Upper Extremities And Spine Musculoskeletal Exam

Front 1

Low back pain red flags

Back 1

- Over age 50
- History of cancer
- Weight loss
- Pain at night or increased by rest
- History of IV drug use
- Presence of infection/fever

Front 2

Lupus (SLE)

Back 2

Presents with back pain and butterfly rash

Front 3

Psoriasis

Back 3

Presents with back pain, scaly rash on flexor surfaces and nail pitting

Front 4

Lyme disease

Back 4

Presents with back pain and an expanding erythematous patch in an early febrile patient.

Front 5

Reiter’s syndrome

Back 5

Presents with back pain and conjunctivitis with urethritis.

Front 6

Acute rheumatic fever

Back 6

Presents with back pain preceding sore throat.

Front 7

Ulcerative colitis or scleroderma

Back 7

Presents with back pain, diarrhea and abdominal pain.

Front 8

What is the most active joint in the body?

Back 8

Temporal Mandibular Joint (TMJ)

Front 9

What muscles, nerves and actions involve the TMJ?

Back 9

Opening the mouth - external pterygoids.
Closing the mouth - masseter, temporalis, internal pterygoids

Innervated by CN V (trigeminal nerve)

Front 10

What muscles comprise the rotator cuff (scapulohumeral) group?

Back 10

Supraspinatus
Infraspinatus
Teres minor
Subscapularis

Action - rotates shoulder laterally

Front 11

What muscles consist of the axioscapular group?

Back 11

Trapezius
Rhomboids
Serratus anterior
Levator scapulae

Action - pulls shoulder back

Front 12

What muscles consist of the sciohumeral group?

Back 12

Pectoralis major
Pectoralis minor
Latissimus dorsi

Action - rotates shoulder internally

Front 13

Flexion of the shoulder joint involves what muscles?

Back 13

- anterior deltoid
- pectoralis major
- biceps brachii
- coracobrachialis

Front 14

Extension of the shoulder joint involves what muscles?

Back 14

- latissimus dorsi
- teres major
- posterior deltoid
- triceps brachii

Front 15

ABduction of the shoulder joint involves what muscles?

Back 15

- supraspinatus (testable with open can test)
- middle deltoid
- serratus anterior

Front 16

ADduction of the shoulder joint involves what muscles?

Back 16

- pectoralis major
- coracobrachialis
- latissimus dorsi
- teres major
- subscapularis

Crossover sign test AC joint stability.

Front 17

Internal rotation of the shoulder joint involves what muscles?

Back 17

- subscapularis (test w/ lift off test)
- anterior deltoid
- pectoralis major
- teres major
- latissimus dorsi

Examine by having patient but hand behind back.

Front 18

External rotation of the shoulder joint involves what muscles?

Back 18

- infraspinatus (testable with isolation)
- teres minor
- posterior deltoid

Examine by having patient but hand behind head.

Front 19

What tests indicate shoulder impingement?

Back 19

Neer's and Hawkin's sign

Front 20

Neer’s sign

Back 20

Press on scapula with one hand to prevent motion, raise the arm with the other hand.

Pain with movement = positive sign

Front 21

Hawkin’s sign

Back 21

Flex shoulder/elbow to 90 degree with palm down. Place one hand on arm and one on forearm, rotate the arm internally.

Pain with movement = positive sign

Front 22

What tests evaluate the rotator cuff?

Back 22

Empty can test - supraspinatus strength

Drop arm - supraspinatus strength

Lift off - subscapularis

Internal rotation - infraspinatus

Front 23

What tests evaluate the biceps tendon?

Back 23

Yergason’s test - forearm supination

Speed’s test - forearm supination

Front 24

Yergason’s Test

Back 24

Forearm supination
- Flex the elbow to 90 degree, and pronate hand
- Provide resistance as patient supinates the hand

Pain and clicking = positive biceps tendon injury

Front 25

Speed’s Test

Back 25

Forearm supination
- Flex shoulder to 90 degrees with supination at wrist
- Examiner resists flexion

Pain on movement = positive sign

Front 26

Crossover test

Back 26

Adduct the arm across the chest

Pain/decreased ROM indicates:
- Inflammation of the AC joint
- AC joint instability

Front 27

Sulcus sign

Back 27

- Relax arm at side and grasp forearm
- Apply downward force while observing joint

Sulcus seen = positive
- Indicates glenohumeral (GH) joint instability

Front 28

Apprehension test

Back 28

- Abduct the shoulder to 90 degree
- Externally rotate arm

Pain or patient apprehension = positive
- Indicates anterior joint instability

Front 29

Calcific tendinitis

Back 29

Degenerative process in the tendon associated with the deposition of calcium salts.

Usually involves supraspinatus tendon

Acute, disabling attacks of shoulder pain may occur, usually in patients > age 30, more often in women.

Front 30

Biceps tendonitis

Back 30

Inflammation of the long head of the biceps tendon and tendon sheath causes anterior shoulder pain resembling and often coexisting with rotator cuff tendinitis.

S/S - tenderness is maximal in the bicipital groove.

Externally rotate and abduct the arm to separate this area from the subacromial tenderness of supraspinatus tendinitis.

Positive Yergason's test

Front 31

Adhesive capsulitis

Back 31

Fibrosis of the glenohumeral joint capsule (frozen shoulder)

S/S - diffuse, dull, aching pain in the shoulder

PE - progressive restriction of active and passive range of motion, usually no localized tenderness

Usually unilateral, occurs in ages 50-70

Front 32

Anterior dislocation physical findings

Back 32

- Postive apprehension sign
- Rounded lateral aspect of the shoulder appears flattened
- Deformity with pain
- Patient holds arm in neutral position

Front 33

Medial epicondylitis

Back 33

Pitcher’s elbow
Follows repetitive wrist flexion, as in throwing

Wrist flexion against resistance increases the pain

Front 34

Lateral epicondylitis

Back 34

Tennis elbow
Follows repetitive extension of the wrist or pronation-supination of the forearm.

When the patient tries to extend the wrist against resistance, pain increases.

Front 35

Olecranon Bursitis

Back 35

Swelling and inflammation of the olecranon bursa

May result from trauma or may be associated with rheumatoid or gouty arthritis.

Superficial to olecranon process

Front 36

Arthritis of the elbow

Back 36

Synovial inflammation or fluid felt best in the grooves between the olecranon process and the epicondyles on either side.

Palpate for a boggy, soft, or fluctuant swelling and for tenderness.

Front 37

Rheumatoid arthritis/nodules

Back 37

Subcutaneous nodules may develop at pressure points along the extensor surface of the ulna

Firm and nontender, not attached to the overlying skin

May occur near olecranon bursa or more distally

Front 38

Thenar eminence

Back 38

Three muscles that compose the thumb and provide flexion, extension and opposition

Atrophy may indicate median nerve compression (carpal tunnel syndrome)

Front 39

What signs of osteoarthritis may be observed in the fingers?

Back 39

Heberden’s nodes at DIP
Bouchard’s nodes at PIP

Front 40

Tinel’s sign

Back 40

Tapping lightly over the course the median nerve

Aching and numbness when tapped = positive
- Indicates carpal tunnel syndrome

Front 41

Phalen’s sign

Back 41

Hold the wrists in flexion for 60 seconds

Numbness and tingling in the median nerve distribution = positive
- Indicates carpal tunnel syndrome

Front 42

Finkelstein’s test

Back 42

Patient grips their thumb in the palm and ulnar deviates the wrist

Pain = positive
Indicates de Quervain's tenosynovitis

Front 43

Acute RA

Back 43

Tender, painful, stiff joints in rheumatoid arthritis, usually with symmetric involvement on both sides of the body.

PIP, MCP, and wrist joints are the most frequently affected.
Note the fusiform or spindle-shaped swelling of the PIP joints in acute disease.

Front 44

Ganglion cyst

Back 44

Round, usually nontender swellings along tendon sheaths or joint capsules, frequently at the dorsum of the wrist.

Front 45

Chronic tophaceous gout

Back 45

Joint involvement is usually not as symmetric as in rheumatoid arthritis.
Acute inflammation may be present.
Knobby swellings around the joints ulcerate and discharge white chalklike urates.

Front 46

Trigger finger (type of contracture)

Back 46

Caused by a painless nodule in a flexor tendon in the palm, near the metacarpal head. The nodule is too big to enter easily into the tendon sheath during extension of the fingers from a flexed position.

With extra effort or assistance, the finger extends and flexes with a palpable and audible snap as the nodule pops into the tendon sheath.

Front 47

Neurofibromatosis

Back 47

- Café-au-lait spots (discolored patches of skin)
- Skin tags
- Fibrous tumors

Front 48

Spina bifida occulta (least severe)

Back 48

- Birthmarks
- Port-wine stains
- Hairy patches
- Lipomas often overlie bony defects (possibly unknown to patient)

Front 49

Osteoporosis

Back 49

A progressive bone disease characterized by declining bone mass. Risk factors include:
- Postmenopausal Caucasian women
- Age >50
- Weight < 70kg
- History of fractures
- Family history in 1st degree relative of fractures
- Higher intake of alcohol
- Delayed menarche or early menopause
- Smoker
- Low vitamin D
- Use of corticosteroids for >2 months

Front 50

Osteoporosis/osteopenia diagnosis

Back 50

Bone density accounts for 70% of bone strength

Measured by Dexascan
- Normal T score: -1.0 and above
- Osteopenia: between -2.5 and -1.0
- Osteoporosis: less than -2.5

Front 51

Cauda equina syndrome

Back 51

Low back pain and neurologic dysfunction with urinary retention and overflow incontinence resulting from lesion or tumor of the L1-S5.

Bowel or urinary retention or incontinence.

Front 52

Signs/symptoms of inflammation and arthritis

Back 52

- Swelling
- Warmth
- Tenderness
- Redness

Front 53

What type of joint is the TMJ?

Back 53

Condylar synovial joint, a fibrocartilaginous disc that cushions the action.

Front 54

TMJ inspection

Back 54

Look for joint symmetry, alignment, bony deformities, swelling and/or color changes.

Front 55

TMJ Palpation

Back 55

Palpate joint:
Place tips of index fingers just in front of tragus of each ear and ask patient to open his or her mouth. Fingertips should drop into the joint spaces as the mouth opens.

Palpate muscles:
Masseters - externally at the angle of the mandible
Temporal muscles - externally during clenching and relaxation of the jaw

Front 56

TMJ range of motion (ROM)

Back 56

Grind and hinge motions
- Open/close - normal is 3 fingers can be inserted
- Protrusion/retraction (jutting jaw forward)
--- bottom teeth can be placed in front of upper
- Lateral or side-side motion

Front 57

TMJ Syndrome

Back 57

Typical features are unilateral chronic pain with chewing, jaw clenching, or teeth grinding, often associated with stress, may also present as headache.

Front 58

TMJ syndrome exam/diagnosis

Back 58

Exam - swelling, tenderness, and decreased range of motion in inflammation

Differential diagnosis - temporal arteritis, trigeminal neuralgia

Trauma - dislocation of the TMJ may be seen, palpable crepitus or clicking in poor occlusion, meniscus injury, or synovial swelling from trauma

Front 59

Shoudler girdle

Back 59

Shoulder derives its mobility from a complex interconnected structure of joints, large bones and principal muscle groups.

Front 60

What are the major joints of the shoulder?

Back 60

Glenohumeral
Sternoclavicular (SC joint)
Acromioclavicular (AC joint)

Front 61

Empty can test

Back 61

Supraspinatus strength
- Flex the arm to 60 degree and internally rotate with thumbs pointing down
--- like turning a can upside down and emptying it
- Resistance pressure downward

Weakness = positive, indicates possible rotator cuff (RTC) tear

Front 62

Drop arm sign

Back 62

Supraspinatus strength
- Abduct the shoulder to 90 degrees, then slowly lower, move arm up, pt moves arm down

Patient cannot lower smoothly = positive, indicates possible RTC tear

Front 63

Apley scratch test

Back 63

Overall shoulder rotation
- Ask patient to touch the opposite scapula using two motions - scratching upper and lower back

Front 64

Rotator cuff tendonitis

Back 64

Cause - repeated shoulder motion, as in throwing or swimming.

S/S - can cause edema and hemorrhage followed by inflammation, most commonly involving the supraspinatus tendon. Acute, recurrent, or chronic pain may result, often aggravated by activity. Patients report sharp catches of pain, grating, and weakness when lifting the arm overhead.

Physical findings - when the supraspinatus tendon is involved, tenderness is maximal just below the tip of the acromion.

Risk factors - patients are typically athletically active.

Front 65

Rotator cuff tear

Back 65

Cause - when arm is raised in forward flexion, rotator cuff may impinge against undersurface of acromion and coracoacromial ligament. Injury from a fall or repeated impingement may weaken the rotator cuff, causing a partial or complete tear, usually after age 40.

S/S - weakness, atrophy of the supraspinatus and infraspinatus muscles, pain, and tenderness may ensue.

Physical findings - in a complete tear of the supraspinatus tendon (illustrated), active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrugging of the shoulder and a positive “drop arm” test.

Front 66

Acromioclavicular arthritis

Back 66

Uncommon, usually arising from direct injury to the shoulder girdle with resulting degenerative changes.

S/S - tenderness localized over acromioclavicular joint, glenohumeral joint motion is not painful, but movement of the scapula, as in shoulder shrugging, is painful

Front 67

Anterior dislocation

Back 67

Shoulder instability from anterior dislocation of the humerus usually results from a fall or forceful throwing motion, then becomes recurrent.

Dislocations may also be inferior, posterior (relatively rare), and multidirectional.

Front 68

What muscles are involved in elbow flexion?

Back 68

Biceps brachii
Brachialis
Brachioradialis

Front 69

What muscles are involved in elbow extension?

Back 69

Triceps brachii
Anconeus

Front 70

What muscles are involved in elbow supination?

Back 70

Biceps brachii
Supinator

Front 71

What muscles are involved in elbow pronation?

Back 71

Pronator teres
Pronator quadratus

Front 72

Nursemaid's elbow

Back 72

Radial head subluxation at elbow, annular ligament becomes trapped

Caused by pulling on a extended pronated arm (as in pulling up on a unruly child’s arm)

Front 73

Dupuytren's contractures

Back 73

Thickening of the palmar fascia

Flexion contracture at 3rd, 4th and 5th fingers

Skin in this area puckers, and a thickened fibrotic cord develops between palm and finger. Flexion contracture of the fingers may gradually ensue.

Front 74

de Quervain's tenosynovitis

Back 74

Inflammation of the abductor pollicis longus and extensor pollicis brevis tendon and sheath.

Positive Finkelstein's test

Front 75

Hand grip strength

Back 75

Grip examiners 2nd and 3rd fingers
Tests intrinsic muscles of the hand

Causes - arthritis, CTS, epicondylitis, cervical radiculopathy

Front 76

How to test finger range of motion

Back 76

Flexion - make a fist
Extension - extend or open the fist
Abduction/Adduction - spread fingers apart and back together

Thumb ROM - flexion, extension, abduction, adduction, opposition

Front 77

Acute tenosynovitis

Back 77

Infection of the flexor tendon sheaths may follow local injury.

Finger is held in slight flexion; finger extension is very painful. If the infection progresses, it may extend from the tendon sheath into the adjacent fascial spaces within the palm.

Early diagnosis and treatment are important.

Front 78

What area of the back is especially vulnerable to injury?

Back 78

L5-S1 due to sharp posterior angle

Front 79

How common is low back pain?

Back 79

2/3 of adults have LBP at least once

85% have idiopathic back pain

Front 80

Spine inspection

Back 80

- Observe posture
- Assess patient for movements and gait
- Observe landmarks
- Inspect spinal curves

Front 81

Thoracic kyphosis

Back 81

Increased thoracic kyphosis occurs with:
- Aging
- Osteoporosis
- In children, it is a correctable structural deformity and should be pursued.

Front 82

Spinal landmarks

Back 82

Spinous processes (C7/T1)

Paravertebral muscles

Iliac crests
- Unequal heights (pelvic tilt) suggests leg length, scoliosis, or abnormality of hips

Posterior superior iliac spine (skin dimples)
- Line drawn across iliac crests usually marks L4

Shoulder symmetry
- Unequal shoulder heights in scoliosis, winging of the scapula, trapezius weakness

Front 83

Spine palpation

Back 83

Spinous processes (with thumb) – noting any “step off’s” (slips) of spondylolisthesis (displaced discs) – forward slippage of one vertebrae can compress spinal cord

Cervical facet joints (relaxed neck)

Sacroiliac joint – tenderness of SI joint indicates ankylosing spondylitis

Paravertebral muscles – not spasm and pain

Sciatic nerve – with hip flexed and patient lying on opposite side (L4-S3 nerve roots), tenderness suggests herniated disc

Tenderness of spinous processes indicates fracture, infection, arthritis, or dislocation.

Front 84

How to palpate the sciatic nerve

Back 84

Patient lies on side and flexes hip to opposite side.

The nerve lies midway between the greater trochanter and the ischial tuberosity as it leaves the pelvis through the sciatic notch.

Tenderness suggests herniated disc near L4-S3 nerve roots.

Front 85

Neck ROM

Back 85

Flexion and extension (chin down/up)
- Between the skull and C1, the atlas
- Flexion - SCM, scalene, prevertebral muscles
- Extension-splenius capitus, cervicis, intrinsic muscles

Rotation at C1-C2, axis (chin to each shoulder)
- Sternocleidomastoid, small intrinsic neck muscles

Lateral bending at C2-C7 (ear to each shoulder)
- Scalenes and small intrinsic neck muscles

Front 86

Spinal flexion

Back 86

Psoas major, psoas minor, quadratus lumborum; abdominal muscles attaching to the anterior vertebrae, such as the internal and external obliques and rectus abdominis

Bend forward and try to touch your toes

As flexion proceeds, the lumbar concavity (curve in lumbar area) should flatten out.

Front 87

Spinal extension

Back 87

Deep intrinsic muscles of the back, such as the erector spinae and transversospinalis groups.

Bend back as far as possible

Support the patient by placing your hand on the posterior superior iliac spine, with your fingers pointing toward the midline.

Front 88

Spinal rotation

Back 88

Abdominal muscles, intrinsic muscles of the back

Rotate from side to side

Stabilize the patient's pelvis by placing one hand on the patient's hip and the other on the opposite shoulder then rotate the trunk by pulling the shoulder and then the hip posteriorly and repeat these maneuvers for the opposite side.

Front 89

Spinal lateral bending

Back 89

Abdominal muscles, intrinsic muscles of the back

Bend to the side from the waist

Stabilize the patient's pelvis by placing your hand on the patient's hip and repeat for the opposite side.

Front 90

Scoliosis

Back 90

Lateral and rotatory curvature of the spine to bring the head back to midline.

Often becomes evident during adolescence, before symptoms appear.

Deformity of the thorax on forward bending.