MANUAL INVESTIGATION OF LOCOMOTOR SYSTEM

Professor D.Andersone
Head of the Center of rheumatology
2019. 7 october

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 THE LOCOMOTOR SYSTEM

The locomotor system includes the joints, the muscles and the tendons
which move the joints, and the bones and ligaments which provide
support.
Though any these components can be affected by disease, joints are the
most commonly disordered.
Pain and stiffness are the principial symptoms. Pain frequently has a
characteristic pattern in relation to physical activity.
In RA , for example, both pain and stiffness are worse after resting and
gradually improve as the joints are used.
In OA, in contrast, exercise makes the joint pain worse. Joint pain
without swelling is called arthralgia, and it is common in different
rheumatic and nonrheumatic diseases

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JOINT S STRUCTURE

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 HISTORY, EXAMINATION AND INVESTIGATION OF JOINT
DISAESE

There are three steps involved in making a diagnosis in a patient with a

rheumatological problem :
history,
examination
investigation - and they are always taken in this order.
The history will usually point to those parts of the examination which
need emphasis in a particular patient; a patient with a painfull knee will
need very careful examination of the joint.
A detailed examination of all the joints is not required in a patient whose
complaints do not suggest any articular problem.
In that case a more superficial check of the locomotor system can
usefully be combined with routine examination of the nervous system.

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IMPORTANT POINTS IN THE HISTORY OF A PATIENT WITH
ARTHRITIS

Important points in the history of a patient with arthritis

Age ; sex; race; occupation.
Pain :
situation
radiation
onset and precipitating factors
aggravating and relieving factors
If episodic:
frequency, regularity and duration of attacks.

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 HISTORY, EXAMINATION AND INVESTIGATION OF JOINT
DISEASE

Before starting to analyse the patient s complaints , it is

important to document some background information
including age, sex and occupation

Arthropathies affect particular age groups: for example

polymyalgia rheumatica is usually a disease of the over 60 s,

RA is 2 or 3 times more often in women than men.

The important points in the history are summarised in table.

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POSTURE

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 GENERAL PRINCIPLES OF JOINT EXAMINATION

• It is important to follow a definite sequence when examining

a joint

• First inspect it, than feel it, move it , compare it to the

opposite side and, if appropriate, measure it

• It is important to have a regular sequence in examining

joints, for example , starting with the spine and moving to
the arm and leg

• Start the examination of the spine by noting posture.

Adequate time is essential , so that the patient must be
undressed

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 GENERAL PRINCIPLES OF JOINT EXAMINATION

The locomotor system is examined by inspection and

palpation both at rest and in action
Nearly abnormalities as the restriction of joint movement,
joint swelling, muscle wasting and injuries are particularly well
suited to measurement and recording by diagram.
Posture and gait.
This alters with age and disease, particularly of the spine, for
example kyphosis or scoliosis
Kyphosis on the thoracic region is a common abnormality in
the elderly as result of osteoporosis ( deficiency of bone
matrix) or occasionally os osteomalacia ( demineralisation of
bone

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 STEPS IN THE EXAMINATION OF A JOINT

• LOOK
• for swelling
• for deformity
• at the overlying skin
• at surrounding structures
• FEEL
• for the nature of the swelling
• for warmth
• for tenderness

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Swan neck, Buttonhole
deformity

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 GENERAL PRINCIPLES OF JOINT EXAMINATION

Joint swelling

Swelling is usually best detcted by inspection.

Joint swelling has three important causes:
Fluid ( effusions) may occur almost any joint pathology, bony
swelling suggests osteoarthritis,
synovial thickening is evidence of inflammatory sunovitis
A wide variety of localised swellings occur in relation to joints ,
including the fluid-filled synovial extension from the wrist joint,
a so-called “ganglion”, rheumatoid nodules or gouty tophi.

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Saussage fingers

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Skin desquamation called keratodermija
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 GENERAL PRINCIPLES OF JOINT EXAMINATION

Any increased flexion is

called kyphosis, extension
or lordosis and lateral
curvature is scoliosis.

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 GENERAL PRINCIPLES OF JOINT EXAMINATION

It is particularly important to remember that examination of

lower limb must include observations with patient s
standing and walking

When active movement of a joint is impaired, or if abnormal

mobility is suspected, the cause may become apparent
during passive movements

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POINTS WHICH HELP TO DIFFERENTIALE INFLAMMATORY AND
MECHANICAL PAIN

Prolonged and generalised morning stiffness is a most

important feature of the history of a patient with
inflammatory arthritis such as RA.
It also occurs in polymialgia rheumatica and patients often
say that they are so stiff on walking that they cannot get out
of bed.
A brief period of stiffness occurs in the affected joints of
osteoarthritis patients either in the mornings of after sitting.

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 STEPS IN THE EXAMINATION OF A JOINT

• LOOK
• for swelling
• for deformity
• at the overlying skin
• at surrounding structures
• FEEL
• for the nature of the swelling
• for warmth
• for tenderness

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 Warmth and erythema

Warmth and erythema

The skin overlying a joint deserves attention.

Erythema may be seen over an infected joint, indicating acute
inflammation. Such redness is uncommomn over RA joints, but is seen in
acute crystal deposition such as gout.
A much more sensitive method of identifying increased vascularity is by
a rise in skin .
The back of the examiners hand carried backwards and forwards over
the skin of the knees will easily detected minor differences
If both knees are warm, the comparison is made with the skin above and
below the joint

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 Measure the range of active movements

Watch the patients face for any indication of pain a common cause of limited
movement.
Compare the T of a swelling joint with that of the same joint on the opposite
side.
Palpate for coarse crepitus, which may be audible, if the articular cartilage is
severely damaged.
Localise any points of tenderness and if possible identify the tissue involved by
putting stress on the structure thought to be affected ( Pain will result if a
strained ligaments is streched or if a torn muscle is contracted).
To detected an effusion of the knee joint , grasp the lower part of the front of
the thigh with one hand and empty any fluid from the suprapatellar pouch, With
the other hand, depress the patella sharply onto the femur( a distinct tap
indicates the presence of fluid and helps to distinguish the swelling from
that due to synovial thickening

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The investigation of the joints must be eye contact, Watch the
patients face for any indication of pain a common cause of limited
movement.
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a phenomenon of balotyne, with one hand covering the knee jointis putted the
other on the patella. Patellas fluctuations in the fluid in the joint are observed

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Does it worry you when I push
your arm back ?
 STEPS IN THE EXAMINATION OF A JOINT

• MOVE
• note the range of movement
• note crepitus
• note pain
• note instability
• Compare with the opposite side and record the pattern of
joint involvement.
• remember posture and gait.
• remember that complete physical examination is essential

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G.G.Hunder. Atlas of Rheumatology, 1999
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 STEPS IN THE EXAMINATION OF A JOINT

• MOVE
• note the range of movement
• note crepitus
• note pain
• note instability
• Compare with the opposite side and record the pattern of
joint involvement.
• remember posture and gait.
• remember that complete physical examination is essential

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 GENERAL PRINCIPLES OF JOINT EXAMINATION

Joint movement
Various aspects of joint movement have to be tested. For
measuring the range of movement, a goniometer is required.
By convention, joint movements is measured from a’” neutral zero
position” in which all joints are regarded as being at zero degrees
when the patient stands to attention with palms pointing forwards.
Movements from this position are described as so many degrees
of flexion or extension .
The one exeption is the forearm. : here the neutral zero position is
with the elbow by the side and flexed to 90 degrees with the thumb
pointing straight up.

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 GENERAL PRINCIPLES OF JOINT EXAMINATION

Joint movement
The normal range of movement varies considerably between
individuals. It tends to be greater in the young, in females, and in
coloroued races.
Comparison with the joint on the opposite side is often a usefull
yardstick.
Active movement.
Patients often find helpful if the examiner first demonstrates what
to do. At the time, this gives a range of movement for comparison.
Passive movement and palpation. When active movement of a
joint is impaired, or if abnormal mobility is suspected, the cause
may become apparent during passive movements

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 THE LOCOMOTOR SYSTEM

Special note should be made of the sequence of joint involvement.

Whether joint symptoms moved from one joint to another ( flitting), or
whether joint involvement progressed to affect an increasing number of
joint.
In inflammatory joint disorders, other connective tissues may also be
involved to suggest vasculitis or immunologically- mediated disorders
The degree of functional disability is best assessed by asking questions
such as:
Can you dress yourself and how long does it take you to do so? “Can you
walk to the shop ?” or
Do you have difficulty climbing up and down stairs?”

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 GALS=
GAIT
ARMS
LEGS
SPINE

10/5/2019 51
Joint motion angle measurement with
gonometer

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Quantification of neck motion

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Carpal tunnel syndrome wrist test right angles shifting up and
down keeping the upper arm horizontal

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Vertebral mobility test

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 HISTORY, EXAMINATION AND INVESTIGATION OF JOINT
DISEASE

It should include posture, gait, inspection of the limbs,

particulary the hands, palpation and movement of the
lumbar spine.
Conversely, patients in whom the history points to an
articular will certainly also need a general examination
including all other systems.
The clue to a rheumatological diagnosis may lie, for example,
in the eye, in the mouth or on the skin

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Joint pain localization

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 Inflammatory and Mechanical Pain

The pattern of pain and stiffness are important in distinguishing

inflammatory and mechanical causes of joint and back pain.

In inflammatory diseases like RA and AS, pain is worst in the morning on

waking; the patient is stiff and may take several hours to “ loosen up”.
Patients often say that they are so stiff, that they cannot get out of bed.
Stiffness recurs after any period of rest.

By contrast , in mechanical disorders there is no morning stiffness.; pain

is usually worst after activity and at the end of the day.
Some of the points which help to differentiate mechanical from
inflammatory conditions are summarised in the table

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POINTS WHICH HELP TO DIFFERENTIALE INFLAMMATORY AND
MECHANICAL PAIN

Inflammatory Mechanical

Worst time Morning Evening

Effect of Relieves Aggravates

exercise
Morning Present Absent
stiffness
Best treatment NSAID s Analgesics

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 IMPORTANT POINTS IN THE HISTORY OF A PATIENT WITH
ARTHRITIS

• Associated symptoms:
stiffness
swelling
rashes,
iritis e.t.c.
• Pattern of joint involvement
• Past medical history
• Family history
• Consequences, disabilities and special problems.

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 CT, MRI, US, and RTG PIE RA
MCP LOCĪTAVĀS

2019.10.05.
Døhn et al. Arthritis Res Ther 2006;8:R110 66
2012.03.02. 67
 Kapilaroscopy is non-invasive
image technique used
microcirculation measurement in
vivo

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2012.03.02.
 Capillaries of the nail bed are optically examined

2012.03.02. 69
 Capillaries are arranged
regularly and in parallel Capillaries areare
Capillaries arranged in in
arranged
Number of loops 11 / mm parallel,
parallel, heterogeneous;
heterogeneous;
Slightly enlarged blood Loops
Loops 3 /3mm/ mm
vessels Large
Large open-air
open-air areas;
areas;
Conclusion: This kind
Conclusion: This kind of
of avascularity is never
avascularity is never observed
observed in healthy human subjects
in healthy human subjects

2012.03.02. 70
 Changes in capillary bed vessel vessels

tree capillaries Angioģenēze

Irregularly increased
Capillary bearing
capillary loops
2012.03.02. 71
disorganization
 SUMMARY
A clinical history of pain and/or stiffness after resting suggests an
active synovitis; pain and stiffness during exercise suggest a
degenerative joint disorder.
Observe the posture and gait for evidence of osteogenic or
neurogenic disorders.
Joint inflammation is suggested by the presence of pain, heat,
swelling, redness and impaired function.
Examine active before passive joint movements and remember the
spinal movements.
Compare and affected joint with the same joint on the opposite side.

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THANK YOU !