Year 2 MBChB

Clinical Skills Session

Musculoskeletal Examination

Reviewed & ratified by:

Mr Lyndon Mason - Musculoskeletal System Lead

Mr Ashley Newton – Trauma & Orthopaedic

August 2018

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Musculoskeletal Examination

Objectives

Objective: To revise anatomy and physiology of the Musculoskeletal (MSK) system

Objective: To link the anatomy and physiology to the examination

Objective: To be able to perform a MSK examination including an understanding of the common abnormalities

Theory and background

Musculoskeletal examination involves assessment of how the bones, joints, tendons, ligaments and muscles work in conjunction with each other, assessing for abnormalities including deformities, swellings and abnormal posture can aid diagnosis.

General principles

Ensure the patient’s joints which are to be examined are fully exposed and that the patient is resting comfortably,

enabling the examiner to compare limbs and examine the joint above and below the affected area.

The routine for joint examination is:

o Inspection (look)

o Palpation (feel)

o Movement of joint(s) (move)

Indications for doing a Musculoskeletal examination

There are many reasons for performing a musculoskeletal (MSK) examination, if a patient presents with any of

the following; injury, pain, reduced range of movement etc. you would consider doing the examination. Arthritis

Research UK (2011) states that musculoskeletal disorders are the commonest disability cause in the UK. Only by

taking a comprehensive history in conjunction with an examination can you aim to make an accurate diagnosis

for a patient complaining of musculoskeletal problems.

Arthritis Research UK (2011, pg. 5) recommend considering five questions during the history, these are; “

o Does the problem arise from the joint, tendon or muscle?

o Is the condition acute or chronic?

o Is the condition inflammatory or non-inflammatory?

o What is the pattern of the affected areas/ joints/ joint spaces?

o What is the impact of the condition on the patient’s life?”

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Which joints to examine?

Examine the joint associated with the presenting complaint initially and then examine the joint above and below. This is to ensure that;

o Pain has not been referred from/ to another joint. o The weight has not been abnormally distributed on a joint because of problems with the joint above o The patient has not compensated by using another joint due to problems with another

If examination of all the joints is required, use a systematic approach, be aware that the patient may have to be in underwear only, especially if a spinal examination is required, inspection of the area while mobilising is important

Patient Safety

On first meeting a patient introduce yourself, confirm that you have the correct patient with the name and date

of birth, if available please check this with the name band and written documentation and the NHS/ hospital

number/ first line of address.

Check the patient’s allergy status, being aware of the equipment you will be using in your examination. Ensure

the procedure is explained to the patient in terms that they understand, gain informed consent and ensure that

you are supervised, with a chaperone available as appropriate. Don personal protective equipment as required,

especially if you are likely to come into contact with bodily fluids.

Be aware of hand hygiene and preventing the spread of disease, WHO (2018) http://www.who.int/infection-

prevention/tools/hand-hygiene/en/

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Inspection of the joint

Observe for the following;

Swellings

Skin changes

o colour - redness -

inflammation or infection

or darkened areas indicating

poor vascularisation

o scars, previous surgery

o rashes

Abnormality of adjacent structures

o muscles - wasting of muscles above and

below a joint often accompanies joint disease

o compare to opposite side

Deformity – acute or chronic

o misalignment of bones making up the

joint

o Valgus - distal part displaced laterally

o Varus - distal part displaced medially

Palpation of the joint

Neuro-vascular function

To ensure that the neuro-vascular function is intact you should check the limb distal to the injury for:

o A palpable pulse

o Evidence of a peripheral nerve injury e.g. loss of sensation and power in the radial nerve distribution

after a humeral fracture

o A normal capillary refill time on the affected limb, which is less than 2 seconds.

o Temperature

Compare each of the above on the opposite limb. Loss of neuro-vascular function should be classed as a

medical emergency, please seek senior clinician’s advice.

Palpation Feel for any swelling and its nature

o hard suggests bone o spongy or boggy suggests synovial thickening o fluctuance suggests an effusion (fluid) o the position of the swelling, is it in the joint(articular) or

periarticular Palpate for any tenderness and assess the joint margin, related ligaments, tendons and adjacent bony structures.

Olecranon Bursitis, inflammation of the bursae

in the elbow

This work has been released into the public domain by its

author, NJC123.

Arthritic changes to

knees, left total knee

replacement

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Whilst palpating assess for any changes in temperature, especially in comparison to the opposite limb, however if there is bilateral joint involvement compare the tissues above and below the joint. Crepitus Crepitus is described as grinding, creaking, grating, crunching or popping when a joint is moved. This may be felt over the joint as it moves, but may also be heard and occasionally seen. Crepitus is potentially caused by: Air bubbles popping in the joint (cracking knuckles) Tendons or ligaments snapping over bony structures, may cause pain Arthritis where articular cartilage has degenerated, may cause pain All above can be normal if occurs occasionally but if regular and accompanied by pain, swelling etc. it may indicate arthritis or other conditions. Please be aware that crepitus can be palpated after the patient has sustained 1 or more fractures of a bone. Joint movement

Assess the range of joint movement, this can be done actively or passively;

Active movement is movement undertaken by the patient alone

Passive movement is movement undertaken by the examiner

Please note, the spine should not be moved passively. However with all other joints, if a full range of

movement is demonstrated actively then passive is not required. If movement is impeded, passive

movement can help identify if the cause. Bear in mind that symptoms or signs may not always be caused by

the joint itself, but may be due to problems with bone, soft tissues, muscles or nerves. Some of these are

covered in previous study guides, like the Motor examination study guide.

Examination of muscles

Evidence of wasting - compare sides

(measure limb circumferences) has

there been muscle disuse, eg; from

removal of leg cast following

fracture, lower motor neurone

lesions or joint disease, or is it a

primary muscle disease?

Is there abnormal bulk, eg; with body

builders or muscular dystrophies?

Are there any spontaneous

contractions due to muscle spasms or

abnormal movements or

fasciculation?

If you palpate the muscle, is there

any tenderness? This could be from

acute injury or some myopathies.

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The anatomical/neutral position

Anatomical movements

Adduction - movement of the part distal to the joint towards the midline

Abduction - movement away from the midline

Flexion - bending of joint away from neutral position

Extension - movement to straighten a joint towards the neutral position

Hyperextension - occurs when the joint can be extended beyond the neutral position

Pronation - rotation of the forearm so that the palm faces backwards

Supination - rotation of the forearm so that the palm faces forwards

o The range of most movements are

described with the

anatomical/neutral position in mind

o In the anatomical/neutral position

the limbs are extended with the feet

dorsiflexed to 90 degrees and the

palms facing forward

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Main anatomical movements Video

Please see prep from last year.

https://liverpoolclinicalskills.com/home/mbchb-students-2/year-1/elements-of-musculoskeletal-

examination-and-limited-mobility/musculoskeletal-examination-prep/

Examination of upper limb joints

Inspection and palpation of the hand and wrist joints, inspect both hands and wrists as one

Inspect the front, back and sides of all joints, comparing sides and palpating joints between finger and thumb,

don’t forget to support the joint whilst palpating, taking the weight of the patient’s limb where possible.

Interphalangeal joints (IP’s)

Palpate the interphalangeal joints individually between finger

and thumb

DIP is the distal interphalangeal joint

PIP is the proximal interphalangeal joint.

Metacarpophalangeal joints (MCP’s)

Use a similar technique to palpate the metacarpo-phalangeal

joints. With the patient’s palms facing down, support the palms

with your fingers. Place your thumbs on dorsal metacarpo-

phalangeal surface and gently palpate, observing for

abnormalities and pain.

Finger movements

o Flexion

o Extension

o Abduction

o Adduction

o Opposition

PIP

MCP

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It is always best to demonstrate movements first so that the patient understands what is required. If the patient

complains of pain or movement is limited, palpate during movement to note any palpable abnormalities such as

crepitus.

Ask the patient to make a fist (flexion and adduction of distal and proximal interphalangeal

and metacarpophalangeal joint). Then ask the patient to open their hand (extension and

abduction of interphalangeal and metacarpophalangeal joints).

Metacarpophalangeal and interphalangeal joints flex to 90 degrees, however

metacarpophalangeal joints may normally hyperextend to approx. 10 degrees. If the patient

is unable to do the above, break it down into flexion extension, adduction and abduction.

For demonstrating abduction, ask the patient to spread their fingers apart and for adduction

ask them to put them back together. For flexion ask them to bend into a fist and then

straighten hand out.

Thumb flexion and extension

Flexion occurs across the palm, the thumb needs to flex at the MCP and IP,

extension takes the thumb away from the lateral aspect of the palm, and

movement occurs at the MCP joint or metacarpophalangeal joint. Ask the

patient to slide thumb across palm (flexion), then slide the thumb across

palm out and away (extension).

Thumb abduction and adduction

Abduction occurs at 90° to the palm, whilst adduction returns the

thumb to the palm, this occurs at CMC joint, or carpometacarpal

joint.

Ask the patient to lift the thumb from the side of the palm so the

thumb is facing the ceiling (abduction), then bring the thumb to the

palm edge (adduction)

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Thumb opposition

The thumb is used to touch the base of the little finger, this movement is

important for fine manipulative skills.

Wrist joints

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With the patient’s palms facing down, support the palmar aspect of their

wrist with your fingers, place your thumbs on the dorsal wrist surface and

gently palpate, observing for abnormality or discomfort.

Movement of the wrist

Compare one wrist with the other, in appearance and whilst moving. The wrist movements are listed below;

o 1-Palmar flexion – approx. 75o

o 2-Dorsiflexion (extension) – approx. 75o

o 3-Ulnar flexion – approx. 20 o

o 4 -Radial flexion - approx. 20 o

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Movement of the forearm.

Isolate the forearm by asking the patient to put their arm against their body with the elbow bent or

asking the patient “bring your elbows into your sides”. Pronation is rotating the arm through 90

degrees so that the palm faces downwards. Supination is rotating the forearm so that the palm faces

upwards, observe for pain, discomfort or reduced range of movement.

Movement of the elbow

Flexion - is possible to approx. 150 degrees

Extension - returns the joint to the neutral position of 0 degrees

Pronation supination flexion extension.mp4

Inspection and palpation of the elbow joint

Inspect the elbow joint from the front, sides and behind

With the elbow flexed at around 70o palpate:

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Shoulder Movement

Shoulder movements;

o Flexion – 180o approx. 90o is attributable to the glenohumeral joint

o Extension – approx. 65o

o Abduction (1)

o Adduction (2)– consists of 2 parts, the 1st part is

glenohumeral joint movement and the 2nd is

principally due to scapular rotation

o Internal rotation – approx. 90o involves moving the flexed forearm across the front of the body.

The movement is limited by the chest wall

o External rotation – approx. 60o the flexed forearm is moved outwards

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Shoulder Movements – combined

You can combine all movements made by the shoulder joint by

asking the patient to put their hands behind their head (abduction,

flexion and external rotation) and then behind them in the small of

their back (adduction, extension and internal rotation)

These manoeuvres will demonstrate:

Flexion & extension

Internal & external rotation

Abduction & adduction

If the patient cannot do these manoeuvers then each movement

has to be assessed individually.

Inspection and palpation of the shoulder

Inspect the shoulder joint from the front, side and back. Inspect the shoulder contour for abnormalities

or inequalities in symmetry. Feel for tenderness and swelling, check for crepitus during motion (some

crepitus may be normal for that patient).

Palpate:

A. Sternoclavicular joint

B. Clavicle

C. Acromioclavicular joint

D. Acromial process

E. Head of humerus

F. Coracoid process

G. Greater tuberosisty of humerus

H. Spine of scapula (situated on the back of the

scapula)

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Movements of the spine

Observe the following movements;

o Flexion

o Extension

o Lateral Flexion right and left

o Lateral Rotation right and left

All movements of the spine are active and are NOT moved passively

Inspection and palpation of the spine

Ask the patient to undress down to their underwear, inspect

from the front, sides and behind ideally with patient sitting and

standing.

In particular inspect for:

o Pigmentations, abnormal hair growth (could indicate

spina bifida) or unusual skin creases (could indicate

abnormal alignment)

o Alignment of the neck and shoulder symmetry

o Kyphosis (thoracic spine curves giving a round

shouldered or hunched appearance)

o Lordosis (lumber spine curves pushing abdomen out,

seen in late stages of pregnancy)

o Scoliosis (thoracic and or lumbar spine curve laterally

forming an S or a C shape)

Palpation of the spine

Palpate the shoulder and neck muscles for tenderness

Palpate each of the spinal processes noting any prominence or steps

Palpate the paraspinal muscles for tenderness or spasm (this would feel firmer and

could indicate a herniated disc)

Palpate the sacroiliac joints for tenderness

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Cervical spine movements

Flexion - ask the patient to touch their chin to their chest, normal

flexion is about 45 degrees

Extension - ask the patient to look upwards and back, normal

extension is about 45 degrees

Lateral flexion - ask the patient to touch their ears to their shoulders,

without raising the shoulders, normal lateral flexion is approx. 45 degrees.

Then cervical rotation - ask the patient to look back over each shoulder in

turn, keeping the spine, or shoulders in the same position, normal

rotation is approx. 70 degrees.

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Thoracolumbar spine

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Modified Schober’s test

Modified Schober’s test is performed to measure the

ability of lumbar flexion. With the patient standing

upright, take note of the point between the Dimples

of Venus, some clinicians will place a finger or a

measuring tape on this point, (occasionally some will

draw this point however you have to gain consent for

this from the patient) then note a second spot 10cm

above the first.

Ask the patient to reach towards their toes as far as

they are able. The 10cm distance between the 2 spots/ lines should increase by more than 5 cm in the normal

person. The most common cause of decreased flexion tends to be ankylosing spondylitis, a positive modified

Schober’s test may indicate this.

Straight leg raise

If a patient complains of lower back pain, you may assess to see if the pain is caused by a herniated disc, this is

done by performing a straight leg raise. With the patient lying supine or on their back, the examiner lifts the

patient’s leg while the knee is straight.

If the patient experiences sciatic pain (pain radiates down sciatic nerve, often felt in the buttocks) when the

straight leg is at an angle between 30 and 70 degrees or the pain extends beyond the knee, the test is positive

and a radiculopathy (pinched nerve) or herniated disc is the most likely cause of pain.

Examination of lower limb joints

Movement of the Hip Joint

Flexion – approx. 115o

Extension – approx. 30o

Abduction – approx. 45o - Pain on abduction could be from a number of causes, including trochanteric bursitis,

or early hip pathology

Adduction – approx. 30o

Internal rotation – approx. 45o

External rotation – approx. 45o

Try to ensure that the patient does not tilt their pelvis when assessing the hip joint.

Inspection of the lower limb

The lower limbs bear the weight of the entire body. It is quite common for patients to present with problems

with a specific joint when it is an entirely different joint which is the root cause.

It is imperative that the lower limb is inspected as a whole and compared to the other leg, look for:

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o The position of the joints, the knee may externally rotate when a hip joint is broken or diseased for

example

o Muscle bulk, obvious deformity, scars and swellings etc.

o Pelvic tilting which can occur if the patient is trying to avoid weight bearing on the affected side, as

joints should be at the same level as one another.

Inspection and palpation of the hip joint

The hip joint is not visible externally, but inspect (ideally with patient standing) for any obvious deformities.

Palpation for joint tenderness is only possible just distal to the midpoint of the inguinal ligament also palpate

soft tissues around the area for tenderness.

Palpate bony prominences

such as anterior superior iliac

spine and iliac crest to ensure

they are anatomically

comparable. (In pelvic trauma,

do not disturb the pelvis as

this could lead to major

haemorrhage).

The sacro-iliac joint can cause

pain, and patients may

present complaining of hip or

lower back pain. This joint

should be checked to be ruled

out as the cause.

The joint can be palpated with

the patient lying on their

front;

For further information

regarding testing, please

explore SI Joint provocative

Tests,

eg https://si-bone.com/providers/diagnostic-resources/provocative-tests

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Movements of knee and ligaments

Movements of the knee joint and

ligaments are:

Flexion - approx. 135o

Extension -

Hyperextension – approx. 5o

Lateral and medial collateral

ligaments

Anterior and posterior cruciate

ligaments

Inspection and palpation of the

knee

Inspect the knee comparing knees

whilst the patient is supine and

standing. Observe for swellings,

which may only be detected by a loss

of the medial and or lateral dimples

suggestive of an effusion.

Palpate for:

o The presence and absence of

the patella and its mobility,

increased calcification is

common following knee

injury.

o Collateral ligaments

o The joint line for tenderness

Testing knee ligaments -

Please do not do any of these tests unless supervised by a competent clinician.

Assessing cruciate

ligaments

Drawer sign

Anterior and posterior

cruciate ligaments are

tested with the knee in 90

degrees of flexion

The foot is fixed (the

examiner may sit on it,

with the patient’s consent

to stabilize the leg).

Anterior cruciate ligament

is assessed by cupping the

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hands behind the lower limb, thumbs are placed on the tibial tuberosity and pulling forward, whereas the

posterior cruciate ligament is tested by pushing the tibial tuberosity back.

A Positive drawer sign

Movement of lower limb forward indicates a lax or torn anterior ligament (positive anterior drawer sign)

Movement of lower limb backwards indicates a lax or torn posterior ligament (positive posterior drawer sign).

Right medial collateral ligament assessment

With the knee flexed at 20o try to displace the lower limb medially,

5o of lateral movement in the lower limbs is normal.

Right collateral lateral ligament assessment

With the knee flexed at 20o try to displace the lower limb laterally

5o is medial movement in the lower limbs is normal.

These movements may also be done with the patient sitting and are dependent on room layout, patient comfort

and clinician preferences.

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McMurray’s test

The McMurray test is no longer recommended because of concerns that it exacerbates the injury and its low

diagnostic accuracy. See references (Hing et al 2009)

However, it is still performed by a considerable number of competent physicians for meniscal injury or a

degenerative tear. Therefore, knowledge of this test and how to perform it is required.

This is a specialist test that YOU will NOT perform unless you are an expert in this field.

With the patient supine the examiner holds the knee and palpates the joint line with one hand, thumb on one

side and fingers on the other, whilst the other hand holds the sole of the foot and acts to support the limb and

provide the required movement through range. The examiner then

applies a valgus stress to the knee whilst the other hand rotates the leg

externally and extends the knee.

Pain and/or an audible click while preforming this manoeuvre can indicate

a torn medial meniscus.

To examine the lateral meniscus the examiner repeats this process from

full flexion but applies a Varus stress to the knee and medial rotation to

the tibia prior to extending the knee once again.

Effusion

Joint effusions are commonly caused by injuries, infection or arthritis. It is an increase in the intra- articular fluid

and is most common in the knee. Moderate effusions are assessed by performing a patella tap, or a sweep test

please follow link for an example.

Physiotutors

Published on 10 Oct 2015

https://youtu.be/r18O50lzMGw

Movement of the ankle and foot

Movements of the ankle;

o Dorsiflexion

o Plantar flexion

o Inversion

o Eversion

Movements of the toes;

o Extension

o Flexion

Inspection and palpation of the ankle and foot

Inspect the foot including arches and ankles ideally with patient standing and more carefully with the patient

supine

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Look for, thickened areas of tissue, callous formation on the feet indicating abnormal gait

Look at the shoes for abnormal wear or stretching, palpate for tenderness particularly over bony

prominences placing thumbs on sole of foot and finger tips on dorsum, assess the metatarsophalangeal

joints by gently squeezing between index finger and thumb

A click sound or pain indicates a neuroma which is a build-up of fibrous tissue around the nerves of the

foot (Morton’s Neuroma).

Palpation of the ankle and foot.

Dorsiflexion and plantar flexion – occurs at the ankle joint

Ask the person to bend their foot down into plantar flexion - normal

approx. 50 degrees

Ask the person to bend the foot upwards into dorsiflexion - normal

approx. 20 degrees

If they can move actively there is no need to assess passively

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Eversion and Inversion – occurs at the subtalar joint

Isolate the heel by holding it firmly

Attempt inversion and eversion by twisting

the mid-foot medially and laterally.

Inversion & eversion is a sub talar joint

movement

If they can move actively there is no need to

assess passively

Movement of the Toes

Ask the patient to flex and extend the toes

Remember the big toe can usually move independently of the others, compare to the other side.

Trendelenburg test

This test is used to assess hip stability.

The patient is asked to stand on one leg then the other, normally the

non-weight bearing limb is elevated or remains level with the weight

bearing leg. In joint or muscle disease the non-weight bearing side

sags, or there is pain on the weight bearing side.

A ‘Negative’ Trendelenburg test is normal

PhysicalTherapyHaven https://www.youtube.com/watch?v=IuEeKzqsfmk

Physiotutors Published on 7 Nov 2015

https://www.youtube.com/watch?v=0rcczDEWDqU

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Measurement of leg length

Inequality of leg length can indicate gait abnormalities, ultimately resulting in

degenerative arthritis.

True leg length is measured from anterior superior iliac spine to medial

malleolus.

Apparent leg length is measured from the umbilicus to the medial malleolus

but true is the preferred method if imaging is not being used. (Sabharwal and

Kumar 2008)

True leg length differences are often due to hip disease on the shorter side. 1-

1.5cm difference is classed as normal, anything greater would be abnormal.

Documentation

Remember to document your findings referring to the joint or

area of the joint affected.

References and other Useful Resources

Doherty M et al (1992) Ann Rheum Dis 51:1165-1169

Hing, W., White, S., Reid, D., & Marshall, R. (2009). Validity of the McMurray's test and modified versions of the

test: A systematic literature review. Journal of Manual & Manipulative Therapy, 17(1), 22-35

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Newton, A. W., Tonge, X. N., Hawkes, D. H., & Bhalaik, V. (2019). Key aspects of anatomy, surgical approaches

and clinical examination of the hand. Orthopaedics and Trauma, 33(1), 1-13.

Sabharwal, S., & Kumar, A. (2008). Methods for assessing leg length discrepancy. Clinical orthopaedics and related research, 466(12), 2910-22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628227/ Sources and useful resources –

Clinical assessment of the musculoskeletal system:

www.arthritisresearchuk.org/health-professionals-and-students/student-handbook.aspx

NICE guidance, musculoskeletal conditions:

https://www.nice.org.uk/guidance/conditions-and-diseases/musculoskeletal-conditions

NICE guidance Knee pain

https://cks.nice.org.uk/knee-pain-assessment#!scenariorecommendation:7

Beighton Score

https://www.durbanrheumatologist.co.za/joint-hypermobility.php

Hip flexion-extension; Elson and Aspinall 2008

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2505147/

Morton’s Neuroma;

https://cks.nice.org.uk/mortons-neuroma

McMurrays Test. Wayne Hing, Steve White, Duncan Reid, and Rob Marshall (2009) Validity of the McMurray's

Test and Modified Versions of the Test: A Systematic Literature Review

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704345/

Glossary

Abduction Away from the midline

Adduction Toward the midline

Bursae Small sacs of synovial fluid in the body, aiding muscles or

. tendons to slide across the bone

Periarticular Around a joint

Pronation Palmer surface of the hand facing the floor

Supination Palmer surface facing upwards

Flexion Closing the angle of a joint

Extension Opening the angle of a joint

Inversion Turning in of the ankle in the midline

Eversion Turning out of the ankle away from the midline

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Internal rotation Rotation of a joint towards the body

External rotation Rotation of a joint away from the body