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.

Spine examination

LOOK 

Deformity - scoliosis, kyphosis, lordosis, pelvic obliquity

Scars - longitudinal midline scar (discectomy, spinal fusion, scoliosis surgery - if longer scar)

FEEL 

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

MOVE

Range 

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.

            

SPECIAL

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.

                        Myotomes:

                                    L2: hip flexion

                                    L3: knee extension

                                    L4: ankle dorsiflexion

                                    L5: big toe extension

                                    S1: ankle plantar flexion

                        Dermatomes:

                                    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

                        Reflexes:

                                    L3,4: patellar

                                    S1,2: ankle jerk