year 2 mh linical skills session musculoskeletal examination · musculoskeletal examination...
TRANSCRIPT
Year 2 MBChB
Clinical Skills Session
Musculoskeletal Examination
Reviewed & ratified by:
Mr Lyndon Mason - Musculoskeletal System Lead
Mr Ashley Newton – Trauma & Orthopaedic
August 2018
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Musculoskeletal Examination
Objectives
Objective: To revise anatomy and physiology of the Musculoskeletal (MSK) system
Objective: To link the anatomy and physiology to the examination
Objective: To be able to perform a MSK examination including an understanding of the common abnormalities
Theory and background
Musculoskeletal examination involves assessment of how the bones, joints, tendons, ligaments and muscles work in conjunction with each other, assessing for abnormalities including deformities, swellings and abnormal posture can aid diagnosis.
General principles
Ensure the patient’s joints which are to be examined are fully exposed and that the patient is resting comfortably,
enabling the examiner to compare limbs and examine the joint above and below the affected area.
The routine for joint examination is:
o Inspection (look)
o Palpation (feel)
o Movement of joint(s) (move)
Indications for doing a Musculoskeletal examination
There are many reasons for performing a musculoskeletal (MSK) examination, if a patient presents with any of
the following; injury, pain, reduced range of movement etc. you would consider doing the examination. Arthritis
Research UK (2011) states that musculoskeletal disorders are the commonest disability cause in the UK. Only by
taking a comprehensive history in conjunction with an examination can you aim to make an accurate diagnosis
for a patient complaining of musculoskeletal problems.
Arthritis Research UK (2011, pg. 5) recommend considering five questions during the history, these are; “
o Does the problem arise from the joint, tendon or muscle?
o Is the condition acute or chronic?
o Is the condition inflammatory or non-inflammatory?
o What is the pattern of the affected areas/ joints/ joint spaces?
o What is the impact of the condition on the patient’s life?”
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Which joints to examine?
Examine the joint associated with the presenting complaint initially and then examine the joint above and below. This is to ensure that;
o Pain has not been referred from/ to another joint. o The weight has not been abnormally distributed on a joint because of problems with the joint above o The patient has not compensated by using another joint due to problems with another
If examination of all the joints is required, use a systematic approach, be aware that the patient may have to be in underwear only, especially if a spinal examination is required, inspection of the area while mobilising is important
Patient Safety
On first meeting a patient introduce yourself, confirm that you have the correct patient with the name and date
of birth, if available please check this with the name band and written documentation and the NHS/ hospital
number/ first line of address.
Check the patient’s allergy status, being aware of the equipment you will be using in your examination. Ensure
the procedure is explained to the patient in terms that they understand, gain informed consent and ensure that
you are supervised, with a chaperone available as appropriate. Don personal protective equipment as required,
especially if you are likely to come into contact with bodily fluids.
Be aware of hand hygiene and preventing the spread of disease, WHO (2018) http://www.who.int/infection-
prevention/tools/hand-hygiene/en/
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Inspection of the joint
Observe for the following;
Swellings
Skin changes
o colour - redness -
inflammation or infection
or darkened areas indicating
poor vascularisation
o scars, previous surgery
o rashes
Abnormality of adjacent structures
o muscles - wasting of muscles above and
below a joint often accompanies joint disease
o compare to opposite side
Deformity – acute or chronic
o misalignment of bones making up the
joint
o Valgus - distal part displaced laterally
o Varus - distal part displaced medially
Palpation of the joint
Neuro-vascular function
To ensure that the neuro-vascular function is intact you should check the limb distal to the injury for:
o A palpable pulse
o Evidence of a peripheral nerve injury e.g. loss of sensation and power in the radial nerve distribution
after a humeral fracture
o A normal capillary refill time on the affected limb, which is less than 2 seconds.
o Temperature
Compare each of the above on the opposite limb. Loss of neuro-vascular function should be classed as a
medical emergency, please seek senior clinician’s advice.
Palpation Feel for any swelling and its nature
o hard suggests bone o spongy or boggy suggests synovial thickening o fluctuance suggests an effusion (fluid) o the position of the swelling, is it in the joint(articular) or
periarticular Palpate for any tenderness and assess the joint margin, related ligaments, tendons and adjacent bony structures.
Olecranon Bursitis, inflammation of the bursae
in the elbow
This work has been released into the public domain by its
author, NJC123.
Arthritic changes to
knees, left total knee
replacement
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Whilst palpating assess for any changes in temperature, especially in comparison to the opposite limb, however if there is bilateral joint involvement compare the tissues above and below the joint. Crepitus Crepitus is described as grinding, creaking, grating, crunching or popping when a joint is moved. This may be felt over the joint as it moves, but may also be heard and occasionally seen. Crepitus is potentially caused by: Air bubbles popping in the joint (cracking knuckles) Tendons or ligaments snapping over bony structures, may cause pain Arthritis where articular cartilage has degenerated, may cause pain All above can be normal if occurs occasionally but if regular and accompanied by pain, swelling etc. it may indicate arthritis or other conditions. Please be aware that crepitus can be palpated after the patient has sustained 1 or more fractures of a bone. Joint movement
Assess the range of joint movement, this can be done actively or passively;
Active movement is movement undertaken by the patient alone
Passive movement is movement undertaken by the examiner
Please note, the spine should not be moved passively. However with all other joints, if a full range of
movement is demonstrated actively then passive is not required. If movement is impeded, passive
movement can help identify if the cause. Bear in mind that symptoms or signs may not always be caused by
the joint itself, but may be due to problems with bone, soft tissues, muscles or nerves. Some of these are
covered in previous study guides, like the Motor examination study guide.
Examination of muscles
Evidence of wasting - compare sides
(measure limb circumferences) has
there been muscle disuse, eg; from
removal of leg cast following
fracture, lower motor neurone
lesions or joint disease, or is it a
primary muscle disease?
Is there abnormal bulk, eg; with body
builders or muscular dystrophies?
Are there any spontaneous
contractions due to muscle spasms or
abnormal movements or
fasciculation?
If you palpate the muscle, is there
any tenderness? This could be from
acute injury or some myopathies.
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The anatomical/neutral position
Anatomical movements
Adduction - movement of the part distal to the joint towards the midline
Abduction - movement away from the midline
Flexion - bending of joint away from neutral position
Extension - movement to straighten a joint towards the neutral position
Hyperextension - occurs when the joint can be extended beyond the neutral position
Pronation - rotation of the forearm so that the palm faces backwards
Supination - rotation of the forearm so that the palm faces forwards
o The range of most movements are
described with the
anatomical/neutral position in mind
o In the anatomical/neutral position
the limbs are extended with the feet
dorsiflexed to 90 degrees and the
palms facing forward
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Main anatomical movements Video
Please see prep from last year.
https://liverpoolclinicalskills.com/home/mbchb-students-2/year-1/elements-of-musculoskeletal-
examination-and-limited-mobility/musculoskeletal-examination-prep/
Examination of upper limb joints
Inspection and palpation of the hand and wrist joints, inspect both hands and wrists as one
Inspect the front, back and sides of all joints, comparing sides and palpating joints between finger and thumb,
don’t forget to support the joint whilst palpating, taking the weight of the patient’s limb where possible.
Interphalangeal joints (IP’s)
Palpate the interphalangeal joints individually between finger
and thumb
DIP is the distal interphalangeal joint
PIP is the proximal interphalangeal joint.
Metacarpophalangeal joints (MCP’s)
Use a similar technique to palpate the metacarpo-phalangeal
joints. With the patient’s palms facing down, support the palms
with your fingers. Place your thumbs on dorsal metacarpo-
phalangeal surface and gently palpate, observing for
abnormalities and pain.
Finger movements
o Flexion
o Extension
o Abduction
o Adduction
o Opposition
PIP
MCP
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It is always best to demonstrate movements first so that the patient understands what is required. If the patient
complains of pain or movement is limited, palpate during movement to note any palpable abnormalities such as
crepitus.
Ask the patient to make a fist (flexion and adduction of distal and proximal interphalangeal
and metacarpophalangeal joint). Then ask the patient to open their hand (extension and
abduction of interphalangeal and metacarpophalangeal joints).
Metacarpophalangeal and interphalangeal joints flex to 90 degrees, however
metacarpophalangeal joints may normally hyperextend to approx. 10 degrees. If the patient
is unable to do the above, break it down into flexion extension, adduction and abduction.
For demonstrating abduction, ask the patient to spread their fingers apart and for adduction
ask them to put them back together. For flexion ask them to bend into a fist and then
straighten hand out.
Thumb flexion and extension
Flexion occurs across the palm, the thumb needs to flex at the MCP and IP,
extension takes the thumb away from the lateral aspect of the palm, and
movement occurs at the MCP joint or metacarpophalangeal joint. Ask the
patient to slide thumb across palm (flexion), then slide the thumb across
palm out and away (extension).
Thumb abduction and adduction
Abduction occurs at 90° to the palm, whilst adduction returns the
thumb to the palm, this occurs at CMC joint, or carpometacarpal
joint.
Ask the patient to lift the thumb from the side of the palm so the
thumb is facing the ceiling (abduction), then bring the thumb to the
palm edge (adduction)
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Thumb opposition
The thumb is used to touch the base of the little finger, this movement is
important for fine manipulative skills.
Wrist joints
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With the patient’s palms facing down, support the palmar aspect of their
wrist with your fingers, place your thumbs on the dorsal wrist surface and
gently palpate, observing for abnormality or discomfort.
Movement of the wrist
Compare one wrist with the other, in appearance and whilst moving. The wrist movements are listed below;
o 1-Palmar flexion – approx. 75o
o 2-Dorsiflexion (extension) – approx. 75o
o 3-Ulnar flexion – approx. 20 o
o 4 -Radial flexion - approx. 20 o
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Movement of the forearm.
Isolate the forearm by asking the patient to put their arm against their body with the elbow bent or
asking the patient “bring your elbows into your sides”. Pronation is rotating the arm through 90
degrees so that the palm faces downwards. Supination is rotating the forearm so that the palm faces
upwards, observe for pain, discomfort or reduced range of movement.
Movement of the elbow
Flexion - is possible to approx. 150 degrees
Extension - returns the joint to the neutral position of 0 degrees
Pronation supination flexion extension.mp4
Inspection and palpation of the elbow joint
Inspect the elbow joint from the front, sides and behind
With the elbow flexed at around 70o palpate:
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Shoulder Movement
Shoulder movements;
o Flexion – 180o approx. 90o is attributable to the glenohumeral joint
o Extension – approx. 65o
o Abduction (1)
o Adduction (2)– consists of 2 parts, the 1st part is
glenohumeral joint movement and the 2nd is
principally due to scapular rotation
o Internal rotation – approx. 90o involves moving the flexed forearm across the front of the body.
The movement is limited by the chest wall
o External rotation – approx. 60o the flexed forearm is moved outwards
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Shoulder Movements – combined
You can combine all movements made by the shoulder joint by
asking the patient to put their hands behind their head (abduction,
flexion and external rotation) and then behind them in the small of
their back (adduction, extension and internal rotation)
These manoeuvres will demonstrate:
Flexion & extension
Internal & external rotation
Abduction & adduction
If the patient cannot do these manoeuvers then each movement
has to be assessed individually.
Inspection and palpation of the shoulder
Inspect the shoulder joint from the front, side and back. Inspect the shoulder contour for abnormalities
or inequalities in symmetry. Feel for tenderness and swelling, check for crepitus during motion (some
crepitus may be normal for that patient).
Palpate:
A. Sternoclavicular joint
B. Clavicle
C. Acromioclavicular joint
D. Acromial process
E. Head of humerus
F. Coracoid process
G. Greater tuberosisty of humerus
H. Spine of scapula (situated on the back of the
scapula)
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Movements of the spine
Observe the following movements;
o Flexion
o Extension
o Lateral Flexion right and left
o Lateral Rotation right and left
All movements of the spine are active and are NOT moved passively
Inspection and palpation of the spine
Ask the patient to undress down to their underwear, inspect
from the front, sides and behind ideally with patient sitting and
standing.
In particular inspect for:
o Pigmentations, abnormal hair growth (could indicate
spina bifida) or unusual skin creases (could indicate
abnormal alignment)
o Alignment of the neck and shoulder symmetry
o Kyphosis (thoracic spine curves giving a round
shouldered or hunched appearance)
o Lordosis (lumber spine curves pushing abdomen out,
seen in late stages of pregnancy)
o Scoliosis (thoracic and or lumbar spine curve laterally
forming an S or a C shape)
Palpation of the spine
Palpate the shoulder and neck muscles for tenderness
Palpate each of the spinal processes noting any prominence or steps
Palpate the paraspinal muscles for tenderness or spasm (this would feel firmer and
could indicate a herniated disc)
Palpate the sacroiliac joints for tenderness
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Cervical spine movements
Flexion - ask the patient to touch their chin to their chest, normal
flexion is about 45 degrees
Extension - ask the patient to look upwards and back, normal
extension is about 45 degrees
Lateral flexion - ask the patient to touch their ears to their shoulders,
without raising the shoulders, normal lateral flexion is approx. 45 degrees.
Then cervical rotation - ask the patient to look back over each shoulder in
turn, keeping the spine, or shoulders in the same position, normal
rotation is approx. 70 degrees.
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Thoracolumbar spine
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Modified Schober’s test
Modified Schober’s test is performed to measure the
ability of lumbar flexion. With the patient standing
upright, take note of the point between the Dimples
of Venus, some clinicians will place a finger or a
measuring tape on this point, (occasionally some will
draw this point however you have to gain consent for
this from the patient) then note a second spot 10cm
above the first.
Ask the patient to reach towards their toes as far as
they are able. The 10cm distance between the 2 spots/ lines should increase by more than 5 cm in the normal
person. The most common cause of decreased flexion tends to be ankylosing spondylitis, a positive modified
Schober’s test may indicate this.
Straight leg raise
If a patient complains of lower back pain, you may assess to see if the pain is caused by a herniated disc, this is
done by performing a straight leg raise. With the patient lying supine or on their back, the examiner lifts the
patient’s leg while the knee is straight.
If the patient experiences sciatic pain (pain radiates down sciatic nerve, often felt in the buttocks) when the
straight leg is at an angle between 30 and 70 degrees or the pain extends beyond the knee, the test is positive
and a radiculopathy (pinched nerve) or herniated disc is the most likely cause of pain.
Examination of lower limb joints
Movement of the Hip Joint
Flexion – approx. 115o
Extension – approx. 30o
Abduction – approx. 45o - Pain on abduction could be from a number of causes, including trochanteric bursitis,
or early hip pathology
Adduction – approx. 30o
Internal rotation – approx. 45o
External rotation – approx. 45o
Try to ensure that the patient does not tilt their pelvis when assessing the hip joint.
Inspection of the lower limb
The lower limbs bear the weight of the entire body. It is quite common for patients to present with problems
with a specific joint when it is an entirely different joint which is the root cause.
It is imperative that the lower limb is inspected as a whole and compared to the other leg, look for:
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o The position of the joints, the knee may externally rotate when a hip joint is broken or diseased for
example
o Muscle bulk, obvious deformity, scars and swellings etc.
o Pelvic tilting which can occur if the patient is trying to avoid weight bearing on the affected side, as
joints should be at the same level as one another.
Inspection and palpation of the hip joint
The hip joint is not visible externally, but inspect (ideally with patient standing) for any obvious deformities.
Palpation for joint tenderness is only possible just distal to the midpoint of the inguinal ligament also palpate
soft tissues around the area for tenderness.
Palpate bony prominences
such as anterior superior iliac
spine and iliac crest to ensure
they are anatomically
comparable. (In pelvic trauma,
do not disturb the pelvis as
this could lead to major
haemorrhage).
The sacro-iliac joint can cause
pain, and patients may
present complaining of hip or
lower back pain. This joint
should be checked to be ruled
out as the cause.
The joint can be palpated with
the patient lying on their
front;
For further information
regarding testing, please
explore SI Joint provocative
Tests,
eg https://si-bone.com/providers/diagnostic-resources/provocative-tests
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Movements of knee and ligaments
Movements of the knee joint and
ligaments are:
Flexion - approx. 135o
Extension -
Hyperextension – approx. 5o
Lateral and medial collateral
ligaments
Anterior and posterior cruciate
ligaments
Inspection and palpation of the
knee
Inspect the knee comparing knees
whilst the patient is supine and
standing. Observe for swellings,
which may only be detected by a loss
of the medial and or lateral dimples
suggestive of an effusion.
Palpate for:
o The presence and absence of
the patella and its mobility,
increased calcification is
common following knee
injury.
o Collateral ligaments
o The joint line for tenderness
Testing knee ligaments -
Please do not do any of these tests unless supervised by a competent clinician.
Assessing cruciate
ligaments
Drawer sign
Anterior and posterior
cruciate ligaments are
tested with the knee in 90
degrees of flexion
The foot is fixed (the
examiner may sit on it,
with the patient’s consent
to stabilize the leg).
Anterior cruciate ligament
is assessed by cupping the
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hands behind the lower limb, thumbs are placed on the tibial tuberosity and pulling forward, whereas the
posterior cruciate ligament is tested by pushing the tibial tuberosity back.
A Positive drawer sign
Movement of lower limb forward indicates a lax or torn anterior ligament (positive anterior drawer sign)
Movement of lower limb backwards indicates a lax or torn posterior ligament (positive posterior drawer sign).
Right medial collateral ligament assessment
With the knee flexed at 20o try to displace the lower limb medially,
5o of lateral movement in the lower limbs is normal.
Right collateral lateral ligament assessment
With the knee flexed at 20o try to displace the lower limb laterally
5o is medial movement in the lower limbs is normal.
These movements may also be done with the patient sitting and are dependent on room layout, patient comfort
and clinician preferences.
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McMurray’s test
The McMurray test is no longer recommended because of concerns that it exacerbates the injury and its low
diagnostic accuracy. See references (Hing et al 2009)
However, it is still performed by a considerable number of competent physicians for meniscal injury or a
degenerative tear. Therefore, knowledge of this test and how to perform it is required.
This is a specialist test that YOU will NOT perform unless you are an expert in this field.
With the patient supine the examiner holds the knee and palpates the joint line with one hand, thumb on one
side and fingers on the other, whilst the other hand holds the sole of the foot and acts to support the limb and
provide the required movement through range. The examiner then
applies a valgus stress to the knee whilst the other hand rotates the leg
externally and extends the knee.
Pain and/or an audible click while preforming this manoeuvre can indicate
a torn medial meniscus.
To examine the lateral meniscus the examiner repeats this process from
full flexion but applies a Varus stress to the knee and medial rotation to
the tibia prior to extending the knee once again.
Effusion
Joint effusions are commonly caused by injuries, infection or arthritis. It is an increase in the intra- articular fluid
and is most common in the knee. Moderate effusions are assessed by performing a patella tap, or a sweep test
please follow link for an example.
Physiotutors
Published on 10 Oct 2015
https://youtu.be/r18O50lzMGw
Movement of the ankle and foot
Movements of the ankle;
o Dorsiflexion
o Plantar flexion
o Inversion
o Eversion
Movements of the toes;
o Extension
o Flexion
Inspection and palpation of the ankle and foot
Inspect the foot including arches and ankles ideally with patient standing and more carefully with the patient
supine
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Look for, thickened areas of tissue, callous formation on the feet indicating abnormal gait
Look at the shoes for abnormal wear or stretching, palpate for tenderness particularly over bony
prominences placing thumbs on sole of foot and finger tips on dorsum, assess the metatarsophalangeal
joints by gently squeezing between index finger and thumb
A click sound or pain indicates a neuroma which is a build-up of fibrous tissue around the nerves of the
foot (Morton’s Neuroma).
Palpation of the ankle and foot.
Dorsiflexion and plantar flexion – occurs at the ankle joint
Ask the person to bend their foot down into plantar flexion - normal
approx. 50 degrees
Ask the person to bend the foot upwards into dorsiflexion - normal
approx. 20 degrees
If they can move actively there is no need to assess passively
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Eversion and Inversion – occurs at the subtalar joint
Isolate the heel by holding it firmly
Attempt inversion and eversion by twisting
the mid-foot medially and laterally.
Inversion & eversion is a sub talar joint
movement
If they can move actively there is no need to
assess passively
Movement of the Toes
Ask the patient to flex and extend the toes
Remember the big toe can usually move independently of the others, compare to the other side.
Trendelenburg test
This test is used to assess hip stability.
The patient is asked to stand on one leg then the other, normally the
non-weight bearing limb is elevated or remains level with the weight
bearing leg. In joint or muscle disease the non-weight bearing side
sags, or there is pain on the weight bearing side.
A ‘Negative’ Trendelenburg test is normal
PhysicalTherapyHaven https://www.youtube.com/watch?v=IuEeKzqsfmk
Physiotutors Published on 7 Nov 2015
https://www.youtube.com/watch?v=0rcczDEWDqU
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Measurement of leg length
Inequality of leg length can indicate gait abnormalities, ultimately resulting in
degenerative arthritis.
True leg length is measured from anterior superior iliac spine to medial
malleolus.
Apparent leg length is measured from the umbilicus to the medial malleolus
but true is the preferred method if imaging is not being used. (Sabharwal and
Kumar 2008)
True leg length differences are often due to hip disease on the shorter side. 1-
1.5cm difference is classed as normal, anything greater would be abnormal.
Documentation
Remember to document your findings referring to the joint or
area of the joint affected.
References and other Useful Resources
Doherty M et al (1992) Ann Rheum Dis 51:1165-1169
Hing, W., White, S., Reid, D., & Marshall, R. (2009). Validity of the McMurray's test and modified versions of the
test: A systematic literature review. Journal of Manual & Manipulative Therapy, 17(1), 22-35
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Newton, A. W., Tonge, X. N., Hawkes, D. H., & Bhalaik, V. (2019). Key aspects of anatomy, surgical approaches
and clinical examination of the hand. Orthopaedics and Trauma, 33(1), 1-13.
Sabharwal, S., & Kumar, A. (2008). Methods for assessing leg length discrepancy. Clinical orthopaedics and related research, 466(12), 2910-22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628227/ Sources and useful resources –
Clinical assessment of the musculoskeletal system:
www.arthritisresearchuk.org/health-professionals-and-students/student-handbook.aspx
NICE guidance, musculoskeletal conditions:
https://www.nice.org.uk/guidance/conditions-and-diseases/musculoskeletal-conditions
NICE guidance Knee pain
https://cks.nice.org.uk/knee-pain-assessment#!scenariorecommendation:7
Beighton Score
https://www.durbanrheumatologist.co.za/joint-hypermobility.php
Hip flexion-extension; Elson and Aspinall 2008
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2505147/
Morton’s Neuroma;
https://cks.nice.org.uk/mortons-neuroma
McMurrays Test. Wayne Hing, Steve White, Duncan Reid, and Rob Marshall (2009) Validity of the McMurray's
Test and Modified Versions of the Test: A Systematic Literature Review
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704345/
Glossary
Abduction Away from the midline
Adduction Toward the midline
Bursae Small sacs of synovial fluid in the body, aiding muscles or
. tendons to slide across the bone
Periarticular Around a joint
Pronation Palmer surface of the hand facing the floor
Supination Palmer surface facing upwards
Flexion Closing the angle of a joint
Extension Opening the angle of a joint
Inversion Turning in of the ankle in the midline
Eversion Turning out of the ankle away from the midline
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Internal rotation Rotation of a joint towards the body
External rotation Rotation of a joint away from the body