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.
Observing the patient as they walk into the examination room and sit down can give the physiotherapist valuable information about the state of their joint. Slow and guarded movement is common, along with splinting of the joint and carrying it in a close and protected position to minimise joint stresses. Once the physio has taken a history they will check out the joint visually, looking for swelling, effusion, warmth or a joint deformity. If there is no obvious problem in a cool, settled joint the physiotherapist will need to stress the joint more thoroughly to find the restriction. However, a swollen, inflamed joint should be treated acutely as soon as possible.
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.
Assessment of the active joint ranges of motion is routinely recorded by the physiotherapist, who also records why the joint range is not full and states the results in degrees or as a proportion of normal. The physio then tests the passive joint ranges, with the patient relaxing the joint, to see if there are restrictions or pain with this technique. If the patient cant move their joint through its full range but the physiotherapist can then muscular weakness or pain is the likely limiting reason. If the patients own movement is limited and the physio can get no more on testing, then stiffness of the joint and/or pain may be involved.
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.
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. Jonathan Blood Smyth is Superintendent of a large team of Physiotherapists at an NHS hospital in Devon. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Cambridge or elsewhere in the UK.