Musculoskeletal disorders

General approach to arthritis

History:

Ask patients how long they have been sick, which joints hurt first and whether there is morning stiffness. Ask about activities of daily living. Don’t forget to ask about non-articular symptoms such as hair loss and mouth ulcers of other features suggestive of other organ system involvement.

On examination:

• Get the patient to lie on a couch or bed.
• Look at the hands – nodules or deformity
• Feel the elbows for nodules (RA or gout)
• If there is no obvious swelling or redness, feel each joint looking for tenderness: lateral compression of foot, joint line palpation of the ankles, knees, wrists, elbows and shoulders. Don’t forget the temporomandibular joint – tenderness on palpation here is highly suggestive of a generalised arthritis.
• Ask the patient to lie on the side and feel over the hip joints for tenderness, and also over the sacroiliac joints and the spine.
• Movement – get the patient to make a fist, and thereafter oppose thumb and little finger. Can she put a hand on the back of her neck? (Elbow flexion, shoulder abduction and external rotation) Check hip and knee flexion and extension.

A capsular pattern of movements causing worse pain is suggestive of an arthritis rather than soft tissue problems. (The capsular movements are best thought of as someone on traffic point duty with a full bladder trying to stop you (think arthritis!): shoulder abducted, elbow flexed, wrist neutral, fingers extended, hips internally rotated, knees flexed…)

Document your findings!