Easy assessment of Easy assessment of musculoskeletal musculoskeletal system for GPssystem for GPs

Aspects of examining Aspects of examining the musculoskeletal the musculoskeletal

systemsystem

Revisiting the basicsRevisiting the basics GALSGALS VideoVideo Some bits and pieces / a personal Some bits and pieces / a personal

viewview

HistoryHistory

““Have you any pain or stiffness in Have you any pain or stiffness in your muscles, joints or back?”your muscles, joints or back?”

““Do you have any trouble getting up Do you have any trouble getting up or down stairs?”or down stairs?”

““Do you have any difficulty getting Do you have any difficulty getting dressed?”dressed?”

Revisiting the basicsRevisiting the basics

InspectionInspection LookLook Palpation Palpation FeelFeel MovementMovement MoveMove StabilityStability FunctionFunction Compare with opposite sideCompare with opposite side

InspectionInspection

Skin colour / rashesSkin colour / rashes SwellingSwelling DeformityDeformity ScarsScars Muscle wastingMuscle wasting Surrounding structures - bursae, Surrounding structures - bursae,

tendonstendons

PalpationPalpation

Nature of swellingNature of swelling– bonybony– synovialsynovial– effusioneffusion

WarmthWarmth TendernessTenderness

MovementMovement

Active and passiveActive and passive Range of movementRange of movement CrepitusCrepitus Note painNote pain InstabilityInstability

StabilityStability

Subluxation or dislocationSubluxation or dislocation– MCPMCP– RadioulnarRadioulnar– subtalarsubtalar– MTPMTP

FunctionFunction

Lower limbs - gaitLower limbs - gait HandsHands

–pincer grippincer grip–power grippower grip

G A L SG A L S Doherty, Dacre, Dieppe and Snaith Doherty, Dacre, Dieppe and Snaith

(1992) The GALS locomotor screen, (1992) The GALS locomotor screen, Annals of Rheumatic diseases 51: 1165-9Annals of Rheumatic diseases 51: 1165-9

GAITGAIT ARMSARMS LEGSLEGS SPINESPINE

G A L SG A L S “…“…provide a valuable screening test for provide a valuable screening test for

use in general practice”use in general practice” ““the procedure can be viewed as a the procedure can be viewed as a

general functional (disability), as well as general functional (disability), as well as a basic musculoskeletal assessment”a basic musculoskeletal assessment”

““..be useful in selective situations as a ..be useful in selective situations as a rapid test of functional performance and rapid test of functional performance and to screen out regional locomotor to screen out regional locomotor abnormalities that merit closer scrutiny”abnormalities that merit closer scrutiny”

GALS recordingGALS recording

G A MA

L

S

Bits and piecesBits and pieces

HandsHands Wrists - CTS + de Wrists - CTS + de

QQ ShouldersShoulders BacksBacks HipsHips Feet - Feet -

biomechanicsbiomechanics

HypermobilityHypermobility FibromyalgiaFibromyalgia

Hand - RAHand - RA

Early synovitisEarly synovitis

PIP - skin discolouration and PIP - skin discolouration and tendernesstenderness

Clench fist - MCPs should be white Clench fist - MCPs should be white with no infillingwith no infilling

MCP squeeze to elicit tendernessMCP squeeze to elicit tenderness Inferior radio ulnar stress testInferior radio ulnar stress test Bulge sign at kneeBulge sign at knee MTP squeeze testMTP squeeze test

Hand OAHand OA

Raynauds 1Raynauds 1

Raynauds 2Raynauds 2

Scleroderma earlyScleroderma early

Scleroderma Scleroderma

Sclerodactaly Sclerodactaly (acrosclerosis)(acrosclerosis)

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

•Phalen’s

•Tinel’s

De Quervains De Quervains tenosynovitistenosynovitis

APL and EPB tendonsAPL and EPB tendons tender over radial styloidtender over radial styloid sometimes nodule (thickened sometimes nodule (thickened

sheath)sheath) Finkelsteins testFinkelsteins test Rest itRest it Inject itInject it

ShouldersShoulders

Shoulder or notShoulder or not Glenohumeral or not - external Glenohumeral or not - external

rotationrotation Tenderness Tenderness

– bicipital groovebicipital groove– subacromialsubacromial

Painful arc of abductionPainful arc of abduction

Shoulder - abductionShoulder - abduction

Shoulder function related Shoulder function related to abductionto abduction

BacksBacks

Lumbar flexionLumbar flexion– Modified Schobers - or Modified Schobers - or

use your fingersuse your fingers– Fingers to floor = Fingers to floor =

misleadingmisleading Lumbar extensionLumbar extension Lumbar lateral flexionLumbar lateral flexion ““Sacroiliac restriction”Sacroiliac restriction”

Backs - neurologyBacks - neurology

Root Sensory loss Motor weakness Reflex

L4 Medial calf andankle

Knee extension,foot inversion

Knee

L5 Medial foot andhallux

Dorsiflexion footand hallux

None

S1 Outer foot andsole

Plantar flexion foot Ankle

HipsHips

Internal rotation - can examine Internal rotation - can examine sittingsitting

Trochanteric bursitisTrochanteric bursitis

Trendelenburg - Trendelenburg - to distinguish lumbosacral to distinguish lumbosacral from hip painfrom hip pain

Trendelenburg testTrendelenburg test

Foot - biomechanicsFoot - biomechanics

Swing phaseSwing phase

Stance phaseStance phase– Contact (27%)Contact (27%)– Midstance (40%)Midstance (40%)– Propulsive (33%)Propulsive (33%)

Biomechanics - stance Biomechanics - stance phasephase

Contact Contact – outer border heel strikes thenouter border heel strikes then– PRONATION at subtalar joint shifts PRONATION at subtalar joint shifts

centre gravity mediallycentre gravity medially– causes tibia to internally rotatecauses tibia to internally rotate– purpose is shock absorption/adaption purpose is shock absorption/adaption

uneven grounduneven ground

Biomechanics - stance phase Biomechanics - stance phase (2)(2)

MidstanceMidstance– forefoot loadedforefoot loaded– subtalar joint supinatessubtalar joint supinates– causes tibia to externally rotatecauses tibia to externally rotate– foot is converted to rigid lever ready foot is converted to rigid lever ready

for propulsionfor propulsion– ends with heel liftends with heel lift

Biomechanics - stance phase Biomechanics - stance phase (3)(3)

PropulsionPropulsion– app 25% bodyweight on metatarsals app 25% bodyweight on metatarsals

and toes (esp 1st)and toes (esp 1st)– ends with toes offends with toes off

Abnormal pronation and Abnormal pronation and supinationsupination

Over pronationOver pronation

Subtalar Subtalar pronation pronation uncheckedunchecked

longitudinal arch longitudinal arch stretches and stretches and flattensflattens

excess rotation of excess rotation of tibiatibia

Hallux valgusHallux valgus Plantar fasciitisPlantar fasciitis Achilles tendonitisAchilles tendonitis Post tibial Post tibial

tendonitistendonitis stress# navicularstress# navicular anterior knee painanterior knee pain low back painlow back pain

HypermobilityHypermobility

1 Dorsiflexion of 5th MCP to 90 degreesDorsiflexion of 5th MCP to 90 degrees2 Apposition of thumb to volar aspect of Apposition of thumb to volar aspect of

forearmforearm3 Hyperextension of elbow by 10 degreesHyperextension of elbow by 10 degrees4 Hyperextension of knee by 10 degreesHyperextension of knee by 10 degrees5 Hands flat on floor with knees extendedHands flat on floor with knees extended

FibromyalgiaFibromyalgia

The End