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.
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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.
Musculoskeletal Examination and Joint Injection Techniques
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.
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. Gradually abduct the leg as far as possible without producing motion of the pelvis. Abduction should be possible to 40 degrees or greater.
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Perform the same maneuver on the left leg. Rotation may be measured with both the knee and the hip flexed at 90 degrees. The opposite leg should be fully extended. Internal rotation is measured by moving the ankle outward, which should be possible to 40 degrees. External rotation is measured by moving the ankle inward, which should be possible to 45 degrees or greater. Rotation of the hip may also be measured with the patient lying prone on the table and the hip fully extended.
In this case the knee on the side being measured should be flexed to 90 degrees and fully extended on the opposite side. Flexion contracture of the hip is detected by flexing the opposite hip until the lumbar lordosis is flattened on the table. Ask the patient to cooperate in this examination by holding the flexed knee.
The leg on the side of the hip being examined is then slowly lowered to the table. If a contracture exists, this maneuver cannot be performed completely.
Hyperextension of the hip can be checked by asking the patient to lie prone on the table and slowly lifting the leg being examined; this should be possible to 15 degrees or greater. The musculoskeletal system is composed of muscles, bones, joints, and the other connective tissue components that join these structures.
Taken as a whole, the musculoskeletal system is the mechanism by which the body performs all mechanical functions. Each joint is designed to perform a specific set of motions, and there is a complicated system of muscles, tendons, bursae, etc. An abnormality in any of these structures will produce a malfunction.
Some of the most common problems in the musculoskeletal system as well as some characteristics that are helpful in arriving at a correct diagnosis are listed in Table Turn recording back on. National Center for Biotechnology Information , U. Boston: Butterworths ; Search term. Definition Table If abnormalities are detected in the musculoskeletal examination, there are several questions that the examiner should keep in mind while collecting and recording the data: Table Technique In examining the musculoskeletal system it is important to keep the concept of function in mind.
Upper Extremity Observe and palpate both hands and wrists, noting areas of color change, enlargement, and temperature change described elsewhere. Normal range of motion for the fingers: Distal interphalangeal joints digits 2—5 : 0 to 80 degrees of flexion. Spine Inspect the cervical spine for loss of the normal lordotic curve. Other maneuvers that might produce pain in a sacroiliac joint when inflammation is present are: Compression of the iliac crests: This is performed by asking the patient to lie on his or her side, placing firm downward pressure on the upper iliac crest.
If pain is produced by this maneuver in a sacroiliac joint, this can aid diagnosis; but the absence of pain does not rule out involvement of the sacroiliac joint. Jarring the sacroiliac joint: The patient is asked to lie on his or her side, facing the examiner. The inferior leg is flexed at the hip and knee, and the upper leg is fully extended.
Place your hand on the upper iliac crest and produce a sharp jar on the patient's flexed knee with the palm of your hand. Again, pain in a sacroiliac joint is considered a positive test, but a negative test does not rule out possible involvement of a sacroiliac joint. Passive hyperextension of the lower extremity: Ask the patient to move close to the edge of the examining table in the supine position.
With the patient fully relaxed, the examiner supports a lower extremity and slowly allows it to hyperextend passively over the side of the examining table. Lower Extremity The feet are inspected for abnormal coloration and localized areas of swelling. Fluid or effusion in the knee is perceived in two fashions: Use the left hand to compress the reflection of the joint capsule beneath the quadriceps tendon and the fingers of the left hand cupped around the lateral margin of the joint to compress the fluid if present beneath the patella.
Then use the right hand to exert downward pressure on the patella, producing a ballottement and a click as the patella strikes the femoral condyles. Small amounts of fluid can be perceived by producing pressure on the lateral surface of the joint in a stroking fashion to express fluid if present to the medial portion of the joint.
Pressure is then placed on the medial portion of the joint to produce a fluid bulge as the fluid is expressed back into the lateral portion. This same maneuver can be performed by stroking the medial surface to express the fluid and producing the bulge on the medial surface. Lateral stability is checked by asking the patient to extend the knee fully, grasping the inside lower end of the femur with the left hand and the tibia just above the ankle with the right hand. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.
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