The primary methods used for physical examination of musculoskeletal system are inspection and palpation. Percussion and auscultation are only used in special situations such as percussion pain of vertebrae, auscultation for bone crepitus. The examination should include assessment of muscle strength and range of motion and maneuvers to test joint function and stability.
Both active movements where the patient moves the joint themselves and passive movements where the examiner moves the joint should be performed. Notice the symmetry, looking for symmetry of involvement and noting any joint deformities or malalignment of joints or bones. Examination should also include assessment of surrounding tissues, noting skin changes, subcutaneous nodules and muscle atrophy, and assessment of inflammation especially redness, swelling, warmth and tenderness.
Ascertain whether or not there are local signs of an inflammatory process. Determine if anatomic disruption is present; ie, joint instability, tendon rupture, bone fracture, or deformity. Distinguish between true muscle weakness as opposed to fatigue or disuse atrophy. Establish if constitutional symptoms, such as fever or weight loss, implicate a systemic process, or other symptoms are present that direct attention to other organs.
Alternatively, if the patient is already in the examining room or on the examination table when first encountered, the examiner should request at some point during the assessment that the patient stand, walk a few yards, and sit again. Gait analysis for limp can help separate primary from antalgic or extra-articular manifestations of musculoskeletal disease, such Forgot Password? What is MyAccess? Otherwise it is hidden from view.
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Davis PT Collection. Murtagh Collection. Purposive sampling, using the grids as the basis of availability, was undertaken to produce four mixed-speciality groups and two single-speciality groups. Final group sizes ranged in size from three to six participants. Final groups consisted of nine rheumatologists, five geriatricians, five orthopaedic surgeons and four general practitioners. The focus groups were held over a 4-week period and were facilitated by the author DC. Two in-depth interviews were also held involving a consultant orthopaedic surgeon and consultant rheumatologist in order to triangulate the findings from the groups.
A topic guide was used to direct the group discussion.
The general principles of examination, followed by the examination of each joint in turn, were discussed in each group. In addition, the barriers to effective musculoskeletal examination teaching and the ways of overcoming them were also discussed. Each group and interview was taped and transcribed verbatim.
enter Framework analysis was carried out on the transcripts using the phases outlined by Ritchie and Spencer [ 17 ] in order to identify common themes by the lead researcher. Applying framework analysis to all transcripts allowed data on similarities, differences and associations between individual experiences and specialities to be pulled out. Further triangulation occurred by the use of independent researchers.
They reviewed the original transcripts, charting process and identification of themes. Respondent validation was also undertaken by feeding back the focus group analysis to a selection of participants. Neither of these measures resulted in any changes to the identified themes.
Results from the qualitative work were used to inform the content of a national questionnaire. Cognitive pretesting of the questionnaire was performed with clinicians from the rheumatology department and a selection of general practitioners. The questionnaire was then piloted in the Northern region among 19 consultant rheumatologists, consultant orthopaedic surgeons, 62 consultant geriatricians and general practitioners.
In an attempt to improve the response rate following this initial pilot, the size of the questionnaire was reduced by the identification and exclusion of redundant questions. This revised questionnaire was then repiloted amongst 55 general practitioners from the North West Deanery of Scotland. The final questionnaire was then sent out nationally to a total of clinicians, consisting of consultant orthopaedic surgeons, consultant rheumatologists and consultant geriatricians these represented all consultants nationally, as identified through their respective society handbooks and cross-referenced with an NHS directory [ 18 ] where necessary and a selection of general practice trainers.
One follow-up reminder was sent after a 2-week period to non-responders.
A mean score between 1 and 5 was calculated for each clinical skill by speciality. This allowed the data to be ranked twice for each speciality: by their mean and by the percentage agreement. Space was also available for free-text comments. The findings from both the qualitative and quantitative phases were then presented to a national group of six members with representation from each of the involved specialities two rheumatologists, two general practitioners, one geriatrician and one orthopaedic surgeon. A modified group-nominative technique [ 19 ] was used. Participants were given an overview of the study through a min presentation by the lead researcher.
This included the list of clinical skills accepted at the pilot phase as well as the response rates of the national questionnaire. They were also introduced to the modified group-nominative technique. Each participant was then given a booklet. This contained each of the clinical skills.
The ranking of each clinical skill by mean was presented for each speciality, along with the direct focus group transcripts relating to the skill. The ranking of skills by each speciality by percentage agreement and by the overall mean , presented during the group nominative phase is available as supplementary material at Rheumatology Online. Each clinical skill was then assessed in turn through a process of voting and discussion see Results. This initial qualitative work has been published elsewhere [ 20 ].
A broad and diverse set of views amongst specialities was exposed and is summarized below. The strongest theme to emerge by far was the desire to simplify and standardize the regional examination as much as possible. All specialities feared that too many complex and specialist tests would confuse the medical student and perhaps lower their overall confidence in examining the musculoskeletal system. General practitioners and geriatricians favoured the functional aspect of the examination and were unaware of many of the special and eponymous tests.
Orthopaedic surgeons were aware of the confusion created by the use of special tests and eponymous terms and felt that they were often unhelpful in the clinical assessment of a patient, and there was dubious advantage in teaching them to medical students. However, a variety of other reasons for performing a thorough physical examination emerged.
Not all were simply related to achieving an accurate diagnosis. These included the enhancement of the doctor—patient relationship. For example, it was deemed important that at the end of a consultation the patient should feel they had been thoroughly examined. It was also suggested that having a standardized regional musculoskeletal examination would help raise the profile of musculoskeletal examination.
Table lists abnormalities that may be discovered in the musculoskeletal system. If abnormalities are detected in the musculoskeletal examination, there. A brief screening examination, which takes 1–2 minutes, has been devised for use in routine clinical assessment. It involves inspecting carefully for joint swelling and abnormal posture, as well as assessing the joints for normal movement. This screening examination is known by the.
Sixty-six items were identified from the qualitative data and included in the pilot questionnaire. The overall response rate for all specialities was Individual response rates for each speciality in the pilot phase were This revised item questionnaire was repiloted among 55 general practitioner trainers from the North West Deanery of Scotland the lowest response group to the initial pilot. This resulted in an improved response rate of No further changes were made to the questionnaire at this stage and the results from the repilot were included in the final analysis.
The distribution and responses for each of the four groups are shown in Table 1. Eighty-three questionnaires were returned due to retirement or incorrect addressing and were therefore excluded from the analysis. A summary of results is shown in Table 2.
This table represents the contents on the national questionnaire with the results for each speciality for each item represented. The figures in each of the speciality columns Rheum, Ortho, Geri and GPs correspond to the percentage of respondents scoring that item as either a 4 or 5 on the five-point Likert scale i. When we looked at the ranked data by mean score and proportion of agreement there were clear differences in how certain specialities regarded certain clinical skills.
General practitioners appeared to favour clinical tests of the knee, in particular the assessment of collateral and anterior cruciate stability, along with specific tests for cartilage tears. The consistently least popular skills included thoracic spine examination which was only popular amongst rheumatologists and examination of the feet including a lateral squeeze across the metatarsophalangeal joints.