CHAPTER 311 APPROACH TO ARTICULAR AND MUSCULOSKELETAL  (-) Deformity

DISORDERS  (+)Crepitation
 PE findings
 (+)Instability remote from
• Musculoskeletal complaints account for a lot of consultations joint capsule

(+) Locking or
• Usually self-limited but may be serious as to require further deformity
evaluation and additional laboratory tests INFLAMMATORY VS. NON-INFLAMMATORY
Inflammatory Non-inflammatory
Causes  Infection  Trauma (rotator
• Goals of Clinician  Crystal-induced cuff tear)
 Accurate diagnosis (pseudo-/gout)  Ineffective repair
 Timely provision of therapy  Immune-related (OA)
 Avoidance of unnecessary diagnostic testing (SLE)  Neoplasm
 Reactive (RF, (villonodular
Reiter’s) synovitis)
• Approach  Idiopathic  Pain amplification
(fibromyalgia)
 Anatomic localization of complaint
Characteristics  Inflammation  Pain without
 Aricular
 Systemic sx swelling or warmth
 Non-articular
 (-) inflammatory
 Morning
or systemic
 Determination of the nature of the pathologic process stiffness features
 Inflammatory (precipitated
 Minimal morning
 Non-inflammatory by rest)
stiffness (in OA,
 Fatigue relieved by rest)
 Determination of the extent of involvement  Fever  Normal or negative
 Monoarticular  Weight loss laboratory
 Polyarticular  Lab evidence of investigations (for
 Focal inflammation age)
 Widespread  ↑ESR

 Determination of chronology  ↑CRP

 Acute  ↑WBC
 Chronic ↓RBC
 Formulation of differential diagnosis  ↓Albumin

ALGORITHM FOR DIAGNOSIS OF MUSCULOSKELETAL COMPLAINTS

• “Red Flag” Diagnoses (conditions that must be diagnosed 1. Initial rheumatic history and PE
promptly or avoid significant morbid or mortal sequelae) a. Is it articular?
 Septic arthritis NO (proceed to number 2)
 Acute crystal-induced arthritis (gout) YES (proceed to number 3)
 Fracture b. Chronology?
c. Inflammation present?
May be suspected by an acute onset, monoarticular or d. How many joints are involved?
presenting complaint. 2. Non-Articular, Consider the following:
• Trauma/fracture
• Fibromyalgia
• Evaluation of a patient with musculoskeletal complaints • Polymyalgia rheumatica
 History • Bursitis
 Comprehensive physical exam • Tendinitis
 Laboratory testing
3. Articular: Is complaint > 6 weeks?
ARTICULAR VS. NONARTICULAR NO (proceed to number 4)
• Discriminate anatomic site(s) of origin of patient’s complaint YES (proceed to number 5)
ASPECTS ARTICULAR NONARTICULAR
Structures  Synovium  Supportive
 Synovial fluid intraarticular
4. Acute Articular (<6 weeks), consider:
ligaments • Acute arthritis
 Articular
 Ligaments • Infectious arthritis
cartilage
 Intraarticular  Tendons • Gout
ligaments  Bursae • Pseudogout
 Joint capsule  Muscle • Reiter’s syndrome
 Juxtaarticular  Fascia • Initial presentation of chronic arthritis
bone  Bone
 Nerve 5. Chronic Articular (>6 weeks)
 Overlying skins a. Is inflammation present?
Characteristics  Deep or diffuse  Point or focal  Is there prolonged morning stiffness?
of disorder pain tenderness in  Is there soft tissue swelling?
regions  Are there systemic symptoms?
 Limited ROM on  Painful on active  Is the ESR or CRP elevated?
active and motion
passive  (-) Crepitus NO (proceed to number 6)
movement  (-) Instability YES (proceed to number 7)
  Onset
6. CHRONIC NON-INFLAMMATORY Arthritis  Abrupt onset
 Septic arthritis
a. Osteoarthritis (DIP, CMC, hip or knee joints
 Gout
involved)
 Indolent onset
b. Osteonecrosis or Charcot arthritis (other joints  OA
involved)  RA
 Fibromyalgia
7. Chronic Inflammatory Arthritis
How many joints are involved?  Evolution
a. 1-3 joints (Go to number 8)  Chronic
b. >3 joints (Go to number 9)
 OA
 Intermittent
8. MONOARTICULAR/OLIGOARTICULAR CHRONIC  Gout
INFLAMMATORY Arthritis, consider the follwing:  Migratory
 Indolent infection  Rheumatic fever
 Psoriatic arthritis  Gonococcal arthritides
 Reiter’s syndrome  Viral arthritides
 Pauciarticular JA  Additive
 RA
9. POLYARTICULAR: Chronic inflammatory polyarthritis  Reiter’s syndrome
a. ASYMMETRIC Chronic Inflammatory Polyarthritis  Duration
 Acute
 Psoriatic arthritis
 Chronic
 Reiter’s syndrome
b. Symmetric (go to number 10) • NUMBER
 Monoarticular (one joint)
10. SYMMETRIC Chronic inflammatory Polyarthritis  Trauma
 Gout
a. Rheumatoid arthritis (PIP, MCP, MTP joints involved)  Oligoarticular or Pauciarticular (2-4 joints)
b. SLE, Scleroderma, Polymyositis (other joints)  Polyarticular (>4 joints)
 Polymyositis
CLINICAL HISTORY  RA
• PATIENT’S PROFILE  Fibromyalgia
 Age
 Young • DISTRIBUTION
 SLE  Upper Extremities: RA
 Rheumatic fever  Lower Extremities: Reiter’s syndrome & Gout
 Reiter’s syndrome  Axial skeleton: OA and Ankylosing spondylitis
 Middle age
 Fibromyalgia • PRECIPITATING EVENTS
 Old CONDITIONS CULPRIT DRUGS
 Osteoarthritis Arthralgias Quinidine Vaccines
 Polymyalgia Cimetidine Rifabutin
Quinolones Amphotericin B
 Sex Chronic acyclovir IL-2
 Male Nicardipine
 Gout Myalgias/ Colchicine Pravastatin
 Spondyloarthroathies (Ankylosing spondylitis, myopathy Hydrochloroquiine Levostatin
Reither’s syndrome) Alcohol Simvastatin
 Female Glucocorticoids Docetaxel
Penicillamine Taxol
 RA
IL-2 Interferon
 Fibromyalgia
Cocaine Clofibrate
Azathioprine Quinolone
 Race
Gout Cytotoxics Cyclosporine
 Whites Alcohol Aspirin
 Polymyalgia rheumatica Diuretics Moonshine
 Giant cell arteritis Ethambutol
 Wegener’s granulomatosis Drug-induced Chlorpromazine Methyldopa
 African Americans lupus Hydralazine Procainamide
 Sarcoidosis Isonized Phenytoine
 SLE Lithium Penicillamine
Infliximab Quinidine
 Family history Tetracycline
 Ankylosing spondylitis Osteonecrosis Radiation
 Gout Alcohol
 RA Glucocorticoids
 Heberden’s nodes Osteopenia Phenytoin Methotrexate
Glucocorticoids Chronic heparin
Scleroderma Bleomycin Pentazocine
• CHRONOLOGY Organic solvent Vinyl chloride
Rapeseed oil Carbidopa
 Tryptophan • Synovial effusion (True articular swelling) vs. Synovial
Vasculitis Thiazides Cocaine proliferation (Nonarticular or Periarticular involvement)
Allopurinol Ampetamine Synovial Effusion Synovial Proliferation
Penicillamine PTU From true articular swelling From non-articular or peri-
 Trauma articular involvement
 Antecedent or intercurrent illnesses 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
• RHEUMATIC REVIEW OF SYSTEMS Limited ROM on active and Passive motion not as painful
 Fever passive motion as active motion
 SLE (+) Bulge sign
 Infection (+) Ballotement
 Rash (+) Flexion contractures
 SLE
 Reiter’s syndrome • Assess strength, atrophy, pain or spasm
 Dermatomyositis
• Muscle strength
Muscle Assessment
 Myalgias, weakness Grade
 Polymyositis Grade 0 No movement
 Polymyalgia rheumatica Grade 1 Trace movement or twitch
Grade 2 Movement with gravity eliminated
 Morning stiffness Grade 3 Movement against gravity only
 Inflammatory arthritis Grade 4 Movement against gravity and resistance
Grade 5 Normal strength
 Eye involvement
 Behcet’s disease
LABORATORY INVESTIGATIONS
 Sarcoidosis
• Candidates for evaluation
 Reiter’s syndrome
 Monoarticular conditions
 GIT involvement  Traumatic conditions
 Scleroderma  Inflammatory conditions
 IBD  Conditions accompanied by neurologic changes or systemic
manifestations of serious disease
 GUT involvement  Individuals with chronic symptoms especially when there
 Reiter’s syndrome has been a lack of response to symptomatic measures
 Gonococcemia
• Extent and nature of additional investigation should be dictate
by clinical features
 Nervous system involvement
 Lyme disease
• Indications for laboratory tests
 Vasculitis
 Confirm specific clinical diagnosis
PHYSICAL EXAMINATION  Evaluate patients with vaque rheumatic complaints
DIAGNOSTIC DEFINITION
SIGNS • Lab tests done
Crepitus Palpable or vibratory crackling sensation elicited  CBC
with joint motion  WBC with differential
Subluxation Alteration of joint  ESR
Dislocation Abnormal displacement of articulating surface  CRP
ROM Arc of measurable movement through which the  Uric acid (in cases of gout)
joint moves in a single plane
Contracture Loss of full movement resulting from a fixed • Serologic tests
resistance due to tonic spasm of muscle  Rheumatoid factor (BUT also found in 4-5% of healthy
(reversible) or to fibrosis of periarticular population): only 1% have RA
structures (permanent)  Antinuclear antibodies
Reflect trauma or antecedent synovial
inflammation  Found in 4-5% of healthy population (only 0.4% have
Deformity Abrnomal shape or size from SLE)
 Bony hypertrophy  Found in nearly all patients with SLE
 Malalignment of articulating structures  Seen in patients with autoimmune diseases
 Damage to periarticular supportive structures (polymmyositis, scleroderma, APAS)
Indicates long-standing or aggressive pathologic  Seen in drug-induced lupus (Hydralazine,
process Procainamide, Quinidine)
Enthesitis Inflammation of enthuses (tendinous or  Seen in chronic hepatitic or renal disorders
ligamentous insertions on bone)  Complement levels
Epicondylitis Infection or inflammation involving an epicondyle  Lyme and antineutrophil cytoplasmic antibodies
• Most joints are examined except for axial (zygapophyseal) and  Antistreptolysin O
inaccessible joints (sacroiliac and hip joint)  IgM Rheumatoid factor
 Found in 80% of patients with RA
• Determine presence of pain, warmth, erythema or swelling  Seen in low titers in patients with chronic infections
(TB, leprosy, pulmonary, hepatic and renal diseases)
• Assess number of joints involved and pain intensity and autoimmune diseases (Sjogren’s syndrome, SLE)
 Immunofluorescence pattern
  Peripheral or rim pattern (most specific and suggestive • Pseudogout (Calcium pyrophosphate dehydrate =
of anti-dsDNA antibodies): seen in SLE patients short, rhomboid-hspaed, positively bifringent crystals)
 Diffuse and speckled (least specific) • Chondrocalcinosis (Calcium pyrophosphate dehydrate)
PMNs without crystals (Go to number 7)
• Aspiration and analysis of synovial fluids
 Appearance 7. PMNs without crystals: WBC > 50,000/µL?
 Viscosity PMNs without crystals only
 Cell count
The following are usually not recommended since they are • Probable Inflammatory arthritis
insensitive and have little discriminatory value: PMNs without crystals with high WBC
 Glucose • Possible septic arthritis
 Protein
 LDH
 Lactic acid DIAGNOSTIC IMAGING IN JOINT DISEASE
• CONVENTIONAL RADIOGRAPHY
 Autoantibodies
 Purpose: Diagnosis and staging of articular disorders
Non-inflammatory Inflammatory Infectious
(Effusions)  Indications:
Clear, amber-colored Turbid, yellow Opaque, purulent  History of trauma
Viscous (with Normal viscosity Low viscosity  Suspected chronic infection
stringing effect)  Progressive disability
WBC < 2000/µL WBC = 2000-5000/µL WBC >50,000/µL  Monoarticular involvement
Mononuclears (PMNs) (PMNs)  When therapeutic alterations are considered
Normal RA Septic arthritis  When baseline assessment is desired
OA/Osteonecrosis Gout Psoriatic arthritis
Charcot’s arthritis CT diseases  Expected results
 Soft tissue swelling or juxtaarticular demineralization
Hemorrhagic synovial fluid seen in trauma, hemarthrosis or  Calcification of soft tissues, cartilage, bone
neuropathic arthritis  Joint space narrowing
 Erosions
Algorithm for Synovial Fluid Aspiration and Analyis
 Bony ankylosis
1. Indications for synovial fluid aspiration and analysis
 New bone formation (sclerosis, osteophytes or
a. Monoarthritis (acute or chronic)
periostitis)
b. Trauma with joint effusions
c. Monoarthritis in a patients with chronic polyarthritis  Subchondral cysts
d. Suspicion of joint infection, crystal-induced arthritis, or
hemarthrosis
• ULTRASONOGRAPHY
2. Analyze fluid for:  Purpose: Detection of soft tissue abnormalities not fully
a. Appearance, viscosity appreciated by clinical examination
b. WBC count, differential  Indications:
c. Gram stain, culture and sensitivity (if indicated)
d. Crystal identification by polarized microscopy
 Diagnosis of Baker’s cysts (synovial cysts)
 Evaluation of rotator cuff tears
 Evaluation of tendon injuries
3. Is the effusion hemorrhagic?
Hemorrhagic Effusions due to:
• Trauma or mechanical derangement • RADIONUCLIDE SCINTIGRAPHY
• Coagulopathy  Purpose: Provides useful information regarding the
metabolic status of the bone
• Neuropathic arthropathy
 Indications:
Non-hemorrhagic: (proceed to number 4)
 Total-body assessment of extent and distribution of
musculoskeletal involvement

4. (Non-hemorrhagic) Inflammatory or non-inflammatory articular

condition: WBC > 2000/µL?  Pertechnate or Diphosphonate scintigraphy (99mTc)
Non-inflammatory arthritis  Metastatic bone survey
• Osteoarthritis  Evaluation of Piaget’s disease
• Trauma  Quantitative joint assessment
Inflammatory/Infectious arthritis: (go to no 5)  Acute infection
 Acute and chronic osteomyelitis
 111
In-WBC
5. (Inflammatory/Infectious arthritis) PMNs present?
 superior to Ga in early diagnosis of osteomyelitis
No PMNs
and infected prosthetic joints
• See causes of non-inflammatory arthritis
(+) PMNs (Proceed to number 6)  affected by prior treatment with antbitoics)
⇒ Acute infection
⇒ Prosthetic infection
6. (with PMNs): are there crystals? ⇒ Acute osteomyelitis
PMNs with crystals
 67
Ga
• Gout (Monosodium urate: long, needle-shaped,
negatively bifringent intracellular crystals)  Bnds to serum and cellular transferring and
lactoferrin;
  Taken up by neturophils, macrophages, bacteria  ↑ESR
and tumor tissue
 ↓RF
 Afected by prior treatment with antbitoics)
 ↓ANA
⇒ Acute and chronic infection
• Exclude common geriatric musculoskeletal disorders
⇒ Acute osteomyelitis
• Emphasize on identifying rheumatic consequences of
intercurrent medical conditions and therapy
• Common diseases in the elderly
• COMPUTED TOMOGRAPHY (CT)  OA
 Purpose: Assessment of axial skeleton  Osteoporosis
 Advantages:  Gout
 Provides rapid reconstruction of sagittal, coronal and  Pseudogout
axial images and spatial relationships among anatomic  Polymyaliga rheumatica
structures  Vasculitis
 Indications:  Drug-induced SLE
 Herniated intervertebral disks  Chronic salicylate toxicity
 Low back pain syndromes
 Sacriliitis
 Spinal stenosis APPROACH TO REGIONAL RHEUMATIC COMPLAINTS
 Spinal trauma • History
 Ostoid osteoma  Pattern of onset
 Tarsal coalition  Evolution
 Osteomyelitis  Localization
 Intraarticular osteochondral fragments • Selected maneuvers/tests
 Advanced osteonecrosis
 Helical or spiral CT Hand Pain
 Diagnosis of pulmonary embolism or obscure fractures • Focal or unilateral hand pain
 Rapid, cost-effective and sensitive  Trauma
 High-resolution CT  Overuse
 Evaluation of suspected or established infiltrative lung  Infection
disease (Scleroderma, Rheumatoid lungs)  Reactive or crystal-induced arthritis
• Bilateral hand complaints
 Degenerative: OA
• MAGNETIC RESONANCE IMAGING (MRI)
 Systemic or inflammatory/immune: RA
 Purpose: Image musculoskeletal systems • Distribution
 Advantages Joints Involved
 Provide multipanar images with fine anatomic detail DISEASE DIP PIP MCP Wrist
and contrast resolution Reiter’s syndrome
 No ionizing radiation and adverse effects SLE
 Has superior ability to visualize bon marrow and soft Hemochromatosis
tissue periarticular structures Gonococcal arthritis
Juvenile arthritis
 Disadvantages CTS
 High cost OA (1st CMC also)
 Long procedural time Psoriatic arthritis
 Features RA
 Can image fascia, vessels, nerve, muscle, cartilage, Pseudogout
ligaments, tendons, pannus, synovial effusions, bone
marrow
 Sensitive to changes in marrow, fat BUT not specific in
detecting osteonecrosis and osteomyelitis
 More sensitive than arthrography or CT in diagnosis of  DeQuervain’s tendinitis
soft tissue injury, intraarticular derangements and  Focal wrist pain localized to the radial aspect
spinal cord damage, subluxation, or synovitis resulting from inflammation of the tendon sheaths
involving APOL or EPOB
 Indications  Due to overuse or follows pregnancy
 Avascular necrosis  Diagnosis by Finkelstein’s test
 Osteomyelitis
 Intraarticular derangement and soft tissue injury  Positive: wrist pain induced after the thumb is
 Derangements of axial skeleton and spinal cord flexed across the palm and placed inside a
clenced fist and the patient actively deviates the
 Herniated IVD
hand downward with ulnar deviation at the wrist
pigmented villonodular synovitis
 Inflammatory and metabolic muscle pathology
 Carpal Tunnel Syndrome
RHEUMATOLOGIC EVALUATION OF THE ELDERLY  Due to compression of median nerve within the carpal
tunnel
• Incidence of rheumatic diseases increases with age
• Signs and symptoms are insidious, chronic or overshadowed by  Clinical Manifestations:
comorbidities compounded by diminished reliability of
laboratory testing in the elderly since they have nonpathologic
⇒ Paresthesia in the thumb, 2nd, 3rd and radial half
of the 4th finger
abnormal results
 ⇒ Atrophy of thenar musculature
 Complete tear is common in the elderly
 Associated with the following  Results from trauma
⇒ Pregnancy  Diagnosis: Drop arm test
⇒ Edema ⇒ Inability to maintain arms outstretched once it is
⇒ Trauma passively abducted
⇒ OA ⇒ Positive: If patient is unable to hold arm up once
⇒ Inflammatory arthritis 90° of abduction is reached
⇒ Infiltrative disorders (amyloidosis)
 Confirmed by MRI or arthrography
 Diagnosis by Tinel’s test or Phalen’s sign
⇒ Paresthesia in median nerve distribution induced
or increased by either thumping the volar aspect Knee Pain
of the wrist (TInel’s sign) or pressing the extensor • History
surfaces of both flexed wrists against each other  Chronology of knee complaint
(Phalen’s test)  Predisposing conditions
 Trauma
 Medications

Shoulder Pain • Physical Examination

• History  Knee position inspected in the upright (weight-bearing) and
 Trauma prone positions for swelling, erythema, contusion,
 Infection laceration, or malalignment (genu varum or bowlegs &
 Inflammatory disease genu valgum or knock knees)
 Occupational hazards
 Previous cervical disease  Bony swelling of the knee joints
 Activities that elicit shoulder pain  Hypertrophic osseous changes (OA and neuropathic
arthropathy)
• Physical Examination  Fluctuant
 Frequently referred to the cervical spine from the  Ballotable
intrathoracic lesions (Pancoast tumors) or from gall  Soft tissue enlargement in the suprapatellar
bladder, hepatic or diaphragmatic disease pouch (superior reflection of the synovial cavity)
 Test full ROM or lateral and medial to the patella
 Manual inspection
• Diseases
 Direct manual pressure  Synovial effusions
 Subacromial bursitis: pain lateral to and immediately  Ballotement
beneath the acromion upon palpation  Bulge sign: with extended knee, milk synovial fluid
down from suprapatellar pouch LATERAL to the patella
 Bicipital tendinitis: pain in the bicipital groove while and observe fluid shift to the medial aspect; useful in
rotating the humerus internally and externally upon assessing small to moderate effusions (<100 mL)
palpation
 Palpation of acromioclavicular joint
 Local pain  Popliteal or Baker’s cyst
 Bony hypertrophy  Palpated with knees partially flexed and best seen
 Synovial swelling with the patient standing and knees fully extended to
visualize popliteal swelling or fullness from posterior
 Site of OA and RA
view
 Palpation of glenohumeral joint (anterior over humeral
head, medial and inferior to the coracoid process)
 Pain upon rotating the humerus internall and  Anserine Bursitis
externally  Pes anserine bursa: underlies the semimembranous
 Indicative of glenohumeral pathology tendon
 Often missed periarticular cause of knee pain in adults
 Synovial effusion  Cause
 Seldom palpable  Trauma
 Suggests infection, RA or acute tear of rotator cuff  Overuse
 Rotator cuff tendinitis  Inflammation
 Common cause of should pain  Clinical Manifestation
 Rotator cuff  Point tenderness inferior and medial to the
⇒ Supraspinatus patella and overlies themedial tibial plateau
⇒ Inraspinatus  Knee pain
⇒ Teres minor
⇒ Subscapularis  Prepatellar bursa
 Superfical pain in inferior portion of the patella
 Pain on active abduction
 Pain over lateral deltoid  Infrapatellar bursa
 Night pain  Deep pain beneath the patellar ligament before its
insertion on the tibial muscle
 Impingement sign: raising the arm into forced flexion
while stabilizing and preventing rotation of scapula  Pain, stiffness, swelling, warmth
 RA
⇒ Positive: Pain before 180° of forward flexion  Gout
  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