Musculoskeletal System Examination

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Musculoskeletal System Examination

• Robert J Kaplan MD
• Associate Professor Rehabilitation Medicine
• KUMC

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Educational Objectives

• To demonstrate and describe the musculoskeletal
  examination of the spine and the extremities
• To provide selected clinical correlates to
  identify common disorders of the spine and
  extremity in clinical rotations

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Musculoskeletal System

• Provides stability and mobility for necessary
  physical activity

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Anatomy and Physiology

• Major parts
• Joints
• Ligaments
• Muscles
• Tendons
• Cartilage

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Exam Findings

• Consist of inspection and palpation
• There is minimal role for auscultation

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Exam Findings Inspection

• For the limbs the principle of laterality often
  provides a reference point for comparing normal
  and abnormal findings
• When would this be misleading?

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Exam Findings Inspection

• Answer Polyarticular diseases

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Exam Findings Palpation

• Palpate bones/joints/surrounding muscles
• Feel for
• Heat
• Tenderness
• Swelling
• Fluctuation
• Crepitus
• Masses/change in soft tissue consistency

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Exam Findings Range of Motion

• Active ROM/passive ROM for each joint and related
  muscle group
• Note
• Pain
• Limited movement secondary to hypertonicity or
  soft tissue contracture
• Joint instability
• Deformity

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Exam Findings Range of Motion

• PROM may exceed active ROM by 5 degrees
• Active ROM/passive ROM should be equal in
  contralateral joints

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Range of motion measurement

• Goniometry

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Goniometry

• Is most appropriate for the measurement of medium
  and small appendicular joints
• The examination procedure and techniques used
  must be consistent

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• For reference
• The clinical measurement of joint motion by the
  AAOS
• Measurement of joint motion by Norkin et al
• JBJS vol 77-A (5) 5/95 784-798

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Inclinometer
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Exam Findings Muscle Strength
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• MMT may provide a general indication of
  improvement or worsening over time but, it is
  deficient in measuring degrees of change over
  time
• JBJS 72 (a) 10 12/90 1562-1574
• In addition to authors sited earlier

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Exam Findings Cervical Spine

• Inspect
• Head alignment (anterior and posterior)
• Symmetry of muscles and skinfolds
• Palpate
• Cervical Spine, Paravertebral muscles, Trapezius
  muscles and Sternocleidomastoid muscles for
• Tone
• Symmetry
• Tenderness
• Spasm

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Exam Findings Cervical Spine

• Assess Active and Passive ROM
• Flexion (Chin to Chest)
• Extension (Head Back)
• Rotation (Chin to Each Shoulder
• Lateral Flexion (Ear to Each Shoulder)

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Manual muscle testing re UE
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Exam Findings Shoulders

• Inspect
• Shoulder girdle, Clavicle, and Scapula for
• Size
• Symmetry
• Contour
• Dislocation/winging of scapula
• Palpate
• Sternoclavicular joint
• Acromioclavicular joint
• Shoulder muscles
• Biceps Groove

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Exam Findings Shoulders

• Assess Active and Passive ROM
• Forward flexion
• The arm is kept straightened and brought upward
  through the frontal plane, and moved as far as
  the patient can go above his head. Note for
  recording purposes, 0 degrees is defined as
  straight down at the patient's side, and 180
  degrees is straight up

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Exam Findings Shoulders

• Assess Active and Passive ROM
• Extension

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Exam Findings Shoulders

• Assess Active and Passive ROM
• Abduction
  Adduction

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Exam Findings Shoulders

• Assess Active and Passive ROM
• External rotation (hands behind head)
• The patient is positioned sitting and the elbow
  is flexed 90 degrees.
• While the elbow is held against the patient's
  side, the examiner externally rotates the arm as
  permitted

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Exam Findings Shoulders

• Assess Active and Passive ROM
• Internal rotation (hands behind back)
• The patient should be positioned sitting.
• Again with the elbows at the patient's side, the
  examiner should raise the thumb up the spine, and
  record the position in relation to the spine
  (reaching T7 is normal, unless bilateral symmetry
  is observed).

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Apley scratch test. The patient attempts to
touch the opposite scapula to test range of
motion of the shoulder. (Left) Testing abduction
and external rotation. (Right) Testing adduction
and internal rotation.
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Supraspinatus examination ("empty can" test). The
patient attempts to elevate the arms against
resistance while the elbows are extended, the
arms are abducted and the thumbs are pointing
downward.
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Infraspinatus/teres minor examination. The
patient attempts to externally rotate the arms
against resistance while the arms are at the
sides and the elbows are flexed to 90 degrees.
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Bursitis
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Special tests

• Just know they exist

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DiFferential diagnosis Shoulders
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Elbow
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HISTORY

• In addition to the standard musculoskeletal
  history, the following items of information
  should be obtained from patients presenting with
  elbow dysfunction age, duration of the
  complaint, or time since onset of the
  elbow-related symptoms.
• The dominant side needs to be ascertained
  specifically, it must be established whether
  there has been a recent reversal of the natural
  dominance, which would show that function has
  been severely impaired.
• The severity of the patients pain is assessed
  using a visual analogue scale.
• The site of the pain may provide valuable clues.

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• Conditions involving the lateral compartment
  (radiocapitellar joint) provoke pain that extends
  over the lateral aspect of the elbow, with
  radiation proximally to the midhumerus and
  distally over the forearm this pain may be deep.
  
• Diffuse pathological conditions, on the other
  hand, cause pain that is described as
  periarticular in distribution.
• The patient should be questioned about locking,
  pain and/or instability during throwing
  movements, joint swelling, or fleeting inability
  to extend the elbow, which would suggest a joint
  effusion.
• Paraesthesias of the hand may, in some cases, be
  related to ulnar nerve compromise at the level of
  the elbow.
• A note should also be made of any previous
  treatments of the elbow (arhtrocentesis,
  intra-articular injections, surgery)

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Exam Findings Elbows

• Inspect
• Contour
• Carrying angle
• Subcutaneous nodules
• Palpate elbow, olecranon bursa, and grooves on
  each side of olecranon for
• Tenderness
• Swelling
• Thickening

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Exam Findings Elbows

• Assess ROM and strength
• Flexion
• Extension

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Exam Findings Elbows

• Assess ROM and strength
• Pronation
• Supination

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STABILITY
Testing mediolateral elbow stability To
eliminate interfering movements during varus
instability testing, the humerus is placed in
full internal rotation and the forearm in
pronation. To eliminate interfering movements
during valgus instability testing, the humerus is
placed in full external rotation. Valgus
testing is done with the forearm pronated, to
test the medial collateral ligament, followed by
testing in supination, to check the lateral
collateral complex.
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Tennis Elbow
Strap alters the action of the stressed muscles
in the forearm and splint the area
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Wrist and Hand
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Exam Findings Hands/Wrists

• Assess ROM Wrist
• Flexion
  Extension
• Radial Deviation Ulnar Deviation

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Exam Findings Hands/Wrists

• Inspect DIP/PIP joints, MP joints, and wrist
  joints for
• Contour
• Position
• Shape
• Number/ completeness of digits
• Finger deviation

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Exam Findings Hands/Wrists

• Palpate joints (DIP, PIP, MP, Wrist)
• Texture
• Swelling
• Tenderness
• Bogginess
• Nodules
• Bony overgrowths

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Exam Findings Hands/Wrists

• Assess ROM Fingers
• DIP, MIP, PIP joint flexion/hyperextension
• Finger abduction/adduction
• Thumb opposition

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Exam Findings Hands/Wrists

• Assess muscle strength
• Hand Grip
• Wrist extension (Radial)
• Wrist flexion
• Thumb opposition (Median)
• Little finger abduction (Ulnar)

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Disorders
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Osteoarthritis

• Chronic disease involving the joints
• Characterized by destruction of articular
  cartilage, overgrowth of bone with lipping and
  spur formation and impaired function
• Occurs in almost all individuals over 75 years of
  age

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Osteoarthritis
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Osteoarthritis
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Heberdens Nodes

• Hard nodules or bony swellings which develop
  around the distal interphangeal joints.
• 2nd and 3rd finger most often affected, produced
  by calcific spurs of the articular cartilage at
  the base of the terminal phalanges in
  osteorthritis.
• Associated with osteoarthritis

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Bouchards Nodes

• Nodes similar to, but less common than Heberdens
  nodes, occurring on proximal interphalangeal
  joints.
• Associated with osteoarthritis

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Rheumatoid Arthritis
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Tenosynovitis

• Inflammation of a tendon sheath
• May occurs as a result of puncture wounds,
  contusions, and lacerations

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De Quervains Tenosynovitis

• Tensynovitis due to relative narrowness of the
  tendon sheath of the abductor pollicis longus and
  the extensor pollicis brevis

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Carpal Tunnel Syndrome

• Paresthesias, pain, or numbness affecting some
  part of the median nerve distribution of the
  hand(s)
• palmar side of thumb, index finger, and radial
  half of the ring finger, and radial half of the
  palm
• Symptoms may radiate
  to the arm

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Carpal Tunnel Syndrome
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Tinel Sign

• Assess median nerve
• Tinel sign
• Useful in diagnosing carpal tunnel syndrome
• percuss the skin over the median nerve just
  proximal to the carpal tunnel
• if positive, the patient will complain of
  electric sensation radiating into the thumb,
  index, middle, or ring fingers

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Phalen Test

• Assess median nerve
• Reverse Phalen test
• test for diagnosing carpal tunnel syndrome
• wrist is extended
• positive test pain or tingling to thumb, index,
  middle, or ring fingers within 60 seconds of
  onset of wrist extension.
• Phalen test
• test for diagnosing carpal tunnel syndrome
• wrist is flexed
• positive test pain or tingling to thumb, index,
  middle, or ring fingers within 60 seconds of
  onset of wrist flexion.

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Musculoskeletal System II
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Exam Findings Hips

• Inspect
• Symmetry
• Size
• Gluteal folds
• Palpate Pelvis
• Stability
• Tenderness

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Exam Findings Hips

• Assess ROM
• Flexion/extension
• Abduction/adduction
• Internal/external rotation
• Assess muscle strength
• All of the above against resistance

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Flexion/Extension of Hip
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Abduction/Adduction of Hip
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Internal/External Rotation of Hip
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Exam Findings Hips

• Special Tests
• Trendelenburg sign
• Detects weak hip abductor muscles
• Patient balances on one foot ant then the other
• Not any asymmetry or change in level of iliac
  crests
• If iliac crest drops on the side of the lifted
  leg, the hip abductor muscles on the
  weight-bearing side are weak

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Exam Findings Hips

• Special Tests
• Sacroiliac pain
• Palpate the sacroiliac joint
• Pain in this joint will also be elicited by
  externally rotating the hips combined with
  flexion and abduction- FABERE or Patricks test
• Others include Gaenslens test and compression
  test look these up for yourselvesenough spoon
  feeding

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Exam Findings Limb Measurement

• When difference is suspected
• Measure bilateral
• Circumference
• Length
• Should be no more than 1-cm difference in
  length/circumference between matching extremities

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Exam Findings Hips

• Special Tests
• Limb length
• Do when you suspect a difference in length or
  circumference of matching extremities
• Leg length is measured from the anterior superior
  iliac spine to the medial malleolus of the ankle,
  crossing the knee on the medial side
• Arm length is measures from the acromion process
  through the olecranon process to the distal ulnar
  prominence

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Exam Findings Knees

• Inspect
• Landmarks
• Concavities
• Alignment

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Exam Findings Knees

• Palpate supraptellar pouch, femoral epicondyles,
  on each side of patella , over tibiofemoral joint
  space and popliteal space for
• Swelling
• Tenderness
• Bogginess
• Crepitus

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Exam Findings Knees

• Assess ROM
• Flexion
• Extension
• Assess muscle strength

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Exam Findings Knee

• Ballottement
• Used to determine the presence of excess fluid or
  an effusion in the knee
• Knee extended, apply downward pressure to the
  suprapatellar pouch
• Push the patella sharply against the femur
• If effusion is present, fluid will return to the
  suprapatellar pouch and the patella will float up
  when pressure is released

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Exam Findings Knee

• Bulge sign
• Test for excess fluid in the knee
• Knee extended, place the left hand above the knee
  and apply pressure on the suprapatellar pouch,
  milking fluid downward
• Stroke downward on the medial aspect of the knee
  and apply pressure to force fluid into the
  lateral area
• Tap the knee just behind the lateral margin of
  the patella with the right hand
• Observe for a bulge of returning fluid to the
  hollow area medial to the patella

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Exam Findings Knee

• McMurray test
• Used to detect a torn medial or lateral meniscus
• Flex knee completely, rotate foot to lateral
  position, and keeping foot in that position,
  extend the knee to 90 degrees
• Not any palpable or audible clicks, grinding,
  pain, or limited extension of the knee
• Flex knee again and repeat procedure with food in
  medial position

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McMurray Test
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Exam Findings Knee

• Anterior drawer test
• Used to identify instability of the anterior
• With the patient supine, hips flexed and knees
  flexed to 90 degrees and feet flat on the table,
  cup your hands around the knee with the thumbs on
  the medial and lateral joint line and the fingers
  on the medial and lateral insertions of the
  hamstrings
• Draw the tibia forward and observe if it slides
  forward (like a drawer) from under the femur
• Compare both knees movement greater than 5mm is
  positive finding

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Anterior Drawer Test
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Exam Findings Knee

• Posterior drawer test
• Used to identify instability of the posterior
  cruciate ligament
• Position the patient and place your hands int eh
  positions described for the anterior drawer test
• Push the tibia posteriorly and observe the degree
  of backward movement in the femur
• Movement of the knee greater than 5mm is a
  positive finding

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Posterior Drawer Test
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Exam Findings Knee

• Lachman test
• Used to evaluate anterior cruciate ligament
  integrity
• With the patient supine, flex the knee to 10-15
  degrees with the heel on the table
• Place one hand above the knee to stabilize the
  femur, place the other hand around the proximal
  tibia
• Pull tibia anteriorly
• Movement greater than 5mm compared to the
  uninjured side indicates injury to the ligament

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Lachman Test
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Exam Findings Knee

• Valgus stress test
• Tests the stability of the medial collateral
  ligament (MCL)
• With patient supine and knee slightly flexed,
  move the thigh about 30 degrees laterally to the
  side of the table
• Place one hand against the lateral knee to
  stabilize the femur and the other hand around the
  medial ankle
• Push medially against the knee and pull laterally
  at the ankle to open the knee joint on the medial
  side
• Laxity indicates injury to the meniscus

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Valgus Stress Test
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Exam Findings Knee

• Varus stress test
• Test stability of the lateral collateral ligament
  (LCL)
• Knee and thigh in same position as for Valgus
  stress test
• Place one hand against the medial surface of the
  knee and the other around the lateral ankle
• Push medially against the knee and pull laterally
  at the ankle to open the knee joint on the
  lateral side
• Laxity in this position indicates injury to the
  meniscus

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Varus Stress Test
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Exam Findings Knee

• Apley test
• Detects a meniscal tear
• Patient lies prone and flex the knee to 90
  degrees
• Place your hand on the heel of the foot and press
  firmly, opposing the tibia to the femur
• Rotate the lower leg externally and internally
• Clicks, locking, or pain in the knee is a
  positive
• Apley sign

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Bursitis
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Bursitis
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Exam Findings Feet/Ankles

• Inspect
• Contour/position
• Toe deformities
• Alignment
• Weight bearing
• Arch

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Exam Findings Feet/Ankles

• Palpate anterior surface of ankle joint, achilles
  tendon, and metatarsal heads for
• Heat
• Swelling
• Tenderness
• Palpate M.P Joint Compression

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Exam Findings Feet/Ankles

• Assess ROM
• Dorsiflexion/plantar flexion
• Inversion/eversion
• Abduction/adduction
• Flexion/Extension of toes
• Assess muscle strength
• All the above against resistance
• Flexion/Extension of big toe against resistance

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Flexion/Extension of Ankle
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Adduction/Abduction of Ankle
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Inversion/Eversion of Ankle
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Examination of the thoracic lumbar spine
pelvis
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Exam Findings Thoracic/Lumbar Spine

• Inspect
• Alignment
• Straightness
• Curves
• Lordosis/kyphosis
• Scoliosis
• Palpate spinous processes, paraspinal muscles and
  SI joints for tenderness

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Spine Curvature

• Kyphosis
• exageration or angulation of normal posterior
  curve of spine
• Humpback, Hunchback
• Lordosis
• Abnormal anterior convexity of the spine

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Exam Findings Thoracic/Lumbar Spine

• Assess ROM
• Flexion
• Hyperextension
• Lateral bending
• Rotation
• Stabilize the pelvis with rotation

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Flexion/Hyperextension of Back
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Rotation/Lateral Bending of Back
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Neurologic Examination

• Test for S1 root function (L5-S1 disk) Plantar
  flexion against resistance, ankle deep tendon
  reflexes and lateral foot sensation.
• Test for L5 root function (L4-L5 disk)
  dorsiflexion of the ankle and big toe against
  resistance and sensation on the anterior, medial
  dorsal foot.

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Exam Findings Thoracic/Lumbar Spine

• Special Tests
• Straight Leg Raising
• Tests nerve root irritation or lumbar disk
  herniation at the L4, L5, and S1 levels
• Record the degree of elevation at which pain
  occurs, the quality and distribution of the pain
• Tightness and mild discomfort in the hamstrings
  with these maneuvers are common and do not
  indicate a positive finding
• Can also do with patient in sitting position
  (malingering)

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Straight leg raising

• Pain in leg, buttock, or back at 60 degrees or
  less of leg elevation usually worsened by
  dorsiflexion of ankle and relieved by flexion of
  knee and hip
• Sensitivity 0.80 Specificity 0.40

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Crossed and Reverse Straight Leg Raising

• Crossed
• pain in contralateral, symptomatic leg when
  asymptomatic leg raised
• sensitivity 0.25 specificity 0.90
• Reverse
• lies prone or on side and thigh is extended one
  at a time pain over involved nerve root
• usually L3 or L4 irritation

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PE -Lumbar disc herniation

• Test sensitivity
  specificity
• ipsilateral SLR 0.80 0.40
• crossed SLR 0.25 0.90
• impaired ankle reflex 0.50 0.60
• ankle plantar flexor weak 0.06 0.95
• great toe extensor weak 0.50 0.70
• ankle dorsiflexor weak 0.35 0.70

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L3

• L3/L4- quadriceps muscle
• sit on table and attempt to straighten bent knee
  against resistance
• sensation - oblique band on anterior
  thigh-immediately above knee cap

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L4

• Tibialis anterior-offer resistance to
  dorsiflexion and inversion of foot
• Patellar reflex
• sensation - medial leg and foot

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L5

• Extensor hallucis longus-resist dorsiflexion of
  great toe or heel walk (foot drop)
• Gluteus medius - resist abduction of leg
• No reflex
• sensation- dorsum of foot
• 98 L4/5 or L5/S1 herniations-affects L5 and S1
  levels

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S1

• Peroneus longus and brevis-oppose plantar
  flexion/eversion of foot by pushing on 5th
  metatarsal with palm of hand
• inability to walk on toes
• Achilles reflex
• sensation-lateral malleolus and lateral/plantar
  surface of foot

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Disorders
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Sacroiliac joint (SIJ) dysfunction

• Epidemiology
• 20 of patients with cLBP
• Localization of pain
• 94 buttocks
• 72 lower lumbar
• 14 groin
• 2 abdomen

Bernard TN, Kirkaldy-Willis WH Clin Ortho 1987 ,
Slipman CW et al Pain Physician 2001
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Diagnosis of SI joint dysfunction

• Provocative SIJ tests
• sensitivity range of 77 to 87 with 3 ()
• Imaging
• role is to rule out other potential causes of
  pain (particularly disc disease)
• Gold standard?
• double-blinded, fluoroscopically-directed nerve
  blocks with gt80 ? in VAS pain scores

Broadhurst Bond, J Spinal Disord 1998
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Differential Diagnosis

• Mechanical Low Back or Leg Pain 97
• Nonmechanical Spinal Conditions 1
• Visceral Diseases 2

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Differential Dx Mechanical Low Back or Leg Pain
(97)

• Lumbar strain/sprain 70
• Degenerative process 10
• Herniated discs 4
• Spinal stenosis 3
• Compression fx 4
• Spondylolisthesis 2

• Traumatic fracture lt1
• Congenital diseasesevere kyphosis or scoliosis,
  transitional vertebrae lt1
• Spondylolysis
• Internal disc disruption
• Presumed instability

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Differential DxNonmechanical Spinal Conditions
(1)

• Neoplasia 0.7
• multiple myeloma
• mets
• lymphoma/leukemia
• spinal cord tumors
• retroperitoneal tumors
• primary vert. Tumors
• Infection 0.01
• osteomyelitis
• septic diskitis
• paraspinous abscess
• shingles

• Inflammatory arthritis 0.3
• ankylosing spondylitis
• psoriatic spondylitis
• Reiters syndrome
• Inflammatory bowel disease
• Pagets disease
• Scheuermanns disease

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Differential Dx Visceral Disease (2)

• Disease of pelvic organs
• prostatitis
• endometriosis
• chronic PID
• Renal disease
• nephrolithiasis
• pyelonephritis
• perinephric abscess

• Aortic aneurysms
• Gastrointestinal diseases
• pancreatitis
• cholecystitis
• penetrating ulcer

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RED FLAGS!!

• 3 with acute LBP may have a potentially
  life-threatening condition
• Cancer
• fever/chills
• unexplained weight loss
• persistent night pain
• greater than 50 years old
• previous history of cancer (may require early
  imaging)

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Cancer

• History sensitivity
  specificity
• Age gt 50 0.77 0.71
• previous history 0.31 0.98 of
  cancer
• failure to improve 0.31 0.90 in 1 mo. of
  therapy
• no relief -bed rest gt0.90 0.46
• duration gt 1 mo 0.50 0.81
• age gt50 or cancer hx or 1.00 0.60
  unexplained wt loss or
  failure of conservative
  tx.
• Insidious onset
• constitutional symptoms

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RED FLAGS!!

• Spinal Infection
• fever with or without chills
• worsening back pain, especially at night
• increased risk if
• IV drugs
• immunocompromised
• recent bacterial infection (UTI, wound, dental
  work)

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Infection

• Intravenous drug abuse, UTI, or skin infection in
  40
• also,
• immune suppression
• insidious onset
• previous surgery
• constitutional symptoms

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Ankylosing Spondylitis

• Ankylosing spondylitis (AS) is a rheumatic
  disease that causes arthritis of the spine and
  sacroiliac joints.
• It varies from intermittent episodes of back pain
  that occur throughout life to a severe chronic
  disease that attacks the spine, peripheral joints
  and other body organs, resulting in severe joint
  and back stiffness, loss of motion and deformity
  as life progresses.

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Ankylosing Spondylitis

• History sensitivity
  specificity
• age at onset lt40 1.00 0.07
• pain not relieved by supine 0.80 0.49
• morning back stiffness 0.64 0.59
• pain duration gt3 months 0.71 0.54
• 4 of 5 questions above positive 0.23 0.82
  
• also improved by exercise
• worse after rest, heat helps

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Ankylosing Spondylitis
150
Schobers test

• Technique
• Patient stands erect with normal posture
• Identify level of posterosuperior iliac spine
• Mark midline at 5 cm below iliac spine
• Mark midline at 10 cm above iliac spine
• Patient bends at waist to full forward flexion
• Measure distance between 2 lines (started 15 cm
  apart)
• Interpretation
• Normal distance between 2 lines increases to gt20
  cm
• Abnormal distance does not increase to gt20 cm
• Suggests decreased Lumbar spine range of motion
• May suggest Ankylosing Spondylitis

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Herniated Disc

• Sciatica
• sensitivity 0.95 specificity 0.88
• aching pain in buttock-- paresthesias radiating
  into posterior thigh and calf or posterior
  lateral thigh and lateral foreleg
• pain worsened by flexion
• aggravated by sneeze, cough, Valsalva

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EMERGENCY!

• Saddle anesthesia
• Diminished neurological response (decreased
  reflexes)
• Bladder retention
• Lax anal sphincter
• Foot drop or other major muscle weakness in legs,
  ankles or feet
• CAUDA EQUINA SYNDROME!

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Scoliosis

• Lateral curvature of the spine
• Usually consists of two curves, the original
  abnormal curve and a compensatory curve in the
  opposite direction

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Scoliosis
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Disorders ankle and foot
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Gout

• Metabolic disease that is a form of acute
  arthritis
• Causes inflammation of the joints in any location
  (but usually begins in the knee or foot)
• Acute onset of pain (usually at night) that
  increases in severity
• Caused by excessive uric acid in the blood and
  deposits of urates of sodium in and around joints

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Gout

• General physical exam is normal
• Intense erythema over the ankle and first MTP
• Severe pain with active and passive motion
• Marked tenderness to palpation of ankle and MTP
  joint lines
• No inguinal or femoral lymphadenopathy

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Strain

• Trauma to the muscle or the musculotendinous unit
  from violent contraction or excessive forcible
  stretch

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Sprain

• Trauma to a joint that causes pain and disability
  depending upon degree of injury to ligaments
• Ligaments may be completely torn
• Ankle joint is most common
• Signs
• swelling, heat, and disability, limitation of
  function
• cannot always subjectively tell difference
  between sprain and fracture

161
Sprain
162
Sprain
163
Questions?