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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 “” Jason Kolfenbach, MD University of Colorado Disclosures

I have no disclosures related to the content of this talk. “Doc, I got arthritis...... ”

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“Doc, I got musculoskeletal pain...... ” Away from Away From Joint Musculoskeletal “Non-articular” System Muscle “Referred” Bone Visceral Vascular Around Joint = Neurologic “Periarticular” Tendon Within Joint = Tenosynovium “Arthritis” Enthesis Subchondral bone Bursa Cartilage Ligament Synovial fluid Synovium Learning objectives 1) Identify key elements from history & exam that allow localization of MSK complaints 2) Differentiate inflammatory & non-inflammatory etiologies of articular disease and know the common diseases in each category 3) Implement a systemic approach to the differential diagnosis of arthritis (monoarticular, oligoarticular, polyarticular) 4) Utilize data from the history & physical to drive the selection of subsequent studies “Arthritis” Musculoskeletal Pain

Arthritis Periarticular Nonarticular Referred SC bone - AVN Tendonitis Muscle Visceral cartilage - OA Tenosynovitis Bone Vascular SF - Enthesopathy Neurologic synovium - RA Ligament Bursitis Other

History PE Arthritis • History • Pain in joint area • Pain in all directions of movement • Physical exam • Swelling and tenderness of entire joint line • Limited/painful ROM in all directions • Pain with active ROM = passive ROM • Effusion=arthritis Periarticular Pain • History • Pain localized near joint • Pain with some movements • Physical exam • Tenderness/swelling over part of joint • Limited/painful ROM in some directions • Pain with active ROM > passive ROM Non-articular Pain: muscle & bone • History: “Hurts All Over” • Diffuse pain • Unrelated to joint ROM • History doesn’t fit “pattern” • Exam: • non-articular patterns • non-joint physical findings (e.g. long bone tenderness, tender/trigger points) Non-articular Pain: Referred • Visceral pain • Vascular • Neurologic pain • Symptoms: numbness, paresthesias, burning, weakness • Signs: weakness, sensory loss, reflex changes • Regional pain (CTS, tarsal tunnel, CRPS) Musculoskeletal Pain

Arthritis Periarticular Nonarticular Referred

Inflammatory Noninflammatory Crystal Endo/metabolic/other Septic Miscellaneous -Trauma RA, CTD -AVN Spondylos -Neuropathic/Charcot -Neoplastic Key Historical Elements Cardinal signs of present (including AM stiffness)? Onset: hyper-acute; acute; chronic (> 6wks) Course: additive vs. migratory; intermittent versus persistent Specific joint complaints (localization): pain in specific positions; ‘locking’ or ‘giving away’

‘Rheumatologic ROS’ Travel history; sick contacts; ‘bad habits’ Key PMH or FH elements: history of IBD, inflammatory eye disease, psoriasis, renal insufficiency, thyroid disease, family history of any of these Medication review Key Exam Elements Localization: articular vs. periarticular vs. non-articular Pain with passive vs. active ROM Presence of swelling = arthritis (if red/hot joints think crystal or septic; possibly internal derangement) Pattern: monoarticular, oligoarticular, polyarticular axial vs. non-axial symmetric vs. non-symmetric small joint involvement vs. large

Extra-articular findings: eye, oral/nasal, LN, skin FOCUS ON: (IA) Inflammatory Arthritis (IA) Positive signs of inflammation: rubor, color, tumor, dolor, functio laesa -AM stiffness > 60 min; improved with activity, worse w/ rest

Often associated systemic findings (, malaise, lab evidence of inflammation, additional organ involvement)

Symptoms often have a waxing/waning course

Visible swelling described; stiffness > or = pain complaints -Exam: palpable swelling appreciated Inflammatory arthritis (IA) Onset • Rapid and severe: crystal, septic, palindromic (if hyper-acute think non-inflammatory) • Insidous course: RA, IA associated with CTD, chronic/indolent infection (commonly monoarticular)

Course • Migratory: acute rheumatic fever (ARF), gono/meningococcal, Lyme, sarcoid, Whipples • Intermittent: crystal, palindromic rheumatism, RA, sarcoid • Additive: RA classically (polyarticular); SpA may present this way as well (oligoarticular) Monoarticular Arthritis Acute Monoarticular IA: ‘Aspirate or Litigate’ • Non-gonococcal • Red-hot weight-bearing joint> other joint; with fever • Immunosuppressed or IVDA at increased risk • Lyme disease exposure hx ( tick bite in endemic area): migratory joint involvement, target skin lesion

• Gonococcal septic arthritis • Prodrome: fever, rash, tenosynovitis, migratory arthritis first 2-3 days • Localization to 1 (or more joints) after first 48hrs • Red, hot knee > wt bearing jts > hands/wrists with fever

Acute Monoarticular IA: ‘Aspirate or Litigate’ • Gout • Red,hot peripheral joint (LE>UE) esp first MTP, onset over hours. May have > 1 joint involved. Peeling of skin after attack • Male > age 30, postmenopausal females • Asian, alcohol abuse, obesity • Pseudogout • Red, hot knee or wrist > other joints. May be >1 jt. • Age >55. Hyperparathyroidism should be ruled out (hemochromatosis, thyroid disease are other possible causes) • Rarer causes: ReA, PsA, palindromic rheumatism, hydroxyapatite, RA, JIA, osteomyelitis

Chronic Monoarticular IA • Fungal, mycobacterial, mycoplasma, Lyme • Foreign-body synovitis • Osteomyelitis • Sarcoid arthritis • SpA: ReA, psoriatic • Children: pauciarticular JIA (evaluate eye for chronic uveitis)

Typically the knee > other joints Joint redness and fever are variable All chronic monoarticular inflammatory arthritides need a synovial biopsy with culture if not diagnosed by other means Oligoarticular Arthritis Oligoarticular IA • All causes of acute & chronic monoarticular IA can present with more than one joint • 80% of septic arthritis is monoarticular (but not 100%!!) • Spondyloarthritis (SpA) • : hips, back pain, uveitis • ReA: asymmetric large joint predominance, LE > UE, toe dactylitis, hx GI/GU infection, conjunctivitis, rash (palms, soles, penile) • Psoriatic: UE > LE, DIP involvement, finger dactylitis, rash & nail involvement • IBD associated: knee > other jts

Polyarticular Arthritis Acute Polyarticular IA • Viral- parvovirus is a prototypical example in young adults • Young female with children, daycare worker • Rash, small/large joint arthritis, low grade fever • Hepatitis B > hepatitis C > HIV • Risk factors for exposure • Urticarial rash, prior to jaundice (Hep B) • Sarcoid (Lofgren’s syndrome) • Young white/Hispanic females • Bilateral ankle arthritis, hilar LAD, E. nodosum

Acute Polyarticular IA Rheumatic fever/post streptococcal ARF: age 4-15, sore throat, migratory, large > small joint arthritis PSRA: females > age 18, exposure to children with strep, non-migratory, large > small joints, no other symptoms of ARF Polymyalgia rheumatica Caucasian females, > age 50-60, shoulder & hip pain and stiffness > small joint involvement, increased ESR (80-90% sensitive) Vasculitis Usually more than arthritis but can see arthritis in HSP, ANCA-associated vasculitis, cryoglobulinemia Initial phase of all chronic polyarticular IA and rarer causes (SBE, paraneoplastic (ovarian)) Chronic polyarticular IA (‘the prototype’) Symmetric, small joints of hands, wrists, feet Connective tissue diseases Look for other systemic signs/symptoms SLE: females (9:1), non-Caucasian groups disproportionately affected, symmetric arthritis, hands/wrists/knees, r/o meds (drug-induced lupus) Polymyositis/dermatomyositis, scleroderma, MCTD : may present with an RA-like pattern Adult onset Still’s: high fever, serositis, rash, seronegative, high ferritin Hepatitis C associated arthritis RA-like presentation; arthralgias > arthritis Ask about risk factors; Hep C serologies; often RF+, but CCP negative Medical drawings from my med school copy of Netter, Frank H. Atlas of Human Anatomy, 2nd Edition. 1998

Rheumatic Disease ROS/PE: Important in oligo & polyarticular IA Fever: septic, crystal, Still’s disease, SLE & RA less commonly (in patients with known SLE or RA, fever = infection until proven otherwise) A Thorough ROS & Exam is Alopecia: SLE Critical To Form a DDx In Patients Red/painful eyes: Sjogren’s, ReA, AS, RA, sarcoidosis, Behcet’s with Oligo & Polyarthritis Dry mouth/eyes: Sjogren’s

Pleuropericarditis: SLE/CTD, Still’s (and other rare periodic fever Copies of this talk available syndromes), RA, viral etiologies (consider path for universal in PDF form under the ViP primer) section of ACR website Pulmonary disease: Scleroderma, PM/DM, SLE, RA, Sjogren’s, ANCA, Behcet’s (pulmonary aneurysms) Raynaud’s: Scleroderma, SLE/CTD Rheumatic Disease ROS/PE: Important in oligo & polyarticular IA Dermatology: Psoriasis, ReA, Lyme disease (ECM), enteropathic/sarcoid (E. Nodosum), SLE (malar rash/photosensitivity), dermatomyositis, gonococcal, vasculitis, scleroderma, tophi Oral/nasal ulcers: SLE, ReA, IBD-associated arthritis, Behcet’s, GPA (not hard palate-cocaine) Headaches: Giant cell arteritis, SLE, vasculitis, APS (anti-phospholipid antibody syndrome) Paresthesias: Sjogren’s, RA, CTS, vasculitis (mononeuritis multiplex classically, but stocking glove possible) Endocrine disease: thyroid (Hashimoto’s) Rheumatic Disease ROS/PE: Important in oligo & polyarticular IA Sore throat: rheumatic fever, Still’s Diarrhea/stool : ReA, enteropathic arthritis Dysuria/penile/vaginal infection: ReA, gonococcal CNS Sxs: SLE, vasculitis, APS, Sjogrens Renal Dz: SLE, vasculitis Habits: alcohol, smoking, drug use, sexual contact, obesity Risk factors: IV drugs, HIV, hepatitis C Medications: minocycline, hydralazine (SLE), statins (myopathy), fluoroquinolones (Achilles tendinitis), others Musculoskeletal Pain

Arthritis Periarticular Nonarticular Referred

Inflammatory Noninflammatory

Polyarticular Oligoarticular Monoarticular 1. RA Septic 2. RA Ankylosing spondylitis Gout 3. RA Reactive arthritis Pseudogout SLE/CTD Psoriatic arthritis Hep B/C/viral Inflammatory bowel Taking it Back to the Patient: It All Starts with the Recognition of Synovitis Hand examination Hand examination

Hand examination = synovitis

= Foot exam OA: 1st MTP RA: 2nd-5th MTPs -erosive disease can commonly originate at 4th/5th MTPs -MTP swelling can be difficult to appreciate; look for splaying of the toes -anterior displacement of fat pads with cock up deformity

Normal Splaying Anterior displacement of fat pads Posterior tibial dysfunction Cock-up deformities of the toes -hindfoot valgus -acquired pes planus -forefoot abduction (‘too many toes sign’) Pattern recognition

RA PsA AS OA The patient's history and physical examination are the cake. Lab and x-ray are the frosting. You've got to bake the cake before you reach for the frosting. -Geordie Lawry, MD

Additional presentations on OA and regional MSK exam in upcoming presentations as part of the Adult ViP program. 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.