Musculoskeletal (MSK) OSCE guides
This should be possible to 90 degrees or parallel to the floor when the patient is standing or sitting erect. Ask the patient to rotate and to continue to flex the shoulders, placing both hands together over the head with arms parallel to and against the ears. This should be possible in the normal state to degrees. Ask the patient to abduct both shoulders, which should again be possible to 90 degrees, and to rotate and further abduct the shoulders touching both hands together over the head with the upper arms tightly pressed against the ears.
Ask the patient to clasp both hands behind the occiput to check for external rotation. Ask the patient to spread both elbows wide apart, then to release the handclasp but maintain the flexion of the elbows and touch the elbows together in front of the head. The patient is then asked to elevate both shoulders as if shrugging them. In this instance it is difficult to describe specific angles and motion, but the examiner will gain experience in detecting abnormalities. The temporomandibular joints are inspected and palpated as described previously for other joints.
Continue to palpate the temporomandibular joints while asking the patient to open and close the mouth and to move the jaw from side to side. Again, it is very difficult to describe a specific range of motion, but experience will help in detecting abnormalities. Palpate and listen for crepitation while the motion is being performed. Inspect the cervical spine for loss of the normal lordotic curve.
Palpate for local areas of tenderness and crepitation. Next, ask the patient to put the chin on the chest to check flexion, to put first the right ear on the right shoulder and the left ear on the left shoulder for lateral flexion, and to extend the neck as far as possible by looking back over the ceiling as far as possible.
Rotation is then checked by asking the patient to put the chin on the right shoulder and then the left shoulder. Examine the thoracic and lumbar spine together. Examine the back and palpate for areas of muscle spasm and tenderness. Lightly percuss over the spinous processes throughout the spine to check further for tenderness. Observe the patient both standing and sitting from behind and from the side to check for kyphosis an abnormal forward flexed position and scoliosis an abnormal curvature of the spine on one side or the other.
The presence of scoliosis can best be judged by determining if a list is present. If the first thoracic vertebra is not centered over the sacrum, the patient is said to have a list. This can easily be measured by dropping a perpendicular from the first thoracic vertebra and measuring how far to the right or left of the gluteal fold it falls. If a list is demonstrated, scoliosis must be present. Also observe whether the lumbar lordosis is present in increased amount or abnormally absent. Check for forward flexion in the sitting position by asking the patient to place the nose on the knee, and in the standing position by asking the patient to touch the toes.
To check for lateral flexion, ask the patient to hyperextend the spine as much as possible and then to pass the hand straight down the thigh, first on the right and then on the left, keeping the hips straight. Ask the patient to maintain the pelvic girdle in a flexed position and rotate the shoulders first to the right and then to the left to check for rotation. With the patient standing, check for a pelvic tilt by placing your hands on the iliac crests and observing if these are parallel. Angles of motion can be estimated from an imaginary line passing straight up through the spine, perpendicular to the floor or to the table.
It is very difficult to measure these accurately or to list accurate normal measurements. The most accurate parameter of measurement is the amount of lengthening of the spine in forward flexion. The normal spine should lengthen more than 5 cm in the thoracic area and more than 7. Costovertebral joint motion can be measured by placing the hands with fingers spread on the thorax and having the patient inspire and expire fully. If there is an abnormality, an accurate measurement of chest expansion at the nipple line should be recorded as a baseline.
For straight leg raising tests , ask the patient to lie with the spine on the table and to relax completely. With the knee fully extended, first one leg and then the other is slowly lifted and flexed at the hip. This produces stretch on the sciatic nerve, at which point sciatic pain is produced.
If this maneuver produces pain in the hip or low back with radiation in the sciatic area, the test is considered positive for nerve root irritation. The angle of elevation of the leg from the table at the point where pain is produced should be recorded. The sacroiliac joints are examined by palpation and by light fist percussion for tenderness. Other maneuvers that might produce pain in a sacroiliac joint when inflammation is present are:. The feet are inspected for abnormal coloration and localized areas of swelling. Note should be taken of skin lesions about the feet and toes.
Palpate and record arterial pulsations dorsalis pedis and posterior tibial. In addition, observe for lowering of the longitudinal arch pes planus, or flat foot , abnormal elevation of the longitudinal arch pes cavus , abnormal angulation of the first metatarsophalangeal joint hallux valgus , hammertoe or cock-up deformities of the toes, and the formation of callouses or bursae over the pressure areas. Ask the patient to perform flexion and extension of the toes actively. If there appears to be an abnormality, each toe must be passively put through a range of motion.
Mobility of the midtarsal joints is measured by grasping the foot with both hands and gently rotating the hands in opposite directions. Examine the ankle for discoloration and swelling and palpate for tenderness, swelling, effusion, and crepitus on range of motion. Ask the patient to dorsiflex the ankles this should be possible to approximately 20 degrees and to plantar-flex the ankles this should be possible to approximately 45 degrees. Then ask the patient to invert supinate the ankle, which should be possible to 30 degrees, and to evert pronate the ankle, which should be possible to 20 degrees.
Ask the patient to stand and walk. Note attitudes of pronation or supination and toeing in and toeing out with walking. The knee , the largest joint in the body, is a compound condylar joint. The specific anatomy of the knee should be reviewed.
Inspect the knees for discoloration, swelling, and deformities and note whether they are laterally angulated genu varum or medially angulated genu valgum. In addition, note a backward bowing of the knee genu recurvatum and lack of full extension of the knee flexion contracture. The abnormalities mentioned on inspection up to this point are best noted with the patient standing and weight-bearing. The remainder of the examination of the knees is best done with the patient supine. Look for atrophy of the quadriceps muscles and observe the contour of the knees. In palpating a knee that appears swollen, attempt to identify the structures producing the enlargement.
Synovial thickening, as in chronic synovitis, produces a swelling of doughy consistency. This can best be perceived as a thickening of the synovial edge as it reflects in the suprapatellar pouch. It is noted as a longitudinal ridge approximately 4 to 5 cm above the upper border of the patella. With the left hand held firmly over the patella, ask the patient to flex and extend the knee slowly. In performing this maneuver, note the angles of extension and flexion and whether or not crepitus is present as the joint moves. Extension should be full to degrees or 0 degrees, and flexion should be possible to degrees.
If there is a limitation in this range, then these motions should be performed passively by the examiner with the patient relaxed in order to delineate the cause of the limitation. The hip is a ball-and-socket joint and consequently capable of complex motions of flexion, extension, abduction, adduction, and rotation. A number of specialized tests can be performed about the hip to delineate specific abnormalities.
These will not be discussed exhaustively in this section. Should an abnormality be observed in the standard routine examination, refer to a good orthopedic or rheumatology textbook such as those listed in the references. The patient is observed in a standing position for tilt of the pelvis, as noted above in the spinal examination. A tilt may be due to disease of the hip or to unequal leg length.
The gait is observed to detect a limp that might be secondary to pain in the hips, or limitation of motion due to structural damage to the joint itself or to the musculature and innervation about the joint. Ask the patient to lie supine on the table and to actively flex first one hip and then the other with the opposite hip fully extended.
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Flexion with the knee straight should be possible to 90 degrees and, with the knee bent, to degrees or greater. Tests for abduction of the hip are easier to perform passively. Place the left hand on the crest of the ilium and grasp the right leg with the right hand. Clinical examples are given to assist the reader in understanding these terms and how they are applied. Nine self-report measures are discussed. There is a superb chart that illustrates the reliability and the minimal clinically important difference for each of these self-report forms when they have been reported in the literature.
These are referred to as red flags. Pain diagrams illustrate different patterns of pain that might be present with specific diseases. Clinical predication rules for deep vein thrombosis are presented. The level of specificity and sensitivity and the positive and negative likelihood ratios of specific questions and their answers are provided according to system: cardiovascular, gastrointestinal, genitourinary, endocrine, pulmonary, and integumentary.
There also are screenings for depression, peripheral arterial disease, neurologic disorders, and a mini-mental examination. The CD is most useful in conjunction with the remainder of the book. The CD contains the full text of the book along with accompanying videos that demonstrate the specific evaluative maneuvers. This allows the reader not only to read the directions for the proper manner in which to perform the test, but to see it as well.
The pictures and videos are clear and demonstrate both the therapist's and patient's positioning. These are the strengths and real value of this text. Region-specific historical questions are presented in each section to assist the reader in making a more accurate diagnosis. For example, in the cervicothoracic spine examination section, likelihood ratios are presented for 2 questions that will assist the reader in identifying a patient with cervical radiculopathy.
Although treatment techniques are not the focus of this book, the editors present evidence regarding specific treatment regimens. In the lumbar spine section, test item clusters are listed for patients who are likely to benefit from either lumbar manipulation or stabilization exercise treatment.
The book includes examination schemes and procedures for the cervicothoracic spine, shoulder, elbow, wrist and hand, temporomandibular joint, lumbar spine, hip, knee, and the foot and ankle. The examination scheme is specific and includes historical examination and visceral referral patterns; observation, functional tests, and palpation; active range of motion, passive range of motion, and overpressure; and resisted muscle tests, assessment of accessory movements, and special tests.
Rather than demonstrating every examination test available, the editors have selected those tests that are evidence based and assist the clinician in making a more accurate diagnosis. This book is unique in combining evidence and physical examination, helping the clinician to make a diagnosis more accurately.
It is well referenced and up to date. Updates to the book are available on the Internet. While use of multiple provocative tests is probably more predictive of pathology, the exact combination and number of provocative musculoskeletal tests to improve diagnostic accuracy remains unclear. References Braddom RL.
Physical Medicine and Rehabilitation. Philadelphia, PA: Elsevier; , Magee DJ. Orthopedic Physical Assessment. Louis: Elsevier; The value of provocative tests in diagnosis of cervical radiculopathy. J Res Med Sci. Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician , ; Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests.
Br J Sports Med. Hegedus EJ. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests.
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J Sports Med. Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review.
Journal of Pain. Evaluation of acute knee pain in primary care. Ann Intern Med. Original Version of the Topic Robert A. Lavin, MD, Ryan K. Murphy, DO. Specialized musculoskeletal examination. Author Disclosure Robert A. Lavin, MD Nothing to Disclose. Lavin, MD Comments are off. Article Search Search for:. All rights reserved. Bryn Mawr Ave. Ste Rosemont, IL Phone: In supine position, depress shoulder, then abduct, extend, and externally rotate arm, supinate forearm up to but do not induce pain, then extend elbow and wrist. Examiner palpates radial pulse. Hawkins-Kennedy Impingement Supraspinatus tendinitis.
Arm flexed forward at 90 degrees then forced internal rotation of shoulder. Shoulder abduction to 90 degrees in neutral and resisted downward by examiner. Neer Impingement Supraspinatus tendinitis, biceps tendinitis, inferior instability of humeral head in glenoid fossa, adhesive capsulitis, arthritis. Stabilize posterior scapula, internally rotate arm and forcibly forward flex shoulder.
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Pain due compression of anterior acromion and greater trochanter of humerus. Internally rotate shoulder so that hand is behind back with palm facing away from back, then patient pushes away from back against resistance. Abduct arm to 90 degrees and flex elbow to 90 degrees, then patient rotates arm externally against resistance. Shoulder is forward flexed to 90 degrees. Shoulder is abducted to 90 degrees passively by examiner, then patient lowers arm slowly.
Shoulder flexed to 90 degrees and the elbow fully extended, the arm is adducted across midline with the shoulder internally rotated thumb points down. Pain with shoulder in internal rotation thumb down ; no pain with external rotation palm up. Patient lies supine, abduct arm to 90 degrees and flex elbow to 90 degrees, then externally rotate shoulder 90 degrees.
Patient supine and passively flex hip. Patient supine and passively raise unaffected contralateral leg with knee extended similar to maneuver in straight leg raising test.