Musculoskeletal Reference Guide PDF

Musculoskeletal REFERENCE GUIDE Taking a history from a patient with a possible musculoskeletal complaint....................... 2 Common Conditions that affect the Joints Muscles & Bones.........................................

Musculoskeletal REFERENCE GUIDE Taking a history from a patient with a possible musculoskeletal complaint....................... 2 Common Conditions that affect the Joints Muscles & Bones............................................11 Specific considerations in a musculoskeletal presentation...............................................13 The Musculoskeletal Examination...................................................................................14 Terminology in the musculoskeletal examination................................................................... 16 General principles of the musculoskeletal examination........................................................... 19 Examination of a Lump........................................................................................................... 26 Examination of the gait.......................................................................................................... 28 Examination of the spine........................................................................................................ 30 Examination of the shoulders................................................................................................. 37 Examination of the knees....................................................................................................... 40 Musculoskeletal Symptoms............................................................................................47 1  Taking a history from a patient with a possible musculoskeletal complaint There is a wide range of complaints that will prompt a patient to seek medical help. When a patient initially presents it may not be obvious what system(s) the complaint(s) relate to. You will need to use your medical knowledge to fully explore the following aspects when you take the history: A detailed history of the presenting complaint o biomedical perspective ▪ ensuring you get a clear sequence of events ▪ thoroughly analysing the presenting complaint(s) ▪ asking about and analysing relevant associated symptoms ▪ asking about and exploring relevant features of the presentation o patient’s perspective ▪ genuinely considering the patient’s views on the presenting complaint(s) including: - their ideas about the presenting complaint(s) - their concerns regarding the presenting complaint(s) - their expectations of the consultation - the impact of the presenting complaint(s) on their life ▪ allow the patient to express their feelings about anything they tell you Background information o These parts of the history are explored, and relevant details gathered: ▪ Past medical and surgical history ▪ Medications ▪ Allergies ▪ Family history ▪ Personal and social history We will use this template to consider what is relevant when a patient presents with a possible musculoskeletal complaint. 2 History of Presenting Complaint Biomedical perspective Sequence of events Gaining a full understanding of the sequence of events in a musculoskeletal presentation will help you focus on the conditions that are most likely to be causing the patient’s complaint(s). If the patient had a fall yesterday and their knee has been sore since they are likely to have an acute injury affecting the knee. If the patient had knee surgery 30 years ago following a fall and they have had a sore knee for the past 2 months they are likely to have a chronic, possibly degenerative, condition affecting the knee. Find out about: Time of onset o The date and time it started (if applicable) o When did it start? o When they were last completely well. (This can be very useful to ask if the onset is not well defined.) Mode of onset o How the symptoms started. Was it over seconds, minutes, hours, days, or months? The chart below lists conditions according to their onset. Precipitant o What triggered the symptoms o What brought it on? Was it related to trauma? o What was going on around the time the symptoms started? Time course o Step by step what has happened from the very start until now. If there was an injury find out the exact details of what happened. Duration o How long do/did the symptoms last? o If symptoms are intermittent find out how long each episode lasts Frequency o If symptoms are intermittent find out how often they occur Pattern o Is there a pattern? ▪ Inflammatory conditions are symptomatic for hours on waking while osteoarthritic conditions are symptomatic for fewer than 30 minutes on waking o Are the symptoms staying the same? Deteriorating? Random? o Are there exacerbations and remissions? This can occur in Rheumatoid arthritis. Recovery – If there are exacerbations and remissions what is the recovery period like? 3 The table below describes the mode of unset, time course, and aetiology of common musculoskeletal conditions. (Further details about these conditions can be found on page 11). Mode of onset Time course Aetiology Condition Acute Seconds-minutes Trauma Soft tissue damage Tendon laceration Ligament injury Fracture Dislocation Disc prolapse (ELM3) Sub-acute Hours-days Trauma Acute bursitis Inflammatory Gout Infective Septic arthritis Insidious Weeks-months Inflammatory Rheumatoid arthritis Polymyalgia rheumatica Psoriatic arthritis Temporal arteritis Trauma Chronic bursitis Carpal tunnel syndrome (ELM3) Cubital tunnel syndrome (ELM3) Degenerative Osteoarthritis 4 Symptom analysis (Biomedical perspective cont..) You will need to analyse each symptom. SOCRATES can be useful to analyse pain. WWQQAA (where, when, quality, quantity, aggravating and alleviating factors) can be useful for other symptoms. Where: This may help you narrow down the anatomical structures that are involved. o Is it a localised problem, or more widespread? o Which part of the body is affected? o Is it symmetrical? o Is it in a recognisable pattern? (such as polyarticular affecting small joints of hands and feet in early rheumatoid arthritis or monoarticular in gout) When: Determine the onset and sequence of events o When did it start? o How long does it last? o Is it sudden, rapid, or gradual in onset? o Are the symptoms static, or deteriorating, or are there exacerbations and remissions such as those that occur over long periods of time in rheumatoid arthritis? Quality and quantity: Get a good description and a clear understanding of what the patient means. o What is it like? o Tell me what you mean by... Aggravating: Many musculoskeletal conditions get worse with initial movement and weight bearing. o What makes it worse? o What triggers the symptoms? Relieving/Alleviating: Rest and elevation may relieve symptoms in traumatic musculoskeletal conditions o What makes it better? o 5 Relevant associated symptoms (Biomedical perspective cont.) Relevant associated symptoms for a musculoskeletal presentation will include: Relevant musculoskeletal symptoms and Relevant general symptoms Relevant associated symptoms for a musculoskeletal presentation may include: Relevant symptoms from other body systems You will ask about relevant associated musculoskeletal symptoms. The common musculoskeletal symptoms are: Pain Stiffness Joint swelling Heat Deformity Weakness Locking Instability Altered functional capacity Extra-articular symptoms There is more detail about musculoskeletal symptoms on page 47. You will also ask about relevant general symptoms. Musculoskeletal problems may be associated with general symptoms. There is detailed information about general symptoms in the General Symptoms Reference Guide. General symptoms are: fever fatigue problems sleeping mood change (agitation, tearfulness, depression, or elation), appetite change weight change You may also need to ask about symptoms related to other body systems. A presentation that initially appears to be musculoskeletal in origin may be due to a problem in another system. For example, a painful shoulder may be due to pain referred from the liver. 6 Relevant features (Biomedical perspective cont.) There may also be specific features of the presenting complaint that you can explore that may be relevant to a musculoskeletal presentation. Ability to perform the usual activities of daily living can be a useful indicator of the severity of the problem. A relatively minor break in the skin may be the entry point of bacteria causing septic arthritis. Rheumatoid arthritis can go into remission and recur. A past history of rheumatoid arthritis may be significant. Patient’s perspective It is essential to explore the patient’s perspective. Musculoskeletal complaints can be very limiting and may have significant short and long-term impacts on the patient, their dependents, and their support network. Make sure you have a clear appreciation of: The patient’s ideas about the presentation What the patient is concerned about What the patient is expecting from the consultation The effect that the presenting problem is having on the patient’s life Ensure that you allow the patient to express their feelings about anything they tell you. 7 Background information When you are gathering information about the patient’s background it is useful to know what is relevant for the system that the patient has a problem with. The following is a summary of what can be considered in a musculoskeletal presentation. This summary is not exhaustive, and you will continue to add to this as your knowledge grows. Relevant Past medical/surgical history: It may be appropriate to ask about a history of: Previous musculoskeletal conditions such as inflammatory arthritis or osteoarthritis Psoriasis Fracture/trauma Recent infection (hepatitis, Streptococcal pharyngitis, rubella, diarrhoeal conditions, and tuberculosis may all be associated with arthritis or arthralgia) Inflammatory bowel disease Diabetes (causes joint disease due to reduced proprioception/pain sensation) Significant co-morbidities: o Diabetes o Steroid treatment o Osteoporosis o Ischemic heart disease o Cerebrovascular accident o Obesity Relevant medication history: Asking specifically about prior or current use of particular medications may be appropriate including: Analgesia (use can give an indication of the severity of the complaint) Non-steroidal anti-inflammatory use (these can be purchased over the counter, and we need to be aware of this before prescribing more) Herbal remedies (turmeric, glucosamine) Diuretics (associated with gout) IV drug use (associated with Tb, HIV, or hepatitis which can cause arthropathy) Steroids (can cause osteoporosis) Statins (can cause myopathy) ACE inhibitors (can cause myalgia and arthralgia) Anti-epileptics (can cause osteoporosis and arthralgia) Immunosuppressants (can increase risk of infection such as septic arthritis) Quinolones such as ciprofloxacin can cause tendinopathy and tendon rupture 8 Relevant family history: Ask specifically about health of first-degree relatives (each parent and all siblings) If first degree relatives have died find out the cause and age of death Ask if other family members have had a presentation similar the patient’s presenting complaint These conditions have a genetic component and could be enquired about if appropriate to the presentation: o Osteoarthritis o Rheumatoid arthritis (multigene disorder) o Psoriasis (multifactorial with some genetic contribution) o Hereditary haemochromatosis (causes haemochromatosis arthropathy/joint disease) o Haemophilia (causes haemophilic arthropathy due to frequent bleeds in to joints) Relevant personal and social history: Impact on life and function: o Ability to carry out activities of daily living ▪ Toileting ▪ Eating ▪ Washing ▪ Dressing ▪ Meal preparation ▪ Housework o Occupation can be affected by a musculoskeletal condition or cause a musculoskeletal condition: ▪ Consider impact of condition on work ▪ Consider implications of time off work ▪ Consider work-related condition such as occupational overuse syndrome o Physical activity is important to explore. Find out what the patient does, what they have done in the past, and what they would they like to be able to do. Physical activity has positive and negative effects on the musculoskeletal system: ▪ increases muscle strength and bone density ▪ improves and maintains mobility ▪ improves pain ▪ may aggravate musculoskeletal symptoms o Hobbies and interests: o Consider impact of condition on these o Support and dependents ▪ the musculoskeletal condition may affect ability to care for themselves or their dependents. We need to find out how support could be provided. o Housing stairs etc Alcohol is associated with musculoskeletal conditions: o Musculoskeletal trauma o Gout o Myopathy o Neuropathy Tobacco smoking is associated with musculoskeletal conditions such as: 9  o Cancer causing bony metastases o Rheumatoid arthritis o Osteoporosis Other recreational drugs o IV recreational drug use increases risk of septic arthritis o Opioids can cause myalgia (muscle pain) Nutrition o Consider nutritional deficiency such as low Vitamin D and low calcium intake that can contribute to osteoporosis 10  Common Conditions that affect the Joints Muscles & Bones Trauma or Injury can affect any aspect of the joint, bone or surrounding soft structures, and may have short and long-term consequences. Trauma can cause significant soft tissue damage, tendon laceration, ligament injury, fracture, and dislocation. All bones have the potential to fracture. A relatively common tendon injury is rupture of the Achilles tendon due to sudden plantar flexion at the ankle. A rotator cuff injury can affect the shoulder affecting all movements. Osteoarthritis (OA) is a chronic (lasting more than 6 weeks) condition affecting the joint surface, generally seen in patients over the age of 50. It may occur at a younger age following injury. The onset is gradual over months to years. It usually involves larger weight-bearing joints (such as hips and knees) with pain on movement and weight-bearing. The patient has short-lived morning stiffness lasting fewer than 30 minutes. As osteoarthritis progresses it causes reduced function and can affect all aspects of a person’s life. Bursitis is inflammation of a bursa associated with a joint. Acute bursitis is often due to injury, infection, or an inflammatory condition. Chronic bursitis often follows a prolonged period of repetitive use. It can cause pain, swelling, and reduced range of movement. Olecranon bursitis at the elbow, and shoulder bursitis can affect the upper limb. Trochanteric bursitis at the hip, prepatellar bursitis (housemaid’s knee) and a Bakers cyst or bursal enlargement in popliteal fossa can affect the lower limb. Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory arthritis. It often develops slowly over weeks to months. It typically presents with pain and stiffness in the small joints of the hands and feet. The wrists, elbows, shoulders, knees, and ankles can also be affected. Fatigue is common. Pain and stiffness are worse in the morning and last for more than 30 minutes. Sleep is disturbed. Considerable deformity can be seen in advanced stages of RA where disease modifying treatment has not been given. If RA progresses it causes reduced function and can affect all aspects of a person’s life. Osteoporosis is a condition that causes “thin bones” with an increased risk of fracture. It is common, affecting more than half of women, and one third of men, over the age of sixty. Risk factors include a family history of osteoporosis, smoking, very low body weight, excessive alcohol, increasing age, a diet low in calcium and vitamin D, and physical inactivity. It is often asymptomatic until the person presents with a fracture that has occurred with minimal trauma. Fractures in older people can severely impact mobility and independence. Prevention of osteoporosis with early diagnosis and treatment can reduce this impact. Polymyalgia rheumatica (PMR) is an inflammatory condition that causes myalgia, fatigue, and stiffness. It typically develops over two weeks to two months. It usually occurs over the age of 50 and affects the girdle muscles – the shoulders and pelvis. It tends to present acutely. It usually responds very well to treatment with oral corticosteroids. 11 Temporal arteritis is an inflammatory condition that can occur in association with PMR. It is rare under the age of 50. It typically develops over days to months. It can present with severe headache, scalp tenderness, jaw claudication when eating, and tenderness of the temporal or occipital arteries. Early diagnosis is essential because it may cause sudden permanent blindness due to involvement of the ophthalmic artery. Psoriatic arthritis is another chronic inflammatory arthritis, at times clinically indistinguishable from RA. The patient often presents with asymmetric polyarthritis. The onset is typically insidious over weeks to months. It is associated with nail pitting and the typical rash of psoriasis. Gout is a crystal arthropathy, caused by the precipitation of uric acid crystals in the joint spaces. The patient typically presents acutely over 12 to 24 hours. They have severe inflammation, swelling, and extreme pain. Gout classically affects the metatarsophalangeal joint of the great toe. It can affect other joints. It affects men more than women. There are many things that can precipitate gout such as diuretics, alcohol excess, or dehydration. Septic arthritis is an infection in the joint space, most commonly caused by Staphylococcus aureus. This is a serious condition. The patient may have an area of broken skin that provided an entry point for infection. Clinical features include an acute presentation with symptoms developing over hours to days. It causes a very painful and rapidly progressive monoarthritis with associated general symptoms of infection (fever, sweating, fatigue, and feeling very unwell). Neurological conditions that affect the limbs (You will learn more about these in ELM3 – these conditions are included for your interest and will not be assessed with a FOSCE in ELM2. They may be assessed with a FOSCE in ELM3.) Carpal tunnel syndrome – compression on the median nerve at the wrist causing pain, paraesthesiae, and sometimes reduced function in the median nerve distribution of the hand. The onset is typically insidious. Cubital tunnel syndrome – compression on the ulna nerve at the elbow causing pain, paraesthesiae, and sometimes reduced function in the ulna nerve distribution of the hand. Onset is typically insidious. Disc prolapse causing nerve compression – causing pain and paraesthesiae and sometimes reduced function in the area supplied by the affected nerve. The onset is typically acute over seconds to minutes. 12  Specific considerations in a musculoskeletal presentation Pattern of Joint Involvement Patterns of joint involvement often give an important clue to the underlying cause. Find out what joint or joints are involved, whether it is: Monoarticular (single joint) – such as gout, septic arthritis, or trauma Oligoarticular (2-4 joints) – such as osteoarthritis or psoriatic arthritis Polyarticular (5 or more joints) – such as rheumatoid arthritis or viral arthritis Symmetrical or asymmetrical – RA is more likely to have a symmetrical pattern than OA for instance Acute or chronic Musculoskeletal disorders are considered to be acute if they last less than 6 weeks and chronic if they last longer. An acute problem can be due to trauma or infection, crystal induced (such as gout), or the initial presentation of a chronic musculoskeletal problem. Chronic disorders can be autoimmune such as Rheumatoid Arthritis or degenerative such as Osteoarthritis. Trauma Has there been a history of injury or accident? What is the mechanism of injury? It is useful to take the patient through this step by step as it is important to establish a clear sequence of events. Surgery Has there been any orthopaedic surgery recently? Or previously? 13  The Musculoskeletal Examination Tikanga - best practice in clinical examinations Generally speaking, tikanga are Māori customary practices or behaviours. This concept is derived from the Māori word ‘tika’ which means ‘right’ or ‘correct’. In Māori terms, to act in accordance with tikanga is to behave in a way that is culturally proper or appropriate. One example of tikanga in clinical examination is to avoid touching another person’s head, unless invited. Māori regard the head as very tapu (sacred). For many Pacific ethnic groups, the head area is sacred or ‘tabu’. People from countries with large Buddhist populations such as China, Thailand, Laos, and Cambodia regard the head as the highest part of the body as sacred. They may find that touching the head is disturbing. It is important to get permission from a patient before carrying out any examination, and especially before touching anyone’s māhunga, kaki, kanohi, and whatu (head, neck, face, and eyes). The physical examination skill of examining the cervical spine will involve touching a patient’s māhunga and kaki (head and neck) and it is essential to act in accordance with tikanga. Tikanga Best Practice - Tapu and Noa Tapu and noa are key concepts that underpin many practices for Māori. Tapu means sacred/forbidden/restricted. Noa means free from tapu/unrestricted. It is important for example, to keep things that are tapu separate from things that are noa. The concepts of tapu and noa align well with good health and safe medical practice. If you always consider and support the concepts of tapu and noa this will contribute to safe medical practice in every consultation. WellSouth is the primary health organisation (PHO) for Otago and Southland. They organise and support primary health care services including general practices in Otago and Southland. These Tikanga Best Practice Guidelines from WellSouth have been adapted for use in ELM Clinical Skills: https://wellsouth.nz/care-provider/tikanga-best-practice-guidelines/ You can support the concepts of tapu and noa by: Clearly explaining the reason you want to do the examination Obtaining permission from the patient before touching them Having different coloured linen and pillows for the head and for other parts of the body (it is suggested that you use white for the head and another colour for the rest of the body) 14  If you put a patient’s foot on a pillow to support it during the physical examination you should use the pillow that is not used for the patient’s head If you use a pillow to support a patient’s foot during the musculoskeletal examination it should not be the one that is used for the patient’s head It is important that the patient understands and gives permission for the examination. The tone of your voice and the way you explain things is just as important as the examination process. Remember to thank the patient for allowing you to do the examination. Please consider and incorporate appropriate tikanga as you learn about and practice clinical skills in ELM. Practice of appropriate tikanga will be part of your lifelong medical practice. The Clinical Skills Team thanks Dr Iris Wainiqolo, Dr Esther Willing, and Tūī Kent for sharing their knowledge and wisdom so that we could write this part of the reference guide. 15 Terminology in the musculoskeletal examination You will use medical terminology to record and report what you find on examination. The following information will be helpful. Useful prefixes and suffixes ab-: away from ad(d)-: towards -algia: pain arthr(o)-: joint -ia: condition iso-: equal -itis: infection or inflammation musculo-: muscle my(o)-: muscle mon(o)-: single olig(o)-: few poly-: many Useful definitions Pain: The sensation of discomfort that the patient experiences Tenderness: The sensation of discomfort that the doctor elicits Arthralgia: Pain in a joint or joints Myalgia: Pain in a muscle or group of muscles Arthritis: Inflammation of a joint Monoarthritis: Inflammation affecting a single joint. Oligoarthritis: Inflammation affecting 2-4 joints. Polyarthritis: Inflammation affecting five or more joints. Synovitis: Inflammation of the joint synovium e.g., in Rheumatoid Arthritis. Subluxation: Joint surfaces are displaced and partly in contact. Dislocation: Joint surfaces have lost contact. Effusion: A collection of fluid (e.g., within a joint). May be purulent, bloody, or serous. Fixed Flexion Deformity: The patient is unable to fully extend the joint in question - the joint is fixed in flexion. Fixed Extension Deformity: The patient is unable to fully flex the joint in question - the joint is fixed in extension. 16 Anatomical planes in the anatomical position: Attribution: Edoarado, CC BY-SA 3.0 , via Wikimedia Commons When describing joint movements: Flexion: Bending at a joint from the anatomical position (or moving anteriorly at the shoulder or hip). Extension: Straightening of a joint back to the neutral position (or moving posteriorly at the shoulder or hip). Hyperextension: Extension beyond the normal range, generally due to either ligamentous laxity or damage. Adduction: Movement towards the midline of the body. Abduction: Movement away from the midline of the body. Pronation: Palm downwards Supination: Palm upwards Internal Rotation: Rotation towards the centre of the body. External Rotation: Rotation away from the centre of the body. Active movement: Movement powered by the patient’s muscles. Passive movement: Movement powered by the examiner; the patient is asked to relax and let the examiner move the joint. Crepitus: A grating sensation or noise from a joint, usually from irregular joint surfaces. (Suggests a chronic condition). 17 When describing the Spine: Lordosis: Curvature of the spine in the sagittal (anteroposterior) plane with the apex of the curvature anterior. This is seen normally in the cervical and lumbar spine, and best observed looking from the side of the patient. Kyphosis: Curvature of the spine in the sagittal (anteroposterior) plane with the apex of the curvature posterior. This is seen normally in the thoracic spine, and best observed looking from the side of the patient. Scoliosis: Side to side curvature of the spine (in an 'S' shape) best observed looking from behind the patient. When describing limbs: Valgus: The distal part of the limb deviates away from the midline such as “knock- knees”. May be normal or pathological. Varus: The distal part of a limb deviates towards the midline such as “bow-legs”. May be normal or pathological. When describing the foot and hand: Dorsal: o The posterior aspect or back of the hand o The upper surface of the foot Palmar: The anterior aspect or palm of the hand Plantar: The under surface or sole of the foot Naming the fingers (laterally to medially): 1st digit: Thumb 2nd digit: Index finger 3rd digit: Middle (or long) finger 4th digit: Ring finger 5th digit: Little finger Naming the toes (medially to laterally): 1st digit: Great toe / Hallux 2nd digit: 2nd toe 3rd digit: 3rd toe 4th digit: 4th toe 5th digit: 5th toe 18 General principles of the musculoskeletal examination Ask the patient if there is pain and where it is before beginning. Always observe your patient throughout the examination for signs of discomfort Do not cause the patient unnecessary pain Always compare the right side with the left Always expose the joints above and below the affected joint1 Use the “Look, Feel, Move” approach to examine the patient A framework for the physical examination of the musculoskeletal system 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role), o explain what you want to do o explain what the examination will involve o gain permission to continue Position: o Patient ▪ Sitting (cervical and thoracic spine) ▪ Standing (gait and lumbar spine) ▪ Examination couch (lower limb examinations) o Yourself so you can carry out the examination effectively and comfortably Expose the patient as appropriate for each part of the musculoskeletal examination. In general, you should expose the joints above and below the joint you are examining. Right: o if examining the patient on the examination couch, examine from the patient’s RIGHT. This is standard clinical practice that will help you to correctly identify and record the side of any abnormality you detect. It will also allow you to carry out your examinations in a consistent and reproducible manner. o when examining the patient sitting, standing, and walking, determine the patient’s RIGHT. This will help you to correctly identify and record the side of any abnormality you detect. 2. Use the “Look, Feel, Move” approach to examine the patient 3. Ask the patient if they have any pain before you start and tell them to let you know if any part of the examination causes pain. 1An exception is the knee examination when you will not expose the hips. You will cover them lightly with the modesty cloth if the patient is wearing underwear. 19 4. Communicate with the patient throughout the examination as necessary: to keep them informed of progress, check they are ok, and gain permission where appropriate as you move through your examination 5. Ensure the patient is comfortable with dignity preserved throughout the examination 6. Observe the patient throughout the examination to check whether the examination is causing pain or distress 7. End the examination: Thank the patient Let the patient know what to do next which might include putting on any removed footwear or clothing, and returning to their chair Wash your hands Look (Inspection) To assess “Look”: 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role), o explain what you want to do “I want to check the bones, muscles, and joints in your spine, arms and legs.” o explain what the examination will involve “I’ll need you to stand and walk for part of the examination, and I’ll need you to lie on the examination couch for the final part.” o gain permission to continue “Is that ok?” Position: o Patient ▪ Sitting (cervical and thoracic spine) ▪ Standing (gait and lumbar spine) ▪ Examination couch (lower limb examinations) o Yourself so you can carry out the examination effectively and comfortably Expose the patient as appropriate for each part of the musculoskeletal examination. Expose the joints above and below the joint you are examining. “I’ll need to be able to see your spine. Is that ok? Go behind that screen and take your top off then put on the gown that is under the pillow. If you put it on so it is open at the back, I’ll be able to see your spine easily. Let me know if you need any help.” Right: o if examining the patient on the examination couch, examine from the patient’s RIGHT. This is standard clinical practice that will help you to correctly identify and record the side of any abnormality you detect. It will also allow you to carry out your examinations in a consistent and reproducible manner. 20  o when examining the patient sitting, standing, and walking, determine the patient’s RIGHT. This will help you to correctly identify and record the side of any abnormality you detect. 2. Ask the patient if they have any pain before you start and tell them to let you know if any part of the examination causes pain. 3. Use the “Look” part of the “Look, Feel, Move” approach to examine the patient Take every opportunity to assess function by observing: o Assess the patient’s gait by looking when you see them walking o Assess function of the fingers and hand by looking when you see them writing o Assess function of the hands, arms, spine, lower limbs when you see them take off shoes o Assess function of the upper limbs when you see them take off jacket o Assess function of the limbs and spine when you see them get on examination couch Look at the joints and limbs in question from all sides (they are 3-dimensional). Look for signs that may be seen in the skin: o Erythema: Redness - suggests active inflammation or infection o Atrophy: Skin thinning - suggests chronic underlying disease, old age, and steroid use o Scars: Indicate previous trauma, or surgery o Rash: May suggest associated conditions such as psoriasis o Nodules due to: ▪ Rheumatoid arthritis - firm non tender subcutaneous nodules on extensor surface of forearm ▪ Gouty tophi - firm irregular subcutaneous crystal collections on extensor aspects of fingers ▪ Osteoarthritic Heberden’s nodes – bony nodules on lateral aspects DIP joints ▪ Osteoarthritic Bouchard’s nodes – bony nodules on lateral aspects of the PIP joints Look for signs that may be seen in the joint: o Swelling: Could be caused by joint effusion, synovial inflammation or hypertrophy, bony overgrowth, or involvement of tissues around the joint (such as tendonitis or bursitis) o Deformity: Suggests a chronic, destructive process (such as swan-neck deformity, Boutonnière deformity, ulnar and radial deviation, and Z deformity, all seen in the hands in advancing rheumatoid arthritis). o Muscle wasting: Visible around the joint can be due to disuse, inflammatory processes, or nerve entrapment. 4. Communicate with the patient throughout the examination as necessary: to keep them informed of progress, check they are ok, and gain permission where appropriate as you move through your examination 5. Ensure the patient is comfortable with dignity preserved throughout the examination 21 6. Observe the patient throughout the examination to check whether the examination is causing pain or distress 7. End the examination: Thank the patient Let the patient know what to do next which might include putting on any removed footwear or clothing, and returning to their chair Wash your hands Feel (Palpation) We use palpation to assess the temperature of the area we are palpating, whether there is any lump, swelling or deformity, and whether there is any area of tenderness. Skin temperature: A cool joint is unlikely to be involved in an acute inflammatory process such as infection, synovitis, or crystal arthritis such as gout. Use the backs of the hands Compare surrounding structures Compare right with left Tenderness to palpation: Palpate the joint, surrounding structures, muscles, and bone gently with the fingers Watch the patient’s face for discomfort Lump or swelling: Ask the patient where they feel pain or swelling Palpate the joint with the fingers to find o Synovitis - a generalised soft and ‘rubbery’, ‘spongy’ or ‘boggy’ swelling o Joint effusion – fluctuant and mobile swelling o Bony swelling - hard and immobile Watch the patient’s face for discomfort To assess “Feel”: 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role), o explain what you want to do “I want to check the bones, muscles, and joints in your spine, arms and legs.” o explain what the examination will involve “I’ll need to touch your spine and your legs and arms to do the next part of the check. I may need to touch your head when I check out your neck.” o gain permission to continue “Is that ok?” Position: o Patient ▪ Sitting (cervical and thoracic spine) 22  ▪ Standing (gait and lumbar spine) ▪ Examination couch (lower limb examinations) o Yourself so you can carry out the examination effectively and comfortably Expose the patient as appropriate for each part of the musculoskeletal examination. Expose the joints above and below the joint you are examining. “I’ll need to be able to see your spine/arms/legs. Is that ok? Go behind that screen and take your top off then put on the gown that is under the pillow. If you put it on so it is open at the back, I’ll be able to see your spine/arms/legs easily. Let me know if you need any help.” Right: o if examining the patient on the examination couch, examine from the patient’s RIGHT. This is standard clinical practice that will help you to correctly identify and record the side of any abnormality you detect. It will also allow you to carry out your examinations in a consistent and reproducible manner. o when examining the patient sitting, standing, and walking, determine the patient’s RIGHT. This will help you to correctly identify and record the side of any abnormality you detect. 2. Ask the patient if they have any pain before you start and tell them to let you know if any part of the examination causes pain. 3. Use the “Feel” part of the “Look, Feel, Move” approach to examine the patient Use the back of your hand to assess temperature and compare with surrounding structures and the other side. Palpate the joints and surrounding structures gently with your fingers. o Palpate around the joint with your fingertips and consider the normal anatomy of the joint. What do you feel beneath your fingers? Are you feeling a normal bony prominence or is it an abnormal lump? (further information about examination of a lump on page 26) o Identify any areas of swelling ▪ A synovitis is generalised soft and ‘rubbery,’ ‘spongy’ or ‘boggy’ swelling. ▪ A joint effusion is a fluctuant and mobile swelling. Watch the patient’s face for signs of discomfort as you palpate to determine if there are any areas of tenderness. If so, ask the patient where they feel the pain. 4. Communicate with the patient throughout the examination as necessary: to keep them informed of progress, check they are ok, and gain permission where appropriate as you move through your examination 5. Ensure the patient is comfortable with dignity preserved throughout the examination 6. Observe the patient throughout the examination to check whether the examination is causing pain or distress 7. End the examination: Thank the patient Let the patient know what to do next which might include putting on any removed footwear or clothing, and returning to their chair Wash your hands 23 Move Diseased joints may have reduced range of movement or ligamentous laxity. To assess “Move”: 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role), o explain what you want to do “I want to see how well the bones, muscles, and joints in your spine, arms and legs can move.” o explain what the examination will involve “I’ll get you to do some movements and then I’ll gently move the joints myself to see how far they move. I’ll need to touch your arms and legs. I won’t need to touch your neck or spine.” o gain permission to continue “Is that ok?” Position: o Patient ▪ Sitting (cervical and thoracic spine) ▪ Standing (gait, lumbar spine, shoulders) ▪ Examination couch (lower limb) o Yourself so you can carry out the examination effectively and comfortably Expose the patient as appropriate for each part of the musculoskeletal examination. Expose the joints above and below the joint you are examining. “I’ll need to be able to see your spine/arms/legs. Is that ok? Go behind that screen and take your top off then put on the gown that is under the pillow. If you put it on so it is open at the back I’ll be able to see your spine/arms/legs easily. Let me know if you need any help.” Right: o if examining the patient on the examination couch, examine from the patient’s RIGHT. This is standard clinical practice that will help you to correctly identify and record the side of any abnormality you detect. It will also allow you to carry out your examinations in a consistent and reproducible manner. o when examining the patient sitting, standing, and walking, determine the patient’s RIGHT. This will help you to correctly identify and record the side of any abnormality you detect. 2. Ask the patient if they have any pain before you start and tell them to let you know if any part of the examination causes pain. 3. Use the “Move” part of the “Look, Feel, Move” approach to examine the patient Active movement (the patient moves the limb themselves): o Should be assessed before passive movement. o Limited by: ▪ joint disease, ▪ muscle weakness ▪ tendon problems 24  ▪ nerve problems ▪ pain Passive movement (the examiner moves the relaxed limb for the patient): o Generally provides more information than active movement o Must be attempted gently o May be obviously inappropriate in the case of injury. o Limited by: ▪ Pain ▪ Tense joint effusion ▪ Fixed deformity Ask the patient where they feel pain Always compare both sides. Always watch the patient throughout the examination for signs of discomfort. 4. Communicate with the patient throughout the examination as necessary: to keep them informed of progress, check they are ok, and gain permission where appropriate as you move through your examination 5. Ensure the patient is comfortable with dignity preserved throughout the examination 6. Observe the patient throughout the examination to check whether the examination is causing pain or distress 7. End the examination: Thank the patient Let the patient know what to do next which might include putting on any removed footwear or clothing, and returning to their chair Wash your hands 25 Examination of a Lump Lumps can be a presenting concern of a patient. They can also be noticed on inspection or discovered on palpation. You may find a lump when you are palpating a joint. Lumps need to be examined by further inspection and palpation taking note of the following features: Site, size, shape, consistency, mobility and tenderness In what tissue or tissue layer is the lump situated? o in dermis or epidermis - the lump with move with the skin o in subcutaneous layer - the skin can be moved over the lump o in nerve – pressure on the lump may produce pins and needles in the distribution of that nerve, and the lump will only move in a horizontal axis and not in a longitudinal axis o in muscle or tendon - contraction of the muscle or tendon will affect the mobility of the lump o in bone – the lump will be immobile Fluctuance – press the lump gently halfway between periphery and centre of lump. If fluctuant then the tissue of the lump will bulge towards the other side of the lump Transillumination – using a small torch shine a light through the lump. If the lump is cystic light will travel through it so it will appear to glow when transilluminated Signs of inflammation – redness (erythema), heat, tenderness and swelling To assess a lump: 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role), o explain what you want to do “I want to check put that lump. I’ll need to have a good look at it and then gently touch it and move it with my fingers.” o explain what the examination will involve “I’ll need to be able to see the lump and examine it. You’ll need to take your top off. I’ve got a gown you can wear if you’d like to do that.” o gain permission to continue “Is that ok?” Position: o Patient ▪ Sitting ▪ Examination couch o Yourself so you can carry out the examination effectively and comfortably Expose the patient as appropriate so you can see and palpate the lump. “I’ll need to be able to see that lump. Is that ok? Go behind that screen and take your top off then put on the gown that is under the pillow. Let me know if you need any help.” 26  Right: o if examining the patient on the examination couch, examine from the patient’s RIGHT. This is standard clinical practice that will help you to correctly identify and record the side of any abnormality you detect. It will also allow you to carry out your examinations in a consistent and reproducible manner. o when examining the patient sitting, standing, and walking, determine the patient’s RIGHT. This will help you to correctly identify and record the side of any abnormality you detect. 2. Ask the patient if they have any pain before you start and tell them to let you know if any part of the examination causes pain. 3. Examine the lump: Look for signs of inflammation – redness (erythema) and swelling Use the back of your hand to assess temperature and compare the heat with surrounding structures and the other side. Palpate the lump and the surrounding area gently with your fingertips. Consider: o Site, size, shape, consistency, mobility and tenderness o In what tissue or tissue layer is the lump situated? ▪ in dermis or epidermis - the lump with move with the skin ▪ in subcutaneous layer - the skin can be moved over the lump ▪ in nerve – pressure on the lump may produce pins and needles in the distribution of that nerve, and the lump will only move in a horizontal axis and not in a longitudinal axis ▪ in muscle or tendon - contraction of the muscle or tendon will affect the mobility of the lump ▪ in bone – the lump will be immobile o Fluctuance – press the lump gently halfway between periphery and centre of lump. If fluctuant then the tissue of the lump will bulge towards the other side of the lump Check for transillumination – use a small torch to shine a light through the lump. If the lump is cystic light will travel through it so it will appear to glow when transilluminated Watch the patient’s face for signs of discomfort as you examine to determine if there are any areas of tenderness. If so, ask the patient where they feel the pain. 4. Communicate with the patient throughout the examination as necessary: to keep them informed of progress, check they are ok, and gain permission where appropriate as you move through your examination 5. Ensure the patient is comfortable with dignity preserved throughout the examination 6. Observe the patient throughout the examination to check whether the examination is causing pain or distress 7. End the examination: Thank the patient Let the patient know what to do next which might include putting on any removed footwear or clothing, and returning to their chair Wash your hands 27 Examination of the gait Gait is the pattern of motion that carries the body forwards. Put simply, it is the way a person walks. Gait is generally smooth and symmetrical with each leg 50% out of phase with the other. Gait has two phases - swing and stance. Swing occurs from toe-off to heel-strike. This leg is non-weight bearing. Stance occurs from heel-strike to toe-off. The leg in the stance phase is weight-bearing. A limp is an abnormal gait and may be caused by pain, structural change, or neurological abnormality. To assess gait, you need to observe the patient’s normal walking pattern. This part of the clinical assessment begins the from the moment you see the patient walking. To assess your patient’s gait: 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role), o explain what you want to do “I want to see how you walk.” o explain what the examination will involve “I’ll get you to take off your shoes and socks and walk to the end of the room, turn around and walk back.” o gain permission to continue “Is that ok?” Position: o Patient standing o Yourself so you can carry out the examination effectively and comfortably Expose the patient so you can see their feet. “I’ll need you to take off your shoes and socks. Is that ok?” Right: o determine the patient’s RIGHT side. This will help you to correctly identify and record the side of any abnormality you detect. 2. Ask the patient if they have any pain before you start and tell them to let you know if any part of the examination causes pain. 3. Assess the gait: Ask your patient to remove their shoes and socks, then walk across the room, stop, turn around and walk back towards you. You may need to ask them to do this several times to make a full assessment. Use clear instructions for your patient - tell them exactly what you want them to do. “Mr Brown…please remove your shoes and walk over towards the door. Now turn around and walk back towards me. Could you do that again please?” Make specific observations of the: o Symmetry and cadence (rhythm) of the walking pattern o Balance or steadiness of your patient o Stride length (Regular or variable? Short steps? Shuffling?) o Gait pattern (Presence of a limp, recognisable gait disorder) 28  o Use of any walking aid, prosthesis, or orthotic device o Ability to stop, change direction and turn around 4. Communicate with the patient throughout the examination as necessary: to keep them informed of progress, check they are ok, and gain permission where appropriate as you move through your examination 5. Ensure the patient is comfortable with dignity preserved throughout the examination 6. Observe the patient throughout the examination to check whether the examination is causing pain or distress 7. End the examination: Thank the patient Let the patient know what to do next which might include putting on any removed footwear or clothing, and returning to their chair Wash your hands Example of reporting findings following examination of the gait: “Today I was asked to see Mrs Alice Talalima, a 73-year-old woman who is a retired schoolteacher. She had her right hip replaced 6 months ago and has come for a checkup. I examined Mrs Talalima’s gait. Mrs Talalima walked without a walking aid. Her gait had a normal rhythm. She was steady throughout the examination. The length of her stride was normal in each leg. She did not have a limp and had normal arm swing. She had no difficulty with turning around and changing direction. In summary her gait was normal.” 29 Examination of the spine The spine is divided in to the cervical, thoracic, lumbar, and sacral segments. We will learn about examination of the cervical, thoracic, and lumbar spine. The most common presentation of a spinal problem is pain. While you are examining the patient you need to be aware of how the patient responds to the examination and what parts of the examination cause pain. Back problems are common presentations in primary care. One in four adults will present with a low back problem over a six-month period.2 Cervical Spine This examination is best done with the patient sitting. The neck, shoulders, and arms should be exposed. You may offer a gown and advise the patient to wear it with the opening at the back. Make sure you explain what you want to do and that you will be touching the patient’s neck and possibly their head. Act in accordance with tikanga and ensure you have permission to proceed. To assess the cervical spine with “Look, Feel, Move”: 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role), o explain what you want to do “I want to check out your neck.” o explain what the examination will involve “I’ll have a good look at your neck, check out the muscles and bones, and then I’ll get you to do some head movements.” o gain permission to continue “Is that ok?” Position: o Patient ▪ Sitting o Yourself so you can carry out the examination effectively and comfortably Expose the patient so that you can see their neck, shoulders, and arms. Patients will need to take off jackets and clothing with sleeves. Offer a gown. “I’ll need to be able to see your neck, shoulders and arms. Is that ok? Go behind that screen and take your top off then put on the gown that is under the pillow. If you put it on so it is open at the back I’ll be able to see your neck more easily. Let me know if you need any help.” Right: 2 Kent PM, Keating JL. The epidemiology of low back pain in primary care. Chiropr Osteopat. 2005;13:13. Published 2005 Jul 26. doi:10.1186/1746-1340-13-13 30  o when examining the patient sitting determine the patient’s RIGHT side. This will help you to correctly identify and record the side of any abnormality you detect. 2. Ask the patient if they have any pain before you start and tell them to let you know if any part of the examination causes pain. 3. Use the “Look, Feel, Move” approach to examine the cervical spine Look o Observe the posture of the head and neck. o Note any change in the normal cervical lordosis o Note the muscle bulk. o Check symmetry. Feel oPalpate the midline spinous processes from the occiput to T1 (usually most prominent) o Note alignment of spinous processes and tenderness o Palpate the paraspinal soft tissues for tenderness or tension o You may need to use counter pressure on the forehead to allow adequate palpation Move o Assess active movements by asking patient to: o Look down to the floor (forward flexion) o Look up to the ceiling as far as possible(extension) o Put their right ear on their right shoulder (lateral flexion to right) o Put their left ear on their left shoulder (lateral flexion to left) o Look over their right shoulder (lateral rotation to right) o Look over their left shoulder (lateral rotation to left) o Assess passive movements if active movements are reduced 4. Always compare sides. 5. Communicate with the patient throughout the examination as necessary: to keep them informed of progress, check they are ok, and gain permission where appropriate as you move through your examination 6. Ensure the patient is comfortable with dignity preserved throughout the examination 7. Observe the patient throughout the examination to check whether the examination is causing pain or distress 8. End the examination: Thank the patient Let the patient know what to do next which might include putting on any removed clothing Wash your hands 31 Thoracic Spine This examination is best done with the patient both standing (to allow inspection and palpation) and sitting (to assess movement). The neck chest and back should be exposed. You may offer a gown and advise the patient to wear it with the opening at the back. To assess the thoracic spine with “Look, Feel, Move”: 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role), o explain what you want to do “I want to check out your upper back.” o explain what the examination will involve “I’ll have a good look at your back, check out the muscles and bones, and then I’ll get you to do some movements.” o gain permission to continue “Is that ok?” Position: o Patient ▪ Standing to inspect and palpate ▪ Sitting to assess movement o Yourself so you can carry out the examination effectively and comfortably Expose the patient so that you can see their upper back and chest. Patients will need to take off jackets and upper clothing. Offer a gown. “I’ll need to be able to see your upper back and chest. Is that ok? Go behind that screen and take your top off then put on the gown that is under the pillow. If you put it on so it is open at the back I’ll be able to see your neck more easily. Let me know if you need any help.” Right: o when examining the patient standing and sitting, determine the patient’s RIGHT side. This will help you to correctly identify and record the side of any abnormality you detect. 2. Ask the patient if they have any pain before you start and tell them to let you know if any part of the examination causes pain. 3. Use the “Look, Feel, Move” approach to examine the thoracic spine Look (patient standing) o Observe the posture from behind, the side, and the front. o Note any deformity such as abnormal curvature. o Note the muscle bulk. o Check symmetry. Feel (patient standing) o Palpate the midline spinous processes from T1 (usually most prominent) to T12 o Note alignment of spinous processes and tenderness o Palpate the paraspinal soft tissues for tenderness or tension 32  Move (patient sitting) o Assess active movement by asking patient to: ▪ Cross their arms ▪ Twist around to look behind on the right (thoracic rotation to right) ▪ Twist around to look behind on the left (thoracic rotation to left) 4. Always compare sides. 5. Communicate with the patient throughout the examination as necessary: to keep them informed of progress, check they are ok, and gain permission where appropriate as you move through your examination 6. Ensure the patient is comfortable with dignity preserved throughout the examination 7. Observe the patient throughout the examination to check whether the examination is causing pain or distress 8. End the examination: Thank the patient Let the patient know what to do next which might include putting on any removed clothing, and returning to their chair Wash your hands 33 Lumbar Spine This examination is done with the patient standing. The back should be fully exposed. You may offer a gown and advise the patient to wear it with the opening at the back. To assess the lumbar spine with “Look, Feel, Move”: 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role), o explain what you want to do “I want to check out your lower back.” o explain what the examination will involve “I’ll have a good look at your back, check out the muscles and bones, and then I’ll get you to do some movements.” o gain permission to continue “Is that ok?” Position: o Patient standing o Yourself so you can carry out the examination effectively and comfortably Expose the patient so that you can see their upper back and chest. Patients will need to take off jackets and upper clothing. Offer a gown. “I’ll need to be able to see your lower back. Is that ok? Go behind that screen and take your top off then put on the gown that is under the pillow. If you put it on so it is open at the back I’ll be able to see your back more easily. Let me know if you need any help.” Right: o when examining the patient determine the patient’s RIGHT side. This will help you to correctly identify and record the side of any abnormality you detect. 2. Ask the patient if they have any pain before you start and tell them to let you know if any part of the examination causes pain. 3. Use the “Look, Feel, Move” approach to examine the lumbar spine Look o Observe the posture from behind, the side, and the front. o Note any deformity such as abnormal curvature. o Look at the height of each shoulder to check they are symmetrical*. o Look at the level of each iliac crest to check they are symmetrical*. o Note the muscle bulk. Feel o Palpate the midline spinous processes from T12 to L5 o Note alignment of spinous processes and tenderness o Palpate the paraspinal soft tissues for tenderness or tension o Palpate the iliac crests to assess they are at equal height* Move o Assess active movement by asking patient to: ▪ Touch their toes with legs straight (lumbar flexion) ▪ Straighten up and lean back as far as possible (lumbar extension) 34  ▪ Bend sideways sliding the palm of hand down the outside of the thigh (lateral flexion) o Compare how far they can go on each side. o If this is done with the patient standing in front of a wall a more accurate assessment can be made as the patient is not able to combine lateral flexion with flexion. Summary of Spinal Movements Cervical spine: Lateral flexion (ear to shoulder) Flexion (look down) Extension (look up) Rotation (look over shoulder) Thoracic spine: Rotation (twisting in sitting) Lumbar spine: Flexion (bend forwards) Extension (return to upright and tilt backwards) Lateral flexion (bend sideways) *Asymmetry of the height of the shoulders and iliac crests suggests scoliosis or leg length discrepancy. Example of reporting findings following examination of the spine: “Today I was asked to examine Toby Smith’s spine. He is a 27-year-old builder with no past medical history of note. He has come for a diving medical examination. On observing Toby I noticed he had normal posture of the head and neck. He had a normal cervical lordosis with symmetrical muscle bulk in the paraspinal muscles. There was no tenderness of the spinous processes of the cervical spine and there was normal alignment. There was no tenderness or tension in the paraspinal muscles of the cervical spine. Toby had full active movement of the cervical spine with normal flexion and extension, normal lateral flexion to the right and left, and normal lateral rotation to the right and left. On inspection of his thoracic spine there was no deformity and he had a normal thoracic kyphosis with no asymmetry and normal muscle bulk. On palpation of the thoracic spine there was no tenderness of the spinous processes e and there was normal alignment. There was no tenderness or tension in the paraspinal muscles of the thoracic spine. Toby had normal and symmetrical thoracic rotation. On inspecting Toby’s lumbar spine there was no deformity. The shoulders were at the same height and the iliac crests were symmetrical. 35 On palpation the spinous processes from T12 to L5 were aligned and there was no tenderness. The paraspinal muscles were normal to palpation. Toby had full range of movement in the lumbar spine with normal flexion, extension and lateral flexion to the right and left. In summary, the examination of Toby’s spine was normal” 36 Examination of the shoulders The shoulder is the most mobile joint in the body. Seventeen muscles are involved in the movements of the shoulder. Joint stability depends on four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis. Common shoulder presentations are listed below. Trauma causing fracture, or dislocation Trauma causing muscle or tendon injury such as rotator cuff syndrome Osteoarthritis Inflammatory problems such as bursitis causing pain and reduced function with reduction in range of motion As a general rule intraarticular shoulder disease causes painful movement in all directions, tendonitis causes painful movement in one plane only, and tendon rupture or neurological problems cause painless weakness. The examination begins when the patient undresses. Look to see if they have trouble taking off outer layers of clothing. The shoulder examination is best done with the patient standing in front of you with their arms exposed. To assess the shoulders with “Look, Feel, Move”: 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role), o explain what you want to do “I want to check out your shoulders.” o explain what the examination will involve “I’ll have a good look at your shoulders, and I’ll check the muscles and bones, and then get you to do some movements. I might need to touch your neck.” o gain permission to continue “Is that ok?” Position: o Patient standing o Yourself so you can carry out the examination effectively and comfortably Expose the patient’s arms. “I’ll need to be able to see your arms. Is that ok? Could you take your jacket off? You can leave your singlet top on.” Right: o when examining the patient standing determine the patient’s RIGHT side. This will help you to correctly identify and record the side of any abnormality you detect. 2. Ask the patient if they have any pain before you start and tell them to let you know if any part of the examination causes pain. 3. Use the “Look, Feel, Move” approach to examine the shoulders Look: “I’m going to have a look at your shoulders.” o Compare sides looking for 37  ▪ Arms at same level ▪ Shoulder contours and outlines of acromioclavicular joints the same ▪ Deltoid wasting ▪ Scars ▪ Size and position of scapula (elevated, depressed, “winged”) Feel: “Is it sore anywhere? I’m just going to check your shoulder and collarbone.” o Tenderness/deformity ▪ Palpate clavicle from acromioclavicular joint to sternoclavicular joint ▪ Palpate acromioclavicular joint ▪ Palpate coracoid process 2cm inferior and medial to clavicle tip Move: “I’m going to check how well your shoulders move.” o Assess active flexion (to 180 degrees) ▪ Ask patient to lift their arm up in front of them o Assess active extension (to 60 degrees) ▪ Ask patient to swing their arm backwards as if they are marching o Assess active adduction (to 50 degrees) ▪ Ask patient to move their arm forwards in front of their chest o Assess active abduction (0-180 degrees) ▪ Ask patient to lift arm away from their side 0-15 degrees - supraspinatus 15-90 degrees – deltoid 90-180 degrees3 – trapezius and serratus anterior o Assess active internal rotation – subscapularis and pectoralis major ▪ Ask patient to put their hand behind their back as far up as they can (note the highest spinous process they can reach with their thumb) o Assess active external rotation – infraspinatus and teres minor ▪ Ask patient to tuck their elbow at the side, bent to 90 degrees, and then rotate the hand outwards o Check passive movement if there is abnormal active range of motion. o If there is normal passive movement and abnormal active movement there may be a problem with pain, loss of motor strength (nerve injury, tendon or muscle problem) or stiffness. o Compare sides 4. Communicate with the patient throughout the examination as necessary: to keep them informed of progress, check they are ok, and gain permission where appropriate as you move through your examination 5. Ensure the patient is comfortable with dignity preserved throughout the examination 6. Observe the patient throughout the examination to check whether the examination is causing pain or distress 7. End the examination: Thank the patient 3 Shoulder abduction from 90-180 degrees is also called elevation and involves rotation of the scapula 38  Let the patient know what to do next which might include putting on any removed footwear or clothing, and returning to their chair Wash your hands Reporting findings on examination of the shoulders Today I examined Sally Peterson who wrenched her right shoulder when her dog pulled suddenly on the lead when it was scared by another dog walking towards them. Sally is a 72 year old retired financial planner. On examination Sally looked well. She had difficulty taking her cardigan and top off due to pain in her right shoulder. On examination of the shoulders the contours were normal bilaterally. The skin was normal. There was no tenderness to palpation bilaterally. On assessment of the range of movement in the right shoulder Sally had normal active flexion and extension. She had full abduction, and she had pain from 60-120 degrees. She had reduced active and passive internal and external rotation on the right. She had full range of motion in the left shoulder. 39 Examination of the knees The knee is a hinge joint. It is a large and complex joint and can absorb a vertical force of up to seven times a person’s body weight.4 Patients with a knee problem often present with pain. Pain is likely to be localised if there is an injury or mechanical abnormality and generalised if there is an inflammatory problem Common knee presentations are listed below: Trauma affecting bones, ligaments, menisci, tendons, soft tissue Inflammation due to gout, rheumatoid arthritis, septic arthritis Bursitis - prepatellar bursitis (housemaid’s knee) or Baker’s cyst (bursa enlargement in popliteal fossa) Osteoarthritis This examination is carried out with the patient dressed so that you can see the thighs, knees and lower legs. Shorts are ideal. In practice most patients will need to strip down to their underwear. Use a modesty cloth draped lightly over their underwear and upper body. The examination is performed with the patient lying supine (face up) on the examination couch. Ask the patient to lie on the examination couch with both legs fully exposed. To assess the knees with “Look, Feel, Move”: 1. Start the examination (use the mnemonic WIPER): Wash your hands Introductions: o introduce yourself (full name and role), o explain what you want to do “I want to check out your knees.” o explain what the examination will involve “I’ll look at your knees, check the joints and ligaments, and then get you to do some movements. I’ll need to touch your knees.” o gain permission to continue “Is that ok?” Position: o Patient lying on examination couch with head flat or slightly raised o Yourself so you can carry out the examination effectively and comfortably Expose the patient’s knees and feet. “I’ll need to be able to see your knees and feet. Is that ok? I’ll need you to take your jeans, shoes, and socks off. I’ve got a gown if you’d like one, and I’ll cover most of you with a sheet, so you won’t feel too exposed.” Right: 4 R. Drake, W. Vogl, A. Mitchell, et al.Gray’s Anatomy for Students Elsevier/Churchill Livingstone, Philadelphia (2005) 40  o Start the examination from the patient’s RIGHT. You will need to stand on the patient’s left to carry out parts of the knee examination. 2. Ask the patient if they have any pain before you start and tell them to let you know if any part of the examination causes pain. 3. Use the “Look, Feel, Move” approach to examine the knees Look: “I’m going to have a look at your knees.” o Look for: ▪ Position of knee (a painful knee is often partially flexed) ▪ Swelling Joint swelling (on either side of the patella, suprapatellar region) Swelling in bursae around the knee such as pre-patellar or popliteal bursa Localised swellings that move with knee movement (loose body) ▪ Skin Erythema Skin atrophy Rash (psoriasis on extensor surface) Scars ▪ Muscle wasting (quadriceps) ▪ Deformity (best observed with the patient standing) Look for bow leg (genu varus) Look for knock knee (genu valgus) Look for flexion deformity Look for hyperextension Feel: “I’m going to examine your knee joints for tenderness and fluid in the joint.” o Look at the patient’s face as you palpate so you can assess tenderness accurately o Palpate for: ▪ Increased temperature ▪ Quadriceps wasting – ask patient to contract the quadriceps muscle and compare sides ▪ Tenderness at any tendon or ligament insertion or in the joint line ▪ Medial collateral ligament, Lateral collateral ligament, Patellar tendon ▪ Synovitis - palpate for sponginess on both sides of the quadriceps tendon ▪ Joint-line tenderness – palpate medial and lateral joint lines ▪ Crepitus as knee is moved (usually from patella) ▪ Joint effusions – using “patellar tap” and “ripple sign” techniques Methods for performing the palpation techniques listed above are described on the following pages 41  Move: “I want to see how well you can move your knees and then I’m going to move your knees to see how well they work.” o Look at the patient’s face as movement is assessed so you can evaluate pain o Active flexion and extension ▪ ask the patient to flex or bend their knee up putting their “heel towards the bottom” ▪ then ask them the extend the knee back down to lie on the couch ▪ normal range 0 - 140º o Fixed Flexion Deformity ▪ place your hands under the patient’s knees and ask them to push their knees downwards into your hands. You should feel good and equal pressure on both sides. There should not be a gap between the knee and the couch. o Active Extension ▪ ask the patient to lift their leg into the air with the knee joint in extension (straight) and note any extensor lag (inability to extend) o Passive Extension/hyperextension ▪ check for hyperextension by lifting each leg in turn by picking up the foot and inspecting to see how far the knee joint extends. Full extension is 0º. ▪ Up to 10º of hyperextension is within normal limits. o Assess the ligaments 4. Communicate with the patient throughout the examination as necessary: to keep them informed of progress, check they are ok, and gain permission where appropriate as you move through your examination 5. Ensure the patient is comfortable with dignity preserved throughout the examination 6. Observe the patient throughout the examination to check whether the examination is causing pain or distress 7. End the examination: Thank the patient Let the patient know what to do next which might include putting on any removed footwear or clothing, and returning to their chair Wash your hands Reporting findings on examination of the knee I examined Raymond Yee who injured his left knee skiing last week. Raymond is a 20-year old 3rd year physio student who works part time in hospitality. On examination he walked with a limp. He was able to get on to the examination couch with ease. His left knee was swollen. It was not red. The knee was not hot. He had tenderness of the medial joint line. There was a positive patellar tap. He had reduced active flexion in the knee. The ligaments were intact. The right knee was normal to examination. 42 Palpation for joint effusions Patellar Tap (moderate-large effusion): With the knee relaxed and extended empty the supra-patellar bursa by sliding your left hand down the thigh until you reach the upper edge of the patella. Keep your hand there. With the fingertips of your right hand firmly on the patella, push down briskly. In a moderate sized effusion you will feel a tapping sensation as you push the ‘floating’ patella down to strike the femur. Ripple Sign (small effusion): With the knee relaxed and extended empty the suprapatellar bursa with your left hand. Keep your hand there. Stroke the medial side of the knee with your right hand to remove fluid. Stroke the lateral side of the knee with your right hand. If a small effusion is present you will see a bulge (or ripple) medially when the fluid is pushed back to the medial side of the knee. Patellar Tap (moderate-large effusion): With the knee extended, empty the supra-patellar bursa by sliding your left hand down the thigh until you reach the upper edge of the patella. With the fingertips of your right hand firmly on the patella, push down briskly. In a moderate sized effusion you will feel a tapping sensation as you push the ‘floating’ patella down to strike the femur. Ripple Sign (small effusion): With the knee relaxed and extended empty the suprapatellar bursa with your left hand and keep your hand there. Stroke the medial side of the knee with your right hand. Stroke the lateral side of the knee with your right hand. If a small effusion is present you will see a bulge (or ripple) of fluid on the medial side of the knee. (Images used with permission from Queen's University Belfast). 43 Assessment of knee ligaments: These assessments have been described in detail so that you can practice independently. Collateral ligaments: The patient lies on the examination couch and the knees must be relaxed! Medial and lateral collateral ligaments are assessed with the knee in extension, and with the knee in 20-30 degrees of flexion to relax the posterior capsule There should be no varus or valgus movement when the collateral ligaments are assessed with the knee in extension There may be up to 10° of lateral movement when the collateral ligaments are assessed with the knee flexed to 20-30° to relax the posterior capsule To assess collateral ligaments in the right knee with the knee in extension: o Stand on the right side of the patient so you can see the patient’s face easily while assessing the right knee o The patient lies supine on the examination couch with both legs relaxed and the knees in full extension o To assess the right medial collateral ligament place your left hand at the lateral side of the knee. Place your right hand at the medial side of the ankle o Apply a valgus (outward) stress by pushing the ankle outwards with your right hand while keeping the knee in position with your left hand o To assess the right lateral collateral ligament place your right hand at the medial side of the knee. Place your left hand at the lateral side of the ankle o Apply a varus (inward) stress by pushing the ankle inwards with your left hand while keeping the knee in position with your right hand o Note any pain or laxity To assess collateral ligaments in the right knee with the knee in 20-30 degrees flexion: o Stand on the right side of the patient so you can see the patient’s face easily while assessing the right knee o The patient continues to lie supine on the examination couch o Bend your right knee and place it on the couch to provide a platform to keep the right knee relaxed in 20-30 degrees flexion o To assess the right medial collateral ligament place your left hand at the lateral side of the knee. Place your right hand at the medial side of the ankle o Apply a valgus (outward) stress by pushing the ankle outwards with your right hand while keeping the knee in position with your left hand o To assess the right lateral collateral ligament place your right hand at the medial side of the knee. Place your left hand at the lateral side of the ankle o Apply a varus (inward) stress by pushing the ankle inwards with your left hand while keeping the knee in position with your right hand o Note any pain or laxity 44 To assess collateral ligaments in the left knee with the knee in extension: o Stand on the left side of the patient so you can see the patient’s face easily while assessing the left knee o The patient lies supine on the examination couch with both legs relaxed and the knees in full extension o To assess the left medial collateral ligament place your right hand at the lateral side of the knee. Place your left hand at the medial side of the ankle o Apply a valgus (outward) stress by pushing the ankle outwards with your left hand while keeping the knee in position with your right hand o To assess the left lateral collateral ligament place your left hand at the medial side of the knee. Place your right hand at the lateral side of the ankle o Apply a varus (inward) stress by pushing the ankle inwards with your right hand while keeping the knee in position with your left hand o Note any pain or laxity To assess collateral ligaments in the right knee with the knee in 20-30 degrees flexion: o Stand on the right side of the patient so you can see the patient’s face easily while assessing the right knee o The patient continues to lie supine on the examination couch o Bend your right knee and place it on the couch to provide a platform to keep the right knee relaxed in 20-30 degrees flexion o To assess the right medial collateral ligament place your left hand at the lateral side of the knee. Place your right hand at the medial side of the ankle o Apply a valgus (outward) stress by pushing the ankle outwards with your right hand while keeping the knee in position with your left hand o To assess the right lateral collateral ligament place your right hand at the medial side of the knee. Place your left hand at the lateral side of the ankle o Apply a varus (inward) stress by pushing the ankle inwards with your left hand while keeping the knee in position with your right hand o Note any pain or laxity To assess collateral ligaments in the left knee with the knee in 20-30 degrees flexion: o Stand on the left side of the patient so you can see the patient’s face easily while assessing the left knee o The patient continues to lie supine on the examination couch o Bend your left knee and place it on the couch to provide a platform to keep the left knee relaxed in 20-30 degrees flexion o To assess the left medial collateral ligament place your right hand at the lateral side of the knee. Place your left hand at the medial side of the ankle o Apply a valgus (outward) stress by pushing the ankle outwards with your left hand while keeping the knee in position with your right hand o To assess the left lateral collateral ligament place your left hand at the medial side of the knee. Place your right hand at the lateral side of the ankle o Apply a varus (inward) stress by pushing the ankle inwards with your right hand while keeping the knee in position with your left hand o Note any pain or laxity 45 To assess the right cruciate ligaments: o The patient is still lying supine on the examination couch o Stand on the right side of the patient o Ask the patient to bend their knees so they are at 90° o Look at the knee and check for posterior sag by comparing with the left side. Posterior sag is posterior subluxation of the tibia on the femur. This can cause a false positive anterior drawer sign. o Fix the right knee in place by sitting with your right thigh on the foot to immobilise it o Anterior draw test: gently and firmly pull the proximal tibia anteriorly (forwards). This assesses anterior cruciate ligament stability. More than 5mm of movement suggests a torn anterior cruciate ligament. o Posterior draw test: gently and firmly push the proximal tibia posteriorly (backwards). This assesses posterior cruciate ligament stability. More than 5mm of movement suggests a torn posterior cruciate ligament. To assess the left cruciate ligaments: o The patient is still lying supine on the examination couch o S