Approach to a Patient with Musculoskeletal Complaints - Rheumatology Notes

Rheumatological and MSK History

  • Gout is the oldest disease discovered.
  • Rheumatoid arthritis.
  • Patients come in different types, sizes, ages.

Objectives

  1. Be able to take a relevant rheumatological and MSK history.
  2. Understand the different components of MSK pain with regards to:
    • Onset, duration, and course.
    • Localization, radiation, and distribution.
    • Aggravating and relieving factors.
    • Differentiating between mechanical and inflammatory cause pain.
  3. Understand the relevance of passive / active and passive-resisted movement
  4. Recognize systemic involvement in MSK conditions
  5. Recognize DISEASE TARGETS, DISEASE PROCESSES and PATTERNS of INVOLVEMENT

Rheumatic Disorders

  • There are >120 rheumatic disorders.
  • While patients often present with joint-related symptoms, arthritis is a systemic disorder.
  • 20% of the population have MSK symptoms requiring medical care.
  • 80% of rheumatic diseases can be diagnosed based on history.
  • Physical examination and special investigations are essential to confirm our diagnosis.

History

  • 80% of rheumatological diagnosis is made on HISTORY
  • Relevant background includes:
    • Age, gender.
    • Medical history.
    • Preceding illness.
    • Injury.
    • Chronic medication.
    • Occupation.
    • Social Habits: smoking, alcohol.
    • Family history.

Musculoskeletal Pain

  • (joints + muscle)

Differential Diagnosis

  • Everything that aches is not rheumatological.
    • Heart attack.
    • Liver abscess.
    • Orthopedic problem – rotator cuff tear.
    • Rheumatological disease?
  • Not every RHEUMATOLOGICAL pain is due to ARTHRITIS!
    • ARTHRALGIA: Joint pain.
    • ARTHRITIS: Inflammation of joint involving synovium (synovitis).
    • PERIarticular: Tendons, ligaments, bursae… localized.
      • Enthesitis: Inflammation of ligamentous insertions.
    • Soft tissue rheumatism.
      • Fibromyalgia… diffuse.
      • Regional – rotator cuff syndrome / carpal tunnel

Soft Tissue Involvement

  • Diffuse (poorly localized): Fibromyalgia
  • Regional:
    1. Polymyalgia rheumatica
  • Periarticular (Well localized):
    1. Olecranon bursitis
    2. Epicondylitis /tennis elbow
    3. Rotator cuff syndrome
  • Enthesitis

Components of MSK Pain

  • Important components of MSK pain:
    • A. Where does the pain localize?
      1. Specific joint area: joint/periarticular
      2. Diffuse: diffuse soft tissue, muscle / bone
      3. Axial: back, necks, sacral-illiac
      4. Small: hands + feet versus peripheral
      5. Symmetrical v asymmetrical: not really completely mirroring
      6. Nr of joints involved:
        • Mono = 1
        • Oligo = 2-4
        • Poly = 5 and more
        • >hip, knee
    • B. Where to?
      1. Spine:
        • Localized or may radiate according to nerve roots (radiculopathy) down arm / leg
      2. Shoulder
        • Glenohumeral joint and sub -acromial pathology: C5 dermatome
        • Acromioclavicular joint: C4 dermatome
    • “Hip pain”
      • Hip joint: groin to knee
      • Lumbar pain with radiculopathy
      • SI joint: buttock pain
      • Trochanteric bursitis – localized pain
      • Iliotibial band – lateral thigh
    • C. What is the onset and course of the pain?
      1. Onset:
        • Acute: sudden onset –aware of day / even time
        • Insidious: “uncertain about day”, usually weeks – months
      2. Duration:
        • Acute: <6 weeks
        • Chronic: ≥ 6 weeks
      3. Course:
        • Persistent with flares
        • Remits (asymptomatic phases) with relapses (flares)
    • D. Additional aspects:
      1. What makes it better / worse?
        • Activity v rest
        • Inflammatory arthritis improves with activity
        • Effect of NSAIDs
        • Inflammatory pain - good NSAID response
      2. Morning stiffness / ”gelling”
        • Following inactivity
        • Prolonged if inflammatory (>30 min)
      3. Nocturnal symptoms
        • Inflammatory pain – wakes early

Inflammatory vs Mechanical Pain

INFLAMMATORYNon – INFLAMM / (Mechanical)
Early Morningprolonged<30 min
Stiffness
Nocturnal SxProminentMild / limited
ExersizeImprovesWorsens
RestWorsensImproves
Systemic complaintsassociated wl underlying systemic diseaseAbsent; if present

Appropriate vs Inappropriate Inflammation

  • Appropriate Inflammation:
    • HEALING process
    • mechanical cause of pain
  • Inappropriate inflammation:
    • triggered by auto-immunity / auto-inflammation
    • → ongoing damage

Rheumatological Examination

A. Look
B. Feel
C. Move
1. Active movement
2. Passive movement
3. Active resisted movement

Active Movement
  • ACTIVE movement - screen
  • Does not differentiate between pain coming from…
    • CONTRACTILE structures (muscle, tendon) and
    • INERT structures (joint capsule, synovium, cartilage)
Passive Movement
  • Patient is PASSIVE, doctor MOVES the joint
  • We are testing the INERT structures by eliminating the CONTRACTILE structures
Capsular Pattern
  • Capsular pattern of a joint
  • Specific PASSIVE movement that stretches the joint capsule early will cause PAIN and LIMITATION in movement.
    • SHOULDER:
      1. ABduction and
      2. EXTERNAL rotation and
      3. INTERNAL rotation
    • HIP:
Active Resisted Movement
  • Patient attempts to abduct (supraspinatus)
  • But any movement is RESISTED by examiner.
  • Thus NO movement of the joint, while the contractile structure is strained.
Pathology Sites
ACTIVE movementPASSIVE movementACTIVE RESISTED movement
True joint diseasereducedreducedNA
Contractile structures (peri-articular)reducednormalReduced / increased pain
Referred painnormalnormalnormal
Systemic Involvement
  • Indications of systemic involvement
    1. General:
      • Constitutional (fever, weight loss)
      • Anemia of chronic disease
    2. Organ-specific
      • Any system may be involved
      • Often more than one
Information
  • Information from HISTORY and EXAMINATION is key
    • A. What is the target?
    • B. Disease processes?
    • C. Pattern recognition
Target Articular Disease
  • Target of articular disease
    • Symmetrical / asymmetrical TARGET?
      • Synovium
      • Cartilage
      • Small joint -oligo - poly
      • Large joint - monoarticular -oligoarticular
      • Enthesis
      • Axial
      • Peripheral
Disease Process
  • What is the disease process / pathogenesis?
    • Disease process / Pathogenesis
      • Inflammatory
        • Auto-immune
          • Rheumatoid arthritis
          • Connective tissue disease (SLE)
        • Auto-inflammatory
          • crystal arthropathy
          • SpA
      • Degenerative (cartilage)
        • age
        • trauma (injury other disease process)
Pattern Recognition
Disease Features
DiseaseNr of jointsDistributionAssociated features
Primary OsteoarthritisMono- / oligo- / poly-Hands: PIP, DIP, 1st CMC, 1st MTP; Large weight-bearing joints (hip, knee), Lower C- and L-spineBouchard’s and Heberdene’s nodes (PIP, DIP) in hands
Rheumatoid arthritisPoly- (may start oligo-)Symmetrical, predominantly small joints of hands and feetRheumatoid nodules; extra-articular complications
Psoriatic arthritisPoly-1. RA-like; 2. Predominantly DIP / asymmetrical large 3. Axial (spondyloarthropathy)May be very destructive (arthritis mutilans) Typical skin and nail changes Dactylitis and enthesitis
Polyarticular, chronic tophaceous goutPoly- (usually starts as mono- or oligo-)1. 1st MTP (podagra) 2. RA-like; 3. Predilection for damaged joints (OA)Metabolic phenotype; Tophi; H/o kidney stones or podagra (acute 1st MTP arthritis) Relaps / asymptomatic in between (early)
Connective tissue diseasesPoly-RA-like, may be mild disease- of underlying connective tissue disease eg skin / myopathy / systemic involvement
SpondyloarthropathiesOligo- (peripheral)1. Axial + sacroiliitis with 2. peripheral arthritis: asymmetrical, large or small jointsTypical extra-articular manifestations Dactylitis and enthesitis Form part of psoriatic arthritis, inflammatory bowel disease, reactive arthritis Infection associated (HIV / Hep B etc)
Infection associatedOligo-1. Asymmetrical, large joints 2. RA-distributionPreceding / chronic infection
Diagnosis Confirmation

A. Blood tests
* Markers of inflammation:
* ESR, C-reactive protein
* Disease-specific markers:
* Auto-antibodies (ANA, RF, aCCP)
* Genetic markers: HLA-B27
* Complications:
* Full blood count, renal, liver function

B. Synovial fluid analysis

MacroscopicViscosityLeucocyte count (% neutrophils)Cause
Non-inflammatoryClear / straw-colored+ve string test200-2 000 (<25%)Osteoarthritis
InflammatoryOpaque, deep straw colored-ve string test2 000-50 00 (>50%)RA, PsA, ReA
SepticOpaque, purulent-ve string test>50 000 (>80%)Gout Septic arthritis
HaemorrhagicBloody+-Trauma, haemophilia
Imaging
  • C. Imaging
    • Diagnostic / disease activity
      • Xray
      • Ultrasound
      • MRI
    • Complications
      • Xray, Echo, CT, U/S, MRI, PET-CT
Awareness
  • Some of these conditions develop insidiously, change with time, evolve, and complicate.
  • Your first step is an awareness, and then a hunger to find the answer.