Insepction and Palpation are the 2 primary techniques.

Notable characteristics:

1. Range of motion - evaluate extension, flexion, abduction, and adduction; limitations reflect an abnormality; access using active (patient initiated) and passive (examiner initiated) movement

2. swelling - around joints, due to accum. of synovial fluid in the joint space itself, or by swelling of synovial membrane => boggy feeling to joint

3. tenderness to palpation of synovium or joint space

4. heat or warmth of joint - compare bilaterally, with back of hands

5. redness of overlying skin

6. crepitation  - creaking or grating effect that is palpable and sometimes audbile with movement of the involved joint.

7. deformities - bony overgrowth, partial dislocations termed subluxations, contractures, shortening or angulation

8. symmetry of involvement - rheumatoid arthritis affects joints in a symmetric fashion

9. condition of the surrounding skin and tissues - look for presence of subcutaneous nodules

10. muscular strength

chest pain secondary to costochondritis causes localized pain and tenderness; worsens with palpation

chest pain secondary to angina pectoris does not worsen with palpation, precipitates on exertion, squeezing or burning pain, pain may radiate, shortness of breath, or emotional upset.

shoulder pain - can present anywhere along the C5 dermatome - (e.g. deltoid area to outside of arm to wrist); pain secondary to acromioclavicular joint is part of C4 dermatome

1. Impingement syndrome - inflammation of subacromial and subdeltoid bursae due to raising arm too much, forcing humerous against the edge of the acromion process; abduction of shoulder and reaching into back pocket aggravates pain (recall thoracic outlet syndrome); swelling, tenderness, pain in antero-lateral shoulder, pain may radiate into neck and down into elbow;

2. Deltoid bursitis - inflammation of subdeltoid bursae. Pain worsens when lying on it.

3. Bicipital tendinitis - tendon of the long head of the biceps passes to the shoulder through the bicipital groove; difficult to diff. with subdeltoid bursitis. palpation when patient's arm and forearm are rotated externally while examiner uses his thumb to palpate anteriorly over the bicipital groove for tenderness, swelling or crepitus. supination of patient's forearm against resistance while the elbow is held flexed at 90 degrees may elicit pain.

4. Rotator cuff inflammation - degeneration assoc. w/ acute minor trauma; most tears occur in the supraspinatus tendon in people older than 40 y/o, which has decreasing blood supply. History of minor trauma, age-related degeneration, and poor healing. pain w/ active or passive ABduction  from 60-120 degrees; 

complete tear of supraspintus - unable to initiate and carry out abduction from 0-90 degrees; however if examiner passively aducts pt. arm to 90 degrees; pt. can abduct with deltoid to 180 and hold. Active pressure from above will cause arm to collapse.

5. Adhesive capsulitis (frozen shoulder) - painful condition of shoulder that results from severe inflammation of joint capsule. Can develop from injury, but also without warning or trauama. limited range of motion in any direction and actively or passively. At some point, shoulder motion stops and can't go any further.

6. Osteoarthritis (of GH joint) - pain localized to shoulder as result of destruction of joint cartilage. no constitutional symptoms; no prolonged morning stiffness; no signs of active joint inflammation;

7. Rheumatoid arthritis (of GH joint) - assoc. with systemic distribution of other joints and constitutional symptoms; morning stiffness; extra-articular manifestations

8. Degenerative cervical disc disease - can result in shoulder pain

C5 cervical root irritation
– Abnormal biceps reflex
– Weak deltoid muscle
C6 cervical root irritation
– Abnormal brachioradialis reflex
– Weak biceps muscle
C7 cervical root irritation
– Abnormal triceps reflex
– Weak triceps strength

9. Cardiac Disease - Pain in one or both shoulders with physical exertion, or emotional upset. Palpation does not make it worse. Viseral pain is less localized.

10. Abdominal etiology (gallbladder, spleen, stomach, diaphgramatic)

11. Pulmonary disease - deep breathing or coughing makes it worse, localized.

12. Vascular disease (desccending thoracic aortic aneurysm) - most common of aneuryms

Rheumatoid Arthritis (RA)

Constitutional symptoms - fever, weakness, anorexia, weight loss, and malaise
Active inflammation - multiple joints
Bilateral involvement - stiffness from doing nothing
Morning stiffness - lasting at least 1 hour

DIP sparing (as opp. to OA)
Extra-articular manifestations

– Pulmonary, Felty’s syndrome (splenomegaly, neutropenia, and anemia), subcutaneous nodules

Joint deformities -

ulnar deviation of digits (subluxation of MCP joints)

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swan neck deformities (hyperext. PIP, flex DIP) - rupture of flexor tendon of PIP

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boutonniere deformities (flex PIP, hyper ext DIP) - rupture of the extensor tendon of PIP

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Osteoarthritis (OA) - degenerative joint disease (DJD)

Joint Pain -
Advancing age, trauma, repetitive activity

No constitutional symptoms
No signs of active joint inflammation

No prolonged morning stiffness
MCP joints are spared

DIP joints affected - Heberden's nodes

Base of thumb - mushroom deformitiy
Hip, knee, spine – commonly involved
Not symmetric

Deformity of joints less common and lesser degree

No extra-articular manifestations

Extra-articular manifestations of RA

1. Subcutaneous nodules -necrotic material, macrophages, and granulation tissue

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2. Diffuse vasculitis of skin, nerve, and internal organs

3. Pulmonary fibrosis, pleural fibrosis, and pulmonary nodules

4. Felty's syndrome - splenomegaly, neutropenia, and anemia

carpal tunnel syndrome - median nerve compressed under transverse carpal ligament

classic hand diagram (+LR = 2.4): pain in at least 2 out of the first 3 digits, symptoms permitted on 4th and 5th, wrist, and proximal to wrist; no symptoms allowed on palm or back of wrist

probable hand diagram (+LR = 2.4): same as above, put allowpalmar symptoms unless confined only to unlar aspect

Tinel's test - tap over median nerve with reflex hammer to indue tingling = (+) test; doesn't distinguish bet. other conditions that cause dysesthesias in hand

Phalan's test - patient maximally flex wrist for 60 seconds, holding dorsums together, causing symptoms simular to patient complaints; doesn't distinguish bet. other conditions that cause dysesthesias in hand

Pain may radiate up into the arm and even the neck.

Dupytren's contracture- Nodule that results in a flexion deformity of the fingers

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indicative of alcoholic liver disease

1. hip joint diasease - pain localized to groin, lateral thigh, buttocks

2. MCL tear - test by doing a valgus force (knock knees)

3. LCL tear - test by doing a varus force (bow legged)

4. ACL tear - bloody knee effusion, tense swelling imm. after 2 hours following knee injury; (+) anterior drawer sign

5. PCL tear - swelling, but no bleeding; (+) posterior drawer sign)

6. medial/lateral meniscal tear - severe pain, swelling present at joint line; knees knock or buckle; pain and tenderness along medial/lateral joint line; (+) McMurray test

7. chondromalacia  of the articular surface of patella- quads pull patella to one side, or cartilage wears down from OA, anterior knee pain,

8. iliotibial band syndrome - lateral knee pain; tightness and burning pain over lateral knee after running or cycling

9. OA of knee- affects medial side more than lateral

valgus = knock knees

varus = bow legged

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Gouty arthritis - sudden onset of acute inflammation of the MTP joint of the big doe; recurrence is common

Gout

Extracellular fluid urate saturation
Acute inflammatory arthritis – usually intermittent
Urate crystals present in the synovial fluid
May have tophi deposition in tissues
Most commonly affects the first MTP joint of big toe