Aids
Shoes - raises / wear patterns
Stigmata generalised disease
Hands - RA, CMT
Front
Knee alignment
Forefoot - Hallux & Lesser toes
Scars
Circulatory changes
Medial Side
Turn affected side away & ask to step foot forward
Flexed attitude of knee
Medial arch - planus / cavus
Behind
Spine - scoliosis / spinal dysraphism
Hindfoot varus / valgus
Forefoot (Too many toes)
Scars
Calf wasting
Double heel raise
- Heel swings into varus or remains in valgus
- ? mobile subtalar joint
- ? Medial arch restoration
Single heel raise
- Must put patient close to blank wall half a foot length from the wall
- otherwise will cheat by pushing up or leaning forward against wall
Lateral side
Haglund's
Peroneal tendons
Ankle
- Stiff / Fixed equinus
- Weak / Foot drop
- Painful / Antalgic
Foot Progression angle
Tip toe - strong S1
Heel walk - strong L4
On edge of bed with legs hanging
- examiner sits on chair
Screen active ROM AKJ and STJ bilaterally
Look at sole
- normal distribution weight pattern
- callosities
- lumps / plantar fibromatosis
" Where is it painful?"
Lateral aspect
- lateral malleolus
- lateral ligament complex
- Peroneal tendons
- sinus tarsi
- base of 5th
Posterior aspect
- tendo-achilles
- insertional / non insertional
Medially
- deltoid ligament
- tibialis posterior
- MT joints
- sustenaculum tali
Anterior
- ankle joint tenderness / effusion
- AITLF
Sole
- fat pad
- insertion of plantar fascia
Midfoot
Forefoot
- hallux rigidus
- sesamoids
- metatarsalgia
- Mulder test / interdigital tenderness
DF - active and passive range 20o
PF - active and passive range 50o
Subtalar joint motion
- ankle in 90° DF
- thumb on talar neck to detect talar movement
- opposite hand cups heel and inverts & everts
- Inversion 10-15o
- Eversion 0-5o
Midtarsal joint
- Foot at 90 to lock ankle mortise
- Adduct foot 20o
- abduct foot 10o
- dorsiflex
- plantarflex
T Ach
- Tenderness along tendon /Insertion, ? lump
- test power / pain
Tibialis posterior
- Prominent with plantarflexion and inversion
- Thickening
- Tenderness
- Check power if abnormal
Peroneus brevis & longus
- thickening
- Tenderness
- Dislocation (resisted eversion)
- active eversion
Tibialis anterior
- Prominent with dorsiflexion and inversion
- Insertion
EHL & EDL - Dorsiflex toes
Anterior drawer
- Due to complete tear of ATFL
- Grasp lower tibia and cup calcaneum
- "clunk" or draw
- compare with other side > 3 mm
Lateral instability
- Inversion stress
- Gaping of soft tissues
- Talar tilt (may occur in normal & must compare with other side)
- Needs to be confirmed on stress views
- > 20o
Medial instability
- Eversion stress
- Gaping / widening
- Needs to be confirmed on stress views
Test if limited dorsiflexion
Silverskiold Test
- Extend knee - dorsiflexion limited by both soleus & gastrocnemius contracture
- Flex knee - gastrocnemius relaxed (crosses knee joint)
- If dorsiflexion still limited it is due to soleus contracture
- If limited in extension & not in flexion then due to gastrocnemius contraction
Claw toes - flexible / fixed
Individual power compared with other side
- Tibialis anterior (inversion in DF)
- Tibialis posterior (inversion in PF)
- Peronei
Coleman block test
- Dynamic visualisation of hindfoot correction
- Stand on 2cm block
Passive correction of plantar-flexed 1st MT
Spine / Neuro Exam
MTPJ Painful / limited range
- flexion 45o
- extension 70-90o
- redo range with correction
IPJ
- hallux interphalangeus
- extension / flexion
Lesser toes
- fixed / mobile
- dislocated
Spine
Neuro exam
Vascular exam
Ligamentous laxity
Limp - asymmetrical gait pattern
Note: Children assume adult walking patterns by the age of eight
1. Rate
- increased, decreased or normal
2. Rhythm
- normal or limp
- limp is a disturbance in normal rhythm
- numerous causes - see below
3. Gait cycle
- individual cycle
- from one foot strike to the same foot strike
- stance 60% swing 40%
Initial contact - knee extended
Loading response - knee flexed, ankle DF
Mid stance
Terminal stance - hip extends, heel rise
Pre swing - ankle PF
Initial swing
- need foot clearance
- knee flexed, ankle DF
Mid swing
Terminal swing
STRAWS
Short
Trendelenburg (gait or lurch)
Rigid - hip / knee / ankle
Antalgic - painful, shortened stance phase
Weak - hip (trendelenberg), knee (back knee gait), ankle (high stepping)
Supratentorial (CNS - spastic / ataxic / toe walking / crouch / jump)
Examine in coronal plane (from front) and in sagittal plane (from side)
Foot
Coronal
- foot progression angle
- bilateral in / out toeing
- old SUFE (walk with ER)
Sagittal (F/E)
- should have 3 rocker phases (might have just one or two)
- Heel Strike / Plant / Toe off
- nil heel strike in toe walker / cp - equinus may be fixed or not
- high stepping gait if weak
- equinus if LLD (shouldn't be fixed)
Knee
Coronal
- varus / valgus malalignment & thrust
- squinting / medially facing patella secondary increase PFA
Sagittal (F/E)
- achieving full extension in stance (not in a cp)
- back leg gait (weak knee extensors eg polio)
- may hold flexed in LLD
Hip
Coronal
- abductor lurch
- scissoring (adductor tightness in cp, increased PFA)
Sagittal (F/E)
- hyperflexion / FFD (hyperlordosis)
- weak hip flexors - back extension
Pelvis
Coronal
- pelvic asymmetry secondary to LLD / scoliosis
Sagittal
- hyperlordosis (hip FFD)
Trunk
Coronal - swaying side to side
Head - up and down with LLD
UL
- a hemiplegic will swing only one arm
Short
- head and shoulders drop as patient steps onto short limb (bobbing up & down of head and shoulders in sagittal plane)
- Pelvis drops on affected side with heel strike and exaggerated head motion in sagittal plane
- vaulting gait
- flexion knee, equinus ankle
Stiff
Hip
- head & torso sways front to back in sagittal plane as walks
- Decreased hip flexion on swing phase and lumbar motion increases (AP sway)
Knee
- hip circumducts
- little flexion / extension through stance
Ankle
- may turn foot out to use STJ
- limitation F/E in sagittal plane
- DDX unilateral fixed equinus
- Tight TA / Hemiplegic CP / Short leg / Foot drop
Pain
- shortened stance phase
Weak
Hip
- Trendelenberg / abductor lurch
- head and shoulders sway side to side
Knee
- weak quads
- back knee gait
Ankle
- Foot drop gait
- High stepping gait
Neuromuscular
Spastic gait
Diplegic
1. Equinus gait - nil heel strike in rocker phases
2. Jump gait - ankle equinus, knee flexion
3. Crouch gait - ankle / knee + hip flexion
4. Scissoring gait
Hemiplegic
- unilateral loss heel strike, knee held flexed
- nil movement of arm in swing
Ataxia
- broad based gait
Walking aid
Footwear - shoe raises
Front
- Overall alignment of Lower Limb
Side
- lumbar lordosis
- flexed attitude of hip / knee
- scars
Back
- lumbar spine
- buttock wasting
- popliteal creases
- examine ROM
- try to differentiate spine and hip
Attain symmetrical stance
- knees extended
- feet flat on ground
- check levels of ASIS
- comment on
A. Pelvis is level / not level
B. Stance is symmetrical
C. Coronal plane deformity - Knee is flexed, ankle is in equinus
Situations
A. Pelvis is level with symmetrical stance
- no LLD
B. Pelvis is not level with symmetrical stance
- uncompensated LLD
C. Pelvis is level with asymmetrical stance
- compensated LLD
D. Pelvis is not level with asymmetrical stance
- partially compensated LLD
- contractures
Blocks
- if pelvis not level
- to assess functional leg length discrepancy
Aim
- assess if patient's abductors can elevate ASIS on affected side
- without using trunk
Technique
- visualise ASIS or PSIS
- stand on good leg
- opposite ASIS should rise
- stand on bad leg
- cannot raise opposite ASIS
- either fall or have to lean trunk over
False negative test
- able to maintain abduction with no abductor function
- fixed abduction contracture
- arthrodesed hip in abduction
Invalid if
- poor balance
- generalised weakness
- lack of co-ordination or understanding
- costo-pelvic impingement
Causes
1. Pain
- painful disorder of hip
- centre over hip to decrease abductor pull
- decrease joint reaction forces
2. Pivot
- dislocation or subluxation of hip
- shortening of femoral neck
- abductors cannot work correctly
3. Power
- weakness of abductors
STRAWS
Short
- shoulder drops on ipsilateral side
- head up and down
Trendelenburg
- abductor lurch
Rigid / Stiff
- hip
- knee
Antalgic
- shortened stance phase
Weak
- back knee gait
- foot drop
Supratentorial (CNS)
Feel
Along line of inguinal ligament from medial to lateral
- masses (dislocated femoral head, hernias, aneurysms, lymph nodes)
- tenderness (LCFN)
Along posterior greater trochanter
- tenderness (trochanteric bursitis)
Exclude FFD of knee
- allows assessment of leg length (correct with pillow)
- allows assessment of FFD of hip (must put knee over bed)
Valgus knee
- difficulty measuring LL
- will be unable to put other leg in same position
- must measure components
Normal ROM
- Flexion / extension 140o
- adduction / abduction 400
- IR / ER
Thomas' Test
Angle through which thigh is raised from couch is angle of fixed flexion
Fixed flexion deformity of knee
- place patient at edge of couch
- when assessing FFD, move heel over edge of couch
- lower heel below level of couch
- to eliminate effect of knee FFD
Method
- passively flex both knees to 45o
- place hand behind back and
- ask patient to clutch unaffected knee to chest
- ensure lumbar lordosis eliminated
- this fixes pelvis
Extension
- gently extend affected hip passively
- lift heel off bed
- stop when painful
- fixed flexion deformity of (x)o
Flexion
- ask patient to actively flex affected hip
- gently passively maximise flexion
- comment
- flexes to (y)o
- flexion arc of (x)o FFD to (y)o
Abduction / Adduction in Extension
Position
- hip and knee extended
- fix pelvis by abducting unaffected hip so that leg dangles over edge of couch
- palpate ipsilateral ASIS
- abduction / adduction both sides
- know at extremes of limit when ASIS / Pelvis begins to move
Internal and External Rotation in Flexion
Position
- hip flexed to 90o
- hold leg with one hand
- hand in popliteal fossa
- leg resting on forearm
- assess pelvis movement with other hand
- palpate contralateral ASIS
- internal rotation, turn foot out
- external rotation, turn foot in
- examine contralateral side
Make pelvis square with bed
- attempt to make legs square with pelvis and straight
- ensure buttocks not in dip in bed
- ensure normal heel height
- ensure no asymmetrical buttock wasting
Apparent LL
- leg length measured without correcting for sagittal or coronal plane deformity
- from umbilicus to medial malleolus
- tape measure
True LL
- leg length measured once coronal & sagittal plane deformity corrected for
- sum of intercalated segments
- ASIS to medial malleolus
Correct for
1. Abduction contracture
- comment on contracture
- unable to place legs perpendicular to pelvis because of abduction contracture
- must place other leg in same position
- abduct unaffected hip same degree
- measure leg length
2. Adduction contracture
- comment on contracture
- unable to place legs perpendicular to pelvis because of adduction contracture
- must place other leg in same position
- measure leg lengths sequentially
- cross one leg and measure
- cross other leg and measure
3. FFD Hip or Knee
- correct with pillows
4. Equinus foot
- look below medial malleolus
- difference in effective heel height because of equinus contracture
5. Coronal plane deformity knees
- cannot correct for
- must measure intercalated segments
Identify level of leg length discrepancy
Flex knees to 90o with hips and ankles at 45o
- put malleoli at same level
- any hindfoot asymmetry makes test inaccurate
Femurs parallel
- tibias same height
- discrepancy above knee
Tibias parallel
- femurs same length
- discrepancy in tibia
- knees at different levels
1. Bryant's triangle
- identify ASIS with thumb & tip of greater trochanter with forefinger
- drop imaginary lines down to floor
- distance between the lines
- difference in distance between ASIS and GT suggests discrepancy proximal to GT
- assess perpendicular distance between points with fingers of other hand
- perpendicular distance between points is different by (x) fingerwidths
2. Schoemaker's line
- line from greater trochanter thru ASIS
- projection from each side should cross proximal to umbilicus
- if shortening above gr trochanter then the lines will cross below the umbilicus
3. Nelaton's line
- ischial tuberosity to ASIS
- with patient lying on the side
- the greater trochanter should lie on the line
Shoes
Walking aids
Front
Knee alignment
- physiological valgus
Patellar rotation
- squinting (inwards, increased PFA)
- grasshopper eyes (high and lateral)
Swelling
Quads Wasting
Scars
Side
Knee attitude
- flexion
- recurvatum
- push knees back
Step foot forward and bear weight
- examine arch
Scars
Behind
Hindfoot valgus
Swelling popliteal fossa
Wasting of hamstrings or calf
Level popliteal creases
Other Side
Knee attitude
- flexion
- recurvatum
- push knees back
Step foot forward
Scars
Rigid / Stiff
- decreased flexion / extension range
Antalgic
Weak knee
- back knee gait
Medial or lateral thrust
- valgus or varus moment about the knee
Foot progression angle
Patella tracking
- crepitus
J tracking
- patellar sharply deviates laterally in terminal extension
- or travel laterally until jumps into trochlea at midrange of flexion
Look
- quads wasting
- alignment
- scars
Effusion
- swipe, ballot, tap
Range
- FFD / Recurvatum / lift foot in air
- active extension / quads lag
- range of flexion bilaterally
FFD
- effusion
- entrapped meniscus
- ACL stump
- loose body
Flat
- Extensor mechanism
- patella
- tibial tuberosity
Flexed
- Joint lines, MCL, LCL
- tibial and femoral condyles
- popliteal fossa
Palpate distal femur for osteochondromas
Collaterals
Test at 0 and 30o
- if loose at 0, loss of secondary stabilisers
Grading
1+ Surfaces separate 5mm or less
2+ 5 - 10 mm
3+ 10 mm or more
ACL / PCL
Lachmann's
- 85% sensitive awake
- 100% asleep
Check loss of tibial step off
- posterior sag
- MTP normally 1 cm anterior to MFC
Quadriceps active
- knee at 90o
- stabilise foot & ask to slide foot down bed
- N < 1mm / PCL > 3mm
Anterior / Posterior drawer
- restore tibial step off
Posterolateral drawer
- 30o IR
- tightens PLC
Posteromedial drawer
- 15o ER
- tightens PMC
Pivot Shift
- valgus stress with IR + axial compression
- knee moved from extension to flexion
- in chronic ACL deficiency, the LTC is subluxed anteriorly
- at 30o it reduces backwards
- this is when ITB passes behind axis of rotation and becomes flexor
- grade pivot glide / 1 / 2 / 3
Must have 4 things
- MCL to pivot about
- intact ITB
- no FFD
- ability to glide i.e. no meniscal pathology
PCL / Posterolateral Corner (PLC)
External rotation / Recurvatum
- hold big toe and assess PLC
- knee moves into recurvatum, tibia externally rotates & subtle varus
- indicates PCL + PLC + LCL
Reverse pivot shift
- with valgus and ER
- flexion to extension
- in flexion, the LTP is posteriorly subluxed
- ITB become extensor
- reduces as extend
- must compare with other side
- present in 30% normal population especially ligamentous lax
Dial test / Prone
- measure thigh foot angle
- examiner holds knees together
- increase at 30o only - PLC
- increases at 30 then again at 90 - PLC + PCL
- isolated PCL - no increase
- >10o compared with normal side
Meniscus
McMurray
- Flexion to extension
- Full IR - LM
- Full ER - MM
- i.e. test meniscus heel is pointing towards
- positive test is palpable / audible thud, snap, click
Squat test
- feet IR and ER
Concealed / popliteal fossa
Cephalad / Hip
- rotation in flexion
- adduction / abduction in extension
Circulation
Collagen
Stigmata Generalised disease
- Marfan's
Ligamentous laxity Wynne Davies
- positive if 3/5 pairs
- thumb touches volar forearm
- fingers parallel to forearm dorsally
- elbow hyperextends past 0o
- knee hyperextends past 0o
- ankle dorsiflexes > 45o
VMO bulk
Swelling
Scars of previous surgery i.e. TTT
Planovalgus Feet / Hyperpronation
Genu Valgum
Squinting patella
- Proximal Femoral Anteversion (PFA)
- patellae point inwards when standing
Grasshopper eyes
- patellas sit high & lateral
- due to patella alta
- patella subluxed laterally
Flexed attitude Knee
Scars
Level Popliteal creases
Valgus Heels
Foot Progression Angle
- Normal 10° (0-30°)
- any in-toeing
- indicative of PFA
Patella Tracking
- J sign
- lateral subluxation in terminal extension
Crepitus
Effusion
1. Tenderness
- tibial tuberosity
- lateral patella retinaculum
- patella
- Bassett's sign (MPFL on med epicondyle)
- pain with patella grind (compression)
2. Clark's test
- gentle pressure on superior pole
- patient asked to contract quadriceps
- compare with other side
3. Patellar Tilt Test
- Patient supine and relaxed with knees extended
- Trans- epicondylar axis placed parallel to table
- Lateral edge of patella elevated & medial edge depressed
- normal is lateral tilt 0-20°
- Abnormal if unable to tilt to horizontal
- indicated lateral retinaculum tightness
1. Q angle
- Knee at 30° flexion so patella engages femoral sulcus
- ASIS to centre of patella to tibial tuberosity
- abnormal > 15° in males
- abnormal > 20° in female
2. Patellar glide test (Sage Mobility)
- Graded by number of 1/4 widths that patella displaces
- > 3 insufficient medial restraints
- < 1 tight lateral retinaculum
- > 3 insufficient lateral restraints
3. Apprehension test
- patient supine and relaxed
- patella pushed laterally while knee flexed 30o
- positive if patient uncomfortable (pain or apprehension)
Best is all assessed prone
1. Lateral border of foot
- metatarsus adductus
2. Tibial Torsion
- thigh foot angle > 15o
- trans-malleolar axis > 30o
3. Femoral anteversion
- excessive IR
- increased Gage's trochanteric angle
Wasting of anterior & lateral compartments leg
Scars at fibula head
Masses
Feet for dystrophic changes
Back - surgery / dystrophic changes
Hip - scars
Foot drop gait, high stepping, slapping
Along CPN
Tinel’s
Sensation Tibial nerve
- sole of foot
Sensation CPN
- SPN dorsum of foot
- DPN 1st webspace
Tibial nerve
- hamstrings
- T. Ach
- FHL
- FDL
CPN
- T. Ant (L4)
- EHL (L5) – often 1st damaged as most prox br
- EDL (L5,S1) – isolated with ankle in DF
- PL & PB (L5,S1) – eversion & palpate
L5 v Sciatic / Tibial
- examine Abductors (L5)
CPN above knee v below knee
- short head biceps EMG
Aids
AFO / KAFO
- ankle foot orthosis
- knee ankle foot orthosis
GRAFO
- ground reaction AFO
Kaye walker
- seat on it
- co-ordinates walking
Reciprocal Gait Orthoses
Sitting
Short adducted leg - dislocated hip
Scoliosis
Kyphosis - query secondary tight hamstrings
Decreased velocity
Coronal Plane
- scissoring / tight adductors)
- asymmetrical arm swing / hemiplegia
- LLD / hip dislocation
Sagittal
- equinus / jump / crouch
A. Equinus
- ankle in equinus
- knee straight or in recurvatum
- hip extends full
B. Jump
- equinus of ankle
- flexion of knees and hips, never extend fully
C. Crouch
- ankle in dorsiflexion
- over lengthening of T Achilles
- have to flex knees and hips to regain centre of balance
Lower Limb
R1 - do slowly
R2 - do quickly
Looking for a difference between the R1 and R2
- if reduced ROM on R2, have spasticity / dynamic element
- amenable to botox
1. Psoas
- FFD / Thomas test
- must test knee first
- do over edge of bed if FFD knee
2. Adductors
- scissored gait if bilateral
- apparent leg length inequality if unilateral
- Trendelenburg gait
- decreased hip abduction
3. Hamstrings
- FFD at knee
- knee flexed at start of stance phase
Popliteal angle (hip flexed at 90°)
- straight is 0˚
Unable to sit up with legs straight
- decreased SLR
- can't touch toes
4. Triceps Surae
- ankle equinus
- tiptoe gait
Silverskiold test
- distinguish between the gastrocnemius and soleus
- test ankle DF range with knee flexed and extended
- if gastrocnemius tight, reduced DF with knee extended
5. Iliotibial Tract
Obers' test
- patient on side and flex knee with hip in neutral abduction then as flex knee further hip abducts
6. Quadriceps
- stiff leg gait
- inability to flex knee with hip extended suggests tight rectus
Ely test (RF)
- child prone
- when the knee is flexed the hip flexes suggesting tight RF
7. Rotational profile
Increased / clonus / clasp knife
Increased
Primitive Reflexes
Moro
- child supine in arms, allow head to drop back
- arms & legs stick out in extension
- disappears by 4 months
Parachute
- arms and legs extend when child held prone
- appears at 5 months
Labyrinthine
- tone reduced & arms/legs flex when prone but increased tone & extended arms & legs with supine position
General
- resting position
- contractures
- joint stability
Hand placement
- ability to place hand in space
- < 10 seconds
Stereognosis
- ability to identify ojects in hand without looking
A. LL Equality
- Components equal with no deformity
B. Components equal with bilateral symmetrical deformity
- eg Bilateral varus knees
Uncompensated LLD
A. Fully Compensated LLD
- Flexed contralateral knee
- Equinus ipsilateral ankle
B. Sagittal deformity with ipsilateral sagittal compensation
- FFD knee with Equinus & hip flex OR
- Fixed Equinus with flex knee & hip OR
- FFD hip with equinus & flex knee
C. Coronal deformity with contralateral coronal deformity
- Valgus of knee & contralat varus of knee
A. Partly compensated LLD
- Partly flexed contralateral knee
- Partly equinus of ipsilateral ankle
B. Coronal hip deformity with sagittal compensation
- Fixed hip adduction with contralateral knee flexion / ipsilateral equinus
- Fixed hip abduction with ipsilateral knee flexion / contralat equinus
C. Sagittal def c coronal compensation
- FFD knee c ipsilateral hip abduction
- Fixed equinus c ipsilateral hip ADD
Posture
- flexed knee
Signs hemihypertrophy
- NF
- haemangiomas / lipomas (Proteus, Klippel-Trenau-Weber, Beckwith)
Scars
- trauma, infection
Aids / Shoes
- heel inserts / raises
Children
Compensate well
- Walk on toes short leg usually / equinus
- Flexion long knee uncommon as energy++
Adults
Compensate less well
- Walk with bilateral heel-toe gait
- Vaults over long leg
- Excess Sagittal head motion
A. Functional LLD
- on blocks
- heels flat, nil knee FFD (if able)
- correct pelvic tilt
- should correct scoliosis
Conclusion
- if can make pelvis stable
- ASIS equal
- blocks are a quantitative measure of functional LLD
B. Apparent LLD
Lying on bed
- measure from xiphisternum to medial malleolus
- no correction for contractures
C. Real / True LLD
Must correct for deformity in coronal and sagittal plane
Exclude
- hip adduction / abduction contracture
- hip FFD
- knee FFD
Scenarios
1. Hip FFD
- pillow under both thighs
2. Knee FFD
- pillow under both knees
3. Hip adduction contracture won't correct to neutral
- measure each leg crossed over the other
4. Hip abduction contracture won't correct to neutral
- place both legs in similar position
If there is a contracture, perform the above measures
- then meaure the intercalated segments
- from ASIS to medial joint line
- medial joint line to medial malleolus
Galeazzi
- must not forget can have small foot / old calcaneal fracture / wasted buttock
- hips and knees flexed
- side by side
- look for tibial / femoral shortening
If shortening above knee, find out if shortened above greater trochanter
- i.e. hip deformity
Bryant's triangle
- line perpendicular to GT and ASIS
- distance between
- quantify in fingerbreadths
Nelaton's line
- line from ischial tuberosity to ASIS
- GT should be on or below line
Klisics line
- GT to ASIS
- should aim to umbilicus
- will be more parallel
Examine Knee stability
- can have problems lengthening femur if ACL deficient
- i.e. fibula hemimelia
Original Paper
2486 individuals examined
- aged 1 week to 18 years
- at birth - no child lax jointed by criteria
- 2 years - 45% of normal children lax jointed
- 6 years - only 5% of normal children had lax joints
- 12 years - <1% of normal children had lax joints
Criteria
If 3 of the 5 pairs of joints examined in any one individual showed this degree of laxity it is taken as positive
1. Thumb touching forearm on flexing wrist
2. Fingers parallel to forearm with wrist extension
3. Elbows extend past 180°
4. Knees extend past 180°
5. Foot dorsiflex past 45°
1. Identify possible aetiology
- NM axis
- RA
- trauma
- clubfoot / arthrogryposis
2. Define the deformity & its flexibility
- fixed / flexible forefoot
- fixed / flexible hind foot
- fixed / flexible lesser toes
Aids / shoes
Front
Stork Legs
Lesser toes clawing
Scars
Hands (dorsal wasting intrinsics (CMT 1), rheumatoid hands)
Medial Side
High Medial arch
Plantar flexed first ray
Claw first toe
Behind
Hindfoot varus
Calf muscle bulk
Back
- scoliosis
- cutaneous manifestations spinal dysraphism
Double heel raise
- Heel swings into varus or remains in valgus
- does the medial arch restore
- bilateral suggests neurological
Single heel raise
- Must put patient close to wall
- otherwise will cheat by pushing up or leaning forward against wall
Coleman Block Test
- block under lateral foot
- allow first ray to touch ground
- Assess hindfoot
- If hindfoot varus flexible, heel corrects
- Elimination of forefoot deformity will correct hindfoot deformity if hindfoot flexible
Lateral side
Exclude calcaneo-cavus
Stiff ankle
Marionette Gait / High stepping
- Fixed equinus (weak Tib ant)(back knee gait)
Tip toe & heel walk
Examine Sole
- callosities over metatarsal head
Feel
- tenderness
- thickening CPN
Move
- range AKJ
- range STJ
- Silverskiold
- active v passive
Motor examination
- T. Ach strong / plantarflexion
- T. Ant weak / dorsiflexion and inversion
- T. Post strong / plantarflexion and inversion
- PB weak / eversion
First MT
- is plantar flexion correctable
Claw toes
- correctible
Abdominal Reflexes
Decreased or absent DTR
- CMT 1
Sensory decrease in 25%
In-toeing is normal up til 8 - 10 years
- combination ITT / PFA
- anteversion decreases, ETT increases
PFA
- usually symmetrical
- unilateral consider CP
ITT
- usually asymmetrical
Foot
- metatarsus adductus
- CTEV
- metatarsus primus varus
- skewfoot
ETT
- usually unilateral
- consider NM cause i.e. CP, SB
SUFE
Staheli's Torsional Profile
Squinting patella
- rotation above patella, in femur
Foot Progression angle
- Us 10° out (0°-30°)
Foot
- curved lateral border
- heel bisector should pass through second MT
Thigh- Foot Angle TFA
- knees flexed
- Reconstruct foot
- Usually 15° (0°-30°) ER
Transmalleolar Axis (TMA)
- knees flexed
- Usually 0 - 30° ER
Hip Internal Rotation
- Usually < 65°
- > 70° = FAV
Gage's trochanteric angle
- GT most prominent laterally
- angle of tibia from verticle
Hip External Rotation
- Usually 40° (20-60°)
- Greater in young child
- Note IR + ER should = 90°
1. Identify cause
- Marfan's / Neurofibromatosis / Skeletal Dysplasia
2. Balance & body asymmetry
3. Exclude LLD as cause
- correct with blocks or sit patient
4. Forward flexion / Adams forward bending
- look for rotation / rib hump
5. Assess flexibility if considering surgery
The right shoulder is raised
The right scapula is prominent
The loin creases are asymmetrical
The pelvis is level
There is flattening of the normal thoracic kyphosis
There is a normal lumbar lordosis
On forward bending, there is a (mild/moderate/severe) (well rounded/angular) rib hump and a mild left lumbar fullness
Maturity
- height / breasts / pubic hair
Skin
- cafe-au-lait spots
- axillary freckling (look in axilla)
- neurofibromas
Eyes
- Lisch nodule (NF)
- blue sclera (OI)
- cloudy cornea (mucopoly)
- dislocated lens (Marfan's)
- optic glioma
Mouth
- Abnormal teeth (OI)
- high-arched palate (Marfan's)
- large tongue (Achondroplastic)
Trunk
- pectus carinatum or excavatum
- protruberant sternum with sharp manubriosternal angle
Limbs
- hemihypertrophy
- dolichostenomelia (long limbs)
- arachnodactyly (thumb in palm)
- clubfoot - often first sign of dysraphism
- cavovarus foot
LLD
Thoracic kyphosis
- exaggerated, normal or reduced / hypokyphotic
Lumbar lordosis
- exaggerated, normal or reduced
Protruberant abdomen
Curve
- right or left
Balanced or Unbalanced
- alignment of C7 over gluteal cleft (ask for plumb bob)
Shoulder height
Scapular symmetry
Loin creases / lumbar fullness
Flattened heart-shaped buttocks
Pelvis
- level or not (pant line or PSIS)
Spinal dysraphism
- hyperpigmentation / hairy patch / dimple / lipoma / tail
Leg length
- if abnormal use blocks & reassess curve
- hands together & bend forwards to touch floor
- mild/mod/severe rib hump
- well rounded or angular
- satisfactory unroll
SLR
- hamstring tightness
Neurological
- Reflexes UL / LL / Abdominal / Babinski
- Sensation
- Power UL/LL
Scoliosis + No Abdominal reflexes & No Axillary sensation
Syrinx till proven otherwise
Abdominal reflexes disappear during teens
"This is a PA spine radiograph of a __ old skeletally mat/immature Risser __ male/ female with Scoliosis"
"There is a R/L typical/atypical curve thoracic/lumbar curve ± a R/L T/TL/L lower curve"
"The spine is/isn't balanced, the pelvis is/isn't level & the curve has a rotational component"
"The curve appears to be Idiopathic / Congenital / NF ? NM
Don't mention which is 1°/ 2° or postural or structural
1. Diagnose Myelopathy
- heel toe
- Rhomberg
- finger escape
- clench and release
- high tone
- inverted BR / Hoffmans
2. Identify Neurology
Front
- Position of head & neck
- Torticollis
- SCM tumour
- wasting limbs
Side
- Kyphosis
- Webbed neck
Back
- Low posterior hairline
- Sprengel shoulder
- Wasting Peri-scapular
Toe walking (S1)
Heel walking (L4)
Toe-to-heel walking
- looking for balance difficulty
- ataxia
Romberg
- assess dorsal column / proprioception
- stand feet together, close eyes
- positive if sway or fall
Finger escape
- hold hands out
- try to keep LF together with other fingers
Clench and release
- should be > 20 times in 10 seconds
Spinous processes
Paravertebral - trapezius
Posterior triangle
Sternomastoid
Forward flexion
- Chin to chest
- Total range of F/E is 130°
- Alanto Occiptial Joint (40% Nodding) / Subaxial (60% Forward translation)
Extension
- Plane of nose & forehead horizontal
Rotation
- Chin nearly to plane of shoulder 80°
- Atlantoaxial Joint (50%) / Subaxial (50%)
Lateral Flexion
- Ear to shoulder with shrug 45°
- Occurs at lower Cervical vertebrae
Spurling's Sign
- Nerve root compression is confirmed by Spurling's sign
- extension and rotation toward the symptomatic side reproduces the radicular symptoms
Thoracic Outlet Syndrome Tests
- Addsons
- Roos
Tone
High tone / clasp knife rigidity
Power
C5 - Deltoid / Biceps
C6 - Wrist Extension
C7 - Triceps
C8 - Finger Flexion
T1 - Interossei
Reflexes
C5 - Biceps
C6 - Brachioradialis
C7 - Triceps
Myelopathy reflexes
Inverted Brachioradialis
- tap on BR
- flexion of thumb and index finger
Hoffmann's reflex
- forced flexion of MF DIPJ
- reflex finger and thumb flexion is elicited
Scapulohumeral Reflex
- tapping tip of spine of scapula
- brisk elevation of scapula & abduction of the humerus
- positive in > 95% of myelopaths
Jaw Jerk
- a cerebellar sign
- distinguishes myelopathy from cerebellum
Sensation
C5 - deltoid
C6 - lateral forearm, thumb
C7 - middle finger, posterior arm
C8 - little finger
T1 - medial forearm
T2 - medial arm
Walking / mobility aids
Lumbar brace
AFO / shoes
Wasting - quadriceps
Manifestations of systematic disease
LLD
Normal
- there is a thoracic kyphosis and a lumbar lordosis
Abnormal
- exaggerated
- reduced
Scoliosis
Scars
Signs spinal dysraphism
Wasting - buttocks / thighs / calves
Tenderness
- vertebral level
- sacro-iliac joints
Forward flexion test
- standing with feet together & knees straight
- aiming to touch floor with hands on legs
Comment on
- pain
- level reached (fingertips in relation to front of legs)
- normal unrolling of the lumbar spine
Schobar's test
- thumb on LS junction
- line joining dimples of Venus
- reconfirms level pelvis
- index finger 10 cm above
- width of hand
- amount of increased separation of fingers on spine
- should be at least 50%
Extension
- one hand in small of back and one hand on shoulder
- normal 15-30°
Lateral flexion
- one hand on hip and other hand on shoulder
- normal 15-30°
Rotation
- feet still & twist body
- look from above
- angle between plane of shoulders and pelvis
- amount 45°
Tiptoes (L5 / S1)
Heels (L4)
Squat / single leg squat (L3)
Hip ROM
- flex hip to 90° and rotate hip
- comment painless range of hip movement
SLR
- patient lifts leg actively from bed with knee straight
- at what angle of hip flexion is pain reproduced
- pain must be in distribution of sciatic nerve / below knee
- differentiate from hamstring pain
Lasegue
- lower leg until pain just disappears
- forcibly dorsiflex foot and assess if pain recurs
Tone
- normal, increased or decreased
- clonus ankle (normal < 2 beats)
- clonus patella
Power
L2 - hip flexion / pull knee to chest
L3 - knee extension / hold knee straight
L4 - ankle dorsiflexion / T anterior / pull foot up
L5 - hallux dorsiflexion / FHL / pull big toe up
S1 - ankle plantarfiexion / push foot down
MRC Muscle Power Grading
0 - no movement
1 - flicker only
2 - movement with gravity eliminated
3 - movement against gravity
4 - movement against resistance
5 - normal movement
Reflexes
Knee jerk (L4)
Ankle jerk (S1)
Babinski - scratch soles
Sensation - light touch
LI - groin
L2 - thigh
L3 - knee
L4 - medial malleolus
L5 - bunion / dorsum foot
S1 - sole / lateral foot
S2 - posterior calf
S3,4 - 'bulls-eye' around perineum
Femoral stretch test
- flex knee to 90o
- extend hip
- positive if reproduces leg pain in distribution of femoral nerve
Abductor power (L5)
- lift leg up
- palpate contraction
- grade power
SI joint
- semilateral position
- leg flexed and adducted across body
- forced adduction
- reproduce pain
Ankylosing spondylitis
- wall test
- stand with back to wall
- heels, buttocks and occiput touch wall normal
Kyphosis
- forward bending test
- hyperextension while prone
Waddell's Signs (DR TOS)
- distracted SLR
- rotation causes pain
- tenderness non anatomical
- overreaction
- superficial tenderness
- appropriately disrobed / generalised disease / orthotics
- sagittal alignment entire spine
- wasting / lumbar spine coronal plane alignment / spinal dysraphism
Wide based gait
Heel Toe
- arms outstretched in front
- close eyes
- positive if lose balance once visual aids removed
- hold hands out, fingers together
- medial two fingers drift apart
- takes 30 – 60 seconds
- 20 times in 10 seconds
- myelopathy patients much slower
Palpate neck
- central / paraspinal / trapezius / posterior triangle
- flexion (should be able to get chin to chest)
- extension (should be able to get forehead parallel to ground)
- ear to shoulder
- rotation 80o
- Cogwheel rigidity
- clonus in feet
- ASIA (American Spinal Injury Association)
- look for interosseous wasting
- power often especially decreased in hands
- increased / inverted BR / Hoffman / Babinski
- decreased sensation globally / reduced vibration / proprioception
What is differential?
- Central / cerebellar cause / Demyelinating disorder
How do you differentiate Cerebellar causes?
- Nystagmus / Jaw Jerk
What is treatment?
- Depends on Imaging
- No kyphosis, multilevel degeneration - laminoplasty
- Kyphosis / discs / anterior vertebral osteophytes - ACDF / corpectomy and strut grafting
Supraclavicular
- nerve root patterns of sensation and motor disturbance
Infraclavicular
- peripheral nerve root pattern / cord
Supraclavicular preganglionic
- dorsal scapular, long thoracic, suprascapular
- Horner's
- lack of sensation supraclavicular
- no tinel's
Supraclavicular postganglionic
- + Tinels
- tender posterior triangle
Aids
Front
Horner's
- suggests C8/T1 root avulsion
Posterior triangle swelling / bruising
Wasting deltoid / biceps / pectoralis
Wrist drop
Side
Hand on head
- axillary scars
Back
Trapezius
Deltoid
Supraspinatus/ Infraspinatus
Static winging
Palpate post triangle
- tenderness
- supraclavicular post ganglionic
Tinel's in post triangle
- supraclavicular post ganglionic
Ask sensation
Supraclavicular C4
- suggests preganglionic injury
Axillary nerve C5
LCNF C6 musculocut n
SRN C6 (1st dorsal webspace)
C6 median n (thumb)
C7 median n (MF)
C8 ulnar n (LF)
C8 MCNF m cord (med forearm)
T1 MCNA m cord
T2 ICBN
Trapezius
- function of accessory nerve important
Roots / From Behind
Rhomboids
- shoulders back
- DSN C5
Serratus anterior
- push shoulder forward
- LTN C5-7
Suggest preganglionic
Trunk
Suprascapular Nerve (C5)
- supraspinatous
- infraspinatous
Front / Nerve Root innervation
Deltoid
- C5
- axillary / posterior cord
Bicep
- C5
- musculocutaneous / lateral cord
Tricep
- C7
- radial / posterior cord
Wrist extension
- C6
- radial / posterior cord
Finger flexion
- C8
- median / medial and lateral cord
Finger abduction
- T1
- ulna nerve / medial cord
Decide if fits root pattern
- otherwise consider cord injury
Cords
Posterior Cord
- axillary nerve (deltoid + T minor)
- radial nerve
- subscapularis
- lat dorsi TDN C7 (hand on hip / cough)
Medial Cord
- medial median (FDP, FPL, AbPB)
- medial pectoral (sternal head)
- ulna nerve (interossei, LOAF)
- MCNA / MCNFA (decreased sensation medially)
Lateral Cord
- lateral median (FCR, PT)
- musculocutaneous (biceps, sensation lateral forearm)
- lateral pectoral (clavicular head)
Biceps C5
Triceps C7
BR C6
Cephalad joint - Neck
Concealed - axilla
Circulation
Collagen
Palms up
Scars / Dimples / pits
Nodules - palm, proximal to distal palmar crease
Cords - extend into fingers & cause contracture
Thumb
Fingers - contracture of MCPJ, PIPJ
Palms down
Garrod knuckle pads
Hueston Table Top Test
- contracture MCPJ
- contracure PIPJ
Nodules / Cords / Webspaces (Natatory cords)
Sensation
Deformities
- stiff or flexible
PIPJ
- true v apparent FFD
- spiral cord crossing MCPJ and PIPJ may contract both
- flex MCPJ
- assess PIPJ
MCPJ Contracture
- Always correctable by removal of pretendinous bands
- Collateral ligaments are tightest in flexion
- Flexion deformity does not lead to collateral shortening
- Resection central cord restores extension
PIPJ
Contracture due to 4 cords
1.Central
2.Spiral
- pushes NV bundle volar and midline
- from spiral band and Grayson's ligaments
3.Lateral
- lateral digital sheath
4.Retrovascular
Not always correctable unless release volar plate & accessory collateral ligaments
- Collateral ligaments tightest in extension
- Flexion deformity leads to collateral shortening
Introduce
Aids - slings
Expose - shirt off
Stigmata generalised disease
Neck
ROM / exclude cervical radiculopathy
Shoulder
ROM
- touch hands on head
- behind head
- to mouth
- back pocket
Elbows
1. Extend elbows to front
A. Elbow
- carrying angle (N 7° - 12°)
- deformity
- bony prominences
- biceps bulk
B. Forearm contour
- ulnar border - FDP
- radial border - mobile wad
C. Hand
- thenar eminence
- hypothenar eminence
- look for clawing
2. Flex elbows to front
- olecranon wounds / bursa
- medial or lateral surgical scars
3. Flex elbows to side
- angle of flexion
- comment medial scars
- axilla
4 Extend elbows to side
- angle of extension / FFD
5. Pronation and supination
- 80o each
- thumb up / thumb down with elbows in
Hands
Look at dorsum for interossei wasting
Wrist Flexion / Extension
Fist with thumb in and out
Spread fingers
Medially
- medial epicondyle
- ulnar nerve tinel's / subluxation
Posterior
- oleranon/ triceps tendon
Laterally
- lateral epicondyle / tennis elbow
- radial head - stability / pain with rotation
Medially
- cubital fossa masses / biceps tendon
Medial Epicondylitis
- resisted wrist flexion & pronation
Lateral epicondylitis
- resisted wrist extension
- resisted MC Ill extension (ECRB)
Note stability in extension is predominantly bony
Valgus Instability
Jobe's Test
- MCL
- flex elbow to 25° (unlocks olecranon)
- pronate forearm (prevents false +ves due to lateral laxity)
- gentle valgus stress
- compare opposite side
Varus Instability
Varus strain
- with elbow at 25°
O'Driscoll's Test / elbow Pivot Shift
- patients describe clunk on full extension & feel posterolateral pain
- ulnar portion of LCL (LUCL) is the key
- dislocation occurs with a valgus ER force pivoting the elbow on the intact MCL
Technique
- patient supine with examiner at head of bed
- GHJ full flexed with hand over head
- Forearm supinated and Elbow extended
- Valgus stress applied
- Axial load
Positive if
- prominent radial head (dislocates) / pivot / pain
- max subluxation is at 40° flexion
- with increased flexion reduces with snap
Circulation
- brachial / radial pulse / ulnar
- Allen's test
Cephalad joint
- shoulder ROM
Collagen
- ligamentous laxity
Concealed
- cubital fossa
Palm up
- Pointing index finger (Bennett's / AIN)
- Wasting thenar eminence
- wasted forearm muscles
- volar scarring
Thumb up
- wasting thenar eminence
- radial border wrist
Palm down
Palms together
- LF
- Axilla scars
Sensation
Lateral forearm - LCNF / lateral cord / C6
Thenar eminence - Palmar Branch Median Nerve / C6
IF - C6 Median nerve
MF - C7 Median nerve
LF - C8 Ulna nerve
Median Forearm - MFCN / medial cord / T1
Is sensation loss peripheral / dermatomal?
Median nerve
PT (C6)
- first branch
- test with elbow flexed
FCR (C6)
- flex wrist & palpate
FDS(C8)
PL (C8)
AIN
FDP IF/MF (C8)
- make fist & resists IF extension
FPL (C8)
- resists extension of IPJ
PQ (C8)
- test with elbow extended (eliminate PT)
Motor Recurrent Branch (T1)
AbPB
- patient abduct thumb away from palm against resistance
- palpate muscle belly
1st Lumbrical
- Lateral Digital Branch
- thumb to IF pad to pad
2nd Lumbrical
- Medial Digital Branch
- thumb to MF pad to pad
Lumbricals
- extend DIPJ
- if not functioning --> unable to pulp to pulp
- will only be able to bring tip to tip
- because unable to extend DIPJ
Tinel's
- start distal & move proximally
Phalen's
- 60 second patient holds wrist flexed
Allen's test
- if considering CTD
CTS
- normal sensation thenar eminence and forearm
AIN palsy
- no sensory deficit
- weak FPL / FDP / PQ
Pronator syndrome
- Pain only
C6
- weak wrist extensors
- decreased sensation medial forearm
TOS
- C8 / T1
- weak thenar eminence
- abnormal sensation medial forearm and LF
Brachial Plexus
Pronator Syndrome
- ligament of struthers
- lacertus fibrosis
- pronator teres
- FDS
AIN Syndrome
- pronator teres
- FDS
- aberrant muscles or blood vessels
- trauma
CTS
- palmar branch is not involved
Neck
- ROM
Shoulder
- behind head / to mouth
- to back pocket
Elbows
- flex / extend elbows
- pronation / supination with thumb up & elbows by side
Wrist
- flexion / extension
Hand
- make fist with thumb in and out
- spread fingers
Power Grip
Precision Grip
Hook Grip
Lateral Pinch Grip
Tip Pinch
1. Tip to Tip Pinch Grip
- pick up coin
2. Lateral pinch grip
- turn key
3. Precision grip
- write with pen
4. Power Grip
- turn knob
5. Hook Grip
- hold suitcase / fingers
Palms up
Scars
- CTD / flexor tendon synovectomy
Swelling
- flexor sheath synovium
Thenar & Hypothenar eminences
Thumb up
Thenar wasting
Swan neck / Boutonniere deformity
Palms down
Wrist
- synovitis / synovectomy
- wrist fusion
- caput ulna
- radial drift
MCPJ
- ulna drift / replacement / synovitis
- tendon subluxation
Fingers
- Swan neck, Boutonniere
Sensation
- median nerve / CTS
- ulnar nerve
Extensor tendons
- drop fingers
- DDx - locked trigger, tendon subluxation, joint subluxation, PIN palsy
EPL
- ruptures over Listers
- IPJ is extended by intrinsics also
Flexor tendons
- rupture IF & thumb (synovitis)
- rupture FPL alone over trapezial ridge (Mannerfelt)
- triggering
MCPJs
- ? subluxed
Boutonniere deformity
- degree of lag
- passively correctable
- ? arthritic changes
Swan neck deformity
- passively correctable
- intrinsic tightness / Bunnell test
- arthritic changes
Bunnell Test
- test with MCP extended and flexed
- correct ulna deviation
- invalidated by MCPJ dislocation
- with tight interossei will have reduced PIPJ flexion with MCPJ extension
Splints
Wasting
- triceps / extensor forearm
Arm up
- axilla / posterior / lateral elbow scars
Sensation
Axillary nerve - C5 / posterior cord
PCNFA
LCNF - C6 / Lateral Cord
SRN - C6 / Dorsal 1st Web
Median C6
- IF
State dermatomal or peripheral nerve
Move
Triceps C7
BR / ECRL - Radial Nerve
ECRB / EDC / EPL / EI - PIN
Supinator
- elbow extension to eliminate biceps, resist pronation
Tinels
C7 lesion
- triceps power / reflex lost
- good wrist extension (C6)
C6 lesion
- triceps intact
- wrist extension lost
Posterior cord
- radial nerve + axillary nerve + subscapularis + lat dorsi
High lesion / no triceps
- Saturday night palsy
Intermediate lesion / triceps intact / no BR or ECRL
- humeral fracture
Low lesion / PIN Compression (FREAS)
- fascial bands
- recurrent radial
- ECRB
- arcade of Frohse
- exit supinator
Exposure
Splint
Sling
From Front
Skin
- scars
Swelling
- SCJ
- clavicle
- ACJ
- biceps (rupture long head)
Wasting
- deltoid
- trapezius
- arm
From Side
Turn affected side towards you
Wasting
- pectoral contour
From Back
Scapular symmetry
- height
- winging
Wasting
- supraspinatus
- infraspinatus
"Where is it painful ?"
Bony prominences
- SCJ
- clavicle
- ACJ (compare with other side)
- acromium
- biceps tendon
Scapular spine
Supraspinous fossa
- ganglion
- osteochondroma
Infraspinous fossa
- tenderness
- cuff defect
Forward flexion
Active
- both arms raised forward, supinated
- range
- check axilla
Abduction
Active
- elevate both arms in coronal plane, supinated
- initiation
- range (160°-180°)
- rhythm
- arc of pain
- shoulder hiking
Passive
- if not full, passive to 180?
- active v passive
Observe arm lowering
- arc of pain
- drop arm
Extension
Active
- both arms raised backward
External rotation
Active
Elbows flexed to 90o and arms by side
- start with arms forward
- rotate arms outwards (90°)
Passive
If not full, passive
Internal rotation
Active
- ask to run thumb up spine
- mark good and compare bad
- thigh / buttocks / waist / LS / T12 / angle of scapula (T7) / tip of scapula (T2)
Power of supraspinatous
- 30° abduction
- in plane of scapula (30° forward from coronal plane)
- forearm pronated (thumb to the ground)
- resisted abduction
Power of Infraspinatous
1. Grade power external rotation
2. Extensor lag
- take out to full passive ER
- release and see if lags
3. Hornblower's
- positive if drop and IR
- suggests massive PS tear
- teres minor
Power of Subscapularis
1. Gerber's Lift off test
- Gerber's test is normal if patient can hold hand off buttock
- patient must have full IR & not be limited by pain to use this test
- "Pathological lift off test - patient is unable to lift the dorsum of his hand off his back"
- put dorsum of patient's hand on buttock then lift it off buttock & let go
2. Belly Press Test / Nelaton Test
- resisted internal rotation with hand on belly
- must keep elbow forward
- otherwise patient uses shoulder retractors
- positive if drop elbow
Neer's impingement test
- passive forward flexion
- forearm pronated
- scapula stabilised
- positive test - pain at arc 70-120°
Hawkin's impingement test
- forward flex elbow to 90°
- internally rotate and adduct arm
- positive test - pain
Cross body adduction
Speed's test
- resisted forward flexion at 90° with forearm supinated
- assess pain or popping at bicipital groove (long head of biceps)
Yergason's Test
- externally rotate arm with elbow 90°
- resisted supination
- assess pain or popping at bicipital groove (long head of biceps)
Compression-Rotation test / McMurray's Shoulder test
- test for SLAP lesion
- patient supine
- shoulder abducted 90°, elbow flexed 90°
- compression force to humerus
- humerus rotated
- attempt to trap torn labrum, positive if pain & click
O'Brien's
- SLAP lesion
- arm across body, in plane of scapula
- pain with stress abduction, thumb down
- nil pain with thumb up
Sulcus sign
- needs to be compared to the opposite side
- patient
- in front of patient
- hands in lap
- pull down on both elbows
- look for sulcus
Anterior / Posterior Drawer
- sit next to patient
- stabilise shoulder girdle with 1 hand
- thumb on spine of scapula
- forefinger on coracoid
- centralize humerus
- must compare to normal side
- translate humeral head forward with other hand
- anterior & posterior translation noted
Anterior Apprehension Test
- patient lying
- shoulder abducted and elbow flexed 90°
- externally rotate shoulder
- positive test - look for apprehension
Jobe Relocation Test
- patient supine
- arm abducted to 90°
- forced external rotation
- relocate by pushing humeral head posteriorly & superiorly
- usually described by putting hand on humeral shaft
Posterior Stress Test
- stabilise scapula
- place shoulder in 90° forward flexion & 90° IR & adducted
- apply posterior force
- patient experiences pain +/- apprehension
- unlike anterior test patient has positive test if pain only
- note should reproduce the patients symptoms
Load and Shift
- patient lying down
- their hand under examiners armpit
- grasp neck of humerus with both hands
- load humerus into glenoid axially
- examinate stability annterior and posterior
Wynne-Davies Criteria
1. Thumb touching forearm on flexing wrist
2. Fingers parallel to forearm with wrist extension
3. Elbows extend past 180°
4. Knees extend past 180°
5. Foot dorsiflex past 45°
"If 3 of the 5 pairs of joints examined in any one individual showed this degree of laxity it is taken as positive."
Adson Manoeuvre
- head toward side tested, neck extended
- palpate radial pulse of extended arm
- patient inhales deeply
- positive test if decrease or obliteration in pulse with concomitant reproduction of symptoms
Wright's Manoeuvre
- head turned away from tested arm, neck extended
- arm in 90° abduction & 90° extension
- palpate radial pulse
- patient inhales deeply
- positive test if decrease or obliteration in pulse with concomitant reproduction of symptoms
Cephalad Joint Neck
ROM
Compression Test
- slight extension
- compression
Spurling's test
- neck in lateral flexion, rotation
- stressed with compression
- positive if pain in ipsilateral extremity
Circulation
Radial pulse
Concealed
Axilla
Collagen
Splints
Extend elbow to side
- medial wounds
- extension
Flex elbow to side
- flexion range
Flex elbow to front
- olecranon wound
Extend elbow to front
- anterior wounds
- carrying angle
- forearm wasting
Palm up
- clawing
- hypothenar eminence
- scars
Thumb up
- thenar eminence
Palm down
- interossei / adductor pollicis wasting
Palms together
- claw
- hypothenar eminence
Sensation
1. LF & RF
2. Dorsal branch ulna nerve
- branches above wrist
- runs under FCU
- dorsum of hand, ulna side
- dorsum LF and half RF to P2
3. Palmar cutaneous branch
- above wrist
- hypothenar eminence
3. Medial forearm (MCNF / T1)
- above ulna
Above elbow
1. FCU (C7)
- patient flexes wrist, palpate
2. FDP (C8)
- patient makes fist & resists extension of LF
Below wrist
1. AbDM
- LF together
- first branch deep nerve
2. 1st Dorsal Interossei
- push both IF together
- last branch deep nerve
3. Adductor Pollicis
- Froment's sign
- hold paper between thumb and IF
- positive if patient uses FPL to grip
4. Card sign
- between index and middle finger
- PAD
- palmar interossei adducting
5. Lateral 2 lumbricals
- unable to pad to pad LF / RF
- lumbricals extend DIPJ
- patient can only tip to tip
Tinel's - Cubital tunnel, Guyon's
Ulna nerve subluxation / tenderness
T1
- thumb APB weak / wasted
C8
- EDC / Wrist extension weak
TOS
- sensory loss above wrist
- Addson sign
1. Medial Intermuscular septum
- arcade of Struthers (fascial band)
- septum
- hypertrophied medial head triceps
2. Medial epicondyle
- tardy ulna nerve palsy, previous fracture
3. Epicondylar groove
- intrinsic (SOL, synovitis, rheumatoid nodule
4. Cubital Tunnel
- tendinous arch of FCU
5. Exit FCU
6. Guyon's canal
- FDP OK
- palmar & dorsal br spared
- all small hand m's affected
7. Deep motor branch only
- can be compressed against pisiform & hamate
- with using mallet, vibrating tools
- sensation normal
Take watch off
Palm up
- thenar wasting
- STT gangion
- thumb OA
- flexor synovitis
Thumb up
- thenar wasting
Palm down
- dorsal SL ganglion
- extensor synovitis
Palms together
- claw ulna
- elbow scars
Wrist
- extension
- flexion
- radial / ulna deviation
- pronation / supination (thumb up)
Finger flex and extend
- thumb in and out
- spread fingers
Sensation
- ulna nerve / radial / median nerve / CTS
Radial side
Distal Radius
1st extensor compartment
- swelling EPB / APL
- Finklestein's
- flex and extend thumb
- feel crepitus
Intersection
- tenderness crossover EPB APL
Scaphoid
- snuffbox
- tuberosity
- Watson's test
Base of thumb
- tenderness
- deformity
- Grind Test
MCPJ thumb
- tenderness
- weakness ulna collateral
SL joint
Wartenberg's radial neuritis
Ulna side
ECU tendon
Lunotriquetral joint
- instability test
- one under each thumb & toggle
- look for movement or pain
Ulna head
- deformity
- instability
Hamate Hook
- tenderness with #
DRUJ
- synovitis
- tenderness
- piano key
- pro/sup subluxation, pain, clicking
TFCC
- palpate for tenderness distal to ulna
- Grind test circ & press
- look for pain & crepitus
PisoTriquetral Joint
- occupational injury
- press & rock against Triquetrum
- look for pain & crepitus
- similar concept to patella
Guyon's canal
- Tinel's
Allen's test
CTS
Ulna Nerve