GUIDE TO THE CLINICAL ASSESSMENT OF PATIENTS WITH MUSCULOSKELETAL CONDITIONS WE ARE 03

Versus Arthritis is dedicated to stopping the 18 MILLION devastating impact that arthritis has on people’s lives. When we talk about arthritis, we include all PEOPLE IN THE musculoskeletal conditions that affect the joints, bones and muscles – including osteoarthritis, UK LIVE WITH A rheumatoid arthritis, back pain and osteoporosis. Although these long-term conditions may be MUSCULOSKELETAL different in pathology, the impact they can have on people’s lives is similar. Pain is the most prevalent CONDITION symptom for people with arthritis, with many experiencing this every day and living with it for THAT’S THREE years or even decades. IN EVERY TEN Musculoskeletal conditions are a costly and growing problem. Their prevalence is expected to continue PEOPLE to increase due to our ageing population, rising levels of obesity and physical inactivity. The role of healthcare professionals in enabling people with The impact of arthritis can be arthritis to live well, to understand their condition, huge as the condition slowly and to have access to the appropriate information intrudes on everyday life, and support to self-manage has never been more affecting the ability to work, important. to care for a family, to move free from pain and to live Versus Arthritis is here to help you. Our education independently. Yet arthritis and training resources for frontline healthcare is often dismissed as an professionals are accessible, relevant and evidence inevitable part of ageing or based. They are designed to support you in shrugged off as ‘just a bit of confidently diagnosing and managing a range of arthritis’. We don’t think that musculoskeletal conditions, as well as honing your this is OK. Building on the skills in providing patient-centred, holistic care. legacies and expertise of both Our ‘Guide to the clinical assessment of patients Arthritis Research UK and with musculoskeletal conditions’ has been Arthritis Care, Versus Arthritis developed as a study guide for medical, nursing is here to change that. and allied health professional students. It takes a step by step approach to assessing people with musculoskeletal conditions to help you become competent and confident in their care.

Registered office: Versus Arthritis, Copeman House, St Mary’s Gate, Chesterfield S41 7TD Registered Charity England and Wales No. 207711, Scotland No. SC041156. 01. ABOUT THIS GUIDE 08 BIOGRAPHIES 09 FOREWORD 09 LIST OF ABBREVIATIONS USED 09 TERMINOLOGY 09 ACKNOWLEDGEMENTS

02. INTRODUCTION 12 INTRODUCTION TO MUSCULOSKELETAL ASSESSMENT 12 INITIAL APPROACH

03. THE MUSCULOSKELETAL HISTORY 16 ARE THE SYMPTOMS FROM THE JOINT OR THE SOFT TISSUES? 17 IS THE CONDITION ACUTE OR CHRONIC? 18 IS THE CONDITION INFLAMMATORY OR NON-INFLAMMATORY? 20 WHA T IS THE PATTERN OF AFFECTED AREAS/JOINTS? 22 WHAT IS THE IMPACT OF THE CONDITION ON THE PATIENT’S LIFE? 23 ARE OTHER SYSTEMS INVOLVED? 04. THE MUSCULOSKELETAL EXAMINATION 26 THE MUSCULOSKELETAL SCREEN: ‘GALS’ QUESTIONS AND EXAMINATION 34 PERF ORMING A REGIONAL EXAMINATION OF THE MUSCULOSKELETAL SYSTEM ‘REMS’

05. INVESTIGATIONS 50 IMAGING OF BONES AND JOINTS 51 BLOOD TESTS 51 SYNOVIAL FLUID ANALYSIS

06. CONCLUSION 54 APPENDIX 1: REVISION CHECKLISTS 58 APPEN DIX 2: THE CORE SET OF REGIONAL MUSCULOSKELETAL EXAMINATION SKILLS APPROPRIATE FOR A MEDICAL STUDENT AT THE POINT OF QUALIFICATION 59 APPENDIX 3: PGALS AND PREMS 60 BIBLIOGRAPHY 60 ENDORSEMENTS 01. ABOUT THIS GUIDE 08 BIOGRAPHIES 09 FOREWORD 09 LIST OF ABBREVIATIONS USED 09 TERMINOLOGY 09 ACKNOWLEDGEMENTS BIOGRAPHIES

Author Medical Editor David Coady is a consultant rheumatologist Mark Lillicrap is a consultant rheumatologist at Sunderland Royal Hospital. He previously at Addenbrooke’s Hospital in Cambridge and held an Educational Research Fellowship Hinchingbrooke Hospital in Huntingdon. His funded by Arthritis Research UK. This focused interest is in medical education and teaching. on identifying the core clinical skills of He is an associate lecturer and curriculum sub- musculoskeletal examination for undergraduates. dean at the University of Cambridge, has led the He produced the REMS videos which have been undergraduate musculoskeletal curriculum in used for teaching since 2001. He maintains a Cambridge, is a lecturer on the Cambridge PGCert keen interest in education, educational research in Medical Education and is the director of the and sailing. undergraduate clinical supervisor programme in Cambridge. Mark has also worked as the director of medical education at Hinchingbrooke and is a postgraduate educational supervisor for rheumatology specialist trainees.

DAVID AND MARK HAVE BOTH BEEN CLOSELY INVOLVED IN DEVELOPING PREVIOUS EDITIONS OF THE GUIDE AND HOPE THAT THIS UPDATED VERSION WILL PROVE TO BE A USEFUL RESOURCE FOR EVERYONE INVOLVED IN ASSESSING PATIENTS WITH MUSCULOSKELETAL CONDITIONS. 09 FOREWORD FOREWORD

Dr Pippa Watson List of abbreviations used Consultant Rheumatologist CMC(J) carpometacarpal (joint) and Honorary Senior Lecturer CT computerised tomography University Hospital of DEXA dual-energy x-ray absorptiometry South Manchester DIP(J) distal interphalangeal (joint) ESR erythrocyte sedimentation rate GALS gait, arms, legs and spine I’m delighted to introduce the updated Versus Arthritis MCP(J) metacarpophalangeal (joint) ‘Guide to the clinical assessment of patients with MRI magnetic resonance imaging musculoskeletal conditions’. I remember using this MTP(J) metatarsophalangeal (joint) guide during my training and finding it to be a clear NSAIDs non-steroidal anti-inflammatory drugs and useful resource. A few years later I find myself OA osteoarthritis using it again when teaching medical students. I PIP(J) proximal interphalangeal (joint) look forward to using this updated version – I think it RA rheumatoid arthritis brilliantly achieves its aim of demystifying examination REMS regional examination of the musculoskeletal of the musculoskeletal system, an area which students system have previously reported finding difficult. The guide includes the ‘GALS’ (Gait, Arms, Legs, Terminology Spine) screening examination developed by It could be argued that the term ‘arthritis’ should Professors Paul Dieppe and Mike Doherty. For patients only be used to describe inflammatory disorders who report symptoms or have positive findings on of the joint whilst ‘arthropathy’ should be used to the GALS screen it offers Regional Examination describe non-inflammatory disorders of the joint. of the Musculoskeletal System (REMS). The core However, the term ‘arthritis’ is in such widespread skills included in REMS are based on a consensus use to describe any disorder of the joint that, for the reached across a broad spectrum of UK clinicians in a purpose of this guide, it will be used in that sense. study led by Dr David Coady. Regional examinations Acknowledgements are structured using the look/feel/move/function We remain indebted to Professor Paul Dieppe – his approach making them easy to recall and perform. earlier version of this guide has been widely referred This new edition focuses on examination, but also to by medical students in the UK since 1991 and his includes tips on history taking and investigations text remains influential in this new edition. that will assist in making a diagnosis. It also includes We would like to thank David Coady and Mark paediatric examination incorporating work led by Lillicrap for their considerable time and commitment Professor Helen Foster which led to the development in updating the content, Pippa Watson for her of paediatric versions pGALS and pREMS. feedback and additional support during the filming These are based on the adult examinations with of the video material, and all those who took the additions to improve detection and identification of time to comment on the previous edition and early musculoskeletal problems in school-aged children. drafts of the new guide – Onebieni Ana, Ivan Cheuk I hope you will enjoy it and find it useful too. Over to Li, Nathan Ng, Jamie Nicholson, Sarah-Jane Ryan, you – time to get reading and then practising! Sophia Wakefield, Louise Warburton and Anita Williams. 02. INTRODUCTION 12 INTRODUCTION TO MUSCULOSKELETAL ASSESSMENT 12 INITIAL APPROACH 12 INTRODUCTION TO MUSCULOSKELETAL ASSESSMENT INTRODUCTION TO INITIAL MUSCULOSKELETAL APPROACH ASSESSMENT

It is estimated that musculoskeletal disorders Before considering a diagnosis, it is useful to try to account for approximately 30 per cent of a GP’s broadly categorise the symptoms and signs (from workload (Department of Health, 2006) and are the history and examination) by answering the the most common cause of repeat consultations in following key questions: primary care. About 30 per cent of those with any • Are the symptoms from the joint itself or the soft physical disability, and 60 per cent of those with a tissues (tendons/muscles)? severe disability, have a musculoskeletal disorder as • Is the condition acute or chronic? the primary cause of their problems. • Is the condition inflammatory or non- Clinical assessment skills – i.e. history taking and inflammatory? examination – are the key to making an accurate • What is the pattern of affected areas/joints? diagnosis and appropriately managing any patient • What is the impact of the condition on the presenting with a musculoskeletal problem. This patient’s life? guide aims to introduce you to the methods you • Are other systems involved? might use during the initial clinical assessment. It is not exhaustive or intended to replace direct clinical The answers to these questions should enable you teaching and experience, but to be used as an aid to to produce a succinct summary of the patient’s learning. condition and would lead you to a narrower differential diagnosis. An example of a patient summary produced using this method might be:

‘This patient has a chronic symmetrical inflammatory polyarthritis, mainly affecting the small joints of the hands and feet, which is causing pain, difficulty with dressing and hygiene, and is limiting their mobility.’ 13 INTRODUCTION TO MUSCULOSKELETAL ASSESSMENT e.g. e.g. Spine scoliosis Poly e.g. OA e.g. Chronic Mono Non-inflammatory Spine Poly Acute Mono e.g. torn torn e.g. cruciate cruciate ligament Arthritis e.g. AS e.g. Spine Poly e.g. RA e.g. Chronic Mono Inflammatory Spine Poly Acute septic Mono arthritis e.g. gout,e.g. Figure 1. of the arthritides:Classification joint); Mono = monoarticular (one joints) (several = polyarticular Poly 03. THE MUSCULOSKELETAL HISTORY 16 ARE THE SYMPTOMS FROM THE JOINT OR THE SOFT TISSUES? 17 IS THE CONDITION ACUTE OR CHRONIC? 18 IS THE CONDITION INFLAMMATORY OR NON-INFLAMMATORY? 20 WHA T IS THE PATTERN OF AFFECTED AREAS/JOINTS? 22 WHAT IS THE IMPACT OF THE CONDITION ON THE PATIENT’S LIFE? 23 ARE OTHER SYSTEMS INVOLVED? 16 THE MUSCULOSKELETAL HISTORY THE ARE THE SYMPTOMS MUSCULOSKELETAL FROM THE JOINT OR HISTORY THE SOFT TISSUES?

Clinical communication skills (of which This guide is primarily concerned with problems history taking is one part) are among the most arising from the joints – that is from the articular important skills for any healthcare practitioner and periarticular structures. (These structures to acquire – this can only be achieved through are shown in Figure 2, while Figures 3a and 3b regular practice. A good history backed up by represent diagrammatically the changes that clinical examination findings will lead you to a occur in the two main types of arthritis). However, diagnosis. Below we look more closely at the it is important to identify those cases where pain key questions that need to be addressed. may appear to arise from the joint but is in fact referred pain – for example, where the patient describes pain in the left shoulder, which might in fact be referred pain from the diaphragm, the neck, or perhaps ischaemic cardiac pain. In cases where examination reveals no abnormalities in the joint, other clues will be obtained by taking a thorough history. A common cause of widespread pain with normal joint examination for example is fibromyalgia.

Figure 2. Figure 3a. Figure 3b. X-ray and X-ray and X-ray and cross-sectional diagrammatic diagrammatic diagram of representation representation a synovial of an index of an index joint and its finger MCP finger periarticular joint affected MCP joint structures by rheumatoid affected by arthritis. osteoarthritis. • Normal joint space made • Osteopenia • Sclerosis up of cartilage (bone loss) (thickening • Smooth bone • Loss of joint of bone) contours space • Joint space • Erosions loss (cartilage loss) • Osteophyte formation (extra bone growth) 17 THE MUSCULOSKELETAL HISTORY IS THE CONDITION ACUTE OR CHRONIC?

You will need to listen to the patient’s history to find Musculoskeletal symptoms lasting more than six out: weeks are generally described as chronic. Chronic • When did the symptoms start and how have diseases may start insidiously and may have a they evolved? Was the onset sudden or gradual? variable course with remissions and exacerbations • Was the onset associated with a particular influenced by therapy and other factors. It may be event – for example, trauma or infection? helpful to represent the chronology of a condition graphically (see Figure 4). • Which treatments has the condition responded to? The way in which symptoms evolve and respond to treatment can be an important guide in making a diagnosis. Gout, for example, is characterised by acute attacks – these often start in the middle of the night, become excruciatingly painful within a few hours, and respond well to non-steroidal anti- inflammatory drugs (NSAIDs).

Figure 4. Graphs representing the PATIENT A.H. – ACUTE GOUT chronology of a condition: (a) for a patient with gout; (b) for a patient with rheumatoid arthritis.

PAIN New Year Party stubbed toe on a run

(a) JAN APR JUL OCT

PATIENT J.R. – INFLAMMATORY POLYARTHRITIS (RA)

flare change from sulfasalazine to methatrexate PAIN

bereavement condition worsening despite treatment stable on treatment

JAN APR JUL OCT (b) 18 THE MUSCULOSKELETAL HISTORY IS THE CONDITION INFLAMMATORY OR NON-INFLAMMATORY?

The main symptoms of musculoskeletal Pain conditions are pain, stiffness and joint As with all pain, it is important to record the site, swelling. character, radiation, and aggravating and relieving factors. Assessment of these symptoms and clinical assessment can allow differentiation to be made Patients may localise their pain accurately to the between inflammatory and non-inflammatory affected joint, or they may feel it radiating from the conditions. joint or even into an adjacent joint. In the shoulder, for example, pain from the acromioclavicular joint Inflammatory joint conditions, such as rheumatoid is usually felt in that joint, whereas pain from the arthritis (RA), are frequently associated with glenohumeral joint or rotator cuff is usually felt in prolonged early morning stiffness that eases with the upper arm. Pain from the knee may be felt in activity – whilst non-inflammatory conditions, such the knee but can sometimes be felt in the hip or the as osteoarthritis (OA) are associated with pain ankle. Pain due to irritation of a nerve will be felt in the more than stiffness, and the symptoms are usually distribution of the nerve – as in sciatica, for example. exacerbated by activity. The pain may localise to a structure near rather than in the joint – for example, the pain from tennis elbow will usually be felt on the outside of the elbow joint. The character of the pain is sometimes helpful. Is it sharp, deep, achy, burning or stabbing? Pain due to pressure on nerves often has a combination of numbness and tingling associated with it. Pain of a non-inflammatory origin is more directly related to use – the more you do the worse it gets – and may be relieved by rest. Pain can be sharp and stabbing or achy at times. Pain caused by inflammation is often present at rest as well as on use and tends to vary from day to day and from week to week in an unpredictable fashion. It flares up and then it settles down and can be associated with tenderness to the touch. Severe bone pain (suggestive of underlying malignancy) is often unremitting and persists through the night, disturbing the patient’s sleep. 19 THE MUSCULOSKELETAL HISTORY

Stiffness Joint swelling In general, inflammatory arthritis is associated with A history of joint swelling, especially if it is prolonged morning stiffness which is generalised intermittent, is normally a good indication of an and may last for several hours. The duration of the inflammatory disease process. Patients often morning stiffness is a rough guide to the activity of describe rings becoming tight or a sensation of the inflammation. walking on pebbles. Non-inflammatory arthritis, such as osteoarthritis of There are exceptions however. Nodal osteoarthritis, the knee, tends to cause localised stiffness which for example, causes bony, hard and non-tender may be short-lasting (less than 30 minutes) but can swelling in the proximal interphalangeal (PIP) and recur after sitting for short periods. distal interphalangeal (DIP) joints of the fingers. Swelling of the knee is also less suggestive of With inflammatory diseases such as rheumatoid inflammatory disease as it can also occur with arthritis, where joint destruction occurs over a trauma and in OA. Ankle swelling is a common prolonged period, the inflammatory component complaint, but this is more commonly due to may eventually become less active and give way oedema than to swelling of the joint. to secondary mechanical pain as a result of the damage. It is therefore sometimes difficult for patients to distinguish between pain and stiffness, so your questions will need to be specific.

Box 1. Features of inflammatory cf. degenerative symptoms

Inflammatory disease is

Less likely More likely

Pain after use/at end of day Pain worse after rest/in morning

Morning stiffness for <30 minutes Morning stiffness for >30 minutes

No systemic symptoms Systemic symptoms present

Chronic symptoms Acute/subacute presentation 20 THE MUSCULOSKELETAL HISTORY WHAT IS THE PATTERN OF AFFECTED AREAS/JOINTS?

The pattern of joint involvement is very helpful in Note, however, that this describes established defining the type of arthritis, as different patterns are disease and early RA can affect any pattern of associated with different diseases. joints. Common patterns of joint involvement include: Spondyloarthritides, such as psoriatic arthritis, Monoarticular – only one joint affected (e.g. septic are more likely to be asymmetrical and may be arthritis) associated with inflammatory symptoms, such as early morning stiffness involving the spine. Pauciarticular (or oligoarticular) – only a few joints affected (e.g. psoriatic arthritis) Osteoarthritis tends to affect weight-bearing joints Polyarticular – many joints affected (e.g. and the parts of the spine that move most (lumbar rheumatoid arthritis) and cervical). Axial – the spine is predominantly affected (e.g. Table 1 provides a summary of typical features of ankylosing spondylitis) some common musculoskeletal conditions. As well as the number of joints affected, it is useful to consider whether the large or small joints are involved, and whether the pattern is symmetrical or asymmetrical. Rheumatoid arthritis, for example, is a polyarthritis (it affects lots of joints) that tends to be symmetrical (if it affects one joint, it will affect the same joint on the other side), and if it affects one of a group of joints it will often affect them all, for example, the metacarpophalangeal (MCP) joints. 21 THE MUSCULOSKELETAL HISTORY

Fibromyalgia Chronic Female: 7:1 male 30–50Age Widespread pain quality Poor sleep of soft Tender tissue ‘trigger points’ on examination Multiple symptoms

Common non-inflammatory conditions Osteoarthritis Osteoarthritis (OA) Chronic OA Hand common more females in Usually ≥45 age Normally polyarticular Hands, knees, hip and feet common most or Heberden’s Bouchard’s nodes Crepitus

Female: Female: 2:1 male Usually andshoulder girdle pelvic Severe Severe stiffness May have lap overlap temporal with arteritis Polymyalgia Polymyalgia rheumatica (PMR) acute/ Usually subacute

Female: male 1:3 rare Very in pre- menopausal women Monoarthritis most – commonly ankle,MTP, knee Risk factors: factors: Risk obesity, alcohol, diuretic treatment Gout acute Usually

Any age be Can monoarthritis assymetrical or polyarthritis spine or Tendon insertion insertion Tendon (enthesitis) pain Psoriasis Inflammatory disease bowel Uveitis Seronegative Seronegative arthritides reactive (e.g. and psoriatic arthritis) Acute/subacute chronic Or

Common inflammatory conditions Female: 3:1 male Any age Usually symmetrical feet and hands Raynaud’s syndrome eyes Dry mouth and Systemic upset Rheumatoid Rheumatoid (RA)arthritis Usually acuteUsually or subacute

Onset of joint gender Typical Typical Pattern age and age Other clues Other involvement Table 1. look to What for: diagnostic tips 22 THE MUSCULOSKELETAL HISTORY WHAT IS THE IMPACT OF THE CONDITION ON THE PATIENT’S LIFE?

Understanding the impact of the disease their ideas, concerns and expectations? Later on the patient is crucial to negotiating negotiations with the patient on balancing the a suitable management plan. risks and benefits of an intervention will be greatly affected by the patient’s priorities. Ask open-ended questions about functional issues and difficulty with day-to-day activities. It may All healthcare practitioners should have an be easiest to get the patient to describe a typical awareness of the relationship between functional day, from getting out of bed to washing, dressing, loss, limitation of activity, and restriction of toileting etc. Potentially sensitive areas – such as participation as indicated in the World Health hygiene or sexual activity, mood, depression and Organization’s International Classification of anxiety – should be approached with simple, direct, Functioning, Disability and Health (see Figure 5). open questions. The impact of the disease on the Being unable to fully flex a finger (loss of function) patient’s employment will be crucial. might lead to difficulty, for example, with fastening buttons (activity) which might have a minor impact A patient’s needs and aspirations are an important on general life (participation). The same loss of part of the equation and will influence their ability function, however, might prevent a pianist from to adapt to the condition. Questioning around the playing (activity) which, for a professional musician, things a person would like to do, but is currently might have a significant impact on his/her way of life unable to, may pinpoint key issues. What are (participation). (see Figure 5).

Figure 5. A model of disability – the relationship between Health condition loss of function, limitation of activity and (disorders, diseases, injuries) restriction of participation. Based on the World Health Organization’s International Classication of Functioning, Disability and Health. Disability and function are the result of the interactions between a health condition and contextual factors (environmental and personal factors).

Body functions Participation & structure (RESTRICTION) (IMPAIRMENT) Activity (LIMITATION)

Environmental factors Personal factors 23 THE MUSCULOSKELETAL HISTORY Arthritis may occur on a background of other on a background occur Arthritis may illnesses other consider to it is important and ongoing health issues, with an particularly of A combination ageing population. increasingly than either one alone, will be worse problems two be will therefore and the impact the patient on be affected may In addition, other conditions greater. the arthritis – for for prescribed the treatments by limit the disease may of liver the presence example, use of disease-modifying inflammatory drugs for arthritis, because most of thesedrugs can upset the liver.

Fatigue and depression may be common in any be common may and depression Fatigue is functional loss or chronic there arthritis where must include the history pain. A comprehensive as as well questions all systems for usual screening of known complications to specific enquiries relating disorders. specific musculoskeletal Inflammatory arthritis often involves other often arthritis involves Inflammatory lungs and eyes, including the skin, systems with inflammatory In addition, patients kidneys. suchsymptoms general from disease often suffer night and loss,as malaise, weight mild fevers Osteoarthritis, the in contrast,sweats. to is limited and is not associated with system musculoskeletal would symptoms Systemic immune activation. not be expected. therefore INVOLVED? INVOLVED? SYSTEMS SYSTEMS ARE OTHER OTHER ARE 04. THE MUSCULOSKELETAL EXAMINATION 26 THE MUSCULOSKELETAL SCREEN: ‘GALS’ QUESTIONS AND EXAMINATION 34 PERFORMING A REGIONAL EXAMINATION OF THE MUSCULOSKELETAL SYSTEM ‘REMS’ 26 THE MUSCULOSKELETAL EXAMINATION THE MUSCULOSKELETAL SCREEN: ‘GALS’ QUESTIONS AND EXAMINATION

So far, the discussions of history taking above Routine screening questions have assumed that the patient has come to see Screening questions that assess the musculoskeletal you with joint-related pain. However, it is also system should be incorporated into the routine important to make a routine assessment of any systemic enquiry of every patient. As discussed, musculoskeletal problems irrespective of their the main symptoms arising from disorders of the presenting symptoms. musculoskeletal system are pain, stiffness, swelling, and associated functional problems. The screening The GALS – Gait, Arms, Legs and Spine – screen questions we use to directly address these areas are: consists of three simple questions and a brief examination developed to detect significant musculoskeletal abnormalities (Doherty et al, 1992). Question Rationale It can also be used as a screening tool prior to a Do you have any pain, focuses on the more focused examination. swelling or stiffness common symptoms in your muscles, joints of a musculoskeletal or back? problem Can you dress yourself focuses on upper completely without any limb function difficulty? Can you walk up and focuses on lower down stairs without any limb function difficulty?

A patient who has no pain or stiffness, and no difficulty with dressing or with climbing stairs is unlikely to be suffering from any significant musculoskeletal disorder. If the patient does have pain or stiffness, or difficulty with either of these activities, then a more detailed history should be taken.

Watch the real time run through and step by step GALS examination videos. www.versusarthritis.org/GALSexamination 27 THE MUSCULOSKELETAL EXAMINATION 28 THE MUSCULOSKELETAL EXAMINATION THE SCREENING EXAMINATION (‘GALS’)

This examination was devised for use in routine Introduction clinical assessment and takes 1–2 minutes to It is important to introduce yourself, explain to perform. It involves inspecting carefully for the patient what you are going to do, gain verbal joint swelling and abnormal posture, as well as consent to examine, and ask the patient to let you assessing the joints for normal movement. know if you cause them any pain or discomfort at any time. In all cases it is important to make the If an abnormality of an individual area is noted in patient feel comfortable about being examined and the GALS screen, that area should be examined in this extends to the clothing they wear and level of more detail using the relevant regional examination exposure. routine (REMS). The GALS screen is not designed to tell you what the problem is, only that there is a A good musculoskeletal examination relies on problem that requires further assessment. patient cooperation, in order for them to relax their muscles, but also the ability to view and compare The sequence in which these four elements (Gait, joints and muscle groups if important clinical signs are assessed can be varied – Arms, Legs and Spine) are not to be missed. in practice, it is usually more convenient to complete the elements for which the patient is standing before asking the patient to lie onto the couch.

FIGURE 6. With the patient in the anatomical position, observe from behind, from the side, and from the front, checking for: Shoulder muscle bulk and symmetry

Spinal alignment

Full elbow extension

Gluteal muscle bulk and symmetry

Quadriceps bulk and symmetry Popliteal swelling or abnormalities

Calf muscle bulk and symmetry

Forefoot abnormalities Hindfoot abnormalities 29 THE MUSCULOSKELETAL EXAMINATION

Watch the real time run through and step by step GALS examination videos. www.versusarthritis.org/GALSexamination

Gait - popliteal swelling • Ask the patient to walk a few steps, turn and walk - abnormalities in the feet such as an excessively back. Observe the patient’s gait for symmetry, high or low arch profile, clawing/retraction of the smoothness and the ability to turn quickly. toes and/or presence of hallux valgus (see Figure • With the patient standing in the anatomical 6). position, observe from behind, from the side, and from in front for: - bulk and symmetry of the shoulder, gluteal, quadriceps and calf muscles - limb alignment - alignment of the spine - equal level of the iliac crests - ability to fully extend the elbows and knees

Cervical lordosis

Thoracic kyphosis

Lumbar lordosis TO Knee flexion/ 1 2 hyperextension MINUTES EXAMINATION TIME 30 THE MUSCULOSKELETAL EXAMINATION THE SCREENING EXAMINATION (‘GALS’)

Arms • Look at the palms for muscle bulk and for any • Ask the patient to put their hands behind their visual signs of abnormality. head. This assesses shoulder abduction (the first • Ask the patient to make a fist. Visually assess movement affected by rotator cuff problems) and power grip, hand and wrist function, and range of external rotation (the first movement affected by movement in the fingers. glenohumeral problems). It also assesses elbow • Ask the patient to squeeze your fingers. Assess flexion. grip strength. • Ask the patient to straighten out their arms • Ask the patient to bring each finger in turn to completely to assess full elbow extension (the first meet the thumb. Assess fine precision pinch movement affected by elbow problems). (which is important functionally). • With the patient’s hands held out, palms down, • Gently squeeze across the metacarpophalangeal fingers outstretched, observe the backs of the (MCP) joints to check for tenderness suggesting hands for joint swelling and deformity. Inspect the inflammation within the joints (see figure 7). (Be nails and skin at the same time. sure to watch the patient’s face for non-verbal • Ask the patient to turn their hands over (the signs of discomfort.) movement of supination assesses both wrist and elbow movement).

FIGURE 7. FIGURE 8. MCP squeeze test. Gently squeeze across the metacarpophalangeal Patellar tap test. Slide your hand down the patient’s thigh, compressing joints to check for tenderness suggesting inflammation within the joints. the suprapatellar pouch. This forces any effusion behind the patellar. With two or three fingers of the other hand, push the patella down gently. In a positive test the patella will bounce and tap. 31 THE MUSCULOSKELETAL EXAMINATION   S F joints to check for tenderness check for suggesting to joints the watch to joint disease. (Beinflammatory sure signs of discomfort.) for face patient’s localised or general swelling, deformity such as such deformity swelling, localised or general and callosities clawing of the toes, hallux valgus, under theon the soles occur which typically (MTP). joints metatarsophalangeal  Small effusions may not be detected with the with not be detected effusions may Small may test and a sweep/bulge test tap patella the test, a sweep/bulge be useful. For stroke (towards medial knee side of the upwards the medial empty pouch) to the suprapatellar the lateral then stroke of fluid, compartment 9). The Figure (see (distally) side downwards a bulge of fluid and produce refill medial side may an effusion. indicating (MTP) metatarsophalangeal the across queeze inspect for thefeet theendofcouch, rom

- • •

e flexed to 90°, holding the 90°, to e flexed

 For a patellar tap, slide your hand down the thigh, slide your tap, a patellar For pouch so the suprapatellar pushing down over behind the patella. forced effusion is any that the upper pole of the patella, reach When you Use pressure. and maintain hand there your keep push of the other hand to fingers or three two 8). Does it Figure down gently (see the patella of the presence and ‘tap’? This indicates bounce effusion. large a relatively

P With the hip and kne With the pa patellar tap or a sweep/bulge test: or a sweep/bulge tap patellar knee and ankle to guide the movement,knee and ankle to assess is often (this of each hip in flexion rotation internal by hip problems). affected movement the first flexion and extension of both knees, over feeling and extension flexion during the crepitus for joint line the tibiofemoral movements. -   

aknee effusionusingeither acheck for erform a

assesstient lyingonthecouch, full FIGURE 9. towards the medial side of the knee upwards test. Stroke Sweep/bulge pouch. This empties of fluid. The the medial compartment the suprapatellar and refill The medial side may (distally). side downwards the lateral stroke of an effusion. the presence a bulge of fluid, indicating produce

Legs • www.versusarthritis.org/GALSexamination Watch the real time run through and step step by GALS examination videos. • • 32 THE MUSCULOSKELETAL EXAMINATION THE SCREENING EXAMINATION (‘GALS’)

Spine • With the patient standing, inspect the spine from behind for evidence of scoliosis, and from the side for abnormal lordosis or kyphosis. Note any obvious asymmetry by looking from behind initially at the shoulders, then the pelvis, the backs of the knees and then the ankle. • Ask the patient to tilt their head to each side, bringing the ear towards the shoulder. This assesses lateral flexion of the neck, which is sensitive in the detection of early neck problems. • Ask the patient to bend to touch their toes. This movement is the first movement affected by lumbar spinal problems and is important functionally (for dressing). However, it can be achieved by relying on good hip flexion, so it is important to palpate for normal movement of the vertebrae. Assess lumbar spine flexion by placing two or three fingers on the lumbar vertebrae. Your fingers should move apart on flexion and back together on extension (see Figure 10).

Figure 10. Assessing lumbar spine flexion. Place two or three fingers on the lumbar vertebrae. Your fingers should move apart on flexion and back together on extension. 33 THE MUSCULOSKELETAL EXAMINATION

If you have been alerted to a musculoskeletal a musculoskeletal to been alerted have If you questions, your the screening – by problem of the complaints or the spontaneous examination history a detailed take will need to – you patient conduct should also You described above). (as this is – joints of relevant examination a regional described in the sections follow. that Recording the findings from the from findings the Recording (GALS) screening examination and negative both positive record to It is important of or absence The presence findings in the notes. the – in or movement changes – in appearance For gait, legs or spine should be arms, recorded. NAD’ is sufficient. If there ‘GALS: a normal result of abnormalities or restriction such as swelling are a brief with movement, these should be recorded note.descriptive 34 THE MUSCULOSKELETAL EXAMINATION PERFORMING A REGIONAL EXAMINATION OF THE MUSCULOSKELETAL SYSTEM (‘REMS’)

Regional examination of the musculoskeletal system Introduce yourself refers to the more detailed examination that should As highlighted in the GALS screening assessment, be carried out once an abnormality has been it is important to introduce yourself, explain to the detected either through the history or through the patient what you are going to do (and why), gain screening examination (GALS). REMS involves the verbal consent to examine, and ask the patient to let examination of a group of joints that are linked by you know if you cause them any pain or discomfort function, and may sometimes require a detailed at any time. neurological and vascular examination. REMS was born out of a desire to standardise and Look simplify examination of the musculoskeletal system, The examination should always start with a visual allowing for more systematic teaching and learning inspection of the exposed area at rest. Compare for medical students. It is now being used more one side with the other, checking for symmetry. You widely within medical practice and members of should look specifically for skin changes, muscle the wider musculoskeletal team. It was developed bulk, and swelling in and around the joint. Look also through a national consensus process involving UK for deformity in terms of alignment and posture of consultants in rheumatology, orthopaedics and care the joint. of the elderly, and selected general practitioners (Coady et al, 2004). It led to an agreed set of ‘core’ skills (see Appendix 2). Feel For the purposes of this guide (and the Using the back of your hand, feel for skin accompanying videos) the REMS examination temperature across the joint line and at relevant has been divided into seven areas, each of neighbouring sites. Any swellings should be which is described in detail below. assessed for fluctuance and mobility. The hard, bony However, it should be remembered that this is an swellings of osteoarthritis should be distinguished artificial division and that one group of joints may from the soft, rubbery swellings of inflammatory joint need to be examined in conjunction with another disease. Tenderness is an important clinical sign group (e.g. the shoulder and cervical spine). to elicit – both in and around the joint. Identifying inflammation of a joint (synovitis) relies on detecting There are some key stages which need to be the triad of warmth, swelling and tenderness. completed during an examination of the joints in any part of the body: • Introduce yourself. • Look at the joint(s). • Feel the joint(s). • Move the joint(s). • Test function of the joint(s). • Perform special tests if relevant. 35 THE MUSCULOSKELETAL EXAMINATION

Watch the video introducing how to perform a regional examination of the musculoskeletal system: www.versusarthritis.org/introductiontoREMS

Function Move The full range of movement of the joint should It is important to make a functional assessment of be assessed. Compare one side with the other. the joint – for example, in the case of limited elbow Generally, both active movements (where the flexion, does this make it difficult for the patient to patient moves the joint themselves) and passive bring their hands to their mouth? In the case of the movements (where the examiner moves the joint) lower limbs, function mainly involves gait and the should be performed. If there is a loss of active patient’s ability to get out of a chair and walk. movement, but passive movement is unaffected, this may suggest a problem with the muscles, tendons Special tests or nerves rather than the joints themselves, or it may Several additional tests may be used by experienced be an effect of pain in the joints. In certain instances, musculoskeletal practitioners as an adjunct to joints may move further than expected – this is the REMS examination. Known as ‘special tests’, called hypermobility. these are often performed towards the end of the examination and would follow on from ‘Move’ and It is important to elicit a loss of full flexion or a loss ‘Function’. of full extension as either may affect function. A loss of movement should be recorded as mild, moderate Covering all possible tests, including their specificity or severe. Specialists may often document how and sensitivity in different scenarios, is beyond the many degrees of movement are restricted since scope of this guide. However, a small number of this allows future comparison to be made. The tests that may be appropriate for undergraduates quality of movement should also be recorded, with have been included and highlighted in the sections reference to abnormalities such as increased muscle that follow. tone or the presence of crepitus. With experience it is possible to assess the quality particularly at the extremes or ‘end range’ of movement. A degenerative joint often has a more solid ‘end feel’. 36 THE MUSCULOSKELETAL EXAMINATION EXAMINATION OF THE HAND AND WRIST

This should normally take place with the With the patient’s hands palms up: patient’s forearms exposed to above the • L ook again for muscle wasting – if present, is it in elbows. The patient’s hands should be resting both the thenar and hypothenar eminences? If it on a pillow as it can be painful for patients with is only in the thenar eminence, then perhaps the elbow or shoulder problems to hold their hands patient has carpal tunnel syndrome. Look for signs up for long periods. of palmar erythema. Look at the wrist for a carpal tunnel release scar. Look • L ook at the elbow for rheumatoid nodules, With the patient’s hands palms down: psoriatic plaques and surgical scars. • Look at the posture and check for obvious swelling, deformity, muscle wasting and scars. Feel • Look at the skin for thinning and bruising With the patient’s hands palms up: (possible signs of long-term steroid use) or rashes. • Feel for peripheral pulses (ischaemia could be •  Look at the nails for psoriatic changes such as causing pain). pitting or onycholysis (see Figure 11), and evidence • Feel for bulk of the thenar and hypothenar of nailfold vasculitis. eminences and for tendon thickening. •  Decide whether the changes are symmetrical or • Assess median and ulnar nerve sensation asymmetrical. by gently touching over both the thenar and • Do the changes mainly involve the small joints hypothenar eminences, and the index and little (PIPs and DIPs, MCPs etc) or the wrists? fingers respectively – if not normal and equal, this It is often helpful to structure the inspection from may indicate an entrapment neuropathy. proximal to distal to ensure that all areas are systematically assessed. Ask the patient to turn their hands back over, so their palms are face down: Ask the patient to turn their hands over: • Assess radial nerve sensation by light touch over • Does the patient have problems with this due to the thumb and index finger web space. proximal or distal radioulnar joint involvement? • Using the back of your hand, assess skin temperature at the patient’s forearm, wrist and MCP joints. Are there differences?

FIGURE 11. Fingernails affected by psoriasis: (a) pitting; (b) onycholysis

(a) (b) 37 THE MUSCULOSKELETAL EXAMINATION

Watch the hand and wrist examination video: www.versusarthritis.org/handandwristexamination

• Gently squeeze across the row of MCP joints to tucking the fingers into the palm, this may be an early assess for tenderness (watching the patient’s face sign of tendon or small joint involvement. Move the for signs of discomfort). fingers passively to assess whether the problem is • Bimanually palpate any MCP joints and any PIP with the tendon or nerves, or in the joint. or DIP joints that appear swollen or painful. Is • Assess wrist flexion and extension actively (e.g. by there evidence of active synovitis? (The joints making the ‘prayer’ sign) and passively (see Figure will be warm, swollen and tender and may have a 12). ‘rubbery’ feel, or you may even detect effusions). • In patients where the history and examination • Are there hard, bony swellings? Check for suggest carpal tunnel syndrome perform Phalen’s squaring of the carpometacarpal (CMC) joint of test (forced flexion of the wrists for 60 seconds) the thumb and for Heberden’s nodes on the DIPs. – in a positive test this reproduces the patient’s There may be evidence of previous synovitis symptoms. (thickened, rubbery but non-tender joints). • Assess power of the muscles innervated by • Compare one joint with another, or with your own, the median and ulnar nerves. This can be done to decide whether the small joints are normal. by abduction of the thumb, and finger spread, • Bimanually palpate the patient’s wrists. respectively. • Finally run your hand up the patient’s arm along the ulnar border to the elbow. Feel and look for Function rheumatoid nodules or psoriatic plaques on the • A sk the patient to grip your two fingers to assess extensor surfaces. power grip. • A sk the patient to pinch your finger. This assesses Move pincer grip, which is very important functionally. •  Ask the patient to straighten their fingers fully • A sk the patient to pick a small object such as a (against gravity). If the patient is unable to do this coin out of your hand or check their ability to undo it may be due to joint disease, extensor tendon buttons. This assesses pincer grip and function. rupture or neurological damage – this can be assessed by moving the fingers passively. •  Ask the patient to make a fist. If they have difficulty

FIGURE 12. The ‘prayer sign’ assesses wrist flexion and extension: If the patient’s history and examination suggest carpal tunnel syndrome, Phalen’s test (forced flexion of the wrist for 60 seconds) may reproduce the patient’s symptoms. 38 THE MUSCULOSKELETAL EXAMINATION EXAMINATION EXAMINATION OF THE ELBOW OF THE SHOULDER

Look Look • Look from the front for the carrying angle, and • With the shoulder fully exposed, inspect the from the side for flexion deformity. patient in stance from the front, from the side •  Look for scars, rashes, muscle wasting, rheumatoid and from behind, checking for symmetry, posture, nodules, psoriatic plaques, and swellings such as muscle wasting and scars. olecranon bursitis. Feel Feel • Assess the temperature over the front of the • Using the back of your hand, feel the temperature shoulder (the glenohumeral joint). across the joint and the forearm. • Palpate the bony landmarks for tenderness, • Hold the forearm with one hand and, with the starting at the sternoclavicular joint, then the elbow flexed to 90°, palpate the elbow, feeling clavicle, acromioclavicular joint, acromion process the head of the radius and the joint line with your and around the scapula. thumb. If there is swelling, is it fluctuant? Synovitis • Palpate the glenohumeral joint line – anterior and is usually felt as a fullness between the olecranon posterior. and the lateral epicondyle. • Palpate the muscle bulk of the supraspinatus, • Palpate the medial and lateral epicondyles (for infraspinatus and deltoid muscles. golfer’s and tennis elbow respectively) and the olecranon process for tenderness and evidence of bursitis.

Move •  Does the elbow extend fully and flex fully? Assess both actively and passively, and compare one side with the other. If there is limitation, note how severe it is. • Assess pronation and supination, both actively and passively, feeling for crepitus.

Function • An important function of the elbow is to allow the hand to reach the mouth. Other functionally important movements (such as hands behind head) will have been assessed during the screening examination.

Watch the elbow examination video: www.versusarthritis.org/elbowexamination 39 THE MUSCULOSKELETAL EXAMINATION

Watch the shoulder examination video: www.versusarthritis.org/shoulderexamination

Move Function • Ask the patient to put their hands behind their • Function of the shoulder includes getting the head to assess external rotation, and then behind hands behind the head and back. This is important their back to assess internal rotation, comparing in washing, toileting and other self-care. If this one side with the other. If there is a restriction in has not been assessed during the screening the latter movement, describe how far the patient examination, it should be done now. can reach – for example, to the lumbar, lower thoracic or mid-thoracic level. • With the elbow flexed at 90° and tucked into the patient’s side, assess external rotation of the shoulder. Loss of external rotation may indicate adhesive capsulitis (‘frozen shoulder’) or other glenohumeral joint problems. • Ask the patient to raise their arms behind them and to the front. Assess flexion and extension. • Ask the patient to abduct the arm to assess for a painful arc (between 10° and 120°) (see Figure 13). Can you passively take the arm further? Be sure to assess abduction from behind the patient and observe scapular movement. Restricted glenohumeral movement can be compensated for by scapular/thoracic movements.

FIGURE 13. Abduction of the arm to assess for a painful arc.

120°

10° 40 THE MUSCULOSKELETAL EXAMINATION EXAMINATION OF THE HIP

Look Feel • With the patient standing, assess for muscle • Palpate over the greater trochanter for tenderness wasting (gluteal muscle bulk in particular). (suggestive of trochanteric bursitis) and in the • With the patient lying flat and face up, observe the groin for true hip joint problems. legs, comparing one side with the other – is there an obvious flexion deformity of the hip suggesting Move osteoarthritis? • With the knee flexed at 90°, assess full hip flexion, • If there is a suggestion of leg length disparity, comparing one side with the other and watching assess true leg lengths using a tape measure. the patient’s face for signs of pain. Measurements are taken from the anterior superior iliac crest to the medial malleolus • Assess for a fixed flexion deformity of the hip of the ankle on the same side. Compare the by performing the Thomas test. Keep one hand measurements. In a fractured neck of femur, the under the patient’s back to ensure that normal leg is shortened and externally rotated. There lumbar lordosis is removed. Fully flex one hip may also be an indication of this on the patient’s and observe the opposite leg (see Figure 14). If footwear with excessive wear on one heel. it lifts off the couch, then there is a fixed flexion deformity in that hip. (As the pelvis is forced to • Check for scars overlying the hip. tilt a normal hip would extend allowing the leg to remain on the couch.)

Figure 14. Thomas test for fixed flexion deformity of the hip. Keep one hand under the patient’s back to ensure that there is no lumbar lordosis. Fully flex one hip. If the opposite leg lifts off the couch, there is a fixed flexion deformity. (As the pelvis tilts a normal hip would extend allowing the leg to remain on the couch.) 41 THE MUSCULOSKELETAL EXAMINATION

Watch the hip examination video: www.versusarthritis.org/hipexamination

• With the hip and knee flexed at 90°, assess Function internal and external rotation of both hips. This is • A sk the patient to walk – look for an antalgic often limited in hip disease and internal rotation is or Trendelenburg gait. An antalgic gait simply frequently the first movement affected (see GALS means a painful gait, normally resulting in a limp. A screen). Trendelenburg gait results from proximal muscle • Assess the hip and proximal (gluteal) muscle weakness and commonly results in a ‘waddling’ strength by performing the Trendelenburg test. walk. This involves the patient alternately standing on each leg alone. In a negative test, the pelvis remains level or even rises. In an abnormal test, the pelvis will dip on the contralateral side. (See Figure 15.).

Figure 15. The Trendelenburg test assesses hip and gluteal muscle strength. In a normal test, the pelvis remains level. In an abnormal test, the pelvis Normal dips on the contralateral side. Abnormal 42 THE MUSCULOSKELETAL EXAMINATION EXAMINATION OF THE KNEE

Look • From the end of the couch and with the patient’s Feel legs straight, observe the knees, comparing one • Using the back of your hand, feel the skin with the other for symmetry and alignment. temperature, starting with the mid-thigh and • Is the posture of the knee normal? Look for comparing it to the temperature over the knee. valgus deformity – where the leg below the knee Compare one knee to the other. is deviated laterally (knock-kneed) – and for • Palpate for tenderness along the borders of varus deformity – where the leg below the knee is the patella. deviated medially (bow-legged). • With the knee flexed to 90°, palpate for • Check for a knee flexion deformity (distinguishing tenderness and swelling along the joint line from this from hip flexion deformity by examining hip the femoral condyles to the inferior pole of the movements as above). patella, then down the inferior patella tendon to • Check for muscle wasting of the quadriceps the tibial tuberosity. or scars. • Feel behind the knee for a popliteal (Baker’s) cyst. • Look for redness suggesting inflammation • Assess for an effusion by performing either a or infection. sweep/bulge test or a patellar tap, as described in • Look for obvious swelling. the section on the GALS screening examination • Check for a rash suggesting psoriasis (usually on (see Figures 8 and 9 on p.30-31). the extensor surface of the knee). Note: Popliteal swellings, varus and valgus deformities may be more apparent with the patient weight-bearing.

Figure 16. Anterior draw test. Place both hands around the upper tibia, with your thumbs over the tibial tuberosity and your index fingers tucked under the hamstrings to make sure these are relaxed. Stabilise the lower tibia with your forearm and gently pull the upper tibia forward. There should normally be a small degree of movement; more substantial movement suggests laxity of the anterior cruciate ligaments. 43 THE MUSCULOSKELETAL EXAMINATION

Watch the knee examination video: www.versusarthritis.org/kneeexamination

Move • Ask the patient to flex the knee as far as possible (see Figure 16). In a relaxed, normal patient there to assess active movement. Making sure the is normally a small degree of movement. More patient is fully relaxed, assess passive movement. significant movement suggests anterior cruciate This is done by placing one hand on the knee ligament laxity. (feeling for crepitus) and flexing the knee as far as • A ssess medial and lateral collateral ligament possible, noting the range of movement. Assess stability by flexing the knee to 15° and alternately full flexion and extension of the knees, comparing stressing the joint line on each side. Place one one to the other. hand on the opposite side of the joint line to that • With the knee flexed to 90°, check the stability of which you are testing and apply force to the lower the knee ligaments. Look initially from the side of tibia (see Figure 17). This may be done with the the knee, checking for a posterior sag or step- leg on the couch or with the lower tibia supported back of the tibia, suggesting posterior cruciate on the side of the examiners hip ligament damage. • Perform an anterior draw test. Place both hands Function round the upper tibia, with your thumbs over • A sk the patient to stand and then walk a few the tibial tuberosity and index fingers tucked steps, looking again for a varus or valgus deformity under the hamstrings to make sure these are (see Figure 18). relaxed. Stabilise the lower tibia with your forearm and gently pull the upper tibia forward

Figure 17. Assessing medial and lateral collateral ligament stability. With the patient’s leg on the couch or supported on your pelvis, place one hand on the Figure 18. opposite side of the joint line to that which you are testing and alternately With the patient standing, assess stress the joint line on each side by applying gentle force on the tibia. for a varus or valgus deformity.

Valgus Varus 44 THE MUSCULOSKELETAL EXAMINATION EXAMINATION OF THE FOOT AND ANKLE

Look Feel With the patient sitting on the couch, their feet • Assess the temperature over the forefoot, midfoot overhanging the end of it: and ankle. • Observe the feet, comparing one with the other • Check for the presence of a peripheral pulse for symmetry. palpating the dorsalis pedis on the dorsum of the • Look specifically at the forefoot for nail changes foot. or skin rashes, such as psoriasis. • Gently squeeze across the MTP joints, watching • Look for alignment of the toes, evidence of hallux the patient’s face for signs of pain or discomfort. valgus of the big toe or subluxation (partial • Palpate the midfoot, the ankle and subtalar joints dislocation) of the joints. for tenderness. • Look for clawing of the toes, joint swelling and callus formation which typically occurs over the Move metatarsophalangeal joints on the plantar aspect and over the dorsum and/or apex of the toes. • Assess, both actively and passively, movements of inversion and eversion at the subtalar joint, plus • Look at the underside or plantar surface for callus dorsi- and plantar flexion at the big toe formation. and ankle joint checking for any restrictions • Look at the patient’s footwear. Check for and/or crepitus. abnormal or asymmetrical wearing of the sole or • Movement of the mid-tarsal joints can also be upper, for evidence of poor fit or the presence of performed by fixing the heel with one hand and, special insoles. with the other hand, passively inverting and With the patient weight-bearing: everting the forefoot • Look again at the forefoot for toe alignment and whether they are in contact with the ground. Function • Look at the midfoot for foot arch position • If not already done, assess the patient’s gait, (a low arch profile in a patient with normal joint watching for the normal cycle of heel strike, movement should resolve when standing on stance, and toe-off, speed of walking and turning. tip toes). • From behind, look at the hindfoot for Achilles tendon thickening or swelling. • Look for normal alignment of the hindfoot (see Figure 18). Disease of the ankle or subtalar joint may lead to a varus or valgus deformity.

Watch the foot and ankle examination video: www.versusarthritis.org/footandankleexamination 45 THE MUSCULOSKELETAL EXAMINATION

EXAMINATION Watch the spine examination video: OF THE SPINE www.versusarthritis.org/spineexamination

Look • Observe the patient standing. Look initially (rotation); bring their chin towards their chest from behind the patient for any obvious muscle (flexion); and tilt their head backwards (extension). wasting, asymmetry, or scoliosis of the spine. As highlighted in the GALS screen, lateral flexion • Look from the side for normal cervical lordosis, is usually the first movement to be restricted. thoracic kyphosis, and lumbar lordosis. • With the patient sitting on the edge of the couch to fix their pelvis and their arms crossed in front of Feel them, assess thoracic rotation (with your hands on the patient’s shoulders to guide the movement) • Feel down the spinal processes from the top of (see Figure 19). the neck to the sacrum and over the sacroiliac •  With the patient lying as flat as possible, perform joints for alignment and tenderness. straight leg raising (see Figure 20). Dorsiflexion of the • Palpate the paraspinal muscles for tenderness. foot with the leg raised may exacerbate the pain from a nerve root entrapment or irritation such as that Move caused by a prolapsed intervertebral disc. • Assess lumbar flexion and extension by placing two or three fingers over the lumbar spine. Ask Function the patient to bend to touch their toes. Your •  A brief neurovascular examination should be carried fingers should move apart during flexion and back out including assessment of upper and lower limb together during extension (see Figure 10 on p.32). reflexes, dorsiflexion of the big toe, and assessment • Ask the patient to run each hand in turn down the of peripheral pulses. If there has been any indication outside of the adjacent leg to assess lateral flexion from the history of a relevant abnormality, a full of the spine. neurological and vascular assessment – including • Next, assess the cervical spine movements. Ask sensation, tone and power – should also be made. the patient to: tilt their head to each side, bringing the ear towards the adjacent shoulder (lateral flexion); turn their head to look over each shoulder

Figure 19. Figure 20. With the patient seated on Dorsiflexion of the foot with the couch to fix the pelvis, the leg straight and raised assess thoracic rotation. may exacerbate pain from a nerve root entrapment or prolapsed disc. 46 THE MUSCULOSKELETAL EXAMINATION RECORDING THE FINDINGS FROM THE REGIONAL EXAMINATION

The positive and significant negative findings of the REMS examination are usually documented longhand in the notes. You may find it helpful to document joint involvement on a homunculus such as the one shown in Figure 21. In electronic patient records there is often a similar homunculus for ease of documentation. The total number of tender and swollen joints can be used for calculating a Disease Activity Score (DAS) – these are useful in monitoring disease severity and response to treatment over time. 47 THE MUSCULOSKELETAL EXAMINATION

Figure 21. Printed homunculus for annotation. 05. INVESTIGATIONS 50 IMAGING OF BONES AND JOINTS 51 BLOOD TESTS 51 SYNOVIAL FLUID ANALYSIS 50 INVESTIGATIONS INVESTIGATIONS IMAGING OF BONES AND JOINTS

There are three main types of investigations that A plain x-ray of the affected joint is one of the can be used to further classify musculoskeletal most useful investigations. Changes that occur presentations: on plain x-ray can be characteristic of specific • imaging of bones and joints musculoskeletal diseases such as rheumatoid • blood tests arthritis, osteoarthritis and gout. Most changes occur over a prolonged period and x-rays can • synovial fluid analysis. therefore provide a useful historical record. This guide aims to outline the methods you might Ultrasound is becoming increasingly widely used, use in the initial clinical assessment and so a particularly in identifying early joint inflammation comprehensive overview of investigations is not (see Figures 22, 23), although it doesn’t necessarily possible here. However, this section gives a brief add significantly to the clinical assessment in introduction to some of the investigations that patients with clinical signs. Other investigations might be considered. – including magnetic resonance imaging (MRI), computerised tomography (CT) scanning, isotope bone scans and dual-energy x-ray absorptiometry (DEXA) scans (for osteoporosis) – all have an important role.

Figure 22. Figure 23. Grey-scale scan of early osteoarthritis of the 1st Power Doppler scan of the 1st metatarsophalangeal joint, showing a metatarsophalangeal joint, showing a small anechoic effusion small anechoic effusion surrounded by a grade 3 Doppler signal that with some hypoechoic synovial thickening within the joint represents florid synovitis. (A = anechoic effusion; D = Doppler signal; capsule. (A = anechoic effusion; H = hypoechoic synovium). M = metatarsal head; P = proximal phalanx).

Joint capsule 1 1 2Joint capsule 2 Synovial hypertrophy Synovial hypertrophy Effusion Effusion

Effusion Effusion Synovium Synovium

Proximal phalanx Metatarsal headProximal phalanx Metatarsal head Metatarsal head Proximal phalanx Proximal phalanx Metatarsal head

7 7 8 Erosion 8 Erosion Patellar ligament Patellar ligament Tibial Tibial tubercle tubercle Proximal phalanx Metacarpal head Proximal phalanx Metacarpal head Deep Deep infrapatellar infrapatellar bursa bursa

10 10 9 9 Deltoid muscle Deltoid muscle

Subacromial bursa Subacromial bursa Double contour Double contour

Tibia Tibia Supraspinatus Supraspinatus Supraspinatus Supraspinatus Dome of talus tendon Dometendon of talus tendon tendon

Humerus Humerus

12 Flexor renaculum 12 FlUlnarexor renaculum Ulnar 11 11 artery artery Median nerve Median nerve Achilles tendon Achilles tendon Calcaneal spur Calcaneal spur

Calcaneus Calcaneus

Retrocalcaneal Retrocalcaneal bursa bursa Radius Ulna Radius Ulna 51 INVESTIGATIONS BLOOD TESTS SYNOVIAL FLUID ANALYSIS

Blood tests can be useful in indicating the degree of Obtaining a sample of synovial fluid for analysis is inflammation and in monitoring response to therapy an important skill to learn and is vital to perform in as well as helping to achieve a diagnosis: order to exclude infection of a joint, which would • The erythrocyte sedimentation rate (ESR) normally present with an acute monoarthritis with is one of the best-known inflammatory markers systemic symptoms. Synovial fluid should be sent for and indicates what has been happening over culture and gram staining. If gout or other crystals the last few days or longer. It is non-specific and are considered as a cause of the problem, the fluid influenced by many things including anaemia. is examined for crystals under a polarizing light microscope. • C-reactive protein responds more rapidly to changes in inflammation – normally within days. • Serum uric acid may be raised in gout, although it may be unreliable during an acute episode. • Incr eased titres of a number of autoantibodies may be found, although their significance is not always clear. Tests for rheumatoid factor and anti-CCP (cyclic citrullinated peptide) antibody, for example, are both often strongly positive in patients with rheumatoid arthritis. However, rheumatoid factor may also be positive in other disease states and in the elderly, and is therefore not highly specific. It is also important to consider infection as a cause of an arthropathy, particularly in the case of a single joint – blood cultures for infection should be taken even if there is no fever. 06. CONCLUSION 54 APPENDIX 1: REVISION CHECKLISTS 58 APPENDIX 2: THE CORE SET OF REGIONAL MUSCULOSKELETAL EXAMINATION SKILLS APPROPRIATE FOR A MEDICAL STUDENT AT THE POINT OF QUALIFICATION 59 APPENDIX 3: PGALS AND PREMS 60 BIBLIOGRAPHY 60 ENDORSEMENTS 54 CONCLUSION APPENDIX 1: REVISION CHECKLISTS

History Taking (p.16) GALS Screening Examination (p.28) Symptoms Gait † Pain † Observe gait for symmetry and † Pain smoothness of movement, normal stride length and ability to turn normally † Stiffness Observe patient in anatomical position † Swelling † † Pattern of joint involvement Arms † Observe movement – hands behind head, Evolution arms out straight, and normal pronation/ † Acute or chronic? supination of forearm † Associated events † Observe backs of hands and wrists for † Response to treatment swelling/deformity Involvement of other systems † Observe palms for muscle wasting † Skin, eye, lung or kidney symptoms? † Assess power grip and grip strength † Malaise, weight loss, fevers, night sweats? † Assess fine precision pinch Impact on patient’s lifestyle † Squeeze MCP joints † Patient’s needs/aspirations Legs † Ability to adapt to functional loss † Assess full flexion and extension, checking for crepitus during passive knee flexion † Assess internal rotation of hips † Assess for a knee effusion/swelling/deformity GALS Screening Questions (p.26) † Inspect feet for calluses † Squeeze MTP joints † Do you have any pain or stiffness in your muscles, joints or back? Spine † Can you dress yourself completely † Inspect spine for muscle bulk, level iliac without any difficulty? crests, normal kyphosis and lordosis, and † Can you walk up and down stairs for scoliosis without any difficulty? † Assess lateral flexion of neck † Assess lumbar spine movement 55 CONCLUSION

(p.38) Assess nose or mouth hand to function – e.g. Introduce yourself/gain consent to examine to consent yourself/gain Introduce release carpal tunnel Check wrist for Assess skin temperature MCP joints Squeeze along ulnar border and feel Look Assess finger tuck and full full finger extension Assess power median and ulnar nerve and passive epicondyles and lateral pronation Assess and extension, full flexion and passively – actively and supination Bimanually palpate swollen or painful joints, swollen Bimanually palpate including wrists – active Assess and extension wrist flexion Assess function:pinch, picking up grip and small object (if suggestion test of carpal Phalen’s Perform syndrome) tunnel examine to consent yourself/gain Introduce or rashes swellings scars, for Look Assess skin temperature joint line, medial of radius, head over Palpate Inspect hands (palms and backs) for muscle for Inspect and backs) hands (palms changes skin and nail wasting, and thickening pulse, tendon radial for Feel Assess nerve median, ulnar and radial sensation bulk of thenar and hypothenar eminences bulk of thenar and hypothenar

† † † † † † † † † of the elbow Examination † † † † † † † † † † † Examination of the hand and wrist (p.36) Examination Functional assessmentFunctional of joint Restriction – mild, moderate or severe? Restriction – mild, moderate Temperature Swellings Tenderness passive and – active of movement range Full Rashes Muscle wasting Introduce yourself Introduce examine to Gain consent verbal Scars Swellings

† † Function † † † Move † † † for: Feel † † † Look for: Introduction † REMS General Principles (p.34)REMS General 56 CONCLUSION APPENDIX 1: REVISION CHECKLISTS

Examination of the shoulder (p.38) Examination of the knee (p.42) † Introduce yourself/gain consent to examine † Introduce yourself/gain consent to examine † Inspect shoulders from in front, from the side With the patient lying on couch: and from behind † Look from the end of the couch for varus/ † Assess skin temperature valgus deformity, muscle wasting, scars and † Palpate bony landmarks and surrounding swellings muscles † Look from the side for fixed flexion deformity † Assess movement and function: hands † Assess skin temperature behind head, hands behind back † With the knee slightly flexed palpate the joint † Assess (actively and passively) external line and the borders of the patella rotation, flexion, extension and abduction † Feel the popliteal fossa † Observe scapular movement † Perform a patellar tap and cross fluctuation (bulge sign) † Assess full flexion and extension (actively and passively) Examination of the hip (p.40) † Assess stability of knee ligaments medial and lateral collateral – and perform anterior † Introduce yourself/gain consent to examine draw test

With the patient lying on couch: With the patient standing: † Look for flexion deformity and leg length † Look again for varus/valgus deformity and disparity popliteal swellings † Check for scars † Assess the patient’s gait † Feel the greater trochanter for tenderness † Assess full hip flexion, internal and external rotation † Perform the Thomas test With the patient standing: † Look for gluteal muscle bulk Perform the Trendelenburg test † Assess the patient’s gait 57 CONCLUSION Inspect from the side and from behind the side and from Inspect from Perform straight leg raising and dorsiflexion of and dorsiflexion leg raising straight Perform the big toe Assess limb reflexes Introduce yourself/gain consent to examine to consent yourself/gain Introduce and paraspinal the spinal processes Palpate muscles Assess and lumbar flexion movement: flexion, cervical flexion; and lateral extension flexion and lateral rotation extension, Assess rotation thoracic

With the patient lying on couch:With the patient † † † standing: With the patient † † † † With the patient sitting on couch:With the patient Examination of the spine (p.45) Examination

Look at the patient’s footwear the patient’s at Look Palpate for peripheral pulses peripheral for Palpate the MTP joints Squeeze Look at dorsal and plantar surfaces of the foot surfaces dorsal at and plantar Look Assess skin temperature Assess stance, (heel strike, the gait cycle Look at the forefoot, midfoot (foot arch) and arch) the forefoot, at (foot midfoot Look the subtalar joint (inversion and eversion), the and eversion), joint (inversion the subtalar the ankle flexion), and plantar (dorsi- big toe and mid-tarsal flexion) and plantar joint (dorsi- rotation) (passive joints Palpate the midfoot,Palpate and ankle joint line at and passively) Assess (actively movement Introduce yourself/gain consent to examine to consent yourself/gain Introduce the hindfoot subtalar joint subtalar toe-off)

† With the patient standing: With the patient † † † † † † † † † lying on couch: With the patient Examination of the foot and ankle (p.44) Examination 58 CONCLUSION APPENDIX 2: THE CORE SET OF REGIONAL MUSCULOSKELETAL EXAMINATION SKILLS (COADY ET AL, 2004) A student at the point of qualification should be able to: 1 detect the difference between bony and soft 24 perform external/internal rotation of the tissue swelling shoulder with the elbow flexed to 90° and held 2 elicit tenderness around a joint in against the patient’s side 3 elicit temperature around a joint 25 examine a patient’s shoulder from behind for scapular movement 4 detect synovitis assess the acromioclavicular joint (by palpation 5 understand the difference between active 26 and passive movements alone) palpate for tenderness over the epicondyles of 6 perform passive and active movements at 27 all relevant joints the elbow palpate for tenderness over the greater 7 detect a loss of full extension and a loss of 28 full flexion trochanter of the hip perform internal and external rotation of the hip 8 assess gait 29 with it flexed to 90° 9 correctly use the terms ‘varus’ and ‘valgus’ 30 perform Trendelenburg test 10 assess limb reflexes routinely – when examining the spine and in other relevant circumstances 31 perform the Thomas test detect an effusion at the knee 11 have an understanding of the term ‘subluxation’ 32 perform a patellar tap 12 where appropriate, examine neurological and 33 vascular systems when assessing a problematic 34 demonstrate cross-fluctuation or the bulge sign joint (check for intact sensation and peripheral when looking for a knee effusion pulses) 35 test for collateral ligament stability in the knee 13 assess leg length with a tape measure when 36 use the anterior draw test to assess anterior assessing for a real leg length discrepancy cruciate ligament stability in the knee 14 make a qualitative assessment of movement 37 examine the soles of a patient’s feet (features such as cog-wheeling) 38 recognise hallux valgus, claw and hammer toes 15 assess the median and ulnar nerves 39 assess a patient’s feet with them standing 16 be able to localise tenderness within the joints of 40 assess for flat feet (including the patient the hand (palpate each small joint of the hand if standing on tip toes) necessary) 41 recognise hindfoot/heel pathologies assess power grip 17 42 assess plantar and dorsiflexion of the ankle assess pincer grip in the hand 18 43 assess movements of inversion and eversion of 19 make a functional assessment of the hand such the foot as holding a cup 44 assess the subtalar joint correctly use the term ‘Heberden’s nodes’ 20 45 perform a lateral squeeze across the 21 be able to perform Phalen’s test metatarsophalangeal joints 22 detect a painful arc and frozen shoulder 46 assess flexion/extension of the big toe 23 make a functional assessment of the shoulder 47 examine a patient’s footwear (can the patient put their hands behind their 48 palpate the spinal processes head and back?) 49 assess lateral and forward flexion of the lumbar spine (using fingers, not tape measure) 50 assess thoracic rotation with the patient sitting 59 CONCLUSION APPENDIX 3: PGALS AND PREMS

pGALS follows the same approach as GALS but pREMS follows the same approach as REMS with with additions as listed in the table below. These ‘look, feel, move’ but with the addition of ‘measure’ were added as adult GALS missed significant in certain regions (for example measurement abnormalities when tested on school-aged children. of leg length or thigh girth). The table below lists suggestions for examinations (for example, Movement Purpose neurological or muscle strength) that should be conducted in addition to those included in the adult Walk on heels and Assesses foot REMS. then on tiptoes and ankles, gives information about pREMS additional features balance and co- ordination Hand and wrist • Iliotibial band • Tinel’ s test (carpal tightness Open mouth and Assess tunnel syndrome) • Knock-knee/bow- insert 3 of the child’s temporomandibular • Nailf old capillaroscopy leg assessment own fingers into their joint opening and • Hypermobility • Thigh girth measurement mouth symmetry Elbow • Muscle power • Muscle power Reach up and Assess full extension • Peripheral nerves • Hypermobility touch the sky at the elbow joint • Peripheral pulses • Normal development and rotation at the • Hypermobility of leg alignment shoulder joints • Entheses Foot and ankle • Thigh-foot angle Shoulder Look at the ceiling Assesses cervical • Hypermobility spine extension • Muscle power • Peripheral nerves • Entheses • Peripheral pulses • Muscle power • Hypermobility • Nailf old capillaroscopy

Spine Gait • 1-leg standing spine • Limb and trunk extension test proportions • Jaw profile Hip • Gower’s test Hypermobility and • Entheses inherited collagen • Muscle power disorders • Hypermobility • Beighton score • Hypermobility Knee • Habitus • Clarke’s test • Skin elasticity • Patellar tracking • Sclerae • Thigh-foot angle • Hamstring tightness Entheses Video demonstrations of pGALS and pREMS are • Knee available at Paediatric Musculoskeletal Matters: • Foot and ankle pmmonline.org/ 60 CONCLUSION BIBLIOGRAPHY ENDORSEMENTS

Coady D, Walker D and Kay L, 2004. Regional Examination of the Musculoskeletal System (REMS): a core set of clinical skills for medical students. Rheumatology, 43(5), pp.633-639. https://academic.oup. This guide is endorsed by the British Society for com/rheumatology/article/43/5/633/1788669 Accessed: Rheumatology. Rheumatology is a fun, friendly and 10/07/2019 rewarding specialty, with a strong focus on teamwork and cohesiveness across the entire multi-disciplinary team. Department of Health, 2006. The musculoskeletal Rheumatologists work closely with other specialties services framework. A joint responsibility: doing it to solve difficult diagnoses and often have an active differently. https://webarchive.nationalarchives.gov. role in research; trainees have plenty of opportunities uk/20130124073659/http://www.dh.gov.uk/prod_consum_ to get involved in education, clinical governance and dh/groups/dh_digitalassets/@dh/@en/documents/ management. digitalasset/dh_4138412.pdf The British Society for Rheumatology is there for you Accessed: 10/07/2019 from the start of your career in the specialty. They’ll help Doherty M, Dacre J, Dieppe P and Snaith M, 1992. The you progress, collaborate and innovate to deliver the best ‘GALS’ locomotor screen. Annals of the Rheumatic care for your patients through a wide range of courses, Diseases, 51(10), pp.1165-1169. https://ard.bmj.com/ conferences, fellowships, bursaries and awards, as well as content/51/10/1165.short Accessed: 10/07/2019 a mentoring programme and peer-reviewed eLearning lectures and modules. Foster HE, Kay LJ, Friswell M, Coady D and Myers A, 2006. Musculoskeletal screening examination (pGALS) To find out more about how they can support you, go to for school age children based on the adult GALS www.rheumatology.org.uk/membership. screen. Arthritis Care & Research: Official Journal of the American College of Rheumatology, 55(5), pp.709-716. https://onlinelibrary.wiley.com/doi/full/10.1002/art.22230 Accessed: 10/07/2019 Foster H, Kay L, May C. and Rapley T, 2011. Pediatric regional examination of the musculoskeletal system: A This guide is endorsed by The British Orthopaedic practice and consensus based approach. Arthritis care & Association. The British Orthopaedic Association research, 63(11), pp.1503-1510. https://onlinelibrary.wiley. supports 5,000 members throughout the UK and com/doi/full/10.1002/acr.20569 Accessed:10/07/2019 internationally. By bringing together all those working in trauma and orthopaedic surgery they aim to provide Global Burden of Disease Collaborative Network. Global national leadership and a unifying focus supporting their Burden of Disease Study 2017 (GBD 2017) Results. members to deliver excellence in patient care. Institute for Health Metrics and Evaluation (IHME), Seattle, 2018. Being a trauma and orthopaedic surgeon is an extremely rewarding career: there are few areas in medicine where Vos T, Abajobir AA, Abate KH, Abbafati C, Abbas KM, you have the opportunity to transform people’s lives, Abd-Allah F, Abdulkader RS, Abdulle AM, Abebo TA, whether you are putting them back together after Abera SF and Aboyans V, 2017. Global, regional, and severe trauma, or you are giving someone back their national incidence, prevalence, and years lived with independence by relieving the pain from an arthritic disability for 328 diseases and injuries for 195 countries, joint. A career in trauma and orthopaedics combines 1990–2016: a systematic analysis for the Global Burden theoretical knowledge with practical skills, but also of Disease Study 2016. The Lancet, 390(10100), pp.1211- involves an interface with technology, industry and a 1259. https://www.sciencedirect.com/science/article/pii/ multidisciplinary team unlike any other specialty. S0140673617321542 Accessed:10/07/2019 To find out more about how they can support you, go to World Health Organization, 2016. International Statistical www.boa.ac.uk Classification of Diseases and Related Health Problems, 10th revision. https://icd.who.int/browse10/2016/en Accessed: 10/07/2019 61 CONCLUSION

However, the importance of guided THIS GUIDE, clinical teaching and the development of clinical reasoning skills cannot be TOGETHER overemphasised. It is only through real- life clinical practice that competence WITH THE and confidence in musculoskeletal ACCOMPANYING clinical examination can be achieved. VIDEOS, HAS We hope that you will find the guide valuable for reference and DOCUMENTED THE revision, but Versus Arthritis is always delighted to receive feedback CORE SKILLS OF at: professionalengagement@ MUSCULOSKELETAL versusarthritis.org EXAMINATION AND HISTORY TAKING 62 NOTES 63 NOTES FOR YOU... FOR YOUR PATIENTS...

• Join our professional network and become part of • Order or download patient information a growing community working together to change leaflets free of charge the face of MSK care. We’ll keep you connected • Encourage your patients to call the free with the latest developments in MSK health and Versus Arthritis helpline care, you’ll receive bulletins containing practical • Signpost to our arthritis virtual assistant, tips, and development opportunities as well as the a 24/7 tool that provides fast, easy to latest Versus Arthritis patient information. access information •  If you’re looking to gain some hands-on, practical • Explore our online community which will training in MSK then check out our Core Skills connect your patients with real people in Musculoskeletal Care. Core Skills is designed who share the same everyday experiences to help you feel confident and knowledgeable • Connect to local groups and find out in managing patients with MSK conditions. Our what’s going on where your patients are e-learning is free to access, and you can build on this with some hands-on learning at one of our Find out more at practical workshops running across the UK. www.versusarthritis.org/get-help/ •  Through our MSK champions programme we are aiming to create leaders of change who are committed to driving improvements in musculoskeletal care. Keep your eye on our website for dates for applications for the next cohort. Find out more at www.versusarthritis.org/about-arthritis/ healthcare-professionals/

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