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Approach to a patient with musculoskeletal complaint

Charito Cruz-Bermudez, MD, FPCP, FPRA. Approach to a patient with musculoskeletal complaint. Core competencies in the clinical assessment of a musculoskeletal problem. Take a relevant history with the knowledge of the characteristics of the major musculoskeletal (MS) condition

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Approach to a patient with musculoskeletal complaint

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  1. Charito Cruz-Bermudez, MD, FPCP, FPRA Approach to a patient with musculoskeletal complaint

  2. Core competencies in the clinical assessment of a musculoskeletal problem • Take a relevant history with the knowledge of the characteristics of the major musculoskeletal (MS) condition • Perform a clinical examination of the MS system • Distinguish abnormal from normal features by history and PE. • Apply a screening history and examination as part of the general inquiry

  3. Questions for the clinician to address • Is the problem regional or generalized, symmetric or asymmetric, peripheral or central? • Is it an acute, subacute or chronic problem? Is it progressive? • Are the symptoms inflammatory or non-inflammatory? • Is there evidence of a systemic process? Are there associated extra-articular features? • Is there an underlying risk factors or medical disorder which may predispose to a specific rheumatologic problem? • Has there been a functional loss/disability?

  4. Goals of Initial Encounter • Formulate a differential diagnosis  Accurate diagnosis • Avoidance of unnecessary diagnostic testing • Timely provision of therapy

  5. Symptoms of musculoskeletal problems Specific Symptoms: • Pain • Swelling • Stiffness • Deformity • Weakness • Loss of function

  6. Symptoms of musculoskeletal problems General symptoms • Fatigue and malaise • Generalized weakness • Depression • Sleep disturbance

  7. Symptoms of musculoskeletal problems RED FLAGS • Weight loss • Fever • Temple headache w/ scalp tenderness • Loss of sensation • Loss of motor function • Difficulty in urination or defecation

  8. Background: JOINT PAIN • Joint pain can be caused by diverse processes, including inflammation, cartilage degeneration, crystal deposition, infection, and trauma. • The differential diagnoses of joint pain are generated in large part from the history and physical examination.1

  9. Background: JOINT PAIN • Screening laboratory test results serve primarily to confirm clinical impressions and can be misleading if used indiscriminately. • The initial aim of the evaluation is to localize the source of the joint symptoms and to determine the type of pathophysiologic process responsible for their presence.

  10. General approach in the diagnosis of rheumatic disease • 1. Anatomic location2. Determine the nature of pathologic process3. Determine extent of involvement4. Determine chronology5. Formulate differential diagnosis

  11.  Determine whether the pain is: • Articular or non-articular (site) • Localized, diffuse or systemic (pattern) • Acute or Chronic (timing) • Inflammatory or non-inflammatory (nature)

  12. I. Is the pain articular or non-articular? • Articular: involving the joints -is there swelling, stiffness, limited active and passive ROM, or deformity? eg., Rheumatoid arthritis, gout, osteoarthritis, reactive arthritis

  13. Determine the anatomic site(s) of origin of the complaint: articular or non articular

  14. I. Is the pain articular or non-articular? • Non-articular: involving bones, muscles and tissues around the joints such as tendons, bursae and overlying skin - is there tenderness outside the joint or loss of active but not passive ROM, absence of deformity? eg., tendinitis, bursitis, tenosynovitis, ligament/muscle strain

  15. II. Is the pain localized, diffuse or systemic? • Localized pain: involves only one joint (monoarticular) • - trauma, monoarticular arthritis, tendinitis, bursitis (eg. Hip pain in the trochanteric region trochanteric bursitis)

  16. II. Is the pain localized, diffuse or systemic? • Diffuse: usually polyarticular -if polyarticular, is it symmetrical or asymmetrical; is it migratory or additive? • If migratory, consider rheumatic fever or gonococcal arthritis • If additive, symmetrical, consider rheumatoid arthritis

  17. III. Is the pain acute or chronic? • Did the pain or discomfort develop rapidly over a few hours or days? (ACUTE) eg. Gout, septic arthritis - if more rapid in onset, how did the pain arise? Was there an acute injury or overuse from repetetive motion of the same part of the body?

  18. III. Is the pain acute or chronic? • Did the pain develop insiduously over weeks or even months? (CHRONIC) eg. Rheumatoid arthritis, osteoarthritis, chronic infections like TB

  19. III. Is the pain acute or chronic? • Acute onset is consistent with infectious, crystal-induced, or traumatic origin. It can also occur in the setting of a connective tissue disorder. • Chronic complaints are seen with rheumatoid arthritis (RA), seronegativespondyloarthropathies, and osteoarthritis or the chronic sequelae of traumatic or degenerative back problems.

  20. What is the Pattern of involvement? • The pattern of joint involvement is very important in defining the type of joint disorder. • Symmetric polyarthritis of the small joints of the hands and feet is characteristic of RA • asymmetric involvement of the large joints of the lower extremities is most typical of the seronegative spondyloarthropathies. • migratory pattern of joint inflammation is seen in rheumatic fever and disseminated gonococcemia.

  21. IV. Is the pain inflammatory or non-inflammatory? • Is there warmth, tenderness, or redness? • Are there any systemic manifestations like fever, chills, weight loss, rash, weakness?

  22. Inflammatory vs Noninflammatory

  23. VI. What is the evolution of the complaint? • Acute: <6 weeks eg. Infectious/septic arthritis, gout, reactive arthritis • Chronic: >6 weeks eg., RA, OA • Migratory: RF, gonococcal, viral arthritis • Additive : RA, Reiter’s syndrome

  24. Record theseverity of disease, as revealed by a chronologic review of the following: • Ability to work during months or years. • Need for hospitalization or home confinement. • When applicable, ability to do household chores, activities of daily living and personal care. • Landmarks or significant functional change, such as retirement from work, need for household help, assistance for personal care, and use of cane, crutches, or wheelchair

  25. VII. What are the precipitating events? • Trauma • drug administration (ASA, diuretics,steroids, hydralazine, procainamide, statins) • Antecedent illness: diarhhea, urethritis • Physical inactivity, smoking • Excess alcohol

  26. Are there any systemic organ manifestations? • I. Skin • - butterfly rash (SLE) - scaly rash and nail pitting (psoriatic arthritis) -papules, pustules, vesicles on the distal extremities (gonococcal arthritis) -penile erosions (Reiter’s syndrome) -nail pitting

  27. Are there any systemic organ manifestations? • II. Eyes • Is there conjunctivitis? -ReA Is there history of uveitis? - Ankylosing spondylitis, RA, Reiter’s syndrome, SLE Is there blurring of vision? - giant cell arteritis, takayasus arteritis

  28. III. Is there history of UTI/diarrhea prior to the onest of pains? Reiter’s Syn., Ulcerative colitis

  29. Are there any systemic organ manifestations? • IV. Is there accompanying muscle weakness? • (polymyositis, dermatomyositis) • V. Is there CNS involvement? • (SLE, Behcets syndrome, vasculitis)

  30. Are there any systemic involvement- Possible differentials • Rashes: SLE, vasculitis, dermatomyositis, scleroderma, psoriatic arthritis, Still’s disease, HSP • Eye involvement: Sjogrens syndrome, Behcets’ disease, SLE, RA, SpA, temporal arteritis • Oral ulcers: SLE, enteropathic arhtritis, Behcets disease • Raynauds phenomenon: SLE, MCTD, scleroderma, RA

  31. Are there any systemic involvement? • Hematologic ( anemia, leucopenia, thrombocytopenia/thrombocytosis): SLE, vasculitis • Serositis: SLE, RA, Still’s disease • CNS involvement: SLE, behcets disease, vasculitis • GI involvement: SLE, scerolderma, PM/DM

  32. Identification of clinical signs of musculoskeletal problems • Look for swelling,ROM, deformity, muscle wating, and skin changes, at rest and during movement • Feel for tenderness, swelling, deformity, crepitations, and temperature. • Move actively then passively and against resistance to see if different. • Test for strength to assess function

  33. Techniques of Joint Examination

  34. Important areas of joint examination • Inspection for joint symmetry, alignment and bony deformities • Inspection and palpation of surrounding tissues for skin changes, nodules, crepitus and muscle atrophy • Range of motion and maneuvers to test joint function and stability • Assessment of inflammation (swelling,warmth, tenderness and redness)

  35. Important points to remember • Initial survey: assess general appearance, body proportions and ease of movement • As you apply techniques of MS exam, visualize the underlying anatomy, recall the key elements of the history (eg.the time course of symptoms and limitation in function in arthritis)

  36. Important points to remember • Joint examination should be systematic • It should include inspection, palpation of bony landmarks/ related joint and soft tissue structures) • Assessment of range of motion • Assessment of muscle strength

  37. Important points to remember • Determine the signs of inflammation and arthrtis • 1. Swelling: boggy or doughy synovial membrane, effusion, swelling of bursa/tendons? • 2. Warmth • 3. Tenderness • 4. Redness

  38. Systematic exmination of the joint: Inspection, palpation, and movement of joints may reveal swelling, tenderness, temperature and color changes over the joint, crepitation, and deformity. • Tenderness on direct pressure over the joint and stress pain produced when the joint, at the limit of its range of motion, is nudged a little farther are important findings of inflammation. • Crepitation is a palpable or audible sensation with joint motion caused by roughened articular or extraarticular surfaces rubbing each other. • Bony enlargement, subluxation, and ankylosis in abnormal positions cause deformity.

  39. The temporomandibular joint • Inspection and palpation for swelling and tenderness, and decreased range of motion • Palpation: place the tip of your index fingers just in front of the tragus of each ear as the patient opens his mouth

  40. The shoulder joint • Inspection: observe the shoulder girdle, scapular, related muscles • : note for swelling of the joint capsule anteriorly or subacromial bursa, deformity or muscle atrophy

  41. The shoulder joint • Palpation: • - acromion process • -acromioclavicular joint • -coracoid process

  42. The shoulder joint • Palpation: • Clues as to the origin of pain: • - top of the shoulder radiating toward the neck: AC joint • -lateral aspect of the shoulder radiating toward the deltoid: rotator cuff • -anterior shoulder: bicipital tendon

  43. The shoulder joint • Localized tenderness/pain with adduction inflammation of AC loint • Localized tenderness  subacromial/subdeltoid bursitis • Swelling  bursal tear • Tenderness over the SITS muscle insertion/inability to lift arm above the shoulder  sprains, tears, tendon rupture of rot.cuff (supraspinatous)

  44. The shoulder joint • “drop arm” test: px unable to hold the arm fully abducted at shoulder level  rot. cuff tear • Tenderness and effusion  GHJ synovitis

  45. The Elbow Joint • Inspection: medial / lateral epicondyles and olecranon proces • Palpation: swelling over the olecranon processolecranon bursitis; effusion arthritis

  46. The elbow joint • tenderness in lateral epicondyle: tennis elbow • tenderness in medial epicondyle: golfer’s elbow • Posterior displacement of olecranon posterior dislocation of the elbow or supracondylar fracture

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