Examining joints Flashcards
What causes a waddling gait (Trendelenburg gait)?
- loss of hip abductor function / weak gluteus medius
What causes an antalgic gait (painful limp)?
- caused by any painful condition (patient tries to offload the painful limb by quickening and shortening the weight-bearing stance phase of the gait cycle)
What causes a short-leg gait (dipping off shoulder on affected side)?
- any condition causing significant leg discrepancy
What causes a high-stepping gait (knee is flexed and foot is lifted high to avoid foot dragging on floor)?
- nerve palsy (peroneal or sciatic)
- sometimes called foot drop
What causes a stiff knee gait (knee cleared of floor by swinging out away from the body)?
- fusion of knee
What are the main steps to an examination?
- LOOK: check for swelling, muscle wasting, scars, erythema, and deformity
- FEEL: palpate the joint, noting any effusions, tenderness, and heat
- MOVE: demonstrate joint movement actively and passively
- SPECIAL TESTS
- note: also examine joints above and below
Lower limb dermatomes…
Reflexes tested…
- knee: L3-L4
- ankle: L5-S1
- plantar
Upper limb dermatomes…
Reflexes tested…
- biceps: C5-C6
- triceps: C7
- brachioradialis: C6-C7
Vertebral column diagram…
Testing lower-limb muscle function (myotomes)…
Nerve roots tested : muscle action
- L1, L2 : hip flexion (iliopsoas)
- L3 : knee flexion (quadriceps)
- L4 : ankle dorsiflexion (tibialis anterior)
- L5 : great toe extension (extensor hallucis longus)
- S1 : ankle plantar flexion (soleus/gastrocnemius)
Testing upper-limb muscle function (myotomes)…
Nerve roots tested : muscle action
- C5 : shoulder abduction
- C6, C7 : shoulder adduction
- C5, C6 : elbow flexion
- C7, C8 : elbow extension
- C6, C7 : wrist flexion / extension
- C7, C8 : MCP/IP flexion/extension
- T1 : MCP abduction/adduction
How do you measure true-leg length in a hip examination?
- measure both limbs from ASIS (anterior-superior iliac spine) to medial malleolus and compare the values
- (note: apparent leg length is belly button to medial malleolus)
What does tenderness over the greater trochanter indicate?
- trochanteric bursitis
What movements are tested in a hip examination?
- hip flexion / extension
- hip abduction / adduction
- hip internal / external rotation
What special tests are carried out in a hip examination?
- Thomas’ test (test for fixed flexion deformity): patient positioned supine, opposite hip is flexed fully, lordosis is felt, if extended hip lifts off couch then positive test
- Trendelenburg test (test for weak hip abductors / weak gluteus medius): patient holds onto your hands and lifts leg off ground, if hip tilts down then positive test for opposite leg
What are you looking for in an examination of the knee?
- quadriceps wasting (measure thigh circumference)
- note any effusions, scars, erythema, or evidence of psoriasis
- varus/valgus deformities
Why do we palpate the posterior aspect of the knee in a knee examination?
- a Baker’s cyst or bursa may be present
What movements are tested in a knee examination?
- knee flexion/extension (feel for patella crepitus)
- note any fixed flexion or hyperextension of the knee
What special tests are carried out in a knee examination?
- patellar tap test (test for effusion): fluid pushed from suprapatellar pouch, if patellar bounces then +ve
- swipe test (test for effusion): more sensitive to smaller effusions
- anterior/posterior draw test (ACL/PCL)
- (posterior sag: tibia falls posteriorly if PCL ruptured)
- lateral/medial collateral ligaments
What are you looking for in an ankle/foot examination?
- erythema, swelling, scars
- any evidence of psoriatic changes to nails and skin
- note: synovitis of ankle usually produces diffuse swelling (lateral and medial malleoli contours not clear)
- flat feet (Pes planus): can cause valgus deformity of the heel
- hallux valgus: deformity of great toe (abducted at MTP joint)
What movements are tested in an ankle/foot examination?
- inversion/eversion (subtalar joint)
- plantar flexion and dorsiflexion: midtarsal joint
- inversion/eversion: midtarsal joint (stabilise heel and move foot)
- movements of MTP, PIP, and DIP joints should also be tested
What special test is performed in an ankle/foot examination?
- squeeze patient’s calf to check for Achilles tendon rupture
- +ve test: foot does not plantar flex
What are you looking for in a spinal examination?
- patient’s posture: check for cervical lordosis, thoracic kyphosis, and lumbar lordosis
- muscle wasting, asymmetry, scoliosis (scoliosis more clearly seen when patient bends over)
What are we feeling in a spinal examination?
- spinous processes
- paraspinal muscles
- sacroiliac joints
What movements do we do for cervical spine examination?
- cervical spine flexion/extension
- cervical spine lateral flexion
- cervical spine rotation
What movements do we do for thoracolumbar examination?
- thoracolumbar flexion/extension
- thoracolumbar lateral flexion
- thoracolumbar rotation
What special test do we perform in a spinal examination (tests for nerve root irritation/radiculopathy)?
- straight-leg raise
- with patient supine, elevate affected leg passively (keeping it straight)
- next step is to bend the knee (this will relieve tension on the nerve so symptoms should go away)
- if pain radiates to foot then positive test (indicated nerve radiculopathy, eg. sciatica)
What do we look for in a shoulder examination?
- patient’s posture and any asymmetry
- muscle wasting: can be due to nerve pathology, rotator cuff tendinopathy, or chronic disuse
- any swelling, scars, erythema
What do we palpate in a shoulder examination?
- palpate sternoclavicular, acromioclavicular, glenohumeral joints, and clavicle
- feel joint temperature
- any tenderness in surrounding muscles
What movements do we assess in a shoulder examination?
- shoulder flexion/extension
- shoulder abduction/adduction
- shoulder internal/external rotation
- (note: hands on head with elbows back tests shoulder flexion, abduction, and external rotation)
- (note: hands behind back on thoracic area tests shoulder extension, adduction, and internal rotation)
What does loss of passive shoulder extension and abduction?
- adhesive capsulitis (frozen shoulder)
- note: frozen shoulder is an unknown disease (thought to be inflammation of the synovium within the shoulder joint which causes stiffness)
What does scapular winging indicate in a shoulder examination?
- scapula winging is a common sign of serratus anterior dysfunction, caused by damage to the long thoracic nerve
Serratus anterior and long thoracic nerve diagram…
What 4 muscles make up the rotator cuff?
- supraspinatus
- infraspinatus
- teres minor
- subscapularis
What is the ‘painful arc’ in a shoulder examination?
- shoulder abduction (between 60 and 120 degrees)
- pain indicates supraspinatus impingement
How do you test the rotator cuff muscles?
- supraspinatus: empty can test (Jobe’s test)
- subscapularis: resisted internal rotation
- infraspinatus / teres minor: resisted external rotation
What does the scarf test in shoulder examination test?
- acromioclavicular joint injury
The elbow consists of two articulations, one provides elbow flexion/extension, the other allows wrist rotation of the wrist through 180 degrees, what are they?
- first is between humerus, radius, and ulna
- second is the superior radioulnar joint
What are you looking for in an elbow examination?
- scars, swelling, erythema, muscle wasting
- rheumatoid nodules, psoriatic plaques, olecranon bursitis
What are you feeling in an elbow examination?
- olecranon process, radial head, ulnar head
- medial epicondyle tenderness: golfer’s elbow
- lateral epicondyle tenderness: tennis elbow
What movements are assessed in an elbow examination?
- elbow flexion/extension
- pronation/supination (palm down, palm up respectively)
- note: also check for hyperextension
How do you test for tennis elbow and golfer’s elbow?
- resisted wrist extension pain: tennis elbow
- resisted wrist flexion pain: golfer’s elbow
- (note; tenderness over lateral epicondyle is tennis elbow, tenderness over medial epicondyle is golfer’s elbow)
What are you looking for in a hand/wrist examination?
- skin: psoriasis, nodules, scleroderma (skin tightening)
- nails: pitting, onycholysis (psoriatic changes), splinter haemorrhages in vasculitis
- joints: deformity/swelling, OA (DIP/PIP joints affected), RA (PIP/MCP joints affected)
- muscles: thenar wasting (suggests carpal tunnel syndrome), hypothenar wasting (suggests cubital tunnel syndrome), dorsal interossei wasting (seen in RA)
What do we assess in the feel aspect of a wrist/hand examination?
- palpate wrist joint, MCP, PIP, DIP joints
- MCP squeeze
- palpate anatomical snuff box
- check sensation of radial, median, and ulnar nerve distributions
What movements do we assess in a hand/wrist examination?
- wrist flexion/extension (prayer sign and opposite respectively)
- finger flexion/extension (ask patient to make a fist)
- finger abduction/adduction
How do you put tension on the radial, median, and ulnar nerves to test function?
- radial: wrist/finger extension against resistance
- median: thumb abduction against resistance
- ulnar: finger abduction against resistance
What special tests are performed in a hand/wrist examination?
- Tinel’s test: tap on wrist over carpal tunnel
- Phalen’s test: hold wrist flexion for 60 seconds
- assess power grip
- assess pincer grip
- assess picking up a small object
What peripheral pulses can you palpate in the upper limb?
- radial pulse
- ulnar pulse
What peripheral pulses can you palpate in the lower limb?
- dorsalis pedis
- posterior tibial
What is the terrible triad?
- ACL (anterior cruciate ligament)
- MCL (medial collateral ligament)
- meniscus
Does being hypermobile affect knee replacement surgery?
- yes
- often the surgery will make the joint more stable but will cause more pain for the patient
What does localised weakness suggest and what does generalised weakness suggest?
- localised: peripheral nerve lesion
- generalised: systemic cause
What muscle is responsible for hip flexion?
- iliopsoas
what muscle is responsible for knee flexion?
- quadriceps
What muscle is responsible for ankle dorsiflexion?
- tibialis anterior
What muscle is responsible for great toe extension?
- extensor hallucis longus
What is a common way for true hip pain to present in a patient?
- true hip pain is often felt in the groin and may radiate to the knee on movement
Depuytren’s contracture…
- thickening of the connective tissue in the hand (often forming nodules)
What is De Quervain’s tenosynovitis?
- De Quervain syndrome is mucoid degeneration of two tendons that control movement of the thumb and their tendon sheath
- this results in pain and tenderness on the lateral (radial) aspect of the wrist
What is Finklestein’s test?
- test for De Quervain’s tenosynovitis
- examiner ulnar deviates the hand/wrist and pain will be felt on the radial side of the hand/wrist
