Musculoskeletal Examination

Musculoskeletal Examination:

General:

Look
Feel
Move

Begin with inspection, then palpate and finish with active and passive movement.

GALS: A Screening Tool:

Gait, Arms, Legs and Spine
• Useful in detecting significant abnormalities of the musculoskeletal system
• Adequately expose the patient (to undergarments)

- Do you have any pain or stiffness in your joints, muscle or back?
- Are you able to dress yourself completely with no difficulty?
- Are you able to go up and down stairs without any difficulty?

If the patient has none of the above it is unlikely he/she suffers from any significant musculoskeletal problem.

Gait:

Can you walk towards the wall, turn and walk back again?
- symmetry and smoothness of movement
Note any abnormality of gait:
- Antalgic gait: shortened stance phase - usually a limp to avoid weightbearing in a painful limb or joint.
- Osteogenic gait: seen in people with unequal leg length (may have shoes which correct this- becomes evident when walk barefoot
- Waddling gait: proximal myopathy is aossicated with this. Patient walks on a wide base with trunk moving side to side on each step and the pelvis drooping as the leg leaves the ground

Note if any pain on movement.

With the patient standing in the anatomical position:

- Observe from behind noting:
• shoulder girdle and paraspinal muscle bulk and symmetry
• spinal alignment: any scoliosis
• equal level of the iliac crests
• gluteal muscle bulk and symmetry
• popliteal swelling or abnormalties
• calf muscle bulk and symmetry
• hindfoot abnormalities

- Observing from the front:
• full elbow extension
• quadriceps bulk and symmetry
• bow leg or knock- knee
• forefoot abnormalities

- Observing from the side
• Alignment of the spine: cervical and lumbar lordosis and thoracic kyphosis
• Knee flexion or hyperextension
• Any abnormal kyphosis or lordosis?
• Ask the patient to bend and touch their toes (flexion and extension of lumbar spine)- place two fingers over two spinous processes: should come together as the spine extends) --> this movement relies on hip flexion and movement at the vertebrae


Look at patient from the front: ask them to:
• Tilt their head so their ear touches the shoulder (lateral flexion)
• Look up then put their chin to their chest (extension and flexion)
• Ask the patient to touch the side of their knee without bending their legs (lateral flexion of spine)

Ask the patient to:
• Place their hands behind their head and push their elbows back: this assesses shoulder abduction and external rotation as well as elbow flexion
• Bring the arms down and behind the small of their back (internal rotation and extension)
• Bring arms down to side (in anatomical position)- look again for normal shoulder bulk and normal elbow extension on both sides


With the patient’s elbows tucked in to the side and their hands in front with palm down and fingers outstretched:
• Look for any deformities or swellings at finger joints or wrist
• Ability to extend fingers
With the elbows still tucked in ask the patient to turn the hands over (supinate) so palm is up (tests wrist joint: proximal and distal radial-ulnar joint)
• Look for muscle bulk, and for any visual signs of abnormality
• Can you squeeze my hand (do both simultaneously)- use three fingers: grip strength
• Bring tip of each finger in turn to meet the tip of the thumb: assesses fine precision pinch (functionally important)
• Gently squeeze across the MCP joints- check for tenderness suggesting inflammatory joint disease (watch patient’s face).

Ask the patient to lie down on the couch, comfortable?:
• From end of couch look for any obvious deformity
• Assess full flexion and extension of knees, feeling for crepitus
• With hip flexed and knee extended at 90o holding knee and ankle to guide the movement assess internal rotation of each hip
• Perform a patellar tap to check for knee effusion: do this by sliding hand down thigh pushing down over suprapatellar pouch so any effusion is forced behind patella. Keep hand there and maintain pressure. Use to or three fingers of other hand to push patella down gently: does it bounce and tap? If so indicates presence of effusion
• Return to the end of the couch: inspect feet for deformities, swellings and callosities on soles (suggest abnormal weight bearing in foot)
• Ask if any pain in the MPT joints. Squeeze across the metatarsophalangeal joints (MTP) to check tenderness suggestive of inflammatory joint disease (watch patient’s face).

Thank patient- help with dressing if required.

Record findings