1. Goals During the Initial Encounter With the
Patient.
Dr. Mohit Mathur
Reader (Dept. of Medicine)

2. Determine Whether the
musculoskeletal Complaint Is Articular or peri-articular in origin?
 Inflammatory or non-inflammatory?
 Acute or chronic in duration?
 Localized or widespread(systemic) in
distribution?

3. ARTICULAR STRUCTURES
• synovium
• Synovial fluid
• Articular cartilage
• Intra-articular ligaments
• Joint capsule
• Juxta-articular bone

4. NONARTICULAR (PERI-ARTICULAR)
STRUCTURES
• Supportive extraarticular ligaments ex- collateral
•
•
•
•
•
•
•
ligaments in knee.
Tendons
Bursae
Muscle
Fascia
Bone
Nerve
And overlying skin.

5. Characteristics of Articular
Disorders.
 Deep or diffuse jt. pain.
 Limited range of motion on active as well as
passive movement.
 Swelling (effusion or synovial proliferation).
 Crepitation.
 Instability.
 Locking.
 Deformity.

6. Characteristics of Nonarticular
Disorders
 Pain on active but not on passive movement of
joint.
 Point or focal tenderness.
 Presence of physical findings distant from the
joint capsule.

7. Inflammatory Vs. Non-inflammatory
Disorders.

8. Factors Leading to
Inflammation in Joint.
 Infections( gonorrhea, tuberculosis).
 Crystal arthopathy( gout, pseudogout).
 Immune related( RA, SLE).
 Reactive( rheumatic fever, Reiter's syn.).
 Idiopathic.

9. Features of Inflammatory Joint
Disorders.
 Local features – pain (also during rest),
tenderness, swelling, warmth & erythema.
 Systemic features – prolonged morning
stiffness, fatigue, weight loss, fever.
 Laboratory evidences – elevated ESR & CRP,
thrombocytosis, anemia of chronic disease or
hypoalbuminemia.

10. Inflammatory Vs Mechanical
 Inflammatory
 Mechanical
1.
Prolonged Immobility stiffness
1.
Minimal inactivity stiffness
2.
Rest pain usually get better
with activity
2.
Pain on activity usually
improving on rest
3.
Joint swelling,erythema,heat
3.
Joint crepitus, Instability and
locking
4.
Systemic symptoms & Multiorgan involvement
4.
History of trauma, strain or
overuse

11. Acute Vs Chronic Disorders

12.  Musculoskeletal disorders are called acute if they
last less than 6 weeks and chronic if they last longer.
 Acute disorders tend to be infectious, crystal
induced, reactive or they can be the initial
presentation of chronic arthritis.
 Chronic disorders are often immune related,
such as Systemic Lupus Erythematosus and
Rheumatoid Arthritis.

13. Extent of Joint Involvement

14.  Monoarticular disorders- one joint involved
 Oligoarticular or pauciarticular disorders - two or
three joints involved
 Polyarticular disorders - more than three joints
involved

15. Mono/oligoarthritis
Infective arthritis
osteoarthritis
Reiter’s syndrome
Gout
Polyarthritis
Rheumatoid
arthritis
SLE
Scleroderma

16. Rheumatoid Arthritis

17. Rheumatoid Arthritis
 Rheumatoid arthritis is a chronic multisystem
disease of unknown cause.
 It’s
characteristic feature is persistent
inflammatory synovitis usually involving
peripheral joints in a symmetrical distribution.

18. Clinical Presentation
 RA begin insidiously with fatigue, anorexia,
generalized
weakness
and
vague
musculoskeletal symptoms.
 Specific symptoms appear gradually as several
joints(hands, wrists, knees and feet) become
affected in symmetric fashion.
 The joint with synovial inflammation become
painful. There is tenderness, swelling and
limitation in mobility.

19. Clinical Presentation
 Generalized stiffness is frequent.
 Constitutional symptoms- weakness, easy
fatigability, anemia, anorexia & weight loss.

20. American Rheumatology Association Revised
Criteria (1988)
1.
2.
3.
4.
5.
6.
7.
Morning stiffness in & around joints lasting 1 hr. or
more before maximum improvement.
Arthritis of three or more joint areas (duration of 6
weeks or more).
Arthritis of hand joints (duration of 6 weeks or more).
Symmetric arthritis.
Rheumatoid nodules.
Elevated serum rheumatoid factor.
Radiographic changes : juxta-articular osteopenia.
Diagnosis of RA is made with 4 or more criteria

21. Problems in Diagnosis.
Diagnosis is difficult in the initial course of illness
when only constitutional symptoms or
intermittent arthralgias or arthritis in
asymmetric distribution may be present. A
period of observation is necessary before
diagnosis can be established.

22. Disorders resembling rheumatoid
arthritis
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Systemic lupus erythematosis.
Systemic sclerosis.
Reiter’s syndrome.
Psoriatic arthritis.
Crystal deposition arthropathies.
Nodal osteoarthritis.
Gonococcal arthritis.
Farber’s disease.
Vascuilitis.
Amyloidosis.

23. 11) Anti-phospholipid syndrome.
12) Mixed connective tissue disease.
13) Viral arthritis ( eg parvovirus, rubella, hepatitis)
14) Polymyalgia rheumatica.

24. Systemic Lupus erythematoses
 Almost all patients of SLE experience arthralgias & myalgias.
Most develop intermittent arthritis involving hand joints.
 Unlike RA the arthritis in SLE is non-erosive and joint
deformities are unusual. Skin involvement with
photosensitive rash is much more common in SLE than in
RA.

25. Systemic Sclerosis
 More than half the patients of SS complain of pain, swelling
& stiffness of the fingers and knees. A symmetrical
polyarthritis resembling RA may be seen.
 The onset of SS is frequently in the form of Raynaud’s
phenomena & puffiness in fingers.
 Raynaud’s phenomena affect a greater no. of patients of SS
(80-90% patients) than of RA and may be the only symptom
of scleroderma for years.

26. Reiter’s Syndrome
 It is a reactive polyarthritis which develop several weeks
after non-gonococcal urethritis and enteric infections.
 Only a minority of patients have other findings of
classical Reiter’s syndrome including urethritis,
conjunctivitis, uveitis, oral ulcers and rash. The joint
involvement is usually in the form of asymmetric
oligoarthritis affecting mainly the knees, ankles & feet.
 The history of preceding infection will help in the
diagnosis.

27. Psoriatic Arthritis
 It can present as asymmetric inflammatory arthritis,
symmetric arthritis or psoriatic spondylitis
 It is a sero-negative arthritis which mainly involve DIP, PIP,
MCP, MTP, sternoclavicular and large peripheral joints.
 Practically all patients have onychodystrophy ( onycholysis,
ridging and pitting of nails).
 Psoriasis and inflammatory arthritis usually develop
simultaneously.

28. Monosodium Urate Arthopathy
(Gout)
 It commonly present as acute oligoarticular arthritis
affecting middle aged to elderly men. The MTP jt. of 1 st
toe is often involved but tarsal joints, ankles & knees are
also commonly affected. The first episode usually begin
at night with pain in joint together with tenderness, heat
& redness over affected joint.
 Women represent only 5 to 17% of all patients with gout
& most of them are post-menopausal & elderly females.
Most have an underlying degenerative jt. disease.
 Diagnosis – confirmed by needle aspiration of jt. or
tophaceous deposits.

29.  Most of the crystal arthopathies such as CPPD deposition
disease, HA deposition disease & CaOx deposition disease
affect elderly who usually have a preexisting degenerative
joint disease.
 In some cases they produce synovitis which may mimic RA.
Diagnosis is confirmed by analysis of synovial fluid or
articular tissue.

30. crystal arthopathies e.g. gout
Tophi

31. Vasculitis
 Vasculitis is a heterogeneous group of disorders
characterized by inflammation & damage to blood vessels.
The vessel lumen is compromised and is associated with
ischaemia of the tissues supplied by the involved vessel.
 Vasculitis are considered as immune-complex mediated
diseases.

32. Vasculitis syndromes
classification
VASCULITIS
Localized
Cutaneous vasculitis
Generalized
Classical PAN
Wegener’s granulomatosis
Temporal arteritis

33. Classic polyarteritis nodosa
 Systemic- fever, weight loss & malaise.
 Renal(60%)- hypertension, renal insufficiency or





hemorrhage.
Musculoskeletal(64%)- arthritis, arthralgia & myalgia.
Peripheral nervous system(51%)- peripheral neuropathy.
GIT(41%)- abdominal pain, nausea & vomiting.
Skin(43%)- rash, purpura, livedo reticularis, raynaud’s
phenomena.
Cardiac- cardiac failure, AMI.

34. Polymyalgia rheumatica and
GCA
 Exclusively occur in persons over





55 yrs. Of age
GCA – large vessel arteritis
C/F- fever, anemia, raised ESR &
headache in elderly person with
or without symptoms of
polymyalgia rheumatica (stiffness
& pain in muscles of neck,
shoulders, lower back, hips &
thighs).
Temporal artery- tender,
thickened & nodular.
jaw claudication visual
disturbance, systemic upset.
TA biopsy

35. Antinuclear cytoplasmic
antibodies (ANCA)
 Antinuclear cytoplasmic antibodies (ANCA) are
antibodies directed against certain proteins in the
cytoplasm of neutrophils. They are present in a high
percentage of patients with systemic vasculitis
e.g.Wagener's granulomatosis but are rare in other
inflammatory disorders.
 Two major categories of ANCA- cytoplasmic © ANCA
and perinuclear (p) ANCA

36. Farber Disease
 Autosomal recessive disorder
 Results from deficiency of lyzozomal enzyme ceramidase
& the accumulation of ceramide in various tissues
especially joints.
 Symptoms begin as early as 1st year of life with painful jt.
swelling & nodule formation.
 It’s diagnosis should be suspected in patients who have
nodule formation over jt’s. but no other finding of RA.

37. Amyloidosis
 Articular structures are involved in primary idiopathic
amyloidosis (light chain amyloidosis) which is associated
with multiple myeloma.
 Amyloid arthritis can present as symmetrical arthritis of
small jt’s. with nodules, morning stiffness & fatigue.
 Synovial fluid analysis- low WBC count, good to fair
mucin clot, predominance of mononuclear cells & no
crystals.

38. Osteoarthritis
 Mechanical symptoms
 Bony swelling, crepitus
 DIP (Heberden), PIP
(Bouchard), 1st CMCJ,
neck, lower back, hips,
knees, 1st MTP

39. Fibromyalgia
 “All over pain”
 Fatigue
 Sleep disturbance
 Depression
 Anxiety
 Irritable bowel
 Tender spots
 Diagnosis by exclusion

40. Investigations
 Blood Examination- Hb estimation, FBC, ESR, CRP,






RF,
synovial fluid analysis
X-Ray- Hands and feet
Serological Test (ANA, RF, anti-DNAase, ANCA,
complement)
Urine Examination
Liver Function tests
Organ based investigations- biopsy, angiogram

41. Synovial fluid analysis
Normal
Noninflamm RA, Gout
atory
(OA,trauma)
Septic
arthritis
Appearance
clear
Clear/amber Turbid/yellow
colored
Turbid/opaque
Viscosity
viscous
viscous
Reduced
viscosity
Reduced
viscosity
Cell count
<180
cells/mcl
<2000/mcl
2000-50,000
>100,000
Mononuclea Polymorphon
uclear
Mononuclea r cells
leukocytes
r cells
Polymorphon
uclear
leukocytes
(>75%)

42. Other conditions where Rheumatoid
factor is found in serum.
Infection: Acute infection eg infectious mononucleosis; Chronic
infection eg SBE, TB; Parasitic eg malaria; vaccination
Inflammatory disease: RA, CTD, Fibrosing alveolitis, Chronic active
hepatitis, cryoglobulinaemia
Malignancy: Lymphoma, leukaemia, myeloma, solid tumours
5% healthy population
RF <15 not significant unless associated with appropriate clinical
scenario

43. Auto-antibodies and corresponding
disorders
 ANA – SLE; not significant in titers of 1/40 unless associated





with appropriate clinical scenario
Anti-Ro and anti-La – Sjogrens syndrome
Antitopoisomerase 1(Scl 70) and anti-centromere –
Scleroderma
Anti-RNP – mixed CTD
Anti-Jo-1 - myositis
ANCA – vascuilitis

44. Radiological features - OA
 Four cardinal features:
 Joint space narrowing
 Sclerosis
 Subchondral cysts
 Osteophytes

45. Radiological features - RA
 soft tissue swelling
 juxta-articular osteoporosis
 juxta-articular and subchondral
erosions
 joint space narrowing &
subluxation
 secondary OA & bony ankylosis

46. Thank you