Observe for full finger joint extension. The volar surfaces of the palms and fingers should make full contact when placed together. In making a fist, each fingertip should touch the MCP crease.
Synovial swelling of the proximal interphalangeal (PIP) and MCP joints can be detected readily by the presence of soft tissue swelling on either side of the dorsal aspects. The examiner supports the palm in individual fingers with both hands and palpates the joint margins using the thumbs. When synovial fluid swelling is present, the joint margins will be less distinct compared to the same joint on the opposite hand. Inflammation of the distal interphalangeal (DIP) joints has a limited differential diagnosis that includes osteoarthritis (typically characterized by Heberden nodes), gout (with tophi often occurring at sites of Heberden nodes), and psoriatic arthritis. Septic arthritis, trauma, sarcoidosis, and syphilis are also in the differential diagnosis. Classic rheumatoid arthritis rarely involves the PIP joint alone. Psoriatic arthritis of the PIP joints commonly stimulates the juxta-articular periosteum, giving them a fusiform, erythematous appearance called a sausage digit. Pain caused by lateral compression of the MCP joints as a group is a good screening test for small joint polyarthritis.
Secondary contracture of the intrinsic muscles of the hand in patient with rheumatoid arthritis leads to the swan-neck deformity characterized by fixed hyperextension of the PIP and flexion of the DIP joints. Ulnar deviation and inability to extend the MCP joints of the fingers are the result of the rheumatoid disruption of the soft tissue tethers that allowed the long extensor tendons to slip off the metacarpal heads. Inability to fully extend the PIP joints is a result of separation of the two slips of the long extensor tendon and their subluxation to either side of the joint. This leads to what is known as the boutonniere deformity. Extensive inflammation of finger joint capsules and ligaments in patients with systemic lupus erythematosus can result in joint laxity and diverse deformities in the absence of bone erosion.
Bony enlargements of the DIP joints (Heberden nodes) are a feature of hereditary osteoarthrosis and are often accompanied by similar changes in the PIP joints (Bouchard nodes). That process commonly affects the thumb carpometacarpal joint also, producing a squared appearance to the base of the joint and inability to extend it fully. The MCP joints are rarely, if ever, affected by osteoarthritis but a similar appearance of the second and third MCP joints may be seen in patients with hemochromatosis. Localized swelling of the tendon that restricts its motion within the sheath can be felt if the examiner palpates over the tendon at the distal palmar crease as the finger is flexed or extended.
Arthritis of the wrists is usually caused by an inflammatory process. The exceptions are wrist pain related to carpal subluxation or fracture that can be reliably detected only by radiography. Synovitis of either the true radiocarpal or intercarpal joints is common among patients with rheumatic disorders. The absence of pain at the wrist on pronation or supination of the forearm suggests that the process is restricted to the carpus. When swelling is prominent on the dorsal or volar aspects of the joint, tenosynovitis of the extensor or flexor tendons respectively should be suspected and can be confirmed by observing the axial movement of the swelling when the fingers are moved. Swelling and tenderness over the ulnar styloid is common in rheumatoid arthritis and may be followed by dorsal subluxation of the ulnar head.
Pain and tenderness at the radial styloid is often caused by irritation of the extensor pollicis longus tendon where it crosses the radial head. This disorder, known as de Quervain tenosynovitis, is caused by repeated lifting with the palm oriented vertically. The diagnosis of de Quervain tenosynovitis can be confirmed by Finkelstein test.
The causes of inflammation of the elbow joint include rheumatoid arthritis, seronegative arthritides, septic arthritis, and gout. Swelling and effusions in the joints present at the radial head on the lateral aspect of the radiohumeral joint. Pronation and supination of the forearm is often painful and restricted. Synovial swelling in the olecranon fossa prevents full extension of the joint by limiting entry of the olecranon process. Acute inflammation of the olecranon bursa over the tip of the elbow is usually caused by gout or infection, but more chronic benign swelling can also be caused merely by direct trauma. The extensor surface of the ulna just below the olecranon is a common site for a rheumatoid nodule.
Epicondylitis is an enthesopathy of the common wrist flexor origin at the medial epicondyle (golfer’s elbow) or that of the extensors at the lateral epicondyles (tennis elbow). Tenderness is present over or immediately below the epicondyle and pain is elicited by resisted wrist flexion or extension, respectively.
The motion of the shoulder is the most complex of any joint. Consequently, it is often difficult to determine the exact cause of shoulder pain. With most activities, the glenohumeral joint moves in several planes simultaneously and scapulothoracic translocation can increase its apparent range misleadingly. The joint should be examined while scapular motion is observed or restricted by placing a hand over the shoulder on the trapezius ridge. The range of motion of the glenohumeral joint precludes ligamentous stabilization, which is replaced by dynamic control provided by the concerted action of the four rotator cuff muscles. Painful contractions of the shoulder tend to induce rotator cuff muscle dyssynergia, which is itself painful and can obscure the primary cause of the problem. Passive or active motions that minimize rotator cuff function include rotation of the humerus while the arm is hanging vertically oriented for flexion and extension in the sagittal plane. If those movements produce pain, true glenohumeral joint disease is present.
Shoulder joint pain is felt in the area of the deltoid muscle. Pain proximal to the olecranon is more often of cervical or thoracic apex origin. The capsule of the glenohumeral joint extends medially to the coracoid process. Tenderness at that site is the only place where it can be confidently assigned to the glenohumeral joint because the rest of the area is covered by the rotator cuff apparatus. Swelling of the glenohumeral joint is best appreciated at the anterior margin of the deltoid muscle just below the acromion, where an effusion, if present, can be balloted.
The shoulder drop sign is a good test for rotator cuff pathology. The shoulder should be passively flexed in the sagittal plane to 90 degrees, preferably with the elbow also flexed to reduce leverage. The humerus is supported while being rotated to the coronal plane and the forearm is extended and pronated. Support of the arm is then gently withdrawn while the patient is instructed to maintain the arm in this abducted position. The onset of pain and dropping of the arm is a positive sign. Tenderness over the lateral tip of the shoulder just below the acromion is often attributed to subacromial bursitis but is almost always attributable to supraspinatous tendon pathology. Inflammation of the long head of the biceps tendon at the groove where it crosses the humerus may cause widespread shoulder pain. In addition to tenderness immediately over the bicipital groove, the diagnosis can be confirmed by Yergason sign. The patient should sit with the elbow flexed and the forearm pronated, resting on the thigh. The examiner grasps the wrist and asks the patient to supinate the forearm against resistance, which will cause pain in the bicipital groove.
Restricted and painful active or passive motion of the shoulder in all directions is diagnostic of a frozen shoulder caused by generalized capsular inflammation and constriction. This is frequently idiopathic but may also result from traumatic injury. The patient may be able to move the arm only by scapulothoracic motion. Inflammation of the acromioclavicular or sternoclavicular joints can occur in rheumatoid arthritis or septic arthritis, the latter being especially common in injection drug users. Tenderness and swelling is easily appreciated at the site. Shrugging of the shoulder while lying on the affected side is painful.
Gait analysis can help define the nature of hip disease. Dwell time on the affected hip is limited compared to its opposite. Forward lurching as the leg is extended with each step indicates either fixed hip flexion or pain caused by tensing a swollen or inflamed hip capsule. Movement of the upper trunk over the weight-bearing hip suggests either adductor (gluteus maximus) weakness or its inhibition. Joint loading, by increasing intra-articular pressure, aggravates many different causes of hip pain. A positive Trendelenburg sign will be detected. This sign is demonstrated by having the examiner place his or her hands on both iliac crests and asking the patient to raise one leg or the other. Weight bearing on the painful side cause the opposite iliac crest to drop.
Restricted hip motion can be masked by compensatory movement of the pelvis. Children with very mobile lumbar spines, for example, can nearly completely conceal a fused hip. In order to restrict pelvic motion during examination, the patient should hold the opposite hip fully flexed. Any pelvic motion will be revealed by movement of the flexed knee. Loss of motion caused by hip disease first restricts full extension followed by inversion, eversion, and then abduction. Inability to keep the extended leg on the table while fully flexing the opposite indicates some loss of full extension as a result of either hip disease or a periarticular problem, such as iliopsoas tendinitis. Passive log rolling of the extended leg while the patient is supine can detect early guarding and restricted motion. Performing the FABER maneuver (flexion, abduction, and external rotation) is a test for painful—as well as limited—motion. Because the hip joint is supplied by the femoral nerve, pain emanating from the true hip joint is perceived in the groin, anteromedial thigh, and often in the knee. In some cases, hip pain is felt only in the knee. Pain in the buttock is more often caused by a sciatic nerve problem.
Groin or anterior thigh pain when the hip is actively flexed against resistance or passively extended may be caused by iliopsoas tendinitis or bursitis. Local tenderness is usually present. Iliopsoas lesions must be distinguished from femoral hernias and enthesopathy of the thigh adductors. In the latter case, the tenderness is located at the pubic tubercle more medially. Pain located in the buttock, on passive internal rotation and adduction of the hip (as an initiating a golf swing) is symptomatic of piriformis tendinitis or bursitis. When felt deep inside the pelvis it may be a symptom of obturator bursitis, which can be confirmed by palpating the margin of the lesser sciatic foramen per rectum.
Apparent and true leg length discrepancy may reflect either fixed hip abduction, abduction, or lumbar spine scoliosis. It can be distinguished from true leg shortening by measuring each side from the anterior/superior iliac spine to the medial tibial plateau or medial malleolus. True leg length shortening occurs in superior subluxation of the hip or severe destructive disease of the joint.
Pain over the greater trochanter points to trochanteric bursitis or, equally commonly, gluteus enthesopathy (usually of the gluteus medius) or a tear of the gluteus muscle. Because the gluteus tendons insert into the trochanter, it can be difficult to differentiate these problems by palpation. Pain felt while rolling over in bed is most likely due to bursitis. In contrast, trochanteric pain aggravated by prolonged standing or stair climbing typically indicates gluteus medius tendinitis.
The knee is the most commonly painful joint because it is subject to almost all causes of articular pathology. The alignment of the knee should be observed while the patient is standing. Varus or valgus malalignment may be congenital or acquired. Erosion of articular cartilage from either the medial or lateral tibiofemoral compartment is a common cause. Valgus alignment results in abnormal compression of the lateral opposing surfaces of the patellofemoral articulation. In individuals who are symptomatic, manual displacement of the patella on an extended knee produces discomfort. This is known as the apprehension sign. The lateral angle at the extended knee, the acute angle, is measured along the axis of the femur and through the midpoint of the patella to the tibial tubercle. The valgus angles in young women of less than 20 degrees can be ignored and corrects as the skeleton matures. Activities that involve excessive weight bearing on partially flexed knees cause chondromalacia of the undersurface of the patella. This condition is associated with a feeling of crepitus when the hand is placed over the patella as the knees are extended against gravity. When severe, it can be a cause of the pain. Crepitus can also indicate the presence of loose bodies within the joint.
Most knee disorders are accompanied by a synovial effusion that is best detected by eliciting the bulge sign. The knee must be as fully extended as possible. The effusion is demonstrated by first directing the fluid entered into the suprapatellar synovial recess by stroking upward over the medial patellofemoral articulation. Fingers are then immediately drawn downward from above the lateral patellofemoral groove while carefully observing the hollow between the patella and a medial condyle for a bulge. Chronic and relatively painless effusions may also protrude posteriorly into the popliteal space to produce a Baker cyst. Although such cysts can be sizable and track down beneath the gastrocnemius muscle, they are more often felt as a firm lump in the popliteal space. The knee must be fully extended since even slight flexion increases the capacity of the joint and a small effusion will diminish. Chronic synovial swelling, as in patients with rheumatoid arthritis, will produce a collar-like thickening immediately above the patella where the suprapatellar recess creates a double layer of the joint lining. It is frequently tender to palpation.
Because the tibial plateau is almost flat, translocation of the femoral condyles (rolling across the examination table) during flexion and extension is prevented by the menisci, which form a shallow cup, and the cruciate ligaments. A tendency within knee to give way while bearing weight or to lock suggests the presence of damage to the structures or a loose soft tissue fragment in the joint. Displaced menisci may be palpated along the margin of the tibial plateau but can be more reliably detected by the McMurray test. The McMurray test is performed by flexing the knee as far as possible, grasping the foot holding the thigh with the other hand and either internally or externally rotating the tibia while exerting either a varus or valgus strain. During knee extension, a torn meniscal fragment may become caught in the joint, producing pain and arrested motion.
Classically, the torn meniscus is opposite to the direction of tibial rotation, although that is not invariable. An injured infrapatellar synovial fold (plica), which is attached to the intracondylar notch, can result in symptoms that are similar to those of a torn meniscus, especially in young athletes.
Traumatic elongation or rupture of the cruciate ligaments allows abnormal anteroposterior translocation of the femoral condyles onto the tibial plateau. The anterior cruciate ligament limits posterior condylar translocation (ie, it prevents the tibia from sliding anteriorly) and the posterior cruciate ligament limits anterior displacement of the femur. The drawer test demonstrates increased anteroposterior instability of the joint by attempting to move the proximal tibia back and forth over the femoral condyles. Because the anterior cruciate ligament is normally relaxed by flexion of the knee, any abnormal laxity of that structure should be tested within knee and no more than 20–30 degrees of flexion. When the posterior cruciate ligament has been damaged, hamstring spasm may draw the tibia posteriorly. This must be minimized by flexing the knee to 90 degrees when testing for the integrity of the posterior cruciate ligament.
Pain caused by medial or collateral ligament injury or insufficiency is listed by supporting the knee in a fully extended position and abruptly applying a valgus or varus strain to the tibia. Some slight laxity is usually observed, especially in young or loose-jointed individuals. Comparison of the two sides is necessary.
There are several bursae around the knee. Inflammation in these bursae can cause pain upon weight bearing. The prepatellar bursa can be injured by prolonged kneeling. Another bursa under the patellar tendon is subject to both direct pressure and excessive quadriceps tension. The anserine bursa, which is located below the medial tibial plateau between the tibia and the biceps femoris tendon, becomes painful and swollen in individuals who are overweight and have valgus knee alignment.
Careful examination is required to distinguish between true talotibial and subtalar joint pathology as well as injury to the complex ligamentous support of those joints. In addition, the tendons to the foot may be injured where they turn sharply behind the malleolae. Examination by sequential active, passive, and resisted isometric maneuvers can usually distinguish between those possible sources of pain. Synovial swelling and effusions of the talotibial joint are appreciated best over the anterior joint line, on either side of the tibialis anterior tendon and over the synovial fold below the flexor retinaculum over the neck of the talus. Swelling in relation to the malleolae is usually present also but is difficult to distinguish from that caused by injury to a ligament or tendon in the area.
Pain and limitation of motion related to the subtalar joint is detected by grasping the heel and applying a varus or valgus strain while holding the tibia. A normal range of motion is variable. The ankle and foot should also be examined while the patient is standing in order to detect eversion of the hindfoot, manifested as valgus deviation of the calcaneus and Achilles tendon. This may reflect either deltoid ligament insufficiency or weakness of the tibialis posterior muscle. Pes planus is also best seen on standing.
Inflammation of the joints or tendon sheaths in the compartment below the medial malleolus can compress the posterior tibial nerve and cause chronic pain in the foot and ankle.
Pain around the heel has several possible causes. It is a common manifestation of reactive arthritis. Tenderness near the insertion of the Achilles tendon reflects either enthesopathy or inflammation of the bursa that lies immediately above the upper corner of the calcaneus and the tendon insertion. Plantar surface heel pain and tenderness is usually caused by so-called plantar fasciitis, which includes enthesopathy of the plantar ligament or the origin of the flexor digitorum brevis at its attachment to the calcaneus just anterior to the heel pad. The heel pad itself may become painful by prolonged standing on hard surface without adequate heel cushioning. Pain elicited by lateral compression of the heel distinguishes talalgia from plantar enthesopathy.
Inflammation of the intertarsal and tarsometatarsal joints is often difficult to localize. There is variable intraconnectivity of the synovial cavities in the midfoot, and this region may become diffusely swollen. In patients with rheumatoid arthritis or its seronegative variants, the MTP and PIP joints are affected as much as the hands, and they should be examined in the same way. Chronic inflammation that results from damage to the transverse metatarsal ligaments leads to cockup deformities of the toes and prolapse of the metatarsal heads. The metatarsal arch is flattened and the metatarsal heads can be felt as tender, pebble-like structures on the plantar service at the base of the toes. Transverse compression of the metatarsals is a good sign for arthritis of any of the MTP joints. This maneuver can also identify pain from a Morton neuroma in one of the intraosseous nerves.
Stiffness of the first MTP joint (hallux rigidus) or valgus toe deviation that may be associated with varus positioning of the metacarpal can cause chronic foot pain.
For the detection of scoliotic or kyphotic deformities, the patient should be observed standing, preferably barefoot. The range of normal lumbar lordosis is considerable but a curve of more than 30 degrees or none at all is usually abnormal. Have the patient bend forward as far as possible. A rotational deformity will be revealed by twisting of the thorax. The Schober index, a measure of a loss of flexibility of the lumbar spine, is useful in the longitudinal evaluation of patients with ankylosing spondylitis. The Schober index is measured by marking the lumbosacral junction (the first “valley” detected while probing up toward the midline over the sacrum), measuring up a distance of 10–15 cm, and making a second mark. The patient is then asked to flex forward as far as possible. The line should separate by a distance about 50% greater than that originally measured. The index is more useful for following disease progression than for initial diagnosis. Measuring the distance between the fingertips and the floor when fully flexed is also useful; however, it can be limited by reduced hip flexion.
Observe neck rotation, flexion, and extension. Patients with normal neck flexion and extension can touch the tip of the jaw to the sternum and to extend the neck to form a straight line from the surface of the sternum to the horizontal ramus of the mandible. The ability to bend the neck in the coronal plane (ie, tilt the head) is variable but is often the most painful motion with intravertebral disk disease or the presence of nerve root compression. Measuring the distance between the occiput and the wall while the patient is standing with his heels against it is a good way to document flexion deformity of the upper trunk and neck.
Lateral bending of the thoracolumbar spine is assessed with the patient standing. The spine should form a smooth curve from the lower lumbar to midthoracic levels. A straight segment indicates either an abnormality of that level or paraspinous muscle spasm. This can be an early manifestation of ankylosing spondylitis.
The spondyloarthropathies often affect the costovertebral joints, thus limiting chest expansion. Measuring chest expansion helps identify and follow those disorders. Inflammation of the sacroiliac joints is a common early manifestation of the spondyloarthropathies. It is often asymmetric in psoriatic or reactive arthritis. Local tenderness may be detected over the joints at the “dimples of Venus.” A sensitive test for sacroiliac inflammation is the McCunnell maneuver. This is performed by having the patient lie on the side of the less painful joint and grasp and hold the dependent leg fully flexed while the examiner supports and extends the other leg with one hand. The examiner restricts pelvic motion during leg extension by placing the other hand on the iliac crest. The McCunnell maneuver, which causes a twisting strain through the joints, should be performed gently because it can be quite painful in the presence of sacroiliitis.