Always observe a patient, looking for disabilities, as he or she walks into the room and sits down. General and neurological examinations are often necessary. Guidelines for rapid examinations of the limbs and spine are shown in Practical box 10.1.

Practical Box 10.1 Rapid examinations of the limb and spine

Rapid examination of the upper limbs Raise arms sideways to the ears (abduction). Reach behind neck and back. Difficulties with these movements indicate a shoulder or rotator cuff problem. Hold the arms forward, with elbows straight and fingers apart, palm up and palm down. Fixed flexion at the elbow indicates an elbow problem. Examine the hands for swelling, wasting and deformity. Place the hands in the ‘prayer’ position with the elbows apart. Flexion deformities of the fingers may be due to arthritis, flexor tenosynovitis or skin disease. Painful restriction of the wrist limits the person’s ability to move the elbows out with the hands held together. Make a tight fist. Difficulty with this indicates a loss of flexion or grip. Grip strength can be measured. Rapid examination of the lower limbs Ask the patient to walk a short distance away from and towards you, and to stand still. Look for abnormal posture or stance. Ask the patient to stand on each leg. Severe hip disease causes the pelvis on the non-weight-bearing side to sag (positive Trendelenburg test). Watch the patient stand and sit, looking for hip and/or knee problems. Ask the patient to straighten and flex each knee. Ask the patient to place each foot in turn on the opposite knee with the hip externally rotated. This tests for painful restriction of hip or knee. Abnormal hips or knees must be examined lying. Move each ankle up and down. Examine the ankle joint and tendons, medial arch and toes whilst standing.

Rapid examination of the spine

Stand behind the patient. Ask the patient to (a) bend forwards to touch the toes with straight knees, (b) extend backwards, (c) flex sideways, and (d) look over each shoulder, flexing and extending and side-flexing the neck. Observe abnormal spinal curves – scoliosis (lateral curve), kyphosis (forward bending) or lordosis (backward bending). A cervical and lumbar lordosis and a thoracic kyphosis are normal. Muscle spasm is worse whilst standing and bending. Leg length inequality leads to a scoliosis which decreases on sitting or lying (the lengths are measured lying). Ask the patient to lie supine. Examine any restriction of straight-leg raising. Ask the patient to lie prone. Examine for anterior thigh pain during a femoral stretch test (flexing knee whilst prone), which indicates a high lumbar disc problem. Palpate the spine and buttocks for tender areas.

Examining an individual joint involves three stages – looking, feeling and moving:

• Appearance. Look at it for swelling, rash or erythema, muscle wasting, deformity such as a distal bone displaced laterally as in knock knees (genu valgus) or bowed legs (genu varus), fixed flexion or hyperextension, loss of normal range and lack of fluidity of movement, and any pain caused by movement.
• Feel it for tenderness, warmth (indicates inflammation) and swelling which may be due to fluid, soft tissue or
  bone. Common descriptors are ‘fluctuant’ (fluid), ‘firm’ or ‘boggy’ (swelling of the synovium), and ‘hard’ (bony).
• Movement. Move it to assess the passive range of movement (e.g. flexion, extension, abduction, adduction and rotation), any instability, or the production of pain and crepitus (grating) seen with cartilage damage. The normal range varies between individuals. Comparing right with left and asking the patient about any change in range help to assess whether the endpoints are normal or not. A screening examination of the locomotor system, known by the acronym GALS (global assessment of the locomotor system) has been devised.

X-ray of the joint often forms an integral part of the examination.