Clinical examination

Tuesday, 19 July 2022 21:25

Gradings for strength of muscle contraction

M5: Normal power
M4: X full strength, movement against resistance/ gravity
M3: Weak contraction, movement against gravity
M2: Very weak contraction X movement against gravity
M1: Flicker of contraction seen or palpated-> X cause joint movement
M0: No active contraction

Gradings for sensation (ASK S3+/S3)

S0: X sensation
S1: w Deep pain sensation
S2: w Protective sensation (skin touch, pain & thermal sensation)
S3: w Accurate localization, cold sensitivity & hypersensivity
S3+: w 2 pt discrimination/ recognize object & texture
*Decreased cold sensitivity & hypersensivity
S4: Normal

Upper Limb
Hand
1. Inspection:
-> Skin: scars/ swelling/ skin changes (pigment, erythema, jaundice)/ deformity/
consistency
-> Nail: pitting/ onycholysis/ nail fold infarct/ sphincter hemorrhage
-> Finger clubbing
-> Lesion: purpura, psoariasis, vasculitis, telangiectasia, tophi, neurofibroma
-> Muscle wasting (ex. Thenar eminence for median nerve palsy)
-> Tremor, fasiculation, dupuytren's contracture, nodule

2. Palpate: pain/ tenderness/ swelling (soft/ bony), temperature

3. ROM: angle & symmetry
-> Wrist: Dorsiflex & volarflex (C6/7)/ supination (C6)& pronation (C7,8)/ ulnar (C8
& radial deviation
-> Thumb opposition
-> MCP/IP: flex (clench fist), extend (stretch outwards) C78

4. Functional testing
-> Grip strength (squeeze doc finger)
-> Opposition strength (separate thumb with index/pinky)
8)
 -> MCP/IP: flex (clench fist), extend (stretch outwards) C78

4. Functional testing
-> Grip strength (squeeze doc finger)
-> Opposition strength (separate thumb with index/pinky)

Shoulder
1. Inspection
- Scar/ swelling/ skin changes/ deformity
- Shape:
- Squaring of shoulder: dislocation of glenohumeral joint
- Muscle wasting
- Joint swelling
- Structures (from anterior)
- Sternoclavicular joint: prominent-> subluxation
- Clavicle: deformity-> fracture
- Acromioclavicular joint: prominent-> subluxation
- Deltoid: wasting-> axillary nerve palsy
- Pectoralis: wasting-> disuse
(from posterior)
- Winging of scapula: damaged innervation to serratus anterior (long thoracic
nerve C5-7)
○ Exaggerated by pushing against wall)
- Supra/ infraspinous fossae wasting: rotator cuff pathology

2. Palpate:
- Joint temperature
- Pain/ tenderness
○ Ant: sternum/ SCJ, clavicle, ACJ, acromion
○ (Pt hand on waist): greater & lesser tuberosity/ bicipital groove/ coracoid
process
○ Post: scapular spine
○ Elbow: medial/ lateral epicondyle, olecranon
*Coracoid process: 3muscle (pec min/ coracobrachialis/ short head of biceps)
/ 3 ligament (coracoacromial/ coracohumeral/ coracoglenoid)

3. ROM: (active-> passive)

*If with pain: painkiller-> LA injection-> put under anesthesia
(For screening): Apley scratch test
- ER/ ABduct: Back & touch superior part of opposite scapula: to T4
- IR/ ADduct:
§ Back & touch inferior part of opposite scapula: to T8
§ Front & touch opposite shoulder: if X-> suspect ACJ pathology/
impingement
What caused Active/ Passive loss of ROM
- Active: strength and contractile tissue (muscle,
teendon & attachement)
- Passive: muscular strain, ligamentous/ joint capsule
 - IR/ ADduct:
§ Back & touch inferior part of opposite scapula: to T8
§ Front & touch opposite shoulder: if X-> suspect ACJ pathology/
impingement

(Measure in front)
- ABduction (supraspinatus-> deltoid) 150-180
- Initiation: X-> major shoulder cuff tear
- Decreased ROM
- Shoulder shrugging in early abduction-> GHJ patho
- Pain
§ Mid-arc (70-120): impingement at acromion
§ End arc: impingement at ACJ/ OA of ACJ
- Drop arm sign (sudden drop when lowering arm): major supraspinaturs
tear
- ADduction (pectoralis major/ LD) 50
(Measure from side)
- Flexion (Ant deltoid/clavicular part of pec maj) 150-180
- Extension (Post deltoid/ LD) 60
(Measure from top-down)
- External rotate (infraspinatus)
- Internal rotate (pec maj/ LD)

4. Muscle Power (+ MUSCLE/NERVE INVOLVED WHEN FREE)

- Shoulder ABduction: C5
- Shoulder ADduction: C6/7
- Elbow flexion: C5/6
- Elbow extension: C6/7
- Wrist flexion: C6/7
- Wrist extension: C6/7
- Wrist supinate/ pronate: c6
- Finger flexion: C7/8
- Finger extension: C7/8
- Finger abduct/ adduct: T1
- Thumb abduction: T1

5. Sensory (C5/6/7/8/T1)

6. Special test
(Shoulder)
- Rotator cuff test
*Flexion
Passive/active ROM reduced: Fixed flexion deformity->
inside joint (mechanical)
Active ROM reduced only: Flexion lag-> Extra-arrticular
Muscle/ tendon/ neural problem

*Empty: stroke towards patella

- So when doing movement-> joint fluid X leave
-> Test more positive
 5. Sensory (C5/6/7/8/T1)

6. Special test
(Shoulder)
- Rotator cuff test
○ Rotator cuff: to stabilize shoulder
§ Supraspinatus: abduction of arm
§ Infraspinatus & Teres minor: Lateral (external) rotation of arm
§ Subscapularis: Medial (internal) rotation of arm
- Shoulder impingement:
○ Hawkins test: pt shoulder + elbow flex to 90=> one hand stabilize arm;
other hand IR forearm
§ +ve for subacromial impingement: pain
○ Neer impingement sign: pt arm in IR=> one hand stabilize scapula; other
hand flex arm
§ +ve for subacromial impingement: pain
○ Neer's test: Repeat Neer impingement sign after injecting 10mL 1%
lignocaine into subacromial space
§ +ve for subacromial impingement: X pain
(Elbow)
- Extensor stress:
- Flexor stress
(Hand)
- Finkelstein for De Quervain
○ Hold thumb & ulnar deviate wrist sharply-> + ve if pain
○ ~Eichoff maneuver: pt form wrist with thumb & ulnar deviate
- Phalen for carpal tunnel syndrome (median nerve compression)
○ Pt palmarflex both wrist: +ve if pain & paresthesia along median nerve
distribution)
- Froment's sign for ulnar nerve palsy

Spine
Pt standing
1, Inspect
- Scar, swelling, skin changes
- Assymetry, shoulder level spinal contrature/spasm
- CL/TK/LL, scoliosis (Inspect frorm back & side)
○ Note level of iliac crest

2, Palpate: pain/ tenderness (i: press with fingers; ii: tap with fist)
-> First bony prominence at neck C7-> continue C8T12L4
-> Iliac crest L4-> Continue from L5-S1
-> Paraspinal muscles (observe any spasm)
(If suspect ankylosing spondylitis)
-> Sacroiliac area: pt sitting
-> Pelvic springing: push pt pelvis while supine
 -> First bony prominence at neck C7-> continue C8T12L4
-> Iliac crest L4-> Continue from L5-S1
-> Paraspinal muscles (observe any spasm)
(If suspect ankylosing spondylitis)
-> Sacroiliac area: pt sitting
-> Pelvic springing: push pt pelvis while supine

3, ROM
(C-spine): Flexion (look down)/ extension (look up)/ twist/ lateral flexion
(T-spine)
-> Chest expansion: measure changes in chest circumference when pt take deep breath
-> Rotation: pt sit on bed while turn laterally
(L-spine)
-> Flexion: i) bend over & measure finger-floor distance; ii) Schober's test: measure
line between PSIS to th point 10cm above it-> ask patient to bend down-> measure
lengthening (<5cm: limited ex by AS)
-> Extension: lean backward
-> Lateral flexion: slide hand down leg to reach knee
- If No pain-> Lumbar quadrant test (combined extension, rotation & lateral flexion):
ilicit pain
- Pt turn to on side and attempt to touch popliteal fossa

4, Tests for sciatica (+ if radiating numbness; - if hamstring tightness)

- Straight leg raise: raise ipsilateral leg till resistance
- Laseque: raise ipsilateral leg till resistance-> lower leg by 5o & dorsiflex ankle
- Bowstring: Flex ipsilateral leg to 90o-> lift knee & compress popliteal fossa
- Slump test
- Pt slump forward-> flex neck-> straighten leg-> dorsiflex foot
○ If pain: ask pt to extend neck w/o ankle plantarflex=> +VE
5, Others
- Faber/ patrick test: for hip pathology
- Pt supine with foot on opposite knee (forms 4 shape)-> doctor one hand stabilise
opposite ASIS & other hand press knee down
- +ve if X go below opposite knee/ groin pain=> hip pathology (Note if back/
buttock pain: may indicatee sacroiliac joint pathology)

Knee joint
1. Insepct:
- Scar/ skin change (color, rash, ulcer)/ swelling
- Deformity: Genu varus/ valgus/ recurvatum (hyperextension), flexion deformity
○ Valgus: OA/RA; Varus: OA
- Mass (popliteal cyst, dislocated patella)
- Patella swelling (synovial thickening, fluid accum, bony swelling)
- Muscle wasting (esp quadriceps)

2. Peripheral edema: check for pitting edema at medial malleolus

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 ○ Valgus: OA/RA; Varus: OA
- Mass (popliteal cyst, dislocated patella)
- Patella swelling (synovial thickening, fluid accum, bony swelling)
- Muscle wasting (esp quadriceps)

2. Peripheral edema: check for pitting edema at medial malleolus

3. Palpate: (pt extend leg, use thumb)

- Temperature
- Flex knee to 90o & palpate with thumb: tenderness
○ Tibiofemoral joint line/ patellofemoral joint
○ Ant: Patella, patellar tendon, tibial tuberosity
○ Post: Popliteal fossa (for popliteal cyst)
- Crepitus at patella (Flex/ extend knee with one hand on patella)
○ Soft: synovial fluid/ thickening; Rough: degeneration

4. Joint effusion test

○ Trauma: ligamentous, osseous & meniscal injury/ overuse/ arthritis,
infection, gout, tumor
- Large effusion-- Cross fluctuation: LH: empty suprapatellar pouch + RH below
patella-> squeeze alternatively for fluid impulse
- Moderate effusion-- Patellar tap (ballotment) test: empty suprapatellar pouch->
feel for floating sensation at patella
- Small effusion-- Fluid shift test: stroke (up) medial parapatellar side> stroke
(down) lateral side-> look for bulge medially

5. ROM: extension/ flexion

6. Test for ligament & meniscus tear
- PCL:
○ Posterior sagging
○ Posterior drawer test: +ve if proximal tibia translates posteriorly (pt
supine, knee flex to 90o-> sit on feet-> push tibia)
- ACL:
○ Anterior drawer test: +ve if anterior translation (pt supine, knee flex to
90o-> sit on feet-> pull tibia towards me)
*Fingers on to relax hamstring-> prevent tensing which support movemen
○ Lachman test: +ve if anterior translation/ soft or absent endpt (pt supine,
knee flex to 15-20o-> one hand on thigh + other pull tibia towards me)
○ Pivot shift test: +ve if sudden posterior reduction of tibia: frrom iliotibial -
band tension (pt knee extend & internally rotate leg in air-> apply valgus
stress: displace medially + flex knee)
- MCL: Valgus stress test: +ve if pain/ laxity/ X endpoint (Hand at lateral side of
patella-> apply valgus stress: push knee medially at 30o flexion)
- LCL: Varus stress test: +ve if pain/ laxity/ X endpoint (Hand at medial side of
patella-> apply varus stress: push knee laterally at 30o flexion)
- Meniscus: McMurray test: +ve if pain, snapping, clicking or locking sounds
○ Medial meniscus (pt knee fullu flexed & externally rotate leg in air-> apply
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 - MCL: Valgus stress test: +ve if pain/ laxity/ X endpoint (Hand at lateral side of
patella-> apply valgus stress: push knee medially at 30o flexion)
- LCL: Varus stress test: +ve if pain/ laxity/ X endpoint (Hand at medial side of
patella-> apply varus stress: push knee laterally at 30o flexion)
- Meniscus: McMurray test: +ve if pain, snapping, clicking or locking sounds
○ Medial meniscus (pt knee fullu flexed & externally rotate leg in air-> apply
valgus stress: displace medially + extend knee)
○ Lateral meniscus (pt knee fully flexed & internally rotate leg in air-> apply
varus stress: displace laterally + extend knee)
Hip joint
1. Inspection: Scar/ swelling/ skin changes/ deformity
- Muscle wasting:
- (Inspect at end of bed): leg length discrepancy & measure from ASIS to MM
○ Apparent LLD: X position hip (Umbilicus-MM)
○ True LLD: Square pelvis (ASIS-MM)
§ Galeazzi test: Flex knee to 90o with heels tgt
□ Femoral discrep: look from proximal; Tibial discrep: look from
distal
§ Bryant triangle test: measure ASIS to greater trochanter-> compare
normal & abnormal side
□ Closer-> Femoral discrep's cause is above trochanter (hip joint)

2. Palpate: pain and tenderness at greater trochanter, proximal femur, anterior hip
joint
3. ROM
- Abduction/ adduction: stabilize pelvis
- Internal/ external rotation *Internal: first ROM reduced
- Thomas test + Flexion ROM
○ Procedure: Lhand under lumbar lordosis-> ipsi: active passive flex
-> Observe contralateal hip for flexion (if X correctable: fixed flexion
deformity)
-> Flex contralateral hip-> Compare L/R hip flexion
○ Fixed flxion deformity: arthritis, mechanical (skin contracture, cerebral
palsy) *May be corrected by increased lumbar lordosis
4. Other test
- Trendelenburg test: Pelvic tilt (weakness of hip abductor muscle)
○ Procedure: Stand on ipsilateral leg with contralateral knee flexed to 90o +
put hand on ASIS for pelvic tilting
○ Feel for ipsilateral increased pressure (+: Pelvic tilt towards the flexed
knee)
○ +: gluteal weakness, hip joint destructive pathology
§ Gluteal: gluteus medius (poss. cause: superior gluteal nerve palsy)

5. Gait examination
- Antalgic: shortened stance due to pain
- Short limb
- Stiff knee
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 § Gluteal: gluteus medius (poss. cause: superior gluteal nerve palsy)

5. Gait examination
- Antalgic: shortened stance due to pain
- Short limb
- Stiff knee
- Trendelenburg

- Hip flex: L1-2 (nerve to iliopsoas: iliacus, psoas)

- Hip extend: L5-S1 (Inferior gluteal nerve: gluteus maximus)
- Hip abduct: L4-5 (Superior gluteal nerve: gluteus medius, tensor fasciae lata)
- Hip adduct: L2-3 (Obturator n: Adductor longus, brevis, magnus)

- Knee flexion L5-S2 (Tibial n: hamstrings)

- Knee extension L3-4 (Femoral n: Quadriceps femoris)

- Plantarflex S1-2 (Tibial n: Gastrocnemius, soleus)

- Dorsiflex L4-5 (Deep peroneal nerve: Tibialis anterior, extensor digitorum/ hallucis
longus)
- Ankle eversion: L5-S1 (Superior peroneal nerve: Peroneus longus/ brevis, extensor
digitorum longus)
- Ankle inversion L5-S1 (Deep peroneal nerve: Tibialis anterior)
- Great toe extension L5

DISEASE:
- Osteosarcoma
- Arthritis