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Joint Examination and Physiotherapy

Our ability to participate in functional activities is greatly dependent on the state of our body joints, from the knees and hips which bear weight and allow walking to the jaw joints which aid speaking and eating. Our joints are exceptionally well designed to allow us to move about and accomplish tasks and mostly they do their jobs quietly and very well. Illness, injury or disease can damage the joints, causing pain and stiffness and limiting functional activity. Physiotherapy examination of the joints is a core skill, demanding a logical approach, the finding of pathological signs and the formation of a treatment plan.

Joints, the junctions between two bones, can have weight carrying, force transmission or movement properties depending on their design and position in the body. An example of a movement joint is the shoulder with its great range, the acromio-clavicular joint is a force transmission joint allowing arm function and the back and hips are weight bearing joints with some movement function. The most obvious of our joints are all synovial joints, a particular and very important joint type. The bone ends are coated with articular cartilage which reduces friction, the joint fluid is secreted by the synovial joint lining membrane and the joint capsule, formed by the ligaments, holds the joint protected against mechanical forces.

Physiotherapy examination of a joint starts with observating how the person uses the joint as they move into the consultation room and sit down. They may hold the joint protectively in a low-risk position, move carefully and guardedly to avoid stressing the joint or splint the joint in some way. The physio takes a history then looks at the joint, noting any deformity, warmth, swelling or effusion, all signs of inflammation. A cool, non-swollen joint in a good position may still have a problem but it is not acute and will need to be searched for. A hot joint with tight swelling will need immediate treatment with the acute injury protocols.

After the visual examination the physiotherapist will palpate the joint and surrounding structures, which means exploring or stressing an area logically with the fingers or hand, an important physio skill to clarify the diagnosis. The physio will palpate around the joint margins, the joint line itself, the tendon insertions and the ligaments surrounding the joint. Effusion, which means the presence of synovial fluid in a joint, can be felt by the resistance it gives if it is tight, by its thickness and plasticity if it is sticky and by the way it can be moved around the joint if it watery.

Once the joint has been assessed visually, which takes a very short time, the physiotherapist will move on to palpation of the joint structures which will help identify which parts of the joint are affected. Palpation involves systematically feeling and stressing structures in an anatomical area to pin down faulty structures more closely. Palpation of the joint involves testing the joint line, the insertions of the tendons and ligaments, along the ligaments themselves and around the joint margins. Fluid in the joint is called an effusion and can be thick and sticky, very tight and firm if there is a lot, or movable if the fluid is thin

The physiotherapist will assess the active range of the joint movement which is what the patient can manage independently, noting the ranges as a proportion of normal and why the joint could not achieve full range, e.g. pain or muscle weakness. The physio will then move the patients joint passively without the patients effort to see if the joint ranges are different. If the physio can move the joint through its full normal range but the patient cannot do this, then either pain or muscle weakness is the likely cause. If neither the physio nor the patient can get the joint to full range, pain or joint stiffness may be the problem.

Ligaments are very important for normal function of a joint and the physiotherapist will routinely test their integrity, stressing them strongly by manual testing. The ligaments of major joints are very strong and testing a normal ligament should show no effect but it can uncover an absent, painful or stretched ligament by its effect on joint stability. Physios use the Oxford 0-5 scale to grade muscle strength, allowing for anxiety or pain which might interfere with a patients effort. Proprioception and joint sensibility may also be tested to ascertain if good feedback from the joint to the brain is present, this being important in normal movement planning.

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