examination

Question 1

• Young: instability
• Middle-aged: adhesive capsulits, calcific tendonitis, impingement
• Old: RC, OA

Answer 1

Stand the patient

• Look: ask them to do a quick screen of neck movements (? Painful) – look in front – laterally – from the backthe axilla and finally at the back
• Feel: bony prominences: SCJ → clavicle (feel for #) → ACJ → coracoid → biceps → spina scapulae
• Move: FF – ABD (look from the front and the back observing scapulothoracic movement) – IR – ER (for passive immobilize scapula)
• Impingement tests: Neer’s sign - Hawkin’s – Cross adduction test – Speed’s – O’Brien
• MM:
  
  • 1st: RC: SS (Jobe’s), IS (ER ), TM (Hornblower’s), Sb (Lift-off)
  • Consider other mm:
  • From the front (3): deltoid, pec major, lat dorsi
  • From the back (3): rhomboids, trapezius, serratus anterior

Sit patient (or lie)

• Instability tests: first ask if they have instability!
• Anterior & posterior draw test (0-25%: G0 – 25-50%: G1 – 50-100%: G2 – dislocatable: G3)
• Sulcus sign (acromio-humeral interval) (0-1cm: G1 – 1-2cm: G2 - >2cm G3)
• Anterior apprehension – Posterior apprehension
• Beighton score

Question 2

• Test for deltoid: Passively abduct the shoulder at 90⁰ . Then extend it. Ask the patient to resist as you push downwards on the arm. Feel the muscle. At the same abducted position, push forward and backwards and tell the patient to resist.
• Test for pectoralis major: Hands-on the waist and squeeze them. Palpate the muscle.
• Test for latissimus dorsi: elbow flexed to 90⁰, arm by the side, push forwards at the elbow: palpate the muscle
• Test for rhomboids: Bring your shoulder blades together. Feel muscle.
• Test for serratus anterior: Patient pushes against all with an outstretched arm, the fingers and palm pointing downwards on the wall: Scapular winging: palpate the muscle
• Test for trapezius: Patients shrugs shoulders against resistance, palpate the muscle

Answer 2

tests for thoracic outlet syndrome:

• Adson’s test is performed for the vascular component:
  
  • Extend the head and rotate it to the affected side. Abduct the ipsilateral arm 30ο “ and feel the radial pulse. Ask the patient to take a deep breath and hold it. If the radial pulse disappears then the test is positive.
• Roos test is for the neurological component:
  
  • Brace the shoulders back fully and flex the elbows 90ο Flex and extend the fingers rapidly. If symptoms are reproduced then this confirms the diagnosis

Question 3

Look

• On standing the patient look for the position that the patient holds the arm: Erb’s or Klumpke’s
• Look at the neck for any swelling
• Look for scars including in the axilla: surgical scars or scars related to a penetrating injury
• Look for wasting of the muscles
• Look for Horner’s syndrome: ptosis, myosis, anhydrosis and enopthalmus: damage to the sympathetic chain which is in very close proximity to the nerve roots: poor prognosis
• If the patient cannot stand then there is a possibility that the BP lesion involves the nerve roots which themselves may be associated with long tract injuries

Poor prognostic signs:

• High E injury
• Older age
• Flaccid limb
• Painful anaesthetic limb
• Signs of pre-ganglionic injuries (Horner’s, rhomboids or serratus anterior affected)

Answer 3

Feel

• Over bony areas
• Sensation: dermatomes (roots/trunks) - peripheral nerves (cords/branches): does it feel the same and normal?
• Feel Pulse: damage to the BP may result in subclavian artery injuries
• Feel for sweating: if neuro-apraxia it is preserved

Move

Determine the level of the lesion

• Supraclavicular: roots and trunks:
• Pre-ganglionic: poor prognosis, may require nerve or muscle transfers
• Post-ganglionic

Assess the muscles supplied at the level of the roots:

• Dorsal scapular nerve: Rhomboids
• LTN : Serratus Anterior
• Examine the muscles supplied at the level of the trunks:
• Suprascapular nerve (C5/6) upper trunk: Supraspinatus and infraspinatus
• Trapezius can be tested to indicate trunk lesions because the XI cranial nerve lies in the posterior triangle of the neck near to the trunks

Examine the muscles supplied at the level of the cords:

• Medial and Lateral cord: Pectoralis major:
• Medial pectoral nerve: sternal head
• Lateral pectoral nerve: clavicular head

Posterior cord

• Thoracodorsal nerve: Lat dorsi by asking the patient to push down on the abducted arm
• Subscapularis: Upper and Lower subscapular nerve

Assess the myotomes of the upper limb

Examine the muscles supplied by the terminal branches:

• Radial nerve
• Medial nerve
• Ulnar nerve
• Axillary nerve
• MCN

Reflexes

Question 4

Stand the patient

• Look: form the front assess the carrying angle – lateral (effusion) and posterior – always medial for scars
• Move: ask patient to abduct 90ο both elbows, fully extend and flex them, bring them forward and check at the medial side, pronate and supinate

Feel

• Olecranon, medial epicondyle, biceps aponeurosis, radial head, lateral epicondyle
• Then flex and extend the elbow and feel for subluxing ulnar nerve
• Put one finger on the medial epicondyle, one finger on the lateral epicondyle and one on the tip of the olecranon: in extension normally these 3 bony prominences form a straight line but in 90ο of flexion they form an isosceles triangle

Provocative tests:

• Medial side: ask the patient to flex the wrist and prevent the patient from straightening it resulting in pain in the medial epicondyle
• Lateral side: trying to straighten an extended wrist against resistance – if this results in pain in the region of the lateral epicondylitis = tennis elbow, Mills test
• Long finger extension test – Tennis elbow and Radial tunnel

Instability

• MCL: externally rotate the shoulder to lock it and by slightly flexing the elbow to unlock it and provide a valgus force to the elbow
• LCL: internally rotate the shoulder to lock it, slightly flexing the elbow to unlock it and provide a varus force

Answer 4

The Pivot Shift test

• is a painful test and is usually not required to be carried out in the clinical exam.
• It is performed on a supine patient. The shoulder is flexed overhead.
• The elbow is fully extended and an axial force is applied to the supinated forearm.
• At the same time, a valgus force is applied to the elbow.
• As the elbow is flexed to 45⁰ the radial head subluxes maximally and creates a posterolateral prominence with a dimple in the skin just proximal to it.
• Increasing the flexion beyond this results in a reduction of the radial head and the dimple disappears

Question 5

Pillow

Look:

• palmar and dorsal aspects
• Flex elbows at 90ο and check at medial side scars
• Pain: radial, ulnar, central or global wrist pain / Dorsal or palmar pain

Move:

• Prayer and reverse prayer positions
• Make fists: Radial and ulnar deviation
• Pronation and supination

Feel:

• Lister’s just proximal to SLL

Special tests:
TFCC: 3 factors

• Pronation leads to the radius lying obliquely across the ulna which is effectively longer. Sensitive structures at the end of the distal ulna will therefore be squashed against the triquetrum in full pronation
• Ulnar deviation of the wrist
• Dorso-palmar stretching of the cartilage by pushing the distal ulna down (palmar) and the pisiform – triquetrum up (dorsal)
• TFCC grind test: forearm in neutral, handshaking, ulnar deviation and palmar-dorsi flexion

Simple compression of the DRUJ by squeezing the two bones together will localize pain if the joint is the source

Answer 5

special tests:

• Tenderness over SLL: Kirk-Watson test: Palpable clunk with passive radial deviation of the wrist with the scaphoid stabilised volarly with the index and the thumb at the SL interval
• LTL: LT ballottement test: The lunate is stabilised with the examiner’s thumb and index finger of one hand. The triquetrum and pisiform are passively pistoned volar to dorsal to volar and so on with the other hand
• SL ballottement test: The scaphoid is grasped between finger and thumb of one hand and the lunate between finger and thumb of the other. Palmar–dorsal passive motion is then assessed for pain and compared with the other wrist
• Kleinman’s shear test: This test applies a palmar dorsal shear to the lunotriquetral ligament using one hand in the following manner. Using the hand opposite to that which you are examining (i.e. your left hand to examine the patient’s right), grasp the luno-triquetral complex in a pinch grip by applying pressure dorsally on the lunate with the index finger, and palmarly on the pisiform (and therefore triquetrum) with the thumb. Gently squeeze these together and shear the lunate against the triquetrum.
• Pisotriquetral grind: Rub the pisiform against the underlying triquetrum by applying pressure (with rotation) on the palmar surface of the pisiform
• ECU dislocation test: ECU dislocates with active ulnar deviation and supination
• Reagan ‘shuck’ test for midcarpal instability: The word ‘shuck’ means ‘to shift’ and this test assesses peritriquetral instability. Grasping the triquetrum and pisiform between thumb and index finger of one hand, and the rest of the carpus with the other, allows ballottment between the two examiner’s hands to assess stability. Compare with the other side. Excessive motion implies instability between triquetrum and lunate and between triquetrum and hamate

Question 6

Screen test:

• Prayer, reverse prayer, Ulnar and radial deviation, Supination and pronation
• Pronation - make a fist - straighten out - adduct – supinate – abduct – make a fist
• Lift your hand over their shoulder looking for scars including around the elbow and axilla
• Grasp: shake my hand and grasp tight

Types of pinch:

• Chuck pinch: pick up this coin from my hand
• End or pen pinch: hold this pen
• Side or key pinch: hold this key

Routine palpation: Hamate , pisiform, lunate, scaphoid tubercle, CMCJ, Radial styloid, 1st extensor comp, snuffbox, SL lig, DRUJ, TFCC, MCPJ and fingers

Swellings:

• Volar:
  
  • inclusion dermoid cysts
  • A1 pulley ganglion
  • GCT of flexor sheath
• Dorsal
  
  • rheumatoid nodules
  • gouty tophi
  • subungual exostosis
  • Heberden’s nodes
  • mucous cyst (DIPJ)
  • Bouchard’s nodes
  • CMTC boss

Answer 6

Dupuytren’s:

• perform the tabletop test (failure to be able to put a hand flat on the table indicates either a PIPJ flexion contracture or an MCPJ flexion contracture >30^ο)
• measure fixed flexion deformities at MCPJ and the PIPJ: must flex MCP to assess PIPJ

Indications for surgery:

• (+) tabletop test – MCPJ flexion contracture >30^ο – PIPJ flexion contracture >0^ο

Question 7

Start from proximal to distal firstly on the extensor side then

proximal to distal on the flexor side stating all the abnormalities

Answer 7

On the extensor side from proximal to distal the possible abnormalities are:

• DRUJ instability with caput ulnae (piano key sign)
• Extensor tendon rupture (Vaughn Jackson syndrome)
• MCP joint subluxation and ulnar deviation
• Finger deformities such as mallet finger, boutonniere’s deformity, swan neck deformity
• Z deformity of the thumb

On the flexor side abnormalities such as:

• thickening of the carpal tunnel resulting in carpal tunnel syndrome
• thenar wasting
• tendon ruptures such as FPL (Mannerfelt-Norman syndrome)
• trigger finger

Question 8

• *Stand the patient**
• *Look**:
• from the back: curves, scars, hair, naevi and other stigmata (café au lait spots), pelvic tilting
• From the side: lumbar lordosis, thoracic kyphosis, cervical lordosis
• From the front

Feel:

• palpate down the bony prominences of the spinal column
• Romberg
• Forward flexion: Schober’s test: draw a line between the posterior iliac spines. Mark a point 10 cm above this horizontal line in the midline, then ask the patient to forward flex. In a normal lumbar spine, this point should be increased by 5cm
• Lateral flexion: distance from the fingers to the floor
• Extension
• Rotation: fixing the pelvis with the hands or asking the patient to sit and rotate
• Walk the patient: Before walking the patient it may sometimes be helpful to do a quick screen
• for the lower lumbar nerve roots by asking patient to
  
  • squat and get up (assessing quadriceps function) L3
  • stand on heels assessing L4
  • stand on one leg effectively performing Trendelenburg’s test L5
  • stand on tip toes for testing S1

Answer 8

Lie the patient down

Dermatomes

• Hip ROM:
  
  • hip flexion L2
  • All the movements on the posterior aspect of the lower limb are essentially S1
  • Hip adduction is L2, foot inversion L5, foot eversion S1
• Pulses
• Reflexes: L4 - S1
• Provocative tests:
  
  • Cross sciatic stretch test that is ie, if a patient has a positive cross sciatic stretch test by lifting the contralateral leg then they are most likely to have sciatica
  • straight leg raising as far as possible until the patient gets pain radiating down the leg. At that point stop, decrease the angle of straight leg raising until the pain subsides and then passively dorsiflex the ankle. If this elicits pain then the patient has a positive test
  • The bowstring test is performed by doing the straight leg raise test first and then flexing the knee. On flexing the knee the pain is relieved. Pressure in the popliteal fossa over the region of the sciatic nerve or the branches will then stimulate pain radiating down the leg.
  • Femoral stretch test is performed by asking the patient to roll over on to their abdomen and extending the leg at the hip
  • FABER: pain on the ipsilateral side anteriorly: hip disorder / pain on the contralateral side posteriorly: SIJ
  • Gaenslen’s test: supine, painful leg on the edge of the bed, the non-symptomatic hip is maximally flexed with both arms close to the chest and I apply a downward P to the symptomatic leg

PR

Question 9

• Stand
• Look
• Feel
• Move: include Romberg
• Walk: wide-based gait for myelopathy

Answer 9

Lie patient down:

• Neurological examination UL and LL:
• Hoffman’s (upper motor neurons): Flick the DIPJ of the index or middle finger into flexion and observe the thumb IPJ - In a positive test this joint will flex
• Lehrmitte’s: barber chair phenomenon, an electrical sensation that runs down the back and into the limbs, elicited by bending the head forward, caused by involvement of the posterior columns
• Spurling’s: radicular pain, the examiner turns the patient’s head to the affected side while extending and applying downward pressure to the top of the patient’s head. A positive Spurling’s sign (i.e. the Spurling’s test is positive) is when the pain arising in the neck radiates in the direction of the corresponding dermatome ipsilaterally

PR

Question 10

Scoliosis

• Stand
• Look
• Feel
• Move
• Walk
• Lie the patient down
• Complete neurologic examination
• Provocative Tests

Answer 10

The difference is that:

• On looking, look for any stigmata for the cause ( eg neurofibromas, pes cavus etc)
• When feeling you can assess the balance of the spine by using a plumb line – natal cleft: occipito-sacral line
• When asking the patient to forward flex look for a rib prominence (structural scoliosis)
• When assessing reflexes include the abdominal reflex as an abdominal reflex is an indicator of thoracic pathology
  
  • In the supine patient, a key is used to stroke around the umbilicus in a diamond shape ie 4 quadrants. Normally this would stimulate the underlying musculature to involuntarily contract to result in movement of the umbilicus in the direction being stimulated.
  • The asymmetry between left and right side may indicate spinal dysraphism and should prompt and MRI whole spine

Question 11

Stand the patient:

• Expose the patient remembering to lift the underwear looking closely for any scars.
• Look at the general attitude of the lower limb.
• Look from the front, side, both laterally and medially and behind.
• A lumbar lordosis may indicate a FFD of the hip and a scoliosis may help to indicate a LLD

Walk the patient:

• Remember to look for walking aids
• If there is a Trendelenburg gait, does the patient also lower their shoulder on the side of the painful hip on walking to try to centralize the centre of gravity? This is sometimes called a ‘lurching gait’.
• Trendelenburg test:
  
  • Trendelenburg correctly attributed the normal elevation of the opposite half of the pelvis to the weight bearing side as being due to abductor muscle function.
  • Trendelenburg test is negative if the pelvis lifts up on the unsupported side. This pelvic tilting on single leg stance is normal and the centre of gravity moves over the supporting leg.
  • The test is positive when the pelvis dips down on the unsupported side and the shoulders move over the weight-bearing hip.

Answer 11

• Sit the patient:
  
  • does the scoliosis correct? Then it may be due to LL
• Palpation: GT and anterior hip

Lie patient down

• Square the pelvis
• Thomas test: DO NOT PERFORM IF THR:
• Up to 30^ο of FFD of the hip can be compensated by increasing lumbar lordosis
• Square the pelvis: Flexion: active then passive
• Square the pelvis: IR and ER in extension and flexion
• Square the pelvis: Abduction and Adduction
• Complete neurovascular examination of the limb as well as the spine and the knee (joints above - below)

Question 12

Leg length measurement

• Both limbs need to be placed in exactly the same degree of deformity in order for the measurement to be accurate
• Apparent LLD is the impression that is given with the patient lying on the bed with the pelvis tilted usually due to fixed abduction or adduction hip contracture
• Galeazzi’s test: assess whether it is above or below the knee
• Bryant’s triangle: assess whether the discrepancy is coming from above or below the GT: A vertical line is drawn from the ASIS to the couch, and a perpendicular is drawn from this line to the top of the GT. Measure on the other side
• Then if necessary stand the patient and perform the Block test: takes into account discrepancy below medial malleolus

Answer 12

Ober’s

Question 13

​​

• Stand and Check shoes:
  
  • wear pattern –
  • external heel raise
  • internal heel raise
  • medial arch support – bunion – bunionette

Look

• Walk
  
  • stages of gait cycle
  • varus or valgus lurch
  • foot and patella progression angles

Sit the patient down:

• assess patella height
• tracking (J sign) and crepitus

Lie the patient down:

• Look: quantify quadriceps wasting, tape
• Feel for temperature and effusion or tenderness:
• Wipe test: mild effusion
• Patella tap: moderate effusion
• Palpate: everything + POPLITEAL FOSSA

Move:

• SLR and then lifting both heels in the hands and assessing any degree of recurvatum.
• Flexion is assessed first actively and then passively comparing both knees

Answer 13

Assess ligaments:

• Cruciates: Flex both knees to 90^ο with heels together. Look from the side and look for a posterior sag. If there is a sag then perform the Quads active test
• PM and PL corners
• Lachman’s
• Collaterals
• Meniscus
• Patella: apprehension test and Clarke’s test:
  
  • active contraction of the Qceps while I exert P on the superior pole of the patella to prevent its proximal migration: pain
• Prone: Dial test

Question 14

• Look for facial dysmorphism
• Look at parents’ legs
  
  • if similar problem, think of AD (hypophosphataemic rickets), HME, dysplasia
• Height, weight, percentiles for age
• Standing and sitting height to rule out skeletal dysplasia
• Uni or bilateral? Symmetric or asymmetric? Correctable?
• Is there gradual bowing or abrupt angulation?
• If there is deformity, where does it lie?
• Identify ASIS – patella and midline of the ankle: mechanical line can be assessed by dropping a plumb line from the centre of femoral head to the ankle center which should bisect the knee

Answer 14

• Intermalleolar distance when standing: both patellae should point forwards: in genu valgum should be <8 cm
• Assess lower limb rotational profile
  
  • WALK: Foot progression angle: -5ο - +20ο
  • STAND: Internal tibial torsion: difference bt transmalleolar axis - bicondylar axis of the knee: abnormal >-15ο
  • PRONE: Thigh-foot angle : normal 0-20^ο
  • PRONE: Heel bisector: normal is through 2nd and 3rd toe webspaces
  • Assess knee for ligament laxity

ASK FOR X-rays:

• Tibiofemoral angle as per Selenius curve
• Metaphyseal-diaphyseal angle of Drennan: normal <11^ο , abnormal >16^ο
• Metaphyseal-epiphyseal angle: normal <20^ο , first line through 2 points at the normal side of the epiphysis and the 2nd line between metaphyseal beak and center of epiphysis

Question 15

Stand the patient

• Look: heel position, equinus, foot position, back for signs of spinal pathology, bulk of calf musculature
• Walk: stages of gait
  
  • Pes cavus: consider looking at the hand for muscle wasting, Coleman’s Block test
  • Pes planus: tip toe test (do both heels invert indicating normal subtalar joint?), Jack’s test
  • Beighton’s test

Go to wall for single heel rise (x20)

Answer 15

Sit the patient down:

1. Look at sole of foot and consider looking at shoes and walking aids

Movements:

• Ankle, subtalar, midfoot
• Hammer toe deformity: differentiate between a fixed deformity at the PIPJ and a flexible. To do this the PIPJ movements need to be examined with the long flexors of the toes relaxed. This can be accomplished by either plantarflexing the ankles or exerting upward pressure on the metatarsal heads
• The true range of dorsiflexion of the 1st MTPJ can only be measured with the ankle at a right angle. If one omits this a diagnosis of hallux rigidus may be missed

Question 16

1: What is the problem?

• Toe deformity rubbing on shoes – footwear deformity
• Painful calluses under the MTT heads caused by forefoot plantarflexion and fixed toe deformity
• Lateral foot pain and painful calluses on the lateral foot border owing to hindfoot varus
• Walking difficulty owing to foot deformity or foot drop
• Ankle instability owing to hindfoot varus and PB weakness
• Worries about progression

2: Is it progressive?

• Length of history: when did it appear? – were you born with it? – is it getting worse? – any problems with bowel or bladder? – any weakness in hands or shoulder?
• Any previous history of ulcers or infection?

3: Is there an identifiable neurological cause?

• Any problems with hands, back, vision? – Similar problem with a family member?

Causes:

• Congenital: idiopathic – CTEV – arthrogryposis
• Acquired: trauma – neuromuscular (muscular dystrophy – HMSN – Polio – spina bifida – spinal dysraphism – Friedreich’s ataxia – CP)

Answer 16

4: What are the patient’s expectations?
* How can I help you? – is it the pain or the ulcer that really bothers you?

5: Search for any underlying condition (full neurological evaluation)

• Inspection: Are the leg mm wasted? – Check at the hands
• Is there a high medial arch? Is it bilateral? Is it symmetrical?
• Is the heel in varus, neutral, valgus? Is it in equinus or calcaneus?
• Is the whole forefoot plantraflexed (plantaris) or is the 1st ray most plantraflexed?
• Is there toe clawing? Callosities, ulceration?
• Look at shoes and walking aids
• Walk the patient

Palpation:

• Are the deformities correctable or fixed?

Hindfoot:

• Varus – Coleman test
• Equinus: ATT tightness (Silfverkiold test)
• 1st ray: can this be brought level with the other rays? Secure the hindfoot with the left hand in a neutral position and look at the rays from the front. Are they level? If not, can they brought level?
• Assess for tenderness at the callosities
• Sensation: glove and stocking type in HSMN and dermatomal in spinal disorders

Assess foot circulation

Movement:

• the common pattern is the foot dorsiflexion is powered by the toes flexors rather than ATT

X-rays:

• WB lateral (calcaneal pitch: normal <30^ο - lateral Meary’s angle: normal 0^ο)
• PA: Meary’s angle: normal 0ο

MRI: spine and brain

Muscle enzymes and genetic screening

Question 17

Forefoot:

• Hallux Valgus (rarely varus)
• Claw toes
• Dislocated MTPJ’s of lesser toes resulting in plantar fat pad being pulled forwards

Midfoot:

• Abduction deformity due to talo-navicular subluxation
• Flattened arch

Answer 17

Hindfoot:

• PTT rupture
• Subtalar joint involvement
• These lead to hind foot valgus
  
  • too many toes sign”

Question 18

• Remember to communicate with the child as well as the parent.
• Examination of the small child does not necessarily need to be on the couch. It can be on the parent’s lap or even the floor.
• Respect the child’s modesty and undress in stages if necessary.
• Look: Inspection must start immediately as a relaxed child may give away hints that would otherwise be difficult to pick up such as:
  
  • W-sign of increased femoral anteversion in the sitting child
  • Gower’s sign child uses the hands to climb upon himself to stand up from a sitting position
  • Looking should start from the sitting position followed by asking the child to stand and walk

Gait

• antalgic
• short leg (LLD)
• Trendelenburg
• high stepping gait – ataxic – neurologic – crouch
• back kneeing (Quadriceps is weak. Patients’ back knees‘ to prevent the collapse of the knee on stance phase, polio)
• outoeing - SUFE, also ↓abduction, IR and flexion)

Answer 18

• Feet: Feet flat at birth - Medial arch develops by 6 yrs
• Lower limb rotational profile
• Walk the patient:
• Foot progression angle
• Patella progression angle
• Sit the patient:
• Intermalleolar axis. Normally fibula is 20ο posterior to medial malleolus. In internal tibial torsion the fibula may be at the same level or in front
• Scoliosis: non-structural and structural scoliosis (rib prominence)
• Lie patient supine: Check for metatarsus adductus

Question 20

• Square pelvis. Thomas test and hip ROM:
• Assess ER and IR:
  
  • Increased IR with increased femoral anteversion: Gage’s sign
• DDH: On inspection may see asymmetric groin or buttock crease. Also limitation of abduction + LLD
• Perthes: On palpation there may be a prominent GT. They have ↓adduction and ↓IR
• Galeazzi – Bryant’s triangle - Nelaton’s line: Draw a line from ASIS to ischial tuberosity. GT should be on or just below this line – block test
• ACL deficiency: congenital short femur or longitudinal deficiencies of the lower limb

Foot & Ankle:

• Pes planus: In the child remember tarsal coalition as a cause of rigid flatfoot.
• For flat foot instead of asking child to tip toe you can perform Jack’s test: Active dorsiflexion of the big toe in a WB child results in a recreation of the medial arch in a flexible flat foot

CTEV:

• Look: At the parents feet - Is the child syndromic? Other congenital conditions with increased joint contractures such as arthrogryposis or diastrophic dwarfism
• Turn patient over and look at back for a neurological cause
• Look for other “packaging problems”: torticollis, DDH, femoral anteversion, tibial torsion
• Examine the feet to assess how correctable

Answer 20

Shoulder:

• Sprengel’s shoulder: undescended scapula with winging, hypoplasia and omovertebral connections
• Poland’s syndrome: absence of sternal part of pectoralis major
• Cleidocranial dysostoses: clavicles may be absent
• Pseudoarthrosis of the clavicle: defect may be palpable
• Multidirectional instability: generalized ligamentous laxity

Elbow:

• Increased carrying angle: may be seen in Turner’s syndrome
• Reduced carrying angle - gunstock deformity: usually after supracondylar #
• Radio-ulnar synostosis: usually bilateral, AD

Wrist and Hand:

• Madelung deformity: prominence of distal ulna with radial and volar deviation of the wrist. Bilateral in the familial condition and unilateral if post-traumatic (growth arrest of distal radius)

Common finger deformities:

• Kirner’s deformity: radial and palmar curvature of DIPJ of little finger
• Clinodactyly: only radial curvature of DIPJ of the little finger
• Camptodactyly: flexion deformity of PIPJ of little finger
• Syndactyly: complete – incomplete / simple - complex
• Polydactyly

Question 21

General:

• Look at the trunk for gastrostomy or subcutaneous reservoir for a baclofen pump

Pattern of involvement

• Need for walking aids, orthoses, speed, symmetry
• Head: is it steady, does it move from side to side or up and down?
• Shoulders and upper body: posture, excessive movement?

Standing/sitting: scoliosis?

• Idiopathic: vertebral rotation (rib prominence) and possible compensatory curve
• Long C or neuromuscular curve: single curve from neck to lumbosacral junction

Standing:

• pelvic obliquity and LLD contractures and increased lumbar lordosis
• Walk patient if possible: functional scoliosis, pelvic obliquity (? Type I or II curve)

Answer 21

Lie patient supine:

• Leg length
• ROM and assess for contractures of hip, knee, ankle
• Hip: Thomas’ test
• Phelp’s test: Tests for a tight gracilis. The hip is abducted to the fullest with the knee flexed. The knee is then extended. If there is loss of some abduction at the hip then this indicates that gracilis is tight
• Knee: Popliteal angle: indicates the degree of hamstring tightness or contracture. Normal values are <20ο. The hip is flexed to 90ο and the knee is then extended from a flexed position. The angle created between the front of the leg and a line extended from the front of the thigh is the popliteal angle

Ankle

• Silverskiold’s test: This test differentiates gastrocnemius contracture from that of soleus. Dorsiflex the ankle with the knee flexed then with the knee extended. If the degree of dorsiflexion is less with the knee extended then the gastrocnemius is the main site of contracture. If there is no change of angle then contracture of both muscles are present

Gage’s test:

• The patient is prone and the knee is flexed 90ο. The angle created by the leg to an imaginary vertical line when the GT becomes most prominent on rotating the limb from maximal internal rotation to maximal external rotation is the angle of anteversion of the femur

Thigh - foot angle

• The foot can also be observed for abnormalities eg. Metatarsus varus

Staheli Test:

• This is considered by many as a more accurate assessment of FFD than Thomas’s test in a CP child. The child is placed at the end of the couch with the pelvis and legs hanging off. This allows the hips to flex and the lumbar spine to flatten. The hip is then extended. When the buttock starts to rise, the angle created by the thigh to the lumbosacral spine is the amount of FFD of the hip

Duncan Ely Test:

• With the patient prone flex the knee. If the buttock rises off the couch from this manoeuver then rectus femoris tightness is present

Ober’s test:

• The patient lies on the side opposite to the one to be tested. The uninvolved knee and hip are maximally flexed in order to flatten the lumbar spine. With the knee flexed, the hip to be tested is then abducted and fully flexed. It is then positioned in full extension. Loss of abduction by moving the hip from flexion to full extension indicates ITB tightness

Question 22

• The main reasons why you may be getting a patient with spina bifida in the exam is firstly to make the diagnosis and secondly to assess the level of the disability*
• The LOOK-FEEL-MOVE sequence can work here. LOOK is probably the most important

LOOK

• Look at the legs generally describing any wasting or areas of ulceration
• Look at the spine describing any obvious dimples, hair, naevus or indeed an obvious myelomeningocoele
• Look for the presence of any catheter which indicates that the patient may have lost control of bladder function
• Look around for the presence of an orthosis. The type of orthosis is an indicator of the functional level:
• HKAFO orthosis indicates a functional level L1 or higher (hip knee foot all not working)
• KAFO orthosis indicates hip working: L2 functional level
• AFO orthosis indicates hip, knee working: L3 functional level
• No orthosis. Hip, knee ankle all working L5

Answer 22

FEEL

• The sensation is difficult to assess in a young patient with spina bifida

MOVE

• Motor: Tone, Power, Reflexes. Again maybe difficult but should be carried out if necessary in the exam.
• Most of the required information would, however, be obtained from inspection.
• Finally, get the patient to WALK +/- orthosis

Question 23

Hoffmans Relfex

Answer 23

• Hoffman’s sign – flick the distal interphalangeal joint of the index or middle finger into flexion and observe the thumb interphalangeal joint. In a positive test this joint will flex
• positive test indicates an upper motor neuron lesion

Question 24

Inverted radial reflex: (C5 - C6)

Answer 24

• inverted radial reflex may be present when cord & root compression are present at the C5 level;
• this reflex is demonstrated by tapping brachioradialis tendo
• diminished reflex is noted along with a reflex contraction of spastic finger flexors
• this specific reflex occurs due to peripheral compression of the C6 nerve root (from disc or spur) which allows upper motor neuron reflex to occur;
• biceps reflex primarily indicates neurologic integrity of C5;
• the reflex also has a C6 component;

Question 25

myelopathic hand:

Answer 25

1. finger escape sign (small finger spontaneously abducts due to weak intrinsics) indicating cervical myelopathy;

Question 27

Romberg’s test,

Answer 27

• Romberg’s sign is a test used in an exam of neurological function for balance,
• The exam is based on the premise that a person requires at least two of the three following senses to maintain balance while standing: proprioception (the ability to know one’s body position in space); vestibular function (the ability to know one’s head position in space); and vision (which can be used to monitor and adjust for changes in body position).
• A patient who has a problem with proprioception can still maintain balance by using vestibular function and vision. In the Romberg test, the standing patient is asked to close their eyes. An increased loss of balance is interpreted as a positive Romberg’s test.
• Procedure - Ask the subject to stand erect with feet together and eyes closed. Stand close by as a precaution in order to stop the person from falling over and hurting themself.
• Watch the movement of the body in relation to a perpendicular object behind the subject (corner of the room, door, window etc.).
• A positive sign is noted when a swaying, sometimes irregular swaying and even toppling over occurs. The essential feature is that the patient becomes more unsteady with eyes closed.

The essential features of the test are as follows:

the subject stands with feet together, eyes open and hands by the sides.

the subject closes the eyes while the examiner observes for a full minute.

Because the examiner is trying to elicit whether the patient falls when the eyes are closed, it is advisable to stand ready to catch the falling patient. For large subjects, a strong assistant is recommended.

Romberg’s test is positive if the patient falls while the eyes are closed. Swaying is not a positive sign as it shows proprioceptive correction.[4]

Question 29

• Schobergs test

Answer 29

Purpose

• Schober’s test is classically used to determine if there is a decrease in lumbar spine range of motion (flexion), most commonly as a result of ankylosing spondylitis.[1].
• The measurement of this test is useful for
• Screening the status of ankylosing spondylitis disease
• Determination of progression and therapeutic effects of ankylosing spondylitis and other pathologic conditions associated with low back pain[2].

Technique

• Patient is standing, examiner marks the L5 spinous process by drawing a horizontal line across the patients back.
• A second line is marked 10 cm above the first line.
• Patient is then instructed to flex forward as if attempting to touch his/her toes, examiner remeasures distance between two lines with patient fully flexed.
• The difference between the measurements in erect and flexion positions indicates the outcome of the lumbar flexion [1].
• Modified Schober Test (eliminates the errors in identification of lumbosacral junction and makes sure that the entire lumbar spine was included
• Patient is standing, examiner marks both posterior superior iliac spine (PSIS) and then draws a horizontal line at the centre of both marks
• A second line is marked 5 cm below the first line.
• A third line is marked 10 cm above the first line.
• Patient is then instructed to flex forward as if attempting to touch his/her toes, examiner remeasures distance between the top and bottom line. [1].

Interpretation

• For both versions of the test, an increase of less than 5cm is a positive test and may indicate ankylosing spondylitis (AS). (Image shows region of spine mainly involved in AS)
• Positive Schober’s Test
• Less than 5cm increase in length with forward flexion: Decreased lumbar spine range of motion, ankylosing spondylitis

Clinical Notes

Question 30

Chin-brow-to-vertical angle (CBVA)

Answer 30

• Chin-brow vertical angle was an objective index for evaluating horizontal gaze
• measured from standing exam of standing lateral radiograph
• useful for preoperative planning
• correction of this angle correlates with improved surgical outcomes

Question 31

Adam Forward bedning test

Answer 31

Definition/ Description

• The patient takes off his/her t-shirt so that the spine is visible. The patient needs to bend forward, starting at the waist until the back comes in the horizontal plane, with the feet together, arms hanging and the knees in extension. The palms are hold together. The examiner stands at the back of the patient and looks along the horizontal plane of the spine, searching for abnormalities of the spinal curve, like increased or decreased lordosis/ kyphosis, and an asymmetry of the trunk

Clinically Relevant Anatomy

• The spine consists of 7 vertebrae cervicales, 12 vertebrae thoracicae, 5 vertebrae lumbales and an os sacrum composed of 5 vertebrae sacrales. For more information, see scoliosis on Physiopedia. When you look at the vertebral column in the sagittal plane, you see a cervical lordosis, thoracic kyfosis, lumbar lordosis and sacral kyfosis. [5]D Normally, the processus spinosi form a straight line. In patients with scoliosis, you see a lateral deviation in the frontal plane and a vertebral rotation, which can develop into a rib hump. [6], [7], [8]When the scoliosis progresses, the prossesus spinosi will rotate to the concave side of the column vertebrae. The costae are close together at the concavity of the curve and more separated at the convex side. The ribs follow the rotation of the corpus vertebrae and thus those of the processus spinosi. The rib hump develops because the posterior ribs on the convex side are being pushed to posterior and the anterior ribs on the concave side are pushed anteriorly

Purpose

• The purpose of the Adam’s forward bend test is detecting structural or functional scoliosis. This test is most often used during school screening for scoliosis. It can also be used with patients who have a family history of scoliotic posture or with patients who have detectable scoliosis of uncertain etiology. The scoliosis is functional when the characteristics of scoliosis becomes more visible while the patient bends. With a structural scoliosis, the scoliotic deformity will remain the same as in the standing position. If there is an increased kyphosis when bending forward, Scheuermann’s disease or congential kyphosis is also possible.

Technique

• Before you perform the Adam’s forward bend test, it is best to look for limb length discrepancy. The spine needs to be visible. The patient bends forward at the waist until the back comes in the horizontal plane, with feet together, arms hanging and knees extended. The palms are held together. The examiner looks from behind, along the horizontal plane of the column vertebrae. The examiner looks for indicators of scoliosis, such as spinal asymmetry, unlevel shoulders, scapula asymmetry, unlevel hips, the head that does not line up with the pelvis or a rib hump. An increased or decreased lordosis/kyphosis can also be a sign for scoliosis. [14], [15] The rotation deformity or rib hump can be measured with a scoliometer.

Question 32

Jobes test

• The Empty Can Test is used to assess the supraspinatus muscle and supraspinatus tendon.

Answer 32

Technique

• The patient can be seated or standing for this test. The patient’s arm should be elevated to 90 degrees in the scapular plane, with the elbow extended, full internal rotation, and pronation of the forearm. This results in a thumbs-down position, as if the patient were pouring liquid out of a can. The therapist should stabilize the shoulder while applying a downwardly directed force to the arm, the patient tries to resist this motion. This test is considered positive if the patient experiences pain or weakness with resistance.
• Empty can test as sensitivities of 88.6% and specificities of 58.8% in diagnosing the supraspinatus tendon tear.
• https://www.youtube.com/watch?v=NuBOHdm20cc

Question 33

Hawkins / Kennedy Impingement Test of the Shoulder

• This test is commonly used to identify possible subacromial impingement syndrome.

Answer 33

• The examiner places the patient’s arm shoulder in 90 degrees of shoulder flexion with the elbow flexed to 90 degrees and then internally rotates the arm. The test is considered to be positive if the patient experiences pain with internal rotation.[1]
• https://www.youtube.com/watch?time_continue=4&v=2mSv7gLXyYg&feature=emb_logo

Question 34

Lift-off test and Passive Lift Off Test

Belly Press

Belly-off sign

Bear Hug Test

Answer 34

Lift-off test

• To test for a lesion of the subscapularis muscle and scapular instability. The patient stands and places the dorsum of the hand against mid-lumbar spine. The patient then lifts his hand away from the back. An inability to perform this action indicates a lesion of the subscapularis muscle.
• https://www.youtube.com/watch?v=AgkTH52_PBI

Question 35

Hornblower’s Sign

• To test for teres minor tear.

Answer 35

• The patient is seated or standing. The examiner places the patient’s arm to 90oin the scapular plane and flexes the elbow to 90o. The patient is then asked to externally rotate against resistance. The test is positive if the patient is unable to perform external rotation.

https://www.youtube.com/watch?v=KcNBtbVaatY&feature=emb_logo

Question 36

Anterior Apprehension Test

Answer 36

• In supine the patient is positioned with the scapula supported by the edge of the examining table. The arm is positioned in 90 °abduction and external rotation. With increasing external rotation the examiner watches for apprehension on the part ofthe patient. This test is often performed in sitting in the clinic setting and the examiner exerts an anterior translatory force with their thumb placed posteriorly on the humerus. However their fmgers are anterior to control any sudden instability episode that may occur.
• Essentially this test must produce an apprehension (see note regarding apprehension) response from the patient. Pain alone does not = a positive test. In the case of a positive test then proceed to the relocation test. Record the amount of external rotation achieved at onset of Sx/response. A positive test is usually correlated with a labral lesion and/or bony lesion at the anterior inferior rim of the glenoid
• https://www.youtube.com/watch?v=hy7zgoEsbzQ

Question 37

Finkelstein Test

Answer 37

Introduction

• Finkelstein’s test is the classic provocative test for diagnosis of De Quervain’s disease. Finkelstein hypothesized that the entry of the muscle bellies of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons into the first extensor compartment was responsible for the findings observed in his now eponymous test.

Clinically Relevant Anatomy

• Extensor Pollicis Brevis (EPB)
• Radial abduction of wrist (0-25°)
• Thumb extension (90°)
• Abductor Pollicis Longus (APL)
• Wrist radial abduction (0- 25°)
• Thumb abduction (70°- 80°)

Purpose of Testing

• The Finkelstein test is used in the diagnosis of De Quervain’s syndrome. This fact implies a tenovaginitis and tenosynovitis of the M. extensor pollicis brevis and M. abductor pollicis longus. Finkelstein maneuver is a helpful test to diagnose De Quervain’s Tendonitis or first dorsal compartment tendonitis named after the Swiss surgeon Fritz de Quervain. This is a condition brought on by irritation or inflammation of the wrist tendons at the base of the thumb. The inflammation causes the compartment (a tunnel or a sheath) around the tendon to swell and enlarge, making thumb and wrist movement painful.

Testing Position

• Sitting or standing.

Technique

• To begin, the patient must sit comfortable and relaxed on the examination table. Next, examine the patients hand in the air, while the other hand rests just beside the body. The therapist then asks the patient to make a fist around a thumb and to perform a ulnar deviation.
• A modified version of the test is that the patient must sit comfortable and relaxed on the examination table. The patient must hold his afflicted hand in the air, while the other hand should be resting against his/ her body. The therapist grasps the afflicted hand of the patient and rotates it in ulnar deviation. He pulls the patient’s thumb across the palm of his/ her hand. This causes additional stress on the extensor tendons of the thumb. [1][2]
• The patient actively (or active assistive) flexes thumb maximally and wraps fingers over thumb, making a fist. The patient then ulnarly deviates his/her wrist to stretch the muscles of the 1st extensor compartment. The test is positive if the patient complains of pain over the 1st extensor compartment of the wrist.
• https://www.youtube.com/watch?v=eL2Uzfd26SA&feature=emb_logo

Question 38

Scaphoid shift test

Answer 38

Purpose

• The scaphoid shift test is a provocative maneuver used to examine the dynamic stability of the scaphoid and reproduce a patient’s symptoms. It is used to diagnose scapholunate interosseous ligament instability (SLIL).[1] Watson first described the test to the American Research in General Orthopedics conference in New Orleans in March 1978. The test is found helpful during the examination of the wrist and more specifically the scaphoid. Beside the stability, the examiner will also be able to reflect the quality of the adjoining articular surfaces.[2][3]

Clinically Relevant Anatomy

• The ligaments that are thought to provide the principle support to the scaphoid are the radioscaphocapitate ligament, the scaphoid-trapezoid-trapezium ligament and the scapholunate interosseous ligament. [4]
• The scapholunate interosseous ligament(SLIL) is the link between carpal scaphoid and lunate bone. It ensures stability of the scapholunate joint and helps keep the entire wrist stabilized.
• The scapholunate interosseous ligament is an intra-articular structure (ie, synovial) composed of three regions:[1][5]
• Dorsal ligament: transversely oriented collagen fibers providing primary restraint for distraction and torsional/translational movements
• Palmar ligament: provides rotational stability
• Proximal fibrocartilage: negligible contribution to restraint of abnormal motion

Technique

• To perform the scaphoid shift test, the patient should rest his arm with his elbow on the table and his forearm lifted. The examiner sits across the table and places his arm next to the patient’s arm (like in an arm wrestling position right to right or left to left). The patient’s hand is slightly pronated and the examiner places his thumb on the palmar side of the scaphoid (on the scaphoid tubercule), his other fingers are wrapped around the back of the wrist at the distal part of the radius. This will allow the examiner to put pressure on the scaphoid with his thumb. With his other hand the examiner holds the patient’s hand at the metacarpal level. [2][6]The hand is put into ulnar deviation and in slight dorsal flexion; in this position the scaphoid lies almost ‘in line’ with the ulna. From this position the hand is moved passively by the examiner into radial deviation and slight palmar flexion. Meanwhile a constant pressure is given by the thumb on the scaphoid tubercule. During the radial deviation and slight palmar flexion, the distal part of the scaphoid tilts forward and thereby pushes against the examiner’s thumb (which is pushing in the opposite direction) causing stress on the joints. [2][4][7]This stress is overcome in a normal wrist (minimal movement can be tolerated), but results in a dorsal displacement (‘shift’) of the scaphoid in relation to the other carpal bones in the wrist of a patient with ligamentous laxity. When the thumb force is then abruptly taken away the shift will be reduced and the scaphoid will fall back in its normal position, this may result in a painful ‘thunk’.[2] [6][7] It is important to perform this technique on both wrists and compare them.

Interpretation

• Positive test: A palpable and/or audible reduction of the subluxed scaphoid[1][2] and elicitation of symptomatic pain, usually on the dorsal side.[2]
• Negative test: Scaphoid moves normally, pushing back on the examiner’s thumb with ulnar deviation of the wrist, and there is no symptomatic pain.

https://www.youtube.com/watch?v=DGH-pHmeLnQ&feature=emb_logo

Question 39

Thumb
Grind test

Answer 39

Purpose

• The purpose of the Thumb CMC Grind Test is to assess the integrity of the thumb CMC joint. Reproduction of the patient’s pain and crepitus is a positive test for arthrosis and synovitis. Therapists must be aware of the crank test which both evaluates the joint quality and translational laxity, the distraction test where a pain response indicates joint inflammation and volar compression of the first metacarpal base which also indicates joint inflammation

Technique

• The grind test is performed by gripping the patient’s metacarpal bone of the thumb and moving it in a circle and loading it with gentle axial forces. A patient with thumb joint arthritis generally complains of a sudden sharp pain at the CMC joint which can also be associated with Crepitus[2]. This indicates a positive test