Joint musculoskeletal assessment

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

History and physical examination are the corner stones of a proper diagnosis. History will contribute up to 80% to the diagnosis, followed by physical examination (6%) and tests (14%).

Here are a few of the maneuvers used in assessing patients who have musculoskeletal disorders. This by no means a complete listing.

Patients who have knee instability may be assessed with the anterior drawer sign for cruciate ligament injury.

The knee is flexed to 90 degrees and the foot rested on the table. The femur is grasped with one hand while the tibia is pulled forward and the amount of movement noted. In normal subjects no forward movement is elicited.

A procedure used to evaluate a patient for meniscus tear is the Apley's test. The patient will lie prone on the examining table with one leg flexed to 90 degrees. While pushing down on the foot rotate the knee medially or laterally. Pain on either side will indicate a meniscal tear.

The Lachman Test is used to test for cruciate ligament injury in extension. If the knee after an acute injury cannot flex to 90 degrees the Lachman test should be performed.

The femur is grasped with one hand while the tibia is pulled forward and the amount of movement noted. In normal subjects no forward movement is seen.

A test for meniscus tears of the knee is the McMurray test.

The knee is flexed to 90 degrees; then foot is grasped and rotated internally or externally. The leg is then slowly extended while applying valgus stress. If an audible or palpable click is noted there is probably a tear of the medial meniscus present. This finding can be supported by pain of the medial knee joint line.

If there is a suspected injury involving the posterior cruciate in the knee, a Godfrey test may be performed. The examiner raises the patient's foot (hips and knees flexed 90 degrees) and views the tibial tubercle from the side. Posterior sagging of the tibia relative to the femur indicates significant PCL injury.

For patients who have pain involving the outside of the thumb, tendonitis affecting the abductor pollicis longus and brevis tendons is the usual cause. A Finkelstein’s maneuver will be performed. Instruct the patient to make a fist, with the thumb tucked inside of the other fingers. Stabilize the forearm with one hand and deviate the wrist to the ulnar side. If there is sharp pain in the area of the tendons, there is strong evidence for tenosynovitis.

Patients who have sacroiliac pain will have a Gaenslen's test done for detection of sacroiliac joint abnormalities The patient will lie supine on the examining table with both legs drawn to the chest. Then shift the patient to the side of the table so that one buttock extends over the edge while the other remains on it. Allow the unsupported leg to drop over the edge while the other leg remains flexed. SI joint abnormalities will elicit pain of the stressed joint.

The Patrick test (also known as the Faber test) is used to detect pathology in the hip as well as the sacroiliac joint. The patient will lie supine on the examining table. Place the foot of his involved side on the opposite knee. Pain in the inguinal area indicates hip disease. To stress the sacroiliac joint, extend the range of motion by pushing on the flexed knee as well as on the superior iliac spine of the opposite side. Pain in the sacroiliac joint line indicates abnormalities.

Shoulder pain is a common complaint. In the test for the Hawkins sign, the patient flexes the humerus forward to 90 degrees. The examiner places the shoulder in horizontal adduction and internal rotation. Pain is caused by impingement on the rotator cuff.

When a rotator cuff impingement is suspected, a specific maneuver called the Neer test is done. To test for the Neer impingement sign, the examiner elevates the humerus with one hand while depressing the scapula to restrict movement with the other. Pain at greater than 120 degrees of forward flexion constitutes a positive result

Yergason Test is done to test for biceps tendon stability in bicipital groove. The elbow is flexed to 90 degrees, the patient is asked to resist while externally rotating the arm. A positive test result is indicated by a snap and pain when the biceps tendon slips over the lesser tubercle

Speed’s maneuver is done to also assess biceps tendon for inflammation. The patient is asked to extend the arm forward with the palm facing up. Resisted elevation of the arm will produce pain in the anterior shoulder in patients who have bicipital tendonitis.

Spurling sign for testing cervical radiculopathy goes like this… The patient laterally bends the neck to each side while maintaining cervical extension. Pain intensified with ipsilateral bending strongly suggests a diagnosis of radiculopathy. Pain with contralateral bending suggests a musculo-ligamentous origin.

The Steinberg Test is used for the clinical evaluation of Marfan patients. Instruct the patient to fold his thumb into the closed fist. This test is positive if the thumb tip extends from palm of hand.

The Walker-Murdoch Sign is used for the evaluation of patients with Marfan syndrome. Instruct the patient to grip his wrist with his opposite hand. If thumb and fifth finger of the hand overlap with each other, this represents a positive Walker-Murdoch sign.

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