DIAGNOSTIC STRATEGY IN

RHEUMATOLOGY
4
th
year, General Medicine, 2013 - 2014

MAIN SYNDROMES

1. REGIONAL SYNDROMES
2. GENERALIZED PAIN
3. BACK AND NECK PAIN
4. ARTICULAR SYNDROME
5. OSTEOPOROSIS SYNDROM
6. BONE SYNDROME
7. MUSCULAR SYNDROME
8. SYSTEMIC SYNDROME


Main Syndromes
1. REGIONAL SYNDROMES :

Pain that affects a single musculoskeletal area
(eg: shoulder, hand, or knee)

Origins of pain :
1. periarticular pain : predominate in the shoulders and
elbows
2. joint pain : are more commonly the cause of pain in the
forefeet and knees
3. neurogenic pain : sciatica and the carpal tunnel
syndrome.
4. referred pain




REGIONAL SYNDROMES
1.1. PERIARTICULAR PAIN :

originates in anatomical structures that are located
outside the joint capsule (the tendon and ligament)
as a result of repeated local trauma (e.g. intensive
use of the hands or shoulder) or as local
manifestations of systemic synovial diseases, like
rheumatoid arthritis.





REGIONAL SYNDROMES
1.1. PERIARTICULAR PAIN:

SELECTIVITY OF PAINFUL MOVEMENTS (SOME
MOVEMENTS ARE PAINFUL )
pain is made worse by positions that induce a compression of
the structure (eg, increased pain by laying on the affected
shoulder, in rotator cuff tendonitis)
passive movement is not limited in periarticular lesions;
resisted movements cause exacerbated pain;
palpation directly on the inflamed structure will cause pain;
swelling, heat and redness are usually not seen.





Periarticular pain

SELECTIVITY OF PAINFUL
MOVEMENTS
some movements are
painful: abduction and
external rotation in rotator
cuff tendinitis
REGIONAL SYNDROMES
1.1. PERIARTICULAR PAIN:

selectivity of painful movements (some movements are painful )
pain is made worse in positions that induce a compression of the
structure (eg, increased pain by laying on the affected shoulder,
in rotator cuff tendonitis)
passive movement is not limited in periarticular lesions
RESISTED MOVEMENTS CAUSE EXACERBATED PAIN
palpation directly on the inflamed structure will cause pain
swelling, heat and redness are usually not seen,





Periarticular pain

RESISTED
MOVEMENTS
INVOLVING THE
INFLAMED
STRUCTURE WILL
CAUSE INTENSE PAIN
(abduction and external
rotation)

REGIONAL SYNDROMES
1.1. PERIARTICULAR PAIN:

selectivity of painful movements (some movements are painful )
pain is made worse in positions that induce a compression of the
structure (eg, increased pain by laying on the affected shoulder,
in rotator cuff tendonitis)
passive movement is not limited in periarticular lesions
resisted movements cause exacerbated pain
PALPATION DIRECTLY ON THE INFLAMED STRUCTURE
WILL CAUSE PAIN
swelling, heat and redness are usually not seen,





Periarticular pain


PALPATION DIRECTLY ON
THE INFLAMED
STRUCTURE WILL CAUSE
PAIN
REGIONAL SYNDROMES
1.1. Periarticular pain:

selectivity of painful movements (some movements are painful )
PAIN IS MADE WORSE IN POSITIONS THAT INDUCE A
COMPRESSION OF THE STRUCTURE (EG, INCREASED
PAIN BY LAYING ON THE AFFECTED SHOULDER, IN
ROTATOR CUFF TENDONITIS)
PASSIVE MOVEMENT IS NOT LIMITED IN PERIARTICULAR
LESIONS
resisted movements cause exacerbated pain
palpation directly on the inflamed structure will cause pain
SWELLING, HEAT AND REDNESS ARE USUALLY NOT
SEEN,





Periarticular pain

Bursitis
Tenosynovitis
Bursitis
Bursa : sac like structure containing synovial fluid that
protects soft tissues from underlying bony prominences
Superficial (subcutaneous) between skin and ligaments,
periosteum;
Deep between fibrous tissues (ligaments) and bony
prominences.

Definition : inflammation of bursae (bursitis) results in
spontaneous pain, exacerbated on motion and often during
the night.

Causes: trauma, gout, RA, infection/sepsis (secondary to
cutaneous lesions or cellulite), aseptic inflammation
(presence of crystals )

Simptoms/signs : pain, local swelling



BURSAE IN THE HIP
Trochanteric Bursitis
It occurs predominantly in middleaged to elderly
people, and somewhat more often in women
than men.

The main symptom is aching over the
trochanteric area and lateral thigh :
Walking, various movements, and lying on the
involved hip may intensify the pain.

Local trauma and degeneration play a role in the
pathogenesis : OA of the lumbar spine or of the
hip, leg length discrepancy, and scoliosis.

Trochanteric Bursitis

The best way to diagnose
trochanteric bursitis is to
palpate over the
trochanteric area and
elicit point tenderness

Pain may be worse with
external rotation and
abduction against
resistance

Treatment consists of
local injection of depot
corticosteroid

Trochanteric Bursitis
external rotation and abduction against resistance
BURSAE IN THE KNEE
Popliteal Cysts : Bakers cysts
A naturally occurring communication may exist
between the knee joint and the
semimembranosus gastrocnemius bursa,
which is located beneath the medial head of the
gastrocnemius muscle

Any knee disease having a synovi : popliteal
cysts are most common secondary to RA, OA,
or internal derangements of the kneeal effusion
can be complicated by a popliteal cyst


Popliteal Cysts : Bakers cysts

Pain and discomfort are experienced,
particularly on full flexion or extension

A syndrome mimicking thrombophlebitis may
occur, resulting from cyst dissection into the calf
or actual rupture of the cyst :
diffuse swelling of the calf,
pain, and
sometimes erythema and edema of the ankle.
Knee Bursae : superficial prepatellar bursitis

Location: between the
patella and the overlying
skin
Pain and superficial
swelling located on the
antero-inferioar face of
the patella
Results from direct
pressure and friction of
repetitive kneeling
("housemaid's knee")
Its infection is very
common
It may be inflamed by
urate crystals
Elbow Bursitis
Tenosynovitis, tendonitis

Definition : inflammation of synovial sheath of
the tendon or of the tendon itself
Causes :
overuse,
inflammatory rheumatic diseases (RA), gout or
idiopatic
pregnancy , menopause, endocrine diseases,
amiloidosis, infections, drugs (fluoroquinolone,
corticosteroids, anabolic steroids) may be associated
especially with hand tenosynovitis.

Tenosynovitis, tendonitis
Rotator cuff tendonitis


The most common cause of non-traumatic shoulder pain;

Inflammation and tendons attrition (impingement) by rotator
cuff compression between humeral neck and acromion during
the glenohumeral movement;

Usually after an episod of glenohumeral instability (dislocation
with subluxatie of humeral neck), in degenerative or in
inflammatory rheumatic diseases;

The most common affected is supraspinatus tendon;

Frequently associated with subacromial bursitis;




Rotator cuff tendonitis

The more typical chronic
rotator cuff tendinitis
manifests as an ache in
the shoulder, usually over
the lateral deltoid, and
occurs on various
movements, especially on
abduction and internal
rotation
Neer test
The key finding is
pain in the rotator cuff
on active abduction,
especially between
60 and 120, and
sometimes when
lowering the arm

Passive abduction is
then carried out.
Tenosynovitis, tendonitis

Hand Tenosynovitis : Du Quervain Tenosinovitis

It affects scurt extensor si lung abductor ai policelui muscles.
Spontaneous pain with/ without radius stiloid swelling.
The pain is exacerbated by:

resisting thumb extension
abduction isometrically

It may also appear during pregnancy or postpartum.

Spontaneous pain with/ without radius stiloid swelling
This image shows a movement
called: resistent thumb extension

The examiner
supports the patient's
arm with one hand,
and asks the patient
to extend the thumb
against resistance
applied by the
opposite hand of the
examiner
The Finkelstein maneuver




The examiner gently
rotates the patient's wrist
ulnarly (arrow) while the
patient's fingers are
folded over the thumb
REGIONAL SYNDROMES
1.2. Monoarthropathy :

a lesion that affects a single joint
all movements tend to cause pain
resisted movement do not cause exacerbated pain
affected joints are frequently tender on palpation
along the joint margins.
crepitus, swelling, effusion and articular heat can,
when present, make the involvement of the joint
obvious.







Monoarthropathy :


The patellar borders
are effaced and there
is suprapatellar
fullness of the left
knee.

Monoarthropathy

Affected joints are
frequently tender on
palpation along the
joint margins
REGIONAL SYNDROMES
1.3. Neurogenic pain :

is caused by the compression or irritation of nerve
roots or peripheral nerves;

is typically disaestesic (burning, tingling, numbness,
electric shock);

affects the sensitive area of a particular nerve or root.


Testing for lumbar nerve root compromise


CARPAL TUNNEL SYNDROME

HAND-SYMPTOM DIAGRAM FOR CARPAL
TUNNEL SYNDROME

TERITORIUL SENZORIAL AL
NERVULUI MEDIAN


Testul Phalen


The Hoffman-Tinel test
CARPAL TUNNEL SYNDROME ETIOLOGY

Idiopatic 43%

Colles' fracture or other wrist trauma 13.4 %

Rheumatoid arthritis and other inflammatory rheumatic diseases 6.5 %

Menopause 6.4%

Diabetes mellitus 6.1 %

Wrist osteoarthritis 5.3%

Pregnancy 4.6%
REGIONAL SYNDROMES
1.4. Referred Pain :

refers to symptoms felt at a distance from their
anatomical origin

localized musculoskeletal pain can be referred from
internal viscera or , more rarely, other joints

the pain has uncharacteristic rhythm (more affected by
the physiology of the viscera than by joint movement)
and may be accompanied by suggestive symptoms

local examination is normal

Most common sites and origins of referred pain
GENERALIZED PAIN

In this syndrome, pain affects different parts of the body
diffusely and imprecisely, with little or no focus on joints.

Fibromyalgia accounts for the majority of the cases of
generalized pain syndrome.

The association of fibromyalgia with any other rheumatic
condition is common and represents some of the most
difficult clinical situations in rheumatology.



GENERALIZED PAIN
Fibromyalgia
Patients often use or agree with the expression pain
all over.
Pain is often migratory and worse after, rather then
during, exercise.
Exposure to cold and stress are frequently recognized
as aggravating factors.
It is common that other symptoms are present like
stress headaches, migraine, irritable bowel syndrome,
tight chest, depression, insomnia
Laboratory tests and imaging should be normal




GENERALIZED PAIN
FIBROMYALGIA : tender points

BACK AND NECK PAIN

Back pain is extremely frequent in medical
practice.

The vast majority of cases will escape
precise aetiological diagnosis even after
meticulous investigation (the complexity of
the spine, muscles, ligaments, nerves and
supporting soft tissues in the area leading to a
multiplicity of potential causes).
BACK AND NECK PAIN
The contribution of current diagnostic methods
to clinical diagnosis is very limited :
The correlation between even sophisticated imaging
and clinical manifestations is poor.
Used inappropriately, imaging can, actually, lead
to more problems than solutions in this area.
The most recommended strategy for back and
cervical pain is based on the search and recognition
of alarm symptoms and signs, red flags that indicate
a higher probability for an underlying specific cause.




BACK AND NECK PAIN
Red flags
Back pain with inflammatory
rhythm ( no relieved by rest)
Localized pain
Nocturnal pain
Visceral or constitutional
symptoms
Onset before age 30 or after
50
Pain at movement on all
directions
History of neoplasm
Risk or evidence of
osteoporosis
Neurological manifestations


Sacroiliitis
Spondylodiscitis
Metastases
Osteoporotic fracture
Neurogenic pain
Referred pain
Interspinous
ligamentitis


BACK AND NECK PAIN
NO Red flags

The pain has a mechanical rhythm : it is
triggered by movement and relieved by rest
Acute mechanical low back pain
Chronic mechanical low back pain

Mechanical disorders are the most common
causes of low back pain
They include muscle strain, herniated nucleus
pulposus, osteoarthritis, spinal stenosis,
spondylolisthesis, and adult scoliosis




ARTICULAR SYNDROME


Arthropathies, ie, diseases affecting the joints

On the first step we have to recognize that this
is an articular syndrome

On the second step, the most important goal is
to evaluate the clues of degenerative versus
inflammatory joint disease


ARTICULAR SYNDROME


On the first step we have to recognize that this
is an articular syndrome :

all movements tend to cause pain
resisted movement do not cause exacerbated pain
affected joints are frequently tender on palpation
along the joint margins.
pain has similar intensity with active and passive
mobilization and both can be limited in range


ARTICULAR SYNDROME

There are two main categories of
articular syndrome :
noninflammatory (degenerative joint
disease) and
inflammatory
ARTICULAR SYNDROME
Degenerative joint disease (osteoarthritis) is typically
associated with mechanical pain:
pain that increases with repeated use of the joint and is worst at
the end of day
pain intensity decreases during rest, is rarely present at night
and the patient can usually find a pain-free position
patients can describe that pain increases again after resting and
this may be accompanied by gelling, stiffness that subsides in
2-3 minutes
early morning stiffness associated with degenerative arthritis
ceases in a few minutes (<10).
crepitus, focal pain along the joint margin and/or osteophytes are
found; effusion can be present in later stages of the disease.


ARTICULAR SYNDROME
Conversely, in active inflammatory disease :
pain is worst in the morning and is relieved by continued use of
the joint.
the patient may have pain during the night, not related to
movement in bed and cannot identify a pain-free position.
morning stiffness lasts for longer than 30 minutes and post-rest
stiffness may persist for more than 5 minutes.
associated extraarticular manifestations may accompany a
variety of inflammatory arthritis but they are absent in
degenerative joint disease
we can find articular swelling of a firm rubbery consistency,
which is a sign of an inflamed, engorged synovium and
associated effusion
local heat is frequently found but redness is uncommon, except
in gout, septic and psoriatic arthritis.




ARTICULAR SYNDROME
Number of joints affected
Monoarthritis: one single joint involved
Oligoarthritis: 2 to 4 joints involved
Polyarthritis: 5 or more joints involved
Acute versus Chronic
Acute: onset in hours or days
Chronic: onset over weeks or months
Additive versus Migratory
Additive: the affected joints are added progressively
Migratory: the inflammatory process flits from one joint to another
Persistent versus Recurrent
Persistent: once it has set, the arthritis persists over the time
Recurrent: episodes or crisis of arthritis separated by symptom-free
intervals



ARTICULAR SYNDROME
Proximal versus predominantly Distal
Proximal: arthritis mainly involves large joints, i.e,
proximal to the wrist or ankle, and the spine
Distal: the arthritis mainly involves the small joints of
the hands and feet, with or without the wrist and ankle
Symmetrical versus Assymmetrical
Symmetrical: affects approximately the same joint
groups of each side of the body
Asymmetrical: there is no relationship between the
joints involved on either side of the body
With or without inflammatory low back pain
With or without systemic manifestations


Osteoarthritis: Heberdens and Bouchards nodes
Rheumatoid arthritis: fusiform swelling, hand
Psoriatic arthritis: nail changes, rash, and arthritis, hands
Psoriatic arthritis: asymmetric synoyitis, knees
OSTEOPOROSIS SYNDROME
Osteoporosis is a silent condition characterized by
reduced bone mass and microarchitectural changes
leading to increased bone fragility and susceptibility to
fracture.

Over 10 million people have osteoporosis and over 1.5
million osteoporosis-related fractures occur each year in
the United States alone (2007)

Osteoporotic fractures most often involve the femoral
neck, the vertebral bodies, or the wrist.
Ninety percent (90%) of all hip and spinal fractures are related to
osteoporosis.
OSTEOPOROSIS SYNDROME
This is characterized by the presence of risk factors for
osteoporosis :
post-menopausal status,
early menopause,
late menarche,
low weight and height,
prolonged corticosteroid therapy,
sedentary lifestyle,
insufficient intake of dairy products,
family history of osteoporosis or fracture
some diseases can lead to secondary osteoporosis :
hyperthyroidism, hyperparathyroidism, malabsorption, chronic
alcoholism and liver disease.


OSTEOPOROSIS SYNDROME
The diagnosis of osteoporosis is made either
from the results of bone density testing or
because of the occurrence of a fragility fracture :
Bone mineral density (BMD) criteria can be used to
diagnose osteoporosis
The World Health Organization (WHO) defines
osteoporosis as a T score 2.5the
T score is the number of standard deviations the patients
BMD measurement is above or below the young-normal
mean BMD.

VERTEBRAL FRACTURES

Cifoza
Pierdere in inaltime
Marirea abdomenului
Durere acuta si cronica
Tulburari respiratorii, simptome de reflux si alte
simptome gastrointestinale
Depresie
Calitate a vietii scazuta
VERTEBRAL FRACTURES
wedge fracture- fractura biconcava cruch fracture
VERTEBRAL FRACTURES
1
1
3
3
BONE SYNDROME
It is characterized by :
deep, diffuse, continuous pain, unrelated to
movement
frequently pain will be worse at night and
disturb the patients sleep
more commonly it will affect the spine, pelvis,
and the proximal segments of the limbs
the local examination is usually normal.




BONE SYNDROME

These features should raise the
hypotheses of :
bone tumors : metastatic tumours are the
most common neoplasms of bone and bone is
the third most common site of metastasis after
lung and liver
metabolic bone diseases or inflammation of
the periosteum

MUSCULAR SYNDROME
The pathological involvement of muscles is most
commonly reflected by :
predominantly proximal weakness and
muscular atrophy.
Myopathic patients may have difficulty:
going up and down stairs,
getting up from a low chair or
combing their hair but their handshake is firm ant they can walk
on tiptoe.
Polymyositis, dermatomyositis and inclusion-body
myositis are the most typical causes of this pattern.




MUSCULAR SYNDROME
Rheumatologists should also give special
attention to commonly used medications
which can cause neuromuscular
complications, including:
glucocorticoids,
hydroxychloroquine,
colchicine,
cyclosporine,
statins and fibrates among many others.


SYSTEMIC SYNDROME
All inflammatory joint diseases may be
accompanied by extra-articular manifestations,
involving other organs and systems

Constitutional manifestations : fever, weight
loss, severe fatigue

Skin manifestations : photosensitivity,skin
rash, scleroderma, purpura, livedo reticularis,
alopecia

8. SINDROMUL SISTEMIC
8.2. MANIFESTARI CUTANATE
8. SINDROMUL SISTEMIC
8.2. MANIFESTARI CUTANATE
SYSTEMIC SYNDROME
Mucosal manifestations : oral and
genital aphthae, dry eyes and mouth, red
eye, balanitis
Serositis
Raynauds phenomenon
Arterial or venous thrombosis
Recurrent abortion
Convulsions, psychosis, peripheral
neuropathy





8. SINDROMUL SISTEMIC
8.3. MANIFESTARI MUCOASE
Raynauds phenomenon
Reactive arthritis: conjunctivitis
Ankylosing spondylitis: iridocyclitis with
synechiae
Reactive arhtritis: erosions, tongue
LABORATORY INVESTIGATIONS

Inflammation : ESR, CRP, HL;
Muscular syndrome : TGO, CK, LDH;
Osteolisis : Alkaline phosphatase, serum
calcium;
Autoantibodies :
- sensitive -RF, ANA (many ANA positive
patients dont have SLE or any other disease);
- specific - anti CCP, anti DNA dc, anti Sm
HLA-B27


Rheumatoid Factor (RF):

Positive in 70-80% of RA cases;
Positive in healthy individuals (especially old ones), in other
collagen diseases (SLE, SJOGREN SYNDROME), TB, EBS

Antinuclear antibodies (ANA):
95% of SLE patients are ANA +: ANA - makes SLE dg
improbable;
5% of general population is ANA +;
SLE =rare disease (1:2000) : many ANA+ people dont have SLE
or any other inflammatory disease.

LABORATORY INVESTIGATIONS
Synovial liquid examination
Synovial liquid examination: septic arthritis, acute gout arthritis,
posttraumatic lesions etc.

When the diagnosis of an infl ammatory arthropathy is unclear,
synovial fl uid should be evaluated for the three Cs : cell count,
culture, and crystals.

Synovial fluid neutrophil counts in excess of 100,000/mm3 spells an
infection until provenotherwise, and should be treated empirically
with antibiotics until the results of culture are available.

Microcrystalline disorders (gout and pseudogout) occasionally lead
to synovial fluid neutrophil counts >100,000/mm3.

Examination of synovial fl uid under polarized microscopy is the only
way of securing the diagnosis of a microcrystalline disease.
Synovial liquid examination
IMAGISTIC INVESTIGATIONS
Musculoskeletal radiographs (antero-posterior and lateral): bone,
cartilage;

Ultrasonography: periarticular structures (tendons, ligaments, muscles),
synovium, cartilage, bone;

Technetium99 Scintigraphy: bone or articular lesion;

Computer tomography (CT): bone;

Magnetic resonance (IRM) : bone, synovium, periarticular structures;

Osteodensitometry : osteoporosis diagnosis.
IMAGISTIC INVESTIGATIONS
Conventional radiographs are the initial imaging
agent of choice for most rheumatic conditions

Trabecular bone and small bone erosions are
visualized well by conventional radiography

Computed tomography (CT) is superior to
conventional radiographs in the assessment of
certain joint conditions, including many cases of
tarsal coalition, sacroiliitis, osteonecrosis, and
sternoclavicular joint disease.
IMAGISTIC INVESTIGATIONS
High resolution CT of the lungs is an essential adjunct to
the evaluation of many infl ammatory rheumatic
diseases, for example, systemic sclerosis, systemic
vasculitis, and other disorders associated with signs of
interstitial lung disease.

Magnetic resonance imaging (MRI), which has superior
imaging capabilities of soft tissue and bone marrow
lesions, is the study of choice for a host of
musculoskeletal diagnoses, including meniscal tears of
the knee, spinal disc herniations, osteonecrosis,
osteomyelitis, skeletal neoplasms, and others

Bone densitometry plays a crucial role in the diagnosis
and treatment of osteopenia and osteoporosis.
Rheumatoid arthritis: hand, progressive
metacarpophalangeal erosion (radiographs)


Rheumatoid arthritis: hands, advanced deformity
(radiograph)
Isenberg DA, Renton P, Imaging in Rheumatology, 2003

Osteoarthritis: knees, medial and lateral cartilage
degeneration (radiographs)
Ultrasonografie musculoscheletala
Bradley M, ODonell P, Muskuloskeletal Ultrsound Anatomy, 2002
Martino F, Silvestri S, Muskuloskeletal Sonography, 2006
Isenberg DA, Renton P, Imaging in Rheumatology,
2003
Bahk Yong-Wahee, Combined Scintigraphic and
Radiographic Diagnosis of Bone and Joint Disease, 2002
Isenberg DA, Renton P, Imaging in Rheumatology, 2003
Isenberg DA, Renton P, Imaging in Rheumatology, 2003
Isenberg DA, Renton P, Imaging in Rheumatology, 2003
Popliteal cyst: knee (MRI)