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286 • THE RENAL SYSTEM
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Integrated examination sequence for renal disease
• Position the patient: Start with patient at a 45-degree angle.
• Examine the general appearance:
• Uremic facies
• Myoclonus
• Scratch marks
• Dyspnoea, hyperventilation
• Check the hands, arms and face:
• Splinter haemorrhages
• Arteriovenous fistulae and scars
• Tunnelled vascular access catheter
• Pallor, eye inflammation
• Examine skin for vasculitic (purpuric) rash
• Assess fluid balance:
• Pulse, blood pressure, skin turgor and jugular venous pressure
• Heart sounds
• Chest examination: percussion and auscultation to assess for pleural effusions or pulmonary oedema
• Sacral and ankle oedema
• Reposition the patient: supine with their arms at their sides.
• Perform an abdominal examination:
• Inspection: peritoneal dialysis catheter, abdominal distension due to ascites or enlarged kidneys, scars from a renal transplant
• Palpation: ballot for enlarged kidneys, palpate the suprapubic area for the bladder and any renal transplant in the right or left iliac fossa
• Percussion: shifting dullness for ascites, enlarged kidneys resonant to percussion, suprapubic dullness indicating bladder enlargement
• Auscultation: abdominal bruits
• Other:
• In men with a history of urinary outflow problems, perform a rectal examination of the prostate.
• Perform dipstick urinalysis.
Jane Gibson
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Phil Walmsley
13
The musculoskeletal system
The history 288
Common presenting symptoms 288
Past medical history 292
Drug history 292
Family history 292
Social history 293
The physical examination 293
General principles 293
General examination 293
Detailed examination of the musculoskeletal system 296
Gait 296
Spine 297
Upper limb 302
Lower limb 309
Fractures, dislocations and trauma 319
The history 319
The physical examination 319
Investigations 320
OSCE example 1: Right shoulder pain 322
OSCE example 2: Painful hands 322
Integrated examination sequence for the locomotor system 323
288 • THE MUSCULOSKELETAL SYSTEM
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The history
Common presenting symptom s
Pain
In musculoskeletal pain, the acronym SOCRATES (see Box 2.2,p.
12) suggests questions that help reveal useful diagnostic clues.
Site
Fig. 13.1 illustrates the anatomy of a typical joint. Determine
which component is painful: the joint (arthralgia), muscle
(myalgia) or other soft tissue. Pain may be localised and may
suggest the diagnosis, for example, a red, hot, tender first
metatarsophalangeal joint in gout (Fig. 13.2), or swelling of
Skin and
subcutaneous
tissue
Bone
Capsule
Synovium
Fibrocartilage pad
Joint space
Articular cartilage
Fig. 13.1 Structure of a joint and surrounding tissues.
Fig. 13.2 Acute gout of the first metatarsophalangeal joint. This causes
swelling, erythema, and extreme pain and tenderness (podagra). From Colledge NR, Walker BR, Ralston SH, eds. Davidson’s Principles and Practice of
Medicine. 21st ed. Edinburgh: Churchill Livingstone; 2010.
Bursa
Tendon
Tendon sheath
Ligamentous
thickening
of capsule
Muscle
Bursa
several joints suggesting inflammatory arthritis. Causes of
arthralgia and myalgia are shown in Boxes 13.1 and 13.2.
Onset
Pain from traumatic injury is usually immediate and exacerbated
by movement. An affected joint may develop haemarthrosis
(bleeding into the joint). Inflammatory arthritis can develop over
24 hours or more insidiously. Crystal arthritis (gout and pseudogout) causes acute, severe pain that develops quickly, often
overnight. Joint sepsis causes pain that develops over 1–2 days.
Character
Bone pain can be described as a ‘deep ache’ or ‘penetrating’
and is characteristically worse at night. Common causes of
localised pain are tumours, osteomyelitis (infection), osteonecrosis or osteoid osteoma (a benign bone tumour). Generalised
bony conditions, such as osteomalacia, more commonly cause
diffuse pain.
Pain from fractures is usually sharp and stabbing, aggravated
by any movement and relieved by rest and splintage.
Muscle pain may be described as ‘stiffness’ or ‘aching’ and is
aggravated by use of the affected muscle(s).
13.1 Common causes of arthralgia (joint pain)
Infective
• Viral (e.g. rubella, parvovirus B19, mumps, hepatitis B, chikungunya)
• Bacterial (e.g. staphylococci, Mycobacterium tuberculosis, Borrelia)
• Fungal
Postinfective
• Rheumatic fever
• Reactive arthritis
Inflammatory
• Rheumatoid Arthritis
Degenerative
• Osteoarthritis
Tumour
• Primary (e.g. osteosarcoma, chondrosarcoma)
• Metastatic (e.g. from lung, breast, prostate)
• Systemic tumour effects (e.g. hypertrophic pulmonary
osteoarthropathy)
Crystal formation
• Gout, pseudogout
Trauma
• For example, Road traffic accidents
Others
• Chronic pain disorders (e.g. fibromyalgia (usually diffuse pain))
• Hypermobile Ehler’s Danlos syndrome
f
A
The history • 289
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13.2 Causes of muscle pain (myalgia)
Infective
• Viral: Coxsackie, cytomegalovirus, echovirus, dengue, SARS CoV2
• Bacterial: Streptococcus pneumoniae, Mycoplasma
• Parasitic: schistosomiasis, toxoplasmosis
Traumatic
• Tears
• Haematoma
• Rhabdomyolysis
Inflammatory
• Polymyalgia rheumatica
• Myositis
• Dermatomyositis
Drugs
• Alcohol withdrawal
• Statins
• Triptans
Metabolic
• Hypothyroidism
• Hyperthyroidism
• Addison’s disease
• Vitamin D deficiency
• Neuropathic
13.3 Common patterns of referred and radicular
musculoskeletal pain
Site where pain is perceived Site of pathology
Occiput C1, 2
Interscapular region C3, 4
Tip of shoulder, upper outer aspect of arm C5
Interscapular region or radial fingers and thumb C6, 7
Ulnar side of forearm, ring and little fingers C8
Medial aspect of upper arm T1
Chest Thoracic spine
Buttocks, knees, legs Lumbar spine
Lateral aspect of upper arm Shoulder
Forearm Elbow
Anterior thigh, knee Hip
Thigh, hip Knee
pain, early-morning stiffness and loss of function is likely to be
inflammatory arthritis. ‘Flitting’ pain, starting in one joint and
moving to others over a period of days, is a feature of rheumatic
13.4 Clinical vignette: arthralgia and fatigue
13
‘Shooting’ pain is often caused by impingement of a peripheral
nerve or nerve root; for example, buttock pain, which ‘shoots
down the back of the leg’, is caused by lumbar disc protrusion.
Progressive joint pain in patients over 40 years old is most
commonly caused by osteoarthritis.
Fibromyalgia, a chronic pain syndrome, causes widespread,
constant pain with little diurnal variation, which is poorly
controlled by conventional analgesic/anti-inflammatory drugs.
Radiation
Pain from nerve compression radiates to the distribution of the
affected nerve or nerve root (see Fig. 7.26), such as lower leg
pain in intervertebral disc prolapse or hand pain in carpal tunnel
syndrome. Neck pain radiates to the shoulder or scalp. Hip pain
is commonly felt in the groin but may radiate to the thigh or knee.
Common patterns of radiation are summarised in Box 13.3.
Associated symptoms
For example, swelling and redness of a joint indicate inflammatory arthritis.
Timing (frequency, duration and periodicity of
symptoms)
A history of several years of pain with a normal examination
suggests fibromyalgia (Box 13.4). A history of several weeks of
A 34-year-old mother-of-two presents to her General Practitioner (GP)
with a 1-year history of gradually worsening pain and persistent fatigue.
The pain moves around and involves the back, neck, shoulders, elbows,
hands and knees. All joints are described as swollen, particularly her
hands, which swell ‘all over’. Further history reveals poor sleep, with the
patient wakening every 2 hours and feeling unrefreshed in the morning.
She has a difficult social background and a past history of depression and
irritable bowel syndrome. Examination shows no skin or joint abnormality
but there is widespread tenderness, particularly across her shoulders, in
her neck and down her back (see figure). Blood tests are all normal.
She is diagnosed with fibromyalgia.
Low cervical spine
Medial
end of
2nd rib
Lateral
epicondyle
Medial
fat pad
of knee
Trapezius
Outer
gluteal
muscle
Greater
trochanter
Occiput
Medial
border o
scapula
B
Typical tender points in fibromyalgia. A Anterior view. B Posterior view.
A
290 • THE MUSCULOSKELETAL SYSTEM
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fever and gonococcal arthritis. If intermittent, with resolution
between episodes, it may be palindromic rheumatism.
Exacerbating/relieving factors
Pain from joints damaged by intra-articular derangement or
osteoarthritic degeneration worsens with exercise. Pain from
inflammatory arthritis worsens with rest. Pain from a septic joint is
present both at rest and with movement.
Severity
Apart from trauma, the most severe joint pain occurs in septic
and crystal arthritis. Disproportionately, severe pain is seen
acutely in compartment syndrome (increased pressure in a
fascial compartment, compromising perfusion and viability of
compartmental structures) and chronically in complex
regional pain syndrome. Neurological involvement in diabetes
mellitus, leprosy, syringomyelia and syphilis (tabes dorsalis)
may impair joint sensation, reducing pain despite obvious
pathology on examination. Grossly abnormal joints may
even be pain-free (e.g. Charcot joints, Fig 10.14C,p.237).
Partial muscle tears are painful; a complete rupture may be
less so.
Patterns of joint involvement
Different patterns of joint involvement aid the differential diagnosis (Fig. 13.3). Are the small or large joints of the arms or legs
affected? How many joints are involved? Involvement of one joint
is called monoarthritis; 2–4 joints, oligoarthritis; and more than 4,
polyarthritis.
• Predominant involvement of the small joints of the hands and
feet suggests inflammatory arthritis, such as rheumatoid
arthritis or systemic lupus erythematosus (SLE).
• Medium- or large-joint swelling is more likely to be degenerative (osteoarthritis) or seronegative arthritis (such as psoriatic
arthritis).
• Nodal osteoarthritis particularly affects the distal interphalangeal (DIP) joints of the hands and the carpometacarpal
(CMC) joint of the thumb.
Stiffness
Ask what the patient means by stiffness. Is it:
• restricted range of movement?
• difficulty moving, but with a normal range?
• painful movement?
• localised to a particular joint or more generalised?
There are characteristic differences between inflammatory and
non-inflammatory presentations of joint stiffness. Inflammatory
arthritis causes early-morning stiffness that takes at least 30 minutes to wear off with activity. Non-inflammatory, mechanical
arthritis causes stiffness after rest that eases rapidly on movement.
Disease of the soft tissues rather than the joint itself may cause
stiffness. In polymyalgia rheumatica, stiffness commonly affects
the shoulder and pelvic areas.
Swelling
Ask about the site, extent and time course of the swelling.
Rheumatoid arthritis Psoriatic arthritis Axial spondyloarthritis Osteoarthritis
Fig. 13.3 Contrasting patterns of joint involvement in polyarthritis. A Rheumatoid arthritis (symmetrical, small and large joints, upper and lower limbs).
B Psoriatic arthritis (asymmetrical, large > small joints, swelling of a whole digit – dactylitis, enthesitis). C Axial spondyloarthritis (spine and sacroiliac joints,
asymmetrical peripheral arthritis, large > small joints, enthesitis).
joints).
BCD
D Osteoarthritis (symmetrical, small and large joints, base of thumb, distal interphalangeal
The history • 291
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The speed of onset of swelling is a clue to the diagnosis:
• Rapid (<30 minutes), severe swelling suggests a haemarth-
rosis (Fig. 13.4B). This occurs when vascular structures such
as bone or ligament are injured and becomes worse in the
presence of anticoagulants or bleeding disorders.
• Swelling over hours, or days, post injury suggests traumatic
effusion, such as with a meniscal tear or articular cartilage
abrasion.
• Septic arthritis develops over a few hours up to two days with
pain, marked swelling, tenderness, redness and extreme
reluctance to move the joint actively or passively. Concurrent
glucocorticoid or non-steroidal anti-inflammatory drug therapy suppresses these features.
• Crystal-induced arthritis (gout or pseudogout) can mimic
septic arthritis. It commonly starts overnight or early in the
morning due to the rise in serum urate following the evening
meal.
A
Erythema and warmth
Erythema (redness) can occur with infective, traumatic and
crystal-induced conditions and may be present in inflammatory
arthritis. All affected joints will be warm. Erythema associated
with DIP joint swelling helps to distinguish DIP joint psoriatic
arthritis from the Heberden’s nodes of osteoarthritis.
Weakness
Weakness suggests joint, neurological or muscle disease. The
problem may be focal or generalised.
Joint disorders can cause weakness, either by inhibition of
function due to pain or by disruption of the joint and its supporting
structures. Nerve entrapment may be a cause, for example, carpal
tunnel syndrome at the wrist. Muscle disorders can produce
widespread weakness associated with pain and fatigue, such as in
myositis, and with a rash, as in dermatomyositis. Proximal muscle
weakness can occur in endocrine disorders: for example, hypothyroidism or excess of glucocorticoids.
13
Locking and triggering
‘Locking’ is an incomplete range of movement at a joint because
of an anatomical block. It may be associated with pain. Patients
use ‘locking’ to describe various problems, so clarify exactly
what they mean.
True locking is a block to the normal range of movement caused
by mechanical obstruction, typically preventing full extension, for
example from a loose body or torn meniscus, within the joint. The
patient may be able to ‘unlock’ the joint by trick manoeuvres.
Pseudolocking is a loss of the range of movement due to pain.
Triggering is a block to the extension of a finger, which then
‘gives’ suddenly when extending from a flexed position. In adults,
it normally affects the ring or middle fingers and is caused by
nodular or fibrous thickening of the flexor sheath due to chronic
low-grade trauma. The cause may be occupational or associated
with inflammatory arthritis. Triggering can also be congenital, in
which case, it usually affects the thumb.
B
Fig. 13.4 A Olecranon bursitis. B Right-knee haemarthrosis.
Extra-articular symptoms
Patients may present with extra-articular features of a disease
(Box 13.5) that they may not connect with musculoskeletal
problems.
Ask about:
• Rashes: occur with psoriasis, vasculitis, viral infections,
connective tissue diseases, sarcoidosis and autoinflammatory disease. Ask whether they are photosensitive
(SLE, Box 13.6).
• Weight loss, low-grade fever and malaise: associated with
rheumatoid arthritis and SLE. High-spiking fevers in the
evening, accompanied by a rash, occur in adult-onset Still’s
disease.
292 • THE MUSCULOSKELETAL SYSTEM
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13.5 Extra-articular signs in rheumatic conditions
Condition Extra-articular signs
Rheumatoid arthritis Rheumatoid nodules, palmar erythema, episcleritis, dry eyes, interstitial lung disease, pleural
Psoriatic arthritis Psoriasis, nail pitting, onycholysis, enthesitis, dactylitis, episcleritis
Reactive arthritis Urethritis, mouth and/or genital ulcers, conjunctivitis, iritis, enthesitis (inflammation of tendon or
Axial spondyloarthritis Inflammatory bowel disease, psoriasis, enthesitis, iritis, episcleritis, aortic regurgitation, apical interstitial
Septic arthritis Fever, malaise, source of sepsis (e.g. skin, throat, gut)
Gout Tophi, signs of renal failure or alcoholic liver disease, obesity
Sjögren’s syndrome ‘Dry eyes’ (keratoconjunctivitis sicca), xerostomia (reduced or absent saliva production), salivary gland
Systemic lupus erythematosus Photosensitive rash, especially on face, mucocutaneous ulcers, alopecia, fever, pleural pericardial
Systemic sclerosis Skin tightening (scleroderma, see Fig. 3.30C), telangiectasia, Raynaud’s phenomenon, calcific deposits
Vasculitis Rash, fever, malaise, neuropathy, tender cranial arteries in giant cell arteritis, nasal crusting and saddle
Auto-inflammatory Diseases Rash, recurrent fever, serositis, aphthous ulceration, hepatomegaly, splenomegaly, deafness
Other Erythema nodosum of shins in sarcoidosis and Behçet’s disease, viral rashes, drug rashes, oral and
pericardial effusion, small-vessel vasculitis, Raynaud’s phenomenon, low-grade fever, weight loss,
lymphadenopathy, splenomegaly, leg ulcers
ligament attachments) (e.g. Achilles enthesitis/plantar fasciitis, rash (keratoderma blennorrhagica))
fibrosis
enlargement, Raynaud’s phenomenon, neuropathy
effusion, diaphragmatic paralysis, pulmonary fibrosis (rare), Raynaud’s phenomenon, lymphopenia
in fingers, dilated nail-fold capillaries, pulmonary fibrosis
nose in granulomatous polyangiitis
genital ulceration in Behçet’s disease
• Headache, jaw pain on chewing (claudication) and scalp
tenderness: features of temporal arteritis.
Connective tissue disease may present with multiple extra-
articular features:
• Raynaud’s phenomenon.
• Sicca symptoms (dryness of mouth and eyes).
• Rashes.
• Gastrointestinal problems, including dysphagia and mouth
ulcers.
• Respiratory problems, including dyspnoea from interstitial
lung disease, or pleural pain or effusions associated with
rheumatoid arthritis or connective tissue disease.
• Back pain and stiffness or arthritis associated with abdominal
pain, diarrhoea, bloody stool and mouth ulcers. They may
suggest arthritis associated with inflammatory bowel disease.
Past medical history
Note past episodes of musculoskeletal involvement, extra-articular
diseases as listed in the previous section, fractures and possible
complicating comorbidities such as diabetes or obesity.
Drug history
Many drugs have side effects that may either worsen or precipitate musculoskeletal conditions (Box 13.7).
13.6 Clinical vignette: joint pain and rash
A 32-year-old woman is seen in the outpatient clinic with fatigue and
intermittent pain and swelling in her hands, which she has had for the last
year. She noticed a rash across her cheeks and on her arms while she
was on holiday in Spain recently, and this seems to have sparked off
painful mouth ulcers and worsening joint pain. She has no other relevant
history. Examination shows a ‘butterfly’ rash across the cheeks and nose,
several mouth ulcers and two swollen metacarpophalangeal joints. Blood
tests reveal anaemia, lymphopenia, positive antinuclear antibody and
raised anti-double-stranded deoxyribonucleic acid antibodies.
A diagnosis of systemic lupus erythematosus is made.
Family history
Inflammatory arthritis is more common if a first-degree relative is
affected. Osteoarthritis, osteoporosis and gout are heritable in a
variable polygenic fashion. Spondyloarthritis is more common in
patients with human leucocyte antigen B27. A single-gene defect
(monogenic inheritance) is found in hereditary sensorimotor
neuropathy (Charcot–Marie–Tooth disease), osteogenesis
imperfecta, Ehlers–Danlos syndrome, Marfan’s syndrome and
muscular dystrophies.
The physical examination • 293
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13.7 Drugs associated with adverse musculoskeletal
effects
Possible adverse
Drug
Glucocorticoids Osteoporosis, myopathy,
Statins Myalgia, myositis, myopathy
Angiotensin-converting enzyme
inhibitors
Antiepileptics Osteomalacia, arthralgia
Immunosuppressants Infections
Quinolones Tendinopathy, tendon rupture
musculoskeletal effects
osteonecrosis, infection
Myalgia, arthralgia, positive
antinuclear antibody
Social history
Identify functional difficulties, including the ability to use pens,
tools and cutlery. How does the condition affect the patient’s
activities of daily living, such as washing, dressing and toileting?
Can they use the stairs, and do they need walking aids? Ask
about functional independence, especially cooking, housework
and shopping.
Ask about current and prev ious occupations. Is the pa tient
working full- or part-time, on sick leave or receiving benefits?
Has the patient had to take time off work because of the
condition and is their job at risk? Litigation may be pending
following injury and in occupational disorders such as repetitive
strain disorder, hand vibration syndrome and fatigue fractures.
Smoking is a risk factor for rheumatoid arthritis and possibly
other inflammatory arthritides. High alcohol intake contributes to
gout and falls that may result in fracture. It can also cause
myopathy, neuropathy and rhabdomyolysis.
Some conditions are seen in certain ethnic groups; for
example, sickle cell disease may present with bone and joint pain
in African patients. Osteomalacia is more common in Asian patients. Bone and joint tuberculosis is more common in African
and Asian patients.
A sexual history may be relevant (Chapter 2, p. 17) since
sexually transmitted diseases are associated with musculoskeletal problems, such as reactive arthritis, gonococcal arthritis,
human immunodeficiency virus infection and hepatitis B.
The physical examination
Practise examining as many joints as possible to become familiar
with normal appearances and ranges of movement.
General principles
Firstly, examine the patient’s overall appearance for features
such as pallor, rash, skin tightening and hair changes.
Look – feel – move
Follow a process of observation, palpation and movement for
each joint or group of joints in turn.
Look at the skin, subcutaneous tissues and bony outline of
each area. Before palpating, ask the patient which area is painful
or tender. Feel for warmth, swelling, stability and deformity.
Assess if the deformity is reducible or fixed. Assess active before
passive movement. Do not cause the patient additional pain.
Compare one limb with the opposite side. Always expose the
joint above and below the affected one. In suspected systemic
disease, examine all joints and systems fully.
Use standard terminology to describe position and movement.
Describe movements from the neutral position:
• flexion: bending at a joint from the neutral position
• extension: straightening a joint towards the neutral position
• hyperextension: moving beyond the normal neutral position
(indicating a torn ligament or ligamentous laxity, such as
Hypermobile Ehler’s Danlos syndrome)
• adduction: moving towards the midline of the body (finger
adduction is movement towards the axis of the limb)
• abduction: moving away from the midline.
To describe altered limb position due to joint/bone deformity,
use:
• valgus: the distal part deviates away from the midline
• varus: the distal part deviates towards the midline.
In the wrist and hand, use:
• radial deviation: the distal part deviates towards the radial side
• ulnar deviation: the distal part deviates towards the ulnar side.
General examination
Skin, nail and soft tissues
The skin and nails are common sites of associated lesions. Skin
changes of psoriasis may be hidden in the umbilicus, natal cleft
or scalp (Fig. 14.3B, p. 329), for example. The rash of SLE is
found across the cheeks and bridge of the nose. Nail pitting and
onycholysis occur in psoriasis (Fig. 3.7A, p. 27).
Small, dark-red spots due to capillary infarcts occur in rheumatoid arthritis, SLE and systemic vasculitis. Common sites are
the nail folds (Fig. 13.5, often seen in rheumatoid arthritis) and the
lower legs in systemic vasculitis (fig 14.7, p. 331).
In systemic sclerosis, the thickened, tight skin produces a
characteristic facial appearance (see Fig. 3.30C on p. 39). In the
hands, flexion contractures, calcium deposits in the finger pulps
(Fig. 13.6) and tissue ischaemia leading to ulceration may occur.
The telangiectasias of systemic sclerosis are purplish, blanch with
pressure and are most common on the hands and face. In the
fingers, the pallor of Raynaud’s phenomenon, pulp atrophy or
ulceration may be evident.
Reactive arthritis is associated with conjunctivitis, urethritis,
circinate balanitis (painless superficial ulcers on the prepuce and
glans) and superficial mouth ulcers.
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294 • THE MUSCULOSKELETAL SYSTEM
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Fig. 13.7 Rheumatoid nodules at the olecranon and ulnar border.
Fig. 13.5 Nail-fold infarcts caused by small-vessel vasculitis.
A
B
Fig. 13.6 Systemic sclerosis in the hand. A Calcium deposits ulcerating
through the skin.
Jackson WF. Colour Atlas of Clinical Medicine. 3rd ed. Edinburgh: Mosby;
2003.
B x-ray showing calcium deposits. (A) From Forbes CD,
Nodules
The firm, non-tender, subcutaneous nodules of rheumatoid
arthritis most commonly occur on the extensor surface of the
forearm (Fig. 13.7), sites of pressure or friction such as the sacrum
or Achilles tendon, or in the lungs. Multiple small nodules can occur
in the hands. Rheumatoid nodules are strongly associated with a
positive anti-cyclic citrullinated peptide (anti-CCP) antibody or
rheumatoid factor.
Bony nodules in osteoarthritis affect the lateral aspects of the
DIP joints (Heberden’s nodes) or the proximal interphalangeal
(PIP) joints (Bouchard’s nodes, Fig. 13.8). They are smaller and
harder than rheumatoid nodules.
Gouty tophi are firm, irregular subcutaneous crystal collections
(monosodium urate monohydrate). Common sites are the olecranon bursa, helix of the ear and the fingers (Fig. 13.9), hands,
knees and toes. If superficial, they may appear white, and may
ulcerate, discharge crystals and become secondarily infected.
Eyes
Redness of the eyes may be due to conjunctivitis in reactive
arthritis or ‘dry eyes’ in Sjögren’s syndrome, rheumatoid arthritis
and other connective tissue disorders. Scleritis and episcleritis
occur in rheumatoid arthritis and psoriatic arthritis. An acutely
painful, very red eye due to iritis occurs in axial spondyloarthritis
(Fig. 13.13, p. 298). The sclerae are blue in certain types of
osteogenesis imperfecta (see Fig. 3.30A on p. 39) and in the
scleromalacia of longstanding rheumatoid arthritis.
General features
Weight loss, muscle loss, fever and lymphadenopathy are all
features of systemic involvement in inflammatory arthritis and
connective tissue disease.
Joints: the GALS screen
GALS (gait, arms, legs, spine) is a rapid screen for musculoskeletal and neurological deficits and for functional ability; it helps
identify joints that require more detailed examination, as
described later.
Initial questions
• Do you have any pain or stiffness in your muscles, joints or
back?
• Do you have difficulty dressing yourself?
Fig. 13.8 Osteoarthritis of the hand Heberden’s (single arrow) and Bou-
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chard’s (double arrow) nodes.
Fig. 13.9 Gouty tophi.
• Do you have difficulty walking up and down the stairs?
If all three replies are negative, the patient is unlikely to have a
significant musculoskeletal problem; otherwise, perform the
GALS screen.
Examination sequence (Video 24)
Ask the patient to undress to their underwear and stand in front
of you. Demonstrate actions to the patient rather than simply
telling them what to do. Any asymmetry, reduced range of
movement, pain or deformity demands a detailed examination.
The physical examination • 295
AB
Fig. 13.10 Assessing the wrist. A Extension. B Flexion. There is a
reduced range of movement at the right wrist.
Gait
• Ask the patient to walk ahead in a straight line, then turn and
walk back towards you. Look for smoothness and symmetry
of the gait.
Arms
• Stand in front of the patient.
• Inspect the dorsum of the hands and check for full extension
at the metacarpophalangeal (MCP), PIP and DIP joints.
• Gently squeeze across the MCP joints. Tenderness suggests
inflammation, as in rheumatoid arthritis.
• Ask the patient to:
• Clench their fists and then open their hands flat.
• Squeeze your index and middle fingers.
• Touch each of their fingertips with the thumb.
• Make a ‘prayer sign’, with their elbows as high as possible.
Then reverse this with the backs of their hands together and
elbows low (Fig. 13.10).
• Put their arms straight out in front of their body.
• Bend their arms up to touch their shoulders.
• Place their elbows by the side of their body, bent at 90 de-
grees. Turn their palms up and down.
• Put their hands behind their head, with their elbows back.
• Put their hands behind their back.
Legs
• Ask the patient to lie supine on the couch.
• Palpate each knee for warmth, swelling and patellar tap.
• Flex each hip and knee with your hand on the patient’s knee.
Feel for crepitus in the patellofemoral joint and knee.
• Unless contraindicated, perform Thomas’s test for fixed
flexion deformity on both hips (see Fig. 13.35).
• Flex the patient’s knee and hip to 90 degrees, and passively
rotate each hip internally and externally.
• Look at the feet for any abnormality. Examine the soles,
looking for calluses and ulcers, indicating abnormal load
bearing.
• Gently squeeze across the metatarsal heads for tenderness.
Spine
• Stand behind the patient. Assess the straightness of the
spine, muscle bulk and symmetry in the trunk, legs, ankle and
foot.
• Stand beside the patient. Ask them to bend down and try to
touch their toes, while you look for abnormal spinal curvature
or limited hip flexion.
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