‘The musculoskeletal system’ is not an independent, solitary entity, although the name suggests otherwise. It is generally understood to include a collection of bones, joints, muscles, and nerves and their functional interaction. The inseparable cohesion between the different organ systems often makes it difficult to make a primary distinction between an orthopaedic, neurological, vascular, psychogenic or internal medicine-based causes of a complaint. Consequently the diagnosis established is often no more than guesswork packaged in an impressive sounding name (PHS, lumbago) which covers a complex of poorly understood complaints. A systematically and conscientiously executed history-taking can often lend the key to the mechanisms that are at the basis of the complaint. Although this book is intended as a manual for practical skills, we certainly do not wish to ignore the history-taking. In most cases, pain is the symptom that initiates the visit to a physician. Ideally, during the explorative phase of the history-taking, the patient is given the opportunity to clearly describe the nature of the pain, how it is experienced, to what degree the symptom influences his daily life and what is expected from the physician. The specific history-taking is the phase in which the patient is asked about the modalities of the complaint (aetiology, provocation, course of the problem over time, triggers for improvement or deterioration, associated symptoms, radiation). In addition, the musculoskeletal system is assessed in more detail. Associated symptoms, such as paresthesia and loss of strength, indicate a need for further neurovascular examination; concomitant symptoms such as swelling, redness and movement limitations point in the direction of an inflammatory process and require additional haematological and biochemical investigations. It is important to realise that what may appear to be totally different symptoms (e.g. joint complaints with urethritis and/or eye complaints) can form part of one syndrome and may give reason for further clinical exploration. To complicate matters, a direct relation between the site where the pain is felt and the location of the pain-inducing process is not always present (‘referred pain’). Therefore, there are occasionally good reasons to examine certain systems further to explore the possibility of angina pectoris, gall bladder disease, Pancoast’s tumour, extrauterine pregnancy, irritation of the liver capsule, etc.
Just as the musculoskeletal system is stripped and dissected into anatomical structures, the examination will also be split into subsidiary examinations based on anatomy and kinesiology insights and knowledge. These examinations will be discussed below in an order that is based on two premises:
- The examination should be built up in a logical and systematic manner. It entails the following, schematically and in order of execution:
- inspection
- active movement (function) examination
- passive movement (function) examination
- muscle tests
- palpation
- specific tests
- circumference measurement
- neurovascular examination
Further discussion of these sections will follow later.
- The inconvenience to the patient should be kept to a minimum by making full use of the patient’s initial position (standing up, sitting down, lying down). If the sequence of the examination is adhered to too strictly, it may disrupt the relaxed nature of the examination and place additional burden on the patient. Furthermore, all the above-mentioned subsidiary examinations are not always indicated. In this book, the subsidiary examinations will be discussed in sequence.
The inspection
The visual observation effectively begins when the doctor and patient initially meet and ends when the patient closes the door after the consultation. The inspection is therefore an activity that is not limited to just the first part of the examination. There are, however, considerable advantages to explicitly dedicating part of the overall examination to inspection. To gain maximum information from this subsidiary examination, a number of conditions should be met:
- the patient should be sufficiently undressed;
- the patient should be placed in the correct starting position (standing up, sitting down, lying down); the instructions for the patient should be provided in a clear and unequivocal manner;
- the ambient temperature should be pleasant;
- there should be sufficient space and uniform lighting in the room;
- the examiner should be able to stand at sufficient distance from the patient (postural aspects in particular can only be assessed properly at a sufficient distance);
- there should be adequate measures in place to guarantee privacy.
During inspection the following four aspects should observed:
- Shape. The shape of the physical ‘appearance’ is predominantly determined by bones and joints, muscle and adipose tissue.
- Skin. Colour, hair, scars, vascular pattern and other aspects often provide important information about underlying disorders or abnormalities.
- Position. This involves everything related to posture, e.g. position of the lower leg in relation to the upper leg (genu varum/valgum/antecurvatum and recurvatum) or position of the sternum (pectus carinatum/excavatum) etc. It is advisable to initially examine the patient in their spontaneous starting position and only thereafter in the ‘anatomical position’. In the latter position the patient should stand up straight with the face and feet directed forward, and with the arms alongside the body and the palms facing forward.
- Movement. This includes both spontaneous movements (pulsations, fasciculations, tics, breathing movements) and voluntary movements. The latter are assessed during the active movement examination.
Left-right differences determine the degree of asymmetry and are expressed in terms of shape and/or position and movement (e.g. muscle atrophy). In some situations it is necessary to gain an objective impression by palpating the structures observed during inspection.
The active movement examination
The active movement examination is characterised by having the patient attempt to perform the required movement themselves, on the left and right side simultaneously if possible. The examination conditions are the same as those mentioned for inspection. Instructing the patient is of extra importance; this should be clear and unequivocal. If necessary, the examiner can demonstrate the desired movement. Naturally, space is very important, as a proper movement examination cannot take place in a confined space. Some patients require encouragement. During the examination, the focus should be on the following:
- the course of the movement (suppleness)
- the maximum range of motion
- occurrence of pain
- compensatory movements
- occurrence of crepitations, crunching, snapping noises (discoid meniscus; snapping hip).
The passive movement examination
The passive movement examination is characterised by having the patient fully relax while the examiner performs a certain movement on the patient. This is the most important condition for this examination, but in practice many patients find it impossible to relax fully. The examiner’s inventiveness and patience are regularly tested during this examination. Both the patient and examiner should be able to comfortably sit down or stand up. Another important condition is that the joint that is to be examined should be held correctly. Do this in such a way that:
- apart from the joint that is to be examined, as few other joints as possible are between the examiner’s hands;
- the desired movement can be carried out properly.
During the passive movement examination, attention should be paid to the following aspects:
- the course of the movement (interrupted course, e.g. with extrapyramidal disorders)
- the maximum range of motion (limitations)
- occurrence of pain
- occurrence of muscle resistance (antalgic)
- occurrence of crepitations, crunching, snapping
- left-right comparison for abnormal findings.
The muscle tests
If, in the case of pain symptoms in or around the joint (e.g. the shoulder), it is not entirely clear whether the pain symptoms can be ascribed to a tendon-muscular or capsular-arthrogenous cause or a combination of factors, you can ask the patient to tense a particular group of muscles against resistance offered by the examiner, without allowing any movement. The occurrence of pain during such a manoeuvre often points in the direction of a tendon-muscular cause. This suspicion is reinforced if, during passive movement, there is hardly any pain or no pain. If pain arises while testing the various muscle groups then (after comparing the left side with the right side) the examiner should test the various individual muscles as selectively as possible. The conditions for this examination are the same as those already mentioned for the inspection of the patient; it is particularly important that the patient is given precise and clear instructions. The paragraph at the end of this chapter describing neurological and vascular examination covers the examination of muscle strength. One should be aware that there is a considerable difference in how you examine muscles, depending on the intention. If they are examined ‘orthopaedically’ (i.e. does it hurt?) the test will be isometric and possibly only unilateral, whereas if the examination is ‘neurological’ (i.e. how powerful is the muscle strength?) the strength and left-right comparison are central themes. Occasionally a muscle or muscle group that is painful upon tension will contract less effectively as a result of the pain!
Palpation
Palpation should preferably be carried out following the inspection, the function examination and the muscle tests, to minimise the burden to the patient (logical transition to other starting positions and pain provocation in the later stage of the examination). In the case of abnormal findings, compare left and right. Specific additional information can be obtained with palpation. The conditions for achieving correct findings are identical to those mentioned for the inspection. In addition, the hands of the examiner should be warm and clean, with the nails clipped short. Both the examiner and the patient should be comfortably positioned before the examination commences. Although the aim is often maximum muscle relaxation in the patient, it can sometimes be useful to palpate both tensed and relaxed muscles. In many cases the presence of pain will make complete relaxation impossible. The following characteristics can be investigated by means of palpation:
- The skin temperature (preferably palpate with the back of the hand).
- The humidity level of the skin.
- Structure and elasticity of the skin.
- The characteristics of a tumour (borders, surface, size, mobility etc.) Sometimes it is useful, particularly if it is not clear whether there is a lipoma or a (muscle) hernia, to have the patient tense the muscle group in question. A lipoma will remain fairly mobile, whereas a hernia will harden. Also, tensing the muscles often clarifies the location of tendons and intramuscular and intermuscular septa.
- Location of tissues (such as muscle tissue, tendon tissue, nerve tissue, bone tissue, cartilage tissue, ligaments, blood vessels) and their characteristics, e.g. the tone of a muscle. Bone tissue feels solid and cannot be indented. The way a muscle feels will vary with the degree of stretch and contraction and also depends on the firmness of the fascia etc. The tone of a muscle is palpated by placing the fingertips transverse to the direction of the muscle fibres. Hernias (as a result of fascia defects) and pits or dimples (as a result of muscle rupture) should be palpated by placing the finger tips lengthwise along the muscle.
- Location of pain. With (suspected) inflammatory processes and acute trauma, the point of maximum pain intensity will indicate the location of the process precisely. It is important to realise, however, that with diffuse pain patterns and chronic problems palpation will sometimes result in misleading information (‘referred pain’).
- Axial compression pain. If a fracture is suspected, it is important to establish whether compression along the axis of the structure in question (conducted by the examiner) causes localised pain. In practice, if the history-taking suggests a clear suspicion of a fracture, the axial compression test is often carried out before the functional examination.
Specific tests
Specific tests concern all examinations that cannot be categorised in the above-mentioned subsidiary examinations or the neuro-vascular examination. These tests will be covered for each joint.
Recent evidence based research shows that the sensitivity and/or specificity of many classic specific tests is limited. A dependable diagnosis can rarely be made or discarded exclusively based on a specific test. A concienciously taken medical history, combined with physical examination and laboratory and/or radiographic examination, is always necessary.
Specific tests will continue to be incorporated in the physical-diagnostic examination considering the following reasons:
- practically: they are still being practiced in various medical centres
- didactically: they may help in giving more insight into the pathology being examined
- necessity: in areas where sophisticated diagnostic techniques are not available
Circumference measurement
If during inspection it becomes apparent that there may be atrophy of one or more muscles, or if the patient presents with symptoms of loss of strength, measuring the circumference is indicated.
Neurological and vascular examination
The pure neurological examination falls outside the scope of this book. It is covered extensively in another book from this series. The same applies to the examination of the peripheral circulation. Here, we will restrict ourselves to a note on the examination of muscle strength. Testing muscle(s) for strength is indicated in particular if the patient complains of loss of strength and/or when visible atrophy is identified during inspection. This atrophy can be quantified by means of circumference measurements. During the examination of muscle strength, the patient should tense the muscle as far as possible and the examiner should try to force an opposite movement (e.g., to test the strength of the biceps muscle: the patient holds the elbow in flexion, and the examiner attempts to extend the elbow). By making a left-right comparison, intra-individual differences in muscle strength of comparable muscles or muscle groups can be investigated.
Strength is scored on a scale of 0 to 5:
| 0 | no movement possible, muscle tension is not palpable |
| 1 |
the muscle is tensed (visible contraction) but there is no movement |
| 2 |
the patient can make a movement in the absence of gravity or if gravity |
| 3 |
the patient can overcome gravity |
| 4 |
the resistance from the patient is less than the examiner would expect |
| 5 |
the resistance provided by the patient is normal |