Joint Examination

Question 1

What should be inspected for in a joint exam?

Answer 1

Wasting (assess muscle bulk)

Asymmetry

Redness

Deformity/alignment (varus vs valgus, others)

Swelling (confirm with palpation to determine if soft, firm or hard), scars (from injury and/or surgery)

Question 2

When might a swelling be soft vs firm vs hard?

Answer 2

Soft: synovitis, fluid

Firm: tophus, nodule

Hard: bone

Question 3

What is lateral epicondyle tenderness suggestive of?

Question 4

What does tenderness over the achilles tendon suggest?

Answer 4

Achilles tendonitis

Question 5

What does the Trendelenberg test assess?

Answer 5

Abductor weakness at hip

Question 6

What does the Thomas test assess?

Answer 6

Fixed flexion deformity of hip

Question 7

What should be looked for on observation in the hip exam?

Answer 7

Gait: limp (antalgic gait), Trendelenberg gait, other abnormality

Muscle wasting: are the gluteal, quadriceps, hamstring muscles wasted or is there asymmetry of muscle bulk

Tredelenberg test: positive or negative

Question 8

How is the Trendelenberg test performed and interpreted?

Answer 8

Doctor stands behind the patient and observes the line between the iliac crests

Patient asked to lift one leg off the ground (non-stance leg) to test the leg remaining on the ground (stance leg)

Once patient is balanced they are asked to lift the leg as high as possible and hold this position for 30 seconds

Negative test (normal): patient can hold non-stance leg flexed for 30 secs and the iliac crest on the non-stance side is higher than the stance side

Positive test (abnormal): unable to achieve or maintain position

Interpretation: generally weakness of hip abductor muscles on stance side often associated with OA of that hip

Question 9

How should adduction and abduction be tested?

Answer 9

With pelvis stabilised

Question 10

How should the Thomas test be performed and interpreted?

Answer 10

Detects fixed flexion deformity of the hip

Place your hand in the mid lumbar region of the patient’s back

Fully flex the R hip (this should remove the normal lumbar lordosis and put pressure on your hand)

If there is no fixed flexion deformity of the L hip it should remain in the same position on the couch

If there is a fixed flexion deformity the L hip will flex and lift off the couch

Repeat on the other side

Question 11

What is the difference between apparent and true leg length?

Answer 11

Apparent: measure from umbilicus to medial malleolus

True: measure from ASIS to medial malleolus

Question 12

Mrs MH, 54 year old woman, presents with progressively worsening R knee pain over 2 years; now has significant pain walking 100m

Is overweight but has not injured her knee

Likely Dx? What features O/E would support this?

Answer 12

OA

Look: varus angulation (suggesting medial compartmental cartilage loss in knee), quadriceps wasting (suggesting chronic knee pathology), possibly a small knee effusion

Feel: tenderness over medial joint line, a small effusion (bulge test positive)

Move: some restriction of ROM is likely with pain on movement

Special tests: medial collateral ligament test may be lax due to loss of cartilage in medial compartment, other tests may not be useful

Question 14

What are the basic steps of the shoulder examination?

Answer 14

Should include assessment of glenohumeral and acromioclavicular joints, tendons and ligaments

Look for wasting, effusion anterior to joint

Feel for AC joint, subacromial (supraspinatus) and tendon of long head of biceps tenderness

Move (abduction, adduction, flexion, extension, internal and external rotation)

Question 15

Mrs FG, 45 year old woman, presents with L shoulder pain on movement; this pain has been present since her arm was “wrenched forward” by her dog 2/12 ago

She currently as trouble doing up her bra and hanging out the washing

What does this suggest? What findings O/E would support this?

Answer 15

Hx suggests rotator cuff injury

Look: affected shoulder may be higher than unaffected shoulder (non-specific)

Feel: may be tenderness at site of supraspinatus insertion

Move: movement may be restricted but key sign is presence of pain in adduction/abduction

Question 16

Mrs MT, 34 year old woman with RA arthritis for 3 years, has recently been started on a new treatment (etanercept, a TNF inhibitor) and returns for r/v

Joint pain has substantially improved

What features O/E would suggest improvement in her RA activity?

Answer 16

Compare number and location of swollen joints at commencement of new therapy with current swollen joint count

Question 17

Compare the pattern of joint involvement in RA vs OA

Answer 17

Question 18

What is GALS?

Answer 18

Rapid MSK screening examination

Gait, Arms, Legs, Spine

Question 19

Describe the steps in the GALS examination

Answer 19

Gait: assess for symmetry and smoothness as well as ability to turn around quickly

With 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

In anatomical position, inspect for shoulder muscle bulk, elbow extension, quadriceps muscle bulk and symmetry, knee swelling and deformity, foot arches, any midfoot or forefoot deformity

Lateral flexion of cervical spine is performed, followed by assessment of the temporomandibular joints

Examine from the side, looking for normal cervical lordosis, thoracis kyphosis, lumbar lordosis and evidence of knee flexion or hyperextension

Asking 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

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 palms of hands for muscle bulk and other visual abnormality