Musculoskeletal stations

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

“Are you comfortable? Do you need any pain relief?”

“I have been asked to examine your hand/wrist. This will involve me looking at both your hands, wrists and elbows. I will be feeling these areas: testing the strength; the feeling, and doing some other tests. Is this ok with you?”

“Would you like a chaperone present?”

“Please can you ensure your arms from your elbows down are exposed and rest your hands on the table in front of you.”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me what the problem is?”

“Which hand do you write with?”

“What is your occupation?”

“Do you have special hobbies in which you use your hands?”

Lacerations:

• Establish the full tetanus vaccination history, including previous doses and the date of the last dose.
• Assess wound type, contamination and delay to treatment; use the current UKHSA wound-management guidance to decide prophylaxis.

Inspection

Compare both hands, including the dorsal and palmar surfaces.

“Please place your hands palm down on the table.”

“I am inspecting the DORSUM hands for:

• Any gross: deformities; swellings; scars; wasting; contractures,
• For swelling in particular looking for any pattern of swelling (e.g. Rheumatoid arthritis: MCPJ/PIPJ)
• Nail changes: pitting; koilonychia; onycholysis; splinter haemorrhages"

'Please turn your hands over, I am inspecting the PALMAR aspect of the hands for:

• any gross: deformities; swellings; scars; wasting; contractures
• for swelling in particular looking for any pattern of swelling (e.g. RA: MCPJ/PIPJ)
• nail changes: pitting; koilonychia; onycholysis; splinter haemorrhages
• palmar erythema
• the cascade"

"Please gently bend your fingers into a fist. I am checking the finger cascade, looking for overlap or scissoring that suggests rotational deformity, and observing any triggering.”

“Please can you bend your arm so I can look at your elbows: rheumatoid nodules; psoriatic plaques”

Palpation

“Please show me where it hurts. I will start away from that area and feel gently.”

• Compare temperature, capillary refill and radial/ulnar pulses as indicated.
• Palpate relevant bones and joints, thenar and hypothenar areas, palm and tendon sheaths; use a gentle MCP squeeze only when appropriate.
• After trauma, assess the anatomical snuffbox and scaphoid tubercle. A normal initial X-ray does not exclude a scaphoid fracture; immobilise and arrange the appropriate imaging/follow-up pathway if suspicion remains.
• Allen’s test addresses a specific arterial-perfusion question; it is not required in every hand examination or a guarantee of adequate perfusion.

BSSH — suspected scaphoid fracture

Move

Compare active movement first. Add gentle passive movement and resisted testing when safe; suspected fracture or significant tendon injury may limit testing.

Wrist and forearm

• Wrist flexion, extension, radial and ulnar deviation.
• Forearm pronation and supination, with the elbow supported.

Fingers and tendons

• Assess MCP, PIP and DIP flexion and extension; look for an extension lag. Test finger abduction and adduction.
• FDP: hold the PIP joint extended and ask the patient to bend the fingertip at the DIP joint. Test each digit.
• FDS: keep the other fingers extended and ask the patient to flex the PIP joint of the selected finger. Interpret an absent little-finger FDS action cautiously because anatomical variation occurs.
• Inspect wounds carefully: preserved movement does not exclude a partial tendon injury.

Thumb

• Assess flexion, extension, opposition, abduction away from the palm and adduction back towards it.
• The thumb ulnar collateral ligament stabilises the MCP joint. If assessment is appropriate after considering fracture, stabilise the metacarpal and apply gentle valgus stress to the proximal phalanx, comparing laxity and the end point. Avoid repeated painful stress and seek specialist advice when uncertain.

MCP = metacarpophalangeal; PIP = proximal interphalangeal; DIP = distal interphalangeal. FDP = flexor digitorum profundus; FDS = flexor digitorum superficialis.

BSSH — thumb UCL guidance

Special tests

De Quervain’s tenosynovitis

Radial-styloid pain with appropriate gentle provocation supports this diagnosis. The thumb-inside-a-fist manoeuvre with ulnar deviation is Eichhoff’s test, often mislabeled Finkelstein’s. It can provoke pain in people without the condition. Do not force either manoeuvre or diagnose from one test alone.

Finkelstein versus Eichhoff — primary study

Peripheral nerves

Nerve	Useful sensory and motor checks
Radial	Sensation in the first dorsal web space; wrist, finger and thumb extension.
Median	Sensation at the palmar index-finger pulp; thumb palmar abduction and opposition. The “OK” sign tests the anterior interosseous motor branch.
Ulnar	Sensation at the little-finger pulp (ulnar/medial one-and-a-half digits); finger abduction and adduction. Froment’s sign is thumb IP flexion compensating for weak adductor pollicis when holding paper.

Compare sides and map any deficit; these are useful test points rather than a complete sensory map. Record perfusion as well as nerve function.

Carpal tunnel

Phalen’s wrist-flexion test and Tinel’s percussion over the median nerve are supportive when they reproduce the patient’s typical median-distribution tingling or numbness. Pain alone, or a rigid time threshold, is not diagnostic.

Functional assessment

• Grasp cup
• Pinch something
• Grip strength
• Hook – yours and patients fingers together and try to straighten against resistance.

Close

“Thank you. That is the end of the examination. Would you like help getting dressed?”

Summarise the findings, explain your working diagnosis and agree the next steps. Invite questions and describe symptoms that should prompt urgent reassessment.

Complete a focused examination of the elbow where relevant. Document neurovascular findings and any limits caused by pain. Choose investigations and referral for the presentation.

Further reading

• Geeky Medics — Hand examination
• Oxford Medical Education — Hand examination
• UKHSA — current Green Book tetanus chapter
• BSSH — scaphoid fracture standards
• TeachMeAnatomy — Hand anatomy
• UKHSA — current tetanus wound-management guidance
• BSSH — thumb UCL guidance

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

“Are you comfortable? Do you need any pain relief?”

“I have been asked to conduct an examination of your elbow. This will involve me looking at both elbows: looking; feeling; moving them and assessing your strength and the sensation. Would that be ok with you?”

“Would you like a chaperone present?”

“Are you ok to ensure the whole of both your arms are visible please?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me what the problem is?”

“Which hand do you write with?”

“What is your occupation?”

“Do you have special hobbies?”

Inspection

“Please can you stand up and face me, with your arms out by your sides, palms facing forward.”

“I am inspecting from front; back and sides looking for…”

• scars
• deformity including: swelling; bruising; redness (note normal slight valgus position)
• hyperextension
• wasting
• fasciculations
• rheumatoid nodules

Assess the carrying angle with the elbows extended and forearms supinated, comparing both sides.

Palpation

“I am going to feel your elbows, assessing for…”

Comment on:

• warmth
• swelling
• bogginess
• crepitus in movement
• pain

Structures:

• medial epicondyle
• olecranon
• lateral epicondyle
• elbow flexed: radial head (thumb on head, supinate and pronate)
• biceps tendon (hook test)
• brachial and radial pulse

Move

Active; passive and resisted

• Flexion
• Extension
• Supination and pronation (flexed elbow; thumbs up and thumbs down)

Special tests

Nerve	Useful sensory and motor checks
Radial	Sensation in the first dorsal web space; wrist, finger and thumb extension.
Median	Sensation at the palmar index-finger pulp; thumb palmar abduction and opposition. The “OK” sign tests the anterior interosseous motor branch.
Ulnar	Sensation at the little-finger pulp (ulnar/medial one-and-a-half digits); finger abduction and adduction. Froment’s sign is thumb IP flexion compensating for weak adductor pollicis when holding paper.

Compare sides and map any deficit; these are useful test points rather than a complete sensory map. Record perfusion as well as nerve function.

Epicondylar tendinopathy

• Lateral: palpate the lateral epicondyle while testing resisted wrist extension with the forearm pronated. Reproduction of the usual lateral pain supports extensor tendinopathy.
• Medial: test resisted wrist flexion and forearm pronation, looking for pain at the medial epicondyle.
• Interpret these tests with the history, tenderness and range of movement. Assess distal biceps integrity after an appropriate mechanism; the hook test should be performed gently by a clinician familiar with the technique.

Close

“Thank you. That is the end of the examination. Would you like help getting dressed?”

Summarise the findings, explain your working diagnosis and agree the next steps. Invite questions and describe symptoms that should prompt urgent reassessment.

Complete a focused examination of the wrist and shoulder where relevant. Document neurovascular findings and any limits caused by pain. Choose investigations and referral for the presentation.

Further reading

• Geeky Medics — Elbow examination
• TeachMeAnatomy — Elbow anatomy

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

“Are you comfortable? Do you need any pain relief?”

“I have been asked to conduct an examination of your shoulder. This will involve me looking at both shoulders: looking; feeling; and moving them and assessing your strength and the sensation. Would that be ok with you?”

“Would you like a chaperone present?”

“Are you ok to ensure the whole of both your arms are visible please?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me what the problem is?”

“Which hand do you write with?”

“What is your occupation?”

“Do you have special hobbies?”

Inspection

“Please can you stand up and face me, with your arms out by your sides, palms facing forward.”

“I am inspecting from the front; back; sides and axilla looking for…”

• scars
• deformity including: swelling; bruising; redness
• wasting
• fasciculations

Palpation

“I am going to feel your shoulders. I am palpating..”

Anteriorly: SCJ → Clavicle → Acromoclavicular joint → coracoid process → long-head biceps tendon in the bicipital groove → greater tuberosity of humerus

Posteriorly: Acromion → spine of scapula → suprascapular and interscapular muscles

Move

• Observe active flexion, extension, abduction, adduction and internal/external rotation, including scapular movement.
• Compare sides and distinguish pain-limited movement from weakness. Add gentle passive movement if safe; stabilise the scapula when specifically isolating glenohumeral movement.
• Use resisted testing to assess relevant muscle groups. Stop if pain or suspected acute injury makes testing inappropriate.

Special tests

Select tests for the clinical question. Pain, weakness and laxity need interpretation together; no isolated test establishes a tear or symptomatic instability.

• Empty can — supraspinatus: elevate the arms to approximately 90° in the scapular plane (about 30° forward of the coronal plane), thumbs down, and apply gentle downward resistance. Note pain and weakness.
• Drop arm: from about 90° abduction, ask for controlled lowering. Inability to control the descent raises concern for rotator-cuff dysfunction.
• Gerber lift-off — subscapularis: with the dorsum of the hand against the lower back, ask the patient to lift it away; add gentle resistance if appropriate.
• Resisted external rotation: elbows by the sides and flexed to 90°. Assess infraspinatus/teres minor function, noting pain and weakness.
• Neer manoeuvre: stabilise the scapula and gently elevate the internally rotated arm. Stop with pain; never force to the limit.
• Sulcus sign: gentle downward traction on the relaxed arm may reveal inferior laxity. Interpret alongside symptoms and comparison with the other shoulder.

Stanford — shoulder examination

Close

“Thank you. That is the end of the examination. Would you like help getting dressed?”

Summarise the findings, explain your working diagnosis and agree the next steps. Invite questions and describe symptoms that should prompt urgent reassessment.

Complete a focused examination of the neck and elbow where relevant. Document neurovascular findings and any limits caused by pain. Choose investigations and referral for the presentation.

Further reading

• Geeky Medics — Shoulder examination
• Oxford Medical Education — Shoulder examination orthopaedics
• TeachMeAnatomy — Shoulder anatomy
• Stanford — shoulder examination

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

“Are you comfortable? Do you need any pain relief?”

“I have been asked to conduct an examination of your neck. This will involve me looking and feeling your neck, asking you to do some movements and assessing the strength and feeling in your arms. Would that be ok with you?”

“Would you like a chaperone present?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you tell me about the pain, any injury and whether you have noticed weakness, numbness, clumsy hands or difficulty walking?”

Ask about onset, radiation, function, occupation, fever, cancer history and bladder/bowel symptoms when relevant. After trauma, maintain appropriate spinal precautions and use the NICE cervical-spine assessment pathway. Do not start a routine movement or provocative-test sequence before injury has been assessed.

NICE NG41 — spinal injury · NICE NG232 — head injury and cervical imaging

Inspection

Inspect posture, alignment, scars, swelling, bruising and muscle wasting from the front, sides and back, maintaining any necessary spinal precautions. Look for relevant neurological signs, including ptosis and miosis when clinically indicated.

Palpation

“I will gently feel along your neck and the muscles on either side. Please tell me if anything is tender.”

Assess temperature, swelling and tenderness over the cervical midline and paraspinal muscles. Examine the supraclavicular region when relevant. Avoid unnecessary movement in suspected injury; carotid palpation is not part of a routine musculoskeletal neck examination.

Move

When safe, ask for comfortable active flexion, extension, lateral flexion and rotation. Do not force movement. In trauma, the Canadian C-spine rule permits active rotation assessment only in appropriately selected low-risk patients; follow the complete NICE pathway rather than testing movement in everyone.

Special tests

Possible cord involvement

• Hoffmann’s sign: a brisk flick of the distal middle finger may produce thumb/index flexion. Interpret with tone, reflexes, power, sensation and gait; it is not a diagnosis on its own.
• Lhermitte’s phenomenon: ask about an electric-shock sensation into the trunk or limbs with neck flexion. Avoid repeatedly provoking symptoms or forcing neck movement.

Thoracic outlet symptoms

Adson’s manoeuvre has false-positive results in healthy people. Loss of the radial pulse alone does not diagnose thoracic outlet syndrome. Assess the symptom pattern, neurological findings and perfusion, and arrange appropriate further assessment.

Primary study — false-positive provocative tests

Meningism

Kernig’s and Brudzinski’s signs belong to a clinically indicated assessment for meningitis, not every musculoskeletal station. Kernig’s involves painful/resisted knee extension with the hip flexed; Brudzinski’s is involuntary hip/knee flexion with neck flexion. Their absence does not exclude meningitis. Do not force the neck or delay urgent assessment and treatment when meningitis is suspected.

NICE NG240 — meningitis

Upper limb neurology

Tone

“I am going to hold each of your hands and do some movements with them to assess your tone…” (Flexion; extension; supination and pronation at the elbow)

“I am assessing whether tone is increased, reduced or normal.”

Power

“I need to assess your strength by asking you to make some movements against resistance.”

Compare sides, test proximal and distal groups, and document power on the MRC 0–5 scale, including pain or other limitations. Muscles have overlapping root supplies; these are useful key movements, not a complete map of each muscle’s innervation.

Key movement	Clinical root anchor
Elbow flexion	C5
Wrist extension	C6
Elbow extension	C7
Finger flexion (distal phalanx of middle finger)	C8
Little-finger abduction	T1

Also assess shoulder abduction, wrist flexion, finger extension and relevant thumb movements. Specify the movement and peripheral nerve being assessed; thumb extension, opposition and finger abduction are not all simply “T1”.

ASIA: key muscles and neurological assessment

Sensation

“I need to test how well you can feel areas on your skin…”

• Can you feel here? (on upper chest)
• Bring your arms straight by your side with your palms facing forward (‘anatomical’ position).
• Please can you close your eyes and tell me when you feel something.

“I will compare sensation on both sides, test relevant dermatomes and peripheral nerve territories, and map any abnormality using:”

• Light touch (cotton wool)
• Sharp/dull (neurotip)
• Vibration sense (128Hz tuning fork): start on a distal bony prominence and move proximally
• Proprioception (joint position sense)
• Temperature

Reflexes

“Let your arm relax while I check the reflexes with this tendon hammer.”

• Support the limb and compare sides: biceps C5–C6, brachioradialis C5–C6 and triceps mainly C7.
• Describe whether reflexes are absent, reduced, normal or brisk, and use reinforcement if needed without contracting the muscle being tested.

Stanford Medicine 25 — tendon reflexes

Coordination

“Please touch your nose and then my finger, and repeat on the other side.”

• Assess finger–nose testing with eyes open for dysmetria and intention tremor.
• Test rapid alternating hand movements for dysdiadochokinesia.
• Assess pronator drift with the arms extended forwards, palms upwards and eyes closed; look for pronation and downward drift.

University of Utah — motor examination

If myelopathy is suspected, assess the lower limbs and gait as well. Use Chapter 6’s neurological examination for the full sequence.

Close

“Thank you. That is the end of the examination. Would you like help getting dressed?”

Summarise the findings, explain your working diagnosis and agree the next steps. Invite questions and describe symptoms that should prompt urgent reassessment.

Complete a focused examination of the shoulders, and the legs if myelopathy is suspected where relevant. Document neurovascular findings and any limits caused by pain. Choose investigations and referral for the presentation.

Further reading

• Geeky Medics — Spine examination
• Canadian C spine rules
• Nexus decision rule
• NICE NG232 — head injury and cervical imaging
• NICE Spinal injury: assessment and initial management
• Oxford Medical Education — C-spine injury: Immobilisation (initial assessment of the trauma patient)
• Oxford Medical Education — C-spine injury: Collar application (initial assessment of the trauma patient)
• TeachMeAnatomy — Neck anatomy
• NICE NG41 — spinal injury assessment
• ASIA — neurological assessment resources

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

“Are you comfortable? Do you need any pain relief?”

“I have been asked to conduct an examination of your back. This will involve me looking at your back, feeling along the spine, and asking you to do some movements. Would that be ok with you?”

“Would you like a chaperone present?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Where is the pain, does it travel into either leg, and have you noticed weakness or changes to your bladder, bowels or sensation?”

• Ask about trauma, fever, infection risk, cancer history, unexplained weight loss and severe or progressive symptoms.
• Ask specifically about new difficulty starting urination, altered urinary flow sensation, saddle/genital sensory change, loss of rectal fullness, sexual dysfunction and progressive bilateral leg weakness.
• For possible inflammatory pain, ask about prolonged morning stiffness, night waking, improvement with movement, psoriasis, uveitis and inflammatory bowel disease.

Possible cauda equina syndrome requires urgent assessment through the local emergency MRI pathway. Negative physical findings do not rule it out. GIRFT does not require a digital rectal examination for referral; document the symptoms and neurological findings, including reported perianal sensory change. Do not use anal tone or a low post-void residual to provide false reassurance.

GIRFT — national suspected cauda equina pathway (March 2026)

Inspection

“If it is safe and comfortable, please stand so I can look at your back from the front, side and behind.”

Observe posture, gait where appropriate, lumbar/cervical lordosis, thoracic kyphosis, scoliosis, scars and skin changes. Do not require single-leg standing in someone with acute pain or an unsafe gait.

Palpation

“I am going to gently feel all the bones along your spine, as well as the muscles either side.”

Comment on:

• warmth
• swelling
• bogginess
• crepitus in movement
• pain
• widened spinous processes

All vertebrae: cervical; thoracic; lumbar spine on both sides

Move

• Flexion
• Extension
• Rotation
• Lateral flexion

Special tests

Modified Schober: mark the midline at the level of the posterior superior iliac spines, then 5 cm below and 10 cm above. Ask for forward flexion and measure the increase from the initial 15 cm. Reduced excursion (often less than about 5 cm) supports restricted lumbar flexion; record the measurement and technique.

Straight-leg raise: with the patient supine, passively elevate the straight leg. Reproduction of the familiar radiating leg pain, typically at about 30–70°, supports lumbosacral nerve-root irritation; back pain or hamstring tightness alone is not a positive radicular test.

Crossed straight-leg raise: lifting the unaffected leg reproduces radicular pain in the affected leg. This supports nerve-root irritation; it does not establish disc size or location.

Bowstring manoeuvre: an optional nerve-tension adjunct for a trained examiner. Flexing the knee after a symptomatic straight-leg raise should ease tension; gentle pressure in the popliteal region may reproduce symptoms. Avoid forceful pressure over the common peroneal nerve and do not treat this test as diagnostic in isolation.

FABER: flex, abduct and externally rotate the hip, resting the ankle above the opposite knee. Stabilise the opposite pelvis and lower the flexed knee gently. Record where pain occurs: groin pain may arise from the hip; posterior pain may implicate the sacroiliac region. The test does not establish osteoarthritis or sacroiliac disease by itself.

Femoral nerve stretch: with the patient prone when suitable, gently flex the knee and, if needed, extend the hip. Familiar anterior-thigh radicular pain supports upper lumbar nerve irritation; distinguish it from quadriceps stretch discomfort.

Complete a lower-limb neurological examination and assess other possible sources of pain as indicated.

Stanford — low-back examination

Close

“Thank you. That is the end of the examination. Would you like help getting dressed?”

Summarise the findings, explain your working diagnosis and agree the next steps. Invite questions and describe symptoms that should prompt urgent reassessment.

Complete a focused examination of the hips and relevant abdominal causes where relevant. Document neurovascular findings and any limits caused by pain. Choose investigations and referral for the presentation.

A rectal examination is not a routine part of this joint examination. If cauda equina syndrome is suspected, follow the urgent pathway described in the back section; a reassuring examination must not delay appropriate assessment.

Further reading

• Geeky Medics — Spine examination
• Oxford Medical Education — Cord compression presentations
• NICE CKS — NICE Back pain (without radiculopathy)
• NICE NG59 — low back pain and sciatica
• NICE NG65 — spondyloarthritis
• GIRFT — suspected cauda equina syndrome pathway

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

“Are you comfortable? Do you need any pain relief?”

“I have been asked to conduct an examination of your hip. This will involve me looking at both hips; your walking and assessing the movement. Would that be ok with you?”

“Would you like a chaperone present?”

“I will need to see both your legs; are you able to change into shorts?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me what the problem is?”

“What is your occupation?”

“Have you been involved in any trauma?”

“Have you had any previous operations on your hips?”

“Have you had a fever?”

Gait

“If it is comfortable and safe, please walk a short distance, turn and walk back.”

Observe symmetry, stance, stride, an antalgic pattern, pelvic drop and foot drop. Use the person’s usual walking aid and provide support. Do not ask someone with suspected fracture or an acutely painful injury to walk for the sake of completing a checklist.

Inspection

Compare both hips and legs, assessing scars, deformity, skin changes, muscle bulk and resting posture.

Trendelenburg test: if safe, provide secure support and ask the patient to stand briefly on one leg. A drop of the pelvis on the opposite, unsupported side suggests abductor dysfunction on the stance side. Pain and balance difficulty can affect the test. Compare sides.

Palpation

“Please lie comfortably. I will feel around the hip and compare the two sides.”

• Assess warmth, swelling and tenderness. Palpate relevant accessible landmarks, including the iliac crest, ASIS and greater trochanter; examine other areas only when indicated and with appropriate explanation.
• The lesser trochanter is not a routine externally palpable landmark; the ischial tuberosity is not the same structure as the pubic ramus.
• For leg length, align the pelvis and place the legs symmetrically. Measure true length from ASIS to medial malleolus and apparent length from umbilicus to medial malleolus, comparing sides.

Move

Compare active and gentle passive flexion, extension, abduction, adduction and internal/external rotation, according to comfort and suspected injury. Assess resisted strength when appropriate. Pushing the heel into the couch tests extension strength; it does not measure the range of hip extension.

Special tests

Thomas test: with the patient supine, flex one hip towards the chest to flatten lumbar lordosis, monitoring the pelvis/lower back. If the opposite thigh lifts off the couch, this suggests a flexion contracture of that hip. Do not exaggerate lumbar lordosis.

Straight-leg raise: with the patient supine, passively elevate the straight leg. Reproduction of the familiar radiating leg pain, typically at about 30–70°, supports lumbosacral nerve-root irritation; back pain or hamstring tightness alone is not a positive radicular test.

FABER: flex, abduct and externally rotate the hip, resting the ankle above the opposite knee. Stabilise the opposite pelvis and lower the flexed knee gently. Record where pain occurs: groin pain may arise from the hip; posterior pain may implicate the sacroiliac region. The test does not establish osteoarthritis or sacroiliac disease by itself.

Stanford — regional hip examination

A child with a limp: examine the joints above and below because hip disease may present as knee pain. Acute inability to bear weight is a red flag; a hot, painful, restricted joint, especially with fever, needs urgent assessment for infection. Follow local paediatric pathways.

RCH — limping or non-weight-bearing child

Close

“Thank you. That is the end of the examination. Would you like help getting dressed?”

Summarise the findings, explain your working diagnosis and agree the next steps. Invite questions and describe symptoms that should prompt urgent reassessment.

Complete a focused examination of the lumbar spine and knees where relevant. Document neurovascular findings and any limits caused by pain. Choose investigations and referral for the presentation.

A rectal examination is not a routine part of this joint examination. If cauda equina syndrome is suspected, follow the urgent pathway described in the back section; a reassuring examination must not delay appropriate assessment.

Further reading

• Geeky Medics — Hip examination
• Oxford Medical Education — Hip examination orthopaedics
• Geeky Medics — Paediatric hip – disorders
• RCH — the limping or non-weight-bearing child
• limping child
• fever and limp
• TeachMeAnatomy — Hip anatomy

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

“Are you comfortable? Do you need any pain relief?”

“I have been asked to conduct an examination of your knee. This will involve me looking at both knees: how you are walking and assessing the movement and strength. Would that be ok with you?”

“Would you like a chaperone present?”

“I will need to see both your legs, are you able to change into shorts?”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me what the problem is?”

“What is your occupation?”

“Have you been involved in any trauma?”

“Have you had any previous operations on your knees?”

“Have you been unwell recently?”

Gait

“If it is comfortable and safe, please walk a short distance, turn and walk back.”

Observe symmetry, stance, stride, an antalgic pattern, pelvic drop and foot drop. Use the person’s usual walking aid and provide support. Do not ask someone with suspected fracture or an acutely painful injury to walk for the sake of completing a checklist.

Inspection

“Please can you stand up straight. I am inspecting the knees from the front; back, and sides. I am looking for…”

• scars
• skin changes
• wasting
• muscle bulk of quadriceps
• deformity: varus (out); valgus (in)
• popliteal mass or swelling

Palpation

“Please can you lie down on the couch. I need to feel the knees for…”

Comment on:

• warmth – use the back of your hand to compare to the other side and rest of the leg
• swelling
• bogginess
• crepitus in movement
• pain

“I now need to palpate the joint line or any tenderness, and also assess for effusion”

• Knee flexed at 90^o
• Start in the hollow next to medial part of patellar tendon
• Medial joint line → medial tibial plateau (inferiorly) → medial femoral condyle (superiorly) → quads tendon and muscles → lateral femoral condyle → lateral joint line → lateral tibial plateau → patella tendon → fibular head → patella

Effusion

• milk the knee → squeeze thigh and push towards feet
• maintain hold → apply pressure to medial, then lateral side → looking for a bulge
• Patella tap – larger effusion.
  • Empty supra-patellar pouch → press gently on the patella with thumb and index finger → tap + bounce back if effusion)

Move

Active; passive, resisted (with hand over patella to feel for crepitus)

• flexion
• extension

Special tests

• Extensor mechanism: ask for an active straight-leg raise and look for an extension lag; this is different from passive nerve-tension testing.
• Patellar apprehension: with slight knee flexion, gently translate the patella laterally. Stop if apprehension occurs; do not push through pain.
• ACL: use Lachman testing at about 20–30° flexion. For anterior drawer, flex the knee to 90°, support the foot, relax the hamstrings, hold the proximal tibia with fingers behind and thumbs in front, and apply controlled anterior translation. Compare excursion and end point; avoid a sharp jerk.
• PCL: inspect posterior sag with the knee at 90°, then assess controlled posterior translation if appropriate.
• Collateral ligaments: at about 20–30° knee flexion, valgus stress tests the MCL and varus stress tests the LCL. Compare opening and end point, distinguishing pain from laxity.
• McMurray: from flexion, guide the knee towards extension using external tibial rotation with valgus for the medial meniscus, and internal rotation with varus for the lateral meniscus. A painful joint-line click or locking supports meniscal injury; painless cracking alone is not diagnostic.

An acutely painful or swollen knee may prevent reliable testing. Provide analgesia, consider fracture and arrange appropriate reassessment or imaging rather than forcing special tests.

Merck Manual — knee ligament and meniscal assessment · NICE NG38 — fracture assessment and Ottawa rules

Close

“Thank you. That is the end of the examination. Would you like help getting dressed?”

Summarise the findings, explain your working diagnosis and agree the next steps. Invite questions and describe symptoms that should prompt urgent reassessment.

Complete a focused examination of the hip and ankle where relevant. Document neurovascular findings and any limits caused by pain. Choose investigations and referral for the presentation.

A rectal examination is not a routine part of this joint examination. If cauda equina syndrome is suspected, follow the urgent pathway described in the back section; a reassuring examination must not delay appropriate assessment.

Further reading

• Geeky Medics — Knee examination
• Oxford Medical Education — Knee examination orthopaedics
• NICE CKS — NICE: How do i exclude fracture using the Ottawa knee rules?
• TeachMeAnatomy — Knee joint anatomy
• NICE NG38 — fracture assessment

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

“Are you comfortable? Do you need any pain relief?”

“I have been asked to conduct an examination of your ankle and foot This will involve me looking at both of them; seeing how you are walking and assessing the movement and strength. Would that be ok with you?”

“Would you like a chaperone present?”

“I will need to be able to see your legs from the knee down please.”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Brief history

“Can you briefly tell me what the problem is?”

“What is your occupation?”

“Have you been involved in any trauma?”

“Have you been unwell recently?”

Gait

“If it is comfortable and safe, please walk a short distance, turn and walk back.”

Observe symmetry, stance, stride, an antalgic pattern, pelvic drop and foot drop. Use the person’s usual walking aid and provide support. Do not ask someone with suspected fracture or an acutely painful injury to walk for the sake of completing a checklist.

Inspection

“Please can you stand up. I am inspecting the feet and ankles from the front; back, and sides. I am looking for…”

• scars
• skin changes
• wasting
• Deformity:
  • toes: claw toes (MTP hyperextension with PIP/DIP flexion); hammer toe (predominantly PIP flexion)
  • arches: high arch; flat foot

"Please can you sit down on the chair so I can examine…”

• sole of foot – plantar bruising (Lisfranc)
• between toes

Palpation

"I am feeling the ankle and feet for…”

• warmth – use the back of your hand to compare to the other side and rest of the leg
• swelling
• bogginess
• crepitus in movement
• pain

Bones

• foot
• ankle
• fibula head

Ligaments

• anterior talofibular
• deltoid
• syndesmotic squeeze (high ankle sprain)

Move

Compare active, gentle passive and resisted dorsiflexion (foot upwards), plantarflexion (foot downwards), inversion and eversion, where safe. Support the heel and assess toe movements as indicated. Stop when pain or suspected injury limits the examination.

Special tests

Simmonds–Thompson calf-squeeze test: with the patient prone and feet free over the edge of the couch, squeeze the calf and compare sides. Absent or reduced plantarflexion supports Achilles rupture. Preserved voluntary plantarflexion does not exclude rupture.

CUH — Achilles rupture · Thompson test — clinical report

Morton’s neuroma: compress the forefoot while applying gentle pressure to the relevant plantar web space. Reproduction of the usual web-space pain/paraesthesia into adjacent toes, sometimes with a click (Mulder’s sign), supports the diagnosis.

After trauma, assess the malleoli, navicular, base of the fifth metatarsal, midfoot and proximal fibula as appropriate. Plantar bruising raises concern for Lisfranc injury. The Ottawa rules address the need for radiographs in their intended population; they do not exclude every important ligament, tendon or midfoot injury.

NICE NG38 — Ottawa ankle and foot rules

Close

“Thank you. That is the end of the examination. Would you like help getting dressed?”

Summarise the findings, explain your working diagnosis and agree the next steps. Invite questions and describe symptoms that should prompt urgent reassessment.

Complete a focused examination of the knee where relevant. Document neurovascular findings and any limits caused by pain. Choose investigations and referral for the presentation.

A rectal examination is not a routine part of this joint examination. If cauda equina syndrome is suspected, follow the urgent pathway described in the back section; a reassuring examination must not delay appropriate assessment.

Further reading

• Geeky Medics — Foot and ankle exam
• TeachMeAnatomy — Ankle anatomy
• TeachMeAnatomy — Foot anatomy
• NICE CKS — NICE: How should I assess a strain or sprain (includes the Ottawa ankle rules)
• CUH — Achilles tendon rupture
• NICE NG38 — fracture assessment

Introduction

“Hello, my name is Dr Smith I am one of the Senior Doctors working in the Emergency Department today.”

“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

“Are you comfortable? Do you need any pain relief?”

“I have been asked to conduct a screening examination of your musculoskeletal system. This will involve me asking you a couple of questions, then briefly assessing your gait (walking); arms; legs and spinal movements. Would that be ok with you?”

“Would you like a chaperone present?”

“Are you happy to ensure your arms are fully visible from shoulder to fingers; take off both shoes and socks and roll your trousers up to above your knees.”

“I will explain what I am doing as we go.”

“Please tell me if anything hurts or you want me to stop.”

Three questions

• Do you have pain, stiffness or swelling in your joints, muscles or back?
• Can you dress yourself completely without difficulty?
• Can you walk up and down stairs without difficulty?

GALS examination

GALS = Gait, Arms, Legs and Spine. This is a screen; an abnormal finding prompts a focused regional examination.

Gait

Observe walking, turning, posture and limb alignment, with support if needed.

Arms

Ask for hands behind the head and elbows back; then arms forward, palms down and up. Inspect hands, make a fist, assess grip and finger–thumb pinch, and gently squeeze the MCP joints.

Legs

With the patient supine, inspect alignment, assess knee flexion/extension and hip internal rotation, check the knees for swelling, and inspect the feet with a gentle MTP squeeze.

Spine

Inspect spinal alignment and curves. Assess lateral neck flexion and forward lumbar flexion when safe.

Arthritis UK — full GALS demonstration

Close

“Thank you. That is the end of the examination. Would you like help getting dressed?”

Summarise the findings, explain your working diagnosis and agree the next steps. Invite questions and describe symptoms that should prompt urgent reassessment.

Complete a focused examination of the any symptomatic region where relevant. Document neurovascular findings and any limits caused by pain. Choose investigations and referral for the presentation.

Further reading

• Geeky Medics — GALS examination
• Arthritis UK — GALS demonstration