HOW TRAINING MATERIAL 2010/11

SESSION 1

THE SHOULDER
History
Pain from shoulder or its surrounding tendons is felt anterolaterally & at the insertion of
deltoids; sometimes it radiates down the arm. Pain on top of shoulder suggests
acromioclavicular dysfunction or a cervical spine disorder. The entire shoulder is a common
site of referred pain from cervical spine, heart, mediastinum & diaphragm
Stiffness may be progressive & severe : so much so as to merit the term frozen shoulder
Deformity may consists of prominence of acromioclavicular jt or winging of scapula
Loss of function is expressed as inability to reach behind the back & difficulty with combing hair
or dressing
The painful shoulder
a) Referred pain
1 Cervical spondylosis
2 Mediastinal pathology
3 Cardiac ischaemia
b) Joint disorders
1 Glenohumeral arthritis
2 Acromioclavicular arthritis
c) Rotator cuff disorders
1 Tendinitis
2 Rupture
3 Frozen shoulder
Examination
The pt should always be examined from in front & from behind. Both upper limbs, neck & chest
must be visible. Because shoulder & neck symptoms are often felt in same areas, examination
of shoulder must include a full examination of neck & vice versa
Look
a) Skin
Scars or sinuses are noted; dont forget the axilla !
b) Shape
Asymmetry of shoulders, winging of scapula, wasting of deltoid or short rotators &
acromioclavicular dislocation are best seen from behind; jt swelling or wasting of
pectoral muscles is more obvious from in front. A jt effusion may point in axilla
c) Position
If the arm is held internally rotated, think of posterior dislocation of shoulder
Feel
Because the jt is well covered, inflammation rarely influences skin T. the soft tissues & bony
points are carefully palpated, following a mental picture of anatomy. Start with
sternoclavicular jt, then follow clavicle laterally to acromioclavicular jt, on to anterior edge of
acromion & around acromio to back of jt. The supraspinatus tendon lies just below anterior
edge of acromion. Tenderness & crepitus can often be accurately localized to a particular
structure

HOW TRAINING MATERIAL 2010/11

SESSION 1

Move
a) Active movements
The pt is asked to raise both arms sideways until fingers point to ceiling. Abduction may
be
1 Difficult to initiate
2 Diminished in range
3 Altered in rhythm, the scapula moving too early & creating a shrugging effect
If movement is painful, the arc of pain must be noted; pain in mid range of abduction
suggests a rotator cuff tear or supraspinatus tendinitis; pain at the end of abduction is
often d/t acromioclavicular arthritis
Pt is then asked to perform other active movements; flexion & extension by raising the
arms forwards & then backwards as far as possible; adduction by moving each arm
across the front of body; and rotation by holding the arms close to body, flexing elbows
to 90 & 1st separating hands as widely as possible (external rotation) & then folding the
forearms across front of body (internal rotation)
3 composite movements are essential for normal function
1 Clasping the hands behind necks
2 Reaching high up on back
3 Performing a circular pot stirring movement with each arm in turn
b) Passive movements
These can be deceptive because even with a stiff shoulder the arm can raised to 90 by
scapulothoracic movement
To test glenohumeral abduction, scapula must 1st be anchored; this is done by pressing
firmly down on top of shoulder with 1 hand while the other hand moves pts arm
c) Power
Deltoid is examined while pt abducts against resistance
To test serratus anterior (long thoracic nerve), ask pt to push forcefully against a wall
with both hands; if the muscle is weak, scapula is not stabilized on thorax & stand out
prominently (winged scapula)
Pectoralis major is tested by pt thrusting both hands firmly into waist. Any difference in
muscle bulk between 2 sides is noted at the same time
Imaging
At least 2 x ray views should be obtained : an AP view in plane of glenoid & an axillary
projection with arm in abduction to show relationship of humeral head to glenoid. Look for
evidence of subluxation, or dislocation, jt space narrowing, bone erosion & calcification in soft
tissues
Double contrast arthrography, US, CT and MRI are useful methods for diagnosing rotator cuff
tears or atypical forms of shoulder instability
Arthroscopy
Is useful for diagnosing intra articular lesions, detachment of glenoid labrum & rotator cuff
tears. In some cases the disorder can be dealt with surgically at the same time

HOW TRAINING MATERIAL 2010/11

SESSION 1

THE ELBOW
History
Pain may be felt diffusely on medial side of jt (ulnohumeral), posterolateral side (radiohumeral), or
acutely localized to one of the humeral epicondyles (tennis elbow on lateral side & golfers elbow
on medial side). Pain over back of elbow is often d/t an olecranon bursitis
Stiffness, if severe can be very disabling; pt may be unable to reach to the mouth (loss of flexion) or
perineum (loss of extension); limited supination makes it difficult to hold something in palm or to carry
large objects
Swelling may be d/t injury or inflammation; a soft lump on back of elbow suggests an olecranon
bursitis
Deformity is usually result of previous trauma
1 Cubitus varus d/t a malunited supracondylar fracture
2 Cubitus valgus d/t an old displaced & malunited fracture of lateral condyle
Instability is not uncommon in late stage of rheumatoid arthritis
Ulnar nerve symptoms (tingling, numbness & weakness of hand) may occur in elbow disorders because
the nerve is so near the jt
Loss of function is noticed in grooming activities, carrying & hand work
Examination
Both upper limbs must be completely exposed & it is essential to look at back as well as front
The neck, shoulders & hands should also be examined
Look
Looking at pt from front, with his or her arms outstretched alongside body & palms facing forwards,
elbows are seen to be held in 5 10 of valgus; this is normal carrying angle. Anything more, especially
if unilateral, is regarded as a valgus deformity. Varus deformity is less obvious, but if pt raises the arms
to shoulder height, it is easily seen
The most common swelling is in olecranon bursa at the back of elbow
Feel
Important body landmarks are the medial & lateral condyles & tip of olecranon. These are palpated to
determine whether jt is correctly positioned
Superficial structures are examined for warmth & SC nodules. The jt line (including radioulnar jt
depression) is located & palpated for synovial thickening. Tenderness can usually be localized to a
particular structure
The ulnar nerve is fairly superficial behind medial condyle & here it can be rolled under fingers to feel if
it is thickened or hypersensitive
Move
Flexion & extension are compared on 2 sides. Then, elbows tucked into sides and flexed to a right angle,
radioulnar jts are tested for pronation & supination
General examination
If symptoms & signs do not point clearly to a local disorder, other parts are examined
1 Neck (for cervical disc lesions)
2 Shoulder (for cuff lesions)
3 Hand (for nerve lesions)
X ray
The position of each bone is noted, then jt line & space. Next, the individual bones are inspected for
evidence of old injury or bone destruction. Finally, loose bodies are sought

HOW TRAINING MATERIAL 2010/11

SESSION 2

The hand
Clinical assessment
A) History
Pain felt in the palm or in the finger joints. A poorly defined ache may be referred from the neck,shoulder or
mediastinum.
Deformity
appear suddenly (due to tendon rupture) or
slowly( bone or joint pathology)
Swelling localized /many joints simultaneously.
E.g. rheumathoid arthritis swelling of the proximal joints, osteoarthritis the distal joints.
Loss of function
Sensory symptoms and motor weakness neurological disorders affecting the lower cervical nerve roots and their
peripheral extensions.
B) Examination
compare both upper limbs
Look scar, colour, dry/ moist, and hairy or smooth, Wasting and deformity, lumps, Resting posture, Swelling.
Feel temperature and texture of the skin, nodule (underlying tendon should be moved to show if it is attached).
Tenderness. Swelling (in subcutaneous tissue, in a tendon sheath or in a joint).
Move
a) Passive movements
range of movement metacarpophalangeal (MCP), proximal interphalangeal(Pip), distal interphalangeal(DIP)
joints.
b) Active movements
Method (what patient need to do):
1. palms facing upwards, curl the fingers into full flexion may show lagging finger.
2. Motor function Test
flexor digitorum profundus PIP joint immobilized then bend the tip of the finger.
flexor digitorum superficialis inactivate flexor profundus
grasping all the fingers, except the one being examined, and holding them firmly in
full extension
flex the isolated finger which is being examined
exceptions:
1st, the little finger sometimes has no independent flexor digitorum superficialis
2nd, the index finger often has an entirely separate flexor profundus, which cannot be
inactivated by the usual mass action manoeuvre. Instead,flexor superficialis is tested by
asking the patient to pinch ard with the DIP joint in full extension and the PIP joint in full
flexion; this position can be maintained only if the superficialis tendon is active and
intact.
long extensors extend the MCP joints
MCP flexion and IP extensions extend the fingers with the MCP joints flexed (the duckbill position).
interossei abduct and adduct finger.
Thumb movements five types of movement
extension(sideways movement towards the palm in the plane of the palm) abduction(upward
movement at right angles to the palm)
opposition(touching the tips of the fingers).
flexor pollicis longus immobilizing the thumb MCP joint.
Grip strength
Squeeze the examiners fingers diminished muscle weakness, tendon damage, finger stiffness or wrist
instability.
more accurately with a mechanical dynamometer.
Pinch grip also should be measured.
Neurogical assessment
if symptoms such as numbness, tingling or weakness exist and in all cases of trauma a full neurological
examination of the upper limbs. Further refinement is achieved by testing two point discrimination, sensitivity
to heat and cold and stereognosis.

HOW TRAINING MATERIAL 2010/11

SESSION 2

THE WRIST
History
Pain may be localized to radial side (esp in tenovaginitis of thumb tendons), to the ulnar side (possibly from
radioulnar jt) or to dorsum (usual site in disorders of carpus)
a) Jt disorders
1 Infection
2 Kienbocks Ds
3 Carpal instability
4 Rheumatoid arthritis
5 Osteoarthritis
b) Periarticular disorders
1 de Quervains Ds
2 Tenosynovitis
c) Referred pain
1 Cervical spondylosis
Stiffness is often not noticed until it is severe
Swelling may signify involvement of either jt or tendon sheaths
Deformity is a late symptom except after trauma
Loss of function affects both wrist & hand. Firm grip is possible only with a strong, stable, painless wrist that
has a reasonable range of movement
Examination
Examination of wrist is not complete w/o also examining the elbow, forearm & hand. Both upper limbs
should be completely exposed
Look
The skin is inspected for scars. Both wrists & forearms are compared to see if there is any deformity. If there
is swelling, note whether it is diffuse or localized to one of the tendon sheaths
Feel
Undue warmth is noted. Tender areas must be accurately localized & bony landmarks compared with those
of normal wrist
Move
Passive flexion & extension of wrist can be measured on each side in turn. To view both sides simultaneously
& compare them, ask pt 1st to place his or her palms together in a position of prayer, elevating the elbows,
then to repeat manoeuvre with the writsts back to back. The normal range for both flexion & extension is
80 90. Radial deviation & ulnar deviation are measured in palms up position; ulnar deviation is considerably
greater than radial deviation
Pronation & supination are included in wrist movements. The pt holds his or her elbows at right angles &
tucked into sides, fingers extended & palms facing each other; hands are then turned 1st palms downwards
& then palms upwards
Active movements should be tested against resistance; loss of power may be d/t pain, tendon rupture or
muscle weakness. Grip strength can be gauged by having pt squeeze the examiners hand; mechanical
instruments allow more accurate assessment
Investigations
a) X ray
Often both wrists must be examined for comparison
Special oblique views are necessary to show up difficult scaphoid fractures
Note the position of carpal bones & look for evidence of jt space narrowing, esp at carpometacarpal
jt of thumb
b) MRI
Useful for demonstrating early features of avascular necrosis or detecting soft tissue lesions such as
an occult ganglio
c) Arthroscopy
The most reliable way of diagnosing tears of triangular fibrocartilage complex (TFCC)
It will also reveal early changes of osteoarthritis

HOW TRAINING MATERIAL 2010/11

SESSION 3

The neck
Clinical assessment
A) History
common symptoms of neck disorder are pain and stiffness.
Pain referred to the shoulders or arms. suddenly (as with an acute intervertebral disc
prolapse)
gradually (as in chronic disc degeneration)
Stiffness intermittent /continuous.
Deformity wry neck/ neck fixed in flexion.
Numbness, tingling and weakness in the upper limbs due to pressure on a nerve root;
weakness in the lower limbs may result from cord compression in the neck.
Headache sometimes emanates from the neck, but if this is the only symptom, other
causes should be suspected.
B) Examination
The entire upper trunk and both upper lmbs should be exposed.
when patient standing: examine neck posture and movements, shoulder.
When patient seated: examine anterior structures (trachea,thyroid,oesophagus).
When patient lying down: prone feel for muscle spasm and point tenderness (neck
supported by a pillow).
Supine Neurological examination.
Look deformity. Skin blemishes, scapular abnormilities or muscular asymmetry (seen
from back). muscle wasting in the arm or hand.
Feel neck and shoulders palpated for tender areas,lumps and muscle spasm.
Move
Flexion, extension, lateral flexion, rotation and the range of movements. Shoulder
movements.
Neurological examination of the upper limbs in all cases, sometimes, the lower limbs.
Imaging
x ray examination from the base of the occiput to TI .
a) AP view should show the regular, undulating outline of the lateral
masses
symmetry may be disturbed by destructive lesions or fractures.
A projection through the mouth is required to show the upper two
vertebrae.
b) lateral view, disc spaces are inspected; disc space narrowing and
osteophyte formation at the anterior and posterior edges of the vertebral
bodies are features of intervertebral disc degeneration.
c) Flexion and extension views are required to demonstrate instability.
CT and MRI are essential for defining the intervertebral discs, the neural structures and
the outlines of the spinal canal and intervertebral foramina.

HOW TRAINING MATERIAL 2010/11

SESSION 3

The back
Clinical assessment
History
usual symptoms of back disorder pain, stiffness and deformity in the back, and pain, paraesthesia or
weakness in the legs.
The mode of onset start suddenly (perhaps after lifting)/gradually
symptoms constant/ remission
particular posture
Pain
Back usually low down and on either side the midline /extending into the buttock and down the limb.
thigh and calf, though called sciatica, is rarely due to sciatic nerve disorder. It is referred pain, either
from:
a) root dura characteristically more intense and often accompanied by numbness or paraesthesia.
b) A joint or ligament more inconstant and is not accompanied by neurological symptoms but both are
distributed more or less along te path of the sciatic nerve.
sciatica alone is non specific. Sciatica plus neurological symptoms suggests nerve root compression.
Stiffness sudden and almost complete (after a disc prolapsed) /continuous and predictably worse in the
mornings(suggesting arthritis or ankylosing spondylitis).
Deformity In disc prolapsed, arthritis and ankylosing spondylitis, scoliosis.
Numbness or paraesthesia is felt anywhere in the lower limb, but can usually be mapped fairly accurately
over one of the dermatomes. It is important to ask if it is aggravated by standing upright or walking and
relieved by bending forward or sitting down a classic feature of spinal stenosis.
Other symptoms urethral discharge, diarrhea and sore eyes; these are features of reiters disease, one
of the causes of reactive spondylitis.
B) Examination
When patient standing:
Look
1. Stand in front of the patient and note his or her general physique and posture.
2. move round and stand behind the patient. Patient stand upright /lean over to one side, pelvis
level/ one leg shorter than the other, spine look straight or curved (scoliosis)
Scars or other skin markings that may suggest a spinal disorder
lateral view, the thoracic spine hyperkyphosis, kyphos.
the lumbar spine unusually flat or excessively lordosed.
Feel
The spinous processes and the interspinous ligaments are palpated, noting any prominence or a step
Move
Flexion
Ask the patient to bend forward and try to touch the floor.
watch the lumbar spine to see if it really moves or better still, measure the spinal excursion.
The mode of flexion resistant movements, especially on regaining the upright position, may signify
pain or segmental instability.
Extension
Ask the patient to lean backwards; with a stiff spine, he or she may cheat by bending the knees.
The wall test will unmask a disguised loss of extension: standing with the back flush against a wall, the
heels, buttocks, shoulders and occiput normally all make contact with the surface.
Lateral flexion
Ask the patient to bend first to one side and then to the other; compare the range of movement to right
and left.

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SESSION 3

Rotation
Ask the patient to twist the trunk to each side in turn while the pelvis is anchored by the examiners
hands; this is essentially a thoracic movement and should not be limited in lumbosacral disease.
Chest expansion
Rib excursion is assessed by measuring the chest circumference in full expiration and then full
inspiration; the normal excursion is about 7cm
Muscle power
Distal muscle power is tested and compared by asking the patient to stand up on tiptoes (plantar
flexion)and then to rock back on the heels(dorsiflexion)
When patient lying prone:
Bony outlines and small lumps can be felt more easily wit the patient lying face down.
Deep tenderness is easy to localize, but difficult to ascribe to a particular structure.
Some neurological features are ideally elicited with the patient lying prone.
Hamstring power test patient flex the knee against resistance.
The femoral stretch bending the patients knee with is or her hip flat against the couch; a positive sign is
pain felt in the front of the thigh and the back, suggesting lumbar root tension.
Popliteal and posterior tibial pulses are conveniently felt in this position.
When patient lying supine:
The patient is observed for pain and stiffness while turning over.
Hip and knee mobility are examined before testing for cord or nerve root involvement.
check the femoral and pedal pulses.
The straight leg raising test
This is the classic test for lumbosacral root tension.
Knee held straight, the leg is lifted from the couch until the patient experiences pain not merely in the
thigh (which is commom and not significant), but in the buttock and back. The angle at which this occurs is
noted (Normally raise the leg to 90 degrees without causing undue discomfort).
At this point, an additional stretch is imposed by passively dorsiflexing the foot, may cause an
additional stab of pain.
If the knee is then slightly flexed, buttock pain is suddenly relieved; pain may then be re induced by
simply pressing on the common peroneal nerve behind the knee, to tighten it like a bowstring.
Sometimes straight leg raising on the unaffected side produces pain on the affected side. This
crossed sciatic tension is indicated of severe root tension, usually due to a prolapsed disc.
Neurological examination
A full neurological examination of the lower limbs is essential in every patient with a back problem
General examination
While the patient is lying undressed, a rapid examination is carried out to detect te presence of any
suspicious lumps in the breasts, abdomen or genitalia.
Imaging
x rays
AP view, the spine should look perfectly straight. Individual vertebrae may show alterations in structure
and the intervertebral spaces may be edged by bony spurs. The sacroiliac joints may show erosion or
ankylosis.
lateral view, the normal thoracic kyphosis and lumbar lordosis regular and uninterrupted. There may
be anterior shift to an upper segment upon a lower (spondylolisthesis). Individual vertebrae, which should
be rectangular, may be wedged or biconcave. Compare the intervertebral disc spaces: there may be undue
narrowing (flattening) of the disc at one or more levels.
Special techniques
CT, MRI and (occasionally) contrast myelography are useful for outlining the disc and the spinal canal.

HOW TRAINING MATERIAL 2010/11

SESSION 4

THE HIP
History
Pain in hip joint : Groin, front of thigh, knee(sometimes; or even only symptom!)
Stiffness: with problem with putting socks or sitting in a low chair.
Limp with sometimes leg is getting shorter
Walking distance: shortened or using walking stick
Signs
a) Upright
Gait: Antalgic (due to pain), Short leg limp, Trendelenburg lurch (abductor weakness)
Trendelenburg test(stability) : patient is asked to stand, unassisted, on each leg in turn; one leg is lifted and
bending the knee of the other side of leg(not the hip). Positive test:
Dislocation or subluxation of hip
Weakness of abductors
Shortening of femoral neck
Any painful disorder of hip
b) Lying supine
Look: Be sure patient is comfortable, pelvis at same level and legs are placed symmetrically. Check
level of both medial malleoli or shortening of one leg,
scar or sinuses,
swelling or wasting,
deformity or malposition
Asymmetry of skin creases (in babies).
a) Limb length
Placing of 2 lower limbs in comparable positions in relation to pelvis and then measuring distance
from anterior superior iliac spine to medial malleolus on each side.
Shortening? Flex both knees and place heel together discrepancy is below or above knee? If
above: is abnormality lies above greater trochanter?

Thumbs are pressed firmly against the anterior superior iliac spine and miffle fingers feel for the
tops of greater trochanters to check for any elevation of 1 side.
b) Apparent Shortening or lengthening (not true shortening or lengthening)
Happens when pelvis is tilted and one limb is hitched upwards. Reasons: Uncorrected deformity in
the hip
with fixed adduction one one side, the limbs would tend to be crossed; when the legs are
placed side by side, the pelvis has to tilt upwards on the affected side, giving the impression of
a shortened limb.
Or the opposite with fixed abduction, and the limb seems to be longer on the affected side.

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SESSION 4

Feel
Bone contour are felt when leveling the pelvis and judging the height of greater trochanters.
Tenderness elicited in and around the joint.
Surface marking of the joint of the femoral head: halfway between anterior superior iliac spine and
pubic tubercle.
Move
Thomass test ( fixed flexion deformity test): both hips are flexed simultaneously to their limit
(lumbar lordosis obliterated); holding the sound hip firmly in this position (and thus keeping the
pelvis still), the other limb is lowered gently . Measure the full range of flexion( Normal: 130 degrees).
Postive Thomass test: with any flexion deformity, the knee will not rest on the couch.
Abduction test: Place the sound hip in full abduction and keeping it there, thus fixing the pelvis in
the coronal plane. A hand is placed on one iliac crest to detect the slightest movement of the pelvis.
Then, after checking that the anterior iliac spines are level, the affected joint is moved gently into
abduction. (N range: 45 degrees)
Adduction test: Crossing one limb over the other; the pelvis must be watched and felt to determine
the point at which it starts to tilt. (N range: 30 degrees)
Rotation test: both legs are lifted by ankles, are rotated first internally then externally; the patellae
are watched to estimate the amount of rotation. Rotation in flexion is tested with hio and knee each
flexed 90 degrees.
Abnormal movement(movement greatly excess the norm, or ability to elicit telescoping by
alternativeky pulling and pushing the limb in its long axis) suggests either instability or an
pseudoarthrosis of hip).
c) Lying prone
Scars, sinuses or wasting.
Extension of 2 hips( more accurate than patient in lying supine)
Rotation with flexion of both knees and moving the legs: first away from each other and then crossing each
other.

HOW TRAINING MATERIAL 2010/11

SESSION 4

THE KNEE
HISTORY
Pain: anterior knee , diffuse(degenerative or inflammatory disorders) or localized(mechanical disorder especially after
injury.(maybe with remembrance of mechanism by patient)
Swelling: Localized or diffuse. Time of appearance(immediately: heamarthrosis , or late: torn of meniscus). Chronic:
synovitis or arthritis.
Stiffness: fluctuates? When it feels worse or better? (early morning stiffness: inflammatory; stiffness after period of
inactivity: osteoarthristis)
Locking: torn meniscus or loose body. (Unlocking: Obstructing objects has moved and joint can now move freely
again.)
Deformity: unilateral or bilateral = valgus or varus, fixed flexion or hyperextension. (knock knees and bandy legs
common in children and heal spontaneously when grown up)
Giving way: due to muscles weakness or mechanical disorder(torn meniscus or faulty patellar extensor mechanism)
Loss of function: diminishing walking distance, inability to run and difficulty going up and down steps.
P/S: could be referred pain from hip disorder.
SIGN WITH PATIENT UPRIGHT
Valgus or varus deformity
Walking pattern
SIGN WIH PATIENT LYING SUPINE
Look
Position of knee: valgus or varus, partially flexed or hyperextended.
Swelling
Scars or sinuses , small lumps
Wasting of quadriceps(sign of joint disorder)
Visual impression measuring the girth of thigh at same level in each limb: fixed distance above the joint line or
a hands breadth above the patella
Feel
Warmth comparison between 2 knees.
Temperature gradient by hand running down the limb( N: linear decrease in warmth from proximal to distal).
soft tissues and bony outlines for abnormal outlines and localized tenderness: knee is bent and examiner sits
on the edge of couch facing the knee; place both hands over the front of knee to trace with fingers the
anatomical outlines of joint margins, patellar ligament, collateral ligaments, iliotibial band and pes anserinus.
Then, the knee is placed flat on couch and the edges of patellofemoral joint are palpated while pushing the
patella first to one side then to other.
Synovial thickening is appreciated by placing knee in extension, grasp the edges of patella in a pincher made
of thumb and middle finger, and tries to life the patella forwards ( N: grasp easily firmly; if thickened
synovium it will slip off the edges of patella)
Move
Knee is flexed until the calf meets the ham, and extends completely with a snap (crepitus: sign of
patellofemoral degeneration or wear).

HOW TRAINING MATERIAL 2010/11

SESSION 4

Test of intra articular fluid

a) Cross fluctuation (only with large joint effusion):hand compresses and empties the suprapatellar pouch while
the right hand straddles the front of the oint below the patella; by squeezing with each hand alternatively, a
fluid impulse is transmitted across the joint.
b) Pattelar tap: suprapatellar pouch is compressed with the left hand, while the index finger of right hand
pushes the patella sharply backwards. Positive test: patella can be felt striking the femur and bouncing off
again.
c) Bulge test (useful when very little fluid is present): medial compartment is emptied by pressing n that side of
the joint whilst at the same time the suprapatellar pouch is kept closed by the other hand; the first hand is
then lifted away from the medial side and moved to the lateral side, which is then sharply compressed; a
distinct ripple is seen on the flattened medial surface.
d) Patellar hollow test: hollow appears lateral to patellar ligament when normal knee is flexed, and disappears
with further flexion; with excess fluid, the hollow fills and disappears at a lesser angle of flexion.
Patellar test
a) Patellar friction test: pain elicited by rubbing patella against the femoral trochlea or by pressing against
patella and ask patient to contract quadriceps muscles.
b) Apprehension test( diagnostic of recurrent patellar subluxation or dislocation): pressing the patella laterally
with thumb while flexing the knee slightly may induce intense anxiety and resistance to further movement.
Test for ligamentous stability
a) Medial and lateral ligaments: stressing the knee into valgus and varus by tucking patients foot under your
arm and supporting the knee firmly with one hand on each side of joint; the leg is then angulated
alternatively towards abduction and adduction. The test is perfomed at 30 degrees of flexion and again at full
extension. ( torn or stretched collateral ligament if there is excessive angle with mediolateral movement)
b) Cruciate ligaments: examine for abnormal gliding movement in AP plane. With both flexed 90 degrees and
the feet resting on the couch, the upper tibia is inspected from the side;
if its upper end has dropped back, or can be gently pushed back, this indicates a tear of the posterior
cruciate ligament(the sag sign).
With the knee in the same position, foot is anchored by the examiner sitting on it (provided it is not
painful); then using both hands, the upper end of the tibia is grasped firmly and rocked backwards
and forwards to see if there is any AP glide (the drawer test) [p/s: make sure the hamstring is
relaxed].
1. Positive anterior drawer sign: anterior cruciate laxity
2. Positive posterior drawer sign: posterior cruciate laxity
Lachman test: patients knee is flexed 20 degrees; with one hand grasping the lower thigh and the
other upper part of leg, the joint surfaces are shifted backwards and forwards upon each other. If
the knee is stable, there should be no gliding.
SIGN WITH PATIENT LYING PRONE
Scars or lumps in popliteal fossa
Swelling( midline: bulging capsule or one side: bursa)
Baker cyst
Palpable lump , pulsatile? Emptied into joint?
Appleys test:
a) Knee is flexed to 9 degrees and rotated while a compression force is applied. (grinding test: if a meniscus is
torn).
b) Distraction test: rotation is then repeated while the leg is pulled upwards with the surgeons knee holding the
thigh down, producing increased pain if only there is ligament damage.

HOW TRAINING MATERIAL 2010/11

SESSION 5

THE ANKLE AND FOOT

HISTORY
Pain: over a bony prominence or a joint is due to local factor; across the entire the forefoot(metatarsalgia) is less specific
and is often associated with uneven loading and muscles fatigue.
Deformity: maybe ankle, foot or toes. Children with flat footed or pigeon toed.
Swelling: diffuse and bilateral, or localized. (swelling over medial side of first metatarsal head[bunion] is common in older
woman)
Giving away: due to pain or instability at ankle or subtalar joint.
p/s: standing or walking provokes symptoms and whether shoe pressure is a factor.
Corns and callosities: hardened, often tender, patches of skin on the toes and soles of the feet are produced by localized
pressure and friction, usually due to shoe condition.
Numbness and paraesthesia: in all toes or in a circumscribed field served by a single nerve.
SIGN WITH PATIENT STANDING AND WALKING
Norm:Heels are slight valgus while syanding and inverted when on tiptoes; degree of inversion equals on 2 sides, showing
that subtalar joints are mobile and tibialis posterior muscles functioning.
Deformity: flat foot, cavus(hight arched) foot, hallux valgus,crooked toes
Corns over proximal toe joints and callosities on soles (common on older patient)
Walking gait: smooth or halting and whether the feet are well balanced. The position and mobility of ankles .
a) A fixed equines deformilty results in heel failing to strike the ground at begging of walking cycle; sometimes the
patient forces heel contact by hyperextending the knee.
b) Foot drop, if the ankle dorsiflexions are weak, the forefoot may strike the ground prematurely, causing a slap.
c) High stepping gait: during swing through, the leg is lifted higher than usual so that the foot can clear the ground.
P/S: examine the shoes
SIGNS WITH PATIETN SITTING OR LYING.
Look: heel is held square so that the shape of the foot can be properly assessed. The toes are examined for deformities
and soles for callosities.
Feel: skin temperature and pulse, tenderness , swelling, lumps, edema, sensation.
Move: range of both passive and active movements of each series of joints, muscles power.
a) Ankle joint: with the heel grasped in the left hand and the midfoot in the right; plantarfelxion and dorsiflexion are
tested
b) Subtalar joint: inversion and eversion( make sure the ankle is fully plantigrade=at right angle to the leg)
c) Mid tarsal joint: heel is held still with one hand while the other moves the tarsus up and down and from side to side.
d) Toes: test both metatarsophalangeal and interphalangeal joints.
Test of stability
Tested in both coronal and sagittal planes and comparing 2 sides.
Ankle is held in 10 degrees ofplantarflexion and the joint is stressed into valgus and then varus.
Anterior drawer test: ankle held in 10degrees of plantarflexiokn, the distal tibia is gripped with one hand while the
other grasps the heel and tries to shift the hindfoot forwards and backwards.
P/s: patient should be on LA if he got recent ligamentous injury
P/s: test can be performed under x ray and positions of 2 ankles measured and compared.
GENERAL EXAMINATION
Any signs and symptoms of vascular or neurological impairement, or maybe a general examination .