INTRODUCTION

In order to diagnose and manage the patient presenting with musculoskeletal symptoms, it is important to distinguish whether the pathology is arising primarily in the so-called hard tissues (such as bone) or the soft tissues (such as cartilage, disc, synovium, capsule, muscle, tendon, tendon sheath). It is also important to distinguish between the two most common causes of musculoskeletal symptoms, namely inflammatory and degenerative.

HISTORY AND EXAMINATION

The history and physical examination are the two most important components of the diagnostic process for identifying the cause of musculoskeletal symptoms, and pattern recognition is the key to diagnosis.

Some arthropathies present with an acute onset of pain, with peak intensity reached within hours or days; in others it occurs gradually over weeks to months. The clinical pattern may be monarticular, oligoarticular or polyarticular. Variations of these patterns may occur within the same disorder. For example, rheumatoid arthritis may present as an acute monarthritis of the knee before spreading to other joints, or as an acute polyarthritis. Although almost any arthropathy may begin as a monarthritis, the initial pattern of certain disorders is characteristically monarticular, with pain, redness and swelling. Certain diagnoses, such as infection or crystal arthritis, should be suspected in this situation (see Box 33.2). Infectious monarthritis is an important diagnosis to make early, as joint damage can occur if untreated.

Chronic monarthritis is the presenting manifestation of a variety of joint disorders, some of which are listed in Box 33.3. Involvement of two to four joints is usually referred to as oligoarthritis. There are a number of conditions in which involvement of two or three joints rather than one may significantly narrow the differential diagnosis, including pseudogout and psoriatic arthritis. The third pattern is the one in which polyarticular involvement dominates the clinical picture. A variety of inflammatory and non-inflammatory disorders, both common and uncommon, may present as polyarthritis (see Table 33.1).

TABLE 33.1 Distribution of common oligo- and polyarthritides

FIGURE 33.1 Anatomy of knee: A anterior, B medial, C lateral and D posterior views

FIGURE 33.2 Anatomy of hip

FIGURE 33.3 Anatomy of ankle

FIGURE 33.4 Anatomy of shoulder

FIGURE 33.5 Anatomy of right elbow: A, B anterior and posterior views; C posterior view with 90° flexion; D lateral view

FIGURE 33.6 Anatomy of wrist

AETIOLOGY

The accepted aetiology of the common arthropathies is as follows:

DIAGNOSIS

As noted above, the history and physical examination are the two most important aspects of the diagnostic process in patients complaining of musculoskeletal systems. However, laboratory tests and imaging may help in confirming a suspected diagnosis or excluding certain conditions.

IMAGING PROCEDURES

X-rays

Plain X-rays often provide useful diagnostic information in patients with inflammatory or degenerative arthritis (see Table 33.2).

TABLE 33.2 Typical X-ray findings in osteoarthritis vs rheumatoid arthritis

	Osteoarthritis	Rheumatoid arthritis
Joint space narrowing	Yes	Yes
Erosions	No	Yes
Periarticular osteoporosis	No	Yes
Subchondral sclerosis	Yes	No

CT scanning

Computed tomography (CT) has become widely established as a tool for evaluating bone and soft tissue disorders. In many situations, CT scanning can provide additional information to that provided by plain X-rays because of its increase in dynamic range. It is generally more useful than plain X-rays for imaging of the spine. Subtle cortical and intra-osseous lesions can be visualised by CT. Multiplanar reconstruction helps to better image three-dimensional structures.

FIGURE 33.7 Rheumatoid arthritis

FIGURE 33.8 X-ray of rheumatoid arthritis. A Seen typically is narrowing of the carpal joint with subchondrial cyst formation (dark arrows) and periarticular erosions (white arrow). B Late changes include subluxation and ulnar derivation at the metacarpophalageal joint. C Silicone joint replacements (arrows) in a patient with rapidly progressing disease

Ultrasound

Ultrasound is a more expensive imaging modality used for a wide range of arthritic conditions. Tendon and muscle abnormalities such as rotator cuff tears can be diagnosed using the technique. Synovial effusions, synovial hypertrophy and inflammation can be evaluated using ultrasound. Power Doppler can be used for assessing synovial membrane inflammation. It is important to note that the effectiveness of ultrasound is very much dependent on the experience of the operator.

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