Capita Selecta

Rheumatic disease : Physical

diagnosis

Hendrata Erry Andisari

Rheumatology- Imunology Division
Departement of Internal Medicine
Hang Tuah University/ Ramelan Naval Hospital
2017
 Rheumatic disease

• Soft tissue rheumatism

• Osteoarthritis
• Gout
• Arthritis with rash
• Rheumatoid arthritis
• Emergency conditions
 Soft tissue rheumatism
• Tendonitis
• Bursitis
• Muscular strain/Myofascial pain

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 Joint structure
bone skin & subcutaneous
tissue
capsule bursa
enthesis
synovium tendon sheath
fibrocartilage tendon
pad muscle
joint space ligamentous
thickening
hyaline articular of capsule
cartilage bursa
STENOSING TENOSYNOVITIS

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DE QUERVAIN’S TENOSYNOVITIS

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CARPAL TUNNEL SYNDROME

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LATERAL EPICONDYLITIS

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 SHOULDER PAIN SYNDROMES
Supraspinatus Clavicle
muscle
Acromion
Glenohumeral
fossa Coracoacromial
ligament
Subacromial Coracoid
bursa process
Lesser Subscapular
tubercle fossa
Greater Intertubercular
tubercle synovial sheath
Intertubercular Humerus
groove Scapula
Deltoid
muscle
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Anterior aspect of the shoulder joint
SHOULDER PAIN SYNDROMES
• Impingement syndrome
(rotator cuff tendonitis)
• Subacromial tendonitis
• Bicipital tendonitis
• Myofascial pain

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HIP PAIN SYNDROMES

Trochanteric bursitis
 Pain in the greater
trochanter region
 Local tenderness over
lateral hip area
 Calcification of bursa
may occur

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ANKLE and FOOT PAIN
SYNDROMES
• Achilles tendonitis
• Calcaneal bursitis
• Plantar fasciitis

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ANKLE and FOOT PAIN
SYNDROMES Achilles
medial and lateral tendon
subcutaneous malleolar
or “last” bursa retrocalcaneal
bursa

retroachilleal
bursa

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plantar aponeurosis subcalcaneal bursa

Osteoarthritis
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 ACR Diagnostic Criteria for OA of Knee
Knee pain
and
Osteophytes
+
One of the following:
• Age > 50 y
• Stiffness < 30 min
• Crepitus
ACR = American College of Rheumatology
Altman et al. Arthritis Rheum. 1986; 29: 1039–1049
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KNEE PAIN SYNDROMES
Quadriceps femoris
muscle
Gastrocnemius muscle Suprapatellar
(medial head) bursa
Semimembranosus bursa Quadriceps
communicating with joint tendon
space
Prepatellar
Gastrocnemius bursa bursa
communicating with Infrapatellar
joint space bursa
Medial collateral lig. Superficial & deep
Anserine bursa Infrapatellar bursa
OSTEOARTHRITIS: GENERALITIES
• Cartilage degradation: loss of matrix integrity
• Role of cytokines, enzymes, nitric oxide
• Age is the strongest risk factor
• Other risk factors: obesity, injury, muscle
weakness
• Knees and hips are most commonly affected
• Heberden’s and Bouchard’s nodes
• Mechanical pain, no systemic features

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Gout
DIFFERENTIAL DIAGNOSES FOR
MONOARTHRITIS
• Gout
• Pseudogout
• Septic arthritis
• Reactive arthritis
• Trauma
• Beginning polyarthritis
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THE SPECTRUM OF GOUT
• Hyperuricemia
• Acute gouty arthritis
• Tophaceous deposition of urate crystals
• Urolithiasis
• Interstitial deposition of urate crystals in
renal parenchyma
• Uric acid nephropathy
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GOUTY ARTHRITIS:
GENERALITIES
• Extremely painful episodes of arthritis
• Intermittent course, usually monoarticular
involving the big toe, ankle, knee
• May later be oligo- or polyarticular
• Tendency to abuse NSAIDs (and steroids)
• May be precipitated by stress e.g. surgery,
blood transfusion
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GOUT:
SOME ASSOCIATED FACTORS
• Alcohol
• Dyslipidemia
• Hypertension
• Urolithiasis
• Drugs e.g. pyrazinamide, low dose ASA
• Renal disease
• Myeloproliferative disorder
• Strong family history

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ARTHRITIS-RASH
SYNDROMES

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SOME ARTHRITIS-RASH
SYNDROMES
• Viral arthritis
• Reiter’s
• Psoriatic arthritis
• Rheumatic fever
• Henoch-Schonlein purpura
• Systemic lupus erythematosus
• Other vasculitides and CTDs
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Rheumatoid arthritis
RHEUMATOID ARTHRITIS

• Chronic inflammatory synovitis

• Potentially disabling polyarthritis
• Female predilection
• May have extra-articular/systemic
manifestations

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NORMAL vs. RA SYNOVIUM
Normal Rheumatoid Synovitis
bursitis cartilage

bone lining cell

hyperplasia
tendonitis pannus
polymorph
exudate
synovitis mononuclear
infiltrate
fibrosis

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ACR 1987 CLASSIFICATION CRITERIA
FOR RHEUMATOID ARTHRITIS
Requires four out of the seven criteria:
1. Morning stiffness*
2. Arthritis of three or more joints*
3. Arthritis of hand joints*
4. Symmetric arthritis*
5. Rheumatoid nodules
6. Serum rheumatoid factor
7. Radiographic changes
*Must have been present for at least six weeks ACRFP
 PRACTICAL DECISION-MAKING
IN THE RHEUMATIC DISEASES I
Musculoskeletal complaint

History and P.E.

Non-articular Articular
Tendonitis
Bursitis Inflammation
Myofascial pain Present Minimal
Monoarthritis Polyarthritis OA
Gout
Septic arthritis Spine involvement
Trauma Prominent Minimal/None
Reiter’s* AS, PsA* RA, Viral*, SLE*
* Extra-articular features e.g. rash may be present
SERIOUS RHEUMATIC
DISORDERS

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EXAMPLES of SERIOUS
RHEUMATIC DISEASES
• Infection
• Malignancy
• Vasculitis

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WARNING SIGNS OF A SERIOUS
RHEUMATIC DISEASE
• Persistent, worsening pains
• Pains unrelieved by regular intake of
NSAIDs or other potent analgesics
• “Nerve pains”, “vascular pains”,
“bone pains”
• Accompanying fever, weight loss, pallor etc.
• Elderly
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LABORATORY CLUES TO A
SERIOUS RHEUMATIC DISORDER
• Anemia, thrombocytopenia, leucocytosis,
leucopenia
• Elevated ESR (corrected for age and anemia)
• Active urine sediment
• Abnormal radiographs e.g. pulmonary mass,
lytic/blastic lesions on skeletal x-rays
• Others: elevated alkaline phosphatase,
acid phosphatase, creatinine
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CASE

• 40 M
• alcoholic, DM type 2
• recent arthrotomy for “TB arthritis”
• 2 weeks post-op:
non-healing wound/persistent effusion

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CASE

• 25 M
• fever, cough, back pains
• ESR 120 mm/1st hr
• draining sinuses
• recent paraparesis

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CASE

• 60 M
• heavy smoker
• progressive painful swelling of right
shoulder
• no relief with NSAIDs/potent analgesics

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CASE
• 73 M
• bone pains and weight loss
• elevated acid phosphatase

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CASE
• 54 F
• bone pains, weight loss
• anemia, azotemia

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CASE
• 63 F
• 50 pack-year smoking history
• distal extremity pains and tenderness
• bulbous deformity of digits

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 PRACTICAL DECISION-MAKING
IN THE RHEUMATIC DISEASES* II
Non-articular Articular

“Warning signs”

Absent Present
(“benign”) (“potentially serious”)

Symptomatic Symptomatic treatment

treatment Work-up
Refer
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THANK YOU

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