Examination

Question 1

General Inspection

Answer 1

-Body habitus: obesity RF joint pathology due to increased mechanical load (e.g. osteoarthritis).
-Age, frailty
-Scars: previous lower limb surgery.
-Wasting of muscles: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron injury.
-Walking aids: the ability to walk can be impacted by a wide range of knee, hip and ankle pathology. Shoes- orthoses
-Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications (e.g. analgesia). Oxygen, systemic illness
-Posture, malalignments

Question 2

Closer inspection of hips

Answer 2

STAND AND TURN IN 90* INCREEMENTS

-Anterior
=Scars (iliac crest to groin), bruising (recent trauma/ surgery), swelling (asymmetry: unilateral- effusion, inflammatory arthropathy, septic A), quad wasting (diffuse atrophy, LMN), leg length discrepancy (congenital/ acquired- degenerative joint disease, trauma to epiphyseal endplate prior to skeletal maturity), pelvic tilt (scoliosis, length discrepancy, hip abductor weakness)

-Lateral
=Flexion abnormalities (fixed deformity- contractures secondary to previous trauma, inflammatory conditions or neurological disease)
=Kyphosis lordosis
=Greater trochanter scar

-Posterior
=Scars, muscle wasting, spine assessment (shoulder level, straight, pelvis level, buttock atrophy secondary to nerve damage in surgery)

Question 3

Gait assessment

Answer 3

-Gait cycle: toe-off or heel strike
-Range of movement: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, inflammatory arthritis).
-Limping: may suggest joint pain (i.e. antalgic gait) or weakness.
-Leg length: note any discrepancy which may be the cause or the result of joint pathology.
-Turning: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
-Trendelenburg’s gait: an abnormal gait caused by unilateral weakness of the hip abductor muscles secondary to a superior gluteal nerve lesion or L5 radiculopathy.
-Waddling gait: an abnormal gait caused by bilateral weakness of the hip abductor muscles, typically associated with myopathies (e.g. muscular dystrophy).
-Antalgic gait
-Assess the patient’s footwear: unequal sole wearing is suggestive of an abnormal gait

Question 4

The phases of gait cycle

Answer 4

1. Heel-strike: initial contact of the heel with the floor.
2. Foot flat: weight is transferred onto this leg.
3. Mid-stance: the weight is aligned and balanced on this leg.
4. Heel-off: the heel lifts off the floor as the foot rises but the toes remain in contact with the floor.
5. Toe-off: as the foot continues to rise the toes lift off the floor.
6. Swing: the foot swings forward and comes back into contact with the floor with a heel strike (and the gait cycle repeats).

Question 5

“Feel” in hip exam

Answer 5

-Temperature (septic/ inflammatory A)
-Hip joint palpation (palpate greater trochanter of each leg for tenderness in trochanteric bursitis)
-Leg length assessment (true and apparent- secondary to lateral pelvic tilt)

Question 6

True vs apparent leg length

Answer 6

-True: anterior superior iliac spine to tip of medial malleolus (tibia or femur as hip dysplasia or fracture)
-Apparent: measure and compare distance between umbilicus (or xiphisternum) and tip of medial malleolus (different in pelvic tilt and scoliosis)

Question 7

Describe Trendelenburg’s gait

Answer 7

-Unilateral hip abductor weakness, which is typically described as ‘lurching’ in nature.
-As the pelvis sags towards the unaffected side, the trunk lurches towards the opposite side in an effort to maintain balance
-If a patient has unilateral hip abductor weakness, the pelvis will drop toward the contralateral side when the leg on that side leaves the ground (i.e. if there is left hip abductor weakness, the pelvis will drop towards the right whenever the right foot is lifted off the ground).
-It’s important to remember that the pelvis falls on the contralateral side to the weakness. This sagging of the pelvis secondary to hip abductor weakness is known as Trendelenburg’s sign.
-Unilateral hip abductor weakness is typically caused by a superior gluteal nerve lesion or L5 radiculopathy

Question 8

Describe Waddling gait

Answer 8

-If an individual has bilateral hip abductor weakness, they typically present with a waddling gait, caused by the overuse of circumduction to compensate for gluteal weakness.
-Bilateral hip abductor weakness is typically associated with myopathies (e.g. muscular dystrophy).

Question 9

“Move” in hip exam

Answer 9

-Assess normal leg first
-Straight leg raise: assess nerve tension signs in spine pathology, if discomfort flex hip and reduce pain as reduced nerve tension
-Active: hip flexion and extension
-Passive: flexion, internal rotational, external rotation, abduction, adduction, extension

Question 10

Describe the active movement tests of the hip

Answer 10

-Look for restrictions in range and signs of discomfort
-Flexion: Place your hand under the lumbar spine to detect masking of restricted hip joint movement by the pelvis and lumbar spine. Normal range of movement: 120°. Ask the patient to flex their hip as far as they are able – “Bring your knee as close to your chest as you can.”
-Extension: Normal range of movement: the leg should be able to lie flat (180°). Ask the patient to extend their leg, so that it is flat on the bed – “Straighten your leg out so that it is flat on the bed.”

Question 11

Describe the passive movement tests of the hip

Answer 11

-Assess for crepitus, discomfort, restriction
-Flexion: 120, Whilst supporting the patient’s leg, flex the hip as far as you are able, making sure to observe for signs of discomfort- another 10 to 20 degrees
-Internal rotation: 20-40, Flex the patient’s hip and knee joint to 90° and then rotate their foot laterally.
-External rotation: 30-45, Flex the patient’s hip and knee joint to 90° and then rotate their foot medially
-Abduction: 30-45, With the patient’s legs straight and flat on the bed, use one of your hands to hold the ankle of the hip being assessed and place your other hand over the contralateral iliac crest to stabilise the pelvis. Move the patient’s ankle laterally to abduct the hip until the pelvis begins to tilt
-Adduction: 20-30, With the patient’s legs straight and flat on the bed, use one of your hands to hold the ankle of the hip being assessed and place your other hand over the contralateral iliac crest to stabilise the pelvis. Move the patient’s ankle medially to adduct the hip until the pelvis begins to tilt.
-Extension: 10-20, prone position, one hand to hold ankle of leg being assessed and place other hand on ipsilateral pelvis, lift the leg to extend hip joint and assess range of extension

Question 12

Special hip tests

Answer 12

-Thomas’s
=Fixed flexion deformity (inability to fully extend leg)
=Flat on bed, place a hand below their lumbar spine with your palm facing upwards (this helps to prevent the patient from masking a fixed flexion deformity by increasing lumbar lordosis). Passively flex the hip of the unaffected leg as far as you are able to and observe the contralateral limb. Repeat the assessment on the contralateral hip
=Positive: affected thigh raises off bed indicating loss of hip joint extension, not be performed on patients who have had a hip replacement as it can cause dislocation

-Trendelenburg’s test is used to screen for hip abductor weakness (gluteus medius and minimus, stabilise pelvis).
1. With the patient upright, stand in front of them and ask them to place their hands on your forearms or shoulders for stability.
2. Position your fingers on each side of the patient’s pelvis at the iliac crest (pelvic tilt?).
3. Ask the patient to stand on one leg and observe your fingers for evidence of lateral pelvic tilt.
4. Repeat the assessment with the patient standing on the other leg
=If abductors functioning normally pelvis should remain stable or rise slightly on side of raised leg, if pelvis drops on side of raised leg suggests contralateral hip abductor weakness

True and apparent leg length

Question 13

Further assessments and investigations in hip examination

Answer 13

-Neurovascular examination of both lower limbs.
-Examination of the joints above and below (lumbar spine and knee joint).
-Further imaging if indicated (e.g. X-ray and MRI).

Question 14

General inspection in knee examination

Answer 14

-Body habitus (joint pathology due to increased mechanical load)
-Scars
-Wasting of muscle (disuse atrophy secondary to joint pathology or a lower motor neuron injury)
-Walking aids
-Prescriptions

Question 15

Anterior knee inspection

Answer 15

-Scars: arthroscopy port entry sites) or indicate previous joint trauma.
=Midline anterior incision and port sites
-Bruising: recent trauma or spontaneous haemarthrosis (e.g. patients on anticoagulants or with clotting disorders such as haemophilia).
-Swelling: asymmetry in the size of the knee joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, septic arthritis, haemarthrosis). Erythema
-Psoriasis plaques: typically present over extensor surfaces and important to note due to the increased risk of psoriatic arthritis.
-Patellar position: the patella is normally located over the centre of the knee joint and any deviation from this central position may indicate patellar dislocation or subluxation (i.e. partial dislocation).
-Valgus deformity of the knee: the tibia is turned outward in relation to the femur, resulting in the knees ‘knocking’ together.
-Varus deformity of the knee: the tibia is turned inward in relation to the femur, resulting in a bowlegged appearance.
-Quadriceps wasting: asymmetry in the bulk of the quadriceps muscles which may be due to disuse atrophy or a lower motor neuron lesion.

Question 16

Lateral inspection of knee

Answer 16

-Extension abnormalities: knee hyperextension can occur secondary to cruciate ligament injury.
-Flexion abnormalities: fixed flexion deformity at the knee joint may suggest the presence of contractures secondary to previous trauma, inflammatory conditions or neurological disease.
-Baker’s cyst= bulge at back of knee, OA

Question 17

Posterior inspection of knee

Answer 17

-Scars: again look for scars indicative of previous trauma or surgery.
-Muscle wasting: inspect for any asymmetry in the muscle bulk of the posterior compartment of the thigh or lower leg suggestive of disuse atrophy or a lower motor neuron lesion.
-Popliteal swellings: possible causes include a Baker’s cyst or popliteal aneurysm (typically pulsatile).

Question 18

Gait assessment in knee exam

Answer 18

-Gait cycle: note any abnormalities of the gait cycle (e.g. abnormalities in toe-off or heel strike).
=Antalgic
=Stiff kneed
-Range of movement: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, inflammatory arthritis).
-Limping: may suggest joint pain (i.e. antalgic gait), weakness or joint instability (e.g. ligamentous injury).
-Leg length: note any discrepancy which may be the cause or the result of joint pathology.
-Turning: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
-Height of steps: high-stepping gait is associated with foot drop, which can be caused by peroneal nerve palsy (e.g. trauma, surgery).

Question 19

“Feel” exam in knee

Answer 19

45*
-Temp: SA, inflammatory arthritis, gout or pseudogout
-Measurement of quadriceps bulk: secondary to diffuse atrophy, circumference with tape 20cm above tibial tuberosity
-Effusion- sweep test or tap test

Question 20

Palpation of extended knee

Answer 20

With the patient’s leg straight and relaxed, systematically palpate the joint lines and surrounding structures of each knee joint.

-Patella
1. Assess the medial and lateral border of the patella for tenderness by stabilising one side of the patella and palpating the other with a fingertip:
=Tenderness may represent injury or patellofemoral arthritis.
=If the patient appears apprehensive, developing tension in the muscles of the leg as you begin to mobilise the patella (typically in the lateral direction), it may suggest a history of recurrent patellar dislocation which the patient is anticipating (this can be formally assessed using the patellar apprehension test).
2. Palpate the patellar ligament for tenderness suggestive of tendonitis or rupture.

-Medial and lateral joint lines
1. Palpate the medial and lateral joint lines of the knee including the collateral ligaments for evidence of tenderness which may suggest:
=Fracture
=Meniscal injury (e.g. meniscal tear)
=Collateral ligament injury (e.g. rupture)
2. Palpate the quadriceps tendon for tenderness suggestive of tendonitis or rupture.

Question 21

Palpation of flexed knee

Answer 21

With the patient’s knee flexed at 90° repeat the same process of palpation as you did when the knee was extended. Joint lines and the popliteal fossa are often easier to assess with the knee flexed.

-Patella
=Palpate the patellar ligament for tenderness suggestive of tendonitis or rupture.

-Medial and lateral joint lines
=Palpate the medial and lateral joint lines of the knee including the collateral ligaments for evidence of tenderness which may suggest:
=Fracture
=Meniscal injury (e.g. meniscal tear)
=Collateral ligament injury (e.g. rupture)

-Tibial tuberosity and the head of the fibula
=Palpate the tibial tuberosity for evidence of a bony elevation and tenderness which is typically associated with Osgood-Schlatter disease.
=Palpate the head of the fibula for tenderness which is often associated with fracture.

-Popliteal fossa
=With your thumbs placed on the tibial tuberosity, curl your fingers into the popliteal fossa and palpate for evidence of a swelling which may indicate the presence of a popliteal cyst (often referred to as a Baker’s cyst). A pulsatile mass in the popliteal fossa may represent a popliteal aneurysm.

Question 22

Assess active movement of the knee

Answer 22

-Straight leg raise= nerve root tension, extensor mechanism, hip/ spine problems

-Active knee flexion
=0-140° (130)
=Ask the patient to flex their knee as far as they are comfortably able to – “Move your heel as close to your bottom as you can manage.”

-Active knee extension
=leg should be able to lie flat (180°)
=Ask the patient to extend their knee, so that their leg is flat on the bed – “Straighten your leg out so that it is flat on the bed.”

Question 23

Passive movement of knee

Answer 23

-Passive knee flexion
=0-140°
=Whilst supporting the patient’s leg, flex the knee as far as you are able, making sure to observe for signs of discomfort.

-Passive knee extension
If the patient is able to lay their legs flat on the bed, they are already demonstrating a normal range of movement for knee extension. To assess for hyperextension:
1. On the leg being assessed, hold above the ankle joint and gently lift the leg upwards.
2. Inspect the knee joint for evidence of hyperextension, with less than 10° being considered normal. Excessive knee hyperextension may suggest pathology affecting the integrity of the knee joint’s ligaments.

Question 24

Special knee tests

Answer 24

-Cruciate ligament assessment
=Posterior sag sign
=Anterior drawer test
=Posterior drawer test
=Lachman’s test

-Collateral ligament assessment
=Lateral (varus stress)
=Medial (valgus stress)

-Menisci
=McMurray’s for medial and lateral

Question 25

Cruciate ligament assessment tests

Answer 25

-Posterior sag sign: PCL ruptured= tibia sags posteriorly in relation to femur (usually prevents backward displacement of tibia or forward sliding of femur)
=Relaxed and ask them to flex their knee to 90º with their foot placed flat on the bed. Inspect the lateral aspect of the knee joint for evidence of posterior sag.
=Tear can result in false positive anterior drawer sign

-Anterior drawer test: integrity of cruciate ligament
1. Position the patient supine on the clinical examination couch with their knee flexed to 90º.
2. Wrap your hands around the proximal tibia with your fingers around the back of the knee joint.
3. Rest your forearm down the patient’s lower leg to fix its position.
4. Position your thumbs over the tibial tuberosity.
5. Ask the patient to keep their legs as relaxed as tense hamstrings can mask pathology.
6. Pull the tibia anteriorly and feel for any anterior movement of the tibia on the femur. With healthy cruciate ligaments, there should be little or no movement noted. Significant movement may suggest anterior cruciate ligament laxity or rupture.

-Posterior drawer test
=Repeat steps 1-5 and then push the tibia posteriorly. With healthy cruciate ligaments, there should be little or no movement noted. Significant posterior movement may suggest posterior cruciate ligament laxity or rupture

-Lachman’s test: alternative test assessing for laxity or rupture of the anterior cruciate ligament (ACL).
1. Flex the patient’s knee to 30°.
2. Hold the lower leg with your dominant hand with your thumb on the tibial tuberosity and your fingers over the calf.
3. With the non-dominant hand, hold the thigh just above the patella.
4. Use the dominant hand to pull the tibia forwards on the femur while the other hand stabilises the femur.
Significant anterior movement of the tibia on the femur suggests ACL laxity or rupture.

Question 26

Collateral ligament assessments

Answer 26

-Lateral collateral ligament (LCL) assessment involves the application of a varus force to assess the integrity of the LCL of the knee joint.
1. Extend the patient’s knee fully so that the leg is straight.
2. Hold the patient’s ankle between your right elbow and side.
3. Position your right palm over the medial aspect of the knee.
4. Position your left palm a little lower down over the lateral aspect of the lower limb, with your fingers reaching upwards to palpate the lateral knee joint line.
5. Push steadily outward with your right palm whilst pushing inwards with the left palm.
6. Whilst performing this manoeuvre, palpate the lateral knee joint line with the fingers of your left hand.
=With healthy collateral ligaments, there should be no abduction or adduction possible.
=If there is LCL laxity or rupture your fingers should be able to feel a palpable gap caused by the lateral aspect of the joint opening up secondary to the varus force being applied.

-Medial collateral ligament assessment (valgus stress test)
1. Extend the patient’s knee fully so that the leg is straight.
2. Hold the patient’s ankle between your right elbow and side.
3. Position your left palm over the lateral aspect of the knee.
4. Position your right palm a little lower down over the medial aspect of the lower limb, with your fingers reaching upwards to palpate the medial knee joint line.
5. Push steadily inward with your left hand whilst pushing outwards with the right hand.
6. Whilst performing this manoeuvre, palpate the medial knee joint line with the fingers of your right hand.
=With healthy collateral ligaments, there should be no abduction or adduction possible.
=If there is MCL laxity or rupture your fingers should be able to feel a palpable gap caused by the medial aspect of the joint opening up secondary to the valgus force being applied.

Further collateral ligament assessment
If after this assessment the knee appears stable you can further assess the collateral ligaments by repeating this test with the knee flexed at 30°. At this position, the cruciate ligament is not taught so minor collateral ligament laxity can be more easily detected.

Question 27

Assessments of the menisci

Answer 27

-Evidence of meniscal tear

-Medial meniscus
1. With the patient supine on the clinical examination couch, passively flex the knee being assessed as far as is possible.
2. Hold the patient’s right knee with your left hand, with your thumb over the medial aspect and fingers over the lateral aspect of the joint lines.
3. Hold the patient’s right foot by the sole using your right hand.
4. Create valgus stress on the knee joint with your left hand by applying outward pressure as if trying to abduct the leg at the hip whilst fixating and externally rotating the foot. At the same time slowly extend the knee joint.
=The presence of a click and discomfort is suggestive of a medial meniscal tear.

-McMurray’s test for assessing the lateral meniscus
1. With the patient supine on the clinical examination couch, passively flex the knee being assessed as far as is possible.
2. Hold the patient’s right knee with your left hand, with your thumb over the medial aspect and fingers over the lateral aspect of the joint lines.
3. Hold the patient’s right foot by the sole using your right hand.
4. Create varus stress on the knee joint with your left hand by applying inward pressure as if trying to adduct the leg at the hip whilst fixating and internally rotating the foot. At the same time slowly extend the knee joint.
=The presence of a click and discomfort is suggestive of a lateral meniscal tear.

Question 28

Further knee tests

Answer 28

-Neurovascular examination of both lower limbs.
-Examination of the joints above and below (e.g. ankle and hip).
-Further imaging if indicated (e.g. X-ray and MRI).

Question 29

Foot and ankle examination

Answer 29

-General
-Gait: walk on tip toes and heels: arthritis or lower limb muscle weakness will struggle to perform tasks
=Painful hindfoot not heel stroke
=Painful forefoot: avoid push off (heel only)

Question 30

Anterior examination of foot/ankle

Answer 30

-Scars: note the location of scars as they may provide clues as to the patient’s previous surgical history or indicate previous joint trauma.
-Bruising: suggestive of recent trauma or spontaneous haemarthrosis (e.g. patients on anticoagulants or with clotting disorders such as haemophilia).
-Swelling: note any evidence of asymmetry in the size of the ankle joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, septic arthritis, haemarthrosis, Charcot joint).
-Psoriasis plaques: typically present over extensor surfaces and important to note due to the association with psoriatic arthritis.
-Atrophic changes, nail pitting or onycholysis
-Fixed flexion deformity of the toes: subtypes include hammer-toe and mallet-toe.
-Big toe misalignment: note any evidence of lateral (hallux valgus/bunion) or medial (hallux varus) big toe angulation.
-Calluses: thickened, hardened skin that develops as a result of repetitive friction which may be caused by poorly fitting footwear or a gait abnormality.
-Asymmetric wear anywhere, insoles, orthoses
-Clawing, hammer toes
-Plantar view: midfoot deformity, hallux valgus, varus

Question 31

Lateral examination of foot/ankle

Answer 31

Foot arch: inspect for evidence of flat feet (pes planus) or an abnormally raised foot arch (pes cavus).

Question 32

Posterior inspection of foot/ankle

Answer 32

-Scars: again look for scars indicative of previous trauma or surgery.
-Muscle wasting: inspect for any asymmetry in the muscle bulk of the posterior compartment of the lower leg suggestive of disuse atrophy or a lower motor neuron lesion.
-Heel misalignment: may be caused by a valgus or varus deformity of the ankle joint.
-Achilles tendon: discontinuity and swelling may indicate tendonitis and/or rupture

Question 33

“Feel” exam of foot/ knee

Answer 33

-Temp
-Pulses: posterior tibial pulse (posterior to medial malleolus of tibia), dorsalis pedis (dorsum of foot lateral to extensor hallucis longus tendon over second and third cuneiform bones)
-Metatarsophalangeal joint squeeze (verbal and non-verbal discomfort- active inflammatory arthropathy), midtarsal joint
-Palpation
=Metatarsal and tarsal bones, tarsal, ankle, subtalar, calcaneum, medial/lateral malleoli, distal fibula
-Achilles tendon palpation: gastrocnemius muscle and tendon (focal tenderness or swelling like tendonitis, discontinuity in tendon for rupture)

Question 34

Movements of foot/ankle

Answer 34

-Foot plantarflexion
=0-50° (40)
=“Push your feet downwards, like you are pressing a car pedal.”

-Foot dorsiflexion
=0-20º
=“Extend your feet backwards, like you’re trying to point them up towards your head.”

-Toe flexion
=“Curl up your toes as tight as you can.” (40)

-Toe extension
=“Extend your toes backwards, like you’re trying to point them towards your head.” (70)

-Ankle/foot inversion
=0-35º (30)
=“Try to touch the soles of your feet together.”

-Ankle/foot eversion
=0-15º (20)
=“Try to angle the soles of your feet outwards as far as you are able to.”

-Passive movement only
=Subtalar joint (stabilise ankle)
=Midtarsal joint (twisting)

Question 35

Special tests in foot/ankle

Answer 35

-Simmonds’ test is used to assess for clinical evidence of Achilles tendon rupture:
1. Ask the patient to kneel on a chair with their feet hanging over the edge.
2. Squeeze each of the patient’s calves in turn.
=In healthy individuals, the foot should plantarflex when you squeeze the calf due to the contraction of the gastrocnemius muscle and the subsequent pulling force transmitted via the Achilles tendon.
=There will be no movement of the foot if the Achilles tendon is ruptured due to loss of continuity between the gastrocnemius and the foot.

Question 36

Anterior inspection of shoulder

Answer 36

-Age: instability (young), older (more elective), elderly (rotator cuff arthropathy, arthritis)

-Scars: note the location of the scar as this may provide clues as to the patient’s previous surgical history or suggest previous joint trauma. (Deltoid pectoral scar, port sites), clavicle dislocation
-Bruising: suggestive of recent trauma or surgery.
-Asymmetry of the shoulder girdle: may be caused by scoliosis, arthritis, fractures or dislocation.
-Swelling: note any evidence of asymmetry in the size of the shoulder joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, dislocation).
-Abnormal bony prominence: may indicate fracture (e.g. clavicular fracture) or anterior dislocation of the glenohumeral joint.
-Deltoid wasting: note any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary nerve injury.

Question 37

Lateral inspection of shoulder

Answer 37

-Scars: again look for scars indicative of previous trauma or surgery.
-Deltoid wasting: note any asymmetry in the bulk of the deltoid muscles which may be due to disuse atrophy or axillary nerve injury.
-Posture in spine

Question 38

Posterior inspection of shoulder

Answer 38

-Scars: again look for scars indicative of previous trauma or surgery.
-Trapezius muscle asymmetry: suggestive of muscle wasting secondary to disuse atrophy or a spinal accessory nerve lesion.
-Supraspinatus and infraspinatus asymmetry: suggestive of muscle wasting secondary to chronic rotator cuff tear or a suprascapular nerve lesion.
-Scoliosis: lateral curvature of the spine that may be congenital or acquired.
-Winged scapula: ask the patient to push against a wall with both hands spaced shoulder-width apart whilst you inspect the back. The protrusion of a scapula (known as scapular winging) is suggestive of ipsilateral serratus anterior muscle weakness, typically secondary to a long thoracic nerve injury.

Question 39

Shoulder joint palpation

Answer 39

-Sternoclavicular joint: the joint between the sternum and the clavicle.
-Clavicle: extends between the sternum and the acromion of the scapula.
-Acromioclavicular joint: the joint between the acromion and the clavicle.
-Acromion: a continuation of the scapular spine and the most superolateral bony prominence of the shoulder.
-Coracoid process of the scapula: a small hook-like bony prominence located 2cm inferior and medial to the clavicular tip.
-Head of the humerus: located 1cm inferolateral to the coracoid process.
-Greater tubercle of the humerus: located slightly anterolateral to the head of the humerus.
-The spine of the scapula: easily palpable on the posterior aspect of the scapula, running from the acromion towards the thoracic vertebrae.

Question 40

Compound movements (screening) for shoulder

Answer 40

-Compound movements are often used as a rapid screening tool for shoulder joint pathology as they test a number of the rotator cuff muscles in one go. If the patient experiences pain or is unable to perform these movements you would then proceed to perform a more detailed examination of the shoulder joint including the further movements explained below.

-External rotation and abduction of the shoulder joint: Ask the patient to put their hands behind their head and point their elbows out to the side.

-Internal rotation and adduction of the shoulder joint: Ask the patient to place each hand behind their back and reach as far up their spine as they are able to.

Question 41

Active shoulder movements

Answer 41

-Neck movements

-Active shoulder flexion
=150°- 180°
=Ask the patient to raise their arms forwards until they’re pointing up towards the ceiling.

-Active shoulder extension
=40°
=Ask the patient to stretch out their arms behind them.

-Active shoulder ABduction
=180°
=Ask the patient to raise their arms out to the sides in an arc-like motion until their hands touch above their head.

Active shoulder ADduction
=30°- 40°
=Ask the patient to keep their arms straight and move them across the front of their body to the opposite side.

Active external rotation
=80° – 90° (40)
=Ask the patient to keep their elbows by their sides flexed at 90° whilst they move their forearms outwards in an arc-like motion.

Active internal rotation
=80° – 90° (90)
= Ask the patient to keep their elbows by their sides flexed at 90° whilst they move their forearms inwards across their body.

Scapular movement
=Ask the patient to abduct their shoulder, whilst you simultaneously palpate the inferior pole of the scapula. Assess the degree and smoothness of scapular movement.
=On average 50-70% of the scapula’s initial movement occurs at the glenohumeral joint.

If the glenohumeral joint’s movement is reduced due to injury or inflammation then the majority of abduction will occur via increased scapular movement over the chest wall.

Question 42

Special shoulder tests

Answer 42

-Supraspinatus assessment (empty can test/Jobe’s test)
This clinical test assesses the function of the supraspinatus muscle.
1. Abduct the patient’s arm to 90° and then angle the arm forwards by approximately 30° so that the shoulder is in the plane of the scapula.
2. Internally rotate the arm so that the thumb points down towards the floor.
3. Now push down on the arm whilst the patient resists.
=Assesses for weakness and/or impingement of supraspinatus. Weakness may represent a tear in the supraspinatus tendon or pain due to impingement.

-The painful arc (impingement syndrome)
=This clinical test assesses for impingement of supraspinatus.
1. Passively abduct the patient’s arm to its maximum point of abduction.
2. Ask the patient to lower their arm slowly back to a neutral position.
=Impingement or supraspinatus tendonitis typically causes pain between 60-120° of abduction, however, this test is not specific as many other conditions can cause pain in this arc of motion and therefore it should not be used in isolation for diagnosis.

-External rotation against resistance
=This clinical test assesses the function of the infraspinatus muscle and teres minor.
1. Position the patient’s arm with the elbow flexed at 90°and in slight abduction (the abduction tests whether the patient can keep the arm externally rotated against gravity).
2. Passively externally rotate the arm to its maximum.
=Pain on resisted external rotation may suggest tendonitis (infraspinatus/teres minor).
=If the arm falls back to internal rotation or there is a loss of power it may suggest a tear in the infraspinatus or teres minor tendon, muscle wasting and/or a lower motor neurone lesion (suprascapular or axillary nerve).

-Internal rotation against resistance (Gerber’s lift-off test)
=This clinical test assesses the function of the subscapularis muscle.
1. Ask the patient to place the dorsum of their hand on their lower back.
2. Apply light resistance to the hand (pressing it towards their back).
3. Ask the patient to move their hand off their back.
=If the patient is unable to move their hand off their back this may indicate pathology of the subscapularis muscle (e.g. tendonitis/tear) or a subscapular nerve lesion.

-Scarf test
=The scarf test assesses the function of the acromioclavicular joint.
1. Passively flex the shoulder joint to 90° and ask the patient to place the hand on the side you are examining on to the contralateral shoulder.
2. Apply resistance to the elbow in the direction of the contralateral shoulder.
=If the patient experiences pain the test is considered positive and suggestive of acromioclavicular joint pathology (e.g. osteoarthritis).

Question 43

Anterior inspection of elbow

Answer 43

-Carrying angle: a small degree of cubitus valgus, formed between the axis of a radially deviated forearm and the axis of the humerus. The presence of a carrying angle of between 5-15° is normal (females typically have a more significant carrying angle than males).
-Cubitus valgus: a carrying angle of greater than 15°. Cubitus valgus is typically associated with previous elbow joint trauma or congenital deformity (e.g. Turner’s syndrome).
-Cubitus varus: a carrying angle of less than 5° which is also known as “gunstock deformity”. Cubitus varus typically develops after supracondylar fracture of the humerus.
-Scars: note the location of the scar as this may provide clues as to the patient’s previous surgical history or indicate previous joint trauma. (posterior midline for ulnar nerve)
-Bruising: suggestive of recent trauma or surgery.
-Swelling: note any evidence of asymmetry in the size of the elbow joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, dislocation, olecranon bursa).
-Abnormal bony prominence: may indicate fracture or dislocation of the elbow joint.

Question 44

Lateral inspection of elbow

Answer 44

-Scars: again look for scars indicative of previous trauma or surgery.
-Fixed flexion deformity of the arm: may be caused by previous joint trauma or muscular spasticity.
-Muscle wasting: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron lesion

Question 45

Posterior inspection of elbow

Answer 45

-Scars: again look for scars indicative of previous trauma or surgery.
-Rheumatoid nodules: subcutaneous firm lumps typically located over the elbow joint associated with rheumatoid arthritis.
-Psoriatic plaques: well-demarcated scaly plaques typically arising over the extensor surfaces such as the elbow joint. It is important to be able to recognise psoriasis in a musculoskeletal examination given the strong association between psoriasis and psoriatic arthritis.

Question 46

“Feel” elbow exam

Answer 46

-Elbow joint
=Radial head
=Radiocapitellar joint
=Lateral epicondyle of the humerus
=Olecranon
=Medial epicondyle of the humerus

-Biceps tendon
=assess for evidence of tendonitis or rupture:
1. Ask the patient to actively flex their elbow to 90º.
2. Palpate over the anterior elbow flexion crease and identify the biceps tendon which should feel taut. Note any tenderness and feel for evidence of discontinuity suggestive of rupture.
=Resisted supination of the forearm is weak in patients with a biceps tendon rupture and painful in biceps tendonitis.

Question 47

Movement in elbow exam

Answer 47

-Active elbow flexion
=0-145° (130)
=Ask the patient to bend their elbows.

-Active elbow extension
=0°
=Ask the patient to straighten out their arms as far as they are able to.

-Active pronation
=0-85° (70)
=Ask the patient to turn their forearm so that their palm is facing the ground.

-Active supination
=0-90° (70)
=Ask the patient to turn their forearm so that their palm is facing the ceiling.

Question 48

Special elbow tests

Answer 48

-Medial epicondylitis (golfer’s elbow): flexor
Active wrist flexion against resistance
1. Ask the patient to take a seat and flex their elbow to 90º.
2. Stabilise the patient’s elbow by supporting the forearm whilst firmly palpating the medial epicondyle with your fingers.
3. Hold the patient’s wrist with your other hand.
4. Ask the patient to make a fist and flex their wrist whilst you apply resistance.
=Positive test: The combination of firm palpation over the medial epicondyle and resisted flexion will likely elicit a familiar pain experienced by the patient over the medial epicondyle.

-Lateral epicondylitis (a.k.a. tennis elbow)
Active wrist extension against resistance (extensor)
1. Ask the patient to take a seat and flex their elbow to 90º.
2. Stabilise the patient’s elbow by supporting the forearm whilst firmly palpating the lateral epicondyle with your fingers.
3. Hold the patient’s wrist with your other hand.
4. Ask the patient to make a fist and extend their wrist whilst you apply resistance.
=Positive test: The combination of firm palpation over the lateral epicondyle and resisted extension will likely elicit a familiar pain experienced by the patient over the lateral epicondyle.

Function: eat to mouth, wipe bum: 30-130 degrees (functional arc)

Question 49

Dorsal aspect of hand inspection

Answer 49

-Hand posture: note any abnormalities of hand posture which may indicate underlying pathology (e.g. Dupuytren’s contracture, ulnar deviation secondary to rheumatoid arthritis).
-Scars: inspect for evidence of scars which may indicate previous surgery or trauma.
-Swelling: note any areas of swelling, by comparing the hands and the wrists.
-Skin colour: erythema of the soft tissue may indicate cellulitis or joint sepsis
-Bouchard’s nodes: occur at the proximal interphalangeal joints (PIPJ) and are associated with osteoarthritis.
-Heberden’s nodes: occur at the distal interphalangeal joints (DIPJ) and are associated with osteoarthritis.
-Swan neck deformity: occurs at the distal interphalangeal joint (DIPJ) with clinical features including DIPJ flexion with PIPJ hyperextension. Swan neck deformity is typically associated with rheumatoid arthritis.
-Z-thumb: hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the metacarpophalangeal joint (MCPJ). Z-thumb is associated with rheumatoid arthritis.
-Boutonnières deformity: PIPJ flexion with DIPJ hyperextension associated with rheumatoid arthritis.
-Skin thinning or bruising: can be associated with long-term steroid use (e.g. common in patients with active inflammatory arthritis).
-Psoriatic plaques: salmon coloured plaques with a silvery scale. Patients who have psoriasis are at significantly increased risk of developing psoriatic arthritis. ELBOW
-Muscle wasting: can occur secondary to chronic joint pathology or lower motor neuron lesions (e.g. median nerve damage secondary to carpal tunnel syndrome).
-Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
-Nail pitting and onycholysis: associated with psoriasis and psoriatic arthritis.

Question 50

Palmar aspect of hand inspection

Answer 50

-Hand posture: note any evidence of abnormal hand posture (e.g. clawed hand secondary to Dupuytren’s contracture).
-Scars: inspect for evidence of scars which may indicate previous surgery or trauma (e.g. carpal tunnel surgery).
-Swelling: note any areas of swelling, by comparing the hands and the wrists.
-Dupuytren’s contracture involves thickening of the palmar fascia, resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb.
-Thenar/hypothenar wasting: isolated wasting of the thenar eminence is suggestive of median nerve damage (e.g. carpal tunnel syndrome).
-Elbows: inspect for evidence of psoriatic plaques or rheumatoid nodules.
-Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.
-Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis.

Question 51

“Feel” palms up (hands and wrist)

Answer 51

-Temp
-Radial and ulnar pulse
=Palpate the radial and ulnar pulse to confirm adequate blood supply to the hand.
-Thenar and hypothenar eminence bulk
=Palpate the muscle bulk of the thenar and hypothenar eminences: wasting can be caused by disuse atrophy as well as lower motor neuron lesions (e.g. ulnar and median nerve).
-Palmar thickening
=Support the patient’s hand and palpate the palm to detect the typical bands of thickened palmar fascia associated with Dupuytren’s contracture.
-Median and ulnar nerve sensation
1. Assess median nerve sensation over the thenar eminence and index finger.
2. Assess ulnar nerve sensation over the hypothenar eminence and little finger.

Question 52

Palms down “feel” hand/wrist

Answer 52

-Radial nerve sensation
=Assess radial nerve sensation over the first dorsal webspace.
-Temp
-Metacarpophalangeal joint squeeze
-Bimanual joint palpation
=Bimanually palpate the joints of the hand, assessing and comparing for tenderness, irregularities and warmth:
=Metacarpophalangeal joint (MCPJ)
=Proximal interphalangeal joint (PIPJ)
=Distal interphalangeal joint (DIPJ)
=Carpometacarpal joint (CMCJ) of the thumb (squaring of the joint is associated with OA)
-Anatomical snuffbox
=Palpate the anatomical snuffbox for tenderness which is suggestive of a scaphoid fracture.
-Bimanual wrist palpation
=Palpate the wrists for evidence of joint line irregularities or tenderness.

Question 53

Elbow palpation in hand/wrist

Answer 53

Palpate the patient’s arm along the ulnar border to the elbow and note any tenderness, rheumatoid nodules or psoriatic plaques.

Question 54

Hand/wrist movement

Answer 54

-Finger extension
=“Open your fist and splay your fingers.”

-Finger flexion
=“Make a fist.”

-Wrist extension
=90º (70)
=“Put the palms of your hands together and extend your wrists fully.”

-Wrist flexion
=90º
=“Put the backs of your hands together and flex your wrists fully.”

Deviation (ulnar, radial)

Question 55

Motor assessment of hand/wrist

Answer 55

-Wrist and finger extension against resistance
=Nerve assessed: radial nerve
=Muscles assessed: extensors of the wrist and fingers
1. Ask the patient to hold their arms out in front of them with their palms facing downwards –“Hold your arms out in front of you, with your palms facing the ground.”
2. Ask the patient to extend their fingers and wrist joints, keeping their hands in this position whilst you apply resistance – “Extend your fingers out in front of you, cock your wrists back and don’t let me pull them downwards.”
Sensation first dorsal interspace

-Index finger ABduction against resistance
=Nerve assessed: ulnar nerve
=Muscles assessed: first dorsal interosseous (FDI)
1. Ask the patient to splay their fingers and stop you from pushing their fingers together – “Splay your fingers outwards and don’t let me push them together.”
2. Apply resistance to the patient’s index finger using your own index finger to assess abduction. (Little finger feel abductor digiti minimi contraction)
Sensation tip of little finger

-Thumb ABduction against resistance
=Nerve assessed: median nerve
=Muscle assessed: abductor pollicis brevis
=Ask the patient to turn their hand over so their palm is facing upwards and to position their thumb over the midline of the palm. Advise them to keep it in this position whilst you apply downward resistance with your own thumb – “Point your thumbs to the ceiling and don’t let me push them down.”
=Sensory: tip of pointer finger)

Question 56

Assessment of hand function

Answer 56

-Power grip
= “Squeeze my fingers with your hands.”

-Pincer grip
=“Squeeze my finger between your thumb and index finger.”

-Pick up a small object
=“Could you please pick up the coin off the table.”

Question 57

Special hand/wrist assessments

Answer 57

-Tinel’s test is used to identify median nerve compression and can be useful in the diagnosis of carpal tunnel syndrome.
=To perform the test, simply tap over the carpal tunnel with your finger.
=If the patient develops tingling in the thumb and radial two and a half fingers this is suggestive of median nerve compression.

-Phalen’s test
=Ask the patient to hold their wrist in maximum forced flexion (pushing the dorsal surfaces of both hands together) for 60 seconds.
=If the patient’s symptoms of carpal tunnel syndrome are reproduced then the test is positive (e.g burning, tingling or numb sensation in the thumb, index, middle and ring fingers).