MSK: The Basic Examination - Dr Mark Burgin
10/05/22. Dr. Mark Burgin BM BCh (oxon) MRCGP explains the minimum necessary examination in MSK cases to comply with GMC guidance.
The medical legal expert is expected to perform an examination that is sufficient to determine the anatomical area that is injured and any pre-existing problems.
This examination is no more detailed than that which would be performed in a General Practice but needs to recorded so that a solicitor can read it.
The expert must include relevant negatives that might not be included in a clinical record and an interpretation of the findings.
In this article I have restricted my description to the spine for simplicity but similar approaches can be used for joints and muscle injuries.
Range of motion
Many experts use a non-touch technique based upon the range of motion of the neck and back which is usually only reduced in severe cases.
The range of motion may be restricted because of emotional factors, pre-existing conditions or muscle spasm related to the injury.
Many experts feel that lack of both sensitivity and specificity restricts the usefulness of any statements about global movement unless gross.
I believe that comparing movements to the right with those to the left improves its performance and allows detection of subtle changes.
Palpation
It is impossible to determine the anatomical structure that is tender without palpation as pain radiates from one area to another.
The areas of palpation should include the paraspinal muscles (for spasm), the spinous processes (bony injury – traumatic or wear and tear) and nerves.
Some experts will also palpate the lateral aspects of the vertebral bodies (nerve root origins), facet joints and back muscles (e.g. upper fibres of trapezius).
My experience is that the pattern of tenderness can indicate the likely cause of ongoing symptoms in those who have delayed recovery.
MSK Tests
There are many thousands of MSK tests which can assist the diagnosis of specific conditions suspected from history and examination.
The Waddell signs assesses the likely presence of psychosocial risk factors although GPs and physios use a different test to consider the same issue.
Few experts will rely solely upon tests but there are some conditions that can only be identified on a test such as hypermobility syndrome and postural problems.
I recommend that all PI experts learn a few tests for the common situations; recurrent flare ups, delayed recovery, stress and depression.
Conclusions
It is no longer reasonable to say ‘the neck examination was normal’ as this gives insufficient information as to what examination was performed.
Range of motion should compare one side with the other rather than with ‘normal values’ which are unlikely to apply to the claimant.
Most claimants who have ongoing symptoms have signs on careful examination which can assist the expert in identifying the likely cause.
The expert should perform simple tests to confirm pre-existing problems such as hypermobility record relevant negatives.
Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.
Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk
Image ©iStockphoto.com/poike
