Is It Arthritis ?

7/30/2019 Is It Arthritis ?

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Review

Synthse

Dr. Ensworth is ClinicalAssistant Professorof Medicine, Mary PackArthritis Centre and theArthritis Research Centreof Canada, Vancouver, BC.

This article has been peer reviewed.

CMAJ2000;162(7):10116

Series editor:Dr. John M. Esdaile,Professor and Head, Division ofRheumatology, University of BritishColumbia, and Scientific Director,

Arthritis Research Centre ofCanada, Vancouver, BC.

This series has been reviewed

and endorsed by the CanadianRheumatology Association.

The Arthritis Society salutesCMAJfor their extensive series of articleson arthritis. The society believesthat this kind of information iscrucial to educating physiciansabout this devastating disease.

Case 1A 29-year-old woman consults her physician 2 months after the birth of hersecond child because she woke one morning with pain and swelling in herwrists, small joints of the hands, knees, ankles and balls of the feet. She is stifffor an hour after arising and is extremely fatigued but has no other associatedsymptoms or preceding illnesses. She had reported similar, milder symptomsafter her first pregnancy, but the joint pains and stiffness disappeared after 1month of ibuprofen (400 mg, 4 times daily) treatment. Blood tests reveal ahigh level of rheumatoid factor and antinuclear antibodies.

Case 2A 69-year-old woman reports that in the year since her last checkup she hashad progressive pain in the joints of her fingers, at the base of her thumbs andin her knees, and she has bunions. The pain is worse with activity. She hashad minimal (20 min) morning stiffness and no joint swelling, although thesmall joints of her fingers and the bunions have been developing increasingdeformities with deviations and bony enlargements. She recalls that hermother had gnarled fingers at an older age. Her complete blood count anderythrocyte sedimentation rate (11 mm/h) are normal.

Case 3A 40-year-old father of 3 has recently become unable to work as a construc-tion worker because of chronic low-back pain and stiffness, which beganwhen he was in his early 20s. He consults his physician for the first time be-cause his livelihood is in jeopardy. Recently, his thoracic spine between theshoulder blades has been stiff, his shoulders have been painful and 1 knee hasbeen swollen. Otherwise, he is well and blood tests are normal.

Case 4A 50-year-old school teacher has a 3-year history of progressive vague low-back pain associated with pain in the muscles, bones and joints of the arms,legs, neck and chest, sparing the hands. All of the pains are exacerbated byactivity. She has some morning stiffness but denies swollen joints. In addition,she has progressively marked fatigue and episodic diarrhea, alternating withconstipation. She now feels unable to work because of pain and fatigue.Blood tests and radiographs of her lumbar spine are normal.

T

hese cases demonstrate the diversity of rheumatic diseases and their po-tential impact on society. Rheumatology is not synonymous with geriatric

medicine people of all ages can be affected. Some diseases are inflam-matory and some are not. For inflammatory causes of arthritis especially, promptdiagnosis and the early initiation of appropriate treatment is increasingly recog-nized as the standard of care that is required. Appropriate early treatment may alterthe course of many of the systemic inflammatory disorders so that damage, disabil-ity and the incidence of premature death are reduced. Some rheumatic disordersare curable, while others can enter a long-term remission with the appropriatetreatment.

Musculoskeletal complaints are among the most common reasons people seekmedical attention from a primary care physician and are the number 1 cause of long-term disability and inability to work in Canada.13 Many rheumatic disorders strikepeople in their most productive years. Yet, of all organ-system disorders, many physi-

Rheumatology: 1. Is it arthritis?

Stephanie Ensworth

CMAJ APR. 4, 2000; 162 (7)1011

2000 Canadian Medical Association or its licensors

Clinical basics


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cians report that they feel the least comfortable treating mus-culoskeletal complaints.13

The diagnosis of rheumatic disease is based primarilyon the patients history and physical examination. Sophisti-cated serologic tests can support a clinical diagnosis, but

more often they mislead the unwary; if the serology doesnot match, the clinical impression prevails. Similarly, imag-ing only supports or confirms the clinical impression. Testswill often be normal early in the course of a rheumatic dis-ease, as illustrated in 3 of the 4 cases previously described.

After completing a thorough musculoskeletal historyand physical examination, the physician can focus on a lim-ited differential diagnosis. To evaluate joint pain and arriveat a diagnosis the following questions should be answered: Is the pain articular or nonarticular? Is the problem inflammatory or noninflammatory? Is the problem acute or chronic? What is the pattern of the joints involved?

Are there any associated symptoms or signs?

Is the pain articular or nonarticular?

The first and most important step in making a muscu-loskeletal diagnosis is to determine if a complaint of jointpain is truly an articular (or joint) problem or if the prob-lem is actually in the tissues surrounding the joint.

An articular problem usually indicates arthritis of somesort. Exceptions to this include nonarthritic intra-articularproblems such as a meniscal injury in the knee, an intra-articular loose body, intra-articular fractures (includingavascular necrosis of the bone), hemarthroses and ex-

tremely rare joint tumours. Nonarticular problems, whicharise from the surrounding structures, include bursitis, ten-dinitis, enthesitis (inflammation at sites of ligament and

tendon attachment to bone), ligament injuries and muscleproblems, including fibromyalgia.

To differentiate between articular and nonarticularproblems, the physician should begin by asking the patientto identify the exact site of pain by pointing to the painful

area. This is particularly helpful in assessing complaints ofwhat a patient will call hip pain or ankle pain. Whencomplaining of hip pain, most patients are actually experi-encing a nonarticular hip problem and, when asked, willpoint to the region of the greater trochanter (trochantericbursitis or fibromyalgia tender point) or the buttock (often

Ensworth

1012JAMC 4 AVR. 2000; 162 (7)

Fig. 1: Glenohumeral joint of the shoulder showing ligamen-tous and musculotendinous attachments.

Table 1: Differentiating articular from nonarticular pain on physical examination

Physical feature Articular (capsular pattern) Nonarticular (noncapsular pattern)

Ranges of motion in the joint Restricted more or less equally throughout allranges of motion

Asymmetrically restricted (e.g., flexion may be restricted,but extension may be normal)

Active (performed by patient) v.passive (performed by physician)ranges of motion

Restrictions in active ranges of motion will besimilar to restrictions in passive ranges of motion

Restrictions in active and passive ranges of motion will bedifferent

Pain Pain or stress pain (pain at end-range of motion)on testing all ranges of motion

Pain or stress pain only on testing some ranges of motion

Tenderness on palpation Over the joint line In periarticular areas

Timing of the report of pain When the joint is moved through all ranges ofmotionWhen the joint is palpated

When the joint is moved through some ranges of motionMay be reported after the joint has been palpated or moved

Swelling (if present) Diffuse Localized, defined area, such as in a bursa or around atendon

Special tests (isometric resistedmuscle testing)

Negative or positive for all periarticular musclestested

Positive for 1 particular muscle group (tendinitis andenthesitis)May be positive for more than 1 periarticular muscle group(bursitis and fibromyalgia) but will not give all-negative orall-positive pattern, as in articular problem


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a low-back disorder). A true hip-joint problem causes ante-rior groin pain. True ankle-joint pain is felt along the ante-rior tibiotalar joint line. Most patients with Achilles ten-dinitis or medial or lateral malleolar pain will complain ofankle pain, but will point to 1 of these nonarticular struc-

tures when asked to identify the exact site of pain.Second, the physician should determine which ranges of

motion are painful or restricted. A patient with a true jointproblem will describe pain or restriction for all ranges of mo-tion tested in the specific joint and will describe reaching thelimit of joint motion as the most painful (often called stresspain). A patient with a nonarticular problem will describepain or restriction for only some of the ranges of motion ofthat particular joint, and reachingthe limit of the range may notnecessarily be associated with themost pain.4,5

This information is especially

helpful in evaluating a painfulshoulder a joint that has manyperiarticular structures (e.g., bur-sas, rotator cuff and other ten-dons and prominent periarticularmuscles). A patient with trueglenohumeral joint arthritis willdescribe pain or restriction in allranges of motion of the shoulder(i.e., elevation, abduction, adduc-tion, internal rotation and exter-nal rotation) and will describethe pain as most severe on reaching the limits of motion. A

patient with a periarticular shoulder problem (e.g., sub-acromial bursitis or tendinitis of 1 of the rotator cuff ten-dons) will describe pain or restriction on performing someshoulder motions, especially abduction (the so-calledpainful arc) and usually internal rotation, but external ro-tation will be normal. Some shoulder periarticular prob-lems will be associated with the most pain through themidrange of motion, and the pain will ease off as the limitsof joint range are reached. For example, supraspinatus ten-dinitis will cause pain on arm abduction between approxi-mately 60 and 120, but at full elevation the pain will actu-ally decrease. Fig. 1 shows the glenohumeral joint of theshoulder with the ligamentous and musculotendinous at-

tachments (including rotator cuff tendons), joint capsuleand subacromial bursa.Physical examination is also important in differentiating

articular from nonarticular pain (Table 1). True jointpathology is described as producing a capsular or articularpattern in the reduction of passive joint ranges of motion(i.e., the passive ranges of motion of the particular joint be-ing examined are reduced approximately equally). Nonar-ticular problems produce a noncapsular or nonarticularpattern in the reduction of passive ranges of motion of thejoint (i.e., 1 or several of that joints ranges of motion arereduced much more than others).5 The only exceptions to

this rule are the glenohumeral joints and hip joints. In theglenohumeral joint an early or mild capsular pattern, a truejoint problem, will reduce external rotation before otherpassive ranges of motion in the joint. In the hip joint, how-ever, internal rotation will be reduced before other passive

ranges of motion.5

Is the disorder inflammatory ornoninflammatory?

The second most important step in arriving at a correctdiagnosis that will form the basis of treatment is determin-

ing if the disorder is inflamma-tory or noninflammatory. A pa-tient with inflammatory articularproblems will have a history of 1or all of the following: joint

swelling, warmth and, on the rareoccasion, redness (e.g., a septicjoint is red , but a rheumatoidjoint is not). These signs are notassociated with noninflammatoryarticular problems. An inflamedjoint will be stiff in the morningfor at least 30 minutes and afterperiods of rest during the day(gelling); noninflammatory formsof arthritis such as osteoarthritiswill not be associated with morn-

ing stiffness (or the morning stiffness will last less than 30

minutes), and gelling will last no more than a few minutes.The only exception to this rule is the nonarticular nonin-flammatory condition, fibromyalgia, which is associated withwidespread nonarticular pain in bones, muscles, joints, neckand back; normal ranges of motion; exacerbation of painwith exercise, especially after exercise; and nonrestorativesleep disorder. For reasons that are not understood, somepatients with fibromyalgia report significant durations ofmorning stiffness or stiffness that persists all day. A nonartic-ular problem might be described as swollen, hot or red (e.g.,septic olecranon or prepatellar bursitis) but not stiff. Thephysical features that differentiate inflammatory articularconditions from noninflammatory articular problems and in-

flammatory nonarticular problems are listed in Table 2.

Is the disorder acute or chronic?

The third step in evaluating a joint disorder is to deter-mine whether the problem is acute (< 6 weeks in duration)or chronic (> 6 weeks duration). The main causes of acuteinflammation of the joint include septic arthritis, injury(hemarthroses) and crystal arthritis. Any of the chronicforms of arthritis might also result in an acutely inflamedjoint, but the chronic forms would be considered only afterexcluding sepsis, injury and crystal arthritis. The diagnostic

Diagnosing arthritis

CMAJ APR. 4, 2000; 162 (7)1013

Key points

Rheumatic diseases are diverse, affect peo-ple of all ages and have a significant im-pact on society.

Musculoskeletal problems are the number1 cause of long-term disability in Canadaand the second-most common reason peo-ple consult a primary care physician.

Early diagnosis and treatment can alter thecourse of many of these diseases, particu-larly the most severe.


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factors to be considered in an acute inflammatory nonartic-ular problem (e.g., bursitis, tendinitis) are similar to thosefor acute arthritis.

Chronic inflammatory arthritis, bursitis, tendinitis andenthesitis support a diagnosis of

1 of the chronic systemic inflam-matory disorders (i.e., rheuma-toid arthritis, 1 of the seronega-tive spondyloarthropathies, 1 ofthe crystal arthropathies or aconnective tissue disorder). Non-inflammatory joint problems(e.g., osteoarthritis) are usuallychronic in nature.

What is the pattern of thejoints involved?

The fourth step in evaluatinga joint complaint is to determinethe pattern of the joints affected their symmetry, size and num-ber and whether the axialskeleton is involved. Are the affected joints sym-

metrically involved (e.g., isthere arthritis in both wristjoints or just 1)?

Are large joints (shoulders,hips, knees) or small joints (wrist, metacarpophalangeal,

proximal interphalangeal, distal interphalangeal, ankle,midtarsal, metatarsophalangeal joints) affected? How many joints are affected? This step is referred to

as the joint count. Monoarticular refers to the in-volvement of 1 joint, oligoarticular, to the involvementof 24 joints, and polyarticular is used when 5 or moreare affected.

Is the axial skeleton (thoracic spine, lumbar spine,sacroiliac joints or anterior costochondral joints)affected?

Determining whether the condition is articular or nonar-ticular, inflammatory or noninflammatory, and acute or

chronic and assessing the pattern of the joints involved willprovide a detailed description of the musculoskeletal problemthat can stand alone as the diagnosis or may facilitate a morespecific one. For example, the patient may have a chronic, in-

flammatory, symmetrical, small-

joint polyarthritis. The most com-mon rheumatic diseases fitting thisdescription, and the most likelyspecific diagnoses, are rheumatoidarthritis, psoriatic arthritis or 1 ofthe connective tissue disorders. Ifthe patient has a chronic, inflam-matory, asymmetrical, large-jointpolyarthritis with inflammatoryspine involvement, the diagnosisis most probably 1 of the seroneg-ative spondyloarthropathies,whereas a chronic, inflammatory,

asymmetrical, small-joint oligo-arthritis strongly suggests a diag-nosis of psoriatic arthritis.

The pattern and type of jointsinvolved will also help the physi-cian arrive at a specific rheuma-tologic diagnosis. Osteoarthritiscommonly affects the proximaland distal interphalangeal jointsof the fingers and the first carpo-metacarpal joints in the handsbut rarely involves the metacar-

pophalangeal joints, wrists, elbows or ankles. Chronic, in-

flammatory polyarthritis involving the metacarpophalan-geal joints in the hands, wrists, elbows or ankles is typical ofrheumatoid arthritis, psoriatic arthritis or 1 of the connec-tive tissue disorders.

Are there any associated signs or symptoms?

In arriving at a specific rheumatologic diagnosis, thephysician should also proceed through a review of systemsto determine whether there are any extra-articular symp-toms or signs associated with the joint problem. A collec-tion of certain features (a syndrome) in association with the

Ensworth

1014JAMC 4 AVR. 2000; 162 (7)

Key points

Diagnosis of rheumatic disease is basedprimarily on the patients history and phys-ical examination.

Once the patient has identified the exactsite of the pain the physician should deter-mine if the conditions is: Articular or nonarticular. To determine

this the active and passive ranges ofmotion of the affected joints should beevaluated.

Inflammatory or noninflammatory. This

will form the the basis of treatment. Acute or chronic.

The pattern of joint involvement will helpthe physician arrive at a specific rheumato-logic diagnosis.

The patient should also be examined forextra-articular features that are often asso-ciated with the common rheumatologicdiseases; these may lead the physician to amore specific diagnosis.

Table 2: Differentiating inflammatory from noninflammatory conditions

SignInflammatory articular

problems (e.g., arthritis)Noninflammatory articular

problems (e.g., osteoarthritis)Inflammatory nonarticular

problems (e.g., bursitis, tendinitis)

Warmth Yes, diffusely over thejoint

No Sometimes, but localized over thestructure (i.e., tendon or bursa)

Swelling Yes, usually; the joint isdiffusely swollen (effusion)

No joint effusion, but bonyenlargement may be present

Yes, but swelling is localizedover the particular structure

Redness Rarely; i f present the jointis diffusely red

No Rarely, but again, localized

Tenderness Yes, over the joint line Yes, over the joint line Yes, over the particular structure


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appropriate musculoskeletal description, will confirm thediagnosis of the rheumatic condition. Table 3 lists the mainextra-articular features associated with the most commonrheumatologic diseases. In isolation, many of these extra-articular manifestations do not indicate a specific diagnosis;

it is when several of these features are present together thata more specific syndrome can be recognized. The physicianmust specifically ask for this information because patientsdo not usually volunteer it.

Dry eyes or mouth

Many patients complain of dry eyes or mouth. Truexero-ophthalmia may be present when the patient can nolonger wear contact lenses because of dry eyes, continues tohave dry eyes when they stop wearing contact lenses, wak-ens through the night or in the morning with dry eyes andhas sought the use of artificial tears. The patient should be

sent to an ophthalmologist for a Schirmers test or RoseBengal test if it is necessary to document dry eyes. 6 Truexerostomia (dry mouth) may be present if the patient is nolonger able to eat or swallow dry foods without fluids. Of-ten the patient will need to carry water or keep water at thebedside at night. Physical examination of the mouth is usu-ally normal until xerostomia is advanced.

Hair loss

Hair loss is probably significant if the pillowcase is cov-ered with hair in the morning. To determine the extent ofthe problem patients can be asked to count the number of

hairs lost per day; more than 200 is considered significanthair loss.

Oral and nasal ulcerations

Patients should be questioned about and examined fororal and nasal ulcerations. A physical examination is re-quired because, although some ulcers can be very painful,

others may be painless. If the patient has been experiencingintermittent ulcerations throughout life and there has beenno change in frequency or severity, the ulcerations areprobably not significant. However, if the ulcerations are ofrecent onset, occur in outbreaks or clusters in the absenceof any precipitant and occur frequently (i.e., more thanonce monthly), they are probably significant and could beassociated with a rheumatic disease.6

Malar erythema

Patients with systemic lupus erythematosus may experi-ence malar erythema that is flat or raised but not pustular;

malar erythema with pustules is typical of the commonrash, acne rosacea. A systemic lupus erythematosus malarrash usually involves the cheeks and the bridge of the nosebut spares the nasolabial folds, while acne rosacea involvesthe nasolabial folds. Both are often photosensitive.7

Photosensitive rash

A significant photosensitive rash is usually an erythema-tous, maculopapular eruption that might ulcerate or scale(but is not vesicular); it occurs quickly on sun-exposed areas(within 30 min of sun exposure), often takes several days tosubside once out of the sun and is often reported to be pru-

ritic but is tender when scratched.7

Raynauds phenomenon

Raynauds phenomenon occurs in about 8% of women.It is probably significant if the onset is recent (within thepast 2 years), it involves 1 or several digits at a time but notall digits at the same time, and it occurs on exposure to ei-ther mildly cold temperatures or at any time unrelated tocold exposure.8 Raynauds phenomenon is pathologic ifthere are associated digital ulcerations, digital pitting scarsor digital tuft loss. Although classic Raynauds phenomenonis triphasic (white, blue and hyperemic colour phases), for

diagnosis the patient need only describe the white phase.In addition to these symptoms and signs, which arecommon in the rheumatic diseases but are not specific forthe rheumatic diseases, a few findings are characteristic(pathognomic) of rheumatic disease. Nail-fold infarctionsare tiny, painful black dots in the periungual areas and indi-cate the presence of small-vessel vasculitis. They are partic-ularly common in rheumatoid arthritis but might also beseen in systemic lupus erythematosus or in 1 of the vas-culitic disorders. Rheumatoid nodules are nontender, non-erythematous, mobile, subcutaneous nodules that usuallyoccur around joints or on pressure areas; they are also vas-

Diagnosing arthritis

CMAJ APR. 4, 2000; 162 (7)1015

Table 3: Extra-articular features of common rheumatic dis-orders

Rheumatic disorder Common extra-articular features

Rheumatoid arthritis Dry eyes, scleritis, dry mouth, nail-foldinfarcts, rheumatoid nodules, pleuritis

Connective tissuedisorders*

Hair loss, oral or nasal ulcerations, dry eyes,dry mouth, malar erythema, photosensitivity,pleuritis, pericarditis, Raynaudsphenomenon, sclerodactyly, esophageal

dysmotilitySeronegativespondyloarthropathies

Psoriasis or nail pits (seen in psoriaticarthritis), inflammatory bowel disease (seen ininflammatory bowel disease-associatedspondyloarthritis), conjunctivitis and urethritisor cervicitis (seen in reactive spondyloarthritisor Reiters syndrome)

Gout Tophi

Fibromyalgia Irritable bowel syndrome, irritable bladdersyndrome, depression, vague paresthesias

*Includes systemic lupus erythematosus, Sjgrens syndrome, systemic sclerosis and variants,mixed connective tissue disease, dermatomyositis and polymyositis.


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culitic lesions and occur commonly in severe rheumatoidarthritis, but may also be seen in the connective tissue dis-eases, especially systemic lupus erythematosus. Goutytophi, which are pathognomic for gout, can resemblerheumatoid nodules and are often in the same locations as

rheumatoid nodules (except gouty tophi can occur on thehelix of the ears). Sclerodactyly (i.e., thickening of the skindistal to the metacarpophalangeal joints of the hands or themetatarsalphalangeal joints of the feet so that the skin can-not be pinched by the examiner) usually indicates the pres-ence of connective tissue disease, specifically, systemic scle-rosis, CREST (calcinosis, Raynauds phenomenon,esophageal dysmotility, sclerodactyly, telangiectasias) syn-drome or mixed connective tissue disease but may also oc-cur rarely after exposure to certain antineoplastic agents orin hematologic malignancies.

Diagnosing our patients problems

Returning to our patients, the 29-year-old woman hasrecurrent (suggesting chronicity), inflammatory, symmetri-cal small-joint polyarthritis in the absence of any extra-articular features except fatigue. The onset was postpartum.This clinical picture is most consistent with a diagnosis ofrheumatoid arthritis.

The 69-year-old woman has chronic, noninflammatoryjoint pains in the pattern of joints typically seen with os-teoarthritis, without extra-articular features. The diagnosisis primary generalized osteoarthritis.

The 40-year-old man has chronic, inflammatory, asym-metric, large-joint oligoarthritis with inflammatory spine

involvement compatible with a diagnosis of ankylosingspondylitis.The 50-year-old school teacher has chronic, generalized,

noninflammatory, nonarticular musculoskeletal complaintstypical of fibromyalgia syndrome. In addition, she has de-scribed irritable bowel syndrome, which is common in pa-tients with fibromyalgia.

In summary, musculoskeletal problems are the second-

most common complaint for which medical attention issought at the primary care level. By following the 5 basicsteps described here, a physician can arrive at a rheumato-logic diagnosis that is precise enough to serve as the basisfor further investigations and treatment.

References

1. Glazier RH, Dalby DM, Badley EM, Hawker GA, Bell MJ, Buchbinder R.Determinants of physician confidence in the primary care management ofmusculoskeletal disorders.J Rheumatol1996;23:351-6.

2. Glazier RH, Dalby DM, Badley EM, Hawker GA, Bell MJ, Buchbinder R, etal. Management of the early and late presentations of rheumatoid arthritis: asurvey of Ontario primary care physicians. CMAJ1996;155(6):679-87. Ab-stract available: www.cma.ca/cmaj/vol-155/issue-6/0679.htm

3. Glazier RH, Dalby DM, Badley EM, Hawker GA, Bell MJ, Buchbinder R, etal. Management of common musculoskeletal problems: a survey of Ontarioprimary care physicians. CMAJ1998;158(8):1037-40. Abstract available: www.cma.ca/cmaj/vol-158/issue-8/1037.htm

4. Hoppenfeld S.Physical examination of the spine and extremities. London: Apple-ton-Century-Crofts; 1976.

5. Cyriax JH, Cyriax PJ. Cyriaxs illustrated manual of orthopaedic medicine. 2nd ed.Oxford: Butterworth Heinemann; 1993.

6. Klippel JH, Dieppe PA, editors. Rheumatology. 2nd ed. Philadelphia: Mosby;1998.

7. Wallace DJ, Hahn BH, editors. Dubois lupus erythematosus. 5th ed. Baltimore:Williams and Wilkins; 1997.

8. Kelley WN, Harris ED Jr, Ruddy S, Sledge CB, editors. Textbook of rheuma-tology. 5th ed. Philadelphia: WB Saunders; 1997.

Ensworth

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Competing interests: None declared.

Reprint requests to:Dr. Stephanie Ensworth, Clinical Assistant

Professor of Medicine, University of British Columbia, Mary PackArthritis Centre, 895 W 10th Ave., Vancouver BC V5Z 1L7;fax 604 871-4556; [email protected]

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