Approach towards a case of musculoskeletal disorder.#
Goals During the Initial Encounter With the
Dr. Mohit Mathur
Reader (Dept. of Medicine)
Determine Whether the
musculoskeletal Complaint Is Articular or peri-articular in origin?
Inflammatory or non-inflammatory?
Acute or chronic in duration?
Localized or widespread(systemic) in
• Supportive extraarticular ligaments ex- collateral
ligaments in knee.
And overlying skin.
Characteristics of Articular
Deep or diffuse jt. pain.
Limited range of motion on active as well as
Swelling (effusion or synovial proliferation).
Characteristics of Nonarticular
Pain on active but not on passive movement of
Point or focal tenderness.
Presence of physical findings distant from the
Factors Leading to
Inflammation in Joint.
Infections( gonorrhea, tuberculosis).
Crystal arthopathy( gout, pseudogout).
Immune related( RA, SLE).
Reactive( rheumatic fever, Reiter's syn.).
Features of Inflammatory Joint
Local features – pain (also during rest),
tenderness, swelling, warmth & erythema.
Systemic features – prolonged morning
stiffness, fatigue, weight loss, fever.
Laboratory evidences – elevated ESR & CRP,
thrombocytosis, anemia of chronic disease or
Inflammatory Vs Mechanical
Prolonged Immobility stiffness
Minimal inactivity stiffness
Rest pain usually get better
Pain on activity usually
improving on rest
Joint crepitus, Instability and
Systemic symptoms & Multiorgan involvement
History of trauma, strain or
Musculoskeletal disorders are called acute if they
last less than 6 weeks and chronic if they last longer.
Acute disorders tend to be infectious, crystal
induced, reactive or they can be the initial
presentation of chronic arthritis.
Chronic disorders are often immune related,
such as Systemic Lupus Erythematosus and
Rheumatoid arthritis is a chronic multisystem
disease of unknown cause.
characteristic feature is persistent
inflammatory synovitis usually involving
peripheral joints in a symmetrical distribution.
RA begin insidiously with fatigue, anorexia,
Specific symptoms appear gradually as several
joints(hands, wrists, knees and feet) become
affected in symmetric fashion.
The joint with synovial inflammation become
painful. There is tenderness, swelling and
limitation in mobility.
American Rheumatology Association Revised
Morning stiffness in & around joints lasting 1 hr. or
more before maximum improvement.
Arthritis of three or more joint areas (duration of 6
weeks or more).
Arthritis of hand joints (duration of 6 weeks or more).
Elevated serum rheumatoid factor.
Radiographic changes : juxta-articular osteopenia.
Diagnosis of RA is made with 4 or more criteria
Problems in Diagnosis.
Diagnosis is difficult in the initial course of illness
when only constitutional symptoms or
intermittent arthralgias or arthritis in
asymmetric distribution may be present. A
period of observation is necessary before
diagnosis can be established.
Systemic Lupus erythematoses
Almost all patients of SLE experience arthralgias & myalgias.
Most develop intermittent arthritis involving hand joints.
Unlike RA the arthritis in SLE is non-erosive and joint
deformities are unusual. Skin involvement with
photosensitive rash is much more common in SLE than in
More than half the patients of SS complain of pain, swelling
& stiffness of the fingers and knees. A symmetrical
polyarthritis resembling RA may be seen.
The onset of SS is frequently in the form of Raynaud’s
phenomena & puffiness in fingers.
Raynaud’s phenomena affect a greater no. of patients of SS
(80-90% patients) than of RA and may be the only symptom
of scleroderma for years.
It is a reactive polyarthritis which develop several weeks
after non-gonococcal urethritis and enteric infections.
Only a minority of patients have other findings of
classical Reiter’s syndrome including urethritis,
conjunctivitis, uveitis, oral ulcers and rash. The joint
involvement is usually in the form of asymmetric
oligoarthritis affecting mainly the knees, ankles & feet.
The history of preceding infection will help in the
It can present as asymmetric inflammatory arthritis,
symmetric arthritis or psoriatic spondylitis
It is a sero-negative arthritis which mainly involve DIP, PIP,
MCP, MTP, sternoclavicular and large peripheral joints.
Practically all patients have onychodystrophy ( onycholysis,
ridging and pitting of nails).
Psoriasis and inflammatory arthritis usually develop
Monosodium Urate Arthopathy
It commonly present as acute oligoarticular arthritis
affecting middle aged to elderly men. The MTP jt. of 1 st
toe is often involved but tarsal joints, ankles & knees are
also commonly affected. The first episode usually begin
at night with pain in joint together with tenderness, heat
& redness over affected joint.
Women represent only 5 to 17% of all patients with gout
& most of them are post-menopausal & elderly females.
Most have an underlying degenerative jt. disease.
Diagnosis – confirmed by needle aspiration of jt. or
Most of the crystal arthopathies such as CPPD deposition
disease, HA deposition disease & CaOx deposition disease
affect elderly who usually have a preexisting degenerative
In some cases they produce synovitis which may mimic RA.
Diagnosis is confirmed by analysis of synovial fluid or
Vasculitis is a heterogeneous group of disorders
characterized by inflammation & damage to blood vessels.
The vessel lumen is compromised and is associated with
ischaemia of the tissues supplied by the involved vessel.
Vasculitis are considered as immune-complex mediated
Polymyalgia rheumatica and
Exclusively occur in persons over
55 yrs. Of age
GCA – large vessel arteritis
C/F- fever, anemia, raised ESR &
headache in elderly person with
or without symptoms of
polymyalgia rheumatica (stiffness
& pain in muscles of neck,
shoulders, lower back, hips &
Temporal artery- tender,
thickened & nodular.
jaw claudication visual
disturbance, systemic upset.
Autosomal recessive disorder
Results from deficiency of lyzozomal enzyme ceramidase
& the accumulation of ceramide in various tissues
Symptoms begin as early as 1st year of life with painful jt.
swelling & nodule formation.
It’s diagnosis should be suspected in patients who have
nodule formation over jt’s. but no other finding of RA.
Articular structures are involved in primary idiopathic
amyloidosis (light chain amyloidosis) which is associated
with multiple myeloma.
Amyloid arthritis can present as symmetrical arthritis of
small jt’s. with nodules, morning stiffness & fatigue.
Synovial fluid analysis- low WBC count, good to fair
mucin clot, predominance of mononuclear cells & no