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13.8 The Beighton scoring system to assess
hypermobility
Ask the patient to Score
Bring the thumb to touch the forearm, with the
wrist flexed
Extend the little finger >90 degrees, with the
hand in a neutral position
Extend the elbow >10 degrees 1 point each side
Extend the knee >10 degrees 1 point each side
Touch the floor, with the palms of hands and
the knees straight
A score of 4 indicates hypermobility
Reproduced from Beighton P, Solomon L, Soskolne CL. Articular
mobility in an African population. Ann Rheum Dis. 1973; 32(5):413, with
permission from BMJ Publishing Group.
• Stand behind the patient, hold their pelvis, and ask them to
turn from side to side without moving their feet.
• Ask them to slide their hand down the lateral aspect of their
leg towards their knee.
• Stand in front of the patient. Ask them to put their ear to each
shoulder in turn.
• Ask the patient to look down to the floor and then up to the
ceiling.
• Ask them to open their jaw wide and move it from side to
side.
1 point each side
1 point each side
1 point
Hypermobility
Some patients have a greater than normal range of joint movement. If this is severe, patients may present with recurrent dislocations or sensations of instability. Milder cases may develop
arthralgia or be symptom-free. Mild hypermobility is normal, but
Marfan’s and Hypermobile Ehler’s Danlos syndromes (Box 13.8)
cause significant hypermobility.
Detailed examination of the
musculoskeletal system
The GALS screen provides a rapid but limited assessment. This
section describes the detailed examination required for thorough
evaluation.
Gait
initial contact when the foot is off the ground. When both feet are
on the ground, this is a double stance.
A limp, or antalgic gait, is an abnormal gait due to pain,
structural change or spasticity.
Examination sequence (Video 24A)
• Ask the patient to walk barefoot in a straight line. Then repeat
in shoes.
• Observe the patient from behind, in front and from the side.
• Evaluate what happens at each level (foot, ankle, knee, hip and
pelvis, trunk and spine) during both stance and swing phases.
Pain
An antalgic gait is one altered to reduce pain. Pain in a lower limb
is usually aggravated by weight bearing, so minimal time is spent
in the stance phase on that side. This results in a ‘dot–dash’
mode of walking. If the source of pain is in the spine, axial
rotatory movements are decreased, resulting in a slow gait with
small paces. Patients with hip pain may lean towards the affected
side, as this decreases the joint reaction force in the hip joint.
Structural change
Patients with limb-length discrepancy may limp or walk on tiptoe
on the shorter side, with compensatory hip and knee flexion on
the longer side. Assess for limb-length discrepancy (see
Fig. 13.36). Other structural changes producing an abnormal gait
include joint fusion, bone malunion and contracture.
Weakness
This may be due to nerve or muscle pathology or altered muscle
tone. In a normal gait, the hip abductors of the stance leg raise
the contralateral hemipelvis. In Trendelenburg gait, abductor
function is poor when weight-bearing on the affected side, so the
contralateral hemipelvis falls (see Fig. 13.37).
Common causes of a Trendelenburg gait are:
• painful hip joint problems, as in osteoarthritis
• weak hip abductors, as in poliomyelitis or after hip
replacement
• structural hip joint problems, as in congenital dislocation.
A high-stepping gait occurs in foot drop due to common
peroneal nerve palsy. The knee is raised high to bring the weak
foot off the ground.
Gait is the cyclical pattern of musculoskeletal motion that carries
the body forwards. Normal gait is smooth, symmetrical and
ergonomically economical, with each leg 50% out of phase with
the other. It has two phases: stance and swing. The stance
phase is from initial contact to toe-off, when the foot is on the
ground and load-bearing. The swing phase is from toe-off to
Increased tone
This occurs with upper motor neurone lesions, such as cerebrovascular accident (stroke) or cerebral palsy. The gait depends
on the specific lesion, contractures and compensatory mechanisms (see Box 7.7 on p. XXX).
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Spine
The spine is divided into the cervical, thoracic, lumbar and sacral
segments (Fig. 13.11). Most spinal diseases affect multiple segments, causing altered posture or function of the whole spine.
Spinal disease may occur without local symptoms, presenting with
referred pain, neurological symptoms or signs in the trunk or limbs.
Common causes of spinal pain are shown in Box 13.9.
Definitions
Scoliosis is the lateral curvature of the spine (Fig. 13.12A).
Kyphosis is the curvature of the spine in the sagittal (anterior–
posterior) plane, with the apex posterior (see Fig. 13.12B). The
thoracic spine normally has a mild kyphosis.
Lordosis is the curvature of the spine in the sagittal plane, with
the apex anterior (see Fig. 13.12C).
C1
1
C1
C2
2
2
C3
3
3
4
C4
5
T10
T11
T12
4
C5
6
5
C6
C7
C8
T1
T2
T3
T4
T5
T6
T7
T8
T9
L1
L2
L3
L4
L5
S1
S2
S3
S4
S5
Co
7
6
7
T1
10
11
12
L1
2
3
4
5
C5, C6 – Arm abduction
Elbow flexion
C6, C7 – Wrist extension
C7, C8 – Elbow extension
C8, T1 – Finger abduction
T2–T7 – Chest muscles
T9–T12 – Abdominal muscles
L1, L3, L4 – Knee extension
Cauda
equina
L4, L5, S1, S2 – Knee flexion
L4, L5 – Ankle dorsiflexion
L5, S1 – Great toe extension
S1, S2 – Ankle plantar flexion
Hand grasp
L1, L2, L3 – Hip flexion
S2, S3, S4 – Voluntary
rectal tone
Fig. 13.11 The normal spinal curves and root innervations.
Cervical
lordosis
8
1
2
2
3
3
4
5
4
6
5
7
6
8
7
9
10
8
11
9
12
1
2
3
4
5
1
2
3
4
5
Lumbar
lordosis
Thoracic
kyphosis
Gibbus is a spinal deformity caused by an anterior wedge
deformity of a single vertebra, producing localised angular flexion
(see Fig. 13.12D).
Cervical spine
Anatomy and physiology
Head nodding occurs at the atlanto-occipital joint, and rotational
neck movements mainly at the atlantoaxial joint. Flexion, extension and lateral flexion occur mainly at the mid-cervical level. The
13.9 Common spinal problems
• Mechanical back pain
• Prolapsed intervertebral disc
• Spinal stenosis
• Axial Spondyloarthritis
• Compensatory scoliosis from leg-length discrepancy
• Cervical myelopathy
• Pathological pain/deformity (e.g. osteomyelitis, tumour, myeloma)
• Osteoporotic vertebral fracture resulting in kyphosis (or rarely lordosis),
especially in the thoracic spine with loss of height
• Cervical rib
• Scoliosis
• Spinal instability (e.g. spondylolisthesis)
Scoliosis
AB
Increased
lumbar
lordosis
CD
Fig. 13.12 Spinal deformities.
Kyphosis
Gibbus
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neural canal contains the spinal cord and the emerging nerve
roots, which pass through the exit foramina bounded by the
facet joints posteriorly and the intervertebral discs and neurocentral joints anteriorly. The nerve roots, particularly in the lower
cervical spine, may be compressed or irritated by lateral disc
protrusion or by osteophytes arising from the facet or neurocentral joints. Central disc protrusions may press directly on the
cord (see Fig. 7.30 on p. 166).
The history
The most common symptoms are pain and difficulty turning the
head and neck. Neck pain is usually felt posteriorly but may be
referred to the head, shoulder, arm or interscapular region.
Cervical disc lesions cause radicular pain in one arm or the other,
roughly following the dermatomes of the affected nerve roots
(see Box 13.3). If the spinal cord is compromised (cervical
myelopathy), upper motor neurone leg weakness, altered
sensation and sphincter disturbance may occur.
The physical examination
Be particularly careful when examining patients with rheumatoid
arthritis, as atlantoaxial instability can lead to spinal cord damage
when the neck is flexed.
In patients with neck injury, never move the neck. Splint it and
check for abnormal posture. Check for neurological function in
the limbs and x-ray or computed tomography (CT) to assess
bony injury.
Examination sequence (Video 25)
Ask the patient to remove enough clothing for you to see their
neck and upper thorax, then direct them to sit on a chair.
Look
• Face the patient. Observe the posture of their head and neck.
Note any abnormality (Box 13.10), such as loss of lordosis
(usually due to muscle spasm).
Feel
• Feel the midline spinous processes from the occiput to T1
(usually the most prominent).
• Feel the paraspinal soft tissues.
• Feel the supraclavicular fossae for cervical ribs or enlarged
lymph nodes.
• Feel the anterior neck structures, including the thyroid.
• Note any tenderness in the spine, trapezius, interscapular
and paraspinal muscles.
Move
Assess active movements (Fig. 13.13).
Ask the patient to:
• Look down to the floor so you can assess forward flexion.
The normal range is 0 (neutral) to 80 degrees. Record the
decreased range as the chin–chest distance.
• Look upwards at the ceiling as far back as possible, to
assess extension. The normal range is 0 (neutral) to 50 degrees. The combined flexion–extension arc is normally
approximately 130 degrees.
• Put their ear on to their shoulder so that you can assess
lateral flexion. The normal range is 0 (neutral) to 45 degrees.
• Look over their right/left shoulder. The normal range of lateral
rotation is 0 (neutral) to 80 degrees.
If any of the active movements are reduced, gently perform
passive movements. Confirm whether the end of a range has a
sudden or gradual resistance, plus whether it is pain or stiffness
that restricts movement. Pain or paraesthesiae in the arm on
passive neck movement suggests nerve root involvement.
Thoracic spine
Anatomy and physiology
This segment of the spine is the least mobile and maintains a
physiological kyphosis throughout life. Movement is mainly
rotational with a very limited amount of flexion, extension and
lateral flexion.
13.10 Causes of abnormal neck posture
Loss of lordosis or flexion deformity
• Acute lesions, rheumatoid arthritis, trauma
Increased lordosis
• Axial Spondyloarthritis
Torticollis (wry neck)
• Sternocleidomastoid spasm, contracture, trauma
• Pharyngeal/parapharyngeal infection
Lateral flexion
• Erosion of lateral mass of atlas in rheumatoid arthritis
Neutral
Fig. 13.13 Movements of the cervical spine.
Rotation
Lateral flexionFlexion and extension
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The history
Presenting symptoms in the thoracic spine are: localised spinal
pain (Box 13.11), pain radiating round the chest wall or, less
frequently, signs of cord compression – upper motor neurone leg
weakness (paraparesis), sensory loss, and loss of bladder or
bowel control. Thoracic spine disc lesions are rare but may cause
pain radiating around the chest, mimicking cardiac or pleural
disease. Osteoporotic vertebral fractures can present with acute
pain or painless loss of height with increased kyphosis.
Vertebral collapse from malignancy may cause cord
compression. Infection causes acute pain, often with systemic
upset or fever. With poorly localised thoracic pain, consider
intrathoracic causes such as myocardial ischaemia or infarction,
oesophageal or pleural pain, and aortic aneurysm.
The physical examination
Examination sequence (Video 26)
Ask the patient to undress to expose their neck, chest and
back.
Look
• With the patient standing, inspect their posture from behind,
from the side and the front, noting any deformity, such as a
rib hump or abnormal curvature (see Fig. 13.12).
Feel
• Palpate the midline spinous processes from T1 to T12. Feel
for increased prominence of one or more posterior spinal
processes, implying an anterior wedge-shaped collapse of
the vertebral body.
• Feel the paraspinal soft tissues for tenderness.
Move
• Ask the patient to sit with their arms crossed. Ask them to
twist round both ways and look behind.
Lumbar spine
Anatomy and physiology
The surface markings are the spinous process of L4, which is
level with the pelvic brim, and the ‘dimples of Venus’, overlying
the sacroiliac joints. The normal lordosis may be lost in disorders
such as axial spondyloarthritis and lumbar disc protrusion.
13.11 Causes of thoracic spine pain
Adolescents and young adults
• Scheuermann’s disease
• Axial spondyloarthritis
Middle-aged and elderly
• Degenerative change
• Dissecting aortic aneurysm
Any age
• Tumour • Infection
• Disc protrusion (rare)
• Osteoporotic fracture
The principal movements are flexion, extension, lateral flexion
and rotation. In flexion, the upper segments move first, followed
by the lower segments, to produce a smooth lumbar curve.
However, even with a rigid lumbar spine, patients may be able to
touch their toes if their hips are mobile.
In an adult, the spinal cord ends at L2. Below this, only the
spinal nerve roots may be injured by disc protrusion.
The history
Low back pain is an extremely common symptom. Most
commonly this is ‘mechanical’ and caused by degenerative
changes in discs and facet joints (spondylosis).
Analyse the symptoms using ‘SOCRATES’. For back pain, ask
specifically about:
• occupational or recreational activity that may strain the back
• additional clinical features suggesting significant spinal pa-
thology (Box 13.12)
• prior treatment with glucocorticoids.
Radicular pain, caused by sciatic nerve root compression,
radiates down the posterior aspect of the leg to the lower leg or
ankle (sciatica). Groin and thigh pain in the absence of hip abnormality suggests referred pain from L1 to L2.
Consider also abdominal and retroperitoneal pathology, such
as abdominal aortic aneurysm.
Mechanical low back pain is common after standing for too
long or sitting in a poor position. Symptoms worsen as the day
progresses and improve after resting.
13.12 Important features for history-taking in acute
low back pain
Features that may indicate serious pathology and require urgent
referral
History
• Age <20 years or >55 years
• Recent significant trauma
(fracture)
• Pain:
• Non-mechanical (infection/
tumour/pathological
fracture)
• Fever (infection)
• Difficulty in micturition
Past medical history
• Cancer (metastases)
• Previous glucocorticoid use (osteoporotic collapse)
System review
• Weight loss/malaise without obvious cause (e.g. cancer)
Psychosocial factors associated with greater likelihood of longterm chronicity and disability
• A history of anxiety, depression, chronic pain, irritable bowel syndrome,
chronic fatigue, social withdrawal
• A belief that the diagnosis is severe (e.g. cancer). Faulty beliefs can
lead to ‘catastrophisation’ and avoidance of activity
• Lack of belief that the patient can improve leads to an expectation that
only passive, rather than active, treatment will be effective
• Ongoing litigation or compensation claims (e.g. work, road trafficaccident)
• Faecal incontinence
• Motor weakness
• Sensory changes in the
perineum (saddle anaesthesia)
• Sexual dysfunction (e.g. erectile/
ejaculatory failure)
• Gait change (cauda equina
syndrome)
• Bilateral ‘sciatica’
13
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Insidious onset of back or buttock ache and stiffness in an
adolescent or young adult suggests inflammatory disease of the
sacroiliac joints and lumbar spine (axial spondyloarthritis,
Box 13.13). Symptoms are worse in the morning or after inac-
tivity and ease with movement. Morning stiffness is more marked
than in osteoarthritis or mechanical pain, lasting at least 30 minutes. Other clues to the diagnosis are peripheral joint involvement, extra-articular features or a positive family history.
Acute onset of low back pain in a young adult, often associated with bending or lifting, is typical of an acute disc protrusion
(slipped disc). Coughing or straining to open the bowels exacerbates the pain. There may be symptoms of lumbar or sacral
nerve root compression. Cauda equina syndrome occurs when a
central disc prolapses or another space-occupying lesion compresses the cauda equina. There are features of sensory and
13.13 Clinical vignette: back pain
A 34-year-old man attends his general practitioner’s surgery with back pain.
He first developedpain in his late teens, but it improvedfor a few years.He has
had persistent pain in hislowerback and sometimesinhisbuttocks for5 years
now. It wakes him from sleep, and he can be very stiff in the mornings,
althoughthis eases as the morningprogresses.There is no radiationto the leg.
He is stiff after sitting or driving. He has always put it down to his occupation.
He has used ibuprofen to good effect but has had diarrhoea and abdominal
pain recently, which he attributes to this drug. Examination in the outpatient
clinic shows a thin man with reduced lumbar mobility (modified Schober’s
index, reducedat 2 cm; see Fig. 13.15), pain on sacroiliac jointcompression,
and tenderness at his Achilles insertion. Investigations show him to have a
raised C-reactive protein, an anaemia of chronic disease, a positive human
leucocyte antigen B27 and a raised faecal calprotectin, suggesting inflammatory bowel disease. Magnetic resonance imaging confirms bilateral sacroiliitis and inflammatory changes in the lumbar spine.
A diagnosis of axial spondyloarthritis is made.
Axial spondyloarthritis. The patient trying to touch his toes.
motor disturbance, including diminished perianal sensation and
disturbance of bladder function. The motor disturbance may be
profound, as in paraplegia. Cauda equina syndrome and spinal
cord compression are neurosurgical emergencies.
Acute back pain in the middle-aged, elderly or those with risk
factors, such as glucocorticoid therapy, may be due to osteoporotic fracture. This is eased by lying, exacerbated by spinal
flexion and not usually associated with neurological symptoms.
Acute onset of severe progressive pain, especially when
associated with malaise, weight loss or night sweats, may indicate pyogenic or tuberculous infection of the lumbar spine or
sacroiliac joint. The infection may involve the intervertebral discs
and adjacent vertebrae and may track into the psoas muscle
sheath, presenting as a painful flexed hip or groin swelling.
Consider a malignant disease involving a vertebral body in
patients with unremitting spinal pain of recent onset that disturbs
sleep. Other clues are a previous history of cancer, and systemic
symptoms or weight loss.
Chronic intermittent pain in the lumbar spine is typical of
degenerative disc disease. There is stiffness in the morning or
after immobility. Pain and stiffness are relieved by gentle activity
but recur with, or after, excessive activity.
Diffuse pain in the buttocks or thighs brought on by standing
too long or walking is the presenting symptom of lumbosacral
spinal stenosis. This can be difficult to distinguish from intermittent claudication (Chapter 4, p. 70). The pain may be accompanied by tingling and numbness. Typically, it is relieved by rest
or spinal flexion. Stooping or holding on to a supermarket trolley
may increase exercise tolerance.
The physical examination
Examination sequence
Ask the patient to stand with their back fully exposed.
Look
• Look for obvious deformity (decreased/increased lordosis,
scoliosis) and soft-tissue abnormalities such as a hairy patch
or lipoma that might overlie a congenital abnormality, for
example, spina bifida.
Feel
• Palpate the spinous processes and paraspinal tissues. Note
overall alignment and focal tenderness.
• After warning the patient, lightly percuss the spine with your
closed fist and note any tenderness.
Move (Fig. 13.14)
• Flexion: ask the patient to try to touch their toes with their legs
straight. Record how far down the legs they can reach. Some
of this movement depends on hip flexion. Usually, the upper
segments flex before the lower ones, but the progression
should be smooth.
• Extension: ask the patient to straighten up and lean back as
far as possible (normal 1020 degrees from a neutral erect
posture).
• Lateral flexion: ask them to reach down to each side,
touching the outside of their leg as far down as possible while
keeping their legs straight.
t
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Flexion Extension
Left Righ
RotationLateral flexion
Fig. 13.14 Movements of the lumbar and dorsal spine.
Special tests
Schober’s test for forward flexion
Examination sequence (Video 26A)
• Mark the skin in the midline at the level of the posterior iliac
spines (L5) (Fig. 13.15; mark A).
• Use a tape measure to draw two more marks: one 10 cm
above (mark B) and one 5 cm below this (mark C).
• Place the end of the tape measure on the upper mark (B). Ask
the patient to touch their toes. The distance from B to C
should increase from 15 to more than 20 cm.
In this test, the distance between the two points should increase by at least 5 cm. An increase of less than 5 cm indicates
restriction in the lumbar spine that may be due to axial
spondyloarthritis.
Root compression tests
Intervertebral disc prolapses causing nerve root pressure occurs
most often in the lower lumbar region, leading to compression of
the corresponding nerve roots.
The sciatic nerve (L4–5; S1–3) runs behind the pelvis, so
straight-leg raising stretches the L4, L5 and S1 nerve roots
(affected by L3/4, L4/5 and L5/S1 disc prolapse, respectively).
Fig. 13.15 Schober’s test. When the patient bends forward maximally with
the knees straight, distance BC should increase by at least 5 cm.
The femoral nerve (L2–4) lies anterior to the pubic ramus, so
straight-leg raising or other forms of hip flexion do not pull on its
roots. Problems with the femoral nerve roots may cause quadriceps weakness and/or diminished knee jerk on that side.
Sciatic nerve stretch test (L4–S1)
Examination sequence (Videos 26B
and 26C)
• With the patient lying supine, lift their foot to flex the hip
passively, keeping the knee straight.
• When a limit is reached, raise the leg to just less than this level,
and dorsiflex the foot to test for nerve root tension (Fig. 13.16).
Femoral nerve stretch test (L2–4)
Examination sequence (Video 26D)
• With the patient lying on their front (prone), flex their knee and
extend the hip (Fig. 13.17). This stretches the femoral nerve.
A positive result is when pain is felt in the back or the front of
the thigh. This test can, if necessary, be performed with the
patient lying on their side (with the test side uppermost).
Flip test for functional overlay
Examination sequence
• Ask the patient to sit on the end of the couch with their hips
and knees flexed to 90 degrees (Fig. 13.18A).
• Examine the knee reflexes.
• Extend the patient’s knee, as if to examine the ankle jerk. If
achieved, this puts the straight leg at 90 degrees of hip flexion
(see Fig. 13.18B) and excludes sciatic nerve root compression; patients with root compression will lie back (‘flip’).
Sacroiliac joints
In general, examination of the sacroiliac joints is unreliable.
13
A
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Fig. 13.16 Stretch test: sciatic nerve. A Straight-leg raising limited by
the tension of the root over a prolapsed disc.
dorsiflexion of the foot (Bragard’s test).
at the knee.
posterior tibial nerve, which is ‘bowstringing’ across the fossa, causing pain
locally and radiation into the back.
D Pressure over the centre of the popliteal fossa bears on the
B Tension is increased by
C Root tension is relieved by flexion
Examination sequence
• Lay the patient supine, flex the hip to 90 degrees and press
down on the knee to transfer pressure through to the
sacroiliac joints. This may cause pain in the buttock or lower
back if the sacroiliac joint is inflamed.
Upper limb
The prime function of the upper limb is to position the hand
appropriately in space. This requires intact shoulder, elbow and
wrist movements. The hand may function in both precision and
power modes, with the intrinsic muscles of the hand providing
Fig. 13.17 Stretch test: femoral nerve. A Pain may be triggered by knee
flexion alone.
hip extension.
B Pain may be triggered by knee flexion in combination with
Negative
B
Fig. 13.18 Sciatic nerve: ‘flip’ test. A Divert the patient’s attention to the
tendon reflexes.
permit full extension of the leg.
grip and fine manipulative movements, and the forearm muscles
supplying power and stability.
It is important to distinguish between systemic and local pathology. Systemic pathology, such as rheumatoid arthritis, usually affects several sites. Local conditions should be differentiated
from referred or radicular pain and establish whether the condition is inflammatory or not from the pattern of diurnal stiffness
and pain.
B The patient with physical nerve root compression cannot
Hand and wrist
The wrist joint has metacarpocarpal, intercarpal, ulnocarpal and
radiocarpal components. Together, they provide a wide range of
possible movements, including flexion, extension, adduction
(deviation towards the ulnar side), abduction (deviation towards
the radial side) and composite movement of circumduction (the
hand moves in a conical fashion on the wrist). Always name the
affected digit (index, middle, ring, little fingers and thumb) in
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documentation to avoid confusion. The PIP and DIP joints are
hinge joints and allow only flexion and extension. The MCP joints
allow flexion and extension, and some abduction/adduction,
which is greatest when the MCP joints are extended.
Motor and sensory innervation of the hand is shown in
Fig. 7.27 on page 163.
The history
The patient will often localise symptoms of pain, stiffness, loss of
function, contractures, disfigurement and trauma. If symptoms
are vague or diffuse, consider referred pain or a compressive
neuropathy such as carpal tunnel syndrome (see Box 7.11 on p.
164). If PIP or MCP joint swelling is prominent, consider inflammatory arthritis.
Painful, swollen and stiff hand joints are common and important presenting symptoms and scoring systems (Box 13.14) are
used to define the presence of rheumatoid arthritis.
The physical examination
Examination sequence (Video 27)
Seat the patient facing you, with their arms and shoulders
exposed. Start by examining the hand and fingers, then move
proximally.
Look
• Erythema suggests acute inflammation caused by soft-tissue
infection, septic arthritis, tendon sheath infection or crystal
arthritis. Palmar erythema is associated with rheumatoid
arthritis.
• Swelling of MCP joints due to synovitis produces loss of
interknuckle indentation on the dorsum of the hand, especially when the MCP and interphalangeal joints are fully flexed
(loss of the normal ‘hill–valley–hill’ aspect; Fig. 13.19A).
‘Spindling’ (swelling at the joint, tapering proximally and
distally; Fig. 13.19B) is seen when the PIP joints are affected.
• Deformity of phalangeal fractures may produce rotation. Ask
the patient to flex the fingers together (Fig. 13.20) and then in
turn. Normally, with the MCP and interphalangeal joints
flexed, the fingers should not cross and should point to the
scaphoid tubercle in the wrist.
• The fingers are long in Marfan’s syndrome (arachnodactyly,
Fig. 3.21B on p. 33).
• Boutonnière (or buttonhook) deformity is a fixed flexion
deformity at the PIP joint with hyperextension at the DIP joint.
‘Swan neck’ deformity is hyperextension at the PIP joint with
flexion at the DIP joint (Fig. 13.21).
• A ‘mallet’ finger (see Fig. 13.21)isaflexion deformity at the
DIP joints that is passively correctable. This is usually caused
by minor trauma disrupting the extensor expansion at the
base of the distal phalanx, with or without bony avulsion.
• There may be subluxation and ulnar deviation at the MCP
joints in rheumatoid arthritis (Fig. 13.22).
• Bony expansion of the DIP, PIP joints of the fingers and CMC
joint of the thumb is typical of osteoarthritis (see Fig. 13.8).
• Anterior (or volar) displacement (partial dislocation) of the
wrist may be seen in rheumatoid arthritis.
13.14 American College of Rheumatology/European
League Against Rheumatism classification criteria for
rheumatoid arthritis, 2010
Criteria Score
Duration of symptoms (as reported by patient)
<6 weeks 0
>6 weeks 1
Joint distribution (0–5)
1 large joint
2–10 large joints 1
1–3 small joints
4–10 small joints (large joints not counted) 3
>10 joints (at least 1 small joint) 5
Serology (0–3)
Negative RF and negative ACPA 0
Low positive RF or low positive ACPA 2
High positive RF or high positive ACPA 3
Acute-phase reactants
Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
Patients must have at least 1 swollen joint not better explained by another
disease.
A score of 6 classifies the patient as having definite rheumatoid
arthritis. A score of 4–5 is probable rheumatoid arthritis (i.e. a patient may
have clinical rheumatoid arthritis but not fulfil all criteria).
a
Large joints: shoulders, elbows, hips, knees and ankles
b
Small joints: all metacarpophalangeal and proximal interphalangeal
joints, thumb interphalangeal joint, wrists and 2nd–5th metatarsophalangeal joints.
ACPA, Anti-cyclic citrullinated peptide antibody; CRP, C-reactive
protein; ESR, erythrocyte sedimentation rate; RF, rheumatoid factor.
Reproduced from Aletaha D, Neogi T, Silman AJ, et al. Rheumatoid
arthritis classification criteria: an American College of Rheumatology/
European League Against Rheumatism collaborative initiative. Arthritis
Rheumatol. 2010; 62(9): 2569–2581, with permission from John Wiley
and Sons.
a
b
(large joints not counted) 2
0
Extra-articular signs
• Dupuytren’s contracture affects the palmar fascia, resulting in
fixed flexion of the MCP and PIP joints of the little and ring
fingers (see Fig. 3.5).
• Wasting of the interossei occurs in inflammatory arthritis and
ulnar nerve palsy. Carpal tunnel syndrome causes wasting of
the thenar eminence. T1 nerve root lesions (Fig. 13.23) cause
wasting of all small hand muscles.
• Look for nail-fold infarcts, telangiectasia, palmar erythema,
psoriasis, scars of carpal tunnel decompression, tendon
transfer or MCP joint replacement.
13
304 • THE MUSCULOSKELETAL SYSTEM
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A
B
Fig. 13.19 Swelling of the metacarpophalangeal (MCP) and proximal
interphalangeal (PIP) joints.
straight on to detect any loss of the ‘hill–valley–hill’ aspect.
erythema of the middle finger MCP joint and index and middle finger PIP
joints. Note also small muscle wasting.
A Ask the patient to make a fist. Look at it
B Swelling and
Fig. 13.21 Deformities of the fingers. Swan neck and boutonnière de-
formities occur in rheumatoid arthritis. Mallet finger occurs with trauma. DIP,
Distal interphalangeal; MCP, metacarpophalangeal; PIP, proximal
interphalangeal.
Scaphoid
tubercle
Fig. 13.20 Flexion of the fingers showing rotational deformity of the
ring finger.
• Nail changes, such as pitting and onycholysis (separation of
the nail from its bed), occur in psoriatic arthritis (see Fig. 3.7A
on p. 27).
Fig. 13.22 Advanced rheumatoid arthritis. Small muscle wasting, sub-
luxation and ulnar deviation at the metacarpophalangeal joints, boutonnière
deformities at the ring and little fingers, and swelling and deformity of the
wrist.
Feel
• Hard swellings usually arise from bone; soft swellings suggest
synovitis.
• Palpate above and below the interphalangeal joints with your
thumb and index finger to detect sponginess.
r
A
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AB
C
D
Fig. 13.23 T1 root lesion (cervical rib) affecting the right hand. Wasting
of the thenar eminence and interossei, and flexed posture of the fingers due to
lumbrical denervation.
• Test the MCP joints by examining for sponginess and
squeeze gently across them for pain.
• Palpate the flexor tendon sheaths in the hand and fingers to
detect swelling or tenderness. Ask the patient to flex and then
extend their fingers to establish whether there is triggering.
• De Quervain’s tenosynovitis causes swelling, tenderness and
crepitus (a creaking sensation that may even be audible) of
the tendon sheaths of abductor pollicis longus and extensor
pollicis brevis. Symptoms are aggravated by movements of
the wrist and thumb.
• Crepitus may also occur with movement of the radiocarpal
joints in osteoarthritis, most commonly secondary to old
scaphoid or distal radial fractures.
Move
E
Fig. 13.24 Testing the flexors and extensors of the fingers and thumb.
A Flexor digitorum profundus. B Flexor digitorum superficialis. C Extensor
digitorum. D Flexor pollicis longus. E Extensor pollicis longus.
13
Active movements
• Ask the patient to make a fist and then extend their fingers
fully.
• Flexor digitorum profundus: ask the patient to flex the DIP
joint while you hold the PIP joint in extension (Fig. 13.24A).
• Flexor digitorum superficialis: hold the patient’s other fingers
fully extended (to eliminate the action of the flexor digitorum
profundus, as it can also flex the PIP joint) and ask the patient
to flex the PIP joint in question (see Fig. 13.24B).
• Extensor digitorum: ask the patient to extend their fingers
with the wrist in the neutral position (see Fig. 13.24C).
• Flexor and extensor pollicis longus: hold the proximal phalanx
of the patient’s thumb firmly and ask them to flex and extend
the interphalangeal joint (see Fig. 13.24D).
• Extensor pollicis longus: ask the patient to place their palm on
a flat surface and to extend their thumb like a hitch-hiker (see
Fig. 13.24E). Pain occurs in de Quervain’s disease.
• Insert your index and middle finger from the thumb side into
the patient’s palm and ask them to squeeze them as hard as
possible to test their grip.
• Ask the patient to put the palms of their hands together and
extend their wrists fully in the ‘prayer sign’ (normal is 90 degrees of extension, Fig. 13.10A).
Fig. 13.25 Terms used to describe upper limb movements.
• Ask the patient to put the backs of their hands together and
• Check pronation and supination, flexion and extension, and
Supination
B
Dorsal
Neutral
Flexion of the wrist
flex their wrists fully – the ‘reverse prayer sign’ (normal is 90
degrees of flexion, Fig. 13.10B).
ulnar and radial deviation (Fig. 13.25).
Palmar
Radial
Pronation
Ulna
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