 This seems like a funny place to begin a discussion on orthopedic examination of air crew members. But it was World War I that proved the need for medical standards. Allied air units had a very heavy accident rate. And no wonder. The British, for example, made pilots out of tired infantrymen. And even they're wounded. Then investigation showed that 60% of the accidents were directly caused by some physical defect of the pilot. We were a little better off, but not much. Out of the bitter experience of those years came a clear understanding that pilots must meet rigorous medical standards. Or they pose a hazard to themselves, their aircraft, and their passengers. Today it seems obvious that a pilot's eyes, hearing, lungs, and heart have to be in prime condition. What may not be so obvious is why bones and joints are important. Consider, a helicopter pilot must be agile enough to make the awkward climb so he can pre-flight the aircraft. Hip, leg, and foot joints have to be flexible and strong. Both in pre-flight checks and while flying, he needs manual dexterity for little tasks, like flipping the correct switch or turning a knob. In flight, he has to be able to look around for safety. He needs strength and flexibility in hands and arms for controlling the aircraft. In short, his orthopedic condition is an important part in answering the questions of whether he is medically fit to fly. The orthopedic examination is an essential part of every aviation medical exam. This film details the procedures you should use for conducting a thorough orthopedic examination of an aircrew member. The examination must be individualized. You cannot successfully do an orthopedic examination on a group of people and mass. The examination is the same, whether for a flight training applicant, a rated pilot, or a non-aviator aircrew member. The standards, however, differ slightly, as detailed in current regulations. There's some terminology we'll be using that you may have forgotten, since you don't have much occasion to need it. Let's review these key terms before we start. Flexion generally means bringing bones together. The opposite is extension, most often used in the sense of moving the bones apart. Abduction, ABduction, is movement away from the trunk of the body. Abduction, ADduction, is movement back toward the trunk. There are some other terms for specific movements. They are external rotation, radial deviation, dorsiflexion, and plantar flexion. The entire examination takes only a few minutes to perform. Basically, you have the examinee run through a series of movements that demonstrate range of motion of the joints, and then you examine the major joints one at a time. Throughout, you should be observing for these things. Movement, is there any less than normal, or any more, as in a flail joint? Power. Is there any reduced motor power, for example, for muscle injury, or lengthened tendon? Strength and coordination. Does he appear to have normal strength and coordination in all test movements? Pain and confirmation. Does he report or show any signs of pain? Is there any swelling, deformity, or atrophy as shown in this demonstration? So much for preliminaries. Now, here's how you actually conduct the procedure. First, range of motion, beginning with the shoulders. Arms to the front, rotate at the shoulders. Then, thumbs on the points of the shoulders. Raise and lower the arms. He should be able to do this in a sharp, quick movement. The next one begins with arms out, palms together, thumbs up. Move the arms quickly back as far as possible. Note that thumbs should remain pointing up. Normal range of motion is like this. Observe for lack of coordination. Ask the examinee whether he has ever had a dislocated shoulder, hips, or lower extremities. The first exercise begins with the thumbs locked, hands overhead, bent toward the floor, keeping the knees straight from the position, hands on hips. Raise one leg, knee rigid. Heel off the floor. Move the foot about the ankle in all directions. An excellent way to judge is simply to observe whether range of motion is the same on each side. Knee motion. Bend the knee freely. Kick forcibly backward and forward with each leg. Ankles and feet. Stand on the toes of both feet. Now have the examinee squat sharply several times. He should be able to get all the way down without difficulty. The final exercise in this series is to kneel, coming down on both knees at the same time. If he comes down one at a time, you should suspect an infirmity. Now for a more detailed examination. Again, we'll begin with the shoulder. Inspect anterior and posterior for any asymmetry, abnormal configuration, or atrophy. Palpate the shoulders for tenderness. The next exercises all begin from the anatomical position. Palms out. Feet apart. Observe the scapulohumeral rhythm as the man elevates his arms to directly overhead. There should be no arrhythmia which might indicate a shoulder joint abnormality. Flexion. Raise the arms from a long side through forward position with palms up to overhead. Palms together. Extension. Move arms backward as far as possible. Adduction. ABduction. Raise arms to the sides, then overhead. Adduction. ADduction. Move the arms back toward the trunk. Rotation. With arms out to the sides and elbows flexed, rotate hands to straight up. External rotation. And to straight down. External rotation. Next the neck. Palpate anteriorly for tenderness and posteriorly for spasms. Test the motions. Head down and back. Tilted from side to side and rotated. A tape measure may be used as a plumb line to check for scoliosis and kyphosis. Palpate for step off defect. Palpate at the lumbosacral junction. Look for scars that might show a previous disc surgery. Observe the general configuration of the back and the symmetry of shoulders and hips. Look for abnormal curvature such as abnormal dorsal kyphosis. A round back or excessive lumbar lordosis. Sway back. Also check for scoliosis by observing if the ribs are higher on one side than the other when he bends over. Observe the ease with which he does the exercises and watch for indications of pain. Have him bend forward as far as possible and bend back. Then side to side and rotation. The knees are another area to check carefully. A tricked knee or torn meniscus is common. Observe the general muscular development of the legs, especially the thighs. Check for crepitus and observe for pain as he squats. Watch for any hesitancy or weakness. Ask about a history of locking, instability, or recurrent effusion. Inspect the elbow function. Have the man assume this position with elbows against the side of the body. Then observe if he has full forearm supination as he rotates his hands upward. And the full range of forearm pronation as he rotates his hands to palm down. Often excessive muscular development precludes the subject from assuming this position. Examine the palms and fingers for excessive perspiration. Abnormal color or appearance or a tremor. The wrist and hand exercises begin from the same elbow flexed position. Flexion, fingers closed. Note that the fingers should be able to touch the flexion creases of the palm. Extension, hands raised. Forearms kept horizontal to the floor. Radial deviation, hands angled inward toward each other. Ulnar deviation, hands angled outward. There are several things to check with regard to functioning of the thumb. Let's go through it slowly. Observe opposition of the thumb by having the man touch each fingertip in turn. For the little finger, observe the motion closely. Make certain the thumb moves up and around. It should not slide along near the palm and then move upward. Then test the pinch with two fingers and thumb. And the thumb against the side of the index finger. Finally, have him pretend to grasp a beverage can. The fingers should curl around it, closing all at the same time. So much for the wrist and hand. Next, the hip. Have him stand on one foot and flex the other knee and hip. Observe his balance. And note any weakness of the hip muscle or instability of the joint, which would be indicated by a dropping downward of the buttock and pelvis of the raised hip. There remains only the examination of the feet. Check for strength of the feet by having him walk and hop on his toes. Observe the range of motion in ankle dorsiflexion. Raising the feet and ankle plantar flexion. Lowering them. Manipulate each foot to determine spasticity and rigidity. Examine for calluses. Lowering of the longitudinal arch or bowing of the Achilles tendon. Question the examinee about symptoms that may be brought on or exaggerated by the use of the foot. Aking feet, aching in the calf or low back strain. You may also want to observe the gait. A quick look at the shoes can be very revealing. With practice, you can learn to spot a problem by signs of abnormal wear on the sole, heel, and instep of the shoe. When no impairments are found, that's all there is to the examination. But what do you do in the other cases when some impairment is found? You must take goniometer readings of the impaired joint. This technique is outlined in TM8-640. Your basic reference is AR40-501, which explains what impairments are disqualifying. For comparison, you must also take goniometer readings of the corresponding normal joint. In some cases, tape measurements may be required. For example, if there is muscle atrophy, question the examinee. It's important that you gather all appropriate data. Order x-rays when called for. Consider whether to obtain a consultation. When you prepare the record on any case in which the man does not meet the standards, remember that the record has to be reviewed at higher levels by other doctors who will not see the examinee. Standard Form 88 and Standard Form 93 are used to prepare the report. Refer to your notes taken during examination. You are not expected to know all the vocabulary of an orthopedist, but the terms you do use need to be used correctly. Make sure that what you do submit is thorough, complete, and accurate. Army Flight Surgeons Manual's ST-105-8 Volumes 1 and 2 are recommended as references for the orthopedic examination. Flying by its very nature puts men into a hostile and unforgiving environment. If they are not medically fit, the danger becomes substantial. You, as the flight surgeon, need to recognize that the orthopedic examination can be as important for safety as any other part of the flight physical.