I. HISTORY TAKING POINTS

1. Patient Profile

• Name, Age, Gender, Occupation, Hand dominance (right/left-handed)
• Residence (rural/urban; relevance in trauma, infection)
• Socioeconomic status
• Risk factors in occupation (repetitive stress, vibration exposure, heavy lifting)

2. Chief Complaints

Record in the patient’s own words, along with:

• Duration of symptoms
• Site of complaint (joint, bone, muscle, back)
• Pattern: Single joint / multiple joints / generalized
• Main symptom(s):
  • Pain
  • Swelling
  • Stiffness
  • Deformity
  • Weakness
  • Difficulty in movement / gait abnormalities
  • Numbness / Paresthesia

3. History of Present Illness

A. Pain Analysis

• Onset: Acute / Subacute / Insidious
• Location: Joint / Bone / Muscle / Periarticular
• Character: Dull, aching, sharp, throbbing, burning
• Severity and grading
• Radiation: Nerve distribution pattern (sciatica, brachialgia)
• Aggravating factors: Activity, rest, cold, weight-bearing, specific movements
• Relieving factors: Rest, analgesics, position
• Diurnal variation:
  • Morning stiffness (inflammatory arthritis)
  • Night pain (neoplasm, infection)
• Nocturnal awakening: Suggests mechanical or malignant cause

B. Swelling Analysis

• Site, onset, progression
• Associated redness, warmth, fluctuation, consistency
• Relation to joint movement

C. Stiffness

• Duration of stiffness (minutes to hours)
• Morning stiffness: Inflammatory conditions
• Stiffness after rest: Osteoarthritis
• Improvement with activity or rest

D. Deformity

• Onset, progression
• Functional limitation
• Cosmetic concerns

E. Instability

• Sensation of joint giving way, locking, catching

F. Functional Limitations

• Difficulty in Activities of Daily Living (ADLs)
• Gait disturbance, imbalance, claudication
• Difficulty in specific movements

G. Neurological Symptoms

• Paresthesia, numbness, weakness
• Radicular pain, spinal cord symptoms

H. Systemic Features

• Fever, weight loss, malaise
• Skin rash, photosensitivity, oral ulcers
• Eye involvement (uveitis, scleritis)
• Respiratory symptoms (restrictive lung disease in connective tissue disorders)
• GI symptoms (IBD-related arthritis)

4. Past History

• Previous trauma, fractures, joint dislocations
• Previous episodes of joint complaints
• History of tuberculosis, infections
• Chronic systemic illness (Diabetes, Gout, Psoriasis)
• Any malignancy

5. Family History

• Inflammatory arthritis (RA, AS, Psoriatic arthritis)
• Congenital musculoskeletal disorders
• Metabolic bone disease

6. Personal History

• Dietary habits (Calcium, Vitamin D intake)
• Smoking, Alcohol consumption (risk factors for osteoporosis, AVN)
• Physical activity level
• Menstrual & obstetric history in females (osteoporosis risk)

7. Drug History

• Steroid usage
• Antiepileptics (bone demineralization)
• Statins (myopathy)
• Anti-TB drugs (arthropathy)
• Recent fluoroquinolone usage (tendon rupture risk)

8. Occupational and Environmental History

• Repetitive joint use, heavy lifting, sports injury
• Exposure to zoonotic infections (Brucellosis, TB)

9. Psychosocial and Quality of Life Impact

• Impact on daily activities
• Mental health impact: Depression, anxiety
• Sleep disturbance due to pain
• Work productivity impairment

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II. CLINICAL EXAMINATION POINTS

General Guidelines:
Always examine in a systematic, comparative manner. Examine all four limbs, axial skeleton, joints, bones, muscles, and neural components in an integrated approach.

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1. General Physical Examination

• General appearance: Cachexia, obesity, muscle wasting
• Pallor, icterus, cyanosis
• Clubbing (hypertrophic osteoarthropathy)
• Lymphadenopathy
• Nail changes (psoriasis, SLE)
• Skin examination: Rashes, nodules, ulcers
• Eye examination: Scleritis, Uveitis
• Vitals: Especially fever, BP

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2. Local Examination (Systematic Approach)

A. Inspection

• Attitude and posture

• Gait analysis:

  • Antalgic gait
  • Trendelenburg gait
  • Waddling gait
  • High-stepping gait
  • Hemiplegic / Spastic gait
  • Ataxic gait

• Alignment and symmetry:

  • Scoliosis, kyphosis, lordosis
  • Deformities: Varus, valgus, swan neck, boutonniere, Z-thumb

• Swelling

  • Site, extent, shape
  • Skin changes over swelling (redness, atrophy, ulceration)

• Muscle bulk

  • Wasting
  • Hypertrophy
  • Fasciculations

• Scars, Sinuses, Discharging fistulas

• Bony prominences

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B. Palpation

• Local temperature
• Tenderness
  • Pinpoint, diffuse, deep-seated
• Swelling characteristics
  • Consistency, fluctuation, mobility, reducibility, compressibility
• Joint line tenderness
• Crepitus on movement
• Synovial thickening
• Effusion
• Muscle tone
• Bony irregularities
• Peripheral pulses (in trauma)
• Neurological palpation (nerve thickening, tenderness)

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C. Movements Assessment

Assess both Active and Passive movements:

• Range of motion: Flexion, extension, abduction, adduction, rotation
• Restriction of movement: Painful, mechanical block, muscle spasm
• Instability testing
• Special tests for specific joints (see below)

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D. Measurements

• Limb length discrepancy
• Muscle girth comparison
• Joint line distance

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E. Functional Assessment

• Power grading of affected muscles (MRC scale)
• Joint stability tests
• Functional performance tests:
  • Squat test
  • Sit-to-stand test
  • Stairs climbing

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3. Examination of Specific Joints and Regions

Shoulder

• Drop arm test
• Neer’s impingement test
• Hawkin’s test
• Apprehension test

Elbow

• Carrying angle assessment
• Cozen’s test (Tennis elbow)
• Valgus and varus stress test

Wrist and Hand

• Finkelstein’s test
• Tinel’s sign
• Phalen’s test
• Bunnel-Littler test
• Grind test for CMC arthritis

Spine

• Inspection for scoliosis, kyphosis, lordosis
• Schober’s test (lumbar flexibility)
• Adam’s forward bending test
• Palpation of spinous processes
• Straight leg raising test
• Femoral nerve stretch test

Hip

• Trendelenburg test
• Telescoping test
• Patrick’s test
• Thomas test (Flexion deformity)

Knee

• Effusion tests: Patellar tap, Fluctuation test
• Ligamentous instability: Anterior/Posterior drawer, Lachman’s test, Varus/Valgus stress test
• Meniscal tests: McMurray’s, Apley’s grind test

Ankle and Foot

• Anterior drawer test
• Talar tilt test
• Thompson test (Achilles tendon rupture)

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4. Neurological Examination (Locomotor relevance)

• Sensory examination: Touch, pain, temperature, vibration, proprioception
• Motor power examination
• Reflexes
• Upper motor neuron signs: Clonus, Babinski sign
• Lower motor neuron signs: Hypotonia, fasciculations

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5. Vascular Examination

• Peripheral pulses
• Capillary refill time
• Ankle-brachial index (if vascular insufficiency suspected)

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6. Systemic Examination

• Cardiovascular: Aortic regurgitation (seen in AS)
• Respiratory: Fibrosis in Ankylosing Spondylitis
• Abdominal: Hepatosplenomegaly (SLE, Felty syndrome)
• Skin, Eye, Nail examination (as earlier described)

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Optional Advanced Techniques

• Dynamic gait analysis using software
• Pressure plate analysis
• Musculoskeletal Ultrasound examination
• Thermography for inflammatory focus
• Electromyography / Nerve conduction study
• Bone densitometry
• Functional Outcome Scores: DASH, Oxford Knee Score, HAQ

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LOCOMOTOR SYSTEM EXAMINATION

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1. HISTORY TAKING – Subheadings & Points

A. Chief Complaints

• Pain (site, onset, duration, character, aggravating & relieving factors, radiation, diurnal variation)
• Swelling (location, onset, duration, progression)
• Stiffness (morning, evening, continuous)
• Weakness (focal/generalized, proximal/distal)
• Deformity (congenital/acquired)
• Gait disturbance
• Joint instability or giving way
• Functional impairment

B. History of Present Illness

• Onset: Acute/Chronic, sudden/insidious
• Course: Progressive, intermittent, relapsing-remitting
• Pattern: Monoarticular, oligoarticular, polyarticular
• Associated symptoms:
  • Fever (Infective, autoimmune)
  • Skin rash (Psoriatic arthritis, SLE)
  • Eye symptoms (Uveitis – Ankylosing spondylitis)
  • Oral/genital ulcers (Behçet’s disease)
  • Urinary complaints (Reiter’s syndrome)
  • Weight loss, malaise
• Morning stiffness: Duration (>1 hour → Inflammatory; <30 min → Mechanical)
• Joint involvement sequence (Additive, migratory, intermittent)
• Diurnal variation: Worse in morning → Inflammatory; worse at end of day → Osteoarthritis
• Functional limitation: Bedridden, joint restriction, activities of daily living (ADLs)
• Deformities: Onset, progression
• Neurological symptoms: Tingling, numbness, bowel/bladder involvement

C. Past History

• Trauma
• Infections (TB, septic arthritis)
• Previous surgeries or joint injections
• History of similar illness
• Fractures

D. Drug History

• Steroid use → Avascular necrosis
• Quinolones → Tendinopathy
• Anticonvulsants → Osteomalacia

E. Family History

• Rheumatoid arthritis, Ankylosing spondylitis, Osteoporosis

F. Personal History

• Occupation (Repetitive stress injury)
• Smoking, Alcohol (Gout, osteoporosis)
• Diet (Calcium/Vitamin D intake)

G. Menstrual/Obstetric History

• Early menopause → Osteoporosis

H. Systemic Review

• Skin, Respiratory, Cardiovascular, CNS symptoms

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2. PHYSICAL EXAMINATION – Subheadings & Points

A. General Physical Examination

• Pallor
• Edema
• Clubbing
• Cyanosis
• Lymphadenopathy
• Skin lesions (Psoriasis, SLE rash, nodules)
• Muscle wasting
• Deformities (Genu valgum, varum, kyphosis)

B. Vitals

• Fever (Septic arthritis, autoimmune disease)
• Tachycardia (Systemic illness)
• BP (Vasculitis)
• Respiratory rate (Restrictive lung disease in SLE)

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3. LOCAL EXAMINATION – Systematic Approach

I. Inspection

• Swelling
  • Site, size, shape, skin over swelling, sinuses, scars
• Deformity
  • Angular (valgus, varus), rotational, length discrepancy
• Muscle wasting
• Joint alignment & posture
• Scars/sinuses
• Gait observation
  • Antalgic, Trendelenburg, High-stepping, Spastic, Scissor gait

II. Palpation

• Temperature over joint
• Tenderness
  • Localized, diffuse, specific anatomical point
  • Grading: Grade 1-4
• Swelling consistency
  • Bony, cystic, fluctuant, soft
• Synovial thickening
  • Slippage sign
• Crepitus
  • Fine (Degenerative), Coarse (Inflammatory)
• Muscle tone
  • Hypotonia (LMN), Hypertonia (UMN)
• Bony irregularities

III. Movement

Assess active and passive movements

• Range of motion (ROM) in all planes
• Painful/restricted/free movement
• Crepitus during movement
• Stability tests
  • Stress tests
  • Anterior drawer, Lachman’s test (Knee instability)
  • Varus-valgus stress

Types of Movement Limitation:

• Painful → Inflammatory/infective
• Mechanical block → Loose body, bony block
• Spasticity/Contracture → Neurological

IV. Measurements

• Length of limb (True, apparent)
• Circumference of muscles (atrophy/hypertrophy)
• Joint angles
• Leg length discrepancy

V. Special Tests (Joint specific)

Shoulder

• Neer’s Impingement test
• Hawkins-Kennedy test
• Apprehension test (instability)
• Drop arm test (Supraspinatus tear)

Elbow

• Valgus/Varus stress
• Tinel’s sign

Wrist & Hand

• Phalen’s test, Tinel’s sign (Carpal Tunnel)
• Finkelstein test (De Quervain’s)
• Allen test (Vascular supply)

Hip

• Trendelenburg test
• Thomas test (Hip flexion contracture)
• FABER (Flexion, Abduction, External Rotation)

Knee

• Anterior drawer test, Lachman test (ACL)
• Posterior drawer test (PCL)
• McMurray’s test (Meniscus)
• Varus/Valgus stress

Ankle & Foot

• Anterior drawer test (ATFL injury)
• Talar tilt test

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4. SYSTEMIC EXAMINATION

To rule out systemic involvement:

• Cardiovascular (Rheumatic disease, Vasculitis)
• Respiratory (SLE, RA lung)
• Abdominal (Hepatosplenomegaly)
• Neurological (Myopathy, Neuropathy)

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5. FUNCTIONAL ASSESSMENT

• Activities of Daily Living (ADL) – Dressing, bathing, ambulation
• Gait analysis
• Balance tests

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6. CLINICAL CORRELATION & DIFFERENTIAL POINTS

Pain

• Inflammatory: Morning stiffness >1 hour, improves with activity
• Mechanical: Worsens with use, relieved by rest

Swelling

• Soft: Effusion
• Firm: Synovial thickening
• Hard: Bony overgrowth

Deformity

• Acute: Dislocation
• Chronic: Rheumatoid deformity, OA

Weakness

• Proximal: Myopathy
• Distal: Neuropathy

Joint Pattern

• Monoarthritis: Gout, septic arthritis
• Oligoarthritis: Spondyloarthropathy
• Polyarthritis: RA, SLE

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