Examining for swelling
Back to Examination for musculoskeletal pain Synovitis
Synovitis may be described as ‘boggy’ or ‘squidgy’ swelling. It may be felt along the joint line, but inflammation of the tendon lining (tenosynovitis) results in swelling often located away from the joint.
Patients with chronic inflammatory arthritis may have chronic synovial thickening. This swelling isn't tender but you can feel it during examination.
Synovitis can be indicated by:
tenderness, demonstrated by pain when you palpate the area using just enough pressure to make your nail start to turn white
How can I test for synovitis?
The squeeze test is a useful clinical test to determine subtle synovitis if you can't feel any swelling. You can perform it at the metacarpophalangeal (MCP) or metatarsophalangeal (MTP) joints. If the patient experiences tenderness when you gently squeeze the joint, it suggest synovitis.
Synovitis can be difficult to detect by just through examination. New imaging techniques now pick up 'subclininal' synovitis in patients with normal examination findings.
What if the examination is normal?
A normal examination doesn't rule out an underlying inflammatory condition. Examination may be normal between episodes in palindromic rheumatism, in early osteoarthritis, or even in early rheumatoid arthritis due to day-to-day variability of symptoms.
It's reasonable to refer the patient if their history suggests an inflammatory condition.
Although erythema is a cardinal feature of inflammation, it's often not a striking feature in inflammatory arthritis. The exceptions to this are:
crystal arthritis (gout and acute calcium pyrophosphate deposition arthritis, formerly referred to as pseudogout)
psoriatic arthritis in which overlying erythema may be marked and lead to diagnostic confusion with cellulitis.
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