Arthrography is often used to help diagnose the cause of unexplained joint pain. A contrast iodine solution is injected into the joint area to help highlight the joint structures, such as the ligaments, cartilage, tendons and joint capsule. Several X-rays of the joint are taken, using a fluoroscope, a special piece of X-ray equipment that immediately shows the image. You may be asked to fast prior to the exam. During the examination, you may be asked to move the joint into various positions as the images are taken. It is normal to experience some discomfort or tingling during the procedure. If you are or may be pregnant, or are allergic to iodine or shellfish, notify your physician; you may be at a higher risk of complications.
As part of your examination, your orthopaedist may order a variety of blood tests. Some conditions, such as rheumatoid arthritis, may be identified by the presence of a specific substance in your blood. You may be asked to fast prior to the exam.
Two very different kinds of tests may be called bone scans. One type tests the density of the bone and is used to diagnose osteoporosis. This type of bone scan uses narrow X-ray beams or ultrasound to see how solid the bone is. No preparation is required for this test, which takes only a few minutes and has no side effects. The second type of bone scan is used to identify areas where there is unusually active bone formation. It is frequently used to pinpoint stress fracture sites or the presence of arthritis, infection, or cancer. About three hours before the scan, you will be given a dose of a mildly radioactive substance called "technetium" through an intravenous line (IV). This substance occurs naturally in your body and is used in the bone formation process. The bone scan itself is performed about three hours later, which gives the bone time to absorb the technetium. As you lie on a table, a special nuclear camera takes a picture of your entire body. Areas of abnormal bone formation activity will appear brighter than the rest of the skeleton.
Computed Tomography (CT Scan)
A CT scan (computed tomography) combines X-rays with computer technology to produce a more detailed, cross-sectional image of your body. It may be ordered if your doctor suspects a tumor or a frature that doesn't appear on X-rays (such as in your collarbone or pelvis) or if you've had severe trauma to the chest, abdomen, pelvis or spinal cord. The process is painless. You lie motionless on a table as it slides into the center of the cylinder-like CT scanner. An X-ray tube slowly rotates around you, taking many pictures from all directions. A computer combines the images to produce a clear, two-dimensional view on a television screen. You may need to drink or be injected with barium sulfate or a dye so that certain parts of your body can be seen more clearly.
Discography is a test used to determine whether the discs, the cushioning pads that separate the bones of the spine, are the source of back pain. It may be performed before surgery to positively identify the painful disc(s). Before the procedure begins, you will be given antibiotics and relaxation medications through an IV line. Medication is used to numb the skin over the test site. During the procedure, the doctor inserts a needle into one or more discs and injects a contrast dye. You'll feel pain when the dye is introduced into the problem disc. Afterward, a CT scan will show any changes in the disc size or shape. You may experience some muscle discomfort after the procedure; your doctor can prescribe pain relievers to ease the discomfort.
An orthopaedist who suspects that you have a blockage in the blood vessels of your legs or arms may prescribe an ultrasound test. An ultrasound uses high-frequency sound waves that echo off the body. This creates a picture of the blood vessels. The Doppler audio system transmits the "swishing" sound of the blood flow. This is a noninvasive test that has no side effects. A clear jelly is applied to the skin over the blood vessels being tested. The technician uses a sensor that looks like a microphone. The sensor is placed against the skin and moved up and down across the area being tested. The technician will apply pressure every few inches to see if the blood vessels change their shape.
Dual-Energy X-ray Absorptiometry
Dual-energy X-ray absorptiometry (DEXA) is the most widely used test for measuring bone density. It can accurately and precisely monitor changes in bone density in patients with osteoporosis who are undergoing treatments. This machine takes a picture of the bones in the spine, hip, total body and wrist and calculates their density. For this exam, you lie on a padded table while the X-ray scanning machine moves over your body to capture images of your hip, spine or entire body. Your bone density and risk of fracture are compared to the "normal" range for people your age as well as to the maximum bone density possible.
An electromyography (EMG) records and analyzes the electrical activity in your muscles. It is used to learn more about the functioning of nerves in the arms and legs. For example, a fracture of the upper arm bone (humerus) may tear or pinch the radial nerve. An EMG can be used to identify the damage if nerve function doesn't return within 4 months of the injury. During an EMG, small, thin needles are placed in the muscle to record the electrical activity. When the needles are inserted, you may feel some pain and discomfort. The doctor will ask you to relax the muscle and then to tense it slightly. The electrical signals generated by your muscle are broadcast on a TV-like screen. When the needles are removed, you may experience some soreness and bruising, but this will disappear in a few days. There are no long-term side effects. If you are taking blood-thinning medications, have lung disease or are at risk for infection, tell the physician who is conducting the test.
Flexibility tests are used to measure the range of motion in a joint and are often part of the physical examination. They may be used to help determine whether you have a muscle imbalance or arthritis in a joint. They may also be used to help determine the progression of a condition such as shoulder impingement or a sprain. There are several different kinds of flexibility tests, geared to specific joints and muscles.
Intrathecal Contrast Enhanced CT Scan
This test uses contrast dye to better visualize the spinal canal and nerve roots in the spine. It may be used to help diagnose back problems such as spinal stenosis, particularly in patients with pacemakers or others who cannot have an MRI. The physician applies a numbing medication to the skin, which may sting for several minutes. The doctor uses X-ray guidance to inject a very low dose of contrast fluid (dye) into the spinal fluid. The CT scan is then administered.
Joint Aspiration and Analysis
Joint aspiration may be both a diagnostic test and a treatment option. In conditions such as bursitis, there is a fluid build-up that results in swelling and pressure. A similar fluid build-up around the joints can occur with injuries and arthritis. Aspiration, or removing the fluid through a syringe, can reduce swelling and relieve pressure. The doctor will swab the skin with an antibacterial solution before inserting the aspirating needle. You may feel some pressure and pain as the needle is inserted, but this should be relieved as the fluid is removed.
Laboratory studies of blood, urine or joint (synovial) fluids are used to identify the presence and amount of chemicals, proteins, and other substances. Your doctor may order various laboratory studies depending on what he or she finds during the initial examination. Laboratory tests are usually required before surgeries to identify medical abnormalities.
Magnetic Resonance Imaging (MRI)
An MRI (magnetic resonance image) uses magnetic fields and a sophisticated computer to take high-resolution pictures of your bones and soft tissues, resulting in a cross-sectional image of your body. It can be used to help diagnose torn muscles, ligaments and cartilage, heriated disks, hip or pelvic problems and other conditions. As with a CT scan, you lie on a table that slides into the tube-shaped MRI scanner. The MRI creates a magnetic field around you, then pulses radio waves to the area of your body to be pictured. The radio waves cause your tissues to resonate. A computer records the rate at which your body's various parts (tendons, ligaments, nerves) give off these vibrations, and translates the data into a detailed, two-dimensional picture.
Because muscles are soft tissues, they do not appear on X-rays. So muscle testing is an important part of the physical examination. Weakness in a muscle may indicate injury to the tendons that connect the muscle to bone, injury to the nerves that enervate the muscle, or a generalized weakness of the muscle itself from disuse. To test the strength of your muscles, your physician may ask you to move in certain ways while he or she applies a resistive force. Measuring grip strength by asking you to squeeze the doctor's hand is another type of muscle test.
Nerve Conduction Study (NCS)
Nerve conduction studies are often done along with an electromyogram to determine if a nerve is functioning normally. It may be recommended if you have symptoms of carpal tunnel syndrome or ulnar nerve entrapment. The doctor conducting the test will tape wires (electrodes) to the skin in various places along the nerve pathway. Then the doctor stimulates the nerve with an electric current. As the current travels down the nerve pathway, the electrodes placed along the way capture the signal and measure its speed. In healthy nerves, electrical signals can travel at speeds of up to 120 miles per hour. If the nerve is damaged, however, the signal will be slower and weaker. By stimulating the nerve at various places, the doctor can determine the specific site of the injury. Nerve conduction studies also may be used during treatment to test the progress being made.
During the physical examination, your doctor may feel your joints to see if they are warm or swollen, signs of inflammation. He or she may apply pressure to a muscle or joint to identify an area of tenderness. Palpation can also be used to identify the location of growths such as tumors or cysts. A physician may place a hand over a joint and ask you to move the joint, particularly if you complain of a "popping" or "snapping" sensation. This enables the physician to feel the tendons as they move over the joint. If you have a joint dislocation, the doctor may palpate the area before attempting to realign the bones.
Your physician can tell a lot about your health simply by looking at you. Obvious signs and symptoms include weak (atrophied) or asymmetrical muscles, improper alignment, swelling, changes in skin color (such as bruises or redness that might indicate inflammation) and growths such as cysts, calluses or corns. But the physical examination is much more than just a cursory look. It can also involve gait analysis (how you walk), palpation, muscle testing, flexibility (range of motion) testing, reflex response, and laboratory tests such as a complete blood count and urine analysis.
X-rays (radiographs) are the most common and widely available diagnostic imaging technique. X-rays are always used for fractures and joint dislocations, and may also be recommended if your doctor suspects damage to a bone or joint from other conditions such as arthritis or osteonecrosis (bone cell death). The part of your body being pictured is positioned between the X-ray machine and photographic film. As you hold still, the machine briefly sends electromagnetic waves (radiation) through your body. This exposes the film, creating a picture of your internal structure. The level of radiation exposure from X-rays is minimal, but your doctor will take special precautions if you are pregnant. Bones, tumors and other dense matter appear white or light because they absorb the radiation. Soft tissues and breaks in bone let radiation pass through, making these parts look darker. Sometimes, to make certain organs stand out in the picture, you are asked to drink barium sulfate or be injected with a dye. Several X-rays from different angles may be needed.
Range of Motion Testing
Range of motion tests may also be called flexibility tests. They are used to measure how well you can move a joint. Range of motion tests may be active or passive. In active tests, you do all the movement. In passive tests, the doctor will hold the extremity and move it. He or she may also hold the next joint steady to isolate the movement of the joint being tested.
A treadmill stress test measures the effectiveness of your cardiovascular system (your heart, lungs, and blood vessels). However, because your bones, muscles and connective tissues (ligaments and tendons) are constantly responding to stress (pressure or force), your orthopaedist may use applied stress to measure their response. Excessive or asymmetrical motion indicates that your ligaments are overstretched or loose.
This is the same kind of test as the Doppler ultrasound, but without the audio effect.
Venography is used to determine whether you have a blood clot in your leg, a condition called deep vein thrombosis. This is a serious condition because if the clot breaks free, it could travel to your lungs, creating a potentially fatal condition called pulmonary embolism. In this test, a contrast solution (or dye) is slowly injected into your leg as you lie on a tilting X-ray table. The dye causes a warm, flushed feeling in the leg and might also make you feel nauseous. X-rays are taken to identify the location of the clot. After the test, a clear fluid is injected in the same spot to clear the dye from your veins.