Musculoskeletal examination

1. Easy assessment of
musculoskeletal system
for GPs
Aspects of examining the
musculoskeletal system

2.  Revisiting the basics
 GALS
 Video
 Some bits and pieces / a personal view

3. History
 “Have you any pain or stiffness in your
muscles, joints or back?”
 “Do you have any trouble getting up or
down stairs?”
 “Do you have any difficulty getting
dressed?”

5. Revisiting the basics
 Inspection Look
 Palpation Feel
 Movement Move
 Stability
 Function
 Compare with opposite side

6. Inspection
 Skin colour / rashes
 Swelling
 Deformity
 Scars
 Muscle wasting
 Surrounding structures - bursae,
tendons

7. Palpation
 Nature of swelling
–bony
–synovial
–effusion
 Warmth
 Tenderness

8. Movement
 Active and passive
 Range of movement
 Crepitus
 Note pain
 Instability

9. Stability
 Subluxation or dislocation
– MCP
– Radioulnar
– subtalar
– MTP

10. Function
 Lower limbs - gait
 Hands
–pincer grip
–power grip

12. G A L S
 Doherty, Dacre, Dieppe and Snaith (1992)
The GALS locomotor screen, Annals of
Rheumatic diseases 51: 1165-9
 GAIT
 ARMS
 LEGS
 SPINE

13. G A L S
 “…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”

14. GALS recording
G  A M
A  
L  
S  

16. Bits and pieces
 Hands
 Wrists - CTS + de Q
 Shoulders
 Backs
 Hips
 Feet - biomechanics
 Hypermobility
 Fibromyalgia

17. Hand - RA

18. 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

19. Hand OA

20. Raynauds 1

21. Raynauds 2

22. Scleroderma early

23. Scleroderma

24. Sclerodactaly (acrosclerosis)

25. Carpal Tunnel Syndrome
•Phalen’s
•Tinel’s

26. De Quervains tenosynovitis
 APL and EPB tendons
 tender over radial styloid
 sometimes nodule (thickened sheath)
 Finkelsteins test
 Rest it
 Inject it

27. Shoulders
 Shoulder or not
 Glenohumeral or not - external rotation
 Tenderness
– bicipital groove
– subacromial
 Painful arc of abduction

28. Shoulder - abduction

29. Shoulder function related to
abduction

30. Backs
 Lumbar flexion
– Modified Schobers - or use
your fingers
– Fingers to floor =
misleading
 Lumbar extension
 Lumbar lateral flexion
 “Sacroiliac restriction”

31. 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

32. Hips
 Internal rotation - can examine sitting
 Trochanteric bursitis
 Trendelenburg - to distinguish lumbosacral from
hip pain

33. Trendelenburg test

34. Foot - biomechanics
 Swing phase
 Stance phase
– Contact (27%)
– Midstance (40%)
– Propulsive (33%)

35. Biomechanics - stance phase
 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

36. Biomechanics - stance phase (2)
 Midstance
– forefoot loaded
– subtalar joint supinates
– causes tibia to externally rotate
– foot is converted to rigid lever ready for
propulsion
– ends with heel lift

37. Biomechanics - stance phase (3)
 Propulsion
– app 25% bodyweight on metatarsals and
toes (esp 1st)
– ends with toes off

38. Abnormal pronation and
supination

39. Over pronation
 Subtalar pronation
unchecked
 longitudinal arch
stretches and
flattens
 excess rotation of
tibia
 Hallux valgus
 Plantar fasciitis
 Achilles tendonitis
 Post tibial tendonitis
 stress# navicular
 anterior knee pain
 low back pain

40. Hypermobility
1 Dorsiflexion of 5th MCP to 90 degrees
2 Apposition of thumb to volar aspect of
forearm
3 Hyperextension of elbow by 10 degrees
4 Hyperextension of knee by 10 degrees
5 Hands flat on floor with knees extended

41. Fibromyalgia

42. The End