Examinations

Lower Limb

Foot & Ankle Exam

Look

 

Aids

Shoes - raises / wear patterns

Stigmata generalised disease

Hands - RA, CMT

 

Front

 

Knee alignment

Forefoot - Hallux & Lesser toes 

Scars

Circulatory changes

 

Medial Side

 

Turn affected side away & ask to step foot forward

Flexed attitude of knee

Medial arch - planus / cavus

 

Behind

 

Spine - scoliosis / spinal dysraphism

Hindfoot varus / valgus

Forefoot (Too many toes)

Scars

 

Calf wasting

 

Double heel raise 

- Heel swings into varus or remains in valgus

- ? mobile subtalar joint

- ? Medial arch restoration

 

Single heel raise

- Must put patient close to blank wall half a foot length from the wall

- otherwise will cheat by pushing up or leaning forward against wall 

 

Lateral side

 

Haglund's

Peroneal tendons

 

Gait

 

Ankle

- Stiff / Fixed equinus 

- Weak / Foot drop

- Painful / Antalgic

 

Foot Progression angle

Tip toe - strong S1

Heel walk - strong L4

 

Sit

 

On edge of bed with legs hanging

- examiner sits on chair

 

Screen active ROM AKJ and STJ bilaterally

 

Look at sole

- normal distribution weight pattern

- callosities

- lumps / plantar fibromatosis

 

Feel

" Where is it painful?"

 

Lateral aspect

- lateral malleolus

- lateral ligament complex

- Peroneal tendons

- sinus tarsi

- base of 5th 

 

Posterior aspect

- tendo-achilles

- insertional / non insertional

 

Medially

- deltoid ligament

- tibialis posterior

- MT joints

- sustenaculum tali

 

Anterior

- ankle joint tenderness / effusion

- AITLF

 

Sole

- fat pad

- insertion of plantar fascia

 

Midfoot

 

Forefoot

- hallux rigidus

- sesamoids

- metatarsalgia

- Mulder test / interdigital tenderness

 

Move

 

DF - active and passive range 20o

 

PF - active and passive range 50o

 

Subtalar joint motion 

- ankle in 90° DF

- thumb on talar neck to detect talar movement 

- opposite hand cups heel and inverts & everts 

- Inversion 10-15o

- Eversion 0-5o

 

Midtarsal joint

- Foot at 90 to lock ankle mortise

- Adduct foot 20o

- abduct foot 10o

- dorsiflex

- plantarflex

 

T Ach

- Tenderness along tendon /Insertion, ? lump

- test power / pain

 

Foot Exam Tibialis AnteriorFoot Exam Tibialis PosteriorFoot Exam Peroneals

 

Tibialis posterior

- Prominent with plantarflexion and inversion

- Thickening

- Tenderness

- Check power if abnormal

 

Peroneus brevis & longus

- thickening

- Tenderness

- Dislocation (resisted eversion)

- active eversion

 

Tibialis anterior

- Prominent with dorsiflexion and inversion

- Insertion

 

EHL & EDL - Dorsiflex toes

 

Special tests

 

Instability

 

Anterior drawer

- Due to complete tear of ATFL

- Grasp lower tibia and cup calcaneum

- "clunk" or draw

- compare with other side > 3 mm

 

Lateral instability

- Inversion stress

- Gaping of soft tissues

- Talar tilt (may occur in normal & must compare with other side)

- Needs to be confirmed on stress views

- > 20o

 

Medial instability

- Eversion stress

- Gaping / widening

- Needs to be confirmed on stress views

 

Gastrocnemius /soleus contracture

 

Test if limited dorsiflexion

 

Silverskiold Test

- Extend knee - dorsiflexion limited by both soleus & gastrocnemius contracture

- Flex knee - gastrocnemius relaxed (crosses knee joint)

- If dorsiflexion still limited it is due to soleus contracture

- If limited in extension & not in flexion then due to gastrocnemius contraction

 

Pes cavus

 

Claw toes - flexible / fixed

 

Individual power compared with other side

- Tibialis anterior (inversion in DF)

- Tibialis posterior (inversion in PF)

- Peronei

 

Coleman block test

- Dynamic visualisation of hindfoot correction

- Stand on 2cm block

 

Passive correction of plantar-flexed 1st MT

 

Spine / Neuro Exam

 

Hallux valgus

 

MTPJ Painful / limited range

- flexion 45o

- extension 70-90o

- redo range with correction

 

IPJ

- hallux interphalangeus

- extension / flexion

 

Lesser toes

- fixed / mobile

- dislocated

 

Concealed

 

Spine

Neuro exam

Vascular exam

Ligamentous laxity

 

 

Gait Exam

Definition

 

Limp - asymmetrical gait pattern

Note:  Children assume adult walking patterns by the age of eight

 

Normal Gait

 

1.  Rate

- increased, decreased or normal

 

2.  Rhythm

- normal or limp

- limp is a disturbance in normal rhythm

- numerous causes - see below

 

3. Gait cycle

- individual cycle

- from one foot strike to the same foot strike

- stance 60% swing 40%

 

Phases

 

Initial contact - knee extended

 

Loading response - knee flexed, ankle DF

 

Mid stance

 

Terminal stance - hip extends, heel rise

 

Pre swing - ankle PF

 

Initial swing 

- need foot clearance 

- knee flexed, ankle DF

 

Mid swing

 

Terminal swing

 

Elements of gait asymmetry

 

STRAWS

 

Short 

Trendelenburg (gait or lurch)

Rigid -  hip / knee / ankle

Antalgic - painful, shortened stance phase

Weak - hip (trendelenberg), knee (back knee gait), ankle (high stepping)

Supratentorial (CNS - spastic / ataxic / toe walking / crouch / jump)

 

Gait Examination

 

Examine in coronal plane (from front) and in sagittal plane (from side)

 

Foot

 

Coronal

- foot progression angle

- bilateral in / out toeing

- old SUFE (walk with ER)

 

Sagittal (F/E)

- should have 3 rocker phases (might have just one or two)

- Heel Strike / Plant / Toe off

- nil heel strike in toe walker / cp - equinus may be fixed or not

- high stepping gait if weak

- equinus if LLD (shouldn't be fixed)

 

Knee

 

Coronal

- varus / valgus malalignment & thrust

- squinting / medially facing patella secondary increase PFA

 

Sagittal (F/E)

- achieving full extension in stance (not in a cp)

- back leg gait (weak knee extensors eg polio)

- may hold flexed in LLD

 

Hip

 

Coronal

- abductor lurch

- scissoring (adductor tightness in cp, increased PFA)

 

Sagittal (F/E)

- hyperflexion / FFD (hyperlordosis)

- weak hip flexors - back extension

 

Pelvis

 

Coronal

- pelvic asymmetry secondary to LLD / scoliosis

 

Sagittal

- hyperlordosis (hip FFD)

 

Trunk

 

Coronal - swaying side to side

 

Head - up and down with LLD

 

UL

- a hemiplegic will swing only one arm

 

Specific Gait patterns

 

Short 

- head and shoulders drop as patient steps onto short limb (bobbing up & down of head and shoulders in sagittal plane)

- Pelvis drops on affected side with heel strike and exaggerated head motion in sagittal plane

- vaulting gait

- flexion knee, equinus ankle 

 

Stiff

 

Hip 

- head & torso sways front to back in sagittal plane as walks

- Decreased hip flexion on swing phase and lumbar motion increases (AP sway)

 

Knee

- hip circumducts

- little flexion / extension through stance

 

Ankle

- may turn foot out to use STJ

- limitation F/E in sagittal plane

- DDX unilateral fixed equinus

- Tight TA / Hemiplegic CP / Short leg / Foot drop

 

Pain

- shortened stance phase

 

Weak

 

Hip

- Trendelenberg / abductor lurch

- head and shoulders sway side to side

 

Knee

- weak quads

- back knee gait

 

Ankle

- Foot drop gait

- High stepping gait

 

Neuromuscular

 

Spastic gait 

 

Diplegic

1.  Equinus gait - nil heel strike in rocker phases

2.  Jump gait - ankle equinus, knee flexion

3.  Crouch gait - ankle / knee + hip flexion

4.  Scissoring gait

 

Hemiplegic

- unilateral loss heel strike, knee held flexed

- nil movement of arm in swing

 

Ataxia 

- broad based gait

 

 

 

Hip Exam

Look

 

Walking aid

 

Footwear - shoe raises

 

Front

- Overall alignment of Lower Limb

 

Side

- lumbar lordosis

- flexed attitude of hip / knee

- scars

 

Back

- lumbar spine

- buttock wasting

- popliteal creases

- examine ROM

- try to differentiate spine and hip

 

Functional Leg Length

 

Attain symmetrical stance

- knees extended

- feet flat on ground

- check levels of ASIS

- comment on

 

A.  Pelvis is level / not level

B.  Stance is symmetrical

C.  Coronal plane deformity - Knee is flexed, ankle is in equinus 

 

Situations

 

A.  Pelvis is level with symmetrical stance

- no LLD

 

B.  Pelvis is not level with symmetrical stance

- uncompensated LLD

 

C.  Pelvis is level with asymmetrical stance

- compensated LLD

 

D.  Pelvis is not level with asymmetrical stance

- partially compensated LLD

- contractures

 

Blocks 

- if pelvis not level

- to assess functional leg length discrepancy

 

Trendelenberg

 

Aim

- assess if patient's abductors can elevate ASIS on affected side

- without using trunk

 

Technique

- visualise ASIS or PSIS

- stand on good leg

- opposite ASIS should rise

- stand on bad leg

- cannot raise opposite ASIS
- either fall or have to lean trunk over

 

False negative test

- able to maintain abduction with no abductor function

- fixed abduction contracture

- arthrodesed hip in abduction

 

Invalid if

- poor balance

- generalised weakness

- lack of co-ordination or understanding

- costo-pelvic impingement

 

Causes

 

1. Pain

- painful disorder of hip

- centre over hip to decrease abductor pull

- decrease joint reaction forces  

 

2. Pivot

- dislocation or subluxation of hip

- shortening of femoral neck 

- abductors cannot work correctly

 

3. Power 

- weakness of abductors

 

Gait

 

STRAWS

 

Short 

- shoulder drops on ipsilateral side

- head up and down

 

Trendelenburg 

- abductor lurch

 

Rigid / Stiff

- hip

- knee

 

Antalgic

- shortened stance phase

 

Weak

- back knee gait

- foot drop

 

Supratentorial (CNS)

 

Supine on Examination Bed

 

Feel

 

Along line of inguinal ligament from medial to lateral

- masses (dislocated femoral head, hernias, aneurysms, lymph nodes)

- tenderness (LCFN)

 

Along posterior greater trochanter

- tenderness (trochanteric bursitis)

 

Knee

 

Exclude FFD of knee

- allows assessment of leg length (correct with pillow)

- allows assessment of FFD of hip (must put knee over bed)

 

Valgus knee

- difficulty measuring LL

- will be unable to put other leg in same position

- must measure components

 

Hip

 

Normal ROM

- Flexion / extension 140o

- adduction / abduction 400

- IR / ER

 

Thomas' Test

 

Angle through which thigh is raised from couch is angle of fixed flexion

 

Fixed flexion deformity of knee

- place patient at edge of couch

- when assessing FFD, move heel over edge of couch

- lower heel below level of couch

- to eliminate effect of knee FFD

 

Method

- passively flex both knees to 45o

- place hand behind back and

- ask patient to clutch unaffected knee to chest

- ensure lumbar lordosis eliminated

- this fixes pelvis

 

Extension

- gently extend affected hip passively

- lift heel off bed

- stop when painful

- fixed flexion deformity of (x)o

 

Flexion

- ask patient to actively flex affected hip

- gently passively maximise flexion

- comment

- flexes to (y)o

- flexion arc of (x)o FFD to (y)o

 

Abduction / Adduction in Extension

 

Position

- hip and knee extended

- fix pelvis by abducting unaffected hip so that leg dangles over edge of couch

- palpate ipsilateral ASIS

- abduction / adduction both sides

- know at extremes of limit when ASIS / Pelvis begins to move

 

Internal and External Rotation in Flexion

 

Position

- hip flexed to 90o

- hold leg with one hand

- hand in popliteal fossa

- leg resting on forearm

- assess pelvis movement with other hand

- palpate contralateral ASIS

- internal rotation, turn foot out

- external rotation, turn foot in

- examine contralateral side 

 

Leg Length

 

Make pelvis square with bed

- attempt to make legs square with pelvis and straight

- ensure buttocks not in dip in bed

- ensure normal heel height

- ensure no asymmetrical buttock wasting

 

Apparent LL 

- leg length measured without correcting for sagittal or coronal plane deformity

- from umbilicus to medial malleolus

- tape measure

 

True LL 

- leg length measured once coronal & sagittal plane deformity corrected for 

- sum of intercalated segments

- ASIS to medial malleolus

 

Correct for 

 

1.  Abduction contracture

- comment on contracture

- unable to place legs perpendicular to pelvis because of abduction contracture

- must place other leg in same position

- abduct unaffected hip same degree

- measure leg length

 

2.  Adduction contracture

- comment on contracture

- unable to place legs perpendicular to pelvis because of adduction contracture

- must place other leg in same position

- measure leg lengths sequentially

- cross one leg and measure

- cross other leg and measure

 

3.  FFD Hip or Knee

- correct with pillows

 

4.  Equinus foot

- look below medial malleolus

- difference in effective heel height because of equinus contracture

 

5. Coronal plane deformity knees

- cannot correct for 

- must measure intercalated segments

 

Galeazzi's sign

 

Identify level of leg length discrepancy

 

Flex knees to 90o with hips and ankles at 45o

- put malleoli at same level

- any hindfoot asymmetry makes test inaccurate

 

Femurs parallel

- tibias same height

- discrepancy above knee

 

Tibias parallel

- femurs same length

- discrepancy in tibia

- knees at different levels

 

LLD above GT

 

1.  Bryant's triangle

- identify ASIS with thumb & tip of greater trochanter with forefinger

- drop imaginary lines down to floor

- distance between the lines

- difference in distance between ASIS and GT suggests discrepancy proximal to GT

- assess perpendicular distance between points with fingers of other hand

- perpendicular distance between points is different by (x) fingerwidths

 

2.  Schoemaker's line 

- line from greater trochanter thru ASIS

- projection from each side should cross proximal to umbilicus

- if shortening above gr trochanter then the lines will cross below the umbilicus

 

3.  Nelaton's line 

- ischial tuberosity to ASIS

- with patient lying on the side

- the greater trochanter should lie on the line

 

Knee Exam

Look

 

Shoes

Walking aids

 

Front

 

Knee alignment 

- physiological valgus

 

Patellar rotation 

- squinting (inwards, increased PFA) 

- grasshopper eyes (high and lateral)

 

Swelling

Quads Wasting

Scars

 

Knee effusion

 

Side

 

Knee attitude

- flexion

- recurvatum

- push knees back

 

Knee FFD Standing

 

Step foot forward and bear weight

- examine arch

 

Scars

 

Behind

 

Hindfoot valgus

Swelling popliteal fossa

Wasting of hamstrings or calf

Level popliteal creases

 

Other Side

 

Knee attitude

- flexion

- recurvatum

- push knees back

 

Step foot forward

 

Scars

 

Gait

 

Rigid / Stiff

- decreased flexion / extension range

 

Antalgic

 

Weak knee

- back knee gait

 

Medial or lateral thrust

- valgus or varus moment about the knee

 

Foot progression angle

 

Sit on Edge of Bed

 

Patella tracking

- crepitus

 

J tracking

- patellar sharply deviates laterally in terminal extension

- or travel laterally until jumps into trochlea at midrange of flexion

 

Supine

 

Look 

- quads wasting

- alignment

- scars

 

Effusion

- swipe, ballot, tap

 

Range

- FFD / Recurvatum / lift foot in air

- active extension / quads lag

- range of flexion bilaterally

 

Knee FFD LyingKnee FFD Fixed

 

FFD

- effusion

- entrapped meniscus

- ACL stump

- loose body

 

Feel

 

Flat

- Extensor mechanism

- patella

- tibial tuberosity

 

Flexed

- Joint lines, MCL, LCL

- tibial and femoral condyles

- popliteal fossa

 

Palpate distal femur for osteochondromas

 

Examine Ligaments

 

Collaterals

 

Test at 0 and 30o

- if loose at 0, loss of secondary stabilisers

 

Grading

1+   Surfaces separate 5mm or less

2+   5 - 10 mm

3+   10 mm or more

 

ACL / PCL

 

Lachmann's

- 85% sensitive awake

- 100% asleep

 

Check loss of tibial step off

- posterior sag

- MTP normally 1 cm anterior to MFC

 

Quadriceps active

- knee at 90o

- stabilise foot & ask to slide foot down bed

- N < 1mm / PCL > 3mm

 

Anterior / Posterior drawer

- restore tibial step off

 

Posterolateral drawer

- 30o IR

- tightens PLC

 

Posteromedial drawer

- 15o ER

- tightens PMC

 

Pivot Shift

- valgus stress with IR + axial compression

- knee moved from extension to flexion

- in chronic ACL deficiency, the LTC is subluxed anteriorly

- at 30o it reduces backwards

- this is when ITB passes behind axis of rotation and becomes flexor

- grade pivot glide / 1 / 2 / 3

 

Must have 4 things

- MCL to pivot about

- intact ITB

- no FFD

- ability to glide i.e. no meniscal pathology

 

PCL / Posterolateral Corner (PLC)

 

External rotation / Recurvatum

- hold big toe and assess PLC

- knee moves into recurvatum, tibia externally rotates & subtle varus

- indicates PCL + PLC + LCL

 

Reverse pivot shift 

- with valgus and ER

- flexion to extension

- in flexion, the LTP is posteriorly subluxed

- ITB become extensor

- reduces as extend

- must compare with other side

- present in 30% normal population especially ligamentous lax

 

Dial test / Prone

- measure thigh foot angle

- examiner holds knees together

- increase at 30o only  - PLC

- increases at 30 then again at 90 - PLC + PCL

- isolated PCL - no increase

- >10o compared with normal side

 

Meniscus

 

McMurray

- Flexion to extension

- Full IR - LM

- Full ER - MM

- i.e. test meniscus heel is pointing towards

- positive test is palpable / audible thud, snap, click

 

Squat test

- feet IR and ER

 

4Cs

 

Concealed / popliteal fossa

 

Cephalad / Hip

- rotation in flexion

- adduction / abduction in extension

 

Circulation

 

Collagen

 

PFJ Exam

Look

 

Stigmata Generalised disease

- Marfan's

 

Ligamentous laxity Wynne Davies

- positive if 3/5 pairs

- thumb touches volar forearm

- fingers parallel to forearm dorsally

- elbow hyperextends past 0o

- knee hyperextends past 0o

- ankle dorsiflexes > 45o

 

Front

 

VMO bulk

Swelling

Scars of previous surgery i.e. TTT

 

Planovalgus Feet / Hyperpronation

 

Genu Valgum

 

Squinting patella 

- Proximal Femoral Anteversion  (PFA)

- patellae point inwards when standing

 

Grasshopper eyes 

- patellas sit high & lateral

- due to patella alta 

- patella subluxed laterally 

 

Side

 

Flexed attitude Knee

Scars

 

Back

 

Level Popliteal creases

Valgus Heels

 

Gait 

 

Foot Progression Angle

- Normal 10° (0-30°)

- any in-toeing

- indicative of PFA

 

Sit on ege of Bed

 

Patella Tracking

- J sign

- lateral subluxation in terminal extension

 

Crepitus

 

Supine

 

Effusion

 

3 signs in Extension

 

1.  Tenderness

- tibial tuberosity

- lateral patella retinaculum

- patella

- Bassett's sign (MPFL on med epicondyle)

- pain with patella grind (compression)

 

2.  Clark's test

- gentle pressure on superior pole

- patient asked to contract quadriceps

- compare with other side

 

3.  Patellar Tilt Test

- Patient supine and relaxed with knees extended

- Trans- epicondylar axis placed parallel to table

- Lateral edge of patella elevated & medial edge depressed

- normal is lateral tilt 0-20°

- Abnormal if unable to tilt to horizontal

- indicated lateral retinaculum tightness

 

3 Signs in 30o Flexion

 

1.  Q angle 

- Knee at 30° flexion so patella engages femoral sulcus

- ASIS to centre of patella to tibial tuberosity

- abnormal > 15° in males 

- abnormal > 20° in female

 

2.  Patellar glide test (Sage Mobility)

-  Graded by number of 1/4 widths that patella displaces

- > 3 insufficient medial restraints

- < 1 tight lateral retinaculum

- > 3 insufficient lateral restraints

 

3.  Apprehension test

- patient supine and relaxed

- patella pushed laterally while knee flexed 30o

- positive if patient uncomfortable (pain or apprehension)

 

Prone / Rotational profile

 

Best is all assessed prone

 

1.  Lateral border of foot

- metatarsus adductus

 

2.  Tibial Torsion

- thigh foot angle > 15o

- trans-malleolar axis > 30o

 

3.  Femoral anteversion 

- excessive IR

- increased Gage's trochanteric angle

 

 

 

Sciatic Nerve Exam

Look

 

Wasting of anterior & lateral compartments leg

Scars at fibula head

Masses

Feet for dystrophic changes

Back - surgery / dystrophic changes

Hip - scars

 

Gait

 

Foot drop gait, high stepping, slapping

 

Feel 

 

Along CPN

 

Tinel’s

 

Sensation Tibial nerve

- sole of foot

 

Sensation CPN

- SPN dorsum of foot

- DPN 1st webspace

 

Move

 

Tibial nerve

- hamstrings

- T. Ach

- FHL

- FDL

 

CPN

- T. Ant (L4)

- EHL (L5) – often 1st damaged as most prox br

- EDL (L5,S1) – isolated with ankle in DF

- PL & PB (L5,S1) – eversion & palpate

 

DDx

 

L5 v Sciatic / Tibial

- examine Abductors (L5)

 

CPN above knee v below knee

- short head biceps EMG

 

 

 

Paediatric

Cerebral Palsy

Examination

 

Aids 

 

AFO / KAFO

- ankle foot orthosis

- knee ankle foot orthosis

 

GRAFO

- ground reaction AFO

 

Kaye walker 

- seat on it

- co-ordinates walking

 

Reciprocal Gait Orthoses

 

Sitting

 

Short adducted leg - dislocated hip

Scoliosis

Kyphosis - query secondary tight hamstrings

 

Walking

 

Decreased velocity 

 

Coronal Plane

- scissoring / tight adductors)

- asymmetrical arm swing / hemiplegia

- LLD / hip dislocation

 

Sagittal

- equinus / jump / crouch 

 

A.  Equinus

- ankle in equinus

- knee straight or in recurvatum

- hip extends full

 

B.  Jump

- equinus of ankle

- flexion of knees and hips, never extend fully

 

C.  Crouch

- ankle in dorsiflexion

- over lengthening of T Achilles

- have to flex knees and hips to regain centre of balance 

 

Lower Limb

 

R1 - do slowly

R2 - do quickly

 

Looking for a difference between the R1 and R2

- if reduced ROM on R2, have spasticity / dynamic element

- amenable to botox

 

Supine

 

1. Psoas

- FFD / Thomas test

- must test knee first

- do over edge of bed if FFD knee

 

2. Adductors

- scissored gait if bilateral

- apparent leg length inequality if unilateral

- Trendelenburg gait 

- decreased hip abduction

 

3. Hamstrings

- FFD at knee

- knee flexed at start of stance phase

 

Popliteal angle (hip flexed at 90°)

- straight is 0˚

 

Unable to sit up with legs straight

- decreased  SLR

- can't touch toes

 

4. Triceps Surae

- ankle equinus

- tiptoe gait

 

Silverskiold test 

- distinguish between the gastrocnemius and soleus

- test ankle DF range with knee flexed and extended

- if gastrocnemius tight, reduced DF with knee extended

 

On side

 

5. Iliotibial Tract

 

Obers' test 

- patient on side and flex knee with hip in neutral abduction then as flex knee further hip abducts 

 

Prone

 

6. Quadriceps

- stiff leg gait

- inability to flex knee with hip extended suggests tight rectus

 

Ely test (RF)

- child prone 

- when the knee is flexed the hip flexes suggesting tight RF

 

7.  Rotational profile

 

Tone

 

Increased / clonus / clasp knife

 

Reflexes

 

Increased

 

Primitive Reflexes

 

Moro  

- child supine in arms, allow head to drop back 

- arms & legs stick out in extension

- disappears by 4 months

 

Parachute

- arms and legs extend when child held prone

- appears at 5 months

 

Labyrinthine

- tone reduced & arms/legs flex when prone but increased tone & extended arms & legs with supine position

 

Upper Limbs 

 

General

- resting position

- contractures

- joint stability

 

Hand placement

- ability to place hand in space

- < 10 seconds

 

Stereognosis

- ability to identify ojects in hand without looking

 

LLD Exam

Four Physical Outcomes

 

1.  Symmetrical Stance & Level Pelvis 

 

A.  LL Equality

- Components equal with no deformity

 

B.  Components equal with bilateral symmetrical deformity

- eg Bilateral varus knees

 

2.  Symmetrical Stance with Oblique Pelvis 

 

Uncompensated LLD

 

3.  Asymmetrical Stance & Level Pelvis 

 

A. Fully Compensated LLD

- Flexed contralateral knee 

- Equinus ipsilateral ankle

 

B. Sagittal deformity with ipsilateral sagittal compensation

- FFD knee with Equinus & hip flex OR

- Fixed Equinus with flex knee & hip OR

- FFD hip with equinus & flex knee

 

C.  Coronal deformity with contralateral coronal deformity

- Valgus of knee & contralat varus of knee

 

4. Asymmetrical Stance with Oblique Pelvis 

 

A.  Partly compensated LLD

- Partly flexed contralateral knee

- Partly equinus of ipsilateral ankle

 

B. Coronal hip deformity with sagittal compensation

- Fixed hip adduction with contralateral knee flexion / ipsilateral equinus

- Fixed hip abduction with ipsilateral knee flexion / contralat equinus

 

C.  Sagittal def c coronal compensation

- FFD knee c ipsilateral hip abduction

- Fixed equinus c ipsilateral hip ADD

 

Leg length Examination

 

1.  Look

 

Posture

- flexed knee

 

Signs hemihypertrophy

- NF
- haemangiomas / lipomas (Proteus, Klippel-Trenau-Weber, Beckwith)

 

Scars

- trauma, infection

 

Aids / Shoes

- heel inserts / raises

 

2.  Gait

 

Children

 

Compensate well 

- Walk on toes short leg usually / equinus

- Flexion long knee uncommon as energy++

 

Adults

 

Compensate less well

- Walk with bilateral heel-toe gait

- Vaults over long leg

- Excess Sagittal head motion

 

3.  Measure LLD
 

A.  Functional LLD

- on blocks

- heels flat, nil knee FFD (if able)

- correct pelvic tilt

- should correct scoliosis

 

Conclusion

- if can make pelvis stable

- ASIS equal

- blocks are a quantitative measure of functional LLD

 

B.  Apparent LLD

 

Lying on bed

- measure from xiphisternum to medial malleolus

- no correction for contractures

 

C. Real / True LLD

 

Must correct for deformity in coronal and sagittal plane

 

Exclude

- hip adduction / abduction contracture

- hip FFD

- knee FFD

 

Scenarios

1.  Hip FFD

- pillow under both thighs

2.  Knee FFD

- pillow under both knees

3.  Hip adduction contracture won't correct to neutral

- measure each leg crossed over the other

4.  Hip abduction contracture won't correct to neutral

- place both legs in similar position

 

If there is a contracture, perform the above measures

- then meaure the intercalated segments

- from ASIS to medial joint line

- medial joint line to medial malleolus

 

4.  Identify site of shortening

 

Galeazzi

- must not forget can have small foot / old calcaneal fracture / wasted buttock

- hips and knees flexed

- side by side

- look for tibial / femoral shortening

 

If shortening above knee, find out if shortened above greater trochanter

- i.e. hip deformity

 

Bryant's triangle

- line perpendicular to GT and ASIS

- distance between

- quantify in fingerbreadths

 

Nelaton's line

- line from ischial tuberosity to ASIS

- GT should be on or below line

 

Klisics line

- GT to ASIS

- should aim to umbilicus

- will be more parallel

 

5.  Other

 

Examine Knee stability

- can have problems lengthening femur if ACL deficient

- i.e. fibula hemimelia

Ligamentous Laxity

Wynne Davies Ligamentous Laxity JBJS 1970

 

Original Paper

 

2486 individuals examined

- aged 1 week to 18 years

- at birth - no child lax jointed by criteria

- 2 years - 45% of normal children lax jointed

- 6 years - only 5% of normal children had lax joints

- 12 years - <1% of normal children had lax joints

 

Criteria

 

If 3 of the 5 pairs of joints examined in any one individual showed this degree of laxity it is taken as positive

 

1. Thumb touching forearm on flexing wrist

2. Fingers parallel to forearm with wrist extension

3. Elbows extend past 180°

4. Knees extend past 180°

5. Foot dorsiflex past 45°

 

Ligamentous Laxity Thumb to ForearmLigamentous Laxity Elbow HyperextensionLigamentous Laxity Knee HyperextensionLigamentous Laxity Hands to Floor.

 

 

 

 

 

 

Pes Cavus

Goal Of Examination

 

1.  Identify possible aetiology

- NM axis

- RA

- trauma

- clubfoot / arthrogryposis

 

2.  Define the deformity & its flexibility

- fixed / flexible forefoot

- fixed / flexible hind foot

- fixed / flexible lesser toes

 

Look

 

Aids / shoes

 

Front

 

Stork Legs

Lesser toes clawing

Scars

Hands (dorsal wasting intrinsics (CMT 1), rheumatoid hands)

 

Medial Side

 

High Medial arch

Plantar flexed first ray

Claw first toe

 

Behind

 

Hindfoot varus

Calf muscle bulk

 

Back 

- scoliosis

- cutaneous manifestations spinal dysraphism

 

Double heel raise 

- Heel swings into varus or remains in valgus

- does the medial arch restore

- bilateral suggests neurological

 

Single heel raise

- Must put patient close to wall

- otherwise will cheat by pushing up or leaning forward against wall 

 

Coleman Block Test

- block under lateral foot

- allow first ray to touch ground

- Assess hindfoot

- If hindfoot varus flexible, heel corrects

- Elimination of forefoot deformity will correct hindfoot deformity if hindfoot flexible

 

Lateral side

 

Exclude calcaneo-cavus

 

Gait

 

Stiff ankle 

 

Marionette Gait / High stepping

- Fixed equinus (weak Tib ant)(back knee gait)

 

Tip toe & heel walk

 

Sit

 

Examine Sole

- callosities over metatarsal head

 

Feel

- tenderness

- thickening CPN

 

Move

- range AKJ

- range STJ

- Silverskiold

- active v passive

 

Motor examination

- T. Ach strong / plantarflexion

- T. Ant weak / dorsiflexion and inversion

- T. Post strong / plantarflexion and inversion

- PB weak / eversion

 

First MT

- is plantar flexion correctable

 

Claw toes 

- correctible

 

Neurological Exam

 

Abdominal Reflexes

 

Decreased or absent DTR

- CMT 1

 

Sensory decrease in 25%

Rotational Deformity Exam

NHx

 

In-toeing is normal up til 8 - 10 years

- combination ITT / PFA

- anteversion decreases, ETT increases

 

Causes Intoeing

 

PFA

- usually symmetrical

- unilateral consider CP

 

ITT

- usually asymmetrical

 

Foot

- metatarsus adductus

- CTEV

- metatarsus primus varus

- skewfoot

 

Causes out-toeing

 

ETT

- usually unilateral

- consider NM cause i.e. CP, SB

 

SUFE

 

Examination

 

Staheli's Torsional Profile

 

Look

 

Squinting patella

- rotation above patella, in femur

 

Foot Progression angle

- Us 10° out (0°-30°) 

 

Prone

 

Foot

- curved lateral border

- heel bisector should pass through second MT

 

Thigh- Foot Angle TFA

- knees flexed

- Reconstruct foot

- Usually 15° (0°-30°) ER

 

Transmalleolar Axis (TMA)

- knees flexed

- Usually 0 - 30° ER

 

Hip Internal Rotation

- Usually < 65° 

- > 70° = FAV

 

Gage's trochanteric angle

- GT most prominent laterally

- angle of tibia from verticle

 

Hip External Rotation

- Usually 40° (20-60°)

- Greater in young child

- Note IR + ER should  = 90°

 

 

Scoliosis Exam

Aims of Examination

 

1.  Identify cause

 

- Marfan's / Neurofibromatosis / Skeletal Dysplasia

 

2.  Balance & body asymmetry

 

3.  Exclude LLD as cause

- correct with blocks or sit patient

 

4.  Forward flexion / Adams forward bending

- look for rotation / rib hump

 

5.  Assess flexibility if considering surgery

 

Typical curve

 

The right shoulder is raised

The right scapula is prominent

The loin creases are asymmetrical

The pelvis is level

There is flattening of the normal thoracic kyphosis

There is a normal lumbar lordosis

On forward bending, there is a (mild/moderate/severe) (well rounded/angular) rib hump and a mild left lumbar fullness

 

Front

 

Maturity

- height / breasts / pubic hair

 

Skin

- cafe-au-lait spots

- axillary freckling (look in axilla)

- neurofibromas

 

Eyes

- Lisch nodule (NF)

- blue sclera (OI)

- cloudy cornea (mucopoly)

- dislocated lens (Marfan's)

- optic glioma

 

Mouth

- Abnormal teeth (OI)

- high-arched palate (Marfan's)

- large tongue (Achondroplastic)

 

Trunk

- pectus carinatum or excavatum

- protruberant sternum with sharp manubriosternal angle

 

Limbs

- hemihypertrophy

- dolichostenomelia (long limbs)

- arachnodactyly (thumb in palm)

- clubfoot - often first sign of dysraphism

- cavovarus foot

 

LLD

 

Side

 

Thoracic kyphosis

- exaggerated, normal or reduced / hypokyphotic

 

Lumbar lordosis

- exaggerated, normal or reduced

 

Protruberant abdomen

 

Back

 

Curve 

- right or left

 

Balanced or Unbalanced 

- alignment of C7 over gluteal cleft (ask for plumb bob)

 

Shoulder height

 

Scapular symmetry

 

Loin creases / lumbar fullness

 

Flattened heart-shaped buttocks

 

Pelvis 

- level or not (pant line or PSIS)

 

Spinal dysraphism

- hyperpigmentation / hairy patch / dimple / lipoma / tail

 

Leg length 

- if abnormal use blocks & reassess curve

 

Adam's test 

- hands together & bend forwards to touch floor

- mild/mod/severe rib hump

- well rounded or angular

- satisfactory unroll

 

Supine

 

SLR

- hamstring tightness

 

Neurological

- Reflexes UL / LL / Abdominal / Babinski

- Sensation

- Power UL/LL

 

Scoliosis + No Abdominal reflexes & No Axillary sensation 

 Syrinx till proven otherwise

 

Abdominal reflexes disappear during teens

 

Xray

 

"This is a PA spine radiograph of a __ old skeletally mat/immature Risser __ male/ female with Scoliosis"

 

"There is a R/L typical/atypical curve thoracic/lumbar curve ±  a R/L T/TL/L lower curve"

 

"The spine is/isn't balanced, the pelvis is/isn't level & the curve has a rotational component"

 

"The curve appears to be Idiopathic / Congenital / NF ? NM

 

Don't mention which is 1°/ 2° or postural or structural

 

Spine

Cervical Spine Exam

Require

 

1.  Diagnose Myelopathy

- heel toe

- Rhomberg

- finger escape

- clench and release

- high tone

- inverted BR / Hoffmans

 

2.  Identify Neurology

 

Look 

 

Front

- Position of head & neck

- Torticollis

- SCM tumour

- wasting limbs

 

Side

- Kyphosis

- Webbed neck

 

Back

- Low posterior hairline

- Sprengel shoulder

- Wasting Peri-scapular

 

Gait 

 

Toe walking (S1)

Heel walking  (L4)

 

Toe-to-heel walking

- looking for balance difficulty

- ataxia

 

Romberg

- assess dorsal column / proprioception

- stand feet together, close eyes

- positive if sway or fall

 

Finger escape

- hold hands out

- try to keep LF together with other fingers

 

Clench and release

- should be > 20 times in 10 seconds

 

Feel

 

Spinous processes

Paravertebral - trapezius

Posterior triangle

Sternomastoid

 

Move

 

Forward flexion

- Chin to chest

- Total range of F/E is 130°

- Alanto Occiptial Joint (40% Nodding) / Subaxial (60% Forward translation)

 

Extension

- Plane of nose & forehead horizontal

 

Rotation

- Chin nearly to plane of shoulder 80°

- Atlantoaxial Joint (50%) / Subaxial (50%)

 

Lateral Flexion 

- Ear to shoulder with shrug 45°

- Occurs at lower Cervical vertebrae

 

Special Tests

 

Spurling's Sign

- Nerve root compression is confirmed by Spurling's sign 

- extension and rotation toward the symptomatic side reproduces the radicular symptoms

 

Thoracic Outlet Syndrome Tests

- Addsons

- Roos

 

Neurological Exam

 

Tone

 

High tone / clasp knife rigidity

 

Power

 

C5 - Deltoid / Biceps

C6 - Wrist Extension

C7 - Triceps

C8  - Finger Flexion

T1 - Interossei

 

Reflexes

 

C5 - Biceps

C6 - Brachioradialis

C7 - Triceps

 

Myelopathy reflexes

 

Inverted Brachioradialis

- tap on BR

- flexion of thumb and index finger

 

Hoffmann's reflex 

- forced flexion of MF DIPJ

- reflex finger and thumb flexion is elicited  

 

Scapulohumeral Reflex 

- tapping tip of spine of scapula

- brisk elevation of scapula & abduction of the humerus

- positive in > 95% of myelopaths

 

Jaw Jerk

- a cerebellar sign

- distinguishes myelopathy from cerebellum

 

Sensation

 

C5 - deltoid

C6 - lateral forearm, thumb

C7 - middle finger, posterior arm

C8 - little finger

T1 - medial forearm

T2 - medial arm

 

 

Lumbar Exam

Look

 

Walking / mobility aids

Lumbar brace

AFO / shoes

 

Front

 

Wasting - quadriceps

Manifestations of systematic disease

LLD

 

Side

 

Normal 

- there is a thoracic kyphosis and a lumbar lordosis

 

Abnormal

- exaggerated

- reduced

 

Back

 

Scoliosis

Scars

Signs spinal dysraphism

Wasting - buttocks / thighs / calves

 

Tenderness

- vertebral level

- sacro-iliac joints

 

ROM

 

Forward flexion test

- standing with feet together & knees straight

- aiming to touch floor with hands on legs

 

Comment on

- pain

- level reached (fingertips in relation to front of legs)

- normal unrolling of the lumbar spine

 

Schobar's test

- thumb on LS junction

- line joining dimples of Venus

- reconfirms level pelvis

- index finger 10 cm above

- width of hand

- amount of increased separation of fingers on spine

- should be at least 50%

 

Extension

- one hand in small of back and one hand on shoulder

- normal 15-30°

 

Lateral flexion

- one hand on hip and other hand on shoulder

- normal 15-30°

 

Rotation

- feet still & twist body

- look from above

- angle between plane of shoulders and pelvis

- amount 45°

 

Gait

 

Tiptoes (L5 / S1)

Heels (L4)

Squat / single leg squat (L3)

 

Supine

 

Hip ROM 

- flex hip to 90° and rotate hip

- comment painless range of hip movement

 

SLR

- patient lifts leg actively from bed with knee straight

- at what angle of hip flexion is pain reproduced

- pain must be in distribution of sciatic nerve / below knee

- differentiate from hamstring pain

 

Lasegue

- lower leg until pain just disappears

- forcibly dorsiflex foot and assess if pain recurs

 

Neurological Exam

 

Tone

- normal, increased or decreased

- clonus ankle (normal < 2 beats)

- clonus patella

 

Power

 

L2 - hip flexion / pull knee to chest

L3 - knee extension / hold knee straight

L4 - ankle dorsiflexion / T anterior / pull foot up

L5 - hallux dorsiflexion / FHL / pull big toe up

S1 - ankle plantarfiexion / push foot down

 

MRC Muscle Power Grading

0 - no movement

1 - flicker only

2 - movement with gravity eliminated

3 - movement against gravity

4 - movement against resistance

5 - normal movement

 

Reflexes

 

Knee jerk (L4) 

Ankle jerk (S1) 

Babinski - scratch soles

 

Sensation - light touch

 

LI - groin

L2 - thigh

L3 - knee

L4 - medial malleolus

L5 - bunion / dorsum foot

S1 -  sole / lateral foot

S2 - posterior calf

S3,4 - 'bulls-eye' around perineum

 

Lateral Side

 

Femoral stretch test

- flex knee to 90o

- extend hip

- positive if reproduces leg pain in distribution of femoral nerve

 

Abductor power (L5)

- lift leg up

- palpate contraction

- grade power

 

SI joint

- semilateral position

- leg flexed and adducted across body

- forced adduction

- reproduce pain

 

Special

 

Ankylosing spondylitis 

- wall test

- stand with back to wall

- heels, buttocks and occiput touch wall normal

 

Kyphosis

- forward bending test

- hyperextension while prone

 

Waddell's Signs (DR TOS)

- distracted SLR

- rotation causes pain

- tenderness non anatomical

- overreaction

- superficial tenderness

 

 

Myelopathy Exam

Look

 

Front

- appropriately disrobed / generalised disease / orthotics

 

Side

- sagittal alignment entire spine

 

Back

- wasting / lumbar spine coronal plane alignment / spinal dysraphism

 

Gait

 

Wide based gait

Heel Toe

 

Specific Tests

 

Rhomberg

- arms outstretched in front

- close eyes

- positive if lose balance once visual aids removed

 

Finger escape sign

- hold hands out, fingers together

- medial two fingers drift apart

- takes 30 – 60 seconds

 

Grip and Release / disdiadokinesis

- 20 times in 10 seconds

- myelopathy patients much slower

 

Sit

 

Feel

 

Palpate neck

- central / paraspinal / trapezius / posterior triangle

 

Move

 

ROM

- flexion (should be able to get chin to chest)

- extension (should be able to get forehead parallel to ground)

- ear to shoulder

- rotation 80o

 

Tone

- Cogwheel rigidity

- clonus in feet

 

Power

- ASIA (American Spinal Injury Association)

- look for interosseous wasting

- power often especially decreased in hands

 

Reflexes

- increased / inverted BR / Hoffman / Babinski

 

Sensation

- decreased sensation globally / reduced vibration / proprioception

 

Questions

 

What is differential?

- Central / cerebellar cause / Demyelinating disorder

 

How do you differentiate Cerebellar causes?

- Nystagmus / Jaw Jerk

 

What is treatment?

- Depends on Imaging

- No kyphosis, multilevel degeneration - laminoplasty

- Kyphosis / discs / anterior vertebral osteophytes - ACDF / corpectomy and strut grafting

Upper Limb

Brachial Plexus

Diagnostic Issues

 

Supraclavicular

- nerve root patterns of sensation and motor disturbance

 

Infraclavicular

- peripheral nerve root pattern / cord

 

Supraclavicular preganglionic

- dorsal scapular, long thoracic, suprascapular

- Horner's

- lack of sensation supraclavicular

- no tinel's

 

Supraclavicular postganglionic

- + Tinels

- tender posterior triangle

 

Look

 

Aids

 

Front

 

Horner's 

- suggests C8/T1 root avulsion

 

Posterior triangle swelling / bruising

 

Wasting deltoid / biceps / pectoralis

 

Biceps Wasting

 

Wrist drop

 

Side

 

Hand on head

- axillary scars

 

Back

 

Trapezius

Deltoid

Supraspinatus/ Infraspinatus

Static winging

 

Supraspinatous Infraspinatous Wasting

 

Feel

 

Palpate post triangle

- tenderness

- supraclavicular post ganglionic

 

Tinel's in post triangle

- supraclavicular post ganglionic

 

Sensation

 

Ask sensation

 

Supraclavicular C4 

- suggests preganglionic injury

 

Axillary nerve C5 

 

LCNF C6 musculocut n

 

SRN C6 (1st dorsal webspace) 

 

C6 median n (thumb)

 

C7 median n (MF)

 

C8 ulnar n (LF)

 

C8 MCNF m cord (med forearm)

 

T1 MCNA m cord

 

T2 ICBN

 

Motor

 

Trapezius 

- function of accessory nerve important

 

Roots / From Behind

 

Rhomboids

- shoulders back

- DSN C5

 

Rhomboid Testing

 

Serratus anterior

- push shoulder forward

- LTN C5-7

 

Suggest preganglionic

 

Trunk

 

Suprascapular Nerve (C5)

- supraspinatous

- infraspinatous

 

Front / Nerve Root innervation

 

Deltoid 

- C5

- axillary / posterior cord

 

Bicep

- C5

- musculocutaneous / lateral cord

 

Tricep

- C7

- radial / posterior cord

 

Wrist extension

- C6

- radial / posterior cord

 

Finger flexion

- C8

- median / medial and lateral cord

 

Finger abduction

- T1

- ulna nerve / medial cord

 

Decide if fits root pattern

- otherwise consider cord injury

 

Cords

 

Posterior Cord

- axillary nerve (deltoid + T minor)

- radial nerve

- subscapularis

- lat dorsi TDN C7 (hand on hip / cough)

 

Medial Cord

- medial median (FDP, FPL, AbPB)

- medial pectoral (sternal head)

- ulna nerve (interossei, LOAF)

- MCNA / MCNFA (decreased sensation medially)

 

Pectoralis Testing

 

Lateral Cord

- lateral median (FCR, PT)

- musculocutaneous (biceps, sensation lateral forearm)

- lateral pectoral (clavicular head)

 

Reflexes

 

Biceps C5

Triceps C7

BR C6

 

4Cs

 

Cephalad joint - Neck

Concealed - axilla

Circulation

Collagen

 

 

 

 

Dupuytren's Exam

Look

 

Palms up

 

Scars / Dimples / pits 

 

Nodules - palm, proximal to distal palmar crease

 

Cords - extend into fingers & cause contracture

 

Thumb

 

Fingers - contracture of MCPJ, PIPJ

 

Palms down

 

Garrod knuckle pads

 

Hueston Table Top Test

- contracture MCPJ

- contracure PIPJ

 

Feel

 

Nodules / Cords / Webspaces (Natatory cords)

 

Sensation

 

Move

 

Deformities 

- stiff or flexible

 

PIPJ

- true v apparent FFD

- spiral cord crossing MCPJ and PIPJ may contract both

- flex MCPJ

- assess PIPJ

 

Concepts

 

MCPJ Contracture

- Always correctable by removal of pretendinous bands

- Collateral ligaments are tightest in flexion

- Flexion deformity does not lead to collateral shortening 

- Resection central cord restores extension

 

PIPJ 

 

Contracture due to 4 cords

1.Central 

2.Spiral

- pushes NV bundle volar and midline 

- from spiral band and Grayson's ligaments

3.Lateral 

- lateral digital sheath

4.Retrovascular

 

Not always correctable unless release volar plate & accessory collateral ligaments 

- Collateral ligaments tightest in extension 

- Flexion deformity leads to collateral shortening 

 

 

Elbow

Intially

 

Introduce

Aids - slings

Expose - shirt off

Stigmata generalised disease

 

Look/ Move

 

Neck

 

ROM / exclude cervical radiculopathy

 

Shoulder

 

ROM

- touch hands on head 

- behind head

- to mouth 

- back pocket  

 

Elbows

 

1. Extend elbows to front

 

A.  Elbow

- carrying angle (N 7° - 12°)

- deformity

- bony prominences

- biceps bulk

 

B.  Forearm contour

- ulnar border - FDP

- radial border - mobile wad

 

C.  Hand

- thenar eminence

- hypothenar eminence

- look for clawing

 

2.  Flex elbows to front

- olecranon wounds / bursa

- medial or lateral surgical scars

 

3.  Flex elbows to side

- angle of flexion

- comment medial scars

- axilla

 

4 Extend  elbows to side

- angle of extension / FFD

 

5.  Pronation and supination 

- 80o each

- thumb up / thumb down with elbows in

 

Hands

 

Look at dorsum for interossei wasting

Wrist Flexion / Extension

Fist with thumb in and out 

Spread fingers

 

Feel

 

Medially

- medial epicondyle

- ulnar nerve tinel's / subluxation

 

Posterior

- oleranon/ triceps tendon

 

Laterally

- lateral epicondyle / tennis elbow

- radial head - stability / pain with rotation

 

Medially

- cubital fossa masses / biceps tendon

 

Special Tests

 

Medial Epicondylitis

- resisted wrist flexion & pronation

 

Lateral epicondylitis

- resisted wrist extension

- resisted MC Ill extension (ECRB)

 

Stability

 

Note stability in extension is predominantly bony

 

Valgus Instability

 

Jobe's Test

- MCL

- flex elbow to 25° (unlocks olecranon)

- pronate forearm (prevents false +ves due to lateral laxity)

- gentle valgus stress

- compare opposite side

 

Varus Instability

 

Varus strain 

- with elbow at 25°

 

O'Driscoll's Test / elbow Pivot Shift

- patients describe clunk on full extension & feel posterolateral pain

- ulnar portion of LCL (LUCL) is the key

- dislocation occurs with a valgus ER force pivoting the elbow on the intact MCL

 

Technique

- patient  supine with examiner at head of bed

- GHJ full flexed with hand over head

- Forearm supinated and Elbow extended

- Valgus stress applied

- Axial load

 

Positive if

- prominent radial head (dislocates) / pivot / pain

- max subluxation is at 40° flexion 

- with increased flexion reduces with snap

 

4Cs

 

Circulation

- brachial / radial pulse / ulnar

- Allen's test

 

Cephalad joint

- shoulder ROM

 

Collagen

- ligamentous laxity

 

Concealed

- cubital fossa

 

 

 

 

 

 

Median Nerve Exam

Look

 

Palm up

- Pointing index finger (Bennett's / AIN)

- Wasting thenar eminence

- wasted forearm muscles

- volar scarring

 

Thumb up

- wasting thenar eminence

- radial border wrist

 

Palm down

 

Palms together

- LF

- Axilla scars

 

Feel

 

Sensation

 

Lateral forearm - LCNF / lateral cord / C6

 

Thenar eminence - Palmar Branch Median Nerve / C6

 

IF - C6 Median nerve

 

MF - C7 Median nerve

 

LF - C8 Ulna nerve

 

Median Forearm - MFCN / medial cord / T1

 

Is sensation loss peripheral / dermatomal?

 

Move

 

Median nerve

 

PT (C6)

- first branch 

- test with elbow flexed

 

FCR (C6)

- flex wrist & palpate

 

FDS(C8) 

 

PL (C8)

 

AIN 

 

FDP IF/MF (C8) 

- make fist & resists IF extension

 

FPL (C8) 

- resists extension of IPJ

 

PQ (C8) 

- test with elbow extended (eliminate PT)

 

Motor Recurrent Branch (T1)

 

AbPB 

- patient abduct thumb away from palm against resistance

- palpate muscle belly

 

1st Lumbrical

- Lateral Digital Branch

- thumb to IF pad to pad

 

2nd Lumbrical 

- Medial Digital Branch

- thumb to MF pad to pad

 

Lumbricals

- extend DIPJ

- if not functioning --> unable to pulp to pulp

- will only be able to bring tip to tip

- because unable to extend DIPJ

 

Special Tests

 

Tinel's 

- start distal & move proximally

 

Phalen's 

- 60 second patient holds wrist flexed

 

Allen's test

- if considering CTD

 

C-spine examination

 

DDx

 

CTS

- normal sensation thenar eminence and forearm

 

AIN palsy

- no sensory deficit

- weak FPL / FDP / PQ

 

Pronator syndrome

- Pain only

 

C6

- weak wrist extensors

- decreased sensation medial forearm

 

TOS

- C8 / T1

- weak thenar eminence

- abnormal sensation medial forearm and LF

 

Brachial Plexus

 

Compression syndromes

 

Pronator Syndrome 

- ligament of struthers

- lacertus fibrosis

- pronator teres

- FDS

 

AIN Syndrome

- pronator teres

- FDS

- aberrant muscles or blood vessels

- trauma

 

CTS 

- palmar branch is not involved

RA Hand Exam

Screening of Joints

 

Neck

-  ROM

 

Shoulder

- behind head / to mouth

- to back pocket 

 

Elbows

- flex / extend elbows 

- pronation / supination with thumb up & elbows by side

 

Wrist

- flexion / extension

 

Hand

- make fist with thumb in and out 

- spread fingers

 

Functional Assessment of Hand

 

Power Grip 

Precision Grip 

Hook Grip 

Lateral Pinch Grip 

Tip Pinch

 

1.  Tip to Tip Pinch Grip

- pick up coin 

 

Tip to Tip Pinch Grip

 

2. Lateral pinch grip

- turn key

 

Lateral Pinch Grip

 

3. Precision grip

- write with pen

 

Precision Grip

 

4.  Power Grip

- turn knob 

 

Power Grip

 

5.  Hook Grip

- hold suitcase / fingers

 

Hook Grip

 

Look at Hands / Place on Pillow

 

Palms up

 

Scars

- CTD / flexor tendon synovectomy

Swelling

- flexor sheath synovium

Thenar & Hypothenar eminences

 

Thumb up

 

Thenar wasting

Swan neck / Boutonniere deformity

 

Palms down

 

RA Palm down

 

Wrist 

- synovitis / synovectomy

- wrist fusion

- caput ulna

- radial drift 

 

MCPJ 

- ulna drift / replacement / synovitis

- tendon subluxation

 

Fingers

- Swan neck, Boutonniere

 

Feel

 

Sensation

- median nerve / CTS

- ulnar nerve

 

Move

 

Extensor tendons

- drop fingers

- DDx - locked trigger, tendon subluxation, joint subluxation, PIN palsy

 

EPL

- ruptures over Listers

- IPJ is extended by intrinsics also

 

Flexor tendons

- rupture IF & thumb (synovitis)

- rupture FPL alone over trapezial ridge (Mannerfelt)

- triggering

 

MCPJs

- ? subluxed

 

Boutonniere deformity

- degree of lag

- passively correctable

- ? arthritic changes

 

Swan neck deformity

- passively correctable

- intrinsic tightness / Bunnell test

- arthritic changes

 

Bunnell Test

- test with MCP extended and flexed

- correct ulna deviation

- invalidated by MCPJ dislocation

- with tight interossei will have reduced PIPJ flexion with MCPJ extension

 

 

 

Radial Nerve Exam

Look

 

Splints

 

Wasting 

- triceps / extensor forearm

 

Arm up

- axilla / posterior / lateral elbow scars

 

Feel

 

Sensation

 

Axillary nerve - C5 / posterior cord

 

PCNFA

 

LCNF - C6 / Lateral Cord

 

SRN - C6 / Dorsal 1st Web

 

Median C6

- IF

 

State dermatomal or peripheral nerve

 

Move

 

Triceps C7

 

BR / ECRL - Radial Nerve

 

ECRB / EDC / EPL / EI - PIN

 

Supinator 

- elbow extension to eliminate biceps, resist pronation

 

Special Tests

 

Tinels

 

DDx

 

C7 lesion

- triceps power / reflex lost

- good wrist extension (C6)

 

C6 lesion

- triceps intact

- wrist extension lost

 

Posterior cord

- radial nerve + axillary nerve + subscapularis + lat dorsi

 

Site of injury

 

High lesion / no triceps

- Saturday night palsy

 

Intermediate lesion / triceps intact / no BR or ECRL

- humeral fracture

 

Low lesion / PIN Compression (FREAS)

- fascial bands

- recurrent radial

- ECRB

- arcade of Frohse

- exit supinator

 

 

 

Shoulder

Look

 

Exposure

Splint

Sling

 

From Front

 

Skin

- scars

 

Swelling

- SCJ

- clavicle

- ACJ

- biceps (rupture long head)

 

Popeye Biceps

 

Wasting

- deltoid

- trapezius

- arm

 

Deltoid Wasting

 

From Side

 

Turn affected side towards you

Wasting

- pectoral contour

 

From Back

 

Scapular symmetry

- height

- winging 

 

Wasting

- supraspinatus

- infraspinatus

 

SS IS Clinical Photo 1SS IS Clinical Photo 2

 

Feel

"Where is it painful ?"

 

Bony prominences

- SCJ

- clavicle

- ACJ (compare with other side)

- acromium

- biceps tendon

 

Scapular spine

 

Supraspinous fossa

- ganglion

- osteochondroma

 

Infraspinous fossa

- tenderness

- cuff defect

 

Move

 

Forward flexion

 

Active

- both arms raised forward, supinated

- range

- check axilla

 

Abduction

 

Active

- elevate both arms in coronal plane, supinated

- initiation

- range (160°-180°)

- rhythm

- arc of pain

- shoulder hiking

 

Passive

- if not full, passive to 180?

- active v passive

 

Observe arm lowering 

- arc of pain

- drop arm

 

Extension

 

Active

- both arms raised backward

 

External rotation

 

Active

 

Elbows flexed to 90o and arms by side

- start with arms forward

- rotate arms outwards (90°)

 

Passive

If not full, passive

 

Reduced ER

 

Internal rotation

 

Active

- ask to run thumb up spine

- mark good and compare bad

- thigh / buttocks / waist / LS / T12 / angle of scapula (T7) / tip of scapula (T2)

 

Rotator Cuff Power / Integrity

 

Power of supraspinatous

- 30° abduction

- in plane of scapula (30° forward from coronal plane)

- forearm pronated (thumb to the ground)

- resisted abduction

 

Supraspinatous testing

 

Power of Infraspinatous

 

1. Grade power external rotation

 

Infraspinatous Power

 

2.  Extensor lag

- take out to full passive ER

- release and see if lags

 

3.  Hornblower's

- positive if drop and IR

- suggests massive PS tear

- teres minor

 

Power of Subscapularis

 

1.  Gerber's Lift off test

- Gerber's test is normal if patient can hold hand off buttock

- patient must have full IR & not be limited by pain to use this test

- "Pathological lift off test - patient is unable to lift the dorsum of his hand off his back"

- put dorsum of patient's hand on buttock then lift it off buttock & let go

 

Subscapularis Lift Off Test 1Subscapularis Lift Off Test 2

 

2. Belly Press Test / Nelaton Test

- resisted internal rotation with hand on belly

- must keep elbow forward

- otherwise patient uses shoulder retractors

- positive if drop elbow

 

Subscapularis Belly Press Test

 

Impingement tests

 

Neer's impingement test

- passive forward flexion 

- forearm pronated

- scapula stabilised

- positive test - pain at arc 70-120°

 

Shoulder Neers Test

 

Hawkin's impingement test

- forward flex elbow to 90°

- internally rotate and adduct arm

- positive test - pain

 

Shoulders Impingement Test

 

ACJ

 

Cross body adduction

 

ACj Cross Body Adduction Test

 

Biceps

 

Speed's test

- resisted forward flexion at 90° with forearm supinated

- assess pain or popping at bicipital groove (long head of biceps)

 

Speeds Test

 

Yergason's Test

- externally rotate arm with elbow 90°

- resisted supination

- assess pain or popping at bicipital groove (long head of biceps)

 

Yergason's Test

 

Compression-Rotation test / McMurray's Shoulder test

- test for SLAP lesion

- patient supine 

- shoulder abducted 90°, elbow flexed 90°

- compression force to humerus

- humerus rotated

- attempt to trap torn labrum, positive if pain & click

 

O'Brien's

- SLAP lesion

- arm across body, in plane of scapula

- pain with stress abduction, thumb down

- nil pain with thumb up

 

Obriens Test

 

Instability

 

Sulcus sign

- needs to be compared to the opposite side

- patient

- in front of patient

- hands in lap

- pull down on both elbows

- look for sulcus

 

Shoulder Sulcus Sign

 

Anterior / Posterior Drawer

- sit next to patient

- stabilise shoulder girdle with 1 hand

- thumb on spine of scapula

- forefinger on coracoid

- centralize humerus

- must compare to normal side

- translate humeral head forward with other hand

- anterior & posterior translation noted

 

Anterior Apprehension Test

- patient lying

- shoulder abducted and elbow flexed 90°

- externally rotate shoulder

- positive test - look for apprehension 

 

Jobe Relocation Test

- patient supine

- arm abducted to 90°

- forced external rotation

- relocate by pushing humeral head posteriorly & superiorly

- usually described by putting hand on humeral shaft

 

Posterior Stress Test 

- stabilise scapula

- place shoulder in 90° forward flexion & 90° IR & adducted

- apply posterior force

- patient experiences pain +/- apprehension

- unlike anterior test patient has positive test if pain only

- note should reproduce the patients symptoms

 

Load and Shift

- patient lying down

- their hand under examiners armpit

- grasp neck of humerus with both hands

- load humerus into glenoid axially

- examinate stability annterior and posterior

 

Ligamentous Laxity

 

Wynne-Davies Criteria

1. Thumb touching forearm on flexing wrist

2. Fingers parallel to forearm with wrist extension

3. Elbows extend past 180°

4. Knees extend past 180°

5. Foot dorsiflex past 45°

 

Ligamentous Laxity Elbow HyperextensionLigamentous Laxity Thumb to Forearm

 

"If 3 of the 5 pairs of joints examined in any one individual showed this degree of laxity it is taken as positive."

 

Thoracic Outlet Tests

 

Adson Manoeuvre

- head toward side tested, neck extended

- palpate radial pulse of extended arm

- patient inhales deeply

- positive test if decrease or obliteration in pulse with concomitant reproduction of symptoms

 

Wright's Manoeuvre

- head turned away from tested arm, neck extended

- arm in 90° abduction & 90° extension

- palpate radial pulse 

- patient inhales deeply

- positive test if decrease or obliteration in pulse with concomitant reproduction of symptoms

 

4C's

 

Cephalad Joint Neck

 

ROM

 

Compression Test

- slight extension

- compression

 

Spurling's test

- neck in lateral flexion, rotation

- stressed with compression

- positive if pain in ipsilateral extremity

 

Circulation

 

Radial pulse

 

Concealed

 

Axilla

 

Collagen

 

 

Ulnar Nerve Exam

Look

 

Splints

 

Extend elbow to side

- medial wounds

- extension

 

Flex elbow to side

- flexion range

 

Flex elbow to front

- olecranon wound

 

Extend elbow to front

- anterior wounds

- carrying angle

- forearm wasting

 

Palm up

- clawing

- hypothenar eminence

- scars

 

Ulna Nerve Laceration

 

Thumb up

- thenar eminence

 

Ulna nerve wasting

 

Palm down

- interossei / adductor pollicis wasting

 

Adductor Pollicis WastingUlna nerve wasting

 

Palms together

- claw

- hypothenar eminence

 

Feel

 

Sensation

 

1.  LF & RF

 

2.  Dorsal branch ulna nerve

- branches above wrist

- runs under FCU

- dorsum of hand, ulna side

- dorsum LF and half RF to P2

 

3.  Palmar cutaneous branch

- above wrist

- hypothenar eminence

 

3.  Medial forearm (MCNF / T1)

- above ulna

 

Move

 

Above elbow

 

1.  FCU (C7)

- patient flexes wrist, palpate

 

2.  FDP (C8) 

- patient makes fist & resists extension of LF

 

Below wrist

 

1.  AbDM

- LF together

- first branch deep nerve

 

2.   1st Dorsal Interossei

- push both IF together

- last branch deep nerve

 

3.  Adductor Pollicis

- Froment's sign

- hold paper between thumb and IF
- positive if patient uses FPL to grip

 

Ulna Nerve Positive Froment's Sign

 

4.  Card sign

- between index and middle finger

- PAD

- palmar interossei adducting

 

5.  Lateral 2 lumbricals

- unable to pad to pad  LF / RF

- lumbricals extend DIPJ

- patient can only tip to tip

 

Special Tests

 

Tinel's - Cubital tunnel, Guyon's

 

Ulna nerve subluxation / tenderness

 

DDx

 

T1

- thumb APB weak / wasted

 

C8

- EDC / Wrist extension weak

 

TOS

- sensory loss above wrist

- Addson sign

 

Compression Syndromes

 

1.  Medial Intermuscular septum 

- arcade of Struthers (fascial band)

- septum

- hypertrophied medial head triceps

 

2.  Medial epicondyle

- tardy ulna nerve palsy, previous fracture

 

3.  Epicondylar groove

- intrinsic (SOL, synovitis, rheumatoid nodule

 

4.  Cubital Tunnel 

- tendinous arch of FCU

 

5.  Exit FCU

 

6.  Guyon's canal

- FDP OK

- palmar & dorsal br spared

- all small hand m's affected

 

7.  Deep motor branch only

- can be compressed against pisiform & hamate 

- with using mallet, vibrating tools

- sensation normal

Wrist Exam

Take watch off

 

Look

 

Palm up

- thenar wasting

- STT gangion

- thumb OA

- flexor synovitis

 

Thenar Wasting

 

Thumb up

- thenar wasting

 

Palm down

- dorsal SL ganglion

- extensor synovitis

 

Palms together

- claw ulna

- elbow scars

 

Move

 

Wrist 

- extension

- flexion

- radial / ulna deviation

- pronation / supination (thumb up)

 

Finger flex and extend

- thumb in and out

- spread fingers

 

 

Feel

 

Sensation

- ulna nerve / radial / median nerve / CTS

 

Radial side

 

Distal Radius

 

1st extensor compartment

- swelling EPB / APL

- Finklestein's

- flex and extend thumb

- feel crepitus

 

Intersection

- tenderness crossover EPB APL

 

Scaphoid

- snuffbox

- tuberosity

- Watson's test

 

Base of thumb

- tenderness

- deformity

- Grind Test

 

MCPJ thumb

- tenderness

- weakness ulna collateral

 

SL joint

Wartenberg's radial neuritis

 

Ulna side

 

ECU tendon

 

Lunotriquetral joint 

- instability test 

- one under each thumb & toggle 

- look for movement or pain

 

Ulna head

- deformity

- instability

 

Hamate Hook

- tenderness with #

 

DRUJ 

- synovitis

- tenderness

- piano key

- pro/sup subluxation, pain, clicking

 

TFCC 

- palpate for tenderness distal to ulna

- Grind test circ & press

- look for pain & crepitus

 

PisoTriquetral Joint 

- occupational injury

- press & rock against Triquetrum 

- look for pain & crepitus

- similar concept to patella

 

Guyon's canal

- Tinel's

 

Other

 

Allen's test

CTS

Ulna Nerve