Abstract
The clinical examination is an important part of any patient consultation. After the primary survey and taking the patient history, a more in-depth examination is sometimes required to aid making a working diagnosis and help negate other differential diagnoses. The extent of this depends on the stability of the patient and may not be possible in time-critical circumstances. However, clinical examination is an increasing part of paramedic practice owing to the continued expansion of the scope of the paramedic role in both urgent and emergency care. Education on clinical examination concerning each of the main body systems is now an integral part of undergraduate paramedic curricula.
This clinical examination series provides a step-by-step overview for each of the main body systems. Continuing professional development (CPD) is an essential requirement for all clinicians to maintain and to demonstrate that they are staying up to date and advancing in their roles.
This series gives an overview of each type of examination to support students, newly qualified paramedics and paramedics wishing to use these articles as a CPD development activity and an aide-memoire for clinical practice. This article, which explores the the musculoskeletal system, gives an overview of initial examination considerations.
How to use these guides
The articles in this series, which can be torn out for use in practice, are intended to support clinician development and to assist in the overall assessment of patient presentations. The information should be used to aid consideration of differential diagnoses in situations where life-threatening conditions have been ruled out.
The extent and explanation of each examination will not be to the depth of those provided in core literature texts, so further reading and consolidation are advised to support understanding supplemental to these articles. Key questions are included for reader consideration and to direct further study.
Most examinations are taught in a rigid format. However, in clinical practice, practitioners need to be flexible and adapt their approach depending on the presenting condition and circumstances. While there is no single set way to carry out each of these examinations, a good structure will reduce omissions and errors, and support the gathering of information to inform patient care.
Contemporary texts provide the underpinning reference sources throughout this series, as many of the examination processes and techniques are universally applied; however, differences will be highlighted. Readers will be signposted to these key texts for each clinical examination.
The series will cover the following systems:
Cardiovascular system
Peripheral vascular system
Neurological system (upper and lower limbs)
Cranial nerves
Gastrointestinal system
Respiratory system
Musculoskeletal system
Musculoskeletal examination
This article sets out a structured approach to aid with the assessment of the lower musculoskeletal (MSK) system.
The joints of the MSK system are examined in turn, according to the ‘look, feel, move and function’ structure outlined below. Familiarity with techniques and processes for each joint will foster confidence in patient assessment and form a foundation for further research and knowledge with regard to diagnosis and treatment.
This examination comprises a mixture of observation and physical assessment, and should always be carried out in conjunction with the patient's history-taking.
Taking a history from the patient will allow you to gauge their normal levels of movement through information they provide regarding their activities of daily living (Bickley and Szilagyi, 2017).
A general survey of the patient will provide an overview and, alongside specific information regarding the mechanism of injury, will help to inform the MSK examination as you proceed (Innes et al, 2018).
No specific equipment is required for the examination of the musculoskeletal joints unless specific data are being collected (e.g. a range of movement or test of power).
General observations
The examination of the joints of the body can be structured using: look; feel; move; and function (Bickley and Szilagyi, 2017).
Look
Observe posture, symmetry, skin changes, scars and swelling.
Look for changes in the patient's posture. This should be considered from different angles, i.e. the front, side and back
Consider the area in symmetry; for example, what does the patient's left wrist look like in comparison to the right? Look for scars, swelling and skin changes
Although reddening is a classic sign of inflammation, its presence is less reliable in joints and less likely to be present except in the fingers, toes and knees where the joint is more superficial (Bickley and Szilagyi, 2017)
If there is pain in the joint or the degree of movement is reduced, imaging should be considered before movement (Innes et al, 2018). Local guidelines should be followed for pain relief.
REFLECTION
Consider bedside items that may indicate a chronic or ongoing musculoskeletal illness or injury
Feel
Feel for temperature, tenderness and swelling at the joint and around it.
Look for evidence of temperature changes
Check for swelling, which may indicate the presence of arthritis or inflammation
Note any crepitus, where a crunching is heard or felt during the movement of tendons or ligaments over bones or areas of cartilage loss (Bickley and Szilagyi, 2017); this may be found during the examination but should not be actively sought during movement or palpation
Maintain an index of suspicion for possible fractures, which would indicate that support and immobilisation are needed, rather than a movement assessment
Observing and communicating with the patient during palpation will help to identify areas of tenderness.
REFLECTION
What aspects of your bedside manner would be important in establishing a rapport with the patient before and during the palpation of a joint?
Consider why it may be important to examine the joint above or below the one initially indicated
Move
Consider the range of movement for the limb being examined, including extension, flexion, abduction and adduction as appropriate.
Try to begin each movement with the patient facing forwards with their hands at their sides as demonstrated by the anatomical position (Agur and Dalley, 2019). This will ensure that there is no confusion regarding the location of any abnormality identified.
If the patient can mirror your actions, this may help with communication
Special function tests are specific to the joint being examined and common injuries to that joint
The examination of range of movement involves active and passive movements. The purpose of this is to determine the degree of movement in the joint being examined. Passive examination should follow active examination so the patient's own range of movement can be observed first (Innes et al, 2018)Active movement is where the patient moves independently, with no help from the clinician (Innes et al, 2018)Passive movement is where the patient relaxes and the clinician makes the movement. Relaxation is important; if the patient is tense, more rigidity in the limbs will make passive movement more difficult.
REFLECTION
Ensure you are clear about each directional movement by documenting the location of injuries using directional terms such as lateral, medial and superior
Hip
The hip is a ball-and-socket joint, formed from three bones: the ilium, ischium and pubis (Dalley and Agur, 2019). Hip pain is commonly felt in the groin but may present as referred pain and felt in the thigh, knee or buttock (Innes et al, 2018).
Look
It may be beneficial to look at the posture of the patient while they are standing and lying down as the position of the iliac crest or leg length may change when they are weight-bearing. Consider the sequence of your examination so the patient does not make unnecessary movements
As you will need to look for any skin changes, swelling or muscle wasting, the patient may need to remove some clothing during the assessment
Consider dignity and warmth for the patient as well their level of ability to perform the movements requested.
Feel
The superior aspect of the iliac can be felt by palpating laterally from spinal level L4 around the iliac crest and then distally to the greater trochanter (Bickley and Szilagyi, 2017)
The greater trochanter is a protrusion like a golf ball at the top of the femur, just before it joins the hip bone (Agur and Dalley, 2019)
The clinician should feel for any tenderness, swelling or temperature changes. Consider the implications of the skin area being hot or cold to touch.
Move
The movement of the hip may be assessed with the patient lying down (Bickley and Szilagyi, 2017; Innes et al, 2018) or, alternatively, you may support the patient to actively move the limb while standing (Kauffman, 2014)
The decision on which way to assess hip movement will vary according to the individual patient and their presentation. Maintain an index of suspicion for possible fractures, which would indicate support and immobilisation rather than assessing movement
The description here will be as though the patient were supine
For abduction and adduction, use one hand to move the limb while placing the other hand on the opposite iliac crest; this will help to stabilise the pelvis during movement (Innes et al, 2018)
To abduct, move the straightened leg away from the midline and to adduct move the straight leg across the opposite leg
There is a greater range of movement in abduction than in adduction
As this is being performed passively, the range of movement in either direction should not be excessive and caution should be exercised while conducting the movement
Supporting the patient's leg with their knee flexed at 90°, move the foot laterally or medially to show the internal or external rotation of the hip (Innes et al, 2018)
The direction of the foot medially will produce an external rotation and vice versa
Extensor movement can be achieved with the patient moving to a prone position and the extended leg being raised while observing for pelvic movement (Innes et al, 2018)
The Trendelenburg test can be used to assess gluteal muscle strengthWhen the patient stands on one leg, there should be a rise in the level of the iliac crest for the leg that is unsupportedAn abnormal response is where the iliac crest does not rise in the unsupported leg (Innes et al, 2018).
REFLECTION
Consider the implications of using the Thomas test within hip assessment
Knee
The knee is the largest joint in the body, and forms a hinge at the femur, tibia and patella. It has three articulating surfaces held together by four ligaments: lateral, medial, anterior and posterior (Agur and Dalley, 2019). Movement, pressure and a lack of musculature and tissue around the joint make it prone to injury (Bickley and Szilagyi, 2017).
Look
Look for varus (bow legs) or valgus (knock knees) deformity in the patient's posture (Innes et al, 2018)
Consider muscle wasting in the upper and lower leg
Compare for signs of asymmetry or swelling, scars and any obvious trauma.
Feel
Feel for any temperature changes or tenderness
A gathering of fluid at the back of the knee may indicate a Baker's cyst (Bickley and Szilagyi, 2017)
At the distal end of the femur, above and around the patella bone, are rounded areas called condyles
Inferior to the patella is the tibial tuberosity. This is the rounded section at the proximal tibia, just above the flat anterior aspect of the bone (Agur and Dalley, 2019).
Movement
Flexion and extension can be achieved by bending and straightening the leg or by asking the patient to squat and then stand (Bickley and Szilagyi, 2017)
Internal or external rotation can be seen when the patient is seated and moving their foot medially or laterally
The knee does not move in any other direction but gentle pressure may be exerted laterally and medially when testing the ligaments. This should be a controlled exercise to prevent further injury and is used to assess for laxity (Kauffman, 2014).
An anterior drawer test could also be performed to check the stability in the joint (Bickley and Szilagyi, 2017)
Sweeping your hand down the knee or up and over the knee can reveal the presence of fluid over the joint
Applying a downward motion with one hand until just above the patella, followed by a tap on the patella may indicate effusion if the patella moves against the femur (Innes et al, 2018)
Observation of the patient's gait will give valuable information which may determine the application of the aforementioned tests.
REFLECTION
Consider where you apply pressure for the anterior drawer test and what could be the cause or reasons for laxity in the knee joint
Foot and ankle
The ankle absorbs pressure through the heel as well as the weight of the body during movement. The cushioning pads in the foot help to absorb pressure while ankle ligaments aid stability (Agur and Dalley, 2019).
Look
The patient will need to remove their shoes and socks for this examination
Begin with the patient standing and then either seated or lying down for further assessment
Examine the position of the toes in relation to the foot. Are there any changes in the position of the foot arches?
Is there an obvious thickening of the Achilles tendon at the rear of the ankle?
Check symmetry and for the presence of any skin changes or swelling around the foot or ankle
Consider examining the patient's shoes for wear on the sole, damage to the shoe(s) and poor fitting
A check of the nails for signs previously discussed in the cardiovascular examination unit may indicate an overall systemic illness.
Feel
Feel for any temperature changes, tenderness or swelling around the joints of the ankle and feet.
Check and mark the peripheral pulses, dorsalis pedis and posterior tibial pulse (Agur and Dalley, 2019).
Move
Movement in the foot and toes is through dorsi and plantar flexion (Bickley and Szilagyi, 2017). Dorsi is movement upwards and plantar, like planting your foot, is downwards
Remember that people's ability to move their feet and toes varies
Stabilising the ankle will allow the clinician to test inversion and eversion of the foot. Crepitus may be apparent while these movements are assessed
Observing the patient's gait will help to identify areas of abnormality in the feet and ankles (Innes et al, 2018).
Conclusion
To conclude the examination, thank your patient and discuss any questions or treatment options. You should consider whether it would be appropriate to examine another joint to aid your diagnosis and treatment plan.
Record your findings, including the range of movement in the joint and any abnormalities identified (Bickley and Szilagyi, 2017; Innes et al, 2018).
Although this examination is based on the musculoskeletal system, consider whether an examination of another system such as the cardiovascular or respiratory would help with your diagnosis.
