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INTRODUCTION

Musculoskeletal complaints are extremely common in outpatient medical practice and are among the leading causes of disability and absenteeism from work. Pain in the joints must be evaluated in a uniform, thorough, and logical fashion to ensure the best chance of accurate diagnosis and to plan appropriate follow-up testing and therapy. Joint pain and swelling may be manifestations of disorders affecting primarily the musculoskeletal system or may reflect systemic disease.

INITIAL ASSESSMENT OF A MUSCULOSKELETAL COMPLAINT

  1. Articular versus nonarticular (See Fig. 53-1). Is the pain located in a joint or in a periarticular structure such as soft tissue or muscle?

  2. Inflammatory versus noninflammatory. Inflammatory disease is suggested by local signs of inflammation (erythema, warmth, swelling); systemic features (morning stiffness, fatigue, fever, weight loss); or laboratory evidence of inflammation (thrombocytosis, elevated ESR or C-reactive protein).

  3. Acute (≤ 6 weeks) versus chronic.

  4. Localized versus systemic.

FIGURE 53-1

Algorithm for the diagnosis of musculoskeletal complaints. An approach to formulating a differential diagnosis (shown in italics). CMC, carpometacarpal; CRP, C-reactive protein; DIP, distal interphalangeal; ESR, erythrocyte sedimentation rate; JA, juvenile arthritis; MCP, metacarpophalangeal; MTP, metatarsophalangeal; PIP, proximal interphalangeal; SLE, systemic lupus erythematosus.

HISTORIC FEATURES

  • Age, sex, race, and family history

  • Symptom onset (abrupt or gradual), evolution (chronic constant, intermittent, migratory, additive), and duration (acute versus chronic)

  • Number and distribution of involved structures: monarticular (one joint), oligoarticular (2–3 joints), polyarticular (>3 joints); symmetry

  • Other articular features: morning stiffness, effect of movement, features that improve/worsen Sx

  • Extraarticular Sx: e.g., fever, rash, weight loss, visual change, dyspnea, diarrhea, dysuria, numbness, weakness

  • Recent events: e.g., trauma, drug administration, travel, other illnesses

PHYSICAL EXAMINATION

Complete examination is essential: particular attention to skin, mucous membranes, nails (may reveal characteristic pitting in psoriasis), eyes. Careful and thorough examination of involved and uninvolved joints and periarticular structures; this should proceed in an organized fashion from head to foot or from extremities inward toward axial skeleton; special attention should be paid to identifying the presence or absence of:

  • Warmth and/or erythema

  • Swelling

  • Synovial thickening

  • Subluxation, dislocation, joint deformity

  • Joint instability

  • Limitations to active and passive range of motion

  • Crepitus

  • Periarticular changes

  • Muscular changes including weakness, atrophy

LABORATORY INVESTIGATIONS

Additional evaluation usually indicated for monarticular, traumatic, inflammatory, or chronic conditions or for conditions accompanied by neurologic changes or systemic manifestations.

  • For all evaluations: include CBC, ESR, or C-reactive protein

  • Where there are suggestive clinical features, include: rheumatoid factor, ANA, antineutrophilic cytoplasmic antibodies (ANCA), antistreptolysin O titer, Lyme antibodies

  • Where systemic disease is present or suspected: renal/hepatic function tests, UA

  • Uric acid: useful only when gout diagnosed and therapy contemplated

  • CPK, aldolase: consider with muscle pain, weakness

  • Synovial fluid aspiration and analysis: always indicated ...

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