Clinical

assessment of the
musculoskeletal
system
a guide for
medical students
and healthcare
professionals
Clinical assessment of the musculoskeletal system:
a guide for medical students and healthcare professionals
Contents
Foreword 3
Acknowledgements 3
List of abbreviations used 4

Introduction to musculoskeletal assessment 5

The musculoskeletal history 5

– Current symptoms 7
– Evolution of the problem: is it acute or chronic? 9
– Involvement of other systems 9
– Impact of the condition on the patient 9
– Screening questions for musculoskeletal disorders 10

The musculoskeletal examination 11

– Screening examination for musculoskeletal disorders (‘GALS’) 11
– Gait 11
– Arms 11
– Legs 13
– Spine 13
– Recording the findings from the screening examination 13
– Performing a regional examination of the musculoskeletal system (‘REMS’) 14
– Examination of the hand and wrist 16
– Examination of the elbow 18
– Examination of the shoulder 18
– Examination of the hip 19
– Examination of the knee 20
– Examination of the foot and ankle 22
– Examination of the spine 23
– Recording the findings from the regional examination 24

Investigations 25
– Imaging of bones and joints 25
– Blood tests 26
– Synovial fluid analysis 26

Conclusion 26
– Appendix 1: Revision checklists 27
– Appendix 2: The core set of regional musculoskeletal examination skills 31
appropriate for a medical student at the point of qualification
– Bibliography 32
Arthritis Research UK
Copeman House, St Mary’s Court
St Mary’s Gate, Chesterfield
Derbyshire S41 7TD

Registered Charity England and Wales No. 207711,

Scotland No. SC041156

© Arthritis Research UK 2011 All rights reserved

This edition published April 2011 ISBN 978 1 901815 17 7

3321/STUD/11-2
Foreword
Arthritis Research UK is delighted to offer this updated version of the guide to clinical
assessment of patients with musculoskeletal disorders. The guide should prove an
invaluable aid to medical, nursing and allied healthcare professional students.

The guide has evolved from an idea developed by Professor Paul Dieppe while a hostage
in Kuwait in 1990. From its inception, the guide included the ‘GALS’ musculoskeletal
screening examination, developed by Professor Dieppe and Professor Mike Doherty in
the early 1990s. The GALS, firstly, has proved an excellent method of identifying patients
with potential neuromuscular disorders, and secondly, has been an invaluable vehicle
in drawing to the attention of healthcare students the importance of identifying
patients with musculoskeletal problems. It is now included in many OSCE examinations.

The next iteration of the guide included the innovative work of Dr David Coady and
colleagues, highlighting, in the regional examination of the musculoskeletal system
(‘REMS’), core techniques of musculoskeletal assessment, as identified in a robust study
of a wide spectrum of clinicians across the UK. This guide also included a DVD
demonstrating the examination techniques.

In the latest version, Drs Coady and Mark Lillicrap have made refinements to the previous
guide in the light of feedback and experience, but have also included a re-structuring
to reflect more closely the sequence of events in clinical practice.

We hope the guide will facilitate confidence and competence in assessing people with
musculoskeletal problems – a key activity in ensuring effective care of this very large
group of patients.

Professor Andrew Hassell

Chairman Education Strategy Committee 2005–2011

Acknowledgements
We remain indebted, in particular, to Professor Paul Dieppe – his earlier version of this
handbook has been widely referred to by medical students in the UK since 1991 and his
text remains influential in this new edition.

Caution regarding infection control

The photographs and videos used in this handbook were produced before the introduction
of current UK guidelines on infection control (‘bare below the elbows’ guidelines). Before
examining a patient, and in any clinical situation, wrist watches and wrist jewellery should
be removed, sleeves should be rolled up above the elbow, ties should be tucked in or
removed, and appropriate hand hygiene should be undertaken.

3
List of abbreviations used

CMC(J) carpometacarpal (joint) MRI magnetic resonance imaging

CT computerized tomography MTP(J) metatarsophalangeal (joint)
DEXA dual-energy x-ray NSAID non-steroidal anti-inflammatory
absorptiometry drug
DIP(J) distal interphalangeal (joint) OA osteoarthritis
ESR erythrocyte sedimentation PIP(J) proximal interphalangeal (joint)
rate RA rheumatoid arthritis
GALS gait, arms, legs and spine REMS regional examination of the
MCP(J) metacarpophalangeal (joint) musculoskeletal system

Paediatric screening examination for musculoskeletal

disorders (pGALS) and regional examination (pREMS)

pGALS is a simple, quick and effective way to screen the musculoskeletal system
in school-aged children. Developed from the adult GALS screening examination,
pGALS takes just a few minutes to perform. The amendments to the adult GALS
are all simple manoeuvres that are commonly used in clinical practice by doctors
and therapists experienced in the assessment of children.
Further details, including a video of the pGALS examination can be found at the
Arthritis Research UK website: http://www.arthritisresearchuk.org/health-
professionals-and-students/video-resources/pgals.aspx

A paediatric version of adult REMS, called pREMS has also been developed* and
educational resources are in production.
* Foster HE, Kay LJ, May CR, Rapley TR. Pediatric regional examination of the musculoskeletal
system: a practice- and consensus-based approach. Arthritis Care & Research 2011;63(11):1503-1510

4
Introduction to non-inflammatory) and, in general, it is
musculoskeletal assessment not necessary for a practising clinician to
know about all of these. A more realistic
Musculoskeletal disorders are the com- approach is to adopt a classification
monest cause of disability in the UK. scheme, and to learn how to place
Each year 15 per cent of patients on a patients’ problems within this classifi-
general practitioner’s list will consult their cation, using information gained
doctor with a locomotor problem, and through a full history and examination
such conditions form 20–25 per cent of a (as described in detail in the sections
GP’s workload. About 30 per cent of those which follow).
with any physical disability, and 60 per The five key questions which need to be
cent of those with a severe disability, answered are:
have a musculoskeletal disorder as the
t
Does the problem arise from the joint,
primary cause of their problems.
tendon or muscle?
Clinical skills – i.e. competent history t
Is the condition acute or chronic?
taking and examination – are the key t
Is the condition inflammatory or
to making an accurate diagnosis and non-inflammatory?
assessment of a patient complaining of t
What is the pattern of affected areas/
joint problems. This booklet aims to joints?
outline the methods you might use. It is t
What is the impact of the condition on
not intended to replace clinical teaching the patient’s life?
and experience but to be used as an aid
The answers to these questions should
to learning.
enable you to produce a succinct summary
‘Arthritis’ is a term that is frequently used of the patient’s condition. An example
to describe any joint disorder (and not of a patient summary produced using
infrequently any musculoskeletal prob- this method might be:
lem). It could be argued that the term
‘arthritis’ should be used to describe ‘This patient has a chronic
inflammatory disorders of the joint whilst symmetrical inflammatory
‘arthropathy’ should be used to describe polyarthritis, mainly affecting the
non-inflammatory disorders. Other mus- small joints of the hands and feet,
culoskeletal problems should similarly be which is causing pain, difficulty
described according to their anatomical with dressing and hygiene, and is
site (e.g. muscle or tendon) and whether limiting her mobility.’
they are of inflammatory or non-
inflammatory aetiology. However, the This would result in the patient being
term ‘arthritis’ is in such widespread placed as indicated on the classification
general use to describe any disorder of tree (see Figure 1).
the joint that, for the purpose of this
guide, it will be used in that sense. The musculoskeletal history
There are over 200 different types of History taking is one of the most import-
‘arthritis’ (both inflammatory and ant skills for any doctor or practitioner to
5
 Arthritis

Inflammatory Connective tissue Non-inflammatory

disease

Acute Chronic Acute Chronic

Mono Poly Spine Mono Poly Spine Mono Spine Mono Poly Spine
e.g. gout, e.g. e.g. e.g. torn e.g. e.g.
septic RA AS cruciate OA scoliosis
arthritis ligament

Figure 1. Classification of the arthritides

acquire and this can only be achieved identify those cases where pain may
through regular practice. appear to arise from the joint but is in
fact referred pain – for example, where
This handbook is primarily concerned the patient describes pain in the left
with problems arising from the joints – shoulder, which might in fact be referred
that is from the articular and periarticular pain from the diaphragm, the neck, or
structures. (These structures are shown perhaps ischaemic cardiac pain. In cases
in Figure 2, while Figure 3 represents where examination reveals no abnor-
diagrammatically the changes which malities in the joint, other clues will be
occur in the two main types of arthritis.) obtained by taking a full history.
However, it is clearly important to Assuming the patient’s problems do
arise from the joint(s), the aims of the
Bone Muscle history will be to differentiate between
Bursa
inflammatory and degenerative/mech-
anical problems, to identify patterns that
may help with the diagnosis, and to assess
Capsule
the impact of the problem upon the
Synovium
patient. There are four important areas
Cartilage which need to be covered when taking a
musculoskeletal history:
Tendon
Ligament t
the current symptoms
insertion Tendon sheath
t
the evolution of the problem (is it
Tendon insertion acute or chronic?)
Figure 2. Cross-sectional diagram of t
the involvement of other systems
a synovial joint and its periarticular t
the impact of the disease on the
structures person’s life.

6
 swelling affecting one or more joints.
Bone
Assessment of the patient’s current
Muscle symptoms may allow differentiation to
Ligament be made between inflammatory and
Synovium non-inflammatory conditions. Inflam-
Cartilage matory joint conditions are frequently
Synovial associated with prolonged early morning
fluid
stiffness that eases with activity, whilst
non-inflammatory conditions are associ-
(a) ated with pain more than stiffness, and
the symptoms are usually exacerbated
Bone by activity.
Pain
Erosion
of bone As with all pain, it is important to record
the site, character, radiation, and
Effusion Synovium aggravating and relieving factors.
(excess spreading
fluid) over Patients may localize their pain accu-
damaged rately to the affected joint, or they may
cartilage
feel it radiating from the joint or even
(b)
into an adjacent joint. In the shoulder, for
Bone example, pain from the acromioclavicular
joint is usually felt in that joint, whereas
Painful pain from the glenohumeral joint or
friction rotator cuff is usually felt in the upper
Osteo- point
arm. Pain from the knee may be felt in
phyte
Scarred the knee, but can sometimes be felt in
synovium
the hip or the ankle. Pain due to irritation
Damaged of a nerve will be felt in the distribution
Effusion cartilage
(excess fluid) of the nerve – as in sciatica, for example.
The pain may localize to a structure near
(c)
rather than in the joint – for example, the
Figure 3. Diagrammatic represen- pain from tennis elbow will usually be
tation of the two main types of felt on the outside of the elbow joint.
arthritis: (a) a normal joint; (b) a
joint affected by rheumatoid The character of the pain is sometimes
arthritis; (c) a joint affected by helpful. Pain due to pressure on nerves
osteoarthritis often has a combination of numbness
and tingling associated with it. However,
the character of musculoskeletal pain
The assessment of these four areas is
can be very variable and is not always
discussed in the sections which follow.
helpful in making a diagnosis.
Current symptoms Pain of a non-inflammatory origin is
The main symptoms of musculoskeletal more directly related to use: the more
conditions are pain, stiffness and joint you do the worse it gets. Pain caused by
7
inflammation is often present at rest as of inflammatory disease as it can also occur
well as on use, and tends to vary from with trauma and in OA. Ankle swelling is
day to day and from week to week in an a common complaint, but this is more
unpredictable fashion. It flares up and commonly due to oedema than to swell-
then it settles down. Severe bone pain is ing of the joint.
often unremitting and persists through
the night, disturbing the patient’s sleep. Pattern of joint involvement
The pattern of joint involvement is very
Stiffness helpful in defining the type of arthritis,
In general, inflammatory arthritis is as different patterns are associated with
associated with prolonged morning different diseases. Common patterns of
stiffness which is generalized and may joint involvement include:
last for several hours. The duration of the
morning stiffness is a rough guide to the
Monoarticular – only one joint
activity of the inflammation. Commonly,
patients with inflammatory disease will affected
also describe worse stiffness in the eve- Pauciarticular (or oligoarticular)
ning as part of a diurnal variation. With – less than four joints affected
inflammatory diseases such as rheumatoid Polyarticular – a number of
arthritis (RA), where joint destruction joints affected
occurs over a prolonged period, the Axial – the spine is
inflammatory component may eventually predominantly affected
become less active and the patient may
then only complain of brief stiffness in As well as the number of joints affected, it
the morning. In contrast, osteoarthritis is useful to consider whether the large or
(OA) causes localized stiffness in the small joints are involved, and whether the
affected joints which is short-lasting (less pattern is symmetrical or asymmetrical.
than 30 minutes) but recurs after periods Rheumatoid arthritis, for example, is a
of inactivity. It is sometimes difficult for polyarthritis (it affects lots of joints) which
patients to distinguish between pain and tends to be symmetrical (if it affects one
stiffness, so your questions will need to joint it will affect the same joint on the
be specific. It may help to remind the other side), and if it affects one of a group
patient that stiffness means difficulty in of joints it will often affect them all, for
moving the joint. example, the MCP joints. Note, however,
Joint swelling that this describes established disease and
A history of joint swelling, especially if it early RA can affect any pattern of joints.
is intermittent, is normally a good indi- Spondyloarthritides, such as psoriatic
cation of an inflammatory disease pro- arthritis, are more likely to be asymmetri-
cess – but there are exceptions. Nodal cal and may be associated with inflam-
osteoarthritis, for example, causes bony, matory symptoms, such as early morning
hard and non-tender swelling in the stiffness, involving the spine. Osteoarthritis
proximal interphalangeal (PIP) and distal tends to affect weight-bearing joints and
interphalangeal (DIP) joints of the fingers. the parts of the spine that move most
Swelling of the knee is also less suggestive (lumbar and cervical).
8
Evolution of the problem: is it
acute or chronic?
You will need to listen to the patient’s
history to find out: Pain

t
When did the symptoms start

(a) Jan Apr Jul Oct
and how have they evolved? Was
the onset sudden or gradual?
t
Was the onset associated with a
particular event, e.g. trauma or
infection? Pain
t
Which treatments has the
condition responded to?
(b) Jan Apr Jul Oct
The way in which symptoms evolve and
respond to treatment can be an import- Figure 4. Graphs representing the
ant guide in making a diagnosis. Gout, chronology of a condition:
for example, is characterized by acute (a) for a patient with gout; (b) for a
attacks – these often start in the middle patient with rheumatoid arthritis
of the night, become excruciatingly
painful within a few hours, and respond questions for all systems as well as
well to non-steroidal anti-inflammatory specific enquiries relating to known
drugs (NSAIDs). complications of specific musculoskeletal
Musculoskeletal symptoms lasting more disorders.
than 6 weeks are generally described as The presence of an arthritis does not
chronic. Chronic diseases may start in- exclude other diseases, and these other
sidiously and may have a variable course conditions may affect both the patient
with remissions and exacerbations influ- and their arthritis. A combination of two
enced by therapy and other factors. It disabling diseases will be worse than
may be helpful to represent the chron- either one alone, and the impact on the
ology of a condition graphically (see patient will therefore be greater. In ad-
Figure 4). dition, other conditions may be affected
by the treatments prescribed for the
Involvement of other systems arthritis – for example, the presence of
Inflammatory arthropathies often involve liver disease may limit the use of disease-
other systems including the skin, eyes, modifying drugs for inflammatory arthritis,
lungs and kidneys. In addition, patients because most of these drugs can upset
with inflammatory disease often suffer the liver.
from general symptoms such as malaise,
weight loss, mild fevers and night sweats. Impact of the condition
Fatigue and depression are also common. on the patient
Osteoarthritis in contrast is limited to the Understanding the impact of the disease
musculoskeletal system. A comprehensive on the patient is crucial to negotiating a
history must include the usual screening suitable management plan. Ask open
9
questions about functional problems Medical students, doctors and prac-
and difficulty in doing things. It may be titioners should have an awareness of
easiest to get the patient to describe a the relationship between functional loss,
typical day, from getting out of bed to limitation of activity, and restriction of
washing, dressing, toileting etc. Poten- participation. Being unable to fully flex
tially sensitive areas, such as hygiene or a finger (loss of function) might lead to
sexual activity, should be approached difficulty, for example, with fastening
with simple, direct, open questions. The buttons (activity) which might have a
impact of the disease on the patient’s fairly minor impact on general life (par-
employment will be important. ticipation). The same loss of function,
however, might prevent a pianist from
A patient’s needs and aspirations are an playing (activity) which, for a professional
important part of the equation and will musician, might have a significant impact
influence their ability to adapt to the on his/her way of life (participation) (see
condition. Questions concerning the Figure 5).
things a person would like to do, but is
currently unable to, may pinpoint key Screening questions for
problems. Later negotiations with the musculoskeletal disorders
patient on balancing the risks and ben- These screening questions should be
efits of an intervention will be greatly incorporated into the routine systemic
affected by the patient’s priorities for enquiry of every patient. The main symp-
treatment. toms arising from disorders of the mus-

Health condition
(disorders, diseases, injuries)

Body functions & structure Activity Participation

(IMPAIRMENT) (LIMITATION) (RESTRICTION)

Environmental Personal
factors factors

Contextual factors

Figure 5. A model of disability – the relationship between loss of function, limitation

of activity and restriction of participation. Based on the World Health Organization’s
International Classification 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).

10
culoskeletal system are pain, stiffness, bearing before asking the patient to
swelling, and associated functional climb onto the couch (this is the approach
problems. The screening questions adopted in the accompanying DVD).
directly address these aspects:
pGALS (paediatric GALS) is a modification
of ‘GALS’ for use in school-aged children
t
‘Do you have any pain or stiffness
(see page 4 for further details).
in your muscles, joints or back?’
t
‘Can you dress yourself completely Gait
without any difficulty?’ t
Ask the patient to walk a few steps,
t
‘Can you walk up and down stairs turn and walk back. Observe the
without any difficulty?’ patient’s gait for symmetry, smooth-
ness and the ability to turn quickly.
A patient who has no pain or stiffness, t
With the patient standing in the ana-
and no difficulty with dressing or with tomical position, observe from behind,
climbing stairs is unlikely to be suffering from the side, and from in front for:
from any significant musculoskeletal bulk and symmetry of the shoulder,
disorder. If the patient does have pain or gluteal, quadriceps and calf muscles;
stiffness, or difficulty with either of these limb alignment; alignment of the
activities, then a more detailed history spine; equal level of the iliac crests;
should be taken (as described above). ability to fully extend the elbows and
knees; popliteal swelling; abnormali-
The musculoskeletal ties in the feet such as an excessively
examination high or low arch profile, clawing/
retraction of the toes and/or presence
Screening examination for of hallux valgus (see Figure 6).
musculoskeletal disorders Arms
(‘GALS’) t
Ask the patient to put their hands behind
A brief screening examination, which their head. Assess shoulder abduction
takes 1–2 minutes, has been devised for and external rotation, and elbow flexion
use in routine clinical assessment. This (these are often the first movements to
has been shown to be highly sensitive in be affected by shoulder problems).
detecting significant abnormalities of the t
With the patient’s hands held out, palms
musculoskeletal system. It involves in- down, fingers outstretched, observe the
specting carefully for joint swelling and backs of the hands for joint swelling
abnormal posture, as well as assessing and deformity.
the joints for normal movement. t
Ask the patient to turn their hands over.
Look at the palms for muscle bulk and
This screening examination is known by for any visual signs of abnormality.
the acronym ‘GALS’, which stands for Gait, t
Ask the patient to make a fist. Visually
Arms, Legs and Spine. The sequence in assess power grip, hand and wrist
which these four elements are assessed function, and range of movement in
can be varied – in practice, it is usually the fingers.
more convenient to complete the el- t
Ask the patient to squeeze your fingers.
ements for which the patient is weight- Assess grip strength.
11
Figure 6. With the patient in the anatomical position,
observe from behind, from the side, and from the front,
checking for:

Full elbow extension

Quadriceps bulk and symmetry

Forefoot abnormalities

Shoulder muscle bulk and symmetry

Spinal alignment

Gluteal muscle bulk and symmetry

Popliteal swelling or abnormalities

Calf muscle bulk and symmetry

Hindfoot abnormalities

Cervical lordosis
Thoracic kyphosis

Lumbar lordosis

Knee flexion/hyperextension

12
t
Ask the patient to bring each finger in
turn to meet the thumb. Assess fine
precision pinch (this is important
functionally).
t
Gently squeeze across the metacarpo-
phalangeal (MCP) joints to check for
tenderness suggesting inflammatory
joint disease. (Be sure to watch the
patient’s face for non-verbal signs of
discomfort.)
Legs Figure 7. Patellar tap test. Slide your
t
With the patient lying on the couch, hand down the patient’s thigh, compress-
ing the suprapatellar pouch. This forces
assess full flexion and extension of
any effusion behind the patella. With two
both knees, feeling for crepitus.
or three fingers of the other hand push
t
With the hip and knee flexed to 90º,
the patella down gently. In a positive test
holding the knee and ankle to guide the the patella will bounce and tap.
movement, assess internal rotation of
each hip in flexion (this is often the first
movement affected by hip problems). t
Ask the patient to tilt their head to
t
Perform a patellar tap to check for a each side, bringing the ear towards
knee effusion. Slide your hand down the shoulder. Assess lateral flexion of
the thigh, pushing down over the the neck (this is sensitive in the
suprapatellar pouch so that any detection of early neck problems).
effusion is forced behind the patella. t
Ask the patient to bend to touch their
When you reach the upper pole of the toes. This movement is important
patella, keep your hand there and functionally (for dressing) but can be
maintain pressure. Use two or three achieved relying on good hip flexion,
fingers of the other hand to push the so it is important to palpate for normal
patella down gently (see Figure 7). movement of the vertebrae. Assess
Does it bounce and ‘tap’? This indi-
lumbar spine flexion by placing two or
cates the presence of an effusion.
three fingers on the lumbar vertebrae.
t
From the end of the couch, inspect Your fingers should move apart on
the feet for swelling, deformity, and flexion and back together on extension
callosities on the soles. (see Figure 8).
t
Squeeze across the matatarsophalan-
Recording the findings from the
geal (MTP) joints to check for tender-
screening examination (GALS)
ness suggesting inflammatory joint
disease. (Be sure to watch the patient’s It is important to record both positive
face for signs of discomfort.) and negative findings in the notes. The
presence or absence of changes – in
Spine appearance or movement – in the gait,
t
With the patient standing, inspect the arms, legs or spine should be noted in a
spine from behind for evidence of grid. Figure 9(a) shows a normal result. If
scoliosis, and from the side for abnor- there are abnormalities, these should be
mal lordosis or kyphosis. recorded with a cross, and a note should
13
 (a)
Appearance Movement
Gait
Arms
Legs
Spine

(b)
Appearance Movement
Gait
Arms
Legs
Spine

Figure 9. Recording the findings

Figure 8. Assessing lumbar spine from the GALS screening examin-
flexion. Place two or three fingers on ation: (a) a normal result; (b) the
the lumbar vertebrae. Your fingers should results for a patient with wrist and
move apart on flexion and back together knee swelling and associated loss of
on extension. movement.

be made describing the abnormalities – either through the history or through the
for a patient with wrist and knee swelling screening examination (GALS). REMS
and associated loss of movement the re- involves the examination of a group of
cording might be as shown in Figure 9(b). joints which are linked by function, and
may require a detailed neurological and
If you have been alerted to a musculo- vascular examination.
skeletal problem – by the screening
questions, your examination or the REMS was born out of a desire to standard-
spontaneous complaints of the patient ize examination of the musculoskeletal
– you will need to take a detailed history system, allowing for more systematic
(as described above). You should also teaching and learning. It was developed
conduct a regional examination of rel- through a national consensus process
evant joints – this is described in the involving UK consultants in rheumatol-
sections which follow. ogy, orthopaedics and care of the elderly
and selected general practitioners. It led
Performing a regional to an agreed set of ‘core’ skills (see Appen-
examination of the musculo- dix 2). It is important to note, however,
skeletal system (‘REMS’) that a number of other specific tests may
be used by musculoskeletal practitioners
Regional examination of the musculo- as an adjunct to the REMS examination.
skeletal system refers to the more detailed
examination that should be carried out A paediatric REMS (pREMS) has also been
once an abnormality has been detected developed (see page 4 for further details).
14
There are five key stages which need to in and around the joint. Identifying in-
be completed during an examination of flammation of a joint (synovitis) relies on
the joints in any part of the body: detecting the triad of warmth, swelling
and tenderness.
t
Introduce yourself. Move
t
Look at the joint(s). The full range of movement of the joint
t
Feel the joint(s). should be assessed. Compare one side
t
Move the joint(s). with the other. As a general rule both
t
Assess the function of the joint(s). active movements (where the patient
moves the joint themselves) and passive
Introduction movements (where the examiner moves
the joint) should be performed. If there is
It is important to introduce yourself, ex-
a loss of active movement, but passive
plain to the patient what you are going
movement is unaffected, this may suggest
to do, gain verbal consent to examine,
a problem with the muscles, tendons or
and ask the patient to let you know if you
nerves rather than in the joints, or it may
cause them any pain or discomfort at any
be an effect of pain in the joints. In certain
time. In all cases it is important to make
instances joints may move further than
the patient feel comfortable about being
expected – this is called hypermobility.
examined. A good musculoskeletal ex-
amination relies on patient cooperation, It is important to elicit a loss of full flexion
in order for them to relax their muscles, or a loss of full extension as either may
if important clinical signs are not to be affect function. A loss of movement
missed. should be recorded as mild, moderate or
severe. The quality of movement should
Look
be recorded, with reference to abnor-
The examination should always start
malities such as increased muscle tone
with a visual inspection of the exposed
or the presence of crepitus.
area at rest. Compare one side with the
other, checking for symmetry. You should Function
look specifically for skin changes, muscle It is important to make a functional
bulk, and swelling in and around the joint. assessment of the joint – for example, in
Look also for deformity in terms of align- the case of limited elbow flexion, does
ment and posture of the joint. this make it difficult for the patient to
bring their hands to their mouth? In the
Feel
case of the lower limbs, function mainly
Using the back of your hand, feel for skin involves gait and the patient’s ability to
temperature across the joint line and at get out of a chair.
relevant neighbouring sites. Any swell-
ings should be assessed for fluctuance For the purposes of this handbook (and
and mobility. The hard bony swellings of the accompanying DVD) the REMS exam-
osteoarthritis should be distinguished ination has been divided into seven areas,
from the soft, rubbery swellings of in- each of which is described in detail below.
flammatory joint disease. Tenderness is However, it should be remembered that
an important clinical sign to elicit – both this is an artificial division and that one
15
group of joints may need to be ex- With the patient’s hands palms up:
amined in conjunction with another t
Look again for muscle wasting – if
group (e.g. the shoulder and cervical present, is it in both the thenar and
spine). hypothenar eminences? If it is only in
Examination of the hand and wrist the thenar eminence, then perhaps
This should normally take place with the the patient has carpal tunnel syndrome.
patient’s hands resting on a pillow as it Look for signs of palmar erythema.
can be painful for patients with elbow or Look at the wrist for a carpal tunnel
shoulder problems to hold their hands release scar.
up for long.
Feel
Look
With the patient’s hands palms up:
With the patient’s hands palms down:
t
Feel for peripheral pulses.
t
Look at the posture and for obvious
t
Feel for bulk of the thenar and hypo-
swelling, deformity, muscle wasting
and scars. thenar eminences and for tendon
t
Look at the skin for thinning and thickening.
bruising (signs of long-term steroid t
Assess median and ulnar nerve sen-
use) or rashes. sation by gently touching over both
t
Look at the nails for psoriatic changes the thenar and hypothenar eminences,
such as pitting or onycholysis (see and the index and little fingers respect-
Figure 10), and evidence of nailfold ively – is sensation normal and equal?
vasculitis.
t
Decide whether the changes are Ask the patient to turn their hands back
symmetrical or asymmetrical. over, so their palms are face down:
t
Do the changes mainly involve the t
Assess radial nerve sensation by light
small joints – PIPs and DIPs, MCPs, or touch over the thumb and index finger
the wrists? web space.
Ask the patient to turn their hands over: t
Using the back of your hand, assess
t
Does the patient have problems with skin temperature at the patient’s fore-
this due to radioulnar joint involvement? arm, wrist and MCP joints. Are there
differences?
t
Gently squeeze across the row of MCP
joints to assess for tenderness (watch-
ing the patient’s face for signs of dis-
comfort).
t
Bimanually palpate any MCP joints and
any PIP or DIP joints that appear swollen
or painful. Is there evidence of active
(a) (b) synovitis? (The joints will be warm,
swollen and tender and may have a
Figure 10. Fingernails affected by
‘rubbery’ feel, or you may even detect
psoriasis: (a) pitting; (b) onycholysis
effusions).
16
t
Are there hard, bony swellings? Check Function
for squaring of the carpometacarpal t
Ask the patient to grip your two
(CMC) joint of the thumb and for Heber- fingers to assess power grip.
den’s nodes on the DIPs. There may be t
Ask the patient to pinch your finger.
evidence of previous synovitis (thick- This assesses pincer grip, which is very
ened, rubbery but non-tender joints). important functionally.
t
Compare one joint with another, or
with your own, to decide whether the
small joints are normal.
t
Bimanually palpate the patient’s
wrists.
t
Finally run your hand up the patient’s
arm along the ulnar border to the
elbow. Feel and look for rheumatoid
nodules or psoriatic plaques on the
extensor surfaces.

Move
t
Ask the patient to straighten their
fingers fully (against gravity). If the
patient is unable to do this it may be
due to joint disease, extensor tendon
rupture or neurological damage – this
can be assessed by moving the fingers
passively.
t
Ask the patient to make a fist. If they
have difficulty tucking the fingers into
the palm, this may be an early sign of
tendon or small joint involvement.
Move the fingers passively to assess
whether the problem is with the ten-
don or nerves, or in the joint.
t
Assess wrist flexion and extension
actively (e.g. by making the ‘prayer’
sign) and passively (see Figure 11).
t
In patients where the history and ex-
amination suggest carpal tunnel syn-
drome perform Phalen’s test (forced
flexion of the wrists for 60 seconds) –
in a positive test this reproduces the Figure 11. The ‘prayer sign’ assesses
patient’s symptoms. wrist flexion and extension. If the
patient’s history and examination suggest
t
Assess the median and ulnar nerves
carpal tunnel syndrome, Phalen’s test
for power. This can be done by abduc-
(forced flexion of the wrist for 60 seconds)
tion of the thumb, and finger spread, may reproduce the patient’s symptoms.
respectively.
17
t
Ask the patient to pick a small object movements (such as hands behind
such as a coin out of your hand or head) will have been assessed during
check their ability to undo buttons. the screening examination.
This assesses pincer grip and function.
Examination of the shoulder
Examination of the elbow Look
Look t
With the shoulder fully exposed, in-
t
Look from the front for the carrying spect the patient from the front, from
angle, and from the side for flexion the side and from behind, checking
deformity. for symmetry, posture, muscle wasting
t
Look for scars, rashes, muscle wasting, and scars.
rheumatoid nodules, psoriatic plaques,
and swellings such as olecranon Feel
bursitis. t
Assess the temperature over the front
of the shoulder.
Feel t
Palpate the bony landmarks for tender-
t
Using the back of your hand, feel the ness, starting at the sternoclavicular
temperature across the joint and the joint, then the clavicle, acromioclav-
forearm. icular joint, acromion process and
t
Hold the forearm with one hand and, around the scapula.
with the elbow flexed to 90°, palpate t
Palpate the joint line – anterior and
the elbow, feeling the head of the posterior.
radius and the joint line with your t
Palpate the muscle bulk of the supra-
thumb. If there is swelling, is it fluc-
spinatus, infraspinatus and deltoid
tuant? Synovitis is usually felt as a
muscles.
fullness between the olecranon and
the lateral epicondyle. Move
t
Palpate the medial and lateral epi- t
Ask the patient to put their hands
condyles (for golfer’s and tennis elbow behind their head to assess external
respectively) and the olecranon process rotation, and then behind their back
for tenderness and evidence of bursitis. to assess internal rotation, comparing
Move one side with the other. If there is a
restriction in the latter movement,
t
Does the elbow extend fully and flex
fully? Assess both actively and pass- describe how far the patient can reach
ively, and compare one side with the – for example, to the lumbar, lower
other. thoracic or mid-thoracic level.
t
Assess pronation and supination, both t
With the elbow flexed at 90º and tucked
actively and passively, feeling for into the patient’s side, assess external
crepitus. rotation of the shoulder. Loss of ex-
ternal rotation may indicate a frozen
Function shoulder.
t
An important function of the elbow is t
Ask the patient to raise their arms
to allow the hand to reach the mouth. behind them and to the front. Assess
Other functionally important flexion and extension.
18
t
Ask the patient to abduct the arm to t
If there is a suggestion of leg length
assess for a painful arc (between 10º disparity, assess true leg lengths using
and 120º) (see Figure 12). Can you a tape measure. Measurements are
passively take the arm further? Be sure taken from the anterior superior iliac
to assess abduction from behind the crest to the medial malleolus of the
patient and observe scapular move- ankle on the same side. Compare the
ment. Restricted glenohumeral
measurements. In a fractured neck of
movement can be compensated for
femur the leg is shortened and
by scapular/thoracic movements.
externally rotated.
Function t
Check for scars overlying the hip.
t
Function of the shoulder includes
Feel
getting the hands behind the head
and back. This is important in washing t
Palpate over the greater trochanter for
and grooming. If this has not been tenderness.
assessed during the screening ex- Move
amination it should be done now. t
With the knee flexed at 90º, assess full
hip flexion, comparing one side with
Examination of the hip
the other and watching the patient’s
Look
face for signs of pain.
t
With the patient standing, assess for
t
Assess for a fixed flexion deformity of
muscle wasting (gluteal muscle bulk
in particular). the hip by performing Thomas’ test.
t
With the patient lying flat and face up, Keep one hand under the patient’s
observe the legs, comparing one side back to ensure that normal lumbar
with the other – is there an obvious lordosis is removed. Fully flex one hip
flexion deformity of the hip? and observe the opposite leg (see
Figure 13). If it lifts off the couch then
120º there is a fixed flexion deformity in
that hip. (As the pelvis is forced to tilt
a normal hip would extend allowing
the leg to remain on the couch.)
t
With the hip and knee flexed at 90º,
assess internal and external rotation
of both hips. This is often limited in
hip disease.
t
Assess the hip and proximal (gluteal)
muscle strength by performing the
Trendelenberg test. This involves the
patient alternately standing on each
10º
leg alone. In a negative test the pelvis
remains level or even rises. In an ab-
Figure 12. Abduction of the arm to
normal test the pelvis will dip on the
assess for a painful arc
contralateral side. (See Figure 14.)
19
Function
t
Ask the patient to walk – look for an
antalgic or Trendelenberg gait. An
antalgic gait simply means a painful
gait, normally resulting in a limp.
A Trendelenberg gait results from
proximal muscle weakness and com-
monly results in a ‘waddling’ walk.
Examination of the knee
Look
t
From the end of the couch and with
the patient’s legs straight, observe the Figure 13. Thomas’ test for fixed
knees, comparing one with the other, flexion deformity of the hip. Keep one
for symmetry and alignment. hand under the patient’s back to ensure
t
Is the posture of the knee normal? that there is no lumbar lordosis. Fully flex
Look for valgus deformity – where the one hip. If the opposite leg lifts off the
couch there is a fixed flexion deformity.
leg below the knee is deviated laterally
(As the pelvis tilts a normal hip would
(knock-kneed) – and for varus deform- extend allowing the leg to remain on the
ity – where the leg below the knee is couch.)
deviated medially (bow-legged).
t
Check for a knee flexion deformity
(distinguishing this from hip flexion
deformity by examining hip move-
ments as above).
t
Check for muscle wasting or scars. Normal
t
Look for redness suggesting inflam-
Abnormal
mation or infection.
t
Look for obvious swelling.
t
Check for a rash suggesting psoriasis.

NOTE: Popliteal swellings, varus and valgus

deformities may be more apparent with
the patient weight-bearing.

Feel
t
Using the back of your hand, feel the
skin temperature, starting with the
mid-thigh and comparing it to the
temperature over the knee. Compare
one knee to the other. Figure 14. The Trendelenberg Test
assesses hip and gluteal muscle
t
Palpate for tenderness along the
strength. In a normal test the pelvis
borders of the patella.
remains level. In an abnormal test the
t
With the knee flexed to 90º, palpate pelvis dips on the contralateral side.
for tenderness and swelling along the
20
 joint line from the femoral condyles to
the inferior pole of the patella, then
down the inferior patella tendon to
the tibial tuberosity.
t
Feel behind the knee for a popliteal
(Baker’s) cyst.
t
Assess for an effusion by performing a
patellar tap, as described for the
screening examination (see Figure 7).
t
If there is no obvious patellar tap, assess
for a fluid bulge by cross fluctuation.
Stroke the medial side of the knee
upwards (towards the suprapatellar
pouch) to empty the medial compart-
ment of fluid, then stroke the lateral
side downwards (distally) (see Figure
15). The medial side may refill, and
produce a bulge of fluid indicating an
Figure 15. Cross fluctuation (‘The
effusion. Bulge Sign’). Stroke the medial side of
the knee upwards towards the suprapatellar
Move
pouch. This empties the medial compart-
t
Ask the patient to flex the knee as far ment of fluid. Then stroke the lateral side
as possible to assess active movement. downwards (distally). The medial side may
Making sure the patient is fully relaxed, refill and produce a bulge of fluid, indicating
assess passive movement. This is done the presence of an effusion.
by placing one hand on the knee (feel-
ing for crepitus) and flexing the knee In a relaxed, normal patient there is
as far as possible, noting the range of normally a small degree of movement.
movement. Assess full flexion and ex- More significant movement suggests
tension of the knees, comparing one anterior cruciate ligament laxity.
to the other. t
Assess medial and lateral collateral
t
With the knee flexed to 90º, check the ligament stability by flexing the knee
stability of the knee ligaments. Look to 15º and alternately stressing the
initially from the side of the knee, joint line on each side. Place one hand
checking for a posterior sag or step- on the opposite side of the joint line
back of the tibia, suggesting posterior to that which you are testing, and
cruciate ligament damage. apply force to the lower tibia (see
t
Perform an anterior draw test. Place Figure 17). This may be done with the
both hands round the upper tibia, leg on the couch or with the lower tibia
with your thumbs over the tibial supported on the examiner’s pelvis.
tuberosity and index fingers tucked
under the hamstrings to make sure Function
these are relaxed. Stabilize the lower t
Ask the patient to stand and then walk
tibia with your forearm and gently pull a few steps, looking again for a varus
the upper tibia forward (see Figure 16). or valgus deformity (see Figure 18).
21
Examination of the foot and ankle
Look
With the patient sitting on the couch, their
feet overhanging the end of it:
t
Observe the feet, comparing one with
the other for symmetry.
t
Look specifically at the forefoot for nail
changes or skin rashes such as psoriasis.
t
Look for alignment of the toes and evi-
dence of hallux valgus of the big toe.
Look for clawing of the toes, joint swell-
ing and callus formation. If there is
clawing of the toes, calluses above
and below the MTP joints, pain and
restriction of movement, then there is
likely to be subluxation (partial dislo-
cation) of the MTP joints.
t
Look at the underside or plantar surface Figure 16. Anterior Draw Test. Place
both hands around the upper tibia, with
for callus formation.
your thumbs over the tibial tuberosity and
t
Look at the patient’s footwear. Check your index fingers tucked under the ham-
for abnormal or asymmetrical wearing strings to make sure these are relaxed.
of the sole or upper, for evidence of Stabilize the lower tibia with your forearm
poor fit or the presence of special and gently pull the upper tibia forward.
insoles. There should normally be a small degree
of movement; more substantial movement
With the patient weight-bearing: suggests laxity of the anterior cruciate
t
Look again at the forefoot for toe align- ligaments.
ment.
t
Look at the midfoot for foot arch t
Gently squeeze across the MTP joints,
position (a dropped arch in a normal watching the patient’s face for signs of
subject should resolve when standing discomfort.
on tip toes). t
Palpate the midfoot, the ankle and
t
From behind, look at the hindfoot for subtalar joints for tenderness.
Achilles tendon thickening or swelling.
t
Look for normal alignment of the hind- Move
foot (see fig. 18). Disease of the ankle t
Assess, both actively and passively,
or subtalar joint may lead to a varus or movements of inversion and eversion
valgus deformity.
at the subtalar joint, plus dorsi- and
Feel plantar flexion at the big toe and
t
Assess the temperature over the fore- ankle joint.
foot, midfoot and ankle. t
Movement of the mid-tarsal joints can
t
Check for the presence of a peripheral also be performed by fixing the heel
pulse. with one hand and, with the other
22
 hand, passively inverting and everting
the forefoot.

Function
t
If not already done, assess the patient’s
gait, watching for the normal cycle of
heel strike, stance, and toe-off.

Examination of the spine

Look
t
Observe the patient standing. Look
initially from behind the patient for any
obvious muscle wasting, asymmetry,
or scoliosis of the spine.
t
Look from the side for normal cervical
lordosis, thoracic kyphosis, and lumbar
lordosis.

Feel
Figure 17. Assessing medial and t
Feel down the spinal processes and
lateral collateral ligament stability. over the sacroiliac joints for alignment
With the patient’s leg on the couch or
supported on your pelvis, place one hand
and tenderness.
on the opposite side of the joint line to that t
Palpate the paraspinal muscles for
which you are testing and alternately stress tenderness.
the joint line on each side by applying
gentle force on the tibia. Move
t
Assess lumbar flexion and extension
by placing two or three fingers over
the lumbar spine. Ask the patient to
bend to touch their toes. Your fingers
should move apart during flexion and
back together during extension (see
Figure 8).
t
Ask the patient to run each hand in
turn down the outside of the adjacent
leg to assess lateral flexion of the spine.
t
Next, assess the cervical spine move-
ments. Ask the patient to: tilt their
head to each side, bringing the ear
towards the adjacent shoulder (lateral
valgus varus flexion); turn their head to look over
each shoulder (rotation); bring their
Figure 18. With the patient standing,
chin towards their chest (flexion); and
assess for a varus or valgus deformity.
tilt their head backwards (extension).
23
t
With the patient sitting on the edge of
the couch to fix their pelvis and their
arms crossed in front of them, assess
thoracic rotation (with your hands on
the patient’s shoulders to guide the
movement) (see Figure 19).
t
With the patient lying as flat as possible,
perform straight leg raising (see Fig-
ure 20). Dorsiflexion of the foot with
the leg raised may exacerbate the
pain from a nerve root entrapment or
irritation such as that caused by a
prolapsed intervertebral disc.
t
Assess limb reflexes (upper and lower)
and dorsiflexion of the big toe.

A brief neurovascular examination

should be carried out including assess- Figure 19. With the patient seated
ment of upper and lower limb reflexes, on the couch to fix the pelvis, assess
thoracic rotation.
dorsiflexion of the big toe, and assess-
ment of peripheral pulses. If there has
been any indication from the history of a
relevant abnormality, a full neurological
and vascular assessment – including
sensation, tone and power – should also
be made.

Recording the findings from the

regional examination
The positive and significant negative
findings of the REMS examination are
usually documented longhand in the
notes. If no abnormality is found then
‘REMS normal’ is sufficient. You may find
it helpful to document joint involvement
on a homunculus such as the one shown
in Figure 21. The total number of tender
and swollen joints can be used for cal- Figure 20. Dorsiflexion of the foot
culating disease activity scores – these with the leg straight and raised may
exacerbate pain from a nerve root
are useful in monitoring disease severity
entrapment or prolapsed disc.
and response to treatment over time.
24
 Investigations
There are three main types of investi-
gations: imaging of bones and joints,
blood tests, and synovial fluid analysis.

Imaging of bones and joints

A plain x-ray of the affected joint is one
of the most useful investigations. Changes
that occur on plain x-ray can be character-
istic of specific musculoskeletal diseases
such as rheumatoid arthritis, osteoarthritis
and gout (see Figure 22). Most changes
occur over a prolonged period of time
and x-rays can therefore provide a useful
historical record. Ultrasound is becoming
increasingly widely used, particularly in
identifying early joint inflammation (see
Figure 23). Other investigations including
magnetic resonance imaging (MRI), com-
puterized tomography (CT) scanning,
isotope bone scans and dual-energy x-ray
Figure 21. Printed homunculus for
annotation absorptiometry (DEXA) scans (for osteo-
porosis) all have an important role.

(d)
(a)
(b)
(a) (c) (c) (a)

(b) (c)
(b)

Normal Osteoarthritis Rheumatoid arthritis Gout

(a) narrow joint space (a) soft-tissue swelling (a) asymmetrical soft-
(b) osteophytes (b) ill-defined marginal tissue swelling
(c) subchondral sclerosis erosions (b) well-defined peri-
cysts (c) loss of joint space articular erosions
(d) periarticular osteoporosis (c) bony ‘hooks’

Figure 22. Diagrammatic representation of x-ray changes seen in chronic

rheumatic diseases
25
 in patients with rheumatoid arthritis.
A However, rheumatoid factor may also be
positive in other disease states and in the
* * J elderly, and is therefore not highly specific.
M
It is also important to consider infection
P as a cause of an arthropathy, particularly
in the case of a single joint – blood cul-
tures for infection should be taken even
if there is no fever.

Synovial fluid analysis

Figure 23. Ultrasound image of a Obtaining a sample of synovial fluid for
normal metacarpophalangeal joint.
analysis is an important skill to learn, and
M=metacarpal head, P=proximal phalanx,
A= articular cartilage, J= joint space, is vital to perform in order to exclude
**= synovial joint recess infection of a joint. Synovial fluid should
be sent for culture and gram staining.
If gout or other crystals are considered
Blood tests
as a cause of the problem, the fluid is
Blood tests can be useful in indicating examined for crystals under a polarizing
the degree of inflammation and in light microscope.
monitoring response to therapy. The
erythrocyte sedimentation rate (ESR) is Conclusion
one of the best-known inflammatory
markers and indicates what has been This handbook, together with the
happening over the last few days or accompanying DVD, has documented
longer. It is non-specific and influenced the core skills of musculoskeletal
by many things including anaemia. examination and history taking.
C-reactive protein responds more rapidly However, the importance of guided
to changes in inflammation – normally clinical teaching cannot be over-
within days. emphasized, and it is only through
A specific biochemical test which may be real-life clinical practice that competence
useful is for serum uric acid, which may and confidence in musculoskeletal
be raised in gout, although it may be clinical examination can be achieved.
unreliable during an acute episode.
We hope that you will find the handbook
Many of the inflammatory arthropathies and DVD valuable for reference and
are associated with increased titres of a revision, but Arthritis Research UK is
number of autoantibodies, although always delighted to receive feedback on
their significance is not always clear. its publications, and we would be very
Tests for rheumatoid factor, and the grateful if you would take the time to
more recently used anti-CCP (cyclic complete and return the response form
citrullinated peptide) antibody test, for at the back of the booklet, or write to the
example, are both often strongly positive address shown with your comments.

26
Appendix 1: Revision checklists
For full descriptions of the examination procedures please refer to the relevant sections
of the text.

History Taking

Current symptoms Involvement of other systems

t
Pain t
Skin, eye, lung or kidney symptoms?
t
Stiffness t
Malaise, weight loss, fevers, night
t
Swelling sweats?
t
Pattern of joint involvement Impact on patient’s lifestyle
Evolution t
Patient’s needs/aspirations
t
Acute or chronic? t
Ability to adapt to functional loss
t
Associated events
t
Response to treatment

Screening Questions

t
‘Do you have any pain or stiffness in your muscles, joints or back?’
t
‘Can you dress yourself completely without any difficulty?’
t
‘Can you walk up and down stairs without any difficulty?’

‘GALS’ Screening Examination

Gait Legs
t
Observe gait t
Assess full flexion and extension
t
Observe patient in anatomical t
Assess internal rotation of hips
position t
Perform patellar tap
Arms t
Inspect feet
t
Observe movement – hands t
Squeeze MTPJs
behind head Spine
t
Observe backs of hands and wrists t
Inspect spine
t
Observe palms t
Assess lateral flexion of neck
t
Assess power grip and grip strength t
Assess lumbar spine movement
t
Assess fine precision pinch
t
Squeeze MCPJs

27
‘REMS’ General Principles

Introduction t
Swellings
t
Introduce yourself t
Tenderness
t
Gain verbal consent to examine Move
Look for: t
Full range of movement – active
t
Scars and passive
t
Swellings t
Restriction – mild, moderate or
t
Rashes severe?
t
Muscle wasting Function
Feel for: t
Functional assessment of joint
t
Temperature

Examination of the hand and wrist

t
Introduce yourself/gain consent to t
Bimanually palpate swollen or

examine painful joints, including wrists
t
Inspect hands (palms and backs) for t
Look and feel along ulnar border
muscle wasting, skin and nail t
Assess full finger extension and full
changes finger tuck
t
Check wrist for carpal tunnel release t
Assess wrist flexion and extension
t
Feel for radial pulse, tendon – active and passive
thickening and bulk of thenar and t
Assess median and ulnar nerve
hypothenar eminences power
t
Assess median, ulnar and radial t
Assess function: grip and pinch,
nerve sensation picking up small object
t
Assess skin temperature t
Perform Phalen’s test (if suggestion
t
Squeeze MCPJs of carpal tunnel syndrome)

Examination of the elbow

t
Introduce yourself/gain consent to t
Assess full flexion and extension,

examine pronation and supination – actively
t
Look for scars, swellings or rashes and passively
t
Assess skin temperature t
Assess function – e.g. hand to nose
t
Palpate over head of radius, joint or mouth
line, medial and lateral epicondyles

28
Examination of the shoulder

t
Introduce yourself/gain consent to t
Assess movement and function:

examine hands behind head, hands behind
t
Inspect shoulders from in front, back
from the side and from behind t
Assess (actively and passively)
t
Assess skin temperature external rotation, flexion, extension
t
Palpate bony landmarks and and abduction
surrounding muscles t
Observe scapular movement

Examination of the hip

t
Introduce yourself/gain consent to t
Assess full hip flexion, internal and

examine external rotation
With the patient lying on couch: t
Perform Thomas’ test
t
Look for flexion deformity and leg With the patient standing:
length disparity t
Look for gluteal muscle bulk
t
Check for scars t
Perform the Trendelenberg test
t
Feel the greater trochanter for t
Assess the patient’s gait
tenderness

Examination of the knee

t
Introduce yourself/gain consent to t
Feel the popliteal fossa

examine t
Perform a patellar tap and cross
With the patient lying on couch: fluctuation (bulge sign)
t
Look from the end of the couch for t
Assess full flexion and extension
varus/valgus deformity, muscle (actively and passively)
wasting, scars and swellings t
Assess stability of knee ligaments
t
Look from the side for fixed flexion – medial and lateral collateral – and
deformity perform anterior draw test
t
Assess skin temperature With the patient standing:
t
With the knee slightly flexed t
Look again for varus/valgus
palpate the joint line and the deformity and popliteal swellings
borders of the patella t
Assess the patient’s gait

29
Examination of the foot and ankle

t
Introduce yourself/gain consent to (inversion and eversion), the big

examine toe (dorsi- and plantar flexion),
With the patient lying on couch: the ankle joint (dorsi- and plantar
t
Look at dorsal and plantar surfaces flexion) and mid-tarsal joints
of the foot (passive rotation)
t
Assess skin temperature t
Look at the patient’s footwear
t
Palpate for peripheral pulses With the patient standing:
t
Squeeze the MTPJs t
Look at the forefoot, midfoot (foot
t
Palpate the midfoot, ankle joint line arch) and the hindfoot
and subtalar joint t
Assess the gait cycle (heel strike,
t
Assess movement (actively and stance, toe-off)
passively) at the subtalar joint

Examination of the spine

t
Introduce yourself/gain consent to cervical flexion, extension, rotation

examine and lateral flexion
With the patient standing: With the patient sitting on couch:
t
Inspect from the side and from t
Assess thoracic rotation
behind With the patient lying on couch:
t
Palpate the spinal processes and t
Perform straight leg raising and
paraspinal muscles dorsiflexion of the big toe
t
Assess movement: lumbar flexion t
Assess limb reflexes
and extension and lateral flexion;

30
Appendix 2 : The core set of regional musculoskeletal
examination skills appropriate for a medical student at the
point of qualification (Coady et al 2004)

A student at the point of qualification 18. assess pincer grip in the hand
should be able to: 19. make a functional assessment of the
hand such as holding a cup
1. detect the difference between bony
20. correctly use the term ‘Heberden’s
and soft tissue swelling
nodes’
2. elicit tenderness around a joint
21. be able to perform Phalen’s test
3. elicit temperature around a joint
22. detect a painful arc and frozen
4. detect synovitis shoulder
5. understand the difference between 23. make a functional assessment of the
active and passive movements shoulder (can the patient put their
6. perform passive and active hands behind their head and back?)
movements at all relevant joints 24. perform external/internal rotation of
7. detect a loss of full extension and a the shoulder with the elbow flexed
loss of full flexion to 90º and held in against the
8. assess gait patient’s side
9. correctly use the terms ‘varus’ and 25. examine a patient’s shoulder from
‘valgus’ behind for scapular movement
10. assess limb reflexes routinely – when 26. assess the acromoclavicular joint (by
examining the spine and in other palpation alone)
relevant circumstances 27. palpate for tenderness over the
11. have an understanding of the term epicondyles of the elbow
‘subluxation’ 28. palpate for tenderness over the
12. where appropriate, examine greater trochanter of the hip
neurological and vascular systems 29. perform internal and external
when assessing a problematic joint rotation of the hip with it flexed to
(check for intact sensation and 90º
peripheral pulses) 30. perform Trendelenberg test
13. assess leg length with a tape 31. perform Thomas’ test
measure when assessing for a real 32. detect an effusion at the knee
leg length discrepancy 33. perform a patellar tap
14. make a qualitative assessment of 34. demonstrate cross-fluctuation or the
movement (not joint end feel but bulge sign when looking for a knee
features such as cog-wheeling) effusion
15. assess the median and ulnar nerves 35. test for collateral ligament stability
16. be able to localize tenderness within in the knee
the joints of the hand (palpate each 36. use the anterior draw test to assess
small joint of the hand if necessary) anterior cruciate ligament stability in
17. assess power grip the knee
31
37. examine the soles of a patient’s feet 48. palpate the spinal processes
38. recognize hallux valgus, claw and 49. assess lateral and forward flexion of
hammer toes the lumbar spine (using fingers not
39. assess a patient’s feet with them tape measure)
standing 50. assess thoracic rotation with the
40. assess for flat feet (including the patient sitting
patient standing on tip toes)
41. recognize hindfoot/heel pathologies
42. assess plantar and dorsiflexion of Bibliography
the ankle
43. assess movements of inversion and Doherty M, Dacre J, Dieppe P, Snaith M.
eversion of the foot The ‘GALS’ locomotor screen. Annals of
the Rheumatic Diseases 1992;51(10):1165–9.
44. assess the subtalar joint
45. perform a lateral squeeze across Coady D, Walker D, Kay L. Regional
the metatarsophalangeal joints examination of the musculoskeletal
46. assess flexion/extension of the system (REMS): a core set of clinical skills
big toe for medical students. Rheumatology
47. examine a patient’s footwear 2004;43(5):633–9.

This handbook and the accompanying DVD have been produced as a result of an
Arthritis Research UK Educational Research Fellowship. For details of all the research grants
and fellowships available please visit the website: www.arthritisresearchuk.org

For further copies of the DVD (stock code 3964), or to receive a full list of Arthritis Research
UK’s other educational resources, please contact:

Arthritis Research UK, PO Box 5050, Sherwood Park, Annesley, Nottingham NG15 0DL
Email: [email protected]
Phone: 0800 389 6692
32
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An overview of Practical advice for

current research and GPs on management
practice in rheumatic of rheumatic disease

Topical disease

Hands On
Reviews Reports on the Rheumatic Diseases | Series 6 | Summer 2012 | Hands On No 12
Reports on the Rheumatic Diseases | Series 6 | Summer 2012 | Topical Reviews No 12

The Bone and Joint Decade: Sport and exercise medicine

working together to make musculoskeletal Patrick Wheeler1,2,3, James Hopkinson1, Ricky Shamji1, Ruth Pearson1

conditions a public health priority

1
Department of Sport and Exercise Medicine, University Hospitals of Leicester NHS Trust
2
Department for Health, University of Bath
3
School of Sport, Exercise and Health Sciences, Loughborough University

Anthony D Woolf Musculoskeletal conditions are common in all Introduction

Chair, International Coordinating Council, countries and cultures. They include joint diseases, Editorial
Physical activity and musculoskeletal problems
Bone and Joint Decade 2010–2020 spinal disorders, back and regional pain problems, The wait for the 2012 Olympic and Paralympic
osteoporosis and fragility fractures, and conse- are closely intertwined, and both are significant
Duke of Cornwall Department of Rheumatology, Games in London is nearly over. We are all
Royal Cornwall Hospital, Truro quences of injuries and trauma. They affect hundreds issues affecting healthcare worldwide. Physical
looking forward to exciting and inspiring per-
of millions of people around the world. They are inactivity is one of the leading public health
formances from the world’s elite sportspeople.
t
Musculoskeletal conditions are common in characterised by long-term pain and physical dis- Hopefully the Olympics will encourage people problems in the UK, and musculoskeletal prob-
all countries and cultures ability, of which they are the commonest cause. of all abilities to take up exercise which will lems have historically constituted the group of
They have the worst impact on quality of life of have significant benefits at a personal and conditions with the greatest health burden in
t
Worldwide, they are the commonest cause many chronic diseases. As a consequence they are a public health level. the UK. The majority of issues relating to these
of long-term pain and physical disability, major burden on health and social care. This burden two domains can be appropriately managed
and have a major impact on quality of life Primary care is ideally placed to promote and
will increase with changing demographics of popu- within general practice; however, when the re-
prescribe exercise to patients. Inevitably some
t
There are effective strategies to prevent lations across the globe. There are effective ways of quirements of an individual exceed what it is
people will develop musculoskeletal problems
and treat many of these disorders preventing and controlling musculoskeletal con- and will need our help. In general these needs possible to provide within primary care the new
ditions but these are not being implemented with can be managed successfully without need specialty of Sport and Exercise Medicine (SEM) is
t
These chronic conditions are not given equity and there is a lack of policies and priorities to call on the expertise of secondary care but ideally placed to assist.
the public health priority afforded to high- for the prevention, management and research sometimes this is necessary.
mortality conditions such as cancer and related to these conditions. As a result there is Patients commonly present to general practice
infectious diseases. As a result there is enormous unmet need and avoidable disability. Sport and Exercise Medicine (SEM) was rec- with musculoskeletal problems, and only a small
enormous unmet need and avoidable ognised in the United Kingdom as a medical number need investigations or onward referral
The Bone and Joint Decade (BJD) is a global alliance specialty in its own right in 2006 and specialist to secondary care. In addition many patients with
disability
promoting musculoskeletal health. It brings together training and consultant posts continue to musculoskeletal problems will see allied health
t
The Bone and Joint Decade is a global professional, scientific and patient organisations develop. Now is a good opportunity to intro-
professionals at some point: these include physio-
alliance which aims to increase awareness from all countries relevant to all conditions that duce this new speciality and highlight how
important it is for it to be commissioned and therapists and podiatrists both within and outside
and influence policy around musculo- affect musculoskeletal health. It has come together
made widely available across the country. the NHS, as well as osteopaths and chiropractors
skeletal conditions because of the lack of recognition of the importance
of musculoskeletal health and of the needs of people who have historically worked outside the NHS but
Simon Somerville whom some services are now choosing to employ
with musculoskeletal conditions. Entering the second
on a sessional basis.

Providing answers today and tomorrow Providing answers today and tomorrow
Other resources we offer
In addition to this guide, Arthritis Research UK offers a range of other resources for students
and healthcare professionals. These include our Reports on Rheumatic Diseases, Hands
On and Topical Reviews, DVDs including pGALS (paediatric Gait, Arms, Legs, Spine), the
JointZone website www.jointzone.org.uk, and our Collected Reports volumes. Please
visit our website www.arthritisresearchuk.org and follow the links.

Funding opportunities
(for further details, visit our website www.arthritisresearchuk.org or return the form
overleaf to the address shown)

For medical students:

Student electives – provide the opportunity and the funding for medical students to take
part in an overseas elective relevant to rheumatology/musculoskeletal medicine.
Medical student prize – offered each year in each UK medical school. In addition to the
prize money, winners receive a certificate and silver medal, and three national winners are
also given funding to attend the BSR annual conference.
Summer studentships – provide a stipend to allow medical students to take part in
supervised biomedical and/or clinical research projects in musculoskeletal disease. The
research would normally be linked to a larger project but would have specific objectives
which are achievable within the 8-week studentship.

For nurses and allied health professionals:

Training fellowships – offered to nurses and allied health professionals committed to the
care of patients with musculoskeletal diseases to undertake training or research at a UK
institution leading to a PhD or other higher degree.
Training bursaries – provide funding for research, practical experience, and formal
education in rheumatology. Funding is offered towards the costs of attending either:
t
a short training/diploma course or modules from a taught MSc programme in the UK
t
a full MSc course or taught/professional doctorate in the UK
Educational travel awards – offered to nurses or allied health professionals either:
t
towards the costs of attending a national or international meeting in order to present a
paper or poster, chair a session or lead a discussion, or
t
to enable nurses or allied health professionals to visit wards/units in their specialty for
the purpose of studying other methods of care of patients with arthritis and related
musculoskeletal diseases.
Nursing and AHP prizes – offered each year in association with BHPR and other specialist
rheumatology AHP groups. In addition to the prize money, winners receive a silver medal
and certificate in recognition of their achievement.
Arthritis Research UK is the charity leading the fight
against arthritis.
We’re working to take the pain away for sufferers of all forms of arthritis and
helping people to remain active. We do this by funding high class research,
providing information and campaigning.

This guide is made available free of charge because of

donations we receive. Can you help support our work?

Visit www.arthritisresearchuk.org/events.aspx
to find out more about our fundraising events.
Copeman House, St Mary’s Court
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