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Am Fam Physician. 2021;103(3):147-154

Published online January 12, 2021.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Telemedicine can provide patients with cost-effective, quality care. The coronavirus disease 2019 pandemic has highlighted the need for alternative methods of delivering health care. Family physicians can benefit from using a standardized approach to evaluate and diagnose musculoskeletal issues via telemedicine visits. Previsit planning establishes appropriate use of telemedicine and ensures that the patient and physician have functional telehealth equipment. Specific instructions to patients regarding ideal setting, camera angles, body positioning, and attire enhance virtual visits. Physicians can obtain a thorough history and perform a structured musculoskeletal examination via telemedicine. The use of common household items allows physicians to replicate in-person clinical examination maneuvers. Home care instructions and online rehabilitation resources are available for initial management. Patients should be scheduled for an in-person visit when the diagnosis or management plan is in question. Patients with a possible deformity or neurovascular compromise should be referred for urgent evaluation. Follow-up can be done virtually if the patient's condition is improving as expected. If the condition is worsening or not improving, the patient should have an in-office assessment, with consideration for referral to formal physical therapy or specialty services when appropriate.

Telemedicine has rapidly become a valuable tool during the coronavirus disease 2019 (COVID-19) pandemic.1 Given that musculoskeletal issues are a common reason for primary care visits,2,3 a standardized examination to evaluate these issues via telemedicine is useful. Video-assisted orthopedic consultation for selected patients is cost-effective and does not result in serious adverse events.4,5

Clinical recommendationEvidence ratingComments
Video-assisted orthopedic consultation for selected patients is cost-effective.4 BEconomic evaluation based on randomized controlled trial comparing video-assisted remote consultation with standard care
Video-assisted orthopedic consultation for selected patients does not result in serious adverse events.5 BRandomized controlled trial comparing video-assisted remote consultation at a regional medical center with standard consultation at an orthopedic outpatient clinic
The management of musculoskeletal conditions via telerehabilitation is effective in improving physical function, disability, and pain.24 BSystematic review

This article discusses telemedicine methods and techniques, including visit preparation, history collection, virtual physical examination, and initial treatment options.

Virtual Visit Preparation

Before the visit, initial preparation includes confirming that the patient has functional audiovisual resources and providing instructions on ideal setting, camera angles, body positioning, and attire.6 The physician should review any previous imaging studies beforehand. Multiple telehealth platforms are compliant with the U.S. Health Insurance Portability and Accountability Act (HIPAA).7 A guide for preparing a medical practice for virtual visits was published previously in FPM.8

Virtual Musculoskeletal Evaluation

Patients should be asked about the timing and characteristics of symptom onset, associated trauma, location of pain, presence of swelling, subsequent course, and current status. Functional impact on activities of daily living, employment, and recreational activities should be established. Physicians should ask about previous injuries and surgeries, as well as previous management and response.

The virtual physical examination should include inspection, palpation, range of motion, strength, neurovascular assessment, and special tests.9,10 Although certain maneuvers are difficult to perform virtually, modifications can provide useful information. It may be helpful for the patient to mirror the physician's motions.

SHOULDER

For shoulder problems, the physician should ask if the patient's primary concern is pain, weakness, or decreased range of motion. Pain in the absence of a recent traumatic event often indicates shoulder impingement or calcific tendinopathy.11 Pain with cross-arm adduction can indicate acromioclavicular pathology.9,11,12 Weakness suggests complete rotator cuff tear or nerve pathology. Decreased range of motion raises suspicion for adhesive capsulitis or severe osteoarthritis.9,13,14 Patients should also be asked about distal neurovascular symptoms of the upper extremity, such as weakness or paresthesia.

The virtual physical examination begins with inspection. The patient should wear a tank top or sports bra according to individual comfort. The patient should be asked to face the camera and then slowly rotate their body 360 degrees so that the physician can observe the shoulder joint in all planes. The physician should look for asymmetry, deformity, abnormal posture, overlying skin changes, atrophy, erythema, and ecchymosis.

The physician should ask the patient to point to the area of maximal tenderness. The patient should be directed to use the contralateral hand to palpate the sternoclavicular joint, clavicle, acromioclavicular joint, acromion, and spine of the scapula, as range of motion allows. Patients can also locate and palpate the bicipital groove and greater tuberosity of the humerus with direction from the physician (Figure 1).

Shoulder abduction, forward flexion, extension, external rotation, and internal rotation active range of motion (Table 111) should be assessed. Alterations of scapular motion during abduction and flexion indicate scapular dyskinesia or weakness of the scapular stabilizing muscles.

Plane of range of motionPatient body positioning*Normal range of motion (degrees)11
Shoulder
AbductionAway from the camera180
Extension90 degrees to the side45 to 60
Flexion90 degrees to the side for measurement, away from the camera for scapular stability180
Internal rotationAway from the camera for Apley scratch testAble to reach vertebral height of T4–T8
90 degrees to the side, elbow abducted to 90 degrees90
External rotation90 degrees to the side, elbow at the side90
90 degrees to the side, elbow abducted to 90 degrees90
Elbow
FlexionFacing the camera, arm abducted to 90 degrees135 to 150
ExtensionSame as flexion−10 to 0
SupinationFacing the camera, elbow resting on table with arm to the side and elbow flexed to 90 degrees75 to 90
PronationSame as supination75 to 90
Wrist
Dorsiflexion90 degrees to the side70
Palmar flexionSame as dorsiflexion80 to 90
Radial deviationFacing the camera20 to 30
Ulnar deviationFacing the camera50

Strength testing can be performed by asking the patient to move their shoulder against gravity or by using common household items (Table 2). Table 3 summarizes suggested rotator cuff strength tests.9,11,15 Neurovascular assessment can be completed by having the patient perform a wall push-up so that the physician can look for scapular winging. Special tests of the shoulder, such as Speed test to check for proximal biceps tendinopathy and O'Brien test to detect labral pathology, can be performed using household items as resistance.

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