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

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

4. 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?”

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

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

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

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

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

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

13. G A L S n Doherty, Dacre, Dieppe and Snaith (1992) The GALS locomotor screen, Annals of Rheumatic diseases 51: 1165-9 n GAIT n ARMS n LEGS n SPINE

14. 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”

15. GALS recording

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

18. Hand - RA

19. 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

20. Hand OA

21. Raynauds 1

22. Raynauds 2

23. Scleroderma early

24. Scleroderma

25. Sclerodactaly (acrosclerosis)

26. Carpal Tunnel Syndrome Phalen’s Tinel’s

27. 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

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

29. Shoulder - abduction

30. Shoulder function related to abduction

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

32. Backs - neurology

33. Sham backache

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

35. Trendelenburg test

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

37. 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

38. 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

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

40. Abnormal pronation and supination

41. 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

42. 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

43. Fibromyalgia

44. The End