CLINICAL EXAMINATION

Diagnostic approach depends upon assessment of function

SELECTIVE TENSION Passive movements stress inert structures Resisted movements test contractile structures

EXAMINATION FOLLOWS A SET ROUTINE

OBSERVATION Face Posture Gait

HISTORY Age and occupation, sports hobbies, lifestyle Site and spread Onset and duration

HISTORY Symptoms and behaviour Other joint involvement Past medical history Medications

INSPECTION Bony deformity Colour changes Wasting Swelling

PERIPHERAL JOINTS Palpate for: Heat Swelling Synovial thickness Not for tenderness

STATE AT REST Position of the pain

ACTIVE MOVEMENTS Pain Range Willingness

OTHER FINDINGS Painful arc

PASSIVE MOVEMENTS FOR INERT STRUCTURES Joint capsule Bursa Dura mater Nerve root Ligament Fascia Dural nerve root sleeve Relaxed muscle and tendon

PASSIVE MOVEMENTS FOR INERT STRUCTURES Pain Range End-feel

PASSIVE MOVEMENTS Capsular pattern Non-capsular pattern

NORMAL END-FEEL Hard Soft Elastic

ABNORMAL END- FEEL ‘ Hard ’ Spasm Springy Empty

CAPSULAR PATTERN Arthritis Varies from joint to joint Limitation in a fixed proportion which varies according to the joint Same whatever the cause of the arthritis

NON-CAPSULAR PATTERN Intra-articular displacement Ligamentous lesion Extra-articular lesion

RESISTED TESTS FOR CONTRACTILE STRUCTURES Muscle Tendon Attachments to bone

RESISTED TESTS Pain Power Relaxed contractile unit may produce pain on passive stretching

RESISTED TESTS Joint in mid position No joint movement Eliminate muscles not tested Test muscles strongly Patient and examiner positioned to advantage

RESISTED TESTS Strong and painless Strong and painful Weak and painless Weak and painful Painful on repetition All painful/juddering

NEUROLOGICAL EXAMINATION Reflexes Power Sensation Plantar response

OTHER TESTS Mechanical/neural tests Blood tests X-ray EMG Scans

PALPATION Once the structure at fault has been identified