Editors: Thomas, James; Monaghan, Tanya Title: Oxford Handbook of Clinical Examination and Practical kills, !

st Edition Co"yright #$%&&' Oxford (ni)ersity Press * Table of Contents * Cha"ter !! + The ,ocomotor ystem Cha"ter !! The ,ocomotor ystem The hand examination is described in P.-// Cha"ter -, ".'%

0""lied anatomy and "hysiology The 1oint 0 1oint 2artic3lation4 is a connection or "oint of contact bet5een bones or bet5een bone and cartilage. Joints are classified according to the ty"e of material 3niting the artic3lating bones as 5ell as the degree of mo)ement they allo5. There are - ty"es: 6ibro3s 1oints: held together by fibro3s 2collageno3s4 connecti)e tiss3e and are 789fixed78: or 789immo)eable78:. They do not ha)e a 1oint ca)ity. Exam"les incl3de the connections of the sk3ll bones. Cartilageno3s 1oints: held together by cartilage, are slightly mo)eable and again ha)e no ca)ity. 0n exam"le is the )ertebral 1oints.

yno)ial 1oints: co)ered by cartilage 5ith a syno)ial membrane enclosing a 1oint ca)ity. These 1oints are freely mo)eable and are the most common ty"e of 1oint f3nctionally, being ty"ical of nearly all the 1oints of the limbs.

yno)ial 1oints 0rtic3lar cartilage co)ers the s3rface of the bones and 7;< the friction at the 1oint and facilitates shock absor"tion. 0 slee)e+like bag 2a fibro3s ca"s3le lined 5ith a syno)ial membrane4 s3rro3nds the syno)ial 1oint. The inner syno)ial membrane secretes syno)ial fl3id 5hich has a n3mber of f3nctions incl3ding l3brication and the s3""ly of n3trients to the cartilage. The fl3id contains "hagocytic cells that remo)e microbes and debris 5ithin the 1oint ca)ity. yno)ial 1oints are 3s3ally s3""orted by accessory ligaments and m3scle. There are different ty"es of syno)ial 1oints and some of the more im"ortant ty"es are: Hinge: mo)ement occ3rs "rimarily in a single "lane 2e.g. elbo5, knee, and inter"halangeal 1oints4. =all and socket: allo5s mo)ement aro3nd - axes 2flexion>extension, abd3ction>add3ction, and rotation4. Exam"les are the sho3lder and hi".

Pi)ot: a ring of bone and ligament s3rro3nds the s3rface of the other bone allo5ing rotation only 2e.g. atlanto+axial 1oint at C! and C% )ertebrae and the connection bet5een the radi3s and 3lna4.

?liding: flat bone s3rfaces allo5 side+to+side and back5ards and for5ards mo)ements 2e.g. bet5een car"als, tarsals, stern3m and cla)icle and the sca"3la and cla)icle4. addle: similar to a hinge 1oint b3t 5ith a degree of mo)ement in a second "lane 2e.g. base of th3mb4.

P.-/'

6ig. !!.! @iagrammatic re"resentation of a cross+section thro3gh aty"ical syno)ial 1oint4. =ox !!.! ome mo)ements at syno)ial 1oints 0ng3lar mo)ements 6lexion: a decrease in the angle bet5een the artic3lating bones 2e.g. bending the elbo5 A elbo5 flexion4. Extension: an increase in the angle bet5een the artic3lating bones 2e.g. straightening the elbo5 A elbo5 extension4.

0bd3ction: mo)ement of a bone a5ay from the midline 2e.g. mo)ing the arm o3t to the side A sho3lder abd3ction4. 0dd3ction: mo)ement of a bone to5ards the midline 2e.g. bring the arm in to the side of the body A sho3lder add3ction4.

Botation Mo)ement of a bone abo3t its longit3dinal axis. Cnternal or medial rotation: rotating a bone to5ards the midline 2e.g. t3rning the lo5er limb s3ch that the toes "oint in5ards A internal rotation at the hi"4. External or lateral rotation: rotating a bone a5ay from the midline 2e.g. t3rning the lo5er limb s3ch that the toes "oint o3t5ards A external rotation at the hi"4.

"ecial mo)ements These occ3r at s"ecific 1oints only. Pronation: mo)ing the forearm as if t3rning a door+knob anticlock5ise 2internal rotation of the forearm in the anatomical "osition4. 3"ination: mo)ing the forearm as if t3rning a door+knob clock5ise 2external rotation of the forearm in the anatomical "osition4.

@orsiflexion: mo)ing the ankle to bring the dors3m of the foot to5ards the tibia. Plantar flexion: mo)ing the ankle to bring the "lantar s3rface in line 5ith the tibia 2e.g. "ointing the toes or de"ressing a "edal4. Cn)ersion: tilting the soles of the feet in5ards to face each other. E)ersion: tilting the soles of the feet o3t5ards a5ay from each other. Protraction: mo)ing the mandible for5ard. Betraction: mo)ing the mandible back5ards.

P.-/D Cm"ortant locomotor sym"toms 0s 5ith any system, b3t es"ecially the locomotor system, a caref3lly and acc3rately com"iled history can be )ery informati)e and may "oint to a diagnosis e)en before examination or laboratory tests. Pain The most common sym"tom in "roblems of the locomotor system and sho3ld be a""roached in the same manner as any other ty"e of "ain 2 ".xxx4. @etermine the character, nat3re of onset, site, radiation, se)erity, "eriodicity, exacerbating and relie)ing factors 25ith "artic3lar reference to ho5 it is infl3enced by rest and acti)ity4, and di3rnal )ariation. Pain in a 1oint is called 789arthralgia78:. Pain in a m3scle is called 789myalgia78:. Character =one "ain is ty"ically ex"erienced as boring, "enetrating and often 5orse at night. Ca3ses incl3de t3mo3r, chronic infection, a)asc3lar necrosis, and osteoid osteoma. Pain associated 5ith a fract3re is 3s3ally shar" and stabbing in nat3re and often exacerbated by mo)ement.

hooting "ain is s3ggesti)e of ner)e entra"ment 2e.g. disc "rotr3sion4. 0c3te onset of "ain is often a manifestation of infection s3ch as se"tic arthritis or crystal arthro"athies 2e.g. go3t4. Osteoarthritis and rhe3matoid arthritis can ca3se chronic "ain.

Onset

ite @etermine the exact site of maximal "ain if "ossible and any associated lesser "ains. Bemember that the site of "ain is not necessarily the site of "athology; often "ain is referred. Beferred "ain is d3e to the inability of the cerebral cortex to disting3ish bet5een sensory messages from embryologically related sites. ee tables o""osite. =ox !!.% ome ca3ses of knee arthralgia ex"lained Chondromalacia "atellae This arises d3e to softening of the "atellar artic3lar cartilage and is felt as a "atellar ache after "rolonged sitting. (s3ally seen in yo3ng "eo"le. Osteochondritis dissecans (s3ally associated 5ith tra3ma res3lting in an osteochondral fract3re 5hich forms a loose body in the 1oint 5ith 3nderlying necrosis. Osgood+ chlatterEs disease 0rises as a res3lt of a traction in13ry of the tibial e"i"hysis 5hich is classically associated 5ith a l3m" o)er the tibia. P.-/F =ox !!.- ome ca3ses of arthralgia in ad3lts Gnee Osteoarthritis. Beferred from the hi".

Chondromalacia "atellae. Tra3ma. Osteochondritis dissecans. =3rsitis. Tendonitis. Osgood+ chlatterEs disease. Bhe3matoid arthritis. Cnfection. Malignancy. Osteoarthritis. Beferred "ain78He.g. from a l3mber s"ine abnormality. Tra3ma. Bhe3matoid arthritis.

Hi"

Cnfection. Hernia. Tendonitis. =3rsitis.

ho3lder Botator c3ff disorders 2e.g. tendonitis, r3"t3re, adhesi)e ca"s3litis>froIen sho3lder4. Beferred "ain78He.g. cer)ical, mediastinal, cardiac.

0rthritis78Hglenoh3meral, acromiocla)ic3lar. ,ateral e"icondylitis 2tennis elbo54. Medial e"icondylitis 2golferEs elbo54. Olecranon b3rsitis. Beferred "ain from neck>sho3lder 2e.g. cer)ical s"ondylosis4. Osteoarthritis. Bhe3matoid arthritis.

Elbo5

Mechanical>degenerati)e back "ain 0rthritis. Tra3ma.

@isc "rola"se. Osteo"orosis. Cnfection. 0nkylosing s"ondylitis. "ondylolisthesis. ,3mbar s"inal>lateral recess stenosis. "inal t3mo3rs78H es"ecially metastases from l3ng, breast, "rostate, thyroid, kidney. Metabolic bone disease.

P.-'& tiffness

This is a s3b1ecti)e sym"tom 5hich m3st be ex"lored in detail to establish exactly 5hat the "atient means. tiffness is the inability to mo)e the 1oints after a "eriod of rest. Ct may be d3e to mechanical dysf3nction, local inflammation of a 1oint or a combination of both. 7JK Cf stiffness "redominates o)er "ain, consider s"asticity or tetany. ,ook for hy"ertonia and other 3""er motor ne3ron signs 2 ".-LM4. 0sk the "atient: Nhen is the stiffness 5orstO o 789Early morning stiffness78: is seen in inflammatory conditions 2e.g. rhe3matoid arthritis4 5hereas mechanical 1oint disease 5ill become 5orse as the day "rogresses.

Nhich 1oints are in)ol)edO78P Or is the stiffness generaliIedO

o

0 generaliIed stiffness may be seen in rhe3matoid arthritis and ankylosing s"ondylitis.

Ho5 long does it takes them to 789get going78: in the morningO Ho5 is the stiffness related to rest and acti)ityO
o

Mechanical 1oint diseases 5ill be exacerbated by "rolonged acti)ity.

,ocking This is the s3dden inability to com"lete a certain mo)ement and s3ggests a mechanical block or obstr3ction 3s3ally ca3sed by a loose body or torn cartilage 5ithin the 1oint 2often secondary to tra3ma4. 5elling Joint s5elling can be d3e to a )ariety of factors incl3ding inflammation of the syno)ial lining, an 7;Q in the )ol3me of syno)ial fl3id, hy"ertro"hy of bone, or s5elling of str3ct3res s3rro3nding the 1oint. This sym"tom is "artic3larly significant in the "resence of 1oint "ain and stiffness. Establish: Nhich 1oints are affected 2small or large4O Cs the distrib3tion symmetrical or notO

Nhat 5as the nat3re of onset of the s5ellingO

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Ba"id onset: haematoma or haemarthrosis 2exacerbated by anticoag3lants or any 3nderlying bleeding disorder4. lo5 onset is s3ggesti)e of a 1oint eff3sion.

0re the 1oints al5ays s5ollen or does it come and go 2and 5hen4O Cs there any associated "ainO @o the 1oints feel hot to to3chO

Cs there erythemaO 2Common in infecti)e, tra3matic and crystal arthro"athies4. Ha)e the 1oints in R3estion s3stained any in13riesO

@eformity Establish: The time frame o)er 5hich the deformity has de)elo"ed. 0ny associated sym"toms s3ch as "ain and s5elling.

0ny res3ltant loss of f3nctionO 2Nhat is the "atient no5 3nable to do 5ith the 1oint in R3estionO4

P.-'! 0c3te deformity may arise 5ith a fract3re or dislocation. Chronic deformity is more ty"ical of bone malalignment and may be "artial>s3bl3xed or com"lete>dislocated. ome common deformities are disc3ssed later in this cha"ter. Neakness 0l5ays enR3ire abo3t the "resence of localiIed or generaliIed 5eakness 5hich s3ggest a "eri"heral ner)e lesion or a systemic ca3se res"ecti)ely. Consider that the 5eakness may be ne3rogenic or myo"athic in origin. ensory dist3rbance 0sk abo3t the exact distrib3tion of any n3mbness or "araesthesia as 5ell as doc3menting any exacerbating and relie)ing factors. ,oss of f3nction This is the inability to "erform an action 2disability4 and is disting3ished from the term 789handica"78: 5hich is the social>f3nctional res3lt or im"act that disability has on the indi)id3alEs life. ,oss of f3nction can be ca3sed by a combination of m3scle 5eakness, "ain, mechanical factors and damage to the ner)e s3""ly. The R3estions yo3 ask 5ill de"end "artly on the "atientEs occ3"ation. Ct is also essential to gain some insight into the "atientEs mobility 2can they 3se stairsO Ho5 they co"e 5ith "ersonal care s3ch as feeding, 5ashing and dressingO Can they manage sho""ing and cookingO4. Extra+artic3lar feat3res e)eral locomotor disorders 2e.g. rhe3matoid arthritis4 ca3se extra+artic3lar or m3ltisystem feat3res, some of 5hich are o3tlined belo5: ystemic sym"toms: fe)er, 5eight loss, fatig3e, lethargy. kin rash.

Bayna3dEs "henomenon. ?astrointestinal 2e.g. diarrhoea and res3ltant reacti)e arthritis or entero"athic arthritis secondary to inflammatory bo5el disease4. (rethritis 2BeiterEs syndrome4.

Eye sym"toms. Cardiores"iratory: breathlessness 2"3lmonary fibrosisO4, "ericardial and "le3ritic chest "ain, aortic reg3rgitation and s"ondyloarthro"athies. Se3rological: ner)e entra"ment, migraine, de"ression, stroke.

=ox !!.M ome terminology of 1oint deformity Talg3s The bone or "art of limb distal to the 1oint is de)iated laterally. 6or exam"le, a )alg3s deformity at the knees 5o3ld gi)e 789knock knees78: that tend to meet in the middle des"ite the feet being a"art. Tar3s Here, the bone or "art of limb distal to the 1oint is de)iated medially. 6or exam"le, a )ar3s deformity at the knees 5o3ld gi)e 789bo5 legs78: 5ith a ga" bet5een the knees e)en if the feet are together. P.-'% The rest of the history Past medical history 0sk abo3t all "re)io3s medical and s3rgical disorders and enR3ire s"ecifically abo3t any "re)io3s history of tra3ma or m3sc3loskeletal disease. 6amily history Ct is im"ortant to note any 6Hx of illness, es"ecially those locomotor conditions 5ith a heritable element: Osteoarthritis. Bhe3matoid arthritis.

Osteo"orosis.

Sote that the seronegati)e s"ondyloarthro"athies 2e.g. ankylosing s"ondylosis4 are more "re)alent in "atients 5ith the H,0 =%' ha"loty"e. @r3g history Take a f3ll @Hx incl3ding all "rescribed and o)er+the+co3nter medications. 0ttem"t to assess the efficacy of each treatment, incl3ding all those "ast and "resent. 0sk abo3t any side effects of any dr3gs taken for locomotor disease incl3ding: ?astric 3"set associated 5ith non+steroidal anti+inflammatory dr3gs. ,ong+term side effects of steroid thera"y s3ch as osteo"orosis, myo"athy, infections and a)asc3lar necrosis. 0sk also abo3t medication 5ith kno5n ad)erse m3sc3loskeletal effects incl3ding: tatins: myalgia, myosistis, and myo"athy. 0CE+inhibitors: myalgia.

0nticon)3lsants: osteomalacia.

U3inolone: tendino"athy. @i3retics, as"irin, alcohol: go3t. Procainamide, hydralaIine, isoniaIid: ,E.

7JK Ct is also 5orth bearing in mind that illicit dr3gs may 7;Q the risk of de)elo"ing infectio3s diseases s3ch as t3berc3losis, HCT, and he"atitis, all of 5hich can ca3se m3sc3loskeletal com"laints. moking and alcohol 0s al5ays, f3ll smoking and alcohol histories sho3ld be taken 2 ".MM4. ocial history This sho3ld form a nat3ral extension of the f3nctional enR3iry and sho3ld incl3de a record of the "atientEs occ3"ation if not already noted, as 5ell as ethnicity. Certain occ3"ations "redis"ose to s"ecific locomotor "roblems. 6or exam"le, re"etiti)e strain in13ry, hand+)ibration syndrome, and fatig3e fract3res seen sometimes in dancers and athletes. Ethnicity is rele)ant as there is an o)erre"resentation of l3"3s, and T= in the 0sian "o"3lation, both of 5hich are linked to a )ariety of locomotor com"laints. P.-'-

Cf the "atient is an older "erson, make a note abo3t the acti)ities of daily li)ing, ho5 mobile the "atient is and if there are any home ada"tations s3ch as a chair lift or railings. Bemember to ask abo3t home care or other s3""orts. Nhere a""ro"riate, take a sex3al history. This is im"ortant beca3se reacti)e arthritis or BeiterEs syndrome may be ca3sed by sex3ally transmitted diseases s3ch as Chlamydia and gonorrhoea.

P.-'M O3tline examination 0 f3ll examination of the entire locomotor system can be long and com"licated. Cn this cha"ter, 5e ha)e broken the examination do5n into the follo5ing 1oints>regions: elbo5, sho3lder, s"ine, hi", knee, ankle, and foot. =ox !!.L Examination frame5ork The examination of each 1oint sho3ld follo5 the standard format: ,ook. 6eel.

Mo)eV.

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Passi)e. 0cti)e.

Meas3re. "ecial tests. 63nction.

7JK Cn a thoro3gh locomotor examination, yo3 sho3ld examine the 1oints 789abo)e78: and 789belo578: the sym"tomatic one. 6or exam"le, for an elbo5 com"laint, also examine the sho3lder and 5rist. 7JK The hand examination is disc3ssed in P.-'L P.-'/ The ?0, screen The o)erall integrity of the locomotor system can be screened )ery R3ickly by 3sing the 789?0, 78: method of assessment. Wo3 may 3se this to make R3ick, 789screening78: examination of the 5hole locomotor system in order to identify 5hich 1oints or regions to examine in more detail. The ?0, screen consists of M com"onents: ? A ?ait. 0 A 0rms.

Cha"ter -, ".'%.

, A ,egs. A "ine.

P.-'' =ox !!./ Modified ?0, screen The ?0, screen 5as de)ised as a R3ick screen for abnormality in the absence of sym"toms. V Nith a"ologies to the original a3thors, belo5 is o3r slightly modified )ersion: ?ait Natch the "atient 5alk. o There sho3ld be symmetry and smoothness of mo)ement and arm s5ing 5ith no "el)ic tilt and normal stride length. The "atient sho3ld be able to start, sto" and t3rn R3ickly. 0rms 2sitting on co3ch4

Cns"ection: look for m3scle 5asting and 1oint deformity at the sho3lders, elbo5s, 5rists and fingers. R3eeIe across the %nd+Lth metacar"als78Hthere sho3ld be no tenderness. ho3lder abd3ction: 789raise yo3r arms o3t side5ays, abo)e yo3r head78:. Sormal range !'&+!D&#X. ho3lder external rotation: 789to3ch yo3r back bet5een yo3r sho3lder blades78:. ho3lder internal rotation: 789to3ch the small of yo3r back78:. ho3ld to3ch abo)e T!&. Elbo5 extension: 789 traighten yo3r arms o3t78:. Sormal is &#X. Nrist and finger extension: the "rayer sign 2 ".'L4. ".'L4.

Nrist flexion and finger extension: the re)erse "rayer sign 2 Po5er gri": 789make a tight fist78:78Hsho3ld hide fingernails. Precision gri": 789"3t yo3r fingerti"s on yo3r th3mb78:.

,egs 2lying on co3ch4 Cns"ection: ,ook for s5elling or deformity at the knee, ankle and foot as 5ell as R3adrice"s m3scle 5asting. R3eeIe across the metatarsals78Hthere sho3ld be no tenderness. Hi" and knee flexion: test "assi)ely and acti)ely. Sormal hi" flexion is !%&#X, normal knee flexion is !-L#X.

Hi" internal rotation: normal is F&#X at ML#X flexion. ee Gnee: b3lge test 2 ".-D/4 and "atellar ta" 2 ".-D/4.

".-DM.

0nkle: test dorsiflexion 2normal !L#X4 and "lanarflexion 2normal LL#X4.

"ine 2standing4 Cns"ection from behind: look for scoliosis, m3scle b3lk at the "aras"inals, sho3lders and gl3teals, le)el iliac crests. Cns"ection from the side: look for normal thoracic ky"hosis and l3mbar and cercial lordosis.

V

Tenderness: feel o)er the mid+s3"ras"inat3s78Hthere sho3ld be no tenderness. ,3mbar flexion: 789to3ch yo3r toes78:. Sormal is finger+floor distance Y!Lcm. ,3mbar ex"ansion 2 choberEs test ".-D-4. Cer)ical lateral flexion: 789"3t yo3r ear on yo3r sho3lder78:.

@oherty et al 2!FF%4. 0nnals Bhe3m @is L!:!!/L+F.

P.-'D Elbo5 ,ook ,ook aro3nd the bed for any mobility aids or other cl3es. 0sk the "atient to stand, make s3re both 3""er limbs are ex"osed and look at the "atient from to" to toe. Cns"ect the elbo5 1oint from the front, side, and behind, and note: Malalignment of the bones. cars.

kin change 2e.g. "soriatic "laR3es4. kin or s3bc3taneo3s nod3les. @eformities.

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Tar3s 2789c3bit3s )ar3s78:4: can be ca3sed by a s3"racondylar fract3re. Talg3s 2789c3bit3s )alg3s78:4: can be ca3sed by non+3nion of a lateral condylar fract3re.

M3scle 5asting. 5elling.

6eel 7JK 0l5ays ask abo3t "ain before getting started. Pal"ate the 1oint "osteriorly and feel for: Tem"erat3re. 3bc3taneo3s nod3les.

5elling.
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oft s5elling may be d3e to olecranon b3rsitis. Hard s5ellings s3ggests a bony deformity. =oggy s5elling s3ggests syno)ial thickening 2e.g. secondary to B04.

Cf fl3id is "resent, attem"t to dis"lace it on either side of the olecranon. Caref3lly "al"ate the 1oint margin for tenderness and note if it is localiIed to the medial e"icondyle 2golferEs elbo54 or the lateral e"icondyle 2tennis elbo54.

Mo)e Check that there is good sho3lder f3nction before attem"ting to assess elbo5 mo)ements. 7JK Bemember to test "assi)e mo)ements 2yo3 do the mo)ing4 and acti)e mo)ements 2the "atient does the mo)ing4 at each stage.

0sk the "atient to "lace their arms on the back of their head. Sext assess elbo5 flexion and extension 5ith the 3""er arm fixed.
o

Bemember to com"are 5ith the o""osite side.

Nith the elbo5s t3cked into the sides and flexed to a right angle, test the radio+3lnar 1oints for "ronation 2"alms to5ards floor4 and s3"ination 2"alms to5ards the sky4.

Meas3re Meas3re elbo5 flexion and extension in degrees from the ne3tral "osition 2i.e. consider a straight elbo5 1oint to be &#X4. 63nction Obser)e the "atient "o3r a glass of 5ater and then "3t on a 1acket. P.-'F

6ig. !!.% Mo)ements at the elbo5 1oint. 2a4 6lexion and extension. 2b4 Pronation and s3"ination 2remember that "ronation and s3"ination reR3ire mo)ement at the elbo5 as 5ell as at the 5rist4. P.-D& ho3lder ,ook ,ook aro3nd for any aids or ada"tations. 0sk the "atient to remo)e any co)ering clothing and ex"ose both 3""er limbs, the neck, and chest. can the "atient from to" to toe. Cns"ect from the front, side, and behind. ,ook es"ecially for: Conto3rs.

Make note of any ob)io3s asymmetry or deformity s3ch as 5inging of the sca"3la, "rominence of the acromiocla)ic3lar 1oint and 5asting of the deltoid or short rotators 5hich o)erlie the 3""er and lo5er segments of the sca"3la.

Joint s5elling.
o

This is more ob)io3s from the front and may be a cl3e to ac3te bleeds, rhe3matoid eff3sions, "se3dogo3t, or se"sis.

cars. =r3ising or other skin>s3bc3taneo3s tiss3e changes. The "osition of both sho3lders looking for e)idence of dislocation.
o

Posterior dislocation can be seen 5hen the arm is held in an internally rotated "osition. 0nterior dislocation can be seen easily 5ith the arm is dis"laced in a for5ard and do5n5ard "osition.

7JK Bemember to ins"ect the axillary regions.

6eel 7JK 0l5ays ask abo3t "ain before getting started. Make note of any tem"erat3re changes, tenderness, or cre"it3s. tanding in front of the "atient: Pal"ate the soft tiss3es and bony "oints in the follo5ing order: sternocla)ic3lar 1oint, cla)icle, acromiocla)ic3lar 1oint, acromial "rocess, head of h3mer3s, coracoid "rocess, s"ine of sca"3la, greater t3berosity of h3mer3s. Check the intersca"3lar area for "ain.

Pal"ate the s3"racla)ic3lar area for lym"hadeno"athy.

Mo)e 7JK Bemember to test "assi)e mo)ements 2yo3 do the mo)ing4 and acti)e mo)ements 2the "atient does the mo)ing4 at each stage. U3antify any mo)ement in degrees 2meas3re4. To test tr3e glenoh3meral mo)ement, anchor the sca"3la by "ressing firmly do5n on the to" of the sho3lder. 0fter abo3t '&#X of abd3ction, the sca"3la rotates on the thorax78Hmo)ement is sca"3lothoracic. 6lexion: ask the "atient to raise their arms for5ards abo)e their head. Extension: straighten the arms back5ards as far as "ossible.

0bd3ction: mo)e the arm a5ay from the side of the body 3ntil the fingerti"s are "ointing to the ceiling. 0dd3ction: ask the "atient to mo)e the arm in5ards to5ards the o""osite side, across the tr3nk.

External rotation: 5ith the elbo5s held close to the body and flexed to F&#X, ask the "atient to mo)e the forearms a"art in an arc+like motion in order to se"arate the hands as 5idely as "ossible. P.-D!

Cnternal rotation: ask the "atient to bring the hands together again across the body. 2,oss of rotation s3ggests a ca"s3litis.4 Com"o3nd mo)ements: these ty"es of mo)ements may be em"loyed as screening tests to assess sho3lder dysf3nction, taking the "lace of a f3ller examination if no abnormalities are detected. ee 6ig. !!.-.
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0sk the "atient to "3t both hands behind the head 2external rotation in abd3ction4. 0sk the "atient to reach 3" their back 5ith the fingers to to3ch a s"ot bet5een their sho3lder blades 2internal rotation in add3ction4.

"ecial tests Testing for a rotator c3ff lesion>tendonitis: 789the "ainf3l arc78: 0sk the "atient to abd3ct the sho3lder against light resistance. Pain in early abd3ction s3ggests a rotator c3ff lesion and 3s3ally occ3rs bet5een M&#X+!%&#X. This is d3e to a damaged and inflamed s3"ras"inat3s tendon being com"ressed against the acromial arch. Testing for acromiocla)ic3lar arthritis Cf there is "ain d3ring a high arc of mo)ement 2starting aro3nd F&#X4 and the "atient is 3nable to raise their arm straight 3" abo)e their head to !D&#X, e)en "assi)ely, this is s3ggesti)e of acromiocla)ic3lar arthritis. 63nction 0sk the "atient to scratch the centre of their back or to "3t on a 1acket.

6ig. !!.- Com"o3nd mo)ements. 2a4 External rotation and abd3ction. 2b4 Cnternal rotation and

add3ction. =ox !!.' 0 5ord abo3t 5inging of the sca"3la This arises d3e to 5eakness of serrat3s anterior as a res3lt of damage to the long thoracic ner)e, in13ry to the brachial "lex3s, in13ry or )iral infections of CL+' ner)e roots and m3sc3lar dystro"hy. Ninging only becomes ob)io3s 5hen the serrat3s anterior contracts against resistance s3ch as "3shing o3tstretched hands against a 5all. P.-D% "ine ,ook can aro3nd the room for any cl3es s3ch as a 5heelchair or 5alking aids. Natch ho5 the "atient 5alks into the room or mo)es aro3nd the bed area. t3dy their "ost3re, "aying "artic3lar attention to the neck. 0sk the "atient to stri" do5n to their 3nder5ear. Cns"ect from in front, the side and behind in both the standing and sitting "ositions. ,ook es"ecially for: cars. Pigmentation.

0bnormal hair gro5th. (n3s3al skin creases. 0symmetry incl3ding abnormal s"inal c3r)at3re:
o o o

Gy"hosis: 2con)ex c3r)at3re78Hnormal in the T+s"ine4. ,ordosis: 2conca)e c3r)at3re78Hnormal in the ,+ and C+s"ines4. coliosis: 2side+to+side c3r)at3re a5ay from the midline4.

7JK 0 789R3estion mark78: s"ine 5ith exaggerated thoracic ky"hosis and a loss of l3mbar lordosis is classic of ankylosing s"ondylitis. 6eel Pal"ate each s"ino3s "rocess noting any "rominence or ste" and feel the "aras"inal m3scles for tenderness. Wo3 sho3ld also make a "oint of "al"ating the sacroiliac 1oints. Mo)e C+s"ine 0ssess acti)e mo)ements of the cer)ical+s"ine first. These incl3de flexion, extension, lateral flexion, and rotation. Ct is often hel"f3l to demonstrate these mo)ements yo3rself. 6lexion: ask the "atient to "3t their chin on their chest. Extension: ask the "atient to look 3" to the ceiling.

,ateral flexion: ask the "atient to lean their head side5ays, "lacing an ear on their sho3lder.

Botation: ask the "atient to look o)er each sho3lder.

T+ and ,+s"ine Mo)ements at the thoracic and l3mbar s"ine incl3de flexion, extension, lateral flexion, and rotation. 6lexion: ask the "atient to to3ch their toes. Extension: ask the "atient to lean back5ards.

,ateral flexion: ask the "atient to bend side5ays, sliding each hand do5n their leg as far as "ossible. Botation: anchor the "el)is 2"3t a hand on either side4 and ask the "atient to t5ist at the 5aist to each side in t3rn.

P.-DMeas3re choberEs test This is 3sef3l meas3rement of l3mbar flexion. 0sk the "atient to stand erect 5ith normal "ost3re and identify the le)el of the "osterior s3"erior iliac s"ines on the )ertebral col3mn. These are located at Z,L.

Make a small "en mark at the midline Lcm belo5 and !&cm abo)e this "oint. So5 instr3ct the "atient to bend at the 5aist to f3ll for5ard flexion. Meas3re the distance bet5een the % marks 3sing a ta"e meas3re. The distance sho3ld ha)e increased to *%&cm 2an increase of *Lcm4. Cf not, there is a limitation in l3mbar flexion 2e.g. fo3nd in ankylosing s"ondylitis4.

"ecial tests ciatic ner)e stretch test This test is 3sed to look for e)idence of ner)e root irritation. Nith the "atient lying s3"ine, hold the ankle and lift the leg, straight, to F&#X. Once there, dorsiflex the foot 2=ragard test4. Cf "ositi)e, "ain 5ill be felt at the back of the thigh. The "ain may be relie)ed by knee flexion

0 "ositi)e stretch test s3ggests tension of the ner)e roots s3""lying the sciatic ner)e 2,L+ %4, commonly o)er a "rola"sed disc 2,M>L or ,L> !4. This test is "artially age de"endent. Most elderly "eo"le 5ill str3ggle to flex their hi" beyond '&#X.

6emoral ner)e stretch test

Nith the "atient lying "rone, abd3ct and extend the hi", flex the knee and "lantar+flex the foot. The stretch test is "ositi)e if "ain is felt in the thigh>ing3inal region. ee ".-MD. =ox !!.D Se3rological examination @onEt forget the ne3rological as"ects of the examination. The femoral and sciatic stretch tests may 3nco)er root irritation78Hb3t yo3 sho3ld also examine for the ne3rological and f3nctional conseR3ences as in P.-DM Cha"ter !&.

Hi" ,ook Ex"ose the 5hole lo5er limb. ,ook aro3nd the room for any aids or de)ices s3ch as ortho"aedic shoes or 5alking aids. Cf they ha)e not done so already, ask the "atient to 5alk and note the gait. Sote if there is e)idence of a lim" or ob)io3s "ain. Nith the "atient in the standing "osition, ins"ect from the front, side, and behind. ,ook for: cars. in3ses.

0symmetry of skin creases. 5elling. M3scle 5asting. @eformities.

Pay attention to the "osition of the limbs 2e.g. external rotation, "el)ic tilting, standing 5ith one knee bent or foot held "lantarflexed>in eR3in3s4. 6eel 6eel for bony "rominences s3ch as the anterior s3"erior iliac s"ines and greater trochanters. Check that they are in the ex"ected "osition. Pal"ate the soft tiss3e conto3rs and feel for any tenderness in and aro3nd the 1oint. Mo)e 0sk the "atient if they ha)e any "ain before examining. 7JK 6ix the "el)is by 3sing yo3r left hand to stabiliIe the contralateral anterior s3"erior iliac s"ine since any limitation of hi" mo)ement can easily be hidden by mo)ement of the "el)is. Nith the "atient s3"ine: 6lexion: ask the "atient to flex the hi" 3ntil the knee meets the abdomen, normal is aro3nd Z!%&#X. 0bd3ction: 5ith the "atientEs leg held straight, ask them to mo)e it a5ay from the midline, normal is -&+M&#X.

0dd3ction: 5ith the "atientEs leg held straight, ask them to mo)e it across the midline, normal is Z-&#X.

Nith the "atient "rone:

Extension: asking the "atient to raise each leg off the bed, normal is only a fe5 degrees. Cnternal rotation: ask the "atient to kee" the knees tight together and s"reading the ankles as far as "ossible. External rotation: ask the "atient to cross the legs o)er.

Passi)e mo)ements Most sho3ld be assessed by the examiner as for acti)e mo)ements 5hilst the "atient is in a relaxed state. Passi)e external and internal rotation: 5ith the "atient s3"ine, flex the knee, stabiliIing it 5ith one hand 5hilst the other hand mo)es the heel laterally or medially so that the heel either mo)es a5ay or to5ards the midline 2internal and external rotation res"ecti)ely4. P.-DL Meas3re 2limb length4 Tr3e shortening, in 5hich there is loss of bone length, m3st not be conf3sed 5ith a""arent shortening d3e to a deformity at the hi", in 5hich there is no loss of bone length. TechniR3e Nith the "atient s3"ine, "lace the "el)is sR3are and the lo5er limbs in com"arable "ositions in relation to the "el)is. Meas3re the distance from the anterior s3"erior iliac s"ine to the medial malleol3s on each side 2tr3e length4.
o

0""arent length is meas3red from a midline str3ct3re s3ch as the xi"histern3m to the medial malleol3s.

"ecial tests Trendelenberg test This is 3sef3l as an o)erall assessment of the f3nction of the hi" and 5ill ex"ose dislocations or s3bl3xations, 5eakness of the abd3ctors, shortening of the femoral neck, or any "ainf3l disorder of the hi". 0sk the "atient to stand 3" straight 5itho3t any s3""ort. 0sk them to raise their left leg by bending the knee.

Natch the "el)is 2sho3ld normally rise on the side of the lifted leg4. Be"eat the test 5ith the "atient standing on the left leg. 0 "ositi)e test is 5hen the "el)is falls on the side of the lifted leg indicating hi" instability on the s3""orting side 2i.e. the "el)is falls to the left A right hi" 5eakness4.

ThomasEs test 0 fixed flexion deformity of the hi" 2often seen in osteoarthritis4 can be hidden 5hen the "atient lies s3"ine by tilting the "el)is and arching the back. The Thomas test 5ill ex"ose any flexion deformity.

Nith the "atient lying s3"ine, feel for a l3mbar lordosis 2"alm 3"5ards4. Nith the other hand, flex the o""osite hi" and knee f3lly to ens3re that the l3mbar s"ine becomes flattened. Cf a fixed flexion deformity is "resent, the o""osite leg flexes too 2meas3re the angle relati)e to the bed4. Bemember to re"eat the test on the other hi".

63nction 0ssess gait. ee P.-D/ ".-L&.

Gnee ,ook can the room for any 5alking aids or other cl3es and ins"ect the "atient standing. The lo5er limbs sho3ld be com"letely ex"osed exce"t for 3nder5ear so that com"arisons can be made. Com"are one side to the other and look for: @eformity 2)alg3s, )ar3s, or flexion4. cars or 5o3nds to s3ggest infection "ast or "resentO

M3scle 5asting 2R3adrice"s4. 5elling 2incl3ding "osteriorly4. Erythema. ,ook for loss of the medial and lateral dim"les aro3nd the knees 5hich s3ggest the "resence of an eff3sion.

6eel 7JK 0l5ays ask abo3t "ain before getting started. 0l5ays com"are sides. Nith the "atient lying s3"ine: Pal"ate for tem"erat3re 3sing the back of the hand. 0sk if the knee is tender on "al"ation.

6eel aro3nd the 1oint line 5hile asking the "atient to bend the knee slightly. Pal"ate the collateral ligaments 2either side of the 1oint4. 6eel the "atellofemoral 1oint 2by tilting the "atella4.

Examining for a small eff3sion78Hthe 789b3lge sign78: Holding the "atella still, em"ty the medial 1oint recess 3sing a 5i"ing motion of yo3r index finger 26ig. !!.Ma4. o This 5ill milk any fl3id into the lateral 1oint recess.

So5 a""ly a similar 5i"ing motion to the lateral recess and78P Natch the medial recess 26ig. !!.Mb4.
o

Cf there is fl3id "resent, a distinct b3lge sho3ld a""ear on the flattened, medial s3rface and it is milked o3t of the lateral side.

Examining for a large eff3sion78Hthe 789"atellar ta"78: Cf the eff3sion is large, the b3lge sign is absent as yo3 5ill be 3nable to em"ty either recess of fl3id78H3se the "atellar ta" instead. Mo)e any fl3id from the medial and lateral com"artments into the retro"atellar s"ace. o 0""ly firm "ress3re o)er the s3"ra"atellar "o3ch 5ith the flat of the hand and 3se yo3r th3mb and index finger "laced either side of the "atella to "3sh any fl3id centrally 2see 6ig. !!.La4.

Nith the first one or t5o fingers of the other hand, "3sh the "atella do5n firmly 2see 6ig. !!.Lb4. Cf fl3id is "resent, the "atella 5ill bo3nce off the lateral femoral condyle behind. Wo3 5ill feel it being "3shed do5n and then 789ta"78: against the fem3r.

P.-D' Mo)e 7JK Bemember to test "assi)e mo)ements 2yo3 do the mo)ing4 and acti)e mo)ements 2the "atient does the mo)ing4 at each stage. U3antify any mo)ement in degrees 2meas3re4. =egin by the mo)ing the 1oint "assi)ely and feel o)er the knee 5ith one hand for any cre"it3s. 6lexion: ask the "atient to maximally flex the knee, normal 7[\!-L#X.

Extension: ask the "atient to straighten the leg at the knee. Hy"erextension: assess by 5atching the "atient lift the leg off the bed and then, holding the feet stable in both hands abo)e the bed>co3ch and ask the "atient to relax Ens3re that yo3 are not ca3sing the "atient any discomfort.

Meas3re The )is3al im"ression of 5asting of the R3adrice"s can be confirmed by meas3ring the circ3mference of the thighs at the same le)el 3sing a fixed bony "oint of reference e.g. %.Lcm abo)e the tibial t3bercle.

6ig. !!.M Examining for the 789b3lge sign78:. 2a4 Ni"e any fl3id from the medial 1oint recess. 2b4 Ni"e the fl3id back o3t of the lateral 1oint recess and 5atch the medial side.

6ig. !!.L Testing for 789"atellar ta"78:. 2a4 (se the "almar s3rface, th3mb and index finger of one hand to mo)e any fl3id into the retro"atellar s"ace. 2b4 0ttem"t to 789ta"78: the "atella on the fem3r 3sing the other hand. P.-DD "ecial tests Testing for medial and lateral collateral ligament instability Take the "atientEs foot 3nder yo3r right 3""er arm. Hold the "atientEs extended knee firmly 5ith both hands.

0ttem"t to bend the distal leg medially 2)ar3s4.

o

This tests the lateral collateral ligament.

0ttem"t to bend the distal leg laterally 2)alg3s4.

o

This tests the medial collateral ligament.

Be"eat the abo)e 5ith the knee at -&#X of flexion.

o

Sormally, the 1oint sho3ld mo)e no more than a fe5 degrees, excessi)e mo)ement s3ggests a torn or stretched collateral ligament.

0nterior and "osterior dra5er tests

These test the anterior and "osterior cr3ciate ligaments. These ligaments "re)ent the distal "art of the knee mo)ing anteriorly and "osteriorly 789dra5er tests78:. Ens3re the "atient is lying in a relaxed s3"ine "osition. 0sk the "atient to flex the knee to F&#X.

Wo3 may 5ish to "osition yo3rself "erched on the "atientEs foot to stabiliIe the leg. Narn the "atient abo3t this first] Nra" yo3r fingers aro3nd the back of the knee 3sing both hands, "ositioning the th3mbs o)er the "atella "ointing to5ards the ceiling. P3sh 3" 5ith yo3r index fingers to ens3re the hamstrings are relaxed. The 3""er end of the tibia is then "3lled for5ards and "3shed back5ards in a rocking motion.
o o o

Sormally, there sho3ld be )ery little or no mo)ement seen. Excessi)e anterior mo)ement reflects anterior cr3ciate laxity. Excessi)e "osterior mo)ement denotes "osterior cr3ciate laxity.

McM3rrayEs test 0 test for meniscal tears. Nith the "atient lying s3"ine, bend the hi" and knee to F&#X. ?ri" the heel 5ith yo3r right hand and "ress on the medial and lateral cartilage 5ith yo3r left hand.

Cnternally rotate the tibia on the fem3r and slo5ly extend the knee. Be"eat b3t externally rotate the distal leg 5hilst extending the knee. Be"eated 5ith )arying degrees of knee flexion.
o

Cf there is a torn menisc3s, a tag of cartilage may become tra""ed bet5een the artic3lar s3rfaces, and ca3se "ain and an a3dible click. Wo3 may also be able to feel the click 5ith yo3r left hand.

0"leyEs test 0nother test for meniscal tears. Position the "atient "rone 5ith the knee flexed to F&#X. tabiliIe the thigh 5ith yo3r left hand.

Nith the right hand, gri" the foot. Botate or t5ist the foot and "ress do5n5ards in a 789grinding motion78:.
o

This test sho3ld "rod3ce sym"toms if a menisc3s is torn.

P.-DF

6ig. !!./ Testing collateral ligament stability.

6ig. !!.' Performing the anterior dra5er test. P.-F&

6ig. !!.D Testing for meniscal tears. 2a4 McM3rraysE test. 2b4 0"leyEs grinding test. P.-F! P.-F% 0nkle and foot

,ook Ex"ose the lo5er limbs and make a note of any 5alking or other aids "resent. Take a moment to also examine the shoes caref3lly for any abnormal 5ear or stretching. Examine the feet and ankles both 5hen the "atient is standing and, more caref3lly, 5ith the "atient lying on a co3ch or bed. ,ook for: kin or soft tiss3e lesions incl3ding call3ses, s5ellings, 3lcers and scars. M3scle 5asting at the calf and lo5er leg.

@eformities, es"ecially in)ol)ing the arch.

o o

Pes "lan3s 2flat foot4. Pes ca)3s 2high+arched foot4.

,ook for a b3nion 2bony deformity4 at the !st MTP 1oint. ,ook for a b3nionette at the Lth MTP 1oint. Examine the nails caref3lly for any abnormalities s3ch as f3ngal infections or in+gro5ing toenails. 7JK @onEt forget to look bet5een the toes.

Wo3 may also 5ish to ins"ect for e)idence of other abnormalities s3ch as hammer toes, cla5 toes or cl3bbing of the feet 2tali"es eR3ino)ar3s4. 6eel 7JK 0l5ays ask abo3t "ain before getting started. 0ssess the skin tem"erat3re and com"are o)er both the feet. ,ook for areas of tenderness, "artic3larly o)er bony "rominences 2lateral and medial malleoli, MTP 1oints, inter"halangeal 1oints and heel4 as 5ell as the metatarsal heads.

R3eeIe across the MTP 1oints and assess "ain and mo)ement. Bemember to "al"ate any s5elling, oedema, or l3m"s.

Mo)e The ankle and foot is a series of 1oints 5hich f3nction as a 3nit. 7JK Bemember to test "assi)e mo)ements 2yo3 do the mo)ing4 and acti)e mo)ements 2the "atient does the mo)ing4 at each stage. 0cti)e mo)ements sho3ld be "erformed 5ith the "atientEs legs hanging o)er the edge of the bed. 0nkle dorsiflexion: ask the "atient to "oint their toes at their head. 0nkle "lanarflexion: ask the "atient to "3sh the toes do5n to5ards the floor 789like "3shing on a "edal78:.

Cn)ersion: 2s3btalar 1oint bet5een the tal3s and calcane3m4. ?ras" the ankle 5ith one hand and 5ith the other, gras" the heel, thereby fixing the calcane3m and t3rn the sole in5ards to5ards the midline. E)ersion: as in)ersion b3t t3rn the sole o3t5ards, a5ay from the midline.

Midtarsal 1oints: gras" the heel 5ith one hand and attem"t to mo)e the tars3s 3" and do5n and from side to side 5ith the other. Toe flexion: ask the "atient to c3rl their toes. Toe extension: ask the "atient to straighten the toes. Toe abd3ction: ask the "atient to fan o3t their toes as far as "ossible. Toe add3ction: ask the "atient to hold a "iece of "a"er bet5een their toes.

P.-FMeas3re Calf circ3mference can be meas3red bilaterally to check for any discre"ancies 5hich may highlight m3scle 5asting>hy"ertro"hy. 2e.g. !&cm belo5 the tibial t3berosities4. "ecial tests immondEs test This test is 3sed to assess for a r3"t3red 0chilles tendon. 0sk the "atient to kneel on a chair 5ith their feet hanging o)er the edge. R3eeIes both cal)es Sormally the feet sho3ld "lantarflex. Cf the 0chilles tendon is r3"t3red, there 5ill be no mo)ement on the affected side. 63nction Ct is also hel"f3l to obser)e the "atientEs gait 5ith and 5itho3t shoes. =e s3re to ask the "atient if they are able to do this. =ox !!.F 0 5ord on in)ersion and e)ersion Ortho"aedic "3rists 5ill say that the 789ankle78: cannot in)ert or e)ert as it is mainly a sim"le hinge78Hthe e)ersion and in)ersion tests are, therefore, a 789fail3re only78: test. Wo3 sho3ld note that some e)ersion and in)ersion is "ossible in the normal state at the tarsal 1oints78Has tested by the ne3rologists. Ortho"aedic "ractitioners test "athological in)ersion and e)ersion by 5atching the heels from behind as the "atient stands on ti"+toes. P.-FM Cm"ortant "resenting "atterns Bhe3matoid arthritis 2B04 B0 is a chronic inflammatory m3ltisystem a3toimm3ne disease mediated by "ro+inflammatory cytokines s3ch as t3mo3r necrosis factor al"ha 2TS6^_4 and in some cases is characteriIed by the "resence of the rhe3matoid factor. There is a strong association 5ith H,0+@BM and "atients 5ith @BM tend to ha)e more se)ere disease. Ct affects aro3nd !+-` of the "o"3lation in all racial gro3"s, 5ith "eak age of onset in the Mth and Lth decades and a female:male ratio of -:!.

The 3s3al "attern of disease is insidio3s b3t can also be e"isodic 5ith com"lete resol3tion bet5een attacks 2"alindromic4 or ac3te. The clinical feat3res of B0 can be di)ided into artic3lar and extra+artic3lar feat3res and are s3mmariIed belo5. 0rtic3lar feat3res B0 3s3ally "resents as a symmetrical "olyarthritis affecting the 5rists and small 1oints of the hands and feet. Occasionally, a "atient "resents 5ith a monoarthritis of a larger 1oint s3ch as the knee or sho3lder. Common "resenting sym"toms are 1oint "ain, stiffness, and s5elling 5hich are ty"ically 5orse in the mornings and im"ro)es as the day "rogresses. The disease e)ent3ally leads to )arying degrees of f3nctional loss. igns of B0 in the hands>5rist yno)itis in)ol)ing the 5rists, metacar"o+"halangeal and "roximal inter"halangeal 1oints 5ith s"aring of the distal inter"halangeal 1oints. (lnar de)iation of fingers 2s3bl3xation>dislocation at the MCP 1oints4. 5an neck deformity: hy"erextension of PCP 1oints 5ith flexion of MCP and @CP 1oints.

=o3tonniereEs deformity: flexion deformity of PCP 1oints 5ith extension of @CP and MCP 1oints. a deformity of th3mb: flexed MCP 1oint 5ith extended inter"halangeal 1oint of th3mb. Triggering of finger. ?eneraliIed 5asting of small m3scles of hand. C3taneo3s )asc3litis.

igns of B0 in the feet 6orefoot syno)itis 5ith "roximal "halangeal s3bl3xation dorsally. Metatarsal head erosion and dis"lacement to5ards the floor. Patient feels it 789like 5alking on marbles78:.

Talg3s deformities. Colla"se of longit3dinal arch.

igns of B0 in the s"ine 0tlanto+axial s3bl3xation #_ s"inal cord com"ression P.-FL Extra+artic3lar feat3res of B0 Bhe3matoid nod3les: common at sites of "ress3re 2elbo5s and 5rists4. 0ssociated 5ith more se)ere disease and al5ays rhe3matoid factor "ositi)e. Tenosyno)itis and b3rsitis.

Car"al t3nnel syndrome. 0naemia: ca3ses incl3de:

o o o

0naemia of chronic disease. ?C bleeding associated 5ith S 0C@ 3se. =one marro5 s3""ression secondary to disease+modifying anti+rhe3matic dr3gs s3ch as gold and "enicillamine. Megaloblastic anaemia from folic acid deficiency 2also secondary to methotrexate4 or "ernicio3s anaemia. 6eltyEs syndrome 2B0, s"lenomegaly, and le3co"enia4.

,3ng feat3res:
o o o o o o

Ple3ritic "ain. Ple3ral eff3sions. P3lmonary fibrosis. P3lmonary nod3les. Obliterati)e bronchiolitis. Ca"lanEs syndrome 2massi)e l3ng fibrosis in B0 "atients 5ith "ne3moniosis4.

Se3rological feat3res:
o o o o

Peri"heral ner)e entra"ment. Monone3ritis m3lti"lex. Peri"heral ne3ro"athy. Cer)ical myelo"athy d3e to atlanto+axial s3bl3xation.

Cardiac feat3res:
o o

Pericarditis. Pericardial eff3sions.

Eye feat3res:
o o o o o

Painless e"iscleritis. Painf3l scleritis. cleromalacia "erforans. Geratocon13ncti)itis sicca. 1ogrenEs syndrome.

Cataracts 2chloroR3ine, steroids4.

Tasc3litis:
o o o o o

Sail fold infarcts. C3taneo3s 3lceration. @igital gangrene. Cerebral and mesenteric infarction. Coronary and renal )asc3litis 2rare4.

kin lesions:
o o

Palmar erythema. Pyoderma gangrenos3m.

0myloidosis 2"rotein3ria, he"atos"lenomegaly4. ystemic feat3res 2fe)er, malaise, 5eight loss, and lym"hadeno"athy4.

P.-F/ Osteoarthritis Osteoarthritis is a chronic disorder of syno)ial 1oints characteriIed by focal cartilage loss and an accom"anying re"arati)e bone res"onse. Ct re"resents the single most im"ortant ca3se of locomotor disability 5ith a "re)alence 5hich 7;Q 5ith age and a female "re"onderance. The 1oints commonly affected incl3de the hi"s, knees, s"ine, !st car"ometacar"al, !st metatarsal, and distal inter"halangeal 1oints. econdary ca3ses incl3de tra3ma, B0, infection, ne3ro"athic 2CharcotEs4 1oints, and metabolic 2e.g. PagetEs disease, acromegaly, haemachromatosis, a)asc3lar necrosis, and hy"o"arathyroidism4. Clinical feat3res Common sym"toms incl3de s5elling, deformity, stiffness, 5eakness, and "ain 5hich is normally 5orse after acti)ity and relie)ed by rest. Common signs incl3de: Hard, bony s5ellings of the @CP 1oints 2HeberdenEs nodes4. =ony nod3les at the PCP 1oints 2=o3chardEs nodes4.
o

These are bony o3tgro5ths at the 1oint margins 2osteo"hytes4.

789 R3are hand deformity78: d3e to s3bl3xation of the base of the th3mb. Talg3s and )ar3s deformities.

Cre"it3s. Nasting and 5eakness 2es"ecially of the R3adrice"s and gl3tei4. Tilting of the "el)is.

Crystal arthro"athies ?o3t 0 disorder of "3rine metabolism. CharacteriIed by hy"er3ricaemia d3e to either o)er"rod3ction or 3nderexcretion of 3ric acid. Prolonged hy"er3ricaemia leads to the formation of 3rate crystals in the syno)i3m, other connecti)e tiss3es and the kidney. Clinical feat3res of ac3te go3t e)ere "ain and s5elling classically in the great toe MTP 1oint, 5orse at night and associated 5ith redness. Occasionally m3lti"le 1oints are in)ol)ed.

#_ ystemic sym"toms.

Clinical feat3res of chronic 2to"haceo3s4 go3t To"h3s formation 2soft tiss3e de"osits of 3rate fo3nd es"ecially in digits, helix of the ear, b3rsae and tendon sheaths4. o #_ O)erlying necrotic skin 5ith chalky ex3date of 3rate crystals. Pse3dogo3t Ca3sed by de"osition of calci3m "yro"hos"hate crystals in the syno)i3m, 1oint ca"s3le and tendons. Ct is the commonest ca3se of an ac3te monoarthritis in the elderly and may "resent as either an ac3te syno)itis or as a chronic arthritis. ,inked to chondrocalcinosis 2calcification of artic3lar cartilage4. On examination, yo3 may find a s5ollen, erythemato3s and tender 1oint 2often knees, 5rist, elbo5, ankle, or sho3lder and MCP 1oints es"ecially the index and middle4 associated 5ith systemic 3"set. P.-F' =ox !!.!& Ca3ses of hy"er3ricaemia @r3gs: di3retics, ethanol, lo5 dose salicylates, "yraIinamide, ethamb3tol, nicotinic acid and ciclos"orin4. Chronic renal fail3re.

Myelo"roliferati)e and lym"ho"roliferati)e disorders 27;Q "3rine metabolism4. Obesity. Hy"ertension. Hy"othyroidism. Hy"erthyroidism.

6amilial. Excessi)e dietary "3rines. 7JK More common in the s3mmer months d3e to red3ced fl3id intake and increased fl3id loss.

=ox !!.!! Conditions associated 5ith go3t Obesity. Ty"e CT hy"erli"idaemia.

Hy"ertension. Cm"aired gl3cose tolerance>diabetes. Cschaemic heart disease.

P.-FD "ondyloarthro"athies These incl3de ankylosing s"ondylitis, "soriatic arthritis, reacti)e arthritis, and entero"athic arthritis. This is a gro3" of related and o)erla""ing forms of inflammatory arthritis 5hich characteristically lack rhe3matoid factor and are associated 5ith H,0+=%'. They "resent at any age, tho3gh yo3ng males are "rimarily affected. They also share a n3mber of key feat3res 5hich are: Enthesitis 2an enthesis is the insertion of a tendon, ligament or ca"s3le into a bone4. yno)itis.

acroiliitis. @actylitis. Peri"heral arthritis "redominantly affecting the large 1oints.

0nkylosing s"ondylitis 0nkylosing s"ondylitis 3s3ally de)elo"s in early ad3lthood 5ith a "eak age of onset in the mid %&s and is - times more common in males. Common sym"toms ,o5er back "ain and stiffness 5hich is ty"ically 5orse in the morning and after long "eriods of rest. Chest "ain as a res3lt of T+s"ine in)ol)ement as 5ell as enthesitis at the costochondral 1oints.

Tender sacro+iliac 1oints. Pain in "eri"heral 1oints s3ch as the sho3lders and knees.

M3sc3loskeletal feat3res>signs

789U3estion mark78: "ost3re 2loss of l3mbar lordosis, fixed ky"hoscoliosis of the T+ s"ine, com"ensatory extension of the C+s"ine4. Prot3berant abdomen. choberEs test "ositi)e 2see 0chilles tendonitis. Plantar fasciitis. ".-D-4.

ome extra+skeletal feat3res 0nterior 3)eitis. 0ortic reg3rgitation.

0"ical l3ng fibrosis. 0T block. 0myloidosis 2secondary4. 0tlantoaxial dislocation. Tra3matic fract3re of a rigid s"ine. Hy"oxia. 6e)er. Neight loss.

P.-FF Psoriatic arthritis Psoriatic arthro"athy affects 3" to !&` of "atients 5ith "soriasis and may "recede or follo5 the skin disease. 7JK Cm"ortantly the arthro"athy does not correlate 5ith the se)erity of the skin lesions. There are L main s3bty"es of "soriatic arthro"athy: 0symmetrical distal inter"halangeal 1oint arthro"athy. 0symmetrical large 1oint mono+ or oligoarthro"athy.

"ondyloarthro"athy and sacroiliitis. Bhe3matoid+like hands 2clinically identical to B0 b3t seronegati)e4. 0rthritis m3tilans 2a se)erely destr3cti)e form 5ith telesco"ing of the fingers4.

0ssociated clinical feat3res

Psoriatic "laR3es 2classically fo3nd on the extensor s3rfaces, scal", behind the ears, in the na)el and natal cleft4. Sail in)ol)ement 2"itting, onycholysis, discoloration, and thickening4. @actylitis 2sa3sage+sha"ed s5elling of the digits d3e to tenosyno)itis4.

Beacti)e arthritis 0n ase"tic arthritis, strongly linked to a recogniIed e"isode of infection. Common ca3ses are g3t and genito3rinary "athogens. Ct mainly affects yo3ng ad3lts and 3s3ally "resents 5ith an asymmetric and oligoartic3lar arthritis 5ith sym"toms starting a fe5 days to a fe5 5eeks after the infection.

Enthesitis and dactylitis are other common feat3res and "atients may ex"erience "ain in the artic3lar 1oints.

0ssociated extra+skeletal feat3res (rethritis. Con13ncti)itis.

kin and m3cosal lesions.

BeiterEs syndrome 0 form of reacti)e arthritis associated 5ith the classic triad of: 0rthritis. (rethritis.

Con13ncti)itis.

Ct often follo5s dysenteric infections s3ch as higella, almonella, Cam"ylobacteria, and Wersinia or infections of the genital tract. Other findings 5hich may be enco3ntered are mo3th 3lceration, circinate balanitis, keratoderma blennorrhagica 2"3st3lar+like lesions fo3nd on the "alms or soles4 and "ersistent "lantar fasciitis. Entero"athic arthritis Entero"athic arthritis is a "eri"heral or axial arthritis occ3rring in association 5ith inflammatory bo5el disease and does not ty"ically correlate 5ith the se)erity of bo5el disease. Ho5e)er, the "eri"heral arthritis has been sho5n to im"ro)e if the affected bo5el is resected. P.M&& Osteo"orosis Osteo"orosis is a systemic skeletal disorder in)ol)ing 7;< bone mass 2osteo"enia4 and micro+ architect3ral deterioration, res3lting in an 7;Q risk of fract3re. Classification 2and treatment4 is based on meas3rement of the bone mineral density 2=M@4, 5ith com"arision to that of a yo3ng healthy ad3lt. ee OHCM/, "./FD. The 3nderlying "athology is related to an imbalance bet5een the osteoblast cells "rod3cing bone and the osteoclast cells remo)ing bone 5hich 3ltimately "rod3ces a net loss of bone.

Ty"e C: accelerated 2mainly trabec3lar4 bone loss secondary to oestrogen deficiency and leads to fract3re of )ertebral bodies as 5ell as the distal forearm in 5omen in their late /&s and '&s. Ty"e CC: age+related cortical and trabec3lar bone loss occ3rring in both sexes and leads to fract3res of the "roximal fem3r in the elderly.

Clinical feat3res The "rocess leading to established osteo"orosis is asym"tomatic and the condition 3s3ally "resents only after bone fract3res. 6eat3res differ according to the fract3re site. The most common clinical feat3res incl3de: Marked ky"hosis. ,oss of height.

Prot3berant abdomen. "inal tenderness.

PagetEs disease 0 disorder of bone remodelling characteriIed by 7;Q osteoclastic and osteoblastic cell acti)ity, leading to accelerated b3t disorganiIed bone resor"tion and formation.V PagetEs disease is the %nd commonest disease of bone after osteo"orosis, is more common in males and affects aro3nd -` of the "o"3lation *M& years of age. Ct occ3rs more commonly in =ritain than any5here else in the 5orld and there are tho3ght to be 3" to one million s3fferers in the (G. The exact aetiology remains 3nkno5n, ho5e)er, a n3mber of factors ha)e been im"licated, incl3ding a slo5 )iral infection. -&` of PagetEs "atients ha)e an affected !st degree relati)e. Cm"ortant clinical feat3res and com"lications: Enlargement of the sk3ll. Hearing loss 2ossicles are in)ol)ed and TCCC ner)e com"ression4.

O"tic atro"hy and angioid streaks. Cardiac fail3re. Gy"hosis, anterior bo5ing of the tibia, lateral bo5ing of the fem3r. 7;Q bone 5armth. 7;< mobility. 6ract3res. arcomato3s change 2rare4. Cord com"ression. Cerebellar signs. Hy"ercalcaemia.

P.M&! =ox !!.!% Bisk factors for osteo"orosis moking. High alcohol cons3m"tion.

=MC Y!F. 6Hx. Premat3re meno"a3se. Prolonged immobiliIation. Prolonged secondary amenorrhoea. Primary hy"ogonadism. ,o5 dietary calci3m and )itamins. Older age. 6emale gender. edentary lifestyle. Ca3casian or 0sian origin. Chronic disorders s3ch as:
o o o o o o

0norexia ner)osa. Malabsor"tion syndromes. Primary hy"erthyroidism. Post trans"lantation. C3shingEs syndrome. Chronic renal fail3re.

=ox !!.!- ome im"ortant ca3ses of a s5ollen knee B0. B3"t3red =akerEs cyst.

Pse3dogo3t. ?o3t. Oedamato3s states 2e.g. CC6, ne"hrotic syndrome4.

Tra3ma. CharcotEs knee. e"tic arthritis. Haemarthrosis.

P.M&% The elderly "atient Bhe3matological diseases re"resent a h3ge s"ectr3m of illness in older "eo"le, often com"licating and conc3rrent 5ith other diseases78He.g. the im"act of se)ere arthritis on COP@ or heart fail3re or the effect of hi" or knee arthritis on reco)ery after ac3te stroke. 0rthritis and osteo"orosis are t5o ma1or factors in the 789geriatric giants78: of immobility and instability78H"ertinent reminders of the 5ides"read effect of locomotor illness 5ith ad)ancing age. History Method of "resentation: can )ary, ranging from the fall that leads to a femoral neck fract3re or a referral 789off legs78: or 5ith declining mobility. Older "eo"le 5ill often ha)e an existing diagnosis of some form of arthritis78Hthe diffic3lty is not in the diagnosis, b3t 3nderstanding the im"act on e)eryday life. ,ocomotor illnesses are a key "art of s3ch "resentations, and attention to these illnesses is )ital. Ho5e)er, it is im"ortant to remember that "resentations s3ch as falls are m3ltifactorial78Htry to 5ork o3t ho5 locomotor illness contrib3tes to mobility or falls risk Cnterc3rrent illness: may often "reci"itate go3t or "artic3larly "se3dogo3t. ER3ally im"ortant are those illnesses that dist3rb caref3lly balanced homeostasis, leading to a fall and fract3re. Wo3r task is not 13st to treat the conseR3ence of the fall, b3t look at 5hy it ha""ened in the first "lace

e"tic 1oints: can be notorio3sly diffic3lt to diagnose at times. (nilateral large 1oint s5elling>ac3te arthritis sho3ld ring alarm bells instantly, es"ecially if the "atient is 3n5ell. 0 myriad of ca3ses contrib3te to back "ain, b3t ne)er forget dee" seated infection s3ch as discitis or osteomyelitis 5hich may be a conseR3ence of something innoc3o3s as a 3rinary infection. @Hx: as e)er, a keystone of any assessment. Consider the side effect "rofile of S 0C@s, or 5hether go3t has been "reci"itated by the effects of di3retics or lo5 dose as"irin. Cf yo3r "atient has s3stained a fragility fract3re d3e to osteo"orosis, are they on a""ro"riate treatmentO Se)er forget the 7;Q n3mber of older "eo"le 5hose arthritis is s3ccessf3lly treated 5ith disease modifying dr3gs78Hand 3nderstand the effects of s3ch dr3gs 2and the need to "rescribe conc3rrent folic acid 5ith methotrexate78HdonEt forget]4. 0cti)ities, occ3"ation, and interests: o)erla"s 5ith the f3nctional history, a key message of these "ages. M3lti+disci"linary assessment is )ital in terms of tailoring rehabilitation, aids and f3t3re care 5here a""ro"riate. 0sk too abo3t hobbies and interests78Him"ro)ing balance, minimiIing "ain and maximiIing f3nction may allo5 "atients to carry on 5ith

acti)ities that are a key "art of their li)es 2and might re"resent an o""ort3nity for contin3ed exercise or rehabilitation4. P.M&Examination ?eneral: the signs are often )ery clear, b3t des"ite this, easily o)erlooked. The need here is for a caref3l and tho3ghtf3l assessment of f3nction as 5ell as disease acti)ity. 0l5ays be solicito3s of yo3r "atientEs comfort78Hand examine caref3lly, ex"laining 5hat yo3 5ish to do to a)oid mis3nderstanding and "ain. Pattern of disease: is 5ell described in the "re)io3s "ages of this cha"ter. ,ook o3t for ty"ical "atterns of disease, and also single 1oint "athology. ,ook at ankles, feet, and back78Hit takes only a little more time to 3ndertake a good examination, b3t is de"ressingly common to see "atients 5ith "oor balance and falls 5ith a clerking that details no locomotor assessment.

@isease acti)ity: be caref3l 5hen "al"ating78Hb3t look to see if an ac3te exacerbation of 1oint disease may 5ell ha)e contrib3ted to the c3rrent "resentation. ?ait and balance: often o)erlooked, b3t a )ital "art of the examination. ,earn 2e.g. from the 5ard "hysiothera"ist4 ho5 to 3ndertake the 789get 3" and go test78:, a 5ell )alidated test of gait and balance 2see belo54. This assessment sho3ld o)erla" 5ith ne3rological assessment 5hen a""ro"riate.

=ox !!.!M ?et 3" and go 0n easy test to do, and one 5hich gi)es a 5ealth of information. Cn essence, ask yo3 "atient to rise to standing from a chair, 5alk - metres, t3rn and ret3rn to the chair. This is not a "3re obser)er role for the clinician78Hyo3 m3st make an assessment of safety and be on hand to s3""ort the "atient if needed. Ne thank @r richard 63ller for contrib3ting this "age.