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Orthopedic examination findings

Last updated: May 28, 2021

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Physical examination plays a central role in orthopedic diagnostics. Orthopedic examination is performed in the following sequence: inspection, palpation, determining the range of motion of the joint, focused neurological examination, and special tests to evaluate for a particular disorder. Inspection aims to reveal gross orthopedic abnormalities and associated findings (e.g., signs of inflammation or bruising). Palpation is performed to check for local temperature changes, tenderness, muscle bulk, and pulses on the vessels of the examined body part. Range of motion, a measurement of joint movement in angular degrees, is used to evaluate mobility. This article outlines examination techniques for the major parts of the musculoskeletal system, with the exception of the shoulder, which is covered in “Orthopedic examination of the shoulder.”

Inspection

  • Ask the examinee to uncover the areas of the body to be examined.
  • Compare structures on both sides.
  • Assess for the presence of the following:
  • See sections below for additional considerations for the examination of particular body parts.

Palpation

  • The examiner assesses for temperature changes using the dorsal surface of their hand.
  • Palpate pulses on the extremities (see “Pulses” in “Cardiovascular examination”).
  • Palpate muscle groups to assess bulk and for the presence of spasm or tenderness.
  • Palpate or percuss bony structures to assess for tenderness.
  • If any lump is present, assess its characteristics (e.g., mobility, fluctuation, texture).

Range of motion (ROM) [1]

General considerations

  • Definition: the extent of movement possible in a joint; measured in degrees
  • Assessment
    • The following techniques can be used to measure ROM: [1]
      • Active ROM: The examinee is asked to move the joint.
      • Passive ROM: The examiner moves the examinee's joint.
    • The angle of the joint is recorded at the extremes of its range; see “Reporting and recording ROM” for an overview of how to report the angles.
    • Note if any pain occurs in the available range.
  • Measurement: The angle is measured with one of the following devices.
    • Goniometer
      • A device consisting of a protractor, a moving limb, and a stationary limb
        • The stationary arm is aligned with the midline of the stationary segment of the joint.
        • The moving limb is aligned with the midline of the moving segment of the joint.
        • The fulcrum is aligned with a bony landmark close to the axis of movement.
      • For example, when measuring ROM in an elbow, align the stationary limb with a shoulder, moving limb with a forearm, and the fulcrum with the lateral epicondyle of the humerus.
      • Inclinometer
        • A device consisting of a scale and a disc with a fluid reservoir sitting on a base.
        • To measure an angle in a limb, place the base of the inclinometer on the moving segment of the limb, with one point of contact close to the axis of the movement.
        • Mainly used to measure ROM in the spine

Reporting and recording ROM

  • The 0–180 system is used to report ROM.
    • Anatomical position is assumed as a starting position for all joints (except the forearm, which should be supinated) and marked as 0°.
    • As the movement proceeds, motion progresses toward 180°.
    • The result is recorded for motions in a single plane (e.g., flexion and extension, medial and lateral rotation) using three numbers: the first number represents the extreme of motion in one direction (e.g., flexion), the second number represents the starting point, and the third number represents the extreme of motion in another direction.
    • If motion in either direction cannot be carried out, the corresponding value in degrees is recorded as zero.
  • Examples

Focused neurological examination

Focused motor and sensory examination of the affected body part should be performed. For details on the examination, see “Motor function” and “Sensory function” in “Neurological examination”.

Special tests

Special tests are used to assess for abnormalities that affect particular anatomical structures (e.g., anterior drawer test for anterior cruciate ligament rupture). See individual sections below for information about specific tests.

Inspection

Palpation

  • Percuss the spinal processes from the cervical region to the lumbosacral region to assess for local tenderness.
  • Palpate the paraspinal muscles to check for tenderness, muscle spasm, and trigger points.

ROM [1]

ROM of the spine
Cervical spine Thoracic spine Lumbar spine
Lateral flexion
  • 20–45°
  • 20–40°
  • 15–20°
Extension
  • 45–70°
  • 25–45°
  • 20–35°
Flexion
  • 45–90°
  • 25–45°
  • 40–60°
Rotation
  • 70–90°
  • 35–50°
  • 3–18°

Special tests

Spine mobility tests

  • Schober test
    • Procedure
      • With the examinee standing, the examiner marks two points on the back, one at L5 and one 10 cm above L5.
      • The examinee flexes forward as far as possible while keeping their knees straight.
      • The distance between the two marks is measured.
    • Interpretation: An increase in the distance between the marks < 4 cm suggests impaired lumbar spine mobility.
  • Ott test
    • Procedure
      • With the examinee standing, the examiner marks two points, one at the spinous process of the C7 vertebra and one 30 cm below C7.
      • The examinee flexes forward as far as possible while keeping their knees straight.
      • The distance between the two marks is measured.
    • Interpretation: An increase in the distance between the marks < 2 cm suggests impaired thoracic spine mobility.

Root impingement tests

  • Neck compression test (Spurling test)
    • Procedure: The examiner extends the examinee's neck to the side of the pain and applies downward pressure to the head.
    • Interpretation: The emergence of limb pain/paresthesia indicates cervical radiculopathy.
  • Straight leg raise test
    • Procedure
      • The examinee lies in a supine position.
      • The examiner lifts the examinee's leg 30º–70º with the knee in extension.
    • Interpretation: Emergence of pain radiating down the same leg, below the knee, indicates lumbar nerve root impingement (Lasegue sign).

Other tests

  • Adam forward bend test
    • Procedure
      • The examinee bends forward at the waist with the knees straight.
      • The examiner looks at the patient from behind.
    • Interpretation: Asymmetry of the spine indicates scoliosis.
  • Mennell sign

For an overview of arm and hand anatomy, see “Upper arm and elbow” and “Forearm, wrist, and hand”.

Inspection

Palpation

ROM [1]

ROM of the arm and hand
Flexion Extension Other
Elbow
  • ∼ 135°
  • 0–5°
Wrist
  • 50–80°
  • 50–80°
Thumb
Carpometacarpal joint
  • 0°–15°
  • 0°–20°
  • -
Metacarpophalangeal joint
  • 50°
Interphalangeal joints
  • 80°
  • 0°–20°
Digits II–V
Metacarpophalangeal joint
  • 90°
  • 0–30°
Proximal interphalangeal joint
  • 100°
  • -
Distal interphalangeal joint
  • 95°

Special tests

Elbow joint tests [2]

Provocative wrist and hand tests

  • Tinel sign
  • Phalen maneuver
  • Hand elevation test
  • Finkelstein test
    • Procedure: The examiner grasps the examinee's affected thumb and exerts longitudinal traction across the palm of the hand towards the ulnar side.
    • Interpretation: Pain in the thumb indicates de Quervain tenosynovitis.

For an overview of hip anatomy, see “Hip joint” in “Pelvis and hip joint”.

Inspection

ROM [1]

Special tests

  • Trendelenburg test (hip drop test)
    • Description: The examinee stands on one leg (i.e., the leg to be tested).
    • Interpretation: Pelvic drop on the side of the lifted leg indicates gluteus medius and/or minimus muscle pathology on the opposite leg.
  • FABER test (Patrick test)
    • Procedure: Flexion, ABduction, External Rotation
      • The examinee lies supine.
      • The examiner sequentially performs passive hip flexion, abduction, and external rotation, so that the patient's legs are arranged in a figure-of-4 position.
      • After performing the final rotation, the examiner gently pushes down on the knee of the folded leg.
    • Interpretation: The emergence of pain in the hip or sacroiliac joints indicates pathology in the corresponding structure.
  • Thomas test
  • Drehman sign

For an overview of knee anatomy, see “The knee joint” in “Thigh, knee, and popliteal fossa”.

Inspection

Palpation

ROM [1]

Special tests

Tests for cruciate ligaments

Tests for collateral ligaments

Tests for meniscus injury

Tests for joint effusion

  • Patellar tap test
    • Procedure
      • The examinee lies supine with the knee extended.
      • The examiner pushes the fluid from the suprapatellar pouch to the knee joint with one hand and uses the other hand to gently tap the area over the patella.
    • Interpretation: floating of patella indicates joint effusion
  • Knee bulge test
    • Description: The examiner applies pressure above the patella to milk fluid from the suprapatellar pouch and then applies pressure behind the lateral margin of the patella.
    • Interpretation: The appearance of a bulge on the medial aspect of the knee indicates the presence of knee joint effusion.

  1. Reese NB, Bandy WD. Joint Range of Motion and Muscle Length Testing - E-Book. Elsevier Health Sciences ; 2013
  2. Fink B, Egl M, Singer J, Fuerst M, Bubenheim M, Neuen-Jacob E. Morphologic changes in the vastus medialis muscle in patients with osteoarthritis of the knee. Arthritis & Rheumatism. 2007; 56 (11): p.3626-3633. doi: 10.1002/art.22960 . | Open in Read by QxMD
  3. Dong C, Li M, Hao K, et al. Dose atrophy of vastus medialis obliquus and vastus lateralis exist in patients with patellofemoral pain syndrome. J Orthop Surg. 2021; 16 (1). doi: 10.1186/s13018-021-02251-6 . | Open in Read by QxMD
  4. Zwerus EL, Somford MP, Maissan F, Heisen J, Eygendaal D, van den Bekerom MP. Physical examination of the elbow, what is the evidence? A systematic literature review. Br J Sports Med. 2017; 52 (19): p.1253-1260. doi: 10.1136/bjsports-2016-096712 . | Open in Read by QxMD