Examination – Orthopaedics – Look – Feel – Move

The “Look, Feel, Move” approach is a systematic method used in orthopedic examinations to assess the functionality and integrity of the musculoskeletal system. This methodical examination helps in identifying abnormalities, determining the extent of an injury, and formulating a diagnosis. It’s particularly useful because it provides a structured way to gather information about the bones, joints, muscles, and related structures through observation, palpation, and movement. Here’s how it breaks down:

Introduction

We begin in the usual way:

  • Handwashing
  • Introduction
  • Explanation (including the need for adequate Exposure)
  • Consent
  • Pain – ask the patient about pain and tell them to let you know if you cause any

Look

The first step involves a visual inspection of the affected area, comparing it to the contralateral (opposite) side if necessary. This part of the examination aims to identify any visible abnormalities without physically manipulating the area. Key aspects include:

  • Alignment of Limbs and Joints:
    • Check for any deformities, abnormal positioning, or curvatures.
  • Skin Changes:
    • Observe for bruises, scars, rashes, or changes in colour that may indicate underlying conditions.
  • Swelling and Muscle Atrophy:
    • Look for any signs of swelling around joints or muscles and noting any areas of muscle wasting or hypertrophy.
  • Posture and Gait:
    • Observe the patient’s posture, standing, and walking, if applicable, to assess functional impairments.

Feel

After the initial visual inspection, the next step involves palpation of the area to assess for any tenderness, warmth, swelling, or other abnormalities that weren’t apparent on visual inspection.

  • Temperature:
    • Feeling for areas of warmth that may indicate inflammation or infection.
  • Tenderness:
    • Palpating to locate areas of pain or discomfort that can help pinpoint the affected structure.
  • Swelling:
    • Assessing for fluid accumulation, bony enlargements, or soft tissue swelling.
  • Crepitus:
    • A palpable or audible crunching sensation during joint movement, indicating joint surface irregularities.

Move

The final step involves assessing the range of motion (ROM), both passive (the examiner moves the limb) and active (the patient moves the limb). This helps determine the functional limitations and the integrity of the joints and surrounding structures.

  • Active Range of Motion (AROM):
    • The patient is asked to move the joint through its full movement to assess muscular strength, joint function, and the presence of pain.
  • Passive Range of Motion (PROM):
    • The examiner moves the joint to assess the integrity of the joint structures without muscle contraction. Comparison with AROM can help localize the source of the problem.
  • Special Tests:
    • Depending on the findings from the previous steps, specific maneuvers can be performed to test the integrity of ligaments, tendons, and other structures.
    • For example, the anterior drawer test is performed on the anterior cruciate ligament in the knee.

This structured approach ensures a comprehensive examination of the musculoskeletal system, allowing the practitioner to make a more accurate diagnosis and plan for further investigations or treatment as necessary. It’s a fundamental skill in orthopedics, emphasizing a thorough and methodical evaluation to guide clinical decision-making.

Special Tests

Shoulder Special Tests

  1. Wall Push-Up Test (Serratus Anterior Test)
    • Performance: The patient stands facing and places their hands on the wall at shoulder height and performs a push-up against the wall.
    • Positive Finding: If the medial border of the scapula protrudes posteriorly (i.e., “wings out”) during the push-up, this indicates weakness or dysfunction of the serratus anterior muscle, which is often caused by injury to the long thoracic nerve.
  2. Neer Impingement Test
    • Performance: The examiner stabilizes the patient’s scapula with one hand while passively flexing the patient’s arm forward with the other hand.
    • Positive Finding: Pain during the maneuver suggests impingement of the rotator cuff tendons under the acromion.
  3. Hawkins-Kennedy Test
    • Performance: The patient’s arm is flexed to 90 degrees, the elbow is flexed to 90 degrees, and the shoulder is forcibly internally rotated by the examiner.
    • Positive Finding: Pain indicates possible impingement of the supraspinatus tendon.
  4. Empty Can Test
    • Performance: The patient abducts the arms to 90 degrees, then forward flexes 30 degrees and internally rotates the arms so thumbs point downward. The examiner applies downward pressure.
    • Positive Finding: Pain or weakness suggests a supraspinatus tendon tear or tendonitis.
  5. Drop Arm Test
    • Performance: The patient abducts the arm to 90 degrees and slowly lowers it.
    • Positive Finding: Inability to control the arm descent or severe pain indicates a rotator cuff tear.
  6. Apprehension Test
    • Performance: With the patient’s arm in 90 degrees of abduction and the elbow flexed, the examiner slowly externally rotates the shoulder.
    • Positive Finding: Patient shows apprehension or discomfort, indicating anterior shoulder instability.
  7. Relocation Test
    • Performance: Following a positive apprehension test, the examiner applies posterior pressure to the humeral head.
    • Positive Finding: Relief of apprehension or pain indicates anterior instability.
  8. Sulcus Sign
    • Performance: The examiner pulls down on the patient’s elbow or wrist while the arm is at the patient’s side.
    • Positive Finding: A visible sulcus or depression inferior to the acromion suggests inferior shoulder instability.
  9. Speed’s Test
    • Performance: The patient’s arm is extended and supinated. The examiner resists shoulder flexion.
    • Positive Finding: Pain in the bicipital groove indicates biceps tendonitis.
  10. O’Brien’s Test
    • Performance: The patient’s arm is flexed to 90 degrees, adducted 15 degrees, and internally rotated. The examiner applies downward force; the test is repeated with the arm in external rotation.
    • Positive Finding: Pain or clicking inside the shoulder in internal rotation, relieved in external rotation, suggests a SLAP lesion.

Elbow Special Tests

  1. Valgus Stress Test
    • Performance: The patient’s elbow is flexed to 20-30 degrees. The examiner applies a valgus (inward) force to the elbow.
    • Positive Finding: Pain or excessive gapping indicates a medial collateral ligament (MCL) injury.
  2. Varus Stress Test
    • Performance: The patient’s elbow is flexed to 20-30 degrees. The examiner applies a varus (outward) force to the elbow.
    • Positive Finding: Pain or excessive gapping indicates a lateral collateral ligament (LCL) injury.
  3. Cozen’s Test
    • Performance: The patient makes a fist, pronates the forearm, and extends the wrist. The examiner stabilizes the patient’s elbow and resists wrist extension.
    • Positive Finding: Pain over the lateral epicondyle indicates lateral epicondylitis (tennis elbow).
  4. Mill’s Test
    • Performance: The examiner palpates the lateral epicondyle while pronating the patient’s forearm, fully flexing the wrist, and extending the elbow.
    • Positive Finding: Pain over the lateral epicondyle indicates lateral epicondylitis.
  5. Maudsley’s Test
    • Performance: The examiner resists extension of the patient’s third digit distal to the proximal interphalangeal joint, stressing the extensor digitorum muscle and tendon.
    • Positive Finding: Pain over the lateral epicondyle indicates lateral epicondylitis.
  6. Tinel’s Sign at the Elbow
    • Performance: The examiner taps over the ulnar nerve at the medial epicondyle.
    • Positive Finding: Tingling or paresthesia along the ulnar nerve distribution indicates ulnar nerve entrapment.
  7. Elbow Flexion Test
    • Performance: The patient fully flexes the elbow, extends the wrist, and holds this position for 3-5 minutes.
    • Positive Finding: Tingling or paresthesia along the ulnar nerve distribution indicates ulnar nerve entrapment.

Wrist Special Tests

  1. Phalen’s Test
    • Performance: The patient flexes the wrists maximally and holds the backs of the hands together for 60 seconds.
    • Positive Finding: Tingling or numbness in the median nerve distribution indicates carpal tunnel syndrome.
  2. Tinel’s Sign at the Wrist
    • Performance: The examiner taps over the median nerve at the wrist.
    • Positive Finding: Tingling or paresthesia in the median nerve distribution indicates carpal tunnel syndrome.
  3. Finkelstein’s Test
    • Performance: The patient makes a fist with the thumb inside the fingers. The examiner stabilizes the forearm and ulnarly deviates the wrist.
    • Positive Finding: Pain over the radial styloid process indicates De Quervain’s tenosynovitis.
  4. Allen’s Test
    • Performance: The patient makes a fist several times to “pump” blood out of the hand. The examiner occludes the radial and ulnar arteries, then releases pressure on one artery while observing blood return to the hand.
    • Positive Finding: Delayed or absent blood return indicates compromised blood flow in the tested artery.
  5. Watson (Scaphoid Shift) Test
    • Performance: The examiner grasps the patient’s wrist and applies pressure to the scaphoid tubercle while moving the wrist from ulnar to radial deviation.
    • Positive Finding: Pain, a clunk, or a scaphoid shift indicates scapholunate instability.
  6. Grind Test
    • Performance: The examiner grasps the patient’s thumb, applies axial compression, and rotates the thumb’s metacarpal.
    • Positive Finding: Pain or crepitus in the carpometacarpal joint indicates osteoarthritis.
  7. Froment’s Sign
    • Performance: The patient attempts to grasp a piece of paper between the thumb and index finger while the examiner tries to pull it away.
    • Positive Finding: Flexion of the thumb’s interphalangeal joint indicates ulnar nerve palsy.

Hip Special Tests

  1. FABER (Patrick’s) Test
    • Performance: The patient lies supine. The examiner places the foot of the tested leg on the opposite knee (hip flexion, abduction, and external rotation) and gently presses down on the knee.
    • Positive Finding: Pain in the hip or sacroiliac joint indicates pathology in these areas.
  2. FADIR Test
    • Performance: The patient lies supine, the examiner flexes, adducts, and internally rotates the hip.
    • Positive Finding: Pain indicates femoroacetabular impingement (FAI).
  3. Trendelenburg Test
    • Performance: The patient stands on one leg. The examiner observes the pelvis.
    • Positive Finding: Pelvic drop on the unsupported side suggests gluteus medius weakness on the standing leg side.
  4. Thomas Test
    • Performance: The patient lies supine, the examiner flexes one hip to the chest while the other leg remains extended.
    • Positive Finding: If the extended leg rises off the table, it indicates hip flexor tightness.
  5. Ober’s Test
    • Performance: The patient lies on the side with the lower leg flexed. The examiner abducts and extends the upper leg, then slowly lowers it.
    • Positive Finding: If the leg does not adduct past horizontal, it indicates iliotibial band tightness.
  6. Scour Test
    • Performance: The patient lies supine, the examiner flexes the hip and knee, and applies axial compression while moving the hip through adduction and abduction.
    • Positive Finding: Pain or a grinding sensation indicates intra-articular hip pathology.
  7. Log Roll Test
    • Performance: The patient lies supine, and the examiner rolls the leg internally and externally.
    • Positive Finding: Increased pain or clicking may indicate hip joint pathology.

Knee Special Tests

  1. Lachman Test
    • Performance: The patient lies supine with the knee flexed to 20-30 degrees. The examiner stabilizes the femur with one hand and pulls the tibia anteriorly with the other hand.
    • Positive Finding: Excessive anterior translation of the tibia indicates an ACL tear.
  2. Anterior Drawer Test
    • Performance: The patient lies supine with the knee flexed to 90 degrees. The examiner pulls the tibia anteriorly.
    • Positive Finding: Excessive anterior movement of the tibia indicates an ACL tear.
  3. Posterior Drawer Test
    • Performance: The patient lies supine with the knee flexed to 90 degrees. The examiner pushes the tibia posteriorly.
    • Positive Finding: Excessive posterior movement of the tibia indicates a PCL tear.
  4. McMurray’s Test
    • Performance: The patient lies supine. The examiner flexes the knee and then rotates the tibia internally and externally while extending the knee.
    • Positive Finding: A click or pain during the maneuver indicates a meniscal tear.
  5. Apley’s Compression Test
    • Performance: The patient lies prone with the knee flexed to 90 degrees. The examiner applies downward pressure on the heel while rotating the tibia.
    • Positive Finding: Pain or clicking indicates a meniscal tear.
  6. Valgus Stress Test
    • Performance: The patient lies supine. The examiner applies valgus (inward) force to the knee while the leg is slightly flexed.
    • Positive Finding: Pain or excessive gapping indicates MCL injury.
  7. Varus Stress Test
    • Performance: The patient lies supine. The examiner applies varus (outward) force to the knee while the leg is slightly flexed.
    • Positive Finding: Pain or excessive gapping indicates LCL injury.
  8. Patellar Apprehension Test
    • Performance: The examiner applies lateral force to the patella with the knee flexed to 30 degrees.
    • Positive Finding: Apprehension or pain indicates patellar instability.
  9. Thessaly Test
    • Performance: The patient stands on one leg, flexes the knee to 20 degrees, and rotates the body internally and externally.
    • Positive Finding: Pain or locking/clicking in the knee suggests a meniscal tear.

Ankle Special Tests

  1. Anterior Drawer Test
    • Performance: The patient sits with the knee flexed and the foot relaxed. The examiner stabilizes the tibia and pulls the calcaneus forward.
    • Positive Finding: Excessive forward movement of the talus indicates anterior talofibular ligament injury.
  2. Talar Tilt Test
    • Performance: The patient sits with the foot hanging off the table. The examiner inverts the foot.
    • Positive Finding: Excessive inversion suggests a calcaneofibular ligament injury.
  3. Thompson Test
    • Performance: The patient lies prone with their feet hanging off the edge of the table. The examiner squeezes the calf muscle.
    • Positive Finding: Absence of plantar flexion indicates Achilles tendon rupture.
  4. Homan’s Sign
    • Performance: The patient’s knee is slightly flexed. The examiner dorsiflexes the foot and squeezes the calf.
    • Positive Finding: Pain in the calf suggests deep vein thrombosis.
  5. Squeeze Test
    • Performance: The examiner squeezes the tibia and fibula together at the mid-calf.
    • Positive Finding: Pain in the distal tibiofibular syndesmosis indicates a syndesmotic injury.
  6. External Rotation Test
    • Performance: The patient sits with the knee flexed to 90 degrees. The examiner stabilizes the leg and externally rotates the foot.
    • Positive Finding: Pain in the syndesmosis area indicates a syndesmotic injury.
  7. Tinel’s Sign
    • Performance: The examiner taps over the posterior tibial nerve.
    • Positive Finding: Tingling or paresthesia along the nerve distribution indicates tarsal tunnel syndrome.

These descriptions provide a detailed guide for performing each test and interpreting the results, helping in diagnosing various musculoskeletal conditions.