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Examination of the Joints and Extremities Evelyn O. Salido, MD, FPCP, FPRA Internal Medicine and Rheumatology January 2009 Objectives in doing MSS PE To screen for MSS problems among asymptomatic and symptomatic individuals To determine if complaint in the back or limb is due to a MSS problem To localize the MSS problem- intra or periarticular To diagnose Who should be examined? Musculoskeletal complaints Pain Deformity Disability (loss of function) Individuals consulting for other complaints What should be examined? Scope of the examination Back Upper Extremities Lower Extremities Systemic PE Physical Examination will tell us … Source of pain Inflammatory or not Pattern and extent of joint involvement single, few, multiple axial, appendicular distal vs proximal, small vs large Localized or systemic Requirements for a good PE Enough room and light Sufficient exposure of parts to be examined while considering privacy Relaxed and comfortable patient and examiner Good working knowledge of anatomy Adequate medical history Physical Exam MUST REMEMBER!!! Examine each joint, not only the source of complaint. Assess each joint separately. Perform an orderly exam including the spine, the upper and lower extremities. Proper positioning- as appropriate to the examination being done Maneuvers in the PE Inspection Palpation Range of motion Measurements Inspection: still & in motion Posture Contours Symmetry Deformities Atrophy/hypertrophy Masses or nodules Swelling Redness Skin lesions Instability Abnormal movements Posture, Contour, Symmetry Deformity Swelling and Redness Redness, Skin Lesion Masses & Nodules Discrepancies e.g. Atrophy Localized Generalized Document by measuring limb circumference Instability Diseased joints are able to move into abnormal positions due to joint surface damage or to laxity of ligaments passive maneuver by examiner observation of active movement during weightbearing and walking wobbling, “movement” of bones, “giving-way” Maneuvers in the PE Inspection Palpation Range of motion Measurements Palpate the joint, surrounding tissues and the muscles of the limbs and back Palpation Increased Warmth Tenderness Swelling- bony, soft tissue, effusion Tenderness Unusual sensitivity to touch or pressure Grade I- pain only II- pain and wincing III- wincing and withdrawal IV- palpation not tolerated Swelling Bony swelling- osteophyte & new bone formation Synovitis- edematous synovium, boggy swelling, usually tender Effusion- excessive fluid in joint cavity, bulge sign Swelling Localized periarticular swelling does not communicate with main joint cavity infrapatellar bursitis Pitting edema of tissues over a joint Maneuvers in the PE Inspection Palpation Range of motion Measurements Range of motion Requires knowledge of normal motion of particular joints Active or Passive When should ROM test be deferred Limitation of Motion Comparison with an unaffected joint of the opposite extremity to evaluate individual variations Increased muscle tension may result in what appears to be significant decreased ROM May be due to limitation in the joint itself or the periarticular structures Active motion limited- joint or periarticular problem Only active motion limited-periarticular problem Crepitus palpable &/or audible grating or crunching sensation produced by motion. arises when roughened articular or extraarticular surfaces are rubbed together by active motion or by manual compression fine or coarse – depending on rough the opposing cartilage surfaces are differentiate from cracking sounds caused by the slipping of ligaments or tendons over bony surfaces- normal joints Doing the Actual PE Rapid Screen- GALS Extensive PE GALS Step 1- Ask 3 basic questions Have you any pain or stiffness in your muscles, joints, or back? Can you dress yourself completely without any difficulty? Can you walk up and down stairs without any difficulty? GALS Step 2- Gait Symmetry Smoothness of movement Normal stride length Normal heel strike, stance, toe-off, swing through Able to turn quickly Heel Strike, Stance, Toe Off, Swing width of the base should be 2-4 in from heel to heel flexion of the knee during toe off and swing GALS Step 3- Inspection from Behind Straight spine Normal & symmetric paraspinal muscles Normal shoulder & gluteal muscle bulk Level iliac crests No popliteal cysts nor swelling No hindfoot swelling or abnormality GALS Step 4: Inspection from the side Normal cervical & lumbar lordosis Normal thoracic kyphosis GALS Step 5. “Touch your toes.” Normal lumbar spine (and hip) flexion GALS step 6: Inspection from the front- Arms Place your hands behind your head (elbows out)- normal glenohumeral, sternoclavicular, & acromioclavicular joint movement by your side (elbows straight)- full elbow extension In front (palms down)- no wrist/finger swelling or deformity; able to fully extend fingers Turn your hands over- normal supination/pronation; normal palms Make a fist- normal grip power Place the tip of each finger on the tip of the thumb- normal fine precision, pinch GALS step 6: Inspection from the front Spine Legs Normal quadricep bulk/symmetry No knee swelling or deformity No forefoot/midfoot deformity Normal arches No abnormal callous formation “Place your ear on your shoulder.” Normal cervical lateral flexion Regional Examination Back Upper Extremities Lower Extremities Back Look: Contour, Deformity, Mass, Skin lesion Feel: spinous processes, paravertebral muscles, SI joint Move: cervical, lumbar; Schober’s test for spine flexibility Back: Look 1="Vertebra prominens" Spinous process of C7 2= 2nd Lumbar vertebra 3= L4-5 inter vertebral space 4= Iliac crests 5= Dimples of Venus / Sacroiliac joints 1= Cervical lordosis 2=Thoracic kyphosis 3= Lumbar lordosis 4= Sacral kyphosis Back: Feel & Move Back flexibility: Schober’s test TMJ Look Feel Move Put picture here Shoulder Inspection Look for symmetry between both shoulders Check the skin for any signs of current or past pathology Identify the clavicle, deltoid & biceps muscles, bicipital groove, scapula Shoulder Palpation Assess the soft tissue tone, consistency, size and shape of muscles, and tenderness Check the axilla for lymph nodes Shoulder Look- swelling, redness Feel- tenderness Movecircumduction Elbow Humero-ulnar joint (hinge) is main articulation, radio-ulnar & humero radial In a bent arm, the triangle is quite pronounced. In a staight arm, the "elbow bump" can be at, and sometimes even above, the condyles. Elbow joint Inspection With palms facing anterior or in anatomic position, note the valgus angle made by the forearm and the upper arm Palpation Palpate the bony structures: Medial and lateral epicondyles, Medial and lateral supracondylar line of the humerus, Olecranon & Radial head Palpate the soft tissue structures Medial aspect: ulnar nerve, wrist flexors and pronators Posterior aspect: olecranon bursa, triceps muscles Lateral aspect: wrist extensors, lateral collateral ligament, annular ligament Anterior aspect: cubital fossa Range of motion: flexion, extension at humeroulnar articulation forearm supination, pronation at proximal and distal radioulnar joints passive Wrist and Hand •True wrist/radiocarpal articulation- biaxial ellipsoidal joint (radius, triangular fibrocartilage, 3 carpal bones) Palmar flexion & dorsiflexion •Distal RU joint is a pivot joint Pronation & supination Radial & ulnar deviation Wrist Keep in mind that there are 6 dorsal passageways and 2 palm tunnels through which pass nerves, arteries, veins and tendons. Some anatomic structures worth mentioning are the carpal tunnel and the median nerve Wrist Palpation Bone palpation includes the following: Radial and ulnar styloid processes Tubercle of the radius Bones of the wrist: eight carpal bones Scaphoid, navicular, lunate, triguetrum pisiform, trapezium, trapezoid, capitate, hamate Range of motion Flexion (80 degrees from neutral) Extension (70 degrees from neutral Ulnar and radial deviation Hand Inspection Ventral surface: creases, thenar and hypothenar eminences, MCP joint area Dorsal surface: MCP and soft tissue “valleys,” DIP’s and PIP’s, fingernails MCPs Hand Palpation Thenar and hypothenar eminences Palm aponeurosis Flexor and extensor tendons Fingers: dorsal and palm surfaces of MCP, PIP and DIP joints Fingernails and nail fold capillaries Range of motion MCPs- hinge joints Fingers: Abd 20°, Flex (make a fist to touch palm crease), Add, Ext 1st CMC joint- saddleshaped Thumb: opposition, flexion/extension, abduction and adduction Hip Inspection: pelvic tilt, rotational deformity, muscle wasting, leg length Palpation: anterior joint line, greater trochanter, ischial tuberosity Range of motion (ball & socket joint)- F,E,Ab,Ad,R Knee 10 Quadriceps femoris tendon 1 Patella 4 Fibular head 11 Patellar ligament 5 Anterior tibeal tuberosity Look- swelling, bulges Feel- including bulge test Move- flexion-extension only Ligaments 18 Hamstring muscle group 19 Calf muscle What is wrong here? Test for effusions: Bulge test & Patellar ballotment Ankle and Feet True Ankle joint- distal ends of tibia & fibula and proximal part of body of the talus - hinge joint; dorsi & plantar flexion Subtalar joint- inversion & eversion Toes Maneuvers in the PE Inspection Palpation Range of motion Measurements Measurement Reporting Your Findings Inspection Palpation Range of Motion Measurements Objectives in doing MSS PE To screen for MSS problems among asymptomatic and symptomatic individuals To determine if complaint in the back or limb is due to a MSS problem To localize the MSS problem- intra or periarticular To diagnose Articular vs Non-articular Disease ARTICULAR EXTRA-ARTICULAR ROM Tender ness Pain pain on active & passive motion jt surface circumference generalized, poorly localized more on active & specific motion over bony prominences along tendons well-localized superficial Evaluation of patient with musculoskeletal complaint Logical differentials Accurate diagnosis Performance of necessary diagnostic tests Timely provision of appropriate therapy