Ankylosing Spondylitis: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

  • General physical examination – including blood pressure, pulse, body temperature, body weight, body height; furthermore:
    • Inspection (viewing).
      • Skin (normal: intact; abrasions/wounds, redness, hematomas (bruises), scars) and mucous membranes.
      • Gait (fluid, limping).
      • Body or joint posture (upright, bent, relieved posture) [hunchback formation; increased cervical lordosis and thoracic kyphosis].
      • Malpositions [deformities, contractures, shortenings]
      • Muscle atrophies (side comparison!, if necessary circumference measurements).
      • Joint [abrasions/wounds, swelling (tumor), redness (rubor), hyperthermia (calor); injury indications such as hematoma formation, arthritic joint lumpiness, leg axis assessment].
    • Palpation (palpation) of vertebral bodies, tendons, ligaments; musculature (tone, tenderness, contractures of paraverebral muscles); soft tissue swelling; tenderness (localization! ); restricted mobility (movement restrictions of the spine); “tapping signs” (testing of painfulness of the spinous processes, transverse processes as well as the costotransverse joints (vertebral-rib joints) and the back muscles); illiosacral joints (sacroiliac joint) (pressure and tapping pain? ; compression pain, from the front, side or saggital); hyper- or hypomobility? [Sensitivity of the spine to movement; Sensitivity of the spine to vibration; Bony tenderness, especially at the iliac crests and spinous processes]Detection of sacroiliitis (inflammatory, destructive change in the joints between the sacrum and ilium) by the Mennell handle:The patient lies prone. The examiner fixes the sacrum and pelvis with the hand and then hyperextends the thigh dorsally (“backward”). If pain is indicated, this is referred to as a positive Mennell’s sign, i.e., sacroiliitis is probably present. A negative sign does not rule out damage to the sacroiliac joint.
    • Palpation of the joints [arthritis (joint inflammation) of the shoulder/hip joints – occurs in up to 35% of affected individuals; arthritis (joint inflammation) of truncal joints (= peripheral arthritis* or/and heel pain) – occurs in up to 30% of cases; * asymmetric synovitis (synovial inflammation) predominantly in the lower extremity (especially knee, ankle joint)]
    • Measurement of joint mobility and range of motion of the joint (according to the neutral zero method: the range of motion is expressed as the maximum displacement of the joint from the neutral position in angular degrees, where the neutral position is designated as 0°. The starting position is the “neutral position”: the person stands upright with the arms hanging down and relaxed, the thumbs pointing forward and the feet parallel. The adjacent angles are defined as the zero position. Standard is that the value away from the body is given first). Comparative measurements with the contralateral joint (side comparison) can reveal even small lateral differences.
    • Functional tests
      • Finger-to-floor distance: assessment of the overall mobility of the spine, hips and pelvis. This is done by measuring the distance between the floor and the fingertips at maximum forward flexion, with the knees extended through. Normal finding: FBA 0-10 cm
      • Ott sign: Checking the mobility of the thoracic spine. For this purpose, a skin mark is applied to the standing patient above the spinous process of the seventh cervical vertebra (C7, HWK 7) and 30 cm further caudally (below). The changes in the measured distance during flexion (bending) are recorded. Normal findings: 3-4 cm.
      • Schober sign: Checking the mobility of the lumbar spine. For this purpose, a skin mark is applied to the standing patient above the spinous process of S1 and 10 cm further cranial (above). At maximum flexion (after forward bending), the skin marks usually diverge by 5 cm, at retroflexion (after backward bending), the distance decreases by 1-2 cm.
      • Ischialgiform pain (or positive Mennel’s sign – with jerky hyperextension of the patient’s extended leg, lying in prone or lateral position, in the sacroiliac joint (ISG). If pain is reported during this process, it is referred to as a positive Mennell’s sign.A negative sign does not rule out damage to the sacroiliac joint).
    • Further test: measurement of thoracic respiratory excursion (using measuring tape): restricted respiratory width at the level of the 4th intercostal space (difference between inspiration and expiration usually less than 2 cm).
    • Occiput-to-wall distance: when the patient stands with his back against the wall [always pathological in ankylosing spondylitis because of rounded back]
  • If necessary, ophthalmological examination [due tosymptom: uveitis (inflammation of the middle eye skin (uvea))]
  • Health check

Square brackets [ ] indicate possible pathological (pathological) physical findings.