1. What are the four key features of the MSK exam?
o 1) articular or extra-articular
o 2) an acute (< 6 wks) or chronic (> 12 wks) complaint;
o 3) inflammatory or non-inflammatory
o 4) localized or diffuse
2. How is acute joint pain classified? Chronic?
o acute (< 6 wks)
o chronic (> 12 wks)
3. Which are some examples of monoarticular disease processes? Polyarticular?
o monoarticular – localized over a single joint
1. monoarticular arthritis - Pain in a single joint suggests injury
2. tendonitis or bursitis (extra-articular)
3. lateral hip pain w/ focal tenderness (OA of hip--will usually present with groin pain)
o polyarticular (more than 4 joints involved) – involves several joints
1. Causes of polyarthritis include viral or inflammatory from RA, systemic lupus
erythematosus (SLE), or psoriasis
2. Rheumatoid arthritis or gonococcal arthritis: migratory pattern
3. RA: pattern is additive & progressive, symmetrical
4. Rheumatic fever and gonococcal arthritis exhibit a migratory pattern of spread.
5. In RA, the pattern is additive and progressive with symmetric involvement.
6. Involvement is usually asymmetric in psoriatic, reactive, and inflammatory bowel
disease (IBD)-associated arthritis
o Extraarticular
1. bursitis, tendonitis, tenosynovitis (tendon sheaths) as well as sprains of ligaments
4. What is crepitus? What does it indicate?
o an audible or palpable crunching during movement of tendons or ligaments over bone or
areas of cartilage loss.
o It may occur in joints without pain and is more significant when associated with
symptoms or signs.
5. What are the four cardinal signs of inflammation?
o Swelling. Palpable swelling may involve: (1) the synovial membrane, which can feel
boggy or doughy; (2) effusion from excess synovial fluid within the joint space; or (3)
soft tissue structures, such as bursae, tendons, and tendon sheaths.
o Warmth. Use the backs of your fingers to compare the involved joint with its unaffected
contralateral joint or with nearby tissues if both joints are involved.
o Redness. Redness of the overlying skin is the least common sign of inflammation near
the joints and is usually seen in more superficial joints like fingers, toes, and knees.
o Pain or tenderness. Try to identify the specific anatomic structure that is tender.
6. What history and exam findings are consistent with rheumatoid arthritis?
o Chronic inflammation of synovial membranes with secondary erosion of adjacent
cartilage and bone. Damage to ligaments and tendons
o systemic, polyarticular, symmetrical
o starts in hands (PIP, MCP, MTP)
o ulnar deviation of fingers
, o bilateral swelling and tenderness
o MCPs boggy and tender
o stiffness for at least an hour in AM and after inactivity
o generalized symptoms of low-grade fever, fatigue
o If age <60 years, consider rheumatoid arthritis (RA)
o Subcutaneous nodules may develop at pressure points along the extensor surface of the
ulna in patients with RA or acute rheumatic fever. They are firm and nontender. They are
not attached to the overlying skin but may be attached to the underlying periosteum.
They can develop in the area of the olecranon bursa, but often occur more distally.
7. Osteoarthritis?
o Noninflammatory, loss of joint cartilage from mechanical stress, with damage to
underlying bone & formation of new bone at the cartilage margins
o monoarticular, nonsymmetrical
o MCP not involved
o radial deviation of distal phalanx
o knees, hips, spine, wrist, hands
o brief (10 min) stiffness in AM or after inactivity
o Heberden nodes on the dorsolateral aspects of the distal interphalangeal (DIP) joints
from bony overgrowth.
1. Usually hard and painless, they affect middle-aged or older adults and are often
associated with arthritic changes in other joints.
2. Flexion and deviation deformities may develop.
o Bouchard nodes on the proximal interphalangeal (PIP) joints
1. The metacarpophalangeal (MCP) joints are generally spared.
8. What is the general approach to the newborn MSK exam?
o
9. How would the FNP perform a preparticipation sports physical? What would be abnormal
findings and what would these finding indicate?
o Step 1: Stand straight, facing forward. Note for any asymmetry or swelling of joints.
o Step 2: Move neck in all directions. Note for any loss of range of motion.
o Step 3: Shrug shoulders against resistance. Note for any weakness of shoulder, neck, or
trapezius muscles.
o Step 4: Hold arms out to the side against resistance, and actively raise arms over the head. Note
for any loss of strength of deltoid muscle.
o Step 5: Hold arms out to side with elbows bent 90 degrees; raise and lower arms. Note for any
loss of external rotation and injury of glenohumeral joint.
o Step 6: Hold arms out, completely bend, and straighten elbows (should be able to easily touch
the shoulder). Note for any reduced range of motion of elbow.
o Step 7: Hold arms down, bend elbows 90 degrees, and pronate and supinate forearms. Note for
any reduced range of motion from prior injury to forearm, elbow, or wrist.
o Step 8: Make a fist, clench, and then spread fingers. Note for protruding knuckle, reduced range
of motion of fingers from prior sprain or fracture.
o Step 9: Squat and duck-walk for four steps forward. Note for inability to fully flex knees and
difficulty standing up from prior knee or ankle injury.
o Step 10: Stand straight with arms at sides, facing back. Check whether shoulders, scapula, and
hips are even. Note for asymmetry from scoliosis, leg-length discrepancy, or weakness from
prior injury.
o 1) articular or extra-articular
o 2) an acute (< 6 wks) or chronic (> 12 wks) complaint;
o 3) inflammatory or non-inflammatory
o 4) localized or diffuse
2. How is acute joint pain classified? Chronic?
o acute (< 6 wks)
o chronic (> 12 wks)
3. Which are some examples of monoarticular disease processes? Polyarticular?
o monoarticular – localized over a single joint
1. monoarticular arthritis - Pain in a single joint suggests injury
2. tendonitis or bursitis (extra-articular)
3. lateral hip pain w/ focal tenderness (OA of hip--will usually present with groin pain)
o polyarticular (more than 4 joints involved) – involves several joints
1. Causes of polyarthritis include viral or inflammatory from RA, systemic lupus
erythematosus (SLE), or psoriasis
2. Rheumatoid arthritis or gonococcal arthritis: migratory pattern
3. RA: pattern is additive & progressive, symmetrical
4. Rheumatic fever and gonococcal arthritis exhibit a migratory pattern of spread.
5. In RA, the pattern is additive and progressive with symmetric involvement.
6. Involvement is usually asymmetric in psoriatic, reactive, and inflammatory bowel
disease (IBD)-associated arthritis
o Extraarticular
1. bursitis, tendonitis, tenosynovitis (tendon sheaths) as well as sprains of ligaments
4. What is crepitus? What does it indicate?
o an audible or palpable crunching during movement of tendons or ligaments over bone or
areas of cartilage loss.
o It may occur in joints without pain and is more significant when associated with
symptoms or signs.
5. What are the four cardinal signs of inflammation?
o Swelling. Palpable swelling may involve: (1) the synovial membrane, which can feel
boggy or doughy; (2) effusion from excess synovial fluid within the joint space; or (3)
soft tissue structures, such as bursae, tendons, and tendon sheaths.
o Warmth. Use the backs of your fingers to compare the involved joint with its unaffected
contralateral joint or with nearby tissues if both joints are involved.
o Redness. Redness of the overlying skin is the least common sign of inflammation near
the joints and is usually seen in more superficial joints like fingers, toes, and knees.
o Pain or tenderness. Try to identify the specific anatomic structure that is tender.
6. What history and exam findings are consistent with rheumatoid arthritis?
o Chronic inflammation of synovial membranes with secondary erosion of adjacent
cartilage and bone. Damage to ligaments and tendons
o systemic, polyarticular, symmetrical
o starts in hands (PIP, MCP, MTP)
o ulnar deviation of fingers
, o bilateral swelling and tenderness
o MCPs boggy and tender
o stiffness for at least an hour in AM and after inactivity
o generalized symptoms of low-grade fever, fatigue
o If age <60 years, consider rheumatoid arthritis (RA)
o Subcutaneous nodules may develop at pressure points along the extensor surface of the
ulna in patients with RA or acute rheumatic fever. They are firm and nontender. They are
not attached to the overlying skin but may be attached to the underlying periosteum.
They can develop in the area of the olecranon bursa, but often occur more distally.
7. Osteoarthritis?
o Noninflammatory, loss of joint cartilage from mechanical stress, with damage to
underlying bone & formation of new bone at the cartilage margins
o monoarticular, nonsymmetrical
o MCP not involved
o radial deviation of distal phalanx
o knees, hips, spine, wrist, hands
o brief (10 min) stiffness in AM or after inactivity
o Heberden nodes on the dorsolateral aspects of the distal interphalangeal (DIP) joints
from bony overgrowth.
1. Usually hard and painless, they affect middle-aged or older adults and are often
associated with arthritic changes in other joints.
2. Flexion and deviation deformities may develop.
o Bouchard nodes on the proximal interphalangeal (PIP) joints
1. The metacarpophalangeal (MCP) joints are generally spared.
8. What is the general approach to the newborn MSK exam?
o
9. How would the FNP perform a preparticipation sports physical? What would be abnormal
findings and what would these finding indicate?
o Step 1: Stand straight, facing forward. Note for any asymmetry or swelling of joints.
o Step 2: Move neck in all directions. Note for any loss of range of motion.
o Step 3: Shrug shoulders against resistance. Note for any weakness of shoulder, neck, or
trapezius muscles.
o Step 4: Hold arms out to the side against resistance, and actively raise arms over the head. Note
for any loss of strength of deltoid muscle.
o Step 5: Hold arms out to side with elbows bent 90 degrees; raise and lower arms. Note for any
loss of external rotation and injury of glenohumeral joint.
o Step 6: Hold arms out, completely bend, and straighten elbows (should be able to easily touch
the shoulder). Note for any reduced range of motion of elbow.
o Step 7: Hold arms down, bend elbows 90 degrees, and pronate and supinate forearms. Note for
any reduced range of motion from prior injury to forearm, elbow, or wrist.
o Step 8: Make a fist, clench, and then spread fingers. Note for protruding knuckle, reduced range
of motion of fingers from prior sprain or fracture.
o Step 9: Squat and duck-walk for four steps forward. Note for inability to fully flex knees and
difficulty standing up from prior knee or ankle injury.
o Step 10: Stand straight with arms at sides, facing back. Check whether shoulders, scapula, and
hips are even. Note for asymmetry from scoliosis, leg-length discrepancy, or weakness from
prior injury.
