Physical Examination

No special equipment is necessary for the examination of the musculoskeletal system.

The purpose of the internist's musculoskeletal examination is as a screening examination to indicate or exclude functional impairment of the musculoskeletal system. The examination should take only a few minutes and should be part of the routine examination of all patients. If an abnormality is noted or if the patient has specific symptoms referable to a particular joint, a more detailed examination of that area is indicated. Detailed descriptions of the examination of specific joints follow the discussion of the screening examination.

Screening Examination

In the screening examination, the clinician should pay particular attention to the following:

Inspection Palpation

Passive and active range of motion Muscle strength Integrated function

General Principles

During inspection, asymmetry should be assessed. Nodules, wasting, masses, or deformities may be responsible for the absence of symmetry. Are there any signs of inflammation? Swelling, warmth, redness, and tenderness are suggestive of inflammation. To determine a difference in temperature, use the back of your hand to compare one side with the other.

Palpation may reveal areas of tenderness or discontinuity of a bone. Is crepitus present? Crepitus is a palpable crunching sensation often felt in the presence of roughened articular cartilages.

The assessment of range of motion of specific joints is next. Keep in mind that inflamed or arthritic joints may be painful. Move these joints slowly.

Muscle strength and integrated function are usually evaluated during the neurologic examination, and these topics are discussed in Chapter 21, The Nervous System.

Evaluate Gait

The first part of the screening examination consists of inspection of gait and posture. To determine any eccentricity of gait, ask the patient to disrobe down to underwear and walk barefoot. Have the patient walk away from you, then back to you on tiptoes, away from you on the heels, and finally back to you in tandem gait. If there is any gait difficulty, these maneuvers must be modified. The positions of the foot during the normal gait cycle are shown in Figure 20-23.

Observe the rate, rhythm, and arm motion used in walking. Does the patient have a staggering gait? Are the feet lifted high and slapped downward firmly? Does the patient walk with an extended leg that is swung laterally during walking? Are the steps short and shuffling? A complete discussion of gait abnormalities can be found in Chapter 21, The Nervous System. Figure 21-59 illustrates common gait abnormalities.

Evaluate the Spine

Attention should then focus on the spine to detect any abnormal spinal curvatures. Have the patient stand erect, and stand at the patient's side to inspect the profile of the patient's spine. Are the cervical, thoracic, and lumbar curves normal?

Move to inspect the patient's back. What is the level of the iliac crests? A difference may result from a leg length inequality, scoliosis, or flexion deformity of the hip. An imaginary line extending from the posterior occipital tuberosity should run over the intergluteal cleft. Any lateral curvature is abnormal. Figure 20-24 illustrates this point. Figure 20-25A shows severe kyphoscoliosis. See also Figure 13-6.

Ask the patient to bend forward, flexing at the trunk as far as possible with the knees extended. Note the smoothness of this action. This position is best for determining whether scoliosis is present. As the patient bends forward, the lumbar concavity should flatten. Figure 20-25B shows the patient in Figure 20-25A when bending forward. A persistence of the concavity may indicate an arthritic condition of the spine called ankylosing spondylitis.

Ask the patient to bend to each side from the waist and then bend backward from the waist to test extension of the spine, as shown in Figure 20-26A.

To test rotation of the lumbar spine, sit on a stool behind the patient and stabilize the patient's hips by placing your hands on them. Ask the patient to rotate the shoulders one way and then reverse, as shown in Figure 20-26B.

Evaluate Strength of the Lower Extremities

To assess the function of all major joints of the lower extremities, stand in front of the patient. Have the patient squat, with knees and hips fully flexed. Assist the patient by holding his or her hands to secure balance. This is shown in Figure 20-27. Ask the patient to stand. Observing the

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