School of Medicine

Regional Examination of the

Musculoskeletal System (REMS)

Year 3

Session 2021-2022

COURSE DOCUMENTATION FOR THE MBCHB DEGREE COURSE

Please send corrections/suggestions to improve this handbook to

[email protected]

Authors
Mr Nasir Hussain, Consultant Orthopaedic Surgeon
Ms Ros McKenna, Staff Associate Specialist, Orthopaedics
Dr James Dale, Consultant Rheumatologist
Ms Catherine Kellet, Consultant Orthopaedic Surgeon
Dr Martin Perry, Consultant Rheumatologist
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 YEAR 3 REGIONAL EXAMINATION OF THE
MUSCULOSKELETAL SYSTEM

CONTENTS

Regional Examination of the Musculoskeletal System (REMS)

- General Principles

- Hand and Wrist

- Elbow

- Shoulder

- Hip

- Knee

- Foot and Ankle

- Spine

INTRODUCTION

One of the key skills to learn as a medical student is the ability to take a comprehensive history
and accurately elicit and interpret clinical signs. There are some guidance notes on taking a
MSK history on the Moodle website. The aim of this academic day is to address the latter skill
and to teach you a basic method for Regional Examination of the Musculoskeletal System
(REMS). This builds upon the surface anatomy tutorials in the 1st year Limbs and Back block
which were carried out in the same format i.e. LOOK, FEEL, MOVE.

This teaching material presented below supports the musculoskeletal Academic Days on
Regional Examination of the Musculoskeletal System (REMS). You should read, revise and
practice the examination techniques in this document BEFORE attending the session to get the
best value from the day. There are videos on Moodle which detail the method of REMS
examination. Please watch these videos before the academic day.

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Regional Examination of Musculoskeletal System
(REMS)
The principles of REMS are undernoted below but can vary slightly from region to region as
detailed later:-

EXPOSURE It is important to expose the area to be examined adequately and with

consideration of the patient’s dignity. When examining limbs, both limbs
should be exposed for comparison
LOOK Compare both sides for symmetry
Look for 1. skin changes/ colour 2. muscle wasting 3. intra- and extra-
articular swelling 4. deformity and 5. scars
For lower limb - Gait assessment
FEEL (watch Enquire about tenderness before palpating
patient’s face Consider from which structure tenderness is arising (Skin, soft tissue,
for pain) bone)
Use back of hand to check for temperature
Identify if a joint is swollen and the quality of the swelling (fluctuant,
synovitic, hard)
Identify and characterise an extra-articular swelling (size, colour,
consistency, attached deeply/superficially, skin changes, relationship to
joint)
Assess pulses and capillary refill
Assess sensation
MOVE (watch Check range of movement – compare to normal. Is it more/less.
patient’s face ACTIVE movement - patient does it, PASSIVE movement - you do it.
for pain) If passive movement is greater than active it suggests pain inhibition or
loss of function of a nerve, muscle or tendon
Describe quality of muscle tone (normal, increased or decreased)
Assess muscle power (MRC grading)
Detect crepitus
FUNCTION Individual to each region
AND SPECIAL Functional tests
TESTS Tests to diagnose a specific pathology
Stability tests

There are some other overarching principles which can be helpful. Using observation at all
times - before, during and after the formal examination starts is a useful clinical skill to acquire
early. Assessing your patients mobility is important including watching them rise from a chair,
their gait during walking, adapted postures or movements including how they protect painful
areas, undress ready for examination or climb on the couch.
If the patient has pain it is important to deviate from any standard examination and examine the
area that hurts, and anywhere that the pain might radiate from. Whilst a full MSK is usually
desirable if a limited MSK examination is being performed it is essential to examine the area at
least from the joint above so as to identify these types of problems.
Watch the patient’s reaction - watching the patient’s face whilst you examine may be the only
way you detect discomfort or apprehension. Always position yourself to see the patient’s face,
and get into the habit of looking at it much of the time.

Learning the clear instructions that allow the patient to do exactly what you want is an
important skill. Often you can show them an action which helps them to copy. A slick
examination is reliant on clear instructions to the patients.

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REMS Examination of the hands and wrists
Patient sitting. Rest the patient’s hands on a pillow on their lap

EXPOSURE Expose both arms to above elbow

LOOK 1. skin changes/ colour
- esp rashes, skin thinning and erythema. Nails for pitting, onycholysis, nail
fold infarction
2. muscle wasting
- thenar, hypothenar and interosseus
3. intra- and extra-articular swelling
- esp. Ganglions
4. deformity
- swan neck, boutonniere, mallet finger, ulna drift of MCPs
5. scars
- operative esp. Carpal tunnel and traumatic
Consider symmetry and distribution of any joint abnormalities
FEEL Palpate joints systematically: distal radio-ulnar joint (Piano key test), radio-
carpal joint, thumb CMC (grind test), MCPs (incl metacarpal squeeze),
IPJs (bimanual palpation)
Assess and record any intra- or extra-articular swellings
Assess temperature over forearm, wrist and MCPs
Assess radial and ulnar pulses
Measure capillary refill
Test median / ulnar / radial nerve sensation.
Median = thenar eminence and/or index finger
Ulnar = hypothenar eminence and/or little finger
Radial = web space between thumb and index finger
MOVE Assess active movement: - wrist extension/flexion, pronation/supination,
radial /ulna deviation; finger flexion/extension, abduction/adduction; thumb
flexion/extension, abduction/adduction, opposition.
If active movement reduced assess passive movement.
Assess motor function in Median, Ulna and Radial Nerves:-
Median = Thumb abduction;
Ulnar = Finger abduction (spread)
Radial = Wrist extension
FUNCTION Phalen’s Test (forced wrist flexion producing tingling/pain in median nerve
AND SPECIAL distribution) is +ve in carpal tunnel syndrome (CTS)
TESTS Tinel’s Test at wrist (tap over median nerve at wrist crease producing
tingling/pain in median nerve distribution) is +ve in carpal tunnel
syndrome (CTS)
Tinel’s Test at elbow (tap over ulnar nerve behind medial epicondyle
producing tingling/pain in ulna nerve distribution) is +ve in ulnar nerve
compression

Assess power grip (squeeze 2 of examiner’s fingers)

Assess precision grip (Pick up coin from palm surface)

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REMS Examination of the elbows
Patient standing or sitting

EXPOSURE Expose both arms to shoulders

LOOK 1. skin changes/ colour
- rashes – esp. Erythema, eczema or psoriasis
2. muscle wasting/ injury
- Popeye sign for ruptured biceps tendon
3. intra- and extra-articular swelling
- esp. Rheumatoid nodules and olecranon bursitis
4. deformity
- cubitus varus and vlagus
5. scars
- operative or traumatic
FEEL Palpate joints systematically: Proximal radio-ulnar joint; ulno-trochlear
joint
Palpate epicondyles - medial (golfer’s elbow) and lateral (tennis
elbow)
Palpate olecranon for bursitis
Assess any intra- or extra-articular swellings
Assess temperature over forearm and elbow
Bend elbow to 900 to look for effusion
-Synovial or fluid swelling felt in triangle between olecranon, radial
head and lateral epicondyle
MOVE Assess active movement: Elbow flexion/extension,
pronation/supination
If active movement reduced assess passive movement.
Feel for crepitus
FUNCTION
AND SPECIAL Can the hand reach the mouth
TESTS

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REMS Examination of the shoulders
Examine the patient standing in the anatomical position

EXPOSURE Expose both shoulders and arms. In a female patient there should
be no straps over the shoulder. In this case a gown should be
provided that is applied and tied underneath the axillae.
LOOK 1. skin changes/ colour
- Erythema
2. muscle wasting/ injury
- deltoid, infraspinatus, supraspinatus
3. intra- and extra-articular swelling
4. deformity
- scapula winging (ask patient to press hands against a wall)
5. scars
- operative or traumatic
FEEL Palpate joints systematically: sterno-clavicular joint; acromio-calvicular
joint, gleno-humeral joint
Assess any intra- or extra-articular swellings
Assess temperature anteriorly over gleno-humoral joint.
MOVE Assess active movement (Assess abduction and internal rotation from
behind subject):
Abduction/adduction,
Forward flexion/ extension,
External rotation with elbows at sides,
Internal rotation (reach behind back with thumb tip. Measure how far
thumb can reach e.g. trochanter, SI joint, mid-scapular)
Combine passive movement with special tests (see below)
FUNCTION Passive external rotation – loss of passive external rotation with arm at
AND SPECIAL side is pathognomonic for frozen shoulder
TESTS Passive forward flexion - Impingement sign – pain elicited between 60
and 120 degrees on passive forward flexion – indicates impingement
Passive abduction - Painful Arc - pain elicited between 60 and 120
degrees on passive abduction – indicates impingement
Rotator cuff strength tests: – for cuff tears
-supraspinatus – weakness on resisted abduction (at 30 degrees).
-subscapularis – Gerber’s lift off test.
-infraspinatus and teres minor – weakness on resisted external rotation.
Anterior apprehension test – pain/uneasiness when arm is placed 90
degrees abduction (with elbow flexed) and gently pressed backwards
into forced external rotation – indicates shoulder instability

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REMS Examination of the hip
EXPOSURE Patient requires to be stripped to underwear with a gown to wear
GAIT Antalgic – painful. Limps with short stance phase.
Trendelenberg – waddling gait that shifts weight form side to side.
LOOK 1. skin changes/ colour
- Erythema
2. muscle wasting
- gluteals
3. intra- and extra-articular swelling
4. deformity
- leg length discrepancy (see below)
5. scars
- operative or traumatic

Examine the patient standing

Perform Trendelenberg test (assesses gluteal muscle strength). Stand in front
of patient and place your hands on their ASIS while they grasp your forearm.
Ask patient to stand on one hip at a time. A positive test is the pelvis level
falling on the non weight-bearing side
Examine the patient supine for leg length (use tape measure)
1. Compare leg lengths from bottom of bed – is there any shortening
visible? If no shortening then no further testing required
2. If visible shortening then check if pelvis is straight or tilted. If tilted can it
be straightened or is it fixed? If fixed = apparent shortening. Measure
from the umbilicus or xiphisternum to the medial malleolus of each
ankle and compare – this quantifies apparent shortening
3. If there is visible shortening and the pelvis is straight = true shortening.
Measure from the ASIS (Anterior Superior Illiac Spine) to the medial
malleolus of each leg and compare – this quantifies true shortening

FEEL Palpate trochanters and hip joint.

Palpate for hernia and lymphadenopathy
Check capilliary refill and pedal pulses
MOVE Assess active and passive motion combined by gently guiding the patients leg -
flexion (Flex knee and hip together. Extension not required)
-abduction (Place one hand on the opposite ASIS as you abduct the leg to
make sure pelvis does not tilt. Tilting of pelvis indicates the limit of hip joint
abduction.
-adduction (Place one hand on the ipsilateral ASIS as you adduct to make sure
the pelvis does not lift. Lifting of pelvis indicates the limit of hip adduction.
-internal and external rotation in flexion and extension
FUNCTION A fixed flexion deformity at the hip can be masked by a a hyperlordosis at the
AND lumbar spine which tilts the pelvis in order to flatten the leg.
SPECIAL This can be unmasked by Thomas’ test :-
TESTS Hand under the lumbar spine – you should feel the gap of a lumbar lordosis
Flex the normal hip up as far as possible – this tilts the pelvis back flat and
abolishes the lumbar lordosis which you should feel by pressure on your hand.
If the other leg lifts off the bed (usually it will bend at the knee rather than lift
entirely into the air) this indicates a fixed flexion deformity of that hip.

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REMS Examination of the knee
EXPOSURE Patient requires to be stripped to underwear (or shorts)
GAIT Antalgic – painful. Limps with short stance phase.
Stiff knee – swings leg out to side
LOOK Start with patient standing then lying
1. skin changes/ colour
- Erythema, skin rashes
2. muscle wasting
- quadriceps esp vastus medialis obliquus (VMO)
3. intra- and extra-articular swelling
- esp pre-patella bursitis and Baker’s cyst (best seen standing)
4. deformity
- genu valgus and varus (best seen standing), fixed flexion
5. scars
- operative or traumatic
FEEL Assess temperature - back of the hand compare knee joints with mid calves
Palpate for tenderness around patella, patella tendon and tibial tuberosity.
Perform patella apprehension test (gently push patella laterally. In positive test
patient experiences discomfort or uneasiness)
Palpate for Baker’s cyst behind the knee in popliteal fossa between the
hamstring muscles
Assess intra-articular swelling:
Perform patellar tap:
Slide one hand down the anterior thigh to push fluid out of supra-patellar pouch
Push firmly on patella - does it lift off femur and feel springy
If patella tap negative try cross fluctuation test for small effusions:
Firmly stroke medial side of knee joint upwards to move fluid into joint cavity
and suprapatellar pouch
Then stroke the supero-lateral aspect of the knee downwards - watch medial
side for a bulge of fluid if there is an effusion.
Flex knee to 90 degrees
Palpate joint line from anteriorly to posteriorly for meniscal and/or ligamentous
tenderness
MOVE Assess active movement: Knee flexion/extension
If active movement reduced check passive movement and feel for crepitus
Test integrity of extensor mechanism by asking patient to lift extended leg off
bed.
FUNCTION Stability Tests – consider how sore the patient is before performing these tests
AND SPECIAL
TESTS Flex knee to 900 and check for knee falling backwards (posterior sag - posterior
cruciate ligament laxity)

Perform Anterior draw test:

Place thumbs on tibial tuberosity and hands round upper tibia with index
fingers tucked behind the hamstrings. Stabilise the tibia with your forearm and
pull tibia forwards
(anterior cruciate ligament laxity)

Hold knee at 150 and stress medial and lateral collateral ligaments by holding
ankle and stressing in both directions

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REMS Examination of the foot and ankle
EXPOSURE Expose legs and feet from above knee down
GAIT Antalgic – painful. Limps with short stance phase.
Look for the heel strike, stance and toe off phase of the normal gait
cycle
Check footwear for abnormal / asymmetrical wear or poor fitting or
insoles
LOOK Start with patient standing then sitting/lying
1. skin changes/ colour
- Erythema, skin rashes, nail changes
2. muscle wasting
3. intra- and extra-articular swelling
- esp bunions and corns
4. deformity
- pes planus (see below), hallux valgus, lesser toe deformities
5. scars
- operative or traumatic
With the patient standing
Look for foot and toe alignment. Look for Pes Planus (flat foot) and
Pes Cavus (high arch foot).
If arch looks flat ask patient to stand on tip toes. If arch reforms then
flat foot is dynamic (not pathological)
Observe from behind look for Achilles tendon thickening / swelling.
Examine for alignment of hind-foot - varus / valgus ankle deformity
FEEL Assess temperature over ankle and foot
Assess any intra- or extra-articular swellings
Palpate joints systematically: Ankle joint, subtalar joint, midtarsal
joint, MTP squeeze, great toe MTPJ, IP joints (bimanually)
Check capillary refill and pedal pulses
MOVE Assess active movement:
Ankle flexion/dorsiflexion
subtalar inversion/eversion
toe flexion/extension.
If active movement reduced assess passive movement.

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REMS Examination of the spine
EXPOSURE Patient stripped to underwear and wearing a gown
GAIT Antalgic – painful. Limps with short stance phase.
Foot drop – lifts leg higher than other side to clear foot
LOOK With patient standing
1. skin changes/ colour
- Erythema, skin rashes
2. muscle wasting/ spasm
- look for spasm of paraspinal muscles in acute prolapsed disc
3. intra- and extra-articular swelling
4. deformity
- esp thoracic hyperkyphosis, scoliosis
5. scars
- operative or traumatic
FEEL With patient standing
Assess any extra-articular swellings
Palpate spinous processes and sacroiliac joints
Palpate spinal muscles for tenderness
MOVE Lumbar Spine.
Flexion and extension. Place two fingers on separate spinous
processes. Ask patient to bend forward and watch fingers move
apart and together when patient stands up again
Lateral flexion. Ask patient to run hand down side of the leg to the
knee to assess lateral flexion
Cervical Spine
Tilt head to each side (ear to shoulder) for lateral flexion
Turn head to look over either shoulder for rotation
Chin to chest and tilt head back for flexion and extension
Examine the patient sitting on a couch side with arms
crossed
Thoracic Spine
This fixes the pelvis and allows assessment of thoracic spine
Look over each shoulder to check for thoracic rotation
Examine the patient lying on the couch
Straight leg raising test:
This stretches the sciatic nerve and is elicits pain with lumbar disc
disease. Dorsiflex the foot and passively raise patient’s leg
straight. Watch for pain and note the degree of hip flexion when
the pain comes on
FUNCTION Assess sensation in dermatomes
AND SPECIAL Assess power in myotomes
TESTS Assess tone and limb reflexes bilaterally and Babinski response.
Assess pedal pulses

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