Holistic Approach to rheumatic patients Ahmed Yehia Ismaeel, Lecturer of internal Medicine, Immunology, rheumatology and allergy How to approach a musculoskeletal pain step by step? Differentiating different rheumatic diseases

1. Holistic Approach to
rheumatic patients
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 & timely therapy, while
avoiding excessive diagnostic
testing & unnecessary
treatment.

3. 1st , back to
basics……

5. Entheseopathy/itis

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

7. • 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.

8. Stepwise approach
to musculoskeletal
pain
•What questions
should I answer to
reach a final
diagnosis?
(Diagnostic steps)

9. (Approach to
history taking
in
rheumatolog
y)
L. Alharbi
and H.
Almoallim

10. Approach to
arthritis can be
classified into 8
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, oligo or polyarticular (Number)
6. Distribution: Symmetrical or
asymmetrical; with or without axial
involvement
7. Extraarticular manifestations present or
absent
8. The patient as a whole (demographics)

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. Pain may originate from:
ARTICULAR STRUCTURES
(SYNOVIAL MEMBRANE,
CARTILAGE, INTRA-ARTICULAR
LIGAMENTS, CAPSULE, OR JUXTA-
ARTICULAR BONE SURFACES).
PERIARTICULAR
STRUCTURES (BURSAE,
TENDONS, MUSCLE, BONE,
NERVE, SKIN).
NON-MUSCULOSKELETAL
STRUCTURES (CARDIAC
PAIN REFERRED TO THE
SHOULDER).

13. 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

14. STR
Isolated tendon &/or
ligament
usually noninflammatory
disorders (mechanical
injury/irritation, overuse,
or degeneration) e.g.
rotator cuff disorders or
tennis elbow.
Widespread
musculoskeletal pain
fibromyalgia

15. Feature STR Articular pain
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/Locking
Absent Often present

16. Active movement: Patient
is active (moves the joint
himself/herself).
Passive movement: Patient
is passive.

17. Many presenting with the above (localized
syndromes) may have 1 of the following
generalized disorders:
Fibromyalgia
syndrome (chronic
pain-amplification
syndrome)
Chronic fatigue
syndrome
Joint hypermobility
syndrome (JHS)

19. Don’t forget
referred pain!

20. Ali, Y. (Ed.). (2022). Rheumatology for Primary Care
Providers: A Clinical Casebook. Springer Nature.

21. Step 2: Is it
arthralgia
or
arthritis?

22. Often non-specifc, arthralgias are encountered in
several non-rheumatological conditions.
Hematological diseases
Post-viral fever
Hypothyroidism
Statin use, etc

23. Arthralgia refers to joint pain without abnormalities on joint examination.
Arthritis indicates the presence of abnormality in the joint (warmth,
swelling, erythema, tenderness).
Synovitis (inflammation of the synovial membrane that covers the joint)
presents as boggy, tender swelling around the joint. The joint loses its
sharp edges on examination. Synovitis is easy to detect in finger & wrist
joints.

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

25. Acute Arthritis < 6 weeks caused by
• acute viral illnesses e.g. parvovirus B19 infection can cause RA-
like arthritis.
Chronic inflammatory arthritis > 6 weeks
• RA, SLE, JIA.

27. Classification criteria of
JIA
• Onset: before 16 years of age.
• Duration: manifestations
persist for at least six weeks.
• Exclusion: etiology is unknown.
Per ILAR criteria, JIA is a
diagnosis of exclusion.

28. Step 4: Is it inflammatory
arthritis?

29. Inflammatory Non-inflammatory
Stiffness (Morning
stiffness)
> 60 min. Brief
Swelling, redness,
hotness (Synovitis)
++++ -
Systemic
manifestations
+++ -
Symptoms worsen by Rest (immobility) Use &
weight bearing
Spontaneous flares Common Uncommon

30. Inflammatory Non-inflammatory
Symmetry (bilateral) Occasional Common
Sedimentation rate
(ESR) & CRP
+++ Normal
Serology (RF, Anti-
CCCP, ANA,…)
Usually positive Negative
Synovial fluid
WBCs
>2000/pL mainly neutrophils
in acute inflammation
& monocytes in chronic
inflammation
200-2000/pL ,
mainly
monocytes
Locking or
instability
Implies loose body, internal
derangement, or weakness
Uncommon

31. Signs of degenerative or mechanical joint disease (non-inflammatory)
• 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

32. Inflammatory
disorders may be
Immune
mediated (SLE,
RA),
Reactive (reactive
arthritis [ReA]),
Infectious (septic)
gonococcal [GC]
arthritis),
crystal induced
(gout, CPPD).

33. Screening questions in history “PASS”
•Arthralgia
Pain
•Arthritis
Activity limitation
•Arthritis
Swelling in joints or
soft tissues
•Inflammatory arthritis
Stiffness

34. Hotness & redness are usually seen in
acute arthritis (gout or septic)

35. • Patients with inflammatory joint disease can develop mechanical
symptoms, e.g., secondary OA of knees in a patient with RA.

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

37. Case
•A 35-year-old man presented to you
with 2 days of severe knee pain and
swelling (as in the image).
• What is the most likely diagnosis?
•How to approach? What is the best next
step?

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

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

40. HVC
RECOMMENDATION
•Joint aspiration is usually
the most effective means
of diagnosing the
underlying cause of acute
monoarthritis.

41. Protein & sugar estimations in synovial fuid, unlike
CSF or pleural/peritoneal fluids, are of no value.
Tests for mucin clot & viscosity are no longer
performed.
Polymerase chain reaction (PCR) for Mycobacterium
tuberculosis in synovial specimens can be
associated with false positives & should never be
interpreted in isolation from clinical findings.

42. Etiology of
monoarthritis
Acute
Inflammatory
Non-
inflammatory
Chronic
Inflammatory
Non-
inflammatory

43. Etiology of monoarthritis
Acute
Inflammatory
Septic Crystal
Early rheumatic
disease
Non-
inflammatory
Trauma Hemarthrosis
AVN
Chronic
Inflammatory
Chronic
infectious
Fungal Mycobacterial
Borrelia
burgdorferi
Rheumatic
diseasses
Non-
inflammatory
OA AVN

44. 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)

45. Case
A 40-year-old female with
SLE, antiphospholipid
syndrome & lupus
nephritis class IV presents
with right hip pain for 2
weeks with limping.
How to approach?

46. Acute monoarthritis
• Septic Arthritis
• Gout & Pseudogout
• Systemic rheumatic disease manifesting as
monoarticular involvement
Inflammatory
• Juxta-articular fracture
• Trauma
• Hemarthrosis
• Osteonecrosis (AVN)
Noninflammatory

47. Inflammatory
• Chronic infectious arthritis
• Lyme Disease
• Crystalline synovitis
• Pauciarticular juvenile idiopathic 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

48. Oligoarticular JIA may
present as chronic
monoarthritis.
• Persistent
• Extending
Oligoarticular
• RF+ve
• RF-ve
Polyarticular
Systemic onset
Enthesitis-related arthritis (ERA)
Psoriatic arthritis (PsA)
Undifferentiated
ILAR
classification

49. Single red hot joint in RA: It should be remembered
that the uncommon occurrence of a red hot joint in
the context of RA may be due to superimposed
septic arthritis and not to the disease process itself.
Monoarthritis in SLE: The occurrence of
monoarthritis in a patient with SLE suggests infection
or osteonecrosis.
L. Alharbi and H. Almoallim

50. Oligoarthritis
(2:4) (usually
asymmetric)
Acute
Inflammatory
Gonorrhea
ARF
Non-
inflammatory
Chronic
Inflammatory
Autoimmune
diseases e.g.
SpA
SpA
Non-
inflammatory
OA

52. Acute
polyarthritis
viral infections
parvovirus 819 HIV hepatitis viruses Rubella
Early manifestation of
chronic inflammatory
polyarthritis
RA SLE

53. 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

54. 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

56. Step 6 : distribution
Symmetric or not
Axial or peripheral
Small or large
Pattern & time-relation
Specific joint affection

57. Pattern
recognition
Articular
As in the
approach steps
Extra-articular
Constitutional Organ-specific

58. L. Alharbi and H. Almoallim
Each rheumatological
disease has a pattern
of presentation.
•
Recognize the
pattern early.
Each pattern has a
differential diagnosis
•Construct your D.D.
list.

59. Some diseases are multi-
patterned. The clinical
patterns were originally
described by Moll & Wright
Distal arthritis with involvement of DIP joints
Asymmetric oligoarthritis, in which less than
five small and/or large joints are affected in an
asymmetric distribution
Symmetric polyarthritis, similar to and, at
times, indistinguishable from RA
Arthritis mutilans, characterized by deforming
and destructive arthritis
SpA, including both sacroiliitis

60. Highly suggestive
features (Ds)
DIP affection
Dactylitis
Destruction
Distribution (pattern)
Dermatological affection

61. • The involvement of right 4th, 5th & left 2nd MCP joints is deemed
symmetrical involvement of MP joints.
• Is this symmetrical?

62. • Symmetrical involvement refers to the affection of the same joints on the right
and left sides. Even in symmetrical involvement, mirror-image symmetry is not
required. To clarify things, the involvement of right 4th, 5th & left 2nd MCP joints
is deemed symmetrical involvement of MP joints.
• Psoriasis can cause either asymmetric oligoarthritis or symmetric polyarthritis.

64. Specific joint involvement
First carpometacarpal joint is typical of OA, while the ankle and shoulder are
rarely involved in primary OA.
(DIP) joint involvement is characteristic of OA, while DIP joints are spared in
RA. Other conditions that give rise to DIP joint involvement are psoriasis & SSc.
Spinal involvement other than the cervical spine is rare in RA. In contrast,
inflammatory low back pain is a characteristic feature of SpA.

70. 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.

71. The temporal
patterns
migratory
additive or
simultaneous
intermittent

72. migratory pattern
• inflammation for only a few days in each
joint (e.g., 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, ARF, gout, pseudogout, Lyme arthritis).

73. Step 7: Extra-articular features
Constitutional
manifestations
Organ
involvement

74. Step 7: Extra-articular features

80. 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

81. Step 8: The patient as a whole (demographics)
Age
Sex
Residence

83. Differential
diagnosis of
joint pains
associated
with
nodules
Rheumatoid arthritis
Tophaceous gout
Rheumatic fever
Multicentric reticulohistiocytosis
Sarcoidosis
Erythema nodosum
Vasculitides
Infective endocarditis

84. Multicentric Reticulohistiocytosis
Gouty Tophus

85. OA-Heberden & Bouchard nodes

86. Arthritides
associated with
Mucocutaneous
lesions
SLE
Gonococcal arthritis
Reactive arthritis
Behcet’s syndrome
Erythema nodosum
Psoriasis
Vasculitides
Systemic sclerosis

87. Differential
diagnosis
of joint
pains
associated
with fever
SLE
JIA (systemic-onset type)—Still’s disease
Infective endocarditis
Rheumatic fever
Vasculitis
Adult-onset Still’s disease

89. 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

90. 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.

91. 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. Symmetric or asymmetric; with or without
axial involvement (Distribution & pattern)
7. Extraarticular manifestations??

92. Another pathway: Track the pain
(Usual pain analysis): OLD CARTS
• Onset:
• Sudden or gradual
• Location
• All joint line or point
• Duration
• Acute or chronic
• Character
• Associated symptoms:
• inflammatory manifestations/
• Extra-articular
• Constitutional
• Other organs
• Alleviating/Aggravating factors
• movement & rest
• Radiation
• Timing
• Early morning, during the day, at night, during sleep
• Severity

93. Another
pathway: Track
the pain (Usual
pain analysis):
OLD CARTS
Onset: Sudden or gradual
Location
All joint line or
point
Duration Acute or chronic
Character
Associated
symptoms
Inflammatory
manifestations
Extra-
articular
Constitutional
Other organs
Alleviating/Aggr
avating factors
movement
& rest
Radiation
Timing
Early morning, during the
day, at night, during sleep
Severity

94. Another pathway: Track the pain
(Usual pain analysis): OLD CARTS
• Onset:
• Sudden or gradual
• Location
• All joint line or point
• Duration
• Acute or chronic
• Character
• Associated symptoms:
• inflammatory manifestations/
• Extra-articular
• Constitutional
• Other organs
• Alleviating/Aggravating factors
• movement & rest
• Radiation
• Timing
• Early morning, during the day, at night, during sleep
• Severity

95. Another pathway: Track
the pain (Usual pain
analysis)

97. Review of systems
Most rheumatological diseases are systemic diseases with significant involvements of other
body parts.
Some patients may not correlate the relationship between numbness, tingling sensations &
joints pain(s) (some patients may present with arthritis and mononeuritis multiplex like in
vasculitis or RA). Others may not remember to mention history of skin disease like psoriasis.
All possible symptoms are complied in an approach from head to toe just to help you
mastering this part of the history.

98. Musculoskeletal
pain
Non-articular Articular
Arthralgia Arthritis
Mechanical Inflammatory
Mono Oligo Poly
Axial
Cervical. Dorsal
or lumbar
Peripheral
Small or large
Symmetric or
not
Upper, lower
or both
Extra-articular
manifestations

99. acute onset of RA!
• Diseases don’t read our books. So,
• Deviations from the textbook typical picture are
uncommon, but not unknown! As is said,
exceptions prove the rule.

100. ‫خيرا‬ ‫هللا‬ ‫جزاكم‬