RheumatologySheet.doc

Reumatology Sheet Dr./ Abdel Azeim Alhefny, MD.

IDIAL GUID TO

RHEUMATOLOGY

HISTORY TAKING & CLINICAL EXAMINATION

WITH 22 CASES

Dr./ Abdel Azeim Al-Hefny. MD Prof. Internal Medicine, Rheumatology, Allergy & Immunology.

Ain Shams University

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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 = joint aspiration to exclude septic & crystal- induced arthritis.

4. Chronic monoarthritis > 8 weeks of unknown cause needs synovial biopsy.

5. Gout does not occur in premenopausal females or in joints close to spine.

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=RA, nor +ve. ANA = SLE .10.Fever or multisystem complaints, in Rhc. Pt., rule out infection & other non-Rhc. causes as a 1ry.

(Infections cause death in Rhc. pt. more than the 1ry dis. does).

Remember nothing is 100%

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Rheumatology Sheet


Synovial (diarthrotic) Joints. These are freely mobile joints in which there is a joint cavity between the articulating bones. These are the commonest joints in the body.

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TerminologyRheumatism: 1st. introduced in 1642 when they realized that arthritis could be a systemic disease. It was an obsolete term for ARF. Now it is defined as various abnormal conditions marked by recurrent pain, stiffness & other manifestations of articular origin in joints, back, or muscles.

Rheumatology: Rheuma= substance that flows- from brain to various parts of the body causing chr. illness (1st. century AD). Or medical science dealing with diseases/abnormalities in the musculoskeletal syst.

Arthropathy =A term meaning 'joint disorder'. This can be arthritis or arthralgia and is often used when the nature of the joint disorder is uncertain.

Arthritis= A term referring to inflammation of a joint or joints. (The suffix '-itis' means inflammation). There is usually visible evidence of inflammation (objective abnormality) such as Joint pain, stiffness, tenderness, redness, hotness, swelling & limited movement. While if the patient only experienced pain without obvious abnormality; it is called Arthralgia= (subjective=Joint pain without signs of inflammation).

Inflammation= Tissue reaction to injury. It may be acute (as in a burn or in gouty arthritis) or chronic (as in rheumatoid arthritis or chronic infections such as tuberculosis).

Cartilage= A white semiopaque nonvascular connective tissue. There are two types. Hyaline cartilage is the very smooth 'gristle' that covers the articulating surfaces of bones that form the joint. Fibrocartilage is the type that is found in the menisci in the knee for example.

Capsule= The thick membrane that joins bones making up a joint. It also isolates the joint cavity from surrounding tissue.

Enthesis= The anatomical site of attachment of ligament, tendon, joint capsule or fascia to bone. Enthesitis= inflammation of enthesis.

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Tendon= A band of fibrous tissue by which muscle is attached to bone. Tendenitis= inflammation of tendon, Tenosynovitis= inflammation of tendon sheath.

Ligament= A band of tough tissue which restrains joint movement and confers stability on a joint. There is a high collagen content Sprain = stretch or sprain of the ligament.

Synovium= A thin membrane (normally one cell thick) which is found within the joint capsule. It produces synovial fluid which lubricates and nourishes the joint cartilage. It becomes inflamed and thickened (synovitis) in inflammatory arthritis such as rheumatoid disease.

Joint effusion =Accumulation of fluid in a joint.

Bursa= A fluid-filled sac. They are found between tissue planes where shearing forces may act - e.g. at the knee and elbow. They are lined by synovium and contain synovial fluid - like the joint. Bursitis occurs when they are inflamed. eg: prepatellar bursitis. (Housemaid's knee).

Monoarthritis= one joint inflamed. Oligo/Pauci-arthritis= 2-4 joints or small joint groups eg: wrist. Polyarthritis= > 4 joints (or groups) inflamed.

Spondylitis=Inflammation of axial vertebrae & related structures (discs & ligaments).

Myopathy:Disease/Abnormality of the muscles. Myositis (polymyositis): Inflammatory disease of the muscle (skeletal/ striated muscle).

Vasculitis, arteritis: Necrosis and inflammation of blood vessel wall. This results in clinical manifestations due to interference with blood supply to those organs.

Subluxation: malalignment of a joint; so that articulating surfaces incompletely approximate each other.Dislocation: Abnormal displacement of articulating surfaces (not in contact).

Deformity: Abnormal shape or size dt. bony hypertrophy, malalignment of articulating joint, or damage to periarticular supporting structures.

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ROM= Range of motion: The arc of measurable movement through which the joint moves in a single plane.

Contracture: Loss of full movement dt. fixed resistance by tonic mus. spasm (reversible) or fibrosis of periarticular structure (permanent).

Rheumatoid factor=An immunoglobulin directed against the Fc portion of IgG. Rheumatoid factors may be found in all immunoglobulin classes but the rheumatoid factor test detects IgM-RF. Some conventionally 'seronegative' patients(20%) may have rheumatoid factors of other Ig classes & +ve CCP.

Rheumatoid nodules = subcutaneous soft tissue swellings which may vary inconsistency from very soft to moderately hard. Sometimes attached to deeper structures. They occur in approximately 20% of patients with rheumatoid arthritis, most commonly on the elbow on the extensor surface.

Ganglion = A soft tissue swelling which arises in relation to a tendon. It is usually firm and relatively small. A swelling of the dorsal tendon sheath at the wrist is sometimes mistakenly referred to as a ganglion.

Carpal tunnel = The space at the flexor aspect of the wrist bounded by the carpal bones and the flexor retinaculum. Flexor tendons and the median nerve traverse the carpal tunnel

Periostitis =Inflammation involving the periosteum. This may result in new bone formation

Onycholysis =A nail abnormality seen in psoriasis. It may be accompanied by pitting of the nail.

Sacroiliitis =Inflammation of the sacroiliac joints at the base of the spine. This may give rise to low back or buttock pain. It occurs particularly in HLA B27-related conditions such as ankylosing spondylitis

Haemarthrosis = A collection of blood within a joint.

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Rheumatology history taking

Screening questions in Rheumatology:Pain, joint swelling & stiffness are the most common symptoms pointing to

the locomotor system; impairment of its function (movement) is the most important consequence; so, before proceeding in rh. history taking, we ask the following questions:1. Have you any pain or stiffness in your muscle, joints or back?2. Can you dress your self without any difficulty?3. Can you walk up & down stairs easily?

Personal History

Age:Young: ARF (5-15), HSP (4), Kawasaki (5) Middle age: RA (all ages), SLE, PAN (40), RP (20-40), Reiter (20-40yrs.),

Takayasu (15-25), Wegner (40)Old: OA, Giant Cell Arteritis (GCA>50), Gout (50yrs)

Sex: F>M M>F M=F

SLE 9:1RA 3:1Behcet 2:1Vasculitis 3:1RP 5:1

GCA 2:1 Takayasu 9:1 Wegner 3:2

Gout (7:1)ReiterAS

PAN (2:1)

ARF HSP

Habits:

Addicts---------- viral, infectious arthropathy

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Residency:Crowded humid damp area: ARF

Occupation:Vibrating tools, pianist, typist------- RP

Health providers, blood bank staff ------ Viral arthropathy, cryo, vascul.

Past History

Precipitating factors???Drugs:

Drug-induced Lupus eg.: Hydralazine, Methyl dopa, Procainamide, Phenytoin, Isoniazid, Chlorpromazine.BB-------RP.Lovastatin------Myositis.L-tryptophan-------Esinophelia-myalgia syndrome.

Infections:B haemolytic streptococcal A. infection----------ARFTBGonorrheaSepsis

Diet:-----------Delayed hypersensitivity reaction------ Arthropathy.Trauma: Fracture, Haemarthrosis.Joint Surgery: Open, Laparoscopic, Aspiration:-

Indications, results, & follow up.Response to previous therapeutic modalities: drug TTT, PT, surgical corrections----------- clues for diagnosis, effects, side effects, compliance.

Complaint: Chief symptom & its duration

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.

History of the present illness:

If there is any abnormality suspetected we have to proceed for analysis of symptomatology:-

I- Pain: SITE: Where exactly is the pain experienced? (Ask the

patient to point). Site of maximum intensity= localizing pathology. Diffuse pain, variable, poorly described, or unrelated to anatomical structures= fibromialgia, malingering, or psychogenic.

RADIATION: Does the pain radiate elsewhere? = Neuropathy. CHARACTER. SEVERITY: visual analog scale 1-10 (intolerable pain in pt. doing normal

activities=psychogenic) ONSET, COURSE & DURATION , continuous or intermittent? FREQUENCY DIURNAL VARIATION Rest pain = inflammatory (RA). Usage pain = mechanical (OA). PRECIPITATING-FACTORS, trauma,…. WHAT Increase, WHAT Decrease ASSOCIATED SYMPTOMS, stiffness, redness or swelling IMPACT ON GENERAL CONDITION & LIFE STYLE ( sleep and functional capacity -- in relation to work? On normal daily life? Associated extra articular symptoms (skin rashes, eye inflammation etc.). PAST HISTORY OF SIMILAR ATTACKS, infections, autoimmune diseases,… any relevant past medical history?.

II- Stiffness:Joint tightness d.t. accumulation of inflammatory exudates & edema fluids--- distention of the periarticular tissues (capsule, tendosynovium, bursa). After activity; fluids washout from the inflammatory tissues & stiffness wears off. <1/2 hr. = mechanical. > 1hr. in the morning, or after a period of rest = inflammatory.

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Site: Affecting hands in RA & back in AS.

III- Swelling:Bony (hard), fluid (+ve fluctuation) or synovial thickening (firm in consistency). Specify & count the swollen joints. Diffuse or localized. Constant or episodic. Duration. + Signs of inflammation (pain, hotness, redness & limitation of

movement).

IV- Deformity:Fixed or correctable?Characteristic & specific?

V- Movement (Function): Normal painless daily activity? Painful daily activity? Limited movements? No movement (ankylosis)? Disability (unable to perform ordinary important movements, need for

house hold help) or handicapped (necessitates change of the life style &/or change or retirement from job)? = severity

VI- Muscle Weakness: distribution, duration & course. Myositis=proximal, persistent & progressive muscle. weakness.

VII- Sleep disturbance: (organic or psychogenic effects).

VIII- Systemic features (generalized constitutional symptoms)= systemic disease or paraneoplastic syndrome:

Low grade fever. Easy fatigability. Malaise. Weight loss. *Night sweets & fever.

IX- Extra-articular manifestations & review of systems:

Skin:

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Overlying traumatic/surgical scars or skin discoloration= clue for diagnosis.

Erythematous joint=sepsis or crystal.Rash (malar, photosensitivity, = SLE, purpuric eruptions= Vasculitis).

Adherent silver-like plaques = Ps A. Subcutaneous nodules: RA, SLE, RcF, PAN, Sarcoidosis.

Tophi: Gout.Alopecia: SLE, SScRaynaude’s phenomena (pallor, cyanosis then erythema): SSc, SLE,

RA, PM/DM, Vasc.Sclerodactyly, digital ulcers & gangrene: SSc. Palmar erythema: RA (most common pathologic cause>liver c. &

thyrotox.), while pregnancy is the most common physiologic cause.Keratoderma blenohemorrhageca= Reiter.

Nail changes:Clubbing: hypertrophic pulmonary osteoarthropathy & fibrosing alveolitis

(in SSc).Pitting, onycholysis, dystrophy: psoriasis, chronic Reiter’s syn.Splinter hge.: Vasculitis.

Mouth:Xerostomia, dysphagia: Sjogren (SS)Ulcers + genital = Behcet, SLE, Vasculitis (painful) & Reiter (painless).

Eye:Xerophthalmia: Sjogren (SS) (usually asymptomatic)== Schirmer test

(screening, confirmed by Rose Bengal stain & slit-lamp. D: lip biopsy).

Conjunctivitis: acute Reiter, SS.Episcleritis & scleritis: RA, Vasculitis.Iritis: AS, chr. Reiter.Iridocyclitis: pausiarticular juvenile chr. arthritis.

Cardiopulmonary:Dyspnea, chest pain, cough, haemoptysis: pleurisy, pericarditis (SLE, RA, SSC), vasculitis, pulmonary embolism & infarction, CHF, IHD,…

Endocrinal arthropathy:DM----------Neuropathic or septic arthritis.Hypothyroidism: carpal tunnel S., & myopathy.

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Hyperparathyroidism: pseudogout. Acromegaly: sever OA.GIT:

Reflux, dysphagia---- SSC.Abd. Pain, bleeding per rectum, diarrhea,= IBD--AS, Vasculitis.Jaundice = Viral hepatitis with arthropathy or vasculitis, cryoglobuline.

Genitourinary:Urithritis (dysuria, dyscharge)—Reiter, Gonorrhea,..Ulcers--- Reiter, Behcet.

Renal (nephritic, nephrotic): Puffiness, smoky urine, HPT, bilateral LL pitting swelling = SLE,

Vasculitis, RA, drugs… amyloidosis. Renal colic (stones), nephrocalcinosis= Hyperparathyroidism.

Hematological: Anemia, leukopenia, thrombocytopenia = SLE, BM depression by

drugs, hypersplenism in RA. DVT, fetal losses= APS. Hemochromatosis—sever OA.

CNS: Neuropathy, fits, behavioral changes, weakness, TIA, strokes = Lupus

cerebritis, vasculitis. Temporal headache = GCA.

Others: HCV, HBV, HIV,…

Family history

Similar condition in the family.Consanguinity.

Musculoskeletal diseases running in families:1. RA. 2. Gout. 3. ARF.4. AS. 5. Seronegative arthropathy (30% in PA).6. OA especially nodal disease of the fingers. 7. Marfan’s syndrome.

**Pt. understanding of the dis., goals of TTT, & psychosocial consequences must be discussed friendly bet. the pt.& his treating physician.

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DD. of Musculoskeletal pain:

I- Articular or Non-articular in origin:

(a) Articular Pain (eg. Arthritis) ==

*Diffuse pain & tenderness allover the joint line.

*Aggravated by both active & passive joint movement in ROM.

*Generalized joint swelling.

*Limited j. movement in all planes of ROM.

(b) Non-articular (periarticular) pain:==

To be differentiated from regional cellulites, erysipelas, peripheral neuropathy, skin injuries &/or inflammations.

Diffuse Localized*Generalized hypermobility.*Fibromyalgia Rheumatica.

*Localized for periarticular structures (ligaments, muscles, tendons, or bursa).*Localized swelling, tenderness, limitation of movement & aggravated by active movement only in the direction of the affected structure.

Ex. of localized pain by its origin:

Ligament==

Localized pain & tenderness at the point of attachment. Pain on stretch Instability if major tear.

Tendon==

Localized pain & tenderness at the line of muscle attachment. Swollen tendon line. Pain on resisted active movement.

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Bursa==Localized tenderness & swelling.

Pain on stretching adjacent structures.

Muscle==

Pain on active & resistant movement & on stretch of certain muscle.

II- Acute or Chronic onset:

Acute ChronicDuration <6 weeks >6 weeksEx. *Infectious arthritis.

*Crystal- induced.

*Traumatic.

*Reactive (Reiter, ?ARF).

*RA.

*Seronegative Spondyloarthropathy.

*OA.

* Chr. Sequences of trauma or back problems.

III- Inflammatory or Non-inflammatory:

5 cardinal signs of inflammation:

*Swelling (synovial distention).

*Warmth (the back of hand is a sensitive thermometer).

*Erythema (in septic & crystal arthritis + in palindromic RH., Reiter, ARF). *Tenderness. *Loss of function (limited ROM).

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Clinical markers of disease activity in inflammatory arthritis:

*Duration of MS.

*Night pain.

*Severity of constitutional symptoms.

*Additional joint involvement.

NB. The severity of pain is less important marker of inflammation as it is too subjected.

Comparison between Inflammatory & Noninflammatory arthritis:

Inflammatory Non-inflammatoryMS > 1hr. <1/2 hr.

Fatigue Significant. Minimal.

Activity Improve symptoms. Worsen.

Rest Worsen Improve.

Systemic manifestations

+ + - -

ESR, CRP + + - -

Corticosteroid Improve No effect

Ex. RA. Systemic rheumatic dis.

(SLE, SSC, Vas.). Infect.: Bact, Viral. Crystal. Reactive (Reiter, RF). Seroneg. (AS,IBD). Sarcoidosis, FMF,..

OA. Traumatic. Osteonecrosis. Neuropathic J. Metabolic

(hemochromatosis),

Endocrinal (thyroid, DM, Acromegaly)

IV- Pattern of joint involvement:

(a) Number of affected joints:

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* 1 joint = Monoarticular.

Acute Monoarthritis:

Inflammatory NoninflammatoryCrystal

Bacterial

Spondyloarthropathy

Palindromic Rheumatism

Traumatic

Sickle-Cell Disease

Osteonecrosis

In cases of erythematious acute monoarthritis, exclude septic or gouty arth. as a primary cause. Synovial fl. aspiration is diagnostic.

Chronic Monoarthritis:

Inflammatory Noninflammatory

Infectious: TB, Fung, Lyme.

Crystal.

Spon. A., Hemophilic

Synovial Tum.

OA

Osteonecrosis

Neuropathic

Adjacent bone lesion (Tum,Inf)

**2-4 joints affected= pausy or oligoarticular.

Ex.: Seronegative , Spondyloarthropatheis (AS, Reiter, PA & IBD)

*** >5 joints affected = Polyarticular. Ex.: RA, SLE.

.

V- Distribution of joint involvement:

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Symmetrical AsymmetricalEx. RA

SLEReiter

PsA

ASPeripheral Axial

Ex. RASLE

AS

PsA (70%-also affects IPJ--- sausage digits)

ReiterSmall Large

Ex. RASLE

Seronegative

Reiter

RF

VI- Sequence of joint involvement:

1- Migratory (fleeting) polyarthritis:Symptoms disappear in the affected joints to reappear in others.Ex.: ARF., Gonococcal, Viral.

2- AdditiveSymptoms persist with addition of new joint inflammationEx.: RA.

3- IntermittentAttacks of remissions & exacerbations in the same joint. Ex.: Gout.

Rheumatological Examination

General Examination

Pulse:Rapid due to Anemia, fever (ARF or activity, SLE, infections)

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Tachycardia out of proportion of fever (1ºc=10 b/m)= myocarditisBradycardia (HB), arrhythmia= SSc

Blood Pressure:HPT = SLE, Vasculitis, SSc, RA + renal, CVS---drugs?Hypo. = HF, dehydration, bleeding!

PallorActivity of CTD (anemia of chronic disease).Anemia (hemolytic, iron def. bl. loss, aplastic-drugs, ..)

CyanosisIPF=SSc, RA (bronchiolitis, fibrosing alveoltis, Caplan’s lung), Bilateral or extensive pleural effusion= SLEPericardial effusion=SLEHt. failure

JaundiceHemolytic = SLEDrugsViral hepatitis associated with or causing arthritis. Cryoglobulinemic arthritis in hepatitis pt.,Vasculitis.

FaceMalnutrition =TB, malignancy, sever disease, drugs.Cushingoid= steroid, endocrinal arthropathy.Alopecia=SLE, Drugs, SScButter fly rash sparing the nasolabial fold=SLEHeiotrope rash (puple-erythematous discoloration of upper eye

lid, nasolabial, forehead+ periorbital oedema)= DM.

EyeColorsDry (xerophthalmia)=SSCataract: premature, posterior capsular=Steroid, chloroquine.Puffiness: L. nephritis, NS, Amyloid, Drugs

MouthDry (xerostomia) = SSUlcers (B, R, SLE).

Neck:

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Thyroid swelling – autoimmune + SLE, hypothyroid with carpal tunnel, hypo or hyperthyroid with proximal muscle weakness.Neck veins: CHF, SLE, NS, Pericaldial, pleural effusion,LN: RA, Felty, SLE.

HandClubbing: Fibrosing alveolitis in RA, SSc, IBD, hyperthyroidNail pitting, loss of luster, splitting= PA.Onycholysis (separation of distal end from its plate):PA, thyrotox.Splinter hemorrhage, tender Osler nodes at finger pulps (tender

palpable nodules)& Janeway lesions=palpable purpuric spots on palm dt. microthrombi—necrotic lesions: RF+ SBE

Sclerodactyly: smooth, shiny, tapered fingers with taut, bound down skin.

Palmar erythema: RAMus wasting: RA (interossei), carpal t. S (thenar).Nodules: RA, ARF.Tophi: GOUTHeberden & Bouchard nodes: OAGottron’s papules (violaceous & flat erythematous & scally

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papules on the extensor aspect of PIP, MCP, elbow, knee, medial maleoli): PM/DMDigital ulcers & gangrene: RA, SLE, Vasculitis, SScNail bed infarcts= SLE-Vasculitis, RA, DM, SScTelangectasia of nail fold: DM, SLE.RP: SSc, MCTD.

Mechanics hand= DM

Skin:Characteristic rash: Butterfly malar, descoid,

photosensitive=SLEPsoriatic lesions (well-defined, raised itchy erythematosus

plaques covered by a loosely adherent silvery scales) =PA.

Purperic eruptions, Raised =VasculitisFlat=thombocytopenic purpera= SLE,Felty, drugs (gold, D- penicillamine)

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V-sign, Shawl-sign rash=PM/DM

Erythema marginatum (flat or raised annular erythematous macules or papules on trunk OR extremities) =ARFErythema nodosum (tender erythematous sc. Nodules on extensor aspects- shins)= Behcet, IBD, TB, Deep fungal infections,

leprosy, Sarcoidosis, drugs: sulfonamides, oral contraceptivesSC. Nodules: Firm, non tender & not attached to skin. ARF (0.5 cm over bony prominences of elbows, knuckles, ankles and occiput, don't ulcerate). RA (up to several cm, on elbows, t. achilles, scapula, hands, feet, sclera & myocardium), may ulcerate.Livedo reticularis: (erythematous netlike deep vascular

discoloration mostly on LL)=Vasculitis, SLETelangiectasis: dilated venules, capillaries & arterioles, matte-

oval or polygonal macules 2-7mm on hands, face, lips, oral GI mucosa- may bleed--anemia.

Thickening of the skin=SScCalcinosis: cutaneous deposits of calcium, firm, irreg.,

nontender,1mm-few cm, may inflame,on extensors of elbows, knees , PIP, finger tips

Vesiculopustular lesions, hemorrhagic papules=gonococcal arthritis.

Tophi (irregular firm nodules on extensor of fingers, forearm, elbow, achilles & helix of ear, may ulcerate discharging white chalky material MSUM) + preceded 10 yrs. by acute Gouty arthritis=.

LL: Oedema= NS, LN, amyloidosis (RA, Drugs), DVT (SLE, APS), Ulcers: Vasculitis + Still’s, RA, SLE. Or hemolytic anemia.Ischemia: Vasculitis.Keratoderma blennorrhagicum =vesicles, pustules, on palms

& soles with thick hyperkeratotic plaques =Reiter

Genitalia: Genital & Oral Ulcers = Behcet (on scrotum or labia, may penis

or vagina), Reiter (with circinate balanitis= confluent eroded red papules on corona & glands penis)

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Heart: Carry Coomb's murmur (Oedema of MV) = ARFSLE----Libman-Sacks endocarditis=verrucous---post. Leaflet MVPericarditis, myocarditis, IHD, systemic, pulmonary HPT = SLE

& Vasculitis Ankylosing Spondylytis--AR

Chest: Pleurisy, effusion=SLE, RA VAS.Pneumonitis, Alveolitis, Caplan's lung = RAPulmonary embolism, inf= APS

Abdomen: Splenomegaly = Felty, JRAHSM= SLE, RA

CNS: PN, Lateralization, muscle weakness = Vas, SLE, Entrapment neuropathy = RA

PM/DMLocal Examination

Physical examination of the locomotor system is extensive & complex; so, a brief screening procedure to pick up problems in certain

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regions is more appropriate. If an abnormality is detected, more detailed examination of the affected region can be undertaken.

Normal joint should be:1. Asymptomatic 2. Looks normal3. No special resting position 4. Moves smoothly through its ROM

Characteristic findings of inflammatory joint:

Synovitis: Most comfortable in neutral position. Decreased movements in all planes. Stress pain all direction (most sensitive). Capsular swelling/effusion (most specific). Joint line/capsular tenderness. Warmth. + Fine cripitus.

Tenosynovitis: Joint positioned to decrease tension on tendon. Decreased movement in the plan of tendon. Selective stress pain. Linear swelling & tenderness. + Fine cripitus. + triggering.

Mechanical arthritis: Abnormal shape (deformed joint). Coarse cripitus. Decreased movements in all planes. + Ligamentous stress pain/instability. + Synovitis.

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Rheumatologic Examination


: Screening examination of MSK system.(Gait, Arms, Legs & Spine)

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GALSGALS


Inspection

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Attitude = Position of the affected area at rest. Swelling. Deformity. Muscle wasting. Skin changes over the affected MSK area (erythema,

discoloration or scars). Telangiectasia, rash, or bruising. Symmetrical affection of MSK elements.

Palpation Warmth = inflammation. Tenderness (diffuse or localized). Swelling (hard, cystic fluctuation or firm). Deformity (correctable or not), dislocation or subluxation. Cripitus =audible & palpable during movement (fine, or

coarse). Muscle state (normal or atrophied) & muscle power.

Movement Active = by the patient Passive = by the examiner ROM (range of movement)=depends on age, sex & race. Stress test (moving joint passively toward its limitation) =

universal=all direct. in synovitis, selective in localized lesions. Resisted active movement= test periarticular (ms, tn, en)

*Synovitis= restricted both active & passive movements in all planes of ROM.*Myositis, bursitis, tendenitis….= restricted active with normal passive movements, only in the plane.

Joint stability.

Functional assessment: self care, ambulation, lifting, grasping, sleep..

Examination of specific joint movements

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Ask the patient to do active movements & compare with passive if limited.

I) Upper Limbs:

a) Hands =MCP, PIP, DIP J.

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Inspect for: skin changes, swelling (Heberden on DIP, Bouchard on PIP nodes), deformities (Swan neck, Boutonniere, ulnar deviation & z-shaped thumb) & muscle wasting.

Palpate for: tenderness, warmth, swelling, muscle bulk & power.

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Z-shaped thumb


Movements: Open & spread the fingers (extension & abduction). Fist=Close all fingers (flex, add.) to reach the palm &

thumb closes over them. Grip=pt. maximum strength in grasping 2 fingers of the

examiner. Pinch the tips of thumb with index finger. Metacarpal squeeze: between the examiner’s thumb &

fingers proximal to metacarpal heads if tender= arthritis.

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b) Wrists =radiocarpal J.

Inspect & palpate for: swellings, warmth & tenderness.

Stress test: to elicit mild tenderness= mild arthritis

Movements:

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Prayer position =full extension & dorsiflexion75 ْ . Full flexion=planter flexion 70 ْْ. Ulnar deviation 45 ْْ & radial deviation 20 ْْ. Carpal tunnel syndrome provocation:

Carpal tunnel syndrome =Occurs when the carpal tunnel space is reduced (e.g. when there is swelling of synovium due to inflammatory arthritis). The resulting compression of the (median) nerve causes a sensation of pins and needles and numbness and/or pain in the hand.

1) Tinel's sign =Paraesthesiae in lateral 3 1/2 fingers (mainly in the middle finger) experienced on percussion over the flexor retinaculum at the extended wrist.

2) Phalen's sign = The wrist is passively held in flexion for up to a minute. A positive result is when the patient experiences paraesthesiae in the fingers, usually predominantly the middle finger.

c) Elbow =Humeroradial, radioulnar J.:

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Inspect & palpate for:-

olecranon bursitis. Synovitis= firm, tender, hot swelling at fossae between

olecranon & medial or lateral epicandyles. Subcutaneous nodules & tophi, at or below olecranon.

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Movement: Bend (flex=0-150 ْ) & straighten both elbows (ext=0 ْ). ْWْith elbows flexed at 90 ْْ & fixed to his side (to

prevent shoulder movements) ask pt. to turn palms up (supination 0-90 ْْ) & down (pronation 0-90 ْْ) using thumb as indicator.

Resisted active movements: Lateral epicondylitis & Medial epicondylitis.

d) Shoulders = Glino-humeral, scapulo-thorasic, acromio-clavicular, sterno-clavicular J.:

Inspect for: skin changes, swelling, deformities& muscle wasting.

Palpate for: warmth, swelling, tenderness over the anterior aspect & tip of shoulder, acromio-clavicular, sterno- clavicular, scapulo-thorasic , muscle bulk, contour & power.

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Winging of the scapula due to a palsy of the long thoracic nerve. The appearance of winging may be exaggerated by asking the patient to hold the arms out in front of him and especially if they push against something at the same time. .

Movements:(Flexion, extension, abduction, adduction & rotation)

Pt. put both hands behind the head with elbows pointing laterally (abd, flx., & ext. rot).

Hands down, hands behind back & thumb pointing up marking the highest vertebra pt. can touch by each side (ext., add. & int. rot.).

Restriction of movements &/or pain in the shoulder may be due to abnormalities in:

1. Glenohumeral joint: pathology excluded if passive external rotation not limited.

2. Rotator cuff muscles tendon inflammation= commonest cause of shoulder pain as arm moves up through mid arc of abduction (40-120 ْْ ). (SITS= supraspinatus, infraspinatus, teris minor & subscapularis).

3. Acromioclavecular joint-OA---hard swelling & tenderness with pain in shoulder abduction >120 ْْ.

II) Lower limb:

a) Hip joint:

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Inspect for: Gait, pelvic tilt-scoliosis, swelling, deformities & muscle wasting.

Palpate for: warmth, swelling & tenderness.

Measurement: True leg length=from ASIS—lateral maleolus (to

detect congenital or acquired disorders).Apparent leg length= Umbilicus –medial maleolus (to

detect scoliosis, pelvic contractures--- pelvic tilt.

Movements: Hip flexion 0-120° & extension -10°. Internal 25° & external rotation 35° examined while

both hip & knee flexed 90°; using the tibia as indicator for the angle of rotation.

Leg roll maneuver: to examine Internal 90° & external rotation 90°while hip & knee are extended, using foot as indicator for the angle of rotation.

The last 2 tests are sensitive for hip pathology.Trendelenberg’s sign:

Normally on standing on normal leg, the pelvis tilts to the same side. On standing on the side of the diseased hip, the pelvis fails to tilt towards the same side, so, drops to the other side=weak gluteus medius.

b) Knee

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Inspection: Swelling, redness, muscle wasting, & specific deformities: Genovulgum=knock knees. Genuvarum=bow leg.

Palpation: Swelling (soft, cystic or hard / diffuse, localized), warmth, tenderness = localized or along joint line = inflammatory. Muscle wasting / compare thigh circumferences 10cm above the patella.

Signs of knee effusion:

Patellar tap = for large amount, left hand of examiner compressing the suprapatellar & parapatellar areas—pushing fluid behind patella, with other hand fingers push patella against femur –tapping sensation.

Patellar bulge sign=for small amount, milking effusion from medial upward & laterally, then tap behind & lateral to patella observing the medial patellar fossa for

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refilling, thumb pressing on patella.

Movements: Flexion & extension (0-150)

Patellofemoral Crepitus: With examiner’s palm on knee during full flexion & extension. Fine / coarse.

Patellofemoral compression test: push patella against femur while knee in extension & pt. contracting quadriceps—sever pain & tenderness=patello-femoral pathology.

Stability: Lachman’s test =integrity of anterior cruciate ligament. Knee flexed 20, femur grasped with lt. hand & pulling tibia forwards with rt. hand.

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Collateral ligaments: abduction & adduction (medial & lateral displacement) stretch between tibia & femur while knee in flexion to elicit any movement.

Popliteal area: Backer cyst-rupture-DD: DVT

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c) Ankle & foot:

Inspection: synovial soft tissue swelling at both malleoli, DD. Periarticular oedeme, cellulites & fat pad.

Deformities: Pes planus (flat foot= talar head displaced medially & plantar-ward), pes cavus (high arch),

Hallux valgus=lateral displacement of proximal phalanges on metatarsal heads in RA.

Cock-up (claw) toe: flexion of IPJ +MTP subluxation. Hammer toe: hyper ext. MTP, flex. PIP, hyper ext. DIP.

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Palpation:

Tender ankle or MTP=synovitis, tenderness in between metatarsals 3rd-4th /2nd-3rd =Morton neuroma, over metatarsals=? march fracture. Metatarsal compression test=squeeze between examiner’s thumb & fingers just proximal to metatarsal heads= ?synovitis.

Movements:

Ankle & foot=3 groups of joints:* Tibiotalar=ankle—Plantar flexion 50° & dorsiflexion 20°.

* Subtalar=talocalcaneal j.: Stabilize the ankle or distal leg by lt. hand & rotate the foot passively by rt = 5° of inversion or eversion.

* Mid tarsal j.----Stabilize the heel=calcneum by lt. hand & rotate the forefoot passively by rt. ---inversion 35° & eversion 20°.

* 1st. MTP – plantar flexion 40° & dorsiflexion 65°.

III) Spine:

Inspection:

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Normal cervical & lumbar lordosis (concavity to back) & thoracic kyphosis (front concavity)

Deformities: scoliosis (lateral deviation of spine), kyphosis (anterior deviation), lordosis (posterior) & gibbus (kyphosis with acute angle due to infection/TB or fracture).

Palpation: For tenderness, warmth, muscle wasting, bony abnormalities.

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Movements:Cervical spine: notice any localized or radiating pain/

tenderness or limited mobility on active or passive: Flexion=75, extension 60, Rt. & Lt. Rotation 80, Rt. & Lt. bending 45.

Thoracic spine: Rt. & Lt. rotation at thoracolumbar 45.Chest expansion = difference bet. full expiration & insp>6cm

Lumbar spine: Flexion 90, Extension 30, Lateral bending (to touch sides of knees)15-30.

Lumbosacral: anterior flexion--- increased distance bet. D12-L1>7cm.

Schober test: limited flexion ?AS.Put a mark at the level of PSIS or lumbosacral j.& another10 cm above, ask pt. to touch the toes with extended knees, measure the distance bet. the 2 marks should be>17cm.

Finger tips-floor distance <10cm =index for combined hip & lumbosacral flexion.

.

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Nerve Stretch signs

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Sciatic N root compression: L5 & S1, stressed by

1. Straight leg raising with hip flexion (normally to 90), if limited by pain flex knee to allow more hip flexion, then straighten it if pain = +ve Lasegue test.

2. Confirmed by flexing knee slightly, dorsiflex ankle (+ve Bragard test),

3. Pressure over the popliteal fossa may also induces root irritation (bowstring)

Femoral N roots=L2,3&4, stressed by asking pt. to lie prone, flexion of knee—pain exacerbated by hip extension.

Pain worsens after compressing the spine by pressing on head vertically of standing or sitting pt.

Level of lesion:L4 root=lost knee reflex & weakness of quadriceps.L5=weak extensor hallucis longusS1=lost ankle reflex & weak soleus

.

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Sacroiliac Joint:

pelvic compression with pt. on his side. Or by compression with springing of the pelvis while pt. in flat supine position, pushing the 2 ASIP by the 2 examiner’s hands postero-laterally=trying to open the book. Or by hip flexion & adduction to push knee toward the other ASIS, iliac fossa. Or by local examination on prone position to elicit any swelling, warmth, or tenderness.

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Approach to patient with musculoskeletal symptoms

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Musculoskeletal complaint


Interpretation of Synovial fluid analysis

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Indications for synovial fluid aspiration: Monoarthritis (acute or chronic). Joint trauma & effusion. Suspicion of joint infection, crystal, or hemarthrosis. Acute monoarthritis in pt. with chr. Polyarthritis.

Is the effusion hemorrhagic?

Analyze fluid for: Appearance, viscosity. WBC count & differential. Gram stain, culture & sensitivity. Crystal identification by polarized microscopy.

DD: Traumatic or

mechanical. Coagulopathy. Neuropathic.

Inflammatory or noninflammatory articular condition?

Noninflammatory: OA TraumaticIs WBC>

2000/cmm?

Inflammatory or septic arthritis?Is PMNs> 75%?

Are crystals present?Gout or Pseudogout.

Other Inflammatory or septic?Gram stain & culture essential.WBC>50,000/

cmm?Inflammatory? Septic?

History & Examination? Articular or non Acute or chr. Inflammatory or non. No. & distribution

Articular?Nonarticular: Traumatic Fibromyalgia Polymyalgia R. Bursitis/tendenitis

Acute or Chronic ?

Chronic>6W.Acute<6 W.

Acute arthritis: Infectious Crystal-induced Reiter’s Presentation of

Chr. Arth.

Inflammatory or noninfl.

Chronic non-inflammatory

arthritis

Chronic inflammatory arthritis= MS>1hr,

synovial swelling, warm, j.tender, syst. Manifes.,

CRP, ESR

>4 J = polyarthritis1-4=mono-oligo AChr. Inf.PA- RS- PJA

Affects Wt. Br. J. (H&k)., DIP< CMC

Symetrical

PIP, MCP, MTP

PA, RSOsteonecrosis

CharcotarthritisOA

RASLE, SSc, PM


Common Presentations Of Common Rheumatic Diseases:

1. Acute migratory polyarthritis (extremely painful) affecting large joints (knees, ankles, elbows & wrists) in a child (5-15ys.); fever, exertional dyspnea (cardotis), involuntary movements (chorea-may occur after months), skin erythematous plaques with rounded borders over trunk (erythema marginatum), sc. nodules, after a history (18 days)of URTI. (Group A-B-H. strept.=Rheumatogenic) = ARF.

2. Chronic polyarthritis affecting small joints bilaterally & symmetrical, with additive sequence in female. Both hands are almost involved + MS>1hr. deformities, with systemic and extra-articular effects, nodules, RF, X-R=RA.

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3. Symmetrical polyarthritis/arthralgia affecting peripheral joints in middle aged female, with FUO, butter fly rash, photosensitivity, alopecia, oral ulcers, headache (HPT), behavioral changes, +fits, puffiness/LL swelling, dyspnea, chest pain, pallor, easy fatigue, peripheral vascular manifestations (ischemia, RP, DVT), smoky urine =SLE.

4. Chronic oligoarthritis affecting large axial joints, LBP & morning back stiffness for >3 months in a male patient, improved by exercise, unrelieved by rest+ limitation of lumbar spine movements & chest expansion=AS. If with symptoms & signs of IBS; =enteropathic arthritis.

5. Sudden LBP after lifting heavy object or bending with radiation to lateral leg= disc herniation & sciatica.

6. Asymmetrical oligoarthritis affecting large, small joints (sausage digits) &/ or back (Spondyloarthropathy) with psoriatic skin & nail pitting= PsA.

7. Arthritis/enthesitis, urethritis, conjunctivitis or uveitis, cercinate balanitis, keratoderma blennorragicum & painless mucosal ulcers; 1-4w after attack of GI or genitourinary infections=RS.

8. Arthritis in large weight bearing joint in obese post menopausal woman pain increasing at night after the day time usage +/- Heberden & Bouchard nodes=OA.

9. Polyarthritis/arthralgia, joint stiffness, flexion contractures in a female with tight skin, sclerodactyly, telangiectasia, sc. calcifications, progressively repeated attacks of RP, digital ulcers/gangrene, dysphagia, GERD, dyspnea, cyanosis, cardiac and renal troubles=SSc.

10. Acute intermittent attacks of monoarthritis with sever pain, redness, swelling of 1st MTP=podagra, ankle, knee-exclude

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septic arthritis (30% polyarticular) after diuretic, alcohol, surgery, CRD, wt. Reduction & inf. =Gout.

11. Recurrent oral ulcers, > 3 times in 1yr.+ genital ulcer or scare, uveitis, cells in vitreous, retinal vasculitis, superficial thrombophlebitis, erythema nodosum, papulopustules + pathergy (2mm eryth- 1-2days-25g-5mmdepth) =Behcet.

12. Arthritis, palpable purpuric eruptions in LL & abdominal pain + hemoptysis & GI bleeding in a child after upper respiratory tract infection = HSP.

13. A history of asthma, allergic rhynitis, atopy, peripheral neuropathy, cutaneous eruptions, pericarditis, cardiomyopathy, myocardial infarction and hypereosinophilia may suggest Churg-Strauss syndrome (CSS).

14. In any patient over the age of 50 with recent onset of headache, Jaw claudication and scalp tenderness, loss of vision, myalgias, fever (FUO), a high ESR, or anemia ??? The diagnosis of GCA should be considered.

15. Involvement of the lung (dyspnea, hemoptysis), kidney (hematuria, proteinuria), and upper respiratory tract (nasal sinus) should suggest the possibility of WG.

16. Arthritis, acute onset of high fever, bilateral conjunctival congestion, "strawberry" tongue. Painful cervical LN, exanthema of the trunk, carditis with heart murmurs and ECG changes. Coronary artery lesions, abdominal pain, vomiting, & diarrhea in child <5yrs.= Kawasaki.

17. Myalgias, arthralgias, fever, sudden onset of sever HPT, LL swelling (nephrotic syndrome) & renal failure (GN), chest pain, dyspnea on exertion (angina or myocardial infarction, pericarditis). Abdominal pain, bleeding, and bowel obstruction or perforation, intraperitoneal hemorrhage (Rupture of mesenteric

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aneurysm). Peripheral neuropathy, painful mononeuritis multiplex, seizures, CVA. Palpable purpura, urticaria, livedo reticularis, peripheral gangrene and skin nodules. Orchitis and epididymitis in a male, around 40s = PAN.

18. Myalgias, arthralgias & Symptoms of vascular insufficiency (claudication, transient visual disturbances, and syncope) occur with bruits, weak pulses, and discrepancies of limb blood pressure (LL>UL), in young women 15-25yrs.=Takayasu.

19. Arthralgia, Proximal muscle weakness & tenderness, heliotrope rash on the upper eye lid, Gottron eruption over PIP & MCP. Cardiomyopathy, Ht. Failure + S & S of malignancy (lung, stomach, colon & breast)= Polymyositis & Dermatomyositis

20. Pain & tenderness at the lateral epicondyl & extensor mus. Close to it dt. repetitive wrist extension or supination & pronation increased by resisted active wrist extension= Tennis elbow= lateral epicondylitis

21. Carpal tunnel syndrome (CTS) commonly occurs in diabetic, hypothyroid & acromegalic patients. Up to 15% of all patients with CTS will have diabetes. Patients present with numbness in the median nerve distribution. Nocturnal paresthesias, hand pain, and pain radiating to the elbow or shoulder (Valleix phenomenon) can also occur. Tinel’s and Phalen’s signs may be positive. Thenar atrophy is a late sign and indicates muscle denerva tion.

22. Chronic diffuse pain (>3months), tender points, normal lab., + MS, fatigue, sleep disturbance, depression, anexiety, headache, paresthesias & RP = Fibromialgia Rheumatica.

Raynaud's phenomenon =Blanching of the extremities on exposure to cold. It is usually followed by blue, cyanotic discolouration on rewarming. It may occur in isolation or in association with a connective tissue disease

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References Atlas Rheumatic diseases Barbara Bates, A guide to physical examination & history taking, 6th ed , 1995. Davidson's principles & practice of Medicine 19th ed. 2002. Harrison's principles of Internal Medicine, 14th ed. 1998. ILAR, EULAR Reumatology Web siteS Kelly's text book rheumatology 6th ed. 2001. Manual of Reumatology & outpatient Orthopedic disorders, 4th ed. 2000. Medscape Reumatology Web sites Oxford handbook of Rheumatology, 2002. Rheumatology examination &injection techniques, 1992. Rheumatology Secrets, 2nd. Ed. 2002. WWW.oup.com

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