1. GALS & MSK Exams

2. History 53 year old man with left knee pain Take a history Give your differential diagnosis and management plan

3. Case 53 year old post man Left knee pain worsening over last 1 year, occ swelling, not red not hot. No clicking, no locking or giving way No morning stiffness Worse at end of day No joint swelling No history of trauma Family history of arthritis- unsure which Shx- keen runner of marathons- unable to run due to pain, ok walking but can be more painful in cold weather Dhx- no known allergies Tried paracetamol with no relief

4. GALS: Gait, arms, legs & spine http://www.youtube.com/watch?v=g8-dMuzWal4 http://www.youtube.com/watch?v=IKZukBf7t1I ASK: 1. Do you have any pain or stiffness in your muscles, joints or back? 2. Can you dress yourself completely without difficulty? 3. Can you walk up and down the stairs without difficulty

5. Basic GALS Wash hands, intro, consent 3 questions Ask patient to walk and turn Most MSK exams = look, feel, move (+ measure), special tests

6. Observe top to bottom.. FROM BACK - Shoulder muscle bulk - Straight spine - Iliac crests - gluts - popliteal fossa - calves - hindfoot

7. Observation Cont.. FROM THE SIDE - cervical lordosis - thoracic kyphosis - lumbar lordosis - knee flexion / hyperex - ASK PT TO TOUCH TOES (2 fingers on lumbar spine) FROM THE FRONT (anatomical position) - Shoulder bulk - Elbow extension - Quads bulk and symmetry - Knee swelling / deformity - Feet – arches, mid / forefoot deformities

8. Standing up… Lateral flexion of C spine: Ear to shoulder TMJ Hands behind head: shoulder abduction & ext rotation Wrists and hands - Inspect muscle bulk etc - Power grip, squeezing fingers, precision pinch - Squeeze MCP joint

9. On the couch… Knee & hip - knee flexion & internal rotation of hip - Internal rotation of hip (knee flexed) - Patella tap Feet - Soles for callous - Squeeze MCP joints

10. Record in a table GAM A L S A = APPEARANCE M = MOVEMENT

11. Knee Exam http://www.youtube.com/watch?v=wOplC9qMfrU

12. Knee http://www.osceskills.com/e-learning/subjects/knee- examination/

14. KNEE HISTORY Pain A 'popping' or 'snapping' sound may suggest rupture of a ligament. Swelling: - RAPID (0-2 hours) - ?haemarthrosis…ACL or PCL ruputure / patella dislocation - GRADUAL (6-24hrs) - ?meniscal tear - OVER 24hrs - no trauma – consider septic arthritis or inflammaotry arthritis Locking or clicking suggests a loose body and may be due to meniscal injury. The knee giving way suggests instability (eg ACL injury) or muscle weakness. Also ask about previous history of knee injury, other past medical history, occupation and level of exercise.

15. Acute knee injury Cartilage (meniscal) Ligamnet (MCL, LCL, CL, ACL) Fractures / dislocations (knee, distal femur / proximal tib / fib / patella) Patella tendon rupture

16. Global Knee Pain Arthritis – monoarthritis, polyarthritis Crystal arthropaties – gout / pseudogo Seronegative arthropathies - Ank spond, Reiter’s, Enteropathic arthritis, Psoriatic arthritis, Bechet’s, Juvenile idiopathic arthritis Infective: septic arthritis, osteomyelitis Diseases of the bone: osteosarcome (kids, pain with activity, knee and proximal humerus) Referred pain (from hip) Rare: Rh fever, haemachromotosis, spontaneous haemarthrosis in clotting disorders

17. Anterior Knee Pain COMMON: Patellofemoral pain syndrome (aka chrondromalacia patellae) Fat pad impingement: the infrapatellar fat pad is impinged between the patella and the femoral condyle due to a direct blow to the knee. Treatment includes patellar taping to relieve impingement. Patellofemoral instability (or recurrent patellar subluxation): esp females - patellar hypermobility. Treatment can include bracing and crutches to reduce weight-bearing. Exercises to strengthen the vastus medialis obliquus are needed. Surgery may be required.

18. Other causes of anterior knee pain Referred pain from the hip, eg SUFE, Perthes' disease. Osteochondritis dissecans. Bone tumour. Prepatellar bursitis / infrapatella bursitis Patellar stress fracture Osgood Schlatters disease

19. Lateral knee pain Iliotibial band friction syndrome:- - Due to friction between the IT band and the underlying lateral epicondyle of the femur. - Affects cyclists, dancers, long-distance runners, football players, and military recruits. - Tenderness over the lateral epicondyle of the femur 1-2 cm above the lateral joint line. Flexion/extension of the knee can reproduce symptoms. - Treatment: NSAIDs, massage, stretching, muscle strengthening and correction of predisposing factors (eg downhill running). Steroid injection and surgery are rarely needed. Lateral meniscus problem (tear, degeneration, cyst). Other causes include: common peroneal nerve injury, patellofemoral syndrome, OA, referred pain from hip / lumbar spine

20. Medial Knee Pain Patellofemoral syndrome Medial meniscus problem (tear, degeneration, cyst). Other causes include: tumour, referred pain from the hip or the lumbar spine, MCL injury, osteoarthritis.

21. Posterior Knee Pain Knee joint effusion Referred pain from lumbar spine or patellofemoral joint PCL injury Bakers cyst DVT PVD

22. SHOULDER EXAM http://www.youtube.com/watch?v=clmF_rM49ao http://geekymedics.com/2010/10/04/shoulder- examination/ ( I like this one best) http://geekymedics.com/2010/10/04/shoulder- examination/

23. Other things to think about… Hand exam Ankle exam Spine exam

24. QUIZ!