SCrEEnIng ChECklIST

Standing: q inspect from front

q inspect from behind
q cervical spine extension, flexion, rotation,
lateral flexion
q chest expansion (costovertebral movement)
q lumbar flexion, extension, lateral flexion
q observe gait
The Musculoskeletal
Sitting: q inspect dorsum of hands, finger extension Screening Examination
q MCP flexion
q PIP, DIP flexion
q inspect palms
q arm forward flexion, pronation
q wrist flexion, extension
q forearm supination, elbow extension
q elbow flexion, extension
q inspect shoulders
q observe active shoulder abduction, external
rotation, internal rotation
q compare passive shoulder abduction,
external & internal rotation
q assess temporomandibular joint movement

Lying: q hip flexion, internal rotation, external rotation John M. Thompson MD FRCPC
q knee flexion & extension
q assess for knee effusion and Ainsley Walton
q ankle dorsiflexion & plantar flexion
q assess subtalar inversion and eversion
q screen for MTP pain

02CB21E
Contents
Dedicated To
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.1 hugh little MD FrCPC
Patient Standing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.3 mentor, colleague and friend
Patient Sitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.12
Patient lying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.26
The Financial assistance of
The Arcangelo Rea Family Foundation
is gratefully acknowledged

Supported by an educational grant

from Pfizer Canada Inc.

Written By
Thanks to
John M. Thompson MD FrCPC
Division of rheumatology karen and John hueston of the Aylmer Express
Department of Medicine Anne lyddiatt
Faculty of Medicine and my colleagues in the Division of rheumatology
University of Western Ontario

St. Joseph’s hospital

268 grosvenor Street
london, Ontario n6A 4V2

Illustrated By

Ainsley S. Walton

©1998 by John M. Thompson

Unauthorized duplication of these materials is strictly prohibited.

 THE SCREENING MUSCULOSKELETAL EXAMINATION

his rapid, systematic “once-over” is organized to detect deviations from the normal. If
T any are found, they can be more closely scrutinized through joint-specific examination.
There is no “gold standard” screening examination — but this is one that most physicians
would agree is reasonably comprehensive.
This examination can be carried out quickly. Once mastered, it should take less than 5
minutes, and can be integrated smoothly into the general physical examination.
The order described here — the patient standing, then sitting, then lying supine — differs
from the sequence “sitting - lying - standing” preferred by many. However, by placing the
“standing” component first, lower extremity abnormalities that may be obvious only on
weight-bearing can be detected. Joints so singled out can then be subject to close attention
when the patient is lying.

BASIC PRINCIPLES Humans are bilaterally symmetrical. As the examiner moves from one
area to another, one side is compared not just to an ideal
“normal”, but to the other side.
Observation and comparison, as each area is examined in
sequence, is particularly useful in determining if there are
abnormalities of
• alignment of one bone on another
• muscle bulk
• joint swelling
• the range of motion the patient can carry out
(this is termed “active movement”)
Palpation adds specific information regarding
• joint warmth — usually signifying inflammation
• joint tenderness
• joint effusion — indicating the presence of fluid within the joint
• crepitus — palpable or audible “grinding” as a joint is moved.
— Crepitus may be bony, cartilaginous, or synovial.
• joint instability
• restricted range— here the examiner attempts to take the joint
— through its normal range (“passive movement”)
— and compares this to the active range

The Screening Musculoskeletal Examination 1

 PATIENT The patient should remove all but underclothing. A gown, tied at
PREPARATION the back of the neck, allows for both warmth and modesty. When
the shoulders are being examined, the arms may be slipped out of
the sleeves. A woman may tuck the gown into the top of her bra.
Listed, in sequence, is a rational order of examination. For each step
there is a suggested verbal command. It is often effective, however, to
show, as well as tell, the patient what is wanted. Thus, when
assessing shoulder abduction and external rotation, instruction is
combined with demonstration —- “put your hands behind your head
like this — now elbows way back like this — and stick out your chest
like this.”

SEQUENCE OF EXAMINATION
PATIENT • assessment modality: active movement
STANDING • integrate with lower body neurological assessment,
• especially muscle strength

PATIENT • assessment modality: both active and passive movement

SITTING • integrate with vital signs, head and neck, thorax, neurological

PATIENT • assessment modality: passive movement

LYING • integrate with cardiovascular, abdomen, genitalia, nodes

2 The Screening Musculoskeletal Examination

 STEP 1.
I PATIENT STANDING Inspect the patient from the front

Direction: “raise your gown to mid-thigh, and stand

with your feet slightly apart facing me.”

Observe: Comment:
thigh muscle mass, ■ quadriceps wasting often
symmetry accompanies knee arthritis

knee alignment ■ “bow-leg” = genu varus

■ “knock-knee” = genu valgus
■ hyperextension = genu recurvatum

knee swelling ■ look for suprapatellar bulging,

filling in of medial and lateral
parapatellar “gutters”

ankle alignment ■ neutral, varus, valgus

ankle swelling ■ malleoli should be sharply defined

longitudinal arch ■ “flat foot” = pes planus

toe alignment ■ “bunion” = hallux valgus

■ “hammer toes”
■ “claw toes”

toe swelling ■ “sausage toe” = dactylitis

The fine print:

• Knee varus or valgus may be normal for an individual. It may also result from arthritic change in
either the medial tibiofemoral compartment (causing varus) or lateral tibiofemoral compartment
(causing valgus).
• Knee valgus is often linked to patellofemoral pain, and crepitus, presumably because the angulation
leads to abnormal gliding of the patella between the femoral condyles as the knee moves through
flexion and extension.
• Genu recurvatum (that is, the knees hyperextend past 180°) is particularly common in young
women. It may be part of a general tendency to joint hypermobility. Elbows, fingers, and thumbs
may also bend backwards. Such an individual may be able to place, with knees straight, palms
flat on the floor. Such hypermobility may be a source of joint pain.
• Dactylitis of a toe (or a finger) is most commonly seen in psoriatic arthritis. The swelling is usually
red or purplish in colour and can be mistaken for infection.

I Patient Standing 3
 STEP 2.
I PATIENT STANDING Observe the patient from behind

Direction: “Now turn around so that I can

look at your spine”

Observe: Comment:
spinal curves in sagittal ■ cervical lordosis
plane ■ dorsal kyphosis
■ lumbar lordosis

Observe: Comment:
spinal curve in coronal ■ normal (occiput over midsacrum)
plane or ■ scoliosis

waist skin creases ■ asymmetry may indicate scoliosis

or leg length discrepancy

thigh muscle bulk

& symmetry

popliteal fossa ■ asymmetrical fullness may

(back of knee) indicate a Baker’s cyst

calf muscle bulk

& symmetry

ankle alignment ■ neutral, varus, valgus

Achilles tendon, malleoli ■ should be sharply sculpted

4 The Screening Musculoskeletal Examination

The fine print:
• Scoliosis may be more obvious when the patient demonstrates forward flexion (step 3)
• A difference in leg length, either actual or factitious (due to incomplete extension of either the hip
or knee) may be assessed by palpating the iliac crests in the mid-axillary line. With an index finger
on each side, look to see if they line up horizontally, or if there is a pelvic tilt.
• In roughly a third of all patients, a communication exists between the knee joint space and the
popliteal bursa. In the presence of a knee effusion, joint fluid will drain from the high pressure
knee to low pressure bursa, resulting in bursal swelling (a Baker’s cyst). If the swelling comes on
rapidly, the bursa may rupture, with calf pain and ankle bruising, simulating a deep vein
thrombosis of the calf. If the swelling is chronic, it may expand into the calf beneath the
gastrocnemius, causing calf asymmetry.
• A unilaterally thickened Achilles tendon, often red and tender, is a hallmark of seronegative
arthritis.
• The normal concavity beneath the malleoli may be “filled in” in the case of tenosynovitis involving
the posterior tibial tendon (medially) or peroneus longus tendon (laterally)

I Patient Standing 5
 STEP 3.
I PATIENT STANDING Observe spinal movement

Cervical spine: Gently touch the right or left acromioclavicular joint

with your finger as instructions for rotation and
lateral flexion are given. DO NOT attempt to push the
patient’s head through the desired range.

Direction: Movement:
“look at the ceiling” ■ extension

“touch your chin to ■ flexion

your chest”

Direction: Movement:
“touch your chin to ■ rotation
each shoulder”

Direction: Movement:
“now touch your ear ■ lateral flexion
to each shoulder”

6 The Screening Musculoskeletal Examination

 Thoracic: Make a caliper of your two hands, encircling
(costovertebral) the chest just below the scapulae, thumbs touching in
the midline. As the patient breathes in and out deeply,
assess both symmetry and range of chest movement.

Direction: Movement:
“ take a deep breath ■ chest expansion
and let it out”

The fine print:

• Chest expansion may be symmetrically limited in patients with emphysema, whose lungs are
chronically hyperinflated, or in those with ankylosing spondylitis, where free movement of
costovertebral joints may be severely restricted. To document this, a tape is placed about the thorax
at the level of the nipples, and measurements taken at full inspiration and expiration. It should be
at least 2 cm (4-5 cm of excursion is usual).

• Asymmetric limitation of expansion usually indicates intra-thoracic disease

(such as a large unilateral pleural effusion).

I Patient Standing 7
 STEP 3. CONTINUED
I PATIENT STANDING Observe spinal movement

Lumbar spine: Align right hand finger tips in the lumbar lordotic
curve, and note the degree of finger separation with
forward flexion.

Direction: Movement:
“knees straight, try to ■ flexion
touch your toes”

Align spread finger tips in the lumbar lordotic curve,

gently supporting the patient, and note extent to
which finger tips come together.

Direction: Movement:
“hands on hips, lean ■ extension
way back”

8 The Screening Musculoskeletal Examination

 Patient tries to touch examiner’s finger, which is
placed on head of fibula.

Direction: Movement:
“knees straight, ■ lateral flexion
tip sideways to
touch my finger”

The fine print:

• As lumbar flexion is carried out, the normal lordotic curve flattens to neutral, then reverses in
kyphosis. Pain experienced with flexion may reflect lumbar disc disease.
• The Schober test is a measurement of spinal flexion which can be used to monitor improvement or
deterioration in ankylosing spondylitis. One variant of this test consists of placing a mark over the
lumbar spine at the level of the dimples of Venus while the patient is erect in the neutral position.
Two other marks are made, one 10 cm above and one 5 cm below the original mark. The patient
then bends forward as far as possible. The distance between the marks is re-measured, and should
be at least 20 cm.
• Restricted lumbar extension, with discomfort, is common and is felt to reflect facet joint arthritis.
• Lumbar spine movement, including lateral flexion, is commonly restricted in ankylosing spondylitis

I Patient Standing 9
 STEP 4.
I PATIENT STANDING Observe patient walking

Direction: “now walk away from me, turn around,

and walk back”

heel strike phase loading stance toe-off swing phase

Compare one side with the other:

“swing” phase —
when the foot swings forward after push-off

“stance” phase —
from heel-strike through flat foot contact to toe push-off

Once the patient has taken three steps, the gait

pattern is established. There is a lot to watch – the
lumbar spine, pelvis, hips, knees, ankles, and feet.
Compare the timing and duration of stance phase on
each side; check to see if stride lengths are equal.
Look from front and back and, if necessary, the side.

10 The Screening Musculoskeletal Examination

The fine print:
• The antalgic (antalgic = “against pain”) gait may reflect a painful focus anywhere from the foot up
to the pelvis. The patient attempts to “unload” the painful side. Consequently, the stance phase on
that side is briefer, and the swing phase on the opposite (normal) side is shorter – making for a
shorter stride.
• The arthrogenic (stiff knee or hip) gait is a consequence of joint stiffness, and is not necessarily
painful. Because there is a limited hip/knee flexion on the affected side, there is exaggerated foot
plantar flexion on the “good” side (the patient goes up higher on the toes), whereas the “bad” leg
is circumducted during the swing phase to allow toe clearance.
• Trendelenburg’s Gait results from unilateral hip abductor muscle dysfunction. This may be a
consequence of neurological weakness, or of hip joint dysfunction (e.g. hip osteoarthritis) that
would be aggravated by adductor contraction (which can double the weight-bearing load on that
hip). There are two components to the Trendelenburg gait. The thorax is thrust laterally to place
the center of gravity over the “bad” leg during the stance phase, and simultaneously the pelvis
sags on the contralateral side (because the ipsilateral hip adductors do not contract to hold the
pelvis level).

I Patient Standing 11
 STEP 1.
II PATIENT SITTING Inspect the dorsum of the hands and test finger
extension

Direction: “show me the backs of your hands —

spread your fingers as far as possible”

Observe: Comment:
wrist bony landmarks ■ ulnar styloid visible or lost in soft
tissue swelling

finger alignment ■ straight, without ulnar or

radial deviation

contours of MCP, PIP, ■ evidence of soft tissue or bony

DIP joints enlargement

skin colour over ■ reddened

knuckles

fingernails ■ clubbing, pitting, nail fold

vasculitis, onycholysis

skin of fingers ■ shiny, taut, swollen, or normally

wrinkled

12 The Screening Musculoskeletal Examination

The fine print:
• Ulnar deviation of the fingers, due to rheumatoid arthritis, occurs only after several years of active
disease.
• If the fingers cannot be fully extended, there is probably a finger flexion contracture. This can be
confirmed by the “prayer sign” — ask the patient to oppose palms and digits as if praying. There
should be no visible gap between palmar surfaces of the fingers.
• The most common cause of enlargement of the DIP joint is nodal osteoarthritis. These bony bumps
are known as Heberden’s nodes (their counterparts in the PIP joints are known as Bouchard’s
nodes). Early in their development they may be quite tender and even inflamed, but not as
inflamed as the swollen, red, tender DIP joints seen in some patients with psoriatic arthritis.
• Redness of knuckles, denoting inflammation, is seldom seen in the commonest form of
inflammatory arthritis, rheumatoid arthritis — but it is a feature of gouty arthritis, infection,
psoriatic arthritis, and even in some cases of nodal osteoarthritis (see above).
• Clubbing may be a clue to an underlying malignancy or endocarditis. Pitting of the fingernails, or
separation of the nail from the underlying tissue (onycholysis), may provide the essential clue to a
diagnosis of psoriatic arthritis. Nail fold vasculitis is seen in lupus and rheumatoid arthritis.
• Taut skin over the fingers may be a clue to scleroderma.

II Patient Sitting 13
 STEP 2.
II PATIENT SITTING Assess MCP joint flexion

Direction: “Make a fist”

Observe: Comment:
knuckles flex to almost
90°

troughs between MCPs ■ “filled in” troughs may be due to

are concave subcutaneous tissue (“pudgy
hands”) or to MCP joint capsular
distension.

The fine print:

• Inflammation of the MCP joints, evidenced by capsular distension, is
one of the hallmarks of rheumatoid arthritis. If suspected, the MCP
joints should be palpated, using both thumbs (see illustration). Try
to feel the joint lines.

• A quick “screen” for MCP arthritis is the manoeuvre shown

(compression of the MCPs from the side). A similar “screen” is
carried out on the MTP joints of the feet.

14 The Screening Musculoskeletal Examination

 STEP 3.
Inspect the palm

Direction: “Now open your fingers”

Observe: Comment:
thenar and hypothenar loss of thenar muscle mass may
eminences indicate chronic median nerve
pressure in the carpal tunnel

ulnar border of the palm ulnar nerve damage may cause

wasting of the abductor digiti
minimi

puckering, nodular Dupuytren’s contracture

thickening (subcutaneous fibrotic thickening)
most commonly involves 4th and
5th digits, leading to digital flexion
deformity

palms fully supinated failure may be a clue to elbow

arthritis

The fine print:

• Pressure on the median nerve in the carpal tunnel has many causes, including wrist synovitis.
The “pins and needles” of median nerve compression may be diagnostically reproduced by the
Tinel Test (firm percussion with a finger tip or a reflex hammer at the level of the distal crease on
the volar wrist) or Phalen’s manoeuvre (the patient is asked to press the backs of the hands
together, wrists at 90o flexion) held for 45 to 60 seconds.

II Patient Sitting
 STEP 4.
Assess interphalangeal (PIP, DIP) joint flexion

Direction: “Now turn your hand over and tuck your fingers
into your palm”

Observe: Comment:
finger tips touch palm failure may imply either IP joint or
overlying metacarpal flexor tendon dysfunction
heads

The fine print:

• To distinguish between IP joint effusion and flexor tendon dysfunction:
(1) Palpate the IP joint for capsular distension or bony enlargement.
Apply firm pressure with thumb and finger of one hand from
above and below, while simultaneously using the thumb and
finger of the other hand to press firmly at the joint line, feeling
for the “bounce” of a joint capsule under tension. This skill is of
prime importance in detecting evidence of early inflammatory
arthritis.
and
(2) Palpate the flexor tendon. Ask the patient if the finger ever
“triggers” (gets “stuck” on attempted closing or opening,
suddenly releasing with continued effort with a painful snap).
Feel for a nodule in the flexor tendon, particularly just proximal
to the metacarpal head, as the finger is both actively and
passively flexed.

The Screening Musculoskeletal Examination

 STEP 5.
II PATIENT SITTING Assess arm forward flexion, pronation,
then wrist flexion, extension

Direction: “Hands out straight — now bend your wrist straight

down, then as far back as possible”

Observe: Comment:
contour of dorsum of ■ subluxation of wrist is a late
wrist consequence of rheumatoid
arthritis

■ wrist joint synovitis or extensor

tendon synovitis in RA may “heap
up”, particularly with full extension

Palpate:
for increased joint ■ with the wrist in the neutral
warmth position, run the back of your
hand from mid-forearm across
palmar and dorsal wrist, feeling for
evidence of inflammation

II Patient Sitting 17
 STEP 6.
II PATIENT SITTING Assess elbow supination and extension, then elbow
flexion and extension

Direction: “Now turn your palms up, elbows out straight”

“I’m going to gently move your arm all the way up,
then all the way out”

Observe:

gently place the index finger and thumb of one hand

in the “gutters” on either side of the olecranon, and
with the other hand grasp the supinated forearm just
proximal to the wrist and take the elbow through a
full range of flexion/extension

18 The Screening Musculoskeletal Examination

 Observe: Comment:
palm fully supinates to ■ failure to fully supinate may be
horizontal subtle sign of elbow dysfunction

degree of valgus ■ elbow valgus greater in women

deviation at elbow than men

flexion so forearm meets

biceps

both elbows extend at ■ women (and those with

least to neutral hypermobility) commonly
hyperextend 10-15°)

Palpate:
feel for crepitus as the
joint moves

The fine print:

• Feel for “bulging” of elbow joint capsule with index finger/thumb tips, particularly as full
extension/flexion is approached. Full extension may be inhibited by elbow inflammation, and
capsular bulging may betray it.
• At the end of this elbow assessment, quickly palpate the extensor surface of the forearm over the
tip of the olecranon and the 3 to 4 cm just distal to it — this is where a thickened or swollen
olecranon bursa and rheumatoid nodules may be felt.
• “Tennis elbow” and “golfer’s elbow” are common causes of elbow pain. Firm pressure over the
lateral and medial epicondyles of the elbow (respectively) may elicit pain. Indirect stressing of the
lateral enthesis (enthesis = site of attachment of ligament/tendon to bone) is a useful diagnostic
test for a “tennis elbow”. Ask the patient to keep the wrist in extension while you attempt, by
pressure on the dorsum of the hand, to force it into the neutral position. Pain over the lateral
epicondyle constitutes a positive test. Attempts to overcome active flexion of the wrist may
provoke the pain of a “golfer’s elbow”, or medial epicondylitis.

II Patient Sitting 19
 STEP 7.
II PATIENT SITTING Inspect the shoulders

this is done with clavicles, shoulders, scapulae fully

exposed (see “Patient Preparation”). Compare one
side with the other, front and back.

Observe: Comment:
compare shoulder ■ dominant side may be
contours from the front more muscled, lower than
non-dominant side
■ deltoid muscle wasting due to
shoulder arthritis may “square off”
the normal contour

compare alignment of
clavicles, symmetry of
prominence of
sternoclavicular and
acromioclavicular joints

compare scapulae from ■ supraspinatus wasting occurs with

behind (have patient rotator cuff or glenohumeral
cross arms in front of disease
chest to bring scapulae
into prominence)

20 The Screening Musculoskeletal Examination

The fine print:
• Palpation, particularly to elicit pain and/or crepitus in patients with shoulder pain, can be added to
observation, and takes very little additional time.
• Both the sternoclavicular and acromioclavicular joints may be checked for pain and palpable
crepitus by asking the patient to shrug while the respective joints are firmly palpated. Using the
tips of the fingers of each hand, each pair can be assessed at the same time.
• The bicipital tendon, located in the bicipital groove between the greater and lesser tuberosities, can
be palpated for tenderness, as can the subdeltoid bursa (an extension of the subacromial bursa) in
the groove at the tip of the acromion.

II Patient Sitting 21
 STEP 8.
II PATIENT SITTING Observe shoulder range of motion (active)

Movements should be smooth, symmetrical,

and simultaneous

Abduction
Direction:
“Bring your arms from your side straight overhead, palms
touching; now bring them slowly down to your side again.”

External rotation
Direction:
“Put your hands behind your head, bring elbows way back,
and stick out your chest”

Internal rotation (and extension)

Direction:
“Now put one hand behind your back and touch the opposite
shoulder blade. Now do the same with the other hand”

22 The Screening Musculoskeletal Examination

The fine print:
• If the patient experiences pain at the mid-range of abduction (arc “A”), its origin is likely
subacromial (e.g. supraspinatus tendon, subacromial bursa). Shoulder pain in the last 10-15° of
abduction (arc “B”) is more likely to arise from the acromioclavicular joint.

II Patient Sitting 23
 STEP 9.
II PATIENT SITTING Compare passive shoulder range of motion with
active range of motion

Facing the patient, and assessing the right shoulder,

place your right hand over the patient’s right
trapezius, fingers firmly pressing the supraspinatus
muscle. With your left hand, gently grasp the
forearm just below the elbow and raise (abduct) the
arm in the coronal plane. Continue to abduct until
you feel the scapula begin to rotate under your
restraining hand.

Next, gently externally rotate the arm, the elbow bent

at 90°, until pain or tissue resistance calls a halt to
the manoeuvre. Reverse the movement, assessing
internal rotation, the arm still fully abducted, elbow
bent, until the forearm movement is arrested.

The fine print:

• Pain and impairment of movement when the patient carries out the movement (active), but which
is absent when the examiner takes the joint through the same range (passive), suggests a soft
tissue problem (e.g. tendinitis).
• Significant pain and restriction with both active and passive movement points to the glenohumeral
joint.
• In the case of a “frozen shoulder”, end-range discomfort is present, but the major impression is
that of severely restricted movement in all planes.
• Passive movement of the shoulder (the examiner does the moving) can also be carried out from
behind, with the left hand (when the right shoulder is being assessed) fixing the angle of the
scapula against rotation, and the right hand grasping the arm just above the elbow. The elbow is
then lifted to the end point of scapular movement (normally 90°). The forearm, hanging straight
down in “scarecrow” position (full internal rotation) is then pivoted to the vertical with the fingers
of the right hand (full external rotation).

24 The Screening Musculoskeletal Examination

 STEP 10.
II PATIENT Assess temporomandibular joint movement

Direction: “open and close your mouth”

Observe:

palpate both temporomandibular joints with

the index and long fingers of each hand
(alternatively, gently place index finger tips in the
external ear canals with mild forward pressure).

observe the central incisors of the mandible for

any deviation from the midline

observe that the upper incisors just overlap

the lower incisors

The fine print:

• In the case of a TMJ arthritis there may be crepitus and tenderness elicited as the jaw moves. The
central incisors may initially deviate toward the painful side.
• Childhood arthritis may result in growth restriction of the mandible (“micrognathia”) with a
marked overbite
• Patients with TMJ arthritis, and patients with scleroderma, may have
marked restriction and be unable to pass the “three finger test”. If such
restriction is suspected, ask the patient to attempt to place three fingers,
vertically, between the upper and lower teeth (see illustration)

II Patient Sitting 25
 STEP 1.
III PATIENT LYING Hip flexion, internal rotation, & external rotation
Knee flexion, extension

Direction: “now I’m going to bend your knee up to your chest,

then twist your leg in and out”

Gently place one hand over the patella and with the
other gently grasp just above the ankle. Guide the
hip into full flexion (almost to chest), then take it
back into 90° of flexion.

Gently guide the hip through the full range of internal

rotation (heel out), followed by external rotation
(heel in).

Now rotate the hip joint back into the neutral

position and guide the leg into full knee flexion. The
heel should almost touch the buttock.

Bring the leg down into full extension. No gap should

appear behind knee.
Repeat with the other leg, and compare.

26 The Screening Musculoskeletal Examination

The fine print:
• Watch the opposite leg when assessing full hip flexion. If it lifts off the examining table, there is
probably a flexion contracture on that side.
• The earliest finding in hip disease is usually restriction of internal rotation (in the shoulder, it is
usually restriction of external rotation).
• By palpating the patella as the range is assessed passively, knee joint crepitus may be detected.
If the patello-femoral articulation is the culprit, this may be confirmed by grasping the patella and
moving it side-to-side — you may feel crepitus and the patient may show, in facial expression,
displeasure (the “apprehension sign”).
• If there appears to be quadriceps muscle bulk asymmetry (common in knee arthritis), mark the
skin on each leg a fixed distance above the upper patellar poles (e.g. 6 cm), measure the
circumference and compare the two sides
• A rough assessment of leg length inequality may be made by measuring each leg from anterior
superior iliac spine to medial malleolus (you can also check to see how the heels line up with the
legs fully extended on the examining table).

III Patient Lying 27

 STEP 2.
III PATIENT LYING Assess for knee effusion

Observe: Feel:
repeat observations for ■ check for increased warmth over
suprapatellar bulging, the patella — run the back of your
filling in of parapatellar hand from distal thigh over patella
“gutters” to proximal shin. The normal
sequence is “warm — cool —
warm”. All inflammatory effusions
(and some in non-inflammatory
conditions as well) will be betrayed
by the loss of normal pre-patellar
coolness.

Test for a small effusion:

very small effusions can be pushed from one side of the knee to
the other (the “bulge” sign). A single firm sweep up the inner
Step 1 patellofemoral “gutter” (Step 1) is followed by a single firm
sweep down (Step 2) the outer patellofemoral “gutter”. Take
care not to displace the patella medially. Look for a “bulge” on
the inner knee after a second’s delay.

Step 2

The fine print:

• Effusions may be very difficult to detect in individuals with “fat” knees, and prepatellar warmth
may be the only clue.
• The “patellar tap” test is a manoeuvre designed to detect larger effusions — those that have caused
the patella to float up out of its normal position of rest in the groove between the femoral condyles.
The examiner, placing the tips of one or more fingers of the right hand securely on the patella,
thrusts firmly downward toward the intercondylar groove. Patellar movement is estimated.
Normally, there is none. If a knee effusion is present, downward movement may be detected, and
arrested with a palpable “tap” or click. More often, however, even though movement is detected,
the “tap” is absent. You may try to augment this test by compressing the suprapatellar pouch with
the palm of your left hand while attempting the “tap” with your right.

28 The Screening Musculoskeletal Examination

 STEP 3.
III PATIENT LYING Assess ankle dorsiflexion and plantar flexion

each heel (calcaneus) can be cupped, in turn, in the

palm of the hand. With gentle pressure from the
volar wrist the foot can be brought up into full
dorsiflexion (about 15° past neutral), then into full
plantar flexion (approximately 55°) below neutral.

STEP 4.
III PATIENT LYING Assess subtalar movement (inversion & eversion)

grasp the calcaneus and, with the foot pressed up

into full dorsiflexion (to lock the talus in the ankle
mortice), gently exert inward pressure on the
calcaneus followed by outward pressure.

Subtalar arthritis is a common source of hindfoot

pain, and this manoeuvre may bring it out.

STEP 5.
III PATIENT LYING Screen for MTP pain

with one hand, gently but firmly exert a sideways

compressive force on the MTP’s of each foot. If pain
is elicited, palpate, between thumb and forefinger, the
individual MTPs to determine the specific painful site.

III Patient Lying 29

Notes
Notes
Notes
Contents
Dedicated To
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.1 hugh little MD FrCPC
Patient Standing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.3 mentor, colleague and friend
Patient Sitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.12
Patient lying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.26
The Financial assistance of
The Arcangelo Rea Family Foundation
is gratefully acknowledged

Supported by an educational grant

from Pfizer Canada Inc.

Written By
Thanks to
John M. Thompson MD FrCPC
Division of rheumatology karen and John hueston of the Aylmer Express
Department of Medicine Anne lyddiatt
Faculty of Medicine and my colleagues in the Division of rheumatology
University of Western Ontario

St. Joseph’s hospital

268 grosvenor Street
london, Ontario n6A 4V2

Illustrated By

Ainsley S. Walton

©1998 by John M. Thompson

Unauthorized duplication of these materials is strictly prohibited.

 SCrEEnIng ChECklIST
Standing: q inspect from front
q inspect from behind
q cervical spine extension, flexion, rotation,
lateral flexion
q chest expansion (costovertebral movement)
q lumbar flexion, extension, lateral flexion
q observe gait
The Musculoskeletal
Sitting: q inspect dorsum of hands, finger extension Screening Examination
q MCP flexion
q PIP, DIP flexion
q inspect palms
q arm forward flexion, pronation
q wrist flexion, extension
q forearm supination, elbow extension
q elbow flexion, extension
q inspect shoulders
q observe active shoulder abduction, external
rotation, internal rotation
q compare passive shoulder abduction,
external & internal rotation
q assess temporomandibular joint movement

Lying: q hip flexion, internal rotation, external rotation John M. Thompson MD FRCPC
q knee flexion & extension
q assess for knee effusion and Ainsley Walton
q ankle dorsiflexion & plantar flexion
q assess subtalar inversion and eversion
q screen for MTP pain

02CB21E