Musculoskeletal Exam2004-2005

Primary Care Sports MedicineDepartment of Family PracticeHennepin County Medical Center

ShoulderBone and soft tissue anatomy (anterior view)

AcromionAcromion ClavicleClavicle

A-C JointA-C Joint

Coracoid ProcessCoracoid Process

Longhead of biceps tendonLonghead of biceps tendon

ShoulderBone and soft tissue anatomy (lateral view)

Spine ofSpine ofscapulascapula

A-C jointA-C joint ClavicleClavicle

Greater tuberosityGreater tuberosity

Lesser tuberosityLesser tuberosity

Coracoid Coracoid processprocessSupraspinatus InsertionSupraspinatus Insertion

Infraspinatus InsertionInfraspinatus Insertion

Teres Minor InsertionTeres Minor Insertion

Subscapular InsertionSubscapular Insertion

ShoulderBone and soft tissue anatomy (posterior view)

Spine of scapulaSpine of scapula

ScapulaScapula

ShoulderRange of Motion

Flexion 0 - 180°Extension 0 - 60°Abduction 0 - 180°Adduction 0 - 75° IR (add)0 – 90ºER (add) 0 – 90ºIR (abd)0 – 90ºER (abd) 0 – 90º

ShoulderRange of motion

Combination ROM(extension, adduction, and internal rotation)

ShoulderStrength testing

Supraspinatus(“empty-can” sign)

Evaluate for strength and presence of pain.

ShoulderStrength testing

Infraspinatus(resisted external rotation in adduction)

Evaluate for strength and presence of pain.

ShoulderStrength testing

Teres minor and infraspinatus(resisted external rotation in abduction)

ShoulderStrength testing

Subscapularis(resisted internal rotation)

Evaluate for strength and presence of pain.

ShoulderStrength testing

Subscapularis(“belly press”)If the elbow endsin the adductedposition, the subscapularisis weak.

ShoulderImpingement tests

Neer’s test

Test is (+) if pain occurs.

ShoulderImpingement tests

Hawkin’s tests

Impingement

Coracoid impingement

Tests (+) if pain occurs.

ShoulderStability tests

Anterior

“Apprehension” test

When (+) and accompanied by recent acute trauma, suggests anterior dislocation.

ShoulderStability tests

Anterior

Relocation test

When (+), suggests chronic anterior instability.

ShoulderStability tests

Anterior

“Load and shift” test

Up to 25% anterior translation is considered normal.

ShoulderStability tests

Inferior

“Sulcus sign”

Shoulder – Sulcus sign

Without stress

With stress

(+) sulcus sign

ShoulderStability tests

Posterior

Apply axial load.

ShoulderStability tests

Posterior

“Load and shift” test

Up to 25% posterior translation is considered normal.

ShoulderTests for superior labral tears

O’Brien’s test

A positive test occurs when pain occurs only in the “thumb down” position.

ShoulderTests for superior labral tears

Anterior slide testThe test is (+) when pain or a “pop” or “click” occurs at the anterior-superior shoulder or if the maneuver reproduces the patient’s pain.

ShoulderTests for superior labral tears

“Clunk” test

The test is (+) if a “clunk” occurs or if the patient’s pain is reproduced.

ShoulderAcromioclavicular (AC) tests

Palpation

ShoulderAcromioclavicular (AC) tests

Crossed adduction test

The test is (+) if the process of adduction causes pain at the AC joint.

ShoulderLonghead of biceps test

Speed’s test

Test is (+) if pain is reproduced at longhead of biceps in humeral groove.

ShoulderScapular stabilizer tests

Serratus anterior

Test is positive if scapular “winging” exists.

ShoulderScapular stabilizer tests

“Wall push”

Test is (+) if scapular “winging” is observed.

KneeBone and soft tissue anatomy (anterior)

Rightknee PatellaPatella

Patellar tendonPatellar tendon

Medial joint lineMedial joint line

MedialMedialCollateral Collateral ligamentligament

Tibial tubercleTibial tubercle

Lateral joint lineLateral joint line

Lateral Lateral CollateralCollateralligamentligament

KneeBone and soft tissue anatomy (medial)

Right knee flexed to 90°

Medial joint lineMedial joint lineMCLMCL

Tibial tubercleTibial tubercle

PatellaPatella

Medial femoralMedial femoralcondylecondyle

KneeBone and soft tissue anatomy (lateral)

Right kneeflexed to 90°

PatellaPatella

FibulaFibula

Lateral joint lineLateral joint line

Patellar tendonPatellar tendon

LCLLCL

Lateral Lateral femoral condylefemoral condyle

KneeRange of motion

Flexion 0 - 135°

Extension 0 - 15°

Int Rotation 0 – 20 to 30°

Ext Rotation 0 – 30 to 40°

KneeTests of medial stability (MCL)

Valgus stress test

Test performed at 30° of flexion. Note “end point” and if joint opens compared to uninvolved side.

KneeTest of lateral stability (LCL)

Varus stress test

Test performed at 30° flexion. Note “end point” and if joint opens compared to uninvolved side.

KneeTest for meniscal injury

Palpate for joint line tenderness.

KneeTest for meniscal injury

McMurray’s test

Note pain and/or “click” or subluxing meniscus.

KneeTest for meniscal injury

Spring (“bounce”) test

Test is (+) if pain occurs along joint line when knee “bounces” into extension.

KneeTest for anterior stability (ACL)

Lachman’s test

Note “end point” and or anterior translation of tibia.

Kneetest for anterior stability (ACL)

Lachman’s test (modification)

KneeTest for anterior stability (ACL)

Lachman’s test(Modification)

KneeTests for anterior stability

Anterior drawer

Note anterior tibial translation and presence or absence of “end point”.

KneeTests for posterior instability

Recurvatum test

Presence of unilateral recurvatum suggests injury to posterolateral corner.

KneeTests for posterior stability

Posterior sag

KneeTests for posterior stability

Posterior drawer

Note position of tibial plateau in relationship to lateral femoral condyle.

KneeTests for posterior stability

Quadriceps active test

Test is (+) if tibia translates in anterior direction when quadriceps contract.

KneePatellofemoral tests

Patellar pseudocompression test

Test is (+) if pain is present.

KneePatellofemoral tests

Compression test

Test is (+) if active contraction and compression cause pain.

KneePatellofemoral tests

Palpate medial and lateral patellar facets.

Tenderness along superior and medial aspect of patella may suggest medial plica syndrome.

KneeTest for patellar dislocation

Patellar apprehension test

Test is (+) if test causes pain and/or fear that patella might dislocate.

ElbowBone and soft tissue anatomy (lateral view)

Right elbow

Lateral epicondyleLateral epicondyle

OlecranonOlecranon

ElbowBone and soft tissue anatomy (anterior view)

MedialMedialepicondyleepicondyle

Lateral epicondyleLateral epicondyle

ElbowBone and soft tissue anatomy (posterior view)

Rightelbow

Medial epicondyleMedial epicondyleLateralLateralepicondyleepicondyle

OlecranonOlecranon

Ulnar Ulnar groovegroove

ElbowRange of motion

Flexion 0 - 140°

Extension 0 - 10°Hyperextension?

Pronation 0 - 90°

Supination 0 - 90°

ElbowMedial epicondylitis

Tender to palpation over medial epicondyle.

Pain with resisted wrist flexion.

ElbowLateral epicondylitis

Tender to palpation over lateral epicondyle.

Pain with resisted wrist extension.

Pain with resisted middle finger extension.

ElbowUlnar collateral ligament injury

Valgus stress to medial epicondyle

Test is (+) when stress causes pain and/or instability.

ElbowUlnar collateral ligament injury

“Milk maid’s” test

Test is (+) when maneuver causes pain.

Wrist/HandBone and soft tissue anatomy

Right wrist(dorsal view)

Ulnar styloid Radial styloidTFCC

1st dorsalcompartment (black)Site of deQuervain’s

2nd dorsalcompartment (red)

Site of intersectionsyndrome(“squeaker’s wrist”)

Wrist/HandBone and soft tissue anatomy

Right wrist(radial view)

Anatomical snuffbox

1st dorsal compartment

2nd dorsalcompartment

Wrist/HandBone and soft tissue anatomy

Right wrist(ulnar view)

Ulnar styloid

TFCCTFCC

WristRange of motion

Flexion 0 - 80°

Extension 0 - 70°

Ulnar deviation0 - 30°

Radial deviation0 - 15°

WristCarpal tunnel syndrome

Tinel’s sign

Test is (+) if paresthesias are produced.

WristCarpal tunnel syndrome

Phalen’s sign

Test is (+) if symptoms are reproduced when hands are held in that position. May have to maintain that position for 30-60 seconds.

Wristde Quervain’s tenosynovitis

Finkelstein’s test

Test is (+) if pain is produced by maneuver.

WristIntersection syndrome (Squeaker’s wrist”)

Swelling, tenderness, and crepitation (squeaking) over intersection of 1st and 2nd dorsal compartments with radial and ulnar deviation.

WristScaphoid fracture

Tenderness over anatomical “snuffbox.

Tenderness over scaphoid tubercle.

WristScapholunate dissociation

Tenderness over scapholunate interval.

Scaphoid shift (Watson “click” test)

Test is (+) if pain/click occur during maneuver.

HandSkier’s thumb (Gamekeeper’s thumb)

Flex thumb 20°, apply valgus stress to thumb and compare instability to uninvolved side.

Test is (+) if pain/instability occur.

FingerFlexor tendon injury

Evaluation of flexor digitorum superficialis.

FingerFlexor tendon injury

Evaluation of flexor digitorum profundus.

Foot/AnkleBone and soft tissue anatomy

Right ankle(anterior view)

Medial malleolusLateral malleolus

Anteriortalofibular ligament (ATFL)

Anterior tibiofibular ligamentAnterior tibiofibular ligament(syndesmotic ligament)(syndesmotic ligament)

Foot/AnkleBone and soft tissue anatomy

Right ankle(lateral view)

Lateral malleolus

ATFLATFL

CalcaneofibularCalcaneofibularligamentligament

Posteriortalofibular ligament

Anterior tibiofibularAnterior tibiofibularligamentligament

Foot/AnkleBone and soft tissue anatomy

Right ankle(medial view)

Medial malleolus

Tarsal navicularTarsal navicular

Foot/AnkleBone and soft tissue anatomy

Right ankle(posterior view)

Medial malleolus Lateral malleolus

Achilles tendonPosteriortalofibular ligament

Foot/AnkleBone and soft tissue anatomy

Right foot(plantar view)

CalcaneusCalcaneus

Distal, medial calcaneus (siteof pain of plantar fasciitis)

Foot/AnkleRange of motion

Dorsiflexion 0 – 20º

Plantarflexion0 – 50º

Inversion 0 – 45 to 60º

Eversion 0 – 15 to 30º

Foot/AnkleSpecial tests: ATFL injury

Anterior drawer

Test is (+) if movement of the tibia is greater than uninvolved side. (+) test suggests tear of anterior talofibular ligament (ATFL).

Foot/AnkleSpecial tests: (CFL injury)

Talar tilt

Test is (+) if there is greater subtalar motion compared to uninvolved side. (+) test suggests tear of calcaneofibular ligament (CFL).

Foot/AnkleSpecial tests: Syndesmotic (“high”) sprain

External rotation test

Test is (+) if maneuver produces pain at site of syndesmotic ligament (anterior tibiofibular ligament).

Foot/AnkleSpecial tests: Syndesmotic (“high”) sprain

“Squeeze” test

Test is (+) if maneuver produces pain at site of syndesmotic ligament.

Back – Lumbar SpineRange of motion

Forward flexion0 – 40 to 60º

Extension 0 – 25 to 35º

Lateral flexion 0 – 15 to 20º

Rotation 0 – 3 to 18º

Back – Lumbar SpineHerniated nucleus pulposus

Straight-leg raising test

Test is (+) if radicular pain is reproduced by holding leg 30 - 70° flexion

Back – Lumbar SpineSpondylolysis

Single-leg extension test (“stork” test)

Test is (+) if pain localizes with extension.

Back – Lumbar SpineSacroiliac (SI) dysfunction

FABER test (Flexion, Abduction, External Rotation)

Test is (+) if pain is reproduced at SI joint on same side as pain.

Back – Lumbar SpineSI dysfunction

Gaenslen’s test

Test is (+) if maneuver reproduces SI pain.

The EndThe End