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Easy assessment of musculoskeletal system for GPs. Aspects of examining the musculoskeletal system. Revisiting the basics GALS Video Some bits and pieces / a personal view. History . “Have you any pain or stiffness in your muscles, joints or back?”
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Easy assessment of musculoskeletal system for GPs Aspects of examining the musculoskeletal system
Revisiting the basics • GALS • Video • Some bits and pieces / a personal view
History • “Have you any pain or stiffness in your muscles, joints or back?” • “Do you have any trouble getting up or down stairs?” • “Do you have any difficulty getting dressed?”
Revisiting the basics • Inspection Look • Palpation Feel • Movement Move • Stability • Function • Compare with opposite side
Inspection • Skin colour / rashes • Swelling • Deformity • Scars • Muscle wasting • Surrounding structures - bursae, tendons
Palpation • Nature of swelling • bony • synovial • effusion • Warmth • Tenderness
Movement • Active and passive • Range of movement • Crepitus • Note pain • Instability
Stability • Subluxation or dislocation • MCP • Radioulnar • subtalar • MTP
Function • Lower limbs - gait • Hands • pincer grip • power grip
Doherty, Dacre, Dieppe and Snaith (1992) The GALS locomotor screen, Annals of Rheumatic diseases 51: 1165-9 GAIT ARMS LEGS SPINE G A L S
G A L S • “…provide a valuable screening test for use in general practice” • “the procedure can be viewed as a general functional (disability), as well as a basic musculoskeletal assessment” • “..be useful in selective situations as a rapid test of functional performance and to screen out regional locomotor abnormalities that merit closer scrutiny”
Hands Wrists - CTS + de Q Shoulders Backs Hips Feet - biomechanics Hypermobility Fibromyalgia Bits and pieces
Early synovitis • PIP - skin discolouration and tenderness • Clench fist - MCPs should be white with no infilling • MCP squeeze to elicit tenderness • Inferior radio ulnar stress test • Bulge sign at knee • MTP squeeze test
Carpal Tunnel Syndrome • Phalen’s • Tinel’s
De Quervains tenosynovitis • APL and EPB tendons • tender over radial styloid • sometimes nodule (thickened sheath) • Finkelsteins test • Rest it • Inject it
Shoulders • Shoulder or not • Glenohumeral or not - external rotation • Tenderness • bicipital groove • subacromial • Painful arc of abduction
Backs • Lumbar flexion • Modified Schobers - or use your fingers • Fingers to floor = misleading • Lumbar extension • Lumbar lateral flexion • “Sacroiliac restriction”
Hips • Internal rotation - can examine sitting • Trochanteric bursitis • Trendelenburg - to distinguish lumbosacral from hip pain
Foot - biomechanics • Swing phase • Stance phase • Contact (27%) • Midstance (40%) • Propulsive (33%)
Biomechanics - stance phase • 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
Biomechanics - stance phase (2) • Midstance • forefoot loaded • subtalar joint supinates • causes tibia to externally rotate • foot is converted to rigid lever ready for propulsion • ends with heel lift
Biomechanics - stance phase (3) • Propulsion • app 25% bodyweight on metatarsals and toes (esp 1st) • ends with toes off
Subtalar pronation unchecked longitudinal arch stretches and flattens excess rotation of tibia Hallux valgus Plantar fasciitis Achilles tendonitis Post tibial tendonitis stress# navicular anterior knee pain low back pain Over pronation
Hypermobility • Dorsiflexion of 5th MCP to 90 degrees • Apposition of thumb to volar aspect of forearm • Hyperextension of elbow by 10 degrees • Hyperextension of knee by 10 degrees • Hands flat on floor with knees extended