Musculoskeletal Examination Principles
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.
There are three elements to the physical examination. They are colloquially termed "look, feel, move"; 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 musculoskeletal exam is not the neurological exam. A neurological examination is only appropriate if there are neurological symptoms.
Components
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
Palpation should be done in layers. The examiner should be ever-conscious as to the local anatomy. The most pertinent finding for palpation is tenderness. Tenderness may be quite focal, or diffuse. 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.
Movement Testing
Movements assessed through active range, passive range, accessory motion, and challenging restraints.
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.
Passive range of motion is tested through the same ranges with the examiner providing passive force.
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.
Challenging restraints are restraints to movement that can arise from bones, joint capsules, ligaments, tendons, and muscles. They 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.
