INTERNAL MEDICINE - RHEUMATOLOGY

APPROACH TO ARTICULAR AND MSK DISORDER

Dr. Ruth Saguil-Sy August 25, 2022

EVALUATION OF PATIENTS WITH MSK COMPLAINTS

Goals: INFLAMMATORY VS. NONINFLAMMATORY
● Accurate diagnosis INFLAMMATORY NONINFLAMMATORY
● TImely provision of therapy
● Avoidance of unnecessary diagnostic testing Types Infectious Related to trauma,
Idiopathic repetitive use,
● Identification of acute, focal/monoarticular “red Crystal induced degeneration or
flag” conditions Immune related ineffective repair,
neoplasm or pain
Approach amplification
● Determine the chronology (acute vs. chronic)
● Determine the nature of the pathologic process Cardinal signs of Pain w/o swelling or
inflammation warmth
(inflammatory vs. noninflammatory)
● Determine the extent of involvement Systemic Present Absent
(monoarticular, polyarticular, focal, orwidespread) symptoms
● Anatomic localization of the complaint (articular vs. CRP, ESR Elevated Normal or decreased
nonarticular)
● Consider the most common disorders first Thrombocytos Yes No
is
● Consider the need for diagnostic testing
● Formulate a differential diagnosis Anemia of Yes No
chronic
disease
ARTICULAR VS. NONARTICULAR
ARTICULAR NONARTICULAR Daytime Gel Yes No
Phenomena
Location Synovium, synovial Supportive
fluid, articular cartilage, extra-articular
intra articular ligaments, tendons, ALGORITHM FOR THE DIAGNOSIS OF MSK
ligaments, bursae, muscle, fascia, COMPLAINTS (*last page)
joint capsule, juxta bone, nerve
articular bone and overlying skin

Character of Deep or diffuse pain Pain or focal

pain tenderness

Range of limited on active and painful on active but

motion passive movement not on passive

Swelling Yes Seldom

Crepitation Yes Seldom

I
Instability Yes Seldom

Deformity Yes Seldom

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 INTERNAL MEDICINE - RHEUMATOLOGY
APPROACH TO ARTICULAR AND MSK DISORDER
Dr. Ruth Saguil-Sy August 25, 2022
■ Intermittent: crystal or Lyme
MOST COMMON MUSCULOSKELETAL CONDITIONS arthritis
■ Migratory: rheumatic fever,
gonococcal or viral arthritis
■ Additive: RA, psoriatic arthritis
○ Duration
■ Acute: <6 weeks
■ Chronic: >6 weeks
● Articular disorders are classified based on the
number of joints FormP piponejoint
of ○ Monoarticular: One joint inareasila
○ Oligoarticular or pauciarticular: two or
three joints

O
○ Polyarticular: four or more joints
■ crystal and infectious arthritis are
often mono- or oligoarticular
■ OA and RA are polyarticular
● Nonarticular disorders may be classified as
either focal or widespread
○ Focal: tendinitis or carpal tunnel syndrome
○ Widespread: weakness and myalgia,
caused by polymyositis or fibromyalgia
● Anatomical locations involved:
CLINICAL HISTORY
○ Upper extremities: RA and OA
● Historic features may reveal important clues to the
○ Lower extremities: Reactive arthritis and
diagnosis
gout at their onset
● Patient profile:
○ Axial skeleton: OA and ankylosing
○ Age
spondylitis
○ Sex
● Drug-induced Musculoskeletal Conditions
○ Race
○ Familial aggregation
● Certain diagnoses are more frequent in different
age groups
○ SLE and reactive arthritis occur more
frequently in the young
○ Fibromyalgia and RA are frequent in
middle age
○ OA and polymyalgia rheumatica are
more prevalent among the elderly
● Chronology of the complaint can be divided into:
○ Onset
■ Abrupt onset: septic arthritis or
gout effusion, or bony enlargement
■ Indolent: OA, RA, and fibromyalgia
○ Evolution
■ Chronic: OA

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 INTERNAL MEDICINE - RHEUMATOLOGY
APPROACH TO ARTICULAR AND MSK DISORDER
Dr. Ruth Saguil-Sy August 25, 2022
Rheumatic Evaluation of the Elderly
● 58% of >65 yrs old
● Not usually diagnosed becaused signs and
symptoms may be insidious, overlooked or
overshadowed by comorbids
● Diminished reliability of laboratory testing
● Emphasis on identifying potential rheumatic
consequences of medical comorbids and therapies
Rheumatic Evaluation of the Hospitalized Patient
● Greater symptom severity
F
● More acute presentations
● Greater interplay of comorbidities
● Reason for admission
○ acute onset of inflammatory arthritis
○ undiagnosed systemic or febrile illness
○ musculoskeletal trauma
○ exacerbation or deterioration of an existing
autoimmune disorder
○ new medical comorbidities arising in
patients with an established rheumatic
disorder
● Febrile, multisystem disorders
○ require exclusion of crystal, infectious or
neoplastic etiologies
● Rheumatic disease patients admitted to the
hospital
○ Usually not for a medical problem related
to their autoimmune disease
○ Because of either a comorbid condition or
complication of drug therapy
● Patients with chronic inflammatory disorders
○ augmented risk of infection, cardiovascular
events and neoplasia
● Laboratory testing
○ often yield abnormal findings that are
better explained by the patient's
preexisting conditions rather than a new
inflammatory or autoimmune disorder.
PHYSICAL EXAMINATION
00
● Examination of involved and uninvolved joints will
determine whether pain, warmth, erythema, or
swelling is present
● Examination of 28 easily palpated joints (PIPs,
MCPs, wrists, elbows, shoulders, and knees) can
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quantify the number of tender or swollen joints
(0-28) involved
● Goals:
○ ascertain the structures
I
○ the nature the underlying pathology
○ the functional consequences of the
process
○ presence of systemic or extra-articular
I
manifestations
● Depends largely on careful inspection, palpation,
and a variety of specific physical maneuvers to
elicit diagnostic signs
● Patient will attempt to minimize the pain by
maintaining the joint in the position of least
intraarticular pressure and greatest volume,
usually partial flexion
○ inflammatory effusions may give rise to
flexion contractures
○ fluctuant or "squishy" swelling in larger
joints and grape-like compressibility in
smaller joints
● Active and passive range of motion should be
assessed in all planes with contralateral
comparison.
● GONIOMETER
- may be used to quantify the arc of
movement
● Extreme range of motion
- hypermobility syndrome, with joint pain
and connective tissue laxity
- Ehlers-Danlos or Marfan's syndrome.
● Limitation of motion
- inflammation, effusion, pain, deformity,
contracture or restriction from
neuromyopathic causes
O
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 INTERNAL MEDICINE - RHEUMATOLOGY
APPROACH TO ARTICULAR AND MSK DISORDER
Dr. Ruth Saguil-Sy August 25, 2022

*Contractures APPROACH TO REGIONAL RHEUMATIC COMPLAINTS

- may reflect antecedent synovial inflammation or HAND PAIN
trauma
7Should beunder
not captain
- Minor joint crepitus is common during joint
Focal or unilateral hand pain
- from trauma, overuse, infection, or a reactive or
palpation and maneuvers but only indicates crystal-induced arthritis
significant cartilage degeneration as it becomes Bilateral hand complaints
coarser - suggest a degenerative (e.g. OA), systemic, or,
*Joint Deformity inflammatory/immune (e.g. RA) etiology
- indicates a long-standing or aggressive pathologic
process
- may result from ligamentous destruction, soft
tissue contracture, bony enlargement, ankylosis,
erosive disease, subluxation, trauma or loss of
proprioception

● Musculature

○ will document strength, atrophy, pain or
spasm
○ Appendicular muscle weakness should be
characterized as proximal or distal.
○ Muscle strength
■ Should be assessed by observing
the patient's performance
○ Graded on a 5-point scale:
■ 0 for no movement
■ 1 for trace movement or twitch
■ 2 for movement with gravity
eliminated
■ 3 for movement against gravity
■ 4 for movement against gravity
and resistance
■ 5 for normal strength.
● Specific maneuvers
○ may reveal common nonarticular
abnormalities
○ carpal tunnel syndrome
■ Tinel's or Phalen's sign
○ olecranon bursitis, epicondylitis
■ tennis elbow
○ enthesitis
■ Achilles tendinitis
○ tender trigger points associated with
fibromyalgia.
I
Dactylitis
- manifests as soft tissue swelling of the whole digit
- sausage-like appearance
- psoriatic arthritis, spondyloarthritis, juvenile
spondylitis, mixed connective tissue disease,
scleroderma, sarcoidosis, and sickle cell disease
Tenosynovitis
- suggested by localized warmth, swelling, or pitting
edema
- may be confirmed when the soft tissue swelling
tracks with tendon movement such as flexion and
extension of fingers
- pain is induced while stretching the extensor
tendon sheaths
Carpal Tunnel Syndrome
- common disorder of the upper extremity
- results from compression of the median nerve
within the carpal tunnel
- Manifestations:

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 INTERNAL MEDICINE - RHEUMATOLOGY
APPROACH TO ARTICULAR AND MSK DISORDER
Dr. Ruth Saguil-Sy August 25, 2022
-
C
pain in the wrist that may radiate with
paresthesia to the thumb, second and third
fingers and radial half of the fourth finger
- atrophy of thenar musculature
- commonly associated with pregnancy, edema,
trauma, OA, inflammatory arthritis, and infiltrative
disorders
- Physical exam:
● positive Tinel’s sign
○ paresthesia in a median nerve
distribution is induced or increased
by either "thumping" the volar
aspect of the wrist
● positive Phalen’s sign:
○ paresthesia in a median nerve
distribution is induced or increased
by pressing the extensor surfaces
of both flexed wrists against each
other
SHOULDER PAIN
Examiner should carefully note any history of trauma,
fibromyalgia, infection, inflammatory disease, occupational
hazards, or previous cervical disease
Patient should be questioned as to the activities or
movement(s) that elicit shoulder pain
● Arthritis is suggested by pain on movement in all
planes
● Periarticular (nonarticular) process is suggested
by pain with specific active motion
Origin of shoulder pain:
- glenohumeral or acromioclavicular joints,
subacromial (subdeltoid) bursa, periarticular soft
tissues (e.g., fibromyalgia, rotator cuff
tear/tendinitis), or cervical spine
Referred pain:
- Referred frequently from the cervical spine but
may also be referred from intrathoracic lesions
(e.g., a Pancoast tumor) or from gallbladder,
hepatic, or diaphragmatic disease
Glenohumeral involvement
- Best detected by placing the thumb over the
glenohumeral just medial and inferior to the
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coracoid process and applying pressure anteriorly
while internal and externally rotating the humeral
head
Synovial effusion or tissue
- Seldom palpable; if present may suggest infection,
RA, amyloidosis or an acute tear of the rotator cuff
Subacromial Bursitis
- Frequent cause of shoulder pain
- Best identified by palpating it in its groove as the
patient rotates the humerus internally and
externally
Fibromyalgia
- suspected when glenohumeral pain is cuff
tendinitis or tear as a primary cause
Rotator Cuff Tendinitis
- Pain on active abduction (but not passive
abduction), pain over the lateral deltoid muscle,
night pain
- Common in elderly often results from trauma o
Evidence of the impingement signs (pain with
overhead arm activities)
- Physical exam:
● Positive Neer Sign
○ Test for impingement that is performed by
examiner raising the patient’s arm into
forced flexion while stabilizing and
preventing rotation of the scapula
○ Positive sign is present if pain develops
before 180° of forward flexion
● Drop Arm Test
○ Abnormal with supraspinatus pathology
○ Demonstrated by passive abduction of the
arm to 90° by the examiner
○ Positive test if patient is unable to hold the
arm up actively or unable to lower the arm
slowly without dropping
- Confirmatory test: MRI or ultrasound
- Confirms tendinitis or tear of rotator cuff
KNEE PAIN
Result from intra-articular (OA, RA) or periarticular
(anserine bursitis, collateral ligament strain) processes or
be referred from hip pathology
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 INTERNAL MEDICINE - RHEUMATOLOGY
APPROACH TO ARTICULAR AND MSK DISORDER
Dr. Ruth Saguil-Sy August 25, 2022
Careful history should delineate the chronology of the
knee complaint
c
Observation of the patient’s gait is also important
- Most common malalignment in the knee is
genu varum (bowlegs) or genu valgum
(knock-knees) resulting from asymmetric
cartilage loss medially or laterally
Bony swelling of the knee joint:
- Swelling caused by hypertrophy of the synovium or
synovial effusion may manifest as a fluctuant,
ballotable, or soft tissue enlargement in the
suprapatellar pouch (suprapatellar reflection of the
synovial cavity) or regions lateral and medial to the
patella
Synovial effusion:
- detected by balloting the patella downward toward
the femoral groove or by eliciting a “bulge sign”
- examiner should manually compress, or “milk,”
synovial fluid down from the suprapatellar pouch
and lateral to the patellae
- patella may cause an observable shift in synovial
fluid (bulge) to the medial aspect
- maneuver is only effective in detecting small to
moderate effusions (<100 mL)
Inflammatory disorders:
- Produce significant pain, stiffness, swelling, or
warmth
Anserine bursitis
- Often missed periarticular cause of knee pain in
adults
- Pes anserine bursa underlies the insertion of
the conjoined tendons (sartorius, gracilis,
semitendinosus) on the anteromedial proximal tibia
- Painful following trauma, overuse, or inflammation
- Tender in patients with fibromyalgia, obesity and
knee OA
Internal derangement of knee
- Result from trauma or degenerative processes
Damage to the meniscal cartilage (medial or lateral)
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- Suspected when there is a history of trauma,
athletic activity, or chronic knee arthritis, and when
the patient relates symptoms of “locking” or “giving
-
way” of the knee
Physical exam:
wi Thr te
● McMurray Test
n
○ knee is first flexed at 90°, and the leg is
then extended while the lower extremity is
simultaneously torqued medially or
laterally
○ painful click during inward rotation may
indicate a lateral meniscus tear
○ pain during outward rotation may indicate
a tear in the medial meniscus
HIP PAIN
Best evaluated by observing the patient’s gait and
assessing range of motion
Majority of patients reporting “hip pain” localize their pain
unilaterally to the posterior gluteal musculature
- may or may not be associated with low back pain
complaints
Trochanteric Bursitis or Entheitis
- inducing point tenderness over the trochanteric
bursa
Fibromyalgia
- Gluteal and trochanteric pain
- ROM limited by pain
- hip joint pain is less common and tends to be
located anteriorly, over the inguinal ligament and
may radiate medially to the groin
Iliopsas bursitis
- may be suggested by a history of trauma or
inflammatory arthritis
- pain localized to the groin or anterior thigh and
tends to worsen with hyperextension of the hip
- Patients prefer to flex and externally rotate the hip
to reduce the pain from a distended bursa
LABORATORY INVESTIGATIONS
Majority of musculoskeletal disorder can be diagnosed by a
complete history and PE
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 INTERNAL MEDICINE - RHEUMATOLOGY
APPROACH TO ARTICULAR AND MSK DISORDER
Dr. Ruth Saguil-Sy August 25, 2022
Additional evaluation is indicated with:
1. monoarticular conditions
2. traumatic or inflammatory conditions
3. the presence of neurologic findings
4. systemic manifestations
5. chronic symptoms (>6 weeks) and a lack of
response to symptomatic measures
Laboratory tests should be used to confirm a specific
clinical diagnosis and not be used to screen or evaluate
patients with vague rheumatic complaint
Complete blood count
- including a white blood cell (WBC) and differential
count, the routine evaluation should include a
determination of an acute phase reactant such as
the ESR or CRP, which can be useful in
discriminating inflammatory from noninflammatory
disorders
Serum uric acid determinations
- useful in the diagnosis of gout and in monitoring
the response to urate-lowering therapy
- Uric acid levels (and the risk of gout) may be
increased by inborn errors of metabolism
(Lesch-Nyhan syndrome), disease states (renal
insufficiency, myeloproliferative disease, psoriasis),
or drugs (alcohol, cytotoxic therapy, thiazides)
not recommended because they have no
diagnostic value
- Normal synovial fluid:
- clear, viscous, and amber-colored, with a
WBC count of <2000/uL and
predominance of mononuclear cells
synovitis or osteitis
- viscosity: a stringing effect, with a long tail
behind each
DIAGNOSTIC IMAGING IN JOINT DISEASE
-Valuable tool in the diagnosis and staging of articular
disorders
Plain x-rays
- Most appropriate and cost effective when there is a
history of trauma, suspected chronic infection,
progressive disability, or monoarticular involvement
- When therapeutic alterations are considered
- When a baseline assessment is desired for what
appears to be a chronic process
- ACUTE CONDITIONS: rarely helpful in
establishing a diagnosis and may only reveal soft
tissue swelling or juxta-articular demineralization

Serologic tests for RF, cyclic anticitrullinated peptide

(CCP or ACPA) antibodies, ANAs, complement levels,
Lyme and antineutrophil cytoplasmic antibodies (ANCA), or
antistreptolysin O (ASO) titer should be carried out only
when there is clinical evidence to specifically suggest an
associated diagnosis
- poor predictive value when used for screening

Synovial Fluid Analysis

- indicated in acute monoarthritis or when an
infectious or crystal-induced arthropathy is
suspected
- distinguish between non-inflammatory and
inflammatory processes by analysis of the
appearance, viscosity, and cell count
- Tests for synovial fluid glucose, protein, lactate
dehydrogenase, lactic acid, or autoantibodies are

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 INTERNAL MEDICINE - RHEUMATOLOGY
APPROACH TO ARTICULAR AND MSK DISORDER
Dr. Ruth Saguil-Sy August 25, 2022

References:
Dra. Sy Lecture/PPT
amaliMD trans
Harrison’s 21st

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