Chapter 165: Other Musculoskeletal Disorders

Both peripheral and axial arthritis may be associated with the inflammatory bowel diseases (IBD) of ulcerative colitis or Crohn's disease. The arthritis can occur after or before the onset of intestinal symptoms. Peripheral arthritis is episodic and asymmetric; it most frequently affects knee and ankle. Attacks usually subside within several weeks and characteristically resolve completely without residual joint damage. Enthesitis (inflammation at insertion of tendons and ligaments into bone) can occur with manifestations of "sausage digit," Achilles tendinitis, and plantar fasciitis. Axial involvement can manifest as spondylitis and/or sacroiliitis (often symmetric). Laboratory findings are nonspecific; rheumatoid factor (RF) absent; HLA-B27 is positive in 70% with IBD and axial disease but <15% with IBD and peripheral arthritis; radiographs of peripheral joints usually normal; axial involvement is often indistinguishable from ankylosing spondylitis.

WHIPPLE'S DISEASE

Characterized by arthritis in up to 75% of pts that usually precedes appearance of other symptoms. Usually oligo- or polyarticular, symmetric, transient but may become chronic. Joint manifestations respond to antibiotic therapy.

Also known as Charcot's joint, this is a severe destructive arthropathy that occurs in joints deprived of pain and position sense; may occur in diabetes mellitus, tabes dorsalis, syringomyelia, amyloidosis, spinal cord or peripheral nerve injury. Distribution depends on the underlying joint disease. Joint effusions are usually noninflammatory but can be hemorrhagic. Radiographs can reveal either bone resorption or new bone formation with bone dislocation and fragmentation.

An idiopathic disorder characterized by recurrent inflammation of cartilaginous structures. Cardinal manifestations include ear and nose involvement with floppy ear and saddlenose deformities, inflammation and collapse of tracheal and bronchial cartilaginous rings, and asymmetric episodic nondeforming polyarthritis. Other features can include scleritis, conjunctivitis, iritis, keratitis, aortic regurgitation, glomerulonephritis, and other features of systemic vasculitis. Onset is frequently abrupt, with the appearance of 1–2 sites of cartilaginous inflammation. Diagnosis is made clinically and may be confirmed by biopsy of affected cartilage.

Syndrome consisting of periosteal new bone formation, digital clubbing, and arthritis. Most commonly seen in association with lung carcinoma but, also occurs with selected chronic lung or liver disease; congenital heart, lung, or liver disease in children; and idiopathic and familial forms. Symptoms include burning and aching pain most pronounced in distal extremities. Radiographs show periosteal thickening with new bone formation of distal ends of long bones.

A common disorder characterized by chronic widespread musculoskeletal pain, aching, stiffness, paresthesia, disturbed sleep, and easy fatigability along with multiple tender points. More common in women than in men. Diagnosis is made clinically; evaluation reveals soft tissue tender points but no objective joint abnormalities by examination, laboratory, or radiograph.

Clinical syndrome characterized by aching and morning stiffness in the shoulder girdle, hip girdle, or neck for >1 month, elevated ESR, and rapid response to low-dose prednisone (10–20 mg qd). Rarely occurs before age 50; more common in women. PMR can occur in association with giant cell arteritis, which requires treatment with higher doses of prednisone. Evaluation should include a careful history to elicit symptoms suggestive of giant cell arteritis (Chap. 159); ESR; laboratory test results to rule out other processes usually include RF, ANA, CBC, CPK, serum protein electrophoresis; and renal, hepatic, and thyroid function tests.

Caused by death of cellular elements of bone, believed to be due to impairment in blood supply. Frequent associations include glucocorticoid treatment, connective tissue disease, trauma, sickle cell disease, embolization, alcohol use, and HIV disease. Commonly involved sites include femoral and humeral heads, femoral condyles, and proximal tibia. Hip disease is bilateral in >50% of cases. Clinical presentation is usually the abrupt onset of articular pain. Early changes are not visible on plain radiograph and are best seen by MRI; later stages demonstrate bone collapse (“crescent sign”), flattening of articular surface with joint space loss. Osteonecrosis of the jaw is a rare occurrence associated with cancer treatments (including radiation), infection, glucocorticoids, or bone antiresorptive therapies.

BURSITIS

Inflammation of the thin-walled bursal sac surrounding tendons and muscles over bony prominences. The subacromial and greater trochanteric bursae are most commonly involved.

TENDINITIS

May involve virtually any tendon but frequently affects tendons of the rotator cuff around shoulder, especially the supraspinatus. Pain is dull and aching but becomes acute and sharp when tendon is squeezed below acromion.

CALCIFIC TENDINITIS

Results from deposition of calcium salts (primarily hydroxyapatite) in tendon, usually supraspinatus. The resulting pain may be sudden and severe.

ADHESIVE CAPSULITIS ("FROZEN SHOULDER")

Results from conditions that enforce prolonged immobility of shoulder joint. Shoulder is painful and tender to palpation, and both active and passive range of motion is restricted.