Conducting An Office-Based Musculoskeletal Exam (Pt 1)

Recognizing the life-threatening disorders that may underlie some common musculoskeletal complaints is necessary for thorough evaluation and successful treatment. This review, the first of a two-part series, focuses on the evaluation of disorders of the shoulder, spine, and upper extremities.

By Kristin Bird, MD, and Gerald Moore, MD

Dr. Bird is a resident and Dr. Moore is a professor of medicine in the department of internal medicine at the University of Nebraska Medical Center in Omaha.

It is estimated that one in seven patients seen by primary care physicians complains of musculoskeletal pain or dysfunction. Many of these patients have self-limiting conditions, but others have systemic disease. Determining whether a patient's symptoms are caused by local injury or inflammation, a mechanical disorder, or systemic illness is crucial to successful treatment.

In this article, the first in a two-part series, we will discuss potentially life-threatening conditions that must be ruled out immediately during a musculoskeletal examination. We will then review the proper sequence of steps in the evaluation of musculoskeletal complaints involving the upper body, starting with the shoulder and proceeding to the elbow, wrist, hand, and spine. This review will include a discussion of common disorders affecting those anatomical sites.

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Recognizing Potentially Life-Threatening Conditions

When evaluating a patient who has musculoskeletal complaints, it is imperative to recognize serious or life-threatening conditions, such as trauma, compartment syndrome, and septic arthritis, that warrant immediate action (see table below). Red flags indicating a need for immediate evaluation include a red, hot joint, fracture or evidence of deformity, focal neurologic deficits, and constitutional signs and symptoms, such as fever or weight loss.

Patients with a history of trauma may present with a fracture or dislocation and evidence of deformity that necessitates immediate radiographic imaging and evaluation. Compartment syndrome occurs when increased tissue pressure within a closed muscle compartment compromises local circulation and neuromuscular function. Patients typically present with severe pain that seems disproportionate to the underlying condition. Other findings include pain that occurs during passive stretching of the compartment, muscle weakness, decreased pulses, and altered sensation. Immediate surgery is usually necessary to prevent permanent tissue loss and neurologic deficit.

Septic arthritis is a musculoskeletal emergency-a delay in its diagnosis reduces the likelihood of a successful outcome-and it is a major cause of other disorders. Joint destruction can occur within one week and cause permanent functional disability. Most articular infections involve a single joint, but some are polyarticular. In acute bacterial arthritis, joint pain is usually moderate to severe and worsened by movement or palpation. The involved joint is warm, swollen, and red. Most patients complain of fever.

Prosthetic joints and diseased joints are predisposed to septic arthritis. Other concurrent conditions associated with bacterial infection of joints include diabetes mellitus, rheumatoid arthritis, systemic lupus erythematosus (SLE), sickle cell disease, and intravenous drug abuse.

Bacteria can inoculate a joint after trauma or a surgical procedure or from a soft tissue abscess or contiguous focus of osteomyelitis. Bacteria may also reach a joint by hematogenous spreading from a distant site of infection.

Synovial fluid analysis is the most important test in diagnosing acute septic arthritis. The joint should be aspirated and Gram's stain and cultures obtained before empiric antibiotic therapy is begun. Antibiotic administration should then be modified on the basis of the test results.

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Orderly Evaluation

Once potentially life-threatening conditions have been ruled out, an orderly evaluation will help sort out musculoskeletal complaints, the most common of which is "arthritis." In such cases, it is important to distinguish between true articular disease and a soft tissue disorder such as bursitis, tendinitis, or muscle injury (see table below).

An evaluation of a patient's active and passive range of motion can help the physician make this distinction. The active range of motion is revealed as the patient imitates the movements the physician makes while demonstrating the key motions of the affected joint. Point tenderness that occurs in combination with reduced active range of motion and preserved passive range of motion is characteristic of a soft tissue disorder. A reduction of both active and passive range of motion suggests a true joint disorder.

The presence of joint fluid in the absence of trauma or infection usually indicates synovitis, a sign of articular involvement. Palpation reveals a boggy consistency and decreased range of motion in the affected joint. Another sign of articular disease is crepitation, a palpable or audible grating or crunching sensation produced by motion.

Swelling and pain may occur in both periarticular and articular disorders. In soft tissue disorders, however, pain is usually produced only during extremes of motion, whereas in articular disease pain occurs during all ranges of motion.

Pain, in fact, is the symptom that prompts most patients with musculoskeletal complaints to seek medical treatment. Eliciting details about the character of the pain, including its location and quality as well as its alleviating and aggravating characteristics, will provide important diagnostic clues. For example, pain described as numbness, a "pins and needles" sensation, or burning may indicate neuropathy. Pain associated with arterial insufficiency is produced by activity and is relieved promptly by rest. Articular pain is often described as an aching sensation that may be aggravated by movement and alleviated by rest.

Pain must be distinguished from stiffness that develops after inactivity. Morning stiffness associated with noninflammatory joint disease is usually short-lived, lasting less than a half-hour. Inflammatory disorders such as rheumatoid arthritis and polymyalgia rheumatica, however, are marked by prolonged stiffness that lasts more than an hour.

A complete physical examination and thorough review of systems should be performed on patients who have musculoskeletal complaints. Constitutional symptoms, including fever, should be noted. A temperature above 38.5ºC may reflect underlying infection, cancer, or an inflammatory condition such as SLE or vasculitis. Further evaluation is necessary when systemic disease is suggested by the presence of extra-articular symptoms, such as rash; uveitis, manifested as acute painful red eye with photophobia and blurry vision; pericardial or pleural rubs; diarrhea; urethritis; or lymphadenopathy.

Patients presenting with nonarticular disorders such as tendinitis or bursitis require a more focused evaluation. The most common disorders affecting each joint area and the corresponding examination findings are discussed below.

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Shoulder Disorders

The shoulder is a ball-and-socket joint in which the humeral head articulates with the glenoid fossa. The joint is made stable by the muscles and tendons surrounding it, including the rotator cuff, deltoid, latissimus dorsi, and pectoral muscles.

Evaluation of the shoulder should begin with visual inspection. The examiner should be alert for evidence of asymmetry, swelling, erythema, or a bony deformity. Next, palpation of the shoulder, bicipital groove, subdeltoid area, and trapezius should be performed to detect tenderness. Active range of motion should also be assessed. Normal shoulder range of motion is 180º of forward flexion and 60º of extension, 90º of internal and external rotation with the elbow flexed at 90º, and 180º of abduction and 30º of adduction.

Rotator cuff tendinitis. Also called shoulder impingement syndrome, rotator cuff tendinitis is one of the most common causes of shoulder pain and can include one or several of the muscles of the rotator cuff. The impingement syndrome is occasionally associated with calcific deposits in the rotator cuff. Pain often occurs laterally in the deltoid muscle and may be worsened when the patient lies on the shoulder.

Pain that occurs during active abduction of the arm is the key finding. The disorder may also be indicated by the Neer impingement sign, which can be elicited when the examiner raises the patient's arm in forced forward flexion while the scapula is stabilized. Impingement is indicated by pain that occurs at or before 180º of forward flexion. Treatment consists of rest followed by stretching and strengthening exercises. Nonsteroidal anti-inflammatory drugs (NSAIDs) and local injection of the subacromial bursa with corticosteroids provide symptomatic relief.

Rotator cuff tears. Tears may develop in the rotator cuff after trauma-as occurs when someone falls on an outstretched hand or lifts a heavy object-or as a result of long-standing tendinitis or chronic inflammation caused by rheumatoid arthritis. Weakness in the rotator cuff will be demonstrated as the examiner resists external rotation or abduction. Incomplete tears are often difficult to distinguish from rotator cuff tendinitis. An arthrogram may provide a definitive diagnosis.

Small, complete tears and incomplete tears may be treated conservatively with rest, an NSAID, and physical therapy. Patients who fail to respond to this regimen or have acute full-thickness tears with functional weakness can undergo anterior acromioplasty and rotator cuff repair.

Bicipital tendinitis. Usually producing pain in the anterior shoulder and bicipital groove and radiating down the forearm, bicipital tendinitis is caused by the acromion impinging on the biceps tendon. Palpation of the bicipital groove will elicit the pain, as will supination of the forearm against resistance-the Yergason test (see figure below). Treatment is usually conservative-rest and analgesic therapy.

Rupture of the bicipital tendon is characterized by a bulge in the belly of the biceps muscle-known as the Popeye sign. In older patients, in whom rupture is often due to attrition, conservative management is preferred, since most patients are asymptomatic. Acute rupture occurring in in young, active patients is best treated surgically.

Adhesive capsulitis. Also known as frozen shoulder, adhesive capsulitis is associated with pain and limited range of motion in all planes. The shoulder capsule becomes thickened and fibrotic. When the shoulder is abducted, premature movement of the scapula at approximately 45º to 60º will be evident. Inflammatory arthritis, diabetes, or any prior injuries to the shoulder are potential causes of adhesive capsulitis.

Treatment of the disorder consists of a corticosteroid injection administered in the glenohumeral joint and NSAID therapy given for symptomatic relief. An aggressive physical therapy program should also be initiated, including range-of-motion exercises, transcutaneous electrical nerve stimulation, and ultrasound treatment. In refractory cases, surgical intervention may be necessary.

Osteoarthritis. A relatively uncommon condition of the shoulder, osteoarthritis is usually seen in conjunction with a history of trauma or injury to the shoulder or with certain occupations, such as jackhammer operator. If a patient has no predisposing history, other pathologic processes may be the cause, such as neuropathy in a joint caused by diabetes or syringomyelia. Analgesic therapy may provide symptomatic relief.

Inflammatory arthritis. Rheumatoid arthritis is the most common disorder that causes inflammatory arthritis of the shoulder. However, other systemic disorders, such as SLE, seronegative spondyloarthropathy, and psoriatic arthritis may also involve the glenohumeral joint. Patients with these disorders often have signs and symptoms of systemic disease and should be referred to a rheumatologist.

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Common Elbow Disorders

The elbow is a hinge joint consisting of three bony articulations. A visual inspection of the elbow should focus on detecting asymmetry, nodules, and swelling. Extensor nodules are most commonly seen in rheumatoid arthritis and gout, but they can also accompany other conditions. Rheumatoid arthritis nodules and gouty tophi are difficult to differentiate on the basis of physical examination findings alone. Swelling of the elbow may be caused by cellulitis or olecranon bursitis.

Normal range of motion for the elbow includes flexion to 160º and extension to 0º, although some women will demonstrate hyperextension to -15º. Pronation and supination should be assessed with the elbow flexed at 90º. Synovitis at the radiohumeral joint may limit supination. Palpation of the ulnar groove may reveal fullness, which suggests the presence of synovitis. Tenderness at the medial and lateral epicondyle may indicate a soft tissue process.

Lateral epicondylitis. Commonly known as tennis elbow, lateral epicondylitis produces localized tenderness directly over or slightly distal to the lateral epicondyle. Pain may be elicited through resisted dorsiflexion of the wrist. Although repetitive motion may be the underlying cause of lateral epicondylitis in tennis players and carpenters, the disorder is often idiopathic.

Rest is the most important aspect of treatment. When the pain is severe, a splint may be used to immobilize the elbow in 90º of flexion. Ice packs and NSAID therapy may also provide relief of pain and tenderness. When these symptoms have subsided, a muscle strengthening and flexibility program is essential therapy to prevent recurrence. A local corticosteroid injection is occasionally necessary.

Medial epicondylitis. Also known as golfer's elbow, medial epicondylitis is a similar condition that is less common than lateral epicondylitis. Pain usually occurs over the medial epicondyle. Treatment entails a short period of rest for the elbow and a course of NSAID therapy.

Ulnar nerve entrapment. An impingement of the nerve at the elbow, ulnar nerve entrapment produces numbness of the little finger and adjacent ring finger. Patients often report pain in the medial aspect of the elbow and tenderness when the ulnar groove is palpated. They may also complain of a loss of manual dexterity along with weakness of the little finger during abduction and flexion. Trauma, prolonged bed rest, or compression during anesthesia may cause ulnar nerve injury. Ulnar nerve entrapment may also accompany rheumatoid arthritis, in which synovial hypertrophy may produce compression of the nerve.

Avoiding repetitive activity and keeping pressure off the elbow may be all that is required for treatment. In severe cases, surgical correction may be necessary.

Olecranon bursitis. Easily identified by localized swelling around the olecranon process, olecranon bursitis is seen in conjunction with rheumatoid arthritis, calcium pyrophosphate dihydrate deposition, gout, and trauma (see figure below). It may be accompanied by warmth and erythema produced by an underlying infection. Aspiration of fluid may be both therapeutic and diagnostic. If no signs or symptoms of infection are present, no treatment is usually required.

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Wrist and Hand Disorders

The wrist is a complex joint consisting of the radius and ulna and seven carpal bones. Normal range of motion of the wrist includes palmar flexion to 90º and dorsiflexion to 70º. Normal ulnar deviation of the hand is approximately 50º and radial deviation 20º to 30º.

The wrist should be inspected for evidence of asymmetry, swelling, or deformity. Swelling may be associated with a disorder of the tendon sheaths or the wrist joint itself. Swelling caused by tenosynovitis tends to be more localized. Flexing and extending the fingers will change the appearance of the swelling. Articular swelling is more diffuse, extending laterally and distally to the radius and ulna. Synovitis of the wrist joint is best detected by palpating the dorsal surface of the wrist.

One of the most important steps in the physical examination of patients with articular disorders is the inspection of the hand. Bony enlargements that appear on the distal interphalangeal (DIP) joints (known as Heberden's nodes) and proximal interphalangeal (PIP) joints (Bouchard's nodes) are common in osteoarthritis. Palpation can easily distinguish these changes from soft tissue swelling or synovitis.

Several other abnormalities are common in inflammatory arthritis, including swan neck deformity, which is a hyperextension of the PIP joint accompanied by flexion contracture of the DIP joint, and boutonniere deformity, a flexion contracture of the PIP joint accompanied by hyperextension of the DIP joint (see figure below). If these deformities are nonreducible, rheumatoid arthritis is the likely diagnosis; if they are fully reversible, SLE should be suspected.

Another abnormality is the telescoping or shortening of the digits, which is produced by resorption of the ends of the phalanges. This condition is associated with arthritis mutilans resulting from psoriatic arthritis, which is often accompanied by pitting of the nails. Sclerodactyly, cyanosis, and atrophy of the fingertips occur in scleroderma.

With the proximal phalanges flexed slightly, the metacarpophalangeal (MCP) joints should be palpated on the dorsal aspect of the metacarpal heads on each side of the extensor tendons. Slight swelling in one or more joints can best be detected by comparing the joints in question with unaffected joints. Synovitis of the MCP joints is often associated with lateral compression tenderness, which can be elicited by squeezing the hand at the level of the joints. The PIP and DIP joints are best examined by firmly squeezing the joints on their lateral aspects. A spongy feeling suggests synovitis.

Range of motion is usually determined by observing the patient make a fist. An inability to completely close the fingers at the palm may suggest arthritis, but this finding is usually nonspecific.

Ganglia. A ganglion is a cystic enlargement arising from a joint or tendon sheath. It occurs most commonly over the dorsum of the wrist. Ganglia are lined with synovium and may contain a gelatinous material. They are painless and may develop after trauma, but most are idiopathic. No treatment is usually required.

De Quervain's tenosynovitis. Produced by inflammation of the abductor pollicis longus and extensor pollicis brevis at the base of the thumb, de Quervain's tenosynovitis may be aggravated by repetitive activity that involves a pinching motion with the thumb while the wrist is moved. Pain will be present in the area of the radial styloid. The disorder may also be confirmed by pain that occurs during the Finkelstein test: The thumb is folded into the palm and the fingers are flexed into a fist over the thumb while the examiner passively places the wrist into ulnar deviation.

Tenosynovitis occurs in other flexor and extensor tendons of the wrist besides those involved in de Quervain's tenosynovitis. The findings vary depending on the involved tendon, but localized pain, tenderness, and swelling are usually present. Pain that is provoked by resisted movement is also typical.

Treatment involves rest, splinting, and cessation of the task that induced the pain. In addition, NSAID therapy and an injection of corticosteroids along the tendon sheath are often useful.

Radial nerve palsy. Compression of the radial nerve against the humerus will cause paralysis of the nerve. Wrist drop may be evident, which is demonstrated by palmar flexion of the MCP joints and adduction of the thumb. If the radial nerve is compressed more proximally-through improper use of crutches, for example, or from placing the arm over the back of a chair-weakness may develop in the triceps and brachioradialis muscles. Compression injuries usually heal spontaneously within a few weeks.

Carpal tunnel syndrome. The most common cause of paresthesias of the hand, carpal tunnel syndrome occurs when the median nerve is compressed in the fibro-osseous tunnel of the wrist. Episodes of burning, tingling, or numbness in the hand occur and are typically worse at night. Symptoms may be aggravated by such activities as driving or holding up a newspaper. The classic presentation involves paresthesias in the thumb, index finger, middle finger, and lateral half of the ring finger.

Tapping on the median nerve may reproduce these paresthesias, known as Tinel's sign They may also be revealed by the Phalen's test, in which the flexed wrists are held against each other. In chronic cases, thenar muscle atrophy may be observed. The syndrome may be caused by any process that encroaches on the carpal tunnel, such as edema associated with pregnancy or trauma. Other conditions that have been associated with carpal tunnel syndrome include inflammatory disorders of the wrist, such as gout, pseudogout, and rheumatoid arthritis, as well as myxedema, acromegaly, lipomas, and ganglia.

In mild cases, symptoms are often relieved by immobilization of the wrist in the neutral position and cessation of the aggravating activity. Local corticosteroid injections and NSAID therapy may also be helpful. When conservative treatment fails, surgical decompression may be indicated.

Dupuytren's contracture. A flexion deformity of a finger, Dupuytren's contracture occurs when the palmar fascia becomes thickened and contracted, drawing one or more fingers into flexion at the MCP joint. Palpation of the palmar fascia may reveal a fibrous nodule, and dimpling and puckering of the skin over the involved fascia may be observed. Chronic diseases such as epilepsy, alcoholism, and diabetes mellitus have been associated with the disorder.

Treatment depends on the condition's severity. In many cases, no treatment is required, although stretching and local corticosteroid injection can be beneficial. When contractures actually limit function, fasciotomy may be necessary.

Trigger finger. The most common cause of trigger finger is the formation of tendon nodules that obstruct full flexion and extension of the finger. In effect, the finger locks in place and cannot be extended except by external force. This condition may or may not be painful. Injection of the tendinous sheath with corticosteroids and local anesthetics is effective in most cases.

Osteoarthritis of the first carpometacarpal joint. Osteoarthritis at the base of the thumb is very common in older people. A bony prominence at the base develops in response to gradual lateral subluxation of the joint. Any activity involving a pinching motion of the thumb is painful. Radiographs show joint space narrowing and loss of articular cartilage between the first metacarpal and trapezium. Symptomatic relief is often provided by rest, splinting, NSAID therapy, and local corticosteroid injections. In refractory cases, arthroplasty may be indicated.

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Disorders of the Spine

A thorough neurologic and physical examination should be performed for all patients presenting with neck or back complaints.

With the patient standing, the spine should be examined for evidence of kyphosis, lumbar lordosis, or other abnormal curvatures. Palpation of the spinous processes and paraspinous musculature may reveal scoliosis, tenderness, or muscle spasm. Tenderness distal to either of the posterior superior iliac spines may indicate sacroiliitis.

The cervical range of motion is tested by flexing and extending the neck and bending it laterally to the left and right. For the assessment of cervical rotation, the patient tries to touch the chin to the shoulder, first on one side, then the other.

The Schöber maneuver is used to assess a patient's lumbar flexion (see figure below). First, the patient's back is marked in the midline at the level of the posterior superior iliac spines. A second mark is made 10 cm above the first. Next, the patient bends forward as far as possible. While the patient is in this position, the distance between the two marks is measured again. Normally, the distance increases by three to five centimeters. An increase of less than three centimeters indicates decreased lumbar flexion that may be the result of ankylosing spondylitis.

Back strain. Typically preceded by a traumatic event such as an awkward twisting or the lifting of a heavy object, back sprain produces acute pain that radiates up the ipsilateral paraspinous muscles. Limited range of motion and paraspinous muscle contraction and pain are common findings on physical examination. Neurologic abnormalities are absent. Symptomatic relief is provided by a gradual increase in physical activity and by medical therapy that includes NSAIDs, other analgesics, and muscle relaxants.

Lumbar disc herniation. Herniation of a lumbar disc causes inflammation and nerve impingement that produces radicular pain in the lower back, which typically radiates into the posterior thigh. The pain is exacerbated by motions that increase intradiscal pressure, such as bending or sitting, or by the Valsalva maneuver. Straight-leg raising elicits radicular pain by applying tension on the affected nerve. Neurologic examination may reveal sensory deficit, asymmetric reflexes, or motor weakness corresponding to the damaged spinal nerve root.

Conservative treatment for lumbar disc herniation includes a short period of bed rest along with medical therapy consisting of NSAIDs, analgesics, and muscle relaxants. Once symptoms resolve, back-strengthening exercises may be helpful. Epidural steroid injections may relieve more chronic symptoms in patients who fail to respond to conservative treatment.

Laminectomy is indicated for intolerable pain that is unresponsive to the measures described above and for pronounced muscle weakness or progressive neurologic deficits. In the cauda equina syndrome, a central midline herniation causes paralysis of the sacral roots along with bladder and bowel dysfunction, saddle anesthesia, and the inability to walk. Cauda equina syndrome is a surgical emergency that warrants immediate laminectomy.

Osteoarthritis of the lumbosacral spine. A common cause of localized low back pain, osteoarthritis of the lumbosacral spine begins insidiously and worsens at the end of the day and after activity. Pain is exacerbated by extension of the back, but no neurologic deficits are present on physical examination. Radiographs of the lumbar spine demonstrate facet joint narrowing, periarticular sclerosis, and osteophytes. Increased narrowing of the spinal canal may progress to a form of spinal stenosis known as neurogenic claudication, which manifests as pain in the back of the legs as a person is walking or assuming an erect position. This discomfort usually resolves quickly upon sitting or spinal flexion. Unlike that of arterial claudication, the walking distance that elicits symptoms of neurogenic claudication can vary.

Relief is often provided by NSAID therapy or epidural steroid injections. If conservative treatment fails, surgery is often effective in relieving symptoms in the leg and improving walking distance.

Inflammatory back disease. Possible causes of inflammatory back disease include ankylosing spondylitis, Reiter's syndrome, and other systemic disorders. This condition, unlike mechanical disorders of the spine in which stiffness generally lasts less than an hour, produces back pain accompanied by prolonged morning stiffness that typically lasts several hours. Tenderness over one or both sacroiliac joints may be observed on physical examination. Some limitation in spinal motion is usually seen and may be demonstrated by the Schöber maneuver. Extra-articular signs and symptoms are often present in patients with inflammatory back disease. Most patients obtain symptomatic relief through NSAID therapy. Sulfasalazine and methotrexate may be useful for patients who have refractory disease.

Suggested Reading American College of Rheumatology Ad Hoc Committee on Clinical Guidelines: Guidelines for initial evaluation of the patient with acute musculoskeletal symptoms. Arthritis Rheum 39:1, 1996. Doherty M, et al: Rheumatology Examination and Injection Techniques, 2nd ed. London, W.B. Saunders Company, 1999. Gates SJ and Mooar PA: Musculoskeletal Primary Care, 1st ed. Philadelphia, Lippincott, 1999. Kelley WN et al: Textbook of Rheumatology, 5th ed. Philadelphia, W.B. Saunders Company, 1997. Klippel JH, (ed.): Primer on the Rheumatic Diseases, 11th ed. Atlanta, Arthritis Foundation, 1997. Snider RK, et al. (ed.): Essentials of Musculoskeletal Care, 1st ed. Rosemont, Illinois, American Academy of Orthopedic Surgeons, 1997.

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