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REMS complete video

Introduction

Clinical examination of the musculoskeletal system has for a long time been regarded as difficult by medical students. It appears complex and until recently there has been no agreement on which skills medical students should learn by the time of their final exams.

These video clips present the findings of a national project funded by the Arthritis Research Campaign. The aim of the project was to define a core set of musculoskeletal clinical skills for the medical student to achieve by the time of final exams.

This core set of skills includes the routine screening examination called GALS, which stands for Gait Arms Legs and Spine, and also regional joint examination or REMS, which stands for Regional Examination of the Musculoskeletal System.

The GALS screening examination

The GALS screening examination is designed for routine clerking of a patient. It is available in both video and CD format elsewhere. A brief revision form is presented here.

The screening examination includes three questions which should be incorporated into routine systemic enquiry. These include:

  • “Do you have any pain or stiffness in your muscles, joints or back?”
  • “Can you dress yourself completely without any difficulty?”
  • “Can you walk up and down the stairs without any difficulty?”

Gait:

The patient’s gait is assessed for symmetry and smoothness as well as the ability to turn quickly.

With the patient standing:

  • From behind, observe the patient for normal shoulder muscle bulk, straight spine, level iliac crests, gluteal bulk and symmetry, any popliteal swelling, calf muscle bulk and any hindfoot abnormalities.
  • Examine from the side, looking for normal cervical lordosis, thoracic kyphosis, lumbar lordosis and evidence of knee flexion or hyperextension.
  • Asking the patient to touch their toes assesses both hip and lumbar flexion. Lumbar movement is assessed by placing two or three fingers on the lumbar spine.
  • In the anatomical position, inspect for shoulder bulk, elbow extension, quadriceps bulk and symmetry, knee swelling and deformity, foot arches and any mid-foot or forefoot deformity.
  • Lateral flexion of the cervical spine is performed, followed by assessment of the temporomandibular joints.
  • Full shoulder abduction and external rotation is performed by asking the patient to place their hands behind their head.
  • Inspect for swelling and deformity of wrists and hands.
  • Inspect the palms of the hands for muscle bulk and other visual abnormality.
  • Power grip assesses wrist and hand function; squeezing the examiner’s fingers assesses strength.
    Fine precision pinch tests hand joint movement, co-ordination and concentration.
  • Gently squeezing the metacarpophalangeal joints screens for inflammatory joint disease.

With the patient on the examination couch:

  • With the patient on the couch assess full knee flexion and internal rotation of the hip in flexion.
  • A patellar tap should be performed to exclude knee effusions.
  • The soles of the feet should be inspected for callus formation, and finally squeeze the metatarsophalangeal joints again to screen for inflammatory arthritis.

The results of the screening examination can be recorded in a table.

Regional Examination of the Musculoskeletal System (REMS)

Regional examination of the musculoskeletal system refers to the more detailed examination that would be expected once an abnormality has been detected through either the history or screening examination.

Regional examination refers to a group of joints linked together by function, examination of which may require detailed neurological and vascular examination including examination of all joints within that region. For the purposes of this video the examination has been divided into the following areas:

  • hand and wrist
  • elbow
  • shoulder
  • hip
  • knee
  • foot and ankle
  • spine.

It should be remembered that this is an artificial divide and that the examination of the shoulder, for example, should often be taken into context with cervical spine examination.

The following general principles should be followed during the examination process:

Introduction

  • Firstly, introduce yourself to the patient.
  • Explain what you are going to do to the patient.
  • Gain verbal consent to examine.
  • Ask the patient to let you know if you cause them pain or discomfort during the examination.

Look

You should look for skin changes, muscle bulk and swellings in and around the joint. And look for deformity in terms of alignment and posture of the joint.

Feel

Feel for skin temperature across the joint line and other relevant sites. Assess swellings for fluctuance and mobility. Vascular and neurological assessment should also be made.
As a general principle students should be able to detect synovitis using the triad of warmth, swelling and tenderness.

Move

The full range of movement of the joint should be assessed both actively and passively. By doing this a loss of movement or degree of extra movement known as hypermobility may be detected.

Function

A functional assessment should be made particularly relating to how the patient uses that particular joint.

Examination of the hand and wrist

Look

It is most comfortable for the patient to have their hands positioned on a pillow. In this position look for obvious swellings, loss of alignment, muscle wasting and scars. Try to decide if changes are symmetrical or asymmetrical. Look at the nails for psoriatic changes of pitting and onycholysis, and also nailfold vasculitis.

Which joints are mainly affected? The distal interphalangeal joints, the proximal interphalangeal joints, the metacarpophalangeal joints or the wrists?

Look at the skin for rashes or signs of long-term steroid use such as thinning or bruising. Again, look at the palms of the hands:

  • at the finger pulp
  • signs of palmar erythema
  • scars from carpal tunnel release.

Feel

Feel for peripheral pulses, muscle bulk and tendon thickening. Assess median and ulnar nerve sensation by touching gently either over the thenar and hyperthenar eminences or index and little fingers respectively. Radial nerve sensation is most reliably tested over the thumb and index finger web space.

Temperature can be assessed by comparing the forearm to the wrist and metacarpophalangeal joints. Gently squeeze across the metacarpophalangeal joints while watching the patient’s face.

Bimanually palpate any metacarpophalangeal joints which appear tender or swollen – this should be done by having your thumbs above and index fingers below the joint. The proximal and distal interphalangeal joints can be palpated again by using thumbs and index fingers to encircle the joint, squeezing each side gently in turn to detect fluctuance.

Both wrists should be bimanually palpated in a similar manner.

You should look at both elbows carefully for evidence of psoriasis and rheumatoid nodules, and feel along the ulnar border.

Move

Wrist flexion and hyperextension should be assessed both actively and passively.

Ask the patient to extend their fingers fully against gravity – if they can’t, this may be due to joint disease, extensor tendon rupture or neurological damage – you may assess this by passive movement.

Extensor power and finger spread assesses radial and ulnar nerves. Abduction of the thumb assesses the median nerve.

The patient should be asked to make a full finger tuck – if they are unable to do this, again it may be due to nerve, joint or tendon damage – this again can be assessed passively.

Function

Power grip is important functionally, as is pincer grip power. Other functional tests may be made such as picking up a small object, doing up a button or holding a pen or cup.

Phalen’s test for carpal tunnel syndrome: In patients whose history suggests a carpal tunnel syndrome Phalen’s test can be performed. This includes forced flexion of the wrist for 60 seconds reproducing the patient’s symptoms. This may be done in one of two ways [as demonstrated]. 

Examination of the elbow

Look

Begin with looking at the patient from the front for the normal carrying angle, and from the side for any flexion deformity. The posterior aspect of the elbow is inspected for obvious scars, swellings, rashes or signs of olecranon bursitis, or rheumatoid nodules or psoriatic plaques and, again, the medial aspect should also be inspected. Temperature is assessed by comparing adjacent sites.

Feel

The olecranon process, lateral and medial epicondyles should be palpated for tenderness.

Move

Full extension and full flexion should be assessed actively along with pronation and supination. These should also be assessed passively while holding the joint and feeling for crepitus. Here, excessive extension, i.e. hypermobility, may easily be detected. During pronation and supination the radial head and joint line can be easily identified.

Function

Function can be assessed by asking the patient’s ability to perform a relevant task.

Examination of the shoulder

Look

With both shoulders fully exposed, look from the front, the side and behind the patient for obvious loss of symmetry, muscle wasting or scars.

Feel

The temperature over the joint line should be assessed; and then bony landmarks, joint line and surrounding muscles should be palpated for tenderness.

Move

Shoulder movement and function can be assessed by asking the patient to put their hands behind their head and behind their back. Internal rotation can be given a measure by how far up the back the hands can go – in this case to the mid-thoracic level. Full extension, flexion and abduction should be assessed.

Markedly reduced external rotation with the elbow flexed to 90° and tucked into the patient’s side is a useful diagnostic test of frozen shoulder. Place your hand on top of the shoulder to isolate the glenohumeral movement.

Passive movements should be performed while feeling for crepitus. Passive movement may be particularly helpful in abduction when assessing a patient with a painful arc where pain may be experienced between 10 and 120 degrees.

Assessment of scapular movement during full abduction should be assessed by both feeling and observing the scapula from behind the patient.
Function

Function has already been assessed by asking the patient to place their hands behind their head and behind their back. 

Examination of the hip

Look

With the patient lying as flat as possible look from the end of the bed comparing for symmetry. In a fractured neck of femur, for example, one leg may be shortened and externally rotated.

Any obvious leg length discrepancy may be seen and can be checked for using a tape measure. For this, a measurement can be taken from a fixed point such as the anterior superior iliac crest to the medial malleolus of the ankle. Both sides are compared. A difference suggests a real leg length discrepancy.

Feel

Obvious flexion deformity of the hip may be seen. Obvious scars should be checked for, and the greater trochanter should be palpated for tenderness.

Move

Full flexion of the hip should be checked for, along with internal and external rotation with the hip and knee flexed to 90°. Both sides can be compared.

Thomas’ test: Thomas’ test assesses for a fixed flexion deformity of the contralateral hip. The examiner’s hand is placed under the patient’s back to check that lumbar lordosis is removed during full flexion of the hip. The contralateral hip should then be observed. If there is a fixed flexion deformity this leg will be forced off the couch.

Trendelenberg’s test: Trendelenberg’s test involves the patient standing alternately on each leg alone. It assesses the hip and gluteal muscle strength of the side they are standing on. In a negative test the pelvis remains level or even rises. In a positive test the pelvis will dip on the contralateral side.

Function

Function is assessed by asking the patient to walk. A waddling gait may be a sign of hip pain or proximal muscle weakness. 

Examination of the knee

Look

Look initially from the end of the bed for loss of symmetry and loss of normal leg alignment such as varus deformity – where distal to the knee is deviated medially leading to a bow-legged appearance – or valgus deformity – where distal to the knee is deviated laterally leading to a knock-kneed appearance.

Look for rashes, scars, swellings, and muscle wasting and any fixed flexion of the knee.

Feel

Temperature is assessed by starting at the mid-thigh and moving down, and comparing both knees to each other. Feel around the border of the patella for tenderness and behind the knee for popliteal cysts or swellings.

Assess for a knee effusion by using a patellar tap; while pushing vertically down on the suprapatellar pouch two or three fingers of the other hand attempt to bounce the patella. For smaller effusions, cross-fluctuation or the bulge sign is performed by emptying the medial gutter of any fluid. When the hand is swept over the suprapatellar pouch and down the lateral gutter the medial side may refill – producing a bulge of fluid.

With the knee flexed to 90° the joint line is opened and can be palpated along with the patellar tendon insertion.

Move

Movements of full flexion and extension are performed both actively and passively. Excessive extension is a sign of hypermobility. Both sides should be compared.

Anterior Draw Test: With the knee flexed to 90° the knee should be viewed from the side. A posterior sag or step-back in the tibia may be suggestive of posterior cruciate ligament damage. With the hand behind the knee and checking the hamstrings are relaxed the thumbs are placed over the tibia and a forward pull applied. Significant movement indicates a positive draw test and suggests anterior cruciate ligament damage. The lower leg may be stabilised during this by the examiner’s forearm.

Collateral Ligament Assessment: Medial and lateral collateral ligaments are assessed by flexing the knee to 15° and alternately stressing each side of the knee.

With the patient standing, popliteal swellings may more readily be seen and varus or valgus deformities may be more apparent with the patient weight-bearing.

Function

Functional assessment includes asking the patient to walk. 

Examination of the foot and ankle

Look

With the patient on a couch and their feet overhanging the end of it, look at the feet, comparing for symmetry. In the forefoot look for nail changes and skin rashes. Look for the alignment of the toes and any evidence of hallux valgus of the big toe. Look for clawing of the toes, joint swelling and callus formation. Look at the underside or plantar surface for callus formation. Look at the patient’s shoes for asymmetrical wearing of the sole, the presence of insoles or other signs of poor fit.

Feel

Assess the temperature of the ankle and forefoot and check for the presence of a peripheral pulse. Gently squeeze across the metatarsophalangeal joints while watching the patient’s face. The tarsal joints, ankle joint line and subtalar joints should all be palpated for tenderness.

Move

Range of movement in the foot and ankle includes inversion and eversion at the subtalar joint, dorsiflexion and plantar flexion at the big toe, and dorsiflexion and plantar flexion at the ankle joint. These should all be done both actively and passively. Mid-tarsal and subtalar movements can also be assessed passively.

With the patient weight-bearing, toe alignment and the foot arch should be checked. A dropped arch in a normal subject resolves when standing on tip-toes. The hindfoot should also be observed. Achilles tendon thickening or swelling may be seen. There should be normal alignment of the hindfoot, and disease of the ankle or subtalar joint may lead to a varus or a valgus deformity.

Function

Gait should be assessed looking for the normal cycle of heel-strike and toe-off.

Examination of the spine

Look

Look initially from behind the patient for any obvious muscle wasting, asymmetry or scoliosis of the spine. Look from the side for normal: cervical lordosis thoracic kyphosis and lumbar lordosis.

Feel

Feel down the spinal processes, over the sacroiliac joints and palpate the paraspinal muscles for any obvious tenderness.

Move

Flexion and extension should be assessed. Two or three fingers placed over the lumbar spine will move apart and then together during flexion and extension. Lateral flexion is assessed by asking the patient to run each hand down the ouside of the adjacent leg in turn. Cervical movements include lateral flexion, rotation and full flexion and extension.

With the patient sitting on the couch to fix their pelvis, and their arms crossed in front of them, thoracic rotation is assessed.

With the patient lying as flat as possible on the couch, straight leg raising is performed. Dorsiflexion of the foot may exacerbate the pain caused by nerve root entrapment or irritation such as a prolapsed intervertebral disc. A brief neurovascular examination including the assessment of limb reflexes, dorsiflexion of the big toe, and assessment of peripheral pulses should be made. If there has been any indication of abnormality from the history, a full neurological and vascular examination including sensation, tone and power should also be performed. 



 

Introduction

Clinical examination of the musculoskeletal system has for a long time been regarded as difficult by medical students. It appears complex and until recently there has been no agreement on which skills medical students should learn by the time of their final exams.

These video clips present the findings of a national project funded by the Arthritis Research Campaign. The aim of the project was to define a core set of musculoskeletal clinical skills for the medical student to achieve by the time of final exams.

This core set of skills includes the routine screening examination called GALS, which stands for Gait Arms Legs and Spine, and also regional joint examination or REMS, which stands for Regional Examination of the Musculoskeletal System.

The GALS screening examination

The GALS screening examination is designed for routine clerking of a patient. It is available in both video and CD format elsewhere. A brief revision form is presented here.

The screening examination includes three questions which should be incorporated into routine systemic enquiry. These include:

  • “Do you have any pain or stiffness in your muscles, joints or back?”
  • “Can you dress yourself completely without any difficulty?”
  • “Can you walk up and down the stairs without any difficulty?”

Gait:

The patient’s gait is assessed for symmetry and smoothness as well as the ability to turn quickly.

With the patient standing:

  • From behind, observe the patient for normal shoulder muscle bulk, straight spine, level iliac crests, gluteal bulk and symmetry, any popliteal swelling, calf muscle bulk and any hindfoot abnormalities.
  • Examine from the side, looking for normal cervical lordosis, thoracic kyphosis, lumbar lordosis and evidence of knee flexion or hyperextension.
  • Asking the patient to touch their toes assesses both hip and lumbar flexion. Lumbar movement is assessed by placing two or three fingers on the lumbar spine.
  • In the anatomical position, inspect for shoulder bulk, elbow extension, quadriceps bulk and symmetry, knee swelling and deformity, foot arches and any mid-foot or forefoot deformity.
  • Lateral flexion of the cervical spine is performed, followed by assessment of the temporomandibular joints.
  • Full shoulder abduction and external rotation is performed by asking the patient to place their hands behind their head.
  • Inspect for swelling and deformity of wrists and hands.
  • Inspect the palms of the hands for muscle bulk and other visual abnormality.
  • Power grip assesses wrist and hand function; squeezing the examiner’s fingers assesses strength.
    Fine precision pinch tests hand joint movement, co-ordination and concentration.
  • Gently squeezing the metacarpophalangeal joints screens for inflammatory joint disease.

With the patient on the examination couch:

  • With the patient on the couch assess full knee flexion and internal rotation of the hip in flexion.
  • A patellar tap should be performed to exclude knee effusions.
  • The soles of the feet should be inspected for callus formation, and finally squeeze the metatarsophalangeal joints again to screen for inflammatory arthritis.

The results of the screening examination can be recorded in a table.

Regional Examination of the Musculoskeletal System (REMS)

Regional examination of the musculoskeletal system refers to the more detailed examination that would be expected once an abnormality has been detected through either the history or screening examination.

Regional examination refers to a group of joints linked together by function, examination of which may require detailed neurological and vascular examination including examination of all joints within that region. For the purposes of this video the examination has been divided into the following areas:

  • hand and wrist
  • elbow
  • shoulder
  • hip
  • knee
  • foot and ankle
  • spine.

It should be remembered that this is an artificial divide and that the examination of the shoulder, for example, should often be taken into context with cervical spine examination.

The following general principles should be followed during the examination process:

Introduction

  • Firstly, introduce yourself to the patient.
  • Explain what you are going to do to the patient.
  • Gain verbal consent to examine.
  • Ask the patient to let you know if you cause them pain or discomfort during the examination.

Look

You should look for skin changes, muscle bulk and swellings in and around the joint. And look for deformity in terms of alignment and posture of the joint.

Feel

Feel for skin temperature across the joint line and other relevant sites. Assess swellings for fluctuance and mobility. Vascular and neurological assessment should also be made.
As a general principle students should be able to detect synovitis using the triad of warmth, swelling and tenderness.

Move

The full range of movement of the joint should be assessed both actively and passively. By doing this a loss of movement or degree of extra movement known as hypermobility may be detected.

Function

A functional assessment should be made particularly relating to how the patient uses that particular joint.

Examination of the hand and wrist

Look

It is most comfortable for the patient to have their hands positioned on a pillow. In this position look for obvious swellings, loss of alignment, muscle wasting and scars. Try to decide if changes are symmetrical or asymmetrical. Look at the nails for psoriatic changes of pitting and onycholysis, and also nailfold vasculitis.

Which joints are mainly affected? The distal interphalangeal joints, the proximal interphalangeal joints, the metacarpophalangeal joints or the wrists?

Look at the skin for rashes or signs of long-term steroid use such as thinning or bruising. Again, look at the palms of the hands:

  • at the finger pulp
  • signs of palmar erythema
  • scars from carpal tunnel release.

Feel

Feel for peripheral pulses, muscle bulk and tendon thickening. Assess median and ulnar nerve sensation by touching gently either over the thenar and hyperthenar eminences or index and little fingers respectively. Radial nerve sensation is most reliably tested over the thumb and index finger web space.

Temperature can be assessed by comparing the forearm to the wrist and metacarpophalangeal joints. Gently squeeze across the metacarpophalangeal joints while watching the patient’s face.

Bimanually palpate any metacarpophalangeal joints which appear tender or swollen – this should be done by having your thumbs above and index fingers below the joint. The proximal and distal interphalangeal joints can be palpated again by using thumbs and index fingers to encircle the joint, squeezing each side gently in turn to detect fluctuance.

Both wrists should be bimanually palpated in a similar manner.

You should look at both elbows carefully for evidence of psoriasis and rheumatoid nodules, and feel along the ulnar border.

Move

Wrist flexion and hyperextension should be assessed both actively and passively.

Ask the patient to extend their fingers fully against gravity – if they can’t, this may be due to joint disease, extensor tendon rupture or neurological damage – you may assess this by passive movement.

Extensor power and finger spread assesses radial and ulnar nerves. Abduction of the thumb assesses the median nerve.

The patient should be asked to make a full finger tuck – if they are unable to do this, again it may be due to nerve, joint or tendon damage – this again can be assessed passively.

Function

Power grip is important functionally, as is pincer grip power. Other functional tests may be made such as picking up a small object, doing up a button or holding a pen or cup.

Phalen’s test for carpal tunnel syndrome: In patients whose history suggests a carpal tunnel syndrome Phalen’s test can be performed. This includes forced flexion of the wrist for 60 seconds reproducing the patient’s symptoms. This may be done in one of two ways [as demonstrated]. 

Examination of the elbow

Look

Begin with looking at the patient from the front for the normal carrying angle, and from the side for any flexion deformity. The posterior aspect of the elbow is inspected for obvious scars, swellings, rashes or signs of olecranon bursitis, or rheumatoid nodules or psoriatic plaques and, again, the medial aspect should also be inspected. Temperature is assessed by comparing adjacent sites.

Feel

The olecranon process, lateral and medial epicondyles should be palpated for tenderness.

Move

Full extension and full flexion should be assessed actively along with pronation and supination. These should also be assessed passively while holding the joint and feeling for crepitus. Here, excessive extension, i.e. hypermobility, may easily be detected. During pronation and supination the radial head and joint line can be easily identified.

Function

Function can be assessed by asking the patient’s ability to perform a relevant task.

Examination of the shoulder

Look

With both shoulders fully exposed, look from the front, the side and behind the patient for obvious loss of symmetry, muscle wasting or scars.

Feel

The temperature over the joint line should be assessed; and then bony landmarks, joint line and surrounding muscles should be palpated for tenderness.

Move

Shoulder movement and function can be assessed by asking the patient to put their hands behind their head and behind their back. Internal rotation can be given a measure by how far up the back the hands can go – in this case to the mid-thoracic level. Full extension, flexion and abduction should be assessed.

Markedly reduced external rotation with the elbow flexed to 90° and tucked into the patient’s side is a useful diagnostic test of frozen shoulder. Place your hand on top of the shoulder to isolate the glenohumeral movement.

Passive movements should be performed while feeling for crepitus. Passive movement may be particularly helpful in abduction when assessing a patient with a painful arc where pain may be experienced between 10 and 120 degrees.

Assessment of scapular movement during full abduction should be assessed by both feeling and observing the scapula from behind the patient.
Function

Function has already been assessed by asking the patient to place their hands behind their head and behind their back. 

Examination of the hip

Look

With the patient lying as flat as possible look from the end of the bed comparing for symmetry. In a fractured neck of femur, for example, one leg may be shortened and externally rotated.

Any obvious leg length discrepancy may be seen and can be checked for using a tape measure. For this, a measurement can be taken from a fixed point such as the anterior superior iliac crest to the medial malleolus of the ankle. Both sides are compared. A difference suggests a real leg length discrepancy.

Feel

Obvious flexion deformity of the hip may be seen. Obvious scars should be checked for, and the greater trochanter should be palpated for tenderness.

Move

Full flexion of the hip should be checked for, along with internal and external rotation with the hip and knee flexed to 90°. Both sides can be compared.

Thomas’ test: Thomas’ test assesses for a fixed flexion deformity of the contralateral hip. The examiner’s hand is placed under the patient’s back to check that lumbar lordosis is removed during full flexion of the hip. The contralateral hip should then be observed. If there is a fixed flexion deformity this leg will be forced off the couch.

Trendelenberg’s test: Trendelenberg’s test involves the patient standing alternately on each leg alone. It assesses the hip and gluteal muscle strength of the side they are standing on. In a negative test the pelvis remains level or even rises. In a positive test the pelvis will dip on the contralateral side.

Function

Function is assessed by asking the patient to walk. A waddling gait may be a sign of hip pain or proximal muscle weakness. 

Examination of the knee

Look

Look initially from the end of the bed for loss of symmetry and loss of normal leg alignment such as varus deformity – where distal to the knee is deviated medially leading to a bow-legged appearance – or valgus deformity – where distal to the knee is deviated laterally leading to a knock-kneed appearance.

Look for rashes, scars, swellings, and muscle wasting and any fixed flexion of the knee.

Feel

Temperature is assessed by starting at the mid-thigh and moving down, and comparing both knees to each other. Feel around the border of the patella for tenderness and behind the knee for popliteal cysts or swellings.

Assess for a knee effusion by using a patellar tap; while pushing vertically down on the suprapatellar pouch two or three fingers of the other hand attempt to bounce the patella. For smaller effusions, cross-fluctuation or the bulge sign is performed by emptying the medial gutter of any fluid. When the hand is swept over the suprapatellar pouch and down the lateral gutter the medial side may refill – producing a bulge of fluid.

With the knee flexed to 90° the joint line is opened and can be palpated along with the patellar tendon insertion.

Move

Movements of full flexion and extension are performed both actively and passively. Excessive extension is a sign of hypermobility. Both sides should be compared.

Anterior Draw Test: With the knee flexed to 90° the knee should be viewed from the side. A posterior sag or step-back in the tibia may be suggestive of posterior cruciate ligament damage. With the hand behind the knee and checking the hamstrings are relaxed the thumbs are placed over the tibia and a forward pull applied. Significant movement indicates a positive draw test and suggests anterior cruciate ligament damage. The lower leg may be stabilised during this by the examiner’s forearm.

Collateral Ligament Assessment: Medial and lateral collateral ligaments are assessed by flexing the knee to 15° and alternately stressing each side of the knee.

With the patient standing, popliteal swellings may more readily be seen and varus or valgus deformities may be more apparent with the patient weight-bearing.

Function

Functional assessment includes asking the patient to walk. 

Examination of the foot and ankle

Look

With the patient on a couch and their feet overhanging the end of it, look at the feet, comparing for symmetry. In the forefoot look for nail changes and skin rashes. Look for the alignment of the toes and any evidence of hallux valgus of the big toe. Look for clawing of the toes, joint swelling and callus formation. Look at the underside or plantar surface for callus formation. Look at the patient’s shoes for asymmetrical wearing of the sole, the presence of insoles or other signs of poor fit.

Feel

Assess the temperature of the ankle and forefoot and check for the presence of a peripheral pulse. Gently squeeze across the metatarsophalangeal joints while watching the patient’s face. The tarsal joints, ankle joint line and subtalar joints should all be palpated for tenderness.

Move

Range of movement in the foot and ankle includes inversion and eversion at the subtalar joint, dorsiflexion and plantar flexion at the big toe, and dorsiflexion and plantar flexion at the ankle joint. These should all be done both actively and passively. Mid-tarsal and subtalar movements can also be assessed passively.

With the patient weight-bearing, toe alignment and the foot arch should be checked. A dropped arch in a normal subject resolves when standing on tip-toes. The hindfoot should also be observed. Achilles tendon thickening or swelling may be seen. There should be normal alignment of the hindfoot, and disease of the ankle or subtalar joint may lead to a varus or a valgus deformity.

Function

Gait should be assessed looking for the normal cycle of heel-strike and toe-off.

Examination of the spine

Look

Look initially from behind the patient for any obvious muscle wasting, asymmetry or scoliosis of the spine. Look from the side for normal: cervical lordosis thoracic kyphosis and lumbar lordosis.

Feel

Feel down the spinal processes, over the sacroiliac joints and palpate the paraspinal muscles for any obvious tenderness.

Move

Flexion and extension should be assessed. Two or three fingers placed over the lumbar spine will move apart and then together during flexion and extension. Lateral flexion is assessed by asking the patient to run each hand down the ouside of the adjacent leg in turn. Cervical movements include lateral flexion, rotation and full flexion and extension.

With the patient sitting on the couch to fix their pelvis, and their arms crossed in front of them, thoracic rotation is assessed.

With the patient lying as flat as possible on the couch, straight leg raising is performed. Dorsiflexion of the foot may exacerbate the pain caused by nerve root entrapment or irritation such as a prolapsed intervertebral disc. A brief neurovascular examination including the assessment of limb reflexes, dorsiflexion of the big toe, and assessment of peripheral pulses should be made. If there has been any indication of abnormality from the history, a full neurological and vascular examination including sensation, tone and power should also be performed. 



 

Student handbook

Download 'Clinical assessment of the musculoskeletal system: a guide for medical students and healthcare professionals'
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