approach towards a case of musculoskeletal disorder.#

Goals During the Initial Encounter With the Patient.

Dr. Mohit MathurReader (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

distribution?

ARTICULAR STRUCTURES

• synovium• Synovial fluid• Articular cartilage• Intra-articular ligaments• Joint capsule• Juxta-articular bone

NONARTICULAR (PERI-ARTICULAR) STRUCTURES

• Supportive extraarticular ligaments ex- collateral ligaments in knee.

• Tendons• Bursae• Muscle• Fascia• Bone• Nerve• And overlying skin.

Characteristics of Articular Disorders.

Deep or diffuse jt. pain. Limited range of motion on active as well

as passive movement. Swelling (effusion or synovial

proliferation). Crepitation. Instability. Locking. Deformity.

Characteristics of Nonarticular Disorders

Pain on active but not on passive movement of joint.

Point or focal tenderness.Presence of physical findings distant

from the joint capsule.

Inflammatory Vs. Non-inflammatory Disorders.

Factors Leading to Inflammation in Joint.

Infections( gonorrhea, tuberculosis). Crystal arthopathy( gout,

pseudogout). Immune related( RA, SLE). Reactive( rheumatic fever, Reiter's

syn.). Idiopathic.

Features of Inflammatory Joint Disorders.

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 hypoalbuminemia.

Inflammatory Vs Mechanical

Inflammatory1. Prolonged Immobility

stiffness

2. Rest pain usually get better with activity

3. Joint swelling,erythema,heat

4. Systemic symptoms & Multi-organ involvement

Mechanical1. Minimal inactivity

stiffness

2. Pain on activity usually improving on rest

3. Joint crepitus, Instability and locking

4. History of trauma, strain or overuse

Acute Vs Chronic Disorders

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.

Extent of Joint Involvement

Monoarticular disorders- one joint involved

Oligoarticular or pauciarticular disorders - two or three joints involved

Polyarticular disorders - more than three joints involved

Mono/oligoarthritis

Infective arthritisosteoarthritisReiter’s syndromeGout

Polyarthritis

Rheumatoid arthritisSLEScleroderma

Rheumatoid Arthritis

Rheumatoid Arthritis

Rheumatoid arthritis is a chronic multisystem disease of unknown cause.

It’s characteristic feature is persistent inflammatory synovitis usually involving peripheral joints in a symmetrical distribution.

Clinical Presentation

RA begin insidiously with fatigue, anorexia, generalized weakness and vague musculoskeletal symptoms.

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.

Clinical Presentation

Generalized stiffness is frequent. Constitutional symptoms- weakness,

easy fatigability, anemia, anorexia & weight loss.

American Rheumatology Association Revised Criteria (1988)

1. Morning stiffness in & around joints lasting 1 hr. or more before maximum improvement.

2. Arthritis of three or more joint areas (duration of 6 weeks or more).

3. Arthritis of hand joints (duration of 6 weeks or more).

4. Symmetric arthritis.5. Rheumatoid nodules.6. Elevated serum rheumatoid factor.7. 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.

Disorders resembling rheumatoid arthritis

1) Systemic lupus erythematosis.2) Systemic sclerosis.3) Reiter’s syndrome.4) Psoriatic arthritis.5) Crystal deposition arthropathies.6) Nodal osteoarthritis.7) Gonococcal arthritis.8) Farber’s disease.9) Vascuilitis.10)Amyloidosis.

11) Anti-phospholipid syndrome.

12) Mixed connective tissue disease.

13) Viral arthritis ( eg parvovirus, rubella, hepatitis)

14) Polymyalgia rheumatica.

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 RA.

Systemic Sclerosis

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.

Reiter’s Syndrome

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 diagnosis.

Psoriatic Arthritis

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 simultaneously.

Monosodium Urate Arthopathy (Gout) It commonly present as acute oligoarticular

arthritis affecting middle aged to elderly men. The MTP jt. of 1st 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 tophaceous deposits.

Most of the crystal arthopathies such as CPPD deposition disease, HA deposition disease & CaOx deposition disease affect elderly who usually have a preexisting degenerative joint disease.

In some cases they produce synovitis which may mimic RA. Diagnosis is confirmed by analysis of synovial fluid or articular tissue.

crystal arthopathies e.g. gout

Tophi

Vasculitis

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 diseases.

Vasculitis syndromes classification

VASCULITIS

Localized Generalized

Cutaneous vasculitis Classical PAN Wegener’s granulomatosis Temporal arteritis

Classic polyarteritis nodosa Systemic- fever, weight loss & malaise. Renal(60%)- hypertension, renal insufficiency

or hemorrhage. Musculoskeletal(64%)- arthritis, arthralgia &

myalgia. Peripheral nervous system(51%)- peripheral

neuropathy. GIT(41%)- abdominal pain, nausea & vomiting. Skin(43%)- rash, purpura, livedo reticularis,

raynaud’s phenomena. Cardiac- cardiac failure, AMI.

Polymyalgia rheumatica and GCA 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 & thighs).

Temporal artery- tender, thickened & nodular.

jaw claudication visual disturbance, systemic upset.

TA biopsy

Antinuclear cytoplasmic antibodies (ANCA) Antinuclear cytoplasmic antibodies (ANCA) are

antibodies directed against certain proteins in the cytoplasm of neutrophils. They are present in a high percentage of patients with systemic vasculitis e.g.Wagener's granulomatosis but are rare in other inflammatory disorders.

Two major categories of ANCA- cytoplasmic © ANCA and perinuclear (p) ANCA

Farber Disease

Autosomal recessive disorder Results from deficiency of lyzozomal enzyme

ceramidase & the accumulation of ceramide in various tissues especially joints.

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.

Amyloidosis

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 crystals.

Osteoarthritis

Mechanical symptoms

Bony swelling, crepitus

DIP (Heberden), PIP (Bouchard), 1st CMCJ, neck, lower back, hips, knees, 1st MTP

Fibromyalgia

“All over pain” Fatigue Sleep disturbance Depression Anxiety Irritable bowel Tender spots Diagnosis by

exclusion

Investigations

Blood Examination- Hb estimation, FBC, ESR, CRP, RF,

synovial fluid analysis X-Ray- Hands and feet Serological Test (ANA, RF, anti-DNAase,

ANCA, complement) Urine Examination Liver Function tests Organ based investigations- biopsy,

angiogram

Synovial fluid analysis

NormalNormal NoninflamNoninflammatory matory (OA,traum(OA,trauma)a)

RA, GoutRA, Gout Septic Septic arthritisarthritis

AppearancAppearancee

clearclear Clear/Clear/amber amber coloredcolored

Turbid/Turbid/yellowyellow

Turbid/Turbid/opaqueopaque

ViscosityViscosity viscousviscous viscousviscous Reduced Reduced viscosityviscosity

Reduced Reduced viscosityviscosity

Cell countCell count <180 <180 cells/mclcells/mcl

MononucleMononuclear cellsar cells

<2000/mcl<2000/mcl

MononucleMononuclear cellsar cells

2000-50,0002000-50,000

PolymorphoPolymorphonuclear nuclear leukocytesleukocytes

>100,000>100,000

PolymorphoPolymorphonuclear nuclear leukocytesleukocytes

(>75%)(>75%)

Other conditions where Rheumatoid factor is found in serum.Infection: Acute infection eg infectious mononucleosis;

Chronicinfection eg SBE, TB; Parasitic eg malaria; vaccination

Inflammatory disease: RA, CTD, Fibrosing alveolitis, Chronic active

hepatitis, cryoglobulinaemia

Malignancy: Lymphoma, leukaemia, myeloma, solid tumours

5% healthy population

RF <15 not significant unless associated with appropriate clinical scenario

Auto-antibodies and corresponding disorders

ANA – SLE; not significant in titers of 1/40 unless associated with appropriate clinical scenario

Anti-Ro and anti-La – Sjogrens syndrome Antitopoisomerase 1(Scl 70) and anti-centromere

– Scleroderma Anti-RNP – mixed CTD Anti-Jo-1 - myositis ANCA – vascuilitis

Radiological features - OA

Four cardinal features: Joint space

narrowing Sclerosis Subchondral cysts Osteophytes

Radiological features - RA

soft tissue swelling

juxta-articular osteoporosis

juxta-articular and subchondral erosions

joint space narrowing & subluxation

secondary OA & bony ankylosis

Thank you