Mastering Your

Musculoskeletal Exam
Laurel Short, DNP, MSN, FNP-C
 Disclosure

I have no current affiliation or financial interest with any grantor or

commercial interests that may have direct interest in the subject matter of the
CE Program.
 Here’s what we’ll cover

• Review key components of a comprehensive musculoskeletal

exam
• Describe an organized approach to exam techniques
• Identify history questions used to assess patients presenting with
problems for the upper and lower extremity
• Identify functional anatomy with clinical significance
• Discuss pharmacologic and non-pharmacologic treatment
options for common musculoskeletal conditions
 Preparing for a
Comprehensive MSK
Workshop

So many topics to cover!

MSK Exam and Primary
Care
Musculoskeletal problems are in
the top reasons for PCP visits
Over half of chronic medical
conditions in the U.S. are related to
MSK diagnoses
 Components of MSK Exam
• Observation
• Palpation
• Active & Passive range of motion
(ROM)
• Strength
• Reflexes and Sensation
• Gait
 Helpful Terms

• Abduction • Insertion
• Adduction • Volar
• Proximal • Dorsal
• Distal • Valgus
• Origin • Varus
Observation
• Skin appearance-
breakdown, color, scar
• Swelling, edema,
erythema
• Symmetry or asymmetry
• Posture
• Patient affect
Pressure level: light prior to firm

Identify location: tendon attachment,

muscle, joint?
Palpation
Type of pain provoked

Focal vs. radiating pain

Range of
Motion
 Range of Motion
• Passive vs. Active
• Types of joints
• Is range limited due to pain/guarding, weakness, or
muscle/joint issue?
• Always check the unaffected side first for comparison
• Is there pain associated with the reduced range of
motion?
American Spinal Injury Association Strength
Grading
0 Total paralysis
1 Palpable or visible contraction
2 Active Movement
3 Active movement against gravity
4 Active movement against gravity with some degree of
resistance
5 Active movement with full resistance (normal)
 Reflex Grading
0 No response
1+ Slight by definite response (may or
may not be normal)
2+ Brisk response (normal)
3+ Very brisk (may or may not be normal)
4+ Repeating response/clonus (always
abnormal)
Dermatome Review!
 Type of Pain

Somatic Neurogenic
Consistent Physical Exam!

ROM & Focused Special

Strength Area(s) Tests
Make friends with a physical therapist!
Upper Limb
 Shoulder
Anatomy

3 Bones
•scapula
•clavicle
•humerus
Rotator cuff muscles (SITS)
•Supraspinatus
•Infraspinatus
•Teres Minor
•Subscapularis
 Shoulder

• Very mobile joint with shallow glenoid fossa

• Stability depends on muscles and connective tissue
• Assess posture!
• Inspection, palpation, muscle testing, special tests
 Special Shoulder Tests

• Impingement signs: Neer, • Apprehension sign

Hawkins, Empty Can • Drop arm test
• Cross body adduction • Wall push-up
 Shoulder Diagnostic Testing
Will the test change your treatment plan?
• X-ray
• MRI
• EMG (especially if numbness/tingling, weakness)
• http://www.abemexam.org/Verify-Certification/ABEM-Directory
• Consider visceral causes (e.g. cardiac, gallbladder, etc)
• Always assess for cervical spine symptoms
Shoulder Case Study

o History of intermittent
impingement syndrome
o Patient enjoys cycling, fell while
on a summer ride
o Began physical therapy ~1 month
after symptoms began
o MRI completed due to lack of
progress RTC tear
o Surgery completed in January,
started post-op rehab when
cleared by surgeon
 Common Shoulder Diagnoses

• Impingement syndrome- also referred to as separate

diagnoses of bursitis, rotator cuff tendinosis
• Osteoarthritis (glenohumeral and/or acromioclavicular
joint)
• Biceps tendinosis (tendon rupture less common)
• Rotator Cuff Tear (partial or complete)
 “Universal” Conservative Treatment

• NSAIDs- oral and/or topical

• Ice/HEAT
• Physical Therapy
• Home Exercises
• Cortisone injection
• Refer if significant weakness of RC or lack of
progress with 2-3 months of rehab
 Elbow

• Hinge joint
• Stable with firm bone support
• Joint articulations include the humerus, radius, and ulna
• Special tests: Resisted supination/pronation, resisted
middle finger, Resisted wrist extension/flexion, Tinel at
the ulnar groove
 Common Elbow Diagnoses

• Lateral-Tennis Elbow • Bursitis

• Tendonitis of extensor • Cubital tunnel syndrome
carpi radialis brevis (ulnar neuropathy)

• extensor – supinator • Fracture of radial head

group • Osteoarthritis of elbow
• Medial- Golf Elbow • Radial tunnel syndrome
• flexor – pronator group (posterior interosseous nerve)
• Triceps tendinosis
 Wrist/Hand

• Bilateral comparison to look for asymmetry

• Inspect for atrophy, joint swelling, triggering of finger
• Special Tests: Tinel (wrist AND elbow), Phalen, Median nerve
compression, Finkelstein, CMC grind
• Include exam of shoulder and elbow to determine etiology
(e.g. cervical radiculopathy vs. carpal tunnel syndrome)
 Common Wrist/Hand Diagnoses
• Carpal tunnel syndrome
• Osteoarthritis (especially CMC joint)
• DeQuervain’s Tenosynovitis (“texting thumb”)
• Ice, thumb spica splint, injection, avoid aggravating activity
• Ganglion cyst
• Trigger Finger
• Dupuytren’s contracture
 Trigger Finger
• Snapping or triggering at
the MCP (A1 pulley)
-Tender, swollen nodule
at the A1 pulley
-Often history of
repetitive grasping or
pinching
-Triggering transmitted
to DIP, locking
• NSAIDs, injection, mixed
results with splinting
• Often requires surgical
release if persistent
 Carpal Tunnel Syndrome Treatment

• Splinting (nighttime)
• Injection – can be diagnostic and used prior to surgery
• Surgical intervention for median nerve release
• EMG can assess severity
• Refer patient for consult if symptoms are progressive and/or if exam
shows weakness, sensory changes
 Dupytren’s
Prayer sign contracture

Thenar atrophy
 “Universal”
Conservative Treatment
• NSAIDs- oral and/or topical
• Ice/HEAT
• Physical Therapy and Home Exercises
• Cortisone injection
• PRP and newer therapies (?)
• Refer if significant weakness, neurologic findings, or lack of progress with 2-
3 months of rehab
Lower Limb
 Hip
Pelvic Girdle: 3 joints
Hip joint
Sacroiliac joint
Pubic symphysis
Diagnosing Hip Pain: • BACK PAIN
Often Challenging • GLUTEAL PAIN
Common Chief Complaints • LATERAL HIP PAIN
• ANTERIOR HIP PAIN
• GROIN PAIN
• LEG PAIN OR TINGLING
• SCIATICA
• WEAKNESS
• GAIT DIFFICULTY
• SPASM
 Diagnostic Testing
Will the test change your treatment plan?
• X-ray
• MRI
• EMG (especially if numbness/tingling, weakness)
• http://www.abemexam.org/Verify-Certification/ABEM-Directory
• Consider visceral causes
• Always assess for lumbar spine symptoms
Observation example:
Different approaches
for hip replacement
incisions
 Hip

• Key point: Identify if pain is from hip joint, a surrounding

area, or lumbar spine
• Assess anterior, lateral, and posterior hip
• Good lumbar spine exam
• Special tests: Stinchfield (resisted flexion with extended
knee), Faber, Gaenslon, Ober
 Common Hip Diagnoses
• Osteoarthritis
• Trochanteric bursitis (Greater trochanteric pain syndrome)
• Hip flexor tendinosis, Psoas tendinosis
• Sacroiliac Joint Dysfunction/Pain
• Piriformis Syndrome
• Meralgia Paresthetica
• Lumbar Spine etiology
Meralgia Paresthetica
 Trochanteric Pain
Syndrome

Key Point: Often a

secondary issue/symptom
of gluteal weakness, gait
abnormality, and/or
iliotibial band syndrome
Piriformis Syndrome
 + For Right
gluteal weakness

Trendelenburg Sign

Testing the STANDING leg

Dropping the opposite
side indicates gluteal
weakness
 Knee

• Largest joint in the body • Meniscal tear testing

(McMurray, Apley)
• Modified hinge joint
• Ligament stability testing:
• Greatest range of motion is
flexion Anterior and posterior
cruciate ligaments (Anterior
• More exposed joint, therefore & Posterior Drawer,
higher risk of injury Lachman)
• Is pain intra-articular or extra- Medial and lateral collateral
articular? ligaments (Varus/Valgus
test)
 Knee X-ray Views:
Include Weight Bearing
& Sunrise View
 Common Knee Diagnoses
• Osteoarthritis
• Effusion (secondary to trauma or OA)
• Tendinosis: Patellar, Quadriceps
• Pes Anserine Bursitis
• Iliotibial band syndrome
• Patellofemoral syndrome (aka “runner’s knee”)
• Ligament strain or tear
• Meniscal tear
Managing knee
pain can be
integral for
patient quality
of life!
Peroneal Neuropathy
 Knee Treatment

P.R.I.C.E. NSAID

Hinged Physical
Brace (OA) Therapy

Aspiration,
Injection
 Foot/Ankle

• Foot and ankle are focal points of support for the body to weight bear and
ambulate
• Heel and toe pads act as shock absorbers for walking and activity
• Complex joints allow for balance on variable terrain
• Morton’s Neuroma: Squeeze test- usually between 3rd and 4th metatarsal
heads
 Common Foot & Ankle Diagnoses
• Achilles Tendinosis (complete • Plantar Fasciitis
rupture less common)
• Morton’s Neuroma
• Gastroc strain
• Metatarsalgia
• Peroneal and Posterior Tibial
tendinosis • Hallux Valgus
• Ankle Sprain- ATF, CF, PTF • Pes Planus
• Anterior Tibial Stress Syndrome
(Shin splints)
 Foot and Ankle

Deformed Joint Pes Planus

• Include inspection of shoes

• Sensation • Add visual of foot

• Proprioception
• Arches

Charcot Joint
Injury may effect all 3! ATF, PTF, CFL
(CFL least common)
 Plantar fasciitis
Tenderness over the
medial tuberosity of the
calcaneus, tightness
with dorsiflexion

Assess for gastric

tightness, arches
Metatarsalgia & Morton’s Neuroma
 May occur with low impact/no trauma

Assess for swelling

Foot
Fractures
Key: Pain with percussion?

Think about osteoporosis

 “Universal”
Conservative Treatment
• NSAIDs- oral and/or topical
• Ice/HEAT
• Physical Therapy and Home Exercises
• Cortisone injection
• PRP and newer therapies (?)
• Refer if significant weakness, neurologic findings, or lack of progress with 2-
3 months of rehab
SHOULDER EXAM: No atrophy. Normal strength of rotator cuff and shoulder girdle. Special tests are negative.
Range of Motion: Pain with Internal Rotation, External Rotation, Abduction. Painful arc of motion 80-120 degrees
(supraspinatus/impingement).
Special Tests: Positive impingement testing.
ELBOW EXAM: No atrophy, no effusion, redness or warmth. ROM is pain-free and within functional limits, normal strength.
Inspection/Palpation:
Tenderness at: lateral epicondyle.
Special Tests: Positive resisted middle finger extension, resisted supination.
WRIST/HAND EXAM: No swelling, redness or warmth. No skin breakdown or nail abnormalities. No palmar or dorsal atrophy.
Range of motion is pain free and within functional limits, normal strength.
Inspection: thenar atrophy.
Special Tests: Positive Phalen's, Tinel's, Median nerve compression.
HIP EXAM: No atrophy.Inspection/Palpation:
Tenderness at: trochanteric bursa, piriformis, SI joint.
Special Tests: Negative FABER's, Stinchfield's (resisted hip flexion).
KNEE EXAM: No atrophy, no effusion, redness or warmth. ROM is pain-free and within functional limits, normal strength. Good
ligamentous stability.
ANKLE/FOOT EXAM: No swelling, redness or warmth. No skin breakdown or gross deformity. No atrophy. Range of motion is pain
free and within functional limits, normal strength. Special tests are negative.
Thorough Exam PT/OT

Modify Activity NSAID/Ice/Injection

Challenge Yourself,
Practice These
Skills, &
Achieve Confidence
with MSK Issues!

✓ Functional Anatomy
✓ Good Exam
✓ Partner with the
Patient
✓ Reassess
 References
Akhtar S, Bradley MJ, Quinton DN, Burke FD. Management and referral for trigger finger/thumb. BMJ 2005, 331:30-3.
Brown, K.,L. & Merrill, E. (2015). Musculoskeletal management matters: principles of assessment and triage for the nurse practitioner.
The Journal for Nurse Practitioners, 11(10), 929-939. http://dx.doi.org/10.1016/j.nurpra.2015.08.036
Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Annual Incidence of Common
Musculoskeletal Procedures and Treatment. http://www.aaos.org/research/stats/CommonProceduresTreatments-March2014.pdf
Published March 2014. Accessed [09/01/2017].
Holm, G. (2015). Musculoskeletal assessment and treatment of the upper extremities (Powerpoint slides).
Hoppenfeld, S., & Hutton, R. (1976). Physical examination of the spine and extremities. New York: Appleton-Century-Crofts.
Musculoskeletal Medicine. PM&R Knowledge Now. Retrieved on 09/01/2017 from https://now.aapmr.org/category/musculoskeletal-
medicine/
Sallis, R. (n.d.) Examination skills of the musculoskeletal system. American Academy of Family Physicians. Retrieved on 09/01/2017
from
http://www.ucdenver.edu/academics/colleges/medicalschool/departments/familymed/education/fellowship/sportsmedfellow/Docume
nts/MS%20exam.pdf
Sarwark, J. F., & Carl, R. L. (2010). Essentials of musculoskeletal care. Rosemont, IL: American Academy of Orthopaedic Surgeons.
Silva MB, Skare TL.(2012). Musuloskeletal disorders in diabetes mellitus. Rev Bras Rheumatoly, 52(4), 594-609.
Contact Info: Laurel Short, DNP, MSN, FNP-C
Kansas City Bone & Joint Clinic
[email protected]
@Laurelontherun