History and Physical Examination of the Musculoskeletal System

40 History and Physical Examination of the Musculoskeletal System

John M. Davis, III., Kevin G. Moder, Gene G. Hunder

Taking a detailed and accurate history is crucial for making the correct diagnosis for patients with musculoskeletal diseases.

The cardinal symptoms of musculoskeletal disease are pain, stiffness, swelling, limitation of motion, weakness, fatigue, and loss of function.

Understanding the anatomy, the planes of motion, and particularly the configuration of the synovial lining is imperative for proper physical diagnosis of musculoskeletal diseases.

It is important to record qualitative and quantitative aspects of the joint examination to monitor disease activity in patients with inflammatory arthropathies.

Early recognition of how patients’ psychosocial factors affect their musculoskeletal symptoms and musculoskeletal examination enhances clinical assessment.

History in a Patient with Musculoskeletal Disease

Taking an accurate and comprehensive history of a patient’s musculoskeletal symptoms is crucial for making the correct diagnosis. This history must include a precise understanding of what the patient means by the description of symptoms. The physician must obtain a detailed account of symptom onset, location, patterns of progression, and severity, as well as exacerbating and alleviating factors and associated symptoms. The relationship of the symptoms to psychosocial stressors is important and should be determined. The impact of the symptoms on all aspects of the patient’s functioning must be assessed to guide therapy.

The effects of current or previous therapy on the course of the illness are helpful in efforts to understand current symptoms. Response to anti-inflammatory or glucocorticoid medications may suggest an inflammatory origin. Such responses are not specific to inflammatory rheumatic diseases, however, and must be considered in light of the entire history and physical examination. The physician must assess compliance with therapies for musculoskeletal diseases. Noncompliance with the recommended treatment must be differentiated from treatment failure as the explanation for the patient’s lack of improvement.

While the physician is taking the patient’s history, the patient provides verbal and nonverbal clues to the nature of the illness and how the patient has responded to it. Patients with early rheumatoid arthritis may hold their hands in a flexed posture to minimize intra-articular pressure and pain. Some patients may be overly concerned, whereas others may seem inappropriately indifferent to their symptoms. The physician must appreciate the patient’s understanding of the illness and attitudes toward it to begin effective treatment.

Pain

Pain is the most common symptom that brings a patient with musculoskeletal diseases to the physician. Pain is a subjective hurting sensation or experience described in various terms, often of actual or perceived physical damage. Pain is a complex sensation that is difficult to define, qualify, and measure. The patient’s pain may be modified by emotional factors and previous experiences.

The character of the pain usually is best defined early in the interview because this can be helpful in categorizing the patient’s complaints. Aching in a joint area suggests an arthritic disorder, whereas “burning” or “numbness” in an extremity may indicate a neuropathy. Descriptions of pain as “excruciating” or “intolerable” when the patient is otherwise able to function provide a clue that emotional or psychosocial factors are contributing to or amplifying the symptoms.

The physician must elicit the distribution of the patient’s pain and determine whether this fits with anatomic structures. Patients describe their pain location in terms of body part names, but frequently the terms are used in a nonanatomic manner. Patients frequently complain of “hip” pain when actually referring to pain in the low back, buttock, or thigh. The interviewer must attempt to clarify this complaint by asking the patient to point to the area of pain with one finger. Pain localized in the distribution of a joint or joints likely reflects an articular disorder. Pain may localize to bursae, tendons, ligaments, or nerves, implying disorders of these structures. In contrast to superficial structures, deep structures often give rise to poorly localizing pain. Similarly, pain arising from small, peripheral joints is often more focal than pain arising from proximal, large joints, such as the shoulders and hips. Pain that is widespread, vaguely described, and not respecting anatomic distributions generally suggests a chronic pain syndrome, such as fibromyalgia or psychiatric disease.

The severity of pain should be assessed. A common approach is to ask the patient to describe the level of pain on a numeric scale of intensity from 0 (no pain) to 10 (very severe pain). For monitoring of disease activity of inflammatory arthritis, measuring pain on a visual analogue scale by having the patient mark the severity of pain over the past week on a 100-mm line can be helpful. Similar scales are used in validated instruments such as the McGill Pain Questionnaire.

The physician must determine what exacerbates and alleviates the pain. Joint pain present at rest but worse with movement suggests an inflammatory process, whereas pain occurring primarily with activity and relieved by rest generally indicates a mechanical disorder, such as degenerative arthritis. Timing of pain symptoms during the day and night also provides important information, as discussed in the next section.

Stiffness

Stiffness is a common complaint among patients with arthritis. What is meant by stiffness varies from patient to patient, however. Some patients may use the term stiffness to refer to pain, soreness, weakness, fatigue, or limitation of motion.¹ Rheumatologists generally use the term stiffness to describe discomfort and limitation on attempted movement of joints after a period of inactivity. This “gel” phenomenon occurs usually after an hour or more of inactivity. The duration of stiffness related to inactivity varies, with mild stiffness lasting minutes and severe stiffness lasting hours.

Morning stiffness is an early feature of inflammatory arthropathies and is particularly noted in rheumatoid arthritis and polymyalgia rheumatica, in which morning stiffness may last for several hours. The absence of morning stiffness does not exclude inflammatory arthritis, but its absence is uncommon. A useful question to assess morning stiffness is this: “In the morning, how long does it take for your joints to limber up to as good as they are going to get for the day?” Morning stiffness associated with noninflammatory joint diseases, such as degenerative arthritis, generally is of short duration (usually <30 minutes) and is less severe than stiffness of inflammatory joint disease. Additionally, the degree of stiffness in noninflammatory joint diseases is related to the extent of use of the damaged joint—stiffness is worse after excessive use, generally improving within several days to the baseline level. Morning stiffness is not specific for inflammatory arthropathies and may be described by patients with fibromyalgia or chronic idiopathic pain syndromes, neurologic disorders such as Parkinson’s disease (although generally without limbering up), and sleep-related breathing disorders.

Limitation of Motion

Limitation of motion is a common complaint among patients with articular disorders. This complaint must be differentiated from stiffness, which usually is transient and variable, whereas limitation of motion secondary to joint disease is generally fixed and varies less over time. The interviewer should determine the extent of disability resulting from the restriction in joint motion. The duration of the restriction in joint motion frequently predicts the likelihood of improvement with interventions such as oral and intra-articular glucocorticoids or physical therapy. Determining the rapidity of onset of the limitation of motion may be helpful in the differential diagnosis; abrupt onset of the limitation of motion suggests a structural derangement, such as a tendon rupture or torn knee cartilage, whereas insidious onset of restricted joint motion is more common with inflammatory joint disease.

Swelling

Joint swelling is an important symptom in patients with rheumatic diseases. The presence of true joint swelling narrows the differential diagnosis in a patient with arthralgia. To determine whether the swelling is related to joint synovitis as opposed to soft tissue conditions, clarifying the anatomic location and distribution of the swelling is key. Diffuse soft tissue swelling can occur because of venous or lymphatic obstruction, soft tissue injury, or obesity. The description of swelling in patients with such conditions usually is ill defined or is not in a distribution of particular joints, bursae, or tendons. Obese patients may interpret normal adipose tissue over the medial aspect of the elbow, the knee, or the lateral aspect of the ankle as joint swelling. In contrast, patients with inflammatory arthritis may describe swelling of joints in a distribution typical of a specific disease—symmetric swelling of the metacarpophalangeal joints and wrists in rheumatoid arthritis, or swelling of several toes and a knee in psoriatic arthritis.

It is useful to delineate the onset and progression of swelling and the factors that influence it. Swelling of a joint resulting from synovitis or bursitis frequently is associated with discomfort with motion because of tension on the inflamed tissues. If swollen tissues are periarticular, however, no discomfort may be present with joint motion because the inflamed tissues are not stressed. Swelling of a confined structure, such as a synovial cavity or bursa, is most painful when it has developed acutely, whereas a similar degree of swelling that has developed slowly often is much more tolerable.

Weakness

Weakness is another common complaint that can be associated with myriad different subjective meanings. True weakness is the loss of muscle power. When present, it is demonstrable on physical examination.

The temporal course of weakness is important to the differential diagnosis. Weakness of sudden onset without trauma often indicates a neurologic disorder, such as an acute cerebrovascular event, which generally results in a fixed, nonprogressive deficit. Weakness of insidious onset more often suggests a muscle disease, such as an inflammatory myopathy (i.e., polymyositis). The latter tends to be ongoing and progressive. Weakness that is intermittent suggests a disorder of the neuromuscular junction, such as myasthenia gravis. Patients with this disease may describe muscle fatigue with activity as opposed to true weakness.

The physician should determine the distribution of the patient’s weakness. Proximal weakness that is bilateral and symmetric suggests an inflammatory myopathy. In contrast, inclusion body myositis causes an asymmetric and more distal weakness. The presence of a unilateral or isolated deficit generally indicates a neurogenic origin. Distal weakness, in the absence of joint findings, generally indicates neurologic disorders, such as peripheral neuropathy. Patients with peripheral neuropathies also complain of pain and sensory symptoms, such as paresthesias. In contrast, patients with inflammatory myopathy often present with painless weakness.

Inquiring about the patient’s family history may provide valuable information. A history of other family members with similar symptoms may increase the likelihood that the patient has a hereditary disorder, such as muscular dystrophy or familial neuropathy.

It also is important to review medication taken recently or currently. Many medications, including corticosteroids and lipid-lowering agents, can cause muscle injury. Less commonly, environmental exposure can lead to symptoms of weakness. Heavy metal poisoning causes a peripheral neuropathy. Dietary exposure also should be investigated such as eating undercooked pork as a source of trichinosis. Excessive alcohol intake has been associated with neuropathy and myopathy.

Taking a complete review of systems is helpful in evaluating a patient with weakness. Constitutional symptoms, such as weight loss and night sweats, may indicate the presence of a malignancy as the cause of generalized weakness. Rash, arthralgia, or Raynaud’s phenomenon may prompt further testing for a connective tissue disease.

Fatigue

Patients with musculoskeletal disorders frequently complain of fatigue. Fatigue can be defined as an inclination to rest even though pain and weakness are not limiting factors. Fatigue after varying degrees of activity that is relieved by rest is normal. Patients with rheumatic diseases experience fatigue even without activity. Fatigue generally improves as the systemic rheumatic disease improves. Malaise frequently occurs with, but is not synonymous with, fatigue. Malaise indicates the lack of well-being that often occurs at the onset of an illness. Fatigue and malaise may occur in the absence of identifiable disease, and psychosocial factors, anxiety, or depression may account for the symptoms.

Loss of Function

The comprehensive history should include an assessment of the patient’s ability to perform activities of daily living, as loss of function is a common manifestation of musculoskeletal disease with serious impact on health and quality of life. The extent of disability may vary from loss of the ability to use one finger joint due to arthritis to complete physical incapacitation due to severe inflammatory polyarthritis. Irrespective of the cause, loss of physical function often has a profound impact on patient social activities, exercise routine, work capacity, and even basic self-care. Assessing for the presence and degree of functional disability is important in evaluating the severity of illness and in making treatment recommendations, particularly in rheumatoid arthritis, where disability is among the best predictors of long-term outcomes and mortality.²^–⁴

Functional capacity is assessed first by asking general questions about the patient’s ability to perform daily activities, including grooming, dressing, bathing, eating, walking, climbing stairs, opening doors, carrying objects, and so forth. A report of a specific loss of function, such as difficulty opening a milk carton, should be investigated further to clarify why the task is difficult, which will inform the differential diagnosis and guide clinical examination. This information will also yield important information for management, such as opportunities for physical and occupational therapy, use of splints/braces, and so forth. Overall functional capacity may be evaluated with the use of an instrument such as the Health Assessment Questionnaire (see Chapter 33), which is widely used in research and in the clinic to monitor changes in physical function in response to therapy among patients with rheumatoid arthritis and other rheumatic diseases.

Systematic Method of Examination

The musculoskeletal examination should be a systematic, thorough assessment of the status of the joints, periarticular soft tissues, tendons, ligaments, bursae, and muscles. Rheumatologists commonly begin by examining the upper extremities followed by the trunk and lower extremities, but many routines may be effective, provided that a systematic, consistent approach is used. Gentle handling of tender and painful joints enhances cooperation by the patient and allows an accurate evaluation of the joints.

The general aim of the examination of the joints is to detect abnormalities in structure and function. Key signs of articular disease include swelling, tenderness, limitation of motion, crepitation, deformity, and instability.

General Observation

A general examination of the patient should be done to look for any signs of systemic illness. This should include an examination of the skin, noting signs of pallor (which may suggest anemia), nodules (which may suggest rheumatoid arthritis or gout), or rashes (which may suggest lupus, vasculitis, or dermatomyositis). The patient should be appropriately undressed for examination. The physician should assess gait by asking the patient to walk in the examining room or down the hallway, because an antalgic gait may be seen in various musculoskeletal disorders of the spine or lower extremities, and various gait disorders may occur in neuromuscular diseases. 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, and overall physical function. The patient should be assessed for appearance of the muscles, including bulk, tone, and tenderness. Muscle bulk should be compared on one side of the body with the other to look for any asymmetry, hypertrophy, or atrophy. The patient’s manner and body language may provide information on his or her mood and anxiety level, which merits consideration in evaluating pain and tenderness.

Swelling

Swelling around a joint may be caused by intra-articular effusion, synovial proliferation, periarticular subcutaneous tissue inflammation, bursitis, tendinitis, bony enlargement, or extra-articular fat pads. A keen understanding of the anatomic configuration of each joint’s synovial membrane is crucial in differentiating soft tissue swelling secondary to a joint effusion from swelling of periarticular tissues. First, the examiner should inspect the joints for visible evidence of swelling, such as loss of normal landmarks or contours. It is frequently helpful to visually compare the same joints on both sides of the body to detect subtle evidence of swelling and to appreciate symmetry.

Second, the examiner should palpate each joint. The normal synovial membrane is too thin to palpate, whereas the thickened synovial membrane in many chronic inflammatory arthritides, such as rheumatoid arthritis, may have a “doughy” or “boggy” consistency. In some joints, such as the knee, the extent of the synovial cavity can be delineated on physical examination by compressing the fluid into one of the extreme synovial recesses. The edge of the resulting bulge may be palpated more easily. If this palpable edge is within the anatomic confines of the synovial membrane and disappears on release of compression, the distention usually represents synovial effusion; if it persists, it is an indication of a thickened synovial membrane. Reliable differentiation between synovial membrane thickening and effusion is not always possible by physical examination, however. Ultrasonography is being used increasingly as an extension of the physical examination, allowing the examiner to differentiate between synovial proliferation and effusion.

Tenderness

In the musculoskeletal examination, tenderness indicates unusual discomfort on palpating and putting pressure on articular and periarticular tissues. Localizing the tenderness to palpation may assist the examiner in determining whether the pathology is intra-articular or periarticular in location, such as a fat pad, tendon attachment, ligament, bursa, or muscle, or skin. It can be useful to palpate structures that are not involved to assess the importance of tenderness. Finding tender joints in a patient who also has numerous other myofascial tender points is less of a concern for arthritis than finding tender joints in a patient with no extra- articular tenderness.

Limitation of Motion

Limitation of motion is a common manifestation of articular disease; the examiner must know the normal type and range of motion for each joint. Comparison of the affected joint with an unaffected joint of the opposite extremity is useful in evaluating individual variation. Restricted joint motion may be caused by changes in the joint itself or in periarticular structures. To distinguish these possibilities, it is crucial to compare the passive with the active range of motion. If the passive range of motion is greater than the active range of motion, the restriction may be the result of pain, weakness, or the state of articular or periarticular structures. It also is important to distinguish muscle tension from a true limitation of joint motion, emphasizing the importance of ensuring relaxation of the patient. Pain that occurs with attempts to move a joint passively to the limit of range of motion in one plane is referred to as stress pain. Pain in the joint with attempted active or passive range of motion usually indicates an abnormality in the joint.

Crepitation

Crepitation is a palpable or audible grating or crunching sensation produced by motion. This sensation may or may not be accompanied by discomfort. Crepitation occurs when roughened articular or extra-articular surfaces are rubbed together by active motion or by manual compression. Fine crepitation often is palpable over joints involved by chronic inflammatory arthritis and usually indicates roughening of the opposing cartilage surfaces as a result of erosion or the presence of granulation tissue. Coarse crepitation may be caused by inflammatory or noninflammatory arthritis. Bone-on-bone crepitus produces a higher-frequency, palpable, audible squeak. Crepitation from within a joint should be differentiated from cracking or popping sounds caused by the slipping of ligaments or tendons over bony surfaces during motion. The latter phenomena are usually less contributory to the diagnosis of joint disease and may be heard over normal joints. In scleroderma, a distinct, coarse, creaking, leathery crepitation may be palpable or audible over tendon sheaths.

Deformity

Deformity of the joints may manifest as a bony enlargement, articular subluxation, contracture, or ankylosis in nonanatomic positions. Deformed joints usually do not function normally, frequently restrict activities, and may be associated with pain, especially with overuse. Occasionally, a deformed joint may function well but is a cosmetic concern. Joint deformities may be reversible or irreversible. Multiple swan neck deformities of the fingers that can be corrected with manipulation may indicate Jaccoud’s arthropathy of lupus. In contrast, hand deformities in rheumatoid arthritis generally are not correctable.

Instability

Joint instability is present when the joint has greater than normal movement in any plane. Subluxation refers to a joint in which there is partial displacement of the articular surfaces but still some joint surface-to-surface contact. A dislocated joint has lost all cartilage surface-to-surface contact. Instability is best determined by supporting the joint between the examiner’s hands and stressing the adjacent bones in directions in which the normal joint does not move. The patient must be relaxed during the examination because muscle tension may stabilize an otherwise unstable joint. A knee with a deficient ligament might appear stable if the patient contracts the quadriceps muscles during evaluation.

Other Aspects of the Examination

Examinations of the cervical spine and low back are discussed in Chapters 45 and 47.

Recording the Joint Examination

Documentation of the joint examination is important in making decisions about therapy, monitoring the activity of arthritis, and determining the efficacy of interventions. Many different recording methods have been described. Abbreviations for each joint can be used, such as PIP for the proximal interphalangeal joints. 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.⁵ This method remains useful but is used less commonly today because of increasing reliance on electronic medical records. It is easier to describe joint findings in narrative form, for example, “there is 2+ swelling of the second and third MCP joints,” where grade 0 indicates no swelling, grade 1 indicates palpable synovial thickening, grade 2 indicates loss of normal joint contours, and grade 3 indicates frank cystic swelling of the metacarpophalangeal joint. An alternative method is to record joint examination findings using a schematic skeleton or homunculus. When accuracy is necessary, the range of motion of individual joints may be measured using a goniometer.

Joint counts are being used increasingly to monitor the activity of inflammatory arthritides in practice and in clinical trials.⁶ For monitoring disease activity of rheumatoid arthritis, a 28-joint count for tenderness and swelling has been recommended. To assess the tender joint count, the examiner documents which joints the patient indicates are painful on palpation with enough pressure to blanch the nail bed of the examiner’s thumb and index fingers. To assess the swollen joint count, the examiner documents which joints have palpable soft tissue swelling or fluctuance, excluding joints affected only by deformity or bony hypertrophy. The 28-joint count⁷ includes the shoulders, elbows, wrists, first to fifth metacarpophalangeal joints, first to fifth proximal interphalangeal joints, and knees on both sides of the body. Compared with more extensive joint counts, the 28-joint count has the advantage of being quick and easy to perform; however, it is limited by the fact that the ankles and metatarsophalangeal joints are not included, so active disease in the feet may be underestimated. The 28-joint count is used to calculate the Disease Activity Score 28 (DAS28),⁸ which is a validated instrument used to monitor disease activity.

The function of the joints in normal use is not captured by assessments of tenderness, swelling, or range of motion, so other examination techniques are necessary. Other tests are available that attempt to 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). The results of such functional tests may vary, however. Biologic factors, such as circadian changes in joint size and grip strength among rheumatoid patients observed during a 24-hour interval, contribute to variability.

INTERPRETING the Joint Examination

The physician must understand the significance of specific joint findings, both their presence and absence, to make appropriate treatment decisions. As with any diagnostic assessment, the accuracy and reliability of the joint examination are important considerations. With regard to accuracy in detecting physical signs of inflammatory synovitis, numerous studies have shown that joint examination is far less sensitive in detecting synovitis or effusions than high-resolution ultrasonography or magnetic resonance imaging.⁹^–¹¹ Although it prevails that swollen joints are more specific for active synovitis, recent clinical studies have suggested that joint tenderness has similar value in predicting the progression of radiographic joint damage as compared with swelling.¹² Demonstrable physical signs of arthritis may be particularly subtle for patients with early disease.¹³ 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.

The joint examination is also affected by variability. For observations such as joint tenderness or grip strength, interobserver variability usually is greater than intraobserver variability. Considerable intraobserver variability may be noted in observations of the same patient, even over a short interval. Interobserver reliability, in general, is higher for joint-line tenderness than for swelling and is specifically related to the underlying disease, such as higher reliability of the examination for joint swelling in rheumatoid arthritis than in psoriatic arthritis.¹¹

Examination of Specific Joints

Temporomandibular Joint

The temporomandibular joint is formed by the condyle of the mandible and the fossa of the temporal bone just anterior to the external auditory canal. It is difficult to visualize swelling of this joint. 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.¹⁴ The presence of synovial thickness or swelling of minimal or moderate degree can be detected most easily if the synovitis is unilateral or asymmetric compared with the other side. To assess vertical movement of the temporomandibular joint, 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. Audible or palpable crepitus or clicking may be present in patients with and without evidence of severe arthritis.

Many arthritides can affect the temporomandibular joints, including juvenile and adult rheumatoid arthritis. Children in whom these joints are affected may develop micrognathia, resulting from arrested bone growth of the mandible. Patients without inflammatory arthritis may develop arthralgias of the temporomandibular joint, consistent with the temporomandibular joint syndrome (see Chapter 51). This syndrome is thought by some investigators to result from bruxism and is likely to be a form of myofascial pain, similar to fibromyalgia.

Cricoarytenoid Joints

The paired cricoarytenoid joints are formed by the articulation of the base of the small pyramidal arytenoid cartilage and the upper posterolateral border of the cricoid cartilage. The vocal ligaments (true vocal cords) are attached to the arytenoid cartilages. The cricoarytenoid joints are diarthrodial joints that normally move medially and laterally and rotate during opening and closing of the vocal cords. Examination of these joints is done by direct or indirect laryngoscopy. Erythema, swelling, and lack of mobility during phonation may result from inflammation of the joints. The cricoarytenoid joints may be involved in rheumatoid arthritis, trauma, and infection. Involvement in rheumatoid arthritis is more common than is clinically apparent. Symptoms may include hoarseness or a sense of fullness or discomfort in the throat, which is worse on speaking or swallowing. Severe airway obstruction may rarely occur.

Sternoclavicular, Manubriosternal, and Sternocostal Joints

The medial ends of the clavicles articulate on each side of the sternum at its upper end to form the sternoclavicular joints. The articulations of the first ribs and the sternum (sternocostal joints) are immediately caudal. The articulation of the manubrium and the body of the sternum is at the level of attachment of the second costal cartilage to the sternum. The third through seventh sternocostal joints articulate distally along the lateral borders of the sternum. The sternoclavicular joints are the only articulations in this group that are always diarthrodial; the others are amphiarthroses or synchondroses. The sternoclavicular joints are the only true points of articulation of the shoulder girdle with the trunk. These joints are just beneath the skin; synovitis usually is visible and palpable. These joints have only slight movement, which cannot be accurately measured.

The sternoclavicular joints are commonly involved by ankylosing spondylitis, rheumatoid arthritis, and degenerative arthritis, although this involvement is often subclinical. The sternoclavicular joint may be the site of septic arthritis, especially in injection drug users. These joints should be examined for tenderness, swelling, and bony abnormalities. Tenderness of the manubriosternal or sternocostal joints is much more frequent than actual swelling. Tenderness of these joints without actual swelling has been termed costochondritis; if actual swelling is present, Tietze’s syndrome may be the term used.

Acromioclavicular Joint

The acromioclavicular joint is formed by the lateral end of the clavicle and the medial margin of the acromion process of the scapula. Arthritis of the acromioclavicular joint is most commonly attributable to trauma leading to degenerative arthritis. Bony enlargement of this joint is typically observed, but soft tissue swelling is not usually visible or palpable. Tenderness or pain with adduction of the arm across the chest indicates pathology of the acromioclavicular joint. Movement of this joint occurs with shoulder motion but is difficult to measure accurately. The acromioclavicular joint may be involved by rheumatoid arthritis or spondyloarthropathies, although these often are not severe enough to come to clinical attention.

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Jul 3, 2016 | Posted by admin in RHEUMATOLOGY | Comments Off

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