Musculoskeletal

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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 2 nd to 5 th 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 GAM A L S A = APPEARANCE M = MOVEMENT

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