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• Musculoskeletal disorders (MSDs) can affect the body's:

o muscles, joints, tendons, ligaments and nerves.


• Musculoskeletal dos Etiology is very broad and can be due to:

o injury, inflammatory disease, mechanical degeneration, infection, metabolic disorders, crystal accumulation, cancer or environmental exposure.


• Joint Classifications:

o Synarthroses- ‘suture lines’ found in skull
o Amphiarthroses- adjacent bones bound by flexible fibrocartilage (ex: pubic symphysis, SI jt upper 2/3rds, intervertebral discs)
o Diarthroses-articular design, contain synovial membrane and synovial fluid (lower 1/3rd SI joint, crico arytenoid, TMJ, facets, knee, etc.)


• Synovial Fluid roles:

o Reduction of friction - lubricates the articulating joints
o Shock absorption - becomes more viscous under applied pressure.
o Nutrient and waste transportation


• Tenosynovium:

o Protective lining of tendons


• Articular Cartilage:

o Reduce friction and absorb shock
o 70% water
o Type II collagen
o Large proteoglycan


• Terms for # of joints involved:

o Monoarticular- involving one joint
o Pauciarticular- involving 2-4 joints
o Polyarticular- involving 5 or greater joints


• Types of inflammation of the synovium:

o Synovitis- Inflammation of the synovial membrane
o Tenosynovitis- Inflammation of a tendon and its enveloping sheath.
o Stenosing- swelling of a tendon sheath causing “triggering”
o Serous synovitis- synovitis with a large effusion of nonpurulent fluid


• General hx for M/S dos:

o Onset and progression
o location of pain
o Regional vs generalized
o Symmetrical vs asymmetrical
o Peripheral vs central
o Acute vs chronic
o Progressive vs static


• Specific hx for M/S do:

o Morning stiffness? (>1hr → inflam dz)
o quality of pain? Pain scale
o pain at rest? Time of day. How long does it last?
o ADLs impacted? Work, school, cooking, etc
o Modalities
o Travel?
o Swelling? ROM?
o Diet, Exercise, Hobbies, Sex hx, Toxic exposure, Hx trauma
o family members w similar problems?


• patterns of joint involvement in M/S dos:

o Symmetrical: RA, polymyalgia rheumatica, SLE, viral arthritis and drug/serum sickness reactions.
o Asymmetrical: gout, PsA, ReA
o Monoarthritis: infx, crystals, trauma, tumor


• Assoc sxs to ask about w M/S do:

o fever, weight loss, fatigue, weakness
o scalp tenderness, vaginal burning, penile discharge,
o deformity, locking, giving way, snapping?
o Assoc eye, bowel, skin rash, oral ulcers, pleurisy?


• General PE for M/S do?

o Temp
o Eyes: inflammation
o Skin: rashes, vasculitis
o extensor aspects of forearms: nodules
o Shins: erythema nodosum
o Nail changes: PsA
o suspect rheumatic fever, listen to heart
o LA
o Other systems if indicated


• Categories of abnormality in a jt exam:

o Deformity
o Swelling (hard or soft?)
o Color Change
o Muscle atrophy
o Changes in ROM
o Changes in Gait


• Upper Extremity- ROM

o Observe dorsal and palmer surfaces for atrophy
o Spread all fingers (extension)
o Make a fist (flexion)
o Pronate and supinate with fist
o Flex/ext wrist, then elbow
o AROM of shoulder is all directions, place hands behind head of ext rotation assessment


• Lower Extremity- ROM

o Inspect (standing and lying)
o Hip flexion by lifting knee, then open for external rotation
o Return leg to neutral and internally rotate ankle for hip internal rotation
o Flex/extend knee
o Feel up the shin for cool knees
o Ballottement of the patella? Not the most sensitive test!


• Pattern of joint involvement for dos: Hands

o OA - DIPS, PIPS. rare MCP, wrist
o RA - PIPS, MCP’s, wrist. very rare DIPS
o Psoriatic - nails, asymmetric. DIP; PIP, MCP, sausage fingers
o SLE-similar to RA, interarticular dermatitis, periungual erythema
o Scleroderma - skin thickened, flexion contractures, Raynaud’s
o Crystal arthropathies, Sarcoidosis – DIP, PIP, MCP


• Jt patterns in elbow:

o loss of 180° of extension is early change in arthritis
o tennis elbow- pain w pressure over lat. Epicondyle


• jt patterns in shoulder:

o raise hands over head- assess ROM, weakness, pai
o RA- occ. Swellin
o bursitis- common are
o tendonitis- common


• jt patterns in feet and ankle:

o RA- rubbery below, front of, behind malleoli; MTP’s or whole midfoot swollen, tender
o ReA, PsA: IP synovitis
o Gout- IP synovitis, 1st MTP of great toe


• Jt patterns in spine:

o OA - ↓ cervical flexion, facet joints often affected
o Ankylosing spondylitis- ↓lumbar flexion, chest expansion
o Osteomyelitis, leukemia, CA, compression fxs, herniated disk- localized bone pain
o Fibromyalgia- trigger points


• Jt patterns in knee:

o look for meniscus tear, collateral ligament injuries, cruciate via M/S exam
o Assess for edema


• Jt patterns in hip:

o OA - large weight-bearing joints
o Arthritis- limp
o bursitis- tenderness over greater trochanter


• general labs for M/S dos:

o ESR- non-specific
o CRP- more sensitive
o Serum uric acid (gout)
o CBC: infx, anemia (of chronic dz)
o Urinalysis: any renal involvement (esp SLE)


• Antibodies in M/S dos:

o RF: not specific for RA. (-) in osteoarthritis, gout, rheumatic fever, reactive arthritis, infection arthritis, ulcerative colitis
o Anti-CCP (anti-cyclic citrullinated peptide antibody)- more specific than RF. RA. Also (+): SLE, Sjögren’s, TB
o ANA: SLE 95%, scleroderma 60 -70%, Sjorgen’s 50 - 60%, RA 20 - 50%, dermatomyositis 10-50%, polyarteritis 10%
o Anti-DNA, anti-Sm, anti-ribonucleoprotein- SLE


• Other assoc w M/S do:

o HLA-B27: spondyloarthropathies (AS), ReA, PsA
o Vit D def: many M/S dos


• X-rays for M/S dos:

o tumors, calcifications, cysts, jt space narrowing, Periarticular osteopenia
o useful first line investigation.
o Other imaging modalities may be needed


• Synovial fluid as a dx tool:

o Assess inflam, infx, hemorrhagic, crystals
o suspicion of septic arthritis (acute monoarthritis) → immediate aspiration of synovial fluid
o dx: crystal arthropathies and inflam conditions


• Types of causes of polyarthritis:

o Infx: viral, direct bacterial, reactive to bacterial, other infx
o Crystal arthropathy/metabolic disease
o Systemic rheumatological disease
o Systemic vasculitic disease
o Spondyloarthropathies
o Endocrine disease
o Malignancy
o Degenerative/structural
o Miscellaneous


• Viral infx causng polyarthritis:

o EBV, CMV, HBV, Mumps, HIV