Chapter 1 Introduction to clinical examination techniques for the FRCS(Tr&Orth)

It is usually fairly obvious when taking a candidate through a mock clinical examination whether they have a system that is going to work for them on the real examination day. Technique usually needs more polish and refinement, but the foundation of the pass is based on a learnt standardised routine to clinical examination.

With some coaching and adjustment of technique it is surprising how a bad technique and poor flow can be put right. In a lot of cases the exam routine had already been learnt but perhaps not practised enough times.

That said some candidates do seem however to instinctively or intuitively know how to go about their clinical examination routine whilst others find this art has be rigorously practised and rehearsed

There are a large number of clinical examination books already out there on the market. Most clinical book having a particular style and a target audience ranging from medical students, physiotherapist students to senior orthopaedic trainees. Some books are too complicated and not particularly geared towards the FRCS (Tr&Orth) exam whilst others read like a short notes prompt without any real explanation or guidance on how to actually perform your clinical examination for a short or intermediate case.

It is always a bit artificial attempting to standardise the approach to the examination of a particular joint. We always seemed to get a little tongue tied at the beginning of any examination especially during a practice session with a normal joint. The usual chant of “There are no obvious scars, skin discolouration swellings, muscle wastage or asymmetry” always seems a little forced and artificial. In some ways it is much easier if a joint has some real pathology to comment on. This was particularly so when practising shoulder or foot examination in which a large part of the examination revolves around inspection.

The clinical section will provide guidance in how to go about developing a routine and will give you some practical help in formulating your approach to a particular case. We make no apologies in that at times we spoon feed you with mundane patient examination instructions. However, these instructions are an important part of the skill of examining; being able to communicate in an easy straightforward and understandable manner with patients. These instructions can cause so much unnecessary havoc when refining your examination technique

The individual joint chapters may come across as though we are using a recipe cook book approach to clinical examination but frequently this method is found to be the most effective way to achieve fluidity in your clinical examination technique.

The main thing to stress is that clinical examination cannot be learnt overnight; the whole process takes many months to refine and get right. It is like learning to play guitar; it has to be a disciplined approach continually practised until it becomes natural without any second thoughts about what comes next.

There are patterns of examination for each joint. Every joint examination sequence is a unique dance.

A good clinical course is like gold dust in your key preparation towards the clinical section of the exam. Rather controversially we argue that it can be very difficult to gain any significant learning benefit out of a clinical course that only goes through the basics of examination technique involving candidate volunteers or perhaps medical students[i]. Without examining really clinical patients the course focus can become very artificial, as you really do need to see, appreciate and elicit positive clinical signs in patients. Perhaps at best these courses are adequate at the start of your registrar training to refresh your memory of how to perform an orthopaedic examination. Nearer the real exam they will probably only be of marginal benefit and end up frustrating you. Even worse the clinical examination technique can be poorly taught or uninspiring and dull.

Practicing your examination technique on colleagues is fine if it is maybe part of your registrar teaching and free but make sure when you sign up for a clinical course that there will be reasonable numbers of real patients that you will be able to examine

To gain the maximum benefit from a clinical examination course involving real patients this should be within around 6-12 months of sitting your Part B and you should have done the homework beforehand. You should be going to the course to refine and polish your skills not as a quick revision aid to somehow stumble or blab your way through the clinicals. This is unlikely to prove successful

Clinical coaching is something which we believe may help out candidates who find the clinicals particularly difficult to navigate through.This involves a more in depth practice and critique of examination technique highlighting areas of potential difficulty.For example a candidate may revise up and improve Trendelenburg testing of the hip on a clinical course and be just about ok with this as a bare 6 pass.However the candidate will be scrapping through and may not come across particularly practiced or polished.The candidate may be easily thrown off tract if first in to examine when the patient doesn’t fully understand the less than clear instructions or more simply the cases are not flowing that well coming across as bitty and forced with no natural rhyme or flow. Far better to spend a longer period of time dissecting down pitfalls and controversies with the test in order to gain extra knowledge and confidence

[i] This is a point of view certainly open for debate, but we still end up coming back to an uneasy feeling that a course is downgraded when no real clinical patients are involved

“Preparation for the clinical component of the FRCS(Tr&Orth) exam requires practice, practice and practice again”

At many points in the book we emphasise the need to keep practising, practising and practising until you have mastered your examination technique. All good and well but to practice to a degree that masters your clinical skills requires sound organisational ability. You have to plan your revision and be efficient and effective with it.

Have a provisional timetable of what you want to cover, be prepared to put in the time and put on hold non essential hobbies and interests. Some evenings you are just going to have to stay in and get some studying done and forget about seeing that new film or football match

Passing the clinical examination stations requires a systematic approach that appears almost involuntary. Examiners are unlikely to interrupt or prompt a candidate to any great degree, so it is vital to display a professional savvy examination performance from the off set

The best method for a candidate to ensure that they perform successfully during the intermediate case is to practice, practice and practice beforehand. This will ensure that a candidate develops a structured and systematic approach that is easily identifiable to the examiners.

It is important to have rehearsed a standard strategy for the introduction and finish of a clinical examination station. It needs to appear natural (not forced over rehearsed or insincere) and be easily recallable despite the intense nerves that can plague you at various times during the exam. It is important not to forget hand washing before and after each case. There shouldn’t be too many painful cases in the exam, but a patient may be sore after the 10th examination of their hip by a candidate so it is important to reassure the patient (and examiners) you will stop straight away if it becomes too painful

“Hello, my name is Mr. Smith I am one of the candidates for the examination today. Do you mind if I examine your hip? Please let me know if I hurt you and I will stop immediately.”

“I am going to be talking to the examiners as we go along. Are you ok with this”?

At the end don’t forget to thank the patient for letting you examine them and wash your hands. If appropriate help the patient sit up off the couch or dress even if you feel you are losing a certain amount of examining time and therefore scoring opportunities.The opposite is generally true that candidates will lose marks if they appear too rushed and unsympathetic to a patient.Candidates will make it very easy for the examiners to find a reason to mark them down that requires very little justification  

“Thank you for taking part in the examination today. Do you need any help sitting up”?

Patients are most very happy to volunteer with helping with the clinical examinations. It is vital candidates are as courteous and kind as possible to these patients. Failure to introduce yourself and to respect these patients will be unacceptable to the examiners, particularly if any patient has a painful lesion.

Many patients will be nervous and anxious about taking part in a clinical examination.Patients may also be unsure of exactly what is expected of them.Some may be worried about saying something that may fail a candidate.Examiners will often ask patients what they thought about the performance of the various candidates examining them.A confident polite courteous approach putting a patient at ease will go a long way towards making a good impression with a patient.

Some of the candidate/patient interaction may seem a little forced cheesy or contrived and yet it is something that just has to be done.Try to come across as sincere in your patient interactions as paying lip service to something you only doing because you have to for the exam is more obvious to the examiners than it appears.

This needs practice.Several marks can be easily gained or lost in this section.Time is tight at 5 minutes but with a practiced approach it is amazing how much extra ground can be covered in the limited time available.A practiced approach on real patients will mean that  you are more aware of some of the difficulties you may encounter and have hopefully worked through a strategy or tactics to get around them.For example the patient that keeps talking and goes off tangent to the questions asked “Sorry if I interrupt you to get you back onto the questions I need to ask.I don’t mean to be rude”.

Try to avoid asking to many open questions as this will drain your time

There are general questions that you must ask for each joint and then diagnosis specific questions that can be asked. Be careful with diagnosis specific questions as if the diagnosis is wrong this technique can backfire on you. Candidates must either be told the diagnosis by the patient[i] or be very much certain as to what it is[ii].   

There are essentially 2 parts to the history taking. The first part is the extraction of the presenting complaint and past medical history/social history/drug history. This needs to be succinct and focused but also comprehensive. This is somewhat contradictory but again with practice tactics becomes clearer and you realize where you have to go with this

Final sweep around/check[iii]

What are your expectations from treatment.

Is there anything else you want to tell me?

Is there anything I have missed to ask you?

Make sure you are alert on the day for the history and up for it.Avoid being not too slow or off the mark or else the process may become quite tedious .Although the two terms are contradictory it is very important to extract a focused but comprehensive history that doesn’t appear rushed and covers all the bases.

Don’t appear rushed. Speak up and be clear when extracting a history.

[i] Patients are generally asked not to disclose their diagnosis to exam candidates, but it can sometimes slip out inadvertently

[ii] Wouldn’t guess unless absolutely certain

[iii] Like a hotel room before you leave to make sure you haven’t left anything behind

Good hand hygiene is vital so don’t forget to gel your hands as you walk between between all cases. Hand washing facilities will also be available and can be used but in practice for ease of purpose and speed most candidates will stick to hand gel.

Introductions need to be practiced and natural not forced even if they may appear contrived to you don’t over worry about this.

Candidates need to develop a slick fast but unhurried examination technique

Stick to your learnt routine.

We include this for completeness sake and some readers may find this useful. It may be little cliché ridden for some full of overused or unoriginal phrases, but themes do keep repeating themselves

I did the standard introduction and finish talk for each of the 6 patients in the short cases. It all felt a bit forced at times and unnatural especially with the last 2 patients, but I was very happy with this strategy as the examiners expected this and I am sure the they marked me up for being polite and courteous 

It is important with examination aids you know how to use them. Don’t look as though you are using them for the first time

You need to be nauseatingly nice to the patient in front of the examiners

Listen to the examiner’s instructions

Be directed by the examiner to the part to be examined

Candidates are sometimes allowed to ask 1 or 2 questions

The clue to the diagnosis lies in the scenario

Chase the diagnosis

Eyes on the prize?

Learn a technique so that if you get caught like a rabbit in headlights and your mind goes blank and you panic you will still have a system to get yourself out of jail. If this even fails the default position is Apley’s look, feel and move and this can be used to get you starting until you recover your composure and remember your examine sequence. When the pressure is on and you are feeling tense and anxious just start looking and it should all hopefully come to you

It’s not “What you do” but “How you do it” that counts.

Don’t forget the 5 P’s.

Tips, tricks, tactics and avoiding traps are absolutely vital in the clinicals. Add in candidate exam differentiators for good measures and this will make sure that you are prepared as much as you can be for the pivotal situations that the clinicals can hinge on.

Candidate exam differentiator

These are tests in which the examiners claim they are intuitively able to differentiate between well rehearsed polished candidates who use the test regularly in clinic and those that have quickly learnt the test for the exam. Perhaps the under rehearsed candidate appears less confident and slightly unsure of the technique and this is picked up in the stress of the exam.

There are a number of these tests and it would seem sensible to spend a bit more time refining your technique for them. Best of all practise them in clinic so that you become one of those candidates that regularly uses the test in clinic!!


Invaluable tips to get candidates that extra mark 


Be careful with traps.Marks easily lost 

Different hands

With knee ligament testing,elbow ligament testing and movements of the foot and ankle different hands for left and right examination need to be used.As such it is fairly easy for the examiners to tell if a candidate is practiced with them as they have to switch their hands.  For all other joints either the  left or right hand can be used