Orthopaedic examination of any bone or joint follow the same basic structure:
LOOK - gait (if lower limb), erythema, swelling, scars, deformity, muscle wasting
FEEL - warmth, tenderness, swelling, crepitus
MOVE - range of motion, power
SPECIAL TESTS - joint stability, isolated muscle power, provocative tests
JOINT ABOVE & BELOW - ensure pain not radiating from elsewhere
NEUROVASCULAR - examine neurological and vascular supply to limb
This is followed by INVESTIGATIONS - blood tests, X-rays, further imaging
Each section describes a basic technique to examine the joints regularly seen in the exams and clinics. By following the routine described above, most joints can be examined thoroughly. The text does not provide an exhaustive description of every test available but outlines the commonly used basic examinations.
Deformity - scoliosis, kyphosis, lordosis, pelvic obliquity
Scars - longitudinal midline scar (discectomy, spinal fusion, scoliosis surgery - if longer scar)
Tenderness - midline tenderness along spine. Tenderness in para-spinal muscles along whole length of spine. Sacroiliac joint tenderness
Temperature - feel for warmth over length of spine indicating infection
Abdominal examination - ensure no evidence of abdominal aortic aneurysm, pancreatitis. Perform digital rectal examination if necessary
1. flexion - bend and touch toes - hands to mid-shin is normal
2. extension - combined thoracic and lumbar is about 45° lateral flexion - slide hands down sides of thighs - should be equal
3. rotation - sit on couch, cross arms, then rotate - normal is about 40°
Hip - hip pathology may present as back pain - perform isolated hip motion to ensure this is not the source of symptoms.
Lie patient supine on examination couch.
Straight leg raise.sciatic stretch test - flex hip with knee extended and foot dorsiflexed. Onset of back or leg pain is positive. Paraesthesia or pain in root distribution indicates nerve root irritation. Back pain indicates central disc prolapse. Lower leg slightly and dorsiflex foot more - aggravated pain is a positive sciatic stretch test.
Bowstring test - Once straight leg raise has caused pain, lower the leg slightly and flex the knee. Apply firm pressure in the popliteal fossa over the stretched tibial nerve. Resumption of pain and paraesthesia suggests nerve root irritation
Femoral stretch test - lie the patient prone. Flex each knee. If pain occurs in anterior thigh and is worsened by hip extension, this is a positive femoral stretch test (irritation of L2-4 nerve roots)
Neurological examination - thorough examination of tone, power by myotomes, sensation by dermatomes and reflexes is vital.
L2: hip flexion
L3: knee extension
L4: ankle dorsiflexion
L5: big toe extension
S1: ankle plantar flexion
L2: anterior thigh
L3: anterior knee
L4: medial aspect of the lower leg
L5: lateral aspect of the lower leg, medial side dorsum of the foot
S1: lateral aspect of the foot, the heel and most of the sole
S2: posterior aspect of the knee
S3-S5: concentric rings around the anus, the outermost of which is S3
S1,2: ankle jerk