Which assessment findings are common symptoms of musculoskeletal impairment?

Caveats

The musculoskeletal (MSK) examination confirms the diagnostic impression and lays the foundation for the physiatric treatment plan. It incorporates inspection, palpation, passive and active ROM, assessment of joint stability, manual muscle testing, joint-specific provocative maneuvers, and special tests (Table 1.8).29,36,46 The functional unit of the musculoskeletal system is the joint, and its comprehensive examination includes related structures, such as muscles, ligaments, and the synovial capsule.47 The MSK examination also indirectly tests coordination, sensation, and endurance.29,50 There is overlap between the examination (and clinical presentation) of the neurologic and musculoskeletal systems. Neurologic disease may lead to secondary musculoskeletal complications of immobility and suboptimal movement. The MSK examination should be performed in a routine sequence for efficiency and consistency and must be approached with a solid knowledge of anatomy. Of importance is that the MSK examination is largely subjective. Close attention should be paid to objective findings such as atrophy, instability, or joint effusion or deformity. The reader is referred to several references that provide in-depth reviews of the MSK examination.a

Musculoskeletal Examination

The integrity of the tendons is individually tested (Fig. 70.11). Flexion at distal joints of the thumb and fingers confirms that the FPL and FDP, respectively, are intact. Testing of FDS tendons is more complex. It is not possible to flex the DIP joints independently of one another because of a common origin of the FDP tendons. Thus, the other fingers are fixed in extension by the examiner, and the patient is asked to flex the remaining digits. Movement is produced by the FDS and occurs at the PIP joint. In approximately one third of patients, the FDS cannot produce little finger flexion. In 50% of these, in turn, there is a common origin with the ring finger, so flexion will occur if the ring finger is permitted to flex simultaneously. More uncommonly, there is no profundus tendon to the little finger and the superficialis inserts into the middle and distal phalanges. The long and short extensors (EPL and EPB) and the long abductor of the thumb are tested by asking the patient to extend his or her thumb against resistance while these tendons are individually palpated. Long extensors of the fingers are tested by asking the patient to extend them against resistance applied to the dorsum of the proximal phalanx.

A closed boutonnière jamming injury may be difficult to initially diagnose. In this type of injury, the central slip insertion is disrupted from the middle phalanx and the triangular ligament on each side of the central slip is stretched or disrupted. The lateral bands then migrate volar. It takes time for this deformity to evolve. Initial presentation may not be immediately obvious until the lateral bands subluxate volarly and create the obvious boutonnière problem with PIP joint flexion and DIP joint hyperextension. The Elson test may help make this diagnosis. Normally, with the PIP joint blocked in flexion, one cannot actively extend the DIP joint because of slack in the lateral bands (Fig. 70.12).

Musculoskeletal System

The musculoskeletal examination in adult patients is almost always driven by symptoms (Chapters 264 and 271Chapter 264Chapter 271). Most patients have back pain at some point during their lives (Chapter 407). Back pain is second only to upper respiratory illness as a reason for seeking outpatient care. Most patients’ musculoskeletal discomfort will be self limited. The patient's history helps assess the likelihood of an underlying systemic disease (age, history of systemic malignancy, unexplained weight loss, duration of pain, responsiveness to previous therapy, intravenous drug use, urinary infection, or fever). The most important physical examination findings for lumbar disc herniation in patients with sciatica all have excellent reliability, including ipsilateral straight leg raising causing pain, contralateral straight leg raising causing pain, and ankle or great toe dorsiflexion weakness (all with κ > 0.6).

The generalist physician should evaluate an adult patient with knee discomfort for torn menisci or ligaments. The best maneuver for demonstrating a tear in the anterior cruciate ligament is the anterior drawer or Lachman maneuver, in which the examiner detects the lack of a discrete end point as the tibia is pulled toward the examiner while the femur is stabilized. A variety of maneuvers that assess for pain, popping, or grinding along the joint line between the femur and tibia are used to evaluate for meniscal tears. As with many musculoskeletal disorders, no single finding has the accuracy of the orthopedist's examination, which factors in the history and a variety of clinical findings.

The shoulder examination is directed toward determining range of motion, maneuvers that cause discomfort, and assessment of functional disability. Hip osteoarthritis is detected by evidence of restriction of internal rotation and abduction of the affected hip. Generalist physicians often rely on radiographs to determine the need for referral to orthopedic physicians, but routine radiographs are not needed early in the course of shoulder or hip disorders. The degree of pain and disability experienced by the patient may prompt confirmation of the diagnosis and referral.

The hands and feet may show evidence of osteoarthritis (local or as part of a systemic process) (Chapter 270), rheumatoid arthritis (Chapter 272), gout (Chapter 281), or other connective tissue diseases. In addition to regional musculoskeletal disorders, such as carpal tunnel syndrome, a variety of medical and neurologic conditions should prompt routine examination of the distal ends of the extremities to prevent complications (e.g., diabetes [neuropathy or ulcers] or hereditary sensorimotor neuropathy [claw toe deformity]).

Musculoskeletal Examination

Like the neurological examination discussed previously, the musculoskeletal examination is often a very important part of an evaluation. Questions in the history related to this examination include the following48,77–81:

Have you ever pulled (strained) or hurt a muscle?

Have you ever torn (sprained) or stretched a ligament?

Have you ever subluxated or dislocated a joint or had a bone come out of joint?

Have you ever broken (fractured) a bone?

Have any of your joints ever swollen?

Have you ever had pain in your muscles or joints at work or during or after activity, exercise, or sports (Table 17.4)?

Have you ever had regular prolonged (more than 30 minutes) morning stiffness?

Have you ever had any rashes, eye infections, diarrhea associated with joint pain, and/or swelling?

Have you ever had any proximal weakness, excessive cramping, or muscle fasciculations?

A positive response to any of these questions requires further investigation.

The musculoskeletal examination begins with observation of the patient’s posture (seeChapter 15), looking for any asymmetry. Asymmetry, combined with the history, may lead the examiner to do a detailed assessment of a specific joint (seeChapters 3 to 13Chapter 3Chapter 4Chapter 5Chapter 6Chapter 7Chapter 8Chapter 9Chapter 10Chapter 11Chapter 12Chapter 13). If no problems are noted, the examiner can do a quickupper and lower scanning orscreening examination to check for potential problems and abnormal movement (e.g., hypomobility, hypermobility, capsular patterns, weakness, abnormal movement patterns, “cheating movements”).65,82

Upper and Lower Scanning Examination

Cervical spine: flexion, extension, side flexion, rotation

Shoulder shrug (resistance may be added)

Shoulder: elevation through abduction, forward flexion and the plane of the scapula; medial and lateral rotation (resistance may be added)

Elbow: flexion, extension, supination, pronation

Wrist: flexion, extension, radial, and ulnar deviation

Fingers and thumb: open hands wide, make a tight fist

Thoracic and lumbar spine: flexion (touch toes, knees straight—watch for spine versus hip movement), extension, side flexion, rotation

Tighten quadriceps (quadriceps strength, symmetry)

Test hamstring tightness

Hip, knee, ankle, and foot: squat and bounce, heel-toe walking

Neuromuscular and General Examination

A thorough musculoskeletal examination should include inspection, palpation of soft tissues surrounding the joint of interest, and assessment of both muscle strength and flexibility. First, gait should be observed. There may be an antalgic gait or a slow gait pattern because of pain in a specific joint. If the patient uses a cane, appropriate use of the cane should be assessed during gait.

Both functional strength and manual muscle testing should be performed. Periarticular muscle atrophy and weakness may be present in chronic OA, but functional tests like sit-to-stand testing, which often provokes pain in OA of the knee and hip, may be more informative. Palpation and dynamic testing of soft tissues may differentiate pain from tendinopathy or bursitis from OA. Joint-specific provocative maneuvers may help to isolate the source in symptomatic patients with poorly localized pain. A careful neurologic examination should be performed to make sure that pain is not due to nerve impingement or a neuropathic process.

Clinicians may also consider performing a general examination. Evaluation of other systems may also help to differentiate primary OA from secondary OA due to a systemic process. Because obesity is the most important modifiable risk factor for OA, assessment of the patient’s body mass index is essential.

Physical Examination of the Pelvic Floor

A thorough musculoskeletal examination of the lumbar spine, hips, pelvic girdle, lower limbs, and PFMs will guide the differential diagnosis. The pelvic floor examination consists of a vaginal and rectal examination of PFM function and a neurologic examination of the lower sacral segments. A musculoskeletal pelvic floor examination does not obviate the need for gynecologic, urologic, or colorectal evaluation because visceral structures are not typically evaluated. Verbal consent from the patient is required. The examination should occur in a private examination or treatment room.

The musculoskeletal pelvic examination begins with external inspection for swelling, cysts, scars, and lesions that may necessitate appropriate referral to another specialist. Next, the examiner visualizes the lift of the perineal body with a voluntary contraction (termed a Kegel contraction) and involuntary contraction (cough) as well as normal descent of the perineal body with voluntary relaxation and then involuntary relaxation (Valsalva maneuver). In women, the vaginal vestibule is evaluated for any visible organ prolapse. The Q-tip test for vulvodynia is performed by lightly touching a cotton swab at vulvar and vestibular sites to elicit any pain or allodynia. The examiner proceeds to an external sensory examination of the S2 to S5 sacral dermatomes (see Fig. 38.3). An anal wink reflex is obtained near the anus to test the sacral reflex arc. The superficial PFMs are palpated for any tenderness.

Next, the examiner moves on to an examination of the internal pelvic floor; both vaginal and rectal examinations may be performed. It is best to use a flat examining table without stirrups. The vaginal examination is performed in hook lying position, supine with the knees bent, and ankles hip-width apart. The rectal examination is typically performed in a left lateral decubitus position.

One lubricated gloved finger is inserted into the vaginal introitus or anal canal to palpate the PFMs internally. A clock-face diagram is useful to correctly identify the anatomic positions of the PFMs, with the pubic bone at 12 o’clock and the anus and coccyx at 6 o’clock (Fig. 38.4). The levator ani can be palpated on both vaginal and rectal examinations from 1 to 5 o’clock on the left and 7 to 11 o’clock on the right, with the pubococcygeus located more anteriorly and the iliococcygeus located more posteriorly. The obturator internus is located just above 3 o’clock on the left and 9 o’clock on the right and is separated from the levator ani by locating the arcus tendineus, which feels similar to a guitar string on palpation (see Fig. 38.2). The obturator internus can also be identified by having the patient rotate the hip externally to activate the muscle, causing it to bulge medially, which can be appreciated with internal digital palpation. Rectal examination affords the ability to additionally assess anal sphincter tone as well as the coccygeus, piriformis, and puborectalis muscles. The puborectalis, forming the innermost portion of the anal canal, can easily be appreciated. The coccyx can be examined intrarectally to assess for tenderness, mobility, and anterior or lateral deviation. The PFMs are palpated for tenderness, taut bands, and referring trigger points. The presence of intramuscular scar tissue should be noted. PFM tone can be assessed as either an increased or decreased resting state of the muscle. A Tinel sign can be obtained by tapping over the pudendal nerve as it courses inferior to the ischial spine and may provoke pelvic floor or perineal paresthesias.

Voluntary contraction of the PFMs that occurs upon demand is felt as a tightening, lifting, and squeezing action under the examining finger.111 Voluntary contraction is graded with the modified Oxford scale.56 Similar to manual muscle testing for limb muscles, the scale ranges from 0/5, signifying “absent” contraction, to 5/5, which implies that the patient is able to “lift, tighten, and maintain for 10 seconds” (Table 38.3). Strength testing should be performed in four quadrants, especially in patients with neurologic deficits such as hemiplegia. Endurance is tested by asking the patient to hold a full contraction for 10 seconds. Coordination is tested by performing “quick flicks” or asking the patient to contract and relax the PFMs rapidly. Voluntary relaxation of the PFMs is felt as a termination of the contraction as the muscles return to their resting state. The examiner then has the patient cough, to look for the presence or absence of involuntary contraction, and then to perform a Valsalva maneuver, to look for presence or absence of involuntary relaxation. It is important to assess for dyssynergia or inappropriate contraction of the PFMs during attempts at Valsalva.

Physical Examination

A neurologic and musculoskeletal examination is carried out in evaluation of a patient with symptoms of radiculopathy or radicular pain. Fig. 89.7 illustrates the clinical features of disk herniation at various levels.91 Objective neurologic signs of radiculopathy, with dermatomal abnormalities, myotomal weakness, reflex inhibition, and positive straight leg raising, indicate radiculopathy. The clinical examination does not differentiate, however, among a multitude of causes in disk herniation even though a few of the causes were described previously from all the tests; straight leg raising has the best sensitivity, but low specificity.92 The other clinical tests have modest to poor sensitivities and specificities. Combinations of multiple tests considered together also have not been shown to improve likelihood ratios.92 During the history and physical examination, the following three elements are important in the diagnosis of lumbar disk herniation:

Predominant leg or radicular pain below the knee in a dermatomal distribution

Nerve root tension signs with straight leg raising between 30 and 70 degrees or a positive cross-leg straight leg raising

Corroboration of neurologic signs with muscle weakness and wasting, sensory impairment, and reflex suppression

The physical findings may be corroborated with imaging or electrophysiologic studies.

Examination/Imaging

▪

Neurologic and musculoskeletal examination.

Preoperative imaging should include plain radiographs (Fig. 1A), computed tomography (CT) (Fig. 1B), and magnetic resonance imaging (MRI) (Fig. 1C) and magnetic resonance angiography (MRA) of the cervical spine.

Radiographs should include anteroposterior (AP), lateral, open-mouth, and supervised dynamic lateral flexion and extension views. Combined lateral mass displacement in excess of 7 mm or an atlantodens interval greater than 3 mm suggests transverse ligament disruption.

A CT scan with axial, sagittal, and coronal thin-cut (1-mm) reconstruction images through the upper cervical spine is an important part of preoperative planning.

It provides accurate detail of the bony anatomy and any associated injuries.

It delineates the position of the foramen transversarium through which the vertebral artery runs.

It allows you to measure the length of the screws that will be utilized in the C1 lateral mass and C2 pedicle.

Approximately 20% of patients requiring atlantoaxial fusion using the transarticular or Harms technique show anatomic variations in the path of the vertebral artery and osseous anatomy that would preclude screw placement (Jun, 1998; Madawi et al., 1997). In addition to evaluating vertebral artery dominance, CT or MRA can delineate the spatial relationship of the vertebral artery relative to the C1 lateral mass and C2 pedicle.

MRI allows enhanced visualization of any soft tissue injuries including injury to the transverse atlantal ligament, as well as visualization of the spinal cord.

Odontoid fractures with transverse atlantal ligament injury can be addressed with a posterior fusion. Anterior odontoid screw fixation alone will not restore atlantoaxial stability secondary to transverse ligamentous disruption.

In rheumatoid patients, it is also useful to identify a pannus posterior to the odontoid that could compress the cord with any posterior translation of the dens.

Treatment Options

C1-2 transarticular facet screws (Magerl technique)

Gallie “bone block” graft placed posteriorly between the arches of C1 and C2, secured with sublaminar wires

What is the most common symptom of a musculoskeletal disorder?

What are the signs and symptoms of musculoskeletal disorders?

Which of the following findings in a musculoskeletal assessment would be considered abnormal?

What is in a musculoskeletal assessment?