Rheumatology Joint Examination

1. Rheumatology Joint Examination Thomas Griffin, MD October 12, 2011

2. Purpose of the Joint Exam • THE test for “Arthritis” • No blood tests for arthritis – not RF, ANA, ESR, CRP • More cost-effective than MRI or ultrasound • Less invasive than synovial biopsy • Arthritis = Inflamed Synovium • “Active Joint” • Swelling of synovial tissue, or • Limited range of motion and tenderness • Asymmetry can be very helpful

3. Active Joints • Swelling of synovial tissue • Inflamed synovium unless proven otherwise • Capsular swelling is most specific sign of synovitis • Not joint effusion, boney enlargement, or “peri-articular” soft tissue swelling • Some joints are impossible/difficult to feel swollen synovium – hip, shoulder, spine, sacroiliac • Swollen capsule may become “firmer” at extremes of movement

4. Active Joints • Limited range of motion • Active – range achieved without applied force • Passive – range achieved with applied force • Example – hyper-extension of MCPs • Arthritis usually impairs both active and passive motion • Selective loss of active motion suggests muscle/tendon/motor problem • A few joints don’t move much • Sacroiliac • Sternoclavicular, acromioclavicular

5. Active Joints • Tenderness • With palpation • Tenderness of synovium (joint line) • Encompass the entire joint margin • With range of motion • Often limiting factor • “stress pain” increases as joints move toward extremes of restricted movement (most sensitive sign of synovitis) • Pain throughout range of motion is more likely mechanical

6. Approach to a Joint • Signs observed on examination • Inspection at rest • Does a joint look normal and assume a normal resting position? • Inspection during movement • Does a joint move smoothly through its range of movement? • Palpation • Does a joint feel normal?

7. Inspection • Attitude • Inflamed joints often held in positions that minimize intra-articular pressure/maximize intra-capsular capacity • Example: Shoulder adducted and internally rotated (as if in a sling) • Deformity • At rest vs. with weight-bearing/use • Correctable (soft tissues) vs. non-correctable (capsule/joint damage) • Example: Swan-neck – hyper-extended PIP/hyper-flexed DIP

8. Inspection • Skin changes • Erythema – peri-articular inflammation • Sepsis, crystals • Muscle • Wasting of muscles that act across an inflamed joint • Local spinal reflex • Example: Quadriceps atrophy with knee arthritis

9. Palpation • Warmth • Cardinal sign of inflammation • Back of the hand • Swelling • Fluid, soft tissue, or bone • Bulge sign, balloon sign

10. Palpation • Resisted active movement • Demonstrates muscle tendon or enthesitis • Isometric muscle contraction against examiner – removes contribution of joint • Examples: • External rotation of shoulder – rotator cuff lesion • Wrist extension – tennis elbow (lateral epicondylitis) • Passive stress test – tendonitis • Example – Ankle dorsiflexion with pain at Achilles tendon

11. Palpation • Crepitus • Crunching throughout range of motion • Fine crepitus (palpable but not audible) – inflamed tissue • Coarse crepitus (audible) – cartilage or bone damage • Joint cracking by distraction – negative pressure forms an intra-articular gas bubble – painless and inconsequential • Ligamentous snaps – single, loud and painless

12. Hand • Inspect hands held out in front, palms down, fingers straight and spread • Turn hands over (supination) • Make a tight fist – thumb out • Oppose 5th finger to thumb • Palpate MCPs and PIPs – swollen synovium will bulge dorsally and to the sides • Hyperextend/hyperflex MCPs • Can measure grip and pinch strength

13. Wrist • Palpate radiocarpal and ulnocarpal joints – swollen synovium will bulge dorsally • Press palms together, press backs of hands together • 3 planes of motion • Extension (>70)/flexion (>80) • Lateral deviation (Ulnar>Radial) • Supination/pronation • 8 bones in the carpus – SLCHTTTP

14. Elbow • Inspect for swelling from behind • Palpate para-olecranon grooves and head of radius • Two planes of motion • Extension/Flexion • Supination/Pronation (demonstrates head of radius) • Proximal Ulna common site for rheumatoid nodules

15. Shoulder • Three joints to palpate • Glenohumeral • Acromioclavicular • Sternoclavicular • Test shoulder motion by having patient place hands behind head with elbows back • External rotation and abduction is earliest motion lost with glenohumeral arthritis • Also moves acromioclavicular and sternoclavicular joints

16. TMJ • Most active joints in the body • Inspect for symmetry – shortening on affected side, micrognathia • Open jaw wide • Should accommodate 3 of the patient’s fingers vertically (>35 mm) • “Locking” due to disc displacement – impaired opening when condyle cannot slide forward with disc • Deviation to affected side • Move side to side in open position • First range lost (>10 mm) • Protrude forward – lower teeth in front of upper teeth • Palpate joint from behind

17. Spine • Cervical spine – 3 planes of motion • Most sensitive is loss of lateral flexion (keep shoulders from raising) and extension (forehead and tip of nose form horizontal line) • Lumbar spine • Loss of lordosis • Tender with direct palpation (not specific) • Modified Schober’s Test with forward flexion • 2 marks – at dimples of Venus and 10 cm above – normal expansion with forward flexion is ≥5 cm

18. Sacroiliac • Minimal movement – difficult to assess • FABER sign – Flex, ABduct, Externally Rotate hip • Compresses sacroiliac – unfortunately not very specific • Direct palpation is unreliable • MRI may be indicated to verify sacroiliitis • Xrays unreliable (joint space narrowing and peri-articular sclerosis are late findings and easily misinterpreted) • “Inflammatory back pain” – symptoms correlate with ESR/CRP

19. Hip • Inspect attitude of hip at rest – arthritic hip often held in external rotation • Deep femoral-acetabular joint is difficult to palpate • Internally rotate hip with hip flexed at 90 degrees - sensitive • Thomas’ test – Flex good hip (>120) and observe if bad hip remains extended • Flexion contracture manifest by exaggerated lumbar lordosis

20. Knee • Palpate synovial reflection inferomedial to patella • Assess effusion by testing for bulge and balloon signs – patellar tap • Baker’s cyst will bulge into popliteal fossa • Hold and flex knee, feeling for crepitus and assess range

21. Hindfoot • Tibiotalar synovial swelling often best appreciated by inspection from behind • Most sensitive areas for tenderness are anterior and distal to medial and lateral malleoli • Subtalar joint assessed by inversion of hindfoot – best in prone position with knees flexed

22. Midfoot • Calcaneocuboid joint anterior to distal fibula • Talonavicular joint anterior to medial malleolus • Test by rotation of midfoot

23. Forefoot • Squeeze all MTPs before testing individual MTPs • Inspection of soles of shoes can provide clues to arthritis in feet

24. Posture and Gait • Inspect in standing position • Alignment of shoulders and iliac crests, straightness of spine, normal lordosis/kyphosis (back to the wall) • Symmetry of muscle bulk • Knee and ankle deformities with bearing weight • Leg length inequality – lying down (compensations when standing) • Measure from anterior superior iliac spine to medial malleolus • Inspect the walking patient • Arms, pelvis, hips, knees, feet • “Antalgic gait” – More time on one leg than the other • “Trendelenburg gait” – Pelvis drops on good side to compensate for impaired hip abduction on affected side

25. Questions?