Inspection

For all examinations you should explain to the patient what you will be doing and that you have met all essential examination conditions.

Procedure

• Allow the patient to undress, inform them to keep underwear on (including bra for women) [Figure 1].
• Allow the patient to stand upright and inspect at approximately 2 to 3 meters distance the ventral side, the dorsal side and both lateral sides, respectively.
• Preferably, inspect in a cranial to caudal direction.
• If necessary, palpate the location to better localise a certain structure.
• First assess the spontaneous posture (‘individual neutral position’) and subsequently ask the patient to completely stretch the knees and to place both feet next to each other.
• Simultaneously assess all bony structures for shape, posture or static aspects (individual and mutual position of the bone structures and joints), comparing left and right.

Figure 1

Ventral side

Stand in front of the patient and inspect the shape and position of the following structures:

Bones and joints

• head (tilting) and neck (torticollis)
• shoulders (clavicle in relation to the thorax and the humerus in relation to the scapula)
• (mild asymmetry can be a normal phenomenon)
• thorax (pectus excavatum, pectus carinatum)
• torso and arms (waist triangle) [Figure 2]
  • pelvis (tilting) [Figure 3]
    (for this, palpate bilaterally the following reference points: iliac crest, superior anterior iliac spine)

Figure 2

Figure 3

• legs (rotational abnormalities of the upper and lower leg based on the position of the patella) (stress?)
• knees (genu valgum (bow legs), genu varum (knock knees); elevated position of the patella) [Figure 4]
• feet (pes planovalgus, pes planotransversus, pes equinus) [Figure 5]

Figure 4

Figure 5

Soft tissues [Figure 6]
Skin (including hair growth on the median line)

Figure 6

Muscle outlines of the:

• trapezius muscle (1)
• pectoralis major muscle (2)
• deltoid muscle (3)
• biceps brachii muscle (4)
• rectus abdominis muscle (5)
• quadriceps femoris muscle (6)

Dorsal side

Allow the patient to turn 180 degrees or stand behind the patient and inspect the shape and position of the following structures on the back:

Bones and joints [Figure 7]

• head (tilting)

Figure 7

• shoulders (scapulae) [Figure 8]
  (palpate bilaterally the following reference points: inferior angle and spina scapulae)

Figure 8

• spine (spinous processes; if required, palpate these superficially to detect scoliosis) [Figure 9]

Figure 9

• torso and arms (waist triangle)
• pelvis (tilting) (for this, palpate bilaterally the following reference points: iliac crest, superior posterior iliac spine) [Figure 10]

Figure 10

• lower extremities (genu valgum, genu varum; calcaneus) [Figure 11]

Figure 11

Soft tissues [Figure 12]
Skin

Figure 12

Muscle outlines of the:

• descending part of the trapezius muscle (1)
• transverse part of the trapezius muscle (2)
• ascending part of the trapezius muscle (3)
• S.I.T. muscles
  • supraspinatus muscle (4)
  • infraspinatus muscle (5)
  • teres minor muscle (6)
• teres major muscle (7)
• latissimus dorsi muscle (8)
• triceps brachii muscle (9)
• erector muscle of spine
  • spinalis muscle (10)
  • longissimus muscle (11)
  • iliocostalis muscle (12)
    (the latter 2 are particularly visible at lower thoracic level and higher lumbar level)
• multifidus muscle (visible at lower lumbar level in particular) (13)
• hamstrings (14)
• triceps surae muscle (15)

Lateral side

Finally, inspect both sides of the patient. For this examination, allow the patient to turn 90° and subsequently 180°.
On either side assess the shape and position of the following structures:

Bones and joints [Figure 13]

• head (earlobe and middle of upper arm should be almost in an imaginary vertical line)
• cervical spinal column (lordosis)
• thoracic spinal column (kyphosis)
• scapulae (scapulae alatae; ask the patient to turn another 10-20° for this assessment)
• umbar spinal column (lordosis)
• pelvis (forward or backward tilting) [Figure 14]
  (palpate the superior anterior iliac spine and the superior posterior iliac spine at the side in question; the pelvis is normally tilted forward approximately 10° in men and approximately 25° in women)
• lower extremities (genu recurvatum, flexion contracture in knee and hip joint) [Figure 15]

Figure 13

Figure 14

Figure 15

Overall static
In the sagittal plane, the following anatomical structures are aligned in an almost vertical line: the middle of the earlobe, the middle of the upper arm, the middle of the upper leg (trochanter major), the ventral side of the knee joint and ventral side of the lateral malleolus.

Soft tissues
Skin

Gait

Ask the patient to walk and pay attention to:

• (a)symmetry
  (torso rotation, Duchenne’s sign, Trendelenburg’s sign, antalgic gait)
  (Duchenne’s sign: torso leans over the weight-bearing leg [Figure 16]; Trendelenburg’s sign: the pelvis drops contralateral in relation to the weight-bearing leg [Figure 17])

Figure 16

Figure 17

• stride length
• weight distribution amongst left and right leg (equal?)