Transcript Aspects of Musculoskeletal Examination

Easy assessment of
musculoskeletal system
for GPs
Aspects of examining the
musculoskeletal system
Revisiting the basics
 GALS
 Video
 Some bits and pieces / a personal view
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History
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“Have you any pain or stiffness in your
muscles, joints or back?”
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“Do you have any trouble getting up or
down stairs?”
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“Do you have any difficulty getting
dressed?”
Revisiting the basics
Inspection
Look
 Palpation
Feel
 Movement
Move
 Stability
 Function
 Compare with opposite side
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Inspection
Skin colour / rashes
 Swelling
 Deformity
 Scars
 Muscle wasting
 Surrounding structures - bursae,
tendons
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Palpation

Nature of swelling
–bony
–synovial
–effusion
Warmth
 Tenderness
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Movement
Active and passive
 Range of movement
 Crepitus
 Note pain
 Instability

Stability

Subluxation or dislocation
– MCP
– Radioulnar
– subtalar
– MTP
Function
Lower limbs - gait
 Hands
–pincer grip
–power grip
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GALS
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Doherty, Dacre, Dieppe and Snaith (1992)
The GALS locomotor screen, Annals of
Rheumatic diseases 51: 1165-9
GAIT
 ARMS
 LEGS
 SPINE
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GALS
“…provide a valuable screening test for
use in general practice”
 “the procedure can be viewed as a
general functional (disability), as well as
a basic musculoskeletal assessment”
 “..be useful in selective situations as a
rapid test of functional performance and
to screen out regional locomotor
abnormalities that merit closer scrutiny”
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GALS recording
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Bits and pieces
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Hands
Wrists - CTS + de Q
Shoulders
Backs
Hips
Feet - biomechanics
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Hypermobility
Fibromyalgia
Hand - RA
Early synovitis
PIP - skin discolouration and tenderness
 Clench fist - MCPs should be white with
no infilling
 MCP squeeze to elicit tenderness
 Inferior radio ulnar stress test
 Bulge sign at knee
 MTP squeeze test
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Hand OA
Raynauds 1
Raynauds 2
Scleroderma early
Scleroderma
Sclerodactaly (acrosclerosis)
Carpal Tunnel Syndrome
•Phalen’s
•Tinel’s
De Quervains tenosynovitis
APL and EPB tendons
 tender over radial styloid
 sometimes nodule (thickened sheath)
 Finkelsteins test
 Rest it
 Inject it

Shoulders
Shoulder or not
 Glenohumeral or not - external rotation
 Tenderness

– bicipital groove
– subacromial
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Painful arc of abduction
Shoulder - abduction
Shoulder function related to
abduction
Backs
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Lumbar flexion
– Modified Schobers - or use
your fingers
– Fingers to floor =
misleading
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Lumbar extension
Lumbar lateral flexion
“Sacroiliac restriction”
Backs - neurology
Root
Sensory loss
Motor weakness
Reflex
L4
Medial calf and
ankle
Knee extension,
foot inversion
Knee
L5
Medial foot and
hallux
Dorsiflexion foot
and hallux
None
S1
Outer foot and
sole
Plantar flexion foot
Ankle
Hips
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Internal rotation - can examine sitting
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Trochanteric bursitis
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Trendelenburg hip pain
to distinguish lumbosacral from
Trendelenburg test
Foot - biomechanics
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Swing phase
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Stance phase
– Contact (27%)
– Midstance (40%)
– Propulsive (33%)
Biomechanics - stance phase
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Contact
– outer border heel strikes then
– PRONATION at subtalar joint shifts centre
gravity medially
– causes tibia to internally rotate
– purpose is shock absorption/adaption
uneven ground
Biomechanics - stance phase (2)
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Midstance
– forefoot loaded
– subtalar joint supinates
– causes tibia to externally rotate
– foot is converted to rigid lever ready for
propulsion
– ends with heel lift
Biomechanics - stance phase (3)
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Propulsion
– app 25% bodyweight on metatarsals and
toes (esp 1st)
– ends with toes off
Abnormal pronation and
supination
Over pronation
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Subtalar pronation
unchecked
longitudinal arch
stretches and
flattens
excess rotation of
tibia
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Hallux valgus
Plantar fasciitis
Achilles tendonitis
Post tibial tendonitis
stress# navicular
anterior knee pain
low back pain
Hypermobility
1
2
3
4
5
Dorsiflexion of 5th MCP to 90 degrees
Apposition of thumb to volar aspect of
forearm
Hyperextension of elbow by 10 degrees
Hyperextension of knee by 10 degrees
Hands flat on floor with knees extended
Fibromyalgia
The End