Musculoskeletal

Examination in
Rheumatology
Components of joint examination

• Look (inspection): Skin and SC, muscle , joint (swelling- deformity)

• Feel (palpation): for temperature, joint tenderness and effusion,
presence of crepitus, special swelling of any localized swelling
• Move and Muscular power for functional assessment:
- Active movements
- Passive movements
• Special tests: according to the joint being examined.
Hand and wrist Anatomy
• Common acute problems of hand and wrist include fractures,
tendonitis and trigger finger. Common chronic problems include
carpal tunnel syndrome, ganglions and arthritis.
•   There are three main conditions commonly examined:
osteoarthritis, rheumatoid arthritis and psoriatic arthritis
•   Finding may include, swan neck deformity, Bouchard’s nodes and
Heberden’s nodes.
Inspection
• Skin for any abnormality like rash, erythema, psoriatic lesions, scars,
subcutaneous nodules and nail abnormalities ……
• muscle thenar, hypothenar and dorsal interossei
• Joint (swelling- deformity)
• Firstly place the patient’s hands on a pillow in between you and them,
ensuring the patient is comfortable.
• Position the patient so they are comfortable
• Inspect the patient’s hands. In particular look for swellings,
deformities, muscle wasting, scars – particularly carpal tunnel release
scars, skin changes, rashes, nail pitting, onycholysis, nailfold vasculitis,
palmar erythema. If there are joint swellings note which joints are
involved and whether the changes
• are symmetrical or not. Remember to check both sides of the hands
• Bouchard’s nodes and Heberden’s nodes
• At this point the extensor surface of the elbows should be checked for
any psoriatic plaques and rheumatoid nodules. Psoriatic plaques
could suggest the presence of psoriatic arthritis.
Palpation
• Now palpate the hands. This should look as smooth as possible so try
and develop your own technique. A good suggestion is to start
proximally and work towards the fingers.
Assess the temperature over the joint areas and compare these with
the temperature of the forearm
Palpation
• Begin by palpating the wrist joints with your thumbs on the extensor
surface and your index fingers on the flexor surface, work your way
distally to the carpal bones.
The movements which should be assessed
are:
• wrist flexion
• wristextension
• finger extension
• finger flexion
• finger abduction
• thumb abduction
• thumbopposition
Finger extension Wrist extension Wrist extension
Functional assessment and power
Trigger finger is a
condition in which one
of your fingers gets stuck
in a bent position. 

• inflammation within a tendon

sheath, restricting tendon
motion. 
• Also called stenosing
tenosynovitis
Special Tests
Tests for Carpal tunnel syndrome: median n
compression
For testing medial nerve decompression
1. Phalen`s test
2. Tinnel`s test
3. Carpal Compression test
Phalen`s test

Lateral 3 and ½ fingers

Tinel`s test
Carpal compression test
Finkelstein test
Froment’s sign is a test which may also be performed to check Ulnar nerve function. This is
performed by asking the patient to hold a piece of paper between their thumb and index finger; this
will check the function of the adductor pollicis. In a patient with Ulnar nerve palsy the
interphalangeal joint of the thumb will flex to compensate.
 Knee anatomy

Anterior view of the knee

joint,
Inspection of the Knee
• Skin for any abnormality like rash, erythema, psoriatic lesions, scars,
subcutaneous nodules and nail abnormalities ……
• Quadriceps muscle bulk
• Joint (swelling- deformity)
• DON`T FORGET TO inspect back of the knee while the patient is
standing for swelling in popliteal fossa “ baker`s cyst”
• Inspection of the knee can be done while the patient is standing to
better assess deformity
Quadriceps wasting
Knee deformities
Knee Palpation
• Now palpate the knee joint, start by assessing the temperature using
the back of your hands and comparing with the surrounding areas
• Palpate the border of the patella for any tenderness, behind the knee
for any swellings, along all of the joint lines for tenderness and at the
point of insertion of the patellar tendon.
• Finally, tap the patella to see if there is any effusion deep to the
patella.
• The main movements which should be examined both actively and
passively are:
• a. Flexion b. Extension
• A full range of movements should be demonstrated and you should
feel for any crepitus.
Pulge test
The Ankle and Foot
• Inspection
• The ankle and foot are inspected in both resting and standing
positions for evidence of swelling, deformities, erythema, tophi,
subcutaneous nodules, ulcers, flat foot or achillis abnormality.
• Arthritis of the ankle joint: produces a diffuse swelling anteriorly,
with obliteration of the two small depressions that are present
normally in front of the malleoli.
• Synovitis of the MTP joint: is associated with diffuse swelling on the
dorsum of the forefoot that may obscure the extensor tendons.
Synovitis of PIP & DIP
• Inspection while the patient is standing may reveal lowering of the
longitudinal arch (pes planus) or increased height of the arch (pes
cavus).
Toes deformities
• Hallux valgus deformity refers to a lateraldeviation of the first (great) toe on the first
metatarsal
greater than 100 to 150.
Halluxvarus isstraightening or medial deviation of the great toe on the first
metatarsal.
“Cock-up” or “claw toe” deformity refers to dorsiflexion ofthe MTP joint and plantar
flexion of both the PIP and DIPjoints (Fig. 8–10).
• A hammer toe refers to plantar flexiondeformity of the PIP joint, usually associated
with dorsiflexion
of the MTP and DIP joints.
In mallet toedeformity, the DIP joint is plantar flexed and the PIP jointis neutral (or
the PIP joint is plantar flexed and the DIP jointis neutral). It is usually associated with
a dorsiflexed MTPjoint.
Hammer toes
Halux valgus

Halux varus
Palpation
• For temperature
• For tenderness
• The ankle joint is palpated with the foot in slight plantar flexion. The joint is
supported by the fingers of both hands while the thumbs firmly palpate the
anterior aspect of the joint.
The capsule and synovial membrane are best palpated over the joint line,
just distal to the lower end of the tibia and medial to the tibialis anterior
tendon. The margins of a swollen synovium in other locations may be
difficult to outline because of the overlying tendons. A large ankle effusion
may bulge both medial and lateral to the extensor tendons and produce
fluctuance: pressure with one hand on one side of the joint causes a fluid
wave to be transmitted to the second hand placed on the other side of the
joint. Ankle tenosynovitis produces a superficial, linear, tender swelling that
extends beyond the joint margins.
Range of Movements
Test for Tarsal tunnel syndrome
Examination of the Spine and Sacroiliacs
• Look (inspection): Skin and SC, muscle , Spine Curvature
• Feel (palpation): for tenderness over vertebrae and para vertebral
muscles and SI joints
• Movement and functional assessment:
• Special tests: according to the segment being examined.
Observe the curve of the whole body and the
back
Scoliosis
Cervical Vertebrae • Look (inspection):
Cervical
Vertebrae
• Movement and
functional assessment:
Cervical Vertebrae • Movement and functional assessment:
Cervical, Special tests:
Occiput to wall test
Cervical, Special tests:
Thoracic vertebrae examination
• (a) Normal curvature, (b) Kyphosis and (c) Lordosis

Dhatt, S. et al. (2019). Dorsal Spine Clinical Examination. In: Dhatt, S., Prabhakar, S. (eds) Handbook of
Clinical Examination in Orthopedics. Springer, Singapore. https://doi.org/10.1007/978-981-13-1235-9_7
Thoracic vertebrae
• Abnormal curve
Thoracic vertebrae
• Don`t forget to comment on symmetry of the levels of both shoulders
and shoulder muscle status

Difference in shoulder heights in scoliosis

Movement
• Limited degrees of flexion, extension, lateral flexion and rotation
Chest Expansion

Measurement of chest expansion at the level of fourth intercostal space

Test for winging of the scapula

The most common etiology of a winged scapula is usually due to damage or impaired innervation
to the serratus anterior muscle. The nerve that innervates this muscle is the long thoracic nerve.
Sometimes, this nerve can be damaged or impinged, leading to malfunction of the serratus anterior
muscle.
Lumber vertebrae
• Curve abnormality
Lumber vertebrae
Movement
Lumber vertebrae
• Special tests for lumber flexion:
1. modified schober
 Lumber vertebrae
• Special tests for lumber flexion:
1. Finger to floor test
As forward bending flexibility is highly variable even in the
asymptomatic population no normative values exist. 
May be used for follow up
Lumber
vertebrae
• Special tests testing lateral
flexion
• 1. spinal lateral flexion
• Normal value:
average of both sides >=18 cm
Lumber
vertebrae
• Special tests: attesting lateral
lumber flexion
2. lateral Schober:
Normally the measurement
should increase from 20 cm to
at least 25 cm
Sacroiliac examination
Sacral dimples
Direct palpaion of SI joints
• Tenderness of the sacroiliac joint with direct pressure
Sacroiliac tests
• Provocative tests are a
commonly used method to
determine whether pain is
originating from the SI joint
especially early in the disease.
• A positive result is indicated
by pain or replication of the
patient's symptoms can indicate
a SIJ pathology.
• Tests for SIJ examination:
1. pelvic compression
2. Pelvic distraction/ eversion test
3. Gaenslen’s test
4. Patrick`s/ FABER test
5. Thigh Thrust test
6. Sacral thrust test
7. Yeoman`s test
Anteroposterior and lateral pelvic compression
Pelvic distraction/ eversion test
Gaenslen’s test
Patrick/ FABER test(flexion-abduction- external rotation of the hip)
Thigh Thrust test
Sacral Thrust test
Measuring intermalleolar distance for hip movement
Thank you &
Good Luck