The document provides guidance on systematically examining the joints. Key points include: - Examine joints from upper extremities to lower, gently handling painful areas. Note skin signs and gait. - Evaluate swelling, tenderness, range of motion, crepitus, deformities, and instability. Record findings using methods like S-T-L or a 28-joint count. - Interpret findings considering sensitivity limits and need to correlate to symptoms. Examine specific small and large joints for signs of inflammation, damage or deformity.

1. PART5-Chapter 43
Systematic
Method of
Examination
19
Muhanna Kazempour MD

2. Systematic Method of Examination
Aim: to detect abnormalities in structure and function.
Joints
periarticular soft tissues
Tendons
ligaments
Bursae
muscles

3. ➢upper extremities followed by the trunk and lower extremities
➢Gentle handling of tender and painful joints.

4. General Observation
look for any signs of systemic illness
Skin
➢pallor (which may suggest anemia)
➢nodules (which may suggest RA or gout)
➢rashes (which may suggest lupus, vasculitis, or dermatomyositis)

5. antalgic gait
musculoskeletal disorders of the spine or lower extremities
Trendelenburg gait
various gait
neuromuscular diseases
General Observation

6. The ability of the patient to arise and transfer to
the examining table should also be evaluated, as
this will provide information on
➢ pain
➢proximal muscle strength
➢overall physical function.

7. ➢Bulk
(compared on one side of the body; asymmetry, hypertrophy, or atrophy)
➢Tone
➢tenderness of the muscles

8. The patient’s manner
and body language
✓mood
✓anxiety level
✓pain
✓tenderness

9. Key signs of articular disease
Swelling
Tenderness
Limitation of motion
Crepitus
Deformity
Instability

10. cause:
❑ intra-articular effusion
❑synovial proliferation
❑periarticular subcutaneous tissue
inflammation
❑Bursitis
❑tendinitis
❑bony enlargement
❑extra-articular fat pads
Swelling 1. inspect the joints
loss of normal landmarks or contours
compare the same joints on both sides
2. palpate each joint
normal synovial membrane :thin thickened
synovial membrane RA
differentiate between synovial
proliferation and effusion:
➢ understanding of the anatomic
configuration of each joint’s
➢ Ultrasonography

11. Tenderness
➢intra-articular
➢ periarticular
fat pad, tendon attachment, ligament, bursa, muscle, or skin

12. Limitation of Motion
➢know the normal type and ROM for each joint.
➢Comparison of the affected joint with an unaffected joint
Restricted joint motion:
➢joint
➢periarticular structures.
➢To distinguish :compare the passive with the active ROM
➢passive ROM > active ROM: pain, weakness, or the state of articular or periarticular structures.
➢Pain in the joint with attempted active or passive ROM :abnormality in the joint.
➢distinguish muscle tension from a true limitation of joint motion
✓ Pain that occurs with attempts to move a joint passively to the limit of ROM in one plane is
referred to as stress pain.

13. Crepitus
➢palpable or audible grating or crunching sensation produced by
motion.
➢Fine crepitus: chronic inflammatory arthritis
➢Coarse crepitus: inflammatory or non-inflammatory arthritis.
➢Boneon- bone crepitus produces a higher-frequency, palpable, audible squeak.
➢In scleroderma, a distinct, coarse, creaking, leathery crepitus may be palpable
or audible over tendon sheaths.

14. Deformity of the joints
✓bony enlargement
✓articular subluxation
✓Contracture
✓ankylosis
❑do not function normally
❑frequently restrict activities
❑may be associated with pain, especially with overuse.
➢Joint deformities may be reversible or irreversible.

15. Jaccoud’s arthropathy of lupus can be corrected with manipulation
In contrast, hand deformities in RA generally are not correctable.

16. Instability
Subluxation: partial displacement of the articular surfaces but still
some joint surface-to-surface contact.
Dislocated joint: lost all cartilage surface-to-surface contact.
The patient must be relaxed during the examination
➢if the patient contracts the quadriceps muscles during
evaluation, A knee with a deficient ligament might appear stable

17. Recording the Joint Examination
➢Therapy
➢monitoring the activity of arthritis
➢determining the efficacy of interventions.

18. Many different recording methods
✓Abbreviations for each joint can be used, such as PIP for the proximal interphalangeal joints.
❑S-T-L system
❑schematic skeleton or homunculus
❑Joint counts (28-joint count): standard assessments to
monitor

19. ❑The S-T-L system has been used historically to record the degree of
swelling (S), tenderness (T), and limitation of motion (L) of each joint
on the basis of a quantitative estimate of gradation.
➢This method remains useful but is used less commonly today
❑It is easier to describe joint findings in narrative form, for example,
“there is 2+ swelling of the second and third metacarpophalangeal
(MCP) joints,” where
grade 0 indicates no swelling,
grade 1 indicates palpable synovial thickening,
grade 2 indicates loss of normal joint contours
grade 3 indicates frank cystic swelling of the MCP joint.

20. 28-joint count
➢shoulders, elbows, wrists, first to fifth MCP
joints, first to fifth PIP joints, and knees on both
sides of the body.
➢tenderness and swelling
➢quick and easy to perform
➢ankles and MTP joints are not included, so
active disease in the feet may be
underestimated.
➢calculate the Disease Activity Score 28 (DAS28),
which is a validated instrument used to monitor
disease activity.

21. Function of the joints
✓The function of the joints in normal use is not captured by
assessments of tenderness, swelling, or ROM.
✓measure joint function by assessing the patient’s ability to
perform a coordinated task (e.g., shoulder arc of motion,
measuring the 50-foot walk time).

22. Interpreting the Joint Examination
➢joint examination is far less sensitive in detecting synovitis or effusions than high-resolution
ultrasonography or MRI.
➢swollen joints are more specific for active synovitis
➢joint tenderness has similar value compared with swellingin predicting the progression of
radiographic joint damage.
▪Demonstrable physical signs of arthritis may be particularly subtle for patients with early
disease.
▪Considering that MRI bone marrow edema is a predictor of radiographic damage, it is notable
that one study reported that 35% to 57% of joints with bone marrow edema were negative for
physical signs of synovitis.
Thus the examiner must consider the physical findings in view of the complete history of joint
symptoms to make an accurate diagnosis, assess prognosis, and prescribe management.

23. Examination of Specific Joints
❖Temporomandibular Joint
❖Cricoarytenoid Joints
❖Sternoclavicular
❖Acromioclavicular Joint
❖Elbow
❖Wrist and Carpal Joints
❖Metacarpophalangeal, Proximal and Distal Interphalangeal Joints
❖Hip
❖Knee
❖Ankle

24. Temporomandibular Joint
✓Audible or palpable crepitus or clicking
✓difficult to visualize swelling of this joint.
✓can be detected most easily if the synovitis is unilateral or asymmetric
compared with the other side.
❖JRA and adult RA.
❖Micrognathia may develop in children in whom these joints are affected
➢The examiner may palpate the joint by placing a finger just anterior to the external
auditory canal and asking the patient to open and close the mouth and to move the
mandible from side to side.
➢To assess vertical movement : the examiner should ask the patient to open the mouth
maximally and then measure the distance between the upper and lower incisor teeth,
normally 3 to 6 cm.
➢Lateral movement can be determined by using incisor teeth as landmarks.

25. Cricoarytenoid Joints
Examination: direct or indirect laryngoscopy.
❖RA, trauma, infection.
Symptoms: hoarseness or a sense of fullness or discomfort in
the throat, which is worse on speaking or swallowing.
Severe airway obstruction may occur in rare cases.

26. Sternoclavicular
▪synovitis usually is visible and palpable.
▪often subclinical
✓Ankylosing spondylitis
✓ RA
✓degenerative arthritis
✓The sternoclavicular joint may be the site of septic arthritis, especially in
injection drug users.

27. Tenderness >> swelling
Tenderness without actual swelling : costochondritis
actual swelling :Tietze’s syndrome
Manubriosternalor sternocostal

28. Acromioclavicular
Joint arthritis
▪Tenderness or pain with adduction of the arm across the chest indicates
pathology of the acromioclavicular joint.
▪most commonly attributable to trauma leading to degenerative arthritis.
▪RA or spondyloarthropathies
✓although these often are not severe enough to come to clinical attention.
Bony enlargement of this joint is typically observed,
but soft tissue swelling is not usually visible or palpable.

29. Elbow
The examiner relaxes and passively moves the elbow through flexion,
extension, and rotation.
Synovial swelling is most easily palpated.
Synovitis or effusion generally results in limitation of elbow extension.
✓ noting abnormalities such as psoriatic plaques, rheumatoid
nodules, or tophi.

30. Olecranon bursitis
➢After chronic local trauma
➢Rheumatic diseases(RA and gout)
A septic olecranon bursitis may occur.
large collection of fluid palpable as a cystic mass, often requiring
aspiration and drainage.
There is generally no pain with elbow movement.

31. Tennis elbow & Golfer’s elbow
Tenderness at the epicondyles without swelling or other signs of inflammation
may indicate overuse tendinopathy
➢lateral epicondylitis (tennis elbow)
➢medial epicondylitis (golfer’s elbow)
In lateral epicondylitis, discomfort can be elicited by resisted supination of the
forearm or resisted extension of the pronated wrist.
In medial epicondylitis, discomfort can be elicited by resisted flexion of the
supinated wrist.

32. Rupture the attachment site of one of
the heads of the biceps
visible and palpable muscle swelling on the anterior upper arm.

33. wrist
➢extended to 70 to 80 degrees
➢ flexed to 80 to 90 degrees.
➢ Ulnar deviation :50 degrees
➢radial deviation: 20 to 30 degrees
Pronation and supination of the hand and forearm occur primarily at
the proximal and distal radioulnar joints.
Loss of extension is the most incapacitating functional impairment of
wrist motion.

34. Examine the wrist
examiner should palpate the joint gently between the thumbs
dorsally and the fingers on the volar aspect.
Synovitis of the wrist is best detected by palpation of the dorsal
aspect of the joint.
When this thickening or proliferation is severe, the ROM of the
wrist joint frequently is limited and associated with stress pain.

35. Dupuytren’s contracture
A fibrosing condition, affects the palmar aponeurosis (fascia),
may draw one or more fingers into flexion at the MCP joint.
The fourth finger is frequently affected first.

36. Swelling of the wrist may be caused by
▪Effusion
Articular swelling tends to be more diffuse and protrudes anteriorly and posteriorly
from under the tendons
▪synovial proliferation
▪Tenosynovitis
swelling is localized to the distribution of a particular tendon sheath or compartment
▪combination

37. Articular swelling ▪Tenosynovitis

38. ➢A cystic enlargement arising from a joint capsule
➢volar or dorsal aspect of the wrist between the tendons.
Ganglion

39. Subluxation of the ulna
➢severe chronic inflammatory arthritis.
➢a prominence on the dorsomedial wrist
✓Chronic irritation of the extensor tendons, primarily the fourth and fifth
finger extensor tendons, may cause these tendons to rupture.

40. Trigger fingers
➢secondary to stenosing tenosynovitis
➢history of the affected finger catching or locking with
movement.
➢ detected by palpating crepitus or nodules along the tendons
in the palm while the patient slowly flexes and extends the
fingers.

41. De Quervain’s tenosynovitis
➢pain at the radial aspect of the wrist
Tenosynovitis of the first extensor compartment
(abductor pollicis longus and extensor pollicis brevis muscles)
Finkelstein test : asking the patient to make a fist with the thumb
enclosed in the palm of the hand, then to move the wrist into
ulnar deviation.
➢Severe pain over the radial styloid is a positive finding

42. Examine the MCP joints
➢Two-finger technique
➢Dorsal four-finger technique
greater sensitivity and negative predictive value for clinical synovitis
➢Squeeze test :Gentle lateral compression with force applied at
the base of the second and fifth MCP joints often elicits pain if
synovitis is present.

45. Squeeze test

46. palpating gently over the lateral and medial aspects of the joint,
where the flexor and extensor tendons do not interfere with
assessment of the synovial membrane.
Alternatively, the joint can be compressed anteroposteriorly by
the thumb and index finger of one of the examiner’s hands,
while the other thumb and index finger palpate for synovial
distention medially and laterally.
PIP and DIP

47. The Bunnell test is useful in differentiating synovitis of the PIP joints from
tightening of the intrinsic muscles
The MCP joint is held in an extended position and the therapist passively
flexes the PIP making note of the available range. The test is then repeated
with the MCP joint flexed.
➢ If no change in motion is detected between the two tests, then capsular
restriction at the PIP joint is implicated.
➢If the motion increases when the MCP joint is flexed, then muscle tightness
is implicated.

48. Swelling of the fingers
➢ articular
Synovial swelling :symmetric
➢periarticular causes.
extra-articular: Asymmetric

49. Diffuse swelling of an entire digit
❑tenosynovitis
❑Spondyloarthropathies
➢reactive arthritis
➢ psoriatic arthritis.
Dactylitis and sausage digit

50. ➢firm periarticular swellings
➢frequently overlie the joints or bony prominences in patients
with chronic rheumatoid disease.
Rheumatoid nodules

51. Ulnar deviation of the fingers
Chronic swelling with distention of the MCP joints tends to
produce stretching and laxity of the articular capsule and
ligaments.
This laxity + muscle imbalance extensor tendons of the
digits slipping off the metacarpal heads to the ulnar sides of the
joints =ulnar deviation of the fingers

52. Ulnar deviation of the fingers

53. Swan neck
deformity
A finger with a:
➢ flexion contracture of the MCP
➢ hyperextension of the PIP joint
➢ flexion of the DIP joint.

54. Boutonnière deformity
A finger with
➢flexion contracture of the PIP joint
&
➢hyperextension of the DIP joint.
The deformity is common in RA.

55. Telescopingorshorteningofthedigits
resorption of the ends of the phalanges secondary to destructive arthropathy.
➢arthritis mutilans form of psoriatic arthritis.
Shortening of the fingers is associated with wrinkling of the skin
over involved joints and is called operaglass hand or la main en
lorgnette.

56. ➢The is a test for lunate dislocation.
The third metacarpal head usually is more prominent than the
second and fourth.
If the third metacarpal is level with the second and fourth, the
finding is positive for lunate dislocation
Murphy sign

57. Heberden nodes: Enlarged, bony, hypertrophic DIP joints
Bouchard nodes: similar changes at the PIP joints
differentiated from the synovitis of inflammatory arthritis
➢enlargement is hard or bony
➢signs of inflammation are minimal
distinguished from rheumatoid nodules
but patients occasionally confuse these when describing swellings over joints.

58. Other causes of joint enlargement
or nodules on the hands
multicentric reticulohistiocytosis.
tophaceous gout

59. psoriatic arthritis:
Ridging
onycholysis
nail pitting
Osteoarthritis:
groove deformity of the nail on
a digit with a Heberden node.
(This nail deformity has been
called a Heberden node nail.)
Fingernails

60. ❑make a fist.
❑Finger opposition
❑asking the patient to pick up a small object.
Hand function

61. Strength of the hands
➢asking the patient to grip firmly two or more of the examiner’s
fingers.
➢More accurate measures of grip strength can be made by
using a dynamometer or by having the patient squeeze a
partially inflated sphygmomanometer (at 20 mm Hg).
It sometimes is useful to test the strength of the fingers
separately.

62. Examination of the hip
➢observation of the patient’s stance and gait.
Pelvic tilt or obliquity related to:
▪structural scoliosis
▪ anatomic leg-length discrepancy
▪ hip disease.
➢Hip contractures may result in abduction or adduction
deformities.

63. Fixed abduction deformity
➢The pelvis becomes elevated on the normal side during
standing or walking.
This elevation causes an apparent shortening of the normal leg
and forces the patient to stand or walk on the toes of the normal
side or to flex the knee on the abnormal leg.

64. Adducted hip contracture
Viewed from behind with the legs parallel
asymmetric gluteal folds secondary to pelvic tilt, with the
diseased side elevated.
In this situation, the patient is unable to stand with the foot of
the involved leg flat on the floor.

65. Hip flexion deformity
commonly occurs in diseases of the hip.
Unilateral flexion of the hip in the standing position
reduces weight bearing on the involved side and relaxes
the joint capsule, causing less pain.
A hyperlordosis curve of the lumbar spine compensates
for lack of full hip extension.

66. Two abnormalities of gait
Gait should be assessed in the patient with possible hip joint disease.
1. Antalgic (limping) gait
➢ frequently seen with painful hips
➢placing the body weight directly over the joint to avoid painful contraction of the hip abductors.
2. Trendelenburg gait
with weight bearing on the affected side, the pelvis drops and the trunk shifts to the normal side.
➢in patients with weak hip abductors
A mild Trendelenburg gait is seen often in healthy individuals.

67. Trendelenburg test
➢Assess the stability of the hip
➢measure of the gluteus medius hip abductor strength.
The patient is asked to stand while bearing weight on only
one leg.
Normally, the abductors hold the pelvis level or the
nonsupported side slightly elevated.
If the non–weight-bearing side drops, the test is positive for
weakness of the weight-bearing side hip abductors,
especially the gluteus medius muscle.
This test is nonspecific and may be used in primary
neurologic or muscle disorders and in hip diseases

68. Range of motion of the hip
✓supine position
Flexion
Extension
Abduction
Adduction
Internal and external rotation, and circumduction.

69. Flexion of the hip
If the knee is held in
extension, the hamstrings limit
hip flexion to approximately 90
degrees
When the knee is held flexed
at 90 degrees, the hip
normally flexes to an angle of
120 degrees between the
thigh and the long axis of the
body.
.

70. ➢ showstheflexioncontracture.
Withthistest,theoppositehipisfullyflexedtoflattenthelumbarlordosis
andfixthepelvis.
Thepatient’sinvolvedlegshouldbeextendedtowardtheexamination
tableasfaraspossible.
Thomas test

71. Measurement for leg-length
➢supine position and the legs fully extended.
Each leg is measured from the anterior superior iliac spine to the medial malleolus.
A difference of 1 cm or less is unlikely to cause any abnormality of gait and may be considered normal.
apparent leg-length discrepancies may result from:
▪true leg-length asymmetries
▪pelvic tilt
▪abduction or adduction contracture of the hip.

72. Abduction
➢supine position and the leg in an extended
position, perpendicular to the pelvis.
➢Alternatively, the examiner could stand at the foot
of the table, grasp both of the patient’s ankles, and
simultaneously abduct both legs.
➢Abduction to approximately 45 degrees is normal.
➢ It is helpful to compare one side with the other
because the normal range of motion may vary.
Abduction is commonly limited in hip joint disease.

73. Adduction
Normal adduction is approximately 2
to 30 degrees.

74. Hip rotation
Hip rotation may be tested with the hip and knee flexed to 90
degrees or with the leg extended.
Rotation decreases with extension.
Normal hip external rotation and internal rotation are observed
to 45 and 40 degrees, respectively.
Limitation of internal rotation of the hip is a sensitive indicator
of hip joint disease.

75. Hip Extension
➢patient in the prone position.
Normal extension ranges from 10 to 20 degrees.
Limitation of extension often occurs secondary to
a hip flexion contracture

76. (FABER) test
✓Flexion abduction external rotation (FABER) test
✓Patrick test
➢screening test for intra-articular hip pathology
➢positive when the maneuver reproduces the patient’s pain.
➢very sensitive for hip joint disease
➢This test is not specific because a positive test may indicate
iliopsoas tightness or sacroiliac joint disease.

77. Ober test
evaluates the iliotibial band for contracture.
1. The patient lies on the side, with the lower leg flexed at the
hip and knee.
2. The examiner abducts and extends the upper leg with the
knee flexed at 90 degrees.
3. The examiner slowly lowers the patient’s limb with the
muscles relaxed.
A positive test result indicative of an iliotibial band contracture
occurs if the leg does not fall back to the level of the tabletop.

78. Clinically
Important
Bursae
Iliopsoas bursa lies between the psoas muscle and the joint
surface.
Trochanteric bursa lies between the gluteus maximus muscle
and the posterolateral greater trochanter
Ischiogluteal bursa overlies the ischial tuberosity.

79. Trochanteric bursitis
A common cause of lateral hip pain
when they attempt to lie on the affected side or climb stairs.
The greater trochanter should be palpated for tenderness and
compared with the opposite side.
The pain of trochanteric bursitis is aggravated by actively
resisted abduction of the hip.

80. Anterior hip and groin pain
➢hip abnormality, degenerative arthritis (decreased range of motion )
➢iliopsoas bursitis
in which swelling and tenderness may be noted in the middle third of the inguinal
ligament lateral to the femoral pulse.
This pain is aggravated by hip extension and is reduced by flexion.
➢tendinitis of the iliopsoas muscle.
If the patient has tenderness in the region of the iliopsoas bursa, but no swelling is palpable,
the examiner should consider
➢ The inguinal region should be palpated for other abnormalities,
such as hernias, femoral aneurysms, adenopathy, tumor, and psoas
abscess or masses.

81. Hip flexor strength test
➢iliopsoas muscle (nerve roots L2 and L3)
➢ patient sitting at the edge of a table.
The examiner exerts downward pressure against the thigh proximal
to the knee while the patient attempts to flex the hip.
The pelvis may be stabilized by the examiner’s other hand placed on
the ipsilateral iliac crest.
➢Alternatively, with the patient supine and holding the leg in 90
degrees of flexion at the hip, the examiner may attempt to straighten
the hip.

82. Hip Extension strength test
➢gluteus maximus muscle (L5 and S1).
➢patient lying prone.
With the patient’s knee flexed to remove hamstring action, the
patient is instructed to extend the hip and thigh off the surface of
the table while the examiner places a forearm across the posterior
iliac crest to stabilize the pelvis and applies downward pressure to
prevent the lateral trunk muscles from elevating the pelvis and leg
off the table.

83. Hip abductor & adductor strength test
Hip adductors : three adductors (longus, brevis, and magnus) plus
the gracilis and pectineus muscles.
Hip abductor : gluteus medius

84. Knee
➢Knee extension: quadriceps femoris muscle
➢knee flexion :hamstrings.
➢externally rotates: biceps femoris muscle
➢mediate internal rotation: popliteus and
semitendinosus muscles.

85. ▪superficial prepatellar bursa
▪superficial and deep infrapatellar bursae
▪pes anserine bursa
▪posterior medial semimembranosus
▪posterolateral gastrocnemius bursae.

86. Askthepatientabout
❖Locking is the sudden loss of ability to extend the knee
(painful ,audible noise, such as a click or pop.)
✓extensive intra-articular abnormality, including loose bodies or cartilaginous
tears.
❖ Catching refers to a subjective sensation of the patient that the knee might
lock;
the patient may experience a momentary interruption in the smooth ROM of the
joint but is able to continue with normal motion after this brief hesitation.
❖True give-way indicates that the knee actually buckles and gives out in certain
positions or with certain activities.
Patients often experience a sensation that the knee will give out when it actually
does not.
✓severe intra-articular abnormality, such as an unstable joint from ligamentous
injury or incompetence.

87. Examination of the knees
▪genu varum
▪genu valgum
▪genu recurvatum
✓gait abnormalities

88. Inspection of the knees
✓standing and supine
➢compare side to side (asymmetry; swelling or muscle atrophy)
➢Suprapatellar swelling
knee joint effusion or synovitis.
➢Localized swelling over the surface of the patella
is generally secondary to prepatellar bursitis.
➢Patellar alignment should be noted, including high-riding or laterally
displaced patellae.
➢inspect the knee from behind to identify popliteal swelling caused
by a popliteal or Baker cyst

89. Quadriceps femoris muscle
atrophy
➢usually develops in chronic arthritis of the knee.
➢Atrophy of the vastus medialis muscle is the
earliest change
❖comparing the two thighs for medial asymmetry and
circumference.
❖Measurement of the thigh circumference should be
performed at 15 cm above the knee to avoid spurious results
due to suprapatellar effusions.

90. Palpation of the knee
➢joint relaxed
➢supine and the knees fully extended
➢Palpation should begin over the anterior thigh
approximately 10 cm above the patella.
palpate the anterior thigh, moving distally toward the knee.

91. Palpation of the knee
Swelling, thickening, nodules, loose bodies, tenderness, and
warmth should be noted.
A thickened synovial membrane has a boggy, doughy
consistency, which differs from the surrounding soft tissue and
muscle.
It usually is palpated earlier over the medial aspect of the
suprapatellar pouch and the medial tibiofemoral joint.

92. Detection
of
knee fluid
❑ballottement test
1. suprapatellar pouch is compressed with the palm of the
hand placed just proximal to the patella.
2. The synovial fluid forced into the inferior distal articular
cavity is palpated with the opposite thumb and index finger
laterally and medially to the patella.
❑With a large effusion, the patella can be balloted by pushing it
posteriorly against the femur with the right forefinger, while
maintaining suprapatellar compression with the left hand.

93. Bulge sign
Effusions of 4 to 8 mL can be detected.
This test is performed with the patient’s knee extended and
relaxed.
A) Empty the suprapatellar pouch
B) compresses the medial side of the joint to displace excess
fluid to the lateral side of the joint.
C) compresses the lateral side while watching the medial side
closely for a bulge
✓A so-called spontaneous bulge sign occurs if, on compression along the
medial side of the joint space, fluid reaccumulates with no pressure or
compression along the lateral side of the joint.

94. Tenderness of joint margins of
medial and lateral tibiofemoral
Joint margins palpated easily with the hip flexed to 45 degrees, the knee
flexed to 90 degrees, and the foot resting on the examining table.
➢articular cartilage disease
➢medial or lateral meniscal abnormality
➢medial or lateral collateral ligament injury.
Other causes of tenderness :
▪pathologic conditions in the underlying bony structures
▪Bursitis (pes anserine , prepatellar bursae)

95. Patellofemoral
malalignment
another common cause of knee pain.
It is more common in female patients because of the wider Q angle caused
by the broader female pelvis.
The Q angle is the angle formed between the quadriceps and the patellar
tendon.

96. Patellofemoral disease
▪stiffness in the knee after a period of flexion (moviegoer sign)
▪particular difficulty with stair climbing.
▪sensation of catching as the patella moves over the distal
femur(Some)
➢Slight crepitation may be observed in many normally functioning knees.
➢ Pain with crepitation may suggest patellofemoral degenerative arthritis or
chondromalacia patellae.

97. ➢Retropatellar pain occurring with active knee flexion and extension and
secondary to patellofemoral disease may be differentiated from
tibiofemoral articular pain.
➢To test this, the examiner should attempt to lift the patella away from
the knee, while passively moving the knee through the ROM.
Painless motion during this maneuver indicates that the patellofemoral
joint is the likely source of the pain.
➢patellar grind test is useful in patients with extensive patellofemoral
abnormality.
examiner compresses the patella distally away from the femoral condyles,
while instructing the patient to contract the quadriceps isometrically.
Sudden patellar pain and quadriceps relaxation indicate a positive test
result.

98. Fairbanks apprehension test
Patellar stability should be assessed.
1. patient supine, the quadriceps relaxed, and the knee in 30
degrees of flexion.
2. The examiner slowly pushes the patella laterally.
A sudden contraction of the quadriceps and a distressed
reaction from the patient constitute a positive apprehension
test result.
patellar dislocations :positive

99. The normal knee range of motion
full extension(0 degrees),
Some normal individuals may be able to hyperextend to 15 degrees.
full flexion of 120 to 150 degrees
Reversible loss of full extension (knee joint effusion, synovitis)
Permanent loss of extension (flexion contracture due to chronic arthritis
of the knee)

100. posterior subluxation of the tibia on
the femur
advanced arthritis of RA

101. Knee flexion strength
test
➢flexion supplied by the hamstrings
(i.e., the biceps femoris, semitendinosus, and semimembranosus)
(nerve roots L5 to S3)
The hamstrings are best tested with the patient prone and
attempting to move the knee from 90 degrees to maximal flexion.
The ankle should be kept in a neutral position or dorsiflexed to
remove gastrocnemius action.

102. Knee extension strength test
➢extension supplied by the quadriceps femoris (L2, L3, and L4).
Extension is tested with the patient sitting upright with the knee fully
extended.
The examiner stabilizes the thigh with downward pressure just proximal to
the knee and places downward pressure at the ankle to test the knee
extensors.

103. Ankle
movement is limited to plantar flexion and dorsiflexion.
Inversion and eversion occur at the subtalar joint.
20 degrees of dorsiflexion
45 degrees of plantar flexion.
20 degrees of eversion
30 degrees of inversion.
The tibia forms the weight-bearing portion of the ankle joint.

104. The medial and lateral ligaments surrounding the ankle contribute to medial and
lateral stability of the joint.
➢The deltoid ligament, the only ligament on the medial side of the ankle, is a
triangle-shaped fibrous band that resists eversion of the foot.
It may be torn in eversion sprains of the ankle.
➢The lateral ligaments of the foot consist of three distinct bands forming the
posterior talofibular, the calcaneofibular, and the anterior talofibular ligaments.
These ligaments may be injured in inversion sprains of the ankle.

105. The calcaneus tendon (Achilles tendon),
subject to :
➢external trauma
➢various inflammatory reactions
➢irritations from bone spurs

106. Synovial swelling of the ankle joint:
fullness over the anterior or anterolateral
Swelling of the heels :
enthesitis of the Achilles tendon insertion, in SPA.

107. Synovitis of the intertarsal joints
It is difficult to observe
Erythematous puffiness or fullness over the dorsum of the foot.

108. Test the subtalar joint
examiner grasps the calcaneus with a hand and attempts to
invert and evert it, holding the ankle motionless.

109. Ageneral assessment of muscularstrengthof theankle
❑asking the patient to walk on toes and on heels.
➢If the patient can walk satisfactorily ;the flexors and extensors of the ankle
can be considered normal.
➢If this cannot be accomplished, it is desirable to test the muscles
individually.

110. Flexors of the ankle :
gastrocnemius(nerverootsS1andS2)andthesoleus(S1andS2)muscles

111. Extensor(dorsiflexors) of theankle:
tibialisanteriormuscle(L4,L5,andS1).

112. Inverter:
tibialisposteriormuscle(L5andS1)

113. Everters of thefoot :
peroneuslongus(L4,L5,andS1)andperoneusbrevis(L4,L5,andS1)muscles