Locomotor Examination Mbchb4

LOCOMOTOR – FOOT AND ANKLE EXAMINATION

Overview

1. Look Gait
Standing – front, back, side
End of Bed
2. Feel Temperature
Palpate - Tenderness / Swelling
3. Move Dorsiflexion, Plantarflexion, Inversion, Eversion
4. Special Talar Tilt
Anterior Draw
Achilles Squeeze Test (Thomsons)
5. Other Neurovascular (reflexes, sensation, pulses)
Joint above/below

• Greet patient. Introduce self.
• Adequate exposure – at least see knees; ideally entire lower limbs.
• Look at shoes – abnormal or asymmetric wear and tear pattern of soles.
• Look for any walking aids and look at shoes

1. Look

a. Gait
• Walk normally - heal toe gait, normal forward alignment of feet, no limp, any abnormalities eg foot drop
• Walk on toes and heels - to test suppleness of foot and ankle and screen for generalized power of leg muscles (plantar and dorsiflexors)
• Walk on inverted and everted feet (tests stability of subtalar joint)

b. Standing (from 6 ft away) - WADSSS
From front
- symmetry, wasting, swelling, clawing of toes
From back
- Wasting (esp calf muscles)
- Swelling
- I can see…..toes laterally, foot is in normal physiological valgus to ankle
- Ask patient to rise on toes – look for normal varus progression of heel
From side
- abnormalities of feet e.g. flat feet (pes planus), high arch (pes cavus).

c. Sitting on edge of bed
- look at soles of feet and between toes for atrophic changes e.g. callous, ulcers, pressure sores, corns, nail conditions.

Due to time constraints in this exam, say you will only be assessing one foot but you would in a normal clinical situation assess both feet

2. Feel
Patient still sitting on bed

a. Temperature of legs (comparing both sides)

b. For tenderness + swelling (look at patient + ask them to report any pain)
• Fibula head
• Fibula shaft
• Lateral malleolus
• Posterior and Anterior Talofibular ligaments + Calcanofibular ligament
• Styloid process of the 5th metatarsal
• Anterior joint line + tibiofibular joint
• Navicular bone
• Deltoid ligament
• Medial malleolus
• Posterior tibialis tendon
• Calcaneus
• Calcaneal tendon

3. Move (Active Passive Power)
Say that you would examine the good side first to compare.
Always ask patient if they are in pain before moving them.
Do active movement, then passive, feel for tendon and test for power.

Patient sitting on bed

a. Dorsiflexion
- active movement (active movement to ..’)
- passive movement (“additional ..’ on passive movement”)
- power (“don’t let me push your foot down”)
b. Plantarflexion
- active movement (active movement to ..’)
- passive movement (“additional ..’ on passive movement”)
- power (“don’t let me pull your foot down”)
- feel for tibialis anterior tendon
c. Inversion
- passive movement only
- feel for tibialis posterior (this tendon is important for the reconstitution of the arch of the foot)?
d. Eversion
- passive movement only
- feel for peroneus longus and brevis tendons

4. Special tests

Patient still sitting on bed
a. Anterior drawer’s test
- To test laxity or integrity of anterior talofibular ligament.
- Place left hand at distal tibiofibular joint and right hand on patient’s heel. Left hand pushes in while right hand tugs the heel anteriorly. Place hand on talus not calcaneus.
b. Talar tilt test
- To test laxity or integrity of calcaneofibular ligament.
- Grasp patient’s heel and forcibly invert the foot, feeling for any opening-up of the lateral side of the ankle between tibia and talus. Also look for hollow in the joint if it is lax – sulcus sign

Patient lying prone
c. Thomson’s test (calf squeeze test)
- To test for Achilles tendon rupture.
- Squeeze calf. Foot should move as ankle plantarflexes.

Proceed to reflexes of neurovascular exam if required

5. Other

a. neurovascular (ask if they want you to examine)
- reflexes (straight from thomson’s test (S1/2 ankle and L3/4 knee)
- sensation (ensure patient’s eyes are closed and compare both sides)
- Medial malleolus – Saphenous nerve
- Lateral malleolus – Sural nerve
- Dorsum of foot – Superficial peroneal nerve
- Between big toe and 2nd toe – Deep peroneal nerve
- Medial side of sole – Medial plantar nerve
- Lateral side of sole – Lateral plantar nerve
- Back of sole – Calcaneal nerve
- pulses – post tibial, dorsalis pedis (feel with whole hand → max surface area)
b. knee
c. toes

LOCOMOTOR EXAMINATION – HAND (RHEUMATOLOGY)

Introduction and Permission
Exposure – expose patient to above the elbow both sides (place patient’s hand on pillow or flat surface if pillow unavailable)
For practice – google rheumatoid hand

1. Look (WADSSS) – wasting, alignment, deformities, scars, swelling, skin changes, symmetry

Dorsal Forearm Wasting of muscles
Skin – bruising/thinness
Scars Bruising and thin skin associated with prednisone
Dorsal aspect wrist Radial or ulnar shift
Swelling
Scars
Skin – bruising/thinness
Prominence of ulnar head
Dorsum of hand Interosseous wasting
Swelling (tendon sheath)
Scars
Skin – bruising/thinness
Dorsal aspect MCP joints Palmar subluxation
Ulnar deviation
Prominence of MCP heads
Scars
Swelling Palmar sublux and ulnar deviation indicative of RA
Dorsal aspect fingers Swan neck deformity (hyperextension PIP and flexion DIP joints)
Buutonniere’s deformity (flexion PIP and hyperextension DIP joints)
Dactylitis (sausage fingers due to inflammation)
Shortened telescoped fingers
Nails folds Periungal erythema
Rheumatoid vasculitis Periungal erythema found particulary in those with RA
Nails (signs subtle – close inspection required) Pitting (pin marks)
Longitudinal ridging
Oncholysis – loss of convexity and significant amount of white in the nail which is lifting of the nail bed or about to do so
Hyperkeratosis (thickening)
Can look like tinea unguium (fungal infection) due to yellow appearance and thickening Pitting, ridging, oncholysis and hyperkeratosis are the 4 characteristics of nails in psoriatic arthritis
Ventral forearm Muscle wasting
Ventral aspect wrist Scars (esp from carpal tunnel release – often longitudinal) Carpal tunnel syndr is assoc with RA and Psor arth
Palms Palmar erythema
Dupytrens contractures
Wasting of thenar and hypothenar eminence
Warts
Calluses
Loss of finger pulps
Plaques Palmar erythema is assoc esp with RA
Dupytrens affects the flexor tendon sheath
Calluses may be due to MCP subluxation
Loss of finger pulp assoc w CT dis
Elbows (inspect extensor surface) Scaly silver plaques
Scabs reflecting former plaques
Firm but compressible nodules which nay move somewhat under the skin Plaques and the healing process that may ensue assoc with psor arth
Rheumatoid nodules assoc w RA

2. Feel

“Normally I would examine both hands – would you like me to?”

Dorsal aspect wrist
- Distal radioulnar joint
- Radiocarpal joint
- Ulnar carpal margin
MCP joints
- Place thumb on dorsal aspect of the joint
- Place index and long fingers on the ventral aspect of the joint
PIP joints
- Place thumb and index finger of one hand on the sides of the joint
- Place thumb and index finger of the other hand on the dorsal and ventral aspects of joint
- Alternate between pressing the sides of the joint and the dorsum/ventrum of the joint Bouchards nodes (bony swellings)
Synovial thickening
Fluid movement Bouchards nodes are a feat of OA
Synovial thickening assoc w longstanding RA (chr sign)
Fluid movement or bogginess is assoc w acute effusions
DIP joints
- as per PIP joints Heberden’s nodes (bony swellings – same as bouchards nodes but different joint location)
Synovial thickening
Fluid movement Heberden’s nodes are a feat of OA
Synovial thickening assoc w longstanding RA (but RA generally prefers PIP over DIP joints)
Fluid movement or bogginess is assoc w acute effusions
IP joints of thumb Z deformity
Palms Palmar tendon crepitus
Flexion contractures (dupytrens)

3. Move

Pronation
Supination
Prayer position Restricted wrist extension Indicates RA and Psor arth
Inverted prayer position (phalens test)
- ask patient whether they are experiencing any burning or tingling in the hands (ideally hold for 30s) Restricted flexion at wrist
Paraesthesiae Paraesthesiae indicative of carpal tunnel syndr and hence assoc w psor arth and RA
Make a fist
Pinch grip
- test power by placing index finger in the gap between the patients thumb and finger and attempting to separate thumb and finger Inability to oppose thumb an index finger
Opposition with reduced power
Key grip
- ask patient to turn handle of key against resistance
C grip
- ask patient to hold a cup of water and take it to their mouth
Writing
- give the patient a pen and ask them to write their name Fine motor function
Buttons
- ask patient to undo a button and then do it up

LOCOMOTOR – HIP EXAMINATION

Overview

1. Look Gait
Standing – front, side, back
Pelvic squaring
Trendelenburg’s Test
Look from end of bed

2. Feel Measure leg length – apparent and true LLDs
Palpate – greater trochanter, groin, ischium

3. Move Flexion + Thomas Test (supine)
Abduction + Adduction (supine)
Internal + External Rotation (supine)
Extension (prone)
IR / ER (prone)

4. Other Knees, Lumbar spine and Neurovascular

Greet patient and introduce self. Ask for permission.
Expose patient. Want to see legs and lower back. Remove socks and shoes.
Look for any walking aids. Use of stick on side opposite to affected hip (reverse is true in knees).

1. Look

a. Gait
- heel-toe progression, alignment of feet, no limp
- no stiffness
- no obvious LLD

b. Standing (WADSSS)
front quads wasting
alignment – straight stance, shoulders symmetrical over shoulders
scars
swelling
side normal physiological lordosis
flexion contractures
scars
back wasting – calves, gluts
alignment of pelvic crests
deformities - spine straight

Patient remains standing and facing away from examiner

c. Pelvic Squaring (alignment)
- Place hands over iliac crest (squaring the pelvis) - look for asymmetry (Pelvic tilt due to LLD, sciatica, scoliosis, abduction/adduction deformity of the hip)

d. Trendelenburg’s Test
- Stand behind patient and hold on to iliac crests and PSIS.
- Tell patient which hip is having problems and ask them to slightly lift other leg off the ground - eg “so your right hip is sore, please lift your left leg off the ground”
- Ideally – assess for 30 secs - look for sound side sag
- Positive if hemipelvis falls below horizontal toward side of lifted leg – caused by weak gluteal abductors (glut med/min), inhibition from hip pain (OA, struct abnormality) or mechanical instability

Ask patient to climb onto examination bed and watch how they do it - Comment - Patient lying supine

e. Look again from end of bed
- any other abnormalities
- note - NOFF = shortened + external rotation of legs

2. Feel

a. Measure leg length
- Apparent leg length (umbilicus to medial malleolus) → adduction or flexion deformity of hip / pelvis asymmetry OR a true leg length difference
- True leg length required if apparent leg length difference (ASIS to medial malleolus) – causes of true shortening lower limb →
NOFF
SUFE
Unreduced hip disloc
Other – post total hip arthroplasty, perthes (epiphyseal osteonecrosis femur), septic arthritis, loss of articular cartilage, congen coax vara (altered angle of fem neck to axis fem shaft <135’ ie fem neck more horizontal), missed congenital hip disloc, growth disturbance femur/tibia by poliomyelitis, fractures, osteomylitis, septic arthritis, epiphyseal injury
- if true LLD → flex knees + hips, align medial condyles + medial malleoli → to determine if length discrepancy tibial or femoral
- if femoral difference → determine whether prox or distal to greater trochanter - detect w thumb on ASIS + fingers to gr trochanter

b. Palpate
- ASIS (then find greater trochanter)
- Greater trochanter - tenderness + temperature (back of hand). (trochanteric bursitis – tender, red, hot +swollen) - Point of insertion of gluteus medius/minimus, piriformis, gamellus superior and inferior, obturator internus.
- Groin pain (hip OA)
- Ischium (hamstrings insertion – strain)

3. Move
Say that you would usually do the good side first for comparison. Ask examiner if they would like you to assess the other side as well.
Ask patient if he/she is in any pain before moving him/her.
Check active movement, passive movement and power.
Remember to look at patient’s face when doing movements

a Flexion “can you bend your leg up”
- Normal range 120o (active + passive) + Power
Combine flexion with the thomas test –
- Check hip flexion etc in problem leg first, then get patient to flex good side and hold knee with their hands
- Place one hand under lumbar spine to ensure lumbar lordosis obliterated then flex good hip.
- Positive → bad leg lifts off bed with fixed flexion contractures (hip OA).
- Do not perform if patient has a hip replacement on the non-test side - forced flexion may cause disloc.

b. Hip Abduction + Adduction
- Remember to fix patient’s hip by placing fingers on ASIS and ensuring pelvis does not move - use other arm to move the leg.
- check active and passive ROM + power
- Abduction normal range 40-45’
- Adduction normal range 20-30’

c. Internal Rotation + External Rotation
- performed in flexion and extension - Hip flexed at 90o and then swing foot laterally/medially.
- check active and passive ROM + power
Internal Rotation – (limited or tender IR first sign of hip OA) - Normal range 30-35o
External Rotation - Normal range 40-45o

Patient lying prone – Remember the problem leg changes side

d. Extension
- Apply downward pressure with one hand over sacrum to fix pelvis. Flex knee to 90’. Lift thigh with the other hand.
- Normal range 10-15o
- Active, Passive and Power

e. IR/ER again

4. Other

- Knees
- Lumbar spine (referred pain to hip)
- Neurovascular examination

LOCOMOTOR – KNEE EXAMINATION

Overview

1. Look Walk
Standing (360)
Bed
2. Feel Quad circumference
Temperature
Effusion
Tenderness
3. Move Active knee flexion (ROM)
Power knee flexion
Power knee extension
Passive knee extension (crepitus)
Leg lift for knee extension
4. Speical Collateral ligaments - MCL/LCL – 0’ and 30’
Cruciate ligaments - ACL/PCL – observe posterior sag, anterior/posterior draw test (70’), lachmann’s test (15’)
Patellar apprehension
Meniscal grinding test
Patellar tracking
5. Other Pulses, Hip, Ankle

Introduce self. Ask for permission.
Expose patient’s legs, ideally whole leg.

1. Look (6 ft away)

A. Walk
- Look for abnormal gait e.g. antalgic gait, foot drop, lateral thrust
- Walking aid?
- Shoes
“Normal heel-toe gait, feet are in alignment, no limp”

B. Standing (WADSSS)
Front
- Alignment of limbs. Normally slightly valgus 5-7o. Valgus or Varum.
- Symmetry
- Wasting: Quads
- Swelling – concavities/suprapatellar pouch
- Scars
- Redness
- Masses
- Squat - Any pain? Screening for meniscal problem

Side
- flexion contractures at knee join
- genu recovartum

Back
- wasting (calves and hamstrings)
- swelling in popliteal fossa (popliteal cyst)
- scars

C. Patient lying on bed
- Look for same things as above from up close i.e. swellings, scars etc
- Look esp for quads wasting – if present, measure quads circumference (measure about 4 fingerbreadths (6 cm) above patella to avoid suprapatellar bursa)

2. Feel

A. Quad Circumference – measure >6cm above patella
Offer to measure for LLD as per hip exam

B. Temperature

C. Effusion (3 Tests)
Patient lying on bed
- Observe. Look for loss of concavities. Occurring in large effusions. “There is or is not any obvious joint effusion”
- Patellar tap – knee extended, empty suprapatellar pouch by sliding L hand down thigh until reach upper endge patella – keep hand there and with fingertips of R hand, press down briskly and firmly over patellar (bone not tendon) (in moderate effusion → tapping sensation as patella strikes the femur)
- Patellar sweep test – knee extended + quads relaxed, empty suprapatellar pouch (as below), then with fingers extended, stroke medial side of the joint, then stroke lateral side and watch the medial side for a bulge or ripple as fluid reaccumulates on that side.

D. Tenderness
Patient lying on bed with knee bent slightly
Ask patient to tell you if it’s sore and name your landmarks as you palpate them
- Origins and insertions of collateral ligaments – femoral condyles and fibula/tibia – LCL/MCL
- Fibula head (biceps femoris attachment – peroneal n over bone → vulnerable to damage with #)
- Patella for retropatellar pain
- Patellar tendon
- Joint line for meniscal pathology
- Tibial tuberosity
- Femoral condyles
- Popliteal fossa

3. Move

Patient still lying on bed
Compare one side with the other
Before starting – ask if any pain and when examining, always look at the patient’s face
Active and Passive movements then Power (assess together)

a. active knee flexion (ankle to bottom) - <140’ normal
b. power of knee flexion (“don’t let me pull your leg”)
c. power of knee extension (“push away with your leg”)
d. passive knee extension (feel for crepitus)
e. extend knee by lifting straight leg up (<10’ normal)

4. Special Tests

Looking for laxity
Patient lying with straight legs

a. Collateral Ligaments - Medial and lateral collateral ligaments at 0o and 30’ – assess laxity
- At 0o, hold patient’s ankle between your elbow and your waist, supporting with the hand, and using the other hand to exert lateral and medial force.
- At 30o, hang patient’s leg off the side of the bed a little bit and do it in that position (↑ laxity at 30’)
- Lateral collateral ligaments small and insignificant

b. Cruciate Ligaments
- Posterior Tibial Dropback - Flex both knees and hips and line them up. Look sideways at knees and comment on presence or absence of a posterior sag. Absence means that the PCLs are working fine.
- Anterior Draw and Posterior Draw Tests – For OSCE, compare both sides if time permits. Ask patient if you can sit on his/her foot. Ensure patient’s leg at about 70o. Ensure hamstrings relaxed (can prevent tibial movement anteriorly). Hands behind upper tibia and both thumbs over tibial tuberosity. Then do anterior drawer and posterior drawer tests. Is there a firm end point? Normal <1-1.5cm. A positive anterior drawer test must always be confirmed by a positive Lachmann’s test.
- Lachmann’s Test - Leg extended to approx 15o. Is there a firm end point? ACL damage will always be seen here while there are many false positives in the ant drawer. This test requires a strong grip.
Note - you only need to yank once and not a hundred times. Laxity on ant/post draw followed by a negative lachmanns test indicates a problem with the PCL

c. Patella Apprehension
- Patella apprehension test at 20o. Sit on bed, put patient’s knee over your leg, push patella laterally while flexing knee slowly. Look for apprehension from patient

Patient moves to prone position

d. Meniscal Grinding Test
- Patient prone, knee flexion, push knee into table, rotate/grind meniscus (like stirring with a spoon)

Patient sits over side of bed

e. Patella Tracking
– First observe position of patellar (middle + looking ahead). Extend leg and look for patellar tracking (always laterally due to valgus force – patellar disloc more common F>M due to q angle) – indicates prone to dislocation and possible premature degeneration.

5. Other

 Pulses
 Hip (SUFE causes knee pain)
 Ankle

Thank the patient

LOCOMOTOR – SHOULDER EXAMINATION

Overview

1. Look Standing – front, side, back (scapula winging), top

2. Feel Palpate for tenderness and swelling

3. Move Range of movement – active and passive
Power rotator cuff muscles and deltoid muscle

4. Special Tests Sulcus sign
Apprehension test (anterior dislocation)
Posterior dislocation test
Impingment test
AC joint pathology

5. Other Neurovascular – pulses and sensation
Joint above and below – C-spine and elbow

Introduce self. Ask for permission.
Expose adequately. Male: shirts off. Female: Bra can remain but straps down, gown made into a strapless dress.

1. Look (compare both sides) - WADSSS

Patient standing up

a. Front (from medial to lateral)
- SC joint: Prominence, Swelling
- Clavicles: Deformities, Asymmetry
- AC joint: Swelling, Dislocation/subluxation
- GH joint: Dislocations
- Deltoid muscle: Wasting

b. Side
- Scars.
- Swelling

c. Back (lateral to medial)
- Scapula: Present/absent, position and size, winging (ask patient to push against something) Scapula winging is due to long thoracic nerve palsy which leads to paralysis of serratus anterior muscle which holds down scapula.(C5,6,7)
- Supraspinatus and infraspinatus muscles: Wasting.

d. From top (may need to get patient to sit)
- Glenohumeral joint – Look for posterior dislocation of shoulder.
- Symmetry of clavicles

2. Feel

Feel one side at a time, medial to lateral – one hand only so you can isolate any pain
Tell patient: I’m going to feel around your shoulder. Please tell me if you feel sore”
Feel for temperature, tenderness, swelling, prominences, masses

Patient still standing up
- SC joint
- Clavicles
- AC joint
- Coracoid process
- GH joint: Palpate anterior and lateral aspects, greater tuberosity of humerus (it is tender in rotator cuff syndrome)
- Deltoid
- Biceps tendon

Patient turns around facing away from you
- Scapula: Spine, medial and lateral borders.
- Supraspinatus + Infraspinatus: wasting (indicating rotator cuff problems or suprascapular n palsy)

3. Move

Say that you would normally start with the good side for comparison.
Ask patient if he/she is sore.
Do active and then passive movement, i.e. ask patient to do the movement (active) and then move it further (passive)
Patient still standing up

a. Range of Movement
I. Flexion – active and passive
II. Extension – active and passive
III. Abduction - Look for painful arc sign. Pain on initiating abduction (between 80o-120o) due to tear of supraspinatus tendon. Pain due to greater tuberosity pressing on inflamed supraspinatus tendon - Sign of rotator cuff tendonitis. Then passive movement.
Low arc pain – bursitis, RC tendon
Mid arc pain – bursitis (subacromial or subdeltoid)
High arc pain – OA AC joint
IV. Adduction
V. External rotation – Reach hand behind head (sup border scapula T3 / scapula spine to T4 / inf border scapula T7)
VI. Internal rotation - Put hand behind back and reach highest possible point of opposite scapula

Patient remains standing – progress straight position of internal rotation to testing of subscapularis

b. Power of rotator cuff muscles and other important muscles
a. Subscapularis - Like putting hand in “back pocket”, at waist level. Ask patient to push outwards onto your hand.
b. Supraspinatus – arm abducted out at 60’ approx (full extension of elbow) and thumbs pointed down – patient tries to abduct against resistance
c. Infraspinatus - Externally rotate patient’s shoulder and push in. Ask patient to resist.
d. Deltoid - Shoulder abduction. Push down and ask patient to resist.

4. Special tests

Patient standing up

a. Sulcus Sign – pull arm downwards with hand on biceps (not below elbow) – assess laxity of ligaments at shoulder

Stop – Ask patient if they have either dislocated their shoulder

b. Apprehension test of anterior dislocation – ask if pain and access apprehension
- if patient apprehensive or has tenderness, perform a relocation and surprise test

c. Posterior dislocation test – patient’s arm in block position, put your hand on their shoulder and drape their arm across yours, angle at 60’ to line up with GH joint, then push backward

d. Impingment test – patient puts hand in stop position, then internally rotate patients hand, ask if any pain and also feel for crepitus
- pain is a sign of rotator cuff tendonitis occurring when the humerus head impinges on the acromion

e. AC joint pathology – adduct patients straight arm and ask if there is any pain

5. Other

a. Neurovascular
- brachial and radial pulse
- sensation – Axillary nerve (deltoid)
Radial nerve (posterolateral aspect arm)
Musculocutaneous nerve (lateral forearm)
b. Cervical spine and elbow

LOCOMOTOR – SPINE AND BACK EXAMINATION

Overview

1. Look Walk -
Standing – front, back, side

2. Feel Tenderness
Muscle tenderness
Steps

3. Move Lumbar Spine – flexion (schobers test), extension, lateral flexion, rotation (standing)
Cervical Spine – flexion, extension, lateral flexion, rotation (standing)

4. Special Tests Straight leg raise (supine)
Lassague test (supine)
Bowstring test (supine)
Femoral nerve stretch test (prone)

5. Testing spinal nerve roots Sensation (sitting)
Power (sitting)
Reflexes (sitting)
Hip Flexion (supine)

6. Other pulses, sphincter, hip, abdomen

Introduce self. Ask patient for permission to examine.
Exposure of whole back, ideally stripped down to underwear.

Anatomy - L4/5 interspinous space = iliac crest
- Dimples of venus – overlie sacroiliac joints
- Spinal cord ends at L2 (disc protrusion effects after this level – before the whole spinal cord affected)

1. Look

a. Walk
Gait
On toes – functioning plantarflexors - intact S1/2
On heels – functioning dorsiflexors – intact L4/5

b. Standing (from 6 feet) - WADSSS
Front - Quad wasting
Shoulder tilt – indicating PID (prolapsed intervetrebral disc)
Posture of head and neck
Side - Thoracic kyphosis (↑ in Ank spon)
Lumbar lordosis – (↑in spondylolisthesis (ant slippage of one disc on inf disc), OA, flexion deformity of hips)
Flexion of spine, hips and knees (simian stance) – indicating spinal stenosis
Back - Wasting – gluts, hamstrings, calves, paravetrebral muscles
Alignment – pelvic crests equal
Deformity – Scoliosis (if seen on standing, ask patient to bend forward - in postural scoliosis due to LLD then, curve will be obiliterated) – other causes
include PID, true structural abnormality, neurofibramotosis
Muscle Spasm
Scars
Swelling
Skin
Bend forward – look for paravetrebral hump

2. Feel

Ask patient to say if it is sore

a. Tenderness - Punch along spinous processes for bony tenderness (infection or mets)
b. Muscle tenderness - Feel along paraspinal soft tissues for muscle tenderness, esp at lumbosacral junction (PID), over lumbar muscles (PID), sacroiliac joint (AS, infection)
c. Steps – spondylolisthesis

3. Move

A. Lumbar Spine

a. Flexion
- Put a finger each at 2 spots along the spine. Look for increase in distance between the 2 fingers as patient bends forward. This is to ensure that patient is flexing at the lumbar spine and not the hip. “there is lumbar flexion at the spine, rhythm is smooth”
- Schober’s test – Mark midline of spine at SI joint dimples, then 10 cm above and 5 cm below – upon flexion should increase by approx 5 cm to 20 cm. Normal excursion of spine during flexion is 7 cm. Restricted flexion is seen in AS.
b. Extension - 10-20’ normal. Pain due to PID.
c. Lateral flexion
d. Rotation - Patient’s hands on head - Remember to fix patient’s pelvis as he does this.

B. Cervical Spine

a. Neck Flexion (0-80)
b. Neck extension (0-50)
c. Lateral neck flexion (0-45)
d. Lateral neck rotation (0-80)
Perform passive movements if any active movements are reduced

4. Special Tests

Patient lying down on bed on one pillow only

Look – if knee and hip flexed, possible sciatica

Start with normal side
1. SLR (straight leg raise) – no pain at 70’ (sciatic nerve irritation) – if pain, ask patient to report where pain is
2. Lassague – as per SLR but also dorsiflex ankle (more sciatic nerve provocation)
3. Bowstring (tibial nerve stretch test) – push in popliteal fossa while patient’s leg drapes across your shoulder (more sciatic nerve provocation)
If patient is positive for sciatic irritation on SLR, there is no real need to provoke them with Lassague or Bowstring tests.
Patient moves from lying supine to lying prone.
4. Femoral nerve stretch test – patient prone, flex knee and extend hip – positive test if pain in front or back of thigh

5. Testing spinal nerve roots

Patient sitting on bed – watch and comment on how patient sits on bed

a. Sensation (dermatomes)
- L2: Upper anterior thigh
- L3: Anterior part of knee.
- L4: Medial part of ant leg.
- L5: Lateral part of ant leg.
- S1: Lateral part of dorsum of foot.
- S2: Central part of calf.

Patient remains sitting on bed

b. Power
- Knee extension against resistance. Place hand over quads and lift patient’s leg up. Ask patient to hold leg up against resistance. (L3, L4)
- Ankle dorsiflexion against resistance (L4, L5)
- Extension of big toe against resistance (L5)
- Plantarflexion against resistance (S1, S2)
- Toes flexion (S2, S3)
- Hip flexion performed after reflexes

c. Reflexes
- Patellar reflex (L3, L4)
- Ankle reflex (S1, S2)

Patient lies supine

d. Hip Flexion against resistance (L2/3) - iliopsoas

6. Other

a. pulses
b. sphincter (tone and sensation)
c. hip
d. abdomen (AAA)

LOCOMOTOR – EXAMINATION OF WRIST LACERATION

Overview

1. Look

2. Circulation Color
Temperature
Capillary refill
Radial and ulnar pulse
Allan’s test

3. Tendons PL, FCR, FCU
FDP, FDS
FPL, EPL, EPB, APL
ECR / ECU

4. Nerves Sensation – radial, median, ulnar
Motor + Froments sign (ulnar nerve palsy)

Introduce self and task. Ask for permission to examine.
Expose whole arm.

1. Look

- At patient. Is he/she feeling alright? In pain or distress?
- Describe the laceration. Where is it?
- Ask if there’s any other injuries elsewhere. Look for bruising, swelling, deformity, active bleeding.
- Natural cascade of fingers (disrupted if tendon torn)

2. Circulation

- Colour
- Temperature: Styloid process, MCP, PIP, DIP, thenar, hypothenar parts of hand.
- Capillary refill (<2 secs)
- Pulse: radial and ulnar.
- Allen’s test.

3. Tendons

PL / FCU / FCR
• Palmaris longus tendon. Thumb and little finger in opposition.
• Flexor carpi ulnaris + radialis tendons. Flex and adduct wrist against resistance. Look for strong and intact tendons.
FDP / FDS
• Flexor digitorum profundus. Fix rest of finger except at DIP joint. Ask patient to flex at DIP joint against resistance. Test each finger.
• Flexor digitorum superficialis. Fix proximal phalanx + other fingers and ask patient to flex at PIP joint against resistance. Test each finger.
FPL / EPL / EPB
• Flexor pollicis longus. Fix proximal phalanx and ask patient to flex distal phalanx against resistance.
• Extensor pollicis longus tendon. Ask patient to place hand on a surface and lift thumb up.
• Extensor pollicis brevis tendon. Ask patient to extend thumb at MCP joint against resistance.
• Abductor pollicis longus tendon. Ask patient to abduct thumb against resistance. The tendon is anterior and closely adjacent to the tendon of EPB.
ECU / ECR
• Extensor carpi ulnaris tendon. Ask patient to extend and adduct hand at wrist against resistance.
• Extensor carpi radialis tendon. Ask patient to extend and abduct hand at wrist against resistance.

4. Nerves

a) Sensation
- Radial nerve: Web space between thumb and index finger.
- Median nerve: Pulp of index finger.
- Ulnar nerve: Pulp of little finger.

b) Power
Radial Nerve
- Test extensor digitorum. Ask patient to extend fingers. Push down on MCP (knuckles) and ask patient to resist.
- Test extensor carpi radialis and ulnaris. Ask patient to dorsiflex wrist. Push it down and ask patient to resist.
Median Nerve
- Test abductor pollicis longus. Ask patient to abduct thumb against resistance.
- Test opponens pollicis. Ask patient to make a pinch grip against resistance.
(Median nerve supplies: LOAF; Lumbricals(only 1st and 2nd), Opponens pollicis, Abductor pollicis longus + brevis, Flexor pollicis brevis + longus)?
Ulnar Nerve
- Test dorsal interossei muscles. Ask patients to splay (abduct) fingers. Try to adduct patient’s fingers and ask patient to resist.
- Froment’s test. Testing adductor pollicis. Put a piece of paper between patient’s thumbs. Ask patient to hold it with the flat of their thumbs as you try to pull the paper out. Positive if patient tries to hold paper by flexing the IP joint of the thumb (flexor pollicis longus = median nerve)

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