Examination of the

Joints and
Extremities
Evelyn O. Salido, MD, FPCP, FPRA
Internal Medicine and Rheumatology
January 2009
Objectives in doing MSS PE
 To screen for MSS problems among
asymptomatic and symptomatic individuals
 To determine if complaint in the back or limb is
due to a MSS problem
 To localize the MSS problem- intra or
periarticular
 To diagnose
Who should be examined?

 Musculoskeletal complaints
 Pain

 Deformity

 Disability (loss of function)

 Individuals consulting for other complaints
What should be examined?

Scope of the examination

 Back
 Upper Extremities
 Lower Extremities
 Systemic PE
Physical Examination will tell us …
 Source of pain
 Inflammatory or not
 Pattern and extent of
joint involvement
 single, few, multiple
 axial, appendicular
 distal vs proximal, small
vs large
 Localized or systemic
Requirements for a good PE
 Enough room and light
 Sufficient exposure of parts to be
examined while considering privacy
 Relaxed and comfortable patient and
examiner
 Good working knowledge of anatomy
 Adequate medical history
Physical Exam
MUST REMEMBER!!!
 Examine each joint, not only the source of
complaint.
 Assess each joint separately.
 Perform an orderly exam including the spine,
the upper and lower extremities.
 Proper positioning- as appropriate to the
examination being done
Maneuvers in the PE
 Inspection
 Palpation
 Range of motion
 Measurements
Inspection: still & in motion
 Posture  Swelling
 Contours
 Symmetry
 Redness
 Deformities  Skin lesions
 Atrophy/hypertrophy  Instability
 Masses or nodules
 Abnormal movements
Posture, Contour, Symmetry
Deformity
Swelling and Redness
Redness, Skin Lesion
Masses & Nodules
Discrepancies e.g. Atrophy
 Localized
 Generalized
 Document by
measuring limb
circumference
Instability
 Diseased joints are able to move into abnormal
positions
 due to joint surface damage or to laxity of
ligaments
 passive maneuver by examiner
 observation of active movement during
weightbearing and walking
 wobbling, “movement” of bones, “giving-way”
Maneuvers in the PE
 Inspection
 Palpation
 Range of motion
 Measurements

Palpate the joint, surrounding

tissues and the muscles of the
limbs and back
Palpation

 Increased Warmth
 Tenderness
 Swelling- bony, soft tissue, effusion
Tenderness

 Unusual sensitivity to touch or pressure

 Grade I- pain only

II- pain and wincing
III- wincing and withdrawal
IV- palpation not tolerated
 Swelling
 Bony swelling- osteophyte
& new bone formation
 Synovitis- edematous
synovium, boggy swelling,
usually tender
 Effusion- excessive fluid in
joint cavity, bulge sign
Swelling
 Localized periarticular swelling
 does not communicate with main joint cavity
infrapatellar bursitis
 Pitting edema of tissues over a joint
Maneuvers in the PE
 Inspection
 Palpation
 Range of motion
 Measurements
Range of motion

 Requires knowledge of normal motion

of particular joints
 Active or Passive
 When should ROM test be deferred
Limitation of Motion
 Comparison with an unaffected joint of the
opposite extremity to evaluate individual
variations
 Increased muscle tension may result in what
appears to be significant decreased ROM
 May be due to limitation in the joint itself or the
periarticular structures
 Active motion limited- joint or periarticular
problem
 Only active motion limited-periarticular problem
Crepitus
 palpable &/or audible grating or crunching
sensation produced by motion.
 arises when roughened articular or extra-
articular surfaces are rubbed together by
active motion or by manual compression
 fine or coarse – depending on rough the
opposing cartilage surfaces are
 differentiate from cracking sounds caused by
the slipping of ligaments or tendons over
bony surfaces- normal joints
Doing the Actual PE

Rapid Screen- GALS

Extensive PE
GALS Step 1- Ask 3 basic questions

 Have you any pain or stiffness in your muscles,

joints, or back?
 Can you dress yourself completely without any
difficulty?
 Can you walk up and down stairs without any
difficulty?
GALS Step 2- Gait

 Symmetry
 Smoothness of
movement
 Normal stride length
 Normal heel strike,
stance, toe-off, swing
through
 Able to turn quickly
Heel Strike, Stance, Toe Off, Swing
width of the base should be 2-4 in from heel to heel
flexion of the knee during toe off and swing
GALS Step 3- Inspection from Behind

 Straight spine
 Normal & symmetric paraspinal
muscles
 Normal shoulder & gluteal
muscle bulk
 Level iliac crests
 No popliteal cysts nor swelling
 No hindfoot swelling or
abnormality
 GALS Step 4: Inspection from the side

 Normal cervical & lumbar

lordosis
 Normal thoracic kyphosis
 GALS Step 5. “Touch your toes.”

 Normal lumbar spine

(and hip) flexion
GALS step 6: Inspection from the
front- Arms
Place your hands
 behind your head (elbows out)- normal glenohumeral,
sternoclavicular, & acromioclavicular joint movement
 by your side (elbows straight)- full elbow extension
 In front (palms down)- no wrist/finger swelling or
deformity; able to fully extend fingers
Turn your hands over- normal supination/pronation; normal
palms
Make a fist- normal grip power
Place the tip of each finger on the tip of the thumb- normal
fine precision, pinch
GALS step 6: Inspection from the
front Spine
 “Place your ear on your
Legs shoulder.”
 Normal quadricep
Normal cervical lateral
bulk/symmetry flexion
 No knee swelling or
deformity
 No forefoot/midfoot
deformity
 Normal arches
 No abnormal

callous formation
Regional Examination

Back
Upper Extremities
Lower Extremities
Back
 Look: Contour, Deformity,
Mass, Skin lesion
 Feel: spinous processes,
paravertebral muscles, SI
joint
 Move: cervical, lumbar;
Schober’s test for spine
flexibility
Back: Look
1="Vertebra 1= Cervical
prominens" lordosis
Spinous process
of C7
2=Thoracic
2= 2nd Lumbar kyphosis
vertebra
3= Lumbar
3= L4-5 inter lordosis
vertebral space
4= Sacral
4= Iliac crests
kyphosis
5= Dimples of
Venus / Sacroiliac
joints
Back: Feel & Move
Back flexibility: Schober’s test
TMJ
 Look  Put picture here
 Feel
 Move
Shoulder
Inspection
 Look for symmetry
between both shoulders
 Check the skin for any
signs of current or past
pathology
 Identify the clavicle,
deltoid & biceps muscles,
bicipital groove, scapula
Shoulder
 Palpation
 Assess the soft tissue tone, consistency, size
and shape of muscles, and tenderness
 Check the axilla for lymph nodes
 Shoulder

Look- swelling,
redness
Feel- tenderness
Move-
circumduction
Elbow Humero-ulnar joint (hinge) is main articulation,
radio-ulnar & humero radial

In a staight arm, the

"elbow bump" can be
In a bent arm, at, and sometimes
the triangle is even above, the
quite condyles.
pronounced.
Elbow joint
Inspection
 With palms facing anterior or in
anatomic position, note the
valgus angle made by the
forearm and the upper arm
Palpation
 Palpate the bony structures:
Medial and lateral epicondyles,
Medial and lateral supracondylar
line of the humerus, Olecranon &
Radial head
 Palpate the soft tissue structures
 Medial aspect: ulnar nerve, wrist  Range of motion:
flexors and pronators  flexion, extension at humeroulnar
 Posterior aspect: olecranon articulation
bursa, triceps muscles  forearm supination, pronation at
 Lateral aspect: wrist extensors, proximal and distal radioulnar
lateral collateral ligament, joints
 passive
annular ligament
 Anterior aspect: cubital fossa
 Wrist and Hand

•True wrist/radiocarpal
articulation- biaxial ellipsoidal Palmar flexion & dorsiflexion
joint (radius, triangular
fibrocartilage, 3 carpal bones) Radial & ulnar deviation

•Distal RU joint is a pivot joint Pronation & supination

Wrist
 Keep in mind that there are 6 dorsal
passageways and 2 palm tunnels through
which pass nerves, arteries, veins and
tendons.
 Some anatomic structures worth
mentioning are the carpal tunnel and the
median nerve
Wrist
 Palpation  Range of motion
 Bone palpation includes  Flexion (80 degrees from
the following: neutral)
 Radial and ulnar styloid  Extension (70 degrees
processes from neutral
 Tubercle of the radius  Ulnar and radial deviation
 Bones of the wrist: eight
carpal bones
 Scaphoid, navicular,
lunate, triguetrum
pisiform, trapezium,
trapezoid, capitate,
hamate
Hand
 Inspection
 Ventral surface:
creases, thenar and
hypothenar
eminences, MCP joint
area
 Dorsal surface: MCP
and soft tissue
“valleys,” DIP’s and
PIP’s, fingernails
MCPs
Hand
 Palpation Range of motion
 Thenar and hypothenar  MCPs- hinge joints
eminences  Fingers: Abd 20°, Flex
 Palm aponeurosis (make a fist to touch palm
 Flexor and extensor crease), Add, Ext
tendons  1st CMC joint- saddle-
 Fingers: dorsal and palm
shaped
surfaces of MCP, PIP and
DIP joints
 Thumb: opposition,
flexion/extension,
 Fingernails and nail fold
abduction and adduction
capillaries
 Hip

Inspection: pelvic tilt,

rotational deformity, muscle
wasting, leg length
Palpation: anterior joint line,
greater trochanter, ischial
tuberosity
Range of motion (ball &
socket joint)- F,E,Ab,Ad,R
 Knee
10 Quadriceps
femoris tendon
1 Patella
4 Fibular head
11 Patellar
ligament
5 Anterior tibeal
tuberosity

Look- swelling, bulges 18 Hamstring muscle

Feel- including bulge test group
Move- flexion-extension only 19 Calf muscle
Ligaments
What is wrong here?

Test for effusions: Bulge test & Patellar ballotment

Stability of Collateral Ligaments
 Medial collateral ligaments- abduction or valgus
test
 Medial joint line separation with knee extended- tear
of MCL & PCL
 Positive when knee flexed 30°- MCL tear only
 Lateral collateral ligament- adduction or varus
stress tests
 Lateral joint line separation with knee extended- tear
of LCL & PCL
 Positive when knee flexed 30°- LCL tear only
Cruciate Ligaments: Drawer test
 Hip flexed 45°, knee flexed 90°
 Examiner stabilizes the knee
 Sitson the foot while grasping the posterior calf with
both hands or
 Supports lower leg between his lateral chest wall &
forearm
 Anterior drawer test- pull tibia forward
 Posterior drawer test- push tibia towards patient
 >6 mm of movement- cruciate ligament laxity or
tear
Test for meniscal tear
locking during joint extension, clicking or popping during
motion, localized tenderness along lateral or medial joint line

Mc Murray test- tear esp at posterior half of menisci

 Knee in full flexion
 Examiner places hand over knee with fingers along the side
of the knee over the joint line & the thumb at the other side
 Other hand holds leg at ankle and is used to rotate the leg
medially or laterally to apply stress.
 Can be done repeatedly with knee in decreasing degrees of
flexion
 Audible or palpable snap indicates a tear
Ankle and Feet

True Ankle joint- distal ends of tibia

& fibula and proximal part of body
of the talus
- hinge joint; dorsi & plantar flexion
Subtalar joint- inversion & eversion
Toes
Maneuvers in the PE
 Inspection
 Palpation
 Range of motion
 Measurements
Measurement
Reporting Your Findings
 Inspection
 Palpation
 Range of Motion
 Measurements
Objectives in doing MSS PE
 To screen for MSS problems among
asymptomatic and symptomatic individuals
 To determine if complaint in the back or limb is
due to a MSS problem
 To localize the MSS problem- intra or
periarticular
 To diagnose
Articular vs Non-articular
Disease
ARTICULAR EXTRA-ARTICULAR
ROM pain on active & more on active &
passive motion specific motion

Tender jt surface over bony

ness circumference prominences
along tendons

Pain generalized, well-localized

poorly localized superficial
Evaluation of patient with
musculoskeletal complaint
 Logical differentials
 Accurate diagnosis
 Performance of necessary diagnostic
tests
 Timely provision of appropriate
therapy
 Deformity
 Inability to carry out normal ROM
e.g. flexion deformity of knee
 Malalignment of articulating bones without
change in articulation e.g. ulnar deviation
of fingers
 Malalignment due to altered relationship
between articulating surfaces
e.g. subluxation, dislocation