CLINICAL EXAMINATION IN

RHEUMATOLOGY

Michael Doherty • John Doherty

Chapter 1 - Introduction

 Symptoms
o Pain
o Stiffness
o Swelling/Deformity
o Disability and Handicap
o Systemic Illness
o Sleep Disturbance/Affect
 Signs
o Attitude
o Deformity
 o Skin Changes
o Swelling
o Tenderness
o Muscle
o Warmth
o Movement
o Crepitus
o Stability
o Function
o Generalised Hypermobility
o Fibromyalgia (non-restorative sleep disorder)
o Recording locomotor signs
o Aspects of the general examination
 Assimilation of Findings

Chapter 2 - Preliminary Rheumatological Examination

 Screening History
 Screening Examination
o Inspection of the Walking Patient
o Inspection of the Standing Patient
 From behind
 From the side
 From in front
o Inspection/Examination of the Patient Lying on a Couch
 Recording the Screen
 Summary of Screening Examination

Chapter 3 - Hand

 Function
 Basic Anatomy
 Symptoms
 Inspection at rest
o Inspection of the extensor surface
 Skin Changes
 Swelling
 Wasting
 Attitude
o Inspection of the palmar surface
 Skin Changes
 Swelling
 Wasting
o Lateral inspection
 Ability to Fully Extend Fingers
 Volar subluxation of wrist
  Swelling
 Wasting
 Inspection during usage
 Palpation
o Increased Warmth
o Radiocarpal Joint
o Inferior Radioulnar Joint
o MCPJs
o IPJs
o The Thumb
 Additional Tests
o Stability of Small Joints
o Fixed Flexion of IPJ
o De Quervain's tenosynovitis
o Carpal Tunnel Syndrome
o Ulnar Nerve Lesion
o Radial Nerve Lesion
 Summary of examination of the hand

Chapter 4 - Elbow

 Functional Anatomy
 Symptoms
 Examination
o Inspection at Rest
o Inspection During Movement
o Palpation
 From Behind
 From in Front
 Additional Tests
o Collateral Ligament Stability
o Tests For Nerve Entrapment at Elbow
 Summary of Elbow Examination

Chapter 5 - Shoulder

 Functional Anatomy
 Symptoms
 Examination
o Inspection at Rest
 Inspection From in Front
 Inspection From Behind
o Inspection During Movement
o Palpation
o Resisted Active Movements
o Test for Glenohumeral Instability
  Summary of Shoulder Examination

Chapter 6 - Spine and Sacroiliac Joints

 Pain and Pain Syndromes

o 'Mechanical' spinal pain
o Nerve root entrapment
o Lumbar canal stenosis
o 'Inflammatory' neck or back pain
o Sacroiliac pain
o 'Bony pain'
o Referred pain
 Examination of the Spine
o Inspection of the standing patient
 Loss of normal curves (cervical and lumbar lordosis, thoracic
kyphosis)
 Scoliosis
 Reduced chest movement
 Paraspinal muscle spasm
 Skin changes
o Inspection of the walking patient
o Inspection during movement
o Palpation
o Examination of the SIJ
o Neurological aspects
o Examination of other systems
o Additional tests/procedures
 Summary of examination of spine

Chapter 7 - Hip

 Symptoms
 Examination
o Inspection of the Standing Patient
o Inspection of the Walking Patient
o Inspection of the Patient Lying on a Couch
 Inspection
 Palpation
 Summary of hip examination

Chapter 8 - Knee

 Symptoms
 Inspection
 o Inspection of the Standing Patient
 Deformity
 Swelling
o Inspection of the Walking Patient
o Inspection of the Patient Lying on a Couch
 Skin Changes
 Swelling
 Muscle
 Deformity
 Attitude
o Palpation
 Temperature
 Swelling
 Patellofemoral Compartment
 Active Assisted and Passive Movement
 Tibiofemoral compartments
 Periarticular Lesions
 The Popliteal Fossa
 Stability
 Additional Tests For Mechanical Derangement
 Summary of Knee Examination

Chapter 9 - Ankle and Foot

 Hindfoot Joints
 Midfoot Joints
 Forefoot Joints
 The Arch of the Foot
 Tendons, Bursae and Fascia
 Symptoms
o Hindfoot Pain
o Midfoot Pain
o Forefoot Pain
o Referred Pain
 Examination
o Inspection of the Standing Patient
 Swelling
 Deformity
o Inspection of the Walking Patient
 Hindfoot Problem
 Midfoot Problem
 Forefoot Problem
o Examination of the Recumbent Patient
 Examination of the Soles and the Interdigital Clefts
 Palpation
 Additional Tests for Stability
 Summary of hip examination
Chapter 10 - Temporomandibular Joint

 Anatomy
 Examination
o Inspection at Rest
o Inspection During Movement
o Palpation
 Summary of TMJ Examination
Clinical
Examination in
Rheumatology
1. Introduction

 Development and Basic Structure of Joints

 Principles of the Examination of a Patient With Rheumatic Disease
 Terminology
 Symptoms
o Pain
o Stiffness
o Swelling/Deformity
o Disability and Handicap
o Systemic Illness
o Sleep Disturbance/Affect
 Signs
o Attitude
o Deformity
o Skin Changes
o Swelling
o Tenderness
o Muscle
o Warmth
o Movement
o Crepitus
o Stability
o Function
o Generalised Hypermobility
o Fibromyalgia (non-restorative sleep disorder)
o Recording Locomotor Signs
o Aspects of the General Examination
 Assimilation of Findings
The locomotor system is concerned with controlled motion, and the structure of its integral
parts reflects this functional requirement.

Development and Basic Structures of Joints

Bone, cartilage, and muscle develop from mesenchymal tissue. Their basic organisation is
self differentiating and occurs during the embryonic period (4-8 weeks). The remainder of
gestation (the foetal period) is largely concerned with growth: during this period and
throughout life, locomotor development is strongly influenced by movement, usage, and
physical stresses, which thus help adapt locomotor tissues to their functional demands. Points
worthy of note (particularly in respect of congenital skeletal anomalies) include:

 Axial development occurs in a cranial-caudal manner.

 Limb buds grow peripherally.
 Upper limbs develop a little in advance of lower limbs (insults during the period
of limb development affect the distal parts of the arms more than the legs).
 The number of rays increases distally (one in the upper arm and thigh, two in the
forearm and shin, three in the carpus and tarsus, five in the hand and foot).
 Dermatomes, myotomes, and sclerotomes (tissues sharing the same segmental
innervation) give rise, respectively, to skin, muscle, and joint/bone tissues.

Joints are discontinuities in the skeleton that permit controlled mobility. If very little
movement is required the bone-ends are firmly joined in a continuous fashion (synarthirosis,
1-3), being bridged by either one of:

 Fibrous tissue (syndesmosis), permitting almost no motion (e.g. skull sutures).

 Cartilage (synchondrosis), permitting limited movement. Primary cartilaginous
joints, e.g. between the epiphysis and diaphysis, are linked by hyaline cartilage,
which eventually ossifies: secondary cartilaginous joints (symphyses) are joined
by compressible fibrocartilage and are predominantly axial, e.g. symphysis pubis,
intervertebral joints, and manubrio-sternal joints.
1-3 Examples of synarthoses: (1) skull suture (syndesmosis); (2) interosseous membrane (syndesmosis);
(3)symphysis (synchondrosis).

If a moderate or wide range of movement is required, a space develops, forming a

discontinuous diarthrosis or synovial joint (4). In such joints, the bone-ends are covered by
hyaline cartilage: in some, additional fibrocartilage pads divide the cavity completely (discs)
or partially (menisci).
 4. Diagrammatic structure of a synovial joint (diarthosis).

A capsule encircles the joint: its outer portion is fibrous, its inner lining forms the villous
synovial membrane. The major functions of the latter include:

 Secretion of viscous synovial fluid (a modified ultrafiltrate) that fills the joint
'space', being important in lubrication and nutrition of cartilage.
 Provision of an efficient macrophage system to remove particulate and foreign
matter.

The synovium possesses inward-facing fat-containing processes (plicae). Ligaments insert

between the bones as thickened portions of capsule or as separate structures. The site of firm
attachment of fibrous structures (tendon, ligament, capsule) into periosteum and bone is
called the enthesis.

Bursae are fluid-filled sacs that facilitate smooth movement between articulating structures.
Their lining lacks a basement membrane and appears identical to the synovium.
Subcutaneous bursae (e.g. olecranon, prepatellar bursae) form after birth in response to
normal external friction: deep bursae (e.g. subacromial bursae) usually form before birth in
response to internal movement between muscles and bones, and may or may not
communicate with joint cavities. 'Adventitious' bursae (e.g. over the first metatarsal head)
form in response to abnormal shearing stresses.

Muscles acting over the joint move it through its normal range - forceful movement in one
direction being controlled by relaxation of antagonist muscles. The balanced action of
muscles constrains as well as powers joint movement. Tendons anchor muscle to bone.
Muscle is not required for tendon differentiation, but without good muscle strength sustained
development of tendons fails. Many tendons, particularly those with a large range of motion,
have sheaths (tenosynovium) resembling the capsule/synovium of joints to permit easy
gliding movement.

The range of movement and stability of individual synovial joints varies according to:

 The shape of the articular surfaces.

 Capsular strength.
  Ligaments.
 Muscles acting across the joint.
 The presence of adjacent structures.

Descriptive classification, especially of synovial joints, is often based on the type of

movement undertaken (5-9).

5-9 Joint Classification according to movement:(5) Hinge (e.g.humeroulnar); (6) Pivot, peg-in-a-hole (e.g.
proximal radioulnar); (7) Pivot, swing (e.g. distal radioulnar); (8) Sliding (e.g. intervertebral apophyseal); (9)
Ball and socket (e.g. glenohumeral).

Principles of the Examination of a Patient With

Rheumatic Disease
The rheumatological examination is an exercise in applied anatomy, with utilisation of simple
provocation or stress tests. Screening of the locomotor system should be included in any full
general medical examination: many rheumatic diseases involve other systems and,
conversely, many 'general medical' conditions (particularly endocrine, metabolic, and
neoplastic) affect locomotor structures. In this introduction, only important aspects of the
locomotor history and examination will be emphasised: an accompanying systems enquiry
and examination is assumed, and only aspects relating to key extra-articular target sites will
be emphasised.
Terminology
The following glossary relates to the site and nature of rheumatological problems:

 Arthralgia. Pain that arises in joints (not necessarily with obvious abnormality).
 Arthritis/Arthropathy. Objective joint abnormality.
 Chondropathy. A process that results in loss ofcartilage.
 Monoarthritis. Arthropathy of only one joint.
 Oligoarthritis/Pauciarticular disease. Arthritis that affects from two to four
joints (or small joint groups, e.g. 'wrist').
 Polyarthritis. Arthritis that affects more than four joints (or groups).
 Synovitis. Clinically apparent synovial joint inflammation.
 Capsulitis. Inflammation/disease of capsule.
 Tenosynovitis. Tendon sheath inflammation.
 Tendinitis. Inflammation of tendon.
 Bursitis. Inflammation of a bursa.
 Enthesopathy. Inflammation/abnormality of an enthesis.
 Myopathy. Disease/abnormality of muscle.
 Myositis. Inflammatory disease of muscle.
 Subluxation. Where two articular surfaces are abnormally aligned but remain in
direct contact.
 Dislocation. Where two articular surfaces are so out of alignment that there is no
direct surface-to -surface contact.

Symptoms
Locomotor symptoms that require clear delineation in the history are summarised in 10. It is
important to ascertain:

 The site/distribution of involvement.

 Chronological onset.
 Preceding provoking factors.
 Factors which worsen or improve symptoms.
 Symptom response to health interventions.
 10. Important locomotor symptoms.

Pain
This is the usual, most important symptom for the patient. The examiner must be certain of
the site of pain. Patient terminology (e.g. 'shoulder' or 'hip') may be misleading; the patient
should point to the site of maximum intensity and map out the area over which pain is
experienced.

Articular or periarticular pain may radiate widely and present distant from the originating
structure (11). Such 'referred' pain is an error in perception at the sensory cortex, reflecting
shared innervation by structures derived from the same embryonic segment (which divides
into dermatome, myotome, and sclerotome). Cortical cells most commonly receive stimuli
from skin: when the same cells receive, for the first time, a painful stimulus from a deeply
situated myotomal/sclerotomal structure they interpret the signal on past experience and 'feel'
pain in the area of skin (dermatome) which shares that connection. An important difference is
that the pain is felt deeply, rather than in the skin itself, and its boundaries are indistinct. In
general:

 Referred pain radiates segmentally without crossing the midline.

 The dermatome often extends more distally than the myotome, so pain is mainly
referred distally. The more distal the originating structure the more accurate the
pain localisation is likely to be.
 In addition to pain referral, tenderness may also be experienced at a distant site.
 Dermatomes are variable between individuals - the precise area of pain referral
may thus differ between patients with the same locomotor problem.
  In general, the more superficial a soft-tissue structure the more precise its pain
localisation (pain from deep, but hard, structures, such as bone and periosteum,
hardly radiates at all).
 Massage over the area of referred pain may improve rather than worsen the pain
(whereas pressure over the originating structure may reproduce the pain).

Quality of pain is generally unhelpful. Exceptions include (1) sharp, shooting pain that travels
a distance, characteristic of root entrapment, and (2) extreme pain ('worst experienced'),
typical of crystal synovitis. Although topographical localisation is at the sensory cortex level,
pain appreciation and severity is determined by cells in the supra-orbital region of the frontal
lobes, which explains why the patient's emotional state has such an influence over 'severity'.
The memory of pain is retained in the temporal lobes: duration rather than severity
determines recall.
Factors that exacerbate or ameliorate the pain should be sought. Pain confined to usage
suggests a mechanical problem, particularly if it worsens during use and quickly improves on
resting. Rest pain and pain worse at the beginning rather than end of usage implies a marked
inflammatory component. Night pain is a distressing symptom: it reflects intra-osseous
hypertension and accompanies serious problems such as avascular necrosis or bone collapse
adjacent to a severely arthritic joint. Persistent (day and night) 'bony pain' is characteristic of
neoplastic invasion.

11. Examples of pain radiation from articular periarticular sites: (a) gleno-humeral joint/rotator cuff; (b) hip
joint; (c) trochanteric bursitis; (d) de Quervain's tenosynovitis; (e) lumbar facet joint syndrome; (f) sacroiliac
joint; (g) tennis elbow syndrome.
Stiffness
Stiffness is a subjective sensation of resistance to movement tightness that probably reflects
fluid distension of the limiting boundary of the inflamed tissue (capsule, tenosynovium,
bursa). It is most marked on arising from bed, and following inactivity or rest. As normal
usage resumes, fluid clearance from the inflamed structure is encouraged and stiffness 'wears
off'. Duration and severity of early morning and inactivity stiffness thus reflect the degree
of local inflammation.

Swelling/Deformity
Patients may notice swelling, discoloration, or abnormal contour or alignment of a locomotor
structure. Although 'deformity' describes any abnormality, the term is usually restricted to
malalignment or subluxation/dislocation.

Disability and Handicap

Disability is present when a tissue, organ, or system cannot function adequately. Handicap is
when disability interferes with daily activities or social/occupational performance. Marked
disability need not necessarily cause handicap (e.g. an above-knee amputee may not be
disadvantaged in a sedentary job); conversely, minor disability may produce major handicap
(e.g. an ingrowing toenail in a professional footballer). Therefore, both require separate
assessment.

Systemic Illness
Inflammatory locomotor disease (� multisystem involvement) may trigger a marked acute
phase response and cause non-specific symptoms of systemic upset; for example, fevers
(particularly at night), reduced appetite, weight loss, fatigability, lethargy, and irritability.
The patient may volunteer no specific complaints but just feel 'ill'. In the elderly, particularly,
florid acute inflammation (e.g. crystal synovitis) may cause confusion.

Sleep Disturbance/Affect
Several factors may interfere with normal sleep patterns and associate with anxiety and
depression. For example:

 Chronic pain.
 Triggering of the acute phase response.
  Reasonable anxiety concerning deformity and morbidity.
 CNS side-effects from pain-relieving drugs.
 Severe arthropathy (hip, knee especially) may compromise sexual function, and
contribute to marital/social disharmony.

Features of masked or overt depression (e.g. psychomotor retardation, constipation,

weepiness, no thoughts of the future) should specifically be sought, particularly in those with
severe locomotor disease. Poor sleep pattern is also a feature of fibromyalgia.

Signs
Principal headings for signs at any region are shown in 12. The order of examination
applicable to most regions is (1) inspection at rest, (2) inspection during movement, and
(3) palpation (often with movement).

12. Important Locomotor Signs

Attitude
Observe the way the patient positions an affected region. A joint with synovitis has intra-
articular hypertension and is most comfortable in the position that minimises pressure
increase. Such a position (generally mild-mid flexion) is mainly determined by the
configuration of the capsule. For example, glenohumeral synovitis is most comfortable with
the arm adducted and internally rotated as if in a sling; conversely, the opposite movements,
abduction and external rotation, are the earliest affected and most uncomfortable since these
maximise intra-articular hypertension. The attitude and pattern of restricted movement may
thus suggest the underlying problem.

Deformity
Although deformities may be observed at rest,most become more apparent on weight bearing
or usage. It should be determined whether the deformity is correctable (usually implying soft
tissue factors in causation) or non-correctable (usually capsular restriction or joint damage).
Many conditions associate with characteristic deformities (e.g. at the knee, 13-17), but no
deformity is pathognomonic of one disease. Shorthand terms are used for combined
deformities (e.g. 'swan-neck' finger deformity for hyperextension at the proximal and fixed
flexion at the distal interphalangeal joint).

13-17 Principle knee deformities: (13) varus: typical of osteoarthritis (a focal condition maximally affecting
the medial compartment); (14) valgus: typical of pan-compartmental inflammatory conditions, e.g.
rheumatoid and psoriatic arthritis, pyrophosphate arthropathy; (15) recurvatum: common in generalised
hypermobility; (16) posterior tibial subluxion: characteristic of arthropathies occuring during growth, e.g.
hamophilia, juvenille chronic arthropathy; (17) fixed flexion: common in various arthropathies.

Skin Changes
Overlying scars or skin disease (e.g. psoriasis) may be important clues to causation.
Erythema (commonly followed by desquarnation) is an important sign reflecting
periarticular inflammation: although this may occur in several conditions (Table 1) , a red
joint or bursa should always raise suspicion of sepsis or crystals.

Swelling
This may be due to fluid, soft tissue, or bone. Fluid within a joint collects initially and
maximally at sites of least resistance within the capsular confines, producing characteristic
swelling at individual sites (18-20); for example:
  Knee effusions fill the medial dimple and, subsequently, the suprapatellar pouch,
giving a horseshoe swelling above and around the patella.
 Interphalangeal joint synovitis is initially apparent as posterolateral swelling
between the extensor tendon and lateral collateral ligaments.
 Glenohumeral effusion fills the triangular depression between the clavicle and
the deltoid, in front of pectoralis.
 Ankle effusions present anteriorly.

Table 1. Causes of Erythema Overlying Joints.

Major
Sepsis
Crystals (gout, pseudogout, calcific
periarthritis)
Minor
Palindromic rheumatism
Acute Reiter's or reactive arthropathy
Early Heberden's or Bouchard's nodes
Inflammatory (erosive) osteoarthritis
(hands)
Erythema nodosum arthropathy
Rheumatic fever
Erythema implies periarticular inflammation
 18-20 Characteristic swellings produced by synovial hypertrophy/effusion: (18 the knee; (19) finger
interphalangeal joint; (20) shoulder.

For small fluid volumes in a confined cavity, a bulge sign may be produced (e.g. at the knee,
massage fluid from the medial dimple to the lateral aspect of the patella and back again).
Larger volumes produce a balloon sign (fluctuance), where pressure over one point causes
'ballooning' at other parts of the swelling (21). This is the most specific sign for fluid (joints,
bursae). Capsular swelling is the most specific sign of synovitis: swelling is delineated by
the capsular confines and becomes firmer towards the extremes of movement (palpate during
passive movement).

Tenderness
Precise localisation of tenderness is perhaps the most useful sign in determining the cause of
the patient's problem (22, 23). Joint-line/capsular tenderness is localised to the joint
boundary and signifies arthropathy/capsular disease if present around the whole margin
(localised jointline tenderness suggests localised intracapsular pathology, e.g. anterior medial
tibiofemoral compartment tenderness with medial meniscal tears). Periarticular point
tenderness away from the joint line usually signifies bursitis or enthesopathy.

21. 'Balloon sign' at knee. Pressure over patella with one hand causes 'ballooning' of the other hand closely
applied over suprapatellar expansion.
 22 , 23 Example of differentiation between periarticular and joint-line tenderness at the knee: (22)
tenderness confined to patella tendon insertion into the tibial tubercle (Osgood-Schlatter disease); (23)
tenderness confined to anterior joint line of medial tibiofemoral compartment (medial meniscal injury).

Muscle
Muscle wasting is a common sign, but can be difficult to detect - particularly in the elderly.
Synovitis quickly produces local spinal reflex inhibition of muscles acting across the joint:
wasting can be rapid (within several days in septic arthritis). Severe arthropathy produces
widespread periarticular wasting: localised wasting is more characteristic of a mechanical
tendon/muscle problem or nerve entrapment. Power is more important than bulk and can be
tested either by grading from 0-5 (Table 2 : appropriate, for example, for proximal girdle and
neck muscle weakness in polymyositis), or by assessment of functional capabilities (more
appropriate, for example, for weakness of small hand muscles in rheumatoid arthritis).

Warmth
This is one of the cardinal signs of inflammation. The back of the hand is a sensitive
thermometer for comparing skin temperature above, over, and below an inflamed structure.

Movement
Assess range of active and passive movement, with comparison between sides (to
demonstrate unilateral reduction). Synovitis reduces most or all joint movements
('proportional' limitation or 'capsular pattern'), though some are affected initially and
maximally, e.g. external rotation and abduction at the glenohumeral joint. Tenosynovitis and
periarticular lesions affect movement in one plane only. Synovitis and arthropathy cause
similar reduction of active and passive movement: far greater passive than active movement
suggests a muscle/tendon/motor problem.
The pattern of pain on movement is of diagnostic significance. Pain absent or minimal in the
mid-range but increasing towards the extremes of restricted movement is 'stress pain'.
Universal stress pain (in most/all directions) is the most sensitive sign of synovitis (24).
Selective stress pain (in one plane of movement only) is characteristic of a localised intra- or
periarticular lesion. Pain uniformiy present throughout a range of movement usually reflects
mechanical rather than inflammatory problems (Table 3 ).
Ranges of movement are age-, sex- and race- dependent. Attempts to measure degrees of
movement (by a variety of instruments) are inaccurate, have poor reproducibility, and are not
recommended for routine examination purposes.

Table 2. Muscle power grading ( Medical Research Council scale).

Grade
Definition
No.
0 No visible contraction
Visible or palpable contraction without
1
motion
2 Motion only with gravity eliminated
3 Motion against gravity
4 Motion against gravity and an applied load
5 Normal power, i.e. against a significant load

Table 3. Summary of principal signs relating to synovitis, tenosynovitis and joint damage.

Synovitis
Held in neutral
Decreased movement ALL planes
Stress pain ALL directions
CAPSULAR swelling/effusion
JOINT-LINE/CAPSULAR tenderness
Increased warmth
± Fine crepitus
CAPSULAR SWELLING is the most
specific sign
STRESS PAIN is the most sensitive sign
Tenosynovitis
Joint positioned to decrease tension
Decreased movement in plane of tendon
Selective stress pain
 Linear swelling
Localised (linear) tenderness
± Fine crepitus
± Triggering
Joint Damage
Abnormal shape/subluxation
Coarse crepitus
Decreased movement
± Ligamentous stress pain/instability
± Triggering

24. Stress pain at the wrist: no discomfort in mild flexion, but progressive pain towards the extremes of
restricted flexion and extension.

A useful method for demonstrating periarticular problems is 'resisted active (isometric)

movement' (25-27). The patient pushes against the examiner's restraining hand, to contract
the muscle of interest without moving adjacent joints. If the patient's pain is reproduced (and
no joint has moved) it probably arises from muscle, tendon, or tendon insertion. For example,
resisted hip adduction produces medial groin pain in adductor tendonitis; resisted
glenohumeral abduction produces upper-arm pain with supraspinatus muscle/tendon lesions;
resisted wrist extension reproduces lateral epicondyle pain in tennis elbow. Similarly, passive
stress tests reproduce pain by stretching the responsible ligament/tendon (e.g. Finkelstein's
test for de Quervain's tenosynovitis, where passive stretch of the abductor pollicis longus and
extensor pollicis brevis muscles reproduces pain).
24-27 Resisted active movement and stress tests: (25 ) attempted external rotation at the shoulder causes
upper arm pain in an infraspinatus/teres minor rotator cuff lesion; (26 ) resisited wrist extension reproduces
lateral epicondyle pain in tennis elbow: (27 ) Finkelstein's test: passive ulnar flexion with thumb held
stretches abductor pollicis longus and extensor pollicis brevis to reproduce the pain of de Quervain's
tenosynovitis

Crepitus
Crepitus is palpable crunching that is present throughout the movement of the involved
structure. Fine crepitus may be audible by stethoscope and is not transmitted through
adjacent bone: it may accompany inflammation of tendon sheath, bursa, or synovium. Coarse
crepitus may be audible at a distance and is palpable through bone: it usually reflects
cartilage or bone damage. Other noises include ligamentous snaps (usually single, loud,
painless: common around the upper femur as 'clicking hips'); 'cracking' by joint distraction
(common at finger joints and caused by production of an intra-articular gas bubble 'cracking'
cannot be repeated until the bubble has resorbed); and reproducible clonking noises at
irregular surfaces (e.g. the scapula moving on the ribs).

Stability
Localised ligamentous or capsular instability may result from traumatic or inflammatory
lesions. Arthropathy (particularly inflammatory) may produce instability via cartilage loss
and capsular inflammation, as well as by ligamentous rupture. Stability is determined by
demonstration of excessive movement on stressing the joint. Comparison with the other side
is often helpful.

Function
Function is assessed by observation during normal usage (e.g. rising from a chair and walking
for hips, knees and feet; power grip and fine-precision pinch for the hand). Activities of daily
living , or ADL (e.g. dressing, brushing teeth, going to the toilet unaided, and cooking) are of
direct relevance to the patient, and screening questions or observations of ADL are invaluable
in assessment. Handicap is mainly determined by questioning related to work and social
activities. The World Health Organisation define health status as 'a comprehensive state of
physical, mental and social wellbeing', emphasising that psychological and emotional factors,
specific to patients rather than to their condition, are important in determining the functional
impact and effects of disease on the individual. A variety of tested and validated
questionnaires/scoring systems are now available for both functional and quality of life
(overall health status) assessments.

Generalised Hypermobility
This is one of two generalised conditions (with fibromyalgia) that is easily missed unless
specifically considered. Ten per cent of people fall within the lax end of a normal spectrum of
joint mobility. Although normal, such hypermobility may contribute to locomotor problems
(e.g. enthesopathy, dislocation). Within this 10% are also the small number ot individuals
with disease-related hypermobility (e.g. Marfan's syndrome, Ehlers-Danlos syndrome,
acromegaly). Generalised hypermobility can be screened for by using a modified Beighton
score (Table 4, fig.28).
 28. Features of generalised hypermobility (see Table 4)

Table 4 . Recognition of generalised hypermobility.

1. Extend little finger >90° (1 point each side)

2. Bring thumb back parallel to/touching forearm(1 point each)
3. Extend elbow >10° (1 point each)
4. Extend knee >10° (1 point each)
5. Touch floor with flat of hand, legs straight (1 point)

Maximum score = 9
Hypermobile = 6 or more

Fibromyalgia (non-restorative sleep disorder)

This common syndrome is characterised by:

 Poor sleep pattern(waking unrefreshed).

 Fatigability, lethargy.
 Irritability.
 Multiple regional pain (predominantly axial,often 'all over'), unresponsive to
analgesics.
 Hypersensitivity of normal tender sites. (29)

Fibromyalgia may be primary (particularly affecting middle-aged women) or secondary

(superimposed on a recognised painful condition). It is suggested by the features in the
history and confirmed principally by the finding of tender sites (with no hyperalgesia at other
control sites) and elimination of other causes of widespread aches and pains (e.g.
hyperparathyroidism, hypothyroidism, lupus).

29. Common tender sites in fibromyalgia syndrome.

Recording locomotor signs

Although physical findings can be written in note form, annotation around skeleton charts, or
homunculi (30), is recommended. Such visual recording greatly aids pattern recognition.
 30. Homunculus for annotated recording of locomotor signs.

Aspects of the general examination

In the context of a complete systems examination, particular emphasis may be given to skin
(including scalp, umbilicus, andnatal cleft for occult psoriasis), nails, mucous membranes
(especially orogenital and nasal), and eyes.

Nodules are particularly relevant to locomotor disease (Table 5). Whatever their cause,
nodules are usually most prominent over poorly covered extensor surfaces. (e.g. back of the
hands, elbow, posterior heel, and sacrum)

Nail changes of interest include clubbing (most causes of clubbing have locomotor
associations, but hypertrophic pulmonary ostecoarthropathy and fibrosing alveolitis are
particularly relevant); 'thimble pitting', onycholysis and nail dystrophy (psoriatic arthropathy,
chronic Reiter's); nailfold hyperaemia (often prominent in dermatomyositis); splinter
haemorrhages (small-vessel vasculitis); and Beau's lines (systemic illness) (31-34).
Rheumatoid is the commonest pathological cause of palmar erythema (above cirrhosis or
thyrotoxicosis).

Mucous membrane lesions may be asymptomatic (common in Reiter's/reactive arthropathy)

or symptomatic (most usual in lupus, vasculitides, Beçet's syndrome), and inspection of
orogenital and nasal mucosae for ulcers and telangiectasia is warranted. Absence of saliva
either side of the frenulum suggests sicca syndrome.

Eye changes (Table 6) include episcleritis and scleritis (rheumatoid, vasculitides,

polychondritis); iritis (ankylosing spondylitis, chronic Reiter's); iridocyclitis (pauciarticular
juvenile chronic arthritis); and conjunctivitis (acute Reiter's syndrome, sicca syndrome).
Fundoscopy, in particular, may be relevant in suspected vasculitis.

Nail changes: 31 clubbing; (32) thimble pitting; (33) oncholysis, nail dystrophy (plus distal interphalangeal
joint swelling); (34) splinter haemorrhages.

Table 5. Causes of nodules plus arthropathy.

Common
Rheumatoid arthritis
Gout (nodules = 'tophi')
 Hyperlipidaemia (nodules = 'xanthomata')
Rare
Systemic lupus (small nodules)
Rheumatic fever (small nodules)
Multicentric reticulohistiocytosis
Polyarteritis nodosa
Sarcoidosis

Most nodules (and small vessel vasculitis) occur over extensor surfaces and pressure areas.

Table 6. Characteristics of important causes of a red eye.

Conjunctivitis
Itchiness, irritation
Diffusely red due to engorged vessel
network
Redness extends over bulbar surface of
eyelids
Vessels can be moved over surface
Mucopurulent discharge common ('sticky
eye')
Episcleritis
Usually asymptomatic
Diffuse or localised ('nodular' episcleritis)
Bright red flush, individual vessels often
visible
Vessels cannot be moved over eyeball
Vessels constrict to local adrenaline drops
(1:1000)
Scleritis
Usually painful, often severe
Deep red/purple colour, vessels indistinct
Deep vessels do not constrict to
adrenaline drops
Often accompanied by episcleritis
May be visual disturbance
Localised ('nodular') scleritis causes
elevated lesion due to oedema
Diffuse scleritis causes less pain but may
involve cornea, causing keratitis and
keratolysis ('corneal melt')
 Healed scleritis may leave sclera more
transparent and permit the dark
underlying choroid to be seen
('scleromalacia')
Acute iritis
Severe throbbing pain
Blurring of vision, photophobia,
lacrimation
Usually involves only one eye at a time:
light in other eye will exacerbate pain as
iris constricts
Small vessels of limbus are engorged
('ciliary flush')
Small spastic pupil, may be irregular (due
to posterior adhesions or 'synechiae')
Clouding of aqueous ± anterior chamber
pus collection inferiorly ('hypopyon')

Assimilation of findings
Following the history and examination it is often helpful to organise findings under the titles
in 35. Consideration of just age and sex will narrow diagnostic possibilities considerably. For
arthropathy the temporal presentation (acute, chronic, or relapsing), number of joints
involved, distribution, and degree of inflammatory component (Table 7) will then usually
suggest the most likely diagnosis with few options: the presence of particular extra-articular
features may narrow possibilities further. Any investigations can then be highly selected and
a rheumatologic 'screen' with multiple investigations should never be required. Only in
adequate history and examination will permit correct diagnosis and an appropriate
management plan. It should be remembered that apparently mundane and localised lesions
(e.g. Achilles tendinitis) may be the presenting feature of a widespread or multisystem
condition.

Table 7. Symptoms and signs that might suggest a marked inflammatory component to arthropathy.

Local
Early morning stiffness
Inactivity stiffness
Swelling
Warmth
Effusion
Capsular swelling
Stress pain
Systemic
Weight loss
Fevers, sweats
Lethargy, irritability, depression
Anaemia

35. Principal considerations when organising findings.

2. Preliminary Rheumatological
Examination

 Screening History
 Screening Examination
o Inspection of the Walking Patient
o Inspection of the Standing Patient
 From behind
 From the side
 From in front
o Inspection/Examination of the Patient Lying on a Couch
 Recording the Screen
 Summary of Screening Examination

An exhaustive history and extensive examination for all conceivable rheumatological

abnormalities in every patient are time-consuming and unnecessary. As with other systems, a
brief screening procedure to pick up problems in defined regions is more appropriate. If an
abnormality is detected, a more detailed examination of affected regions (as described in
subsequent chapters) can be undertaken to define the problem more precisely.

Screening is a compromise between brevity and sensitivity to detect abnormality. To screen a

joint for arthropathy the movement that is affected first and maximally is selected for
scrutiny: if normal, other movements of that joint can be omitted. Many such movements
have functional importance, and the screen is one of function as well as joint/muscle
abnormality. Students will develop their own variation of the 'minimum screen' for the
locomotor just as for other systems, and the following is offered as a guide rather than a
doctrine. Such a screen can readily be included within the systems enquiry and examination
that comprises the routine medical clerical procedure. Certain aspects (e.g. gait) overlap with
screening of other systems (particularly neurological) and in the setting of a routine clerking
procedure the screen takes only a minute or so to perform.

Screening History
Pain and stiffness are the most common symptoms, and functional impairment the most
important consequence of rheumatological abnormality. Therefore, reasonable screening
questions are:

'Have you any pain or stiffness in your muscles, joints or back?'

'Can you dress yourself completely without any difficulty?'

'Can you walk up and down stairs without any difficulty?'

Dressing is a daily event with which the patient readily identifies in terms of problems.
Ability to dress completely (including shoes and socks) is a sensitive functional test of most
upper and lower limb joints, and if the patient has no pain or difficulty dressing then
significant or widespread locomotor disease is unlikely. If the patient can go up and down
stairs without any problem then most lower limb muscles and joints are functioning well: up
and down stairs is a better test of hip and knee, particularly patellofemoral, problems than
walking on the flat. If none of these questions detects a problem, further questioning is
unlikely to do so. If a problem is found, more detailed questioning is obviously warranted.
(Note that the two functional questions are not specific to locomotor disease and may have
been included elsewhere in a systems enquiry.)

Screening Examination
This mainly comprises inspection at rest and inspection during selected movements. Brief
palpation and stress tests of joints commonly involved in inflammatory arthropathy
(metacarpophalangeal and metatarsophalangeal joints and knees) completes the screen.

The normal joint should:

 Look normal. With advancing age the features of a joint become more visible,
and muscle bulk diminishes, without necessarily signifying disease.
 Assume a normal resting position. Abnormal positioning of a normal joint may
result from poor postural habit, neurological abnormality, or psychogenic
disorder with feigning of disease. Postural abnormalities should disappear when
the patient is asked to adopt the normal position and undertake normal
movement. Psychogenic posturing is often odd, inconsistent, and unique to the
patient.
 Move smoothly through its range of movement. Articular or periarticular lesions
often cause jerky, guarded movement, and the patient may use trick manoeuvres
to minimise disability.

The patient should be assessed during walking, while standing, and while lying on a couch.
Observation of the patient getting undressed is a further useful functional screen, though
some physicians prefer to spare the patient any embarrassment this may cause. The order in
which the screening is performed is unimportant, and although described here as individual
procedures inspection, palpation and stress tests of a region can often be undertaken
simultaneously. The procedure is facilitated and hastened if the examiner undertakes the
movements so that the patient can see and copy exactly what is required.

Inspection of the Walking Patient

With the patient barefoot and undressed to their underwear, observe their gait as they walk
forwards, turn and walk back again. Scrutinise movements of arms, pelvis, hips, knees,
hindfoot, midfoot, and forefoot, in turn. Normal gait (36-39) is characterised by:

 Flowing arm movement linked to movement of the opposite leg.

 Smooth, symmetrical movement of the pelvis, .rotating forward with the
advancing leg
 Hip flexion at heel strike, hip extension at toe-off.
  Knee extension at heel strike, flexion during swing.
 Normal heel strike, foot pronation in midstance, heel rise before push-off, and
ankle dorsiflexion during swing.
 Smooth turning ability.

36-39 Principal phases of gait (nearest leg): (36) heel strike phase; (37) loading/stance phase; (38) toe-off;
(39) swing phase.

As the patient walks and turns, look particularly for an antalgic gait (40) where pain or
deformity causes the patient to hurry off one leg and to spend most time on the other leg
(often with accompanying asymmetry of arm movement). The type of antalgic gait may
suggest the region that is involved. For example:

 Low back problem. Decreased rotation of the pelvis with the advancing leg
results in a shortened step and caution when turning.
 Hip problem. The body 'bobs' over the painful side: fixed flexion may accentuate
lumbar lordosis and exaggerate buttock prominence.
 Knee problem. Synovitis/deformity may prevent full extension during swing and
soften heel strike. If the knee is held stiffly the body pivots around the leg during
the stance phase and the leg is swung forward by circumduction.
 Hindfoot problem. With reduced ankle movement the leg may be externally
rotated and slightly abducted. If the heel is painful, heel strike may be replaced
by 'foot strike': the heel is kept off the floor and the knee does not fully extend.
With Achilles tendon problems, pushoff is avoided.
 Midfoot problem. The foot is held inverted (supinated) and push-off is from the
lateral side
 Forefoot problem. To prevent weight bearing on the forefoot the heel does not
rise in late stance, and there is no push-off. The knee, hip, and trunk flex to
maintain forward motion, and swing phase on the normal side is shortened,
 resulting in forward 'bobbing' during late stance on the painful side. Involvement
of both fore feet combines to give a forward-leaning, shortstepped, shuffling gait.

40. Antalgic Gait.

Other abnormal (including neurological) gaits include:

 Trendelenburg gait. Due to ineffective hip abduction the pelvis drops down on
the opposite side during stance phase on the affected side (41)
 Waddling gait. This is a bilateral Trendelenburg gait.
 Hysterical/psychogenic gait. Often variable, exaggerated or bizarre, conforming
to no easily recognised pattern.
 Spastic gait. A narrow-based dragging gait; the patient has difficulty bending the
knee, and the foot is raised by tilting the pelvis and swinging the leg forward in
an arc of circumduction, with the toes scraping the ground.
 High-stepping gait. With a slap of the foot in the contact phase (due to
unrestrained ankle plantar flexion) high-stepping gait occurs with weakness of
tibialis anterior ('foot drop').
 Wide-based stamping gait (sensory ataxia). The patient suddenly raises the foot
high and jerks it forward before bringing it to the ground with a stamp: the eyes
are usually fixed to the ground to help compensate for loss of positional sense.
Gait and balance are worsened by eye closure.
 Wide-based staggering gait (cerebellar ataxia). The feet are wide apart and
placed irregularly; the arms are flung out to improve balance. Closing the eyes
makes little difference
  Stooping, festinant gait (parkinsonism). The arms do not swing; starting is slow,
but after small shuffling steps the patient may break into a tottering run.

41. Trendelenburg Gait.

If the observed gait is entirely normal the patient is unlikely to have any major locomotor
abnormality in the lower limbs or lumbar spine.

Inspection of the Standing Patient

Ask the patient to stand upright with arms outstretched by the sides.

Inspection from behind

Comparing one side with the other (42), look particularly for:

 A straight spine (no scoliosis/rib-cage asymmetry)

 Iliac crests at equal height.
 Normal muscle bulk/symmetry, especially of paraspinal, shoulder, and gluteal
muscles.
 Popliteal swelling.
 Swelling/asymmetry around the Achilles tendons.
 Hindfoot deformity (valgus/varus)

While in this position apply point pressure to the midpoint of each supraspinatus (43), and
undertake skin-fold rolling of the overlying skin (44), looking for increased tenderness
suggestive of fibromyalgia.
 42. Inspection of the standing patient from behind.

43. Applied pressure over midpoint of supraspinatus.

44. Skin fold rolling (for fibromyalgia)

Inspection from the side

Look particularly for:

  Loss of normal cervical and lumbar lordosis, and alteration of normal mild
thoracic kyphosis.
 Knee deformity (fixed flexion, genu recurvatum, posterior tibial subluxation).

While in this position (45), test lumbar spine and hip flexion by placing several fingers over
the posterior spinous processes of the lower lumbar vertebrae and asking the patient to 'bend
forwards and touch toes' as best they can (46). The thoracolumbar spine should form a
smooth curve and the palpating fingers move apart if the lumbar spine is normal: a good
range of movement implies normal hip flexion.

45. Inspection of the standing patient from the side.

46. Inspection/palpation of patient attempting 'touching of toes'

Inspection from in front

Comparing one side with the other (47), look particularly for:

 Swelling, abnormal position, skin change over sternoclavicular and

acromioclavicular joints.
 Equal shoulder height.
 Muscle wasting/asymmetry, especially of deltoids and quadriceps.
 Inability to fully extend elbows.
 Deformity (particularly varus, valgus) of knee.
 Deformity (particularly of hallux, MTPJs) of forefoot and alteration of foot
arches (especially flat feet)
 47. Inspection of the standing patient from in front.

While in this position ask the patient to (1) laterally flex the neck to each side (48), and look
for pain or restriction (lateral flexion is a sensitive test for cervical spine abnormality). (2)
Open the jaw wide and move it from side to side (49). It should open easily, without deviation
to either side. (3) Place both hands behind the head with the elbows back (50). External
rotation and abduction are the earliest, most severely affected glenohumeral movements.
Hands behind head also moves the acromioclavicular and sternoclavicular joints, and tests
supraspinatus, infraspinatus, and teres minor. (4) Place both hands out in front, palms down,
fingers straight, with elbows at 90° at the side (51). Inspect for abnormalities (particularly
swelling, deformity, attitude, and skin changes) at distal radioulnar joint, wrists, MCPJs, and
IPJs. Look for extensor tenosynovitis. (5) Turn the hands over (supination, (52), testing
proximal and distal radioulnar joints). Inspect the palmar aspects (particularly for wasting,
skin changes, and flexor tenosynovitis swelling). (6) Make a tight fist with each hand (53).
Observe ability to curl fingers tightly into palms (power grip). (7) Place the tip of each finger
onto the tip of the thumb in turn (54). Observe dexterity for fine precision pinch. (8) Squeeze
across the second-fifth metacarpals (55).
 48. 'Place your ear on your left, then right shoulder'.

49. 'Open your mouth wide, and move it from side to side'.
 50. 'Place your hands behind your head'.

51. Inspect dorsal aspects of hands. 52 Inspect palmar aspects of hands.

 53. Observe a tight fist (power grip).

54. Observe fine-precision pinch.

55. Metacarpal squeeze.

Inspection/Examination of the Patient Lying on a Couch

Elderly patients, in particular, often find it uncomfortable to lie totally flat, and a sitting-up
position is adequate for screening manoeuvres. With the patient reclining comfortably, the
examiner should (1) flex each hip and knee while holding the knee (56). Ensure normal knee
flexion and feel for crepitus. This again tests hip flexion. (2) Passively internally rotate each
hip with the hip still flexed (57). This is a sensitive test for hip disease. (3) Press on each
patella and palpate for a balloon sign (58). This tests the patellofemoral compartment and for
synovitis in a joint commonly affected by all arthropathies. (4) Squeeze all the metatarsals
(59) to test the MTPjs. (5) Inspect the soles for callosities (60).

57. Internal rotation of the flexed hip.

58. Patellofemoral stress test and palpation for balloon sign.
 59. Metatarsal squeeze.
60. Inspection of the soles.

If findings for all the above are normal it is very unlikely, with a negative locomotor history
screen, that significant abnormalities are present.

Recording the Screen

A useful shorthand for recording this screen in note form is the 'GALS' template

(G = gait, A = arms, L = legs, S = spine).

If the appearance (A) and movement (M) of each component are normal, a tick is given:

If abnormality is detected at one or more of these regions the tick is replaced by a cross, and
further note of the abnormality is made. For example, in a patient with knee osteoarthritis:
Summary of Screening Examination
(1) Inspection of the patient walking, turning, and walking back
(2) Inspection of the patient standing
(a) From behind
- Press over mid-supraspinatus
- Skin fold rolling
(b) From the side
- 'Touch toes' (lumbar flexion)
(c) From the front
- 'Ear on shoulder' (lateral cervical flexion)
- 'Open jaw, move side to side' (TMJs)
- 'Hands behind head'(glenohumeral)
- Inspect dorsum of hands
- Observe supination of hands, inspect palms
- 'Make a fist' (power grip)
- 'Touch fingers on thumb' (precision pinch)
- Metacarpal squeeze
(3) Examination of the patient lying on a couch
- Feel knee crepitus during knee/hip flexion
- Internal rotation of hip in flexion
- Metatarsal squeeze
- Inspect soles
3. Hand

 Function
 Basic Anatomy
 Symptoms
 Inspection at rest
o Inspection of the extensor surface
 Skin Changes
 Swelling
 Wasting
 Attitude
o Inspection of the palmar surface
 Skin Changes
 Swelling
 Wasting
o Lateral inspection
 Ability to Fully Extend Fingers
 Volar subluxation of wrist
 Swelling
 Wasting
 Inspection during usage
 Palpation
o Increased Warmth
o Radiocarpal Joint
o Inferior Radioulnar Joint
o MCPJs
o IPJs
o The Thumb
 Additional Tests
o Stability of Small Joints
o Fixed Flexion of IPJ
o De Quervain's tenosynovitis
o Carpal Tunnel Syndrome
o Ulnar Nerve Lesion
o Radial Nerve Lesion
 Summary of examination of the hand

Function
The wrist and hand, each comprising many small joints, act as a single functional unit. The
hand undertakes a variety of important functions including:

1. Grip and manipulation. The two important basic grips are:

  Fine precision pinch(61). This is achieved by opposing the pulp surfaces of the
thumb and finger (usually the index finger), and requires rotation of the thumb
(and to some extent finger) during opposition. 'Scissors' pinch is less precise
opposition of the thumb against the side of the index finger.
 Power grip (62). Achieved by curling the fingers tight into the palm, the power
grip is optimised by extension and locking of the wrist (permitting full power
from the finger flexors). The grip is maximal with 90° rotation and 45° ulnar
deviation ('hammering' position). The hook grip is a modification of the power
configuration.

A range of variants can be generated from these basic grips, giving the hand great flexibility
for manipulation. Grip is enhanced by complementary use of both hands, and impaired
function in one hand may reduce overall function considerably.

2. Proprioception. Hands are the principal point of contact for touch sensitivity with the
environment.

3. Communication. Hands undertake a range of non-verbal signals and are important in social
contact (e.g. hand shakes, caresses).

4. Locomotion. e.g. during crawling, swimming.

61. Fine precision pinch.

 62. Power grip.

Basic Anatomy
The inferior radioulnar joint (63) is delineated distally by the triangular disc or 'ligament' (a
key stabiliser to the wrist). The capsule and synovium extend proximally between the radius
and the ulnar as the sacciform recess. Together with the superior radioulnar joint it permits
supination/flexion.
 63. Bones and joints of the wrist (S = scaphoid, L = lunate, C = capitate, H = hamate).

The radiocarpal joint, with its separate synovial cavity, permits flexion, extension and lateral
movement between the radius (and triangular ligament) and the proximal row of the carpus
(scaphoid, lunate, triquetrum). The midcarpal joint has a separate synovial space (often
communicating with carpometacarpal cavities) and connects the proximal and distal rows
(trapezium, trapezoid, capitate, hamate): only minor movement (flexion, extension, some
rotation) occurs here. The second and third carpometacarpal joints (CMCJs) permit little if
any movement; the second and third metacarpals and distal carpal row thus form a fixed L-
shaped unit (64) around which, in functional terms, the rest of the hand is built. The first
CMCJ is exceptionally mobile: the metacarpal sits astride the trapezium, facing the ulnar
border. The fourth and fifth CMCJs are less mobile than the first but move together on the
hamate, permitting formation of a'hollow palm'.
 64. The L-shaped immobile segment.

The metacarpophalangeal joints (MCPJs: 65) are modified hinge joints: their position is
marked on the palmar surface by the distal palmar crease. Each proximal phalanx base has a
cartilaginous volar extension (the palmar ligament or plate). The deep transverse metacarpal
ligament joins the second to fifth volar plates (66). Each MCPJ has a radial and uInar lateral
ligament eccentrically placed across the joint, tightening only in flexion (67).

65. Metacarpophalangeal and interphalangeal joints.

 66. Volar plate arrangement.
67. Tightening of MCPJ collateral ligaments in flexion.

The proximal and distal interphalangeal joints (PIPJs, DIPJs) are true hinge joints. They also
possess palmar plates, and fibrous tunnels occur on the palmar aspects of the phalanges. Each
interphalangeal joint (IPJ) has radial and ulnar collateral ligaments centrally placed across the
joint (tight in both flexion and extension). The synovium of each MCPJ and IPJ extends more
proximally than distally (65) due to the arrangement of tendon slips and other structures
which cause progressive tightening of space distally.

The hand is primarily designed for flexion (gripping). The long flexor tendons (68) run in the
common flexor tendon sheath (flexor pollicis longus often has a separate sheath): all are
encased by the flexor retinaculum. The palmar fascia (an extension of palmaris longus)
attaches to the flexor retinaculum and partly divides into four, attaching to the deep
transverse metacarpal ligament and phalanges. The median nerve passes tight alongside the
flexor tendons beneath the retinaculum in the carpal tunnel (it may thus be compressed by
tenosynovitis). The extensor tendons are also long structures enclosed by the extensor
retinaculum (69). Extensor pollicis brevis and abductor pollicis longus are encased in a
separate fibrous canal at the radial styloid region where inflammation may give rise to
stenosing tenovaginitis (de Quervain's tenosynovitis).

Wrist and hand joints are commonly involved in inflammatory conditions (e.g . rheumatoid,
seronegative spondarthropathy). Generalised osteoarthritis predominantly involves DIPJs and
PIPJs, the first CMCJ and the scapho-trapezoid joint (other carpal joints are spared). Isolated
involvement of radiocarpal and midcarpal joints is common in crystal-associated arthropathy
(pyrophosphate arthropathy and gout).

68. Flexor tendons and sheaths ( retinaculum removed).

69. Extensor tendons and sheaths.

Symptoms
Pain from any of the small joints in the wrist and hand is usually well localised and the
patient easily pinpoints its source. However, three common conditions ma cause radiation of
pain on the radial side of the hand (70-72)

 First CMCJ arthropathy (usually osteoarthritis).This is the one joint that may
cause wide radiation (distally up the thumb, proximally up the distal forearm),
though pain is maximal over the joint itself.
 De Quervain's tenosynovitis. Pain is maximal around the radial styloid but often
radiates into the thumb and proximally up the forearm.
 Carpal tunnel syndrome. The key symptom suggesting peripheral nerve
entrapment is nocturnal or early morning exacerbation of symptoms (symptoms
may be confined to this time). In carpal tunnel syndrome, median nerve
compression may cause (1) paraesthesia and dysaesthesia distally to the thumb,
index and middle fingers, often with clumsiness, and (2) painful aching
proximally up the forearm, occasionally to the elbow.

Problems (particularly synovitis) affecting hand joints are often very apparent to the patient,
due to early interference with activities of daily living (dressing, etc.): even mild
tenosynovitis or IPJ synovitis may cause tightness of rings.

Pain and sensory disturbance may radiate into the hand from above, particularly the elbow
(arthritis, epicondylitis), shoulder (arthropathy, rotator cuff), and cervical spine (root
entrapment of C6, 7, 8). In these situations symptoms are often less well defined and
accompanied by more proximal symptoms.
70 - 72 Pain radiation in: (70) first metacarpal joint arthropathy, (71) de Quervain's tenosynovitis, and (72)
carpal tunnel syndrome.

Inspection at rest
Inspect and compare the dorsal and palmar surfaces of both hands, then inspect from the side
with hands outstretched.
 73. Inspection of the back of the hands.

Inspection of the extensor surface

Inspect the back of the hands rested on the patient's lap or on a flat surface (73). Look for:

Skin and nail changes

These include erythema, psoriasis, vitiligo, mixed hyper/hypopigmentation ('salt and pepper'
appearance of scleroderma), skin tightness with loss of flexures (sclerodactyly: typical of
scleroderma and overlap connective tissue syndromes); and current or past evidence of
trauma. Violaceous/silvery raised lesions (Gottron's papules) occur over extensor surfaces in
dermatomyositis. Lupus rashes often affect skin between joints, vasculitic rashes often affect
lateral more than dorsal aspects of fingers. The nails require inspection for clubbing, thimble
pitting, splinter haemorrhages, subungual hyperkeratosis, dystrophy and abnormalities of
nailfold capillaries.

Swelling

All joint swellings are most prominent on the dorsal surface. Radiocarpal synovitis (74)
produces rectangular swelling symmetrically placed each side of the joint line; inferior
radioulnar synovitis causes a domed swelling that rounds off the distal ulnar prominence;
intercarpal and CMCJ synovitis usually produce modest swelling centred over their joint
lines. However, both MCPJ and IPJ synovitis cause swelling more proximal than distal to the
joint line (75), MCPJ synovitis producing swelling between the metacarpal heads, and IPJ
swelling producing posterolateral bulging between the extensor tendon above and the lateral
collateral ligaments on each side. With moderate-gross IPJ swelling, stretching of the skin
makes the overlying wrinkles less distinct. Extensor tenosynovitis also produces swelling
over the carpus: it may differ from radiocarpal synovitis in being asymmetrically spread
across the joint line, extending more distally over the metacarpals and having an irregular
distal contour (76).

74. Position and shape of swelling due to radiocarpal (black) and inferior radioulnar (stippled) synovitis.

75. Swelling of MCPJ and IPJ synovitis.

76. Extensor tenosynovitis swelling.
Deformity

A variety of deformities may occur, all best seen from the dorsal aspect. Apart from
synovitis, undue prominence of the ulnar styloid may result from subluxation caused by
weakening and rupture of the distal radioulnar ligament (usually rheumatoid). Conversely,
the ulnar prominence may not be apparent, due to erosive disease or previous surgery.
Osteophytosis of the first CMCJ may cause 'squaring' of the hand (77). Ulnar deviation at
MCPJs (78) usually accompanies and follows radial deviation at the wrist (usually
rheumatoid). Volar subluxation of phalanges at MCPJs leads to prominence of metacarpal
heads and a step-down deformity. Lateral deviation (radial or ulnar) at IPJs (77), and firm
posterolateral swellings of DIPJs (Heberden's nodes) and PIPJs (Bouchard's nodes) are
characteristic of osteoarthritis. Combined deformities include 'swan neck' (PIPJ
hyperextension, DIPJ hyperflexion: 79), 'boutonniere' ('buttonhole': PIPJ hyperflexion, DIPJ
hyperextension - the PIPJ pushing through the extensor tendon like a button through a
buttonhole - 80), and 'Z' deformity of the thumb (MCPJ hyperflexion, IPJ hyperextension:
81). Inability to place the fingers flat (fixed flexion) can result from flexor tendon or joint
problems.

Wasting

This is often difficult to observe. Apart from wasting of dorsal interosseus muscles, marked
'guttering' between extensor tendons may result from volar subluxation of the carpus, which
automatically makes the extensor tendons and gaps between them more prominent.

Attitude

The way the patient holds the hand may suggest the degree of pain and discomfort. With
synovitis of any hand/wrist joints the patient is most comfortable in mild flexion.
 77. Typical hand deformities in generalised osteoarthritis.

78. Ulnar deviation at MCPJ's accompanying radial deviation at the wrist.

 79 - 81 Combined deformities: (79) Swanneck; (80) boutonniere; (81) Z deformity of thumb.

Inspection of the palmar surface

Ask the patient to pronate the hands. Difficulty or pain during pronation reflects problems
with the superior and/or inferior radioulnar joints. Supination/pronation involves the radius
moving over the stationary ulna: if the radioulnar joints are compromised the patient may use
a trick manoeuvre (82, 83), bringing the elbow across the abdomen to increase supination (by
partly rotating the ulna).
 82 , 83 Pronation with flexed elbow: (82) normal; (83) with compromised radioulnar joints.

On the palmar surface look for:

Skin changes

Palmar erythema is common in rheumatoid disease. Dupuytren's contracture is recognised as

puckering of the skin with thickening of the palmar fascia: in established cases there may be
fixed flexion contracture, predominantly affecting the ring and little fingers (84). Small vessel
infarcts often occur as black spots, particularly on finger pulps.
 84. Dupuytren's contracture.

Swelling

Swelling on the volar aspect most commonly represents flexor tenosynovitis, often most
obvious proximal to the wrist crease, between the distal palmar crease and finger base, and
occasionally between the skin creases of the fingers (85). As a result of the thick flexor
apparatus, joint swelling is rarely apparent on the palmar surface.
 85. Flexor tenosynovitis swelling.

Wasting

Unlike the dorsal surface the palms are an excellent site to observe muscle wasting.
Irrespective of age, both thenar and hypothenar eminences should be convex. Localised outer
thenar wasting usually reflects median nerve compression: it often also accompanies first
CMCJ arthritis.

Lateral Inspection
Ask the patient to outstretch the hands and inspect from the side. The main features to note
are:

Ablity to Fully Extend Fingers

The patient may have almost no active extension of one or more fingers (commonly the little
finger and the ring finger: 86). The examiner, however, may be able to extend the finger
passively, only to see it drop down when the finger is released. This combination reflects
extensor tendon rupture (in inflammatory disease this usually occurs close to the ulnar
styloid). Some patients have partial active, but full passive, extension: this reflects rupture of
the extensor tendon slips, permitting the extensor tendon to drop to the ulnar side of the
MCPJ. Sometimes the slipped extensor tendon can be palpated and pushed onto its usual
position above the MCPJ: if the examiner holds it there, the patient may be able to fully
extend the finger only for it to return to the original situation when the examiner lets go (87,
88).
 86. Complete extensor rupture (ring finger and little finger).

87 , 88 Extensor tendon slip. In (87) the examiner can correct the slip, permitting full finger extension.
When the examiner lets go (88) the fingers drop again.

Volar Subluxation of the Carpus

This produces a 'dinner fork' deformity (89: perhaps the most characteristic hand deformity of
rheumatoid).

89. Volar Subluxation of Wrist.

Swelling over dorsum of wrist

This may have been noted earlier, reflecting synovitis (radiocarpal, midcarpal) or extensor
tenosynovitis. To differentiate tendon sheath from joint swelling, inspect the swelling with
the MCPJs flexed; then ask the patient to fully extend the fingers (90). Tenosynovial swelling
moves proximally with the tendons, its distal boundary becoming more definite as the
tenosynovium 'tucks' in (the 'tuck' or 'shelf sign). Joint swelling remains unaltered by
extensor tendon movement.

90. The'tuck' sign of extensor tenosynovitis.

Volar Subluxation at the MCPJs

This may be more obvious from the lateral view (see 78).

Inspection During Usage

Ask the patient to clench the fist in a power grip (see 62), observing the ability to curl the
fingers tightly into the palm. Assess power by asking the patient to grip the examiner's
finger(s) as hard as possible. Next, observe the fine precision pinch (see 61) by asking the
patient to oppose the tip of the thumb to the tip of each finger in turn: to test whether this
movement is functional, ask the patient to pinch the examiner's finger (looking for weakness,
thumb instability). Such screening. together with the history, gives a good indication of the
patient's likely functional problems.

Palpation
This is best done by facing the patient at a slight distance, and supporting the relaxed hand
from below with the fingers of one hand. Assess the following in turn:

Increased Warmth

This is felt by sweeping the back of the hand down over the forearm, the wrist, the back of
the hand and the fingers. Normally, skin temperature decreases towards the periphery:
marked coolness may be noted with Raynaud's. Increased warmth, particularly over the wrist
and the MCPJs, is easily felt if present.

Radiocarpal Joint
Identify the joint line by palpating with the left thumb while the right hand uses the
second/third metacarpals as a lever to passively flex and extend the joint (91). The triangular
space between radius, scaphoid and Innate is usually easily felt, representing the centre of the
joint line. Press all along the dorsal joint line for tenderness. If there is soft-tissue swelling,
palpate to delineate its boundaries (radiocarpal synovitis symmetrically spreads across the
joint line). Then feel across the top and bottom of the joint for crepitus while assessing the
range of extension and flexion passively (92, 93). Note any restriction and presence of stress
pain. Lateral radial and ulnar movement at the joint can also be assessed.

91. Palpation for radiocarpal joint line.

92 , 93 Palpation for crepitus while assessing radiocarpal flexion (92) and extension (93).
Inferior Radioulnar Joint

Move the left thumb to the distal uInar prominence and palpate to ensure the styloid region is
intact and has not been whittled away by erosive disease and to detect any soft-tissue
swelling due to synovitis (if moderate-to-marked, a balloon sign may be detected).

Pull the carpus over to the radial side and press the uInar styloid firmly in a volar direction
(94) to:

 Elicit any pain from the joint.

 Feel for crepitus.
 Detect any increased movement (the 'piano key' sign, reflecting weakness or
rupture of the distal radiouInar ligament).

94. Palpation for 'piano key' sign crepitus and tenderness of the inferior radioulnar joint.

MCPJs

Inspect the joints flexed (95) to look for filling in of the gutters between the metacarpal heads
(representing synovial swelling). Tenderness of all the MCPJs can be elicited by squeezing
with one hand across all the metacarpals ('metacarpal squeeze', 96): tenderness reflects
inflammation of one or more MCPJs. For individual MCPJs, continue to support the patient's
hand from underneath with the fingers of both hands and use the thumbs to detect the
posterolateral joint line either side of the extensor tendon. The joint line is surprisingly distal
and is best found by moving the thumbs proximally along the proximal phalanx to find its
expanded base - between this and the metacarpal head is the valley of the MCP joint line
(97). To confirm, keep palpating while slightly flexing and extending the proximal phalanx:
this additionally allows detection of any crepitus and palpation for volar subluxation. Having
confirmed the position of the joint line, press firmly with both thumbs for joint-line
tenderness, then palpate around each side of the metacarpal head to determine the presence
and extent of any soft tissue swelling. Examine each of the second-fourth MCPJs in this way.

95. Inspection of flexed MCPJs for swelling due to synovitis.

96. Metacarpal squeeze.

97. Palpation of MCPJ.

To assess MCPJ movement, gently supinate the patient's hand. Place your left thumb
proximally in the palm to feel for crepitus of flexor tenosynovitis while your other hand holds
the proximal phalanx and moves the MCPJ from full extension through to maximal flexion
(98, 99). Repeat this with each of the second-fifth MCPJs.

98 , 99 Feeling for crepitus from flexor tenosynovitis while assessing MCPJ extension (98) and flexion (99)

IPJs

Having just concurrently assessed MCPJ movement while feeling for tenosynovitis, continue
in similar fashion assessing the range of movement of the second-fifth PIFJs and DIPJs, again
feeling for crepitus over the flexor tendon sheath. For each PIPJ, place the left thumb over the
flexor tendon as it crosses the proximal phalanx and with the right hand move the middle
phalanx from extension through to maximal flexion (100). For each DIPJ, place the left
thumb over the flexor tendon, as it crosses the middle phalanx (to detect crepitus), while the
right hand uses the distal phalanx to move the DIPJ from extension through to full flexion.

Now passively pronate the patient's hand again to palpate the IPJs (PIPJs and DIPJs are
examined identically). Place the thumb and index finger of the left hand on the two
posterolateral aspects of each IPJ (between the extensor tendon and the collateral ligaments
on each side; 101). Passively flex and extend the IPJ with the other hand to confirm correct
positioning over the joint line and to feel for any crepitus. Then squeeze on the posterolateral
aspects for joint-line/capsular tenderness and palpate proximally for soft-tissue swelling. If
swelling at this site extends proximally much more than distally, and becomes more tense as
the finger is flexed, it is capsular/synovial in nature.
 100 Assessing range of movement of DIPJ and presence of crepitus from flexor tenosynovitis.
101 Palpation of posterolateral aspects of IPJs

The thumb

Identify the first CMCJ by palpating with one hand while passively moving the thumb
metacarpal with the other (102): feel for crepitus as the range of movement is assessed. Press
firmly for joint-line/capsular tenderness and palpate for any capsular swelling. Next, place the
left thumb and finger over the posterolateral aspects of the thumb MCPJ, while the right hand
passively moves the joint, assessing the range of movement and feeling for crepitus. Having
identified the joint line, press firmly for tenderness (103) and palpate for capsular swelling
(this extends proximally more than distally, and tenses on flexion of the MCPJ). The thumb
IPJ is assessed similarly to the other IPJs.
 102. Palpation of first CMCJ.
103. Palation of thumb MCPJ.

Additional Tests
Stability of small joints
Stability of IPJs is tested by holding the phalanx joint and moving one laterally while the
other is held in position. Normally there is little lateral movement, irrespective of whether the
IPJ is flexed or extended. Stability of MCPJs is tested by forced lateral movement while each
side of the MCPJ is fully flexed (MCPJ collateral ligaments tighten only in flexion - in
extension,they are lax and permit marked lateral movement).

Fixed flexion of IPJ

To determine whether this results from problems with the flexor tendon apparatus or with the
capsule/joint itself, assess the degree of flexion with the proximal joint in full extension
(104). Then flex the proximal joint, relaxing the flexor tendons (105), and again assess the
range of movement in the joint of interest. If there is now more movement than before (106)
it suggests that the flexor tendon apparatus is primarily at fault. If, however, the range of
movement is equally reduced with the proximal joint flexed or extended, it is more likely that
restriction is due to capsular/ joint damage.
104 - 106 Fixed flexion of IPJ (e.g.PIPJ): Assess extension with proximal joint (MCPJ) extended (104); and
then flexed (105). If there is no increase in IPJ extension (105) the joint is probably at fault; if extension
increases (106) the flexor tendon apparatus is responsible.

De Quervain's tenosynovitis
In this condition a localised area of tenderness may be detected in a line along the lateral
border of the distal radius. This may be accompanied by increased temperature and linear
soft-tissue swelling. A useful stress test is to ask the patient to grasp the thumb in the palm
while the examiner cautiously performs passively lateral flexion to the ulnar side (107). This
manoeuvre can be uncomfortable in normal individuals but in de Quervain's tenosynovitis it
causes marked pain (Finkelstein's test).

107. Finkelstein's test.

Carpal tunnel syndrome

The median nerve gives off a sensory branch (supplying skin on the radial side of the palm)
above the wrist before it passes through the carpal tunnel. Compression in the tunnel
therefore causes numbness/dysaesthesia and altered sensation only in the thumb, index and
middle fingers. The patient's symptoms may be reproduced (1) by percussion over the
anterior wrist distal to the proximal skin crease (Tinel's sign), or (2) by asking the patient to
sustain forced flexion of the wrist for at least 1 min (Phalen's test; 108)

108. Phalen's sign.

The median supplies the lateral two lumbricals, opponens pollicis, abductor pollicis brevis
and flexor pollicis brevis ('LOAF'). To determine early weakness, test abductor pollicis brevis
(always median nerve supply) by asking the patient to raise the thumb vertically from a flat
supinated hand against resistance, feeling the muscle as it contracts (109). Later diminution
of thumb opposition power is tested by asking the patient to oppose the thumb and indtex
finger as the examiner tries to pull through the loop with an index finger. Wasting of abductor
brevis and opponens may cause conspicuous hollowing of the outer thenar eminence.

109. Testing abductor pollicis brevis.

Ulnar nerve lesion

Compression is usually at the elbow but may also occur (± combined carpal tunnel syndrome)
at the wrist as the nerve passes through Guyon's canal (formed by the pisohamate ligament
bridging the pisiform and hamate). The ulnar gives off two sensory branches above the wrist
(supplying the palmar and dorsal surfaces of the hand): therefore, compression in Guyon's
canal causes altered sensation only in the little and ring fingers (±small muscle changes).

For early ulnar nerve lesions look for weakness (± wasting) of the first dorsal interosseous:
with the hand flat, ask the patient to abduct the index finger against resistance, comparing one
side with the other. Later weakness of all dorsal interossei and abductor digiti minimi (ulnar
nerve; C8, T1) and all palmar interossei (ulnar nerve; C8, T1) leads to weak abduction and
adduction of the second-fifth fingers. To test these movements the hand must be flat since the
long extensors and flexors act to some extent as abductors and adductors (110). Apart from
resisted active movements, adduction can be tested by trying to remove a strip of paper held
between the patient's adducted fingers. Adductor pollicis brevis is also supplied by the uInar
nerve and may be tested by asking the patient to grasp a piece of paper between the adducted
thumb and index finger: as the examiner attempts to pull the paper away the terminal phalanx
of the thumb will flex due to weakness of the adductor and unopposed pull of the flexor
pollicis longus (Froment's sign: 111, 112).
 110. Testing finger abduction.

111, 112 Froment's sign: (111) positive (thumb flexes); (112) normal (thumb adducts).

Radial nerve lesion

This causes weak wrist dorsiflexion if mild, wrist drop if severe, with wasting of the forearm
muscles. Sensory loss on the dorsum of the hand is minimal.

Summary of Screening Examination

(1) Inspection at rest
(a) Dorsal surface
- Skin, nail changes
- Swelling (joint synovitis, tenosynovitis)
- Deformity
- Wasting
- Attitude
(b) Palmar surface
- Skin changes (erythema, Dupuytren's)
- swelling (tenosynovitis)
- wasting
(c) From side, fingers outstretched
- Tendon rupture, slip
- deformity (volar subluxation of the wrist and MCPJs)
- Wrist swelling (tuck sign)
(2) Inspection during usage
(a) Power grip
(b) Fine precision pinch
(3) Palpation
(a) Increased warmth
(b) Each joint in turn (swelling, joint-line tenderness, crepitus, movement)
- radiocarpal joint
-inferior radioulnar joint
- Second-fifth MCPJs (+ metacarpal squeeze, flexor tendon sheath crepitus
- second-fifth IPJs (+ flexor tendon sheath crepitus)
- Thumb joints: first CMCJ, MCPJ, IPJ
Elbow

 Functional Anatomy
 Symptoms
 Examination
o Inspection at Rest
o Inspection During Movement
o Palpation
 From Behind
 From in Front
 Additional Tests
o Collateral Ligament Stability
o Tests For Nerve Entrapment at Elbow
 Summary of Elbow Examination

The primary role of the elbow is to permit accurate spatial positioning of the hand. The elbow
anchors the strong flexors and extensors of the wrist and hand, and once the shoulder has
grossly directed the arm, elbow movements permit fine adjustment to limb height and length.
In addition, forearm rotation (at elbow and wrist) helps place the hand in the most effective
functional position.

Heavy demands on forearm muscles and poor soft tissue protection make the elbow
particularly prone to enthesopathy and bursitis. Although not uncommonly involved in
inflammatory arthropathies (e.g. rheumatoid), the elbow is an uncommon target site for
arthritis other than haemophilia and syringomyelia-associated Charcot arthropathy. Primary
osteoarthritis is distinctly unusual.

Functional Anatomy
 113 , 114 The elbow joint: (113) anterior view (114) posterior view.

The elbow is a compound joint comprising three articulations: the humeroulnar and
humeroradial joints (permitting flexion/extension) and the proximal radioulnar joint (which,
with the humeroradial and inferior radioulnar joints, permits rotation: 113,114).

The humeroulnar ('trochlea) joint forms a uniaxial hinge between the trochlea of the humerus
and the ulna trochlea notch. When the elbow is fully flexed (about 145°) the longitudinal axes
of the upper arm and forearm are parallel; however, due to the shape of the trochlea, as the
arm extends in the anatomical position (palms forward) the upper arm and forearm form a
valgus 'carrying angle' at the elbow (115). This is wider in females (10-15°) than in males
(5°) and may be increased (cubitus valgus) as a developmental abnormality (e.g. part of
Turner's syndrome).

115. Extension of the elbow, showing 'carrying angle'.

The humeroradial joint is a modified uniaxial hinge (allowing rotation and

flexion/extension), corresponding to a ball and socket between the capitulum of the humerus
and the concave fovea of the radial head: during supination/pronation the radial head revolves
on the capitulum. The superior radioulnar joint comprises the pivot between the proximal
rim of the radial head and the uInar radial notch, together with the cartilage-lined annular
ligament that encircles the radial head. The strong interosseous membrane of the forearm
prevents parallel displacement of the uIna and the radius and transmits longitudinal stresses
from one bone to the other.

The three joints share a common capsule (116, 117). On the radius the capsule extends as the
sacciform recess beneath the annular ligament. Large intracapsular fat pads lie in the three
fossae of the humerus, buttressing against extremes of movement. Stability is afforded by the
shape of the trochlear joint, the annular ligament, and the cord-like radial and fan-shaped
ulnar collateral ligaments (118, 119). The latter, together with flexor carpi ulnaris, form the
cubital tunnel through which the uInar nerve passes.
 116 , 117 Synovial outline of the elbow: (116) posterior view; (117) section through the joint.

118 , 119 Ligaments around the elbow: (118) the three portions of the fan-shaped medial ligament; (119)
the lateral ligament.

The axis of flexion/extension runs through the two epicondyles: muscles in front of this axis
act as flexors, those behind as extensors. Many of the muscles act on several joints - their
action at the elbow varies according to the attitude of neighbouring joints. Principal elbow
flexors (120-122) are the biceps (inserting into the radial tuberosity, thus supinating as well
as flexing: 120), the brachialis (a short pure flexor: 121), and the brachioradialis (a flexor
with the forearm in neutral rotation: 122). The principal elbow extensor is the triceps, joining
the scapula (long head) and humerus (medial, lateral heads) to the olecranon (123). Pronation
is principally via the pronator teres (the anterior interosseous nerve passes between its two
heads) and the pronator quadratus. Although the biceps is the strongest supinator in flexion,
the supinator muscle acts in any flexion/ extension position (in 30% of people the posterior
interosseous nerve passes through the fibrous arcade of Frohse between the two heads of the
supinator and may rarely become compressed 'radial tunnel syndrome' - causing weakness of
the forearm extensors but no sensory loss).
120-122. Principal flexors of the elbow.

123. Principal extensor of the elbow.

Normal active flexion is about 145° from the fully extended position: passive flexion often
achieves another 10-15°. The elbow hyperextends 10° in many normal women (more in the
hypermobility syndrome). Muscular individuals may lack 10° at each end of the range. The
bones and ligaments around the elbow anchor the forearm muscles. The origins of extensores
carpi radialis brevis and longus ('fist clenchers') at the lateral epicondyle (with the
brachioradialis origin just above) are the usual site of pain in 'lateral epicondylitis' (124, 125).
Both muscles are weak elbow flexors but principally extend the wrist, optimising the action
of the flexors in the power grip. The common tendon insertion at the medial epicondyle (for
pronator teres, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris) is, similarly, the
site of pain in 'medial epicondylitis' (126).

124-125. Tendon insertions around the lateral epicondyle.

126. Tendon insertions around the medial epicondyle.

Several bursae, none communicating with the joint, occur around the elbow, the largest being
the superficial olecranon bursa overlying the olecranon prominence.

Symptoms
Pain from the three elbow compartments is usually felt maximally at the elbow, close to its
origin: severe arthropathy may cause radiation of pain down the forearm and, to a lesser
extent, proximally to the upper arm (127). Pain of lateral epicondylitis ('tennis elbow') is
usually maximal close to the epicondyle, radiating down the outer aspect of the forearm
towards the wrist (128): it is particularly marked during power grip with the wrist extended.
Medial epicondylitis (golfer's elbow') causes pain maximum around the medial epicondyle,
radiating down the flexor aspect of the forearm towards the wrist (129). Pain from olecranon
bursitis is well localised, usually showing no clear relationship to passive or resisted elbow
movement: it may be provoked by leaning the elbow on a table, or on flexion at the elbow
when tight clothing is worn.

Four dermatomes cover sensation around the elbow (130). Pain referred from above is
usually ill-defined at the elbow, with the site of maximum intensity elsewhere: it may
originate from glenohumeral or rotator cuff lesions or from root entrapment (C5 or C6; less
commonly, T1 or T2). Pain may refer up towards the elbow from de Quervain's
tenosynovitis, carpal tunnel syndrome or, rarely, severe wrist arthropathy.

127. Site of pain radiation from the elbow joint.

 128. Pain pattern in lateral epicondylitis.
129. Pain pattern in medial epicondylitis.
130. Dermatomes around the elbow.

Examination
Inspect from in front and from behind with the patient's arm hanging by the side; then inspect
during active flexion, extension, and supination/pronation; then palpate.

Inspection at rest

From behind

(131) the most prominent feature is the olecranon process: para-olecranon grooves separate
this from the epicondyles, the medial epicondyle being more prominent than the lateral (the
three bony prominences form a straight line with the elbow extended). From in front the
triangular cubital fossa (132) forms a hollow bounded superiorly by the biceps and its tendon,
medially by the pronator teres and the common flexors, laterally by the brachioradialis, and
the floor comprising the brachialis muscle and tendon (+ joint capsule and supinator). The
fossa contains the brachial artery and veins, the median and musculocutaneous nerves, and,
superficially, the median cubital vein (joining the medially placed basilic to the cephalic
vein).
 131. Surface landmarks of the elbow - posterior view.
132. Surface landmarks of the elbow - anterior view.

With the patient's arms extended by the side, examine from in front and then from behind for
the following:

Skin changes

For example, erythema (confined in bursitis or over the whole joint) and scars: the extensor
aspect is a common site for psoriasis, nodules, and pressure sores (133).

Swelling

Synovial swelling is most apparent over the radial head anteriorly, and over the para-
olecranon grooves posteriorly (medial > lateral): if marked, the whole elbow region may
appear swollen. Olecranon bursitis causes localised smooth swelling around the olecranon
prominence (134): nodules within it may produce a lumpy contour.
 133. Nodules around the elbow.
134. Olecranon bursitis.

Defortmity

In particular, cubitus valgus or varus, and fixed extension (from in front); and posterior
subluxation of the olecranon on the humerus (from behind).

Attitude

A capsular pattern of restriction usually affects flexion more than extension, with supination/
pronation affected last: in the presence of synovitis or effusion the patient is therefore most
comfortable with the elbow positioned in flexion (about 45 - 70°).

Inspection during movement

Ask the patient to bend up the elbow, assessing active flexion and extension for restriction
and presence of stress pain. Then ask the patient to supinate and pronate the hands with the
elbows tucked into the side at 90° flexion (135). If proximal or distal radioulnar (or
humeroradial) joints are compromised, these movements may be painful andlor reduced: the
patient often undertakes a trick manoeuvre, adducting the elbow across the abdomen to rotate
the uinar and thus increase supination (136).
 135 , 136 Supination with flexed elbow: (135) normal; (136) trick manoeuvre (limited supination).

Palpation

1. From behind

Stand behind the patient with their shoulder extended and elbow pointing backwards in mild
flexion. Feel for:

Increased warmth

Pass the back of the hand over the distal upper arm, elbow, and forearm to detect increased
warmth over the para-olecranon grooves and olecranon bursa.

Swelling, tenderness

Synovitis produces palpable soft-tissue swelling in the para-olecranon grooves: firm

palpation at these sites may produce capsular tenderness (137).
Feel for swelling of ofecranon bursitis with the elbow extended: as the arm goes into flexion
the bursa becomes more tense and prominent. A balloon sign will confirm a moderate-to-
large fluid collection. Palpate for nodules along the extensor forearm border.

137. Palpation of the elbow (posterior approach).

Deformity

The landmarks of the medial and lateral epicondyles are easily felt. Place a thumb and two
fingers of one hand over the olecranon, medial epicondyle, and lateral epicondyle. In
extension the three fingers form a straight line, in flexion they form an equilateral triangle
(138, 139). Loss of such symmetry on flexion implies loss of height at the elbow due to
cartilage and bone attrition ('triangle sign').
138 , 139 Normal triangle sign: (138) in flexion, the examiner's fingers form an equilateral triangle; (139) in
extension, the examiner's fingers form a straight line.

Crepitus

Place a finger in each para-olecranon groove to feel for crepitus from the humeroulnar and
humeroradial joint while the patient flexes or extends.

Periarticular structures

On the medial side feel for the ulnar nerve below the epicondyle for thickening and
disproportionate tenderness: this is the most common site for ulnar nerve entrapment. The
medial supracondylar lymph nodes may be palpable if enlarged.

2. From in front

Increased warmth

Again use the back of the hand to feel for increased warmth over the radial head region.

Swelling

Palpate over the radial head for the soft-tissue swelling of synovitis. Occasionally, palpable
anterior synovial extensions may almost fill the cubital fossa (predisposing to partial radial
nerve palsy from pressure on the posterior interosseous nerve).

Proximal radioulnar joint (tenderness, laxity, crepitus, passive movement)

Pressure over the radial head may produce capsular/joint-line tenderness and, if there is
associated joint damage and annular ligament laxity, excessive movement of the radial head
with crepitus. Keeping the thumb over the radial head region, passively supinate and pronate
with the other hand (the thumb is placed over the ulnar styloid region, 140) to detect crepitus
(both joints), assess range of passive movement, and enquire concerning pain.

140. Palpation during pronation/supination.

Passive movement humeroulnar joint

Assess the range of passive flexion and extension (looking for restriction ± stress pain) and
compare with active movements: similar restriction suggests synovitis; a greater passive
range favours a neuromuscular rather than joint cause.

Epicondylar tenderness, resisted active movements

For tennis elbow, palpate for tenderness over the common extensor origin at the lateral
epicondyle: in some cases tenderness is more distal, occurring over the radial head region.
Confirmation is by resisted active wrist extension, which reproduces the pain (141). For
golfer's elbow, palpate for tenderness over the medial epicondyle at the insertion of the wrist
flexor/pronator group (pronator teres, flexor carpi radialis, palmaris longus, flexor carpi
ulnaris). Resisted active wrist flexion with the hand supinated reproduces the pain (142).
 141. Resisted active wrist extension for lateral epicondylitis.
142 Resisted active wrist flexion for medial epicondylitis.

Additional tests
Collateral ligament stability
This may be tested by flexing the patient's elbow to about 20-30° and then holding the elbow
in one hand while applying a progressive varus force (testing the lateral ligament) followed
by a valgus force (medial ligament) on the distal forearm (143), noting any pain or increased
lateral movement.
 143. Testing collateral ligament stability.

Tests for nerve entrapment at elbow

The ulnar is affected more commonly than median or radial nerves. Helpful tests include:

Tinel's sign

Light percussion over the ulnar nerve as it travels through the medial para-olecranon groove
produces tingling in an ulnar distribution in the forearm/hand distal to the point of
compression (144).
 144. Tinel's sign.

Elbow flexion test

The patient holds the elbow in full flexion for 5 min. Tingling in an ulnar distribution again
suggests a cubital tunnel syndrome.

Pinch grip test

The patient attempts to oppose the tips of the index finger and thumb. If the normal tip-to-tip
pinch is replaced by a pulp-to-pulp pinch (145), reflecting impairment of index finger and
thumb flexors, entrapment of the anterior interosseus nerve, as it passes between the two
heads of the pronator teres, is suggested ('anterior interosseous nerve syndrome'). If the
median nerve is compressed just prior to the anterior interosseous division, the flexor carpi
radialis, palmaris longus and flexor digitorum muscles are also weak ('pronator teres
syndrome'). In both cases there is sensory impairment in a median nerve distribution. Rarely,
the median nerve is compressed as it passes (± the brachial artery) beneath the ligament of
Struthers, an anomalous band in 1% of people that runs from a spur on the humerus to the
medial epicondyle; in this case ('humerus supracondylar process syndrome') the pronator
teres is also involved (±vascular, as well as neurological, symptoms).
 145. Pinch grip test.

Summary of elbow examination

(1) Inspection at rest
skin changes
swelling (synovitis, bursitis, nodules)
deformity (valgus, varus, posterior subluxation)
attitude
(2) Inspection during movement
flexion/extension
supination/pronation
(3) Palpation from behind
warmth
para-olecranon grooves
- swelling
- tenderness
- crepitus
- deformity(triangle sign)
- palpable ulnar nerve, enlarged nodes
olecranon region (bursa, nodules)
(4) Palpation from in front
warmth
swelling
radial head (proximal radioulnar joint)
- tenderness
- laxity
- crepitus
passive movements
- supination/pronation
- flexion/extension
peri-epicondylar tenderness
resisted active wrist extension (tennis elbow)
resisted active wrist flexion (golfer's elbow)
5. Shoulder

 Functional Anatomy
 Symptoms
 Examination
o Inspection at Rest
 Inspection From in Front
 Inspection From Behind
o Inspection During Movement
o Palpation
o Resisted Active Movements
o Test for Glenohumeral Instability
 Summary of Shoulder Examination

Functional Anatomy
The shoulder girdle comprises three joints (sternoclavicular, acromioclavicular, and
glenohumeral) and one articulation (scapulothoracic).

The sternoclavicular joint (SCJ) is a saddleshaped synovial joint that connects the medial
clavicle, manubrium sternum, and cartilage of the first rib (146). It is divided into two
cavities by a fibrocartilage disc. The capsule is strengthened by the sternoclavicular (anterior
and posterior) and interclavicular ligaments; the costoclavicular ligament binds the
undersurface of the clavicle to the first rib.

146. The sternoclavicular joint.

The acromioclavicular joint (ACJ) is a plane synovial joint, angled to allow the clavicle to
slide over the acromion (147, 148); a disc is variably present. Stability is due to the
coracoclavicular ligament (comprising lateral 'trapezoid' and medial 'conoid' portions) and the
acromioclavicular ligament. The joint has sensory branches to the suprascapular and long
thoracic nerves.

147 , 148. The acromioclavicular joint, ligaments and glenohumeral capsule.

The glenohumeral joint is a multiaxial, spheroidal synovial joint (149). Its range of
movement, greater than that of any other joint, is permitted at the expense of stability. The
glenoid fossa, though widened by the fibrocartilaginous labrum, is shallow, the capsule is lax
and thin, and there are 110 strong traversing ligaments. Stability primarily depends on the
muscles and conjoining tendons of the rotator cuff (150, 151). Supraspinatus, infraspinatus
and teres minor arise posteriorly on the scapula and insert into the greater tuberosity;
subscapularis arises anteriorly on the scapula and inserts into the lesser tuberosity. The
deltoid and the rotator cuff form a mechanical couple: the rotators stabilise the humerus and
cause the head to 'drop down' into the lower, wider part of the glenoid cavity, converting the
deltoid's upward pull into a powerful abducting force.
 149. The glenohumeral joint (in section).

150 , 151. Rotator cuff muscles.

The joint is protected superiorly by an 'arch' formed by the coracoid process, the acromion,
and the coracoacromial ligament. The lax capsule has a deep inferior fold and two openings
(see 148); one allows the long head of the biceps tendon to enter the bicipital groove (taking
an extension of the synovium with it as its sheath: 152), the other permits an outpouching of
the synovium to act as a bursa for the subscapularis.
 152. Syonvial limits, and extension around the biceps tendon (long head) in the bicipital groove.

A large subacromial bursa permits smooth movement between the rotator cuff and the
undersurface of the acromion: it extends laterally into the subdeltoid bursa. The subacromial
bursa communicates with the joint cavity in some normal individuals: since the supraspinatus
tendon forms the floor of the bursa and the roof of the capsule, any tear of the tendon/cuff is
likely to lead to communication between the two. The subcoracoid bursa, between the
coracoid and the capsule, may be separate or communicate with the subacromial bursa. The
suprascapular nerve supplies the superior and posterior parts of the joint and capsule and
most of the rotator cuff; the axillary nerve supplies the anterior aspect of the joint and
capsule.

The SCJ is commonly affected by major arthropathies (e.g. rheumatoid, osteoarthritis,

seronegative spondyloarthropathy), and is an occasional site for sepsis, particularly in the
immunocompromised. Although it is common to find abnormal signs at the SCJ it is an
uncommon site for symptoms. The ACJ is also often involved in major arthropathies
(particularly osteoarthritis); unlike the SCJ, it is a common source of symptoms. The
glenohumeral joint may be involved in inflammatory arthropathy (e.g. rheumatoid,
seronegative spondyloarthropathies): though an uncommon site for 'primary' osteoarthritis it
is often involved in the subset of pyrophosphate arthropathy in the elderIv. Rotator cuff
injuries are exceedingly common, and the cuff and bursae can be directIv involved in
inflammatory conditions. Because of its close relationships, subacromial bursitis can result
from pathology relating to the rotator cuff, ACJ, or the glenohumeral joint.

The scapulothoracic articulation is of little rheumatological interest. It is a common site of

painless, reproducible grating, or 'clonking': such noises are, in general, abolished by moving
the scapula laterally and merely reflect movement over uneven surfaces.

Symptoms
SCJ pain is usually well localised, with little radiation (153). The ACJ derives from C4 and
produces pain close to its origin, with some radiation to the shoulder tip but no significant
radiation to the arm. All glenohumeral joint structures, including the rotator cuff and the
subacromial bursa, develop from the C5 sclerotome and produce pain maximal at the outer
aspect of the upper arm close to the deltoid insertion; if severe, pain may radiate down the
radial aspect of the forearm to the elbow (rarely to the wrist) and upwards to the shoulder
(rarely to the neck). Such pain will be worsened by shoulder movements. Tendinitis of the
long head of biceps also produces upper arm pain (C5/6).

153. Pain patterns around the shoulder: (a) bicipital tendinitis; (b) acromioclavicular joint; (c)
sternoclavicular joint; (d) glenohumeral joint/rotator cuff/acromial bursitis.

Pain over the superior aspect of the shoulder and the C4/5 distribution (154) may also be
referred from the neck: such pain may involve the whole length of the arm (± the hand), be
worsened by neck movements (and only the extremes of shoulder movements), and be
accompanied by sensory or motor impairment in the limb. Radiation of pain into the arm
associated with numbness, or paraesthesia, suggests compressive neuropathy (e.g. thoracic
outlet syndrome, suprascapular or axillary nerve entrapment). Lesions involving or close to
the diaphragm may cause pain referred to the shoulder tip region, unrelated to shoulder
movement. Myocardial pain may produce variable aching and pain down the arm.
 154. Dermatomes around the shoulder.

Differentiation between glenohumeral-joint and rotator-cuff disease is often suggested by the

history (Table 8). A typical rotator-cuff patient has often performed unaccustomed exercise
with the involved arm (e.g. decorating the ceiling): the patient usually notices nothing at the
time, but the following day complains of upper arm aching as a single regional pain
syndrome. Pain is nonprogressive and is usually noted only during one or two movements of
the arm (e.g. reaching up to a shelf): it is generally more an inconvenience than a major
problem, and uncommonly interferes with sleep. Conversely, though acute monoarthritis of
the glenohumeral joint can occur, arthritis at this site is usually part of an oligo- or
polyarthritis that produces multiple regional pain problems. Pain is often insidious in onset
without an obvious provoking event: it is variable but usually progressive, often keeps the
patient awake, affects several (eventually all) shoulder movernents, and tends to interfere
greatly with simple activities of daily living. Acute subacromial or subdeltoid bursitis is often
characterised by its speed of onset, the patient being unable to abduct the arm within just a
few days.

Table 8. Comparison between typical symptoms arising from rotator cuff lesions and glenohumeral arthritis.

Rotator cuff Glenohumeral arthritis

Pain: Onset Acute Insidious
Pain: Progression Non-progressive Variable, progressive
Movements affected Few Many
Provoking factor Often apparent Absent
Localised problem Usually Uncommonly
Severity ++ ++++

Examination
Inspection at rest
Get the patient standing or seated on a chair or the side of the couch/bed, to permit inspection
from in front and from behind.

Inspection from in front

Look at the SCJ region where the jugular notch above the manubrium is clearly evident
(155). Look for erythema and swelling overlying the medial end of the clavicle: fluid from
the joint will appear as a smooth rounded swelling; irregular swelling is more likely to be
osteophyte. If the SCJ is subluxed the medial end of the clavicle comes anteriorly, medially,
and inferiorly across the sternum, appearing more prominent than usual (comparison between
the two sides is helpful if unilateral). Look along the clavicle for irregularity and bony
swelling (e.g. from an old fracture, Paget's, or a primary or secondary tumour).
 155. Normal surface landmarks (anterior view).

The site of the ACJ may be apparent due to prominence of the lateral end of the clavicle, but
in many subjects this is a flat joint with no surface landmark. Inspection over the approximate
area proximal to the shoulder tip, however, may show erythema or swelling (fluid at this site
is rare and swelling usually reflects osteophyte).

Inspect muscle bulk. All individuals, whatever their age, should have a convex, full deltoid.
Large glenohumeral effusions are uncommon but if present may push anteromedially and
present as a swelling which fills the usual triangular depression bordered superiorly by the
lateral end of the clavicle, laterally by the medial curve of the deltoid, and inferiorly by
pectoralis (156). A large subdeltoid bursa may cause undue prominence of the deltoid
contour. The typical attitude of a patient with glenohumeral arthropathy is for the shoulder to
be held in internal rotation and adduction, with the hand folded across the abdomen as if in a
sling: this is the most comfortable position for minimising intra-articular hypertension
(conversely, when the examiner comes to palpation, the opposite movements - external
rotation and abduction - are the earliest and most severely involved, in terms of pain and
restriction).
 156. Swelling due to right glenohumeral joint effusion.

Inspection from behind

Now go behind the patient and again inspect for muscle bulk on the two sides, looking
particularly at the supraspinatus and the infraspinatus muscles, but also comparing the
trapezius and rhomboid muscle bulk. Glenohumeral lesions commonly cause generalised
wasting of shoulder girdle muscles. Isolated wasting, e.g. of supraspinatus muscle, suggests a
local periarticular lesion. Occasionally, a congenitally underdeveloped, elevated scapula may
be noted (Sprengel's deformity).

Inspection during movement

All individual glenohumeral movements can be examined in turn, comparing one side with
the other; Put to quickly screen for joint and rotator cuff problems ask the patient to perform
two composite active movements (157, 158):

 Place the hands round behind the neck (testing abduction, external rotation, and
flexion of the glenohumeral joint and the supraspinatus, infraspinatus, and teres
minor muscles).
 Take the hands down and round behind the back (testing internal rotation,
abduction and extension of the glenohumeral joint, and principally, the
subscapularis muscle).
 Composite movement testing:157. 'hands behind the head. 158. 'hands behind the back.

If the patient is able to perform both movements without any problem the glenohumeral and
rotator cuff apparatus are probably normal.

However, if the patient has pain or difficulty with these actions, look for a painful arc. For
this, ask the patient to raise the arm slowly through 180° towards the ceiling, and then slowly
to lower it again. This is a composite movement (159), the initial 90° representing
glenohumeral abduction, the next 70° being principally scapula rotation, and the final 20°
being further glenohurneral movement. During the latter-half of this composite movement the
SCJ and ACJ are also moving, and many people also tend to rotate their arm. Two principal
patterns of painful arc may be observed: painful middle arc and superior painful arc.
 159. Painful arc patterns: (a) middle arc (supraspinatus/subacromial bursitis); (b) superior arc (ACJ).

1. Painful middle arc

The patient experiences pain when the hand gets within the central 30° or so of the painful
arc (i.e. around the end of initial glenohumeral abduction). In this situation the greater
tuberosity of the humerus rises relative to the acromion and can squeeze the intervening
structures (supraspinatus tendon and subacromial bursa). As the arm is further elevated the
greater tuberosity drops relative to the acromion and relieves the pressure. This arc is
characteristic of a supraspinatus lesion or subacromial bursitis. Supination of the hand may
decrease impingement of the humerus on the acromion and reduce or eliminate the pain in the
middle arc.

2. Superior painful arc

Pain occurs at the top 20-30° of the arc. This is when there is maximal stress on the ACJ,
suggesting a lesion of that joint.

Occasionally, patients with supraspinatus lesions have no painful arc on moving their arm
upwards, but on slowly lowering the arm they experience a painful catching sensation in the
middle-arc range, which causes them to quickly drop the arm to their side. The patient should
therefore be asked to take the arm slowly up and down.

Palpation
Palpation is best conducted from behind. With the patient seated, the standing examiner is in
an ideal position. A typical procedure is as follows:

To palpate the SCJ identify the manubrial notch, then take the fingers laterally to the medial
end of the clavicle. Having found the approximate position ask the patient to move the joint
by shrugging the shoulders upwards (160). This will allow the examiner to:

 Confirm the position of the joint.

 Feel for crepitus.
 Feel for subluxation (shrugging exaggerates subluxation and the examiner may
feel the medial end of the clavicle push his fingers anteriorly, inferiorly, and
medially across the front of the manubrium).

160. Palpation of SCJ as patient shrugs

Having found the SCJ press firmly for joint tenderness. Palpate for swelling to determine
whether it is soft or bony (bony osteophyte is the most common cause of swelling). If the
swelling is soft, look for a balloon sign by placing two fingers of one hand at opposite limits
of the swelling and pressing with the other hand over its centre. Pass the back of the hand
over the joint and with the same sweep continue over the clavicle and the ACJ to determine
increased temperature at each site. Palpate along the clavicle for any obvious localised
tenderness and then come to the ACJ.

The site of the ACJ may be visible if the distal end of the clavicle is prominent. However, if
unsure, feel the outermost bony contour at the shoulder tip (i.e. the coracoid as it slopes
posteriorly) and palpate approximately two fingers' breadth in from that site (this
approximates to the joint line in adults). With the fingers in the approximate joint position ask
the patient to move the joint by shrugging the shoulder or abducting the arm. This allows the
examiner to:
  Localise the correct joint site.
 Feel for crepitus.

Having found the joint line, press on it for tenderness (161) and palpate for soft or bony
swelling (the latter, resulting from osteophyte, is again most common). If the swelling is soft,
look for a balloon sign (rarely present). If the ACJ appears to be the main problem, forced
adduction of the arm across the front of the patient's chest stresses the joint and may
reproduce the pain (this movement is not painful in glenohumeral disease).

The glenohumeral joint is well protected from the examiner's hands by the partially encircling
rotator cuff, the acromion superiorly, and the overlying deltoid. The anterior part of the joint
is the most accessible for palpation. Start by palpating the anterior triangular region just
inferior to the clavicle at the medial border of the deltoid: if there is any soft-tissue fullness
(suggesting a glenohumeral effusion) press firmly and then release to see if fluid refills the
swelling. Move the palpating finger laterally from this position to identify the forward-
pointing coracoid process. Taking the finger further laterally (between the coracoid process
medially and the humeral head laterally: 162) push firmly upwards and backwards to elicit
any anterior joint-line/capsular tenderness (often marked in glenohumeral arthritis and
'capsulitis').

161. Palpation of ACJ.

162. Palpation for anterior glenohumeral joint-line tenderness.

Keep the fingers over the anterior joint line to feel for crepitus while the glenohumeral joint is
now moved. Since abduction and external rotation are the movements affected earliest and
maximally by glenohumeral disease they are good screening movements to test. First, locate
the blade of the scapula and place the thumb and finger either side of its lower limit so that
any scapula movement can be identified. With one hand palpating for crepitus over the
anterior joint line and the other holding onto the scapula (163), ask the patient to slowly take
the arm out in abduction and assess the range of movement (normally 80-90°). If there is
glenohumeral restriction the examiner will feel the scapular move early before the arm has
got to 90° the patient often performs a trick manoeuvre, with hunching of the shoulder up
towards the ear. If active abduction is painful, determine whether this is in a stress-pain
pattern (progressive pain towards the limit of restricted abduction). If pain or restriction of
active abduction is present, rest one hand on top of the spine of the scapula (to assess scapula
movement) and passively abduct the arm with the other hand to determine the extent of
passive glenohurneral abduction (164). In glenohumeral/capsular disease, active and passive
findings will be similar for both pain and degree of restriction. If, however, passive
movement is far greater and less painful than active movement, a muscle/tendon (or nerve)
lesion is more likely.

163. Position of hands while testing active abduction at the glenohumeral joint
164. Passive abduction at the glenohumeral joint.

While still behind the patient, palpate the anterior part of the humeral head, while passively
internally and externally rotating the arm. The stationary palpating finger should feel greater
(lateral) and lesser (medial) tuberosities passing to and fro underneath. Having identified the
two tuberosities, palpate firmly up and down in a line between them, over the biceps tendon
(165): this may reproduce the patient's pain if bicipital tendinitis is present.
 165. Palpating for tenderness over the biceps tendon.

Tenderness of the rotator cuff and subacromial bursa can also be sought while the examiner
stands behind the patient. The cuff is protected beneath the acromion while the patient's arm
is by the side. If the patient places the hand onto the opposite shoulder, however, this
produces posterior rotation of the humeral head and will partly bring the rotator cuff from
underneath the protective cover of the acromion. Palpation just below the posterior aspect of
the acromion may then elicit tenderness of the posterior part of the rotator cuff (166).
Similarly, if the patient places the hand round behind the back, this causes anterior movement
of the humeral head and brings the anterior part of the cuff from beneath the acromion.
Palpation just in front of the acromion will then elicit tenderness of the anterior part of the
cuff (167). Palpation below the lateral part of the acromion may occasionally produce
tenderness in subacromial/subdeltoid bursitis. Palpation directly over the supraspinatus and
infraspinatus may produce tenderness in lesions of these muscles.
166. Palpation for tenderness of the posterior aspect of the rotator cuff. 167 Palpation for tenderness of the
anterior aspect of the rotator cuff.

Resisted active movements

Resisted active movements are used to detect rotator cuff lesions. Sit alongside the patient
and place the patient's elbow at their side with the elbow at 90° and the hand pointing
forwards with clenched fist and thumb upwards. The following movements are then tested:

 Resisted active abduction. Abduction is a strong movement and the examiner

should place his arm around the patient and hold onto the other shoulder while
the patient is asked to push their elbow outwards against the examiner's hand
(168). Supraspinatus initiates abduction and with lesions of the muscle or tendon
this attempted movement will reproduce pain in the upper arm (away from the
examiner's restraining hand). If the patient had a painful middle arc and resisted
active abduction reproduces pain then a supraspinatus lesion is the likely cause of
pain. If, however, they have a painful middle arc and resisted active abduction is
pain-free then the likely problem is subacromial bursitis (resisted active
abduction does nothing to the subacromial bursa).
 Resisted active external rotation. Steady the patient's elbow at their side with one
hand (to prevent any abduction) and ask the patient to push the hand outwards
against the examiner's other restraining hand (169). Pain experienced in the upper
arm suggests an infraspinatus/teres minor lesion.
 Resisted internal rotation. Again, steady the patient's elbow at their side and ask
them to push the hand inwards against the examiner's restraining other hand
 (170). Pain experienced in the upper arm suggests a subscapularis muscle/tendon
lesion.

168. Resisted active abduction.

169. Resisted active external rotation.

Weakness of any of these movements may result from pain, partial or complete tears of the
cuff, or from neurological abnormality (if power is restored following injection of a local
anaesthetic into the subacromial space, pain inhibition rather than rupture is implied).

Bicipital tendinitis is also tested by resisted active movement (171). With the patient's arm in
the same position as for rotator cuff testing, hold onto the patient's clenched fist with both
hands and ask the patient to turn the wrist outwards in supination. This is a very strong
movement and the examiner can observe the biceps tensing up: upper arm pain will be
reproduced with bicipital tendinitis. If the patient has ruptured the tendon of the long head of
biceps, the muscle bulge produced by this manoeuvre will be predominantly in the distal part
of the upper arm, producing a larger, more localised, swelling than usual.
 170. Resisted active internal rotation.
171. Resisted supination for bicipital tendinitis.

Test for glenohumeral instability

These are particularly important in the younger patient with a history suggestive of
subluxation/dislocation (sometimes as part of generalised hypermobility). Stability should be
tested in anterior, posterior, and inferior directions.

With the patient standing, and the arm hanging relaxed by their side, fix the scapula and
shoulder girdle from behind with one hand while gripping the top of the humerus with the
other (172): move the humeral head backwards and forwards in the glenoid fossa, noting the
degree of movement and any palpable clicks which may signify labral pathology.
 172. Testing for anterior and posterior instability.

Next, position the patient with their shoulder abducted to 90° and the elbow flexed (173).
Gently, passively extend and externally rotate the glenohumeral joint: a positive test for
anterior instability is when the patient experiences apprehension as an external rotation force
is applied.

173. 'Apprehension Test'.

A more controlled method involves the patient lying supine, with the shoulder at the edge of
the couch. Support the arm with one hand while fixing the scapula/girdle firmly with the
other: move the humeral head anteriorly, posteriorly, and inferiorly using direct pressure.
Pain may be reproduced at the limits of movement. If there is significant inferior subluxation
a distinct gap may be felt between the humerus and the acromion. As in the apprehension test,
position the arm in abduction and external rotation until the patient experiences discomfort:
backward pressure on the upper humerus (i.e. anterior glenohumeral support) may now
relieve the patient's pain and permit further passive external rotation. If the stabilising force to
the upper arm is then removed, the patient may again experience pain if anterior instability is
present. Flexion of the arm in this position, with gentle axial pressure, can be used to
demonstrate posterior subluxation.

Summary of shoulder examination

(1) Inspection at rest
from in front (skin changes, swelling, wasting, attitude)
from behind (wasting, Sprengel's deformity)
(2) Inspection during movement
'hands behind head', 'hands behind back'
painful arc
(3) Palpation
SCJ (crepitus, subluxation, tenderness, swelling, warmth)
ACJ (crepitus, tenderness, swelling, warmth)
glenohumeral joint:
- effusion
- anterior joint-line/capsular tenderness
- active abduction (restriction, pain, crepitus)
- passive abduction (restriction, pain)
periarticular tenderness (biceps tendon, rotator cuff, muscles, bursae)
(4) Resisted active movements (weakness, pain)
abduction (supraspinatus)
external rotation (infraspinatus, teres minor)
internal rotation (subscapularis)
wrist supination (biceps)
6. Spine and Sacroiliac Joints

 Pain and Pain Syndromes

o 'Mechanical' spinal pain
o Nerve root entrapment
o Lumbar canal stenosis
o 'Inflammatory' neck or back pain
o Sacroiliac pain
o 'Bony pain'
o Referred pain
 Examination of the Spine
o Inspection of the standing patient
 Loss of normal curves (cervical and lumbar lordosis, thoracic
kyphosis)
 Scoliosis
 Reduced chest movement
 Paraspinal muscle spasm
 Skin changes
o Inspection of the walking patient
o Inspection during movement
o Palpation
o Examination of the SIJ
o Neurological aspects
o Examination of other systems
o Additional tests/procedures
 Summary of examination of spine

The unique structure of the vertebral column serves to protect the spinal cord, accompanying
vessels, and viscera, and to allow controlled movement of the back, neck and head. The
normal balanced spinal curves (cervical and lumbar lordosis, thoracic and sacral kyphosis;
174) help maintain an upright posture with minimal muscular effort and, together with the
resilience of the intervertebral discs, facilitate impact loading through the spine.
 174. Spinal vertebrae and curvatures.

The vertebrae from C3 to L5 have a common pattern of an anterior vertebral body and a
posterior neural arch (175-177). The arch comprises three processes, two lateral (transverse)
and one posterior (spinous), that are primarily adapted for muscle attachment, and a synovial
facet or apophyseal joints above and below, for articulation with adjacent arches. The bodies
and their separating discs are the main weight-bearing portions, body size increasing from C2
to the first sacral segment, then decreasing down to the coccyx as body weight transmits to
the pelvis. The sliding apophyseal joints help stabilise the vertebrae, particularly limiting
anterior displacement: varying alignment of their articular surfaces largely determines the
extent and type of movement at different regions. Differences between levels are
superimposed on this basic pattern:

 Cervical vertebrae have foramina in the transverse processes for vertebral

arteries, and superolateral ridges (uncal processes) for the joints of Luschka
(these increase lateral stability while facilitating free motion between vertebrae).
  Thoracic vertebrae have long transverse processes directed posteriorly; articular
facets for ribs occur on their tips and on the posterior corners of the bodies.
 Lumbar vertebrae have facet joints orientated in the saggital plane.

175-177 Vertebral configuration at different levels:(175) cervical; (176) thoracic; (177) lumbar.

The atlas (Cl) and the axis (C2) are unique (178, 179), the axis having the odontoid peg, and
the atlas being a ring that receives the odontoid peg anteriorly, held in place by the transverse
ligament. No disc exists between the atlas and the axis (or occiput and atlas), the axis
articulating with the atlas through midline and paired lateral synovial joints. The midline joint
has two synovial cavities that extend between the peg and anterior arch of the atlas, and
between the peg and transverse ligament: synovitis here may damage the peg and ligament,
leading to Cl/C2 instability and cord damage.

178-179 : Atlas (178) and axis (179) viewed from above.

Intervertebral discs (IVDs) are complex symphyses comprising about 25% of the total height
of the spine. Each consists of two zones (180, 18l):

 The outermost fibrocartilaginous annulus fibrosus, with concentrically arranged

fibres (kept under tension by the nucleus), firm attachment to the vertebral
bodies, and innervation to its outer layer. The interwoven concentric fibre
arrangement affords great tensile strength while facilitating torsional movements.
 The central mucoid nucleus pulposus, containing a high proportion of water,
permitting shape (but not volume) change in response to compressive force. Loss
of spinal height with age largely results from decrease in water content of the
nucleus (from about 90% in youth to 65% in old age: associated decrease in
turgor slackens tension in the annulus, predisposing to tears).

180-181 Intervertebral disc structure: (180) disc viewed from above, showing concentric fibre
arrangement;(181) saggital section.

IVD height (and movement between vertebrae) is greatest in the cervical and lumbar regions,
and their anteroposterior asymmetry largely determines the normal spinal curves. Posture has
a profound effect on intra-disc pressure, particularly at the lumbosacral junction where
forward flexion associates with the highest increase. The lumbosacral junction is the point of
transition between movable and immovable parts of the spine: the spine can act as a lever on
the pelvis at this point (this, together with the marked angulation between L4, L5, and S1,
makes it a common site for spondylolisthesis). Particularly vulnerable to mechanical stress,
the lumbosacral region is also a common site for congenital anomalies of the vertebrae and
abnormalities of the IVDs.

The spine is stabilised by numerous strong ligaments (182). The posterior and anterior
longitudinal ligaments run the length of the spine attaching to discs (particularly the posterior
ligament) and vertebral bodies (especially the stronger anterior ligament): they act to restrict
flexion and extension and protect the discs. There are also ligaments between adjacent
vertebral arches (ligamenta flava), transverse processes (intertransverse ligaments) and
spinous processes (interspinous and supraspinous ligaments).

182. Principal ligaments attached to vertebrae.

The large superficial muscles of the back (trapezius, latissimus dorsi) largely cover the deeper
lavers of intrinsic muscles within the lumbodorsal fascia. The numerous deep longitudinal
muscles join adjacent segments and span several segments. The longest and strongest
extensors are the erector spinae (sacrospinalis), which run either side of the spinous
processes, from the sacrum to the skull; they are most developed in the lumbar region. The
supra and infra hvoid muscles assist in neck flexion; the pectorlis minor and major assist
thoracic flexion; and most lumbar flexion is by the paired rectus abdominae, assisted by
muscles attached to the anterior vertebrae (quadratus lumborum, iliopsoas). Lateral flexion
and rotation is achieved by the oblique abdominal muscles. The neck has a complex system
of musculature that enables fine movements to be accurately controlled.

Movement of occipital condyles on the atlas produces discrete nodding (about 30% and the
atlanto-axial joint permits discrete rotation (about 30°) of the head. Below the craniocervical
junction, movement involves distortion of IVDs and sliding movements of the facet joints.
Flexion and extension is mainly at the low cervical and low lumbar spine, lateral flexion is
greatest in the neck, and rotation greatest in the lower thoracic spine.
The variable sacroiliac joints (SIJs) lie between the wedge-shaped sacrum and the medial
aspect of each ilium (183, 184). Fibrocartilage covers the iliac side, and thicker hyaline
cartilage the sacral side. The lower portion of each SIJ is aligned in an anteroposterior plane,
but the upper portion is oblique, with the ilia extending beyond the lateral aspect of the
sacrurn posteriorly. Viewed from in front, the upper one-third (superior, posterior) is a
fibrous joint (syndesmosis), while the lower two-thirds (anterior, inferior) is synovial. The
bones are bound by ventral and dorsal interosseous, sacrotuberous, sacrospinous and
iliolumbar ligaments and, except in pregnancy (and childhood), there is no movement.

183-184: The sacroiliac joints viewed from in front (183) and in transverse section(184).

Basic neurological aspects require consideration in respect of the spine. The narrow, rigid
confines of the spinal canal and emerging foramina may cause problems relating to root or,
less commonly, cord compression. The cervical cord is widest and most susceptible to
compression; it is also vulnerable to damage by atlanto-axial subluxation. The lumbar cord
ends opposite the L1/2 disc space, so lower lesions cause root syndromes only. Nerve roots
are most vulnerable as they emerge from their dural sheaths, just after leaving the exit
foramina: they lie in the immediate path of a prolapsing lateral disc. In the lumbar spine such
prolapse compresses the lower emerging root. Cervical roots Cl-C7 emerge over the top of
their respective vertebra, but the C8 root emerges below C7 and above T1 (giving eight
cervical roots but only seven vertebrae). Below T1 all roots emerge below their respective
vertebrae. Movements and their root supplies are shown in 185 and 186; dermatomes are
shown in 187 and 188.
185. Upper limb movements and their root supply.

186. Lower limb movements and their root supply.

 187-188: Dermatomes of the upper (187) and lower (188) limb.

Upright posture is still a relatively recent evolutionary development. As a result of high

mechanical stresses through the spine (amplified by poor posture and muscle tone, and
obesity), sprain injuries of ligaments, entheses, and muscles are particularly common.
Apophyseal joint osteoarthritis and degenerative disc disease are also common, especially at
the mobile, stressed lower cervical and lower lumbar regions: root syndromes, caused by
pressure from extruded disc material or bony encroachment (particularly apophyseal joint
osteophyte) also predominate here. Less commonly, spinal joints and entheses are target sites
for inflammatory disease (especially, seronegative spondyloarthropathy), and bone
involvement by malignancy or sepsis may also occur.

Pain and Pain Syndromes

Innervation of apophyseal joints, outer annulus, longitudinal and short ligaments, and spinal
dura is ultimately shared by the same spinal nerve, with considerable overlap between
segments. Pain from spinal locomotor structures is thus poorly defined, with radiation over a
wide area (which includes, potentially, the head, thorax, abdomen, and the upper or lower
limb). The differential diagnosis of spinal syndromes may therefore be wide and embrace
other systems.

'Mechanical' spinal pain

This heterogeneous group is by far the most common problem encountered. The pain is
predominantly axial (unilateral, bilateral, or central) but may radiate into proximal or even
distal limbs in an ill-defined, non-dermatomal pattern. It may be made worse by movement
(usually in one plane) or prolonged standing or lifting, and is usually relieved by rest. On
examination there may be painful restriction of movement in one direction more than
another; a localised site of maximal tenderness (reproducing the pain); 'referred' tenderness
and spasm of paraspinal muscles; and absence of neurological signs. In many cases,
anatomical localisation is difficult and no specific title can be given; in some cases, however,
localised tenderness may permit labelling in anatomical terms (189).

189. Pain patterns in (a) quadratus lumborum and (b) iliolumbar syndromes.

Nerve root entrapment

Symptoms may be three-fold:

 Axial or unilateral proximal girdle pain from unilateral compression and tension
of the dura mater.
 Root pain along part or all of the dermatome (variable between individuals) from
pressure on dural sheath.
 Weakness, paraesthesiae and numbness due to nerve root (parenchymal)
compression

Root pain may occur on its own or be superimposed or follow mechanical back pain. It is
characteristically sharp and shooting, and made worse by movement and increased intrathecal
pressure (coughing, sneezing, straining at stool). Examination may reveal neurological signs
(altered sensation, reduced power, reduced reflex) consistent with single root involvement.

Lumbar canal stenosis

This causes symptoms typical of low 'mechanical' back pain, except that:

 Paraesthesiae (non-dermatomal) occurs in one or both legs.

 Although symptoms worsen on activity, they may be absent or improve when the
lumbar spine flexes forward, increasing the diameter of the canal (walking up
steep inclines is better than down, cycling may cause no problems). The patient
may adopt a 'simian' posture for this reason (hips, knees, lumbar spine slightly
flexed).
 Neurological signs (decreased sensation, reflexes) may be present, though these
may occur only after exercise.
'Inflammatory' neck or back pain
This is characterised by diffuse axial pain and stiffness, worsened by rest, but improved by
continuing exercise (initial movement may worsen it). Early morning and inactivity stiffness
may be marked. Examination shows diffuse, symmetrical tenderness and muscle spasm, and
restriction of movement in several or all directions. It may accompany sacroiliac symptoms
or signs.

Sacroiliac pain
Characterised by diffuse, ill-defined pain in the ipsilateral buttock, radiating down the back of
the leg (190), sacroiliac pain is worsened by stressing the joint, e.g. by running, or by
standing on one leg.

190 SIJ pain.

'Bony pain'
Neck or back pain that is constant, severe, progressive, and present at night is very suggestive
of malignancy or infection.

Referred pain
This may be from proximal locomotor structures (especially glenohumeral, hip joints), the
major viscera, retroperitoneal structures, the urogenital system, or aorta. Associated features
in the history and general examination should suggest the correct diagnosis; the pain shows
no clear relationship to spinal movement; and examination of the spine is predominantly
normal (referred tenderness can occur, but the patient's pain will not be reproduced by
pressure on spinal structures).

Examination of the Spine

The patient should be wearing only loose underwear. Inspect the standing patient from in
front, from the side and from behind; inspect during walking: examine movements; then
undertake palpation and appropriate neurological testing with the patient on a couch.

Inspection of the standing patient

Upper cervical and lumbar spinous processes normally lie deep within the spinal
muscles:spinous processes of C7 ('vertebra prominens') and T1 (even more prominent) are
most readily identified (191), and the thoracic spines are usually well seen, particularly on
bending forward. After T1 the spine of each thoracic vertebra overlies the body of the
vertebra below. The 'dimples of Venus' overlie the posterior iliac spines: a line between them
overlies the S2 spinous process. The iliac crests may be visible (always palpable), and a line
between these overlies the L4/5 interspace. The tip of the coccyx lies in the upper part of the
natal cleft.

191. Normal surface landmarks (posterior view).

Look particularly for the following symptoms.

Loss of normal curves (cervical and lumbar lordosis, thoracic kyphosis)

Forward or lateral angulation of the head is common, resulting from diminished lower
cervical lordosis and compensatory extension at the craniocervical junction: this may cause
prominence of posterior muscles and horizontal skin folds below the occiput. Lateral
angulation with rotation may accompany sternomastoid contracture, and several congenital
abnormalities result in a short neck. If the thoracic spine shows excess forward angulation,
note whether it is a smooth kyphosis (due to multisegment vertebral/ disc disease) or sharply
angulated (localised vertebral damage).

Scoliosis

Its site is represented by the apex of the curve (thoracic, thoracolumbar, or lumbar), its
laterality by the side of the convexity (192). Scoliosis may be compensated (T1 centred over
sacrum) or uncompensated (a perpendicular from T1 lying outside the sacrum). Postural
scoliosis (no intrinsic bony abnormality in spine or ribs) resolves as the patient flexes
forwards; by contrast, structural scoliosis persists or is accentuated by flexion. With thoracic
scoliosis, rotation of vertebrae may produce a hump or 'gibbus' of the ribs on the convex side.
Pelvic tilt (iliac crests at different heights ± asymmetry of gluteal folds) may accompany
scoliosis or relate to leg shortening, or to hip or other lower limb arthropathy. 'Sciatic'
scoliosis resulting from spinal pain is postural and usually mild.

192. Scoliosis (right thoracic).

Reduced chest movement

Usually resulting from intrathoracic disease, reduced chest movement may also occur with
arthropathy. If expansion appears reduced, measure from full expiration to full inspiration at
the nipple line, with the patient's arms on or behind their head (normally 4 cm or more in the
adult male).

Paraspinal muscle spasm

The muscles look as though they are bulging out alongside the spinous processes. Spasm may
be unilateral or bilateral, and may associate with spasm of ipsilateral buttock muscles
(especially with sciatic pain due to disc prolapse).

Skin changes

Moles, vascular malformations, and hairy tufts may indicate the site of underlying congenital
abnormalities of vertebral bodies. Note any scars or nodules (most common over the bony
prominences).

Inspection of the walking patient

With low-back problems the pelvis may not rotate fully with the advancing leg, remaining
mainly aligned with the thorax. This gives a shortened step, jerkiness of movement, and
considerable caution and awkwardness when turning. SIJ pain may be worsened by weight
bearing and is particularly provoked by standing on one (the ipsilateral) leg.

Inspection during movement

As far as possible it is best to isolate movements at different segments. Look for any
asymmetry, restriction, or pain on movement.

Lumbar movements

With the patient still standing, the examiner places the fingers of one hand over consecutive
lumbar spinous processes and asks the patient to bend forward to touch the toes (this also
involves hip flexion). The lumbar lordosis should be replaced by a smooth curve, the degree
of movement indicated by separation of the examiner's fingers (193). If present, observe any
change in scoliosis. Then, stabilising the pelvis firmly with both hands, ask the patient to
bend backwards (extension; 194), and then slide their hand down each leg (lateral flexion -
lumbar and thoracic segments; 195).
193. Thoracolumbar flexion.

194. Extension;
195. Lateral flexion.
Thoracolumbar rotation and cervical movements

For these, fix the shoulder girdles to the trunk by getting the patient to clasp their arms across
their chest, and fix the pelvis by firmly holding each iliac crest (with the patient's feet apart)
or, preferably, by seating the patient astride a chair. Ask the patient to turn round as far as
possible to each side (rotation - mainly thoracic, 196). Then, holding the patient's 'fixed'
shoulders, ask the patient to put their chin on their chest (flexion, 197), look up in the air
(extension, 198), look round to each side (rotation, 199), and then put each ear over onto the
shoulder (lateral flexion, 200). During lateral flexion, pain felt on the side to which the head
moves suggests facet joint disease, whereas pain on the opposite side is more likely muscle
spasm.

196. Rotation.
197-198: Cervical flexion (197) and extension (198).
 199-200: Cervical rotation (199) and cervical lateral flexion (200).

Palpation
Lay the patient face down on the couch, relaxed with arms folded underneath. For palpation
of the neck, place a pillow under the upper chest; for the thoracic and lumbar spine, move the
pillow under the abdomen - this helps to relax the muscles, supports the spine in flexion, and
aids separation of the spinous processes (201, 202).

201-202: Position for palpation of (201) back and (201) neck.

Palpate in turn the following areas:

 Skin and subcutaneous tissues. Palpate in a line down each side of the trunk. Use
a 'skin rolling' technique (203), to look for areas of hyperaesthesiae. This is a
useful but poor localising sign suggesting possible pathology in the nearby region
of the spine (analogous to generalised abdominal tenderness with appendicitis).
 The paraspinal muscles. Feel for increased tone and tenderness on one or both
sides (204). This again is a poor localising sign
 The interspinous ligaments. Apply firm pressure over each in turn (205).
Tenderness with reproduction of the patient's pain suggests local ligamentous or
 disc disease. Other abnormalities to note during palpation include defects in the
spinous processes (spina bifida occulta), or a 'step' deformity of spondylolisthesis
(usually L4/5) or retrolisthesis (more common in the cervical spine).
 The facet joints. Applying firm, jarring pressure with each thumb just lateral to
the spinous process (206) may cause pain relating to local facet joint, disc, or
ligament lesions.
 Mid-trapezius. This is palpated for hyperalgesia of fibromyalgia syndrome.
 The medial iliac crest. This is a common site of tenderness, with reproduction of
the patient's pain ('iliolumbar' or 'iliac crest syndrome').

203-204: 'Skin rolling' for hyperaesthesia (203); Palpation of paraspinal muscles (204).
 205-206: Palpation of interspinous processes (205); Palpation for facet joint tenderness (206).

Examination of the SIJ

The SIJ, which is inaccessible to palpation, is difficult to assess clinically. Only florid
inflammation or damage to the fibrous portion is likely to result in local tenderness
posteriorly (most such tenderness is probably ligamentous). Tests designed to stress the SIJs
and reproduce pain in the buttock are non-specific and include:

 Distraction tests. Firm downward pressure over both sides of the pelvis with the
patient lying supine (207), or over the pelvis with the patient lying on one side
(208).
 'Knee- to-shoulder' test (209). With the patient lying flat, flex and adduct one hip
and push the flexed knee towards the opposite shoulder, stressing the ipsilateral
SIJ. This test is helpful only if the hip and lumbar spine are normal.
207-208: SIJ distraction tests: (207) Patient supine; (208) patient on side.
 209.: Knee-to-shoulder test.

Neurological aspects

Provocation tests for root lesions

Numerous named tests exist, all using manoeuvres to distract roots or increase intrathecal
pressure and thus reproduce the patient's symptoms.

Straight leg raising (SLR, Lasègue's test)

The most common test used. With the patient lying flat on the back and completely relaxed,
slowly raise the straightened leg on the affected side by 70°, maintaining full extension at the
knee, until the patient complains of pain or tightness down the leg (210-212). Note the angle
of elevation, then drop the leg back slightly to eliminate the pain. Now ask the patient to flex
the neck by putting the chin on the chest, or passively dorsiflex the raised foot. Reproduction
of pain by either action indicates stretching of the dura (a central prolapse often causing back
> leg pain, a lateral prolapse the reverse); SLR pain not reproduced by these actions suggests
hamstring pain (mainly posterior thigh) or lumbar or sacroiliac pain (felt more in the back
than the leg).
210-212: SLR test: (210) elevate to cause pain; (211) lower the leg, then dorsiflex the foot; or (212) flex the
head.
During elevation of the leg from 0 to 40°, there is no traction on the roots but 'slack' in the
sciatic arborisation is taken up; between 40 and 70°, there is tension applied to the roots
(mainly L5, S1, and S2); above 70°, no further root deformation occurs, and any pain after
this elevation is probably articular. Compare both legs for any difference. Reproduction of
pain in the affected side by elevation of the opposite leg (cross-over sign' or 'well leg raise
test) indicates thecal compression by an often large lesion medial to the nerve root (disc or
tumour). If both legs are raised together ('bilateral SLR'), little distortion of nerve roots
occurs; pain appearing before 70° probably arises from SIJs, pain beyond 70° from the
lumbar spine (213).

213-214: Bilateral SLR (213) ; Femoral nerve stretch test (214).

Femoral nerve stretch test

This produces traction on the L2, L3, and L4 nerve roots. Lay the patient on the unaffected
side with the affected hip and knee slightly flexed, the back straight and the head flexed.
Gently extend the hip and increase knee flexion; pain down the anterior thigh indicates a
positive test (214). As with SLR, a contralateral positive test may also occur.

Neurological examination for root abnormality

The principal abnormalities of sensation, power, and reflexes accompanying individual root
lesions are summarised in Tables 9 and 10.

Examination for cord signs

A spastic gait, lower limb ataxia, increased reflexes, and extensor plantar responses (i.e.
upper motor neurone signs) indicate pressure or damage to the cord, the level being
determined principally by the division between normal and abnormal reflexes and the level of
any accompanying lower neurone signs.

Table 9. Principal cervical root syndromes (affected dermatomes, myotomes, and reflexes).

Root Sensation Weakness Reflex

C5 Lateral upper arm Shoulder abduction Biceps
C6 Lateral forearm Elbow flexion, wrist extension Brachioradialis
C7 Middle finger Elbow extension, wrist flexion Triceps
C8 Medial forearm Thumb extension, ulnar deviation of wrist -
T1 Medial elbow region Hand intrinsics, finger ab/adduction -

Table 10. Principal lumbar root syndromes (affected dermatomes, myotomes, and reflexes).

Root Sensation Weakness Reflex

L4 Anterior leg, medial foot Ankle dorsiflexion (tibalis anterior) Knee jerk
Lateral leg/thigh, web of Extension of great toe (ext.hallucis
L5 -
hallux longus)
Ankle
S1 Posterior leg, lateral foot Eversion of foot (peroneals)
jerk

Assessment of power, plantar responses, and sensation may be difficult in patients with
polyarthritis and joint deformity, muscle wasting, and entrapment or peripheral neuropathy.
Upper cervical cord damage due to C1/2 instability in rheumatoid arthritis is a particular
problem: helpful signs in this situation may include positive pectoralis jerks (215; suggesting
a lesion above C4), a normal jaw jerk (implying a lesion below the brainstem), and
diminished/absent corneal reflex (the sensory part of the fifth cranial nerve centre extends
into the upper cervical cord).
 215. Pectoralis jerk.

Examination of other systems

Pain in the spine may be referred, and a thorough assessment of other systems (particularly
the lower bowel and genital tract) may be required in individual cases.

Additional tests/procedures

Measurements of spinal movements

In addition to simply assessing distraction of fingers placed on spinous processes,

thoracolumbar flexion can be estimated by the modified Schober test (216). Get the patient as
flexed as possible (standing or sitting) and, starting from an upper sacral spinous prominence,
mark out three 10cm segments up the spine. Then remeasure the distances between the marks
with the patient erect: the lowest segment should shorten by at least 50%, the middle by 40%,
the upper by 30% (shortening is greater in tall subjects). An alternative is to measure the C7-
T12 and T12-S1 distances erect and then during maximal flexion; the thoracic measurement
should increase 2-3cm, the lumbar distance 7-8 cm.

Other measurements employed include the finger-to-floor distance when the standing patient
attempts to touch the floor with legs straight; and the occiput-to-wall distance, measured with
the patient standing upright, heels back against a wall, eyes level.
 216. Modified Schober test.

Foraminal compression/distraction tests

These may be used for cervical entrapment syndromes, but are rarely positive. Passively
rotate and laterally flex the neck towards the affected side, then carefully press down on the
head; reproduction of pain down the arm or around the scapula region suggests root
entrapment or facet joint disease (foraminal compression test; 217). Conversely, upward
traction on the neck, by lifting with one hand under the chin and the other under the occiput,
may relieve pain due to root compression (distraction test; 218).

217-218 Modified Schober test; (217) Cervical distraction (218).

Milgram's and Hoover's tests

These are used to distinguish 'organic' from 'functional' pain. In Milgram's test the supine
patient performs active bilateral SLR to a height of 6 inches. This greatly increases thecal
pressure and ability to hold this position for any time excludes significant thecal pathology.
In Hoover's test the patient performs unilateral SLR with the examiner's hand under the other
heel; absence of downward heel pressure indicates that the patient is not really trying (219).

219. Hoover's test.

Summary of examination of spine

(1) Inspection of the standing patient
(a) from in front (head angulation, chest expansion)
(b) from the side (spinal curves)
(c) from behind (scoliosis, pelvic tilt, muscles, skin)
(2) Inspection of the walking patient
(3) Inspection during movement (restriction, pain)
(a) standing
flexion - 'touch toes' (± modified Schober test)
- extension
- lateral flexion
(b) preferably sitting astride chair
- thoracolumbar rotation
- cervical flexion, extension, lateral flexion, rotation
(4) Palpation of patient lying on couch
(a) 'skin rolling' each side (hyperaesthesia)
(b) paraspinal muscles (tone, tenderness)
(c) interspinous ligaments (pain)
 (d) facet joint region (pain)
(e) medial iliac crest (tenderness)
(5) Stressing of sacroiliac joints
(a) distraction
(b) knee-to-shoulder test
(6) Provocation tests for root entrapment
(a) straight leg raising each side
(b) bilateral SLR
(c) femoral nerve stretch test
(7) Neurological examination (power, reflexes, sensation)
(8) Detailed examination of other systems as required
7. Hip

 Symptoms
 Examination
o Inspection of the Standing Patient
o Inspection of the Walking Patient
o Inspection of the Patient Lying on a Couch
 Inspection
 Palpation
 Summary of hip examination

The hip is a large ball-and-socket joint that plays a major role in weight bearing, stance and
locomotion (walking, running, jumping, swimming, etc.). It thus needs to permit a wide range
of movement while maintaining great stability. Mobility is aided by the elongated femoral
neck which offsets the shaft from the head, an arrangement which also gives great leverage to
muscles acting at the proximal femur. Stability is due to:

 The powerful muscles acting across the hip.

 The strong fibrous capsule.
 The deep insertion of the femoral head into the acetabulum.

Forces across each hip are often great: for example, standing on both feet (one-third body
weight), standing on one leg (2.5 x body weight), or walking (1. 5 - 6 X body weight). Under
low loads the joint surfaces are incongruous, but under heavy loads they become congruous,
providing maximum surface contact to keep the load/unit area within tolerable limits.

The acetabular cavity is formed at the meeting point of the three bones comprising the
innominate (the ileum, the ischium, and the pubis: 220, 221). It opens outwards, forwards,
and downwards, and is strongest superiorly and posteriorly (where it is subject to greatest
strain in the erect or stooped position). The rim is deepened by the fibrocartilaginous labrum,
which forms a collar around the femoral head, narrowing the outlet and stabilising the head
within the acetabulum. A gap in the lower portion of the labrum, the acetabular notch, is
bridged by the transverse ligament, converting the notch into a foramen through which blood
vessels pass into the joint. The articular cartilage is horseshoe shaped with the open part
pointing inferiorly; a fat mass fills the fossa at the bottom of the acetabulum. Hyaline
cartilage covers the whole of the femoral head except at the attachment of ligamenturn teres,
where there is a small bony defect, the fovea.
 220. Bony contours of the acetabulum. The inset shows the arrangement of the labrum, transverse
ligament, ligamentum, and central fat.

221. Section through the hip joint.

The strong, dense fibrous capsule arises circumferentially from the acetabulum, labrum, and
transverse ligament. It attaches distally to the intertrochanteric line of the femur anteriorly,
and about half-way along the neck posteriorly. It is reinforced in front by the Y-shaped
iliofemoral ligament (the strongest in the body), inferiorly by the pubofemoral ligament, and
posteriorly by the ischiofemoral ligament (222). The ligamentum teres is an intracapsular
ligament that runs from the transverse ligament to the fovea: it has no joint stabilising
function but carries blood vessels which supply a small area of the head around the fovea.
The synovium lines the capsule, labrum and fat pad, and excludes the ligamentum teres;
distally, it reflects onto the femoral neck and extends to the cartilage of the head. The
iliotibial band is part of the fascia lata, extending from its main attachment at the iliac crest to
the lateral tibial tubercle. Clinically relevant bursae (223) around the hip include:

 The large, often multilocular, trochanteric bursa between the greater trochanter
and gluteus maximus.
 The iliopectineal bursa between the anterior capsule and iliopsoas
(communicating with the joint in about 15%).
 The ischiogluteal bursa over the ischial tuberosity, overlying the sciatic nerve.

222-223: Joint capsule and ligaments.(222) Clinically important bursae. (223)

The strong muscles around the hip have complex actions, and hip movements are influenced
by the position of the lumbar spine, the knee, and the opposite hip (e.g. flexion increases if
the knee and spine also flex; extension increases if the knee is extended; abduction increases
if both hips are slightly flexed). The prime movers are:

 Flexors: iliopsoas, (pectineus, rectus femoris) - (L2,3 nerve root supply)

 Extensors: gluteus maximus, hamstrings - (L4,5; S1,2)
 Abductors: gluteus medius, (gluteus minimus) - (L4,5; S1)
 Adductors: adductor longus, magnus, brevis - (L3,4,5; S1)
 Rotation: External: piriformis, obturator,gemelli, gluteus medius - (L4,5; S1)
 Rotation: Internal: gluteus minimus, gluteus medius, tensor fascia latae - (L4,5;
S1)

Important structures adjacent to the joint include the neurovascular bundle ariteriorly, and the
sciatic nerve running close to the posterior aspect. In the adult the hip is an important site of
involvement in osteoarthritis and, less commonly, other major arthropathies: periarticular
lesions (bursitis, enthesopathy) are common. In the neonate and child, congenital dislocation,
Perthes' disease, slipped femoral epiphysis, and sepsis are the principal conditions.

Symptoms
The hip joint is formed largely from the L3 segment. Hip pain is often ill-defined, worsened
by loading and movement (e.g. rising from sitting, standing, walking, putting on socks), and
felt primarily in the anterior groin (224). However, it may radiate widely to the anterior and
lateral aspects of the thigh, the buttock, the anterior aspect of the knee, and rarely down the
front of the shin to above the ankle. Presentation may be with isolated knee pain (the hip and
knee both contribute fibres to the obturator and femoral nerves).

224. Pain distribution in (a) hip disease and (b) trochanteric bursitis.

Because of its wide and variable radiation, hip pain requires differentiation from a number of
0 other local or distant causes, including:

 Sacroiliac pain. This is felt deep in the buttock, with variable radiation down the
posterior thigh. It is often exacerbated by standing on one leg (the affected side:
ch 6, fig.190).
 Bursitis. Trochanteric bursitis causes localised pain and tenderness over the
trochanter, with occasional radiation down the lateral thigh. It is particularly
painful when lying on the affected side (e.g. in bed). Pain from ischiogluteal
bursitis is felt mainly posteriorly and is particularly worsened by sitting.
 Enthesopathy. Adductor enthesopathy ('groin strain') usually follows a sporting
injury and causes pain in the medial groin, worsened by standing on the affected
leg. Abductor enthesopathy produces similar pain to trochanteric bursitis, but is
usually worsened by walking.
  Meralgia paraesthetica. Entrapment neuropathy of the lateral cutaneous nerve of
the thigh (beneath the inguinal ligament) causes burning pain and numbness over
the anterolateral thigh. It may accompany massive or rapid-onset obesity,
pregnancy, and wearing of tight corsets or jeans.
 Root pain. Prolapsed intervertebral discs or lesions involving Ll/L2 nerve roots
(both rare) may produce groin pain (225). Its sharp quality and exacerbation by
straining/coughing (± accompanying back pain) help suggest its nature.
 Symphysitis. This may produce supra-pubic pain and tenderness, worse during
the stance phase of walking.

225. Dermatomes around the hip and thigh.

Examination
The patient, undressed to underwear, is examined standing, walking, and then lying.

Inspection of the Standing Patient

Ask the patient to point to the site of maximum pain and to delineate the area over which pain
is felt. Inspect from in front, the side, and from behind.

Readily identifiable landmarks include the iliac crests, running between the anterior and
posterior superior iliac spines, the greater trochanters, the ischial tuberosities, the gluteal
folds, and the rounded proximal buttock muscles (226)
 226. Anterior and posterior landmarks.

From in front, look particularly for:

 Pelvic tilt - shown by loss of level between the anterior superior iliac spines. This
may be due to adduction or abduction deformity from hip disease, a short leg, or
primary scoliosis.
 Rotational deformity (227) - see whether the feet face forwards to the same
degree.

227. Rotational deformity.

From the side, look particularly for:

 Exaggerated lumbar lordosis - this may indicate a fixed flexion deformity of one
or both hips.

From behind, look particularly for:

 Pelvic tilt (228) - shown by loss of level between the iliac crests, and asymmetry
of the gluteal folds. With fixed adduction, the abnormal side is elevated and the
patient may be unable to place the ipsilateral foot flat on the floor. With an
abduction deformity, the situation is reversed.
 Scoliosis - this often accompanies pelvic tilt.
 Muscle wasting - secondary to hip, primary muscle or neurological disease.

228. Pelvic tilt.

The Trendelenburg test shows up gross weakness of the hip abductors (gluteus medius,
minimus). Ask the patient to lift one foot off the ground (229, 230). Normally, to retain
balance, the abductors on the weight-bearing side contract to elevate the unsupported side. If
the abductors are weak, the pelvis may drop down on the contralateral side: the patient may
lose balance, stumble, and be unable to keep the foot raised. A modification is to stand facing
the patient, providing support by holding the hands; as the foot is raised it is easy to
appreciate the increased load transmitted from the patient with weak abductors. The common
causes of a positive Trendelenburg test are hip disease (unilateral or bilateral), an L5 root
lesion (unilateral), and conditions characterised by generalised weakness (usually bilateral).
 229-230 The Trendelenburg test:(229) normal; (229) abnormal

Inspection of the Walking Patient

Two non-specific gait abnormalities commonly result from hip disease:

 Antalgic gait (see Chapter 2; 231) - usually indicating a painful hip. The patient
shortens stance phase on the affected hip, leaning over the affected side to avoid
painful contraction of the hip abductors.
 Trendelenburg gait ('abductor limp'; 232) - indicating weakness of the abductors
on the affected side. During the stance phase on the affected side, the
contralateral pelvis dips down and the body leans to the unaffected side. If
bilateral, this produces 'waddling gait'.
 231-232 Gait:(231) Analtic; (232) Trendelenburg

Inspection of the Patient Lying on a Couch

The patient, in general, should be lying straight out, as flat as is compatible with
cardiorespiratory function. Ensure that both anterior superior iliac spines are level and the
two legs are aligned.

Inspection

Look particularly for:

 Skin changes (especially scars, inguinal rash).

 Swelling. Swelling of the iliopectineal bursa may occasionally be apparent in the
medial aspect of the groin. The hip joint is deep and swelling is usually not
apparent. Anteromedial swelling extending down the thigh may occur with large
synovial (Baker's) cyst extensions.
 Deformity - particularly fixed flexion, external rotation or abduction deformity
(these often accumulate sequentially as hip disease progresses; 233). With a
severe flexion deformity the patient will be unable to straighten the legs without
sitting up. With fixed adduction the affected leg may cross the other. Rotational
deformities are obvious by looking at the position of the patella and feet on the
two sides. Restricted hip flexion may be compensated by an increase in lumbar
lordosis which then ,masks' the fixed flexion deformity. If fixed flexion is not
readily apparent utilise Thomas' test (234). Flex the other hip to 90° to eliminate
 the lumbar lordosis (confirmed by placing a hand under the patient's lumbar
spine) and watch for flexion of the affected hip.

(233.) Deformities : fixed flexion, external rotation, external rotation, abduction

(234) Thomas' test

 Leg length inequality- apparent by looking at the heels. If there is apparent

discrepancy use a soft tape measure to estimate on each side:
(a) the true leg length - between the anterior superior iliac spine and the medial
malleolus (235). If one leg is flexed or externally rotated the other must be
positioned similarly before measurement. Shortening (> 1 cm) is often due to, but
is not specific to, hip disease.
(b) the apparent leg length - from the medial malleolus to a fixed point on the
trunk (the xiphisternum is more 'fixed' than the umbilicus; in children the
manubriosternal junction is more readily palpable). Inequality most commonly
results from pelvic tilt.
 Attitude - a painful hip with synovitis is most comfortable if held in mild flexion,
abduction, and external rotation. Observe if this is the position the patient keeps
wanting to adopt.
 235. True and apparent leg length.

Palpation

Palpate for tenderness (± swelling) over the following areas:

 With the patient supine, palpate the anterior joint line just lateral to the femoral
artery pulsation, below the middle third of the inguinal ligament (236).
Tenderness here may reflect hip synovitis or iliopectineal bursitis. Bursal
swelling may be palpable and give a positive balloon sign (reflecting localised
bursitis or a synovial cyst communicating with an inflamed joint). Bursal
swelling requires differentiation from other swellings in this region (particularly
femoral hernia - usually medial to the artery). Tenderness over the adductor
origins along the superior or inferior aspect of the pubic bone may reflect
adductor enthesopathy: resisted active adduction (237) may reproduce the pain.
 236. Palpation of anterior joint-line region.
237 Resisted active adduction and site of tenderness in adductor enthesopathy.

 With the patient on their side palpate around the greater trochanter for tenderness
due to trochanteric bursitis or abductor enthesopathy (238). In obese subjects
locate the trochanter by feeling proximally up the femur. Active abduction of the
affected leg (alone or against resistance) may reproduce the pain of abductor
enthesopathy (239), but will not usually worsen bursitis.
 238. Palpation of trochanteric bursitis and abductor enthsopathy.
239 Resisted active abduction.

 With the patient still on their side, flex their knee and hip and feel for the
prominent ischial tuberosity (240). Tenderness here suggests ischiogluteal
bursitis (this is also an infrequent site for rheumatoid nodules).

239. Palpation of ischial tuberosity and ischiogluteal bursitis.

Movements

With the exception of extension, hip movements are best tested with the patient supine. Look
for restriction and presence of pain for each movement in turn.

 Flexion (about 120°). This is tested with the knee flexed to relax the hamstrings
(241).
 241. Hip flexion.

 Abduction (about 45°) and adduction (about 30°). With the patient's legs
extended and the pelvis square, stabilise the pelvis with one hand on the opposite
iliac crest, hold the ankle with the other hand and passively abduct the leg (242).
The hand on the pelvis is to detect when hip abduction finishes (i.e. when the
pelvis starts to move) and further lateral leg movement begins to result from
lateral flexion of the lumbar spine. An alternative method is to 'fix' the pelvis by
keeping the opposite leg fully abducted, either extended along the couch or (with
the knee flexed) draped over the side of the bed (243). For adduction cross the
patient's leg over the other (244).
 242. Hip abduction.

243. Hip abduction with pelvis fixed.

244. Hip adduction.

 Internal and external rotation (about 45° each). Flex the hip and knee to 90° and
move the foot out laterally (internal rotation; 245) and medially (external
rotation; 246). Internal rotation in flexion is the earliest and most constant
movement to be affected by hip disease. Rotation can also be assessed with the
hip extended and che leg straight: roll each leg on the couch, first one way and
then the other, looking at the foot as an indicator of rotation (247, 248)

245-246: Internal (245) and external (246) rotation in flexion.

 247-248: Internal (247) and external (248) rotation with hip extended.

 Extension (about 15°). Thomas' test detects loss of extension (i.e. fixed flexion).
For smaller losses of extension lay the patient prone and attempt to immobilise
the pelvis by downward pressure with one hand (over the sacrum) while
extending the hip with the other hand (under the thigh: 249). If the patient has
difficulty lying prone, lay them on their side and get them to flex the lower leg
and hold it firmly (to stabilise the pelvis); stand behind the patient and support
the upper leg while extending the hip, checking with the other hand over the
lumbosacral junction for any spinal/pelvic movement.

249. Extension assessed in prone position.

Summary of hip examination

(1) Inspection of the standing patient
(a) from in front (pelvic tilt, rotational deformity)
(b) from the side (increased lumbar lordosis)
(c) from behind (pelvic tilt, scoliosis, wasting)
(2) Inspection of the walking patient (antalgic, Trendelenburg gait)
(3) Inspection of the patient lying on a couch
(a) inspection:
- skin
- swelling
- deformity
- Thomas' test (fixed flexion)
- leg length inequality (true + apparent leg length)
(b) palpation:
- anterior joint line
- adductor origins
- greater trochanter (patient on side)
- ischial tuberosity (patient on side)
(c) movements:
- flexion
- abduction, adduction
- internal, external rotation
- extension (patient prone or on side)
8. Knee

 Symptoms
 Inspection
o Inspection of the Standing Patient
 Deformity
 Swelling
o Inspection of the Walking Patient
o Inspection of the Patient Lying on a Couch
 Skin Changes
 Swelling
 Muscle
 Deformity
 Attitude
o Palpation
 Temperature
 Swelling
 Patellofemoral Compartment
 Active Assisted and Passive Movement
 Tibiofemoral compartments
 Periarticular Lesions
 The Popliteal Fossa
 Stability
 Additional Tests For Mechanical Derangement
 Summary of Knee Examination

The knee is the largest synovial joint and contains the largest sesamoid (the patella). The
three compartments (medial and lateral tibiofemoral and patellofemoral) share a common
cavity (250). The suprapatellar synovial reflection (pouch) is more extensive on the medial
aspect and offers little resistance to fluid distension. Posteriorly, in the popliteal fossa, the
synovial cavity is more constrained; its contour is moulded by tendons into convoluted
recesses, the largest of which are the semimembranosus and lateral and medial gastrocnemius
bursae and the subpopliteal recess (all of which communicate with the main cavity).
Noncommunicating bursae also occur, the most important clinically being the prepatellar
bursa, the superficial and deep infrapatellar bursae (251), and the anserine bursa (252).
 250. Knee compartments.

251. Synovial contour and non-communicating bursae.

252. Medial collateral ligament and sites of insertion of sartorius, gracilis and semitendinosus.

The two fibrocartilage menisci (semilunar cartilages) are important load-transmitting

structures (253). The medial meniscus has a thickened outer and thin inner edge; it attaches
centrally to the intercondylar tubercles and medially to the capsule. The lateral meniscus
attaches to the popliteus and is more mobile than the medial meniscus (and therefore less
easily torn). The medial collateral ligament is broad, flat, and attached firmly to both the
capsule and the medial meniscus (252). The lateral collateral ligament (254) is a longer cord-
like structure attached to the femur and fibula, independent of the capsule. The two cruciate
ligaments (255, 256) are named according to their tibial attachments: they are intracapsular,
partly covered by synovium, and attached to the condyles in the notch. Knee stability depends
on the collateral and cruciate ligaments, the capsule, the patellar ligament and good muscle
tone.

253. Medial and lateral menisci.

254. Collateral ligaments viewed from in front.

255, 256: Posterior (255)and anterior (256)cruciate ligaments viewed from in the side and from above.
The patella keeps the quadriceps tendon 1-2 cm anterior to the femur, increasing its
mechanical advantage. The tendency for the patella to undergo lateral translocation (due to
the shallower lateral angle of the groove and the lateral pull of the main bulk of quadriceps) is
mainly prevented by the pull of the vastus medialis. The vastus medialis, vastus intermedius,
and vastus lateralis arise from the femur (257) and provide the strong extensor apparatus that
stabilises the knee, particularly on weight bearing: the vastus medialis produces the more
distal muscle bulge and contracts maximally in the last 10° of extension, taking part in the
locking or 'screw home' medial rotation of the femur on the tibia. The rectus femoris (the
fourth quadriceps component) arises from the anterior inferior iliac spine and thus acts across
two joints. The main flexors are the hamstrings (the semimembranosus and semitendinosus
medially and the biceps femoris laterally, 258): they are most effective when the hip is
flexed. Ancillary flexors are the gracilis, the sartorius and the medial gastrocnemius
(medially), and the politeus and the lateral gastrocnemius (laterally). When the knee is flexed
('unlocked') the tibia can rotate on the femur, 40° externally and 30° internally: the lateral
hamstrings and tensor fascia lata externally rotate the tibia, and the medial hamstrings and the
popliteus internally rotate the tibia. The knee is involved in most forms of arthropathy; it is
also a common site of direct and indirect trauma, which may result in cartilage or ligament
damage, enthesopathy, or bursitis.

257. The quadriceps apparatus

258. Principal knee flexors.

Symptoms
Pain from the knee (259) is predominantly felt anteriorly, often with localisation to the
compartment involved (e.g. anteriorly in patellofemoral disease and anteromedially and
anterolaterally in medial and lateral compartment problems, respectively). Pain rarely radiates
far from the knee: prominent radiation down the tibia normally implies marked subchondral
bone collapse or intraosseous hypertension. The front of the knee represents the L2/3
dermatomes (260, 261) and pain may be referred to this site from an L3 root lesion or from
the hip. Referred pain often differs from pain originating in the knee in being (1) less clearly
demarcated, (2) frequently accompanied by pain and aching above the knee, and (3)
exacerbated by different factors. For example, L3 root pain often begins in the buttock, later
affecting the front of the thigh and the knee; it is not usually aggravated by walking but may
be exacerbated by coughing. The back of the knee represents the S1/2 dermatomes (261).
Posterior knee pain alone suggests a complication of arthropathy (e.g. popliteal cyst, posterior
tibial subluxation) or an S2 root lesion; other local causes include hamstring or gastrocnemius
enthesopathy, lymphadenopathy, and popliteal aneurysm.

259. Site of pain arising from knee (a), and site of referred pain to the knee (b, spine;c, hip).
 260, 261 Dermatomes around knee: anterior (260)and posterior (261).

'Locking' is a sudden, usually transient, painful inability to extend the knee. As a symptom, it
is important in suggesting a mechanical derangement, e.g. torn meniscus, 'loose' body, or
trapping of a fold of the synovium ('plica' syndrome).

'Giving way' describes a feeling of apprehension and loss of confidence in weight bearing on
the knee. It predominantly accompanies problems relating to the quadriceps/patellar
mechanism or stability. Weakness of the quadriceps, particularly the vastus medialis, or
patellofemoral disease, alters vertical 'tracking' of the patella as it moves on the femur and
gives rise to this odd feeling of apprehension. Ligamentous instability also alters the
mechanics of the knee during weight bearing, so that the patient knows that 'things are not
right'.

Patellofemoral abnormalities commonly give rise to two characteristic features in the history:

 Anterior knee pain, which is much worse going up and down (particularly down)
stairs or negotiating an incline than walking on the flat. This is because of the
maximal stress through that compartment when weight bearing on a flexed knee.
 Progressive anterior knee pain/aching that develops during prolonged sitting with
the knee flexed. The patient typically gets up, stretches the legs, and the aching
disappears, only to return after 20min or so of again sitting with knees bent.

Inspection
The patient should be inspected while weight bearing and walking and then on a couch at
rest. As usual, comparison of one side with the other may help show abnormality associated
with unilateral lesions.

Inspection of the Standing Patient

The patient stands upright and is inspected from in front, the side, and from behind. The main
features to observe are deformity and swelling in the posterior popliteal fossa, since these are
more apparent when standing than lying.

Deformity

At birth the knee is usually in marked varus: during the toddler and early childhood phases,
valgus is common; during adolescence, the knee tends to straighten again. Conditions that
cause cartilage loss in both tibiofemoral compartments commonly allow the knee to resume
valgus, which is the natural tendency in the majority of individuals.

All deformities other than fixed flexion are best assessed while the patient is standing (262-
266): varus and valgus may be noted with the patient lying on the couch, but these are
inevitably exaggerated on weight bearing. Principal deformities are:

 Genu varus (bow legs). This commonly reflects isolated medial compartment
disease (cartilage loss � subchondral bone collapse) and is the characteristic
deformity of uncomplicated osteoarthritis.
 Genu valgus (knock knees). This is the usual deformity of arthropathies
characterised by synovitis and tricompartmental involvement, leading to cartilage
loss throughout the knee.
 Genu recurvatum. This is particularly characteristic of generalised hypermobility.
 Posterior tibial subluxation. This produces a stepback deformity and is
particularly characteristic of arthropathies that affect the developing knee.
 Fixed flexion. The knee cannot extend and is always in some degree of flexion.
This may complicate a variety of arthropathies, but is particularly common in
conditions characterised by synovitis and resolution by fibrosis (e.g. seronegative
spondyloarthropathies).

If the patient experiences pain on weight bearing, and a deformity is obvious, manual
correction of the deformity (e.g. reducing varus or valgus by pushing from the side) will help
suggest whether the pain is predominantly mechanical and, therefore, likely to be helped by
correction of the deformity.

262-266 Knee deformities: (262)genu varus; (263) genu valgus;(264) genu recurvatum; (265) posterior
tibial subluxation; and (266) fixed flexion.
Swelling

A popliteal cyst may produce a prominent swelling in the popliteal fossa when the patient is
weight bearing and the leg is extended. An abnormally high patella (patella alta) may produce
a 'camel sign' (267, 268): because of the high patella (hump 1), the infrapatellar fat pad
(hump 2) becomes more prominent. When sitting with knees flexed at 90°, the patellae of
such patients may point upwards and be laterally placed (frog's eyes' appearance). Varicose
veins should also be noted.

267, 268 Normal patella position (267)and two swellings ('camel sign') due to patella alta (268).

Inspection of the Walking Patient

Gait is described in Chapter 2. Look particularly for an antalgic gait, a short step due to fixed
flexion, and circumduction of the leg due to fixed extension.

Inspection of the Patient Lying on a Couch

Skin changes

The anterior (extensor) surface of the knee is a common site for psoriasis. Look also for
erythema (either localised over a bursa, or more generalised if the knee is involved), scars, or
other abnormality.

Swelling

Knee effusion
Fluid collecting in the knee first fills in the medial dimple at the side of the patella and then
expands the suprapatellar pouch, giving a horseshoe swelling above and to either side of the
patella (269,270).

269, 270: Normal knee contours (269) ;swelling of knee effusion(270).

Bursae/fat pads

Localised swelling in front of the patella suggests prepatellar bursitis (271). Localised
swelling apparent below the patella, in front of the patellar tendon, suggests a superficial
infrapatellar bursitis (271); less prominent swelling either side of the tendon suggests deep
infrapatellar bursitis or a large infrapatellar fat pad (272). A prominent medial fat pad
(especially in obese women) may produce a large swelling with ill-defined boundaries above
or below the medial joint line; more subtle swelling below the medial joint line may be seen
with anserine bursitis.
 271, 272: Swellings of prepatellar busitis and superficial infrapatellar bursitis (271;side view) ;swelling of
deep infrapatellar bursitis (272;front view).

Muscle

Inspect the quadriceps for wasting (comparison with the other side is helpful in unilateral
lesions). Although all the quadriceps waste uniformly, wasting of the bulky vastus medialis
(particularly in a fit young male) may be the most conspicuous. Quadriceps wasting is a
difficult sign, particularly in the middle-aged/elderly, and especially in women. Some
asymmetry of muscle bulk is common and not necessarily abnormal (e.g. it may relate to
usage and 'footedness'). Measuring quadriceps (thigh) girth with a tape measure at a fixed
point (e.g. 10cm) above the patella on each side is often recommended, but has problems with
reproducibility and lack of agreement as to what difference between the sides constitutes
abnormality.

Deformity

Fixed flexion is best assessed while the patient is lying and attempts to straighten the legs.
Other deformities may also be noted but are usually greater on weight bearing.

Attitude

The way the patient positions the leg and their ease in getting on and off the couch may give
an idea of pain severity. The patient will keep returning to a flexed-knee position if there is
synovitis or a tense effusion causing intra-articular hypertension.

Palpation

Temperature
Run the back of the hand over the leg anteriorly and down each side, comparing skin
temperature above and below the knee to that over the knee. If anything, the knee normally
feels cooler than the thigh or shin. Increase in temperature may reflect synovitis (widespread,
mainly felt over the whole suprapatellar pouch) or bursitis (localised). If increased warmth is
found, be careful this does not relate to varicose veins (often most apparent when standing).

Swelling

Fluid within the joint can be detected by one of three signs.

Bulge sign (273)

This detects a small amount of fluid (and is not necessarily abnormal). Stabilise the patella
while gently massaging down either side of the patella, in turn, observing the opposite side
around the medial and lateral dimples. A small amount of fluid may flick from one side of the
pouch to the other.

Balloon sign

With a moderate/tense effusion, the bulge sign is usually lost and the balloon sign becomes
positive (274). Place the palm of one hand over the patella with the fingers and thumb off to
the medial and lateral sides; then press firmly down and in with the hand - this automatically
encourages fluid to flow down towards the main cavity at the tibiofemoral junction. If
pressure is now applied onto the patella or inferior joint region with the other hand
'ballooning' of the first hand is felt. This is the most specific test for fluid in the knee.

Patella tap

While testing for a balloon sign, the patella may be felt to move through the displacing fluid
and then 'tap' or 'clonk' onto the femur (274). Although common with a large effusion this
also occurs with marked retropatellar or anterior femoral fat.
 273. Bulge sign.
274. Balloon sign and patella tap.

Fluid may be detected in prepatellar or superficial infrapatellar bursitis by placing a finger

and thumb either side of the swelling and pressing at its apex for a balloon sign. For deep
infrapatellar bursitis, press over the patellar tendon and feel for ballooning to either side. A
balloon sign is less commonly present with anserine bursitis.

Patellofemoral compartment

Press the patella back onto the femur with one hand while steadying it with the other (275):
medial and lateral movement of the patella may then elicit tenderness and give rise to
crepitus, felt by both hands. Alternatively, stress the compartment by asking the patient to
tighten the quadriceps by pushing the knee backwards into the couch: this pulls the patella
onto the femur and may reproduce the pain of which they complain (this procedure produces
no hip or other knee compartment movement). Localisation of predominant tenderness to
either the medial or lateral facet can be determined by pushing the patella medially and then
laterally, in turn, out of its tracking, with the quadriceps well relaxed, while palpating firmly
the medial and then lateral facets from each side.

Active assisted and passive movement

The range of active flexion is assessed with the examiner's hand draped over all three
compartments (palm over the patella, fingers medially, thumb laterally) to detect crepitus at
each site (276). Observe flexion from the side as the patient attempts to put the heel to the
bottom (normally about 115-135°), and enquire concerning pain, particularly in a 'stress pain'
pattern (i.e. maximal towards the extremes of limited flexion and extension). Compare active
extension from the flexed position with passive extension (i.e. lift the heel upwards from the
couch): passive extension will correct any 'quadriceps lag' (277, 278). Decreased active
extension usually results from muscle atrophy (to complete the last 15° of extension a 60%
increase in force of quadriceps is required). Extension may also be reduced in joint disease
(similar for active and passive), or increased (>10°) in an unstable, damaged knee or in
generalised hypermobility.

275. Patellofemoral compartment stressing.

276. Action flexion while feeling for crepitus.
 277, 278: Active extension (277) and greater passive extension (278), termed 'quadriceps lag'.

Tibiofemoral compartments

To identify the joint lines, position the knee in moderate flexion. The tibial tubercle is readily
found in the midline (279), and may be locally tender in Osgood-Schlatter disease. As the
palpating finger is taken medially and then proximally from the tubercle the expansion of the
tibial plateau is readily identified; as the finger goes higher the anterior joint line is felt as a
valley dipping backwards between the tibia (below) and the femoral condyle (above) (280).
Internal and external rotation of the tibia will open up the lateral and medial joint lines,
respectively, and permit easier identification in difficult cases (e.g. obese subjects). Having
found the anterior medial joint line, press firmly just medial to the patellar tendon; then,
follow the medial joint line around, pressing firmly all the way. Tenderness localised to the
anterior joint line is characteristic of medial meniscal injury, whereas more generalised
medial joint-line/capsular tenderness suggests arthropathy. Repeat the same procedure for the
lateral tibiofemoral joint line; again, localised anterior tenderness suggests meniscal
pathology whereas generalised tenderness favours arthropathy.
 279, 280: Palpation of tibial tubercle (279) and anterior joint-line tenderness (280); medial tibiofemoral
compartment.

While palpating both anterior joint lines, the examiner assesses the presence of any soft-tissue
swelling. Synovial thickening may cause fullness at both anterior joint lines, with a visible
convex bulge: if pressed it will give, but then immediately reform as pressure is released.
This may be a misleading sign for synovial thickening, since a prominent infrapatellar fat
pad may appear identical. Deep infrapatellar bursitis is another cause of swelling either side
of the patellar tendon; however, it may feel warm, give rise to a balloon sign, and have a
more definite medial and lateral boundary. Localised swelling arising laterally, or
occasionally medially, from the tibiofemoral joint lines may be due to a meniscal cyst: such a
swelling may pop in and out of the joint line as the knee flexes/extends.

Periarticular lesions

Having identified and palpated both tibiofemoral joint lines, palpate for localised sites of
periarticular tenderness. There are no visual landmarks and it is best to take a single finger
and palpate firmly over a wide area below, and then above, the joint line on each side. The
following lesions are most commonly found.

Inferior medial collateral ligament enthesopathy

This produces localised tenderness inferior to the medial joint line, roughly in the midline of
the tibia when observed from the side (this condition is very common, 281).

Anserine bursitis

This produces a more diffuse area of tenderness inferior to the medial joint line, often
overlapping the site of the inferior medial collateral ligament insertion (282). It may
additionally produce localised swelling, warmth, and, occasionally, a balloon sign. The bursa
is named because of the similarity of its contour to that of a webbed goose foot; it lies
between the medial collateral ligament and the tendons of sartorius, gracilis, and
semitendinosus, close to their insertion (this lesion is common, particularly in middle-aged
and elderly subjects).

281. Site of tenderness in inferior medial collateral ligament enthesopathy.

282. Site of tenderness (± swelling) in anserine bursitis.

Superior medial collateral ligament enthesopathy

This produces localised tenderness above the medial joint line, fairly centrally on the femur
when observed from the side (283).

Medial fat pad syndrome

This produces a wide area of tenderness and 'doughy' swelling superior to, and often
overlapping, the medial joint line (this lesion is common, even in non-obese patients). The fat
pad is also a common site for tenderness in fibromyalgia.

Inferior lateral collateral ligament enthesopathy

This produces localised tenderness over the fibula head, felt posteriorly on the lateral side
(this condition is rare, 284).
 281. Site of tenderness in inferior medial collateral ligament enthesopathy.
282. Site of tenderness (± swelling) in anserine bursitis.

Superior collateral ligament enthesopathy

This causes localised tenderness superior to the lateral joint line, centrally on the femur when
observed from the side (284). Lateral ligament strains are uncommon sporting injuries that
characteristically produce a painful arc under flexion loading at 15-30°.

283 Sites of tenderness in superior medial collateral ligament enthesopathy (localised) and medial fat pad
tenderness (diffuse).The examiners right index finger is overlying the medial joint line.
284 Site of tenderness in inferior and superior lateral collaterl ligament enthesopathy.
Iliotibial tract ('band') syndrome

This produces a line of tenderness that extends from the anterolateral tibia, across the joint
line, and up the side of the thigh; tenderness is usually maximal over the lateral femoral
condyle (285). Predominantly a sporting injury, this syndrome also causes a painful arc at
about 30°. Pressure over the lateral femoral condyle as the knee is passively moved from full
flexion to extension may reproduce pain at about 30° of flexion (Noble compression test).

Popliteal tendon enthesopathy

This is predominantly a sporting injury that produces localised tenderness on the lateral
femoral condyle in a more anterior position than the superior insertion of the collateral
ligament (286). It arises, particularly, from running on a cambered, sloped, or uneven track,
which strains the popliteus as it attempts to reduce the rotational movement of the tibia on the
femur (popliteus problems may be associated with injury to the lateral meniscus, to which it
is attached).

285. Iliotibial tract (band) syndrome.

286. Popliteal tendon enthesopathy.

The popliteal fossa

This is palpated with the knee in mild-to-moderate flexion: swelling and tenderness are the
main features of interest.

Swelling

If a swelling is felt, it may be possible to confirm communication with the joint by massaging
its contents back into the main synovial cavity with the knee in flexion. Maintain pressure on
the popliteal fossa, extend the knee, then remove both hands: the swelling will not reappear
until the patient flexes the knee several times, confirming a valve-like communication
between the main cavity and the 'cyst'. The connection is usually patent only with the knee in
mid-flexion, permitting fluid to pass in either direction; as the knee is fully extended or
flexed, tendons and other posterior structures close off the valve.

Tenderness

The medial or lateral hamstring tendons or their insertions, or the medial or lateral insertions
of gastrocnemius may be tender to palpation in runners with hamstring or gastrocnemius
enthesopathy (particularly following sprinting or running uphill when these muscles are
working at full stretch). Such strains are occasionally accompanied by fine crepitus over the
tendons.

Stability

Although a large number of tests for instability exist, none is totally specific for a single
lesion. The following are standard screening tests for ligament or capsule damage:

Collateral ligaments

Assess stability with the knee 'unlocked' in mild flexion (with the leg straight, the cruciates
also prevent lateral movement). Push the femur medially with one hand and the tibia laterally
with the other hand (287), looking for excess lateral movement of the tibia (medial ligament
instability). As long as sufficient purchase can be achieved to demonstrate this sign the
method of holding the leg is immaterial (some examiners place the patient's foot in their
armpit and grasp the tibia firmly with both hands to apply greater pressure: 288). In addition
to excess lateral movement, also note:

 Opening up of the medial joint line ('gap sign').

 Medial knee pain, particularly at the inferior insertion of the ligament, suggesting
collateral ligament enthesopathy (this manoeuvre is basically a stress test for the
medial collateral ligament).

The lateral collateral ligament is similarly tested with the knee in mild flexion, the examiner
pushing the tibia medially and the femur laterally. Again, observe for excess lateral
movement, a gap sign, and pain.
 287. Medial ligament stress test.
288. Medial ligament stressing using firmer grip of the lower leg.

Cruciate ligaments

These are examined with the knee flexed to 90° and the hip to 45° (289). Before testing for
excess movement:

 Palpate the hamstrings to ensure they are relaxed (otherwise, they may restrict
anterior-posterior movement of the tibia and conceal cruciate instability).
 Observe the rounded contour of the knee from the side to ensure the tibia is not
starting in a posteriorly subluxed position (posterior'sag' sign) due to posterior
cruciate instability.

Having made these checks, test for excess anteroposterior movement of the upper tibia on the
femur. Steady the distal tibia with one hand while levering the upper tibia anteriorly and then
posteriorly with the other hand (290); the patient's weight will hold the femur steady. Some
examiners prefer to sit on the patient's foot to steady the lower leg; however, this is
unnecessary and may cause pain in those with arthropathy or other painful lesions of the feet.
If there is excessive anterior movement (anterior drawer' sign) this may reflect anterior
cruciate instability, cartilage loss, or generalised hypermobility. Comparison with the other
knee and other tests for hypermobility should help interpretation of a positive sign. If the tibia
is pushed posteriorly, excess posterior movement implies posterior cruciate instability or,
again, cartilage loss or generalised hypermobility.
 289. Position for cruciate ligament testing.
290. Anterior drawer sign.

Lachman's test is a sensitive test for anterior cruciate injury (particularly of the posterolateral
fibres). With the knee in mild flexion (<30°) and the patient relaxed, grasp the femur with
one hand and the upper shin with the other hand (291), and pull the tibia anteriorly to
demonstrate excessive movement and a soft 'end feel' (this requires a well-relaxed patient and
large examining hands).

br />

291. Lachman's test.

If an anterior drawer sign is detected, Slocum's test for anterolateral and anteromedial
instability may be performed (292). With the patient positioned as for the drawer test, sit on
the couch and passively rotate the tibia medially 30°, keeping it medially rotated by resting
the foot against your buttock. This manoeuvre tightens the lateral capsule, giving enough
stability then to eliminate the anterior drawer sign: if the anterior drawer is still positive in
this position (most anterior movement occurring on the lateral side) it is likely that the lateral
capsule (and/or lateral collateral ligament) is also damaged. Similarly, externally rotate the
tibia to tighten the medial capsule: a positive anterior drawer in this position (most movement
occurring on the medial side) usually implies that medial capsular fibres (and/or medial
collateral ligament) are damaged.

292. Slocum's test.

Additional tests for mechanical derangement

If the history (e.g. 'locking') or examination suggests that the problem is primarily
mechanical, further tests for mechanical derangement may be of use.

The 'pivot shift' manouvre (MacIntosh test)

Another test for anterolateral rotary instability, this manoeuvre is used to demonstrate a
dynamic subluxation where the tibia slips laterally and anteriorly on the femur. The patient is
positioned supine, with the hip flexed (20°) and relaxed in slight medial rotation, and the
knee slightly flexed (5°). The examiner medially rotates the lower tibia with one hand, the
other hand pushing the upper tibia anteriorly on the femur while maintaining a valgus stress
(293). As the knee is then flexed to 30-40° the tibia will suddenly reduce backwards with a
'clunk'. The reduction is due to the iliotibial band moving from an extensor to a flexor
function, pulling the tibia back to its normal position. Normally, the knee's centre of rotation
changes constantly through its range of motion as a result of the shape of the femoral
condyles, ligamentous restraint, and muscle pull. A positive pivot shift test usually suggests
damage to the anterior cruciate, the posterolateral capsule, or the lateral collateral ligament.

293. Pivot shift test.

The mediopatellar plica test

Pain produced by pushing the patella medially with the knee flexed at 30° may be due to a
plica squeezed between the femoral condyle and the patella.

The 'apprehension' test

If the patella is carefully pushed laterally with the knee flexed at 30°, the patient may resist,
contract the quadriceps, and express insecurity if there is recurrent patellar subluxation or
dislocation.

Summary of knee examination

(1) Inspection of the standing patient
(a) from in front (particularly for genu valgus, genu varus)
(b) from the side (particularly for genu recurvatum, posterior tibial subluxation)
(c) from behind (particularly for popliteal cyst)
(2) Inspection of the walking patient
(3) Inspection of the patient on a couch
(a) inspection (knee extended) for:
- skin changes
- swelling (effusion, bursae, fat pad)
- quadriceps wasting
- deformity (particularly fixed flexion)
- attitude
(b) palpation(knee extended) for:
- temperature increase
- swelling (effusion, bursitis)
- patellofemoral tenderness, crepitus
(c) palpation during flexion (crepitus, restriction, pain)
(d) passive extension
(e) palpation (knee flexed)
- tibiofemoral tenderness, swelling
- periarticular tenderness
- collateral ligament enthesopathy
- anserine bursitis
- medial fat pad syndrome
- iliotibial tract syndrome
- popliteal tendon enthesopathy
- popliteal fossa (cyst, tenderness)
(f) stability of ligaments
- medial/lateral collateral stress tests
- anterior drawer (Slocum's test if positive)
- posterior drawer
9. Ankle and Foot

 Hindfoot Joints
 Midfoot Joints
 Forefoot Joints
 The Arch of the Foot
 Tendons, Bursae and Fascia
 Symptoms
o Hindfoot Pain
o Midfoot Pain
o Forefoot Pain
o Referred Pain
 Examination
o Inspection of the Standing Patient
 Swelling
 Deformity
o Inspection of the Walking Patient
 Hindfoot Problem
 Midfoot Problem
 Forefoot Problem
o Examination of the Recumbent Patient
 Examination of the Soles and the Interdigital Clefts
 Palpation
 Additional Tests for Stability
 Summary of hip examination

The lower leg, the ankle, and the foot are well structured for stability in weight bearing and
for propulsion during bipedal gait. The large number of bones and their shape permit both
flexibility and stability: although movement between individual joints is small, their
combined motion permits controlled locomotion over a variety of ground surfaces.

Hindfoot Joints
The true ankle (talocrural) joint is a hinged synovial joint between the medial malleolus
(tibia), the lateral malleolus (fibula), and the talus (294, 295), permitting dorsiflexion and
plantar flexion. The fibula aids stability but transmits little weight (the inferior tibiofibular
joint is a syndesmosis that permits only a small 'spread' of the ankle mortice during
dorsiflexion). Because the trochlea of the talus is wider anteriorly the joint is tighter and more
stable in dorsiflexion (as in climbing uphill) than in plantar flexion (descending). The capsule
is tightest medially and laterally, where it is bound down by ligaments, but lax in front and
behind, being most extensive anteriorly. The enclosed synovial space is usually separate,
having no communications.
 294. Bones and joints of the ankle and hindfoot.
295. Bone and joint arrangement.

The foot has three functional units:

 The hindfoot (the calcaneus and the talus).

 The midfoot (the five small tarsal bones).
 The forefoot (the metatarsals and the phalanges).

Posteriorly, the bones lie over each other, while in the midfoot and forefoot they lie side by
side. This makes the foot higher and narrower at the back, and produces the two (longitudinal
and transverse) arches of the foot.

Stability is maintained by strong collateral ligaments (296, 297). The single medial deltoid
ligament resists eversion of the foot and is very strong (avulsion of the malleolus often occurs
before ligament rupture). The lateral ligament is in three bands (the anterior and posterior
talofibular ligaments and the calcaneofibular ligament). The anterior talofibular ligament is
the first to undergo stress during inversion, and is the most commonly torn. The
calcaneofibular ligament may tear, but only after rupture of the anterior talofibular ligament;
disruption of both leads to ankle instability. The posterior talofibular ligament is damaged
only in severe trauma.

The posterior subtalar joint is between the concave undersurface of the talus and the posterior
convex facet of the calcaneus (see 295). The capsule of this deep joint is tight and permits
little synovial expansion. Together with the talocalcaneal portion of the talocalcaneonavicular
joint, it allows eversion and inversion of the hindfoot
 296. Ligaments of the ankle (medial aspect).
297. Ligaments of the ankle (lateral aspect).

Midfoot Joints
The midtarsal joint is a functional composite formed mainly by the talocalcaneonavicular and
calcaneocuboid joints, which permit forefoot eversion and inversion (some forefoot
abduction and adduction is also possible). Movement is principally talonavicular but also
involves movement between the cuneiform and cuboid bones.

Forefoot Joints
The metatarsophalangeal joints (MTPJs) and proximal and distal interphalangeal joints (IPJs)
are synovial joints similar to the MCPJs and IPJs of the hand. Each MTPJ capsule is
strengthened by a medial and lateral collateral ligament, an extensor tendon dorsally, and a
plantar ligament below. MTPJ stability is dependent mainly on the capsule and if capsular
function is deranged (e.g. by synovitis) the toes become unstable and follow the pull of the
tendons (dorsal subluxation with valgus deformity).

The Arch of the Foot

This permits equal weight distribution between the heel prominence (calcaneus) posteriorly
and the heads of the lateral four metatarsals and two sesamoid bones of the first metatarsal
anteriorly. It provides flexibility and spring for walking and running. The longitudinal arch
has a high, flexible medial component and a low, rigid lateral component; the transverse arch
is high proximally and low distally. The arch is maintained by the joint capsules and the
dorsal and plantar ligaments, and is supported by the long calf muscle tendons (the role of the
plantar fascia and small muscles of the sole is uncertain).

Tendons, Bursae and Fascia

The Achilles tendon, the common insertion of the soleus and the gastrocnemius, attaches to
the posterior aspect of the calcaneus and is separated from it by the retrocalcaneal (pre-
Achilles) bursa (298). Other clinically relevant bursae include the retro-Achilles bursa
(between the skin and the Achilles tendon), the subcalcancal bursa (between the skin and the
undersurface of the calcaneus), and adventitious bursae that form over the medial aspect of
the first MTPJ ('bunion'), and the lateral aspect of the fifth MTPJ ('bunionette').

298. Bursae around the ankle.

Behind each malleolus run tendons within individual tendon sheaths (299, 300):

 Lateral malleolus: the peroneus longus and the peroneus brevis (eversion), held
down by the peroneal retinaculum.
 Medial malleolus: the tibialis posterior (inversion) and, more posteriorly, the
flexor digitorum longus and the flexor hallucis longus, held down by the flexor
retinaculum (forming the tarsal tunnel through which also passes the posterior
tibial nerve).

299. Tendons and tendon sheaths around the ankle (lateral).

300. Tendons and tendon sheaths around the ankle (medial).
Anterior and superficial to the ankle are three tendon sheaths held down bv the extensor
retinaculum (30l): the medial sheath contains the large tendon of the tibialis anterior (the
main dorsiflexor of the foot); the central sheath contains the extensor hallucis longus and the
extensor digitorum longus; and the lateral sheath contains the peroneus tertius.

301. Tendons and tendon sheaths around the ankle (anterior view).

The plantar fascia arises from the median prominence of the calcaneus. It is tough and thick
proximally, but thins as it extends and divides distally before insertion into the bases of the
metatarsal heads (see 298).

The skin on the lateral aspect of the foot, toes, and heel is greatly thickened, and in the
subcutaneous connective tissue beneath the metatarsal heads and tips of the toes are fibro-
fatty pads that act as shock absorbers (302). As a result of the concentrated stresses they
receive, the foot and ankle are common sites for traumatic articular and periarticular lesions,
as well as being target sites for major arthropathies.

302. MTPJs and fibro-fatty pads.

Symptoms
Pain arising from articular or periarticular structures is generally well localised and its site
and characteristics alone often suggest the cause.

Hindfoot Pain
Pain from the ankle joint is felt anteriorly in a broad line joining the two malleoli, and is
characteristically worsened by standing or walking. Conversely, pain from the subtalar joint
is felt mainly posteriorly between the two malleoli, and is particularly aggravated by walking
over uneven surfaces when eversion/inversion is required.

Localised posterior heel pain and tenderness may result from retro-Achilles bursitis,
retrocalcaneal bursitis, or Achilles tendinitis or enthesopathy. With Achilles tendon problems,
the pain is often exacerbated by standing on tiptoe (without shoes). Pain beneath the heel,
which is worsened by prolonged standing or walking, is usually a result of plantar fascia
enthesopathy ('plantar fasciitis').

Midfoot Pain
Midtarsal joint disease gives pain in the 'bootlace' area, often most marked during late stance
and toe-off phases of walking. Loss of the normal arches ('flat foot') may cause pain in the
midsole.

Forefoot Pain
MTPJ pain is felt below the metatarsal heads (metatarsalgia): it is worsened by standing and
walking, and may be described as 'like walking on marbles' if several joints are involved.

Burning pain in the sole and toes suggests a neurogenic cause. Morton's neuroma typically
causes sharp intermittent pain between the third and fourth digits, particularly when the
metatarsal heads are compressed (as with restrictive shoes). Tarsal tunnel syndrome
(posterior tibial nerve entrapment) typically causes burning, tingling, and numbness in the
distal sole and toes.

Inflammation of any tendon sheath may cause localised pain that often extends a distance
along the line of the sheath and is aggravated by movement of the relevant muscle.

Referred Pain
Pain may be referred to the ankle and foot from the spine and, rarely, the hip. Referred pain
from nerve-root irritation follows a dermatomal distribution (303, 304), may be exacerbated
by straining and straight leg raising, and may be accompanied by neurological signs.
 303 , 304: Dermatomes of the lower leg and foot: (303) dorsal aspect; (304) sole.

Examination
Inspect both feet and ankles while the patient, undressed to their underwear, stands and then
walks. Undertake further inspection and palpation, with the patient resting on a couch.
Additional information may be obtained by inspecting the patient's footwear for abnormal
moulding and wear patterns of the sole and heel.

Inspection of the Standing Patient

Compare both sides of the patient, from in front, behind and from the side, looking
particularly for the following abnormalities.

Swelling

Ankle synovitis produces diffuse swelling anteriorly (305), often filling the small depressions
in front of the malleoli. Midtarsal synovitis produces only modest, diffuse puffiness over the
dorsum of the midfoot. MTPJ synovitis often causes swelling over the dorsum of the forefoot,
obscuring the extensor tendons and causing spreading of the metatarsals and toes. The
combination of IPJ synovitis and digital flexor tenosynovitis may produce a 'sausage toe'.

Linear swelling that crosses the ankle is usually a result of extensor tenosynovitis. Peroneal
or tibialis posterior tenosynovitis produces linear or diffuse puffiness around the lateral or
medial malleolus, respectively.

Swelling around the Achilles tendon may result from tendinitis (producing swelling of the
tendon itself), retrocaleaneal bursitis (appearing more as eccentric swelling that fills in either
side of the tendon), or retro-Achilles bursitis (more prominent, superficial swelling; 306).
This is also a common site for nodule formation see Chapter 1, usually appearing as
superficial, eccentric swellings over the Achilles tendon and posterior calcaneus.
 305. Swelling of ankle synovitis.
306. Site of swelling around the Achilles tendon.

Deformity

Ensure that both arches are normal. The longitudinal arch may be increased (pes cavus, often
a result of neurological disease; 307) or diminished (pes plarius or flat foot; 308). In severe
flat foot the displaced talus and navicular cause a prominence in front and just below the
medial malleolus.

307. Pes cavus.

308. Pes planus.

A large number of joint deformities may be seen. The most common toe abnormality is
hallux valgus (309) in which there is abnormal angulation and rotation of the first MTPJ:
associated medial deviation of the metatarsal (metatarsus primus varus) results in a broad
forefoot, and a bunion often develops. Hammertoe deformity (310) results from
hyperextension of the MTPJ, with flexion at the proximal interphalangeal joint, or PIPJ
(usually the second toe, in association with hallux valgus). The distal interphalangeal joint, or
DIPJ, may be straight, flexed or extended and a callus often develops over the prominent
PIPJ. Mallet toe (311) results from flexion deformity at the DIPJ. In cock-up toe (312) flexion
of both IPJs follows extension and often plantar subluxation at the MTPJ (usually due to
polyarthritis). The fibro-fatty pad moves distally, and secondary callus may form below the
exposed metatarsal head and over the flexed PIPJ.

309. Hallux valgus.

310 , 311: Toe deformities: (310.) hammertoe; (311.) mallet toe.

 312. Cock up toe deformity with hallux valgus (due to polyarthritis).

Ankle and subtalar deformities are best seen from behind. Calcaneovalgus (eversion) is most
common (313, 314), usually reflecting damage to both the subtalar and ankle joint:
calcaneovarus (inversion) only occasionally occurs. Fixed plantar flexion (talipes equinus)
usually results from spastic paresis. Congenital clubfoot (talipes) may associate with plantar
flexion of the ankle (talipes equinus) or dorsiflexion (talipes calcaucus). Midfoot deformity
may coexist; for example, talipes equinovarus, or talipes cancaneovalgus.
 313 , 314: Normal hindfoot (313); hindfoot eversion deformity (314).

Skin and nail changes

Relevant observations may include loss of hair over the distal limbs (vascular insufficiency,
neuropathy), vasomotor changes and discoloration (Raynaud's disease, vascular disease,
cryoglobulinaemia), ulceration (gravitational, vasculitis), and psoriatic plaques. As with the
fingers (see Chapter 1, fig.31-34; see Chapter 3, fig.73-74), inspect the nails for pitting and
dystrophy (psoriasis, chronic Reiter's syndrome), vasculitic lesions, and clubbing. Peculiar to
toenails, usually the hallux, is onychogryphosis (gross distortion and hypertrophy).

Inspection of the Walking Patient

Gait is described in Chapter 2. Pain in any part of the foot or ankle may give an antalgic gait.
Other typical abnormalities may suggest the site of involvement.

Hindfoot problem

If ankle movement is reduced, the leg may be externally rotated and slightly abducted, giving
a 'toe-out' gait with outward displacement of the forefoot, the patient attempting to walk by
rolling the foot from the lateral to the medial side. If severe, this results in loss of the
longitudinal arch so the patient walks on the medial aspect of the foot. If the heel is painful,
heel strike is avoided, the step being shortened and the forefoot striking first. With Achilles
tendon problems, push off is guarded or avoided, the step again being shortened.

Midfoot problem

The foot is often held inverted and push off is from the lateral side.

Forefoot problem

To avoid weight bearing on the forefoot, the heel does not rise in late stance and there is
diminished push off. The trunk, hip, and knee flex to maintain forward motion, and swing
phase on the normal side shortens, resulting in 'bobbing' during late stance on the painful
side. Involvement of both forefeet combines to give a forward-leaning, short-stepped,
shuffling gait.

Examination of the Recumbent Patient

With the patient relaxed on the couch, complete inspection by examining the soles; then
undertake palpation and examination of a range of movements.

Examination of the Soles and the Interdigital Clefts

Callosities and inflammed adventitious bursae are particularly common under subluxed
MTPJs (315). They appear to merge into the surrounding skin and may be tender to direct
pressure. Complications that may be present (particularly in rheumatoid disease) include
vasculitic lesions, broken skin with discharge, and secondary infection. Verrucae are tender
to direct and, particularly, laterally applied pressure, and show clear demarcation from
surrounding skin. Pustular psoriatic lesions and keratoderma blennorrhagica appear identical
(316, 317), and plantar erythema is occasionally observed, as on the palms. Part and inspect
the interdigital clefts: macerated skin with fissuring is typical of tinea pedis (athlete's foot) -
common in patients with toe deformities and abnormal skin clefts.

315. Bursae beneath subluxed MTPJs.

316 , 317: Keratoderma blennorrhagica: (316) early, mild; (317) established, severe.
Palpation

Increased warmth

Pass the back of the hand down the dorsum of the foot to feel for increased warmth overlying
the ankle, midtarsal joints, or the MTPJs.

Joint Tenderness, Swelling, and Movement

Work through each joint group looking for:

 Joint-line tenderness.
 Soft-tissue swelling arising from the joint.
 Restriction of passive movement.
 Pain (especially stress pattern) during movement.

Ankle

Identify the anterior joint line by palpating with one or both thumbs while gently dorsiflexing
and plantarflexing the ankle (318). Note any crepitus during this movement, Having
identified the joint line, press firmly for tenderness, and feel for swelling. Synovitis and
effusion are most prominent here because of the slack, extensive anterior capsule: such
intracapsular swelling becomes more obvious during passive dorsiflexion of the ankle and if
pressure is applied over the posterior capsule by a cupped hand pressing beneath and behind
both malleoli (319).
 318. Palpation of the anterior joint line of the ankle.
319. Pressure posteriorly (right hand), increasing anterior swelling (palpable with left hand).

Movement: with the knee moderately flexed and gastrocnemius relaxed, support the lower
leg with one hand, holding the foot firmly with the other hand, and passively move the ankle
into dorsiflexion (about 20°; 320) and plantar flexion (about 45°; 321).

320 , 321: Ankle dorsiflexion (320) and plantar flexion (321).

Subtalar joint

This joint is too deep for palpation and swelling cannot be seen.

Movement: stabilise the distal leg with one hand and, grasping the heel with the other hand,
move the foot into inversion (about 30°; 322) and eversion (about 20°; 323).
 322 , 323: Subtalar joint movement: inversion (322) and eversion (323).

Midtarsal joints

Feel for tenderness and soft-tissue swelling over the dorsum of the midfoot. The muscle belly
of the extensor digitorum brevis on the lateral aspect of the dorsum may simulate synovial
thickening of the ankle or midtarsal joint: it is distinguished by active toe extension, which
shortens, bunches up, and hardens the muscle. Bony swelling over the dorsum occurs with
talonavicular osteoarthritis, and with prominence of the talus in pes cavus (sometimes with
overlying callus formation).

Movement: stabilise the calcaneus in one hand and, holding the forefoot in the other hand,
rotate the foot along its long axis into eversion (about 40°; 324) and inversion (about 30°;
325).
 324 , 325: Midtarsal movement: eversion (324) and inersion (325).

MTPJs

MTPJ tenderness is elicited by squeezing the forefoot laterally across the metatarsal heads
(326). If tenderness is elicited the responsible joints are located by palpating each MTPJ in
turn, squeezing between both thumbs (on the posterolateral aspect) and forefingers (plantar
aspect; 327). Synovitis of MTPJs produces dorsal swelling that comes proximally, filling in
the spaces between the metatarsal heads. Tenderness of a single metatarsal head may indicate
a stress fracture (most commonly the second or third 'March fracture'). Sharply localised
tenderness between the third and fourth (less commonly second and third) metatarsal heads is
characteristic of Morton's interdigital neuroma: altered sensation may be detected on the
lateral and medial aspects of the third and fourth toes, respectively, and rarely a large
neuroma may be felt.
 326. Metatarsal squeeze.

Movement: test each MTPJ by supporting the metatarsal head between the finger and thumb,
and moving the proximal phalanx into extension and flexion (328). The first MTPJ has about
80° extension and 35° flexion; the other MTPJs have about 40° of extension and flexion.

327 , 328: MTPJ: palpation (327) and movement (328).

IPJs
Palpate for tenderness of symptomatic or abnormal IPjs by squeezing the posterolateral
aspects of each IPJ between the finger and thumb (329). Swelling of synovitis is most
prominent on the posterolateral and lateral aspects.

Movement: Wjs are tested by fixing the more proximal and moving the more distal phalanx
(330). PIPJs flex to about 50° and DIPJs to about 40°, with varying extension up to 30°.

329 , 330: IPJ: palpation (329) and movement (330).

Periarticular Structures

Palpate behind and under each malleolus for soft-tissue swelling, tenderness, and warmth
relating to tendon sheaths. Crepitus may be detected, and pain reproduced, by palpating the
relevant tendon sheath with one hand (331) while the other hand passively moves the forefoot
into eversion (stressing tendons around the medial malleolus) or inversion (stressing the
peroneals around the lateral malleolus).

Tenosynovitis overlying the anterior aspect of the ankle is distinguished from ankle synovitis
by:

 Its more superficial, linear configuration.

 Tenderness extending well beyond the joint line.
 Pain produced by the appropriate resisted active movement (dorsiflexion of the
foot, extension of the hallux and toes).

Plantar fasciffis is confirmed by reproducing pain by firm pressure over the midpoint of the
heel (332).
 331.Palpation for peroneal tendon sheath crepitus
332. Tenderness due to plantar fasciitis.

Examination of the posterior heel and Achilles is best undertaken with the patient lying
prone, with the feet extending beyond the end of the couch. Palpate (between the forefinger
and thumb) for tenderness and swelling of:

 The Achilles tendon (Achilles tendinitis, partial rupture).

 The tissues anterior and lateral to the tendon (pre-Achilles bursitis).
 The tendon insertion site into the calcaneus (retro-Achilles bursitis or Achilles
enthesopathy).

Then, test for resisted active plantar flexion by asking the patient to push their foot down
against your hand (333). This may reproduce pain in Achilles tendinitis, enthesopathy, or
partial rupture, but not bursitis. In partial rupture, a defect in the tendon, which becomes more
noticeable during resisted plantar flexion, may be palpable.
 333. Resisted active plantar flexion.

With complete rupture of the tendon, resisted active movement is absent, and firm squeezing
of the relaxed gastrocnemius (shortening it) will not produce any passive plantar flexion. Old
(healed) partial rupture may leave a palpable nodule in the tendon.

Palpate other nodules (due to generalised disease) to determine attachment to the skin or to
underlying structures.

Additional Tests for Stability

Anterior stability

The anterior drawer sign tests the integrity of the anterior talofibular ligament. With the
patient sitting, push back on the lower tibia with one hand while pulling the calcaneus and
talus anteriorly with the other hand (334). Any movement of the foot relative to the tibia
indicates instability.

Lateral stability

This results from anterior talofibular and calcaneofibular ligament damage. Hold the
calcaneus in both hands and palpate beneath the lateral malleolus with one thumb (335).
Slowly invert the heel, looking for excess movement and development of a palpable
'gap'beneath the laterally placed thumb. For deltoid ligament insufficiency (an uncommon
condition), evert the calcaneus and feel for a gap on the medial side.
 334 , 335: Tests for (334) anterior instability and (334) lateral instability.

Summary of foot examination

(1) Inspection of the standing patient
(a) swelling (synovitis, tenosynovitis, tendinitis, bursitis, nodules)
(b) deformity (arches, joints)
(c) skin, nails
(2) Inspection of the walking patient
(3) Examination of the recumbent patient
(a) inspection of soles, interdigital clefts
(b) palpation (warmth, swelling, tenderness) and movement (restriction, pain, crepitus)
of joints:
- ankle (dorsiflexion/plantar flexion)
- subtalar (inversion/eversion of calcaneus)
- midtarsal (inversion/eversion of midfoot)
- MTPJs (flexion/extension)
- IPJs (flexion/extension)
(c) palpation (warmth, swelling, tenderness) with or without movement (pain, crepitus)
of periarticular structures:
- tenosynovitis (extensors, peroneals, tibialis posterior)
- plantar fascia insertion
- Achilles tendon and insertion (patient prone)
- pre-Achilles, retro-Achilles bursitis (patient prone)
(d) tests for stability (anterior, lateral)
10. Temporomandibular Joint

 Anatomy
 Examination
o Inspection at Rest
o Inspection During Movement
o Palpation
 Summary of TMJ Examination

Anatomy
The mandible articulates as a single unit with the skull at three sites: the two
temporomandibular joints (TMjs) and the teeth (the 'trijoint complex'). The TMJs are among
the most frequently used joints in the body, the jaw opening and closing about 2000 times
each day as we chew, suck, swallow, talk, kiss, yawn, snore, etc.

Each TMJ has fibro (not hyaline) articular cartilage, and a fibrocartilage disc completely
divides the cavity into two synovial compartments (336). The upper compartment functions
as a sliding joint (permitting anteroposterior and some lateral movement of the mandible); the
lower compartment acts as a hinge. On opening the mouth the condylar heads rotate; then the
condyles and discs both slide forward on the temporal articulations (337-339). The joint
capsule is lax but condensed laterally as the temporomandibular ligament; the
stylomandibular and sphenomandibular ligaments are further restraints that keep the condyle,
disc, and temporal bones opposed. In general, however, the loose capsule and non-restraining
bony configuration allow the condylar position to be easily influenced by occlusal, muscular,
and postural factors, and by trauma.
 336. Outline of basic temporomandibular joint anatomy.

337 - 339 Normal TMJ opening: (337) the mouth closed; (338) the mouth opening - the condyle rotates and
moves anteriorly with the disc; (339) the mouth fully open.

The lateral pterygoids are the prime openers of the mouth and pull each condyle and disc
forwards: acting together they protrude the jaw; acting individually they laterally deviate it.
The masseter, the temporalis, and the internal pterygoids are prime closers; the temporalis is
the prime retractor.

Pain from a TMJ may be felt locally, but is most commonly referred to the mandible, the
teeth, the side of the head, or the neck (340). Less commonly, pain from the teeth or neck
may be referred to the TMJ area, which approximates to the junction of the C2 and C3
dermatomes (341).
 340. Referred pain patterns to and from the TMJ.
341. Dermatomes around the TMJ.

The TMjs and teeth depend on each other for normal development and function. If TMJ pain
is suspected, specific enquiry should include:

 Pain on opening or closing the mouth, on chewing, yawning, or talking. (If so,
where is it felt?)
 Locking of the jaw (locking in the closed position is usually due to disc problems,
locking in the open position to subluxation).
 'Clicking' of the jaw (often due to partial subluxation or damage to the disc,
lateral pterygoid dysfunction, or to occlusal imbalance).
 Previous or current problems with teeth (caries, malocclusion, extraction,
dentures).
 Occurrence of 'bruxism' (forced clenching/ grinding of the teeth, especially at
night, which may cause TMJ pain).
 Ear problems (hearing loss, blocking of the ears, earache, or dizziness may
denote ear, neck, or TMJ problems).

Examination
Inspection at Rest
Observe and compare the location of each TMJ just anterior to the external auditory meatus.
Swelling from the joint has to be marked before it can be seen as a rounded bulge overlying
this site. Erythema (often accompanied by more widespread soft-tissue swelling) suggests
sepsis or crystal synovitis. Ask the patient to bare teeth and observe for any overbite,
crossbite, or lateral deviation of the jaw. TMJ disease during growth may lead to general
hypoplasia of the jaw and a receding chin ('micrognathia', 342).
 342. Micrognathia.

Inspection During Movement

Each movement should show a smooth, unbroken rhythm and be painfree. Ask the patient to:

 Open the mouth wide (343). The mouth should open and close in a vertical line.
Hypomobility of one TMJ causes jerky movement, with regular deviation of the
jaw to that side on opening, and deviation away from that side on closing.
Variable side-to-side jerkiness on opening or closing more often relates to muscle
imbalance (e.g. following neck hyperextension injury). The jaw normally opens
about 3-6cm, sufficient to accommodate two or three flexed fingers (343).

343. Mouth opening (normal from the front, accommodation of three flexed fingers hled
vertically).
  Protrude the jaw forwards (344). The bottom teeth should easily be placed in
front of the top teeth and there should be no lateral deviation.

344. Jaw protrusion.

 Move the jaw from side to side (345). With the jaw protruded, this permits greater
lateral movement - normally about 1-2cm. TMJ disease may cause earlier and
greater loss of lateral movement than of vertical movement.

345.Lateral jaw movements.

Palpation
Feel for increased warmth with the back of the hand over the region just anterior to the
external meatus. Place the index fingers of each hand over the same TMJ areas and ask the
patient to open and close the mouth: the palpating fingers will be felt to drop into a
depression overlying the joint as the condyles move forward. Fluid/soft-tissue swelling
prevents easy palpation of this depression and may, additionally, give rise to a balloon sign
(fluctuance). Crepitus or clicking may be palpable during movement and comparison of
palpable movements on the two sides permits detection of varying degrees of subluxation.
Pressure over this area may elicit tenderness.

Palpation of the posterior aspect of the TMJ is accomplished by placing the tips of each little
finger into each external meatus (fingernails pointing posteriorly) and pressing anteriorly as
the patient opens and closes the mouth (346). If synovitis is present, tenderness on mouth
closure is more readily appreciated at this site than on palpation over the lateral aspect.

346.Palpation of posterior aspect of TMJ as the patient opens and closes the mouth.

Resisted active (isometric) movement is difficult to perform but useful in differentiating

muscle dysfunction from TMJ disease. The jaw should be in the resting (just open) position.
Test:

 Opening (prime movers = the lateral pterygoids), by asking the patient to resist
an increasing closing force applied by the examiner's hand under their chin (with
their head supported by the other hand to prevent neck extension: 347).
 347.Resisted isometric mouth opening:the examiner prevents the patient opening her mouth.

 Closing (the masseter, the temporalis, and the medial pterygoids), by asking the
patient to resist an increasing opening force applied by the examiner's hand to the
biting surfaces of their lower anterior teeth (or chin, if diseased/ absent teeth),
while supporting their forehead with the other hand to prevent neck flexion
(348).
 348.Resisted isometric mouth closure:the examiner prevents the patient closing her mouth.

 Lateral deviation (prime movers = the ipsilateral lateral pterygoid and the
contralateral medial pterygoid), by asking the patient to resist increasing the
lateral force applied by the examiner's hand on the side of their jaw (349).

349.Resisted isometric lateral deviation:the examiner prevents the patient pushing her jaw laterally (to her
right).

In addition, the lateral pterygoids may be palpated by placing a gloved finger between the
cheek and the upper gum and pushing backwards beyond the last molar against the neck of
the mandible.

As the patient opens their mouth the lateral pterygoid is felt to tighten against the examiner's
fingertip. If the muscle has been traumatised or is in spasm, pain or tenderness may be
elicited.

Inspection and palpation of teeth and gums (e.g. for caries, gingivitis, loose/malfitting
dentures) should also be undertaken if warranted. Palpate the gums and teeth with a gloved
finger, looking for localised tenderness and easy gum bleeding.

Summary of TMJ examination

(1) Inspection at rest (swelling, erythema, micrognathia)
(2) Inspection of bared teeth (overbite, crossbite, lateral deviation)
(3) Inspection during movement
 open mouth wide
protrude jaw forwards
move jaw from side to side
(4) Palpation
warmth
swelling
tenderness (anterior and posterior compartments)
crepitus/clicking during movement
(5) Resisted active movements
jaw opening
jaw closing
lateral deviation
(6) Inspection and palpation inside mouth
(lateral pterygoids, teeth, gums)