Lecture targeting Under & post graduate physicians to facilitate the approach to a patient with musculoskeletal complaints

1. Prof. Dr/ Abdel Azeim Alhefny
Prof. of Internal Medicine, Rheumatology & Immunology
Director of Rheumatology unit
Ain Shams University

2. Introduction
The objectives of performing a
musculoskeletal examination are:
1) To make an accurate diagnosis
2) To assess the severity and complications
of the condition
3) To construct a management plan

3. Ten Golden Rules In Rheumatology
1. A good history & physical examination, with good idea
about the musculoskeletal anatomy is very important for
diagnosis;
You must examine the patient!!
2. Don’t order a lab test unless you know why & what you
will do if it is abnormal?
3. Acute monoarthritis = 1joint inflam. <6w; joint aspiration
to exclude septic & crystal- induced arthritis.
4. Chronic monoarthritis > 6 weeks of unknown cause;==
synovial biopsy.
5. Gout does not occur in premenopausal females or in j.
close to spine.

4. 6. Most shoulder pain is periarticular (bursitis,
tendonitis..), most LBP. is nonsurgical
7. OA in (MCP, wrist, elbow, shoulder, ankle) joints ----
exclude 1ry cause eg. Metabolic dis.
8. 1ry fibromialgia does not occur > 55ys. for 1st time,
nor with abnormal laboratory results.
9. Not all pts. With +ve RF have RA, nor +ve. ANA have
SLE .
10. Fever or multisystem complaints, in Rhc. Pt., rule out
infection & other non-Rhc. Causes (Infections cause
death in Rhc. pt. more than the 1ry dis. does).
Remember nothing is 100%
Ten Golden Rules In Rheumatology

5. Clinical evaluation of the Patient with
Rheumatic Disease
3 simple screening questions
1) Have you any pain or stiffness in your muscles,
joints or back?
2) Can you dress your self completely without any
difficulty?
3) Can you walk up and down stairs without any
difficulty?

6. If the answer to any question is positive , detailed
history must be obtained…Ask about:
1) Pain: Site, radiation, severity, in usage? at rest? at night?
2) Stiffness: subjective feeling of inability to move freely,
duration of early morning stiffness ?
3) Swelling: fluid (effusion) or soft tissue (synovitis) or bone.
which joint? constant or episodic? duration?.
4) Systemic illness: Fever, malaise, fatigue, loss of weight
5) Extraarticular manifestations: Loss of hair, photosensitivity,
dryness of mucous membranes, mouth ulcers, red eyes,
Raynaud's phenomenon, symptoms referable to other
systems.

7. Patterns of pain
Degenerative joint pain: pain on joint use, stiffness after
inactivity, pain at end of day after Use (osteoarthritis)
Inflammatory joint pain: pain and prolonged stiffness in the
morning, at rest, and with use (Inflammatory arthritis)
Mechanical joint pain: pain related to joint use only
(unstable joint)
Bone pain: pain at rest and at night (Tumor, Paget’s, fracture)
Neuropathic :diffuse pain and paresthesia in dermatome,
worsened by specific activity (root or peripheral nerve
compression)

8. A diagnostic approach to the Patient with
Rheumatic Disease
Pearl ! : The diagnosis of many rheumatic diseases
is based mainly on clinical grounds
• Firstly: answer the following questions about the
nature of the disease:
I. Articular or non-articular?
II. Acute or chronic?
III. Inflammatory or non-inflammatory?
IV. Pattern of joint involvement.
V Extraarticular features.
• Lastly: Order investigations that help to confirm
your clinical impression or to sort out your
differential diagnosis.

9. I. Articular or Nonarticular ?
• Articular pain is localized to a specific joint, both
passive and active Range Of Motion (ROM) are
restricted in all planes.
• Nonarticular pain originates from periarticular
structures (tendon or bursa), only active ROM is
restricted in the plane of involved structure.
• Diffuse nonarticular conditions: generalized
hypermobility and fibromyalgia (diffuse aches
and pain)

10. II. Acute or chronic?
• Acute musculoskeletal disorders are defined as
those of <6 weeks duration:
1) viral arthritis 2) gout 3) reactive arthritis
• Chronic MSK disorders are defined as those
lasting > 6 weeks: non-inflammatory
(osteoarthritis) and inflammatory (rheumatoid
arthritis).

11. III. Inflammatory or non-inflammatory ?
Inflammatory disorders identified by:
• Rest pain partially improved by activity
• Local cardinal signs of inflammation (redness,
hotness, pain, swelling and limited movement).
• Prolonged morning stiffness >1 hour.
• Systemic symptoms (fatigue, fever, weight loss)
• Elevated ESR, CRP.

12. Inflammatory Non-inflammatory
MS  >1hr.  <1/2 hr.
Fatigue  Significant.  Minimal.
Activity  Improve symptoms.  Worsen.
Rest  Worsen  Improve.
Systemic
manifestatio
ns
 + +  - -
ESR, CRP  + +  - -
Corticosteroi
d
 Improve  No effect
Ex.  RA.
 Systemic rheumatic dis.(SLE,
SSC, Vas.).
 Infect.: Bact, Viral.
 .
 Reactive (Reiter, RF).
 Seroneg. (AS,IBD).
 Sarcoidosis, FMF,..
 OA.
 Traumatic.
 Osteonecrosis.
 Neuropathic J.
 Metabolic
(hemochromatosis),
 Endocrinal (thyroid, DM,
Acromegaly)
Comparison between Inflammatory & Noninflammatory arthritis

13. IV. Pattern of joint involvement
(pattern recognition)
Sequence of involvement :
1) Migratory polyathritis:
Symptoms are present in certain joints for few days
and then remit to reappear in other joints.
(Acute rheumatic fever and Viral arthritis)
2) Additive polyarthritis:
Symptoms begin in certain joints and persist with
subsequent involvement of other joints.
(rheumatoid arthritis)
3) Intermittent:
Repetitive acute attacks with complete remission.
( gout)

14. Number of joints involved
• Monoarthritis: one joint involved
Septic arthritis and crystal arthropathy .
• Oligoarthritis: (2-4 joints involved)
e.g. spondyloarthropathies (ankylosing
spondylitis, psoriatic arthritis. reactive arthritis
and inflammatory bowel disease related
arthritis).
• Polyarthritis : more than 4 joints involved.
e.g rheumatoid arthritis

15. Distribution of joints
involved
• Symmetrical or asymmetrical
• Axial or peripheral
• Large or small joints

16. Symmetrical Asymmetrical
Ex. RA
SLE
Reiter
PsA
AS
Peripheral Axial
Ex. RA
SLE
AS
PsA (70%-also
affects IPJ--- sausage
digits)
Reiter
Small Large
Ex. RA
SLE
Seronegative
Reiter
RF
Distribution of joints
involved

17. V. Extraarticular manifestations
 Are there extraarticular manifestations that would be
helpful in making the diagnosis of systemic
rheumatic diseases?
• Loss of hair, photosensitivity, dryness of mucous
membranes, mouth ulcers, red eyes, Raynaud's
phenomenon, symptoms and signs referable to other
systems (pulmonary, cardiac, renal, neurological).

18. Examination
• Gait Arm Leg Spine (GALS screen) to
detect important MSK abnormalities and functional
disability.
• Gait:
Observe the patient's gait for rhythm and
symmetry.
Upper limbs:
• Inspection: (Look)
Inspect the hand & upper limb joints for deformity,
swelling or other signs of joint disease.
• Palpation: (Feel) Palpate the upper limb joints for
tenderness, swelling or increased warmth.
Doherty M et al The “GALS” screen. Ann Rheum Dis 1992;51:1165-1169

21. Movement (Move)
• Ask the patient to open and spread the fingers, close the
fingers (power grip), and then to pinch the tip of index finger
and thumb (opposition).
• Ask the patient to put his hands together in the position of
prayer and then to lower the arms keeping the palms together.
This demonstrates the range of extension of the wrists.
• Ask the patient to place the back of his hands together and to
raise the arms upwards. This demonstrates the range of flexion
of wrists.

23. Movement (Move)
• Instruct the patient to bend and straighten both elbows
simultaneously (0-150)
• With elbows flexed to 90, turn hands palm up (supination
0-90) and then palms down (pronation 0-90).
• Ask the patient to put both hands behind the head with elbows
pointing laterally (abduction and external rotation),
• then to put the arms down and reach up behind the back (extension,
adduction and internal rotation).
• Compare active with passive movements, if active range limited.

24. Lower limbs
• Inspection (look):
Inspect the lower limb joints for deformity,
swelling or other sings of rheumatic diseases.
Note the presence of muscle wasting or leg
length inequality.
• Palpation (feel):
• Palpate the lower limb joints for tenderness,
swelling or increased warmth.
• Palpate knee joint for effusion (patellar tap test or
balloon sign) and palpate for a popliteal cyst.

25. Movement (move)
• Rotate the hips with the legs extended using the foot as an
indicator (90 arc of movement).
• With the hip and knee at 90 check the range of internal (30) and
external rotation (45) of the hip.
(Internal rotation is affected first in disorders of the hip joint)
• Complete hip flexion noting the range (0-120).
• Ask the patient to flex each knee in turn and observe the range of
movement (0-150) and any signs of tenderness.
• Ask the patient straightens each knee, place a hand on the knee
to feel the crepitus
• Ask the patient to extend (20) and flex (30) each ankle
• Passively evert (10) and invert (20) the subtalar joints with the
ankles in neutral position.
• Ask the patient to flex and extend the metatarsophalangeal (MTP)
joints.

28. Spine
• Look: observe the standing patient's spine from behind
and the side for abnormal kyphosis or scoliosis .
• Feel: palpate for any points of tenderness over the spine.
• Move :
• Ask the patient to flex then extend the neck, to look right,
left and then tilt the head sideways aiming to touch each ear
on the shoulder.
• Ask the patient to try to touch the toes without bending the
knees and to tilt sideways from the vertical position to try to
touch the sides of the knees.

31. Recording examination findings

33. CLINICAL
PRESENTATIONS

34. Discoid rash
Sub acute Cutaneous Lupus

35. Oral ulcers Arthritis (nonerosive)

36. Localized alopecia
Wide spread non scaring
alopecia

37. Vasculitis
Raynaud’s

40. Joint Effusion

41. Hand deformities
Chronic synovitis and tenosynovitis result in characteristic joint deformities
classic for chronic rheumatoid arthritis.
Patients may have swan neck deformities, Boutonniere's sign, ulnar
deviation, cock-up toes, or hammer toes.

43. Hand deformities
Z deformity

44. Carpal tunnel syndrome
1) Tinel's sign 2) Phalen's sign

45. The Elbow

46. The Shoulder

47. The Knee

49. Foot deformities
Cock-up toes, or hammer toes in RA

50. Bones of the foot

51. Rheumatoid nodules
•20% of patients have SC rheumatoid nodules, most commonly situated over bony prominences but also
observed in the bursae and tendon sheaths. (firm, non-tender, freely mobile)
•Nodules are occasionally seen in the lungs, the sclerae, and other tissues.
•Nodules correlate with the presence of RF ("seropositivity"), as do most other extra-articular
manifestations.
•all patients with rheumatoid nodules are seropositive for RF.

54. 54
PAN
cont.
Gangrene
Livedo reticularis

55. 55

56. 56

57. Behçet's syndrome
Oral ulcers Genital ulcers
57


58. Heberden’s and Bouchard’s Nodes

59. Sciops-Medical Division
Heberden’s nodes :Hard or bony swellings which develop in the DIP.
Bouchard's nodes: bony growths in the proximal interphalangeal (PIP) joints

60. Hallux valgus and cock-up toe
deformities, characteristic of
osteoarthritis in the foot.

61. Knee deformity in OA
Sciencephoto.com

62. Deformities

63. Lab. Evaluation
 Laboratory tests may play an important role
in the diagnosis of patients with rheumatic
diseases.
 Improper use of these tests may result in
misdiagnosis, needless additional testing or
even inappropriate therapy.

64. Erythrocyte Sedimentation Rate (ESR)
 Range :
<15 mm/hr for men
<20mm/hr for women
 Age adjusted:
(Males) Age
2
(Females) (Age + 10)
2

65.  Infections, bacterial (35%) e.g. TB.
 Connective tissue diseases (25%)
 Malignancy : lymphoma , myeloma (15%)
 Other causes (22%)
 Unknown (3%).
Markedly elevated ESR (>100mm/hr)

66. ESR is used:
 To reassure the patient with vague symptoms
and normal examination.
 To confirm clinical impression of the presence
of inflammatory disease.
 Follow up as a marker of treatment success.
The use of the ESR needs always to be
taken in clinical context

67. C-Reactive Protein (CRP)
 CRP is produced as an acute-phase reactant by the
liver in response to inflammation.
 Elevation occurs within 4 hours of tissue injury with
peaks within 24 -72 hours and falls rapidly once the
stimulus is removed.
 More specific than ESR but more costly

68.  A negative RF does not exclude the
diagnosis of RA.
 RA patients with high RF titer tend to have
more severe disease (prognostic value).
 Poor correlation with disease activity.
(no use to repeatedly measure the RF).
Clinical use of RF

69. Rheumatologic diseases:
 Rheumatoid arthritis (70-80%)
 Sjogren's syndrome (75-95%)
 Mixed connective tissue disease (50-60%)
 SLE (15-35%)
 Polymyositis (5-10%)
 Cryoglobulinemia (40-100%)
Causes of positive RF

70. Infections:
 Ch. hepatitis, especially hepatitis C (45%)
 Bacterial endocarditis
 Tuberculosis.
 Syphilis.
 Leprosy.
 HIV infection

71. Other conditions:
 Healthy aging individuals.
 Idiopathic pulmonary fibrosis.
 Cirrhosis.
 Sarcoidosis.
 Neoplasms.

72. Cyclic citrullinated peptide antibodies (Anti-CCP)
or Anti-citrullinated protein antibody (ACPA)
 More recently discovered rheumatoid arthritis specific
antibodies with sensitivity similar to RF and a very good
specificity.
 This test is valuable in confirming the diagnosis of early
RA.
 Anti-CCP antibodies can predict the development of
rheumatoid arthritis.
 High titre of anti-CCP are prognostic for erosive disease.
(Nielen MMJ , Arthritis Rheum 2004)

73. Rheumatoid Factor
Anti CCP
Acute phase reactants (nonspecific)
ESR
CRP
Serological Markers for RA

74. ANA immunofluorescent patterns
diffuse
nucleolar
speckled
peripheral

75. Condition % ANA-positive
 SLE 95-98
 Healthy relatives of SLE patients 15-25
 Rheumatoid arthritis 15-30
 Mixed connective tissue disease (MCTD) 95 -100
 Progressive systemic sclerosis 95
 Polymyositis 80
 Sjögren's syndrome 75-90
 Cirrhosis (all causes) 15
 Autoimmune liver disease (autoimmune hepatitis 60-90
primary biliary cirrhosis
 Chronic HCV infection 10 - 30
 Normals 3 - 5
 Normal elderly (>70 yr.) 20 - 40
 Neoplasia 15-25
Medical conditions associated with positive ANA

76. 76
Serological Tests to Aid Diagnosis of SLE

77. The occurrence of ANCA in different clinical
conditions
 Systemic vasculitis (AAV.. WG, CCS)
 Rheumatological diseases(SLE, RA)
 Inflammatory bowel disease
 Autoimmune liver diseases
 Infectious diseases
Subacute bacterial endocarditis (20%)
Entamoeba hystolytica (C PR3 IN 75%)
 Drug-induced vasculitis

78. Serum Uric Acid
 Hyperuricemia is defined as any level over about 6.8 mg/dL
(the point at which urate's solubility is exceeded)
 Hyperuricemia is a common serum abnormality but does
not result in gout without crystal deposition.
 Serum uric acid level may be normal with acute gouty
arthritis.
 If you see patients who have serum uric acid above the
level of 6.8 mg/dL, search for other cardiovascular risk
factors.

79. ASOT (anti streptolysin O test)
 All patients should have evidence of a
preceding group A streptococcal infection
and the presence of two major
manifestations or one major and two minor
manifestations.
The diagnosis of acute rheumatic fever

80.  ASOT vary with age, season, geographical location
and epidemiologic circumstances. Titers of 200- 400
Todd units are common in healthy children who live in
crowded cities as in our country.
 One should not diagnose the disease on the basis of
increased titers of streptococcal antibodies alone .
ASOT

81. X-ray changes: stages of radiological progression in RA
are:
• I) Periarticular osteopenia ,osteoporosis.
• II) Loss of articular cartilage (joint space narrowing).
• III) Bony erosions, particularly of the MCPs and
ulnar styloid
• IV) Subluxation and ankylosis.
• MRI and ultrasound: are recently used with high
sensitivity for detection of early changes in RA.
Radiographic findings

82. Progressive joint damage in RA

83. X Ray hand in RA
showing typical erosions at the thumb (black and white arrows) and middle MCP
joints (black arrow) and at the ulnar styloid (black arrow).

86. Rheumatoid arthritis: knee joints
symmetric narrowing of medial and lateral joint spaces that is characteristic of RA

88. Radiographic features

89. 1st CMC
(thumb base)

90. Serositis:
• Pleurisy
• pericarditis
CXR : pleurisy

91. Pleural and pericardial effusions
(CT chest)

92. Rheumatoid lung nodules & pl eff in pt with chronic RA
lung
nodules

93. cerebral vasculitis

94. MRI in RA
Both MRI and ultrasonography are more sensitive than radiographs in detecting
bony erosions & soft tissue changes in early RA

95. Higher sensitivity than XR for detection of bone erosions in RA
( M. Szkudlarek et al, eular June,2004)
Ultrasonography in RA

96. • Arthrocentesis is needed to diagnose
superimposed septic arthritis which is a
common complication of RA
• Should be considered whenever RA patient
has acute monoarthritis exacerbation.
SYNOVIAL FLUID EXAMINATION

97. Indications for synovial fluid analysis
1. Suspicion of infection. Gram stain, culture, and WBC
count (>50,000/cmm) and differential (PMNs> 75%
).
2. Suspicion of crystal-induced arthritis. polarizing
microscopy (birefringent crystals).
3. Suspicion of hemarthrosis. Bloody joint fluid =
traumatic arthritis, clotting disorder, and pigmented
villonodular synovitis.
4. Differentiating inflammatory from non-
inflammatory arthritis (Synovial fluid
WBC <2000).

98. Musculoskeletal complaint
History & Examination?
•Articular or non
•Acute or chr.
•Inflammatory or non.
•Number & distribution
Articular?
Acute or Chronic ?
Chronic>6W.Acute<6 W.
Inflammatory or non-infl.
Acute arthritis:
•Infectious
•Crystal-induced
•Reiter’s
•Presentation of Chr. Arth.
1
Non articular
Fibromyalgia R
Hypermobility S

99. Inflammatory or non-inflam.
Chronic inflammatory arthritis=
MS>1hr, synovial swelling,
warm, j.tender, syst.
manifes., CRP, ESR
Chronic non-inflammatory
arthritis
Affects Wt. Br. J.
(H & k)., DIP< CMC
Osteonecrosis
Charcotarthritis
OA
>4 J = polyarthritis1-4=mono-
oligo A
Chr. Inf.
PA- RS- PJA Symetrical
PA, RS PIP, MCP, MTP
SLE, SSc, PM RA
2
_
+
+-

100. 100