day 1 - Clinical Assessment Movement: Orthopaedics & Rheumatology

Question 1

what’s the coronal plane

Answer 1

divides front and back of body

Question 2

what’s the saggital plane

Answer 2

divides the left and right side of the body

Question 3

what are the 3 planes of the body

Answer 3

coronal, sagittal and horizontal

Question 4

what is the horizontal plane of the body

Answer 4

through the belly button

Question 5

terms to describe limb deformity

Answer 5

Deformity of distal part of limb relative to proximal

Varus = towards the midline
Valgus = away from the midline

Cubitus ~ = elbow
Coxa ~ = hip
Genu ~ = knee
Hallux ~ = big toe

Question 6

causes of bone and joint deformity

Answer 6

Bone deformity
Abn growth / metabolic / tumours / post fracture etc

Joint deformity
Soft tissue contracture / muscle imbalance / joint destruction / dislocation etc

Question 7

Hx things to ask about joints and limbs

Answer 7

Pain / Swelling / Stiffness
Mechanical symptoms - ‘locking, crunching, popping’
Deformity - ‘change in shape’
Instability - ‘giving way’
Weakness - ‘dead, can’t control, drop things’
Neurological - ‘tingling, burning, buzzing, numb, electric’
Vascular – ‘cold, blue, changes colour, dry’

Pain:
site / onset / character / radiation / association / radiation / timing / exacerbating or relieving factors / severity

Stiffness:
Single joint vs. multiple
After inactivity (degenerate)
Morning (inflammatory)

Swelling:
Soft tissues vs. joint (effusion / synovitis) vs. bone

Family history
(Developmental history) – in paeds

Occupation

Hand dominance

Social:
Walking aids
Lifestyle modification
Home environment
Social support 
Activity / sports

Expectations

Question 8

when looking at a joint what things should you be noting

Answer 8

Skin
Scars / sinuses / colour

Shape
Swellings / lumps

Position of limb / joint

Question 9

when feeling a joint what should you be feeling for

Answer 9

Skin
Soft tissues (ligaments / muscles / tendons)
Bones
Joints
Lump
Define: site / shape / size / surface / consistency / mobility / compressibility / translumination / tenderness
Bone & limb length

Question 10

how to determine if there is a difference in limb length

Answer 10

Standing feel ASIS / pelvis level
‘Block’ pelvis level
Supine hips and knees bent

Measure apparent LL:
Midline to med mall

Measure true LL:
ASIS to med mall

Question 11

things to consider when assessing limb movement and power

Answer 11

Active movement – what the patient can do
Passive movement – what you can demonstrate

Special tests including provocative tests
Numerous eponymous

MRC muscle grading 0 to 5

Question 12

Medical Research Council (MRC)Muscle power

Answer 12

0 = No movement
1 = Flicker of muscle activity
2 = Movement with gravity eliminated
3 = Movement against gravity
4 = Move against resistance
5 = Normal Power

Question 13

hip tests

Answer 13

Gait

Hip

• Trendelenburg test: Hip abductor competence
• Thomas’ test: Fixed flexion deformity

Question 14

what is the trendelenburg test

Answer 14

The Trendelenburg Test or Brodie-Trendelenburg test is a test which can be carried out as part of a physical examination to determine the competency of the valves in the superficial and deep veins of the legs in patients with varicose veins.[1]

Question 15

what is the trendelenburg sign

Answer 15

Trendelenburg’s sign is found in people with weak or paralyzed abductor muscles of the hip, namely gluteus medius and gluteus minimus. It is named after the German surgeon Friedrich Trendelenburg.

The gluteus medius is very important during the stance phase of the gait cycle to maintain both hips at the same level. Moreover, one leg stance accounts for about 60% of the gait cycle. Furthermore, during the stance phase of the gait cycle, there is approximately three times the body weight transmitted to the hip joint.[citation needed] The hip abductors’ action accounts for two thirds of that body weight. The Trendelenburg sign is said to be positive if, when standing on one leg, the pelvis drops on the side opposite to the stance leg to reduce the load by decreasing the lever arm. By reducing the lever arm, this decreases the work load on the hip abductors. The muscle weakness is present on the side of the stance leg. A Trendelenburg sign can occur when there is presence of a muscular dysfunction (weakness of the gluteus medius or minimus) or when someone is experiencing pain. The body is not able to maintain the center of gravity on the side of the stance leg. Normally, the body shifts the weight to the stance leg, allowing the shift of the center of gravity and consequently stabilizing or balancing the body. However, in this scenario, when the patient/person lifts the opposing leg, the shift is not created and the patient/person cannot maintain balance leading to instability.

so the hip on the other side dips due to the lax muscle in the stance sided hip

Question 16

Knee Special Tests

Answer 16

Effusion
- Patellar tap / bulge test

Collateral ligaments
ACL:
 - Lachmann / Ant Drawer
Mensici:
 - McMurray
Patellar instability

Question 17

what is the mcmurray test

Answer 17

The McMurray test, also known as the McMurray circumduction test is used to evaluate individuals for tears in the meniscus of the knee.[1] It is a rotation test for demonstrating torn cartilage of the knee. A tear in the meniscus may cause a pedunculated tag of the meniscus which may become jammed between the joint surfaces.

To perform the test, the knee is held by one hand, which is placed along the joint line, and flexed to complete flexion while the foot is held by the sole with the other hand. The examiner then places one hand on the lateral side of the knee to stabilize the joint and provide a valgus stress in order to identify a valgus deformity. The other hand rotates the leg externally while extending the knee. If pain or a “click” is felt, this constitutes a “positive McMurray test” for a tear in the medial meniscus.

Likewise the medial knee can be stabilized in a fully flexed position and the leg internally rotated as the leg is extended. A tag, caused by a tear will cause a palpable or even audible click on extension of the knee. A positive test indicates a tear of the lateral meniscus.

According to some sources, the sensitivity of the McMurray test for medial meniscus tears is 53% and the specificity is 59%. In a recent study, clinical test results were compared with arthroscopic and/or arthrotomy findings as reference.[2] The clinical test had a sensitivity of 58.5%, a specificity of 93.4%, and the predictive value of a positive result was 82.6%. A more recent study showed a 97% specificity for meniscal tears.

Question 18

what is the lachman test

Answer 18

The Lachman test is a clinical test used to diagnose injury of the anterior cruciate ligament (ACL). It is recognized as reliable, sensitive, and usually superior to the anterior drawer test.[1]

The knee is flexed at 20–30 degrees with the patient supine.[2] The examiner should place one hand behind the tibia and the other on the patient’s thigh. It is important that the examiner’s thumb be on the tibial tuberosity.[3] The tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur. An intact ACL should prevent forward translational movement (“firm endpoint”) while an ACL-deficient knee will demonstrate increased forward translation without a decisive ‘end-point’ - a soft or mushy endpoint indicative of a positive test. More than about 2 mm of anterior translation compared to the uninvolved knee suggests a torn ACL (“soft endpoint”), as does 10 mm of total anterior translation. An instrument called a “KT-1000” can be used to determine the magnitude of movement in mm. This test can be done in either an on-field evaluation in acute injury, or in a clinical setting when a patient presents for follow-up with knee pain.

Question 19

shoulder special tests

Answer 19

Rotator cuff
- The four muscles are the supraspinatus muscle, the infraspinatus muscle, teres minor muscle, and the subscapularis muscle.

Impingement
- Pain in subacromial space

Apprehension
- Instability (dislocation)

Question 20

what are the muscles of the rotator cuff and their innervation

Answer 20

supraspinatus - Suprascapular nerve (C5)
infraspinatus - Suprascapular nerve (C5-C6)
teres minor - Axillary nerve (C5)
subscapularis - Upper and Lower subscapular nerve (C5-C6)

Question 21

hand and foot/ankle special tests

Answer 21

Carpal tunnel

• Phalen
• Tinel

De Quervains
- Finkelstein

Achilles
- Simmonds (Thompson)

Question 22

what is the phalen manoeuvre

Answer 22

Phalen’s maneuver is a diagnostic test for carpal tunnel syndrome

Question 23

how do you do the phalen manoeuvre

Answer 23

The patient is asked to hold their wrist in complete and forced flexion (pushing the dorsal surfaces of both hands together) for 30–60 seconds. The lumbricals attach in part to the flexor digitorum profundus tendons. As the wrist flexes, the flexor digitorum profundus contracts in a proximal direction, drawing the lumbricals along with it. In some individuals, the lumbricals can be “dragged” into the carpal tunnel with flexor digitorum profundus contraction. As such, Phalen’s maneuver can moderately increase the pressure in the carpal tunnel via this mass effect, pinching the median nerve between the proximal edge of the transverse carpal ligament and the anterior border of the distal end of the radius. By compressing the median nerve within the carpal tunnel, characteristic symptoms (such as burning, tingling or numb sensation over the thumb, index, middle and ring fingers) conveys a positive test result and suggests carpal tunnel syndrome. Because not all individuals will draw the lumbricals into the carpal tunnel with this maneuver, this test cannot be perfectly sensitive or specific for carpal tunnel syndrome.[3]

Question 24

what is tine’s sign

Answer 24

Tinel’s sign is a way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or “pins and needles” in the distribution of the nerve. It takes its name from French neurologist Jules Tinel (1879-1952).[1][2][3]

For example, in carpal tunnel syndrome where the median nerve is compressed at the wrist, Tinel’s sign is often “positive” causing tingling in the thumb, index, middle finger and the radial half of the fourth digit. Tinel’s sign is sometimes referred to as “distal tingling on percussion” or DTP. This distal sign of regeneration can be expected during different stage of somatosensory recovery.[4]

Although most frequently associated with carpal tunnel syndrome, Tinel’s sign is a generalized term, and can also be positive in ulnar nerve impingement at the wrist (Guyon’s canal syndrome), where it affects the other (ulnar) half of the fourth digit and the fifth digit.

Question 25

what is Finkelstein’s test

Answer 25

Finkelstein’s test is used to diagnose De Quervain’s tenosynovitis in people who have wrist pain. To perform the test, the examining physician or therapist grasps the thumb and ulnar deviates the hand sharply, as shown in the image. If sharp pain occurs along the distal radius (top of forearm, close to wrist; see image), de Quervain’s tenosynovitis is likely.[1]

Other practitioners use a modified Eichoff’s test, below, and ask their patients to flex their thumb and clench their fist over the thumb before ulnar deviation, but with ulnar deviation performed by the practitioner.[2] Eichoff’s test is commonly confused with Finkelstein’s test. However the Eichoff’s test may produce false positive results, while a Finkelstein’s test performed by a skilled practitioner is unlikely to produce a false positive

Question 26

the basic mantra when examining any joint

Answer 26

ASK (Hx)/ LOOK / FEEL / MOVE