How are pain and tenderness assessed during physical exam in rheumatoid arthritis (RA)?

Updated: Feb 07, 2020
  • Author: Howard R Smith, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

Direct palpation can elicit joint tenderness, which can vary significantly among patients and with the method of application of force used. To minimize variation over time, the examiner should try to apply approximately the same pressure for each patient examined.

The enlarged synovial membrane, periarticular ligaments, and supporting structures are the major pain-sensitive structures. Muscles may also become tender, but rarely is this due to myositis. Muscle tenderness is not specific for RA. Severe muscle tenderness should suggest another differential diagnosis, including fibromyalgia or a regional pain disorder (see DDx). Bony prominences are generally tender; periarticular structures tend to be more vulnerable to palpation at these sites.

Pain on motion is often used as a surrogate for tenderness in joints that are not readily amenable to direct palpation because of overlying muscle and other tissues. Such areas include the cervical spine, shoulder, and hip.

Pain on motion of the joint may be due to noninflammatory processes that also interfere with the joint’s normal, almost frictionless motion, including damage of cartilage and bone. Additionally, joint instability or subluxation causes pain on motion because of musculotendinous imbalances across the joint. Documenting the positions of motion at which pain occurs can be useful.


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