REMS general principles

Regional examination of the musculoskeletal system refers to the more detailed examination that should be carried out once an abnormality has been detected either through the history or through the screening examination (GALS). REMS involves the examination of a group of joints that are linked by function, and may sometimes require a detailed neurological and vascular examination.

REMS was born out of a desire to standardise and simplify examination of the musculoskeletal system, allowing for more systematic teaching and learning for medical students. It is now being used more widely within medical practice and members of the wider musculoskeletal team. It was developed through a national consensus process involving UK consultants in rheumatology, orthopaedics and care of the elderly, and selected general practitioners ⁽¹⁾. 

There are some key stages which need to be completed during an examination of the joints in any part of the body:

• Introduce yourself.
• Look at the joint(s).
• Feel the joint(s).
• Move the joint(s).
• Test function of the joint(s).
• Perform special tests if relevant.

References: ⁽¹⁾ Coady D, Walker D and Kay L, 2004. Regional Examination of the Musculoskeletal System (REMS): a core set of clinical skills for medical students. Rheumatology, 43(5), pp.633-639.

As highlighted in the GALS screening assessment, it is important to introduce yourself, explain to the patient what you are going to do (and why), gain verbal consent to examine, and ask the patient to let you know if you cause them any pain or discomfort at any time.

The examination should always start with a visual inspection of the exposed area at rest. Compare one side with the other, checking for symmetry. You should look specifically for skin changes, muscle bulk, and swelling in and around the joint. Look also for deformity in terms of alignment and posture of the joint.

Using the back of your hand, feel for skin temperature across the joint line and at relevant neighbouring sites. Any swellings should be assessed for fluctuance and mobility. The hard, bony swellings of osteoarthritis should be distinguished from the soft, rubbery swellings of inflammatory joint disease. Tenderness is an important clinical sign to elicit – both in and around the joint. Identifying inflammation of a joint (synovitis) relies on detecting the triad of warmth, swelling and tenderness.

The full range of movement of the joint should be assessed. Compare one side with the other. Generally, both active movements (where the patient moves the joint themselves) and passive movements (where the examiner moves the joint) should be performed. If there is a loss of active movement, but passive movement is unaffected, this may suggest a problem with the muscles, tendons or nerves rather than the joints themselves, or it may be an effect of pain in the joints. In certain instances, joints may move further than expected – this is called hypermobility.

It is important to elicit a loss of full flexion or a loss of full extension as either may affect function. A loss of movement should be recorded as mild, moderate or severe. Specialists may often document how many degrees of movement are restricted since this allows future comparison to be made. The quality of movement should also be recorded, with reference to abnormalities such as increased muscle tone or the presence of crepitus. With experience it is possible to assess the quality particularly at the extremes or ‘end range’ of movement. A degenerative joint often has a more solid ‘end feel’.

It is important to make a functional assessment of the joint – for example, in the case of limited elbow flexion, does this make it difficult for the patient to bring their hands to their mouth? In the case of the lower limbs, function mainly involves gait and the patient’s ability to get out of a chair and walk.

Several additional tests may be used by experienced musculoskeletal practitioners as an adjunct to the REMS examination. Known as ‘special tests’, these are often performed towards the end of the examination and would follow on from ‘Move’ and ‘Function’.