Musculoskeletal system

Question 1

MSK Ass: typical symptoms; specific x 9, gen* x 5, & Red Flags x 6

Answer 1

Specific symptoms:
- pain - differentiate between pain & tenderness
- swelling - diffuse or localised
- stiffness
- deformity
- weakness
- instability
- loss of function
- altered sensation
- colour changes

General:
- fatigue/malaise
- generalised weakness
- depression & fear
- sleep disturbances
- symptoms of systemic Dx

Red Flags:
- weight loss
- fever
- temporal headache or pain with scalp tenderness or visual disturbances
- loss of sensation
- loss of motor function
- difficulties in urination/defecation

Question 2

MSK Ass: Hx x 7

Answer 2

Hx:
- mechanism of injury
- time of injury
- hand dominance
- employment
- fasting status
- insurance
- ADT immunisation status

Question 3

MSK Ass: gen* approach x 5

Answer 3

LOOK - swelling, range, deformity, muscle wasting, skin changes at rest & w movement

FEEL - tenderness, swelling, deformity, crepitus w movement, & temp

MOVE - actively, then passively & against resistance to see if differences - range, pain, stability & any crepitus to be noted

FUNCTION - assess gen* function; test strength & common functions

SPECIAL TESTS - specific to certain joints - also assess joint above & below an injury

Question 4

REMS; standing: cervical spine, TMJ, & spine

Answer 4

Cervical spine:
- Look - at posture
- Feel - vertebrae for tenderness; palpate paraspinal muscles for spasm/tenderness
- Move - head in all directions w Ex supporting each movement
Do NOT test if post-trauma or instability suspected

Temporomandibular Joint (TMJ):
- Feel - over joint for tenderness or crepitus/clicking during movement
- Move - open mouth wide & deviate jaw from side to side

Spine:
- Look - spinal posture for asymmetry of the scapulae, pelvic girdle, or crease in buttocks
- Feel - down spinous processes to confirm posture, percuss vertebrae for tenderness & palpate paraspinal muscles for spasm/tenderness
- Move - perform a range of movements & note pain, discomfort, stiffness or reduced ROM

Question 5

REMS; standing: upper limbs

Answer 5

Shoulder:
- Look - asymmetry of scapulae or posture & muscle wasting
- Feel - over midpoint of each trapezius & supraspinatus to identify tenderness
- then check other bony prominences & joints
- Move - full ROM tests

Elbow:
- Look - swelling/deformity
- Feel - para-olecranon groove for synovial swelling & tenderness
- then palpate medial & lateral epicondyles for tenderness
- Move - actively, then passively extend & flex elbow & look for hyperextension

Wrist:
- Look - swelling/deformity
- Feel - over joint line for tenderness or synovial swelling
- Move - actively, then passively, looking for ROM, pain & tenderness

Hand:
- Look - swelling/deformity & examine skin & nails
- Feel - over each joint line for tenderness & bony or synovial swelling
- Move - ask Pt to make a fist & actively punch into their other hand
- Note hand dominance
- Neurovascular assessments;
- median, radial, ulnar innervation/sensation
- radial/ulnar arterial supply

Question 6

REMS; standing: lower limbs

Answer 6

Lower limbs:
- hip, pelvis & sacroiliac joints
- look for symmetry of the pelvic girdle
- look for muscle wasting
- observe Pt whilst walking
- Feel - hold the pelvis & ask Pt to stand on one leg to establish if any dropping of pelvis (Trendelenburg’s test; glut* med* tendinopathy/superior glut* nerve palsy)
- Palpate - to clarify the origin of any symptoms, including over the sacroiliac joints & greater trochanter of femurs

Question 7

REMS; laying: hip, pelvis, & sacroiliac joints

Answer 7

Hip, pelvis & sacroiliac joints:
- Pt supine; actively, then passively flex hip as far as possible
- w hip flexed at 90; rotate internally & externally
- leg fully extended; hold the contralateral anterior superior iliac spine to prevent movement of pelvis & passively Adduct & Abduct legs
- Pt prone/lateral; passively extend the straightened leg if poss
- stress the sacroiliac joints by pressing down on flexed knee & hip while simultaneously holding one hand over the joint (??)
CAUTION: elderly Pt 2-3 days post fall; increased urinary freq, bruised inner thighs = likely pubic rami # (non-weight-bearing = consider both pubic rami)

Question 8

REMS; laying: knee & lower leg

Answer 8

Knee:
- Look - at Pt walking, look at quads for wasting, swelling, deformity
- Feel - tenderness/swelling
- Palpate - joint line w knee flexed for tenderness
- Palpate - tibial tubercle & collateral ligaments
- Assess - articulate swelling & effusion
- Check patella for stability & alignment
- Pt Supine; actively & then passively; flex knee as far as poss* w hip in flexion & extend so that it may touch the couch/bench
- Test quad strength
- Test anterior & posterior stability to assess the cruciate ligaments & loss of joint space
- Consider Ottawa knee rules for X-ray

Lower leg (tibia/fibula):
- compare bilaterally
- Look - for erythema, swelling, bruising, discolouration, clinical deformity
- musculature should be symmetrical
- any calf tenderness?
- can the Pt weight bear?

Question 9

REMS, laying: foot & ankle

Answer 9

Foot & ankle:
- Look - the feet when standing & walking for normal longitudinal arch
- Look - for normal heel strike & take off
- Look - any callouses beneath the metatarsal heads
- Look - any swelling of toes & any other deformities
- Feel - tenderness/swelling
- Palpate- malleoli
- Palpate - Achilles tendon insertion & beneath calcaneum
- Squeeze - across metatarsus for tenderness
- Move - actively, then passively, flex & extend ankle
- Consider Ottawa ankle rules for X-ray

Question 10

GALS: screening Qs x 3

Answer 10

Do you suffer from any pain or stiffness in your arms, legs, neck or back?

Do you have any swelling over any of your joints?

Do you have any difficulty with going up or down stairs?

Question 11

GALS: screening exam & standing Pt

Answer 11

Gait:
- observe Pt walking forward a few meters, turning & walking back
- recognise any abnormalities during walking phase
- look for abnormalities in movement of; arms, pelvis, hips, knees, ankles & feet

Inspection of standing Pt:
- View - Pt from front, back & sides
- Look - for abnormalities of posture & symmetry
- Apply - pressure over the midpoint of each supraspinatus & roll an overlying skin fold to examine tenderness (??)

Question 12

GALS: spine, arm, & legs

Answer 12

Spine:
- Ask - Pt to flex their neck laterally, from side to side
- Palpate - over spinous processed when asking Pt to lean forwards
- Observe - normal movement & feeling for the expansion of the spinous processes space

Arms:
- Ask - Pt to place both hands behind their head & move their elbows right back
- Ask - Pt to straighten arms down the side of the body
- Ask - Pt to bend elbows at 90* w palms down & fingers straight
- Ask - Pt to supinate hands, make a fist w each, then in turn place the tip of each finger onto to tip of the thumb (on each hand)
- Squeeze - metacarpals & look for tenderness

Legs:
- Pt to recline on couch/bench
- Flex each hip & knee whilst holding & feeling the knee
- Passively rotate hip internally
- w leg extended & resting on couch; press down on patella whilst cupping it proximally & examine for tenderness/swelling
- Squeeze - all metatarsals & inspect the soles of feet for callouses

Question 13

MSK Management General

Answer 13

Basics still: splinting, elevation, ice PRN & analgesia

Pain relief: good combo is paracetamol & oxycodone (rather than panadeine forte!)

Septic arthritis: can affect any joint, at any age, more common in children
- generally develops over hours to days & can rapidly destroy a joint structure
- Dx by blood culture & synovial joint analysis & culture
- if suspected: REFER immediately

Carpal bones: in particular, the scaphoid, indicated by snuffbox tenderness; REFER w any suspicion

Question 14

Ottawa Knee rules x 5

Answer 14

Aged >/= 55yo

Tenderness at the head of the fibula

Isolated tenderness of the patella

Inability to flex knee to 90*

Inability to weight bear (4 x steps, two steps on each leg, regardless of limping) immediately And @ presentation

Question 15

TMJ: subjective exam x 6 & palpate x 3

Answer 15

Subjective exam:
- nature & location of complaint
- any pain travelling to head or down towards arms
- behaviour, timing & effect of pain on Pt
- any trauma to the TMJ
- any pain or clicking when mouth is open
- review any dental issues or habits

Gentle palpation:
- Pt sitting; gentle pressure is all that’s req to ascertain tenderness
- investigate; localised eff*, discolouration, open sinuses, drainage, incisional areas, body contours & alignment, uncle girth & symmetry
- Palpating posterior; easier w Pt supine

Question 16

TMJ: Posterior aspects bony x 2, soft x 6

Answer 16

Palpate bony structures:
- mastoid process
- transverse processes of C1

Palpate soft tissue structures:
- trapezius
- suboccipital muscles
- semi spinal is cervicis & capitis
- greater occipital nerve
- ligamentum nuchae
- levator scapulae

Question 17

TMJ: anterior aspects; bony x 5 & soft x 6

Answer 17

Palpate bony structures:
- mandible
- teeth
- hyoid
- thyroid
- cervical spine

Palpate soft tissue structures:
- temporalis
- lateral & medial pterygoid
- masseter
- sternocleidomastoid muscle
- scaleni muscles
- suprahyoid muscle

Question 18

TMJ: active movement test x 3(6)

Answer 18

Active movement testing:
- Pt sitting; observe their neck & upper thoracic spine
- Observe; from all 4 views: anterior, posterior, & both laterals
- Full cervical movement exam: forward & backward bending, lateral bending, rotation, tucking chin to chest, & active movement of upper thoracic spine

Question 19

TMJ: passive movement test; physio* x 6 & mob* x 3

Answer 19

Physiological movements:
- Pt sitting
- place one hand on top of head w palm over forehead
- other hand grasps Pt’s occiput
- perform passive movements as per active ( x 6)
- assess for limitation in movement/pain
- DO NOT perform if neck injury suspected

Mobility testing:
- testing of accessory movements; joint play and components
- it will give a degree of laxity or hypomovement present in a joint at the end feel
- one of the tests is the distraction of the TMJ

Question 20

TMJ: resistive x 2 & reflexive x 2 testing

Answer 20

Resistive testing:
- Pt sitting; put resistance for jaw opening & closing
- Pt will normally be able to overcome max resistance

Reflective testing:
- 5th cranial nerve mediates jaw reflex (trigeminal)
- Ask Pt to relax jaw, mouth slightly open; place 3rd & 4th digits under lip & tap fingers w reflex hammer = normal response; jaw closes

Question 21

Shoulder: exam: look ant* x 4, lat* x 3, & post* x 4

Answer 21

Exam:
- explain process & gain consent; exposure upper body
- Pt standing; ask if they have any pain

LOOK
Anterior:
- scars - prev surg/trauma
- asymmetry of shoulder girdle; scoliosis/arthritis/trauma
- swelling; inflam* joint Dx/effusion
- muscle wasting; deltoids, Axillae nerve injury or chronic joint Dx

Lateral:
- scars - as above
- muscle wasting; deltoid
- alignment of should girdle; misalignment, dislocation/scoliosis

Posterior:
- scars - as above
- trapezius; symmetry or wasting
- para-vertebral muscles; swelling or wasting
- scapula; symmetry

Question 22

Shoulder: Feel x 2 & Move x 6

Answer 22

FEEL:
- assess temp; warmth suggests inflam* or inf*
- palpate various bony components; note any swelling/tenderness

MOVE:
- Flexion - ask Pt to raise arms forward until they point upwards (150-170)
- Extension - ask Pt to arms straight & extend them behind them (40)
- Abduction - ask Pt to lift arms away from sides (160-180)
- Adduction - ask Pt to bring arms across their trunk to opposite sides (30-40)
- External rotation - as Pt to hold elbows by sides @ 90* & move forearms only outwards (70)
- Internal rotation - w Pt’s elbow flexed @ 90 & arm by side, ask to reach down their back, behind their head (T5, mid scap* level Avg)

Question 23

Shoulder: scapula movement active & passive

Answer 23

Active movement:
- ask Pt to abduct shoulder & simultaneously Palpate inferior pole of scapula
- assess degree & smoothness of movement; normally 50-70% occurs at glenohumeral head

Passive movement:
- ask Pt to fully relax & allow Ex to move arm
- warn them to notify Ex of pain immediately
- repeat active movements & feel for crepitus

Question 24

Shoulder: special tests x 4

Answer 24

Supraspinatus ass: assessing function of supraspinatus
- ask Pt to abduct their shoulder from neutral position against resistance
- Loss of power suggest supraspinatus tear; pain in early abduction suggests tendonitis

Painful ARC - Impingement syndrome:
- passively abduct Pt’s arm to its max point
- ask Pt to lower arm slowly & back to neutral
- Impingement typically causes pain between 60-120* abduction

External rotation against resistance: tests motor funct* of infraspinatus & teres minor
- Positon Pt’s arms; elbows flexed @ 90* & shoulders flexed @ 30*
- ask Pt to externally rotate should whilst applying light resistance
- Pain on resistance; suggest tendonitis
- Loss of power; indicates tear

Internal rotation against resistance- Gerber lift off test: ass* funct* of subscapularis muscle
- ask Pt to place dorsum of hand on lower back
- apply light resistance to hand
- ask Pt to move their hand off their back
- Inability to do this; ligamentous tear

Question 25

Elbow: Look; front x 3, side x 3 & back x 2

Answer 25

Exam:
- explain process & gain consent; exposure area under exam
- position Pt as needed, ask if they have any pain

LOOK
Front: anatomical position
- scars - prev injury/surgery
- swelling/erythema of joint; acute inj/inflam arthritis or infection
- carrying angle; 5-15*

Side:
- fixed flexion deformity - often post traumatic
- olecranon bursitis - swelling overlying the olecranon often noticed from this angle
- scars/swelling/erythema

Back:
- rheumatoid nodules
- psoriatic plaques

Question 26

Elbow: feel x 2 & move x 4

Answer 26

FEEL:
- temp; inflam/inf
- palpate joint lines; inc* epicondyles & olecranon for any tenderness

MOVE: actively, then passively
- Flexion - arms out to sides, supinated, move hands to head (145)
- Extension - arms out to sides, supinated (0)
- Pronation - elbows tucked in w thumbs up (70)
- Supination - same as above (85)

Question 27

Elbow: special tests x 2

Answer 27

Medial epicondylitis: Golfer’s elbow
- ask Pt to actively flex the wrist while elbow is flexed
- Localised pain over the medial epicondyle; suggests Dx

Lateral epicondylitis: Tennis elbow
- ask Pt to actively extend wrist while elbow is flexed
- Localised pain over the lateral epicondyle; suggests Dx

Question 28

Wrist: Look x 4(6) & feel x 5(5)

Answer 28

LOOK:
- bony deformity/bony alignment
- Dupuytren’s contracture
- Bouchard’s/Heberden’s nodes; OA
- wrist drop
- ulnar drift
- swan neck, boutonnière, Mallet deformities
- trigger finger
- colour change; bruising, inflam, infect, rash
- wasting/spasm/bulk of muscle in particular thenar/hypothenar
- swelling, scarring, skin changes, wounds

FEEL:
- vascular sys; distal pulses, cap* refill
- sensation; peripheral nerve, skin sensation & power
- temp; inf/inflam
- swelling; effusion, synovial thickening, extracapsular
- tenderness;
- elbow
- anatomical snuff box (scaphoid)
- carpal bones
- metacarpals & phalanges
- tendons

Question 29

Wrist: Move x 3 all ROMs

Answer 29

MOVE: actively, then passively
Wrist:
- pronation 90*
- supination 90*
- flexion 90*
- extension 90*
- radial deviation 15*
- ulnar deviation 45*

Fingers:
- flexion; MCP 90, PIP 100, DIP 90*
- extension; MCP 45, PIP 0, DIP 20*
- abduction; 30*
- adduction; 0*

Thumb:
- flexion; CMC 50, MCP 50, IP 0*
- extension; CMC 0, MCP 0, IP 5*
- abduction; 70*
- adduction; 30*
- opposition thumb tip to tips of fingers

End of feel movement:
- normal; hard, soft, elastic
- abnormal; hard, springy, spasm, empty

Question 30

Wrist: muscle power & static resisted testing

Answer 30

Muscle power: 0-5 grading

Static resisted testing: resisted isometric testing - slight Ex pressure (Pt sitting w forearm resting on bench)
Wrist:
- same as full ROM w radial & ulnar dev* (do w fist shape)

Finger:
- flexion
- extension; palm on table
- abduction (interlace Ex fingers between Pt fingers)
- adduction; paper between fingers
- lumbricals; Pt try’s to curl fingers into fist against Ex resistance

Thumb:
- same as full ROM

Question 31

Hand innervation: sensory & motor

Answer 31

Sensory
Radial: dorsum of hand from thumb to midline ring finger

Medial: palmar surface of hand from thumb to midline ring finger

Ulna: dorsal & palmar surfaces of little finger & midline ring finger

Motor
Radial: flexion & extension of wrist & fingers

Medial: ability to touch tips of little finger and thumb together

Ulna: ability to abduct all digits

Question 32

Hand: special tests; Finkelstein/Tinel/Phalen

Answer 32

Finklestein’s test:
- tests for de Quervain tenosynovitis
1- thumb across palm
2- fingers bent down over thumb; fist like
3- ulnar deviation
= POS+ if pain on thumb side of wrist (like my old stretch)

Tinel’s test:
- testing nerve damage by percussing over carpal tunnel regions?
= POS+ if pins & needles like tingling occurs distal to tap

Phalen’s test:
- elbows flexed & wrist falls into Max flexion; put dorsum of each hand against the other & hold together for 20-30secs
= POS+ when Pr’s symptoms are reproduced by test

REVERSE: can also do reverse Phalen’s test too = same

Question 33

Hand: special tests; Froment/OK/Wrist drop

Answer 33

Froment’s test:
- testing palsy of Ulnar nerve ( may occur w entrapment of Ulna nerve in the cubital tunnel)
= perform paper pinch test; POS+ flexion of thumb when trying to pinch paper (abnormal due to nerve palsy)

OK sign:
- testing for paralysis of anterior interosseous nerve (entrapment/compression inj*)
= POS+ unable to make OK sign if paralysis of nerve

Wrist drop:
- injury to Radial nerve
= POS+ Pt unable to extend wrist/fingers; eg: # distal humerus

Question 34

Hand: special tests; Hitch-hike/Allen/Grind

Answer 34

Hitch-hike sign: (thumbs up)
- test for Radial OR Posterior Interosseous nerve injury
= POS+ Pt unable to perform

IF; NO wrist drop, But unable to make H-H sign
- tests Posterior Interosseous nerve specifically
= POS+ wrist extension only, NO finger extension

Allen’s test:
- assesses the arterial blood flow through the Ulnar artery
= elevate hand for 20-30 secs, make fist; Ex occludes the ulnar/radial artery & tests return of perfusion of open palm

Grind test:
- eval* presence of basal thumb arthritis (CMC joint)
= POS+ grinding/crepitus with axial loading, pushing & rotating thumb

Question 35

Hand: special tests; Watson/Lumbrical/Flexor tend*

Answer 35

Watson’s test: AKA; scaphoid shift test
- used to evaluate scaphoid stability: Ex places thumb over Pt’s scaphoid tuberosity (distal pole of the scaphoid, on the voler surface) & other fingers on dorsal surface of hand
- Next; passive ulnar deviation (w slight palmar flexion) & then radial deviation (w slight palmar flexion) - pressure on tuberosity pushes scaphoid dorsally & out of the radial fossa
= POS+ pain & clunk w movement

Lumbrical plus finger:
- tests laceration of flexor Digitorum Profundus distal to the Lumbricals: Pt attempts to make fist, finger unable to remain in gripped pose when Ex releases finger pressure (more common in 2nd Lumb* - middle finger)

Flexor tendon integrity:
Digitorum profundus;
- Ex holds PIP of extended finger & ask Pt to flex DIP/ tip of finger
Digitorum superficialis;
- Ex keeps unaffected fingers extended & ask Pt to flex PIP of affect finger

• multiple slips cut: identify tendons properly - Volar = middle and ring fingers
• ALWAYS test thumb too; skier’s/greenkeepers thumb injury!

Question 36

Hand: special tests; Bunnell/Elson/Finger alignment

Answer 36

Bunnell test:
- testing digit for intrinsic muscle or capsular tightness; Ex supports MCP w finger in extended pos*
1- w MCP joint extended, intrinsic contracture (Interosseous muscle contracture) impedes flexion of PIP
2- when MCP joint passively flexed, PIP joint flexion increases also

Elson’s test:
- test if Pt has central slip tear before the deformity is present (damage to tendons prox/dist to PIP joint
1- Pt has fingers over edge of table; PIP @ 90*
2- Ex places finger on middle phalynx
3- ask Pt to extend finger
= Central slip intact - Ex feels tension of finger being extended
= Ruptured central slip - No tension, Pt unable to extend PIP

Finger alignment test:
- slow, gentle creation of fist like pose watching how fingers align
= Normal; fingers point toward scaphoid
= Malrotation; affected finger will deviate from normal rotational direction
** esp important w Finger # & Metacarpal #

Question 37

Hand: special tests; finger posture & positioning x 4

Answer 37

Mallet finger:
- DIP bent/flexed when finger extended

Sagittal band injury:
- tendon alignment band over MCP - visibly slips to one side when affected finger flexed (done w dorsum of hand visible)

Boutonniere deformity:
- slip of tendons around PIP joint, results in bent finger @ PIP at rest & unable to extend finger

Swan neck deformity:
- hyperextension of PIP joint

Question 38

Hand: special tests; posture & positioning x 4

Answer 38

Mallet finger:

Sagittal band injury:

Boutonniere deformity:

Swan neck deformity:

Question 39

Knee: exam & Hx x 7

Answer 39

Exam:
- explain procedure & gain consent; expose area appropriately
- Pt standing

Hx:
- mechanism of injury
- location of; pain, noise or other sensations (trauma, often localised; inflam* Dx, usually diffuse); unilateral or bilateral?
- ability to weight bear
- location & rapidity of swelling
- Giving way (ligaments): mechanical instability Vs guarding from the pain
- Locking (meniscal): unable to move leg unless physically manipulated to unlock it
- PMHx of knee issues

Question 40

Knee: LOOK: gait + 3 inspection views (5:3:1)

Answer 40

LOOK: inspect for mobility aids & adaptors & Always compare to asymptomatic side

Gait:
- normal heal strike/toe off gait?
- is each step of normal height; increased stepping height is noted in foot drop
- is gait smooth & symmetrical?
- any obvious abnormalities; antalgia, waddling, board base

INSPECT
Anteriorly:
- scars - prev* injury/surg/trauma
- swellings - effusions/inflam arthropathy/septic arth/gout
- asymmetry/leg lengthening discrepancy
- valgus or varus deformity;
- Valgus = angulated outwards or away from midline
- Varus = angulated inwards or towards the midline
- quad muscle wasting - suggests chronic inflam/reduced mobility

Posteriorly:
- scars
- asymmetry
- popliteal swelling

Laterally:
- knee flexion/hyper flexion

Question 41

Knee: FEEL; knee joint, patella tap, sweep/swipe test

Answer 41

FEEL:
- temp of joint
- palpate quadriceps tendon, whilst leg extended; pain = synovitis
- palpate for pulses & assess neurovascular status distally

Palpate Knee joint:
- measure quads 20cm above tibial tuberosity & compare bilaterally
- w leg flexed @ 90*;
- patella - tenderness/effusion
- tibial tuberosity - tenderness may suggest Osgood Schlatter Dx
- head of fibula - irregularities/tenderness
- collateral ligaments - both medial & lateral
- popliteal fossa - any obvious collection of fluid

Patellar tap:
- detects larger effusions
1- empty the suprapatellar pouch by sliding L hand down thigh to patella; keep hand here
2- use R hand to press downwards on patella w fingertips
3- if fluid present = will feel distinct tap as patella bumps femur

Sweep/swipe test:
- detects smaller effusions
1- empty suprapatellar pouch as described, but on the Medial side; release hands
2- now do similar wiping downward on Lateral side of joint
3- watch for bulge/ripple on medial side of patella = suggests effusion

Question 42

Knee: MOVE; active & passive ROMs

Answer 42

Active:
- flexion - normal ROM 0-140*
- extension - as best as poss (0-5*)

Passive:
- test knee flexion & extension - note any crepitus or decreased movement
- hyperextension - elevate both legs by the heels (<10% normal)

Question 43

Knee: special tests; cruciate lig* & collateral lig*s

Answer 43

Cruciate ligaments: (anterior/ posterior drawer test)
- flex Pt’s knee @ 90*
- inspect for posterior sag
- wrap hands around proximal tibia w fingers at back of knee
- forearm along lower leg to stabilise
- ask Pt to remain as relaxed as poss
1- Pull tibia anteriorly = sig* movement suggests Ant* cruciate laxity/rupture
2- Push tibia posteriorly = sig* movement suggests Post* cruciate laxity/rupture

Collateral ligaments: (lateral & medial)
- extend Pt’s knee fully
- hold Pt’s ankle between Ex elbow & side
Medial collateral;
- R hand along lateral aspect of knee
- L hand on lower limb
- push steadily inwards w R hand, while supplying an opposite force w L hand
1- if MCL damaged, will feel medial aspect of the joint opening up

Lateral Collateral;
- R hand along medial aspect of knee
- L hand on lower limb
- push steadily outwards w R hand, while supplying an opposite force w L hand
1- if LCL damaged, will feel lateral aspect of the joint opening up

Question 44

Ankle & Foot: exam & Hx

Answer 44

Examination:
- explain & gain consent & expose Pt’s ankles & feet

Hx:
- able to weight bear?
- PHx ankle injuries or surgeries; intensive exercise; arthritis
- mech* of injury - direct trauma or torsional forces
- usual symptom is pain; ?unilateral
- general or localised tenderness;
- Focal over 1st metatarsophalangeal joint = ? Gout
- Focal over metatarsals = ? Stress #

Question 45

Ankle & Foot: LOOK; gait & 3 x views

Answer 45

Gait:
- is Pt demonstrating normal heal strike/toe off gait?
- is each step normal height?
- is gait smooth & symmetrical?

LOOK
Front:
- symmetry of feet & ankles
- toe alignment
- bunions
- toe clawing
- scars - trauma/surg
- calluses - foot/gait deformity or ill fitting footwear
- swelling/erythema of foot/ankle - injury/inflam/inf
- examine Pt’s SHOES - evidence of asymmetrical wearing may indicate abnormal gait & check Fit

Side:
- foot arched - observe flat feet or high arches
- Flat feet = have Pt stand on tip toes (supple feet will correct; rigid flat feet will not)

Back:
- foot & ankle symmetry - heel alignment - Valgus or Varus deformity
- Achilles tendon - any deformity/discolouration/erythema

Question 46

Ankle & Foot: FEEL;

Answer 46

FEEL: Pt lying on bed
- assess temp & compare bilaterally; ankles, midfoot & toes
- assess pulses bilaterally
- palpate Achilles tendon; thickening or swelling

Palpate Joints/bones:
- work distal to proximal - assess tenderness/swelling/irregularity
- Squeeze MTP joints
- tarsal joint
- ankle joint
- subtalar joint
- medial/lateral malleoli
- proximal fibula

Question 47

Ankle & Foot: MOVE; active & passive

Answer 47

Feeling for crepitus

Active:
- foot plantar-flexion 30-40*
- foot dorsi-flexion 12-18*
- toe flexion & extension
- toe adduction - paper between toes & get them to prevent being pulled out
- toe abduction - spread toes

Passive:
- foot inversion- grasp ankle w one hand & heel w other; turn sole towards midline
- foot eversion - same; turn sole away from midline
- mid-tarsal joints - hold ankle w one hand whilst moving tarsus up & down & side to side

Question 48

Ankle & Foot: special tests

Answer 48

Thompson test (AKA Simmond’s)
- ask Pt to kneel on chair w feet hanging over the edge
- Squeeze each calf in turn
- Normally; the foot should plantar flex
- Ruptured tendon; there will be no movement in the foot

Question 49

Ottawa Ankle Rules x 5 (lateral foot/bony prominence)

Answer 49

1- bony tenderness along distal 6cm of posterior edge of fibula or tip of lateral malleolus

2- bony tenderness along distal 6cm of posterior edge of tibia or tip of medial malleolus

3- bony tenderness at the base of the 5th metatarsal

4- bony tenderness at the navicular (medial bone in front of talus)

5- inability to bear weight both immediately & after injury & for 4 steps during initial evaluation

Ankle X-ray:
- indicated if 1, 2 OR 5 present

Foot X-ray:
- indicated if 3, 4, OR 5 present

Excluded:
- pregnant women
- diminished ability; intoxicated/head injury
- children <6yo - not so well tested