musculoskeletal and connective tissue disorders
Evaluation of the Patient With Joint Symptoms
Physical Examination
Each involved joint should be inspected and palpated, and the range of motion should be estimated. With polyarticular disease, certain nonarticular signs (eg, fever, wasting, rash) may reflect systemic disorders. The rest position of joints is noted, along with any erythema, swelling, deformity, and skin abrasions or punctures. Involved joints are compared with their uninvolved opposites or with those of the examiner. Joints are gently palpated, noting the presence and location of tenderness, warmth, and swelling. Determining whether tenderness is present along the joint line or over tendon insertions or bursae is particularly important. Soft masses, bulges, or tissues that fill normal concavities or spaces (representing joint effusion or synovial proliferation) are noted. Palpation of swollen joints can sometimes differentiate among joint effusion, synovial thickening, and capsular or bony enlargement. Small joints (eg, acromioclavicular, tibiofibular, radioulnar, sternoclavicular) can be the source of pain that was initially believed to arise from a nearby major joint. Bony enlargement (often due to osteophytes) is noted. Active range of motion (the maximum range through which the patient can move the joint) is assessed first; limitation may reflect weakness, pain, or stiffness as well as mechanical abnormalities. Then passive range of motion (the maximum range through which the examiner can move the joint) is assessed; passive limitation typically reflects mechanical abnormalities (eg, scarring, swelling, deformities) rather than weakness or pain. Active and passive movement of an inflamed joint (eg, due to infection or Gout ) may be very painful. Inability to reproduce pain with motion or palpation of the joint suggests the possibility of referred pain. Patterns of joint involvement should be noted. Symmetric involvement of multiple joints is common in systemic diseases (eg, Rheumatoid Arthritis (RA) ); monarticular (involving one joint) or asymmetric oligoarticular (involving Crepitus, a palpable or audible grinding produced by motion of damaged joint structures, is noted. It may be caused by roughened articular cartilage or by tendons; crepitus-causing motions should be determined and may suggest which structures are involved. Specific features should be sought at each joint. Details of the physical examination are discussed separately for the following joints: Evaluation of the Ankle None Evaluation of the Elbow None Evaluation of the Foot None Evaluation of the Hand None Evaluation of the Hip None Evaluation of the Knee None Evaluation of the Shoulder None Evaluation of the Wrist None Evaluation of Neck and Back Pain None 