Prof. Dr/ Abdel Azeim AlhefnyProf. of Internal Medicine, Rheumatology & Immunology

Director of Rheumatology unitAin Shams University

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

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.

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

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?

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.

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)

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 thenature 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.

I. Articular or Nonarticular ?

• Articular pain is localized to a specific joint, both

passive and active Range Of Motion (ROM) arerestricted in all planes.

• Nonarticular pain originates from periarticular

structures (tendon or bursa), only active ROM isrestricted in the plane of involved structure.

• Diffuse nonarticular conditions: generalized

hypermobility and fibromyalgia (diffuse aches

and pain)

II. Acute or chronic?

• Acute musculoskeletal disorders are defined asthose of <6 weeks duration:

1) viral arthritis 2) gout 3) reactive arthritis

• Chronic MSK disorders are defined as thoselasting > 6 weeks: non-inflammatory(osteoarthritis) and inflammatory (rheumatoidarthritis).

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.

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

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 withsubsequent involvement of other joints.

(rheumatoid arthritis)

3) Intermittent:Repetitive acute attacks with complete remission.

( gout)

Number of joints involved

• Monoarthritis: one joint involved

Septic arthritis and crystal arthropathy .

• Oligoarthritis: (2-4 joints involved)

e.g. spondyloarthropathies (ankylosingspondylitis, psoriatic arthritis. reactive arthritis and inflammatory bowel disease related arthritis).

• Polyarthritis : more than 4 joints involved.

e.g rheumatoid arthritis

Distribution of joints

involved

• Symmetrical or asymmetrical

• Axial or peripheral

• Large or small joints

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

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).

Examination

• Gait Arm Leg Spine (GALS screen) to detect important MSK abnormalities and functional disability.

• Gait:

Observe the patient's gait for rhythm andsymmetry.

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 fortenderness, swelling or increased warmth.

Doherty M et al The “GALS” screen. Ann Rheum Dis 1992;51:1165-1169

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.

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.

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.

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) andexternal 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 theankles in neutral position.

• Ask the patient to flex and extend the metatarsophalangeal (MTP) joints.

Spine

• Look: observe the standing patient's spine from behindand 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 earon 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.

Recording examination findings

CLINICAL

PRESENTATIONS

Discoid rash

Sub acute Cutaneous Lupus

Oral ulcers Arthritis (nonerosive)

Localized alopecia

Wide spread non scaring alopecia

Vasculitis

Raynaud’s

Joint Effusion

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, ulnardeviation, cock-up toes, or hammer toes.

Hand deformities

Z deformity

Carpal tunnel syndrome

1) Tinel's sign 2) Phalen's sign

The Elbow

The Shoulder

The Knee

Foot deformities

Cock-up toes, or hammer toes in RA

Bones of the foot

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-articularmanifestations.•all patients with rheumatoid nodules are seropositive for RF.

54

PANcont.

Gangrene

Livedo reticularis

55

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Behçet's syndromeOral ulcers Genital ulcers

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Heberden’s and Bouchard’s Nodes

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

Hallux valgus and cock-up toedeformities, characteristic ofosteoarthritis in the foot.

Knee deformity in OA

Sciencephoto.com

Deformities

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.

Erythrocyte Sedimentation Rate (ESR)

Range :<15 mm/hr for men

<20mm/hr for women

Age adjusted:

(Males) Age

2

(Females) (Age + 10)

2

Infections, bacterial (35%) e.g. TB.

Connective tissue diseases (25%)

Malignancy : lymphoma , myeloma (15%)

Other causes (22%)

Unknown (3%).

Markedly elevated ESR (>100mm/hr)

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

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

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

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

Infections:

Ch. hepatitis, especially hepatitis C (45%)

Bacterial endocarditis

Tuberculosis.

Syphilis.

Leprosy.

HIV infection

Other conditions:

Healthy aging individuals.

Idiopathic pulmonary fibrosis.

Cirrhosis.

Sarcoidosis.

Neoplasms.

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)

Rheumatoid Factor

Anti CCP

Acute phase reactants (nonspecific)

ESR

CRP

Serological Markers for RA

ANA immunofluorescent patterns

diffuse

nucleolarspeckled

peripheral

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

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Serological Tests to Aid Diagnosis of SLE

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

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.

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

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

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

Progressive joint damage in RA

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).

Rheumatoid arthritis: knee joints

symmetric narrowing of medial and lateral joint spaces that is characteristic of RA

Radiographic features

1st CMC

(thumb base)

Serositis:

• Pleurisy

• pericarditis

CXR : pleurisy

Pleural and pericardial effusions

(CT chest)

Rheumatoid lung nodules & pl eff in pt with chronic RA

lung nodules

cerebral vasculitis

MRI in RA

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

Higher sensitivity than XR for detection of bone erosions in RA

( M. Szkudlarek et al, eular June,2004)

Ultrasonography in RA

• 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

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).

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 articularFibromyalgia R

Hypermobility S

Inflammatory or non-inflam.

Chronic inflammatory arthritis= MS>1hr, synovial swelling,

warm, j.tender, syst. manifes., CRP, ESR

Chronic non-inflammatoryarthritis

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

OsteonecrosisCharcotarthritis

OA

>4 J = polyarthritis1-4=mono-oligo AChr. Inf.

PA- RS- PJA Symetrical

PA, RS PIP, MCP, MTP

SLE, SSc, PM RA

2

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+-

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