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Angelfire Basic RA



A middle aged man consults his physician after experiencing severe pain in his left shoulder and upper arm for 2 weeks. He is concerned about possible heart trouble. The pain is made worse by movement, and he has difficulty putting on a shirt or a coat. The pain is worse at night, and he sometimes has to sleep in a reclining chair. He is otherwise well. He rarely exercises, but 3 weeks ago he helped a friend move a lot of heavy boxes. Treatment with ibuprofen has been only slightly helpful.

Localized musculoskeletal pains with associated tenderness are a common but troublesome complaint for many people because they may interfere with day-to-day activities at work or at home. In most cases these problems can be isolated, diagnosed and treated successfully with minimal complications. The key to management lies in the patient's history and careful physical examination, which allow the physician to rule out underlying systemic disease and more serious conditions. Expensive investigations are not usually required. For the most part treatment with local injections of corticosteroids and appropriate physical measures, such as the application of ice or physiotherapy, is successful.

During the examination our middle-aged man's physician found there was restriction of left shoulder movement due to pain, with a painful arc beginning at 80 of abduction. Tenderness was sharply localized at the greater tuberosity of the humerus in the region of the supraspinatus insertion. The joints of the upper extremities and the cervical spine were otherwise unremarkable.

A diagnosis of supraspinatus tendinitis was made and the patient was treated with corticosteroid and lidocaine injection. He was reassured and advised to use acetaminophen for pain control, apply ice daily, carry out range-of-motion exercises twice daily at home and avoid lifting until the pain was resolved. He recovered over the next 2 weeks without incident.

Other Problems-Musculoskeletal:

Regional shoulder complaints are a frequent cause of visits to the family physician and are especially common in elderly people. Shoulder pain frequently occurs after recreational activities or work in the home and garden or may arise spontaneously without any remembered strain or trauma. It may also be part of the spectrum of specific rheumatic diseases such as rheumatoid arthritis or ankylosing spondylitis. Degenerative changes in the acromioclavicular joint or in tendons may contribute to shoulder pain.

Understanding the origins of shoulder pain requires knowledge of the complex anatomy of the shoulder joint. Most shoulder problems can be readily diagnosed from the patient's history, paying special attention to the points listed below, followed by an examination with emphasis on the site or sites of maximum tenderness and the movements that provoke pain. Estimated ranges of shoulder movement should be recorded to provide a gauge of progress with treatment.

Shoulder structures thar are often sites of localized nonarticular pain: 1) Roptator cuff tendons. 2)Greater tuberosity of the humerus with tendon attachment. 3)Subacromial bursa overlying rotator cuff. 4)Tendon of long head of biceps on anterior humerus.

History: 1)Was onset of pain associated with straain or trauma? Was onset sudden or gradual? 2)Where is the pain located? 3)What makes it worse (relation to movement)? 4)Is there pain at night?

Examinations: 1)Ranges of movement. 2)Painful areas (impringement);which movements provoke pain? 3)Point(s) of maximum tenderness.

In the absence of localized findings, one must consider sources of pain outside the shoulder girdle, such as referred pain from the neck or chest, which will require further investigation.

In typical cases of localized shoulder pain, radiographs are rarely necessary. When shoulder pain does not repond to the treatments recommended here, it would be timely to consider referral to a rheumatologist or orthopedist and to reconsider the diagnosis and the need for further study with expensive investigations such as arthrography, computed tomography or magnetic resonance imaging.

Rotator cuff tendinitis: This is the most common cause of localized shoulder pain, usually arising from small tears and inflammation of the rotator cuff tendons, particularly the supraspinatus, near their insertion into the greater tuberosity of the humerus.

The onset of pain may be spontaneous, especially in an older patient, but it may also be related to unusual or prolonged activity often with the arm raised and especially in people who are usually sedentary. Because the pain may arise several days after such activity, an association may be missed by the patient and the physician.

The pain, which is often surprisingly severe and incapacitating, is made worse by use of the arm and is worse when the patient is supine, resulting in loss of sleep and the inability to work. It may refer into the upper arm, causing the patient to insist that the problem is in the arm, not the shoulder.

Active shoulder movements, especially abduction, are restricted by pain. Inflammation of the tendon (or the overlying bursa) causes the typical "impingement sign," or "painful arc" on raising the shoulder as the inflamed and edematous tendon impinges on the undersurface of the acromion and coracoacromial ligament at approximately 90 degrees. There is localized tenderness at the insertion of the tendon on the greater tuberosity of the humerus, which is best demonstrated with the arm slightly extended posteriorly. The tenderness may disappear as the arm is flexed, or abducted.

Calcific tendinitis: This condition, which occurs in 8% of the population, is characterized by the deposition of calcium salts in the tendon and may be associated with calcific deposits in tendons elsewhere. However, the presence of calcium does not usually influence treatment decisions because calcification may exist in asymptomatic tendons. In other cases calcium deposits may provoke an acute inflammatory reaction accompanied by swelling, excruciating pain and exquisite tenderness resembling gout. In such cases radiographs may be helpful for diagnosis.

Tendinitis of the long head of biceps: The mechanism behind this disorder is similar to that for rotator cuff tendinitis because the long head of the biceps is subjected to the same strains as the rotator cuff tendons. Thus, the 2 conditions may occur concurrently. Tenderness is found in the bicipital groove on the anterior humerus. Pain is provoked by shoulder rotation and elevation and may be reproduced by supination of the forearm against resistance (Yergason's sign).

The tendon of the long head of the biceps may rupture occasionally, resulting in the "Popeye sign" caused by bunching up of the contracted biceps belly. This can occur spontaneously, without symptoms, but generally follows unusual strain in young patients.

Subacromial-subdeltoid bursitis: Clinically it is difficult to differentiate inflammation of the subacromial bursa from that of the underlying rotator cuff tendons, and isolated bursitis is probably rare. Onset is usually related to acute or chronic trauma or strain.

There is acute pain and associated tenderness on the lateral aspect of the shoulder, inferior to the tip of the acromion, sometimes with radiation distally and proximally. The impingement sign is present, and shoulder range is limited by pain. Septic bursitis is rare, but if there is unusual redness, swelling or increased warmth, sepsis should be considered, especially in the presence of predisposing factors such as injection drug use. In such cases aspiration and culture are mandatory.

Rotator cuff tendinitis: Tendinitis of the long head of biceps and subacromial bursitis usually respond to similar treatment. In all cases the following conservative measures should be applied, even if injection therapy is recommended. In mild or early cases these measures may provide relief as healing occurs.  A) Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used, though in my experience these provide only partial relief.  B) Analgesics may be helpful for pain control, especially at night.  C) Local ice packs and a sling may provide temporary relief of pain.  D)  Gentle mobilization exercises (not active resistance) may be performed.

Corticosteroid injection therapy is the most effective treatment for most localized inflammatory soft-tissue problems, particularly if used early and followed by the application of ice and mobilizing exercises. The key to effective therapy is to inject into the most tender sites. For the shoulder problems described here, a small amount of the mixture should be cautiously injected after the skin has been prepared. Once analgesia has been obtained, the entire tender area can be infiltrated with the remainder of the dose. It is not uncommon to relieve most of the pain immediately with the lidocaine, indicating that the diagnosis is probably correct and that the active ingredient has been correctly placed to achieve an anti-inflammatory effect. Some physicians prefer to infiltrate first with lidocaine as a therapeutic trial of intervention at a particular site, followed by corticosteroid if the local anesthesia gives a preliminary favourable response.

Local corticosteroids can produce side effects (e.g., local skin and subcutaneous atrophy, discoloration and postinjection pain), but these are uncommon and usually minimal. The risk of infection is minimal with adequate skin preparation and single-use needles and syringes. There may be increased risk of tendon rupture if the needle is not properly placed.

Mobilization exercises are important to prevent stiffening. For active people, referral to a physiotherapist may not be necessary as they can apply ice and carry out appropriate range-of-motion exercises at home with minimal instruction. However, in most cases, follow-up with a physiotherapist familiar with shoulder problems is the best management. Use of weights should be avoided until pain is relieved, then strengthening exercises should be pursued.

In rare cases surgical removal of large calcium deposits may be helpful. In resistant cases acromioplasty for impingement with an intact rotator cuff has been effective. Surgical repair of a ruptured long biceps tendon is not usually indicated because the defect does not significantly compromise function and the patient may be unaware of it. However, acute ruptures in young patients may be amenable to surgical repair.

Frozen shoulder (chronic adhesive capsulitis): A "frozen shoulder" with reduced active and passive range of motion and diffuse shoulder pain occurs when shoulder pain from tendon inflammation or bursitis is prolonged and mobilization is not pursued. This may also be a result of other conditions associated with immobilization of the shoulder, such as strokes. However, the exact cause is not always clear. Localized tenderness is less marked. Without treatment, muscle atrophy or secondary involvement of the hand with reflex sympathetic dystrophy may occur.

The mainstay of treatment is active mobilizing physiotherapy. At times subacromial or intra-articular corticosteroid instillation may be helpful, but the response is not as dramatic as in the acute phase. Most cases resolve over 12-24 months.

Most patients with these types of shoulder pain respond to the conservative measures described for tendinitis. Recalcitrant cases may require surgical treatment.

Rotator cuff tear: In younger people spontaneous tears of the rotator cuff are rare in the absence of underlying disease and are usually associated with trauma, such as a fall. However, in those over 40 years of age even minor strain may produce a cuff tear. Detection of a small or partial cuff tear, as opposed to tendon inflammation, is difficult. In these cases treatment is the same as for rotator cuff tendinitis. Tears should be suspected if symptoms persist despite treatment or in the presence of abductor weakness. The diagnosis may involve ultrasonography, magnetic resonance imaging or arthrography, and surgical repair may be necessary to relieve symptoms.

Elbow: Epicondylitis probably results from cumulative traumatic overuse leading to minute tears and inflammation of the common extensor or common flexor tendons of the forearm, near their origins at the lateral and medial epicondyles respectively. Pain and tenderness at the entheses is common. This condition often occurs in people active in sports, hence the terms "tennis elbow" for lateral epicondylitis and "golfer's elbow" for medial epicondylitis. However, the condition is common in nonathletes and may be associated with occupations such as carpentry and bricklaying.

Swelling is not a usual feature and, if present, should suggest some other pathology. The differential diagnosis of posterior interosseous nerve entrapment as a cause of forearm pain may be excluded if there is no indication of neurologic involvement (e.g., numbness or motor weakness). Radiographs are not usually needed for diagnosis; although a small area of calcification at the tendinous attachment may be present, radiographs are usually normal.

In the treatment of epicondylitis:  I)  NSAIDs may be tried but they are often not helpful.  II)  Many cases respond if precipitating or aggravating activities are avoided, the area is iced and a forearm Tensor bandage ("tennis elbow brace") is placed distal to the epicondyle.  III)  For those who do not respond, corticosteroid and lidocaine injection is the treatment of choice. Using a #25-gauge 5/8-inch needle, the mixture is carefully and slowly injected into the area of maximum localized tenderness. If relief is not immediate, the injection was incorrectly sited and may have to be repeated at a later date.

Treatment must be followed by rest for the elbow and avoidance of aggravating activities, such as sports, for at least 2 weeks, followed by a gradual return to normal activities. The use of a forearm Tensor bandage or a fitted elbow splint may assist the healing process and relieve pain. If relief is incomplete, a second injection may be required in about 4 weeks. A third injection is seldom necessary. When the pain has resolved, muscle stretching and strengthening exercises should be carried out to prevent recurrence.

IV) Surgical consultation is indicated only rarely in resistant cases. Surgical treatment may be necessary in patients with symptoms that are refractory for more than 6-12 months.

Olecranon bursitis: With olecranon bursitis the bursa overlying the olecranon process becomes enlarged and tender. Inflammation may result from a direct blow or from repeated irritation caused by leaning on the elbow. It may also be secondary to other conditions, such as gout or rheumatoid arthritis, or may result from infection if there has been a site of entry for bacteria.

The bursa should be aspirated and, once infection has been excluded, a corticosteroid should be injected into the sac. Septic bursitis requires repeated needle aspiration and appropriate antibiotic treatment. Surgery is rarely required for recalcitrant, recurrent episodes.

Wrist and hand;de Quervain's tenosynovitis;Tenosynovitis of the common sheath of the abductor pollicis longus and extensor pollicis brevis tendons on the radial aspect of the wrist  is a common painful and disabling condition. Pain is felt on the radial aspect of the wrist and may extend proximally into the forearm. It is usually caused by unusual or repeated use of the thumbs involving strain on the tendons. It may occasionally be associated with calcific deposits, although the cause cannot always be identified.

Diagnosis is by demonstration of localized tenderness of the common sheath where it crosses the radial styloid and, distally, radial to the anatomical snuff-box. Finkelstein's test should be performed by having the patient place the thumb in the palm and then clench the fist so that the fingers cover the thumb. Passive ulnar deviation of the wrist (carried out by the examiner) stretches the abductor pollicis longus and extensor pollicis brevis tendons and reproduces the pain over the ulnar side of the wrist. There may be swelling of the tendon sheaths in the distal forearm.

A splint should be used to immobilize the thumb and first metacarpal, and a small amount of corticosteroid and lidocaine mixture should be injected into the tendon sheath. Proper splinting can only be achieved with a customized splint made by an occupational therapist. Surgery is occasionally required.

Digital flexor tenosynovitis (trigger finger): Inflammation of the digital flexor tendons in the palm, usually from overuse, results in the thickening of and formation of nodules on the tendon and sheath. Flexion is unimpaired, but attempted extension causes painful snapping and locking as the enlarged tendon enters the inflamed sheath. One can usually feel localized, tender thickening of the tendon on palpation. The possibility of other causes such as rheumatoid arthritis or, rarely, infection or tumour should be borne in mind.

Treatment is by infiltration of a corticosteroid and lidocaine mixture into the tendon sheath. Injection directly into the tendon can be avoided by using only light injection pressure and asking the patient to flex the finger with the needle in place, which should not move the needle. Those unfamiliar with this technique should consider referring the patient to a specialist for injection. Spontaneous improvement frequently occurs with rest, and injection is not always necessary.

Extensor tenosynovitis at the wrist: Inflammation and swelling of digital extensor tendons and their sheaths is commonly seen in people with rheumatoid arthritis and may result in tendon rupture. Inflammation may cause the "tuck sign" as the painless swelling bunches up on the dorsum of the wrist with active finger extension.  This condition usually responds to treatment of the underlying condition, splinting and, if indicated, a corticosteroid injection.

Hip;Trochanteric bursitis and gluteal tendinitis: Irritation of the bursa about the greater trochanter and gluteal insertions is a common cause of lateral hip pain and localized tenderness. The onset may be insidious and the cause not always apparent, but direct trauma or strain of the gluteal attachments from unusual gait patterns caused by other musculoskeletal problems, such as back pain or hip joint pain, may contribute to this condition.

Pain is felt laterally, with distal radiation to the lateral aspect of the thigh toward the knee. Pain is worse when sitting in a deep chair and at night when lying on the affected side. Hip motion is retained, although external rotation and resisted abduction usually increase the pain. Tenderness can be localized to the bursal region overlying the greater trochanter. Swelling and warmth are uncommon.

With the patient lying on the unaffected side, wide infiltration is performed with a corticosteroid and lidocaine mixture into the site of tenderness using a needle that is at least 111/42 inches long. This is usually curative; ice may also be helpful. Correction of leg-length inequality with a shoe lift may be tried. Stretching exercises are indicated when there is a clear relation to a particular exercise (e.g., jogging). Surgical release of tight fascia or removal of a chronic inflamed bursa is rarely indicated.

Knee;There are several bursas around the knee that may become inflamed and painful. Two of these are described here: Prepatellar bursitis ("house maid's knee"): This condition is usually traumatic in origin and may be seen as a form of septic bursitis. Examination reveals a fluctuant swelling localized to the bursa lying anterior to the patella. There may be increased warmth and redness. Knee-joint motion is unimpaired and painless, indicating that the joint space is not involved. Aspiration is essential to rule out infection.

Treatment in noninfected cases includes a corticosteroid injection (after aspiration) and the application of a firm compressive dressing. Recurrence is common and can be prevented by avoiding the causal activity or by using padding on the knee. Recalcitrant cases may require surgical excision of the bursa.

Anserine bursitis: The anserine bursa lies deep in relation to the tendons of sartorius, gracilis and semitendinosus as they insert on the medial aspect of the proximal tibia, just distal to the joint line. Acute inflammation of the bursa may occur with athletic activities, such as jogging or skiing, and result in medial knee-joint pain. It is often present in "flare-ups" of osteoarthritis of the knee. Stair climbing is especially painful, and there is localized tenderness, which is sometimes accompanied by swelling of the bursa with increased warmth on palpation.

The patient should be cautioned to avoid the initiating activity and should be treated with ice and corticosteroid and lidocaine injection. Once the acute phase has passed, appropriate stretching and conditioning exercises of the knee extensors should prevent recurrence.

Ankle and foot;Achilles tendinitis: Pain associated with swelling and tenderness of the Achilles tendon at or near its attachment to the calcaneus is often seen with chronic strain resulting from recreational athletics. It may be associated with underlying spondyloarthropathy, such as ankylosing spondylitis, psoriatic arthritis or reactive arthritis, but rarely with gout; thus, all patients with this condition should be examined to rule out associated systemic diseases. The examiner must always bear in mind the possibility of tendon rupture and should be familiar with Thomson's test ;with the patient supine or kneeling on a chair and the foot extending over the end of the bed or chair, the examiner squeezes the calf and pushes toward the knee; this produces plantar flexion of the foot if the tendon is intact, but not if it has ruptured. Suspected rupture can be confirmed with magnetic resonance imaging.

The mainstay of treatment is the use of a heel lift in the shoe and avoiding any irritating activity. Once pain free, the patient should follow a program of gastrocnemius-soleus stretching and strengthening. Injections are generally not recommended because of the possibility of tendon rupture.

Plantar fasciitis and heel pain: Heel pain is a frequent complaint in medical practice and can be frustrating to treat. With plantar fasciitis there is disabling plantar heel pain, which is worse with weight bearing and usually most severe during the first few steps after rising in the morning. Tenderness is typically located over the plantar aspect of the medial calcaneal tuberosity (site of attachment of the plantar fascia). There may or may not be a calcaneal spur, but this is not an important finding in most cases. Sometimes the plantar fascia anterior to the heel may be tender. Plantar fasciitis may be a clinical clue to the presence of an underlying spondyloarthropathy.

Time often relieves this condition, and use of a soft silicone heel pad with a gel insert may be all that is required. However, when disability is pronounced, injection of the tender spot with a corticosteroid and lidocaine mixture, using a medial or lateral approach to avoid heel fat-pad atrophy, can result in rapid cure. This should be followed by the use of an impact-absorbing heel insert.

Rheumatic Diseases:
Case 1: A 29-year-old woman consults her physician 2 months after the birth of her second child because she woke one morning with pain and swelling in her wrists, small joints of the hands, knees, ankles and balls of the feet. She is stiff for an hour after arising and is extremely fatigued but has no other associated symptoms or preceding illnesses. She had reported similar, milder symptoms after her first pregnancy, but the joint pains and stiffness disappeared after 1 month of ibuprofen (400 mg, 4 times daily) treatment. Blood tests reveal a high level of rheumatoid factor and antinuclear antibodies.
Case 2: A 69-year-old woman reports that in the year since her last checkup she has had progressive pain in the joints of her fingers, at the base of her thumbs and in her knees, and she has bunions. The pain is worse with activity. She has had minimal (20 min) morning stiffness and no joint swelling, although the small joints of her fingers and the bunions have been developing increasing deformities with deviations and bony enlargements. She recalls that her mother had gnarled fingers at an older age. Her complete blood count and erythrocyte sedimentation rate (11 mm/h) are normal.
Case 3: A 40-year-old father of 3 has recently become unable to work as a construction worker because of chronic low-back pain and stiffness, which began when he was in his early 20s. He consults his physician for the first time because his livelihood is in jeopardy. Recently, his thoracic spine between the shoulder blades has been stiff, his shoulders have been painful and 1 knee has been swollen. Otherwise, he is well and blood tests are normal.
Case 4: A 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 by activity. She has some morning stiffness but denies swollen joints. In addition, she has progressively marked fatigue and episodic diarrhea, alternating with constipation. She now feels unable to work because of pain and fatigue. Blood tests and radiographs of her lumbar spine are normal.
1) The 29-year-old woman has recurrent (suggesting chronicity), inflammatory, symmetrical 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 of rheumatoid arthritis.
2) The 69-year-old woman has chronic, noninflammatory joint pains in the pattern of joints typically seen with osteoarthritis, without extra-articular features. The diagnosis is primary generalized osteoarthritis.
3) The 40-year-old man has chronic, inflammatory, asymmetric, large-joint oligoarthritis with inflammatory spine involvement compatible with a diagnosis of ankylosing spondylitis.
4) The 50-year-old school teacher has chronic, generalized, noninflammatory, nonarticular musculoskeletal complaints typical of fibromyalgia syndrome. In addition, she has described irritable bowel syndrome, which is common in patients with fibromyalgia.
In summary, musculoskeletal problems are the second-most common complaint for which medical attention is sought at the primary care level. By following the 5 basic steps described here, a physician can arrive at a rheumatologic diagnosis that is precise enough to serve as the basis for further investigations and treatment.
These cases demonstrate the diversity of rheumatic diseases and their potential impact on society. Rheumatology is not synonymous with geriatric medicine - people of all ages can be affected. Some diseases are inflammatory and some are not.
For inflammatory causes of arthritis especially, prompt diagnosis and the early initiation of appropriate treatment is increasingly recognized as the standard of care that is required. Appropriate early treatment may alter the course of many of the systemic inflammatory disorders so that damage, disability and the incidence of premature death are reduced. Some rheumatic disorders are curable, while others can enter a long-term remission with the appropriate treatment.
Musculoskeletal complaints are among the most common reasons people seek medical attention from a primary care physician and are the number 1 cause of long-term disability and inability to work. Many rheumatic disorders strike people in their most productive years. Yet, of all organ-system disorders, many physicians report that they feel the least comfortable treating musculoskeletal complaints.
The diagnosis of rheumatic disease is based primarily on the patient's history and physical examination. Sophisticated serologic tests can support a clinical diagnosis, but more often they mislead the unwary; if the serology does not match, the clinical impression prevails. Similarly, imaging only supports or confirms the clinical impression. Tests will often be normal early in the course of a rheumatic disease, as illustrated in 3 of the 4 cases previously described.
After completing a thorough musculoskeletal history and physical examination, the physician can focus on a limited differential diagnosis. To evaluate joint pain and arrive at 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 non articular?
The first and most important step in making a musculoskeletal diagnosis is to determine if a complaint of "joint pain" is truly an articular (or joint) problem or if the problem is actually in the tissues surrounding the joint.
An articular problem usually indicates arthritis of some sort. Exceptions to this include nonarthritic intra-articular problems such as a meniscal injury in the knee, an intra-articular loose body, intra-articular fractures (including avascular necrosis of the bone), hemarthroses and extremely rare joint tumours.
Nonarticular problems, which arise from the surrounding structures, include bursitis, tendinitis, enthesitis (inflammation at sites of ligament and tendon attachment to bone), ligament injuries and muscle problems, including fibromyalgia.
To differentiate between articular and nonarticular problems, the physician should begin by asking the patient to identify the exact site of pain by pointing to the painful area. This is particularly helpful in assessing complaints of what a patient will call "hip pain" or "ankle pain."
 When complaining of hip pain, most patients are actually experiencing a nonarticular hip problem and, when asked, will point to the region of the greater trochanter (trochanteric bursitis or fibromyalgia tender point) or the buttock (often a low-back disorder).
A true hip-joint problem causes anterior groin pain. True ankle-joint pain is felt along the anterior tibiotalar joint line. Most patients with Achilles tendinitis or medial or lateral malleolar pain will complain of ankle pain, but will point to 1 of these nonarticular structures 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 joint problem will describe pain or restriction for all ranges of motion tested in the specific joint and will describe reaching the limit of joint motion as the most painful (often called stress pain).
A patient with a nonarticular problem will describe pain or restriction for only some of the ranges of motion of that particular joint, and reaching the limit of the range may not necessarily be associated with the most pain.  This information is especially helpful in evaluating a painful shoulder - a joint that has many periarticular structures (e.g., bursas, rotator cuff and other tendons and prominent periarticular muscles).
A patient with true glenohumeral joint arthritis will describe pain or restriction in all ranges of motion of the shoulder (i.e., elevation, abduction, adduction, internal rotation and external rotation) and will describe the pain as most severe on reaching the limits of motion.
A patient with a periarticular shoulder problem (e.g., subacromial bursitis or tendinitis of 1 of the rotator cuff tendons) will describe pain or restriction on performing some shoulder motions, especially abduction (the so-called "painful arc") and usually internal rotation, but external rotation will be normal.
Some shoulder periarticular problems will be associated with the most pain through the midrange of motion, and the pain will ease off as the limits of joint range are reached. For example, supraspinatus tendinitis will cause pain on arm abduction between approximately 60 and 120, but at full elevation the pain will actually decrease.
Physical examination is also important in differentiating articular from nonarticular pain. True joint pathology is described as producing a capsular or articular pattern in the reduction of passive joint ranges of motion (i.e., the passive ranges of motion of the particular joint being examined are reduced approximately equally).
Nonarticular problems produce a noncapsular or nonarticular pattern in the reduction of passive ranges of motion of the joint (i.e., 1 or several of that joint's ranges of motion are reduced much more than others). The only exceptions to this rule are the glenohumeral joints and hip joints.
In the glenohumeral joint an early or mild capsular pattern, a true joint problem, will reduce external rotation before other passive ranges of motion in the joint. In the hip joint, however, internal rotation will be reduced before other passive ranges of motion.
The second most important step in arriving at a correct diagnosis that will form the basis of treatment is determining if the disorder is inflammatory or noninflammatory. A patient with inflammatory articular problems will have a history of 1 or all of the following: joint swelling, warmth and, on the rare occasion, redness (e.g., a septic joint is red, but a rheumatoid joint is not).
These signs are not associated with noninflammatory articular problems. An inflamed joint will be stiff in the morning for at least 30 minutes and after periods of rest during the day (gelling); noninflammatory forms of arthritis such as osteoarthritis will not be associated with morning 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 noninflammatory condition, fibromyalgia, which is associated with widespread nonarticular pain in bones, muscles, joints, neck and back; normal ranges of motion; exacerbation of pain with exercise, especially after exercise; and nonrestorative sleep disorder.
For reasons that are not understood, some patients with fibromyalgia report significant durations of morning stiffness or stiffness that persists all day. A nonarticular problem might be described as swollen, hot or red (e.g., septic olecranon or prepatellar bursitis) but not stiff. 
The third step in evaluating a joint disorder is to determine whether the problem is acute (< 6 weeks in duration) or chronic (> 6 weeks duration). The main causes of acute inflammation of the joint include septic arthritis, injury (hemarthroses) and crystal arthritis. Any of the chronic forms of arthritis might also result in an acutely inflamed joint, but the chronic forms would be considered only after excluding sepsis, injury and crystal arthritis. The diagnostic factors to be considered in an acute inflammatory nonarticular problem (e.g., bursitis, tendinitis) are similar to those for acute arthritis.
Chronic inflammatory arthritis, bursitis, tendinitis and enthesitis support a diagnosis of 1 of the chronic systemic inflammatory disorders (i.e., rheumatoid arthritis, 1 of the seronegative spondyloarthropathies, 1 of the crystal arthropathies or a connective tissue disorder). Noninflammatory joint problems (e.g., osteoarthritis) are usually chronic in nature.
The fourth step in evaluating a joint complaint is to determine the pattern of the joints affected - their symmetry, size and number - and whether the axial skeleton is involved. Are the affected joints symmetrically involved (e.g., is there arthritis in both wrist joints 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 involvement of 1 joint, oligoarticular, to the involvement of 2-4 joints, and polyarticular is used when 4 or more are affected. Is the axial skeleton (thoracic spine, lumbar spine, sacroiliac joints or anterior costochondral joints) affected?
Determining whether the condition is articular or nonarticular, inflammatory or noninflammatory, and acute or chronic and assessing the pattern of the joints involved will provide a detailed description of the musculoskeletal problem that can stand alone as the diagnosis or may facilitate a more specific one. For example, the patient may have a chronic, inflammatory, symmetrical, small-joint polyarthritis.
The most common rheumatic diseases fitting this description, and the most likely specific diagnoses, are rheumatoid arthritis, psoriatic arthritis or 1 of the connective tissue disorders. If the patient has a chronic, inflammatory, asymmetrical, large-joint polyarthritis with inflammatory spine involvement, the diagnosis is most probably 1 of the seronegative spondyloarthropathies, whereas a chronic, inflammatory, asymmetrical, small-joint oligoarthritis strongly suggests a diagnosis of psoriatic arthritis.
The pattern and type of joints involved will also help the physician arrive at a specific rheumatologic diagnosis. Osteoarthritis commonly affects the proximal and distal interphalangeal joints of the fingers and the first carpometacarpal joints in the hands but rarely involves the metacarpophalangeal joints, wrists, elbows or ankles. Chronic, inflammatory polyarthritis involving the metacarpophalangeal joints in the hands, wrists, elbows or ankles is typical of rheumatoid arthritis, psoriatic arthritis or 1 of the connective tissue disorders.
In arriving at a specific rheumatologic diagnosis, the physician should also proceed through a review of systems to determine whether there are any extra-articular symptoms or signs associated with the joint problem. A collection of certain features (a syndrome) in association with the appropriate musculoskeletal description, will confirm the diagnosis of the rheumatic condition.
In isolation, many of these extra-articular manifestations do not indicate a specific diagnosis; it is when several of these features are present together that a more specific syndrome can be recognized. The physician must specifically ask for this information because patients do not usually volunteer it.
Many patients complain of dry eyes or mouth. True xero-ophthalmia may be present when the patient can no longer wear contact lenses because of dry eyes, continues to have dry eyes when they stop wearing contact lenses, wakens through the night or in the morning with dry eyes and has sought the use of artificial tears.
The patient should be sent to an ophthalmologist for a Schirmer's test or Rose-Bengal test if it is necessary to document dry eyes.True xerostomia (dry mouth) may be present if the patient is no longer able to eat or swallow dry foods without fluids. Often the patient will need to carry water or keep water at the bedside at night. Physical examination of the mouth is usually normal until xerostomia is advanced.
Hair loss is probably significant if the pillowcase is covered with hair in the morning. To determine the extent of the problem patients can be asked to count the number of hairs lost per day; more than 200 is considered significant hair loss.
Patients should be questioned about and examined for oral and nasal ulcerations. A physical examination is required because, although some ulcers can be very painful, others may be painless. If the patient has been experiencing intermittent ulcerations throughout life and there has been no change in frequency or severity, the ulcerations are probably not significant.
However, if the ulcerations are of recent onset, occur in outbreaks or clusters in the absence of any precipitant and occur frequently (i.e., more than once monthly), they are probably significant and could be associated with a rheumatic disease.
Patients with systemic lupus erythematosus may experience malar erythema that is flat or raised but not pustular; malar erythema with pustules is typical of the common rash, acne rosacea. A systemic lupus erythematosus malar rash usually involves the cheeks and the bridge of the nose but spares the nasolabial folds, while acne rosacea involves the nasolabial folds. Both are often photosensitive.
A significant photosensitive rash is usually an erythematous, 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 to subside once out of the sun and is often reported to be pruritic but is tender when scratched.
Raynaud's phenomenon occurs in about 8% of women. It is probably significant if the onset is recent (within the past 2 years), it involves 1 or several digits at a time but not all digits at the same time, and it occurs on exposure to either mildly cold temperatures or at any time unrelated to cold exposure.
Raynaud's phenomenon is pathologic if there are associated digital ulcerations, digital pitting scars or digital tuft loss. Although classic Raynaud's phenomenon is 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 are common in the rheumatic diseases but are not specific for the rheumatic diseases, a few findings are characteristic (pathognomic) of rheumatic disease. Nail-fold infarctions are tiny, painful black dots in the periungual areas and indicate the presence of small-vessel vasculitis. They are particularly common in rheumatoid arthritis but might also be seen in systemic lupus erythematosus or in 1 of the vasculitic disorders.
Rheumatoid nodules are nontender, nonerythematous, mobile, subcutaneous nodules that usually occur around joints or on pressure areas; they are also vasculitic lesions and occur commonly in severe rheumatoid arthritis, but may also be seen in the connective tissue diseases, especially systemic lupus erythematosus.
Gouty tophi, which are pathognomic for gout, can resemble rheumatoid nodules and are often in the same locations as rheumatoid nodules (except gouty tophi can occur on the helix of the ears). Sclerodactyly (i.e., thickening of the skin distal to the metacarpophalangeal joints of the hands or the metatarsalphalangeal joints of the feet so that the skin cannot be pinched by the examiner) usually indicates the presence of connective tissue disease, specifically, systemic sclerosis, CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias) syndrome or mixed connective tissue disease but may also occur rarely after exposure to certain antineoplastic agents or in hematologic malignancies.
Summary: Rheumatic diseases are diverse, affect people of all ages and have a significant impact on society. Musculoskeletal problems are the number 1 cause of long-termMusculoskeletal problems are the number 1 cause of long-term disability in Canada and the second-most common reason people consult a primary care physician. Early diagnosis and treatment can alter the course of many of these diseases, particularly the most severe.
Diagnosis of rheumatic disease is based primarily on the patient's history and physical examination. Once the patient has identified the exact site of the pain the physician should determine if the conditions is: Articular or nonarticular. To determine this the active and passive ranges of motion of the affected joints should be evaluated. Inflammatory or noninflammatory. This will form the the basis of treatment. Acute or chronic.
The pattern of joint involvement will help the physician arrive at a specific rheumatologic diagnosis. The patient should also be examined for extra-articular features that are often associated with the common rheumatologic diseases; these may lead the physician to a more specific diagnosis.

In November of 1975,Polly Murray made an appointment to see Dr. Allen Steere,a Yale University medical scientist. She was a mother of four living in Lyme,Connecticut,and for 10 years she had been experiencing mysterious and unexplained symptoms,recurring fatigue,depression,weight loss and low grade fever. Several times she had attacks of joint pain and swelling.
She had been examined by many doctors but were unable to explain her symptoms. It had even been suggested that her problem was mental. But in the months before her appointment with Dr. Steere,Mrs. Murray's husband and two of her children developed similar symptoms. She asked around,and discovered others in her community who seem to be affected. By the time she met Dr. Steere she had a list of 35 people who had been variously diagnosed with infectious arthritis,systemic lupus erythematosus,rheumatoid arthritis and juvenile rheumatoid arthritis. She was convinced that all had the same condition and it was due to exposure to some common agent.
Dr. Steere believed Mrs. Murray,and within several months had identified,in Lyme and in two nearby communities,a total of 39 children and 12 adults who appeared to be suffering from some form of epidemic arthritis. The observation that most cases came on in the summer months,and that for many the arthritis had been preceded by a rash resembling one seen in Europe to be caused by a tick bite,pointed the search in the right direction the story unfolded slowly but by 1981 it was evident that it was Lyme disease.
Lyme disease is an inflammatory disorder begun by receiving a bite from a tick that is infected by a bacteria -B.burgdorferic-Ixodes scapularis most common in the northeast and midwest-U.S.-also found in the south and southeast-Ixodes pacificus is found on west coat but it is rare-these ticks are similar in appearance and usually carried by the deer.
There are 3 separate stages of Lyme disease. Each has different symptoms. In the first stage a skin rash may appear at the site of the tick bite. The area may feel hot to the touch,but usually it is not painful. The rash grows in size over time. The rash may develop anywhere ,from a few days,to a month,after the tick bite. Thirty % of people who develop Lyme disease do not get this rash. Fatigue,headaches,fever,chills,aching joints and muscles (arthritis),and skin sores or rashes often appear during the second stage. In the third stage ,Lyme disease may spread to affect areas of the body like the heart and the nervous system,if undetected.
While cases have been reported from most states and provinces in North America,the majority of cases occur in just a few in Canada. The greatest number (couple hundred ) have been found in Ontario. Some of the other provinces have reported no Lyme disease. Lyme disease occurs widely in Europe,parts of Asia and Australia.
In North America it is most common in northeast and northcental regions,and least found on the west coast. Those people that frequent deer or in areas where deer are found have to be cautious. Lyme disease (tick bite ) is carried by deers.