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the session. So for those of you that don't know me, I'm Megan. I'm one of the ski team on today. We're going to be going through the knee and the spine stations s. So I'm going to start off with the knee. Let's get straight into it. So you're greeted at the front of the station with something like this? Um, your foundation, your one doctor. In general practice on, you need to see Mr Steven Grant, who's a 32 your male presenting the knee pain following trauma. So we need a formal examination on start on management. So before we go into any of the histories, examinations or anything like that, I wanted to just talk through the anatomy of the knee because this is really important to understanding the examination on do the findings that you get. So the knee joint is a sign of your conjoint eso the hinge. Part of that is that it just moves in two directions, so it's got movement in one plane. So for the knee, that's flexion extension on. There might be a little bit of rotation medially and laterally, but this isn't a lot. It's mainly flexion extension on. It's a sign of your joint, which means that there's articulating services covered with highly cartilage. Um, and they're enclosed within a joint capsule, which is filled. Would sign of your fluid. Now, can anyone pop in the chapped for me? What three bones form? Theoretical ating, part of the knee joint? Yeah, brilliant. Lots of ounces coming in Well done. Wasn't any view that said the femur, the tibia and the patella I want to emphasize it's know the fibula. The fibula doesn't form an articulation in the knee joint itself. It's just off to the side. It's the femur, the patella and the tibia that form the articulating part of the knee on Do that occurs over two main joints. So on the distal anterior side of the female that articulates with the patella at the patellofemoral joint on what this joint does is it increases thie efficiency off the extension, reckon is, um, that the knee on then, ah, the tibia and the femur articulate between the Medio on natural condyles of each of those bones, which is kind of the weight bearing part of the joint itself. Then within the knee. We also have Minister which you can see here on these are basically fibrocartilage see shapes, which arm top of the condos of the tibia. And what these ain't to do is they interact a shock absorbers number one. So your knees are very high weight bearing joints. They deal with all of your body weight above thumb on. Do you need some shock absorption? They're also deepens the articulating services, which basically just makes the joint a little bit more stable. One thing that's quite clinically important to know is the medial collateral ligament, which runs across the medial side of the joint. Actually, attach is to the medial meniscus. So if you have damage to the medial collateral ligament that can sometimes also called cause a medial meniscus tear brilliance. And then the other thing I wanted to discuss was the ligaments, the knee. Can anyone pop in the chat before main ligaments that we have in the need? Some of which you can see on the diagram? Yeah, Pretty in Yeah, abbreviations are fine. Yeah, brilliant. Well done. So there's four main ones that we need to know. We have the anterior cruciate ligament, the posterior cruciate ligament on Then the medial collateral, collateral ligaments. So starting with the anterior cruciate ligament since is just here on this diagram. That attach is to the anterior into Kandahar region of the tibia. So it's basically the region between the two condos on it ascends up onto the intercom, did a faucet of the femur. So basically the depression in the femur between the two condos on what that does is it pretend prevents anterior dislocation off the tibia so it prevents the tibia from moving too far forward. Then we have the posterior cruciate ligament, which you can see both here and also in this diagram here on. But what that does is the opposite. Basically, So it prevents posterior movement off the tibia, then a Z, I said we have our to collaterals. So these were on the two sides of the knee joint on that prevents the media or a natural movements of the knee joint and keeps it kind of only moving in that one plane that makes it a hinged joint. So you can see on this middle diagram here, the lateral collateral ligament spans from the lateral epicondyle of the femur. So here on it inserts on the Depression on the lateral surface of the fibula head on the other side, which would be over here but isn't labored on this diagram, you would have the medial collateral ligament, which spans in the medial epicondyle of the femur and attach is onto the Medio condo of the tibia. Then finally, the honors meat. We have our birthday, which basically is. You guys know fluid filled sacs that contains I know of your fluids to help. Once again, we're kind of the shock absorption on movements of the knee. Does anyone know before locations of those Say what? What their names are, where they are, anything like that. You pop it in the chapped for me yet Pretty in ready. Good ideas coming in. Yeah, really good. So there's four main locations which I've labeled on. Here s so you have the super potent tell about PSA on. That's between the femur on the quadriceps for Morris muscle, which is just here on that's kind of an extension off the knee synovial cavity, which is here. Then you have the pre patellar bursitis, which is between the anterior surface of the patella and skin. Then you have the infertility, a MBA say There's two of these one superficial on one's deep. Um, and then finally, you have the semimembranosus pasa, which is pasta in the knee joint between the muscles in the back of the knee brilliance that's basically or a left knee done. I've added a few extra images on here for you to review on your own time On the only thing I wanted to flag was just the quadriceps tendon on the patella tendon of the 10 patella ligament. This is really important in clinical enough me just because the patella tendon or the patella ligament is an extension of the quadriceps tendon. And that helps, as I've said before with the extension mechanism of the knee and this attach onto the tibial tuberosity at the front of the tibia on what I've done here is well, as I just laid out some of the functions of those four ligaments that we spoke about, says I said before the anterior cruciate ligament prevents the tibia moving forward, the posterior cruciate ligament prevents the tibia moving back. The medial collateral ligament resist valgus forces, and I'll be going into valgus and various a bit later. But basically that prevents those forces try to push the knees medially push them together So the medial collateral ligament resists those on. Then the lateral collateral ligament is resistant to various forces that trying to push the knees apart so we'll go into spot diagnosis of some knee pathologies. Um, so our first been yet for you. So we have a 16 year old girl who presents following a game of level. One hour ago, she stopped, turned around suddenly and heard a loud, popping sound from her left knee On examination. Her left knee is very swollen. They will have idea of what's happened here. Yeah, brilliant. Well done, everyone think everyone got that right? Really good job. So this is an anterior cruciate ligament tear. Anyone pop in the chart because you'll know it straight away? What parts of that one yet suggests that this is an ACL toe popping, brilliant, immediate swelling really goes twisting movement, sports. Yet yet you guys will get the right idea. See a sudden decelerations, which is suggesting this in our area west. You stopped and she's turned around that twisting on a kind of foot that's planted on the ground. That's classic for an ACL just because when you have your foot flat on the floor. But then you turned me that. It's a lot of stress on the ACL. Onda, as it's structures it and put stress on her income, sometimes cause a tear. Um, as you said, the popping sound as follows quite classic on Do a Swell the the rapid effusion. The fact that this was only an hour ago on her left knee is really swollen, is quite classic. Invasive test on day can caused very large effusions within minutes to hours, because small blood vessels that are within the ligament in that local area content and they can just leak a fluid and blood into the joint. So really good on next one. So you have a 21 year old male he presents after a rugby game? Um, he was tackled and had a large blow to the medial side of his knee joint. He describes the knee giving way. He experiences pain on the medial side of his knee. The structure of his joint looks abnormal now with a mass on the lateral side. Any ideas? What's happened to you? Okay, lots of lateral collateral ligament tear options come in of being a bit sneaky here. I think I think of trucked trick to people. So the correct answer to this one is a patella desiccation. So in of tell a tissue Okay, Shin. In this scenario, you have someone where it's describing that he's had a force to the medial side, um, off his name, Um, and what that's done is that's pushed the patella over to one side. So looking back of the scenario, what what do you think this mass is that I've described? Said there's a mass on the natural light side? Yeah, exactly. That's the patella. So the patellas moved off. It's not in the midline anymore. It's moved off to one side. Um, so when you get that kind of injury to one side of the knee that can kind of dislodged the patella from it's normal, normal place of articulation, and then that could push it off to one side, which can then cause it's desiccated. Looking back of the scenario, it says, Hey describes the knee giving away. Can anyone describe to me What what causes something to give away? What? Just give. Give me why you mean it's a term we often use and like, need pathologies? But what does it actually mean if it's giving way? Yeah, it's unstable. Loss of stability. Yeah, really good, Yeah. So when the new one and he has described is giving way. It's basically where ligaments muscles, the structures that normally hold the knee together aren't working as well as they should. On that means that the knee is is no able to support the body way as well as it normally would, and it can sometimes be painful a swell. So in this case, if the patella is dislocated, that normal extension mechanism of the knee isn't working because the patella is an articulating in the normal place on. So what happens is the knee can't extend as well, and so it flexes. It went all walks. The knee does give way, kind of can't support the body way on, because that know extension mechanism isn't working really goes on Exelon. So we've got a 17 year old female she presents after being hit hard on the outside of her left knee, causing her need to point inwards on palpation. There is tenderness over the medial side of her left knee across the height of her off the knee joint. Any ideas? What? This is MCL Intel. Yeah, really would really good guys yet? So this is a medial collateral ligament tear. So it says, her knees pointing in words. Can anyone tell me, What's the fancy term for pointing inward sneeze point inwards? Getting with the Which one is it? Yeah, really good focus. Yeah, so that kind of knocked knees is what I'm trying to describe that. So it's a valgus position. Um, on why's there tenderness over the medial side of her left knee? Why is that tender? Why? Why is it across the hall height? Yeah, brilliant, Yes. So the fact is, over, the whole height of the joint suggests that, and it could be, Yeah, it's likely to be an MCL tears because that's, um, that's how that's what the MCL ligament spans over. So that's why there's tenderness there really good next one. So a 35 year old male presents with severe anterior knee pain after missing a step point going down the stairs on examination, he is unable to complete a straight leg raise. It is to tell it appears superior to is in the joint. Any idea what's going on here? Tendon tapped. A ligament? Yeah, but I think you guys are on the right idea. So, yes, this is a patellar tendon rupture. Eso Typically, the classic mechanism for this is when the quadriceps suddenly contract while the knees flexed. So maybe when someone's jumping in this case missing a step, we're going down the stairs. That's quite classic as well. Um, or it could be directly from an injury like a ninja read to the front of the knee. That could cause the tendon to rupture if it said Is it um why in the scenario is he unable to perform a straight leg raise? Does they will know if the patella tendon ruptured? Why? Is that significant? Yeah. Brilliant. You guys have got it. I think emphasize that enough already tonight? Yes. So if the patella tendon ruptured, that extensive mechanism of the knee isn't gonna work s so you're not gonna be able to perform a straight leg raise at all because you're not gonna have that extension mechanism there. And how I saw someone put in the chatter. A few people say it could be a quadriceps tendon rupture did. They? Won't know why. That's probably not the case for this one. Why? Why do we think it's a patella tendon rupture instead of a quadriceps tendon? March? Yeah. Brilliant. Yeah, because the patella is pulled up in a patellar tendon rupture because you're losing the force from the patella tendon below the li. So it kind of things up, if you like, it moves upwards. Whereas if you had a contraception and rupture on the tension will be pulling the patella in fairly. So with sit lower down. Really good. So on Exelon, a 29 year old male at 10. Ten's after a car accident. Where his leg. Uh, sorry. Where's leg? His bent legs hit the dashboard on examination. Both anterior posterior. Your tests are positive, and, you know, it is what this one is a CMP. So Okay. I were to say there's only one pathology here. You can't have an ACL while you see a radically. Probably you could. But in this scenario is just one. Yeah, Brilliant. Yeah. So this is a PC elder. This is a posterior cruciate ligament tear. So once again, classic history, it's either someone with bent knees hitting the dashboard. That's quite classic. Or it can also come on. Hyperextension the posterior cruciate ligament. Contrary as well. So But I can see why people thought this was an ACL PCL tear. Can you guys tell me why? Why is it if it's a PCR have why is the anterior door test positive? That's the test for, um I see. All right, Why? Why? Why is that post if it Yeah, brilliant. False, positive. Perfect. So, um, as I've said, posterior testes, usually the test be used for a PCO um, injury, which will be going into later. And the anterior is more for your anterior cruciate ligament injuries. If you imagine the function of the PCL is to make sure that the tibia doesn't sit back if you like, it doesn't fall backwards. Eso if that's ruptured, then that the tibia is going to fall backwards because of the lack of function off that ligament. So then when you do the anterior draw test, the knee will appear to move forward because there's someone put in the chat. You're basically bring it back to its normal position. So it does create a false positive test, and we'll be going more into that later. Um and then the posterior draw test is classic for PCL test. And just remember PCR test. You will get a posse, read your test, but you may also get a false positive anterior door desk drawer. Testis well, but it next one. So a 35 year old female presents with pain and swelling of honey. On examination, there is a fluctuance swelling, which is no erythematous or warm to touch, she mentioned. She is being seeding a new flower bed a lot recently. Any idea what's going on? Yep, radiant. Lots of violence is coming. And, yeah, really good. So this is bursitis. So this is basically those birthday that we showed earlier. Basically, inflammation of those may be due to the irritation. I saw someone put in the chap housemaids knee housemaids, bursitis. There's a couple of different types on because it's basically an inflammation of those where they've been irritated on. That causes those birthday to basically fill up with fluid, which creates this fracture in swelling that we found here. Um, probably hear it's unlikely to be septic because I've said it's not warm to touch is no erythematous, but it's important to rule that out with the site is a swell do. They won't know why it's relevant that she's been gardening. Why does that point towards a bursitis picture? Yeah, brilliant. Yes. If someone's CD a flower bed, they could be needing a lot. Which is quite classic of besides, the Simponi already goods. So next one, So 18 year old female presents. After turning quickly in a basketball game six hours ago, she describes her knee locking shortly after the injury on examination. Her pain is more intense on leg extension, and the knee is moderate, moderately swollen. Any ideas that's going on here? Yep. Couple of good answers of the message to me. Really good. Yeah, really good guys. Yeah. Good. So, yeah, it's a meniscal injury. So this also quite similar to an ACL presents commonly, after turning injuries, the need locking is basically the knee is, uh, kind of in full when it locks. It prevents any kind of fully extending. Um, so if there's a displaced miniscus, it can prevent the knee from Philly extending, and that's why it causes the locking. And hence why the pain is worse when you're trying to extend honey. Um, so, as I said, the the turning quickly. That's also quite classic of an ACO. So how we differentiate between a meniscus injury on an ACL? Any ideas? If someone came in, you want you'll I see a little meniscal injury. How would you go about different changing? Yeah, I just had a message. Really good. Yep, Yeah, yeah, Brilliant. So you can either do it using tests and we'll be going more into those eight when we do the exam. Things like McMurray's, um, or classic for a meniscal injury where, as as we said, anterior door is more associated with the ACL. But you could also, as a new determine, this know, is the rapid nous of the knee swelling. So in an ACO injury, typically the knee swells very quickly. It spells quite a lot. Where is in this case, the knee was only moderately swollen, which is more classic of a meniscal injury really good on our last scenario. So 11 year old boy presents after falling out of a tree on to his knees. On examination, there's a swelling and bruising over the patella and a palpable gap. Any ideas What this is? Yeah, really good answers coming in. Yeah, well, don't go. So yeah, this is a teleprompter s. So it's typically caused by a blow to the front of the knee because that's where you patella sits on. The palpable gap is basically if someone fractures that patella and it split in half, the gap is kind of the gap between the two parts of the patella that you can feel and see might feel that someone has to tell the doctor really good. She finds it really well. So I've put together a little summary sheet for kind of a traumatic knee history. Later on, in the week when we do and the M S K station will be going over mawr, other pathology is to do with the knee that osteoarthritis. But this is more the trauma aspect to the need today s o. Obviously, with any pain that someone will present with most likely you want to go through things that Socrates mechanisms of injury as well, just a listed. So if someone comes in with a direct blow to, um to the front of the knee, what we thinking If you pop it in the job, Someone says I've hit the front of my knee. What? What pathologies? Airway thinking? Yeah, Yeah. Anything to do with the patella yet is generally good, but yet telefax. Er, definitely. If someone's had a blow to the sides, what do we want to start thinking about? Collaterals. Dislocation. Brilliant. Very good. If someone says they suddenly stopped and they turned what we're thinking ACL yet things that decrease Yates. Brilliant. Yep. And if they like twist? Yeah, meniscus ready goods. Or if they want, if they come in and they say, um, I overextended money. What we're thinking then PCL, Britain. Yeah. So you guys have got the idea. Getting the mechanism of injury is really, really crucial for dramatic knee history. Um, then you want to see if they were able to continue the activity? Were they able to weight bear afterwards? Generally, we say, if they can't walk for another, like, four steps after the injury, something like really sinister could be going on like fractures and things. So you want to see if they can't wait there? You want us to send them to an e? Uh then is it on one side by sides. As we said before swelling, How quick was it? How severe is it to help differentiate between those meniscal tears and the HDL? Was there any locking or giving way or reputation sensation on then? In terms of the past medical history? Have they had any surgeries to the knee before they had any other injuries or what was the injury? When was it those kind of things? And do they have any other medical conditions that could affect any? So do they have pre existing arthritis? They have go anything like that. And then we also want to do our class existence review on our social, family and drug histories as well. So this is for you guys reviewing your own time. But I've done a summary table for you, some of the classic traumatic knee histories on but things that you need to know. So why don't we got for our knee histories? So if you take a little break, we'll be back in, um, a few minutes to continue on with the knee examination. Someone's just office If I'll put the other slide up for you guys to read during the break of more stuff about for you, and then we'll be back in two or three minutes. Lovely stuff. Like, Thank you. Could you pull the recording? Oh, yeah. Thanks. Thank you. So let's go on to the knee examination itself. Eso when we start on the exam leave walked into the station. What's the first thing that we want to do when we get that? Yeah. Brilliant. Yeah. White, introduce yourself. All those kind of things. So I've put together a little example for how you start, so hello. My name is Megan, Medical student. And I confirmed your name and your age, please. Today I've been asked for my examination of your knee. What? This involves just me. Have me a general look at you examining you walk feeling around your knee and also having you move your legs. I'll need you to be undressed from the lies down. Is that okay? Do I have your consent? Just that, you know, be talking out loud to the Examiner. What from the examination to let him or her know what I'm looking for on. Then? Just check if they're in any pain on where that pain is, just so you can take that into account during your examination, and it's good to be really impractical. Well, um, and explain if they have any discomfort, but that toe let you know on then you can stop or slow down accordingly. So let's get into the examination. So I'm going to show you some examination findings. And if you guys just pop in the trap, so basically, just say what you see. So you bought into the station. What's that? What can you see here? Yep. Brilliant. Great start, guys. Yet this is a swelling. This is this. Follow me. Eso. As we said before, that could be due to something like a joint effusion from an ACL tear meniscus injury. It could be something like septic arthritis, which is really, really, really important to rule out, especially if it's red and swollen, which isn't the case with this one. But if it was, you really do well on rule out septic arthritis. Um, it could be due to an inflammatory arthritis like rheumatoid arthritis. Or it could be from bleeding into a joint. There's lots of different causes. Be Yeah, swelling is definitely something to look out for. Is something quite common in the injuries. So next one, What's this? Yeah, brilliant. Very good. Yes. So this is the skull. And I think someone's already put in the chat on abbreviation of what type of Scarlett's. Does anyone know what type of ah scholars is? Yeah, Brilliant. Yes. So it's a total. So two knee replacements car and they won't know any other scholars you might see on the knee is a couple of others and thinking, Yeah, brilliant. Yeah, pretty. And that's why I'm thinking off and see what you might have scars just from injury. If they've had previous trauma to the knee, that's another thing to think about. You might have trauma scars or kind of surgery skulls. In terms of another surgery scar, you might see an arthroscopy port sites car, which kind of smaller? This is obviously a kind of, um, vertical line across the knee. You might see smaller little lines where they got him. Reports if they've gone into access the joint itself. So look out for those brilliant. What do we think this is? Yeah. Brilliant. Yeah, Painful. A Z. Yeah. This is a tele desiccation. See, this kind of shows you what I was describing earlier, so it will look like there's a lump in the knee that looks a bit with, but it's actually just the patellas just moved over on. Keep on eye. Out for that one. What do we think this is? Yeah. Brilliant. This is me hyper extension. So you can see the angle here is very big. There's definitely some The hyper extension here on that, as you said before, can occur. Um, can be the mechanism of a posterior cruciate ligament injury. Really good. So going on to our terminology, what deformity is this? Yeah, brilliant. Because I've got it. See, here this is a valve instable deformity. So this is basically when the tibias a run of extending outwards onda knees sit together in comparison to this one. What's this one called? Yeah, pretty. And you guys are Let's see, a varus deformity. So this is the opposite where the tibia is a turned inwards, if you like on the knees are there for quite far apart from each other. What can you see in this photo? Yeah, Brady, Um, older guys? Yes. Oh, yeah. There's a quadriceps muscle wasting specifically, as you said on the left s so we can see that there's a big asymmetry here between, um, like muscle groups. Any ideas why this might occur? Any ideas why we might get muscle wasting in the courts or just muscle wasting in the leg? Sinew it is. Yep. Brilliant. Lack of use you to an injury yet? Yeah, pretty a nerve injury. So yeah, it could be because of deduce. So someone's got a chronic joint pain. They might not want to use that. Like that's in pain or it might be a neurological thing. So there's, like, a low emotion, your own lesion then that can cause, um, problems with the nurse nerve supply to the muscles, which can then cause it to actually and waste away pretty good, right? What do you think? You can see here again? I think I tricked half of you think when you look at the picture, just orientate yourself a sto what direction the knee is in? Yes. I think a lot of you've got it. Yes. This is a popliteal swelling just to be quite general. When some of you guys are worried, you beat me to the question of different types of popliteal swelling so you can over have a baker cyst, which is basically a collection off Sinovel fluid a day back of the knee, which has basically form from a communication of the sign of your fluid in the knee joint itself. Um, and that could be caused by loads of different things, but may need structural changes to the knee that cause that fluid kind of leak out into the back of the knee. If you like any other one, you know, I spoke about really well done is like a popliteal aneurysm. So you have your popliteal artery running in the popliteal fossa behind the knee. Eso if that swells that can then kind of bulge out and create this funding at the back of the knee. Um, does anyone know kind of a finding of the pop it'll aneurysm that would make it quite classic like that you would know it's a popliteal aneurysm on examination. Yeah, brilliant. That's the one I was thinking of. It's pulsatile. So because it's not really have a post on aged to it. Brilliant. So still on all expections things we're looking at, what's their saluting to when you should go into a station? Yeah, pain More generally, I'm just thinking medications. So when you go into a station, look around the bed, make sure to look for anything like allergies or in the case of dramatic knee injuries, that might give you a clue as to what's going on. Finally, for inspection. What? What? These? Well, what my leading to Yeah, The crutches. Yeah. Brilliant. So think about mobility devices. Perfect. Yes. So this continue on idea of someone's functional status. If they're already having kind of treatment for anything, and it can help spotting these mobility AIDS, announce it to the examine. I can see this, and then they will know that you've recognized that there. Brilliant on, then. I don't know why. This is something I really struggled with between various and valve is it? Sounds like you guys got it down, Pat. You know it. But this is just the memory eight that I had for how to remember difference to embarrass and valgus. So, in a varus deformity, you could hold a rum bottle between the knees. So various and drama, both are in it. Um, so I kind of imagine this deformity a bit like a pirate with the wrong bottle in the middle. It's a bit weird, but it helped me to remember it. So for any of you guys that struggling, this was what I used to remember. Valgus interest of forties Brilliant. So we've done on German inspection. We've looked for those things on your own expert of the examination, which is the gait cycle. Now we're going back to our bit of physiology. Does anyone remember the six phases of the gate cycle? Any of them? It'll Yeah. Brilliant. I've had some problem messages for your body. And yes, So this is something that you won't necessarily get tested on it, and I'll skip it. It's good to know when you're looking at someone, get to try and work out where in the gait cycle, something is going wrong. Um, yeah, pretty and bringing in the trap. So it starts off with a heel strike, which does what it says on the tin. It's the first contacted. The hell with the foot on the floor. So your foot's kind of life. But if you like, then you go into a foot flat, which is once again does, which is in the tin. The foot is then flat against floor on, but that's from the body. Weight is kind of first transferred onto, in this case, the bread leg. Then we have midst aunts. So that's when the way is aligned above the for in question on your balance, fully on that leg because the other leg swing at this point, then we have he'll off. That's what's hasn't in hell comes off, so but the toes is still there. Little toe off toes are off. That continues to kind of write up, rise up. And then, as you guys accept, we've got the swing. So that's when your feet basically switch over. That one swings forward, ready to go for a second. He'll strike so really good. So I'm gonna talk through some kind of gay abnormalities that you might see on examination. So when you're testing gay in your needs are so patient to just walk to the end of the room, turn around and walk back. Um, and as I said, you'll check my gait cycle and then you look for other abnormalities that you might see in their gait. And so I'm gonna play you some videos and if you guys just pop in the chapped for me. Um What What abnormality you think you say? So we'll start with this one. Hopefully, that's protecting. Okay. What day abnormality is that? Yeah, Brilliant. Lots of good ideas. Come in. Yeah, really good guys, eh? So you guys were gone for the very professional words I have? No, I've got a limp. You buy that totally right is a untalented gate. And so basically, someone's limping. When there's a drug pathology or pathology that's causing the pain in that leg. So they're spending less time on the injured leg. So if we look back to the video, it's really a lot a lot of time on his right leg, but then know very long on his left leg on a say that's either due to pain. Which of you, as you guys have said, it's called an antalgic gait. Or it could be due to a week there. So the joint feeling unstable, anything like that, um, can cause a limp. Really good, right? I'll next video. And that is what's wrong with this person. Is that working play again? Cause it's quite sure, but that one was high And you it is. Yeah. You guys are good at Well, dumb. Yeah. Brilliant. So this is a high stepping gait, which, as you guys have said, is due to foot drop. So if you watch this video again and look at this patient's right, like you can see the foot as it's raised kind of limps down. It drops if you are. Um, So what he's having to do is he's having too excessively flex that leg in order to make sure that his foot foot is cleared from a floor. Uh, classically, what nerve is damaged that causes a foot drop. Yet you guys are on that component already. Good. And does anyone know what normally is the but mechanism of injury? What What causes a compare new, um, nerve injury. And, yeah, it is. Yeah, buddy. And yeah. So a fracture to the fibula specifically around the neck, because that's where the nerve wraps around. Um, so if that, um, and that gets fractured, that damage nerve than that can cause this, uh, presentation of a high stepping gait. Really good. Um, I was in this video showing you that he's kind of having to raise his foot up. Um, what's another presentation of someone with a component of injury? Does anyone know eso? In this case, he's having to kind of excessively raise his foot. Sometimes you won't see that. And you'll my clothes. You're here. Something else? Um, which could be a sign of a component of foot drop injury. Yeah, that's a good idea. Is coming in. It's not the one I'm thinking off. Okay, so, um, if someone has a compound new injury, as you guys, I said in the chart, I can't dorsiflexed effort. So sometimes when, After you've kind of lift your foot up and you're putting on the floor, you do it in a way that you don't think about it, but you're doing in quite a software A. So there is a bit of infection to make sure that as your foot hits the floor, it kind of it's cushioned in. Whereas if someone's got a compound paraneal injury and they can't do a CT dorsiflex effort when they go to put that foot down, you can sometimes hear something called a foot slap, which is basically where they're not guilty, faxing that for as they as it hits the fall on that could make it snappy noise. That's another thing that you might see. The gate will look fairly normal, but you were just here a slap whenever they place that foot on the ground. And so that's something to look for. Pretty good job for a PSA or next video. Any idea what's going on here? What the abnormality is the pathology? Yeah, pretty. And yeah, really good guys. Yeah, looking at the turning in the gait cycle is really important. As you can see, it was just demonstrated. This lady took quite a while to turn on. That's quite classic of a parkinsonian gait. Um, as you guys, I said as well. She hasn't got a lot of arm swing and she walks on, which is also quite classic, and you could say that her gait is quite shuffling. It's not. It's not really in this video, but sometimes you'll see a shuffling gait on, which can also be quite classic of parks only in gait. And there's other reasons that someone might have so turning. So if someone's got joined instability, if they've got a reduced range of movement, they might also be slow to turn. But in this case, you're right. It was a pocket only in gait. Really good on our last video. So what's going on here? What's causing it? What's going on? Okay, good ideas in the trap. Not not correct. Unfortunately, it is. Any clue. Look at what she's wearing. Yeah, someone's got it. Well done. Yeah. So the shoe was a bit of a clue here. Yes, leg length discrepancy. So in this case, is ladies artificially done it by putting on a shoe. But you can see that this lady's This lady's right leg is longer than her other leg on, but means that after they put their weight on the longer lake in this case, the right the shorter leg will kind of markedly dropped down to the floor after its wings. I'll play again because the after it swings, it kind of she kind of drops to the floor on Sometimes you can also see a swell. She's leaning onto the side of the shorter leg. Um, these can be due to injury, sire. For example, fractures, ligament problems, things like that or it could be congenital. But that's something. Just a look out for a swell. Really engage job, guys. So we've worked through gate. So now I won't, uh, our next bit of the examination, which is your palpations. So I've grouped these into the things that we were doing an extended knee knee effusions on on the flex Nias. Well, so here's your first image. Any ideas? What's going here when you're palpating? What's going on? He saw this a new palpated it. What would you expect to feel? And that's my clue. Yeah, really good. Yes. So when you're, um, palpating the knee, check the temperature. You gonna assess it? Is it really hot? But also compare it to the other side. For example, if someone has a septic joint that's typically unilateral eso, there will be a difference between the two as well. Um, and you kind of want to compare from the quads across the knee and down into the lower legs. Well, using the back of your palms because these are more sensitive to temperatures than our palms are because the farms have really thick skin s. So we use the back of our hands typically, Um, this is a sad You want to kind of rule out septic arthritis, cause that could be really bad. We want to go back out. But there are other pathologies that could cause a kind of hot joint. Canary one think of any Yep. Gout. Brilliant. Similar to go. Yep. So you to go Brilliant. Yeah, that's the other one. I think you have any kind of inflammatory arthritis, like rheumatoid. Brilliant. So next thing that we're gonna palpate what's going on here? You've seen this image already? Not that it's oppositely. The other is wasting what we're going to do in our examination with the equipment I've given you. Yeah, brilliant. We're gonna measure discomforts. Pretty it measure the quadriceps poke on. Be said this could be due to disuse atrophy. Or it could be due to low Motrin urine issues. Obviously, in this image, for the sake of the session, I wanted it to be quite obviously pick out in the image. But sometimes the wasting is quite settle s. So it's really important that we use a measuring tape just to check those kind of subtle abnormalities does. They won't know when we're measuring. Where do we place the tape? Because we want to make sure we're doing it. in the same place I'm on each one. Yeah, but And I just had someone message me The correct answer. Well, don't see it is 20 centimeters above the tibial tuberosity and see you for signed that just below the patella on both on both knees and then measure 20 centimeters up. And then you measure this conference, Um, that pretty in then We've seen this one before, but what are we checking here on our how patient? Yep. Teledesic Asian even brought in that We just want to see where the patella is. So, in this case, is it dislocated? Eso What you do on examination is you to feel for the quadriceps tendon filled the patella. In this case, it's a bit off because it's dislocated. And you'd also feel bloated that for the patella ligament or the patella tendon. Um, on. Do you just see whether they will win the correct position? Basically. So I've said here tell a desiccation could leave the patella to be off any ideas of other pathologies that would cause the patella TV off. We've mentioned some of them already. Yep. Something's been. Tourney. What's been told? A tear to what? Yeah, brilliant. The patella tendon of the coaches at sending. Yeah, that's because our patella position to be off the other things that we want a palpate check. Everything's in the right place. And finally Oh, so I have already shown it already. That was bad. Sorry, Polyjuice. Guys, we wanna palpate for the medial collateral joint lines. So these are the lines basically marking where the femur and the tibia articulate on. That's where the meniscal I are found along these joint lines. Does anyone know any pathology is where there might be joint line tenderness. Why, If someone was tender as you're palpating these? Yep. Meniscal injury Perfect. That's where they all. Anything else? Anything else? Maybe it's you get to the outer, so I didn't say that. Could be causing tenderness to them. The joint lines? Yeah. Fracture. Is it on the joint lines? Pretty good. Yeah. Brilliant. And then you're collateral. Ligaments on the outer sides might produce. Enjoy nine tenderness. Very good guys. So then we're going to need effusion tests. Eso we've said before HDL ruptures. They have large, rapid effusions, meniscal injuries. They will slow more moderate effusions on. We've talked about things that septic arthritis, which can also cause fusions and inflammatory arthritis is a swell, which therefore we need to test for it on the exam. Eso does a one of the two tests that we can do for the infusions sweep. Brilliant teletype. Amazing world. Um, which of those is more sensitive in that it can pick up smaller amounts of effusion. Sweep, sweep, sweep, sweep. Yeah. You guys are going Well, um, yeah, it's the sweet dust. So I said to do tests patella tap and sweet, So we'll go through the patella tap first. So this is mainly used to say, to pick up a larger effusions, the moderate to large in the knee s o. In this, you'd have your knee still extended. The muscles need to be nice and relaxed on, um, with one hand. What you do is you basically push all the fluid that was in the super patella pouches. You can see here in fear, Lee into the main kind of me capsule. Um, and you could do that as this gentleman's done here by sliding your hand down lots of lots of times to push that fluid down into here. Um then what you need to do is keep this hand, um, across the across the top of the knee joint because you don't want that fluid to refill the super patella pouch. Because if you think this person is lying in fear really sorry, this mess is lying flat. So look at this diagram. If you imagine that the bed is kind of here, um, the fluid Viagra Vitti will naturally go back into the super patella pouch. We don't want that. So you need to keep pressing down here, keep putting a lot of firm pressure there. And then what you do is you've seen in this video is you press down on the patella on, but if there's excess fluid, you'll see it kind of Bobby up down, which you can see here on this positive test. You can see it moves, Um, and that's when you get a positive test when the patella moves up and down because it suggests there's fluid underneath and it kind of move up and down on top of that fluid. This doesn't come back into a normal result, which is you can see there's no really any movement of the patella. Little if I play them by. If you'll say up, this one's not getting any movement. But then when this guy presses here, you can see it moving up it down. So that's your patella top. Um, Then you have your sweet test, which I'll show you over here. So this is, you said, is more sensitive it to Texas. Smaller infusions that you can't find on your patella top. And so once again, you have your knee X tended muscles relaxed, and there's different ways of performance. Test people do different things, but basically with one hand, you want to sweep sweet upwards on the medial joint side of the joint multiple times, and that removes all the fluid from the medial side of the joint. Um, and then what you want to do with the other hand is, um, basically sweet down the other side, another stent mints sweeping upwards in this video, Um, and that pushes back all the food back over to the medial side on As you can see in this video, you're looking for a bulge on that medial side. As the fluid moves back across, you could see there was a bulge there, um, and that suggest that there is an infusion president. If we compare this to normal, which you could see sweeps up the medial side removes all the fluid from the medial side of the joint capsule, and then he's gonna sweet sweet down the lateral side and there's no bulge there. So that's a normal or negative test presents be so before with this video. He's going to sleep when we get that bulge. That's what you looking for in that home. Brilliant. So then, at this point in the exam, we're going to pop a patient's knee into a flex position, so we're gonna flex it to 90 degrees. Their foot is firmly on the bed on Be need to recheck a few things, so check the media electric lines again. Check the patella position again. It's actually easier to assess these men. Flax Bet we do it when they're extended anyway. But assess these again on then we're gonna check for a few more things now that the knee is in effect. Position. Um so I've popped on here. Some landmarks in ours came one. Tell me kind of what we want to palpate when the knees flexed. Yep, fibula. Head pretty in. Yeah. Yep. You guys got it yet? Patella tibia to Broschi on the food. Your head of the main one. And that's just marking where the patella rays. So the tibial tuberosity is just below the patella. You feel it on your only now, if you'd like to. It's kind of like a raised area, just just inferior to the patella on this. I said, that's where the patella ligament inserts. Um, then we want to just feel for the head of the fibula is Well, this is more on the lateral aspect of the knee just below the knee joint. And you should be able to feel like around in large, where the head of the fibula is. Um, And if tenderness there, what do we think could be going on? Yeah. Brilliant. I've had some people message. May Yeah. Fracture. Brilliant. Yes. So if there's a tendon that could suggest a regular, um, head or if you'd be a next next rupture, which we want to be aware off and then what we're looking for here, What are we looking? What we trying to feel in the flex knee? Yeah. Brilliant. Our property else for thinks so already gone through them. So the baker cyst on the popliteal aneurysm you want to have a feel for See if you can feel them by just putting your films kind of on the front of the knee and feeling in the back of the knee for those swellings really into, That's all feel section off our exam done. So I'm going to move on to move, So we're gonna get our patient to do and some different movements. So can anyone describe for me what's going on in this video? No, no say before you. But what's the patient doing yet? Knee flexion. What about the knee flexion? Yeah, brilliant. It's an active movement. Yeah, so, um, it's and this is an active infections. This is when the patient is doing the move independently. Um, suit. In this case, you'd ask them to bring their heal up towards the bottom as far as they can go on, then they should be able to really touch it or get quite close, which is about 100 40 degrees on. Then you ask them, in this case to extend their leg back house again, and they should be able to get it flat on the bed, which is about 180 degrees. Um, interesting today. So what's this? So it's it's better up. He's not moving the leg that faster. What is that movement? Passive? Yeah, Brilliance is the passive movement. Instead, this is where you're doing it on the patient themselves. They need to be relaxed. They can't have the muscles tense. Tip for doing this is if you if we watch how he does it. If you place the one hand under the fire initially here, um, just proximal to kind of where the knee joint is. That's where he starts his hand. If I pause it there. So he's got his head just possible to the knee behind the knee and then the other hand is kind of placed in a C shape, a two pack of the ankle. Then, as he moves his hand further up, what you'll see is he switches where where his hands also is bottom hand rotates to come to the front of the ankle on this one comes to the top, um, of the thigh, and that could be easier in helping you move the leg, especially if you've got a larger patient. And then finally, what do we think he's testing for here? Yeah, pretty and hyperextension. Yes, on. I just had a question about this one. To your hand. Be on the knee. So, yeah, that's why you're switching. So he hasn't done it in this case. But if you were feeling, um, the knee joint, you want to have your hand over the knee joint to feel for any practice that might be happening in the knee. So that's why you move your hand. You pop it there to start the movement, but then pop it on top to feel for the practice. Yes, For this video, he's checking for hyper extension off often ing so you can just lift the leg up. That's commonly what's done, but you can also on look and see if there's any hyperextension or in this case, you can kind of pull up on the ankle on place. Pressure just about the knee joint. See if there's any hyperextension there, Um, and if it's greater than about 10 degrees, that's yes, there's a pathology going on. Um, what I will say with all these movements is if you know there's a joint Oh gee, assess the normal side first on going to decide with the pathology at another thing that's really important is to make sure establish whether, when a patient, for example, is doing active movements and say they're not able to complete the movement established why they can't complete it is that because their leg physically won't move? Or is it because they're in too much pain? That's quite important to differentiate, because if someone's in pain, yes, it's causing the pain, and we don't want to cause them to much pain. But they may be able to complete the movement, whereas if they physically can't because their legs locked or it won't move, then that's different. So it's important to different shape. And then I just wanted to show you this is the gait of someone with hyper extensions on the leg. With the knee rolled up, you can see that that leg is again. That leg is hyper extending is as this person walks. You might notice that on the gate as well, and that might be a way to test for, um, hyperextension. But I said you could do it this way as Well, brilliance, that's all. Move. So finally, we want to or special tests. So we're gonna check our cruciate ligament test first. Um, so I'm gonna show you a video, and if you guys can tell me what the sign is, what you're looking for, so looking at those two knees is kind of pointed it already. Any idea what's going on? They live in that? Yeah. Brilliant. So this is the post Aricept signed. Um, in this case is a positive test on the left hand side, you can see there's some sagging of the tibia on. That's basically with the tibia is hanging posteriorly on. This is the Sinus. You conceive a PCL injury. So we said before the PCL prevents backwards sliding of the tibia and some friends moving backwards. So if that's injured, then the tibia kind of hangs posterior. It sags if you like. Um, so you basically do what it did in the video. You get the patient effects any at 90 degrees, relax effort on the bed and just look and see whether there's any sagging that you can see and look for asymmetry between the two knees. I've shown this first in its life for a reason. Why Why do we perform a posterior sacks time first? Why is that really important to do first, before we do any of the other creature ligament tests? Yeah. Brilliant. Someone's got it all done. Yes. So it's that false positive we were talking about earlier. So before we go on to do the anterior drawer, we want to have an idea, at least if the posterior cruciate ligament is injured because of that false positive that we talked about before. So you can see it more clearly with this video. If you then performed an anterior drawn this gentleman, you can see that you would once you flex his knee up until this point, you would then be able to pull his knee forward on anterior door test on that will give you a false positive for an anterior cruciate ligament injury. So it's really important that we do this first to see that the tibia is sitting backwards and therefore we could have a posterior cruciate ligament injury. Very good. Then we've got the anterior drawer test, which I'll show you in this video, which is a positive test here. So in this test is said, it's testing for the ACL. You have the knee flexed to 90 degrees on. You kind of wrap your for the Reds. Beginning wrap your hands around the knee and try and pull it forward. Basically, Um, and you feel for that anterior movement of the tibia against the femur. If there's little no movement, that's normal. But if there is any movement there for play again, you can see there's quite significant movement there. That's a positive test now going to this one. Any ideas? What this test is? Yeah, brilliant. Well done. Yes. So this is the posterior drawer, so you can see it's the exact opposite. You're pushing the tibia posteriorly, and if there's little know, movement or, well, a good. But it's positive. If there's excess movement because of that posterior cruciate ligament, injury or rupture, you can see that leg is moving, especially in this bit. It's moving quite considered back, and you can see when he's doing the anterior door. You can see how that creates a false positive because he is able to do with any forwards really good, and then our last video for Christmas ligaments. The tests. What test. Is this do again? I think I What test is that? Yeah, but in have lots of violence is coming and see how this is, like once test. So this isn't commonly done in your schedule. Your rescues. It's better to use the anterior drawer. It's good to see a positive test example of it s so your patients knee isn't it's flexing this on. It's a 30 degrees on. Do they typically have their heel, either on or off the bed? A new basically, Just hold the tibia with one hand. Um, hold the female with the other and try and pull the tibia forward. Um, it was again if his excess movement, that's a positive test. But if there's not much movement and that's normal, Um, so that was the side of his pathology. If we watched the normal side, you can see this. There's still some movement, but that's better than it is compared to this side where there's a lot more movement. This is a positive test for lack ones. Great job so on, except tests, special tests. So what's going on here? Okay. Again. Yeah, Brilliant. I think it goes to go. Let's see how we're testing. Testing for the medial collateral ligament on this is called The Valve was test of the vial with stress test because the reason why it gets his name is this gentleman is putting a valgus force on the knees. He could see he's pushing into the knees, trying to push it in words into that valgus position that not please position on. That's what's going to stretch the medial collateral ligament, which is here. Um, so in his case, he's putting the force here, and then he's trying to extend. Oh, in this case of duct, the knee outwards, Teo stretch the medial collateral ligament. Um, And if there is excess movement and as you can see in this case, he is able to kind of abduct the knee quite a bit, that's positive. That suggest is a tear because the medial collateral ligament isn't keeping the knee straight. Um, and he is able to abduct. Hence why? It's a positive test if we compare that to this one. What do we think this one is that I wanted to say that we get yeah, pretty intense. This is This is the virus test on in this case, it was positive, which would see more at the end of the video. So it's been hard to say, because you can see his hand. But it's basically putting the knee in words, if you like towards the center, part of the screen eso he's there for putting kind of valgus force on it. He's trying, Uh, sorry. He's trying to put his partner various ports in it because he's trying to pull the knees apart, remembering that room bottle analogy from earlier say, stretching the lateral collateral ligament on this side. Um, so in this case, there is some adoption on, Therefore, it's a positive test. Or is if there wasn't a lot, then that would be a negative or normal test. Brilliant. And then finally, this is, um, uh, meniscal test. Does anyone know what this is called? McMurray's Brilliant. Yeah, well, don't I see how this is once again no commonly used in Oscars, But once again, it's good to see. So in this test, what you do is you flex the knee a Zara's. It will go. You externally rotate the foot on. Then what you do is you apply. Um, you apply. I am various force too many, and that can sometimes cause discomfort. Then you could do the opposite to check for the other meniscus. Where you flexing the again internally, rotate the foot on, apply the opposite force on that can check for discomfort in the other meniscus. You won't have to do this in the Noski, but it's quite um, and you won't necessarily see anything in this video in terms of signs. It's more pain or discomfort that they report, but it's good to see just how it's performed. So I put together a little summary of the special testing me for you guys to review in your own times about how we check the cruciate ligaments, the capitals and then this guy and that completes our the examinations. We done a German inspection or gait feel move and special tests. So at this point, you just think the patient and ask them to restore their clothing on Dive also pops in here. A little example. Presentation back to your examiner for any examination that I'll let you read in your in time so we'll take another break on. Then we'll be back shortly to go onto these fine example So we've done the name now moving on to the spine. So this is not unexamined presentation you might get. So we've got a gentleman with lower back pain. So we need to take a history on start management, but start off with some spot diagnoses. So to start off with, you have a 52 year old obese male he presents with generalized low, lower back pain for four months. He describes it is dull and is worse. Um, movement in certain postures. He was fired from work just before it began. No, no, um, urological impairment is present. What pathology do we think we've got here is what, Jim? A low back pain. What? Dull? Yeah. Brilliant. Yeah. Some of you guys have got the good idea. Yeah, so yeah. Musculoskelatal kind of non specific back paid. So this is a general pain in the lumbar, sacral region of the back. There's no neurological impairment. I've picked out a couple of risk factors for this. Any ideas? What ones have mentioned in this scenario? Based E. Yep. Postures yet that's a classic sign for them. Escape pain. Sudden tree? Yep. Stress. Brilliant. Yes. He was recently fired from work just for it began. Yeah, brilliant. So yeah, it's That's a stress, which can be a risk factor. Brilliant on. Do you guys have mentioned some of the features of mechanical back pain so it can occur or be worsened by movement? Can be relieved by rest. It varies with posture on On examination, you're generally find that the pains quite general, it's not really focused on a particular Tobry does. They won't know what type of diagnosis is is. Is this something we would jump to straight away? Yeah. Brilliant. Yes. This is a diagnosis of exclusion. We want to rule out all other pathologies. We want to rule out loads of red flags that we're going to later. That signs of more sinister causes of back pain before we label somewhere is having an M S K non specific back pain. Pretty it next one. So a 59 year old male presents with low back pain and bilateral aching leg pain that comes on gradually remarking he finds it easier to walk a pill than downhill. Any idea what's going on here? Yeah, brilliant lot of guys, yet spinal stenosis, So spinal stenosis is basically when you get a narrowing of the vertebral Framan, which is basically the central canal of your spinal column. That contagious final cord. It can produce this. Sorry, it can produce this back pain. Or it can produce this aching leg pain, which can be you need actual bilateral on it comes on gradually. What part of scenario gives it away? That spinal stenosis is what made you will jump to spinal stenosis. Better on the uphill. Yeah, Brilliant. What? What's that? Alluding to what my suggesting with why is it easier to walk uphill that down the air? Brilliant. Well done. So, yeah, as you walk uphill because of how we walk in To make sure that our center of gravity is in the right place, we lean forward, which then widens the vegetable for frame and widens the spinal canal on. That's gonna relieve that pressure relief. That pain is when you're walking down here to make sure you don't fall over, you kind of unconsciously lean back a bit. Which narrows the canal. Um, makes the pain worse. I know this isn't necessarily what you jump to in a spine station talk, but sometimes this is related to peripheral arterial disease is something we need to pull out. How would we rule out something like prefer arterial disease, which will come on quite somebody with a gradual, aching, like pain that comes on when walking. What will be due to, um, making think it was spinal stenosis rather than, like, arterial disease. But the legs? Yeah, but and a BP I Great suggestion yet check the pulses S o. He was Finally, nurses will typically have a normal peripheral vascular examination on the positional description of this pain. The kind of walking uphill downhill that's more classic of spinal stenosis. You don't get that with peripheral arterial disease. Pretty in next one. So we've got 68 year old female she presents with Southern back pain. On examination, there's localized tenderness over a lower for us thoracic vertebra on. Just got past medical history of polymyalgia rhuematica. Now, here's what's going on. Yeah, brilliant. Well done. Yes. So this is an osteoporotic compression fracture, But fracture is very good, because that's really good thing to know s Oh, this is quite common in women over the age of 65. It presents with, in this case, quite acute sudden back pain it can present with the loss of height. Um or, um, in this case, quite localized focal tenderness over the bedspread that's been affected. I think someone's already put it in the chat. But what's the relevance of her past medical history? Why is the Polymyalgia rhuematica significant? Yeah, brilliant. Yes, she would have been on steroids on and long term steroids that sometimes used in a polymyalgia rhuematica can thin the bones on that makes people more vulnerable to these type of compression fractures because of osteoporosis. On what drug to be typically give for bone protection for things like that, if someone's are starting a steroid. Yeah, this phosphinates really good. Yeah. Things are alendronic acid. What we use to protect her bones. They're really good. So a 52 year old female visits to anyone. Low back pain and new onset bilateral sciatica. On examination, a mass is felt in the super pubic region. And that is what's going on here. This quite sink you want? Yeah, buddy. And someone's got up. Well done. Yeah, really? Get this is called a coin. Uh, so, um, that's where I order quantities compression at the quarter a quinine, which is below the spinal cord, is that horse tell lumber taken nerve roots that below the actual spinal cord itself. This is a medical emergency on grease in while we're thinking quarter quieter in this instance is because of the bilateral sciatica. That's quite a plastic sign of a quarter A quite a syndrome because it's not a compression lower down that's only affected one leg. It's affecting both on this is a medical emergency. Um, what's the mass that I'm referring to you in the super pubic region? Say, Well, no. What? I Yeah. Bloody brilliant. Yes, it's her bladder on so people can become incontinent of urine record or quieter, but they lose control of being able to empty and the bladder so it can also cause retention, which in this case, is the master. It's felt, um, other signs of quarter A Quite a while the ones to people know you might get a quarter a quarter singer loss of anal tone Saddle on this parasthesia pretty and yep, pretty and well done, guys, you got the main ones. Amazing, right? Next one. So a 61 year old male presents with back pain in the thoracic region, he reports This is worse at night when sneezing. Um, he also reports a chronic cough, which he has not mentioned to his GP on examination. There's localized tenderness over t 12 on. He has a 56 pack year smoking history, and it is that's going on very specific balances in the child. Okay, Yeah, really good. Yeah, this is ah, metastatic spinal cord compression s o in comparison to quarter a prior. Which is that compression of the nerve roots below the level of one where the spinal cord tapers off. This is a spinal cord. Compression above that level, in this case by a tumor is most common in the thoracic regions. Simply because it's the largest region, that spine, it's more likely where it's going to occur. A Z you guys already guessed. Think someone's already got it in the chat, the cough and the smoking history is referring to a lung cancer, which is a common cancer, which then causes metastases to the bones of the spine. You might also get em breast lymphoma, but lung is quite common. Um, on the classic thing about this is the back pain's worse been lying down because you're putting pressure there. And it's also worse in any type of straining when he's sneezing. Coughing anything like that, um, is a sign of metastatic or spinal cord compression. Um, and you may also get some nerve signs as well, which we haven't put in the snow, but you might get as well, brilliance next one. So 29 year old male presents with gradual onset, lower back pain and buttock pain stiffness, which is worse in for two years. The back pain is worse in the morning. Where you stiff for about 90 minutes On examination, there is tenderness over the sacroiliac joints on reduced lateral flexion of the lumbar spine. Yeah, but and you guys got nice and quick. Well done. Yeah, I'm closing spondylitis. This is an infirmary condition. Hence why? It's worse in the morning on a better. And he's got the morning stiffness and it gets better throughout the day. Does they will know what the examination test we'd use will go into it when we do the examination. But the test reduced to look for Thanks, Mom. Yeah. Brilliant. Someone's got it. Yeah, Showbiz test. Really good. So that's looking at a forward flexion that's considered to be reduced in, then closing spondylitis. Really in next neuro. So 21 year old female she presents with lower back pain and fever, their needle track marks in the antecubital fossa. Um, on examination, there's hypotonia and weakness in both lower limbs. And I just What's going on? Yeah, but, um, otherwise, yes, this is a spinal epidural abscess. So it's a collection of pass basically pressing on the spinal cord. Classic histories on IV drug user with fever. Low back pain are they might get kind of neurological deficits in this case in the lower limb. But I get on our last scenario. So we have a 68 year old male presents Any was sudden onset abdominal pain. Radiating to the back is the pressure is 85/60 to heart rate 1 23. Respiratory seven is a positive history of hypertension had cluster anemia. Yeah, well done, everyone. See it ruptured triple. I'm just throwing this one in there because even those is a spinal station. Remember? The pathology is that can radiate it back because someone might come in to you saying I've got back pain, but they might not say, I'll watch. You had abdominal pain first. If someone had a rupture Triple A, they probably mentioned the abdominal pain for us. But just just the point I wanted to make is remember, the pathology is that radiated back on? That's the importance of a systems reviewed in your history. So this is the back pain history summary. I'm not gonna go through this particularly, but just see if we're paying classically go through your Socrates. Where is the pain? Is it directly over the spine? Is it paraspinal muscles? Is it kind of lateral? Maybe a renal colic situation? Things like that Time, as I said, Is it worse if it's like a, um, closing spondylitis? Is it worse? Is it improved with activity worse in the morning? Or do they have it a night? Say there's a spinal met, Um, and I've put in here lots of things that you can ask different neurological and spinal related things that you can ask them for each of these, I recommend you do like a small Socrates, free to those to gather more information. So if say, there was sciatica, is it side is it one sided, both sided. When did it start? How is it progressed, etcetera to do a little mini Socrates for each of these. Um And then obviously we go for our systems review. As I said, to make sure you're not missing any of those technologies that radiate to the back, Um, we want to know of any previous back problems spinal problems, surgeries, except for any cancers that could suggest what pathology is going on. So we're going to play a little game. I've talked about red flags about pain. I'm going to flash up some red flags on what you guys tell me. Is it a red flag or is it no replied. So if someone has pain overlying t eight vertebrae is that red flag or is that not a red flag? Red flag? Well, dumb next one. Poor coping strategies. If someone says I'm struggling to go, I'm not able to use strategies. Help me cope. Is that red flag? Was it know a red flag? Yeah, Someone's message me Well done. Yes, it's not a red flag for coping strategies is actually something called a yellow flag, which is basically a kind of psycho social reason why someone might have back pain. It's not a red flag, but it's a yellow flag and put it in yellow fever. Red flag a lot. It's like right black Well done. Pain when sitting still. What rest? Bread flag? Yep. Brilliant. Sorry, I didn't explain pain. Overlying the t eight vertebrae. Is there anything in the thoracic region? Is a red flag way. Don't like things going on the fasting region. Um, absence of history of trauma or injury? Red flag or not, Red flag? No. Yeah. No, a red flag. So if there was a history of trauma or injury, that would be a red flag on. But the lack off is therefore not a red flag. Kyphosis this if you notice someone's got access kyphosis is that a red flag on up? Bit more mixed on this month. This is a red flag because you've got a spinal deformity. An 18 year old with new onset back pain, red flag or not, or red flags mobitz that again? Yeah, this is not a red flag. I've been a bit cheeky. The criteria for about back plain red flags, which I'll show you in a second suggest, uh, less than 16 is a red flag. So in 18 year old wouldn't be but very close. And finally, a past medical history. Off cancer. Yeah, Pretty. And what's on everyone? Yeah, that is definitely a red flag. So a salute to there's lots of different red flags about pain. I like to remember this with the new Monica tuna fish, which have popped up here. So any trauma, urinary symptoms, neurological symptoms, the age being under 16/50. Any fever on IV drug user? They started juicing in history of concept. That's how you remember the main ones I popped up on here, a more extensive list of red flags about pain for you guys to review in your own time. A second. There's quite a few to fit on the list, but I used to have fish. Just remember the name ones and then because of time getting that. You guys review this in your in time. But once again, this is a summary table off some of the main causes off back pain that you might come across in your skin on. This is how they would be kind of classified into kind of orthopedic reasons, more rheumatological reasons or systemic reasons. And finally, those referred causes of back pain that we talked about. But once again let you review that. And you're in time. So we've taken our history with them going to go on to our investigations. And as you guys know, we spent this up into bedside bloods on imaging and special tests. So think about bed size. Any investigations? You do have kind of any back pain that comes in. What? What would you like to do at the bedside investigations? Mexico ups your analysis. Yeah, well done. Spine exam goods, correct. Owns a, uh, pretty and yeah, really good, guys. Yeah. I've put down on a B C. D. Assessment. If anyone comes in acutely, you always want to say a B c D basically spine exam. A neuro exam. If they're presenting with any neurological findings on a urine dip, a swell on. That's basically just to rule out things like pulling arthritis, renal colic, which, as we said, our preferred causes a pain. That's a good point to add in brilliant. Any ideas? What you do for bloods? What blood would you like to do? But all causes of back pains or not Not specific at this point. CLP Yeah, Yeah. Retains Yeah, So often blood isn't done for back pain. So this is a bit of a hard section to fill in its huge only done it has any signs of infection or malignancy or inflammatory process is going on on diffuse looking for an infection and inflammatory authorities or malignancy. These are the type of blood that you want to do on imaging as well isn't really done for back pain for a while. Cause is the back pain, but will now be going on to the extra investigations for more specific causes. So if someone came in with spinal stenosis, what extra investigations would you guys like to add on to all existing? Less here. MRI. Brilliant. Yet under imaging, MRI, spine. Brilliant. Anything else you can think of? You know, when I did just throw some ideas out where X ray? Yep. Yeah, pretty good. So I've said bedside, do a peripheral vascular examination. As we said before, spinal stenosis can often mimic intermittent claudication or are peripheral arterial disease. So if you do that, then you could help to build back differential in around then, is your guys got straightway MRI whole spine. Really important. This is the best way to demonstrate any narrowing in the canal and find the site of that narrowing. So that's pretty important on did you might consider is well, doing a plain X ray on which can show kind of the degenerative changes or changes to the kind of spinal bones which are causing that spinal stenosis causing that narrowing. Um, which could be useful to know. So quarter a quarter. What extra investigations would you guys like to add in, Uh, gyn Emory whole spine. Brilliant. Yeah. D r e p r. Brilliant. Yeah, really good guys. So, yes, a PR exam, as you guys said before called require, can cause a loss of anal tone. So you want to do a PR, see if that's last an urgent MRI. Um, whole spine, as you said before, was really important. It's best imaging. Modality to review are soft tissues and or quarter a quieter in this case s. So we want Teo get in. Urgent. Um, or a whole spine on. You probably wouldn't do this because the urgent Emory whole spine pick priority by the time you would want to think about doing this. You might consider, like, a bladder scan just to see if there's any urinary retention there. Pretty in. Um, So then onto, I'm closing spondylitis. What extra investigations? Didn't want it at all. X ray. Brilliant hate. Shall I beat be 27 yet? Yeah. Brilliant. Was, um so yes, Hate to a B 27 plastic clay associative. I'm closing spondylitis so we could check for that. Um, plain X rays did. They won't know any of the findings of closing spondylitis on X ray. Bambi's find yet, but the spine is plastic. It's quite late. Sign, but it's something definitely to look out for initially. You want to look out for information of the sacroiliac joints? That's quite a girly, a sign of ankylosing spondylitis. You want to look for other things with the vertebrae? See my t squaring of the lumbar vertebrae, which is basically where the lumbar vertebrae look more like squares. It's basically the step before someone develops a bamboo spine, if you like. Um, if the X ray was negative, um, but you still suspect the diagnosis. You might move onto an MRI. Um, any ideas? Um, we do. We would do a chest X ray. Do They won't know why. We do trust. That's right. What could be seen, Um, in a chest x ray. Thanks, Mom. And yes, Cindy. Smoke syndesmosis itis will be seeing you already get in a, uh, x ray. This one? Yeah. Brilliant up is owned by Bruce. It's really well done on spirometry. What type of finding would be see on spirometry? Why does that need to be done? Yeah. Restrictive. Yeah, pretty good. So, yeah, with ankylosing spondylitis, you can sometimes get stiffening in the mobility of the cost. A vegetable joints that connected your ribs to you about a break on that can create a restrictive picture in someone spirometry. And also we might want to do it. Echoes. Well, because we want to look out for a while, too. Regurgitation that you might find. And I'm closing spondylitis. Brilliant. So then metastatic called compression. What actual investigations would you want to either Lots of good ideas coming through. Yeah, buddy. Good. Really good ideas, guys. So I said, like a whole MRI spine. Um, they won't know why we do a whole MRI spine Why do we not just do the bit of the spine where the core compression is happening? Cause it will be quite focal when you examine them. Why do we know? Yeah, brilliant. Yes, sir. It's we do a whole one more spot because that could be met cells. Where we want to get an idea of this is just one minute or their most women. It's, um and then we can look more broadly for metastases further with a pet scan as well. On then, we may also want to do a CT guided biopsy just to confirm the diagnosis of the tumor. If that's the metastases or a primary, um, we want to look at that as well. So lots of you guys put in the chat different tumor markers. That's really important as well, if you think you know where the primary is. I know lots of people, but ps a look, Look for those kind of things as well in your Bloods that could suggest where that primary is coming from. Brilliant and then from the an osteoporotic, um, compression fracture. Any extra investigations you want to add in there bone profile, Excellent bone density, really good. Anything else anyone want started dexa yet? Really good. You already? Because so, yeah, bone profile. Um, if someone has osteoporosis, what would the results of the bone bird will be? Yeah, really good. They would be normal. Yeah. So you get a normal result of bone program someone's got osteoporosis on. Then a plain X ray off the spine is your first line, and you'll kind of see, like a kind of squash vertebrae will see some in a second, which will suggest that compression fracture. You can do a CT or an MRI, if you want kind of a more detailed view. They're kind of second headline. And then you can do a dexa scan to kind of diagnose and quantify the amount of osteoporosis that someone's got. So really good job, guys. So good. Do some spot diagnosis. So, working from left to right, Can you tell me what you see on the left on the far left image? What? What pathology can you see there? What sign can you say? It's quite a tricky one to say. I've had some people message me what it is, and they put it right swelled up. So this is an closing spondylitis, and this is a bamboo spine. It's quite hard pathology to spot, but you can kind of see that the vertebrae, especially in this section here, are kind of fusing together on that gives the appearance off the bamboo, which is classic. Where you where it gets the same from any ideas. What's happening in the second one? Yeah, brilliant Milton guys. Yes, this is a vegetable compression fracture. So you can clearly see this thoracic vertebra. It has been compressed, and that could be due to something that was your process, for example. Then middle picture. What's going on here? It's quite a discrete pathology focusing on the lower portion of the picture. Yeah, brilliant. Someone's got it. Someone's message me and goes up. Yeah, brilliant. Well done. This's, um spondylolisthesis. This is basically slippage of one vertebrae over another. So in this case, you can see that the L5 vertebrae this one here is slipping for word against a swan or sacrum. So, normally, as you can see more here, it's kind of following a very clear line. They're very aligned. It's really good. Hey, you can see there's a bit with step and at the front as well. On that's classic sign responded. Oh, thesis, which is the slippage of one vertebrae over another full picture. This was quite discreet. It's there could be pictures which would make this pathology more obvious. But I try to pick him up with this great mom. Someone has called it. Anybody else? Got any ideas? Yeah, but you guys are on the right idea, So yes, this is scoliosis. You can kind of see ah lateral bending lateral curvature of the spine. This is quite a satellite pictures you may get maybe way more obvious in this. But I wanted to really test your lunch because I know you guys are very smart. CF, this is Look out for the spine in the shape of it. And if it's got any curvatures on finally this picture on the far right. Any idea what's going on here? The sign. What it's caused by it was a quite a hard one to spot. Well, it's a good idea is coming in the chart. That's not quite the one I was looking for. So this one is very discreet. I've been very me. So this is the winking our sign. So if you look at this vertebrae here, you can see in all of the others. You have kind of two over shapes where the pedicles are, which are the bits of the vertebrae that connects the body to the transverse processes You can see on this one. This side hasn't really got one on that's usually caused by spinal metastases that that pedicle was lost way that metasesis kind of broken down the structure of the bone on bone. Kind of. It kind of looks like an hour winking on, but this is called the winking outside. That's another thing to look out for. Okay, Brilliant. So, in your ski, you may be asked to present some imaging for example, an MRI spine s. I was going to just talk through how we do that s o before we do anything. Obviously, we need to start off by stating the patient's name, date of birth, any information. You're given any information about the date the time of the standoff to compare it to previous scans state the mid ality, the plane and the sequence of the image. If it's an MRI on, then you need to stay any observations that you see on what your different ones might be. Um, so, looking at this image, does anyone have an idea what modality were in? Yeah. Brilliant. CIA. It's an MRI, and I just won't be Sequences T one t two. Yeah. Brilliant. Well done to the Z. That's a T two. That's pretty good. So the way I remember this is t one your fat is Brian. Your fluid is dark. Areas in t to the fat is bright in the fluid is bright as well. So in t two, it's 222 different things. A bright rosen one. Only one is bright. So repeat that in t to the facts brought in the fluid is bright. So two different things bright was in t one. Only the factors, but anyone is bright. So then what I've done here is I've done an example presentation off. How you present this MRI spine? Can any of you guys spot the pathology before I show it? What do you guys think is going on in this MRI spine? Yeah, Yeah. Brilliant. So you guys saying discoloration that's on on the right lines. And but it could be the cause of the pathology. Any ideas of been name of the village You Based on what level of the spinal cord? Yeah, brilliant ones. Onglyza. It's a cold or corner. So I've written this because of time. Well, that you guys read that in your own time. But that's an example of how you present an MRI spine. And then I just want to talk for kind of the management of mechanical low back pain. Because it's quite something that comes up right. Common in general practice and make, um, up in your skin is obviously we want to take a conservative medical and surgical approach. 20 of our management in mechanical low back pain, though there is a really a surgical approach. So we mainly focus on our conservative medical, Um, and we want to start with our conservative measures and only moved medical. It's pretty persistent, I'm said. Start off with patient education. You want patients to continue to then go back to their normal activities as soon as they can. Moving around is better than any bed rest that they may want him, so make sure to get them moving around and explain to them why it's so important, you may offer things that for the therapy group exercise targeted exercises, um, things that that help them move on. But we talked about before some of the risk factors like stress and obesity. So you want to modify those and then based on the risk factors and the reasons why you feel someone might present you want to look in different conservative treatments that you can give. So, for example, if someone's really stressed and you think that might be the main cause of the back pain, you might refer them for CBT. Whereas if someone may be getting some muscle spasms, things like that you might move towards. Maybe he he and I saw my soldiers and things like that, and these are kind of the conservative approaches that we want to take and then our medical approaches. We slowly step up in terms of increasing potency of our, um, analgesia. So we start off with our first line NSAID so, like naproxen ibuprofen on. Then if someone has like an acute flare, we can give thumb parsley tomorrow codeine, and then we can gradually step out over time, getting to kind of weak opioids on dopey oId on weeknights to give skin little muscle relaxants as well. And then I won't go through this now. But this is another side for the enclosing spondylitis management as well for you guys to look at in your own time. Well, don't go as you're doing really well. We've got another final break, and then we'll go ready quickly through the spine exam. And if you want me to go back, 20 slides sit on during the brakeman. Let me know. Okay, so we're gonna move on to the spine exam, so as the same before we want to start with are white and our introduction on I won't read through this, but it's very similar to the previous one. Make sure to introduce yourself, expose the patient on, explained to them what you're going to do. So we're gonna move onto the inspection part of the station. So starting off with German inspection, you want to view the patient from anterior views, lateral views and posteriorly a swell. So starting off with the image on the left. What pathology do you think you guys can see in the inspection that you're looking at on the left? What pathology. Is that brilliant threats? It kyphosis pretty well done. This could be caused by lots of things fractures, dysgenesis a shin osteo processes and say we've talked through, but yet really well done. The major one. Scoliosis. Amazing. Yeah. So this is that lateral curvature of the spine that you can see. It can be idiopathic on, but it can also be caused by various birth defects. Cerebral palsy is another thing it's associated with, um so make sure to look out for any electrical curvature of the spine. I'm finally the one on the right lumber door. Doses you guys on it? Really? Well done. Yes. So this could be caused by lots of lumber problems on. So, for example, on closing spondylitis, poor posture, obesity, things like that. The spondylolisthesis There's things that that you that may cause the lumbar lordosis on. I have a, um, included on this side, but make sure to look for survival low doses as well. Um, although that's less common brilliance. Want or inspection. Like before you want to look for any medication or mobility aids around the bed and what I'm going to, you know, flash up some more images for you guys to tell me what you see. So what we see in the first one, because it's quite a small image. But looking down the middle? Yeah, brilliant. Well, don't goes. Yes, this is a scar. So as you guys have said, it's a vertical. A spinal star. This Once again, you're looking for any stars that indicate previous surgeries or trauma to the spine. Generally, if someone's had open surgery on the spine, it's usually a straight guy, straight line down. But spinal processes that you can see here, whereas if a bit similar to the knee. If they've had endoscopic surgery and you see kind of little kind of ports, smaller lines kind of got it around the spine. Brennan. Any ideas? What I'm alluding to with this one? Yeah, brilliant body habitus a beastie. Things like that. How, um, how patient looks, So obesity is, he said, is a risk factor for various different things. Musculoskeletal pain or so things that osteoarthritis. So make sure to look how the patient is. They're comfortable. Rest. And also, what's that kind of body mass index like is that could be a risk. Sefa um, still a geez that involved, like mechanical loading. Then what do you think this is? Yeah, Brilliant. This is muscle wasting again. You guys have been very specific. The Taxol don't see a paraspinal. Muscles have kind of been wasting here. You can see these kind of divots in the back where they've wasted away once again, that could be too disuse. But often, in the case of the spine, often like a neural issue, this one's a bit hard to see. But what do we think is going on here? Kind of down the center. And also this image Is that an angle? So I can see why you might say scoliosis, But it's know in this case, yeah, pretty. And someone's got it. Yeah, bruising eso. This could indicate trauma to see or any surgeries to look out for any bruising. And on the spine. This one don't focus on the black dots. It's something else. Yeah, brilliant. Yeah. So if you look at his shoulders and there's a symmetry of the shoulder girdle, so make sure to look and check that they're aligned with each other, as you can see them know in this image on on a similar vein What's this gentleman checking for? Yeah, so, like asymmetry of the pelvic girdle. So you want to check the shoulder girdle, and you want to check the pelvic girdle to check that they're inline? That this could be because of leg length discrepancies. One side of the pelvis might be higher on the other. It could be due to scoliosis. Lots of different reasons that you want to check that they're symmetrical just by looking. Then I think this one's already been put in the chart. What do we think this is? Yep. Number lordosis. What's going on with the pelvis? That the line? Yeah. Brilliant. Pelvic till? Yep. So pelvic tilts could be in different directions. This is kind of an interior pelvic tilt. You can, because the pelvis is toting for words. You can get it posteriorly or decide on. And it's basically usually due to an imbalance off muscles that pulling on the pelvis that cause it, Teo till in certain directions. And then finally this one for inspection. Yeah. Brilliant. Modern goes. Yeah. So, yeah, looking for things that hair growth, which in this case could be caused by something called spina bifida, which is when there's no there's no effusion off. The vertebral artery is on the backs of the vertebrae during development on does different categories of it. I won't go into it now, Um, but basically one of those categories completely present with a small hair growth at the back of the spine, which you might be upset on inspection So we don't charge any more inspection. Gonna move on to gate. So I've talked to the gait cycle. We won't go through it again on, but I wanted to show you some abnormalities in gate that you might see. Um, so Oh, sorry. I've revealed this once. This is a trend. Ellenberger gait. Don't know that. You watch the video. See, Hopefully you can see from this video when she walks the left side of her pelvis on this side drops eso when weight is being loaded onto the affected side. So, in this case, the affected. So being this side on her right, the side of her steak where I'll explain there's a weakness, the contralateral side. So in this case, her left side drops on, therefore, she also drops towards that side on. That's because the right side in this case has a weakness off the abductor muscles, which are like your blood. His media is your gluteus minimus, which help to keep the pelvis straight. So when you have weakness, say on this side, that means these muscles come help to support pelvis up to the other side drops. So when you walk, your pelvis isn't held in neutral, so you can see that this side of her is dropping. If I compare it to this one, what gate abnormality do you think you can see in the middle here? Yeah, but I've had some people message me. Yes, so this is a woodland gate. So this is basically when you have the problem that's going on with the trendelenburg where you have a weakness of the hip abductors, but you've got them on both sides. So it's a bit hard to see from this here, But you can kind of see his hips are going like this as they're both dropping as you put weight on the other leg. And that creates this kind of would ling look ast they work and then this is in a video. But just on the right. What do you think I'm getting out with this picture on the right. What's wrong with this person? Shoe? Yeah, brilliant. So it's looking at you need to look at the patient's footwear, and in this case, he's gotten uneven sole on that. Consider Eston Abnormal Gate because the pressure, the pressure on different parts of the feet clearly isn't equal on both sides on dares an abnormal distribution. So if someone has on even souls, then you want to investigate more to look for why they might have that what abnormality with the gait is present. So really well done. We don't Gates. Now we're going to move on to feel so my tip for feeling is, when you're feeling someone's fine, make sure to use one finger as you're feeding down the spine because you want to know exactly where. If they have any tenderness, you want to know exactly the point where that is. You're kind of feeling like this. You're hitting the spine and, like for three different places at once, so that leaves of it. I'm big uti less if you just use my finger. That's that's easier to identify exactly where the pain is on. Remember when you're doing this is well to look at the patient because you will see if they're tender, They will kind of or something like that. You'll notice it if they don't make an audible noise and make sure to look at the patient. So, um, can anyone say if you were feeling this lady spine on the left than anyone, you can probably see. But can you see what the pathology is here? Yeah. Brilliant. So yes, scoliosis. So you're feeling for alignment. So if you're feeling down the spot of this lady, you notice there's a bit of a natural spine movement. So as you were feeling, you kind of going like that, if you like, that's exaggerated. But you want to feel for the alignment of the spine and then what? These images, Um Lutui is where you'll be feeling. So in this image you want to palpate the spinous processes and see if there's any tenderness so that could suggest, like compression, fracture, something like that. And you also want to palpate either side of the vertebrae as well on the paraspinal muscles. But you can see here, which could cause a spasm because I could cause tenderness on that could suggest maybe a muscular skeletal causes back pain. That's how I feel. That's nice and quick. Normal going to remove. So I've popped up the top the different movements that we want our patient to do in terms of movement from three different parts of the spine. And then what I've done is I've got three videos. If you guys can tell me what, um, movement is being limited in each video. Say he's a fast one. Yeah, brilliant. Well done. So reduce lumbar lateral flexion. Really good. Second video, the rest rotation. Really Well done. And I'll find over there on the right. This was a bit of a longer one. See every good. So Michael Flexion Zamichow extension lateral flexion yet and in this case, rotations Well, so in this video, all of his survival movements have been limited across the board. So just remember these movements on these are some examples of what it looks like when a patient can't complete those, that's all. Move it done. So, finally, we've got our special tests, which we've already spoken about a little bit before, so I'm going to talk through each of these, so to start off we have Schober's test, which, as you guys have said, helps to identify a reduced fraction off the lumbar spine, which we might seen. Something that and closing spondylitis. So I'll show you this video of the same time I talk for it, but she's basically finding the posterior superior iliac spines Marquis, a point in the center, and then she's measuring five centimeters below, marking that on and then mark in 10 centimeters above a swell. And then what you'll then do is ask the patient to touch the toes with keeping their legs straight, bend over. And then what you do is you re measure the distance between on because we marked it five centimeters below and 10 m above the level of the posterior superior. We explain that distance before they bend over. It's 15 centimeters. Um, if when they bend over that measurement increases to 20 centimeters, that's normal and suggest that they have normal in flexion of the lumbar spine. It is any less than 20 centimetres. Then that is, um, abnormal, which could suggest apologies to say something that I'm closing spondylitis. Eso if I paused that video, this is more likely how you would do it in on a ski, so you'll just get someone to bend forward on, have two fingers next to each other, and you can see here play again. It's a positive test because her fingers aren't moving that far apart when he bends over, do you see? They stay pretty close together compared to how they started. So that would be a positive test. And if you did it with the take measures, well, it would yield a similar result less than 20 centimetres. Then, if we go on to our straight leg raise to this identifies a site sciatic nerve irritation such as in sciatica s. So what you do is you have the patient laying supine. You hold that ankle and you basically raised their legs so you can see on this gentleman. His right leg was pretty finally, get out, listen high. Whereas with this leg it's already causing him pain at this level. So we check that there's pain by Dorsey flexing the foot's of pulling up on the toes, and that's creating kind of a pain in the posterior. If I on the buttock because that's the path of the sciatic nerve so I'll play against you. This is kind of the normal side. He's lifting up and get it up nice and high. No problems. And then if we go over to his affected side, he's getting pain in his posterior buttock, um, and posterior thigh dose effects. The foot double check lax that extends the nerve, you for more, and he's getting that pain there. If there isn't pain, then obviously that's normal. Test that there is pain, then that's yes. That's a sciatic nerve irritation. And then a femoral nerve stretch test is basically a similar principle, but for the femoral nerve. So in this case, the patient lives prone on. Then you flex the knee to 90 degrees on, extend the hip joint on. Then you can plant effects the foot as well. And this will create pain in the thigh or the inguinal region on, because that's the path off the femoral nerve. So you flex any, extend the hip, and you can plant effects of a swell, and that will create create the pain that they may be experiencing sero main tests. And that's the spiral exam or done so. That point you think the patient and ask them to restore their clothing. Um, once again, I've written out here that will kind of presentation that you get back to examine up for the spine exam. But I'll let you guys review in your in time. So that's that's all done. Sorry. We run over by a few minutes again. I hope that was really helpful. I've added in some post lecture slide as well on the cervical vicryl spinal. I know I haven't had a lot of time to cover today on also some things about CT, an MRI, a swells and stuff about court syndromes that you guys can review in your in time if you fill in the feedback form. But thank you so much for sticking on. I hope it was a useful session. And you learn something about being in the spine. And I can certainly got really amazing Megan. Okay, some people have been asking for that. Okay, That was useful. Guys, please fill out a feedback form or feedback. Good and instructive is really help. That was amazing. Sinus up their recording