Musculoskeletal Musculoskeletal ExaminationExamination

Todd Milbrandt, MD, MSTodd Milbrandt, MD, MS

Pediatric Orthopaedic SurgeonPediatric Orthopaedic Surgeon

Musculoskeletal ExamMusculoskeletal Exam

There are so many moving parts-how am I going to remember them all?

Musculoskeletal ExamMusculoskeletal Exam

I was once a first I was once a first year medical year medical student, too.student, too.

That may have That may have been a long time been a long time ago….butago….but

Consider yourself Consider yourself lucky.lucky.

Musculoskeletal ExamMusculoskeletal Exam

We never had We never had standardized standardized patients.patients.

MSK information MSK information was a big black was a big black box. box.

No one taught it No one taught it because no-one because no-one felt comfortable felt comfortable doing it.doing it.

Musculoskeletal ExamMusculoskeletal Exam

The best part The best part about the MSK about the MSK examination is examination is that you really that you really can touch all the can touch all the parts.parts.

And you have a And you have a “normal” to “normal” to compare it too compare it too (the other side).(the other side).

Musculoskeletal ExamMusculoskeletal Exam

We will divide the We will divide the examination into examination into regions:regions:

Spine, Upper Spine, Upper Extremity and Lower Extremity and Lower Extremity.Extremity.

We will progress We will progress through inspection, through inspection, palpation, range of palpation, range of motion, stability motion, stability testing, and finally testing, and finally “special” tests “special” tests

Musculoskeletal ExamMusculoskeletal Exam

Remember Anatomy?Remember Anatomy? This is where you This is where you

need it. need it. I have a list of I have a list of

students and I am not students and I am not afraid to use it!!afraid to use it!!

Ward learning=Active Ward learning=Active engagement of engagement of participants!participants!

Functional AnatomyFunctional Anatomy

Name the bones Name the bones of the upper of the upper extremityextremity

Functional AnatomyFunctional Anatomy

Name bones Name bones within the axial within the axial skeleton and skeleton and pelvispelvis

Functional AnatomyFunctional Anatomy

Name bones Name bones within the lower within the lower extremityextremity

SpineSpine

InspectionInspection– Shoulder Shoulder

asymmetryasymmetry– Prominent Prominent

scapulascapula– Hairy Hairy

patchespatches– Dimples Dimples

Spine examinationSpine examination

InspectionInspection– KyphosisKyphosis– LordosisLordosis

PalpationPalpation– Spinous Spinous

processesprocesses– Paravertebral Paravertebral

musclesmuscles– Percussion of Percussion of

spine (??)spine (??)

Spine examinationSpine examination

PalpationPalpation– Spinous Spinous

processesprocesses– Paravertebral Paravertebral

musclesmuscles– Percussion of Percussion of

spine (??)spine (??)

Spine examination-Spine examination-Range of MotionRange of Motion ModesModes

– Passive (all Passive (all planes) planes)

– Active (all Active (all planes)planes)

Anatomical Anatomical areasareas– Cervical, Cervical,

thoracic, thoracic, lumbarlumbar

Spine examination-Spine examination-Range of MotionRange of Motion Cervical Cervical

– FlexionFlexion– ExtensionExtension– RotationRotation– Side bendSide bend

Spine examination-Spine examination-Range of MotionRange of Motion ThoracicThoracic

– FlexionFlexion– ExtensionExtension– RotationRotation– Side bendSide bend

Spine examination-Spine examination-Range of MotionRange of Motion ThoracicThoracic

– FlexionFlexion– ExtensionExtension– RotationRotation– Side bendSide bend

Spine examination-Spine examination-Special testsSpecial tests Axial Axial

compressioncompression It called the It called the

Lhermites testLhermites test Don’t do if Don’t do if

suspect C-suspect C-spine injury!spine injury!

Spine examination-Spine examination-Special testsSpecial tests Axial Axial

compression compression with head with head tiltedtilted

Spurling’s Spurling’s maneuvermaneuver

Don’t do if Don’t do if suspect C-suspect C-spine injuryspine injury

Spine examination-Spine examination-Special examSpecial exam Adam’s Adam’s

forward bend forward bend testtest

Shoulder-Cartoon Shoulder-Cartoon AnatomyAnatomy

The Shoulder- X-ray The Shoulder- X-ray AnatomyAnatomy

Shoulder-InspectionShoulder-Inspection

Name those areas Name those areas when inspectingwhen inspecting

DeltoidDeltoid AcromionAcromion ClavicleClavicle AC jointAC joint Spine of the Spine of the

scapluascaplua

Shoulder-InspectionShoulder-Inspection

Name those Name those areas when areas when inspectinginspecting

DeltoidDeltoid AcromionAcromion ClavicleClavicle AC jointAC joint Look for Look for

muscle muscle wastingwasting

Shoulder: PalpationShoulder: Palpation

Acromioclaviular Joint

Shoulder: PalpationShoulder: Palpation

Acromion

Shoulder: PalpationShoulder: Palpation

Shoulder-Range of Shoulder-Range of MotionMotion Must do both Active Must do both Active

and Passive!!!and Passive!!! Must do each side Must do each side

separateseparate Flexion and Flexion and

ExtensionExtension Internal and Internal and

External rotationExternal rotation AbductionAbduction AdductionAdduction

Shoulder-Range of Shoulder-Range of MotionMotion Must do both Active Must do both Active

and Passive!!!and Passive!!! Must do each side Must do each side

separateseparate Flexion and Flexion and

ExtensionExtension Internal and Internal and

External rotationExternal rotation AbductionAbduction AdductionAdduction

Shoulder-Range of Shoulder-Range of MotionMotion Must do both Active Must do both Active

and Passive!!!and Passive!!! Must do each side Must do each side

separateseparate Flexion and Flexion and

ExtensionExtension Internal and Internal and

External rotationExternal rotation AbductionAbduction AdductionAdduction

Shoulder-Range of Shoulder-Range of MotionMotion Must do both Active Must do both Active

and Passive!!!and Passive!!! Must do each side Must do each side

separateseparate Flexion and Flexion and

ExtensionExtension Internal and Internal and

External rotationExternal rotation AbductionAbduction AdductionAdduction

Shoulder-Stability Shoulder-Stability TestingTesting Sulcus signSulcus sign Apprehension Apprehension

SignSign

Shoulder-Stability Shoulder-Stability testingtesting Sulcus signSulcus sign ApprehensioApprehensio

n signn sign

Elbow-Cartoon Elbow-Cartoon AnatomyAnatomy

Elbow-X-ray AnatomyElbow-X-ray Anatomy

Elbow-InspectionElbow-Inspection

Elbow-InspectionElbow-Inspection

Elbows: PalpationElbows: Palpation

Lateral epichondyle Medial epichondyle

Elbows: PalpationElbows: Palpation

Elbow: Range of Elbow: Range of MotionMotion Flexion and Flexion and

ExtensionExtension Pronation and Pronation and

SupinationSupination

Elbow: Range of Elbow: Range of MotionMotion Flexion and Flexion and

ExtensionExtension Pronation and Pronation and

SupinationSupination

Pronation

Elbow: Range of Elbow: Range of MotionMotion Flexion and Flexion and

ExtensionExtension Pronation and Pronation and

SupinationSupination

Pronation

Elbow: Range of Elbow: Range of MotionMotion Flexion and Flexion and

ExtensionExtension Pronation and Pronation and

SupinationSupination

Supination

Elbow: Range of Elbow: Range of MotionMotion Flexion and Flexion and

ExtensionExtension Pronation and Pronation and

SupinationSupination

Supination

Elbow: Stability Elbow: Stability testingtesting Varus Varus ValgusValgus

Elbow: Stability Elbow: Stability testingtesting Varus Varus ValgusValgus

Wrists-Cartoon Wrists-Cartoon AnatomyAnatomy

Wrists-Cartoon Wrists-Cartoon AnatomyAnatomy

Wrists-Xray AnatomyWrists-Xray Anatomy

Wrist-PalpationWrist-Palpation

Distal radus and Distal radus and radial styloidradial styloid

Distal ulna and Distal ulna and ulnar styloidulnar styloid

Wrist-PalpationWrist-Palpation

Anatomical Anatomical “Snuffbox”“Snuffbox”

Wrist: Range of MotionWrist: Range of Motion

FlexionFlexion ExtensionExtension

Wrist: Range of MotionWrist: Range of Motion

Flexion Flexion ExtensionExtension

Wrist: Range of MotionWrist: Range of Motion

Radial-Radial-deviationdeviation

Ulnar Ulnar deviationdeviation

Wrist: Range of MotionWrist: Range of Motion

Radial-Radial-deviationdeviation

Ulnar Ulnar deviationdeviation

Wrist: Special TestWrist: Special Test

Tinel’s SignTinel’s Sign– This is a This is a

tapping over tapping over any area any area over any over any nerve.nerve.

– Most Most commonly commonly associated associated with wristwith wrist

Phalen’s signPhalen’s sign

Wrist: Special TestWrist: Special Test

Tinel’s SignTinel’s Sign Phalen’s signPhalen’s sign

– Hold wrists for Hold wrists for 30-60 seconds30-60 seconds

– What nerve are What nerve are we we compressing?compressing?

– What area will What area will become numb?become numb?

Hands-Carton AnatomyHands-Carton Anatomy

Profundus or superficialis?

Hands: InspectionHands: Inspection

Hands: InspectionHands: Inspection

Hands: PalpationHands: Palpation

Metacarpal Metacarpal Phalangeal Phalangeal joints (MCP joints (MCP joints)joints)

Proximal Proximal InterphalangeInterphalangeal Joints (PIP)al Joints (PIP)

Distal Distal InterphalangeInterphalangeal Joints (DIP)al Joints (DIP)

Hands: PalpationHands: Palpation

Metacarpal Metacarpal Phalangeal Phalangeal joints (MCP joints (MCP joints)joints)

Proximal Proximal InterphalangeInterphalangeal Joints (PIP)al Joints (PIP)

Distal Distal InterphalangeInterphalangeal Joints (DIP)al Joints (DIP)

Hand and Finger: Hand and Finger: Range of MotionRange of Motion

FlexionFlexion ExtensionExtension AbductionAbduction AdductionAdduction Thumb Thumb

oppositionopposition

Hand and Finger: Hand and Finger: Range of MotionRange of Motion

FlexionFlexion ExtensionExtension AbductionAbduction AdductionAdduction Thumb Thumb

oppositionopposition

Hand and Finger: Hand and Finger: Range of MotionRange of Motion

FlexionFlexion ExtensionExtension AbductionAbduction AdductionAdduction Thumb Thumb

oppositionopposition

Hand and Finger: Hand and Finger: Range of MotionRange of Motion

FlexionFlexion ExtensionExtension AbductionAbduction AdductionAdduction Thumb Thumb

oppositionopposition

Hand and Finger: Hand and Finger: Range of MotionRange of Motion

FlexionFlexion ExtensionExtension AbductionAbduction AdductionAdduction Thumb Thumb

oppositionopposition

Hip-Cartoon anatomyHip-Cartoon anatomy

Hip: X-ray anatomyHip: X-ray anatomy

Hip: Gait patternHip: Gait pattern

Hip:Surface Hip:Surface AnatomyAnatomy

Hip:Hip:PalpatioPalpationn

Hip: Range of MotionHip: Range of Motion

FlexionFlexion ExtensionExtension InternalInternal ExternalExternal AbductionAbduction AdductionAdduction

Hip: Range of MotionHip: Range of Motion

FlexionFlexion ExtensionExtension InternalInternal ExternalExternal AbductionAbduction AdductionAdduction

Hip: Range of MotionHip: Range of Motion

FlexionFlexion ExtensionExtension InternalInternal ExternalExternal AbductionAbduction AdductionAdduction

Hip: Range of MotionHip: Range of Motion

FlexionFlexion ExtensionExtension InternalInternal ExternalExternal AbductionAbduction AdductionAdduction

Hip: Range of MotionHip: Range of Motion

FlexionFlexion ExtensionExtension InternalInternal ExternalExternal AbductionAbduction AdductionAdduction

One hand should be on leg and the other on the iliac crest

Hip: Stability Hip: Stability examinationexamination

Barlow testBarlow test Ortolani testOrtolani test

Hip: Stability Hip: Stability examinationexamination

Barlow testBarlow test Ortolani testOrtolani test

You cannot dislocate a normal child’s hip!!!!

Knees: Cartoon Knees: Cartoon anatomyanatomy

Knees: X-ray anatomyKnees: X-ray anatomy

Knees: X-ray Knees: X-ray anatomyanatomy

Knees: X-ray Knees: X-ray anatomyanatomy

Knees: Surface anatomy Knees: Surface anatomy and inspectionand inspection

Knees: Surface anatomy Knees: Surface anatomy and inspectionand inspection

Varus Valgus

Knees: PalpationKnees: Palpation

PatellaPatella Patella tendonPatella tendon Quad tendonQuad tendon Tibial TubercleTibial Tubercle

Knees: PalpationKnees: Palpation

PatellaPatella Patella tendonPatella tendon Quad tendonQuad tendon Tibial TubercleTibial Tubercle

Knees: PalpationKnees: Palpation

PatellaPatella Patella tendonPatella tendon Quad tendonQuad tendon Tibial TubercleTibial Tubercle

Knees: PalpationKnees: Palpation

PatellaPatella Patella tendonPatella tendon Quad tendonQuad tendon Tibial TubercleTibial Tubercle

Knees: PalpationKnees: Palpation

Medial joint lineMedial joint line Lateral joint lineLateral joint line

Knees: PalpationKnees: Palpation

Medial joint lineMedial joint line Lateral joint lineLateral joint line

Knees: Range of Knees: Range of MotionMotion

Flexion Flexion ExtensionExtension

Knees: Range of Knees: Range of MotionMotion

Flexion Flexion ExtensionExtension

Knees: Stability Knees: Stability Examination Examination

Varus Varus ValgusValgus

Knees: Stability Knees: Stability Examination Examination

Varus Varus ValgusValgus

Knees: Stability Knees: Stability Examination Examination

Anterior drawer Anterior drawer (at 90 degrees (at 90 degrees flexion)flexion)– Lachman’s Lachman’s

maneuvermaneuver Posterior drawerPosterior drawer

Knees: Stability Knees: Stability Examination Examination

Anterior drawer Anterior drawer (at 90 degrees (at 90 degrees flexion)flexion)– Lachman’s Lachman’s

maneuver (at 30 maneuver (at 30 degrees of degrees of flexion)flexion)

Posterior drawerPosterior drawer

Knees: Stability Knees: Stability Examination Examination

Anterior drawer Anterior drawer (at 90 degrees (at 90 degrees flexion)flexion)– Lachman’s Lachman’s

maneuver (at 30 maneuver (at 30 degrees of degrees of flexion)flexion)

Posterior drawerPosterior drawer

Knees: Special Tests Knees: Special Tests

Bulge sign or Bulge sign or Balloon signBalloon sign

Knees: Special Tests Knees: Special Tests

McMurray’s test-McMurray’s test-medialmedial– While Palpating While Palpating

medial joint line, medial joint line, axially load and axially load and externally rotate externally rotate the footthe foot

– This “loads” the This “loads” the medial meniscusmedial meniscus

Knees: Special Tests Knees: Special Tests

McMurray’s test-McMurray’s test-LateralLateral– While Palpating While Palpating

lateral joint line, lateral joint line, axially load and axially load and internally rotate internally rotate the footthe foot

– This “loads” the This “loads” the lateral meniscuslateral meniscus

Ankles and Feet: Ankles and Feet: Cartoon AnatomyCartoon Anatomy

Ankles and Feet: X-ray Ankles and Feet: X-ray AnatomyAnatomy

Ankles: palpation of Ankles: palpation of ankleankle

Palpate:Palpate: Anterior aspect Anterior aspect

of jointof joint Achilles tendonAchilles tendon Medial and Medial and

lateral malleolilateral malleoli

Ankles: palpation of Ankles: palpation of ankleankle

Palpate:Palpate: Anterior aspect Anterior aspect

of jointof joint Achilles tendonAchilles tendon Medial and Medial and

lateral malleolilateral malleoli

Ankles: palpation of Ankles: palpation of ankleankle

Palpate:Palpate: Anterior aspect Anterior aspect

of jointof joint Achilles tendonAchilles tendon Medial and Medial and

lateral malleolilateral malleoli

Ankles: palpation of Ankles: palpation of ankleankle

Palpate:Palpate: Plantar FasciaPlantar Fascia Anterior Talo-Anterior Talo-

Fibular LigamentFibular Ligament

Ankles: palpation of Ankles: palpation of ankleankle

Palpate:Palpate: Plantar FasciaPlantar Fascia Anterior Talo-Anterior Talo-

Fibular LigamentFibular Ligament

Foot: palpationFoot: palpation

Palpate:Palpate: Metatarsal headsMetatarsal heads

Foot and Ankle: Range Foot and Ankle: Range of Motionof Motion

FlexionFlexion ExtensionExtension InversionInversion EversionEversion

Foot and Ankle: Range Foot and Ankle: Range of Motionof Motion

FlexionFlexion ExtensionExtension InversionInversion EversionEversion

Whew!!!! You made Whew!!!! You made it!!!it!!! Thanks for listeningThanks for listening Watch the videos on the knee Watch the videos on the knee

exam and shoulder examinationexam and shoulder examination

My contact infoMy contact info

Phone 859 266 2101Phone 859 266 2101

Email: tmilbrandt@shrinenet.orgEmail: tmilbrandt@shrinenet.org