2. Who has rheumatoid arthritis?
Age/Sex Patient Complaints PMHx Labs
67 WM Finger pains/stiffness Interstitial Lung Dz +RF 56 IU
44 WF Carpal Tunnel Syndrome AM Stiffness ESR 54
29 BF Polyarthralgias IVDA, HCV ANA+, RF+
31 LF “Pain/swelling all over” “Migraine” “abnormal”
59 BM Knee effusion Arthroscopy SF WBC 2500
52 FF Painful MCP1 Gym Workout “all normal”
* RF normal < 14 IU Stevens, et al. May Clin Proc 1992; 67:541-548
Mayo Clinic:
1,016 CTS pts
– 57% w/ Med
Dx. 56.8%.
Most Frequent
Colles’ Fx
RA
hormonal Rx
oophorectomy
diabetes
mellitus
occupations
3. Cush JJ. Approach to Articular and Musculoskeletal Disorders, Chpt 363, Harrisons
Principles of Internal Medicine, 2018
4. N. Zealand General Practice Patient Visits
(20.4% of presentations for Rheumatic Disorders)
0 2 4 6 8 10 12 14 16
SpA
OP
Jt. Surgery
CTD
RA
Nerve compr
Gout
OA
Back pain
Regional
% presenting to GP
n=29,152
Taylor W, et al. NZ Med 2004 Oct 8;117(1203):U1098
•. 2004 Oct 8;117(1203):U1098
5. Prevalence of Arthritis & MSK Conditions
126.6 million Americans (1/2 adults) have a MSK condition
(USBJI - 2016)
58.5 million (23.7%) U.S. adults have arthritis (CDC- 2021)
91 million (37%) with arthritis in (NHIS-2015, Felson)
9.2 million in US with Gout- 5.9 mill men; 3.3 mil women
(NHANES – 2016)
3.94 million w/ self-ID Fibromyalgia (1.75% of the population) (NHIS – 2012)
1.3 million adults with Rheumatoid Arthritis (Claims data 2014)
6. Ways to Diagnose Arthritis
1. Identify “Red Flag” conditions (acute monarticular)
2. Arthritis by the Numbers (Most Common Stuff 1st )
3. Most Joint Pain is not from the Joint (AKA think like a rheumatologist)
4. Fibromyalgia first!
5. MSK Exam Clues
6. Pattern Recognition & the Diagnostic “Hook”
7. Lab SPECIFICITY
8. #1 RED FLAG CONDITIONS
SEPTIC ARTHRITIS
GOUT/PSEUDOGOUT
FRACTURE
All present as
ACUTE MONARTHRITIS
DO
Arthrocentesis/Injection
Hospitalization
Xray/Imaging
9. Goals of Assessment
Identify “Red Flag” conditions
Make a timely diagnosis
Many MS conditions are self-limiting
Some conditions require serial evaluation over time
Provide relief, reassurance and plan for evaluation and treatment
Cush JJ, et al: Evaluation of musculoskeletal complaints.
http://www.rheumaknowledgy.com/evaluation-of-musculoskeletal-complaints.
10. #2 Arthritis by the Numbers
What are the 3 most common
causes of Joint pain in the USA?
Joint Disorders
Low Back Pain
Osteoarthritis
Gout
1
2
3
13. Trauma
Fracture
Orthopedic Evaluation
Infectious
Arthritis
(GC, Viral,
Bacterial, Lyme)
Psoriatic
Reiters
IBD Arthritis
Rheumatoid
Arthritis
Gout
(males only)
Repetitive Strain Injury
(carpal tunnel,bursitis)
Septic
Arthritis
(Bacterial)
Osteoporotic
Fracture
Polymyalgia
Rheumatica
Gout
Pseudogout
Osteoarthritis
Fibromyalgia
Low Back
Pain?
Common musculoskeletal conditions by frequency
< 60 yrs. > 60 yrs.
FREQUENCY
MORE
LESS
27 Million
9.2 Million
3+ Million
1.3 Million
1.4 Million
5 Million
59 Million
711,000
Arthritis Rheum 58:15-35, 2008
4-10 Million
2 Million
9.2 Million
14. #3 Most Joint Pain is NOT Arthritis
Think like a rheumatologist
1. 4 Questions
2. Diff Dx – chronology pathology
3. Nonarticular know-how
15. Four Questions
• Rubor, Calor, Dolor, Tumor
Inflammatory vs. Noninflammatory?
• < or > 6 weeks
Acute vs. Chronic ?
• Exam
Articular vs. Periarticular ?
• (Focal) (Widespread)
Mono/Oligoarthritis vs Polyarthritis ?
Easy
Hard
19. History: Clues to Diagnosis
Age
Young: JRA, SLE, Reactive arthritis, GC arthritis
Middle: Fibromyalgia, tendinitis/bursitis, LBP, RA
Elderly: OA, Gout, PMR, GCA, septic, osteoporosis
Sex
Males: Gout, Ankylosing Spondylitis
Females: Fibromyalgia, RA, SLE
Race
White: PMR, GCA and GPA (Wegener's)
Black: SLE, sarcoidosis
Asian: RA, SLE, Takayasu's arteritis, Behcet's
20. 38 yr. WF complains of pain in elbows, wrists, knees & low back
for 2 years. Worsened by activity.
Joint pains are migratory,sometimes swollen. Worse over 6 mos
Morning stiffness = 60 minutes
Denies fever, rash, weight loss, joint erythema
Past history: MVA 10 yrs ago, “colitis” x 5 yrs
Exam: tender over PIPs, wrists, elbows shoulders, knees, but no
synovial swelling
What’s your diagnosis? Red Flag? By Numbers?
Polyarthralgias x 2 yrs
21. What investigations do you order?
Rheumatoid factor
Antinuclear antibodies
Lyme antibody
Uric acid
Hepatitis Panel (HBV, HCV, HAV)
CCP (ACPA) Abs
Thyroid function tests
HLA-B27
Nerve conduction velocities
Colonoscopy
Polyarthralgias x 2 yrs
Think
Like a
Lawyer!
22. Most Joint Pain is Not from the Joint!
Non-Articular Pains
Fracture
Fibromyalgia
Bursitis, Tendinitis, Enthesitis, Periostitis
Carpal tunnel syndrome
Polymyalgia rheumatica
Sickle Cell Crisis
Raynaud’s phenomenon
Reflex sympathetic dystrophy
Myxedema
23. 1. M05. 89 Seropositive RA
2. M79.7 Fibromyalgia
3. M32.10 SLE
4. M25.50 Arthralgias
5. M19.043 OA hands
6. L40.5 Psoriatic arthritis
What is the Correct Diagnosis?
24. #4 Think Fibromyalgia First
The Great Masquerader
Syphilis (Lues)
Tuberculosis
Systemic Lupus Erythematosus
Fibromyalgia
Others (RARE): Sarcoidosis, Vasculitis (GPA), Lymphoma, etc
25. Fibromyalgia Triad
Widespread pain
Many tender trigger points
Sleep disturbance
Hurt allover, impressive
history of dysfunction, but
normal joint exam
Labs: nonrevealing
Aches and Pains
“Total body toothache”
Think Fibromyalgia 1st
26. Most Frequently Missed Diagnoses
Fibromyalgia
No diagnosis (ANA+)
Overuse syndromes (bursitis, tendinitis, CTS)
Fracture
Psoriatic arthritis
Ankylosing Spondyitis
27. The Great Masqueraders
Syphilis (Lues)
Tuberculosis
Systemic Lupus Erythematosus
Fibromyalgia
Others (RARE): Sarcoidosis, Vasculitis (GPA), Lymphoma, etc
Cush J. The Great Masquerader. https://rheumnow.com/blog/great-masquerader-9
28. RHEUMAknowledgy.com
How to Diagnose Fibromyalgia
Suspect Fibromyalgia First
Widespread pain - but NO PHYSICAL FINDINGS
Globally Positive ROS (+organ recital)
NOTALGIA
Multiple Chemical Sensitivities – multiple allergies
“I just don’t like taking medicines”
Arthritis + Psychiatric Disorder/ADHD = Fibromyalgia
Lyme disease in Oklahoma
Hospitalized 6 weeks ago - Still wearing ID bracelet
Folds like a $20 card table when you touch ‘em
Sick n’ Tired of being ….. Sick n’ Tired
29. More Clues to FM Diagnosis
Insomnia, Sleep apnea, Restless leg syndrome
Fatigue
Headaches, migraines
Paraesthesia: nonanatomic, intermittent
Cognitive dysfunction (“brain fog”), Memory loss
Depression, anxiety in 30%
TMJ pain
Atypical chest pain
IBS
Dysmenorrhea
