Orthopedic examination

Physical examination plays a central role in orthopedic diagnostics. Orthopedic examination is performed in the following sequence: inspection, palpation, determining the range of motion of the joint, focused neurological examination, and special tests to evaluate for a particular disorder. Inspection aims to reveal gross orthopedic abnormalities and associated findings (e.g., signs of inflammation or bruising). Palpation is performed to check for local temperature changes, tenderness, muscle bulk, and pulses on the vessels of the examined body part. Range of motion, a measurement of joint movement in angular degrees, is used to evaluate mobility. This article outlines examination techniques for the major parts of the musculoskeletal system, with the exception of the shoulder, which is covered in “Orthopedic shoulder examination.”

Inspection

• Ask the examinee to uncover the areas of the body to be examined.
• Compare structures on both sides.
• Assess for the presence of the following:
  • Skin changes (e.g., erythema, pigmentation, scars)
  • Changes in shape and/or alignment of the body part (e.g., due to edema, atrophy, lumps)
  • Abnormal position (e.g., limb contractures, scoliosis)
• See sections below for additional considerations for the examination of particular body parts.

Palpation

• The examiner assesses for temperature changes using the dorsal surface of their hand.
• Palpate pulses on the extremities (see “Pulses” in “Cardiovascular examination”).
• Palpate muscle groups to assess bulk and for the presence of spasm or tenderness.
• Palpate or percuss bony structures to assess for tenderness.
• If any lump is present, assess its characteristics (e.g., mobility, fluctuation, texture).

Range of motion (ROM) ^[1]

General considerations

• Definition: the extent of movement possible in a joint; measured in degrees
• Assessment
  • The following techniques can be used to measure ROM: ^[1]
    • Active ROM: The examinee is asked to move the joint.
    • Passive ROM: The examiner moves the examinee's joint.
  • The angle of the joint is recorded at the extremes of its range; see “Reporting and recording ROM” for an overview of how to report the angles.
  • Note if any pain occurs in the available range.
• Measurement: The angle is measured with one of the following devices.
  • Goniometer
    • A device consisting of a protractor, a moving limb, and a stationary limb
      • The stationary arm is aligned with the midline of the stationary segment of the joint.
      • The moving limb is aligned with the midline of the moving segment of the joint.
      • The fulcrum is aligned with a bony landmark close to the axis of movement.
    • For example, when measuring ROM in an elbow, align the stationary limb with a shoulder, moving limb with a forearm, and the fulcrum with the lateral epicondyle of the humerus.
    • Inclinometer
      • A device consisting of a scale and a disc with a fluid reservoir sitting on a base.
      • To measure an angle in a limb, place the base of the inclinometer on the moving segment of the limb, with one point of contact close to the axis of the movement.
      • Mainly used to measure ROM in the spine

Reporting and recording ROM

• The 0–180 system is used to report ROM.
  • Anatomical position is assumed as a starting position for all joints (except the forearm, which should be supinated) and marked as 0°.
  • As the movement proceeds, motion progresses toward 180°.
  • The result is recorded for motions in a single plane (e.g., flexion and extension, medial and lateral rotation) using three numbers: the first number represents the extreme of motion in one direction (e.g., flexion), the second number represents the starting point, and the third number represents the extreme of motion in another direction.
  • If motion in either direction cannot be carried out, the corresponding value in degrees is recorded as zero.
• Examples
  • A healthy hip joint would be recorded as extension/flexion 20/0/140.
  • If there is a hip joint flexion contracture of 10° with an inability to perform extension and full preserved flexion, the range of motion is noted as 0/10/140.

Focused neurological examination

Focused motor and sensory examination of the affected body part should be performed. For details on the examination, see “Motor function” and “Sensory function” in “Neurological examination”.

Special tests

Special tests are used to assess for abnormalities that affect particular anatomical structures (e.g., anterior drawer test for anterior cruciate ligament rupture). See individual sections below for information about specific tests.

Inspection

• Check spinal curvatures for scoliosis or excessive kyphosis or lordosis.
  • Assess the alignment of the spine from the front, lateral and back view.
  • Compare the symmetry of the anatomical landmarks (e.g., scapulae, iliac crests).

Palpation

• Percuss the spinal processes from the cervical region to the lumbosacral region to assess for local tenderness.
• Palpate the paraspinal muscles to check for tenderness, muscle spasm, and trigger points.

ROM ^[1]

Special tests

Spine mobility tests

• Schober test
  • Procedure
    • With the examinee standing, the examiner marks two points on the back, one at L5 and one 10 cm above L5.
    • The examinee flexes forward as far as possible while keeping their knees straight.
    • The distance between the two marks is measured.
  • Interpretation: An increase in the distance between the marks < 4 cm suggests impaired lumbar spine mobility.
• Ott test
  • Procedure
    • With the examinee standing, the examiner marks two points, one at the spinous process of the C7 vertebra and one 30 cm below C7.
    • The examinee flexes forward as far as possible while keeping their knees straight.
    • The distance between the two marks is measured.
  • Interpretation: An increase in the distance between the marks < 2 cm suggests impaired thoracic spine mobility.

Root impingement tests

• Neck compression test (Spurling test)
  • Procedure: The examiner extends the examinee's neck to the side of the pain and applies downward pressure to the head.
  • Interpretation: The emergence of limb pain/paresthesia indicates cervical radiculopathy.
• Straight leg raise test
  • Procedure
    • The examinee lies in a supine position.
    • The examiner lifts the examinee's leg 30º–70º with the knee in extension.
  • Interpretation: Emergence of pain radiating down the same leg, below the knee, indicates lumbar nerve root impingement (Lasegue sign).

Other tests

• Adam forward bend test
  • Procedure
    • The examinee bends forward at the waist with the knees straight.
    • The examiner looks at the patient from behind.
  • Interpretation: Asymmetry of the spine indicates scoliosis.
• Mennell sign
  • Procedure: The examinee lies in the lateral position and fully flexes the knee while the examiner extends the hip.
  • Interpretation: Emergence of pain in the sacroiliac joint suggests sacroiliac inflammation.

For an overview of arm and hand anatomy, see “Upper arm and elbow” and “Forearm, wrist, and hand”.

Inspection

• Assess the carrying angle of the examinee's elbows (normally approx. 11° in men and 13° in women).
• Ask the examinee to pronate their hands, then supinate, then flex their elbows; inspect each part separately.
• Look for the following pathological findings:
  • Signs of osteoarthritis (e.g., Heberden nodes, Bouchard nodes)
  • Signs of rheumatoid arthritis (e.g., swan neck deformity or boutonniere deformity on the hands, rheumatoid nodules on the forearms)
  • Dupuytren contracture
  • Atrophy of the thenar, interossei, and/or hypothenar muscles (can indicate neuropathy of median or ulnar nerve, ALS, etc.)
  • Psoriatic plaques on the forearms
  • Gouty tophi

Palpation

• Palpate tendons for any masses.
• Palpate elbow, wrist, and hand joints for tenderness.
• Compression test: Gently press the metacarpophalangeal joints together (tenderness often encountered in inflammatory arthritis, e.g. rheumatoid arthritis).

ROM ^[1]

Special tests

Elbow joint tests ^[2]

• Mill test
  • Procedure: The examiner fully extends the examinee's elbow, flexes the wrist, and pronates the forearm with one hand while palpating the lateral epicondyle with the other hand.
  • Interpretation: The emergence of pain in the area of the lateral epicondyle indicates lateral epicondylitis (tennis elbow).
• Cozen test
  • Procedure: The examinee makes a fist, deviates the wrist radially, and extends it against examiner's resistance from a neutral position, while the examiner stabilizes the elbow and palpates the lateral epicondyle with their thumb.
  • Interpretation: The emergence of pain in the area of the lateral epicondyle indicates lateral epicondylitis (tennis elbow).
• Maudsley test
  • Procedure
    • The examinee puts their forearm and hand on the table with palms facing down and extends their middle finger.
    • The examiner applies resistance to the extension of the examinee's finger.
  • Interpretation: The emergence of pain in the area of the lateral epicondyle indicates lateral epicondylitis (tennis elbow).

Provocative wrist and hand tests

• Tinel sign
  • Procedure: The examiner taps the area over the examinee's carpal canal.
  • Interpretation: Shooting pain and/or tingling in the areas innervated by the median nerve suggests carpal tunnel syndrome.
• Phalen maneuver
  • Procedure: The examiner flexes the examinee's wrist to 90° and holds it for approx. one minute.
  • Interpretation: Paresthesia in the areas innervated by the median nerve indicates carpal tunnel syndrome.
• Hand elevation test
  • Procedure: The examinee elevates their arm above their head and holds it for approx. two minutes.
  • Interpretation: Paresthesia in the areas innervated by the median nerve indicates carpal tunnel syndrome.
• Finkelstein test
  • Procedure: The examiner grasps the examinee's affected thumb and exerts longitudinal traction across the palm of the hand towards the ulnar side.
  • Interpretation: Pain in the thumb indicates de Quervain tenosynovitis.

For an overview of hip anatomy, see “Hip joint” in “Pelvis and hip joint”.

Inspection

• Observe the examinee's gait.
  • Some gait problems can result from dysfunction of pelvic structures (e.g., waddling gait).
  • See “Gait assessment” for more details.
• With the examinee in a standing position, inspect them from the front and the back; note any abnormalities (e.g., pelvic lift, lumbar hyperlordosis).
• Measure the examinee's leg length (measured from anterior superior iliac spine to the medial malleolus).

Palpation

• Assess for pelvic instability while the examinee is in a lying position:
  • Downward compression of the anterior superior iliac spines
  • Lateral compression of the iliac crests
  • Should only be performed once in patients with suspected pelvic fracture in order to preserve fracture site clots

ROM ^[1]

• Extension: 10–15°
• Flexion: 130–140°
• Abduction: 30–45°
• Adduction: 20–30°

Special tests

• Trendelenburg test (hip drop test)
  • Description: The examinee stands on one leg (i.e., the leg to be tested).
  • Interpretation: Pelvic drop on the side of the lifted leg indicates gluteus medius and/or minimus muscle pathology on the opposite leg.
• FABER test (Patrick test)
  • Procedure: Flexion, ABduction, External Rotation
    • The examinee lies supine.
    • The examiner sequentially performs passive hip flexion, abduction, and external rotation, so that the patient's legs are arranged in a figure-of-4 position.
    • After performing the final rotation, the examiner gently pushes down on the knee of the folded leg.
  • Interpretation: The emergence of pain in the hip or sacroiliac joints indicates pathology in the corresponding structure.
• Thomas test
  • Procedure
    • The examinee lies in a supine position.
    • The examiner passively flexes the examinee's opposite hip joint.
  • Interpretation: If flexion contracture is present, the ipsilateral leg bends independently as a reflex response.
• Drehman sign
  • Procedure: The examinee lies supine and flexes their hip.
  • Interpretation: Additional external rotation upon flexion indicates a slipped capital femoral epiphysis.

For an overview of knee anatomy, see “The knee joint” in “Thigh, knee, and popliteal fossa”.

Inspection

• Observe the examinee's gait.
  • An antalgic gait may indicate knee pathology.
  • Persistent pathological gait patterns can cause knee symptoms.
• The examinee is inspected in standing position.
  • Compare the level of the patellae on both sides.
  • Note any deformities (e.g., due to joint swelling, genu valgum, genu varum).
  • Pay specific attention to the bulk of the lower part of vastus medialis muscle (atrophy often emerges early in conditions affecting the knee joint, such as patellofemoral syndrome and osteoarthritis). ^[3][4]

Palpation

• Palpate the point of insertion of the quadriceps muscle and the tibial tuberosity.
• The examinee lies supine with the tested leg flexed 90°.
  • Palpate the popliteal fossa for popliteal masses, such as Baker cyst or popliteal aneurysm.
  • Palpate the lateral and medial lines of the joint (can be tender in meniscal pathology).

ROM ^[1]

• Extension: 0°
• Flexion: 135°

Special tests

Tests for cruciate ligaments

• Anterior drawer test and posterior drawer test
  • Procedure
    • The examinee lies supine with hips flexed to 45° and knees flexed to 90°.
    • The examiner sits on the examinee's feet to secure them in place, holds the leg at the upper ⅓ of calf with both hands, and pushes the leg forward (anterior drawer test) or backward (posterior drawer test).
  • Interpretation
    • Laxity at the endpoint represents a positive test.
    • A positive anterior drawer test indicates anterior cruciate ligament tear.
    • A positive posterior drawer test indicates posterior cruciate ligament tear.
• Lachman test
  • Procedure
    • The examinee lies supine and flexes the knee 20–30° with the heel of the foot resting on the examining table.
    • The examiner stabilizes the femur and moves the proximal tibia anteriorly.
  • Interpretation: Excessive anterior movement indicates anterior cruciate ligament tear.

Tests for collateral ligaments

• Valgus stress test and varus stress test
  • Description
    • The examinee lies supine with the knee flexed to 30°.
    • Valgus stress test: The examiner holds the examinee's ankle with one hand and uses the other hand to apply pressure to the lateral aspect of the knee joint, pushing in a medial direction.
    • Varus stress test: The examiner holds the examinee's ankle with one hand and uses the other hand to apply pressure to the medial aspect of the knee joint, pushing in a lateral direction.
  • Interpretation
    • Laxity at the endpoint is interpreted as a positive test.
    • A positive valgus stress test indicates medial collateral ligament injury.
    • A positive varus stress test indicates lateral collateral ligament injury.

Tests for meniscus injury

• See “Signs of meniscus injury”.

Tests for joint effusion

• Patellar tap test
  • Procedure
    • The examinee lies supine with the knee extended.
    • The examiner pushes the fluid from the suprapatellar pouch to the knee joint with one hand and uses the other hand to gently tap the area over the patella.
  • Interpretation: floating of patella indicates joint effusion
• Knee bulge test
  • Description: The examiner applies pressure above the patella to milk fluid from the suprapatellar pouch and then applies pressure behind the lateral margin of the patella.
  • Interpretation: The appearance of a bulge on the medial aspect of the knee indicates the presence of knee joint effusion.