Clinical Examination of Musculoskeletal System PDF

BASICS OF CLINICAL PRACTISE -clinical examination of musculoskeletal system - Prof.dr.Gordana Kamceva Mihailova FMN-UGD, Shtip, 2022-2023 The musculoskeletal system provides the stability and mobility necessary for physical activity. Physical performance requires bones, tendons, ligaments, muscle...

BASICS OF CLINICAL PRACTISE -clinical examination of musculoskeletal system - Prof.dr.Gordana Kamceva Mihailova FMN-UGD, Shtip, 2022-2023 The musculoskeletal system provides the stability and mobility necessary for physical activity. Physical performance requires bones, tendons, ligaments, muscles, and joints that function smoothly and effortlessly. Because the musculoskeletal system serves as the body’s main defense against external forces, injuries are common. Moreover, numerous disease processes affect the musculoskeletal system and can ultimately cause disability. The purpose of this lecture is to review a systematic approach to the evaluation of the musculoskeletal system. MUSCULOSKELETAL SYSTEM MUSCULOSKELETAL SYSTEM 1. BONE-JOINT SYSTEM - JOINT - TWO OR MORE BONES THAT HAS TWO FUNCTIONS: √ ALLOWS MOVEMENT IN ONE/MORE PLANES √ PROVIDES STABILITY - STATIC ROLE - JOINTS ARE DIVIDED INTO: √ MOVEABLE - DIARTHROSES (FLEXION, EXTENSION, ADUCTION, ABDUCTION , ROTATION), √ IMMOVABLE – SYNARTHROSES. 2. NEUROMUSCULAR SYSTEM THE MOBILITY OF THE JOINT IS THE RESULT OF THE COOPERATION OF THE MUSCLE GROUPS WITH THE HELP OF THE NERVOUS AND AUTONOMIC NERVOUS SYSTEM PERFORM CERTAIN WORK. -TYPES ACCORDING TO FUNCTION: FLEXORS, EXTENSORS, ABDUCTORS, ADDUCTORS, ROTATORS √ MUSCLE VOLUME (EUTROPHY/HYPERTROPHY/HYPOTROPHY, ATROPHY) √ MUSCLE TONE (NORMAL/HYPERTONIA - TETANY, /HYPOTONIA-INAPPROPRIATE VASCULARIZATION, DAMAGE TO PERIPHERAL NERVES/INVOLUNTARY MOVEMENTS-DURING METABOLIC/ NEUROLOGICAL DISEASES) 1. HISTORY PATIENT PROFILE age, sex, race AGE DISTRIBUTION - some diseases occur in certain age groups. e.g. systemic lupus erythematosus, rheumatic fever and Reiter's syndrome occur more often in young people, while fibrositis is most common in middle-aged people, and osteoarthritis and polymyalgia in old age. SEX DISTRIBUTION - gout and spondyloarthropathies are more common in men, while rheumatoid arthritis and fibrositis in women. RACIAL DISTRIBUTION - polymyalgia rheumatica is more common in whites, while sarcoidosis is more common in blacks. MANNER OF APPEARANCE OF THE DISEASE eg. acute in septic arthritis and gout, while osteoarthritis, rheumatoid arthritis and fibrositis have an indeterminate onset. PRECIPITATING FACTORS trauma, certain medications, or previous illness NUMBER AND TYPE OF AFFECTED STRUCTURES: in injury or gout the changes are focal, while in polymyositis, rheumatoid arthritis and fibrositis they are diffuse. Rheumatoid arthritis is usually symmetrical, while spondyloarthropathies are asymmetrical. CHRONOLOGY OF SYMPTOMATOLOGY: eg. osteoarthritis is chronic, gout is intermittent, rheumatic fever has a migratory character. THE DURATION OF SYMPTOMS AND SIGNS, THE SIMULTANEOUS APPEARANCE OF ACCOMPANYING SYMPTOMS AND SIGNS IN OTHER ORGANS e.g. general symptoms (elevated temperature, in case of infection or fever), rash (in case of systemic lupus erythematosus, dermatomyositis), morning stiffness (inflammatory arthritis). AFFECTIONS OF OTHER ORGANS: GIT (scleroderma), nervous system (vasculitis), heart (rheumatic fever). HISTORY OF PRESENT ILLNESS JOINT SYMPTOMS: Character: stiffness or limitation of movement, change in size or contour, swelling or redness, constant pain or pain with particular motion, unilateral or bilateral involvement, interference with daily activities, joint locking or giving way • Associated events: time of day, activity, specific movements, injury, strenuous activity, weather • Temporal factors: change in frequency or character of episodes, better or worse as day progresses, nature of onset (sudden or gradual) • Efforts to treat: exercise, rest, weight reduction, physical therapy, heat, ice, braces or splints • Medications: nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, biologic modifiers and other immunosuppressants, corticosteroids, topical analgesics; glucosamine, chondroitin, hyaluronic acid, complementary therapies • MUSCULAR SYMPTOMS: • Character: limitation of movement, weakness or fatigue, paralysis, tremor, tic, spasms, clumsiness, wasting, aching or pain • Precipitating factors: injury, strenuous activity, sudden movement, stress • Efforts to treat: heat, ice, splints, rest, massage • Medications: muscle relaxants, statins, NSAIDs SKELETAL SYMPTOMS: • Character: difficulty with gait or limping; numbness, tingling, or pressure sensation; pain with movement, crepitus; deformity or change in skeletal contour • Associated event: injury, recent fractures, strenuous activity, sudden movement, stress; postmenopause • Efforts to treat: rest, splints, acupuncture • Medications: hormone therapy, calcium; calcitonin, bisphosphonates INJURY: • Sensation at time of injury: click, pop, tearing, numbness, tingling, catching, locking, grating, snapping, warmth or coldness, ability to bear weight. Mechanism of injury: direct trauma, overuse, sudden change of direction, forceful contraction, overstretch • Pain: location, type, onset (sudden or gradual), aggravating or alleviating factors, position of comfort • Swelling: location, timing (with activity or injury) • Efforts to treat: rest, ice, heat, splints • Medications: analgesics, NSAIDS BACK PAIN: • Abrupt or gradual onset, better or worse with activity • Character of pain and sensation: tearing, burning, or steady ache; tingling or numbness; location and distribution (unilateral or bilateral), radiation to buttocks, groin, or legs; triggered by coughing or sneezing and sudden movements • Associated event: trauma, lifting of heavy weights, long distance driving, sports activities, change in posture or deformity • Efforts to treat: rest, avoid standing or sudden movements, chiropractic, acupuncture PAST MEDICAL HISTORY • Trauma: nerves, soft tissue, bones, joints; residual problems; bone infection • Surgery on joint or bone; amputation, arthroscopy • Chronic illness: cancer, arthritis, sickle cell disease, hemophilia, osteoporosis, renal or neurologic disorder • Skeletal deformities or congenital anomalies FAMILY HISTORY • Congenital abnormalities of hip or foot • Scoliosis or back problems • Arthritis: rheumatoid, osteoarthritis, ankylosing spondylitis, gout • Genetic disorders: osteogenesis imperfecta, skeletal dysplasia, rickets, hypophosphatemia, hypercalciuria etc. DOMINANT SYMPTOMS OF LKM DISEASES ARE: DOLOR, CALLOR, RUBOR, TUMOR, FUNCTIO LESA (PAIN, SWELLING, REDNESS, HEAT AND DISORDERED FUNCTION) PAIN: different in character, intensity, occurrence, provoking factor and duration SWELLING: at the level of long bones - in diseases of bones (tuberculosis, tumors) and/or soft tissues, at the level of joints (tumefaction only, or accompanied by inflammatory signs ) REDNESS AND HEAT (of the joint - in inflammatory conditions) DEFORMITY: is a sign of a serious illness - congenital or acquired (in mechanical injuries, chronic inflammatory and degenerative joint diseases, soft tissue diseases) DISORDERED FUNCTION: temporary - due to spasm of certain muscles groups- contracture - ankylosis of a joint 2. CLINICAL EXAMINATION PHYSICAL EXAMINATION: 1. INSPECTION 2. PALPATION 3. MEASUREMENTS AND EXAMINATION OF MOBILITY OF THE JOINTS AND THE SPINE AIM: TO ASSESS THE AFFECTED STRUCTURES, THE NATURE OF THE DISEASE, THE SCOPE OF FUNCTIONAL CHANGES, THE PRESENCE OF SYSTEMIC DAMAGE. ASSESSMENT IS PERFORMED BY: INSPECTION AND PALPATION, AND VARIOUS SPECIFIC PHYSICAL EXAMINATIONS ARE UNDERTAKEN IN ORDER TO ELICIT DIAGNOSTIC SIGNS. 1. INSPECTION GENERAL PHYSICAL EXAMINATION 1. SKIN (COLOR, CONSISTENCY, WARMTH, MOISTURE), CONDITION OF FINGERS, NAILS, BUTTERFLY-LIKE ERYTHEMA ON THE FACE - SYSTEMIC LUPUS ERYTHEMATOSUS, SCLERODERMA - ON THE EXTREMITIES AROUND THE JOINTS PERIARTICULAR, LIVID ERYTHEMA IN DERMATOMYOSITIS , ANNULAR IN RHEUMATIC FEVER, SUBCUTANEOUS NODULES (NODULES) IN RHEUMATOID ARTHRITIS, TOPHI - NODULES IN GOUT 2. SYMMETRY OF THE BODY 3. MOBILITY OF THE PATIENT - ACTIVE/PASSIVE/ MOTIONLESS 4. WAY OF STANDING - WITHOUT DIFFICULTY/DIFFICULT 5. DEFORMITIES OF: A. SPINE - LORDOSIS/SCOLIOSIS/KYPHOSIS SCOLIOSIS IS LATERAL CURVATURE OF THE SPINE KYPHOSIS IS CURVATURE OF THE SPINE IN THE SAGITTAL (ANTERIOR– POSTERIOR) PLANE, WITH THE APEX POSTERIOR THE THORACIC SPINE NORMALLY HAS A MILD KYPHOSIS LORDOSIS IS CURVATURE OF THE SPINE IN THE SAGITTAL PLANE, WITH THE APEX ANTERIOR B. JOINTS - RHEUMATOID ARTHRITIS/ PSORIATIC ARTHRITIS 2. PALPATION 1. SENSITIVITY OF THE JOINT (PAIN) 2. NATURE OF THE INFLAMMATION (GUMMARYSYNOVITIS/HARD-ARTHROSIS) 3. HEAT OF THE JOINT 4. CREPTATIONS IN THE JOINT (RHEUMATOID ARTHRITIS) 5. PRESENCE OF NODULES 6. JOINT STABILITY IS ASSESSED BY PALPATION AND MANUAL COMPRESSION. 2. PALPATION 1. SWELLING OF THE JOINT: PERIARTICULAR EDEMA, THICKENING OF THE SYNOVIAL MEMBRANE, EFFUSION-HYDROPS IN THE JOINT, CONTRACTURE AND CHANGE DUE TO INCREASED BONE MASS (OSTEOPHYTES) 2. JOINT SENSITIVITY: (ASSESSED BY PALPATION AND DURING MOVEMENT IN THE JOINT) CAN TO BE: INSENSITIVE, SENSITIVE TO PRESSURE, SENSITIVE TO MOVEMENT, SENSITIVE TO MOVEMENT WITH RESISTANCE 3. RESTRICTED MOBILITY OF THE JOINT (JOINT EFFUSION, MUSCLE SPASM, CONTRACTURE OF PERIARTICULAR TISSUE, FIBROSIS, BONE ANKYLOSIS) A. SUBLUXATIONS/LUXATIONS B. CONTRACTURES (PARTIAL)/ANKYLOSIS (COMPLETE) STIFFNESS OF THE JOINT 4. JOINT DEFORMITY (DEPENDS ON THE DISEASE) 5. CHANGES OF THE SURROUNDING STRUCTURES (REFLEX SPASM, MUSCLE WEAKNESS, HYPO/ATROPHY, CONTRACTURE) PRESERVATION OF MUSCLE STRENGTH AND TROPHISM PALPATIONS OF NODULES The firm, non-tender, subcutaneous nodules of rheumatoid arthritis most commonly occur on the extensor surface of the forearm, sites of pressure or friction such as the sacrum or Achilles tendon, or in the lungs. Multiple small nodules can occur in the hands. Bony nodules in osteoarthritis affect the lateral aspects of the DIP joints (Heberden’s nodes) or the proximal interphalangeal (PIP) joints (Bouchard’s nodes). They are smaller and harder than rheumatoid nodules. Gouty tophi are firm, irregular subcutaneous crystal collections (monosodium urate monohydrate). Common sites are the olecranon bursa, helix of the ear and extensor aspects of the fingers, hands, knees and toes. If superficial, they may appear white, and may ulcerate, discharge crystals and become secondarily infected. Gouty tophi Rheumatoid nodules at the olecranon and ulnar border Osteoarthritis of the hand. Heberden’s (single arrow) and Bouchard’s (double arrow) nodes. PALPATION OF PERIPHERAL ARTERIES Palpation of peripheral pulse at typical sites aorta abdominalis a.poplitea a.dorsalis pedis a. femoralis a.tibialis posterior EXAMINATION OF THE RANGE OF MOBILITY OF THE SPINE 1. LUMBAR SPINE - MOBILITY IS DETERMINED BY: √ MEASURING THE DISTANCE OF THE FINGERS FROM THE FLOOR WHEN THE PATIENT BENDS FORWARD WITH FINGERS EXTENDED TO THE FLOOR AND LEGS EXTENDED AT THE KNEES √ MORE PRECISELY BY EXAMINING SCHOBER'S TEST 2. THORACIC SPINE - MOBILITY IS MINIMAL, AND IT IS MEASURED IN THE SAME WAY AS THE LUMBAR - UPPER EDGE OF THE FIRST THORACIC VERTEBRA 30 CM DOWN... AND THE SUM OF THE CHANGE AT MAXIMUM ANTE + RETROFLEXION IS MEASURED, THE RESPIRATORY INDEX IS DETERMINED - THE DIFFERENCE BETWEEN THE VOLUME IN INSPIRATION AND EXPIRATION, MEASURED AT THE LEVEL OF THE NIPPLES (NORMAL 7-12CM) 3. CERVICAL SPINE - IN THE SAME WAY AS THE THORACIC AND LUMBAR SPINE SCHOBER’S TEST FOR FORWARD FLEXION Mark the skin in the midline at the level of the posterior iliac spines (L5) (Fig. 13.15; mark A). Use a tape measure to draw two more marks: one 10 cm above (mark B) and one 5 cm below this (mark C). Place the end of the tape measure on the upper mark (B). Ask the patient to touch their toes. The distance from B to C should increase from 15 to more than 20 cm. BASIC MOVEMENTS IN MOVEABLE JOINTS 1. FLEXION: BENDING AT A JOINT FROM THE NEUTRAL POSITION 2. EXTENSION: STRAIGHTENING A JOINT BACK TO THE NEUTRAL POSITION 3. HYPEREXTENSION: MOVING BEYOND THE NORMAL NEUTRAL POSITION (INDICATING A TORN LIGAMENT OR UNDERLYING LIGAMENTOUS LAXITY, SUCH AS BENIGN JOINT HYPERMOBILITY SYNDROME) 4. ADDUCTION: MOVING TOWARDS THE MIDLINE OF THE BODY(FINGER ADDUCTION IS MOVEMENT TOWARDS THE AXIS OF THE LIMB) 5. ABDUCTION: MOVING AWAY FROM THE MIDLINE 6. ROTATION: INTERNAL AND EXTERNAL JOINT MOBILITY EXAMINATION →THE MOBILITY OF ALL JOINTS (FROM HEAD TO DISTAL) EXPRESSED IN DEGREES. → ACTIVE AND PASSIVE MOBILITY → ALL TYPES OF MOVEMENTS IN THE JOINTS DEFORMITIES OF THE FINGERS 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. AT THE DIP JOINTS A ‘MALLET’ FINGER IS A FLEXION DEFORMITY THAT IS PASSIVELY CORRECTABLE. THIS IS USUALLY CAUSED BY MINOR TRAUMA DISRUPTING TERMINAL EXTENSOR EXPANSION AT THE BASE OF THE DISTAL PHALANX, WITH OR WITHOUT BONY AVULSION. FOOT DEFORMITIES PES VALGUS – foot in abduction and eversion PES EQUINUS –foot in plantar flexion PES VARUS – foot in adduction and inversion PES CALCANEUS – foot in dorsiflexion PES PLANUS – flat foot LMS NORMAL STATUS Extremities without swelling and deformities, and signs of injury, with preserved active and passive mobility, without visible varicosities, and with normal pulsations of the peripheral arteries available for palpation. 12-Nov-15 LINKS https://www.youtube.com/watch?v=5_txE56X2-8 https://www.youtube.com/watch?v=Hkqr3mg6IWQ https://www.youtube.com/watch?v=vu1vuugtvIo https://www.youtube.com/watch?v=NZocTa8RqR80 https://www.youtube.com/watch?v=17ZKya9yR2Y https://www.youtube.com/watch?v=GTVnlhyUWxk THANK YOU