The Rheumatology examination

This technique is the most useful in localizing the pathology. There are three techniques of movement in the joint examination.

• Active movement. The patient utilizes his own muscles and contractile structures to move a particular joint through its range of movement. This tests the joint as well as the contractile structures.
• Passive movement: Here the patient is encouraged to relax and the examiner moves the joint through its accepted range of movement. By ensuring that the joint muscles are relaxed, this checks the actual joint capsule itself. The joint range of movement may be found to be reduced. This suggests age-indeterminate involvement of the joint. Reproduction of the pain on passive movement confirms the joint as source of the complaint. If the pain is not reproduced by movement within the capsular pattern, then the cause lies elsewhere.
• Resisted movement: This isolates the cause to a particular tendon or bursa. The joint is made to relax then force is applied by the patient against resistance of the examiner. Reproduction of the pain confirms the source to be the contractile soft tissue structure.
  
  The capsular pattern is a range of movement that is affected by disease of the joint. In the case of active joint inflammation, passive movement in the capsular pattern will be tender. Should the complaint be reproduced in this manner, then the joint itself is the source of the pain.

Restriction in the capsular pattern suggests age indeterminate disease of that joint.

Each individual joint is examined, including DIP’s, PIP’s and the MCP’s as well as joints of the thumb. Swelling is recorded. The range of movement of the fingers is noted. The finger flexor tendons are then examined by feeling the tension in the pulps at the base of each finger. Tightness suggests tenosynovitis. (Saville sign) The flexors are then palpated for nodules in the palm whilst flexing and extending the fingers. These nodules may be a cause of locking.

The wrists are palpated as a single bony unit for signs of swelling. Range of movement is tested. Flexion should be between 60-90 degrees and extension 60-90 degrees Restriction suggests an inflammatory arthritis. Hypermobility may be examined by extending the 5^th finger to more than 90 degrees and moving the thumb against the volar aspect of the wrist. Tendonitis of the Abductor pollicis longus and Extensor pollicis brevis; De Quervain syndrome, which presents as thumb wrist and forearm pain, is checked by holding the thumb in a closed hand and stretching the tendon by adducting the wrist (Finkelstein’s test).

Check for sensory signs in the hand and for tap tenderness over the median nerve, (lateral to Palmaris longus tendon whilst extending the wrist - Tinel sign). Phalens test with flexion of the wrists produces aggravation of carpal tunnel symptoms.

Palpate the radial and ulnar margins for synovial thickening. Palpate for nodules or tophi on the extensor surface of the elbows. Contracture or deformity is noted. Extension should be 0 degrees whilst hypermobility will allow more than 10 degrees of extension. Flexion of 145 degrees is normal. Movement at the elbow should be checked especially flexion and extension. Passive flexion and extension pain suggests elbow joint involvement.

Lateral epicondylitis (Tennis elbow), is tested by extending the wrist against resistance, with the arm extended at the elbow, whilst palpating the insertion of tendons at the lateral epicondyle. Pain at this point is suggestive of extensor tendonitis.
Medial epicondylitis (Golfers elbow) is tested by resisted flexion of the wrist with the arm extended, and palpating a tender point at the medial epicondyle.

Bicipital tendonitis is found by flexing the supinated forearm against resistance, whilst palpating the tendon insertion at the elbow.

Painful passive movement in the capsular pattern – abduction and external rotation with or without restriction at the joint suggests shoulder joint as a cause of the pain. Restriction of abduction and external rotation suggests age indeterminate involvement. The shoulder movement is glenohumeral up to 90 degrees and scapulothoracic from 90-150 degrees and glenohumeral from 150-180 degrees. The shoulder and scapula should be steadied when examining, to ensure movement tested is glenohumeral.

Painful resisted abduction and external rotation, tested by pressing outward against resistance, is suggestive of rotator cuff disease. The rotator cuff consists of the Teres Minor, Supraspinatus, Deltoid and Infraspinatus muscles. The rotator cuff presents with pain at the shoulder radiating down the outer aspect of the arm. Pain at the rotator cuff with abduction weakness may suggest partial or full thickness tear of the tendon.
Global painful restriction of the shoulder of unknown aetiology is suggestive of adhesive capsulitis. The term ‘frozen shoulder’ applies to such restriction with underlying shoulder or rotator cuff pathology.
Resisted internal rotation tests subscapularis tendonitis. Resisted flexion of the supinated elbow with the shoulder in the neutral position tests biceps tendonitis. This will be felt as tender in the bicipital groove at the shoulder.

This presents with pain over the supraclavicular region radiating to the apex of the shoulder. Test by passive movement of the shoulder to extremes of movement – especially abduction, external rotation and adducting the arm fully in front of the chest.

Neck disease with root symptoms may radiate to the shoulder, but active shoulder movement will not affect pain arising from the neck itself. A neurological assessment is required.

The neurocentral joints are most sensitive to extension, whilst the facet joints are most sensitive to lateral flexion and rotation. Rotation laterally should allow 60-90 degrees. Flexion should allow 60-90 degrees and lateral flexion 30-60 degrees.

The thoracic spine allows 45 – 75 degrees of rotation. Chest expansion should be greater than 4 cm.

Pain in the thoracic spine should always be properly assessed for cause. Feel for bony tenderness and pain on active and passive movement, including extension, lateral flexion and rotation.

Examination of the superficial muscles may reveal trigger points as seen in fibromyalgia. Intercostal muscle problems may produce pain with respiration, as will pain from the costovertebral and costochondral joints, with local tenderness.

Check for lordosis or loss of lordosis and scoliosis.

Pelvic tilt may be noted and leg lengths should be measured from the anterior superior iliac spine to the medial malleolus at the ankle. A difference of one centimetre is acceptable.

Lumbar root symptoms will radiate to the appropriate dermatome and will have a sharp burning or electricity sensation with or without neurological signs. Forward flexion and lateral flexion may aggravate root symptoms, whilst extension will often aggravate symptoms of spinal stenosis. A positive straight leg-raising test suggests root entrapment.

Capsular joint problems, seen in inflammatory arthritis, produce symmetrical pain and restriction to all ranges of motion, flexion, lateral flexion, rotation and extension. The forward flexion is measured by the Shober test. A line is measured 10 cm above and 5 cm below the "dimples of venus" and then remeasured after the patient is flexed fully. The increase should be at least 5 cm.

Lateral flexion should be 30 degrees. Extension should be 30 degrees and rotation 45 degrees.

Hypermobility allows increased forward flexion, tested by ability to flex and place the palms flat against the ground.

Palpate the joint itself, or apply lateral compression of the pelvis.

Examination for hip flexion contracture requires the patient to lie flat, and the lumbar lordosis neutralized by flexing the opposite hip. The involved leg is extended as far as possible and the angle to the surface of the examination couch recorded.

Trochanteric bursitis presents with lateral thigh pain aggravated by lying on the side. It is detected by laying the patient on the side and abducting the thigh against resistance. Palpation at the greater trochanter confirms tenderness. Ilio-psoas bursitis is detected as painful resisted flexion.

Examination of the soft tissues include the supra and infrapatellar tendons which may be tender locally and aggravated by resisted knee extension. The anserine bursa is located medially below the joint margin and may produce local tenderness.

Inspect for swelling and deformity. Palpate for swelling and examine the range of movement. The ankle movement allows 20 degrees of dorsi-flexion and 45 degrees plantar-flexion. The subtalar allows 30 degrees inversion and 20 degrees eversion. Passive movement will test for regional inflammation of the ankle by flexing and extending the ankle and inverting and everting the subtalar joint.

The peroneal tendons are found laterally and extend the ankle and pronate the foot. The medial tendons plantarflex the ankle and supinate the foot. Resisted movement will test the respective tendons.

Stability of the medial and lateral ligaments is tested and derangement of the joint with weight bearing is essential.

The Achilles tendon is inspected and palpated locally for tenderness.

This is examined as a single unit with inspection for deformity and swelling as well as palpation for synovial or bony thickening, and movement for tenderness and restriction. Movement includes dorsiflexion, plantar-flexion, adduction, abduction, medial rotation and lateral rotation. The adduction and medial rotation constitutes the capsular pattern.

The plantar fascia is palpated at the calcaneus for insertion tenderness.

Inspect for deformity, nodules or bony or soft tissue swelling. The capsular pattern consists of flexion and extension. Extension is the most sensitive. The metatarsals are examined, successively for callous, synovial thickening or tenderness. The metatarsals can be tested by squeezing them together to elicit pain. The great toe can usually flex 30 degrees and extend 90 degrees. Bonny swelling or bunions are noted.

The history and examination provide the main information to making a diagnosis. The distribution of the problem, combined with the information regarding presence or absence of inflammation, are then correlated and interpreted. These together with pattern of presentation are vital clues to the definitive diagnosis (Fig 5,6,7).

The severity of the problem is then quantified and the effect on function and daily life are the main issues that determine aggression of therapy. ‘Pain killers’ do not alter prognosis of inflammatory disease.

The main focus of therapy should be early use of disease-modification.

With the presence of increasingly familiar imaging techniques, early changes are visible on MRI that are otherwise seen as normal on X-RAY.

The normal laboratory tests and X-rays do not replace a good examination.

The fundamentals of examination remain the cornerstone of Rheumatology.