Principles for clinical examination

Objective

• Perform a rational clinical examination
• Formulate tentative musculoskeletal diagnoses
• Understand the treatment options available in general practice
• Understand which conditions need to be referred to specialist healthcare services

Indicators of achievement

• Use the medical history to formulate a testable clinical question
• Be able to conduct a relevant clinical examination in 10 minutes
• Be able to make tentative diagnoses based on medical history and findings from clinical examination
• Suggest appropriate treatment measures in general practice
• Suggest relevant further investigations
• Know when and which patients should be referred to specialist healthcare services

Practical exercises

• Be able to carry out functional examination with standard tests
  • Inspection
  • Active movements
  • Passive movements
  • Isometric movements
  • Palpation
• Be able to carry out functional examination with special tests

Issues

• Which tests should you choose?
• Why should you choose them?
• How should you interpret them?

Challenges

• Which musculoskeletal diagnoses is it possible to make in general practice?
• How is it possible, with the help of a clinical examination, to arrive at one or more tentative diagnoses?

What are we looking for?

• Clinical findings that are recognisable and characteristic of a specific musculoskeletal disorder
• Based on history and the conducted clinical examination, try to find a clinical pattern that "as best as possible" can describe the patient's condition
• Which tests are positive and which tests are negative, and based on an overall assessment, draw a conclusion about which diagnosis is "most likely" in the individual case

What do we need to know about the patient?

• Which typical complaints occur in the different age groups
• Prevalence of pain in various parts of the musculoskeletal system
• Whether there is a history of trauma in the medical history
• Whether the pain is load-induced
• Whether there is suspicion of neurological deficits
• Whether there is suspicion of rheumatologic disease
• Whether there is suspicion of an infectious condition

The standard examination consists of five tests

Inspection

swelling, deformity, axes, curves, symmetry

Active movements

will and ability to move the painful area, observes range of motion

Passive movements

stresses non-contractile tissue (joint capsule, ligaments, nerves, bursa), records maximum range of motion and end-feel

Isometric movements

stresses contractile tissue (muscles, tendons), gets an idea of strength performance and pain

Palpation

consistency and tension in muscles, trigger points in muscles, joint swelling, heat

From standard examination to special test

The medical history provides a working hypothesis, a testable problem statement.

Standard examination

• Inspection
• Active movements
• Passive movements
• Isometric movements
• Palpation

• Provides a recognizable clinical picture/pattern
• Provides the possibility to set up tentative diagnoses sorted by likelihood of a condition
• Identifies treatment options available in general practice

Special tests

• Specific tests
• Strengthens or weakens the likelihood of a tentative diagnosis
• Forms a decision basis for further investigation, for example imaging diagnostics
• Forms a decision basis for further treatment, for example surgery

Risk of misdiagnosis

• When using special tests for which there is no indication (low prevalence of the condition in the population)
• When using special tests in the wrong population (for example in general practice instead of at an orthopedic outpatient clinic)
• When using tests for which there is no indication, and when the test is used in the wrong population, the risk of false positive tests increases, which can lead to overdiagnosis, over-investigation, and overtreatment

Overdiagnosis, over-investigation, overtreatment

Overdiagnosis

• The doctor uses unnecessary clinical tests
• The doctor has an unclear clinical issue after taking the medical history
• The doctor uses clinical tests that are not validated for use in general practice

Over-investigation

• Unnecessary blood tests, X-rays, and referrals to specialists
• May be due to uncertainty about which conditions can be treated in general practice
• May be due to uncertainty regarding diagnosis, what is disease?

Over-treatment

• Treatment that does not have documented effect
• Treatment following pressure from the patient/patient associations
• Implementation of more complicated treatment than necessary, problems that can be solved in primary healthcare are treated in hospitals

Maher, C.G., O'Keeffe, M., Buchbinder, R. and Harris, I.A. (2019), Musculoskeletal healthcare: Have we over-egged the pudding?. Int J Rheum Dis, 22: 1957–1960. doi: 10.1111/1756-185X.13710

Examination of passive joint mobility

• Is there a reduced range of motion in the joint?
• How is the end-feel in the range of motion?
• Is there a capsular movement pattern?
• Is there a non-capsular movement pattern?

Normal end-feel

• Stretch in joint capsule (e.g., end point hip rotation)
• Soft tissue against soft tissue (e.g., end point elbow flexion)
• Bone-to-bone (e.g. at the end of elbow extension)

Pathological end-feel

• Hard end-feel/stop feeling in osteoarthritis
• Spastic end-feel (muscular spasm to limit range of motion) in capsulitis/arthritis
• Springy end-feel in meniscus injury (the movement stops earlier than expected and there is a springy resistance to the movement because the meniscus blocks full range of motion)
• Empty end-feel (the patient holds back) when there is unwillingness to move

What is a capsular pattern of movement?

• A capsular pattern of movement is defined as restricted passive motion in a joint that follows a specific pattern where some ranges of motion are more restricted than others
• Caused by inflammation in the synovial membrane (arthritis) or in the joint capsule (capsulitis)
• Each joint in the body has, based on experience, its specific capsular movement pattern, examples:
  • Shoulder: Most reduced external rotation, less for abduction, and least for internal rotation
  • Hip: Most reduced internal rotation, less for flexion and abduction, and least for extension
  • Knee: More reduced flexion than extension

What is a non-capsular movement pattern?

• Reduced range of motion in a joint as not The pain is due to arthritis or capsulitis
• Possible causes may be:
  • Ligament injury
  • Meniscus injury
  • Bursitis
  • Muscle injury
• Examples of non-capsular movement patterns:
  • Painful arc during active abduction of the shoulder
  • Reduced flexion or extension in the knee joint due to meniscus

Inspection

Hyperextension of the knee

Active movements

• Flexion with palms on the floor
• Elbow hyperextension

Passive movements

• Thumb hyperextension
• Little finger hyperextension

Beighton score

• Thumb hyperextension 2 points
• Little finger hyperextension 2 points
• Elbow hyperextension 2 points
• Knee hyperextension 2 points
• Back flexion with palms on the floor 1 point

• Maximum 9 points
• Hypermobility when ≥ 5 points in adults and ≥ 6 points in children

Hypermobility

• Are hypermobile joints the cause of the patient's complaints?
  • Active and passive movement of a hypermobile joint must trigger pain that the patient recognizes as their problem
  • The patient must have had arthralgia in more than 3 joints for more than three months
• If hypermobility causing symptoms is detected, joint instability may be present

Høiseth TCJ. Beighton score. Published: March 30, 2020. Tidsskr Nor Legeforen. doi: 10.4045/tidsskr.19.0487

Grahame R, Bird HA, Child A. The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS). J Rheumatol. 2000 Jul;27(7):1777-9. PMID: 10914867.

Brodal, Per. The Central Nervous System, 5th ed. Oslo: Universitetsforlaget, 2013. ISBN 978-82-15-02112-6

Procedure sensory examination

• Explain to the patient carefully the purpose and objective of the examination
• Make sure the patient understands the purpose
• First demonstrate how a prick and light touch feel on an area with expected normal response
• Ask the patient to close their eyes or prevent the patient from seeing the skin area you are examining
• Compare responses from the affected and healthy side
• Examine superficial sensation with light touch, prick, and possibly with cold metal
• Examine deep sensation with joint and vibration sense
• Be aware that the findings are the patient’s subjective reports with the sources of error that implies
• Determine if there is sensory loss – assess whether it represents a dermatome, a peripheral nerve's innervation area, or if it is stocking-/glove-shaped
• Key points for screening in dermatomes follow recommendations from ASIA (International Standards for the Classification of Spinal Cord Injury)

Grading of sensory loss

• 0 = Absent
• 1 = Altered (reduced or increased)
• 2 = Normal

Interpretation of sensory loss

• Injury of the lateral cord pathway: Loss of pain and temperature sensation on the contralateral side. Can be caused by trauma, compression, inflammation, MS, neuropathy.
• Injury of the posterior cord pathway: Loss of joint and vibration sense on the same side, or opposite side if the injury is above the crossover. Classic complaints: unsteadiness, ataxia, clumsiness. Causes: trauma, compression, MS, vitamin B12 deficiency, among others.
• Mononeuropathy: Loss of multiple modalities in a single peripheral nerve distribution. Causes: compression, diabetes mellitus, inflammatory processes.
• Polyneuropathy: Loss of several modalities in multiple peripheral nerves – typically glove-/sock-shaped deficit. Diabetes is the most common cause.
• Radiculopathy: Loss of several modalities in one or more dermatomes due to compression near the root. Common with herniated discs in the neck and lower back.

Test for pain

• Use a neurotip; goal: to elicit a sharp, mild painful sensation
• Test first on the normal side – set this as 100%
• Then examine the symptomatic side
• Ask the patient to indicate experience of pain
• Significant loss: the patient indicates only 5–25% compared to the normal side

Test for temperature

• Adequate response to pain testing makes separate temperature testing unnecessary
• Cold response: approx. 5–10 ˚C; warm response: approx. 40–45 ˚C
• In general neurological examination, it is sufficient to indicate whether the patient can distinguish between cold and warm

Test for proprioception

• Includes movement, position, vibration, and pressure
• Test with eyes closed; hold on the side of the joint
• Test passive movement in the MTP joint of the big toe and DIP joint of the finger – ask the patient to indicate direction and range of motion
• The patient will notice 1 mm movement in the big toe; micromovements are registered in the DIP joint
• Loss of deep sensation → sensory ataxia. Additional test: Romberg's test

Romberg's test

• Useful in ataxia/coordination problems (Parkinson's, B12 deficiency, Ménière's, tertiary syphilis)
• The patient should first stand steadily with feet together and eyes open
• Close your eyes for 30 seconds – loses balance ⇒ positive test
• Positive test suggests sensory ataxia (cf. tabes dorsalis)

Test for vibration sense

• Use tuning fork 128 Hz
• Start on assumed normal area to calibrate the patient
• Then place on the IP joint of the big toe on the symptomatic leg
• When the patient does not feel vibration: move more proximally (e.g., medial malleolus)
• Record how long the patient senses vibration at the most proximal point
• Tactile loss is seen in demyelinating disease (e.g., MS)
• Distal loss with preserved proximal sensation may indicate polyneuropathy

Test for two-point discrimination

• Ensure that the patient understands the task – start with a large distance
• Hold still for a few seconds before the patient gives a response
• The two-point threshold is the smallest distance between two point stimuli that can be distinguished without sight
• Normal distances: fingertips 2–4 mm, palm 8–12 mm, back of hand 20–30 mm, dorsum of foot 30–40 mm
• Loss without other deficits may indicate damage to the parietal lobe

Sensitization

Increased sensitivity to pain in the tissue

• In case of tissue damage, the nociceptors become hypersensitive
• We get an increased flow of impulses into the spinal cord
• Non-pain-conducting neurons are affected – light touch is perceived as painful
• Inactive neurons become sensitive to mechanical and thermal stimuli

Increased sensitivity to pain in the brain

• Increased activity in nociceptors leads to increased release of neurotransmitters in the spinal cord
• We get faster transmission of pain impulses to the brain
• Nerve cells respond to normal stimulation as if it is painful
• Gradually we get a stronger response – the brain perceives it as pain

S-LANSS (Self-completed Leeds Assessment of Neuropathic Symptoms and Signs)

• Validated form to identify neuropathic pain
• Maximum score is 24
• Score > 12: probable neuropathic pain

Bennett MI, Smith BH, Torrance N, Potter J. The S-LANSS score for identifying pain of predominantly neuropathic origin: validation for use in clinical and postal research. J Pain. 2005 Mar;6(3):149-58. doi: 10.1016/j.jpain.2004.11.007. PMID: 15772908

Neuropathic pain

Neuropathic pain is defined by IASP (International Association for the Study of Pain) as "pain arising as a direct consequence of a lesion or disease affecting the somatosensory system."

Dysfunction of nerve fibers (e.g., diabetic neuropathy)

• The impulses reaching the brain do not correspond with what is happening in the tissue
• The most common symptoms are burning, stabbing, tingling, itching, numbness, crawling sensations, heat or cold (paresthesia)
• The pain feels burning, aching, tingling, or like electric shocks. Can be triggered by normally painless stimuli (allodynia).

Damage to the nerve fibers (e.g., nerve compression)

• The nerve fiber sends spontaneous impulses without stimulation – the brain perceives them as pain
• Sensory changes in the innervation area of the affected nerve
• Altered skin sensitivity to small temperature changes (allodynia) and increased pain sensitivity (hyperalgesia)

Kjersti Nøkleby, Tore Julsrud Berg. Diabetic neuropathy – a clinical overview. Tidsskr Nor Lægeforen 2005;125:1646-9

Concepts

Paresthesia

Skin sensation not caused by external stimuli – burning, stabbing, tingling, itching, numbness, crawling sensations, heat or cold. Intensity is rated on a VAS scale (0–10) and extent is described.

Allodynia

Pain caused by a stimulus that normally does not hurt. The threshold for experiencing pain is lowered; Even light touch or small changes in temperature can trigger intense and long-lasting (often burning) pain. Examine with a cotton ball and light mechanical pressure – register whether the pain spreads to a "healthy" nearby area of skin.

Dysesthesia

Changes in the skin sensation, e.g. light touch or needle sticks are perceived as an unpleasant, burning sensation. Intensity is graded on the VAS scale (0–10), distribution is described.

Hyperalgesia

Increased and abnormal pain sensation even with normal pain stimuli. Light pain stimulation can become very painful. Examined with neurotip – record whether a normal prick (but not painful) stimulus triggers pain and whether the pain spreads to a "healthy" zone.

Brodal, Per. The Central Nervous System, 5th ed. Oslo: Universitetsforlaget, 2013. ISBN 978-82-15-02112-6

Assessment of musculature

Fasciculation

Visible irregular muscle twitches – spontaneous activity in motor units. Seen in atrophied muscles in lower motor neuron syndromes.

Tremor

Involuntary movements that vary in amplitude and frequency. Seen in hyperthyroidism, Parkinson's, high alcohol/coffee consumption, side effects of medications (e.g., Ventoline, Bricanyl).

Tone

Examined by passive movement of the elbow, wrist, knee, and ankle. Hypotonia + atrophy + weakness + absent reflexes = lower motor neuron syndrome. Hypertonia can be spasticity (rapid movement, upper motor neuron syndrome) or rigidity (slow movement – lead-pipe or cogwheel rigidity, seen in Parkinson's).

Different types of muscle work

Concentric muscle work

The muscle develops force and contracts – becomes shorter. Contributes to joint movement.

Eccentric (dynamic) muscle work

The muscle lengthens – releases force to counteract opposing forces (like a brake). Example: slowing down a barbell down → the biceps muscle develops force while being stretched.

Isometric (static) muscle work

The muscle contracts without length change and without creating movement. Stabilizes a joint/body part or holds a joint in a specific position.

Procedure for strength examination

• Check for reduced strength and pain
• Test isometric muscle strength: stabilize the joint in a neutral position – no simultaneous joint movement. Ask the patient to exert force against the resistance from the examiner.
• Interpretation:
  • Strong and painless: No pathology in the muscle–tendon complex
  • Strong and painful: Minor injury in the muscle–tendon complex (muscle strain, tendon inflammation)
  • Weak and painless: Complete rupture, or pathology in nerve supply
  • Weak and painful: Possible serious injury (e.g., fracture)

Grading of muscle strength

• 5 = Normal strength
• 4 = Good strength (movement against resistance; 4− = 25%, 4 = 50%, 4+ = 75% of normal)
• 3 = Fair strength (movement against gravity, no resistance)
• 2 = Poor strength (movement when gravity is removed)
• 1 = Trace strength (no movement, but visible/palpable contractions)
• 0 = Zero strength (paralysis)

Avers D, Brown M. Daniels and Worthingham's Muscle Testing. Techniques of Manual Examination and Performance Testing. 10th edition, Elsevier 2019

Explanation of scoring

5 (Normal strength)

The patient resists, the examiner is unable to break the resistance

4 (Good strength)

The patient is unable to resist the examiner's force – indicates up to 50% decreased motor innervation

3 (Fair strength)

Movement against gravity and maybe very slight resistance; at least 60–70% weakness

2 (Poor strength)

Movement in the horizontal plane without resistance, but not against gravity

1 (Slight contraction)

Observable contractions, not strong enough for movement

0 (No strength)

No observable or palpable contraction

Testing of key musculature ("prime movers")

• Used to diagnose muscle weakness due to nerve root involvement in the neck and lower back
• Along with sensation and reflexes, it provides a basis for determining which nerve root is most likely affected by a herniated disc or compression in a narrow root canal

American Spinal Injury Association (ASIA): International Standards for the Classification of Spinal Cord Injury

Brodal, Per. The Central Nervous System, 5th ed. Oslo: Universitetsforlaget, 2013. ISBN 978-82-15-02112-6

Procedure for reflex examination

• Stretch reflexes are triggered from muscle and tendon structures and result in contraction of the associated muscle
• The muscle is gently stretched, then a firm strike is delivered to the tendon with the reflex hammer. Strike 4–6 times to see if the response stabilizes.
• Absent/decreased reflex may be due to involvement in the reflex arc: afferent nerve, motor anterior horn cell, or efferent nerve

Grading of reflex findings

• 0 = absent
• +1 = present
• +2 = brisk
• +3 = very brisk

Jendrassik maneuver

• If the reflexes are difficult to elicit: ask the patient to clench their teeth (upper extremity) or press their hands together (lower extremity)
• Motor nerve pathways from the brain normally have an inhibitory effect on the deep tendon reflexes – the maneuver temporarily weakens this inhibition

Reflexes in the upper extremity (deep tendon reflexes)

Biceps (C5–C6)

Locate the tendon with the index and middle fingers, stretch the tendon towards the patient's wrist, strike with a specific hit, and check for contraction

Brachioradialis (C6)

Tap just proximal to the radial styloid process and check for flexion and supination in the forearm

Triceps (C7–C8)

Patient lying down, forearm resting on the patient's abdomen with ~40° flexion at the elbow. Tap the tendon just proximal to the olecranon and observe contraction

Reflexes in the lower limb (deep tendon reflexes)

Patellar (L3–L4)

Hip and knee joint in flexed position – hold the leg below the knee joint and observe contraction in the quadriceps

Achilles (S1–S2)

Palpate the Achilles tendon and tap – note plantar flexion in the ankle. Easiest with the patient in prone position, 90° knee flexion, hold the foot

Plantar reflex (skin reflex)

• Note if the big toe dorsiflexes – Babinski sign
• Babinski sign indicates upper motor neuron injury

Interpretation of reflex examination

• Absence of a single reflex: Pathological if simultaneous muscle weakness or sensory loss – indicates peripheral nerve injury or nerve root damage. Without accompanying deficits, the finding is given less weight, but follow-up is recommended.
• Absence bilaterally: Some healthy individuals have no tendon reflexes – not pathological if there is simultaneously no weakness, atrophy, or sensory loss.
• Asymmetric reflexes: May be normal, but important in the diagnosis of hemiparesis and upper motor neuron lesions that give unilateral brisk reflexes.

Brodal, Per. The Central Nervous System, 5th ed. Oslo: Universitetsforlaget, 2013. ISBN 978-82-15-02112-6

Referred pain from n. sinuvertebralis

Multisegmental nociceptive pain from:

• Annulus fibrosus
• Dura mater
• Ligaments

Light pressure, wear, and inflammation in these structures induce nociceptive signals and create referred pain mediated via the n. sinuvertebralis.

Breemer MC, Malessy MJA, Notenboom RGE. Origin, branching pattern, foraminal and intraspinal distribution of the human lumbar sinuvertebral nerves. Spine J. 2022;22(3):472-482. doi: 10.1016/j.spinee.2021.10.021

Peng B, Wu W, Li Z, Guo J, Wang X. Chemical radiculitis. Pain. 2007;127(1-2):11-6. doi: 10.1016/j.pain.2006.06.034

N. sinuvertebralis – function

• Arises from the ventral ramus
• Returns to the spinal canal via the intervertebral foramen
• Provides sensory innervation to the posterior part of the annulus fibrosus, posterior longitudinal ligament, the ligaments of the facet joints and atlantoaxial joints, periosteum of the vertebrae, and the anterior part of the dura mater
• The sensory fibers overlap and extend up and down several segments (multisegmental innervation)
• The nerve contains proprioceptive, nociceptive, and sympathetic fibers

Groen GJ, Baljet B, Drukker J. The innervation of the spinal dura mater: anatomy and clinical implications. Acta Neurochir (Wien). 1988;92(1-4):39-46

Shayota B, Wong TL, Fru D et al. A comprehensive review of the sinuvertebral nerve with clinical applications. Anat Cell Biol. 2019;52(2):128-133

Convergence of nerve impulses – explanatory model

• A neurogenic mechanism where information from multiple sources (nociceptive and non-nociceptive) is gathered in a second-order neuron that transmits to higher levels in the CNS
• Creates an experience of pain located in skin areas of the neck/shoulder, upper extremity, or lower extremity

Somatically referred pain – character

• Feels deep, persistent, aching, and gnawing
• Can also feel like expanding pressure
• Difficult to define the extent, but the most painful point is easy to identify
• The spread of pain follows the segmental innervation of the deep structures of the musculoskeletal system
• It is not the structure that is damaged that determines the distribution, but the structure's nerve supply – any structure innervated from the same segment has the same distribution
• The pain distribution provides an indication of the pain's likely segmental location; systematic clinical examination provides a more precise definition

Bogduk N, Marsland A. The cervical zygapophysial joints as a source of neck pain. Spine. 1988;13(6):615

Roselt D. (2013) Somatic Referred Pain. In: Gebhart GF, Schmidt RF (eds) Encyclopedia of Pain. Springer, Berlin. doi: 10.1007/978-3-642-28753-4_4062

Bogduk N. On the definitions and physiology of back pain, referred pain, and radicular pain. Pain. 2009;147(1-3):17-9

What is a clinical test?

• A clinical test is used to change the clinician's estimate of how likely it is that the patient has a specific disease
• All clinical tests are evaluated against how well they correspond with a reference standard
• The reference standard (e.g., MRI) is considered to be the closest one can get to the truth about whether a disease is present
• The results are compared with the reference standard to determine how many patients are correctly diagnosed

Sensitivity and specificity

• Sensitivity = 100% × a / (a+c)
  • The test's ability to pick out those who actually have the disease
  • High sensitivity is important in diagnostics
  • A negative test with high sensitivity excludes the disease (SnNout)
• Specificity = 100% × d / (b+d)
  • The test's ability to identify those who actually do not have the disease
  • High specificity is important in screening
  • A positive test with high specificity confirms the disease (SpPin)

Predictive value

• Positive predictive value (PPV) = 100% × a / (a+b) – the probability that a patient with a positive test has the disease
• Negative predictive value (NPV) = 100% × d / (c+d) – the probability that a patient with a negative test does not have the disease

Likelihood Ratio (LR)

• Positive LR (positive test) = Sensitivity / (1 − Specificity). Value > 1 = more likely positive test in patients. Good indicator for "ruling-in" the diagnosis.
• Negative LR (negative test) = (1 − Sensitivity) / Specificity. Value < 1 = less likely negative test in patients. Good indicator for "ruling-out" the diagnosis.

Interpretation of Likelihood Ratios

• Positive LR > 1 increases the probability that disease is present given a positive test
• Negative LR < 1 lowers the probability that disease is present given a negative test
• Good tests have LR+ > 10 and LR− < 0.1

The professional's nomogram

Pretest probability = the prevalence of the disease in the population, or when unknown: an overall assessment based on medical history, previous tests, and the doctor's experience. When posttest probability increases, the doctor becomes more certain that the disease is present and can start treatment (treatment threshold).

Example: pretest prevalence 40%, test LR+ = 4 → probability of disease with a positive test increases to 70%.