Musculoskeletal examination

• GALS examination

  • GALS: gait, arm, legs, and spine.
  • GSAL may be a more logical order.

  Screening questions

  • Any pain, swelling, or stiffness in joints/muscles?
  • Any difficulty getting dressed?
  • Any difficulty getting up stairs?

  Gait

  • Ask them to walk, noting smoothness, heel strike, toe off, arm swing, turn speed (ask them to turn quickly).
  • Normal summary: "Gait was smooth, symmetrical, with a quick turn and good arm swing."

  Spine

  • With them standing with hands by side, first note if elbows and knees are fully extended.
  • Observe from behind, from back of head down to back of feet, noting any scoliosis, whether iliac crests are equal, muscle wasting including gluteals and calves, Baker's cysts (RA), and feet abnormalities. Gluteal wasting might mean chronic knee problems, and calf wasting might mean chronic ankle problems.
  • Observe from side: any excess kyphosis or lordosis? Check lumbar function: have them touch toes while you have two fingers on lumbar spine; the normal finger spread may be reduced in ank spond.
  • Observe from front. Are the shoulders even? Any WADES: Wasting (especially biceps or quads), Asymmetry, Deformity, Erythema, Scars or Swelling?
  • Cervical spine function: ask them to tilt head side to side – ear towards shoulder – to check lateral flexion.
  • TMJ function: ask them to open mouth and move side to side.

  Arms

  • Ask them to put hands behind head
  • Ask them to bring hands down to side, elbows pinned in, forearms out with palms down. Inspect.
  • Ask them to turn palms upwards – noting supination – inspect, then squeeze MCP joints 2-5. Are they tender?
  • Ask them to make fist, squeeze your finger, then pincer each finger to their thumb.
  • Comment on movement and coordination.

  Legs

  • Have them lie on bed.
  • Observe again, including soles. Any callouses? Arches normal? WADES?
  • Squeeze MTP joints 1-5: tender?
  • Patellar tap for effusion.
  • Passive movement: check for crepitus at knee, and hip internal rotation (moving foot outwards).

  Summary

  • Record appearance and movement for each of the 4 aspects examined.
  • Summary sentence if normal: "There was normal appearance and movement in all 4 areas examined, and no indication for a REMS exam."

• pGALS examination

  Mostly the same as adult GALS, but with a few small differences, described below.

  Gait

  • Ask them to walk on heels and walk on tip-toes.
  • Most pediatric gait abnormalities don't impair motor development and self-resolve, but they can have pathological causes.

  Findings

  Valgus and varus deformity:

  • Varus: normal if aged <3, but can suggest Rickets.
  • Valgus deformity: normal if aged 2-7, but can suggest JIA.

  In-toeing, often with valgus deformity. Common causes:

  • Internal tibial torsion. Usually resolves by age 5.
  • Increased femoral anteversion, where the patella also faces medially. Usually resolves spontaneously by age 11.
  • Metatarsus adductus: C-shaped lateral border of foot, common and normal under age 2.
  • Uncommon pathological causes: cerebral palsy, developmental dysplasia of the hip.

  Out-toeing, often with varus deformity. Causes:

  • External rotation contracture of the hip. Usually resolves by age 1.
  • External tibial torsion. Often does not resolve but rarely causes problems.
  • Uncommon pathological causes: SUFE, Perthes.

  Flat feet. Causes:

  • Often normal <6 years.
  • Hypermobility

  Toe walking. Causes:

  • Often normal <3 years.
  • Pathological causes: spastic diplegia, muscular dystrophy, cerebral palsy, autism.

  Arms and legs

  • Arms up to sky, look up at ceiling, and prayer-sign up and down with hands.
  • Open mouth wide and place 3 fingers in side to test TMJ function.
  • Legs: active movement of knee in addition to passive, but no MTP squeeze.

• REMS examination – general features

  Regional Examination of the Musculoskeletal System

  Overview:

  • Ask if they have pain in any joints. If so, examine the good side first.
  • For each exam: look, feel, move, special tests, and function.

  Look for WADES:

  • Wasting
  • Asymmetry
  • Deformity
  • Erythema
  • Scars, pSoriasis, Swelling. If swollen, note if soft (effusion), or bony (osteoarthritic).

  Closing examination:

  • If pain found, need to examine the joint above and below.
  • Check neurovascular status (if not already done).
  • Get an X-ray.

• Knee examination

  See non-traumatic knee pain and acute knee trauma for underlying conditions.

  Look

  • Quad wasting.
  • Valgus or varus deformity.
  • Scars: 2-3 small ones in the joint line suggest arthroscopy, large midline scar suggests knee replacement.

  Feel

  • Temperature: compare with back of hands, above and on sides of knee.
  • Tenderness: palpate along the border of patella and the joint line at the sides. Pain suggests a meniscal problem. Flex knee to 90° and palpate again and around back for tenderness and Baker's cyst.
  • Effusions: 'milk' the joint by pressing above the knee and dragging down, then tap patella to see if it hits knee. Also press and drag from medial to lateral, and push back from other side to look for a bulge on the medial side you just emptied.

  Move

  • Active: ask patient to fully flex then extend. Should be able to flex to 140°.
  • Passive: one hand on front of knee as you flex and extend, feeling for crepitus. Crepitus suggest the irregular joint of osteoarthritis or chondromalacia patella.

  Special tests: ligament stability

  Cruciates:

  • Flex to 90° with foot flat.
  • Look from side for posterior sag, which would suggest a posterior cruciate problem.
  • Rest elbow on foot and wrap hands around tibia with thumbs on tuberosity, then push back for posterior drawer test – checking for posterior cruciate problems again – and pull forward for anterior drawer test – checking for anterior cruciate problem.

  Collaterals:

  • Lift leg with your elbow at their feet and hand gripping lower leg.
  • Place other hand over medial side of knee and push inward with your body weight against it (varus stress) to check lateral collateral ligament.
  • Place hand over lateral side and pull outwards with other hand (valgus stress) to check medial collateral ligament.
  • The lower leg should move very little for each movement, showing the ligaments are intact and keeping the knee stable.

  Function

  Ask patient to stand:

  • First inspect again – from front and back – and check for varus/valgus deformity. Check feet for pes cavus (arched) or pas planus (flat), which can affect the knee.
  • Ask patient to walk to observe any abnormal gait, limp

• Shoulder examination

  See shoulder pain for underlying conditions.

  Look

  • Have patient uncover torso.
  • Inspect front then back.
  • Look for symmetry and wasting, especially of deltoids.

  Feel

  • Temperature: compare with back of hands on anterior shoulder.
  • Tenderness: starting from suprasternal notch, then across sternoclavicular joint, clavicle, acromioclavicular joint, acromion, border of scapula on back, then the anterior and posterior joint line.
  • Bulk: check bulk of deltoid, supraspinatus, and infraspinatus.

  Move

  Active, with you demonstrating first:

  • Abduction/adduction including looking from behind to check normal scapula rise at 90°. If earlier, suggests glenohumeral joint problem.
  • Extension/flexion: up to front (flexion) then back with elbows bent.
  • Internal/external rotation: elbows bent, arms at side, move in then out. Reduced movement in frozen shoulder.

  Passive:

  • Hold shoulder as you do the same movements, checking for crepitus.

  Special tests

  • Movement against resistance (subacrominal pain syndrome): abduction (supraspinatus tendinitis), internal rotation (subscapularis tendinitis), external rotation (infraspinatus tendinitis).
  • Neer's sign: passive internal rotation and flexion produces pain in subacrominal pain syndrome.
  • Jobe's test (aka empty can test): with shoulders flexed and abducted to 90°, and wrists pronated so thumbs are pointing down, patient elevates arms against resistance of examiner pushing down. Tests strength of supraspinatus muscle and tendon.
  • Scapula winging: have patient flex shoulder and push against wall. Scapula protrusion suggests serratus anterior paralysis (long thoracic nerve, C5-7).

  Function

  Do the MSK Macarena:

  • Hands on back of head.
  • Each hand on opposite shoulder.
  • Hand around to back with palm facing out and ask them to push out when you pin it in.

• Hand examination

  Look

  Approach

  • Position: hands rested on pillow, with sleeves up to elbow. Look at back of hand first then palm.
  • Look for swelling, deformity, wasting, and scars.
  • Note if changes are symmetrical.
  • Say thumb, index, middle, ring, and little finger, not 1st, 2nd, 3rd, 4th, and 5th.

  Findings

  Osteoarthritis:

  • Thumb CMC squaring.
  • Bouchard's or Heberden's nodes

  Rheumatoid arthritis (RA):

  • Wasting: guttering (visible dorsal tendons), thenar wasting (due to carpal tunnel syndrome), and hypothenar wasting (ulnar nerve entrapment).
  • Deformities: swan-neck or boutonniere, ulnar deviation, Z thumb, palmar erythema, carpal tunnel release scar, and check elbows for nodules.

  Psoriasis:

  • Onycholysis
  • Nail pitting.

  Feel

  Forearm and elbow (look and feel):

  • Have them flex elbow.
  • Run hand up ulnar border of forearm: look and feel for nodules (RA), plaques (psoriasis), or tophi (gout).

  Extend elbow again, with hand palms up:

  • Check radial pulse on each side.
  • Bulk: feel for thenar and hypothenar wasting and Dupuytren's contracture.
  • Sensation: gently touch thenar eminence (median nerve) and hypothenar eminence (ulnar nerve), then turn hands face down and gently touch thumb-index web (radial nerve). Does it feel the same on both sides?
  • Temperature: with bank of hands, compare either side at forearm, at wrist, and on MCPs, PIPs, and DIP.
  • Tender or swollen joints: bimanually palpate wrist and squeeze MCP. Then individually feel joints that look swollen: for MCP, both thumbs on top and both index fingers below, then for PIPs and DIPS, use thumb-finger pincer with one hand for top and bottom and the other for the sides. Throughout, watch the face to look for response.

  Move

  • Fingers: have patient extend them fully against gravity (radial nerve), don't let them be pushed down. Difficulty suggests tendon rupture, or neurological problem if passive movement is possible.
  • Spread fingers – abduction (ulnar nerve) – and don't let them be pushed together.
  • Rotate palm up and ask patient to stick thumb up – abduction (median nerve) – and withstand resistance.
  • Have them make a fist (of 'full finger tuck'); difficulty suggests a tendon or joint problem, or neurological problem if passive movement is possible.
  • Wrist: active movement with prayer sign (extension) and opposite prayer sign (flexion). Then passively move their hand, while stabilizing their wrist with your other hand.

  Special tests: carpal tunnel syndrome

  If the history suggests possible CTS, do Phalen's test:

  • Hold the patient's affected wrist flexed (fingers pointing down) for 1 minute.
  • If they elicit tingling in the fingers, it supports the diagnosis.
  • Alternative is Tinel's sign: tap carpal tunnel area to elicit tingling.

  Function

  • They power grip your 2 fingers, then pincer grip your 1 finger (with their finger and thumb).
  • Pick up coin or undo button to assess pincer grip and function.

• Hip examination

  See hip pain for underlying conditions.

  Look

  • Patient should be undressed to underwear.
  • With patient standing, look for shoulder symmetry, pelvic tilt, gluteal wasting.
  • With patient lying supine, look for a fixed flexion deformity.
  • If you suspect leg length disparity from inspection, measure with tape measure from the ASIS to the medial malleolus (true length). This can be compared to the apparent length, measured form umbilicus to medial malleolus, which will differ from the true length if the pelvis is tilted.
  • Scars overlying hip.

  Feel

  • Palpate over greater trochanter for tenderness = trochanteric bursitis.
  • Other options (not part of REMS): hip joint (pressing deep into groin), pubic rami.

  Move

  Passive:

  • Flexion: with knee flexed at 90°, fully flex hip and watch face for pain. Normal range 0-130°.
  • Thomas test: put your left hand palm upwards under lumbar spine to ensure lumbar lordosis flattens out (and they don't 'cheat' through hyper-lordosis), then fully flex one hip. If the other leg lifts off couch it has a fixed flexion deformity, usually due to capsular fibrosis and osteophytes as part of osteoarthritis (OA).
  • Rotation: with hip and knee flexed at 90°, check internal (foot out, 0-20°) and external (foot in, 0-45°) rotation. Internal rotation is usually the first movement to be impaired in osteoarthritis.
  • Extras (not in REMS): extension (in prone position, 0-10°), adduction (cross limb over other, 0-30°), and abduction (out to side, 0-45°).

  Active movement can also be tested, though this is not part of REMS.

  Special tests: Trendelenburg test

  • Observe patient standing from front, place hands on ASIS (optional), and ask them to stand on one leg for 30 seconds. ASIS should remain level on both sides.
  • If ASIS on unsupported (leg up) side drops, it's a +ve Trendelenburg in the standing (leg down) side. Caused by hip pain – OA, trochanteric bursitis, dislocation, fracture, SUFE – or abductor weakness (glut medius) – seen in nerve root lesion, muscle wasting, and polio.

  Function: gait

  Can do this at the end or the start. If they have a stick, they can use it.

  Findings:

  • Antalgic (limp), with a shorter stance on the affected side. Most commonly due to OA.
  • Trendelenburg: waddling.

• Spine examination

  Similar to spine part of GALS, plus a few extras. See back pain for underlying conditions.

  Look

  • WADES.
  • Scoliosis: most commonly caused by minor leg length discrepancy.
  • From side: hyperlordosis or hyperkyphosis.

  Feel

  • Spiny processes.
  • Paraspinal areas.

  Move

  • Cervical spine: chin to chest, then side to side (ear to shoulder).
  • Thoracic spine: they sit down with their hands crossed and resting on the opposite elbow. Then rotate trunk side to side.
  • Lumbar spine: while standing, they lean side to side, then touch toes with the finger spread test (see GALS, above).

  Special tests: straight leg raise

  • With them lying supine, you passively lift straight leg up to 20-30° ± dorsiflex foot.
  • If there is pain which radiates down leg, suggests sciatica.