My aching joints
1 / 86

My Aching Joints! - PowerPoint PPT Presentation

  • Updated On :

My Aching Joints!. Jon Roebuck CPT MC WRAMC Rheumatology February 7, 2002. Musculoskeletal Pain. 1 in 7 patient visits to primary care Many benign conditions Some are life threatening Pays to know which is which Arthritis Leading causes of disability and absenteeism.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'My Aching Joints!' - salena

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
My aching joints l.jpg

My Aching Joints!

Jon Roebuck CPT MC

WRAMC Rheumatology

February 7, 2002

Musculoskeletal pain l.jpg
Musculoskeletal Pain

  • 1 in 7 patient visits to primary care

  • Many benign conditions

  • Some are life threatening

    • Pays to know which is which

  • Arthritis

    • Leading causes of disability and absenteeism

Goals of the lecture l.jpg
Goals of the Lecture

  • Classification of joint problem

    • Inflammatory Vs. Noninflammatory

    • Acute Vs. chronic

  • Approach to monoarthritis

  • Approach to polyarthritis

  • Rheumatology referral

    • When to order ANA, RF

  • Summary of points

  • Questions

History l.jpg

  • Musculoskeletal emergencies

    • Septic arthritis

    • Subacute bacterial endocarditis

    • Osteomyelitis

    • Necrotizing fasciitis

    • Systemic vasculitis

    • Acute myelopathy

    • Deep venous thrombosis

    • Compartment syndrome

Red flags l.jpg
Red flags

  • History of significant trauma

  • Hot, swollen joint

  • Weakness

    • Focal

    • Diffuse

  • Neurogenic pain

  • Claudication pain

General history l.jpg
General history

  • Joints involved

  • Chronicity

  • Exercise

    • Aggravates or alleviates

  • AM stiffness

  • Swollen joints

    • Rubor, Calor, Dolor, Tumor

  • Fatigue

Historical distinctions l.jpg


Symmetric joint involvement

Stiffness > 1hr


Improves with exercise

Constitutional complaints


One or very few joints

Stiffness <30min

No pain at rest

Worsen with exercise

No constitutional

Historical distinctions

Physical exam l.jpg
Physical Exam

  • Is it really the joint?

  • Articular

    • Painful, limited active ROM

    • Painful, limited passive ROM

  • Periarticular

    • Painful, limited active ROM

    • Full, unlimited passive ROM

Physical exam9 l.jpg
Physical Exam

  • Now is it inflammatory?

  • Warmth

  • Erythema

  • effusion

Physical exam10 l.jpg
Physical Exam

  • Joints involved

    • Small joint symmetric

    • Monoarthritis/oligoarthritis

  • Swelling observed?

  • Rashes

  • Nodules

  • Mucosal sores

  • Weakness

Physical exam refer these patients l.jpg
Physical ExamRefer these patients!

  • Skin as a clue to systemic disease

  • Vasculitis

  • Psoriasis

  • Erythema nodosum

  • Pyoderma gangrenosum

  • Still’s rash

  • Malar and discoid lesions

  • Dermatomyositis

Refer this one to us after the echo l.jpg
Refer this one to us(after the ECHO)

Close up palpable purpura l.jpg
Close-upPalpable purpura

Classic malar l.jpg


Crosses bridge of nose

Spares nasolabial fold

Classic malar

Bad malar l.jpg
Bad malar

  • Same features

  • Possibly discoid

  • Secondarily infected

Classic heliotrope l.jpg
Classic heliotrope

  • Periorbital edema

  • Lilac hue

  • Specific for dermatomyositis

Gottren s papules l.jpg

Most common skin rash

Papulosquamous eruption over joints

Not as specific as heliotrope

Gottren’s papules

Decision time l.jpg
Decision time

  • Acute monoarthritis

  • Acute polyarthritis

    • Symmetric

  • Chronic mono/pauciarthritis

  • Chronic polyarthritis

Monarthritis l.jpg


Acute monoarthritis l.jpg








Pigmented synovitis

Early presentation of systemic disease

Acute monoarthritis

Acute monoarthritis26 l.jpg

Most important intervention…


Cell count

Gram stain/culture

Crystal exam

Acute monoarthritis

Arthrocentesis technique l.jpg
Arthrocentesis technique

  • Considerations

    • Needle and syringe size

    • Skin sterilization

    • Local anesthesia

    • Comfort of you and patient

Slide28 l.jpg

  • Rheumatology

    • Medial

    • anesthesia

  • Orthopedics

    • Lateral

    • Superior

  • If you only know one joint…

What s in that joint l.jpg
What’s in that joint?

  • Inflammatory crystals

    • Gout

    • Pseudogout

    • Basic calcium phosphate

  • Fat

  • Cholesterol

  • Junk

Crystal diagnosis l.jpg
Crystal diagnosis

  • Polarized light microscopy

    • Bright objects on dark background?

    • Crystal morphology?

    • Birefringent?

    • YAG Vs. ABC

Keep it straight l.jpg
Keep it straight

Chondrocalcinosis: XRAY diagnosis





Other crystals l.jpg



Other crystals

Acute monoarthritis33 l.jpg

Most important intervention…

Rheumatology referral

Call us

On call Doc each day

202 782 6734(5)

Acute monoarthritis

Chronic monoarthritis l.jpg
Chronic monoarthritis

  • Rheumatology referral

  • Atypical infection

    • Fungal

    • Mycobacterial

  • Atypical systemic disease

    • RA, SLE, SNSA

  • May need synovial biopsy

Polyarthritis l.jpg


Acute or chronic polyarthritis l.jpg
Acute or chronic polyarthritis

  • Careful history and physical exam

  • Synovitis?

    • No– your problem

    • Yes– our problem

      • Referral. To be helpful

        • Cbc, esr, crp, RF, ANA, bun/cr, UA, TSH

What to write on the referral l.jpg
What to write on the referral

  • What is it?

  • Sometimes it’s a differential

  • Sometimes it’s fairly obvious

  • Sometimes you have no idea

    • We may not either

Inflammatory symmetric small joint l.jpg

Acute (<6 weeks)







Rheumatic fever


Chronic (>6 weeks)



Other CTD

Chronic sequelae of the acute DX’s

Inflammatorysymmetric, small joint

Physical exam39 l.jpg
Physical Exam

  • The entire exam is important

  • However…

  • Hands are the gateway to rheumatologic diagnosis

Physical exam40 l.jpg
Physical Exam

  • I mentioned swelling

    • Synovial

    • Bony

  • Big difference, not always so obvious

Noninflammatory42 l.jpg

  • Osteoarthritis

  • Primary

  • Secondary

    • Hyperparathyroidism

    • Hemachromatosis

    • Acromegaly

    • Hypo/hyperthyroid

Acr criteria for ra l.jpg
ACR Criteria for RA

  • Morning stiffness

    • >1hr

  • Arthritis of 3 or more joint areas

    • Soft tissue swelling or fluid

  • Arthritis of hands

    • Wrist, MCP, PIP

  • Rheumatoid nodules

    • Subcutaneous nodules over bony prominences

  • Serum rheumatoid factor

  • Radiographic changes

    (4/7 criteria satisfy classification criteria)

How do i prevent deformity l.jpg
How do I prevent deformity?

  • Early aggressive therapy

    • Multiple DMARDs

  • Staunch monitoring of disease and medications

  • Low threshold to increase therapy

    • Any evidence of breakthrough disease

  • RHEUMATOLOGY referral!!

Lupus l.jpg

  • Very similar to RA

  • Rashes and other criteria helpful

  • Serologic eval

Acr criteria l.jpg

Renal involvement



Hematologic abnormalities

Oral ulcers

Neurologic sxs

Malar rash



Discoid lesions

Sun sensitivitiy

Notable exclusions




ACR Criteria

How do you prevent deformity in lupus l.jpg
How do you prevent deformity in lupus?

  • Trick question

  • Nonerosive/nondeforming arthritis

  • Jaccoud’s arthropathy

More hands nails and sausages l.jpg
More handsnails and sausages

Distribution isn t everything l.jpg
Distribution isn’t everything

  • Not all DIP disease is OA

Distribution isn t everything55 l.jpg
Distribution isn’t everything

  • Not all DIP disease is OA

Psoriatic arthritis l.jpg
Psoriatic arthritis

  • OA-like

    • DIPs

    • Nails

  • RA-like

  • Seronegative variety

  • Mutilans

  • oligoarthritis

Slide60 l.jpg


  • Clinical/microscopic diagnosis

  • Uric acid is not helpful acutely

  • Allopurinol is not acute treatment

Dupuytren s l.jpg

Nodular fibrosing lesions

Ulnar preference

Intralesional injection

Softening and flattening of nodules

Best early in course


Not sure if its inflammatory l.jpg
Not sure if its inflammatory?

  • Serologies


    • If chronic

  • Rheumatology referral!!

Serology l.jpg





Anemia chronic DZ




No help

Clinical and XRAY diagnosis


Laboratory assessment l.jpg
Laboratory assessment

  • When you you order an ANA

    • RF for that matter

  • Confirm clinical suspicion

  • Very poor screening test

    • Positive predictive value very low

Antinuclear antibodies l.jpg
Antinuclear Antibodies

  • 1 in 10-20 of population are ANA+

    • 5-10%

  • 1 in 1000-2000 have lupus

    • Similar rates for other autoimmune disease

Antinuclear antibodies72 l.jpg
Antinuclear Antibodies

AssumptionANA 5% of normals ANA 10% of Normals

ANA+ in SLE 99% 99%

ANA+ in normal 5% 10%

Prevalence of SLE 1:2000 1:2000

If 2000 people have ANA tests:

-Number ANA+ with SLE 1 1

-Number ANA+ without SLE 100 200

-liklihood of SLE in ANA+ group 1/1001/200

-15% haveMSK symptoms 300 300

-ANA + in that group 15 30

-Therefore liklihood of SLE in pts

with MSK symptoms and ANA+ 1/151/30

Inflammation on film l.jpg
Inflammation on film


Xrays only if chronic l.jpg


Asymmetric joint narrowing


Subchondral sclerosis

Subchondral cysts

Rheumatoid arthritis

Symmetric joint narrowing


Marginal erosions

Soft tissue swelling

XRAYSonly if chronic

What if it s outside the joint l.jpg
What if it’s outside the joint?

  • Bursitis

  • Tendonitis

  • Tenosynovitis

  • Entrapment syndromes

  • Sprains

  • Etc. etc. etc.

Depends on your comfort level l.jpg
Depends on your comfort level

  • Conservative therapy and follow up

  • Local injections

    • Very few absolute contraindications

      • Achilles

      • Through an active infection or abnormal skin

  • Refer to us!

Soft tissue injections l.jpg
Soft tissue injections

  • Whole new lecture

  • Water soluble steroid preferable

  • Any questions about particular sites?

Summary l.jpg

  • Red flags

  • Inflammatory Vs. Noninflammatory

    • History, PE, Lab, XRAY

    • If unsure, REFER!

  • Hands as a gateway to diagnosis

  • When to order ANA

  • When to refer

    • Never a wrong time!