Locomotor Exam

Assessment of the rheumAtologicAl pAtient

Rheumatological examinationJane e Dacre

Jennifer g Worrall

Abstractthe locomotor system is extensive and locomotor problems are com-

mon. the most efficient and effective way to examine the locomotor

system is to perform a screening examination, the gAls (gait, arms, legs,

spine) screen, followed by a more detailed examination of any abnormal

findings. this detailed, regional examination of individual joints follows

the principles of ‘look, feel, move, function’.

Keywords gAls; rheumatological examination; locomotor; musculoskeletal

The locomotor system can be difficult to examine because it involves many different anatomical structures. A full examina-tion is time-consuming and seldom necessary. Most rheumatolo-gists perform a short screening examination followed by a more detailed assessment of the affected structures, with additional examination of other systems if indicated. A screening exami-nation of the locomotor system should be included as part of the routine checking of all patients. This contribution outlines the GALS (gait, arms, legs, spine) screen, which is a quick, reli-able screen of the locomotor system, and describes more detailed examination of the lumbar spine, hip, knee, shoulder, elbow, hand and wrist, which are the most common sites for symptoms of locomotor disease. An abnormal finding on the GALS screen should lead to a more detailed examination of the affected joint. A consensus view of the regional examination of the musculosk-eletal system (REMS) has now been agreed.

Anatomy and physiology of the locomotor system

The locomotor system comprises bones, joints and muscles with associated ligaments, tendons and bursae. The principal types of joint are fibrous and synovial. Synovial joints permit a wide range of movement. Fibrous joints have a simpler structure than synovial joints and are less susceptible to disease and injury; the

Jane E Dacre FRCP is Professor of Medical Education and Director of

the Academic Centre for Medical Education at the Royal Free and

University College Medical School, London, UK, and Consultant

Physician and Rheumatologist at the Whittington Hospital, London.

Conflicts of interest: none declared.

Jennifer G Worrall FRCP is Consultant Rheumatologist at the Whittington

Hospital, London, UK. She qualified from the Royal Free Hospital,

London, and trained in general medicine and rheumatology. Conflicts

of interest: none declared.

meDicine 34:9 34

bones are connected by dense fibrous tissue and only a small range of movement is permitted.

In a synovial joint (Figure 1), the bone ends are covered by hyaline cartilage and the whole structure is enclosed in a cap-sule. The capsule is lined with synovium – a specialized tissue responsible for lubricating the joint and nourishing the articu-lar cartilage, which has no blood supply of its own. Synovium produces synovial fluid by a combination of ultra-filtration of plasma and active secretion of large molecules (e.g. hyaluronan). Normal synovial fluid is highly viscous because of entanglement of these molecules, whereas inflammatory synovial fluid has a low viscosity because the enzymes and free radicals associated with inflammation break them down.

The two main causes of arthritis are degeneration and inflam-mation. In degenerative disease (osteoarthritis), the articular cartilage becomes dehydrated, thin and fibrillated. Abnormal mechanical stress is transmitted to the underlying bone, which remodels, becoming sclerotic and forming osteophytes at the joint margins. Inflammatory disease (e.g. rheumatoid arthritis, RA) is characterized by primary inflammation of the synovium (synovitis), which damages the articular cartilage and bone, leading to bony erosion. Synovium also lines the tendon sheaths and bursae, which may be involved in the disease process.

Tendons, ligaments and fascial structures are attached to the periosteum by a specialized structure called the enthesis. Ankylosing spondylitis and related inflammatory arthritis are associated with inflammation of the enthesis. Plantar fasciitis is an enthesitis.

Structure of a synovial joint

Muscle

Bursa

Bone

Cavity (joint space) containing synovial fluid

Hyaline cartilage

Synovium

Joint capsule

Tendon

Enthesis

Structures in bold may give rise to pain or tenderness

Figure 1

0 © 2006 published by elsevier ltd.


GALS screen

Preliminary assessment using the GALS screen identifies most locomotor system problems. These problems can then be charac-terized in more detail using a regional examination. A method for recording the results of the GALS screen is shown in Table 1.

With the patient undressed to his or her underwear, look from the front, back and sides for any asymmetry or deformity such as unequal leg length, flexion deformity at hip or knee, or abnormality of spinal curvature (e.g. kyphosis, scoliosis, loss of lumbar lordosis).

GaitAsk the patient to walk a few steps, turn around and walk back. Observe whether he or she swings the arms and moves the legs symmetrically. The fluidity of the normal gait may be lost when a patient experiences pain, because persistent muscle contraction splints the painful part.

In an antalgic gait, the patient avoids bearing weight on the painful leg or foot and spends most of the gait cycle on the unaffected leg. If the gait is normal, the patient is unlikely to have any major locomotor problems in the legs or lumbar spine.

Arms • Ask the patient to hold out the hands, palms down. Inspect the arms for obvious abnormalities (e.g. swelling, deformity, nodules). Inspect the hands for skin or nail changes that may be associated with arthritis (e.g. the scaly rash or onycholysis of psoriasis (Figure 2), the digital vasculitis of systemic lupus erythematosus, the colour changes of Raynaud’s disease). • Ask the patient to turn the hands over. This assesses the radio-ulnar joint, which is commonly affected in RA (Figure 3). Ensure that the elbows are tucked in to the trunk to prevent the patient using his or her shoulders to reproduce this movement. Inspect the palms, looking for signs such as Dupuytren’s contracture and thenar wasting. • Ask the patient to make a tight fist with each hand (Figure 4) and check that the fingers flex fully into the palms. Power of grip can be assessed by offering the index and middle fingers of your hands and asking the patient to grip your fingers tightly. • Ask the patient to place the tip of the index finger onto the tip of the thumb. This assesses opposition of the thumb and fine movements, which are often limited in RA. • Squeeze across the hand from the second to the fifth meta-carpophalangeal joints, to assess tenderness.

Record of the GALS locomotor system screening examination in a normal patient

Appearance Movement

g – gait ✓ ✓A – arms ✓ ✓l – legs ✓ ✓s – spine ✓ ✓

Table 1

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• Ask the patient to put the hands behind the head, pressing the elbows back (Figure 5). This movement assesses abduction and external rotation at the shoulders and flexion at the elbows, and is of functional importance in combing the hair.

Legs • With the patient lying supine on the couch, inspect for flexion deformity at the hip or knee, then passively flex the hip and knee with a hand placed over the knee. Assess knee flexion while feel-ing for crepitus and assessing hip flexion. • Passively internally rotate the hip with the knee and hip still flexed (Figure 6). Internal rotation is the first movement to become restricted in hip disease. • Ask the patient to dorsiflex, extend, invert and evert the ankle to assess tibiotalar movement (affected by osteoarthritis) and subtalar movement (affected by RA). • Squeeze across the foot at the level of the metatarsophalan-geal joints, looking for tenderness. • Inspect the feet for callosities from the end of the bed.

Spine • With the patient standing, ask him or her to put the ear on the shoulder on the same side, keeping the shoulder still (Figure 7). This assesses lateral flexion of the cervical spine, which is the first movement to become restricted in degenerative or inflam-matory disease.

Figure 2 onycholysis in psoriatic arthritis.

Figure 3

Assessment

of radio-ulnar

function.



• Place two of your fingers over adjacent spinous processes in the lumbar region and ask the patient to bend over and touch the toes. Your fingers should move apart. This is an essential part of the assessment of the lumbar spine because patients with a rigid spine caused by ankylosing spondylitis may be able to touch their toes without moving the spine if they have supple hips.

Joint examination for common symptoms

If abnormalities are found using the GALS screen, a more detailed examination, or REMS, (‘look, feel, move, function’) of the abnormal joints should be performed. • Look for swelling and deformity. • Feel to assess whether swelling is soft (soft tissue or fluid) or hard (bony) and, if it is soft, whether it is warm or cool. • Move the joint to assess range of movement and instability. Do not worry if you cannot remember the range of movement of all the joints. If the problem is unilateral, you can compare the abnormal side with the normal side; if it is bilateral, compare it with your own joints. • Assess the joints for function.

Figure 4 making a tight fist to assess hand power and function.

Figure 5 Assessment of abduction and external rotation of the

shoulders.

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Neck and back painThe lumbar spine should be examined with the patient standing, then supine and then prone.

Standing: look at the curvature of the spine. Scoliosis may be caused by muscle spasm in acute sciatica or may be postural if the patient’s legs are of unequal length. Loss of normal lordosis is a sign of inflammatory spinal disease (e.g. ankylosing spondy-litis). Palpate the erector spinae muscles to assess spasm.

Ask the patient to lean to each side in turn and run his or her hand down the side of the leg to the knee; this assesses lateral flexion, which is often the first movement to become restricted in spinal disease. Then ask the patient to lean backwards to assess extension. Painful extension suggests facet joint disease (usually degenerative). It is helpful to place your hands lightly on the patient’s shoulders when assessing lateral flexion and extension; this gives patients confidence that you will support them if they feel unsteady.

Ask the patient to lean forwards to assess flexion. Start by placing two fingers on the spine, one finger about 5 cm below the lumbosacral junction and one finger about 10 cm above. As the patient bends forwards, watch how your fingers move apart. This is the modified Schober’s test.

Figure 6 flexion of the knee with internal rotation of the hip.

Figure 7

Assessment of

lateral flexion of

the neck.

© 2006 published by elsevier ltd.


Percuss the spine gently with the side of your closed fist. This may elicit local tenderness in patients with metastases or infec-tion in the bone.

Assess cervical spine movements by asking the patient to bring their ear towards each shoulder in turn (Figure 7), then turn their head to look over each shoulder, then put their chin on their chest, then look up at the ceiling.

Supine: with the patient on the couch, assess movements at both hips (see below) before performing the sciatic stretch test – straight-leg raising may be restricted by hip disease in addition to muscle spasm in sciatica.

To assess straight-leg raising, lift the leg from underneath the ankle (not by grasping the leg from above, which can cause pain), keeping the knee extended. When the limit is reached, perform the sciatic stretch test by passively dorsiflexing the ankle (Figure 8). The test assesses irritation of the lower lumbar and upper sacral nerve roots (L5–S1). If the patient complains of sen-sory disturbance (pain, pins and needles or numbness) anywhere below the knee, the test is positive. Pain in the lumbar spine or at the back of the knee, usually caused by tight hamstrings, is not relevant to the test.

Gaenslen’s test should be performed with the patient supine; this stresses the sacroiliac joints and provokes pain in the affected joint when sacroiliitis is present. To perform the test, passively flex the hip and knee on one side, bringing the knee onto the patient’s trunk, then externally rotate and abduct the hip. While holding the leg in this position, grasp the contra-lateral iliac crest and attempt to distract it laterally. This stresses the sacroiliac joint on that side and, if the joint is inflamed, the patient com-plains of pain in the low back, over that joint.

A brief neurological examination of the legs should also be performed with the patient supine (see MEDICINE 32:9: 27–30).

Prone: ask the patient to turn over, remove the pillow from the head of the couch and place it under the pelvis and abdomen. This slightly flexes the lumbar spine and is a comfortable position for the patient.

Sciatic stretch

Lift the leg with the knee flexed and then extend the knee (a);

in patients with sciatic root irritation, this induces pain. Lift the

straight leg to induce pain and confirm root irritation by lowering

the leg slightly then dorsiflexing the ankle (b).

a

b

Figure 8

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Palpate down the spinous processes in turn and along the erector spinae muscles to assess tenderness, then perform the femoral stretch test (Figure 9) to assess irritation of the upper lumbar nerve roots (L2 and L3), which contribute to the femo-ral nerve. Passively flex the knee and, holding the foot, gently extend the hip. If this provokes spasm of the quadriceps and the patient complains of sensory disturbance over the front of the thigh, the test is positive.

Hip painDisease of the hip joint causes pain in the groin that may radiate down the anterior thigh to the knee. There may be associated muscle wasting on inspection. Pain over the lateral pelvis and thigh generally results from trochanteric bursitis, whereas pain in the buttock may be caused by ischial bursitis, sacroiliitis or lumbar spine disease.

To assess the hip joints, ask the patient to lie supine on the couch. Look for flexion deformity at the hip. The hip joints are deep and cannot be palpated directly. Trochanteric bursitis, how-ever, can be identified by an area of tenderness over, and distal to, the greater trochanter. Assess flexion at the hip with the knee flexed to relax the hamstrings, then assess internal and external rotation in flexion (Figure 6); internal rotation is often restricted early in hip disease. Place the hip in the neutral position, extend the knee, and abduct and adduct the hip in turn (take care in patients who have undergone hip replacement, because forced adduction may cause dislocation). Extension is assessed by hanging the leg over the side of the couch or with the patient in the prone position.

Perform Thomas’s test by placing one hand under the patient’s lumbar spine and fully flexing one hip. Look at the opposite leg which will lift off the couch if there is a fixed flexion deformity at the hip.

Knee painEnsure that the patient is sitting propped up on the couch with the knees extended and the legs relaxed. Look for flexion defor-mity and for valgus and varus deformities. Look at the quadri-ceps muscles, which may be wasted in significant knee disease.

Femoral stretch

With the patient prone, flex the knee to 90˚ (a) then lift the leg (b)

passively extending the hip. If the test is positive, pain is felt over

the anterior thigh.

a

b

Figure 9



Look for swelling. Normal knees have a hollow on the side of the patella; disappearance of this in patients with a large effusion causes obvious suprapatellar swelling (Figure 10). The infrapa-tellar fat pads may be prominent but are normal. Depress the patella with your fingertips; when the pressure is released, it bounces up (the patella tap) when a large effusion is present. A small effusion may be detected by the ‘bulge’ test. Empty the hol-low next to the medial aspect of the patella by stroking it firmly, then push with the flat of your hand against the lateral aspect of the knee. If the medial hollow is filled by a bulge, an effusion is present (the normal knee contains only 1–2 ml of fluid, insuf-ficient to cause a bulge).

Feel the knee for warmth and palpate the popliteal fossa for swelling, which is most often caused by a Baker’s cyst. Effusions and Baker’s cysts are most commonly found in inflammatory dis-ease, but may also occur in osteoarthritis of the knee.

Flex and extend the knee to its fullest extent in both direc-tions, with your hand placed on the knee to feel for crepitus. Lift the foot off the couch to look for hyperextension beyond 10°; this is a feature of hypermobility syndrome and is commonly associ-ated with mechanical knee pain. Assess stability by attempting to stretch the knee medially and laterally while holding it in a few degrees of flexion. If there is abnormal movement, the collateral ligaments are lax.

Examine the anterior cruciate ligament using the Lachman test. Pull the tibia forwards on the femur with the knee flexed at 20–30°. Anterior movement suggests anterior cruciate instability. The anterior and posterior cruciate ligaments can also be tested by flexing the knee and stabilizing the foot on the bed. Hold the knee circumferentially just below the joint, with the thumbs anteriorly. Pull forwards to test the integrity of the anterior cruci-ate ligament, then push to test the posterior cruciate ligament. Instability is revealed as abnormal movement of the tibia in an anterior or a posterior direction.

Shoulder painShoulder pain has many causes. Pain from the glenohumeral joint (the shoulder joint proper) radiates to the front and side of the upper arm. Pain over the top of the shoulder suggests acromioclavicular joint disease, which is confirmed by point tenderness over the joint and pain on forced extension of the shoulder.

Figure 10 suprapatellar swelling.

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With the patient sitting and facing you, observe the shoulders for asymmetry and swelling. Effusions point anteriorly. Palpate the capsule over the anterior humeral head and the supraspina-tus tendon over the lateral upper humerus for tenderness. Assess flexion, extension, abduction, adduction and internal and exter-nal rotation actively and passively. In glenohumeral joint disease such as adhesive capsulitis and RA (degenerative disease of this joint is not common), passive and active movements are equally restricted. In contrast, disease of the rotator cuff (e.g. calcific tendinitis, degenerative rupture) causes restricted active move-ments, but passive movements remain full.

Painful arc syndrome is a feature of rotator cuff disease. It is detected by asking the patient to raise the arms above the head, close to the ears, with the palms turned outwards (i.e. with the shoulders internally rotated), then asking him or her to slowly lower the arms sideways. Increased pain, caused by compression of the inflamed tendon between the acromion and the rotating humeral head, occurs at some point in the arc of movement.

Elbow painThe elbow is seldom affected by degenerative disease but is often involved in inflammatory arthritis, particularly rheumatoid. Carefully inspect the extensor aspect of both elbows; this is a common site for psoriasis, gouty tophi and rheumatoid nodules, and an inflamed olecranon bursa may be found. Elbow effusions may be detected by loss of the gutters normally present between the olecranon and the medial and lateral epicondyles respec-tively. Ask the patient to hold the arms out sideways with the elbows fully extended and look for flexion deformities, then ask him or her to bend the elbows fully. The radio-ulnar joint has been assessed in the GALS screen, but if pronation or supination is painful or restricted, ask the patient to repeat the movement while you palpate the radial head on the lateral side of the elbow; you may feel crepitus.

Pain in the hand and wristThe hand is examined in detail in the GALS screen (see above), but the following tests should also be performed.

When examining the hands, stand in front of the patient and examine both hands simultaneously, comparing the two sides. When you ask patients to hold out their hands, ensure they

Figure 11 Dropped fingers in rheumatoid arthritis as a result of

extensor tendon rupture.



spread their fingers and do not rest their hands on their knees; you will otherwise miss minor degrees of flexion deformity of the fingers and the dropped fingers characteristic of extensor tendon rupture (Figure 11).

Pain in the fingers may be a result of osteoarthritis; look for bony swellings on the distal interphalangeal joints (Heberden’s nodes) and the proximal interphalangeal joints (Bouchard’s nodes). Pronounced soft tissue swelling of these joints indicates inflammatory arthritis. Severe inflammatory arthritis (e.g. rheu-matoid, psoriatic) with marked bone loss may lead to ‘telescop-ing’ of the fingers, with redundancy of the soft tissues, and to flail joints, which have lost all integrity. A combination of fixed joints (caused by bony ankylosis) and flail joints is characteristic of psoriatic arthritis.

Also assess hand function. Ask the patient to write his or her name, to fasten and unfasten buttons, and to hold a cup and bring it to the lips. ◆

FuRTHER REAdiNG

coady D, Walker D, Kay l. regional examination of the musculoskeletal

system (rems). A core set of clinical skills for medical students.

Rheumatology 2004; 43: 633–9.

Dacre J e, Kopelman p. A Handbook of clinical skills. london: manson,

2002.

(A guide to history-taking and examination of all systems.)

meDicine 34:9 34

Doherty m, Dacre J, Dieppe p, snaith m. the ‘gAls’ locomotor screen.

Ann Rheum Dis 1992; 51: 1165–9.

Practice points

• A full examination is time-consuming and seldom

necessary

• most rheumatologists perform a short screening examination

(e.g. gAls)

• if an abnormality is detected during the screen, a regional

examination must be performed

• follow the ‘look, feel, move, function’ protocol

Acknowledgement

the authors thank manson publishing, london, uK for photographs

of the gAls screen, and the photography and illustrations centre at

the Archway campus, royal free and university college london, uK.


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Locomotor Exam