Systematic Musculoskeletal Examination

Examination Program.- Patient-Oriented Aspects.- Examiner-Oriented Aspects.- Examination According to the 5/5 Program.- Structure of the Systematic Examination.- Systematic History.- Basic Physical Examination.- Inspection.- Conduct of Examination.- Palpation.- Conduct of the Examination and Findings.- Motion Testing.- Conduct of the Examination.- Rationale for the Basic Physical Examination.- Adjunctive Neurologic and Angiologic Studies.- Neurologic Studies.- Conduct of the Examination.- Angiologic Studies.- Adjunctive Special Diagnostic Procedures.- Examination Positions.- Body Regions Examined.- Diagnosis.- Disease Groups Involving the Musculoskeletal System.- Structural Analysis of Function Using the Diagnostic Program.- Structural Analysis in the Patient History with Reference to Pain.- Types of Pain from a Structural Perspective.- Basic Principles in the Analysis of Pain.- Analysis of Pain During History Taking.- Joint Pain.- Muscle Pain.- Ligament Pain.- Bursitis, Tendovaginitis.- Nerve Pain.- Vascular Pain.- Vertebragenic Pain.- Structurally Specific Findings in the Arthron.- Examination of the Joint.- Inspection.- Active and Passive Motion Testing.- Palpation.- Joint Play.- Examination of the Spine.- Inspection.- Motion Testing.- Palpation.- Joint Play.- Examination of the Muscles.- Muscle Groups.- Findings of Muscle Examination.- Inspection.- Motion Testing.- Palpation.- Resistance Tests.- Examination of the Nerves.- Inspection.- Active and Passive Motion Testing.- Palpation.- Muscle Tests.- Special Neuropathologic Findings During the Basic Physical Examination.- Inspection.- Complex Motor Sequences.- Spontaneous Muscular Contractions.- Trophic Disturbances (Chiefly Involving the Hands and Feet).- Active and Passive Motion Testing.- Active Motion Testing.- Passive Motion Testing.- Palpation.- Autonomic Nervous Disorders.- Nerve Pressure Points.- Thickening of Nerve Trunks.- Muscle Tests.- Differential Diagnosis of Nerve Lesions.- Symptoms of Nerve Lesions by Location.- 1. Muscular Nociceptive Symptoms (Nociceptive Reaction of Wolff).- 2. Symptoms of Peripheral Nerve Lesions.- 3. Radicular Symptoms.- 4. Symptoms of Plexus Damage.- 5. Symptoms Due to Disturbances Involving the Neuromuscular Junction or Muscle Fiber.- 6. Symptoms of Lesions of the Central Neuron (Central Paralysis).- Practical Relevance of the Structural Analysis of function.- How Does the Control and Warning System Function?.- Proprioception.- Stability.- Coordination.- Nociception.- Testing of Irritation Zones.- Location of the Irritation Zones or Irritation Points.- Examination Technique.- Diagnostic Implications of Irritation Zone Testing.- Basic Examination of the Spine and the Joints of the Extremities.- Detailed Introduction.- Systematic History.- Interpretation of the History.- Current Pain.- 1 Location of Pain: What Hurts ? Where Does it Hurt?.- 1.1 Localized Pain (Monoarticular, Monosegmental).- 1.2 Multifocal Pain (Polyarticular, Vertebral Region or Entire Spine).- 1.3 Referred Pain (Muscle Chains, Nerve Pathways, Vessels).- 1.4 Diffuse Pain.- 1.5 Unilateral or Bilateral Pain.- 2 Pain Occurrence: When Does It Occur and When Did It First Occur?.- 2.1 24-HourRhythm.- 2.2 Periodic Pain (Ovarian Cycle, Seasons, Age).- 2.3 Episodic Pain (With or Without a Change in Pain Location).- 3 Nature of the Pain.- 3.1 Intensity.- 3.2 Character.- 3.3 Course.- 4 What Precipitates on Changes the Pain?.- 4.1 Body Posture.- 4.2 Body Movements.- 4.3 Other Mechanical Influences.- 4.4 Miscellaneous Influences.- 5 Associated Phenomena: What Accompanies the Pain?.- 5.1 Sensory Disturbances.- 5.2 Motor Disturbances.- 5.3 Circulatory Disturbances.- 5.4 Trophic Disturbances.- 5.5 Psychological Disturbances.- Previous Course, General State of Health, Other Current Diseases.- 1 What Treatments Have Been Given in the Past?.- 2 What Improved or Changed the Pain?.- 3 How Are the Vital Functions?.- 4 When Did Previous Pain Occur Involving the Spine and Joints?.- 5 What Other Diseases or Disorders Does the Patient Have Now?.- The Basic Physical Examination: Preliminary Information.- Exceptions.- Abbreviations.- Symbols Used in the Figures on Examination Techniques.- Checklist for Joint Examinations.- Checklist for Muscle Examinations.- Documentation of Findings Using Symbols.- Ten Standard Symbols.- General Symbols.- Inspection.- Palpation.- Motion Testing.- Measurements.- Joints.- Muscles.- General Inspection in the Standing Position (A).- 1 Ordinary Movements.- 1.1 Gait.- 1.2 Other Ordinary Movements.- 2 Posture.- 3 Body Contours and Proportions.- 4 Skin.- 5 Assistive Devices.- Examination of the LPH Region in the Standing Position (A/II).- 1 Inspection (see General Inspection).- 2 Active and Passive Trunk Movements in Three Planes (Regional Diagnosis).- 2.1 Sagittal Plane: Forward and Backward Bending.- 2.2 Frontal Plane: Sidebending.- 2.3 Transverse Plane: Rotation.- 3 Palpation of the Pelvic Joints.- Palpation at Rest.- 3.1 Pelvic Position, Leg Length Discrepancy.- Palpation During Movement - Testing Joint Play in Both SIJs.- 3.2 Standing Flexion Test (SIJ).- Unilateral Joint Play Testing.- 3.3 Recoil Phenomenon (SIJ), "Spine Test".- 3.4 Hip Drop Test (Lumbar Spine).- 3.5 Lateral Shift Test (SIJ).- 4 Tests of Joint Translation.- 4.1 Traction on the Lumbar Spine.- 4.2 Compression of the Lumbar Spine.- 5 Muscle Test.- General Examination of the Lower Extremities in the Standing Position (A/I) (Supplement to Examination of the LPH Region).- 1 Three-Phase Squat.- 2 Standing on the Toes.- 3 Standing on the Heels.- 4 Standing on the Outer Edge of the Foot.- 5 Muscle Tests.- Examination of the LPH Region in the Sitting Position (B/II).- 1 Inspection.- 1.1 Relaxed and Erect Sitting Posture.- 1.2 Pelvic Position - Comparison with Findings in Standing.- 2 Active and Passive Trunk Movements in Three Planes (Regional Diagnosis).- Supplementary SIJ Test for Differentiating Motion Faults in the SIJ and Lumbar Spine.- Regional Motion Testing of the Lumbar (and Thoracic) Spine in Three Planes with the Pelvis Stationary.- 3 Palpation of the SIJ and Lumbar Spine (Segmental Diagnosis).- Palpation at Rest.- 3.1 Pelvic Position.- Palpation During Movement.- 3.2 Seated Flexion Test (for Asymmetric Excursion of the Iliac Spines).- 3.3 Segmental Motion Testing of the Lumbar Spine.- 4 Tests of Joint Translation.- 4.1 Traction.- 4.2 Compression.- 5 Muscle Tests.- Resistance Tests of the Flexors, Rotators, Abductors, and Adductors of the Hip.- Examination of the LPH Region in the Prone Position (C/II).- 1 Inspection.- 1.1 Pelvic Position and Gluteal Profile.- 1.2 Pelvis-Leg Angle.- 1.3 Leg Length Discrepancy.- 1.4 Asymmetric Muscle Contours.- 1.5 Alignment of the Vertebral Column.- 2 Active and Passive Hip and Knee Movements (Regional Diagnosis.- 2.1 Hyperextension of the Hip Joint (Extension from the Neutral Position).- 2.2 Rotation of the Hip Joint.- 2.3 Flexion, Extension, Rotation of the Knee Joint.- 3 Palpation Field of the Dorsal Pelvis: Lumbar Joints/Soft-Tissue Diagnosis (Segmental Diagnosis).- Palpation at Rest.- 3.1 Palpation Field of the Dorsal Pelvis.- 3.2 Test for Functional Leg Length Discrepancy (Functionally Short Leg).- 3.3 Segmental Palpation of the Lumbar Spine (Mobility/Pain).- 3.4 Kibler's Skin Rolling Test.- 3.5 Connective-Tissue Stroke Test.- 4 Tests of Joint Translation.- 4.1 Lumbar Spine.- 4.2 Sacroiliac Joints.- 4.3 Hip Joints: Rotation.- 5 Muscle Tests.- 5.1 Resistance Tests of the Hip Muscles.- 5.2 Knee Muscles.- 5.3 Back Extensors.- Examination of the LPH Region in the Lateral Position (D/II).- 3 Palpation of the Lumbar Spine During Movement (Segmental Mobility).- 3.1 Forward and Backward Bending.- 3.2 Sidebending.- 3.3 Rotation.- 4 Tests of Joint Translation.- 4.1 Hypermobility Test of the SIJ.- 4.2 Hypermobility Test of the Lumbar Spine.- 5 Muscle Tests (Resistance Tests of Hip Muscles).- 5.1 Abductors.- 5.2 Adductors.- Examination of the LPH Region in the Supine Position (E/II).- 1 Inspection.- 1.1 Legs.- 1.2 Pelvic Position.- 1.3 Vertebral Column.- 1.4 Abdominal Wall.- 2 Active and Passive Motion Testing: Hip and Knee Joints, SIJ, and Lumbar Spine.- 2.1 Hip Flexion.- 2.2 Hip Rotation.- 2.3 Hip Abduction.- 2.4 Knee Joint Screening Tests.- 2.5 Differentiation of the LPH Joints: Hip Joint, SIJ, Lumbar Spine, and Muscles.- 3 Palpation Field of the Ventral Pelvis.- Palpation at Rest.- 4 Tests of Joint Translation.- 4.1 Traction and Compression of the Lumbar Spine.- 4.2 Traction and Compression of the Hip Joint.- 4.3 SIJ Springing Test via the Thigh.- 5 Muscle Tests.- 5.1 Resistance Tests of the Hip and Abdominal Muscles.- 5.2 Shortening Tests.- Examination of the Thorax (Thoracic Spine and Ribs) in the Sitting Position (B/III).- 1 Inspection.- 1.1 Thoracic Morphology.- 1.2 Respiratory Movements.- 2 Active and Passive Trunk Movements in Three Planes (Regional Diagnosis).- 3 Palpation of the Thoracic Joints (Segmental Diagnosis).- Palpation at Rest.- 3.1 Sternal and Costal Synchondroses (Sternocostal Joints 2-7), Floating Ribs.- 3.2 Costotransverse Joints.- 3.3 Segmental Muscles.- Palpation During Movement.- 3.4 Segmental Motion Testing of the Thoracic Spine.- 3.5 Segmental Motion Testing of the Ribs ("Harp").- 4 Tests of Joint Translation.- 4.1 Bimanual Compression of the Thorax in the Frontal Plane.- 4.2 Bimanual Compression of the Thorax in the Sagittal Plane.- Examination of the Thorax (Thoracic Spine and Ribs) in the Prone Position (C/III).- 1 Inspection.- 2 Active Movements: Respiratory Movements (Deep Breathing) (Regional Diagnosis).- 3 Palpation of the Thoracic Joints (Segmental Diagnosis).- Palpation at Rest.- 3.1 Palpation Field of the Posterior Thorax.- Palpation During Movement.- 3.2 Rib Movements and Intercostal Spaces.- 4 Tests of Joint Translation.- 4.1 Thoracic Segments.- 4.2 Scapula.- 5 Muscle Tests.- Examination of the Thorax (Thoracic Spine and Ribs) in the Lateral Position (D/III).- 3 Palpation of the Thoracic Joints During Movement (Segmental Diagnosis).- 3.1 Segmental Mobility Testing of the Thoracic Spine.- 3.2 Segmental Mobility Testing of the Cervicothoracic Junction (C6-T3).- 3.3 Segmental Mobility Testing of the Lower (6th-12th) Ribs.- Examination of the Thorax (Ribs) in the Supine Position (E/III).- 1 Inspection.- 2 Active Movements: Respiratory Movements (Deep Breathing) (Regional Diagnosis).- 3 Palpation of the Ribs (Segmental Diagnosis).- Palpation at Rest.- 3.1 Palpation Field of the Anterior Thorax.- Palpation During Movement.- 3.2 Rib Movements and Intercostal Spaces.- 3.3 Segmental Mobility Testing of the Upper (2nd-6th) Ribs.- 4 Tests of Joint Translation.- 4.1 Costal Joints.- 4.2 Sternoclavicular and Acromioclavicular Joint.- 5 Muscle Test: Test for Shortening of the Pectoralis Major.- Examination of the Cervical Spine in the Sitting Position (B/V).- 1 Inspection.- 2 Active and Passive Movements of the Cervical Spine and Head in Three Planes (Regional Diagnosis).- 2.1 Sagittal Plane: Backward and Forward Bending.- 2.2 Frontal Plane: Sidebending.- 2.3 Transverse Plane: Rotation.- 2.4 Provocative Testing of the Vertebral Segments (Modified from de Kleyn).- 2.5 Provocative Test for Motion Segment Laxness (Hypermobility).- 3 Palpation of the Cervical Spine During Movement (Segmental Diagnosis).- 3.1 Mobility Testing of the Occiput/Atlas (C0/C1).- 3.2 Mobility Testing of the Atlas/Axis (C1/C2).- 3.3 Mobility Testing of the C2/C3 Segment.- 3.4 Mobility Testing of the C3-C5 Segments.- 3.5 Mobility Testing of the C5-T3 Segments (Cervicothoracic Junction).- 4 Tests of Joint Translation.- 4.1 Traction.- 4.2 Compression.- 4.3 Tests of Facet Joint Gliding.- 5 Muscle Tests - Resistance Tests of the Cervical Muscles (Synergists).- Examination of the Head (Temporomandibular Joints, Sensory Organs) in the Sitting Position (B/V).- 1 Inspection.- 1.1 Facial Asymmetries.- 1.2 Mimetic Activity.- 1.3 Sensory Organs: Eyes.- 2 Jaw Movements and Swallowing.- 2.1 Opening and Closing of the Jaw.- 2.2 Protraction and Retraction of the Jaw.- 2.3 Lateral Jaw Movements (Grinding Movements).- 3 Palpation Field of the Face.- 3.1 Trigeminal Pressure Points.- 3.2 Corneal Reflex (First Division of the Trigeminal Nerve).- 3.3 Pressure on the Tragus.- 3.4 Palpation of the Temporomandibular Joints.- 3.5 Percussion of the Frontal and Maxillary Sinuses.- 4 Passive Testing of Temporomandibular Joint Motion and Play.- 5 Muscle Tests.- 5.1 Mimetic Muscles.- 5.2 Masticatory Muscles.- 5.3 Lingual Muscles.- 5.4 Ocular Muscles.- Examination of the Cervical Spine in the Supine Position (E/V).- 1 Inspection.- 2 Active and Passive Movements of the Cervical Spine and Head in Three Planes (Regional Diagnosis).- 2.1 Forward Bending, Backward Bending, Sidebending, and Rotation.- 2.2 Side-to-Side Head Movement.- 2.3 Provocative Test for the Vertebral Artery (De Kleyn's Hanging Test).- 3 Palpation of the Cervical Spine During Movement (Segmental Diagnosis).- 3.1 Forward Bending.- 3.2 Backward Bending.- 3.3 Sidebending.- 3.4 Rotation.- 4 Tests of Joint Translation.- 4.1 Three-Dimensional Traction on All Cervical Segments.- 4.2 C0/C1 Segment: Backward and Forward Gliding of the Occipital Condyles on the Atlas (Forward and Backward Nodding).- 4.3 C0/C1/C2 Segment: Combined Movements in the Craniovertebral Joints.- 4.4 C1/C2 Segment: Atlas Traction.- 4.5 C1/C2 Segment: Lateral Gliding of the Atlas on the Axis (Hypermobility Test).- 4.6 C2-C7 Segments: Convergent/Divergent Gliding in the Facet Joints.- 5 Muscle Tests - Resistance Testing of the Cervical Muscles.- Examination of the Upper Extremities in the Sitting Position (B/IV) Shoulder Joint.- 1 Inspection.- 1.1 Shoulder Position.- 1.2 Shoulder Contours.- 2 Active and Passive Movements of the Shoulder Joint.- 2.1 General Active Tests.- 2.2 Frontal Plane: Abduction/Adduction and Rotation of the Arms.- 2.3 Sagittal Plane: Raising the Arms Forward and Behind.- 3 Palpation Field of the Shoulder.- 4 Tests of Joint Translation (Humeral Head).- 5 Resistance Testing of the Shoulder Muscles.- 5.1 Synergists (2x4).- 5.2 Differentiating Tests (3x5).- Joints of the Shoulder Girdle.- 1 Inspection (See B/Shoulder/Sect. 1).- 2.1 Raising and Lowering the Shoulder Girdle.- 2.2 Advancing and Retracting the Shoulder Girdle.- 3 Palpation Field of the Shoulder Girdle.- 3.1 Palpation of the Shoulder Girdle at Rest.- 3.2 Palpation of the Shoulder Girdle During Movement.- 4 Tests of Joint Translation - Clavicle and Scapula.- Sternoclavicular Joint.- Acromioclavicular Joint.- Alternative Techniques.- 5 Resistance Testing of the Muscles of the Shoulder Girdle.- 5.1 Synergists.- 5.2 Scapular Rotators.- 6 Examination of the Cervical Spine.- Elbow Joint, Upper Arm, and Forearm.- 1 Inspection.- 1.1 Joint Position.- 1.2 Joint Contours.- 1.3 Changes in the Muscle Contours of the Upper Extremity.- 2 Active and Passive Elbow Movements.- 2.1 Flexion/Extension.- 2.2 Pronation/Supination.- 2.3 Abduction/Adduction (Collateral Ligament Stability Test).- 3 Palpation Field of the Elbow/Arm.- 3.1 Extensor Side of the Elbow.- 3.2 Lateral (Radial) Epicondyle.- 3.3 Medial (Ulnar) Epicondyle.- 3.4 Flexor Side of the Elbow.- 3.5 Upper Arm and Forearm.- 4 Tests of Joint Translation.- 4.1 Humeroradial Joint.- 4.2 Proximal and Distal Radioulnar Joints.- 4.3 Humeroulnar Joint.- 5 Resistance Testing of the Muscles of the Elbow Joint.- 5.1 Flexors and Extensors.- 5.2 Pronators and Supinators.- Hand and Finger Joints.- 1 Inspection.- 1.1 Shape and Position.- 1.2 Contour Changes.- 1.3 Skin and Nail Changes.- Skin Changes.- Nail Changes.- 2 Active and Passive Wrist and Finger Movements.- 2.1 Wrist Movements in Two Planes.- 2.2 Finger Movements in two Planes.- 2.3 Thumb Movements.- 3 Palpation Field of the Hand.- 3.1 Radial Border of the Hand.- 3.2 Ulnar Border of the Hand.- 3.3 Dorsum of the Hand.- 3.4 Palm of the Hand.- 3.5 Fingers and Thumb.- 4 Tests of Joint Translation.- 4.1 Wrist Joint (Five Tests).- 4.2 Intercarpal Joints (Ten Tests).- 4.3 Carpometacarpal Joint of the Thumb (Five Tests).- 4.4 Second to Fifth Carpometacarpal and Intercarpal Joints (Five Tests).- 4.5 Phalangeal Joints (Five Tests).- 5 Resistance Testing of the Hand and Finger Muscles.- 5.1 Wrist Muscles.- 5.2 Finger Muscles.- 5.3 Thumb Muscles.- Examination of the Lower Extremities in the Supine Position (E/I) Hip Joint (LPH Region).- Knee Joint, Upper Leg, Lower Leg.- 1 Inspection: Abnormalities of Shape and Position, Contours of the Upper and Lower Leg.- 1.1 Anterior Aspect.- 1.2 Lateral Aspect.- 1.3 Posterior Aspect.- 2 Active and Passive Motion Testing of the Knee Joint and Femoropatellar Joint.- 2.1 Knee Joint.- 2.2 Patellar Tracking.- 3 Palpation Field of the Knee Joint and Lower Extremity.- Palpable Findings.- 3.1 Anterior Side of the Knee (Patellar Region).- 3.2 Medial Side of the Knee (Medial Condyle).- 3.3 Lateral Side of the Knee (Lateral Condyle).- 3.4 Popliteal Fossa.- 3.5 Upper and Lower Leg Contours.- 4 Tests of Joint Translation.- 4.1 Mediolateral and Caudal Gliding Movements of the Patella.- 4.2 Traction on the Meniscotibial Joint.- 4.3 Mediolateral Gliding Movements in the Meniscotibial Joint (Shear Test).- 4.4 Anteroposterior Gliding Movements in the Meniscotibial Joint (Drawer Test).- 4.5 Mobility in the Superior Tibiofibular Joint.- 5 Tests of the Menisci and Ligaments.- Testing of the Menisci.- Testing of the Capsule and Ligaments.- Examination Technique.- 5.1 Test Group: Sagittal Plane (Tests 1-3).- Testing of the Menisci.- Testing of the Capsule and Ligaments.- 5.2 Test Group: Frontal Plane (Tests 4-7).- Testing of the Menisci.- Testing of the Capsule and Ligaments.- 5.3 Test Group: Transverse Plane.- Testing of the Menisci.- Testing of the Capsule and Ligaments.- 5.4 Testing the Posterior Horns of the Menisci by a Combination of Flexion, Lateroduction, and Rotation (Test 12).- 5.5 Specific Tests for Rotary Instability.- Joints of the Feet and Toes.- 1 Inspection.- 1.1 Shape and Position of the Foot.- 1.2 Contour Changes.- 1.3 Skin Changes.- 2 Active and Passive Motion Testing of the Pedal Joints.- 2.1 Active Movements.- 2.2 Passive Movements.- 3 Palpation Field of the Foot.- 3.1 Medial Border of the Foot.- 3.2 Lateral Border of the Foot.- 3.3 Dorsum of the Foot.- 3.4 Sole of the Foot.- 4 Tests of Joint Translation.- 4.1 Inferior Tibiofibular Joint (Distal Tibiofibular Syndesmosis).- 4.2 Tarsal Joints (Ten Tests).- 4.3 Metatarsal Joints (Five Tests).- 4.4 Phalangeal Joints: Five Tests.- 5 Resistance Testing of the Foot and Toe Muscles.- 5.1 FootMuscles.- 5.2 Toe Muscles.- Radiography.- Special Diagnostic Procedures.- Radiography.- 1 Rules for the Radiographic Examination of the Vertebral Column and the Joints of the Extremities.- 2 Analysis of the X-ray Image.- Practical Approach to the Analysis of X-ray Films.- 3 Techniques for the Radiographic Examination of the Vertebral Column.- 3.1 Anteroposterior Projection of the LPH Region (After Gutmann).- 3.2 Lateral Projection of the Lumbar Spine.- 3.3 Thoracic Spine.- 3.4 Anteroposterior Projection of the Cervical Spine (After Sandberg-Gutmann).- 3.5 Anteroposterior Functional Views of the Cervical Spine (with Sidebending).- 3.6 Lateral Projection of the Cervical Spine.- 3.7 Lateral Functional Views of the Cervical Spine (Forward and Backward Bending).- 3.8 Arlen's Quantitative Technique for the Functional Evaluation of the Cervical Spine.- References.