Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 17. Musculoskeletal System

EQUIPMENT

image Goniometer

image Skin-marking pencil

image Reflex hammer

image Tape measure

EXAMINATION

Begin examination as patient enters rooms, observing gait and posture. During examination, note ease of movement when patient walks, sits, rises, takes off garments, and responds to directions.

TECHNIQUE

FINDINGS

POSTURE AND GENERAL GUIDELINES

Inspect skeleton and extremities, comparing sides

Inspect anterior, posterior, lateral aspects of posture; ability to stand erect; body parts; extremities.

 

image Size, alignment, contour, symmetry

Measure extremities when lack of symmetry is noted in length or circumference.

EXPECTED:Bilateral symmetry of length, circumference, alignment, position and number of skinfolds; symmetric body parts; and aligned extremities.

UNEXPECTED:Gross deformity, lordosis, kyphosis, scoliosis, bony enlargement.

Inspect skin and subcutaneous tissues over muscles, cartilage, bones, joints

 

UNEXPECTED:Discoloration, swelling, or masses.

Inspect muscles, and compare sides

imageSize and symmetry

EXPECTED:Approximately symmetric bilateral muscle size.

UNEXPECTED:Gross hypertrophy or atrophy, fasciculations, or spasms.

Palpate all bones, joints, surrounding muscles (palpate inflamed joints last)

imageMuscle tone

EXPECTED:Firm.

UNEXPECTED:Hard or doughy, spasticity.

imageCharacteristics

UNEXPECTED:Heat, tenderness, swelling, fluctuation of a joint, synovial thickening, crepitus, resistance to pressure, or discomfort to pressure on bones and joints.

Test each major joint and related muscle groups for active and passive range of motion, and compare sides

Ask patient to move each joint through range of motion (see instructions for specific joints and muscles in individual sections that follow), then ask patient to relax as you passively move same joints until end of range is felt.

EXPECTED:Passive range of motion often exceeds active range of motion by 5 degrees. Range of motion with passive and active maneuvers should be equal between contralateral joints.

UNEXPECTED:Pain, limitation of motion, spastic movement, joint instability, deformity, contracture, discrepancies greater than 5 degrees between active and passive range of motion. When increase or limitation in range of motion is found, measure angles of greatest flexion and extension with goniometer, as shown in figure below, and compare with values as described for specific joints in individual extremities.

image

Goniometer.

Test major muscle groups for strength, and compare contralateral sides

For each muscle group, ask patient to contract a muscle by flexing or extending a joint and to resist as you apply opposing force. Compare bilaterally.

EXPECTED:Bilaterally symmetric strength with full resistance to opposition.

UNEXPECTED:Inability to produce full resistance. Grade muscular strength according to table below.

Muscle Strength Assessment

Muscle Function Level

Grade

No evidence of contractility

0

Slight contractility, no movement

1

Full range of motion, gravity eliminated*

2

Full range of motion against gravity

3

Full range of motion against gravity, some resistance

4

Full range of motion against gravity, full resistance

5

* Passive movement.

From Jacobson, 1998.

TECHNIQUE

FINDINGS

HANDS AND WRISTS

Inspect dorsum and palm of each hand

imageCharacteristics and contour

EXPECTED:Palmar and phalangeal creases, palmar surfaces with central depression with prominent, rounded mound on thumb side (thenar eminence) and less prominent hypothenar eminence on little-finger side.

imagePosition

EXPECTED:Fingers able to fully extend and aligned with forearm when in close approximation to each other.

UNEXPECTED:Deviation of fingers to ulnar side or inability to fully extend fingers; swan neck or boutonnière deformities.

imageShape

EXPECTED:Lateral finger surfaces gradually tapered from proximal to distal aspects.

UNEXPECTED:Spindle-shaped fingers, bony overgrowths at phalangeal joints.

Palpate each joint in hand and wrist

Palpate interphalangeal joints with thumb and index finger, as shown in the figure on p. 220A; metacarpophalangeal joints with both thumbs, as shown in the figure on p. 220B; and wrist and radiocarpal groove with thumbs on dorsal surface and fingers on palmar aspect of wrist, as shown in the figure on p. 220C.

EXPECTED:Joint surfaces smooth.

UNEXPECTED:Nodules, swelling, bogginess, tenderness, or ganglion.

image

A, Palpating the interphalangeal joints with thumb and index finger. B, Palpating metacarpophalangeal joints with both thumbs. C, Palpating radiocarpal groove with thumbs on dorsal surface and fingers on palmar aspect of wrist.

Assess integrity of median nerve

image Tinel sign

Strike median nerve where it passes through carpal tunnel with index or middle finger.

UNEXPECTED:Tingling sensation radiating from wrist to hand along pathway of median nerve.

image Thumb abduction test

Apply downward pressure on thumb as patient holds thumb perpendicular to hand, palm side up.

EXPECTED:Full resistance to pressure.

UNEXPECTED:Inability to produce full resistance.

image Phalen test

Have patient hold both wrists in fully palmar-flexed position with dorsal surfaces pressed together for 1 minute.

UNEXPECTED:Numbness, paresthesia in distribution of median nerve.

image Katz hand diagram

Have patient mark specific locations of pain, numbness, tingling in hands and arms on diagram.

UNEXPECTED:Pain, numbness, tingling in pattern shown in figure on below.

Redrawn from D’Arcy and McGee, 2000.

image

Test range of motion

Ask patient to perform the following movements:

 

image Metacarpophalangeal flexion and hyperextension

Bend fingers forward at metacarpophalangeal joint, then stretch fingers up and back at knuckle.

EXPECTED:90-degree metacarpophalangeal flexion and as much as 30-degree hyperextension.

image Thumb opposition

Touch thumb to each fingertip and to base of little finger, then make a fist.

EXPECTED:Able to perform all movements.

image Finger abduction and adduction

Spread fingers apart, and then touch them together.

EXPECTED:Both movements possible.

image Wrist extension and hyperextension

Bend hand at wrist up and down.

EXPECTED:90-degree flexion and 70-degree hyperextension.

image Radial and ulnar motion

With palm side down, turn each hand to right and left.

EXPECTED:20-degree radial motion and 55-degree ulnar motion.

Test muscle strength

Ask patient to perform the following movements:

 

image Wrist extension and hyperextension

Maintain wrist flexion while you apply opposing force.

EXPECTED:Bilaterally symmetric with full resistance to opposition.

UNEXPECTED:Inability to produce full resistance.

image Hand strength

Grip two of your fingers tightly.

EXPECTED:Firm, sustained grip.

UNEXPECTED:Weakness or pain.

ELBOWS

Inspect elbows in flexed and extended positions

imageContour

UNEXPECTED:Subcutaneous nodules along pressure points of extensor surface of ulna.

image Carrying angle

Inspect with arms at sides passively extended, palms facing forward.

EXPECTED:Usually 5 to 15 degrees laterally.

UNEXPECTED:Lateral angle exceeding 15 degrees (cubitus valgus) or a medial carrying angle (cubitus varus).

Palpate extensor surface of ulna, olecranon process, medial and lateral epicondyles of humerus, groove on each side of olecranon process

Palpate with patient’s elbow flexed at 70 degrees.

UNEXPECTED:Boggy, soft, tenderness at lateral epicondyle or along grooves of olecranon process and epicondyles.

Test range of motion

Ask patient to perform the following movements:

 

image Flexion and extension

Bend and straighten elbow.

EXPECTED:160-degree flexion from full extension at 0 degrees.

image Pronation and supination

With elbow flexed at right angle, rotate hand from palm side down to palm side up.

EXPECTED:90-degree pronation and 90-degree supination.

UNEXPECTED:Increased pain with pronation and supination of elbow.

Test muscle strength

Ask patient to maintain flexion and extension, as well as pronation and supination, while you apply opposing force.

EXPECTED:Bilaterally symmetric with full resistance to opposition.

UNEXPECTED:Inability to produce full resistance.

SHOULDERS

Inspect shoulders, shoulder girdle, clavicles and scapulae, area muscles

image Size and contour

EXPECTED:All shoulder structures symmetric in size and contour.

UNEXPECTED:Asymmetry, hollows in rounding contour, or winged scapula.

Palpate sternoclavicular and acromioclavicular joints, clavicle, scapulae, coracoid process, greater trochanter of humerus, biceps groove, area muscles

Palpate the biceps groove by rotating the arm and forearm externally. Follow the biceps muscle and tendon along the anterior aspect of the humerus into the biceps groove.

Palpate the muscle insertion for the supraspinatus, infraspinatus, and teres minor near the greater tuberosity of the humerus by lifting the elbow posteriorly to extend the shoulder.

EXPECTED:No tenderness or masses, bilateral symmetry.

UNEXPECTED:Pain, tenderness, mass.

Test range of motion

Ask patient to perform the following movements:

 

imageShoulder shrug

EXPECTED:Symmetric rising.

image Forward flexion

Raise both arms forward and straight up over head.

EXPECTED:180-degree forward flexion.

image Hyperextension

Extend and stretch both arms behind back.

EXPECTED:50-degree hyperextension.

image Abduction

Lift both arms laterally and straight up over head.

EXPECTED:180-degree abduction.

image Adduction

Swing each arm across front of body.

EXPECTED:50-degree adduction.

image Internal rotation

Place both arms behind hips, elbows out.

EXPECTED:90-degree internal rotation.

image External rotation

Place both arms behind head, elbows out.

EXPECTED:90-degree external rotation.

Test shoulder girdle muscle strength

Ask patient to maintain the following positions while you apply opposing force:

 

image Shrugged shoulders

(This also tests cranial nerve XI.)

EXPECTED:Bilaterally symmetric with full resistance to opposition.

UNEXPECTED:Inability to produce full resistance.

image

Shrugged shoulders.

imageForward flexion

EXPECTED:Bilaterally symmetric with full resistance to opposition.

UNEXPECTED:Inability to produce full resistance.

imageAbduction

EXPECTED:Bilaterally symmetric with full resistance to opposition.

UNEXPECTED:Inability to produce full resistance.

Assess rotator cuff muscles

Abduct the arm 90 degrees and flex the shoulders forward 30 degrees to test the supraspinatus muscle. Apply downward pressure on the distal humerus when the arm is rotated so that thumb points down or up.

UNEXPECTED:Pain and weakness with opposing force.

Flex the elbow 90 degrees and rotate the forearm medially against resistance to test the subscapularis muscle.

UNEXPECTED:Pain and weakness with opposing force.

With the arm at the side and elbow flexed 90 degrees, rotate the arm laterally against resistance to test the infraspinatus and teres minor muscles.

UNEXPECTED:Pain and weakness with opposing force.

Evaluate the rotator cuff for impingement or a tear

Neer test: Have the patient internally rotate and forward flex the arm at the shoulder, pressing the supraspinatus muscle against the anterior inferior acromion.

UNEXPECTED:Increased shoulder pain.

imageHawkins test: Abduct the shoulder to 90 degrees, flexing the elbow to 90 degrees, and then internally rotating the arm to its limit.

UNEXPECTED:Increased shoulder pain.

image image

Assessment for rotator cuff inflammation or tear. A, Neer test. B, Hawkins test.

TEMPOROMANDIBULAR JOINT

Palpate joint space for clicking, popping, pain

Locate temporomandibular joints with fingertips placed just anterior to tragus of each ear, as shown in figure at right. Ask patient to open mouth and allow fingertips to slip into joint space. Gently palpate.

EXPECTED:Audible or palpable snapping or clicking may be noted.

UNEXPECTED:Pain, crepitus, locking, or popping.

image

Palpating tempormandibular joint.

Test range of motion

Ask patient to:

 

imageOpen and close mouth

EXPECTED:Opens 3 to 6 cm between upper and lower teeth.

imageMove jaw laterally to each side

EXPECTED:Mandible moves 1 to 2 cm in each direction.

imageProtrude and retract jaw

EXPECTED:Both protrusion and retraction possible.

Test strength of temporalis and masseter muscles with patient’s teeth clenched

Ask patient to clench teeth while you palpate contracted muscles and apply opposing force. (This also tests cranial nerve V motor function.)

EXPECTED:Bilaterally symmetric with full resistance to opposition.

UNEXPECTED:Inability to produce full resistance.

CERVICAL SPINE

Inspect neck from anterior and posterior positions

imageAlignment

EXPECTED:Cervical spine straight, with head erect and in approximate alignment.

imageSymmetry of skinfolds

UNEXPECTED:Asymmetric skinfolds, webbed neck.

Palpate posterior neck, cervical spine, and paravertebral, trapezius, and sternocleidomastoid muscles

 

EXPECTED:Good muscle tone, symmetry in size.

UNEXPECTED:Palpable tenderness or muscle spasm.

Test range of motion

image Forward flexion

Bend head forward, chin to chest.

EXPECTED:45-degree flexion.

image Hyperextension

Bend head backward, chin toward ceiling.

EXPECTED:45-degree hyperextension.

image Lateral bending

Bend head to each side, ear to each shoulder.

EXPECTED:40-degree lateral bending.

image Rotation

Turn head to each side, chin to shoulder.

EXPECTED:70-degree rotation.

Test strength of sternocleidomastoid and trapezius muscles

Ask patient to maintain each of the previous positions while you apply opposing force. (Cranial nerve XI is also tested with rotation.)

EXPECTED:Bilaterally symmetric strength with full resistance to opposition.

UNEXPECTED:Inability to produce full resistance.

THORACIC AND LUMBAR SPINE

Inspect spine for alignment

Note major landmarks of back—each spinal process of vertebrae (C7 and T1 usually most prominent), scapulae, iliac crests, paravertebral muscles.

EXPECTED:Head positioned directly over gluteal cleft, vertebrae straight (as indicated by symmetric shoulder, scapular, and iliac crest heights), curves of cervical and lumbar spines concave, curve of thoracic spine convex, and knees and feet aligned with trunk and pointing directly forward.

UNEXPECTED:Lordosis, kyphosis, scoliosis, or sharp angular deformity (gibbus).

Palpate spinal processes and paravertebral muscles

Ask patient to stand erect.

UNEXPECTED:Muscle spasm or spinal tenderness.

Percuss for spinal tenderness

Patient is still standing erect. First, tap each spinal process with one finger, then rap each side of spine along paravertebral muscles with ulnar aspect of fist.

UNEXPECTED:Muscle spasm or spinal tenderness.

Test range of motion and curvature

Ask patient to perform the following movements (mark each spinal process with skin pencil if unexpected curvature suspected):

 

image Forward flexion

Bend forward at waist and try to touch toes. Observe patient from behind to check curvature.

EXPECTED:75- to 90-degree flexion; back remains symmetrically flat as concave curve of lumbar spine becomes convex with forward flexion.

UNEXPECTED:Lateral curvature or rib hump.

image Hyperextension

Bend back at waist as far as possible.

EXPECTED:30-degree hypertension with reversal of lumbar curve.

image Lateral bending

Bend to each side as far as possible.

EXPECTED:35-degree lateral bending on each side.

image Rotation

Swing upper trunk from waist in circular motion, front to side to back to side, while you stabilize pelvis.

EXPECTED:30-degree rotation forward and backward.

Test for lumbar nerve root irritation or disk herniation at L4, L5, or S1 levels (patient supine with neck slightly flexed)

image Straight-leg raising test

Ask patient to raise leg with knee extended. Repeat with other leg.

EXPECTED:No pain below knee with leg raising.

UNEXPECTED:Unable to raise leg more than 30 degrees without pain. Pain below knee in dermatome pattern. Flexion of knee often eliminates pain with leg raising. Crossover pain in affected leg.

image Bragard stretch test

Hold patient’s lower leg with knee extended, and raise it slowly until pain is felt. Lower leg slightly, briskly dorsiflex foot, and internally rotate hip.

UNEXPECTED:Pain when leg is raised less than 70 degrees; aggravated by dorsiflexion and internal rotation of hip.

HIPS

Inspect hips for symmetry and level of gluteal folds

With patient standing, inspect anteriorly and posteriorly, using major landmarks of iliac crest and greater trochanter of femur.

UNEXPECTED:Asymmetry in iliac crest height, size of buttocks, or number and level of gluteal folds.

Test range of motion

While in position indicated, patient should perform the following movements:

 

image Flexion, knee extended

With patient supine, raise leg over body.

EXPECTED:Up to 90-degree flexion.

image Hyperextension

While standing or prone, swing straightened leg behind body without arching the back.

EXPECTED:Up to 30-degree hyperextension.

image Flexion, knee flexed

While supine, raise one knee to chest while keeping other leg straight.

EXPECTED:120-degree flexion.

image Abduction and adduction

While supine, swing leg laterally and medially with knee straight. During adduction movement, lift patient’s opposite leg to permit examined leg full movement.

EXPECTED:Some degree of both abduction and adduction.

image Internal rotation

While supine, flex knee and rotate leg inward toward other leg.

EXPECTED:40-degree internal rotation.

image External rotation

While supine, place lateral aspect of foot on knee of other leg. Move flexed leg toward table.

EXPECTED:45-degree external rotation.

Test hip muscle strength

image Knee in flexion and extension

Ask patient to maintain flexion of hip with knee in flexion and then extension while applying opposing force.

EXPECTED:Bilaterally symmetric with full resistance to opposition.

imageResistance to uncrossing legs while seated

UNEXPECTED:Inability to produce full resistance.

EXPECTED:Bilaterally symmetric with full resistance to opposition.

Perform Trendelenburg test to inspect for weak hip abductor muscles

Ask patient to stand and balance first on one foot, then on other. Observe from behind.

UNEXPECTED:Asymmetry or change in level of iliac crests.

Trendelenburg test. From Magee DJ, 2007.

image

LEGS AND KNEES

Inspect knees and popliteal spaces, flexed and extended

Note major landmarks—tibial tuberosity, medial and lateral tibial condyles, medial and lateral epicondyles of femur, adductor tubercle of femur, patella.

EXPECTED:Natural concavities on anterior aspect, on each side, above patella.

UNEXPECTED:Convex rather than usual concave indentation above patella.

Observe lower leg alignment

 

EXPECTED:Angle between femur and tibia less than 15 degrees. Bowlegs common until 18 months of age; knock-knees common between 2 and 4 years.

UNEXPECTED:Knock-knees (genu valgum) or bowlegs (genu varum) at other ages, excessive hyperextension of knee with weight bearing (genu recurvatum).

Palpate popliteal space

 

UNEXPECTED:Swelling or tenderness.

Palpate tibiofemoral joint space

Identify patella, suprapatellar pouch, infrapatellar fat pad.

EXPECTED:Smooth and firm joint.

UNEXPECTED:Tenderness, bogginess, nodules, or crepitus.

Test range of motion

image Flexion

Ask patient to bend each knee.

EXPECTED:130-degree flexion.

image Extension

Ask patient to straighten leg and stretch it.

EXPECTED:Full extension and up to 15-degree hyperextension.

Test muscle strength

image Flexion and extension

Ask patient to maintain flexion and extension while you apply opposing force.

EXPECTED:Bilaterally symmetric with full resistance to opposition.

UNEXPECTED:Inability to produce full resistance.

ADDITIONAL TECHNIQUES FOR KNEES

Perform ballottement procedure to determine presence of excess fluid or effusion in knee

With knee extended, apply downward pressure on suprapatellar pouch with thumb and finger of one hand, then push patella sharply downward against femur with fingers of other hand, as shown at right. Suddenly release pressure on patella, while keeping fingers lightly on knee.

UNEXPECTED:A tapping or clicking is sensed when patella is pushed against femur. Patella then floats out as if a fluid wave were pushing it.

image

Ballottement.

Test for bulge sign to determine presence of excess fluid in knee

With knee extended, milk medial aspect of knee upward two or three times, as shown in figure below, A, then tap lateral side of patella, as shown below in figure, B.

UNEXPECTED:Bulge of returning fluid to hollow area medial to patella.

image

Bulge sign. A, Milking the medial aspect of the knee two or three times. B, Tap the lateral side of the patella.

Perform McMurray test to detect torn medial or lateral meniscus

Ask patient to lie supine and flex one knee completely with foot flat on table near buttocks. Maintain that flexion with your thumb and index finger on either side of the joint space while stabilizing knee. Hold heel with other hand; rotate foot and lower leg to lateral position. Extend knee to 90-degree angle. Return knee to full flexion, then repeat procedure rotating foot and lower leg to medial position.

UNEXPECTED:Palpable or audible click or limited extension of knee with either lateral or medial movements.

image

Procedure for examination of the knee with the McMurray test. Knee is flexed after lower leg was rotated to medial position.

Perform drawer test to identify instability of anterior and posterior cruciate ligaments

Ask patient, while supine, to flex knee 45 to 90 degrees, placing foot flat on table. Place both hands on lower leg with thumbs on ridge of anterior tibia near tibial tuberosity. Pull tibia, sliding it forward of femur. Then push tibia backward.

UNEXPECTED:Anterior or posterior movement greater than 5 mm.

image

Drawer test.

Perform varus and valgus stress test to identify mediolateral collateral ligament instability

Ask patient to lie supine and extend knee. While you stabilize femur with one hand and hold ankle with other, apply varus force against the ankle (toward midline) and internal rotation.

UNEXPECTED:Excessive laxity felt as joint opening, medial or lateral movement.

Then apply valgus force against the ankle (away from midline) and external rotation. Repeat with knee flexed to 30 degrees.

 

image

Varus and valgus stress test.

FEET AND ANKLES

Inspect during weight bearing (standing and walking) and non–weight bearing

Note major landmarks—medial malleolus, lateral malleolus, Achilles tendon.

 

imageCharacteristics

EXPECTED:Smooth and rounded malleolar prominence, prominent heels, prominent metatarsophalangeal joints.

UNEXPECTED:Calluses and corns.

imageAlignment

EXPECTED:Feet aligned with tibias and weight bearing on foot midline.

UNEXPECTED:In-toeing (pes varus), out-toeing (pes valgus), deviations in forefoot alignment (metatarsus varus or metatarsus valgus), heel pronation, or pain.

imageContour

EXPECTED:Longitudinal arch that may flatten with weight bearing. Foot flat when not bearing weight (pes planus) and high instep (pes cavus) are common variations.

UNEXPECTED:Pain with pes planus.

imageToes

EXPECTED:Toes on each foot straight forward, flat, in alignment.

 

UNEXPECTED:Hammertoe; claw toe; mallet toe; hallux valgus; bunions; or heat, redness, swelling, tenderness of metatarsophalangeal joint of great toe (possibly with draining tophus).

Palpate Achilles tendon and each metatarsal joint

Using thumb and fingers of both hands, compress forefoot, palpating each metatarsophalangeal joint.

EXPECTED:No tenderness or masses, bilateral symmetry.

UNEXPECTED:Pain, masses, thickened Achilles tendon.

Test range of motion

Ask patient to sit, then perform following movements:

 

image Dorsiflexion

Point foot toward ceiling.

EXPECTED:20-degree dorsiflexion.

image Plantar flexion

Point foot toward floor.

EXPECTED:45-degree plantar flexion.

image Inversion and eversion

Bend foot at ankle, then turn sole of foot toward and away from other foot.

EXPECTED:30-degree inversion and 20-degree eversion.

image Abduction and adduction

Rotate ankle, turning away from and then toward other foot (while you stabilize leg).

EXPECTED:10-degree abduction and 20-degree adduction.

image Flexion and extension

Bend and straighten toes.

EXPECTED:Some flexion and extension, especially of great toes.

Test strength of ankle muscles

Ask patient to maintain dorsiflexion and plantar flexion while you apply opposing force.

EXPECTED:Bilaterally symmetric with full resistance to opposition.

UNEXPECTED:Inability to produce full resistance.

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Ankylosing spondylitis

Subjective Data:Develops predominantly in males between 20 and 40 years of age. Begins insidiously with low back pain, also involving hips and shoulders. Pain can fluctuate from one side to the other and progress to reduced spinal mobility.

Objective Data:Restriction in the lumbar flexion of the patient. The shoulders, hips, and knees may be affected later, developing limited range of motion. Uveitis may be present.

Carpal tunnel syndrome

Subjective Data:Numbness, burning, and tingling in the hands often occur at night. Can also be elicited by rotational movements of the wrist. Pain may radiate to the arms.

Objective Data:Weakness of the hand and flattening of the thenar eminence of the palm may result.

Gout

Subjective Data:Sudden onset of a hot, swollen joint; exquisite pain; limited range of motion. Primarily affects men older than 40 years of age and women of postmenopausal age. Classically affects the proximal phalanx of the great toe, although the wrists, hands, ankles, and knees may be involved.

Objective Data:The skin over the swollen joint may be shiny and red or purple. Uric acid crystals may form as tophi under the skin with chronic gout.

Lumbar disk herniation

Subjective Data:Can be associated with lifting heavy objects. Common symptoms include low back pain with radiation to the buttocks and posterior thigh or down the leg in the distribution of the dermatome of the nerve root. Pain relief is often achieved by lying down.

Objective Data:Spasm and tenderness over the paraspinal musculature may also be present. Patient may have difficulty with heel walking (L4 and L5) or toe walking (S1). Numbness, tingling, or weakness may occur in the involved extremity.

Bursitis

Subjective Data:Common sites include the shoulder, elbow, hip, and knee with pain and stiffness surrounding the joint around the inflamed bursa. The pain usually is worse during activity.

Objective Data:Limitation of motion caused by swelling; pain on movement; point tenderness; and an erythematous, warm site. Soreness may radiate to tendons at the site.

Osteoarthritis

See table on p. 241.

Rheumatoid arthritis

See table on p. 241.

Sprain

Subjective Data:Often associated with improper exercise warm-up, fatigue, or previous injury. Severity ranges from a mild intrafibrinous tear to a total rupture of a single muscle.

 

Objective Data:Temporary muscle weakness, spasm, pain, and contusion.

Fracture

Subjective Data:Usually occurs in the setting of acute trauma. Can occur more easily in patients with bone disorders (e.g., osteogenesis imperfecta, osteoporosis, bone metastasis).

Objective Data:Deformity, edema, pain, loss of function, color changes, and paresthesia.

Tenosynovitis (tendinitis)

Subjective Data:Pain with movement of such common sites as the shoulder, knee, heel, and wrist.

Objective Data:Point tenderness over the involved tendon. Pain with active movement, and some limitation of movement in the affected joint.

Rotator cuff tear

Subjective Data:May be pain in the shoulder and deltoid area that can awaken the patient at night.

Objective Data:May be an inability to maintain a lateral raised arm against resistance. Tenderness over the acromioclavicular joint. Grating sound on movement, crepitus, and weakness in external shoulder rotation.

Differential Diagnosis of Arthritis

Signs and Symptoms

Osteoarthritis

Rheumatoid Arthritis

Onset

Insidious

Gradual or sudden (24-48 hours)

Duration of stiffness

Few minutes, localized, but short “gelling” after prolonged rest

Often hours, most pronounced after rest

Pain

On motion, with prolonged activity, relieved by rest

Even at rest, may disturb sleep

Weakness

Usually localized and not severe

Often pronounced, out of proportion with muscle atrophy

Fatigue

Unusual

Often severe, with onset 4 to 5 hours after rising

Emotional depression and lability

Unusual

Common, coincides with fatigue and disease activity, often relieved if in remission

Tenderness over localized afflicted joint

Common

Almost always; most sensitive indicator of inflammation

Swelling

Effusion common, little synovial, reaction swelling rare

Fusiform soft tissue enlargement, effusion common, synovial proliferation and thickening

Heat, erythema

Unusual

Sometimes present

Crepitus, crackling

Coarse to medium on motion

Medium to fine

Joint enlargement

Mild with firm consistency

Moderate to severe

Pediatric Variations

EXAMINATION

Musculoskeletal findings and motor development in infants, children, and adolescents change as they grow. For a complete description of age-specific anticipated pediatric findings, see Chapter 21.

SPORTS PARTICIPATION SCREENING EXAMINATION FOR CHILDREN AND ADOLESCENTS

• Observe posture and general muscle contour bilaterally.

• Observe gait.

• Ask patient to walk on tiptoes and heels.

• Observe patient hop on each foot.

• Ask patient to duck-walk four steps with knees completely bent.

• Inspect spine for curvature and lumbar extension, fingers touching toes with knees straight.

• Palpate shoulder and clavicle for dislocation.

• Check the following for range of motion—neck, shoulder, elbow, forearm, hands, fingers, hips.

• Test knee ligaments for drawer sign.

SAMPLE DOCUMENTATION

Subjective.A 13-year-old female referred by school nurse because of uneven shoulder and hip heights. Active in sports, good strength, no back pain or stiffness.

Objective.Spine straight without obvious deformities when erect, but mild right curvature of thoracic spine with forward flexion. No rib hump. Right shoulder and iliac crest slightly higher than left. Muscles and extremities symmetric; muscle strength appropriate and equal bilaterally; active range of motion without pain, locking, clicking, or limitation in all joints.