4/7/2022

HISTORY AND
PHYSICAL EXAM
IN RHEUMATOLOGY
Jeanine Menassa MD
Head of division of rheumatology, Lebanese University
2020/2021

KEY POINTS

1. A detailed and accurate history is crucial to make the correct diagnosis in

patients with musculoskeletal diseases
2. The primary symptoms of musculoskeletal disease are pain, joint stiffness,
swelling, limitation of motion, weakness, fatigue, and loss of function
3. An understanding of the anatomy, the planes of motion and, particularly, the
configuration of the synovial lining, is imperative for proper physical
diagnosis of musculoskeletal diseases
4. It is important to record qualitative and quantitative aspects of the joint
examination to monitor disease activity in patients with inflammatory
arthropathies
5. Early recognition of how patients’ psychosocial factors affect their
musculoskeletal symptoms and musculoskeletal examination enhances 2
clinical assessment

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HISTORY IN A PATIENT WITH

MUSCULOSKELETAL DISEASE
1. Detailed
2. Symptom onset,
3. Location,
4. Patterns of progression,
5. Severity,
6. Exacerbating and alleviating factors
7. Associated symptoms
8. The relationship to psychosocial stressors
9. The impact on the patient’s functioning
10. The effects of current or previous therapy on the course of the illness
11. Response to anti-inflammatory or glucocorticoid
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12. Compliance with therapies for musculoskeletal diseases

HISTORY IN A PATIENT WITH

MUSCULOSKELETAL DISEASE

1. Pain
2. Stiffness
3. Limitation of motion
4. Swelling

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PAIN

• the most common symptom that brings a patient with musculoskeletal

diseases to the physician.
• Pain is a subjective hurting sensation or experience that is described in
various terms
• Pain is a complex sensation that is difficult to define, qualify, and
measure

PAIN

1. Modified by emotional factors and previous

experiences
2. Character of the pain usually is best defined early in
the interview because this can be helpful in categorizing
the patient’s complaints
1. Aching in a joint area suggests an arthritic disorder,
2. burning or numbness in an extremity may indicate a neuropathy.
3. Descriptions of pain as “excruciating” or “intolerable” when the
patient is otherwise able to function provide a clue that
emotional or psychosocial factors are contributing to or
Jeanine Menassa MD 6
amplifying the symptoms

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PAIN

3. Distribution of the patient’s pain and determine

whether this fits with anatomic structures
4. Location in terms of body part names, but frequently
the terms are used in a nonanatomic manner. Patients
frequently complain of “hip” pain when they are actually
referring to pain in the low back, buttock, or thigh
1. ask the patient to point to the area of pain with one finger. Pain
localized in the distribution of a joint or joints likely reflects an
articular disorder
2. localize to bursae, tendons, ligaments, or nerves, implying
disorders of these structures. 7

jeanine Menassa MD

PAIN

5. Widespread pain, is vaguely described, and does not respect anatomic

distributions generally suggests a chronic pain syndrome, such as fibromyalgia
or psychiatric disease
6. The severity of the pain should be assessed
• numeric scale of intensity from 0 (no pain) to 10 (very severe pain)
• a visual analogue scale by having the patient mark the severity of pain during the past
week on a 100-mm line
7. Exacerbating and alleviating factors
• Joint pain present at rest but worse with movement suggests an inflammatory process,
whereas pain that occurs primarily with activity and is relieved by rest usually indicates a
mechanical disorder such as degenerative arthritis
8. Timing of pain symptoms during the day and night
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STIFFNESS

• Common complaint among patients with arthritis

• Definition: discomfort and limitation when the patient attempts to
move the joints after a period of inactivity
• “gel” phenomenon occurs usually after an hour or more of
inactivity
• duration of stiffness: from minutes to hours
• Morning stiffness is an early feature of inflammatory arthropathies
• “In the morning, how long does it take for your joints to limber up to as good as
they are going to get for the day?”

• Morning stiffness associated with non-inflammatory joint diseases,

such as degenerative arthritis, generally is of short duration
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LIMITATION OF MOTION (LROM)

• a common complaint among patients with articular disorders

• LROM ≠ stiffness, which usually is transient and variable,
• limitation of motion secondary to join disease is generally fixed
• The interviewer should determine the
• extent of disability resulting from the restriction in joint motion
• duration of the restriction in joint motion
• rapidity of onset of the limitation of motion may be helpful
• abrupt onset of the limitation of motion suggests a structural
derangement, such as a tendon rupture or torn knee cartilage
• insidious onset of restricted joint motion is more common with
inflammatory joint disease 10

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SWELLING

• Joint swelling is an important symptom in patients

with rheumatic diseases
• The presence of true joint swelling narrows the
differential diagnosis in a patient with arthralgia
• Patients with inflammatory arthritis may describe
swelling of joints in a distribution typical of a
specific disease
• symmetric swelling of the metacarpophalangeal joints and wrists
in RA,
• swelling of several toes and a knee in psoriatic arthritis.
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SWELLING

• Anatomic location and distribution +++

• Diffuse soft tissue swelling can occur because of venous or lymphatic obstruction,
soft tissue injury, or obesity
• The description of swelling in patients with such conditions usually is ill defined or
is not in a distribution of particular joints, bursae, or tendons
• Soft tissue
• Obesity
• Lymphatic

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SWELLING

• Onset
• Progression of swelling
• Swelling of a confined structure, such as a synovial cavity or bursa, is most
painful when it has developed acutely, whereas a similar degree of swelling
that has developed slowly often is much more tolerable

• Factors that influence it

• Relation to range of motion
• Swelling of a joint resulting from synovitis or bursitis frequently is associated
with discomfort with motion because of tension on the inflamed tissues. If
swollen tissues are periarticular, however, no discomfort may be present 13
with joint motion because the inflamed tissues are not stressed

WEAKNESS

• True weakness is the loss of muscle power

• When present, it is demonstrable on physical examination
1. The temporal course of weakness is important to the differential
diagnosis
• Weakness of sudden onset without trauma often indicates a neurologic
disorder, such as an acute cerebrovascular event, which generally results in a
fixed, nonprogressive deficit
• Weakness of insidious onset more often suggests a muscle disease, such
as an inflammatory myopathy (e.g., polymyositis).The latter tends to be
ongoing and progressive
• Weakness of intermittent course suggests a disorder of the
neuromuscular junction, such as myasthenia gravis. Patients with this disease 14

may describe muscle fatigue with activity as opposed to true weakness.

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WEAKNESS

2. Determine the distribution of the patient’s weakness

• Proximal weakness that is bilateral and symmetric suggests an inflammatory myopathy
• In contrast, inclusion body myositis causes an asymmetric and more distal weakness
• The presence of a unilateral or isolated deficit generally indicates a neurogenic origin
• Distal weakness, in the absence of joint findings, generally indicates neurologic
disorders, such as peripheral neuropathy
3. Presence of sensory symptoms
• Patients with peripheral neuropathies also complain of pain and sensory symptoms,
such as paresthesias In contrast, patients with inflammatory myopathy often present
with painless weakness
4. Family history
• Inquiring about the patient’s family history may provide valuable information. A history
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of other family members with similar symptoms may increase the likelihood that the
patient has a hereditary disorder, such as muscular dystrophy or familial neuropathy

WEAKNESS

5. Medication history
• including corticosteroids and lipid-lowering agents, can cause muscle injury
6. Environmental exposure can lead to symptoms of weakness
• Heavy metal poisoning causes a peripheral neuropathy
7. Dietary exposure also should be investigated, such as eating
undercooked pork as a source of trichinosis
8. Excessive alcohol intake has been associated with neuropathy and
myopathy.
9. Taking a complete review of systems
10. Constitutional symptoms,
• weight loss and night sweats, may indicate the presence of a malignancy 16

• Rash, arthralgia, or Raynaud’s phenomenon in a connective tissue disease

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FATIGUE

• Patients with musculoskeletal disorders frequently complain of fatigue

• Fatigue can be defined as an inclination to rest even though pain and weakness
are not limiting factors
• Fatigue after varying degrees of activity that is relieved by rest is normal

• Patients with rheumatic diseases experience fatigue

even without activity
• Fatigue generally improves as the systemic rheumatic disease improves
• Malaise frequently occurs with, but is not synonymous with, fatigue
• Malaise indicates the lack of well-being that often occurs at the onset of an
illness
• Fatigue and malaise may occur in the absence of identifiable disease, and
psychosocial factors, anxiety, or depression may account for the symptoms
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LOSS OF FUNCTION

• patient’s ability to perform activities of daily living

• a common manifestation of musculoskeletal disease with serious impact on health and
quality of life
• The extent of disability may vary from loss of the ability to use one finger joint because
of arthritis to complete physical incapacitation resulting from severe inflammatory
polyarthritis
• Irrespective of the cause, loss of physical function often has a profound impact on
patient social activities, exercise routine, work capacity, and even basic self-care
• Assessing for the presence and degree of functional disability is important to evaluate
the severity of illness and in making treatment recommendations, particularly in RA, in
which disability is among the strongest predictors of longterm outcomes and mortality.

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LOSS OF FUNCTION
ASSESSMENT

• Asking general questions about the patient’s ability to perform daily

activities, including grooming, dressing, bathing, eating, walking, climbing
stairs, opening doors, carrying objects, …………
• Opportunities for physical and occupational therapy, use of splints/braces,
• Overall functional capacity may be evaluated with the use of an
instrument such as the Health Assessment Questionnaire which is widely
used in research and in the clinic to monitor changes in physical function
in response to therapy among patients with RA and other rheumatic
diseases

Objective of any rheumatological treatment should be to

avoid loss of function
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PHYSICAL EXAM

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GENERAL OBSERVATION

• look for any signs of systemic illness

• skin, noting signs of pallor (which may suggest anemia)

• nodules (which may suggest RA or gout)
• rashes (which may suggest lupus, vasculitis, or
dermatomyositis)

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NODULES

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RASH

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GENERAL OBSERVATION

• Patient should be appropriately undressed

• Assess gait for antalgic gait in various musculoskeletal disorders
• spine
• lower extremities
• neuromuscular diseases
• Assess change from sitting to standing position
• information on pain, proximal muscle strength, and overall physical function.
• Assess for appearance of the muscles symmetrically
• bulk,
• tone,
• The patient’s manner and body language may provide information on his or her mood 25
and anxiety level, which merits consideration in evaluating pain and tenderness

SWELLING

• = intra-articular effusion, synovial proliferation, periarticular subcutaneous tissue

inflammation, bursitis, tendinitis, bony enlargement, or extra-articular fat pads
• Joint effusion or effusion of periarticular tissues?????????????
• Inspect the joints for visible evidence of swelling,
• such as loss of normal landmarks or contours, check bilateral joint look for symmetry
• palpate each joint
• The normal synovial membrane is too thin to palpate, whereas the thickened synovial membrane in
many chronic inflammatory arthritides, such as RA, may have a “doughy” or “boggy” consistency
• Examine the extent of the synovial cavity
• by compressing the fluid into one of the extreme synovial recesses.
• The edge of the resulting bulge may be palpated more easily
• If this palpable edge is within the anatomic confines of the synovial membrane and disappears on
release of compression, the distention usually represents synovial effusion
• if it persists, it is an indication of a thickened synovial membrane
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• Ultrasonography is used increasingly as an extension of the physical examination, allowing the
examiner to differentiate between synovial proliferation and effusion.

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TENDERNESS

• Is unusual discomfort when the physician palpates

and puts pressure on articular and periarticular
tissues
• the pathology is intra-articular or periarticular in
location,

• Finding tender joints in a patient who also has

numerous other myofascial tender points is less of
a concern for arthritis than finding tender joints in
a patient with no extraarticular tenderness
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LIMITATION OF MOTION

• Remember the normal type and range of motion for each joint
• Bilateral Comparison
• Restricted joint motion due to the joint itself or to periarticular structures
• Compare the passive with the active range of motion
• If the passive range of motion is greater than the active range of motion, the
restriction may be the result of pain, weakness, or the state of articular or
periarticular structures
• Pain in the joint with attempted active or passive range of motion usually indicates
an abnormality in the joint

• Check muscle tension mimicking a true limitation of joint motion, emphasizing the
importance of ensuring relaxation of the patient
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CREPITUS

• A palpable or audible grating or crunching sensation produced by

motion
Cracking or
• Occurs when roughened articular or extra-articular surfaces are rubbed
popping
together by active motion or by manual compression
sounds by
• Fine crepitus in chronic inflammatory arthritis and usually indicates slipping
roughening of the opposing cartilage surfaces as a result of erosion or ligaments or
the presence of granulation tissue tendons
• Coarse crepitus may be caused by inflammatory or non-inflammatory
arthritis
• In scleroderma, a distinct, coarse, creaking, leathery crepitus may be
palpable or audible over tendon sheath
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JOINT DEFORMITY

• Bony enlargement,
• Articular subluxation,
• Contracture,
• Ankylosis

• Deformed joints usually do not function normally

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INSTABILITY

• The joint has greater than normal movement

in any plane
• Subluxation: is partial displacement of the
articular surfaces but still some joint surface-to-
surface contact
• Dislocation: no cartilage surface-to-surface
contact
• Instability is best determined by supporting
the joint between the examiner’s hands and
stressing the adjacent bones in directions in
which the normal joint does not move.
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DOCUMENTATION OF PHYSICAL EXAM

• Important in making
decisions about therapy

• Monitoring the activity of

arthritis

• Determining the efficacy of

interventions

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INTERPRETING THE JOINT

EXAMINATION

• The physician must understand the significance of specific joint findings,

• their presence and absence
• As with any diagnostic assessment, the accuracy and reliability of the joint
examination are important considerations
• Thus the examiner must consider the physical findings in view of the complete
history of joint symptoms to make an accurate diagnosis, assess prognosis, and
prescribe management
• Ultrasound examination can also be useful in clarifying the interpretation of
joint pathology and enhancing confidence in clinical decisions about therapies

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PHYSICAL EXAM OF UPPER

EXTREMITY

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TEMPOROMANDIBULAR JOINT
TMJ

• Formed by the condyle of the mandible and the fossa of the

temporal bone anterior to the external auditory canal.
• Difficult to visualize swelling
• Palpate the joint by placing a finger just anterior to the external
auditory canal and ask the patient to open and close the mouth
and to move the mandible from side to side
• Comparative exam
• Vertical / lateral movement
• Many arthritides can affect the temporomandibular joints, including
juvenile and adult RA
• Temporomandibular joint syndrome: bruxism, a form of myofascial
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pain, similar to fibromyalgia

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STERNOCLAVICULAR, MANUBRIOSTERNAL,
AND STERNOCOSTAL JOINTS

1. Sternoclavicular joint:
1. diarthrodial joint
2. medial ends of the clavicles +upper
end of the sternum Manubriocostal
joint
2. Sternocostal joint:
1. the first ribs + manubrium of the
sternum
3. The third through seventh sternocostal
joints articulate distally along the lateral
borders of the sternum
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STERNOCLAVICULAR JOINT

• The sternoclavicular joints:

• synovitis usually is visible and palpable
• Commonly involved by
• ankylosing spondylitis
• RA
• degenerative arthritis
• septic arthritis, especially in injection drug
users
• examined for tenderness, swelling, and bony
abnormalities
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STERNOCOSTAL JOINTS

• Costochondritis or Tietze’s syndrome

• Tenderness of the manubriosternal or
sternocostal joints is much more frequent
than actual swelling
• Spondyloarthritis

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ACROMIOCLAVICULAR JOINT
AC JOINT

• lateral end of the clavicle and the medial

margin of the acromion process of the
scapula.
• degenerative arthritis

• Bony enlargement of this joint is typically

observed

• Pain with adduction of the arm across the

chest indicates pathology of the
acromioclavicular

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SHOULDER

The shoulder consists of three joints:

Acromioclavicular (AC),
Sternoclavicular
Glenohumeral joints 41

THE SHOULDER

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THE SHOULDER
ANTERIOR VIEW

Sommet de l’acromion Apophyse coracoïde

Tête humérale Sous scapulaire

Muscle grand rond

Angle inf. omoplate

Triceps sural 43

THE SHOULDER
POSTERIOR VIEW

Acromion

Sus-épineux

Petit rond
Épine de l’omoplate

Grand rond
Sous épineux
Triceps brachial 44

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THE SHOULDER
SUPERIOR VIEW

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THE SHOULDER
HISTORY
• Patient’s age
• Temporal onset of pain slowly over time, or suddenly after a particular event?
• Weakness:
• The presence of significant weakness with pain upon engaging in overhead actions
• Neck pain? suggests impingement with a rotator cuff tear.
• Pain and weakness also may be noted upon reaching behind the back with the
radicular
shoulder in extension and external rotation, as when reaching into the back seat of a
pain car.
• Neurologic, • Initiating factors relative to the onset of symptoms should be elicited, and any history of
visceral, and shoulder pain or trauma should be carefully documented.
vascular • Pain intensity, character, location, and periodicity and aggravating or alleviating factors
disease • Pain should be graded on a visual analog scale of 0 to 10
• disruption of sleep
• Type of the pain: sharp or dull.
• The location or distribution of the pain should be identified: Is it local around the
shoulder girdle, or does the pain radiate down the arm? Is concomitant sensory loss or
weakness present?
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• Periodicity of the pain as constant or intermittent should be determined, along with
factors that aggravate or alleviate the pain

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THE SHOULDER
PHYSICAL EXAM
INSPECTION
• Standing behind the patient, who has both shoulders exposed
• Comparative study of both shoulders
• Contour, symmetry, any atrophy or asymmetry in shoulder position
• Spinatus muscle atrophy may result from disuse, chronic cuff tear, or
suprascapular or brachial neuropathy.
• scapular winging is evident, the patient should be asked to perform a wall
push-up, which accentuates winging
• The biceps tendon is palpated, along with the coracoid, lesser, and greater
tuberosities and the posterior cuff, and any tenderness is gauged
• Tenderness upon palpation of the long head of the biceps is frequently
associated with rotator cuff tendinopathy and tenderness of the greater
tuberosity
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THE SHOULDER
RANGE OF MOTION

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THE SHOULDER
THE ROTATOR CUFF

• Dynamic stability of the joint

• Supraspinatus: abduction
• Isometric strength
• Active painful arc and drop arm tests
• Empty can test
• Subscapularis: internal rotation
• Gerber’s test
• Infraspinatus: external rotation
• Teres minor:
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THE SHOULDER
RANGE OF MOTION

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THE SHOULDER
RANGE OF MOTION

A, Tenderness upon
palpation of trigger
points
Tenderness upon
palpation of the long
head of the biceps and
greater tuberosity
suggests impingement
with possible cuff
tendinopathy. 51

THE SHOULDER
RANGE OF MOTION
THE IMPINGEMENT SIGN NEER TEST

• the shoulder is elevated in

forward flexion while the
scapula is depressed with
the opposite hand, forcing
the greater tuberosity and
the rotator cuff against the
anterior acromion and
producing pain when
impingement exists
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THE SHOULDER
RANGE OF MOTION
CLANCY TEST – ROTATOR CUFF
IMPINGEMENT
• the patient standing and with the head
turned toward the contralateral
shoulder
• The affected shoulder is circumducted
and adducted across the body to
shoulder level, keeping the elbow in
extension with the arm internally
rotated with the thumb pointed toward
the floor
• In this position, the patient is asked to
resist maximally as a uniform downward
force is applied to the extended arm by
the examiner
• Production of pain or weakness
localized to the anterior lateral portion 95% sensitive
of the shoulder is considered a positive 95% specific 53
test result

THE SHOULDER
RANGE OF MOTION O’BRIEN TEST
AC JOINT IMPINGEMENT

• The test is performed by

forward flexion of the arm
at 90 degrees and
subsequent cross-chest
adduction of the arm.
• Pain localized to the AC
joint is considered a positive
test result.

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THE SHOULDER
RANGE OF MOTION
EXTERNAL ROTATION
INFRASPINATUS

• the patient’s elbow flexed at 90

degrees and held at the patient’s
side by the examiner
• The patient is asked to attempt
external rotation of the shoulder
from a neutral position (0 degrees
of adduction) as the examiner
applies resistance to the forearm.
• Strength is compared with that of
the contralateral arm.

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BICIPITAL TENDON
SPEED’S TEST

• The patient flex the shoulder and

extend the elbow while a
downward force is applied to the
arm
• The production of pain over the
long head of the biceps is a positive
test result and suggests bicipital
tendinitis

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THE SHOULDER
RANGE OF MOTION
ABDUCTION
SUPRASPINATUS

• the patient’s shoulder in 30 degrees

of forward flexion and 90 degrees of
abduction and with the thumb
pointed toward the floor
• The patient is asked to resist as the
examiner exerts a downward force
on the abducted arm
• Strength is compared with the
contralateral shoulder.

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SUPRASPINATUS
ISOMETRIC STRENGTH

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SUPRASPINATUS

IMPINGEMENT SIGN

PA INFUL ARC TEST NE E R TEST

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IMPINGEMENT SIGN
HAWKINS TEST

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SUPRASPINATUS
EMPTY CAN
JOBE TEST

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INTERNAL ROTATION
SUBSCAPULARIS
GERBER TEST

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THE EXTERNAL ROTATION

INFRASPINATUS

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SUPRASPINATUS AND INFRASPINATUS

MUSCLE ATROPHY

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THE SHOULDER
CHECK THE C SPINE

• Cervical range of motion is evaluated, and the paracervical muscles are palpated

• Paracervical tenderness and limited range of motion of the neck may indicate cervical
spondylosis or neurogenic disease

• A Spurling test is performed by flexing the neck laterally while applying axial
compression to the skull
• Pain that radiates to the ipsilateral shoulder is considered a positive test result and indicates
radiculopathy

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THE SHOULDER
DIFFERENTIAL DIAGNOSIS

• Grip strength is checked, and the hands are examined carefully for evidence
of intrinsic atrophy

• The biceps (C5), triceps (C7), and brachioradialis (C6) reflexes are checked
for symmetry and briskness

• Light touch sensory testing should be conducted, and the dermatomal

distribution of any deficits that may suggest that cervical radiculopathy
should be identified

• The cervical, supraclavicular, axillary, and epitrochlear regions should be 67

palpated for enlarged lymph nodes, which may suggest malignancy

THE SHOULDER
DIFFERENTIAL DIAGNOSIS

• In patients with pain out of proportion to objective findings, other causes of

shoulder pain should be sought, including
• calcific tendinitis,
• infection,
• reflex sympathetic dystrophy,
• Fracture
• ParsonageTurner syndrome: wasting of the supraspinatus and infraspinatus
muscles and posterior shoulder pain, especially younger patients, due to
suprascapular neuropathy or brachial neuropathy
• In chronic cuff disease variable disuse atrophy of the supraspinatus and
infraspinatus fossae is present
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ETIOLOGIES FOR SHOULDER PAIN

INTRINSIC CAUSE S E XTRINSIC FACTORS

• Periarticular Disorders
• Rotator cuff tendinitis or impingement syndrome • Regional Disorders

• Calcific tendinitis • Cervical

radiculopathy Abdominal organs
• Rotator cuff tear
• Brachial neuritis Gallbladder disease
• Bicipital tendinitis Splenic trauma
• Acromioclavicular arthritis • Nerve entrapment Subphrenic abscess
syndromes Myocardial infarction
• Glenohumeral Disorders metabolic disorders
• Sternoclavicular
• Inflammatory arthritis Thyroid disease
arthritis
Diabetes mellitus
• Osteoarthritis Renal osteodystrophy
• Reflex sympathetic
• Osteonecrosis dystrophy
• Septic arthritis • Fibrositis
• Glenoid labral tears • Neoplasm
• Adhesive capsulitis 69

• Glenohumeral instability

ELBOW

3 bony articulations

• humeroulnar joint,
• Radiohumeral joint
• proximal radioulnar joint

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ELBOW

• Examine the skin around the elbow joint carefully, noting abnormalities such as
psoriatic plaques, rheumatoid nodules, or tophi
• Palpate the olecranon bursa
• Limitation of motion and crepitus should be noted
• Synovial swelling is most easily palpated because it bulges under the examiner’s
thumb when the elbow is passively extended

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ELBOW

• Synovitis or effusion generally results in limitation of elbow extension

• Olecranon bursitis is common after chronic local trauma, RA, gout and septic olecranon bursitis
• swelling over the olecranon process, which is often tender and may be erythematous.
• Sometimes a large collection of fluid over the area is palpable as a cystic mass, often requiring aspiration and
drainage
• no pain with elbow movement
• Epicondylitis
• overuse tendinopathy, termed lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer’s elbow).
• In lateral epicondylitis, discomfort can be elicited by resisted supination of the forearm or resisted extension
of the pronated wrist
• In medial epicondylitis, discomfort can be elicited by resisted flexion of the supinated wrist
• To assess motor function of the elbow, flexion and extension can be assessed. The principal flexors of the
elbow are the biceps brachii (nerve roots C5 and C6), brachialis (C5 and C6), and brachioradialis (C5
and C6) muscles. The principal extensor of the elbow is the triceps brachii muscle (C7 and C8).
• Bicipital head rupture: one of the heads of the biceps, resulting in visible and palpable muscle swelling on
the anterior upper arm 73

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ELBOW
DISTAL BICIPITAL RUPTURE
POPEYE’S SIGN

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WRIST AND CARPAL JOINTS

• Radiocarpal joint
• triangular
fibrocartilage TLCC
• radioulnar joint
• midcarpal joints
• CMC 1

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WRIST AND CARPAL JOINTS

• Movements of the wrist include

• flexion (palmar flexion) 80 to 90degre
• extension (dorsiflexion) 70-80 degree
• the most incapacitating impairement
• radial deviation 20-30 degree
• ulnar deviation 50 degree
• Circumduction
• Pronation and supination of the hand and forearm occur primarily at the
proximal and distal radioulnar joints.
• CMC 1: moves in three planes.
• Crepitus at this joint is common because it is frequently involved in
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degenerative arthritis

WRIST AND CARPAL JOINTS

Retinaculum: flexor retinaculum (transverse

capal ligmants)

• The long flexor tendons of the forearm

• The median nerve
• The carpal tunnel: carpal bones +
retinaculum

• The extensor tendons of the forearm

musculature are enclosed by six synovial
lined compartments.

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WRIST AND CARPAL JOINTS

• The palmar aponeurosis (fascia) spreads out into the

palm from the flexor retinaculum.

• Dupuytren’s contracture, a fibrosing condition,

affects the palmar aponeurosis, which becomes
thickened and contracted and may draw one or more
fingers into flexion at the metacarpophalangeal joint

79

WRIST AND CARPAL JOINTS

Tendon
sheath
Effusion

Swelling of
the wrist

Synovial Wrist
proliferation joint

80

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WRIST AND CARPAL JOINTS

• Tenosynovitis
• swelling is localized to the distribution of a particular tendon sheath or
compartment
• Arthritis
• Articular swelling tends to be more diffuse and protrudes anteriorly and
posteriorly from under the tendons
• Synovitis of the wrist is best detected by palpation of the dorsal aspect
• Assess the range of motion / frequently is limited

81

WRIST AND CARPAL JOINTS

82

41
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WRIST AND CARPAL JOINTS

• A ganglion is a cystic enlargement arising from a joint capsule

• at the volar or dorsal aspect of the wrist between the tendons
• Trigger fingers secondary to stenosing tenosynovitis
• The affected finger catching or locking with movement.
• De Quervain’s tenosynovitis: of the first extensor compartment, which
encloses the abductor pollicis longus and extensor pollicis brevis muscles of
the thumb,
• Patients complain of pain at the radial aspect of the wrist
• Tenderness may be elicited by palpating near the radial styloid process
• the Finkelstein test:
• make a fist with the thumb enclosed in the palm of the hand, then to move the
wrist into ulnar deviation. 83

• Severe pain over the radial styloid is positive

WRIST AND CARPAL JOINT

84

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WRIST AND CARPAL JOINT

CARPAL TUNNEL SYNDROME

• Results from pressure on the median nerve in

the carpal tunnel

• Muscle function of the wrist may be measured

by testing flexion and extension and supination
and pronation of the forearm

85

METACARPOPHALANGEAL AND PROXIMAL

AND DISTAL INTERPHALANGEAL JOINTS
MCP PIP DIP
• Palpate the dorsal and volar aspects of each joint
• The squeeze test elicits pain if synovitis is present
• The proximal and distal interphalangeal joints are
best examined by palpating gently over the lateral
and medial aspects of the joint,
• Synovitis
• Dactylitis: Diffuse swelling of an entire digit,
sausage digit, may result from tenosynovitis and is
seen most commonly in the spondyloarthropathies
• Rheumatoid nodules: lump in RA patients
occurring on the extensors

86

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87

MCP PIP DIP

• Chronic swelling with distention of the metacarpophalangeal joints tends to

produce stretching and laxity of the articular capsule and ligaments.
• Swan neck deformity a finger with a flexion contracture of the
metacarpophalangeal joint, hyperextension of the proximal interphalangeal
joint, and flexion of the distal interphalangeal joint in RA
• Boutonnière deformity: a finger with a flexion contracture of the proximal
interphalangeal joint associated with hyperextension of the distal
interphalangeal joint
• Telescoping or shortening of the digits produced by resorption of the
ends of the phalanges secondary to destructive arthropathy in arthritis
mutilans a form of psoriatic arthritis
• A mallet finger results from avulsion or rupture of the extensor tendon at
the level of the distal interphalangeal joint results from traumatic injuries. 88

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89

MCP PIP DIP

• Heberden nodes: Enlarged, bony, hypertrophic DIP

joints whereas similar changes

• Bouchard nodes: enlarges bony hyertrophic PIP

joints

• Tophaceous gout

• Fingernails should be inspected for evidence of

clubbing, vasculitis, psoriasis, ulcer tip of the nail in 90

systemic sclerosis

45
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91

92

46
 4/7/2022

93

PHYSICAL EXAM
LOWER EXTREMITY

94

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THE HIP

• A spheroidal or ball-and-socket joint

formed by the rounded head of the
femur and the cup-shaped acetabulum
• Stability of the joint is ensured by
• the fibrocartilaginous labrum
• the dense articular capsule
• surrounding ligaments, (iliofemoral,
pubofemoral, and ischiocapsular ligaments)
95

THE HIP
THE MUSCLE

Flexion: iliopsoas muscle assisted by the sartorius and rectus femoris

96

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THE HIP
THE MUSCLE

• Adduction: adductors (longus, brevis, and magnus) plus the

gracilis and pectineus muscles

97

THE HIP
THE MUSCLE

• Abductor: gluteus medius, maximus, minimus

98

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THE HIP
THE MUSCLE

• Extension: gluteus maximus and hamstrings

99

HIP
THE BURSAE

• The iliopsoas bursa : Anteriorly,

lies between the psoas muscle
and the joint surface

• The trochanteric bursa lies

between the gluteus maximus
muscle and the posterolateral
greater trochanter

• The ischiogluteal bursa overlies

the ischial tuberosity 100

50
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HIP
EXAMINATION
• observation of the patient’s stance and gait
• The patient should stand in front of the examiner so that the anterior iliac
spines are visible
• Pelvic tilt or obliquity may be present and related to structural scoliosis,
anatomic leg-length discrepancy, or hip disease

101

102

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HIP
EXAMINATION
HIP CONTRACTURES

• adduction contracture:
• To compensate, the pelvis is tilted upward on
the side of the contracture
• Viewed from behind with the legs parallel, the
patient with hip disease and an adducted hip
contracture may have asymmetric gluteal folds
secondary to pelvic tilt, with the diseased side
elevated
• In this situation, the patient is unable to
stand with the foot of the involved leg flat
on the floor. 103

HIP
EXAMINATION
HIP CONTRACTURES

• abduction deformity
• the pelvis becomes elevated on the normal side during
standing or walking
• This elevation causes an apparent shortening of the normal leg
and forces the patient to stand or walk on the toes of the
normal side or to flex the knee on the abnormal leg
• In abduction contracture, both legs extended and parallel, the
uninvolved side is elevated.

104

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105

HIP
EXAMINATION
HIP CONTRACTURES

• A hip flexion deformity commonly occurs in

diseases of the hip
• Unilateral flexion of the hip in the standing
position reduces weight bearing on the involved
side and relaxes the joint capsule, causing less
pain
• This posture is best noted by observing the
patient from the side.
• A hyperlordotic curve of the lumbar spine
compensates for lack of full hip extension.
106

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HIP EXAMINATION
GAIT

• a normal gait, the abductors of the weight-bearing leg contract to hold the pelvis
level or to elevate the non–weight-bearing side slightly
• Two abnormalities of gait may be commonly observed in patients with hip disease

107

HIP EXAMINATION
GAIT

1. The antalgic gait:

• The most common abnormality seen with
a painful hip
• With this gait, the individual leans over
the diseased hip during the phase of
weight bearing on that hip,
• placing the body weight directly over the
joint to avoid painful contraction of the
hip abductors

108

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HIP EXAMINATION
GAIT

2. a Trendelenburg gait,
• weight bearing on the affected
side, the pelvis drops and the
trunk shifts to the normal side
• weak hip abductors

109

HIP EXAMINATION
THE TRENDELENBURG TEST
• assesses the stability of the hip, together with the
ability of the hip abductor muscle to stabilize the pelvis
on the femur

• It is a measure of the gluteus medius hip abductor

strength
• The patient is asked to stand while bearing weight on
only one leg
• Normally, the abductors hold the pelvis level or the
nonsupported side slightly elevated
• If the non–weight-bearing side drops, the test is
positive for weakness of the weight-bearing side hip
abductors, especially the gluteus medius muscle

• This test is nonspecific and may be used in primary

neurologic or muscle disorders and in hip diseases that
lead to weakness of the hip abductors.
110

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HIP EXAMINATION
ROM

• With the patient in the supine

position.
• The degree of flexion permitted varies
with the manner with which it is
assessed.
• When the knee is held flexed at 90 degrees, the hip
normally flexes to an angle of 120 degrees between the
thigh and the long axis of the body

• If the knee is held in extension, the hamstrings limit hip

flexion to approximately 90 degrees.

111

HIP EXAMNATION
ROM ABDUCTION

• patient in a supine position

• Pelvic stabilization is achieved by the examiner placing an arm across
the pelvis with the hand on the opposite anterior iliac spine
• With the other hand, the examiner grasps the patient’s ankle and
abducts the leg until the pelvis begins to move
• Abduction to approximately 45 degrees is normal
• compare
• OR: could stand at the foot of the table, grasp both of the patient’s
ankles, and simultaneously abduct both legs
• Abduction is commonly limited in hip joint disease
112

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HIP EXAMNATION
ROM ADDUCTION

• grasping the patient’s ankle and raising

the leg off the examination table by
flexing the hip enough to allow the
tested leg to cross over the opposite
leg
• Normal adduction is approximately 20
to 30 degrees
• Hip rotation may be tested with the hip
and knee flexed to 90 degrees or with
the leg extended. 113

HIP EXAMNATION
ROM ROTATION

• Normal hip external rotation and internal

rotation are observed to 45 degrees and 40
degrees, respectively
• Rotation decreases with extension
• To test hip rotation, the examiner grasps the
extended leg above the ankle and rotates it
externally and internally from the neutral position
• Limitation of internal rotation of the hip is a
sensitive indicator of hip joint disease.

114

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HIP EXMIATION
ROM EXTENSION

115

HIP EXAMNATION
FABER TEST PATRICK TEST

• The flexion abduction external rotation (FABER) test,

• screening test for intra-articular hip pathology
• the patient lie in a supine position with the foot ipsilateral to
the test hip, resting on the contralateral knee
• The examiner then slowly lowers the patient’s test leg toward
the examining table, applying gentle pressure to the knee of
the test hip and the contralateral anterior superior iliac spine
• Normally, the test leg will fall at least parallel to the opposite
leg.The FABER test is considered positive when the maneuver
reproduces the patient’s pain
• Although very sensitive for hip joint disease, this test is not
116
specific because a positive test may indicate iliopsoas tightness
or sacroiliac joint disease .

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HIP EXAMINATION
THE THOMAS TEST

• the flexion contracture

• the opposite hip is fully flexed to flatten the lumbar lordosis and fix the pelvis
• The patient’s involved leg should be extended toward the examination table as far
as possible.
• Flexion contracture of the diseased hip becomes more obvious and can be
estimated in degrees from full extension

117

HIP EXAMNATION
LEG LENGTH DISCREPANCY

• the patient in a supine position and the legs fully

extended
• Each leg is measured from the anterior superior iliac
spine to the medial malleolus
• > 1 cm ABNORMAL

• apparent leg-length discrepancies may result from

pelvic tilt or abduction or adduction contractures of
the hip

118

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HIP EXAMINATION
OBER TEST

• the iliotibial band syndrome / tensor fasciae latae muscle

contraction or inflammation
• Young woman
• The patient lies on the side, with the lower leg flexed at the hip and knee.
• The examiner abducts and extends the upper leg with the knee flexed at 90
degrees.
• The hips should be slightly extended to allow the iliotibial band to pass over
the greater trochanter
• The examiner slowly lowers the patient’s limb with the muscles relaxed.
• A positive test result indicative of an iliotibial band contracture occurs if the
leg does not fall back to the level of the tabletop
119

HIP EXAMINATION
TROCHANTERIC BURSITIS

• A common cause of lateral hip pain

• pain and tenderness when they attempt to lie on the affected
side or climb stairs
• The greater trochanter should be palpated for tenderness and
compared with the opposite side
• In trochanteric bursitis, this area is usually exquisitely tender.
• The pain of trochanteric bursitis is aggravated by actively
resisted abduction of the hip
• Aching and tenderness over the buttock area may be secondary 120

to an ischial bursitis

60
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121

HIP EXAMINATION

• Anterior hip and groin pain may be secondary to hip

abnormality, most commonly degenerative arthritis
• iliopsoas bursitis:
• swelling and tenderness noted in the middle third of the
inguinal ligament lateral to the femoral pulse
• This pain is aggravated by hip extension and is reduced by
flexion.
• The bursitis may be a localized problem or may represent
extension of hip synovitis
122

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HIP EXAMINATION

• The inguinal region should be palpated for other abnormalities,

such as hernias, femoral aneurysms, adenopathy, tumor, and psoas
abscess or masses

• Remember to do a neuro exam

123

THE KNEE

124

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KNEE

• The knee is a compound condylar joint

• three articulations:
• the patellofemoral
• the lateral mediofemoral condyle with the fibrocartilaginous meniscus
• medial tibiofemoral condyles with theifibrocartilaginous meniscus
• The knee is stabilized by
• articular capsule,
• the patellar ligament,
• medial and lateral collateral ligaments - medial and lateral stability,
• anterior and posterior cruciate ligaments - anteroposterior and rotatory
125
stability.

THE KNEE
ANATOMY

126

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KNEE
RANGE OF MOTION

• Flexion or extension and rotation

• With flexion, the tibia internally rotates, and with
extension, it externally rotates on the femur
• Knee extension is primarily mediated by the quadriceps
femoris muscle
• knee flexion is mediated by the hamstrings.
• The biceps femoris muscle externally rotates the lower leg
on the femur,
• the popliteus and semitendinous muscles mediate internal 127

rotation

THE KNEE
MUSCLE

128

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THE KNEE BURSAE

129

THE KNEE
SYNOVIAL MEMBRANE

The surrounding synovial

membrane is the largest
of the body’s joints; it
extends 6 cm proximal
to the joint as the
suprapatellar pouch
beneath the quadriceps
femoris muscle

130

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KNEE
HISTORY

• symptoms of knee locking, catching, or giving way

• Locking is the sudden loss of ability to extend the knee; it usually is painful
and may be associated with an audible noise, such as a click or pop. It often
implies extensive intra-articular abnormality, including loose bodies or
cartilaginous tears
• Catching refers to a subjective sensation of the patient that the knee might
lock; the patient may experience a momentary interruption in the smooth
range of motion of the joint but is able to continue with normal motion
• True giveway indicates that the knee actually buckles and gives out in
certain positions or with certain activities
• True give-way implies severe intra-articular abnormality, such as an unstable
joint from ligamentous injury or incompetence

131

THE KNEE
PHYSICAL EXAM

• Observation of the patient while standing and walking

• Deviation of the knees,
• genu varum (lateral deviation of the knee joint with medial deviation of the lower leg)
• genu valgum (medial deviation of the knee with lateral deviation of the lower leg),
• genu recurvatum (hyperextension deformity of the knee),
• Ambulate for gait abnormalities
• Compare side to side, noting any asymmetry that may be caused by swelling or
muscle atrophy
• Suprapatellar swelling with fullness of the distal anterior thigh that obliterates the normal
depressed contours along the sides of the patella usually indicates knee joint effusion or
synovitis.
• Localized swelling over the surface of the patella is generally secondary to prepatellar
bursitis 132

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THE KNEE
DEVIATIONS OF THE KNEE

133

THE KNEE
FRONTAL VIEW
GENU VARUM GENU VALGUM

134

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THE KNEE
LATERAL VIEW
GENU FLEXUM GENU RECURVATUM

135

THE KNEE SWELLING/ EFFUSION

136

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THE KNEE
EFFUSION

137

THE KNEE
PREPATELLAR BURSITIS

138

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THE KNEE
PHYSICAL EXAM
INSPECTION

• Identify popliteal swelling caused by a popliteal or Baker cyst, most

commonly caused by medial semimembranous bursal swelling
• If the calves appear asymmetric, calf circumference should be measured
and compared bilaterally
• Popliteal cysts
• may rupture and dissect down into the calf muscles, resulting in enlargement
and palpable fullness.
• can mimic thrombophlebitis, with local pain, heat, redness, and swelling
• This is probably a more common cause of unilateral calf swelling in patients
with RA than is deep venous thrombosis
• The two conditions may be difficult to distinguish on physical examination alone
139

BAKER CYST

140

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GIANT BAKER CYST

141

RUPTURED BAKER CYST

CRESCENT SIGN

142

71
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THE KNEE
PHYSICAL EXAM
INSPECTION

• Measurement of the thigh circumference should be performed at 15

cm above the knee to avoid spurious results due to suprapatellar
effusions
• The joint is relaxed
• begin over the anterior thigh approximately 10 cm above the patella
superior margin of the suprapatellar pouch
• Swelling, thickening, nodules, loose bodies, tenderness, and warmth
• A thickened synovial membrane has a boggy, doughy consistency, which
differs from the surrounding soft tissue and muscle
• Palpated over the medial aspect of the suprapatellar pouch and the medial
tibiofemoral joint 143

THE KNEE
PHYSICAL EXAM
FLUID DETECTION

• Patellar tap test

• The patient is lying in supine with the leg extended
• The examiner puts pressure on the proximal side of the knee in an effort to
squeeze the fluid out of the suprapatellar pouch
• The fluid can be moved under the patella while maintaining the pressure on
the suprapatellar pouch
• the examiner uses his/her other hand to press up on the medial and lateral
recesses forcing the fluid under the patella
• Tapping down the patella with the index to create an upward and downward
movement and a palpable ‘click’ as the patella hits the underlying femur.
• A positive test is when the patella can be felt to move down through the fluid 144

and rebounds on the patella

72
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PATELLAR TEST

145

THE KNEE
PHYSICAL EXAM
FLUID DETECTION

• Bulge, wipe or stroke test / Fluid displacement test

• The patient in supine, with the knee in an extended position
• The examiner strokes upwards with the edge of the hand on the medial side of
the knee to milk the fluid 10 cm proximal of the patella into the lateral
compartment, and continues pushing the fluid downwards on the lateral side.

• The test is positive if the examiner sees fluid moving towards the medial side
of the knee

146

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BULGE, WIPE OR STROKE TEST / FLUID

DISPLACEMENT TEST

147

THE KNEE
PHYSICAL EXAM
FLUID DETECTION

• Fluid wave test

• Is used when the effusion is less than 30-50 cc
• The patient is in supine, the examiner presses his/her fingers in both
parapatellar gutters
• Because there’s a pressure from below upward, the gutters are emptied
• The patient is asked to stand while the examiner keeps his/her fingers in the
parapatellar gutters
• If the examiner releases his/her fingers and the fluid comes back in the
parapatellar gutters, it is a positive sign

148

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THE KNEE
BURSITIS

• A cause of localized tenderness around the knee

• the two most common sites are the pes anserine and the prepatellar bursae.
• Exquisite local tenderness usually can be elicited if bursitis is present
• Mild swelling also may be appreciated
• Occasionally, the prepatellar bursa can become quite swollen
• It is important not to interpret this swelling mistakenly as knee joint synovitis.
• The two can be differentiated because the bursal margins can be outlined by palpation;
other features of true joint effusion, such as the bulge sign, are absent.

149

THE KNEE
PATELLOFEMORAL DISEASE

• It is more common in female patients because of the wider Q angle caused by

the broader female pelvis
• The Q angle is the angle formed between the quadriceps and the patellar tendon
• Stiffness in the knee after a period of flexion (the moviegoer sign) or may have
particular difficulty with stair climbing
• Catching as the patella moves over the distal femur
• The knee extended and relaxed
• The patella is compressed and moved so that its entire articular surface comes
into contact with the underlying femur
• Slight crepitation may be observed in many normally functioning knees
• Pain with crepitation may suggest patellofemoral degenerative arthritis or 150

chondromalacia patellae

75
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THE KNEE
ROM

• Full extension (0 degrees)

• Full flexion of 120 to 150 degrees
• Some normal individuals may be able to hyperextend to 15
degrees
• Loss of full extension that is generally reversible frequently
occurs with a knee joint effusion, synovitis,
• Flexion contracture is a common finding that accompanies
chronic arthritis of the knee: permanent loss of extension
151

THE ANKLE

152

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ANKLE

• The true ankle is a hinged joint

• movement is limited to plantar flexion and dorsiflexion
• It is formed by the distal ends of the tibia and fibula and the proximal aspect
of the body of the talus
• Inversion and eversion occur at the subtalar joint
• The malleoli provide medial and lateral stability by enveloping the talus
in a mortise-like fashion
• The articular capsule of the ankle is lax on the anterior and posterior
aspects of the joint, allowing extension and flexion, but it is tightly
bound bilaterally by ligaments
• The synovial membrane of the ankle on the inside of the capsule
153
usually does not communicate with any other joints, bursae, or tendon
sheaths

154

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ANKLE
LIGAMENTS = STABILITY

• The deltoid ligament,

• the only ligament on the medial side of the ankle
• triangle-shaped fibrous band that resists eversion of the foot
• It may be torn in eversion sprains of the ankle
• The lateral ligaments of the foot consist of three distinct bands forming
the
• posterior talofibular,
• the calcaneofibular,
• the anterior talofibular ligaments
• These ligaments may be injured in inversion sprains of the ankle 155

156

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ANKLE TENDON
ANTERIOR / LATERAL VIEW

157

158

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ACHILLES TENDON

159

ANKLE
TENDONS
• Superficial to the articular capsule
• Enclosed in synovial sheaths for part of their course across the ankle
• On the anterior,
• tibialis anterior, extensor digitorum longus, peroneus tertius, and
extensor hallucis longus muscles overlie the articular capsule and
synovial membrane.
• On the medial side, posterior and inferior to the medial malleolus,
• tibialis posterior, flexor digitorum longus, and flexor hallucis longus
muscles
• All three of these muscles plantar flex and supinate the foot
• The tendon of the flexor hallucis longus is located more posteriorly
160
than the other flexor tendons and lies beneath the Achilles tendon for
part of its course

80
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ANKLE
TENDONS

• On the post
• The common tendon of the gastrocnemius and soleus muscles,
inserts into the posterior surface of the calcaneus, where it is
subject to external trauma, various inflammatory reactions, and
irritations from bone spurs beneath it
• On the lateral
• posterior and inferior to the lateral malleolus, a synovial sheath
encloses the tendons of the peroneus longus and peroneus brevis
• These muscles extend the ankle (plantar flex) and evert (pronate)
the foot

161

ANKLE
ARTHRTITIS / SYNOVITIS

162

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ANKLE

• Synovial swelling of the ankle joint is most likely to cause fullness over the anterior or
anterolateral aspect of the joint because the capsule is more lax in this area
• Efforts should be made to differentiate superficial linear swelling localized to the
distribution of the tendon sheaths from more diffuse fullness and swelling attributable to
involvement of the ankle joint
• Swelling of the heels may be observed from behind the standing patient and may be
caused by enthesitis of the Achilles tendon insertion, which can occur in
spondyloarthropathies
• To test the subtalar joint, the examiner grasps the calcaneus with a hand and attempts to
invert and evert it, holding the ankle motionless

163

SUBTALAR JOINT EXAM

164

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ACHILLES TENDON TEAR

165

ACHILLES ENTHESITIS

166

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ACHILLES RUPTURE

167

THE FOOT

168

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THE FOOT ANATOMY

169

FOOT
GAIT ANALYSIS

• Normal human gait is divided into two phases

• The stance phase is the weight-bearing portion of the gait cycle and comprises
roughly 60% of normal walking. This phase begins with heel-strike and then extends
through foot-flat to toe-off motion
• the swing phase of gait extends from toe-off to heel-strike and comprises the
remaining 40% of the gait cycle.
• “antalgic” gait pattern will have a shortened stance phase on the side of the
affected limb, while they attempt to more quickly transfer their weight to the
nonpainful limb
• “steppage” gait This type of gait is characterized by excessive hip and knee
flexion, to allow the foot to clear the ground in the setting of a footdrop

170

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THE FOOT
INSPECTION

• the patient in the sitting and standing position

• The location of swelling: the ankle vs. the talocalcaneal joint
• Deformities
• In RA include hallux valgus, or bunion hammertoes; and flatfoot deformity
(characterized by hindfoot valgus/forefoot abduction)
• Callosities develop over regions of increased pressure and are
associated with deformity and fat pad atrophy
• Rheumatoid nodules in areas of repetitive
• Ulcerations may appear in areas of increased pressure or repeated injury
• Gout and tophi
• Patterns on shoes
171
• “Hoppenfeld“A deformed foot can deform any good shoe

THE FOOT
RHEUMATOID ARTHRITIS

172

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THE FOOT
CALLOSITIES

173

THE FOOT
GOUT

174

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THE FOOT
RANGE OF MOTION

• The first MTP

• 45 degrees of “plantarflexion” (flexion)
• 70 to 90 degrees of “dorsiflexion” (extension)

175

MORTON’S NEUROMA

• a painful condition that

affects the ball of your
foot, most commonly the
area between your third
and fourth toe
• thickening of the tissue
around one of the nerves
leading to your toes.This
can cause a sharp, burning
pain in the ball of your
foot
176

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THE FOOT
STRESS FRACTURE

177

THE FOOT
PLANTAR FASCIITIS

178

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179

BACK
LUMBAR SPINE

180

90
 4/7/2022

LUMBAR SPINE ANATOMY

181

SPINE
HISTORY
OBJECTIVE 1

• Identify the small fraction (5%)

• may have neural compression
• fracture,
• underlying systemic disease (infection, malignancy, or spondyloarthritis)

• Early diagnostic testing (mostly imaging)

• may require specific treatment (e.g., antibiotics for vertebral
osteomyelitis)
• urgent treatment (e.g., surgical decompression in a patient with major
or progressive neural compression) 182

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RED FLAGS FOR POTENTIALLY SERIOUS

183

LOW BACK PAIN HISTORY

KEY QUESTIONS

184

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SPINE
MECHANICAL VS INFLAMMATORY

ME CHA NICAL LBP INFLA MMATORY LBP

• > 95% of LBP
• Due to an anatomic or functional
abnormality in the spine
• It typically increases with physical
activity and upright posture and tends
to be relieved by rest and
recumbency.
• mechanical and degenerative change in the
lumbar spine
• Vertebral fracture due to Osteoporosis:
Severe and acute mechanical LBP in a post-
menopausal woman
• Associated with marked morning
stiffness that usually lasts for more than
30 minutes.
• The pain frequently improves with
exercise but not with rest
• Pain is often worse during the
second half of the night, and some
patients complain of alternating buttock
pain
• Infection or neoplasm or
spondyloarthritides, (SPA in<40years)
185

SPINE HISTORY

• Mechanical vs inflammatory
• Radiate to lower extremity
• spinal stenosis disc herniation
• The pain is often lancinating, shooting, and sharp in quality
• frequently accompanied by numbness and tingling
• may be accompanied by sensory and motor deficits
• Sciatica resulting from disk herniation typically increases
with cough, sneezing, or the Valsalva maneuver
• Bladder dyscfunction:
• cauda equine syndrome 186

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SPINE
PHYSICAL EXAM
INSPECTION / PALPATION
• Scoliosis
• Structural scoliosis is associated with structural changes of the vertebral
column and sometimes the rib cage as well
• Functional scoliosis, which usually results from paravertebral muscle spasm
or leg length discrepancy, usually disappears.
• A tuft of hair in the lumbar spine region may indicate a congenital
structural abnormality such as spina bifida occulta.
• Palpation
• paravertebral muscle spasm
• loss of the normal lumbar lordosis
• Limited spinal motion: not specific, help for monitoring
187

188

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SCOLIOSIS

189

SCOLIOSIS

190

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SPINE
PHYSICAL EXAM

• Chest expansion of less than 2.5 cm has specificity but not sensitivity for
ankylosing spondylitis

• The hip joints should be examined for any decrease in range of motion
because hip arthritis, which normally causes groin pain, may occasionally
refer pain to the back

• Trochanteric bursitis with tenderness over the greater trochanter of the

femur can be confused with LBP

• The presence of more widespread tender points, especially in a female 191

patient, suggests the possibility that LBP may be secondary to fibromyalgia

SPINE
PHYSICAL EXAM

192

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SPINE
PHYSICAL EXAM

• A complete neurologic
• neurologic abnormalities in the upper extremities, such as hyper-reflexia, may
indicate a more proximal etiology of a patient’s lower extremity complaints
• A straight leg–raising test (Laseque)
• with the patient lying on his or her back, the examiner places the heel in the palm of
his or her hand and progressively raises the patient’s leg with the knee fully
extended
• This movement places tension on the sciatic nerve (that originates from L4, L5, S1,
S2, and S3) and thereby stretches the nerve roots (especially L5, S1, and S2)
• If any of these nerve roots is already irritated, such as by impingement from a
herniated disk, further tension on the nerve root by straight leg raising will result in
radicular pain that extends below the knee
• The test is positive if radicular pain is produced when the leg is raised less than 70
degrees. Dorsiflexion of the ankle further stretches the sciatic nerve and increases
the sensitivity of the test
193

SPINE
PHYSICAL EXAM

• The crossed straight leg– raising test

• (with sciatica reproduced when the opposite leg is raised) is highly specific for a disk
herniation
• The neurologic evaluation of the lower extremities in a patient with sciatica can
identify the specific nerve root involved
• motor testing with focus on dorsiflexion of the foot (L4), great toe dorsiflexion
(L5), and foot plantar flexion (S1); determination of knee (L4) and ankle (S1) deep
tendon reflexes; and tests for dermatomal sensory loss.
• The inability to toe walk (mostly S1) and heel walk (mostly L5) indicate muscle
weakness.
• Muscle atrophy can be detected by circumferential measurements of the calf and
thigh at the same level bilaterally
• Patients involved with litigation or with psychological distress occasionally
exaggerate their symptoms.
194

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195

CAUSES OF LOW BACK PAIN

196

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LOW BACK PAIN

• Affects as many as 80% of individuals,

• degenerative changes of the lumbar spine is the most common cause
• More than 90% of these patients are mostly pain free within 8 weeks
• The initial evaluation should focus on identification of the few patients with
neurologic involvement, fracture, or possible systemic disease (infection,
malignancy, or spondyloarthritis) because they may need urgent or specific
intervention
• Psychosocial and other factors that predict risk of chronic disabling LBP should
be assessed
• Imaging is rarely indicated in the absence of significant neurologic involvement,
trauma, or suspicion of systemic disease
• Imaging abnormalities, often the result of age-related degenerative changes,
197
should be carefully interpreted because they are frequently present in
asymptomatic individuals

LOW BACK PAIN

• A precise pathoanatomic diagnosis with identification of the pain generator cannot

be made in up to 85% of patients

• Persistent LBP should be treated with an individually tailored program that includes
analgesia, core strengthening, stretching, aerobic conditioning, loss of excess weight,
and patient education. Intensive interdisciplinary rehabilitation with an emphasis on
cognitive-behavioral therapy should be strongly considered if conservative
measures fail

• The major indication for back surgery is presence of a serious or progressive

neurologic deficit. In the absence of neurologic deficits, back surgery, especially
spinal fusion for degenerative changes, has not been shown to be more effective
than conservative care.
198

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SCOLIOSIS

199

SPONDYLOSIS

200

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OSTEOARTHRITIS
OSTEOPHYTES

201

VERTEBRAL FRACTURE

202

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SPONDYLOLISTHESIS

203

LUMBAR STENOSIS

204

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SPINAL STENOSIS

205

DISK HERNIATION

206

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207

ANKYLOSING SPONDYLITIS

208

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SPONDYLITIS

209

METASTASIS

210

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DISH
DIFFUSE IDIOPATHIC HYPEROSTOSIS

211

SYNOVIAL FLUID ANALYSIS

212

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SYNOVIAL FLUID ANALYSIS

DO NE BY A RTHROCE NT HE SI S

213

SYNOVIAL FLUID ANALYSIS

DONE BY ARTHROCENTHESIS

214

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SYNOVIAL FLUID ANALYSIS

INDICATION

• Acute monoarthritis

• A needle should not be passed through an area of infection (eg, overlying

cellulitis) before entering a joint, because seeding infection into the joint
capsule may occur

215

SYNOVIAL FLUID ANALYSIS

• leukocyte count,
• Cytology
• polarized microscopy
• Gram stain, and culture

• provides key diagnostic information, particularly in acute monoarthritis

216

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CHARACTERISTIC OF SYNOVIAL FLUID

ANALYSIS

217

218

109
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POLYRIZED MICROSCOPE
URATE CRYSTALS

219

POLARIZED MICROSCOPE
PYROPHOSPHATE CRYSTALS

220

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URATE VS PYROPHOSPHATE

Negatively Positively
birefringent birefringent

221

111