Rheumatology E-learning. University of Szeged Department of Rheumatology and Immunology

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Terence McCoy
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1 Rheumatology E-learning University of Szeged Department of Rheumatology and Immunology

2 Case history in rheumatology History of the presenting musculoskeletal complaint Almost always: pain Exact location Character Time of onset/worsening Exaggerating and easing factors Functional disturbance Stiffness Limited range of motion In what and to what extent is the patient restricted?

3 Origin of pain Joint Inflammatory arthritis Osteoarthritis Bone Soft tissue Tendon, tendon sheath, tendon insertion (enthesis), bursa Nerve (neuralgia) Ischaemia Referred visceral pain

4 Character of the pain I. Pain of articular origin: Associated with the movement of the involved joint Osteoarthritis (arthrosis): pain at use and movementinitiation E.g. raising from a chair, starting to walk (hip and knee osteoarthritis) Lumbar spine pain: exacerbated by lifting, raising from bed or bending down eases at rest Inflammatory arthritis: pain worsening at rest Morning stiffness hands in rheumatoid arthritis it can be several hours Ankylosing spondylitis worsens at night, the patients is woken up by the pain several times, most intense in the morning, eases during the day

5 Character of the pain II. Pain of bony (osseous) origin: Permanent, generally strong, independent of movement Tumour, metastasis, pathologic fracture Pain of tendons, tendon-sheaths or tendineal insertions (entheses) Sharp, sudden Triggered by particular types of movement (often of movements of other joints or areas e.g. humeral epicondylitis is triggered by finger movements) Triggered by direct pressure on the enthesis Pain of nerves (neuralgia) Tearing, ripping, burning or piercing type Lumbo-ischialgia (sciatica), cervico-brachialgia the pain is referred to the corresponding dermatoma, occasionally associated with numbness, reduced sensitivity (hypaesthesia), motor deficit or reflex alterations Entrapment ( tunnel ) syndromes the location corresponds to the course of the peripheral nerve, pressure of special trigger points elicits the pain (Tinel sign)

6 Hands Further anamnestic data dysfunction Squeezing force is reduced. In more severe cases, the fist closure is impaired Dressing, buttoning, cutting with knife, opening of bottles, faucets, locks Shoulders Dressing, raising of objects, reaching for objects Lower limb Restriction of walking distance, inability to put on socks, problems with shoes, with squatting

7 Further anamnestic data How many joints hurt you? Mono-, oligo- or polyarthritis Migratory (e.g rheumatic fever), intermittent (e.g. gout) or persistent (e.g rheumatoid arthritis)? The onset of symptoms: insidious (e.g rheumatoid arthritis) or acute (reactive arthritis, gout, trauma)? Fever? Weight loss? Fatigue? Before the onset of symptoms: infection (e.g. reactive arthritis, SLE exacerbation), overuse (eg- soft tissu rheumatism), tick-bite (e.g. Lyme arthritis), travel abroad (tropical infectionassociated arthritis)?

8 Further anamnestic data II. Further symptoms? Easy sunburning on the face (SLE)? Psoriasis? Other skin symptoms (vasculitis, Reiter s syndrome)? Dry mouth or eye (Sjögren s)? Ulcer (aphta) in the mouth (SLE, Behcet)? Eye inflammation (spondyloarthritis, Sjögren s)? Blanching or blueing of the fingers in response to cold-exposure (=Raynaud s phenomenon autoimmune connective tissue diseases)? Abdominal pain, diarrhaea, bloody stools (vasculitis, inflammatory bowel-disease-associated arthritis)? Problems with urine (reactive arthritis)? Stabbing pain in the chest on breathing in (=pleuritis SLE)? How many steps you can ascend (until dyspnea) (interstitial lung disease autoimmune connective tissue diseases)?

9 Case history other questions to clarify Other known illnesses IBD, psoriasis, uveitis, endocrine illness, diabetes, frequent infections (immune deficiency) Previous illnesses Thrombosis, stroke (antiphospholipid sy), tumour, urinary stone (hyperuricaemia), fractures (osteoporosis) Obstetric history Repeated spontaneous abortions (antiphospholipid sy) Drugs Diuretic (hyperuricaemia), NSAID, intramuscular injection, corticosteroid (osteoporosis) Social history Occupation, employment status (soft tissue rheumatism, degenererative spine disease), smoking (rheumatoid arthritis, lung-cancer-associated arthritis), exposure to sunshine (SLE) Family history Autoimmune disease, psoriasis, young-age musculoskeletal (inflammatory) illness

10 Polyarthritis early rheumatoid arthritis

11 Physical examination of the joints Inspection: Swelling Redness Deformity Other discolouration Palpation Nature of the swelling synovitis = intraarticular balloting fluid = active arthritis treat!; or periarticular diffuse soft tissue thickening chronic arthritis activity sign; or bony enlargement osteophyte in osteoarthrosis) Tenderness exact location helps to identify the origin of the complaints joint? tendon? skin? subcutaneous tissue?

12 Physical examination of the joints II. Motion Active (by the patient) and passive (by the doctor) If active is less than passive: muscle weakness, paresis, tendon rupture Limitation of range of motion Involvement (both inflammatory or degenerative) of the joint itself The extent of limitation correlates somewhat with the severity of joint inflammation or damage (e.g. limitation of fist closure with hand small joint and wrist inflammation in rheumatoid arthritis) Contracture : permanent limitation of movement by articular cartilage damage or periarticular fibrosis

13 Acute gouty attack

14 Chronic tophaceous gout

palpated = synovitis = active arthritis; Verification of synovitis is also important for the determination

15 Palpation of joints 1. Identification of the joint space (interosseous space) 2. Pression: if tender: indicates joint pathology (inflammatory or degenerative) if balloting fluid is palpated = synovitis = active arthritis; Verification of synovitis is also important for the determination of intraarticular injection site Reminder active arthritis: 1. activity sign of a systemic disease 2. destroys the articular cartilage treat!

16 RA vs erosive osteoarthritis (arthrosis) Arthrosis: bony bulks, not synovitis, in DIP or PIP joints (RA: wrist, MCP and PIP are most often inflamed) Bouchard s arthrosis Heberden s arthrosis

17 Spinal column Degenerative illnesses: Weakening of the intervertebrate disc Dehydration, degeneration, slowly, proportionally to age - discopathy Abruptly, usually after a sudden inappropriate movement protrusion, disc herniation

neighbouring soft tissues Increased muscle tone myalgia Wearing-off of the

18 Cervical spondylosis The connection between the adjacent vertebrae becomes unstable dyslocation of the vertebrae Mechanic irritation inflammation of the neighbouring soft tissues Increased muscle tone myalgia Wearing-off of the margins of the vertebrae calcification of the surrounding bony surfaces - spondylosis

19 Inflammatory spinal diseases Spondyloarthritis Common, chronic, disabling inflammatory diseases involving the intervertebrate small joints, the intervertebrate discs and ligaments Ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease-associated arthritis, reactive arthritis, etc. Key features: pain, restricted movement, progressive bony fusion (ankylosis) Peripheral involvement (arthritis, enthesitis) is common

21 Inspection: Increased thoracic kyphosis Hump (gibbus)

22 Case history in spinal pain points to clarify Localisation: Low back (lumbar), neck (and upper shoulder), upper back (thoracic) Onset: sudden: disc herniation, vertebral compression Insidious: spondyloarthritis, chronic degenerative diseases Easing and exacerbating factors Worst at night and morning, eases during movement = INFLAMMATORY TYPE PAIN spondyloarthritis, septic spondylodiscitis Worsens after movement (i.e. work, walk, standing), relieved by rest = MECHANICAL TYPE PAIN degenerative diseases, vertebral compression fracture Refers (radiates) to limbs (= nerve root compression): lumboischialgia, cervico-brachialgia Neurological deficit (loss of sensation, paresis, urinary or fecal incontinence) nerve, cauda equina or spinal cord compression

23 Sciatica pain due to ischiadic nerve compression Hypaesthesia Motor deficit Loss of reflexes L-IV: patella S-I: Achilles Laségue test: positive, if an electric sudden linear pain is elicitated

24 Physical examination of the spinal column I. Inspection: Physiological curves Kyphosis Scoliosis Fixed Antalgic Hump (gibbus) Palpation: Spinosus process tender on knocking: compression fracture, vertebral abscess Spastic paravertebral muscles indicate any pathology at the corresponding spinal level

25 Physical examination of the spinal column II. Range of motion Neck: ante- retroflexion, lateral flexion, rotation. Occiput to wall, chin to sternum, ear to shoulder, chin to shoulder distances Thoracic: chest expansion in deep inspiration (normal > 5 cm) Lumbar: anteflexion (next slides), lateral flexion Decreases in all types of spinal diseases Helps to localise pathology, to assess severity and progression Neurological examination Sensation of touch in fingers, toes and proximally dermatomes! Paresis proximal and distal muscles Reflexes patellar, Achilles, biceps, triceps, radial

net/drdsabat/ankylo sing-spondylitis-ug-lecture

26 Restricted range of motion of the lumbar spine in ankylosing spondylitis sing-spondylitis-ug-lecture

27 Physical signs of ankylosing spondylitis Finger to ground distance Mennel s sign - sacroileitis

28 Alarming signs in a patient with spinal pain The pain is exacerbated by rest inflammation Permanent pain not related to movement vertebral compression, tumour Motor deficit, cauda equina syndrome (bladder or rectum sphincher dysorder, perineal hypaesthesia) urgent neurosurgical referral Nerve root compression sign (Laségue test), dermatomal sensory deficit disc herniation neurosurgical referral only if conservative treatment fails Other conditions: acute lumbago (low back pain, chronic low back pain, lumboischialgia, uncomplicated disc herniation no detailed diagnostic procedures are needed. Advise few days of bed-rest, simple analgesic, early mobilisation, active rehabilitation

29 Enthesitis Inflammation of the tendons or their insertion sites Localisation: Tennis elbow (lateral epicondylitis), golfer s elbow (medial epicondylitis) Rotator cuff tendinitis Achilles tendinitis Patella tendinitis Causes: repetitive overload (sport, work inappropriate repeated activities), trauma, direct irritation, systemic illness (rheumatoid arthritis, spondylarthropathy (enthesitis), polymyalgia rheumatica) Physical finding: tenderness upon direct pressure; the pain is triggered by the blocked action (isometric muscle contraction) of the involved tendon

30 Lateral epicondylitis of the humerus (tennis elbow) Pain in the lateral epicondylar region is provoked by resisted extension of the hand, i.e. contraction of extensors inserting at the lateral epicondyle

Pain is provoked by elevation of the arm, when the inflamed tissues impinge under the

31 Rotator cuff injury middle arch sign Supraspinatus muscle tendon or the adjacent subacromial bursa are inflamed (and not the shoulder joint inself). Pain is provoked by elevation of the arm, when the inflamed tissues impinge under the acromion. The pain is highest at the middle third of the elevation arch of the arm and at internal rotation of the shoulder

32 Plantar fasciitis

33 Bursitis - gouty olecranon bursitis Soft, balloting mass. Differentiation from arthritis: The localisation is consistent with the anatomical place of a bursa, subcutaneous, easily movable, and the interosseus space (joint) is not palpable.

34 Trochanteric bursitis Pain at the hip region, that increases when lying on the involved side Hip movements are normal Direct pressure on the greater trochanter when the patient lies on the side triggers the pain Ultrasound or in case of calcification X-ray confirms the diagnosis

Nerve entrapment syndromes Carpal tunnel syndrome Neuralgia: burning, pricking, stabbing pain with numbness, needle-and-pin feeling Wrist pain

35 Nerve entrapment syndromes Carpal tunnel syndrome Neuralgia: burning, pricking, stabbing pain with numbness, needle-and-pin feeling Wrist pain radiating to the I-III fingers, causing numbness and sensory dysfunction In more severe cases: anaesthesia, weakness of the flexion of fingers, thenar atrophy

36 Carpal tunnel syndrome Tinel sign Pressure on the compression site will elicit an electric type sudden pain corresponding to the area supplied by the nerve

37 Cubital tunnel syndrome Compression of the ulnar nerve at the medial aspect of the elbow Symptom: pain, numbness, hypaesthesia in the IV-V. fingers, weakness of the flexion of the IV-V. finger

Femoral neuralgia Femoral nerve laesion, usually in the femoral canal Causes: hip osteoarthrosis, lumbar spine deformity, overuse Symptoms: pain at the anterior aspect of the thigh and the knee,

38 Femoral neuralgia Femoral nerve laesion, usually in the femoral canal Causes: hip osteoarthrosis, lumbar spine deformity, overuse Symptoms: pain at the anterior aspect of the thigh and the knee, numbness at this region, quadriceps muscle weakness, abnormal gait, decreased or lost knee jerk reflex Direct pressure on the femoral nerve is positive Femoral sign: in prone position: flexion of the knee causes a sharp, neuralgiform pain at the anterior aspect of the thigh

inflammation of the ankle, exostosis, irritation by shoe Symptoms:

39 Medial tarsal tunnel syndrome Tinel sign Compression of the tibialis posterior nerve Cause: flat foot, valgus deformity or inflammation of the ankle, exostosis, irritation by shoe Symptoms: pain and numbness in the sole, weakness of plantar muscles (short toe flexors)

Rheumatology E-learning. University of Szeged Department of Rheumatology and Immunology

Rheumatology E-learning. University of Szeged Department of Rheumatology and Immunology Rheumatology E-learning University of Szeged Department of Rheumatology and Immunology Degenerative disorders of the spine I. Pathogenesis: The weakening of the intervertebral cartilagineous discs Gradually,