MSK examinations Flashcards
(159 cards)
1
Q
what is the GALS examination used for?
A
used as a quick screening tool to detect locomotor abnormalities and functional disability
2
Q
what things should be done in introduction to the patient?
A
- introduce yourself to the patient, including your name and role
- confirm patient’s name, DOB, hosp. number, look at their wristband/compare to notes
- explain what the examination will involve
- gain consent
- wash your hands
- adequately expose the patient
- ask if they want a chaperone, have any questions, any pain
- tell them to let you know if they want them to stop
- position patient correctly
3
Q
what are the 3 screening questions for the GALS examination?
A
1: “do you have any pain or stiffness in your muscles, joints or back?”
2: “do you have any difficulty getting yourself dressed without any help?”
3: “do you have any problem going up and down stairs?”
4
Q
what should be assessed in the patient’s gait?
A
- gait cycle
- ROM
- limping
- leg length
- turning
- Trendelenburg’s gait
- waddling gait
- assess footwear
- ask if walking is painful/painless
- pelvic tilt
- stride length
- arm swing
5
Q
what is Trendelenburg’s gait? what is it caused by?
A
an abnormal gait caused by unilateral weakness of the hip abductor muscles secondary to a superior gluteal nerve lesion or L5 radiculopathy
6
Q
what is a waddling gait? what is it caused by?
A
an abnormal gait caused by bilateral weakness of the hip abductor muscles, typically associated with myopathies (e.g. muscular dystrophy)
7
Q
what are the six phases of the gait cycle?
A
- heel strike: initial contact of the heel with the floor
- foot flat: weight is transferred onto this leg
- mid-stance: the weight is aligned and balanced on this leg
- heel-off: the heel lifts off the floor as the foot rises but the toes remain in contact with the floor
- toe-off: as the foot continues to rise the toes lift off the floor
- swing: the foot swings forward and comes back into contact with the floor with a heel strike
8
Q
what should be looked for in general inspection?
A
- body habitus
- scars
- muscle wasting
- psoriasis
- aids and adaptations
- prescriptions
9
Q
what should be looked for in anterior inspection in a GALS examination?
A
- any abnormalities in joints
- posture
- scars
- joint swelling
- joint erythema
- muscle bulk
- elbow extension
- varus/valgus joint deformity
- pelvic tilt
- fixed flexion deformity of the toes
- big toe misaligment
10
Q
what is carrying angle?
A
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).
11
Q
what is cubitus valgus?
A
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).
12
Q
what is cubitus varus?
A
a carrying angle of less than 5° which is also known as “gunstock deformity”. cubitus varus typically develops after supracondylar fracture of the humerus.
13
Q
what is valgus joint deformity?
A
the bone segment distal to the joint is angled laterally. in valgus deformity of the knee, the tibia is turned outward in relation to the femur, resulting in the knees knocking together
14
Q
what is varus joint deformity?
A
the bone segment distal to the joint is angled medially. in varus deformity of the knee, the tibia is turned inward in relation to the femur, resulting in the knees being bowlegged
15
Q
what are the subtypes of fixed flexion deformity of the toes?
A
hammer-toe and mallet-toe
16
Q
what are types of big toe deformities?
A
hallux valgus (lateral angulation) or hallux varus (medial angulation)
17
Q
what is looked for in lateral inspection in a GALS examination?
A
- cervical lordosis
- thoracic kyphosis
- lumbar lordosis
- knee joint hyperextension
- foot arch
- hip and knee flexion deformity
18
Q
what is pes planus/pes cavus?
A
- pes planus = flat feet
- pes cavus = raised foot arch
19
Q
what should be looked for in posterior inspection in a GALS examination?
A
- any abnormalities
- muscle bulk
- spinal alignment
- iliac crest alignment
- popliteal swelling
- Achilles tendon thickening
- varus/valgus joint deformity
20
Q
what movements should be assessed in the arms in a GALS examination?
A
- putting hands behind head and pointing elbows out to side
- hands held out in front with palms facing down and fingers outstretched (inspect dorsum of hands)
- turning hands over with palms facing up (assess thenar and hypothenar eminences)
- making a fist
- grip strength
- precision grip
- MCP squeeze
21
Q
what does the hands behind head position assess?
A
shoulder abduction and external rotation and elbow flexion
- restricted ROM suggests shoulder or elbow pathology
- excessive ROM indicates hypermobility
22
Q
what should be looked for on the dorsum of the hands in a GALS examination?
A
- asymmetry
- joint swelling/deformity
- loss of contours
- muscle wasting
- skin and nail changes
- nodules
23
Q
what movements are assessed in the legs in a GALS examination?
A
- passive knee flexion
- passive knee extension
- passive internal rotation of the hip
- metatarsophalangeal joint squeeze
- patellar tap/bulge test
24
Q
how do you assess for knee hyperextension?
A
- hold above the ankle joint and gently lift the leg upwards
- inspect the knee joint for evidence of hyperextension, with less than 10deg being normal
- excessive hyperextension suggests pathology affecting joint ligaments or hypermobility
25
how do you perform the patellar tap test?
screens for a moderate-to-large knee joint effusion
1. with the patient's knee fully extended, empty the suprapatellar pouch by sliding your left hand down the thigh to the upper border of the patella
2. keep your left hand in position and use your right hand to press downwards on the patella with your fingertips
3. if there is fluid present you will feel a distinct tap as the patella bumps against the femur
26
how do you perform the bulge test?
identifies small joint effusions that may not be obvious in the patellar tap method
1. position the patient supine with the leg relaxed and knee extended
2. empty the suprapatellar pouch by sliding your left hand down the thigh to the upper border of the patella
3. stroke the medial side of the knee joint to move any excess fluid across to the lateral side of the joint
4. now stroke the lateral side of the knee joint which will cause any excess fluid to move back across to the emptied medial side of the knee joint. this causes the appearance of a bulge or ripple on the medial side of the joint indicating the presence of effusion
27
what movements should be assessed in the spine in a GALS examination?
1. cervical lateral flexion
| 2. lumbar flexion
28
how do you assess lumbar flexion?
1. place 2 of your fingers on the lumbar vertebrae 5-10cm apart
2. ask the patient to bend forwards and touch their toes
3. observe your fingers as the patient's lumbar spine flexes (they should move apart)
4. observe your fingers as the patient extends their spine to return to a standing position (your fingers should move back together)
5. if patient can place their hands flat on the floor it may suggest hypermobility
29
what are other tests you should do in a GALS examination?
1. temporomandibular joint
| 2. assess feet for swelling, deformity, callosities
30
how do you assess TMJ function?
1. ask patient to open their mouth wide and put 3 of their fingers into their mouth (demonstrate)
2. this assess ROM and screens for deviation of jaw movement
3. restricted opening may be due to disease
31
what further assessments and investigations should be assessed after a GALS examination?
1. a focused examination of joints with suspected pathology
| 2. further imaging if indicated (e.g. Xray and MRI)
32
how can you explain a hand and wrist examination to the patient?
"today I've been asked to examine the bones of your hands and wrists. this will involve me first looking at your hands then feeling the joints and finally, asking you to do some movements. is this OK? do you have any questions/pain?"
33
what should be looked for in a nail inspection in a hand and wrist examination?
- pitting and/or nail ridges
- onycholysis
- onychogryphosis
- signs of disease elsewhere: splinter haemorrhages, nail fold infarcts, clubbing
34
what is onycholysis? what can cause it?
- separation of the nail from the nailbed
| - psoriasis, fungal infection, hyperthyroidism
35
what is onychogryphosis? what can cause it?
- hypertrophic nails that resemble horns or claws
| - may be post-traumatic or due to PVD
36
what should be looked for in inspection of the dorsal hand in a hand and wrist examination?
- hand posture
- scars
- swelling
- skin colour
- Bouchard's/Herbeden's nodes
- swan neck deformity
- Z thumb
- Boutonniere's deformity
- squaring of the hand at the 1st CMCJ
- windswept deformity
- clawing
- skin thinning or bruising
- psoriatic plaques
- muscle wasting
- splinter haemorrhages
- nail splitting and onycholysis
37
what is swan-neck deformity?
occurs at the distal interphalangeal joint (DIPJ) with clinical features including DIPJ flexion with PIPJ hyperextension. typically associated with rheumatoid arthritis
38
what is 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.
39
what is Boutonniere's deformity?
PIPJ flexion with DIPJ hyperextension associated with rheumatoid arthritis.
40
where do Bouchard's and Herbeden's nodes occur?
- Bouchard's occur at the PIPJ, associated with OA
| - Herbeden's occurs at the DIPJ, associated with OA
41
what are splinter haemorrhages? what are they caused by?
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
42
what is looked for in palmar hand inspection in a hand and wrist examination?
- hand posture
- scars
- skin
- swelling
- thenar and hypothenar muscle wasting
- Dupuytren's contracture
- elbows (inspect for psoriatic plaques or rheumatoid nodules)
43
what is Dupuytren's contracture?
thickening of the palmar fascia, resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb
44
what should be palpated in a hand and wrist examination?
1. assess and compare temp of wrists and small joints of hands using back of your hands
2. palpate radial and ulnar pulse
3. thenar and hypothenar muscle bulk
4. evidence of palmar thickening
5. median, ulnar and radial nerve sensaiton
6. MCP joint squeeze
7. bimanual palpation of MCPJ, PIPJ, DIPJ, CMCJ
8. bimanual wrist joint palpation
9. ulnar border of forearm and elbow joint
10. anatomical snuffbox
45
what hand joints should be palpated in a hand and wrist examination?
MCPJ, PIPJ, DIPJ, CMCJ
46
how is median nerve sensation/function assessed?
over thenar eminence and index finger
| - thumb abduction against resistance
47
how is ulnar nerve sensation assessed?
over hypothenar eminence and little finger
| - index finger abduction against resistance
48
how is radial nerve sensation assessed?
over first dorsal webspace
| - wrist and finger extension against resistance
49
what movements should be assessed in a hand and wrist examination?
1. active finger extension
2. active finger flexion
3. active wrist extension
4. active wrist flexion
5. wrist/finger extension against resistance (radial nerve)
6. index finger abduction against resistance (ulnar nerve)
7. thumb abduction against resistance (median nerve)
8. thumb flexion, extension, palmar abduction, adduction and opposition
9. radial and ulnar deviation
10. repeat above passively
50
how is function assessed in a hand and wrist examination?
1. power grip
2. pincer grip
3. pick up a small object
4. precision (undo/do up buttons)
51
what special tests should be performed in a hand and wrist examination?
1. Tinel's test
| 2. Phalen's test
52
how is Tinel's test done?
used to identify median nerve compression and can be useful in diagnosing carpal tunnel syndrome
1. tap over the carpal tunnel with your finger
2. if the patient develops tingling in the thumb and radial 2.5 fingers this suggests median nerve compression
53
how is Phalen's test done?
1. ask patient to hold their wrist in maximum forced flexion (pushing dorsal surfaces of both hands together) for 60 seconds
2. if patient's symptoms of carpal tunnel syndrome are reproduced then the test is positive
54
what further assessments and investigations should be suggested after a hand and wrist examination?
1. neurovascular examination of the upper limbs
2. examination of the elbow joint and shoulder joint
3. further imaging if indicated (e.g. Xray and MRI)
55
what should be looked for in anterior/lateral inspection in a shoulder examination?
- scars
- posture
- skin changes
- bruising
- asymmetry of the shoulder girdle
- swelling
- abnormal bony prominence
- deltoid wasting
56
what should be looked for in posterior inspection in a shoulder examination?
- scars/skin changes
- trapezius muscle asymmetry
- supraspinatus and infraspinatus asymmetry
- rhomboid muscle bulk
- scoliosis
- winged scapula
- paravertebral muscle wasting
57
what should be palpated in a shoulder examination?
1. assess and compare shoulder joint temp
2. shoulder joint components
3. muscle bulk
58
what parts of the shoulder joint should be palpated in a shoulder examination?
note any swelling, bony irregularities, crepitus, increased temp and tenderness
1. sternoclavicular joint
2. clavicle
3. acromioclavicular joint
4. acromion
5. glenohumeral joint
6. scapula
7. coracoid process of the scapula
8. head of the humerus
9. greater tubercle of the humerus
10. spine of the scapula
59
what muscles should the muscle bulk be palpated in a shoulder examination?
1. deltoid
2. supraspinatus
3. infraspinatus
4. trapezius
60
what is the screening examination in a shoulder examination?
1. ask patient to put their hands behind their head and push their elbows as back as they can (external rotation and abduction)
2. ask patient to put their hands behind their back (internal rotation and adduction)
3. look for any difficulty, limitation or pain on movement
4. describe how far they can reach up their back
61
what movements should be assessed in a shoulder examination?
1. active shoulder flexion
2. active shoulder extension
3. active shoulder abduction
4. active shoulder adduction
5. active external rotation
6. active internal rotation
7. scapular movement (assess degree and smoothness of movement)
8. repeat above movement passively
62
how is function assessed in a shoulder examination?
ask patient if they can dress themselves without difficulty and can wash their own hair
63
what special tests are done in a shoulder examination?
1. supraspinatus assessment (empty can/Jobe's test)
2. painful arc (impingement syndrome)
3. external rotation against resistance
4. external rotation in abduction
5. internal rotation against resistance (Gerber's lift-off test)
6. scarf test
64
how is the empty can test performed? what does it assess?
assesses for weakness and impingement of the supraspinatus muscle
1. abduct the patient's arm to 90deg and angle the arm forwards by 30deg so the shoulder is in plane of the scapula
2. internally rotate the arm so the thumb points down towards the floor
3. push down on the arm while the patient resists
65
how is the painful arc test performed? what does it assess?
assesses for impingement of the supraspinatus muscle
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
3. impingement/supraspinatus tendonitis typically causes pain between 60-120deg of abduction
- not a specific test as other conditions can cause pain in this arc of motion
66
how is the external rotation (of shoulder) against resistance test performed? what does it assess?
assesses for tendonitis or tear of infraspinatus and teres minor
1. position the patient's arm with elbow flexed at 90deg and in slight abduction (tests if they can keep arm externally rotated against gravity)
2. passively externally rotate the arm to its maximum degree
3. pain on resisted external rotation may suggest infraspinatus tendonitis
4. if the arm falls back to internal rotation or there's a loss of power it may suggest a tear, muscle wasting or a LMN lesion (suprascapular or axillary nerve)
67
how is the external rotation (of shoulder) in abduction test performed? what does it assess?
assesses the function of the teres minor muscle
1. perform the arm in 90deg of abduction and bend the elbow to 90deg
2. passively externally rotate the shoulder to its maximum degree
3. inability to keep the arm in this position is known as Hornblower's sign and can be caused by teres minor pathology or an axillary nerve lesion
68
what is Hornblower's sign?
an inability to keep the arm in external rotation in abduction (arm in 90deg of abduction and elbow bent to 90deg), i.e. arm falls back to internal rotation
- can be caused by teres minor pathology or axillary nerve lesion
69
how is Gerber's lift off test performed? what does it assess?
assesses for tendonitis or tear of the subscapularis muscle
1. ask patient to place the dorsum of their hand on their lower back
2. apply light resistance to the hand (press towards back)
3. ask patient to move their hand off their back
4. if they can't move their hand off their back this may suggest pathology or nerve lesion
70
how is the scarf test performed? what does it assess?
assesses function of the acromioclavicular joint
1. passively flex the shoulder joint to 90deg and ask the patient to place the hand on the side you're examining onto the contralateral shoulder
2. apply resistance to the elbow in the direction of the contralateral shoulder
3. if patient experiences pain, this is a positive test and suggestive of acromioclavicular joint pathology
71
what further assessments and investigations should be suggested after a shoulder examination?
1. neurovascular examination of the upper limbs
2. examination of joints above and below (cervical spine and elbow)
3. further imaging e.g. Xray or MRI
72
what should be looked for in anterior/lateral/posterior inspection in an elbow examination?
- carrying angle
- fixed flexion deformity
- cubitus valgus/varus
- scars
- bruising
- rashes
- psoriatic plaques
- rheumatoid nodules and muscle wasting
- swelling
- abnormal bony prominence
- erythema
73
what should be palpated in an elbow examination?
1. assess and compare temp
2. elbow joint palpation
3. biceps tendon palpation
74
what components of the elbow joint should be palpated?
note any swelling, bony irregularity or tenderness
1. radial head
2. radiocapitellar joint
3. lateral and medial epicondyle of the humerus
4. olecranon
75
how should the biceps tendon be palpated in an elbow examination?
1. ask patient to actively flex their elbow to 90deg
2. palpate over the anterior elbow flexion crease and identify biceps tendon, which should feel taut
3. note any tenderness and feel for evidence of discontinuity, suggestive of rupture
4. resisted supination of the forearm is weak in patients with tendon rupture and is painful in biceps tendonitis
76
what movements should be assessed in an elbow examination?
1. active elbow flexion
2. active elbow extension
3. active pronation
4. active pronation
5. active supination
6. repeat above movements passively, feeling for crepitus/discomfort
77
how is function assessed in an elbow examination?
can patient move their hand to their mouth or nose (check both sides)
78
what special tests are performed in an elbow examination?
1. active wrist flexion against resistance (medial epicondylitis)
2. active wrist extension (lateral epicondylitis)
79
what is medial epicondylitis?
- golfer's elbow
| - involves inflammation of the flexor tendons at their insertion point secondary to overload injury
80
what is lateral epicondylitis?
- tennis elbow
| - involves inflammation of the extensor tendons at their insertion point secondary to overload injury
81
how is the active wrist flexion against resistance test performed? what does it assess for?
assesses for medial epicondylitis (golfer's elbow)
1. ask patient to sit and flex their elbow to 90deg in the supinated position
2. stabilise their 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
5. positive test = familiar pain over the medial epicondyle
82
what is a positive result of the active wrist flexion against resistance test?
combination of firm palpation over the medial epicondyle and resisted flexion will likely elicit a familiar pain experienced over the medial epicondyle
83
how is the active wrist extension against resistance test performed? what does it assess for?
assesses for lateral epicondylitis (tennis elbow)
1. ask patient to sit and flex their elbow to 90deg in pronated position
2. stabilise their elbow by supporting their forearm whilst firmly palpating the lateral epicondyle with your fingers
3. hold their wrist with your other hand
4. ask patient to make a fist and extend their wrist while you apply resistance
5. positive test = familiar pain over lateral epicondyle
84
what is a positive result for the active wrist extension against resistance test?
the combination of firm palpation over the lateral epicondyle (origin of extensor muscles) and resisted extension will likely elicit a familiar pain experience over the lateral epicondyle
85
what further assessments and investigations should be suggested after an elbow examination?
1. examination of joint above (shoulder) and below (wrist)
2. full neurovascular examination of the upper limbs
3. further imaging e.g. Xray and MRI
86
what should be looked for in closer inspection in a foot and ankle examination?
- scars
- bruising
- swelling
- erythema
- symmetry
- bunions/calluses
- muscle wasting
- psoriasis plaques
- fixed flexion deformity
- big toe misalignment
- heel misalignment
- varus/valgus ankle deformities
- pes planus/cavus
- Achilles tendon
87
what should be palpated in a foot and ankle examinaiton?
1. temperature
2. posterior tibial pulse
3. dorsalis pedis pulse
4. metatarsophalangeal joint squeeze
5. ankle and foot joint components
6. Achilles tendon
88
where is the posterior tibial pulse located?
posterior to the medial malleolus of the tibia
89
where is the dorsalis pedis pulse located?
over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the second and third cuneiform bones
90
what parts of the ankle and foot joints should be palpated?
1. metatarsal and tarsal bones
2. tarsal joint
3. ankle joint
4. subtalar joint
5. calcaneum
6. medial/lateral malleoli
7. distal fibula
8. shafts of the tibia/fibula
91
how should the Achilles tendon be palpated in an ankle and foot examination?
1. palpate the gastrocnemius muscle and the Achilles tendon
2. note any focal tenderness or swelling suggestive of tendonitis
3. note any discontinuity in the tendon suggestive of rupture
4. note any thickening
92
what movements should be assessed in an ankle and foot examination?
1. foot plantarflexion
2. foot dorsiflexion
3. toe flexion
4. toe extension
5. ankle/foot inversion
6. ankle/foot eversion
7. passive ankle dorsiflexion and plantarflexion
8. passive subtalar/midtarsal inversion and eversion
9. passive dorsiflexion/plantarflexion of the big toe
93
what special tests should be performed in an ankle and foot examination?
1. Simmonds' test
94
how is Simmonds' test performed? what does it assess for?
assesses for clinical evidence of Achilles tendon rupture
1. ask patient to kneel on a chair with their feet hanging over the edge
2. squeeze each of their calves in turn
3. in healthy people, the foot should plantarflex due to the contraction of the gastrocnemius and subsequent pulling force transmitted via the Achilles tendon
4. 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
95
what test is used to assess for Achilles tendon rupture?
Simmond's
96
what further assessments and investigations should be suggested after an ankle and foot examination?
1. neurovascular examination of both lower limbs
2. examination of the hip and knee joints
3. further imaging e.g. Xray and MRI
97
what should be looked for in an anterior inspection in a knee examination?
- scars
- bruising
- swelling
- psoriasis plaques
- genu recurvatum
- patellar position
- varus/valgus deformity
- quadriceps wasting
- foot deformity
- flexion deformity
- stance
98
what is genu recurvatum?
knee hyperextension
99
what should be looked for in a lateral inspection in a knee examination?
- extension abnormalities
- flexion abnormalities
- foot arches
- toes deformities
100
what should be looked for in a posterior inspection in a knee examination?
- scars
- muscle wasting
- popliteal swelling
- iliac crest alignment
- gluteal muscle bulk
- hindfoot abnormalities
101
what should be looked for in an inspection of the patient with the headrest at 45deg in a knee examination?
- abnormalities of knee joints
- scars
- symmetry
- varus/valgus deformity
- rashes
- swelling
- bruising
- quadriceps wasting
- fixed flexion deformity
- abnormal patellar position
102
what should be palpated in a knee examination?
1. temperature
2. measurement of quadriceps bulk
3. palpation of the extended knee
4. assess for joint effusion
5. palpation of flexed knee
103
how is quadriceps bulk assessed?
place a measuring tape around each leg at a point approx. 20cm above the tibial tuberosity
104
what is palpated on the extended knee in a knee examination?
1. patella
| 2. medial and lateral joint lines
105
how is the patella palpated in a knee examination?
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
2. palpate the patellar ligament for tenderness suggestive of tendonitis or rupture
106
how are the medial and lateral joint lines palpated in a knee examination?
1. palpate the medial and lateral joint lines of the knee including the collateral ligaments for evidence of tenderness suggestive of fracture, meniscal injury, collateral ligament injury
2. palpate the quadriceps tendon for tenderness suggestive of tendonitis or rupture
107
how is the patellar apprehension test performed?
1. the patient's knee is fully extended
2. apply lateral pressure to the patella whilst simultaneously slowly flexing the knee joint
3. presence of active resistance from the patient is suggestive of previous patellar instability and dislocation
108
what can a joint effusion be caused by?
ligament rupture, septic arthritis, inflammatory arthritis, osteoarthritis
109
how can you assess for joint effusion in a knee examination?
1. patellar tap
| 2. sweep test
110
what is palpated in the flexed knee in a knee examination?
1. patella
2. medial and lateral joint lines
3. tibial tuberosity and head of the fibula
4. popliteal fossa
111
how is the popliteal fossa palpated in a knee examination?
1. with thumbs placed on the tibial tuberosity, curl your fingers into the popliteal fossa and palpate for evidence of a swelling which may indicate a popliteal cyst
2. a pulsatile mass may represent a popliteal anerysm
112
how does a politeal cyst present?
typically presents as a fluctuant swelling in the popliteal fossa. the swelling will feel tense when the patient’s knee is extended and soft when the knee is flexed (known as Foucher’s sign). the cyst may also transilluminate with a pen torch.
113
when should popliteal aneurysms be considered?
are rare, but if the popliteal pulse is visible and superficially palpable this should be considered. typically the popliteal pulse is only palpable on deep palpation of the popliteal fossa.
114
what movements should be assessed in a knee examination?
1. active knee flexion
2. active knee extension
3. passive knee flexion
4. passive knee extension
115
what special tests should be performed in a knee examination?
1. posterior sag sign
2. anterior drawer test
3. posterior drawer test
4. Lachman's test
5. varus stress test
6. valgus stress test
7. McMurray's test for medial and lateral menisci
116
how is the posterior sag sign test performed? what does it assess for?
the PCL is responsible for preventing backward displacement of the tibia or forward sliding of the femur.
if the PCL is ruptured the tibia can sag posteriorly in relation to the femur (sign)
1. ask relaxed patient to flex knee to 90deg with foot placed flat on bed
2. inspect the lateral aspect of the knee joint for evidence of posterior sag
3. this sign must be identified before doing the anterior drawer test, as a PCL tear can result in a false positive anterior drawer sign
117
why can a PCL tear result in a false positive anterior drawer sign?
- this is because an anterior movement of the tibia will occur during the anterior drawer test due to the tibia moving from a posteriorly subluxed position back to its neutral position.
- this relocation of the tibia to its neutral position may then be misinterpreted as excessive anterior movement secondary to anterior cruciate ligament laxity or rupture.
118
how is the anterior drawer test performed? what does it assess for?
assesses the integrity of the anterior cruciate ligament
1. position the patient supine on the clinical examination couch with their knee flexed to 90deg
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 cruciated ligaments, there should be little or no movement noted
7. significant movement may suggest anterior cruciate ligament laxity or rupture
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how is the posterior drawer test performed? what does it assess?
assesses the integrity of the posterior cruciate ligament
1. position the patient supine on the clinical examination couch with their knee flexed to 90deg
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. push the tibia posteriorly and feel for any posterior movement of the tibia on the femur. with healthy cruciate ligaments, there should be little/no movement
7. significant posterior movement may suggest posterior cruciate ligament laxity or rupture
120
how is Lachman's test performed? what does it assess?
alternative to the anterior drawer test; assesses for laxity or rupture of the anterior cruciate ligament
1. flex patient's knee to 30deg
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
5. significant anterior movement of the tibia on the femur suggests ACL laxity or rupture
121
how is the varus stress test performed? what does it assess?
assesses the lateral collateral ligament
1. these instructions are for the right knee; use opposite hands for the left knee
2. extend the patient's knee fully so it's straight
3. hold patient's ankle between your right elbow and side
4. position your right palm over the medial aspect of the knee
5. 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
6. push steadily outward with your right palm whilst pushing inwards with the left palm
7. whilst performing this manoeuvre, palpate the lateral knee joint line with fingers of your left hand
8. there should be no ab/adduction possible
9. if there's LCL laxity or rupture your fingers should feel a palpable gap caused by the lateral aspect of the joint opening up secondary to the varus force being applied
122
how is the valgus stress test performed? what does it assess?
assesses the medial collateral ligament
1. these instructions are for the right knee; use opposite hands for the left knee
2. extend the patient's knee fully so it's straight
3. hold patient's ankle between your right elbow and side
4. position your left palm over the lateral aspect of the knee
5. 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
6. push steadily inward with your left hand whilst pushing outwards with the right hand
7. whilst performing this manoeuvre, palpate the medial knee joint line with fingers of your left hand
8. there should be no ab/adduction possible
9. if there's MCL laxity or rupture your fingers should feel a palpable gap caused by the lateral aspect of the joint opening up secondary to the varus force being applied
123
how can the collateral ligaments be further assessed?
if the knee appears stable after tests, you can repeat the varus/valgus stress tests with the knee flexed at 30deg - at this position, the cruciate ligament is not taught so minor collateral ligament laxity can be more easily detected
124
how is the McMurrays test performed on the medial meniscus? what does it assess?
assesses integrity of the medial meniscus
1. instructions are for the right knee; use opposite hands for the left
2. with patient supine on the couch, passively flex the knee being assessed as far as possible
3. 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
4. hold patient's right foot by sole using your right hand
5. create varus 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
6. a click and discomfort is suggestive of a medial meniscal tear
125
how is the McMurray's test performed on the lateral meniscus? what does it assess?
assesses integrity of the lateral meniscus
1. instructions are for the right knee; use opposite hands for the left
2. with patient supine on the couch, passively flex the knee being assessed as far as possible
3. 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
4. hold patient's right foot by sole using your right hand
5. create valgus 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
6. a click and discomfort is suggestive of a lateral meniscal tear
126
what further assessments and investigations should be suggested after a knee examination?
1. neurovascular examination of both lower limbs
2. examination of the joints above and below (e.g. ankle and hip)
3. further imaging e.g. Xray and MRI
127
what should be looked for in anterior inspection in a hip examination?
- scars
- bruising
- swelling
- quadriceps wasting
- leg length discrepancy
- pelvic tilt
- joint deformities
128
what should be looked for in lateral inspection in a hip examination?
- flexion abnormalities
- lumbar lordosis
- foot arches
129
what should be looked for in posterior inspection in a hip examination?
- scars
- muscle wasting
- iliac crest alignment
- scoliosis
130
what is Trendelenburg's sign?
- sagging of the pelvis secondary to hip abductor weakness
- 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
- the pelvis falls on the contralateral side to the weakness
131
what can unilateral hip abductor weakness be caused by?
superior gluteal nerve lesion or L5 radiculopathy
132
what is inspected when the patient is on the bed in a hip examination?
- scars in groin, anterior and lateral thighs
- swelling
- bruising
- quadriceps wasting
- hip joint asymmetry
- fixed flexion deformity
133
what should be palpated in a hip examination?
1. temperature in hip joint, upper thigh and greater trochanter
2. greater trochanter
3. assess apparent and true leg length
134
how is apparent leg length assessed?
measure and compare the distance between the umbilicus/xiphisternum and the tip of the medial malleolus of each limb
135
how is true leg length assessed?
measure from the ASIS to the tip of the medial malleolus of each limb
136
what should you do if there is a true leg length discrepancy?
1. assess whether this originated in the tibia or femur
2. position the patient with their knees bent up to a right angle and their heels flat on the bed
3. inspect from the side
4. place your hand across both tibial tuberosities; if there is femoral shortening, your hand will dip down towards the shortened side
5. place your hand across both suprapatellar regions; if there is tibial shortening, your hand will dip down towards the shortened side
137
what movements should be assessed in a hip examination?
1. active hip flexion
2. active hip extension
3. active abduction
4. active hip adduction
5. passive hip flexion
6. passive hip internal rotation
7. passive hip external rotation
8. passive hip abduction
9. passive hip adduction
10. passive hip extension
138
what special tests should be performed in a hip examination?
1. Thomas's test
| 2. Trendelenburg's test
139
how is Thomas's test performed? what does it assess?
used to assess for a fixed flexion deformity of the contralateral hip by flexing the ipsilateral hip fully
1. with the patient positioned flat on the bed, place a hand below their lumbar spine with your palm facing upwards (helps to prevent the patient from masking a fixed flexion deformity by increasing lumbar lordosis)
2. passively flex the hip of the unaffected leg as far as you can and observe the contralateral limb
3. your hand should detect that the lumbar lordosis is now flattened
4. with the unaffected leg flexed the contralateral leg should be flat on the bed
5. positive test = affected thigh raises off the bed, indicating a loss of hip joint extension; suggests a fixed flexion deformity
140
what is a positive result of Thomas's test?
positive test = affected thigh raises off the bed, indicating a loss of hip joint extension; suggests a fixed flexion deformity
141
when should Thomas's test not be performed?
on patients with a hip replacement
142
how is Trendelenburg's test performed? what does it assess?
screens for hip abductor weakness (gluteus medius and minimus)
1. with patient upright, stand in front of them and ask them to place their hands on your forearms/shoulders for stability
2. position your fingers on each side of their pelvis at the iliac crest
3. ask patient to stand on one leg and observe your fingers for evidence of lateral pelvic tilt
4. repeat on other leg
5. if patient's hip abductors are functioning normally the pelvis should remain stable or rise slightly on side of raised leg
6. if pelvis drops on side of raised leg it suggests contralateral hip abductor weakness (Trendelenburg's sign)
143
what further assessments and investigations should be suggested after a hip examination?
1. neurovascular examination of both lower limbs
2. examination of the joints above and below (lumbar spine and knee joint)
3. further imaging e.g. Xrays and MRI
144
what should be looked for in an anterior inspection in a spine examination?
- scars
- skin (cafe-au-lait spots, sacral dimple, naevus or hairy patch in spina bifida occulta, scarring from surgery)
- head and neck posture
- asymmetry of the shoulder girdle
- pelvic tilt
145
what should be looked for in a lateral inspection in a spine examination?
- cervical lordosis
- thoracic kyphosis
- lumbar lordosis
146
what should be looked for in a posterior inspection in a spine examination?
- spinal alignment
- iliac crest alignment
- cervical spine deformity
- kyphosis or scoliosis
muscle wasting
- abnormal hair growth
- bruising
- scars
147
what should be palpated in a spine examination?
1. spinal processes and sacroiliac joints
2. paraspinal muscles
3. supraclavicular fossae
4. thoracolumbar spine and sacrum
5. cervical spine and neck posteriorly in the midline, laterally and anteriorly
148
what movements should be assessed in a spine examinaiton?
1. flexion of cervical spine
2. extension of the cervical spine
3. lateral flexion of the cervical spine
4. rotation of the cervical spine
5. flexion of the lumbar spine
6. extension of the lumbar spine
7. lateral flexion of the lumbar spine
8. rotation of the thoracic spine
9. extension of the thoracic spine
149
what special tests are performed in a spine examination?
1. Schober's test
2. sciatic stretch test
3. straight leg raise
4. Bowstring test
5. femoral nerve stretch test
6. suspected ankylosing spondylitis
150
how is Schober's test performed? what does it assess?
used to identify restricted flexion of the lumbar spine, which may occur in ankylosing spondylitis
1. identify location of PSIS on each side
2. mark the skin in the midline 5cm below the PSIS and 10cm above
3. ask patient to touch their toes to assess lumbar flexion
4. measure distance between 2 lines
5. if patient has normal lumbar flexion, the distance between the two marks should increase from the original 15cm to more than 20cm
6. reduced ROM is associated with ankylosing spondylitis and other conditions
151
how is the sciatic stretch test performed? what does it assess?
used to identify sciatic nerve irritation
1. position patient supine on the examination couch
2. hold their ankle, raise their leg by passively flexing the hip while keeping the patient's knee fully extended
3. normal ROM for passive hip flexion is 80-90deg
4. once patient's hip is flexed, dorsiflex the patient's foot
5. positive = patient experiences pain in posterior thigh or buttock region; suggestive of sciatic nerve irritation
152
what is a positive result for the sciatic stretch test?
patient experiences pain in posterior thigh or buttock region; suggestive of sciatic nerve irritation
153
how is the straight leg raise test performed? what does it assess?
used to identify suspected prolapsed intervertebral disc
1. ask patient to lie flat on the couch
2. passively flex their thigh with their leg extended
3. positive = complains of back or leg pain
4. paraesthesiae or pain in a nerve root distribution indicates nerve root irritation
5. back pain suggests a central disc prolapse and leg pain suggests a lateral protrusion
6. lower the leg gradually until the pain disappears then dorsiflex the foot; this increases tension on the nerve roots, activating any pain or paraesthesiae (Lasegue's sign)
154
what is Lasegue's sign?
Lasègue's sign is said to be positive if the angle to which the leg can be raised (upon straight leg raising) before eliciting pain is <45deg
155
how is the Bowstring test performed? what does it assess?
used to identify suspected prolapsed intervertebral disc
1. perform straight leg raise
2. if the patient experiences pain, flex the knee slightly then apply firm pressure with the thumb in the popliteal fossa to stretch the tibial nerve
3. radiating pain and paraesthesiae suggest nerve root irritation
156
how is the femoral nerve stretch test performed? what does it assess?
used to identify femoral nerve irritation
1. position the patient prone on the examination couch
2. flex the patient's knee to 90deg and extend the hip joint
3. plantarflex the patient's foot
4. positive = patient experiences pain in the anterior thigh and/or inguinal region
157
what is a positive result for the femoral nerve stretch test?
patient experiences pain in the anterior thigh and/or inguinal region
158
how is suspected ankylosing spondylitis assessed in a spine examination?
assess chest expansion at the 4th intercostal space (normal 3-5cm); this may be reduced in ankylosing spondylitis
159
what further assessments and investigations should be suggested after a spine examination?
1. neurovascular examination of upper and lower limbs
2. examination of the hip and shoulder joints
3. further imaging e.g. Xray and MRI
4. abdominal examination in patient with lower back pain
5. examine peripheral pulses
6. examine shoulder joints/hip joints in patients with neck/lower back pain
