This document outlines a 7-step approach to evaluating musculoskeletal pain: 1) Determine if the pain is articular or non-articular, 2) Distinguish between arthralgia and arthritis, 3) Assess if the condition is acute or chronic, 4) Identify if it is inflammatory or non-inflammatory arthritis, 5) Determine if it is monoarticular or polyarticular, 6) Examine the distribution pattern and whether it is symmetrical or asymmetrical, and 7) Look for any extra-articular manifestations. A thorough history and physical exam can provide 80-95% of diagnostic information needed, while imaging and labs only contribute 5%. Certain "red flag" diagnoses like infection require prompt diagnosis and

1. Approach to
musculoskeletal pain
Ahmed Yehia
Lecturer , internal medicine
Immunology &
Rheumatology & Allergy

2. Goal
The goal of the musculoskeletal
evaluation is to formulate a D.D.
that leads to an accurate
diagnosis and timely therapy,
while avoiding excessive
diagnostic testing and
unnecessary treatment.

3. Not to be missed
•There are several urgent
conditions that must be
diagnosed promptly to avoid
significant morbid or mortal
sequelae . These "red flag"
diagnoses include septic
arthritis, acute crystal-induced
arthritis (e.g., gout), and
fracture. Each may be suspected
by its acute onset and
mon0articular or focal
musculoskeletal pain.

4. 1st , back to
basics……

6. Entheseopathy

7. • A careful history provides 80% of the diagnostic information.
• Physical examination adds another 15%.
• While Imaging and raboratory together contribute only 5%.

8. • So , don’t request an
investigation unless:
1. You have done a thorough
history and examination.
2. A D.D. exists in your mind ,
3. It will change the plan of
management and
4. You know how to interpret it.

9. Stepwise approach
to musculoskeletal
pain

10. Approach to
arthritis can be
classified into 7
steps :
1. Articular or non-articular pain
2. Is it arthralgia or arthritis?
3. Acute or chronic (Duration)
4. Inflammatory or non-
inflammatory
5. Mono or polyarticular (Number)
6. Distribution: Symmetrical or
asymmetrical; with or without
axial involvement
7. Extraarticular manifestations
present or absent

11. Step I: Is it soft-
tissue rheumatism
(STR)? (Articular
or nonarticular
pain)?
•This issue must be
addressed first of
all because (STR) is
the commonest
cause of
musculoskeletal
pain.

12. Causes of soft-tissue
rheumatism
Syndrome Examples
Enthesopathy Tennis elbow. Golfer’s elbow plantar fasciitis
Bursitis Subacromial, olecranon, trochanteric, ischial,
Anserine, retrocalcaneal
Tenosynovitis Volar , flexor, DeQuervain’s, trigger finger
Tendonitis Rotator cuff, bicipital, Achilles
Entrapment neuropathy Carpal tunnel, tarsal tunnel,
meralgia paresthetica
Miscellaneous Dupuytren's contracture. Tietze's syndrome,adhesivc
capsuillis, repetitive strain syndrome

13. Feature STR Arthritis
Pain Superficial,
sharply localized
Deep, diffuse
circumferential
Tenderness Localized Circumferential, along joint
line
Active movement Painful in
some directions
Painful in
all directions
Passive
movement
No pain Painful
Synovitis/Effusion Nil Present
Crepitus/Instability/
Deformity
Absent Often present

14. Many presenting with the above (localized
syndromes) may have 1 of the following
generalized disorders:
Fibromyalgia
syndrome (chronic
pain-amplification
syndrome)
Chronic fatigue
syndrome
Benign joint
hypermobility
syndrome (BJHS)

16. Step 2: Is it
arthralgia
or
arthritis?

17. Step 3:Is it acute or chronic?
•6 weeks

18. Step 4: Is it inflammatory arthritis?
• Inflammatory arthritis is characterised by :
I. Some or all of the 4 cardinal signs of inflammation
(swelling. warmth, pain, erythema)
2, Prolonged early morning stiffness (usually 60 minutes or more)
3, Improvement of symptoms on gentle use of joints.
4. Spontaneously fluctuating course
5. Usually symptoms are worse at night.
6. Constitutional symptoms (fatigability, loss of appetite, loss of weight, low-
grade fever or night sweat)
7. Presence of inflammatory markers:
*High ESR, CRP and platelets
*Reversed A/G ratio *Low haemoglobin *WBC high
*Mild elevation of alkaline phosphatase

19. Inflammatory Mechanical
Stiffness (Morning stiffness) > 60 min. Brief
Swelling, redness, hotness (Synovitis) ++++ -
Systemic manifestations +++ -
Symptoms worsen by Rest Movement
Sedimentation rate (ESR) & CRP +++ Normal
Serology Usually positive Negative

20. Signs of degenerative or mechanical joint disease
• at the distal interphalangeal joints - Heberden nodes,
• at the proximal interphalangeal joints are called Bouchard
nodes.
Bony overgrowth of the joints (osteophytes)-
• intra-articular loose bodies,
• osteophyte formation, or subluxation.
Limited range of motion:
Crepitus during active or passive range of motion

22. Step 5: Number of joints
involved?
Monoarthritis
1 joint
Oligoarthritis
2-4
Polyarthritis
>4

23. Step 5: Number of
joints involved?
Monoarthritis
Acute
Septic until
proven
otherwise

24. Acute Monoarthritis
• This is to be treated as a rheumatological
emergency.
• Urgent synovial fluid examination
mandatory for:
• I. Culture & sensitivity: Pathogens (Gram
staining, bacterial culture)
• 2. Crystals (polarised light microscopy)
• 3. White Cell count

25. Differential
diagnosis of
acute
monoarthritis
I. Septic arthritis
2. Crystal arthropathies
3. Haemorrhagic arthropathies
4. Miscellaneous: Palendromic rheumatism, others
5.Monoarticular onset of chronic inflammatory arthritis
(frequently seen in psoriatic arthritis, may occur in RA
and seronegative inflammatory arthritides)

26. Acute monoarthritis
• Inflammatory
• Septic Arthritis
• Gout and Pseudogout
• Systemic rheumatic disease manifesting as
monoarticular involvement
• Noninflammatory
• Juxta-articular fracture
• Trauma
• Hemarthrosis
• Osteonecrosis

27. Inflammatory
• Chronic infectious arthritis
• Lyme Disease
• Crystalline synovitis
• Pauciarticular juvenile rheumatoid arthritis
• Systemic rheumatic disease presenting with monoarticular
involvement
Noninflammatory
• Osteoarthritis
• Ischemic necrosis
• Hemarthrosis
• Paget disease involving the joint
• Stress Fracture
• Osteomyelitis
• Osteosarcoma
• Metastatic tumor
• Synovial osteochondromatosis
Chronic monoarthritis

28. Rheumatic fever Gonococcal Arthritis Polyarticular gout
Polyarticular
pseudogout
Viral arthritis (eg,
hepatitis B infection,
parvovirus B-19
infection)
Bacterial
endocarditis
Rheumatoid
Arthritis
Still disease
Systemic Lupus
Erythematosus
Reactive Arthritis
Acute sarcoid
arthritis
Mediterranean
Fever, Familial
Enteropathic
Arthropathies
Acute
polyarthritis

29. Chronic polyarthritis
• Rheumatoid Arthritis
• Systemic Lupus Erythematosus
• Viral arthritis
• Psoriatic Arthritis
• Reactive Arthritis
• Enteropathic Arthropathies
• Behçet Disease
• Ankylosing Spondylitis and Undifferentiated
Spondyloarthropathy
Inflammatory
• Osteoarthritis
• Traumatic osteoarthritis
• Hemochromatosis
• Ochronosis
• Hypertrophic pulmonary osteoarthropathy
• Amyloidosis
• Acromegaly
Noninflammatory

30. Step 6 : distribution
Symmetric or not
Axial or peripheral
Small or large
Pattern & time-
relation

35. Specific distribution patterns
The distal interphalangeal joints of the
fingers
• involved in psoriatic arthritis, gout, or
osteoarthritis
• spared in RA.
Joints of the lumbar spine
• involved in ankylosing spondylitis
• spared in RA.

36. The temporal
patterns
migratory
additive or
simultaneous
intermittent

37. migratory pattern
• inflammation for only a few days in each
joint (eg, acute rheumatic fever,
disseminated gonococcal infection).
additive or simultaneous pattern
• inflammation persists in involved joints as
new ones become affected.
intermittent pattern
• episodic involvement occurs, with
intervening periods free of joint symptoms
(eg, gout, pseudogout, Lyme arthritis).

38. Step 7: Extra-articular features

41. Step 7:Extra-articular manifestations
• underlying systemic disorder.
• include fatigue, malaise, and weight loss.
Constitutional symptoms
• SLE, dermatomyositis, scleroderma, Lyme disease, psoriasis, Henoch-Schönlein purpura,
and erythema nodosum.
Skin lesions
• Episcleritis and scleritis -RA or Wegener granulomatosis
• anterior uveitis - ankylosing spondylitis,
• iridocyclitis - juvenile RA
• Conjunctivitis -reactive arthritis
Ocular symptoms or signs

43. Red flags.
They can be indicative of any
inflammatory, infective or neoplastic
process:
• Weight loss
• Fever or other systemic manifestation
• Night pain
• Single joint involvement
• Neurological symptoms and signs

44. Approach to arthritis can be classified into 7 steps :
1. Articular or nonarticular pain
2. Is it arthralgia or arthritis?
3. Acute or chronic (Duration) : 6 weeks
4. Inflammatory or non-inflammatory
5. Mono or polyarticular (Number)
6. Symmetrical or asymmetrical; with or
without axial involvement (Distribution)
7. Extraarticular manifestations??

45. ‫خيرا‬ ‫هللا‬ ‫جزاكم‬