Rheumatology Rheumatology
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Rheumatology Final Med revision programme 2007 Dr. David Kane Consultant Rheumatologist AMNCH & TCD Regional examination of the Lower Limb Theory Active joint movement Painless / full Painful / restricted Joint / muscle/ tendon all normal Passive movement Painless and full muscle/ tendon problem Resisted movements Test individual muscles Painful Joint problem General Principles of Joint Examination z Inspection……………..Look z Palpation………………Feel z Active motion…………Move patient puts joint through full range of movement z Passive motion when active range of motion is reduced z Resisted movements (provocative tests) z Special tests……………Special Tests The Lower Limb z Foot z Ankle z Knee z Hip The Hip z Inspection z Palpation z Active motion z Passive motion z Resisted movements z Special tests Examination of the Hip z LOOK z Deeply buried joint z Inspection usually unhelpful (but do it anyway!) Muscle wasting Pelvic tilt Iliopsoas bursa } } } Patient standing z Inspection Scars } Lower limb length discrepancy } Flexion deformity of hip } Patient lying supine Examination of the Hip z FEEL z Palpation may elicit tenderness Anterior groin – true hip joint Lateral aspect hip – greater trochanteric bursitis Examination of the Hip z MOVE z Flexion 135º with knee flexed; 90º with knee extended NB FFD contralateral hip, Thomas’s Test z Internal and External Rotation With hip and knee flexed 90º With knee extended (roll leg) z Abduction and Adduction Trendelenberg test Examination of the Hip z FUNCTION z Antalgic gait z Trendelenburg test Pelvic brim drops when patient stands on one leg Indicates weakness of gluteus medius Normal action is to tilt pelvis whilst walking to enable leg to swing freely Trendelenburg gait Bilateral positive Trendelenburg sign Trunk swings as patient walks to compensate for dysfunctional pelvic tilt The Knee z Inspection z Palpation z Active motion z Passive motion z Special tests Examination of the Knee z LOOK z Symmetry and Alignment z Deformity Fixed flexion Varus Valgus z Operation scars z Quadriceps muscle bulk z Swelling/ heat / colour change z Psoriasis Examination of the Knee z FEEL z Temperature: Back of hand z Tenderness Joint margins Tibial tuberosity z Effusion Patellar tap Cross-fluctuation Baker’s cyst z Patellofemoral crepitus / grind Examination of the Knee z MOVE z Flexion z Extension z Compare both sides z Active and Passive movements z Feel for crepitus on movement Examination of The Knee z Special Tests z Anterior / Posterior Cruciate ligament stability flexed to 900 Anterior and Posterior Drawer sign Knee z Medial / Lateral Collateral ligament stability flexed to 150 Stress each side of knee joint Knee Examination of The Knee z Special Tests z Menisceal tests: only for experienced examiner McMurray’s test Flex/ extend the knee while the internally rotating and then externally rotating the tibia Pain and an associated click felt over the joint line diagnostic of a menisceal tear Apley’s grinding test Examination of The Knee z FUNCTION z Walk a few steps z Observe gait and deformity The Foot and Ankle z Inspection z Palpation z Active motion z Passive motion Examination of the Foot and Ankle z Patient on couch z LOOK z Symmetry / Deformity / Swelling / colour change Toes Midfoot (Midtarsal joint) Hindfoot (Subtarsal joint) Arches (flat foot, pes planus) z Nail changes / Psoriasis z Examine soles for Calluses / keratoderma blenorrhagica / pustular psoriasis z Inspect Shoes for abnormal wear Examination of the Foot and Ankle z FEEL z Temperature z Metatarsal squeeze then palpate individual metatarsals and web spaces if positive z Palpate ankle, subtalar and midfoot z Achilles tenderness Achilles tendonitis z Heel tenderness Plantar fasciitis Examination of the Foot and Ankle z MOVE z Active and Passive z Ankle Dorsiflexion / Plantarflexion z Inversion / Eversion tibialis posterior Peroneal z MTP 1 Dorsiflexion / Plantarflexion Completing the examination of the lower limb z Leg length discrepancy Measure anterior superior iliac spine to lateral malleolus z Gait Antalgic Trendelenburg
