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1CLINICAL HISTORY AND EXAMINATION

James Robb, Daniel Porter, John Keating and Raashid Luqmani

Cases relevant to this chapter

6, 11, 13, 16–21, 24, 28–31, 33, 34, 38, 39, 49–51, 55–57, 61, 66, 68, 69, 71, 73–76, 79, 82–85,

87, 88, 91, 93, 96, 97

1. A diagnosis can usually be made from a good history and inspection of joints.

2. Careful inspection of joints is often more informative than palpation or movement.

3. Proximal joint and adjacent joints need to be included in the examination, because pain in one joint may be referred from pathology in other joints.

4. A systematic approach to examination is recommended.

5. Red fl ag symptoms include: pain preventing sleep; loss of appetite; loss of weight; visual loss; temporal headache and blurred vision; loss of bladder/bowel control; and rapidly progressive symptoms.

6. Red fl ag signs include: ‘drawn’ facial appearance; saddle anaesthesia; bilateral limb neurology; upper motor neurone signs; painful swelling; fever >38°C; inability to weight-bear; or a red, hot joint.

7. Malignant tumours of bone and soft tissues are typically rapidly growing, over 5 cm in size, painful, and deep to the deep fascia.

lEssential facts

GENERAL CONSIDERATIONSHISTORYA diagnosis can often be made from a good history and inspection of joints. Many patients present with pain in a limb; this has a very wide differen-tial diagnosis. It is always important to ask about precipitating factors, to fi nd out if this is the fi rst episode of the problem or a recurrence of a previ-ous problem. The onset of the problem should be described, such as whether it occurred gradually and increased in severity or whether it came on very suddenly. It is useful to know if it started in one area of the body and spread to other areas, and,

in particular, which joints were affected. Rheuma-toid arthritis typically starts in the feet in the meta-tarsophalangeal joints (MTPJ) and the medium-sized joints, such as the ankle and wrist, and involves the metacarpophalangeal joints (MCPJ) and proxi-mal interphalangeal joints (PIPJ) of the hand. By contrast, osteoarthritis in the hands typically involves the distal interphalangeal joints (DIPJ) and to some extent the PIPJ. Some conditions will move from one joint area to another and typically this occurs in infection-related arthritis. It is helpful to know how the problem varies during the course of the day. Is it worse fi rst thing in the morning and associated with stiffness in the joints (which is typical in infl ammatory joint disease) or does it

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CLINICAL HISTORY AND EXAMINATION

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tend to get worse with effort and use of the limb (which is more typical of a mechanical problem in the joints or soft tissue)? Are there associated sys-temic features such as weight loss or fever, rashes or other organ-specifi c problems? This would suggest that this joint problem might be part of an underlying multi-system condition, whether it is infl ammatory or metabolic. For example, patients with diabetes commonly complain of stiff shoul-ders and sore fi ngers, and these may be the fi rst manifestations of their condition. Patients have often tried some sort of remedy themselves using medications bought over the counter or prescribed by their general practitioner (GP). It is important to document what has been tried to determine what is unlikely to work and also what might have caused problems, such as side effects. Response to medication may help in deciding the type of problem. Patients may have sleep disturbance as a result of their musculoskeletal problem. Pain that wakes patients up from sleep may be an indication of more serious pathology, but some conditions that have no clear pathology, e.g. fi bromyalgia, are associated with poor sleep quality. It is useful to know whether the activities of daily living or work have been affected by the condition. Can the patient still perform normal tasks, such as getting dressed, washed, getting up and down stairs, going to the toilet, cooking food, doing the household chores, driving a car or doing the shopping? When the patient comes to see you they may have already had some tests performed and it helps to know the results. The patients will have some expectation of the consultation and it is important to establish what they think so that you can give them appro-priate information about their condition. Family history is particularly important in children, but also in some adults, and social history may be very relevant in terms of what support is available for patients. A history of alcohol consumption should be documented as some conditions, e.g. gout, are related to alcohol, smoking history and signifi cant medical conditions such as diabetes.

For red fl ag symptoms see page 35.

GENERAL PHYSICAL EXAMINATIONA general physical examination will be necessary as well as a musculoskeletal assessment if the patient complains of pain that is not explained by

the musculoskeletal fi ndings. For example, you must check the peripheral pulses in a leg if you suspect ischaemic claudication as a cause of leg pain. Patients who appear to have systemic rheu-matic disease will require a comprehensive medical examination as there may be extra-articular conse-quences of the condition. Examination of the elbows looking for subcutaneous nodules may be a clue to indicate rheumatoid arthritis; in patients with a history suggesting recurrent or chronic gout, search for hard subcutaneous lumps (tophi), which are full of uric acid and typically occur over exten-sor surfaces or at the pinna (ear). Skin lesions of vasculitis may be trivial fi ndings such as nail-edge or nail-fold infarcts; in some cases there is much more severe skin involvement with full-thickness ulceration. Patients with connective tissue diseases often have skin involvement, such as the butterfl y rash of systemic lupus erythematosus or the tight skin of patients with scleroderma. Involvement of internal organs, such as the lungs, heart or gut, may occur in connective tissue diseases and vasculitis. Medications used to treat systemic rheumatic disease may also have side effects in other areas or systems; for example, methotrexate is used widely for treating rheumatoid arthritis and may induce a higher risk of infection. It can cause a form of pneumonitis, which is rare, but if left untreated is fatal in over half of cases. Liver function can be affected by methotrexate and other drugs, but this is rarely a cause of symptoms or signs. Non-steroi-dal anti-infl ammatory drugs (NSAIDs) commonly cause gastrointestinal toxicity, including peptic ulcers and haemorrhage, especially in the elderly. NSAIDs interfere with a number of other medica-tions and may cause kidney and heart problems. Corticosteroids have well known effects including weight gain, moon face, osteoporosis, diabetes, risk of infection and risk of cataract. Similarly, medica-tions used for other conditions may be responsible for, or contribute to, rheumatic problems. Thiazide diuretics used for a long time may increase levels of uric acid and lead to a form of chronic gout. A number of drugs can induce a lupus-like syndrome, e.g. anti-thyroid drugs can induce a vasculitis and many drugs can cause a skin vasculitis as part of an allergic reaction.

It is essential to remember that pain in a joint may be referred from other joints. The joint above and adjacent joints need to be included in the examination. Pain may also be referred from other



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areas, for example nerve root pain or shoulder tip pain arising from diaphragmatic irritation.

For red fl ag signs see page 35.

EVALUATION OF GAITBefore examining the joints of the lower limbs ask the patient to walk and observe their gait. You should observe if the speed is normal, whether or not the patient has a limp and if there is asymmetry of the gait pattern. Do they use a walking aid? Look at the wear pattern of their shoes – is it symmetrical or is one part more worn than another?

The gait cycle consists of two phases: stance and swing, when the foot is on and off the ground respectively (Fig. 1.1). One gait cycle begins when one foot strikes the ground and ends when the same foot strikes the ground again, and a cycle is described as 0–100%. Stance lasts for 60% and swing for 40% of the cycle in normal gait. The stance phase can be subdivided into one period of single support when only one foot is in contact with the ground and two periods of double support when both feet are on the ground, which occurs at the beginning and end of stance. Step length is the distance from the point of contact of one foot to the same point contact of the other foot. Stride length is the distance from initial contact of one foot to the next initial contact of the same foot. Thus two steps equal one stride. Cadence is the number of steps per minute.

Prerequisites of normal gait are:

• stance phase stability• swing phase clearance• adequate foot pre-positioning• adequate step length• energy conservation.

In normal gait the hip has a total arc of about 45° of motion and the knee 60°. When considering

abnormalities of gait it is useful to think of sym-metry or asymmetry of stance time and step length, and whether or not a joint has a normal, reduced or excessive range of motion in gait. For example, arthritis of the hip will produce a stiff joint, which may result in loss of the normal range of hip motion in gait, diminished stance time on the affected side due to pain, increased stance time on the non-affected side and an increased upper body tilt over the affected side in stance to unload the hip. A patient who has had a traumatic division of the common peroneal nerve will have a drop foot in swing, diffi culty in clearing obstructions with the affected foot, abnormal foot pre-positioning in late swing and will make initial contact with the ground through the forefoot. They may compensate for swing phase foot clearance diffi culties by increas-ing lateral movement of the trunk away from the affected limb when it is in swing. A patient who has a paraplegia (traumatic or as a result of spinal cord pathology) or an above-the-knee amputation, for example, will have much higher energy costs than normal when walking. Stance phase instabil-ity might result, for example, from post-traumatic lateral ankle ligament instability resulting in a ten-dency for the foot to invert excessively.

EXAMINATION OF JOINTSToo often, inspection of joints is neglected in the rush to feel and move them. It may be apparent from inspection that a deformity in a joint or in a bone may be a result of arthritis or a fracture. If you can see the abnormality, you can avoid causing the patient unnecessary discomfort and yet still achieve an accurate diagnosis. Table 1.1 summarizes the main points of examination.

The principles of examining joints are similar to those for examination of other body systems. It is best to adopt a systematic approach using ‘Look, Feel, Move and Special Tests’ or the GALS (gait, arms, legs and spine) method (Macleod). With the latter, ask the patient the following three questions:

1. Do you have any pain or stiffness in your muscles, joints or back?

2. Can you dress yourself without diffi culty?3. Can you walk up and down stairs without

diffi culty?

If all three replies are negative the patient is unlikely to have a signifi cant musculoskeletal

Stance Swing

100%60%0%

Doublesupport

Doublesupport

Singlesupport

FIGURE 1.1 Subdivisions of the gait cycle



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problem. If not, examine their gait, arms, legs and spine.

The GALS and Look, Feel, Move and Special Tests approaches are complementary. For example, if you fi nd as a result of your GALS screen there is a problem in the patient’s knee, use the Look, Feel, Move and Special Tests approach to evaluate the knee further.

LookInspection of the joints will require adequate expo-sure. Look for swelling, deformity, redness and rheumatoid nodules to see if there is any asymme-try, but remember that some rheumatic diseases are symmetrical. You should look for associated fea-tures, such as rashes, psoriasis or muscle wasting around a joint that has not been used for some time. There may be scars from previous surgery or injury. The patient may look emaciated if there is an underlying malignancy or signifi cant systemic disease (patients with severe rheumatoid arthritis may have lost a lot of weight). You may observe redness around a joint or limb, or swelling away from a joint. A ruptured Baker’s cyst will cause swelling in the calf with redness and erythema of the overlying skin. Baker’s cysts are common in patients with rheumatoid arthritis and there may also be an associated knee effusion.

FeelGently palpate the joints and limbs, to ascertain a difference in temperature in and around the joint and bony tenderness. Use the back of your hand to assess temperature; feel proximal and distal to the potentially abnormal area. There is usually a tem-perature gradient away from the heart so that the thigh is normally warmer than the knee, which is

warmer than the shin. The back of your hand is very sensitive to these graded temperature changes and you should apply this evaluation routinely when examining large joints such as the knees. Feel the joints for evidence of swelling, which you will have detected on inspection. Feeling for swelling at this stage would confi rm what you have seen, but also determines the nature of the swelling. You want to know whether it is fl uid, soft tissue or bone. Massaging a joint may be a good way of detecting fl uid within a joint, but remember that very swollen joints will fail this test because there is nowhere for the fl uid to go. You should feel for tenderness, so you need to look at the patient’s face during palpation. You should feel the structures around the joints, such as ligaments and tendons, as these could be the source of discomfort. You may observe a deformity; valgus is a deviation of a part away from the midline and varus the opposite.

MoveFinally, you want to move the joint. Active move-ment, i.e. that performed by the patient, should be observed fi rst followed by passive movement per-formed by the examiner. Range of movement may be normal, reduced or excessive. If the patient has an excessive range of movement, this could suggest that they are hypermobile (Fig. 1.2).

If range of movement is restricted this may be due to pain, weakness, loss of neurological func-tion, tissue stiffness, contracture or bony changes, such as ankylosis (fusion of a joint). After observing active movement, check passive movement, but stop if the patient complains of discomfort. The main benefi t of checking passive movement is that, if weakness or stiffness is a limiting factor,

Table 1.1 Important points to observe in joints during clinical examination

Look Scars, sinuses, swelling, deformity and erythema

Feel Skin, soft tissues and joint

Move Active and passive; normal range, reduced or increased range of movement; and stress tests

Special imaging (see Chapter 4 on Imaging)

Plain X-rays are the mainstayCT gives better bony defi nitionMRI gives good defi nition of non-osseous structuresUltrasound is useful for joint effusions and rotator cuff tears of the shoulderArthrography is used to confi rm reduction of a hip in a child



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the thorax), elevation (upward movement) and depression (downward movement). Most shoulder movements are composite and involve scapulo-thoracic and gleno-humeral movement. The rotator cuff muscles, supraspinatus, infraspinatus, teres

minor and subscapularis, attach to the proximal humerus. Supraspinatus, infraspinatus and teres minor insert on to the greater tuberosity, and subscapularis to the lesser tuberosity. These muscles are important dynamic stabilizers of the

Extension

FIGURE 1.4 Summary of the range of motion in the lower limbs (from Douglas et al 2005)



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shoulder joint as well as having a role in specifi c joint motions.

Subscapularis is a medial rotator of the shoul-der, and teres minor and infraspinatus are lateral rotators of the shoulder. Glenohumeral abduction is initiated by supraspinatus and the deltoid abducts the arm beyond the initial 15°. The upper fi bres of trapezius elevate the scapula, its middle fi bres retract the scapula and the lower fi bres depress the scapula. Teres major is also a medial rotator of the shoulder, but also extends the arm at the shoulder joint. Pectoralis major fl exes, adducts and medially rotates the arm at the shoulder joint. Pectoralis minor pulls the tip of the shoulder infe-riorly and protracts the scapula. Serratus anterior protracts the scapula and maintains close apposi-tion of the inferior angle of the scapula against the thoracic wall. Latissimus dorsi adducts, medially rotates and extends the arm at the shoulder.

The muscles of the arm comprise biceps, coraco-brachialis and brachialis anteriorly, and triceps posteriorly. Coracobrachialis fl exes the arm at the shoulder joint; biceps fl exes the elbow and supi-nates the forearm, and also contributes to fl exion of the arm at the shoulder joint. Brachialis is a powerful fl exor of the forearm at the elbow. Figures 1.5 and 1.6 show the details of muscle attachments of the arm.

The surface anatomy of the shoulder is impor-tant clinically, as patients with shoulder pathology may receive intra-articular injections of local anaes-thetic, for example as a diagnostic test of impinge-ment, and an injection of local anaesthetic with steroid in the management of infl ammatory joint disease. The shoulder may be injected anteriorly by inserting the needle just lateral to the coracoid process, subacromially in the interval between the acromion and humeral head, and posteriorly just infero-medial to the most lateral prominence of the spine of the scapula.

LookLook for asymmetry compared to the opposite side, swelling, muscle wasting, winging of the scapula (due to paralysis of serratus anterior), elevation of the scapula (due to Sprengel’s deformity or Klippel–Feil syndrome). Wasting of the deltoid or supra-spinatus and infraspinatus is commonly present in a wide range of shoulder disorders and can be detected by comparison with the normal side.

FIGURE 1.5 Anterior muscles of the shoulder and arm (from Drake et al 2004)

FeelFeel along the clavicle from sternoclavicular to acromioclavicular joints for a malunion, across the acromion for arthritis and along the spine of the scapula. Feel along the blade of the scapula both medially and laterally down to the angle. Feel tra-pezius and deltoid. Feel the anterior triangle of the neck to assess goitre and lymphadenopathy. Palpate the bicipital groove for bicipital tendonitis.

MoveThe movements at the shoulder are forward fl exion, extension, abduction/adduction, internal and external rotation. Movement occurs at both the scapulo-thoracic and glenohumeral joints and it may be necessary to distinguish between the two components. For example, during abduction the tip of the scapula is identifi ed and palpated as the patient is asked to abduct the shoulder. The tip of the scapula will start to rotate away from the midline in the latter stages of abduction. For this reason the total arc of abduction may referred to as ‘combined abduction’. You can use a quick screen-



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FeelFeel for tenderness of abductor pollicis longus and extensor pollicis longus tendons at the base of the thumb, which may indicate de Quervain’s tenosynovitis. Tenderness in the anatomical snuff-box and distal radius may suggest trauma to the scaphoid or distal radius. If swelling is present, it is helpful to determine whether it is soft tissue or bony, and also whether or not the swelling is painful; so remember to look at the patient’s face and ask if the joints are tender.

MoveForearm rotation is evaluated observing pronation and supination at the distal forearm. It may help for the patient to hold a pencil in both fi sts as they rotate the arm. This gives the observer a landmark to follow. Remember to have the patient’s elbows tucked into their sides when doing this; other-wise shoulder abduction/adduction may mimic pronation/supination.

Wrist fl exion and extension are tested by asking the patient to put their hands into the prayer (exten-

sion) and reverse prayer (fl exion) positions. Radial and ulnar deviations are then tested. Test the wrist extensor and fl exor muscles by asking the patient to extend and fl ex the wrist against resistance.

Active extension of the fi ngers is then tested while the patient holds their wrist in the neutral position. The fl exor digitorum superfi cialis fl exes the PIPJ of the fi ngers, but so will the fl exor digito-rum profundus. To distinguish between the two ask the patient to fl ex the fi nger while you hold the PIPJ extended (profundus test) and then ask the patient to fl ex the PIPJ (superfi cialis test) while you hold the remaining fi ngers in extension. Flexion and extension at the IPJ of the thumb are tested as you hold the patient’s thumb and then test abduc-tion/adduction of the thumb.

Finally, compare grip strength between sides and evaluate the hand neurologically if indicated.

NEUROLOGICAL ASSESSMENT OF THE UPPER LIMBGENERALA dermatome is an area of skin supplied by a single spinal cord level and a myotome is a portion of skeletal muscle innervated by a single spinal cord level. Myotomes will also generate movement

Radius

Ulna

Trapezoid

Trapezium

Scaphoid

Capitate

Lunate

Hamate

Pisiform

Triquetrum

FIGURE 1.10 Radiological anatomy of the carpus (from Drake et al 2004)

Box 1.1Anterior muscles of the forearm

• Flexor carpi ulnaris and fl exor carpi radialis

• Flexor digitorum superfi cialis and profundus

• Palmaris longus

• Flexor pollicis longus

Box 1.2Posterior muscles of the forearm

• Extensor carpi radialis longus and brevis, and extensor carpi ulnaris

• Extensor digitorum and extensor digiti minimi

• Abductor pollicis longus



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The patient is then asked to lie supine and again sensation in the lower limbs is tested as well as the pedal pulses. Muscle power of the hip fl exors, knee extensors, knee fl exors, ankle plantar, and dorsi-fl exors, evertors and invertors are tested along with the patellar tendon refl exes. Hip, knee and ankle ranges of movement may also be tested.

The straight leg raising test is performed by keeping the knee extended and at the same time passively fl exing the hip. The test is positive if there is a restriction of straight leg raising by pain radiating from the back down the posterior aspect of the thigh and calf. Tension on the sciatic nerve (sciatic nerve stretch test) can be increased by dorsi-fl exion of the ankle which, if positive, increases the leg pain (Fig. 1.22).

The tibial nerve stretch test is also performed while the patient remains supine. The hip is fl exed to 90° and the knee is extended. Press on the tibial nerve, which is located in the midline of the pop-liteal fossa. The test is positive if the patient com-plains of pain in the posterior calf or thigh. In this position the tibial nerve ‘bowstrings’ across the popliteal fossa. Hamstring shortening will also limit knee extension when the hip is fl exed and the knee is being extended.

It is important to distinguish between nerve root irritation and nerve root compression. An example of the former is a positive straight leg raise test without any other neurological disturbances, and of the latter, loss of a refl ex and muscle weakness. The two may coexist, however.

Loss of the ankle refl ex may indicate a L5/S1 disc prolapse and weakness of extensor hallucis longus may be associated with a L4/5 disc prolapse.

It is also possible to test straight leg raising whilst distracting the patient. One way is to ask the patient to sit up straight when sitting on the bed or couch to see if they are able to keep their knees extended whilst having their hips fl exed to 90°. If they are able to do so it would indicate the equiva-lent of a straight leg raise to 90°. The fl ip test is an alternative method. Ask the patient to sit on the edge of the bed whilst holding their hips and knees at 90°of fl exion. Attempt to extend the knee of the leg under consideration; if they are able to tolerate full knee extension whilst maintaining hip fl exion to 90°, this would suggest an equivalent of a straight leg raise of 90°. If the patient has sciatic nerve irri-tation or compression they may resist having their knee extended. Alternatively, they will arch their

A

B

CFIGURE 1.22 Stretch tests – sciatic nerve roots. In neutral position, the nerve roots are slack. (A) Straight leg raising may be limited by tension of root over prolapsed disc. (B) Root tension relieved by fl exion at the knee. (C) Pressure over centre of popliteal fossa bears on posterior tibial nerve, which is ‘bowstringing’ across the fossa causing pain locally and radiation into the back



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Psoas major

Iliacus

Anterior superioriliac spine

Anterior inferior iliac spine

Inguinal ligament

Lesser trochanter

spine posteriorly, which will relieve tension on the sciatic nerve (fl ip).

During these manoeuvres the patient’s demean-our and ability to carry out these tasks can also be observed.

HIPANATOMY OVERVIEWThe hip is a ball and socket joint and as a result is inherently more stable and less mobile than the shoulder joint. The muscles that act on the hip are shown in Table 1.4. In addition, the tensor fascia latae stabilizes the pelvis and rotates the tibia later-ally on the femur.

The anatomy of hip and thigh muscles is shown in Figures 1.23 to 1.28. The vastus media-lis, lateralis and intermedius extend the knee, as does rectus femoris, which also fl exes the hip. The hamstrings (biceps femoris, semimembranosus and semitendinosus) extend the hip and fl ex the knee (Box 1.3).

The adductors are supplied by the obturator nerve (with the exception of magnus, which also receives a supply from the tibial division of the sciatic nerve), the vasti by the femoral nerve and the hamstrings by the sciatic nerve.

LookThe patient should be suitably undressed down to their underwear and chaperoned where appro-priate. The presence of a hip deformity, for ex -ample a fl exion contracture, muscle wasting, the

spine and a limb length discrepancy can be observed. Ask the patient to walk with and without walking aids if possible. The normal arc of motion at the hip in gait is about 45°. Does the hip have a normal, reduced or excessive range of motion in gait? Is there a limp and if so does it appear to be antalgic, i.e. painful (in which case there may be a reduced stance time on the affected side)? Does the patient have a ‘waddling gait’ suggestive of abductor insuffi ciency or a longstanding hip dislocation?

Perform Trendelenburg’s test by asking the patient to stand on one leg for 30 s and then on the other (Fig. 1.29). You may help the patient by sup-porting their weight through their outstretched hands. The test is positive if the unsupported side of the pelvis drops, and is normal if the unsup-ported side of the pelvis rises. Factors producing a positive sign are weak hip abductors, hip disloca-

FIGURE 1.23 Iliopsoas (from Drake et al 2004)

Table 1.4 Muscles acting on the hip

Muscle type Example

Flexors Psoas, rectus and sartorius

Extensors Gluteus maximus and hamstrings

Abductors Gluteus medius and minimus

Adductors Adductor magnus, longus, brevis and gracilis

Internal rotation Anterior half of gluteus medius

External rotation Gemelli, obturator internus and quadratus femoris



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knee. To test the cruciates, fl ex the knee to 90° and place the patient’s foot on the examining couch. Observe the relationship of the femoral condyles to the tibial plateau – is the plateau displaced poste-riorly (posterior sag test)? This would be consistent with a posterior cruciate injury. Stabilize the foot by sitting on it. Grasp the medial and lateral aspects of the upper tibia with both hands and attempt to draw the tibia forward over the femoral condyles. If there is excessive translation there may be an anterior cruciate injury (anterior drawer test), but remember to compare your fi ndings with the oppo-site side. If you suspect a posterior cruciate injury, try translating the tibial plateau posteriorly over the femoral condyles (posterior drawer test). For both these tests it is important to verify that the starting point of the tibial condyles is in the normal anatomical position, otherwise you may have a false-positive test. Anterior cruciate integrity can also be tested by Lachman’s test. Flex the knee to 10–15°, grasp the distal thigh with one hand and the proximal shin with the other, check that the tibial plateau is in its normal anatomical position and then attempt to translate the tibia forward in relation to the femur. Excessive forward translation would suggest an anterior cruciate injury. Again, compare the fi ndings with the opposite knee.

Meniscal testsThe most common signs associated with a meniscal tear are the presence of a small effusion, reproduc-tion of joint margin pain when squatting down and joint margin tenderness. To detect joint margin ten-derness, ask the patient to fl ex the knee to 90°. The lateral joint margin is located just proximal to Gerdy’s tubercle. The medial joint margin is at the same level on the other side. Meniscal tears are most common in the middle and posterior third of the meniscus, so tenderness is frequently maximal posteriorly.

FOOT AND ANKLEANATOMY OVERVIEWThe ankle joint comprises the tibia, fi bula and talus, or talo-crural joint, and acts as a hinge joint; thus allowing plantarfl exion (fl exion) and dorsi-fl exion (extension). Inversion and eversion are composite movements occurring at the subtalar

(talo-calcaneal) and midtarsal joints (calcaneo-cuboid and talo-navicular) (Fig. 1.33). The move-ment of the foot has also been likened to that of the hand and the terms ‘supination’ and ‘pronation’ of the foot are also used, often interchangeably, with inversion and eversion. This is not strictly correct, and supination can be considered a composite movement incorporating adduction, plantarfl exion and inversion, whereas pronation incorporates abduction, eversion and dorsifl exion. Inversion is produced by tibialis anterior and posterior, and eversion by the peronei. The plantar fl exors are the gastrocnemius and soleus, and there is also a con-tribution from tibialis posterior, fl exor hallucis longus and fl exor digitorum longus, all of which pass around the back of the ankle. Dorsifl exion of the ankle occurs from the action of the anterior tibial muscles, tibialis anterior, extensor hallucis longus and extensor digitorum longus (Box 1.4).

There are three arches of the foot: medial, lateral and transverse.

LookObserve the patient’s gait. Which part of their foot contacts the ground, is the heel in varus/valgus/neutral during stance and swing, does the foot clear the ground during swing? Is the wear on the soles of the patient’s shoes symmetrical? Is there a sym-metrical distribution of callosities in the feet?

Look for calf muscle wasting suggestive of a neurological condition, fl attening of the medial arch (if so, does the arch correct on standing?), pes cavus, bunions, club foot, metatarsus adductus and bony prominences, particularly of the metatarsal heads.

FeelFeel for an ankle effusion or warmth, and for the dorsalis pedis and posterior tibial pulses, which may be reduced and point to an ischaemic cause for the patient’s pain, or be of relevance when con-sidering the potential for wound healing if surgery is being contemplated. Feel for painful bunions or metatarsalgia (under the metatarsal heads).

MoveAssess active and passive dorsi- and plantarfl exion, and inversion and eversion. To distinguish between the hind and mid-foot components of inversion and eversion passively, grasp the shin with one hand and the heel with the other and invert and



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evert the calcaneus (Fig. 1.34). This tests passive movement at the subtalar joint. To assess the midfoot component of inversion and eversion, grasp the heel in one hand and the midfoot in the other and repeat the manoeuvre. There is no active movement at the tarso-metatarsal joints. Mobility

of the toes can be assessed actively and passively. Integrity of the Achilles tendon can be assessed by asking the patient to lie prone with their feet over the end of the couch. You can palpate the Achilles tendon to feel for a gap and then squeeze the patient’s calf. The Achilles tendon is intact if the ankle plantar fl exes on squeezing the calf (Sim-monds or Thompson test).

NEUROLOGICAL ASSESSMENT OF THE LOWER LIMBDermatomes and myotomes in the lower limb can be used to check neurological function (Figs 1.35–1.37, Tables 1.5 & 1.6). Muscle wasting and fascicu-lation should be checked as well as abnormal tone

Medial

Intermediate

Lateral

Cuneiforms

Cuboid

Distal groupof tarsal bones

Talus

Calcaneus

Proximal groupof tarsal bones

Distal

Middle

Proximal

Navicular

Tubercle (on under-surface)

Intermediatetarsal bone

Metatarsals

Phalanges

Talus

Navicular

Cuneiforms

Calcaneus Cuboid

GrooveFibular trochlea

A

B

FIGURE 1.33 Bones of the foot (from Drake et al 2004)

Box 1.4Muscle compartments of the lower leg

• Anterior: tibialis anterior, extensor hallucis longus and extensor digitorum longus

• Posterior: gastrocnemius, soleus, tibialis posterior, fl exor hallucis longus and fl exor digitorum longus

• Lateral: peroneus longus and brevis



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important for the alert clinician to believe his/her own examination fi ndings, and act on them. This will often lead to an early diagnosis and a better patient outcome.

TUMOURMalignant tumours of bone and soft tissues are aggressive and, therefore, grow rapidly. Features indicative of malignant potential include lesions that are:

• rapidly growing• over 5 cm size

Table 1.7 Clinical ‘red fl ag’ features suggesting serious pathology

Symptom Sign

Pain preventing sleep ‘Drawn’ facial appearance

Loss of appetite Saddle anaesthesia

Loss of weight Bilateral limb neurology

Visual loss Upper motor neurone signs

Temporal headache and blurred vision

Painful swelling

Loss of bladder/bowel control Fever >38°C

Rapidly progressive symptoms Inability to weight-bear

Red, hot joint

Table 1.8 Emergency diagnoses and dangers in musculoskeletal patients

Diagnosis Danger

Tumour Loss of life or limb

Infection Bone or joint destruction

Central cord compression Limb/bladder/bowel dysfunction

Cauda equina syndrome Bladder/bowel dysfunction

Giant cell arteritis Blindness

Slipped upper femoral epiphysis Early hip arthritis

• painful• deep to deep fascia.

These lesions should be viewed as a potential malignant tumour until proven otherwise. Even one or two of these features should provoke early investigation. A delay of weeks will compromise treatment options and survival.

INFECTIONFeatures of bone and joint infection are those of local infl ammation. These can be masked in the immunosuppressed; a high index of suspicion should exist in a patient with a musculoskeletal swelling who is unwell, on immunosuppressive therapy or suffering from an immunodefi ciency disorder. In non-immunosuppressed children, clinical features predictive of osteomyelitis or septic arthritis include:

• inability to weight-bear• temperature >38°C• leukocyte count >12 000 cells/mm3

• erythrocyte sedimentation rate (ESR) >40 mm/h.

As in potentially malignant tumours, even one or two of these features should provoke early inves-tigation. A delay of hours or days will lead to estab-lished infection, with bone or joint destruction and more extensive surgical reconstruction.

SPINAL DISORDERSSymptoms predictive of potentially serious spinal pathology are as above; additional features identi-fi ed by the Royal College of General Practitioners are:

• presentation under age 20 or over age 55• non-mechanical pain• thoracic pain• past history of carcinoma, steroids, human

immunodefi ciency virus• widespread neurological symptoms• structural deformity.

Signs of an ‘upper motor neurone’ lesion indi-cating central cord compression include hyper-tonic weakness and rigidity, brisk refl exes and sustained clonus. Causes include spinal infection (pyogenic or tuberculosis), tumour, cervical verte-



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bral subluxation secondary to trauma or rheuma-toid arthritis or a cervical or thoracic central disc prolapse. Symptoms of sphincter and gait distur-bance with saddle anaesthesia are highly sugges-tive of cauda equina syndrome, requiring an urgent magnetic resonance imaging scan for confi rmation of central disc prolapse and appropriate urgent spinal decompression.

GIANT CELL ARTERITISWhen this vasculitic condition affects the temporal artery it is known as ‘temporal arteritis’ and can occasionally involve ciliary artery occlusion, leading to blindness. Symptoms of polymyalgia rheumatica should prompt questions about tempo-ral pain and blurred vision, and examination for temporal tenderness. If these features are present then steroids should be commenced and an imme-diate rheumatological referral made to include tem-poral artery biopsy.

SLIPPED UPPER FEMORAL EPIPHYSISA mild form of this condition of late childhood and adolescence is important to identify early for the prevention of complete slip and a uniformly poor outcome. Acute groin, thigh or knee pain should suggest the possibility of hip pathology. An inabil-ity to weight-bear should result in an immediate

orthopaedic referral. The classical description is of an older boy held between two parents with an externally rotated leg and non-weight-bearing. In an adolescent, a radiograph in the antero-posterior and (especially) lateral planes might reveal a slip of the proximal femoral physis. Long-term progno-sis depends upon the degree of slip. Even in those able to walk, persistent limp or pain for longer than a week should be investigated promptly to avoid a progressive ‘acute on chronic’ slip.

S U M M A R Y

‘Red fl ags’ are key symptoms and signs that alert the clinician to the possibility of serious disease. To elicit them early is of vital importance to a sat-isfactory patient outcome.

F U R T H E R R E A D I N G

Douglas G, Nicol F, Robertson C (eds) 2005 Macleod’s clinical examination, 11th edn. Churchill Livingstone, Edinburgh.

Drake R, Vogl W, Mitchell A 2004 Gray’s anatomy for students. Churchill Livingstone, Edinburgh.

APPENDIXFigure 1.38 provides a structured proforma for use when assessing patients with rheumatic diseases.



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FIGURE 1.38 A suggested history and examination proforma for rheumatology patients



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FIGURE 1.38 Continued


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