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MODULE 15

Clinical skill : Physical examination


Learning objective
1. The student is able to perform screening musculoskeletal
examination GALS (gait, arms, legs and spine).
2. The student is able to record the findings from GALS
examination.
3. The student is able to perform shoulder examination
4. The student is able to perform knee examination
5. The student is able to perform hip examination
6. The student is able to perform leg examination

GALS assessment
In combination with supervised accredited practice the successful student should be to
able to perform a GALS assessment of the musculoskeletal system

Gait Arms Legs Spine


The GALS screening examination is a fast and efficient way to assess the integrity of
the musculoskeletal system. It is not meant to be a diagnostic examination - but a brief
screening examination for significant abnormality of the musculoskeletal system If any
abnormality is detected then a more detailed regional examination should be carried
out. An assessment of the musculoskeletal system should always take place in the
routine clerking in of patients.You will have an opportunity in the CSEC to practice
carrying out a GALS assessment.

Screening questions for musculoskeletal disorders

1. Do you have any pain or stiffness in your arms, legs or back?


2. Can you walk up and down stairs without difficulty?
3. Can you dress yourself in everyday clothes without any difficulty?

Screening examination for musculoskeletal disorders


Ask the patient to walk a few
steps, turn & walk back.
Gait

Observe the patients gait for symmetry, smoothness


and the ability to turn quickly.

With the patient in the


Observe for any abnormalities in the muscles (e.g.
anatomical position inspect
reduced muscle bulk), spine (e.g. abnormal spinal
from the posterior, lateral and
curvature such as scolosis), limbs or joints (e.g. a red
anterior aspects.
swollen knee)
Inspection

Neck movements
Spine

Lumbar spine movement

Inspect the spine for any abnormalities including


abnormal kyphosis, scolosis or loss of lordosis.
Ask the patient to tilt their head to each side, brining
the ear towards their shoulder. Assess the degree of
lateral neck flexion.
Ask the patient to bend forward and touch their toes.
During this movement the patient may depend partly
on good hip flexion to bend forwards. So it is always a
good idea to palpate for the range of lumbar
movement. Place two fingers over the lumbar
vertebra. As the patient bends forward your fingers
should move apart (assuming the patient has a good
range of lumbar spine movement)

Arms
Shoulder movements

Ask the patient to place their hands behind their head,


with their elbows back This movement assesses
abduction, external rotation of the shoulder and elbow
flexion.

Elbow movements & hands

Ask the patient to extend their arms fully and turn their

hands over so palms are down.


Following this ask the patient to turn their hands over.
Observe the hands for any joint swelling or deformities
Click here to see some interesting clinical cases

Grip strength

Precision pinch

Metacarpalphalangeal squeeze
test

Knee movements

Ask the patient to make a fist. Observe the hand and


finger movements
Ask the patient to grip your fingers and assess the
degree of grip strength

Ask the patient in turn to bring each finger in turn to


meet the thumb

Squeeze across the metacarpalphalangeal joints


(tenderness here may indicates synovitis of
metacarpalphalangeal joints)
Click here to see some interesting clinical cases

With the patient lying on the couch assess flexion and


extension of both knees. Make sure to palpate the
knee for crepitus

Hip movement

Hold the knee & hip flexed to 90 degrees. Now assess


the degree of internal rotation in each hip

Patellar tap test

Perform a patellar tap in each knee for the presence


of an effusion

Inspection of feet

Inspect the feet for any swelling, deformity or any


callosities

Metacarpalphalangeal squeeze
test

Squeeze across the metatarsophalangeal joints for


any tenderness

Leg

Record

Record your findings

Skill

Shoulder examination

Learning
outcome

To be able to i) identify surface anatomy of the shoulder


ii) examine a patients shoulder & iii) compare left and right shoulders.

The shoulder joint is the most mobile joint in the body, allowing the hand to be placed into a position
where it can operate efficiently. To achieve its range of mobility, the shoulder is dependent for stability
on surrounding soft tissue structures, in particular a group of muscles called the rotator cuff. The two
main bones of the shoulder are the humerus and the scapula. The joint cavity is cushioned by articular
cartilage covering the head of the humerus and face of the glenoid. The scapula extends up and around
the shoulder joint at the rear to form a roof called the acromion, and around the shoulder joint at the
front to form the coracoid process. The end of the scapula, called the glenoid, meets the head of the
humerus to form a glenohumeral cavity that acts as a flexible ball-and-socket joint. The joint is stabilized
Background by a ring of fibrous cartilage surrounding the glenoid called the labrum. Ligaments connect the bones of
the shoulder, and tendons join the bones to surrounding muscles. The biceps tendon attaches the
biceps muscle to the shoulder and helps to stabilize the joint. A group of short muscles originate on the
scapula and pass around the shoulder where their tendons fuse together to form the rotator cuff.
Movements of the shoulder joint are dependent on five functional areas: glenohumeral joint; the
acromioclavicular joint; the subacromial joint between the acromioclavicular arch above and the head of
the humerus below; the sternoclavicular joint and the scapulothoracic region. Shoulder pain can arise
from a number of sites including: the rotator cuff tendons, biceps tendon, subacromial bursa,
glenohumeral joint, acromioclavicular joint & the sternoclavicular joint.
Procedure INTRODUCTION, PATIENT IDENTIFICATION & CONSENT
HAND WASHING
EXPOSURE
When examining a patients shoulder, their upper garments should be removed. This will also provide an
opportunity to observe the patients shoulder function.
INSPECTION
Observe both shoulder areas from the anterior, lateral and posterior aspects. Observe for any scars,
swelling, erythema, muscle wasting or abnormal contours.

Example of a scar in a patient who has received shoulder surgery.

PALPATION
Prior to palpating the patients shoulders, ask if they are experiencing any pain. It is often useful to have
the patient point to the site where they are experiencing discomfort. Equally you should instruct the
patient to inform you if they experience any pain during the examination.
During palpation observe for any signs of tenderness, swelling, temperature or crepitus.You should
palpate both shoulder joints in a systematic approach. A suggested approach would be:
1) Sternoclavicular joint
2) Clavicle
3) Acromioclavicular joint
4) Humeral head
5) Coracoid process
6) Deltoid muscle
7) Spine of scapula
8) Supraspinatus muscle
9) Infraspinatus muscle
10) Trazpezus muscle
(then repeat on the other side)

MOVEMENT
Note! Remember in assessing the patients range of shoulder movements you should always compare one side
with the other.
When assessing movement in a patients shoulder joint you should assess:
Active movements (i.e. movements performed by the patient on their own)
Passive movements (i.e. movements performed by the examiner)
Resisted movements (i.e. movements against resistance)
A general rule of thumb is that reduced active movements, that improve on passive movement, suggest
muscular / tendon problems. Reduced range of both active and passive movements suggest intra-articular
disease.
The range of movements that we assess for in the shoulder joint include:
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation

Tip! To have the patient perform the various range of shoulder movements try not to use medical jargon (e.g.
Abduct your shoulder please!). Stand in front of the patient, face to face, and ask them to copy the movements
that you make (assuming that your shoulders have a normal range of movement!) - this can make patient
understanding of your instructions a lot easier.

ACTIVE MOVEMENTS:

Active shoulder flexion


Have the patient flex their elbows to 90 degrees, then ask the patient to
move their arms upward as high as possible.
(Normal range - usually 180 degrees)

Active shoulder extension


Have the patient flex their elbows to 90 degrees, then ask the patient to
move their arms backwards as far as possible.
(Normal range ~ usually 50 degrees)

Active shoulder abduction


With the elbows fully extended, ask the patient to bring their arms away
from their body.
(Normal range ~ usually 180 degrees)

Active shoulder adduction


With the elbows fully extended have the patient place their arms across
their trunk.
(Normal range ~ usually 45 degrees)

Active shoulder external rotation


With the elbows flexed to 90 degrees, have the patient pin their elbows
to their side. Now ask them to move there arms out as far as possible
(Normal range ~ usually 90 degrees)

Alternatively you may ask the patient to place their hands behind their
head, with their elbows far back as possible.

Active shoulder internal rotation


Again with the patients elbows flexed to 90 degrees and their elbows
pinned to their side, have the patient bring their arms to their centre
(Normal range ~ usually 50 degrees)

Alternatively you may ask the patient to place their thumbs up their back
and try to touch their back as high as possible

PASSIVE MOVEMENTS:
Prior to passive movements it is important to have your patient relax as
best as possible.

Passive shoulder flexion


Flex the patients elbow to 90 degrees, then move their arm upward as
high as possible. (Repeat on the other side)
(Normal range ~ usually 180 degrees)

Passive shoulder extension


Flex the patients elbow to 90 degrees, then move their arm backwards
as far as possible (Repeat on the other side)
(Normal range ~ usually 50 degrees)

Passive shoulder abduction


Fully extend the patients elbow. The examiner shoulder place a hand on
the patients scapula to fix it in that position. Now move the patients arm
away from their body. By fixing the scapula, allows assessment of the
glenohumeral joint only. The normal range of movement here should be
approx 90. By taking your hand of the patients scapula, should now
allow for scapulothoracic movement which normal can bring the arm
up to 180 degrees. (Repeat on the other side)

Passive shoulder adduction


Fully extend the patients elbow, and then place their arm across their
trunk as far as possible. (Repeat on the other side)
(Normal range ~ usually 45 degrees )

Passive shoulder external rotation


Flex the patients elbow to 90 degrees and pin their elbow to their side.
Now move there arm out as far as possible. (Repeat on the other side)
(Normal range ~ usually 90 degrees )

Passive shoulder internal rotation


Again with the patients elbow flexed to 90 degrees and their elbow
pinned to their side, move their arm to their centre. (Repeat on the other
side)
(Normal range - usually 50 degrees )

Depending on your clinical findings you may want to perform resisted movements. This will be covered in
the CSEC & in your clinical attachments
When making an assessment of a patients shoulder there are many other special tests / manoeuvres that
can be performed. They will not be discussed here.
You may also consider examining the patients peripheral neurological system in the upper limbs and
circulation status.

EXAMINATION OF OTHER AREAS


Remember there are many other conditions that can cause shoulder pain (e.g. pain radiating from the neck,
gallbladder disease, cardiac pain) so depending on the circumstances you may want to perform other relevant
clinical examinations.

Skill

Knee examination

Learning outcome

To be able to i) identify surface anatomy of the knee & ii) examine a patients knee
Knee pain can be a source of significant disability & health care utilization. Around
4.5 million people in the UK have severe knee pain. Because of our ageing
population & increasing levels of obesity, the number of patients with disabling
knee pain is set to increase. In order to make an accurate diagnosis of a patients
knee pain a thorough physical examination needs to take place including

Back ground

i) a careful inspection of the knee


ii) palpation of the knee
iii) assessment for joint effusion
iv) range-of-motion testing
v) evaluation of ligaments for any signs of injury or laxity
vi) assessment of the menisci

PROCEDURE
Introduction

Introduction & patient consent

Hand hygiene

Hand washing

Exposure

Make sure that both knees are fully exposed. The patient
should be in either a gown or shorts. Rolled up trouser legs
generally does not provide adequate exposure.

Inspection

Observe the patient both walking and standing. Do they


walk with a limp or appear to be in pain? Is there any
evidence of muscle wasting?

Is there any evidence of bowing (varus) or knock-kneed


(valgus) deformity?
A patient with genu varum
(Varus deformity of the knee)
due to osteoarthritis
Any scars present?

Recent scar & staples after a total knee


replacement

Does the knee appear red or swollen?

A patient with prepatellar bursitis

Any rashes present?

A patient with psoriasis


For this part of the examination place the patient on the
bed. If the patient has an injured knee, start by examining
the unaffected side. This allows for comparison while
gaining the patients confidence, given that you are not
causing discomfort right from the outset of the
examination. Remember that in all parts of the knee
examination, always compare one knee with the other.
Palpate knee for temperature

Palpation
Feel systematically around the knee joint for tenderness
including the patella, quadriceps tendon, prepatellar &
collateral ligaments. Bend the knee to 90 degrees & feel
around the medial & lateral joint lines for tenderness.
Remember to feel at the back of the knee for a popliteal
(Bakers cyst) With the back of your hand do you feel an
increased temperature compared to the other knee?

Palpate around joint margins


Assess for an
effusion

Patellar tap test :


Slide your hand down the patients thigh, pushing down
over the suprapatellar pouch, so that any effusion is forced
behind the patella. When you reach the upper pole of the
patella, keep your hand there and maintain pressure.
Using the index & middle finger of the other hand push the
patella down gently.
Does it bounce? If so this may indicate the presence of an
effusion.

Milk the suprapatellar pouch

Patella tap

Bulge test:
Using your thumb and index finger - milk down any fluid
from above the knee. Keep this hand in this position.

Applying pressure to the medial side of the


knee

Now with the other hand stroke the medial side of the knee
to empty the medial compartment of fluid then stroke the
lateral side. Observe the medial side of the knee for any
bulging? This may indicate an effusion.
Applying pressure to the lateral aspect of
the knee and observing for any bulging on
the medial side of the knee

The normal range of motion of the knee is from: 0 degrees


(Extension) to approx 135 degrees (Flexion)
Movement

Active movement
Ask the patient to fully bend (flex) then straighten (extend)
their knee. Always compare the range of movement with
the other knee. Is there any reduced range of movement?
Active flexion of the knee
Passive movement
Place one hand on the patients knee and then with the
other hand flex (bend) the knee as far as possible & then
extend the knee. With the hand that is placed over the
knee do you feel a 'grinding' sensation? Such a grinding
sensation (crepitus) is usually indicative of degenerative
knee disease (osteoarthritis) which reflects a loss of the
normal smooth movement between the articulating
structures (i.e. femur, tibia, and patella).

Passive flexion of the knee

Special tests

Medial Collateral Ligament:

Collateral
ligament
assessment

Cradle the patients lower leg between your arm and body.
The knee should be flexed to 30 degrees. Now with your
other hand apply valgus stress to the knee joint. Excessive
movement indicates ligament damage.
Lateral Collateral Ligament
Cradle the patients lower leg between your arm and body.
The knee should be flexed to 30 degrees. Now with your
other hand apply varus stress to the knee joint. Excessive
movement indicates ligament damage.

Cruciate
ligament
assessment

Anterior Cruciate Ligament


The integrity of the anterior cruciate ligaments can be
assessed using the anterior draw test. Have your patient
assume the supine position with their knee flexed to
approx 90 degrees. After checking if the patient does not
have a sore foot, fix the patient's foot by sitting on their
foot, in order to stabilize the lower leg. With the patient's
hamstring muscles relaxed, wrap your fingers around the
back of the knee, keeping your thumbs in front of the
patella. Now pull anteriorly. In a relaxed normal patient
there is usually a small degree of movement. Excessive
movement may be indicative of anterior cruciate ligament
injury.
Posterior cruciate ligament
Simply repeat the process as for anterior draw test but
instead of pulling - push the patients lower leg. Excessive
movement in the posterior plane may be indicative of
posterior cruciate ligament injury.

Menisci

There are several special tests to assess the integrity of


the menisci. In Apley's grind test place the patient in the
prone position. Now flex their knee to 90 degrees. Using
your one hand to stabilize their lower leg, grip the patients
heel with your other hand. Now gently push down while
rotating the ankle back and forth. A grinding sensation or
pain may be indicative of meniscal damage. Another test is
McMurrays test which will be covered at a later date in
your course.

Stablizing the patients lower leg

Assessing for any excessive anterior &


posterior movement

Apley's grind test

Skill

Spine examination

Learning
outcome

In combination with supervised accredited practice the successful student


should be able to perform an assessment of a patients spine.

Background
Disorders of the spine are the commonest form of musculoskeletal conditions
that present in clinical practice. Lower back pain affects 4 out of 5 people at
some time in their lives and has a major impact in terms of morbidity, disability,
socioeconomic burden & lost days at work. Vital to the examination of the spine
is to have a good knowledge of the anatomy of this area.

1= Vertebral body
2= Vertebral foramen
3= Spinous process
4= Pedicle
5= Superior articular process
6= Transverse process
7= Lamina

1= Cervical lordosis
2=Thoracic kyphosis
3= Lumbar lordosis
4= Sacral kyphosis

1="Vertebra prominens"
Spinous process of C7
2= 2nd Lumbar vertebra
3= L4-5 inter vertebral space
4= Iliac crests
5= Dimples of Venus / Sacroiliac joints

Examination of the spine


Introduction Introduce your self to the patient, identify the patient's details and gain
informed consent.
Patient
instructions
Hand
washing

Ask if they are in any pain, and to inform you if they experience any
discomfort during the examination. Exposure of spine- remove upper
garment; ideally should be wearing shorts or an examination gown.
Wash hands prior to examination
Inspection

Inspection

Gait

While the patient is removing their garments, use this opportunity to


observe the patient performing this activity of daily living. Any difficulties
observed?
Ask the patient to walk several yards, turn around and then walk back.
Observe their gait carefully. Is there easy following movement? Is there
symmetrical movement? Is there a normal gait cycle from heel strike to
toe off? Do you observe an Antalgic gait? (where pain or deformity
causes the patient to hurry off one leg and to spend most of the gait
cycle on the other. May suggest abnormality in one region e.g. lumbar
spine or hip)

Orientate your self to the patients


surface anatomy. Observe the patients
posture. How do they hold their neck?
From behind
and in front

Do they have a straight spine or do you


detect a scoliosis (click here for more
information on scoliosis) or rib cage
asymmetry?
Is there normal muscle bulk? Do they
have any scars from previous spinal
surgery?

Is there loss of the normal cervical and


lumbar lordosis (Click here for more
From the side information on abnormal kyphosis)? No
you notice any alteration of the normal
mild thoracic kyphosis?

Palpation
Palpation:

Gently palpate over the spinous process


from the cervical region down. Is there
any tenderness (if so this may indicate
local pathology in that vertebra).

The facet joints may be palpated


laterally to the spinous processes and
further lateral, the paraspinal muscles.

Movement

Cervical
spine

Observe for any restricted movements, smoothness of movement and


for any pain experienced during movements. In addition to your verbal
patient instructions, you may want to demonstrate these movements to
the patient.
Cervical spine
Cervical spine flexion
Touch your chin on your chest

Cervical spine extension


Look up and back

Lateral cervical spine flexion


Touch your shoulder with your ear
(Both sides)
(Not bringing their shoulder up to their
ear!)

Lateral cervical rotation (Both sides)


Touch your shoulder with your chin

Thoracolumbar

Lumbar flexion
Try to touch your toes without bending
knees

Lumbar extension
Lean back

Lateral lumbar flexion (Both sides)


Slide your hand down your leg

Thoracolumbar rotation
Sit down and turn round, looking over
your shoulder
(Sitting down helps fix the patients
pelvis)

Other tests
Schober's test In lumbar spine flexion, hip flexion can
compensate to a considerable extent for
a loss of spinal flexion. You may want to
consider performing Schobers test to
objectively measure the degree of
spinal flexion. Firstly identify the
Dimples of Venus (2). Now in the
midline, use a tape measure and pen to
mark a point 10cm superior (1) to, and
an other mark 5 cm inferior (3) to this
point.

Ask the patient to attempt to touch their


toes (i.e Flexing their lumbar
spine).The distance between these two
marks should be measured when the
patients spine is flexed maximally.

The distance should increase to more


than 21cm in a normal patient. A
modified way to demonstrate lumbar
spine flexion is to place several fingers
over the lower lumbar spinous
processes and ask the patient to bend
forward and touch there toes as best as
possible. In a normal spine your fingers
should move part.

Other tests

Given the close proximity of the spine and the spinal cord and nerve
roots it is very important to consider performing a peripheral
neurological examination, together with some special nerve root
stretch tests. In the CSEC and your attachments you will learn further
information about conditions such as Sciatica and cauda equina (Click
here for further information)

With the patient supine, the examiner


uses their arm to fix the pelvis. The
patient then attempts to raise one leg at
Straight leg
a time, with the knee fully extended.
raising (SLR): Make an assessment of the degree of
movement from the horizontal. Repeat
other on the other side.

Lasegues
test:

Is a refinement of the SLR test. It aims


to assess the limitation of movement
due to sciatic nerve root pressure.
When the limit of SLR is reached,
dorsiflexion of the ankle produces acute
accentuation of pain. Conversely asking
the patient to bend their knee should
relieve the pain.

Femoral
stretch test:

Peripheral
nerve
examination:
Sacroiliac
joints:

Abdominal
examination:

Skill

Have the patient lie prone. Passively


flex the knee as far as it goes. In a
positive test the patient should feel pain
in the ipslateral anterior thigh (i.e. the
distribution of the femoral nerve) Also
pain may be exacerbated on hip
extension.

Consider performing a perpherial nerve examination, including


assessment of saddle sensation and anal tone if clinically required.
Are difficult to assess. They have minimal movement. Pain may be
induced on compression of the pelvis or by distracting it by flexing the
hip & knee and forcibly, adducting the leg across to the contra lateral
iliac fossa.
Several intrabdominal conditions can present as back pain (e.g
abdominal aortic aneurysm, acute pancreatitis) therefore it may be
worthwhile considering performing an abdominal examination.

Hip examination
Learning outcome The successful student should be able to perform a clinical
examination of the hip joint.
Background
The hip is a synoviumlined ball and socket joint that plays
a major role in weight bearing and locomotion. Its stability is
due to the relatively deep insertion of the femoral head into
the acetabulum and the strong capsule and surrounding
muscles. To properly examine the hip joint a good
anatomical knowledge of this area is vital. For further
reading about hip anatomy click here for link.
Some bony anatomical areas worth noting:
1) Anterior superior iliac spine
2) Anterior inferior iliac spine
3) Pubic tubercle
4) Pubic symphysis
5) Superior pubic ramus
6) Inferior pubic ramus
7) Greater trochanter
8) Lesser trochanter
9) Femur
10) Head of femur
11) Ischial spine
12) Ischial tuberosity
13) Sacroiliac joint
14) Posterior inferior iliac spine
15) Crest of ilium

Procedure
Procedure

INTRODUCTION, PATIENT IDENTIFICATION &


CONSENT
HAND WASHING
EXPOSURE
Expose the patient's legs by asking the patient to undress
down to their underwear.

INSPECTION
i) Standing:
Observe the patient from all sides with the patient standing
stationary. Inspect for the level of the iliac crests. Now have
the patient walk to the other side of the room, turn around
and walk back. Observe the patients gait and pelvic
movements. In a Trendelenburg gait the pelvis on the
opposite drops and the body leans away from the affected
side, when weight bearing is on the affected hip.
ii) Lying supine:
Have the patient lie supine on a couch. Are any scars
present? Muscle wasting present? Is there any obvious
discrepancy in leg length?

PALPATION
Palpate around the hip area. Specifically is there any
tenderness around the inguinal area and the greater
trochanter area? Is there any tenderness? Heat? Swelling?
Measurement
True length of the legs using a tape measurer measure
the distance between the anterior iliac spine to the tip of the
medial mallous, with the anterior spines lying at the same
transverse level. Compare one side to the other.

Measuring the true length of the legs

The apparent length - is measured from the xiphisternum to


the tip of the medial mallous, with the legs in a parallel
position.

Measuring the apparent length of the legs

Note! When examining hip movements, the pelvis needs to


be fixed in order to observe the range of movement in the
hip joint and not the pelvis (i.e tilt and shift). Remember to
compare one side with the other.

MOVEMENT:
FLEXION
Have the patient flex their knees & move their
hip joint into the flexed position as fair as
possible.
(Normal range ~ 120 degree)
(If you keep the knee extended the range of
movement in the hip joint is limited by tension in
the hamstring muscles)

ABDUCTION
Make sure you stabilze the pelvis by placing a
hand on the opposite anterior iliac crest and
holding the ankle with the other hand. The hip is
abducted until the pelvis tilts.
(Normal range of movement ~ 45 degrees)

ADDUCTION
Cross one leg over the other until pelvis begins
to tilt.
(Normal range of movement ~ 30 degrees)

INTERNAL ROTATION
Flex the hip and knee to 90 degrees. Now move
the leg laterally.
(Normal range of movement ~ 45 degrees)

EXTERNAL ROTATION
Again with the hip and knee flexed move the
patients leg medially. (Normal range of
movement ~ 60 degrees)

EXTENSION
Have the patient lie prone on the couch.
Immobilise the pelvis with one hand while
extending the hip with the other hand.

SPECIAL TESTS:
i) THOMAS' TEST
Thomas test Is used to detected a fixed flexion
deformity in the hip. Place your hand behind the
small of the patients back, between it and the
couch. There is normally a small gap here due
to normal lumbar lordosis. Abolish the lumbar
lordosis by asking the patient to flex the hip and
feel the lumbar spine flatten out onto your hand.
When you are happy that the lumbar spine is
flat, see if the patients other knee is flat on the
couch. If not, measure the angle of (fixed) hip
flexion. Then repeat the test asking the patient
to clasp their other knee up against their chest
and observe for fixed flexion deformity in the
previously flexed hip.

ii) TRENDELENBURG TEST


Detects weakness of the gluteus medius hip abductors. This can be due to true

weakness as in neurological disease or wasting associated with hip arthritis or to


painful reflex inhibition. In an adult the commonest cause of a positive test is
osteoarthritis of the hip. Ask the patient to stand on each leg in turn. Observe the
pelvis for any tilt. In normal individuals the pelvis will rise on the side of the leg that
has been lifted. With instability, the pelvis may drop on the side of the leg that has
been lifted. Repeat on the other side.

Abnormal - the pelvis


BLOCK
Normal - the pelvis rises on the
drops on the side of

Standing on both
legs

side of the lifted leg

the lifted leg.

Musculoskeletal
1. The Arthritis Research Campaign,2005.
System
2. Rheumatology
Examination and Injection Techniques,2

Further reading

nd

ed. M

Doherty, BL Hazleman, CW Hutton et al. WB Saunders.


3. Current Rheumatology Diagnosis & Treatment. J Imboden, DB
Hellmann, JH Stone. McGraw Hill,2005

BRAWIJAYA UNIVERSITY
FACULTY OF MEDICINE
MALANG
2011

Musculoskeletal system BLOCK


1. Overview
Musculoskeletal block will be held on third semester within 5
weeks. In this block students will learn about musculoskeletal injury
and musculoskeletal disease in scope of anatomic, physiology,

pathophisiology, diagnostic problem and management. Therefore,


skill of history taking, physical examination, laboratorium finding,
radiographic interpretation and management are needed.
This block will use problem based strategy with discussion, skill
station methods and expert lecture.
2. Learning outcome
Upon completion of this block, the student will :
a. Understand about anatomy and physiology aspect of the
musculoskeletal system.
b. Understand about pathophysiology of the musculoskeletal
system injury and disease
c. Be able to perform history taking, physical examination and
supporting diagnostic tools related to musculoskeletal
problems
d. Be able to manage patient with musculoskeletal injury and
musculoskeletal disease based on competency level.
3. Topics
This block divided into 7 topics :
Topic 1
: Anatomy
Topic 2
:
Normal
strucuture
and
function
of
musculoskeletal tissue
Topic 3
: Reaction of musculoskeletal tissues to disorders
and injuries
Topic 4
: Musculoskeletal injuries
Topic 5
: Degenerative and inflammation disorder of
musculoskeletal sytem
Topic 6
: Autoimune disorder of musculoskeletal system
Topic
7
: Clinical skill

4. Topic algorythm and topic tree

MUSCULOSKELET
AL SYSTEM

BASIC SCIENCE
OF
MUSCULOSKELE
TAL SYSTEM
MUSCULOSKELE
TAL INJURY

Upper extremity
fracture

MUSCULOSKELE
TAL DISORDERS

Anatomy

Inflamation

Physiology

Degeneration

Lower extremity
fracture

Biomechanic

Neoplasma

Spine fracture

Farmacology

Congenital

Soft tissue injury

Soft tisuue
injury

Metabolic

Fracture

Bone
injury

Musculoskeletal
Injury

Infection

Musculoskeletal
Disorder

Degeneratio
n

Neoplasma

5. Learning methods
Tutorial
Classroom
Small group discussion
Lecture
Skill station

6. Modul contents

Autoimmun
e

Metabolic

Congenital/
pediatri

a.
b.
c.
d.
e.

Dislocation

Musculoskeletal
System

Each module content :


a. Student guidance
b. Teacher guidance
c. Presentation form
7. Core contributor
a.
b.
c.
d.

Anatomy
Physiology
Orthopaedic & Traumatology
Rheumatology

8. Supplementary contributor
a.
b.
c.
d.
e.
f.

Radiology
Patology
Microbiology
Clinical Pharmacology
IKMKP
Clinical pathology

9. Skill station
a. History taking
b. Musculoskeletal physical examination
10. Expert lecture contents

Physiology
Pharmacology
Pain
Maxillofacial problem
Introduction to musculoskeletal radiology
Inflammation related to musculoskeletal
Muskuloskeletal trauma
Neoplasm
Introduction to rheumatology
Clinical Rheumatology
Laboratory test for rheumatic diseases
Community medicine

11. List of tutor


X
Prof. M. Hidayat
Prof. Bambang Pardjianto

Y
Prof. Handono Kalim
Dr. Bagus P. Suryana

Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.

C. Singgih Wahono
Elly
Hani
Sri Sunarti
Satria Pandu
Eriko
Thomas
Tjuk
Retty
Obed
Sumardini
Ridwan
Edi Mustamsir

Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Dr.

Saifullah Asmiragani
Eviana
Widodo
Panji Sananta
Machlusil
Wening
Nurdiana
Laksmi
Dian Hasanah
Dani
Dian Nugraheni
Onggung
Maimun

12. Block related

Block
Block
Block
Block
Block
Block

struktur, fungsi dan patologi umum


dasar infeksi mikroba dan imunologi
farmakokinetik dan farmakodinamik
basic communication & history taking
siklus hidup & nutrisi
BLS

13. Design schedule


Week 1
Monday
Tuesday
Wednesda
y
Thursday
Friday

Anatom
y

Week
2

Week
3

Basic Science

Week
4

Week
5

Clinical related
and Clinical skill

14. Topic Module


BASIC SCIENCE
Topic 1

: Anatomy

Lecture I
Lecture II
Lecture III

: Anatomy of the upper extremity


: Anatomy of the lower extremity
: Anatomy of the joint

Practice I : Anatomy of the upper extremity


Practice II : Anatomy of the lower extremity
Practice III : Anatomy of the joint
Topic 2
:
Normal
musculoskeletal tissue
Module
Module
Module
Module

I
II
III
IV

:
:
:
:

strucuture

and

function

of

Bone growth, remodelling and bone metabolism


Joints and articular cartilage
Tendon and ligament
Skeletal muscle

Topic 3
: Reaction of musculoskeletal tissues to disorders
and injuries
Module V
injuries

: Reaction of Musculoskeletal tissues to disorders and

CLINICAL RELATED
Topic 4

: Musculoskeletal injuries

Module VI : General concept of trauma


Module VII : Fracture and dislocation
Module VIII : Soft tissue injuries
Topic 5
: Degenerative
musculoskeletal sytem

and

inflammation

disorder

Module IX
Module X
Module XI

: Osteoporosis and osteoarthritis


: Osteomyelitis
: Gouty arthritis

Topic 6

: Autoimune disorder of musculoskeletal system

Module XII : SLE


Module XIII : Rheumatoid arthritis

Topic
Module
Module
Module
Module
Module

7
XIV :
XV :
XVI :
XVII:
XVIII

: Clinical skill

History taking
GALS examination
Shoulder and spine examination
Hip and knee examination
: Pharmacotherapy

of

15. Evaluation

Anatomy evaluation
MCQ format
Laboratory format

Module evaluation
MCQ format

16. Time schedule

08
09
09
10
10
11
11
12
12
13
13
14
14
15

08
09
09
10
10
11
11
12
12
13
13
14
14
15

Senin (12 Sept


2011)
ANATOMY

Selasa (13 Sept


2011)
ANATOMY

Rabu (14 Sept


2011)
ANATOMY

LUNCH/ISHOMA
ANATOMY

ANATOMY

Kamis (15 Sept


2011)
ANATOMY

Jumat (16 Sept


2011)
ANATOMY

FRIDAY PRAY
LUNCH/ISHOMA
ANATOMY

ANATOMY

ANATOMY

08
09
09
10
10
11
11
12
12
13
13
14
14
15

08
09
09
10
10
11
11
12
12
13
13
14
14
15

Senin (19 Sept


2011)
MODULE 1
( tutor X )
SGD ( 15
classes )

BONE GROWTH AND


BONE METABOLISM

Selasa (20 Sept


2011)
MODULE 2
( tutor X )
SGD ( 15
classes )
JOINT AND
CARTILAGE

Rabu (21 Sept


2011)
MODULE 3
( tutor X )
SGD ( 15 classes
)
TENDON AND
LIGAMENT

LUNCH/ISHOMA
EXPERT LECTURE
Pain
Dr Farhad (KBI)
Dr Agus Chairul (A)
Dr Saifullah A (B)

EXPERT LECTURE
Maxillofacial
problem
Prof Bambang P
(KBI)
Dr Herman (A)
Dr Agus Chairul (B)

Kamis (22 Sept


2011)
MODULE 4
( tutor X )
SGD ( 15
classes )

Jumat (23 Sept


2011)
MODULE 5
( tutor X )
SGD ( 15
classes )

SKELETAL MUSCLE

REACTION OF MS
TISSUES TO INJURY

FRIDAY PRAY
LUNCH/ISHOMA
EXPERT LECTURE
Physiology
Dr Retty (KBI)
Dr Sudiarto (A)
Dr Dian (B)

EXPERT LECTURE
Physiology
Dr Retty (KBI)
Dr Sudiarto (A)
Dr Dian (B)

EXPERT
LECTURE
Radiology
Dr Indrastuti (KBI)
Dr Enny (A)
Dr Yuyun (B)

08
09
09
10
10
11
11
12
12
13
13
14
14
15

08
09
09
10
10
11
11
12
12
13
13
14
14
15

Senin (26 Sept


2011)
MODULE 6
( tutor Y )
SGD ( 15
classes )

GENERAL CONCEPT
OF TRAUMA

Selasa (27 Sept


2011)
MODULE 7
( tutor Y )
SGD ( 15
classes )
FRACTURE AND
DISLOCATION

Rabu (28 Sept


2011)
MODULE 8
( tutor Y )
SGD ( 15 classes
)
SOFT TISSUE
INJURY

LUNCH/ISHOMA
EXPERT LECTURE
MSK trauma
Prof M Hidayat
(KBI)
Dr Tjuk (A)
Dr Edi Mustamsir
(B)

Kamis (29 Sept


2011)
MODULE 9 ( tutor
Y)
SGD ( 15 classes )
Osteoporosis and
Osteoarthritis

EXPERT LECTURE
IKM-KP
Dr Jack Roebijoso
(KBI)
Dr Nanik (A)
Dr Sri Andarini (B)

EXPERT
LECTURE
Lab aspect for
musculoskeletal
disor.
Dr Kusworini (KBI)
Prof Edi W (A)
Dr Ati (B)

Jumat (30 Sept


2011)
MODULE 10 ( tutor
Y)
SGD ( 15 classes )
Osteomyelitis
FRIDAY PRAY

LUNCH/ISHOMA
EXPERT LECTURE
Intro.
Rheumatology
Prof Handono Kalim
(KBI)
Dr B Putra (A)
Dr Singgih (B)

Senin (3 Oct

EXPERT LECTURE
Inflam related to
MSK
Dr Norahmawati (KBI)
Dr Imam Sarwono (A)
Dr Muji Wiyono (B)

Selasa (4 Oct

Rabu (5 Oct

08
09
09
10
10
11
11
12
12
13
13
14
14
15

2011)
MODULE 11
( tutor X )
SGD ( 15
classes )

GOUTY ARTHRITIS

2011)
MODULE 12
( tutor X )
SGD ( 15
classes )
SLE

2011)
MODULE 13
( tutor X )
SGD ( 15
classes )
RHEUMATOID
ARTHRITIS

08 09
09
10

10
11
11
12
12
13
13
14
14
15

LUNCH/ISHOMA
EXPERT LECTURE
Clinical
Rheumatology
Prof Handono Kalim
(KBI)
Dr B Putra (A)
Dr Singgih (B)

Kamis (6 Oct
2011)
EXPERT LECTURE
Conge.&ped
disorder
Dr Panji (KBI)
Dr Satria Pandu (A)
Dr Thomas (B)
MODULE 18
Tutor ( pharmaco
)
CLINICAL SKILL
Pharmacotherap
y
10 classes

EXPERT LECTURE
Pharmacology
Dr
Dr
Dr

EXPERT
LECTURE
Neoplasma
Dr Norahmawati
(KBI)
Dr Imam Sarwono
(A)
Dr Muji Wiyono
(B)

Jumat (7 Oct
2011)
MODULE 14
( tutor X )
CLINICAL SKILL
History taking
15 CLASSES

FRIDAY PRAY

LUNCH/ISHOMA
EXPERT LECTURE
Microbiology
Dr.
Dr.
Dr.
Senin (10 Oct
2011)

Selasa (11 Oct


2011)

Rabu (12 Oct


2011)

08
09
09
10
10
11
11
12
12
13
13
14
14
15

08
09
09
10
10
11
11
12
12
13
13
14
14
15

MODULE 15
( tutor Y )
CLINICAL SKILL
GALS
examination
15 CLASSES

MODULE 16
( tutor Y )
CLINICAL SKILL
Shoulder and
arm examination
15 CLASSES

MODULE 17
( tutor Y )
CLINICAL SKILL
Hip and leg
examination
15 CLASSES

LUNCH/ISHOMA
CLINICAL SKILL

CLINICAL SKILL

Kamis (13 Oct


2011)
UJIAN ANATOMI

Jumat (14 Oct


2011)
UJIAN MODULE

LUNCH/ISHOMA

UJIAN
PRAKTIKUM
ANATOMI

CLINICAL SKILL