Special Operations Forces Medical Handbook

3-60

4. Only a few conditions are so painful that the patient can put no weight on the extremity: fracture, septic
   joint, gout.

Objective: Signs
Joint tenderness, redness, warmth and/or edema; fever; weight loss; rash; and morning stiffness.
Using Basic Tools:
Skin Rash: A new rash associated with arthritis usually indicates systemic disease, either infectious or
inammatory. Lesions include: hives (hepatitis B, C, or other viruses); diffuse maculopapular rash (allergic
reaction, drug reaction, serum sickness or virus); scaly, red, hypertrophic lesions (psoriasis; discoid lupus –on
face scalp or elsewhere; Reiter’s syndrome–on palms and soles; circinate balanitis—on penis); maculopapular
rash on palms and soles (syphilis, Rocky Mountain Spotted Fever); papules that progress to vesico-pustules
to larger hemorrhagic or bullous lesions (gonorrhea); large, red, tender subcutaneous nodules on shins that
may coalesce into a more diffuse, red, swollen lower extremity, resembling cellulitis or ankle periarthritis
(Erythema Nodosum).
Eye: Conjunctivitis and iritis (Reiter’s syndrome, vertebral arthritis); dry eyes and dry mouth (Sjögren’s
syndrome, and other connective tissue diseases).
Oral Cavity: Painless ulcers (Reiter’s syndrome, lupus, syphilis).
Lymphadenopathy: Diffuse lymphadenopathy (inammatory diseases like lupus and sarcoidosis).
Chest: Pleuro-pericarditis (lupus-like connective tissue disease); heart block (Lyme disease, vertebral arthri-
tis); heart murmur (endocarditis).
Abdomen: Hepatosplenomegaly (connective tissue diseases).
Extremities: Nodules on extensor surfaces (esp. elbows) (gout, rheumatoid arthritis (RA), and rheumatic
fever); intense inammation of the entire digit (sausage digit), including joints and tendons, (vertebral arthritis).
Joint exam:

1. Palpate joint:
   a. Temperature with the back of your hand and compare to adjacent muscle, other joints, same
   joint on the other extremity and to your joints. The joint should be the coolest part of the
   extremity. Redness (septic; rheumatoid arthritis) is unusual but warmth is common in the
   inamed joint.
   b. Swelling, which may be joint centered, in joint effusion, periarticular from edema or cellulitis,
   or bony in nature as in osteoarthritic nodes of the hands.
   c. Crepitus (snap, crackle, pop; audible or palpable; joint grinding with motion) may be due
   to degenerative or inammatory joint disease. Crepitus without pain or limitation is not
   usually signicant.
   d. Tenderness may be joint centered or in periarticular structures (tendon, ligament, bursa,
   muscles).


2. Assess:
   a. Range of motion (ROM): is it full; with or without pain; can you move the joint further than
   they can or is it ankylosed (stuck in one position); compare their ROM with your ROM.
   b. Joint stability: laxity with valgus or varus stress on a joint (usually elbow or knee) or a
   drawer sign (usually knee or ankle) or repeated joint dislocations is generally a sign of
   ligament or tendon injury.
   c. Attempt to reproduce pain by joint motion or palpation to localize source to either the joint
   itself, the periarticular soft tissue, or to sources outside of the musculoskeletal system (skin,
   vessels, etc.).
   Spine:


3. Inspect for symmetry, scoliosis, pelvic tilt.


4. Palpate for muscle spasm, vertebral tenderness, or SI joint tenderness (see maneuvers that stress
   the SI joint below). Pain increased with maneuvers that torque the sacroiliac joint imply sacroiliitis.
   a. FABER maneuver: with patient supine and one hand on an anterior iliac crest, cross the
   opposite leg into a gure 4 position (Flexion, Abduction and External Rotation at the hip)
   then press down on the bent leg. This distracts the SI joint opposite the crossed leg.
   Sacroiliitis is suggested if this maneuver causes pain in the lower back over the SI joint
   opposite the bent leg. Pain in the back or hip on the same side as the crossed leg does