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This completes the basic musculoskeletal screening examination. The remainder of this section describes the symptoms and examination of specific joints.

Examination of Specific Joints

Any area must be inspected for evidence of swelling, atrophy, redness, and deformity, as well as palpated for swelling, muscle spasm, and local painful areas. The range of motion is assessed both actively and passively.

Figure 20-35 Technique for evaluating the temporomandibular joint.

Temporomandibular Joint Symptoms

A patient with temporomandibular joint problems may complain of unilateral or bilateral jaw pain. The pain is worse in the morning and after chewing or eating. The patient may also complain of ''clicking'' of the jaw.

Examination

To examine this joint, the examiner places his or her index fingers in front of the tragus and instructs the patient to open and close the jaw slowly. The examiner observes the smoothness of the range of motion and notes any tenderness. This is illustrated in Figure 20-35.

Although shoulder pain may be related to a primary shoulder disorder, always consider the possibility that shoulder pain is referred from either the chest or the abdomen. Coronary artery disease, pulmonary tumors, and gallbladder disease are commonly associated with pain referred to the shoulder.

Pain is the main symptom of shoulder disorders. Inflammation of the supraspinatus muscle causes pain that is usually worse at night or when the patient lies on the affected shoulder. The pain often radiates down the arm as far as the elbow. The pain is commonly referred to the lower part of the deltoid area and is characteristically aggravated by combing the hair, putting on a coat, or reaching into the back pocket. Diffuse tenderness of the shoulder associated with pain on moving the humerus posteriorly is associated with disorders of the teres minor, infra-spinatus, and subscapularis muscles. In this case, the pain usually does not radiate into the arm and is usually absent when the arm is dependent.

The movements of the shoulder occur at the glenohumeral, thoracoscapular, acromioclavicular, and sternoclavicular joints. The glenohumeral joint is a ball-and-socket joint. In contrast to the hip joint, which is also a ball-and-socket joint, in the glenohumeral joint the humerus sits in the very shallow glenoid socket. Therefore, the function of the joint depends on the muscles surrounding the socket for stability. These muscles and their tendons form the rotator cuff of the shoulder. For this reason, many shoulder problems are muscular, not bone or joint related, in origin.

Examination

Inspect the shoulder for deformity, wasting, and asymmetry. The shoulder should be palpated for local areas of tenderness. The range of motion for abduction, adduction, external and internal rotation, and flexion is evaluated and compared with that of the other side. Any pain is noted.

Special tests are necessary to determine specific diagnoses. The impingement syndrome, tears of the rotator cuff, and bicipital tendinitis are common. The examinations for these conditions are described in this section.

The impingement syndrome, also known as rotator cuff tendinitis, is usually secondary to sports trauma. Irritation of the avascular portion of the supraspinatus tendon progresses to an

Shoulder Symptoms inflammatory response termed tendinitis. This inflammatory response later involves the biceps tendon, subacromial bursa, and acromioclavicular joint. With continued trauma, rotator cuff tears and calcification may occur. The most reliable test for the impingement syndrome is the reproduction of pain when the examiner forcibly flexes the patient's arm with the elbow extended against resistance.

Sudden onset of shoulder pain in the deltoid area 6 to 10 hours after trauma suggests a rotator cuff tear or rupture. Extreme tenderness over the greater tuberosity of the humerus and pain and restricted motion at the glenohumeral joint are usually present. Active abduction of the glenohumeral joint is markedly reduced. When the examiner attempts to abduct the arm, pain and a characteristic shoulder shrug result.

Generalized tenderness anteriorly over the long head of the biceps that is associated with pain, especially at night, should raise suspicion of bicipital tendinitis. In this condition, there is normal abduction and forward flexion. The hallmark of bicipital tendinitis is the reproduction of anterior shoulder pain during resistance to forearm supination. The patient is asked to place the arm at the side with the elbow flexed 90°. The patient is instructed to supinate the arm against the examiner's resistance. If there is pain in the triceps area with resisted extension of the elbow, tricipital tendinitis may be present.

Elbow Symptoms

The most common symptom of elbow disorders is well-localized elbow pain.

Although it is a simple hinge joint, the elbow is the most complicated joint of the upper extremity. The distal end of the humerus articulates with the proximal ulna and radius. Flexion and extension of the elbow are effected through the humeroulnar portion of the joint. The radius plays little role in this action; its role is primarily in pronation and supination of the forearm. The ulnar nerve lies in a vulnerable position as it passes around the medial epicondyle of the humerus.

Examination

Palpate the elbow for swelling, masses, tenderness, and nodules. Test flexion and extension.

To test for pronation and supination, the elbows should be flexed at 90° and placed firmly on a table. The patient is asked to rotate the forearm with wrist down (pronation), as shown in Figure 20-36A, and wrist up (supination), as shown in Figure 20-36B. Any limitation of motion or pain is noted.

Tennis elbow, also known as lateral epicondylitis, is a common condition characterized by pain in the region of the lateral epicondyle of the humerus. The pain radiates down the extensor surface of the forearm. Patients with tennis elbow often experience pain when attempting to

Figure 20-36 Technique for evaluating pronation and supination at the elbow. A, Pronation. B, Supination.

open a door or when lifting a glass. To test for tennis elbow, the examiner should flex the patient's elbow and fully pronate the hand. Pain over the lateral epicondyle while the elbow is extended is diagnostic of tennis elbow. Another test involves having the patient clench the fist, dorsiflex the wrist, and extend the elbow. Pain is elicited by trying to force the dorsiflexed hand into palmar flexion.

Wrist Symptoms

The symptoms of wrist disorders include pain in the wrist or hand, numbness or tingling in the wrist or fingers, loss of movement and stiffness, and deformities. Pain in the hand may be referred from the neck or elbow.

The wrist is composed of the articulation of the distal end of the radius with the proximal row of the carpal bones. The stability of the wrist is caused by the banding together of these bones by strong ligaments. The distal ulna does not articulate with any of the carpal bones. On the volar aspect of the wrist, the carpal bones are connected by the carpal ligament. The passage under this ligament is the carpal tunnel, through which the median nerve and all the flexors of the wrist pass. Entrapment of the nerve, known as carpal tunnel syndrome, produces symptoms of numbness and tingling.

Examination

Palpate the patient's wrist joint between your thumbs and index fingers, noting tenderness, swelling, or redness (Fig. 20-37).

The range of motion of dorsiflexion and palmar flexion is noted. With the forearms fixed, the degree of supination and pronation is evaluated. Is ulnar or radial deviation present?

When the diagnosis of carpal tunnel syndrome is suspected, a sharp tap or pressure directly over the median nerve may reproduce the paresthesias of carpal tunnel syndrome, called Tinel's sign. Another useful test is for the examiner to stretch the median nerve by extending the patient's elbow and dorsiflexing the wrist. The development of pain or paresthesias is suggestive of the diagnosis. A third test entails the patient's holding both wrists in a fully palmar-fixed position for 2 minutes. The development or exacerbation of paresthesias is suggestive of carpal tunnel syndrome.

Hand Symptoms

Pain and swelling of joints are the most important symptoms of disorders of the hand. Examination

Palpate the patient's metacarpophalangeal joints and note swelling, redness, or tenderness, as demonstrated in Figure 20-38. Palpate the medial and lateral aspects of the proximal and distal interphalangeal joints between your thumb and index finger, as shown in Figure 20-39. Again, note swelling, redness, or tenderness.

Figure 20-38 Technique for palpation of the metacarpophalangeal joints.
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