Approach to Musculoskeletal Pain

Question 1

Articular vs. nonarticular

Answer 1

Articular comes from within the joint…can be from many different things

Nonarticular from outside the joint

Question 2

Articular 
Pain 
ROM 
Swelling 
Others

Answer 2

Constant deep or diffuse…worse with mo[vement

Limited on active and passive

Often prominent

Joint instability, crepitus, popping, clikcing, locking

Question 3

Nonarticular
Pain
ROM
Swelling

Answer 3

Intermittent localized…only with movement

Limited on active only

Usually minimal

Question 4

Synovium and synovitis

Answer 4

CT lining inner surface and produces synovial fluid

Inflammation of synovial membrin…results in synovial hypertrophy or collection of fluid which leads to joint swelling…most common in RA

Question 5

Articular cartialge

Answer 5

Covering the ends of bone to help absorb force and allows smooth motion

Question 6

Degneration of articular cartilage and menisacal injury

Answer 6

Either signifanct event or result of injury from years of trauam and eventual matrix degradation…primary mech of OA

Meniscal - can be injured

Question 7

Intra-articular ligaments and sprain/rupture

Answer 7

Dense collagenous that connect bones within the joint capsule…provides stability and ROM

Forces against the joint overload the intra-articular ligament leading to strain or rupture

Question 8

Joint capsule and capsulitis

Answer 8

Envelope of tissues surrounding the joint consisting of innner synovial membrane and outer fibrous

Chornic inflammation of joint cpasule leading to adhesions and fibrosis of the inner synovial layer (frozen shoulder)

Question 9

Dislocation and subluxation

Answer 9

No longer in contact…focal pain at joint without inflammation

Partial contact…focal pain without inflamation

Question 10

Non-articular characteristics

Answer 10

Pain located outside of the joint itself…pain with active rather than passive and ROM can be preserved…tenderness and signs of inflamm away from joint line

Question 11

Bursae and bursitis

Answer 11

Connective tissue sac with a potential space filled with synovial fluid…allows motion of one tissue over another

Inflammation of bura

Question 12

Tendon and extra-art ligament pain

Sprain

Answer 12

Less severe than bone apin…often described as sharp…worse with stretch or movement

Tearing injyr due to stretching

Question 13

Tendinitis and enthesisi

Answer 13

Inflammation of tendon due to overuse (think rotator cuff from throwing or swimming)

Inflammation of parts that insert into bone (think AI like spondyloarthropathy)

Question 14

Bone pain and fracture

Answer 14

Deep, dull, constant, progressive and occurs at night

Force overcomes the strength of bone

Question 15

Osteomyelitis and malignancy

Answer 15

Infection of bone…usually insidous onset

Cancer

Question 16

Muscle pain and strain

Answer 16

Less intense than bone pai…may have spasms or cramps

Injury due to overuse or excessive force…normally get acute focal pain

Question 17

Myositis and myalgia

Answer 17

Inflammation of muscle…can be seen afrer viral illness…may have ummune mediated without pain…can cause weakness

Widespread chonric muscle pain without inflammation like in fibromyaglia

Question 18

INflammatoru

Timing
Morning
Duration
Exam
Labs 
Radio

Answer 18

Worse after rest and in the morning

MOre than 60 minutes

More acute

Swollen, tender, erythematous, warm

Evleated ESR and CRP

Erosions and joint space narrowing

Question 19

Noninflam

Timing 
Morning
Joint exam
Labs
Radio

Answer 19

Worse after activity and worse in the evening

Less than 30 minutes

More chronic

Bony swelling possible with crepitus

Normal ESR and CRP

OSteophytes and space narrowing

Question 20

ESR

Answer 20

Measure of aggregation of erythrocytes

Accumulation of positive proteins (in inflalmation) with incresase aggregation

Basically indirct measure of fibrinogen levels

Peak 2 weeks after systemic inflammation and declines in about 2 weeks

Question 21

CRP

Answer 21

Producd by liver in response to inflam….IL6, IL1 and TNF alpha induce

CRP is much more direct as it peaks 48 horus

Question 22

Chronic vs acute

Answer 22

Acute less thjan 4 weeks and oftne infection, trauam, or crystal arthropathies

Chronic from arthritis, RA, or another AI joint dz

Question 23

IMportant other tests to run

Answer 23

Anemia, leukopenia, and thrombocytopenia

Liver and kidney function

Question 24

ANA

Answer 24

Test is positive in almost every with SLE…great test to exclude SLE when neg

Question 25

Anti-dsDNA and anti-smith Abs

Answer 25

Specific tests for SLE, but negative does not exclude

Question 26

Antiribonucleoprotein ABs

Answer 26

Strongly associated with mixed conn tissue dz, but can be positive in SLE

Question 27

Anti-SSa and anti-SSB antibodies (anti-ro and la)

Answer 27

NOt sensitive or specific enough to really diagnose…but can help with Sjorgens

Question 28

RF

Answer 28

RF positive not specific for only RA…also associated wiht other AI and HepC

Question 29

joint aspirations and microscopy

Answer 29

WBC more than 2000 with neutrophils is inflammation

WBC over 50000 with neutrophil predom could be septic arthritis

Cna distinguish between gout and pseudogout

Question 30

Localized and acute

Chronic and liocalized

Non articular

Answer 30

Tendinitis, bursitis, plantar fascitis, fracture, ligament spriand

Osteomyelitis, structural diusorder

Question 31

Diffuse and acute

SDiffuse and chronic

Non articular pain

Answer 31

Myositis (viral)

Plymyalgia rheumatic, polymyositis/dermatomyositis, fibromyalgai

Question 32

Noninflam vs inflam non artciular

Answer 32

Inflam will be worse with movement, have local signs of swelling and redness, and lab signs

Non is constant that might be not worse with movement

Question 33

POlymyalagia rhematica

Answer 33

Proximal muscle groups over the age of 50

Inflammatory

May have systemic sx as well

Question 34

Fibromyalgia

Answer 34

Non inflam widesrpeaad pain under 50 y/o