"Right knee with moderate effusion and tenderness over medial meniscus Suggests partial tear of medial along the joint line. Moderate laxity of anterior cruciate ligament (ACL) meniscus and ACL, possibly from on anterior drawer test; posterior cruciate ligament (PCL) and medial sports injury or trauma and lateral collateral ligaments (MCL, LCL) intact—no posterior drawer sign or tenderness with varus or valgus stress. Patellar tendon intact—

patient able to extend lower extremity. All other joints with good range of motion, no other deformity or swelling."

Important Areas of Examination for Each of the Major Joints

■ Inspection for joint symmetry, alignment, bony deformities

■ Inspection and palpation of surrounding tissues for skin changes, nodules, muscle atrophy, crepitus

■ Range of motion and maneuvers to test joint function and stability, integrity of ligaments, tendons, bursae, especially if pain or trauma

■ Assessment of inflammation or arthritis, especially swelling, warmth, tenderness, redness

As you examine the musculoskeletal system, direct your attention to function as well as structure. During the interview you have evaluated the patient's ability to carry out normal activities of daily living. Keep these abilities in mind during your physical examination.

In your initial survey of the patient you have assessed general appearance, body proportions, and ease of movement. Now, as you apply techniques of examination to the musculoskeletal system, visualize the underlying anatomy and recall the key elements of the history—for example, the mechanism of injury if there is trauma, or the time course of symptoms and limitations in function in arthritis.

Your examination should be systematic. It should include inspection, palpation of bony landmarks as well as related joint and soft-tissue structures, assessment of range of motion, and special maneuvers to test specific movements. These steps are described for each of the major joints. Recall that the anatomic shape of each joint determines its range of motion. This range is greatest in synovial or ball-and-socket joints.

Remember the following clues to guide your examination.

■ During inspection, it is especially important to note symmetry of involvement. Is there a symmetric change in joints on both sides of the body, or is the change only in one or two joints?

Acute involvement of only one joint suggests trauma, septic arthritis, gout. Rheumatoid arthritis typically involves several joints, symmetrically distributed.

Also note any joint deformities or malalignment of bones.

Dupuytren's contracture (p. 531), bowlegs or knock-knees (p. 779)

■ Use inspection and palpation to assess the surrounding tissues, noting skin changes, subcutaneous nodules, and muscle atrophy. Note any crepitus, an audible and/or palpable crunching during movement of tendons or ligaments over bone. This may occur in normal joints but is more significant when associated with symptoms or signs.

Subcutaneous nodules in rheumatoid arthritis or rheumatic fever; effusions in trauma; crepitus over inflamed joints, in osteoarthritis, or inflamed tendon sheaths

■ Testing range of motion and maneuvers (described for each joint) may demonstrate limitations in range of motion or increased mobility and joint instability from excess mobility of joint ligaments, called ligamentous laxity.

Decreased range of motion in arthritis, inflammation of tissues around a joint, fibrosis in or around a joint, or bony fixation (ankylosis). Ligamentous laxity of the ACL in knee trauma

■ Finally, testing muscle strength may aid in the assessment of joint function (for these techniques, see Chap. 16).

Muscle atrophy or weakness in rheumatoid arthritis

Be especially alert to signs of inflammation and arthritis.

■ Swelling. Palpable swelling may involve: (1) the synovial membrane, which can feel boggy or doughy; (2) effusion from excess synovial fluid within the joint space; or (3) soft-tissue structures such as bursae, tendons, and tendon sheaths.

Palpable bogginess or doughiness of the synovial membrane indicates synovitis, which is often accompanied by effusion. Palpable joint fluid in effusion, tenderness over the tendon sheaths in tendinitis

■ Warmth. Use the backs of your fingers to compare the involved joint with its unaffected contralateral joint, or with nearby tissues if both joints are involved.

Arthritis, tendinitis, bursitis, osteomyelitis

■ Tenderness. Try to identify the specific anatomic structure that is tender. Trauma may also cause tenderness.

Tenderness and warmth over a thickened synovium may suggest arthritis or infection.

■ Redness. Redness of the overlying skin is the least common sign of inflammation near the joints.

If the person has painful joints, move the person gently. Patients may move more comfortably by themselves. Let them show you how they manage. If joint trauma is present, consider an x-ray before attempting movement.

The detail needed for examining the musculoskeletal system may vary widely. This section presents examination techniques for both comprehensive and targeted assessment of joint function. Patients with extensive or severe musculo-skeletal problems will require more time. A briefer survey for those without musculoskeletal symptoms is outlined in Chapter 3 (see p. 69).

Redness over a tender joint suggests septic or gouty arthritis, or possibly rheumatoid arthritis.

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