APPROACH TO PATIENT WITH

MUSCULOSCELETAL PROBLEM

dr. Hartanto Wijaya, SpPD

Department of Internal Medicine

Faculty of Medicine UKRIDA
2018
 Sasaran pembelajaran
• Setelah mengikuti perkuliahan ini, diharapkan
mahasiswa akan dapat :
• Menjelaskan tentang anatomi & fisiologi dasar sistem
muskuloskeletal
• Menjelaskan tanda dan gejala beberapa penyakit
muskuloskeletal tertentu
• Menjelaskan diagnosis dan penatalaksanaan berbagai
penyakit muskuloskeletal tertentu
• Mengetahui diagnosis banding beberapa penyakit
muskuloskeletal tertentu

3/20/17
 DEFINITION
• Muskuloskeletal terdiri dari kata:
– Muskulo : otot
– Skeletal : tulang
• Muskulo atau muskular  jaringan otot-otot tubuh yg berfungsi mengubah
energi kimia menjadi kerja mekanik sebagai respons tubuh terhadap
perubahan lingkungan (alat gerak aktif)
• Skeletal atau osteo  tulang kerangka tubuh /bagian tubuh yg terdiri dari
tulang, sendi, & tulang rawan (kartilago) sebagai tempat menempelnya otot &
memungkinkan tubuh untuk mempertahankan sikap & posisi (alat gerak pasif)
 The Musculoskeletal System
 System consist of : muscles, tendons, ligaments,
bones, joints & associated tissues that move the
body & maintain its form.

 Skeletal & Muscular systems - works together to

allow movement
 The Musculoskeletal System
 Otot (muscle)

 Tulang (skeletal)

 Sendi; Persambungan/ artikulasio : pertemuan antara dua atau

lebih dari tulang rangka.

 Tendon ; jaringan ikat yang menghubungkan otot & tulang

 Ligamen ; jaringan ikat yang mempertemukan kedua ujung tulang

(mempertahankan stabilitas sendi)

 Bursae ; kantong kecil dari jaringan ikat, antara tulang dan kulit,
antara tulang & tendon atau diantara otot

 Fascia ; jaringan yang mengikat dan membungkus jaringan lunak

seperti otot, saraf dan pembuluh darah.
 MUSCULOSKELETAL
SYSTEM
• Muscles & Bone types
• Muscles & Bone structure
• Muscles & Bone function
• Muscles & Bone growth & metabolism
• Muscles & Bone disorder
 MUSCLE FUNCTION
 Stabilizing joints
 Maintaining posture
 Producing movement
 Moving substances within the body
 Stabilizing body position and regulating organ volume
 Producing heat– muscle contraction generates 85% of
the body’s heat
 Types of Muscle
Skeletal
Smooth Muscle Cardiac Muscle
Muscle
On hollow organs,
Attached to
Location glands and blood Heart
bone
vessels
Heart
Move the Compression of tubes
Function contraction to
whole body & ducts
propel blood
Multiple,
Nucleus Single, central Central & single
peripheral
Control voluntary involuntary involuntary
Striations yes no yes

Cell Shape Cylindrical Spindle-shaped Branched

Types of Muscle
 SKELETAL FUNCTION

Fungsi tulang secara umum:

 Formasi kerangka (penentu bentuk dan ukuran
tubuh)
 Formasi sendi (penggerak)
 Perlengketan otot
 Pengungkit
 Menyokong berat badan
 Proteksi (membentuk rongga melindungi organ yang
halus & lunak, seperti otak, jantung dan paru)
 Haemopoesis (pembentukan sel darah (red marrow)
 Fungsi Imunologi: RES sumsum tulang membentuk
limfosit B dan makrofag
 Penyimpanan Mineral (kalsium & fosfat) dan lipid
(yellow marrow)
 GENERAL ASSESMENT
 Health history
– Chief complaint
– Onset of problem
– Effect on ADLs
– Precipitating events, e.g., trauma
– Examine complaints of pain for location, duration,
radiation character (sharp dull), aggravating, or alleviating
factors
– Inquire about fever, fatigue, weight changes, rash, or
swelling etc
 Physical Examination
 Posture
 Gait
 Ability to walk with or without assistive devices
 Muscle mass, strength & symmetry
 Inspect & palpate bone, joints for visible deformities,
tenderness or pain, swelling, warmth, ROM, crepitus
 Bulge sign & ballottement sign used to assess for fluid
in the knee joint
 Diagnostic Evaluation
 Imaging Procedures – X ray, CT, Bone Scan, MRI,
ultrasound
 Nuclear Studies - radioisotope bone density,
 Endoscopic Studies –arthrocentesis, arthroscopy
 Other Studies –biopsy, synovial fluid, Arthrogram,
venogram, Electromyography, Myelography
 Laboratory Studies
Imaging of The Musculoskeletal
 Laboratory Test
• Blood Tests  CBC, Serum muscle enzymes, Rheumatoid
Factor, LE Prep/Antinuclear Antibodies(ANA) Uric acid,
Calcium, Phosphorous, Alkaline phosphatase, LDH, Enzymes:
creatine kinase, glutamin-oxaloacetic, aldolase, SGOT
• Urine Test
 Approach to The Disease
• Anatomic localization of complaint (articular vs.
nonarticular)
• Determination of the nature of the pathologic process
(inflammatory vs. noninflammatory)
• Determination of the extent of involvement
(monarticular, polyarticular, focal, widespread)
• Determination of chronology (acute vs. chronic)
• Consider the most common disorders first
• Formulation of a differential diagnosis
 ARTHRITIS
DIFFERENTIAL DIAGNOSIS
Monoarthritis Pauci-arthritis
(1 joint) (2 or 3 joints)
 Trauma  Psoriatic arthritis
 Infection-related (eg,  Reactive (Reiter syndrome)
bacterial, fungal, TB,  Enteropathic (eg, IBS)
Lyme disease)  Sarcoidosis (knees, ankles)
 Crystal-mediated  Osteoarthritis
 Trauma  Ankylosing spondylitis
 Hemarthrosis  Amyloid (shoulder)
 Osteoarthritis  Infection-related (eg, Lyme
disease, rheumatic fever,
endocarditis)
 Crystal-mediated
Polyarthritis
(≥4 joints)
 Crystal-mediated
 Rheumatoid arthritis
 Psoriatic arthritis
 Immune complex (eg, lupus,
serum sickness,
hypersensitivity drug
reaction)
 Infection-related (eg, Lyme
disease, viral arthritis,
rheumatic fever,
endocarditis)
 Reactive (Reiter syndrome)
GENERAL MANAGEMENT STRATEGIES:
• Patient & family education + Exercise
• Topical balms & creams, applied 2 or 3 times daily
• Acetaminophen (500–1000 mg q8h)  preferred simple analgesic for older
adults
• NSAIDs (only in good candidates for short terms)
• Because of their adverse effects, prednisone & other glucocorticoids should
not be used indiscriminately  Consultation with a rheumatologist can be
helpful
• Narcotic medications, started in low dosages & titrated slowly, are often
useful when pain is unresponsive to nonpharmacologic therapy or
acetaminophen
• Massage, acupuncture, TENS, neuromuscular electrical stimulation, &
consultation with OT and PT are additional options
GOUT
 Gout
• Gout is the most common type of arthritis worldwide, & its
prevalence varies between 1 and 4% in adults
• Prevalence is greater in men than women (black men > white
men
• Gout  a disorder with on the one hand an autoinflammatory
syndrome, and on the other hand, dysmetabolism characterized
by a positive urate balance leading to hyperuricemia &
articular as well as extraarticular crystallization & chronic
subinflammation.
 Pathophysiology
• Uric acid is a metabolic by-product of purine catabolism
(Purineshypoxanthinexanthineuric acid
• When the balance of dietary intake, synthesis & rate of excretion
are disrupted, hyperuricemia results
– Overproduction (10%)
– Underexcretion (90%)
• accumulation of excess urate crystals (monosodium urate) in joint
fluid, cartilage,bones, tendons, bursas, & other tissues arthritis,
soft tissue masses, nephrolithiasis, urate nephropathy etc
 Risk Factors
• High Purine Diet (Red Meat, Fatty Poultry, High Fat Dairy,
Seafood)
• Alcohol Consumption
• Trauma
• Osteoarthritis
• Surgery
• Starvation
• Dehydration
• Obesity
• Drugs (Allopurinol, uricosuric agents, thiazides, loop diuretics,
low dose aspirin)
• Renal Impairment
• Genetic Mutations (SLC22A9, SLC22A12, ABCG2)
 Stages of Gout
• Asymptomatic tissue deposition
• Acute Gouty Arthritis
• Intercritical Gout
• Chronic Articular and Tophaceous Gout
 Acute Gout
• Often presents  involvement of a single joint or
multiple joints in the lower extremities: first
metatarsophalangeal (podagra; 50% of people with
gout), midtarsal, ankle & knee joints

• Characterized by pain, erythema, swelling & warmth,

desquamation of skin, fever & leukocytosis

• Even without treatment, attacks subside within days

to several weeks
 Chronic Gout

• Characterized by chronic arthritis & tophi,

resulting in chronic inflammatory & destructive
changes  irreversible
 Diagnosis

Diagnosis should be
based on combination
of clinical, historical
and laboratory data if
arthrocentesis cannot
be performed.
 Diagnosis
• Arthrocentesis should be done in patients in whom the
diagnosis has not been previously established.
• Diagnosis requires monosodium urate crystals from synovial
fluid or an aspirate of a tophus (gold standard)
• Radiographs show juxta-articular erosions of the involved
joints
• Labs: cell count with differential, gram stain, culture,
examination for crystals under polarized light microscopy
Differential Diagnosis
Gouty changes in the big
toe

Erosions due to tophi

Diet
Treatment
Treatment
Osteoarthritis
(OA)
DEFINITION
RISK FACTOR
 RISK FACTOR
• Older age
• Female
• Indian
• Family History of OA
• Obesity & metabolic disease
• Trauma
• Congenital disorder
• High Bone density
• Joint predilection: Carpometacarpal 1, Metatarsofalangeal
1, Knee, vertebrae etc
CLASSIFICATION
SIGNS & SYMPTOMS
SIGNS & SYMPTOMPS
SIGNS & SYMPTOMPS
 Laboratory & Imaging test
• Laboratory test  not useful in diagnosis
• Narrowing joint gap (asymmetris)
• Sclerosis subchondral
• Bone cyst
• Osteophyte
• Deformity
 Severe OA of hands

Lateral Medial

DIP = Heberden’s nodes PIP = Bouchard’s nodes

Medial right knee OA

= varus deformity
 Adanya pembentukan osteofit dan
Gambaran sendi tungkai normal penyempitan celah sendi pada
sendi tungkai
Tabel 2.1. Gambaran Radiologis Pada OA Menurut Kellgren & Lawrence

Grade of
Description
Osteoarthritis

0 No radiographic findings of osteoarthritis

1 Minute osteophytes of doubtful clinical significance

2 Definite osteophytes with unimpaired joint space

3 Definite osteophytes with moderate joint space narrowing

Definite osteophytes with severe joint space narrowing and

4
subchondral sclerosis

Sumber : American Journal of Roentgenology, 29 Juni 2006

 OA Treatment (ACR 2012)
• Weight loss
• Participate in cardiovascular (aerobic) and/or resistance land-
based exercise, Participate in aquatic exercise
• Oral/topical analgesic, tramadol (low dose narcotic)
• Acetaminophen
Recommended as 1st line Rx
 Can combine with low dose NSAIDs
 Maximum dose < 3000 mg a day
• Intraarticular steroid injection (adjunctive)
• Surgery
• Recommendations:
• Thermal and manual therapy → TENS, device (bracing,
Joint support etc)
Rheumatoid Arthritis
(RA)
 Rheumatoid arthritis
• Autoimmune disease characterized by chronic systemic &
progresif inflammatory disease  articular (joint primary
target) & extraarticular
• Risk factor: Female > male (3 : 1), family history of
RA,infection & smoking
• RA characterized by synovial proliferation (pannus), bursitis
and nodules
• Periarticular osteoporosis is an early finding , but can also see
generalized osteoporosis
 SIGNS & SYMPTOMS
• Non spesific: fatigue, weakness, anoreksia, subfebrile
• Articular: synovitis  polyarthritis,symmetrical (most
common: MCP, PIP)  deformity (swan neck, boutonniere,
hallux valgus etc)
• Extraarticular: ↑ Rheumatoid factor  Rheumatoid nodul,
vasculitis,pericarditis, pleuritis, osteoporosis, neuropathy etc
 LABORATORY TEST
• Complete blood count
• Rheumatoid factor
• C-reactive protein
• Liver and kidney function test
• Anticyclic citrullinated peptide antibody (anti CCP)
• Anti RA-33
• ANA
• Complement
• Urinalysis
• Joint fluid analysis
 IMAGING TEST
• Plain radiograph
• MRI
• Osteopenia juxtaarticular
• Articular erosion
• Joint effusion.
• Soft tissue swlling
 Deformities
 Ulnar deviation of the digits
 Swan-neck and Boutonniere deformities etc
 PIP joint inflammation

Rheumatoid nodules

Inflammation and
subluxation of MCP joints
 RA of Hands Deformities:

Swan neck = MCP pulling

Boutonierre = PIP slipping

Muscle atrophy due to

inflammation causing nerve
compression at the wrist
(carpal tunnel syndrome)

https://www.youtube.com/watch?v=d6P0MCjz9T4
 MANAGEMENT
• Exercise
• Cod liver oil
• Essential fatty acid
• Oral /topical NSAID
• Steroid
• Disease-modifying anti-rheumatic drugs (DMARDs)
→ started as soon as diagnosis RA is made (Synthetic
/Biologic)
 Algorithm based on the 2016 European League Against Rheumatism (EULAR)
recommendations on rheumatoid arthritis (RA) management.

©2017 by BMJ Publishing Group Ltd and European League Against Rheumatism
 Differential Diagnosis
Gambaran Radiologi Osteoartritis Artritis Reumatoid Gout
Sendi penyangga berat Mengenai sendi-sendi Paling sering pada MTP 1
badan seperti coxae, kecil PIP, MCP,
genu, vertebre pergelangan siku,
Daerah Predileksi
pergelangan kaki, dll

Celah sendi Menyempit Menyempit Baik hingga menyempit

Tidak ada Erosif sekitar sendi Erosi pada pinggir tulang
“over hanging lip”
Erosi Punched out

dengan garis sklerotik

Simetri Tidak simetris Simetris dan bilateral Asimetris

Kista Ada Ada (pseudocyst) Tidak Ada

Ada pada pinggir sendi Tidak ada Tidak ada

Osteofit

Perbadingan OA dengan RA dan Gout

Perbedaan Gambaran Deformitas yang terjadi pada RA dan OA