MSK PE

Straight leg Test

(Lasegue test) 1. verbalize purpose: Suspected sciatica 2. how to do this test: With the patient laying supine, flex the hip passively with knee extended. Then, dorsiflex the foot. 3. verbalize: - reproduction of symptoms with just hip flexion is indicative of lumbosacral radiculopathy - reproduction or worsening of symptoms with foot dorsiflexion is more specific for sciatica.

Neer's Impingement Sign

(mneumonic: near to the ear): 1. verbalize purpose: evaluation of suspected RTC inflammation or tear 2. how to do this test: Depress the scapula against the rib cage. The patient should start with the arm at the side and the elbow fully extended. IR of arm so the thumb is touching the side of the leg. The PA passively flexes the shoulder to greater than 150 degrees 3. verbalize: pain indicates a positive test

Varus and Valgus stress test

(technique from Hoppenfeld) 1. verbalize purpose: Suspected instability of the medial or lateral collateral ligament 2. how to do this test: perform each with the knee at 0 and 30 degrees, w/ pt supine or sitting. Secure the ankle with one hand and place the other hand around the knee. - Valgus: The thenar eminence should be against the fibular head. Push medially against the knee (valgus stress). - Varus: Reverse the position of your hands and push medially against the knee joint (varus stress). 3. verbalize - Gapping or opening of the knee joint medially is a positive test for MCL laxity. - Gapping or opening of the knee joint laterally is a positive test for LCL laxity. Do not do both varus at 0 and 30 AND valgus at 0 and 30 on the same leg before moving to the other side. Do varus 0 & 30 both legs, then valgus 0 & 30 both legs.

McMurray's test

(technique from Hoppenfeld) 1. verbalize purpose: Suspected medial or lateral meniscus tear 2. how to do this test: pt laying supine with their legs flat. With one hand, grasp the heel and flex the leg fully. Then, place your free hand on the knee joint with your fingers touching the medial joint line and your thumb and thenar eminence against the lateral joint line. Rotate the leg IR & ER to loosen the joint. - Apply a VALGUS stress to the joint while ER. Extend the leg slowly while palpating the MEDIAL joint line for clicking. - Apply a VARUS stress to the joint while IR. Extend the leg slowly while palpating the LATERAL joint for clicking 3. verbalize: - clicking over the medial joint line is a positive test for a medial meniscal injury - clicking over the lateral joint line is a positive test for a lateral meniscal injury.

Ankles/Feet physical exam & special test verbalization

1. Inspect *pes cavus (high) and pes planus (flat)* for size, symmetry, swelling, erythema, ecchymosis, atrophy, deformity, nodules, scars 2. Palpate general ankle/foot area for tenderness, swelling, deformity, crepitus & temperature (use back of hands for temp) - specifically palpate *anterior joint space, medial malleoli, lateral malleoli, Achilles tendon, gastrocnemius muscle, anterior tibialis muscle, anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, deltoid ligament, base of 5th metatarsal, and metatarsophalangeal joints* 3. ROM: dorsiflexion, plantarflexion, inversion, eversion, toe extension and flexion 4. Special test: *anterior drawer test* 1) verbalize purpose: Suspected lateral ankle sprain 2) how to do this test: Place the patients foot in slight plantar flexion. Brace the anterior shin with one hand. Pull the heel anteriorly with the other hand 3) verbalize: laxity is a positive test

Hand/Fingers physical exam

1. Inspect for size, symmetry, swelling, erythema, ecchymosis, atrophy, deformity, nodules, scars - making special note of *dorsal and palmar surfaces, thenar and hypothenar eminences for atrophy; fingers for number and completeness of digits, looking for Herberden's & Bouchard's nodes* 2. Palpate for general hand area for tenderness, swelling, deformity, crepitus & temperature (back of hands for temp) - specifically palpate *MCP, PIP, DIP joints* 3. ROM: - make fist, open fist, spread fingers apart (flexion/extension, abduction/adduction) - finger opposition (touch thumb to tip of each finger) - thumb flexion/extension thumb abduction/adduction, thumb circumduction 4. special tests: none

Elbow/Forearm physical exam

1. Inspect: bilateral elbows for size, symmetry, swelling, erythema, ecchymosis, atrophy, deformity, nodules, scars 2. Palpation: general elbow structure for tenderness, swelling, deformity, crepitus & temperature (back of hands) -specifically palpate *olecranon, olecranon bursa, medial epicondyle, lateral epicondyle, ulnar nerve, radial head, distal biceps tendon, triceps tendon, triceps muscle, wrist extensor groups, wrist flexor muscle groups* 3. ROM: Flexion, extension, pronation, supination 4. Special tests: none

shoulder physical exam

1. Inspection: bilat shoulders for size, symmetry, swelling, erythema, ecchymosis, atrophy, deformity, nodules, scars 2. Palpation: tenderness, swelling, deformity, crepitus & temperature using back of hands for temp - specifically palpate: *SC joint, clavicle, AC joint, coracoid process, acromion process, biceps tendon & groove, deltoid muscle, greater tuberosity of humerus, spine of the scapula* 3. ROM: Flex/Ext, Abduct/Adduct (must cross midline), IR/ER (bent elbows, move hands) 4. shoulder special tests 1) Apley's Scratch Test 2) Cross-over test 3) Neer's Impingement Sign 4) Hawkins Impingement Sign 5) Empty Can Test 6) Drop Arm Test

Thoracic spine and Lumbar spine physical exam

1. Inspection: must visualize while *standing behind patient AND from the side* size, symmetry, swelling, erythema, ecchymosis, atrophy, deformity, nodules, scars 2. Palpate for general hand area for tenderness, swelling, deformity, crepitus & temperature (use back of hands for temp) - specifically palpate: *spinous processes of thoracic and lumbar regions, sacroiliac joints and paraspinal muscles* ** Note: the paraspinal muscles may be palpated simultaneously 3. ROM: examiner is behind patient, stabilizing pelvis: flexion, extension, right and left lateral tilt, right and left rotation 4. Special tests: - Straight leg Test (Lasegue test) - Scoliosis screening

Cervical spine physical exam

1. Inspection: must visualize while *standing behind patient AND from the side; inspecting for curvatures of the spine, deformity, shoulder and iliac crest alignment, spasm, posture* - size, symmetry, swelling, erythema, ecchymosis, atrophy, deformity, nodules, scars 2. Palpate general cervical area for tenderness, swelling, deformity, crepitus & temperature (use back of hands for temp) - specifically palpate: *soft tissue, SCM muscle, trapezius, spinous processes* 3. ROM: flexion, extension, lateral tilt left, lateral tilt right, rotation left, rotation right 4. Special tests: none

Wrist physical exam

1. Inspection: size, symmetry, swelling, erythema, ecchymosis, atrophy, deformity, nodules, scars 2. Palpation: general wrist area for tenderness, swelling, deformity, crepitus & temperature (back of hands) - specifically palpate *ulnar styloid process, radial styloid process, radiocarpal joint, anatomical snuffbox (scaphoid bone)* 3. ROM: flexion, extension, radial deviation, ulnar deviation 4. Special tests: 1) Phalen test 2) Tinel test 3) Finkelstein test

Hips physical exam

1. VERBALIZE *inspection is deferred* for OSCE 2. Palpate for general hand area for tenderness, swelling, deformity, crepitus & temperature (use back of hands for temp) - *soft tissue, iliac crest, anterior iliac spine, greater trochanter and bursa, posterior iliac spine* 3. ROM: flexion, extension, IR, ER, abduction, adduction. 4. Special tests: none

inspection general process

1. all joints must be fully exposed 2. compare to the other side 3. regardless of the joint or complaint VERBALIZE inspecting for: - size, symmetry, swelling - erythema, ecchymosis - atrophy, deformity - nodules, scars *you must also state what you are inspecting & palpating for each joint. You cannot make one large blanket statement for all things pertaining to the upper or lower extremity*

three things you always do for MSK exam

1. always compare to the non-injured side 2. always examine non-injured side 1st 3. always assess joint above & below the part that is the focus of the complaint

palpation general process

1. compare to both sides 2. regardless of the joint or complaint, VERBALIZE palpating for: - tenderness, swelling, deformity, crepitus & temperature (w/ back of hands for temp) *you must also state what you are palpating for each joint. You cannot make one large blanket statement for all things pertaining to the upper or lower extremity*

Knees physical exam

1. inspect for size, symmetry, swelling, erythema, ecchymosis, atrophy, deformity, nodules, scars - while knee is in *flexion* (legs dangling over end of bed) and *extension* 2. Palpate for general hand area for tenderness, swelling, deformity, crepitus & temperature (use back of hands for temp) - palpate specifically *(while seated) medial and lateral joint space, medial and lateral collateral ligaments, patella tendon, tibial tuberosity, popliteal fossa - on the posterior knee palpate the semimembranosus and semitendinosus and biceps femoris tendon* 3. ROM: flexion, extension 4. special tests 1. Bulge sign 2. Ballottement sign 3. Patella grind test 4. Anterior drawer test 5. Posterior drawer test 6. Varus & valgus stress test 7. Lachman's test 8. McMurray's tets

Lachman's test

1. verbalize purpose: Suspected instability of anterior cruciate ligament 2. how to do this test: pt laying supine, flex the knee to 10-15 degrees. Place one hand above the knee to stabilize the femur and place the other hand around the proximal tibia. While stabilizing the femur, pull the tibia anteriorly 3. verbalize: increased laxity compared with the uninjured side is a positive test.

Anterior drawer test (knee)

1. verbalize purpose: Suspected instability of the anterior cruciate ligament 2. how to do this test: pt laying supine, flex the knee to 45-90 degrees w/ foot flat on the table. Place both hands on the lower leg with the thumbs on the ridge of the anterior tibia just distal to the tibial tuberosity. Draw the tibia forward (anterior translation) of the femur 3. verbalize: laxity of the joint is a positive test

Posterior drawer test (knee)

1. verbalize purpose: Suspected instability of the posterior cruciate ligament 2. how to do this test: With the pt laying supine, flex the knee to 45-90 degrees w/ foot should flat on the table. Place both hands on the lower leg with the thumbs on the ridge of the anterior tibia just distal to the tibial tuberosity. Push the tibia backward (posterior translation) on the femur 3. verbalize: laxity of the joint is a positive test

Bulge sign

1. verbalize purpose: Suspected knee effusion 2. how to do this test: pts knee extended, milk the medial aspect of the knee upward two or three times then push the fluid laterally. Tap knee laterally and observe the medial aspect 3. verbalize: observation of a bulge of fluid to returning to the hollow area medial to the patella is a positive test

Ballottement sign

1. verbalize purpose: Suspected large knee effusion 2. how to do this test: The pt should be supine on the table. Firmly grasp the area just above the patella with one hand. Then, push the patella downward into the femur with 2-3 fingers using a quick sharp motion. 3. verbalize: a palpable click or the floating rebound of the patella is a positive test

Patella grind test

1. verbalize purpose: Suspected patellofemoral pain syndrome 2. how to do this test: With the patient laying supine, compress the patella (by making a "c" shape with your hand that cups the superior border of the patella) distally in the trochlear groove. Instruct the patient to tighten their quadriceps while the patella is being displaced 3. verbalize: pain or crepitus is a positive test.

Finkelstein test

1. verbalize purpose: de'Quervains tenosynovitis evaluation 2. how to do this test: Instruct the patient to tuck their thumb into their hand with their fingers closed around the thumb (like a fist with the thumb tucked in). then perform ulnar deviation 3. verbalize: pain over the location of the tendons is a positive test (FYI stresses the abductor pollicis longus and extensor pollicis brevis tendons)

Cross-over test

1. verbalize purpose: differentiate AC joint disease from impingement syndrome 2. how to do this test: instruct the patient to adduct arm across the front of the chest and touch their opposite shoulder 3. verbalize: pain indicates a positive test (for AC joint pathology)

Drop Arm Test

1. verbalize purpose: evaluation of a suspected RTC tear 2. how to do this test: Ask the patient to abduct their shoulder above 160 degrees. Instruct the patient to slowly lower their arm 3. verbalize: observing the arm drop in an uncontrolled manner from a position of about 90 degrees is a positive test

Empty Can Test

1. verbalize purpose: evaluation of the supraspinatus muscle for tear or impingement 2. how to do this test: Place the patients arm in 90 degrees of abduction with 30 degrees of forward flexion. Instruct the patient to point their thumbs down toward the ground. Apply downward pressure on the arm against the patient's resistance. 3. verbalize: arm weakness or pain is a positive test

Apley's Scratch test

1. verbalize purpose: provides for quick assessment of ROM at shoulder, this does NOT replace a full ROM assessment 2. how to do the test: instruct the patient to reach behind their head and touch the superior medial angle of the opposite scapula. Finally, ask the patient to reach behind their back to touch the inferior angle of the opposite scapula. Test both sides.

Phalen test

1. verbalize purpose: suspected carpal tunnel syndrome 2. how to do this test: Instruct the patient to place the palms and fingers together in full wrist flexion 3. verbalize "we would typically hold this position for full minute, we will defer this for this OSCE" 4. verbalize reproduction of numbness and/or tingling in the median nerve distribution is a positive test

Tinel test

1. verbalize purpose: suspected carpal tunnel syndrome 2. how to do this test: Strike (tap) pts wrist w/ your index or middle finger where median nerve crosses the wrist joint (aim for the wrist crease) 3. verbalize: tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive test

Hawkins Impingement Sign

1. verbalize purpose: the evaluation of suspected impingement 2. how to do this test: Abduct the shoulder to 90 degrees while flexing the elbow to 90 degrees. Internally rotate the shoulder to its limit 3. verbalize: pain indicates a positive test

Scoliosis screening

1. verbalize: scoliosis screening 2. how to do this test: Instruct the patient to touch their toes. Visualize the curvature of the spine when the patient bends at the waist. 2. verbalize: deviation of the spine from the midline or asymmetry of the ribcage is a positive test.

ROM tests

each joint should be assessed to determine function: 3 types of ROM 1. Active (pt moves body part) - always performed for all MSK complaints - assessing for decreased and/or painful ROM - joints can be evaluated simultaneously, however, if a loss of motion is noted then each joint would need to be evaluated separately 2. Passive (PA moves body part) - done only if decreased and/or painful active ROM found - assesses whether decrease in ROM is secondary to pain or structural (scarring, bony) 3. Resistive - assesses if engaged muscle reproduces or makes pain worse - helps determine if injury is to soft tissue or bony, also assesses strength (neuro)