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Rheumatological Examination 
By 
ASHRAF OKBA 
PROF. OF INTERNAL MEDICINE 
AIN SHAMS UNIVERSITY
Getting Ready 
• Greet the patient with kindness. 
• Introduce yourself to the patient. 
• Explain the procedure to the patient. 
• Expose the area to be examined and ensure that it is not covered by clothes.
Gait 
• Observe for 
– Rhythm 
– Symmetry
Upper limbs 
Inspection
C5–T2 dermatomes.
Upper limbs 
Inspection 
Inspect the hand & wrists for: 
• Swelling, 
• Deformity, 
• Nodule (heberden's nodes, Bouchard nod, tc), 
• Muscle wasting, 
• Skin abnormality 
• Nail abnormality. 
(heberden's nodes, Bouchard nodes
Palpation 
Palpate the hand for 
– tenderness 
– synovial thickening 
– increased warmth 
– sweating. 
Perform 
– Metacarpal squeeze test
palpate 
– Metacarpophalangeal joints 
– Proximal interphalangeal joints 
– Distal interphalangeal, joints
Movement 
• Ask the patient to open and 
spread the fingers, of both 
sides 
Close the fingers (power grip), 
of both sides
• Pinch the tip of index 
finger and thumb 
(precision pinch). of 
both sides and feel its 
power 
• Compare active with 
passive if active range 
limited, 
(precision pinch)
• Ask the patient to put 
his hands together in 
the position of prayer 
and then to lower the 
hands keeping the 
palms together. 
This demonstrates the range of dorsiflexion of the wrists
• Ask the patient to place 
the back of his hands 
together and to raise 
the arms upwards. 
This demonstrates the range of flexion of wrists
Examination of the elbow 
Inspection 
Inspect for: 
• Deformity, 
• Nodule, 
• Muscle wasting, 
• Skin abnormality
Palpation 
– Tenderness 
– Swelling 
– Increased warmth. 
Three bony landmarks - the medial epicondyle, the lateral 
epicondyle, and the apex of the olecranon - form an equilateral 
triangle when the elbow is flexed 90°, and a straight line when 
the elbow is in extension
Movement 
• Instruct the patient to bend and 
straighten both elbows 
simultaneously (0-150°), 
• With elbows flexed to 90° turn 
hands palm up (supination 0-90°) 
and then palms down (pronation 
0-90°).
Examination of the shoulders 
Inspection 
Inspect for 
o Deformity, 
o Nodule, 
o Muscle wasting, 
o Skin abnormality from the front and the back 
Marked atrophy of infra and supraspinous fossae.
SHOULDER JOINT 
• Sternoclavicular joint (SC) 
• acromioclvicular joint 
(AC) 
• glenohumeral joints
Sternoclavicular joint (SC) 
A swelling with bruising over The right sternoclavicular joint
Acromioclvicular joint (AC)
glenohumeral joints 
Normally, it is possible to raise the arm to 
90° while maintaining the scapula fixed. 
Scapula pivots before glenohumeral 
abduction takes place giving this 
aspect of raising of the shoulder
PALPATION OF SHOULDER JOINT 
observe for 
– Tenderness 
– Swelling 
– Temperature 
– Crepitus.
Ask the patient to point to the site where they are 
experiencing discomfort. 
Instruct the patient to inform you if he experience any 
pain during the examination.
Palpate both shoulder joints in a 
systematic approach. 
1) Sternoclavicular joint 
2) Clavicle 
3) Acromioclavicular joint 
4) Humeral head 
5) Coracoid process 
6) Deltoid muscle 
7) Spine of scapula 
8) Supraspinatus muscle 
9) Infraspinatus muscle 
10) Trazpezus muscle 
(then repeat on the other side)
Movement 
• Ask the patient to put both hands behind 
the head with elbows pointing laterally 
(flexion, abduction and external rotation), 
• To put the arms down and reach up behind 
the back (extension, adduction and full 
internal rotation).
Examination of ankles and feet 
Inspection: 
Inspect the ankles and feet joints for: 
• Swelling, 
• Deformity, 
• Nodule 
• Muscle wasting, 
• Skin abnormality and 
• Nail abnormality. 
Bilateral rheumatoid nodule at 
the ankle with superficial bursitis
Palpation 
Palpate joints for: 
• Tenderness, 
• Swelling 
• Increased warmth.
Perform Metatarsal squeeze test
Movement 
Ask the patient to dorsiflex (20°) 
and plantar flex (30°) each ankle 
(wide range of normal). 
Passively evert (10°) and invert 
(20°) the subtalar joints with the 
ankles in neutral.
Flex and extend the MTP joints.
Examination of the knees 
Inspection 
Inspect the knee joints for: 
• Swelling, 
• Deformity, 
• Muscle wasting and 
• Skin abnormality.
Palpation 
• Palpate for: 
o tenderness 
o swelling 
o increased warmth
Examine for knee effusion 
Patellar tap test: 
Slide your hand down the 
patient's thigh, pushing down 
over the suprapatellar pouch, so 
that any effusion is forced 
behind the patella. 
- When you reach the upper pole of the 
patella, keep your hand there and 
maintain pressure 
Using the index & middle finger of the 
other hand push the patella down 
gently. 
- Does it bounce? If so this may indicate 
the presence of an effusion.
Bulge test (massage test) 
- Using your thumb and index finger - milk 
down any fluid from above the knee. 
- Keep this hand in this position. 
-Now with the other hand, stroke the 
medial side of the knee to empty the 
medial compartment of fluid then 
stroke the lateral side. 
- Observe the medial side of the knee for 
any bulging? This may indicate an 
effusion
Movement 
• Ask the patient to flex each 
knee in turn and observe the 
range of movement (0-150°) 
and any signs of pain. 
• Ask the patient straightens 
each knee, place a hand on 
the knee to feel the crepitus.
Examination of the hip 
Palpation 
• Palpate the greater 
trochanter area
Movements 
FLEXION 
Have the patient flex their 
knees & move their hip joint 
into the flexed position as fair 
as possible. (Normal range ~ 
120 degree) 
• If you keep the knee extended 
the range of movement in the 
hip joint is limited by tension 
in the hamstring muscles
ABDUCTION 
Make sure you stabilize the 
pelvis by placing a hand on 
the opposite anterior iliac 
crest and holding the ankle 
with the other hand. The hip 
is abducted until the pelvis 
tilts. (Normal range of 
movement ~ 45 degrees)
ADDUCTION 
Cross one leg over the other until 
pelvis begins to tilt. (Normal 
range of movement ~ 30 
degrees)
INTERNAL ROTATION 
• Flex the hip and knee to 90 degrees. 
Now move the leg laterally. (Normal 
range of movement ~ 45 degrees)
EXTERNAL ROTATION 
• With the hip and knee flexed 
move the patient's leg medially. 
(Normal range of movement ~ 60 
degrees)
EXTENSION 
Have the patient lie prone on the 
couch. Immobilize the pelvis with 
one hand while extending the hip 
with the other hand.
Examine the temporomandibular 
joint 
• Places first two fingers of 
each hand in front of tragus 
of ear and instruct patient 
to open and close mouth.
Examination of the spine and posture 
• Inspect the standing patient's spine and posture 
from behind and the side for: 
– abnormal kyphosis 
– lordosis 
– flattening of the longitudinal arch of the foot.
Palpation of the spine 
• Tenderness 
• Swelling 
• Increased warmth
Movement 
• Cervical spine: 
Ask the patient to look right, left, 
and then tilt the head sideways 
aiming to touch each ear on the 
shoulder.
Thoracic spines 
• Measure the chest expansion by a 
tape at the level of nipple.
Lumbar flexion 
• Try to touch your toes 
without bending knees
Lumbar extension 
Lean back
Lateral lumbar flexion 
(Both sides) 
• Slide your hand down 
your leg
Thoracolumbar rotation 
• “Sit down and turn round, 
looking over your shoulder” 
(Sitting down helps fix the 
patients pelvis)
Schober's test 
• Firstly identify the Dimples of Venus (2) 
Now in the midline, use a tape measure 
and pen to mark a point 10 cm superior 
(1), and another mark 5 cm inferior (3) 
to this line 
• Ask the patient to attempt to “touch 
their toes” (i.e Flexing their lumbar 
spine).The distance between these 
two marks should be measured 
when the patient’s spine is flexed 
maximally 
• The distance should increase to 
more than 21cm in a normal patient. 
In lumbar spine flexion, hip flexion can compensate to a considerable extent for a loss of spinal flexion. You 
may want to consider performing Schober’s test to objectively measure the degree of spinal flexion.
Schober's test
Good Luck

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Clinical approch to rheumatological examination

  • 1. Rheumatological Examination By ASHRAF OKBA PROF. OF INTERNAL MEDICINE AIN SHAMS UNIVERSITY
  • 2. Getting Ready • Greet the patient with kindness. • Introduce yourself to the patient. • Explain the procedure to the patient. • Expose the area to be examined and ensure that it is not covered by clothes.
  • 3. Gait • Observe for – Rhythm – Symmetry
  • 6. Upper limbs Inspection Inspect the hand & wrists for: • Swelling, • Deformity, • Nodule (heberden's nodes, Bouchard nod, tc), • Muscle wasting, • Skin abnormality • Nail abnormality. (heberden's nodes, Bouchard nodes
  • 7. Palpation Palpate the hand for – tenderness – synovial thickening – increased warmth – sweating. Perform – Metacarpal squeeze test
  • 8. palpate – Metacarpophalangeal joints – Proximal interphalangeal joints – Distal interphalangeal, joints
  • 9. Movement • Ask the patient to open and spread the fingers, of both sides Close the fingers (power grip), of both sides
  • 10. • Pinch the tip of index finger and thumb (precision pinch). of both sides and feel its power • Compare active with passive if active range limited, (precision pinch)
  • 11. • Ask the patient to put his hands together in the position of prayer and then to lower the hands keeping the palms together. This demonstrates the range of dorsiflexion of the wrists
  • 12. • Ask the patient to place the back of his hands together and to raise the arms upwards. This demonstrates the range of flexion of wrists
  • 13. Examination of the elbow Inspection Inspect for: • Deformity, • Nodule, • Muscle wasting, • Skin abnormality
  • 14. Palpation – Tenderness – Swelling – Increased warmth. Three bony landmarks - the medial epicondyle, the lateral epicondyle, and the apex of the olecranon - form an equilateral triangle when the elbow is flexed 90°, and a straight line when the elbow is in extension
  • 15. Movement • Instruct the patient to bend and straighten both elbows simultaneously (0-150°), • With elbows flexed to 90° turn hands palm up (supination 0-90°) and then palms down (pronation 0-90°).
  • 16. Examination of the shoulders Inspection Inspect for o Deformity, o Nodule, o Muscle wasting, o Skin abnormality from the front and the back Marked atrophy of infra and supraspinous fossae.
  • 17. SHOULDER JOINT • Sternoclavicular joint (SC) • acromioclvicular joint (AC) • glenohumeral joints
  • 18. Sternoclavicular joint (SC) A swelling with bruising over The right sternoclavicular joint
  • 20. glenohumeral joints Normally, it is possible to raise the arm to 90° while maintaining the scapula fixed. Scapula pivots before glenohumeral abduction takes place giving this aspect of raising of the shoulder
  • 21. PALPATION OF SHOULDER JOINT observe for – Tenderness – Swelling – Temperature – Crepitus.
  • 22. Ask the patient to point to the site where they are experiencing discomfort. Instruct the patient to inform you if he experience any pain during the examination.
  • 23. Palpate both shoulder joints in a systematic approach. 1) Sternoclavicular joint 2) Clavicle 3) Acromioclavicular joint 4) Humeral head 5) Coracoid process 6) Deltoid muscle 7) Spine of scapula 8) Supraspinatus muscle 9) Infraspinatus muscle 10) Trazpezus muscle (then repeat on the other side)
  • 24. Movement • Ask the patient to put both hands behind the head with elbows pointing laterally (flexion, abduction and external rotation), • To put the arms down and reach up behind the back (extension, adduction and full internal rotation).
  • 25. Examination of ankles and feet Inspection: Inspect the ankles and feet joints for: • Swelling, • Deformity, • Nodule • Muscle wasting, • Skin abnormality and • Nail abnormality. Bilateral rheumatoid nodule at the ankle with superficial bursitis
  • 26. Palpation Palpate joints for: • Tenderness, • Swelling • Increased warmth.
  • 28. Movement Ask the patient to dorsiflex (20°) and plantar flex (30°) each ankle (wide range of normal). Passively evert (10°) and invert (20°) the subtalar joints with the ankles in neutral.
  • 29. Flex and extend the MTP joints.
  • 30. Examination of the knees Inspection Inspect the knee joints for: • Swelling, • Deformity, • Muscle wasting and • Skin abnormality.
  • 31. Palpation • Palpate for: o tenderness o swelling o increased warmth
  • 32. Examine for knee effusion Patellar tap test: Slide your hand down the patient's thigh, pushing down over the suprapatellar pouch, so that any effusion is forced behind the patella. - When you reach the upper pole of the patella, keep your hand there and maintain pressure Using the index & middle finger of the other hand push the patella down gently. - Does it bounce? If so this may indicate the presence of an effusion.
  • 33. Bulge test (massage test) - Using your thumb and index finger - milk down any fluid from above the knee. - Keep this hand in this position. -Now with the other hand, stroke the medial side of the knee to empty the medial compartment of fluid then stroke the lateral side. - Observe the medial side of the knee for any bulging? This may indicate an effusion
  • 34. Movement • Ask the patient to flex each knee in turn and observe the range of movement (0-150°) and any signs of pain. • Ask the patient straightens each knee, place a hand on the knee to feel the crepitus.
  • 35. Examination of the hip Palpation • Palpate the greater trochanter area
  • 36. Movements FLEXION Have the patient flex their knees & move their hip joint into the flexed position as fair as possible. (Normal range ~ 120 degree) • If you keep the knee extended the range of movement in the hip joint is limited by tension in the hamstring muscles
  • 37. ABDUCTION Make sure you stabilize the pelvis by placing a hand on the opposite anterior iliac crest and holding the ankle with the other hand. The hip is abducted until the pelvis tilts. (Normal range of movement ~ 45 degrees)
  • 38. ADDUCTION Cross one leg over the other until pelvis begins to tilt. (Normal range of movement ~ 30 degrees)
  • 39. INTERNAL ROTATION • Flex the hip and knee to 90 degrees. Now move the leg laterally. (Normal range of movement ~ 45 degrees)
  • 40. EXTERNAL ROTATION • With the hip and knee flexed move the patient's leg medially. (Normal range of movement ~ 60 degrees)
  • 41. EXTENSION Have the patient lie prone on the couch. Immobilize the pelvis with one hand while extending the hip with the other hand.
  • 42. Examine the temporomandibular joint • Places first two fingers of each hand in front of tragus of ear and instruct patient to open and close mouth.
  • 43. Examination of the spine and posture • Inspect the standing patient's spine and posture from behind and the side for: – abnormal kyphosis – lordosis – flattening of the longitudinal arch of the foot.
  • 44. Palpation of the spine • Tenderness • Swelling • Increased warmth
  • 45. Movement • Cervical spine: Ask the patient to look right, left, and then tilt the head sideways aiming to touch each ear on the shoulder.
  • 46. Thoracic spines • Measure the chest expansion by a tape at the level of nipple.
  • 47. Lumbar flexion • Try to touch your toes without bending knees
  • 49. Lateral lumbar flexion (Both sides) • Slide your hand down your leg
  • 50. Thoracolumbar rotation • “Sit down and turn round, looking over your shoulder” (Sitting down helps fix the patients pelvis)
  • 51. Schober's test • Firstly identify the Dimples of Venus (2) Now in the midline, use a tape measure and pen to mark a point 10 cm superior (1), and another mark 5 cm inferior (3) to this line • Ask the patient to attempt to “touch their toes” (i.e Flexing their lumbar spine).The distance between these two marks should be measured when the patient’s spine is flexed maximally • The distance should increase to more than 21cm in a normal patient. In lumbar spine flexion, hip flexion can compensate to a considerable extent for a loss of spinal flexion. You may want to consider performing Schober’s test to objectively measure the degree of spinal flexion.