Personal injury, trial and other attorneys who deal with medical legal issues increasingly find they need a solid understanding of the musculoskeletal system. In this program, Dr. Jeremy Stern, a board certified orthopedic surgeon will demonstrate and explain the complete orthopedic examination. Understanding clinical evaluation and diagnostic procedures used to do an orthopedic examination will help you to evaluate the medical evidence in your case. A basic understanding of the anatomy of the musculoskeletal system is essential.
The skeleton is compromised of 206 bones, which provides support and protection to vital tissues and organs. Bones are integral to the coordination and movement of joint and muscle groups and produce red blood cells. The appendicular skeleton consists of the bones of the shoulders, arms, legs, and pelvis. There are seven cervical, 12 thoracic, five lumbar, five sacral, and four coccygeal vertebrae in the spinal column. The atlas and axis are the first and second cervicals that allow rotation and angulation of the head. Articular surfaces where the vertebrae interface are protected and held in place by parallel running ligaments on all sides of the spinal column.
Skeletal muscles attached to bones, tendons, and ligaments and make up 40 to 45% of the total body mass with over 600 muscles used for locomotion and movement. Tendons are strong bands of tissue connecting muscle to muscle and to bones. Ligaments are dense, yet flexible bands of tissue that connect bones to other bones. The terms strain and sprain are often used to describe injury to ligaments, muscles, or tendons. However, it’s important to clarify whether the injury is a bruise, tear, or an overstretching. Avulsion is when the soft tissue is detached from the bone. Cartilage is the semi-smooth layer of elastic gel found at the ends of bones. Joints are areas where two bone surfaces meet.
The shoulder is a freely movable joint lined with lubricating synovial fluid. Range of motion is the degree of movement in angulation made by joints. Freely movable joints like the knee have more than one range of motions such as in flexion and extension. Attorneys with the assistance of medical professionals have to evaluate whether damage to the musculoskeletal system has been caused by traumatic injury. Pre-existing conditions such as congenital abnormalities, degenerative diseases and neoplastic conditions complicate diagnosis and prognosis and must be considered during an examination.
Dr. Stern: Performing a complete orthopedic exam consists of several types of exams. Before we begin the physical examination, a health history is taken from the examinee. This is followed by screening exam, then a specific physical examination focused on the patient’s condition. The history should include the patient’s chief complaint, recent and past injuries, general health, and daily activities. I want to determine the onset of the complaint, its duration and frequency, and precipitating or alleviating factors, associated symptoms, and prior treatment.
It is particularly important to determine exactly what the patient does in his or her job and to know any changes in symptoms over time. It is also important to note the dominant arm and to what degree the patient is limited in work and leisure activity. The orthopedic screening exam begins when the patient walks into the patient. You observe the patient for gait, strength, and coordination. And then begin to examine the patient for symmetry. If I could just ask you to stand up. Examining from the front, looking for ecchymosis or bruising, swelling, muscle discrepancy between the right and left side, which could be a sign of neurologic damage or atrophy due to pain response. And could you turn around please? Examining from the back again, looking for the same features.
And if you could turn around one more time. We now measure for limb length inequality by measuring from the anterior superior iliac spine to the medial malleolus or ankle bone. Inequalities in this measurement could be an objective but not very specific sign of joint dysfunction or spasm in the psoas, which couldn’t come from trauma to that muscle. In addition, we would measure the size of the muscles. It’s best to do this from set points, from bony landmarks. Circumferential measurements of the limb should be done with the muscle on the same state of tension so that the measurements are reproducible and accurate from visit to visit and to record these measurements are baseline in the chart.
Changes in the muscle mass again could be due to atrophy, which most commonly would be from a pain response. We are now going to measure range of motion both actively and passively. If I could ask you to sit down right here. Active motion is when the patient uses their muscles to move their joint through a range of motion. If I could ask you to extend your arm as far as you can out in front of you. Here, we see a hyperextension of about four or five degrees. And if you could flex your arm. And here we see active flexion of about 155 degrees. If there is any limitation to active motion, which could be caused by muscle or tendon injuries, nerve problems or joint dysfunction, I would go on to measure passive range of motion where I move the patient’s arm through a range of motion. Here, I would again get a slight hyperextension of five degrees and full flexion of about 155 degrees. Blocks to passive range of motion are almost always due to joint dysfunction. This is a highly objective finding.
Now that we’ve completed the general screening examination, we’ll go on to more specific musculoskeletal systems. In this case, we’ll be examining the cervical spine. I would first examine the spine for alignment and symmetry of the muscles from the front and then from the back. In addition from the back, we’d be looking for the normal cervical lordosis or curvature. Loss of this curvature can be caused by muscle spasm or more importantly by damage to the ligaments or discs in the cervical spine.
Host: Auto accidents lead to many whiplash injuries. Whiplash is a catchall phrase for a hyperextension injury to the neck. This can include damage to discs, facets, ligaments, tendons, and muscles. This group of injuries can be as mild as a muscular strain or as devastating as paralyzing injury. Underlying pre-existing conditions may also increase the severity of injury due to seemingly mild trauma.
Dr. Stern: I’m now going to palpate the spinous processes from the occiput or the base of the skull down to the seventh cervical vertebrae. I’m palpating for tenderness along this area, which could indicate ligament injuries and for spasm in the muscles. Ligament injuries or sprains are created one through three with a grade one sprain being a mild stretch injury with no real elongation to the ligament. A grade two sprain has an elongation and possibly tearing of the ligament but the ligament is still in continuity. Whereas a grade three sprain is a ligament, which is torn into two separate pieces. Sprains can cause very mild injuries, which get better without any treatment at all or more serious injuries, which could require surgical intervention. We are now going to measure the range of motion of the cervical spine.
Some people use a two inclinometer measurement to do this. I more often use the DRE method for estimating the cervical spine motion. Here, I’d ask the patient to actively put his chin as far towards his chest as he could go. And I would see how far the chin was away in inches and ask the patient to tip their head backwards, as far as you can get. Again looking at the distance from the occiput to the back. Now if you could put your head upright and rotate your chin as far towards this shoulder as you can get and then as far towards this shoulder as you can get. Now, bringing your chin back to the middle, I’d ask you to tip your ear down towards this shoulder and again over to this shoulder and back up towards the middle.
If there is any limitation in active motion, I would again test for passive motion, although I think this should be done very carefully in someone who’s had a cervical spine injury because you could cause further damage. Again, I would record the distances from the various anatomic landmarks to the base of shoulder, chest, whichever region we’re measuring. Although range of motion is an objective finding, it does require the patient’s best effort and cooperation to make this meaningful.
Host: Physicians frequently use inclinometers to evaluate range of motion and rate permanent impairment and disability cases. The American Medical Association guides to the evaluation of permanent impairment describe the principles for obtaining accurate inclinometer measurements. The use of the two inclinometer method is preferred as it gives a more accurate assessment of any loss of range of motion. Measurements are taken for cervical flexion and extension, cervical lateral flexion and cervical rotation. Extension angles are determined by subtracting the lower angle from the upper angle.
Dr. Stern: After the completion of the physical examination, supportive diagnostic tests are often ordered. X-rays are ordered in approximately 90% of cervical spine cases and often proved to be quite useful. X-rays can show fractures, facet dislocations or ligamentous tearing if flexion and extension views are obtained. In those cases where x-rays may not be enough, it’s possible to order MRI of the cervical spine, which can show disc herniation and/or ligamentous injury.
The shoulder exam begins by observing the patient from the front, looking for asymmetry in the muscle mass of the deltoid, which could indicate atrophy based on a axillary nerve problem. And for prominence at the AC joints or acromioclavicular joints, which could indicate a ligamentous injury in this area. I would then observe the patient from the back, looking for atrophy in the supraspinatus muscle or the infraspinatus muscle, which could indicate a rotator cuff tear or an injury to the suprascapular nerve. I would then ask the patient to do an active range of motion. Can you raise your hands up as far as you can and bring them back down? And I would do this in the front and to the side please and back down.
Patients who have more pain bringing their arms down than up could be a sign of a rotator cuff tear. The rotator cuff are four muscles above the shoulder, which help hold the ball into the socket and help rotate the arm. These muscles can be damaged by repetitive overhead use or by a single traumatic event. You then check external rotation at zero. Keep your elbows close to your side and rotate your hands outward and back to the middle and external rotation at 90 degrees. If you could bring your arms up and rotate them back again. Hands back as far as you can get them. Good.
The last would be to ask the patient to bring their thumb as far up their back as possible, excellent. Bring that down and do it with the other side, excellent. Loss of internal rotation is one of the earliest findings in someone who has a shoulder joint injury. I’d now be testing the muscular strength, particularly of the rotator cuff. If you could just bring your hands up this way and press up towards the ceiling as hard as you can. This is testing the supraspinatus and I should not be able to push the patient’s hands down. Certainly, the hands should be equal right and left.
Now, if I could ask you to push your hands outwards. This is testing the infraspinatus. Okay. And again, that should be equal. You’d also test the biceps. Don’t let me straighten your arm out, excellent. And the triceps. Don’t let me bend your arm, very good. And lastly, the deltoid muscles out to the side. Don’t let me bring your hands down again, very good. You can bring your hands down. And lastly, we would test for impingement or pinching of the rotator cuff with some provocative tests. Forced forward flexion in the plane of scapula. This would be painful on someone who has rotator cuff tendinitis or bursitis. External rotation and abduction and internal rotation at 90 degrees. I would again compare the two sides to see if there’s a difference. We can also check for instability of the shoulder, which could represent a ligament injury by pulling downward and looking for sulcus sign or increased space between the acromion and top of the humerus.
And also translate the humeral head forward and back with the arm at the side and again at 90 degrees. Any increase in the translation should be noted as to whether its forward, backward, or down. Examination of the lumbar spine would begin by asking the patient to stand and take off his shirt. I’ll be observing the back, particularly the lower portion of the back looking for the normal lumbar lordosis or curvature. I would also be looking for scoliosis or a lateral curvature of the spine, which sometimes presents with a rib hump or rotation of the trunk, difference in height of the shoulders or hips. If you could turn sideways again.
I would ask the patient to bend down and try and touch the toes. Looking again at the alignment of the spine and for how far the patient can get his hands towards the ground. If you could stand up again. Now I’d ask the patient to just stand normally, looking for the muscles, seeing if there is any noticeable swelling, which could indicate damage to the muscles with bleeding within the muscle or spasm by palpating. Just turn sideways a little bit more, palpating particularly around the spine along the paraspinal muscles. Again, this spasm could indicate facet problems, which are small joints within the spine, problems with the muscle or ligaments in the back as well as disc herniations. I would also palpate along the spinous processes, again looking for ligamentous injuries.
To begin an examination of the nerve roots, I’d ask the patient to sit on the table and I’d begin by examining the reflexes. It would start out, just relax your legs, let them hang loosely, by examining for the quadriceps reflex. It’s important to note that the presence or absence of the reflexes is not what is important but really the comparison of the right to left. They should be the same. I would then do ankle jerk reflex and then go on to test for nerve root irritation. Could I ask you to lay down with your head on the pillow? The test most commonly used for nerve root irritation would be the straight leg raise.
In this test, I simply have the patient lying flat on the bed and lift the leg up until such times the patient would indicate that this was painful. A positive test is for pain, which is running down the leg, usually below the knee. Pain in the back during this examination is not considered a positive finding. A positive finding on a straight leg raising would again be caused by nerve root irritation, most commonly from a disc herniation. In addition to the straight leg raise, you could look for crossover sign where I would lift this leg and sometimes the patient would report pain in the opposite leg. This is sometimes positive for a central disc herniation. The Lasègue test is performed by bringing the patients leg again into extension, to the spot where he would indicate that it hurt bending the knee slightly, and then pressing on the popliteal space to see if adding some tension to the nerve roots causes an increase in the patient’s radicular or pain running down the leg.
Next, I would examine the patient for strength, starting with the most distal muscles, being the extensor hallucis longus or the extenders of the big toe. Could you hold your toes up as far as you can this way and don’t let me pull them down? Again what we are looking for is a symmetrical or even muscle strength to both sides. I would then test the whole foot. Can you hold the foot up? This is the tibialis anterior and relax and then ask the patient to press down with the feet. Press hard, very good. I would palpate the calf muscles, ask the patient to hold the leg straight. Don’t let me bend the knee. Testing the quadriceps muscle and bend the knee and don’t let me straighten it out. Testing the hamstring muscles, relax. Any difference between right and left could indicate a problem with nerve, muscle, or tendon.
And last, we would test for sensibility. This can be done with manual palpation. Is there any difference in the way this feels from side to side? Or with a pin wheel or pin, which is not done as frequently anymore because people are afraid of using sharps on one patient after another. Testing for sensibility can also be done with a tuning fork but is not done as commonly.
Host: Compression of the spinal cord is usually from fracture fragments or hematoma. If the examinee has degenerative disease of the cervical spine, the examinee can get compression with simple hyperextension injury. Facet dislocation, a partial dislocation of the spine, can spontaneously reduce leaving a normal x-ray with a severely damaged cord. MRI may reveal a compressed cord. Clients with cord compression can have varying degrees of impairment.
Dr. Stern: We are now going to examine the range of motion of the lower spine by first asking the patient to stand up. Just stand up over here for me. There are a number of different ways to examine range of motion in the spine. One being the two inclinometer method. I’m going to use the more anatomic method and relate this to the DRE or Diagnosis Related Estimate method for determining impairment. If you could just bend down and show me how far you could get your hands towards the floor, okay… and stand back up. In this case, you would record that the patient can touch the palms to the floor. Another circumstances, it might be finger tips to the floor, finger tips to the top of the foot, finger tips six inches from the floor, etc.
Pain with forward flexion again can be caused by nerve root irritation, particularly if the pain runs down the legs and towards the foot. I then ask the patient to bend backwards as far as he could go and stand back. Pain with this motion is most often associated with spinal stenosis or pinching of the spinal cord usually due to arthritic changes within the spine. You would also look at side bending. Again, noting how far the arm gets down the side and to the other side and trunk rotation. Can you turn your body looking as far over this way as you can and as far the other way? And again, this can be recorded by shoulder straight to the front, 20 degrees from the front, etc.
Host: To rate impairment of the lumbosacral area, inclinometer measurements are taken of lumbosacral flexion and extension and lateral flexion. Depending upon the measurement for total sacral motion, a validity test is done by recording the straight leg raising angle of a supine patient.
Dr. Stern: There are five physical findings called the Waddell signs, which are associated with non-physiologic pain. As an example of this, we will show the distraction test whereby when the patient is asked if straight leg raising is painful, responds positively but when the same test is performed with the patient in a seated position… could you please sit up and slide down to the end of the table… where I would pretend to be looking at the patient’s knee but again doing a straight leg raising, the patient does not note pain. This test is very strongly positive for a non-physiologic source of pain. The other four Waddell signs, which are also indicative of non-physiological pain are stocking and glove distribution numbness, which does not follow a normal neural anatomy. Regional disturbances such as weakness, which again is non-anatomic in its nature and does not follow the normal neural anatomy.
Axial loading pain or trunk rotation pain, which should not cause nerve root irritation and pain behavior such grimacing or moaning with light palpation to the back. Any three of the five Waddell signs being positive is strongly significant for a non-physiologic pain. Myelography can be useful in checking for spinal abnormalities such as disc herniation. In this myelogram, we can see a herniated disc at this level causing cut off of dye filling into this nerve root. Spondylolisthesis is a slippage of one lumbar vertebrae on top of another. This can happen from traumatic or congenital causes or in this case, it’s from a degenerative cause. As you can see on this x-ray, the fourth lumbar vertebrae has slipped forward about one centimeter as compared to the fifth lumbar vertebrae. By comparison, the third lumbar vertebrae and fourth lumbar vertebrae line up evenly.
MRIs are highly effective tools for imaging the non-bony portions of the spine. They can be useful in diagnosing spinal stenosis caused by hypotrophy of the ligamentous tissues in the spine or for intraspinal tumors. In this MRI, we see a very large disc herniation ablating the nerve root. Discography can be useful in showing disc herniations and internal disc disruption. The way discography works is that the physician injects radiopaque dye and normal saline into the disc. While he is doing the injection, the physician notes how difficult it is to inject the dye into the disc as this tells you something about the internal portion of the disc as well as the annulus fibrosus. While doing the injection, if the pain the patient has been reporting is reproduced, this would be a positive discogram for herniation at this level.
Knee injuries are some of the most common injuries to the musculoskeletal system. And to begin the knee exam, I would look at the patient with my eyes at about their knee level and the patient fully weight bearing. I’m looking for the alignment of lower extremities whether their knees are knocked or bowed outward, which is a sign of arthritis usually. I’m looking for swelling, in particularly the cuff, which can be a sign of a life-threatening condition of DVT or deep venous thrombosis, which is a blood clot in the venous system of the lower extremity. In addition, I would look for muscle atrophy, which could be caused by any number of injuries to the muscles, tendons, or joint or it can be simply a pain response.
If I could ask you to stand up for me and if you could stand on just your right leg and now just your left leg, now back to both. And if you could squat down fully like I am and stand back up. Pain with a leg in a full squat can often be a sign of a meniscus or cartilage injury but also can be a sign of arthritis. The most important part of looking at the squatting is to see if the two legs are even and to record the depth to which both legs can squat. If I can get you to sit down on the table and lie your head on the pillow. The next portion of the examination would be to check for swelling within the knee joint. You can do this by ballottement of the patella where one hand pushes the swelling as much as you can into the knee, the other hand pressing the knee cap down seeing if its floating on a cushion of fluid. There should be no fluid or very little fluid within the knee joint.
In addition, with the hand in the same position, you can press medially and laterally to see if fluid surges from one side of the knee to the other. Again, there should be very little fluid within the knee joint. The exam would then move on to the patella by palpating all of the surfaces around the patella or knee cap, touching the under surface of the knee cap on the inside, which is often a sign of chondromalacia or chondrosis, which is roughening of the under surface of the knee cap. The same can be true laterally. I would examine the patella for its tilt to see how far it can tip this edge of the patella upward. A normal patella would tilt somewhere around five degrees.
This test, if there is tightness in the lateral structures, which can add to arthritis on the outside portion of the knee. In addition, I would test the glides to see how far I can push the patella to the inside and to the outside. Abnormal findings in this test usually indicate either patellar instability or again patellar tightness. After completing the exam of the patella, I would move on to a ligamentous exam. First, I would test probably the most important ligament of knee, the anterior cruciate ligament or ACL. The most sensitive test for this is the Lachman test where the knee is held in about 15 degrees of flexion. One hand holds the tibia or leg bone and pulls it forward checking for a solid endpoint and getting an idea how much the leg moves forward beneath the thigh.
Most important in this test is to compare one leg to the other because in most people, they are very similar without injury. A second test for the anterior cruciate ligament would be the anterior drawer test where the foot is supported usually by sitting on it. Hands are behind the leg and it is pulled forward sharply. Again, we are looking for anterior translation of the leg beneath the thigh. To test for the posterior cruciate ligament or PCL, we look for the stepoff of the tibia above the femur. We look for a posterior drawer sign or pushing the leg backwards again looking for a solid endpoint and to see if the leg sags when its held in 90 degrees.
The ligamentous exam is completed by checking the inner ligament, the medial collateral and the outer ligament, the lateral collateral in both full extension and in a few degrees of flexion. Any abnormal movements in any of these tests would indicate a ligament injury and one would have to estimate the grade of injury being one, two, or third degree sprain. When the ligament exam is complete, we will go onto an exam of the menisci or knee cartilages. This examination is best done by palpating the joint line manually trying to elicit pain in the patient and looking for swelling along the joint line. In addition, we do a bounce test by letting the knee drop sharply into extension and seeing if this causes pain. A flexion test by forcing the leg into full flexion and see if this causes pain and the McMurray test, where the fingers are placed on the joint line and the leg is twisted into internal and external rotation. Again, looking for pain but in this test also a click along the joint line.
The last part of the test would be to palpate the patellar tendon, patella, and quadriceps tendon looking for tendonitis or bursitis. Tenderness along this area should be compared to the opposite knee, again to try and elicit a response for tendonitis. MRIs and other tool, which can be very useful in helping to make the diagnosis of ligament injuries around the knee. In this MRI, you can clearly see the intact posterior cruciate ligament or PCL and the torn and the anterior cruciate ligament or ACL.
The wrist exam begins with an examination of the forearm and wrist, looking for atrophy of the muscles and testing range of motion. The wrist has range of motion in flexion and extension, radial and ulnar deviation, pronation and supination. Again, these motions will be tested both actively and passively to determine if there’s any muscle, tendon, or joint dysfunction. One of the most common diagnosis of the wrist is carpal tunnel syndrome or CTS. This is a very common repetitive strain or RSI injury. It is a pinching of the median nerve at the wrist and it’s commonly caused by overuse, which means that overtime more is asked of the musculoskeletal system than it can deliver. It’s important to remember that carpal tunnel can also be caused by fractures, scarring, and it’s quite common in pregnancy.
When looking for carpal tunnel syndrome, you would look for atrophy, particularly in the thenar muscles or muscles along the thumb here. These muscles are fed by the median nerve and if the median nerve is pinched at the wrist, this often gets to be smaller and weaker. The most sensitive test for carpal tunnel syndrome is the Phalen test.
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