Approach to Patient With

Musculoskeletal Problem

• Marshell Tendean

• Department of Internal Medicine

• UKRIDA Jakarta
 The Musculoskeletal System
• A system consist of : the system of muscles and
tendons and ligaments and bones and joints and
associated tissues that move the body and maintain its
form.
 Common musculoskeletal
complaint
• Pain

• Swelling

• joint Effusion

• Crepitation

• Entesesis

• Dislocation

• Subluxation

• Epicondylitis
 Musculoskeletal Pain

• Originally somatic pain

• Distributed by free end nerve

• Consist all pain referred to all extremities & torso

• Caused by several disorders either mild or severe

characteristic
 Common musculoskeletal
problems :
• Disease of joint and soft tissue

• Inflamatory joint disease

• Fractures

• Bone Tumor

• Bone Infections
 The Flag Sign :
• Signs related to musculoskeletal emergency :

• History of Trauma

• Fever

• Progressive disease

• History of malignancy
Approach for good diagnosis

• Good history taking

• Accurate physical examination

• Extensive diagnostics
 Evaluation of Patients with
Musculoskeletal Complaints
• Goals
• Accurate diagnosis
• Timely provision of therapy
• Avoidance of unnecessary diagnostic
testing
Approach to The Disease

• Anatomic localization of complaint (articular vs. nonarticular)

• Determination of the nature of the pathologic process
(inflammatory vs. noninflammatory)
• Determination of the extent of involvement (monarticular,
polyarticular, focal, widespread)
• Determination of chronology (acute vs. chronic)
• Consider the most common disorders first
• Formulation of a differential diagnosis
• Articular : Dissorders that affect joints

• Inflamatory : The presence of inflammation (calor, rubor,

dolor, loss of function)

• Monoartrhitis : involving one joints; oligoarthritis :

involving two to three joints; polyarthritis : involving four
and more joints

• Acute : If the symptoms persist less than 6 weeks

• Chronic : if the symptoms persist more than 6 weeks

 Physical Examination
• Comprehensive physical examination

• More emphasize on Gait, Arm, Leg, Spine

• If noted some lateralization or any inequality; focus

on that section and do Look / Feel / Move manouvers

• Always consider any extraarticular findings

 Imaging of The
Musculoskeletal system
 Musculosceletal X-ray
• To be done in 2 different position (AP/Lat/ oblique)

• Present related dissorders according to signs

 Laboratory investigation :
• Blood Examination

• Autoimune examination

• Joint fluid analyses

As trauma, fracture, overuse syndromes, and fibromyalgia
 Gout
• The most common cause of inflammatory arthritis in US adults
(3.9% of Americans; approx. 8.3 million people; 2007-2008)
• Incidence of gout 2x greater among black men than white men
• Men with gout have been shown to have an increased risk of all-
cause mortality and cardiovascular disease mortality
• Cost: 2.3 million ambulatory care visit annually from 2001-2005;
multiple hospitalizations; $7.7 billion attributable to gout between
2005-2011
 Pathophysiology
• Caused by the deposition of monosodium urate crystals in
tissues
• Uric acid is a metabolic by-product of purine catabolism
• Purineshypoxanthinexanthineuric acid
• When the balance of dietary intake, synthesis and rate of
excretion are disrupted, hyperuricemia results
• Overproduction (10%)
• Underexcretion (90%)
• Results in arthritis, soft tissue masses, nephrolithiasis and urate
nephropathy
Pathophysiology

Rees, F. et al. (2014) Optimizing current treatment of gout

Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2014.32
 Risk Factors
• High Purine Diet (Red Meat, Fatty Poultry, High Fat Dairy,
Seafood)
• Alcohol Consumption
• Trauma
• Osteoarthritis
• Surgery
• Starvation
• Dehydration
• Obesity
• Drugs (Allopurinol, uricosuric agents, thiazides, loop diuretics, low
dose aspirin)
• Renal Impairment
• Genetic Mutations (SLC22A9, SLC22A12, ABCG2)
 Stages of Gout
• Asymptomatic tissue deposition

• Acute Gouty Arthritis

• Intercritical Gout

• Chronic Articular and Tophaceous Gout

 Acute Gout
• Often presents as involvement of a single joint or
multiple joints in the lower extremities: first
metatarsophalangeal (podagra; 50% of people with
gout), midtarsal, ankle and knee joints
• Characterized by pain, erythema, swelling and
warmth. Can have desquamation of skin.
• Can even cause fever and leukocytosis
• Maximal severity reached within 12-24 hours
• Even without treatment, attacks subside within
days to several weeks
 Chronic Gout
• Characterized by chronic arthritis and tophi, resulting
in chronic inflammatory and destructive changes

• Hallmarked by presence of multifocal Tophi

 Complications
• Musculoskeletal complications :
• Joint destructions, presence of tophi
• Systemic complications :
• Nephrolithiasis
• Risk factors: increase uric acid excretion, reduced urine volume, and low
urine pH
• Chronic urate nephropathy
• Urate crystals can deposit in renal medullary interstitium producing
inflammatory changes and fibrosis
• Clinical features are non specific: renal function impairment, bland
urinary sediment, mild proteinuria and serum urate concentrations often
higher than expected for the degree of renal impairment.
 Diagnosis

• DDX: Pseudogout and Septic Arthritis

 Diagnosis
• 5 clinical classification criteria for gout currently exist:
Rome, New York, ACR, Mexico and Netherlands
• These classification criteria have not been extensively
validated
• Diagnosis should be based on combination of clinical,
historical and laboratory data if arthrocentesis cannot be
performed.
• Diagnosis is considered provisional.
 Diagnosis
• Arthrocentesis should be done in patients in whom the
diagnosis has not been previously established .

• Labs: cell count with differential, gram stain, culture,

examination for crystals under polarized light
microscopy
Treatment
Treatment
 Treatment
• When initiating urate lowering therapy, can
precipitate acute gouty arthritis.

• Therefore, prophylaxis often given

Diet