Rheumatology

Introduction to Rheumatology

  • Amr Edrees, MD, FACP, FACR

  • Associate Professor of Medicine, Rheumatology Division, University of Missouri-Kansas City

Learning Objectives

  • After completion of this activity, learners will be able to:

    • 1. Perform history and physical examination for diagnosis of rheumatic disease.

    • 2. Understand the basics of laboratory tests and investigations for diagnosis of common rheumatic diseases.

Overview of Rheumatology

  • Rheumatology is a sub-specialty in internal medicine and pediatrics focused on:

    • Diagnosis and therapy of rheumatic diseases.

  • Most rheumatic diseases are classified as:

    • Immune disorders (auto-immune)

    • Inflammatory diseases affecting connective tissue.

Types of Inflammation in Rheumatic Diseases

  • Inflammation may affect various systems including:

    • Joints: Inflammatory arthritis

    • Muscles: Myositis

    • Blood vessels: Vasculitis

    • Skin: Skin rashes and lesions

    • Ligaments and tendons

Systemic Involvement in Rheumatic Diseases

  • Rheumatic diseases commonly exhibit multi-system involvement such as:

    • Kidneys: Glomerulonephritis

    • Peripheral nerves: Neuropathy

    • Serositis: Conditions like pleurisy and pericarditis

Common Inflammatory Rheumatic Diseases

  • Notable conditions include:

    • Rheumatoid Arthritis (RA)

    • Systemic Lupus Erythematosus (SLE)

    • Polymyositis and Dermatomyositis

    • Vasculitis

    • Gout

    • Spondyloarthropathy

    • Systemic sclerosis

Non-inflammatory Rheumatic Diseases

  • Conditions categorized as non-inflammatory:

    • Osteoarthritis

    • Fibromyalgia

Risk Factors for Rheumatic Diseases

  • Risk relationship to ethnicity:

    • Systemic Lupus Erythematosus (SLE): Higher prevalence in African-American women than Caucasian women.

    • Rheumatoid Arthritis (RA): Affects African-Americans and European-Americans equally in the US.

    • Polymyalgia Rheumatica (PMR) and Giant Cell Arteritis (GCA): Higher incidence in individuals of Northern European descent.

Specific Considerations for Spondyloarthropathy and Takayasu Arteritis

  • Spondyloarthropathy (SpA): Group of sero-negative inflammatory rheumatic disorders, unique for HLA-B27 association, more prevalent in Caucasians.

  • Takayasu Arteritis (TAK): Classified as large-vessel vasculitis, primarily affecting the aorta and its branches, notably prevalent in Asia.

History Taking in Rheumatology

  1. Pain Assessment:

    • Ask about:

      • Onset: Acute, sub-acute, chronic

      • Duration: Days, weeks, months, or years

      • Sites and distribution of pain

      • Diurnal variation of pain patterns

      • Aggravating and relieving factors

      • Any preceding trauma

  2. Character of Pain:

    • Consider radiation and severity.

  3. Morning Stiffness: Common indicator in rheumatic conditions.

  4. Swelling: Assess for visible inflammation.

  5. Erythema (Redness) and Warmth: Symptoms indicating potential inflammation.

  6. Weakness: Assess for muscle weakness.

  7. Locking and Triggering: Specific joint movement abnormalities.

Associated Symptoms and Extra-Articular Features

  • Conditions and their corresponding extra-articular features:

    • Septic arthritis: Fever, malaise, potential infectious source.

    • Gout: Tophi, renal failure signs.

    • Reactive arthritis: Urethritis, conjunctivitis, iritis.

    • Ankylosing spondylitis: Enthesopathy, iritis, aortic regurgitation, pulmonary fibrosis.

    • Psoriatic arthritis: Psoriasis, nail pitting, onycholysis.

    • Rheumatoid arthritis: Subcutaneous nodules, dry eyes, pulmonary fibrosis.

    • Sjögren's syndrome: Dry eyes, xerostomia.

    • Systemic lupus erythematosus: Photosensitive rash, mucocutaneous ulcers.

    • Juvenile idiopathic arthritis: Rash, fever, hepatomegaly.

Key Vocabulary in Rheumatology

  1. Patterns in Inflammatory Arthritis:

    • Additive: Seen in Rheumatoid Arthritis

    • Migratory: Common in Rheumatic fever and Reactive arthritis

    • Acute intermittent: Observed in Crystal arthritis.

  2. Number of Involved Joints:

    • Polyarticular (5 or more): Common in Rheumatoid Arthritis

    • Oligoarticular (4 or less): Seen in Spondyloarthritis

    • Monoarticular (1): Common in Crystal arthritis and Septic arthritis.

  3. Symmetry of Involvement:

    • Symmetric Patterns: Common in RA

    • Asymmetric Patterns: Seen in Spondyloarthritis

  4. Common Joints Involved:

    • MCPs, PIPs, Wrists: Indicative of Rheumatoid Arthritis

    • DIPs: Typical for Psoriatic arthritis, Osteoarthritis

    • First CMC: Osteoarthritis

    • First MTP: Gout

Physical Examination Techniques

  1. Inspection:

    • Check for deformity, swelling, and redness.

  2. Palpation:

    • Assess for tenderness, swelling, warmth.

  3. Range of Movement:

    • Evaluate joint flexibility and functionality.

  4. Special Tests:

    • Tests specific to each joint to assess functionality and integrity.

Anatomy of Hand and Wrist

  • Hand Joints:

    • 2nd to 5th fingers: MCP, PIP, DIP

    • 1st finger: 1st CMC, MCP, IP

Symptoms During Examination

  1. Pain

  2. Swelling

  3. Stiffness

  4. Numbness and tingling

  5. Loss of function

Inspection Findings

  1. Swelling

  2. Deformity

  3. Color change

  4. Skin change

General Observational Techniques for Hands

  • Examine palms-up and palms-down for:

    • Alignment, fusiform swelling, bony enlargement, joint deformity (ankylosis, contracture), cysts or nodules.

Palpation Techniques

  1. Joint Palpation:

    • Judicious palpation over joints to assess tenderness, warmth, swelling.

  2. PIP and DIP joints:

    • Assessment for synovial thickening, joint fluid distension.

Manual Tests for Grip Strength

  • Utilize manual gripping of the examiner's fingers to estimate grip strength.

Shoulder Joint Examination

  • **Symptoms:

    • Pain

    • Stiffness and limitation of movement around the shoulder.
      **

  • Inspection Techniques:

    • Assess deformity, swelling, muscle wasting, skin color changes.

  • Palpation Approach:

    • Target tenderness over shoulder joints, subacromial spaces, and biceps tendon.

Range of Movements in Shoulder Joins

  • Movements assessed include flexion, extension, abduction, adduction, internal and external rotation.

Tests for Shoulder Impingement

  1. Neer Test:

    • Pain indicates possible shoulder impingement.

  2. Hawkins Kennedy Test:

    • Positive result suggests impingement upon shoulder internal rotation.

Hip Joint Examination

  • Symptoms:

    • Usually felt in the groin, can refer pain to the anterior thigh, knee or buttock.

  • Inspection Techniques:

    • Assess gait, deformity, skin changes.

Knee Joint Examination

  • A complex hinge joint with components including tibio-femoral and patello-femoral.

  • Symptoms to assess:

    1. Pain

    2. Swelling

    3. Locking

    4. Instability (giving way).

Rehabilitation for Knee Joints

  • Utilize specific tests to assess mechanical stability, including the anterior drawer test, the McMurray test, and various stress tests.

Ankle and Foot Examination

  • A hinge joint enabling dorsiflexion and plantar flexion with involved movements such as inversion and eversion occurring at tarsal joints.

Spinal Examination

  • Structure: Cervical, thoracic, lumbar, and sacral segments.

  • Symptoms assessment includes:

    1. Pain (differentiating between mechanical vs inflammatory causes).

Specific Observations in Spinal Disorders

  • Differentiate between mechanical and inflammatory back pain based on age of onset, symptom characteristics, and response to NSAIDs.

Special Tests for Spinal Flexibility

  1. Schober’s Test:

    • Measures forward flexion of lumbar spine.

Skin Examination in Inflammatory Arthritis

  1. SLE Skin Manifestations:

    • Butterfly rash, discoid lesions characterized by specific features.

  2. Dermatomyositis Skin Features:

    • Heliotrope rash, nailbed changes, “mechanic's hands.”

  3. Psoriatic Arthritis Skin Features:

    • Nail changes, rashes, arthritis symptoms.

  4. Vasculitis Indicators:

    • Palpable purpura.

Clinical Scenario for Case Study

  • A 45-year-old female presents with joint pain and swelling, particularly noted in the hands and wrists with morning stiffness. Evaluation and laboratory investigations indicate elevated inflammatory markers:

    • ESR 60 mm/hr (normal <20 mm/hr)

    • CRP 5 mg/dL (normal 0-1 mg/dL)

    • Complete blood count: Hgb 10.0 gm/dL (normal 12-16 gm/dL)

References

  • Macleod's Clinical Examination, 13th Edition

  • UpToDate.com

  • ACR Slide Collection on Rheumatic Disease

  • Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, et al. Ann Rheum Dis. 2010 Sep;69(9):1580-8.