RCSI Handbook of Clinical Skills 3rd Edition (MSK exam)

Wrist flexion: 0 - 75°, Wrist extension: 0 - 75°

0 - 90°

The patient should be standing with the shoulders and torso exposed for the examination.

The purpose is to assess if the patient has any pain in the shoulder prior to the examination.

The examiner should note any aids, splints, casts, slings, and check for any obvious deformity.

Open your fist and splay your fingers.

Flexion, extension, opposition, abduction, adduction, circumduction.

By using the Oxford Scale (0-5) while resisting movement in the assessed movements.

Ask the patient to squeeze 2 of your fingers.

Ask the patient to oppose the thumb and little finger and resist pulling them apart.

Ask the patient to pick up a pen and write a sentence or open a button.

Full power against resistance

Tuck the thumb into a closed fist and quickly bring the wrist into ulnar deviation. Pain in the tendons of the thumb suggests De Quervain's tenosynovitis.

Commonly used antimicrobials include:

• Flucloxacillin
• Clindamycin
• Cefuroxime
• Vancomycin
• Aciclovir
• Valaciclovir

• Rheumatological assessment
• Neurological assessment
• Vascular assessment
• Consider pathology in one aspect affecting function in others
• Examine the joint above and below the affected area

GALS stands for:

• Gait
• Arms
• Legs
• Spine

Comparing the right and left hands helps to identify asymmetries or differences that may indicate underlying pathology, such as inflammation, deformity, or atrophy, which are crucial for accurate diagnosis and treatment planning.

The nail changes associated with psoriasis arthropathy include:

• Pitting
• Onycholysis
• Hyperkeratosis and ridging
• Discolouration

Purpuric rashes associated with vasculitis are characterized as:

• Non-blanching
• Non-tender

Put palms of your hands together and bring your elbows as high as they will go.

Put backs of your hands together and bring your elbows down to the floor.

Place your palms on the table, keeping your arm still and point your middle finger towards the midline.

Place your palms on the table, keeping your arm still and point your middle finger away from the midline.

Make a fist.

1. Suggest a neurovascular assessment of the hand and wrist
2. Examine the elbow
3. Thank the patient
4. Summarise your findings

1. Wash hands
2. Introduce yourself & confirm patient details
3. Explain examination & gain consent
4. Consider chaperone
5. Expose & position the patient appropriately (patient should sit on the edge of a bed, ensuring visibility of the entire upper limb bilaterally).

• Inspect the limb and elbow from the front, side, and behind.
• Normal carrying angle: 5 - 15°.
• Look for:
  • Redness or erythema (suggesting inflammation, arthritis, or infection).
  • Swelling (bursitis, effusions, rheumatoid nodules).
  • Deformity (fixed flexion deformity of the biceps).
  • Scarring (previous surgery).
  • Atrophy or hypertrophy of associated musculature.

• Feel for calor and tumor associated with effusions and infection using both hands.
• Palpate bony prominences for tenderness:
  • Medial and lateral epicondyles
  • Olecranon
• Palpate the joint lines.

Assess active range of movement (AROM) first, with the patient either standing or sitting for the exam.

The special tests for assessing epicondylitis include:

• Medial Epicondylitis (Golfer's Elbow):

  • Passively extend the elbow, supinate the forearm, and extend the wrist and fingers.
  • Positive: Reproduction of pain.

• Lateral Epicondylitis (Tennis Elbow):

  • Passively extend the elbow, pronate the forearm, and flex the wrist and fingers while palpating the lateral epicondyle.
  • Positive: Reproduction of pain.

Ligamentous laxity is assessed using:

• VARUS stress test (Lateral collateral ligament):

  1. Stabilize the upper arm.
  2. Elbow in 20° flexion and humerus in medial rotation.
  3. Apply a VARUS / Adduction force to the forearm.
  • Positive: Excessive laxity / pain.

• VALGUS stress test (Medial collateral ligament).

1. Stabilize the upper arm.
2. Position the elbow in 20° flexion.
3. Ensure the humerus is in lateral rotation.
4. Apply a VALGUS / Abduction force to the forearm.

Positive result indicates excessive laxity or pain.

1. Suggest a full neurovascular assessment of the upper limb.
2. Thank the patient.
3. Summarize your findings.

1. Wash hands
2. Introduce yourself & confirm patient details
3. Explain examination & gain consent
4. Consider chaperone
5. Expose & position the patient appropriately (patient should sit on the edge of a bed or stand if comfortable, exposed to the waist).

• Inspect the limb from the front, side, and behind while the patient stands with arms hanging by their side.
• Assess for winging of the scapula by having the patient lean against a wall (suggests damage to long thoracic nerve).
• Look for redness or erythema, swelling, deformity (sulcus sign, bony asymmetry), scarring, and atrophy or hypertrophy of associated musculature.

1. Feel the patient's shoulder for calor and tumor associated with effusions and infection.
2. Palpate the bony prominences in the shoulder girdle for tenderness, starting at the SC joint, along the clavicle to the AC joint, and on to the acromion.
3. Palpate the spine of the scapula and finish by assessing the glenohumeral joint.
4. Assess the muscles of the girdle for tenderness.
5. Palpate the axilla for masses or tenderness.

Assess active range of movement (AROM) first.

2. Push backwards. | 0 - 60° |

2. Raise it over your head as far as possible. | 0 - 160° |

2. Raise it over your head if possible. | 0 - 170° |

2. Bring your hand across your midline. | 0 - 45° |

2. Bend your elbow to 90°.
3. Point your hand as far to the floor as possible. | 0 - 70° |

2. Bend your elbow to 90°.
3. Point your hand as far behind you as possible. | 0 - 90° |

1. Ask the patient to put their hand behind their head as if brushing their hair and see how far they can reach along their spine.
2. Ask the patient to put their hands behind their back and reach upwards as far as possible.

1. Place the patient supine.
2. Abduct the shoulder gently to 90°.
3. Gently add lateral rotation.

Positive Result: Apprehension from the patient, indicating anterior shoulder instability.

1. Have the patient standing or sitting with their arm by their side.
2. Grip the elbow at the condyles and pull distally.

Positive Result: A sulcus appears under the acromion, or the patient experiences pain or apprehension, indicating inferior shoulder instability.

1. Have the patient sitting with the shoulder at 90° forward flexion.
2. Flex the elbow to 90°.
3. Gently add passive medial rotation.

Positive Result: Reproduction of symptoms, indicating impingement of the supraspinatus tendon.

1. Place the arm to be examined across the chest to the contralateral shoulder.
2. The examiner pushes the arm into further adduction, mimicking throwing a scarf over the shoulder.

Positive Result: Pain over the AC joint, indicating AC joint pathology.

1. Have the patient sitting or standing, flex their shoulder with the elbow extended and the forearm supinated.
2. The examiner resists shoulder flexion.

Positive Result: Pain in the bicipital groove, indicating bicep tendon pathology.

1. Have the patient sitting or standing, flex the shoulder to 90°, abduct to 30°, and point the thumbs downwards.
2. Resist further abduction of the shoulder.

Positive Result: Pain or weakness, indicating supraspinatus tendon or subscapular nerve pathology.

1. Place the dorsum of the hand against the mid-lumbar region.
2. The patient is asked to lift the hand from the back against resistance from the examiner.

Positive Result: Inability to lift the hand from the back, indicating subscapularis dysfunction.

1. Wash hands
2. Introduce yourself & confirm patient details
3. Explain examination & gain consent
4. Consider chaperone
5. Expose & position the patient appropriately (patient should stand if comfortable and be exposed to the waist, wearing shorts if possible).

The first step is to perform hand hygiene by cleaning hands with alcohol gel.

• Mobility aids or adaptations in use
• Symmetry in the clavicles and shoulders
• Cervical lordosis, thoracic kyphosis, and lumbar lordosis (normal thoracic kyphosis is 20-45°).

• Cerebral palsy
• Muscular dystrophy
• Neurofibromatosis
• Spinal muscle atrophy
• Marfan's
• Ehlers-Danlos | | Degenerative | - Trauma
• Previous surgery | | Idiopathic | - Infantile (affected at birth or < 3 years)
• Juvenile (3-9 years)
• Adolescent (10-18 years old)
• Adult (> 18 years) |

1. Flexion: Touch your chin into your chest (0 - 80°)
2. Extension: Tilt your head up toward the sky (0 - 50°)
3. Lateral flexion: Bring your ear to your shoulder (0 - 45°)
4. Rotation: Turn your head to the left as far as it can go, then repeat to the other side (0 - 80°)

1. Rotation: Cross arms over the chest and ask the patient to turn to one side as far as they can (0 - 40° each side)
2. Compare the range of motion to the other side.

1. Flexion: Touch your toes keeping your knees straight (0 - 60°)
2. Extension: Lean back as far as you can (10 - 20°)
3. Lateral flexion: Slide your hand down the side of your leg as far as possible, keeping your legs straight (0 - 30° to each side)
4. Rotation: Turn your head to the left as far as it can go, then repeat to the other side (0 - 80°)

1. Feel along the length of the spine, palpating the spinous processes to assess for pain.
2. Palpate the sacroiliac joints.
3. Palpate the paraspinal muscles to assess for wasting or spasm.
4. Ask the patient regularly if they are experiencing pain.

Schober's test assesses range of motion (ROM) in the lumbar spine. It involves marking the skin 5cm below and 10cm above the PSIS, asking the patient to touch their toes, and measuring the distance between the marks, which should increase to greater than 20cm. If it is less than 20cm, it may indicate pathology such as Ankylosing spondylitis.

The Straight Leg Raise test is performed with the patient supine. The examiner holds the ankle and keeps the knee straight while passively flexing the hip. Once maximum range of motion is reached, the foot is dorsiflexed. A positive result is indicated by pain in the posterior thigh or buttock, suggesting compression on the sciatic nerve.

In the completion of a musculoskeletal examination, the following should be included:

1. Suggest a full neurovascular assessment of all limbs.
2. Thank the patient and assist with dressing if requested, ensuring consent for assistance has been obtained.
3. Summarise your findings.

1. Wash hands
2. Introduce yourself & confirm patient details
3. Explain examination & gain consent
4. Consider chaperone
5. Expose & position the patient appropriately (the patient should be wearing shorts)

• Mobility aids or adaptations in use
• Patient's posture, scars, and muscle wasting from the front
• Lumbar lordosis from the side
• Scoliosis, gluteal wasting, and pelvic tilt from behind
• Signs of an antalgic gait and patient expression during gait assessment
• Patient's ability to transfer from sitting to standing and any difficulties encountered

• Stance
• Stride length
• Smoothness of swing phase
• Heel strike
• Arm swing
• Trendelenburg gait (indicating weakness in gluteus medius and minimus)

The Trendelenburg pattern is an abnormal gait caused by weakness in the gluteus medius and minimus muscles, often due to a superior gluteal nerve lesion.

1. Flexion (0-120°): Flex the knee to 90° and bring the hip towards the patient's chest.

2. Extension (5 - 20°): The patient lies on their side and pushes their leg backward.

3. Abduction (0 - 40°): Lying supine, bring the leg away from the midline with the knee extended.

4. Adduction (0 - 25°): Lying supine, bring the leg across the midline with the knee extended.

5. Internal rotation at 90° flexion (0-45°): Lying supine, hip flexed to 90°, invert the knee.

6. External rotation at 90° flexion (0 - 45°): Lying supine, hip flexed to 90°, evert the knee.

The Thomas' test assesses for a fixed flexion deformity in the hips.

• The patient is placed supine with a hand or rolled towel under the lumbar spine to limit movement.
• The examiner passively fully flexes one hip.
• If the other hip lifts from the bed, it suggests a fixed flexion deformity of that hip.

The types of end feel assessed during PROM include:

• Boggy: Indicates synovial inflammation.
• Hard: Suggests bone on bone contact, e.g., in Rheumatoid or Osteoarthritis.
• Soft: Indicates muscle on muscle contact.
• None: Suggests subluxation or dislocation.

1. Inspect the limb for any abnormalities.
2. Palpate pulses to assess circulation.
3. Check capillary refill time.
4. Assess sensation in the limb.
5. Evaluate motor function by asking the patient to move the limb.
6. Document findings for further evaluation.

• Thank the patient for their cooperation.
• Assist with dressing if requested or required, ensuring that consent for assistance has been obtained.
• Summarise your findings clearly for documentation and further assessment.

1. Wash hands
2. Introduce yourself & confirm patient details
3. Explain examination & gain consent
4. Consider chaperone
5. Expose & position the patient appropriately (the patient should be wearing shorts)

• Mobility aids or adaptations in use
• Patient's posture, scars, and quadriceps wasting
• Valgus or varus deformity
• Hyperextension and scars from the side
• Baker's cyst, popliteal aneurysm, and scars from behind

• Signs of an antalgic (painful) gait
• Mechanics of the gait and patient expression
• Difficulties in transferring from sitting to standing
• Need for mobility aids
• Bias towards a particular side
• Stance, stride length, smoothness of swing phase, heel strike, arm swing, and Trendelenburg gait when walking

• Check for calor and tumor associated with inflammation and infection
• Palpate bony prominences and joint for tenderness

To ensure the tendon is intact and to check for crepitus in the patellofemoral joint.

Osgood-Schlatter disease.

The presence of an effusion.

Flexion (0 - 140°) and Extension (0 - (-10)°).

Crepitus and end feel, which can indicate various conditions such as synovial inflammation or bone on bone contact.

Using the Oxford Scale (0-5) while resisting movement in the assessed movements.

Full power against resistance

Flex the patient's knee to 90°

Anterior cruciate laxity or rupture

Knee flexed to 15°

Detection of the lateral side of the joint opening up or reproduction of pain on the lateral aspect of the joint

Knee flexed to 15°, hold the patient's ankle, apply inward force while applying opposite force on the knee.

Detection of the medial side of the joint opening up or reproduction of pain on the medial aspect of the joint

1. Hold the knee fully flexed.
2. Place one hand over the knee joint and the other on the sole of the foot.
3. Apply a valgus stress to the knee while rotating the leg externally and extending the knee.
4. Pain and/or an audible click may indicate a torn medial meniscus.
5. To examine the lateral meniscus, repeat the process from full flexion, applying a varus stress to the knee and medial rotation to the tibia before extending the knee.

The examiner should explain what they will be doing and obtain consent from the patient.

• Conduct a full neurovascular assessment of the limb.
• Thank the patient and assist with dressing if requested, ensuring consent for assistance has been obtained.
• Summarise your findings.

During the 'Feel' phase, the following should be assessed:

• Check for calor and tumor associated with inflammation and infection by feeling the ankle and foot.
• Palpate the bony prominences and joints for tenderness.
• Palpate the Achilles tendon to ensure it is intact.
• Palpate the posterior tibial pulse and the dorsalis pedis pulse.
• Palpate the collateral ligaments for pain.
• Measure the circumference of the calf muscle 10cm below the tibial tuberosity and compare right with left.

The AROM movements assessed for the ankle and foot include:

1. Dorsiflexion (0 – 20°): Pull your toe towards your head.
2. Plantarflexion (0 – 50°): Point your toes away from yourself as far as possible.
3. Inversion (0 – 25°): Turn the sole of your foot towards the midline.
4. Eversion (0 – 35°): Turn the sole of your foot away from the midline.
5. Toe flexion and extension: Curl your toes and then straighten them.
6. Toe abduction and adduction: Spread your toes as far as you can, then actively squeeze them closed.

During the PROM assessment, the following should be evaluated:

• Check for crepitus.
• Assess the end feel:
  • Boggy: Indicates synovial inflammation.
  • Hard: Indicates bone on bone contact (e.g., Rheumatoid or Osteoarthritis).
  • Soft: Indicates muscle on muscle contact.
  • None: Indicates subluxation or dislocation.
• Test the interphalangeal joints individually for:
  • Flexion deformity.
  • Pain.

The Thompson test is used to assess whether the patient has an intact Achilles tendon. The patient is positioned prone with feet and ankles hanging off the bed, and the calf is squeezed to observe for ankle plantarflexion. If plantarflexion occurs, the Achilles tendon is intact.

The Anterior Drawer test assesses the integrity of the anterior talofibular ligament. It involves stabilizing the distal tibia, slightly internally rotating the foot, and applying an anteriorly directed force to the calcaneus. Anterior translation of the foot indicates ligamentous laxity and should be compared to the contralateral side.

1. Consider a full neurovascular assessment of the limb.
2. Thank the patient and assist with dressing if requested, ensuring consent for assistance has been obtained.
3. Summarize your findings.

1. Wash hands
2. Introduce yourself & confirm patient details
3. Explain examination & gain consent
4. Consider chaperone
5. Expose & position the patient appropriately (from the knee down)

• Mobility aids or adaptations in use
• Valgus or Varus deformity at the ankle
• Hallux valgus (bunions at the 1st MCP joint)
• Calluses indicating abnormal loading in the foot

• Signs of an antalgic (painful) gait
• Mechanics of the gait and the patient's expression
• Difficulties in transferring from sitting to standing
• Need for mobility aids
• Bias towards a particular side
• Stance, stride length, smoothness of swing phase, and heel strike during walking

• Clawing of the toes
• Longitudinal arch of the foot

• Baker's cyst, popliteal aneurysm, scars, and calf muscle bulk
• Integrity of the Achilles tendon and symmetry of muscle bulk
• Valgus or Varus deformity at the ankle

• Rheumatoid arthritis
• Psoriatic arthritis
• Systemic lupus erythematosus (SLE)
• Some may be used in dermatology (e.g., psoriasis, severe eczema)

Examples:

• TNF-a inhibitors (e.g., adalimumab, infliximab, etanercept)
• B-Cell Inhibitors (e.g., rituximab)
• Interleukin inhibitors (e.g., tocilizumab)
• Selective co-stimulation modulators (e.g., abatacept)

Indications:

• Rheumatoid arthritis
• Psoriatic arthritis
• Spondylarthropathies
• Vasculitis
• Some may be used in dermatology (e.g., psoriasis, severe eczema)

Xanthine oxidase inhibitors are primarily used for the treatment of chronic gout. Examples include allopurinol and febuxostat.

Anti-gout agents, such as colchicine, are indicated for the treatment of acute gout.

Calcium channel blockers, such as nifedipine, are used for the treatment of Raynaud syndrome.

Topical corticosteroids are used to treat:

• Eczema/atopic dermatitis
• Psoriasis

Examples include hydrocortisone and betamethasone.

Topical vitamin D analogues, such as calcipotriol, are indicated for the treatment of psoriasis.

Topical coal tar is used for:

• Psoriasis
• Eczema
• Seborrheic dermatitis

Topical calcineurin inhibitors, such as tacrolimus, are used to treat psoriasis and eczema.

On closer inspection, there are no scars, swelling, erythema, no muscle wasting, no winging of the scapula, or obvious deformity.

• Scars from procedures such as arthroscopy, arthroplasty, or rotator cuff repair.
• Erythema indicating inflammation.
• Swelling or effusion in the joint.
• Deformity or abnormal alignment, such as winging of the scapula or clavicle deformity.
• Muscle wasting in the deltoid or rotator cuff area.

• Bony prominences including SC joint, clavicle, AC joint, spine of scapula, coracoid process, and humerus.
• Check for bone or joint line tenderness, deformity, muscle wasting, and temperature.

• Pain over bony prominences or joint tenderness, particularly at the AC joint.
• Crepitus or swelling in the joint.
• Muscle wasting of the rotator cuff, biceps, or triceps.
• Warmth in the joint compared to the other shoulder.

1. Ask the patient to perform active movements first, comparing with the contralateral side and noting any pain, restriction or weakness.
2. Flexion — move the arm anteriorly away from the body.
3. Extension — move the arm posteriorly.
4. Abduction — move the arm laterally.
5. Adduction — move the arm medially, across the body.
6. Lateral (external) rotation — with elbow flexed 90°, arm at side, move forearm laterally.
7. Medial (internal) rotation — with elbow flexed 90°, arm at side, move forearm medially/across the body.
8. Repeat passive movements and compare range, pain response, crepitus, and end‑feel with the unaffected side.

Jobe's test (Empty Can Test) involves:

• Abducting the shoulder to 90 degrees.
• Horizontally adducting to 30 degrees and internally rotating the arm (as if emptying an imaginary can).
• The examiner attempts to resist further abduction.

This test assesses for rotator cuff pathology, particularly impingement.

1. Perform an upper limb neurological exam.
2. Assess the radial pulse.
3. Examine the cervical spine and elbow joint.
4. Order an AP & lateral x-ray of the shoulder joint if needed.
5. Wash hands and thank the patient.

The first step is to perform hand hygiene by cleaning hands with alcohol gel.

The examiner should explain what they will be doing and obtain consent for the examination.

The patient should be positioned lying flat on the examination bed with the lower limb exposed, typically in shorts.

During the 'Look' phase, the examiner assesses the patient's gait, any walking aids, asymmetry, varus/valgus displacement, and performs the Trendelenburg Test.

A positive Trendelenburg Test indicates that the pelvis drops to the contralateral side during stance on the affected side, suggesting hip abductor weakness.

Expected findings include no scars, swelling, erythema, or fixed flexion deformity of the hip. Muscle bulk should be normal without wasting.

Potential abnormal findings include scars, erythema, swelling, deformity, and muscle wasting, particularly in the gluteal and quadriceps muscles.

During palpation, assess for bony tenderness, increased temperature, muscle bulk or wasting, and limb length discrepancies.

Tenderness over bony prominences such as the ASIS, pubic tubercle, and greater trochanter may indicate underlying issues such as muscle wasting or potential injuries.

Decreased range of motion may indicate conditions such as osteoarthritis, labral tears, avascular necrosis, or hip fractures, which can affect the patient's mobility and function.

A positive Thomas Test indicates a fixed flexion deformity, where the affected leg cannot lie flat on the table when the unaffected knee is held to the chest.

• X-rays in two planes including the joint above and below
• Examination of lumbar spine and knee
• Offer to assess distal pulses & perform neurological exam
• Washes hands
• Thanks patient

• Osteoarthritis - painful movements particularly on internal and external rotation.
• Labral tear - pain on hip extension, may have associated clicking.
• Avascular necrosis - painful movements particularly on internal and external rotation.
• Hip Fracture - leg shortened and externally rotated.
• Fixed Flexion Deformity - if affected leg cannot lie flat when held to the chest, this is a positive test.

• Cleans hands with alcohol gel
• Introduces self with name and level, explains what he/she will be doing and obtains consent for same.

Enquire about pain in the knee, hip, or ankle by asking, 'Do you have any pain in your knee, hip or ankle?'

• Walking aids: Note any use of crutches, sticks, or wheelchairs.
• Gait: Observe for normal gait, antalgic gait, Trendelenburg gait, or drop foot.
• Varus/Valgus: Check for oblique displacements of the joint towards (varus) or away (valgus) from the midline.

• Antalgic gait: Decreased stance phase on the affected side.
• Trendelenburg gait: Lurching gait due to hip abductor weakness.
• Drop foot: High stepping gait due to foot drop.

• Scars: Look for surgical scars or signs of previous injuries.
• Erythema: Check for redness indicating inflammation.
• Swelling: Assess for effusion or localized swelling.
• Deformity: Observe for fixed flexion deformities or varus/valgus deformities.
• Muscle bulk: Note any muscle wasting or hypertrophy.

• Joint line tenderness: Pain on palpation of medial or lateral joint lines.
• Effusion: Presence of swelling, tested by patellar tap.
• Crepitus: A grating sensation during movement.
• Muscle wasting: Notable reduction in muscle size, particularly in the quadriceps.

A positive Lachman's Test indicates an ACL injury, characterized by increased forward motion of the tibia on the femur.

The expected finding is that the patient shows no signs of discomfort when a lateral force is applied to the patella, indicating no patellar instability.

A positive McMurray Test suggests a meniscal tear, with specific tests for lateral and medial meniscus depending on the direction of stress applied.

The posterior sag test assesses for PCL injury, where a posterior sag of the tibia is noted when the hips are flexed to 45° and knees to 90°.

Pain on application of varus stress indicates a potential LCL injury during the knee examination.

Concluding remarks should include performing a lower limb neurological exam, assessing distal pulses, examining the hip and ankle joints, and ordering an AP & lateral x-ray of the knee joint.