Johan van Rensburg

What organ system is involved?

What is the pathology?

What is the possible etiology?Genetic

Environmental

What are the possible complications?

How is the patient’s functioning impaired?

General algorithm

Inflammatory Degenerative

Joints

Local/Regional Generalized

Muscles/Soft tissues

What tipe of metabolic disease? Osteoporosis?

Bone

Are the symptom's from his/her joints, muscles/soft tissues or bone?

Is it likely to be a musculoskeletal problem?

Pain and Stiffness

Arthritis

Degenerative

Osteoartritis

InflammatoryRheumatoid arthritis

Seronegative spondiloarthropaties

GoutSeptic

Lower back pain

History most importantAge, gender, nationalityFamily history?Precipitating factors?

Drugs, Diet, Infections, Work, Play, Injuries, Habits etc.

How many joints?Type of pain?1. Referred2. Mechanical3. Inflammatory

Pattern of joint involvement?1. Symmetrical2. Asymmetrical3. Involvement of Hands4. Involvement of back and SI-Joints5. Soft tissue, enthesopathy, synovial joints and structures, cartilage disease

Pain/disease?Onset, severity, temporal pattern, associated features, duration

Functional status?Never forget to ask for complications of disease and medication

ExaminationGeneral and systemicNeurological examination important in referred pain and back problemsJoints

Look (Be observant)Feel

Tenderness, swelling and warmthJoint outlineStabilityPressure for soft tissue structures and fibromyalgia

MoveActive

Exclude referred painLocalize to joint area

PassiveROMCapsular pattern (joint capsule and synovium)Non-capsular (soft tissue and Internal/degenerative abnormalities)

Movement against resistanceMuscles (strength and tendons)Ligaments and joint stability

Non-inflammatory(soft tissue rheumatism)

Regional/localized

Myofacialsyndrome

Generalized

Fibromyalgia

Inflammatory(soft tissue rheumatism)

BursitisTenosynovitisEnthesopathy

TraumaAcute

Chronic

Due to underlying arthritis

Periarticular calcific deposits

Microcrystal deposits

Anxiety

Depression

LocalizedBursitis

Ganglion

Rotator cuff syndrome

Dupuytran’s contracture

Enthesitis

Tenosynovitis

Adhesive capsulitis

Nerve entrapment syndromes

GeneralizedFibromyalgia

Chronic fatigue syndrome

Myofacial pain syndrome

Psychogenic rheumatism

Localized pain and swelling

Associated conditionsRA

Gout

Infections

Repetitive trauma

Inflammation of synovial tendon sheath

CausesPart of a systemic disorder, e.g. RA

Infections TB

Leprosy

Inflammation at site of insertion of a tendon into the bone

Very characteristic of seronegativespondyloarthropathy e.g. Reiter’s syndrome

Other causesGout

Sports injuries

More than 90% of shoulder painExtra-capsular (soft tissue)

Majority of painful non-traumatic conditionsTendinitis of rotator cuff

DiagnosesGood history

Clinical Examination (non-capsular pattern and impairment of active & resisted movements)

Radiology

MRI

Lateral & medial

Epicondilitis

Olecranon bursitis

Carpal tunnel syndrome

Dupuytran’s contracture

De Quervain’s tenosynovitis

Ganglion

CausesOA

RA

Psoriatic arthritis

HA deposition disease

Bursitis

Enthesitis

Ligament strain

Calcific periarthritis

Achillis tendinitis

Peritendinitis

Plantar faciitis

Bursitis around calcaneous

Especially with Ankylosing spondylitis

Reactive arthritis

GeneralizedSoft tissue rheumatism

Chronic pain affecting the neck and arm regionOccurring in activities requiring control of posture, often of a repetitive nature,

Psychological factors contribute

Clinicalchronic pain in neck, chest wall, arm, hand

impairment of work performance

variable upper limb swellings

poor grip strength

taut proximal muscles

poor sleep patterns

often mood changes

often mild sympathetic dystrophy

Common

Otherwise healthy individualsarticular symptoms

hypermobility

Complicationsmuscle & ligament tears

traumatic & degenarative changes of joints

recurrent dislocations

Chronic musculoskeletal syndrome

Characterizeddiffuse pain

tender points

No synovitis or myositis.

“Intolerance of discomforts”PalpitationMedicationColdIscheamiaMovementLightNoiseHeatExercise

Unrevealing

Laboratory and Radiological negative

Eighty to ninety percent of patients are women

Peak age is 30–50 years

Generalized chronic musculoskeletal pain

Diffuse tenderness at discrete anatomic locations termed tender points

Diagnostic utility but not essential for classification of fibromyalgia

Fatigue

Sleep disturbances

Headaches

Irritable bowel syndrome

Paresthesias

Raynaud’s-like symptoms

Depression and anxiety

Inflammatory vs. Noninflamatory

Acute vs. Chronic

Temporal pattern of joint involvement

Distribution of joint involvement

Age of patient

Sex of patient

Systemic involvement

Morning stiffness>1 hr

FatigueProfound

ActivityImproves symptoms

RestWorsens symptoms

Systemic involvementYes

Swelling, warmth, erythema, tenderness, loss of function

Morning stiffness<30 min

FatigueMinimal

ActivityWorsens symptoms

RestImproves symptoms

Systemic involvementNo

InfectionGonococcal

Meningococcal

Acute rheumatic fever

Bacterial endocarditis

Viral(esp.. rubella, hepatitis B, parvovirus, Epstein-Barr, HIV)

Other inflammatoryRheumatoid arthritis

Juvenile chronic arthritis

SLE

Reiter’s syndrome

Psoriatic arthritis

Polyarticular gout

Sarcoid arthritis

Serum sickness

InflammatoryRheumatoid arthritis

Polyarticular Juvenile chronic arthritis

SLE

Progressive systemic sclerosis

Polymyositis

Reiter’s syndrome

Psoriatic arthritis

Enteropathic arthritis

Polyarticular gout

Pseudogout (CPPD)

Sarcoid arthritis

Vasculitis

Polymialgia rheumatica

NoninflammatoryOsteoarthritis

Pseudogout (CPPD)

Polyarticular gout

Paget’s disease

Fibromyalgia

Benign hypermobility syndrome

Hemochromatosis

Longstanding arthritis (Chronic) leads to deformity

Varus deformities of both knees due to OA of the medial compartment of the knee

Migratory

Rheumatic fever

Gonococcal arthritis

Additive

Nonspecific

Rheumatoid arthritis

SLE

Intermittent

Rheumatoid arthritis

Psoriatic arthritis

Reiter’s syndrome

Palandromic

Gout

Rheumatoid arthritis

Rheumatoid arthritisCommonly involved

Wrist, MCP, PIP, elbow, glenohumeral, cervical spine, hip, knee, ankle, tarsal, MTP

Commonly sparedDIP, thoracolumbar spine

OsteoarthritisCommonly involved

First CMC, DIP, PIP, cervical spine, thoracolumbar spine, hip, knee, first MTP, toe IP

Commonly sparedMCP, wrist, elbow, glenohumeral, ankle, tarsal

Jaccoud artrhropathy in SLE

Deformity reduced

Reiter’s syndromeCommonly involved

Knee, ankle, tarsal, MTP, toe IP, elbow, axial

Gonococcal arthritisCommonly involved

Knee, wrist, ankle, hand IP

Commonly sparedAxial

Early RA

Extensor tenosinovitis

Olecranon bursitis and subcutaneous nodules

A lot of reasons for pain around the hip area

Baker’s popliteal sist

RA feet

Psoriasis in natal cleft

Mono arhtropathy associated with psoriasis

Clinical Picture

Symmetric psoriatic polyarthritis resembling RA

Psoriatic Arthritis

Nail pitting

Skin

Enthesophathy

Dactilitis

Differential diagnosis1. Gout2. Osteoarthritis3. Rheumatoid arthritis4. Psoriasis

Young patient with right knee pain and left tennis elbow

Reactive arthritis

Young lady with swollen and painful left knee

Gonococcal arthritis

Young boy with proteinuria and acute abdominal pain

Henoch-Schonlein Purpura

Young lady with abdominal pain, rectal bleeding associated with a painful left ankle and sacro-illiitis

Inflammatory Bowel Disease

Pyoderma Gangrenosum

These facial and nail bed lesions associated with Raynaud’s phenomenon

Scleroderma

Painful hands and shoulders as well as mouth ulcera

SLE

Difficulty in climbing steps and painful upper legs

Dermatomyositis

Comparing:lupus, dermatomyositis and porphyria

Porphyria

Dermatomyositis

Lupus

What types of arthritis may be associated with these lesions?

1. Inflammatory bowel disease2. Sarcoidosis3. Rheumatic fever4. Tuberculosis5. SLE

Young patient with migrating arthritis

Rheumatic Fever

Erythema

marginatum

RA

Sero-negative Spondyloarthropathies

Sicca syndrome

Corticosteroids

Chloroquin

Patient with non-erosive arthritis and burning of eyes

Sicca Syndrome

Painful red eye in rheumatic diseases

Uveitis

Involving one single jointAcute or Chronic?

Inflammatory or Mechanical?

Articular or extra-articular?

Septic arthritisCrystal induced arthritis

Gout Pseudogout (CPPD)Hydroxy appatite (HA)Cholesterol

HemarthrosisHemophilliaWarfarin

Trauma / overuseLoose body HIVOsteoarthritis

Septic Joint

Acute Monoarthritis is a rheumatologic emergency

Infection may destroy a joint in 48 hours

Infected joint in RA

Back

Goes to bed healthy

Wakes up sudden monoarthritis ( 85% Podagra)

(heel, instep, knee, wrist and hands and elbow -olecranon bursitis)

Rigors with severe pain

Night spent in torture

Joint is red (“ripe tomato”),warm and very tender.

After attack skin around the joint often peels off

Acute attacks usually pass completely until the next attack

Uncontrolled hyperuricaemia may lead to

polyarticular gout

Trauma and surgery

Medication

Alcohol

Diet

Family history, as well as a typical history of

attacks

Typical clinical picture and tophi

Elevated serum urate - (may be normal during

attacks)

Urate crystals in aspiration fluid (as well as

tophi)

X rays: Punched-out erosions (Rat bitten)

Deposition of uric acid crystals in the tissues (tophi)

After repeated attacks after 11 - 12 years

The tophi occur in The auricles - helix

Tendons (hands, achilles tendon and feet)

Bursae - especially olecranon bursa

The tophi may ulcerate with secretion of pasty material

Special investigations

Special investigationsSide roomImaging

X-raySonarCTMRIIsotopes

HeamatologyBiochemistrySerologySynovial aspiratesPathology

Synovial biopsy

Reasons for special

investigations

-Confirm clinical diagnosis

-Help with diagnosis

-Prognostic

-Help determine activity of

inflammation

-Monitor for complications

of disease and drugs