Sports Medicine Physical Examination
Sports Medicine Physical Examination

Sports Medicine Physical Examination

The cornerstone of any thorough sports medicine appointment is the physical examination.  History will usually tell you the diagnosis, or at least narrow down what you have on your differential, but the physical examination is key in ensuring that what the patient has verbally told you matches what their body is telling you through examination, inspection, and testing.

Below I have the outline I use for the complete musculoskeletal examination.  Of course I only do focused examinations for the joint(s) in which the patient has their complaints.  This outline is not all inclusive and I definitely recommend Netter as a reference as well.  If someone hurts in a certain spot I encourage you to please go and look up what structures are located in the particular spot the patient localizes their pain to.  At the end I have also listed any references I like and use.  If possible I recommend you browse before you buy.

jiu jitsu

Musculoskeletal Physical Examination

General

  • “History is king, physical is queen, additional diagnostic tests may or may not help you.” Quote by Dr. Lucio Pascua, Pediatrician
  • Inspection: stance/gait, posture
  • Palpation
  • Range of motion
  • +/- neurologic
  • Special tests
  • Compare to the non-injured contralateral side

Shoulder

Inspection

  • Bony abnormalities of SC and AC joints
  • Scapular winging
  • Muscular atrophy
  • Asymmetric soft tissue findings

Palpation: surface anatomy

  • Bones: SC, clavicle, AC, acromion, scapular spine, scapula, humerus
  • Anterior: AJL, Greater tubercle, biceps tendon in intertubercular groove, lesser tubercle, coracoid process, biceps
  • Lateral: deltoid, subacromial space
  • Posterior: PJL, triceps

ROM:

  • Passive ROM
    • Forward flexion 0-180°
    • Abduction 0-180°
    • Internal/External rotation ~0-90°
  • Active ROM
    • Forward Flexion: 180°
    • Extension: 50-60°
    • Abduction: 180°
    • IR: 60-100°
    • ER: 80-90°

Manual strength:

  • Infraspinatus/teres minor
  • Subscapularis
  • Supraspinatous
  • Biceps (Biceps brachii – short and long head, brachioradialis, coracobrachialis)
  • Triceps
  • Deltoid

Special testing: Wall push-up

Impingement Tests:

  • Hawkin’s impingement
  • Neer’s Impingement

Instability Tests:

  • Apprehension/Relocation
  • Sulcus
  • Posterior jerk

Torn labrum/Instability:

  • Obrien’s test
  • Anterior slide test
  • Crank test

Biceps tendonitis:

  • Speed’s test
  • Yergason’s test

football

Elbow

Inspection:

  • Carrying ankle
  • Joint/bursa swelling, surrounding ecchymosis, muscle atrophy, joint effusion.

Palpation: Surface anatomy

  • Olecranon, coronoid fossa, medial/lateral epicondyle, MCL, LCL, ulnar nerve

ROM:

  • Flexion 45-155°
  • Extension/Hyperextension: 0-5°
  • Pronation/Supination 90°/90°

Muscular Strength: Biceps, Triceps, forearm flexors/extensors (medial epicondyle/lateral epicondyle)

Special Tests:

  • Stability: Valgus/varus stress
  • Resisted wrist extension/flexion
  • Tinels
  • Biceps tendon tear

 

Hand/Wrist

Inspection: Atrophy, swelling, shortening of metacarpal, angulation, malrotation, lumps, deformities

Ape, boutonniere deformity, Dupuytren’s contracture, bishops deformity, swan neck deformity, claw hand, mallet finger

Palpation: surface anatomy, entire involved area, joint above and below, surrounding/associated structures

  • DO NOT MISS snuff box tenderness

ROM:

  • Wrist:
    • Palmar flexion: 80°
    • Dorsiflexion: 70°
    • Radial deviation: 20°
    • Ulnar deviation: 35°
  • Thumb-CMC:
    • Flexion 45-50°
    • Extension 0°
    • Abduction 60-70°
    • Adduction 30°
    • Opposition tip-to-tip
  • Fingers:
    • Flexion – MCP 85-90°, PIP 100-115°, DIP 80-90°
    • Extension – MCP 30-45°, PIP 0°, DIP 20°
    • Abduction – MCP 20-30°
    • Adduction – MCP 0°

Muscular strength: flexors/extensors, abduction/adduction, opposition, grip strength

Special tests:

  • Gamekeepers thumb
  • Finkelstein test
  • Watson test
  • Carpal tunnel – Tinels, Phalens, reverse Phalen’s (prayer sign)
  • Valgus or varus testing of the IP joints
  • TFCC – Ulnar grind, TFCC load test, TFCC press (supinated lift)

Neurologic testing:

  • Radial nerve: 1st dorsal web space between thumb and index finger
  • Median nerve: Palmar second distal phalanx
  • Ulnar nerve: Palmar 5th distal phalanx

jiu jitsu full mount

Back

Red Flag Signs: Night pain, night sweats, history of cancer, TTP over spinous process at vertebral level. Associated fevers, weight loss, bowel/bladder retention

Inspection:

  • Stance/gait
  • Note deformities, atrophy, or spasms
  • Posture while standing & seated, note curvature of spine (lordosis, kyphosis, scoliosis)
  • Leg length discrepancy
  • Gross examination of entire kinetic chain (feet, ankle, knees, hips)

Palpation:  Spinous processes, paraspinal muscles, SI joint

ROM: varies, usually say full, or limited by pain

  • Forward flexion
  • R/L lateral flexion
  • Extension/Hyperextension
  • R/L Rotation

Neurological

  • Sensory: Note myotome, dermatome, or nerve root distribution
  • Motor strength to MMT:
    • Low Back: Hip flexion, Knee flexion, Knee extension, Ankle DF/PF, Great toe DF/PF
    • Cervical Spine: Flexion, extension, R/L rotation, R/L lateral flexion
  • Deep tendon reflexes (normal 2+)

Special Testing:

  • Straight leg test
  • Seated strait leg test
  • Slump test
  • Rhomberg
  • Spurling’s
  • SI compression
  • Hoover test (malingering)
  • Axial loading

Back Pain

Hip

Inspection

  • Stance/gait
  • Posture, standing and seated
  • Leg length discrepancy

Palpation: surface anatomy

  • Medial: Adductors
  • Anterior: Pubic bone, ASIS, AIIS, Sartorius, rectus femoris
  • Lateral: Iliac crest, TFL, gluteus medius, IT band, greater trochanter, trochanteric bursa
  • Posterior: median sacral crest, PSIS, gluteus maximus, hamstring muscles

ROM:

  • Flexion: 120-130°
  • Extension: 10-20°
  • Abduction: 45°
  • Adduction: 30°
  • IR: 45°
  • ER: 50°

Special testing:

  • Trendelenburg
  • FABER’s and FADIR’s test
  • Thomas test
  • Hamstring flexibility
  • Ober’s test
  • Femoral acetabular impingement
  • Ortolani’s and Barlow’s
  • Scour Test

basketball

Knee

ROM:

  • Hyperextension: 3°
  • Flexion: 140° (for routine ADL’s need 115°)

Standing:

  • Alignment of lower extremities
  • Patellar position
  • Inspection for asymmetries (swelling, discoloration, scars)
  • Deep squat test
  • Gait evaluation

Sitting:

  • Patellar position in the trochlear groove
  • Active patellar motion

Supine:

  • Patellofemoral joint
    • Inspection for patellar position
    • Inspection for asymmetries (swelling, discoloration, scars)
    • Palpation effusion
    • Palpation for retropatellar tenderness
    • Evaluation of patellar mobility – apprehension, Clarke’s/Grind
    • Palpation of quadriceps and patellar tendons/insertion
    • VMO bulk and tone
    • Palpation of peripatellar soft tissues (retinaculum, plicae)
  • Tibio-femoral joint
    • Lachman test
    • Anterior and posterior drawer
    • Valgus and varus stress testing (0° and 30°)
    •   Posterior sag sign or loss of the posterior step-off
    • McMurray’s test
    • MCL and LCL palpation
    • Medial and Lateral joint line palpation
    • tibial tuberosity, Gerdy’s tubercle, and pes anserine palpation
    • Palpation of the popliteal space/fossa (lateral)
  • Popliteal angle
  • Noble’s test
  • Ober’s test
  • Thomas test

ninja training

Ankle and Foot

Standing examination

  • Inspection
  • Alignment of the foot and ankle
    • Ankle pronation
    • Heel position (neutral, valgus or varus)
    • Pes planus or pes cavus
    • “Too many toes” sign
  • Swelling
  • Ecchymosis
  • Note shoe wear
  • Special tests:
    • Weight bearing
    • Plantar flexion/heel raise
    • Gait

Sitting examination

  • Inspection
    • Flexible flat foot
    • Rigid flat-footed
    • General
      • Swelling, ecchymoses, erythema, bunion, bunionette, claw toe, hammertoe, Morton’s toe
  • Bony palpation
    • Proximal fibula
    • Medial malleolus
    • Lateral malleolus
    • Base of the fifth metatarsal
    • Talus
    • Calcaneus
    • Navicular
    • Metatarsal
    • Cuboids
    • Sesamoids
  • Soft tissue palpation
    • ATFL
    • CFL
    • PTFL
    • Deltoid Ligament
    • Syndesmotic ligaments
    • Achilles tendon
    • Peroneal Tendon
    • Posterior tibial tendon
    • Plantar fascia insertion into the anterior medial aspect of the calcaneus
  • Active range of motion:
    • Plantar flexion: 50°
    • Plantar flexion/inversion: 15°
    • Dorsiflexion: 20°
    • Dorsiflexion/inversion: 15°
  • Resisted range of motion:
    • Plantar flexion
    • Flexion/inversion
    • Dorsiflexion
    • Dorsiflexion/inversion

Sitting Examination Special tests:

  • Talar tilt
  • Anterior drawer
  • Eversion stress test
  • Dorsiflexion and with external rotation of foot
  • Squeeze test
  • Passive plantar flexion of the toes
  • Tinel’s test
  • Thompson’s test
  • Medial rotation

 shoes and dumbbells

References:

  1. Cook C.  et al.  Orthopedic Physical Examination Tests.  An evidence-based approach. 2008.
  2. Forman, T and Walker, C.  Musculoskeletal Examination of Athletic Injuries, HAFP 2009.
  3. Gulick, D.  Ortho Notes.  Clinical Examination Pocket Guide, 2nd ed.  2009.
  4. Hoppenfeld, S.  Physical Examination of the Spine and Extremities.
  5. Magee, D.  Orthopedic Physical Assessment.  4th Edition 2006.
  6. Muscolino, J.  The Muscular System Manual.  2010.
  7. Starkey C et al.  Orthopedic and Athletic Injury. 2003.

 

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