper segments flex before the lower ones, but the progression should be smooth. Extension: ask the patient to straighten up and lean back as far as possible (normal 10#20 degrees from a neutral erect posture). Lateral flexion: ask them to reach down to each side, touching the outside of their leg as far down as possible while Axial spondyloarthritis. The patient trying to touch his toes. keeping their legs straight.  Detailed examination of the musculoskeletal system 301 Flexion Extension Fig. 13.15 Schober’s test. When the patient bends forward maximally with the knees straight, distance BC should increase by at least 5 cm. The femoral nerve (L2–4) lies anterior to the pubic ramus, so straight-leg raising or other forms of hip flexion do not pull on its roots. Problems with the femoral nerve roots may cause quad- riceps weakness and/or diminished knee jerk on that side. Sciatic nerve stretch test (L4–S1) Examination sequence (Videos 26B 13 Left Right and 26C) With the patient lying supine, lift their foot to flex the hip Lateral flexion Rotation passively, keeping the knee straight. When a limit is reached, raise the leg to just less than this level, Fig. 13.14 Movements of the lumbar and dorsal spine. and dorsiflex the foot to test for nerve root tension (Fig. 13.16). Femoral nerve stretch test (L2–4) Special tests Schober’s test for forward flexion Examination sequence (Video 26D) With the patient lying on their front (prone), flex their knee and Examination sequence (Video 26A) extend the hip (Fig. 13.17). This stretches the femoral nerve. Mark the skin in the midline at the level of the posterior iliac A positive result is when pain is felt in the back or the front of spines (L5) (Fig. 13.15; mark A). the thigh. This test can, if necessary, be performed with the Use a tape measure to draw two more marks: one 10 cm patient lying on their side (with the test side uppermost). above (mark B) and one 5 cm below this (mark C). Place the end of the tape measure on the upper mark (B). Ask Flip test for functional overlay the patient to touch their toes. The distance from B to C should increase from 15 to more than 20 cm. Examination sequence In this test, the distance between the two points should in- Ask the patient to sit on the end of the couch with their hips crease by at least 5 cm. An increase of less than 5 cm indicates and knees flexed to 90 degrees (Fig. 13.18A). restriction in the lumbar spine that may be due to axial Examine the knee reflexes. spondyloarthritis. Extend the patient’s knee, as if to examine the ankle jerk. If Root compression tests achieved, this puts the straight leg at 90 degrees of hip flexion (see Fig. 13.18B) and excludes sciatic nerve root compres- Intervertebral disc prolapses causing nerve root pressure occurs sion; patients with root compression will lie back (‘flip’). most often in the lower lumbar region, leading to compression of the corresponding nerve roots. The sciatic nerve (L4–5; S1–3) runs behind the pelvis, so straight-leg raising stretches the L4, L5 and S1 nerve roots Sacroiliac joints (affected by L3/4, L4/5 and L5/S1 disc prolapse, respectively). In general, examination of the sacroiliac joints is unreliable. 302 THE MUSCULOSKELETAL SYSTEM Fig. 13.17 Stretch test: femoral nerve. A Pain may be triggered by knee flexion alone. B Pain may be triggered by knee flexion in combination with hip extension. Negative A B Fig. 13.18 Sciatic nerve: ‘flip’ test. A Divert the patient’s attention to the tendon reflexes. B The patient with physical nerve root compression cannot Fig. 13.16 Stretch test: sciatic nerve. A Straight-leg raising limited by permit full extension of the leg. the tension of the root over a prolapsed disc. B Tension is increased by dorsiflexion of the foot (Bragard’s test). C Root tension is relieved by flexion at the knee. D Pressure over the centre of the popliteal fossa bears on the grip and fine manipulative movements, and the forearm muscles posterior tibial nerve, which is ‘bowstringing’ across the fossa, causing pain supplying power and stability. locally and radiation into the back. It is important to distinguish between systemic and local pa- thology. Systemic pathology, such as rheumatoid arthritis, usu- ally affects several sites. Local conditions should be differentiated Examination sequence from referred or radicular pain and establish whether the con- Lay the patient supine, flex the hip to 90 degrees and press dition is inflammatory or not from the pattern of diurnal stiffness down on the knee to transfer pressure through to the and pain. sacroiliac joints. This may cause pain in the buttock or lower back if the sacroiliac joint is inflamed. Hand and wrist The wrist joint has metacarpocarpal, intercarpal, ulnocarpal and Upper limb radiocarpal components. Together, they provide a wide range of possible movements, including flexion, extension, adduction The prime function of the upper limb is to position the hand (deviation towards the ulnar side), abduction (deviation towards appropriately in space. This requires intact shoulder, elbow and the radial side) and composite movement of circumduction (the wrist movements. The hand may function in both precision and hand moves in a conical fashion on the wrist). Always name the power modes, with the intrinsic muscles of the hand providing affected digit (index, middle, ring, little fingers and thumb) in  Detailed examination of the musculoskeletal system 303 documentation to avoid confusion. The PIP and DIP joints are hinge joints and allow only flexion and extension. The MCP joints 13.14 American College of Rheumatology/European allow flexion and extension, and some abduction/adduction, League Against Rheumatism classification criteria for which is greatest when the MCP joints are extended. rheumatoid arthritis, 2010 Motor and sensory innervation of the hand is shown in Fig. 7.27 on page 163. Criteria Score Duration of symptoms (as reported by patient) The history 6 weeks 1 function, contractures, disfigurement and trauma. If symptoms are vague or diffuse, consider referred pain or a compressive Joint distribution (0–5) neuropathy such as carpal tunnel syndrome (see Box 7.11 on p. 1 large jointa 0 164). If PIP or MCP joint swelling is prominent, consider inflam- 2–10 large joints 1 matory arthritis. b 1–3 small joints (large joints not counted) 2 Painful, swollen and stiff hand joints are common and impor- 4–10 small joints (large joints not counted) 3 tant presenting symptoms and scoring systems (Box 13.14) are >10 joints (at least 1 small joint) 5 used to define the presence of rheumatoid arthritis. Serology (0–3) The physical examination Negative RF and negative ACPA 0 Low positive RF or low positive ACPA 2 Examination sequence (Video 27) High positive RF or high positive ACPA 3 Seat the patient facing you, with their arms and shoulders 13 Acute-phase reactants exposed. Start by examining the hand and fingers, then move Normal CRP and normal ESR 0 proximally. Abnormal CRP or abnormal ESR 1 Look Patients must have at least 1 swollen joint not better explained by another Erythema suggests acute inflammation caused by soft-tissue disease. infection, septic arthritis, tendon sheath infection or crystal A score of !6 classifies the patient as having definite rheumatoid arthritis. Palmar erythema is associated with rheumatoid arthritis. A score of 4–5 is probable rheumatoid arthritis (i.e. a patient may arthritis. have clinical rheumatoid arthritis but not fulfil all criteria). Swelling of MCP joints due to synovitis produces loss of a Large joints: shoulders, elbows, hips, knees and ankles interknuckle indentation on the dorsum of the hand, espe- b Small joints: all metacarpophalangeal and proximal interphalangeal cially when the MCP and interphalangeal joints are fully flexed joints, thumb interphalangeal joint, wrists and 2nd–5th meta- (loss of the normal ‘hill–valley–hill’ aspect; Fig. 13.19A). tarsophalangeal joints. ‘Spindling’ (swelling at the joint, tapering proximally and ACPA, Anti-cyclic citrullinated peptide antibody; CRP, C-reactive distally; Fig. 13.19B) is seen when the PIP joints are affected. protein; ESR, erythrocyte sedimentation rate; RF, rheumatoid factor. Deformity of phalangeal fractures may produce rotation. Ask Reproduced from Aletaha D, Neogi T, Silman AJ, et al. Rheumatoid the patient to flex the fingers together (Fig. 13.20) and then in arthritis classification criteria: an American College of Rheumatology/ turn. Normally, with the MCP and interphalangeal joints European League Against Rheumatism collaborative initiative. Arthritis flexed, the fingers should not cross and should point to the Rheumatol. 2010; 62(9): 2569–2581, with permission from John Wiley scaphoid tubercle in the wrist. and Sons. The fingers are long in Marfan’s syndrome (arachnodactyly, Fig. 3.21B on p. 33). Boutonnière (or buttonhook) deformity is a fixed flexion deformity at the PIP joint with hyperextension at the DIP joint. ‘Swan neck’ deformity is hyperextension at the PIP joint with flexion at the DIP joint (Fig. 13.21). Extra-articular signs A ‘mallet’ finger (see Fig. 13.21) is a flexion deformity at the Dupuytren’s contracture affects the palmar fascia, resulting in DIP joints that is passively correctable. This is usually caused fixed flexion of the MCP and PIP joints of the little and ring by minor trauma disrupting the extensor expansion at the fingers (see Fig. 3.5). base of the distal phalanx, with or without bony avulsion. Wasting of the interossei occurs in inflammatory arthritis and There may be subluxation and ulnar deviation at the MCP ulnar nerve palsy. Carpal tunnel syndrome causes wasting of joints in rheumatoid arthritis (Fig. 13.22). the thenar eminence. T1 nerve root lesions (Fig. 13.23) cause Bony expansion of the DIP, PIP joints of the fingers and CMC wasting of all small hand muscles. joint of the thumb is typical of osteoarthritis (see Fig. 13.8). Look for nail-fold infarcts, telangiectasia, palmar erythema, Anterior (or volar) displacement (partial dislocation) of the psoriasis, scars of carpal tunnel decompression, tendon wrist may be seen in rheumatoid arthritis. transfer or MCP joint replacement. 304 THE MUSCULOSKELETAL SYSTEM A Fig. 13.21 Deformities of the fingers. Swan neck and boutonnière de- formities occur in rheumatoid arthritis. Mallet finger occurs with trauma. DIP, B Distal interphalangeal; MCP, metacarpophalangeal; PIP, proximal interphalangeal. Fig. 13.19 Swelling of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. A Ask the patient to make a fist. Look at it straight on to detect any loss of the ‘hill–valley–hill’ aspect. B Swelling and erythema of the middle finger MCP joint and index and middle finger PIP joints. Note also small muscle wasting. Scaphoid tubercle Fig. 13.22 Advanced rheumatoid arthritis. Small muscle wasting, sub- luxation and ulnar deviation at the metacarpophalangeal joints, boutonnière deformities at the ring and little fingers, and swelling and deformity of the wrist. Fig. 13.20 Flexion of the fingers showing rotational deformity of the ring finger. Feel Hard swellings usually arise from bone; soft swellings suggest Nail changes, such as pitting and onycholysis (separation of synovitis. the nail from its bed), occur in psoriatic arthritis (see Fig. 3.7A Palpate above and below the interphalangeal joints with your on p. 27). thumb and index finger to detect sponginess.  Detailed examination of the musculoskeletal system 305 A B C D Fig. 13.23 T1 root lesion (cervical rib) affecting the right hand. Wasting of the thenar eminence and interossei, and flexed posture of the fingers due to lumbrical denervation. Test the MCP joints by examining for sponginess and squeeze gently across them for pain. Palpate the flexor tendon sheaths in the hand and fingers to E 13 detect swelling or tenderness. Ask the patient to flex and then extend their fingers to establish whether there is triggering. De Quervain’s tenosynovitis causes swelling, tenderness and crepitus (a creaking sensation that may even be audible) of the tendon sheaths of abductor pollicis longus and extensor pollicis brevis. Symptoms are aggravated by movements of the wrist and thumb. Crepitus may also occur with movement of the radiocarpal joints in osteoarthritis, most commonly secondary to old Fig. 13.24 Testing the flexors and extensors of the fingers and thumb. scaphoid or distal radial fractures. A Flexor digitorum profundus. B Flexor digitorum superficialis. C Extensor Move digitorum. D Flexor pollicis longus. E Extensor pollicis longus. Active movements Ask the patient to make a fist and then extend their fingers fully. A Flexor digitorum profundus: ask the patient to flex the DIP joint while you hold the PIP joint in extension (Fig. 13.24A). Supination Pronation Flexor digitorum superficialis: hold the patient’s other fingers fully extended (to eliminate the action of the flexor digitorum profundus, as it can also flex the PIP joint) and ask the patient B to flex the PIP joint in question (see Fig. 13.24B). Dorsal Radial Ulnar Extensor digitorum: ask the patient to extend their fingers with the wrist in the neutral position (see Fig. 13.24C). Flexor and extensor pollicis longus: hold the proximal phalanx Palmar Neutral of the patient’s thumb firmly and ask them to flex and extend the interphalangeal joint (see Fig. 13.24D). Flexion of the wrist Extensor pollicis longus: ask the patient to place their palm on Fig. 13.25 Terms used to describe upper limb movements. a flat surface and to extend their thumb like a hitch-hiker (see Fig. 13.24E). Pain occurs in de Quervain’s disease. Insert your index and middle finger from the thumb side into the patient’s palm and ask them to squeeze them as hard as possible to test their grip. Ask the patient to put the backs of their hands together and Ask the patient to put the palms of their hands together and flex their wrists fully – the ‘reverse prayer sign’ (normal is 90 extend their wrists fully in the ‘prayer sign’ (normal is 90 de- degrees of flexion, Fig. 13.10B). grees of extension, Fig. 13.10A). Check pronation and supination, flexion and extension, and ulnar and radial deviation (Fig. 13.25). 306 THE MUSCULOSKELETAL SYSTEM time of injury indicate which structures may be potentially Passive movements damaged. Remember, normal movement may still be possible Move each of the patient’s fingers through flexion and even with 90% division of a tendon, so surgical exploration is extension and notice any loss of range of movement. often needed for correct diagnosis and treatment. Sensory as- Fully flex and extend the patient’s wrist and note the range of pects of nerve injury are covered on Chapter 7, page 164. movement and end-feel. Check for radial and ulnar deviation. Radial, ulnar and median nerve motor function Use ‘Paper – scissors – stone – OK’ as an aide-mémoire Elbow (Fig. 13.26). Radial nerve (wrist and finger extensors): ask the patient to Anatomy and physiology extend the wrist and fingers fully (‘paper sign’). The elbow joint has humeroulnar, radiocapitellar and superior Ulnar nerve (hypothenar muscles, interossei, two medial radioulnar articulations. The medial and lateral epicondyles are lumbricals, adductor pollicis, flexor carpi ulnaris and the ulnar the common flexor and extensor origins, respectively, for the half of flexor digitorum profundus): ask the patient to make forearm muscles. These two prominences and the tip of the the ‘scissors sign’. olecranon should be easily palpated. They form an equilateral Median nerve (thenar muscles that abduct and oppose the triangle when the elbow is flexed to 90 degrees, and a straight thumb, the lateral two lumbricals, the medial half of flexor digitorum profundus, flexor digitorum superficialis, flexor carpi line when the elbow is fully extended. A subcutaneous bursa radialis, palmaris longus and pronator teres): ask the patient overlies the olecranon and may become inflamed or infected to clench the fist fully (‘stone sign’). The best test of median (bursitis). Elbow pain may be localised or referred from the neck. nerve motor function is the ability to abduct the thumb away Inflammatory arthritis and epicondylitis are common causes of from the palm because of inconstant crossover in the nerve elbow pain. supply to the thenar eminence muscles other than abductor pollicis brevis. However, clenching the fist fully also depends The physical examination on median function because of its flexor supply. Anterior interosseous nerve (flexor pollicis longus, the index Examination sequence finger flexor digitorum profundus and pronator quadratus): Look ask the patient to make the ‘OK’ sign. This depends on the Look at the overall alignment of the extended elbow. There is function of both flexor pollicis longus and index finger flexor normally a valgus angle of 11–13 degrees with the elbow fully digitorum profundus. extended (the ‘carrying angle’). Look for: Examining the wrist and hand with a wound the swelling of synovitis between the lateral epicondyle and olecranon, resulting in a block to full extension Test the tendons, nerves and circulation in a patient with a wrist Skin changes of psoriasis, olecranon bursitis, tophi or or hand wound. The wound site and the hand position at the nodules rheumatoid nodules on the proximal extensor surface of the forearm (see Fig. 13.7). Feel Palpate the bony contours of the lateral and medial epi- condyles and olecranon tip. Feel for sponginess, suggesting synovitis, on either side of the olecranon when the elbow is fully extended. Feel for focal tenderness over the lateral or medial epicondyle (see ‘Special tests’ below). Feel for olecranon bursa swelling, nodules and tophi. A B Feel for rheumatoid nodules on the proximal extensor surface of the forearm. Move Assess the extension–flexion arc: ask the patient to touch their shoulder on the same side and then straighten the elbow as far as possible. The normal range of movement is 0–145 degrees; a range of less than 30–110 degrees will cause functional problems. Assess supination and pronation: ask the patient to put their C D elbows by the sides of their body and flex them to 90 de- Fig. 13.26 Rapid assessment of the motor functions of the radial, grees. Now ask them to turn their palms upwards (supination: ulnar and median nerves. A Paper (radial). B Scissors (ulnar). C Stone normal range 0–90 degrees) and then downwards (pronation: (median). D OK (median – anterior interosseus). normal range 0–85 degrees).  Detailed examination of the musculoskeletal system 307 Special tests 13.15 Causes of shoulder girdle pain Tennis elbow (lateral epicondylitis) Rotator cuff Degeneration Tendonitis Examination sequence Tendon rupture Calcification Ask the patient to flex their elbow to 90 degrees and pronate Subacromial bursa and flex the hand/wrist fully. Inflammation due to inflammatory arthritis, Calcification Support the patient’s elbow. Ask them to extend their wrist injury or overuse against your resistance. Capsule Pain is produced at the lateral epicondyle and may be Inflammation (Adhesive capsulitis, referred down the extensor aspect of the arm. polymyalgia rheumatica) Head of humerus Golfer’s elbow (medial epicondylitis) Tumour Fracture/dislocation Osteonecrosis Examination sequence Joints Ask the patient to flex their elbow to 90 degrees and supinate Glenohumeral, sternoclavicular: Acromioclavicular: the hand/wrist fully. Inflammatory arthritis, osteoarthritis, Subluxation, Support the patient’s elbow. Ask them to flex their wrist dislocation, infection osteoarthritis against your resistance. Pain is produced at the medial epicondyle and may be 13 referred down the flexor aspect of the arm. 13.16 Common conditions affecting the shoulder Shoulder Non-trauma Anatomy and physiology Rotator cuff syndromes( e.g. Adhesive capsulitis The shoulder joint consists of the glenohumeral joint, acromio- supraspinatus) infraspinatus tendonitis (‘frozen shoulder’) clavicular joint and subacromial space. Movement also occurs Impingement syndromes (involving the Calcific tendonitis between the scapula and the chest wall. The rotator cuff is rotator cuff and subacromial bursa) Bicipital tendonitis composed of the supraspinatus, subscapularis, teres minor and Inflammatory arthritis infraspinatus muscles. They and their tendinous insertions assist Polymyalgia rheumatica stability and movement, particularly abduction at the gleno- Trauma humeral joint. Rotator cuff tear Fracture of the clavicle Glenohumeral dislocation Fracture of the head or The history Acromioclavicular dislocation neck of the humerus Pain is a common symptom (Boxes 13.15 and 13.16) and is frequently referred to in the upper arm. Glenohumeral pain may occur over the anterolateral aspect of the upper arm. Pain felt at the shoulder may also be referred from the cervical spine or diaphragmatic and subdiaphragmatic peritoneum via the phrenic The physical examination nerve. The most common cause of referred pain is cervical spondylosis, where disc-space narrowing and osteophytes Examination sequence (Video 28) cause nerve root impingement and inflammation. Ask the patient to sit or stand and expose their shoulder Stiffness and limitation of movement around the shoulder, completely. caused by adhesive capsulitis of the glenohumeral joint, is common after immobilisation or disuse following injury or stroke. Look Examine from the front and back, and in the axilla, for: This is also termed ‘frozen shoulder’. However, movement can Deformity: Deformities of the anterior glenohumeral and still occur between the scapula and chest wall. complete acromioclavicular joint dislocation should be visible Some rotator cuff disorders, especially impingement syn- (Fig. 13.28), but the shoulder contour in posterior gleno- dromes and tears, present with a painful arc where abduction of humeral dislocation may appear abnormal only when you the arm between 60 and 120 degrees causes discomfort stand above the seated patient and look down on the (Fig. 13.27). shoulder. 308 THE MUSCULOSKELETAL SYSTEM Painful arc Fig. 13.29 ’Winging’ of the left scapula. This caused by paralysis of the nerve to serratus anterior. Move Active movements (Fig. 13.30) Fig. 13.27 Painful arc. Ask the patient to flex and extend their shoulder as far as possible. Abduction: ask the patient to lift their arm away from their side. Palpate the inferior pole of the scapula between your thumb and index finger to detect scapular rotation and determine how much movement occurs at the glenohumeral joint. The first 0– 15 degrees of abduction are produced by the supraspinatus. The middle fibres of the deltoid are responsible for the next 15– 90 degrees. Past 90 degrees, the scapula needs to be rotated to achieve abduction, which is carried out by the trapezius and serratus anterior muscles (Fig. 13.31). If the glenohumeral joint is excessively stiff, movement of the scapula over the chest wall will predominate. If there is any limitation or pain (painful arc) associated with abduction, test the rotator cuff. Fig. 13.28 Right anterior glenohumeral dislocation. Loss of the normal Internal rotation: with the patient’s arm by their side and the shoulder contour. elbow flexed at 90 degrees, ask them to put their hand behind their back and feel as high up the spine as possible. Document the highest spinous process that they can reach Swelling. with the thumb. Muscle wasting, especially of the deltoid, supraspinatus and External rotation: in the same position, with the elbow tucked infraspinatus. Wasting of the supraspinatus or infraspinatus against their side, ask them to rotate their hand outwards. indicates a chronic tear of their tendons. Deltoid: ask the patient to abduct their arm out from their Size and position of the scapula: assess whether it is side, parallel to the floor, and resist while you push down on elevated, depressed or ‘winged’ (Fig. 13.29). the humerus. Compare both sides. Feel Rotator cuff muscles Palpate from the sternoclavicular joint along the clavicle to the To test the component muscles of the rotator cuff, the effect of acromioclavicular joint. other muscles crossing the shoulder needs to be neutralised. Palpate the acromion and coracoid (2 cm inferior and medial Internal rotation of the shoulder – subscapularis and pector- to the clavicle tip) processes, the scapula spine and the bi- alis major: ceps tendon in the bicipital groove. To isolate subscapularis, place the patient’s hand behind Extend the shoulder to bring the supraspinatus anterior to the their back. If they cannot lift it off their back, it suggests a tear acromion process, allowing palpation of the supraspinatus (Gerber test). tendon. Pain on forced internal rotation suggests tendonitis.  Detailed examination of the musculoskeletal system 309 Internal External Abduction of the arm – supraspinatus: With the patient’s arm by their side, test abduction. Full abduc- tion requires both glenohumeral and scapular components. Loss of power suggests a tear. Pain on forced abduction at 60 degrees suggests tendonitis. Determine the degree of glenohumeral abduction by holding the inferior pole of the scapula and asking them to abduct. Abduction should reach 90 degrees before scapular rotation occurs Neutral (adduction) Rotation in External rotation – infraspinatus and teres minor: neutral adduction Test external rotation with the arm in the neutral position and Extension Flexion at 30 degrees to reduce the contribution of the deltoid. Loss