Ankylosing spondylitis physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S[2]

Overview

Patients with ankylosing spondylitis usually appear normal. Physical examination of patients with ankylosing spondylitis is usually remarkable for three areas axial joints, peripheral joints, and entheses. Physical examination of AS includes a typical diagnostic process that includes exams and tests. The physical examination of AS includes cervical spine, thoracic spine, lateral spinal flexion, Schober test, sacroiliac joint tenderness test and hip joint tests.

Physical Examination

Physical examination of patients with ankylosing spondylitis is usually remarkable for three areas axial joints, peripheral joints, and entheses.

Appearance of the Patient

Vital Signs

  • Vital signs are within normal limits in patients with AS.

Cervical spine [1]

  • Forward stooping of the thoracic and cervical spine.
  • The degree of flexion deformity is measured by asking the patient to stand erect with heels and buttocks against a wall and to extend the neck while keeping the mandible in the horizontal position and ask the patient to touch the wall.
  • The degree of flexion deformity is measured by the distance between the occiput and the wall.

Thoracic spine[2]

  • The degree of chest expansion is measured by the range of motion of the costovertebral joints and is measured at the level of the xiphoid process.
  • The physician must ask the patient to raise their arms beyond their heads and then ask the patient to maximal forced expiration how much they can and that is followed by a maximal inspiration.
  • In normal individuals the expansion is usually >2 cm.
  • In normal individuals it is greater than 10 cm.

Lateral spinal flexion[3]

  • Physician must ask the patient with AS to standing erect with heel and back against a wall and knees and hands extended and measure the distance between the tip of the middle finger and the floor.
  • Then ask the patient to bend sideways without bending the knees.

Schober test[4][5][6][7]

  • In patients with AS Schober test is used to measure forward flexion of the lumbar spine.
  • Physician must ask the patient to stands erect then a point is placed at the middle of a line joining the posterior superior iliac spines, another mark is made above 10 cm in the midline then ask the patient to bends forward how much they can without bending the knees and measure the distance.
  • In normal individuals  should exceed 2 cm.

Sacroiliac joint tenderness[8]

  • In AS patients to bring out sacroiliac pain apply direct pressure over the sacroiliac joint.
  • Sacroiliac joint tenderness is also elicit by the following
    • Ask the patient to be supine position, then apply direct pressure on the anterior superior iliac spine and, at the same time physician must apply force on iliac spine laterally.
    • Ask the patient to be on the side, then physician must apply pressure to compress the pelvis.
    • Ask the patient to be supine position, physician must ask the patient to flex one of the knees and then to abduct as well as externally rotate the corresponding hip, then apply pressure on the knee which is flexed and this elicit pain on the sacroiliac joint.

Hip joint[9][10]

  • When a patient with AS is exhibiting abnormal gait hip involvement should be suspected.
  • In AS patients hip involvement lead to flexion deformities and can be assessed by internal and external rotation of the hip.

Dactylitis[11]

  • Dactylitis also called as sausage digits.In AS patients the fingers looks like in appearance.

Lungs[2]

Cardiovascular[12][13][14][15]

References

  1. Cho H, Kim T, Kim TH, Lee S, Lee KH (October 2013). "Spinal mobility, vertebral squaring, pulmonary function, pain, fatigue, and quality of life in patients with ankylosing spondylitis". Ann Rehabil Med. 37 (5): 675–82. PMC 3825944Freely accessible. PMID 24236255. doi:10.5535/arm.2013.37.5.675. 
  2. 2.0 2.1 Cho H, Kim T, Kim TH, Lee S, Lee KH (October 2013). "Spinal mobility, vertebral squaring, pulmonary function, pain, fatigue, and quality of life in patients with ankylosing spondylitis". Ann Rehabil Med. 37 (5): 675–82. PMC 3825944Freely accessible. PMID 24236255. doi:10.5535/arm.2013.37.5.675. 
  3. Ramiro S, van Tubergen A, Stolwijk C, van der Heijde D, Royston P, Landewé R (June 2015). "Reference intervals of spinal mobility measures in normal individuals: the MOBILITY study". Ann. Rheum. Dis. 74 (6): 1218–24. PMID 24665113. doi:10.1136/annrheumdis-2013-204953. 
  4. Yen YR, Luo JF, Liu ML, Lu FJ, Wang SR (2015). "The Anthropometric Measurement of Schober's Test in Normal Taiwanese Population". Biomed Res Int. 2015: 256365. PMC 4530222Freely accessible. PMID 26273601. doi:10.1155/2015/256365. 
  5. Viitanen JV, Kautiainen H, Suni J, Kokko ML, Lehtinen K (1995). "The relative value of spinal and thoracic mobility measurements in ankylosing spondylitis". Scand. J. Rheumatol. 24 (2): 94–7. PMID 7747150. 
  6. Haywood KL, Garratt AM, Jordan K, Dziedzic K, Dawes PT (June 2004). "Spinal mobility in ankylosing spondylitis: reliability, validity and responsiveness". Rheumatology (Oxford). 43 (6): 750–7. PMID 15163832. doi:10.1093/rheumatology/keh169. 
  7. Cidem M, Karacan I, Uludag M (August 2012). "Normal range of spinal mobility for healthy young adult Turkish men". Rheumatol. Int. 32 (8): 2265–9. PMID 21544633. doi:10.1007/s00296-011-1953-4. 
  8. Miller TL, Cass N, Siegel C (February 2014). "Ankylosing spondylitis in an athlete with chronic sacroiliac joint pain". Orthopedics. 37 (2): e207–10. PMID 24679210. doi:10.3928/01477447-20140124-27. 
  9. Söker, Gökhan (2014). "Early Diagnosis of Hip Joint Involvement of Ankylosing Spondylitis Using Magnetic Resonance Imaging in the Absence of Clinical and X-Ray Findings". Archives of Rheumatology. 29 (2): 99–104. ISSN 2148-5046. doi:10.5606/ArchRheumatol.2014.3999. 
  10. Dwosh IL, Resnick D, Becker MA (1976). "Hip involvement in ankylosing spondylitis". Arthritis Rheum. 19 (4): 683–92. PMID 942499. 
  11. Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos-Vargas R, Dougados M, Hermann KG, Landewé R, Maksymowych W, van der Heijde D (June 2009). "The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis". Ann. Rheum. Dis. 68 Suppl 2: ii1–44. PMID 19433414. doi:10.1136/ard.2008.104018. 
  12. Han C, Robinson DW, Hackett MV, Paramore LC, Fraeman KH, Bala MV (November 2006). "Cardiovascular disease and risk factors in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis". J. Rheumatol. 33 (11): 2167–72. PMID 16981296. 
  13. Bremander, Ann; Petersson, Ingemar F.; Bergman, Stefan; Englund, Martin (2011). "Population-based estimates of common comorbidities and cardiovascular disease in ankylosing spondylitis". Arthritis Care & Research. 63 (4): 550–556. ISSN 2151-464X. doi:10.1002/acr.20408. 
  14. Peters, Mike J.; van der Horst-Bruinsma, Irene E.; Dijkmans, Ben A.; Nurmohamed, Michael T. (2004). "Cardiovascular risk profile of patients with spondylarthropathies, particularly ankylosing spondylitis and psoriatic arthritis". Seminars in Arthritis and Rheumatism. 34 (3): 585–592. ISSN 0049-0172. doi:10.1016/j.semarthrit.2004.07.010. 
  15. Momeni, Mahnaz; Taylor, Nora; Tehrani, Mahsa (2011). "Cardiopulmonary Manifestations of Ankylosing Spondylitis". International Journal of Rheumatology. 2011: 1–6. ISSN 1687-9260. doi:10.1155/2011/728471. 

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