Pain
Articular Non-articular
Localized Generalized . Regional Pain Disorders . Myalgias without Weakness Soft Tissue Rheumatism (ex., fibromyalgia, polymyalgia (ex., soft tissue rheumatism rheumatica) tendonitis, tenosynovitis, bursitis, fasciitis) . Myalgia with Weakness (ex., Inflammatory muscle disease)
Clinical Features of Arthritis
Monoarthritis Oligoarthritis Polyarthritis (one joint) (two to five joints) (> five joints)
Acute < 6 weeks Subacute ~ 6 weeks Chronic > 6 weeks Inflammatory Noninflammatory
Differential Diagnosis of Arthritis Differential Diagnosis of Arthritis
Acute Monarthritis Acute Polyarthritis
Inflammatory Inflammatory . Infection . Viral - gonococcal (GC) - hepatitis - nonGC - parvovirus . Crystal deposition - HIV - gout . Rheumatic fever - calcium . GC - pyrophosphate dihydrate (CPPD) . CTD (connective tissue diseases) - hydroxylapatite (HA) - RA . Spondyloarthropathies - systemic lupus erythematosus (SLE) - reactive . Sarcoidosis - psoriatic . - inflammatory bowel disease (IBD) Spondyloarthropathies - reactive - Reiters . - psoriatic Early RA - IBD - Reiters Non-inflammatory . Subacute bacterial endocarditis (SBE) . Trauma . Hemophilia Non-inflammatory . Avascular Necrosis . Hypertrophic osteoarthropathy . Internal derangement
Chronic Monarthritis Chronic Polyarthritis
Inflammatory Inflammatory . Chronic Infection . Bony erosions - fungal, - RA/Juvenile rheumatoid arthritis (JRA ) - tuberculosis (TB) - Crystal deposition . Rheumatoid arthritis (RA) - Infection (15%) - Erosive OA (rare) Non-inflammatory - Spondyloarthropathies . · reactive Osteoarthritis (OA) · psoriatic . Internal derangement · IBD . Neuropathic joint · Reiters . Tumors . No-erosions . Amyloid deposition - SLE - Rheumatic fever - Vasculitis - SBE
Non-inflammatory . OA primary secondary . Amyloid deposition . Hypertrophic osteoarthropathy “Pain” Amplification Syndrome
Incomplete Fibromyalgia
Myofascial Pain Fibromyalgia Allodynia
One to two tender points < 12 tender points 12-18 tender points Diffuse Pain Associated . Migraines . Irritable bowel syndrome . Depression . . . Findings Genital Pain Weight Gain Parestesias
Regional Pain
Differential Diagnosis – Myalgias Pain, Neck
Pain Without Weakness . fibromyalgia . Fibromyalgia . herniated disk . Polymyalgia rheumatica . DJD . Vasculitis . RA - Polyarteritis nodosa (PAN) . ankylosing spondylitis - Charpo-Strauss (C-S) . metastasic CA - Microscopic polyangiitis (MA) . . osteoporosis Polymyositis . . whiplash injury SLE . . temporal arteritis Carcinoma . . local tumors: Musculoskeletal Manifestations (MM) - giant cell tumor . Trichinosis - hemangioma . Hypothyroidism, - osteoid osteoma . Subacute thyroiditis - osteochondroma . Drug abuse - heroin - cocaine Pain, Shoulder . Viral . - hepatitis Impingement syndrome - rotator cuff tears - HIV . . Calcific tendonitis Parkinson’s (early) . . Adhesive capsulitis Medication . - statins Acrornioc lavicular arthritis - azidothymidine (AZT) . Thoracic outlet syndrome . Obstructive sleep apnea . Shoulder instability . Arthritis - rheumatoid arthritis Pain With Weakness - osteoarthritis . Polymyositis . "Milwakee" shoulder . Myoglobinuria . Avascular necrosis . McArdles disease . Reflex sympathetic dystrophy . Hypothyroidism . Cervical spondylosis . Guillain-Barre - C5 - C6 . Referred pains - intrathoracic problems · heart · lungs · diaphragm Pain, Hip Pain, Hip (cont.)
Articular Neurologic . Inflammatory joint disease . Entrapment neuropathies - RA - lateral femoral cutaneous nerve - spondyloarthropathies, · meralgia parestetica - PMR - lumbar nerve root compression . Degenerative joint disease · L2 - OA primary and secondary · L3 . Metabolic Joint diseases · L4 - gout - pseudogout Vascular - ochronosis . Atherosclerosis of aorta iliac vesse - hernochromatosis - Wilson's disease Referred Pain - acromegaly . Thoracolurnbar spine . Infections . Intra-abdominal structures . Tumors . Retroperitoneal structures - Benign · PVN · osteochondromatosis - Malignant · synovial Pain, Low Back · sarcoma · metastasis . abnormal posture . Hemartrosis . herniated disk . In children . DJD - transient toxic synovitis . spondylolysis (rare) - JAS . spondylolisthesis . osteoporosis Peri Articular . MM . Bursitis . CA metastasis - trochanteric . Paget’s disease - ischiogluteal . ankylosing spondylitis - iliopsoas . . psychogenic Tendinits . - adductor osteiitis condensans ilii . - trochanteric acute & chronic spinal infection . Acute calcific periarthritis - TBC . - fungal Heterotrophic calcifications - brucellosis . vertebral epiphysitis Osseous . . coccygodynia Bone lesions . subarachnoid hemorrage - Fxs . - CA herpes zoster . - AVN local tumors - metabolic bone disease - neurofibroma · Paget's - osteoid osteoma · stress - meningioma · Fxs - hemangioma · osteomalacia . fractures · renal . idiopathic scoliosis · osteodystrophy . referred pain · RSD - uterus · hyperparathyroidsim - kidney · transient migratory osteoporosis - pancreas . In children - bowel - congenital hip dislocation - aorta - acetabulatr dysplasia - gallbladder - coxa vara - slipped capitol femoral epyphysis - Legg-Perthes disease - rickets Pain, Knee
. Patellofemoral chondromalacia . Meniscus tears - medial - lateral . Tibial tubercule apophysitis - Osgood-Schlatter disease . Bursitis - patellar - anserine - infrapatellar . Arthritis - osteoarthritis - rheumatoid arthritis - crystal deposition disease - spondyloarthropathies . Avascular necrosis . Trauma - contusions - fixtures . Popliteal cysts - Baker's . Muscle pain - quadriceps infatct (diabetics) . Referred pain - hip - nerve impingement · sciatica · anterolateral femoral - cutaneous nerve