Musculoskeletal Disorders

According to WHO Rheumatic or musculoskeletal conditions comprise over 150 diseases and syndromes and are the leading causes of morbidity and disability, giving rise to enormous healthcare expenditures and loss of work.

Points that may hint to the Diagnosis

Examination:

History:

Onset : Acute (crystal induced arthritis,infectious arthritis) or gradual (RA, Noninfectious arthritis), H/O Injury, un protected sexual contact( Disseminated gonoccocal infection) Previous same complaint

Presence of systemic symptoms (fever, chill, Raynauds phenomenon, eye irritation, photosensitivity, gastrointestinal and pulmonary symptoms)

Pain:

Type of pain: Persistent, Intermittent

Character:

· Burning – neuropathies

· Aching-arthritis

Location: Well localized pain- Point Tenderness-Tendinitis, Tenosynovitis

Tender Soft swelling : Bursitis

Symmetric joint involvement - Systemic disorders, RA

Mono/Oligo articular – OA, Psoriatic arthropathies

Poly articular arthritis – polymyalgia rheumatica, Fibromyalgia , OA, RA

Modalities:

· Pain < movement, > rest- Mechanical disorder (OA)

< Rest and initiating activity-inflammatory cause

< Active motion- Bursitis, Tendinitis

· Rest pain- inflammation

· Weather – aggravation

· Night or bone pain- bone origin

Morning stiffness

· 1 hour- RA, Spondylitis

· < 15 minutes- OA

Joint Instability: weakness of ligaments or structures that stabilize joints

Crepitus: caused by roughened articular cartilage or tendons.

Accompanying symptoms: urethritis- gonococcal infection

Fever-Crystal induced arthritis, septic joint, Osteomyelitis

Signs

Theatre sign: Stiffness and pain upon standing after sitting for several hours, that is relieved by slowly walking - commonly seen in OA

Bulge sign: Used for detection of small knee effusion, knee is fully extended and the leg slightly externally rotated while the patient is supine with muscle relaxed- the medial aspect of knee is stroked to express any fluid away from this area. Placement of one hand on the suprapatellar pouch and gentle stroking or pressing on the lateral aspect of the knee can create a fluid wave or bulge visible medially when an effusion is present.

OSTEO-ARTHRITIS

Osteo arthritis or osteoarthrosis is a progressive degenerative joint condition most commonly affecting the weight bearing joints( knee and hip joint).

Osteoarthritic Joint

Clinical features:

Pain - H/O insidious onset Variable/ intermittent pain, mostly causing night pain- over 1 or few joints
(Knee OA –Pain localized to anterior or medial aspect of knee or upper tibia
Hip OA – Pain in anterior groin, can radiate to buttock, anterior-lateral thigh, knee or shin.)
Pain < movement and weight bearing, > by rest
Morning stiffness- Brief (<15 minutes)
Gait-Antalgic gait

On examination of joints:

Bony swelling around joint margins

Joint Deformity – Commonly Varus Deformity (Knee OA), fixed flexion or external rotation (Hip OA)

Muscle weakness and wasting – Quadriceps (Knee & Hip OA),Gluteal muscles (Hip OA)

Nodal OA- Some cases joint affection may lead to posteriolateral swelling on each side of the extensor tendon, which may enlarge and harden to form nodes (Heberdens node-Distal Inter-phalangeal joint) ,Bouchard node (Proximal Inter-phalangeal nodes)

Restricted movement

Crepitus–(course, can be audible in some cases).

Diagnosis – Plain X-Ray :Joint space narrowing, Bony osteophyte formation (most noticeable at joint margins) ,Subchondral sclerosis(focal increased density of bones), cysts, Osteochondral loose bodies

RHEUMATOID ARTHRITIS

Rheumatoid Arthritis is an autoimmune joint disorder most commonly affecting women.

Risk factors:

3^rd-4^th decade
Female gender (risk increased postpartum, breast feeding)
Cigarette smoking

Clinical features

RA deformities

Pain

Commonly - small joint affection of hands (MCP and PIP), feet and wrists.
Symmetrical joint involvement
Onset-Gradual
< movement

Acute condition may present with: Morning stiffness, Polyarthrtis, Pitting oedema,

Non bony swelling, Rheumatic nodules.

Chronic condition – Deformities in hands (swan necked , Boutenniere deformity), thumb (Z deformity), Wrist (Dorsal subluxation of the ulnar styloid ) , foot (Dorsal subluxation of the MTP joints).

Criteria for diagnosis of RA (by Americal Rheumatism Association 1988 revision)

Diagnosis of RA is made with four or more of :

Morning stiffness( > 1 hr) Symmetrical arthritis Arthritis of 3 or more joint areas

Arthritis of hand joints Rheumatic nodules Rheumatoid factor

Radiological changes Duration of 6 weeks or more

Extra articular manifestations: Systemic symptoms (fever, fatigue, Weight loss, susceptibility to infection), Anaemia, Eosinophilia, Thrombocytosis, Splenomegaly, Felty’s syndrome, Dry eye (due to Sjogren’s syndrome), Painless pericarditis, Coronary vasculitis, Compression neuropathies.

Diagnosis:

Serological test- Rheumatoid factor, Anti-CCP.

Plain X-ray -Periarticular osteopenia, Marginal non-proliferative erosions

GOUT

Gout is a disorder of purine metabolism causing precipitation of Monosodium Urate Monohydrate Crystals in joints and periarticular tissues, most commonly affecting lower limbs (esp. first metatarsophalangeal joint and small joints of feet and hands).

Stages:

Asymptomatic hyperuricaemia
Acute gouty arthritis
Asymptomatic intervals
Chronic tophaceous stage

Acute Gout -Podagra causing swelling, erythema and extreme pain and tenderness of first metatarsophalangeal joint.

Other common sites are- ankle, midfoot, knee, small joints of hands, wrist and elbow.

Uric acid crystal deposition in Gouty Joint

Clinical features:

Onset of pain - Extremely rapid (reaching peak in 2-6 hrs), on waking in early morning.
Extreme tenderness
Marked swelling with red shiny skin
Self limiting– 5-14 days with complete return to normality.
Accompanying symptoms may include fever, malaise and confusion.

Recurrent and chronic Gout- The frequency of attacks increases with time alongwith

Continued MSUM deposition causes joint damage and chronic pain.

Tophi- in the later stages of disease deposition of large MSUM crystals may lead to development of white, irregular firm nodules, usually seen around extensor surfaces and sometimes over helix of the ear.

Large nodules may ulcerate or discharge gritty matter with inflammation.

Renal and urinary tract manifestations: renal colic due to uric acid stones.

Progressive renal disease may result as a complication of severe chronic tophaceous gout.

Investigations: Renal function test: (S. Creatinine, urine testing), Blood glucose

S.lipid profile,Blood- ESR and FBC, Xray: to determine degree of joint damage.

Diagnosis: Fluid aspiration- from joint, bursa or tophus- may show MSUM crystals.

Synovial fluid- increased turbidity, Measurement of 24 hour uric acid excreation on low purine diet.,uric acid > 7 mg/dl (Hyperuricaemia)

Acute phase - elevated CRP, neutrophilia, raised ESR

OSTEOPOROSIS

Osteoporosis is a common clinical condition characterized by reduced bone mineral density, micro-architectural deterioration of bone tissue and increased risk of fracture.

Osteoporotic Bone

Clinical features

Osteoporosis maypresent as an Asymptomatic disorder.

Symptoms such as Fractures (particularly of distal radius, femoral neck and vertebral bodies), Back ache, height loss and kyphosis may be present.

Investigation: Routine biochemical and Haematological tests- S Calcium, Phosphate, thyroid function tests, immunoglobulins, ESR.

Diagnosis: Plain X ray – Osteopenia , Fracture- most commonly of forearm (Colles fracture), spine, femur

BMD measurement- Lumbar spine and Hip-T-score - 2.5 or below-Osteoporosis

T-score- between –1.0- -2.5 Osteopenic range

ANKYLOSING SPONDYLITIS

Ankylosing spondylitis is a chronic progressive seronegative inflammatory arthritis mainly affecting the spine and sacroiliac joints.

Risk factor:

2^nd -3^rd decade of life

Sex- commonly seen in males

Positive family history

Clinical features:

Onset –Insidious
Location- mainly affects lumbosacral area
Recurring episodes of low back pain radiating to buttocks or posterior thighs
Pain and Stiffness -< night, early morning, after inactivity, > movement
On examination: failure to obliterate the lumbar lordosis on forward flexion, pain on sacro illliac compression, kyphosis, Diminished chest expansion
Extra spinal features may include pleuritic chest pains aggravated by breathing, plantar fascitis, Achilles tendonitis, chronic fatigue because of interrupted sleep due to pain.

Diagnosis:

Plain X-ray: sacroilitis, with irregularity and loss of cortical margins, widening of joint spaces, subsequent narrowing and fusion

Lateral thoracolumbar spine X rAy- anterior squaring of vertebrae due to erosion and sclerosis of anterior corners and periostitis of the waist,Typical bamboo spine

Haematology-Elevated ESR, C reactive protein

REACTIVE ARTHRITIS

Reactive arthritis is a seronegative arthritis.characterised by triad of non specific arthritis, conjunctivitis and reactive arthritis

Risk factor

Young age (16-35 yrs)

Predominantly – men (15:1)

Onset- acute

Clinical features:

Asymmetric joint involvement- Predominantly affecting large joints of lower limb and toes

Enthesopathy or inflammation of the tendinous insertions in bone is common

Vesicles on palms and soles and around nails that become hyperkeratotic and form crusts.

Urethritis ,Low grade fever, conjunctivitis, arthritis, fsatigue, weightloss.

Investigations:

Raised ESR and CRP, normochronic, normocytic anaemia

Vaginal swabs: Chlamydia on culture

Aspirated fluid – inflammatory containing giant macrophages (reiter’s cells)

Diagnosis: arthritis with symptoms of GI and GU infections and other extra articular features alongwith positive lab findings.

FIBROMYALGIA

Fibromyalgia is a common non-articular disorder characterized by generalized aching, widespread tenderness of muscles, muscle stiffness, fatigue and poor sleep.

Causes

Commonly seen in women (usually young or middle age)

Environmental or emotional stress

Poor sleep

Trauma

Clinical features

Diffuse Stiffness and pain – Gradual onset

Investigations – Negative laboratory results despite widespread symptoms

MUSCLE CRAMPS

A muscle cramp is a sudden brief, painful contraction of a muscle or group of muscles.

Causes

Tight calf muscles

Electrolyte abnormalities (eg hypokalemia)

Prevention:

Gently stretching the muscles before exercising or going to bed
Drinking plenty of fluids(containing potassium) after exercise
Not consuming stimulants(caffeine, nicotine, ephedrine)

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

SLE is an autoimmune disorder affecting multiple system of the body, commonly seen among females in the 2^nd and 3^rd decade of their life.

Clinical features:

Migratory arthralgia with morning stiffness, Tenosynovitis, small joint synovitis
Painful oral ulcers
Diffuse usually non-scarring alopecia
Three main types of rashes commonly seen in SLE includes:

Classic butterfly rash
Subacute cutaenous lupus erythematosus
Discoid lups lesions

Other skin manifestations include periungual erythema, vasculitis, livedo reticularis. Raynaud’s phenomenon

Renal symptoms may include proliferative glomerulonephritis
Cardiopulmonary features like chest pain from pleurisy or pericarditis may be present
CNS features may include: fatigue, headache, poor concentration

Investigations:

Blood – Neutropenia, Lymphopenia, Thrombocytopenia or Haemolytic anaemia.

Diagnosis: Anti-DNA antibodies, positive anti phospholipid antibodies, Abnormal titre of ANA

References:

Altman,R.D.. (2008). Seronegative Spondyloarthropathies. Available: http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/joint_disorders/seronegative_spondyloarthropathies.html#v905997. Last accessed 11th july 2012.
Jacewicz, M. (2009). Monarticular Joint Pain. Available:
http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/symptoms_of_joint_disorders/monarticular_joint_pain.html. Last accessed 11th july 2012.
Jacewicz, M. (2009). Polyarticular Joint Pain. Available:
http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/symptoms_of_joint_disorders/polyarticular_joint_pain.html. Last accessed 11th july 2012.

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