Chapter 10. Bone, joints and muscle

Chapter



10



Bone, joints and muscle



Shoulder joint



Synovial joint



bone



skin and

subcutaneous

tissue



coracohumeral

ligament



coracoacromial

ligament



bursa



tendon

capsule

synovium

fibrocartilage

pad

joint

space

hyaline

articular

cartilage



tendon

sheath



ligamentous

thickening

of capsule

muscle



Fig. 10.3 The shoulder joint and the attachments of the

coracohumeral ligament.



bursa



Fig. 10.2 Cross-section of a synovial joint.



main types: hyaline, elastic and fibrocartilage. Hyaline

cartilage is found on the articular surface of joints, in the

costal cartilages and in the larynx, trachea and bronchi.

Hyaline cartilage combines elasticity with a capacity

to resist external forces. With increasing age, cartilage

water content falls, with a consequent deterioration in

tensile stiffness, fracture strength and fatigue resistance.

Fibrocartilage is predominantly composed of fibrous

tissue and is a part of the tendon at the point of its

insertion into bone (Sharpey’s fibres). It is also found in

certain joints. Elastic cartilage has a concentrated network

of elastic fibres that give its structure considerable

flexibility. It is found in the pinna and in some of the

laryngeal cartilages.



JOINTS

Joints can be classified into those allowing free movement

(diarthroses), those that are fixed (synarthroses) and

those that permit limited movement (amphiarthroses). In

diarthroses (synovial joints), a space exists between the

bone surfaces, allowing movement of one bone against

the other (Fig. 10.2). Further classification of these joints

can be made according to the type of movement that

occurs (e.g. ball and socket, hinge). A synovial joint is

enclosed by a collagenous capsule attached to the bone

at some distance from the joint. The inner surface of the

capsule is lined by a fluid-producing membrane. Localised

thickenings of the capsule, the ligaments, connect the

adjacent bones. Other ligaments blend into the capsule

266



Fig. 10.4 Longitudinal section through myofibrils.



at one end but are attached to bone at the other

(Fig. 10.3) or remain totally independent of the joint

capsule.

The synovial membrane is one cell thick. One type of

cell ingests foreign or autologous material that has

entered the joint; another synthesises and secretes the

synovial fluid. Synovial fluid is a dialysate of plasma with

the addition of hyaluronate proteoglycan. The ratio of the

concentration of a synovial fluid protein to its serum

concentration is determined by molecular size. The

synovial fluid provides both nutrition for the articular

cartilage and lubricates the joint surfaces.

Temporary synarthroses (synchondroses) are found

at the growing points of long bones in the form of

epiphyseal cartilage. The sutures of the skull are



Chapter



Symptoms of bone, joint and muscle disorders

synarthroses, the bony margins being joined by fibrous

tissue.

Amphiarthroses are permanent joints. A good example

is the intervertebral disc of the spine. An outer layer of

dense concentric bundles of collagen, the annulus

fibrosus, encloses a core of hydrated compact tissue, the

nucleus pulposus.

MUSCLE

A motor neuron innervates 100–1000 skeletal muscle

fibres. Within the muscle fibre is a recurring anatomical

structure, the sarcomere, consisting of thin filaments that

are composed of actin and thick filaments composed of

myosin (Fig. 10.4). During the contraction and relaxation

of muscle, the thin and thick filaments move in relationship

to one another. All the fibres of a particular motor unit

have similar properties. Muscle fibres are divided into fast

and slow twitch (type I and type II) according to their

speed of contraction, although in humans a continuum

of twitch speed exists.

Slowly contracting motor units are innervated by

slowly conducting nerve fibres with a low threshold and

firing frequency. Rapidly contracting motor units are

innervated by axons that conduct rapidly but have a high

threshold. The strength of muscle contraction can be

altered either by varying the number of motor units

recruited or by altering their firing frequency. The

recruitment process begins with small units and progresses

to larger. Firing frequency ranges from 10 to 20 Hz

for slow units and up to 100 Hz for fast units. Slow

twitch muscles have a high myoglobin content, producing

a reddish appearance. Slow twitch fibres use oxidative

mechanisms for energy formation; fast twitch fibres

employ glycolysis. The former are fatigue-resistant,

the latter rapidly fatiguable. In general, slow units

provide sustained muscle tension over long periods,

of the sort required to maintain a particular posture,

whereas fast units allow short-lived, sudden muscle

contraction.



Symptoms of bone, joint and

muscle disorders

BONE

Pain

Bone pain has a deep, boring quality. The pain is focal

in the presence of a bone tumour or infection but diffuse

in generalised disorders (e.g. osteoporosis). The pain

of a fracture is sharp and piercing and exacerbated by

movement but relieved by rest.

JOINTS

Joint symptoms include pain, swelling, crepitus and

locking.



10



Differential diagnosis

Bone pain



Focal pain



•

•

•

•

•



Fracture or trauma

Infection

Malignancy

Paget’s disease

Osteoid osteoma



Diffuse pain



•

•

•

•

•



Malignancy

Paget’s disease

Osteomalacia

Osteoporosis

Metabolic bone disease



Risk factors

Age-related osteoporosis



•

•

•

•

•

•

•

•

•



Female

Premature loss of gonadal function

Family history of osteoporosis

Thin body habitus

Decreased physical activity

Low calcium intake

Smoking

High alcohol intake

Nulliparity



Pain

In an arthritic disorder, pain is usually the most prominent

complaint. Important aspects to determine are the site

and severity of the pain, whether it is acute or chronic,

how it is influenced by rest and activity and whether it

appears during a particular range of movement.

Ask the patient to point to the maximal site of pain.

Although irritation of structures close to the skin produces

well-localised pain, disturbance of deeper structures

produces pain that is poorly localised and eventually

segmental in distribution.

The segments to which the pain is referred (the

sclerotomes) differ somewhat from dermatomal

distributions. Consequently, deep pain can be felt at a

point some distance from the affected structure, that is,

referred pain. Where joint disease exists, misinterpretation

of the site of the disease process can follow (Fig. 10.5).

Spinal pain can also be referred. Abnormal function in

the upper cervical spine can lead to pain over the occipital

region, whereas disorders of the lower lumbar spine may

lead to upper lumbar back pain stemming from the fact

that the posterior longitudinal ligament is innervated by

the upper lumbar nerves.

Severity of joint pain is difficult to judge, depending,

as it does, on the patient’s personality. Osteoarthritis and

267



Chapter



10



Bone, joints and muscle



Joint pain



a



b



rheumatoid arthritis typically result in chronic pain with

periodic exacerbation; septic arthritis or gout produce an

acutely painful joint.

Inflammatory joint disease tends to cause pain on

waking, improving with activity but returning at rest.

Mechanical joint disease (e.g. caused by osteoarthritis)

leads to pain that worsens during the course of the day,

particularly with activity.

For certain joint disorders (e.g. at the shoulder), pain

is apparent only during a specific range of movement. If

confirmed by examination, this selectivity can be valuable

in differential diagnosis.

Swelling and crepitus



c

d



If the patient has noticed joint swelling, elicit for how

long it has been present, whether there is associated pain

and whether the swelling fluctuates. A noisy joint is not

necessarily pathological. Introspective individuals are

likely to interpret periodic clicking in a joint, in the

absence of pain, as having pathological significance. It

does not. Crepitus is a grating noise or sensation; it can

have both auditory and palpable qualities. Fine crepitus

is more readily felt than heard, but crepitus stemming

from advanced degeneration of a large joint (e.g. the hip)

is readily audible.

Locking



Fig. 10.5 Distribution of pain arising from (a) the acromioclavicular

or sternoclavicular joints, (b) the scapulohumeral joint, (c) the hip

joint and (d) the knee joint.



•

•

•

•



Questions to ask



MUSCLE



Joint pain



Muscle symptoms include pain and stiffness, weakness,

wasting, abnormal spontaneous movements and cramps.



Where is the maximal site of pain?

Does the pain change during the course of the day?

Has the pain been there for a short or long time?

Does the pain get better or worse with movement?



Pain and stiffness

Muscle pain tends to be deep, constant and poorly

localised. If caused by local muscle disease, it is likely to



Differential diagnosis



Differential diagnosis



Joint pain



Muscle pain



• Inflammatory

– rheumatoid arthritis

– ankylosing spondylitis

• Mechanical

– osteoarthritis

• Infective

– pyogenic

– tuberculosis

– brucellosis

• Traumatic



268



A joint locks if ectopic material becomes interposed

between the articular surfaces. It is particularly associated

with damage to the knee cartilages. Ascertain if the

locking occurs at a particular point during movement of

the joint.



• Inflammatory

– polymyositis

– dermatomyositis

• Infective

– pyogenic

– cysticercosis

• Traumatic

• Polymyalgia rheumatica

• Neuropathic

– e.g. Guillain–Barré syndrome



Chapter



General principles of examination

be exacerbated by contraction of the muscle and relieved

by rest. If the patient complains more of muscle stiffness

(particularly of the lower limbs) than pain, suspect the

possibility of spasticity caused by an upper motor neuron

lesion.



angularity. Is there limb shortening? Look for tenderness

by gently palpating those parts of the bone close to the

skin surface.



Weakness



You need to follow a strict routine with joint examination,

incorporating inspection, palpation and assessment of

the movement of the joint.



A complaint of global weakness is more likely in neurotic

individuals than in patients with neurological disorders.

Important questions to ask include the distribution of

the weakness, whether it appears related to any pain in

the limb, whether it fluctuates and whether it is static

or progressive. A complaint of predominant proximal

weakness suggests the possibility of primary muscle

disease (e.g. polymyositis or myopathy). A predominantly

distal weakness is more likely to be neuropathic. If the

weakness is fluctuant, and particularly if it worsens during

the course of activity, you will need to consider myasthenia

gravis when you come to examine the patient (see also

Ch. 11). Weakness caused by sudden entrapment of a

peripheral nerve (e.g. a traumatic radial nerve palsy) will

be stable or even improving by the time the patient seeks

medical attention. In other conditions the weakness is

progressive (e.g. motor neuron disease).



Questions to ask

Muscle weakness



•

•

•

•



Is the weakness global or focal?

Is the weakness secondary to a painful limb?

Does the weakness fluctuate?

Is the weakness increasing in severity?



10



JOINTS



Inspection

Things you are looking for include swelling, joint

deformity, overlying skin changes and the appearance of

the surrounding structures.

Swelling Causes of joint swelling include effusions,

thickening of the synovial tissues and of the bony margins

of the joint. Differentiation of these causes is achieved by

palpation. If you suspect joint swelling, compare it with

the joint of the opposite limb. Particularly note if the

swelling appears to be of the joint itself or of the adjacent

structures.

Deformity Deformity results either from misalignment

of the bones forming the joint or from alteration of the

relationship between the articular surfaces. If misalignment

exists, a deviation of the part distal to the joint away from

the midline is called a valgus deformity and a deviation

towards the midline a varus deformity (Fig. 10.6). If a

deformity exists you will need later to determine whether

it is fixed or mobile. Partial loss of contact of the

articulating surfaces is called subluxation, and complete

loss dislocation. Although these are usually traumatic,

they can also be seen in inflammatory joint disease,

particularly rheumatoid arthritis. Swan neck, Boutonnière

and mallet are descriptive terms used for deformities of



Wasting and fasciculation

Both these features form an important part of the

examination, but both may have been noticed by the

patient and volunteered during history-taking. If

the patient describes muscle twitching, ascertain whether

the movement has occurred in several different muscles

or whether it has been confined to one area, most likely

the calf.



Knee deformities



Cramps

Cramps are seldom of pathological significance. They are

usually confined to the calves and can be triggered by

forced contraction of the muscle.



General principles of examination

BONE

Whichever structure is being examined, ensure that it is

completely exposed and that the patient is comfortably

positioned. Determine whether there is any abnormal



genu varum



genu valgum



Fig. 10.6 Genu varum (left) and genu valgum (right).

269



Chapter



10



Bone, joints and muscle



Finger deformities

normal



MCP



PIP

DIP



swan neck



Fig. 10.8 Acute gout of the first metatarsophalangeal joint.



boutonnière



mallet



Fig. 10.7 Deformities of the finger in rheumatoid arthritis.



the metacarpophalangeal and interphalangeal joints of

the hand (Fig. 10.7).

Skin changes You should palpate the skin over a joint

to assess its temperature rather than relying simply on

its colour. Redness of the skin over a joint implies

an underlying acute inflammatory reaction (e.g. gout)

(Fig. 10.8).

Changes of adjacent structures The most striking

change adjacent to a diseased joint is wasting of muscle.

Assess muscle bulk above and below the affected joint,

making a comparison with the opposite limb if that is

spared. Wasting of quadriceps is particularly conspicuous

in severe disease of the knee joint.

Palpation

During palpation of a joint, assess the nature of any

swelling, whether there is tenderness and whether the

joint is hot.

Swelling The method of examining for an effusion will

be described for the individual joints. Your first step is

to determine the consistency of any swelling. Is the

swelling hard, suggesting bone deformities secondary to

osteoarthritis? Certain sites are particularly susceptible to

osteoarthritic change (e.g. the distal interphalangeal

joints of the hand) (Fig. 10.9). A slightly spongy or boggy

swelling suggests synovial thickening and is particularly

associated with rheumatoid arthritis. An effusion is

fluctuant, that is, the fluid can be displaced from one part

of the joint to another. Swellings may also arise adjacent

270



Fig. 10.9 Osteoarthritis of the DIP joint.



to a joint. Again determine their consistency. Soft

fluctuant swellings suggest enlarged bursae. Harder

swellings occur in rheumatoid arthritis and gout.

Tenderness Carefully palpate the joint margin and

adjacent bony surfaces together with the surrounding

ligaments and tendons. Your task is to discover whether

any tenderness is within the joint or outside it, and

whether the tenderness is focal or generalised. In an

acutely inflamed joint, the whole of its palpable contours

will be tender. If there is derangement of a single

knee cartilage, tenderness will be confined to the margin

of that cartilage. In degenerative joint disease, you may

find tenderness in structures adjacent to the joint.

Tenderness close to the joint may reflect primary

pathology in bone (e.g. osteomyelitis) or in the tendon

sheath (e.g. De Quervain’s tenosynovitis) (Figs 10.10,

10.11).

Temperature For a small joint, for example, in the finger,

assess temperature with the finger tips, using an

unaffected joint in the same or the other hand for

comparison. For a larger joint, for example, the knee, rub

the back of your hand across the joint then compare with

the other limb. If the contralateral joint is also affected,

carry your hand above and below the joint margins to

make the comparison.



Chapter



General principles of examination



10



Neutral position



Fig. 10.10 De Quervain’s tenosynovitis of the wrist.



De Quervain’s tenosynovitis

extensor pollicis

longus



Fig. 10.12 The neutral position from which joint measurement is

performed.



Range of joint movement



abductor pollicis

longus



extensor pollicis

brevis



Fig. 10.11 De Quervain’s tenosynovitis. The tendons of abductor

pollicis longus and extensor pollicis brevis are inflamed.



Joint movement

Next proceed to examine the range of movement of the

joint, whether movement is limited by pain and whether

there is instability.

To define the range of joint movement, start with the

joints in the neutral position, defined as the lower limbs

extended with the feet dorsiflexed to 90°, and the

upper limbs midway between pronation and supination

with the arms flexed to 90° at the elbows (Fig. 10.12).

For accurate measurement of joint movement you will

need a goniometer (Fig. 10.13) but for routine purposes

your eye should allow a reasonably true estimate.

Movement of a joint is either active (i.e. induced by the

patient) or passive (i.e. induced by the examiner).

Sometimes you need to assess both but you will generally

assess active movements in the spine but passive

movements in the limb joints. Restriction of active

compared with passive movement is usually due to

muscle weakness.



Fig. 10.13 Measuring the range of joint movement.



From the neutral position, record the degrees of flexion

and extension. If extension does not normally occur at a

joint (e.g. the knee) but is present, describe the movement

as hyperextension and give its range in degrees.

Sometimes there is restriction of the range of movement.

For example, if the knee fails by 30° to reach the extended

position, describe this as either a 30° flexion deformity or

as a 30° lack of extension (Fig. 10.14). For the ankle and

wrist, extension is described as dorsiflexion and flexion

as plantar and palmar flexion, respectively. For a ball and

socket joint, you will need to record the range of flexion,

extension, abduction, adduction and internal and external

271



Chapter



10



Bone, joints and muscle



Types of joint movement



Flexion deformity



dorsal



palmar



0º

flexion



hyperextension



30º

flexion

rotation



Fig. 10.14 30° flexion deformity of the knee.



rotation (Fig. 10.15). The range of joint movement varies

between individuals: an excessive range of movement

can be constitutional as well as pathological. Carefully

note if pain occurs during joint movement. In joint

disease, pain is likely to occur throughout the range of

movement. In certain disease processes around the joint

(e.g. in the ligaments or bursae), pain can be restricted to

a particular range or type of movement. Damage of either

the articular surfaces or of the ligaments related to a joint

can lead to instability. You will discover this partly by

finding that the joint can be moved into abnormal

positions and partly, particularly for the knee joint, by

observing the joint as the patient walks.



GALS

A screening history and examination process for

the musculoskeletal system has been devised for

undergraduate use (GALS – gait, arms, legs and spine).

SCREENING HISTORY

• Have you any pain or stiffness in your muscles, joints

or back?

• Can you dress yourself completely without difficulty?

• Can you walk up and down stairs without difficulty?

If the answers to all three questions are negative,

significant musculoskeletal abnormality is unlikely.

SCREENING EXAMINATION

• Gait – Inspect the patient walking, turning and walking

back.

• Spine – Inspect the patient from three positions from

behind, from the side, then ask the patient to bend

forwards and touch the toes, and finally from in front

272



external

adduction



internal



abduction



Fig. 10.15 Description of joint movement according to the type of

joint.



ask the patient to try to place the relevant ear on each

shoulder in turn (lateral neck flexion).

• Arms – From in front ask the patient to place both

hands behind the head, elbows back.

• Place both hands by the side, elbows straight.

• Place both hands out in front, palms down, fingers

straight.

• Turn both hands over. Make a tight fist with each

hand.

• Place the tip of each finger onto the tip of the thumb

in turn.

• The examiner then squeezes across the second to

the fifth metacarpals to elicit tenderness.

• Legs – Inspect from in front (with the patient

standing).

• Inspect with the patient lying flat.

• Flex each hip and knee while holding the knee

(confirming full knee flexion without knee

crepitus).

• Passively internally rotate each hip in flexion

(checking for pain and restricted movement).



Chapter



GALS

• Press on each patella for tenderness and palpate for

an effusion.

• Squeeze across the metatarsals for tenderness due

to metatarsophalangeal disease.

• Inspect both soles for callosities reflecting abnormal

weight-bearing.

RECORDING FINDINGS

Normal response to the screening questions can be

recorded as:

Pain

Dress

Walk



0

✓

✓



Results of the physical examination can be recorded if

gait (G) is normal, there are no abnormalities to the

appearance (A) of the areas inspected (i.e. no swelling,

deformity, wasting, abnormal position or skin change)

and no abnormalities of movement (M) of the arms (A),

legs (L) or spine (S) as follows:

G

A

L

S



✓

A

✓

✓

✓



M

✓

✓

✓



Any abnormality is recorded as an X and described in

more detail.

MUSCLE

The methods for examining individual muscles will be

given in the section on regional examination. Initially

your assessment will include inspection, palpation, then

testing of muscle power.

Inspection

Look for evidence of muscle wasting, for signs of abnormal

muscle bulk and for spontaneous contractions.

Wasting Remember that striking muscle wasting can

accompany joint disease (e.g. wasting of the small hand

muscles in rheumatoid arthritis and wasting of the

quadriceps in virtually any arthropathy affecting the knee

joint). If there is no significant joint disease, wasting

(other than caused by a profound loss of body weight)

reflects either primary muscle disease or disease of its

innervating neuron. Make allowances for the age of the

patient and his or her occupation. Some thinning of the

hand muscles occurs in elderly people but is not

accompanied by weakness. If you suspect wasting of one

limb, measure the circumference of that limb and compare

it with its fellow. For example, for the thigh, mark the line

of the medial cartilage of the knee joint, measure up, for

example, 20 cm, on each thigh and record the circumference

of the legs at that point.



10



Increased muscle bulk Usually abnormal muscle bulk

reflects the patient’s obsession with his own bodily

strength (it is almost always a man). There are rare

conditions that lead to muscle hypertrophy. If the

enlargement is due to increase in muscle bulk, it is called

true hypertrophy and is seen, for example, in congenital

myotonia. If the increased bulk is due to fatty infiltration

(and you will then discover the muscle is actually

weak), it is called pseudohypertrophy. This finding is

characteristic of certain of the muscular dystrophies (e.g.

Duchenne’s).

Spontaneous contractions Completely expose the

muscle when looking for evidence of spontaneous

contraction. Make sure the patient is warm and relaxed.

Shivering brought on by cold can be difficult to distinguish

from fasciculation. Spontaneous movements can occur

with both upper and lower motor neuron lesions. In the

former, particularly at the spinal level, you may see either

flexor or extensor spasms of the legs, either at the hips

or knees. The movements can occur spontaneously or be

triggered by attempting to move the patient and are often

painful. Fasciculation produces episodic muscle twitching

that can be subtle in small muscles. It is a feature of lower

motor neuron lesions but can also be seen in normal

individuals. Fasciculation is intermittent. Wait for a few

minutes before deciding it is absent. It is particularly

important to determine whether the fasciculation is

confined to a single muscle or whether it is more widely

distributed. The former may reflect the result of cervical

radiculopathy or be physiological (particularly if confined

to the calves); the latter suggests a diagnosis of motor

neuron disease.

Palpation

Muscle palpation is of limited value. If the muscle is

infected or inflamed it is likely to be tender. Most

myopathies are painless but there are exceptions (e.g. the

acute myopathy occurring in alcoholics). Muscle

tenderness can also occur in neurogenic disorders (e.g.

the peripheral neuropathy of thiamine deficiency can

lead to marked calf tenderness).

Testing muscle power

You should follow the UK Medical Research Council

classification (p. 363) when testing and recording muscle

power. Remember to make allowance for sex, age and

the patient’s stature. If the muscle itself, or the joint that

it moves, is painful then power will be correspondingly

limited. Patterns of muscle weakness are particularly

important in neurological diagnosis. Is the weakness

global, does it predominate distally or proximally in the

limb, does its distribution fit with either a peripheral

nerve or root distribution? Sometimes muscle power is

decidedly fluctuant: there is a sudden give, alternating

with more effective contraction. Although this pattern

can occur in myasthenia gravis, it is usually the reflection

of a nonorganic disability. If muscle fatigue is a prominent

273



Chapter



10



Bone, joints and muscle

symptom assess it objectively. For example, for the

deltoid, ask the patient to abduct the shoulder to 90°. Test

power immediately, then after the patient has held that

posture for 60 seconds.

You will need to be selective when deciding which

muscles to test. Your choice will be guided partly by the

patient’s complaints, both in terms of their distribution

and their quality.



Spinal deformities



gibbus



scoliosis



REGIONAL STRUCTURE, FUNCTION

AND EXAMINATION



Temporomandibular joints

Ask the patient to open and close the jaw. If the

temporomandibular joints are lax, there may be

considerable side-to-side movement. Now palpate the

joint margins by placing your fingers immediately in

front of and below the tragus. As the patient opens

the jaw, palpate the head of the mandible as it moves

forwards and downwards. In temporomandibular joint

dysfunction, the joint capsule is tender and chewing is

painful. The generalised arthritic disorders seldom affect

this joint.



The spine

STRUCTURE AND FUNCTION

The primary curvatures of the spine, in the thoracic and

sacral regions, are determined by differences in height

of the anterior and posterior aspects of the vertebrae

at these levels. The secondary curvatures of the cervical

and lumbar regions depend more on the relative

heights of the anterior and posterior aspects of the

intervertebral discs. The nucleus pulposus allows an even

distribution of applied force onto the annulus fibrosus

and the hyaline laminae covering the opposing vertebral

bodies.

Forward flexion and extension occur at all levels of the

spine but are maximal at the junction of the atlas

with the occiput and in the lumbar and cervical regions.

Lateral flexion is greatest at the atlanto-occipital junction,

occurs to some extent in the lumbar and cervical regions,

but minimally in the thoracic region. Rotation other than

at the atlantoaxial joints, is determined by the shape of

the apophyseal joints and is maximal at the thoracic

level.



Examination of the spine

With the patient undressed to the underwear, ask the

patient to stand upright. Assess the posture of the whole

spine before examining its component parts. An increased

flexion is called kyphosis, increased extension, lordosis

and a lateral curvature, scoliosis. Gibbus refers to a focal

274



kyphosis



lordosis



Fig. 10.16 Spinal deformities.



flexion deformity (Fig. 10.16). Using the position of the

spinous processes tends to underestimate the degree

of scoliosis, as the spines rotate towards the midline.

The scoliosis is accentuated when the patient bends

forwards.

For each spinal level, start by inspection and follow by

palpation to elicit any tenderness. Finally, assess the

range of movement and determine whether it is restricted

by pain.

CERVICAL SPINE

The examination is best achieved with the patient sitting.

Note any deformity, then palpate the spinous processes.

A cervical rib is sometimes palpable in the supraclavicular

fossa. Obliteration of the radial pulse by downward

traction of the arm does not reliably predict the presence

of a cervical rib or band.

Examine active then passive movements. For flexion,

ask the patient to bring the chin onto the chest and for

extension ask them to bend the head backwards as far as

possible. Observe both these movements from the

side. For lateral flexion, stand in front of or behind

the patient and ask the patient to bring the ear towards

the shoulder first on one side, then the other. For rotation,

stand in front or over the patient asking the patient to

look over one shoulder then the other (Fig. 10.17).

Note whether any movement triggers pain either locally

or in the upper limb. Repeating the movements while

applying gentle pressure over the vertex of the skull

may trigger pain or paraesthesiae in the arm if there is a



Chapter



The spine



10



Lumbar flexion



Cervical spine

neutral



rotation



10+ cm

10 cm

5 cm



5 cm



Fig. 10.19 Measuring lumbar flexion.



LUMBAR SPINE

flexion and extension



lateral flexion



Fig. 10.17 Movements of the cervical spine.



Skull compression



Having inspected the lumbar spine and tested for

tenderness, assess the range of movement. While

standing at the patient’s side, ask the patient to touch the

toes, keeping the knees straight. To assess the contribution

made to flexion by the lumbar spine, mark the spine at

the lumbosacral junction, then 10 cm above and 5 cm

below this point. On forward flexion the distance between

the two upper marks should increase by approximately

4 cm, the distance between the lower two remaining

unaltered (Fig. 10.19). Now assess extension, again from

the side, then lateral flexion. For this, stand behind the

patient and ask the patient to slide the hand down the

outside of the leg, first on one side and then on the other

(Fig. 10.20).

SACROILIAC JOINTS



Fig. 10.18 Compression of the vertex of the skull to reproduce

cervical root pain. Compression with the head in the neutral position

(left) or laterally flexed to the right is painless (middle). With the

head flexed to the left (right), the side of the root compression,

downward pressure is painful.



critical degree of narrowing at an intervertebral foramen

(Fig. 10.18).

THORACIC SPINE

Sit the patient with the arms folded across the chest, then

ask the patient to twist as far as possible first to one side

then to the other. The range of movement is best

appreciated from above. Next measure chest expansion.

A movement of at least 5 cm should occur and provides

an assessment of the mobility of the costovertebral

junction. Palpate the spinous processes for any tenderness

and assess any deformity.



Palpate the joints, which lie under the dimples found

in the lower lumbar region. To test whether movement

at the joint is painful, first press firmly down over

the midline of the sacrum with the patient prone

(Fig. 10.21) then, with the patient supine, forcibly flex

one hip while maintaining the other in an extended

position.

NERVE STRETCH TESTS

Nerve stretch tests are carried out to determine whether

there is evidence of nerve root irritation, usually as a

consequence of prolapse of a lumbar disc.

Straight leg raising

With the patient supine, carefully elevate the extended

leg at the hip. Normally, 80–90° of flexion is possible.

Restriction of movement can occur with both spinal

and hip disease. In the presence of nerve root irritation

at the L4 level or below, straight leg raising evokes pain

as the sciatic nerve is stretched (Fig. 10.22). If the foot is

now dorsiflexed, the pain increases (Bragard’s test).

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Chapter



10



Bone, joints and muscle



Sacroiliac joint



Thoracolumbar spine



flexion



extension



Fig. 10.21 Assessing the sacroiliac joint.



Differential diagnosis

Back pain



left



lateral flexion



right



•

•

•

•



rotation



•



Fig. 10.20 Movements of the thoracolumbar spine.



Return the foot to the neutral position, then flex the knee.

The hip can now be flexed further before pain reappears

but if the knee is then extended, the pain increases

(Lasegue’s test).



•

•

•

•



Muscle or ligamentous strain

Degenerative intervertebral disc

Spondylolisthesis

Arthritis

– osteoarthritis

– rheumatoid arthritis

– ankylosing spondylitis

Bone infection

– pyogenic

– tuberculous

Trauma

Tumour

Osteochondritis

Metabolic bone disease



Femoral stretch test



Questions to ask



Turn the patient into the prone position. First flex the

knee. If this fails to trigger pain, extend the leg at the hip.

A positive response, with pain in the back extending into

the anterior thigh, suggests irritation of the second, third

or fourth lumbar root on that side (Fig. 10.23).



Back pain



• Is the pain confined to the back or does it radiate to

the upper or lower limb?

• Is the pain exacerbated by coughing or sneezing?

• Did the pain begin suddenly or gradually?



Clinical application

Back pain can arise from disease processes in the

vertebrae, from degenerative changes in the joints

between the vertebrae, from degeneration or actual

prolapse of the intervertebral disc and from the ligaments

and muscles supporting and moving the spine.

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PROLAPSED INTERVERTEBRAL DISC

A prolapse of disc material is most likely to occur either in

the cervical (principally at C5/6) or the lumbar (principally

at L5/S1) region. Once nerve root irritation occurs, likely

symptoms include local and referred pain, with sensory