31st January 2024

Examination

Examine the joint for warmth, erythema, swelling and injury. Assess for impairment in function- depending on the joint involved; it can affect walking, writing, etc. Perform a systemic examination to assess for infection, which could point to septic arthritis or signs to suggest an autoimmune or metabolic-related cause. 

When examining the patient, tell the patient to show the affected joint- they will often be handling it with extreme care and may not wish to be touched immediately due to fear of pain. Be patient and offer to help the patient if they are in discomfort and struggling to expose the joint.

Start with inspection of the joint and compare it to the unaffected joint on the left/ right side. Ensure you carefully inspect both joints at all angles accessible- anterior, lateral, posterior and medial. Inspect the area immediately above and below the joint. Take note of scars, deformities, colour change, swelling or masses and where these are in relation to the joint- are they immediately overlying the joint, or do they appear to be related to the muscle or ligaments, for example. If a swelling is present, ask the patient how long it has been there for and if it has changed- the patient may say it has been there for 10 years, so may be irrelevant to the current presentation.

Following inspection comes palpation. Be mindful of the patient when palpating the joint. Explain clearly what you will do and tell the patient to mention if pain arises. Start with the “normal” side first- this will not only prepare the patient for what is to come for the affected side but will also give you information about the normal range of movement and function of the patient. Palpate above and below the joint. Feel the joint itself- you are trying to elicit any areas of swelling which are not obvious on initial inspection. Active synovitis is an inflammatory change in the joint space itself- it is felt as a fluctuant boggy pocket of fluid. Feel for temperature change- gentle palpation of both joints at the same time to identify temperature discrepancy- use the back of the hand and move proximal to distal. 

Next, assess movement- active movement first, then passive movement. Depending on the joint involved, assessment of flexion, extension, abduction, adduction, internal and external rotation. Assessment of the degrees of movement actively (the patient doing it for themselves) and then passively (the examiner doing the movement for the patient) in comparison to the unaffected side. Whilst moving the joint, the examiner should also comment on evidence of crepitation of the joint and any clear difficulty expressed by the patient in doing these movements. 

Examination of the joint above and below should be performed in thorough assessment of the joint and general physical examination of the individual. General examination can help rule in or rule out differential diagnoses or additional diagnoses that were not elicited on history taking. 

General inspection can give clues about other co-morbidities relevant to joint pathology:

• Plaques seen on the extensor surfaces of the elbows, shins and near the hairline can indicate psoriasis
• Symmetrical deformity of the fingers and toes, as well as nodules near the elbows, can indicate a diagnosis of rheumatoid arthritis.
• Asymmetrical deformity of the distal interphalangeal joints and large joints such as knees can indicate a diagnosis of osteoarthritis.

Finally, assessing the function of the joint involved is key to assessing the effect the problem has on the patient. If the lower limb joints are involved, you may wish to watch the patient walk or take off their shoes and socks. If the upper limb is involved, you may wish to observe the patient pick up a coin, undo and do up buttons of a shirt or watch the patient pick up a pen and write. These demonstrate how the problem is affecting daily living activities. Above all else, an understanding of how the patients’ life is affected by the pain shows a holistic approach to patient care. It can lead to improved management of the patient’s expectations and consideration of prophylactic treatment.