Musculoskeletal assessment

Editor's Notes

• #42 Gait Abnomalities
• #47 injuries to the legs, feet, brain, spine, or inner ear Propulsive gait -- a stooped, rigid posture, with the head and neck bent forward Scissors gait -- legs flexed slightly at the hips and knees, giving the appearance of crouching, with the knees and thighs hitting or crossing in a scissors-like movement Spastic gait -- a stiff, foot-dragging walk caused by one-sided, long-term, muscle contraction Steppage gait -- foot drop where the foot hangs with the toes pointing down, causing the toes to scrape the ground while walking Herniated lumbar disk Waddling gait -- a distinctive duck-like walk that may appear in childhood or later in life Hip dysplasia Spinal muscular atrophy
• #50 Stance widens as they try to steady themselves
• #53 Treatment    Return to top Treatment depends on the cause of the disorder: Congenital kyphosis requires corrective surgery at an early age. Scheuermann's disease is initially treated with a brace and physical therapy. Occasionally surgery is needed for large (greater than 60 degrees), painful curves. Multiple compression fractures from osteoporosis can be left alone if there is no neurologic problems or pain, but the osteoporosis needs to be treated to help prevent future fractures. For debilitating deformity or pain, surgery is an option. Kyphosis caused by infection or tumor needs to be treated more aggressively, often with surgery and medications. Treatment for other types of kyphosis depends on the cause. Surgery may be necessary if neurological symptoms develop. Expectations (prognosis)    Return to top Adolescents with Scheuermann's disease tend do well even if they need surgery, and the disease stops once they stop growing. If the kyphosis is due to degenerative joint disease or multiple compression fractures, correction of the defect is not possible without surgery, and improvement of pain is less reliable. Complications    Return to top Disabling back pain Neurological symptoms including leg weakness or paralysis Decreased lung capacity Round back deformity
• #54 There are three general causes of scoliosis: Congenital scoliosis is due to a problem with the formation of vertebrae or fused ribs during prenatal development. Neuromuscular scoliosis is caused by problems such as poor muscle control or muscular weakness or paralysis due to diseases such as cerebral palsy, muscular dystrophy, spina bifida, and polio. Idiopathic scoliosis is of unknown cause, and appears in a previously straight spine. Idiopathic scoliosis in adolescents is the most common type. Some people may be prone to the curving of the spine. Most cases occur in girls. Curves generally worsen during growth spurts. Scoliosis in infants and juveniles are less common. They commonly affect a similar number of boys and girls. Scoliosis may be suspected when one shoulder appears to be higher than the other, or the pelvis appears to be tilted. Untrained observers usually can't notice the curving. Routine scoliosis screening is now done in middle and junior high schools. Many cases, which  previously would have gone undetected until they were more advanced, are now being caught at an early stage. There may be fatigue in the spine after prolonged sitting or standing. Pain will become persistent if irritation results. The greater the initial curve of the spine, the greater the chance the scoliosis will get worse after growth is complete. Severe scoliosis (curves in the spine greater than 100 degrees) may cause breathing problems. Symptoms    Return to top The spine curves abnormally to the side (laterally) Shoulders or hips appearing uneven Backache or low-back pain Fatigue Treatment depends on the cause of the scoliosis, the size and location of the curve, and how much more growing the patient is expected to do. Most cases of adolescent idiopathic scoliosis (less than 20 degrees) require no treatment, but should be checked often, about every 6 months. As curves get worse (above 25 to 30 degrees in a child who is still growing), bracing is usually recommended to help slow the progression of the curve. There are many different kinds of braces used. The Boston Brace, Wilmington Brace, Milwaukee Brace, and Charleston Brace are named for the centers where they were developed. Each brace looks different. There are different ways of using each type properly. The selection of a brace and the manner in which it is used depends on many factors, including the specific characteristics of your curve. The exact brace will be decided on by the patient and health care practioner. A back brace does not reverse the curve. Instead, it uses pressure to help straighten the spine. The brace can be adjusted with growth. Bracing does not work in congenital or neuromuscular scoliosis, and is less effective in infantile and juvenile idiopathic scoliosis. Curves of 40 degrees or greater usually require surgery because curves this large have a high risk of getting worse even after bone growth stops. Surgery involves correcting the curve (although not all the way) and fusing the bones in the curve together. The bones are held in place with one or two metal rods held down with hooks and screws until the bone heals together. Sometimes surgery is done through a cut in the back, on the abdomen, or beneath the ribs. A brace may be required to stabilize the spine after surgery.
• #65 Each joint is in the book
• #66 Extension Abduction Adduction Hyperextension Internal rotation External rotation Atrophy Hypertrophy
• #78 The knee is flexed at 20–30 degrees with the patient supine.[2] The examiner should place one hand behind the tibia and the other grasping the patient's thigh. It is important that the examiner's thumb be on the tibial tuberosity.[3] The tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur. An intact ACL should prevent forward translational movement ("firm endpoint") while an ACL-deficient knee will demonstrate increased forward translation without a decisive 'end-point' - a soft or mushy endpoint indicative of a positive test. More than about 2 mm of anterior translation compared to the uninvolved knee suggests a torn ACL ("soft endpoint"), as does 10 mm of total anterior translation. An instrument called a "KT-1000" can be used to determine the magnitude of movement in mm. This test can be done in either an on-field evaluation in acute injury, or in a clinical setting when a patient presents for follow-up with knee pain.
• #79 To perform the test, the knee is held by one hand, which is placed along the joint line, and flexed to complete flexion while the foot is held by the sole with the other hand. The examiner then places one hand on the medial side of the knee to provide a varus stress, pushing knee laterally. The other hand rotates the leg externally while extending the knee.[2] If pain or a "click" is felt, this constitutes a "positive McMurray test" for a tear in the medial meniscus.
• #81 The Lachman test is a clinical test used to diagnose injury of the anterior cruciate ligament (ACL). It is recognized as reliable, sensitive, and usually superior to the anterior drawer test.[1] The knee is flexed at 20–30 degrees with the patient supine.[2] The examiner should place one hand behind the tibia and the other grasping the patient's thigh. It is important that the examiner's thumb be on the tibial tuberosity.[3] The tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur. An intact ACL should prevent forward translational movement ("firm endpoint") while an ACL-deficient knee will demonstrate increased forward translation without a decisive 'end-point' - a soft or mushy endpoint indicative of a positive test. More than about 2 mm of anterior translation compared to the uninvolved knee suggests a torn ACL ("soft endpoint"), as does 10 mm of total anterior translation. An instrument called a "KT-1000" can be used to determine the magnitude of movement in mm.