Medicine is an art, and like all art, begins with fundamentals. In musculoskeletal medicine, the physical examination is the basis upon which much of clinical practice rests. While there is certainly a place in musculoskeletal medicine for sophisticated diagnostic tests (or even not-so-sophisticated tests, like plain radiography), to know when to use these tests and for their results to be meaningful, you must master the art of physical examination.
Certain elements in the history often suggest the diagnosis, and the experienced clinician may be able to pounce on a few short physical examination maneuvers to confirm that diagnosis. The novice is not so lucky—but has the advantage of not being fooled by too much knowledge either. He or she is less likely to omit a seemingly irrelevant test, and in so doing may be able to make a diagnosis otherwise missed.
A beginner can expect to need more time for the exam, not only because each step is slower, but because more steps will be taken. I urge you to embrace that. The only way to recognize something is abnormal is to first recognize what is normal; and the best way to do that is to have collected the experience of examining many normal structures.
It may also be helpful to perform a screening musculoskeletal examination on all of your general medical and surgical patients, assessing strength, range of motion, and the absence or presence of pain or swelling in the major joints. The marginal utility of a screening test is fairly low: even if you were to detect an abnormality, it is not clear that it is one that needs treatment. Yet of course without detecting the abnormality in the first place, a discussion of treatment cannot begin. Thus, fast and easy screening exams are good for patients. They are also good for novice examiners. Such exams will allow you to gain facility approaching and making contact with patients. You will also collect a mental database of “normal values”, which in turn will be invaluable when it comes time to recognizing the abnormal. The enclosed CD has a demonstration of the screening examination, which, as you will see, can be performed expertly in less than five minutes.
Even if you are determined to perform a large number of physical examination maneuvers—which, if not painful for the patient, is not such a bad idea—you should articulate to yourself a set of specific maneuvers that answer specific clinical questions. As with any other medical test, the physical examination is used to refine the probability of a diagnostic hypothesis. If, for example, a 45-year-old man reports shoulder pain when serving at tennis, you may suspect rotator cuff disease. You would then perform tests requiring rotator cuff function. The results of those tests will accordingly increase or decrease the probability of rotator cuff disease to the point where the diagnosis is confirmed or another diagnosis is suggested.
All physical examinations begin with inspection. When examining that patient, it is important that you have him undress. You will not detect muscle atrophy through a shirt. The examination of a man’s shoulder is the rare instance when I will remain in the room and have the patient disrobe in my presence: you may gain important diagnostic information by watching the coordinated muscle action needed to remove a shirt. (For ladies and all lower extremity examinations, I excuse myself while the patient puts on a gown.
After inspection, the next step is palpation—but before you palpate, make sure you wash your hands, preferably in the patient’s presence. Palpation can be directed to the known surface landmarks, but it may be equally useful to note whether the patient is very tender in areas that do not correspond to discrete structures. Malingering is not uncommon and tenderness reported in bizarre locations may reflect that.
Failing to adequately expose the area under examination is probably the most common mistake in physical diagnosis. The next most common mistake is to terminate the exam prematurely; ending as soon as one positive finding is encountered and failing to detect the others. Remember the wisdom of the veterinarians: a dog can have lice and fleas! Finding an abnormality is not a license to stop the exam. Indeed, it is known that some injuries and illnesses come in pairs: a sprained anterior cruciate ligament may be seen in association with a sprain of the medial collateral ligament, for example.
There are many excellent books on physical examination and its maneuvers. While the photographs are probably worth a thousand words, viewing pictures of a physical examination is not as good as watching a video (and there are plenty of those as well). Yet all forms of passive learning are dwarfed by the experience of examining live people. So please use the information that follows for grounding, but go see patients!