Musculoskeletal Pain

Key Points

This review discusses examination of the musculoskeletal system.

Before the exam, gather the necessary equipment: a skin-marking pencil, goniometer, tape measure, and reflex hammer.

Begin by simply observing the patient’s gait and posture. Inspect the skeleton and extremities when the patient stands, sits, and walks. Compare sides for alignment. Note the contour, symmetry, and size of body parts as well as any gross deformity.

When examining each region, observe the following guidelines.

Inspect the skin and subcutaneous tissues over the muscles and joints, noting the skin color and number of skinfolds. Observe for any discoloration, swelling, or masses.

• Inspect the muscles and compare contralateral sides for size and symmetry. Stay alert for gross hypertrophy or atrophy, fasciculations, and spasms.
• Palpate the bones, joints, and surrounding muscles to evaluate muscle tone and detect any heat, tenderness, swelling, joint fluctuation, crepitus, pain, or resistance to pressure.
• Examine each major joint for active and passive range of motion. If the range of motion seems increased or decreased, use a goniometer to measure the angle at the joint.
• Test muscle strength by applying resistance as the patient moves. Grade muscle strength from 0 (for no movement) to 5 (for full range of motion against gravity and full resistance).

To examine the joints of the upper extremities, perform the following.

Examine the hands and wrists in four ways.

• First, inspect the dorsum and palm of the hands. Note their contour, position, and shape and the number and completeness of fingers.

Second, palpate each joint in the hand and wrist. Joint surfaces should be smooth and without nodules, swelling, bogginess, or tenderness.

Third, test the range of motion. Metacarpophalangeal flexion should be 90 degrees. Metacarpophalangeal hyperextension should be 30 degrees. The patient should be able to demonstrate thumb opposition, form a fist, and adduct and abduct the fingers. You should see wrist flexion of 90 degrees and wrist hyperextension of 70 degrees. Expect radial motion to be 20 degrees and ulnar motion to be 55 degrees.

Fourth, evaluate muscle strength by testing wrist flexion and hyperextension and hand grip.

• Assess the elbows with four methods.
• First, inspect the elbows in the flexed and extended positions. Note their contour and carrying angle, which should be 5 to 15 degrees laterally.

Second, palpate the extensor surface of the ulna, olecranon process, and medial and lateral epicondyles of the humerus.

Third, check the range of motion. With elbow flexion, range of motion should be 160 degrees. With extension, it should be 180 degrees. With pronation and supination, it should be 90 degrees.

Fourth, assess muscle strength during elbow flexion and extension.

• Evaluate the shoulders using four techniques.
• First, inspect the contour of the shoulders, shoulder girdle, clavicles, scapulae, and surrounding muscles. All shoulder structures should be symmetrical in size and contour.

Second, palpate the sternoclavicular joint, clavicle, acromioclavicular joint, scapula, coracoid process, greater tubercle of the humerus, biceps groove, and area muscles.

Third, examine range of motion. The patient should be able to shrug their shoulders, perform forward flexion to 180 degrees and hyperextension to 50 degrees, complete abduction to 180 degrees and adduction to 50 degrees, and do internal and external rotation of 90 degrees.

Fourth, test the muscle strength as the patient shrugs their shoulders. This maneuver also tests cranial nerve (CN) XI .

To examine the joints of the head and neck, perform the following.

Assess the temporomandibular joint in three ways.

• First, palpate the joint space for clicking, pain, crepitus, locking, or popping.

Second, assess range of motion by having the patient open and close their mouth, move the lower jaw to each side, and protrude and retract the jaw.

Third, test the strength of the temporalis and masseter muscles with the patient’s teeth clenched. With this test, remember you are also evaluating CN V .

• Examine the cervical spine using four techniques.
• First, inspect the neck for alignment as well as symmetry of the skinfolds and muscles.

Second, palpate the posterior neck, cervical spine, and paravertebral, trapezius, and sternocleidomastoid muscles.

Third, evaluate range of motion by forward flexion (which should be about 45 degrees), extension (about 45 degrees), lateral bending (about 40 degrees), and rotation (about 70 degrees).

Fourth, test the strength of the sternocleidomastoid and trapezius muscles. This test also assesses CN XI .

To examine the joints of the spine and hips, perform the following.

Assess the thoracic and lumbar spine with four maneuvers.

• First, inspect the landmarks of the back for alignment. Note the curves of the spine. Remember that lordosis (or inward curvature of the spine) is common in patients who are obese or pregnant.

Second, palpate along the spinal processes and paravertebral muscles.

Third, percuss for spinal tenderness.

Fourth, examine range of motion. Expect forward flexion of 75 to 90 degrees, hyperextension of 30 degrees, lateral bending of 35 degrees, and forward and backward rotation of the upper trunk of 30 degrees.

• Evaluate the hips in three ways.
• First, inspect the hips, checking for symmetry, size of the buttocks, and numbers and level of the gluteal folds.

Second, check the hip range of motion. Hip flexion with the knee extended should be 90 degrees; with the knee flexed, it should be 120 degrees. Hip hyperextension with the knee extended should be 30 degrees. Hip abduction should be 45 degrees, and adduction should be 30 degrees. Internal rotation should be 40 degrees, and external rotation should be 45 degrees.

• Third, test the muscle strength during hip flexion with the knee flexed and then extended, during abduction and adduction, and when the seated patient uncrosses their legs.

To examine the joints of the lower extremities, perform the following.

Assess the legs and knees using four techniques.

• First, inspect the knees, their popliteal spaces, and lower leg alignment. The expected angle between the femur and tibia is less than 15 degrees.

Second, palpate the popliteal space and tibiofemoral joint space, particularly noting tenderness, swelling, bogginess, nodules, or crepitus.

Third, evaluate knee range of motion. Expect 130 degrees of flexion, full extension, and up to 15 degrees of hyperextension.

Fourth, test the strength of the knee muscles while the patient maintains flexion and extension.

• Examine the feet and ankles with four methods.
• First, inspect the feet and ankles while the patient is bearing weight and while sitting. Observe landmarks; contour; arches; foot alignment with the tibia; toe alignment with the other toes; and the position, size, and number of toes.
• Second, palpate the Achilles tendon, anterior surface of the ankle, medial and lateral malleoli, and each metatarsophalangeal joint.

Third, check the range of motion with the patient seated. Dorsiflexion should be 20 degrees. Plantar flexion should be 45 degrees. Expect inversion of 30 degrees and eversion of 20 degrees. Expect abduction of 10 degrees and adduction of 20 degrees. Expect flexion and extension of the toes, especially the great toes.

Fourth, test the muscle strength during dorsiflexion and plantar flexion and possibly during ankle abduction and adduction and great toe flexion and extension.

To further evaluate specific joints, perform these additional procedures.

If you need to evaluate the median nerve in the hand, have the patient mark the locations of pain, numbness, and tingling on the Katz hand diagram. Also test for Tinel sign and perform the thumb abduction and Phalen tests.

To assess the rotator cuff in the shoulder for impingement or a tear, perform the Neer test and the Hawkins test. Also test the strength of the supraspinatus, subscapularis, infraspinatus, and teres minor muscles. Note any weakness and pain.

To further evaluate the lower spine, use the straight leg raising test and the femoral stretch (or hip extension) test.

For suspected hip problems, use the Thomas test to identify flexion contractures and the Trendelenburg test to spot weak hip abductor muscles.

For additional knee assessment, use ballottement and check for the bulge sign to detect excess fluid in the knee. Perform the McMurray test to detect a torn medial or lateral meniscus. Use the anterior and posterior drawer test, Lachman test, and varus and valgus stress tests to identify instability in specific ligaments.

• When you suspect a difference in length or circumference of matching extremities, measure and compare the size of both limbs.