A Poem

Finger-pointing test

Now before you start the tender task

Of examination, you must ask

"Where is this pain? If you can be precise

"To show me its location would be nice"

It's at this stage and often not before

Some patients say "I'm absolutely sure

"It's here, not there where my knee's been treated.

"I feel to some extent that I've been cheated."

With his index finger then he'll point

To the painful region on the joint.

Most often he will indicate quite nicely

The pathology, located most precisely.

Most important, pay attention now,

Because it is extraordinary how

The patient knows, and you as well will see

How true the "finger pointing test" can be.

The test being positive it's now your turn

The patient's indication to confirm, 

So take the chance before it is too late

And use your index finger to palpate

Physical examination - LOOK

Do your examination by the book

By Apley. Starting with the heading "LOOK".

Look in front, behind and then the sides.

See him standing, walking, watch his strides.

Scars

Look for scars -surgical? traumatic?

Are they small, medium or dramatic?

For every scar there'll be a tale to tell

Get that story, document it well.

Record physical findings

Document alignment and his gait;

Put him on the scales, record his weight.

Write down the thigh girth, calf girth, trophic changes;

Measure flexion and extension ranges.

Measure varus,valgus, angle "Q",

Foot pronation, supination too.

Pain receptors in the knee

You must be aware, palpating now

What to feel for, why and how.

The most receptors that transmit the pain

Sensations from the knee to reach the brain

Are in synovial structures in the knee

And also in the capsule where you see

The cruciates and menisci, which both owe

Their origin from capsule, as you know.

Scott Dye from San Francisco published his

Experiments to demonstrate just this.

With only anaesthetic to the skin

An arthroscope and instruments within

The synovial cavity of Scott Dye's knee

Were introduced to probe, to feel and see.

Healthy surface cartilage, he showed

Transmits no pain at all when it is probed.

A dullish ache arises from the bone

When this is probed, Professor Dye has shown.

Menisci, ligaments and capsule make

A more substantial pain with no mistake

About its source, its pressure and location.

This reality needs no imagination.

Synovial membrane in this context now

Is even more precise just where and how

Arthroscopic instruments can point

To their exact location in the joint.

Physical examination - FEEL

Allow your patient first to understand

The pressure of your fingers and your hand.

So first palpate the contra-lateral knee

Area by area systematically.

Now go to the symptomatic joint

Avoiding first the part where he did point.

That tender spot until the last is left,

And even then be gentle, accurate and deft.

Ask him once again " Is this the spot?

"is this the point of tenderness or not?"

Do not be prejudiced by his reply,

The finger pointing test will seldom lie.

Do believe him when he reacts with "Ouch"

To pressure in the suprapatellar pouch.

(And your reaction may well be "Eureka

The pain is from the suprapatellar plica.

Physical examination - MOVE (4 phases of gait)

Watch your patient walking without shoes -

The pattern of his gait and what he does.

Analyse his motion like a dance.

First his foot is on the floor in STANCE,

He then moves on to PUSH OFF from the toe

Then to the SWING THROUGH phase you watch him go

To HEEL STRIKE, and then back again to STANCE

To complete four phases of this dance.

Movements of the foot, the hip, the knee

Through all four phases now you have to see

As he walks towards you, then away

Then back again. Take notice of the sway,

The limp, the varus thrust, the length of stride -

Important observations to decide

What investigations you may need

Before deciding how you should proceed.

 

-

Advertisement