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Musculoskeletal
Examination

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General principles of joint examination
 Ensure that the joints to be examined are
fully exposed and the patient is resting
comfortably.
 The routine for joint examination is:
 Inspection
 Palpation
 Movement of joint(s)

3. Which joints to examine
 If examination of all the joints is required, use
a systematic approach. The patient may
have to be in underwear only.
 The GALS (Gait, arms legs and spine)
locomotor screen developed by Doherty
et al, is commonly used.
 Alternatively if the patient presents with one
affected joint – then examine that joint, and
the joint above and below
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Inspection of joint
 Swellings
 Skin changes
 colour - redness - inflammation or infection
 scars, previous surgery
 rashes
 Adjacent structures
 muscles - wasting of muscles above and below a joint often
accompanies joint disease
 compare to opposite side
 Deformity
 misalignment of bones making up the joint
 valgus - distal part displaced laterally
 varus - distal part displaced medially

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Palpation of joint
 Feel for any swelling and its nature
 hard suggests bone
 spongy or boggy suggests synovial thickening
 fluctuance suggests an effusion (fluid)
 position - joint or periarticular (e.g. bursa)
 Tenderness
 assess joint margin, related ligaments, tendons
and adjacent bony structures

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Palpation of joint
 Temperature
 compare with opposite side
 if bilateral joint involvement compare tissues
above and below the joint for comparison
 Joint crepitus
 a palpable grating sensation appreciated by a
hand placed on the joint during movement
 Tendon crepitus
 a dry, friction rub palpable when tendons move

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Joint movement
 Range of joint movement
 Active movement
 movement undertaken by the patient alone
 Passive movement
 movement undertaken by the examiner
 The spine should not be moved passively
 If a full range of movement is demonstrated actively
then passive is not required. If movement is
impeded or painful passive movement can help
identify if the cause.

8. Other structures
 Symptoms/signs may not always be caused
by the joint itself, but may be due to
problems with bone, soft tissues, muscles or
nerves.
 A summary of the examination of muscles is
included on the following slide.
 The assessment of nerves is covered in your
„Motor Power and Tone‟ study guide.
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Examination of muscles
 Evidence of wasting - compare sides (measure limb
circumferences)
 muscle disuse
 lower motor neurone lesions / joint disease
 primary muscle disease
 Abnormal bulk
 body builders / muscular dystrophies
 Spontaneous contractions
 muscle spasms / abnormal movements / fasciculation
 Palpate
 Tenderness (acute injury / some myopathies)

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The neutral position
 The range of most
movements are
described with the
neutral position in mind
 In the neutral position
the limbs are extended
with the feet dorsiflexed
at 90 degrees and the
forearms in mid-
pronation

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Main anatomical movements
 Measurement
of joint
movement
can be
subjective and
can be more
reliably
measured by
use of a
goniometer

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Main anatomical movements
 Adduction -
movement of the
part distal to the
joint towards the
midline
 Abduction -
movement away
from the midline

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Main anatomical movements
 Flexion - bending of joint
away from neutral
position
 Extension - movement to
straighten a joint towards
the neutral position
 Hyperextension - occurs
when the joint can be
extended beyond the
neutral position

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Main anatomical movements
 Pronation - rotation
of the forearm so
that the palm faces
backwards
 Supination -
rotation of the
forearm so that the
palm faces forwards

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Examination of upper
limb joints

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Inspection and palpation of the
hand and wrist joints
 Inspect both hands and wrists as one
 Inspect the front, back and sides of all joints
 Compare sides
 Palpate joints between finger and thumb
 Support the joint whilst palpating
 Taking the weight of the patients limb where
possible

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Interphalangeal joints (IP‟s)
 Palpate the
interphalangeal
joints individually
between finger
and thumb
 DIP = distal
interphalangeal
joint
 PIP = proximal
interphalangeal

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Metacarpo-phalangeal joints (MCP‟s)
 Use a similar technique
to palpate metacarpo-
phalangeal joints
 With patient palms
facing down,
 support palms with
fingers
 place thumbs on dorsal
metacarpo-phalangeal
surface and gently
palpate

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Finger movements
 Ask the patient to make a fist (= flexion of distal
and proximal interphalangeal and metocarpophalangeal
joints)
 Then ask the patient to open their hand
(=extension of interphalangeal and metocarpophalangeal
joints)
 Metacarpophalangeal and interphalangeal
joints flex to 90 degrees
 Metacarpophalangeal joints may hyperextend
to approx. 10 degrees
 Abduction, ask the patient to spread their
fingers apart. Adduction ask them to put them
back together.

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Thumb flexion and extension
 Movement of flexion
occurs across the palm
 Extension takes the
thumb away from the
lateral aspect of the
palm
 Occurs at the MCP
joint (Metacarpo-
phalangeal joint)

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Thumb abduction and adduction
 Abduction occurs at
90° to the palm
 Adduction returns the
thumb to the palm
 Occurs at CMC joint,
carpo-metacarpal joint

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Thumb opposition
 The thumb is used to
touch the base of the
little finger
 This movement is
important for fine
manipulative skills

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Wrist joints
 With patient palms
facing down,
 support palmar
aspect of wrist with
fingers
 place thumbs on
dorsal wrist surface
and gently palpate

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Movement of the wrist
 Palmar flexion
 Dorsiflexion (extension)
 Ulnar flexion
 Radial flexion
 Compare one wrist with the other

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Wrist movement
 Dorsiflexion - normal
approx. 75 degrees
 Palmar flexion - normal
approx. 75 degrees
 Ulnar flexion - normal
approx. 20 degrees
 Radial flexion - normal
approx. 20 degrees

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Movement of the forearm
 Isolate the forearm by
putting the arm against the
body with the elbow bent
 Pronation - rotates the
arm through 90 degrees so
that the palm faces
downwards
 Supination - rotates the
forearm so that the palm
faces upwards
Neutral positionSupination
Pronation

27. Inspection and palpation of elbow
joints
 Inspect the elbow joint
from the front, sides
and behind
 With the elbow flexed
at around 70o palpate:
 Epicondyles
 Olecranon process and
grove on either side
 Extensor surface of
ulna
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Elbow movements
 Flexion - is possible to
approx. 150 degrees
Extension - returns the joint to the
neutral position of 0 degrees

29. Inspection and palpation of the
shoulder
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B
D
A
D
BF
C
EG
 Inspect from the front, side
 and back
 Palpate
A. Sternoclavicular joint
B. Clavicle
C. Acromioclavicular joint
D. Acromial process
E. Head of humerus
F. Coracoid process
G. Greater tuberosisty of humerus
H. Spine of scapular (situated on
the back of the scapula)

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Shoulder Movement
 Flexion
 Extension
 Abduction
 Adduction
 Internal rotation
 External rotation

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Shoulder movements
 Inspect the shoulder contour
 Feel for tenderness and
swelling and crepitus during
motion
 Flexion - 180 degrees
 approximately 90 degrees is
attributable to the glenohumeral
joint
 Extension - approx. 65
degrees

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Abduction and Adduction
 Adduction -
movement of the
distal part of the
joint towards the
midline
 Abduction -
movement away
from the midline

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Shoulder movements
 Abduction consists of
two parts
 The initial part is
glenohumeral joint
movement
 The second part is
principally due to
scapular rotation
1st
2nd

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Shoulder movements
 Internal rotation -involves
moving the flexed forearm
across the front of the body.
The movement is limited by the
chest wall
 External rotation - the flexed
forearm is moved outwards
 Alternatively, ask patient to put
hands together behind the head
(external) and then together
behind small of back (internal
rotation)

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Examination of the spine

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Inspection of the spine
 Ask patient to undress down to their underwear
 Inspect from the front, sides and behind ideally
with patient sitting and standing. In particular for:
 Pigmentations, abnormal hair growth or unusual skin
creases
 Alignment of the neck and shoulder symmetry
 Kyphosis (thoracic spine curves giving a round
shouldered or hunched appearance)
 Lordosis (lumber spine curves pushing abdomen out,
seen in late stages of pregnancy)
 Scoliosis (thoracic and or lumbar spine curve laterally
forming a S or C shaped)

37. Palpation of the spine
 Palpate the shoulder and
neck muscles for tenderness
 Palpate each of the spinal
processes noting any
prominence or steps
 Palpate the paraspinal
muscles for tenderness or
spasm (feels firmer)
 Palpate the sacroiliac joints
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Movements of the spine
 Observe movements
 Flexion
 Extension
 Lateral Flexion right and left
 Lateral Rotation right and left

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Cervical spine movements
 Flexion - ask the
patient to touch their
chin to their chest -
normal about 45
degrees
 Extension - ask the
patient to look upwards
and back - normal
about 45 degrees

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Cervical spine movements
 Lateral flexion - ask the
patient to touch their
ears to their shoulders,
without raising the
shoulders. Normal
approx. 45 degrees

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Cervical spine movements
 Rotation - ask the
patient to look back
over each shoulder in
turn - normal approx.
70 degrees

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Thoracolumbar spine
 Flexion - the patient is
asked to touch their toes
whilst keeping their knees
straight (ask the patient to
slide hands down the
anterior aspect of the
thighs)
 Extension is assessed by
asking the patient to bend
back as far as possible

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Thoracolumbar spine
 Lateral flexion - ask the
patient to place a hand on
the outer thigh and to run
the hand down that side
without bending forwards
 Rotation is assessed with
the patient seated on a low
stool (to fix the pelvis) and
viewed from above. The
patient is asked to turn to
one side as far as possible
and then the other

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Examination of lower
limb joints

45. Inspection of the lower limb
 The lower limbs bares the weight of the entire body.
 It is common for patients to present with problems
with a joint when it is an entirely different joint which
is the route of the cause.
 It is imperative that the lower limb is inspected as a
whole and compared to the other leg, looking for:
 The position of the joints (the knee may externally rotate
when a hip joint is broken or diseased for example)
 Pelvic tilting (can occur if the patient is trying to avoid
weight baring on the affected side)
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Inspection and palpation of the hip
joint
 The hip joint is not visible externally,
but inspect (ideally with patient
standing) for any obvious deformities
 Palpation for joint tenderness is only
possible just distal to the midpoint of
the inguinal ligament also palpate
soft tissues around the area for
tenderness
 Palpate bony prominences such as
anterior superior iliac spine and iliac
crest to ensure they are anatomically
where they should be

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Movement of the Hip Joint
 Flexion
 Extension
 Abduction
 Adduction
 Internal and external rotation

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Hip movements - flexion and extension
 Flexion - with the patient
lying supine and the knee
flexed passively flex the
hip joint - normal approx.
115 degrees
 Extension - with the
patient lying prone,
support the knee and with
a hand on the buttock
passively extend the joint
(normal approx. 30
degrees)

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Hip movements - abduction and adduction
 Abduction -
normal approx. 45
degrees
 Adduction -
judged by
carrying limb
immediately in
front of the other -
normal approx. 30
degrees

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Hip movements - rotation
 The person flexes the knee
and hip
 The knee is held in one hand
and the foot in the other
 External rotation is achieved
by passively moving the foot
medially (normal approx. 45
degrees)
 Internal rotation is tested by
moving the foot laterally
(normal approx. 45 degrees)

51. Inspection and palpation of the knee
 Inspect, comparing knees with patient supine
 Swellings may be detected by a loss of the medial and
or lateral dimples suggestive of an effusion
 Palpate for:
 presence / absence of patella and its mobility
 collateral ligaments
 the joint line for tenderness
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Movements of knee and ligaments
 Flexion
 Extension
 Hyperextension
 Lateral and medial collateral ligaments
 Anterior and posterior cruciate ligaments

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 Flexion: the knee is
flexed with one hand
resting on the patella -
normal approx. 135
degrees
 Extension: the leg is
straightened to its fullest
extent - normal 5
degrees of
hyperextension
Knee movements

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Testing knee ligaments
 Anterior and posterior cruciate
ligaments are tested with the
knee in 90 degrees of flexion
 The foot is fixed (examiner can
sit on it) and anterior and
posterior movements are
attempted (“Drawer sign”)
 Medial and lateral ligaments are tested with the
knee in 20 degrees of flexion
 With the upper leg supported, lateral and medial
movements are attempted - normal < 5 degrees

55. Inspection and palpation of the ankle
and foot
 Inspect foot and ankles ideally with patient
standing and more carefully with the patient
supine
 Look at the shoes for abnormal wear or stretching
 Palpate for tenderness particularly over bony
prominences placing thumbs on sole of foot and
finger tips on dorsum
 Assess the metatarsophalangeal joints by gently
squeezing between index finger and thumb
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56. Palpate
 Heel (calcaneus)
 Lateral malleoli
 Medial malleoli
 Metatarsal heads
 Metatarsophalangeal joints
 Interphalangeal joints
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Movement of the ankle and foot
 Ankle
 Dorsiflexion
 Plantar flexion
 Inversion
 Eversion
 Toes
 Extension
 Flexion
 Abduction and adduction

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Dorsiflexion and plantar flexion
 Ask the person to bend
their foot down into
plantar flexion - normal
approx. 50 degrees
 Ask the person to bend
the foot upwards into
dorsiflexion - normal
approx. 20 degrees
Plantar surface

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Eversion and Inversion
 Isolate the heel by
holding it firmly
 Attempt inversion
and eversion by
twisting the mid-
foot medially and
laterally.

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Movement of the Toes
 Ask the patient to flex and extend the toes
 Ask the patient to abduct and adduct the toes
 Remember the big toe can usually move
independently of the others.

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Trendelenburg test
 The person is asked to
stand on one leg then the
other
 Normally the non-weight
bearing limb is elevated
 In joint or muscle disease
the non-weight bearing
side sags
 „Negative‟ test is normal
Normal

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Measurement of leg length
 True leg length - measured
from anterior superior iliac
spine to medial malleolus
 True leg length differences due
to hip disease on the shorter
side. 1-1.5cm difference
classed as normal, anything
greater would be abnormal