The semeiology of rheumatic diseases

The clinical and functional criteria for the evaluation of a child with arthritis

Terminology

Arthralgia – algia (pain), which appears in articulation (some disorders can be

absent);

Arthritis / arthropathy – is determined as a objective disorder in articulation;

Chondropathy – process which leads to the loss of cartilage;

Monoarthritis – arthritis of one articulation;

Oligoartritis – arthritis with affection from two to four articulations (or of groups
of small articulations – for example – hand articulations);

Poliarthritis – arthritis with affection of more than five articulations (or of articular
groups);

Synovitis – synovial inflammation of articulation clinically evident;

Capsulitis – inflammation/affection of capsula;

Tenosynovitis – inflammation of tendonous bundle;

Tendinitis – inflammation of tendon;

Bursitis – inflammation of synovial bursa;

Entesopathy – inflammation of entesis (place of tendons and bone ligaments

connection);

Myopathy – affection of muscles;

Myositis – inflammation of muscles;

Subluxation – the articular surfaces are in contact, but their congruence is

disturbed;

Luxation – articular surface is disordered.

Examination of articulations

The examination of musculo-skeletal system in children with rheumatic diseases is

based on the follows:
 complaints of patient
  anamnesis
 examination of musculo-skeletal system
 determination of general state
 performing of paraclinical examination (X-ray of articulations, articular
ultrasonography and of internal organs, laboratory examination, other
instrumental methods).

Complaints

The basic complaints of children with rheumatic diseases are the articular
pains – arthralgias, which represent the principal symptom of patients with
affections of articulations and diffuse diseases of conjunctive tissue. For to
appreciate the intensity of pain there can be used the following gradation:

 0 – absence of pain;
 I – minimal pain, which doesn’t reduce the capacity of work and doesn’t
need treatment, doesn’t disturb the sleeping;
 II – moderated pain, which decreases the work capacity, reduces the
possibility of self-service, but is sensible to analgetic drugs, fact that
ensures normal sleeping;
 III – strong pain, practically permanent, which leads to sleeping
disturbances, reacts weakly or doesn’t react to analgetic drugs, but has
medium sensibility to morphinic drugs, can cause the complete loss of
work capacity;
 IV – insupportable pain, at which the patient for to avoid the pain
intensifying, doesn’t cover the articulation with blanket.

The intensity of pain also can be appreciated conformable to graduation from 0

till 10 cm (visual scale analog to that of pain). The patient must remember the
strongest pain supported formerly in his life, for example after blow, falling down,
trauma), and the intensity of supported pain the patient must mark by dots until 10
cm, the absence of pain being marked by 0 cm. The presence of articular pain is
compared with the strongest pain from anamnesis and is expesed direct
proportionally on gradated rule in interval from 0 till 10 cm.
In the time of anamnesis collection, the physician will pay detailed attention to
the character of pain, specifying:
 the number of painful articulations – mono-, oligo- (until 4 articulations) or
poliarthritis (more than 5 articulations);
 symmetry of articulations affection;
 in which articulation the pain has begin;
 signs of inflammation – general (fever) and local (local hyperemia and fever
at the articulation fever);
 if there is limitation of movements due to pain, if the pain appears at
articulation palpation;
  intensity of pain – soft, medium or maximal;
 the moment of pain appearance – in rest, at movements, daily, in night;
 the factors which ameliorate or intensify the pain.

The character of pain:

 inflammatory pain – the pain is more accentuated in rest or at movements

beginning; the pain in articulations appears more often in morning or during
a big part of night (clinical criterion for juvenile arthritis, reactive arthritis);
 mechanical type – the pains in articulation appear during movement; the
patient walks more, the pains become more accentuated (clinical criterion
characteristic for degenerative processes);
 permanent type – the pain in articulations is strong, exhausting, is
accentuating suddenly in night (connected with ostheodestruction and bone
necrosis, followed by intraosseous hypertension); permanent articular pain
(daily and nightly) appears in bone tumors metastases.

After the character of appearance, the articular pains are:

 acute onset – the symptoms appear during a few hours – in infectious

(septic) arthritis or a few days – in reactive arthritis;
 subacute evolution – the symptoms develop slowly – during one month,
being characteristic for juvenile arthritis, tuberculous arthritis and diffuse
diseases of conjunctive tissue.

One from complains of patients with rheumatic diseases can be articulation

stiffness which is more pronounced morning – morning stiffness. The duration of
pain is from a few minutes till a few hours. Another type is general stiffness –
symptom which reflects the state of vertebral column. The general stiffness can be
attested in ensemble or in one from following levels: cervical, thoracic or lumbar.

The character of pain: lent progressive, rapidly progressive, without progressing,

in accesses without progressing, recurrent with progressing, recurrent with
regressing.

The localization of pain corresponds usually to affected articulation, but

sometimes the pain can irradiate. For example, in coxo-femoral articulation
affection the pain appears at the level of knee joint, in lumbar, inguinal region, in
the region of buttocks. In the case of flat foot the pain irradiates in talo-crural
articulation, in knee joint and in coxo-femoral articulation, and in thoracic
spondillitis – the pain appears in lumbar region etc.
Often the patients with rheumatic diseases have complains on deformations,
swelling and articular hyperemia with active and passive movements limiting;
more seldom, only during physical effort can appear crepitations, followed by pain.
In normal conditions, the movements in articulations must be free, without sounds
and painless.

The pains in muscles, named myalgias, are characteristic both for patients with
affections of articulations, and for these with rheumatic diseases followed by
muscular tissue affection. At the same time, these patients can present complains
on pains in the region of ligaments, tendons and at the level of tendons connection
to bones (entezitis).

Disease anamnesis

In the process of anamnesis collection it is important to specify, how the disease

has begun, at which age have appeared first time arthralgias and were they be
preceded by naso-pharyngeal, intestinal or urinary infection. The influences of
physical factors (sun stroke, overcooling, vibration, physical effort, noxious
habitual conditions), of concomitant pathologies (obesity, diabetes mellitus,
thyrotoxicosis, leukemia, malignant tumors etc.), of pathologic antecedents
(traumas, surgical interventions) also have importance. When is established the
patient suffers long time by affection of articulations, it is important to specify how
the disease has evolved, the factors that ameliorate or aggravate it, the frequency of
exacerbations, how many time after disease onset have appeared the articular
deformations, administered treatment effectiveness, were or not were appeared
complications or adverse reactions.

The examination of locomotor system

The examination of locomotor system is a complexe procedure which needs

special training. The physician examines the patient in different positions: standing
up, laying in bed, seated down, and also during gait. Analyzing the body position,
the character of gait, the movement speed, the presence of articular deformations,
taking into consideration the existence of contractures, he forms general
impression about the presence of locomotor system pathology and articular
functions possibilities.

The presence of acute pain determines the patient to keep forced, antalgic
position, the expression of face demonstrated suggestively the fear of pain.

It’s important to taking into account the patients with rheumatic pathologies,
such as arthritis, ankiloses and articular contractures adopt often forced positions.
From this results the change of normal axis of hands and feet. In normal conditions
the longitudinal axis of hand passes through the center of humerus, of radius and
ulna. At deviation of arm axis towards the hand under opened in interior angle
there is attested an affection named valgus. The axis of inferior member normally
passes through anterior superior crista iliaca, through interior margin of patella and
toe. The deviation of axis leads to changes of this line. If the angle is opened in
inferior there is forming of genu varum, if in exterior – genu valgus.

The usual examination begins from up to down – from temporo-mandibular,

sterno-clavicular articulations, after that is passing on superior members
articulations, body, inferior members, concomitantly being compared the affected
articulations with these non-affected. It must be checked also the position of
member, the changes of articulations contour and configuration, their color and
skin turgor, hyperemia, pigmentation, possible eruptions, nodules, scars, atrophic,
sclerotic processes of ligaments, skin and adjacent cutaneous area edema.

One from principal symptoms of articular pathology is the presence of

tumefaction which is determined by intraarticular effusion, thickening of synovial
tissue and periarticular soft tissues. In soft periarticular tissues edema the
tumefaction has not regulated contour, is diffuse, localized superficially. The soft,
elastic edema on limited area of periarticular tissues denotes the presence of
bursitis.

The tumefaction index (reflects the graduation of tumefaction examinated in 28

articulations):
 0 – absence of tumefaction
 minimal tumefaction
 evident tumefaction
 pronounced tumefaction

The changing of articulation form can be considered as a deformation or

disfigurement. The disfigurement is the temporary change of articular form which,
usually, is in correlation with edema, tumefaction or atrophy of soft tissues. The
deformation contains more accentuated changes, permanent deformations of
articular form resulting from bone system modifications, persistent contractures,
musculo-ligamentar apparatus affections, luxations or subluxations. At the same
time, there can be present the deviation of axis position from that physiologic.

Palpation can mark out the following phenomena:

 hyperthermia
 hypersensibility
 tumefaction
 liquid accumulation
 presence of nodules in soft tissues and enlargement in dimension of burses
 pain on trajectory of ligaments and in the place of connection with bone

The palpation of articulations is performing in rest state and during active and
passive movements. At palpation the left hand is placed on articulation and right
hand performs flexions and extensions. First of all we must palpate the healthy
articulation, after that – affected.

For determination in examined articulation of pathologic process and painful

points localization we must exert a more pressure with the tops of fingers in the
region of articular slot. The thickened and inflamed capsule is palpated in the place
where it is not covered by thick muscular layer.

An important symptom of articular pathology is the pain, that can be found at

palpation being manifested by different intensity: soft, moderate and strong.

There are distinguished 4 degrees of pain during palpation:

 0 – absence of pain;
 1 – minimal pain;
 2 -pain by medium intensity (changing of face mimic);
 3 – pain by high intensity (the patient comes off reflexively from examiner).

Physiologically in articulation there is a small quantity of synovial liquid, but it

can’t be appreciated at palpation. Increasing of free liquid quantity in articulation is
appreciating in function of fluctuation presence.

The palpation during movement can give information referring to pathologic

sounds: crepitation, pop. The pop that is heard at distance is physiologic
phenomenon, often – painless, bilateral. The crepitations are associated usually
with chronic inflammatory processes and can be observed at synovial capsule
villosities, and these coarse with progressive degeneration of cartilage appear as a
consequence of subsided articulation surfaces friction. The pops and crepitations at
movement, followed by pain, indicate the presence of some pathologic process.

The intraarticular crepitation must be differentiated from periarticular crepitations

of ligaments, tendons and muscles, appeared as a result of sliding on bone surface.
In crepitant tendovaginitis the coarse pops are heard more superficially. But in
juvenile arthritis we find more fine and prolonged pops.

At the end we palpate the ligaments, tendons, muscles, lymph nodes. At muscles
palpation we must pay attention to consistence, tonus, presence of pain and
atrophy.

Auscultation of articulations has more secondary importance in report with

examination and palpation. It is realizing only in the process of movement, the
stethoscope being placed usually at the level of articular slot. The patient is pleased
to perform flexion and extension in articulation, on the background of these
movements being assessed also the time of pathologic sounds appearance, their
duration and character. In normal, at articulations auscultation the sounds are not
heard, but in the case of pathologic process we can find the sounds by diverse
character.

Articulations

The articulations can be classified in fibrous, cartilaginous and synovial. The

fibrous articulations (synarthroses) have the bones separated by cartilaginous
conjunctive tissue. The cartilaginous articulations (amfiarthroses) are separated by
cartilaginous tissue. The synovial articulations (diarthroses) have articular space,
synovial membrane between articular surfaces.

Classification of articulations
TYPE CHARACTERISTIC POSSIBLE DISEASES
Fibrous Separated by fibrous Absence
tissue
Cartilaginous Separated by cartilaginous Ankilosant spondillitis
tissue
Synovial Separated by synovial Juvenile arthritis
tissue

The examination of fist articulations

Examination in rest. The external surface: modification of skin color, tumefaction
(synovitis, tendosynovitis), deformation, atrophy, position. Lateral: extended
phalanges, tendons rupture, deformation (primary subluxation of
metacarpophalangean articulations).

Examination in movement. Palpation: local fever, palpation of II-V

metacarpophalangean and of II-V interphalangean articulations.

Examination of elbow articulation

Examination in rest: modification of skin, tumefaction (synovitis, bursitis,
nodules), deformation (valgus, varus, subluxation), position.

Examination in movement: flexion, extension, supination, pronation.

External palpation: fever, tumefaction, pain, crepitation, deformation, nodules.

Internal palpation: fever, tumefaction, pain, hypermobility, crepitations, passive

movements (supination, pronation, flexion, extension), periepicondilar pain.

The examination of shoulder articulation

Examination in rest: anterior (skin, tumefaction, atrophy, position), posterior

(atrophy).
Examination in movement: “hands behind the head”, “hands behind the back”,
painful arch.

Palpation: sternoclavicular articulation (crepitation, subluxation, pain,

tumefaction, local fever), acromioclavicular articulation (crepitation, pain,
tumefaction, local fever), shoulder articulation (exudation, pain in the region of
anterior articular capsule, active adduction, passive adduction), periarticular pain.

Active movements at resistance: pain, weakness, external rotation, internal

rotation, supination of palm.

Examination of vertebral column

Examination of patient in horizontal position: mobility of head, of thorax,

curvatures of vertebral column, scoliosis, muscles, skin.

Examination of patient during gait.

Examination of patient in the time of movement (limitation, pain): in

horizontal position – flexion (Shober test), extension, lateral flexion; seating down
(thoracolumbar rotation); cervical sector (flexion, extension, lateral flexion,
rotation).

Palpation of patient lying on the bed: hyperesthesia, muscles (tonus, pain),

tendons (pain).

Provoking tests: lifting of foot in extension, lifting of both feet in extension.

Neurologic examination: power, reflexes, sensibility.

At necessity, the detailed examination of other systems is performing.

Coxofemoral articulation examination

Examination of patient in vertical position: anterior (shifting of pelvis, rotator

deformation), lateral (expressed lumbar lordosis), posterior (scoliosis, atrophy,
shifting of pelvis). Trendelenburg test.

Examination of patient during gait: antalgic gait, Trendelenburg gait.

Examination of patient lying on the bed: skin color, tumefaction, deformation,

Toms test (fixed flecsion), difference in legs length (real and apparent); palpation;
movements (flexion, adduction, abduction, internal and external rotation,
extension.
Examination of knee articulation

Examination of patient in vertical position: anterior (valgus and varus

deformations), lateral (genu recurvatum, posterior subluxation of shank), posterior
(subpatellar cyst).

Examination of child’s gait

Examination of patient lying on the bed: general inspection (state of skin,

tumefaction, atrophy of quadriceps, deformation, position), palpation (local fever,
tumefaction, pain, crepitation), palpation in the time of flexion (crepitation,
limitation of movements, pain), passive extension, palpation in the position of knee
in flexion (pain, entesopathy, bursitis, subpatellar fossa), state of ligaments (effort
tests).

Examination of sole articulations

Examination of patient in vertical position: tumefaction, deformation, skin,

nails.

Examination of patient during gait.

Examination of patient lying on the bed: examination of soles and

interphalangial spaces, palpation (local fever, tumefaction, pain), mobility
(limitation, pain, crepitation), palpation of small sole and interphalangial
articulations, palpation of tendons, fascia and Achilian tendon insertion points;
tests of anterior and lateral stability.

Examination of vertebral column

Examination of vertebral column, also that of members articulations, includes the

study of complains, anamnesis, objective examination with using of some test
destined to elucidation of symptoms and mobility restrictions.

Complaints. Usually there are evidenced dizziness, paresthezias in hands,

sensation of heaviness, fatigue, discomfort, pains in different places of column,
that appear as a result of some movements, of some static efforts or others. There
are elucidated the intensity, localization, time of appearance, duration, action of
external factors, the rest.

Disease anamnesis establishes the time from the first complaint, the trigger factors
of pathology, pathology duration, general state in the time of remissions and
exacerbations, principal syndromes. Simultaneously we precise what therapeutic
procedures were used, what morphologic substratum is on basis of disease
pathogenesis (intervertebral disks, ligaments, muscles). At the same time with the
indication of affected place, we establish the individual resistance to effort, the
character and degree of movements, we note the sport practice, presence of some
traumas, heredity.

Objective examination. In the process of inspection we fix the data about body,
members and head position, character of movements, form of vertebral column.
We attest the physiologic curvatures of vertebral column in saggital projection:
forward – characteristic for cervical and lumbar vertebral column and behind –
kyphosis - characteristic for thoracic and sacral vertebral column. The kyphotic
form can be in pathology – when the column has curvature behind or in right –
without physiologic curvatures. The inspection supposes the using of some
guidmarks, such as bone protuberances: mastoid process of temporal bone, spinous
apophyses, inferior mandibular angle, scapula, iliac bone wings.

On posterior neck and thorax surface as a guidmarks serve the spinal apophyses C 3
and C4. The articulations between atlant C1 and axis C2 are placed on the line that
unites the top of mastoid process with spinous C2 process, more medially from
sternocleidomastoid muscle. T3 is sitting on scapula medial line, T7 – inferior
scapular angle, L4 – the line passing through the tops of cristae iliacae and S1 at the
level of inferior posterior apophyses of iliac bones.
The guidmarks on lateral part are the lateral processes C1 which are palpating
under the top of mastoid process, and in C2 – 1,5 cm down. The C2 inferior margin
is placed on mandibular angle line. The C6 lateral process – at cricoid cartilage
level. T2 – at the level of sternum, L4 – L5 – at the level of line that units the iliac
crists.
We examine the body contour, the symmetry of neck, shoulders, scapulae, pelvis
line. The asymmetry of scapulae and shoulders is determining by the measurement
of distance from spinous process until the internal angle of scapula both in right
and in left part. The symmetry of pelvis is establishing through the measurement of
distance from left and right spinous apophyses and xyphoid apophysis of sternum.
The asymmetry of sacral bone is determining through the measurement of distance
between superior points of sacrum until spinal apophysis L5.

In frontal projection the healthy vertebral column has not curvatures. The deviation
of vertebral column in frontal projection is naming scoliosis. The lateral deviation
of vertebral column is confirming when at bending forward we observe deviation
of medial line from that vertical.

Palpation of vertebral column is performing in vertical position of body, on

spinous apophyses, with medium finger of right hand. The presence of pain at
palpation demonstrates the existence of some pathologic process in respective
segment. For th precise the place of affection, the patient is lying on abdomen on
hard support and we apply the tangential movements on two vertebrae in affected
segment. The pain in segments C3 – C4 – C5 irradiates in throat, neck, ears. From
segments C5 – C6 – C7 – T1 the irradiation is felt in shoulder, from C6 – C7 – in
the 2-nd and 3-rd finger of hand, from T2 – T6 – in the region of arm and hand,
from T6 – T10 – on the trajectory of intercostals spaces, from T10 – T11 – T12 –
L1 – in the inguinal and buttocks region, in thigh.

The pain in vertebral column also can be caused by internal organs affection. So,
the motive for the pains in C6 – C7 are mastoiditis, esophagitis, migraine, in T3 –
T6 – affections of heart, in T6 – T7 – of stomach, in T10 – T11 – of gallbladder, in
T10 – T12 – of kidneys, in L3 – of ovary, in L4 – of uterus, in S4 – S5 – of urinary
bladder and rectum. The diffuse pain felt at vertebral column palpation can be
caused by muscles affection.

The vertebral column mobility is appreciating in initial position, so, the patient
stays in vertical position, the shoulders are at same level, the knees are straight, the
feet soles are parallel, the head is straight, the sight is oriented forward. The
general mobility is appreciating by flexions performed forward and lateral, taking
into account that in normal conditions at anterior flexion the vertebral column
keeps the aspect of continuous arch, and the fingers touch the floor. In the case of
flexion limitation we measure the distance between the tops of medium fingers and
floor. At lateral flexion performing the fingers slide on exterior part of thigh, the
tops of medium fingers reach the level of knees. At eventual mobility limiting we
also measure the distance until the floor.
For the measurement of flexion and extension degrees we use a protractor. The
summary degree of mobility in cervical segment is forming from the measurement
of head flexion angle, extension, lateral tilt and rotation. For persons until 65 years
age this angle constitutes 70°, that lateral - 35°, rotation angle – 80-90°. For
persons more than 65 years this angle decreases.

The thoracic part of vertebral column is less mobile. The patient makes movements
forward and back, the mobility being possible in segments T1 – T2 and T11 – T12.
The limitation of movements in thoracic part of vertebral column is appreciating
using Ott probe.

The functional examination of lumbar column supposes at beginning the

estimation of configuration in vertical position, then is appreciating by performing
of active movements in this region through flexion, anterior, posterior and lateral
extension of body. The lumbar column mobility is determined by segments L4-L5-
S6.

The sacro-iliac articulations are difficult to palpate. For estimation of pathologic

modifications are used diverse tests of diagnosis.

The diagnostic tests for the pain syndrome and vertebral column mobility
limiting elucidation
1. The evaluation of pain on the trajectory of spinous apophyses and in
paravertebral points.
2. Forestier symptom – for station estimating. The patient is placing with the
back to wall with the adherences at the level of heels, scapulae and head. In
normal conditions the heels, scapulae and neck must be adhered by wall. In
patients with ankilosant spondillitis, Forestier disease, as a consequence of
vertebral column kyphosis development, not one form above enumerated
points doesn’t touch by wall.
3. Appreciation of mobility in cervical segment of vertebral column. At the
level of vertebra C, we measure 8 cm up and mark this point, after that the
patient is requested to incline the head maximally down, measuring again
the distance: in healthy persons it will be increased with 3 cm, and in these
with affected cervical segment we will establishing nonsignificant increasing
or the distance will remain not changed. In patients with ankilosant
spondiloarthritis, in persons with short neck the probe doesn’t informative.
4. The test chin – sternum. In normal, at anterior flexion of head, the chin
touches sternum. When the cervical segment of vertebral column is affected,
there is some distance between chin and sternum.
5. Ott probe – for to determine the mobility of vertebral column thoracic
segment. From the level of vertebra C we measure down 8 cm and mark this
point, and the patient is requested to flex maximal the anterior thorax, after
that the measurement is repeating. In normal this distance is increasing with
4-5 cm, and in patients with ankilosant spondillitis the data are not changed.
6. The appreciation of thorax excursion limitation. For to determine the
pathologic process in costo-vertebral articulations we perform the
measurements using centimeter band at the level of IV rib at inspiration and
expiration: in normal the difference between the perimeters is 6-8 cm. and in
the case of costo-vertebral articulation ankilosis it doesn’t exceed 1-2 cm. In
pulmonary emphysema the test is not informative.
7. Tomaier test – for the appreciation of vertebral column mobility. Having
stretched out the hands, the patient flexes the anterior body until the III
finger and touches the ground, and in the case of vertebral column mobility
limiting we register some distance of non-adherence.
8. Shober test – for to determine the mobility of vertebral column lumbar
segment. At the level of vertebra L5 we measure up 10 cm and mark this
point, and after maximal flexion of anterior body we repeat the
measurement. In normal the distance between two measurements increases
with 4-5 cm, but in the case of vertebral column affection it practically
doesn’t change.
9. Vertebral index (V.I.). for to determine the V.I. we add the following sizes
(cm): the distance between chin and jugular fossa of sternum in maximal
head extension, the Ott probe, the Shober test, the thorax excursion. From
obtained value we subtract the Tomaier probe index (cm). The vertebral
index is approximately 27-30 cm (individual) and is appreciating in
 dynamics, the reducing of V.I. demonstrating the progressing of vertebral
column mobility limiting.

Symptoms characteristic for sacroileitis

1. Kushelevski symptom (I). The patient is in dorsal decubitus on hard support

and the physician performs compression movements with both hands on
the level of iliac cristae: in the case of inflammatory process in sacro-iliac
articulation there is the pain appearance in sacrum bone.
2. Kushelevski symptom (II). The patient is in lateral decubitus, and the
physician performs compression movements on the level of iliac bone: the
patient feels pain in sacrum bone.
3. Kushelevski symptom (III). The patient is in dorsal decubitus, having one
leg flexed in knee joint and displaced laterally, and the physician with one
hand performs compression movements on knee, in the same time with
another hand he compresses the opposed iliac bone: the patient feels pain
in the region of sacro-iliac articulation. The same examination is made on
opposed leg.
4. Makarov sign (I). Using neurologic hammer we perform at the level of
sacro-iliac articulation percussion movements: the pains appear.
5. Makarov sign (II). The patient is in dorsal decubitus and the physician
seizes the patient’s legs upper from talo-crural articulation, and when the
muscles of legs are relaxed he performs suddenly the movements of legs
repel and approaching: the pains in sacro-iliac articulation appear.

The methods of skeletal muscles examination

At inspection of muscles we compare the symmetry of muscles groups (right

group, left group), presence of atrophy (amyotrophy). The deviations from normal
demonstrate the involvement of muscles in pathologic process. The amyotrophy
can be soft, moderate or severe. In majority of pathologies with the articulations
involvement the diffuse atrophy of muscles has place, the local atrophy being
characteristic for mechanical affection of ligaments and muscles or nerves. The
palpation of muscles is performing when the patient is relaxed, this being the basic
method in muscular tonus determining, in the case of muscles rigidity and
contractures. The percussion of muscles determines the painful points and these
conglomerations of muscles which also react with pain at palpation. The
appreciation of muscular force is obtaining through the making by patient of an
opposite effort. For to evaluate the state of thigh muscles, the patient is in dorsal
decubitus, with one lifted leg, and the physician performs pressing movements, at
which the patient puts up resistance. For to determine the muscular force in flexor
muscles of hip, the patient flexes the legs in knee joints, and the physician
performs deflexion movements, feeling the resistance of hip flexor muscles. The
analog methods of flexor and extensor muscles muscular force evaluation are also
applying at the level of superior members.
 Muscular force gradation
Level Character of muscular force
0 There are not attesting muscular contractions
1 Visible or palpable in rest contractions
2 Movements in the absence of weight force
3 Movements for to overcome the weight force
4 Movements against the weight force and exterior resistance
5 Muscular force is normal, movement against exterior resistance by
increased intensity

The objective appreciation of muscles characteristics – fatigue, excitation, force –

is making using ergometer, electromyography, myotonometry and
electrotonometry. The muscular tonus and force are interdependent and
proportional between them. The increasing of hypotrophied muscles force
demonstrates the normalizing of muscular tonus. The evaluation of muscular tonus
is performing in morning, because the fatigue or other factors have influence on it.
For the measurement of force we use dynamometer. For the evaluation in
dynamics the final data are comparing with preceding data or with these of healthy
child. For the estimation of hand force the patient is seating down in front of table,
the dynamometer being placed perpendicular in report with it, the patient is
requested to press with hand the dynamometer 2-3 times, the result with best data
being considered final.

The parameters of clinical report in articular examination

 The number of painful articulations.

 The number of swelled articulations.
 Duration of morning stiffness expressed in hours or minutes.
 The diameter of proximal interphalangeal articulations (it’s measured with
especial apparatus named “Naprometer”); at II-V fingers it’s calculated
summary for both hands.
 The diameter of knee joint (is appreciating with centimeter band).
 The force of hand pressing (is appreciating with special device –
dynamometer); the patient performs the procedure 3 times for each hand,
being calculated the medium value.
 The time necessary for cover the distance of 15 meters (index used in
articular pathology of inferior members).

The methods of rheumatic diseases diagnosis

An important role in rheumatic diseases diagnosis have the radiologic methods of

articulations and internal organs examination. It is also important to mean that in
the debut of articulations affection there is X-ray negative period, and the first
specific changes (ostheoporosis, erosions, cysts) are radiologically visible only
after a few weeks or even months from the appearance of first clinical signs. In
some rheumatic diseases there can appear the early changes of some articulations,
and in the case of rheumatoid arthritis presence suspicion there is necessary to
perform the hands and legs radiography, in the case of gout – of I
metatarsophalangean articulation, in the case of ankilosant spondillopathy – of ilio-
sacral articulation.

Artrography – radiologic examination of articulations with oxygen or carbon

dioxide (artropneumography) or contrast substances introducing. The method
allows to evaluate the synovial membrane, articular cartilage, the state of articular
capsule and ligamentar apparatus.

Isotopic examination of articulations supposes the intravenous introducing of

pyrophosphate and marked technetium. The increased concentration of isotope is
fixed on a paper under the form of scintigram. The isotope accumulation is
proportional with the level of articulation inflammatory process. Due to
scintigraphy there is possible the early diagnosis of arthritis, synoviitis, and also
the differential diagnosis between degenerative and inflammatory articulations
affections.

Artroscopy – visual examination of articular cavity using artroscope. This is an

efficient method of diagnosis in the case of knee joint monoarthritis. The
examination is less traumatic, is informative looking the articular cartilage,
synovial membrane state, the level of meniscus and ligamentar apparatus affection.
The method allows the tissues biopsy performing with their morphologic
examination. The thermic examination of articulation consists in the objective
expression of temperature above articulation and is used in differential diagnosis of
degenerative and inflammatory affections, of oncopathologies and
microcirculatory disturbances. This procedure is performing using liquid crystals
on the basis of cholesterol, that allows to obtain thermogram which determines the
infrared radiation intensity.

Ultrasonography of articulations have also diagnostic importance. In the moment

of ultrasonographic vibrations passing there are determining the structural and
physical properties of examined medium.

In the process of thoracic cage radiologic examination there are establishing the
heart and great vessels dimensions, and there are identifying the basal
pneumofibrosis, pleurisy and pulmonary emphysema.

The esophagus and stomach radiography is performing for to determine the motor
disorders (systemic scleroderma), insufficiency of cardia, esophagitis, gastritis,
ulcer – pathologies which are developing as a consequence of complications after
drug treatment.
Osseous densitometry – for to diagnose the osteoporosis, which is spread in
rheumatic patients. The densitometric methods based on quantitative principles of
computer tomography and ultrasonography are used more often.

The biopsy of synovial membrane, of skin, muscles, kidneys, liver etc., the
morphologic examination of material for the differential diagnosis in different
forms of vasculitis.

The immunohistochemical examinations are performing at necessity for to

diagnose the autoimmune affection of synovial membrane, muscles and vessels.

The electrocardiography and echocardiography have separate role for cardio-

vascular system state estimation.

The reovasography of extremities vessels is informative for to determine the

circulatory disorders, for example – in Raynaud syndrome.

The electroencephalogram is used for the diagnosis of cerebrovasculitis.

The electromyography – method for to appreciate the muscles contractile function,

being on dependence from the expressiveness of inflammatory and degenerative
dystrophic changes.

In cytopenic syndrome, for the appreciation of hematopoiesis at bone marrow level

and for the establishing of differential diagnosis with hemoblastoses, there is
performed the sterna puncture and at indications – trepanobiopsy.

The examination of synovial liquid.

Color: in normal – light-yellow; in degenerative-dystrophic affections – light-

yellow, yellow, straw-colored; in the case of affections with inflammatory
character – from light-yellow to brown, lemon-colored, pink, grey.

Quantity: 0,2 – 2 ml; in articulations pathology – 3 – 25 ml and more.

Transparency: there are distinguished 4 levels of transparency – transparent,

semitransparent, moderated turbid, intense turbid.

Cellular composing: in normal the cytosis must not exceed 0,18 x 10 9/l; the
presence of synovial membrane stratum cells and leucocytes – in normal there is
the predominance of monocytes and lymphocytes (until 75%), the quantity of
polimorpho-nuclear neutrophils – fro 0 until 25%, the quantity of synoviocytes –
from 0 until 12%.
The sediment: in normal the synovial liquid doesn’t form sediment, but in the case
of inflammatory process in articulations the sediment is obligatory present,
representing, as a rule, fragments of membranous cells, fibrinous striae, collagen
fibers, crystals, fragments of cartilage and synovial membrane, which are forming
in the process of destruction.

The density of mucine clot: in normal the mucine clot is dense, and in affections
with inflammatory character – friable or moderate friable; in affections with non-
inflammatory character – moderated dense.

The viscosity of synovial liquid is determining through a few methods. In routine

examinations it is estimating in dependence of mucine thread. There are
distinguished 3 levels of viscosity: low – until 1 cm; moderate – until 5 cm; high –
over 5 cm. In normal the synovial liquid viscosity is high, in the affections with
non-inflammatory character – moderate, and in these inflammatory – low. There
are also instrumental methods of synovial liquid viscosity appreciation –
viscosiometry Ostvalde and Bishoff.

Cytosis: in a test glass containing 0,4 ml of isotonic solution we add 0,02 ml of

synovial liquid, the count of cells being performed in count camera; in non-
inflammatory affections the presence of cells doesn’t exceed 3 x 109, in these
inflammatory it is from 3 till 50 x 109, in septic affections cytosis exceeds 50 x 109.

Synoviocytogram: in articular affections with non-inflammatory character there are

more neutrophils – until 90%.

Ragocytes: in normal the synovial liquid doesn’t contain ragocytes; in

inflammatory processes and in seronegative spondiloarthropathies the quantity of
ragocytes constitutes from 2 till 15% from total cells number; in rheumatoid
arthritis – 40% and more, in dependence from local inflammatory level.

Crystals: these from synovial liquid are identifying using microscope: crystals of
urates and calcium pyrophosphates, which have opposed optic characteristics. The
crystals of hydroxiapatitis have very small dimensions and can be visualized only
by electronic microscope.

Total protein: in normal conditions the containing of proteins in synovial liquid is

15-20g/l, in inflammatory processes – 35-48 g/l, in rheumatoid arthritis – until 60
g/l.

Rheumatoid factor and C reactive protein: in normal conditions in synovial liquid

rheumatoid factor is not found, but in affections of articulations with non-
inflammatory character it can be found in small titers 1:20 – 1:40, in the case of
seropositive rheumatoid arthritis the titer of rheumatoid factor exceeds 1:40. The
level of C reactive protein in synovial liquid in non-inflammatory articular
affections is 0,001 g/l,, and in these inflammatory – from 0,01 g/l till 0,06 g/l and
more.

All methods of rheumatologic patient examination must be applied in dynamics,

with the performing of complex analysis and comparison with preceding data,
taking into account also the possibility of rheumatic pathologies combining or of
transforming of one disease in another nosologic form.

The autoantibodies in rheumatic diseases

Autoantibodies Affection (frequent autoAb) Comments
FR RA (70-80%) Sensible, but non-specific,
indicator of prognosis
Anti CCP RA (80%) Sensibility and specificity ↑↑
Anti-ds DNA SLE (60%) Specific, but not sensible for
SLE, is correlating with
disease activity degree
Anti-histone Drug-induced lupus (90%) Sensible, but not specific for
SLE (50%) drug induced lupus
Anti-Sm SLE (20-30%) Specificity ↑↑, but sensibility
↓ for SLE
Anti-U1RNP SLE (30-40%) Is correlating with disease
Mixt disease of conjunctive activity in SLE
tissue (100%)
Anti-Ro (SS-A) Sjögren syndrome (70-100%) Is associated with primary
SLE (25-60%) Sjögren syndrome, involved
in neonatal lupus
Anti-La (SS-B) Sjögren syndrome (40-94%) Is associated with SLE with
SLE (9-35%) tardy onset, Sjögren
syndrome, neonatal lupus
Anti-centromer CREST syndrome (70-90%) Prognosis marker in patients
with precocious symptoms
of scleroderma (Raynaud
phenomena)
Anti-Scl-70 Scleroderma (until 70%) Specificity ↑↑. Prognosis
marker for scleroderma
Anti-Jo1 Polymyositis and Is associated with pulmonary
dermatomyositis (20-40%) fibrosis and Raynaud
phenomena
c-ANCA Granulomatosis Wegener (80- Sensibility and specificity ↑↑
90%)
p-ANCA Granulomatosis Wegener (10%) Sensibility and specificity ↓↓
Microscopic polyangitis for Wegener disease
Glomerulonephritis
 Diseases associated with rheumatoid factor
Conditions associated with Prevalence of rheumatoid factor (%)
rheumatoid factor
Mixt type II cryoglobulinemia 70-100
Sjögren syndrome 75-90
Mixt disease of conjunctive tissue 50-60
SLE 20-35
Scleroderma 20-35
Juvenile arthritis 15-25
Systemic vasculites 5-20
Polymyositis 5-10
Vasculites through hypersensibilization 5-15

Other conditions (associated with rheumatoid factor):

 Senescence
 Bacterial infections: bacterial endocarditis, salmonellosis, brucellosis,
tuberculosis, syphilis
 Viral infections: mumps, rubella, active chronic hepatitis
 Parasitosis (tripanosoma, plasmodium, schistosoma, trichinellosis)
 Pulmonary affections: sarcoidosis, interstitial fibrosis, silicosis, asbestosis
 Other : primary biliary cirrhosis, malignant affections (especially leukemia
and colon cancer).