Chapter 22General Approach to MSK Physical Examination

Follow SEADS framework: Swelling, Erythema, Atrophy, Deformity, Skin changes/Scarring.

Follow TESTCA framework: Tenderness, Effusion, Swelling, Temperature, Crepitus, Atrophy.

Always compare (or comment that you would compare) both sides.

• During ROM, check for crepitus, clicking, and locking
• Start with active ROM (patient does movement on their own)
• If active ROM is limited, do passive ROM (clinician does movement for the patient with muscles relaxed). For some joints, active and passive can be integrated, with the examiner leading the joint beyond the patient's active ROM.
• If passive ROM is limited, the end-feel is helpful in determining the etiology.
  • Bony end-feel: bony pathology (e.g. osteoarthritis, fracture)
  • Soft end-feel: soft-tissue pathology (e.g. joint capsule, ligaments, tendons, muscles)

This is best done using resisted isometric testing: patient resists the force applied by the examiner (rather than the opposite).

• Position the joint as required, then apply force while the patient resists to prevent movement by the examiner.
• Power is graded using the Medical Research Council (MRC) power grading:
  • Grade 0: no muscle contraction
  • Grade 1: muscle contraction but no joint movement (e.g. can feel muscle activating or see flickers of contraction only)
  • Grade 2: movement of the body part with gravity eliminated (e.g. sliding across a horizontal surface)
  • Grade 3: movement of the body part against gravity only
  • Grade 4: movement of the body part against gravity and some resistance
  • Grade 5: movement against gravity with full resistance

A gait assessment should be performed whenever assessing GALS, the back, or any part of the lower limb. It’s a good idea to do this first, both for efficiency and to reduce the chance of forgetting to do it.

• Gait components
  • Stance phase (60% of gait cycle): initial contact (heel strike) → mid-stance → pre-swing (toe-off)
  • Swing phase (40% of gait cycle): initial swing → mid-swing → terminal swing
  • Note: Former terminology in brackets re. heel-strike and toe-off.
• Gait quality
  • Symmetry
  • Smoothness of movement (legs, arm swing, pelvic tilting)
  • Normal stride length
  • Ability to turn quickly
• Examples of abnormal gait
  • Antalgic (painful) gait
    • Stance phase is shortened on the affected side, typically indicating pain on weight-bearing
  • Trendelenburg gait
    • This indicates weakness of the hip abductor muscles
    • During stance phase, if the hip abductors are weak on the standing side, the pelvis will drop on the opposite side
    • The trunk may compensate by lurching towards the side of the weakened abductor muscles
    • Bilateral hip abductor weakness produces a waddling gait

Depending on the clinical scenario, you should be prepared to perform a neurological and vascular assessment. This may include:

• Pulses, capillary refill
• Tone
• Power
• Sensation according to dermatomes
• Reflexes

Note: The Neurological Examination will be practiced in detail in the MF4 Neurology Subunit (Sessions 5-8).