HOWTRAININGMATERIAL2010/11 SESSION1

THESHOULDER
History
Painfromshoulderoritssurroundingtendonsisfeltanterolaterally&attheinsertionof
deltoids;sometimesitradiatesdownthearm.Painontopofshouldersuggests
acromioclaviculardysfunctionoracervicalspinedisorder.Theentireshoulderisacommon
siteofreferredpainfromcervicalspine,heart,mediastinum&diaphragm
Stiffnessmaybeprogressive&severe:somuchsoastomeritthetermfrozenshoulder
Deformitymayconsistsofprominenceofacromioclavicularjtorwingingofscapula
Lossoffunctionisexpressedasinabilitytoreachbehindtheback&difficultywithcombinghair
ordressing
Thepainfulshoulder
a) Referredpain
1 Cervicalspondylosis
2 Mediastinalpathology
3 Cardiacischaemia
b) Jointdisorders
1 Glenohumeralarthritis
2 Acromioclaviculararthritis
c) Rotatorcuffdisorders
1 Tendinitis
2 Rupture
3 Frozenshoulder
Examination
Theptshouldalwaysbeexaminedfrominfront&frombehind.Bothupperlimbs,neck&chest
mustbevisible.Becauseshoulder&necksymptomsareoftenfeltinsameareas,examination
ofshouldermustincludeafullexaminationofneck&viceversa
Look
a) Skin
Scarsorsinusesarenoted;dontforgettheaxilla!
b) Shape
Asymmetryofshoulders,wingingofscapula,wastingofdeltoidorshortrotators&
acromioclaviculardislocationarebestseenfrombehind;jtswellingorwastingof
pectoralmusclesismoreobviousfrominfront.Ajteffusionmaypointinaxilla
c) Position
Ifthearmisheldinternallyrotated,thinkofposteriordislocationofshoulder
Feel
Becausethejtiswellcovered,inflammationrarelyinfluencesskinT.thesofttissues&bony
pointsarecarefullypalpated,followingamentalpictureofanatomy.Startwith
sternoclavicularjt,thenfollowclaviclelaterallytoacromioclavicularjt,ontoanterioredgeof
acromion&aroundacromiotobackofjt.Thesupraspinatustendonliesjustbelowanterior
edgeofacromion.Tenderness&crepituscanoftenbeaccuratelylocalizedtoaparticular
structure

HOWTRAININGMATERIAL2010/11 SESSION1
Move
a) Activemovements
Theptisaskedtoraisebotharmssidewaysuntilfingerspointtoceiling.Abductionmay
be
1 Difficulttoinitiate
2 Diminishedinrange
3 Alteredinrhythm,thescapulamovingtooearly&creatingashruggingeffect
Ifmovementispainful,thearcofpainmustbenoted;paininmidrangeofabduction
suggestsarotatorcufftearorsupraspinatustendinitis;painattheendofabductionis
oftend/tacromioclaviculararthritis
Ptisthenaskedtoperformotheractivemovements;flexion&extensionbyraisingthe
armsforwards&thenbackwardsasfaraspossible;adductionbymovingeacharm
acrossthefrontofbody;androtationbyholdingthearmsclosetobody,flexingelbows
to90&1stseparatinghandsaswidelyaspossible(externalrotation)&thenfoldingthe
forearmsacrossfrontofbody(internalrotation)
3compositemovementsareessentialfornormalfunction
1 Claspingthehandsbehindnecks
2 Reachinghighuponback
3 Performingacircularpotstirringmovementwitheacharminturn
b) Passivemovements
Thesecanbedeceptivebecauseevenwithastiffshoulderthearmcanraisedto90by
scapulothoracicmovement
Totestglenohumeralabduction,scapulamust1stbeanchored;thisisdonebypressing
firmlydownontopofshoulderwith1handwhiletheotherhandmovesptsarm
c) Power
Deltoidisexaminedwhileptabductsagainstresistance
Totestserratusanterior(longthoracicnerve),askpttopushforcefullyagainstawall
withbothhands;ifthemuscleisweak,scapulaisnotstabilizedonthorax&standout
prominently(wingedscapula)
Pectoralismajoristestedbyptthrustingbothhandsfirmlyintowaist.Anydifferencein
musclebulkbetween2sidesisnotedatthesametime
Imaging
Atleast2xrayviewsshouldbeobtained:anAPviewinplaneofglenoid&anaxillary
projectionwitharminabductiontoshowrelationshipofhumeralheadtoglenoid.Lookfor
evidenceofsubluxation,ordislocation,jtspacenarrowing,boneerosion&calcificationinsoft
tissues
Doublecontrastarthrography,US,CTandMRIareusefulmethodsfordiagnosingrotatorcuff
tearsoratypicalformsofshoulderinstability
Arthroscopy
Isusefulfordiagnosingintraarticularlesions,detachmentofglenoidlabrum&rotatorcuff
tears.Insomecasesthedisordercanbedealtwithsurgicallyatthesametime
HOWTRAININGMATERIAL2010/11 SESSION1
THEELBOW
History
Painmaybefeltdiffuselyonmedialsideofjt(ulnohumeral),posterolateralside(radiohumeral),or
acutelylocalizedtooneofthehumeralepicondyles(tenniselbowonlateralside&golferselbow
onmedialside).Painoverbackofelbowisoftend/tanolecranonbursitis
Stiffness,ifseverecanbeverydisabling;ptmaybeunabletoreachtothemouth(lossofflexion)or
perineum(lossofextension);limitedsupinationmakesitdifficulttoholdsomethinginpalmortocarry
largeobjects
Swellingmaybed/tinjuryorinflammation;asoftlumponbackofelbowsuggestsanolecranon
bursitis
Deformityisusuallyresultofprevioustrauma
1 Cubitusvarusd/tamalunitedsupracondylarfracture
2 Cubitusvalgusd/tanolddisplaced&malunitedfractureoflateralcondyle
Instabilityisnotuncommoninlatestageofrheumatoidarthritis
Ulnarnervesymptoms(tingling,numbness&weaknessofhand)mayoccurinelbowdisordersbecause
thenerveissonearthejt
Lossoffunctionisnoticedingroomingactivities,carrying&handwork
Examination
Bothupperlimbsmustbecompletelyexposed&itisessentialtolookatbackaswellasfront
Theneck,shoulders&handsshouldalsobeexamined
Look
Lookingatptfromfront,withhisorherarmsoutstretchedalongsidebody&palmsfacingforwards,
elbowsareseentobeheldin510ofvalgus;thisisnormalcarryingangle.Anythingmore,especially
ifunilateral,isregardedasavalgusdeformity.Varusdeformityislessobvious,butifptraisesthearms
toshoulderheight,itiseasilyseen
Themostcommonswellingisinolecranonbursaatthebackofelbow
Feel
Importantbodylandmarksarethemedial&lateralcondyles&tipofolecranon.Thesearepalpatedto
determinewhetherjtiscorrectlypositioned
Superficialstructuresareexaminedforwarmth&SCnodules.Thejtline(includingradioulnarjt
depression)islocated&palpatedforsynovialthickening.Tendernesscanusuallybelocalizedtoa
particularstructure
Theulnarnerveisfairlysuperficialbehindmedialcondyle&hereitcanberolledunderfingerstofeelif
itisthickenedorhypersensitive
Move
Flexion&extensionarecomparedon2sides.Then,elbowstuckedintosidesandflexedtoarightangle,
radioulnarjtsaretestedforpronation&supination

Generalexamination
Ifsymptoms&signsdonotpointclearlytoalocaldisorder,otherpartsareexamined
1 Neck(forcervicaldisclesions)
2 Shoulder(forcufflesions)
3 Hand(fornervelesions)
Xray
Thepositionofeachboneisnoted,thenjtline&space.Next,theindividualbonesareinspectedfor
evidenceofoldinjuryorbonedestruction.Finally,loosebodiesaresought

HOWTRAININGMATERIAL2010/11 SESSION2
THEWRIST
History
Painmaybelocalizedtoradialside(espintenovaginitisofthumbtendons),totheulnarside(possiblyfrom
radioulnarjt)ortodorsum(usualsiteindisordersofcarpus)
a) Jtdisorders
1 Infection
2 KienbocksDs
3 Carpalinstability
4 Rheumatoidarthritis
5 Osteoarthritis
b) Periarticulardisorders
1 deQuervainsDs
2 Tenosynovitis
c) Referredpain
1 Cervicalspondylosis
Stiffnessisoftennotnoticeduntilitissevere
Swellingmaysignifyinvolvementofeitherjtortendonsheaths
Deformityisalatesymptomexceptaftertrauma
Lossoffunctionaffectsbothwrist&hand.Firmgripispossibleonlywithastrong,stable,painlesswristthat
hasareasonablerangeofmovement
Examination
Examinationofwristisnotcompletew/oalsoexaminingtheelbow,forearm&hand.Bothupperlimbs
shouldbecompletelyexposed
Look
Theskinisinspectedforscars.Bothwrists&forearmsarecomparedtoseeifthereisanydeformity.Ifthere
isswelling,notewhetheritisdiffuseorlocalizedtooneofthetendonsheaths
Feel
Unduewarmthisnoted.Tenderareasmustbeaccuratelylocalized&bonylandmarkscomparedwiththose
ofnormalwrist
Move
Passiveflexion&extensionofwristcanbemeasuredoneachsideinturn.Toviewbothsidessimultaneously
&comparethem,askpt1sttoplacehisorherpalmstogetherinapositionofprayer,elevatingtheelbows,
thentorepeatmanoeuvrewiththewritstsbacktoback.Thenormalrangeforbothflexion&extensionis
8090.Radialdeviation&ulnardeviationaremeasuredinpalmsupposition;ulnardeviationisconsiderably
greaterthanradialdeviation
Pronation&supinationareincludedinwristmovements.Theptholdshisorherelbowsatrightangles&
tuckedintosides,fingersextended&palmsfacingeachother;handsarethenturned1stpalmsdownwards
&thenpalmsupwards
Activemovementsshouldbetestedagainstresistance;lossofpowermaybed/tpain,tendonruptureor
muscleweakness.Gripstrengthcanbegaugedbyhavingptsqueezetheexaminershand;mechanical
instrumentsallowmoreaccurateassessment
Investigations
a) Xray
Oftenbothwristsmustbeexaminedforcomparison
Specialobliqueviewsarenecessarytoshowupdifficultscaphoidfractures
Notethepositionofcarpalbones&lookforevidenceofjtspacenarrowing,espatcarpometacarpal
jtofthumb
b) MRI
Usefulfordemonstratingearlyfeaturesofavascularnecrosisordetectingsofttissuelesionssuchas
anoccultganglio
c) Arthroscopy
Themostreliablewayofdiagnosingtearsoftriangularfibrocartilagecomplex(TFCC)
Itwillalsorevealearlychangesofosteoarthritis

HOWTRAININGMATERIAL2010/11 SESSION2
Thehand
Clinicalassessment
A)History
Painfeltinthepalmorinthefingerjoints.Apoorlydefinedachemaybereferredfromtheneck,shoulderor
mediastinum.
Deformity appearsuddenly(duetotendonrupture)or
slowly(boneorjointpathology)
Swellinglocalized/manyjointssimultaneously.
E.g.rheumathoidarthritisswellingoftheproximaljoints,osteoarthritisthedistaljoints.
Lossoffunction
Sensorysymptomsandmotorweaknessneurologicaldisordersaffectingthelowercervicalnerverootsandtheir
peripheralextensions.

B)Examination
comparebothupperlimbs
Lookscar,colour,dry/moist,andhairyorsmooth,Wastinganddeformity,lumps,Restingposture,Swelling.
Feeltemperatureandtextureoftheskin,nodule(underlyingtendonshouldbemovedtoshowifitisattached).
Tenderness.Swelling(insubcutaneoustissue,inatendonsheathorinajoint).
Move
a)Passivemovements
rangeofmovementmetacarpophalangeal(MCP),proximalinterphalangeal(Pip),distalinterphalangeal(DIP)
joints.
b)Activemovements
Method(whatpatientneedtodo):
1. palmsfacingupwards,curlthefingersintofullflexionmayshowlaggingfinger.
2. MotorfunctionTest
flexordigitorumprofundusPIPjointimmobilizedthenbendthetipofthefinger.
flexordigitorumsuperficialisinactivateflexorprofundus
graspingallthefingers,excepttheonebeingexamined,andholdingthemfirmlyin
fullextension
flextheisolatedfingerwhichisbeingexamined
exceptions:
1st,thelittlefingersometimeshasnoindependentflexordigitorumsuperficialis
2nd,theindexfingeroftenhasanentirelyseparateflexorprofundus,whichcannotbe
inactivatedbytheusualmassactionmanoeuvre.Instead,flexorsuperficialisistestedby
askingthepatienttopinchardwiththeDIPjointinfullextensionandthePIPjointinfull
flexion;thispositioncanbemaintainedonlyifthesuperficialistendonisactiveand
intact.
longextensorsextendtheMCPjoints
MCPflexionandIPextensionsextendthefingerswiththeMCPjointsflexed(theduckbillposition).
interosseiabductandadductfinger.
Thumbmovementsfivetypesofmovement
extension(sidewaysmovementtowardsthepalmintheplaneofthepalm)abduction(upward
movementatrightanglestothepalm)
opposition(touchingthetipsofthefingers).
flexorpollicislongusimmobilizingthethumbMCPjoint.
Gripstrength
Squeezetheexaminersfingersdiminishedmuscleweakness,tendondamage,fingerstiffnessorwrist
instability.
moreaccuratelywithamechanicaldynamometer.
Pinchgripalsoshouldbemeasured.
Neurogicalassessment
ifsymptomssuchasnumbness,tinglingorweaknessexistandinallcasesoftraumaafullneurological
examinationoftheupperlimbs.Furtherrefinementisachievedbytestingtwopointdiscrimination,sensitivity
toheatandcoldandstereognosis.
HOWTRAININGMATERIAL2010/11 SESSION3
Theneck
Clinicalassessment

A)History
commonsymptomsofneckdisorderarepainandstiffness.
Painreferredtotheshouldersorarms.suddenly(aswithanacuteintervertebraldisc
prolapse)
gradually(asinchronicdiscdegeneration)
Stiffnessintermittent/continuous.
Deformitywryneck/neckfixedinflexion.
Numbness,tinglingandweaknessintheupperlimbsduetopressureonanerveroot;
weaknessinthelowerlimbsmayresultfromcordcompressionintheneck.
Headachesometimesemanatesfromtheneck,butifthisistheonlysymptom,other
causesshouldbesuspected.

B)Examination
Theentireuppertrunkandbothupperlmbsshouldbeexposed.
whenpatientstanding:examineneckpostureandmovements,shoulder.
Whenpatientseated:examineanteriorstructures(trachea,thyroid,oesophagus).
Whenpatientlyingdown:pronefeelformusclespasmandpointtenderness(neck
supportedbyapillow).
SupineNeurologicalexamination.
Lookdeformity.Skinblemishes,scapularabnormilitiesormuscularasymmetry(seen
fromback).musclewastinginthearmorhand.
Feelneckandshoulderspalpatedfortenderareas,lumpsandmusclespasm.
Move
Flexion,extension,lateralflexion,rotationandtherangeofmovements.Shoulder
movements.
Neurologicalexaminationoftheupperlimbsinallcases,sometimes,thelowerlimbs.
Imaging
xrayexaminationfromthebaseoftheocciputtoTI.
a)APviewshouldshowtheregular,undulatingoutlineofthelateral
masses
symmetrymaybedisturbedbydestructivelesionsorfractures.
Aprojectionthroughthemouthisrequiredtoshowtheuppertwo
vertebrae.
b)lateralview,discspacesareinspected;discspacenarrowingand
osteophyteformationattheanteriorandposterioredgesofthevertebral
bodiesarefeaturesofintervertebraldiscdegeneration.
c)Flexionandextensionviewsarerequiredtodemonstrateinstability.
CTandMRIareessentialfordefiningtheintervertebraldiscs,theneuralstructuresand
theoutlinesofthespinalcanalandintervertebralforamina.

HOWTRAININGMATERIAL2010/11 SESSION3
Theback
Clinicalassessment
History
usualsymptomsofbackdisorderpain,stiffnessanddeformityintheback,andpain,paraesthesiaor
weaknessinthelegs.
Themodeofonsetstartsuddenly(perhapsafterlifting)/gradually
symptomsconstant/remission
particularposture
Pain
Backusuallylowdownandoneithersidethemidline/extendingintothebuttockanddownthelimb.
thighandcalf,thoughcalledsciatica,israrelyduetosciaticnervedisorder.Itisreferredpain,either
from:
a)rootduracharacteristicallymoreintenseandoftenaccompaniedbynumbnessorparaesthesia.
b)Ajointorligamentmoreinconstantandisnotaccompaniedbyneurologicalsymptomsbutbothare
distributedmoreorlessalongtepathofthesciaticnerve.
sciaticaaloneisnonspecific.Sciaticaplusneurologicalsymptomssuggestsnerverootcompression.
Stiffnesssuddenandalmostcomplete(afteradiscprolapsed)/continuousandpredictablyworseinthe
mornings(suggestingarthritisorankylosingspondylitis).
DeformityIndiscprolapsed,arthritisandankylosingspondylitis,scoliosis.
Numbnessorparaesthesiaisfeltanywhereinthelowerlimb,butcanusuallybemappedfairlyaccurately
overoneofthedermatomes.Itisimportanttoaskifitisaggravatedbystandinguprightorwalkingand
relievedbybendingforwardorsittingdownaclassicfeatureofspinalstenosis.
Othersymptomsurethraldischarge,diarrheaandsoreeyes;thesearefeaturesofreitersdisease,one
ofthecausesofreactivespondylitis.

B)Examination
Whenpatientstanding:
Look
1. Standinfrontofthepatientandnotehisorhergeneralphysiqueandposture.
2. moveroundandstandbehindthepatient.Patientstandupright/leanovertooneside,pelvis
level/onelegshorterthantheother,spinelookstraightorcurved(scoliosis)
Scarsorotherskinmarkingsthatmaysuggestaspinaldisorder
lateralview,thethoracicspinehyperkyphosis,kyphos.
thelumbarspineunusuallyflatorexcessivelylordosed.
Feel
Thespinousprocessesandtheinterspinousligamentsarepalpated,notinganyprominenceorastep
Move
Flexion
Askthepatienttobendforwardandtrytotouchthefloor.
watchthelumbarspinetoseeifitreallymovesorbetterstill,measurethespinalexcursion.
Themodeofflexionresistantmovements,especiallyonregainingtheuprightposition,maysignify
painorsegmentalinstability.
Extension
Askthepatienttoleanbackwards;withastiffspine,heorshemaycheatbybendingtheknees.
Thewalltestwillunmaskadisguisedlossofextension:standingwiththebackflushagainstawall,the
heels,buttocks,shouldersandocciputnormallyallmakecontactwiththesurface.
Lateralflexion
Askthepatienttobendfirsttoonesideandthentotheother;comparetherangeofmovementtoright
andleft.

HOWTRAININGMATERIAL2010/11 SESSION3
Rotation
Askthepatienttotwistthetrunktoeachsideinturnwhilethepelvisisanchoredbytheexaminers
hands;thisisessentiallyathoracicmovementandshouldnotbelimitedinlumbosacraldisease.
Chestexpansion
Ribexcursionisassessedbymeasuringthechestcircumferenceinfullexpirationandthenfull
inspiration;thenormalexcursionisabout7cm
Musclepower
Distalmusclepoweristestedandcomparedbyaskingthepatienttostandupontiptoes(plantar
flexion)andthentorockbackontheheels(dorsiflexion)

Whenpatientlyingprone:
Bonyoutlinesandsmalllumpscanbefeltmoreeasilywitthepatientlyingfacedown.
Deeptendernessiseasytolocalize,butdifficulttoascribetoaparticularstructure.
Someneurologicalfeaturesareideallyelicitedwiththepatientlyingprone.
Hamstringpowertestpatientflexthekneeagainstresistance.
Thefemoralstretchbendingthepatientskneewithisorherhipflatagainstthecouch;apositivesignis
painfeltinthefrontofthethighandtheback,suggestinglumbarroottension.
Poplitealandposteriortibialpulsesareconvenientlyfeltinthisposition.

Whenpatientlyingsupine:
Thepatientisobservedforpainandstiffnesswhileturningover.
Hipandkneemobilityareexaminedbeforetestingforcordornerverootinvolvement.
checkthefemoralandpedalpulses.
Thestraightlegraisingtest
Thisistheclassictestforlumbosacralroottension.
Kneeheldstraight,thelegisliftedfromthecouchuntilthepatientexperiencespainnotmerelyinthe
thigh(whichiscommomandnotsignificant),butinthebuttockandback.Theangleatwhichthisoccursis
noted(Normallyraisethelegto90degreeswithoutcausingunduediscomfort).
Atthispoint,anadditionalstretchisimposedbypassivelydorsiflexingthefoot,maycausean
additionalstabofpain.
Ifthekneeisthenslightlyflexed,buttockpainissuddenlyrelieved;painmaythenbereinducedby
simplypressingonthecommonperonealnervebehindtheknee,totightenitlikeabowstring.
Sometimesstraightlegraisingontheunaffectedsideproducespainontheaffectedside.This
crossedsciatictensionisindicatedofsevereroottension,usuallyduetoaprolapseddisc.
Neurologicalexamination
Afullneurologicalexaminationofthelowerlimbsisessentialineverypatientwithabackproblem
Generalexamination
Whilethepatientislyingundressed,arapidexaminationiscarriedouttodetecttepresenceofany
suspiciouslumpsinthebreasts,abdomenorgenitalia.

Imaging
xrays
APview,thespineshouldlookperfectlystraight.Individualvertebraemayshowalterationsinstructure
andtheintervertebralspacesmaybeedgedbybonyspurs.Thesacroiliacjointsmayshowerosionor
ankylosis.
lateralview,thenormalthoracickyphosisandlumbarlordosisregularanduninterrupted.Theremay
beanteriorshifttoanuppersegmentuponalower(spondylolisthesis).Individualvertebrae,whichshould
berectangular,maybewedgedorbiconcave.Comparetheintervertebraldiscspaces:theremaybeundue
narrowing(flattening)ofthediscatoneormorelevels.
Specialtechniques
CT,MRIand(occasionally)contrastmyelographyareusefulforoutliningthediscandthespinalcanal.
HOWTRAININGMATERIAL2010/11 SESSION4
THEHIP

History

Paininhipjoint:Groin,frontofthigh,knee(sometimes;orevenonlysymptom!)
Stiffness:withproblemwithputtingsocksorsittinginalowchair.
Limpwithsometimeslegisgettingshorter
Walkingdistance:shortenedorusingwalkingstick

Signs

a) Upright
Gait:Antalgic(duetopain),Shortleglimp,Trendelenburglurch(abductorweakness)
Trendelenburgtest(stability):patientisaskedtostand,unassisted,oneachleginturn;onelegisliftedand
bendingthekneeoftheothersideofleg(notthehip).Positivetest:
Dislocationorsubluxationofhip
Weaknessofabductors
Shorteningoffemoralneck
Anypainfuldisorderofhip

b) Lyingsupine
Look:Besurepatientiscomfortable,pelvisatsamelevelandlegsareplacedsymmetrically.Check
levelofbothmedialmalleoliorshorteningofoneleg,
scarorsinuses,
swellingorwasting,
deformityormalposition
Asymmetryofskincreases(inbabies).

a) Limblength
Placingof2lowerlimbsincomparablepositionsinrelationtopelvisandthenmeasuringdistance
fromanteriorsuperioriliacspinetomedialmalleolusoneachside.
Shortening?Flexbothkneesandplaceheeltogetherdiscrepancyisbeloworaboveknee?If
above:isabnormalityliesabovegreatertrochanter?

Thumbsarepressedfirmlyagainsttheanteriorsuperioriliacspineandmifflefingersfeelforthe
topsofgreatertrochanterstocheckforanyelevationof1side.

b) ApparentShorteningorlengthening(nottrueshorteningorlengthening)
Happenswhenpelvisistiltedandonelimbishitchedupwards.Reasons:Uncorrecteddeformityin
thehip
withfixedadductiononeoneside,thelimbswouldtendtobecrossed;whenthelegsare
placedsidebyside,thepelvishastotiltupwardsontheaffectedside,givingtheimpressionof
ashortenedlimb.
Ortheoppositewithfixedabduction,andthelimbseemstobelongerontheaffectedside.


HOWTRAININGMATERIAL2010/11 SESSION4
Feel
Bonecontourarefeltwhenlevelingthepelvisandjudgingtheheightofgreatertrochanters.
Tendernesselicitedinandaroundthejoint.
Surfacemarkingofthejointofthefemoralhead:halfwaybetweenanteriorsuperioriliacspineand
pubictubercle.

Move
Thomasstest(fixedflexiondeformitytest):bothhipsareflexedsimultaneouslytotheirlimit
(lumbarlordosisobliterated);holdingthesoundhipfirmlyinthisposition(andthuskeepingthe
pelvisstill),theotherlimbisloweredgently.Measurethefullrangeofflexion(Normal:130degrees).
PostiveThomasstest:withanyflexiondeformity,thekneewillnotrestonthecouch.

Abductiontest:Placethesoundhipinfullabductionandkeepingitthere,thusfixingthepelvisin
thecoronalplane.Ahandisplacedononeiliaccresttodetecttheslightestmovementofthepelvis.
Then,aftercheckingthattheanterioriliacspinesarelevel,theaffectedjointismovedgentlyinto
abduction.(Nrange:45degrees)

Adductiontest:Crossingonelimbovertheother;thepelvismustbewatchedandfelttodetermine
thepointatwhichitstartstotilt.(Nrange:30degrees)

Rotationtest:bothlegsareliftedbyankles,arerotatedfirstinternallythenexternally;thepatellae
arewatchedtoestimatetheamountofrotation.Rotationinflexionistestedwithhioandkneeeach
flexed90degrees.

Abnormalmovement(movementgreatlyexcessthenorm,orabilitytoelicittelescopingby
alternativekypullingandpushingthelimbinitslongaxis)suggestseitherinstabilityoran
pseudoarthrosisofhip).

c) Lyingprone
Scars,sinusesorwasting.
Extensionof2hips(moreaccuratethanpatientinlyingsupine)
Rotationwithflexionofbothkneesandmovingthelegs:firstawayfromeachotherandthencrossingeach
other.
HOWTRAININGMATERIAL2010/11 SESSION4
THEKNEE

HISTORY
Pain:anteriorknee,diffuse(degenerativeorinflammatorydisorders)orlocalized(mechanicaldisorderespeciallyafter
injury.(maybewithremembranceofmechanismbypatient)
Swelling:Localizedordiffuse.Timeofappearance(immediately:heamarthrosis,orlate:tornofmeniscus).Chronic:
synovitisorarthritis.
Stiffness:fluctuates?Whenitfeelsworseorbetter?(earlymorningstiffness:inflammatory;stiffnessafterperiodof
inactivity:osteoarthristis)
Locking:tornmeniscusorloosebody.(Unlocking:Obstructingobjectshasmovedandjointcannowmovefreely
again.)
Deformity:unilateralorbilateral=valgusorvarus,fixedflexionorhyperextension.(knockkneesandbandylegs
commoninchildrenandhealspontaneouslywhengrownup)
Givingway:duetomusclesweaknessormechanicaldisorder(tornmeniscusorfaultypatellarextensormechanism)
Lossoffunction:diminishingwalkingdistance,inabilitytorunanddifficultygoingupanddownsteps.

P/S:couldbereferredpainfromhipdisorder.

SIGNWITHPATIENTUPRIGHT

Valgusorvarusdeformity
Walkingpattern

SIGNWIHPATIENTLYINGSUPINE

Look
Positionofknee:valgusorvarus,partiallyflexedorhyperextended.
Swelling
Scarsorsinuses,smalllumps
Wastingofquadriceps(signofjointdisorder)
Visualimpressionmeasuringthegirthofthighatsamelevelineachlimb:fixeddistanceabovethejointlineor
ahandsbreadthabovethepatella

Feel
Warmthcomparisonbetween2knees.
Temperaturegradientbyhandrunningdownthelimb(N:lineardecreaseinwarmthfromproximaltodistal).
softtissuesandbonyoutlinesforabnormaloutlinesandlocalizedtenderness:kneeisbentandexaminersits
ontheedgeofcouchfacingtheknee;placebothhandsoverthefrontofkneetotracewithfingersthe
anatomicaloutlinesofjointmargins,patellarligament,collateralligaments,iliotibialbandandpesanserinus.
Then,thekneeisplacedflatoncouchandtheedgesofpatellofemoraljointarepalpatedwhilepushingthe
patellafirsttoonesidethentoother.
Synovialthickeningisappreciatedbyplacingkneeinextension,grasptheedgesofpatellainapinchermade
ofthumbandmiddlefinger,andtriestolifethepatellaforwards(N:graspeasilyfirmly;ifthickened
synoviumitwillslipofftheedgesofpatella)

Move
Kneeisflexeduntilthecalfmeetstheham,andextendscompletelywithasnap(crepitus:signof
patellofemoraldegenerationorwear).

HOWTRAININGMATERIAL2010/11 SESSION4
Testofintraarticularfluid
a) Crossfluctuation(onlywithlargejointeffusion):handcompressesandemptiesthesuprapatellarpouchwhile
therighthandstraddlesthefrontoftheointbelowthepatella;bysqueezingwitheachhandalternatively,a
fluidimpulseistransmittedacrossthejoint.
b) Pattelartap:suprapatellarpouchiscompressedwiththelefthand,whiletheindexfingerofrighthand
pushesthepatellasharplybackwards.Positivetest:patellacanbefeltstrikingthefemurandbouncingoff
again.
c) Bulgetest(usefulwhenverylittlefluidispresent):medialcompartmentisemptiedbypressingnthatsideof
thejointwhilstatthesametimethesuprapatellarpouchiskeptclosedbytheotherhand;thefirsthandis
thenliftedawayfromthemedialsideandmovedtothelateralside,whichisthensharplycompressed;a
distinctrippleisseenontheflattenedmedialsurface.
d) Patellarhollowtest:hollowappearslateraltopatellarligamentwhennormalkneeisflexed,anddisappears
withfurtherflexion;withexcessfluid,thehollowfillsanddisappearsatalesserangleofflexion.

Patellartest
a) Patellarfrictiontest:painelicitedbyrubbingpatellaagainstthefemoraltrochleaorbypressingagainst
patellaandaskpatienttocontractquadricepsmuscles.
b) Apprehensiontest(diagnosticofrecurrentpatellarsubluxationordislocation):pressingthepatellalaterally
withthumbwhileflexingthekneeslightlymayinduceintenseanxietyandresistancetofurthermovement.

Testforligamentousstability
a) Medialandlateralligaments:stressingthekneeintovalgusandvarusbytuckingpatientsfootunderyour
armandsupportingthekneefirmlywithonehandoneachsideofjoint;thelegisthenangulated
alternativelytowardsabductionandadduction.Thetestisperfomedat30degreesofflexionandagainatfull
extension.(tornorstretchedcollateralligamentifthereisexcessiveanglewithmediolateralmovement)
b) Cruciateligaments:examineforabnormalglidingmovementinAPplane.Withbothflexed90degreesand
thefeetrestingonthecouch,theuppertibiaisinspectedfromtheside;
ifitsupperendhasdroppedback,orcanbegentlypushedback,thisindicatesatearoftheposterior
cruciateligament(thesagsign).
Withthekneeinthesameposition,footisanchoredbytheexaminersittingonit(provideditisnot
painful);thenusingbothhands,theupperendofthetibiaisgraspedfirmlyandrockedbackwards
andforwardstoseeifthereisanyAPglide(thedrawertest)[p/s:makesurethehamstringis
relaxed].
1. Positiveanteriordrawersign:anteriorcruciatelaxity
2. Positiveposteriordrawersign:posteriorcruciatelaxity

Lachmantest:patientskneeisflexed20degrees;withonehandgraspingthelowerthighandthe
otherupperpartofleg,thejointsurfacesareshiftedbackwardsandforwardsuponeachother.If
thekneeisstable,thereshouldbenogliding.

SIGNWITHPATIENTLYINGPRONE
Scarsorlumpsinpoplitealfossa
Swelling(midline:bulgingcapsuleoroneside:bursa)
Bakercyst
Palpablelump,pulsatile?Emptiedintojoint?
Appleystest:
a) Kneeisflexedto9degreesandrotatedwhileacompressionforceisapplied.(grindingtest:ifameniscusis
torn).
b) Distractiontest:rotationisthenrepeatedwhilethelegispulledupwardswiththesurgeonskneeholdingthe
thighdown,producingincreasedpainifonlythereisligamentdamage.
HOWTRAININGMATERIAL2010/11 SESSION5
THEANKLEANDFOOT
HISTORY
Pain:overabonyprominenceorajointisduetolocalfactor;acrosstheentiretheforefoot(metatarsalgia)islessspecific
andisoftenassociatedwithunevenloadingandmusclesfatigue.
Deformity:maybeankle,footortoes.Childrenwithflatfootedorpigeontoed.
Swelling:diffuseandbilateral,orlocalized.(swellingovermedialsideoffirstmetatarsalhead[bunion]iscommoninolder
woman)
Givingaway:duetopainorinstabilityatankleorsubtalarjoint.

p/s:standingorwalkingprovokessymptomsandwhethershoepressureisafactor.

Cornsandcallosities:hardened,oftentender,patchesofskinonthetoesandsolesofthefeetareproducedbylocalized
pressureandfriction,usuallyduetoshoecondition.
Numbnessandparaesthesia:inalltoesorinacircumscribedfieldservedbyasinglenerve.

SIGNWITHPATIENTSTANDINGANDWALKING
Norm:Heelsareslightvalguswhilesyandingandinvertedwhenontiptoes;degreeofinversionequalson2sides,showing
thatsubtalarjointsaremobileandtibialisposteriormusclesfunctioning.
Deformity:flatfoot,cavus(hightarched)foot,halluxvalgus,crookedtoes
Cornsoverproximaltoejointsandcallositiesonsoles(commononolderpatient)
Walkinggait:smoothorhaltingandwhetherthefeetarewellbalanced.Thepositionandmobilityofankles.
a) Afixedequinesdeformiltyresultsinheelfailingtostrikethegroundatbeggingofwalkingcycle;sometimesthe
patientforcesheelcontactbyhyperextendingtheknee.
b) Footdrop,iftheankledorsiflexionsareweak,theforefootmaystrikethegroundprematurely,causingaslap.
c) Highsteppinggait:duringswingthrough,thelegisliftedhigherthanusualsothatthefootcancleartheground.

P/S:examinetheshoes

SIGNSWITHPATIETNSITTINGORLYING.
Look:heelisheldsquaresothattheshapeofthefootcanbeproperlyassessed.Thetoesareexaminedfordeformities
andsolesforcallosities.
Feel:skintemperatureandpulse,tenderness,swelling,lumps,edema,sensation.
Move:rangeofbothpassiveandactivemovementsofeachseriesofjoints,musclespower.
a) Anklejoint:withtheheelgraspedinthelefthandandthemidfootintheright;plantarfelxionanddorsiflexionare
tested
b) Subtalarjoint:inversionandeversion(makesuretheankleisfullyplantigrade=atrightangletotheleg)
c) Midtarsaljoint:heelisheldstillwithonehandwhiletheothermovesthetarsusupanddownandfromsidetoside.
d) Toes:testbothmetatarsophalangealandinterphalangealjoints.
Testofstability
Testedinbothcoronalandsagittalplanesandcomparing2sides.
Ankleisheldin10degreesofplantarflexionandthejointisstressedintovalgusandthenvarus.
Anteriordrawertest:ankleheldin10degreesofplantarflexiokn,thedistaltibiaisgrippedwithonehandwhilethe
othergraspstheheelandtriestoshiftthehindfootforwardsandbackwards.
P/s:patientshouldbeonLAifhegotrecentligamentousinjury
P/s:testcanbeperformedunderxrayandpositionsof2anklesmeasuredandcompared.

GENERALEXAMINATION
Anysignsandsymptomsofvascularorneurologicalimpairement,ormaybeageneralexamination.