Musculoskeletal

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• History Taking• QUIZ• Examinations

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GALS: Gait, arms, legs & spine

Screening Questions• 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

History Taking

• Joint pain- SOCRATES, Distribution, symmetry• Morning stiffness• Joint swelling• Family history• Systemic disease• Injury

• Pmh- previous fractures, early menopause• Dhx – steroid use• Shx – alcohol

KNEE HISTORY• Pain • A 'popping' or 'snapping' sound may suggest ligament rupture• 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 inflammatory

arthritis• Locking or clicking suggests a loose body and may be due to meniscal

injury• Knee giving way suggests instability (eg ACL injury) or muscle weakness• Previous history of knee injury, other past medical history, occupation

and level of exercise.

Acute knee injury

• Cartilage (meniscal)• Ligament (MCL, LCL, CL, ACL)• Fractures / dislocations (knee, distal femur /

proximal tib / fib / patella)• Patella tendon rupture

Generalised Knee Pain

• Arthritis – monoarthritis, polyarthritis• Crystal arthropaties – gout / pseudogout• Seronegative arthropathies - Ank spond, Reiter’s,

Enteropathic arthritis, Psoriatic arthritis, Bechet’s, Juvenile idiopathic arthritis

• Infective: septic arthritis, osteomyelitis• Diseases of the bone: osteosarcoma (kids, pain with activity,

knee and proximal humerus)• Referred pain from hip• Rare: Rh fever, haemachromotosis, spontaneous

haemarthrosis in clotting disorders

Anterior Knee Pain• Patellofemoral pain syndrome (chrondromalacia

patellae) • Fat pad impingement: the infrapatellar fat pad

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 -bracing and crutches to reduce weight-bearing. Exercises to strengthen or Surgery may be required.

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

Lateral knee pain• Iliotibial band friction syndrome:-- 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

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.

Posterior Knee Pain

• Knee joint effusion • Referred pain from lumbar spine or

patellofemoral joint • PCL injury• Bakers cyst• DVT• PVD

QUIZ

Genu Valgum

Genum varum

Basic GALS

• Wash hands, intro, consent• 3 questions• Ask patient to walk and turn

• Most MSK exams = look, feel, move (+ measure), special tests

GALS

• General• The patient should be undressed to their

underwear and observed from the front, back and sides, looking for any symmetry or deformity (e.g. unequal leg length, kyphosis, scoliosis, loss of lumbar lordosis).

• Ask the patient about any pain

Gait

• Ask the patient to walk, observe posture, symmetry, legs and arm swinging.

Abnormal gaits • painful hip• Parkinson’s gait• wide based gate• Trendelenburg gait• Antalgic gait

Arms• Ask patient to hold out hands, palm down. Inspect the arms for obvious

abnormalities (e.g swelling, deformity,)• Inspect skin or nail changes that may be associated with arthritis. (e.g.

psoriasis rash, nail pitting, skin changes of Raynaurd’s disease)• Ask the patient to turn their hands over, with arms flexed at the elbow.

assessing the radioulnar joint which is commonly affected in RA• Inspect the palms. Look for Dupuytren’s contracture and thenar waisting• Ask the patient to make a tight fist. Check that the fingers can fully flex

into the palms• Power-Ask the patient to grip two of your fingers• Ask the patient to tip each finger in turn onto the tip of the thumb. This

assesses opposition of the thumb and fine movements which are often limited in RA

• Squeeze across hand from the 2nd to 5th MCP joints- Assess for tenderness• Ask patients to put their hands behind their head, pressing the elbows

back. This movement assesses abduction and external rotation at the shoulder and flexion at the elbows and is of functional importance in combing hair.

Legs• Patient lying supine on the couch, inspect for flexion

deformity at the hip or knee.• Passively flex the hip and knee with a hand placed over the

knee.• Assess knee flexion whilst feeling for crepitus and assessing

hip flexion.• Passively internally rotate the hip with hip and knee still flexed

(both at 90º). Internal rotation is the first movement to become restricted in hip disease.

• Ask patient to flex, extend, invert and evert the ankle. Assesses the tibiotalar movements (affected by OA) and subtalar movements affected by RA.

• Squeeze across the foot at the level of the MTP joints. Assess for tenderness.

Spine

• Inspect • Ask patient to put their ear on the same side

keeping the shoulder still to assess lateral flexion of the cervical spine, which is the first movement to become restricted in degenerative or inflammatory disease.

• Place two of your fingers over adjacent spinous processes in the lumbar region and ask the patient to bend over and touch their toes. Your fingers should move apart.

Record in a table

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