• COMMON MUSCULOSKELETAL DISEASES BY AGE:
  • Childhood: Juvenile RA, Rheumatic Fever
  • Young adult: Reiter's Syndrome, SLE
  • Middle Age: Fibrositis
  • Old Age: Osteoarthritis
• COMMON MUSCULOSKELETAL DISEASES BY SEX:
  • Male: Gout
  • Female: SLE, RA
• COMMON MUSCULOSKELETAL DISEASES BY RACE
  • Black: Sarcoidosis, SLE
  • White: Polymyalgia Rheumatica

SYMPTOMS:

• REITER'S SYNDROME:
  • Symptoms: Conjunctivitis, Urethritis, Arthritis.
  • Signs:
    • Keratoderma Blennorrhagia: Rash on palms and soles.
    • Circinate Balanitis: Circular rash on penis.
    • Sausage fingers: Swelling of the tendon sheath of the hands.
• PSORIATIC ARTHRITIS: Arthritis occurring with Psoriasis.
  • Signs:
    • Sausage fingers: Swelling of the tendon sheath of the hands.
    • DIP joints may be inflamed unilaterally.
• GOUT:
  • Symptoms:
    • Podagra: Severe gouty pain at the base of the great toe.
• RHEUMATIC FEVER:
  • Symptoms:
    • Migratory Pain: Typical finding. Pain moving from joint to joint.
  • Jones Criteria: Diagnostic criteria for Rheumatic Fever. Two major criteria, or one major and two minor criteria are required.
    • Major Criteria:
      • Carditis: Myocarditis, Pericarditis
      • Polyarthritis
      • Chorea: Purposeless movements of various muscle groups
      • Erythema Marginatum: Pink, circular rash on trunk on proximal arms.
      • Subcutaneous Nodules: Granulomatous nodules on extensor surfaces, often associated with cardiac involvement.
    • Minor Criteria:
      • History, Symptoms:
        • History of previous rheumatic fever or rheumatic heart disease.
        • Arthralgia
        • Fever
      • Labs:
        • Acute phase reactants: increased ESR, C-Reactive Protein, leukocytosis.
        • ECG abnormalities
        • Recent streptococcal infection.
• GONORRHEA, DISSEMINATED (Gonococcal Arthritis):
  • Symptoms:
    • Migratory Pain: Typical finding. Pain moving from joint to joint.
• RHEUMATOID ARTHRITIS:
  • Symptoms:
    • Morning stiffness: Pain in the morning, which tends to loosen up as the day progresses.
    • Fatigue: During the day, fatigue sets in. The earlier the fatigue sets in, the worse is the RA.
  • Signs: The proximal (PIP and MCP) joints are characteristically more involved than the DIP joints.
    • Synovial Thickening -- swelling of joints.
    • Entire phalanx may deviate laterally or medially.
    • Boutonniere Deformity, Swan-Neck Deformity, Ulnar Deviation: Characteristic deformities of hands and wrists seen in Rheumatoid Arthritis.
• OSTEOARTHRITIS: Degenerative arthritis.
  • Symptoms:
    • Pain usually gets worse as the day progresses, leading to fatigue in the afternoon.
  • Signs: The distal (DIP) joints are characteristically more involved than the PIP joints.
    • Distal phalanx may deviate laterally.
    • Heberden's Nodes: Bony overgrowths on the dorsum of the DIP joints, typical of osteoarthritis.
• SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): Diagnostic Criteria. 4 of 11 at any time is diagnostic.
  • Malar Rash
  • Discoid rash
  • Photosensitivity
  • Oral ulcers
  • Arthritis
  • Serositis (pleuritis, pericarditis)
  • Renal disorder
  • Neurologic disorder (seizures, psychosis)
  • Hematologic (anemia, leukopenia, lymphopenia, thrombocytopenia).
  • Immunologic (elevated anti-DNA, LE-Prep, or biological false positive for Syphilis (RPR))
  • Antinuclear Antibody (ANA)

TERMS:

• Kyphosis: Anterior curvature of the spine. Normally found in thoracic area, characterized by extensive flexion.
• Lordosis: Posterior curvature of the spine, normally found in cervical and lumbar areas.
• Scoliosis: Lateral curvature of the spine.
• Varus: Medial deviation.
• Valgus: Lateral deviation.

SYMPTOMS:

• PAIN:
  • Generally, the deeper the musculoskeletal structure, the more diffuse the pain.
    • Pain from bone is deep or boring pain.
    • Pain from periosteum is more localized.
  • Referred pain: Don't forget the Ddx of CAD in shoulder pain.
  • Arthralgia: Defined as joint pains without objective signs of inflammation. It is caused by many processes, both inflammatory and non-inflammatory.
  • Arthritis: Joint inflammation.
• STIFFNESS:
• WEAKNESS:
  • Weakness: Loss of strength, due to mechanical or neurological impairment.
  • Fatigue: Poor endurance.

INSPECTION

PALPATION: May find the following abnormalities on palpation:

• Swelling
  • Synovial thickening (pannus formation) is characteristic of RA.
  • Swelling of tendon-sheath (sausage-shaped digit) occurs in Reiter's Syndrome and Psoriatic Arthritis.
  • Effusions: Fluid is most commonly found in the knee.
• Deformity
  • Ganglia: Fluid-filled cysts found along joint capsules, usually in the wrist.
  • Rheumatoid Nodules: Firm nodules found on extensor surfaces of bony prominences. They contain mononuclear cells and fibrosis.
  • Gouty Tophi: Joint nodules associated with urate deposits.
  • Bursitis: Inflammation of the bursa in the knee or elbow.
• Erythema and Warmth: Especially in inflammatory or infectious processes.
• Limitation of Range of Motion:
• Tenderness: The subjective sensation of pain upon pressure.
  • Grading:
    • 0: No tenderness
    • 1: Patient says it is tender
    • 2: Patient says it is tender and winces
    • 3: Patient says it is tender, winces, and pulls back
    • 4: Patient will not allow palpation.
• Joint noises or locking:

AUSCULTATION:

• Crepitus: Grating or grinding sensation felt by patient, or heard by examiner. Rubbing of bones due to degeneration of articular cartilage.
• Cracking, Snapping: Snapping of joints is usually not pathologic, unless it occurs repeatedly.
• Clicking: May indicate an abnormality when it occurs in TMJ joint.

MUSCLE STRENGTH: Graded on a scale from 5 to 0.

• 5: Full strength
• 4: Strength against gravity and added resistance.
• 3: Strength only against gravity, not added resistance.
• 2: Muscle contraction occurs, but not sufficient to overcome gravity.
• 1: Muscle contracts with little or no movement.
• 0: No muscle contraction.

RANGE OF MOTION

• Active Range of Motion: Voluntary movement
• Passive Range of Motion: Examiner moves the joint.
• Goniometer: Device used to measure angles, to assess the range of motion of a joint.
• Unstable Joint: Excessive joint motion (excessive extension) of the knee may be seen in osteoarthritis.

HEAD EXAM:

• TMJ Abnormalities are caused by dental malocclusion, trauma to the jaw, RA.

NECK (CERVICAL SPINE):

• Arthritis may limit rotation or lateral flexion of the neck.

SHOULDER:

• Rotator Cuff Injury: Pain or spasm in mid-abduction is a sign of rotator cuff injury. This is due to degeneration in the subacromial bursa, resulting in friction between the supraspinatus muscle and acromial process at mid-abduction.
  • Arm can't rise above about 90, the extent to which the Deltoid can abduct it.
• Adhesive Capsulitis (Frozen Shoulder): Unilateral diffuse, dull, aching pain.
  • Tenderness is diffuse.
• AC Degenerative Arthritis: Maybe from trauma. It hurts upon movement of scapula.
• Bicipital Tendinitis (Impingement Syndrome): Inflammation of the tendon of the supraspinatus muscle.
• Calcific Tendinitis: Prolonged inflammation of the supraspinatus tendon, with resulting calcification.

ELBOW:

• Tennis Elbow: Tender and inflamed lateral epicondyle, resulting from repeated extension. Patient will experience pain when asked to extend the elbow against resistance.
• Golfer's Elbow: Inflammation of the medial epicondyle. Typically shows pain when asked to lift with the palms facing upward (volar aspect).

WRIST:

• Diseases:
  • DEQUERVAIN'S TENOSYNOVITIS: Involves the extensor tendon of the thumb. Ask patient to apply pressure with thumb against the forefinger, and pain will result.
  • GANGLION: Cyst caused by herniated synovium into soft tissues.
  • CARPAL TUNNEL SYNDROME: Compression of median nerve through carpal tunnel.
    • Phalen's Test: Ask patient to flex each wrist at 90 for one minute. Positive test occurs if numbness and tingling over median distribution results.
    • Tinel's Sign: Tingling shots of pain over median nerve upon percussion of the wrist.
  • DUPUYTREN'S CONTRACTURE: Fibrous contraction of the palmar aponeurosis.
    • May be found in RA, alcoholism, or familial.
• Signs:
  • Bouchard's Nodes: Swelling of the PIP joints, which is less common than swelling of the DIP joints.
  • Heberden's Nodes: Bony overgrowths on the dorsum of the DIP joints, typical of osteoarthritis.
  • Boutonniere Deformity: Flexion contracture of the PIP joint, with hyperextension of the DIP joint. Caused by injury or RA.
  • Swan Neck Deformity: Hyperextended PIP joints and flexed DIP joints. May accompany RA.

SPINE:

• SCOLIOSIS: Lateral curvature of spine. When bending over, muscular prominences on one side of the back is more prominent than the other side.
• Straight Back Syndrome: Lack of normal thoracic kyphosis.
• Dowager's Hump: Marked kyphosis of dorsal spine in elderly women.
• Ankylosing Spondylitis: RA-like disease affecting the lower spine and sacroiliac joints.
• Lumbosacral Strain: Lower back pain from obesity and or poor posture.
• Herniated Nucleus Pulposus:
• Sciatica:

HIP:

• If one leg is shorter than the other as measured from ASIS to ankle, hip disease is likely.
• Trendelenburg Test: Have patient stand on one foot. The contralateral hip should pull upward. If it doesn't, and the same hip on which patient is standing instead pulls downward, then that is a positive test and is indicative of hip disease.
• Antalgic Gait: Walking funny (limping) in order to avoid pain in the hip.

KNEE:

• Baker's Cyst: Extension of the synovium into the popliteal space. Felt on posterior knee.
• Osgood-Schlatter Disease: Partial separation of the quadriceps femoris tendon at the tibial tuberosity, making the tibial tuberosity swollen and tender. Seen in adolescents.
• Genu Valgus: Knock kneed. Knees bend inward.
• Genu Varus: Bowlegged. Knees bend outward.
• Genu Recurvatum: Excessive extension of the knee.

ANKLE and FEET:

• Bunion: Swelling of the great toe. Usually valgus is seen too.
• Flat Foot (pes planus): Relaxation of longitudinal arches, resulting in flattening of the arch of the foot. Patients tend to wear down the soles of their shoes on the medial side.
• High Arches (pes cavus): Have excessive wear on their soles at the base of the heal and under the metatarsal heads.
• Heel Spur: Tenderness may happen at the insertion of the plantar longitudinal tendon on the calcaneous.
• Morton Neuroma: Pinching of fibrous neuromas between metatarsal heads, resulting severe burning pain.