# Move

Move

There are three stages to assessing movement. The words used to describe a particular movement are shown in Table 35.3 /uni25CF Active . Ask the patient to move the joint within the limits of  their pain. /uni25CF Passive . Move the limb or joint yourself. Record the range of  movement in ‘degrees’ (a goniometer may be helpful). Comparison of active and passive range allows the three causes of  loss of  range of  movement to be distin guished. In limitation caused by pain or sti ff ness the ranges are the same but one is painful. In weakness passive range is greater than active. - - /uni25CF Stability . Stability has a static and a dynamic compo - nent: static tests assess the integrity of  the ligaments and joint (bone) surfaces; dynamic tests assess the integrity and . functions of  the muscles and tendons. Ask the patient to move the joint actively through its range of  motion while you try to stop the movement. Record pow er using the Medical Research Council (MRC) grading system as illus - trated in Table 35.4 . Consider the muscles that drive each movement, the peripheral nerves that supply them and the nerve root values ( Table 35.5 ). - In the following sections, in addition to the approach of ‘look, feel, move’, we hav e included details of  special tests for each joint as well as neurological examination of the limb. The peripheral nerve examination comprises sensory and motor testing, reflexes, tone and coordination and proprioception. 

TABLE 35.2
Swelling: an acronym for history and
examination of a lump.
S
tart
Did it appear after trauma or gradually on its
own?
W
here
Anatomical site and layer (skin, fat, muscle);
does it move in relation to these?
E
xternal features
Size, surface and de
/f_i
nition of margins
L
ymph nodes
Are the local ones enlarged?
L
iquid
Is it
/f_l
uctuant? Can it be transilluminated?
I
nternal features
Is it hard? Is it tender?
N
oise
Is there a thrill? Is there a bruit?
G
eneral
Examination of the whole patient for general
lumps
movement.
Flexion
Forward or anterior movement of the trunk or
limb
Lateral
/f_l
exion Bending of the forward-facing head and trunk
to either side
Extension Backward or posterior movement
Abduction A movement away from the midline of the
body
Adduction A movement towards the midline of the body
Internal rotation Rotation towards the midline of the body
External rotation Rotation away from the midline
Supination Movement of the forearm so that the palm
faces anteriorly
Pronation Movement of the forearm so that the palm
faces posteriorly
Circumduction A combination of
/f_l
exion, abduction, extension
and adduction without rotation
Inversion Movement of the foot that directs the sole of
the foot medially
Eversion Movement of the foot that directs the sole of
the foot laterally
Retraction Backwards movement of the head, jaw or
shoulders
TABLE 35.4
The Medical Research Council grading
system of muscle power.
Grade
Description
0
No movement
1
Flicker of movement
2
Active movement with gravity elimination
3
Active movement against gravity
4
Active movement against resistance but power less than
full
5
Normal power



Root level Sensation
C5
Lateral upper arm
C6
Lateral forearm
C7
Middle
/f_i
nger
C8
Little
/f_i
nger
T1
Medial forearm
L1
Anterior thigh
L2
Anterior thigh/groin
L3
Anterior and lateral thigh
L4
Medial leg and foot
L5
Lateral leg and
/f_i
rst dorsal web space Extensor hallucis longus
S1
Lateral and plantar foot
S2–S4 Perianal

Move

Range of  motion is limited in the thoracic spine: /uni25CF Forward bending test ( Figure 35.6 ). Ask the patient to bend forwards to touch their toes: /uni25CF structural scoliosis : a rib hump will increase in size (bulge posteriorly on the thoracic convex side) as the patient bends forwards; this is diagnostic of  idiopathic thoracic scoliosis (rotatory deformity); /uni25CF functional scoliosis : the spine straightens as the patient bends forwards and no rib hump is visible; this flexible deformity is secondary to other abnormalities such as abnormal leg lengths and muscle spasm in the lumbar region. /uni25CF Lateral bending . This can be used to assess the flexibil - ity of  a scoliosis. Radiographs can be taken in this position to supplement the assessment. Move

The wrist can be moved into flexion and extension, and ulnar and radial deviation. /uni25CF Wrist . Extension is tested by asking the patient to push the hands together into a ‘prayer’ position ( Figure 35.13a If there is loss of extension, the palms will not meet and/ or one forearm will be dropped. Palmar flexion is tested in a similar fashion but with the hands pointing down and the back of  the hands in contact ( Figure 35.13b ). Ulnar and radial deviation are tested by taking the patient’s hand in your own and moving the hand into these directions. /uni25CF Hand . A general screening assessment is to ask the patient to roll up their fingers from full extension to full flexion. This will reveal a trigger finger. Move

Di ff erentiate between movements of the shoulder joint and scapulothoracic movement of  the scapula on the chest wall. Patients with a painful shoulder will commonly move from the scapulothoracic joint. Stabilise the scapula by placing the thumb over the coracoid process and the fingers of  the same hand over the spine of  the scapula. Start in the ‘neutral - position’ with the arms by the sides, elbows extended and the palms facing forwards. Note any pain throughout the range of movement ( Figure 35.23 ). /uni25CF Forward flexion . Ask the patient to raise their hands in front to touch the ceiling while keeping the elbows extended (0–180°). /uni25CF Extension . Ask the patient to extend both arms behind (0–30°). /uni25CF Abduction . Shoulder abduction involves the glenohu meral joint and scapulothoracic movement. The first 60° of  movement is mainly at the glenohumeral joint. Beyond this the scapula begins to rotate on the thorax and final movements are almost entirely scapulothoracic. Raise the arms sideways until the fingers point to the ceiling (180°). /uni25CF Adduction . Ask the patient to touch their other shoulder tip. /uni25CF Internal rotation . Ask the patient to touch their back with the dorsum of  the hand and to raise their hand up the back as high as possible (normal range is thoracic spine level T7–9). /uni25CF External rotation . With the arms by the sides, bend the elbows to 90° and rotate the forearms to the mid-prone Christopher Jobe , contemporary , American orthopedic surgeon, specialising in shoulder and knee surgery , diagnostic musculoskeletal ultrasound and sports injuries. position. Ask the patient to separate their hands as much as possible (0–40°). 

(d)
(e)
Figure 35.23
Movements of
the shoulder:
(a)
forward
/f_l
ex
-
ion;
(b)
extension;
(c)
adduc
-
tion;
(d)
internal rotation;
(e)
external rotation.

Move

The hip joint can be moved into flexion, extension, abduc - tion and adduction, and internal and external rotation ( Figure 35.27 ). True hip movement ends when the pelvis begins to move. To detect true hip movement, simultaneously place a finger/hand on the ASIS contralateral to the hip being examined. Remember to compare both sides. Passive movement Hip flexion (120–0°) when lying supine The patient is asked to lie on their back and then roll themselves into a ball, flexing the hips and the spine fully . A comparison of the flexion of  the two hips can be made in this position. The patient is then asked to hold onto the knee of  the ‘bad’ leg with both hands (thereby fixing the pelvis in flexion) and the other leg is allowed to extend down onto the couch. A note is made - of  any fixed flexion deformity (inability of  the thigh to come down onto the couch). This ‘good’ hip is then returned to full flexion and the patient grasps that knee while dropping the other, ‘bad’, hip into extension. This modified Thomas’s test is the most comfortable and accurate way of  measuring flexion and extension of  the hip, minimising movement of  the painful - hip ( Figure 35.28 ). Hip extension (0–10°) when lying in a prone position Hip extension can be measured by asking the patient to roll onto their front and extend the hip. Rotation /uni25CF Internal rotation (45°) . With the hip flexed to 90° and the knee in 90° of  flexion, hold the front of  the knee with one hand and the foot with the other. Internally rotate the hip (the foot goes outwards), then externally rotate the hip (the foot goes in). The angle that the tibia makes with the vertical indicates the range of  movement. Pain at the extremes of  movement suggests inflammation in the hip. /uni25CF Abduction (40°) . The hip should be abducted by mov - ing the leg away from the midline with the other hand on the patient’s pelvis to detect any tilt in the pelvis. 

(c)
Figure 35.28
Modi
/f_i
ed Thomas’s test for assessing a
/f_i
xed
/f_l
exion
deformity. A
/f_i
xed
/f_l
exion deformity of the right hip is indicated by an
inability to fully straighten the right leg (arrow).
(d)
Figure 35.27
Hip movements:
(a)
internal rotation;
(b)
external
rotation;
(c)
adduction;
(d)
abduction.

Move

The knee moves principally in flexion (0–135°) and extension (from 0 to –10°) ( Figure 35.30 ). Assess hyperextension by placing one of  your hands on the anterior aspect of  the distal femur. Now lift the distal tibia with the other hand. Measure the angle or the height that the heel can be lifted o ff the couch before the knee starts to move. Perform a lag test to assess the integrity of  the extensor mechanism. The patient is asked to lift the whole leg up o ff the bed (10°) with the knee straight. They are then asked to bend the knee and then try to straighten it again with the leg still held in the air. If  they ar e unable to re-straighten the knee they have a positive lag. This indicates significant weakness of the quadriceps mechanism. In the presence of an apparent fixed flexion deformity of the knee (seen in osteoarthritis), decide whether this is arising from the knee or the hip joint. To di ff erentiate, sit the patient up with the knees hanging over the edge of  the couch; this obliterates the e ff ect of  any hip flexion deformity . Passively try to extend the knee fully . With a flexion deformity of  the knee, this is not possible. 

(c)
Figure 35.31
Assessing the medial
(a, b)
and lateral
(c, d)
collateral ligaments.

Move

The movements of  the foot and ankle are linked via the ankle, subtalar and midfoot joints. Remember the acronyms PAED – pronation, abduction, eversion and dorsiflexion – and SAPI – supination, adduction, plantarflexion and inversion. These are the two common general foot deformities. Move

There are three stages to assessing movement. The words used to describe a particular movement are shown in Table 35.3 /uni25CF Active . Ask the patient to move the joint within the limits of  their pain. /uni25CF Passive . Move the limb or joint yourself. Record the range of  movement in ‘degrees’ (a goniometer may be helpful). Comparison of active and passive range allows the three causes of  loss of  range of  movement to be distin guished. In limitation caused by pain or sti ff ness the ranges are the same but one is painful. In weakness passive range is greater than active. - - /uni25CF Stability . Stability has a static and a dynamic compo - nent: static tests assess the integrity of  the ligaments and joint (bone) surfaces; dynamic tests assess the integrity and . functions of  the muscles and tendons. Ask the patient to move the joint actively through its range of  motion while you try to stop the movement. Record pow er using the Medical Research Council (MRC) grading system as illus - trated in Table 35.4 . Consider the muscles that drive each movement, the peripheral nerves that supply them and the nerve root values ( Table 35.5 ). - In the following sections, in addition to the approach of ‘look, feel, move’, we hav e included details of  special tests for each joint as well as neurological examination of the limb. The peripheral nerve examination comprises sensory and motor testing, reflexes, tone and coordination and proprioception. 

TABLE 35.2
Swelling: an acronym for history and
examination of a lump.
S
tart
Did it appear after trauma or gradually on its
own?
W
here
Anatomical site and layer (skin, fat, muscle);
does it move in relation to these?
E
xternal features
Size, surface and de
/f_i
nition of margins
L
ymph nodes
Are the local ones enlarged?
L
iquid
Is it
/f_l
uctuant? Can it be transilluminated?
I
nternal features
Is it hard? Is it tender?
N
oise
Is there a thrill? Is there a bruit?
G
eneral
Examination of the whole patient for general
lumps
movement.
Flexion
Forward or anterior movement of the trunk or
limb
Lateral
/f_l
exion Bending of the forward-facing head and trunk
to either side
Extension Backward or posterior movement
Abduction A movement away from the midline of the
body
Adduction A movement towards the midline of the body
Internal rotation Rotation towards the midline of the body
External rotation Rotation away from the midline
Supination Movement of the forearm so that the palm
faces anteriorly
Pronation Movement of the forearm so that the palm
faces posteriorly
Circumduction A combination of
/f_l
exion, abduction, extension
and adduction without rotation
Inversion Movement of the foot that directs the sole of
the foot medially
Eversion Movement of the foot that directs the sole of
the foot laterally
Retraction Backwards movement of the head, jaw or
shoulders
TABLE 35.4
The Medical Research Council grading
system of muscle power.
Grade
Description
0
No movement
1
Flicker of movement
2
Active movement with gravity elimination
3
Active movement against gravity
4
Active movement against resistance but power less than
full
5
Normal power



Root level Sensation
C5
Lateral upper arm
C6
Lateral forearm
C7
Middle
/f_i
nger
C8
Little
/f_i
nger
T1
Medial forearm
L1
Anterior thigh
L2
Anterior thigh/groin
L3
Anterior and lateral thigh
L4
Medial leg and foot
L5
Lateral leg and
/f_i
rst dorsal web space Extensor hallucis longus
S1
Lateral and plantar foot
S2–S4 Perianal

Move

Range of  motion is limited in the thoracic spine: /uni25CF Forward bending test ( Figure 35.6 ). Ask the patient to bend forwards to touch their toes: /uni25CF structural scoliosis : a rib hump will increase in size (bulge posteriorly on the thoracic convex side) as the patient bends forwards; this is diagnostic of  idiopathic thoracic scoliosis (rotatory deformity); /uni25CF functional scoliosis : the spine straightens as the patient bends forwards and no rib hump is visible; this flexible deformity is secondary to other abnormalities such as abnormal leg lengths and muscle spasm in the lumbar region. /uni25CF Lateral bending . This can be used to assess the flexibil - ity of  a scoliosis. Radiographs can be taken in this position to supplement the assessment. Move

The wrist can be moved into flexion and extension, and ulnar and radial deviation. /uni25CF Wrist . Extension is tested by asking the patient to push the hands together into a ‘prayer’ position ( Figure 35.13a If there is loss of extension, the palms will not meet and/ or one forearm will be dropped. Palmar flexion is tested in a similar fashion but with the hands pointing down and the back of  the hands in contact ( Figure 35.13b ). Ulnar and radial deviation are tested by taking the patient’s hand in your own and moving the hand into these directions. /uni25CF Hand . A general screening assessment is to ask the patient to roll up their fingers from full extension to full flexion. This will reveal a trigger finger. Move

Di ff erentiate between movements of the shoulder joint and scapulothoracic movement of  the scapula on the chest wall. Patients with a painful shoulder will commonly move from the scapulothoracic joint. Stabilise the scapula by placing the thumb over the coracoid process and the fingers of  the same hand over the spine of  the scapula. Start in the ‘neutral - position’ with the arms by the sides, elbows extended and the palms facing forwards. Note any pain throughout the range of movement ( Figure 35.23 ). /uni25CF Forward flexion . Ask the patient to raise their hands in front to touch the ceiling while keeping the elbows extended (0–180°). /uni25CF Extension . Ask the patient to extend both arms behind (0–30°). /uni25CF Abduction . Shoulder abduction involves the glenohu meral joint and scapulothoracic movement. The first 60° of  movement is mainly at the glenohumeral joint. Beyond this the scapula begins to rotate on the thorax and final movements are almost entirely scapulothoracic. Raise the arms sideways until the fingers point to the ceiling (180°). /uni25CF Adduction . Ask the patient to touch their other shoulder tip. /uni25CF Internal rotation . Ask the patient to touch their back with the dorsum of  the hand and to raise their hand up the back as high as possible (normal range is thoracic spine level T7–9). /uni25CF External rotation . With the arms by the sides, bend the elbows to 90° and rotate the forearms to the mid-prone Christopher Jobe , contemporary , American orthopedic surgeon, specialising in shoulder and knee surgery , diagnostic musculoskeletal ultrasound and sports injuries. position. Ask the patient to separate their hands as much as possible (0–40°). 

(d)
(e)
Figure 35.23
Movements of
the shoulder:
(a)
forward
/f_l
ex
-
ion;
(b)
extension;
(c)
adduc
-
tion;
(d)
internal rotation;
(e)
external rotation.

Move

The hip joint can be moved into flexion, extension, abduc - tion and adduction, and internal and external rotation ( Figure 35.27 ). True hip movement ends when the pelvis begins to move. To detect true hip movement, simultaneously place a finger/hand on the ASIS contralateral to the hip being examined. Remember to compare both sides. Passive movement Hip flexion (120–0°) when lying supine The patient is asked to lie on their back and then roll themselves into a ball, flexing the hips and the spine fully . A comparison of the flexion of  the two hips can be made in this position. The patient is then asked to hold onto the knee of  the ‘bad’ leg with both hands (thereby fixing the pelvis in flexion) and the other leg is allowed to extend down onto the couch. A note is made - of  any fixed flexion deformity (inability of  the thigh to come down onto the couch). This ‘good’ hip is then returned to full flexion and the patient grasps that knee while dropping the other, ‘bad’, hip into extension. This modified Thomas’s test is the most comfortable and accurate way of  measuring flexion and extension of  the hip, minimising movement of  the painful - hip ( Figure 35.28 ). Hip extension (0–10°) when lying in a prone position Hip extension can be measured by asking the patient to roll onto their front and extend the hip. Rotation /uni25CF Internal rotation (45°) . With the hip flexed to 90° and the knee in 90° of  flexion, hold the front of  the knee with one hand and the foot with the other. Internally rotate the hip (the foot goes outwards), then externally rotate the hip (the foot goes in). The angle that the tibia makes with the vertical indicates the range of  movement. Pain at the extremes of  movement suggests inflammation in the hip. /uni25CF Abduction (40°) . The hip should be abducted by mov - ing the leg away from the midline with the other hand on the patient’s pelvis to detect any tilt in the pelvis. 

(c)
Figure 35.28
Modi
/f_i
ed Thomas’s test for assessing a
/f_i
xed
/f_l
exion
deformity. A
/f_i
xed
/f_l
exion deformity of the right hip is indicated by an
inability to fully straighten the right leg (arrow).
(d)
Figure 35.27
Hip movements:
(a)
internal rotation;
(b)
external
rotation;
(c)
adduction;
(d)
abduction.

Move

The knee moves principally in flexion (0–135°) and extension (from 0 to –10°) ( Figure 35.30 ). Assess hyperextension by placing one of  your hands on the anterior aspect of  the distal femur. Now lift the distal tibia with the other hand. Measure the angle or the height that the heel can be lifted o ff the couch before the knee starts to move. Perform a lag test to assess the integrity of  the extensor mechanism. The patient is asked to lift the whole leg up o ff the bed (10°) with the knee straight. They are then asked to bend the knee and then try to straighten it again with the leg still held in the air. If  they ar e unable to re-straighten the knee they have a positive lag. This indicates significant weakness of the quadriceps mechanism. In the presence of an apparent fixed flexion deformity of the knee (seen in osteoarthritis), decide whether this is arising from the knee or the hip joint. To di ff erentiate, sit the patient up with the knees hanging over the edge of  the couch; this obliterates the e ff ect of  any hip flexion deformity . Passively try to extend the knee fully . With a flexion deformity of  the knee, this is not possible. 

(c)
Figure 35.31
Assessing the medial
(a, b)
and lateral
(c, d)
collateral ligaments.

Move

The movements of  the foot and ankle are linked via the ankle, subtalar and midfoot joints. Remember the acronyms PAED – pronation, abduction, eversion and dorsiflexion – and SAPI – supination, adduction, plantarflexion and inversion. These are the two common general foot deformities.