MODULE 15

Learning objective

1. The student is able to perform screening musculoskeletal examination GALS (gait, arms, legs and spine).

2. The student is able to record the findings from GALS examination. 3. The student is able to perform shoulder examination 4. The student is able to perform knee examination 5. The student is able to perform hip examination 6. The student is able to perform leg examination

GALS assessment

In combination with supervised accredited practice the successful student should be to

able to perform a GALS assessment of the musculoskeletal system

Gait Arms Legs Spine

The GALS screening examination is a fast and efficient way to assess the integrity of the musculoskeletal system. It is not meant to be a diagnostic examination - but a brief screening examination for significant abnormality of the musculoskeletal system If any abnormality is detected then a more detailed regional examination should be carried out. An assessment of the musculoskeletal system should always take place in the routine clerking in of patients.You will have an opportunity in the CSEC to practice carrying out a GALS assessment.

Clinical skill : Physical examination

Screening questions for musculoskeletal disorders

1. Do you have any pain or stiffness in your arms, legs or back? 2. Can you walk up and down stairs without difficulty? 3. Can you dress yourself in everyday clothes without any difficulty?

Screening examination for musculoskeletal disorders

Gait

Ask the patient to walk a few

steps, turn & walk back.

Observe the patients gait for symmetry, smoothness and the ability to turn quickly.

With the patient in the anatomical position inspect

from the posterior, lateral and anterior aspects.

Observe for any abnormalities in the muscles (e.g. reduced muscle bulk), spine (e.g. abnormal spinal

curvature such as scolosis), limbs or joints (e.g. a red swollen knee)

Spine

Inspection

Inspect the spine for any abnormalities including abnormal kyphosis, scolosis or loss of lordosis.

Neck movements

Ask the patient to tilt their head to each side, brining the ear towards their shoulder. Assess the degree of

lateral neck flexion.

Lumbar spine movement

Ask the patient to bend forward and touch their toes. During this movement the patient may depend partly

on good hip flexion to bend forwards. So it is always a good idea to palpate for the range of lumbar

movement. Place two fingers over the lumbar vertebra. As the patient bends forward your fingers

should move apart (assuming the patient has a good range of lumbar spine movement)

Arms

Ask the patient to place their hands behind their head,

Shoulder movements

with their elbows back This movement assesses abduction, external rotation of the shoulder and elbow

flexion.

Elbow movements & hands

Ask the patient to extend their arms fully and turn their hands over so palms are down.

Following this ask the patient to turn their hands over.

Observe the hands for any joint swelling or deformities

Click here to see some interesting clinical cases

Grip strength

Ask the patient to make a fist. Observe the hand and finger movements

Ask the patient to grip your fingers and assess the degree of grip strength

Precision pinch

Ask the patient in turn to bring each finger in turn to meet the thumb

Metacarpalphalangeal squeeze test

Squeeze across the metacarpalphalangeal joints (tenderness here may indicates synovitis of

metacarpalphalangeal joints)

Click here to see some interesting clinical cases

Leg

Knee movements

With the patient lying on the couch assess flexion and extension of both knees. Make sure to palpate the

knee for crepitus

Hip movement

Hold the knee & hip flexed to 90 degrees. Now assess the degree of internal rotation in each hip

Patellar tap test Perform a patellar tap in each knee for the presence

of an effusion

Inspection of feet Inspect the feet for any swelling, deformity or any

callosities

http://www.qub.ac.uk/cskills/hands(rheumatology).htmhttp://www.qub.ac.uk/cskills/feet(rheumatology).htm

Metacarpalphalangeal squeeze test

Squeeze across the metatarsophalangeal joints for any tenderness

Record Record your findings

Skill Shoulder examination

Learning outcome

To be able to i) identify surface anatomy of the shoulder ii) examine a patients shoulder & iii) compare left and right shoulders.

Background

The shoulder joint is the most mobile joint in the body, allowing the hand to be placed into a position where it can operate efficiently. To achieve its range of mobility, the shoulder is dependent for stability on surrounding soft tissue structures, in particular a group of muscles called the rotator cuff. The two main bones of the shoulder are the humerus and the scapula. The joint cavity is cushioned by articular cartilage covering the head of the humerus and face of the glenoid. The scapula extends up and around the shoulder joint at the rear to form a roof called the acromion, and around the shoulder joint at the front to form the coracoid process. The end of the scapula, called the glenoid, meets the head of the humerus to form a glenohumeral cavity that acts as a flexible ball-and-socket joint. The joint is stabilized by a ring of fibrous cartilage surrounding the glenoid called the labrum. Ligaments connect the bones of the shoulder, and tendons join the bones to surrounding muscles. The biceps tendon attaches the biceps muscle to the shoulder and helps to stabilize the joint. A group of short muscles originate on the scapula and pass around the shoulder where their tendons fuse together to form the rotator cuff. Movements of the shoulder joint are dependent on five functional areas: glenohumeral joint; the acromioclavicular joint; the subacromial joint between the acromioclavicular arch above and the head of the humerus below; the sternoclavicular joint and the scapulothoracic region. Shoulder pain can arise from a number of sites including: the rotator cuff tendons, biceps tendon, subacromial bursa, glenohumeral joint, acromioclavicular joint & the sternoclavicular joint.

Procedure INTRODUCTION, PATIENT IDENTIFICATION & CONSENT

HAND WASHING

EXPOSURE When examining a patients shoulder, their upper garments should be removed. This will also provide an opportunity to observe the patients shoulder function.

INSPECTION Observe both shoulder areas from the anterior, lateral and posterior aspects. Observe for any scars, swelling, erythema, muscle wasting or abnormal contours.

Example of a scar in a patient who has received shoulder surgery.

PALPATION Prior to palpating the patients shoulders, ask if they are experiencing any pain. It is often useful to have the patient point to the site where they are experiencing discomfort. Equally you should instruct the patient to inform you if they experience any pain during the examination.

During palpation observe for any signs of tenderness, swelling, temperature or crepitus.You should palpate both shoulder joints in a systematic approach. A suggested approach would be:

1) Sternoclavicular joint 2) Clavicle

3) Acromioclavicular joint 4) Humeral head

5) Coracoid process 6) Deltoid muscle

7) Spine of scapula 8) Supraspinatus muscle 9) Infraspinatus muscle 10) Trazpezus muscle

(then repeat on the other side)

MOVEMENT

Note! Remember in assessing the patients range of shoulder movements you should always compare one side

with the other.

When assessing movement in a patients shoulder joint you should assess: Active movements (i.e. movements performed by the patient on their own) Passive movements (i.e. movements performed by the examiner) Resisted movements (i.e. movements against resistance)

A general rule of thumb is that reduced active movements, that improve on passive movement, suggest muscular / tendon problems. Reduced range of both active and passive movements suggest intra-articular disease.

The range of movements that we assess for in the shoulder joint include:

Flexion Extension Abduction Adduction

Internal rotation External rotation

Tip! To have the patient perform the various range of shoulder movements try not to use medical jargon (e.g. Abduct your shoulder please!). Stand in front of the patient, face to face, and ask them to copy the movements that you make (assuming that your shoulders have a normal range of movement!) - this can make patient

understanding of your instructions a lot easier.

ACTIVE MOVEMENTS:

Active shoulder flexion

Have the patient flex their elbows to 90 degrees, then ask the patient to move their arms upward as high as possible.

(Normal range - usually 180 degrees)

Active shoulder extension

Have the patient flex their elbows to 90 degrees, then ask the patient to move their arms backwards as far as possible.

(Normal range ~ usually 50 degrees)

Active shoulder abduction

With the elbows fully extended, ask the patient to bring their arms away from their body.

(Normal range ~ usually 180 degrees)

Active shoulder adduction

With the elbows fully extended have the patient place their arms across their trunk.

(Normal range ~ usually 45 degrees)

Active shoulder external rotation

With the elbows flexed to 90 degrees, have the patient pin their elbows to their side. Now ask them to move there arms out as far as possible

(Normal range ~ usually 90 degrees)

Alternatively you may ask the patient to place their hands behind their

head, with their elbows far back as possible.

Active shoulder internal rotation

Again with the patients elbows flexed to 90 degrees and their elbows pinned to their side, have the patient bring their arms to their centre

(Normal range ~ usually 50 degrees)

Alternatively you may ask the patient to place their thumbs up their back and try to touch their back as high as possible

PASSIVE MOVEMENTS:

Prior to passive movements it is important to have your patient relax as best as possible.

Passive shoulder flexion

Flex the patients elbow to 90 degrees, then move their arm upward as high as possible. (Repeat on the other side)

(Normal range ~ usually 180 degrees)

Passive shoulder extension

Flex the patients elbow to 90 degrees, then move their arm backwards as far as possible (Repeat on the other side)

(Normal range ~ usually 50 degrees)

Passive shoulder abduction

Fully extend the patients elbow. The examiner shoulder place a hand on the patients scapula to fix it in that position. Now move the patients arm away from their body. By fixing the scapula, allows assessment of the

glenohumeral joint only. The normal range of movement here should be approx 90. By taking your hand of the patients scapula, should now

allow for scapulothoracic movement which normal can bring the arm up to 180 degrees. (Repeat on the other side)

Passive shoulder adduction

Fully extend the patients elbow, and then place their arm across their trunk as far as possible. (Repeat on the other side)

(Normal range ~ usually 45 degrees )

Passive shoulder external rotation

Flex the patients elbow to 90 degrees and pin their elbow to their side. Now move there arm out as far as possible. (Repeat on the other side)

(Normal range ~ usually 90 degrees )

Passive shoulder internal rotation

Again with the patients elbow flexed to 90 degrees and their elbow pinned to their side, move their arm to their centre. (Repeat on the other

side)

(Normal range - usually 50 degrees )

Depending on your clinical findings you may want to perform resisted movements. This will be covered in the CSEC & in your clinical attachments

When making an assessment of a patients shoulder there are many other special tests / manoeuvres that can be performed. They will not be discussed here.

You may also consider examining the patients peripheral neurological system in the upper limbs and circulation status.

EXAMINATION OF OTHER AREAS

Remember there are many other conditions that can cause shoulder pain (e.g. pain radiating from the neck, gallbladder disease, cardiac pain) so depending on the circumstances you may want to perform other relevant clinical examinations.

Skill Knee examination

Learning outcome To be able to i) identify surface anatomy of the knee & ii) examine a patients knee

Back ground

Knee pain can be a source of significant disability & health care utilization. Around 4.5 million people in the UK have severe knee pain. Because of our ageing population & increasing levels of obesity, the number of patients with disabling knee pain is set to increase. In order to make an accurate diagnosis of a patients knee pain a thorough physical examination needs to take place including

i) a careful inspection of the knee ii) palpation of the knee

iii) assessment for joint effusion

iv) range-of-motion testing v) evaluation of ligaments for any signs of injury or laxity

vi) assessment of the menisci

PROCEDURE

Introduction Introduction & patient consent

Hand hygiene

Hand washing

Exposure Make sure that both knees are fully exposed. The patient

should be in either a gown or shorts. Rolled up trouser legs generally does not provide adequate exposure.

Inspection Observe the patient both walking and standing. Do they

walk with a limp or appear to be in pain? Is there any evidence of muscle wasting?

Is there any evidence of bowing (varus) or knock-kneed

(valgus) deformity?

A patient with genu varum

(Varus deformity of the knee) due to osteoarthritis

Any scars present?

Recent scar & staples after a total knee

replacement

Does the knee appear red or swollen?

A patient with prepatellar bursitis

Any rashes present?

A patient with psoriasis

Palpation

For this part of the examination place the patient on the bed. If the patient has an injured knee, start by examining

the unaffected side. This allows for comparison while gaining the patients confidence, given that you are not

causing discomfort right from the outset of the examination. Remember that in all parts of the knee

examination, always compare one knee with the other.

Feel systematically around the knee joint for tenderness including the patella, quadriceps tendon, prepatellar &

collateral ligaments. Bend the knee to 90 degrees & feel around the medial & lateral joint lines for tenderness.

Remember to feel at the back of the knee for a popliteal (Bakers cyst) With the back of your hand do you feel an

increased temperature compared to the other knee?

Palpate knee for temperature

Palpate around joint margins

Assess for an effusion

Patellar tap test :

Slide your hand down the patients thigh, pushing down over the suprapatellar pouch, so that any effusion is forced behind the patella. When you reach the upper pole of the

patella, keep your hand there and maintain pressure. Using the index & middle finger of the other hand push the

patella down gently. Does it bounce? If so this may indicate the presence of an

effusion.

Milk the suprapatellar pouch

Patella tap

Bulge test:

Using your thumb and index finger - milk down any fluid

from above the knee. Keep this hand in this position.

Now with the other hand stroke the medial side of the knee to empty the medial compartment of fluid then stroke the lateral side. Observe the medial side of the knee for any

bulging? This may indicate an effusion.

Applying pressure to the medial side of

the knee

Applying pressure to the lateral aspect of the knee and observing for any bulging on

the medial side of the knee

Movement

The normal range of motion of the knee is from: 0 degrees

(Extension) to approx 135 degrees (Flexion)

Active movement Ask the patient to fully bend (flex) then straighten (extend) their knee. Always compare the range of movement with

the other knee. Is there any reduced range of movement?

Active flexion of the knee

Passive movement Place one hand on the patients knee and then with the

other hand flex (bend) the knee as far as possible & then extend the knee. With the hand that is placed over the

knee do you feel a 'grinding' sensation? Such a grinding sensation (crepitus) is usually indicative of degenerative knee disease (osteoarthritis) which reflects a loss of the

normal smooth movement between the articulating structures (i.e. femur, tibia, and patella).

Passive flexion of the knee

Special tests

Collateral ligament

assessment

Medial Collateral Ligament:

Cradle the patients lower leg between your arm and body. The knee should be flexed to 30 degrees. Now with your

other hand apply valgus stress to the knee joint. Excessive movement indicates ligament damage.

Lateral Collateral Ligament

Cradle the patients lower leg between your arm and body. The knee should be flexed to 30 degrees. Now with your

other hand apply varus stress to the knee joint. Excessive movement indicates ligament damage.

Cruciate ligament

assessment

Anterior Cruciate Ligament The integrity of the anterior cruciate ligaments can be

assessed using the anterior draw test. Have your patient assume the supine position with their knee flexed to

approx 90 degrees. After checking if the patient does not have a sore foot, fix the patient's foot by sitting on their

foot, in order to stabilize the lower leg. With the patient's hamstring muscles relaxed, wrap your fingers around the

back of the knee, keeping your thumbs in front of the patella. Now pull anteriorly. In a relaxed normal patient there is usually a small degree of movement. Excessive

movement may be indicative of anterior cruciate ligament injury.

Posterior cruciate ligament Simply repeat the process as for anterior draw test but

instead of pulling - push the patients lower leg. Excessive movement in the posterior plane may be indicative of

posterior cruciate ligament injury.

Stablizing the patients lower leg

Assessing for any excessive anterior &

posterior movement

Menisci

There are several special tests to assess the integrity of the menisci. In Apley's grind test place the patient in the prone position. Now flex their knee to 90 degrees. Using

your one hand to stabilize their lower leg, grip the patients heel with your other hand. Now gently push down while

rotating the ankle back and forth. A grinding sensation or pain may be indicative of meniscal damage. Another test is McMurrays test which will be covered at a later date in

your course.

Apley's grind test

Skill

Spine examination

Learning outcome

In combination with supervised accredited practice the successful student

should be able to perform an assessment of a patients spine.

Background

Disorders of the spine are the commonest form of musculoskeletal conditions that present in clinical practice. Lower back pain affects 4 out of 5 people at

some time in their lives and has a major impact in terms of morbidity, disability, socioeconomic burden & lost days at work. Vital to the examination of the

spine is to have a good knowledge of the anatomy of this area.

1= Vertebral body

2= Vertebral foramen

3= Spinous process

4= Pedicle

5= Superior articular process

6= Transverse process

7= Lamina

1= Cervical lordosis 2=Thoracic kyphosis 3= Lumbar lordosis 4= Sacral kyphosis

1="Vertebra prominens" Spinous process of C7 2= 2nd Lumbar vertebra 3= L4-5 inter vertebral space 4= Iliac crests 5= Dimples of Venus / Sacroiliac joints

Examination of the spine

Introduction

Introduce your self to the patient, identify the patient's details and gain informed consent.

Patient instructions

Ask if they are in any pain, and to inform you if they experience any

discomfort during the examination. Exposure of spine- remove upper garment; ideally should be wearing shorts or an examination gown.

Hand washing

Wash hands prior to examination

Inspection

Inspection

While the patient is removing their garments, use this opportunity to

observe the patient performing this activity of daily living. Any difficulties observed?

Gait

Ask the patient to walk several yards, turn around and then walk back. Observe their gait carefully. Is there easy following movement? Is there symmetrical movement? Is there a normal gait cycle from heel strike to

toe off? Do you observe an Antalgic gait? (where pain or deformity causes the patient to hurry off one leg and to spend most of the gait

cycle on the other. May suggest abnormality in one region e.g. lumbar spine or hip)

From behind and in front

Orientate your self to the patients surface anatomy. Observe the patients posture. How do they hold their neck?

Do they have a straight spine or do you detect a scoliosis (click here for more information on scoliosis) or rib cage

asymmetry?

Is there normal muscle bulk? Do they have any scars from previous spinal

surgery?

http://www.schneiderchildrenshospital.org/peds_html_fixed/peds/orthopaedics/scolio.htm

From the side

Is there loss of the normal cervical and lumbar lordosis (Click here for more

information on abnormal kyphosis)? No you notice any alteration of the normal

mild thoracic kyphosis?

Palpation

Palpation:

Gently palpate over the spinous process from the cervical region down. Is there any tenderness (if so this may

indicate local pathology in that vertebra).

http://www.nlm.nih.gov/medlineplus/ency/imagepages/9499.htm

The facet joints may be palpated laterally to the spinous processes and further lateral, the paraspinal muscles.

Movement

Observe for any restricted movements, smoothness of movement and for any pain experienced during movements. In addition to your verbal patient instructions, you may want to demonstrate these movements to

the patient.

Cervical spine

Cervical spine

Cervical spine flexion Touch your chin on your chest

Cervical spine extension Look up and back

Lateral cervical spine flexion Touch your shoulder with your ear

(Both sides) (Not bringing their shoulder up to their

ear!)

Lateral cervical rotation (Both sides) Touch your shoulder with your chin

Thoracolumbar

Lumbar flexion Try to touch your toes without bending

knees

Lumbar extension Lean back

Lateral lumbar flexion (Both sides) Slide your hand down your leg

Thoracolumbar rotation Sit down and turn round, looking over

your shoulder

(Sitting down helps fix the patients pelvis)

Other tests

Schober's test

In lumbar spine flexion, hip flexion can compensate to a considerable extent for a loss of spinal flexion. You may

want to consider performing Schobers test to objectively measure the degree

of spinal flexion. Firstly identify the Dimples of Venus (2). Now in the

midline, use a tape measure and pen to mark a point 10cm superior (1) to, and an other mark 5 cm inferior (3) to this

point.

Ask the patient to attempt to touch their toes (i.e Flexing their lumbar

spine).The distance between these two marks should be measured when the patients spine is flexed maximally.

The distance should increase to more than 21cm in a normal patient. A

modified way to demonstrate lumbar spine flexion is to place several fingers

over the lower lumbar spinous processes and ask the patient to bend

forward and touch there toes as best as possible. In a normal spine your fingers

should move part.

Other tests

Given the close proximity of the spine and the spinal cord and nerve

roots it is very important to consider performing a peripheral neurological examination, together with some special nerve root

stretch tests. In the CSEC and your attachments you will learn further information about conditions such as Sciatica and cauda equina (Click

here for further information)

Straight leg raising (SLR):

With the patient supine, the examiner uses their arm to fix the pelvis. The

patient then attempts to raise one leg at a time, with the knee fully extended.

Make an assessment of the degree of movement from the horizontal. Repeat

other on the other side.

Lasegues test:

Is a refinement of the SLR test. It aims to assess the limitation of movement

due to sciatic nerve root pressure. When the limit of SLR is reached,

dorsiflexion of the ankle produces acute accentuation of pain. Conversely asking

the patient to bend their knee should relieve the pain.

http://www.emedicine.com/emerg/topic85.htm

Femoral stretch test:

Have the patient lie prone. Passively flex the knee as far as it goes. In a positive test the patient should feel pain in the ipslateral anterior thigh (i.e. the distribution of the femoral nerve) Also pain may be exacerbated on hip extension.

Peripheral nerve

examination:

Consider performing a perpherial nerve examination, including

assessment of saddle sensation and anal tone if clinically required.

Sacroiliac joints:

Are difficult to assess. They have minimal movement. Pain may be

induced on compression of the pelvis or by distracting it by flexing the hip & knee and forcibly, adducting the leg across to the contra lateral

iliac fossa.

Abdominal examination:

Several intrabdominal conditions can present as back pain (e.g

abdominal aortic aneurysm, acute pancreatitis) therefore it may be worthwhile considering performing an abdominal examination.

Skill

Hip examination

Learning outcome

The successful student should be able to perform a clinical

examination of the hip joint.

Background

The hip is a synoviumlined ball and socket joint that plays a major role in weight bearing and locomotion. Its stability is due to the relatively deep insertion of the femoral head into

the acetabulum and the strong capsule and surrounding muscles. To properly examine the hip joint a good

anatomical knowledge of this area is vital. For further reading about hip anatomy click here for link.

Some bony anatomical areas worth noting:

1) Anterior superior iliac spine 2) Anterior inferior iliac spine

3) Pubic tubercle 4) Pubic symphysis

5) Superior pubic ramus 6) Inferior pubic ramus 7) Greater trochanter 8) Lesser trochanter

9) Femur 10) Head of femur 11) Ischial spine

12) Ischial tuberosity 13) Sacroiliac joint

14) Posterior inferior iliac spine 15) Crest of ilium

http://www.bartleby.com/107/57.html

Procedure

Procedure

INTRODUCTION, PATIENT IDENTIFICATION & CONSENT

HAND WASHING

EXPOSURE Expose the patient's legs by asking the patient to undress down to their underwear.

INSPECTION i) Standing: Observe the patient from all sides with the patient standing stationary. Inspect for the level of the iliac crests. Now have the patient walk to the other side of the room, turn around and walk back. Observe the patients gait and pelvic movements. In a Trendelenburg gait the pelvis on the opposite drops and the body leans away from the affected side, when weight bearing is on the affected hip.

ii) Lying supine: Have the patient lie supine on a couch. Are any scars present? Muscle wasting present? Is there any obvious discrepancy in leg length?

PALPATION Palpate around the hip area. Specifically is there any tenderness around the inguinal area and the greater trochanter area? Is there any tenderness? Heat? Swelling?

Measurement True length of the legs using a tape measurer measure the distance between the anterior iliac spine to the tip of the medial mallous, with the anterior spines lying at the same transverse level. Compare one side to the other.

Measuring the true length of the legs

The apparent length - is measured from the xiphisternum to the tip of the medial mallous, with the legs in a parallel position.

Measuring the apparent length of the legs

Note! When examining hip movements, the pelvis needs to be fixed in order to observe the range of movement in the hip joint and not the pelvis (i.e tilt and shift). Remember to

compare one side with the other.

MOVEMENT:

FLEXION Have the patient flex their knees & move their

hip joint into the flexed position as fair as possible.

(Normal range ~ 120 degree)

(If you keep the knee extended the range of movement in the hip joint is limited by tension in

the hamstring muscles)

ABDUCTION Make sure you stabilze the pelvis by placing a hand on the opposite anterior iliac crest and

holding the ankle with the other hand. The hip is abducted until the pelvis tilts.

(Normal range of movement ~ 45 degrees)

ADDUCTION Cross one leg over the other until pelvis begins

to tilt. (Normal range of movement ~ 30 degrees)

INTERNAL ROTATION Flex the hip and knee to 90 degrees. Now move

the leg laterally. (Normal range of movement ~ 45 degrees)

EXTERNAL ROTATION Again with the hip and knee flexed move the

patients leg medially. (Normal range of movement ~ 60 degrees)

EXTENSION Have the patient lie prone on the couch.

Immobilise the pelvis with one hand while extending the hip with the other hand.

SPECIAL TESTS:

i) THOMAS' TEST Thomas test Is used to detected a fixed flexion deformity in the hip. Place your hand behind the small of the patients back, between it and the couch. There is normally a small gap here due to normal lumbar lordosis. Abolish the lumbar lordosis by asking the patient to flex the hip and feel the lumbar spine flatten out onto your hand. When you are happy that the lumbar spine is flat, see if the patients other knee is flat on the couch. If not, measure the angle of (fixed) hip flexion. Then repeat the test asking the patient to clasp their other knee up against their chest and observe for fixed flexion deformity in the previously flexed hip.

ii) TRENDELENBURG TEST Detects weakness of the gluteus medius hip abductors. This can be due to true weakness as in neurological disease or wasting associated with hip arthritis or to painful reflex inhibition. In an adult the commonest cause of a positive test is osteoarthritis of the hip. Ask the patient to stand on each leg in turn. Observe the pelvis for any tilt. In normal individuals the pelvis will rise on the side of the leg that has been lifted. With instability, the pelvis may drop on the side of the leg that has been lifted. Repeat on the other side.

Standing on both legs

Normal - the pelvis rises on the side of the lifted leg

Abnormal - the pelvis drops on the side of the lifted leg.

Further reading

1. The Arthritis Research Campaign,2005. 2. Rheumatology Examination and Injection Techniques,2nd ed. M Doherty, BL

Hazleman, CW Hutton et al. WB Saunders. 3. Current Rheumatology Diagnosis & Treatment. J Imboden, DB Hellmann, JH

Stone. McGraw Hill,2005