MODULE 15
Learning objective
1. The student is able to perform screening musculoskeletal examination GALS (gait, arms, legs and spine).
2. The student is able to record the findings from GALS examination.
3. The student is able to perform shoulder examination
4. The student is able to perform knee examination
5. The student is able to perform hip examination
6. The student is able to perform leg examination
GALS assessment
In combination with supervised accredited practice the successful student should be to able to perform a GALS assessment of the musculoskeletal system
Gait Arms Legs Spine
The GALS screening examination is a fast and efficient way to assess the integrity of the musculoskeletal system. It is not meant to be a diagnostic examination - but a brief screening examination for significant abnormality of the musculoskeletal system If any abnormality is detected then a more detailed regional examination should be carried out. An assessment of the musculoskeletal system should always take place in the routine clerking in of patients.You will have an opportunity in the CSEC to practice carrying out a GALS assessment.
Screening questions for musculoskeletal disorders
1. Do you have any pain or stiffness in your arms, legs or back?2. Can you walk up and down stairs without difficulty?3. Can you dress yourself in everyday clothes without any difficulty?
Screening examination for musculoskeletal disorders
Gait
Ask the patient to walk a few steps, turn & walk back.
Observe the patients gait for symmetry, smoothness and the ability to turn quickly.
With the patient in the anatomical position inspect from the posterior, lateral and anterior aspects.
Observe for any abnormalities in the muscles (e.g. reduced muscle bulk), spine (e.g. abnormal spinal curvature such as scolosis), limbs or joints (e.g. a red swollen knee)
Spine
Inspection
Inspect the spine for any abnormalities including abnormal kyphosis, scolosis or loss of lordosis.
Neck movements
Ask the patient to tilt their head to each side, brining the ear towards their shoulder. Assess the degree of lateral neck flexion.
Lumbar spine movement
Ask the patient to bend forward and touch their toes. During this movement the patient may depend partly on good hip flexion to bend forwards. So it is always a good idea to palpate for the range of lumbar movement. Place two fingers over the lumbar vertebra. As the patient bends forward your fingers should move apart (assuming the patient has a good range of lumbar spine movement)
Arms
Shoulder movements
Ask the patient to place their hands behind their head, with their elbows back This movement assesses abduction, external rotation of the shoulder and elbow flexion.
Elbow movements & hands
Ask the patient to extend their arms fully and turn their hands over so palms are down.
Following this ask the patient to turn their hands over.
Observe the hands for any joint swelling or deformities
Click here to see some interesting clinical cases
Grip strength
Ask the patient to make a fist. Observe the hand and finger movements
Ask the patient to grip your fingers and assess the degree of grip strength
Precision pinch
Ask the patient in turn to bring each finger in turn to meet the thumb
Metacarpalphalangeal squeeze test
Squeeze across the metacarpalphalangeal joints (tenderness here may indicates synovitis of metacarpalphalangeal joints)
Click here to see some interesting clinical cases
Leg
Knee movements
With the patient lying on the couch assess flexion and extension of both knees. Make sure to palpate the knee for crepitus
Hip movement
Hold the knee & hip flexed to 90 degrees. Now assess the degree of internal rotation in each hip
Patellar tap test
Perform a patellar tap in each knee for the presence of an effusion
Inspection of feet
Inspect the feet for any swelling, deformity or any callosities
Metacarpalphalangeal squeeze test
Squeeze across the metatarsophalangeal joints for any tenderness
Record
Record your findings
Skill
Shoulder examination
Learning outcome
To be able to i) identify surface anatomy of the shoulder ii) examine a patients shoulder & iii) compare left and right shoulders.
Background
The shoulder joint is the most mobile joint in the body, allowing the hand to be placed into a position where it can operate efficiently. To achieve its range of mobility, the shoulder is dependent for stability on surrounding soft tissue structures, in particular a group of muscles called the rotator cuff. The two main bones of the shoulder are the humerus and the scapula. The joint cavity is cushioned by articular cartilage covering the head of the humerus and face of the glenoid. The scapula extends up and around the shoulder joint at the rear to form a roof called the acromion, and around the shoulder joint at the front to form the coracoid process. The end of the scapula, called the glenoid, meets the head of the humerus to form a glenohumeral cavity that acts as a flexible ball-and-socket joint. The joint is stabilized by a ring of fibrous cartilage surrounding the glenoid called the labrum. Ligaments connect the bones of the shoulder, and tendons join the bones to surrounding muscles. The biceps tendon attaches the biceps muscle to the shoulder and helps to stabilize the joint. A group of short muscles originate on the scapula and pass around the shoulder where their tendons fuse together to form the rotator cuff. Movements of the shoulder joint are dependent on five functional areas: glenohumeral joint; the acromioclavicular joint; the subacromial joint between the acromioclavicular arch above and the head of the humerus below; the sternoclavicular joint and the scapulothoracic region. Shoulder pain can arise from a number of sites including: the rotator cuff tendons, biceps tendon, subacromial bursa, glenohumeral joint, acromioclavicular joint & the sternoclavicular joint.
Procedure
INTRODUCTION, PATIENT IDENTIFICATION & CONSENT
HAND WASHING
EXPOSURE When examining a patients shoulder, their upper garments should be removed. This will also provide an opportunity to observe the patients shoulder function.
INSPECTIONObserve both shoulder areas from the anterior, lateral and posterior aspects. Observe for any scars, swelling, erythema, muscle wasting or abnormal contours.
Example of a scar in a patient who has received shoulder surgery.
PALPATION Prior to palpating the patients shoulders, ask if they are experiencing any pain. It is often useful to have the patient point to the site where they are experiencing discomfort. Equally you should instruct the patient to inform you if they experience any pain during the examination.
During palpation observe for any signs of tenderness, swelling, temperature or crepitus.You should palpate both shoulder joints in a systematic approach. A suggested approach would be:
1) Sternoclavicular joint 2) Clavicle 3) Acromioclavicular joint 4) Humeral head 5) Coracoid process 6) Deltoid muscle 7) Spine of scapula 8) Supraspinatus muscle 9) Infraspinatus muscle 10) Trazpezus muscle (then repeat on the other side)
MOVEMENT
Note! Remember in assessing the patients range of shoulder movements you should always compare one side with the other.
When assessing movement in a patients shoulder joint you should assess:Active movements (i.e. movements performed by the patient on their own)Passive movements (i.e. movements performed by the examiner)Resisted movements (i.e. movements against resistance)
A general rule of thumb is that reduced active movements, that improve on passive movement, suggest muscular / tendon problems. Reduced range of both active and passive movements suggest intra-articular disease.
The range of movements that we assess for in the shoulder joint include:
Flexion Extension Abduction Adduction Internal rotation External rotation
Tip! To have the patient perform the various range of shoulder movements try not to use medical jargon (e.g. Abduct your shoulder please!). Stand in front of the patient, face to face, and ask them to copy the movements that you make (assuming that your shoulders have a normal range of movement!) - this can make patient understanding of your instructions a lot easier.
ACTIVE MOVEMENTS:
Active shoulder flexion
Have the patient flex their elbows to 90 degrees, then ask the patient to move their arms upward as high as possible.
(Normal range - usually 180 degrees)
Active shoulder extension
Have the patient flex their elbows to 90 degrees, then ask the patient to move their arms backwards as far as possible.
(Normal range ~ usually 50 degrees)
Active shoulder abduction
With the elbows fully extended, ask the patient to bring their arms away from their body.
(Normal range ~ usually 180 degrees)
Active shoulder adduction
With the elbows fully extended have the patient place their arms across their trunk.
(Normal range ~ usually 45 degrees)
Active shoulder external rotation
With the elbows flexed to 90 degrees, have the patient pin their elbows to their side. Now ask them to move there arms out as far as possible
(Normal range ~ usually 90 degrees)
Alternatively you may ask the patient to place their hands behind their head, with their elbows far back as possible.
Active shoulder internal rotation
Again with the patients elbows flexed to 90 degrees and their elbows pinned to their side, have the patient bring their arms to their centre
(Normal range ~ usually 50 degrees)
Alternatively you may ask the patient to place their thumbs up their back and try to touch their back as high as possible
PASSIVE MOVEMENTS:
Prior to passive movements it is important to have your patient relax as best as possible.
Passive shoulder flexion
Flex the patients elbow to 90 degrees, then move their arm upward as high as possible. (Repeat on the other side)
(Normal range ~ usually 180 degrees)
Passive shoulder extension
Flex the patients elbow to 90 degrees, then move their arm backwards as far as possible (Repeat on the other side)
(Normal range ~ usually 50 degrees)
Passive shoulder abduction
Fully extend the patients elbow. The examiner shoulder place a hand on the patients scapula to fix it in that position. Now move the patients arm away from their body. By fixing the scapula, allows assessment of the glenohumeral joint only. The normal range of movement here should be approx 90. By taking your hand of the patients scapula, should now allow for scapulothoracic movement which normal can bring the arm up to 180 degrees. (Repeat on the other side)
Passive shoulder adduction
Fully extend the patients elbow, and then place their arm across their trunk as far as possible. (Repeat on the other side)
(Normal range ~ usually 45 degrees )
Passive shoulder external rotation
Flex the patients elbow to 90 degrees and pin their elbow to their side. Now move there arm out as far as possible. (Repeat on the other side)
(Normal range ~ usually 90 degrees )
Passive shoulder internal rotation
Again with the patients elbow flexed to 90 degrees and their elbow pinned to their side, move their arm to their centre. (Repeat on the other side)
(Normal range - usually 50 degrees )
Depending on your clinical findings you may want to perform resisted movements. This will be covered in the CSEC & in your clinical attachments
When making an assessment of a patients shoulder there are many other special tests / manoeuvres that can be performed. They will not be discussed here.
You may also consider examining the patients peripheral neurological system in the upper limbs and circulation status.
EXAMINATION OF OTHER AREAS
Remember there are many other conditions that can cause shoulder pain (e.g. pain radiating from the neck, gallbladder disease, cardiac pain) so depending on the circumstances you may want to perform other relevant clinical examinations.
Skill
Knee examination
Learning outcome
To be able to i) identify surface anatomy of the knee & ii) examine a patients knee
Back ground
Knee pain can be a source of significant disability & health care utilization. Around 4.5 million people in the UK have severe knee pain. Because of our ageing population & increasing levels of obesity, the number of patients with disabling knee pain is set to increase. In order to make an accurate diagnosis of a patients knee pain a thorough physical examination needs to take place including
i) a careful inspection of the kneeii) palpation of the knee iii) assessment for joint effusion iv) range-of-motion testing v) evaluation of ligaments for any signs of injury or laxityvi) assessment of the menisci
PROCEDURE
Introduction
Introduction & patient consent
Hand hygiene
Hand washing
Exposure
Make sure that both knees are fully exposed. The patient should be in either a gown or shorts. Rolled up trouser legs generally does not provide adequate exposure.
Inspection
Observe the patient both walking and standing. Do they walk with a limp or appear to be in pain? Is there any evidence of muscle wasting?
Is there any evidence of bowing (varus) or knock-kneed (valgus) deformity?
A patient with genu varum (Varus deformity of the knee) due to osteoarthritis
Any scars present?
Recent scar & staples after a total knee replacement
Does the knee appear red or swollen?
A patient with prepatellar bursitis
Any rashes present?
A patient with psoriasis
Palpation
For this part of the examination place the patient on the bed. If the patient has an injured knee, start by examining the unaffected side. This allows for comparison while gaining the patients confidence, given that you are not causing discomfort right from the outset of the examination. Remember that in all parts of the knee examination, always compare one knee with the other.
Feel systematically around the knee joint for tenderness including the patella, quadriceps tendon, prepatellar & collateral ligaments. Bend the knee to 90 degrees & feel around the medial & lateral joint lines for tenderness. Remember to feel at the back of the knee for a popliteal (Bakers cyst) With the back of your hand do you feel an increased temperature compared to the other knee?
Palpate knee for temperature
Palpate around joint margins
Assess for an effusion
Patellar tap test : Slide your hand down the patients thigh, pushing down over the suprapatellar pouch, so that any effusion is forced behind the patella. When you reach the upper pole of the patella, keep your hand there and maintain pressure. Using the index & middle finger of the other hand push the patella down gently.Does it bounce? If so this may indicate the presence of an effusion.
Milk the suprapatellar pouch
Patella tap
Bulge test:
Using your thumb and index finger - milk down any fluid from above the knee. Keep this hand in this position.
Now with the other hand stroke the medial side of the knee to empty the medial compartment of fluid then stroke the lateral side. Observe the medial side of the knee for any bulging? This may indicate an effusion.
Applying pressure to the medial side of the knee
Applying pressure to the lateral aspect of the knee and observing for any bulging on the medial side of the knee
Movement
The normal range of motion of the knee is from: 0 degrees (Extension) to approx 135 degrees (Flexion)
Active movementAsk the patient to fully bend (flex) then straighten (extend) their knee. Always compare the range of movement with the other knee. Is there any reduced range of movement?
Active flexion of the knee
Passive movementPlace one hand on the patients knee and then with the other hand flex (bend) the knee as far as possible & then extend the knee. With the hand that is placed over the knee do you feel a 'grinding' sensation? Such a grinding sensation (crepitus) is usually indicative of degenerative knee disease (osteoarthritis) which reflects a loss of the normal smooth movement between the articulating structures (i.e. femur, tibia, and patella).
Passive flexion of the knee
Special tests
Collateral ligament assessment
Medial Collateral Ligament:
Cradle the patients lower leg between your arm and body. The knee should be flexed to 30 degrees. Now with your other hand apply valgus stress to the knee joint. Excessive movement indicates ligament damage.
Lateral Collateral Ligament
Cradle the patients lower leg between your arm and body. The knee should be flexed to 30 degrees. Now with your other hand apply varus stress to the knee joint. Excessive movement indicates ligament damage.
Cruciate ligament assessment
Anterior Cruciate LigamentThe integrity of the anterior cruciate ligaments can be assessed using the anterior draw test. Have your patient assume the supine position with their knee flexed to approx 90 degrees. After checking if the patient does not have a sore foot, fix the patient's foot by sitting on their foot, in order to stabilize the lower leg. With the patient's hamstring muscles relaxed, wrap your fingers around the back of the knee, keeping your thumbs in front of the patella. Now pull anteriorly. In a relaxed normal patient there is usually a small degree of movement. Excessive movement may be indicative of anterior cruciate ligament injury.
Posterior cruciate ligamentSimply repeat the process as for anterior draw test but instead of pulling - push the patients lower leg. Excessive movement in the posterior plane may be indicative of posterior cruciate ligament injury.
Stablizing the patients lower leg
Assessing for any excessive anterior & posterior movement
Menisci
There are several special tests to assess the integrity of the menisci. In Apley's grind test place the patient in the prone position. Now flex their knee to 90 degrees. Using your one hand to stabilize their lower leg, grip the patients heel with your other hand. Now gently push down while rotating the ankle back and forth. A grinding sensation or pain may be indicative of meniscal damage. Another test is McMurrays test which will be covered at a later date in your course.
Apley's grind test
Skill
Spine examination
Learning outcome
In combination with supervised accredited practice the successful student should be able to perform an assessment of a patients spine.
Background
Disorders of the spine are the commonest form of musculoskeletal conditions that present in clinical practice. Lower back pain affects 4 out of 5 people at some time in their lives and has a major impact in terms of morbidity, disability, socioeconomic burden & lost days at work. Vital to the examination of the spine is to have a good knowledge of the anatomy of this area.
1= Vertebral body2= Vertebral foramen3= Spinous process4= Pedicle5= Superior articular process6= Transverse process7= Lamina
1= Cervical lordosis2=Thoracic kyphosis3= Lumbar lordosis4= Sacral kyphosis
1="Vertebra prominens" Spinous process of C72= 2nd Lumbar vertebra3= L4-5 inter vertebral space4= Iliac crests5= Dimples of Venus / Sacroiliac joints
Examination of the spine
Introduction
Introduce your self to the patient, identify the patient's details and gain informed consent.
Patient instructions
Ask if they are in any pain, and to inform you if they experience any discomfort during the examination. Exposure of spine- remove upper garment; ideally should be wearing shorts or an examination gown.
Hand washing
Wash hands prior to examination
Inspection
Inspection
While the patient is removing their garments, use this opportunity to observe the patient performing this activity of daily living. Any difficulties observed?
Gait
Ask the patient to walk several yards, turn around and then walk back. Observe their gait carefully. Is there easy following movement? Is there symmetrical movement? Is there a normal gait cycle from heel strike to toe off? Do you observe an Antalgic gait? (where pain or deformity causes the patient to hurry off one leg and to spend most of the gait cycle on the other. May suggest abnormality in one region e.g. lumbar spine or hip)
From behind and in front
Orientate your self to the patients surface anatomy. Observe the patients posture. How do they hold their neck? Do they have a straight spine or do you detect a scoliosis (click here for more information on scoliosis) or rib cage asymmetry? Is there normal muscle bulk? Do they have any scars from previous spinal surgery?
From the side
Is there loss of the normal cervical and lumbar lordosis (Click here for more information on abnormal kyphosis)? No you notice any alteration of the normal mild thoracic kyphosis?
Palpation
Palpation:
Gently palpate over the spinous process from the cervical region down. Is there any tenderness (if so this may indicate local pathology in that vertebra).
The facet joints may be palpated laterally to the spinous processes and further lateral, the paraspinal muscles.
Movement
Observe for any restricted movements, smoothness of movement and for any pain experienced during movements. In addition to your verbal patient instructions, you may want to demonstrate these movements to the patient.
Cervical spine
Cervical spine
Cervical spine flexionTouch your chin on your chest
Cervical spine extension Look up and back
Lateral cervical spine flexion Touch your shoulder with your ear (Both sides) (Not bringing their shoulder up to their ear!)
Lateral cervical rotation (Both sides) Touch your shoulder with your chin
Thoracolumbar
Lumbar flexion Try to touch your toes without bending knees
Lumbar extensionLean back
Lateral lumbar flexion (Both sides) Slide your hand down your leg
Thoracolumbar rotation Sit down and turn round, looking over your shoulder
(Sitting down helps fix the patients pelvis)
Other tests
Schober's test
In lumbar spine flexion, hip flexion can compensate to a considerable extent for a loss of spinal flexion. You may want to consider performing Schobers test to objectively measure the degree of spinal flexion. Firstly identify the Dimples of Venus (2). Now in the midline, use a tape measure and pen to mark a point 10cm superior (1) to, and an other mark 5 cm inferior (3) to this point.
Ask the patient to attempt to touch their toes (i.e Flexing their lumbar spine).The distance between these two marks should be measured when the patients spine is flexed maximally.
The distance should increase to more than 21cm in a normal patient. A modified way to demonstrate lumbar spine flexion is to place several fingers over the lower lumbar spinous processes and ask the patient to bend forward and touch there toes as best as possible. In a normal spine your fingers should move part.
Other tests
Given the close proximity of the spine and the spinal cord and nerve roots it is very important to consider performing a peripheral neurological examination, together with some special nerve root stretch tests. In the CSEC and your attachments you will learn further information about conditions such as Sciatica and cauda equina (Click here for further information)
Straight leg raising (SLR):
With the patient supine, the examiner uses their arm to fix the pelvis. The patient then attempts to raise one leg at a time, with the knee fully extended. Make an assessment of the degree of movement from the horizontal. Repeat other on the other side.
Lasegues test:
Is a refinement of the SLR test. It aims to assess the limitation of movement due to sciatic nerve root pressure. When the limit of SLR is reached, dorsiflexion of the ankle produces acute accentuation of pain. Conversely asking the patient to bend their knee should relieve the pain.
Femoral stretch test:
Have the patient lie prone. Passively flex the knee as far as it goes. In a positive test the patient should feel pain in the ipslateral anterior thigh (i.e. the distribution of the femoral nerve) Also pain may be exacerbated on hip extension.
Peripheral nerve examination:
Consider performing a perpherial nerve examination, including assessment of saddle sensation and anal tone if clinically required.
Sacroiliac joints:
Are difficult to assess. They have minimal movement. Pain may be induced on compression of the pelvis or by distracting it by flexing the hip & knee and forcibly, adducting the leg across to the contra lateral iliac fossa.
Abdominal examination:
Several intrabdominal conditions can present as back pain (e.g abdominal aortic aneurysm, acute pancreatitis) therefore it may be worthwhile considering performing an abdominal examination.
Skill
Hip examination
Learning outcome
The successful student should be able to perform a clinical examination of the hip joint.
Background
The hip is a synoviumlined ball and socket joint that plays a major role in weight bearing and locomotion. Its stability is due to the relatively deep insertion of the femoral head into the acetabulum and the strong capsule and surrounding muscles. To properly examine the hip joint a good anatomical knowledge of this area is vital. For further reading about hip anatomy click here for link.
Some bony anatomical areas worth noting:
1) Anterior superior iliac spine 2) Anterior inferior iliac spine 3) Pubic tubercle 4) Pubic symphysis 5) Superior pubic ramus 6) Inferior pubic ramus 7) Greater trochanter 8) Lesser trochanter 9) Femur 10) Head of femur11) Ischial spine 12) Ischial tuberosity 13) Sacroiliac joint14) Posterior inferior iliac spine 15) Crest of ilium
Procedure
Procedure
INTRODUCTION, PATIENT IDENTIFICATION & CONSENT
HAND WASHING
EXPOSUREExpose the patient's legs by asking the patient to undress down to their underwear.
INSPECTIONi) Standing:Observe the patient from all sides with the patient standing stationary. Inspect for the level of the iliac crests. Now have the patient walk to the other side of the room, turn around and walk back. Observe the patients gait and pelvic movements. In a Trendelenburg gait the pelvis on the opposite drops and the body leans away from the affected side, when weight bearing is on the affected hip.
ii) Lying supine: Have the patient lie supine on a couch. Are any scars present? Muscle wasting present? Is there any obvious discrepancy in leg length?
PALPATION Palpate around the hip area. Specifically is there any tenderness around the inguinal area and the greater trochanter area? Is there any tenderness? Heat? Swelling?
MeasurementTrue length of the legs using a tape measurer measure the distance between the anterior iliac spine to the tip of the medial mallous, with the anterior spines lying at the same transverse level. Compare one side to the other.
Measuring the true length of the legs
The apparent length - is measured from the xiphisternum to the tip of the medial mallous, with the legs in a parallel position.
Measuring the apparent length of the legs
Note! When examining hip movements, the pelvis needs to be fixed in order to observe the range of movement in the hip joint and not the pelvis (i.e tilt and shift). Remember to compare one side with the other.
MOVEMENT:
FLEXIONHave the patient flex their knees & move their hip joint into the flexed position as fair as possible. (Normal range ~ 120 degree)(If you keep the knee extended the range of movement in the hip joint is limited by tension in the hamstring muscles)
ABDUCTIONMake sure you stabilze the pelvis by placing a hand on the opposite anterior iliac crest and holding the ankle with the other hand. The hip is abducted until the pelvis tilts. (Normal range of movement ~ 45 degrees)
ADDUCTIONCross one leg over the other until pelvis begins to tilt. (Normal range of movement ~ 30 degrees)
INTERNAL ROTATIONFlex the hip and knee to 90 degrees. Now move the leg laterally. (Normal range of movement ~ 45 degrees)
EXTERNAL ROTATIONAgain with the hip and knee flexed move the patients leg medially. (Normal range of movement ~ 60 degrees)
EXTENSION Have the patient lie prone on the couch. Immobilise the pelvis with one hand while extending the hip with the other hand.
SPECIAL TESTS:
i) THOMAS' TESTThomas test Is used to detected a fixed flexion deformity in the hip. Place your hand behind the small of the patients back, between it and the couch. There is normally a small gap here due to normal lumbar lordosis. Abolish the lumbar lordosis by asking the patient to flex the hip and feel the lumbar spine flatten out onto your hand. When you are happy that the lumbar spine is flat, see if the patients other knee is flat on the couch. If not, measure the angle of (fixed) hip flexion. Then repeat the test asking the patient to clasp their other knee up against their chest and observe for fixed flexion deformity in the previously flexed hip.
ii) TRENDELENBURG TESTDetects weakness of the gluteus medius hip abductors. This can be due to true weakness as in neurological disease or wasting associated with hip arthritis or to painful reflex inhibition. In an adult the commonest cause of a positive test is osteoarthritis of the hip. Ask the patient to stand on each leg in turn. Observe the pelvis for any tilt. In normal individuals the pelvis will rise on the side of the leg that has been lifted. With instability, the pelvis may drop on the side of the leg that has been lifted. Repeat on the other side.
Standing on both legs
Normal - the pelvis rises on the side of the lifted leg
Abnormal - the pelvis drops on the side of the lifted leg.
Further reading
1. The Arthritis Research Campaign,2005.
2. Rheumatology Examination and Injection Techniques,2nd ed. M Doherty, BL Hazleman, CW Hutton et al. WB Saunders.
3. Current Rheumatology Diagnosis & Treatment. J Imboden, DB Hellmann, JH Stone. McGraw Hill,2005
Musculoskeletal system BLOCK
1. Overview
Musculoskeletal block will be held on third semester within 5 weeks. In this block students will learn about musculoskeletal injury and musculoskeletal disease in scope of anatomic, physiology, pathophisiology, diagnostic problem and management. Therefore, skill of history taking, physical examination, laboratorium finding, radiographic interpretation and management are needed.
This block will use problem based strategy with discussion, skill station methods and expert lecture.
2. Learning outcome
Upon completion of this block, the student will :
a. Understand about anatomy and physiology aspect of the musculoskeletal system.
b. Understand about pathophysiology of the musculoskeletal system injury and disease
c. Be able to perform history taking, physical examination and supporting diagnostic tools related to musculoskeletal problems
d. Be able to manage patient with musculoskeletal injury and musculoskeletal disease based on competency level.
3. Topics
This block divided into 7 topics :
Topic 1: Anatomy
Topic 2: Normal strucuture and function of musculoskeletal tissue
Topic 3: Reaction of musculoskeletal tissues to disorders and injuries
Topic 4: Musculoskeletal injuries
Topic 5: Degenerative and inflammation disorder of musculoskeletal sytem
Topic 6: Autoimune disorder of musculoskeletal system
Topic 7: Clinical skill
4. Topic algorythm and topic tree
5. Learning methods
a. Tutorial
b. Classroom
c. Small group discussion
d. Lecture
e. Skill station
6. Modul contents
Each module content :
a. Student guidance
b. Teacher guidance
c. Presentation form
7. Core contributor
a. Anatomy
b. Physiology
c. Orthopaedic & Traumatology
d. Rheumatology
8. Supplementary contributor
a. Radiology
b. Patology
c. Microbiology
d. Clinical Pharmacology
e. IKMKP
f. Clinical pathology
9. Skill station
a. History taking
b. Musculoskeletal physical examination
10. Expert lecture contents
Physiology
Pharmacology
Pain
Maxillofacial problem
Introduction to musculoskeletal radiology
Inflammation related to musculoskeletal
Muskuloskeletal trauma
Neoplasm
Introduction to rheumatology
Clinical Rheumatology
Laboratory test for rheumatic diseases
Community medicine
11. List of tutor
X
Y
Prof. M. Hidayat
Prof. Handono Kalim
Prof. Bambang Pardjianto
Dr. Bagus P. Suryana
Dr. C. Singgih Wahono
Dr. Saifullah Asmiragani
Dr. Elly
Dr. Eviana
Dr. Hani
Dr. Widodo
Dr. Sri Sunarti
Dr. Panji Sananta
Dr. Satria Pandu
Dr. Machlusil
Dr. Eriko
Dr. Wening
Dr. Thomas
Dr. Nurdiana
Dr. Tjuk
Dr. Laksmi
Dr. Retty
Dr. Dian Hasanah
Dr. Obed
Dr. Dani
Dr. Sumardini
Dr. Dian Nugraheni
Dr. Ridwan
Dr. Onggung
Dr. Edi Mustamsir
Dr. Maimun
12. Block related
Block struktur, fungsi dan patologi umum
Block dasar infeksi mikroba dan imunologi
Block farmakokinetik dan farmakodinamik
Block basic communication & history taking
Block siklus hidup & nutrisi
Block BLS
13. Design schedule
Week 1
Week 2
Week 3
Week 4
Week 5
Monday
Anatomy
Basic Science
Clinical related and Clinical skill
Tuesday
Wednesday
Thursday
Friday
14. Topic Module
BASIC SCIENCE
Topic 1: Anatomy
Lecture I: Anatomy of the upper extremity
Lecture II: Anatomy of the lower extremity
Lecture III: Anatomy of the joint
Practice I: Anatomy of the upper extremity
Practice II: Anatomy of the lower extremity
Practice III: Anatomy of the joint
Topic 2: Normal strucuture and function of musculoskeletal tissue
Module I: Bone growth, remodelling and bone metabolism
Module II: Joints and articular cartilage
Module III: Tendon and ligament
Module IV: Skeletal muscle
Topic 3: Reaction of musculoskeletal tissues to disorders and injuries
Module V: Reaction of Musculoskeletal tissues to disorders and injuries
CLINICAL RELATED
Topic 4: Musculoskeletal injuries
Module VI: General concept of trauma
Module VII: Fracture and dislocation
Module VIII: Soft tissue injuries
Topic 5: Degenerative and inflammation disorder of musculoskeletal sytem
Module IX: Osteoporosis and osteoarthritis
Module X: Osteomyelitis
Module XI: Gouty arthritis
Topic 6: Autoimune disorder of musculoskeletal system
Module XII: SLE
Module XIII: Rheumatoid arthritis
Topic 7: Clinical skill
Module XIV: History taking
Module XV: GALS examination
Module XVI: Shoulder and spine examination
Module XVII: Hip and knee examination
Module XVIII: Pharmacotherapy
15. Evaluation
Anatomy evaluation
MCQ format
Laboratory format
Module evaluation
MCQ format
16. Time schedule
Senin (12 Sept 2011)
Selasa (13 Sept 2011)
Rabu (14 Sept 2011)
08 - 09
ANATOMY
ANATOMY
ANATOMY
09 10
10 11
11 12
12 13
LUNCH/ISHOMA
13 14
ANATOMY
ANATOMY
ANATOMY
14 15
Kamis (15 Sept 2011)
Jumat (16 Sept 2011)
08 - 09
ANATOMY
ANATOMY
09 10
10 11
11 12
FRIDAY PRAY
12 13
LUNCH/ISHOMA
13 14
ANATOMY
ANATOMY
14 15
Senin (19 Sept 2011)
Selasa (20 Sept 2011)
Rabu (21 Sept 2011)
08 - 09
MODULE 1 ( tutor X )
SGD ( 15 classes )
BONE GROWTH AND
BONE METABOLISM
MODULE 2 ( tutor X )
SGD ( 15 classes )
JOINT AND CARTILAGE
MODULE 3 ( tutor X )
SGD ( 15 classes )
TENDON AND LIGAMENT
09 10
10 11
11 12
12 13
LUNCH/ISHOMA
13 14
EXPERT LECTURE
Pain
Dr Farhad (KBI)
Dr Agus Chairul (A)
Dr Saifullah A (B)
EXPERT LECTURE
Maxillofacial problem
Prof Bambang P (KBI)
Dr Herman (A)
Dr Agus Chairul (B)
EXPERT LECTURE
Radiology
Dr Indrastuti (KBI)
Dr Enny (A)
Dr Yuyun (B)
14 15
Kamis (22 Sept 2011)
Jumat (23 Sept 2011)
08 - 09
MODULE 4 ( tutor X )
SGD ( 15 classes )
SKELETAL MUSCLE
MODULE 5 ( tutor X )
SGD ( 15 classes )
REACTION OF MS TISSUES TO INJURY
09 10
10 11
11 12
FRIDAY PRAY
12 13
LUNCH/ISHOMA
13 14
EXPERT LECTURE
Physiology
Dr Retty (KBI)
Dr Sudiarto (A)
Dr Dian (B)
EXPERT LECTURE
Physiology
Dr Retty (KBI)
Dr Sudiarto (A)
Dr Dian (B)
14 15
Senin (26 Sept 2011)
Selasa (27 Sept 2011)
Rabu (28 Sept 2011)
08 - 09
MODULE 6 ( tutor Y )
SGD ( 15 classes )
GENERAL CONCEPT OF TRAUMA
MODULE 7 ( tutor Y )
SGD ( 15 classes )
FRACTURE AND DISLOCATION
MODULE 8 ( tutor Y )
SGD ( 15 classes )
SOFT TISSUE INJURY
09 10
10 11
11 12
12 13
LUNCH/ISHOMA
13 14
EXPERT LECTURE
MSK trauma
Prof M Hidayat (KBI)
Dr Tjuk (A)
Dr Edi Mustamsir (B)
EXPERT LECTURE
IKM-KP
Dr Jack Roebijoso (KBI)
Dr Nanik (A)
Dr Sri Andarini (B)
EXPERT LECTURE
Lab aspect for musculoskeletal disor.
Dr Kusworini (KBI)
Prof Edi W (A)
Dr Ati (B)
14 15
Kamis (29 Sept 2011)
Jumat (30 Sept 2011)
08 - 09
MODULE 9 ( tutor Y )
SGD ( 15 classes )
Osteoporosis and
Osteoarthritis
MODULE 10 ( tutor Y )
SGD ( 15 classes )
Osteomyelitis
09 10
10 11
11 12
FRIDAY PRAY
12 13
LUNCH/ISHOMA
13 14
EXPERT LECTURE
Intro. Rheumatology
Prof Handono Kalim (KBI)
Dr B Putra (A)
Dr Singgih (B)
EXPERT LECTURE
Inflam related to MSK
Dr Norahmawati (KBI)
Dr Imam Sarwono (A)
Dr Muji Wiyono (B)
14 15
Senin (3 Oct 2011)
Selasa (4 Oct 2011)
Rabu (5 Oct 2011)
08 - 09
MODULE 11 ( tutor X )
SGD ( 15 classes )
GOUTY ARTHRITIS
MODULE 12 ( tutor X )
SGD ( 15 classes )
SLE
MODULE 13 ( tutor X )
SGD ( 15 classes )
RHEUMATOID ARTHRITIS
09 10
10 11
11 12
12 13
LUNCH/ISHOMA
13 14
EXPERT LECTURE
Clinical Rheumatology
Prof Handono Kalim (KBI)
Dr B Putra (A)
Dr Singgih (B)
EXPERT LECTURE
Pharmacology
Dr
Dr
Dr
EXPERT LECTURE
Neoplasma
Dr Norahmawati (KBI)
Dr Imam Sarwono (A)
Dr Muji Wiyono (B)
14 15
Kamis (6 Oct 2011)
Jumat (7 Oct 2011)
08 - 09
EXPERT LECTURE
Conge.&ped disorder
Dr Panji (KBI)
Dr Satria Pandu (A)
Dr Thomas (B)
MODULE 14 ( tutor X )
CLINICAL SKILL
History taking
15 CLASSES
09 10
10 11
MODULE 18
Tutor ( pharmaco )
CLINICAL SKILL
Pharmacotherapy
10 classes
11 12
FRIDAY PRAY
12 13
LUNCH/ISHOMA
13 14
EXPERT LECTURE
Microbiology
Dr.
Dr.
Dr.
14 15
Senin (10 Oct 2011)
Selasa (11 Oct 2011)
Rabu (12 Oct 2011)
08 - 09
MODULE 15 ( tutor Y )
CLINICAL SKILL
GALS examination
15 CLASSES
MODULE 16 ( tutor Y )
CLINICAL SKILL Shoulder and arm examination
15 CLASSES
MODULE 17 ( tutor Y )
CLINICAL SKILL
Hip and leg examination
15 CLASSES
09 10
10 11
11 12
12 13
LUNCH/ISHOMA
13 14
CLINICAL SKILL
CLINICAL SKILL
CLINICAL SKILL
14 15
Kamis (13 Oct 2011)
Jumat (14 Oct 2011)
08 - 09
UJIAN ANATOMI
UJIAN MODULE
09 10
10 11
11 12
12 13
LUNCH/ISHOMA
13 14
UJIAN PRAKTIKUM
ANATOMI
14 15
Clinical skill : Physical examination
BLOCK
Musculoskeletal
System
BRAWIJAYA UNIVERSITY
FACULTY OF MEDICINE
MALANG
2011
MUSCULOSKELETAL SYSTEM
BASIC SCIENCE OF MUSCULOSKELETAL SYSTEM
MUSCULOSKELETAL INJURY
MUSCULOSKELETAL DISORDERS
Anatomy
Physiology
Biomechanic
Farmacology
Inflamation
Degeneration
Neoplasma
Congenital
Metabolic
Upper extremity fracture
Lower extremity fracture
Spine fracture
Soft tissue injury
Fracture
Bone
injury
Soft tisuue
injury
Musculoskeletal
Injury
Dislocation
Musculoskeletal
System
Infection
Musculoskeletal
Disorder
Autoimmune
Degeneration
Neoplasma
Metabolic
Congenital/
pediatri