Rheumatology: the science that deals with the diseases affecting the joints, bones,

muscles, and ligaments, be it inflammatory, mechanical, traumatic, etc.

Complaints in rheumatology:

Pain: most common complaint | SOCRATES

o Acute: gout, pseudogout, trauma, septic arthritis, etc.
o Chronic, SLE, rheumatoid arthritis, osteoarthritis, etc.
o Lumbar pain radiating to below the knee with paresthesia and numbness
suspect disc prolapse.
Stiffness
o Not only joints get stiff, but so do muscles, e.g., polymyalgia rheumatica
o Differentiates inflammatory and non-inflammatory diseases
> 30 min morning stiffness inflammatory

but because of pain

Swelling
o Acute: hemarthrosis (e.g., in hemophiliacs), septic arthritis
o Chronic/gradual: RA, OA, etc.
Erythema:
o Acute erythema + pain, swelling, etc. gout, septic arthritis, etc.
Weakness:
o Tends to be the domain of neurologists
o E.g., polymyositis, dermatomyositis, inclusion body myositis
o The patient perform activities such as dressing themselves, combing
their hair, sit and stand, etc.
Past medical history: same as usual, with some additional points

History of musculoskeletal disease

Trauma
Chronic medical conditions as they may be associated

Surgical history: relevant surgeries are especially important (musculoskeletal surgeries),

e.g., total joint replacement
Drug history:

Medications may be associated with rheumatological diseases, weakness, and

osteoporosis
 The most severe adverse effect of statins is myotoxicity, in the form of
myopathy, myalgia, myositis or rhabdomyolysis
Chemotherapy can cause osteonecrosis.

Family history

Diseases that tend to be familial or run in families, such as osteoarthritis, gout,

rheumatoid arthritis
Hereditary diseases, e.g., osteogenesis imperfecta, Marfan syndrome, Ehlers-
Danlos syndrome, etc.
Social history

Occupations, present and past

Smoking: important risk factor for rheumatoid arthritis
Alcohol: associated with gout
General examination
Face:

Malar rash: SLE (DDX: cellulitis, rosacea, erysipelas, dermatomyositis, and pellagra)
Saddle nose: vasculitis
heliotrope rash: a reddish purple rash on or around the eyelids, often accompanied by
swelling dermatomyositis
systemic sclerosis: beaked nose, small mouth, shiny tight skin
telangectasias
discoid lupus on the face
Lupus pernio (bluish-red or violaceous nodules and plaques over the nose, cheeks and
ears) in sarcoidosis
Eye problems may be present in rheumatology, e.g., pain, redness, etc.
Lupus mouth ulcers, aphthous ulcers

Hands:

Deformities, e.g.,
o Rheumatoid arthritis: Swan-neck deformity, Z-shaped deformity of the thumb,
boutonniere deformity, wrist radial deviation and MCPJ ulnar deviation,
subluxation (wrist, MCPJ), rheumatoid nodules
o Osteoarthritis: Heberden (distal I-P joint) and Bouchard (proximal I-P joint)
nodes.
if present at the time of presentation; purplish/whitish
discoloration
o Cold (and emotional) stimuli may trigger vasospasm, leading to the
characteristic sequence of digital pallor due to vasospasm, cyanosis due to
deoxygenated blood, and rubor due to reactive hyperemia.
Nail and nail bed:
o examine in psoriasis for nail pitting, oil spots (salmon patch), onycholysis with
proximal red rim, splinter hemorrhages, subungual debris (Subungual
hyperkeratosis)
o peri-ungual telangectasias in systemic sclerosis (best seen with the aid of an
ophthalmoscope or other form of magnification)

ropathy in SLE

Vital signs:

Pulse rate
Temperature: important in septic arthritis
Blood pressure:
o Systemic sclerosis can lead to increased blood pressure
o Medications such as steroids can lead to increased blood pressure
Respiratory rate: the lungs can be involved by rheumatological diseases
Local (joint) examination
• Inspection (look)
• Palpation (Feel)
• Movement (move)
• Specific examinations for each joint.
While you can only examine the joint of complaint, in some diseases such as RA it’s
important to examine other joints as well.
Inflammatory arthritis can be very painful, so being gentle is important.
 Dr. Niaz practical history and examination

Locomotor
symptoms

Peripheral joints Spine

Mechanical: OA, Inflammatory

Mechanical: OA,
trauma trauma, DH, spasm

Septic: acute, Inflammatory (4

chronic; bacterial, Nonseptic groups):
viral, fungal Infection
(brucellosis, TB);
tumor (primary,
e.g., multiple
Crystal-induced arthropathies: gout, myeloma, or
pseudogout secondary, e.g., Ca
prostate in men, Ca
breast in women);
SNSAP;
vasculitis (e.g.,
Immune Behcet)
OA: osteoarthritis | RA: disturbance:
rheumatoid arthritis | SNSAP:
RA;
seronegative
spondyloarthropathy | JIA: SNSAP;
SNSAP:
juvenile idiopathic arthritis | JIA;
CTD: connective tissue Reactive arthritis,
Vasculitis;
disease Ankylosing spondylitis,
CTD
Enteropathic arthropathy,
Polymyositis
Psoriatic arthritis
etc.
(domain of orthopedics if peripheral joint pain, and neurology if spinal pain) or
inflammatory:

How to differentiate mechanical and inflammatory pain:

History
o Is the pain worsened by rest (inflammatory) or movement (mechanical)
(or is the pain relieved by movement or rest, respectively)?
Pain worsened by rest may wake the patient up from sleep
o Is there morning stiffness? (inflammatory)
Mechanical
Not to be confused with the gel phenomenon of advanced
osteoarthritis; a short duration stiffness could still be due to
inflammatory disease that is responding to medications
Examination
o Signs of joint inflammation: redness, hotness, joint-line tenderness
The signs of inflammation include redness, hotness, swelling,
tenderness, and loss of function. Swelling and loss of function are
present in mechanical disease, but not redness, hotness, and
joint-line tenderness.
Peripheral inflammatory joint pain: the history of present illness consists of two parts:

Details of locomotor complaint:

o Number of joints affected (mono, oligo [2-4], poly [5 or more])
o Migratory or additive
Migratory: pain and swelling in one joint, then the pain and
swelling goes to another join
the first joint (in hours, days, or weeks)
Has monoarthritis at the time of presentation but in the
history, other joints were involved previously
o
additive and you bother checking if
migratory or additive
DDX:
o Rheumatic fever
o Gonococcal arthritis
o Enteropathic arthropathy
Additive: new joints are added on but the previous joints are still
affected.
Symmetrical (same joints on both sides) or asymmetrical
Small joints, large joints, or both
 Upper limb, lower limb, or both
Extraarticular findings:

Note: ask if temporally related to the locomotor complaint

o Hair loss: CTD, SLE, systemic sclerosis, rheumatoid arthritis (could be a
side effect of medications), vasculitis
o Eye problems
Vasculitis: uveitis
SNSAP: uveitis
Rheumatoid arthritis: scleritis and episcleritis
SLE: reactive conjunctivitis

o Mouth ulcers, e.g., SLE, systemic sclerosis, vasculitis, reactive arthritis,

Enteropathic arthropathy (IBD)
o Photosensitivity (do you get burns when you go out in the sun?)
o Skin rash
Rheumatoid arthritis: rheumatoid nodules
SLE: discoid rash
Psoriatic arthritis: rash of psoriasis
Behce disease: acne, erythema nodosum
Enteropathic arthropathy (IBD): erythema nodosum, pyoderma
gangrenosum
o Bloody diarrhea, severe UTI (related to reactive arthritis, preceding its
onset by 1-2 months)
o History of IBD (related to Enteropathic arthropathy)
Differential diagnoses:

Monoarthritis
o Mechanical
o Inflammatory
Septic arthritis
Crystal-induced arthritis
Immune-disturbances are less likely; they atypically present with
monoarthritis
Oligoarthritis:
o Mechanical: less likely
o Inflammatory
Septic arthritis: less likely
Crystal-induced arthritis: less likely
Immune disturbances: mainly SNSAP
 o Polyarthritis:
Acute
First DDX: viral infection (HCV, HBV, HIV, COVID-19)
Rheumatoid arthritis
Connective tissue disease
Psoriatic arthritis: 5% present with symmetrical
polyarthritis similar to rheumatoid arthritis
Primary nodular osteoarthritis (familial)
Chronic tophaceous gout
Sarcoidosis
Vasculitis
Chronic: same differential diagnosis as acute, but viral infection
goes to the end of the list.
Spinal pain:

1)

2) if inflammatory, you have to know the presentations of the different causes of inflammatory
spinal pain and ask direct questions about these symptoms

Infections:
o Fever: Present in regular inflammatory processes as low-grade continuous fever.
In brucellosis and tuberculosis, there is sweating, worse at night
o Brucellosis can also affect the hip, ankle, shoulder, and other joints.
al joints
o Features of pulmonary tuberculosis, e.g., cough, hemoptysis, weight loss, etc.
Tumors:
o Old age
o History of cancer
o Anorexia, weight loss, and inflammatory back pain tumor of the spine
(extra) another criteria that relies on a scoring system
diagnosis

SNSAP:
o Reactive arthritis:
Bloody diarrhea or severe UTI 1-2 months before the onset
Characteristic fever: high grade (39-40°), intermittent fever, causing 3-4
attacks a day each lasting 2-3 hours
Red eyes
Mouth ulcers
Genital ulcers
Skin rash: erythematous skin rash all over the body, particularly during
attacks of fever
Generalized lymphadenopathy and hepatosplenomegaly.
o Psoriatic arthritis: history of psoriasis (psoriasis rash)
o Enteropathic arthropathy: history of IBD
o Ankylosing spondylitis: diagnosed according to criteria

ARC criteria of ankylosing spondylitis

Major criteria: radiological findings of sacroiliitis
o Grade 1: pseudowidening
o Note: inflammation produces osteopenia of surrounding joint, which
appears dark on the x-ray, and this darker bone may be mistaken for joint
space and hence make you think the joint space has widened
o Grade 2: narrowing sclerosis
o Grade 3: narrowing, sclerosis, and erosion
 o Grade 4: loss of joint space, fused/ankylosed
Grade 1 or 2 bilaterally, grade 3 or 4 unilateral
Minor criteria (clinical criteria):

o Inflammatory back pain

o Decreased chest expansion (assessed by measuring chest expansion with a tape
measure at full inspiration and expiration at the 4th intercostal space; normal
chest expansion os > 2.5 cm)
o Decreased lumbar motion (assessed by )
Note: early on, there is only inflammatory back pain, but decreased chest expansion
and decreased lumbar motion develops later on in the disease
A diagnosis is made with the major criteria with one minor criteria

a decrease in lumbar spine

range of motion (flexion), most commonly as a result of ankylosing spondylitis.

Patient is standing, examiner marks the L5 spinous process by drawing a

horizontal line across the patients back.
A second line is marked 10 cm above the first line.
Patient is then instructed to flex forward as if attempting to touch his/her toes,
examiner remeasures distance between two lines with patient fully flexed.
The difference between the measurements in erect and flexion positions
indicates the outcome of the lumbar flexion. An increase of less than 5cm is a
positive test and may indicate ankylosing spondylitis (AS).

Criteria for inflammatory back pain:

Morning Stiffness (more than 1 hour)

Aggravated by rest (extra: or does not improve with rest)
Relieved by exercise
More than 3 months of pain
 o AS is a diagnosis of exclusion; in these 3 months, other causes would have either

Examination

3 steps: look, feel, move (if you have Dr. Khalid, say inspection, palpation, move)

Look:

Skin overlying the joints

o Color, e.g., erythema (present in inflammatory but not mechanical disease)
o Ulcers
o Scars
o Hair distribution
Muscles around the joint: wasting and atrophy
Bones around the joint: deformity, swelling
The joint itself: deformity, swelling.

Feel

Temperature (hotness is another sign of inflammation)

o Assessed with the dorsum of the fingers
o Compare both sides: either use both hands simultaneously or feel with one
hand but alternate between the two sides
o Examine the joint, and distal and proximal to the joint

Tenderness: helps differentiate mechanical and inflammatory joint pain

o Palpate for joint-
o Joint-line tenderness: inflammatory disease
o Tenderness but not of the joint line: mechanical process (from periarticular, not
intraarticular, tissue)
Effusion:
techniques is enough.

Move: active then passive

Active
Passive
o Dr. Massar: always do both
o Dr. Niaz: do passive movement if there was restriction on active movement to
determine if the range of motion limitation is due to pain or a joint problem.
o Techniques for joint line tenderness:
Elbow: palpate for tenderness in the groove located dorsally
Start by palpating the posterior aspect: the three palpation
landmarks (the medial epi-condyle, the lateral epicondyle, and
the apex of the olecranon) form an equilateral triangle when
the elbow is flexed 90°, and a straight line when the elbow is in
extension. The points between the olecranon process, while the
elbow is in 90° of flexion, and the medial or lateral epicondyle,
represent the joint line of the elbow joint. If there is tenderness
elicited while palpating these points, it indicates elbow joint
arthritis. Otherwise, effusion may be elicited by palpation[1].

Wrist: examined with two hands. Palpate the wrist by placing your two
thumbs on the posterior aspect of the wrist and use your remaining
fingers to support the wrist. Ensure the arm is generally supported, such
as by resting the elbow on the arm of the chair.
MCP joints: squeeze the 4 joints to check for tenderness. If tenderness is
present, examine each one to determine which ones are tender
The shoulder consists of two joints, the acromioclavicular and
glenohumeral joints. The glenohumeral joints and hip joints are both
deep joints in which look and feel are not helpful; these may only
examined by movement.
Ankles: palpation for tenderness and swelling in the ankle is undertaken
medial and lateral to the extensor tendons on the anterior part of the
joint below the malleoli[1].
 Metatarsophalangeal joints: same as MCP

Patellar tap test (ballottement test):

squeezing the
upper thigh with your left hand and sliding your left hand down the thigh until you reach
the upper edge of the patella.
o Dr. Massar: start with the left hand on the upper thigh and the right hand on the
lower leg; move your hands down and up respectively till you reach the knee
joint, and then move your right hand into the proper position (with the thumb,
index and middle finger in the position described in the bullet point below)
WITHOUT letting go of the pressure of your hands.
Keep your hand there and, with the fingertips of your right hand (three fingers: thumb
and middle finger on either side of the joint, and the index over the patella), press
briskly and firmly over the patella (using the index finger) (Fig. 13.39)
Dr. Niaz and Massar: the patella can be felt going up and down/being balloted (+ve test)

(extra)

o Macleod: In a moderate-sized effusion you will feel a tapping sensation as the

patella strikes the femur.
o Tapping down the patella with the index to create an upward and downward
movement and/or a palpable 'click' as the patella hits the underlying femur.
o A positive test is defined as either rebounding movement of the patella or a
This test is assessed as present without click, present with
 that is, patella moving downwardly and then rebounded upon removing
pable click was felt as the

of the patella occurred and no click was felt[1].

Bulge test (extra):

compartment into the suprapatellar bursa and lateral side by stroking the medial side of
the knee (Fig. 13.40A).
Empty the suprapatellar bursa by sliding your hand down the thigh to the patella (Fig.
13.40B).
Without lifting your hand off the knee, extend your fingers (or thumb) to stroke the
lateral side of the knee (Fig. 13.40C).
The test is positive if a ripple or bulge of fluid appears on the medial side of the knee. It
is useful for detecting small amounts of fluid but may be falsely negative if a tense
effusion is present.
Hip: Internal and external rotation

Flex the knee and hip to 90°

One hand is on the thigh and the other grasps the lower leg medially for internal
rotation and laterally for external rotation [Dr. Niaz]
Normal ROM: internal rotation 30-40° | external rotation 40-60°
Acute osteoarthritis of the hip: limitation of internal rotation
Chronic osteoarthritis of the hip: limitation of internal AND external rotation.

tested with the leg extended by rolling the leg[1]

Miscellaneous notes:

Tumor lysis syndrome may occur spontaneously, but most commonly it occurs in
hematological malignancies such as lymphoma and leukemia, often 2-3 days after the
start of treatment.
Secondary gout develops as a complication caused by hyperuricemia caused by massive
tumor cell death in tumor lysis syndrome[1]; this is a form of uric acid overproduction.
In addition to hyperuricemia, there is also hyperkalemia, hyperphosphatemia, and
hypocalcemia with various clinical consequences.
Spontaneous TLS can be the first presentation of underlying malignancy.
For example, a young patient presenting with gout may have underlying lymphoma that
has undergone tumor lysis syndrome; malignancy should be excluded in such patients.
24-hour urine uric acid collection
o Normally <800 mg/24 hour
o Overproduction: >800 mg/24 hour exclude malignancy
o Underexcretion: <800 mg/24 hour

Colchicine is an anti-neutrophil agent

Two diseases affecting the DIP of the hands: osteoarthritis and psoriatic arthritis.