APPROACH TO DIAGNOSIS OF ARTHRITIS

Lectures Series For Medical Students and

Allied Professions
 Background
Essential orientation...
• Musculoskeletal (MS) problems present varied
challenges to the clinician
• Ease of diagnosis does vary from self-evident to
doubtful
• The TWO keys to diagnosis of MS complaints are
to:
1. take a careful history, and
2. examine the joints carefully ...
... in order to identify the anatomic structure(s)
involved
 Background
ALWAYS be mindful of diversity of aetiologies...
• Joint pain can be caused by diverse processes,
including:
– inflammation,
– cartilage degeneration,
– crystal deposition,
– infection, and
– trauma.
• This highlights the point: ‘The differential diagnoses
of joint pain are generated largely from the history and
physical examination’
 Background
Role for laboratory tests?...
• Screening laboratory test results [mostly] serve
to confirm clinical impressions
– They can be misleading if used without much
deductive thinking

Goal of clinical enquiry...

• The initial aim of the clinical evaluation is to:
– localize the source of the joint symptoms, and
– to determine the type of patho-physiological process
responsible for their presence.
 Patho-physiological processes in joint
pain
1.Joint pain may arise from structures within or
adjacent to the joint or may be referred from
more distant sites.
2.Sources of pain within the joint include the
joint capsule, periosteum, ligaments,
subchondral bone, and synovium,

– Determination of the anatomic part responsible

for joint pain guides the approach to diagnosis and
therapy.
 Lecture Objective

This lecture aims to teach a

standardized approach to the clinical
evaluation of patients with joint pain
and other musculoskeletal symptoms
 Specific Learning Objectives
By the end of this lesson, the learner should:

1- Be able to take a relevant history and perform a

focused examination of patients with joint pain / other
MS problems and elicit diagnostic clues

2-Recognize diagnostic patterns of joint involvement

that are helpful in differential diagnosis of various causes
of arthritis

3- Be able to apply a screening history and

examination as part of a general systemic inquiry on all
patients
 Evaluation of a patient with arthritis
Diagnostic clues from historical features
 Precepts
Assessment of the musculoskeletal system
• Should be approached in
the same way as for
diseases of any other
system – that is by:
– careful history taking,
– examination, and
– use of appropriate
investigations
• In addition, assess for
impact of the condition
on physical and mental
function of patient
 Precepts
Understanding Patho-physiologic basis of joint
symptoms
• TWO DETERMINATIONS serve to focus the
history and physical examination of a patient
with joint pain:
1.The first is whether the pain stems from the joint or
an adjacent structure (e.g., bursa, tendon, ligament,
bone, or muscle).
2.The second is whether the pain is referred from
elsewhere (e.g., a visceral organ or nerve root).
 Precepts
Understanding Patho-physiologic basis of joint
symptoms (Cont’d)
• If the pain is stemming from the joint, THREE
broad categories of joint disease must be
differentiated:
1.The first is inflammatory arthritis

2.The second category is non-inflammatory arthritis

3.The third category is arthralgia

 Precepts
Usefulness of signs of inflammation in differential
diagnosis of painful joints
• Inflammatory arthritis
– Is characterized by inflammation affecting joint
structures, such as the synovium, synovial cavity, and
entheses
– With inflammatory joint disease:
• Pain is present both at rest and with motion.
• Pain is worse at rest than at the end of usage
• stiffness is present upon waking and typically lasts 30-60
minutes or longer
• joint swelling is related to synovial hypertrophy, synovial
effusion, and/or inflammation of peri-articular structures.
 Precepts
• Usefulness of signs of inflammation in differential diagnosis of
painful joints
• non-inflammatory arthritis:
– Results primarily from alterations in the structure or mechanics of
the joint
– The joint disease may occur as a result of degenerative, traumatic
or mechanical damage
– With non-inflammatory joint disease:
– Pain occurs mainly or only during motion and improves quickly with rest.
– stiffness is experienced briefly (e.g., 15 min) upon waking in the morning or
following periods of inactivity.
– Swelling results from formation of osteophytes (bony swelling) or from soft
tissue swelling related to synovial cysts, thickening, or effusions
 Precepts
• Usefulness of signs of inflammation in differential
diagnosis of painful joints
• Arthralgia:
– Apart from joint tenderness, no abnormalities of the
joint can be identified.
– May be due to an early rheumatic syndrome whose
clinical signs are not yet apparent
 Precepts
Differential diagnostic clues from historical
features
1. Temporal pattern of arthritis
a. ONSET OF SYMPTOMS - Abrupt or insidious
• Abrupt onset:
– joint symptoms develop over minutes to hours.
– May occur in trauma, crystal arthritis, or infection.
• Insidious onset:
– joint symptoms develop over weeks to months.
– This onset is typical of most forms of arthritis, including
rheumatoid arthritis (RA) and osteoarthritis.
 Precepts
Differential diagnostic clues from historical
features
1. Temporal pattern of arthritis (cont’d)
b. DURATION OF SYMPTOMS - Acute or Chronic
• Acute is less than 6 weeks in duration;
– Inflammatory: e.g., Septic arthritis; Gout
– Non-inflammatory: e.g., Juxta-articular fracture; Trauma
• chronic is 6 or more weeks in duration
– Inflammatory: e.g., Septic arthritis; Gout; Rheumatic fever,
RA,SLE, and Reactive arthritis
– Non-inflammatory: e.g., Juxta-articular fracture; Trauma; OA,
Haemochromatosis, avascular necrosis, stress fracture
 Precepts
Differential diagnostic clues from historical features
1. Temporal pattern of arthritis (cont’d)
c. PATTERNS OF JOINT INVOLVEMENT
• Migratory: inflammation persists for only a few days
in each joint (e.g., acute rheumatic fever,
disseminated gonococcal infection)
• Additive or simultaneous: inflammation persists in
involved joints as new ones become affected
(systemic rheumatic diseases, e.g., RA)
• Intermittent: episodic involvement occurs, with
intervening periods free of joint symptoms (e.g.,
gout).
 Precepts
Differential diagnostic clues from historical features
2. Number of involved joints
• Monoarthritis: involvement of one joint.
• Oligoarthritis: involvement of 2-5 joints.
• Polyarthritis: involvement of 6 or more joints.
3. Symmetry of joint involvement
• Symmetric arthritis: characterized by involvement of the
same joints on each side of the body. This symmetry is
typical of RA and SLE.
• Asymmetric arthritis: characteristic of
spondyloarthropathies (e.g., psoriatic arthritis, and reactive
arthritis)
 Precepts
Differential diagnostic clues from historical features
4. Distribution of affected joints
• The distal inter-phalangeal (DIP) joints of the fingers are
usually involved in psoriatic arthritis, gout, or osteoarthritis
but are usually spared in RA.
• Joints of the lumbar spine are typically involved in
ankylosing spondylitis but are spared in RA.
5. Distinctive types of musculoskeletal involvement
• E.g., Spondyloarthropathy involves entheses, leading to:
– heel pain (inflammation at the insertions of the Achilles tendon
and/or plantar fascia),
– dactylitis (sausage digits),
– tendonitis, and
– back pain (sacroiliitis and vertebral disc insertions).
 Precepts
Differential diagnostic clues from historical features
6. Extra-articular manifestations
• Constitutional symptoms suggest an underlying systemic
disorder and are not expected in patients with
degenerative joint disease.
• Skin lesions may be present and may indicate the specific
diagnosis of a number of rheumatic diseases, e.g., SLE,
dermatomyositis, scleroderma, psoriasis
• Ocular symptoms or signs
– Episcleritis and scleritis may be associated with RA or Wegener
granulomatosis,
– Anterior uveitis with spondyloarthropathies
– iridocyclitis with juvenile Idiopathis Arthritis
– Conjunctivitis may be caused by reactive arthritis.
 Summary
Differential diagnostic clues from historical features
in Clinical Evaluation of a patient with arthritis
 PATTERNS OF DIAGNOSTIC IMPORTANCE: Onset,
context of pain experience and chronology
When did it start and what pattern has followed with time.
Example Characteristics of pain…
• Gout: rapid onset and extreme pain and tenderness
• Bone pain owing to metastatic bone disease is usually
persistent day and night
• Inflammatory pain: occurs at rest and is associated with
stiffness especially in the mornings
• Osteoarthritic pain is related to joint use and is
associated with short lived stiffness after periods of
inactivity
• Nerve / neuralgic pain is deep and might be associated
with paresthesias
PATTERNS OF DIAGNOSTIC IMPORTANCE:
Number of joints involved- Monoarthritis
Causes: Causes:
1. Infection 3. Bone / Cartilage disorder
– Bacterial, Viral, Fungal – Osteoarthritis,
osteonecrosis, Loose body,
2. Inflammatory Arthritis
tumour
– Crystal
– Rheumatoid Arthritis
4. Traumatic
– – Fracture
Juvenile idiopathic Arthritis
– – Internal derangement
Spondyloarthropathy
– Hemathrosis
PATTERNS OF DIAGNOSTIC IMPORTANCE:
Number of joints involved- Polyarthritis
Causes: Causes:
1. Rheumatoid Arthritis 3. SLE
2. Seronegative 4. Gout
spondyloarthropathies 5. Osteoarthritis
– Reactive arthritis /Reiter’s
6. Viral arthritis
disease
– Psoriatic arthritis
– Undifferentiated
spondyloarthropathy
PATTERNS OF DIAGNOSTIC IMPORTANCE :
Pattern of joint involvement
1. Flitting arthritis
– Rheumatic fever
2. Asymmetrical DIP joint involvement
– Seronegative arthritides
– Osteoarthritis
3. History of attacks in big toe
– Gout
 PATTERNS OF DIAGNOSTIC IMPORTANCE :
Mode of onset

ACUTE ONSET: SUB-ACUTE / CHRONIC

1. Viral 1. Rheumatoid arthritis

2. Reactive arthritis /Reiter’s 2. Seronegative

disease spondyloarthropathy

3. Crystal arthropathies 3. Chronic Gout

 PATTERNS OF DIAGNOSTIC IMPORTANCE : Associated
systemic symptoms or extra-articular lesions

1. Connective tissue disorders

1. SLE
2. Dermatomyositis
3. Scleroderma
2. Rheumatoid arthritis
3. Spondyloarthropathies
4. Rheumatic fever
5. Polymyalgia rheumatica
6. Bacterial endocarditis
7. Sarcoidosis
 PATTERNS OF DIAGNOSTIC IMPORTANCE : Other
Associated problems symptoms

1. Spinal pain
– Cervical spine – RA, OA
– Low back- spondyloarthropathy (SpA), OA
2. Eye symptoms
– Conjunctivitis -(SpA),
– Uveitis -(SpA),
3. Urogenital symptoms
– Urethral or vaginal discharge -(SpA),
4. Diarrhoea / dysentery
– Urethral or vaginal discharge -(SpA),
 Evaluation of a patient with arthritis
Diagnostic clues from Physical examination
 Precepts
Assessment of the musculoskeletal system
• Should be approached in
the same way as for
diseases of any other
system – that is by:
– careful history taking,
– examination, and
– use of appropriate
investigations
• In addition, assess for
impact of the condition
on physical and mental
function of patient
 Precepts
Differential diagnostic clues from the examination
• THE MUSCULOSKELETAL EXAMINATION
– helps distinguish joint inflammation
(e.g., RA) from joint damage (e.g.,
degenerative joint disease)
– It also helps elucidate:
• Site of involvement (e.g., synovitis,
enthesitis, tenosynovitis, bursitis) and
• the distribution of joint involvement.
 Precepts
Differential diagnostic clues from the examination
1.Signs of inflammatory joint disease
– Synovial hypertrophy
• This is the most reliable sign of an
inflammatory arthritis.
• The synovial membrane is normally too thin
to palpate.
• In a person with chronic inflammatory
arthritis, the synovial membrane has a
doughy or boggy consistency,
– This feature is best appreciated at the joint line or margin.
 Precepts
Differential diagnostic clues from the examination
1.Signs of inflammatory joint disease (cont’d)
– Joint effusions
• Effusions develop in response to:
– synovial inflammation,
– trauma,
– anasarca,
– intra-articular hemorrhage (hemarthrosis), or
– an adjacent focus of acute inflammation (sympathetic effusion).
• Effusions are detected by performing fluid
ballottement or cross-fluctuation through the
synovial cavity
 Precepts
Differential diagnostic clues from the examination
1. Signs of inflammatory joint disease (cont’d)
– Pain with motion
• Pain throughout the whole range of
motion is observed in a person with an
acutely inflamed joint (Synovitis).
• Pain not present throughout the entire
range of motion may indicate an extra-
articular source, such as tendinitis.
 Precepts
Differential diagnostic clues from the examination
1.Signs of inflammatory joint disease
– Limited range of motion:
• In a person with inflammatory joint disease,
limitation of motion results from:
–the presence of a tense effusion,
–markedly thickened synovium,
–adhesions,
–capsular fibrosis, or
–pain.
 Precepts
Differential diagnostic clues from the examination
1. Signs of inflammatory joint disease (cont’d)
– Erythema and warmth
• Erythema of the joint is restricted to acute inflammatory
forms of arthritis, such as gout, septic arthritis, or acute
rheumatic fever. Rare in persons with RA and psoriatic
arthritis.
• Warmth of the joint is a sensitive sign of inflammatory
arthritis
– It can be detected by passing the hand back and forth from the
joint to a neutral area distal or proximal. Differences in warmth can
also be detected by comparing the same joint on each side of the
body.
 Precepts
Differential diagnostic clues from the examination
1.Signs of inflammatory joint disease (cont’d)
– Joint tenderness
• This is a sensitive sign of joint disease,
– However, it is not specific for inflammatory arthritides
• In an acutely inflamed joint, tenderness can
be elicited over the entire joint.
• Focal tenderness may indicate a focus of
inflammation outside the joint, such as
tendinitis, osteomyelitis, or fracture.
 Precepts
Differential diagnostic clues from the examination
2.Signs of degenerative/mechanical joint disease
– Bony overgrowth of the joints (osteophytes):
• In hands: those located at the distal interphalangeal joints
are called Heberden nodes, while those located at the
proximal interphalangeal joints are called Bouchard nodes.
– Limited range of motion: In persons with
degenerative/mechanical joint disease, the limitation
of motion may result from:
• intra-articular loose bodies,
• osteophyte formation, or
• subluxation.
 Precepts
Differential diagnostic clues from the examination
2.Signs of degenerative/mechanical joint disease
(cont’d)
– Crepitus during active or passive range of motion
• A palpable or audible grating sensation is produced during
motion of the joint.
• Soft, fine crepitus may be felt (or heard with a stethoscope)
in a rheumatoid joint when the cartilage surface is no
longer smooth.
• Coarse crepitus or grating may be felt in joints severely
damaged by long-standing rheumatoid or degenerative
arthritis.
 Precepts
Differential diagnostic clues from the examination
2.Signs of degenerative/mechanical joint disease
(cont’d)
– Joint deformity
• Several types must be distinguished as follows:
– Restriction in the normal range of motion, e.g., lack of
full joint extension that results in a flexion deformity
– Mal-alignment of the articulating bones, such as ulnar
deviation of the fingers or valgus deformity of the
knee
– Alteration in the relationship of the two articulating
surfaces, such as subluxation and dislocation
 Precepts
DIAGNOSTIC CLUES FROM THE EXAMINATION
Look at
3. Eyes
1. The affected joint, and – Conjunctivitis
the contra-lateral joint – Uveitis
2. Skin and nails – Dryness
– Psoriasis 4. Genitalia
– Rash of SLE – Ulceration
– Nodules, tophi – Balanitis
– Erytherma marginatum – Discharge
– Pits / ridges on nails 5. Mouth
– Etc – Ulceration
 Precepts
Schema for MS examination
• SYSTEMATIC & SEQUENTIAL
– LOOK
– FEEL
– MOVE
• ACTIVE & PASSIVE

• Starting with the symptomatic region or limb,

examine the whole MSK system and do a general
examination: in particular dermatological,
neurological, or peripheral vascular
 Precepts
Schema for MS examination
LOOK (at rest and during movement)
for gait, posture/attitude, swelling,
deformity, range, muscle wasting, skin
changes,

FEEL for tenderness, swelling,

deformity, muscle spasm, crepitus with
movement, and temperature

MOVE (actively, then passively, and

against resistance). Assess range and
stability, presence of pain.
Test FUNCTION and STRENGTH
 Summary:
Physical Examination of a patient with arthritis

• Be organized, systematic and thorough

• Do a GENERAL examination
– Start by looking at the whole person

• Then examine the symptomatic joint or region

• Continue to examine region by region from the head

downwards
• Compare the contra-lateral side with the symptomatic one
 Evaluation of a patient with arthritis
Diagnostic clues from Laboratory and other tests
 Precepts
Assessment of the musculoskeletal system
• Should be approached in
the same way as for
diseases of any other
system – that is by:
– careful history taking,
– examination, and
– use of appropriate
investigations
• In addition, assess for
impact of the condition
on physical and mental
function of patient
Investigations for Joint Disorders
There are three main types of investigations:

1. Blood tests,

2. Imaging of bones and joints, and

3. Synovial fluid analysis and/or synovial biopsy.

 Precepts
Diagnostic clues from Laboratory tests
1. Screening blood tests for all types of
inflammatory arthritis
– Erythrocyte sedimentation rate (ESR): an elevated ESR
supports the presence of an inflammatory arthritis.
– C-reactive protein (CRP): This test is an alternative to
obtaining the ESR.
– Rheumatoid factor and cyclic citrullinated peptide (CCP):
A rheumatoid factor test should be obtained when
rheumatoid arthritis (RA) is at least moderately possible in
the patient. Measuring antibodies to CCP is a new test for
RA; it has higher specificity but lower sensitivity than
rheumatoid factor.
 Precepts
Diagnostic clues from Laboratory tests
1. Screening blood tests for all types of
inflammatory arthritis (cont’d)
– ANAs: ANA tests are commonly obtained in patients
with arthralgias or arthritis as a screening test for SLE
or another connective-tissue disorder.
• More than 95% of patients with SLE have ANAs; thus, a negative ANA
result is a strong indicator that SLE is not present.
• However, a positive ANA result lacks specificity and may occur in
persons with other connective-tissue diseases or certain medical
illnesses.
• The diagnostic yield of the ANA test is increased substantially when the
patient has features that suggest a diagnosis of SLE or another
autoimmune disease in addition to joint pain.
 Precepts
2. Diagnostic clues from imaging studies
1. Plain radiography:
• The least expensive imaging modality
• Most useful for clarifying the nature of joint abnormalities already
noted during the physical examination, e.g.,
– swelling [bony vs soft tissue],
– loss of motion [bony vs soft tissue],
– instability [ligamentous vs destruction of articular surface],
– focal bony tenderness [fracture vs osteomyelitis]
• Joint appearance on plain radiographs is often distinctive for various
forms of arthritis. However these characteristic changes may not be
apparent early in the disease course.
• Plain radiographs are useful for monitoring the progression of chronic
arthritides (eg, osteoarthritis, RA).
 Precepts
2. Diagnostic clues from imaging studies (cont’d)
2. CT scan:
• This technique obtains cross-sectional images of skeletal
structures.
• It is most useful for:
– assessing trauma of the spine and pelvis,
– evaluating arthritis in axial joints (e.g., sacroiliac, atlantoaxial,
sternoclavicular),
– evaluating pain in complex joints in which overlying structures
obscure plain radiography views (e.g., ankle, wrist,
temporomandibular joints), and
– evaluating degenerative disc disease of the spine and possible disc
herniations.
 Precepts
2. Diagnostic clues from imaging studies (cont’d)
3. MRI:
• Is best for assessing soft tissue and spinal cord elements.
• It is of greatest use for assessing:
– rotator cuff tears,
– spinal stenosis,
– ligamentous or meniscal abnormalities of the knee and wrist joints,
– osteonecrosis (ie, avascular necrosis of bone),
– stress fractures,
– osteomyelitis, and
– subchondral bone injury in osteoarthritis or meniscal tears.
 Precepts
2. Diagnostic clues from imaging studies (cont’d)
4. Arthrography:
• Is of greatest use for defining abnormal communication
between the synovial space and adjacent bursae and soft
tissue, e.g.,
– popliteal cysts,
– rupture of rotator cuff with communication between glenohumeral
joint space and subacromial bursa.
 Precepts
2. Diagnostic clues from imaging studies (cont’d)
5. Radionuclide bone scanning:
• It is most useful for assessing:
– osteomyelitis,
– stress fractures, and
– bony metastasis.
• It may be used to exclude skeletal disease in patients with
diffuse musculoskeletal pain.
 Precepts
3. Diagnostic clues from Synovial fluid studies
– Synovial fluid (SF) analysis
• This test is used to broadly characterize the type of arthritis:
– E.g., to identify crystals, and to establish the diagnosis of septic
arthritis and crystal-induced synovitis.
• Synovial fluid types are classified as:
– normal,
– Non-inflammatory,
– inflammatory,
– septic, or
– hemorrhagic.
 Precepts
3. Diagnostic clues from Synovial fluid studies
– Synovial fluid (SF) analysis (cont’d)
• Normal SF: Characteristics include:
– clear to pale yellow colour, transparent clarity, WBC
count of less than 200/µL with less than 25% PMN
leukocytes, and very high viscosity.
• Non-inflammatory SF: Characteristics include:
– pale yellow colour, transparent clarity, WBC count of
200-2000/µL with less than 25% PMN leukocytes, and
high viscosity. It typifies osteoarthritis, traumatic
arthritis, and an early or resolving stage of an
inflammatory arthritis.
 Precepts
3. Diagnostic clues from Synovial fluid studies
– Synovial fluid (SF) analysis (cont’d)
• Inflammatory SF: Characteristics include:
– yellow-to-white colour, translucent-to-opaque clarity, WBC count
of 2000-50,000/µL with more than 70% PMN leukocytes, and low
viscosity. It typifies RA and other chronic inflammatory arthritides
• Septic SF: Characteristics include:
– a white-to-cream colour, opaque clarity, WBC count of more than
50,000/µL with more than 90% PMN leukocytes, and very low
viscosity. It typifies bacterial arthritis, but it also may occasionally
be seen in crystalline arthritis and flares of RA.
• Hemorrhagic SF: Characteristics include:
– a hemorrhagic colour and opaque clarity. Fat globules should be
sought in hemorrhagic fluids by centrifuging the synovial fluid. A
supernatant of fat is indicative of a juxta-articular fracture.
 Precepts
4. Diagnostic clues from Synovial biopsy
– Synovial Biopsy
– In the majority of patients with rheumatic diseases, an
accurate diagnosis can be established without
performing a synovial biopsy.
– For certain conditions, histopathologic findings in the
synovium are either pathognomonic or highly specific.
These include:
• various granulomatous arthritides, e.g., tuberculous,
sarcoidosis
• amyloidosis,
• synovial tumors
 Precepts
Prudent use of laboratory & other Investigations
1. Most useful diagnostic tests for specific
rheumatic diseases
– Septic arthritis: Order a Gram stain and culture of
synovial fluid
– Gout or pseudogout: Use polarized light microscopy
to examine a drop of synovial fluid for intracellular
urate (gout) or calcium pyrophosphate dihydrate
(pseudogout) crystals
– Ankylosing spondylitis: Obtain sacroiliac joint
radiographs to demonstrate bilateral sacroiliitis
 Precepts
Prudent use of laboratory & other Investigations
1. Most useful diagnostic tests for specific
rheumatic diseases (cont’d)
– Osteoarthritis: Obtain radiographic images of the
affected joint
– Systemic lupus erythematosus (SLE): Screen with an
antinuclear antibody (ANA) test.
• If positive, test for Smith (Sm) and double-stranded DNA
antibodies. These antibodies are more specific for SLE but
are present in only 30-60% of patients with SLE,
respectively.
 Summary
Differential diagnostic clues from laboratory tests in
patients with arthritis

•The are NO pathognomonic laboratory

tests...
•Screening laboratory test results [mostly]
serve to confirm clinical impressions
– They can be misleading if used without much
deductive thinking
 Background
Role for laboratory tests?...
• Screening laboratory test results [mostly] serve
to confirm clinical impressions
– They can be misleading if used without much
deductive thinking

Goal of clinical enquiry...

• The initial aim of the clinical evaluation is to:
– localize the source of the joint symptoms, and
– to determine the type of patho-physiological process
responsible for their presence.
Routine screening history and
examination for musculoskeletal
problems
An essential screening history and
examination to be applied as part of a
general inquiry in all encounters with
patients to identify those with
musculoskeletal problems
 Core concepts in evaluating MS disease
This section teaches three concepts key in the
logical sequence required for evaluation of MS
disorders:
1.‘Asking’ Screening questions for
musculoskeletal disorders
2.Performing a Screening examination for
musculoskeletal disorders- The ‘GALS’
3.Performing a regional examination
of the musculoskeletal system (‘REMS’)
Screening for disorders of the musculoskeletal
system (MSS)
• An assessment of the MSS
should be incorporated into
your routine clerking of all
patients
– just as you would for the
cardiovascular or other systems.
• This is achieved through the
use of screening questions
and a screening examination,
both of which have been
developed specifically for
musculoskeletal disorders.
 1. Screening questions for musculoskeletal
disorders

Screening questions for MS

Screening questions for MS
disorders-Rationale
disorders

1. ‘Do you have any pain or

• The main symptoms arising
from disorders of the MSS
are pain, stiffness, swelling,
and associated functional
problems.
• The screening questions
have been designed to
directly address these
aspects
stiffness in your muscles,
joints or back?’
2. ‘Can you dress yourself
completely without any
difficulty?’
3. ‘Can you walk up and
down steps/stairs without
any difficulty?’
Screening questions for disorders of the
musculoskeletal system (MSS)
• Interpretation of screening
questions and a screening
for musculoskeletal
disorders.
– A positive response to one or
more of the screening
questions should be followed
up by taking a more detailed
history and by carrying out
the screening examination.
– Similarly, an abnormal finding
in the screening examination
should lead to a more
detailed regional examination
and a review of the patient’s
history.
Screening questions for musculoskeletal
disorders: Interpretation
• If the patient has no pain or stiffness, and no
difficulty with dressing or with climbing stairs it is
unlikely that s/he suffers from any significant
musculoskeletal disorder.

• If the patient does have pain or stiffness, or

difficulty with either of these activities, then a
more detailed history should be taken.
2. Screening examination for musculoskeletal
disorders- The ‘GALS’
• A brief screening examination,
which takes 1–2 minutes, has
been devised for use in routine
clinical assessment.
• It is highly sensitive in detecting
significant abnormalities of the
MSS.
• It involves inspecting carefully for
joint swelling and abnormal
posture, as well as assessing the
joints for normal movement.
• This screening examination is
known by the acronym ‘GALS’,
which stands for Gait, Arms, Legs
and Spine.
 ‘GALS’ Screening Examination
Gait Legs
• Observe gait • Assess full flexion and extension
• Observe patient in anatomical • Assess internal rotation of hips
position • Perform patellar tap
• Inspect feet
Arms • Squeeze MTPJs
• Observe movement – hands
behind head
Spine
• Observe backs of hands and wrists
• Inspect spine
• Observe palms
• Assess lateral flexion of neck
• Assess power grip and grip
• Assess lumbar spine movement
strength
• Assess fine precision pinch
• Squeeze MCPJs
 ‘GALS’ Screening Examination
GAIT (Ask the patient to walk a few steps, turn, and walk back)

1.Observe the patient’s gait for symmetry, smoothness and the ability to turn
quickly

2.With the patient standing in the anatomical position, observe from behind, from
the side, and from in front for:
1. bulk and symmetry of the shoulder, gluteal, quadriceps and calf muscles;
2. limb alignment;
3. alignment of the spine;
4. equal level of the iliac crests;
5. ability to fully extend the elbows and knees;
6. popliteal swelling; abnormalities in the feet (see Figure 2).
 ‘GALS’ Screening Examination
ARMS
• Ask the patient to put their hands • Ask the patient to squeeze your
behind their head. fingers. Assess grip strength.
– Assess shoulder abduction and external • Ask the patient to bring each finger in
rotation, and elbow flexion. (These are often
the first movements to be affected by turn to meet the thumb. Assess fine
shoulder problems.) precision pinch.
• With the patient’s hands held out, • While watching the patient’s face for
palms down, fingers outstretched, signs of discomfort, gently squeeze
observe the backs of the hands for joint across the MCP joints to check for
swelling and deformity. tenderness suggesting inflammatory
• Ask the patient to turn their hands over. joint disease.
Look at the palms for muscle bulk and
for any visual signs of abnormality.
• Ask the patient to make a fist. Visually
assess power grip, hand and wrist
function, and range of movement in the
fingers.
 ‘GALS’ Screening Examination
LEGS (With the patient lying on the couch)
• Assess full flexion and extension of both knees, feeling for crepitus.
• With the hip and knee flexed to 90º, and while holding the knee and ankle to guide
the movement, assess internal rotation of each hip
• Perform a patellar tap to check for a knee effusion.
• From the end of the couch, inspect the feet for swelling, deformity, and callosities
on the soles.
• While watching the patient’s face for signs of discomfort, Squeeze across the MTP
joints to check for tenderness suggesting inflammatory joint disease.
 ‘GALS’ Screening Examination
SPINE (With the patient standing)
• Inspect the spine from behind for
evidence of scoliosis, and from the
side for abnormal lordosis or
kyphosis.
• Ask the patient to tilt their head
to each side, bringing the ear
towards the shoulder.
• Assess lateral flexion of the neck.
(This is sensitive in the detection
of early neck problems.)
• Ask the patient to bend to touch
their toes. This movement can be
achieved relying on good hip
flexion, so it is important to
palpate for normal movement of
the vertebrae.
– Assess lumbar spine flexion by
placing two or three fingers on
the lumbar vertebrae.
– Your fingers should move apart
on flexion and back together on
extension
3. Performing a regional examination
of the musculoskeletal system (‘REMS’)
• Regional examination of the musculoskeletal
system (REMS)refers to the more detailed
examination of the MSS
• REMS:
– should be carried out once an abnormality has been
detected either through the history or through the
screening examination (GALS)
– involves the examination of a group of joints which
are linked by function
– may also require a detailed neurological and vascular
examination.
 Performing a regional examination
of the musculoskeletal system (‘REMS’)
• There are five key stages • LOOK for attitude, swelling, range,

which need to be deformity, muscle wasting, skin

completed during an changes, at rest and during

examination of the joints
in any part of the body:
1. Introduce yourself.
2. Look at the joint(s).
3. Feel the joint(s).
4. Move the joint(s).
5. Assess the function of the
joint(s).
movement
• FEEL for tenderness, swelling,
deformity, and crepitus with
movement and temperature
• MOVE actively, then passively and
against resistance to see if different.
Look for pain, range and stability.
• Test FUNCTION and strength
Some useful terms and definitions
1. Definitions / rheumatological jargon
A. Relating to names of joints / joint areas
• MCP: Metacarpophalangeal

• MTP: Metatarsophalangeal

• PIP: Proximal inter-phalangeal

• DIP: Distal Inter-phalangeal

 1. Definitions / rheumatological jargon
B. Relating to joint size

• Large joints: Hips, knees, ankles, shoulders,

elbows, and wrists.

• Small joints: MCP, MTP, and phalangeal joints of

hands and feet.
 1. Definitions / rheumatological jargon

C. Relating to pattern of joint involvement

• Monarticular: affecting one joint

• Polyarticular: affecting more than five joints.

• Pauciarticular: affecting five or less joints.

• Bilateral: Affecting the same joint on both sides of the
body.

• Symmetrical: Affecting the same joints to the same

extent on both sides of the body.

 1. Definitions / rheumatological jargon
D. Relating to mode of joint involvement
• Episodic: Two or more attacks of arthritis with periods of
complete remission between them.
• Migratory: Arthritis moving from joint to joint, the first
affected joint becoming normal when the second is
involved.
• Simultaneous: Arthritis affecting a number of joints, all of
which are affected from the beginning of the illness.
• Additive: Arthritis moving from joint to joint, the first
affected joint persisting with the involvement of the second
and subsequent joints.