Joint in Women: Evaluation and When to Refer? Deeba Minhas, MD, Clinical Lecturer, Department of Internal Medicine, Michigan Medicine Different Patterns to Joint Pain

Inflammatory Arthritis • AM stiffness significant • Improvement with activity • Swelling common Mechanical • up to 30 minutes of AM stiffness • Pain worse with use • AM stiffness significant • Poor sleep quality • Head to Toe Pain • Colorful descriptors • When overdo it, pay for it the next day • HA, numbness, tingling etc

Cases • 45 yo female comes in with hand pain. • Notes 30 mins of morning stiffness • She is an avid gardener, and notes pain worse after pulling weeds and planting flowers • This her hand when you examine her • And her XR • What do you tell her?

Ranawat, et al. Journal of Arthroplasty, 2016 Cases • A 40 yo woman with progressively worsening pain in her wrists, and MCPs. She notes 2-3 hrs of AM stiffness. • She also describes generalized muscle pain and aching, head to toe, also notes HA, IBS symptoms, Plastichandandsurgery.com numbness, tingling • On days she feels good she Inflammatory arthritis? will try to do several tasks, Osteoarthritis? then will pay for it the next few days. She has difficulty Fibromyalgia? sleeping Occam’s Razor vs Hickam’s Dictum

• Simplest explanation is the most likely • Implies in medicine that diagnostician should assume a single cause for multiple symptoms

Wikipedia Different locations of Joint pain

Shutterstock.com RA OA RA OA

Physio-pedia.org Diagnoses by Location

Harrison’s Principles of Internal Medicine Crystalline Arthritis Initial Workup if Concern for inflammatory arthritis • CBC, CMP, ESR, CRP • RF, CCP  RA • Uric acid  Gout • Mag, Phos, Calcium, TIBC, ferritin, TSH  Pseudogout, Hemochromatosis • Depending on risk factors: • HIV • Hepatitis Panel, esp Hepatitis C • Transglutaminase IgA Antibody • Parvovirus IgM and IgG antibody • Quantiferon TB • ASO Note about labs at U of M

• ANA by IFA gold standard • RNP increased rate of false positives • Scl-70 increased rates of false positive  automatically send confirmatory to RDL labs • Lab can provide titer Early ID and Treatment

• Rheumatologic diagnoses respond best to EARLY recognition and treatment

• Emery Criteria for early referral (of suspected RA) • ≥3 swollen joints; • a positive MCP squeeze test, and • morning stiffness of ≥30 minutes Referral Criteria

• Analysis in study of patients referred for SMALL joint pain > 6 weeks found to have 9 variables with high specificity (90%) and PPV (>75%) and likelihood ratio (>~2) for inflammatory arthritis: • Loss of appetite • Swelling of MCP joint 2 or 5 • Swelling of PIP joint 2 or 3 • Wrist swelling, Wrist tenderness, • +RF, + CCP

Almoallim, H. Open Access Rheumatol. 2017 Does the ANA reeeeally need to be ordered? • 25 yo F noted to feel not herself, she brings a sheet full of complaints, and her pain is worst in her low back and neck. She wakes up very stiff and in pain. She cannot sit for long periods of time without getting worsening pain and stiffness. • She is on the verge of quitting her job as she is so worn down, by the end of the day, and the day after • Workup by PCP shows ANA 1:80 • Referred to and asks how are you going to manage my ? ANA in Primary Care clinic • Abeles, A et al study • 90% of patients who were referred with positive ANA had no evidence of an ANA-associated rheumatic disease

• ANA 1:160 PPV • 2.1 % for Lupus • 9.1 % for any ANA- associated rheumatic disease

Abeles, A et al. The American journal of medicine. 2013 What are the current reasons ANA is ordered?

Abeles, A et al. The American journal of medicine. 2013 Order ANA: ONLY when suspected

Arthritis with fever  Sicca syndrome Glomerulonephritis Raynaud phenomenon Unexplained Systemic sclerosis multisystem disorder Palpable purpura and Immune cytopenias Urticarial Unexplained neurologic Pleurisy or Pericarditis disease Photosensitive rash Polyserositis Myositis

 Otherwise, a + ANA test confounds diagnosis  ANA can be found in the general population  & wide array of other disorders where they have no diagnostic or prognostic value Diffuse Head to Toe Pain

• Unlikely to be rheumatologic • Would not order ANA

Sleep • Refer for Sleep Study, Sleep Insomnia Clinic

Check for Ligamentous Laxity/ • PT/OT

Benign Joint Hypermobility  Constantly outside normal joint ROM

 Pain in all joints

 Extensor tendonitis

 Dislocations, sprains, strains

https://www.capitalareapt.com/physical-therapy-joint-pain-caused-hypermobility/ Inflammatory Back Pain

 IBP ~ 25% have disease

 HLA B 27  2% have AS

 XR SI

 Non-radiographic AS diagnosis  still need MRI

Creakyjoints.com IBP vs Mechanical BP

Rheum Secrets (Modified with permission from Lawry GV, Kreder HJ, Hawker G, Jerome D. Fam's Musculoskeletal Examination and Joint Injection Techniques, 2nd ed. Mosby/Elsevier, 2010, p. 104.) The compensatory nature of these balanced curves allows the normal resting erect posture to be maintained with minimal muscular effort.

Citation: Chapter 7. The Regional Musculoskeletal Examination of the Low Back, Lawry GV. Systematic Musculoskeletal Examinations; 2012. Available at: https://mhmedical.com/ Accessed: May 22, 2019 Copyright © 2019 McGraw-Hill Education. All rights reserved Disc Positioning and Pressure Disc Positioning and Pressure

 Prolonged sitting causes lumbar flexion

 Posterior annular protrusion

Ducat Chiropractic Prolonged Sitting

Coccyx Lumbar Pillow Roll Sleeping Positions

Backintelligence.com Sleep

Wedge Pillow Exercise Therapy

Iowastatedaily.com Core strengthening Restore the coordination and control of the Motor Control Exercises trunk muscles to improve control of the lumbar spine and pelvis Exercise Therapy

• Massage • Strengthen/stretch • Low back, hips, quads – bridges, clamshells • Pilates • RCT: improvement pain and disability at 6 weeks • https://www.nhs.uk/video/Pages/pilates-for-chronic- back-pain.aspx

Muscleandfitness.com Exercise Therapy- Yoga

physiopedia Shoulder, Neck Pain, HA, TMJ What’s going on?

Sleeping Positions for Neck Pain

• Neck in neutral

• Avoid pillow gap  neck strain • Roll towel and place under head, to support neck • McKenzie cervical roll, put in pillow case

• Stomach sleeping  increased headaches Is it really PMR?

www.123rf.com Practicalpainmanagement.com PMR Mimics Sleeping Positions

Side Sleeping with shoulder/hip bursitis will not resolve