The history indicates the presence of painful sites and you must show extreme gentleness during palpation; watch a patient’s face (also later in active and passive movement). Tenderness is an important sign of pathology, localize its site as accurately as possible. Remember, however, that tenderness, like pain, can be referred from a damaged to a distant area. Commences with palpation of the adjacent bones, their surfaces and the joint line.

There may be tenderness along this line, as with damaged menisci in the knee joint. Ligamentous tenderness may be due to tears at the joint line or the ligament attachments on either side of it.

Palpation should detect warmth, which may signify an active synovitis or infection, and tenderness of the joint or periarticular tissues. Stroking a limb from proximal to distal encounters a gradual cooling of temperature and abnormality can be readily appreciated; use the medial side of your hand for this manoeuvre.

The joint is systematically palpated for evidence of swelling, this may be of the skin, subcutaneous tissues, muscles, joint capsule, ligaments, synovial membrane, bursae, bone or intracapsular structures, such as an effusion or abnormal cartilages. Soft tissue swelling around the joint causes deformity, with loss of the normal contour and palpable landmarks. An effusion is fluctuant and, using specific tests, fluid can be made to shift within the joint. However, there may be associated inflammatory edema and surrounding inflamed tendons or a hemarthrosis. Synovial thickening and synovitis have a soft and boggy characteristic, with associated warmth and redness. Sustained pressure is usually required to produce any indentation of the inflammatory edema. These conditions untreated may lead to permanent damage to the joint surfaces.

Tenderness of bones is characteristic of osteitis fibrosa, multiple myeloma, leukemic infiltration of bones, secondary deposits and osteomyelitis. Fractures may be accompanied by swelling, deformity, crepitus, abnormal mobility and loss of function.

Map out any areas of altered cutaneous sensation.