2022 introductory lecture to incoming internal medicine residents of the Department of Internal Medicine, East Avenue Medical Center

1. Sidney Erwin T. Manahan, MD, FPCP, FPRA
Fellowship Training Officer
EAMC Section of Rheumatology
Approach to
JOINT AND BACK PAINS
Review and Reference for Internal Medicine Training

2. Disclosures
• None

3. Lecture Objectives
At the end of the discussion, the participant should be able to:
• Adopt a conceptual framework helpful in arriving at a
diagnosis for a patient with joint and back pains
• Generate differential diagnoses
• Reduce unnecessary diagnostic tests
• Triage patients based on expected competencies
for internists

4. Most Common Conditions
IN PRIMARY HEALTHCARE
CLINICIAN REPORTED
• URTIs
• Hypertension
• Health maintenance
• Arthritis
• Diabetes
• Depression/ Anxiety
• Pneumonia
• Otitis media
• Back pain
• Dermatitis
PATIENT REPORTED
• Cough
• Back pain
• Abdominal problems
• Pharyngitis
• Dermatitis
• Fever
• Headache
• Leg pains
• Respiratory
• Fatigue
Finley C, et al. What are the most common conditions in primary care? Systematic review. Canadian Family Physician 2018; 64: 832-840

5. Leading Causes of Consultation
Adult OPD of Region 1 Medical Center, 2012
Rank Diagnosis %
1 Hypertension 8.82
2 Urinary tract infection 7.14
3 Type 2 Diabetes mellitus 6.28
4 Lower respiratory tract infection 5.61
5 Community acquired pneumonia 4.32
6 Pulmonary tuberculosis 3.51
7 Musculoskeletal disease 3.44
8 Ischemic heart disease 2.88
9 Upper respiratory tract infection 2.86
10 Cerebrovascular disease 2.18
>100
forms of arthritis
and rheumatism

6. Approach to
JOINT PAINS

8. A +DIE Pattern Recognition
ARTICULAR OR NON-ARTICULAR
By Madhero88 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=10158699
ARTICULAR PERI-ARTICULAR
Deep or diffuse pain Localized or focal pain
Limited in both active and
passive ROM
Limited more with active
rather than passive ROM
Swelling Radiation
Crepitation, Instability
Locking, PE findings distant
from joint area

9. A +DIE Pattern Recognition
EVOLUTION
Acute (<6 weeks) Chronic (>6 weeks)
“Persistent for >6 weeks”
“On most days of the week for >6 weeks”
“Happens for <1 week 2-3x a year for 3 years”
Intermittent
Migratory
“Affects a joint for several days then moves to
another joint for >6 weeks”
tion-monkey-australopithecus-neanderthal-animal_10700613.htm#query=human%20evolution&position=0&from_view=keyword">Image by macrovector</a> on Freepik

10. A +DIE Pattern Recognition
INFLAMMATION
NON-INFLAMMATORY
INFLAMMATORY
OTHER SYMPTOMS
Fever
Weight loss
Anorexia
Malaise
Easy fatiguability
Morning stiffness >45 minutes
LABORATORY EVIDENCE
Elevated acute phase reactants/ proteins

11. A +DIE Pattern Recognition
DISTRIBUTION
Mono- (1 joint)
Oligo- (2-3 joints)
Poly- (>3 joints)
Widespread Pain
Pain above and below the waist AND
pain on both sides of the body
Regional Pain
Pain confined to one body region

12. A +DIE Pattern Recognition
OTHER FEATURES
Mucocutaneous findings
Skin appendages changes
Soft tissue mass
Muscle weakness
Eye findings
Other organs/ systems involvement

13. A +DIE Pattern Recognition
Evolution Inflammation Distribution Area + (Others)
Acute
Chronic
Intermittent
Migratory
Inflammatory
Non-inflammatory
Mono
Oligo
Poly
Regional
Widespread
Articular
Peri-articular
Mucocutaneoous
Skin appendages
Soft tissues
Muscles
Organs/ Systems
Inflammatory Articular Arthritis
Non-inflammatory Articular Arthralgia

14. Pattern Recognition: Arthritis
ACUTE ARTHRITIS
Infectious Arthritis
Trauma
Gout
Pseudogout
Reactive arthritis
Initial presentation of chronic arthritis
CHRONIC ARTHRALGIA
Osteoarthritis
Osteonecrosis
Charcot/ neuropathic arthropathy
Hemochromatosis
CHRONIC MONOARTHRITIS
OLIGOARTHRITIS
TB arthritis
Fungal arthritis
Psoriatic arthritis
Reactive arthritis
Juvenile idiopathic arthritis
CHRONIC POLYARTHRITIS
Rheumatoid arthritis
Systemic lupus erythematosus
Scleroderma
Inflammatory myopathies
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis
Some infectious arthritis
REACTIVE ARTHRITIS
Acute arthritis
Chronic mono arthritis
Chronic oligo arthritis
Chronic poly arthritis
GOUTY ARTHRITIS
Acute mono arthritis
Acute oligo arthritis
Acute poly arthritis
Intermittent arthritis
Chronic poly arthritis

15. Acute monoarthritis
• 32F with left knee pain of 5 days duration
• 5 days of pain, warmth, swelling of the the left
knee with difficulty walking
• PE: warm, tender, left knee with effusion; kept in
flexed position; limited active and passive ROM.
No open wounds/ no subcutaneous crepitations.
• On re-history, treated for UTI with co-amoxyclav
2 weeks prior.
Gout
Septic arthritis
Pseudogout
Reactive arthritis

16. Acute monoarthritis
• 32F with left knee pain of 5 days duration
• 5 days of pain, warmth, swelling of the the left
knee with difficulty walking
• PE: warm, tender, left knee with effusion; kept in
flexed position; limited active and passive ROM.
No open wounds/ no subcutaneous crepitations.
• On re-history, treated for UTI with co-amoxyclav
2 weeks prior.
Gout
Septic arthritis
Pseudogout
Reactive arthritis

17. Acute polyarthritis
• 38M with joint pains of 2 weeks duration
• Microbiologically confirmed PTB 3 weeks ago,
started on HRZE; 2 weeks of ankle and knee
pains associated with difficulty ambulating.
• PE: warm, tender, and swollen - both knees and
both ankles - with limited active and passive
ROM. Antalgic gait.
Gout
Septic arthritis
Pseudogout
Reactive arthritis

18. Acute polyarthritis
• 38M with joint pains of 2 weeks duration
• Microbiologically confirmed PTB 3 weeks ago,
started on HRZE; 2 weeks of ankle and knee
pains associated with difficulty ambulating.
• PE: warm, tender, and swollen - both knees and
both ankles - with limited active and passive
ROM. Antalgic gait.
Gout
Septic arthritis
Pseudogout
Reactive arthritis
(i.e., Poncet’s arthritis)

19. Chronic polyarthritis
• 29F with joint pains of 6 months duration
• 6 months of joint pains affecting in an additive
pattern the hands, wrists, elbows, and knees.
There is morning stiffness of 4 hours before
maximal improvement. She reports feeling
fatigued with some loss of appetite.
• PE: (+) swelling, tenderness, and LROM (active,
passive) of both knees, elbows, and wrists. (+)
swelling and tenderness of MCP 2-4, PIP 2-5 on
both hands. No muscle weakness or skin
changes.
SLE
Rheumatoid arthritis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis
Scleroderma
Inflammatory myopathies

20. Chronic polyarthritis
• 29F with joint pains of 6 months duration
• 6 months of joint pains affecting in an additive
pattern the hands, wrists, elbows, and knees.
There is morning stiffness of 4 hours before
maximal improvement. She reports feeling
fatigued with some loss of appetite.
• PE: (+) swelling, tenderness, and LROM (active,
passive) of both knees, elbows, and wrists. (+)
swelling and tenderness of MCP 2-4, PIP 2-5 on
both hands. No muscle weakness or skin
changes.
SLE
Rheumatoid arthritis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis
Scleroderma
Inflammatory myopathies

21. Chronic polyarthralgia
• 65F with joint pains of 5 years duration
• 5 years of knee pains, worsened by activity, with AM
stiffness <15 mins. Pains relieved by resting or
paracetamol.
• 3 years ago, noted more frequent knee pains, happening
with less strenuous activities. Developed hand joint pains
with AM stiffness <15 mins. Gradually noted enlargement
of DIP joints. Observed gelling.
• 1 month ago, still with above symptoms, started to have
back pain during prolonged standing and activity. Denies
any trauma prior.
• PE: (+) bony enlargement, coarse crepitations, and LROM
of both knees; (+) Heberden’s nodes on 7/10 fingers;
straightened lumbar lordosis with limited ROM of spine.
Osteonecrosis
Osteoarthritis
Charcot arthropathy

22. Chronic polyarthralgia
• 65F with joint pains of 5 years duration
• 5 years of knee pains, worsened by activity, with AM
stiffness <15 mins. Pains relieved by resting or
paracetamol.
• 3 years ago, noted more frequent knee pains, happening
with less strenuous activities. Developed hand joint pains
with AM stiffness <15 mins. Gradually noted enlargement
of DIP joints. Observed gelling.
• 1 month ago, still with above symptoms, started to have
back pain during prolonged standing and activity. Denies
any trauma prior.
• PE: (+) bony enlargement, coarse crepitations, and LROM
of both knees; (+) Heberden’s nodes on 7/10 fingers;
straightened lumbar lordosis with limited ROM of spine.
Osteonecrosis
Osteoarthritis
Charcot arthropathy

23. Soft Tissue Rheumatism
Conditions of the Peri-articular Structures
HANDS/ WRISTS
Flexor tenosynovitis
De Quervain’s tenosynovitis
Carpal tunnel syndrome
Cubital tunnel syndrome
Basal joint arthropathy
ECU/ FCR/ FCU tendinopathies
Extensor tendinopathies
ELBOWS
Epicondylitis
SHOULDERS
Bicipital tendinitis
Rotator cuff tendinopathy
Myofascial pain syndrome
Calcific tendinitis
Rotator cuff tears
Polymyalgia Rheumatica
ANKLE/ FEET
Plantar Fasciitis
Achilles tendonitis
Retroachilleal bursitis
Tarsal tunnel syndrome
Tendon dysfunction
HIPS/ KNEES
Bursitis
Iliotibial band syndrome
Femoro-acetabular impingement

24. Approach to
BACK PAIN

25. Evaluation of Back Pain
The Things We SHOULD Ask For
• Provoking Factors
• Quality of the Pain
• Relieving Factors
• Severity of the Pain
• Timing of the symptoms
• Radiation to other parts
• Red Flag Features
• Understanding
PQR3STU

26. Red Flag Features in Back Pain
These Reflects the NEED for Further Evaluation
FRACTURE CANCER, INFECTION CAUDA EQUINA INFLAMMATORY
Trauma
Prolonged use of steroids
Age > 70 years
Unexplained weight loss
History of malignancy
Immunosuppression
History of illicit IV drug use
Nocturnal pain
Fever
Urinary retention
Bowel or bladder
incontinence
Saddle anesthesia
Bilateral or progressive motor
weakness
Severe AM stiffness
Pain improves with activity
and not with rest
Pain during second half of
the night
Alternating buttock pain
Age < 40 years
Radiographic evaluation - CT or MRI - are rarely indicated for
patients with non-specific low back pain
60?

27. Differential Diagnoses for Back Pain
A non-exhaustive list
• Fracture
• Malignancy
• Infection
• Cauda Equina Syndrome
• Spinal Stenosis
• Spondyloarthritis
• Herniated disc
• Annular disc tears
• Degenerative disc disease
• Spondylosis
• Spondylolisthesis
• Non-specific low back pain
• Psychosocial Issues
• Referred Pain
5-6%
1.4%
85%

28. Suggested Approach
What Should We Do
PATTERN IMAGING OTHER TESTS TREATMENT
Any Back Pain
(+) Red Flags
Prompt CT or MRI Disease-directed work-up
Refer immediately to ORTHO
Analgesics, NSAIDs
Acute LBP
(-) Red Flags
No Imaging Needed None
Analgesics, NSAIDs,
+ Muscle Relaxants
Rest < 48 hours
Chronic LBP
(-) Red Flags
(-) Radiculopathy
Imaging based on diagnosis CBC, Crea, AST, ALT
Analgesics, NSAIDs,
Physical therapy
Refer to Rheuma
Chronic LBP
(-) Red Flags
(+) Radiculopathy
Imaging based on diagnosis;
MRI if surgery is being
contemplated
CBC, Crea, AST, ALT
Analgesics, NSAIDs,
Anti-convulsants
Refer to ORTHO or RHEUMA
(based on dx)
Inflammatory Back
Pain
Plain Radiograph
as INITIAL IMAGING
CBC, Creatinine, AST, ALT,
ESR, hsCRP
Refer to Rheum; Start NSAIDs

29. Acute LBP (-) red flags/ radiculopathy
• 22M with back pain of 2 days
• Surgery clerk; Came from virtual classes
• Back pain started after assisting in an operation;
described as soreness with VAS 6-8/10; non-
radiating; worsened by prolonged standing,
bending over; improves with rest or lying down;
no radiation; no red flags
• PE: (+) para-lumbar muscle spasm; (-) SLR; full
ROM but pain on forward flexion; (-) neuro
deficits; MMT 5/5
None
IMAGING
Muscle relaxant
NSAID
Rest x 24H
Back strengthening ex
TREATMENT
Follow up after 2 weeks if still
with symptoms; Have tests (XR,
CBC, ESR, Crea, AST, ALT)
done if he’ll follow up
ADVISE

30. Chronic LBP (-) red flags/ radiculopathy
• 55F with back pain of 6 months
• Nurse supervisor assigned to ER
• Dull back pain on most days of the week;
worsened by activity; VAS 5-6/10; non-radiating;
improves with rest or lying down; no radiation;
no red flags; limits her in doing her duties.
• PE: (-) muscle spasm; (-) SLR; full ROM but
pain on extreme ROM; (-) neuro deficits; MMT
5/5
Lumbar spine XR APL
IMAGING
NSAID
Refer to Rheum
Refer to Rehab
TREATMENT
Tests: CBC, ESR, Crea, AST,
ALT; Activity modification
OTHERS

31. Acute LBP (+) red flags/ radiculopathy
• 75M with back pain for 2 days
• Retired government employee
• Back pain started after he tried moving the sofa;
VAS 8-10/10; Radiation down left leg; Pain
worsened by standing up, activity; Some relief
when resting; No bowel/ bladder incontinence.
• PE: (+) tenderness on L3 vertebra; (+) SLR, left;
unable to do ROM, MMT due to pain; (+) 50%
sensory loss around L3;
Lumbar spine XR APL
IMAGING
Tramadol, Gabapentin
Refer to Ortho
TREATMENT
Tests: CBC, ESR, Crea, AST,
ALT, Albumin, Ca; Send to ER
OTHERS

32. Reference Criteria
Rheumatologic Conditions
• 2015 ACR/ EULAR Classification Criteria for Gout
• 2019 EULAR/ ACR Classification Criteria for SLE
• 2012 SLICC Classification Criteria for SLE
• 2010 ACR/ EULAR Classification Criteria for RA
• 2017 EULAR/ ACR Classification Criteria for IIM
• 2016 Classification Criteria for Psoriatic Arthritis (CASPAR)
• 2009 ASAS Classification Criteria for Axial Spondyloarthritis
• 2016 Revised ACR Diagnostic Criteria for Fibromyalgia

33. Summary
Approach to Joint and Back Pains
• Differentials for joint pains depend on the evolution and distribution of joint
symptoms, presence of inflammatory features, involvement of other organs/
systems, and whether articular or peri-articular structures are affected
• Work-up depends on the differential diagnoses for the joint problems
• Red flag features should be sought in the evaluation of back pain
• Imaging studies are not always needed when assessing back pain
• Management depends on duration, presence of radiculopathy, and presence
of red flag features

34. Terminal Competencies for the MS System
PCP Outcome- and Competency- Based Training Program
• Assess common medical problems
• Joint and back pains (10)
• Bone and joint deformities (10)
• Undiagnosed systemic disease (2)
• Abnormal rheumatology serologic tests (ANA, RF, etc) (2)

35. Terminal Competencies for the MS System
PCP Outcome- and Competency- Based Training Program
• Diagnose and manage common medical conditions and diseases
• Osteoarthritis (10)
• Gout (10)
• Skin and soft tissue infections (5)
• Simple back pain (5)
• Soft tissue rheumatism (5)
• Post-menopausal osteoporosis (2)

36. Terminal Competencies for the MS System
PCP Outcome- and Competency- Based Training Program
• Diagnose and initiate management of common but complicated medical conditions/
diseases AND refer to appropriate sub-specialists
• Inflammatory arthritis (RA, SpA) (10)
• Psoriatic arthritis (1)
• IBD associated arthritis (1)
• Acute arthritis (Pseudogout/ Reactive arthritis) (1)
• Connective tissue diseases (5)
• Infections of the joint (Bacterial/ TB) (2)
• Bone diseases (GIO/ CKD-MBD) (5)
• Systemic vasculitides (3)
• Carpal tunnel syndrome (5)

37. Terminal Competencies for the MS System
PCP Outcome- and Competency- Based Training Program
• Diagnose and manage common emergency conditions
• Acute Gout (5)

38. Terminal Competencies for the MS System
PCP Outcome- and Competency- Based Training Program
• Diagnose and initiate management of common but complicated emergency
conditions/ diseases AND refer to appropriate sub-specialists
• Septic arthritis (5)
• Acute low back pain (5)
• Acute muscle weakness (2)
• SLE with flare or other complications (3)

39. Terminal Competencies for the MS System
PCP Outcome- and Competency- Based Training Program
• Explain the indications and steps of common diagnostic tests, interpret, and
correlate results with the patient’s condition
• Anti-nuclear antibodies (10)