MSK Examinations

Question 1

Relationship between speed of knee swelling and pathology?

Answer 1

• Rapid (<30 mins) and severe –> haemarthrosis
• Less severe over 24 hours –> traumatic effusion (meniscal tear)
• Menisci are avascular – tears do not cause haemarthrosis

Question 2

What is knee locking? What causes it?

Answer 2

A block to full extension.

• Loose body – osteochondritis dissecans, OA or synovial chondromatosis
• Meniscal tear – especially bucket handle and anterior beak

Question 3

Aspects of ‘feel’ in knee exam?

Answer 3

• Temperature
• Effusion
  
  • Patellar Tap
  • Bulge/Ripple Test - empty suprapatellar, stroke medially then stroke laterally while watching medial side.
• Joint lines

Question 5

Full range of movement of knee?

Answer 5

Extension = 0

Flexion = 140

Question 6

Special tests for knee ligaments?

Answer 6

• Collateral ligaments
• Posterior sag (can cause false +ve anterior drawer)
• Anterior drawer
• Posterior drawer

Question 7

Special tests for knee menisici?

Answer 7

• Apley’s grind test
  
  • Patient prone with knee flexed at 90. Apply downward force and rotate internally/externally –> pain crepitus = +ve.
• McMurray’s test
  
  • Supine with knee fully flexed.
  • Medial men = external rotate foot, valgus force
  • Lateral men = internally rotate foot, varus force
• Squat test
  
  • Ask patient to squat, keeping feet and heels flat on the group. If they can’t, there is incomplete flexion on affected side à may be caused by tear of posterior horn of menisci

Question 8

Aspects of ‘look’ in hip examination?

Answer 8

• Assess gait
• General inspection; ask the patient to stand
• Front
  
  • Observe whether stance is straight
  • Whether shoulders are parallel to the ground and symmetrically over the pelvis
  • Hip, knee, ankle or foot deformity
  • Muscle wasting
• Side
  
  • Assess for stop or increased lumbar lordosis (may result from flexion contracture)
• Behind
  
  • Assess whether spine is straight or curved laterally (scoliosis)
  • Not relative positions of shoulders and pelvis and measure leg lengths
  • Assess whether there is any gluteal atrophy

Look for scars, sinuses, dressings or skin changes around the hip.

Question 9

Aspects of ‘feel’ in hip examination?

Answer 9

• Tenderness over greater trochanter suggests trochanteric bursitis
• Tenderness over lesser trochanter and ischial tuberosity is common in sporting injuries due to strains of ilipsoas and hamstring insertions respectively.

Question 10

Normal range of hip movements?

Answer 10

• Flexion = 0-120
• Abudction = 45
• Adduction = 25
• Internal/External rotation = 45 (with hip and knee flexed - foot medial = external, foot lateral = interal)
• Extension = (in prone position) 20 degrees

Question 11

Special tests for hip?

Answer 11

• Leg length
• Trendelenburg’s sign
• Thomas’ test

Question 12

Leg length in hip exam?

Answer 12

• Patient lies supine and stretches both legs out as far as possible equally to eliminate any soft-tissue contracture/abnormal posture.
• Measure with tape:
  
  • Umbilicus to medial malleolus = apparent length
  • ASIS to medial malleolus = true length
• Can do ‘block testing’ if leg is shorter
  
  • Ask patient to strand with both feet flat on ground
  • Raise the shorter leg using a series of blocks of graduated thickness until both iliac crests feel level.

Question 13

Trendelenburg’s sign?

Answer 13

• Stand in front of patient and palpate both iliac crests – ask patient to stand on one leg for 30 seconds
• Normally the iliac crest on the side with the foot off the ground should rise – test is abnormal is hemipelvis drops below horizontal
  
  • Caused by gluteal weakness or inhibition from hip pain, or structural abnormality of hip joint.

Question 14

Thomas’ test?

Answer 14

• Measures fixed flexion deformity, which may be masked by compensatory movement at lumbar spine or pelvis and increasing lumbar lordosis
  
  • Contraindication = Do not perform if patient has hip replacement on non-test side – forced flexion may cause dislocation
• Patient lies supine on couch.
• Place left hand palm under lumbar spine – passively flex both legs (hips and knees) as far as possible. Keep non-test hip maximally flexed and by feeling with left hand confirm that the lordotic curve of lumbar spine remains eliminated.
• Ask patient to extend the test hip. Incomplete extension in this position indicates fixed flexion

Question 15

Where do you need to palpate for Ottowa ankle rules?

Answer 15

1. Both malleoli
2. Navicular
3. Base of 5th metatarsal

Question 16

Range of movements of foot/ankle?

Answer 16

Dorsi = 45 degrees

Plantar = 15 degrees

Inversion = 20 degrees

Eversion = 10 degrees

Question 17

Where to feel in shoulder exam?

Answer 17

• Feel for joint temperature.
• Feel from sternoclavicular joint along clavicle to acromioclavicular join
• Palpate acromion and coracoid (2cm inferior and medial to clavicle tip) processes, the spine/borders of the scapula and biceps tendon in bicipital groove.
• Extend the shoulder to bring supraspinatus anterior to acromion process. Palpate its tendon.

Question 18

Screening test for movement in shoulder exam?

Answer 18

• Stand behind patient
• Ask patient to put both hands behind head and push elbows back as far as they’ll go.
• Then put the arms down and reach behind back to touch shoulder blades

If there is pain, swelling, or limitation of movement à examine fully

Question 19

Normal range of movements of shoulder?

Answer 19

Flexion = 180 degrees

Extension = 60 degrees

Abudction = 180 degrees

Adduction = 45 degrees

External rotation = 70-80 degrees

Internal rotation (feeling as high up the spine as possible) = T5

Question 20

Special tests in shoulder exam?

Answer 20

1. Rotator cuff
   
   • Abducting arm against resistance
2. Inpingement (painful arc)
   
   • Patient actively abducts arm - pain between 60 and 120 degrees = impingement of subscapularis tendon under acromion.
3. Infrapinatus/Teres minor
   
   • External rotation against resistance with arm in neutral position and shoulder flexed 30 degrees
4. Lift off test
   
   • Isolates subscapularis - “Place back of hand on small of the back and push out against my hand”