Fig. 7C.29: Demonstration of palpation of knee joint.

Patellar Tap Test

Used to detect effusion in the knee joint.

Slide your hand down the patient’s thigh compressing the suprapatellar pouch (Fig. 7C.30).

This forces all the fluid to collect behind the patella. With two fingers of the other hand push the patella down gently (Fig. 7C.31).

In a positive test, the patella will bounce back with the tap.

Bulge Sign/Cross Fluctuation Sign (Figs. 7C.32A and B)

Stroke the medial side of the knee upwards towards the suprapatellar pouch.

This empties the medial compartment of the fluid.

Now stroke the lateral side downwards.

The medial side will now refill and bulge indicating joint effusion.

Fig. 7C.30: Slide your hand down the patient’s thigh

compressing the suprapatellar pouch.

Fig. 7C.32B: The cross fluctuation sign (bulge sign): Stroke the

lateral side downwards.

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Fig. 7C.31: With two fingers of the other hand push the

patella down gently.

Fig. 7C.32A: The cross fluctuation sign (bulge sign): Stroke

the medial side of the knee upwards towards the

suprapatellar pouch.

Fig. 7C.33: Examination of ankle joint.

Examination of Ankle Joint

Palpate the bare area of the ankle [bare area is the triangular area in front of the ankle, between the

two tendons of extensor hallucis longus (EHL) and extensor digitorum longus (EDL)] for tenderness

and synovial thickening (Fig. 7C.33).

Examination of Achilles Tendon for Swelling

Palpate the Achilles tendon for swelling and tenderness (Fig. 7C.34). Enthesitis is classically seen in

case of seronegative spondyloarthropathies.

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Fig. 7C.34: Examination of swelling over Achilles tendon.

Examination of Metatarsophalangeal Joints

Squeezing the metatarsophalangeal joints to look for pain (Fig. 7C.35)

Fig. 7C.35: Examination of metatarsophalangeal joints.

Fig. 7C.36: Hip joint deformities.

Figs. 7C.37A to C: Knee joint deformities. (A) Normal; (B) Genu vaigus (kknock knees); (C) Genu

varus (bow legs).

Deformities of leg:

Hip joint (Fig. 7C.36) Coxa vara/valgum

Knee joint (Figs. 7C.37A to C) Genu varum (bow legs)/genu valgum (knock knee)

Foot (Fig. 7C.38) Hallux varus/hallux valgus/hammer toes

Metatarsophalangeal (Fig. 7C.39) Gout/podagra

Fig. 7C.38: Hallux valgus and hallux varus deformity.

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Fig. 7C.39: Acute gouty arthritis involving the first metatarsophalangeal (MTP) joint (termed podagra).

6. EXAMINATION OF SPINE

Occiput to wall Distance/Flesche test (Fig. 7C.40)

Ask the patient to stand erect against a wall, with heels and buttocks placed against a wall.

Now, ask the patient to extend the neck maximally.

The distance between the occiput and the wall is measured in degree of flexion deformity of cervical

spine.

Normally the occiput to wall distance is zero.

It is increased in cervical flexion deformity as in ankylosing spondylitis.

Fig. 7C.40: Demonstration of Flesche test.

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Schober’s Test (Fig. 7C.41)

Mark a point approximately at L5 (A)

Now mark two horizontal lines, one 10 cm above (B) and one 5 cm below L5 (C)

Ask the patient to touch his/her toes

Normally the distance between two lines increases by 5 cm (total >20 cm)

If the increase is less than 5 cm, it suggests restriction.

Modified Schober’s Test (Fig. 7C.42)

Mark a line connecting two posterior superior iliac spine.

Draw a parallel line 10 cm above this line.

Now ask the patient to bend and touch his toes as much as possible.

The distance between the two lines must be >15 cm. If it is less than 15 cm, it indicates restricted

movement of the lumbar spine as seen in ankylosing spondylosis.

Fig. 7C.41: Demonstration of Schober’s test.

Fig. 7C.42: Demonstration of modified Schober’s test.

Straight Leg Raising Test (Fig. 7C.43)

Patient lying in supine position, the heel of the leg (with knee extended) is cupped by examiner and

elevated slowly.

The test is considered positive if sciatic pain is reproduced between 35° and 70° of elevation.

The straight leg raise (SLR) test is best for eliciting L4, L5, or S1 radiculopathy.

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Fig. 7C.43: Straight leg raising test.

Patrick’s Test (Figure-of-4 test) (Fig. 7C.44)

One leg is guided into “figure-of-4” position with the ipsilateral ankle resting across the contralateral

thigh.

The ipsilateral knee is then pressed downwards with one hand while providing counter pressure with

the other hand on the contralateral anterior superior iliac spine.

Pain indicates sacroiliac joint involvement.

Fig. 7C.44: Demonstration of Patrick’s test (figure-of-4).

Gaenslen Maneuver (Fig. 7C.45)

Ask the patient to lie down on supine.

One hip if flexed maximally and the other hip is extended by allowing the leg to dangle off the side of

the examining table as shown in the Figure 7C.45.

Pain indicates sacroiliac joint involvement.

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Fig. 7C.45: Demonstration of Gaenslen test.

Deformities of spine (Fig. 7C.46)

Lordosis Anterior curvature

Kyphosis Posterior curvature

Scoliosis Lateral curvature

Knuckle deformity or step deformity Prominence of one spinous process

Gibbus deformity (e.g. Pott’s spine/metastasis) Prominence of two spinous processes

Fig. 7C.46: Various spine deformities.

7. EXAMINATION OF OTHER JOINTS

Temporomandibular Joints (Fig. 7C.47)

Palpate the temporomandibular joint by asking the patient to open the mouth.

Observe for tenderness, synovial thickening, and crepitus.

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Fig. 7C.47: Examination of temporomandibular joint (TMJ).

Examination of Sternoclavicular Joint (Fig. 7C.48)

Palpate the sternoclavicular joint.

Look for tenderness and synovial thickening.

Fig. 7C.48: Examination of sternoclavicular joint.

8. EXAMINATION OF OTHER SYSTEMS IN RHEUMATOLOGICAL

DISORDERS

Cardiovascular system

Pericarditis RA

SLE

Endocarditis SLE

Aortitis and aortic regurgitation RA

Psoriasis

Ankylosing spondylitis

Reiter’s

Conduction defects SLE

Nervous system

Myelopathy RA—atlantoaxial dislocation

Vasculitis

Neuropathy (entrapment/mononeuritis multiplex) RA

SLE

Vasculitis (especially PAN)

Stroke RA

SLE

APLA

Vasculitis

Myopathy Polymyositis

Dermatomyositis

Respiratory system

Upper respiratory tract Wegener’s granulomatosis

Pleural effusion RA

SLE

Fibrosis RA

SLE

Systemic sclerosis

Lung nodules RA (Caplan’s syndrome)

Alveolar hemorrhage Microscopic polyangiitis

Goodpasture’s syndrome Wegener’s granulomatosis

Asthma Churg–Strauss syndrome

Decreased chest expansion Ankylosing spondylosis

Gastrointestinal system

Oral ulcers SLE

Behcet’s disease

IBD Seronegative spondyloarthropathies

Hepatosplenomegaly SLE

RA

Stills disease

GI bleeding Henoch–Schönlein purpura

Other vasculitis

Analgesic use

Genitourinary system

Urethritis Reactive arthritis

Glomerulonephritis SLE

Microscopic polyangiitis

Goodpasture’s syndrome Wegener’s granulomatosis

Renal failure Analgesics use

Vasculitis

Endocrinology

Diabetes Steroid induced

Thyroid disease Associated autoimmune conditions

Blood

Anemia SLE

Thrombocytopenia

Pancytopenia

RA (Felty’s syndrome)

9. DISCUSSION ON COMMON RHEUMATOLOGICAL DISEASES

Rheumatoid Arthritis

American College of Rheumatology (ACR) criteria for rheumatoid arthritis.

Morning stiffness

Arthritis of 3 joint areas

Arthritis of the hands

Symmetric arthritis

Rheumatoid nodules

Serum rheumatoid factor positive

Radiographic changes

These criteria must be present for more than 6 weeks. Presence of four or more criteria favors definite diagnosis of RA.

European League against Rheumatism (EULAR) classification criteria for rheumatoid arthritis: 2010.

A. Joint involvement (Fig. 7C.49)

1 large joint (shoulder, elbow, hip, knee, ankle) 0

2–10 large joints 1

1–3 small joints (MCP, PIP, thumb IP, MTP, wrists) + involvement of large joints 2

4–10 small joints + involvement of large joints 3

>10 joints (at least 1 small joint) 5

B. Serology (at least one test result is needed for classification)

Negative RF and negative ACPA 0

Low-positive RF or low-positive ACPA (≤3 times ULN) 2

High-positive RF or high-positive ACPA (≥3 times ULN) 3

C. Acute-phase reactants (at least one test result is needed for classification)

Normal CRP and normal ESR 0

Abnormal CRP or abnormal ESR 1

D. Duration of symptoms

<6 weeks 0

≥6 weeks 1

Above criteria yields a score of 0–10. A score of ≥6 required for definitive diagnosis of RA.

A score of <6/10 are not classifiable as RA, but their status to be reassessed over time.

(ACPA: Anticitrullinated protein antibodies; CRP: C-reactive protein; ESR: erythrocyte sedimentation

rate; IP: interphalangeal joint; MCP: Metacarpophalangeal joint; MTP: metatarsophalangeal joint; PIP:

proximal interphalangeal joint; RF: rheumatoid factor; ULN: upper limit of normal)

Fig. 7C.49: The 28 joints to be examined in rheumatoid arthritis include the 5 proximal interphalangeal

joints of the 2 hands, the 5 metacarpophalangeal joints of the 2 hands, the 2 wrists, the 2 elbows, the 2

shoulders, and the 2 knees.

Fig. 7C.50: Extra-articular manifestations of rheumatoid arthritis.

Systemic Lupus Erythomatosis (Fig. 7C.51)

Systemic Lupus International Collaborating Clinics (SLICC) Classification 2012 criteria

Biopsy proven LUPUS NEPHRITIS and ANA/anti-DNA (or) atleast four criteria (one needs to be immunological)

Clinical Immunological

Acute cutaneous LE

Chronic cutaneous LE

Oral ulcer

Alopecia

Synovitis

Serositis

ANA

Anti-dsDNA

Anti-Sm

aPL antibodies

Low complement

Direct Coombs’ test positive

Renal

Neurologic

Hemolytic anemia

Leukopenia/lymphopenia

Thrombocytopenia

Fig. 7C.51: Clinical features of systemic lupus erythematosus (SLE).

Differences between rheumatoid arthritis and SLE

Features Rheumatoid arthritis Systemic lupus erythematosus

Smoking Predisposing factor No relation

Female:Male 3:1 9:1

Type of arthritis Erosive Nonerosive

Deformities Common Rare, Jaccoud’s arthropathy (10%)

Systemic involvement Relatively less Marked

Nodules Rheumatoid nodules Absent

Malar (skin) rash Nil Striking feature: Malar rash, discoid rash

Photosensitivity Absent Photosensitivity present

Oral ulcer and alopecia Absent Present

Spine involvement Involves cervical spine Rare

Pyoderma gangrenosum May develop Rare

Renal involvement Uncommon Common and severe

Platelet abnormality Thrombocythemia Thrombocytopenia

Serology RA factor and ACPA ANA and anti-dsDNA

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Criteria for diagnosis ACR/EULAR SLICC/ACR

Response to DMARDs Present Less response

(ACPA: anticyclic citrullinated peptide antibodies; ACR: American College of Rheumatology; ANA:

antinuclear antibodies; DMARD: disease-modifying antirheumatic drugs; dsDNA: double-stranded

deoxyribonucleic acid; EULAR: European league against rheumatism; RA: rheumatoid arthritis; SLICC:

systemic lupus international collaborating clinics)

Osteoarthritis (Fig. 7C.52)

Osteoarthritis (OA) is a noninflammatory, slowly progressive joint disease, mainly involving the

cartilage. It shows progressive destruction of articular cartilage of weight-bearing joints of

genetically susceptible older persons. It leads to narrowing of joint space, subchondral bone

thickening, and finally painful and nonfunctioning joints.

Fibromyalgia

Fibromyalgia syndrome (FMS) is characterized by chronic widespread pain, and is defined as pain for

more than three months both above and below the waist.

Diagnostic Criteria for FMS

At least 3 months of widespread pain that is bilateral, above and below the waist.

It includes axial skeletal pain and pain to palpation at a minimum of 11 of 18 predefined tender points

(Fig. 7C.53).

The diagnosis of other diseases does not exclude the diagnosis of FMS.

Fig. 7C.52: Pattern of joint involvement in osteoarthritis.

10. SCORING SYSTEMS FOR SEVERITY OF DISEASE

Disease activity score 28 (DAS28)

DAS28 is a common measurement of disease activity in RA and provides score that tells you how well

controlled your RA is and whether treatment is working.

Twenty-eight joints (20 hand joints, 2 shoulder joints, 2 elbow joints, 2 wrist joints, and 2 knee joints)

are examined throughout your body. Each joint is squeezed and the number of tender and swollen joints

is calculated.

DAS28 Implication

Less than 2.6 Disease remission

Usually no action necessary except

Continue current medication

2.6–3.2 Low disease activity

May merit change in therapy for some patients

3.2–5.1 Moderate disease activity

May merit change in therapy

More than 5.1 Severe disease activity require change in therapy

Consider biologic treatment

Fig. 7C.53: Trigger points in fibromyalgia.

Clinical Disease Activity Index (CDAI) (Fig. 7C.54)

Fig. 7C.54: Clinical disease activity index.

NOTES

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