Musculoskeletal examination in rheumatic disease

Musculoskeletal (MSK) Examination 

1. General Principles of MSK Examination

• Inspection and Palpation: Essential steps for examining each part of the MSK system to ensure findings are not missed. 

• Bilateral Comparison: Always compare both sides of the body to detect subtle differences. 

• Systematic Approach: Examine in a distal-to-proximal sequence or vice versa to maintain thoroughness. 

• Key Joints: Include the spine and central joints such as the sternoclavicular, pubic symphysis, and sacroiliac joints. Do not forget to examine the temporomandibular joint (TMJ). 

2. Inspection

• Skin: Look for redness, rashes, color changes, or loss of skin wrinkling, which may indicate underlying swelling. 

• Swelling: Inspect for synovial sheath swelling over tendons. 

• Muscles and Bones: Assess for muscle wasting or obvious deformities. 

• Deformities: Observe for contractures, malalignment (e.g., genu valgum or varum), or other structural abnormalities. 

3. Palpation

• Tenderness: Assess tenderness over bones, joints, tendons, bursae, and fascia. Joint line tenderness may indicate arthritis. 

• Warmth: Check for one of the cardinal signs of inflammation by palpating for warmth. 

• Swelling: Determine whether the swelling involves fluid, soft tissue, or bone by palpation techniques. 

4. Screening and Range of Motion (ROM) Testing

• Active ROM: Conduct initial gross pathology screening by assessing the patient’s ability to move joints independently. 

• Passive ROM: Helps differentiate between intra-articular and periarticular disease processes. Intra-articular disease (e.g., inflammatory arthritis) restricts both active and passive ROM, while periarticular issues (e.g., tendinitis) only limit active ROM. 

5. Posture and Gait

• Posture: Assess for symmetry in shoulder height, scapulae, pelvic brim, and buttock creases. Inspect the spine for normal curves or scoliosis. 

• Gait Patterns: 

• Antalgic Gait: Shortened stance phase on the affected limb due to pain. 

• Trendelenburg Gait: Dipping of the pelvis to the opposite side due to weak hip abductors. 

• High-Stepping Gait: Compensation for foot drop by lifting the leg higher during the swing phase. 

6. Identifying Abnormalities

• Inflammation: Redness is uncommon but can be seen in acute gout or infections. 

• Warmth: Use the back of the hand to detect warmth over joints. 

• Swelling: Detect effusions using techniques such as the bulge sign and patellar tap. 

• Deformities: Assess for crepitus, restricted movement, and abnormal joint alignment. 

7. Regional Examination

Head, Spine, and Pelvis 

• Cervical Spine: Inspect for hyperextension or loss of lordosis. Percuss for tenderness and assess ROM (flexion, extension, rotation, and lateral flexion). 

• TMJ: Palpate for tenderness, crepitus, or clicking. Assess movement by asking the patient to open the mouth wide and deviate the jaw side to side. 

• Dorsal and Lumbar Spine: Inspect for kyphosis or scoliosis. Assess flexion, extension, lateral bending, and rotation. 

• Pelvis and Sacroiliac Joints: Stress tests (e.g., distraction test, knee-to-shoulder test) can help identify sacroiliitis. 

Upper Extremity 

• Shoulder: Inspect for asymmetry, muscle wasting, and deformities. Palpate the acromioclavicular joint, glenohumeral joint, and bicipital groove. Assess ROM (abduction, flexion, internal and external rotation). 

• Elbow: Look for swelling or deformity. Palpate for synovial swelling and tenderness. Assess ROM (flexion, extension, and hyperextension). 

• Wrist and Hand: Examine for deformities (e.g., swan-neck, boutonnière deformities) and assess grip strength. Palpate joint lines and tendon sheaths for tenderness. 

Lower Extremity 

• Hip: Assess for muscle wasting, tenderness, and ROM (internal and external rotation, flexion, and abduction). Internal rotation is often restricted first in hip disorders. 

• Knee: Look for effusion, palpate for tenderness, and assess flexion and extension. Test ligament stability (anterior and posterior drawer tests). 

• Foot and Ankle: Observe for deformities (pes planus, hallux valgus) and assess ROM (inversion, eversion, dorsiflexion, and plantarflexion). 

8. Named Special Tests in MSK Examination

Shoulder 

• Neer Impingement Test: Pain on arm elevation suggests impingement. 

• Hawkins Test: Pain with internal rotation indicates impingement. 

• Drop Arm Test: Indicates supraspinatus tear. 

• Speed Test: Pain on resisted shoulder flexion suggests biceps tendon pathology. 

Hip 

• Trendelenburg Test: Detects weak hip abductors. 

• Ober Test: Assesses iliotibial band tightness. 

• FABER Test: Pain in the groin suggests hip disease; sacroiliac pain may indicate spondylitis. 

Knee 

• Lachman Test: Detects ACL tears. 

• McMurray Test: Assesses meniscal injury. 

• Apley Test: Differentiates between meniscal and ligament injuries. 

9. Documentation

• Maintain clear and systematic documentation, preferably using homunculus diagrams. 

• Record joint swelling, tenderness, and restricted movement systematically to ensure comprehensive clinical notes. 

Conclusion 

A thorough MSK examination is essential for accurate diagnosis and effective management of musculoskeletal disorders. Key steps include inspection, palpation, range of motion testing, and special tests to detect abnormalities. Bilateral comparison and systematic documentation ensure comprehensive assessment. This approach aids in identifying conditions early and guides targeted treatment decisions.