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Chapter 1. Physical Examination of the Musculoskeletal System

John A. Mills, MD

A thorough knowledge of musculoskeletal anatomy is essential to the performance of an accurate and meaningful examination. As a quick reference, an atlas should be near at hand (or only a few computer strokes away). Manifestations that are elicited objectively, eg, swelling, warmth, effusions, or clearly limited range of motion, must be distinguished from more subjective findings such as tenderness and pain on motion.

The musculoskeletal system constitutes a demanding part of the physical examination in terms of both knowledge and time. The skillful examiner focuses this critical task through information obtained in a careful 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, which are outlined in Table 1–1, should be kept in mind.

Table 1–1. Overall Objectives of the Physical Examination.
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Table 1–1. Overall Objectives of the Physical Examination.

  1. Define the anatomic distribution of the problem. Is the process:

    • Monoarticular?
    • Polyarticular? If so, it is symmetric or asymmetric?
    • Does it involve only one extremity?
    • Is it axial?
    • Is it complex?

  2. Ascertain whether or not there are local signs of an inflammatory process.

  3. Determine if anatomic disruption is present; ie, joint instability, tendon rupture, bone fracture, or deformity.

  4. Distinguish between true muscle weakness as opposed to fatigue or disuse atrophy.

  5. Establish if constitutional symptoms, such as fever or weight loss, implicate a systemic process, or other symptoms are present that direct attention to other organs.

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) can help separate primary from antalgic or extra-articular manifestations of musculoskeletal disease, such as ...

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