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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