Approach to Arthralgia: Hx: 1. 2. 3. 4. 5. Location/pattern Articular/non-articular Onset/timecourse Inflammatory /non-inflammatory (inclu. precipitating/relieving factors, ie.

pqrst) Extra-articular symptoms

Do symptoms limit the patients ADLs? *Further questions may allow focussing in on possible diagnoses based on presentation. OA - trauma, previous jnt infn or gout, Charcot jnt (due to decreased sensory eg. DM) Gout - Hx of acute attacks. Tophi. Acutely painful with pressure. psoriatic - skin and nail involvment reactive - coincident urethritis or conjunctivitis. New sexual partners. Change in bowel habits. (Recent (3/52) infn with chlamydia, salm, shig, yers, campy.) septic - fever, very tender, clear source of infn (eg. wound, endocarditis, abscess). weird an wonderfuls (gonorrhea, TB, ricketsia, brucellosis, listeria, leptospirosis) RA - Fatigue. Involvement of skin, eyes, mucous membranes, heart, lungs. For RA dx assess: Morning stiffness . Arthritis of three or more joint areas (PIP, MCP, wrists, elbows, knees, ankles, and MTP). Arthritis of hand joints. Symmetric arthritis. Rheumatoid nodules. RF Positive (in 80%). Radiographic changes

On exam: 1. 2. 3. 4. 5. Inspect (symmetry, inflammation, scars, ulnar deviation, swan neck, boutonniere) Palpate (joint line, bony landmarks, effusion, nodules, crepitus, tenderness) ROM (active, passive. Check ligament stabilities/laxity). Strength (can help assess joint function) Special tests

*Exam joint above and below, due to referred pain

Shoulder Teaching Script Jennifer Sunderwood 2000 Starting off: Ensure the pt is draped appropriately (women-evening gown approach) Ensure adequate lighting Ensure the patient is comfortable Inform the pt what you are doing and instruct them to interrupt with questions or if there is any discomfort to let you know immediately Dont Forget to Mention: Examine the joint above (neck) and below (elbow) because of referred pain patterns Compare your examination from side to side Comment that the shoulder very mobile with a shallow glenoid fossa The Routine: 1. Inspection When the patient walks into the room comment on arm swing (symmetry) *Sprengels deformity-partially undescended scapula Front/side/back Discoloration/redness/evidence of inflammation Scars/abrasions Muscle bulk Attitude Deformity Three joints Sternoclavicular Acromioclavicular Glenohumeral One articulation Scapular thoracic *Scapular surface anatomy-covers ribs 2-7; medial border approximately 2 from the spinous processes; spine is opposite to T3 2. Palpation I start medial and move laterally then to the back Bony Palpation: Palpating for warmth/swelling Start at the sternoclavicular joint (dislocation-medial/superiorly) Along the clavicle (convex medial 2/3 then the concave lateral 1/3-protuberances, crepitation, or loss of continuity) to the acromioclavicular joint (pt to flex and extend the shoulder-feel the joint?crepitations) Coracoid process-1 inch below the lateral flat part of the clavicle-inferior and medial to the acromioclavicular joint Greater tuberosity-lateral to the acromion; a step down Bicipital groove-anteromedial to the greater tuberositybest felt when shoulder externally rotatedBE GENTLE

 Spine of the scapula Vertebral border of the scapula Soft tissue palpation Assess the tone, consistency, size and shape to the individual muscles and comment on atrophy or hypertrophy and tenderness Rotator cuff Passive extension of the shoulder renders the cuff palpable-it lies below the acromion 3 onto the greater tuberosity-SIT-supraspinatus(the MOST problematic), infraspinatus and teres minor subscapularis is not palpable restriction with shoulder abduction Subacromial and subdeltoid bursa-just the general area palpate for tenderness again shoulder extension serves to expose (lies over the SIT) *Axilla Anterior wall the pectoralis major Posterior wall the latissimus dorsi musclemedial wall is the ribs (2-6) and serratus anterior muscle Lateral wall bicipitla groove of the humerus Apex is the glenohumeral joint Prominent muscles of the shoulder girdle Sternocleidomastoid Pectoralis major Biceps Deltoid Trapezius muscle onto spine of scapula Rhomboids which attach the med border of scapula to the vertebrae Latissimus dorsi Serratus anterior-holds down the inferior corner of the scapula Ballot for glenohumeral joint fluid

3.

Active ROM Flexion Extension Internal rotation External rotation Can do resisted external with the elbow at the trunk Abduction Resisted starting with the elbow against the truck Pure glenohumeral motion up to 90 degrees Scapulothoracic motion 90-120 degrees combo Adduction Hands behind head and push the elbows back-external rotation and abduction Hands behind back as high as they can go-internal rotation and adduction

4.

Passive ROM

Above but now you do it and remember to feel for crepitus/warmth

5. Special Tests External rotation (in the neutral position) is lost first in arthritis of the glenohumeral joint Testing the supraspinatus tendon/muscle First 15-20 degrees of abduction Thumb up-90 degree abduction then move forward 30 degrees and have them direct the thumbs downapply resistance down. Watch for pain and weakness Apprehension test Have patient pretend to throw a baseball Grip the upper arm and apply pressure posterior to the glenohumeral jointthe patient will resist the movement if the joint is unstable Look for winging of the scapula Drop Arm Test Rotator cuff tears/injury Flex up to 180palms in then instruct pt to slowly adduct Pain if positivemay drop quickly secondary to pain Impingement Test Arm held abducted and flexed at 90 degrees with examiner supporting the flexed elbow-with the other hand hold down the shoulder girdle whilst forcibly internally rotating and elevating the affected arm Speeds Test Flex the shoulder against resistance with an extended elbow with the forearm supinated Tests the bicipital tendon Yergason Test Biceps tendon stability Fully flex the elbow Grasp the flexed elbow in one hand while holding the wrist in the other (in the pronated position then try and supinate against resistance)externally rotate the arm against resistance and pull down on the elbow

*Muscle Testing primary muscle groups (others may be contributing) 1. 2. 3. 4. Flexion Anterior portion of the deltoid (C5) Coracobrachialis (C5-C6) Extension Latissimus dorsi (C6-C8) Teres major (C5-C6) Posterior protion of the deltoid (C5-C6) Abduction Middle portion of the deltoid (C5-C6) Supraspinatus (C5-C6) Adduction Pectoralis major (C5-T1) Latissimus dorsi (C6-C8)

5. 6.

Internal rotation Subscapular (C5-C6) Pectoralis major Latissimus dorsi Teres major External rotation Infraspinatus (C5-C6) Teres minor (C5)