- History is most important in diagnosing musculoskeletal problems.
- The mechanism of injury can explain the pathology and symptoms.
- Determine whether the injury is traumatic or atraumatic, acute
or chronic, high or low velocity (greater velocity suggests more structural
damage), or whether any movement aggravates or relieves pain associated with
Musculoskeletal problems account for about 10-20% of
outpatient primary care clinical visits. Orthopedic problems can
be classified as traumatic (ie, injury-related) or atraumatic (ie,
degenerative or overuse syndromes) as well as acute or chronic.
The mechanism of injury is usually the most helpful part of the
history in determining the diagnosis.
The onset of symptoms should be elicited. With acute traumatic
injuries, patients typically seek medical attention within 1–6 weeks
of onset. The patient should describe the exact location of symptoms,
which helps determine anatomic structures that may be damaged. If
the patient is vague, the clinician can ask the patient to point
with one finger only to the point of maximal tenderness.
The chief musculoskeletal complaints are typically pain (most common), instability or dysfunction around the joints. Since symptoms and signs are often nonspecific, recognizing the expected combination of symptoms and physical examination signs can help facilitate the clinical diagnosis. Patients may describe symptoms of “locking” or “catching,” suggesting internal derangement in joints. Symptoms of “instability” or “giving way” suggest ligamentous injury; however, these symptoms may also be due to pain causing muscular inhibition. Constitutional symptoms of fever or weight loss, swelling with no injury, or systemic illness suggest medical conditions (such as infection, cancer, or rheumatologic disease).
Initial evaluation should follow routine trauma guidelines to
rule out serious joint injury. However, typical evaluations in the clinic
follow the traditional components of the physical examination and
should include inspection, palpation, and assessment of range of
motion and neurovascular status.
Inspection includes observation of swelling, erythema, atrophy, deformity, and (surgical) scars (remembered by the mnemonic, “SEADS”).
The patient should be asked to move joints of concern (For example, see Table 41–1). If motion is asymmetric,
the clinician should assess the passive range of motion for any
Table 41–1. Shoulder Examination.
| Save Table
Table 41–1. Shoulder Examination.
Check the patient's posture and “SEADS” (swelling, erythema, atrophy, deformity,
Include important landmarks: acromioclavicular (AC) joint,
long head of biceps tendon, coracoid, and greater tuberosity (supraspinatus insertion).
Range of motion testing
Check range of motion actively (patient performs) and
passively (clinician performs).
Move the arm forward as high as possible in the sagittal
Check with the patient's elbow touching their body so that external
rotation occurs predominantly at the glenohumeral joint.
The patient is asked to reach the thumbs as high as possible behind
the spine on each side. The clinician can record the highest spinous
process that the individual can reach on each side (iliac crest = L4,
inferior angle of scapula = T8).
Rotator cuff strength testing
Supraspinatus (open can) test
Perform resisted shoulder abduction at 90 degrees with slight
forward flexion to around 45 degrees to test for supraspinatus tendon
strength (“open can” test), or with shoulder abduction
at 30 degrees and flexion to 30 degrees ("empty can" test).
The patient resists by externally rotating the arms with
elbows at his or her side.
Internal rotation (lift off test)
A positive "lift-off” test is the inability of
the patient to hold his or her hand away from the body when reaching
toward the small of the back. The clinician pushes the patient's
hand toward the back while the patient resists. A positive lift-off
indicates subscapularis tendon insufficiency.
Internal rotation (belly press test)
A positive “belly-press” test is the inability
to hold the elbow in front of the trunk while pressing down with
the hand on the belly. A positive belly press test indicates subscapularis
Neer impingement sign
Perform by having the clinician flex the shoulder maximally
in an overhead position. The test is positive when pain is reproduced
with full passive shoulder flexion. Sensitivity is 79%;
specificity is 53%.
Hawkins impingement sign
Perform with the shoulder forward flexed 90 degrees and
the elbow flexed at 90 degrees. The shoulder is then maximally internally
rotated to impinge the greater tuberosity on the undersurface of
the acromion. The test is considered positive when the patient’s
pain is reproduced by this maneuver. Sensitivity is 79%;
specificity is 59%.
With persistent anterior instability or a recent dislocation,
the patient feels pain or guards when the shoulder is abducted and externally rotated
at 90 degrees. With posterior instability, the patient is apprehensive with
the shoulder forward flexed and internally rotated to 90 degrees
with a posteriorly directed force
Load and shift test
Perform to determine shoulder instability by manually
translating the humeral head anteriorly and posteriorly in relation
to the glenoid. However, this test can be difficult to perform when the
patient is not relaxed.
Performed to rule out labral cartilage tears that often
occur following a shoulder subluxation or dislocation. The test
involves flexing the patient’s arm to 90 degrees, fully internally
rotating the arm so the thumb is facing down (palm down) and adducting
the arm to 10 degrees. Once positioned properly, the clinician applies
downward force and asks the patient to resist. The test is then
repeated in the same position except that the patient has his arm
fully supinated (palm up). A positive O’Brien test for labral
tear is pain deep in the shoulder with palm down more than the palm
up. The O’Brien test can also be used ...
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