Case 1 – Tutor Guide

History and Examination of the

Musculoskeletal System

Clinical Skills Teaching

Year 1 Medical Students MB BCh

Contents

Introduction to workshop .............................................................................................. 3

Introduction to C21 Clinical Skills Curriculum ................................................................ 4

Providing feedback to students ..................................................................................... 5

Background – Case 1 ...................................................................................................... 6

Week 1 – History and Examination of the Musculoskeletal System (GALS).............. 7

Suggested Workshop Structure – Guidance for Tutors .................................................. 8

Week 2 – History and Examination of the Musculoskeletal System (Knee) .............. 9

Suggested Workshop Structure – Guidance for Tutors ................................................ 10

Further Information and Teaching Suggestions ........................................................... 11

Appendix A - The Calgary-Cambridge Guide ................................................................ 14

Appendix B - Generic Guide to History Taking ............................................................. 15

Appendix C – Guide to the Musculoskeletal Examination – GALS (Gait, Arms, Legs,

spine)............................................................................................................................ 16

Appendix D – Guide to the Musculoskeletal Examination – The Knee ........................ 19

Clinical Skills and Simulation Team – October 2016 Page 2 of 21

Introduction to workshop

Welcome!

Thank you for agreeing to help with this teaching.

These workshops occurs in the first case of Year 1. This means they are at the start of a block
of approximately 12 weeks when they will learn for the first time how to take histories from
patients and how to perform physical examinations. First impressions count so please try to
make these sessions engaging and educational!

The focus for all these sessions is to introduce the students to the particular tasks and give
them an opportunity to practice.

The students will have further opportunities to practice most of these skills in timetabled
sessions in Year 2. They also can attend the Self Directed Learning area in the Clinical Skills
Centre to practice the skills further.

This teaching session is delivered in parallel across the four centres used for year 1 and Year 2
clinical skills teaching – Merthyr, Newport, Bridgend and Cardiff.

Each centre may adapt the session to suit their own practical arrangements but it is
important that all students get the same core teaching.

This teaching session is formatively assessed – this means that attendance is compulsory and
students should get feedback whenever possible on their performance. If tutors are
concerned that a student is not engaging with the session or is performing particularly
poorly please inform the undergraduate manager or Paul Kinnersley (see below).

There is a formal assessment of the students’ clinical skills including their history and
examination skills at the end of Year 2.

Students have access through the Learning Resource Platform (Blackboard) to a ‘Guide to
examining the Musculoskeletal System’. This guide should be read in conjunction with this
teaching plan.

If you have questions about this teaching please contact Paul Kinnersley, Director of Clinical
Skills, kinnersley@cf.ac.uk or Sian Williams, Lead for Procedural skills teaching
WilliamsSE17@cf.ac.uk

Thank you again for your participation

The Clinical Skills and Simulation Team

Clinical Skills and Simulation Team – October 2016 Page 3 of 21

Introduction to C21 Clinical Skills Curriculum

The aim of C21 early clinical learning is that students learn to integrate their clinical, basic, behavioural
and social sciences whilst exploring patients’ experiences of illness. It also seeks to help the student
gain competence in history taking and in conducting physical examinations, whilst learning clinical
reasoning and decision making skills. Good consultation skills lie at the heart of healthcare and as such
students will be taught how to consult effectively from the beginning of the C21 course. Core skills are
essential and may be learnt and developed through experiential learning, in order that students
become equipped with a core set of skills to enable them to progress and master more complex
consultations during their careers.

Through meeting real patients from the earliest stages of their undergraduate course and learning
about the experiences of illness, we want students to develop a patient-centred approach to clinical
practice and develop professional attitudes towards patients and colleagues.

The process of learning clinical skills:

Practise clinical Practise clinical

Learn clinical skill in
skills in controlled skills in ‘real-life’
class room
clinical setting clinical setting

In Phase 1 B students spend 1 day each week on Community Based Learning Placements (half the day)
and learning clinical skills (half the day). During their Community Based Learning placements, students
will rotate through a range of activities – visiting patients in their own home, visiting community physio
clinics and see patients in GP surgeries so they meet real patients in a variety of settings which will
‘bring to life’ and contextualise their case-based learning and give them the opportunity to witness
the effect of social environment on health and healthcare. They will also develop and learn
transferable skills and informed professional attitudes, through contact with a multi-professional
cohort of teachers.

Clinical skills teaching in Phase 1B consists of seven history and examination teaching sessions, three
procedural teaching sessions, one session on assessing respiratory function and one on examining the
eyes and ears.

Please note – the clinical skills teaching session are matched with Community based teaching
sessions (students will do clinical skills in the morning and Community based learning in the
afternoon or vice versa). There is overlap between these teaching sessions – see individual lesson
plans – in the afternoon sessions please remember to ask students what they have done already in
the morning so we can build on their prior learning.

Clinical Skills and Simulation Team – October 2016 Page 4 of 21

Providing feedback to students
A key part of Clinical Skills teaching is providing feedback to students on their performance. To help
learning, feedback needs to be objective and aligned with what the student is trying to achieve (their
learning agenda or their individual learning needs). Early in the course students find it difficult to
identify individual learning needs because they simply feel they need to learn everything – however it
can still be helpful to start with this approach.

There are generally 2 agendas for feedback in the workshops and the tutor should seek to incorporate
both:

 What do the students feel they want/need to learn?

 What do we want to teach them?

Where possible, feedback should be:

S - Specific, Significant, Stretching

M - Measurable, Meaningful, Motivational
A - Agreed upon, Attainable, Achievable, Acceptable, Action-oriented
R - Realistic, Relevant, Reasonable, Rewarding, Results-oriented
T - Time-based, Timely, Tangible, Trackable

The way in which we give feedback can directly influence how the students respond to the learning
experience, and so if we are to nurture them, we need to do this in a supportive, safe fashion.

 Review learner’s original agenda and encourage self-feedback from student

 Provide constructive, timely feedback based on observations from tutor
 Encourage supportive input from other students to solve problems
 Re rehearsal of new skills, either by the individual, or by subsequent students incorporating
lessons learnt earlier in workshop through observation of their peers.

– Ask the student ‘How did that go?’

– Link this to the students own agenda
– Ask the student ‘What could be improved?’
– Open discussion to the other things for them to improve/ focus upon

Struggling students

It is important that students who struggle with their clinical skills for whatever reason are identified
early. If a student in your group raises concerns, please take a little time at the end of the session to
clarify how the student felt the session went. Some may just be nervous or unfamiliar with the
teaching methods used. However, we routinely offer, all students who need them, remedial sessions
– but we want to target these at those who need them most and need your help to identify these
students. Tutors are therefore encouraged to be proactive about identifying students who they feel
might benefit from such extra support, and pass their details to Jo Sloan (sloanjm@cf.ac.uk), so that
students can be contacted at the appropriate time.
If you have major concerns about a student’s behaviour please discuss your concerns with them if
appropriate AND send a report to Paul Kinnersley (kinnersley@cf.ac.uk).

All students will be informed that you may raise your concerns with them and that this is meant to
be helpful rather than to be seen as criticism.

Clinical Skills and Simulation Team – October 2016 Page 5 of 21

Background – Case 1

Brief summary (adapted from the Case Facilitator’s guide)

The first case, a knee injury, will promote the application of musculoskeletal human anatomy and
physiology to a specific common clinical problem. By emphasising the normal structure and function,
the comparison to pathological concepts will demonstrate the application of the integrated science to
common clinical presentations. The case will build on your knowledge of pain mechanisms from Phase
1a and develop the role of therapeutics in the treatment of pain. Using the communication skills
learned in Phase 1a, the history and examination skills relevant to the musculoskeletal system will be
introduced. This will be applied, in a patient centred manner during the community sessions, allowing
you to explore patient experiences and interdisciplinary team work.

In the case fortnight students will get further anatomy and physiology teaching relevant to the
musculoskeletal system and also make community visits to physio clinics and visit patients at home.
Whenever possible it is helpful if tutors help students connect together the various elements of their
learning within the case.

The Higher Level Clinical Skills Learning Outcomes for the Case are:

H1. Perform a musculoskeletal history

H2. Perform a musculoskeletal examination
H3. Demonstrate the ability to organise the information gathered from a patient
H4. Identify relevant diagnostic hypotheses

There are two ‘history and examination’ clinical skills sessions in this case – both sessions
should include opportunities to learn history taking from patients (or actors) with
musculoskeletal problems and the sessions should also include teaching on performing the
GALS (Gait, Arms, Legs, Spine) examination and also examining the knee (as an example of
a generic joint examination)

The order of the two physical examinations can be decided by the different teaching centres.

Clinical Skills and Simulation Team – October 2016 Page 6 of 21

Week 1 – History and Examination of the Musculoskeletal System (GALS)

Overall Session Aim (3 Hours)

Students will learn the skills required to take a history from a patient with musculoskeletal symptoms
– for example joint pain or stiffness. They should also develop their understanding of the impact of
musculoskeletal diseases on the individual, their family and society and consider how any negative
impacts can be reduced.

Appendices A and B provide diagrams of the structure and content of a generic history (PowerPoint
slides can be provided). If possible please use these with students to talk through both what
information to gather and how to gather it. A video of ‘good’ history taking of a man with palpitations
can be provided and can be used as a generic example of the skills required.

Intended learning outcomes

By the end of this workshop the students should be able to:

 Identify the common symptoms which suggest Musculoskeletal Diseases.

 Practise and perform the consultation skills for gathering information about
Musculoskeletal problems from patients to ensure that they have an accurate
understanding of why the patient is seeking medical help including:

– Key symptoms & their chronology,

– Relevant past medical & medication history,

– Patient’s social circumstances where these impact upon health and the effects of
the illness on the patient’s life

 Demonstrate the ability to organise the information gathered from a patient and identify
relevant diagnostic hypotheses for common gastrointestinal problems using the
diagnostic sieve as a framework

 Practice and perform the GALS (Gait, Arms, Legs, Spine) Screening Examination of the
Musculoskeletal system

Clinical Skills and Simulation Team – October 2016 Page 7 of 21

Suggested Workshop Structure – Guidance for Tutors
Each centre may adapt the session to suit their own practical arrangements but it is important that
all students get the core teaching addressing the learning outcomes above.

History and Examination of the Musculoskeletal System (GALS)

For 12-16 students 2 tutors 2 rooms
Resources For 16-30 students 3-4 tutors 3-4 rooms

Actors or expert patients to provide histories and to be examined

Suggested histories – see later in guide
Couches

Time Activity
20 mins Introduction to session – Common symptoms and signs of Musculoskeletal Diseases

Large Group discussion

Identify the symptoms which suggest Musculoskeletal disorders

Differentiating patterns of joint pain (acute, chronic, intermittent (gout))

Consider impact of Musculoskeletal illness on the patient

Consider how to organise information gathered and begin generating diagnostic

hypotheses

80 mins Split into groups of 7-8 students

Consulting with patients: 4 x 20 mins per patient

20 mins Tea break

50 mins Continue in smaller groups

Physical examination of Musculoskeletal system

Demonstration and student practice

10 mins Conclusion and final discussion

Additional Resources

Geeky Medics Guide - GALS Examination: http://geekymedics.com/gals-assessment/

Guide to the Examination of the Musculoskeletal System (GALS) - See Appendix C

Clinical Skills and Simulation Team – October 2016 Page 8 of 21

Week 2 – History and Examination of the Musculoskeletal System (Knee)

Overall Session Aim (3 Hours)

Students should build on the skills they learnt in Week 1 (see previous page) and get further experience
of gathering information/Taking histories and performing examinations. Again use the diagrams in
Appendices 1 and 2 of this booklet (PowerPoint slides can be provided)

Intended learning outcomes

By the end of this workshop the students should be able to:

 Identify the common symptoms which suggest Musculoskeletal Diseases.

 Practise and perform the consultation skills for gathering information about
Musculoskeletal problems from patients to ensure that they have an accurate
understanding of why the patient is seeking medical help including:

– Key symptoms & their chronology,

– Relevant past medical & medication history,

– Patient’s social circumstances where these impact upon health and the effects of
the illness on the patient’s life

 Demonstrate the ability to organise the information gathered from a patient and identify
relevant diagnostic hypotheses for common gastrointestinal problems using the
diagnostic sieve as a framework

 Practice and perform the Musculoskeletal Examination with a particular focus on the knee

Clinical Skills and Simulation Team – October 2016 Page 9 of 21

Suggested Workshop Structure – Guidance for Tutors
Each centre may adapt the session to suit their own practical arrangements but it is important that
all students get the core teaching addressing the learning outcomes above.

History and Examination of the Musculoskeletal System (knee)

For 12-16 students 2 tutors 2 rooms
Resources For 16-30 students 3-4 tutors 3-4 rooms

Actors or expert patients to provide histories and to be examined

Suggested histories – see later in guide
Couches/stethoscopes

Time Activity
20 mins Introduction to session – Common symptoms and signs of Musculoskeletal Diseases

Large Group discussion

Identify the symptoms which suggest Musculoskeletal disorders

Differentiating different types of joint problems and other symptoms related to

musculoskeletal disorders

Consider impact of Musculoskeletal illness on the patient

Consider how to organise information gathered and begin generating diagnostic

hypotheses

80 mins Split into groups of 7-8 students

Consulting with patients: 4 x 20 mins per patient

20 mins Tea break

50 mins Continue in smaller groups

Physical examination of Musculoskeletal system with particular focus on the knee

Demonstration and student practice

10 mins Conclusion and final discussion

Additional Resources

Geeky Medics Guide – Knee Examination: http://geekymedics.com/knee-examination/

Guide to the Examination of the Musculoskeletal System – See Appendix D

Clinical Skills and Simulation Team – October 2016 Page 10 of 21

Further Information and Teaching Suggestions
A typical History and Examination teaching session

The focus of the history and examination teaching is getting the students to start to understand the
process of gathering information from patients and processing this to form differential diagnoses.

The main sources of information available to doctors are:

The (his)story – Numbers (results of

Pictures (x-rays or
from the patient, The Examination blood and other
other images)
relatives or others tests)

(Thanks to Dr Tom Hughes for this diagram)

The focus in the first year will be equipping the students to gather accurate information from patients
– the story and the examination. Later teaching will bring in pictures and numbers (though of course
if appropriate it can be touched on earlier).

The teaching is organised as being about ‘the Gastro-intestinal history and examination’ – this is for
practical reasons and to integrate it with other learning – these particular focussed history and
examination skills can be considered to be ‘routines’ that doctors use if they think a patient has
symptoms suggestive of a particular system problem. BUT it should be remembered that patients
present with symptoms and doctors work with these to arrive at diagnoses (not from disease to
symptoms as described in many textbooks). So doctors need to be able to take ‘generic’ histories
which are flexible to the patient’s symptoms.

As well as gathering information about the main features of the disease, to enable them to make a
diagnosis, doctors need to also gather information about the patient’s illness experience so that they
can address the patient’s concerns and expectations and thus provide high quality care. Doctors treat
people not diseases. By acquiring these skills, they will become more effective `history takers’ (and
also be better at explaining illnesses and treatments). Clearly some students are naturally more
competent at communicating than others but all students need to be aware of the skills required for
good communication and have opportunities to practise these.

General principles:

We want to work from symptoms to diagnoses

To conduct good consultations students need to consider the ‘content’ – what you say – and the
‘process’ – how you say it – see above

Students should be encouraged to process the data they gather as they go along – this is automatic
for experienced clinicians but not for new students – so for example the tutor might stop the student
after they have gathered only one or two pieces of information from the patient and ask them what
they are thinking. So students should:

Listen to the Listen some

Think Think Ask questions Think
patient more

Clinical Skills and Simulation Team – October 2016 Page 11 of 21

Students need to learn about ‘What’ information they should gather and also ‘How’ to best gather
this information

For this we use the Calgary Cambridge Guide – Appendix A (page 14) – this provides an overall
structure to the consultation and identifies which tasks need to occur where. It is also useful to
organise the skills required for different tasks. In addition we have produced a Generic Guide to
history taking – Appendix B (page 15) – which suggest both the Content (What information to gather)
and the Process (how to gather this information). Whenever possible tutors should refer to these
diagrams – copies of which will be available to students through Learning Central.

Students should use summaries frequently – ‘so you have had chest pain for 3 days and you are
worried it could be lung cancer’ – so that they check they have the facts right, they process the
information internally and they demonstrate listening to the patients

At the end of the history the student should have some diagnostic hypotheses – which may be as
simple as a ‘problem with the GI system’!

Physical Examinations

To start with students should be performing their examinations to learn the routine of the knee or
abdominal examination. They also need to become familiar with the ‘normal’ exam so they can
recognise abnormal findings. Different teaching centres can use actors or real patients for this
teaching. However sometimes it can be frustrating for students examining ‘normal’ people and they
are keen to see pathology – obviously slides of abnormalities can be used and also to make it more
interesting and instructive for the students tutors can ask ‘what would you think if ..... for example -
the patient was tender on the right side of the abdomen’.

Students should be pointed to the surgical sieve to help them think about possible diagnoses. There
are various versions of this but a simple version – for year 1 students would be:

Congenital

Acquired - Trauma
Infection
Inflammatory
Neoplasm
Degeneration
Autoimmune
Environmental

Patient’s Ideas, Concerns, Expectations

Thinking about history taking from patients with GI symptoms is a good opportunity to reinforce the
practice of asking patients about their Ideas, Concerns and Expectations.

I/C Patient’s ideas/concerns – these may be difficult to separate out and there is no real need to
– patients with abdominal pain are very likely to have a range of concerns some of which may
include diagnoses such as cancer – and whether this is diagnostically likely or unlikely the
concern still needs to be addressed. Students need to develop their own phrases for
exploring ideas/concerns – what worries are on your mind? What have you been thinking?
etc.

Clinical Skills and Simulation Team – October 2016 Page 12 of 21

E Elicit expectations – it can be useful to elicit what patients are expecting to happen so that
we can weave these expectations into our management – ‘Yes that’s right I’m sure we need
to do some further tests…’ ‘although you said you thought you might need a whole body MRI
there are some reasons why that wouldn’t be the best thing to do right now…’. Again students
need to work out good phrases – saying ‘What do you expect us to do about this?’ doesn’t
usually work but perhaps ‘Were you thinking we would do some further tests?’ might be more
appropriate.

We warn the students that they may see and be taught slightly different approaches to history
taking and to the physical examination by different people

Suggested patient scenarios – for actors or expert patients can be provided by Paul Kinnersley

Clinical Skills and Simulation Team – October 2016 Page 13 of 21

Appendix A - The Calgary-Cambridge Guide
The Calgary-Cambridge Guide gives a generic structure for the tasks of any consultation

THE ENHANCED CALGARY-CAMBRIDGE GUIDE TO THE MEDICAL INTERVIEW

Jurtz SM, Silverman JD, Benson J & Draper J. (2003)
Marrying Content & Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides.
Academic Medicine

Initiating the Session

Preparation
Establishing initial rapport
Identifying the reason(s) for the Consultation

Providing Building
structure Gathering Information the
relationship

Exploration of the patient’s problems to

Making discover the: Using appropriate
organisation overt Biomedical perspective non- verbal
patient’s perspective behaviour
Background information- context

Attending to flow Developing rapport

Physical Examination

Involving the patient

Explaining & Planning

Providing the correct amount & type of

information
Aiding accurate recall & understanding
Achieving a shared understanding
incorporating the patient’s illness framework
Planning: shared decision making

Closing the Session

Ensuring appropriate point of closure

Forward planning

Clinical Skills and Simulation Team – October 2016 Page 14 of 21

Appendix B - Generic Guide to History Taking
Content Process (suggested not prescriptive)

Getting off to a good start Hello, I’m XXXXX YYYYY,

I’m a first year medical student
Inform patient of name It’s Mrs Roberts isn’t it?
Check patient’s identity Would it be alright if I had a talk to you before you see
Consent to consultation the doctor?
The presenting complaint Open to close cone

WWQQAA (or SOCRATES) Open questions

Where Site What seems to be the problem?
Radiation Can you tell me some more?
Anything else?
When Frequency/periodicity
Duration Summarise
So to summarise……
Quality Character
Further enquiry about main problem
Quantity Severity Tell me some more about this chest pain

Aggravating and alleviating factors Shift to closed (focussed) questions

Now can I ask you some specific questions
Associated (other) symptoms Was there any blood in the vomit?
What makes the pain worse etc?

Patient’s perspective Exploring ICEE

ICEE What’s have you been thinking could be causing this?

Ideas What’s your main worry about all this?
Concerns
Expectations Follow up worries – if patient says ‘and when I started
Effects on life vomiting I was really worried…’ respond with ‘What
thoughts were going through your mind?’ or similar

General health
Are you otherwise well?
Have you had any serious illness in the past?
Systematic Review Have you had any operations?
Have you had diabetes

PMH Additional empathic statements

Drug History
Allergies To build relationship and provide support – ‘That must
be very difficult for you’ (about a chronic problem);
‘So you’ve been really sick’ (more acute problem)
Physical Exam if appropriate

Note: ICEE needs flexible approach as to timing

within consultation – see process
Good ending Thank patient
Inform them of next stages in care ‘I’m going to report to the consultant and then she will
come and see you with me’

Clinical Skills and Simulation Team – October 2016 Page 15 of 21

Appendix C – Guide to the Musculoskeletal Examination – GALS (Gait, Arms,
Legs, spine)
A copy of this guide is available to students through Learning Central

Please note: as with other examinations, different clinicians will perform these examinations in slightly
different ways – and different resources (Macleod’s Clinical Examination, www.geekymedics.com etc.)
may describe the examination slightly differently. Students need to establish their own routine for
performing these examination and this Guide is intended to help them do this. Students do NOT fail
assessments if they do the examination slightly differently to as described here.
Feedback is welcome – please send to Paul Kinnersley (kinnersley@cf.ac.uk)
This guide was written with the help of Dr Rhian Goodfellow

At the start of every examination

Clean hands
Introduce yourself to the patient
Explain what you are going to do and check if patient in any pain – check the patient consents to you
examining them
Expose the patient appropriately preserving dignity

The GALS Examination (Gait, Arms, Legs, Spine)

The GALS examination is a brief screening examination which takes only a few minutes and can thus
be used in routine assessments. It can be useful for detecting problems with the musculoskeletal
system. The particular sequence of the examination may vary but it is usually easier to perform those
parts of the examination with the patient standing up and then get them on to the couch for the
remainder of the exam.
The GALS exam is a good example of an examination using the LOOK/FEEL/MOVE structure

Initial Screening Questions

 Do you have any pain or stiffness in your muscles, joints or back?
 Can you dress yourself fully in the morning?
 Can you climb up and down stairs with no difficulty?

With the patient standing and with ideally exposed trunk and limbs (preserving dignity)
Gait
 Ask the patient to walk a short distance, turn and then walk back.

 Look for symmetry, smoothness of movement, normal stride length, pelvic tilt, arm swing,
normal heel strike, stance, toe-off, swing through and ability to turn with ease.

 Common abnormal gaits are:

Antalgic (a limping gait due to pain)
Trendelenburg (with asymmetric trunk and pelvis due to weakness of the muscles of
hip and pelvis)
Hemiplegic (one leg clearly weaker than the other – as after a stroke)
Parkinsonian gait (small shuffling steps, slow to start moving)

Arms, legs and spine

 From behind
▪ Look for a straight spine (note any scoliosis), normal paraspinal muscle bulk, symmetrical

Clinical Skills and Simulation Team – October 2016 Page 16 of 21

 shoulder and gluteal (buttock) muscle bulk, symmetry of iliac crests, absence of popliteal
swellings, absence of foot or hind foot swellings.
▪ Feel/Palpate: Over mid supraspinatus and roll the skin over the trapezius to test for signs
of hyperalgesia (tenderness or pain felt on comparatively gentle touch found in
fibromyalgia).

 From the side

▪ Look for normal cervical and lumbar lordosis and normal thoracic kyphosis. Whilst
standing beside the patient place your index finger on one of the lumbar vertebral spinous
processes, and your middle finger on the next one down and ask the patient to bend over
and touch their toes, keeping their legs straight. Normally, as the patient bends, the
spinous processes will move apart, so your fingers will move apart also. Note whether this
is the case.

 From the front

▪ Look for normal and symmetrical shoulder and quadriceps muscle bulk, no knee swellings,
no deformity of mid or fore foot.

Now ask the patient to do the following noting any painful, restricted or asymmetrical movements
(work down the patient):

Spine

 "Open your jaw and move it from side to side" to test for pain free normal tempero-
mandibular joint movement.
 "Bend your left ear down towards your left shoulder and then your right ear down towards
your right shoulder" to test for pain free cervical spine lateral flexion.
 Now test for stiffness or pain flexing or extending the cervical spine: "bend your neck forwards
to try to touch your chin against your chest." "Bend your neck back to lift your chin."
 Test lateral flexion of the thoracic and lumbar spine: "Stand up straight and then slide the palm
of your right hand down your thigh towards your knee, bending your shoulder down to the
side." "Now do the same with your left hand down your left leg."
 Test rotation of the thoracic and lumbar spine. Gently hold the patient's hips still and ask them
to: "Turn your shoulders round as far as you can to the left, then do the same to the right."

Arms (it can help to demonstrate the movements you want of the patient)

 "Put your hands behind your head with your elbows as far back as they can go. Now try to
touch the small of your back" to test for normal sterno-clavicular, gleno-humeral and acromio-
clavicular joint movement.
 "Put your hands by your sides with your elbows straight" - looking for full elbow extension.
 "Put your hands out in front of you with your palms down and fingers out straight" looking for
ability to extend fingers, and inspecting for any swelling or deformity of the fingers or wrists.
 "Now turn your hands over" making sure that supination is normal (watch for external rotation
of the shoulder to compensate for poor supination). Inspect the palms for any signs or
swellings.
 "Now make a fist with both hands around my fingers and squeeze tightly" test the grip for
normal and symmetrical power.
 "Place the tip of each finger onto the thumb" to test for fine precision pinch. You may also do
a metacarpal squeeze at this point to test for metacarpal phalangeal tenderness.

Clinical Skills and Simulation Team – October 2016 Page 17 of 21

Now ask the patient to lie on the couch

Legs

 For both legs compare true (anterior superior iliac spine to medial malleolus) and apparent
(umbilicus to medial malleolus) leg length using a tape measure.

Ask the patient to:

 "Bend your knee to bring your heel up to your bottom" to test knee flexion. Place your hand
on the knee and then the hip joints feeling for crepitus as the patient moves these joints.
 Now test internal rotation of the hip with the knee joint flexed to 90 degrees (moving the foot
laterally with the knee flexed causes internal rotation of the hip joint - early OA causes pain
and limitation of this movement).
 Test for an effusion on the knees.
 Inspect the soles of the feet for any calluses, or skin changes. Squeeze the metatarsal joints to
test for any tenderness.

Thank the patient

Summarise your findings

Clinical Skills and Simulation Team – October 2016 Page 18 of 21

Appendix D – Guide to the Musculoskeletal Examination – The Knee
A copy of this guide is available to students through Learning Central

Please note: as with other examinations, different clinicians will perform these examinations in slightly
different ways. For the same reason, different books and websites (Macleod’s Clinical Examination,
www.geekymedics.com etc.) may describe the examination slightly differently.

Students need to establish their own routine for performing these examinations and this Guide is
intended to help them do this. Students do NOT fail assessments if they do the examination slightly
differently to as described here.

Feedback is welcome – please send to Paul Kinnersley (kinnersley@cf.ac.uk)

This guide was written with the help of Mr Kedar Chirputkar and Dr Rhian Goodfellow

The BEST way to learn the examination is to PRACTICE, PRACTICE, PRACTICE!

The knee is a straight-forward examination and the approach used can be applied to any
musculoskeletal examination

Like everything else, repetition in a sequential manner will help you improve your skills.

At the start of every examination

Clean hands
Introduce yourself to the patient
Explain what you are going to do and check if patient in any pain – check the patient consents to you
examining them
Expose the patient appropriately preserving dignity (for example – shoes, socks and trousers removed)

Outline of Knee Musculoskeletal Examination.

Examination of any joint should follow the sequence of

 Look
 Feel
 Move (Active first then passive)
 Special tests

Think about the joints above and below the one you are focussing on – a hip problem can cause pain
felt by the patient at the knee (referred pain).

Always compare both sides. (Please note that other side may NOT be normal)

Look - with patient standing

Inspect the knee from front, side and back looking for any scars, swellings, deformities and muscle
wasting.

Scars- Note location and healing. Probably helpful to ask patient if they have had any operations on
their knee.

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Swelling- Obliteration medial dimples suggests fluid in the knee. If this finding is positive, then you
should proceed with patellar tap test (described later). Look for swelling in the popliteal fossa. Note
location and extent of all swellings.

Any fluid collection in the knee joint (knee effusion) will cause swelling in the supra-patellar pouch
(area proximal to superior pole of patella).

Muscle wasting- Wasting of quadriceps bulk suggests dis-use atrophy (usually secondary to pain).
Most of long term knee pathologies will cause quadriceps muscle wasting.

Quadriceps bulk can be measured using a fixed point to make comparisons – for example 10 cm above
the superior pole of the patella.

Redness- Note location and extent.

Once the standing examination is completed, the patient should be asked to walk to assess their gait

At the end of the gait assessment the patient should be asked to lie down on the examination couch
for further assessment.

Feel - with patient lying

Ask the patient if any particular area is painful. Avoid that area if possible or examine it last.

Re-assure the patient that you will be as gentle as possible.

Temperature- assess this first. Generally the back of your hand gives a more sensitive indication of
temperature. Once you start examining the knee the temperature may change.

Tenderness- Examine tenderness in a sequential manner. Examine for tenderness over lateral and
medial joint lines (arthritis / meniscal problems), patellar ligament origin, mid-substance and insertion,
medial and lateral tibial and femoral condyles and patella.

Patella tap – positive patella tap indicates presence of moderate-large effusion – with the patient lying
supine with legs straight, milk the fluid from the suprapatellar pouch towards the knee and with 2 or
3 fingers of the other hand gently push the patella down. If there is an effusion the patella will feel
spongey rather than firm.

Move

The Knee is a hinge joint and has only two measurable movements, Flexion and Extension.

Always assess active movement first followed by passive movement if required.

Ask the patient to straighten the knee fully to assess knee extension.

Normally the knee will be flat on the bed and you will not be able to put a hand between the bed and
the knee.

Knee which is not fully straight suggests a flexion deformity.

This deformity could be at the knee or at the hip.

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Then ask your patient to fully bend (flex) the knee and assess the distance between the back of the
heel and the buttock (compare both sides).

Ask the patient to do a Straight leg raise. Ability to do this confirms continuity of extensor mechanism
(Quadriceps muscle, patella and patellar ligament)

If active movements are not full then you can help the patient to flex/ extend the knee more. This is
passive movement testing and should not be done if patient is in pain.

Special tests

Anterior/Posterior drawer test

Patient lying supine, with their knee flexed to 90 degrees. Place both your hands on the upper tibia
with your thumbs over the tibial tuberosity and index fingers under the hamstrings to make sure they
are relaxed. Use your forearm to stabilise the lower tibia or sit on the patient’s feet (having got consent
and checked that the patient has no pain). Then pull forward gently on the upper tibia (anterior drawer
test) then push back on the upper tibia (posterior drawer test). Compare two sides.

Interpretation – if the tibia moves forward excessively (Anterior Drawer Test) this suggests damage
to the anterior cruciate ligament; if the tibia move back posteriorly excessively (Posterior Drawer Test)
this suggests damage to the posterior cruciate ligament.

Medial collateral ligament

Patient lying supine with their knee flexed to 15 degrees and one of your hands on the lateral aspect
of their knee, pull out on their lower tibia with your other hand (as if you were trying to bend the knee
outwards).

Lateral collateral ligament

Patient lying supine with their knee flexed to 15 degrees and one of your hands on the medial aspect
of their knee, push in on their lower tibia with your other hand (as if trying to bend the knee inwards).

There are few more commonly described special tests like Appley’s grinding test and McMurrays tests.
These tests are not routinely performed.

Thank the patient

Summarise your findings.

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