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CLINICAL EXAMINATION Diagnostic approach depends upon assessment of function SELECTIVE TENSION • Passive movements stress inert structures • Resisted movements test contractile structures EXAMINATION FOLLOWS A SET ROUTINE OBSERVATION • Face • Posture • Gait HISTORY • Age and occupation, sports hobbies, lifestyle • Site and spread • Onset and duration HISTORY • Symptoms and behaviour • Other joint involvement • Past medical history • Medications INSPECTION • Bony deformity • Colour changes • Wasting • Swelling PERIPHERAL JOINTS Palpate for: • Heat • Swelling • Synovial thickness • Not for tenderness STATE AT REST • Position of the pain ACTIVE MOVEMENTS • Pain • Range • Willingness OTHER FINDINGS • Painful arc PASSIVE MOVEMENTS FOR INERT STRUCTURES • Joint capsule • Bursa • Dura mater • Nerve root • Ligament • Fascia • Dural nerve root sleeve • Relaxed muscle and tendon PASSIVE MOVEMENTS FOR INERT STRUCTURES • Pain • Range • End-feel PASSIVE MOVEMENTS • Capsular pattern • Non-capsular pattern NORMAL END-FEEL • Hard • Soft • Elastic ABNORMAL END- FEEL • ‘Hard’ • Spasm • Springy • Empty CAPSULAR PATTERN • Arthritis • Varies from joint to joint • Limitation in a fixed proportion which varies according to the joint • Same whatever the cause of the arthritis NON-CAPSULAR PATTERN • Intra-articular displacement • Ligamentous lesion • Extra-articular lesion RESISTED TESTS FOR CONTRACTILE STRUCTURES • Muscle • Tendon • Attachments to bone RESISTED TESTS • Pain • Power • Relaxed contractile unit may produce pain on passive stretching RESISTED TESTS • Joint in mid position • No joint movement • Eliminate muscles not tested • Test muscles strongly • Patient and examiner positioned to advantage RESISTED TESTS • Strong and painless • Strong and painful • Weak and painless • Weak and painful • Painful on repetition • All painful/juddering NEUROLOGICAL EXAMINATION • Reflexes • Power • Sensation • Plantar response OTHER TESTS • Mechanical/neural tests • Blood tests • X-ray • EMG • Scans PALPATION Once the structure at fault has been identified
