2/25/2010

Pediatric
Musculoskeletal (MSK)
Examination
Janalee Taylor, RN, MSN, CPNP
Clinical Director
Division of Rheumatology

Disclosure
Member of the Executive Committee and
Board of Directors of the National Arthritis
Foundation and Speakers Bureau

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Evidence Based Medicine Information

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Beighton PH & Horan FT. Dominant inheritance in familial generalized articular Hypermobility. Journal of
Bone and Joint Surgery British 1970; 52 (1): 145-147.
Bickley LS., Szilagyi PG., Bates Guide to Physical Examination and History Taking, 8th Edition, Lippincott
Williams & Wilkins, 2003; 489-535, 623-726.
Billiau AD., et al., Temporomandibular joint arthritis in juvenile idiopathic arthritis: prevalence, clinical and
radiological signs, and relation to dentofacial morphology J Rheumatol. 2007 Sep;34(9):1925-33
Cassidy J., et al., Textbook of Pediatric Rheumatology, 5th Edition, Elsevier, Inc., 2005.
Doherty M., et al., Rheumatology Examination And Injection Techniques,
Katz PP, et al. Patient Outcomes in Rheumatology; A Review of Measures. Arthritis Care & Research
2003; 49 (5) Supplement
Lovell DJ, et al. Development of Validated Disease Activity and Damage Indices for Juvenile Idiopathic
Inflammatory Myopathies. Arthritis Rheum 1999; 42: 2213-2219.
Polley HF., & Hunder GG., Rheumatologic Interviewing and Physical Examination of the Joints, 2nd Edition,
W.B. Saunders Company, 1978.
Ryan-Wenger NA
NA., Core Curriculum for Primary Care Pediatric Nurse Practitioners,
Practitioners Mosby,
Mosby Elsevier Inc
Inc.,
2007, 611-637, 841-859.
Weiner DS., Pediatric Orthopedics for Primary Care Physicians, 2nd edition, Cambridge University Press,
2004.
West S., Rheumatology Secrets, 2nd edition, Philadelphia, Hanley & Belfus Inc. 2002; 451-452, 488.
Wolfe F, et al. Arthritis and Rheumatism; 1990 33 (2): 160-172
Yunus MB, Masi AT. Juvenile Primary Fibromyalgia Syndrome A Clinical Study of Thirty-Three Patients
and Matched Normal Controls. Arthritis and Rheumatism; 28 (2): 138-145.

Whats Different in Children

and Adolescents?
Children are anatomically and physiologically different from adults
Techniques
q
for assessment,, p
physical
y
findings,
g , & abnormalities in
young patients differ as well
Tremendous variations in physical, cognitive, & social development
compared to adults

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C
O
O
P
E
R
A
T
I
O
N!

Conditions Occurring in
Infancy / Early Childhood

Genu varum (bowlegs)

Genu valgum (knock(knock-knees)
Metatarsus adductus
Internal tibial torsion
Femoral anteversion

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Conditions Occurring in
Toddler through School Age

Toe-walking
ToeMetatarsus adductus
Pes planus
Transient toxic synovitis
Legg
Legg--Calve Perthes
Growing pains

Features Not Associated with

Growing Pains

Limp
Joint erythema
Night sweats
Weight loss
Fever
Adenopathy
Bone pain disproportionate to physical findings

Neoplasms can present as musculoskeletal complaints (ie;

ALL, neuroblastoma, Ewings Sarcoma, lymphoma)

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Conditions Occurring in
Adolescence and Puberty

P t ll f
Patellofemoral
l pain
i syndrome
d
Osgood
Osgood--Schlatter disease
Sinding--LarsenSinding
Larsen-Johansson disease
Severs disease
Osteochondritis dissecans
Slipped Capital Femoral Epiphysis (SCFE)
Tarsal coalition
Scoliosis

Observations During MSK Exam

General habitus
Gait/stance
Joint Range of Motion
Swelling, tenderness and/or pain with motion
Symmetry
z
z
z

Skin folds
Limb length
Atrophy

Tendonitis
Strength

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Observe ADLs
during exam

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Important Considerations

Generalized growth disturbances

z Linear growth
z Weight
z Bone health
z Skeletal growth
z Nutrition (protein energy malnutrition)
z Delay in sexual maturation
Localized
oca ed g
growth
o t d
disturbances
stu ba ces in rheumatic
eu at c d
diseases
seases
z Limb length discrepancies
z Jaw
Micrognathia

Systematically Review Aspects

of Musculoskeletal System in
Children/Adolescents

C-spine
TMJs
Hands & wrists
Elbows
Shoulders

Hips
Knees
Ankles, subtalar, &
feet
Spine -- thoracic and
lumbosacral

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Cervical Spine
Extension
Flexion
Rotation
Lateral Flexion

JIA & Cervical Spine

More common in
polyarticular/systemic JIA
Occiput at level of 1st
thoracic vertebrae
Rule of thumb: 10o flexion
restriction = 1 finger b/w chin
and chest wall
all
Concern: Atlantoaxial
instability

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Children with arthritis

can also develop
torticollis
Can be a manifestation
of cervical spine
involvement OR
Idiopathic shortening of
a sternocleidomastoid
muscle

Temporomandibular Joint

Oral appature
z

Normal > 40 mm or 3
finger widths

Palpation
z

Place forefinger in
external auditory canal
OR
Place tip forefinger
anterior to external
auditory meatus

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Temporomandibular Arthritis

Finding can be subtle

occurs insidiously; can
sneak up
Up to 55% depending on
study
Anterior view
view---jaw
jaw
deviates to involved side
Often seen or noted at
times of skeletal growth
Lead to problems with
malocclusion
Observe lateral view
z Micrognathia

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Hands
Supination
Pronation
Overall swelling
Th
Thenar
atrophy
t h

Hands
Should be able to
make
k ffullll fist
fi t
Need to determine
whether loss of full
flexion due to:
MCP involvement
PIP involvement
DIP involvement

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Wrists
Extension
90 degrees

Flexion
90 degrees

Elbows
Anatomical
landmarks
Flexion /Extension
Check for:
joint swelling
contractures
rheumatoid nodules
epitrochlear nodes

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Limb Length Discrepancy

E l in
Early
i disease
di
course
extremity may exhibit
overgrowth or be longer

Late in disease course

extremityy ends up
p
shorter

Ulnar vs. radial drift

Shoulders

Active ROM

Can be helpful in
assessing ability to
perform ADL

Younger children
Simon Says

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Shoulder

Extension

Flexion

Landmarks

ABduction

External rotation /
(Internal rotation)

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Hips

Flexion

Extension w/ abduction

Patrick test

Hamstring tightness

Hips (cont.)

External rotation
Internal rotation

Internal rotation / prone

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Maneuvers to Assess the Hip

Thomas test

Trendelenburg sign

Gaenslens test

Knees

Flexion

Extension

Prone lying
z
z
z

Contracture
Symmetry of calves
Younger children
Symmetry of
skin folds

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Bony Overgrowth
Epiphyseal overgrowth
secondary to inflammation
Valgus deformity

Bakers
Baker s Cyst
Posterior / prone
Bakers cyst

Limb Length Discrepancy

Limb length
g discrepancy
p
y
z

Measure from superior iliac

crest to medial malleolus

Limb length discrepancy

z

Galeazzi test

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Examination Maneuvers to
Assist in Etiology of Symptoms

Patellar apprehension/compression test

McMurray test --- used to evaluate meniscal injury

Apley compression test --- used to evaluate meniscal injury

Lachman test or Anterior Drawer Sign --- used to evaluate ACL injury

Pain with compression of the infrapatellar tendon

tendonJumpers knee

Pain with compression over inferior pole of the patella

patella
Sinding
Sinding--Larsen
Larsen-Johansson disease

Pain with compression over tibial tubercle --- Osgood Schlatters

West S. Rheumatology Secrets, 2nd edition, Philadelphia, Hanley & Belfus Inc. 2002; 451451-452, 488.

Evaluation Patellar Area

Patellar Compression
Test

Patellar Apprehension
Test

Patellar
apprehension

Weiner DS. and Jones K. Patelofemoral Pain Syndrome. In: Pediatric Orthopedics for Primary Care
Physicians, 2nd edition, Cambridge University Press, Cambridge, 2004; 95-97.

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Patellofemoral Syndrome (PFS)

in Children/Adolescents

Probably accounts for greatest number of all cases of

knee pain seen in adolescents
More common in females
Pain is always of a mechanical nature
Abnormal patellar tracking, muscle units, ligamentous
status and osseous structures

Common Findings on Physical

Examination

patellar
patellar mobility
+ patellar
patellar apprehension sign used to assess patellar injury or
dislocation
Patellar facet tenderness
Patellar tendon tenderness and infrapatellar compartment
muscle bulk & weakness of vvastus
astus medialis
Weak hip flexors/tight hamstrings
+p
patellar
atellar compression test
Grating, clicking, catching, Giving out

Malleson PN and Sherry DD. Noninflammatory Musculoskeletal Pain Conditions. In: Cassidy JT, Petty RE, et
al. Textbook of Pediatric Rheumatology,
Rheumatology, 5th edition, Philadelphia, Elsevier Inc. 2005; 680.

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Maneuvers to Evaluate Meniscus

McMurray Test
Apley Test
McMurray test

Apley
Maneuver

McMurray test

Maneuver to Evaluate
Anterior Cruciate Ligament

Lachman Test

Lachman
test

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Feet and Ankles

Dorsiflexion

Plantar flexion

Feet and Ankles (cont.)

Lateral rotation

Medial rotation
MTPs & Toes

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Feet and Ankles (cont.)

Assess prone lying
soles of feet
tight achilles

Assess for enthesitis

Symmetry of calves

Assess hips, knees, ankles all at once---Duck Walk

Spine
Lumbar Flexion

Schobers

Lateral Flexion

Lumbar Extension

Modified
Schobers

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Joint Hypermobility
Joint Hypermobility
The ability to painlessly perform the following
five maneuvers

Passive apposition
of thumb to
forearm

Passive
hyperextension
yp
of fingers
(5th finger can
parallel forearm)

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Active
hyperextension
of elbow >10 degrees

Active
hyperextension of
knee >10 degrees

Ability to flex spine and place palms to floor

without bending knees

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The Beighton Diagnostic/Scoring

Criteria
Specific Joint Laxity

Right

Left

P
Passive
i apposition
iti off th
thumb
b
to forearm

Passive hyperextension of fingers

Active hyperextension of elbow

>10 degrees

Active hyperextension of knee

>10 degrees

Ability to flex spine and place palms

to floor without bending knees

1
_________________
4

4 = 9

Beighton PH & Horan FT. Dominant inheritance in familial generalized articular

hypermobility. Journal of Bone and Joint Surgery British 1970; 52 (1): 145145-147.

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Specific Muscle/Myofascial
Assessment in
Children and Adolescents

Myofascial tenderness

Muscle strength, atrophy, symmetry

Manual Muscle Testing (MMT)

Childhood Myositis Assessment Scale

All evaluations should be developmentally/

functionally based assessments

Tender Point Locations

Base of occiput
occiput---insertion
insertion of muscles
Trapezius--upper border mid portion
Trapezius
Muscle attachments to upper medial border scapula
Anterior aspect of C5, C7 inter
inter--transverse spaces
Second rib space about 3 cm to sternal border
Lateral epicondyle
epicondyle2 cm below bony prominence
Gluteal muscles
musclesupper outer quadrant
Greater trochanter
trochanter
1 cm posterior to insertion of
muscles
Medial fat pad of knee
knee1 cm proximal to joint line

Wolfe F, et al. Arthritis and Rheumatism; 1990 33 (2): 160160-172.

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Tender Point Diagram

Yunus MB, Masi AT. Juvenile Primary Fibromyalgia Syndrome A Clinical Study of Thirty-Three Patients and Matched
Normal Controls. Arthritis and Rheumatism; 28 (2): 138145. (pending permission)

Juvenile Primary Fibromyalgia

Syndrome: Diagnostic Criteria

Major criteria

Generalized musculoskeletal aching at 3 or more sites for 3 or

more months
Absence of underlying condition or cause
Laboratory tests normal
Pain in 5 or more tender points (4kg of pressure)

Minor criteria

3/10 criteria

Yunus, MB, Masi AT. Arthritis Rheum 1985; 28 (2): 138138-145

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Juvenile Primary Fibromyalgia

Syndrome: Diagnostic Criteria

Minor Criteria--Criteria---3/10
3/10

Poor sleep
Fatigue
Chronic anxiety or tension
Chronic headaches
Irritable bowel syndrome
Subjective soft tissue swelling
Numbness
Pain modulated by:
-physical activity, weather, anxiety/stress

Yunus, MB, Masi AT.

AT. Arthritis Rheum 1985; 28 (2): 138138-145.

Manual Muscle Testing

Muscle/muscle groups ability to isometrically

hold or resist an applied force
Grading/scoring scale
5/5
4/5
3/5

= Normal
= Good
= Fair

2/5
1/5

= Poor
= Trace

0/5

= Zero

Full resistance against gravity

Partial resistance against gravity
Unable to provide resistance
against gravity
No movement against gravity
Only slight muscle contraction
(no joint movement)
No muscle activity

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M
Manual
lM
Muscle
l T
Testing
ti C
Can
NOT Be Used in Younger
Children

Childhood Myositis
Assessment Scale (CMAS)*

Validated and q
quantitative,, observational instrument
for composite assessment of:
z
z
z

strength
function
Endurance

14 physical maneuvers

Scores range from 00-52

Points are awarded according to the descriptor that

best fits the patients performance of the maneuver

*Lovell DJ, et al. Development of Validated Disease Activity and Damage Indices for the Juvenile Idiopathic Inflammatory
Myopathies, Arthritis Rheum 1999; 42: 2213-2219.

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Correlation of CMAS Scores*

MD Global (VAS)

r2 = 0.357

P = 0.05

MMT score

r2 = 0.88
0 88

P = 00.001
001

Serum CK level

r2 = 0.40

P = 0.004

JAFAR score

r2 = 0.70

P < 0.001

P d i
Prednisone
ddosage

r2 = 0.61
0 61

P = 00.008
008

*Lovell DJ, et al. Development of Validated Disease Activity and Damage Indices for Juvenile
Idiopathic Inflammatory Myopathies. Arthritis Rheum 1999; 42: 2213-2219.

CMAS: 14 MANEUVERS
1
1.
2.
3.
4.
5.
6.
7.

Head lift
Leg lift/touch
Leg lift/duration
Supine
Supine--Prone
Sit
Sit--ups
Supine
Supine--Sit
Arm lift/straight

8. Arm lift/duration
8
9. Floor Sit
10. All Fours
11. Floor Rise
12. Chair Rise
13. Stool Step
14. Pick
Pick--up

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Head Lift

Timed maneuver
Supine position
Occiput off the table
Maximum 2 minutes
Score from 00- 5

Arm Raise/Straighten

Performed in seated
position
Level of wrists is key
measurement factor
Score from 00- 3

Arm Raise/Duration
Timed maneuver
Raise arms simultaneously
Wrists should be in highest
position possible

Maximum of 60 seconds
Score from 00-4

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Leg Raise/Touch Object

Supine position
Distance of 2 patient foot
lengths
Score from 00- 2

Straight
g Leg
g Lift/Duration
Timed maneuver
Supine position
Distance of 1 patient foot length

Knee extension
Maximum of 2 minutes
Score from 00-5

Supine to Prone

Torso and shoulder

strength
Right arm flexed
Roll over to prone
position
Pulls right arm out
from under torso
Score from 00- 3

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Supine to Sit

Torso strength
Endpoint: legs dangle
freely over table
May use hands or
arms
Score
S
ffrom 00-3

Floor Sit & Floor Rise

Initiate in standing position

Descend into sitting
gp
position
Done with/without support (part
of criteria for scoring)
Score from 00- 3

Begins seated on floor

Rise to kneeling on both knees
Raise left knee in front with foot
on floor (hip and knee at 90
degrees flexion)
Rise from kneeling to standing
Score from 00- 4
* Watch for Gower sign

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All Four Maneuvers

Begins in prone position

Rise to crawling position
Crawl (creep) forward
forward
all 4 weight bearing
points must end in new
position
Extension of right leg
Score from 00- 4

Chair Rise

Seated in armless
chair (age
(age-appropriate size)
Lower legs
perpendicular to floor
Rise to stand
Score
S
ffrom 00-4

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Sit
Sit--Ups:

Total of 6 sit
sit--ups
3 sit
sit--ups with counterbalance
3 sit
sit--ups without counterbalance
Score from 00 -6

Stool Step

Step up approximately 77-8 inches

Done without support
Observe for absence/presence of Gower sign
Score from 00-3

Pick Up

Begin in standing position

Bend over and pick up pen/pencil
Return to erect standing position
Score from 00-3

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Measures of Pediatric Function

Childhood health Assessment Questionnaire (CHAQ)

Juvenile Arthritis Functional Assessment Report (JAFAR)

Juvenile Arthritis Functional Assessment Scale (JAFAS)

Juvenile Arthritis Functional Assessment Index (JASI)

Chronic Activity Limitations Scale (CALS)

Pediatric Orthopedic Surgeons of North America (POSNA)

Pediatric Musculoskeletal Functional Health Questionnaire
Arthritis Care & Research 2003; 49 (5) Supplement

Measures of Pediatric Pain and

Quality of Life

Pain Behavior Observation Methods

P i Coping
Pain
C i Questionnaire
Q
ti
i (PCQ)

Pediatric Pain Questionnaire (PPQ)

Juvenile Arthritis Quality of Life Questionnaire (JAQQ)

Pediatric Quality of Life (PedsQL)

Fibromyalgia (Modified) Impact Questionnaire (FIQ)

Arthritis Care & Research 2003; 49 (5) Supplement

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When I approach a child, they

inspire in me two sentiments:
tenderness for what they are, and
respect for what they may become.
--Louis
-Louis Pasteur

THANK
YOU!

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