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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
PGUIFQBUJFOUTDPNQMBJOU'PSFYBNQMF BOLMFQBJODBOSFTVMU
GSPNBWBSJFUZPGQBUIPMPHJDDPOEJUJPOTJOWPMWJOHEJTQBSBUFBOBUPNJD
John J. Cush TUSVDUVSFT JODMVEJOHHPOPDPDDBMBSUISJUJT DBMDBOFBMGSBDUVSF "DIJMMFT
UFOEJOJUJT  QMBOUBS GBTDJJUJT  DFMMVMJUJT  BOE QFSJQIFSBM PS FOUSBQNFOU
OFVSPQBUIZ%JTUJOHVJTIJOHCFUXFFOBSUJDVMBSBOEOPOBSUJDVMBSDPOEJ-
.VTDVMPTLFMFUBM DPNQMBJOUT BDDPVOU GPS  NJMMJPO PVUQBUJFOU
UJPOTSFRVJSFTBDBSFGVMBOEEFUBJMFEFYBNJOBUJPO"SUJDVMBSTUSVDUVSFT
WJTJUT QFS ZFBS BOE PWFS  PG BMM PVUQBUJFOU WJTJUT JO UIF 6OJUFE
JODMVEFUIFTZOPWJVN TZOPWJBMGMVJE BSUJDVMBSDBSUJMBHF JOUSBBSUJDVMBS
4UBUFT5IF$FOUFSTGPS%JTFBTF$POUSPMBOE1SFWFOUJPOFTUJNBUFUIBU
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 BOEPWFSMZJOHTLJO NBZ
NBOZ QBUJFOUT XJMM IBWF TFMGMJNJUFE DPOEJUJPOT SFRVJSJOH NJOJNBM
CFJOWPMWFEJOUIFQBUIPMPHJDQSPDFTT"MUIPVHINVTDVMPTLFMFUBMDPN-
FWBMVBUJPO BOE POMZ TZNQUPNBUJD UIFSBQZ BOE SFBTTVSBODF  TQFDJGJD
QMBJOUT BSF PGUFO BTDSJCFE UP UIF KPJOUT  OPOBSUJDVMBS EJTPSEFST NPSF
NVTDVMPTLFMFUBMQSFTFOUBUJPOTPSUIFJSQFSTJTUFODFNBZIFSBMEBNPSF
GSFRVFOUMZ VOEFSMJF TVDI DPNQMBJOUT %JTUJOHVJTIJOH CFUXFFO UIFTF
TFSJPVTDPOEJUJPOUIBUSFRVJSFTGVSUIFSFWBMVBUJPOPSMBCPSBUPSZUFTUJOH
QPUFOUJBM TPVSDFT PG QBJO NBZ CF DIBMMFOHJOH UP UIF VOTLJMMFE FYBN-
UPFTUBCMJTIBEJBHOPTJT5IFHPBMPGUIFNVTDVMPTLFMFUBMFWBMVBUJPOJT
PART 15

JOFS"SUJDVMBSEJTPSEFSTNBZCFDIBSBDUFSJ[FECZEFFQPSEJGGVTFQBJO 
UPGPSNVMBUFBEJGGFSFOUJBMEJBHOPTJTUIBUMFBETUPBOBDDVSBUFEJBHOPTJT
QBJOPSMJNJUFESBOHFPGNPUJPOPOBDUJWFBOEQBTTJWFNPWFNFOU BOE
BOE UJNFMZ UIFSBQZ  XIJMF BWPJEJOH FYDFTTJWF EJBHOPTUJD UFTUJOH BOE
TXFMMJOH DBVTFECZTZOPWJBMQSPMJGFSBUJPO FGGVTJPO PSCPOZFOMBSHF-
VOOFDFTTBSZUSFBUNFOU(Table 393-1)5IFSFBSFTFWFSBMVSHFOUDPOEJ-
NFOU
 DSFQJUBUJPO  JOTUBCJMJUZ  iMPDLJOH w PS EFGPSNJUZ #Z DPOUSBTU 
UJPOTUIBUNVTUCFEJBHOPTFEQSPNQUMZUPBWPJETJHOJGJDBOUNPSCJEPS
OPOBSUJDVMBSEJTPSEFSTUFOEUPCFQBJOGVMPOBDUJWF CVUOPUQBTTJWF PS
NPSUBM TFRVFMBF 5IFTF iSFE GMBHw EJBHOPTFT JODMVEF TFQUJD BSUISJUJT 
BTTJTUFE
SBOHFPGNPUJPO1FSJBSUJDVMBSDPOEJUJPOTPGUFOEFNPOTUSBUF
BDVUFDSZTUBMJOEVDFEBSUISJUJT FH HPVU
BOEGSBDUVSF&BDINBZCF
QPJOUPSGPDBMUFOEFSOFTTJOSFHJPOTBEKBDFOUUPBSUJDVMBSTUSVDUVSFT BSF
Immune-Mediated, Inflammatory, and Rheumatologic Disorders

TVTQFDUFECZJUTBDVUFPOTFUBOENPOBSUJDVMBSPSGPDBMNVTDVMPTLFMFUBM
FMJDJUFEXJUIBTQFDJGJDNPWFNFOUPSQPTJUJPO BOEIBWFQIZTJDBMGJOE-
QBJO TFFCFMPX

JOHTSFNPUFGSPNUIFKPJOUDBQTVMF.PSFPWFS OPOBSUJDVMBSEJTPSEFST
%FTQJUFXFMMLOPXOMJOLTCFUXFFODFSUBJOEJTPSEFSTBOEMBCPSBUPSZ
TFMEPNEFNPOTUSBUFTXFMMJOH DSFQJUVT JOTUBCJMJUZ PSEFGPSNJUZPGUIF
UFTUJOH  UIF NBKPSJUZ PG JOEJWJEVBMT XJUI NVTDVMPTLFMFUBM DPNQMBJOUT
KPJOUJUTFMG
DBOCFEJBHOPTFEXJUIBUIPSPVHIIJTUPSZBOEBDPNQSFIFOTJWFQIZTJ-
DBM BOE NVTDVMPTLFMFUBM FYBNJOBUJPO 5IF JOJUJBM FODPVOUFS TIPVME INFLAMMATORY VERSUS NONINFLAMMATORY DISORDERS
EFUFSNJOF XIFUIFS UIF NVTDVMPTLFMFUBM 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
EFUFSNJOFUIFOBUVSFPGUIFVOEFSMZJOHQBUIPMPHJDQSPDFTTBOEXIFUIFS
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 
EJTPSEFSTNBZCFJOGFDUJPVT Neisseria gonorrhoeaePSMycobacterium

 acute PS chronic JO EVSBUJPO  BOE 
 localized (monarticular) PS
tuberculosis
 DSZTUBMJOEVDFE HPVU  QTFVEPHPVU
 JNNVOFSFMBUFE
widespread polyarticular
JOEJTUSJCVUJPO
SIFVNBUPJEBSUISJUJT<3"> TZTUFNJDMVQVTFSZUIFNBUPTVT<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
EJTPSEFSTNBZCFJEFOUJGJFECZBOZPGUIFGPVSDBSEJOBMTJHOTPGJOGMBN-
CF DIBSBDUFSJ[FE FH  BDVUF JOGMBNNBUPSZ NPOBSUISJUJT PS B DISPOJD
NBUJPO FSZUIFNB  XBSNUI  QBJO  PS TXFMMJOH
 TZTUFNJD TZNQUPNT
OPOJOGMBNNBUPSZ OPOBSUJDVMBSXJEFTQSFBEQBJO
UPOBSSPXUIFEJBH-
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 )PXFWFS  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
SFTFNCMFFBDIPUIFSBUUIFPVUTFU BOETPNFNBZUBLFXFFLTPSNPOUIT
NVTDVMPTLFMFUBMEJTPSEFST5IFEVSBUJPOPGTUJGGOFTTNBZCFQSPMPOHFE
CVU OPU ZFBST
 UP FWPMWF JOUP B SFDPHOJ[BCMF EJBHOPTUJD FOUJUZ 5IJT
IPVST
 XJUI JOGMBNNBUPSZ EJTPSEFST TVDI BT 3" PS QPMZNZBMHJB
DPOTJEFSBUJPOTIPVMEUFNQFSUIFEFTJSFUPFTUBCMJTIBEFGJOJUJWFEJBH-
SIFVNBUJDB
BOENBZJNQSPWFXJUIBDUJWJUZ#ZDPOUSBTU JOUFSNJUUFOU
OPTJTBUUIFGJSTUFODPVOUFS
TUJGGOFTT BMTPLOPXOBTHFMQIFOPNFOPO
JTUZQJDBMPGOPOJOGMBNNB-
UPSZDPOEJUJPOT TVDIBTPTUFPBSUISJUJT<0">
TIPSUFSJOEVSBUJPO 
TABLE 393-1 EVALUATION OF PATIENTS WITH MUSCULOSKELETAL COMPLAINTS NJO
BOEFYBDFSCBUFECZBDUJWJUZ'BUJHVFNBZBDDPNQBOZJOGMBNNB-
UJPO BT TFFO JO 3" BOE QPMZNZBMHJB SIFVNBUJDB
 CVU NBZ BMTP CF B
(PBMT
DPOTFRVFODF PG GJCSPNZBMHJB B OPOJOGMBNNBUPSZ EJTPSEFS
 DISPOJD
 "DDVSBUFEJBHOPTJT
QBJO QPPSTMFFQ EFQSFTTJPO BOFNJB DBSEJBDGBJMVSF FOEPDSJOPQBUIZ 
 5JNFMZQSPWJTJPOPGUIFSBQZ PSNBMOVUSJUJPO/POJOGMBNNBUPSZEJTPSEFSTNBZCFSFMBUFEUPUSBVNB
 "WPJEBODFPGVOOFDFTTBSZEJBHOPTUJDUFTUJOH SPUBUPSDVGGUFBS
SFQFUJUJWFVTF CVSTJUJT UFOEJOJUJT
EFHFOFSBUJPOPS
 *EFOUJGJDBUJPOPGBDVUF GPDBMNPOBSUJDVMBSiSFEGMBHwDPOEJUJPOT JOFGGFDUJWFSFQBJS 0"
OFPQMBTN QJHNFOUFEWJMMPOPEVMBSTZOPWJUJT

"QQSPBDI PS QBJO BNQMJGJDBUJPO GJCSPNZBMHJB
 /POJOGMBNNBUPSZ EJTPSEFST
 %FUFSNJOBUJPOPGDISPOPMPHZ BDVUFWTDISPOJD
BSFPGUFODIBSBDUFSJ[FECZQBJOXJUIPVUTZOPWJBMTXFMMJOHPSXBSNUI 
BCTFODFPGJOGMBNNBUPSZPSTZTUFNJDGFBUVSFT EBZUJNFHFMQIFOPNFOB
 %FUFSNJOBUJPOPGUIFOBUVSFPGUIFQBUIPMPHJDQSPDFTT JOGMBNNBUPSZWT
OPOJOGMBNNBUPSZ
SBUIFSUIBONPSOJOHTUJGGOFTT BOEOPSNBM GPSBHF
PSOFHBUJWFMBCPSB-
UPSZJOWFTUJHBUJPOT
 %FUFSNJOBUJPOPGUIFFYUFOUPGJOWPMWFNFOU NPOBSUJDVMBS QPMZBSUJDVMBS 
GPDBM XJEFTQSFBE
*EFOUJGJDBUJPO PG UIF OBUVSF PG UIF VOEFSMZJOH QSPDFTT BOE UIF TJUF
PGUIFDPNQMBJOUXJMMFOBCMFUIFFYBNJOFSUPDIBSBDUFSJ[FUIFNVTDV-
 "OBUPNJDMPDBMJ[BUJPOPGDPNQMBJOU BSUJDVMBSWTOPOBSUJDVMBS

MPTLFMFUBMQSFTFOUBUJPO FH BDVUFJOGMBNNBUPSZNPOBSUISJUJT DISPOJD


 $POTJEFSUIFNPTUDPNNPOEJTPSEFSTGJSTU
OPOJOGMBNNBUPSZ  OPOBSUJDVMBS XJEFTQSFBE QBJO
 OBSSPX UIF EJBH-
 'PSNVMBUFBEJGGFSFOUJBMEJBHOPTJT OPTUJDDPOTJEFSBUJPOT BOEBTTFTTUIFOFFEGPSJNNFEJBUFEJBHOPTUJDPS

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

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?
3Infectious arthritis 3. Are there systemic symptoms?
3Gout 4. Is the ESR or CRP elevated?
3Pseudogout
3Reactive 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
3Indolent infection
Is involvement
3Psoriatic arthritis
No Yes symmetric?
3Reactive arthritis
3Pauciarticular JIA No Yes
Unlikely to be osteoarthritis
Consider Osteoarthritis
Consider Are PIP, MCP, or
3Osteonecrosis 3Psoriatic arthritis MTP joints
3Charcot arthritis 3Reactive arthritis involved?

No Yes

Unlikely to be rheumatoid arthritis Rheumatoid


Consider
3SLE arthritis
3Scleroderma
3Polymyositis

FIGURE 3931 Algorithm for the diagnosis of musculoskeletal complaints."OBQQSPBDIUPGPSNVMBUJOHBEJGGFSFOUJBMEJBHOPTJT TIPXOJO


JUBMJDT
$.$ DBSQPNFUBDBSQBM$31 $SFBDUJWFQSPUFJO%*1 EJTUBMJOUFSQIBMBOHFBM&43 FSZUISPDZUFTFEJNFOUBUJPOSBUF+*" KVWFOJMFJEJPQBUIJD
BSUISJUJT.$1 NFUBDBSQPQIBMBOHFBM.51 NFUBUBSTPQIBMBOHFBM1*1 QSPYJNBMJOUFSQIBMBOHFBM1.3 QPMZNZBMHJBSIFVNBUJDB4-& TZTUFNJDMVQVT
FSZUIFNBUPTVT

UIFSBQFVUJD JOUFSWFOUJPO PS GPS DPOUJOVFE PCTFSWBUJPO Figure 393-1 TZOESPNFT BOEGJCSPNZBMHJBBSFBNPOHUIFNPTUDPNNPODBVTFTPG
QSFTFOUT BO BMHPSJUINJD BQQSPBDI UP UIF FWBMVBUJPO PG QBUJFOUT XJUI KPJOU QBJO  UIFTF TIPVME CF DPOTJEFSFE EVSJOH UIF JOJUJBM FODPVOUFS
NVTDVMPTLFMFUBMDPNQMBJOUT5IJTBQQSPBDISFMJFTPODMJOJDBMBOEIJT- *G UIFTF QPTTJCJMJUJFT BSF FYDMVEFE  PUIFS GSFRVFOUMZ PDDVSSJOH EJT-
UPSJDGFBUVSFT SBUIFSUIBOMBCPSBUPSZUFTUJOH UPEJBHOPTFNBOZDPN- PSEFST TIPVME CF DPOTJEFSFE BDDPSEJOH UP UIF QBUJFOUT BHF )FODF 
NPOSIFVNBUJDEJTPSEFST UIPTFZPVOHFSUIBOZFBSTBSFDPNNPOMZBGGFDUFECZSFQFUJUJWFVTF
"TJNQMFS BMUFSOBUJWFBQQSPBDIXPVMEDPOTJEFSUIFNPTUDPNNPOMZ TUSBJOEJTPSEFST HPVU NFOPOMZ
3" TQPOEZMPBSUISJUJT BOEVODPN-
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 BGGFDUFECZ0" DSZTUBM HPVUBOEQTFVEPHPVU
BSUISJUJT QPMZNZBMHJB
DPNQMBJOUTBSFTIPXOJOFig. 393-2#FDBVTFUSBVNB GSBDUVSF PWFSVTF SIFVNBUJDB PTUFPQPSPUJDGSBDUVSF BOEVODPNNPOMZ TFQUJDBSUISJUJT

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 EJTPSEFSTNBZCFDMBTTJGJFEBTFJUIFSGPDBMPSXJEFTQSFBE$PNQMBJOUT
More
TFDPOEBSZUPUFOEJOJUJTPSDBSQBMUVOOFMTZOESPNFBSFUZQJDBMMZGPDBM 
Orthopedic evaluation XIFSFBT XFBLOFTT BOE NZBMHJB  DBVTFE CZ QPMZNZPTJUJT PS GJCSPNZ-
BMHJB  BSF NPSF XJEFTQSFBE JO UIFJS QSFTFOUBUJPO +PJOU JOWPMWFNFOU
JO3"UFOETUPCFTZNNFUSJDBOEQPMZBSUJDVMBS#ZDPOUSBTU TQPOEZ-
Fibromyalgia
MPBSUISJUJT  SFBDUJWF BSUISJUJT  HPVU  BOE TBSDPJE BSF PGUFO BTZNNFUSJD
Age <60 years Age >60 years
BOEPMJHPBSUJDVMBS0"BOEQTPSJBUJDBSUISJUJTNBZCFFJUIFSTZNNFUSJD
PSBTZNNFUSJDBOEPMJHPPSQPMZBSUJDVMBS5IFVQQFSFYUSFNJUJFTBSF
Repetitive strain injury Osteoarthritis GSFRVFOUMZJOWPMWFEJO3"BOE0" XIFSFBTMPXFSFYUSFNJUZBSUISJUJTJT

FREQUENCY
(Tendinitis, Bursitis) DIBSBDUFSJTUJDPGSFBDUJWFBSUISJUJTBOEHPVUBUUIFJSPOTFU*OWPMWFNFOU
PGUIFBYJBMTLFMFUPOJTDPNNPOJO0"BOEBOLZMPTJOHTQPOEZMJUJTCVU
Gout JTJOGSFRVFOUJO3" XJUIUIFOPUBCMFFYDFQUJPOPGUIFDFSWJDBMTQJOF
Gout (males only) Pseudogout 5IF DMJOJDBM IJTUPSZ TIPVME BMTP JEFOUJGZ precipitating events 
TVDIBTUSBVNB PTUFPOFDSPTJT NFOJTDBMUFBS
ESVHBENJOJTUSBUJPO
(Table 393-2) BOUFDFEFOUPSJOUFSDVSSFOUJOGFDUJPO SIFVNBUJDGFWFS 
Rheumatoid arthritis Polymyalgia rheumatica
SFBDUJWFBSUISJUJT IFQBUJUJT
PSJMMOFTTFTUIBUNBZIBWFDPOUSJCVUFEUP
UIFQBUJFOUTDPNQMBJOU$FSUBJODPNPSCJEJUJFTNBZIBWFNVTDVMPTLFM-
Psoriatic, Reactive Osteoporotic fracture FUBM DPOTFRVFODFT 5IJT JT FTQFDJBMMZ TP GPS EJBCFUFT NFMMJUVT DBSQBM
PART 15

arthritis, IBD arthritis UVOOFMTZOESPNF


SFOBMJOTVGGJDJFODZ HPVU
EFQSFTTJPOPSJOTPNOJB
GJCSPNZBMHJB
 NZFMPNB MPX CBDL QBJO
 DBODFS NZPTJUJT
 BOE
Less PTUFPQPSPTJT GSBDUVSF
PSXIFOVTJOHDFSUBJOESVHTTVDIBTHMVDPDPS-
Infectious arthritis Septic arthritis
UJDPJET PTUFPOFDSPTJT TFQUJDBSUISJUJT
BOEEJVSFUJDTPSDIFNPUIFSBQZ
(GC, viral, bacterial, Lyme) (bacterial)
HPVU
 5BCMF

-BTUMZ BUIPSPVHIrheumatic review of systemsNBZEJTDMPTFVTFGVM
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

CPXFMEJTFBTF SBTI 4-& QTPSJBUJDBSUISJUJT
OBJMBCOPSNBMJUJFT QTPSJBUJDPSSFBDUJWF
BSUISJUJT
NZBMHJBT GJCSPNZBMHJB TUBUJOPSESVHJOEVDFENZPQBUIZ


5IFTFDPOEJUJPOTBSFCFUXFFOBOEUJNFTNPSFQSFWBMFOUUIBO TABLE 393-2 DRUG-INDUCED MUSCULOSKELETAL CONDITIONS


PUIFSTFSJPVTBVUPJNNVOFDPOEJUJPOT TVDIBT4-& TDMFSPEFSNB QPMZ- Arthralgias
NZPTJUJT BOEWBTDVMJUJT
 2VJOJEJOF DJNFUJEJOF CFUBCMPDLFST RVJOPMPOFT DISPOJDBDZDMPWJS JOUFS-
GFSPOT *- OJDBSEJQJOF WBDDJOFT SJGBCVUJO BSPNBUBTFBOE)*7QSPUFBTF
CLINICAL HISTORY JOIJCJUPST
"EEJUJPOBM IJTUPSJD GFBUVSFT NBZ SFWFBM JNQPSUBOU DMVFT UP UIF EJBH- Myalgias/myopathy
OPTJT"TQFDUTPGUIFQBUJFOUQSPGJMF DPNQMBJOUDISPOPMPHZ FYUFOUPG  (MVDPDPSUJDPJET QFOJDJMMBNJOF IZESPYZDIMPSPRVJOF ";5 MPWBTUBUJO TJN-
KPJOU JOWPMWFNFOU  BOE QSFDJQJUBUJOH GBDUPST DBO QSPWJEF JNQPSUBOU WBTUBUJO BUPSWBTUBUJO QSBWBTUBUJO DMPGJCSBUF BNJPEBSPOF JOUFSGFSPO *- 
JOGPSNBUJPO $FSUBJO EJBHOPTFT BSF NPSF GSFRVFOU JO EJGGFSFOU age BMDPIPM DPDBJOF QBDMJUBYFM EPDFUBYFM JNBUJOJCNFTZMBUF DPMDIJDJOF RVJOP-
HSPVQT4-&BOESFBDUJWFBSUISJUJTPDDVSNPSFGSFRVFOUMZJOUIFZPVOH  MPOFT DZDMPTQPSJOF UBDSPMJNVT QSPUFBTFJOIJCJUPST
XIFSFBT GJCSPNZBMHJB BOE 3" BSF GSFRVFOU JO NJEEMF BHF  BOE 0" Tendon rupture/tendinitis
BOE QPMZNZBMHJB SIFVNBUJDB BSF NPSF QSFWBMFOU BNPOH UIF FMEFSMZ  2VJOPMPOFT HMVDPDPSUJDPJET JTPUSFUJOPJO TUBUJOT DPMMBHFOBTFJOKFDUJPOT
%JBHOPTUJDDMVTUFSJOHJTBMTPFWJEFOUXIFOsexBOEraceBSFDPOTJEFSFE Gout
(PVU  TQPOEZMPBSUISJUJT  BOE BOLZMPTJOH TQPOEZMJUJT BSF NPSF DPN-
 %JVSFUJDT BTQJSJO DZUPUPYJDT DZDMPTQPSJOF BMDPIPM NPPOTIJOF FUIBNCV-
NPOJONFO XIFSFBT3" GJCSPNZBMHJB BOEMVQVTBSFNPSFGSFRVFOU UPM GSVDUPTFDPOUBJOJOHTPGUESJOLT
JO XPNFO Racial predilections NBZ CF FWJEFOU 5IVT  QPMZNZBMHJB
Drug-induced lupus
SIFVNBUJDB  HJBOU DFMM BSUFSJUJT  BOE HSBOVMPNBUPTJT XJUI QPMZBOHJJUJT
(1" GPSNFSMZ DBMMFE 8FHFOFST HSBOVMPNBUPTJT
 DPNNPOMZ BGGFDU  )ZESBMB[JOF QSPDBJOBNJEF RVJOJEJOF QIFOZUPJO DBSCBNB[FQJOF NFUIZM-
EPQB JTPOJB[JE DIMPSQSPNB[JOF MJUIJVN QFOJDJMMBNJOF UFUSBDZDMJOFT 5/'
XIJUFT  XIFSFBT TBSDPJEPTJT BOE 4-& NPSF DPNNPOMZ BGGFDU "GSJDBO JOIJCJUPST "$&JOIJCJUPST UJDMPQJEJOF
"NFSJDBOT Familial aggregation JT NPTU DPNNPO XJUI BOLZMPTJOH
Drug-induced subacute lupus
TQPOEZMJUJT HPVU BOE)FCFSEFOTOPEFTPG0"
5IFDISPOPMPHZPGUIFDPNQMBJOUJTBOJNQPSUBOUEJBHOPTUJDGFBUVSF  1SPUPOQVNQJOIJCJUPST DBMDJVNDIBOOFMCMPDLFST EJMUJB[FN
"$&
JOIJCJUPST 5/'JOIJCJUPST UFSCJOBGJOF JOUFSGFSPOT BOEB
QBDMJUBYFM 
BOEDBOCFEJWJEFEJOUPUIFonset, evolution BOEduration5IFPOTFU EPDFUBYFM )$5;
PGEJTPSEFSTTVDIBTTFQUJDBSUISJUJTPSHPVUUFOETUPCFBCSVQU XIFSFBT
Osteonecrosis
0" 3" BOEGJCSPNZBMHJBNBZIBWFNPSFJOEPMFOUQSFTFOUBUJPOT5IF
QBUJFOUTDPNQMBJOUTNBZFWPMWFEJGGFSFOUMZBOECFDMBTTJGJFEBTDISPOJD  (MVDPDPSUJDPJET BMDPIPM SBEJBUJPO CJTQIPTQIPOBUFT
0"
 JOUFSNJUUFOU DSZTUBM PS -ZNF BSUISJUJT
 NJHSBUPSZ SIFVNBUJD Osteopenia
GFWFS HPOPDPDDBMPSWJSBMBSUISJUJT
PSBEEJUJWF 3" QTPSJBUJDBSUISJ-  (MVDPDPSUJDPJET DISPOJDIFQBSJO QIFOZUPJO
UJT
 .VTDVMPTLFMFUBM EJTPSEFST BSF UZQJDBMMZ DMBTTJGJFE BT BDVUF PS Scleroderma
DISPOJDCBTFEPOBTZNQUPNEVSBUJPOUIBUJTFJUIFSMFTTUIBOPSHSFBUFS  7
 JOZMDIMPSJEF CMFPNZDJO CBSJDJUJOJC QFOUB[PDJOF PSHBOJDTPMWFOUT DBSCJ-
UIBOXFFLT SFTQFDUJWFMZ"DVUFBSUISPQBUIJFTUFOEUPCFJOGFDUJPVT  EPQB USZQUPQIBO SBQFTFFEPJM
DSZTUBMJOEVDFE  PS SFBDUJWF $ISPOJD DPOEJUJPOT JODMVEF OPOJOGMBN- Vasculitis
NBUPSZ PS JNNVOPMPHJD BSUISJUJEFT FH  0"  3"
 BOE OPOBSUJDVMBS  "MMPQVSJOPM BNQIFUBNJOFT DPDBJOF PGUFOMFWBNJTPMFBEVMUFSBUFE
UIJB-
EJTPSEFST FH GJCSPNZBMHJB
 [JEFT QFOJDJMMBNJOF QSPQZMUIJPVSBDJM NPOUFMVLBTU 5/'JOIJCJUPST IFQBUJUJT#
5IFextentPSdistributionPGBSUJDVMBSJOWPMWFNFOUJTPGUFOJOGPS- WBDDJOF USJNFUIPQSJNTVMGBNFUIPYB[PMF NJOPDZDMJOF IZESBMB[JOF
NBUJWF "SUJDVMBS EJTPSEFST BSF DMBTTJGJFE CBTFE PO UIF OVNCFS PG Abbreviations:"$& BOHJPUFOTJODPOWFSUJOHFO[ZNF";5 [JEPWVEJOF)$5; IZESPDIMP-
KPJOUT JOWPMWFE  BT FJUIFS monarticular POF KPJOU
 oligoarticular PS SPUIJB[JEF*- JOUFSMFVLJO5/' UVNPSOFDSPTJTGBDUPS

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


PSXFBLOFTT QPMZNZPTJUJT OFVSPQBUIZ
*OBEEJUJPO TPNFDPOEJUJPOT PGBNVTDVMPTLFMFUBMDPOEJUJPO-BTUMZ PWFSMZBHHSFTTJWFBOEVOGPDVTFE 2219
BSFBTTPDJBUFEXJUIJOWPMWFNFOUPGPUIFSPSHBOTZTUFNTJODMVEJOHUIF MBCPSBUPSZ UFTUJOH XJMM PGUFO ZJFME BCOPSNBM GJOEJOHT UIBU BSF CFUUFS
FZFT #FIFUTEJTFBTF TBSDPJEPTJT TQPOEZMPBSUISJUJT
HBTUSPJOUFTUJOBM FYQMBJOFECZUIFQBUJFOUTQSFFYJTUJOHDPOEJUJPO T
SBUIFSUIBOBOFX
USBDU TDMFSPEFSNB  JOGMBNNBUPSZ CPXFM EJTFBTF
 HFOJUPVSJOBSZ USBDU JOGMBNNBUPSZPSBVUPJNNVOFEJTPSEFS
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 UIFOBUVSFPGUIFVOEFSMZJOHQBUIPMPHZ UIFGVODUJPOBMDPO-
5IFJODJEFODFPGSIFVNBUJDEJTFBTFTSJTFTXJUIBHF TVDIUIBUPG TFRVFODFTPGUIFQSPDFTT BOEUIFQSFTFODFPGTZTUFNJDPSFYUSBBSUJDVMBS
UIPTFZFBSTXJMMIBWFKPJOUDPNQMBJOUT.VTDVMPTLFMFUBMEJTPSEFST NBOJGFTUBUJPOT"LOPXMFEHFPGUPQPHSBQIJDBOBUPNZJTOFDFTTBSZUP
JOFMEFSMZQBUJFOUTBSFPGUFOOPUEJBHOPTFECFDBVTFUIFTJHOTBOETZNQ- 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
PGMBCPSBUPSZUFTUJOHJOUIFFMEFSMZ XIPPGUFONBOJGFTUOPOQBUIPMPHJD TQFDJGJD QIZTJDBM NBOFVWFST UP FMJDJU EJBHOPTUJD TJHOT (Table 393-3)
BCOPSNBMSFTVMUT'PSFYBNQMF UIF&43NBZCFNJTMFBEJOHMZFMFWBUFE  "MUIPVHI NPTU BSUJDVMBUJPOT PG UIF BQQFOEJDVMBS TLFMFUPO DBO CF
BOEMPXUJUFSQPTJUJWFUFTUTGPSSIFVNBUPJEGBDUPSBOEBOUJOVDMFBSBOUJ- FYBNJOFEJOUIJTNBOOFS BEFRVBUFJOTQFDUJPOBOEQBMQBUJPOBSFOPU
CPEJFT "/"T
NBZCFTFFOJOVQUPPGFMEFSMZQBUJFOUT"MUIPVHI QPTTJCMF GPS NBOZ BYJBM FH  [ZHBQPQIZTFBM
 BOE JOBDDFTTJCMF FH 
OFBSMZBMMSIFVNBUJDEJTPSEFSTBGGMJDUUIFFMEFSMZ HFSJBUSJDQBUJFOUTBSF TBDSPJMJBDPSIJQ
KPJOUT'PSTVDIKPJOUT UIFSFJTBHSFBUFSSFMJBODFPO
QBSUJDVMBSMZ QSPOF UP 0"  PTUFPQPSPTJT  PTUFPQPSPUJD GSBDUVSFT  HPVU  TQFDJGJDNBOFVWFSTBOEJNBHJOHGPSBTTFTTNFOU
QTFVEPHPVU  QPMZNZBMHJB SIFVNBUJDB  WBTDVMJUJT  BOE ESVHJOEVDFE &YBNJOBUJPO PG JOWPMWFE BOE VOJOWPMWFE KPJOUT XJMM EFUFSNJOF

CHAPTER 393 Approach to Articular and Musculoskeletal Disorders


EJTPSEFST 5BCMF
5IFFMEFSMZTIPVMECFBQQSPBDIFEJOUIFTBNF XIFUIFSpain warmth erythema PSswellingJTQSFTFOU5IFMPDBMFBOE
NBOOFS BT PUIFS QBUJFOUT XJUI NVTDVMPTLFMFUBM DPNQMBJOUT  CVU XJUI MFWFMPGQBJOFMJDJUFECZQBMQBUJPOPSNPWFNFOUTIPVMECFRVBOUJGJFE
BO FNQIBTJT PO JEFOUJGZJOH UIF QPUFOUJBM SIFVNBUJD DPOTFRVFODFT PG 0OFTUBOEBSEXPVMECFUPDPVOUUIFOVNCFSPGUFOEFSKPJOUTPOQBM-
NFEJDBMDPNPSCJEJUJFTBOEUIFSBQJFT5IFQIZTJDBMFYBNJOBUJPOTIPVME QBUJPOPGFBTJMZFYBNJOFEKPJOUT QSPYJNBMJOUFSQIBMBOHFBMT NFUB-
JEFOUJGZUIFOBUVSFPGUIFNVTDVMPTLFMFUBMDPNQMBJOUBTXFMMBTDPFY- DBSQPQIBMBOHFBMT  XSJTUT  FMCPXT  TIPVMEFST  BOE LOFFT
 4JNJMBSMZ 
JTUJOHEJTFBTFTUIBUNBZJOGMVFODFEJBHOPTJTBOEDIPJDFPGUSFBUNFOU UIF OVNCFS PG TXPMMFO KPJOUT o
 DBO CF DPVOUFE BOE SFDPSEFE
$BSFGVMFYBNJOBUJPOTIPVMEEJTUJOHVJTICFUXFFOUSVFBSUJDVMBSTXFMM-
RHEUMATOLOGIC EVALUATION OF THE HOSPITALIZED PATIENT JOH DBVTFE CZ CPOZ IZQFSUSPQIZ  TZOPWJBM FGGVTJPO PS QSPMJGFSBUJPO

BOEOPOBSUJDVMBS PSQFSJBSUJDVMBS
JOWPMWFNFOU XIJDIVTVBMMZFYUFOET
&WBMVBUJPOPGBIPTQJUBMJ[FEQBUJFOUXJUISIFVNBUJDDPNQMBJOUTEJGGFST CFZPOE UIF OPSNBM KPJOU NBSHJOT 4ZOPWJBM FGGVTJPO DBO CF EJTUJO-
GSPNUIBUPGBOPVUQBUJFOU PXJOHUPHSFBUFSTZNQUPNTFWFSJUZ NPSF HVJTIFEGSPNTZOPWJBMIZQFSUSPQIZPSCPOZIZQFSUSPQIZCZQBMQBUJPO
BDVUF QSFTFOUBUJPOT  BOE HSFBUFS JOUFSQMBZ PG DPNPSCJEJUJFT 1BUJFOUT PSTQFDJGJDNBOFVWFST'PSFYBNQMF TNBMMUPNPEFSBUFLOFFFGGVTJPOT
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
BSFPGUFOGPDBM QFSJBSUJDVMBS PWFSMJFCPOZQSPNJOFODFT BOEBSF
UJPOPSEFUFSJPSBUJPOPGBOFYJTUJOHBVUPJNNVOFEJTPSEFS FH 4-&
 GMVDUVBOUXJUITIBSQMZEFGJOFECPSEFST+PJOUstabilityDBOCFBTTFTTFE
PS 
OFXNFEJDBMDPNPSCJEJUJFT FH UISPNCPUJDFWFOU MZNQIPNB  CZTUBCJMJ[JOHUIFQSPYJNBMKPJOU CZQBMQBUJPO BOECZUIFBQQMJDBUJPO
JOGFDUJPO
BSJTJOHJOQBUJFOUTXJUIBOFTUBCMJTIFESIFVNBUJDEJTPSEFS 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
XJEFTQSFBEQBJOPSTFSPMPHJDBCOPSNBMJUJFTPSGPSUIFJOJUJBUJPOPGOFX
UIFSBQJFT
"DVUF NPOBSUJDVMBS JOGMBNNBUPSZ BSUISJUJT NBZ CF B iSFE GMBHw TABLE 393-3 GLOSSARY OF MUSCULOSKELETAL TERMS
DPOEJUJPO FH  TFQUJD BSUISJUJT  HPVU  QTFVEPHPVU
 UIBU XJMM SFRVJSF Crepitus
BSUISPDFOUFTJT BOE  PO PDDBTJPO  IPTQJUBMJ[BUJPO JG JOGFDUJPO JT TVT-  "QBMQBCMF MFTTDPNNPOMZBVEJCMF
WJCSBUPSZPSDSBDLMJOHTFOTBUJPOFMJD-
QFDUFE )PXFWFS  OFXPOTFU JOGMBNNBUPSZ QPMZBSUISJUJT XJMM IBWF JUFEXJUIKPJOUNPUJPOGJOFKPJOUDSFQJUVTJTDPNNPOBOEPGUFOJOTJHOJGJ-
B XJEFS EJGGFSFOUJBM EJBHOPTJT FH  3"  IFQBUJUJTSFMBUFE BSUISJUJT  DBOUJOMBSHFKPJOUTDPBSTFKPJOUDSFQJUVTJOEJDBUFTBEWBODFEDBSUJMBHJOPVT
TFSVN TJDLOFTT  ESVHJOEVDFE MVQVT  QPMZBSUJDVMBS TFQUJD BSUISJUJT
 BOEEFHFOFSBUJWFDIBOHFT BTJOPTUFPBSUISJUJT

BOENBZSFRVJSFUBSHFUFEMBCPSBUPSZJOWFTUJHBUJPOTSBUIFSUIBOTZOP- Subluxation
WJBM GMVJE BOBMZTFT 1BUJFOUT XJUI GFCSJMF  NVMUJTZTUFN EJTPSEFST XJMM  "
 MUFSBUJPOPGKPJOUBMJHONFOUTVDIUIBUBSUJDVMBUJOHTVSGBDFTJODPNQMFUFMZ
SFRVJSFFYDMVTJPOPGDSZTUBM JOGFDUJPVT PSOFPQMBTUJDFUJPMPHJFTBOEBO BQQSPYJNBUFFBDIPUIFS
FWBMVBUJPOESJWFOCZUIFEPNJOBOUTZNQUPNGJOEJOHXJUIUIFHSFBU- Dislocation
FTUTQFDJGJDJUZ$POEJUJPOTXPSUIZPGDPOTJEFSBUJPONBZJODMVEFHPVU  "COPSNBMEJTQMBDFNFOUPGBSUJDVMBUJOHTVSGBDFTTVDIUIBUUIFTVSGBDFTBSF
PSQTFVEPHPVU WBTDVMJUJT HJBOUDFMMBSUFSJUJTJOUIFFMEFSMZPSQPMZBS- OPUJODPOUBDU
UFSJUJT OPEPTB JO ZPVOHFS QBUJFOUT
 BEVMUPOTFU 4UJMMT EJTFBTF  4-&  Range of motion
BOUJQIPTQIPMJQJE BOUJCPEZ TZOESPNF  BOE TBSDPJEPTJT #FDBVTF UIF  'PSEJBSUISPEJBMKPJOUT UIFBSDPGNFBTVSBCMFNPWFNFOUUISPVHIXIJDI
NJTEJBHOPTJTPGDPOOFDUJWFUJTTVFEJTPSEFSTJTDPNNPO QBUJFOUTXIP UIFKPJOUNPWFTJOBTJOHMFQMBOF
QSFTFOU XJUI B SFQPSUFE QSFFYJTUJOH SIFVNBUJD DPOEJUJPO FH  4-&  Contracture
3" BOLZMPTJOHTQPOEZMJUJT
TIPVMEIBWFUIFJSEJBHOPTJTDPOGJSNFECZ
 -PTTPGGVMMNPWFNFOUSFTVMUJOHGSPNBGJYFESFTJTUBODFDBVTFEFJUIFSCZ
DBSFGVMIJTUPSZ QIZTJDBMBOENVTDVMPTLFMFUBMFYBNJOBUJPO BOESFWJFX UPOJDTQBTNPGNVTDMF SFWFSTJCMF
PSCZGJCSPTJTPGQFSJBSUJDVMBSTUSVDUVSFT
PGUIFJSNFEJDBMSFDPSET*UJTJNQPSUBOUUPOPUFUIBUXIFOFTUBCMJTIFE QFSNBOFOU

SIFVNBUJD EJTFBTF QBUJFOUT BSF BENJUUFE UP UIF IPTQJUBM  JU JT VTVBMMZ Deformity
OPU GPS B NFEJDBM QSPCMFN SFMBUFE UP UIFJS BVUPJNNVOF EJTFBTF  CVU
 "COPSNBMTIBQFPSTJ[FSFTVMUJOHGSPNCPOZIZQFSUSPQIZ NBMBMJHONFOUPG
SBUIFSCFDBVTFPGFJUIFSBDPNPSCJEDPOEJUJPOPSDPNQMJDBUJPOPGESVH BSUJDVMBUJOHTUSVDUVSFT PSEBNBHFUPQFSJBSUJDVMBSTVQQPSUJWFTUSVDUVSFT
UIFSBQZ1BUJFOUTXJUIDISPOJDJOGMBNNBUPSZEJTPSEFST FH 3" 4-& 
Enthesitis
QTPSJBTJT
IBWFBOBVHNFOUFESJTLPGJOGFDUJPO DBSEJPWBTDVMBSFWFOUT 
 *OGMBNNBUJPOPGUIFFOUIFTFT UFOEJOPVTPSMJHBNFOUPVTJOTFSUJPOTPO
BOEOFPQMBTJB
CPOF

$FSUBJODPOEJUJPOT TVDIBTBDVUFHPVU DBOCFQSFDJQJUBUFEJOIPTQJ-


Epicondylitis
UBMJ[FEQBUJFOUTCZTVSHFSZ EFIZESBUJPO PSPUIFSFWFOUTBOETIPVMECF
DPOTJEFSFEXIFOIPTQJUBMJ[FEQBUJFOUTBSFFWBMVBUFEGPSUIFBDVUFPOTFU  *OGFDUJPOPSJOGMBNNBUJPOJOWPMWJOHBOFQJDPOEZMF

HPIM19_Part15_p2103-p2250.indd 2219 1/23/15 10:50 AM


2220 DBVTFT  DBO CF BTTFTTFE CZ JOTQFDUJPO BOE QBMQBUJPO +PJOU swelling
PS volume DBO CF BTTFTTFE CZ QBMQBUJPO %JTUFOUJPO PG UIF BSUJDVMBS
DBQTVMF VTVBMMZ DBVTFT QBJO BOE FWJEFOU FOMBSHFNFOU PS GMVDUVBODF
5IFQBUJFOUXJMMBUUFNQUUPNJOJNJ[FUIFQBJOCZNBJOUBJOJOHUIFKPJOU
JO UIF QPTJUJPO PG MFBTU JOUSBBSUJDVMBS QSFTTVSF BOE HSFBUFTU WPMVNF 
VTVBMMZ QBSUJBM GMFYJPO 'PS UIJT SFBTPO  JOGMBNNBUPSZ FGGVTJPOT NBZ
HJWF SJTF UP GMFYJPO DPOUSBDUVSFT $MJOJDBMMZ  UIJT NBZ CF EFUFDUFE BT DIP: OA,
GMVDUVBOU PS iTRVJTIZw TXFMMJOH JO MBSHFS KPJOUT BOE HSBQFMJLF DPN- psoriatic or
QSFTTJCJMJUZJOTNBMMFSKPJOUT*OGMBNNBUJPONBZSFTVMUJOGJYFEGMFYJPO reactive arthritis
EFGPSNJUJFTPSEJNJOJTIFESBOHFPGNPUJPOFTQFDJBMMZPOFYUFOTJPO 
PIP: OA, SLE,
XIFOJOUSBBSUJDVMBSQSFTTVSFJTJODSFBTFE"DUJWFBOEQBTTJWFrange of
RA, psoriatic arthritis
motionTIPVMECFBTTFTTFEJOBMMQMBOFT XJUIDPOUSBMBUFSBMDPNQBSJTPO
" HPOJPNFUFS NBZ CF VTFE UP RVBOUJGZ UIF BSD PG NPWFNFOU &BDI
KPJOUTIPVMECFQBTTJWFMZNBOJQVMBUFEUISPVHIJUTGVMMSBOHFPGNPUJPO MCP: RA,
JODMVEJOH  BT BQQSPQSJBUF  GMFYJPO  FYUFOTJPO  SPUBUJPO  BCEVDUJPO  pseudogout,
hemochromatosis
BEEVDUJPO  MBUFSBM CFOEJOH  JOWFSTJPO  FWFSTJPO  TVQJOBUJPO  QSPOB-
UJPO  NFEJBMMBUFSBM EFWJBUJPO  BOE QMBOUBS PS EPSTJGMFYJPO
 &YUSFNF 1st CMC: OA
SBOHFPGNPUJPONBZCFTFFOXJUIIZQFSNPCJMJUZTZOESPNF XJUIKPJOU
QBJOBOEDPOOFDUJWFUJTTVFMBYJUZ PGUFOBTTPDJBUFEXJUI&IMFST%BOMPT
Wrist: RA,
PS .BSGBOT TZOESPNF -JNJUBUJPO PG NPUJPO JT GSFRVFOUMZ DBVTFE CZ de Quervain's pseudogout,
JOGMBNNBUJPO  FGGVTJPO  QBJO  EFGPSNJUZ  DPOUSBDUVSF  PS SFTUSJDUJPO tenosynovitis gonococcal arthritis,
PART 15

GSPNOFVSPNZPQBUIJDDBVTFT*GQBTTJWFNPUJPOFYDFFETBDUJWFNPUJPO  juvenile arthritis,


BQFSJBSUJDVMBSQSPDFTT FH UFOEJOJUJT UFOEPOSVQUVSF PSNZPQBUIZ
 carpal tunnel syndrome
TIPVME CF DPOTJEFSFE Contractures NBZ SFGMFDU BOUFDFEFOU TZOPWJBM
JOGMBNNBUJPO PS USBVNB .JOPS KPJOU crepitus JT DPNNPO EVSJOH
KPJOUQBMQBUJPOBOENBOFVWFSTCVUPOMZJOEJDBUFTTJHOJGJDBOUDBSUJMBHF FIGURE 3933 Sites of hand or wrist involvement and their poten-
EFHFOFSBUJPOBTJUCFDPNFTDPBSTFS FH 0"
+PJOUdeformityVTVBMMZ tial disease associations.$.$ DBSQPNFUBDBSQBM%*1 EJTUBMJOUFSQIB-
JOEJDBUFTBMPOHTUBOEJOHPSBHHSFTTJWFQBUIPMPHJDQSPDFTT%FGPSNJUJFT MBOHFBM.$1 NFUBDBSQPQIBMBOHFBM0" PTUFPBSUISJUJT1*1 QSPYJNBM
Immune-Mediated, Inflammatory, and Rheumatologic Disorders

NBZSFTVMUGSPNMJHBNFOUPVTEFTUSVDUJPO TPGUUJTTVFDPOUSBDUVSF CPOZ JOUFSQIBMBOHFBM3" SIFVNBUPJEBSUISJUJT4-& TZTUFNJDMVQVTFSZUIF-


FOMBSHFNFOU  BOLZMPTJT  FSPTJWF EJTFBTF  TVCMVYBUJPO  USBVNB  PS MPTT NBUPTVT(From JJ Cush et al: Evaluation of musculoskeletal complaints,
PG QSPQSJPDFQUJPO &YBNJOBUJPO PG UIF NVTDVMBUVSF XJMM EPDVNFOU in Rheumatology: Diagnosis and Therapeutics, 2nd ed, JJ Cush et al [eds].
TUSFOHUI  BUSPQIZ  QBJO  PS TQBTN "QQFOEJDVMBS NVTDMF XFBLOFTT Philadelphia, Lippincott Williams & Wilkins, 2005, pp 320. Used with
TIPVMECFDIBSBDUFSJ[FEBTQSPYJNBMPSEJTUBM.VTDMFTUSFOHUITIPVME permission from Dr. John J. Cush.)
CFBTTFTTFECZPCTFSWJOHUIFQBUJFOUTQFSGPSNBODF FH XBMLJOH SJT-
JOHGSPNBDIBJS HSBTQJOH XSJUJOH
4USFOHUINBZBMTPCFHSBEFEPOB
QPJOUTDBMFGPSOPNPWFNFOUGPSUSBDFNPWFNFOUPSUXJUDI
GPSNPWFNFOUXJUIHSBWJUZFMJNJOBUFEGPSNPWFNFOUBHBJOTUHSBWJUZ JOWPMWJOH UIF CBTF PG UIF UIVNC GJSTU DBSQPNFUBDBSQBM KPJOU
 JT BMTP
POMZGPSNPWFNFOUBHBJOTUHSBWJUZBOESFTJTUBODFBOEGPSOPSNBM IJHIMZ TVHHFTUJWF PG 0" #Z DPOUSBTU  3" UFOET UP DBVTF TZNNFUSJD 
TUSFOHUI5IFFYBNJOFSTIPVMEBTTFTTGPSPGUFOPWFSMPPLFEOPOBSUJDV- QPMZBSUJDVMBS JOWPMWFNFOU PG UIF 1*1  NFUBDBSQPQIBMBOHFBM .$1

MBSPSQFSJBSUJDVMBSJOWPMWFNFOU FTQFDJBMMZXIFOBSUJDVMBSDPNQMBJOUT JOUFSDBSQBM BOEDBSQPNFUBDBSQBMKPJOUT XSJTU
XJUIQBJOBOEQBMQBCMF
BSFOPUTVQQPSUFECZPCKFDUJWFGJOEJOHTSFGFSBCMFUPUIFKPJOUDBQTVMF TZOPWJBMUJTTVFIZQFSUSPQIZ1TPSJBUJDBSUISJUJTNBZNJNJDUIFQBUUFSO
5IFJEFOUJGJDBUJPOPGTPGUUJTTVFOPOBSUJDVMBSQBJOXJMMQSFWFOUVOXBS- PGKPJOUJOWPMWFNFOUTFFOJO0" %*1BOE1*1KPJOUT
CVUDBOCFEJT-
SBOUFEBOEPGUFOFYQFOTJWFBEEJUJPOBMFWBMVBUJPOT4QFDJGJDNBOFVWFST UJOHVJTIFECZUIFQSFTFODFPGJOGMBNNBUPSZTJHOT FSZUIFNB XBSNUI 
NBZSFWFBMDPNNPOOPOBSUJDVMBSBCOPSNBMJUJFT TVDIBTBDBSQBMUVO- TZOPWJBMTXFMMJOH
XJUIPSXJUIPVUDBSQBMJOWPMWFNFOU OBJMQJUUJOH PS
OFM TZOESPNF XIJDI DBO CF JEFOUJGJFE CZ 5JOFMT PS 1IBMFOT TJHO
 POZDIPMZTJT8IFSFBTMBUFSBMPSNFEJBMTVCMVYBUJPOTBUUIF1*1PS%*1
0UIFSFYBNQMFTPGTPGUUJTTVFBCOPSNBMJUJFTJODMVEFPMFDSBOPOCVSTJUJT  KPJOUT BSF NPTU MJLFMZ EVF UP JOGMBNNBUPSZ 0" PS QTPSJBUJD BSUISJUJT 
FQJDPOEZMJUJT FH  UFOOJT FMCPX
 FOUIFTJUJT FH  "DIJMMFT UFOEJOJUJT
 EPSTBM PS WFOUSBM EFGPSNJUJFT TXBO OFDL PS CPVUPOOJSF EFGPSNJ-
BOEUFOEFSUSJHHFSQPJOUTBTTPDJBUFEXJUIGJCSPNZBMHJB UJFT
BSFUZQJDBMPG3")FNPDISPNBUPTJTTIPVMECFDPOTJEFSFEXIFO
EFHFOFSBUJWFDIBOHFT CPOZIZQFSUSPQIZ
BSFTFFOBUUIFTFDPOEBOE
APPROACH TO REGIONAL RHEUMATIC COMPLAINTS UIJSE .$1 KPJOUT XJUI BTTPDJBUFE SBEJPHSBQIJD DIPOESPDBMDJOPTJT PS
"MUIPVHI BMM QBUJFOUT TIPVME CF FWBMVBUFE JO B MPHJDBM BOE UIPSPVHI FQJTPEJD JOGMBNNBUPSZXSJTUBSUISJUJT
NBOOFS NBOZDBTFTXJUIGPDBMNVTDVMPTLFMFUBMDPNQMBJOUTBSFDBVTFE %BDUZMJUJTNBOJGFTUTBTTPGUUJTTVFTXFMMJOHPGUIFXIPMFEJHJUBOENBZ
CZ DPNNPOMZ FODPVOUFSFE EJTPSEFST UIBU FYIJCJU B QSFEJDUBCMF QBU- IBWF B TBVTBHFMJLF BQQFBSBODF $PNNPO DBVTFT PG EBDUZMJUJT JODMVEF
UFSOPGPOTFU FWPMVUJPO BOEMPDBMJ[BUJPOUIFZDBOPGUFOCFEJBHOPTFE QTPSJBUJD BSUISJUJT  TQPOEZMPBSUISJUJT  KVWFOJMF TQPOEZMJUJT  NJYFE DPO-
JNNFEJBUFMZPOUIFCBTJTPGMJNJUFEIJTUPSJDJOGPSNBUJPOBOETFMFDUFE OFDUJWF UJTTVF EJTFBTF  TDMFSPEFSNB  TBSDPJEPTJT  BOE TJDLMF DFMM EJTFBTF
NBOFVWFSTPSUFTUT"MUIPVHIOFBSMZFWFSZKPJOUDPVMECFBQQSPBDIFE 4PGU UJTTVF TXFMMJOH PWFS UIF EPSTVN PG UIF IBOE BOE XSJTU NBZ TVH-
JO UIJT NBOOFS  UIF FWBMVBUJPO PG GPVS DPNNPO JOWPMWFE BOBUPNJD HFTU BO JOGMBNNBUPSZ FYUFOTPS UFOEPO UFOPTZOPWJUJT QPTTJCMZ DBVTFE
SFHJPOTUIFIBOE TIPVMEFS IJQ BOELOFFBSFSFWJFXFEIFSF CZ HPOPDPDDBM JOGFDUJPO  HPVU  PS JOGMBNNBUPSZ BSUISJUJT FH  3"

5FOPTZOPWJUJT JT TVHHFTUFE CZ MPDBMJ[FE XBSNUI  TXFMMJOH  PS QJUUJOH
HAND PAIN FEFNBBOENBZCFDPOGJSNFEXIFOUIFTPGUUJTTVFTXFMMJOHUSBDLTXJUI
'PDBMPSVOJMBUFSBMIBOEQBJONBZSFTVMUGSPNUSBVNB PWFSVTF JOGFD- UFOEPO NPWFNFOU  TVDI BT GMFYJPO BOE FYUFOTJPO PG GJOHFST  PS XIFO
UJPO  PS B SFBDUJWF PS DSZTUBMJOEVDFE BSUISJUJT #Z DPOUSBTU  CJMBUFSBM QBJO JT JOEVDFE XIJMF TUSFUDIJOH UIF FYUFOTPS UFOEPO TIFBUIT GMFYJOH
IBOE DPNQMBJOUT DPNNPOMZ TVHHFTU B EFHFOFSBUJWF FH  0"
 TZT- UIFEJHJUTEJTUBMUPUIF.$1KPJOUTBOENBJOUBJOJOHUIFXSJTUJOBGJYFE 
UFNJD PSJOGMBNNBUPSZJNNVOF FH 3"
FUJPMPHZ5IFEJTUSJCVUJPO OFVUSBMQPTJUJPO

PSQBUUFSOPGKPJOUJOWPMWFNFOUJTIJHIMZTVHHFTUJWFPGDFSUBJOEJTPSEFST 'PDBMXSJTUQBJOMPDBMJ[FEUPUIFSBEJBMBTQFDUNBZCFDBVTFECZEF
(Fig. 393-3) 5IVT  0" PS EFHFOFSBUJWF BSUISJUJT
 NBZ NBOJGFTU BT 2VFSWBJOT UFOPTZOPWJUJT SFTVMUJOH GSPN JOGMBNNBUJPO PG UIF UFOEPO
EJTUBMJOUFSQIBMBOHFBM %*1
BOEQSPYJNBMJOUFSQIBMBOHFBM 1*1
KPJOU TIFBUI T
 JOWPMWJOH UIF BCEVDUPS QPMMJDJT MPOHVT PS FYUFOTPS QPMMJDJT
QBJO XJUI CPOZ IZQFSUSPQIZ TVGGJDJFOU UP QSPEVDF )FCFSEFOT BOE CSFWJT 'JH 
 5IJT DPNNPOMZ SFTVMUT GSPN PWFSVTF PS GPMMPXT
#PVDIBSET OPEFT  SFTQFDUJWFMZ 1BJO  XJUI PS XJUIPVU CPOZ TXFMMJOH  QSFHOBODZ BOE NBZ CF EJBHOPTFE XJUI 'JOLFMTUFJOT UFTU " QPTJUJWF

HPIM19_Part15_p2103-p2250.indd 2220 1/23/15 10:50 AM


SFTVMUJTQSFTFOUXIFOSBEJBMXSJTUQBJOJTJOEVDFEBGUFSUIFUIVNCJT XIFOHMFOPIVNFSBMQBJOJTBDDPNQBOJFECZEJGGVTFQFSJBSUJDVMBS JF  2221
GMFYFEBOEQMBDFEJOTJEFBDMFODIFEGJTUBOEUIFQBUJFOUBDUJWFMZEFWJ- TVCBDSPNJBM CJDJQJUBM
QBJOBOEUFOEFSQPJOUT JF USBQF[JVTPSTVQSB-
BUFT UIF IBOE EPXOXBSE XJUI VMOBS EFWJBUJPO BU UIF XSJTU $BSQBM TQJOBUVT
5IFTIPVMEFSTIPVMECFQVUUISPVHIJUTGVMMSBOHFPGNPUJPO
UVOOFMTZOESPNFJTBOPUIFSDPNNPOEJTPSEFSPGUIFVQQFSFYUSFNJUZ CPUIBDUJWFMZBOEQBTTJWFMZ XJUIFYBNJOFSBTTJTUBODF
GPSXBSEGMFYJPO 
BOESFTVMUTGSPNDPNQSFTTJPOPGUIFNFEJBOOFSWFXJUIJOUIFDBSQBM FYUFOTJPO  BCEVDUJPO  BEEVDUJPO  BOE JOUFSOBM BOE FYUFSOBM SPUBUJPO
UVOOFM.BOJGFTUBUJPOTJODMVEFQBJOJOUIFXSJTUUIBUNBZSBEJBUFXJUI .BOVBM JOTQFDUJPO PG UIF QFSJBSUJDVMBS TUSVDUVSFT XJMM PGUFO QSPWJEF
QBSFTUIFTJBUPUIFUIVNC TFDPOEBOEUIJSEGJOHFST BOESBEJBMIBMGPG JNQPSUBOUEJBHOPTUJDJOGPSNBUJPO(MFOPIVNFSBMJOWPMWFNFOUJTCFTU
UIFGPVSUIGJOHFSBOE BUUJNFT BUSPQIZPGUIFOBSNVTDVMBUVSF$BSQBM EFUFDUFECZQMBDJOHUIFUIVNCPWFSUIFHMFOPIVNFSBMKPJOUKVTUNFEJBM
UVOOFM TZOESPNF JT DPNNPOMZ BTTPDJBUFE XJUI QSFHOBODZ  FEFNB  BOEJOGFSJPSUPUIFDPSBDPJEQSPDFTTBOEBQQMZJOHQSFTTVSFBOUFSJPSMZ
USBVNB  0"  JOGMBNNBUPSZ BSUISJUJT  BOE JOGJMUSBUJWF EJTPSEFST FH  XIJMFJOUFSOBMMZBOEFYUFSOBMMZSPUBUJOHUIFIVNFSBMIFBE1BJOMPDBM-
BNZMPJEPTJT
5IFEJBHOPTJTNBZCFTVHHFTUFECZBQPTJUJWF5JOFMTPS J[FE UP UIJT SFHJPO JT JOEJDBUJWF PG HMFOPIVNFSBM QBUIPMPHZ 4ZOPWJBM
1IBMFOTTJHO8JUIFBDIUFTU QBSFTUIFTJBJOBNFEJBOOFSWFEJTUSJCV- FGGVTJPOPSUJTTVFJTTFMEPNQBMQBCMFCVU JGQSFTFOU NBZTVHHFTUJOGFD-
UJPOJTJOEVDFEPSJODSFBTFECZFJUIFSiUIVNQJOHwUIFWPMBSBTQFDUPG UJPO 3" BNZMPJEPTJT PSBOBDVUFUFBSPGUIFSPUBUPSDVGG5IFFYBN-
UIFXSJTU 5JOFMTTJHO
PSQSFTTJOHUIFFYUFOTPSTVSGBDFTPGCPUIGMFYFE JOFSTIPVMEBQQMZEJSFDUNBOVBMQSFTTVSFPWFSUIFTVCBDSPNJBMCVSTB
XSJTUTBHBJOTUFBDIPUIFS 1IBMFOTTJHO
5IFMPXTFOTJUJWJUZBOENPE- UIBUMJFTMBUFSBMUPBOEJNNFEJBUFMZCFOFBUIUIFBDSPNJPO 'JH

FSBUF TQFDJGJDJUZ PG UIFTF UFTUT NBZ SFRVJSF OFSWF DPOEVDUJPO WFMPDJUZ 4VCBDSPNJBM CVSTJUJT JT B GSFRVFOU DBVTF PG TIPVMEFS QBJO "OUFSJPS
UFTUJOHUPDPOGJSNBTVTQFDUFEEJBHOPTJT UP UIF TVCBDSPNJBM CVSTB  UIF CJDJQJUBM UFOEPO USBWFSTFT UIF CJDJQJUBM
HSPPWF5IJTUFOEPOJTCFTUJEFOUJGJFECZQBMQBUJOHJUJOJUTHSPPWFBT
SHOULDER PAIN UIFQBUJFOUSPUBUFTUIFIVNFSVTJOUFSOBMMZBOEFYUFSOBMMZ%JSFDUQSFT-
%VSJOH UIF FWBMVBUJPO PG TIPVMEFS EJTPSEFST  UIF FYBNJOFS TIPVME TVSFPWFSUIFUFOEPONBZSFWFBMQBJOJOEJDBUJWFPGCJDJQJUBMUFOEJOJUJT

CHAPTER 393 Approach to Articular and Musculoskeletal Disorders


DBSFGVMMZOPUFBOZIJTUPSZPG USBVNB GJCSPNZBMHJB JOGFDUJPO JOGMBN- 1BMQBUJPOPGUIFBDSPNJPDMBWJDVMBSKPJOUNBZEJTDMPTFMPDBMQBJO CPOZ
NBUPSZ EJTFBTF  PDDVQBUJPOBM IB[BSET  PS QSFWJPVT DFSWJDBM EJTFBTF IZQFSUSPQIZ PS VODPNNPOMZ TZOPWJBMTXFMMJOH8IFSFBT0"BOE3"
*O BEEJUJPO  UIF QBUJFOU TIPVME CF RVFTUJPOFE BT UP UIF BDUJWJUJFT PS DPNNPOMZBGGFDUUIFBDSPNJPDMBWJDVMBSKPJOU 0"TFMEPNJOWPMWFTUIF
NPWFNFOU T
 UIBU FMJDJU TIPVMEFS QBJO 8IJMF BSUISJUJT JT TVHHFTUFE HMFOPIVNFSBMKPJOU VOMFTTUIFSFJTBUSBVNBUJDPSPDDVQBUJPOBMDBVTF
CZ QBJO PO NPWFNFOU JO BMM QMBOFT  QBJO XJUI TQFDJGJD BDUJWF NPUJPO 3PUBUPSDVGGUFOEJOJUJTPSUFBSJTBWFSZDPNNPODBVTFPGTIPVMEFS
TVHHFTUT B QFSJBSUJDVMBS OPOBSUJDVMBS
 QSPDFTT 4IPVMEFS QBJO NBZ QBJO /FBSMZ  QFSDFOU PG UIF FMEFSMZ XJMM IBWF TIPVMEFS QBJO  XJUI
PSJHJOBUFJOUIFHMFOPIVNFSBMPSBDSPNJPDMBWJDVMBSKPJOUT TVCBDSPNJBM SPUBUPS DVGG UFOEJOJUJT PS UFBS BT UIF QSJNBSZ DBVTF 5IF SPUBUPS DVGG
TVCEFMUPJE
CVSTB QFSJBSUJDVMBSTPGUUJTTVFT 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 UFSFTNJOPS BOETVCTDBQVMBSJT
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- EBNBHFE3PUBUPSDVGGUFOEJOJUJTJTTVHHFTUFECZQBJOPOBDUJWFBCEVD-
EFS IFQBUJD PSEJBQISBHNBUJDEJTFBTF5IFTFTBNFWJTDFSBMDBVTFTNBZ UJPO CVUOPUQBTTJWFBCEVDUJPO
QBJOPWFSUIFMBUFSBMEFMUPJENVTDMF 
BMTPNBOJGFTUBTGPDBMTDBQVMBSQBJO'JCSPNZBMHJBTIPVMECFTVTQFDUFE OJHIUQBJO BOEFWJEFODFPGUIFJNQJOHFNFOUTJHOT QBJOXJUIPWFSIFBE
BSN BDUJWJUJFT
 5IF /FFS UFTU GPS JNQJOHFNFOU JT QFSGPSNFE CZ UIF
FYBNJOFSSBJTJOHUIFQBUJFOUTBSNJOUPGPSDFEGMFYJPOXIJMFTUBCJMJ[JOH
BOE QSFWFOUJOH SPUBUJPO PG UIF TDBQVMB " QPTJUJWF TJHO JT QSFTFOU JG
Supraspinatus QBJOEFWFMPQTCFGPSFPGGPSXBSEGMFYJPO5FBSPGUIFSPUBUPSDVGGJT
Acromioclavicular
joint
muscle DPNNPOJOUIFFMEFSMZBOEPGUFOSFTVMUTGSPNUSBVNBJUNBZNBOJGFTU
JOUIFTBNFNBOOFSBTUFOEJOJUJT5IFESPQBSNUFTUJTBCOPSNBMXJUI
Acromion Clavicle TVQSBTQJOBUVTQBUIPMPHZBOEJTEFNPOTUSBUFECZQBTTJWFBCEVDUJPOPG
UIFBSNUPCZUIFFYBNJOFS*GUIFQBUJFOUJTVOBCMFUPIPMEUIFBSN
Supraspinatus VQ BDUJWFMZ PS VOBCMF UP MPXFS UIF BSN TMPXMZ XJUIPVU ESPQQJOH  UIF
tendon UFTUJTQPTJUJWF5FOEJOJUJTPSUFBSPGUIFSPUBUPSDVGGJTCFTUDPOGJSNFE
CZNBHOFUJDSFTPOBODFJNBHJOH .3*
PSVMUSBTPVOE
Subacromial
bursa
KNEE PAIN
,OFF QBJO NBZ SFTVMU GSPN JOUSBBSUJDVMBS 0"  3"
 PS QFSJBSUJDVMBS
BOTFSJOFCVSTJUJT DPMMBUFSBMMJHBNFOUTUSBJO
QSPDFTTFTPSCFSFGFSSFE
GSPNIJQQBUIPMPHZ"DBSFGVMIJTUPSZTIPVMEEFMJOFBUFUIFDISPOPMPHZ
Bicipital PG UIF LOFF DPNQMBJOU BOE XIFUIFS UIFSF BSF QSFEJTQPTJOH DPOEJ-
tendon UJPOT USBVNB PSNFEJDBUJPOTUIBUNJHIUVOEFSMJFUIFDPNQMBJOU'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 WJTJCMFUSBVNB NVTDMFXBTUJOH BOEMFHMFOHUI
Glenohumeral EJTDSFQBODZ 5IF NPTU DPNNPO NBMBMJHONFOU JO UIF LOFF JT genu
(shoulder) joint
varum CPXMFHT
PSgenu valgum LOPDLLOFFT
SFTVMUJOHGSPNBTZN-
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.5IFTDIFNBUJDEJBHSBNPG GFNPSBMHSPPWFPSCZFMJDJUJOHBiCVMHFTJHOw8JUIUIFLOFFFYUFOEFE 
UIFTIPVMEFSJOEJDBUFTXJUIBSSPXTUIFBOBUPNJDPSJHJOTPGTIPVMEFS 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 BOEUSPDIBOUFSJDQBJOBSFDPNNPOGJOEJOHTJOGJCSPNZBMHJB3BOHFPG
BO PCTFSWBCMF TIJGU JO TZOPWJBM GMVJE CVMHF
 UP UIF NFEJBM BTQFDU NPWFNFOUNBZCFMJNJUFECZQBJO1BJOJOUIFIJQKPJOUJTMFTTDPN-
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 JUNBZSBEJBUFNFEJBMMZUPUIFHSPJO6ODPNNPOMZ JMJPQTPBTCVSTJUJT
EJTPSEFST TVDI BT 3"  HPVU  QTFVEPHPVU  BOE QTPSJBUJD BSUISJUJT NBZ NBZNJNJDUSVFIJQKPJOUQBJO%JBHOPTJTPGJMJPQTPBTCVSTJUJTNBZCF
JOWPMWFUIFLOFFKPJOUBOEQSPEVDFTJHOJGJDBOUQBJO TUJGGOFTT TXFMMJOH  TVHHFTUFECZBIJTUPSZPGUSBVNBPSJOGMBNNBUPSZBSUISJUJT1BJOBTTPDJ-
PSXBSNUI"QPQMJUFBMPSBakers cystNBZCFQBMQBUFEXJUIUIFLOFF BUFEXJUIJMJPQTPBTCVSTJUJTJTMPDBMJ[FEUPUIFHSPJOPSBOUFSJPSUIJHI
QBSUJBMMZGMFYFEBOEJTCFTUWJFXFEQPTUFSJPSMZXJUIUIFQBUJFOUTUBOEJOH BOE UFOET UP XPSTFO XJUI IZQFSFYUFOTJPO PG UIF IJQ NBOZ QBUJFOUT
BOE LOFFT GVMMZ FYUFOEFE UP WJTVBMJ[F JTPMBUFE PS VOJMBUFSBM QPQMJUFBM QSFGFSUPGMFYBOEFYUFSOBMMZSPUBUFUIFIJQUPSFEVDFUIFQBJOGSPNB
TXFMMJOHPSGVMMOFTT EJTUFOEFECVSTB
"OTFSJOFCVSTJUJTJTBOPGUFONJTTFEQFSJBSUJDVMBSDBVTFPGLOFFQBJO
JO BEVMUT 5IF QFT BOTFSJOF CVSTB VOEFSMJFT UIF JOTFSUJPO PG UIF DPO-
KPJOFEUFOEPOT TBSUPSJVT HSBDJMJT TFNJUFOEJOPTVT
POUIFBOUFSPNF-
LABORATORY INVESTIGATIONS
EJBMQSPYJNBMUJCJBBOENBZCFQBJOGVMGPMMPXJOHUSBVNB PWFSVTF PS 5IF WBTU NBKPSJUZ PG NVTDVMPTLFMFUBM EJTPSEFST DBO CF FBTJMZ EJBH-
JOGMBNNBUJPO*UJTPGUFOUFOEFSJOQBUJFOUTXJUIGJCSPNZBMHJB PCFTJUZ  OPTFECZBDPNQMFUFIJTUPSZBOEQIZTJDBMFYBNJOBUJPO"OBEEJUJPOBM
BOELOFF0"0UIFSGPSNTPGCVSTJUJTNBZBMTPQSFTFOUBTLOFFQBJO PCKFDUJWF PG UIF JOJUJBM FODPVOUFS JT UP EFUFSNJOF XIFUIFS BEEJUJPOBM
5IFQSFQBUFMMBSCVSTBJTTVQFSGJDJBMBOEJTMPDBUFEPWFSUIFJOGFSJPSQPS- JOWFTUJHBUJPOT PS JNNFEJBUF UIFSBQZ JT SFRVJSFE "EEJUJPOBM FWBMVB-
UJPOPGUIFQBUFMMB5IFJOGSBQBUFMMBSCVSTBJTEFFQFSBOEMJFTCFOFBUI UJPO JT JOEJDBUFE XJUI 
 NPOBSUJDVMBS DPOEJUJPOT 
 USBVNBUJD PS
UIFQBUFMMBSMJHBNFOUCFGPSFJUTJOTFSUJPOPOUIFUJCJBMUVCFSDMF JOGMBNNBUPSZ DPOEJUJPOT 
 UIF QSFTFODF PG OFVSPMPHJD GJOEJOHT
*OUFSOBMEFSBOHFNFOUPGUIFLOFFNBZSFTVMUGSPNUSBVNBPSEFHFO- 
TZTUFNJDNBOJGFTUBUJPOTPS 
DISPOJDTZNQUPNT XFFLT
BOE
FSBUJWF QSPDFTTFT %BNBHF UP UIF NFOJTDBM DBSUJMBHF NFEJBM PS MBUFSBM
 BMBDLPGSFTQPOTFUPTZNQUPNBUJDNFBTVSFT5IFFYUFOUBOEOBUVSFPG
PART 15

GSFRVFOUMZQSFTFOUTBTDISPOJDPSJOUFSNJUUFOULOFFQBJO4VDIBOJOKVSZ UIFBEEJUJPOBMJOWFTUJHBUJPOTIPVMECFEJDUBUFECZUIFDMJOJDBMGFBUVSFT
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
PGiMPDLJOHwPSiHJWJOHXBZwPGUIFLOFF8JUIUIFLOFFGMFYFEBOE FWBMVBUFQBUJFOUTXJUIWBHVFSIFVNBUJDDPNQMBJOUT*OEJTDSJNJOBUFVTF
UIF QBUJFOUT GPPU PO UIF UBCMF  QBJO FMJDJUFE EVSJOH QBMQBUJPO PWFS UIF PG CSPBE CBUUFSJFT PG EJBHOPTUJD UFTUT BOE SBEJPHSBQIJD QSPDFEVSFT JT
KPJOUMJOFPSXIFOUIFLOFFJTTUSFTTFEMBUFSBMMZPSNFEJBMMZNBZTVHHFTU SBSFMZBVTFGVMPSDPTUFGGFDUJWFNFBOTUPFTUBCMJTIBEJBHOPTJT
BNFOJTDBMUFBS"QPTJUJWF.D.VSSBZUFTUNBZBMTPJOEJDBUFBNFOJTDBM #FTJEFTBDPNQMFUFCMPPEDPVOU JODMVEJOHBXIJUFCMPPEDFMM 8#$

Immune-Mediated, Inflammatory, and Rheumatologic Disorders

UFBS5PQFSGPSNUIJTUFTU UIFLOFFJTGJSTUGMFYFEBU BOEUIFMFHJTUIFO BOEEJGGFSFOUJBMDPVOU UIFSPVUJOFFWBMVBUJPOTIPVMEJODMVEFBEFUFS-


FYUFOEFEXIJMFUIFMPXFSFYUSFNJUZJTTJNVMUBOFPVTMZUPSRVFENFEJBMMZ NJOBUJPO PG BO BDVUFQIBTF SFBDUBOU TVDI BT UIF &43 PS $31  XIJDI
PSMBUFSBMMZ"QBJOGVMDMJDLEVSJOHJOXBSESPUBUJPONBZJOEJDBUFBMBUFSBM DBOCFVTFGVMJOEJTDSJNJOBUJOHJOGMBNNBUPSZGSPNOPOJOGMBNNBUPSZ
NFOJTDVTUFBS BOEQBJOEVSJOHPVUXBSESPUBUJPONBZJOEJDBUFBUFBSJO EJTPSEFST#PUIBSFJOFYQFOTJWF FBTJMZPCUBJOFE BOENBZCFFMFWBUFE
UIFNFEJBMNFOJTDVT-BTUMZ EBNBHFUPUIFDSVDJBUFMJHBNFOUTTIPVMECF XJUIJOGFDUJPO JOGMBNNBUJPO BVUPJNNVOFEJTPSEFST OFPQMBTJB QSFH-
TVTQFDUFEXJUIBDVUFPOTFUPGQBJO QPTTJCMZXJUITXFMMJOH BIJTUPSZPG OBODZ SFOBMJOTVGGJDJFODZ BEWBODFEBHF PSIZQFSMJQJEFNJB&YUSFNF
USBVNB PSBTZOPWJBMGMVJEBTQJSBUFUIBUJTHSPTTMZCMPPEZ&YBNJOBUJPO FMFWBUJPOPGUIFBDVUFQIBTFSFBDUBOUT $31 &43
JTTFMEPNTFFOXJUI-
PGUIFDSVDJBUFMJHBNFOUTJTCFTUBDDPNQMJTIFECZFMJDJUJOHBESBXFSTJHO PVUFWJEFODFPGTFSJPVTJMMOFTT FH TFQTJT QMFVSPQFSJDBSEJUJT QPMZNZ-
8JUIUIFQBUJFOUSFDVNCFOU UIFLOFFTIPVMECFQBSUJBMMZGMFYFEBOEUIF BMHJBSIFVNBUJDB HJBOUDFMMBSUFSJUJT BEVMU4UJMMTEJTFBTF

GPPUTUBCJMJ[FEPOUIFFYBNJOJOHTVSGBDF5IFFYBNJOFSTIPVMENBOVBMMZ 4FSVNVSJDBDJEEFUFSNJOBUJPOTBSFVTFGVMJOUIFEJBHOPTJTPGHPVU
BUUFNQUUPEJTQMBDFUIFUJCJBBOUFSJPSMZPSQPTUFSJPSMZXJUISFTQFDUUPUIF BOEJONPOJUPSJOHUIFSFTQPOTFUPVSBUFMPXFSJOHUIFSBQZ6SJDBDJE 
GFNVS *G BOUFSJPS NPWFNFOU JT EFUFDUFE  UIFO BOUFSJPS DSVDJBUF MJHB- UIF FOE QSPEVDU PG QVSJOF NFUBCPMJTN  JT QSJNBSJMZ FYDSFUFE JO UIF
NFOUEBNBHFJTMJLFMZ$POWFSTFMZ TJHOJGJDBOUQPTUFSJPSNPWFNFOUNBZ VSJOF 4FSVN WBMVFT SBOHF GSPN  UP  NPM- o NHE-

JOEJDBUFQPTUFSJPSDSVDJBUFEBNBHF$POUSBMBUFSBMDPNQBSJTPOXJMMBTTJTU JO NFO UIF MPXFS WBMVFT o NPM- <o NHE->
 TFFO JO
UIFFYBNJOFSJOEFUFDUJOHTJHOJGJDBOUBOUFSJPSPS
QPTUFSJPSNPWFNFOU
Anterior Posterior/lateral
HIP PAIN
5IF IJQ JT CFTU FWBMVBUFE CZ PCTFSWJOH UIF
QBUJFOUTHBJUBOEBTTFTTJOHSBOHFPGNPUJPO5IF Sacroiliac pain
WBTU NBKPSJUZ PG QBUJFOUT SFQPSUJOH iIJQ QBJOw
MPDBMJ[F UIFJS QBJO VOJMBUFSBMMZ UP UIF QPTUFSJPS Enthesitis Buttock pain
HMVUFBM NVTDVMBUVSF (Fig. 393-5) 4VDI QBJO (anterior superior referred from
iliac crest) lumbosacral
UFOET UP SBEJBUF EPXO UIF QPTUFSPMBUFSBM BTQFDU
spine
PGUIFUIJHIBOENBZPSNBZOPUCFBTTPDJBUFE
True hip pain,
XJUI DPNQMBJOUT PG MPX CBDL QBJO 5IJT QSF- lliopsoasbursitis Trochanteric
TFOUBUJPO GSFRVFOUMZ SFTVMUT GSPN EFHFOFSBUJWF bursitis/enthesitis
BSUISJUJTPGUIFMVNCPTBDSBMTQJOFPSEJTLTBOE Ischiogluteal
DPNNPOMZGPMMPXTBEFSNBUPNBMEJTUSJCVUJPO Meralgia bursitis
XJUI JOWPMWFNFOU PG OFSWF SPPUT CFUXFFO - paresthetica
Sciatica
BOE 4 4DJBUJDB JT DBVTFE CZ JNQJOHFNFOU PG
UIF- - PS4OFSWF JF GSPNBIFSOJBUFE
EJTL
 BOE NBOJGFTUT BT VOJMBUFSBM OFVSPQBUIJD
QBJOFYUFOEJOHGSPNUIFHMVUFBMSFHJPOEPXOUIF
QPTUFSPMBUFSBM MFH UP UIF GPPU 4PNF JOEJWJEVBMT
JOTUFBE MPDBMJ[F UIFJS iIJQ QBJOw MBUFSBMMZ UP UIF
BSFBPWFSMZJOHUIFUSPDIBOUFSJDCVSTB#FDBVTFPG
UIFEFQUIPGUIJTCVSTB TXFMMJOHBOEXBSNUIBSF FIGURE 3935 Origins of hip pain and dysesthesias.(From JJ Cush et al: Evaluation of mus-
VTVBMMZBCTFOU%JBHOPTJTPGUSPDIBOUFSJDCVSTJUJT culoskeletal complaints, in Rheumatology: Diagnosis and Therapeutics, 2nd ed, JJ Cush et al [eds].
PSFOUIFTJUJTDBOCFDPOGJSNFECZJOEVDJOHQPJOU Philadelphia, Lippincott Williams & Wilkins, 2005, pp 320. Used with permission from Dr. John
UFOEFSOFTT PWFS UIF USPDIBOUFSJD CVSTB (MVUFBM J. Cush.)

HPIM19_Part15_p2103-p2250.indd 2222 1/23/15 10:50 AM


XPNFOBSFDBVTFECZUIFVSJDPTVSJDFGGFDUTPGFTUSPHFO6SJOBSZVSJD TDMFSPEFSNB cBMDJOPTJT  RBZOBVET QIFOPNFOPO  eTPQIBHFBM JOWPMWF- 2223
BDJE MFWFMT BSF OPSNBMMZ  NH QFS  I "MUIPVHI IZQFSVSJDFNJB NFOU sDMFSPEBDUZMZ tFMBOHJFDUBTJB<$3&45>TZOESPNF
PSQSJNBSZCJMJ-
FTQFDJBMMZMFWFMTNPM-<NHE->
JTBTTPDJBUFEXJUIBOJODSFBTFE BSZTDMFSPTJT BOEOVDMFPMBSQBUUFSOTNBZCFTFFOJOQBUJFOUTXJUIEJGGVTF
JODJEFODFPGHPVUBOEOFQISPMJUIJBTJT MFWFMTNBZOPUDPSSFMBUFXJUIUIF TZTUFNJDTDMFSPTJTPSJOGMBNNBUPSZNZPTJUJT
TFWFSJUZPGBSUJDVMBSEJTFBTF6SJDBDJEMFWFMT BOEUIFSJTLPGHPVU
NBZ "TQJSBUJPO BOE BOBMZTJT PG TZOPWJBM GMVJE BSF BMXBZT JOEJDBUFE JO
CFJODSFBTFECZJOCPSOFSSPSTPGNFUBCPMJTN -FTDI/ZIBOTZOESPNF
 BDVUFNPOBSUISJUJTPSXIFOBOJOGFDUJPVTPSDSZTUBMJOEVDFEBSUISPQB-
EJTFBTFTUBUFT SFOBMJOTVGGJDJFODZ NZFMPQSPMJGFSBUJWFEJTFBTF QTPSJBTJT
 UIZ JT TVTQFDUFE 4ZOPWJBM GMVJE NBZ EJTUJOHVJTI CFUXFFO OPOJOGMBN-
PS ESVHT BMDPIPM  DZUPUPYJD UIFSBQZ  UIJB[JEFT
 "MUIPVHI OFBSMZ BMM NBUPSZ BOE JOGMBNNBUPSZ QSPDFTTFT CZ BOBMZTJT PG UIF BQQFBSBODF 
QBUJFOUTXJUIHPVUXJMMEFNPOTUSBUFIZQFSVSJDFNJBBUTPNFUJNFEVS- WJTDPTJUZ BOEDFMMDPVOU5FTUTGPSTZOPWJBMGMVJEHMVDPTF QSPUFJO MBDUBUF
JOHUIFJSJMMOFTT VQUPPGQBUJFOUTXJUIBOBDVUFHPVUZBUUBDLXJMM EFIZESPHFOBTF  MBDUJD BDJE  PS BVUPBOUJCPEJFT BSF OPU SFDPNNFOEFE
IBWFOPSNBMTFSVNVSJDBDJEMFWFMT.POJUPSJOHTFSVNVSJDBDJENBZCF CFDBVTF UIFZ IBWF OP EJBHOPTUJD WBMVF /PSNBM TZOPWJBM GMVJE JT DMFBS
VTFGVM JO BTTFTTJOH UIF SFTQPOTF UP VSBUFMPXFSJOH UIFSBQZ PS DIFNP- PSBQBMFTUSBXDPMPSBOEJTWJTDPVT QSJNBSJMZCFDBVTFPGUIFIJHIMFWFMT
UIFSBQZ XJUIUIFUBSHFUHPBMCFJOHBTFSVNVSBUFNHE- PG IZBMVSPOBUF /POJOGMBNNBUPSZ TZOPWJBM GMVJE JT DMFBS  WJTDPVT  BOE
4FSPMPHJD UFTUT GPS SIFVNBUPJE GBDUPS 3'
 DZDMJD BOUJDJUSVMMJOBUFE BNCFSDPMPSFE  XJUI B 8#$ DPVOU PG - BOE B QSFEPNJOBODF
QFQUJEF $$1 PS "$1"
 BOUJCPEJFT  "/"T  DPNQMFNFOU MFWFMT  -ZNF PG NPOPOVDMFBS DFMMT 5IF WJTDPTJUZ PG TZOPWJBM GMVJE JT BTTFTTFE CZ
BOEBOUJOFVUSPQIJMDZUPQMBTNJDBOUJCPEJFT "/$"
PSBOUJTUSFQUPMZTJO FYQSFTTJOHGMVJEGSPNUIFTZSJOHFPOFESPQBUBUJNF/PSNBMMZ UIFSFJT
0 "40
UJUFSTIPVMECFDBSSJFEPVUPOMZXIFOUIFSFJTDMJOJDBMFWJEFODF BTUSJOHJOHFGGFDU XJUIBMPOHUBJMCFIJOEFBDITZOPWJBMESPQ&GGVTJPOT
UPTQFDJGJDBMMZTVHHFTUBOBTTPDJBUFEEJBHOPTJT CFDBVTFUIFTFIBWFQPPS DBVTFECZ0"PSUSBVNBXJMMIBWFOPSNBMWJTDPTJUZ*OGMBNNBUPSZGMVJEJT
QSFEJDUJWF WBMVF XIFO VTFE GPS TDSFFOJOH  FTQFDJBMMZ XIFO UIF QSFUFTU UVSCJEBOEZFMMPX XJUIBOJODSFBTFE8#$DPVOU o -
BOE
QSPCBCJMJUZ JT MPX 'PS NPTU PG UIFTF  UIFSF JT OP WBMVF UP SFQFBUFE PS BQPMZNPSQIPOVDMFBSMFVLPDZUFQSFEPNJOBODF*OGMBNNBUPSZGMVJEIBT

CHAPTER 393 Approach to Articular and Musculoskeletal Disorders


TFSJBMTFSPMPHJDUFTUJOH"MUIPVHIoPGBIFBMUIZQPQVMBUJPOXJMMIBWF SFEVDFEWJTDPTJUZ EJNJOJTIFEIZBMVSPOBUF BOEMJUUMFPSOPUBJMGPMMPX-
QPTJUJWFUFTUTGPS3'BOE"/"T POMZBOEPGUIFQPQVMBUJPO JOHFBDIESPQPGTZOPWJBMGMVJE4VDIFGGVTJPOTBSFGPVOEJO3" HPVU 
XJMMIBWF3"PS4-& SFTQFDUJWFMZ*H.3' BVUPBOUJCPEJFTBHBJOTUUIF'D BOEPUIFSJOGMBNNBUPSZBSUISJUJEFT4FQUJDGMVJEJTPQBRVFBOEQVSVMFOU 
QPSUJPOPG*H(
JTGPVOEJOPGQBUJFOUTXJUI3"BOENBZBMTPCFTFFO XJUI B 8#$ DPVOU VTVBMMZ  -  B QSFEPNJOBODF PG QPMZNPS-
JO MPX UJUFST JO QBUJFOUT XJUI DISPOJD JOGFDUJPOT UVCFSDVMPTJT  MFQSPTZ  QIPOVDMFBS MFVLPDZUFT 
 BOE MPX WJTDPTJUZ 4VDI FGGVTJPOT BSF
IFQBUJUJT
 PUIFS BVUPJNNVOF EJTFBTFT 4-&  4KHSFOT TZOESPNF
 BOE UZQJDBMPGTFQUJDBSUISJUJTCVUNBZBMTPPDDVSXJUI3"PSHPVU*OBEEJ-
DISPOJD QVMNPOBSZ  IFQBUJD  PS SFOBM EJTFBTFT 8IFO DPOTJEFSJOH 3"  UJPO IFNPSSIBHJDTZOPWJBMGMVJENBZCFTFFOXJUIUSBVNB IFNBSUISP-
CPUITFSVN3'BOEBOUJ$$1BOUJCPEJFTTIPVMECFPCUBJOFEBTUIFTFBSF TJT PSOFVSPQBUIJDBSUISJUJT"OBMHPSJUINGPSTZOPWJBMGMVJEBTQJSBUJPO
DPNQMFNFOUBSZ#PUIBSFDPNQBSBCMZTFOTJUJWF CVU$$1BOUJCPEJFTBSF BOEBOBMZTJTJTTIPXOJOFig. 393-64ZOPWJBMGMVJETIPVMECFBOBMZ[FE
NPSF TQFDJGJD UIBO 3' *O 3"  UIF QSFTFODF PG BOUJ$$1 BOE 3' BOUJ- JNNFEJBUFMZ GPS BQQFBSBODF  WJTDPTJUZ  BOE DFMM DPVOU .POPTPEJVN
CPEJFTNBZJOEJDBUFBHSFBUFSSJTLGPSNPSFTFWFSF FSPTJWFQPMZBSUISJUJT VSBUFDSZTUBMT PCTFSWFEJOHPVU
BSFTFFOCZQPMBSJ[FENJDSPTDPQZBOE
"/"TBSFGPVOEJOOFBSMZBMMQBUJFOUTXJUI4-&BOENBZBMTPCFTFFOJO BSFMPOH OFFEMFTIBQFE OFHBUJWFMZCJSFGSJOHFOU BOEVTVBMMZJOUSBDFMMVMBS
QBUJFOUT XJUI PUIFS BVUPJNNVOF EJTFBTFT QPMZNZPTJUJT  TDMFSPEFSNB  *ODIPOESPDBMDJOPTJTBOEQTFVEPHPVU DBMDJVNQZSPQIPTQIBUFEJIZESBUF
BOUJQIPTQIPMJQJE TZOESPNF  4KHSFOT TZOESPNF
 ESVHJOEVDFE MVQVT DSZTUBMTBSFVTVBMMZTIPSU SIPNCPJETIBQFE BOEQPTJUJWFMZCJSFGSJOHFOU
5BCMF 
 DISPOJD MJWFS PS SFOBM EJTPSEFST  BOE BEWBODFE BHF 8IFOFWFSJOGFDUJPOJTTVTQFDUFE TZOPWJBMGMVJETIPVMECF(SBNTUBJOFE
1PTJUJWF "/"T BSF GPVOE JO  PG BEVMUT BOE JO VQ UP  PG FMEFSMZ BOEDVMUVSFEBQQSPQSJBUFMZ*GHPOPDPDDBMBSUISJUJTJTTVTQFDUFE OVDMFJD
PSDISPOJDBMMZJMMJOEJWJEVBMT5IF"/"UFTUJTWFSZTFOTJUJWFCVUQPPSMZ BDJE BNQMJGJDBUJPO UFTUT TIPVME CF VTFE UP EFUFDU FJUIFS Chlamydia
TQFDJGJDGPSMVQVT BTPOMZoPGBMMQPTJUJWFSFTVMUTXJMMCFDBVTFECZ trachomatis PS N. gonorrhoeae JOGFDUJPO 4ZOPWJBM GMVJE GSPN QBUJFOUT
MVQVTBMPOF5IFJOUFSQSFUBUJPOPGBQPTJUJWF"/"UFTUNBZEFQFOEPO XJUIDISPOJDNPOBSUISJUJTTIPVMEBMTPCFDVMUVSFEGPSM. tuberculosisBOE
UIFNBHOJUVEFPGUIFUJUFSBOEUIFQBUUFSOPCTFSWFECZJNNVOPGMVPSFT- GVOHJ -BTU  JU TIPVME CF OPUFE UIBU DSZTUBMJOEVDFE BSUISJUJT BOE TFQUJD
DFODFNJDSPTDPQZ(Table 393-4)%JGGVTFBOETQFDLMFEQBUUFSOTBSFMFBTU BSUISJUJTPDDBTJPOBMMZPDDVSUPHFUIFSJOUIFTBNFKPJOU
TQFDJGJD XIFSFBTBQFSJQIFSBM PSSJN QBUUFSO SFMBUFEUPBVUPBOUJCPEJFT
BHBJOTU EPVCMFTUSBOE <OBUJWF> %/"
 JT IJHIMZ TQFDJGJD BOE TVHHFT-
UJWF PG MVQVT $FOUSPNFSJD QBUUFSOT BSF TFFO JO QBUJFOUT XJUI MJNJUFE DIAGNOSTIC IMAGING IN JOINT DISEASES
$POWFOUJPOBM SBEJPHSBQIZ IBT CFFO B WBMVBCMF UPPM JO UIF EJBHOPTJT
BOE TUBHJOH PG BSUJDVMBS EJTPSEFST 1MBJO YSBZT BSF NPTU BQQSPQSJBUF
TABLE 393-4 ANTINUCLEAR ANTIBODY (ANA) PATTERNS AND CLINICAL BOEDPTUFGGFDUJWFXIFOUIFSFJTBIJTUPSZPGUSBVNB TVTQFDUFEDISPOJD
ASSOCIATIONS JOGFDUJPO  QSPHSFTTJWF EJTBCJMJUZ  PS NPOBSUJDVMBS JOWPMWFNFOU XIFO
ANA Pattern Antigen Identified Clinical Correlate UIFSBQFVUJD BMUFSBUJPOT BSF DPOTJEFSFE PS XIFO B CBTFMJOF BTTFTTNFOU
%JGGVTF %FPYZSJCPOVDMFPQSPUFJO /POTQFDJGJD
JTEFTJSFEGPSXIBUBQQFBSTUPCFBDISPOJDQSPDFTT)PXFWFS JOBDVUF
JOGMBNNBUPSZBSUISJUJT FBSMZSBEJPHSBQIZJTSBSFMZIFMQGVMJOFTUBCMJTI-
)JTUPOFT %SVHJOEVDFEMVQVT MVQVT
JOHBEJBHOPTJTBOENBZPOMZSFWFBMTPGUUJTTVFTXFMMJOHPSKVYUBBSUJDVMBS
1FSJQIFSBM ET%/" PG4-& TQFDJGJD
EFNJOFSBMJ[BUJPO"TUIFEJTFBTFQSPHSFTTFT DBMDJGJDBUJPO PGTPGUUJTTVFT 
SJN

DBSUJMBHF PSCPOF
KPJOUTQBDFOBSSPXJOH FSPTJPOT CPOZBOLZMPTJT OFX
4QFDLMFE 63/1 PG.$5% CPOFGPSNBUJPO TDMFSPTJT PTUFPQIZUFT PSQFSJPTUJUJT
PSTVCDIPOESBM
4N PG4-& TQFDJGJD
DZTUT NBZ EFWFMPQ BOE TVHHFTU TQFDJGJD DMJOJDBM FOUJUJFT $POTVMUBUJPO
3P 44"
4KHSFOT 4$-& OFPOBUBM XJUIBSBEJPMPHJTUXJMMIFMQEFGJOFUIFPQUJNBMJNBHJOHNPEBMJUZ UFDI-
MVQVT "/"
MVQVT OJRVF PSQPTJUJPOJOHBOEQSFWFOUUIFOFFEGPSGVSUIFSTUVEJFT
-B 44#
PG4KHSFOT MVQVT "EEJUJPOBMJNBHJOHUFDIOJRVFTNBZQPTTFTTHSFBUFSEJBHOPTUJDTFO-
4DM PGEJGGVTFTDMFSPEFSNB TJUJWJUZ BOE GBDJMJUBUF FBSMZ EJBHOPTJT JO B MJNJUFE OVNCFS PG BSUJDVMBS
1. 1PMZNZPTJUJT 1.
EFSNBUPNZPTJUJT EJTPSEFSTBOEJOTFMFDUFEDJSDVNTUBODFTBOEBSFJOEJDBUFEXIFODPO-
+P 1.XQOFVNPOJUJT BSUISJUJT
WFOUJPOBMSBEJPHSBQIZJTJOBEFRVBUFPSOPOEJBHOPTUJD(Table 393-5)
UltrasonographyJTVTFGVMJOUIFEFUFDUJPOPGTPGUUJTTVFBCOPSNBMJUJFT 
/VDMFPMBS 3/"QPMZNFSBTF*  PG144
PUIFST
TVDI BT UFOEJOJUJT  UFOPTZOPWJUJT  FOUIFTJUJT  CVSTJUJT  BOE FOUSBQNFOU
OFVSPQBUIJFT8JEFSVTF MPXFSDPTU CFUUFSUFDIOPMPHZ BOEFOIBODFE
$FOUSPNFSF ,JOFUPDIPSF $3&45 MJNJUFETDMFSPEFSNB

TJUFTQFDJGJDUSBOTEVDFSTOPXBMMPXGPSSPVUJOFVTFJOPVUQBUJFOUDBSF
Abbreviations:"/" BOUJOVDMFBSBOUJCPEZ$3&45 cBMDJOPTJT RBZOBVEQIFOPNFOPO  0XJOH UP MPX DPTU  QPSUBCJMJUZ  BOE XJEFS VTF  VMUSBTPVOE VTF IBT
eTPQIBHFBMJOWPMWFNFOU sDMFSPEBDUZMZ BOEtFMBOHJFDUBTJB.$5% NJYFEDPOOFDUJWFUJTTVF
EJTFBTF144 QSPHSFTTJWFTZTUFNJDTDMFSPTJT4$-& TVCBDVUFDVUBOFPVTMVQVTFSZUIFNBUP- HSPXO BOE JT UIF QSFGFSSFE NFUIPE GPS UIF FWBMVBUJPO PG TZOPWJBM
TVT4-& TZTUFNJDMVQVTFSZUIFNBUPTVT #BLFST
 DZTUT  SPUBUPS DVGG UFBST  UFOEJOJUJT BOE UFOEPO JOKVSZ  BOE

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
imaging
Septic arthritis, infected pros-
) Yes thetic joints
Early sacroiliitis
+)& $(!&''-)+1+-#+$-$, Possible septic arthritis
Intraarticular derangement and
soft tissue injury
FIGURE 3936 Algorithmic approach to the use and interpretation Derangements of axial skeleton
of synovial fluid aspiration and analysis. PMNs, polymorphonucle- and spinal cord
ar (leukocytes); WBC, white blood cell (count). Herniated intervertebral disk
Pigmented villonodular synovitis
crystal deposition on cartilage. Use of power Doppler allows for early Inflammatory and metabolic
muscle pathology
detection of synovitis and bony erosions. Radionuclide scintigraphy is
a very sensitive, but poorly specific, means of detecting inflammatory Relative cost for imaging study.
a

or metabolic alterations in bone or periarticular soft tissue structures. Abbreviations: NA, not commercially available; WBC, white blood cell.
Scintigraphy is best suited for total-body assessment (extent and dis-
tribution) of skeletal involvement (neoplasia, Pagets disease) and the bacteria, and tumor tissue (e.g., lymphoma). As such, it is primarily
assessment of patients with undiagnosed polyarthralgias, looking for used in the identification of occult infection or malignancy. Scanning
occult arthritis. The use of scintigraphy has declined with greater use with 111In-labeled WBCs has been used to detect osteomyelitis and
and declining cost of ultrasound and MRI. The limited tissue con- infectious or inflammatory arthritis. Despite their utility, 111In-labeled
trast resolution of scintigraphy may obscure the distinction between WBC or 67Ga scanning has largely been replaced by MRI, except when
a bony or periarticular process and may necessitate the additional there is a suspicion of septic joint or prosthetic joint infections.
use of MRI. Scintigraphy using 99mTc, 67Ga, or 111In-labeled WBCs Computed tomography (CT) provides detailed visualization of the
has been applied to a variety of articular disorders with variable suc- axial skeleton. Articulations previously considered difficult to visualize
cess (Table 393-5). Although [99mTc] diphosphate scintigraphy may by radiography (e.g., zygapophyseal, sacroiliac, sternoclavicular, hip
be useful in identifying osseous infection, neoplasia, inflammation, joints) can be effectively evaluated using CT. CT has been demon-
increased blood flow, bone remodeling, heterotopic bone formation, or strated to be useful in the diagnosis of low back pain syndromes (e.g.,
avascular necrosis, MRI is preferred in most instances. Gallium scan- spinal stenosis vs herniated disk), sacroiliitis, osteoid osteoma, and
ning uses 67Ga, which binds serum and cellular transferrin and lac- stress fractures. Helical or spiral CT (with or without contrast angiog-
toferrin and is preferentially taken up by neutrophils, macrophages, raphy) is a novel technique that is rapid, cost effective, and sensitive

HPIM19_Part15_p2103-p2250.indd 2224 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.5ISFFEJNFOTJPOBMWPMVNFSFOEFSFEDPSPOBMSFGPSNBUUFE%&$5JNBHFTIPXTUIBUUIFNBTTJTDPNQPTFEPGNPOPTPEJVNVSBUF red

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

JOEJBHOPTJOHQVMNPOBSZFNCPMJTNPSPCTDVSFGSBDUVSFT PGUFOJOUIF
TFUUJOHPGJOJUJBMMZFRVJWPDBMGJOEJOHT)JHISFTPMVUJPO$5DBOCFBEWP-
DBUFEJOUIFFWBMVBUJPOPGTVTQFDUFEPSFTUBCMJTIFEJOGJMUSBUJWFMVOHEJT-
FBTF FH TDMFSPEFSNBPSSIFVNBUPJEMVOH
5IFSFDFOUVTFPGIZCSJE
QPTJUSPOFNJTTJPOUPNPHSBQIZ<1&5>PSTJOHMFQIPUPOFNJTTJPO$5
<41&$5>
$5TDBOTJONFUBTUBUJDFWBMVBUJPOTIBTJODPSQPSBUFE$5UP
QSPWJEFCFUUFSBOBUPNJDMPDBMJ[BUJPOPGTDJOUJHSBQIJDBCOPSNBMJUJFT

''MVPSPEFPYZHMVDPTF '%(
 JT UIF NPTU DPNNPOMZ VTFE SBEJP-
QIBSNBDFVUJDBM JO 1&5 TDBOOJOH '%(1&5$5 TDBOT IBWF CFFO
TFMEPN VTFE JO UIF FWBMVBUJPO PG TFQUJD PS JOGMBNNBUPSZ BSUISJUJT
%VBMFOFSHZ $5 %&$5
 TDBOOJOH  EFWFMPQFE JO VSPMPHZ UP JEFOUJGZ
VSJOBSZDBMDVMJ IBTCFFOBIJHIMZTFOTJUJWFBOETQFDJGJDNFUIPEVTFE
UPJEFOUJGZBOERVBOUJGZVSJDBDJEEFQPTJUJPOJOUJTTVFT(Fig. 393-7)
MRIIBTTJHOJGJDBOUMZBEWBODFEUIFBCJMJUZUPJNBHFNVTDVMPTLFMFUBM
TUSVDUVSFT .3* IBT UIF BEWBOUBHFT PG QSPWJEJOH NVMUJQMBOBS JNBHFT
XJUI GJOF BOBUPNJD EFUBJM BOE DPOUSBTU SFTPMVUJPO (Fig. 393-8) UIBU
BMMPXTGPSUIFTVQFSJPSBCJMJUZUPWJTVBMJ[FCPOFNBSSPXBOETPGUUJTTVF
QFSJBSUJDVMBS TUSVDUVSFT "MUIPVHI NPSF DPTUMZ XJUI B MPOHFS QSPDF-
EVSBMUJNFUIBO$5 UIF.3*IBTCFDPNFUIFQSFGFSSFEUFDIOJRVFXIFO
FWBMVBUJOHDPNQMFYNVTDVMPTLFMFUBMEJTPSEFST
.3* DBO JNBHF GBTDJB  WFTTFMT  OFSWF  NVTDMF  DBSUJMBHF  MJHBNFOUT 
UFOEPOT QBOOVT TZOPWJBMFGGVTJPOT BOECPOFNBSSPX7JTVBMJ[BUJPO
PGQBSUJDVMBSTUSVDUVSFTDBOCFFOIBODFECZBMUFSJOHUIFQVMTFTFRVFODF
UP QSPEVDF FJUIFS 5 PS 5XFJHIUFE TQJO FDIP  HSBEJFOU FDIP  PS
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The author acknowledges the contributions of Dr. Peter E. Lipsky to this POTUSBUFEMPXEFOTJUZTJHOBMJOUIFSJHIUGFNPSBMIFBE EJBHOPTUJDPG
chapter in previous editions. PTUFPOFDSPTJT

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