MSK Exam LE

Question 1

Special tests for hip pathology

Answer 1

• Hip scour test: looks for DJD, supine with hip flexed & adducted, move into abduction while maintaining flexion, may add compressive load
• Patrick FABER test: identifies dysfunction of hip, supine passively flex, abduct, & ER leg so foot is resting just above knee on opposite leg; slowly lower leg down to table

Question 2

Special tests for hip labral lesions

Answer 2

• FADDIR/FADIR test: identifies anterior superior impingement, iliospoas tendinopathy, & anterior labral tear
• Supine, take involved limb passively into full flexion, abduction, & ER then into a full flexed, adducted, and IR position

Question 3

Muscle length tests for the hip

Answer 3

• Thomas test: identifies tightness of hip flexors; supine with one leg maximally flexed while the other remains flat on the table
• Ober’s test: identifies tightness of the TFL & IT band; sidelying with lower limb flexed, passively extend & abduct testing limb & slowly lower limb toward table
• Ely’s test: identifies tightness of rectus femoris; prone & flex knee; pos. if hip of tested limb flexes
• 90-90 HS test:identifies tightness of HS; poos. if knee lacks 10º or greater of knee extension
• Piriformis test: supine, foot of tested limb passively placed lateral to opposite limb’s knee with tested hip adducted; pos. if unable to pass over rested knee
• Trendelenburg sign: identifies gluteus medius weakness, stand on one leg; pos. if ipsilateral hip drops when lower limb support is removed while standing

Question 4

Difference between a true versus functional leg length discrepancy

Answer 4

• True: caused by an anatomical difference in bone lengths (either tibia or femur)
• Functional: not anatomical in origin and are the result of compensation due to abnormal position or posture

Question 5

How to measure for a leg length discrepancy

Answer 5

• Supine with pelvis aligned with lower limbs & trunk
• Measure distance from ASIS to lateral malleolus or medial malleolus on each limb several times for consistency & compare results
• Unequal girths of thigh musculature can skew results if measuring to medial malleolus
• A difference in measurements indicates a true leg length discrepancy

Question 6

Describe the patellar-pubic percussion test

Answer 6

• Identifies for a hip fracture
• Supine, examiner percusses each patella separately while auscultating the pubic symphysis with a stethoscope
• Pos. test is decreased percussion note on the affected side

Question 7

Special tests for anterior knee instability

Answer 7

• Lachman: test ACL, supine with knee flexed 20-30º, stabilize femur & passively translate tibia anteriorly
• Anterior drawer test: test ACL, supine with hip flexed to 45º and knee flexed 90º; passively translate tibia anteriorly

Question 8

Special tests for posterior knee instability

Answer 8

• Posterior drawer test: test PCL, supine hip flexed 45º and knee flexed 90º, passively translate tibia posteriorly
• Posterior sag sign: tests PCL, supine hip flexed 45º and knee flexed 90º, observe to see whether the tibia “sags” posteriorly

Question 9

Special tests for medial-lateral instability of the knee

Answer 9

• Valgus stress test: test MCL, supine apply a medial stress at the knee both at 0º and 30º of knee flexion
• Varus stress test: test for LCL, supine apply a lateral stress at the knee both at 0º and 30º oof knee flexion

Question 10

Describe the pivot shift test

Answer 10

• Test ACL
• Supine with knee extended and hip flexed/abducted 30º with slight IR
• Hold knee with one hand and foot with the other
• Place a valgus force through knee and flex knee
• Pos. if tibia relocates during the test, as knee is flexed tibia clunks backward at ~30-40º

Question 11

Special tests for meniscus tear

Answer 11

• McMurray test: supine with knee maximally flexed, passively IR and extend the knee (test lateral meniscus) and passively ER and extend the knee (test medial meniscus)
• Thessaly test: standing on symptomatic leg holding examiners hands, pt rotates body/leg IR and ER with he knee flexed 5º and at 20º

Question 12

Describe the patellar apprehension test

Answer 12

• Test for patellofemoral instability
• Supine, knee flexed to 30º, quads relaxed
• Passively translate patella laterally
• Pos. if pt expresses apprehension or contracts quads to prevent patella from dislocating

Question 13

Describe the patellar tilt test

Answer 13

• Supine with knee extended
• Lift lateral edge of patella from the lateral femoral condyle
• Pos. if patella is not able to be lifted to at least a neutral angle with respect to the horizontal plane

Question 14

Describe the noble compression test

Answer 14

• Test for IT band friction syndrome
• Supine, knee flexed 90º with hip flexion
• Apply pressure 1-2cm proximal to lateral femoral condyle
• With pressure maintained passively extend pt’s knee
• Pos. if pt experiences pain over the lateral femoral condyle

Question 15

Describe the brush (stroke) test

Answer 15

• Test for swelling
• Supine, knee in full extension
• Start at medial tibiofemoral joint and stroke upward 2-3x toward the supra patellar pouch
• Then stroke downward on the distal lateral thigh just superior to the supra patellar pouch toward lateral joint line
• Pos. if fluid is observed on the medial knee

Question 16

What is the grading scale for the brush (stroke) test

Answer 16

• 0 = no wave produced on down stroke
• Trace = small wave
• 1+ = larger bulge
• 2+ = spontaneous return after upstroke
• 3+ = unable to move effusion out of medial knee

Question 17

What are the Ottawa knee rules for referral for an x-ray

Answer 17

• All OR statements
• Age >55
• Isolated patellar tenderness without other bony tenderness
• Tenderness of the fibular head
• Inability to flex knee to 90º
• Inability to bear weight immediately after injury & in the emergency department

Question 18

Special tests for ankle instability

Answer 18

• Anterior drawer test: test anterior talofibular ligament; supine foot off edge of table & ankle in 20º PF; translate talus anterior while stabilizing the lower leg
• Talar tilt: test calcaneofibular ligament; sidelying knee slightly flexed & ankle in neutral; move foot maximally into adduction and abduction (deltoid lig.)
• Medial subtalar glide test: hold talus in subtalar neutral with one hand and translate the calcaneus medially on the fixed talus with the other hand

Question 19

Special tests for syndesmosis instability

Answer 19

• ER stress (Kleiger) test: test distal tibiofibular syndesmosis; seated knee flexed 90º & ankle in neutral; apply ER force to foot while holding tibia in neutral; pos. if visible joint gapping
• DF ER stress test: test distal tibiofibular syndesmosis; seated knee flexed 90 and ankle in max DF; apply ER force to foot while holding tibia in neutral; pos. if visible joint gapping
• Squeeze test: test distal tibiofibular syndesmosis; seated knee flexed 90º; apply compression b/w middle & distal 1/3 of pt’s leg; pos. if pain reproduced at syndesmosis

Question 20

Describe the Thompson’s test

Answer 20

• Test for achilles rupture
• Prone with foot off edge of bed
• Squeeze calf muscle, ankle should PF under normal conditions
• Pos. if no movement of foot occurs while squeezing calf

Question 21

Special tests for plantar fasciitis

Answer 21

• Windlass test: pain with extension of the great to and ankle DF
• Weight bearing test: stay on step with toes positioned over the edge & equal WBing; passively extend the pt’s 1st MTP
• Non-weight-bearing test: seated with knee flexed 90º; stabilize ankle & passively extend the pt’s 1st MTP
• Pos. is reproduction of plantar surface symptoms

Question 22

What are the Ottawa ankle and foot rules for referral for x-ray

Answer 22

• Do NOT use on patients under 18 years of age
• X-ray required if any pain in the malleolar zones and any of the following
• Bone tenderness from posterior edge/tip of lateral malleolus extending 6cm proximally
• Bone tenderness from posterior edge/tip of medial malleolus extending 6cm proximally
• Inability to take 4 complete steps both immediately & in the emergency department
• Bone tenderness at base of 5th metatarsal
• Bone tenderness of navicular