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A GUIDE TO EXAMINATION OF JOINTS

Dr. Aruljoethy
Department

of

Orthopaedics
Basic rules in examination:
1. The entire area in question with one joint above and one joint below
must be exposed adequately and examined.
2. No Orthopaedic examination is complete unless the joint above, the
joint below, the same joint on the opposite side and a detailed
neurovascular examination is done.
3. Examination has to proceed with the differential diagnosis made at
the end of the history in mind.
4. Sequence in examination : Inspection, Palpation, Movements,
Measurements and Special tests.

EXAMINATION OF THE HIP


Common symptoms: Pain, swelling, deformity, limb length discrepancy,
altered gait
Examination of the hip should be done with the patient supine, prone and
in standing positions.
Examination of the hip includes examination of the knees and the spine.
From the front with the patient supine
Attitude of the limb: position of various joint : direction and degree
Deformity of the hip if any and details therein.
Spine : evidence of exaggerated lumbar lordosis
: level of the shoulders

ASIS : Level of the anterior superior iliac spines : Abduction


/adduction deformities
Femoral triangle examination : swellings and its description
Presence of : swellings, scars and sinuses, dilated veins and
description of each as on inspection of the hip and entire limb
Muscle wasting
Limb length discrepancy
Other bony prominences: levels of patella, position of the patella
(rotational deformities of the limb- level of deformity- comparison
with amount of rotation of the foot) and level of medial malleolus.
From the front with the patient standing:
GAIT of the patient
Level of the shoulders: May indicate the presence of limb length
discrepancy.
From the side:
Evidence of deformity in the spine : normal spinal curvatures and
deformities in the spine: lordosis or kyphosis
Trochanteric area : examination for any swellings.
Findings on the lateral aspect of the hip and limb : swellings, scars,
sinuses etc with detailed description of each as on inspection.
From the back:

Deformities in the spine : Scoliosis


Tell-tale signs in the back : evidence of spinal deformities
Levels of the posterior superior iliac spines
Sacral dimples: levels of the sacroiliac joints
Level of the Gluteal and thigh folds: indication to limb length
discrepancy
Findings on the posterior aspect of the hip and limb : swellings,
scars, sinuses etc with detailed description of each as on inspection.
Look for evidence of deformity of the limb and detail out the
direction of the deformity and amount of deformity if seen.
Inspection of the limb with respect to neurovascular status of the
limb to be done.
PALPATION
Local rise of temperature over the area of interest: all differential
diagnosis to be considered in this respect
Tenderness over the area of interest: all differential diagnosis to be
considered in this respect
Confirm all inspectory findings individually with all relevant details:
{ALL INSPECTORY FINDINGS IN THE SPINE AND THE
BACK} eg. Regarding the spinal deformities, swelling, scars,
sinuses, limb length discrepancy etc.
Look for presence of lymph nodes whenever appropriate.

Bony prominences: ASIS, Greater trochanter (height, tenderness,


width, surface of the greater trochanter in comparison to the
opposite side), patellar height, medial malleolar level.
Bony irregularities: Look for presence of bony irregularities and
details of where such irregularities are palpated. Also look for any
evidence of deformity of the bone and record direction of the
deformity.
Palpate for all peripheral pulses and look for motor and sensory
disturbances in areas concerned.
Vascular sign of Narath: In conditions where the head or neck of
the femur are not in place or are destroyed as a complication of a
disease process, the femoral pulsation on the affected side is less
well felt.
When increased lumbar lordosis is present: indicates primary spinal
deformity or an underlying fixed flexion deformity of the hip. The degree
of deformity has to be measured in degrees by doing the THOMAS
test.
When ASIS is found to be at different levels indicates: spinal deformity
leading to pelvic obliquity or a fixed abduction or adduction deformity of
the hip leading to obliquity of the pelvis. When ASIS on the affected side
is at a lower level it indicates an ABDUCTION deformity on the hip and
when at a higher level indicates an ADDUCTION deformity in the hip.
The degree of the deformity has to be measured by SQUARING THE
PELVIS and unmasking the deformity. Deformity has to be quantified
in degrees.
RANGE OF MOVEMENTS:
All ranges of movements, in all directions normally possible in the joint,
has to be measured in degrees. Movements have to be recorded in a

tabular column showing the movements on the right and the left sides in
each direction and a column to record the difference found in each
direction. This tabular column can also depict the power in each group of
muscle. Eg. flexors, extensors, abductors etc.
When fixed deformities are found :
Movements in the opposite direction is not possible
Movements in the same direction as the deformity may be
possible
Eg: when fixed abduction deformity is seen to be present adduction at the
hip will not be present and vise versa.
RECORDING MOVEMENTS IN THE PRESENCE OF FIXED
DEFORMITIES:
If there is a fixed deformity in one direction of 20 degrees with further
movement in the same direction of 120 degrees possible, then the range of
movement is recorded as 20-120 degrees. This indicates that the joint has
a fixed deformity of 20 deg. and allows further movement in the same
direction of 120 deg. Now if the opposite joint has normal range of
movement of say 0-120 degrees in the same direction then on comparing
the two it is apparent that whereas there is a deformity of 20 deg. in the
affected joint and further movement in the direction in question is full and
normal.
PROBLEM: If the range of movement recorded is 30-100 deg. on the
affected side and 0-120 on the normal side for the same movement then
what is the conclusion??
ANSWER: Fixed deformity of 30 deg. and further movement is also
restricted by 20 deg. when compared to the normal side.
All movements should be recorded as RANGE of movements with a
definite start and end point mentioned in degrees.

MEASUREMENTS
All bony prominences should be marked with a marking pen on
both sides before measurement is done.
The tape should be placed gently on these points during
measurement. Care should be taken to ensure that the points
have not been moved under the examining fingers.
Apparent measurement:
From the Xyphisternum to the Medial malleolus: with the patient supine
and lying down as straight as possible.
True measurement of the entire limb:
Prerequisites:
The pelvis should be squared
Both the limbs have to kept in similar positions when measuring
From the ASIS to the medial malleolus on each side.
SEGMENTAL TRUE MEASUREMENTS
In the same position of a squared pelvis and both limbs in similar
positions the femoral and tibial measurements are individually taken as
follows.
(a) Femoral length: From the ASIS to the Medial joint line.

The medial joint line is palpated


with the knee in about 10-30 deg. of flexion when possible.
the tibial tuberosity is identified and the examining fingers are run
proximally on the tibia along the flare of the tibia.
A depression is felt as the fingers run proximally which is placed
perpendicular to the axis of the femur on the medial and lateral
aspects of the knee. This represents the medial and lateral joint line.
This is confirmed by then moving the joint into flexion and
extension whenever possible with the examining fingers still placed
on the medial and lateral joint lines. The movements are appreciated
to be occurring at that level confirming it to be the joint lines.
(b) Tibial length: From the medial joint line to the medial malleolus.
(c) Measurement of the girth of the limb:
To be done in the presence of muscular wasting.
SPECIAL TESTS
Thomas test
Used to unmask and quantify fixed flexion deformity in the hip
Procedure: With the patient supine on a hard surface eg: examination
table:
1. Look for evidence of excessive lumbar lordosis by:
(a) looking for light passing through and through the lumbar area
(between the back and the couch).

(b)Pass the palm of the hand under the lumbar region: this cannot be
done in a normal situation. If the palm can be passed under the
lumbar region it indicates excess lumbar lordosis.
2. With the palm under the lumbar back, flex the hip on the
unaffected side through its full range of flexion and continue to flex it
beyond till the lumbar back just touches the hand. Notice the hip on the
affected side flexing with this maneuver.
3. With the unaffected hip in the position of flexion as above, passively
extend the hip on the affected side as much as possible without
allowing the patient to arch his back. The angle that the back of the
thigh makes to the couch on the affected side is the amount of fixed
flexion deformity in that hip.
INSTABILITY TESTS:
Telescopy test : done for demonstrating a dislocated hip or unstable hip.
Trendelenberg test: to demonstrate an ineffective abductor mechanism
(Gluteus medius wekness, dislocated or destroyed head of femur,
nonunion of neck of femur, coxa vara, etc.)
Barlows test / Ortalanis test
SPECIAL LINES:
Nelatons line: A line drawn from the ischial tuberosity to the ASIS on
the same side. The line just touches the tip of the greater trochanter in
normal individuals. When the greater trochanter has moved proximally for
any reason, the line cuts the greater trochanter.
Shoemakers line: A line drawn from the greater trochanter to the ASIS
on the same side and extended on to the abdomen will cross the midline at
or above the level of the umbalicus. When the trochanter is high riding the
line passes below the umbilicus.

Kotaris line: To quantify the amount of abduction or adduction


deformity that may be present in the involved hip.
1.
The two ASIS are joined by a line without squaring the pelvis.
2. The midline is drawn passing through the umbilicus.
3. A perpendicular line is drawn to the midline from the ASIS on the
affected side.
4. The angle line1 makes with line 3 is the angle of deformity in the
hip.
Bryants triangle and Nelatons line

EXAMINATION OF THE KNEE


Dr. Aruljoethy
Department

of

Orthopaedics
Common symptoms: Pain, swelling, deformity, locking of the knee,
giving way of the knee, crepitus or clicks at the knee.
Examination of the knee includes that of the hip and ankle on the same
side and the knee on the opposite side.
Examination of the knee is done from the front, side and the back with the
patient supine, prone and standing.
INSPECTION:
Attitude of the limb and the knee in specific
Shape of the knee : Prepatellar area, parapatellar gutters,
suprapatellar pouch and infrapatellar areas for evidence of swelling,
patellar prominence, position of the patella, swelling over the
popliteal area- over the midline and the sides (Bursal swellings).
Tibial tuberosity: look for the tibial tuberosity levels from the side
on both sides simultaneously with the hips flexed to 45 degs. and
knees flexed to 90 degs.

HORSE SHOE SHAPED swelling- suggests effusion in the knee.


Bursal swellings around the knee.
Swellings, scars, sinuses, deformity : details of all these.
Muscular wasting
Limb length discrepancy
GAIT of the patient if he is able to walk.
PALPATION:
Local rise of temperature
Tenderness over the suspected site.
Confirm all inspectory findings by palpation. All swellings, scars etc.
have to be palpated and palpatory findings have to be detailed out.
Confirm the levels of the bony prominences
Look for evidence of any bony irregularities or thickening of the bone
(lower femur and upper tibia and fibula)
Look for any lymph node enlargements
Patellar Tap :
Pre requisites: Knee has to be kept in neutral position
o Milk the supra-patellar pouch empty.
o Push the patella down onto the femoral condyles.
o FEEL the patella tapping on the femoral condyles

o When the tap of the patella on the condyle is felt- patellar tap test is
positive.
o Patella tap can be false-negative when:
Test is done in presence of fixed flexion deformity
Minimal fluid in the knee- fluctuation test- standing position
Tense joint with excess fluid in the knee
Absence of the patella- patellectomy
Faulty technique of eliciting a patellar tap
Palpating for the synovial membrane : The synovium is best
palpated over the superior part of the supra-patellar pouch. This is the
region where the synovium reflects on itself and hence synovial
hypertrophy is best felt here. It is placed about 3-4 finger breadths
above the superior pole of the patella. The supra-patellar pouch
occupies this entire region until the superior border of the patella.
o Start from the superior border of the patella and palpate the suprapatellar area moving in a proximal direction. In the presence of a
synovial hypertrophy it is felt at the superior part of the pouch as a
chord like structure that can be rolled underneath the palpating finger.
Palpation of the patella:
o
o

Shape of the patella


Tenderness of the patella :
prepatellar tenderness
retropatellar tenderness: medial and lateral aspect
retropatellar grating: patello-femoral arthritis
Gap in the continuity of the quadriceps mechanism:
Attachment of the quadriceps to the patella
Patella itself
In the patellar ligament
At the level of the tibial tuberosity

Palpate for clicks and thuds in the joint: Usually indicates possible
meniscal damage or presence of loose bodies in the joint. Also look for

evidence of crepitus in the joint by moving the knee through flexion


and extension.
RANGE OF MOVEMENTS:
All ranges of movements, in all directions normally possible in the joint,
has to be measured in degrees. Movements have to be recorded in a
tabular column showing the movements on the right and the left sides in
each direction and a column to record the difference found in each
direction. This tabular column can also depict the power in each group of
muscle.

MEASUREMENTS:
Measurement of the lower limb as detailed in examination of the hip.
o Apparent length
o True length
o Femoral and tibial length
Muscle girth
SPECIAL TESTS:
Varus and valgus stress tests: for the collateral ligaments
Varus stress test: For lateral collateral ligament
Done with the knee in 10deg flexion and in knee extension
position (neutral position)
Varus stress applied to the knee
Will produce pain over the femoral or fibular attachment of the
lateral collateral ligament or anywhere along the course of the
ligament depending on the site of tear of the ligament.
Valgus stress test: For medial collateral ligament

Done with the knee in 10 deg flexion and knee extension position
(neutral position)
Valgus stress applied to the knee
Will produce pain over the femoral or tibular attachment of the
medial collateral ligament or anywhere along the course of the
ligament depending on the site of tear of the ligament.
Apley grinding test: For integrity of the menisci.
Apley distraction test: For integrity of the collateral ligaments.
McMurrays test for the medial and lateral meniscus
For the medial meniscus:
Flex the knee through its full range of flexion
Externally rotate the tibia on the femur and extend the knee with a
valgus force applied at the knee
For the lateral meniscus:
Flex the knee through its full range of flexion
Internally rotate the tibia on the femur and extend the knee with a
varus force applied at the knee.
In both these tests, look for evidence of pain and/or clicks during
extension of the knee and at what degree of flexion the knee is in, when
patient complains of pain.
If the pain is reproduced with the knee still in more than 100
flexion, the meniscal tear may be placed more posteriorly
(posterior horn tear of the meniscus)
If the pain is reproduced with the knee in 70-100 of flexion, the
tear may be in the middle of the meniscus
If the pain is reproduced with the knee in less than 70 of flexion
the tear may be placed more anteriorly (anterior horn of the
meniscus)
Anterior drawer test: testing integrity of the anterior cruciate ligament

The test is done on the normal side first to determine the normal
range for the given patient.
o Hip place at 45 deg flexion and knee at 90 deg flexion
o Patient is explained to relax the hamstring muscles and this is looked
for, by feeling the hamstring muscles.
o The foot is stabilized and the tibia is stabilised with both hands of the
examiner at the level of the condyles of the tibia and gently pulled
forwards, anteriorly.
o Anterior translation of the tibia on the femur is looked for and
visually approximated.
o The same maneuver is done with the tibia in external rotation and
internal rotation.
o The test is done on the affected side and the amount of forward
translation of the tibia on the femur is compared to the normal side.
o If the amount of translation on the affected side is more the test
on the affected side is said to be positive.
Posterior drawer test: For testing the integrity of the anterior cruciate
ligament
o Procedure is similar to anterior drawer test except that a posterior
push is given to the proximal tibia and the posterior translation of the
tibia on the femur is looked for and compared.
Lachman test: For testing the integrity of the cruciate ligaments.
o With the knee placed in 30 deg of flexion, the lower end of the femur
and upper end of the tibia are held firmly by the examiner.
o With the femur stabilized in one hand the tibia is gently pulled
forwards on the femur.
o Forward translatory movement of the tibia on the femur is looked for
and compared to the normal side. This gives an insight to the integrity
of the anterior cruciate ligament
o The same procedure is done
Q angle : in genu valgum deformity

Intercondylar distance: in genu varus deformity


Intermalleolar distance : in genu valgum deformity

_________________________________

Examination of the Ankle Joint


Dr. Aruljoethy
Department
Orthopaedics
Ankle : Weight bearing joint
Surface area of the joint is small
Weight transmitted per unit square is high
The shape of the ankle is largely due to the malleoli.
Common symptoms: Pain, swelling, deformity, Pain increasing on
bearing weight.
More prone to injury

of

Twisting injury
Vertical compression

Examination:
Inspection
Attitude of the limb and ankle in specific
Examination of the ankle includes that of the knee and foot on the
same side and the ankle on the opposite side.
Examination of the ankle is done from the front, sides
(medial and lateral) and back with the patient supine, prone
and standing.
Look for swelling, scars, sinuses and describe the same
Look for deformity
Whether displaced medially \ laterally or anteriorly \ posteriorly
Excessive broadening-suggests inferior Tibio - Fibular Diastasis
Whether Plantarflexed \ Dorsiflexed
Also look for:
Fullness on either side of Tendo Achilles or bulge across the front
of the joint - suggestive of effusion
Wasting of muscle

Palpation
Local rise of temperature

Tenderness over individual bone prominences and the joint


Confirm inspectory findings
Bones to be examined are:
Medial and lateral Malleolus, Tarsal (Talus and calcaneum
specifically) and Metatarsal bones
Entire length of the tibia and fibula should be palpated
Look for bony irregularity or displacement
Also look for:
Fluctuation on either side of Tendon Achilles
Springing of fibula squeeze the upper end
Feel the Tendo Achilles for any gap

R ange of Movements
Normal

Subtalar

Plantar Flexion

0 - 45

Dorsi Flexion

0 - 20

Inversion

0 - 15

Eversion

0 - 20

Measurement
Measure the tibial length
Medial Malleolus Head of first Metatarsal to Heel
Lateral Malleolus Head of fifth Metatarsal to Heel

Compare with the opposite side


SPECIAL TESTS
Special test
Compression
(Squeeze)
Heel Tap Test

Test for
fracture of tibia and/or fibula

Percussion
(Bump)
Anterior Drawer
(Clunk)

fractures (including stress)


of the tibia
ATF/CF laxity

Kleiger's

Anterior inf. tibiofibular lig

Tibia and Fibula

Talar Tilt (Inversion) damage to CF


Talar Tilt (Eversion) damage to deltoid
Thompson
achilles tendon rupture/
damage
Tinel's Sign
nerve pathology (posterior
tibial nerve)
Homan's Sign
Deep Vein Thrombosis/
phlebitis (DVT)

Positive test
pain elicited in the fibula and/or
tibia around fracture site
Pain along the lower leg may
indicate a fracture of the tibia/ fibula
pain elicited in the tibia around
fracture site
increased laxity and pain,
palpable "clunk" under the ankle
mortise
laxity, medial/lateral pain over
deltoid or sydesmosis
pain, increased laxity
pain, increased laxity
lack or decreased PF
tingling, pain, parasthesia along
nerve distribution
burning, aching, general pain
within calf

EXAMINATION OF THE SPINE


Dr. Aruljoethy
Department

of

Orthopaedics
Common symptoms : pain, deformity, neurological symptoms
Examination of the spine includes examination of the ENTIRE spine,
sacroiliac joint both lower limbs and a detailed neurological examination.
Per rectal examination is a must during spinal examination.
Examination of the spine is done from the back, front and the sides with
the patient in the standing, prone and supine positions.

Bony landmarks in spine examination:


Occiput
C2-3:Mandible
C3:Hyoid cartilage
C4-5: Thyroid cartilage
C6: Cricoid cartilage
C7: Vertebra prominence
T3: Spine of the scapula
T7: Xiphoid, tip of the spine (inferior angle of the scapula)
T10: Umbalicus
L1: Spinal cord ends
L3: radiologically: largest transverse process
L4: Iliac crest
Important to understand:
Levels and exiting nerve roots
o All nerves exit through the spinal nerve root foramina
o They are placed in the upper third of this foramina : important
to know with respect to disc prolapse and level of neurological
involvement.
o There are 7 cervical vertebrae and 8 cervical nerve roots.
o The first pair of spinal nerves go out between occiput and C1.
Hence between C7-T1 the exiting nerve root is C8.
o Between T1-2 the first thoracic nerve root goes out and from
there on the same pattern is followed until the sacral levels.
LEVEL
C1-2
C2-3
C6-7
C7-T1

NERVE ROOT
C2
C3
C7
C8

T1-2
T12-L1
L1-2
L4-5
S1-2

T1
T12
L1
L4
S1

Vertebral and segmental level:


During birth the entire length of the vertebral canal is occupied by the spinal
cord. With growth there is a differential growth in the rate between the bony
vertebral column and the spinal cord and hence in adults the spinal cord ends
at inferior border of L1 vertebra. The nerve roots continue to respective
levels to exit as the cauda equina. Hence between C1 and L1 all segments of
the cord are placed. During fractures of the vertebral column, the bony level
and neurological levels hence do not match.eg: Fracture at T8 vertebra does
not mean involvement of T8 segment of the cord. At this level is placed the
T11 segment of the cord and hence neurological level would be T11
downwards.
The following chart would present a simple way of remembering which
vertebral would represent what segment of the spinal cord and so from what
level downwards to expect a neurological involvement:
VERTEBRAL LEVEL

SEGMENTAL LEVEL

Cervical spine
Upper thoracic T1-6
Lower thoracic T7-9
T10
T11
T12
L1

Add 1
Add 2
Add 3
L1-2
L3-4
L5
Sacral and coccygeal

Eg: -Vertebral injury at C4 : neurological examination will reveal


involvement of the cord from C5 downwards.

-Vertebral injury at T4: would reveal involvement from T6 downwards


- Vertebral injury at T8 would reveal involvement from T11 downwards.
- Vertebral injury at T10 would involve L1 downwards
- Vertebral level L1 would involve the sacral and coccygeal segements
INSPECTION

Attitude of the entire spine

Placement of the head (occiput and the gluteal cleft should be in a


straight line)

Level of the shoulders.

Level of the inferior angle of the scapula (corresponds to T7 level


normally)

Lateral margin of the body from the axilla to the iliac crest whether
there is increased concavity on either side when compared to the other.

Deformity of the spine in both the antero-posterior and the mediolateral plane (torticolis, scoliosis, kyphosis, lordosis). Scoliosis is
looked for by looking at the spinous process of the spine through the
entire length of the spine.

Evidence of tell tale signs in the lower back that may suggest an
under lying spina bifida.

Evidence of caf- au- lait spots that may suggest neurofibromatosis.


This condition is associated with various deformities of the bone.

Level of the posterior superior iliac spine.

Level of the sacral dimples indicating region of the sacroiliac joints.

Level of the anterior superior iliac spine.

Level of the area of ribs with the patient bending forwards in patients
with scoliosis.

In the presence of scoliosis, asking the patient to bend forwards would


differentiate between a structural and a non-structural scoliosis.

Any swellings, scars, sinuses etc on inspection should be detailed out.

Muscle wasting in the back and in the limbs.

Gait of the patient

Evidence of neurological deficit in the limbs.

Inspection of the femoral triangle area is important in spinal


examination as tuberculous abscess can track to the femoral triangle
and present as a swelling in this region.

PALPATION
Local rise of temperature
Tenderness : over the entire length of the spine and the sacroiliac joints.
Confirmation of all inspectory findings and detailing palpatory findings
wherever appropriate. Eg: regarding swelling, scars etc.
Complete detailed neurological examination and findings to be
written in a tabular format.

RANGE OF MOVEMENTS
Active and passive movements in all directions normally occuring
at all levels of the spine have to recorded in degrees.
Cervical : Flexion, extension. rotations, lateral flexion
Thoracic: rotational movements occur at this level
Costovertebral movements: Also indirectly reflects on the status of the
spine as the ribs are attached to the vertebrae. Disease process
involving the spine can affect these joints and present clinically with
restricted movements of the thoracic cage. This is measured by the
amount of chest expansion possible on inspiration. Normally this
would be in excess of 5-7 cms.
Lumbar: Flexion :
o Schobers test to quantify the amount of flexion
o Coin test: when the spine is affected, patient bends at the hip and knee
with the spine being straight and stiff.
Lumbar : Flexion, Extension, lateral flexion.
Sacroiliac movements : moves with the patient bending forwards in the
standing position and also during rotation of the spine.
MEASUREMENTS
Schobers test to quantify the movements occurring in the spine.
Limb length discrepancy in the lower limbs as this can lead to
symptoms in the spine.
SPECIAL TESTS

EVIDENCE OF COMPRESSION ON THE CORD OR NERVE


ROOT
Straight leg raising test :
o Used to identify presence of a lower lumbar or upper sacral
disc- L3/4/5, S1
With the patient supine it is important to first confirm that there is no
evidence of increased lumbar lordosis. Then with the symptomatic limb
kept straight the non-symptomatic limb is raised gently into flexion at the
hip with the knee in extension. Normally, upto beyond 60 deg of flexion
at the hip in this manner, there is no discomfort noticed. Discomfort
at this point even on the normal side may be due to stretching of the
hamstring muscle or may indicate a possible pathology in the
sacroiliac joint. Patient here would complain of pain over these areas.
Now the non-symptomatic side is placed on the bed and the symptomatic
side is flexed in a similar manner. When the patient complains of a
radiating pain over the course of the sciatic nerve in the arc between 060 of flexion at the hip, it is indicative of cord or root compression.
STEP 2: If for example the patient complains of pain at 40 deg. then
reduce the flexion by 10 degrees and then in this position passively
dorsiflex the ankle. If the patient complains of similar pain coming on
again then it is confirmative of a pressure over the cord or nerve root.
This second part of the test is called as the LASSEGUES SIGN.
Femoral nerve stretch test:
o Used to identify prolapse of a upper lumbar disc
With the patient prone the hips in neutral position, the knee is flexed. If
the patient complains of pain in the front of the thigh over the course of
the femoral nerve it indicates a possible disc irritating the cord or root at a
higher lumbar level.

Lhermitts sign:
Used to identify a possible disc prolapse at the cervical spine level
With the patient sitting the hips and the cervical spine are flexed
simultaneously. In the presence of excruciating pain in the spine
radiating down both upper extremities a disc prolapse is a possibility.
TESTS FOR THE SACROILIAC JOINT
Pump handle test:
The patient is placed supine and the test is done on the unaffected
side first. The shoulder of the patient is steadied and the hip is flexed
through its full range of flexion with the knees flexed. The hip is then
forced further into the direction of flexion and towards the opposite
shoulder. Normal sacroiliac joint will not produce any discomfort with
this maneuver.
The same is done on the affected side. Pain is reproduced at the sacroiliac
joint on the affected side.
Genslens test:
With the patient supine, the affected hip and knee is flexed while the
unaffected side is allowed to hyperextend over the edge of the table. This
produces a rotational strain in the sacroiliac joint reproducing pain on the
affected side.
RECTAL AND VAGINAL EXAMINATION
This is an important part of examination of the spine especially in spinal
injuries to determine the extent of damage to the cord (complete or
incomplete) and also in evaluating the period of spinal shock.

Examination of the rectum also is important to look into the status of the
prostate. Malignancies of this organ can produces secondaries in the
spine.
Vaginal examination is important to look into the possibility of cervical
carcinoma, which again can present with secondaries in the spine.

EXAMINATION OF THE SHOULDER


Dr. Aruljoethy
Department
Orthopaedics
Common symptoms presented with are pain, swelling and deformity
around the shoulder.

of

Although we know the shoulder to be the gleno-humeral joint, in reality, it


is a complex of 4 joints. Movements of the shoulder are commonly
thought of as movements occurring in the gleno-humeral joint alone. The
movement actually occurs jointly at the acromio-clavicular, sternoclavicular, gleno-humeral and the scapulo-thoracic joints. Hence
examination of the shoulder joint would include examination of all the
above-mentioned joints and areas around it, as pain from any of these
joints could present with restriction of movement at the shoulder.
Pain around the shoulder could be due to pathologies in other areas like,
the neck, internal organs lung, diaphragm and the heart or from the
upper back.
Pain arising from pathology in the shoulder, may present early, as pain in
the upper arm or forearm. The proximity of the large vessels and nerves of
the upper limb to the shoulder makes it possible for patients with
pathology around the shoulder to present with symptoms pertaining to
these structures.
Examination of the shoulder includes examination of the upper back,
neck, axilla, upper limb and respiratory & cardiac systems.
INSPECTION: (With the arm by the side of the body):
Attitude of the limb and the shoulder in specific
Shape of the shoulder: The shoulder has a rounded contour to it due to
the head of the humerus within the glenoid and the bulk of the deltoid
muscle. The shoulder should be examined from the front, back and
the side.
Examination from the front:
o The shape of the shoulder
o The clavicle: Being a subcutaneous bone the shape of the clavicle

o
o
o

and the adjacent, acromio and sternoclavicular joints can be


inspected.
Suparclavicular area
The front of the chest : The pectoral muscle: wasting
The anterior axillary fold:
Presence of swelling
Level of the fold as compared to the opposite side.
Swellings, scars, sinuses, deformity: details of all these.

Examination from the side:


o The shape of the shoulder
o Swelling on the anterior, posterior or lateral aspect of the shoulder.
o The acromion bone
Examination from the back:
o Examination of the scapula and upper back for swellings, scars,
sinuses, deformity: details of all these.
o Spine of the scapula: deformity
o Wasting of the suprascapular and/or infrascapular muscle (seen as
wasting above and below the spine of the scapula).
o Angle of the scapula: superior and inferior: level on comparison to
the opposite side.
o Medial border of the scapula: evidence of winging of the scapula.
o Level of the posterior axillary fold: compare with opposite side.
Examination of the axilla:
o Swelling in the axilla: In traumatic situations it may well be
the dislocated head of the humerus.
o Scars, sinuses: details of all these.
Limb length discrepancy in the upper limb
PALPATION
Local rise of temperature

Tenderness over the suspected areas


Confirm all inspectory findings
Look for evidence of bony irregularities
Confirm the levels of the bony prominences
Complete neurological and vascular examination
Examination of the neck, elbow, cardiac and respiratory system to be
done in detail.
RANGE OF MOVEMENTS
o All range of movements of both shoulders, both active and passive
to be recorded in all direction in degrees.
MEASUREMENTS
o Apparent and true measurements of the upper limb to be recorded
o Axillary circumference
o Hamiltons ruler test
SPECIAL TESTS
Special Test

Tests for

Positive (+) Test


(+) sign is clicking and/or anterior
subluxation
clicking and/or posterior subluxation
decreased pain and discomfort when
humeral head is relocated (A/P)
pain, discomfort, look of apprehension
on patient's face, feeling that shoulder
will dislocate
grinding or palpable "clunk" in shoulder with
movement

Anterior Drawer

Tests for anterior instability

Posterior Drawer

posterior GH instability

Jobe Relocation Test

anterior instability

Apprehension Test

Instability

Clunk Test

labral tear

Sulcus Sign

multi-directional instability

increased gapping as the humeral head


displaces inferiorly

AC Distraction

AC and/or coracoclavicular
ligament sprain

pain with or without passive movement

Grind Test

labrum tear

Drop Arm

rotator cuff patholgy

pain and/or obvious deformity


(step-off, piano key)
inability to lower arm in a controlled

O'Brien
Empty Can
Active Impingement
Hawkins-Kennedy

SLAP Lesion
supraspinatus weakness,
Impingement
Impingement of active
structures in shoulder
impingement of the
supraspinatus tendon
impingement of biceps or
supraspinatus tendon
SC ligament sprain and
instability

manner from90 to 0 degrees (ADD)


pain with IR but decreased (Active
Compression) with ER;pain/clicking
with movement
decreased strength on involved side;
pain with resistance
pain in mid-arc of ROM
pain upon IR

pain with motion, especially near


terminal end point
elbows do not touch the table
SC stress test
(active test)
inability to lift hand off of /pathology
Gerber Lift-Off
subscapularis weakness
spine; pain with movement
pain @ bicipital groove and/or weakness in
Speed's
biceps tendinitis
shoulder FLEX
pain with movement or "popping" as
Yergason's
biceps tendonitis or subluxation
tendon subluxes
tendon can not be palpated no active
Ludington's
biceps tendon rupture
biceps contraction
compression of subclavian
Adson's Maneuver
diminished/absent radial pulse
artery. by scalenes
(TOS) compression of NV by
Allen
diminished/absent radial pulse
pectoralis minor
(TOS) compression of
Military Brace
subclavian a. by
diminished/absent radial pulse
costoclavicular structures
Inability to maintain test position,
Roos
Thoracic Outlet Syndrome
diminished motor function, and/or loss
of sensation
translation: 25-50% = grade1 Inability to maintain test position,
Load/Shift Test
>50% w/reduction = grade 2
diminished motor function, and/or loss
>50% w/o reduction = grade 3 of sensation
superior pain indicative of AC joint
pathology; anterior pain indicates
subscapularis, biceps tendon, or
Cross-over impingement shoulder impingement
supraspinatus pathology; posterior pain
indicates infraspinatus, teres minor or
posterior capsule pathology
Piano key sign
AC joint instability
Neer Impingement

Appleys scratch test

adduction/IR or abduction/ER

EXAMINATION OF THE ELBOW

Dr. Aruljoethy
Department of Orthopaedics
Common symptoms: Pain, Stiffness, Deformity, Occasional locking
The Elbow joint is formed by the lower end of the humerus, upper ends of the
Ulna ( olecrenon) and the radius ( radial Head)
The ossification of the lower end of the humerus is important to be known.
The bony prominences around the elbow are the Medial epicondyle and Lateral
condyle. The head of the radius and the olcrenon process are also palpable.
INSPECTION
Attitude and Deformity of the limb : Cubitus Varus and Valgus
Carrying angle: The angle between the long axis of the arm o that of the
forearm with the limb in supination and neutral position in the plane of flexion
and extention.
The carrying angle should not commented upon with the limb in any degree of
flexion on in the presence of a flexion deformity.
Patient asked to stand with his hands by the side of the body and observe for
normal carrying angle : 8-10 deg in males and 11-15 deg in females.
Swelling:
Any swelling near the joint to be noted
Look for fullness of normal hollow on either side of Olecronon
Look for any swelling over the olecronon [eg: olecronon bursitis students /
miners elbow]
Tense effusion will show fullness of anticubital fossa
Look for any scars or sinuses and describe them
Muscle Wasting

PALPATION

Local rise of temperature


Tenderness : Soft tissue and bony : can indicate possible site of pathology
Eg: tenderness over origin of Common Extensors - Tennis Elbow
Tenderness over origin of Common Flexor Golfers Elbow
Confirm Inspectory findings
Look for limb length discrepency
Bony prominences
Bony Points
Lower part of humerus
Upper part of ulna and radius

For thickening or irregularity

Three bony points:


Olecronon tip, Medial and Lateral epicondyle
Form a triangle when elbow is flexed
In straight line when elbow is extended
Examination of supra trochlear Lymphnode

RANGE OF MOVEMENTS
Flexion and extension
Additional tests:
Palpation of Ulnar Nerve
Cozens Test
Miltch Manuvuer

MEASUREMENTS:
Distance between the two condyles: Intercondylar distance
Distance between the Olecrenon and the two condyles: Medial and Lateral
Arm and forearm length
EXAMINATION OF THE WRIST JOINT

Dr. Ashutosh Rao


Department

of

Orthopaedics
Common complaints: Pain, Swelling and deformity
Common fractures: Colles. Smiths, Bartons, Chauffers,
Epiphyseal injury
Some disease process: Rheumatoid, Keinbocks disease

Scaphoid,

Like most other joints history is similar pain, swelling etc


INSPECTION:
Attitude and deformities
Common deformity is flexion and ulnar deviation of wrist and Subluxation of
joint: Rheumatoid arthritis
Deformity:
Manus varus and valgus, Madelungs deformity : definition
Look for swellings, scars and sinuses
Swelling
Can be due to effusion : uncommon
The swelling is commonly due to effusion into tendon sheath this has to be
differentiated: extends both proximally and distally beyond the joint
Eg: Compound palmar ganglion [Tubercular tenosynovitis]
A circumscribed small swelling on the dorsum of wrist is commonly a ganglion
Sinus: Tuberculor Sinus
Wasting of Muscles

Palpation:
Local rise of temperature
Tenderness: Soft tissue and bony, Joint line
Confirm Inspectory findings
Look for limb length discrepancy
Describe palpatory findings of swellings
Bony Points:
Lower end of Radius
Lower end of Ulna
Balottment of Ulnar head
Level of Styloids

Range of Movements:
Dorsiflexion [extension]
Palmar flexion
Radial Deviation
Ulnar Deviation

70 to 80
0 to 70
0 to 20
0 to 30