Keyword : arthralgia, arthritis ..

(joint pain) gout, septic arthritis,

rheumatoid arthritis , bursa (periarticular pain)
tennis elbow ( lateral epicondyle ), golf elbow ( medial
epicondyle ), orecranon bursitis (refer
pain) carpal tunnel syndrome
joint pain periarticular pain

Joint pain periarticular pain

- morning stiffness ++/+ - morning stiffness +

- pain all direction of movement ** pain at some direction
- Dull pain - sharp pain

+/- swollen, erythema ** swollen, erythema

and warmth around and warmth
joint only at area of lesion
+/- joint effsion - no joint effusion

inflammatory/ non inflamatory tendinitis

joint disease enthesitis, bursitis
+ muscle pain

joint pain
1. arthritis arthralgia , morning stiffness
arthralgia arthritis
2. arthritis/arthralgia monoarticular (1 ) oligoarticular (< 4 )
polyarticular ( 5 )
3. (arthralgia/arthritis),
(acute/chronic onset) (intermittent/persistant course)
Acute = 6 (1-2 )
3.1 acute monoarthritis
3.2 acute oligo/polyarthritis
Chronic = 6
3.3 chronic intermittent monoarthritis
3.4 chronic persistent monoarthritis
3.5 chronic intermittent oligo/polyarthritis
3.6 chronic persistent oligo/polyarthritis
non-inflammatory
3.7 monoarthralgia
3.8 polyarthralgia

Acute monoarthritis Monoarthalgia (non-inflammatory)
Gout/Pseudogout Osteoarthritis
Septic arthritis Osteocondromatosis
Post-trauma Avascular necrosis
Hemathrosis Neuropathic osteoarthropathy
Osteoarthritis Loose body
Palindomic rheumatism
Behcet
AIDS

Acute oligo/polyarthritis Polyarthralgia (non-inflammatory)

Gonococcal arthritis/DGI Hypertrophic osteoarthropathy
Acute rheumatic fever Paraneoplastic syndrome
Reactive arthritis/SNSA Psychosomatic diseases
Viral arthritis Acromegaly
Palindromic rheumatism
Behcet
AIDS
Leukemia

Chronic intermittent monoarthritis Chronic persistent monoarthritis

Chronic tophaceous gout/CPPD Spondyloarthropathy
Spondyloarthropathy Rheumatoid arthritis
Palindromic rheumatism TB arthritis
SLE Behcet

Chronic intermittent Chronic persistent

oligo/polyarthritis oligo/polyarthritis

Spondyloarthropathy Spondyloarthropathy
SLE Rheumatoid arthritis
Chronic topaceous gout SLE
CPPD Chronic topaceous gout
Osteoarthritis (hand) CPPD
Osteoarthritis (hand)

natural carse

2

autoimmune disease -
rheumatoid arthritis, SLE spondyloarthropathy (Ankylosing
Spondylitis, Psoriatic arthritis, Reiters syndrome)
degeneratine disease crystal induce arthritis (gout, CPPD)
( CPPD > 60 yr) gout

Onset
abrupt onset trauma
crystal induced arthritis (gout, CPPD)
rapid onset 2-3 septic arthritis acute
inflammatory arthritis reactive arthritis, acute rheumatic fever, palindromic rheumatism
insidious onset non-inflammatory
joint disease osteoarthritis, avascular necrosis, neuropathic osteoarthropathy
inflammatory joint disease rheumatoid arthritis, psoriatic arthritis, SLE

Distribution of joint pain

1. Symmetrical VS asymmetrical
- symmetrical distribution 2
rheumatoid arthritis, SLE, viral
arthritis
- asymmetrical distribution 2
spondyloarthropathy
(SNSA), gout/pseudogout, osteoarthritis
2. Predominate upper limbs VS lower limbs
- (predominate upper limbs) rheumatoid arthritis,
psoriatic arthritis, dissiminated gonococcal arthritis (DGI)
- (predominate lower limbs) spondyloarthropathy, septic
arthritis, osteoarthritis, avascular necrosis, crystal induced arthritis
(gout/pseudogout)
3. Peripheral joints VS axial joints
Axial joints C-spine L-S spine, (sacroiliac
joint), sternoclavicular joint costovertebral joint

sacroiliac joint spondyloarthropathy

Ankylosing spondylitis psoriatic arthritis ( inflammatory back pain
)
c-spine Rheumatoid arthritis osteoarthritis
L-S spine Osteoarthritis
sacroiliac joint Spondyloarthropathy, Behcet, Rheumatoid, TB
arthritis, lymphoma
sternoclaricular joint rheumatoid arthritis, spondyloarthropathy, septic
arthritis ( pseudomonas septic arthritis)

3
 1 : Anatomic localization of joint disease

Site of arthritis, arthralgia Disease

1st metatarso phalangeal (MTP) Gout, OA
distal interphalangeal (DIP) OA, psoriatic arthritis
Metacarpophalangeal (MCP) RA, SNSA, SLE
1st carpometacarpal OA
Wrist RA, psoriatic arthritis, TB
Elbow RA, SNSA, SLE
Shoulder RA, SNSA, septic arthritis

HIP Avascular necrosis, OA

Knee Septic arthritis,gout, CPPD,
RA, SNSA
Heel SNSA
Sacroiliac (SI) SNSA, septic arthritis, OA
Cervical spine OA, RA, SNSA
Thoraco-lumbar spine SNSA, OA
Temporo-mandibular (TM joint) RA, SLE, psoriatic arthritis,
Crico-arytenoid SLE, RA

Precipitating factor

Gout alcohol, high purine diet (, , ,

, ) , , trauma, physical stress

Pseudogout (CPPD) trauma, physical stress or critical illness ,

Septic arthritis septicemia, other site of infection, penetrating

wound, intra-articular injection

Acute rheumatic fever acute -streptococcal pharyngitis

Gonococcal arthritis sexual behavior, menstruation, pregnancy

Reiter/Reactive arthritis infective diarrhea, urinary tract infection

Systemic symptoms/sign

, , septic arthritis

4
Disease systemic symptom/sign

Rheumatoid arthritis Rheumatoid nodule, cutanecus

vasculitis, episcleritis

Reiter/Reactive Arthritis Uveitis, urethritis, painless oral ulcer

pitting nail, onychodystrophy

Psoriatic arthritis Silvery erythematous plague

pitting nail/onychodystrophy pustule

SLE Malar rash/ SCLE (maculopapular or

annular lesion) alopecia, anemia, Oral
ulcer, nephritis, vasculitis

Gonococcal arthritis Sterile pustule, lymphangitis, urethritis,

Leukorhea

Septic arthritis Other site of infection e.g. pneumonia,

UTI, diarrhea, cutaneous wound

Gout Tophi, kidney stone (nonopeque)

renal insufficiency, hypertension

Acute rheumatic fever Subcutaneous nodule, Erythema

marginatum

Behcet disease Oral/genital ulcer , vascular thrombosis

Response of previous treatment

inflammatory arthritis NSAID steroid
Gout colchicines 2-3
Osteoarthritis non-inflammatory pattern analgesic drug
paracetamal

(1)
1. general inspection systemic
symptome
2.
general physical examination (inspection), (palpation), (pressure)
(range of motion)

5
 (inspection)
(deformity) (atrophy)

1. e.g.
antalgic gait, limb length discrepancy

2.
- spine scoliosis , posterior iliac crest ,
paraspinal, deltoid, supraspinatous gluteus (atrophy) , Archilles tendon
- Spine loss of lordosis cervical lumbar level , flexion
deformity
- sternoclavicular, acromioclavicular shoulder joint ,
flexion deformity , varus valgus deformity , hallax vulgus
, flat foot high arch foot ,
tendon sheat swelling muscle atrophy, contracture of palmar fascia

(palpation)
(swelling) (synovial thickening),
(effusion) (osteophyte, tophi) swelling synovial
thickening effusion = synovitis), crepitus passive movement

(pressure)
4 / perfusion (joint line)
1/3 ,
(tenderness) synovitis (grasping test)
MCP, PIP, DIP, MTP

(range of motion)

Acute
monoarthritis

Periarticular History and Polyarthritis

syndrome Physical exam

Tendinitis True
Bursitis monoarthritis
Osteomyelitis Fracture
Avulsion
Trauma or Radiograph
Focal pain
OA/CPPD

Effusion CBC/ESR U/S or

CT/MRI

Synovial fluid Arthrocentesis Synovial fluid

WBC > 5000/mm3 Bloody

Acute Synovial fluid MRI / Arthroscopy

Inflammatory WBC < 1000/mm3
arthritis

Non Internal derangement

inflammatory Tumor
arthritis

Kelleys Textbook of Rheumatology , 7th edition (2)

7
 Acute inflammatory arthritis
(synovial fluid WBC > 5000/mm3)

+
Gram stain Septic arthritis

+
Gout / CPPD Crystal exam
+/- superinfection
+

CBC ESR RF ANA

+ Empirical antibiotics
Clinical sepsis 24 hours
awaiting culture

CPPD
Reactive arthritis
Systemic rheumatic disease

NSAIDs
F/U 24-48 hours
Reaspirate joint if worsen

Kelleys Textbook of Rheumatology , 7th edition (2)

8
 Chronic
monoarthritis

+ Osteoarthritis
Radiograph CPPD
Inflammatory arthritis

Synovial fluid WBC

< 1000/mm3 Aspirate joint Synovial fluid WBC
> 5000/mm3

+
Internal derangement Gout/CPPD Crystal exam
Osteoarthritis

RF, ANA, ESR

Culture, PPD

Occult infection
Systemic rheumatic disease
Occult CPPD

Kelleys Textbook of Rheumatology , 7th edition (2)

Polyarthritis systemic disease
1. Nonspecific test of inflammation: ESR, CRP, ( 20-30 mm/hr) CBC (
HCT , WBC , Plt )
2. Specific test for diagnosis: RF, ANA, uric acid, Aso titer (suspected rheumatic
fever), HLA B27(suspected SNSA), CBC, UA, film x-ray, film joint

Causes of elevated ESR

Inflammation
Infection esp. bacterial
High immunoglobulin level e.g. multiple myeloma, macroglobulinemia
Anemia, pregnancy
Chronic renal failure, liver cirrhosis
Hypo/hyperthyroidism
Malignancy
Stress
Elderly
Drugs: heparin, oral contraceptive

9
 Conditions associated with Rhematoid factor

Rheumatic diseases Non-rheumatic disease

Rheumatoid arthritis Acute viral infection

SLE Extensive immunization
Scleroderma Chronic infection
Sjogrens syndrome Malignancy
Overlap syndrome/MCTD Hyperglobulinemic states
Systemic vasculitis Chronic active hepatitis
Sarcoidosis
Aging

ANAs in Rheumatic Diseases (antinuclear antibodies)

Disease Incidence(%)
SLE 80-95
Scleroderma 45-100
Polymyositis 20-75
MCTD 100
RA 25-50
JRA 15-40

Positive ANA in non-rheumatic disease

Autoimmune Infection Other

Chronic active hepatitis Infectious mononucleosis Neoplasm

Primary biliary cirrhosis Herpes virus infection Lymphoproliferative
Ulcerative colitis Tuberculosis disease
Hashimoto thyroiditis Leprosy
Myasthenia gravis Histoplasmosis Idiopathic pulmonary
Pernicious anemia fibrosis

Asbestosis
Silicosis
Pneumoconiosis
Drug reaction
Cardiomyopathy
Thermal burn

10
 Synovial fluid analysis

Type of Fluid Special Features Leukocytes/mm3

Normal Clear, Colorless < 200 (< 25% PMNs)

Viscous

Noninflammatory Clear, Yellow Viscous 200-2,000 (< 25% PMNs)

Inflammatory Cloudy, Yellow >2,000-100,000(> 50% PMNs)

Watery
Glucose May be Low

Septic Purulent > 80,000 (> 75% PMNs)

Glucose Very Low

(3)
SLE Bone erosion Bone
erosion Bone proliferation (e.g. osteophyte, syndesmophyte) gout,
spondyloarthopathy osteoarthritis non-inflamamatory pathern bone
erosion osteophyte inflammatory pathern erosive osteoarthritis (
) Bone erosion ( DIP joints)

Disease Radiographic change

Osteoarthritis Osteophyte, narrow joint space (nonuniform pattern),

subchondral bone sclerosis, subchondral bone cyst

Rheumatoid arthritis Narrow joint space (uniform pattern), marginal bone

Erosion, juxta articular osteopenia, + joint ankylosis

Spondyloarthropathy Narrow joint space (uniform patten), syndesmophyte

or enthesophyte, marginal/non-marginal bone erosion
joint ankylosis, Bamboo spine (AS),
Sacroiliitis: irregular joint surface, pseudo-widening
of SI Joint
Pubic symphysis: subchondral sclerosis, joint
ankylosis

Gout Well define/ punch out (Marginal /non-

marginal) erosion, non marginal osteophyte (over
hanging edge), soft tissue calcified mass (tophi)

Pseudogout (CPPD) Chondrocalcinosis (linear or punctate calcification in

Joint space) = CPPD crystal deposit in cartilage, bone
Erosion, narrow joint space, hypertrophic osteophyte

11

course

critenia for classification and diagnosis of the rheumatic disease

American colledge of rheumatology (4)
[Appendix I] , spondyloarthropathy (SNSA) [Appendix II]
(SLE) [Appendix III]
References
1. Kevin G Moder, Gene G. Hunder. History and Physical Examination of Musculoskeletal
system. In Section V, Kelleys Textbook of Rheumatology. 7th edition, pp.483-500.
2. W. Joseph McCune, JosephthGolbus. Monoarticular Arthritis. In Section V, Kellys
Textbook of Rheumatology. 7 edition, pp.501-513.
3. , , .
4.John H. Klippel, et al. In criteria for the classification and diagnosis of the rheumatic
diseases. In appendix I, Primer on The Rheumatic Diseases. 12th edition.

12
Appendix I

Criteria for the Classification of Rheumatoid Arthritis

Criterion Definition

1. Morning stiffness Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement

2. Arthritis of three or more joint areas At least three joint areas simultaneously have had soft tissue swelling or fluid (not bony
overgrowth alone) observed by a physician. The 14 possible areas are right or left PIP, MCP,
wrist, elbow, knee, ankle, and MCP, or PIP joint
3. Arthritis of hand joint At least one area swollen (as defined above) in a wrist, MCP, or PIP joint
4. Symmetric arthritis Simultaneous involvement of the same joint areas (as defined in 2) on both sides of the body
(bilateral involvement of PIPs, MCPs, or MTPs is acceptable without absolute symmetry)
5. Rheumatoid nodules Subcutaneous nodules, over prominences, or extensor surfaces, or in juxtaarticular regions,
observed by a physician
6. Serum rheumatoid factor Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the
result has been positive in <5% of normal control subjects
7. Radiographic changes Radiographic changes typical of rheumatoid arthritis on posteroanterior hand and wrist
radiographs, which must include erosions or unequivocal bony decalcification localized in or most
marked adjacent to the involved joints (osteoarthritis changes alone do not qualify)

13
Appendix II
Criteria for the Classification of Spondyloarthropathy

Inflammatory spinal pain

Or
Synovitis Asymmetric or Predominantly in the lower limbs
And one or more of the following
Positive family history
Psoriasis
Inflammatory bowel disease
Urethritis, cervicitis, or acute diarrhea within 1 month before arthritis
Enthesopathy
Sacroiliitis

Variable Definition

Inflammatory spinal pain History or present symptoms of spinial pain in back, dorsal, or cervical region, with at least four of the following:
(a) onset before age 45, (b) insidious onset, (c) improved by exercise, (d) associated with morning stiffness, (e) at least 3
months duration
Synovitis Past or present asymmetric arthritis or arthritis predominantly in the lower limbs
Family history Presence in first-degree or second-degree relatives of any of the following: (a) ankylosing spondylitis, (b) psoriasis, (c)
acute uveitis, (d) reactive arthritis, (e) inflammatory bowel disease
Psoriasis Past or present psoriasis diagnosed by a physician
Inflammatory bowel Past or present Crohns disease or ulcerative colitis diagnosed by a physician and cofirmed by radiographic examination
or endoscopy disease
Alternating buttock pain Past or present pain alternating between the right and left gluteal regions
Enthesopathy Past or present spontaneous pain or tenderness at examination of the site of the insertion of the Achilles tendon or plantar
fascia
Acute diarrhea Episode of diarrhea occurring within one month before arthritis
Urethritis Nongonococcal urethritis or cervicitis occurring within one month before arthritis
Sacroiliitis Bilateral grade 2-4 or unilateral grade 3-4, according to the following radiographic grading system:
0 = normal, 1 = possible, 2 = minimal, 3 = moderate, and 4 = ankylosis

14
Appendix III
Criteria for the Classification of Systemic Lupus Erythematosus

Criterion Definition

1. Malar rash Fixed erythema, flat or ratised, over the malar eminences, tending to spare the nasolabial folds
2. Discoid rash Erythematous raised patches with adherent keratotic scaling and follicular plugging; atrophic scarring may occur
in older lesions
3. Photosensitivity Skin rash as a result of unusual reaction to sunlight, by patient history or physician observation
4. Oral ulcers Oral or nasopharyngeal ulceration, usually painless, observed by a physician
5. Arthritis Nonerosive arthritis involving two or more peripheral joints, characterized by tenderness, swelling, or effusion
6. Serositis a) Pleuritis convincing history of pleuritis pain or rub heard by a physician or evidence of pleural effusion or

b) Pericarditis documented by ECG or rub or evidence of pericardial effusion

7. Renal disorder a) Persistent proteinuria greater than 0.5 grams per day or greater than 3+ if quantitation not performed or
b) Cellular casts may be red cell, hemoglobin, granular, tubular, or mixed
8. Neurologic disorder a) Seizures in the absence of offending drugs or known metabolic derangements; eg, uremia, ketoacidosis, or
electrolyte imbalance or
b) Psychosis in the absence of offending drugs or known metabolic derangements; eg, uremia, ketoacidosis, or
electrolyte imbalance
9. Hematologic disorder a) Hemolytic anemia with reticulocytosis or
b) Leukopenia less than 4000/mm3 total on two or more occasions or
c) Lymphopenia less than 1500/mm3 on two or more occasions or
d) Thrombocytopenia less than 100,000/mm3 in the absence of offending drugs
10. Immunologic disorder a) Anti-DNA: antibody to native DNA in abnormal titer or
b) Anti-SM: presence of antibody to SM nuclear antigen or
c) Positive finding of antiphospholipid antibodies based on (1) an abnormal serum level of IgG or IgM anti-
cardiolipin antibodies, (2) a positive test result for lupus anticoagulant using a standard method, or (3) a false
positive serologic test for syphilis known to be positive for at least 6 months and confirmed by Treponema
pallidum immobilization or fluorescent treponemal antibody absorption test
11. Antinuclear antibody An abnormal titer of antinuclear antibody by immunofluorescence or an equivalent assay at any point in time and
in the absence of drugs known to be associated with drug-induced lupus syndrome

15