1. Physical Examination of the Spesific Joints

2. Neck
The clinical examination begins with broadly observing the patient's gait and head and neck posture.
Further palpation, range of motion testing, and neurologic signs, including motor signs, reflexes, sensory signs, autonomic signs, and articular signs, are assessed
Posteriorly and posterolaterally, the occiput, inion, superior nuchal line, mastoid processes, and spinous processes of C2 and C7-T1 are palpable.
Soft tissues around the anterior and posterior triangles of the neck, occipital region, and posterior paraspinal muscles are examined. The sternocleidomastoid muscle is involved with whiplash injuries causing abrupt hyperextension of the neck. The muscle may be tender to palpation, or the patient may be splinting the neck with the head turned away from the injured muscle. This posturing of the neck is termed torticollis, and the clinician should remember that the head is turned away from the side of the involved sternocleidomastoid.
The posterior triangle borders include the sternocleidomastoid muscle, the trapezius muscle (inion to T12), and the clavicle. Flexion injuries may traumatize the trapezius muscle. The occipital region and paraspinal muscles from the inion to C7-T1should be palpated carefully.
Midline cervical tenderness is more concerning for ligament injury, whereas paraspinal muscle tenderness is typically a more benign process. The greater occipital nerves are located lateral to the inion and may be involved in traumatic inflammation associated with flexion or extension injuries resulting in suboccipital headaches.

3. Range of motion examination may reveal pain or limitations in flexion-extension, lateral bending, and rotation.
Sensation testing for light touch, pin prick, temperature, and proprioception should be performed.
These tests are subjective, and both upper extremities should be compared to assess differences in sensation.
Range of motion tests the ligaments, capsules, and fascia, and this range of motion is reduced in the presence of cervical spinal muscular spasm or pain.
Causes of decreased range of motion of the cervical spine include joint locking and bony ankylosis from degenerative changes or arthritides, fibrous contractures, muscle spasm, splinting over painful joints, and nerve root or spinal cord compression or irritation. Decreased range of motion in the presence of pain or weakness warrants further investigation.

4. Motor function should be graded using the standard 0-to-5 nomenclature
Dermatomally, C1 and C2 innervate the occiput region; C3 and C4, the nape of the neck; C5, the deltoid region; C6, the radial aspect of the forearm; C7, the long finger; C8, the ulnar border of the hand; and T1, the medial border of the arm
Motor function should be graded using the standard 0-to-5 nomenclature
A cursory examination can be performed assessing C5 with elbow flexion, C6 with wrist extension, C7 with elbow extensors or wrist flexion, C8 with finger flexion of the middle finger, and T1 with finger abduction of the fifth finger
Deep tendon stretch reflexes should be performed and graded 0 to 3 with 0 being no response, 1 being hyporeflexive, 2 being normal, and 3 being hyperreflexive. C5 is tested by striking the biceps tendon; C6, brachioradialis; C7, triceps
Nerve roots with proximal compression are more susceptible to distal compression in a phenomenon termed “double crush.” The cervical spine should always be considered as the potential etiology in patients who present with symptoms of carpal or cubital tunnel syndrome and peripheral neuropathy.
grade 0 having no function, 1 having trace, 2 having full range of joint motion with gravity eliminated, 3 having antigravity function, 4 having function against slight resistance, and 5 having normal strength against resistance.

5. Provocative tests that are helpful in diagnosing myelopathy :
Provocative tests that can be helpful in confirming compressive extradural monoradiculopathy include
Spurling's test
The axial compression test
Adson Test
Provocative tests that are helpful in diagnosing myelopathy :
Hoffmann's sign
Lhermitte's sign
Spurling's test is performed by the patient extending his or her neck and rotating toward the side of pain. The test is positive if the radicular pain worsens in this position and indicates foraminal stenosis with potential compression of a nerve root.
The axial compression test is performed by pressing on top of the patient's head with the neck in neutral position with a positive result if the radicular symptoms are exacerbated by this maneuver and relieved by placing traction on the head and opening up the foramina.
Provocative tests that are helpful in diagnosing myelopathy include Hoffmann's sign, and Lhermitte's sign.
Hoffmann's sign is obtained by holding the middle finger extended and suddenly extending the distal interphalangeal joint, resulting in flexion of the index finger and thumb if pathologic.
Lhermitte's sign evaluates for changes in the spinal cord itself and occurs when the patient's neck is forcefully flexed resulting in electric-like shocks that travel down the arms and legs.

6. Shoulder Contour and symmetry Range of motion
Spinatus muscle atrophy
scapular winging
Range of motion
scapulothoracic motion
glenohumeral motion.
Palpation of the biceps tendon, coracoid, lesser and greater tuberosities, and posterior cuff is done, and any tenderness is gauged.
Proper physical examination of the shoulder includes close inspection of the shoulder girdle from the front and back. The evaluation is started by standing behind the patient, with both shoulders exposed. The normal shoulder is always inspected and compared with the injured shoulder. Examination can be started with the patient in the sitting or standing position. Contour and symmetry are observed and compared between shoulders, assessing any atrophy or asymmetry in shoulder position or level.
Spinatus muscle atrophy may result from disuse, chronic cuff tear, or suprascapular or brachial neuropathy. If evidence of scapular winging is evident, the patient should be asked to do a wall push-up, which accentuates winging.
Range of motion should be carefully recorded, noticing any absence of rhythmic shoulder motion or excessive scapulothoracic motion that may compensate for the lack of glenohumeral motion. Internal rotation of the shoulder is checked by having the patient reach behind the back with the thumb while the examiner notices the vertebral level. Loss of internal rotation is seen early with shoulder pain and usually indicates some tightness of the posterior shoulder capsule.
Palpation of the biceps tendon, coracoid, lesser and greater tuberosities, and posterior cuff is done, and any tenderness is gauged. Tenderness on palpation of the long head of the biceps frequently is associated with rotator cuff tendinopathy and tenderness of the greater tuberosity. Any spasm or tenderness of the trapezius or levator scapulae may be associated with rotator cuff disease or cervical spine disease.

7. Examination Inspection: Palpation ROM: Neurologic examination Posture
Deformity
Swelling
Atrophy
Skin lesions
Palpation
ROM:
Flexion-abduction: 180
Adduction, external rotation, extension:45, internal rotation: 55
Scapular movements: elevation, depresion, rotation, protraction
Neurologic examination
Muscle strength
Sensory: c4-c5-t1-t2
Special tests

10. resim impingement sign Speed's test Yergason's sign Apprehension test
Drop arm test
resim
Neer testi, subakromial sıkışma testi: Hastanın skapulası stabilize edilir ve kol pasif olarak öne doğru fleksiyona zorlanır. Bu manevra ile tuberkulum majus korakoakromiyal arka doğru itilir. Subakromiyal sıkışma sendromunda, test ile ağrı oluşur.
Speed testi: Bisipital tendiniti gösteren bir diğer testtir. Dirsek ekstansiyonda, kol 90 derece fleksiyonda öne doğru uzatılır. Bu pozisyonda hastanın koluna aşağı doğru kuvvet uygulanırken hasta direnç gösterir. Bisipital tendon, manevra sırasında bisipital oluk boyunca hareket ettiği için patoloji varsa ağrı oluşur.
Yergason testi: Hastaya aktif olarak önkola supinasyon yaptırılıp direnç uygulanır. Bisipital tendinitte bu manevra ile bisipital olukta ağrı meydana gelir. Biseps, önkolun supinator kası olduğundan patolojik durumda kasın proksimal parçası Yergason testi ile irrite olur.
Apprehension test: Anterior instabiliteyi gösteren bu test hasta oturur veya yatar pozisyondayken yapılır. Hastanın kolu pasif olarak 90 derece abduksiyon, dış rotasyon ve ekstansiyona getirilir. Dislokasyon varsa, hastada korku ve endişe ifadesi belirir.
Drop arm: Rotator manşon yırtığı teşhisinde yapılır. Hastanın kolu tam abduksiyona getirilir ve hastadan kolunu yavaşça yana indirmesi istenir. rotator manşonda yırtık varsa hasta kolunu yavaş yavaş indiremez, kol yana düşer
To elicit the impingement sign, the shoulder is elevated passively in forward flexion, while depressing the scapula with the opposite hand, forcing the greater tuberosity against the anterior acromion and producing pain in cases of impingement This maneuver also may be painful in conditions such as adhesive capsulitis, glenohumeral and AC arthritis, glenohumeral instability, and calcific tendinitis.
The sternoclavicular and AC joints should be observed for prominences and palpated for stability and tenderness. Many patients with impingement have tenderness on direct downward palpation of the AC joint owing to impingement on the cuff from undersurface osteophytes of the distal clavicle.
If after a thorough physical examination impingement is suspected, an impingement test should be performed with injection of 5 mL of local anesthetic into the subacromial space.
In cases of suspected bicipital tendinitis, Speed's test is performed by having the patient flex the shoulder and extend the elbow while a downward force is applied to the arm. The production of pain over the long head of the biceps is a positive test result and suggests bicipital tendinitis.

11. ELBOW
The elbow joint is composed of three bony articulations. The principal articulation is the humeroulnar joint.
The radiohumeral and proximal radioulnar articulations allow rotation of the forearm.
examine the skin: psoriatic plaques, rheumatoid nodules, or tophi.
palpate the olecranon bursa to exclude the presence of small nodules or tophi.
Synovitis or effusion generally results in limitation of elbow extension.
In lateral epicondylitis, discomfort can be elicited by resisted supination of the forearm or resisted extension of the pronated wrist. In medial epicondylitis, discomfort can be elicited by resisted flexion of the supinated wrist.
The elbow joint is composed of three bony articulations. The principal articulation is the humeroulnar joint, which is a hinge joint. The radiohumeral and proximal radioulnar articulations allow rotation of the forearm.
One should examine the skin around the elbow joint carefully, noting abnormalities such as psoriatic plaques, rheumatoid nodules, or tophi.
It is useful to palpate the olecranon bursa to exclude the presence of small nodules or tophi.
Synovitis or effusion generally results in limitation of elbow extension.
A patient who has olecranon bursitis usually presents with a swelling over the olecranon process, which is often tender and may be erythematous. Sometimes a large collection of fluid over the area is palpable as a cystic mass and often requires aspiration and drainage.
The medial and lateral epicondyles of the humerus are the sites of attachment of the common flexor and extensor tendons, controlling hand and wrist motion. Tenderness at the epicondyles without swelling or other signs of inflammation may indicate overuse tendinopathy, termed lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer's elbow).
In lateral epicondylitis, discomfort can be elicited by resisted supination of the forearm or resisted extension of the pronated wrist. In medial epicondylitis, discomfort can be elicited by resisted flexion of the supinated wrist.
Tenderness at the epicondyles without swelling or other signs of inflammation may indicate overuse tendinopathy, termed lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer's elbow).

12. WRIST
Movements of the wrist include flexion (palmar flexion), extension (dorsiflexion), radial deviation, ulnar deviation, and circumduction.
Pronation and supination of the hand and forearm occur primarily at the proximal and distal radioulnar joints.
The wrist normally can be extended to 70 to 80 degrees and flexed to 80 to 90 degrees. Ulnar and radial deviation should allow 50 degrees (ulnar) and 20 to 30 degrees (radial) of movement.
The long flexor tendons of the forearm musculature cross the volar aspect of the wrist and are enclosed in the flexor tendon sheath under the flexor retinaculum (transverse carpal ligament). The flexor retinaculum and the underlying carpal bones form the carpal tunnel. The median nerve passes through the carpal tunnel superficial to the flexor tendons.
The extensor tendons of the forearm musculature are enclosed by six synovial-lined compartments.

13. Positive table tab test The Finkelstein test
The palmar aponeurosis (fascia) spreads out into the palm from the flexor retinaculum. Dupuytren's contracture is a fibrosing condition affecting the palmar aponeurosis, which becomes thickened and contracted and may draw one or more fingers into flexion at the metacarpophalangeal joint. The fourth finger is frequently affected first.
A ganglion is a cystic enlargement arising from a joint capsule. Ganglions characteristically occur at the volar or dorsal aspects of the wrist between the tendons.
Trigger fingers” secondary to stenosing tenosynovitis can be detected by palpating crepitus or nodules along the tendons in the palm while the patient slowly flexes and extends the fingers. The patient usually gives a history of the affected finger catching or locking with movement.
Tenosynovitis of the first extensor compartment, which encloses the abductor pollicis longus and extensor pollicis brevis muscles of the thumb, is known as de Quervain's tenosynovitis. Patients complain of pain at the radial aspect of the wrist. Tenderness may be elicited by palpating near the radial styloid process.
The Finkelstein test for de Quervain's tenosynovitis is performed by asking the patient to make a fist with the thumb enclosed in the palm of the hand, then moving the wrist into ulnar deviation. Severe pain over the radial styloid is a positive finding, often indicating stretching of the thumb tendons in a stenosed tendon sheath.

14. Dactylitis and sausage digit Swan neck deformity Boutonnière deformity
Telescoping or shortening of the digits
Swelling of the fingers may result from articular or periarticular causes. Synovial swelling usually produces symmetric enlargement of the joint itself, whereas extra-articular swelling may be diffuse and extend beyond the joint space.
Asymmetric enlargement, involving only one side of the digit or joint, is less common and usually indicates an extra-articular process. Diffuse swelling of an entire digit, known by the terms dactylitis and sausage digit, may result from tenosynovitis and is seen most commonly in the spondyloarthropathies, such as reactive arthritis or psoriatic arthritis.
Chronic swelling and distention of the metacarpophalangeal joints tends to produce stretching and laxity of the articular capsule and ligaments. This laxity, combined with muscle imbalance and other forces, eventually results in the extensor tendons of the digits slipping off the metacarpal heads to the ulnar sides of the joints.

15. Bony hypertrophy: Heberden nodes, Bouchard nodes.
A mallet finger
Bony hypertrophy: Heberden nodes, Bouchard nodes.
A mallet finger results from avulsion or rupture of the extensor tendon at the level of the distal interphalangeal joint. With this deformity, the patient is unable to extend the distal phalanx, which remains in a flexed position. This deformity frequently results from traumatic injuries.
Bony hypertrophy and osteophyte formation are commonly seen, however, at the distal and the proximal interphalangeal joints in patients with osteoarthritis. Enlarged, bony, hypertrophic distal interphalangeal joints are called Heberden nodes, whereas similar changes at the proximal interphalangeal joints are called Bouchard nodes.
The ability to oppose fingers, especially the thumb, is crucial to hand function because of the necessity to grasp or at least pinch for objects. If the patient is unable to form a full fist, a demonstration of the ability or inability to pinch or oppose fingers can be made by asking the patient to pick up a small object.

16. LOMBER SPINE Anterior Elements:
– Vertebral body: provide bulk and height; Sustain compression loads.
• Middle Elements:
– Pedicles: transfer forces from posterior to anterior elements.
• Posterior Elements:
– Articular processes and facet jts, laminae, spinous processes.
– Lock spine to prevent forward sliding and twisting; Insertion sites for muscle.

17. – Intervertebral disc:
3 Joint Complex:
– Intervertebral disc:
principal joint between
vertebrae
– 2 Facet Joints:
formed by superior and inferior
articular processes
• Disc consists of:
– Nucleus polposus
– Annulus fibrosis

18. 3 major groups:
– Psoas major and minor:
provide hip flexion.
– Quadratus lumborum:
assists lateral flexion.
– Paraspinous muscles
(erector spinae): control
flexion,extension and twist.
• Multifidus
• Interspinalis
• Iliocostalis

19. Interspinous Ligament: connects spinous process.
Ligamenum Flavum: connects laminae; roof for spinal canal.
Ant / Post longitudinal ligaments: cover vertebral body for stability.

20. Inspect back for symmetry; – List, scoliosis or other deformity.
Inspection
Inspect back for symmetry;
– List, scoliosis or other deformity.
– Redness (infx), Lipoma or hair growth (spina bifida).
From the side, observe lumber lordosis.
Check pelvic obliquity:
– Line between PSIS should be parallel to floor.
Affected by leg length or scoliosis.
Ask patient to point to area of maximal pain.
Posterior superior iliac spine
Venüs çukuru) altında spina iliaka posterior süperior (SIPS) bulunur.

21. Palpation • Spinous processes and ligaments:
– Feel for step-off at L4-L5-S1 (spondylolisthesis).
– Tender with ligament sprains, fracture, etc.
• Facet joints: deep and lateral to processes; Tender with OA
• Paraspinous muscles: for tenderness or spasm.
• Top of Iliac crests at L4-L5 disc space;
Follow around to PSIS:
– Sacroiliac joints: below and lateral to PSIS.
– Sciatic notch: mid way btw PSIS and ischial tuberosity; Aggravates sciatica.

22. Range of Motion • Forward flexion (80-90o):
– Loads discs and stretches sciatic nerve; More likely to increase disc pain.
– Observe from behind bending forward for asymmetry, suggestive of scoliosis.
• Extension(20-30o): more likely to increase pain from facets or spinal
stenosis.
• Lateral bending (20-30o): loads muscle and discs.
• Twisting (30-40o): loads muscle.

23. Neuro: Strength Testing
• Resisted hip flexion (iliopsoas muscle) tests L1 and L2.
• Resisted knee extension (quad muscle) tests L3.
• Resisted ankle dorsiflexion tests L4.
• Resisted dorsiflexion of great toe tests L5.
• Resisted ankle plantarflexion test S1.
• S2-4 supply bladder and anal sphincter.

24. Neuro: Strength Testing
• Heel walking
–Ankle dorsiflexors (Tibialis anterior)
– L4.
• Toe walking
–Gastroc-soleus muscle group.
– L5 and S1.
Neuro: Sensory Testing
• Check light touch and sharp/dull.
– L4: medial leg and ankle.
– L5: dorsum of foot.
–S1: lateral ankle and foot

25. Neuro: DTR’s and Clonus
• Deep tendon reflexes
–Knee jerk: L4.
– Ankle jerk: S1.
• Ankle clonus
–Check if DTR’s excessively brisk.
–Elicit with sudden ankle dorsiflexion.
–Suggests upper motor neuron lesion

26. Nerve Tension Tests • Test for nerve root compression.
• Key nerves for lumbar and sacral roots:
– Femoral nerve (L2, L3, L4) runs down antero-medial thigh.
– Sciatic nerve (L4, L5, S1,S2, S3) runs down posterior thigh.
Straight Leg Raise (SLR)
• With patient supine or sitting, flex hip and extend knee.
– Note angle at which pain or tightness occurs (normal 70-90o).
– Pain radiating past knee suggests sciatica and lesion at L5 or S1 roots.
– Dorsiflexion of ankle increases sciatic tension and pain (Lasegue’s test).
– Plantar flexion of ankle or flexion of knee relieves sciatic tension
and pain

27. Femoral Nerve Stretch Test
• Used to assess compression at L2-3-4 nerves roots.
• With patient prone on exam table and knee flexed, extend hip by lifting thigh off table.
– Positive with high lumbar disc herniation.
– Reproduces radicular pain to anterior thigh.

28. Other Tests for Disc Herniation
Crossed SLR Test: pain radiating down opposite leg highly suggestive of HNP.
• Valsalva Maneuver:
– increases intrathecal pressure
– Aggravates pain caused by pressure on cord or roots (HNP, tumor, etc).
Kontrlateral DBK

29. HIP The principal hip flexor is the iliopsoas
Hip adduction: adductors (longus, brevis, and magnus)
The gluteus medius is the major hip abductor, the gluteus maximus and hamstrings extend the hip.
There are several clinically important bursae around the hip joint.
stance and gait: the anterior iliac spines are visible. Pelvic tilt or obliquity structural scoliosis, anatomic leg-length discrepancy, or hip disease.
resim
Stability of the joint is ensured by the fibrocartilaginous rim of the glenoid labrum and the dense articular capsule and surrounding ligaments, including the iliofemoral, pubofemoral, and ischiocapsular ligaments that reinforce the capsule. Support also is provided by the powerful muscle groups that surround the hip.
The principal hip flexor is the iliopsoas muscle assisted by the sartorius and the rectus femoris muscles. Hip adduction is accomplished by the three adductors (longus, brevis, and magnus) plus the gracilis and pectineus muscles. The gluteus medius is the major hip abductor, whereas the gluteus maximus and hamstrings extend the hip.
There are several clinically important bursae around the hip joint. Anteriorly, the iliopsoas bursa lies between the psoas muscle and the joint surface. The trochanteric bursa lies between the gluteus maximus muscle and the posterolateral greater trochanter, and the ischiogluteal bursa overlies the ischial tuberosity.
Examination of the hip should begin by observing the patient's stance and gait. The patient should stand in front of the examiner so that the anterior iliac spines are visible. Pelvic tilt or obliquity may be present and related to a structural scoliosis, anatomic leg-length discrepancy, or hip disease.

30. Antalgic (limping) gait Trendelenburg gait Trendelenburg test
Two abnormalities of gait may be commonly observed in patients with hip disease. The most common abnormality seen with a painful hip is the antalgic (limping) gait.
In antalgic gait, the individual leans over the diseased hip during the phase of weight bearing on that hip, placing the body weight directly over the joint to avoid painful contraction of the hip abductors.
In a Trendelenburg gait, with weight bearing on the affected side, the pelvis drops and the trunk shifts to the normal side.
Generally the antalgic gait is frequently seen with painful hips and the Trendelenburg gait is seen in patients with weak hip abductors.
The Trendelenburg test :
assesses the stability of the hip together with the hip abductor muscle's ability to stabilize the pelvis on the femur.
It is a measure of the gluteus medius hip abductor strength.
The patient is asked to stand bearing weight on only one leg. Normally, the abductors hold the pelvis level or the nonsupported side slightly elevated. If the non–weight-bearing side drops, the test is positive for weakness of the weight-bearing side hip abductors, especially the gluteus medius muscle.

31. The motion of the hip should be assessed with the patient in the supine position. The range of motion of the hip includes flexion (120), extension, abduction (45), adduction (20-30), internal and external rotation (40-45).
The Thomas test
The Thomas test shows the flexion contracture. In this test, the opposite hip is fully flexed to flatten the lumbar lordosis and fix the pelvis. The involved leg should be extended toward the table as far as possible. The diseased hip's flexion contracture becomes more obvious and can be estimated in degrees from full extension.

32. The Patrick test or FABERE maneuver (FABERE —flexion, abduction, external rotation, and extension.)
The Patrick test or FABERE maneuver (FABERE —flexion, abduction, external rotation, and extension.):the patient lies supine, and the examiner flexes, abducts, and externally rotates the patient's test leg so that the foot of the test leg is on top of the opposite knee. The examiner then slowly lowers the test leg toward the examining table. A positive result of the Patrick test may indicate hip disease, iliopsoas tightness, or sacroiliac abnormality.
The Ober test evaluates the iliotibial band for contracture. The patient lies on the side with the lower leg flexed at the hip and knee. The examiner abducts and extends the upper leg with the knee flexed at 90 degrees. The hips should be slightly extended to allow the iliotibial band to pass over the greater trochanter. The examiner slowly lowers the limb with the muscles relaxed. A positive test result indicative of an iliotibial band contracture occurs if the leg does not fall back to the level of the table top.

33. Measurement for leg-length discrepancy: anterior superior iliac spine
Measurement for leg-length discrepancy is performed with the patient supine and the legs fully extended. Each leg is measured from the anterior superior iliac spine to the medial malleolus. A difference of 1 cm or less is unlikely to cause any abnormality of gait and may be considered normal. In addition to true leg-length asymmetries, apparent leg-length discrepancies may result from pelvic tilt or abduction or adduction contractures of the hip
The greater trochanter should be palpated for tenderness and compared with the opposite side. In trochanteric bursitis, this area is usually exquisitely tender. The pain of trochanteric bursitis is aggravated by actively resisted abduction of the hip.
Aching and tenderness over the buttock area may be secondary to an ischial bursitis.
Hip and groin pain may be secondary to hip abnormality, most commonly degenerative arthritis. Decreased range of motion should be noted in these patients. femoral aneurysms, adenopathy, tumor, and psoas abscess or masses.

34. KNEE
Examination of the knees should always include observation of the patient while standing and walking.
Deviation of the knees, including genu varum, genu valgum and genu recurvatum,
Inspection: asymmetry that may be caused by swelling or muscle atrophy, Patellar alignment, Baker cyst
Examination of the knees should always include observation of the patient while standing and walking. Deviation of the knees, including genu varum (lateral deviation of the knee joint with medial deviation of the lower leg), genu valgum (medial deviation of the knee with lateral deviation of the lower leg), and genu recurvatum, is most easily appreciated with the patient standing. The patient also should be observed ambulating for evidence of gait abnormalities.
Inspection should be done with the patient standing and supine. It is essential to compare side to side, noting any asymmetry that may be caused by swelling or muscle atrophy.
Patellar alignment should be noted, including high-riding or laterally displaced patellae. The examiner also should inspect the knee from behind to identify popliteal swelling owing to a popliteal or Baker cyst, most commonly caused by medial semimembranous bursal swelling.
If the calves appear asymmetric, calf circumference should be measured and compared bilaterally.

35. Palpation of the knee:
Swelling, thickening, nodules, loose bodies, tenderness, and warmth should be noted.
Bulge sign (patellar schock)
Palpation of the knee should be performed with the joint relaxed. Swelling, thickening, nodules, loose bodies, tenderness, and warmth should be noted.
At the other extreme, effusions 4 to 8 mL can be detected by eliciting the bulge sign. This test is performed with the knee extended and relaxed. The examiner strokes or compresses the medial aspect of the knee proximally and laterally with the palm of a hand to move the fluid from the area. The lateral aspect of the knee is tapped or stroked, and a fluid wave or bulge appears medially.
Tenderness localized over the medial or lateral joint margins may represent articular cartilage disease, medial or lateral meniscal abnormality, or medial or lateral collateral ligament injury. Other causes of tenderness include pathologic conditions in the underlying bony structures. Bursitis is another cause of localized tenderness around the knee, and the two most common sites are the pes anserine and prepatellar bursae.

36. Apprehension test
Patellar dislokasyonda kullanılır. Hasta kuadriseps kası gevşek olarak sırtüstü yatar. Hekim dizi yavaşça 30 derece fleksiyona getirir ve patellayı lateral tarafa doğru iter. Eğer hasta patellanın disloke olacağını hissederse kuadrisepsi kasarak patellayı yerinde tutmaya çalışır ve endişeli bir ifade takınır.
The patellar stability should be assessed. The Fairbanks apprehension test is done with the patient supine, the quadriceps relaxed, and the knee in 30 degrees of flexion. The examiner slowly pushes the patella laterally. A sudden contraction of the quadriceps and a distressed reaction from the patient constitute a positive apprehension test result. A patient who has had previous patella dislocations usually has a positive apprehension test result. The patella also can be examined for subluxation while the knee is moved through a range of motion from full flexion to extension.
The plica syndrome also occasionally causes symptoms that suggest patellofemoral disease. Plicae are bands of synovial tissue, most often located on the medial side of the knee. If present, a tender bandlike structure may be palpated parallel to the medial border of the patella. During flexion and extension, a palpable or audible snapping may be heard, and the patient may experience symptoms of catching.

37. The abduction or valgus test: The adduction or varus test
The normal knee range of motion should be from full extension (0 degrees) to full flexion of 120 to 150 degrees.
Ligamentous instability is tested by applying valgus and varus stress to the knee and by using the drawer test.
The abduction or valgus test:
The adduction or varus test
Ön çekmece testi: Anterior instabilite değerlendirilir. Sırt üstü yatan hastada kalça 45 derece, diz 90 derece fleksiyona getirilir. Hekim hastanın ayağı üzerine oturarak stabilize eder. İki elle tibiayı proksimalinden tutarak öne doğru çeker. Tibia öne doğru kayarsa test + tir. 6 mm'den fazla hareket varsa test pozitiftir. Ön çapraz bağ (ACL) hasarı başta olmak üzere posterolateral kapsül, posteromedial kapsül, medial kollateral ligament, iliotibial bant, posterior oblik ligament, arkuat-popliteus kompleksi hasarlarında test pozitif olabilir.
Posterior instabilitenin değerlendirilmesinde kullanılır. Sırt üstü yatan hastada diz 90 derece fleksiyona getirilir. Hekim hastanın ayağı üzerine oturarak stabilize eder. İki elle tibia proksimalinden tutarak arkaya doğru iter. Medial tibial platonun medial femoral kondil üzerinde 1 cm'den fazla hareketi pozitif olarak yorumlanır. Arka çapraz bağ başta olmak üzere arkuat-popliteus kompleksi ve posterior oblik ligament yaralanmalarında pozitif olabilir.
The normal knee range of motion should be from full extension (0 degrees) to full flexion of 120 to 150 degrees.
Ligamentous instability is tested by applying valgus and varus stress to the knee and by using the drawer test.
The abduction or valgus test: by stabilizing the lower femur, while placing a valgus stress on the knee by abducting the lower leg with the other hand placed proximal to the ankle. A medial joint line separation with the knee fully extended indicates a tear of the medial collateral ligament plus the posterior cruciate ligament. The test is performed with the knee in 30 degrees of flexion. If the test is negative at 0 degrees, but positive at 30 degrees, the instability represents a tear of the medial collateral ligament with the posterior cruciate ligament remaining intact.
The adduction or varus test is performed with the knee extended and again at 30 degrees of flexion. Separation of the lateral joint line indicates a lateral collateral ligament tear—either associated or not with a posterior cruciate ligament tear.

38. A posterior drawer test Mcmurray test Apley test
Lachman test
A posterior drawer test
Mcmurray test
Apley test
Lachman testi: Hasta sırtüstü pozisyondayken dizi 20-30˚ fleksiyonuna getirilir. Test eden kişinin bir eli femuru sabitlerken, diğer el posterior proksimalden tibiayı anteriora doğru transle eder. Sağlam tarafla kıyaslandığında, tibianın daha çok anteriora transle olması ve yumuşak bir son nokta hissi testi pozitif yapar
Ön çapraz bağın, özellikle de posterolateral bandın değerlendirilmesinde kullanılır. Sırtüstü yatan hastada diz derece fleksiyona getirilir. Hekim dıştaki eliyle femuru stabilize ederken diğer eliyle proksimal tibiayı kavrayıp öne çeker. Belirgin bir sert sonlanma olmuyorsa test pozitif kabul edilir.
mcmurreySırtüstü yatan hastanın dizi tam fleksiyona getirilir. Bir el ayak bileğinden, diğer el dizden kavrar. Tibiaya iç rotasyon yaptırılırken diz ekstansiyona getirilir. Lateral menisküs lezyonu varsa bu sırada ağrı ve klik sesi ortaya çıkar. Medial menisküs için test tibiaya dış rotasyon yaptırılırken tekrarlanır.
Apley: Hasta dizi 90 derece fleksiyondayken yüzüstü yatar. Hekim diziyle uyluğa basarak femuru stabilize eder. Bu esnada tibiaya medial ve lateral rotasyonla beraber distraksiyon uygulanır. Negatif test için kısıtlılık, aşırı hareket ya da rahatsızlık olmamalıdır. Daha sonra distraksiyon yerine kompresyon yapılarak değerlendirilir. Rotasyon ve kompresyon diğer taraftan ağrılı ya da rotasyon diğer taraftan azsa menisküs lezyonu düşünülür. Rotasyon ve distraksiyon diğer taraftan daha ağrılı ya darotasyon diğer taraftan fazlaysa ligament lezyonu düşünülür.
The drawer test is performed with the hip flexed to 45 degrees and the knee flexed to 90 degrees. To stabilize the knee, the examiner either sits on the foot while grasping the posterior calf with both hands or supports the lower leg between his or her lateral chest wall and forearm. The anterior drawer test is performed by pulling the tibia forward.
The Lachman test is a modification of the anterior drawer sign and tests for one-plane anterior instability. In the test as originally described, the patient lies supine with the tested knee between full extension and 30 degrees of flexion. The femur is stabilized with a hand of the examiner while the hand pulls the proximal aspect of the tibia forward. A positive test result is indicated by a soft feel rather than a firm end point when the tibia moves forward on the femur. A positive result of the Lachman test may indicate an anterior cruciate injury or abnormality in the posterior oblique ligament or arcuate popliteus complex.
A posterior drawer test may be done with the patient positioned as for an anterior drawer test, but the examiner pushes the tibia toward the patient. A positive test result suggests damage to the posterior cruciate ligament.

39. ANKLE
20 degrees of dorsiflexion and about 45 degrees of plantar flexion.
Inversion and eversion of the foot occur mainly at the subtalar and other intertarsal joints.
20 degrees of eversion
30 degrees of inversion
From the normal position of rest in which there is a right angle between the leg and foot, labeled 0 degrees, the ankle normally allows about 20 degrees of dorsiflexion and about 45 degrees of plantar flexion. Inversion and eversion of the foot occur mainly at the subtalar and other intertarsal joints.
From the normal position of the foot, the subtalar joint normally permits about 20 degrees of eversion and 30 degrees of inversion. To test the subtalar joint, the examiner grasps the calcaneus with a hand and attempts to invert and evert it, holding the ankle motionless.

40. A general assessment of muscular strength of the ankle can be obtained by asking the patient to walk on toes and on heels.
The principal flexors of the ankle are the gastrocnemius (nerve roots S1 and S2) and the soleus (S1 and S2) muscles.
The principal extensor (dorsiflexors) of the ankle is the tibialis anterior muscle (L4, L5, and S1). The tibialis posterior muscle (L5 and S1) is the principal inverter. To test the tibialis posterior muscle, the foot should be in plantar flexion.
The principal everters of the foot are the peroneus longus (L4, L5, and S1) and peroneus brevis (L4, L5, and S1) muscles.
asymmetry, hypertrophy, or atrophy. The distribution of the atrophy should be noted because this may indicate the underlying cause.
Muscle tone
A general assessment of muscular strength of the ankle can be obtained by asking the patient to walk on toes and on heels. If the patient can walk satisfactorily on the toes and on the heels, the muscle strength of the flexors and extensors of the ankle can be considered normal. If this cannot be accomplished, it is desirable to test the muscles individually.
The principal flexors of the ankle are the gastrocnemius (nerve roots S1 and S2) and the soleus (S1 and S2) muscles. The principal extensor (dorsiflexors) of the ankle is the tibialis anterior muscle (L4, L5, and S1). The tibialis posterior muscle (L5 and S1) is the principal inverter. To test the tibialis posterior muscle, the foot should be in plantar flexion. The examiner applies graded resistance on the medial border of the forefoot while the patient attempts to invert the foot. The principal everters of the foot are the peroneus longus (L4, L5, and S1) and peroneus brevis (L4, L5, and S1) muscles.
Muscle bulk should be compared on one side of the body with the other to look for any asymmetry, hypertrophy, or atrophy. The distribution of the atrophy should be noted because this may indicate the underlying cause. Distal atrophy can be seen in patients with motor neuron disease.
Muscle tone also should be evaluated. Increased muscle tone and spasticity can be seen with demyelinating conditions.