Diagnosis of diseases of the musculoskeletal system. Local examination: musculoskeletal system

The motor apparatus is the totality of all parts of the body, the movement of which occurs at the will of a person. These are the muscles and tendons of the upper and lower extremities, fingers, as well as the occipital and shoulder muscles. Usually, the organs of this system are examined only when acute ailments appear, for example, muscle strain or joint pain.

The simplest method of examination of the motor apparatus is palpation, which allows the doctor to assess the condition of the muscles, detect hardening, detect a decrease in muscle tone, and also accurately determine the location of a muscle strain or tear. To check if a posture disorder has occurred, the doctor will ask the patient to take a few steps barefoot. In addition, checking the flexion and extensor function of the various joints will determine if the joints, muscles, and tendons are affected. To assess the condition of the cervical vertebrae and occipital muscles, the doctor will ask the patient to make several head movements.

Sometimes, in the presence of more serious problems associated with the musculoskeletal system, for example, diseases of the bones or muscles, general examination methods are not enough, so special diagnostic methods are used. X-rays and muscle biopsies are usually performed. In the case of meniscal injuries, the knee joint is examined with an endoscope (which is placed in the knee joint).

Survey results

The doctor, by feeling or examining the muscles and tendons, can diagnose acute injuries of the joints, bones and muscles, in addition, he can determine whether the patient is moving correctly and has a normal posture. In the same way, a horse foot, flat feet, calcaneal foot, X- and O-shaped deformities of the lower extremities are detected. By taking an x-ray, the doctor can diagnose bone diseases and pathological changes in the joints. To clarify the diagnosis, a muscle biopsy is performed, and a microscopic examination of a piece of muscle is performed in the laboratory. Based on the results obtained, the doctor can accurately determine which muscle disease the patient suffers from.

Neurological examination of the locomotor system

A simple and reliable method for studying the functions of the motor apparatus is to test various reflexes. For example, a doctor causes a patella reflex in a sitting patient by tapping his muscle tendon with a hammer. There are many other reflexes (arms, legs, eyes, throat, etc.) with which the doctor checks whether the corresponding nerves are affected. If necessary, a more accurate study of the conduction of individual nerves, the so-called. electroneurography (ENG), which is based on the study of the speed of propagation of an impulse along the nerve pathways. During the study, the nerve is irritated by an electric current through the electrodes; the response to irritation registers another electrode. The speed of the onset of the reaction makes it possible to judge the state of the corresponding nerve. This method can also be used to assess the state of neurons in the spinal cord.

Another method is electromyography. Electrodes are placed on the muscle and thus its contractility is studied during passive and active movement. Muscles are also examined using ultrasound, which allows you to determine the degree of their degeneration and the presence of an inflammatory process.

The weakening or absence of a certain reflex is not always a symptom of any disease. By the way, an increase in reflexes (hyperreflexia) can also be a sign of the disease.

Weakening of reflexes or their absence is a symptom of congenital spinal cord disease and other serious diseases, such as paralysis, nerve root damage, hypothyroidism. There are also so-called. pathological reflexes, the presence of which is a sign of some kind of lesion (often the brain). With compression, paralysis and other similar lesions, electroneurography is performed, thus studying the patient's reflexes.

Foot sensation test

For symptoms of paralysis of the leg, the causes of which are not somatic, but mental, the doctor performs a leg sensitivity test: the patient lifts the healthy leg and holds it in this position, and the doctor tries to bend the leg. If the allegedly paralyzed leg is healthy, the patient will involuntarily strain it.

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The study of the musculoskeletal system begins with an examination, which should be carried out in good light and include examination of the patient in a standing position, lying down, sitting and while walking. At the same time, it is important to assess the posture, the nature of the gait, walking speed, the presence of joint deformities, contractures - this gives general idea about the presence of pathology of the musculoskeletal system and its functional capabilities. With a sharp pain, the patient seeks to take a forced posture that reduces pain, the facial expression of such a patient is wary due to fear of the resumption of pain.

When examining a patient, attention should be paid to excess body weight (with increased nutrition, gout and osteoarthritis are more common). On the contrary, with a deficiency of body weight in patients, the syndrome of joint hypermobility is more common. Already at the first visit to the doctor, the patient can detect scoliosis, kyphosis, pelvic tilt, joint deformity.

Patients with rheumatic diseases often take a forced position, which is often observed with severe arthritis, ankylosis and contractures of the joints. In this case, the normal axis of the limbs changes in patients.

So, for example, normally the longitudinal axis of the arm passes through the center of the head of the humerus, radius and ulna. When the forearm deviates relative to the shoulder at an open angle inwards, a varus curvature is formed, and outwardly, a valgus curvature of the arm in the elbow joint is formed. Normally, the axis of the leg passes through the anterior superior iliac spine, through the inner edge of the patella and thumb feet. A change in the normal axis of the leg leads to a curvature of this line. Moreover, if the angle is open inward, then a varus curvature is formed, and if outwards, a valgus curvature is formed.

Examination of the joints usually starts from top to bottom - from the temporomandibular joints, sternoclavicular joints, then the joints of the arms, trunk, legs are examined, while comparing the affected joints with healthy ones. When examining the joints, the position of the limb, changes in the configuration and contours of the joints, color and turgor of the skin over the joint, hyperemia, pigmentation, possible rashes, nodules, scars, atrophic processes, sclerotic changes in the tendons, skin, and swelling of the periarticular tissues are taken into account.

One of the main signs of joint pathology detected during examination is swelling, which may be due to intra-articular effusion, thickening of the synovial membrane, extra-articular soft tissue, bone growth, or extra-articular fat deposits (pillows). With swelling of the periarticular soft tissues, the swelling does not have clear boundaries, is diffuse, more superficially located, more often localized outside the joint space. A soft, elastic swelling in a limited area of periarticular tissues indicates the presence of bursitis.

A change in the shape of the joint is regarded as a defiguration or deformity. Defiguration is a temporary change in the shape of the joint, usually associated with swelling, swelling or atrophy of the soft tissues. Deformation - coarser, persistent changes in the shape of the joint, due to changes in bone structures, persistent contractures, damage to the musculoskeletal system, subluxations and dislocations. A typical example of deformity is Heberden's and Bouchard's nodules in osteoarthritis, various types of hand deformities in rheumatoid arthritis, etc. In addition, when examining the joints, a deviation can be noted - a deviation from the normal location of the joint axis.

Palpation of the joints reveals:
. hyperthermia;
. soreness (sensitivity);
. swelling;
. fluid accumulation;
. the presence of seals and nodules in soft tissues and enlarged bursas;
. soreness along the tendons and in the places of their attachment to the bones. Palpation of the joints is carried out at rest and during active and passive movements. Palpate first healthy, then the affected joint.

To clarify the localization of the pathological process and pain points in the area of the studied joint, fingertips apply stronger pressure in the area of the joint space. An inflamed, thickened capsule is palpable where it is not covered by a thick muscle layer.

An important sign of joint disease is their soreness, which can be detected by palpation of the joints, it is manifested by pain of varying intensity. Its degree can be defined as weak, moderate and strong.

Normally, there is a small amount of synovial fluid in the joint, but it is not detected by palpation.

An increased amount of fluid in the joint cavity is determined by the presence of fluctuations.

Palpation during movement in the joint allows you to feel pathological noises - crunching, crepitus and crackling. A crackle heard at a distance is a physiological phenomenon, usually painless, bilateral. Gentle crepitus is usually associated with a chronic inflammatory process and is observed with the growth of synovial villi, and coarse crepitus is associated with progressive cartilage degeneration due to friction of uneven articular surfaces. Crunch and crepitus during movement, accompanied by pain, indicate the presence of a pathological process in the joint.

Intra-articular crepitus must be distinguished from periarticular crepitus of ligaments, tendons, and muscles caused by their sliding along the bone surface during movement. With crepitating tendovaginitis, the crunch is rough and feels more superficial; osteoarthritis is characterized by a coarse crunch, accompanied by sharp pain. A softer, longer and more tender crunch is more often observed in patients with rheumatoid arthritis.

Palpation is completed with a study of ligaments, tendons, muscles, vascular and lymphatic systems. During palpation of the muscles, attention is paid to their consistency and tone, as well as to the presence of soreness, seals and atrophy.

Auscultation of the joints is somewhat less important than inspection and palpation. It is carried out only during the movement of the joint. The phonendoscope is usually placed at the level of the joint space and the patient is asked to perform flexion and extension in the joint. At the same time, the time of appearance of noise is determined and its duration and nature are estimated. Normally, noises are not audible, however, during a pathological process in the joint, noises of a different nature are heard.

The musculoskeletal system is a diagnostic procedure that allows you to assess the condition of bone, articular and cartilage tissues. The study is carried out to identify pathologies of the musculoskeletal motor system, development of an optimal treatment course and control over the patient's condition.

For what purpose are they carried out?

MRI of the musculoskeletal system is an informative and safest diagnostic method. This method allows you to identify pathologies of bone structures, muscle tissues, synovial membranes, cartilage, joints and spine, which are not visualized using other types of diagnostic studies.

During the procedure, the following organs are examined:

all parts of the spinal column;
bone tissue;
shoulder, hip, knee, ankle joint;
muscle tissue;
ligaments.

note: most often, the MRI method is used by modern specialists in order to identify, as well as the most adequate and safe way their surgical removal.

During this diagnostic study, the functional state of the musculoskeletal system is assessed according to the following criteria:

Important!This technique allows to detect the presence of malignant neoplasms in the area of the musculoskeletal system long before the manifestation of characteristic symptoms, which significantly increases the chances of favorable results of therapy!

In what cases are they prescribed?

Conducting a study of the musculoskeletal system using the magnetic resonance method is recommended for patients in the following cases:

The study of the musculoskeletal system by the magnetic resonance method, due to its accuracy, maximum safety, and the absence of radiation exposure to the patient, is also used in the preparation of the patient for surgical procedures, during the postoperative period, to monitor the effectiveness of the treatment!

When should you apply for a referral?

Doctors identify a number of alarming symptoms indicating traumatic injuries and pathologies of the musculoskeletal system.

They are commonly referred to as:

Important! Having found at least some of the symptoms listed above, it is strongly recommended to contact a specialist as soon as possible and get a referral for an MRI in the area of the musculoskeletal system!

To whom is the study contraindicated?

The magnetic resonance imaging technique is characterized by a rather narrow range of contraindications .

Doctors include the following factors:

Contraindications for conducting a study using contrast agents are as follows:

occurring in acute or chronic form.
Baby waiting period.
Increased susceptibility to allergic reactions.
Individual intolerance and hypersensitivity to gadolinium, which is part of contrast agents.

Among the possible time limits for carrying out this diagnostic method, there is a general serious condition of the patient and a strong pain syndrome that can prevent being immobile for a long time!

note: in the event that a breastfeeding mother undergoes the study, she should feed the baby with artificial mixtures for two days after the procedure!

How to properly prepare?

Examination of the musculoskeletal system, in principle, does not require special training. The patient does not need to adhere to a diet, and he can also take medications according to the usual scheme.

The most important thing is that when going to the procedure itself, put on comfortable loose-fitting clothes and remove all metal objects, accessories and jewelry from yourself. The use of decorative cosmetics before magnetic resonance imaging is also not recommended, since it may contain metallic impurities, which can affect the results and distort the overall clinical picture.

In the event that you were assigned to conduct a contrast study, it means that on the day of the procedure it is necessary to refrain from eating, since contrast agents are administered to patients only on an empty stomach.

Since the research process itself involves a fairly long stay in a stationary state, it is necessary to prepare for this in advance so that nothing strains or distracts during the procedure. For example, immediately before the study, you should visit the toilet, if necessary, take painkillers and sedative medications in advance.

Possible adverse reactions

A study using contrast agents can cause the patient to experience the following adverse reactions:

Note:as a rule, the manifestation of the above side effects is due to the patient's increased tendency to allergic reactions or excessive sensitivity to the active substances of the contrast agent!

In order to avoid such adverse effects, a special test is usually performed before using contrast agents. In the area of \u200b\u200bthe patient's forearm, small scratches are made into which a little contrast agent is injected. With hypersensitivity and individual intolerance at the injection site, they turn red skin, blisters appear on them, there is a feeling of itching and burning. In the presence of such reactions, the study by contrast method is not carried out!

Conducting a survey

Before starting the diagnosis, the patient lies down on a special couch. The patient's arms and legs are fixed with special straps to ensure absolute immobility, as required by this procedure.

If the patient is afraid and has fear of immersion in the capsule, he is given a sedative drug.. If there are indications for a contrast study, a special catheter is inserted into the region of the cubital vein, through which the contrast agent itself is injected.

Important! The examination process is absolutely painless and does not cause any discomfort!

Of course, during the procedure, the patient may experience not the most positive emotions, which is associated with a long stay in a confined space, and even, if necessary, maintain complete immobility.

However, modern cells are equipped with a good ventilation and lighting system, which allows you to make your stay as comfortable as possible. During the procedure, the doctor watches the patient through a special video camera, and the patient himself can communicate with the specialist using the installed sound sensor.

Therefore, do not worry, with any discomfort and deterioration in the general condition of the patient, the diagnostic process can be suspended!

note : the injection of a contrast agent lasts about an hour!

Advantages of the technique

The study of the musculoskeletal system by the magnetic resonance method is very popular. This is easily explained by the following advantages of this diagnostic procedure:

High levels of accuracy and information content.
No radiation exposure to the patient.
Absolute painlessness and non-invasiveness.
No need for preliminary preparation, hospitalization and subsequent recovery of the patient.
The possibility of carrying out during pregnancy.
The minimum list of contraindications and age restrictions.
Ability to assess spinal cord injury.
Obtaining high-quality pictures in various projections.
Ability to visualize nerves.
Fast results.
The possibility of re-examination to control the effectiveness of treatment and the dynamics of the pathological process, without risks to the patient's health.
Low risks of development of undesirable reactions.
Wide range of research.
The possibility of identifying pathological processes at the very initial stages of development.

Disadvantages of the procedure

The disadvantages of the magnetic resonance method for studying the musculoskeletal system usually include the following factors:

Possible adverse reactions with the introduction of a contrast agent.
Psychological discomfort due to the need to lie still in a confined space.
High prices for the study, which makes it unaffordable for many patients.
The dependence of the quality of images, and, consequently, the accuracy of the results, on the state and power of the tomograph.

MRI of the musculoskeletal system is one of the most accurate and reliable methods for diagnosing diseases of the spinal column, joints, bone and muscle tissues. This technique is extremely simple, safe and does not require long, specialized training. She plays important role in the diagnosis of tumor neoplasms in the area of the musculoskeletal system, as well as intervertebral hernias.

Sovinskaya Elena, doctor, medical commentator

“Take care of your joints from a young age,” doctors like to repeat. Modern diagnostic methods will help prevent the development of many diseases of the musculoskeletal system.

About 40% of the world's population by the age of 30-40 experience discomfort in the joints: aching or sharp pain, clicking, creaking. But only a third of them go to the doctor when alarming symptoms appear. And in vain, even pain that rarely manifests itself is a clear sign of pathology. It is not worth hoping that the body will cope with the violations on its own, most likely, over the years everything will only worsen and lead to serious problems.

Call to action

The saying goes, "Pain is the body's watchdog." This applies primarily to the joints. It can be pulling, aching, sharp or pulsating. Edema, redness, swelling or fever in the area of the articulation of the bones are no less alarming signs and are a good reason to see a doctor.

The most common cause of sudden pain in the joints - various types arthrosis(up to 80%). Cause unpleasant symptoms in this case, degenerative changes in the cartilage. Delaying treatment in such a situation is extremely dangerous, the disease tends to affect all periarticular tissues. Osteoarthritis can be primary, occurring for no apparent reason, and secondary - a consequence of injuries or arthritis. Usually the pain appears during physical exertion and increases over time. If the person is at rest, it disappears. That is why many do not attach importance to the problem and do not go to the doctor in time.

The second most common inflammatory disease of the joints is arthritis. In this case, the pain is often accompanied by a slight swelling in the lesion. Arthritis can be caused by infections, autoimmune disorders, metabolic disorders, or joint trauma.

Doctors number about a hundred various diseases joints, all have their own set of symptoms. And in each case, a special diagnostic method is needed, and sometimes several at the same time.

I see right through

Modern devices make it possible to see what is happening in our body at different levels. This allows you to quickly and accurately find sources of discomfort and treat the lesion, not the symptoms.

CT scan

Works on the principle of X-ray. A tomogram allows you to see the state of human tissues in steps from fractions of a millimeter to several centimeters. Today, devices of a new generation are increasingly being used - multislice computed tomography (MSCT). They work several times faster, allow you to take pictures more high resolution, and the radiation load on a person is reduced significantly. This method is very effective when it comes to large joints. An image obtained using CT or MSCT makes it possible to look at the joint in section and see many internal processes. Computed tomography allows you to examine the knee, hip and elbow joints, as well as the hands, wrists, feet and lower legs with high accuracy.

Magnetic resonance imaging (MRI)

MRI “sees” soft tissues well: muscles, intervertebral discs, ligaments, etc., but it poorly reflects bone structures. MRI does not clearly show the state of the joints due to the low content of hydrogen atoms in them. Therefore, such a study is rather needed in order to check the periarticular tissues.

Radiography

This method has been tested for decades and still remains the most affordable. Today, digital X-ray machines are replacing the usual installations. The pictures taken with their help give a three-dimensional, clearer image, and they can be stored and analyzed in a computer. Thanks to this, it is easier for the doctor to observe the development of the disease and changes occurring in the bone tissue.

Ultrasonography

Ultrasound helps to assess the condition of the soft tissues of the joints (muscles, ligaments, cartilage, tendons), while X-ray examination allows you to see only the bone structures of the joint.

Together, these methods give the most complete picture in rheumatic diseases, arthritis, bursitis or inflammation of the ligaments.

Until recently, non-steroidal anti-inflammatory drugs were prescribed for traumatic joint damage. However, the results of the study presented in 2012 showed that homeopathic medicines are no less effective in relieving pain and restoring joint function.

Arthroscopic diagnostics

The arthroscope allows you to see intra-articular structures. Through a small incision, it is inserted into the joint, and the image is displayed on the monitor. This helps to clarify the localization and prevalence of the lesion, as well as to identify internal minor injuries. It is used only if it is necessary to clarify a complex diagnosis and requires anesthesia.

Considering that the pathology of the joints can be one of the manifestations of systemic connective tissue diseases, various infectious processes or oncological diseases, very often doctors recommend to undergo an examination not only of the musculoskeletal system, but also of all other body systems.

An in-depth examination of the musculoskeletal system is one of the most important sections of medical admission to sports. The steady increase in the frequency of acute injuries of the musculoskeletal system in athletes, its chronic physical overstrain and diseases is associated with a progressive increase in both exogenous and endogenous risk factors.

Yes, on present stage In the development of society, about half of children and adolescents are carriers of the actual number of anthropometric and phenotypic markers of connective tissue dysplasia, every fifth is found to have a lag in bone age from the passport age at certain periods of ontogenesis. In some cases, during their in-depth examination, serious anomalies in the development of the spine are determined, which are a direct contraindication to sports due to the possible aggravation of the existing pathology and the occurrence of severe complicated injuries.

Among young athletes involved in various sports, the frequency of identifying individuals with pathobiomechanical disorders of the musculoskeletal system in the form of a change in the position of the spine and pelvic bones, as well as functional blocking in various joints and pathological changes in the tone of individual muscle groups, is not lower, and sometimes and higher than among their peers who are not associated with active muscular activity. At the same time, it should be taken into account that, regardless of the specifics of the sport, increased loads on the spinal column during active muscular activity lead to an increase in the reactivity of the paravertebral muscles, which, with mechanical irritation of the interspinous ligaments, is manifested by the appearance of a vertical muscular defense, which can serve as one of the indirect signs of early degenerative-dystrophic changes in various structures of the spine.

Examination of the musculoskeletal system in athletes should include a determination of:

external signs violations of its functional state;
the true length of the limbs;
the size of the girth of the limbs;
the state of the arches of the feet;
range of motion in the joints;
range of motion in different parts of the spine;
functional strength and tone of individual muscles and muscle groups;
vertical muscular defense;
painful muscle seals, trigger points;
signs of connective tissue dysplasia;
bone age;
with repeated fractures in history - bone mineral density and bone metabolism.

Determination of external signs of violation of the functional state of the musculoskeletal system

The first step in the examination of the musculoskeletal system is an examination. During the examination, the subject is offered to undress to his underwear, take off his shoes, stand freely, legs together or at the width of the transverse size of his own foot, arms freely lowered.

When viewed from the front (Fig. 1), the following are determined: the position of the head (lateral tilt and rotation), the level of the shoulders, the shape of the chest, the degree of uniformity in the development of both sides of the chest, the symmetry of the position of the auricles, collarbones, axillary folds, nipples (has diagnostic value in men), crests and anterior superior iliac spines, relative position and shape of the lower extremities, symmetry of the location of the patella, degree of development and symmetry of the muscles, location of the navel.

When viewed in profile (Fig. 2), the position of the head (tilt forward, backward), the shape of the chest, the course of the ribs, the line of the horizontal axis of the pelvis (angle of inclination), the severity of physiological bends in the sagittal plane, the degree of extension of the legs in the knee joints, flattening foot arches.

When viewed from behind (Fig. 3), the general inclination of the body to one side, the position of the head (tilt to one side, rotation), the symmetry of the location of the shoulders, the spatial position of the shoulder blades relative to the spine (visually determined distance from the inner edge of the shoulder blades to the spine, the level of the angles of the scapulae, the degree of separation of the scapulae from the chest), the symmetry of the shape and depth of the axillary folds, the deviation of the spine from the midline, the location of the line of the spinous processes of the vertebrae, the presence of costal protrusion and muscle ridge, the symmetry of the standing of the ridges and the posterior superior iliac spines, symmetry gluteal folds, popliteal folds, inner and outer ankles, the shape and position of the heels.

The location at different levels of symmetrical landmarks of the musculoskeletal system, such as auricles, mastoid processes, shoulder girdle, collarbones, shoulder blades, nipples, costal arches, waist angles, crests and spines of the pelvis, gluteal and popliteal folds, ankles, may be a sign of deformity of the musculoskeletal system. -motor system against the background of a particular pathology, manifestation of muscle imbalances on various levels and dysplastic changes.

Particular attention is paid to:

short neck syndrome, accompanied by low hair growth;
extreme degree of elasticity of the neck muscles;
asymmetric tension of the muscles of the neck, especially the suboccipital;
asymmetric arrangement of the blades;
deformation and lateral curvature of the spine;
rib deformities;
pronounced hypertonicity of the extensor muscles of the back;
asymmetry of the paravertebral muscle ridges in the thoracic and lumbar regions spine.

Any of these symptoms may serve as an indirect sign of a developmental anomaly or other pathological condition.

A change in the magnitude of the physiological curves of the spine, both in the direction of their increase and in the direction of flattening, can also be a consequence of muscle imbalances, a manifestation of connective tissue dysplasia, or anomalies in the development of one or another part of the spine.

At correct posture indicators of the depth of the cervical and lumbar curves are close in value and fluctuate within 3-4 cm in the younger and 4.0-4.5 cm in the middle and older ages, the body is held straight, the head is raised, the shoulders are at the same level, the stomach is tightened , straight legs.

At stooped posture the depth of the cervical bend increases, but the lumbar is smoothed out; head tilted forward, shoulders lowered.

At lordotic posture the lumbar curve increases, the cervical curve is smoothed out, the abdomen is protruded, the upper part of the body is somewhat tilted back.

At kyphotic posture there is an increase in the cervical and lumbar curves, the back is round, the shoulders are lowered, the head is tilted forward, the stomach is protruded.

Straightened posture characterized by smoothing of all curves, the back is straightened, the stomach is tucked up.

A significant increase in thoracic kyphosis may be a manifestation of Scheuermann-Mau spondylodysplasia in children and adolescents. Such patients need an additional X-ray examination of the spine in a lateral projection to detect underdevelopment of ossification centers in the anterior sections of the apophyses of the vertebral bodies. The vertebrae in this condition take a wedge-shaped shape, the vertical size of the anterior sections of the vertebral bodies is less than the posterior ones.

Additional information is obtained when examining the subject in an inclination forward with his head and arms lowered. It is in this position when viewed from the side of the back that the lateral bends and other deformations of the spinal column, asymmetries of the ribs and muscle ridges located along the spine are most clearly determined. If, with a maximum forward inclination and in the prone position, the lateral bends of the spine, identified in the standing position, are completely straightened (smoothed out), then the cause of such a curvature lies not in the spine, but in other structures of the musculoskeletal system (changes in the pelvis, skull bones, craniocervical transition, shortening of the length of one of the legs, etc.). Such curvature of the spine is sometimes called functional scoliosis (Epifanov V.A. et al., 2000).

When performing a slow forward inclination, the smoothness of the formation of the arch of the spinal column and the order in which the spinal segments are included in the movement are also determined.

An important amount of information is obtained by analyzing the performance of squats by the subject. Squats are performed from a standing position, legs together or foot-width apart, arms raised forward to a horizontal line, heels do not tear off the floor. Deviation of the pelvis or body to the side when squatting, as well as the inability to sit down without lifting the heels off the floor, suggests the presence of any morphofunctional disorders of the musculoskeletal system. These can be congenital or acquired limitations of the mobility of the joints of the legs, functional limitations of mobility in various parts of the spine and pelvis, imbalances in the muscles of the pelvic girdle and lower extremities, and often the upper parts of the trunk and neck.

rice. 4. Kinds of leg shapes

Particular attention should be paid to the shape of the legs (Fig. 4). Normal, X-shaped and O-shaped legs are observed.

In the normal form of the legs in the main stance, the heels, inner ankles, calves, inner condyles and the entire inner thighs either touch or there are small gaps between them at the knees and above the inner ankles. With an O-shape, the legs touch only at the top of the thighs and at the heels. In the X-shaped form, the legs are closed at the hips and knee joints and diverge at the lower leg and heels. The O- and X-shaped legs can be a sign of connective tissue dysplasia, be the result of previous diseases, insufficient muscle development, inferiority of bone tissue, or the result of heavy physical exertion that does not correspond to the degree of development of the bones and muscles of the lower extremities in childhood and adolescence.

Determination of the true length of the limbs

Linear measurements are carried out using a flexible centimeter tape. When determining the length of a limb, generally accepted identification points are used, from which measurements are taken. Bone protrusions that are most accessible to palpation serve as such identification landmarks (Table 1).

Table 1. Topographic landmarks when measuring limb length

Index	Identification landmarks
Relative arm length	Shoulder process of the scapula - styloid process of the radius
Absolute arm length	Greater tubercle of the humerus - styloid process of the radius
Shoulder length	Greater tubercle of the humerus - olecranon of the ulna
Forearm length	Olecranon process of ulna - styloid process of radius
Brush length	Distance from the midpoints of the line connecting both styloid processes of the bones of the forearm to the tip of the second finger on the back side
Relative leg length	Anterior superior iliac spine - medial malleolus
Absolute leg length	Greater trochanter of the femur - the outer edge of the foot at the level of the ankle in the middle position of the foot
Thigh length	Greater trochanter of the femur - gap knee joint outside
Calf length	Knee gap from the inside - inner ankle
Foot length	Distance from the calcaneal tuber to the end of the first finger on the plantar surface

Distinguish between relative and absolute limb length; in the first case, the proximal identification point is a landmark located on the bones of the girdle of the upper or lower limb, in the second case, directly on the humerus or femur. It is necessary to measure both limbs, since only a comparison of the length of the healthy and affected limbs allows a correct assessment.

The length of the lower limbs is measured in the supine position. Most often, the distance from the greater trochanter of the femur to the medial malleolus is recorded.

As an express method, the Derbolovsky test is used, which allows you to quickly differentiate the functional and true shortening of one of the lower limbs. The essence of this test is that when a visual difference in the length of the legs is detected in the supine position, the test person is asked to sit down; if this difference is leveled when moving to a sitting position, then we are talking about a functional (false) shortening of the leg associated with torsion of the pelvis. In this case, the visual criterion for the length of the legs is the position of the medial malleoli.

In 3/4 people, the left leg is longer than the right one, the difference reaches an average of 0.8 cm. Anthropometric studies show that in high jumpers the longer leg (i.e. more leverage) is more often inching; football players, on the contrary, when handling the ball and hitting it, often use a shorter leg, since the shorter length of the lever allows you to quickly make the necessary movements, feints, while the longer leg is the supporting one. However, such differences should not exceed 20 mm. Otherwise, conditions are created for the occurrence of chronic pathology of the musculoskeletal system. As O. Friberg (1982) testifies, even fractures of the legs are most often found in those skydivers who have a difference in the length of the legs, and the shorter one mostly breaks.

Determining the circumference of the limbs

The measurement of the girth of the limb is carried out to determine the degree of atrophy or hypertrophy of the muscles, to detect swelling of the limbs and joints. The position of the patient is lying on his back. The centimeter tape is laid strictly perpendicular to the longitudinal axis of the limb at the place of the measurement.

The most typical are measurements of the girth of the upper limb at the levels of the middle third of the shoulder (with contraction and relaxation of the biceps of the shoulder), the elbow joint, the middle third of the forearm, the wrist joint; measurements of the circumference of the lower limb at the levels of the upper third of the thigh, knee joint, upper third of the lower leg, ankle joint. When evaluating the circumference of a limb, the measurement value is compared with the same value on the opposite limb.

Determining the condition of the arches of the foot

The human foot, being the supporting section of the lower limb, in the process of evolution has acquired a shape that allows you to evenly distribute the load. This is due to the fact that the bones of the tarsus and metatarsus are interconnected by strong interosseous ligaments and form a vault, facing the bulge to the rear and causing the spring function of the foot. The convex arches of the foot are oriented in the longitudinal and transverse directions. Therefore, the foot does not rest on the entire surface, but on three points of support: the calcaneal tubercle, the head of the I and the outer surface of the V metatarsal bones (Fig. 5).

There are three arches: two longitudinal, lateral - AB and medial - AC, as well as transverse - BC. The longitudinal arches of the foot are held by ligaments: the long plantar, cuboid-navicular and plantar aponeuroses, as well as the anterior and posterior tibial muscles and the long flexors of the toes. The top of the arch of the foot is held by the short and long peroneal muscles from the outer surface and the anterior tibial muscle from the inside.

The transverse arch is held by the deep transverse ligaments of the plantar region, the plantar aponeurosis, and the long peroneal muscle.

Thus, the arch of the foot is supported and strengthened by the muscles of the leg, so its damping properties are determined not only by the anatomical features of the bones and ligaments, but also active work muscles.

rice. 6. The shape of the foot depending on the condition of the arch

According to the size of the arch, the feet are divided into flat, flattened, normal and hollow (Fig. 6). The deformity of the foot, characterized by a flattening of its arches, is called flat feet. Longitudinal flat feet - deformity of the foot, characterized by flattening of its longitudinal arches. Transverse flatfoot (transversely spread foot) is a deformity of the foot, characterized by flattening of its transverse arch.

It is a widespread deformity of the feet among the population (especially females). However, in a significant number of cases for a long time it can be compensated (due to the muscles of the lower leg, supinating the foot, and the muscles of the foot itself) and not manifest clinically.

According to the origin of flat feet, there are congenital flat feet, traumatic, paralytic, rachitic and static. Congenital flat foot occurs in approximately 3% of flatfoot cases. It is not easy to establish such a pathology before 5-6 years of life. Traumatic flatfoot is most often a consequence of a fracture of the ankles, calcaneus, tarsal bones. Paralytic flat feet - the result of paralysis of the plantar muscles of the foot and muscles that begin on the lower leg (a consequence of polio). Rachitic flat feet is caused by the load of the body on the weakened bones of the foot. Static - the most common flatfoot (82.1%). It occurs due to weakness of the muscles of the lower leg and foot, ligamentous apparatus and bones.

With functional overload or overwork of the anterior and posterior tibial muscles, the longitudinal arch of the foot loses its cushioning properties, and under the action of the long and short peroneal muscles, the foot gradually turns inward. The short flexors of the fingers, the plantar aponeurosis and the ligamentous apparatus of the foot are not able to support the longitudinal arch. The scaphoid bone settles, resulting in a flattening of the longitudinal arch of the foot.

In the mechanism of transverse flatfoot, the leading role is played by the weakness of the plantar aponeurosis, along with the same reasons as with longitudinal flatfoot.

Normally, the forefoot rests on the heads of the I and V metatarsal bones. With flat feet, the heads of the II-IV metatarsal bones descend and become in one row. The gaps between them increase (Fig. 7). The metatarsophalangeal joints are in the extension position, with time subluxations of the main phalanges develop. Characteristic hyperextension in the metatarsophalangeal joints and flexion in the interphalangeal joints - hammer-like deformity of the fingers (Fig. 8). Expanding the forefoot. In this case, the following options take place:

excessive deviation of the I metatarsal bone inwards, and the first finger outwards (hallux valgus);
excessive deviation of I and V metatarsal bones;
excessive deviation of the fifth metatarsal bone outwards;
fan-shaped divergence of the metatarsal bones.

One of the frequent deformities associated with transverse flatfoot is hallux valgus (Fig. 9), which is usually formed due to varus deviation of the first metatarsal bone and valgus deformity in the first metatarsophalangeal joint. In this case, the angle between the axis of the first finger and the first metatarsal exceeds 15?. Although the causes of this deformity may be different (a juvenile form associated with joint hypermobility is known), most often its progressive variant is observed in individuals with decompensated transverse or combined flat feet.

Flat feet are directly dependent on body weight: the greater the mass and, consequently, the load on the feet, the more pronounced the longitudinal flat feet.

SIGNS OF FLATFOOT

Longitudinal
- Flattening of the longitudinal arch.
- The foot is in contact with the floor almost the entire area of the sole.
- The length of the feet increases (Fig. 10).
transverse
- Flattening of the transverse arch of the foot.
- The forefoot rests on the heads of all five metatarsal bones (normally on metatarsals I and V).
- The length of the feet is reduced due to the fan-shaped divergence of the metatarsal bones.
- Deviation of the I finger outward.
- Hammer-shaped deformity of the middle finger (Fig. 11).

Currently, there are many different methods to assess the degree of development and height of the arch of the foot:

visual - examination by a doctor;
podometry - measurement and comparison of the parameters of the height of the arches and the length of the foot;
plantoscopy - the study of the feet using the plantoscope apparatus;
plantography - the study of the imprint (trace) of the foot;
X-ray diagnostics;
computer diagnostics (study of digital photographs or scans of the foot using software analysis).

For a visual assessment of the condition of the arch of the foot, the subject is examined with bare feet in front, side and rear, standing on a flat surface and while walking. Visual assessment consists of examining the medial arches, the plantar surface of both feet, the presence of flattening, hyperpronation of the feet and deviations of the heel bones from the vertical line. However, this method is not objective, does not give quantification revealed violations and does not allow for the gradation of pathology.

Visual diagnosis of flat feet also includes analysis appearance patient's shoes - with longitudinal flat feet, the inner edge of the heel and soles wear out.

podometry. When using this method, various anatomical formations of the foot are measured, from the ratios of which various indices are calculated; for example, the Friedland index (flattening of the arch of the foot) according to the formula:

Friedland index = arch height * 100 / foot length

The height of the arch is determined by compasses from the floor to the center of the navicular bone. Foot length is measured with a metric tape. Normally, the Friedland index is 30-28, with flat feet - 27-25.

Another method for diagnosing longitudinal flatfoot is to measure the distance between the tuberosity of the scaphoid (a bony protrusion below and anterior to the medial malleolus) and the surface of the support. The measurement is carried out with an ordinary centimeter ruler in the position of the examined standing. For adult men, this distance should be at least 4 cm, for adult women - at least 3 cm. If the corresponding figures are below the indicated limits, a decrease in the longitudinal arch is ascertained.

At the same time, podometry allows us to describe only the anatomical component of the pathology, not taking into account the functional one.

Plantoscopy is used for visual express assessment of the condition of the foot using a plantoscope (Fig. 12).

The plantography method of "ink imprints" and more modern options based on digital photography and video (Fig. 13, 4-14) make it possible to obtain an image of the contact zone of the plantar surface of the foot, according to which various indices and indicators are subsequently calculated.

The simplest graphic impression of a footprint under load can be obtained without the use of any equipment. The foot is lubricated with Lugol's solution, and the patient is asked to stand on a sheet of paper. Potassium iodide and iodine, which are part of Lugol's solution, upon contact with cellulose, give an intense brown color. Any cream containing fat or petroleum jelly can also be used as an indicator material.

To assess the degree of flat feet on the resulting print, as well as on the print obtained using a plantograph, lines are drawn from the middle of the heel to the second interdigital space and to the middle of the base of the first finger. If the contour of the foot print in the middle part does not overlap the lines, the foot is normal; if it overlaps the first line, it is flattened; if the second, it is flat feet (Fig.

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