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29 Orthopedic Examination
Rotator Cuff: consists of the tendons of four muscles: subscapularis, supraspinatus, infraspinatus and teres minor.
Subscapularis muscle: (Suprascapular Nerve C5, 6) Stand behind the patient.
The patient is asked to place the back of his hand into the small of the back (to eliminate the action of pectoralis major).
309
Hawkins/Kennedy Impingement
Patient’s arm shoulder in 90 degrees of shoulder exion with the elbow exed to 90
degrees and then internally rotates the arm.
Vascular:
• Pulsations “see vascular Sheet”.
• Venous disease.
• Edema.
• Whole limb Duplex.Neuro:
Sensory/motor/reexes (axillary N→patch area).
Examination oftheElbow Joint
Most Common Clinical Conditions
• Osteoarthritis
• Fractures and Dislocation
• Olecranon bursitis
• Rheumatoid arthritis
• Tennis elbow
• Golfer’s elbow
General: SCHEME + Cervical spine.
Hyperlaxity: SCHEME.
Gait: as before and we will examine cx spine.
Look A: Alignment static (cubitus varus/valgus) carrying angle.
S: Symmetricity/wasting (girth of arm).
S: Skin/Swelling (olecranon bursitis) (Fig.29.12a, b).
Feel T: temperature (bursa/septic/gout).
T: tender points (bone/soft tissue).
Move Flexion/extension/Pronation/supination (90/90).
Muscle power: against resistance.
310
ab
Fig. 29.12 (a, b) Inspection of the elbow joint
M. Massoud and A. Mohey
Elbow pivot shift
Valgus stress to the elbow while exing and extending it, feeling for a subluxation or reduction of the radial head.
Tennis elbow:
Is characterized by the presence of pain and functional disability associated with
tendon dysfunction of the lateral epicondyle musculature.
Golfer elbow
Patients report medial elbow and proximal forearm pain with activities requiring
wrist exion and forearm pronation. The doctor may rest the arm on a table, palm
side up, and ask the person to raise the hand by bending the wrist against resistance.
Examination oftheHand & Wrist Joint
Most Common Clinical Conditions
• Dorsal Ganglion and trigger ngers
• Osteoarthritis .
• Psoriatic arthritis:
• median, radial, or ulnar nerves lesions
• De Quervain’s tenosynovitis
• Madelung’s deformity.
• Dinner Fork Deformity and Dupuytren’s disease
• Volkmann’s ischemia contracture.
• Wrist drop.
• Rheumatoid arthritis and gout.
General: SCHEME.
Hyperlaxity: SCHEME.
a
b
c
d
29 Orthopedic Examination
Fig. 29.13 (a–d) Tests for hand grips
311
Gait: SCHEME + Cervical spine.
Look:
A: Alignment static (arcade pattern—nail parallel/dynamic).
(Point nger at exion to scaphoid).
Congenital nger: Macrodactly/Microdactly/Syndactly/Clinodactly/
Campotodactly.
Abnormal. Flexion/extension.
S: symmetricity/muscle wasting (nerve injury).
S: skin and/or swelling (ganglion or cord -Dupuytren’s contracture).Feel:
T: temperature (bursa/septic/gout).
T: tender points (bone/soft) and/or Truck “crepitus”.Move
Wrist: Flexion –extension, ulnar-radial deviation and Pronation-supination.
Hand (5 grips): Fist (exors). Hook (extrinsic), hold pen, pinch (intrinsic).
Muscle and key or coin holding test (Flexor polices longus + Flexor digitorum pro-
fundus) (Fig.29.13a–d).
Special Test
Specic totheComplaint
1st Done asScreening
• T: temperature (bursa/septic/gout).
• T: tender points (bone/soft)/Truck: crepitus.
• Carpal tunnel tests: Try to elicit Tinnel’s sign by extending the hand and tapping
on the median nerve in the carpal tunnel.
• Flexor profundus: by holding the nger extended at the proximal interphalangeal
joint and ask the patient to ex the distal interphalangeal joint of that same nger.
• Bunnell test is a physical examination maneuver used to assess the integrity of
the intrinsic muscles and the tightness of the intrinsic and extrinsic nger exors.
312
M. Massoud and A. Mohey
ab c
Fig. 29.14 Bunnel test “a, b”, and The Elson Test “c”
It helps diagnose conditions such as intrinsic muscle tightness, intrinsic-plus n-
ger deformity, and assess joint mobility in the ngers (Fig.29.14a, b) During the
test, the examiner stabilizes the metacarpophalangeal (MCP) joint while pas-
sively exing the proximal interphalangeal (PIP) joint. If the PIP joint cannot be
exed when the MCP joint is held in extension, it suggests intrinsic tightness.
Conversely, if the PIP joint can be exed when the MCP joint is held in exten-
sion, it indicates extrinsic tightness. This test assists in determining the appropri-
ate treatment plan for conditions affecting nger mobility and function.
• for Central Band Disruption in ngers is used to diagnose injuries to the central
slip of the extensor tendon in the ngers, particularly in cases of mallet nger or
central band injuries. The test involves assessing the ability to extend the distal
interphalangeal joint (DIP joint) against resistance with the proximal interpha-
langeal (PIP) joint held in exion. If the DIP joint cannot be extended while the
PIP joint is exed, it suggests a disruption in the central band of the extensor
tendon. This test helps clinicians diagnose and determine the severity of nger
injuries, guiding appropriate treatment plans (Fig.29.14c).
• Tenodesis effect tendon: involves passive exion or extension of the wrist caus-
ing passive movement in the ngers.
Never miss Neurologic: sensory/motor/reexes
Above wrist (Dynamic).
Vascular examination: Distal pulse, Veins and edema.
Hip Joint Examination
Common Clinical Hip Joint Conditions
• Fracture or fracture dislocation of the Hip
• Osteoarthritis.
• Congenital hip dysplasia.
• Avascular necrosis of the Head of the Femur.
• Slipped upper femoral epiphysis.
29 Orthopedic Examination
313
a
Fig. 29.15 (a, b) Trendelenburg gait
b
• Trendelenburg gait.
• Antalgic gait.
General: Screening SCHEME “Above”.
Gait: Trendelenburg Short limb excessive lateral trunk sway or leaning toward
the stance limb during the stance phase of walking. This occurs due to weakness or
dysfunction of the hip abductor muscles, particularly the gluteus medius muscle
(Fig.29.15a, b).
Hyperlaxity: SCHEME “above”.
Look inStanding andSitting Position
Trendelenburg Test (Injury Gluteus Muscle)
Patient stands on one leg while the examiner observes the position of the pelvis. If
the hip abductors are weak or dysfunctional, the pelvis on the unsupported side will
drop or tilt downward instead of remaining level (Fig.29.16a–d).
Feel T: temperature.
T: tender points (bone/soft)/Truck: crepitus.
Leg length discrepancy (Fig.29.17a–d):
Limb length discrepancy (supra/infra trochanteric)
1. **Visual Inspection**: The examiner visually compares the lengths of the lower
extremities while the patient lies supine on an examination table. They observe
the relative positions of the feet and ankles.
314
cd
bd
ab
Fig. 29.16 (a–d) Trendelenburg test
M. Massoud and A. Mohey
a
Fig. 29.17 (a–d) Leg length discrepancy
c
2. **Measuring Tape**: With the patient lying supine, the examiner measures the
distance from the anterior superior iliac spine (ASIS) to the medial malleolus on
each leg using a measuring tape. Any difference in these measurements indicates
leg length inequality.
3. **Block Test**: The patient stands barefoot, and wooden blocks of varying
heights are placed under the shorter limb until the pelvis becomes level. The difference in height between the blocks indicates the leg length inequality.
4. **Functional Assessment**: The patient walks or runs, and the examiner
observes any compensatory movements or gait abnormalities that may be indicative of leg length discrepancy.
Move: SCHEME “Above”
Limb length discrepancy (supra/infra trochanteric)
Special test (supine):
Test Specic to complaint
Flexion abduction external rotation:(FABER)
Fig. 29.18 A: Pain posterior: Sacroiliac pathology
Flexion, adduction, internal, rotation (FADIR) (Fig.29.18b).
Pain anterior: Hip pathology.
Thomas Test+Flexion ROM (Fig.29.18c–e).
Lying at on your back while bringing one knee to your chest. The angle of the
other leg hanging off the edge of the table or bed can indicate the tightness of the hip
exors.
bc
29 Orthopedic Examination
a
de f g
Fig. 29.18 (a–g) Thomas Test + Flexion ROM
Movements:
• Flexion: 0–120 degrees
• Extension: 0–30 degrees
• Abduction: 0–45 degrees
• Adduction: 0–30 degrees
• Internal rotation: 0–45 degrees
• External rotation: 0–45 degreesOn side
315
Ober test (contracture iliotibial tract): the patient lies on their side with the
bottom leg stability, while the examiner passively extends and abducts the upper leg
(Fig.29.18f).
Prone Craig test
On prone position internal rotation of hip joint till greater tubercle is maximum
then measure angle with vertical (Fig.29.18g). The patient lies prone while the
examiner palpates the greater trochanter of the femur. The hip is then exed
and internally and externally rotated until the greater trochanter is felt to be at
its most prominent point. The angle of the thigh relative to the examining table
or bed indicates the degree of femoral anteversion or retroversion.
Trendelenburg gait:
It is a type of abnormal gait pattern characterized by a dropping of the pelvis on
the side of the unsupported leg during the stance phase of walking.
Antalgic gait: It is a type of abnormal gait pattern that is characterized by a
shortened stance phase on the affected side due to pain
• Never miss: Neurologic: sensory/motor/reexes “SCHEME”
• Vascular: arteries. Whole limb, capillaries Rell, duplex Femoral A./popliteal
A., Dorsalis Pedis A., Post. Tibial A. and ABI (ankle brachial index). BP leg/
Arm>0.9 normal.
316
M. Massoud and A. Mohey
Knee Joint Examination
Common Clinical Knee Lesions
• Osteoarthritis and Rheumatoid arthritis.
• Baker’s (popliteal) cyst.
• Prepatellar and infrapatellar bursitis.
• Chondromalacia and subluxation patellae.
• Tibial apophysitis (Osgood-Schlätter’s disease).
• Collateral ligament tears. And meniscal lesions.General SCHEME “Above”
Pain:
Localized pain e.g. meniscus injury
Generalized pain → degenerative changes → patellofemoral joint
Gait Thrust gait: (G. varum, valgum or recurvatum)
Crouch: (hamstring spasm hip/knee)+pseudoequinus.
Hyperlaxity: SCHEME “above”.
Look in standing and sitting position
A: Alignment static: (Genu. Varum, valgum or recurvatum)
S: Symmetricity: m. wasting (muscle girth thigh and/or calf) Localized
swellings:
Anterior aspect of the knee Prepatellar bursitis, Infrapatellar bursitis Lateral
aspect of the knee, Lateral meniscal cyst Postero-medially Semimembranosus bursitis, Posteriorly Baker’s cyst Popliteal aneurysm (rare cause).
Other causes for swelling Ganglion Osteophytes Osgood–Schlätter’s disease
Swelling.
Q Angle: The quadriceps angle or, in short, the “Q angle” is the angle between
the longitudinal axis of quadriceps muscle and the patellar tendon and reect the
angle of quadriceps muscle force.
Feel: Effusion: Effusion is assessed by “milking” uid distally from the suprapatellar pouch and palpating the area adjacent to the patellar tendon for uid accumulation. A ballotable patella may be palpated after similar effusion milking.
Move:
• Flexion: 0–135 degrees
• Extension: 0–0 degrees (fully extended).
• Medial rotation: 0–10 degrees.
• Lateral rotation: 0–30 degrees.SCHEME
Special test: Specic to complaint
Patella: look. site (Baja/Alta) size(brave/magna) shape(osteophytes/bipartite)
Move. Track exion/extension, Lateral Push and Feel.
Ligaments injury: Grade (I/II/III)-
End point: (rm → intact ligament/soft→ partial tear, and
If no end point → complete tear)
29 Orthopedic Examination
317
• Varus Stress Test (for LCL): This test involves applying a varus force (outward
stress) to the knee (Fig.29.19a).
• Valgus Stress Test (for MCL): This test involves applying a valgus force (inward
stress) to the knee while it is slightly exed (Fig.29.19b).
• Apley’s Compression Test: This test involves applying downward pressure on
the foot while rotating the tibia to assess for pain and clicking, which may indi-
cate a meniscal injury (Fig.29.19c).ACL specic anterior drawer test:
The patient lies supine with the knee exed at about 90 degrees. The examiner
stabilizes the lower leg with one hand while grasping the upper tibia with the other
hand and pulls the tibia forward. Excessive anterior translation of the tibia relative
to the femur, (Fig.29.19d), compared to the unaffected side, can indicate a tear or
laxity in the ACL.
PCL posterior drawer test
The patient lies supine with the knee exed at about 90 degrees. The examiner
stabilizes the lower leg with one hand while grasping the upper tibia with the other
hand and pushes the tibia backward. Excessive posterior translation of the tibia relative to the femur, compared to the unaffected side, can indicate a tear or laxity in
the PCL.
PLC dial test:
a
b
d
Fig. 29.19 (a–f) Tests for the knee injuries
c
e
f
318
M. Massoud and A. Mohey
The patient lies prone with the knees exed at 30 degrees and the feet hanging
off the edge of the table. The examiner externally rotates both feet and compares the
degree of external rotation between the injured and uninjured knee. Excessive external rotation or asymmetry between the knees suggests a posterolateral corner injury
(Fig.29.19c).
OCD Wilson test;
The patient is seated with the knee exed at 90 degrees. The examiner internally
and externally rotates the tibia while also applying a valgus and varus stress to the
knee (Fig.29.19e, f).
McMurray’s test (Fig.29.20):
• To test the medial meniscus, palpate the posteromedial margin of the joint. Then
hold the leg in external rotation and extend the knee.
• To test the lateral meniscus, palpate the posterolateral margin of the joint. Then
hold the leg in internal rotation and extend the knee.Never miss
Neurologic: sensory, motor and reexes.
Vascular: Arteries, veins and edema.
Fig.
29.20 McMurray’s test