Waching daily Aug 24 2018

Physical examination of the axial skeleton and peripheral joints are an

integral part of what we do as rheumatologists.

The clinical skills are important both in diagnosis and optimal outcome for our patients. Of all the

patients that we see in rheumatology, the vast majority can be diagnosed based on

history and physical alone, and I believe that's a wonderful aspect of our specialty.

New therapeutic strategies for the treatment arthritis depend on early

treatment, aggressive treatment and treating to a target. The most important

element of the composite indices that we use in these therapeutic strategies; is

the swollen joint. In fact, the swollen joint is critical because it is the key

predictor of radiographic progression over time; it is the key predictor of

structural damage over time. So if we can easily detect a little bit of swelling

in joints, then we will be able to diagnose it earlier. If we're able to

more sensitively detect swollen joints then we're going to be able to

make the right decisions in treating to target over time. The key element and

physical diagnosis in terms of these outcomes is the swollen joint.

So now we're going to turn to the metacarpophalangeal joints, and we're gonna look

for swelling in those joints. And there's the way the world does it, and the way

that I teach, which is actually quite different. So most people, for feeling for

swelling, they flex the finger. And so they flex the MCP and then what they do

is they ballot on either side, that is on either side of the joint line, and the

joint line is about here. And they ballot to see if they can actually feel the

definition of the bones in that area, and if they don't feel the definition, they

say that that's a swollen joint. The problem with that technique is that the

swelling is not only above but it's also in the palm of the hand

and therefore, it is a large surface area to swell so you will not be able to

detect it because you can't get your fingers around it because it's both

above and below the joint; that is on the palm or surface. So what I do differently

from doing this technique, which is the common technique, is I with two fingers,

the fourth and fifth fingers, I literally lift the joint, extend the joint up, and

suddenly you can see even here, you can see swelling. So from here to there,

there's suddenly swelling, and the swelling really relates to the fact you

pushed the fluid to the top. And then all I need to do is take my fourth and fifth

fingers, lift it up, and when I lift it up you suddenly see a bulge on the top.

And then I take my four fingers and I'm literally, you can now see my fingers

moving—it's like a balloon. All I'm doing is pushing my fingers in and out like I

would a balloon; that's ballottement. And you can see now that my fingers are

really moving back and forth or up and down, suggesting in fact that I'm

capturing the fluid on the top of the joint. What you've seen in the physical

examination of the swollen joints is how to sensitively detect joint swelling.

It is the key physical examination outcome that we use for diagnosis and for

following the patient over time in terms of our therapeutic response; it is the

message. Swollen joints counts actually count.