Easy assessment of musculoskeletal system for GPs Aspects of examining the musculoskeletal system

n Revisiting the basics n GALS n Video n Some bits and pieces / a personal view

History n “Have you any pain or stiffness in your muscles, joints or back?” n “Do you have any trouble getting up or down stairs?” n “Do you have any difficulty getting dressed?”

Revisiting the basics n InspectionLook n Palpation Feel n MovementMove n Stability n Function n Compare with opposite side

Inspection n Skin colour / rashes n Swelling n Deformity n Scars n Muscle wasting n Surrounding structures - bursae, tendons

Palpation n Nature of swelling –bony –synovial –effusion n Warmth n Tenderness

Movement n Active and passive n Range of movement n Crepitus n Note pain n Instability

Stability n Subluxation or dislocation –MCP –Radioulnar –subtalar –MTP

Function n Lower limbs - gait n Hands –pincer grip –power grip

G A L S n Doherty, Dacre, Dieppe and Snaith (1992) The GALS locomotor screen, Annals of Rheumatic diseases 51: n GAIT n ARMS n LEGS n SPINE

G A L S n “…provide a valuable screening test for use in general practice” n “the procedure can be viewed as a general functional (disability), as well as a basic musculoskeletal assessment” n “..be useful in selective situations as a rapid test of functional performance and to screen out regional locomotor abnormalities that merit closer scrutiny”

GALS recording

Bits and pieces n Hands n Wrists - CTS + de Q n Shoulders n Backs n Hips n Feet - biomechanics n Hypermobility n Fibromyalgia

Hand - RA

Early synovitis n PIP - skin discolouration and tenderness n Clench fist - MCPs should be white with no infilling n MCP squeeze to elicit tenderness n Inferior radio ulnar stress test n Bulge sign at knee n MTP squeeze test

Hand OA

Raynauds 1

Raynauds 2

Scleroderma early

Scleroderma

Sclerodactaly (acrosclerosis)

Carpal Tunnel Syndrome Phalen’s Tinel’s

De Quervains tenosynovitis n APL and EPB tendons n tender over radial styloid n sometimes nodule (thickened sheath) n Finkelsteins test n Rest it n Inject it

Shoulders n Shoulder or not n Glenohumeral or not - external rotation n Tenderness –bicipital groove –subacromial n Painful arc of abduction

Shoulder - abduction

Shoulder function related to abduction

Backs n Lumbar flexion –Modified Schobers - or use your fingers –Fingers to floor = misleading n Lumbar extension n Lumbar lateral flexion n “Sacroiliac restriction”

Backs - neurology

Sham backache

Hips n Internal rotation - can examine sitting n Trochanteric bursitis n Trendelenburg - to distinguish lumbosacral from hip pain

Trendelenburg test

Foot - biomechanics n Swing phase n Stance phase –Contact (27%) –Midstance (40%) –Propulsive (33%)

Biomechanics - stance phase n Contact –outer border heel strikes then –PRONATION at subtalar joint shifts centre gravity medially –causes tibia to internally rotate –purpose is shock absorption/adaption uneven ground

Biomechanics - stance phase (2) n Midstance –forefoot loaded –subtalar joint supinates –causes tibia to externally rotate –foot is converted to rigid lever ready for propulsion –ends with heel lift

Biomechanics - stance phase (3) n Propulsion –app 25% bodyweight on metatarsals and toes (esp 1st) –ends with toes off

Abnormal pronation and supination

Over pronation n Subtalar pronation unchecked n longitudinal arch stretches and flattens n excess rotation of tibia n Hallux valgus n Plantar fasciitis n Achilles tendonitis n Post tibial tendonitis n stress# navicular n anterior knee pain n low back pain

Hypermobility 1 Dorsiflexion of 5th MCP to 90 degrees 2 Apposition of thumb to volar aspect of forearm 3 Hyperextension of elbow by 10 degrees 4 Hyperextension of knee by 10 degrees 5 Hands flat on floor with knees extended

Fibromyalgia

The End