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Musculoskeletal Exam

Contributor: Alan Erickson, MD and Arundathi Jayatilleke, MD

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CASE 1

An otherwise healthy 45 year old female presents to the primary care office with complaints of pain in the joints of her hands. She notes that her wedding ring won't fit on her finger any more. She tells you that when she is doing her job as a butcher her hand pain worsens. She has also noted times when her hands feel numb, especially in the morning. She thinks that her hands are starting to look like those of her grandmother's. She tells you that she was reading about her problems on the internet and wonders if she may have gout. She denies any other specific complaints, including fever, rash, diarrhea, and dysuria.

On physical examination, she has bony enlargement of her proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints with mild tenderness and no warmth at the DIP joints. She is able to close her fist fully and her hand grip is normal.

What are the key features of her history and physical that will help you make the diagnosis?

The history is essential in determining the etiology of musculoskeletal complaints. Inflammatory joint pain is usually worse in the mornings or after periods of inactivity, with improvement with activity. It also commonly will present with warm and swollen joints, also known as synovitis or tenosynovitis when the tendons are involved. Non-inflammatory joint pain is worse with activity and rarely is there synovitis, although joint effusions may be present at times. The patient should also be questioned about associated symptoms which may be a clue to inflammatory conditions, including fever, fatigue, rash, gastrointestinal complaints, genitourinary complaints, and eye redness.

Approach to the Joint Exam

Observation - In terms of the physical exam, pattern recognition essential to the differential diagnosis. The distribution of involved joints can help guide you: number of joints (monoarticular, oligoarticular, or polyarticular); size of the joint involved (large or small) and symmetric or asymmetric involvement, can provide a clue to the diagnosis. The presence of redness, warmth and swelling is indicative of inflammatory versus non-inflammatory joint disease.

Examination - With the patient seated comfortably and dressed to allow examination of the joints, you should inspect the joints for redness, warmth, swelling or signs of deformity. Then examine the range of motion of the joints.

  • Hands: dorsal and palmar surfaces, spreading the fingers, and making a fist.
  • Wrists and elbows: flexion and extension.
  • Shoulders: raising arms overhead, place hands behind the back and place hands behind the head.
  • Hips: with the patient lying on his or her back, examine flexion, then internally and externally rotate the hip with the knee flexed
  • Knees: flexion and extension; if indicated, examine for anterior and posterior cruciate ligament tears medial and lateral collateral ligament tears and medial meniscus injury.
  • Ankles and feet: dorsiflexion and plantarflexion, plantar surface of foot.

With the patient standing, assess alignment of the spine, knees, heels, and feet as well as the arches. Examine the spine for deformity and range of motion (flexion, extension, and lateral rotation). Finally, observe the gait and note any assistive devices. In addition, you should assess muscle atrophy and the presence of extraarticular tender points).

In this case, the patient describes non-inflammatory sounding pain, in a typical osteoarthritis (OA) distribution-namely, PIP and DIP joints without metacarpophalangeal joint involvement Her clinical picture is most consistent with OA of the hand.

Patient Care

  1. Discuss historical features and physical findings that distinguish inflammatory from non-inflammatory arthritis.
  2. Recognize physical examination findings in common rheumatic diseases.
  3. Recognize clues to multi-system inflammatory diseases and develop a plan for evaluation.
  4. Demonstrate an appropriate joint examination and describe common joint injection techniques.
  5. Recommend appropriate management and follow-up based on the final diagnosis.

Medical Knowledge

  1. Recognize the economic burden of musculoskeletal diseases.
  2. Know how to identify the key differences between inflammatory versus non-inflammatory problems on physical exam.
  3. Generate a differential diagnosis for different regional pain syndromes.

Interpersonal and Communication Skills

  1. Explain risks and benefits for office procedures such injection as therapy.
  2. Be able to direct patients to web-based resources for a variety of different diseases where they can learn more about their disease and medications.
  3. Discuss treatment decisions with referring physician involved in your patient's care.

Professionalism

  1. Recognize the importance of patient privacy, informed consent, and equal care.
  2. Demonstrate integrity and honesty in discussing patient care issues and management with the patient and family.

Practice-Based Learning

  1. Set learning goals for the understanding of the evaluation of patients with musculoskeletal complaints.
  2. Effectively demonstrate your ability to evaluate and treat a patient's complaints.
  3. Integrate and apply the knowledge gained from the history, physical, laboratory, and radiographic assessment to make informed decisions about patient care.
  4. Demonstrate your ability to complete office based procedures.
  5. Develop a willingness to learn from errors and use errors in a constructive way to learn and improve the system for patient care.
  6. Utilize web based resources for the assessment and education of patients.

System-Based Practice

  1. Identify barriers to the delivery of optimal patient care for patients with musculoskeletal complaints.
  2. Demonstrate the ability to collaborate with other health care providers delivering specialized arthritis care.
  3. Mount a project to determine cost-effective management of patients with musculoskeletal complaints then implement the project.
  4. Specify items that are used by patients, or that are consider complimentary or alternative care.
  5. Inventory items that impact costs to the patient, physician, and the health industry

References

  • Klippel, JH: Primer on the Rheumatic Diseases. Thirteenth Edition. Springer Science+Business Media,LLC. 2008
  • Lawry, G. Systematic Musculoskeletal Examinations. McGraw-Hill Medical. 2012

Questions

(Answer questions 1 - 3 on a piece of paper. Find Answer Key at the bottom on the page.)

1) Which of the following is the most appropriate next diagnostic step for this patient?

  1. MRI of the hand.
  2. Ultrasound-guided aspiration of the DIP joint.
  3. Blood testing to include ANA, rheumatoid factor, and sedimentation rate.
  4. No diagnostic testing.

2) The bony prominences at the patient's DIP joints are also known as:

  1. Tophi.
  2. Boutonnière deformities.
  3. Rheumatoid nodules.
  4. Heberden's nodes.

3) If the patient progressed to develop pain at the base of the thumb (first carpometacarpal joint) along with limited abduction of the thumb, the next most appropriate step would be:

  1. Referral to an occupational therapist for splinting of the thumb.
  2. Wrist cock-up splints for carpal tunnel syndrome.
  3. Intra-articular injection of hyaluronic acid derivatives in the first carpometacarpal joint.
  4. Weekly low-dose oral methotrexate.

Answer Key

1) The correct answer is D.

According to the American College of Rheumatology's clinical criteria, hand osteoarthritis can be diagnosed if hand pain is accompanied by at least three of the following features:

  • Hard tissue enlargement of 2 or more of 10 selected joints (second and third PIP and DIP as well as the first CMC joint of both hands)
  • Hard tissue enlargement of 2 or more DIP joints
  • Fewer than 3 swollen MCP joints
  • Deformity of at least 1 of 10 selected joints

This classification method has a sensitivity of 94% and a specificity of 87%. Additional diagnostic testing is not warranted because it has no impact on disease management. MRI can be used to detect soft tissue abnormalities such as tendonitis or early appearance of bony erosions but is not necessary to diagnose osteoarthritis.

Ultrasound-guided aspiration is useful to accurately obtain synovial fluid from small joints or in cases where the anatomy is obscure. In this patient, there is no evidence of effusion and so no need for attempted joint aspiration.

Serologic testing can be useful in the diagnosis of inflammatory arthritis such as rheumatoid arthritis, but in this patient with pain in the distribution of hand osteoarthritis and no alarm symptoms of inflammatory arthritis, is unnecessary.

Source: Altman R, Alarcón G, Appelrouth D, Bloch D, Borenstein D, Brandt K, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hand. Arthritis Rheum 1990; 33:1601-10.

2) The correct answer is D.

These bony prominences at the DIP joints are commonly found on examination of the hands of patients with osteoarthritis. While Heberden's nodes may initially be associated with morning stiffness, erythema, and soft tissue swelling, this eventually subsides, leaving the patient with bony enlargement. Similar bony prominences at the PIP joints are known as Bouchard's nodes.

Tophi are deposits of monosodium urate crystals seen in people with high levels of serum uric acid, and are pathognomonic for gout. They can be seen at the joints but also in the soft tissue.

Boutonnière deformity refers to flexion of the PIP joint accompanied by hyperextension of the DIP joint. This can be seen in rheumatoid arthritis as well as other disease processes affecting the hands, such as tendon laceration, fracture, or dislocation.

Rheumatoid nodules are subcutaneous soft tissue swellings typically found over the elbows and fingers in patients with rheumatoid arthritis. Less commonly they can found in internal organs such as the lungs.

3) The correct answer is A.

Referral to an occupational therapist for splinting of the thumb. There are relatively few RCTs regarding interventions for hand OA in the literature. The American College of Rheumatology's 2012 recommendations for the use of non-pharmacologic and pharmacologic therapies in hand osteoarthritis suggests that splints for the first carpometacarpal (CMC) joint may alleviate some pain in patients with OA at the base of the thumb.

Wrist cock-up splints are typically used for carpal tunnel syndrome to relieve pressure on the median nerve as it passes through the carpal tunnel, which would not benefit thumb osteoarthritis.

There is limited evidence on intra-articular hyaluronic acid derivative injections in the first carpometacarpal joint and their use is not recommended.

Weekly low-dose oral methotrexate is used for the treatment of rheumatoid arthritis rather than osteoarthritis.

Source: Hochberg MC, Altman RD, April KT, et al., American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012 Apr;64(4):465-74.

Last updated February 2015.

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