Table of contents
- 1. Hip Exam
- 2. KNEE Exam
- 3. Back
- 4. Shoulder
- 5. Wrist/Hand
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Hip Exam
Inspection
GALS Screening
- Do you have any pain or stiffness in your muscles joints or back?
- Can you dress yourself completely without difficulty?
- Can you walk up down stairs without difficulty?
- Gait
- Observe shoulders, iliac crests, gluteal, popliteas, foot abnormalities varus/valgus
- Observe: Antaglic gait (limp), Trendelenburg gait, heel strike, toe off, arm swings, alignment of back and shoulders.
- Side: cervical lordosis, thoracic kyphosis, lumbar lordosis
- Front: swelling deformity foot archers, forefoot deformity
- Movement:
- Lateral flecture - touch ear to shoulder
- TM joints - move mouth side to side
- Shoulder abduction + ext rotation: put hands behind head
- Inspect wrists: swelling deformity
- Fist, Power Grip (squeeze fingers)
- Thumb to fingers for joint mobility
- Squeeze MCP joints (inflammatory?)
Non-GALS Inspection
- Symmetry
- Alignment
- Swelling
- Muscle Atrophy
- Trendelenburg Test
- Antalgic gait/Trendelenberg gait
Supine:
- Symmetry, Alignment,
Landmark
- Greater trochanter
- ASIS
- iliac crest,
- IT band
- Lymph nodes + pulse
- Leg Length (true Asis- Med malleolus, apparent, umbilicus – med malleolus)
Palpation
ROM
- Hip Flexion
- Hip Extension (active/passive)
- Hip External Rotation
- Hip Internal Rotation
- Hip Adduction (stabilize contralateral pelvis)
- Hip Abduction
Special Test
- Faber Test: malleolus on left knee, move knee out (Flection, abduction, external rotation)
- Flexion Contraction: Flex knee, see if other knee flexes, support contralateral side or put hand under back.
KNEE Exam
History
- Mechanical
- Locking? (meniscal tear)
- Pop during injury? (ligament injury)
- Knee giving way? (patellar subluxation or ligamentous rupture)
- Effusion:
- Rapid onset: within 2h? (hemarthrosis: rupture of ACL or fracture of tibial plateau, peripheral 1/3 of meniscus torn [vascular part])
- Slow onset (consistent with meniscal injury or ligamentous sprain).
- Mechanism of injury
- Acceleration + deceleration (stopping suddenly): ACL tear
- Twisting component of injury: meniscus
- Direct blow to planted knee: collateral ligament injury
- Hyperextension: ACL or PCL
KNEE
Inspection
- Front/side/back
- SEADS
- Alignment: Varus/valgus deformity/genu recurvatum (hyperextension)
- Symmetry
- Swelling
- Color
- Atrophy
- GAIT:
- full extension flexion of knee while walking
- antalgic gait?
Palpate
- Temperature
- Check Effusion:
- 1. Bulge Sign
- 2. Ballottement Test: Push down on one side, feel fluid with other
- 3. Patellar Tap Test
- 4. Joint Line Tenderness (flexed knee)
- Range of Motion
- Flex/Extend knee look for ROM (touch knee to buttocks)
- Flex/Extend palpate crepitus
- Ligamentous Tests:
- LCL: varus stress @ 30° flexion (also do in full extension: ACL and bone articulation stabilizes it in full ext.).
- MCL: valgus stress @ 30° flexion (also full ext.)
- ACL:
- Drawer Test (recent data not favourable)
- Lachman test: knee 30° flexion: one hand on femur, another on tibia, try ant. displacement of tibia
- PCL
- Posterior Drawer Test
- McMurray’s Tests: (Pain or clicking/catching = positive)
- MCL: flexed knee, int rotation, valgus strain ... then move to extended
- LCL : flexed knee, ext rotated, varus strain...then move to extended.
- Images:
-
Lachman Test McMurray's Test
Back
- Pattern 1: disk problem, worse with flexion
- Pattern 2: stenosis/post joint, worse with extension
- Pattern 3: Sciatica – L4, L5, S1, S2, leg dominant affected by back movement
- Pattern 4: Neurogenic Claudication – leg pain, worse with activity immediately better with rest (vascular >5min rest needed)
- Inspection (undrape upper body, females tie gown at neck)
- Scars/masses/lesions
- Deformities (kyphosis, scoliosis)
- Posture
- Symmetry
- Palpation:
- Along the spine (swelling, bony/soft tissue abnormalities, masses, tender)
- ROM
- 1. Forward Flexion (“Bend forward touch your toes”)
- 2. Extension (“arch your back”)
- 3. Side flexions (“slide your hand down your leg”)
- 4. Rotation (“twist toward each side”) (w/o moving pelvis)
- 5. Chest Expansion
- Tape measure around chest, take deep breath (full insp – rest)
- 6. Schober’s Test (ank. Spond., seronegative)
- Mark midline 5cm below PSIS and 10cm above, ask to flex and measure length (5cm incr or more is normal)
- 7. Check neuro system of legs.
- 8. Straight leg raise – supine raise straight leg (pain at 30-60deg if radiculopathy)
- 9. Femoral stretch test - prone, bend knee to buttocks (pain = tight quads, irritated femoral nerve?)
- Another way to approach it:
- Inspect back
- Palpate back
- Check ROM
- Chest expansion, schrober’s test
- Sit down in chair
- Ankle reflex
- Dorsiflex + extend toes
- Sit in bed:
- Knee jerk, banbinski
- Lie supine
- Straight leg raise
- ROM thigh
- Dorsalis pedis (claudication can present)
- Check abdo sometimes abdo pain can masquerade as back pain
- Lie prone
- Saddle sensation (S1, S2, S3)
- Clench buttocks (S1)
- Femoral stretch test
Shoulder
- Pain, weakness, ROM, function, radiating?
- Inspection: (sitting on edge of bed or standing)
- Skin (scars/masses/lesions)
- Soft Tissue (swelling/asymmetry/atrophy)
- Bone (deformity, asymmetry, winging of scapula - serratus anterior and trapezeus problem)
- Palpation: (watch face for pain)
- Joints (both hands, symmetrically joints)
- SC joint
- Along clavicle
- AC joint
- GH joint
- Scapula
- Cervical spine
- Extra-articular
- Biceps groove, subdeltoid bursa, rotator cuff tendons
- Crepitus (over GH joint), hand on shoulder, circumduct the arm
- Sensation (light touch over deltoids both sides..same? – axillary nerve)
- Joints (both hands, symmetrically joints)
- ROM
- Neck ROM
- Flexion “look down”
- Extension “look up”
- Rotation “turn head side to side”
- Later flexion “ear to shoulder”
- Shoulder ROM
- Trace an arch focus on up/forward (forward flexion/Elevation) [can also test "drop arm test"]
- Reverse arc and focus backwards (extension)
- Raise arms from sides over the head (abduction)
- Apley Scratch test (Adduction + internal rotation) reach up the back (normal ~T7)
- Put hands on head, reach back with elbows (Abduction and External rot.)
- Special tests (if pathology suspected)
- Rotator cuff tear
- Supraspinatus – shoulder abduction
- "Drop arm test". Abduct arm completely, and slowly adduct. Deltoid helps until 90°, then if arms drop to sides = supraspinatus tear or dysfunction.
- Infraspinatus + Teres Minor (ext rot) - bend elbow ask to ext. rotate against resistance
- Subscapularis - hand on back, ask to push backwards against resistance OR pat the abdomen. (NOTE: internal rotation is subscap + pectoralis)
- Drop Arm (suprasp.+ deltoid) à abduct shoulder completely, ask to lower smoothly (if drops pos test)
- Supraspinatus – shoulder abduction
- Impingement tests
- "empty can" abduct shoulders to 90deg thumbs down, examiner pushes down against resistance
- Neer’s test: The arm is fully pronated and placed in forced flexion (Pinch tendons under coracoacromial arch)
- Hawkin’s-Kenedy Test – 90° flexion, internally rotate (push down)…pain?
- AC Joint disorder
- AC joint stress – arm 90° frwd flexion, move arm across chest
- Tests of shoulder instability
- Anterior Apprehension – one hand on shoulder joint, other hand on wrist, arm 90° lat abducted and elbow bent 90° up. Ext rotate arm and push forward shoulder to sublux.
- Post Apprehension – fwd flex arm 90°, push on elbow post. While applying forward pressure to scapula
- Inferior stability – stand arms down, grab below elbow and pull distally
- Rotator cuff tear
- Images:
-
Neers Hawking-Kenedy -
Sulcus sign (inferior apprehension) Spurling's Test (C-spine pain)
- Neck ROM
Wrist/Hand
- Pain
- Numbness tingling (carpal tunnel?)
- Stiffness? Weakness?
- Inspection
- Inspect front/back of hand
- Nails (pitting, hemorrhages)
- Swelling contractures, atrophy
- Joints – Misalignments, deformity
- Tuck sign – make fist and extend slowly (look for fluid on dorsum)
- MCP
- PIP
- DIP
- Palpation
- Joints (Joint line tenderness? Effusion? Bony sructures? Joint pain? Crepitus?)
- Radial-Ulnar joint
- Radial-Carpal joint
- MCP joints
- PIP and DIP joints
- 1st carpal metacarpal joint
- Palm of hand
- Compress palm between thumb and fingers feel tendons (thickening? Tenderness? Nodules?)
- Joints (Joint line tenderness? Effusion? Bony sructures? Joint pain? Crepitus?)
- Range of Motion
- Supination
- Pronation
- Wrist flexion (check stress pain?)
- Wrist extension (check stress pain?)
- Ulnar deviation
- Radial deviation
- Fist, and then extend all joints
- Thumb
- Carpal tunnel test
- Tinnel’s test (Tap on median nerve in wrist, numbness/tingling positive)
- Phelan’s test (Flex wrists against each other dorsal side in for 60s, numbness/tingling positive
- DeQuervain’s Disease test (Finklestein Test)
- Make fist with thumb inside + ulnar deviation..pain?
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