MSK Directed Exam Edit2401

Musculoskeletal System
Directed Examination
Clinical Skills Development
UAG School of Medicine
Dr. Cabrera-Salaiza
Academic Objectives
• Present physical examination maneuvers in order to perform a clinical
exam of the skeletal system based on common chief complaints within
primary care setting.
• Integrate and apply theoretical knowledge into a clinical scenario.
• Develop clinical criteria.
• Evaluate the severity of the limitation/damage.
• Create and construct a clinical diagnosis.
• Analyze the diagnostic value of the focused manoeuvres.
Bloom’s Taxonomy – From Knowledge to Practice. NEJM Knowledge+ is a product of NEJM Group, a division of the Massachusetts Medical Society.
Copyright © 2024 Massachusetts Medical Society. All rights reserved.
Lesson Contents
• Introduction
• Clinical relevance & statistics.
• Required knowledge to conduct this exam.
• Shoulder assessment
• Elbow assessment
• Wrist assessment
• Hip assessment
• Knee assessment
Introduction
• Clinical Relevance:
• Pain is probably the most common chief complaint concerning
the musculoskeletal system therefore a complete interview
should be conducted a priori so a good focused physical
examination is conducted a posteriori.
• Physical examination confirms or at very least narrows clinical

diagnosis.
History Taking
• Note acute vs chronic injuries ~ outcome varies on damage due

to time relationship.
• Traumatic vs atraumatic. Mechanism of injury (MOI)?
• Overuse (repetitive movement)? Degenerative(aging)?
Congenital? Secondary?
• Associated symptoms: weakness, radiation of pain, local swelling,
joint locking or instability, pain only with activity, ability to sleep
with pain, numbness, local bruising?
Required knowledge
• Anatomical concepts & relationship with motion.

• Physiology of skeletal muscle contraction.
• How is movement occurring?
• Professionalism and soft skills attained from previous CSD
lessons are always a good idea to keep in mind.
• You got this!
A brief review: joints
• Physical exam sequence: INSPECTION – PALPATION – MANEUVERS.
• Inspection: the power of observation, watch natural positions,
movements, how patient carries himself/herself, assistive devices,
compensatory movements, evident deformities.
• Palpation: touch for tenderness over bone or soft tissue, suggestive
data of inflammation/infection (4 cardinal signs).
• Maneuvers: range of motion (active/passive), strength, special tests.
• *Focused neurological exam can be conducted if signs of impairment
are present.
• IF ITS NOT BROKEN DON’T BREAK IT.
Shoulder Assessment
Shoulder Exam
• INSPECTION: observe the shoulder anterior and posteriorly. Ask
patient to point where it hurts/radiates. Look for deformities.
• PALPATE: tenderness, pain, swollen areas.
Shoulder Exam
• Test Range of Motion
• Apley’s Scratch Test (Dawbarn’s Test)

• Ext Rot & Adduction / Ext rotation & abduction / Internal Rot
& Adduction.
Almoallim et al. Approach to Musculoskeletal Examination. January 2021, DOI: 10.1007/978-981-15-8323-0_2. In book: Skills in Rheumatology
Shoulder Exam
• AC joint, Scarf test. – Joint integrity
Shoulder Exam
• Rotator cuff special tests: Neer’s – Supraspinatus Impingement –
Painful shoulder syndrome.
Shoulder Exam
• Rotator cuff pathology / Impingement: Empty Can – Supraspinatus
tendon tear. - – Painful shoulder syndrome.
Shoulder Exam
• Rotator cuff special tests: Hawkins-Kennedy – Shoulder
Impingement. – Painful shoulder syndrome.
Shoulder Exam
• Tendinopathy: Yergason’s Test – Biceps brachii tendinitis, painful
upon palpation while resistance to supination by patient.
Shoulder Exam
• Serratus anterior evaluation: Standing Push up – Muscle
Weakness.
Elbow Assessment
Elbow Examination
• INSPECTION: observe the
joint, medial and lateral
aspects. Ask patient to
point where it
hurts/radiates. Look for
deformities.
• PALPATE: tenderness, pain,
swollen areas.
Clinical Images courtesy of Montserrat Ezquerra MD © 2022
Elbow Examination
• ROM
• Humeroulnar &
humeroradial
joints, and the
proximal radio-
ulnar joint.
•Normal range of motion for the elbow joint. Research Gate SMA based exoskeletons for hand, elbow and shoulder rehabilitation September 2017
•2017(4-5):1-11, DOI: 10.1155/2017/1605101
• Lateral epicondylitis (Tennis elbow) can be evaluated with Mills &
Cozen’s Tests are to be performed.
• Medial epicondylitis (Golfer’s elbow) can be
assessed with the following test.
Wrist Assessment
Wrist Examination
• INSPECTION: observe
natural display of the
hands, palmar and dorsal
aspects. Ask patient to
point where it
hurts/radiates. Look for
deformities.
• PALPATE: tenderness, pain,
swollen areas.
Wrist Examination
• When CTS is suspected, Phalen’s & Tinel’s tests can be performed.
• Zhang et al. Accuracy of Provocative Tests for Carpal Tunnel Syndrome. April 2020 Journal of Hand Surgery Global Online 2(3)
DOI: 10.1016/j.jhsg.2020.03.002
•
Wrist Examination
• De Quervain’s Tenosynovitis is evaluated using Finkelstein’s Maneuver.

Positive when provoques pain and area is tender.
The Back & Spine
Inspection
Inspect the entire back for
redness, asymmetry,
deformity, scoliosis or
abnormal hair growth.
Inspection
Scoliosis
Palpation
Palpation
Cervical – Motion Range
Thoracolumbar – Motion Range
Adam’s Test
Hip Assessment
Hip Examination
• INSPECTION: note patient’s
gait. Ask patient to point
where it hurts (originating
point) and where it radiates
(ending point).
• PALPATE: tenderness, local
masses.
Hip Examination
• ROM of the hip.
• Consider modifying technique if patient cannot stand up.
Hip Examination
• Clinically, sacroiliitis can be evaluated using, Patrick’s (FABER) maneuver.
Additionally Gaenslen’s maneuver can contribute too, positive if pain elicits at SIJ.
• When clinical suspicion of lumbar radiculopathy or just
lumbalgia is being assessed Lasègue’s, Bragard’s & Neri’s tests
are to be performed.
Knee Assessment
Knee Examination
• INSPECTION: note patella, inspect superior and inferior aspect. Ask
patient to point where it hurts, listen if it crackles with any movement.
• PALPATE: patellar integrity, tendon and mobility (luxation).
• Patellar syndromes can be assessed with the patellar grind test
(Clarke’s sign) and the patellar apprehension test.
• Meniscal conditions can be approached with the Apley’s
test (distraction and compression of the knee).
• Lateral and medial meniscus pathology or damages can
be evaluated with the McMurray’s test.
• To evaluate ligaments (cruciate ligaments) a
couple of maneuvers are quite useful. Beginning
with Lachman-Trillat test.
• Drawer test’s (anterior and posterior
drawer) are used to asses ACL & PCL
respectively.
Ankle Assessment
• Ankle woman competition, London 1930’s.

Ankle Assessment
• INSPECTION: note position,
inspect anterior medial
(tibial) and lateral (fibular)
aspects. Ask patient to point
where it hurts.
• PALPATE: joint integrity,
swollen or tender areas.
Ankle Assessment
• Squeeze test is performed for
syndesmotic injury (high ankle
sprain).
•
.
To perform the squeeze test, place a heel
of each hand just proximal to the midpoint
of the calf, and compress the tibia and
fibula by squeezing in an anteromedial to
posterolateral direction. A positive test is
marked by reproduction of pain in the
distal syndesmosis, just above the ankle
joint.
Image: Kevin DeWeber MD © 2022 UpToDate, Inc. y/o sus afiliadas. Todos
los derechos reservados.
Squeeze test for syndesmotic injury (high ankle sprain)
• External rotation test is
performed when ankle
sprains whose MOI was
forced external rotation.
.
To perform test, place one hand at mid
tibial segment and the other hand at the
mid ankle, begin rotating laterally the
ankle. A positive test is marked by
reproduction of pain in the articular
surface of tibia and talus.
Molinari A et al. High ankle sprains (syndesmotic): diagnostic

challenges and review of the literature. Available at
ResearchGate
External rotation stress test for syndesmotic injury (high

ankle sprain)
• Thompson test is performed for Achilles tendon injury.
Squeezing calf produces plantar flexion, as a natural response.
Summary
• Shoulder assessment: Apley’s, Scarf, empty can, Neer’s, Hawkins-
Kennedy, Yergason’s, Serratus Anterior.
• Elbow assessment: Mill’s, Cozen’s, Golfer’s.
• Wrist assessment: Phalen’s, Tinel’s, Finkelstein’s.
• Back: Adam’s test.
• Hip assessment: Patrick’s, Gaeslen’s, Lasègue’s, Bragard, Neri’s.
• Knee assessment: Clarke’s, Patellar apprehension, Apleys distraction &
compression, McMurray’s, Lachman, drawers.
• Ankle assessment: Squeeze test, external rotation test & Thompson’s.
Additional Readings
Additional Readings
• The presented material is to be performed on adults, for evaluation of the child with joint pain or
swelling please see:
https://www.uptodate.com/contents/evaluation-of-the-child-with-joint-pain-and-or-
swelling?search=musculoskeletal%20examination&source=search_result&selectedTitle=5~150&usage_type=default&display_ran
k=5
• Additional study material for hip examination: https://www.uptodate.com/contents/musculoskeletal-examination-of-
the-hip-and-
groin?search=musculoskeletal%20examination&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=
1
• A more detailed exam of the hip: https://www.youtube.com/watch?v=Hkqr3mg6IWQ
• Active range of motion: https://www.youtube.com/watch?v=3OiJqAtPQUc
• Passive range of motion: https://www.youtube.com/watch?v=3lTv4gpRWxg
• Complimentary study material for knee examination: https://www.uptodate.com/contents/physical-examination-of-
the-
knee?search=musculoskeletal%20examination&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=
4
• A more detailed exam of the knee: https://www.youtube.com/watch?v=17ZKya9yR2Y
Questions?
• Please contact your CSD instructor/professor or forward all questions
to:
• [email protected]
Thank you!
Andy Warhol - From A to B and Back Again - Art Institute of Chicago, IL. 2019.

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Musculoskeletal System

• Physical examination confirms or at very least narrows clinical

• Note acute vs chronic injuries ~ outcome varies on damage due

• Anatomical concepts & relationship with motion.

• Apley’s Scratch Test (Dawbarn’s Test)

• When CTS is suspected, Phalen’s & Tinel’s tests can be performed.

• De Quervain’s Tenosynovitis is evaluated using Finkelstein’s Maneuver.

• Ankle woman competition, London 1930’s.

Molinari A et al. High ankle sprains (syndesmotic): diagnostic

External rotation stress test for syndesmotic injury (high

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