Rheumatology

Approach to arthritis

Inspection: erythema, ecchymosis, deformity, loss of normal contours

Palpation: increased temperature, tenderness


ROM: Full by Apley scratch test. crepitus

Impingement Sx:

Tender subacromial bursa
Pain on abduction from 45 to 160 degrees, worse w resistance


Complete tear of supraspinatus:

Unable to initiate abduction from 0 degrees
Drop down test

Infraspinatus tendinitis:

Pain with resisted external rotation

Bicipital tendinitis:

Long head of biceps tender
Resisted supination painful

AC joint:

Tenderness, deformity, eccymosis, swelling
Crossover test
Pain on abduction from 120 to 180 degrees


Glenohumeral joint subluxation:

Drawer test
Apprehension test (abduction & ext'l rotation)
Sulcus sign (between acromion & humeral head)

Knee Px

Inspection: erythema, ecchymosis, deformity, loss of normal concavities

Palpation: increased temperature, tenderness medial & lateral tibial plateaus
patellar tap, bulge sign, fluctuation sign

ROM: crepitus

Lachman test:
Posterior drawer test:
valgus stress test:
varus stress test:
McMurray sign:


valgus stress & ext'l rotn:
varus stress & int'l rotn:

Apley compression test:
Patellar apprehension test:

Ankle Px

Inspection: erythema, ecchymosis, deformity, loss of normal contours

Palpation: increased temperature, tenderness


Ottawa ankle rules:

X-rays are only required if there is bony pain in the malleolar zone and any one of the following:
Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus

Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus

Inability to bear weight both immediately and in the emergency department for 4 steps

ROM
active
passive
dorsiflexion
plantarflexion
supination
pronation
Anterior drawer sign
if pos with dorsiflexion → medial & lateral ligaments ruptured
if pos with plantarflexion only → only anterior talofibular ligament ruptured

Palpate proximal fibula

Thompson test

Inspection: erythema, ecchymosis, deformity, loss of normal contours

Palpation: increased temperature, tenderness


Ottawa foot rules:

X-rays are only required if there is bony pain in the midfoot zone and any one of the following:
Bone tenderness at the base of the fifth metatarsal

Bone tenderness at the navicular bone

Inability to bear weight both immediately and in the emergency department for 4 steps

Metatarsal heads tender: metatarsalgia

Tender in spaces between metatarsal heads: Morton's neuroma

Ankylosing spondylitis

Hx: (sensitivity 70% & specificity 80%)
Morning stiffness > 30 mins
Improvement of back pain with exercise but not rest
Nocturnal back pain during second half of the night only
Alternating buttock pain

Px:
Schober's test


Investigations:
No direct test
X-ray studies of the spine show characteristic spinal changes and sacroiliitis (takes 8-10 yrs for changes to occur on plain films)
↑ ESR & CRP during acute inflammatory periods

Chronic fatigue syndrome

Labs


Urinalysis
CBC with differential
ESR
Total protein
C-reactive protein
ALT
ALP
urea
Electrolytes
Cr
Albumin
Globulin
Glucose
Calcium
Phosphorus
TSH and FT4
ANA and rheumatoid factor


Criteria for Rheumatic Diseases

Criteria:
1. History of widespread pain for at least 3 months.

Pain in the left side of the body, pain in the right side of the body, pain above the waist, and pain below the waist.
In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. "Low back" pain is considered lower segment pain.

2. Pain in 11 of 18 tender point sites on digital palpation.
Occiput: Bilateral, at the suboccipital muscle insertions.
Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.
Trapezius: bilateral, at the midpoint of the upper border.
Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.
Second rib: bilateral, at he second costochondral junctions, just lateral to the junctions on upper surfaces.
Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.
Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
Greater trochanter: bilateral, posterior to the trochanteric prominence.
Knee: bilateral, at the medial fat pad proximal to the joint line.

Digital palpation should be performed with an approximate force of 4 kg. For a tender point to be considered "positive" the subject must state that the palpation was painful. "Tender" is not to be considered "painful."

Low back pain

Red flags:

"TACIT"
T umour
AAA
C auda equina Sx
I nfection
T rauma

First episode in younger than 20
First episode in older than 55
Following trauma
Pain is constant & increasing
Pain in upper part of spine
H/o cancer
Steroid use
IV drug user
HIV
Weight loss


Hx to r/o underlying systemic disease:

duration of pain
nighttime pain
response to previous therapy
h/o cancer
unexplained weight loss
injection-drug use
chronic infection


Mechanical or degenerative process is suggested by:

Acute onset of pain
Exacerbation of symptoms with activity
Radicular radiation of pain

Acute low back pain without radicular symptoms (93%):

is usually simple musculoskeletal pain.
Ensure no red flags.

Investigations:
CBC
U/A
ESR


Management:
Conservative therapy for 6 wks

Acute Low Back Pain with radiculopathy

Conservative management in 99% of cases
CT or MRI Spine if not improving by 6 wks
Urgent evaluation in 1% of cases:
Cauda equina Sx
Rapid progression of neurologic deficit
Urinary retention
Saddle anesthesia

Management:
MRI LS spine
Immediate consultation for possible discectomy

Cauda equina Sx

Pathophysiology:
Massive central disc protrusion or
lumbar spinal stenosis or
lumbar spondylosis
→ compression of lumbar spinal nerve roots

Symptoms:
Bilateral sciatica
Dull, aching pain in perineum, bladder, or sacrum
Provoked by exercise or prolonged standing
Relieved with rest or forward bending
Saddle anesthesia
Bowel &/or bladder incontinence


Signs:
Foot drop
Bilateral weak ankle dorsiflexion
Absent ankle jerk


Investigations:
MRI L-spine

Management:
Immediate neurosurgery consultation

Lumbar spinal stenosis

Symptoms:
Constant back pain
Thigh & leg stiffness
Neurogenic intermittent Claudication:
Leg fatigue or weakness
Leg numbness or paresthesias
Bilateral leg pain (burning or cramping) involving buttocks & thighs, & spreads distally into feet
Provoked by lying prone or extending lumbar spine, walking
Not provoked by bicycle riding
Promptly relieved by sitting

Signs:
Neurologic exam often normal
Lower extremity sensory changes
Lower extremity motor changes

Management:
Progressive exercise
Anesthetic block (lasts 1 month)
Surgical decompression (May relieve leg symptoms but not back pain)

Osteoarthritis

Osteoarthritis of the Hand
Hand pain, aching, or stiffness and at least 3/4 of the following:

• Hard tissue enlargement of 2 or more of 10 selected joints
• Hard tissue enlargement of 2 or more DIP joints
• Fewer than 3 swollen MCP joints
• Deformity of at least 1 of 10 selected joints



The 10 selected joints are the 2nd & 3rd DIP, the 2nd & 3rd PIP, and the 1st carpometacarpal joints of both hands. Sensitivity 94%, specificity 87%.

Osteoarthritis of the Hip
Hip pain and at least 2/3:

• ESR<20 mm/hour
• Radiographic femoral or acetabular osteophytes
• Radiographic joint space narrowing

Idiopathic Osteoarthritis of the Knee

Clinical and laboratory	Clinical and radiographic	Clinical
Knee pain	Knee pain	Knee pain
+ at least 5 of 9:	+ at least 1 of 3:	+ at least 3 of 6:
- Age > 50 years	- Age > 50 years	- Age > 50 years
- Stiffness < 30 minutes	- Stiffness < 30 minutes	- Stiffness < 30 minutes
- Crepitus	- Crepitus	- Crepitus
- Bony Tenderness	+ Osteophytes	- Bony Tenderness
- Bony enlargement		- Bony enlargement
- No palpable warmth		- No palpable warmth
- ESR <40 mm/hour
- RF <1:40
- SF OA
92% sensitive	91% sensitive	95% sensitive
75% specific	86% specific	69% specific

SF OA = synovial fluid signs of OA (clear, viscous, or white blood cell count <2,000/mm

Rheumatoid Arthritis
(at least 4/7)

• Morning stiffness of >1 hour most mornings for at least 6 weeks.
• Arthritis and soft-tissue swelling of >3 of 14 joints/joint groups, present for at least 6 weeks
• Arthritis of hand joints, present for at least 6 weeks
• Symmetric arthritis, present for at least 6 weeks
• Subcutaneous nodules in specific places
• Rheumatoid factor > 95th percentile
• Radiological changes suggestive of joint erosion

SLE criteria (at least 4/11)

Criterion	Definition
1. Malar Rash	Fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds
2. Discoid rash	Erythematous raised patches with adherent keratotic scaling and follicular plugging; atrophic scarring may occur in older lesions
3. Photosensitivity	Skin rash as a result of unusual reaction to sunlight, by patient history or physician observation
4. Oral ulcers	Oral or nasopharyngeal ulceration, usually painless, observed by physician
5. Nonerosive Arthritis	Involving 2 or more peripheral joints, characterized by tenderness, swelling, or effusion
6. Pleuritis or Pericarditis	a) Pleuritis--convincing history of pleuritic pain or rubbing heard by a physician or evidence of pleural effusion OR b) Pericarditis--documented by electrocardigram or rub or evidence of pericardial effusion
7. Renal Disorder	a) Persistent proteinuria > 0.5 grams per day or > than 3+ if quantitation not performed OR b) Cellular casts--may be red cell, hemoglobin, granular, tubular, or mixed
8. Neurologic Disorder	a) Seizures--in the absence of offending drugs or known metabolic derangements; e.g., uremia, ketoacidosis, or electrolyte imbalance OR b) Psychosis--in the absence of offending drugs or known metabolic derangements, e.g., uremia, ketoacidosis, or electrolyte imbalance
9. Hematologic Disorder	a) Hemolytic anemia--with reticulocytosis OR b) Leukopenia--< 4,000/mm3 on ≥ 2 occasions OR c) Lyphopenia--< 1,500/ mm3 on ≥ 2 occasions OR d) Thrombocytopenia--<100,000/ mm3 in the absence of offending drugs
10. Immunologic Disorder	a) Anti-DNA: antibody to native DNA in abnormal titer OR b) Anti-Sm: presence of antibody to Sm nuclear antigen OR c) Positive finding of antiphospholipid antibodies on: an abnormal serum level of IgG or IgM anticardiolipin antibodies, a positive test result for lupus anticoagulant using a standard method, or a false-positive test result for at least 6 months confirmed by Treponema pallidum immobilization or fluorescent treponemal antibody absorption test
11. Positive Antinuclear Antibody	An abnormal titer of antinuclear antibody by immunofluorescence or an equivalent assay at any point in time and in the absence of drugs