pe_muscskelexam
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pe_muscskelexam


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Musculoskeletal Examination: 
General Principles and Detailed 
Evaluation Of the Knee & 
Shoulder
Charlie Goldberg, M.D.
Professor of Medicine, UCSD SOM
Charles.Goldberg@va.gov
General Principles
\u2022 Musculoskeletal exam performed if 
symptoms (i.e. injury, pain, decreased 
function) \u2013 Different from \u201cscreening 
exam\u201d 
\u2022 Focused on symptomatic area
\u2022 Musculoskeletal complaints 
commonÆfrequently examined
Historical Clues
\u2022 What\u2019s functional limitation?
\u2022 Symptoms in single v multiple joints? 
\u2022 Acute v slowly progressive?
\u2022 If injuryÆ mechanism?
\u2022 Prior problems w/area?
\u2022 Systemic symptoms?
Examination Keys To Evaluating Any Joint
\u2022 Area well exposed - no shirts, pants, etcÆ gowns
\u2022 Inspect joint(s) in question. Signs inflammation, injury 
(swelling, redness, warmth)? Deformity? Compare 
w/opposite side
\u2022 Understand normal functional anatomy
\u2022 Observe normal activity \u2013 what can\u2019t they do? 
Specific limitations? Discrete event (e.g. trauma)? 
Mechanism of injury?
\u2022 Palpate jointÆwarmth? Point tenderness? Over what 
structure(s)?
\u2022 Range of motion, active (patient moves it) and passive 
(you move it).
\u2022 Strength, neuro-vascular assessment.
\u2022 Specific provocative maneuvers
\u2022 If acute injury & painÆ difficult to assess as patient 
\u201cprotects\u201dÆ limiting movement, examination 
\u2013 examine unaffected side first (gain confidence, 
develop sense of their normal)
Wrist Extension
Flexion
Elbow Flexion
Extension
Shoulder Abduction
Adduction
Hip Flexion
Hip Extension
Hip 
Abducition
Hip 
Adduction
Knee
Extension
Knee
Flexion Plantarflexion
Dorsiflexion
Terminology: Flexion/Extension, 
Abduction/Adduction
\u2022 Anatomic Position & Planes Of The Body
\u2022 Flexion:Moving forward out of the frontal plane of the body (except knee and foot)
\u2022 Extension:Movement in direction opposite to flexion
\u2022 Abduction: movement that brings a structure away from the body (along frontal plane)
\u2022 Adduction: movement that brings a structure towards the body (along frontal plane)
Knee Anatomy:
Observation & Identification of Landmarks
\u2022 Hinge-type joint - tolerates sig force, weight
\u2022 Anatomy straight forwardÆ Exam make sense!
\u2022 Fully exposeÆtake off pants, use gown or shorts!
\u2022 Surface land marks: patella (knee cap), patellar tendon, 
medial joint line, lateral joint line, quadriceps muscle, 
hamstring muscle group, tibia, anterior tibial tuberosity
(insertion of patellar tendon), femur.
Hamstring
Muscles
eOrthopod.com 
Knee Anatomy
Observation (cont)
\u2022 Obvious pain w/walking?
\u2022 Landmarks 
\u2022 ScarsÆ past surgery? 
\u2022 SwellingÆfluid in the joint (aka effusion)? 
\u2022 Atrophic muscles (e.g. from chronic disuse)? 
\u2022 Bowing of legs (inward =s Valgus, outward =s 
Varus)?
Varus Deformity 
(bowing outward)
Surgical
Scars
Obvious right knee 
effusion
Range of Motion (ROM)
1. Active then passive (you move the joint)
2. Hand on patella w/extens. & flex Æosteoarthritis, 
may feel grinding sensation (crepitus)
Normal range of motion:
Full Flexion: 140 Full Extension: 0
Assessment For A Large Effusion - Ballotment
An effusion =s fluid w/in joint space 
\u2013 Large effusionsÆobvious
To Examine:
1. Flex knee 
2. Hand on supra-pateallar 
pouchÆabove patella, 
communicates w/joint space. 
3. Push down & towards patellaÆ
fluid center of joint. 
4. Push down on patella w/thumb. 
5. If large effusionÆpatella floats 
& "bounces" back up when 
pushed down.
Menisci \u2013 Normal Function and Anatomy
Femur (articular cartilage covers bone)
Fibula
Tibia
Medial
Meniscus
Lateral 
Meniscus
\u2022 Medial & lateral menisci on top of tibiaÆ cushioned articulating 
surface betwn femur & tibia 
\u2022 Provides joint stability, distributes force, & protects underlying 
articular cartilage (covers bone, allows smooth movement)
\u2022 Menisci damaged by trauma or degenerative changes w/age.
\u2022 Symptoms if torn piece interrupts normal smooth movement of jointÆ
pain, instability ("giving out"), locking &/or swelling
eOrthopod.com
Anatomy&Function
Meniscus
Evaluating for Meniscal Injury \u2013 Joint Line 
Palpation
Joint Line TendernessÆ
medial or lateral 
meniscal injury (& OA)
1. Slightly flex knee. 
2. Find joint space along 
lateral & medial 
margins. Joint line 
perpendicular to long 
axix tibia. 
3. Palpate along medial, 
then lateral margins. 
4. Pain suggest 
underlying meniscus 
damage or OA
eOrthopod.com
Meniscal Injuries
Additional Tests For Meniscal Injury 
McMurray\u2019s Test \u2013 Medial Meniscus
McMurray\u2019s manipulates kneeÆ
torn meniscus \u201cpinched\u201dÆ
Symptoms
Medial meniscus:
1. Left hand w/middle, index, & 
ring fingers on medial joint line. 
2. Grasp heel w/right hand, fully 
flex knee. 
3. Turn ankleÆ foot pointed 
outward (everted). Direct 
kneeÆpointed outward. 
4. Holding foot in everted position, 
extend & flex knee.
5. If medial meniscal injury, feel 
"click" w/hand on knee 
w/extension. May also elicit 
pain. 
Simulated McMurray\u2019s \u2013 Note 
pressure placed on medial meniscus
McMurray\u2019s Test \u2013 Lateral Meniscus
1. Return knee to fully flexed 
position, turn foot inwards 
(inverted). 
2. Direct knee so pointed 
inward. 
3. Hand on knee, fingers along 
joint lines
4. Extend and flex knee. 
5. If lateral meniscal injuryÆ
feel "click" w/fingers on joint 
line; May also elicit pain.
Note: McMurray\u2019s Test for medial 
and lateral meniscus injuries 
are performed together
Additional Assessment For Meniscal Injury \u2013
Appley Grind Test
1. Patient lies on 
stomach. 
2. Grasp ankle & foot 
w/both hand, flex 
knee to ninety 
degrees.
3. Hold leg down w/your 
leg on back of thigh 
4. Push down while 
rotating ankle. 
5. Puts direct pressure 
on menisciÆif
injuredÆ pain. 
6. Test opposite leg
Simulated Appley \u2013 Note how downward 
pressure pinches menisci
Ligaments \u2013 Normal Anatomy 
and Function
\u2022 4 bands tissue, connecting femurÆtibia \u2013 provide stability
\u2022 Ligamentous injury (requires significant force \u2013 eg leg struck from side 
w/foot planted)Æacute pain, swelling & often report hearing a "pop" (sound 
of ligament tearing). 
\u2022 After acute swelling & pain, patient may report pain & instability (sensation 
of knee giving out) w/maneuver exposing deficiency assoc w/damaged 
ligament
Femur (articular cartilage covers bone)
eOrthopod.com
Knee Anatomy
Fibula
Tibia
Medial
Meniscus
Lateral 
Meniscus
Specifics of Testing \u2013 Medial 
Collateral Ligament (MCL)
1. Flex knee ~ 30 degrees. 
2. Left hand on lateral aspect 
knee. 
3. Right hand on ankle or calf. 
4. Push inward w/left hand 
while supplying opposite 
force w/ right. 
5. If MCL torn, joint "opens up" 
along medial aspect. 
6. May also elicit pain w/direct 
palpation over ligament
Compare w/non-affected side \u2013
\u201cnormal\u201d laxity varies from 
patient to patient
Direction of Force
eOrthopod.com
Anatomy \u2013 Collateral Ligament Injuries
Lateral Collateral Ligament (LCL)
1. Flex knee ~ 30 
degrees. 
2. Right hand medial 
aspect knee. 
3. Left hand on ankle or 
calf. 
4. Push steadily w/right 
hand while supplying 
opposite force w/ left. 
5. If LCL torn, joint will 
"open up" on lateral 
aspect. 
6. May elicit pain on 
direct palpation of 
injured ligament
Direction of Forces
eOrthopod.com
Anatomy \u2013 Collateral Ligament Injuries
Another Method For Assessing 
The LCL and MCL
1. Flex knee ~ 30 
degrees, cradle 
heel between arm 
& body. 
2. Place index 
fingers across joint 
lines. 
3. Using your body & 
index fingers, 
provide medial 
then lateral stress 
to joint
Anterior Cruciate Ligament (ACL) 
\u2013 Lachman\u2019s Test
1. Grasp femur w/left