OK, the orthopaedic examination of the dog in general practise. This is a presentation for ordinary GP vets, as well as young vets, inexperienced vets, or perhaps even vet students. Basically, it's guidelines for vets in general practise about the orthopaedic examination of the dog.
Just a little bit of background about myself. I'm part of an organisation called Peggy Hub Mobile Canine Rehabilitation that I run together with my partner Rimante Bokutte and of course our little piggy dog Spiky, and we are an independent family owned vet letigytico mobile canine rehabilitation service, and we've been doing that for the last couple of years. And we offer bespoke personalised service in canine rehabilitation, pain management, osteoarthritis management, and also Western veterinary acupuncture and herbal medicine.
So enough about us. Let's start about what we're really here for, which is talking about the orthopaedic examination. So the purpose of this presentation is really to describe how to in general practise, perform a nice structure.
It's methodical and a consistent orthopaedic exam of the front and the hind leg of the dog, as well as the spine, which of course connects it all. It's also to make sure that nothing is missed during one of those orthopaedic examinations. I'm also here to impart some tips that I've gained for many years of experience in general practise.
And of course this will lead to all of us being able to give the best possible service both to our patients as well as our clients each and every time in a consistent way. And the other thing I would like to say is it's nice to be able to rely on your hands and your brain first and foremost rather than to rely on modern techniques like advanced imaging, which of course is is available more and more in general practise, but this presentation is really about the basic orthopaedic examination of the dog as it comes into your console room. So there are several parts to the examination, and they're all equally important.
We are gonna talk about the signalling of the patient, the history, what's been going on. An important part of an orthopaedic examination is the gait analysis. And then the examination itself, and we have to pay attention to the soft tissues, pads, muscles, tendons, and ligaments, as well as the bones and the joints.
I remember very well that over many years I would really look very carefully at bones and joints, but often sort of forget about the soft tissues. As I've become more experienced and also had some experience in the rehabilitation techniques, I feel that more and more now the soft tissues are absolutely vital important of the clinical examination. We're going to talk a little bit about diagnostic imaging, which of course is things like radiography or X-rays, but also advanced imaging like CT and MRI.
We'll talk a little bit about arthroscopy and about joint taps and musculoskeletal ultrasound, which is fast taking over as the number one imaging technique in orthopaedics. The signal, a number of things are really, really important. For instance, the breed of the dog, it can be linked to various specific conditions like we see elbow dysplasia or development of elbow disease, mostly in Labradors.
We see intercondylar. Huable fissure mostly in spaniels like springer spaniels. We see cranial crocier disease perhaps in Rottweilers, hip dysplasia in Labradors or coli, medial patella laxation or in little terrius, horns, mostly in greyhounds, medial shoulder instability, mostly in agility dogs, and so, so you will already have a little bit of an idea when the dog first comes into your console.
Age, of course, is important because most of the hereditary and developmental conditions we come across in general practise were sort of between 3 and 10 months of age, whereas most, degenerative problems may start later on in life. It's important to realise that sex and neuter status is important as well because some conditions prevalence is linked linked to neuter status. And activity is very important.
Some conditions are based on the dog's job, such as being an agility dog or a working dog, a police dog, search and rescue, etc. For instance, medial shoulder instability or biceps, tendinopathies, we see a lot in working dogs such as agility dogs. And of course, the weight is important, it can have an absolutely massive effect on the likelihood of certain conditions in their development.
The history is also very important. You need to take a very, very careful history from the owner. What exactly are the symptoms?
When did they start? Have they gotten better or worse over this time? What is your dog's lifestyle or activity levels and the relation to the lameness?
Does it start straight after activity or after rest, for instance? Also, the perception of the owner of the location or the severity of the lameness, but do bear in mind that owners very, very often get this wrong. And the simplest way to say this is if an owner says my dog is lame on the left, it very, very often will be lame on the right, sometimes on both legs, and especially if lamenesses are bilateral or chronic, it can be very hard for an owner to accurately describe what kind of lameness it is.
You need to ask the owner if it's better or worse after exercise, like with arthritis, you usually get better after exercise, whereas soft tissue injuries usually get worse after exercise. We need to know about any kind of previous or current treatments and also whether the owners have done any home remedies and things like what food do they feed? Do you use any supplements?
Have any investigations been done already? But other symptoms are also important. For instance, behavioural symptoms, facial features, playfulness, any signs of pain like aggression, lack of appetite, body posture, and even sometimes, of course, vocalisation.
Then we go to the gait analysis. Now there are a number of ways in which we can do that. The most common one is just a visual gait analysis by literally having a look with your eyes at how the dog stands and moves.
But we can also use more fancy equipment like a stance analyzer, a force plate walkway, or a force plate treadmill. We need to observe the patient at rest when they're standing, when they're sitting or lying down. When they're walking and trotting or going up and down steps if possible, and you can do that both indoors and outdoors.
You need to take a little bit of time to properly observe your patients even when you're taking the history, you will already be observing your patient in the consult room. Ideally, when you do gait analysis, you will see them both on the front and the back as well as sideways and see if you can have a observation of the patient doing its normal activity and ask people, for instance, for video. Most people will have videos on their phones of their dogs walking out in the park or doing agility at a competition, and it can be very useful to have that sometimes even in advance of the consultation.
When I do a gate analysis, I always take my own phone out and I nearly always take a video, nearly always in slow motion to properly look at that and assess it at a later stage as well. It is so easy now with mobile phones. You have to, of course, be very aware of neurological conditions because neurological conditions and orthopaedic conditions can sometimes look alike, can sometimes happen at the same time in the same patients.
You need to check for things like scuffing, ataxia, hypermetria, weakness, stumbling, and muscle atrophy. And then of course you need to try and grade the lameness. I personally use a 1 to 10 scale, which of course is always very subjective.
Some other people use a 1 in 4 or 1 in 5 scale, equally valid as long as you do the same thing time and time again. And then the examination itself. So we've now taken our history, we've looked at the signal and, we've done our gait analysis.
It's time to put our hands on the dog and do our full clinical examination. My number one tip is do the same every single time. Consistency leads to accuracy.
If you know what you're doing time after time after time. It makes it easier to not forget things. You can work from the top down or from the bottom up, but always do the same.
And you can do that with the patient standing or on the floor, on the table. You can, of course, also do that with the patient lying down. Personally, I think it's better and easier to do it with the patient standing, of course, if they're able to do so.
If there is one particular leg that the dog is lame on, I always start with a non-lame leg, and I always end with a suspected lame leg and to not cause any, any reactions. Sometimes the owner will point out to you that you're examining the wrong leg, and I always explain to them that it's better to do the good leg first so you know exactly what is normal in that particular patient. Try and forget your suspicion from the sigrement, the history and the gate analysis.
In other words, keep an open mind. Of patients have multiple morbidities or multiple problems at the same time, and if you are just concentrating on the one thing that you already expect, you might miss something else that is really important. And then my main point on this slide probably is to examine the soft tissues, the muscles, the tendons, the ligaments, the nerves, as well as the bones and the joints, either together or separately, but do not neglect any of them.
Very, very often soft tissue reactions and soft tissue changes can point you in the correct direction of where the problem might be. Also, it's always important to be safe, have a helper, have an experienced helper, ideally not the owner. Use a muzzle if you need it.
Don't be afraid to ask the patient to be muzzled, especially if you think you might cause some pain during the examination, which in orthopaedics is not uncommon. And also support the patient during the examination. Sometimes you can do that by having a hand or arm underneath the abdomen.
Sometimes you can do that by putting one of your knees in between the hind legs or under the abdomen, and so on. So when we talk about the soft tissue examination, let's start with the pads. It's very easy to forget about the pads, but always inspect the pads carefully.
Digital pads, the metacarpal metatarsal were the main pads, as well as the carpal stopper pads on the front leg, and we're checking for things like cuts and abrasions, cracks, and especially in greyhounds horns. I will never forget the story of a very experienced orthopaedic surgeon who told me he examined the dog, which had been seen by multiple people, had had lots of scans done and MRIs and everything, and it actually was suffering from a corn that was clearly missed. Coins are particularly common in greyhounds, and for many, many years we've been dealing with them by cutting them out.
Nowadays, that's been superseded by either complete or partial flexor tendon tenotomy. The muscles, the muscles are also super important in the soft tissue department, and we're checking for bulk, symmetry, tonicity, spasms, pain, heat, and swelling, and just gently run your hands over the dog at each and every time you examine them. On the front leg, if we have any muscle wastage, it's mainly discernible on the sup infraspinatus muscles, whereas on the hind leg, it's mainly the quadriceps and the conteal muscles that give away that there's some muscle wastage.
Muscle waste that's due to neurological issues is always much more quick and much more severe than muscle wastage due to this due to orthopaedic issues in general. There are specific muscle tension tests we can do by doing the exact opposite movement of what the muscle normally activates and by putting a stretch on that muscle, each of them individually, you can really tell if a muscle is sore, painful, tender, and so on. And of course, also remember that certain muscle injuries can cause very specific gaits in the patient.
When we talk about tendons and ligaments, tendons, of course, are continuous with muscles. Usually there's one tendon on each hand and the origin and the insertion of the muscle, and they move the bones through the action of the muscle. Ligaments actually connect bones together to age stability.
Now some tendons are a little bit special, like the patella tendon and the Achilles tendon. They need very, very careful examination to establish their integrity. Some ligaments are special as well, like the cranial cruciate ligaments, or caudal cruciate ligaments, the medial shoulder ligaments.
They also need special careful examination with special tests. Tendons are always strong and flexible, but not elastic. Ligaments are strong and flexible as well as elastic.
An injury to a tendon or a muscle is usually called a strain, but it's an angry injury to a ligament it is called a sprain. Next is the examination of the bones, and again, all the bones need a really careful palpation if at all possible, again for swelling, pain, heat, abnormal position and conformation. And what is most painful in bones is if the periosteum with lots of nerve endings gets stretched, like for instance in osteomyelitis and neoplastic bone disease.
We need to have knowledge of the predilection sites for osteosarcoma, which is by far and away the most common neoplasm in bones. It's essential to realise that the proximal humulus distal radiusular distal femur and proximal tibia or away from the elbow and around the knee are the most common areas for these kind of cancers. In young dogs, we sometimes see panosteitis which causes very painful long bones on firm palpation or squeezing of the bone.
When we get to the joints, it's probably the most important part of a lameness investigation. Most conditions do involve a joint or even multiple joints, and each joint should be examined for pain, heat, swelling, fibrosis, thickening around the outside, laxity or looseness, effusion, crepitus, a grating sensation, and also the end feel and the range of movement or range of motion. And joints should be put through a range of movements such as flexion and extension, rotation, abduction and abduction, and in relation to the front leg, also rotation and supination.
Some joints are examined by doing all of this, plus some special tests like the anterior drawer test for cranial cruciate ligament disease, Ortolani test for hip dysplasia or laxity, and the MSI test for medial shoulder instability, and so on. Specific information about various joints like the carpus. It consists of the radiocarpal joints, the intracarpal joints, and the carpal metacarpal joints.
The most common problem we come across in the carpus is laxity or rupture of the palm and ligament at any level, and that then causes hyperextension of the foot. Other problems we see are fissures and fractures of the carpal bones themselves, very often associated with ligament disruption at the same time. The most common solution for severe carpal problems is a pentarpal arthrodesis.
The elbow joint, it might look like a relatively simple joint, but it's actually a very complex joint and very often involved in lameness of the front leg in dogs. There are many different forms of developmental elbow disease previously called elbow dysplasia, and all causing very specific reactions on the examination. For instance, if we do elbow flexion, together with supination or coronation, it can give severe pain in cases of medial coronoid disease or medial compartment disease.
In those cases, there is also often pain on deep pressure palpation of the medial aspect of the joint. Whereas elbow extension can cause severe pain in cases of humeral intercondylar fissure, which was previously called incomplete ossification of the humeral condom. So again, specific conditions can give specific reactions during your examination.
The shoulder joint, which is inherently an unstable joint with a very shallow glenoid cavity and without any real significant strong ligaments, it is stabilised by the supran infraspinatus tendons and muscles on the lateral side and the subscalaus muscle and tendon on the medial side. The biceps bray tendon. And cranially and a very weak medial glino scapular ligament which is basically a fibrous thickening of the joint capsule only, and the most common injuries that we see in the shoulder of the dog are medial shoulder instability due to a weakening of medial joint stabilisers and the bicipital tendinopathy.
We can of course also see luxations and fractures affecting the shoulder joints. Most shoulder injuries, however, do cause a relatively mild lameness and can often be missed quite easily on examination as well as gait analysis. Most owners are not even aware that the shoulder might be involved.
So there are special tests that we can do for media shoulder instability in by substand injuries as well. This is a video that just shows you how to perform the medial shoulder instability and biceps tendon tests on the front neck of the dog. This dog, which is a normal shoulder for medial shoulder instability, we do a full extension of the shoulder and then an abduction of the lower leg.
In a normal dope with full extension of the shoulder and abduction, we shouldn't get more than about 20-30 degrees. At the same time, we're going to check for biceps tendon, but you're gonna do full flexion of the shoulder and try and extend the elbow. There shouldn't be more than about 90 degree angle in the elbow.
If you have full extension of the shoulder, elbow shouldn't extend more than about 90 degrees. So medial shoulder instability, about 20-30 degrees, full flexion of the shoulder, no more than 90 degrees on the elbow. OK?
Roll them up this door. Now the other side of the same door. On this affected shoulder we've got two problems at the same time.
We've got a little bit of a mild medial shoulder instability in full extension of the shoulder we can get much more abduction in that front leg, probably to about 40 to 45 degrees. We can measure that. And also if we do full flexion of the.
I can extend the elbow way beyond the 90 degrees. That should only be possible if there is a total or partial erosion of the biceps tendon, full flexion of the shoulder, much more extension of the elbow than on the other side, full extension of the shoulder, abduction of the shoulder more than the other side as well. And then we have a full front leg examination that explains all the bits and pieces that are involved in the examination of the front leg of the dog.
OK? The orthopaedic exam of the dog. Right, with the front leg, you can either go bottom to top or top to bottom.
It doesn't really matter as long as you're consistent in doing the same thing every time. So what I would normally do is check the toes first. I will check the pads, I will squeeze the pads, I will move the toes through a full range of motion, extension, and flexion.
And feel for the bones individually. You check the pads as well, never forget the pads. Then we go to the metacarpal phalangeal joints, make sure they can fully flex and extend without any pain, without any swellings, without any arthritic change, and so on.
Then you feel the individual metacarpals all the way from the metacarpal phalangeal joints to the carpus, and you check the dulo as well. Once you've done that, we orientate ourselves on the carpus, so we check for extension, which is usually slightly more than 180 degrees. And we check for flexion, and in a normal dog, you can put the pole onto the back of the antebrachiium.
That's normal. So we do flexion and extension, and you can check for rotation and varus and valgus deformity as well. Then we go to the forearm or antibraium, we feel the radius and ulna.
All the way to the elbow joint. Next is the elbow joint. So again, we check for extension, we check for flexion.
It's easier to flex when you flex the cars as well, but beware that you need to isolate the joint so that you don't flex the carpus too much when you flex the elbow because you might get a pain reaction on the carpus rather than the. So in a bigger dog, I would hold the antebrachium and just flex the elbow, extend the elbow, check for vagus and valgus, but also in full flexion, do supination and pronation because with certain types of elbow dysplasia, there will only be painful and full flexion together with supination, like with cobinoid disease. Once you've done the elbow, you feel the humerus all the way to the shoulder.
And then you check for swellings and pain and so on. And with the shoulder joint, again, we do a full extension of the shoulder, we do full flexion of the shoulder. In flexion of the shoulder, we see how much the elbow extends, and in full flexion it shouldn't extend more than about 90 degrees.
If it does, we've got biceps issues and in full extension of the shoulder, we also check for abduction, AB duction. That shouldn't be more than about 20-30 degrees in extension. Inflexion, it can abduct much more in extension, it shouldn't.
So we check all those, we check the shoulder blade to the top and you're done at the front leg. OK. Let's move to the rear leg.
Starting with the thysus, the thyus consists of the thysocleal joint, in thyal joints, and the tarsal metatarsal joints. The most common problem we come across in the thysis is laxity or looseness of the joints at different levels. Another common problem is tendinopathy of the Achilles tendon, which has 5 components to it, and most commonly, this will be a chronic injury, but acute ruptures do, of course, occur.
And depending on what part or parts of the structure is affected, we can see various clinical appearances. We often see plantar ligament disruption as well, and this is especially common in shelties. Then of course we see tarsal bone fission and fractures and OCD of the talus can be an occurrence as well.
The most common solution for severe tarsal problems again is an arthrodesis, a tarsal arthrodesis. Let me move to the stifle. The stifle joint is made up of the The femoral patella and the tibial fibular joints.
There are generally at least 6 bones, 6 ligaments, and 2 menisci. It's actually quite a complicated joint. The stifle is by far and away the most commonly affected joint in the hind leg in dogs in cases of lameness, and the most common pathologies are the crucial cranial cruciate ligament disease or rupture and medial lateral patellar laxation, which comes in 4 different grades.
On top of that, we sometimes see OCD of the medial condyle of the humerus as well as fractures and meniscal damage, most often medial meniscal damage, together with cranial cruciate ligament disease. We do also see some ruptures of the collateral ligaments. There are some special tests that we can perform for crucier disease.
And of course, the most common repair techniques for ul disease currently are the TPLO, the TTA, and the extracapsular repair. The special tests for cranial cruciate ligament disease are the cranial drawer test. For the cranial drawer test, we attempt to get an anterior sliding movement of the tibia relative to the femur, both inflexion and extension.
Impartial juice test is often only positive inflexion. But with the tibial thrust test, we're feeling for a cranial displacement of the proximal tibia when we're flexing the hook whilst keeping the stifle joint extended. It's very important that both of these tests that the placement of the fingers is exactly in the right place to establish the test and get the most information from it.
The hip joint or coxal femoral joint is inherently a very stable ball and soccer joint, a very strong round ligament, and a very strong joint capsule, as well as lots of big strong muscles around it. The most common pathology in the hip is joint laxity, often due to hip dysplasia. This will eventually, of course, lead to remodelling and severe osteoarthritis.
Other abnormalities we often see in the hip joints are femoral head necrosis, fractures, sometimes of the proximorphosis of the femur, and dislocations which are nearly always traumatic in origin. Now I have also some special tests for the hip joint examination. The three tests are Barlow sign, Barden sign, and Ortolani sign.
And with the Barlow sign, we're pushing the fem approximately and subluxating the hip with a palpable click. The Barden sign is if we can actually lift the femoral head out of the acetabbeum if the dog is in natural recumbency. And the Ortolani sign is if the femoral head is luxated by using abduction and then the repositioning using abduction, it can lead to a palpable click or a clunk.
Here is a video of the complete examination of a hind leg in the dog. 200 pounds. Are you ready?
Yes. The hind leg, again, you can go top to bottom or bottom to top. I generally go bottom to top.
We check all the toes exactly the same as in the front leg. We check the nails, we check the pads, we check for pain, swelling, irritation, redness, and so on. Check in between the pads, check the main pads.
We feel the toes and. The actual thickness of the toes, we do extension of the toes and flexion of the toes. Then we go to the metatarsop phalangeal joints, see if there's full flexion and extension possible on that joint, and we then go up the metatars feel each each of them independently.
We get to the thysis, we do extension of the thys and flexion of the thyaxis. You can only flex the thysis if you flex the stifle at the same time. In an extended stifle, you can't flex the thysis with a flexed typho you can, and it should flex to about 30 degrees and extends to about 170.
In this puppy is easily 180 degrees because it's very flexible. We check for the calcaneus as well. We checked for vagus and valgus deformity, and we feel the Achilles tendon and then work our way up the tibia and fibula and just feel for swellings and pain and irritation and so on.
Then we get to the important joint, the stifle. So again, we do flexion of the stifle for which it's easier to flex the hog at the same time. If you keep the hook extended, you can still flex the stifle, but it makes more sense to do it that way, an extension of the stifle.
The angles are all well described in text as well. We check for eggas and Valer deformity, and then we do the important and check for cranial cruise ship. Instability, finger on the patella, finger on the back of the femur, finger on the tibial crest, finger on the back of the tibia, and we try to make this cranial caudal movement.
So rather than doing the flexing and extension, we try to get a cranial caudal drawer. In this case, I can actually feel an abrupt stop to that movement by the intact cranial cruciate ligament. We also hold a finger with a tip on the tibial crest and the base of the finger over the patella, and in an extended knee, try and flex the hook.
If you do that, the tibia wants to go cranially, gets stopped by the cranial cruciate ligament. This is anterior thrust that's negative in this puppy. We then go to femur, the femur inside and outside, and we get to the hip joint.
We just orient on the tubercocate, tubersaticum, and greater trocantum of the femur, which should be in a nice triangle. If it's not in a triangle but in a straight line, we have a dislocated hip. The hip joint itself, we do full extension, we do flexion, and we do abduction, and we check for things like ortolani, laxity, hip laxity, and so on, and we do rotation at the same time.
We also feel for all the muscles, the quatics, the hams, the sartorius and the glutes muscles, etc. That's it. Thank you.
So that will be a good 200 pounds. And then let's not forget about the spine. The spine, of course, connects all the other parts of the dog and should not be forgotten during a clinical examination of the dog.
A lot of dogs with mobility issues, either off the front or hind legs, will also have spinal pain, either primary or secondary. And we need to check the spine carefully from head to tail, palpating both the bony as well as again the soft tissue structures. We need to pay particular attention to the tho lumbar and the number sacral junctions, as those areas are the two most common areas within the spine of the door where we find problems.
We can see spinalarticular facet osteoarthritis, intervertebral disc disease, lumbosacal disease. They're all very, very common. Of course, we can also come across fractures and dislocations.
Spongylosis, usually a radiographic diagnosis, is usually not clinically significant. So let's talk a little bit about the radiography or the taking of X-rays. It's still the number one imaging technique used for most orthopaedic conditions in the dock, and it's essential to have a really good technique positioning, exposure, coloration, settings, contrast, labelling, and so on, very important, as well as always doing bilateral and orthogonal views.
You need to get the most out of your radiography. And the bones are assessed for things like trabecular pattern and osteop periosteal margins, their opacity, their shape, sclerosis, subchondral sclerosis, and so on, and then compared to the contralateral bone. Joints are assessed for congruity, luxation and subluxation.
Subcondo bone opacity, osteohesophytes, joint diffusion and or mineralization, extra-articular mineralization, and again always compared to that of the other side. In the shoulder Medoletto and cranial corar views are mandatory. Skyline views are sometimes done, especially for things like biceps tendon injuries.
For elbows, we always do medial lateral flexed and extended, especially in young animals, and nicely positioned cranial code of uses. For carpus and foot, we normally do medial lateral and cranial caudal or dorsal palmer views. Sometimes you can do stressed or rotated views as well.
For a hip, we normally do a lateral view as well as a ventro dorsal, either extended views only or sometimes also the frog view. There is also a distracted pan hip view which can be done as well, especially for the examination of hip dysplasia. For the stifle, we generally do the medial lateral and a cranial coal or a cold or cranial view.
And for tarsus and foot, again we do mediallateal and cocranial or pal dorsal or dorsal palm of views and you can do again a rotated and stress fuse. Then there is advanced imaging. So CT and MRI are more and more common nowadays, of course.
CT generally is better for the investigation of bony conditions like neoplasms, subconal changes, and so on, whereas MRI generally is better for investigation of the soft tissue like neurological tissue, joint fusions, menisci. For instance, CT is quite essential nowadays for a proper diagnosis of development of elbow disease in most cases, especially if you're going to consider surgery, whereas MRI is essential for diagnosis of intervertebral disc disease and other spinal cord conditions like FCE and neoplasms. Again, especially your surgery is to be considered.
Arthroscopy gives the best visual assessment of joints on the inside, especially the cartilage, quality of the cartilage, and lesions like in developmental elbow disease cases, as well as the menisci and cruciate ligaments and cranial cruciate ligament disease cases, but also for shoulder issues like biceps tendon issues and medial glinohumeral ligament issues. Arthroscopy is nearly essential. Synovial centesis or joint taps is the analysis of synovial fluid from a joint in aseptic fashion.
Especially useful for examination of suspected cases or inflammatory or remediated arthritis. It is essential that good technique is used and the same technique is used for intra-articular injections. It has to be done on the sedation or anaesthetic and in aseptic way, otherwise you can definitely do a lot of damage.
But this is not a very difficult technique and can very easily be learned quickly. Finally, we got musculoskeletal ultrasound or MSK ultrasound. It's becoming more and more commonplace in orthopaedic and especially rehabilitation-based examinations, as well as for targeted injections of POP and stem cells, for instance.
Very, very useful, especially for the examination of tendons and ligaments, but it is operator dependent. It takes a lot of experience to be able to interpret the images correctly. And more and more nowadays do we see handheld point of care ultrasound becoming the standard for musculoskelet or ultrasound and there are some really nice pieces of equipment on the market for not very high prices.
In conclusion, hopefully this presentation will have helped a little bit to be able to complete perform a complete methodical and consistent orthopaedic examination in general practise, just to allow a thorough examination without missing anything of significance. And ultimately a thorough assessment of signment history, gait analysis, together with a thorough and complete physical examination will in nearly all cases give a very strong suspicion of a clinical condition, even without the use of further diagnostics. So good luck with your examinations in general practise, and I hope that this has been in some way helpful for you.
Thank you very much for your attention.