ASSESSMENT OF THE RHEUMATOLOGICAL PATIENT
The rheumatological
examination
Rebecca Batten
David Coady
Abstract
Musculoskeletal disorders are the most common cause of disability in the
UK. They are associated with significant morbidity and polypharmacy,
particularly in an ageing population with multiple co-morbidities. Two pro-
grammes of examination that have been developed include a screening
assessment (Gait, Arms, Legs, Spine (GALS)) and a more in-depth
Regional Examination of the Musculoskeletal System (REMS). These pro-
grammes provide a structured assessment, which enables competent
and confident examination skills, ensuring an accurate diagnosis.
Keywords Arthritis; clinical; education; examination;
musculoskeletal
Introduction
Musculoskeletal disorders can present to a variety of specialties.
They account for up to 25% of a general practitioner’s work-
load.1 Presenting symptoms can be non-specific, including fa-
tigue, joint pain and stiffness. Competent history-taking and
examination skills are therefore key to making an accurate
diagnosis.
The examiner should consider the anatomy involved (e.g.
joint, muscle, tendon), whether the condition is acute or chronic,
and inflammatory or non-inflammatory, the pattern of involve-
ment (e.g. mono-, oligo- or polyarticular or axial) and the impact
of the condition on the patient.
Gait, Arms, Legs, Spine (GALS) screening examination
This rapid screening examination aims to identify a problem
(Table 1). It should be incorporated into the routine systematic
enquiry of every patient. It is not intended to be diagnostic but
guides further examination and investigation. It is important to
document the presence or absence of any changes. An adapted
version for paediatrics has also been developed for the systemic
enquiry (pGALS).3
Screening questions for musculoskeletal disorders:
 Do you suffer from any pain or stiffness in your muscles or
back?
 Do you have any difficulty dressing yourself?
 Do you have any difficulty walking up and down stairs?
Rebecca Batten MB BS MRCP is a Specialist Trainee at City Hospitals
Sunderland, UK. Competing interests: none declared.
David Coady MBBS MRCP MD has been a Consultant Rheumatologist
at City Hospitals Sunderland, UK, since 2007. He previously
undertook an ARUK education fellowship leading to the production
of REMS. Competing interests: none declared.
MEDICINE 46:3
Key points
C Musculoskeletal disorders are common and cause significant
morbidity
C Gait, Arms, Legs, Spine (GALS) and Regional Examination of
the Musculoskeletal System (REMS) provide a structure to
enable a thorough and focused examination
C Experience and practice using GALS and REMS will improve
diagnostic acumen
Regional Examination of the Musculoskeletal System
(REMS)
This core set of examination skills (Table 2) enables the exam-
iner to localize and describe any abnormality detected by GALS.
MRCP; It was developed by a robust consensus study of UK clinicians
across a number of specialties.4
A standardized programme of examination is essential for
teaching and assessment focused on specific learning outcomes.5
Medical students are expected to be competent in GALS and
REMS at graduation. With experience, the examination can be
further tailored to the history. The full examination is available to
view on line, download or order at www.arthritisresearchuk.org/
health-professionals-and-students/student-handbook.aspx.
The examiner must be mindful of the fact that many muscu-
loskeletal conditions are multisystem diseases, and therefore
respiratory, cardiovascular, gastrointestinal and neurological ex-
amination should be considered where appropriate. Malignancy
screening should also be considered, particularly in patients pre-
senting with bony pain, weight loss, night sweats, paraneoplastic
phenomena or raised inflammatory markers. Table 3 documents
disease-specific features of the musculoskeletal examination.
Examination of the hand and wrist
2
With the patient resting their hands on a pillow, palms down,
observe any skin thinning, bruising (signs of long-term cortico-
steroid use) or rashes. Look at the nails for any psoriatic changes or
nail fold vasculitis. Look for any swelling. What is the distribution
of involvement e distal interphalangeal (DIP), proximal inter-
phalangeal (PIP) or metacarpophalangeal (MCP) joints, or wrists?
With the patient’s palms upwards, look for palmar erythema
and muscle wasting of the thenar and hypothenar eminences. If
wasting is present only at the thenar eminence, this suggests
carpal tunnel syndrome. Look for a carpal tunnel release scar and
consider Phalen’s test.
Feel the peripheral pulses. Feel for the muscle bulk of the
thenar and hypothenar eminences, and tendon thickening.
Assess median nerve sensation over the thenar eminence, and
ulnar nerve sensation over the hypothenar eminence. With the
patient’s palms down, assess radial nerve sensation by touching
lightly over the thumb and index finger web space. Feel the skin
temperature with the back of your hand over the forearm, wrist
and MCP joints, comparing right and left.
Squeeze the MCP joints, observing the patient for any
discomfort. Bimanually palpate the MCP joints and any PIP or
161 Ó 2018 Elsevier Ltd. All rights reserved.
 ASSESSMENT OF THE RHEUMATOLOGICAL PATIENT
GALS
Appearance
Gait Assess from behind, the side and in front:
C Muscle bulk and symmetry
C Limb alignment
C Straight spine
C Level iliac crests
C Ability to fully extend the elbows and knees
Arms C Joint swelling and deformity in the hands and
wrists
C Observe the palms for muscle bulk
Legs (patient lying C Inspect the feet for swelling and deformity, and
on couch) callosities on the soles
C Squeeze the metatarsophalangeal (MTP) joints to
assess for tenderness
Spine C Inspect from behind for scoliosis
C Inspect from the side for abnormal lordosis/
kyphosis
Table 1
DIP joints that look swollen. Active synovitis is suggested by the
presence of warmth, tenderness, ‘boggy’ swelling, and occa-
sionally effusions. Feel the ulnar border of the elbow for the
presence of rheumatoid nodules or psoriatic plaques.
Ask the patient to fully straighten their fingers against gravity.
This may be limited by joint disease, extensor tendon rupture or
neurological damage e moving the patient’s fingers passively
can assess this. Ask the patient to make a fist. Assess wrist
flexion and extension actively and passively.
Phalen’s test requires forced flexion at the wrists for 60 seconds.
A positive test reproduces the patient’s symptoms (sensitivity
85%, specificity 90%).
For assessment of function, see Table 2.
Examination of the elbow
Observe the carrying angle from the front, and any fixed flexion
deformity at the side. Look for scars, rashes, muscle wasting,
rheumatoid nodules, psoriatic plaques and swelling, such as
olecranon bursitis.
Feel for temperature changes and swelling over the joint.
Synovitis may be felt between the olecranon and lateral epi-
condyle. Palpate for an olecranon bursa. Palpate the medial and
lateral epicondyles for golfer’s and tennis elbow, respectively.
Actively and passively flex and extend the elbow, comparing
one side with the other. Feel for crepitus on active and passive
pronation and supination.
MEDICINE 46:3 162
Movement
C Symmetry and smoothness
C Ability to turn quickly
C Ask the patient to place their hands behind their head (assesses
external rotation and abduction of the shoulder, and elbow
flexion)
C Assess the power grip by asking the patient to make a fist
C Assess grip strength by asking the patient to squeeze the ex-
aminer’s fingers
C Fine precision pinch (functional importance,
e.g. fastening/unfastening buttons)
C Squeeze the MCP joints for tenderness e observe the patient’s
face when doing this
C Assess full flexion and extension of both knees e feeling for
crepitus
C Assess internal rotation of the hips with the hip and knee flexed
to 90
C Patellar tap to look for effusion at the knee
C Assess lateral flexion of the neck (ask the patient to touch each
ear to their shoulder in turn)
C Ask the patient to touch their toes, looking and feeling for
normal vertebral movement
Examination of the shoulder
Look from the front, the side and behind for asymmetry,
abnormal posture, muscle wasting and scars.
Feel for temperature over the front of the shoulder. Palpate
bony landmarks, beginning at the sternoclavicular joint and
working around to the clavicle, acromioclavicular joint, coracoid
process and spine of the scapula. Palpate the anterior and pos-
terior joint lines. Palpate the muscle bulk of the supraspinatus,
infraspinatus and deltoid muscles.
Ask the patient to place their hands behind their head
(assessing external rotation and abduction), and then behind their
back (internal rotation, adduction). Assess external rotation of the
shoulder by flexing the patient’s elbow to 90 , tucking it into their
side and then externally rotating it. Loss of external rotation can
indicate a frozen shoulder. Assess flexion and extension at the
shoulder, remembering both passive and active movement.
To assess for a painful arc (between 10 and 120 ), stand
behind the patient and ask them to actively abduct the arm. Look
for smooth scapular movement.
Examination of the hip
With the patient standing, look for gluteal muscle wasting and
scars. With the patient lying flat, look for flexion deformity.
Measure the true leg length if there is a suggestion of disparity.
Measurement is taken from the anterior superior iliac crest to the
Ó 2018 Elsevier Ltd. All rights reserved.
 ASSESSMENT OF THE RHEUMATOLOGICAL PATIENT
Core principles of REMS
General principles
C Introduce yourself, ensure that the patient is comfortable, expose
the area to be examined, explain what you would like to do, gain
verbal consent, and ask the patient to tell you at any time if they
are in any pain or discomfort
Look
C Visual inspection of the area to be examined at rest
C Compare both sides, looking for symmetry
C Observe for skin changes, muscle bulk and swelling
C Look for abnormal alignment or deformity
C Consider any neurovascular compromise
Feel
C Feel for skin and temperature changes with the back of your hand
at the joint line, above and below the joint
C Assess any swellings, e.g. hard bony swelling of osteoarthritis
versus soft ‘boggy’ swelling of inflammatory joints
Move
C The full range of movement should be assessed e both sides
should be compared
C Active and passive movement should be performed where
possible
C Document any restriction in the range of movement
C Comment on the quality of movement, e.g. crepitus, cog
wheeling, rigidity
Functional assessment of the affected joint
C Hand and wrist: power grip, pincer grip, picking up small object
such as a coin
C Elbow: can the patient reach their hand to their mouth?
C Shoulder: Hands behind head? Hands behind back?
C Hip: antalgic or Trendelenburg gait when walking?
C Knee: gait, varus or valgus deformity?
C Foot and ankle: gait, normal cycle of heel strike and toe-off?
Table 2
medial malleolus. Palpate over the greater trochanter for
tenderness.
With the knee flexed to 90 , assess full hip flexion (observing
for any discomfort). With the knee and hip flexed to 90 , assess
internal and external rotation of both hips.
Thomas’s test is used to detect a fixed flexion deformity at
the hip. With the patient lying supine on a couch a hand is
placed under the lumbar spine. The hip and knee on the non-
affected side are both flexed until the normal lumbar lordosis
is lost. Continuing to flex the unaffected hip and knee will begin
to tilt the pelvis. If there is a fixed flexion deformity then the
contralateral hip will be forced off the couch indicating a posi-
tive test.
The Trendelenburg test assesses weakness of the hip abduc-
tors (gluteus minimus and medius). The patient is asked to stand
on the affected leg. In a positive test, the pelvis tilts to the
contralateral side (sensitivity 37e55%, specificity 70e81%).
MEDICINE 46:3
Examination of the knee
With the patient lying on the couch with the knees straight,
observe symmetry and alignment, particularly looking for any
varus or valgus deformity. Look for fixed flexion deformity
(distinguishing it from hip flexion deformity by Thomas’s test, as
described above). Observe for muscle wasting, scars, erythema,
swelling and rashes. Observe for posterior sag (posterior cruciate
ligament instability) with the knee flexed to 90 .
Feel for temperature differences between the mid-thigh and
knee joint. Compare left and right. Palpate the border of the
patella for tenderness. With the knee flexed to 90 , palpate the
joint line from the femoral epicondyles to the inferior pole of the
patella and down the inferior patellar tendon to the tibial tu-
berosity. Feel behind the knee for the presence of a Baker’s cyst.
The patellar tap assesses for the presence of a knee effusion.
Apply pressure to the suprapatellar bursa. This forces any fluid
behind the knee. Gently push the patella down with two or three
fingers. In a positive test, the patella bounces (sensitivity 85%,
specificity 42%).
Assess active and passive flexion and extension of the knee.
Feel for crepitus.
The anterior drawer test assesses for anterior cruciate ligament
(ACL) instability. The examiner places both hands around the
upper tibia with the thumbs over the tibial tuberosity and the
fingers tucked under the hamstrings to ensure that they are
relaxed. The lower tibia is stabilized with the forearm, and the
upper tibia is gently pulled forward. A small amount of movement
can be expected, but more substantial movement is suggestive of
ACL laxity (sensitivity 20%, specificity 80%). The posterior
drawer test is similar except that the upper tibia is gently pushed
backwards; this tests for posterior cruciate ligament laxity.
To assess medial and lateral collateral ligament stability, place
one hand on the side of the knee opposite to the side you are
testing. The leg is stabilized either on the couch or on the side of
the examiner’s pelvis. The joint line is alternately stressed on
each side by applying gentle force to the tibia.
Examination of the foot and ankle
With the patient sitting on the couch with the feet overhanging it,
look for symmetry, rashes and nail changes. Observe for hallux
valgus of the big toe, clawing of the toes, joint swelling and callus
formation. Ensure that both the dorsal and volar aspects are
examined. Observe the footwear, looking for asymmetrical
wearing of the sole, insoles and evidence of poor fit.
With the patient weight-bearing, observe for any dropped foot
arch; this resolves on standing on tiptoes if it is a normal variant.
Observe the hind foot for Achilles tendon thickening or swelling,
and varus or valgus deformity of the ankle, suggestive of subtalar
joint pathology.
Feel for temperature changes and examine the dorsalis pedis
and posterior tibialis pulses bilaterally. Gently squeeze the met-
atarsophalangeal (MTP) joints, mid-foot, ankle and subtalar
joints, observing for any discomfort.
Actively and passively assess inversion and eversion, and
plantar flexion and dorsiflexion of the ankle. Fixing the heel with
one hand and passively everting and inverting the forefoot can
assess movement of the mid-tarsal joints.
163 Ó 2018 Elsevier Ltd. All rights reserved.
 MEDICINE 46:3

Disease-specific features

Disease Joint Skin/mucocutaneous changes Nail changes Systemic features

Psoriatic arthritis Oligoarticular arthritis, enthesitis, Scaly, erythematous plaques of Pitting, onycholysis, subungual Uveitis
spondylitis, dactylitis, tenosynovitis psoriasis hyperkeratosis, Beau lines,
transverse ridging

Rheumatoid arthritis Polyarticular arthritis, boutonni
ere and Rheumatoid nodules, palmar erythema, Splinter haemorrhages Entrapment neuropathy, pericardial
swan neck deformities, volar vasculitic lesions, pyoderma effusion, interstitial lung disease,
subluxation, ulnar deviation, gangrenosum, scleritis, pleural effusions, Felty’s syndrome

ASSESSMENT OF THE RHEUMATOLOGICAL PATIENT

tenosynovitis, muscle wasting keratoconjunctivitis sicca (splenomegaly, neutropenia)

Reactive arthritis Oligoarticular arthritis, dactylitis, Keratoderma blennorrhagica, pustules, Subungual pustular collections, Recent diarrhoeal illness, recent upper
enthesitis oral ulceration, geographical tongue, onychodystrophy respiratory tract symptoms
erythema nodosum, conjunctivitis

Systemic lupus Arthralgia, non-erosive arthropathy Malar rash (nasolabial sparing), Periungual erythema, telangectasia Nephrotic syndrome (peripheral
erythematosus (Jaccoud’s arthropathy) photosensitive rash, discoid rash, oedema), neuropsychiatric
164

annular lesions, orogenital ulceration, complications, pleuropericarditis

Raynaud’s phenomenon, alopecia, (friction rubs), LibmaneSachs
livedo reticularis endocarditis (systolic murmur)

€gren’s
Primary Sjo Non-erosive arthritis Keratoconjunctivitis sicca, xerostomia, Bilateral parotid gland enlargement,
syndrome dental caries, oral candida lymphadenopathy

Vasculitides Inflammatory arthritis, myalgia Oral and genital ulceration (Behc‚et’s Conjunctivitis/scleritis/retinal vasculitis,
disease), purpura, petechiae, livedo orbital inflammation, hearing loss,
reticularis, tender subcutaneous nasal bridge swelling/saddle nose
nodules (polyarteritis nodosa) deformity, mononeuritis multiplex

Dermatomyositis Proximal symmetrical muscle Gottron’s papules, heliotrope rash Dilated capillary loops, cuticular Raynaud’s phenomenon
weakness, non-erosive symmetrical (violaceous rash with periorbital hypertrophy, ragged cuticles, splinter Cardiac conduction abnormalities
small joint arthritis oedema), mechanic’s hands haemorrhages Bibasal rales (interstitial lung disease)
Ó 2018 Elsevier Ltd. All rights reserved.

Systemic sclerosis Inflammatory arthritis, myositis Sclerodactyly, telangiectasia, Nail fold dilatation and capillary Heart failure (pulmonary hypertension),
calcinosis, Raynaud’s phenomenon, destruction bibasal rales (interstitial lung disease)
palmar erythema, digital ulcers

Table 3
 ASSESSMENT OF THE RHEUMATOLOGICAL PATIENT
Examination of the spine
Observe the patient standing. Look initially from behind for muscle
wasting, asymmetry and scoliosis. Look from the side, assessing for
normal cervical lordosis, thoracic kyphosis and lumbar lordosis.
Feel down the spinal processes and over the sacro-iliac joints.
Palpate the paraspinal muscles for tenderness. Assess lumbar
flexion, extension and lateral flexion.
Next assess cervical flexion, extension, lateral flexion and
rotation. Thoracic rotation is assessed with the patient seated on
the couch (in order to fix the pelvis) with the arms crossed across
the chest. With your hands placed on the patient’s shoulders,
guide rotational movement.
Straight leg raises identify nerve root impingement or irrita-
tion. With the patient supine, the affected leg is elevated as far as
possible. Passive dorsiflexion of the foot may worsen symptoms
of dural or sciatic nerve root irritation.
Assess upper and lower limb reflexes, and dorsiflexion of the
big toe against resistance.
Disease activity assessment
A number of validated tests have been developed to assess dis-
ease activity. The Disease Activity Score 28 (DAS28) for rheu-
matoid arthritis is a composite of the number of tender and
swollen (synovitic) joints amongst 28 joints and inflammatory
blood marker levels. Synovitis is present when there is fluctuant
or ‘rubbery’ swelling of the joint line, and can include warmth
TEST YOURSELF
To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the
end of the issue or online here.
Question 1
A 69-year-old man presented with difficulty walking as a result of
pain in the left hip.
On examination, he was asked to stand only on the affected leg.
When he did so, the right side of his pelvis dropped.
What is the best interpretation of this finding?
A Fixed flexion deformity of the left hip
B Weakness of the left hip adductors
C Weakness of the left hip abductors
D Weakness of the left gluteus maximus
E Displacement of the head of the left femur in the
acetabulum
Question 2
A 32-year-old woman presented with a 1-month history of a
painful right ankle. At about the same time, she had had an
episode of food poisoning.
On clinical examination, there was swelling of the joint, asso-
ciated with thickening of the Achilles tendon and nail
dystrophy.
MEDICINE 46:3
and erythema. Rodnan skin score for systemic sclerosis measures
skin thickness at different anatomical locations, and Bath
Ankylosing Spondylitis Disease Activity Index (BASDAI) mea-
sures fatigue, pain, swelling, tenderness and early morning
stiffness in ankylosing spondylitis. These scores aim to make
clinical examination findings more objective and reproducible
and are often taken into account when addressing both treatment
options and response to treatment. A
KEY REFERENCES
1 Arthritis Research UK National Primary Care Centre. Musculo-
skeletal matters: Keele University, 2009.
2 Doherty M, Dacre J, Dieppe P, et al. The ‘GALS’ locomotor screen.
Ann Rheum Dis 1992; 51: 1165e9.
3 Foster H, Jandial S. pGALS e paediatric Gait Arms Legs and
Spine: a simple examination of the musculoskeletal system. Pediatr
Rheumatol 2013; 11: 44.
4 Coady D, Walker D, Kay L. Regional examination of the musculo-
skeletal system: a core set of clinical skills for medical students.
Rheumatology (Oxford) 2004; 43: 633e9.
5 Kay L. Principles of clinical examination in adults. In: Watts Richard
A, Conaghan Philip G, Denton Christopher, Foster Helen,
Isaacs John, Mu €ller-Ladner Ulf, eds. Oxford textbook of rheuma-
tology. 4th ed. Oxford: Oxford University Press, 2013; 49e60.
What is the most likely diagnosis?
A Repetitive strain injury
B Psoriatic arthropathy
C Reactive arthritis
D Systemic lupus erythematosus arthropathy
E Enteropathic arthritis
Question 3
A 56-year-old man presented with frequently dropping objects.
He also complained of pins and needles in his hands, which was
worse at night.
On clinical examination, there was wasting of the thenar
eminence.
What additional clinical feature will help to confirm the most
likely diagnosis?:
A Reproduction of symptoms on forced flexion of the wrist
B Wasting of the hypothenar eminence
C Reproduction of symptoms by compression over the ulnar
nerve
D Reproduction of symptoms on ulnar deviation of the wrist
E Reduced sensation in the fourth and fifth fingers
165 Ó 2018 Elsevier Ltd. All rights reserved.