Non-Inflammatory Arthritis Non-Inflammatory Arthritis

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The moderator will review your questions and present them to the Welcome to lecturer at the end of the presentation At the bottom of your screen are three options for the ViP Adult comments/questions: Chat is to used to make general comments that everyone can see Webinar Raise Your Hand is to be used to notify the Host that you need attention. The Host will send you a private chat in response. Q&A is used to post questions relevant to the lecture. These questions can only be seen by the lecturer and moderator. Approach to the Patient with “Arthritis” Jason Kolfenbach, MD University of Colorado Disclosures

I have no disclosures related to the content of this talk. FOCUS ON: Non-inflammatory arthritis Non-inflammatory Arthritis

• History • no “believable” red/hot joints • slow steady progression • mechanical pain:  use,  rest/night • no profound/prolonged morning stiffness • no systemic findings • Physical exam • swelling: • effusion/osteophytes/ligaments • crepitus/grating • local joint line tenderness Acute Non-inflammatory Monoarthritis Trauma Internal derangement (meniscal tear) Osteoarthritis Hemophilia Avascular necrosis Sickle cell disease Transient osteoporosis of the hip Chronic Non-inflammatory Monoarthritis Osteoarthritis Internal derangement Tumors: PVNS (chocolate SF), synovial sarcoma Charcot: Diabetes, syphilis, syringomyelia Others: Avascular necrosis, hemarthrosis (bleeding disorder; coumadin use), synovial chondromatosis Windswept knees (not specific to tabes dorsalis)

RA Syphilis (Charcot joint) Non-inflammatory Polyarticular OA: bony enlargement/crepitus Primary OA: Heberden’s (DIP) and Bouchard’s nodes (PIPs), first CMC/MTP, family hx (particularly females) Other common joints: C-spine, L-spine, hips, knees, AC joint

‘OA in joints that shouldn’t have it’ like MCPs, wrists, elbows, shoulder, ankles: Hemochromatosis: male >20, post-menopausal females, MCPs, wrists, ankles Chronic CPPD disease: > age 55, MCPs, wrists, shoulders (r/o hydroxyapatite) Non-inflammatory Polyarticular Hypertrophic osteoarthropathy Very painful and acute onset in distal upper & lower extremity joints Often seen in patients with lung disease (cancer, etc.) Look for clubbing on exam; periarticular fullness; classic periosteal elevation on plain films Amyloid arthropathy (extremely rare in era of modern dialysis) Wrists, shoulders, hips Dialysis patient (rare with modern dialysis membranes) or elderly patient with monoclonal spike or myeloma OA: Heberden’s and Bouchard’s nodes OA: hallux valgus, cock- up deformities (hammertoe) ‘OA in joints that shouldn’t get OA’: CPPD and hemochromatosis can have a predilection for the 2nd and 3rd MCPs and PIPs

Pattern of involvement sometimes referred to as the Victory sign Milwaukee shoulder syndrome (MSS): -caused by hydroxyapatite crystals (a type of basic calcium phosphate-BCP crystal) -sometimes referred to as ‘old bloody shoulder’ due to bloody synovial fluid -despite destructive nature, synovial fluid may be < 2000 WBC -crystals not identifiable on polarized microscopy (too small) Musculoskeletal Pain

Arthritis Periarticular Nonarticular Referred

Inflammatory Noninflammatory

Polyarticular Monoarticular 1. OA Trauma/Internal derangement/OA 2. OA AVN 3. OA Sickle cell Chronic CPPD Bleeding disorders Rare forms: HPO, amyloid, Tumors Hemochromatosis, acromegaly, Charcot joint ochronosis Additional Slides: Reference Material for Non-articular Sources of Pain FOCUS ON: Periarticular sources of pain Periarticular Pain

• Diffuse • Hypermobility syndrome (R/O Ehlers Danlos): diagnosis made if 5 of 9 ‘points’ met (Beighton criteria) Thumb to forearm Fingers > 90 degrees extension Elbow and/or knee hyperextension> 10 degrees (if both still only 2) Ankle dorsiflexion > 45 degrees Back flexion with palms flat on floor • Localized: bursitis, tendonitis, enthesitis Hypermobility Syndrome Localized Upper Extremity Shoulder: bicipital tendonitis, supraspinatus tendonitis, impingement syndrome, subacromial bursitis, frozen shoulder

Elbow: Lateral and medial epicondylitis, olecranon bursitis (trauma, septic, gout, RA)

Wrist: DeQuervain’s tendinitis

Fingers: Trigger finger A) Speed’s B) Yerguson’s

A & B) Hawkin’s C) Neer’s Resisted wrist extension for detection of lateral epicondylitis (tennis elbow) Olecranon bursitis (Popeye elbow): common etiologies include trauma, gout, RA -painful with elbow flexion/extension, but not typically with pronation/supination (true elbow swelling/arthritis would be painful with pronation/supination at wrist) Localized Lower Extremity • Hip: true hip pain in groin. If not there then consider trochanteric bursitis (lateral), piriformis syndrome (posterior), ischial bursitis • Knee: Anserine bursitis (inferomedial), prepatellar bursitis, tensor fascia lata (snapping laterally) • Ankle: posterior tibial tendonitis (medial pain worse with standing on toes, weak foot inversion with plantarflexion), Achilles tendinitis( r/o fluroquinolones) • Feet: heel (plantar fasciitis, Achilles enthesitis), sesamoiditis (under first MTP)

FOCUS ON: Non-articular sources of pain: Muscle & Bone Non-articular: muscle & bone pain as mimics of MSK complaints • Acute, localized: muscle (trigger points); bone (stress fracture, osteomyelitis) • Diffuse muscle pain with weakness: • PMR-weakness due to pain • Polymyositis-mild pain but often severe weakness • Medications-statins, colchicine, Plaquenil, AZT, others • Fibromyalgia: diffuse pain without objective weakness, classic tender points (no longer required for diagnosis) • R/O thyroid dz, obstructive sleep apnea, abuse (sex/physical) • Diffuse pain for >2 years without objective changes in other organ systems by physical exam, labs, or X-ray is never threatening • Diffuse bone pain: hyperparathyroidism, bone pain related to bisphosphonate use, periostitis (related to HPO or other cause), underlying cancer (pain at night; more common in children) FOCUS ON: Referred sources of pain Referred pain and/or weakness • Visceral: aortic aneurysm causing back pain; GB and shoulder pain • Hip pain referred to medial knee • Knee pain (patellofemoral disease), stemming from flat foot • Vascular sources: DVT, arterial insufficiency (claudication, Raynauds) • Neurologic entrapment syndromes • CTS: paresthesias palmar surface 3.5 fingers, Tinel’s and Phalen’s sign, can refer pain to shoulder (Valleix phenomenon) • Cubital tunnel (elbow) and tarsal tunnel (foot) • Neurologic radicular syndromes • Consider herpes zoster (shingles) UE Radicular Syndromes Injury site Motor Sensory Reflex

C5 Weak shoulder abd Lateral deltoid ↓ biceps numb C6 Weak biceps, wrist ext Six shooter ↓ biceps, numb brachiorad C7 Weak triceps, wrist Middle finger ↓ triceps flex & finger ext (form numb 7) C8 Weak finger flex(form Numb ulnar side None 8) hand/arm LE Radicular Syndromes Injury site Motor Sensory Reflex

L4 Weak quads(4) Numb inner ↓ quad(4) and foot lower leg and reflex inverters foot L5 Weak toe ext(5 Numb dorsum No reflex toes), hip abd of foot and (5) toes S1 Weak gastroc Numb lateral ↓ Achilles (up on toes), foot foot everters Thank you, best of luck in your training, and feel free to contact me with additional questions! [email protected] The webinar will start promptly at the scheduled time

All attendees are muted throughout the webinar

The moderator will review your questions and present them to the Thank you! lecturer at the end of the presentation At the bottom of your screen are three options for comments/questions:

Chat is to used to make general comments that everyone can see Raise Your Hand is to be used to notify the Host that you need attention. The Host will send you a private chat in response. Q&A is used to post questions relevant to the lecture. These questions can only be seen by the lecturer and moderator.