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INTRODUCTION

The musculoskeletal system constitutes a demanding part of the physical examination in terms of both knowledge and time. The most important insight with regard to the physical examination is that the skillful examiner focuses this critical task through information obtained in a careful history. The second critical realization is that a thorough knowledge of musculoskeletal anatomy is essential to the performance of an accurate and meaningful examination. An atlas should be at hand (or only a few computer strokes away) as a quick reference.

OBTAINING A HISTORY

The clinician may begin the patient interview by asking the following two questions: (1) Are the patient’s symptoms articular in nature? and (2) do they derive from a musculotendinous location? If the answer to either of these questions is yes, then the examiner can begin to focus his or her efforts on the specific anatomic parts referred to by the patient in the history, bearing in mind two points:

  • Referred pain and an incomplete understanding of the anatomy may affect the patient’s localization of the complaint. For example, “hip pain” perceived over the lateral side while rolling over in bed at night is more likely to be trochanteric bursitis than pathology of the true hip joint.

  • Musculoskeletal complaints are sometimes part of overarching, systemic disorders that affect the joints, muscles, bones, and tendons.

Pain present at rest usually indicates an acute inflammatory, neurologic, or neoplastic process. In addition to determining which musculoskeletal structures are the source of the patient’s symptoms, the overall objectives of the examination should be kept in mind. These are outlined in Table 1–1.

Table 1–1.Overall objectives of the physical examination.

SPECIFIC EXAMINATION TECHNIQUES

Observation

The examiner should take the opportunity to observe the patient’s posture and mobility when he or she first enters the examination room. Alternatively, if the patient is already in the examining room or on the examination table when first encountered, the examiner should request at some point during the assessment that the patient stand, walk a few yards, and sit again. Gait analysis (for limp) ...

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