Eye Changes

Dryness of eyes Sjogren’s syndrome

Episcleritis/scleritis (Fig. 7C.9) Rheumatoid arthritis

Iritis/iridocyclitis Ankylosing spondylitis

Conjunctivitis Reiter’s disease

Tenosynovitis of superior oblique Rheumatoid arthritis (Brown’s syndrome)

Scleromalacia perforans Rheumatoid arthritis

Fig. 7C.9: Slit-lamp examination showing keratitis.

3. EXAMINATION PATTERN OF MUSCULOSKELETAL SYSTEM

Gait, arms, legs, spine (gals) screening

Gait Observe the gait

Arms Examine the range of movement of joints.

Joint deformities.

Synovial thickening.

Legs Examine the range of movement of joints.

Joint deformities.

Synovial thickening.

Special tests.

Spine Look for spine deformity.

Special test.

Regional examination of musculoskeletal system (REMS) examination (Look, feel, move)

Look for Swellings

Redness

Rashes

Scars

Muscle wasting

Feel for Temperature

Swelling

Tenderness

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Move Full range of movement—active and passive (refer the table and figure) (Figs. 7C.10A to H)

Restriction—mild/moderate/severe

Function Functional assessment of joint

All the joints have to be examined in the above headings.

Range of movement of joints (Figs. 7C.10A to H):

Flexion Extension Abduction Adduction Rotation

Wrist 70° 70° 30° 30°

MCP 45° 90°

PIP 120°

DIP 90° 10°

Elbow 160° 5°

Shoulder 160° 60° 175° 50° 70°

Hip 110° 30° 30° 30° 45°

Knee 130°

Ankle 40° (dorsiflexion) 50° (plantar flexion)

Others:

Subtalar joint—has 5° of inversion and eversion.

Midtarsal joint—has 30° of inversion and eversion.

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Figs. 7C.10A to H: Demonstration of range of movement of joints.

4. EXAMINATION OF UPPER LIMBS

Examination of shoulder

Examination of glenohumeral joint (Fig. 7C.11):

Examine for tenderness and swelling along the joint line as shown in the Figure 7C.11.

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Fig. 7C.11: Image showing examination of tenderness and swelling along the joint line of shoulder joint.

Impingement test (Fig. 7C.12):

Fig. 7C.12: Demonstration of impingement test.

Apprehension test (Fig. 7C.13):

Flex the patients elbow to 90°

Abduct the patients shoulder to 90°

Now attempt external rotation of the shoulder

Apprehension to the test is considered positive suggesting glenohumeral instability with possibility of

labral tear.

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Fig. 7C.13: Demonstration of apprehension test.

Examination of Elbow (Fig. 7C.14)

Palpate the joint for tenderness and synovial thickening along the joint line as shown in the Figure

7C.14.

Fig. 7C.14: Palpation of elbow.

Examination of wrist joint

(Two-thumb technique) (Fig. 7C.15)

The examiner’s thumb should follow the third metacarpal bone on the dorsal aspect of the hand until a

dimple is reached at the capitate level.

Continuous pressure is exerted by the thumb.

The other thumb is used to intermittently apply pressure approximately half an inch away on the wrist

joint in order to identify swelling and/or tenderness.

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Fig. 7C.15: Examination of wrist joint.

Prayer sign (Fig. 7C.16):

The patient is asked to dorsiflex both the wrist and hold the palms together actively as in praying

Pain or inability to perform this activity would suggest joint involvement or carpal tunnel syndrome

Also seen with diabetic cheiroarthropathy.

Fig. 7C.16: Demonstration of prayer sign.

Metacarpophalangeal Joint Assessment (Figs. 7C.17A to C)

Scissor technique: A scissor-like shape is made with the fingers. The patient’s hand is held from

the sides at the MCP level.

The MCPs are flexed to 90°. The thumbs are used to palpate the joint—one to apply pressure to the

joint, the other to assess for effusion, swelling, and/or tenderness.

Squeeze test: Squeeze the metacarpophalangeal joints as shown in the Figure 7C.17C and watch

for tenderness.

Fig. 7C.17A: Examination of metacarpophalangeal joint.

Fig. 7C.17B: Examination of metacarpophalangeal joint.

Fig. 7C.17C: Squeeze test of hand for assessment of metacarpophalangeal joint.

Interphalangeal Joint Assessment (Fig. 7C.18)

(Four-finger technique)

Each interphalangeal joint is held by the thumb and index finger of one hand of the examiner. Pressure

is applied until the distal finger becomes whitened due to low blood supply. The thumb and index finger

of the examiner’s other hand are used palpate the joint to identify effusion, swelling, and/or tenderness.

Fig. 7C.18: Examination of interphalangeal joints (four finger technique).

Deformities of hand

Spindling of the

fingers

It is the earliest finding characterized by swelling of the proximal, but not the distal interphalangeal joints.

Swan-neck

deformity (Figs.

7C.19 and 7C.20)

It is due to hyperextension of the proximal interphalangeal joints (PIP) with flexion of the distal

interphalangeal joints (DIP). At DIP joint, there is elongation or rupture of attachment of the extensor tendon

to the base of the distal phalanx; this results in mallet deformity of distal joint and in addition, an extensor

tendon imbalance, leading to hyperextension deformity at PIP joint.

Boutonniere’ or

“button-hole”

deformity (Figs.

7C.19 and 7C.21)

This deformity is due to flexion of the PIP joints and extension of the DIP joints. Disruption of the central slip

of the extensor tendon and the triangular ligament allows each of the conjoint lateral bands of the digit to

slide volarly resulting in a pathologic flexion force and an extension lag; all tendons traversing the PIP joint in

this setting elicit flexion of the joint.

Ulnar deviation

(Fig. 7C.22)

It results from subluxation of the metacarpophalangeal (MCP) joints, with subluxation of the proximal phalanx

to the volar side of the hand.

Hitchhiker’s

thumb (Fig.

7C.23)

A condition where the thumb can bend backwards to an angle of almost 45°. Thumb flexes at the metacarpophalangeal joint and hyperextends at the interphalangeal joint.

“Z” deformity

(Fig. 7C.24)

It is due to radial deviation of the wrist, ulnar deviation of the digits with palmar subluxation of the first MCP

joint with hyperextension of the first interphalangeal (IP) joint.

Carpal tunnel

syndrome

Due to synovial proliferation in and around the wrists producing compression of the median nerve.

Bow string sign Prominence of the tendons in the extensor compartment of the hand.

Heberden’s

nodes (Fig.

7C.25)

DIP swelling in osteoarthritis.

Bouchard’s node

(Fig. 7C.25)

PIP swelling in osteoarthritis.

Sausage digits

(Fig. 7C.26)

Dactylitis involving both PIP and DIP as seen in psoriatic arthritis.

Pencil in cup

deformity

Psoriatic arthritis.

Arthritis mutilans

Psoriatic arthritis.

Fig. 7C.19: Boutonniere and swan—neck deformity.

Fig. 7C.20: Swan-neck deformity.

Fig. 7C.21: Boutonniere deformity. Fig. 7C.24: Z-shaped deformity of thumb in RA.

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Fig. 7C.22: Ulnar deviation of hand.

Fig. 7C.25: Osteoarthritis showing Heberden’s nodes (on DIP) a

Bouchard’s nodes (on PIP).

Fig. 7C.23: Hitchhiker’s thumb.

Fig. 7C.26: Sausage digits in psoriatic arthritis and psoriatic nai

5. EXAMINATION OF LOWER LIMB

Examination Hip Joint

Trendelenburg test (Fig. 7C.27)

Assesses the proximal hip muscles strength.

This involves patient alternately standing on each leg alone.

In a negative test, the pelvis remains level.

In an abnormal test, the pelvis will dip to the contralateral side suggesting gluteus medius weakness.

This test is abnormal, if the hip is involved either due to arthritis or avascular necrosis. Also proximal

muscle weakness can be secondary to drugs used like steroids.

Thomas test (Fig. 7C.28)

To look for fixed flexion deformity of hip.

Keep one hand under the patient’s back to ensure that there is no lumbar lordosis.

Fully flex one hip.

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If the opposite leg lifts off the couch, there is a fixed flexion deformity (normally as the pelvis tilts, the

hip would extend allowing the leg to remain on the couch).

Examination of Knee Joint

Palpation of knee joint to look for tenderness and synovial thickening (Fig. 7C.29).

Fig. 7C.27: Trendelenburg sign.

Fig. 7C.28: Demonstration of Thomas test.

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