Examination of the Musculoskeletal System

Following the initial examination of the painful area, a full musculoskeletal exam should be performed. The musculoskeletal examination starts with inspection of the patient, including front, side, and back. Attention is directed to the posture, any deviations with limb alignment, or other abnormalities, such as flattened foot arches. Symmetry within the body, especially the arms, pelvis, and legs, is important as asymmetry can lead to poor posture or strained extremities, contributing to development of painful symptoms.

After the gross inspection, an assessment of the patient's gait should be performed. The practitioner should note the patient's arm swing, stride length, push off and heel strike, and abnormal side-to-side movements while walking. Next, the patient should walk on his/her toes to test the motor function of the S1 nerve root, followed by walking on his/her heels to test L5 nerve root.

The patient's soft tissues, bony structures, and stationary or moving joints should be palpated for signs of temperature differences, edema, fluid collections, crepitus, gaps, clicks, or tenderness. A functional comparison of the left and right sides may identify possible mechanisms and locations of underlying pathologic processes.

Examination of the range of motion should be done with both active and passive participation by the patient. Active movement of the joint allows the practitioner to determine the range, muscle strength, and willingness of the patient to co-operate. In contrast, passive movements test for pain and range. The physician should also assess for the presence of hypermobility and hypomobility of the joint.

The range of motion of the neck should be measured in full flexion and extension, lateral flexion, and rotational movement. With normal function, the chin touches the chest in full flexion and the examiners pointer and middle fingers are trapped between the occiput and the C-7 spinous process in full extension. With rotation of the head, the patient should be able to turn more than 70 degrees from the sagittal plane. Lateral flexion should be equal bilaterally and at least 45 degrees from neutral.

To evaluate muscle function of the upper extremity, the patient is tested for hand grip, raising of the shoulder, abduction of the arms, flexion, extension, supination, and pronation of the forearm, flexion, and extension of the wrist, abduction and adduction of the fingers, and touching the fifth finger with the thumb. By asking the patient to fully abduct his/her arms and place his/her palms together above his/her head, the functional range of the shoulder, acromioclavicular, rotator cuff, sternoclavicular joints, and lateral rotation of the humerus can be evaluated.

When assessing the passive range of motion, the examiner instructs the patient to flex and extend his/her arm, thereby eliciting signs of discomfort or decreased range of motion. Abduction to 90 degrees, adduction, and internal and external rotation of the shoulder assess range of motion and muscular involvement of shoulder pain. While stabilizing the scapula with one hand, the shoulder should then be externally and internally rotated to evaluate glenohumeral motion.

To evaluate range of motion of the lower extremity, first have the patient step up, raise his/her leg, rise from a squatting position, flex, and extend the leg, foot, and toes. By studying the manner in which the patient sits and stands, the physician can obtain an overall impression of the patient's muscle function. The hip can be externally and internally rotated, abducted, and adducted. Both the knee and ankle have extension and flexion of the joint, while the ankle can be internally and externally everted.

To assess spinal flexibility, the examiner should have the patient flex, extend, rotate as well as laterally flex his/her spine. Immobility secondary to pain may result from disease of the zygapophyseal joint or discogenic, muscular, or ligamentous pathology.

Finally, assessment of the sacroiliac joint is performed by pushing the ilia outward and downward in the supine position. The ilia should then be compressed midline to test the posterior sacroiliac ligaments. To evaluate ligamentous strain (i.e., Patrick's test), the patient's femur is flexed, abducted, and externally rotated while the contralateral side is held flush to the examination bed.

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