OnExam

Inspection

General

  • Comfort
    • Vitals/general appearance/facial expression
    • Hesitancy, apprehension, willingness to move limbs
    • Guarding/favouring the limb
  • Movements
    • Reproduction of symptoms
    • Quality of movements
      • Smooth or jerking
      • Controlled or uncontrolled
    • Any limitations/deficiencies
    • Crepitus or abnormal sounds
  • SEADSS
    • Swelling
    • Erythema
    • Atrophy
    • Deformity: changes in posture, alignment or shape
    • Symmetry: limb positions, joint alignment, bony contours, musculature and soft tissues
    • Skin changes: colour, temperature, surface integrity, scars, rashes, lesions, fasciculations

Palpation

  • All bones, joints, soft tissues
    • Note any abnormalities during palpation
      • SEADSS, pain, contour, size, thickness, texture/quality, fixed or maneuverable
  • Differences in temperature, pulses, skin dryness or moisture
  • Note the presence of nodules, masses, warmth, effusion, tremor and fasciculations
  • Note any asymmetry
  • Complete neurological testing if necessary
  • Complete peripheral vascular testing if necessary

Active Range of Motion

  • Have patient perform active ROM of joint prior to passive ROM
  • If no limitations in active ROM, passive ROM may be skipped
  • Limitations of ROM should be described from anatomical position
  • During active ROM, note:
    • Reproduction of symptoms
    • Any limitations or deficiencies
    • Movements causing pain and the quality and severity thereof
    • Patient hesitancy or apprehension
    • Quality of movements: smooth, jerky, controlled, uncontrolled
  • Active ROM may be limited by:
    • Pain
    • Soft tissue impingement or adhesion
    • Neurological problems (weakness, spasticity)
    • Soft tissue deficits: muscle or tendon
    • Bony obstacles
    • Loose bodies in the joint
    • Joint stiffness

Passive Range of Motion

  • Performed by examiner with patient relaxed
  • During passive ROM, note:
    • Reproduction of symptoms
    • Any limitations or deficiencies
    • Movements causing pain including the quality, severity and location
    • Note patient hesitancy/apprehension to movement
    • Note quality of movement: smooth, jerky
    • Note end feel: the sensation at the limit of a joint’s ROM (abnormal end feel often suggests pathology)
      • Abnormal Findings
        • Bone-to-bone: a definite, unyielding, firm compression preventing further movement (e.g., elbow extension)
        • Soft tissue approximation: a yielding compression where soft tissue prevents further movement (e.g., knee flexion)
        • Tissue stretch: a firm elastic resistance to movement with increasing tension toward end of ROM (e.g., lateral rotation of knee)
  • Passive range of motion may be limited by:
    • Pain
    • Soft tissue impingement or adhesion
    • Neurologic pathology (weakness, spasticity)
    • Soft tissue deficits (muscle or tendon abnormalities)
    • Bony obstacles
    • Loose bodies within the joint
    • Joint stiffness

Strength Assessment

Assess strength as outlined in the Muscle Strength special test section. This involves the patient performing isometric contractions against force applied by an examiner. Note any weakness or asymmetry.

Functional Assessment

  • Should be performed for the affected joint
  • May involve performing specific tasks
  • May involve inquiring about activities of daily living (ADLs) such as gait, sit to stand, stairs, getting dressed, washing hair, brushing teeth, toilet and tub transfers, use of assistive devices or supports (cane, walker, wheelchair)
  • Often requires examination of joint above and below affeted joint

Specific Assessments

The following is a list of specific joint and body part assessments that are outlined in more detail:

References

  1. Baxter S, ed., McScheffrey G, ed. Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
  2. Bickley L. Bate’s Guide to Physical Examination and History Taking. 10th ed. New York: Lippincott Williams & Wilkins; 2009.
  3. Filate W, Leung R, Ng D, Sinyor M, eds. Essentials of Clinical Examination Handbook. 5th ed. Toronto, ON. University of Toronto, 2005.
  4. Hurley K. OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.
  5. Pawa J, Lesniak, D., & Lott, A. Approach to the OSCE: The Edmonton Manual of Common Clinical Scenarios. Edmonton Manual; 2011.