Rheumatology E-learning

University of Szeged

Department of Rheumatology and Immunology

Case history in rheumatology

History of the presenting musculoskeletalcomplaint 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?

Origin of pain

Joint Inflammatory arthritis

Osteoarthritis

Bone

Soft tissue Tendon, tendon sheath, tendon insertion (enthesis),

bursa

Nerve (neuralgia)

Ischaemia

Referred visceral pain

Character of the pain I.

Pain of articular origin: Associated with the movement of the involved joint

Osteoarthritis (arthrosis): pain at use and movement-initiation 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

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 tendinealinsertions (entheses) Sharp, sudden Triggered by particular types of movement (often of movements

of other joints or areas – e.g. humeral epicondylitis is triggeredby 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, occasionallyassociated with numbness, reduced sensitivity (hypaesthesia), motor deficit or reflex alterations

Entrapment („tunnel”) syndromes – the location corresponds tothe course of the peripheral nerve, pressure of special triggerpoints elicits the pain (Tinel sign)

Further anamnestic data – dysfunction

Hands

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…

Further anamnestic data

How many joints hurt you? – Mono-, oligo- orpolyarthritis

Migratory (e.g rheumatic fever), intermittent (e.g. gout) or persistent (e.g rheumatoid arthritis)?

The onset of symptoms: insidious (e.grheumatoid arthritis) or acute (reactive arthritis, gout, trauma)?

Fever? Weight loss? Fatigue? Before the onset of symptoms: infection (e.g.

reactive arthritis, SLE exacerbation), overuse (e-g- soft tissu rheumatism), tick-bite (e.g. Lyme arthritis), travel abroad (tropical infection-associated arthritis)?

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 lungdisease – autoimmune connective tissue diseases)?

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

Polyarthritis – early rheumatoid arthritis

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 – chronicarthritis ≠ activity sign;

○ or bony enlargement – osteophyte in osteoarthrosis)

Tenderness – exact location helps to identify theorigin of the complaints – joint? tendon? skin? subcutaneous tissue?

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, tendonrupture

Limitation of range of motion○ Involvement (both inflammatory or degenerative) of the joint itself

○ The extent of limitation correlates somewhat with the severity ofjoint inflammation or damage (e.g. limitation of fist closure withhand small joint and wrist inflammation in rheumatoid arthritis)

○ Contracture : permanent limitation of movement by articularcartilage damage or periarticular fibrosis

Acute gouty attack

Chronic tophaceous gout

Palpation of joints1. 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!

RA vs erosive osteoarthritis

(arthrosis)

Heberden’s

arthrosis

Bouchard’s arthrosis

Arthrosis: bony bulks, not

synovitis, in DIP or PIP joints

(RA: wrist, MCP and PIP are

most often inflamed)

Spinal column

Degenerativeillnesses: Weakening of the

intervertebrate disc○ Dehydration,

degeneration, slowly, proportionally to age -discopathy

○ Abruptly, usually after a sudden inappropriatemovement –protrusion, discherniation

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

Inflammatory spinal diseases

Spondyloarthritis

Common, chronic, disabling inflammatorydiseases 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

www.images.rheumatology.org

Inspection:

Increased

thoracic

kyphosis

Hump

(gibbus)

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, vertebralcompression fracture

Refers (radiates) to limbs (= nerve root compression): lumbo-ischialgia, cervico-brachialgia

Neurological deficit (loss of sensation, paresis, urinary or fecalincontinence) – nerve, cauda equina or spinal cord compression

Sciatica – pain due to ischiadic nerve

compression

Laségue test: positive, if an

„electric” sudden linear pain is

elicitated

Hypaesthesia

Motor deficit

Loss of reflexes

L-IV: patella

S-I: Achilles

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 thecorresponding spinal level

Range of motion Neck: ante- retroflexion, lateral flexion, rotation. Occiput to

wall, chin to sternum, ear to shoulder, chin to shoulderdistances

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

Physical examination of the spinal column

II.

Restricted range of motion of the lumbar

spine in ankylosing spondylitis

https://www.slideshare.net/drdsabat/ankylo

sing-spondylitis-ug-lecture

https://www.slideshare.net/drdsabat/ankylosing-spondylitis-ug-lecture

Physical signs of ankylosing spondylitis

Mennel’s sign - sacroileitisFinger to ground distance

„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, perinealhypaesthesia) – urgent neurosurgical referral

Nerve root compression sign (Laségue test), dermatomal sensory deficit – disc herniation –neurosurgical referral only if conservativetreatment fails

Other conditions: acute lumbago (low back pain, chronic low back pain, lumboischialgia, uncomplicated disc herniation – no detaileddiagnostic procedures are needed. Advise fewdays of bed-rest, simple analgesic, earlymobilisation, active rehabilitation

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 – inappropriaterepeated activities), trauma, direct irritation, systemicillness (rheumatoid arthritis, spondylarthropathy(enthesitis), polymyalgia rheumatica)

Physical finding: tenderness upon direct pressure; thepain is triggered by the blocked action (isometric musclecontraction) of the involved tendon

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

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

Plantar fasciitis

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.

Trochanteric bursitis

Pain at the hip region, thatincreases when lying on theinvolved side

Hip movements are normal

Direct pressure on the greatertrochanter when the patient lieson the side triggers the pain

Ultrasound or – in case of calcification – X-ray confirmsthe diagnosis

Nerve entrapment syndromes Carpal

tunnel syndrome

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

Neuralgia: burning,

pricking, stabbing

pain with numbness,

needle-and-pin

feeling

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

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 inthe femoral canal

Causes: hip osteoarthrosis, lumbarspine deformity, overuse

Symptoms: pain at the anterioraspect of the thigh and the knee, numbness at this region, quadricepsmuscle weakness, abnormal gait, decreased or lost knee jerk reflex

Direct pressure on the femoralnerve is positive

Femoral sign: in prone position: flexion of the knee causes a sharp, neuralgiform pain at the anterioraspect of the thigh

Medial tarsal tunnel syndrome

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)

Tinel sign