The Locomotor System

Question 1

Locomotor history: diagnoses by number of joints involved, one joint (monoarthritis)

Answer 1

Crystal arthropathy
Haemarthrosis
Infection
Degenerative
Post-traumatic
A mono-articular presentation of an oligo- or polyarthritis

Question 2

Locomotor history: diagnoses by number of joints involved, 2-4 joints (oligoarthritis)

Answer 2

Inflammatory arthritis (rheumatoid, psoriatic, reactive, ankylosing spondylitis).
Infection (endocarditis, acute rheumatic fever).
Osteoarthritis.

Question 3

Locomotor history: diagnoses by number of joints involved, >5 joints (polyarthritis)

Answer 3

Inflammatory (rheumatoid, psoriatic, SLE).

Osteoarthritis.

Question 4

Locomotor history: diagnoses by pattern of involvement, rheumatoid arthritis

Answer 4

MCP joints, PIP joints, and MTP joints.

Typically does not affect DIP joints & 1st CMC joint.

Question 5

Locomotor history: diagnoses by pattern of involvement, psoriatic arthritis

Answer 5

Typically affects DIP joints more commonly than other hand joints.
May sometimes mimic rheumatoid arthritis.

Question 6

Locomotor history: diagnoses by pattern of involvement, ankylosing spondylitis

Answer 6

Sacroiliac joints, spine, shoulder, and hips.

Question 7

Locomotor history: diagnoses by pattern of involvement, SLE

Answer 7

MCP joints and wrists.

Question 8

Locomotor history: diagnoses by pattern of involvement, osteoarthritis

Answer 8

Knees, 1st CMC joint, DIP joint, PIP joint, spinal apophyseal joints, hips and ankle.

Question 9

Locomotor history: diagnoses by pattern of involvement, gout

Answer 9

1st MTP joint, IP joints, knees and ankles.

Question 10

Locomotor history: diagnoses by onset and progression, single attack of acute arthritis

Answer 10

Reactive arthritis
First presentation crystal or inflammatory arthritis
Septic arthritis

Question 11

Locomotor history: diagnoses by onset and progression, multiple completely resolving episodes

Answer 11

Crystal synovitis (gout, acute CPP crystal synovitis)
Palindromic rheumatoid arthritis

Question 12

Locomotor history: diagnoses by onset and progression, persistent or progressive ‘additive’ joint involvement

Answer 12

Rheumatoid arthritis (typically symmetric)
Seronegative inflammatory arthritis (typically asymmetric)
Progression may be over months or years.

Question 13

Locomotor history: diagnoses by onset and progression, persistent or progressive sacroiliac joint and spinal involvement

Answer 13

Seronegative spondarthropathy.

Peripheral large joint oligoarthritis may also occur.

Question 14

Locomotor history: diagnoses by onset and progression, one joint involved after the other over years

Answer 14

Osteoarthritis: progressive involvement of several IP joints over a period of few months may occur at disease onset in ‘nodal’ OA- typically in postmenopausal women.

Question 15

The GALS screen: overview

Answer 15

The overall integrity of the locomotor system can be screened very quickly by using the 'GALS' method of assessment.
GAIT
ARMS
LEGS
SPINE

Question 16

The GALS screen: gait

Answer 16

Watch the patient walk, turn, and then walk back.
There should be symmetry and smoothness of movement and arm swing with no pelvic tilt and normal stride length.
The patient should be able to start, stop, and turn quickly.

Question 17

The GALS screen: arms

Answer 17

Patient is seated.
Inspection: look for muscle wasting and joint deformity at the shoulders, elbows, wrists, and fingers.
Squeeze across the 2nd-5th metacarpals- there should be no tenderness.
Shoulder abduction: ‘raise your arms out sideways, above your head’- normal range 170-180 degrees.
Shoulder external rotation: ‘touch your back between your shoulder blades’.
Shoulder internal rotation: ‘touch the small of your back’- should touch above T10.
Elbow extension: ‘straighten your arms out’- normal is 0 degrees.
Wrist and finger extension: the prayer sign.
Wrist flexion and finger extension: reverse the prayer sign.
Power grip: ‘make a tight fist’- should hide fingernails.
Precision grip: ‘put your fingertips on your thumb’.

Question 18

The GALS screen: legs

Answer 18

Patient lies down.
Inspection: look for swelling or deformity at the knee, ankle, and foot as well as quadriceps muscle wasting.
Squeeze across the metatarsals- there should be no tenderness.
Hip and knee flexion: test passively and actively- normal hip flexion is 120 degrees, normal knee flexion is 135 degrees.
Hip internal rotation: normal is 90 degrees at 45 degree flexion.
Knee: bulge test and patellar tap.
Ankle: test dorsiflexion (normal 15 degrees) and plantar flexion (normal 55 degrees).

Question 19

The GALS screen: spine

Answer 19

Patient standing.
Inspection from behind: look for scoliosis, muscle bulk at the paraspinals, shoulders, and gluteals, level iliac crests.
Inspection from the spine: look for normal thoracic kyphosis and lumbar and cervical lordosis.
Tenderness: feel over the mid-supraspinatus- there should be no tenderness.
Lumbar flexion: ‘touch your toes’- normal is finger-floor distance <15cm; lumbar expansion (Schober’s test).
Cervical lateral flexion: ‘put your ear to your shoulder’.