Easy assessment of musculoskeletal system for GPs

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Easy assessment of musculoskeletal system for GPs

• Aspects of examining the musculoskeletal system

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• Revisiting the basics
• GALS
• Video
• Some bits and pieces / a personal view

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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?

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Revisiting the basics

• Inspection Look
• Palpation Feel
• Movement Move
• Stability
• Function
• Compare with opposite side

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Inspection

• Skin colour / rashes
• Swelling
• Deformity
• Scars
• Muscle wasting
• Surrounding structures - bursae, tendons

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Palpation

• Nature of swelling
• bony
• synovial
• effusion
• Warmth
• Tenderness

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Movement

• Active and passive
• Range of movement
• Crepitus
• Note pain
• Instability

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Stability

• Subluxation or dislocation
• MCP
• Radioulnar
• subtalar
• MTP

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Function

• Lower limbs - gait
• Hands
• pincer grip
• power grip

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G A L S

• Doherty, Dacre, Dieppe and Snaith (1992) The GALS
  locomotor screen, Annals of Rheumatic diseases
  51 1165-9

• GAIT
• ARMS
• LEGS
• SPINE

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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

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GALS recording
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Bits and pieces

• Hands
• Wrists - CTS de Q
• Shoulders
• Backs
• Hips
• Feet - biomechanics

• Hypermobility
• Fibromyalgia

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Hand - RA
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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

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Hand OA
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Raynauds 1
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Raynauds 2
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Scleroderma early
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Scleroderma
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Sclerodactaly (acrosclerosis)
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Carpal Tunnel Syndrome

• Phalens
• Tinels

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De Quervains tenosynovitis

• APL and EPB tendons
• tender over radial styloid
• sometimes nodule (thickened sheath)
• Finkelsteins test
• Rest it
• Inject it

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Shoulders

• Shoulder or not
• Glenohumeral or not - external rotation
• Tenderness
• bicipital groove
• subacromial
• Painful arc of abduction

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Shoulder - abduction
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Shoulder function related to abduction
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Backs

• Lumbar flexion
• Modified Schobers - or use your fingers
• Fingers to floor misleading
• Lumbar extension
• Lumbar lateral flexion
• Sacroiliac restriction

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Backs - neurology
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Sham backache
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Hips

• Internal rotation - can examine sitting
• Trochanteric bursitis
• Trendelenburg - to distinguish lumbosacral from
  hip pain

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Trendelenburg test
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Foot - biomechanics

• Swing phase
• Stance phase
• Contact (27)
• Midstance (40)
• Propulsive (33)

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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

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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

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Biomechanics - stance phase (3)

• Propulsion
• app 25 bodyweight on metatarsals and toes (esp
  1st)
• ends with toes off

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Abnormal pronation and supination
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Over pronation

• 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

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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

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Fibromyalgia
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The End