The whole point of making an effort to achieve proper exposure is to enable you to do a complete inspection. The different things that we are looking for during inspection are 1. Muscle bulk including muscle atrophy, muscle hypertrophy, pseudohypertrophy or edema of the limbs 2. Abnormal movements such as fasciculations, tremors, dyskinesias, myoclonus and dystonias 3. Evaluating for posture including abnormal posture or placement of the limb, scoliosis, lordosis, kyphosis or bony abnormalities Muscle bulk reduction i.e. muscle atrophy can be visibly reduced in many neuromuscular disorders. Sometimes inspection alone reveals to you the pattern of muscle involvement such as distal versus proximal muscle atrophy. Examples would be proximal muscle atrophy seen in proximal myopathies such as fascio-scapulohumeral muscular dystrophy or inverted champagne bottle legs seen in charcot-marie-toothed disease. The examiner should observe if the muscle atrophy finding is symmetrically distributed or is asymmetrically distributed. It is important to visually compare the affected limb to the contralateral side to evaluate for symmetry. A good example is atrophy of the bilateral FTI muscle in early motor neuron disease. It is important to note that neuromuscular disorders don't just result in muscle atrophy. Sometimes it can result in muscle hypertrophy. We are talking about muscle hypertrophy in the absence of any exercise. Such hypertrophy can be seen in conditions such as myotonia congenita, amyloidosis, sarcoidosis, hypothyroid myopathy and some other conditions. Dystonic conditions such as cervical dystonia or limb dystonia may result in hypertrophy of the dystonic muscles which can be clearly seen on inspection and palpation. Finally, pseudohypertrophy, what looks like hypertrophied muscle but in fact is just fat and connective tissue, also deserves identification. Such findings can be seen in congenital myopathies such as Duchenne muscular dystrophy, Becker muscular dystrophy, etc. Especially in the calf muscles. Natural positioning of the joint such as flexion, extension, rotation or elevation should be observed carefully. Different peripheral nerve entrapments, for example, would result in characteristic posture of the affected limb which can readily be recognized on inspection. For example, ulnar neuropathy at the elbow can result in claw-hand deformity, especially later in the course. Similarly, hammer toes can be seen in hereditary peripheral neuropathy. Other clear examples of abnormal posture would be cervical dystonia which can result in lateral bending, lateral rotation or shoulder elevation on one side to name a few. Please note that pain can contribute to abnormal posture as well. Abnormal movements such as fasciculations need proper inspections of the muscles as well. Fasciculations in the proximal extremities can easily be missed, especially if one is not looking for them as those areas are normally hidden under the clothes. Tapping the muscle to bring out fasciculations in a particular muscle is a good technique to remember. Sometimes you have to observe the muscle in question for some time before you will actually see a fasciculation occurring. To save time, you can always continue to observe a muscle while you are obtaining history from the patient in order to look for fasciculations. Don't forget to look for fasciculations in the chest and thoracic regions anteriorly and posteriorly. Tongue fasciculations can be hard to visualize if the tongue is not relaxed. Ask the patients to open their mouth and keep their tongue rested inside their mouth. This enables you to avoid misinterpreting any random tongue movements as fasciculations. While you are doing so, observe the tongue for atrophy as well.

muscle atrophy

muscle hypertrophy

pseudohypertrophy

abnormal posture

fasciculations