Clinical Diagnosis of Joint Inflammation in the Adult
Essentials
Before clinical examination of joints, inquire about any underlying disorders (such as gout, other rheumatic disease, infections).
In an acute situation, examine the joints causing the most symptoms.
Use both hands for examining the joints.
To test for effusion, try to "milk" synovial fluid by pressing supply and softly on different sides of the joint and, with your other hand, palpating the area on the opposite side for fluid movement.
Ultrasound examination should be used for examining inflammation and the bursae of deep joints, such as hip and shoulder joints.
Later, in your office, examine all of the patient's joints and perform a general clinical examination.
The diagnosis of arthritis should always be based on clinical examination: absence of clinical signs precludes a diagnosis of joint inflammation.
According to the American College of Rheumatology (ACR), arthritis is defined as swelling or reduced mobility of the joint with associated heat, tenderness or pain on movement.
When joint inflammation is suspected, inspection of the skin and nails should always be included in the clinical examination (picture 1).
Skin temperature
With the dorsum of your fingers, feel carefully, without pressing, the temperature of symptomatic joints, and compare it with that of the skin over the same joints on the contralateral side.
In the knees, ankles, elbows and wrists, asymmetric arthritis almost always causes a temperature difference.
Fingers
Place the patient's hands at rest on a cushion, for instance. First turn the hands from one side to the other and, without palpating, compare the findings to the contralateral hand. This inspection alone can often reveal abnormal colour changes and bulging of the skin in the area of joints or tendons.
Then ask the patient to clench their fists so that their fingertips touch the metacarpophalangeal (MCP) joints on the side of the palm (= ball of the hand). A flexion deficit in any finger may suggest swelling of a joint or, more commonly, a tendon.
Then flex all fingers, one after another, at the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints while keeping the MCP joint straight.
Normally, the fingertips reach the ball of the hand (picture 2).
There may be a flexion deficit due to a bony change, for instance, even in the absence of visible swelling.
The flexion deficit is often caused by tenosynovitis.
Place all your fingers or just your thumb transversely at the MCP level on the patient's palm without exerting strong pressure, and ask the patient to simultaneously flex their fingers actively onto yours; you will be able to easily feel thickened tendons, any nodules in them and even fluid movements.
Spindle-shaped, plumply soft, warm, shiny swelling of the PIP joints is an almost certain sign of rheumatoid arthritis (picture 3).
Knuckles
Swelling of MCP joints is visible as bulging around the joints on top of the hand and particularly in the superior recess of the MCP joint and felt as supple puffiness between the joints upon palpation.
Pain is elicited when the fingers are flexed.
When you press the patient's hand on the sides at the knuckles as if to shake hands, the patient will spontaneously report tenderness.
Reduced mobility can be seen when flexing the joints (normal flexion 90°).
Inflammation of MCP joints is a typical symptom of rheumatoid arthritis.
Wrists
Swelling is located at the dorsal aspect of the joint space; it is shallow, sometimes fluctuating. The retinaculum surrounding the wrist is often the thickest structure. It is easy to aspirate synovial fluid here.
Dorsiflexion (normally at least 70°) is first limited (picture 4). Fluid and capsular swelling can best be elicited in extreme dorsiflexion.
Elbow joints
Swelling of the elbow joint is visible on the sides of the olecranon and felt as bulging of the lateral sulcus. At this site on the elbow joint there is normally a fossa that can be described as a "dimple". Bulging of the fossa strongly suggests bulging inside the joint.
Extension is the first movement to be limited.
Shoulder joints
Clinical examination of the shoulder joint should be done using the palms and fingers of both hands. Place your hands flat behind and in front of the shoulder joint, with the joint in a resting position.
Work synovial fluid softly in the direction of your other hand and then in the opposite direction without using your fingertips.
If there is fluid in the shoulder joint, you will feel its movement and the movement of the joint capsule on the palm of your other hand. If you cannot feel such movement, the amount of synovial fluid has probably not increased.
You can observe bursal oedema in this area in the same way.
Nevertheless, ultrasonography should be used for full examination of the shoulder joint, as far as possible.
Test rotation of the shoulder joints. See also the article Examination of the shoulder joint Examination of the Shoulder Joint> Clinical examination.
Toes and metatarsophalangeal (MTP) joints
As when examining the hands, it is best to place the patient's naked feet and ankles in front of you so that you can see both at the same time. First observe both feet and both ankles.
Asymmetric sausage-shaped thickening of the toes can be seen on inspection when comparing the toes on both feet.
Tenderness of the MTP joints can be elicited by pressing at the ball of the foot from both sides simultaneously or by flexing the toes forcefully in the dorsal and volar directions.
Even a slight increase in the amount of synovial fluid in a MTP joint will raise the toe upwards.
Even though the puffiness of the joint space is difficult to assess, you can detect it by pressing any synovial fluid and thickened joint capsule lightly between the fingertips of your both hands. Remember not to press with your nails.
Ankles
First compare the right and left ankles, noting any asymmetry without provocation.
Swelling is often seen around the malleoli and, when viewed from behind, on both sides of the Achilles tendon but also directly in front of you over the TC joint.
Then test passive dorsiflexion and plantarflexion at the ankle joint (talocrural joint).
Grip the calcaneus firmly with one hand and, placing the calcaneus against your palm, with the other hand twist the foot into inversion and eversion to test the subtalar joint, registering any asymmetry.
Patients often say that the joint you are twisting is tender.
To facilitate knee examination, particularly if there is pain and swelling, place a thin support, such as a kidney bowl, below the hollow of the knee. This makes it easier for the patient to relax the affected knee.
Inflammation of the knee joint is usually accompanied by effusion.
Massive effusion causes suprapatellar bulging.
Minor effusion can be diagnosed by pressing the fluid away from above the patella with supple fingers (not nails) or palm. You can then feel a fluid wave on both sides of the patella with the thumb and the index finger of your other hand (picture 5).
The most sensitive sign of effusion is the "bulge sign".
With your left hand, press the fluid away from above the patella.
Place your other hand on the tibial tuberosity, supporting the patella on the lateral side of your index finger, and place your thumbs next to each other on the other side of the patella.
First use supple fingers to press any fluid away from the contralateral side of the knee.
Then use your thumb to press on the other side of the knee; the fluid will be squeezed to the other side of the patella, where it can be seen as bulging.
Remember to palpate Hoffa's fat pad in the fossa between the patella and the tibia and the pes anserinus bursa between the tibia and the insertion site of the hamstring muscles.
Before assessing any limitation of extension, remove the support from under the hollow of the knee. Then examine extension of the knee by supporting the patient's legs by the heels with the patient lying supine, and examine knee flexion by bending the knee so that the heel moves towards the buttock.
Palpate the back of the knee (in order to identify Baker's cyst; see Baker's Cyst).
Ultrasonography will facilitate correct diagnosis when assessing different knee structures.
See also the article on painful knee Painful Knee.
Hips
Ultrasonography is quite essential when examining arthritis of the hip joints but before ultrasonography the hips should be examined clinically as described below.
Test the rotation of the hip joints with the patient supine and the hip and knee in 90 degrees flexion (picture 6). When the hip joints are inflamed:
inward rotation is usually limited, asymmetric and painful
there is pain in the inguinal region, not on the lateral side of the hip (trochanteric bursitis!) or in the buttock (sacroiliac joint)
patients often report that the pain is worst at night.
Detection of an extension deficit of the hip joint
With the patient supine flex one hip joint maximally, whereby the lordosis of the lumbosacral spine is straightened.
If there is an extension deficit of the opposite hip, that thigh is elevated, and the angle between the thigh and the examination couch indicates the degree of extension deficit.
Sacroiliac joint
Inflammatory pain in the SI joint typically appears in the small hours and is alleviated by moving.
With the patient in the prone position (on their stomach), press your palm on the sacral bone with your arm straight (helped by your other hand) pressing directly downwards towards the couch. The test is positive if the patient reports pain in the area of the SI joint.
Alternatively, SI joint pain can be elicited by asking the patient to lie on their side and pressing their pelvis firmly from one side and simultaneously bending the crests of the iliac bone forward in order to bring the anterior superior iliac spines closer: pain originating from the SI joint radiates towards the buttock.
Hopping on one foot is a good test for identifying sacroiliitis (the patient is not able to hop on the foot that is on the side affected by sacroiliitis).
In the FABER test of the SI joint (Patrick's test, picture 7, and examination of patients with lower back problems the supine patient bends the knee of the side to be examined and places the ankle on the knee of the opposite, extended leg; the examiner then pushes the flexed knee towards the couch. In a patient with sacroiliitis, the test provokes pain in the buttock.