CHAPTER 311 APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERS • • Musculoskeletal complaints account for a lot of consultations Usually self

-limited but may be serious as to require further evaluation and additional laboratory tests Goals of Clinician  Accurate diagnosis  Timely provision of therapy  Avoidance of unnecessary diagnostic testing Approach  Anatomic localization of complaint  Aricular  Non-articular  Determination of the nature of the pathologic process  Inflammatory  Non-inflammatory Determination of the extent of involvement  Monoarticular  Polyarticular  Focal  Widespread Determination of chronology  Acute  Chronic Formulation of differential diagnosis

(+) Locking or deformity INFLAMMATORY VS. NON-INFLAMMATORY Inflammatory Causes  Infection  Crystal-induced (pseudo-/gout)  Immune-related (SLE)  Reactive (RF, Reiter’s)  Idiopathic Characteristics   Inflammation Systemic sx

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(+)Crepitation (+)Instability

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(-) Deformity PE findings remote from joint capsule

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Morning stiffness (precipitated by rest)  Fatigue  Fever  Weight loss Lab evidence of inflammation

Non-inflammatory Trauma (rotator cuff tear) Ineffective repair (OA) Neoplasm (villonodular synovitis) Pain amplification (fibromyalgia) Pain without swelling or warmth (-) inflammatory or systemic features Minimal morning stiffness (in OA, relieved by rest) Normal or negative laboratory investigations (for age)

   

↑ESR ↑CRP ↑WBC ↓RBC ↓Albumin

 •

“Red Flag” Diagnoses (conditions that must be diagnosed promptly or avoid significant morbid or mortal sequelae)  Septic arthritis  Acute crystal-induced arthritis (gout)  Fracture May be suspected by an acute onset, monoarticular or presenting complaint.

ALGORITHM FOR DIAGNOSIS OF MUSCULOSKELETAL COMPLAINTS 1. Initial rheumatic history and PE a. Is it articular? NO (proceed to number 2) YES (proceed to number 3) b. Chronology? c. Inflammation present? d. How many joints are involved?


Evaluation of a patient with musculoskeletal complaints  History  Comprehensive physical exam  Laboratory testing 3. of patient’s complaint NONARTICULAR  Supportive intraarticular ligaments  Ligaments  Tendons  Bursae  Muscle  Fascia  Bone  Nerve  Overlying skins  Point or focal tenderness in regions  Painful on active motion  (-) Crepitus  (-) Instability

Non-Articular, Consider the following: • Trauma/fracture • Fibromyalgia • Polymyalgia rheumatica • Bursitis • Tendinitis Articular: Is complaint > 6 weeks? NO (proceed to number 4) YES (proceed to number 5) Acute Articular (<6 weeks), consider: • Acute arthritis • Infectious arthritis • Gout • Pseudogout • Reiter’s syndrome • Initial presentation of chronic arthritis Chronic Articular (>6 weeks) a. Is inflammation present?  Is there prolonged morning stiffness?  Is there soft tissue swelling?  Are there systemic symptoms?  Is the ESR or CRP elevated? NO (proceed to number 6) YES (proceed to number 7)

ARTICULAR VS. NONARTICULAR • Discriminate anatomic site(s) of origin ASPECTS ARTICULAR Structures  Synovium  Synovial fluid  Articular cartilage  Intraarticular ligaments  Joint capsule  Juxtaarticular bone



Characteristics of disorder

Deep or diffuse pain Limited ROM on active and passive movement



a. b. 7.

Osteoarthritis (DIP, CMC, hip or knee joints involved) Osteonecrosis or Charcot arthritis (other joints involved)

Onset  Abrupt onset  Septic arthritis  Gout  Indolent onset  OA  RA  Fibromyalgia Evolution

Chronic Inflammatory Arthritis How many joints are involved? a. 1-3 joints (Go to number 8) b. >3 joints (Go to number 9) MONOARTICULAR/OLIGOARTICULAR CHRONIC INFLAMMATORY Arthritis, consider the follwing:  Indolent infection  Psoriatic arthritis  Reiter’s syndrome  Pauciarticular JA POLYARTICULAR: Chronic inflammatory polyarthritis



a. b.

ASYMMETRIC Chronic Inflammatory Polyarthritis  Psoriatic arthritis  Reiter’s syndrome Symmetric (go to number 10) •

Chronic  OA  Intermittent  Gout  Migratory  Rheumatic fever  Gonococcal arthritides  Viral arthritides  Additive  RA  Reiter’s syndrome Duration  Acute  Chronic

10. SYMMETRIC Chronic inflammatory Polyarthritis a. Rheumatoid arthritis (PIP, MCP, MTP joints involved) b. SLE, Scleroderma, Polymyositis (other joints)
CLINICAL HISTORY • PATIENT’S PROFILE  Age  Young  SLE  Rheumatic fever  Reiter’s syndrome  Middle age  Fibromyalgia  Old  Osteoarthritis  Polymyalgia  Sex  Male  Gout  Spondyloarthroathies Reither’s syndrome)  Female  RA  Fibromyalgia

NUMBER  Monoarticular (one joint)  Trauma  Gout  Oligoarticular or Pauciarticular (2-4 joints)  Polyarticular (>4 joints)  Polymyositis  RA  Fibromyalgia DISTRIBUTION  Upper Extremities: RA  Lower Extremities: Reiter’s syndrome & Gout  Axial skeleton: OA and Ankylosing spondylitis



Race  Whites  Polymyalgia rheumatica  Giant cell arteritis  Wegener’s granulomatosis  African Americans  Sarcoidosis  SLE Family history  Ankylosing spondylitis  Gout  RA  Heberden’s nodes


• PRECIPITATING EVENTS CONDITIONS CULPRIT DRUGS Arthralgias Quinidine Vaccines Cimetidine Rifabutin Quinolones Amphotericin B Chronic acyclovir IL-2 Nicardipine Myalgias/ Colchicine Pravastatin myopathy Hydrochloroquiine Levostatin Alcohol Simvastatin Glucocorticoids Docetaxel Penicillamine Taxol IL-2 Interferon Cocaine Clofibrate Azathioprine Quinolone Gout Cytotoxics Cyclosporine Alcohol Aspirin Diuretics Moonshine Ethambutol Drug-induced Chlorpromazine Methyldopa lupus Hydralazine Procainamide Isonized Phenytoine Lithium Penicillamine Infliximab Quinidine Tetracycline Osteonecrosis Radiation Alcohol Glucocorticoids Osteopenia Phenytoin Methotrexate Glucocorticoids Chronic heparin Scleroderma Bleomycin Pentazocine Organic solvent Vinyl chloride Rapeseed oil Carbidopa


Tryptophan Thiazides Allopurinol Penicillamine

Cocaine Ampetamine PTU

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Trauma Antecedent or intercurrent illnesses

RHEUMATIC REVIEW OF SYSTEMS  Fever  SLE  Infection  Rash  SLE  Reiter’s syndrome  Dermatomyositis

Synovial effusion (True articular swelling) vs. Synovial proliferation (Nonarticular or Periarticular involvement) Synovial Effusion Synovial Proliferation From true articular swelling From non-articular or periarticular involvement Does not extend beyond Extends beyond normal joint normal joint margins or full margins or full extent of the extent of the synovial space synovial space Limited ROM on active and Passive motion not as painful passive motion as active motion (+) Bulge sign (+) Ballotement (+) Flexion contractures Assess strength, atrophy, pain or spasm Muscle strength Muscle Grade Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

• •

Myalgias, weakness  Polymyositis  Polymyalgia rheumatica Morning stiffness  Inflammatory arthritis Eye    involvement Behcet’s disease Sarcoidosis Reiter’s syndrome

Assessment No movement Trace movement or twitch Movement with gravity eliminated Movement against gravity only Movement against gravity and resistance Normal strength

GIT involvement  Scleroderma  IBD GUT involvement  Reiter’s syndrome  Gonococcemia Nervous system involvement  Lyme disease  Vasculitis

LABORATORY INVESTIGATIONS • Candidates for evaluation  Monoarticular conditions  Traumatic conditions  Inflammatory conditions  Conditions accompanied by neurologic changes or systemic manifestations of serious disease  Individuals with chronic symptoms especially when there has been a lack of response to symptomatic measures • • Extent and nature of additional investigation should be dictate by clinical features Indications for laboratory tests  Confirm specific clinical diagnosis  Evaluate patients with vaque rheumatic complaints Lab      tests done CBC WBC with differential ESR CRP Uric acid (in cases of gout)

PHYSICAL EXAMINATION DIAGNOSTIC DEFINITION SIGNS Crepitus Palpable or vibratory crackling sensation elicited with joint motion Subluxation Alteration of joint Dislocation Abnormal displacement of articulating surface ROM Arc of measurable movement through which the joint moves in a single plane Contracture Loss of full movement resulting from a fixed resistance due to tonic spasm of muscle (reversible) or to fibrosis of periarticular structures (permanent) Reflect trauma or antecedent synovial inflammation Deformity Abrnomal shape or size from  Bony hypertrophy  Malalignment of articulating structures  Damage to periarticular supportive structures Indicates long-standing or aggressive pathologic process Enthesitis Inflammation of enthuses (tendinous or ligamentous insertions on bone) Epicondylitis Infection or inflammation involving an epicondyle • Most joints are examined except for axial (zygapophyseal) and inaccessible joints (sacroiliac and hip joint) • • Determine presence of pain, warmth, erythema or swelling Assess number of joints involved and pain intensity

Serologic tests  Rheumatoid factor (BUT also found in 4-5% of healthy population): only 1% have RA  Antinuclear antibodies

   

Found in 4-5% of healthy population (only 0.4% have SLE)  Found in nearly all patients with SLE  Seen in patients with autoimmune diseases (polymmyositis, scleroderma, APAS)  Seen in drug-induced lupus (Hydralazine, Procainamide, Quinidine)  Seen in chronic hepatitic or renal disorders Complement levels Lyme and antineutrophil cytoplasmic antibodies Antistreptolysin O IgM Rheumatoid factor  Found in 80% of patients with RA  Seen in low titers in patients with chronic infections (TB, leprosy, pulmonary, hepatic and renal diseases) and autoimmune diseases (Sjogren’s syndrome, SLE) Immunofluorescence pattern

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Peripheral or rim pattern (most specific and suggestive of anti-dsDNA antibodies): seen in SLE patients Diffuse and speckled (least specific)

Aspiration and analysis of synovial fluids  Appearance  Viscosity  Cell count The following are usually not recommended since they are insensitive and have little discriminatory value:  Glucose  Protein  LDH  Lactic acid

Pseudogout (Calcium pyrophosphate dehydrate = short, rhomboid-hspaed, positively bifringent crystals) • Chondrocalcinosis (Calcium pyrophosphate dehydrate) PMNs without crystals (Go to number 7)


PMNs without crystals: WBC > 50,000/µL? PMNs without crystals only

• Probable Inflammatory arthritis PMNs without crystals with high WBC • Possible septic arthritis

Autoantibodies Inflammatory (Effusions) Turbid, yellow Normal viscosity WBC = 2000-5000/µL (PMNs) RA Gout CT diseases Infectious

 Opaque, purulent Low viscosity WBC >50,000/µL (PMNs) Septic arthritis Psoriatic arthritis 

Purpose: Diagnosis and staging of articular disorders Indications:  History of trauma  Suspected chronic infection  Progressive disability  Monoarticular involvement  When therapeutic alterations are considered  When baseline assessment is desired Expected results  Soft tissue swelling or juxtaarticular demineralization  Calcification of soft tissues, cartilage, bone  Joint space narrowing  Erosions  Bony ankylosis  New bone formation (sclerosis, osteophytes or periostitis)  Subchondral cysts

Non-inflammatory Clear, amber-colored Viscous (with stringing effect) WBC < 2000/µL Mononuclears Normal OA/Osteonecrosis Charcot’s arthritis

Hemorrhagic synovial fluid seen in trauma, hemarthrosis or neuropathic arthritis Algorithm for Synovial Fluid Aspiration and Analyis 1. Indications for synovial fluid aspiration and analysis a. Monoarthritis (acute or chronic) b. Trauma with joint effusions c. Monoarthritis in a patients with chronic polyarthritis d. Suspicion of joint infection, crystal-induced arthritis, or hemarthrosis 2. Analyze fluid for: a. Appearance, viscosity b. WBC count, differential c. Gram stain, culture and sensitivity (if indicated) d. Crystal identification by polarized microscopy Is the effusion hemorrhagic? Hemorrhagic Effusions due to: • Trauma or mechanical derangement • Coagulopathy • Neuropathic arthropathy Non-hemorrhagic: (proceed to number 4)

ULTRASONOGRAPHY  Purpose: Detection of soft tissue abnormalities not fully appreciated by clinical examination  Indications:

  •

Diagnosis of Baker’s cysts (synovial cysts) Evaluation of rotator cuff tears Evaluation of tendon injuries


RADIONUCLIDE SCINTIGRAPHY  Purpose: Provides useful information regarding the metabolic status of the bone  Indications:  Total-body assessment of extent and distribution of musculoskeletal involvement


(Non-hemorrhagic) Inflammatory or non-inflammatory articular condition: WBC > 2000/µL? Non-inflammatory arthritis • Osteoarthritis • Trauma Inflammatory/Infectious arthritis: (go to no 5) (Inflammatory/Infectious arthritis) PMNs present? No PMNs • See causes of non-inflammatory arthritis (+) PMNs (Proceed to number 6) (with PMNs): are there crystals? PMNs with crystals

Pertechnate or Diphosphonate scintigraphy (99mTc)  Metastatic bone survey  Evaluation of Piaget’s disease  Quantitative joint assessment  Acute infection  Acute and chronic osteomyelitis


In-WBC superior to Ga in early diagnosis of osteomyelitis and infected prosthetic joints affected by prior treatment with antbitoics) ⇒ Acute infection ⇒ Prosthetic infection ⇒ Acute osteomyelitis Bnds to serum and cellular transferring and lactoferrin;


Gout (Monosodium urate: long, needle-shaped, negatively bifringent intracellular crystals)



 

Taken up by neturophils, macrophages, bacteria and tumor tissue Afected by prior treatment with antbitoics) ⇒ Acute and chronic infection ⇒ Acute osteomyelitis

• • •

COMPUTED TOMOGRAPHY (CT)  Purpose: Assessment of axial skeleton  Advantages:  Provides rapid reconstruction of sagittal, coronal and axial images and spatial relationships among anatomic structures  Indications:  Herniated intervertebral disks  Low back pain syndromes  Sacriliitis  Spinal stenosis  Spinal trauma  Ostoid osteoma  Tarsal coalition  Osteomyelitis  Intraarticular osteochondral fragments  Advanced osteonecrosis  Helical or spiral CT  Diagnosis of pulmonary embolism or obscure fractures  Rapid, cost-effective and sensitive  High-resolution CT  Evaluation of suspected or established infiltrative lung disease (Scleroderma, Rheumatoid lungs) MAGNETIC RESONANCE IMAGING (MRI)

↓ANA Exclude common geriatric musculoskeletal disorders Emphasize on identifying rheumatic consequences intercurrent medical conditions and therapy Common diseases in the elderly  OA  Osteoporosis  Gout  Pseudogout  Polymyaliga rheumatica  Vasculitis  Drug-induced SLE  Chronic salicylate toxicity

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APPROACH TO REGIONAL RHEUMATIC COMPLAINTS • History  Pattern of onset  Evolution  Localization • Selected maneuvers/tests Hand Pain • Focal or unilateral hand pain  Trauma  Overuse  Infection  Reactive or crystal-induced arthritis • Bilateral hand complaints  Degenerative: OA

Purpose: Image musculoskeletal systems Advantages  Provide multipanar images with fine anatomic detail and contrast resolution  No ionizing radiation and adverse effects  Has superior ability to visualize bon marrow and soft tissue periarticular structures Disadvantages  High cost  Long procedural time Features  Can image fascia, vessels, nerve, muscle, cartilage, ligaments, tendons, pannus, synovial effusions, bone marrow

Systemic or inflammatory/immune: RA Distribution Joints Involved DISEASE DIP PIP MCP Reiter’s syndrome SLE Hemochromatosis Gonococcal arthritis Juvenile arthritis CTS OA (1st CMC also) Psoriatic arthritis RA Pseudogout


Sensitive to changes in marrow, fat BUT not specific in detecting osteonecrosis and osteomyelitis More sensitive than arthrography or CT in diagnosis of soft tissue injury, intraarticular derangements and spinal cord damage, subluxation, or synovitis

Indications  Avascular necrosis  Osteomyelitis  Intraarticular derangement and soft tissue injury  Derangements of axial skeleton and spinal cord  Herniated pigmented villonodular synovitis  Inflammatory and metabolic muscle pathology

DeQuervain’s tendinitis  Focal wrist pain localized to the radial aspect resulting from inflammation of the tendon sheaths involving APOL or EPOB  Due to overuse or follows pregnancy  Diagnosis by Finkelstein’s test


Positive: wrist pain induced after the thumb is flexed across the palm and placed inside a clenced fist and the patient actively deviates the hand downward with ulnar deviation at the wrist

 RHEUMATOLOGIC EVALUATION OF THE ELDERLY • Incidence of rheumatic diseases increases with age

Carpal Tunnel Syndrome  Due to compression of median nerve within the carpal tunnel  Clinical Manifestations:

Signs and symptoms are insidious, chronic or overshadowed by comorbidities compounded by diminished reliability of laboratory testing in the elderly since they have nonpathologic abnormal results

Paresthesia in the thumb, 2nd, 3rd and radial half of the 4th finger

⇒ 

Atrophy of thenar musculature    Complete tear is common in the elderly Results from trauma Diagnosis: Drop arm test ⇒ Inability to maintain arms outstretched once it is passively abducted

Associated with the following ⇒ Pregnancy ⇒ Edema ⇒ Trauma ⇒ OA ⇒ Inflammatory arthritis ⇒ Infiltrative disorders (amyloidosis) Diagnosis by Tinel’s test or Phalen’s sign ⇒ Paresthesia in median nerve distribution induced or increased by either thumping the volar aspect of the wrist (TInel’s sign) or pressing the extensor surfaces of both flexed wrists against each other (Phalen’s test)

Positive: If patient is unable to hold arm up once 90° of abduction is reached

Confirmed by MRI or arthrography

Knee Pain • History  Chronology of knee complaint  Predisposing conditions  Trauma  Medications • Physical Examination

Shoulder Pain • History  Trauma  Infection  Inflammatory disease  Occupational hazards  Previous cervical disease  Activities that elicit shoulder pain • Physical Examination  Frequently referred to the cervical spine from the intrathoracic lesions (Pancoast tumors) or from gall bladder, hepatic or diaphragmatic disease  Test full ROM  Manual inspection  Direct manual pressure  Subacromial bursitis: pain lateral to and immediately beneath the acromion upon palpation

Knee position inspected in the upright (weight-bearing) and prone positions for swelling, erythema, contusion, laceration, or malalignment (genu varum or bowlegs & genu valgum or knock knees) Bony swelling of the knee joints  Hypertrophic osseous changes (OA and neuropathic arthropathy)  Fluctuant  Ballotable  Soft tissue enlargement in the suprapatellar pouch (superior reflection of the synovial cavity) or lateral and medial to the patella

Bicipital tendinitis: pain in the bicipital groove while rotating the humerus internally and externally upon palpation Palpation of acromioclavicular joint  Local pain  Bony hypertrophy  Synovial swelling  Site of OA and RA Palpation of glenohumeral joint (anterior over humeral head, medial and inferior to the coracoid process)  Pain upon rotating the humerus internall and externally  Indicative of glenohumeral pathology

Diseases  Synovial effusions  Ballotement  Bulge sign: with extended knee, milk synovial fluid down from suprapatellar pouch LATERAL to the patella and observe fluid shift to the medial aspect; useful in assessing small to moderate effusions (<100 mL)

Popliteal or Baker’s cyst  Palpated with knees partially flexed and best seen with the patient standing and knees fully extended to visualize popliteal swelling or fullness from posterior view Anserine Bursitis  Pes anserine bursa: underlies the semimembranous tendon  Often missed periarticular cause of knee pain in adults  Cause  Trauma  Overuse  Inflammation  Clinical Manifestation  Point tenderness inferior and medial to the patella and overlies themedial tibial plateau  Knee pain Prepatellar bursa  Superfical pain in inferior portion of the patella Infrapatellar bursa  Deep pain beneath the patellar ligament before its insertion on the tibial muscle Pain, stiffness, swelling, warmth  RA  Gout

Synovial effusion  Seldom palpable  Suggests infection, RA or acute tear of rotator cuff Rotator cuff tendinitis  Common cause of should pain  Rotator cuff ⇒ Supraspinatus ⇒ Inraspinatus ⇒ Teres minor ⇒ Subscapularis     Pain on active abduction Pain over lateral deltoid Night pain Impingement sign: raising the arm into forced flexion while stabilizing and preventing rotation of scapula

Positive: Pain before 180° of forward flexion

 

Reiter’s syndrome

Internal derangement of the knee from trauma or degenerative process  Damage to the meniscal cartilage (medial or lateral)

  

History of trauma or athletic activity Chronic or intermittent pain With symptoms of “locking”, clicking, or “giving away” of the joint Pain on palpation over the medial or lateral joint line Diagnosis: ipslateral joint line pain when the joint is stressed laterally or medially Positive McMurray test indicates meniscal tear (knees flexed at 90° and leg is extended while simultaneously LE is being torqued medially or laterally

 

⇒ ⇒

Painful click during INWARD rotation → LATERAL meniscus tear Pain during OUTWARD rotation → MEDIAL meniscal tear

Damage to cruciate ligament  Acute onset of pain and welling  History of trauma  Synovial fluid aspirate of gross blood  (+) Drawer sign: patient in recumbent, knees are partially flexed and foot stabilized; displace tibia anteriorly or posteriorly ⇒ Anteior movement: Anterior cruciate ligament damage ⇒ Posterior movement: Posterior cruciate ligament damage

Hip Pain

• • •

Best evaluated by observing gait and addressing range of motion Localized unilaterally With or without low back pain With radiation to posterolateral thigh Due to degenerative arthritis of lumbosacral spine With dermatomal distribution (L5 to S1) No warmth and swelling Limited ROM due to pain Pain located anteriorly over inguinal ligaments which may radiate medially to the groin or along anteromedial thigh May mimic iliopsoas bursitis Diagnosis of iliopsoas bursitis

• • • • •

  

History of trauma or inflammatory arthritis Pain localized to the groin or anterior thigh Pain worsens wit hyperextension of the hippatients prefer to felx and externally rotate the hip to reduce pain

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