Joint Examination Pre-reading

Joint Examination Skills

Conor McClenahan

Teaching Fellow

Learning Outcomes

• By the end of this session:

• Understand the rationale and sequence of the musculoskeletal examinations
• Develop a greater understanding of the anatomy relating to joints
• Be able to perform musculoskeletal examinations to OSCE standards
• Understand which pathological findings identified on examination of joints relate to orthopaedic and rheumatology conditions

Contents

• Joints you will be commonly asked to examine during medical practice

• Shoulder

• Elbow

• Wrist and Hand

• Hip

• Knee

• Ankle and Foot

• Spine

Why it is important

• MSK issues are one of the most common reasons for people to present to their GP or A&E

• You will often be asked to examine a joint as part of your assessment

• Common and EASY OSCE station for exams

Method

• Every MSK examination will follow the same basic assessment:

• Look
• Feel
• Move
• Special Tests
• Neurovascular examination
• Other joints – generally joint above and below

General assessment of
patient

• Look

• Is there evidence of systemic disease?

• Cushingoid appearance due to systemic steroids
• Gouty tophi on ears related to gout
• Any tremors
• Generalised muscle wasting
• Evidence of slings/walking aids or wrist supports
• Any signs of vasculitis/telangiectasia
• Any signs of thyroid disease

Shoulder Joint

• The shoulder joint is formed by articulation of the humeral head with the glenoid cavity

• One of the most mobile
joints but at the cost of joint stability

Shoulder Movements

• Extension

• Upper limbs moves backwards in sagittal plane

• Flexion

• Upper limbs forwards in sagittal plane

• Abduction

• Upper limb away from the midline in coronal plane

• Adduction

• Upper limbs towards midline in coronal plane

• Internal rotation

• Rotation towards the midline, so thumb is pointing medially

• External rotation

• Rotation away from the midline, so thumb is pointing laterally

• Circumduction

• Moving upper limbs in a circle

Mobility and Stability

Factors which promote mobility

Ball and socket joint

Shallow glenoid cavity and large humeral head

Inherent laxity of the joint capsule

Factors which promote stability

Rotator cuff muscles surround the shoulder joint and the resting tone of msucles act to compress the humeral into the glenoid cavity

Glenoid labrum deepens cavity and creates and creates a seal around the humeral head

Ligaments reinforce the joint capsule

Biceps tendon

Rotator Cuff Muscles

• Supraspinatus

• Performs abduction for 1st 15 degrees
• Assists deltoid between 15 and 90 degrees

• Infraspinatus

• External rotation

• Teres minor

• External rotation

• Subscapularis

• Internal rotation

Assessment

• Introduction, patient identification and consent

• Infection control measures

Look

• Assess each shoulder from anterior, lateral and posterior aspects to check for:

Scars, swelling, erythema, muscle wasting in deltoid, supraspinatus and infraspinatus muscles or abnormal contours
Scapula winging

Palpate

• Check if they have any pain prior to starting
• During palpation, observe for signs of tenderness, swelling, crepitus or temperature
• You should palpate the shoulder joint systematically

Palpation of shoulder

1. Sternoclavicular joint

2. Clavicle

3. Acromioclavicular joint

4. Humeral Head

5. Coracoid process of the scapula

6. Deltoid muscle

7. The spine of the scapula

8. Supraspinatus muscle

9. Infraspinatus muscle

10. Trapezius

11. Repeat on the other side

Movement

• When assessing movements you should assess:

• Active movements – patient’s own movements

• Passive movements – movements performed by you

• Resisted movements – movements against resistance

• Movements to test

• Flexion and extension
• Abduction and adduction
• Internal and external rotation
• Supination and pronation

• Reduced active movements that improve on passive movement suggest muscular/tendon problems

• Reduced range of active and passive movement suggest intra-articular disease

Special Tests

• Jobe’s test (empty can test)

• Assess function of the supra-spinatus muscle
• Abduct the arm to 90 degrees and then angle the arm so that the shoulder is in the plane of the scapula

• Internally rotate the arm so thumb points inferiorly
• Push down the arm whilst the patient resists

• Assesses for weakness &/or impingement of supraspinatus

• Weakness may represent a tear in the supraspinatus tendon

Special Tests

• Scarf Test

• Assesses the function of the acromioclavicular joint

• Passively flex the shoulder joint to 90 degrees and patient places their hand onto the contra-lateral shoulder

• Apply resistance to the elbow in the direction of the contra-lateral shoulder

• If the patient experiences pain then there may be acromioclavicular joint pathology

Special Tests

• The painful arc (impingement syndrome)

• Passively abduct the patient’s arm to its maximum point of abduction
• Ask patient to lower their arm back to a neutral position

• Impingement or supraspinatus tendonitis typically causes pain between 60 – 120 degrees of abduction

• This is not a specific test so can not be used in isolation

• Shoulder impingement involves inflammation of the rotator cuff muscles as they pass through the subacromial space

Multiple Choice

Teres minor is responsible for which movement of the shoulder?

• External Rotation

• Abduction

• Internal Rotation

• Adduction

Match

Match the following rotator cuff muscles to the correct movement

• Supraspinatus

• Infraspinatus

• Subscapularis

• Teres Minor

Initiates abduction

External Rotation

Internal Rotation and adduction

External Rotation

• Initiates abduction

• External Rotation

• Internal Rotation and adduction

• External Rotation

Elbow

• Hinge type synovial joint

• Consists of two separate articulations

• Trochlear notch of the ulna and the trochlea of the humerus

• Head of the radius and the capitulum of the humerus

• Movements

• Extension
• Flexion

Inspection of the elbow

• Scars – previous surgeries or injuries
• Muscle wasting – disuse atrophy due to joint deformity
• Aids or adaptions

• Anterior inspection

• Carrying angle

• There should be a small amount of cubitus valgus typically around 5 – 15 degrees
• Cubitus valgus – previous elbow trauma or congenital abnormality
• Cubitus varus – develops post supracondylar fracture

• Bruising
• Scars
• Swelling
• Abnormal bony prominence

​On general inspection check for:

Inspection of elbow - continued

• Lateral inspection

• Scars
• Fixed flexion deformity
• Muscle wasting

• Posterior inspection

• Scars
• Rheumatoid nodules
• Psoriatic plaques

Assessment of elbow - feel

• Temperature

• Palpation of the elbow joint

• Radial head
• Radiocapitellar joint
• Lateral epicondyle of the humerus
• Olecranon
• Medial epicondyle of the humerus

• Palpation of the biceps tendon –tendonitis or rupture

• Arm is flexed to 90 degrees
• Palpate over the anterior elbow flexion and identify the biceps tendon

Assessment of elbow - Movement

• Active Movement

• Elbow flexion
• Elbow extension
• Pronation
• Supination

• Passive Movement

• Repeat the above movements while checking for crepitus

Elbow - special tests

• Active wrist flexion against resistance

• Elbow is flexed and the medial epicondyle is palpated while stabilising the elbow
• Patient makes a fist and flexes their wrist while you provide resistance

• A positive test should elicit pain over the medial epicondyle

• Active wrist extension against resistance

• Elbow is flexed and the lateral epicondyle is palpated while stabilising the elbow
• Patient makes a fist and extends their wrist against resistance

• A positive test should elicit pain over the lateral epicondyle

Hand and Wrist

• Wrist joint (radio-carpal joint) is a

synovial joint marking the transition
between the forearm and the hand

• Formed by the proximal row of carpal

bones (except the pisiform)

• Formed by the distal end of the radius and the articular disk

• The ulna is not part of the wrist joint – it

articulates with the radius just proximal
to the wrist joint

Neurovascular supply

• Innervation to the wrist is

delivered by branches of 3 nerves

• Median nerve
• Radial Nerve
• Ulnar nerve

• Innervation to the hand is delivered by branches the above 3 nerves in both motor and sensory functions

Movements of wrist

• The wrist is an ellipsoidal (condyloid) synovial joint, allowing for movement along

2 axes

• Flexion, extension, adduction and abduction can all occur

• All movements of the wrist are performed by muscles of the forearm

• Flexion

• Produced by the flexor carpi ulnaris, flexor carpi radialis with assistance from flexor digitorum superficialis

• Extension

• Produced by the entensor carpi radialis longus and brevis and extensor carpi ulnaris with assistance from the extensor digitorum

• Adduction

• Produced by the extensor carpi ulnaris and flexor carpi ulnaris

• Abduction

• Produced by the abdcuctor pollicis longus, flexor carpi radialis, extensor carpi radialis longus and brevis

Superficial muscles of the posterior
compartment of forearm

Superficial muscles of the anterior
compartment of the forearm

Wrist Drop

• Wrist drop is a sign of injury of a radial nerve injury that

has occurred proximal to the elbow

• 2 common sites

• Axilla – injured via humeral dislocations or fractures of the

proximal humerus

• Radial groove of the humerus – injured via a humeral shaft fracture

• As the radial innervates all the muscles of the extensor compartment of the forearm then there is paralysis of
these muscles

• The muscles that flex the wrist are innervated by the median nerve so there is unopposed flexion of the wrist

Assessment of the hand and wrist - look

Look at the dorsal aspect ( with patient's hands palms down)

• Posture
• Obvious swelling, deformity, muscle wasting and scars

• Any finger deformities such as Swan Neck or Boutonniere's deformity or dactylitis

• Skin

• Thinning and bruising
• Rashes

• Nails

• Psoriatic changes such as pitting, onycholysis

• Are changes symmetrical
• Pattern of any changes

• Look at the palmar aspect

• Is the patient able to turn their hands over, if not, there may be a problem with radioulnar joint

• Is there muscle wasting in the thenar or hypothenar eminences

• If only the thenar eminence – then consider carpal tunnel syndrome

• Is there any palmar erythema
• Is there a carpal tunnel release scar

Assessment of hands and wrist - feel

• With patient’s palms up:

• Check bulk of the thenar and hypothenar eminences and for tendon thickening

• Check peripheral pulses
• Check for palmar thickening – if present, consider Dupuytren's contracture

• Assess sensation

• Assess median nerve over the thenar eminence and index finger

• Assess ulnar nerve over the hypothenar eminence and the 5th finger

• With the patient’s palms down

• Assess temperature of joints
• Palpate the joints of the hands bimanually assessing for tenderness, irregularities and warmth

• Metacarpophalangeal joint
• Proximal interphalangeal joint
• Distal interphalangeal joint
• Carpometacarpal joint of the thumb

• Assess radial nerve sensation over the 1st dorsal webspace
• Palpate the anatomical snuffbox for tenderness
• Palpate the wrists

Assessments of hands and wrist - move

• If there is a known issue with movement – assess the ‘normal hand’ first

• Active movements

• Finger extension
• Finger flexion
• Wrist extension
• Wrist flexion

• Passive movements

• Repeat the above movements while checking for crepitus

Assessments of hands and wrist - motor

• The following screening tests allow assessment of motor function of radial, ulnar and median nerve

• Wrist and finger extension against resistance – assesses radial nerve
• Index finger abduction against resistance – assesses ulnar nerve
• Thumb abduction against resistance – assesses median nerve

Assessments of hand and wrist - function

• Assess the hand function using fine motor screening tests

• Power grip

• Pincer grip

• Pick up a small object

Assessment of hand and wrist - special tests
• Tinel’s test

• Used to identify median nerve compression
• Tap over the carpal tunnel
• If there is tingling over the thumb and the radial 2 and a half fingers - then this is suggestive median nerve compression

• Phalen’s test

• Ask the patient to hold their wrist in maximum forced flexion

• Ask if patient’s symptoms are suggestive of carpal tunnel

Multiple Choice

Wrist and finger extension against resistance tests which nerve?

• Ulnar

• Median

• Radial

• Axillary

Hip Joint

• Ball and socket synovial joint formed by

articulation between the pelvic acetabulum and head of the femur

• Ligaments of the hip joint increase stability, these are both intracapsular and
extracapsular

Assessment of Hip - look

• Anterior inspection

• Scars
• Bruising
• Swelling
• Quadriceps wasting
• Leg length discrepancy

• True length – ASIS to medial malleolus
• Apparent length – umbilicus to medial malleolus

• Lateral inspection

• Flexion deformities

• Fixed flexion deformity

Assessment of Hip - Look

• Standing and Gait

• From the front, assess whether:

• The shoulders are parallel to the ground
• There is a pelvic tilt
• The hips, knees and ankles are properly aligned

• Ask the patient to walk across the room, while you look for:

• Antalgic gait (limping)
• Trendelenburg gait (pelvis tilting awayfrom the affected hip, trunk tilting
towards affected hip)

Causes of true leg shortening

Pathology proximal to the greater
trochanter
• Fractured neck of femur
• Post hip arthroplasty
• Hip dislocation
• Arthritis
• Slipped upper femoral epiphysis
• Perthes’ disease

Pathology distal to the greater
trochanter
• Fractures
• Osteomyelitis
• Septic arthritis
• Epiphyseal injury
• Polio
• Rare conditions E.g. hemihypertrophy (also known as hemihyperplasia)

Assessment of Hip - Feel

• Check for any tenderness
• Palpate the hip joint

• Tenderness over the greater trochanter occurs in trochanteric bursitis

• Palpate inguinal area for tenderness

• Check for temperature

• Palpate for any swelling

Assessment of Hip - Move

• When examining hip movements, the pelvis needs to be fixed in order to observe the range of movement in the hip joint and not the pelvis

• Assess active movements

• Flexion - Ask patient to flex their knees to 90 degrees and then flex their hip as much as they can
• Normal range is 120 degrees

• Abduction – ensure the pelvis is stablisied by placing a hand on the opposite antrior iliac crest

• The hip is abducted until the pelvis tilts
• Normal range is approx. 45 degrees

Assessment of hip – Move

• Adduction

• Cross one leg over the other until the pelvis tilts
• Normal range of movement is approx. 30 degrees

• Internal rotation

• Flex the hip and knee to 90 degrees and move the leg laterally
• Normal range of movement is approx 45 degrees

• External rotation

• With the hip and knee flexed, move the leg medially
• Normal rage of movement is approx 60 degrees

• Extension

• Patient lies on prone on couch, immobilise pelvis and extend the hip

Assessment of Hip – Special Tests

• Thomas’ Test

• Place one hand below the lower back (to ensure that the resting lordosis is

removed)

• Fully flex the non-test hip with your other hand until the lumbar spine touches the fingers of the hand under the back

• Look at the opposite leg

• If this is lifted off the couch as a result of this manoeuvre, there is a fixed flexion

deformity

• A positive test implies a hip flexion contracture

Assessment of Hip – Special Tests

• Trendelenburg’s Test

• With the patient standing, crouch in front of the patient and place one hand on each of the ASIS

• Ask the patient to stand on each leg in turn
• In a negative test, the pelvis remains level
• In a positive test, the pelvis will dip on the

unsupported side

• Due to failure or weakness of the hip abductors on the opposite side

Open Ended

What is the Thomas Test and Trendelenburg Test?

Multiple Choice

When testing internal rotation, which of the following is correct?

• Flex hip and knee to 90 degrees and move leg medially

• Flex hip and extend knee and move leg laterally

• Flex hip and flex knee to 90 degrees and move leg laterally

• Extend hip and knee and move leg medially

Knee joint

• The knee joint is a hinge type

synovial joint

• The joint allows for flexion and

extension with a small degree of medial and lateral rotation

• Formed by articulations between the patella, femur and tibia

Knee Joint Continued

• Knee pain can be a source of significant disability and health care utilisation

• Around 5 million people in the UK have severe knee pain

• Due to an ageing population and increasing levels of obesity

• Numbers of individuals with knee pain will increase

Assessment of knee - look

• Inspection of anterior aspect

• Scars
• Bruising
• Swelling

• Such as prepatellar bursitis

• Psoriasis plaques
• Patellar position
• Valgus or varus deformity of the knee

• a varus deformity of the knee can be secondary to osteoarthritis

• Quadriceps wasting

• Inspection of the lateral aspect

• Extension aspect
• Flexion aspect

Assessment of knee - look

• Inspection of the posterior aspect

• Scars
• Muscle wasting
• Popliteal swellings

• Gait

• Can be done at the start of the exam

Assessment of knee - feel

• If the patient has an injured knee - examine the other knee first

• Check temperature of the knee joint

• Palpation of the extended knee

• Joint lines
• Pre-patellar region
• Quadriceps tendon
• Collateral ligaments

Assessment of Knee - Feel

• Flex the knee to 90 degrees

• Palpate the medial and lateral joint lines for tenderness

• Palpate the posterior fossa of the knee for a popliteal cyst

• Assessing for a pleural effusion

• Patellar tap test:

• Slide hand down the thigh, pushing inferiorly to the suprapatellar pouch, so that any effusion is forced behind the patella

• Maintain pressure over the upper pole of the patella with one hand and push the patella down with index and middle finger of the other hand

• If there is a bounce, then there is an effusion

Assessment of Knee – Feel
(Continued)

• Assessing for an effusion:

• Bulge Test:

• Using thumb and index finger –

milk down any fluid superior to
the knee

• Keep hand in this position
• With the other hand, empty the medial compartment of the knee
of fluid and then stroke the lateral
compartment

• Observe the medial side of the knee for any bulging – this may
indicate an effusion

Assessment of knee - Move

• There are 4 main movements of the knee joint

• Extension

• Produced by quadriceps femoris

• Flexion

• Produced by hamstrings, gracilis, sartorius and popliteus

• Lateral rotation

• Produced by biceps femoris

• Medial rotation

• Produced by 5 muscles: semimembranosus, semitendinosus, gracilis, Sartorius and popliteus

Assessment of Knee - Move

• Main movements assessed will be flexion and extension

• Active

• Flexion
• Extension

• Passive

• Same movements as above but feeling over the patella for crepitus

Assessment of Knee – Special Tests

• Patellar Apprehension Test

• Assesses for patella dislocation
• With knee fully extended, apply a lateral force to the patella while slowly flexing the knee

• Resistance to flexion is a positive result

• Anterior drawer test for the anterior cruciate ligament

• With the patient supine and the knee flexed to 90 degrees, grip the upper tibia with thumbs on the tibial tuberosity

• Sit on the patient’s foot to act as a ballast
• Pull the tibia firmly towards you

Assessment of Knee – Special Tests

• Posterior Draw Test for the posterior cruciate ligament

• Similar to the anterior draw test but you push the tibia away rather than towards you.

• Posterior sag sign is present if the PCL is ruptured.

• Medial and lateral collateral ligaments

• Fully extend the knee
• Place the distal tibia of the leg being tested between your elbow and side
• Hold the knee joint with hands either side
• Apply valgus strain to assess the medial collateral ligament
• Apply varus strain to assess the lateral collateral ligament

Multiple Choice

Extension of the knee joint is facilitated by which muscle?

• Sartorius

• Biceps femoris

• Gracilis

• Quadriceps femoris

Ankle Joint

• The ankle joint is a hinge type synovial joint

• Allows for dorsiflexion and plantarflexion of the foot

• Formed by three bones

• Tibia
• Fibula
• Talus

• The tibia and fibula are joined by strong tibiofibular ligaments forming a socket known as the mortise

Ankle joint and foot

• The articulating portion of the ankle joint is the talus bone which fits into the mortise

• Dorsiflexion – anterior part of the talus is in the mortise and joint is stable
• Plantarflexion – posterior part of the talus is in the mortise and joint is less stable

• There are two main sets of ligaments in the ankle

• Medial ligament (deltoid ligament) is attached to the medial malleolous

• Primary action is to prevent over-eversion of the foot

• Lateral ligament originates from the lateral malleolus

• Primary action is to resist over-inversion of the foot
• Comprised of 3 separate ligaments

• Anterior talofibular
• Posterior talofibular
• Calcaneofibular

Movements of
the ankle joint

• Plantarflexion

• Produced by the muscles in the posterior compartment of the leg

• Gastrocnemius
• Soleus
• Plantaris
• Posterior tibialis

• Dorsiflexion

• Produced by muscles in the

anterior compartment of the leg

• Tibialis anterior
• Extensor halluces longus
• Extensor digitorum longus

Assessment of the ankle and foot

• Gait

• Gait cycle

• Checking for abnormalities of the gait cycle

• Range of movement

• Reduced in the context of chronic joint pathology eg. arthritis

• Limping

• May suggest joint pain

• Leg length
• Turning

• May turn slowly due to restrictions in range of movements or instability

• Height of steps

• Associated with foot drop

• Ask the patient to walk on their tip-toes and heels to further screen for pathology

Assessment of foot and ankle

• Inspect the anterior aspect of the ankles and feet

• Scars
• Bruising
• Swelling
• Psoriasis plaques
• Fixed flexion deformity of the toes
• Big toe misalignment
• Calluses

​Assessment of foot and ankle - look

​•Inspect the posterior aspect of the ankles and feet

Scars
Muscle wasting

Heel misalignment – may be cause by a valgus or varus deformity

Achilles Tendon

​Assessment of ankle and foot - feel

​•Assess temperature of ankle and feet

•Assess foot pulses

Posterior tibial pulse

Dorsalis pedis pulse

•Perform a metatarsophalangeal joint squeeze

Tenderness suggests active inflammatory arthropathy

​Assessment of ankle and foot - feel

​Palpate the ankle

Metatarsal and tarsal bones

Tarsal bone

Ankle joint

Subtalar

Calcaneum

Medial and lateral malleoli

Distal fibula

​Assessment of ankle and foot - feel

​Assess the Achilles tendon with knees flexed

Palpate the gastrocnemius muscle and the Achilles tendon
Any tenderness or swelling suggests tendonitis
Any breaks in the tendon suggestive of rupture

​Assessment of ankle and foot - move

​Assess the following movements actively and passively

Foot plantarflexion - normal range of movement is 0 - 50 degrees
Foot dorsiflexion - normal range of movement is 0 - 20 degrees
Hallux flexion
Hallux extension
Ankle/foot inversion - normal range of movement is 0 - 35 degrees
Ankle/foot eversion - normal range of movement if 0 - 15 degrees

​Assessment of ankle and foot - special tests

​Simmonds' tests

•Used to assess for clinical evidence of Achilles tendon rupture

Ask the patient to kneel on a chair with their feet hanging over the edge

Squeeze each of the patient’s calves in turn

•Interpretation of the test

Foot should plantarflex when the calf is squeezed due to gastrocnemius contracting

There will be no movement if the tendon is ruptured

Spine

• Cervical

• The cervical spine is the most superior portion of the spinal column
• Has 7 distinct vertebrae, 2 have unique names:

• C1 – atlas
• C2 – axis

• The joints of the cervical spine can be divided into 2 groups:

• Present throughout the vertebral column
• Unique cervical spine joints

• The joints present throughout the spinal column

• Intervertebral discs formed of fibrocartilage
• Synovial joints formed by articulation of superior and inferior articular processes
from adjacent vertebrae between the
vertebral arches

• Joints unique to the cervical spine

• Lateral atlanto-axial joints: articulation of inferior facets of C1 and superior facets of C2

• Medial atlanto axial joints: articulation of dens of C2 and articular facet of C1

• Atlanto – occipital joints: articulation between spine and cranium allows for
nodding

Spine

• Lumbar

• The lumbar spine is the third of the vertebral column
• Made up of five distinct vertebrae – largest of the spinal column
• Main function of the lumbar spine is a weight bearing structure

• There are two types of joints in the lumbar, same joints are throughout the spinal columnpresent

• At the level of L1, the spinal cord terminates and the cauda equina begins

Assessment of Spine - Look

• Brief general inspection of patient

• Body habitus
• Scars: previous spinal surgery
• Wasting of muscles: suggestive of disuse atrophy
• Aids or adaptations: walking sticks or wheelchairs

Assessment of Spine - Look

• Anterior inspection

• Scars

• Previous surgery

• Posture

• Joint pathology or scoliosis

• Asymmetry of the shoulder girdle

• Scoliosis, arthritis, fractures or dislocation

• Pelvic tilt

• Scoliosis, length discrepancy or hip abductor weakness

• Lateral inspection

• Cervical lordosis

• hyperlordosis associated with chronic degenerative joint disease

• Thoracic kyphosis

• Hyperkyphosis is associated with Scheuermann’s disease

• Lateral inspection (cont)

• Lumbar lordosis – loss of lordosis is

associated with SI joint disease (ankylosing
spondylitis)

• Posterior inspection

• Spinal alignment

• lateral curvature indicates scoliosis

• Iliac crest alignment

• leg length discrepancy or hip abductor weakness

• Muscle wasting

• Wasting of the para-spinal muscles may indicate

spinal pathology and reduced mobility

• Abnormal hair growth

• May indicate bony abnormalities such as spina bifida

• Bruising

• Recent trauma or surgery

Assessment of spine - Look

• Check gait

• Gait cycle
• Range of movement
• Limping
• Leg length
• Turning
• Trendelenburg’s gait
• Waddling gait

Assessment of spine - Feel

• Check for heat – infection

• Palpate the spinal processes and sacro-iliac joints

• Check alignment and tenderness

• Palpate the paraspinal muscles noting any tenderness or muscular spasms

Assessment of spine - Move

• Cervical spine

• Flexion

• Ask patient to touch chin to their chest
• Normal range is 0-80 degrees

• Extension

• Ask patient to look up to ceiling
• Normal range is 0-50 degrees

• Lateral flexion

• Ask the patient to bring their ear to their shoulder
• Normal range is 0-45 degrees

• Rotation

• Patient to turn their head left and right
• Normal range of 0-80 degrees

Assessment of Spine - Move

• Thoracic Spine

• Rotation

• Patient sits on examination couch or chair and crosses their arms across their chest
• Patient then turns to the left and right as far as they can

Assessment of Spine - Move

• Lumbar spine

• Flexion

• Patient to touch their toes whilst keeping legs straight

• Extension

• Patient to lean back as far as they are able to
• Normal range of 10 – 20 degrees

• Lateral flexion

• Patient slides hand down lateral aspect of leg as far as they can on each side

Assessment of Spine – Special Tests

• Modified Schober’s test

• Can be used to identify restricted flexion of the lumbar spine such as in ankylosing spondylitis

• Assessment

• Identify the location of the posterior superior iliac spine (PSIS)
• Mark the skin in the midline 5cm below the PSIS
• Mark the skin in the midline 10cm above the PSIS
• Ask the patient to touch their toes
• Measure the distance between the 2 lines

• If patient has a normal lumbar flexion, the distance between the 2 marks should increase from initial 15cm -> >20cm

• Reduced range of motion is associated with ankylosing spondylitis

Assessment of Spine – Special tests

• Sciatic Stretch Test

• Used to identify sciatic nerve irritation

• Assessment

• Position the patient supine on the couch
• Holding ankle, raise their leg by passively flexing

the hip while keeping knee extended

• Once the patient’s hip is flexed, dorsiflex the

patient’s foot

• The sciatic stretch test is positive if the patient experiences pain in the posterior thigh or buttock region

• Sciatic nerve irritation secondary to lumbar disc prolapse

Multiple Choice

How many vertebrae does the cervical spine have?

• 5

• 6

• 7

• 8

Conclusion

• Joint exams are a fundamental part of primary and secondary practice

• It can elucidate many signs and symptoms of orthopaedic and rheumatology conditions

• Practice on as many patients as you can to ensure you have a quick and accurate exam