2216

SECTION 3 DISORDERS OF THE JOINTS AND ADJACENT TISSUES

393
ARTICULAR VERSUS NONARTICULAR
Approach to Articular and 5IF
NVTDVMPTLFMFUBM
FWBMVBUJPO
NVTU
EJTDSJNJOBUF
UIF
BOBUPNJD

Musculoskeletal Disorders PSJHJO T

PG
UIF
QBUJFOUT
DPNQMBJOU
'PS
FYBNQMF
BOLMF
QBJO
DBO
SFTVMU

GSPN
B
WBSJFUZ
PG
QBUIPMPHJD
DPOEJUJPOT
JOWPMWJOH
EJTQBSBUF
BOBUPNJD

John J. Cush TUSVDUVSFT
JODMVEJOH
HPOPDPDDBM
BSUISJUJT
DBMDBOFBM
GSBDUVSF
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UFOEJOJUJT
QMBOUBS
GBTDJJUJT
DFMMVMJUJT
BOE
QFSJQIFSBM
PS
FOUSBQNFOU

OFVSPQBUIZ
%JTUJOHVJTIJOH
CFUXFFO
BSUJDVMBS
BOE
OPOBSUJDVMBS
DPOEJ-
.VTDVMPTLFMFUBM
DPNQMBJOUT
BDDPVOU
GPS

NJMMJPO
PVUQBUJFOU

UJPOT
SFRVJSFT
B
DBSFGVM
BOE
EFUBJMFE
FYBNJOBUJPO
"SUJDVMBS
TUSVDUVSFT

WJTJUT
QFS
ZFBS
BOE
PWFS

PG
BMM
PVUQBUJFOU
WJTJUT
JO
UIF
6OJUFE

JODMVEF
UIF
TZOPWJVN
TZOPWJBM
GMVJE
BSUJDVMBS
DBSUJMBHF
JOUSBBSUJDVMBS

4UBUFT
5IF
$FOUFST
GPS
%JTFBTF
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BOE
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FTUJNBUF
UIBU

MJHBNFOUT
KPJOU
DBQTVMF
BOE
KVYUBBSUJDVMBS
CPOF
/POBSUJDVMBS
PS



NJMMJPO

PG
UIF
64
QPQVMBUJPO
IBT
QIZTJDJBOEJBHOPTFE

QFSJBSUJDVMBS

TUSVDUVSFT
TVDI
BT
TVQQPSUJWF
FYUSBBSUJDVMBS
MJHBNFOUT

BSUISJUJT
BOE

NJMMJPO
IBWF
TJHOJGJDBOU
GVODUJPOBM
MJNJUBUJPO
8IJMF

UFOEPOT
CVSTBF
NVTDMF
GBTDJB
CPOF
OFSWF
BOE
PWFSMZJOH
TLJO
NBZ

NBOZ
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XJMM
IBWF
TFMGMJNJUFE
DPOEJUJPOT
SFRVJSJOH
NJOJNBM

CF
JOWPMWFE
JO
UIF
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QSPDFTT
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NVTDVMPTLFMFUBM
DPN-
FWBMVBUJPO
BOE
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UIFSBQZ
BOE
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TQFDJGJD

QMBJOUT
BSF
PGUFO
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UP
UIF
KPJOUT
OPOBSUJDVMBS
EJTPSEFST
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NVTDVMPTLFMFUBM
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NBZ
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B
NPSF

GSFRVFOUMZ
VOEFSMJF
TVDI
DPNQMBJOUT
%JTUJOHVJTIJOH
CFUXFFO
UIFTF

TFSJPVT
DPOEJUJPO
UIBU
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FWBMVBUJPO
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MBCPSBUPSZ
UFTUJOH

QPUFOUJBM
TPVSDFT
PG
QBJO
NBZ
CF
DIBMMFOHJOH
UP
UIF
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FYBN-
UP
FTUBCMJTI
B
EJBHOPTJT
5IF
HPBM
PG
UIF
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FWBMVBUJPO
JT

PART 15

JOFS
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NBZ
CF
DIBSBDUFSJ[FE
CZ
EFFQ
PS
EJGGVTF
QBJO

UP
GPSNVMBUF
B
EJGGFSFOUJBM
EJBHOPTJT
UIBU
MFBET
UP
BO
BDDVSBUF
EJBHOPTJT

QBJO
PS
MJNJUFE
SBOHF
PG
NPUJPO
PO
BDUJWF
BOE
QBTTJWF
NPWFNFOU
BOE

BOE
UJNFMZ
UIFSBQZ
XIJMF
BWPJEJOH
FYDFTTJWF
EJBHOPTUJD
UFTUJOH
BOE

TXFMMJOH
DBVTFE
CZ
TZOPWJBM
QSPMJGFSBUJPO
FGGVTJPO
PS
CPOZ
FOMBSHF-
VOOFDFTTBSZ
USFBUNFOU
(Table 393-1)
5IFSF
BSF
TFWFSBM
VSHFOU
DPOEJ-
NFOU

DSFQJUBUJPO
JOTUBCJMJUZ
iMPDLJOH w
PS
EFGPSNJUZ
#Z
DPOUSBTU

UJPOT
UIBU
NVTU
CF
EJBHOPTFE
QSPNQUMZ
UP
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TJHOJGJDBOU
NPSCJE
PS

OPOBSUJDVMBS
EJTPSEFST
UFOE
UP
CF
QBJOGVM
PO
BDUJWF
CVU
OPU
QBTTJWF
PS

NPSUBM
TFRVFMBF
5IFTF
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GMBHw
EJBHOPTFT
JODMVEF
TFQUJD
BSUISJUJT

BTTJTUFE

SBOHF
PG
NPUJPO
1FSJBSUJDVMBS
DPOEJUJPOT
PGUFO
EFNPOTUSBUF

BDVUF
DSZTUBMJOEVDFE
BSUISJUJT
FH
HPVU

BOE
GSBDUVSF
&BDI
NBZ
CF

QPJOU
PS
GPDBM
UFOEFSOFTT
JO
SFHJPOT
BEKBDFOU
UP
BSUJDVMBS
TUSVDUVSFT
BSF

Immune-Mediated, Inflammatory, and Rheumatologic Disorders

TVTQFDUFE
CZ
JUT
BDVUF
POTFU
BOE
NPOBSUJDVMBS
PS
GPDBM
NVTDVMPTLFMFUBM

FMJDJUFE
XJUI
B
TQFDJGJD
NPWFNFOU
PS
QPTJUJPO
BOE
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QIZTJDBM
GJOE-
QBJO
TFF
CFMPX

JOHT
SFNPUF
GSPN
UIF
KPJOU
DBQTVMF
.PSFPWFS
OPOBSUJDVMBS
EJTPSEFST

%FTQJUF
XFMMLOPXO
MJOLT
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DFSUBJO
EJTPSEFST
BOE
MBCPSBUPSZ

TFMEPN
EFNPOTUSBUF
TXFMMJOH
DSFQJUVT
JOTUBCJMJUZ
PS
EFGPSNJUZ
PG
UIF

UFTUJOH
UIF
NBKPSJUZ
PG
JOEJWJEVBMT
XJUI
NVTDVMPTLFMFUBM
DPNQMBJOUT

KPJOU
JUTFMG
DBO
CF
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XJUI
B
UIPSPVHI
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BOE
B
DPNQSFIFOTJWF
QIZTJ-
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BOE
NVTDVMPTLFMFUBM
FYBNJOBUJPO
5IF
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FODPVOUFS
TIPVME
INFLAMMATORY VERSUS NONINFLAMMATORY DISORDERS
EFUFSNJOF
XIFUIFS
UIF
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DPNQMBJOU
TJHOBMT
B
SFE
GMBH

*O
UIF
DPVSTF
PG
B
NVTDVMPTLFMFUBM
FWBMVBUJPO
UIF
FYBNJOFS
TIPVME

DPOEJUJPO
TFQUJD
BSUISJUJT
HPVU
PS
GSBDUVSF

PS
OPU
5IF
FWBMVBUJPO

EFUFSNJOF
UIF
OBUVSF
PG
UIF
VOEFSMZJOH
QBUIPMPHJD
QSPDFTT
BOE
XIFUIFS

TIPVME
QSPDFFE
UP
BTDFSUBJO
JG
UIF
DPNQMBJOU
JT


articular
PS
non-
JOGMBNNBUPSZ
PS
OPOJOGMBNNBUPSZ
GJOEJOHT
FYJTU
*OGMBNNBUPSZ

articular
JO
PSJHJO


inflammatory
PS
noninflammatory
JO
OBUVSF


EJTPSEFST
NBZ
CF
JOGFDUJPVT
Neisseria gonorrhoeae
PS
Mycobacterium


acute
PS
chronic
JO
EVSBUJPO
BOE


localized (monarticular)
PS

tuberculosis

DSZTUBMJOEVDFE
HPVU
QTFVEPHPVU

JNNVOFSFMBUFE

widespread
polyarticular

JO
EJTUSJCVUJPO
SIFVNBUPJE
BSUISJUJT
<3">
TZTUFNJD
MVQVT
FSZUIFNBUPTVT
<4-&>

SFBD-
8JUI
TVDI
BO
BQQSPBDI
BOE
BO
VOEFSTUBOEJOH
PG
UIF
QBUIPQIZTJ-
UJWF
SIFVNBUJD
GFWFS
SFBDUJWF
BSUISJUJT

PS
JEJPQBUIJD
*OGMBNNBUPSZ

PMPHJD
QSPDFTTFT
UIF
NVTDVMPTLFMFUBM
DPNQMBJOU
PS
QSFTFOUBUJPO
DBO

EJTPSEFST
NBZ
CF
JEFOUJGJFE
CZ
BOZ
PG
UIF
GPVS
DBSEJOBM
TJHOT
PG
JOGMBN-
CF
DIBSBDUFSJ[FE
FH
BDVUF
JOGMBNNBUPSZ
NPOBSUISJUJT
PS
B
DISPOJD

NBUJPO
FSZUIFNB
XBSNUI
QBJO
PS
TXFMMJOH

TZTUFNJD
TZNQUPNT

OPOJOGMBNNBUPSZ
OPOBSUJDVMBS
XJEFTQSFBE
QBJO

UP
OBSSPX
UIF
EJBH-
GBUJHVF
GFWFS
SBTI
XFJHIU
MPTT

PS
MBCPSBUPSZ
FWJEFODF
PG
JOGMBN-
OPTUJD
QPTTJCJMJUJFT
"
EJBHOPTJT
DBO
CF
NBEF
JO
UIF
WBTU
NBKPSJUZ
PG

NBUJPO
FMFWBUFE
FSZUISPDZUF
TFEJNFOUBUJPO
SBUF
<&43>
PS
$SFBDUJWF

JOEJWJEVBMT
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TPNF
QBUJFOUT
XJMM
OPU
GJU
JNNFEJBUFMZ
JOUP

QSPUFJO
<$31>
UISPNCPDZUPTJT
BOFNJB
PG
DISPOJD
EJTFBTF
PS
IZQP-
BO
FTUBCMJTIFE
EJBHOPTUJD
DBUFHPSZ
.BOZ
NVTDVMPTLFMFUBM
EJTPSEFST

BMCVNJOFNJB

"SUJDVMBS
TUJGGOFTT
DPNNPOMZ
BDDPNQBOJFT
DISPOJD

SFTFNCMF
FBDI
PUIFS
BU
UIF
PVUTFU
BOE
TPNF
NBZ
UBLF
XFFLT
PS
NPOUIT

NVTDVMPTLFMFUBM
EJTPSEFST

5IF
EVSBUJPO
PG
TUJGGOFTT
NBZ
CF
QSPMPOHFE

CVU
OPU
ZFBST

UP
FWPMWF
JOUP
B
SFDPHOJ[BCMF
EJBHOPTUJD
FOUJUZ
5IJT

IPVST

XJUI
JOGMBNNBUPSZ
EJTPSEFST
TVDI
BT
3"
PS
QPMZNZBMHJB

DPOTJEFSBUJPO
TIPVME
UFNQFS
UIF
EFTJSF
UP
FTUBCMJTI
B
EFGJOJUJWF
EJBH-
SIFVNBUJDB

BOE
NBZ
JNQSPWF
XJUI
BDUJWJUZ
#Z
DPOUSBTU
JOUFSNJUUFOU

OPTJT
BU
UIF
GJSTU
FODPVOUFS
TUJGGOFTT
BMTP
LOPXO
BT
HFM
QIFOPNFOPO

JT
UZQJDBM
PG
OPOJOGMBNNB-
UPSZ
DPOEJUJPOT
TVDI
BT
PTUFPBSUISJUJT
<0">

TIPSUFS
JO
EVSBUJPO


TABLE 393-1 EVALUATION OF PATIENTS WITH MUSCULOSKELETAL COMPLAINTS NJO

BOE
FYBDFSCBUFE
CZ
BDUJWJUZ
'BUJHVF
NBZ
BDDPNQBOZ
JOGMBNNB-
UJPO
BT
TFFO
JO
3"
BOE
QPMZNZBMHJB
SIFVNBUJDB

CVU
NBZ
BMTP
CF
B

(PBMT
DPOTFRVFODF
PG
GJCSPNZBMHJB
B
OPOJOGMBNNBUPSZ
EJTPSEFS

DISPOJD


"DDVSBUF
EJBHOPTJT
QBJO
QPPS
TMFFQ
EFQSFTTJPO
BOFNJB
DBSEJBD
GBJMVSF
FOEPDSJOPQBUIZ


5JNFMZ
QSPWJTJPO
PG
UIFSBQZ PS
NBMOVUSJUJPO
/POJOGMBNNBUPSZ
EJTPSEFST
NBZ
CF
SFMBUFE
UP
USBVNB


"WPJEBODF
PG
VOOFDFTTBSZ
EJBHOPTUJD
UFTUJOH SPUBUPS
DVGG
UFBS

SFQFUJUJWF
VTF
CVSTJUJT
UFOEJOJUJT

EFHFOFSBUJPO
PS


*EFOUJGJDBUJPO
PG
BDVUF
GPDBMNPOBSUJDVMBS
iSFE
GMBHw
DPOEJUJPOT JOFGGFDUJWF
SFQBJS
0"

OFPQMBTN
QJHNFOUFE
WJMMPOPEVMBS
TZOPWJUJT


"QQSPBDI PS
QBJO
BNQMJGJDBUJPO
GJCSPNZBMHJB

/POJOGMBNNBUPSZ
EJTPSEFST


%FUFSNJOBUJPO
PG
DISPOPMPHZ
BDVUF
WT
DISPOJD
BSF
PGUFO
DIBSBDUFSJ[FE
CZ
QBJO
XJUIPVU
TZOPWJBM
TXFMMJOH
PS
XBSNUI

BCTFODF
PG
JOGMBNNBUPSZ
PS
TZTUFNJD
GFBUVSFT
EBZUJNF
HFM
QIFOPNFOB



%FUFSNJOBUJPO
PG
UIF
OBUVSF
PG
UIF
QBUIPMPHJD
QSPDFTT
JOGMBNNBUPSZ
WT

OPOJOGMBNNBUPSZ
SBUIFS
UIBO
NPSOJOH
TUJGGOFTT
BOE
OPSNBM
GPS
BHF

PS
OFHBUJWF
MBCPSB-
UPSZ
JOWFTUJHBUJPOT


%FUFSNJOBUJPO
PG
UIF
FYUFOU
PG
JOWPMWFNFOU
NPOBSUJDVMBS
QPMZBSUJDVMBS

GPDBM
XJEFTQSFBE
*EFOUJGJDBUJPO
PG
UIF
OBUVSF
PG
UIF
VOEFSMZJOH
QSPDFTT
BOE
UIF
TJUF

PG
UIF
DPNQMBJOU
XJMM
FOBCMF
UIF
FYBNJOFS
UP
DIBSBDUFSJ[F
UIF
NVTDV-

"OBUPNJD
MPDBMJ[BUJPO
PG
DPNQMBJOU
BSUJDVMBS
WT
OPOBSUJDVMBS

MPTLFMFUBM
QSFTFOUBUJPO
FH
BDVUF
JOGMBNNBUPSZ
NPOBSUISJUJT
DISPOJD

$POTJEFS
UIF
NPTU
DPNNPO
EJTPSEFST
GJSTU
OPOJOGMBNNBUPSZ
OPOBSUJDVMBS
XJEFTQSFBE
QBJO

OBSSPX
UIF
EJBH-

'PSNVMBUF
B
EJGGFSFOUJBM
EJBHOPTJT OPTUJD
DPOTJEFSBUJPOT
BOE
BTTFTT
UIF
OFFE
GPS
JNNFEJBUF
EJBHOPTUJD
PS

HPIM19_Part15_p2103-p2250.indd 2216 1/23/15 10:50 AM

 2217
ALGORITHM FOR MUSCULOSKELETAL COMPLAINTS

Musculoskeletal Complaint

Initial rheumatic history and physical

exam to determine
1. Is it articular?
2. Is it acute or chronic?
3. Is inflammation present?
4. How many/which joints are involved?

Nonarticular condition No Is it articular?

Consider Yes
3
Trauma/fracture
3
Fibromyalgia
Is complaint > 6 wk?
3
Polymyalgia rheumatica
3
Bursitis No Yes
3
Tendinitis

CHAPTER 393 Approach to Articular and Musculoskeletal Disorders

Acute Chronic

Is inflammation present?
Consider 1. Is there prolonged morning stiffness?
3
-,
*,!*","+ 2. Is there soft tissue swelling?
3
Infectious arthritis 3. Are there systemic symptoms?
3
Gout 4. Is the ESR or CRP elevated?
3
Pseudogout
3
Reactive arthritis No Yes
3
'","%
)*+',,"('
of chronic arthritis Chronic Chronic
How many
noninflammatory inflammatory
joints involved?
arthritis arthritis

1 3 >3

Chronic inflammatory Chronic inflammatory

Are DIP, CMC1, hip or polyarthritis
mono/oligoarthritis
knee joints involved?
Consider
3
Indolent infection
Is involvement
3
Psoriatic arthritis
No Yes symmetric?
3
Reactive arthritis
3
Pauciarticular JIA No Yes
Unlikely to be osteoarthritis
Consider Osteoarthritis
Consider Are PIP, MCP, or
3
Osteonecrosis 3
Psoriatic arthritis MTP joints
3
Charcot arthritis 3
Reactive arthritis involved?

No Yes

Unlikely to be rheumatoid arthritis Rheumatoid

Consider


3
SLE arthritis


3
Scleroderma


3
Polymyositis

FIGURE 3931 Algorithm for the diagnosis of musculoskeletal complaints.
"O
BQQSPBDI
UP
GPSNVMBUJOH
B
EJGGFSFOUJBM
EJBHOPTJT
TIPXO
JO

JUBMJDT

$.$
DBSQPNFUBDBSQBM
$31
$SFBDUJWF
QSPUFJO
%*1
EJTUBM
JOUFSQIBMBOHFBM
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TFEJNFOUBUJPO
SBUF
+*"
KVWFOJMF
JEJPQBUIJD

BSUISJUJT
.$1
NFUBDBSQPQIBMBOHFBM
.51
NFUBUBSTPQIBMBOHFBM
1*1
QSPYJNBM
JOUFSQIBMBOHFBM
1.3
QPMZNZBMHJB
SIFVNBUJDB
4-&
TZTUFNJD
MVQVT

FSZUIFNBUPTVT

UIFSBQFVUJD
JOUFSWFOUJPO
PS
GPS
DPOUJOVFE
PCTFSWBUJPO
Figure 393-1

TZOESPNFT
BOE
GJCSPNZBMHJB
BSF
BNPOH
UIF
NPTU
DPNNPO
DBVTFT
PG

QSFTFOUT
BO
BMHPSJUINJD
BQQSPBDI
UP
UIF
FWBMVBUJPO
PG
QBUJFOUT
XJUI
KPJOU
QBJO
UIFTF
TIPVME
CF
DPOTJEFSFE
EVSJOH
UIF
JOJUJBM
FODPVOUFS

NVTDVMPTLFMFUBM
DPNQMBJOUT
5IJT
BQQSPBDI
SFMJFT
PO
DMJOJDBM
BOE
IJT- *G
UIFTF
QPTTJCJMJUJFT
BSF
FYDMVEFE
PUIFS
GSFRVFOUMZ
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EJT-
UPSJD
GFBUVSFT
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UIBO
MBCPSBUPSZ
UFTUJOH
UP
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NBOZ
DPN- PSEFST
TIPVME
CF
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BDDPSEJOH
UP
UIF
QBUJFOUT
BHF
)FODF

NPO
SIFVNBUJD
EJTPSEFST UIPTF
ZPVOHFS
UIBO

ZFBST
BSF
DPNNPOMZ
BGGFDUFE
CZ
SFQFUJUJWF
VTF
"
TJNQMFS
BMUFSOBUJWF
BQQSPBDI
XPVME
DPOTJEFS
UIF
NPTU
DPNNPOMZ
TUSBJO
EJTPSEFST
HPVU
NFO
POMZ

3"
TQPOEZMPBSUISJUJT
BOE
VODPN-
FODPVOUFSFE
DPNQMBJOUT
GJSTU
CBTFE
PO
GSFRVFODZ
JO
ZPVOHFS
WFSTVT
NPOMZ
JOGFDUJPVT
BSUISJUJT
1BUJFOUT
PWFS
BHF

ZFBST
BSF
GSFRVFOUMZ

PMEFS
QPQVMBUJPOT
5IF
NPTU
QSFWBMFOU
DBVTFT
PG
NVTDVMPTLFMFUBM
BGGFDUFE
CZ
0"
DSZTUBM
HPVU
BOE
QTFVEPHPVU

BSUISJUJT
QPMZNZBMHJB

DPNQMBJOUT
BSF
TIPXO
JO
Fig. 393-2
#FDBVTF
USBVNB
GSBDUVSF
PWFSVTF
SIFVNBUJDB
PTUFPQPSPUJD
GSBDUVSF
BOE
VODPNNPOMZ
TFQUJD
BSUISJUJT

HPIM19_Part15_p2103-p2250.indd 2217 1/23/15 10:50 AM

 2218 MOST COMMON MUSCULOSKELETAL CONDITIONS pauciarticular
UXP
PS
UISFF
KPJOUT

PS
polyarticular
GPVS
PS
NPSF

KPJOUT

"MUIPVHI
DSZTUBM
BOE
JOGFDUJPVT
BSUISJUJT
BSF
PGUFO
NPOP
PS

PMJHPBSUJDVMBS
0"
BOE
3"
BSF
QPMZBSUJDVMBS
EJTPSEFST
/POBSUJDVMBS

Trauma/fracture Low back pain EJTPSEFST
NBZ
CF
DMBTTJGJFE
BT
FJUIFS
GPDBM
PS
XJEFTQSFBE
$PNQMBJOUT

More
TFDPOEBSZ
UP
UFOEJOJUJT
PS
DBSQBM
UVOOFM
TZOESPNF
BSF
UZQJDBMMZ
GPDBM

Orthopedic evaluation XIFSFBT
XFBLOFTT
BOE
NZBMHJB
DBVTFE
CZ
QPMZNZPTJUJT
PS
GJCSPNZ-
BMHJB
BSF
NPSF
XJEFTQSFBE
JO
UIFJS
QSFTFOUBUJPO
+PJOU
JOWPMWFNFOU

JO
3"
UFOET
UP
CF
TZNNFUSJD
BOE
QPMZBSUJDVMBS
#Z
DPOUSBTU
TQPOEZ-
Fibromyalgia
MPBSUISJUJT
SFBDUJWF
BSUISJUJT
HPVU
BOE
TBSDPJE
BSF
PGUFO
BTZNNFUSJD

Age <60 years Age >60 years
BOE
PMJHPBSUJDVMBS
0"
BOE
QTPSJBUJD
BSUISJUJT
NBZ
CF
FJUIFS
TZNNFUSJD

PS
BTZNNFUSJD
BOE
PMJHP
PS
QPMZBSUJDVMBS
5IF
VQQFS
FYUSFNJUJFT
BSF

Repetitive strain injury Osteoarthritis GSFRVFOUMZ
JOWPMWFE
JO
3"
BOE
0"
XIFSFBT
MPXFS
FYUSFNJUZ
BSUISJUJT
JT

FREQUENCY
(Tendinitis, Bursitis) DIBSBDUFSJTUJD
PG
SFBDUJWF
BSUISJUJT
BOE
HPVU
BU
UIFJS
POTFU
*OWPMWFNFOU

PG
UIF
BYJBM
TLFMFUPO
JT
DPNNPO
JO
0"
BOE
BOLZMPTJOH
TQPOEZMJUJT
CVU

Gout JT
JOGSFRVFOU
JO
3"
XJUI
UIF
OPUBCMF
FYDFQUJPO
PG
UIF
DFSWJDBM
TQJOF
Gout (males only) Pseudogout 5IF
DMJOJDBM
IJTUPSZ
TIPVME
BMTP
JEFOUJGZ
precipitating events

TVDI
BT
USBVNB
PTUFPOFDSPTJT
NFOJTDBM
UFBS

ESVH
BENJOJTUSBUJPO

(Table 393-2)
BOUFDFEFOU
PS
JOUFSDVSSFOU
JOGFDUJPO
SIFVNBUJD
GFWFS

Rheumatoid arthritis Polymyalgia rheumatica
SFBDUJWF
BSUISJUJT
IFQBUJUJT

PS
JMMOFTTFT
UIBU
NBZ
IBWF
DPOUSJCVUFE
UP

UIF
QBUJFOUT
DPNQMBJOU
$FSUBJO
DPNPSCJEJUJFT
NBZ
IBWF
NVTDVMPTLFM-
Psoriatic, Reactive Osteoporotic fracture FUBM
DPOTFRVFODFT
5IJT
JT
FTQFDJBMMZ
TP
GPS
EJBCFUFT
NFMMJUVT
DBSQBM

PART 15

arthritis, IBD arthritis UVOOFM
TZOESPNF

SFOBM
JOTVGGJDJFODZ
HPVU

EFQSFTTJPO
PS
JOTPNOJB

GJCSPNZBMHJB

NZFMPNB
MPX
CBDL
QBJO

DBODFS
NZPTJUJT

BOE

Less PTUFPQPSPTJT
GSBDUVSF

PS
XIFO
VTJOH
DFSUBJO
ESVHT
TVDI
BT
HMVDPDPS-
Infectious arthritis Septic arthritis
UJDPJET
PTUFPOFDSPTJT
TFQUJD
BSUISJUJT

BOE
EJVSFUJDT
PS
DIFNPUIFSBQZ

(GC, viral, bacterial, Lyme) (bacterial)
HPVU

5BCMF


-BTUMZ
B
UIPSPVHI
rheumatic review of systems
NBZ
EJTDMPTF
VTFGVM

FIGURE 3932 Algorithm for consideration of the most common EJBHOPTUJD
JOGPSNBUJPO
"
WBSJFUZ
PG
NVTDVMPTLFMFUBM
EJTPSEFST
NBZ

Immune-Mediated, Inflammatory, and Rheumatologic Disorders

musculoskeletal conditions.
($
HPOPDPDDBM
*#%
JOGMBNNBUPSZ
CF
BTTPDJBUFE
XJUI
TZTUFNJD
GFBUVSFT
TVDI
BT
GFWFS
4-&
JOGFDUJPO


CPXFM
EJTFBTF SBTI
4-&
QTPSJBUJD
BSUISJUJT

OBJM
BCOPSNBMJUJFT
QTPSJBUJD
PS
SFBDUJWF

BSUISJUJT

NZBMHJBT
GJCSPNZBMHJB
TUBUJO
PS
ESVHJOEVDFE
NZPQBUIZ

5IFTF
DPOEJUJPOT
BSF
CFUXFFO

BOE

UJNFT
NPSF
QSFWBMFOU
UIBO
TABLE 393-2 DRUG-INDUCED MUSCULOSKELETAL CONDITIONS

PUIFS
TFSJPVT
BVUPJNNVOF
DPOEJUJPOT
TVDI
BT
4-&
TDMFSPEFSNB
QPMZ- Arthralgias
NZPTJUJT
BOE
WBTDVMJUJT


2VJOJEJOF
DJNFUJEJOF
CFUB
CMPDLFST
RVJOPMPOFT
DISPOJD
BDZDMPWJS
JOUFS-
GFSPOT
*-
OJDBSEJQJOF
WBDDJOFT
SJGBCVUJO
BSPNBUBTF
BOE
)*7
QSPUFBTF

CLINICAL HISTORY JOIJCJUPST
"EEJUJPOBM
IJTUPSJD
GFBUVSFT
NBZ
SFWFBM
JNQPSUBOU
DMVFT
UP
UIF
EJBH- Myalgias/myopathy
OPTJT
"TQFDUT
PG
UIF
QBUJFOU
QSPGJMF
DPNQMBJOU
DISPOPMPHZ
FYUFOU
PG


(MVDPDPSUJDPJET
QFOJDJMMBNJOF
IZESPYZDIMPSPRVJOF
";5
MPWBTUBUJO
TJN-
KPJOU
JOWPMWFNFOU
BOE
QSFDJQJUBUJOH
GBDUPST
DBO
QSPWJEF
JNQPSUBOU
WBTUBUJO
BUPSWBTUBUJO
QSBWBTUBUJO
DMPGJCSBUF
BNJPEBSPOF
JOUFSGFSPO
*-

JOGPSNBUJPO
$FSUBJO
EJBHOPTFT
BSF
NPSF
GSFRVFOU
JO
EJGGFSFOU
age
BMDPIPM
DPDBJOF
QBDMJUBYFM
EPDFUBYFM
JNBUJOJC
NFTZMBUF
DPMDIJDJOF
RVJOP-
HSPVQT
4-&
BOE
SFBDUJWF
BSUISJUJT
PDDVS
NPSF
GSFRVFOUMZ
JO
UIF
ZPVOH
MPOFT
DZDMPTQPSJOF
UBDSPMJNVT
QSPUFBTF
JOIJCJUPST
XIFSFBT
GJCSPNZBMHJB
BOE
3"
BSF
GSFRVFOU
JO
NJEEMF
BHF
BOE
0"
Tendon rupture/tendinitis
BOE
QPMZNZBMHJB
SIFVNBUJDB
BSF
NPSF
QSFWBMFOU
BNPOH
UIF
FMEFSMZ

2VJOPMPOFT
HMVDPDPSUJDPJET
JTPUSFUJOPJO
TUBUJOT
DPMMBHFOBTF
JOKFDUJPOT
%JBHOPTUJD
DMVTUFSJOH
JT
BMTP
FWJEFOU
XIFO
sex
BOE
race
BSF
DPOTJEFSFE
Gout
(PVU
TQPOEZMPBSUISJUJT
BOE
BOLZMPTJOH
TQPOEZMJUJT
BSF
NPSF
DPN-


%JVSFUJDT
BTQJSJO
DZUPUPYJDT
DZDMPTQPSJOF
BMDPIPM
NPPOTIJOF
FUIBNCV-
NPO
JO
NFO
XIFSFBT
3"
GJCSPNZBMHJB
BOE
MVQVT
BSF
NPSF
GSFRVFOU
UPM
GSVDUPTFDPOUBJOJOH
TPGU
ESJOLT
JO
XPNFO
Racial predilections
NBZ
CF
FWJEFOU
5IVT
QPMZNZBMHJB

Drug-induced lupus
SIFVNBUJDB
HJBOU
DFMM
BSUFSJUJT
BOE
HSBOVMPNBUPTJT
XJUI
QPMZBOHJJUJT

(1"
GPSNFSMZ
DBMMFE
8FHFOFST
HSBOVMPNBUPTJT

DPNNPOMZ
BGGFDU


)ZESBMB[JOF
QSPDBJOBNJEF
RVJOJEJOF
QIFOZUPJO
DBSCBNB[FQJOF
NFUIZM-
EPQB
JTPOJB[JE
DIMPSQSPNB[JOF
MJUIJVN
QFOJDJMMBNJOF
UFUSBDZDMJOFT
5/'

XIJUFT
XIFSFBT
TBSDPJEPTJT
BOE
4-&
NPSF
DPNNPOMZ
BGGFDU
"GSJDBO
JOIJCJUPST
"$&
JOIJCJUPST
UJDMPQJEJOF
"NFSJDBOT
Familial aggregation
JT
NPTU
DPNNPO
XJUI
BOLZMPTJOH

Drug-induced subacute lupus
TQPOEZMJUJT
HPVU
BOE
)FCFSEFOT
OPEFT
PG
0"
5IF
DISPOPMPHZ
PG
UIF
DPNQMBJOU
JT
BO
JNQPSUBOU
EJBHOPTUJD
GFBUVSF


1SPUPO
QVNQ
JOIJCJUPST
DBMDJVN
DIBOOFM
CMPDLFST
EJMUJB[FN

"$&

JOIJCJUPST
5/'
JOIJCJUPST
UFSCJOBGJOF
JOUFSGFSPOT

BOE
B

QBDMJUBYFM

BOE
DBO
CF
EJWJEFE
JOUP
UIF
onset, evolution
BOE
duration
5IF
POTFU
EPDFUBYFM
)$5;
PG
EJTPSEFST
TVDI
BT
TFQUJD
BSUISJUJT
PS
HPVU
UFOET
UP
CF
BCSVQU
XIFSFBT

Osteonecrosis
0"
3"
BOE
GJCSPNZBMHJB
NBZ
IBWF
NPSF
JOEPMFOU
QSFTFOUBUJPOT
5IF

QBUJFOUT
DPNQMBJOUT
NBZ
FWPMWF
EJGGFSFOUMZ
BOE
CF
DMBTTJGJFE
BT
DISPOJD

(MVDPDPSUJDPJET
BMDPIPM
SBEJBUJPO
CJTQIPTQIPOBUFT
0"

JOUFSNJUUFOU
DSZTUBM
PS
-ZNF
BSUISJUJT

NJHSBUPSZ
SIFVNBUJD
Osteopenia
GFWFS
HPOPDPDDBM
PS
WJSBM
BSUISJUJT

PS
BEEJUJWF
3"
QTPSJBUJD
BSUISJ-
(MVDPDPSUJDPJET
DISPOJD
IFQBSJO
QIFOZUPJO
UJT

.VTDVMPTLFMFUBM
EJTPSEFST
BSF
UZQJDBMMZ
DMBTTJGJFE
BT
BDVUF
PS
Scleroderma
DISPOJD
CBTFE
PO
B
TZNQUPN
EVSBUJPO
UIBU
JT
FJUIFS
MFTT
UIBO
PS
HSFBUFS

7

JOZM
DIMPSJEF
CMFPNZDJO
CBSJDJUJOJC
QFOUB[PDJOF
PSHBOJD
TPMWFOUT
DBSCJ-
UIBO

XFFLT
SFTQFDUJWFMZ
"DVUF
BSUISPQBUIJFT
UFOE
UP
CF
JOGFDUJPVT
EPQB
USZQUPQIBO
SBQFTFFE
PJM
DSZTUBMJOEVDFE
PS
SFBDUJWF
$ISPOJD
DPOEJUJPOT
JODMVEF
OPOJOGMBN- Vasculitis
NBUPSZ
PS
JNNVOPMPHJD
BSUISJUJEFT
FH
0"
3"

BOE
OPOBSUJDVMBS


"MMPQVSJOPM
BNQIFUBNJOFT
DPDBJOF
PGUFO
MFWBNJTPMF
BEVMUFSBUFE

UIJB-
EJTPSEFST
FH
GJCSPNZBMHJB
 [JEFT
QFOJDJMMBNJOF
QSPQZMUIJPVSBDJM
NPOUFMVLBTU
5/'
JOIJCJUPST
IFQBUJUJT
#

5IF
extent
PS
distribution
PG
BSUJDVMBS
JOWPMWFNFOU
JT
PGUFO
JOGPS- WBDDJOF
USJNFUIPQSJNTVMGBNFUIPYB[PMF
NJOPDZDMJOF
IZESBMB[JOF
NBUJWF
"SUJDVMBS
EJTPSEFST
BSF
DMBTTJGJFE
CBTFE
PO
UIF
OVNCFS
PG
Abbreviations:
"$&
BOHJPUFOTJODPOWFSUJOH
FO[ZNF
";5
[JEPWVEJOF
)$5;
IZESPDIMP-
KPJOUT
JOWPMWFE
BT
FJUIFS
monarticular
POF
KPJOU

oligoarticular
PS
SPUIJB[JEF
*-
JOUFSMFVLJO

5/'
UVNPS
OFDSPTJT
GBDUPS

HPIM19_Part15_p2103-p2250.indd 2218 1/23/15 10:50 AM

 PS
XFBLOFTT
QPMZNZPTJUJT
OFVSPQBUIZ

*O
BEEJUJPO
TPNF
DPOEJUJPOT
PG
B
NVTDVMPTLFMFUBM
DPOEJUJPO
-BTUMZ
PWFSMZ
BHHSFTTJWF
BOE
VOGPDVTFE
2219
BSF
BTTPDJBUFE
XJUI
JOWPMWFNFOU
PG
PUIFS
PSHBO
TZTUFNT
JODMVEJOH
UIF
MBCPSBUPSZ
UFTUJOH
XJMM
PGUFO
ZJFME
BCOPSNBM
GJOEJOHT
UIBU
BSF
CFUUFS

FZFT
#FIFUT
EJTFBTF
TBSDPJEPTJT
TQPOEZMPBSUISJUJT

HBTUSPJOUFTUJOBM
FYQMBJOFE
CZ
UIF
QBUJFOUT
QSFFYJTUJOH
DPOEJUJPO T

SBUIFS
UIBO
B
OFX

USBDU
TDMFSPEFSNB
JOGMBNNBUPSZ
CPXFM
EJTFBTF

HFOJUPVSJOBSZ
USBDU
JOGMBNNBUPSZ
PS
BVUPJNNVOF
EJTPSEFS
SFBDUJWF
BSUISJUJT
HPOPDPDDFNJB

PS
OFSWPVT
TZTUFN
-ZNF
EJTFBTF

WBTDVMJUJT
 PHYSICAL EXAMINATION
5IF
HPBM
PG
UIF
QIZTJDBM
FYBNJOBUJPO
JT
UP
BTDFSUBJO
UIF
TUSVDUVSFT

RHEUMATOLOGIC EVALUATION OF THE ELDERLY JOWPMWFE
UIF
OBUVSF
PG
UIF
VOEFSMZJOH
QBUIPMPHZ
UIF
GVODUJPOBM
DPO-
5IF
JODJEFODF
PG
SIFVNBUJD
EJTFBTFT
SJTFT
XJUI
BHF
TVDI
UIBU

PG
TFRVFODFT
PG
UIF
QSPDFTT
BOE
UIF
QSFTFODF
PG
TZTUFNJD
PS
FYUSBBSUJDVMBS

UIPTF

ZFBST
XJMM
IBWF
KPJOU
DPNQMBJOUT
.VTDVMPTLFMFUBM
EJTPSEFST
NBOJGFTUBUJPOT
"
LOPXMFEHF
PG
UPQPHSBQIJD
BOBUPNZ
JT
OFDFTTBSZ
UP

JO
FMEFSMZ
QBUJFOUT
BSF
PGUFO
OPU
EJBHOPTFE
CFDBVTF
UIF
TJHOT
BOE
TZNQ- JEFOUJGZ
UIF
QSJNBSZ
TJUF T

PG
JOWPMWFNFOU
BOE
EJGGFSFOUJBUF
BSUJDV-
UPNT
NBZ
CF
JOTJEJPVT
PWFSMPPLFE
PS
PWFSTIBEPXFE
CZ
DPNPSCJEJ- MBS
GSPN
OPOBSUJDVMBS
EJTPSEFST
5IF
NVTDVMPTLFMFUBM
FYBNJOBUJPO

UJFT
5IFTF
EJGGJDVMUJFT
BSF
DPNQPVOEFE
CZ
UIF
EJNJOJTIFE
SFMJBCJMJUZ
EFQFOET
MBSHFMZ
PO
DBSFGVM
JOTQFDUJPO
QBMQBUJPO
BOE
B
WBSJFUZ
PG

PG
MBCPSBUPSZ
UFTUJOH
JO
UIF
FMEFSMZ
XIP
PGUFO
NBOJGFTU
OPOQBUIPMPHJD
TQFDJGJD
QIZTJDBM
NBOFVWFST
UP
FMJDJU
EJBHOPTUJD
TJHOT
(Table 393-3)

BCOPSNBM
SFTVMUT
'PS
FYBNQMF
UIF
&43
NBZ
CF
NJTMFBEJOHMZ
FMFWBUFE
"MUIPVHI
NPTU
BSUJDVMBUJPOT
PG
UIF
BQQFOEJDVMBS
TLFMFUPO
DBO
CF

BOE
MPXUJUFS
QPTJUJWF
UFTUT
GPS
SIFVNBUPJE
GBDUPS
BOE
BOUJOVDMFBS
BOUJ- FYBNJOFE
JO
UIJT
NBOOFS
BEFRVBUF
JOTQFDUJPO
BOE
QBMQBUJPO
BSF
OPU

CPEJFT
"/"T

NBZ
CF
TFFO
JO
VQ
UP

PG
FMEFSMZ
QBUJFOUT
"MUIPVHI
QPTTJCMF
GPS
NBOZ
BYJBM
FH
[ZHBQPQIZTFBM

BOE
JOBDDFTTJCMF
FH

OFBSMZ
BMM
SIFVNBUJD
EJTPSEFST
BGGMJDU
UIF
FMEFSMZ
HFSJBUSJD
QBUJFOUT
BSF
TBDSPJMJBD
PS
IJQ

KPJOUT
'PS
TVDI
KPJOUT
UIFSF
JT
B
HSFBUFS
SFMJBODF
PO

QBSUJDVMBSMZ
QSPOF
UP
0"
PTUFPQPSPTJT
PTUFPQPSPUJD
GSBDUVSFT
HPVU
TQFDJGJD
NBOFVWFST
BOE
JNBHJOH
GPS
BTTFTTNFOU
QTFVEPHPVU
QPMZNZBMHJB
SIFVNBUJDB
WBTDVMJUJT
BOE
ESVHJOEVDFE
&YBNJOBUJPO
PG
JOWPMWFE
BOE
VOJOWPMWFE
KPJOUT
XJMM
EFUFSNJOF

CHAPTER 393 Approach to Articular and Musculoskeletal Disorders

EJTPSEFST
5BCMF


5IF
FMEFSMZ
TIPVME
CF
BQQSPBDIFE
JO
UIF
TBNF
XIFUIFS
pain
warmth
erythema
PS
swelling
JT
QSFTFOU
5IF
MPDBMF
BOE

NBOOFS
BT
PUIFS
QBUJFOUT
XJUI
NVTDVMPTLFMFUBM
DPNQMBJOUT
CVU
XJUI
MFWFM
PG
QBJO
FMJDJUFE
CZ
QBMQBUJPO
PS
NPWFNFOU
TIPVME
CF
RVBOUJGJFE

BO
FNQIBTJT
PO
JEFOUJGZJOH
UIF
QPUFOUJBM
SIFVNBUJD
DPOTFRVFODFT
PG
0OF
TUBOEBSE
XPVME
CF
UP
DPVOU
UIF
OVNCFS
PG
UFOEFS
KPJOUT
PO
QBM-
NFEJDBM
DPNPSCJEJUJFT
BOE
UIFSBQJFT
5IF
QIZTJDBM
FYBNJOBUJPO
TIPVME
QBUJPO
PG

FBTJMZ
FYBNJOFE
KPJOUT
QSPYJNBM
JOUFSQIBMBOHFBMT
NFUB-
JEFOUJGZ
UIF
OBUVSF
PG
UIF
NVTDVMPTLFMFUBM
DPNQMBJOU
BT
XFMM
BT
DPFY- DBSQPQIBMBOHFBMT
XSJTUT
FMCPXT
TIPVMEFST
BOE
LOFFT

4JNJMBSMZ

JTUJOH
EJTFBTFT
UIBU
NBZ
JOGMVFODF
EJBHOPTJT
BOE
DIPJDF
PG
USFBUNFOU UIF
OVNCFS
PG
TXPMMFO
KPJOUT
o

DBO
CF
DPVOUFE
BOE
SFDPSEFE

$BSFGVM
FYBNJOBUJPO
TIPVME
EJTUJOHVJTI
CFUXFFO
USVF
BSUJDVMBS
TXFMM-
RHEUMATOLOGIC EVALUATION OF THE HOSPITALIZED PATIENT JOH
DBVTFE
CZ
CPOZ
IZQFSUSPQIZ
TZOPWJBM
FGGVTJPO
PS
QSPMJGFSBUJPO


BOE
OPOBSUJDVMBS
PS
QFSJBSUJDVMBS

JOWPMWFNFOU
XIJDI
VTVBMMZ
FYUFOET

&WBMVBUJPO
PG
B
IPTQJUBMJ[FE
QBUJFOU
XJUI
SIFVNBUJD
DPNQMBJOUT
EJGGFST
CFZPOE
UIF
OPSNBM
KPJOU
NBSHJOT
4ZOPWJBM
FGGVTJPO
DBO
CF
EJTUJO-
GSPN
UIBU
PG
BO
PVUQBUJFOU
PXJOH
UP
HSFBUFS
TZNQUPN
TFWFSJUZ
NPSF
HVJTIFE
GSPN
TZOPWJBM
IZQFSUSPQIZ
PS
CPOZ
IZQFSUSPQIZ
CZ
QBMQBUJPO

BDVUF
QSFTFOUBUJPOT
BOE
HSFBUFS
JOUFSQMBZ
PG
DPNPSCJEJUJFT
1BUJFOUT
PS
TQFDJGJD
NBOFVWFST
'PS
FYBNQMF
TNBMM
UP
NPEFSBUF
LOFF
FGGVTJPOT

XJUI
SIFVNBUJD
EJTPSEFST
UFOE
UP
CF
BENJUUFE
GPS
POF
PG
TFWFSBM
NBZ
CF
JEFOUJGJFE
CZ
UIF
iCVMHF
TJHOw
PS
iCBMMPUUFNFOU
PG
UIF
QBUFM-
SFBTPOT


BDVUF
POTFU
PG
JOGMBNNBUPSZ
BSUISJUJT


VOEJBHOPTFE
MBFw
#VSTBM
FGGVTJPOT
FH
FGGVTJPOT
PG
UIF
PMFDSBOPO
PS
QSFQBUFMMBS

TZTUFNJD
PS
GFCSJMF
JMMOFTT


NVTDVMPTLFMFUBM
USBVNB


FYBDFSCB- CVSTB

BSF
PGUFO
GPDBM
QFSJBSUJDVMBS
PWFSMJF
CPOZ
QSPNJOFODFT
BOE
BSF

UJPO
PS
EFUFSJPSBUJPO
PG
BO
FYJTUJOH
BVUPJNNVOF
EJTPSEFS
FH
4-&

GMVDUVBOU
XJUI
TIBSQMZ
EFGJOFE
CPSEFST
+PJOU
stability
DBO
CF
BTTFTTFE

PS


OFX
NFEJDBM
DPNPSCJEJUJFT
FH
UISPNCPUJD
FWFOU
MZNQIPNB
CZ
TUBCJMJ[JOH
UIF
QSPYJNBM
KPJOU
CZ
QBMQBUJPO
BOE
CZ
UIF
BQQMJDBUJPO

JOGFDUJPO

BSJTJOH
JO
QBUJFOUT
XJUI
BO
FTUBCMJTIFE
SIFVNBUJD
EJTPSEFS
PG
NBOVBM
TUSFTT
UP
UIF
EJTUBM
BQQFOEBHF
Subluxation
PS
dislocation

/PUBCMZ
SIFVNBUJD
QBUJFOUT
BSF
TFMEPN
JG
FWFS
BENJUUFE
CFDBVTF
PG
XIJDI
NBZ
CF
TFDPOEBSZ
UP
USBVNBUJD
NFDIBOJDBM
PS
JOGMBNNBUPSZ

XJEFTQSFBE
QBJO
PS
TFSPMPHJD
BCOPSNBMJUJFT
PS
GPS
UIF
JOJUJBUJPO
PG
OFX

UIFSBQJFT
"DVUF
NPOBSUJDVMBS
JOGMBNNBUPSZ
BSUISJUJT
NBZ
CF
B
iSFE
GMBHw
TABLE 393-3 GLOSSARY OF MUSCULOSKELETAL TERMS
DPOEJUJPO
FH
TFQUJD
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HPIM19_Part15_p2103-p2250.indd 2220 1/23/15 10:50 AM

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QMBDFE
JOTJEF
B
DMFODIFE
GJTU
BOE
UIF
QBUJFOU
BDUJWFMZ
EFWJ- TVCBDSPNJBM
CJDJQJUBM

QBJO
BOE
UFOEFS
QPJOUT
JF
USBQF[JVT
PS
TVQSB-
BUFT
UIF
IBOE
EPXOXBSE
XJUI
VMOBS
EFWJBUJPO
BU
UIF
XSJTU
$BSQBM
TQJOBUVT

5IF
TIPVMEFS
TIPVME
CF
QVU
UISPVHI
JUT
GVMM
SBOHF
PG
NPUJPO

UVOOFM
TZOESPNF
JT
BOPUIFS
DPNNPO
EJTPSEFS
PG
UIF
VQQFS
FYUSFNJUZ
CPUI
BDUJWFMZ
BOE
QBTTJWFMZ
XJUI
FYBNJOFS
BTTJTUBODF

GPSXBSE
GMFYJPO

BOE
SFTVMUT
GSPN
DPNQSFTTJPO
PG
UIF
NFEJBO
OFSWF
XJUIJO
UIF
DBSQBM
FYUFOTJPO
BCEVDUJPO
BEEVDUJPO
BOE
JOUFSOBM
BOE
FYUFSOBM
SPUBUJPO

UVOOFM
.BOJGFTUBUJPOT
JODMVEF
QBJO
JO
UIF
XSJTU
UIBU
NBZ
SBEJBUF
XJUI
.BOVBM
JOTQFDUJPO
PG
UIF
QFSJBSUJDVMBS
TUSVDUVSFT
XJMM
PGUFO
QSPWJEF

QBSFTUIFTJB
UP
UIF
UIVNC
TFDPOE
BOE
UIJSE
GJOHFST
BOE
SBEJBM
IBMG
PG
JNQPSUBOU
EJBHOPTUJD
JOGPSNBUJPO
(MFOPIVNFSBM
JOWPMWFNFOU
JT
CFTU

UIF
GPVSUI
GJOHFS
BOE
BU
UJNFT
BUSPQIZ
PG
UIFOBS
NVTDVMBUVSF
$BSQBM
EFUFDUFE
CZ
QMBDJOH
UIF
UIVNC
PWFS
UIF
HMFOPIVNFSBM
KPJOU
KVTU
NFEJBM

UVOOFM
TZOESPNF
JT
DPNNPOMZ
BTTPDJBUFE
XJUI
QSFHOBODZ
FEFNB
BOE
JOGFSJPS
UP
UIF
DPSBDPJE
QSPDFTT
BOE
BQQMZJOH
QSFTTVSF
BOUFSJPSMZ

USBVNB
0"
JOGMBNNBUPSZ
BSUISJUJT
BOE
JOGJMUSBUJWF
EJTPSEFST
FH
XIJMF
JOUFSOBMMZ
BOE
FYUFSOBMMZ
SPUBUJOH
UIF
IVNFSBM
IFBE
1BJO
MPDBM-
BNZMPJEPTJT

5IF
EJBHOPTJT
NBZ
CF
TVHHFTUFE
CZ
B
QPTJUJWF
5JOFMT
PS
J[FE
UP
UIJT
SFHJPO
JT
JOEJDBUJWF
PG
HMFOPIVNFSBM
QBUIPMPHZ
4ZOPWJBM

1IBMFOT
TJHO
8JUI
FBDI
UFTU
QBSFTUIFTJB
JO
B
NFEJBO
OFSWF
EJTUSJCV- FGGVTJPO
PS
UJTTVF
JT
TFMEPN
QBMQBCMF
CVU
JG
QSFTFOU
NBZ
TVHHFTU
JOGFD-
UJPO
JT
JOEVDFE
PS
JODSFBTFE
CZ
FJUIFS
iUIVNQJOHw
UIF
WPMBS
BTQFDU
PG
UJPO
3"
BNZMPJEPTJT
PS
BO
BDVUF
UFBS
PG
UIF
SPUBUPS
DVGG
5IF
FYBN-
UIF
XSJTU
5JOFMT
TJHO

PS
QSFTTJOH
UIF
FYUFOTPS
TVSGBDFT
PG
CPUI
GMFYFE
JOFS
TIPVME
BQQMZ
EJSFDU
NBOVBM
QSFTTVSF
PWFS
UIF
TVCBDSPNJBM
CVSTB

XSJTUT
BHBJOTU
FBDI
PUIFS
1IBMFOT
TJHO

5IF
MPX
TFOTJUJWJUZ
BOE
NPE- UIBU
MJFT
MBUFSBM
UP
BOE
JNNFEJBUFMZ
CFOFBUI
UIF
BDSPNJPO
'JH



FSBUF
TQFDJGJDJUZ
PG
UIFTF
UFTUT
NBZ
SFRVJSF
OFSWF
DPOEVDUJPO
WFMPDJUZ
4VCBDSPNJBM
CVSTJUJT
JT
B
GSFRVFOU
DBVTF
PG
TIPVMEFS
QBJO
"OUFSJPS

UFTUJOH
UP
DPOGJSN
B
TVTQFDUFE
EJBHOPTJT UP
UIF
TVCBDSPNJBM
CVSTB
UIF
CJDJQJUBM
UFOEPO
USBWFSTFT
UIF
CJDJQJUBM

HSPPWF
5IJT
UFOEPO
JT
CFTU
JEFOUJGJFE
CZ
QBMQBUJOH
JU
JO
JUT
HSPPWF
BT

SHOULDER PAIN UIF
QBUJFOU
SPUBUFT
UIF
IVNFSVT
JOUFSOBMMZ
BOE
FYUFSOBMMZ
%JSFDU
QSFT-
%VSJOH
UIF
FWBMVBUJPO
PG
TIPVMEFS
EJTPSEFST
UIF
FYBNJOFS
TIPVME
TVSF
PWFS
UIF
UFOEPO
NBZ
SFWFBM
QBJO
JOEJDBUJWF
PG
CJDJQJUBM
UFOEJOJUJT

CHAPTER 393 Approach to Articular and Musculoskeletal Disorders

DBSFGVMMZ
OPUF
BOZ
IJTUPSZ
PG
USBVNB
GJCSPNZBMHJB
JOGFDUJPO
JOGMBN- 1BMQBUJPO
PG
UIF
BDSPNJPDMBWJDVMBS
KPJOU
NBZ
EJTDMPTF
MPDBM
QBJO
CPOZ

NBUPSZ
EJTFBTF
PDDVQBUJPOBM
IB[BSET
PS
QSFWJPVT
DFSWJDBM
EJTFBTF
IZQFSUSPQIZ
PS
VODPNNPOMZ
TZOPWJBM
TXFMMJOH
8IFSFBT
0"
BOE
3"

*O
BEEJUJPO
UIF
QBUJFOU
TIPVME
CF
RVFTUJPOFE
BT
UP
UIF
BDUJWJUJFT
PS
DPNNPOMZ
BGGFDU
UIF
BDSPNJPDMBWJDVMBS
KPJOU
0"
TFMEPN
JOWPMWFT
UIF

NPWFNFOU T

UIBU
FMJDJU
TIPVMEFS
QBJO
8IJMF
BSUISJUJT
JT
TVHHFTUFE
HMFOPIVNFSBM
KPJOU
VOMFTT
UIFSF
JT
B
USBVNBUJD
PS
PDDVQBUJPOBM
DBVTF
CZ
QBJO
PO
NPWFNFOU
JO
BMM
QMBOFT
QBJO
XJUI
TQFDJGJD
BDUJWF
NPUJPO
3PUBUPS
DVGG
UFOEJOJUJT
PS
UFBS
JT
B
WFSZ
DPNNPO
DBVTF
PG
TIPVMEFS

TVHHFTUT
B
QFSJBSUJDVMBS
OPOBSUJDVMBS

QSPDFTT
4IPVMEFS
QBJO
NBZ
QBJO
/FBSMZ

QFSDFOU
PG
UIF
FMEFSMZ
XJMM
IBWF
TIPVMEFS
QBJO
XJUI

PSJHJOBUF
JO
UIF
HMFOPIVNFSBM
PS
BDSPNJPDMBWJDVMBS
KPJOUT
TVCBDSPNJBM
SPUBUPS
DVGG
UFOEJOJUJT
PS
UFBS
BT
UIF
QSJNBSZ
DBVTF
5IF
SPUBUPS
DVGG

TVCEFMUPJE

CVSTB
QFSJBSUJDVMBS
TPGU
UJTTVFT
FH
GJCSPNZBMHJB
SPUBUPS
JT
GPSNFE
CZ
GPVS
UFOEPOT
UIBU
BUUBDI
UIF
TDBQVMB
UP
UIF
QSPYJNBM

DVGG
UFBSUFOEJOJUJT

PS
DFSWJDBM
TQJOF
(Fig. 393-4)
4IPVMEFS
QBJO
JT
IVNFSVT
TVQSBTQJOBUVT
JOGSBTQJOBUVT
UFSFT
NJOPS
BOE
TVCTDBQVMBSJT

SFGFSSFE
GSFRVFOUMZ
GSPN
UIF
DFSWJDBM
TQJOF
CVU
NBZ
BMTP
CF
SFGFSSFE
UFOEPOT

0G
UIFTF
UIF
TVQSBTQJOBUVT
NVTDMF
JT
UIF
NPTU
DPNNPOMZ

GSPN
JOUSBUIPSBDJD
MFTJPOT
FH
B
1BODPBTU
UVNPS

PS
GSPN
HBMMCMBE- EBNBHFE
3PUBUPS
DVGG
UFOEJOJUJT
JT
TVHHFTUFE
CZ
QBJO
PO
BDUJWF
BCEVD-
EFS
IFQBUJD
PS
EJBQISBHNBUJD
EJTFBTF
5IFTF
TBNF
WJTDFSBM
DBVTFT
NBZ
UJPO
CVU
OPU
QBTTJWF
BCEVDUJPO

QBJO
PWFS
UIF
MBUFSBM
EFMUPJE
NVTDMF

BMTP
NBOJGFTU
BT
GPDBM
TDBQVMBS
QBJO
'JCSPNZBMHJB
TIPVME
CF
TVTQFDUFE
OJHIU
QBJO
BOE
FWJEFODF
PG
UIF
JNQJOHFNFOU
TJHOT
QBJO
XJUI
PWFSIFBE

BSN
BDUJWJUJFT

5IF
/FFS
UFTU
GPS
JNQJOHFNFOU
JT
QFSGPSNFE
CZ
UIF

FYBNJOFS
SBJTJOH
UIF
QBUJFOUT
BSN
JOUP
GPSDFE
GMFYJPO
XIJMF
TUBCJMJ[JOH

BOE
QSFWFOUJOH
SPUBUJPO
PG
UIF
TDBQVMB
"
QPTJUJWF
TJHO
JT
QSFTFOU
JG

Supraspinatus QBJO
EFWFMPQT
CFGPSF

PG
GPSXBSE
GMFYJPO
5FBS
PG
UIF
SPUBUPS
DVGG
JT

Acromioclavicular
joint
muscle DPNNPO
JO
UIF
FMEFSMZ
BOE
PGUFO
SFTVMUT
GSPN
USBVNB
JU
NBZ
NBOJGFTU

JO
UIF
TBNF
NBOOFS
BT
UFOEJOJUJT
5IF
ESPQ
BSN
UFTU
JT
BCOPSNBM
XJUI

Acromion Clavicle TVQSBTQJOBUVT
QBUIPMPHZ
BOE
JT
EFNPOTUSBUFE
CZ
QBTTJWF
BCEVDUJPO
PG

UIF
BSN
UP

CZ
UIF
FYBNJOFS
*G
UIF
QBUJFOU
JT
VOBCMF
UP
IPME
UIF
BSN

Supraspinatus VQ
BDUJWFMZ
PS
VOBCMF
UP
MPXFS
UIF
BSN
TMPXMZ
XJUIPVU
ESPQQJOH
UIF

tendon UFTU
JT
QPTJUJWF
5FOEJOJUJT
PS
UFBS
PG
UIF
SPUBUPS
DVGG
JT
CFTU
DPOGJSNFE

CZ
NBHOFUJD
SFTPOBODF
JNBHJOH
.3*

PS
VMUSBTPVOE
Subacromial
bursa
KNEE PAIN
,OFF
QBJO
NBZ
SFTVMU
GSPN
JOUSBBSUJDVMBS
0"
3"

PS
QFSJBSUJDVMBS

BOTFSJOF
CVSTJUJT
DPMMBUFSBM
MJHBNFOU
TUSBJO

QSPDFTTFT
PS
CF
SFGFSSFE

GSPN
IJQ
QBUIPMPHZ
"
DBSFGVM
IJTUPSZ
TIPVME
EFMJOFBUF
UIF
DISPOPMPHZ

Bicipital PG
UIF
LOFF
DPNQMBJOU
BOE
XIFUIFS
UIFSF
BSF
QSFEJTQPTJOH
DPOEJ-
tendon UJPOT
USBVNB
PS
NFEJDBUJPOT
UIBU
NJHIU
VOEFSMJF
UIF
DPNQMBJOU
'PS

FYBNQMF
QBUFMMPGFNPSBM
EJTFBTF
FH
0"

NBZ
DBVTF
BOUFSJPS
LOFF

Humerus QBJO
UIBU
XPSTFOT
XJUI
DMJNCJOH
TUBJST
0CTFSWBUJPO
PG
UIF
QBUJFOUT

HBJU
JT
BMTP
JNQPSUBOU
5IF
LOFF
TIPVME
CF
DBSFGVMMZ
JOTQFDUFE
JO

UIF
VQSJHIU
XFJHIUCFBSJOH

BOE
TVQJOF
QPTJUJPOT
GPS
TXFMMJOH
FSZ-
UIFNB
NBMBMJHONFOU
WJTJCMF
USBVNB
NVTDMF
XBTUJOH
BOE
MFH
MFOHUI

Glenohumeral EJTDSFQBODZ
5IF
NPTU
DPNNPO
NBMBMJHONFOU
JO
UIF
LOFF
JT
genu
(shoulder) joint
varum
CPXMFHT

PS
genu valgum
LOPDLLOFFT

SFTVMUJOH
GSPN
BTZN-
NFUSJD
DBSUJMBHF
MPTT
NFEJBMMZ
PS
MBUFSBMMZ
#POZ
TXFMMJOH
PG
UIF
LOFF

Subscapularis KPJOU
DPNNPOMZ
SFTVMUT
GSPN
IZQFSUSPQIJD
PTTFPVT
DIBOHFT
TFFO

muscle XJUI
EJTPSEFST
TVDI
BT
0"
BOE
OFVSPQBUIJD
BSUISPQBUIZ
4XFMMJOH

DBVTFE
CZ
IZQFSUSPQIZ
PG
UIF
TZOPWJVN
PS
TZOPWJBM
FGGVTJPO
NBZ

NBOJGFTU
BT
B
GMVDUVBOU
CBMMPUBCMF
PS
TPGU
UJTTVF
FOMBSHFNFOU
JO
UIF

TVQSBQBUFMMBS
QPVDI
TVQSBQBUFMMBS
SFGMFDUJPO
PG
UIF
TZOPWJBM
DBW-
JUZ

PS
SFHJPOT
MBUFSBM
BOE
NFEJBM
UP
UIF
QBUFMMB
4ZOPWJBM
FGGVTJPOT

NBZ
BMTP
CF
EFUFDUFE
CZ
CBMMPUJOH
UIF
QBUFMMB
EPXOXBSE
UPXBSE
UIF

FIGURE 3934 Origins of shoulder pain.
5IF
TDIFNBUJD
EJBHSBN
PG
GFNPSBM
HSPPWF
PS
CZ
FMJDJUJOH
B
iCVMHF
TJHOw
8JUI
UIF
LOFF
FYUFOEFE

UIF
TIPVMEFS
JOEJDBUFT
XJUI
BSSPXT
UIF
BOBUPNJD
PSJHJOT
PG
TIPVMEFS
UIF
FYBNJOFS
TIPVME
NBOVBMMZ
DPNQSFTT
PS
iNJML w
TZOPWJBM
GMVJE

QBJO EPXO
GSPN
UIF
TVQSBQBUFMMBS
QPVDI
BOE
MBUFSBM
UP
UIF
QBUFMMBF
5IF

HPIM19_Part15_p2103-p2250.indd 2221 1/23/15 10:50 AM

 2222 BQQMJDBUJPO
PG
NBOVBM
QSFTTVSF
MBUFSBM
UP
UIF
QBUFMMB
NBZ
DBVTF
BOE
USPDIBOUFSJD
QBJO
BSF
DPNNPO
GJOEJOHT
JO
GJCSPNZBMHJB
3BOHF
PG

BO
PCTFSWBCMF
TIJGU
JO
TZOPWJBM
GMVJE
CVMHF

UP
UIF
NFEJBM
BTQFDU

NPWFNFOU
NBZ
CF
MJNJUFE
CZ
QBJO
1BJO
JO
UIF
IJQ
KPJOU
JT
MFTT
DPN-
5IF
FYBNJOFS
TIPVME
OPUF
UIBU
UIJT
NBOFVWFS
JT
POMZ
FGGFDUJWF
JO
NPO
BOE
UFOET
UP
CF
MPDBUFE
BOUFSJPSMZ
PWFS
UIF
JOHVJOBM
MJHBNFOU

EFUFDUJOH
TNBMM
UP
NPEFSBUF
FGGVTJPOT

N-

*OGMBNNBUPSZ
JU
NBZ
SBEJBUF
NFEJBMMZ
UP
UIF
HSPJO
6ODPNNPOMZ
JMJPQTPBT
CVSTJUJT

EJTPSEFST
TVDI
BT
3"
HPVU
QTFVEPHPVU
BOE
QTPSJBUJD
BSUISJUJT
NBZ
NBZ
NJNJD
USVF
IJQ
KPJOU
QBJO
%JBHOPTJT
PG
JMJPQTPBT
CVSTJUJT
NBZ
CF

JOWPMWF
UIF
LOFF
KPJOU
BOE
QSPEVDF
TJHOJGJDBOU
QBJO
TUJGGOFTT
TXFMMJOH
TVHHFTUFE
CZ
B
IJTUPSZ
PG
USBVNB
PS
JOGMBNNBUPSZ
BSUISJUJT
1BJO
BTTPDJ-
PS
XBSNUI
"
QPQMJUFBM
PS
Bakers cyst
NBZ
CF
QBMQBUFE
XJUI
UIF
LOFF
BUFE
XJUI
JMJPQTPBT
CVSTJUJT
JT
MPDBMJ[FE
UP
UIF
HSPJO
PS
BOUFSJPS
UIJHI

QBSUJBMMZ
GMFYFE
BOE
JT
CFTU
WJFXFE
QPTUFSJPSMZ
XJUI
UIF
QBUJFOU
TUBOEJOH
BOE
UFOET
UP
XPSTFO
XJUI
IZQFSFYUFOTJPO
PG
UIF
IJQ
NBOZ
QBUJFOUT

BOE
LOFFT
GVMMZ
FYUFOEFE
UP
WJTVBMJ[F
JTPMBUFE
PS
VOJMBUFSBM
QPQMJUFBM
QSFGFS
UP
GMFY
BOE
FYUFSOBMMZ
SPUBUF
UIF
IJQ
UP
SFEVDF
UIF
QBJO
GSPN
B

TXFMMJOH
PS
GVMMOFTT EJTUFOEFE
CVSTB
"OTFSJOF
CVSTJUJT
JT
BO
PGUFO
NJTTFE
QFSJBSUJDVMBS
DBVTF
PG
LOFF
QBJO

JO
BEVMUT
5IF
QFT
BOTFSJOF
CVSTB
VOEFSMJFT
UIF
JOTFSUJPO
PG
UIF
DPO-
KPJOFE
UFOEPOT
TBSUPSJVT
HSBDJMJT
TFNJUFOEJOPTVT

PO
UIF
BOUFSPNF-
LABORATORY INVESTIGATIONS
EJBM
QSPYJNBM
UJCJB
BOE
NBZ
CF
QBJOGVM
GPMMPXJOH
USBVNB
PWFSVTF
PS
5IF
WBTU
NBKPSJUZ
PG
NVTDVMPTLFMFUBM
EJTPSEFST
DBO
CF
FBTJMZ
EJBH-
JOGMBNNBUJPO
*U
JT
PGUFO
UFOEFS
JO
QBUJFOUT
XJUI
GJCSPNZBMHJB
PCFTJUZ
OPTFE
CZ
B
DPNQMFUF
IJTUPSZ
BOE
QIZTJDBM
FYBNJOBUJPO
"O
BEEJUJPOBM

BOE
LOFF
0"
0UIFS
GPSNT
PG
CVSTJUJT
NBZ
BMTP
QSFTFOU
BT
LOFF
QBJO
PCKFDUJWF
PG
UIF
JOJUJBM
FODPVOUFS
JT
UP
EFUFSNJOF
XIFUIFS
BEEJUJPOBM

5IF
QSFQBUFMMBS
CVSTB
JT
TVQFSGJDJBM
BOE
JT
MPDBUFE
PWFS
UIF
JOGFSJPS
QPS- JOWFTUJHBUJPOT
PS
JNNFEJBUF
UIFSBQZ
JT
SFRVJSFE
"EEJUJPOBM
FWBMVB-
UJPO
PG
UIF
QBUFMMB
5IF
JOGSBQBUFMMBS
CVSTB
JT
EFFQFS
BOE
MJFT
CFOFBUI
UJPO
JT
JOEJDBUFE
XJUI


NPOBSUJDVMBS
DPOEJUJPOT


USBVNBUJD
PS

UIF
QBUFMMBS
MJHBNFOU
CFGPSF
JUT
JOTFSUJPO
PO
UIF
UJCJBM
UVCFSDMF JOGMBNNBUPSZ
DPOEJUJPOT


UIF
QSFTFODF
PG
OFVSPMPHJD
GJOEJOHT


*OUFSOBM
EFSBOHFNFOU
PG
UIF
LOFF
NBZ
SFTVMU
GSPN
USBVNB
PS
EFHFO- 

TZTUFNJD
NBOJGFTUBUJPOT
PS


DISPOJD
TZNQUPNT

XFFLT

BOE

FSBUJWF
QSPDFTTFT
%BNBHF
UP
UIF
NFOJTDBM
DBSUJMBHF
NFEJBM
PS
MBUFSBM

B
MBDL
PG
SFTQPOTF
UP
TZNQUPNBUJD
NFBTVSFT
5IF
FYUFOU
BOE
OBUVSF
PG

PART 15

GSFRVFOUMZ
QSFTFOUT
BT
DISPOJD
PS
JOUFSNJUUFOU
LOFF
QBJO
4VDI
BO
JOKVSZ
UIF
BEEJUJPOBM
JOWFTUJHBUJPO
TIPVME
CF
EJDUBUFE
CZ
UIF
DMJOJDBM
GFBUVSFT

TIPVME
CF
TVTQFDUFE
XIFO
UIFSF
JT
B
IJTUPSZ
PG
USBVNB
BUIMFUJD
BDUJW- BOE
TVTQFDUFE
QBUIPMPHJD
QSPDFTT
-BCPSBUPSZ
UFTUT
TIPVME
CF
VTFE

JUZ
PS
DISPOJD
LOFF
BSUISJUJT
BOE
XIFO
UIF
QBUJFOU
SFMBUFT
TZNQUPNT
UP
DPOGJSN
B
TQFDJGJD
DMJOJDBM
EJBHOPTJT
BOE
OPU
CF
VTFE
UP
TDSFFO
PS

PG
iMPDLJOHw
PS
iHJWJOH
XBZw
PG
UIF
LOFF
8JUI
UIF
LOFF
GMFYFE

BOE
FWBMVBUF
QBUJFOUT
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FIGURE 3935 Origins of hip pain and dysesthesias.
(From JJ Cush et al: Evaluation of mus-
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culoskeletal complaints, in Rheumatology: Diagnosis and Therapeutics, 2nd ed, JJ Cush et al [eds].
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HPIM19_Part15_p2103-p2250.indd 2222 1/23/15 10:50 AM

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CHAPTER 393 Approach to Articular and Musculoskeletal Disorders

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TABLE 393-4 ANTINUCLEAR ANTIBODY (ANA) PATTERNS AND CLINICAL BOE
DPTU
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HPIM19_Part15_p2103-p2250.indd 2223 1/23/15 10:50 AM

 2224 TABLE 3935 DIAGNOSTIC IMAGING TECHNIQUES FOR MUSCULOSKELETAL
INTERPRETATION OF SYNOVIAL FLUID ASPIRATION
DISORDERS
Strongly consider synovial fluid aspiration Imaging
and analysis if there is Method Time, h Costa Current Indications
3
)(+-#+$-$,
.-
)+
#+)($ Ultrasound <1 ++ Synovial (Bakers) cysts
3
+.'
0$-#
%)$(-
!!.,$)(
3
)(+-#+$-$,
$(

*-$ (-
0$-#
#+)($
*)&1+-#+$-$s Rotator cuff tears
3
.,*$$)(
)!
%)$(-
$(! -$)(
+1,-&$(. 
+-#+$-$,
)+
# '+-#+),$, Bursitis, tendinitis, tendon injury
Enthesitis
Analyze fluid for Carpal tunnel syndrome
3
** +( 
/$,),$-1 Urate or calcium pyrophosphate
3

).(-
$!! + (-$& deposition on cartilage
Is the effusion
3
+'
,-$(
.&-.+ 
( Early detection of synovial
# ')++#"$?


, (,$-$/$-1
$!
$($-  inflammation or erosions
3
+1,-&
$ (-$!$-$)(


1
*)&+$2 
'$+),)*1 Ultrasound-guided injection/
arthrocentesis
) Yes Radionuclide
scintigraphy
(!&''-)+1
)+ )(,$ + 99m
Tc 14 ++ Metastatic bone survey
()($(!&''-)+1 3
+.'
)+
' #($&
articular condition

 +(" ' (- Evaluation of Pagets disease
3
)".&)*-#1 Identifying occult arthritis in
PART 15

3
 .+)*-#$
+-#+)*-#1 patients with undiagnosed

,
-#


L? 3
-# + polyarthralgia
111
In-WBC 24 +++ Acute infection
) Yes
Prosthetic infection
)(,$ + Acute osteomyelitis
)(,$ +
$(!&''-)+1
()($(!&''-)+1 or septic arthritis Ga
67
2448 ++++ Acute and chronic infection
Immune-Mediated, Inflammatory, and Rheumatologic Disorders

articular conditions
Acute osteomyelitis
3
,- )+-#+$-$,
3
+.' Computed <1 +++ Herniated intervertebral disk
3
-# + ) ,
-#

,


? tomography Sacroiliitis
(CT)
Yes Spinal stenosis
)(,$ +
)-# + Spinal trauma
$(!&''-)+1 ) Are crystals present? Osteoid osteoma
or septic arthritides Stress fracture
Yes
3
+'
,-$(
.&-.+


'(-)+1 Dual-energy CT <1 NA Uric acid deposition
+1,-&
$ (-$!$-$)(
!)r Tophus localization
specific diagnosis Magnetic 1/22 ++++ Avascular necrosis
3
).- resonance
,
-#



L? 3
, .)").- Osteomyelitis
) Yes
+)&
$(!&''-)+1
+-#+$-$, Possible septic arthritis
FIGURE 3936 Algorithmic approach to the use and interpretation
of synovial fluid aspiration and analysis. PMNs, polymorphonucle-
ar (leukocytes); WBC, white blood cell (count).
crystal deposition on cartilage. Use of power Doppler allows for early
detection of synovitis and bony erosions. Radionuclide scintigraphy is
a very sensitive, but poorly specific, means of detecting inflammatory
or metabolic alterations in bone or periarticular soft tissue structures.
Scintigraphy is best suited for total-body assessment (extent and dis-
tribution) of skeletal involvement (neoplasia, Pagets disease) and the
assessment of patients with undiagnosed polyarthralgias, looking for
occult arthritis. The use of scintigraphy has declined with greater use
and declining cost of ultrasound and MRI. The limited tissue con-
trast resolution of scintigraphy may obscure the distinction between
a bony or periarticular process and may necessitate the additional
use of MRI. Scintigraphy using 99mTc, 67Ga, or 111In-labeled WBCs
has been applied to a variety of articular disorders with variable suc-
cess (Table 393-5). Although [99mTc] diphosphate scintigraphy may
be useful in identifying osseous infection, neoplasia, inflammation,
increased blood flow, bone remodeling, heterotopic bone formation, or
avascular necrosis, MRI is preferred in most instances. Gallium scan-
ning uses 67Ga, which binds serum and cellular transferrin and lac-
toferrin and is preferentially taken up by neutrophils, macrophages,
HPIM19_Part15_p2103-p2250.indd 2224
imaging
Septic arthritis, infected pros-
thetic joints
Early sacroiliitis
Intraarticular derangement and
soft tissue injury
Derangements of axial skeleton
and spinal cord
Herniated intervertebral disk
Pigmented villonodular synovitis
Inflammatory and metabolic
muscle pathology
Relative cost for imaging study.
a
Abbreviations: NA, not commercially available; WBC, white blood cell.
bacteria, and tumor tissue (e.g., lymphoma). As such, it is primarily
used in the identification of occult infection or malignancy. Scanning
with 111In-labeled WBCs has been used to detect osteomyelitis and
infectious or inflammatory arthritis. Despite their utility, 111In-labeled
WBC or 67Ga scanning has largely been replaced by MRI, except when
there is a suspicion of septic joint or prosthetic joint infections.
Computed tomography (CT) provides detailed visualization of the
axial skeleton. Articulations previously considered difficult to visualize
by radiography (e.g., zygapophyseal, sacroiliac, sternoclavicular, hip
joints) can be effectively evaluated using CT. CT has been demon-
strated to be useful in the diagnosis of low back pain syndromes (e.g.,
spinal stenosis vs herniated disk), sacroiliitis, osteoid osteoma, and
stress fractures. Helical or spiral CT (with or without contrast angiog-
raphy) is a novel technique that is rapid, cost effective, and sensitive
1/29/15 1:06 PM
 2225

CHAPTER 393 Approach to Articular and Musculoskeletal Disorders

FIGURE 3937 Dual-energy computed tomography (DECT) scan from a 45-year-old woman with right ankle swelling around the lateral
malleolus.
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red


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arrow

(Used with permission from S Nicolaou et al: AJR 194:1072, 2010.)

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EFSBOHF- FIGURE 3938 Superior sensitivity of magnetic resonance imag-
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ing (MRI) in the diagnosis of osteonecrosis of the femoral head.

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Acknowledgment TDMFSPTJT
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EFN-
The author acknowledges the contributions of Dr. Peter E. Lipsky to this POTUSBUFE
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PG

chapter in previous editions. PTUFPOFDSPTJT

HPIM19_Part15_p2103-p2250.indd 2225 1/23/15 10:50 AM