Basics approaches to the joint disorders.

1. Approach to articular
disorders
Mono/polyarthraitis
Presented by: Dr. Kanhu Charan Mallik
Moderator: Dr. Srikumar

2. Evaluation of Patients With
Musculoskeletal Complaints
Goals
• Accurate diagnosis
• Timely provision of therapy
• Avoidance of unnecessary diagnostic testing
Approach
 Anatomic localization of complaint (articular vs. nonarticular)
 Determination of the nature of the pathologic process
 (inflammatory vs. noninflammatory)
 Determination of the extent of involvement (monoarticular,
 polyarticular, focal, widespread)
 Determination of chronology (acute vs. chronic)
 Consider the most common disorders first
 Formulation of a differential diagnosis
 What is the impact of the condition on the patient’s life?

3.  Articular Vs. Non-articular
Must discriminate the anatomic origin(s) & pt.s complaint
Requires a careful & detailed examination
Articular
 Articular structures- the synovium,
synovial fluid, articular cartilage,
intra-articular lig., joint capsule and
juxta-articular bone.
 Articular disorders may be
characterised by deep or diffuse
pain, pain or limited ROM on
active and passive movement,
and swelling( caused by synovial
proliferation, effusion, or bony
enlargement), crepitation,
instability, “locking” or deformity.
Non-articular
 Non-articular( Peri-articular) structures-
supportive extra-articular lig.s,
tendons, bursae, muscles, fascia,
bone, nerve and overlying skin.
 By contrast non-articular disorders
tend to be painful on active, but not
on passive(or assisted) ROM. Non-
articular joints seldom demonstrate
swelling, crepitation's, instability or
deformity of jt. itself.
 Peri-articular conditions often
demonstrate joint or focal tenderness
in regions adjacent to articular
structures and have physical findings
remote from the joint capsule

4. Distinguishing Inflammatory vs
Noninflammatory Joint Disease by Features
Feature Inflammatory Noninflammatory
Systemic symptoms Prominent, including
fatigue
Unusual
Onset Insidious
Usually affecting multiple
joints
Gradual
1 joint or a few joints
Morning stiffness > 1 h < 30 min
Worst time of day Morning As day progresses
Effect of activity on
symptoms (joint pain and
stiffness)
Lessen with activity
Worse after periods of rest
May also have pain with
use
Worsen with activity
Lessen with rest

7. Impact of the condition on the patient
 Understanding the impact of the disease on the patient is crucial to
negotiating a suitable management plan.
 Ask open questions about functional problems and difficulty in doing
things.
 It may be easiest to get the patient to describe a typical day, from
getting out of bed to washing, dressing, toileting etc.
 Potentially sensitive areas, such as hygiene or sexual activity, should
be approached with simple, direct, open questions.
 The impact of the disease on the patient’s employment will be
important.
 A patient’s needs and aspirations are an important part of the
equation and will influence their ability to adapt to the condition.

9. Drug-Induced Musculoskeletal Conditions
Arthralgias
Quinidine, cimetidine, quinolones, chronic acyclovir, interferon, IL-2, nicardipine, vaccines, rifabutin, aromatase and
HIVprotease inhibitors
Myalgias/myopathy
Glucocorticoids, penicillamine, hydroxychloroquine, AZT, lovastatin, simvastatin, pravastatin, clofibrate, interferon, IL-2,
alcohol, cocaine, taxol, docetaxel, colchicine, quinolones, cyclosporine, protease inhibitors
Tendon rupture/tendinitis
Quinolones, glucocorticoids, isotretinoin
Gout
Diuretics, aspirin, cytotoxics, cyclosporine, alcohol, moonshine, ethambutol
Drug-induced lupus
Hydralazine, procainamide, quinidine, phenytoin, carbamazepine, methyldopa, isoniazid, chlorpromazine,
lithium, penicillamine, tetracyclines, TNF inhibitors, ACE inhibitors, ticlopidine
Osteonecrosis
Glucocorticoids, alcohol, radiation, bisphosphonates
Osteopenia
Glucocorticoids, chronic heparin, phenytoin, methotrexate
Scleroderma
Vinyl chloride, bleomycin, pentazocine, organic solvents, carbidopa, tryptophan, rapeseed oil
Vasculitis
Allopurinol, amphetamines, cocaine, thiazides, penicillamine, propylthiouracil, montelukast, TNF inhibitors,

10. Clinical history
 Aspects of the pt.s profile( Age, sex, race considerations)
 Complaints chronology
 Extent of joint involvement
 Precipitating factors
 Age groups( Age prevalence of different conditions)
 Sex
 Racial
Young Middle age Elderly
SLE
Reactive arthritis
Fibromyalgia
RA
OA
Polymyalgia
rheumatica
Male Female
Gout
Spondyloarthropathies(e.g. AS)
RA
Fibromyalgia
Lupus

11.  Familial aggregation- as in AS, gout,Heberden’s nodule of OA
 Chronology of the Complains- imp. Diagnostic feature
- divided into onset, evolution, duration
 Onset:
 Evolution
 Duration
Abrupt Indolent
Septic arthritis
Gout
OA
RA
Fibromyalgia
Chronic Intermittent Migratory Additive
OA Crystal or Lyme’s
disease
Rheumatic fever
Gonnococcal or
Viral Arthritis
RA
Psoriatic
arthritis
Acute ( < 6 wk ) Chronic ( > 6 wk )
Infectious
Crystal induced
-non-inflammatory or immunologic arthrides (
e.g. OA, RA ) & non-articular disorders ( e.g.
fibrmyalgia)

12. Precipitating Events
 Trauma( Osteonecrosis, meniscal tear)
 Drug
 Antecedent or intercurrent illness( Rheumatic fever, Reactive arthritis,
Hepatitis)
Co-morbidities predisposing to musculoskeletal complaints
 DM-CTS
 Renal insufficiency- Gout
 Psoriasis- psoriatic arthritis
 Myeloma- low back pain
 Cancer- myositis
 Drugs-
 Glucocorticoids- osteonecrosis, septic arthritis
 Diuretics
 Chemotherapy

13. Symptoms
• Pain
• Stiffness
• Limitation of motion
• Swelling
• Weakness
• Fatigue

14. Pain
 Localize pain anatomically.
 Ask the pt. to point to the area of pain with one finger
 Pain in the jt.- most probably articular disorder
 Pain between jt.s- bone or muscle disorders or referred pain
 Diffuse pain, variable, poorly described or unrelated to
anatomic structures- Fibromyalgia, malingering or
psychogenic problems.
 Severity of pain- 1 t 10
 Jt. Pain at rest and mov.- inflammatory process.
 Pain primarily during activity- Mechanical

15. Stiffness
 Discomfort perceived when the pt. attempts to move jt.s after a
period of inactivity.
 When it occurs stiffness or gelling, usually develops after several
hours of inactivity.
 Morning stiffness- RA
Morning stiffness a/w non-inflammatory jt. Dis. Is
always of short duration( usually less than 30 min) & of less severity than
the stiffness of the inflammatory jt. Dis.
 Absence of morning stiffness though does not exclude systemic
inflammatory diseases, it’s absence is uncommon.

16. Limitation of Motion
 It must be differentiated from stiffness because stiffness is usually
transient but true limitation of motion is fixed & not variable from hour
to hour.
 Determination of the extent of disability resulting from lack of motion is
imp.
 Ascertain- the length of time of limitation of ROM,
whether both active & passive ROM are restricted,
whether it began abruptly( may suggest mechanical
derangement e.g. a tendon rupture) or gradually suggesting
inflammatory jt. Dis.

17. Swelling
 True joint swelling narrows the D.D.
 Ask where & when the swelling occurs
 A description of the exact location of the swelling
 Onset, persistence & factors that influence the joint are also imp.
 Discomfort with use of swollen part may indicate synovitis or bursitis

18. Weakness
o when it is present, a loss of motor power or muscle strength is nearly
always objectively demonstrable on physical examination
o Examiner must determine whether there is “true weakness” or “give
way” weakness.
 In musculoskeletal disorders- weakness is persistent rather than
intermittent
 Initially good strength with subsequent weakness- clue to
neuromuscular disorders
 Inflammatory myopathies- proximal weakness
 Distal weakness- neurologic disorders or inclusion body myositis

19. Fatigue
 Defined as inclination to rest even though pain & weakness are not
limiting factors
 It is a normal phenomena after various degrees of activity but should
resolve after rest.
 In rheumatic disease fatigue may be prominent even after rest.
 Malaise commonly occurs with fatigue.
 Malaise is an indefinite feeling of lack of health.
 Stiffness is a discomfort during movement & weakness is an inability to
move normally, esp. against resistance.

20. Important physical signs of arthritis
• Swelling
• Tenderness
• Limitation of motion
• Crepitation
• Deformity
• Instability

21. Swelling
 Swelling around a joint may be caused by intra-articular effusion, synovial
thickening, periarticular soft tissue inflammation( such as tendinitis or bursitis),
bony enlargements or extra-articular fat pads.
 A joint effusion is often visible, compare jt. Of one side with the opp. Side for
symmetry or asymmetry
 Palpable fluid in a jt. Without recent trauma suggests synovitis.
 Thickened synovial membrane- chr. Inflammatory arthrides such as RA, may have
a “doughy” or “ boggy” consistency.

22. Tenderness
 Is an unusual sensitivity to touch or pressure
 Localization of tenderness by palpation helps to determine whether
the pathologic site is intra- or peri-articular, such as fat pad, tendon
attachment, ligament, bursa or muscle or in the skin.
 Also palpate the non-involved str.s to help asses the significance of
tenderness.

23. Limitation of Motion
 Normal type & ROM of each jt. Must be kept in
mind
 Comparison with an unaffected jt. Of opp.
Extremity should be done
 Limitations in ROM may be d/t limitation in the jt.
Itself or in the periarticular strs.
 In pt. with jt. Dis. Passive ROM is often greater
than the active type, possibly because of pain,
weakness or the state of articular or peri-
articular stress.
 The pt. must be relaxed.

24. Crepitation
 It is a palpable grating or crunching sensation produced by motion.
 May or may not be accompanied by pain.
 Fine creps on palpation over jt.s- Chronic inflammatory arthritis
 Coarse creps- Inflammatory or non-inflammatory
 Bone-on-bone creps- a palpable or audible “squeak” of higher frequency.

25. Deformity
 Is the mal-alignment of the joints
 Manifested by a bony enlargement, articular sublaxation,
contracture or ankyloses in non-anatomical positions.
 Deformed joints:-
1) Do not function normally
2) Frequently restrict activities
3) May give rise to pain esp. hen put to stressful use
4) May be of cosmetic concern

26. Instability
 Is present when the joint has greater than normal movement in any
plane
 Subluxation
 Dislocation
 Again pt. must be relaxed.

27. Rheumatic review of systems
Systemic features:-
o Fever
o Rash
o Nail abnormalities
o Myalgias
o Weakness
Involvement of organs
 Eyes ( Behcet’s disease, Sarcoidosis, Spondyloarthritis)
 GIT ( Scleroderma, IBD)
 GUT ( Reactive arthritis, gonococcemia)
 Nervous system( Lyme’s disease, vasculitis)

28. Red flags:
 These red flags should always prompt consideration of serious pathology and
can be indicative of any inflammatory, infective or neoplastic process
 Erythema, warmth, effusion, and decreased range of motion
 Fever with acute joint pain
 Acute joint pain in a sexually active young adult
 Skin breaks with signs of cellulitis adjacent to the affected joint
 Underlying bleeding disorder or use of anticoagulants
 Systemic or extra-articular symptoms
 Weight loss
 Night pain
 Single joint involvement
 Neurological symptoms and signs

29. Recording of joint Examinations
The “S-T-L “ system records:-
Degree of Swelling (S)
Tenderness (T)
Limitation of movement (M)
on a basis of a quantitative estimation of gradation.
grade ranges from 0(normal) to 4(highly abnormal)
In limitation of motion:
Grade 1= 25% loss of motion
2= 50% loss of motion
3= 75% loss of motion
4= Ankylosis

30.  Performing a regional examination of the musculoskeletal system
(‘REMS’) -
 Regional examination of the musculoskeletal system refers to the
more detailed examination that should be carried out once an
abnormality has been detected either through the history or
through the screening examination.
 REMS involves the examination of a group of joints which are linked
by function, and may require a detailed neurological and vascular
examination.
 five key stages:-
 Introduce yourself.
 Look at the joint(s).
 Feel the joint(s).
 Move the joint(s).
 Assess the function of the joint(s).

31. Introduction
 It is important to introduce yourself, explain to the patient what you
are going to do, gain verbal consent to examine, and ask the
patient to let you know if you cause them any pain or discomfort at
any time.
 In all cases it is important to make the patient feel comfortable
about being examined. A good musculoskeletal examination relies
on patient cooperation, in order for them to relax their muscles, if
important clinical signs are not to be missed.

32. Look
 The examination should always start with a visual inspection of the
exposed area at rest.
 Compare one side with the other, checking for symmetry. You
should look specifically for skin changes, muscle bulk, and swelling in
and around the joint.
 Look also for deformity in terms of alignment and posture of the joint.

33. Feel
 Using the back of your hand, feel for skin temperature across the
joint line and at relevant neighbouring sites.
 Any swellings should be assessed for fluctuance and mobility. The
hard bony swellings of osteoarthritis should be distinguished from the
soft, rubbery swellings of inflammatory joint disease.
 Tenderness is an important clinical sign to elicit – both in and around
the joint.
 Identifying inflammation of a joint (synovitis) relies on detecting the
triad of warmth, swelling and tenderness.

34. Move
 The full range of movement of the joint should be assessed.
 Compare one side with the other. As a general rule both active movements
(where the patient moves the joint themselves) and passive movements (where
the examiner moves the joint) should be performed.
 If there is a loss of active movement, but passive movement is unaffected, this
may suggest a problem with the muscles, tendons or nerves rather than in the
joints, or it may be an effect of pain in the joints.
 In certain instances joints may move further than expected – this is called
hypermobility. It is important to elicit a loss of full flexion or a loss of full extension
as either may affect function.
 A loss of movement should be recorded as mild, moderate or severe. The quality
of movement should be recorded, with reference to abnormalities such as
increased muscle tone or the presence of crepitus.

35. Function
 It is important to make a functional assessment of the joint – for
example, in the case of limited elbow flexion, does this make it
difficult for the patient to bring their hands to their mouth? In the
case of the lower limbs, function mainly involves gait and the
patient’s ability to get out of a chair.
 one group of joints may need to be examined in conjunction with
another group (e.g. the shoulder and cervical spine).

36. RECORDING OF FINDINGS FROM THE REGIONAL
EXAMINATION
 The positive and significant negative
findings of the REMS examination are
usually documented longhand in the
notes.
 If no abnormality is found then ‘REMS
normal’ is sufficient.
 You may find it helpful to document joint
involvement on a homunculus such as
the one shown in fig.
 The total number of tender and swollen
joints can be used for calculating disease
activity scores – these are useful in
monitoring disease severity and response
to treatment over time.

38. LAB. INVESTIGATIONS
 Majority of musculoskeletal disorders can be easily diagnosed by a complete
history & physical examination.
 An additional objective of the initial counter is to determine whether additional
investigations or immediate therapy is required.
Indications for additional evaluation:-
 Monoarticular conditions
 Conditions accompanied by neurologic changes or systemic manifestations of
serious disease
 In individual with Chronic symptoms(>6 wk.), esp. when there’s lack of response
to symptomatic measures.

39. Investigations
 CBC
 ESR
 CRP
 Serum Uric acid
 RF
 Anti-CCP
 ANA
 Complement levels
 ASO titre
 Lymes and ANCA
Only if there is clinical evidence to
suggestion
of associated diagnosis.

40. ESR, CRP
 Ac. Phase reactants
 Useful in discriminating inflammatory Vs. non-
inflammatory
 Elevated in- infection, inflammation, auto-immune
disorders, neoplasia, pregnancy, renal insufficiency,
advanced age, hyperlipidemia.
 Extreme elevation- serious illness, such as( sepsis,
pleuropericarditis, polymyalgia rheumatic, giant cell
arteritis, adult Still’s disease)

41. S. Uric acid
 end product of purine metabolism, excreted in urine
 Useful in diagnosis of gout & in monitoring the response
to urate-lowering therapy
 level is a/w gout, nephrolithiasis, but levels may not
correlate with severity of the disease.
 level ( hence risk of gout)
 Inborn errors of metabolism
 Disease states( renal insufficiency, myeloproliferative disease,
psoriasis)
 Drugs( Alcohol, cytotoxic therapy, thiazides)

42. IgM RF
 Autoantibodies against the Fc portion of IgG
 Found in 80% of pt.s with RA
 Sensitivity= 70% & specificity= 80%
 Also seen in low titres in pt.s with
 Chronic infections( tuberculosis, leprosy, hepatitis)
 Other auto-immune diseases( SLE, Sjogren’s syndrome)
 Chronic pulmonary, hepatic and renal diseases
 When considering RA, both Serum RF and Anti-CCP
antibodies should be obtained as these are
complementary.

43. Anti-CCP
 Now Anti-CCP-3
 Method of estimation- ELISA
 Arbitary unit
 Higher value- higher specificity
 Specificity
 In healthy controls= 99%
 In diseased population= 95%
 In RA presence of both anti-CCP & RF antibodies may indicate a
greater risk for more severe, erosive polyarthritis.

44. ANAs
 Found in all pt.s ith SLE
 Also seen in pt.s with other auto-immune diseases(
polymyositis, scleroderma, anti-phospholipid syndrome,
Sjogren’s syndrome), drug induced lupus(d/t
Hydralazine, procainamide, quinidine, tetracyclines, TNF
inhibitors), Chronic liver or renal disorders and advanced
age.
 The interpretation of a positive ANA test may depend on
the magnitude of the titre & the pattern of IF
microscopy.
 Indirect IF is the Gold standard.

45. Aspiration &
Analysis of Synovial Fluid
.

46. Crystals
Crystals In polarised microscopy
In Gout • Long, needle-shaped,
negatively birefringent
• (Monosodium urate
crystals), usually intra-
cellular
In Calcium Pyrophosphate
Deposition (CPPD) (formerly
called Pseudogout)
& Chondrocalcinosis
• Short, rhomboid shaped
and positively birefringent
• Calcium pyrophosphate
dehydrate crystals
The negatively birefringent crystals appear
yellow when they lie parallel to the optical
axis of the compensator and blue when
perpendicular to it.

47. Diagnostic Imaging in Joint diseases
Conventional radiograph
 Plain x-rays are most appropriate when there is a history
of trauma, suspected chronic infection, progressive
disability, or monoarticular involvement; when
therapeutic alterations are considered; or when a
baseline assessment is desired for what appears to be a
chronic process.
 However, in acute inflammatory arthritis, early
radiography is rarely helpful in establishing a diagnosis
and may only reveal soft tissue swelling or juxtaarticular
demineralization

48. Diagnostic Imaging Techniques for Musculoskeletal Disorders
Method Imaging Time, h Costa Current Indications
Ultrasoundb <1 ++ Synovial cysts, Rotator cuff tears, Tendon injury
Radionuclide
scintigraphy
99mTc 1–4 ++ Metastatic bone survey
Evaluation of Paget's disease
Acute and chronic osteomyelitis
111In-WBC 24 +++ Acute infection, Prosthetic infection, Acute
osteomyelitis
67Ga 24–48 ++++ Acute and chronic infection, Acute osteomyelitis
Computed
tomography
<1 +++ Herniated intervertebral disk, Sacroiliitis ,Spinal
stenosis, Spinal trauma, Osteoid osteoma, Stress
fracture
Magnetic resonance
imaging
1/2–2 ++++ Avascular necrosis, Osteomyelitis, Intraarticular
derangement and soft tissue injury, Derangements of
axial skeleton and spinal cord, Herniated
intervertebral disk, Pigmented villonodular synovitis,
Inflammatory and metabolic muscle pathology

49. Summary
 Clinical history is by far the most important diagnostic tool together
with the power of physical examination.
 Appropriate Lab. & radiological inv.s should only be ordered based
on the strong clinical findings and in difficult & doubtful cases.
 Recognising the Red Flag signs.