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Home / Complete musculoskeletal examination
11-minute physical-examination master page

Complete musculoskeletal examination

Perform a focused joint examination using look, feel and move; recognize a septic joint, avoid harmful maneuvers, and state urgent aspiration, antimicrobial and orthopedic management.

Candidate instructions

Hot swollen knee — focused musculoskeletal examination

Your task

Perform a focused examination of a 57-year-old patient with an acutely painful swollen right knee and fever. At the end, give your leading diagnosis, prioritized differential, investigations and immediate management. You have 11 minutes.

Information available at entry
HR 112/minBP 118/70 mm HgRR 20/minSpO₂ 98% room airTemp 38.5°C
Safety priority: A hot swollen joint with fever and severe pain on passive movement is septic arthritis until proven otherwise. Assess for sepsis, provide analgesia and arrange urgent sterile aspiration and definitive treatment; do not force painful range-of-motion tests.

What examiners expect

  • Introduction, consent, hand hygiene and pain assessment.
  • General inspection for systemic illness and ability to bear weight.
  • Look-feel-move comparison of both knees.
  • Identification of effusion, warmth, erythema and severe restriction.
  • Avoidance of aggressive special tests in a suspected septic joint.
  • Assessment of adjacent joints and neurovascular status when relevant.
  • Recognition of septic arthritis as the leading diagnosis.
  • Urgent aspiration, cultures, antibiotics and orthopedic involvement.
Timed rehearsal

Run the complete station in 11 minutes

Perform the patient-facing examination efficiently, then reserve the final 90–120 seconds for synthesis, differential, investigations, management and safety.

Review procedureOpen practice library
Station time
11:00

Ready for an 11-minute attempt.

Complete procedure

Exact 11-minute examination sequence

Use the sequence as a flexible performance framework. Patient safety and the task on the door always take priority over completing every maneuver.

0:00–0:40

1. Stability, sepsis and pain

Say: “Before examining the knee, I would confirm your vital signs and make sure there are no signs of sepsis or shock.”
  • Assess fever, perfusion and mental status.
  • Offer analgesia early.
  • Ask whether the patient can bear weight.
0:40–1:20

2. Introduce, identify and consent

Say: “I will examine both knees by looking, gently feeling and checking movement. Please tell me if anything is too painful.”
  • Confirm two identifiers.
  • Obtain consent and wash hands.
1:20–2:10

3. Expose and inspect standing/function only if safe

Say: “I would like to compare both knees. I will not ask you to stand if it is unsafe or too painful.”
  • Expose both knees adequately while preserving dignity.
  • Observe swelling, erythema, deformity, scars and muscle wasting.
  • Do not force weight-bearing in severe acute pain.
2:10–3:40

4. Palpation

Say: “I am going to feel around the knee gently, starting away from the most painful area.”
  • Compare temperature.
  • Palpate joint lines, patella, tibial tuberosity and relevant landmarks.
  • Assess for effusion with gentle methods.
  • Note focal tenderness.
3:40–5:20

5. Active and passive movement

Say: “Please bend and straighten the knee as much as you comfortably can.”
  • Assess active flexion/extension.
  • Gently assess passive range only as tolerated.
  • Marked pain with passive movement raises concern for intra-articular pathology/septic arthritis.
  • Stop if pain becomes severe.
5:20–6:20

6. Focused special tests only if appropriate

Say: “Because this joint is acutely inflamed and very painful, I would avoid forceful ligament or meniscal stress tests right now.”
  • If trauma rather than infection is suspected, select appropriate ligament/meniscal tests.
  • Do not perform unnecessary provocative maneuvers in a hot septic-appearing joint.
6:20–7:20

7. Adjacent joints and neurovascular screen

Say: “I would also check the hip and ankle briefly and make sure circulation and sensation are intact.”
  • Inspect/palpate adjacent joints if referred pain is possible.
  • Assess distal pulses, capillary refill and sensation when indicated.
7:20–8:20

8. Look for systemic/source clues

Say: “I would look for skin infection, wounds or other possible sources of infection.”
  • Skin lesions/wounds.
  • Other inflamed joints.
  • Prosthetic joint or recent procedure history from focused history.
8:20–9:10

9. Completion and comfort

Say: “Thank you. I will help you get comfortable and avoid further painful movement.”
  • Cover patient.
  • Hand hygiene.
  • Reassess pain and systemic status.
9:10–11:00

10. Present and act urgently

Say: “The acute hot swollen knee, fever, inability to bear weight and severe pain with passive movement make septic arthritis my leading diagnosis.”
  • State crystals as an important alternative but not a reason to dismiss infection.
  • Urgent synovial fluid aspiration for cell count, Gram stain, culture and crystals.
  • Blood cultures and sepsis bloodwork as indicated.
  • Prompt empiric IV antibiotics after cultures/aspiration when feasible without dangerous delay.
  • Urgent orthopedic consultation for drainage/source control.
Interpretation

High-yield finding patterns

Finding patternClinical interpretation
Hot swollen joint + fever + severe passive-motion painSeptic arthritis until proven otherwise
Very tender first MTP/knee with crystalsCrystal arthritis; infection can coexist
Traumatic effusion/instabilityHemarthrosis or ligament/meniscal injury
Chronic bony enlargement/crepitusOsteoarthritis
Multiple symmetric small-joint synovitisInflammatory polyarthritis
Clinical reasoning

Prioritized differential

  1. Septic arthritis
  2. Crystal arthritis (gout/CPPD)
  3. Hemarthrosis
  4. Traumatic internal derangement
  5. Inflammatory arthritis flare
  6. Cellulitis/bursitis adjacent to the joint

Presentation formula

Start with stability, then the key positive and negative findings, localization or syndrome, leading diagnosis, and the most dangerous alternative that must be excluded.

Avoid: a long unranked list. Explain which finding makes each top diagnosis more or less likely.
Targeted tests

Investigations

Urgent sterile synovial fluid: cell count/differential, Gram stain, culture and crystals

Blood cultures before antibiotics when feasible in a systemically unwell patient

CBC, CRP/ESR, renal function and lactate/sepsis tests as indicated

Plain radiograph when trauma, foreign body, prosthesis or alternative diagnosis is relevant

Ultrasound to confirm/guide aspiration when needed

Immediate plan

Management and disposition

  1. Assess and treat sepsis; provide prompt analgesia.
  2. Obtain blood cultures and urgent synovial fluid when feasible.
  3. Start empiric IV antibiotics promptly after appropriate cultures/aspiration; do not delay dangerously in sepsis.
  4. Urgent orthopedic consultation for washout/drainage and source control.
  5. Adjust antibiotics to culture results and patient factors.
  6. Do not inject intra-articular steroid until infection has been excluded.

Safety-netting

State exactly what would trigger urgent reassessment, specialist escalation, monitored care or admission. Do not hide emergency actions inside a generic “follow up” statement.

  • Recognizes septic arthritis
  • Assesses for sepsis
  • Avoids forceful painful maneuvers
  • Arranges urgent aspiration
  • Requests Gram stain/culture plus crystals
  • Starts prompt antimicrobial pathway
Self-assessment

Critical-action checklist

Use this after a timed attempt. These actions carry disproportionate safety value.

0 / 8 completed
0 / 8 critical actions completed
Evidence and next practice

References and linked learning

Reference starting points

Educational preparation only. Patient care must follow current patient-specific assessment, local policy and current guidelines.

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