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Movement

In examining movement of a joint, it is important to first ask the patient specifically about pain and tenderness in the joint or the limb being examined. Initially the range of active movements is tested before proceeding to a more thorough evaluation of resisted and passive movement. Asking the patient to demonstrate the full range of active movement reveals the extent of dysfunction of a joint. For example doing up a shirt button may reveal the extent of dysfunction of a hand.

Movement of a damaged muscle or its tendons commonly produce pain. This pain can be demonstrated by holding a joint in the mid range of a muscle activity, while the patient forcibly contracts this muscle. As no movement takes place, any pain can be localised to a specific muscle rather than the rigid elements or other muscles acting on the joint.

This ‘resisted movement technique’ requires knowledge of the action of each muscle in order to stand in the appropriate position to hold and resist activity. Note is also taken of any muscle weakness. Power is graded on a scale of 0 to 5: five is normal and zero total paralysis.

Passive movement must be undertaken with extreme gentleness and the patient’s face watched during all these manoeuvres. These precautions give the patient confidence to totally relax while you are testing the full range of movement in each joint. Before you start, consider how you are going to stand and hold the limb to assess the full range of joint movement, without moving your feet or grip during the process. Know the normal end points of the movements of a joint, and whether the end point is a hard bony end point (‘close-pack’- congruence of the bony surfaces), e.g. elbow extension, and tautness of tendons and ligament of knee extension, or a soft end point, limited by soft tissue apposition (the ‘loose-pack’ of non-bony congruence), e.g. knee flexion. Some springiness of the soft tissues is usually present in the mid-range of normal joint movement.

In passive movement of the hip joints, check for associated movement of the pelvis and spine, and in the shoulder, associated scapular movement. In larger joints, the distal limb is usually moved with one hand while the palm of the other rests over the joint surface.

Grinding, grating or creaking sensation of the surfaces may be heard and felt, including crepitus, clicks, clunks, resistance and catching or locking, suggesting irregularity of the articular cartilage or bony surfaces.

The commonest cause of limited movement is pain from the structures attached to the joint or elsewhere within the limb. It may be due to inflammatory changes. Other causes are thickening of the capsule and periarticular structures, joint effusions, muscle spasm, contractures and bony irregularities or ankylosis.

Once the limit of normal movement has been assessed specific manoeuvres are undertaken to identify abnormal movements and joint instability. Excessive movement may be due to lax or torn ligaments and bony deformity.

Movement involves both the neurological and musculoskeletal systems, the emphasis in the former is on tone, power, coordination and reflexes, while in the latter the emphasis is on the measurement of active and passive movement. There is, however, a considerable overlap. In this text, to avoid excessive repetition, the neurological examination considers neuromuscular abnormalities, while in this chapter movement is emphasised. In practice you need to master all techniques for assessing active, passive and resisted movement, and muscle power for use in either system.