Principles of examination

Subjective examination
- Aims of S/E
Source of the symptoms
Cause of the symptoms
Severity and irritability
Precautions and contraindications
Prognosis
- Components of S/E
Body chart: area, type, constancy, depth, severity, other symptoms (P&N’s, numbness)
 Number for multiple areas, clear joints above and below
Aggravating factors: how much, how severe, how long lasting
Easing factors: what, how severe
Functional movement: ADL
24-hour behavior: at night (inflammatory or mechanical pain, effect of position), am (effect
of rest), during the day, pm
Special questions: G.H., abnormal weight loss, medication, XR
Present history: mechanism of injury, predisposing factors
Past history: cause of pain, treatment received
Social history: family responsibilities, lifestyle, patient expectation
- Types of pain
Muscle, ligament, joint capsule: dull and aching pain
Nerve and nerve root: sharp and shooting pain
Bone: dull and deep pain
Vasculature: throbbing and diffuse pain
 Musculoskeletal pain usually lessens at night, and aggravates with mechanical stress
 Systemic pain usually is deep and throbbing, and disturbs sleep

Objective examination
- Aims of O/E
Structures producing pain
Predisposing factors
- Components of O/E
Observation: posture, symmetry, willingness to move, bony landmarks
Functional movement: repeated, speed
Active movement: range, willingness to move, speed, produce comparable signs (pain)
 Full range -> end-range -> add overpressure -> sustain posture
Passive movement: pain, pattern of limitation, end-feel
Isometric muscle test: performed in mid-range of muscle action, joint in neutral position
Muscle length test: muscle shortening
Special test: muscle, ligament, nerve, joint instability
Palpation: tenderness, temperature, pulse, landmarks
Screening test: joints in symptomatic area, above and below, referred pain
 Hip examination
Anatomy
- Joint
Multiaxial ball-and-socket joint
Capsular pattern: F, Abd, IR
 Walking poses more pressure on hip joint than single leg standing
- Ligament
Iliofemoral ligament: reinforce anterior capsule, limit E, ER
Ischiofemoral ligament: reinforce posterior capsule, limit E, IR, Add (when hip is flexed)
Pubofemoral ligament: reinforce anterior and inferior capsule, limit E, Abd

Subjective examination (history)

- Age
ROM, congenital, developmental, osteoporotic
- Mechanism of injury
Land on outside of hip: trochanteric bursitis
Land on knee + jarring of hip: subluxation, acetabular labral tear
Repetitive loading, osteoporosis: femoral stress #
Mechanical hip problem: get worse with activity (sitting, up/down stairs, putting on shoes)
- Details of present illness
Anterior groin pain: anterior labral tear, anterior impingement, OA, iliopsoas tendinitis,
iliopectineal bursitis, femoral head necrosis -> anteromedial thigh to knee
Buttock pain: posterior labral tear, Lx problem, sciatic nerve irritation
Medial pain: overactive adductors caused by pelvic instability
Lateral pain: trochanteric bursitis, glut med tendon tear, ITB syndrome -> L4 nerve root pain
Clicking, snapping: labral tear
 Pain may be referred to hip from other structures (Lx -> posterolateral hip)
- Worsening, improving, remain the same?
- Aggravating/easing factor?
- Weak and abnormal movement?
Piriformis syndrome (sciatic nerve compression): mm tenderness, weak Abd + ER
- Usual activity
Repetitive/sustained posture, functional impairment

Observation
- Principle
Pathological gait: weight lowered, knee bent, step length shortened
Stiffness: trunk swings forward together
Balance of pelvis: pelvic tilting, level of ASIS and PSIS
Flexor extensor imbalance: affect trunk forward-backward movement
Rotator imbalance: hip pivoting, squinting patella (IR>ER), frog eyes patella (ER>IR)
** Undress and expose
- Overall posture
Scoliosis (iliopsoas tightness)
Increased Lx lordo (flexion contracture)
Symmetry of WB
Shortening of limb
Colour and texture of skin, scar
Willingness to move: antalgic gait
Swelling: iliopectineal or trochanteric bursitis
Contour of buttock: gluts wasting

ROM
AROM: F=110-120°, E=10-15°, Abd=30-50°, Add=30°, IR=30-40°, ER=40-60°
PROM (same movements as AROM)

Passive accessory movement

AP glide: open hand and press greater trochanter using thumbs -> oscillate hip joint
Caudal glide: hold leg -> lean body backward and pull along longitudinal axis of femur
Compression: hold above knee joint -> compress along longitudinal axis of femur

Resisted isometric movement

F/E: patient in supine -> hold ankle joint and resist anterior or posterior thigh
Abd/Add: patient in supine -> bilaterally bring together or push away two legs
IR/ER: patient in supine with hip flexed 90° -> hold knee joint and resist lateral or medial leg
 Need to do knee F/E because of two-joint mm (rectus fem, hamstrings)

Functional test
Squat, up/down stairs, cross legs, timed up and go test, 6-min walking test

Special test
- Flexion-adduction test
Patient in supine -> flex hip to 90° and adduct leg over opposite hip
+ve: limited Add with pelvic rolling, pain
- Hip scouring test (=quadrant test) (passive combined movement)
Patient in supine -> flex and adduct hip towards opposite shoulder -> maintain the position
where slight resistance is felt -> Abd hip along an arc of movement
+ve: pain, apprehension
 Cause impingement of femoral neck against acetabulum, need care
 Pinch mm (add longus, pectineus, iliopsoas, sartorius, TFL)
- FABER test (hip joint/SI joint involvement, iliopsoas spasm)
Patient in supine with foot placed on opposite knee -> lower knee of tested leg
+ve: leg remains above opposite straight leg
- FADDIR test (anterior labral tear, anterosuperior impingement, iliopsoas tendinitis)
Patient in supine with leg abducted and knee flexed -> flex, Add, IR hip -> extend hip
+ve: pain, apprehension
Muscle length test
- Thomas test (iliopsoas)
Patient in supine and check for excessive Lx lordo -> flex hip, bring knee to chest
+ve: straight leg rises off the table + muscle stretch, push down the leg -> increased Lx lordo
 If straight leg is abducted (J-sign) -> ITB tight
- Kendall test (rectus fem)
Patient in supine with knee bent over the edge -> bring knee to chest and hold it
+ve: opposite knee angle does not remain at 90 o
 Passively flex knee -> palpate mm tightness (muscle stretch/capsular end feel)
- Ely’s test (rectus fem)
Patient in prone -> passively flex knee
+ve: ipsi hip flexes spontaneously
- Straight leg raise (Lasegue’s test) (hamstrings)
Patient in supine -> flex hip with knee extended
+ve: pain before 70° hip F
- 90/90 (hamstrings)
Patient in supine -> flex both hips to 90° with knee flexed -> actively extend knee
+ve: popliteal angle less than 125°
- Bent-knee stretch test (hamstrings)
Patient in supine -> flex hip and knee maximally -> passively extend knee
+ve: pain at ischial origin (need to clear neurological tissue first)
- Tripod sign (hamstrings)
Patient seated with knee flexed 90o over edge -> passively extend knee
+ve: spine E to relieve hamstrings tension
- 90/90 (glut max)
Patient in supine -> flex both hips to 90° with knee flexed -> palpate ASIS
+ve: ASIS moves up before hip flexes 110-120°
- Ober’s test (TFL, ITB)
Patient in side-lying with lower leg flexed for stability -> passively Abd and extend thigh
(knee straight or at 90°) -> stabilize greater trochanter and slowly lower the leg
+ve: leg remains abducted, does not fall on table
 Knee straight: ITB on greater trochanter
 Knee flexed: stress femoral nerve
- Hip rotators test
Patient in supine with hip and knee flexed 90° -> rotate hip
Normal: IR=30-40°, ER=40-60°
+ve: ROM decreases, end-feel becomes muscle stretch but not capsular

Palpation
Temperature and tenderness
Landmarks: iliac crest, ASIS, greater trochanter, ischial tuberosity, gluts bulk
Hip disorders
- Deformities
Hip flexor contracture: forward trunk bending at heel off
 May have excessive Lx lordo and anterior pelvic tilt
Glut max weakness: backward trunk bending at heel strike to produce hip E torque
Glut med weakness: Trendelenburg sign, ipsilateral trunk lateral flexion
 Bilateral: waddling gait
Leg length discrepancy: circumduction gait
- Pathologies
Femoral fracture: usually at femoral neck, intertrochanteric region (mostly women)
Avulsion fracture: sudden muscle-tendon contraction (mostly athletes)
Posterior hip dislocation: MVA
Avascular necrosis of femoral head: increase in intra-articular pressure
 Medial and lateral circumflex femoral artery
OA: squatting aggravates symptoms, active hip F/E causes pain, +ve hip scouring test
FAI: cam-type (femoral head not round), pincer-type (bone extended from acetabulum)
Iliopectineal bursitis: close to femoral nerve -> anterior thigh
Trochanteric bursitis: hip F and IR causes pain (compression by glut max)
Ischiogluteal bursitis: cover sciatic and posterior femoral cutaneous nerve -> posterior thigh
Muscle strain: two-joint muscles (rectus fem, biceps fem)
Hip pointer: contusion to iliac crest and surrounding soft tissues
 Knee examination
Anatomy
- Tibiofemoral joint
Modified hinge joint
Capsular pattern: F>E
Lateral femoral condyle projects anteriorly more than medial femoral condyle
Screw home mechanism: tibia ER at terminal knee E to tighten both cruciate
Resting position: F=25°
- Patellofemoral joint
Modified plane joint
5 facets: superior, inferior, lateral (wider), medial, odd
 Odd facet starts to contact with femur when F>135°
 Lateral bowstringing force on patella
- Patella
Improve extension efficiency in the last 30°
Guide the patellar tendon
Decrease friction of the quadriceps mechanism
Bony shield for cartilage of femoral condyles
 Incorrect alignment may lead to PFPS
- Meniscus
Blood supply to peripheral 1/3, inner 2/3 avascular
Attached to tibia by coronary ligaments
Glide posteriorly with knee F
Medial meniscus: C-shaped, 2mm excursion, connected to MCL
Lateral meniscus: O-shaped, 10mm excursion, attached to popliteus tendon
- Ligament
MCL: prevent valgus stress and limit tibia ER
LCL: prevent varus stress and limit tibia ER
ACL: limit tibia anterior translation, hyper E, IR
PCL: limit tibia posterior translation, IR, prevent varus and valgus stress
 Tibia IR: taut cruciate, lax collateral
 Tibia ER: taut collateral, lax cruciate

Subjective examination (history)

- Mechanism of injury
Valgus stress: MCL, medial meniscus, ACL, posteromedial capsule
Varus stress: LCL, PCL, posterolateral capsule
Hyperextension: ACL, meniscus tear
F with posterior translation (fall on flexed knee): PCL
Acceleration: menisci
Deceleration: ACL, PCL
- “Pop sound” when the injury occurred?
Ligament tear, popliteus tendon rupture
- Details of present illness
Anterior pain: patellofemoral joint problem, prepatellar bursitis, infrapatellar bursitis
Deep pain: tibiofemoral joint problem -> calf and ankle pain
Superficial and localized pain: ligament tear
Pain on ankle movement: superior tibiofibular joint problem
- Worsening, improving, remain the same?
- Aggravating/easing factor?
- Knee “giving away”?
Knee instability, meniscus tear, patellar subluxation, PFPS
- Knee “locking” (knee cannot fully extend with F being normal)?
Meniscus tear, hamstrings spasm
- Abnormal gait? Terminal knee E? Step length?

Observation
- Overall posture
Genu valgum or varum: patellae face forward, knee and medial malleoli as close as possible
 Knees touch but medial malleoli do not: genu valgum
 Two or more fingers fit between knees while medial malleoli are touching: genu varum
Genu recurvatum (excessive Lx lordo)
Squinting or frog eyes patella (rectus fem, ITB, gastro tightness)
Patella alta or baja: observed from lateral side
 Alta: anterior knee pain, camel sign (2 prominences by patella and infrapatellar fat pad)
Q-angle: between ASIS to mid-point of patella and tibial tuberosity to mid-point of patella
 Male=10-13°, female=13-18°
Symmetry of WB
Swelling: prepatellar bursitis
Muscle contour: quads wasting (mainly VMO)

ROM
AROM: F=135°, E=15°, IR=20-30°, ER=30-40°
 Watch for quadriceps lag and reflex inhibition
PROM (same movements as AROM)

Passive accessory movement

E/Abd: patient in supine with hip IR -> hold heel with knee E -> move in AP direction
E/Add: patient in supine with hip ER -> hold heel with knee E -> move in AP direction
IR/ER: patient in prone with knee flexed 90° -> IR ER tibia
Medial and lateral glide of PFJ: patient in supine with pillow under knee -> press side of
patella with thumb and stabilize with other fingers
Caudal glide of PFJ: patient in supine -> press base of patella by palm -> grasp medial and
lateral borders of patella by another hand
Resisted isometric movement
F/E: patient in supine -> hold knee joint and resist anterior or posterior leg
 Need to do ankle DF/PF because of two-joint mm (gastro)

Functional test
Squat (with bounce at EOR), up/down stairs, run, vertical jump, twist, pivot

Special test
- Brush test (=stroke test) (effusion)
Patient in supine -> stroke suprapatellar pouch up from medial side of patella using palm ->
stroke down from lateral side of patella
+ve: fluid bulges near medial distal patella
- Fluctuation test (effusion)
Patient in supine -> press suprapatellar pouch and inferior margin of patella alternately
+ve: synovial fluid fluctuation
- Patella tap test (knee swelling)
Patient in supine -> hold patella and stroke down on suprapatellar pouch -> tap on patella
+ve: separation of thumb and forefinger, observable swelling
- Clarke’s sign (PFJ pain)
Patient in supine -> push down base of patella -> patient contracts quadriceps
+ve: pain, cannot hold contraction
 Test in different angle: 30°, 60°, 90° knee F
- McConnell test (PFJ pain)
- Valgus stress test (MCL, PCL, posteromedial capsule)
Patient in supine -> hold ankle and apply valgus force -> test with knee flexed 30°
+ve: tibia moves away from femur
 +ve when knee extended: can be ACL tear
- Varus stress test (LCL, ITB, posterolateral capsule)
Patient in supine -> hold ankle and apply varus force -> test with knee flexed 30° and ER
+ve: tibia moves away from femur
 +ve when knee extended: can be ACL or PCL tear
- Anterior drawer test (ACL AM bundle, posterior capsule)
Patient in supine with hip flexed 45° and knee flexed 90° -> sit on foot with thumbs holding
tibial tuberosity -> draw tibia forward on femur
+ve: tibia moves forward more than 6mm
- Lachman test (ACL PL bundle)
Patient in supine with knee flexed 30° and ER -> stabilize femur and draw tibia forward
+ve: soft end feel, disappearance of infrapatellar tendon slope
- Pivot shift test (ACL)
Patient in supine with hip slightly flexed and Abd -> IR tibia with knee extended and maintain
the position -> bend knee together with valgus stress
+ve: anterolateral subluxation of lateral tibial plateau
- Posterior drawer test (PCL)
Patient in supine with hip flexed 45° and knee flexed 90° -> sit on foot with thumbs holding
tibial tuberosity -> draw tibia backward
+ve: tibia is pushed back, posterior sag
- Posterior sag sign (PCL)
Patient in supine with hip flexed 45° and knee flexed 90° -> observe
+ve: medial tibial plateau does not extend 1cm anteriorly to femoral condyle, posterior sag
- McMurray’s test (meniscus)
Patient in supine with knee fully flexed -> IR or ER tibia and extend the knee
+ve: pain, clicking sound
 IR tibia: lateral meniscus, ER tibia: medial meniscus
- Ege’s test (meniscus)
Patient in standing -> IR or ER tibia maximally and fully squat -> stand up
+ve: pain, clicking sound
- Thessaly test (meniscus)
Patient in single leg standing (provide hands for balance) -> flex knee 5° and IR or ER tibia
+ve: joint line discomfort, sense of locking
- Apley’s test (ligament and meniscus)
Patient in prone with knee flexed 90° -> anchor thigh on table with our knee -> IR ER tibia
with distraction and compression
+ve: pain
 +ve when distraction: ligament tear
 +ve when compression: meniscus injury
- Bounce home test (meniscus)
Patient in supine with knee fully flexed -> hold heel and support underneath knee -> move
the leg back and allow gravity to extend the knee
+ve: pain, rubbery end feel

Muscle length test

- Hamstrings, quadriceps, TFL (same as hip examination)

Palpation
Temperature and tenderness
Landmarks: tibiofemoral joint line, tibial and femoral condyles, tibial tuberosity, head of
fibula, patellar ligament, collateral ligaments, hamstrings, bursa
 Prepatellar bursa: patient in supine -> palpate skin over patella
 Infrapatellar bursa: patient in supine -> palpate underneath patellar ligament
 Suprapatellar bursa: patient in supine -> lift skin and underlying tissues

Knee disorders
- Indicators for XR
Acute knee injury (Ottawa): fibular head and patella tenderness, F<90°, unable to WB
Acute knee # (Bauer): joint line tenderness, severe localized swelling, F<90°, unable to WB
- Pathologies
Prepatellar bursitis (housemaid’s knee): prominent swelling in front of patella
Infrapatellar bursitis: full knee F and E causes pain near patellar tendon
Pes anserine bursitis: direct blow, tight hamstrings, OA
Semimembranosus bursitis: swelling and posterior knee pain
Ligament sprain: ACL, MCL, LCL
Meniscus injury: crepitus, joint line tenderness, loss of terminal F and E, +ve meniscus test
 Mostly caused by twisting movement
Muscle strain: rectus fem, hamstrings
- Surgeries
Total knee replacement (TKR): medial parapatellar incision and dislocate patella laterally
 Retain cruciate ligaments with prosthesis in
ACL reconstruction: bone-patellar tendon-bone graft
 Double bundles reconstruction: semitendinosus (AM) and gracilis (PL)
 Ankle and foot examination
Anatomy
- Inferior tibiofibular joint
Syndesmosis
Capsular pattern: pain when joint is stressed
DF: 3-5° fibula ER, PF: 3-5° fibula IR
- Talocrural joint
Synovial hinge joint
Capsular pattern: DF, PF
Protected by ATFL, PTFL, calcaneofibular ligament, deltoid ligament
Resting position: PF=10°
DF: posterior glide of talus, PF: anterior glide of talus
- Subtalar joint
Synovial plane joint
Capsular pattern: varus and valgus stress
Supination: lateral glide of talus, Pronation: medial glide of talus
- Midfoot joints
Talocalcaneonavicular joint: ball and socket joint
Cuboideonavicular joint: fibrous joint
- Forefoot joints
Tarsometatarsal and intermetatarsal joints: synovial plane joints
MTP joints: synovial condylar joints
PIP and DIP joints: synovial hinge joints

ROM
- Talocrural joint and subtalar joint
AROM: DF=20°, PF=50°, Inv(hindfoot)=5°/(forefoot)=35°, Ev(hindfoot)=5°/(forefoot)=15°
- Joints of big toe
AROM: MTPJ F=45°/E=70°, IPJ F=90°/E=0°
- Joints of other toes
AROM: MTPJ F=40°/E=40°, PIPJ F=35°/E=0°, DIPJ F=60°/E=0°

Ankle and foot disorders

- Indicators for XR
Acute ankle injury (Ottawa): tenderness along tips of medial malleolus or lateral malleolus,
base of 5th metatarsal, navicular
- Pathologies
Ankle fracture: 3 types
 A: below ankle, syndesmosis and deltoid ligament intact, medial malleolus fractured
 B: at ankle, syndesmosis intact, deltoid ligament torn, lateral malleolus fractured
 C: above ankle, syndesmosis disrupted, medial malleolus fractured -> ORIF

Inversion sprain: ATFL, PTFL, calcaneofibular ligament rupture

 Grade I: microscopic ligament tear with no functional loss
 Grade II: partial ligament tear with some functional loss
 Grade III: complete ligament tear -> surgery
Pes planus: reduction in medial longitudinal arch
 O/E: valgus calcaneum, pronated mid-tarsal region, medial tilt of talus, navicular drop
 Strengthen TA, TP, PL to support medial longitudinal arch
Plantar fasciitis: pain at medial calcaneal tubercle, damage FDB, ABH, ABDM, QP
 Stretch gastro and soleus to increase DF ROM
 Strengthen TA, TP, PL to support medial longitudinal arch
Tibialis posterior tendonitis: tenderness posterior to medial malleolus
Tarsal tunnel syndrome: compression on TP, FDL, posterior tibial artery, tibial nerve, FHL
Retrocalcaneal bursitis: pain and swelling near Achilles tendon