Physiotherapy Examination of a Joint
Our joints are extremely important for our functional activities, from the temporomandibular joint for eating and talking to the major weight bearing joints such as the hips and knees. Our joints are designed to allow us to move about, to accomplish tasks and to bear weight, a job they do superbly well. However, with injury, illness or disease our joints can be affected in various ways, limiting our abilities and causing stiffness and pain. Physiotherapists are trained to examine joints logically, determine the limiting factors and construct a treatment plan accordingly, with many techniques at their disposal.
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.
The physiotherapist will initially observe the patient as they make their way into the exam room and sit down. They might limp, splint the joint in some way, have very guarded movement to reduce joint stresses or hold the joint in a protective position to minimise further injury. A history will be taken by the physio initially then they will move on to examine the joint visually, looking for normal alignment, any warmth, effusion or tissue swelling. There may be a fault in a cool joint with no swelling but the physio will have to test it more thoroughly to discover the fault. If the joint is inflamed, hot and swollen then acute treatment should be instituted.
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
Passive testing of the joint ligaments is an important part of physiotherapy examination as the ligaments are integral to normal joint function. Ligaments should take the full stress of a persons strength in most major joints without any pain or other problems. Systematically testing the ligaments can identify an injured, painful, stretched or absent ligamentous structure. Muscle testing is done using the Oxford scale of 0-5, taking into account that pain and anxiety may change the muscular force a patient is able or willing to exert. Sensibility and joint position testing can be useful to see if the brain is receiving the correct feedback information it needs from the joint to plan effective and safe movement.
The last part of the examination is to test the joint in functional activities or positions, especially if there is little to find on the more detailed examination. The physiotherapist can see how the patient is willing to use the joint and this may reveal difficulties with joint function which until then have not been clear.