[PDF] - 1 Agenda Define the medical vocabulary components related to the PDF Document

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Slide 1 JSOMTC, SWMG(A)

SOCM Physical Exam of the Musculoskeletal System PFN: SOMPYL0L

Hours: 2.0

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JSOMTC, SWMG(A)

Terminal Learning Objective

 Action: Communicate knowledge of “Physical

Exam of Musculoskeletal System”

 Condition: Given a lecture in a classroom

environment

 Standard: Received a minimum score of 75%

IAW course standards on the formative quizzes and the Physical Exam Practical Test grade sheet

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JSOMTC, SWMG(A)

References

 BATES’ Guide to Physical Examination And History

Taking, 11th Edition, 2013, Chapter 16, Pages 571‐653

 Merck Manual, 18th Edition, 2006, Chapters 30 & 206,

Pages 251‐349; 1748‐1758

 Clinically Oriented Anatomy, 6th edition, 2010  CURRENT Medical Diagnosis & Tx, 56th edition, 2012

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JSOMTC, SWMG(A)

Agenda

 Define the medical vocabulary components

related to the physical exam of the musculoskeletal (MSK) system

 Identify common or concerning symptoms

f the musculoskeletal system

 Communicate the important topics for

health promotion and counseling for the musculoskeletal system

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JSOMTC, SWMG(A)

Agenda

 Communicate the important areas of

examination for each of the major joints of the musculoskeletal system

 Communicate the inspection, palpation,

range of motion, and maneuvers of the shoulder

 Communicate the inspection, palpation,

range of motion, associated structures, and maneuvers of the elbow

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JSOMTC, SWMG(A)

Agenda

 Communicate the inspection, palpation,

range of motion, and maneuvers of the wrist and hands

 Communicate the inspection, palpation,

range of motion, and maneuvers of the spine

 Communicate the inspection, palpation,

range of motion, and maneuvers of the hip

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JSOMTC, SWMG(A)

Agenda

 Communicate the inspection, palpation,

range of motion, and maneuvers of the knee

 Communicate the inspection, palpation,

range of motion, and maneuvers of the ankle and foot

 Communicate the limitation in motion of a

joint and how to record your findings relating to the musculoskeletal system

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JSOMTC, SWMG(A)

Reason

As a SOF medic/corpsman, your ability to conduct a correct physical exam of the musculoskeletal system will be crucial as these patients will represent the bulk of your patient population.

Slide 9 JSOMTC, SWMG(A)

Medical Vocabulary Components Related to the Physical Exam of the Musculoskeletal (MSK) System

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JSOMTC, SWMG(A)

Vocabulary

 Ligament – ropelike bundles of collagen

fibrils that connect bone‐to‐bone

 Tendon – collagen fibers connecting

muscle‐to‐bone

 Bursae – pouches of synovial fluid that

cushion the movement of tendons & muscles over bone or other structures

 Idiopathic –condition that arises

spontaneously or from an obscure or unknown cause

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JSOMTC, SWMG(A)

Vocabulary

 Monoarticular – pertaining to or affecting a

single joint

 Polyarticular – affecting many joints  Myalgia – "aches & pains" in the muscles  Arthralgia – pain but no evidence of arthritis  Scoliosis – lateral & rotatory curvature of the

spine

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JSOMTC, SWMG(A)

Vocabulary

 Osteoporosis – bone density loss of greater

than 25%

 Crepitus – a grating or crackling sound or

sensation (as the produced by the fractured ends of a bone moving against each other; foreign bodies in the joint (tear); subcutaneous emphysema)

 Kyphosis – exaggerated thoracic curvature

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JSOMTC, SWMG(A)

Vocabulary

 Lordosis – exaggerated lumbar curvature  Subluxation – partial dislocation  Genu varum – “bowlegs” (genu = knee)  Genu valgum – “knock‐knees”  Valgus – angulation of the part away from

the midline of the body

 Varus – angulation of the part towards the

midline of the body

Slide 14 JSOMTC, SWMG(A)

Common or Concerning Symptoms

f the Musculoskeletal System

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JSOMTC, SWMG(A)

Common/Concerning Symptoms

 Low back pain (LBP)  Neck pain  Monoarticular or polyarticular joint pain  Inflammatory or infectious joint pain  Joint pain with systemic features  Joint pain with symptoms from other organ

systems

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JSOMTC, SWMG(A)

Common/Concerning Symptoms

 Low back pain

2nd most common reason for office

visits

Midline?
Radiating into the legs?
Bladder or bowel dysfunction?
Red Flags – systemic disease
> 50 y/o
History of cancer
Unexplained weight loss
Pain lasting > 1 month
Pain at night or

rest (>6weeks)

Infection
Hx IV drug use

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JSOMTC, SWMG(A)

Common/Concerning Symptoms

 Neck pain

Trauma
Radiation
Arm/leg weakness
Change in bladder/bowel

function

Degenerative
Note: red flags from LBP

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JSOMTC, SWMG(A)

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Slide 19 JSOMTC, SWMG(A)

The Important Topics for Health Promotion and Counseling for the Musculoskeletal System

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JSOMTC, SWMG(A)

Health Promotion & Counseling

 Nutrition, exercise, and weight

Balanced diet
Nutritional supplements
Regular exercise
Increases and maintains bone mass
Prevents obesity, diabetes, hypertension, PAD
Decreases stress
30 min a day walking
Weight management
Reduces wear and tear on joints

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JSOMTC, SWMG(A)

Health Promotion & Counseling

 Low back

60‐80% experience 1x / lifetime
30‐60% experience recurrences ‐ work related
Correct lifting techniques
Correct posture
Exercise

 Falls – increase in the elderly

Exercise helps mitigate these risk factors

 Osteoporosis

Any age

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Slide 22 JSOMTC, SWMG(A)

The Important Areas of Examination for Each of the Major Joints of the Musculoskeletal System

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JSOMTC, SWMG(A)

Common/Concerning Symptoms: Subjective Exam

 Subjective Exam – What the Pt tells you  Joint pain

History (Hx)
OPQRST
Previous treatments
Do you have any pain in your joints?
Localized – monoarticular
Diffused – polyarticular

 Pattern of involvement  Symmetric  Migrating / spreading? – “Does the pain move?”

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JSOMTC, SWMG(A)

Common/Concerning Symptoms: Subjective Exam

Extra‐articular – tendons, bursae, ligaments

 Myalgias  Arthralgia's

Timing – onset
Rapidly – “How long has this been going on?”
Insidiously over a length of time
Periods of improvement/worsening
Over the course of the day

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JSOMTC, SWMG(A)

Common/Concerning Symptoms: Objective Exam

 Objective Exam – physical exam findings

(Exam, Observation, Inspection, Palpation, ROM, Strength)

Inflammation
Tenderness, warmth, or redness
Swelling
Stiffness – resistance to movement
Decreased range of motion
Changes in level of activity

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JSOMTC, SWMG(A)

General Techniques of Examination: Objective Exam

 Observe general appearance

Body proportions
Gait

 Inspection

Joint symmetry of involvement
Alignment
Bony deformities
Skin changes
Facial expressions
Posture
Nodules
Atrophy
Swelling

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JSOMTC, SWMG(A)

General Techniques of Examination

 Palpation

Tenderness
Swelling
Temperature
Texture ‐ nodules
Pulse
ROM – limitations
Maneuvers ‐ laxity
Muscle strength
Active – by the Pt
Passive – by the examiner

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Slide 28 JSOMTC, SWMG(A)

The Inspection, Palpation, Range of Motion, and Maneuvers of the Shoulder

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Functional anatomy ‐ overview

Glenohumeral (synovial) – ball & socket joint
Flexion, extension, abduction, adduction,

medial & lateral rotation, circumduction

Dynamic stabilizers – SITS muscles
Static stabilizers –
Bony shoulder girdle
Glenoid labrum
Articular capsule
Glenohumeral ligament

Superior glenohumeral ligament Transverse humeral ligament

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Bony anatomy

Humerus
Greater & lesser tubercle
Clavicle – pectoral girdle/axial skeleton
Articulations: AC & SC joints
Scapula
Acromion
Coracoid process

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Joints and articulations

Glenohumeral joint
Sternoclavicular (SC) joint
Acromioclavicular (AC) joint

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Muscle groups (3)

Scapulohumeral group – SITS
Supraspinatus

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Muscle groups (3)

Scapulohumeral group – SITS
Infraspinatus

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Muscle groups (3)

Scapulohumeral group – SITS
Teres minor

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Muscle groups (3)

Scapulohumeral group – SITS
Subscapularis

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Muscle groups

Axioscapular group
Trapezium

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Muscle groups

Axioscapular group
Serratus anterior

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Muscle groups

Axioscapular group
Rhomboids

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Muscle groups

Axioscapular group
Levator scapulae

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Muscle groups

Axiohumeral group
Pectoralis major

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Muscle groups

Axiohumeral group
Pectoralis minor

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Muscle groups

Axiohumeral group
Latissimus dorsi

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Shoulder

 Additional structures

Articular capsule
Bursae
Superior acromial

bursa1

Subacromial bursa2
Subscapular bursa3
Synovial membrane
Glenohumeral joint4
Synovial sheath (long

head BB)5 1 2 3 4 5

Transverse humeral ligament Coracobrachialis Slide 44

JSOMTC, SWMG(A)

Techniques of Examination

 Inspect

Anterior
Posterior
Swelling
Deformities1,4
Muscle atrophy

1

Fasciculations
Abnormal positioning
Color change3
Skin alteration2

2 3 4

Slide 45

JSOMTC, SWMG(A)

Techniques of Examination

 Palpation

SC‐Joint / clavicle
AC‐joint / acromion
Corocoid process
Greater tubercle – SITS

insert

Intertubercular groove

AC joint SC joint biceps

TIP: Start medially at the SC joint, proceed laterally, end posteriorly. Develop your own "Race Track"

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JSOMTC, SWMG(A)

Techniques of Examination

 Palpation

Subacrominal bursa
Subdeltoid bursae
SITS muscles
Articular capsule

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JSOMTC, SWMG(A)

Techniques of Examination

 ROM

Flexion
Extension

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JSOMTC, SWMG(A)

Techniques of Examination

 ROM

Abduction (180°)
Glenohumeral motion

 90°, palm down

Scapulothoracic motion

 Palm up, additional 60°

Final 30°, both motions

Supraspinatus, middle deltoid, serratus anterior

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Slide 49

JSOMTC, SWMG(A)

Techniques of Examination

 ROM

Adduction (45°)
Pectoralis major
Coracobrachialis
latissimus dorsi
teres major
subscapularis

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JSOMTC, SWMG(A)

Techniques of Examination

 ROM

Internal rotation (60° ‐ 90°)
Or the Apley scratch test

 Each side  Mark

Subscapularis, anterior deltoid, pectoralis major, teres major, latissimus dorsi

Slide 51

JSOMTC, SWMG(A)

Techniques of Examination

 ROM

External rotation (80° ‐ 90°)
Or the Apley scratch test

 Each side  Mark

Infraspinatus, teres minor, posterior deltoid

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Slide 52

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

AC‐joint: Crossover test
Overall shoulder rotation: Apley scratch test
Rotator cuff
Neer’s impingement sign
Hawkins impingement sign
Supraspinatus strength
Infraspinatus strength
Subscapularis strength: lift off / belly press
O’Brian Test: AC / Labral
Drop‐arm sign

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

AC‐joint – crossover test
Horiz. adduct Pt Arm across chest w/ overpressure

(pain = positive)

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Overall shoulder rotation – Apley Scratch Test
Difficulty suggest rotator cuff disorder

External rotation and abduction Reach for upper scapula Internal rotation and adduction Reach for lower scapula Compare bilaterally – note level reached

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Slide 55

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Rotator cuff – Neer’s impingement sign
Arm pronated
Scapula stabilized
Flex shoulder

maximally

Passive mnvr
Pain

 Positive test Slide 56

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Rotator cuff – Hawkins impingement sign
Shoulder & elbow flexed to 90°
Maximally internally rotating arm
Pain = positive test

Slide 57

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Rotator cuff – supraspinatus strength
Elevate arms to 90°
Internally rotate arms
Thumbs pointed down
Pt resist downward pressure
Weakness

 Positive test

Most commonly torn tendon

Empty Can Test or Jobe Test

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Slide 58

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Rotator cuff – infraspinatus strength
Arms at side with elbows flexed to 90°
Thumbs pointed up
Pt resist internal rotation
Weakness

 Positive test Slide 59

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Rotator cuff – subscapularis strength
Internally rotation shoulder
Pt – push hand away from back; elbows forward while

applying pressure towards belly

Weakness

 Positive test Slide 60

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Labral, A/C ‐ O’Brian Test
Arm adducted 10° to chest
Shoulder flexed to 90°
Internal and external rotation

Internal rotation External rotation

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Slide 61

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Rotator cuff – drop arm sign
Abduct arm to 90°
Lower slowly
Cannot hold arm abducted

 Positive test

Slide 62 JSOMTC, SWMG(A)

The Inspection, Palpation, Range of Motion, Associated Structures, and Maneuvers of the Elbow

Slide 63

JSOMTC, SWMG(A)

Anatomy Overview ‐ Elbow

 Overview

Hinge joint – synovial – diarthrosis
ROM: flexion, extension, supination, pronation
3 bones: humerus, ulna, radius

 Joints

Three articulations
Humeroulnar joint
Radiohumeral joint
Radioulnar joint

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JSOMTC, SWMG(A)

Anatomy Overview ‐ Elbow

 Bony structures and features

Slide 65

JSOMTC, SWMG(A)

Anatomy Overview ‐ Elbow

 Muscle groups

Flexors
Biceps brachii
Brachioradialis
Brachialis
Extensors
Triceps brachii
Anconeus

Posterior R‐Arm Anterior R‐Arm

Slide 66

JSOMTC, SWMG(A)

Anatomy Overview ‐ Elbow

 Muscle groups

Pronators/supinators
Pronator teres
Pronator quadratus
Biceps brachii
Supinator

Anterior R‐Arm Anterior R‐Arm

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Slide 67

JSOMTC, SWMG(A)

Anatomy Overview ‐ Elbow

 Additional structures

Olecranon bursa
Ulnar nerve
Median nerve (not shown)

Left Posterior Elbow

Slide 68

JSOMTC, SWMG(A)

Techniques of Examination

 Inspection

Medial & lateral epicondyles
Olecranon
Contours
Swelling
Discoloration
Nodules
Dislocation

Slide 69

JSOMTC, SWMG(A)

Techniques of Examination

 Palpation

Olecranon
Epicondyles
Grooves – between
lecranon &

epicondyles

Ulnar n. (sensitivity)
Dislocation
Fx

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Slide 70

JSOMTC, SWMG(A)

Techniques of Examination

 ROM

Flexion
Extension
Supination
Pronation

Slide 71

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Triangle of points
Tennis elbow

Slide 72

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Tinel sign
DTRs

Biceps

Triceps

Brachioradialis

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Slide 73 JSOMTC, SWMG(A)

The Inspection, Palpation, Range of Motion, and Maneuvers of the Wrist and Hand

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JSOMTC, SWMG(A)

Anatomy Overview – Wrist & Hand

 OVERVIEW

8 carpals – 2 rows
Proximal articulates with radius
Distal articulates with metacarpals
Thumb lacks middle phalanx
2‐5 phalanges have distal, middle & proximal

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JSOMTC, SWMG(A)

Anatomy Overview – Wrist & Hand

 Bony structures

POSTERIOR

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Slide 76

JSOMTC, SWMG(A)

Anatomy Overview – Wrist & Hand

 Joints

Wrist joints
Radiocarpal joint
Intercarpal joint
Hand joints
DIP
PIP
MCP (knuckle)

IP

Slide 77

JSOMTC, SWMG(A)

Anatomy Overview – Wrist & Hand

 Intrinsic muscle groups

Wrist
Fingers
Thumb
Thenar eminence
Thumb/fingers

Slide 78

JSOMTC, SWMG(A)

Anatomy Overview – Wrist & Hand

 Additional structures

Tendons
Tendon sheaths
Carpal tunnel
Transverse carpal

ligament

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Slide 79

JSOMTC, SWMG(A)

Techniques of Examination

 Inspection

Normal position1
Swelling2
Deformities3
Contours (see previous slide)
Thickening4

4 1 2 3

Slide 80

JSOMTC, SWMG(A)

Techniques of Examination

 Palpation

Radialcarpal joint
Radial styloid b.
Carpals
Scaphoid b.1
Metacarpals (MCP)2
Phalanges (DIP, PIP)3
Abnormalities

(swelling, inflammation, etc.) 1 3 2

Most common injury

Slide 81

JSOMTC, SWMG(A)

Techniques of Examination

 ROM – wrists

Flexion
Extension
Abduction (radial dev.)
Adduction (ulnar dev.)

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Slide 82

JSOMTC, SWMG(A)

Slide 83

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers ‐ wrist

Sensation

1 2 3 Radial n. Ulnar n. Median n.

1 1 3 2 2 3 3 3 3

Slide 84

JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers ‐ wrist

Hand grip strength1
Phalen’s sign2 – median n.
Tinel’s sign3 – median n.

1 2 3

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Slide 85 JSOMTC, SWMG(A)

The Inspection, Palpation, Range of Motion, and Maneuvers of the Spine

Slide 86

JSOMTC, SWMG(A)

Anatomy Overview ‐ Spine

 Overview

Alignment of body weight
Primary curves
Secondary curves
7 cervical, 12 thoracic, 5 lumbar
5 sacral, 3‐5 coccyxal

Slide 87

JSOMTC, SWMG(A)

Anatomy Overview ‐ Spine

 Bony structures

Vertebral body
Vertebral arch
Transverse process
Spinous process
Pedicle, lamina
Vertebral foramen
Articular processes
Articular facets
Transverse costal facets (T1 – T10)
Intervertebral discs

T12

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Slide 88

JSOMTC, SWMG(A)

Anatomy Overview ‐ Spine

 Joints

Intervertebral discs ‐ load
Annulus fibrosis
Nucleus pulposus
Articular facets ‐ flexibility
Superior
Inferior

Slide 89

JSOMTC, SWMG(A)

Anatomy Overview ‐ Spine

 Muscle groups

Outer
Deep
Intrinsic
Other

Slide 90

JSOMTC, SWMG(A)

Techniques of Examination

 Inspection – posterior aspect

Posture
Alignment
Symmetry

1 2 3 4

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Slide 91

JSOMTC, SWMG(A)

Techniques of Examination

 Inspection – lateral aspect

Spinal curvatures
Cervical
Thoracic
Lumbar
Skin abnormalities
Port‐wine stains1
Café‐au‐lait spots2
Hairy patches

1 2

Slide 92

JSOMTC, SWMG(A)

Techniques of Examination

 Palpation

Spinous processes (all)
Cervical facet joints
Step‐off (lumbar)
SI‐joint (drop‐off)
Sciatic nerve tenderness

Slide 93

JSOMTC, SWMG(A)

Techniques of Examination

 ROM & maneuvers – neck

Flexion – “Chin to chest”
Extension – “Look up”
Rotation – “Look left/right”
Lateral bending – “Ear to shoulder”

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Slide 94

JSOMTC, SWMG(A)

Techniques of Examination

 ROM & maneuvers – spinal column

Flexion – “touch your toes” ‐ careful
Measure flexion

 Mark the lumbosacral junction  Mark 10cm above and 5cm below (standing)  Pt to max flexion (4cm ↑ norm, < 4cm not‐norm)

Slide 95

JSOMTC, SWMG(A)

Techniques of Examination

 ROM & maneuvers – spinal column

Extension1
Rotational2
Lateral Bending3

1 2 3

Slide 96 JSOMTC, SWMG(A)

The Inspection, Palpation, Range of Motion, and Maneuvers of the Hip

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Slide 97

JSOMTC, SWMG(A)

Slide 98

JSOMTC, SWMG(A)

Anatomy Overview ‐ Hip

 Muscle groups

Flexor group
Extensor group
Adductor group
Abductor group – gluteus medius & minimus

Slide 99

JSOMTC, SWMG(A)

Anatomy Overview ‐ Hip

 Additional structures

Bursae
Trochanteric bursa
Ischial (ishiogluteal) bursa
Psoas (iliopectineal or iliopsoas) bursa

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Slide 100

JSOMTC, SWMG(A)

Techniques of Examination

 Inspection

Gait – stance & swing
Width of the base
Pelvic shift
Knee flexion
Lordosis?
Leg length discrepancies?
Atrophy
Bruising

Slide 101

JSOMTC, SWMG(A)

Techniques of Examination

 Palpation – bony landmarks

Anterior
Iliac crest
ASIS
Greater trochanter
Pubic symphysis
Posterior
PSIS
Greater trochanter
Sacroiliac joint

Slide 102

JSOMTC, SWMG(A)

Techniques of Examination

 Palpation – inguinal structures/bursae

Inguinal
Supine, figure 4
Bulges
Lymph nodes
Tenderness
Bursae
Psoas
Trochanteric ‐ side
Ischiogluteal ‐ side

Pubic tubercle ASIS

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Slide 103

JSOMTC, SWMG(A)

Techniques of Examination

 ROM/maneuvers

Flexion
Lumbar flattening1
Opposite knee flex2
Extension
Supine
Leg on or off table
Abduction3

1 2 3

Slide 104

JSOMTC, SWMG(A)

Techniques of Examination

 ROM/maneuvers

Adduction4
External Rotation
Medially5
Internal Rotation
Laterally

4 5

Slide 105 JSOMTC, SWMG(A)

The Inspection, Palpation, Range of Motion, and Maneuvers of the Knee

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Slide 106

JSOMTC, SWMG(A)

Anatomy Overview ‐ Knee

 Overview

Largest joint & joint cavity
Three articular surfaces
Ligament dependent for stability

 Bony structures

Medial
Adductor tubercle
Medial epicondyle
Medial condyle

Slide 107

JSOMTC, SWMG(A)

Anatomy Overview ‐ Knee

 Bony structures

Anterior
Patella
Patellar ligament/tendon
Tibial tuberosity
Lateral
Lateral epicondyle
Lateral condyle

Slide 108

JSOMTC, SWMG(A)

Anatomy Overview ‐ Knee

 Joint – complex hinge joint

Three separate articulations
Lateral tibiofemoral joint
Medial tibiofemoral joint
Patellofemoral joint

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Slide 109

JSOMTC, SWMG(A)

Anatomy Overview ‐ Knee

 Muscle groups ‐ knee

Extensors
Flexors

Vastus intermedius (not shown) Biceps femoris & popliteus (not shown)

Slide 110

JSOMTC, SWMG(A)

Anatomy Overview ‐ Knee

 Additional structures

Medial/lateral menisci
Collateral ligaments
Cruciate ligaments
Suprapatellar pouch
Bursae
Prepatellar
Anserine
Semimembranosus

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Techniques of Examination

 Inspection

Gait – smooth, rhythmic
Stumbling
Alignment/contours
Genu varum (previous slide)
Genu valgum
Flexion contracture
Atrophy
Swelling – intra1, extra‐articular2
Angular deformity
Bruising

1 2

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Techniques of Examination

 Palpation – Pt on edge of exam table, flexed

Tibiofemoral joint
Depressions on either side of patellar tendon
Tibiofemoral joint
Tibial plateau
Converging femur/tibia
Femoral articulating surface
Medial meniscus
Lateral meniscus
Note pain

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JSOMTC, SWMG(A)

Techniques of Examination

 Palpation

Medial joint compartment
Medial femoral condyle
Adductor tubercle
Medial tibial plateau
MCL
Lateral joint compartment
Lateral femoral condyle
Lateral tibial plateau
LCL
Patella – patellar tendon – tibial tuberosity
Patellofemoral grinding test (knee extended)

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JSOMTC, SWMG(A)

Techniques of Examination

 Palpation

Suprapatellar pouch
6 cm above patella, palpate down
Tenderness, warmth, bogginess
Prepatellar bursa
“Housemaid’s knee”
Anserine bursa
Gastrocnemius Semimembranosus bursa
Popliteal (Baker) cyst

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JSOMTC, SWMG(A)

Techniques of Examination

 Palpation

Bulge sign1 – minor effusions
Milk the suprapatellar pouch down
Tap medially/laterally – fluid wave
Balloon sign – major effusions
Palpate each side of the patella
Compress the suprapatellar pouch
Feel for fluid entering
Balloting the patella2 – large

effusions

Compress the suprapatellar pouch
Push on the patella

2 1

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JSOMTC, SWMG(A)

Techniques of Examination

 ROM – knee

Flexion – “flex your knee”
Extension – “straighten your leg”

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

McMurray test – clicking/lock during flex/extension

 Medial meniscus

– Palpate medial/lateral joint line – From heel, rotate externally – Apply varus stress

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40

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

McMurray test – clicking/lock during flex/extension

 Lateral meniscus

– Palpate medial/lateral joint line – From heel, rotate internally – Apply valgus stress

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Abduction (valgus) stress test – MCL tears

 One hand – lateral knee  Other hand ‐ medial ankle  Ligamentous laxity or pain

Straight Flexed

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Adduction (varus) stress test – LCL

 One hand – medial knee  Other hand ‐ lateral ankle  Ligamentous laxity or pain

Straight Flexed

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41

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Anterior drawer sign – ACL
Knee flexed
Pull anteriorly
Greater than a few degrees of movement indicates

ACL tear Hamstrings RELAXED!

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Posterior drawer sign – PCL
Knee flexed
Push posteriorly
Greater than a few degrees of movement indicates

PCL tear & compare to other knee

Slide 123 JSOMTC, SWMG(A)

The Inspection, Palpation, Range of Motion, and Maneuvers of the Ankle and Foot

SLIDE 42

42

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Anatomy Overview – Ankle & Foot

 Bony structures & joints

Malleolus (medial/lateral)
Calcaneus
Tarsals, metatarsals,

phalanges

Tibiotalar joint
Subtalar joint
Proximal, distal

interphalangeal joints

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JSOMTC, SWMG(A)

Anatomy Overview – Ankle & Foot

 Muscle groups & additional structures

Plantar flexors – gastrocnemius, posterior tibial

muscles & toe extensors

Dorsiflexors – anterior tibial muscle & toe extensors
Deltoid (medial) ligament complex

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JSOMTC, SWMG(A)

Anatomy Overview – Ankle & Foot

 Muscle groups & additional structures

Lateral (fibular collateral) ligament complex
Anterior talofibular ligament (ATFL) ‐ weakest
Calcaneofibular ligament (CFL)
Posterior talofibular ligament (PTFL) ‐ strongest

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43

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Techniques of Examination

 History

ID area of tenderness
Twisting, plantarflexion‐inversion injury

 Inspection

Deformities
Nodules
Swelling
Effusion
Calluses
Corns
“Pop?”
Ecchymosis
Circulatory impairment
Shoes

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JSOMTC, SWMG(A)

Techniques of Examination

 Palpation

Joints ‐ tenderness
Tibiotalar, subtalar, transverse tarsal
Bones ‐ tibia, fibula (proximal), malleoli,

posterior/inferior calcaneus, metatarsals

Ligaments – weakest to strongest
ATFL, CFL, PTFL, & deltoid complex
Tendons – achilles, peroneal
Swelling/effusion

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JSOMTC, SWMG(A)

Techniques of Examination

 ROM

Plantar flexion – “point foot toward the floor”
Dorsiflexion – “point foot toward the ceiling”
Inversion – “bend heel inward”
Eversion – “bend heel outward”

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44

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Anterior drawer test
Anterior talofibular ligament (ATFL) ‐ weakest

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Inversion stress test (Talar tilt test)
Calcaneofibular ligament (CFL)

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Lisfranc’s Fracture
Proximal 2nd metatarsal
Midfoot swelling
Inability to bear weight
Potentially career ending

SLIDE 45

45

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JSOMTC, SWMG(A)

Techniques of Examination

 Maneuvers

Morton’s test
Interdigital neuroma
3rd & 4th toes

Slide 134

JSOMTC, SWMG(A)

Techniques of Examination

 Palpation

Gastrocnemius & soleus muscles
Test integrity of the Achilles tendon

 Pt prone, knee & ankle flexed 90°  Squeeze calf  Watch for plantar flexion

Slide 135 JSOMTC, SWMG(A)

The Limitation in Motions of a Joint and How to Record Your Findings Relating to the Musculoskeletal System

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Joint Limitation

 Limited motion of a joint – diminished mobility

Compare with other “good side” – estimate

ROM angles

“Elbow flexes 45° to 90°"
“Elbow flexion deformity of 45° to 90°”

160° 0° 90° 45° 30° 45°

goniometer

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JSOMTC, SWMG(A)

Ortho Consult

 As with radiographs, good idea to compare

injured side with good side (e.g., check laxity

f knee ligaments in “good” knee first, to see

what’s “normal”)

 Once you discover laxity or a complete tear,

there’s no reason to do that test over and

ver, or with more force (causing greater

damage)

 Ortho.consult@us.army.mil – interpret x‐rays

Short turnover for down range

Slide 138

JSOMTC, SWMG(A)

Questions?

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47

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JSOMTC, SWMG(A)

Terminal Learning Objective

 Action: Communicate knowledge of “Physical

Exam of Musculoskeletal System”

 Condition: Given a lecture in a classroom

environment

 Standard: Received a minimum score of 75%

n the written exam IAW course standards

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JSOMTC, SWMG(A)

Agenda

 Define the medical vocabulary components

related to the physical exam of the musculoskeletal (MSK) system

 Identify common or concerning symptoms

f the musculoskeletal system

 Communicate the important topics for

health promotion and counseling for the musculoskeletal system

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JSOMTC, SWMG(A)

Agenda

 Communicate the important areas of

examination for each of the major joints of the musculoskeletal system

 Communicate the inspection, palpation,

range of motion, and maneuvers of the shoulder

 Communicate the inspection, palpation,

range of motion, associated structures, and maneuvers of the elbow

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48

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Agenda

 Communicate the inspection, palpation,

range of motion, and maneuvers of the wrist and hands

 Communicate the inspection, palpation,

range of motion, and maneuvers of the spine

 Communicate the inspection, palpation,

range of motion, and maneuvers of the hip

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JSOMTC, SWMG(A)

Agenda

 Communicate the inspection, palpation,

range of motion, and maneuvers of the knee

 Communicate the inspection, palpation,

range of motion, and maneuvers of the ankle and foot

 Communicate the limitation in motion of a

joint and how to record your findings relating to the musculoskeletal system

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JSOMTC, SWMG(A)

Reason

As a SOF medic/corpsman, your ability to conduct a correct physical exam of the musculoskeletal system will be crucial as these patients will represent the bulk of your patient population.