Musculoskeletal Examination Principles

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Musculoskeletal examination refers to physical examination of the musculoskeletal system. The purpose is to find objective information about the presenting complaint and enhance the doctor-patient relationship.

Components

There are three elements to the physical examination. They are colloquially termed "look, feel, move" by Apley; or more precisely termed inspection, palpation, and movement testing. The sequence "look, feel, move" is appropriate for fractures, but for most other musculoskeletal conditions the sequence "look, move, feel" is more suitable. A fourth category is special tests.

The New Zealand musculoskeletal examination system has been somewhat influenced by the osteopathic approach. The osteopathic perspective looks at the musculoskeletal examination as a tool for identifying somatic dysfunction, and calls the approach "TART" i.e. tenderness, asymmetry, restricted motion, tissue texture changes.

The musculoskeletal exam is not the neurological exam. A neurological examination is only appropriate if there are neurological symptoms.

Inspection

Observations may include both general and specific findings.

• General: gait, gross movements (dynamic posture); standing, sitting, deformities (static posture).
• Specific: pertaining to the affected area, namely discolouration, scars, swelling, local deformities.

Palpation

There are three components to palpatory skills: perception (awareness and knowledge), concentration (amplification), and interpretation (making sense of what you feel).

Palpation should be done in layers. The examiner should be ever-conscious as to the local anatomy. Palpation involves discriminating small differences on a continuum, identifying shapes, assessing tissue texture changes, gauging depth, comparing relative positions, sensing subtle changes in temperature and moisture, and identifying the direction of fibres in tissues.

Different parts of our hands have different utilities in palpation. Fine tactile discrimination is assessed using the finger tips, vibration is assessed using the palmar aspect of the MCP joints, stereognosis (gross shape) is assessed using the palms, and depth is assessed using the tips of the thumbs.

All accessible tissues and structures are potential sites for palpation: skin, subcutaneous and deep fascia, vessels, nerves, muscle and MT junctions, tendons, entheses, bones, joints, ligaments, etc.

Common errors in palpation arise from poor anatomical knowledge, poor concentration, applying too much pressure, and applying too much movement.

The most pertinent finding for palpation is tenderness. Tenderness may be quite focal, or diffuse. Finding tenderness can enhance the doctor-patient relationship and puts them in control to some extent of their pain problem. It lessens the chance of "guruism" as you can't trick the patient into feeling pain. If tenderness is felt, ask the patient if it is similar to their index pain, and whether it causes any somatic referred pain.

Other signs on palpation are sudomotor changes on skin drag, skin sensitivity on pinch roll, alterations of tissue texture, masses, and abnormalities of bony landmarks. Tissue texture frequently takes on a hard or doughy quality, and represents altered autonomic activity in the dysfunctional area.

The osteopathic TART perspective views changes depending on the chronicity of the condition. Some of the changes relate to differences in vasodilation and autonomic effects.

	Acute	Chronic
Temperature	Warm	Cool
Texture	Boggy, rough	Thin, smooth
Moisture	Moist	Dry
Tension	Increased	Ropey, stringy
Tenderness	Greatest	Present but less
Oedema	Yes	No
Erythema test	Redness lasts	Fades quickly
Viscero-somatic effects	Minimal	Common

Movement Testing

Movements assessed through active range, passive range, accessory motion, and challenging restraints. Any restrictions for be noted for both active and passive range of motion, and the cause noted e.g. due to pain or weakness.

For active range of motion assessment, the patient assumes a neutral position and moves the body part in each physiological direction as far as possible.

The movements in question depend on the joint. Spinal motions are extension, flexion, side-bending, and rotation. The appendicular joints are extension, flexion, abduction, adduction, external rotation, and internal rotation. Ranges are visually estimated or measured using a goniometer or inclinometer.

The examiner records any reduction in range of motion and any associated pain or weakness.

Passive range of motion is tested through the same ranges with the examiner providing passive force. Again note any restriction and whether it is due to pain, weakness, or other.

Accessory movements also known as joint play are those motions which can't be performed actively in isolation, but can be performed passively by an examiner. The examiner fixes one body part and moves the other relative to the fixed point. Accessory movements can be translations or rotations. The ranges are generally small.

Accessory movements provide easier assessment of end-feel. A judgement is made whether it feels normal (springy), soft, or hard.

Challenging restraints are restraints to movement that can arise from pain, joint (bony restriction), muscle/ligament shortening, and joint capsules. Restraints are easier to test for large joints (hip, knee, shoulder etc), than smaller joints (intervertebral joints, facet joints, etc).

Restraints are tested actively, passively, and through accessory movements. The examiner judges whether the restraint is due to pain, obstruction by a body or soft tissue, antagonistic muscle action, or tethering by ligaments or fascia. Examples of this are the painful arc in subacromial pain syndrome, and the apprehension sign in glenohumeral joint instability.

Follow Up

Follow up examination findings can be used to monitor treatment or "disease" progress. For example the degree of tenderness, location of tenderness, range of motion, presence/absence of muscle spasm. This adds another dimension to monitoring over and above pain and functional ratings.

Other Benefits

The musculoskeletal examination may help in detecting unrelated but serious conditions such as Parkinson's disease, vascular insufficiency, melanoma, secondary lymphoma, dissecting carotid aneurysm, discitis, psoriatic arthropathy, etc.

With the laying on of hands, oxytocin is released into the blood from the posterior lobe of the pituitary gland.

Evidence Base

Clinical epidemiology is not medical epidemiology. It is the philosophical and rational basis for determining truth in the practice of medicine. It combines statistical methods of epidemiology with clinical reasoning to study clinical populations.

The particular truths relevant in the musculoskeletal examination are reliability, validity, and efficacy. A physical examination manoeuvre should be assessed as we assess any diagnostic test.

There are multiple problems in applying evidence based medicine to musculoskeletal medicine, such as:

• Pain is the most common symptom and is inherently subjective with no objective means of measuring it.
• Pain pathways are complex, for example referred pain, descending modulation, poor localisation for deep pain, and more.
• There is the "shifting sands" problem of anatomical structures
• Examination findings can vary day to day
• Examination findings vary between examiners, and between novices and experts.
• Different examiners may perform different tests

Many research trials show poor validity (i.e. low likelihood ratios), and many show poor reliability (i.e. low kappa scores).

A rational approach to examining a patient involves integrating clinical expertise with the best available external clinical evidence from systematic research. Examination should increase the probability of one diagnosis, and help exclude other diagnoses.

See Also

• A guide for virtual MSK examination in primary care: Murray T, Murray G, Murray J. Remote Musculoskeletal Assessment Framework: A Guide for Primary Care. Cureus. 2021 Jan 19;13(1):e12778. DOI PMID Full Text