Examination of the Joints and Extremities

PDiagnosis 2010/01/18 Evelyn Salido, MD, FPCP, FPRA

A. OBJECTIVES IN DOING THE PHYSICAL EXAM

- To screen for MSS problems among asymptomatic and symptomatic individuals

- To determine if complain in the back or limb is due to a musculoskeletal problem
- To localize the MSS problem (if it is intra- or periarticular)
- To diagnose

1. Who should be examined?

a. Those with musculoskeletal complaints
Those complaining with pain, deformities, or disability (loss of function)
b. Individuals consulting for other complaints

2. What should be examined?

a. Back
b. Upper Extremities
c. Lower Extremities
d. Systemic PE

3. Physical examination will tell us

a. Source of pain
b. Inflammatory or not
c. Pattern and extend of joint involvement
 Single / few / multiple
 Axial / appendicular
 Distal vs proximal, small vs large
d. Localized or systemic

4. Requirements for a good PE

a. Enough room and light
b. Sufficient exposure of parts to be examined while considering privacy
c. Relaxed and comfortable patient and examiner
d. Adequate medical history

PHYSICAL EXAM: MUST REMEMBER!

- Examine each joint, not only the source of the complaint
- Assess each joint separately
- Perform an orderly exam including the spine, the upper and lower
extremities
- Proper positioning as appropriate to the examination being done

B. MANEUVERS IN PHYSICAL EXAM

1. Inspection (still and in motion)

Posture Contours
Symmetry Deformities
Atrophy/Hypertrophy Masses or nodules
Swelling Redness
Skin lesions Instability
Abnormal movements
o Discrepancies (e.g. atrophy): determine if localized or generalized; document by measuring the
limb circumference

o Instability
 Diseased joints are able to move into abnormal positions
 Due to joint surface damage or to laxity of the ligaments
 Passive maneuver by examiner
 Observation of active movement during weightbearing and walking
 Wobbling, „movement‟ of the bones, „giving away‟

o Deformity
 Inability to carry out normal range of motion (e.g. flexion deformity of the knee)
 Malalignment of articular bones without change in articulation (e.g. ulnar deviation of
fingers)
 Malalignment due to altered relationship between articular surfaces (e.g. sublaxation,
dislocation)

[LimeNotes] PDiagnosis / Examination of the Joints and Extremities Total Pages: 5 / Filesize: 33.00kb
Batch 2012: 2009-2010 (2nd Year) Date: 2010 / 01 / 18
Printed on: 2013/07/11 17:41:00
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Examination of the Joints and Extremities

2. Palpation

o Palpate the joint, surrounding tissues, and the muscles of the limbs and back.
o Check for increased warmth, tenderness, swelling (whether bony, soft-tissue, or due to
effusion)

a. Tenderness – unusual sensitivity to touch or pressure

Grade Manifestation
Grade I Pain only
Grade II Pain and wincing
Grade III Wincing and withdrawal
Grade IV Palpation not tolerated

b. Swelling
1. Bony swelling – osteophyte and new bone formation
2. Synovitis – edematous synovium, boggy swelling, usually tender
3. Effusion – excessive fluid in joint cavity, (+) bulge sign
4. Localized periarticular swelling – does not community with the main joint cavity
(e.g. infrapatellar bursitis)
5. Pitting edema of tissues over a joint

3. Range of Motion (ROM)

o Requires knowledge of normal motion of particular joints

o May be active or passive

a. Limitation of Motion
 Comparison with an unaffected joint of the opposite extremity to evaluate individual
variations
 Increased muscle tension may result in what appears to be a significantly decreased
ROM
 May be due to limitation in the joint itself or the periarticular structures
 Active motion limited – may indicate joint or periarticular problem
 Only active motion limited – periarticular problem

b. Crepitus
 Palpable and/or audible grating or crunching sensation produced by motion
 Arises when roughened articular or extra-articular surfaces are rubbed together by
active motion or by manual compression
 Fine or coarse – depending on rough the opposing cartilage surfaces are
 Differentiate from cracking sounds caused by the slipping of ligaments or tendons
over bony surfaces (normal joints)

4. Measurements

C. DOING THE ACTUAL PHYSICAL EXAM

1. GALS

a. GALS Step 1: 1. Have you had any pain or stiffness in your muscle, joints, or
Ask 3 Basic back?
Questions 2. Can you dress yourself without any difficulty?
3. Can you walk up and down the stairs without any difficulty?
b. GALS Step 2: Symmetry
Gait Smoothness of movement
Normal stride length
Normal heel-strike, stance, toe-off, swing through
width of the base should be 2-4 inches from heel-to-heel; flexion of the knee
during toe-off and swing
Able to turn quickly
c. GALS Step 3: Straight spine
Inspection Normal and symmetric paraspinal muscles
from Behind Normal shoulder and gluteal muscle bulk
Level iliac crests
No popliteal cysts or swelling
No hindfoot swelling or abnormality

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d. GALS Step 4: Normal cervical and lumbar lordosis

Inspection Normal thoracic kyphosis
from the Side
e. GALS Step 5: Normal lumbar spine and hip flexion
“Touch your
toes”
f. GALS Step 6: Ask the patient to place his/her hands:
Inspection - Behind the head (elbows out): normal glenohumeral,
from the sternoclavicular and acromioclavicular joint movement
Front – Arms - By your side (elbows straight): no wrist/finger swelling or
and Legs deformity; able to fully extend fingers
Turn your hands over (normal supination/pronation; normal
palms)
Make afist (normal grip power)
Place the tip of each finger on the tip of the thumb (normal fine
precision, pinch)
Legs
- Normal quadriceps bulk and symmetry
- No knee swelling or deformity
- No forefoot/midfoot deformity
- Normal arches
- No abnormal callous formation
Spine
- “Place your ear on your shoulder”
- Normal lateral cervical flexion

2. Regional Examination

a. Back Look: contour, deformity, mass, skin lesions

Feel: spinous processes, paravertebral muscles, SI joint
Move: cervical, lumbar; Schober‟s test for spine flexibility
Look
Inspect: vertebra prominens (spinous process of C7); L2, L4-L5
intervertebral space; iliac crests; dimples of Venus (sacroiliac
joints)
Check the spine:
- Cervical lordosis
- Thoracic kyphosis
- Lumbar lordosis
- Sacral kyphosis
Back flexibility: Schober’s test
b. TMJ Look, feel, and move
c. Shoulder Inspection:
- Look for symmetry between both shoulders
- Check skin for any signs of current or past pathology
- Identify the clavicle, deltoid and biceps muscles, bicipital
groove, scapula
Palpation:
- Assess the soft tissue tone, consistency, size, and shape
of the muscles. Check for tenderness.
- Check the axilla for palpable lymph nodes
Move – circumduction
d. Elbow Humero-ulnar joint (hinge joint) is the main articulation; radio-ulnar and
humeroradial
- In the straight arm, the „elbow bump‟ can be at, and
sometimes even above, the condyles
- In a bent arm, the triangle is quite pronounced
Inspection:
with palms facing anterior or in anatomic position, note the valgus angle
made by the forearm and upper arm
Palpation:
- Palpate the bony structures: medial and lateral
epicondyles, medial and lateral supracondylar line of the

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humerus, olecranon, and radial head

- Palpate the soft tissue structures

o Medial aspect – ulnar nerve, wrist flexors, and
pronators
o Posterior aspect – olecranon bursa, triceps
muscles
o Lateral aspect – wrist extensors, lateral collateral
ligament, annular ligament
o Anterior aspect – cubital fossa
- Range of motion
o Flexion, extension at humeroulnar articulation
o Forearm supination and pronation at proximal
and distal radioulnar joints
o Passive ROM
e. Wrist and - True wrist/radiocarpal articulation – biaxial ellipsoidal joint
hand (radius, triangular fibrocartilage, and 3 carpal bones)
- Distal radioulnar joint – is a pivot joint
- Check palmar flexion and dorsiflexion; radial and ulnar
deviation; pronation and supination

- Keep in mind that there are 6 dorsal passageways and 2

palm tunnels through which pass nerves, arteries, veins,
and tendons
- Some anatomic structures worth mentioning are the carpal
tunnel and the median nerve
Palpation – bone palpation includes the following:
- Radial and ulnar styloid processes
- Tubercle of the radius
- Bones of the wrist: eight carpal bones( scaphoid,
navicular, lunate, triquetrum, pisiform, trapezium,
trapezoid, capitates, hamate)
Range of motion
- Flexion – 80 degrees from neutral
- Extension – 70 degrees from neutral
- Ulnar and radial deviation
f. Hand Inspection of the hand
- Ventral surface – creases, thenar and hypothenar
eminences, MCP joint area
- Dorsal surface – metacarpophalangeal joints and soft
tissue „valleys‟, distal interphalangeal joints (DIPs) and
proximal interphalangeal joints (PIPs), fingernails
Palpation of the hand:
- Thenar and hypothenar eminences
- Palmar aponeurosis
- Flexor and extensor tendons
- Fingers – dorsal and palmar surfaces of the MCP, PIP,
and DIP joints
- Fingernails and nail fold capillaries
Range of motion:
- MCPs: hinge joints – fingers: abduct 20 degrees, flex
(make a fist to touch palm crease), adduction, extension
- First carpometacarpal joint (CMC): saddle-shaped –
thumb: opposition, flexion/extension, abduction and
adduction
g. Hip Inspection: pelvic tilts, rotational deformity, muscle wasting, leg length
Palpation: anterior joint line, greater trochanter, ischial tuberosity
Range of motion: ball-and-socket joint (flexion, extension, abduction,
adduction, rest)
h. Knee Look: swelling, bulges
Feel: including bulge test
Move: flexion-extension only
Ligaments

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1. Stability of collateral ligaments

a. Medial Collateral Ligaments: Abduction or Valgus Test
o Medial joint line separation with knee extended (tear of MCL and
PCL)
o Positive when knee is flexed at 30 degrees (MCL tear only)

2. Lateral Collateral ligament: Adduction or Varus Stress Test

 Lateral joint line separation with knee extended (tear of LCL and PCL)
 Positive when knee flexed at 30 degrees (LCL tear only)

3. Cruciate Ligaments: Drawer Test

 Hip flexed at 45 degrees, knee flexed at 90 degrees
 Examiner stabilizes the knee
o Sits on foot while grasping the posterior calf with both hands -OR-
o Supports lower leg between his lateral chest wall and forearm
 Anterior drawer test – pull tibia forward
 Posterior drawer test – push tibia towards patient
Movement of more than or equal to 6mm indicates laxity or tear of the
cruciate ligament

4. Test for meniscal tear

 Locking during joint extension, clicking or popping during motion, localized
tenderness along lateral or medial joint line

 McMurray Test: tear at posterior half of the menisci

o Knee at full flexion
o Examiner places hand over knee with fingers along the side of the
knee over the joint line and the thumb at the other side
o Other hand holds leg at ankle and is used to rotate the leg medially
or laterally to apply stress
o Can be done repeatedly with knee in decreasing degrees of flexion
o Audible or palpable snap indicates a tear

i. Ankle and Feet True ankle joint – distal ends of tibia and fibula and proximal
parts of body of the talus
Hinge joint, dorsi- and plantarflexion
Subtalar joint – inversion and eversion
j. Toes

ARTICULAR DISEASE NON-ARTICULAR DISEASE

ROM Pain on active and passive motion More on active, specific motion
Tenderness Surface, circumference Over bony prominences along
tendons
Pain Generalized, poorly localized Well-localized, superficial

D. EVALUATION OF PATIENT WITH MUSCULOSKELETAL COMPLAINT

1. Logical differentials
2. Accurate diagnosis
3. Performance of necessary diagnostic tests
4. Timely provision of appropriate therapy

END OF NOTES

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