Chapter 18

Musculoskeletal System

Equipment

• Goniometer

• Skin-marking pencil

• Reflex hammer

• Tape measure

Examination

Begin examination as patient enters rooms, observing gait and posture. During examination, note ease of movement when patient walks, sits, rises, takes off garments, and responds to directions.

Technique	Findings
Posture and General Guidelines
Inspect skeleton and extremities, comparing sides
Inspect anterior, posterior, lateral aspects of posture; ability to stand erect; body parts; extremities.
• Size, alignment, contour, symmetry Measure extremities when lack of symmetry is noted in length or circumference.	EXPECTED: Bilateral symmetry of length, circumference, alignment, position and number of skinfolds; symmetric body parts; and aligned extremities.
	UNEXPECTED: Gross deformity, lordosis, kyphosis, scoliosis, bony enlargement.
Inspect skin and subcutaneous tissues over muscles, cartilage, bones, joints
	UNEXPECTED: Discoloration, swelling, or masses.
Inspect muscles and compare sides
• Size and symmetry	EXPECTED: Approximately symmetric bilateral muscle size.
	UNEXPECTED: Gross hypertrophy or atrophy, fasciculations, or spasms.
Palpate all bones, joints, surrounding muscles (palpate inflamed joints last)
• Muscle tone	EXPECTED: Firm.
	UNEXPECTED: Hard or doughy, spasticity.
• Characteristics	UNEXPECTED: Heat, tenderness, swelling, fluctuation of a joint, synovial thickening, crepitus, resistance to pressure, or discomfort to pressure on bones and joints.
Test each major joint and related muscle groups for active and passive range of motion, and compare sides
Ask patient to move each joint through range of motion (see instructions for specific joints and muscles in individual sections that follow), then ask patient to relax as you passively move same joints until end of range is felt. Goniometer.	EXPECTED: Passive range of motion often exceeds active range of motion by 5 degrees. Range of motion with passive and active maneuvers should be equal between contralateral joints.
	UNEXPECTED: Pain, limitation of motion, spastic movement, joint instability, deformity, contracture, discrepancies greater than 5 degrees between active and passive range of motion. When increase or limitation in range of motion is found, measure angles of greatest flexion and extension with goniometer, as shown in figure below, and compare with values as described for specific joints in individual extremities.
Test major muscle groups for strength, and compare contralateral sides
For each muscle group, ask patient to contract a muscle by flexing or extending a joint and to resist as you apply opposing force. Compare bilaterally.	EXPECTED: Bilaterally symmetric strength with full resistance to opposition.
	UNEXPECTED: Inability to produce full resistance. Grade muscular strength according to the following table.

Muscle Strength Assessment

Muscle Function Level	Grade
No evidence of contractility	0
Slight contractility, no movement	1
Full range of motion, gravity eliminated∗	2
Full range of motion against gravity	3
Full range of motion against gravity, some resistance	4
Full range of motion against gravity, full resistance	5

^∗Passive movement.

(From Jacobson RD: Approach to the child with weakness and clumsiness, Pediatr Clin North Am 45[1]:145-168. 1998.)

Technique	Findings
Hands and Wrists
Inspect dorsum and palm of each hand
• Characteristics and contour	EXPECTED: Palmar and phalangeal creases, palmar surfaces with central depression with prominent, rounded mound on thumb side (thenar eminence) and less prominent hypothenar eminence on little-finger side.
• Position	EXPECTED: Fingers able to fully extend and align with forearm when in close approximation to each other.
	UNEXPECTED: Deviation of fingers to ulnar side or inability to fully extend fingers; swan neck or boutonnière deformities.
• Shape	EXPECTED: Lateral finger surfaces gradually tapered from proximal to distal aspects.
	UNEXPECTED: Spindle-shaped fingers, bony overgrowths at phalangeal joints.
Palpate each joint in hand and wrist
Palpate interphalangeal joints with thumb and index finger, as shown in figure on p. 198, panel A; metacarpophalangeal joints with both thumbs, as shown in figure on p. 198, panel B; and wrist and radiocarpal groove with thumbs on dorsal surface and fingers on palmar aspect of wrist, as shown in figure on p. 198, panel C.	EXPECTED: Joint surfaces smooth. UNEXPECTED: Nodules, swelling, bogginess, tenderness, or ganglion.
A, Palpating the interphalangeal joints with thumb and index finger. B, Palpating metacarpophalangeal joints with both thumbs. C, Palpating radiocarpal groove with thumbs on dorsal surface and fingers on palmar aspect of wrist.
Assess integrity of median nerve
• Tinel sign Strike median nerve where it passes through carpal tunnel with index or middle finger.	UNEXPECTED: Tingling sensation radiating from wrist to hand along pathway of median nerve.
• Thumb abduction test Apply downward pressure on thumb as patient holds thumb perpendicular to hand, palm side up.	EXPECTED: Full resistance to pressure.
	UNEXPECTED: Inability to produce full resistance.
• Phalen test Have patient hold both wrists in fully palmar-flexed position with dorsal surfaces pressed together for 1 minute.	UNEXPECTED: Numbness, paresthesia in distribution of median nerve.
• Katz hand diagram Have patient mark specific locations of pain, numbness, tingling in hands and arms on diagram.	UNEXPECTED: Pain, numbness, tingling in pattern shown in figure below.
Test range of motion
Ask patient to perform the following movements:
• Metacarpophalangeal flexion and hyperextension Bend fingers forward at metacarpophalangeal joint, then stretch fingers up and back at knuckle.	EXPECTED: 90-degree metacarpophalangeal flexion and as much as 30-degree hyperextension.
• Thumb opposition Touch thumb to each fingertip and to base of little finger, then make a fist.	EXPECTED: Able to perform all movements.
• Finger abduction and adduction Spread fingers apart and then touch them together.	EXPECTED: Both movements possible.
• Wrist extension and hyperextension Bend hand at wrist up and down.	EXPECTED: 90-degree flexion and 70-degree hyperextension.
• Radial and ulnar motion With palm side down, turn each hand to right and left.	EXPECTED: 20-degree radial motion and 55-degree ulnar motion.
Test muscle strength
Ask patient to perform the following movements:
• Wrist extension and hyperextension Maintain wrist flexion while you apply opposing force.	EXPECTED: Bilaterally symmetric with full resistance to opposition.
	UNEXPECTED: Inability to produce full resistance.
• Hand strength Grip two of your fingers tightly.	EXPECTED: Firm, sustained grip.
	UNEXPECTED: Weakness or pain.
Elbows
Inspect elbows in flexed and extended positions
• Contour	UNEXPECTED: Subcutaneous nodules along pressure points of extensor surface of ulna.
• Carrying angle Inspect with arms at sides passively extended, palms facing forward.	EXPECTED: Usually 5 to 15 degrees laterally.
	UNEXPECTED: Lateral angle exceeding 15 degrees (cubitus valgus) or a medial carrying angle (cubitus varus).
Palpate extensor surface of ulna, olecranon process, medial and lateral epicondyles of humerus, groove on each side of olecranon process
Palpate with patient’s elbow flexed at 70 degrees.	UNEXPECTED: Boggy, soft, tenderness at lateral epicondyle or along grooves of olecranon process and epicondyles.
Test range of motion
Ask patient to perform the following movements:
• Flexion and extension Bend and straighten elbow.	EXPECTED: 160-degree flexion from full extension at 0 degrees.
• Pronation and supination With elbow flexed at right angle, rotate hand from palm side down to palm side up.	EXPECTED: 90-degree pronation and 90-degree supination.
	UNEXPECTED: Increased pain with pronation and supination of elbow.
Test muscle strength
Ask patient to maintain flexion and extension, as well as pronation and supination, while you apply opposing force.	EXPECTED: Bilaterally symmetric with full resistance to opposition.
	UNEXPECTED: Inability to produce full resistance.
Shoulders
Inspect shoulders, shoulder girdle, clavicles and scapulae, area muscles
• Size and contour	EXPECTED: All shoulder structures symmetric in size and contour.
	UNEXPECTED: Asymmetry, hollows in rounding contour, or winged scapula.
Palpate sternoclavicular and acromioclavicular joints, clavicle, scapulae, coracoid process, greater trochanter of humerus, biceps groove, area muscles
Palpate the biceps groove by rotating the arm and forearm externally. Follow the biceps muscle and tendon along the anterior aspect of the humerus into the biceps groove.	EXPECTED: No tenderness or masses, bilateral symmetry.
Palpate the muscle insertion for the supraspinatus, infraspinatus, and teres minor near the greater tuberosity of the humerus by lifting the elbow posteriorly to extend the shoulder.	UNEXPECTED: Pain, tenderness, mass.
Test range of motion
Ask patient to perform the following movements:
• Shoulder shrug	EXPECTED: Symmetric rising.
• Forward flexion Raise both arms forward and straight up over head.	EXPECTED: 180-degree forward flexion.
• Hyperextension Extend and stretch both arms behind back.	EXPECTED: 50-degree hyperextension.
• Abduction Lift both arms laterally and straight up over head.	EXPECTED: 180-degree abduction.
• Adduction Swing each arm across front of body.	EXPECTED: 50-degree adduction.
• Internal rotation Place both arms behind hips, elbows out.	EXPECTED: 90-degree internal rotation.
• External rotation Place both arms behind head, elbows out.	EXPECTED: 90-degree external rotation.
Test shoulder girdle muscle strength
Ask patient to maintain the following positions while you apply opposing force:
• Shrugged shoulders (This also tests cranial nerve XI.) Shrugged shoulders.	EXPECTED: Bilaterally symmetric with full resistance to opposition.
	UNEXPECTED: Inability to produce full resistance.
• Forward flexion	EXPECTED: Bilaterally symmetric with full resistance to opposition.
	UNEXPECTED: Inability to produce full resistance.
• Abduction	EXPECTED: Bilaterally symmetric with full resistance to opposition.
	UNEXPECTED: Inability to produce full resistance.
Assess rotator cuff muscles
Abduct the arm 90 degrees and flex the shoulders forward 30 degrees to test the supraspinatus muscle. Apply downward pressure on the distal humerus when the arm is rotated so that thumb points down or up.	UNEXPECTED: Pain and weakness with opposing force.
Flex the elbow 90 degrees and rotate the forearm medially against resistance to test the subscapularis muscle.	UNEXPECTED: Pain and weakness with opposing force.
With the arm at the side and elbow flexed 90 degrees, rotate the arm laterally against resistance to test the infraspinatus and teres minor muscles.	UNEXPECTED: Pain and weakness with opposing force.
Evaluate the rotator cuff for impingement or a tear
• Neer test: Have the patient internally rotate and forward flex the arm at the shoulder, pressing the supraspinatus muscle against the anterior inferior acromion.	UNEXPECTED: Increased shoulder pain.
• Hawkins test: Abduct the shoulder to 90 degrees, flexing the elbow to 90 degrees, and then internally rotating the arm to its limit.	UNEXPECTED: Increased shoulder pain. Assessment for rotator cuff inflammation or tear. A, Neer test. B, Hawkins test.
Temporomandibular Joint
Palpate joint space for clicking, popping, pain
Locate temporomandibular joints with fingertips placed just anterior to tragus of each ear, as shown in figure at right. Ask patient to open mouth and allow fingertips to slip into joint space. Gently palpate.	EXPECTED: Audible or palpable snapping or clicking may be noted.
	UNEXPECTED: Pain, crepitus, locking, or popping. Palpating temporomandibular joint.
Test range of motion
Ask patient to:
• Open and close mouth	EXPECTED: Opens 3–6 cm between upper and lower teeth.
• Move jaw laterally to each side	EXPECTED: Mandible moves 1–2 cm in each direction.
• Protrude and retract jaw	EXPECTED: Both protrusion and retraction possible.
Test strength of temporalis and masseter muscles with patient’s teeth clenched
Ask patient to clench teeth while you palpate contracted muscles and apply opposing force. (This also tests cranial nerve V motor function.)	EXPECTED: Bilaterally symmetric with full resistance to opposition.
	UNEXPECTED: Inability to produce full resistance.
Cervical Spine
Inspect neck from anterior and posterior positions
• Alignment	EXPECTED: Cervical spine straight, with head erect and in approximate alignment.
• Symmetry of skinfolds	UNEXPECTED: Asymmetric skinfolds, webbed neck.
Palpate posterior neck, cervical spine, and paravertebral, trapezius, and sternocleidomastoid muscles
	EXPECTED: Good muscle tone, symmetry in size.
	UNEXPECTED: Palpable tenderness or muscle spasm.
Test range of motion
• Forward flexion Bend head forward, chin to chest.	EXPECTED: 45-degree flexion.
• Hyperextension Bend head backward, chin toward ceiling.	EXPECTED: 45-degree hyperextension.
• Lateral bending Bend head to each side, ear to each shoulder.	EXPECTED: 40-degree lateral bending.
• Rotation Turn head to each side, chin to shoulder.	EXPECTED: 70-degree rotation.
Test strength of sternocleidomastoid and trapezius muscles
Ask patient to maintain each of the previous positions while you apply opposing force. (Cranial nerve XI is also tested with rotation.)	EXPECTED: Bilaterally symmetric strength with full resistance to opposition.
	UNEXPECTED: Inability to produce full resistance.
Thoracic and Lumbar Spine
Inspect spine for alignment
Note major landmarks of back—each spinal process of vertebrae (C7 and T1 usually most prominent), scapulae, iliac crests, paravertebral muscles.	EXPECTED: Head positioned directly over gluteal cleft, vertebrae straight (as indicated by symmetric shoulder, scapular, and iliac crest heights), curves of cervical and lumbar spines concave, curve of thoracic spine convex, and knees and feet aligned with trunk and pointing directly forward.
	UNEXPECTED: Lordosis, kyphosis, scoliosis, or sharp angular deformity (gibbus).
Palpate spinal processes and paravertebral muscles
Ask patient to stand erect.	UNEXPECTED: Muscle spasm or spinal tenderness.
Percuss for spinal tenderness
Patient is still standing erect. First, tap each spinal process with one finger, then rap each side of spine along paravertebral muscles with ulnar aspect of fist.	UNEXPECTED: Muscle spasm or spinal tenderness.
Test range of motion and curvature
Ask patient to perform the following movements (mark each spinal process with skin pencil if unexpected curvature suspected):
• Forward flexion Bend forward at waist and try to touch toes. Observe patient from behind to check curvature.	EXPECTED: 75- to 90-degree flexion; back remains symmetrically flat as concave curve of lumbar spine becomes convex with forward flexion.
	UNEXPECTED: Lateral curvature or rib hump.
• Hyperextension Bend back at waist as far as possible.	EXPECTED: 30-degree hypertension with reversal of lumbar curve.
• Lateral bending Bend to each side as far as possible.	EXPECTED: 35-degree lateral bending on each side.
• Rotation Swing upper trunk from waist in circular motion, front to side to back to side, while you stabilize pelvis.	EXPECTED: 30-degree rotation forward and backward.
Test for lumbar nerve root irritation or disk herniation at L4, L5, or S1 levels (patient supine with neck slightly flexed)
• Straight-leg raising test Ask patient to raise leg with knee extended. Repeat with other leg.	EXPECTED: No pain below knee with leg raising.
	UNEXPECTED: Unable to raise leg more than 30 degrees without pain. Pain below knee in dermatome pattern. Flexion of knee often eliminates pain with leg raising. Crossover pain in affected leg.
• Bragard stretch test Hold patient’s lower leg with knee extended, and raise it slowly until pain is felt. Lower leg slightly, briskly dorsiflex foot, and internally rotate hip.	UNEXPECTED: Pain when leg is raised less than 70 degrees; aggravated by dorsiflexion and internal rotation of hip.
Hips
Inspect hips for symmetry and level of gluteal folds
With patient standing, inspect anteriorly and posteriorly, using major landmarks of iliac crest and greater trochanter of femur.	UNEXPECTED: Asymmetry in iliac crest height, size of buttocks, or number and level of gluteal folds.
Test range of motion
While in position indicated, patient should perform the following movements:
• Flexion, knee extended With patient supine, raise leg over body.	EXPECTED: Up to 90-degree flexion.
• Hyperextension While standing or prone, swing straightened leg behind body without arching the back.	EXPECTED: Up to 30-degree hyperextension.
• Flexion, knee flexed While supine, raise one knee to chest while keeping other leg straight.	EXPECTED: 120-degree flexion.
• Abduction and adduction While supine, swing leg laterally and medially with knee straight. During adduction movement, lift patient’s opposite leg to permit examined leg full movement.	EXPECTED: Some degree of both abduction and adduction.
• Internal rotation While supine, flex knee and rotate leg inward toward other leg.	EXPECTED: 40-degree internal rotation.
• External rotation While supine, place lateral aspect of foot on knee of other leg. Move flexed leg toward table.	EXPECTED: 45-degree external rotation.
Test hip muscle strength
• Knee in flexion and extension Ask patient to maintain flexion of hip with knee in flexion and then extension while applying opposing force.	EXPECTED: Bilaterally symmetric with full resistance to opposition.
• Resistance to uncrossing legs while seated	UNEXPECTED: Inability to produce full resistance.
	EXPECTED: Bilaterally symmetric with full resistance to opposition.
Perform Trendelenburg test to inspect for weak hip abductor muscles
Ask patient to stand and balance first on one foot, then on other. Observe from behind. Trendelenburg test. (From Magee DJ: Orthopedic physical assessment, ed 5, St Louis, 2007, Saunders.)	UNEXPECTED: Asymmetry or change in level of iliac crests.
Legs and Knees
Inspect knees and popliteal spaces, flexed and extended
Note major landmarks—tibial tuberosity, medial and lateral tibial condyles, medial and lateral epicondyles of femur, adductor tubercle of femur, patella.	EXPECTED: Natural concavities on anterior aspect, on each side, above patella.
	UNEXPECTED: Convex rather than usual concave indentation above patella.
Observe lower leg alignment
	EXPECTED: Angle between femur and tibia less than 15 degrees. Bowlegs common until 18 months of age; knock-knees common between 2 and 4 years.
	UNEXPECTED: Knock-knees (genu valgum) or bowlegs (genu varum) at other ages, excessive hyperextension of knee with weight bearing (genu recurvatum).
Palpate popliteal space
	UNEXPECTED: Swelling or tenderness.
Palpate tibiofemoral joint space
Identify patella, suprapatellar pouch, infrapatellar fat pad.	EXPECTED: Smooth and firm joint.
	UNEXPECTED: Tenderness, bogginess, nodules, or crepitus.
Test range of motion
• Flexion Ask patient to bend each knee.	EXPECTED: 130-degree flexion.
• Extension Ask patient to straighten leg and stretch it.	EXPECTED: Full extension and up to 15-degree hyperextension.
Test muscle strength
• Flexion and extension Ask patient to maintain flexion and extension while you apply opposing force.	EXPECTED: Bilaterally symmetric with full resistance to opposition.
	UNEXPECTED: Inability to produce full resistance.
Additional Techniques for Knees
Perform ballottement procedure to determine presence of excess fluid or effusion in knee
With knee extended, apply downward pressure on suprapatellar pouch with thumb and finger of one hand, then push patella sharply downward against femur with fingers of other hand, as shown in figure at right. Suddenly release pressure on patella, while keeping fingers lightly on knee.	UNEXPECTED: A tapping or clicking is sensed when patella is pushed against femur. Patella then floats out as if a fluid wave were pushing it. Ballottement.
Test for bulge sign to determine presence of excess fluid in knee
With knee extended, milk medial aspect of knee upward two or three times, as shown in figure below, A, then tap lateral side of patella, as shown below in figure, B. Bulge sign. A, Milking the medial aspect of the knee two or three times. B, Tap the lateral side of the patella.	UNEXPECTED: Bulge of returning fluid to hollow area medial to patella.
Perform McMurray test to detect torn medial or lateral meniscus
Ask patient to lie supine and flex one knee completely with foot flat on table near buttocks. Maintain that flexion with your thumb and index finger on either side of the joint space while stabilizing knee. Hold heel with other hand; rotate foot and lower leg to lateral position. Extend knee to 90-degree angle. Return knee to full flexion, then repeat procedure rotating foot and lower leg to medial position.	UNEXPECTED: Palpable or audible click or limited extension of knee with either lateral or medial movements. Procedure for examination of the knee with the McMurray test. Knee is flexed after lower leg was rotated to medial position.
Perform drawer test to identify instability of anterior and posterior cruciate ligaments
Ask patient, while supine, to flex knee 45–90 degrees, placing foot flat on table. Place both hands on lower leg with thumbs on ridge of anterior tibia near tibial tuberosity. Pull tibia, sliding it forward of femur. Then push tibia backward.	UNEXPECTED: Anterior or posterior movement greater than 5 mm. Drawer test.
Perform varus and valgus stress test to identify mediolateral collateral ligament instability
Ask patient to lie supine and extend knee. While you stabilize femur with one hand and hold ankle with other, apply varus force against the ankle (toward midline) and internal rotation.	UNEXPECTED: Excessive laxity felt as joint opening, medial or lateral movement.
Then apply valgus force against the ankle (away from midline) and external rotation. Repeat with knee flexed to 30 degrees.	Varus and valgus stress test.
Feet and Ankles
Inspect during weight bearing (standing and walking) and non–weight bearing
Note major landmarks—medial malleolus, lateral malleolus, Achilles tendon.
• Characteristics	EXPECTED: Smooth and rounded malleolar prominence, prominent heels, prominent metatarsophalangeal joints.
	UNEXPECTED: Calluses and corns.
• Alignment	EXPECTED: Feet aligned with tibias and weight bearing on foot midline.
	UNEXPECTED: In-toeing (pes varus), out-toeing (pes valgus), deviations in forefoot alignment (metatarsus varus or metatarsus valgus), heel pronation, or pain.
• Contour	EXPECTED: Longitudinal arch that may flatten with weight bearing. Foot flat when not bearing weight (pes planus) and high instep (pes cavus) are common variations.
	UNEXPECTED: Pain with pes planus.
• Toes	EXPECTED: Toes on each foot straight forward, flat, in alignment.
	UNEXPECTED: Hammertoe; claw toe; mallet toe; hallux valgus; bunions; or heat, redness, swelling, tenderness of metatarsophalangeal joint of great toe (possibly with draining tophus).
Palpate Achilles tendon and each metatarsal joint
Using thumb and fingers of both hands, compress forefoot, palpating each metatarsophalangeal joint.	EXPECTED: No tenderness or masses, bilateral symmetry.
	UNEXPECTED: Pain, masses, thickened Achilles tendon.
Test range of motion
Ask patient to sit, then perform following movements:
• Dorsiflexion Point foot toward ceiling.	EXPECTED: 20-degree dorsiflexion.
• Plantar flexion Point foot toward floor.	EXPECTED: 45-degree plantar flexion.
• Inversion and eversion Bend foot at ankle, then turn sole of foot toward and away from other foot.	EXPECTED: 30-degree inversion and 20-degree eversion.
• Abduction and adduction Rotate ankle, turning away from and then toward other foot (while you stabilize leg).	EXPECTED: 10-degree abduction and 20-degree adduction.
• Flexion and extension Bend and straighten toes.	EXPECTED: Some flexion and extension, especially of great toes.
Test strength of ankle muscles
Ask patient to maintain dorsiflexion and plantar flexion while you apply opposing force.	EXPECTED: Bilaterally symmetric with full resistance to opposition.
	UNEXPECTED: Inability to produce full resistance.

Aids To Differential Diagnosis

Subjective Data	Objective Data
Ankylosing Spondylitis
Develops predominantly in male individuals between 20 and 40 years of age. Begins insidiously with low back pain, also involving hips and shoulders. Pain can fluctuate from one side to the other and progress to reduced spinal mobility.	Restriction in the lumbar flexion of the patient. The shoulders, hips, and knees may be affected later, developing limited range of motion. Uveitis may be present.
Carpal Tunnel Syndrome
Numbness, burning, and tingling in the hands often occur at night. Can also be elicited by rotational movements of the wrist. Pain may radiate to the arms.	Weakness of the hand and flattening of the thenar eminence of the palm may result.
Gout
Sudden onset of a hot, swollen joint; exquisite pain; limited range of motion. Primarily affects men older than 40 years and women of postmenopausal age. Classically affects the proximal phalanx of the great toe, although the wrists, hands, ankles, and knees may be involved.	The skin over the swollen joint may be shiny and red or purple. Uric acid crystals may form as tophi under the skin with chronic gout.
Lumbar Disk Herniation
Can be associated with lifting heavy objects. Common symptoms include low back pain with radiation to the buttocks and posterior thigh or down the leg in the distribution of the dermatome of the nerve root. Pain relief is often achieved by lying down.	Spasm and tenderness over the paraspinal musculature may also be present. Patient may have difficulty with heel walking (L4 and L5) or toe walking (S1). Numbness, tingling, or weakness may occur in the involved extremity.
Bursitis
Common sites include the shoulder, elbow, hip, and knee with pain and stiffness surrounding the joint around the inflamed bursa. The pain usually is worse during activity.	Limitation of motion caused by swelling; pain on movement; point tenderness; and an erythematous, warm site. Soreness may radiate to tendons at the site.
Osteoarthritis
See table on p. •••.
Rheumatoid Arthritis
See table on p. •••.
Sprain
Often associated with improper exercise warm-up, fatigue, or previous injury. Severity ranges from a mild intrafibrinous tear to a total rupture of a single muscle.	Temporary muscle weakness, spasm, pain, and contusion.
Fracture
Usually occurs in the setting of acute trauma. Can occur more easily in patients with bone disorders (e.g., osteogenesis imperfecta, osteoporosis, bone metastasis).	Deformity, edema, pain, loss of function, color changes, and paresthesia.
Tenosynovitis (tendinitis)
Pain with movement of such common sites as the shoulder, knee, heel, and wrist.	Point tenderness over the involved tendon. Pain with active movement, and some limitation of movement in the affected joint.
Rotator Cuff Tear
May be pain in the shoulder and deltoid area that can awaken the patient at night.	May be an inability to maintain a lateral raised arm against resistance. Tenderness over the acromioclavicular joint. Grating sound on movement, crepitus, and weakness in external shoulder rotation.

Differential Diagnosis of Arthritis

Signs and Symptoms	Osteoarthritis	Rheumatoid Arthritis
Onset	Insidious	Gradual or sudden (24–48 hours)
Duration of stiffness	Few minutes, localized, but short “gelling” after prolonged rest	Often hours, most pronounced after rest
Pain	On motion, with prolonged activity, relieved by rest	Even at rest, may disturb sleep
Weakness	Usually localized and not severe	Often pronounced, out of proportion with muscle atrophy
Fatigue	Unusual	Often severe, with onset 4–5 hours after rising
Emotional depression and lability	Unusual	Common, coincides with fatigue and disease activity, often relieved if in remission
Tenderness over localized afflicted joint	Common	Almost always; most sensitive indicator of inflammation
Swelling	Effusion common, little synovial, reaction swelling rare	Fusiform soft tissue enlargement, effusion common, synovial proliferation and thickening
Heat, erythema	Unusual	Sometimes present
Crepitus, crackling	Coarse to medium on motion	Medium to fine
Joint enlargement	Mild with firm consistency	Moderate to severe

Pediatric Variations

Examination

Musculoskeletal findings and motor development in infants, children, and adolescents change as they grow. (For a complete description of age-specific anticipated pediatric findings, see Chapter 21.)

Sports Participation Screening Examination for Children and Adolescents

• Observe posture and general muscle contour bilaterally.

• Observe gait.

• Ask patient to walk on tiptoes and heels.

• Observe patient hop on each foot.

• Ask patient to duck-walk four steps with knees completely bent.

• Inspect spine for curvature and lumbar extension, fingers touching toes with knees straight.

• Palpate shoulder and clavicle for dislocation.

• Check the following for range of motion—neck, shoulder, elbow, forearm, hands, fingers, hips.

• Test knee ligaments for drawer sign.

Sample Documentation

Subjective

A 13-year-old girl referred by school nurse because of uneven shoulder and hip heights. Active in sports, good strength, no back pain or stiffness.

Objective

Spine straight without obvious deformities when erect, but mild right curvature of thoracic spine with forward flexion. No rib hump. Right shoulder and iliac crest slightly higher than left. Muscles and extremities symmetric; muscle strength appropriate and equal bilaterally; active range of motion without pain, locking, clicking, or limitation in all joints.