THE EXTREMITIES AND SPINES

GENERAL OBJECTIVES

a. Examine the musculoskeletal system as a means of assessing its structure and

functions.
b. Recognize normal from abnormal findings.
c. Record the result of the physical findings in a standard format using internationally
accepted medical terminologies.
d. Correlate the physical findings with the history to arrive at a possible clinical
diagnosis.

GENERAL APPROACH

a. Observation plays a key role and begins the moment the patient enters the room.
Note how he/she enters or is brought in and the ease of motion involved with:
1. Sitting and getting up from the chair; and
2. Walking to the examining table

b. During the interview, you should have evaluated the patient’s abilities to carry out
normal activities of daily living and keep these abilities on mind during your
physical examination.
1. Have you any pain or stiffness in your muscles, joints or back?
2. Can you dress yourself completely without any difficulty?
3. Can you walk up and downstairs without any difficulty?

c. When dealing with a person with painful joints, be gentle and allow the patient to
move and change positions at his or her own pace.

d. In general, the sequence for examining the musculoskeletal system are:

1. Inspect for redness, swelling, limited motion, deformity, and
condition of overlying skin.
2. Palpate for heat, tenderness, texture, crepitus, instability and muscle
strength. Also note any symmetry of joint involvement.
 e. Preparation of the patient:
1. Examine the head and neck with the patient in a lying position.
2. When examining the upper extremity:
a. Male patient is stripped down to his waist while a female patient
retains her undergarment.
b. Have the patient sit on a stool or on the examining table.
3. When examining the lower extremities and hips:
a. Examine the patient lying on an examination table.
b. The patient is preferably stripped to his undergarments.
4. When examining the spine:
a. Examine the patient in standing position or sitting on a stool.
b. He/she may wear a hospital gown provided that the back is
adequately exposed.

EXAMINATION OF THE HEAD AND NECK

Specific objectives:
1. To review the anatomy and landmarks
2. Inspection
3. Palpation
4. Range of motion
5. Common abnormalities
6. Recording of normal results

TEMPOROMANDIBULAR JOINT

Objective 1: TOPOGRAPHIC ANATOMY AND LANDMARKS

1. BONE
a. Fossa and articular tubercle of the temporal
bone
b. Condyle of the mandible
2. LANDMARK
a. Anterior to the tragus or 0.5cm anterior to the
external auditory meatus
Objective 2: INSPECTION

Observe for symmetry, swelling and redness.

Objective 3: PALPATION

Locate the TMJ by placing your index finger anterior to the tragus of each ear
then ask the patient to open the mouth and feel your index finger slips into the joint
space and gently palpate for tenderness, snapping (clicking) and crepitation.

Objective 4: RANGE OF MOTION

Have the patient perform the following:

1. Open and close the mouth
§ NORMAL - 3-6cm space between the upper and lower incisors
when the mouth is opened
2. Move the jaw laterally to each side
§ NORMAL – mandible should move 1-2 cm in each direction
3. Protruding and retracting the jaw
§ NORMAL – lower teeth may be positioned anterior to the upper
teeth

Objective 5: COMMON ABNORMALITIES

1. TMJ Dysfunction – may present with pain, crepitus, locking or popping
2. TMJ Subluxation and Dislocation

Objective 6: RECORDING OF NORMAL RESULTS

TMJ is symmetrical, no swelling, redness, tenderness, crepitation or

snapping with normal range of motion.
CERVICAL SPINE

Objective 1: TOPOGRAPHIC ANATOMY AND LANDMARKS

1. BONES
a. 7 Cervical Vertebrae
b. 7th Cervical Spine – most prominent spinous
process when the neck is flexed

Objective 2: INSPECTION

Inspect the neck from anterior, posterior and lateral position. Describe the:
1. Alignment of the head with the shoulders
2. Symmetry

Objective 3: PALPATION

Palpate with your thumb the spinous processes of the cervical spine as well as the
trapezius muscle. Note for tenderness.

Objective 4: RANGE OF MOTION

1. FORWARD FLEXION – bend the head forward and touch the chin to the chest
(expected ROM 45 degrees)
2. HYPEREXTENSION – bend the head backward with chin toward the ceiling
(expected ROM 45 degrees)
3. LATERAL BENDING – bend the head to each side with ear to each shoulder (expected
ROM 40 degrees)
4. ROTATION – turn the head to each side with chin to shoulder (expected ROM
70 degrees)
Objective 5: COMMON ABNORMALITIES
1. Torticollis – nape pain with neck muscle spasm
2. Cervical Osteoarthritis

Objective 6: REPORT OF NORMAL RESULTS

Cervical spine curve is concave and symmetrical with normal muscle

tone and no tenderness.

EXAMINATION OF THE UPPER EXTREMITIES

I. WRIST AND HANDS

Specific objectives:
1. To review the anatomy and landmarks
2. Inspection
3. Palpation
4. Range of motion
5. Special Maneuvers
6. Common abnormalities
7. Recording of normal results

Objective 1: TOPOGRAPHIC ANATOMY AND LANDMARKS

Hand and Wrist

 1. BONES
a. Distal end of the ulna and radius
b. Carpal bones – navicular, lunate, pisiform, hamate, trapezoid, triquetrum,
capitate, scaphoid
c. Metacarpal bones
d. Distal, middle and proximal phalanges

2. LANDMARKS
a. Bony tips of the radius (laterally) and the ulna (medially)
b. Groove at the dorsum of the wrist

3. JOINTS
a. Joints at the wrist
§ Radiocarpal or wrist joint
§ Distal radioulnar joint
§ Intercarpal joints
b. Hand Joints
§ Metacarpophalangeal joints (MCP)
§ Proximal interphalangeal joints (PIP)
§ Distal interphalangeal joints (DIP)

Objective 2: INSPECTION

Inspect the dorsal and palmar aspects of the hands and wrists and note for:
1. Swelling and erythema over the joints
2. Deformities, nodules and bony enlargements
3. Muscle atrophy

Objective 3: PALPATION

A. Joints at the wrist

Palpate each radiocarpal joint by placing your thumbs over the dorsum of the
radiocarpal groove. Slide your thumbs slightly distal to palpate for the intercarpal joints.
Note for tenderness.
 B. Metacarpophalangeal Joints

Compress the MCP joints by squeezing the patient’s hand from each side using the
examiner’s thumb and index finger.

If (+) for tenderness, place your thumb just distal to the knuckles on each side of
the extensor tendon. Your fingers should be on the head of the metacarpals in the palm.
Note for any tenderness, swelling or bogginess of each MCPs.

C. Interphalangeal Joints

Palpate the medial and lateral aspect of each PIPs and DIPs between your
thumb and index finger and note for swelling, bogginess, tenderness and bony
enlargement.

Objective 4: RANGE OF MOTION

A. RADIOCARPAL JOINT

With the elbows flexed at 90 degrees and fixed at the waist with palms down:

1. FLEXION – flex the wrist as much as possible (expected ROM 90 degrees)

2. EXTENSION – extend the wrist as much as possible (expected ROM 70
degrees)
3. ULNAR DEVIATION – move hand laterally (expected ROM 55 degrees)
4. RADIAL DEVIATION – move hand medially (expected ROM 20 degrees)

B. 2nd – 5th MCP, PIP and DIP JOINTS

1. FLEXION – make a fist
2. EXTENSION – extend the fingers
3. ABDUCTION – spread the fingers apart
4. ADDUCTION – bring the fingers together

C. 1st MCP and IP JOINTS (THUMB)

1. FLEXION – move the thumb across the palm and touch the base of the 5th
finger
2. EXTENSION – move the thumb back across the palm and away from the
fingers
3. ABDUCTION – place the fingers and thumb in the neutral position with palms
up and then move the thumb anteriorly away from the palm
4. ADDUCTION – move the thumb back down then touch the thumb to each of
the other fingertips
Objective 5: SPECIAL MANEUVERS

A. Wrist: CARPAL TUNNEL SYNDROME

1. Tinel Sign: Percuss the medial side of the

palmaris longus tendon.
o Positive result: tingling sensation
in the palmar aspect of the
thumb, index, middle fingers up
to half of the ring finger (supplied
by the median nerve)

2. Phalen’s test: Ask the patient to press the backs of both

hands together to form right angles.
o This maneuver compresses the median nerve and
produces pain in the areas supplied by the median
nerve and relieved by extension of the wrist.

Objective 6: COMMON ABNORMALITIES

1. Osteoarthritis
a. Bouchard’s node – bony enlargement over the PIP joint
b. Heberden’s node - bony enlargement over the DIP joint

Objective 7: RECORDING OF NORMAL RESULTS

A. INSPECTION

There are no visible deformities, redness, swellings, bony enlargement, nodules and
muscle atrophy.

B. PALPATION

No bogginess, swelling and tenderness on the wrist, MCP, PIP and DIP joints.

C. RANGE OF MOTION

Normal range of motion of the joints of the wrist and hand

ELBOWS
Specific Objectives
1. To review the anatomy and landmarks
2. Inspection
3. Palpation
4. Range of motion
5. Common abnormalities
6. Recording of normal results

Objective 1: TOPOGRAPHIC ANATOMY AND LANDMARKS

1. BONES
a. Distal end of the humerus
b. Proximal end of the ulna and the radius

2. LANDMARKS
a. Medial and lateral epicondyles of the humerus
b. Olecranon process of the ulna
c. Olecranon bursa – between the olecranon process and the skin
d. Ulnar nerve – between the olecranon process and medial epicondyle

3. JOINTS
a. Humeroulnar joint – flexion and extension of the elbow
b. Radiohumeral joint – pronation and supination of the elbow
c. Proximal radioulnar joint – pronation and supination of the elbow

Objective 2: INSPECTION

Inspect the elbows in both fully flexed and fully extended positions and note for:
1. Erythema
2. Swelling
3. Nodules
4. Deformity
Objective 3: PALPATION

Support the patient’s forearm with your left hand so that the elbow is flexed at
about 70 degrees and palpate the:
1. extensor surfaces of the ulna and the olecranon process for any nodules or
swelling
2. medial and lateral epicondyles of the humerus for any tenderness
3. grooves between the epicondyles and the olecranon process for tenderness,
swelling or thickening of the synovial membranes

Objective 4: RANGE OF MOTION

A. HUMEROULNAR JOINT
o FLEXION – with the elbow fully extended at 0 degrees, bend the elbow as much
as possible (expected ROM 160 degrees)
o EXTENSION – with the elbow flexed, straighten the elbow as much as possible

B. RADIOHUMERAL JOINT and PROXIMAL RADIOULNAR JOINT

o SUPINATION - flex the elbow at 90 degrees and turn the palms up (expected
ROM 30 degrees)
o PRONATION - flex the elbow at 90 degrees and turn the palms down
(expected ROM 45 degrees)

Objective 5: COMMON ABNORMALITIES

1. Olecranon bursitis
2. Rheumatoid nodules
3. Osteoarthritis
4. Epicondylitis:
a. Lateral epicondylitis (tennis elbow) – follows repetitive extension of the wrist or
pronation-supination of the forearm
b. Medial epicondylitis (pitcher’s or golfer’s elbow) – follows repetitive wrist
flexion as in throwing

Objective 6: RECORDING OF NORMAL RESULTS

A. INSPECTION: There are no visible deformities, redness, swellings and nodules.

B. PALPATION: No bogginess, swelling nor tenderness on the elbow joint. No

thickening of the synovial membranes.

C. RANGE OF MOTION: Normal range of motion of all the elbow joints.

SHOULDERS
Specific Objectives
1. To review the anatomy and landmarks
2. Inspection
3. Palpation
4. Range of motion
5. Common abnormalities
6. Recording of normal results

Objective 1: TOPOGRAPHIC ANATOMY AND LANDMARKS

1. BONES
o Manubrium sterni
o Clavicles
o Scapulae
o Proximal humerus
2. LANDMARKS
o Acromion process of the
scapula
o Coracoid process of the
scapula
o Greater tubercle of the
humerus
3. JOINTS
o Sternoclavicular joint
o Acromioclavicular joint
o Glenohumeral joint
o Scapulothoracic articulation –
not a true joint

Objective 2: INSPECTION

Inspect the contour of the shoulder and shoulder girdle, clavicles and scapulae,
and the surrounding musculature for any muscular atrophy, swelling or deformity.
Objective 3: PALPATION

Palpate the joint spaces, bones and muscles. Note for tenderness, crepitations
and subluxation.

Objective 4: RANGE OF MOTION

1. FORWARD FLEXION – with palms facing each other, raise both arms forward and
straight up over the head (expected ROM 180 degrees)
2. HYPEREXTENSION – extend and stretch both arms behind the back (expected ROM
50 degrees)
3. ABDUCTION – lift both arms laterally and straight up over the head with palms
facing each other (expected ROM 180 degrees)
4. ADDUCTION – cross each arm in front of the body (expected ROM 50 degrees)
5. INTERNAL ROTATION – place both back of hands behind the hips with elbow out
(expected ROM 90 degrees)
6. EXTERNAL ROTATION – place both palms of the hand behind the head with elbows
out (expected ROM 90 degrees)

Objective 5: COMMON ABNORMALITIES

1. Shoulder Dislocation - asymmetric contour and one shoulder with hollows

in the surrounding contour

2. Adhesive Capsulitis (Frozen Shoulder) – fibrosis of the glenohumeral joint

manifested by diffuse, dull aching pain in the shoulder and progressive
restriction of active and passive ROM but usually with no local tenderness

Objective 6: REPORT OF NORMAL RESULTS

Symmetrical contour, no tenderness on the joints, muscles and tendons.

No crepitus. Normal range of motion.
 EXAMINATION OF THE LOWER EXTREMITIES

HIPS
Specific objectives:
1. To review the anatomy and landmarks
2. Inspection
3. Palpation
4. Range of motion
5. Special Maneuvers
6. Common abnormalities
7. Recording Of Normal Results

Objective 1: TOPOGRAPHIC ANATOMY AND LANDMARKS

1. BONES
o Pelvic girdle (ischium, ilium and pubis)
§ Anterior superior iliac spine
§ Posterior superior iliac spine
§ Symphysis pubis
§ Iliac crest
o Sacrum
o Proximal end of the Femur

2. BURSAE (PICTURE)
o Psoas (iliopectineal or iliopsoas)
§ Anterior to the hip joint
o Trochanteric
§ Lies on the postero-lateral surface of the prominence lateral to the hip
joint
o Ischial (ischiogluteal)
§ Lies under the ischial tuberosity on which the person sits
3. JOINTS
o Acetabulofemoral joint (Hip joint)
§ Lies below the middle third of the inguinal ligament
o Sacroiliac joint
§ Lies under the dimples found in the lower lumbar region

4. MUSCLES (Review Neurologic Examination: Muscle Testing)

Objective 2: INSPECTION

A. Inspect for the GAIT

1. Two phases:
a. STANCE – when the foot is on the ground and bears weight (60% of the
walking cycle).
b. SWING – when the foot moves forward and does not bear weight (40% of
the walking cycle).
2. Width of the base
§ NORMAL – 2 to 4 inches from heel to heel
3. Rhythm
§ NORMAL – smooth and continuous
4. Position of the knee
§ Knee should be flexed throughout the stance phase, except when the
heel strikes the ground to counteract motion at the ankle

B. While STANDING, inspect the hips for:

1. Symmetry
2. Muscle atrophy
3. Deformities
4. Bruising and swelling

C. With the patient SUPINE, measure the TRUE LENGTH of the leg using a tape
measure from the anterior superior iliac spine to medial malleolus and assess for
symmetry.

Objective 3: PALPATION

A. Palpate the hip joint for warmth and tenderness

o With the thumbs on the anterior superior spines, move the fingers downward
from the iliac tubercles to the greater trochanter of the femur.
o Move the thumbs medially and obliquely to the pubic symphysis, which lies at
the same level as the greater trochanter.
o Palpate the posterior-superior iliac spine directly underneath the visible
dimples (Dimples of Venus) just above the buttocks.
 B. Palpate the bursae for warmth and tenderness
o With the patient supine, place the heel of the leg being examined on the
opposite knee:
§ ILIOPECTINEAL BURSA –Palpate deeply below the inguinal ligament
and lateral to the femoral pulse for the hip joint.
o With the patient lying on his non-painful side, flex and internally rotate the
affected hip:
§ TROCHANTERIC BURSA – palpate the bursa over the trochanter of
the femur.
§ ISCHIOGLUTEAL BURSA – palpate over the ischial tuberosity

Objective 4: RANGE OF MOTION

1. FLEXION
In a supine position, place the examiner’s hand under the patient’s lumbar
spine. Ask the patient to bend each knee in turn up to the chest and pull it firmly
against the abdomen. He should be able to flex his knees and hips without difficulty
while the opposite thigh remains near the table. (expected ROM 120 degrees)
o Lifting the extended leg off the examining table indicates a hip flexion
contracture in the extended leg. This is a positive THOMAS test.

2. EXTENSION
In a supine position, position the patient near the edge of the table and extend
the leg posteriorly. (expected ROM 30 degrees)

3. ABDUCTION
In a supine position, stabilize the pelvis by pressing down on the opposite ASIS
with one hand. With the other hand, grasp the ankle and abduct the extended leg until
you feel the iliac spine move on the opposite hip. (expected ROM 45 degrees)

4. ADDUCTION
In a supine position, stabilize the pelvis by pressing down on the opposite ASIS
with one hand. With the other hand, hold one ankle and move the leg medially across
the body and over the opposite extremity. (expected ROM 30 degrees)

5. EXTERNAL AND INTERNAL ROTATION

Flex the leg to 90 at hip and knee, stabilize the thigh with one hand, grasp the
ankle with the other, and swing the lower leg –medially for EXTERNAL ROTATION
(expected ROM 45 degrees) and laterally for INTERNAL ROTATION (expected ROM
40 degrees).
Objective 5: COMMON ABNORMALITIES

1. Osteoarthritis: frequently involves the hip joint. Movements of the joint are both
restricted and painful. The pain is usually felt in the groin but can be referred to
the anterior thigh, the knee or buttock.

2. Trochanteric bursitis: Lateral hip or thigh pain aggravated when lying on the
affected side

3. Shortening of one leg:

a. Fracture of the neck of femur: common in postmenopausal women and those

aged over 70 years following a minor trauma.
b. Dislocations: usually posterior and may be accompanied by acetabular
fractures. The leg is internally rotated, adducted and flexed.

4. Groin strains: common in people involved in sporting activities. The pain is dull
and exacerbated by hip movement.

Objective 6: SPECIAL MANEUVERS:

1. TRENDELENBURG’S TEST:
Ask the patient to stand and balance first on one foot and then the other.
Observing from behind, note for asymmetry or change in the level of the iliac crests.
When the iliac crest drops on the side of the lifted leg, the hip abductor muscles
(Gluteus minimus and medius) on the weight-bearing side are weak.
§ Used to detect hip dislocation of the affected side, gluteal muscle
weakness or paralysis on the weight bearing side
 2. PATRICK TEST/FABER TEST
In a supine position, passively flex the knee to a right angle and place the foot
on the opposite patella. Push the flexed knee laterally as far as the hip joint permits.
This is use to assess lateral rotation of the hip
i. NORMAL (negative PATRICK TEST): The knee of tested leg should fall
to the table or at least parallel to other leg with no pain. This excludes
symptomatic hip joint disease
ii. FABER (flexion, abduction and external rotation)

3. GAENSLEN’S TEST/PASSIVE HYPEREXTENSION:

In a supine position with the unaffected leg at the edge of the table, patient
flexes the knee of the affected side and holds it with both hands to fix the lumbar spine
against the table then hyperextend the unaffected thigh by pushing it downward over
the side of the table.
• Positive Gaenslen Test: pain in affected sacroiliac joint

Objective 7: REPORT OF NORMAL RESULTS

Normal gait, symmetrical legs, normal muscle development,
no deformities, no tenderness.
No limitations in the range of motion.
(-) Thomas Test, (-) Trendelenburg Test,
(-) Patrick Test, (-) Gaenslen Test
KNEES

Specific objectives:
1. To review the anatomy and landmarks
2. Inspection
3. Palpation
4. Range of motion
5. Special Maneuvers
6. Common abnormalities
8. Recording of normal results

Objective 1: TOPOGRAPHIC ANATOMY AND LANDMARKS BONES

Bone Anatomy of the Knee

Ligaments of the Knee

1. BONES
a. Patella
b. Femur
i. Medial epicondyle
ii. Lateral epicondyle
iii. Adductor tubercle
c. Tibia
i. Medial condyle
ii. Lateral condyle
iii. Tibial tuberosity
d. Fibula
i. Head

2. JOINTS
a. Tibiofemoral joints – formed by convex curves of the medial and lateral
condyles of the femur as they articulate with the concave condyles of the
tibia
i. Moves in the sagittal plane to flex and extend and in the transverse
plane to rotate when the knee is bent
b. Patellofemoral joints – patella slides on the groove of the anterior aspect of
the distal femur (called the trochlear groove) during flexion and extension
of the knee

3. MENISCUS
a. Medial and lateral menisci – cushion the action of the femur on the tibia

4. LIGAMENTS
a. Anterior cruciate ligament – from the lateral condyle of the femur to the anterior
intercondylar area
i. Prevents anterior displacement of the tibia relative to the femur

b. Posterior cruciate ligament – from medial condyle of the femur to the posterior
intercondylar area
i. Prevents posterior displacement of the tibia relative to the femur

c. Transverse ligament – from the lateral meniscus to the medial meniscus

i. Stabilizes the medial meniscus
 d. Medial (TIBULAR) collateral ligament – from medial epicondyle of the femur to
the medial tibial condyle
i. Protects the medial side of the knee from being bent open by stress
applied to the lateral side of the knee (valgus force)

e. Lateral (FIBULAR) collateral ligament – from lateral epicondyle of the femur to

the head of the fibula
i. Protects the lateral side of the knee from an inside bending force
(varus force)

5. BURSAE
a. Suprapatellar Pouch – lies 6 centimeters above the upper border of the
patella, lying upward and deep to the quadriceps muscle

b. Prepatellar Bursa – lies between the patella and the overlying skin

c. Anserine Bursa – lies 1-2 inches below the knee joint on the medial surface,
proximal and medial to the attachments of the medial hamstring muscles
on the proximal tibia

d. Semimembranous Bursa – communicates with the joint cavity on the

posterior and medial surfaces of the knee

*(Except for the suprapatellar pouch, bursae are difficult to palpate unless inflamed.)

Objective 2: INSPECTION
With the patient in supine position with knees extended, inspect the knees for:
1. Erythema
2. Swelling (Loss of normal hollows around the patella)
3. Alignment
4. Deformities
5. Atrophy of quadriceps muscle
Objective 3: PALPATION

A. BURSAE
1. Palpation of the Suprapatellar Pouch

With the patient supine and the knee extended, start 10 centimeters above the
superior border of the patella. With your thumb and fingers in a grasping fashion,
move your hand distally in progressive steps, trying to identify the pouch and continue
along the sides of the patella.
§ Note for:
• Tenderness
• Thickening or swelling
• Warmth

B. MENISCUS
1. Palpation of the Medial Meniscus

Palpate the medial soft-tissue depression along the upper edge of the tibial
plateau with the tibia slightly internally rotated.

2. Palpation of the Lateral Meniscus

Palpate the lateral joint line for the lateral meniscus with the knee in slight
flexion.

C. JOINTS: Palpate for tenderness, warmth and crepitus.

1. TIBIOFEMORAL JOINT

Feel for tenderness along the tibial margin by flexing the knee to about
90 degrees and with the thumb press the tibio femoral joint on each side of the
patellar tendon.
i. If positive, do Mc Murray’s Test (see Knees: Special Maneuvers).

D. COLLATERAL LIGAMENTS

Palpate along the course of the collateral ligament laterally and medially and
identify any points of tenderness.
Objective 4: RANGE OF MOTION
1. FLEXION
o Ask the patient to stand on one leg while bending the knee of the other leg.
(expected ROM 130 to 150 degrees)
2. EXTENSION
o From the flexed position, straighten the leg and stretch it. (expected ROM 15
degrees of hyperextension)
3. INTERNAL ROTATION
o While sitting, swing your lower leg toward the midline. (expected ROM 10
degrees)
4. EXTERNAL ROTATION
o While sitting, swing your lower leg away from the midline. (expected ROM 10
degrees)

Objective 5: COMMON ABNORMALITIES

1. Synovial thickening or effusion – normal hollows disappear, may even bulge.
2. Angular deformities
a. Genu varum (bowlegs)
b. Genu valgum (knock knees)
c. Flexion contracture

Objective 6: SPECIAL MANEUVERS

1. PATELLO-FEMORAL GRINDING TEST
With the patient supine and knee extended, use your palm to compress the
patella against the underlying femur then push the patella distally. Ask the patient to
tighten the quadriceps against the examination table.
§ POSITIVE: Pain suggests degenerative diseases of the knees such as
osteoarthritis.

2. TESTS FOR EFFUSION IN THE KNEE JOINT

a. BULGE SIGN (for minor effusion)
With the knee extended, milk the fluid from the suprapatellar pouch and
lateral side into the medial side of the knee. When the fluid has been forced to the
medial side, gently tap the joint over the fluid.
§ POSITIVE: Fluid wave on the lateral side between the patella and the
femur
 b. BALLOON SIGN (for major effusions)

Rest the index finger and the thumb of your right hand on each side of the
patella. With your left hand, compress the suprapatellar pouch back against the
femur and feel for the fluid entering the space under your right thumb and finger.

If fluid is felt, press the patella backward against the femur with your right
hand, as your left hand feels for the fluid returning to the suprapatellar pouch. This
confirms the balloon sign.

3. TEST FOR MENISCAL TEAR

a. Mc MURRAY TEST

With the patient supine, fully flex the knee. Place

your left hand over the knee with the fingers touching the
lateral joint line and the thumb on the medial joint line.
With your other hand, grasp the heel and loosen the joint
by rotating the leg inward and outward.

i. MEDIAL MENISCUS – Apply an inward stress (valgus) on the knee by

external rotation of the leg and then extend the leg slowly.
ii. LATERAL MENISCUS – Apply an outward stress (varus) on the knee
by internal rotation of the leg and then extend the leg slowly.
iii. POSITIVE: An audible or palpable “click” confirms a torn meniscus.

4. TEST FOR CRUCIATE LIGAMENTS

a. DRAWER SIGN

With the patient supine and the affected knee flexed at a right angle,
stabilize the patient’s foot to anchor it by pressing against the examining table
using the left hand or sitting on it. Using your right hand, grasp the upper part of
the leg with your fingers in the popliteal fossa.

i. ANTERIOR DRAWER SIGN/ANTERIOR

CRUCIATE LIGAMENT – pull the head of tibia
1. POSITIVE: significant forward excursion
of the tibia
2.
 ii. POSTERIOR DRAWER SIGN/POSTERIOR
CRUCIATE LIGAMENT – push the head of
the tibia
1. POSITIVE: significant backward
excursion of the tibia

Objective 7: RECORDING OF NORMAL RESULTS

INSPECTION

No erythema, swelling, malalignment, deformities, atrophy of the quadriceps

muscle.

PALPATION

No warmth, tenderness, crepitus, thickening or swelling over the joints, bursae,

meniscus and ligaments.

RANGE OF MOTION

Full range of motion

SPECIAL MANEUVERS

Negative for patellofemoral grinding, Bulge sign, Balloon sign, Mc Murray Test
and Anterior and Posterior Drawer sign.
ANKLES AND FEET

Specific objectives:
1. To review the anatomy and landmarks
2. Inspection
3. Palpation
4. Range of motion
5. Common abnormalities
6. Recording Of Normal Results

Objective 1: TOPOGRAPHIC ANATOMY AND LANDMARKS

The ankle is made up of:

1. BONES:
o Distal end of the tibia: MEDIAL
MALLEOLUS
o Distal end of the fibula: LATERAL
MALLEOLUS
o Calcaneus (heel bone), Talus, Tarsus

2. JOINTS:
o TIBIOTALAR (ankle) JOINT – formed by the articulation of the
medial malleolus with the talus
o SUBTALAR JOINT – formed by the articulation of the talus
posteriorly with the calcaneus
o TRANSVERSE TALAR JOINT – formed by the articulation of the
talus with the tarsal bones

3. TENDONS
o ACHILLES TENDON - inserts the gastrocnemius muscle to the
calcaneus
o PERONEAL TENDON - inserts the peroneus muscle behind and
below the lateral malleolus, and is held in a groove by the superior
peroneal retinaculum.
 4. LIGAMENTS
o TIBIOFIBULAR LIGAMENT -attaches the TIBIA to the FIBULA.
o DELTOID LIGAMENT - attaches the medial malleolus to the talus
and also the calcaneus
o CALCANEOFIBULAR LIGAMENT - attaches the lateral malleolus
to the calcaneus.
o ANTERIOR TALOFIBULAR LIGAMENT - attaches the lateral
malleolus to the talus on the anterior side.
o POSTERIOR TALOFIBULAR LIGAMENT - attaches the lateral
malleolus to the talus on the posterior side

The feet is made up of:

1. BONES
o Phalanges (toes)
o METATARSAL BONES
o TARSAL BONES

2. JOINTS
o Distal and proximal interphalangeal
joints
o Metatarsophalangeal joint
o Metatarsotarsal joints

• LONGITUDINAL ARCH – imaginary line extending from the heads of the metatarsals
to the calcaneus
• Weight bearing area of the foot – imaginary line from the heel midline to between the
2nd and 3rd toes

• FOREFOOT - from the tips of the toes to the head of the metatarsals
• MIDFOOT – from the head of the metatarsals to the tarsal bones
• HINDFOOT – from the tarsals to the calcaneus
Objective 2: INSPECTION

Inspection for:
A. Deformities involving the:
o Longitudinal arch:

pes planus (flat foot) pes cavus (high instep)

o Toes - hammer toes, mallet toes, claw toes

B. Callus and corns

C. Redness and swelling
D. Nodules
E. Malalignments
o hallux valgus (bunion)
o pronation of the heel (medial shift of the weight bearing area)

Objective 3: PALPATION

Palpate for:

A. Tibiotalar (ankle) joint

Place both thumbs on the anterior surface of the joint and feel for any
bogginess, thickening, swelling and tenderness.

B. Achilles tendon
Place the Achilles tendon in between your thumb and 2nd and 3rd finger pads
and feel for tenderness, gouty and or xanthomatous nodules.

C. Metatarsophalangeal joints

o To SCREEN for tenderness

Compress the metatarsophalangeal joints by squeezing the forefoot between the
thumb and the 2nd and 3rd fingers.

If (+) for tenderness, LOCALIZE the tenderness by palpating each metatarsal

heads on the ball of the foot between your thumb and index finger to elicit tenderness.
Objective 4: RANGE OF MOTION
To assess the range of motion of the foot and the ankle, ask the patient to perform the
following movements while he is sitting with his feet hanging.

A. TIBIOTALAR JOINT
o DORSIFLEXION – point the foot towards the ceiling (expected ROM 20 degrees)
o PLANTARFLEXION – point the foot towards the floor (expected ROM
45 degrees)

B. SUBTALAR (talocalcaneal) and TRANSVERSE TARSAL (talotarsal) joint

o INVERSION – turn the sole of the foot towards the other foot
(expected ROM 30 degrees)
o EVERSION – turn the sole of the foot away from the other foot
(expected ROM 20 degrees)
o ABDUCTION – turn the foot laterally away from the other foot
(expected ROM 10 degrees)
o ADDUCTION – turn the foot medially towards the other foot
(expected ROM 20 degrees)

C. Metetarsophalangeal and interphalangeal joints

o FLEXION – curl the toes towards the ball of the foot
o EXTENSION – extend the toes away from the ball of the foot

Objective 5: COMMON ABNORMALITIES

1. Callus - areas of thickened skin due to chronic pressure over the weight bearing area of
the sole of the foot.
o Common locations - ball and heel of the foot
o Usually painless

2. Corns - areas of thickened skin due to chronic pressure over non-weight bearing areas
of the foot.
o Common site - dorsum of the toes
o Usually painful

3. Hallux valgus - lateral deviation of the big toe with

prominence of the first Metatarsophalangeal joint.
o Bunion - highly prominent 1st
metatarsophalangeal joint usually as a
consequence of halux valgus.
 4. Hammer toe - permanently flexed PIP with hyperextension of the DIP and the MTP.
o Usually affect the 2nd toe

5. pes planus ( flatfoot) - flattening of the medial longitudinal arch.

6. pes cavus ( high in-step ) - elevation of the medial longitudinal arch.

7. Pronation of the heel - causes a medial shift of the weight bearing area.
o The heel of the shoes is more worn-out on the medial side instead of the
usual lateral side.

8. Onychocryptosis (ingrown toe nail) -excessive transverse growth of the nail plate
causing painful laceration of the nail fold.
o Usually affects the nail of the big toe.

9. Achilles tendinitis - painful swelling and redness of the achilles tendon.

o Maybe due to wearing high heels, tight heel strap sandals or gonococcal
infection.

Objective 6: RECORDING OF NORMAL RESULTS

INSPECTION

There are no visible deformities, callus, corns, redness, swellings, nodules and
malalignments.

PALPATION

No bogginess, thickening, swelling nor tenderness on the ankle joint. No palpable

nodules and tenderness on the achilles tendon, metatarsophalangeal joint and the
interphalangeal joints.

RANGE OF MOTION

Normal range of motion of all the ankle joints.

 EXAMINATION OF THE SPINE
Specific objectives:
1. Review the anatomy and landmarks
2. Inspection
3. Palpation
4. Range of motion
5. Special Maneuver
6. Common abnormalities

Objective 1: TOPOGRAPHIC ANATOMY AND LANDMARKS

1. BONES
a. Vertebrae – cervical, thoracic, lumbar and
sacrococcygeal
*The spinous processes becomes more evident on
forward flexion.
* C7 and T1 spinous processes of are more
prominent.
b. Scapulae
c. Pelvis - Iliac crest and posterior superior
iliac spines
*A line drawn between the iliac crest crosses
the spinous process of L4.
2. Muscles
a. Trapezius
b. Latissimus dorsi
c. Paravertebral muscles

3. Joints
a. Intervertebral joints – between the vertebral discs
b. Interfacet joints – between the anterior and posterior facets

Objective 2: INSPECTION

1. With the patient standing, inspect the spine from the sides and observe the cervical
and lumbar curves directed outward and the thoracic and sacrococcygeal directed
inward. Note for any deformities, nodules, swelling and malalignment.

2. From behind, observe the bony landmarks and muscles as described above. The
shoulder and the pelvis should be at the same level.
 3. Inspect for lateral curves and note for deformities, nodules, swellings and
malalignment.

Objective 3: PALPATION

1. With patient in sitting or standing position, palpate with your thumb for tenderness of
the spinous process. You may percuss the spine by gently thumping with the ulnar
surface of your fist to elicit tenderness.
2. Palpate along the paravertebral muscle and bony prominences using your finger pads
and note for spasm, masses and tenderness.

Objective 4: RANGE OF MOTION

1. FLEXION - Ask the patient to bend forward to touch his toes. Lateral curvature may
become more evident with this movement. The lumbar curve should flatten out.

2. LATERAL BENDING - Sit behind the patient and stabilize the pelvis with your hand
and ask him to bend to the right and left

3. EXTENSION - Ask the patient to bend backwards towards you.

4. ROTATION - Have the patient twist to the right and left.

Objective 5: SPECIAL MANEUVERS

A. STRAIGHT LEG RAISING (SLR): test for nerve root

compression

1. With the patient in supine position and knee

held in extension, grasp the left ankle and raise
the leg to determine the range of flexion in the
hip joint.
2. Note the degree of hip flexion at which pain occurs.
3. Ask the patient to dorsiflex the foot. Repeat test on the right side.

*Test both limbs separately. Record the angle at which pain is experienced and note for
difference of the 2 sides.
*Shooting pain radiating from the back down the leg or feeling of sudden numbness in the
examined limb at 30 degrees to 70 degrees elevation suggests tension on or compression of the
nerve roots, often caused by a herniated lumbar disc. Dorsiflexion of the foot aggravates the
pain.

*A localized pain at the hamstring area at 90 degrees elevation indicates hamstring muscle
tightness.

B. SCHOBER TEST: measure flexion of lumbar

spine

1. Have the patient stand erect, with his heels

together.
2. Make a mark directly over the spine 5 cm.
below and 10 cm. above the lumbosacral
junction (identified by a horizontal line
between the posterior superior iliac spine).
3. Ask the patient to bend forward maximally.
4. Measure the distance between the 2 marked areas.

*The distance between the 2 marks increases 5 cm. or more in the case of normal mobility and
less than 4 cm. in case of decreased mobility.

Objective 6: COMMON ABNORMALITIES

1. Scoliosis - lateral deviation of the spine (dextroscoliosis if curvature is to the right;

levoscoliosis if curvature is to the left)

2. Lordosis – exaggerated outward or posterior curvature of the spine