1. Congenital and developmental abnormalities (eg. Achondroplasia: normal when born, increasing abn with age)
2. Infection and inflammation (eg. Septic spondylitis, infection: acute/ chronic)
3. Arthritis and rheumatic disorders (physician = drug Tx; ortho = jt deformity, reconstruction, jt replacement)
4. Metabolic dysfunction (eg. gouty arthritis, DM - foot ulcers) and degeneration (eg. As Pt ages - LBP due to degeneration of vertebral column)
5. Tumours and lesions that mimic them (benign and malignant - malignant less common in MSS)
6. Sensory disturbance and muscle weakness (PNS problem, Med = CNS, Ortho = PNS, eg. LBP - radiating to leg, motor and sensory weakness due to prolapsed IV disc)
7. Injury and mechanical derangement

1. Chief compliant
2. History of present illness
3. Past Health
4. Relevant social history, menstrual history, obstetrical history (eg. Previous pelvic injury that may affect childbirth in future)

Injury, pain, stiffness, swelling, deformity, instability, weakness, altered sensibility and loss of function, disability

All leading to ¯ function

• Throbbing pain of an abscess, aching pain of chronic arthritis, burning pain of neuralgia, stabbing pain of a ruptured tendon.

Severity

• Grade I Mild - pain that can easily be ignored, on & off
• Grade II Moderate - pain that cannot be ignored, interferes with function and needs occasional attention
• Grade III Severe - pain that is present most of the time, demanding constant attention, rest pain, nocturnal pain
• Grade IV Totally incapacitating pain.

• Referred pain: Pain arising in or near the skin is usually localised accurately, due to inability of the cerebral cortex to distinguish between sensory messages from embryologically related sites, e.g. hip problems referred to knee due to cortical confusion.

• Sciatica: pain at various points in the buttock, thigh and leg supposedly following the course of the sciatic nerve. Such pain is not necessarily due to pressure on the sciatic nerve; it may be 'referred' from any one of a number of structures in the lumbar spine and pelvis.

• Autonomic pain: vague, often widespread and accompanied by vasomotor and trophic abnormalities, poorly understood

• Generalised (of all planes) or localised (one plane): no movement/all movement involved/ one plane

• Hip stiffness: affect toe nail cutting, putting on socks
• Shoulder stiffness: unable to comb hair, scratch back.
• Eg. Pt cannot say what deficit is, but can describe decreased functional movt

• Soft tissues inflammation, joint effusion, (superficial e.g. finger, wrist, elbow, knee); haematoma (rapid) or a haemarthrosis; painful (acute inflammation, infection) ® Solid/ liquid/ fat

• Bony swelling

• Round shoulders, spinal curvature (kyphosis/ lordosis/ scoliosis), knock-knees, bow legs, (varus/ valgus), pigeon toes and flat feet.
• Variations of normal (e.g. short stature or wide hips);
• Some disappear spontaneously with growth (e.g. flat feet or bandy legs in an infant).
• Joint contractures: cannot flex/ extend fully
• If the deformity is progressive, it may be serious - eg. Scoliosis: 20 degrees at 12 yo, 30-80 degrees at puberty

• Generalised chronic illness : decreased m mass
• Confined to one limb or to a single muscle group - neurological or muscle disorder (myotome)

• 'Giving way' may be due to muscle weakness or to ligamentous deficiency from laxity or rupture
• Muscles: dynamic stabilisers
• Ligaments: static stabilisers

• Tingling or numbness (or decreased sensation) signifies interference with nerve function - pressure from a neighbouring structure (e.g. a prolapsed intervertebral disc), local ischaemia (e.g. nerve entrapment in a fibro-osseous tunnel) or a peripheral neuropathy. Fault lies in a peripheral nerve or in a nerve root.
• What makes it worse or better; a change in posture might be the trigger, thus focusing attention on a particular site.

• 'I can't sit for long' (eg. Prolapsed disc)
• 'Can't put my socks on'

• HT, DM, CHD, CVA
• Gastrointestinal disease, ankylosing spondylitis, history of eye, skin or urogenital disease, cortiosteroids (commonly abused, can be obtained OTT, classified as dangerous drug - required by asthmatics sometimes. Body builders: 'roids': affect immune response -. Uncommon infection (eg. Fungal) - also decrease BMD and tissue healing capacity)

• Work, travel, recreation, home circumstances (some elderly alone all day while family working) and level of support by family and friends
• Alcohol and drug abuse

Objectives of Mx depend on functional demand

• Eg. Elderly woman: slight decreased function in shoulder not much effect
• Eg. Professional athlete: slight decreased function in same jt have serious implications
• Ortho: function (ADL) ® work ® recreation

• ADL, work, housing, toilet (some housing estates only have squatting toilets - important for Pt with hip/ knee surgery), age.

• Tape, Torch, tendon hammer, goniometer (measure jt ROM + contractures, one for big jts, one for small), cotton wool, needle

• Adequate exposure of both sides: eg. Shoulder: many parts
• Compare both sides: compare good with affected sides
• Standing, walking - esp. LL exam
• Inspection (look), palpation (feel), AROM, PROM (move), neurological examination (if indicated), circulation (peripheral pulse)
• No percussion

• Mr Chan is a 35 yo taxi driver

• C/o L hip pain and stiffness for 3m

• No hip pain, walked normally until 3m ago
• No Hx of injury
• Onset insidious, progressively worse in past 3m
• No rest pain/ night pain (not severe)
• Aggravated by walking 15m, relieved by rest (\ mechanical)
• No need for walking stick, but walks with limp
• Hip pain affects work as driver, severe pain when he gets out of taxi
• Hip pain worsening \ takes regular pain killers
• Apart from hip pain, c/o stiffness in L hip
• Difficulty putting on socks and shoelaces
• Cannot cut toenails

• Enjoys good health in past
• No meds for any reason in past 10y

• No family Hx of blood diseases (exclude haemophilia in young male - bleeding into jts)

• Non-smoker
• 3 cans of beer for last 10y
• no special hobby like deep-sea diving (rules out decompression illness: ¯ blood supply to femoral head ® avascular necrosis ® degeneration)
• Married with one daughter
• Lives in apartment, no need to climb stairs

• Chronic infection?
• Congenital hip dysplasia?

Hx ® P/E ® Ix

Pt and Dr across table from each other

Record into record immediately

No jargon

1. Illness or injury: when, where, how, what then?
2. Present condition: Pain, stiffness, swelling, weakness, function
3. Chief complaint: except acute injury, main problem, what to improve?
4. General information: dominance, occupation, social Hx (hobbies)
5. Review medical and surgical information: Previous illness/ injury, immunisation, medications, allergies, family Hx

Dx confirmed on P/E

May be dictated by Pt's condition

1. Explain: what you're going to do, alleviate fear, increase Pt's co-operation
2. Communicate: eye contact, verbal contact
3. Compare: symmetry consistent feature in humans
4. Gentleness: at all times, especially palpation
5. PROM
6. Instability testing
7. Completeness: examine whole of extremity, not just part that has complaint
8. Consideration: if painful, then Pt doesn't want to move often - therefore, cover all necessary aspects with Pt in one position - then move Pt
9. Equipment: wooden blocks (leg length discrepancy), measuring tape, goniometer (ROM, angular deformities), tuning fork, cotton wool, hot/ cold objects, stethoscope (arterial bruit, vascular lesion of bone)

1. Inspect
2. Palpate: bony landmarks, ST
3. ROM - functional, active, passive
4. Neuro
5. Vascular
6. Special tests - specific to relevant area
7. Examination of related areas

What to know

General

Specific

1. Pt
2. Affected limb
3. Good limb
4. Bad

Look, feel, move

• Cubitus, coxa, genu, varus, valga
• Tests: Tredelenburg, Thomas, McMurray, Tinel, Froment, Lackman