Approach_to_Musculoskeletal_Complaints_Lectur_Lauren Clemmons.pdf

Approach to Musculoskeletal Clinical Complaints Lauren Clemmons, DO, FACOFP Learning Objectives Recognize common presentations of musculoskeletal conditions Explain the significance of each part of the HPI (OPPQRRST-A) in regard to developing a differential diagnosis for musculoskeletal conditions r...

Approach to Musculoskeletal Clinical Complaints Lauren Clemmons, DO, FACOFP Learning Objectives Recognize common presentations of musculoskeletal conditions Explain the significance of each part of the HPI (OPPQRRST-A) in regard to developing a differential diagnosis for musculoskeletal conditions related CC Tailor the HPI, PMH, SH, FH, ROS, and PE for a musculoskeletal related CC Describe the significance of the physical exam findings in diagnosing musculoskeletal CC Choose appropriate tests and imaging for evaluating musculoskeletal conditions given a clinical scenario Musculoskeletal Clinical Complaints “My knee hurts” “My muscles ache.” “I think I have rheumatism.” “I think ole Arthur’s got me.” “I hurt everywhere.” “My joints are stiff.” “I have sciatica.” Where do you start? Patient-Centered Questions “Tell me more.” “How’s it affecting you?” “What’s worrying you about it?” Transition Doctor-Centered Questions OPPQRRST-A When did it start? Is it worsening rapidly or gradually? What makes it better or worse? What does the pain feel like? Where is the pain located? Does it radiate? How severe is the pain? Is it constant? Does it come and go? What were you doing when the pain started? 5 Onset Acute vs. chronic Acute 12 weeks Pain from traumatic injury is usually immediate and is exacerbated by movement or hemarthrosis (bleeding into the affected joint). Crystal arthritis (gout and pseudogout) causes acute, sometimes extreme pain which develops quickly, often overnight. Pain from inflammatory arthritis can develop over 24 hours, or more insidiously. Joint sepsis causes pain that develops over a day or two. Osteoarthritis is usually gradual onset. Provocative/Palliative Factors Worse with movement, better at rest – mechanical problem Osteoarthritis Worse with rest, eases with movement, often worse in AM Inflammatory arthritis Present with movement and at rest – septic joint 7 Quality of Pain Bone pain – penetrating, deep, worse at night Blood pooled distally from a calf tear Localized pain – tumor, infection, osteonecrosis, osteosarcoma Diffuse pain – osteomalacia Fracture – sharp, stabbing, worse with movement, relieved by rest Muscle pain – stiffness, aching, worse with muscle use Shooting pain – impingement of nerve or nerve root Progressive joint pain – osteoarthritis Fibromyalgia – widespread, constant pain with little diurnal variation, poorly controlled by analgesics Partial muscle tears are painful, complete rupture may be less painful 8 Stiffness Restricted ROM? Difficulty moving, but normal ROM? Painful movement? Localized to a particular joint or more generalized? Examples Early-morning stiffness that takes >30 minutes to wear off with activity Inflammatory arthritis Stiffness after rest that eases rapidly with movement Non-inflammatory, mechanical arthritis 9 Common patterns of referred and radicular musculoskeletal pain Site where pain is perceived Site of Pathology Occiput C1, C2 Interscapular region C3, C4 Tip of shoulder, upper outer aspect of arm C5 Interscapular region or radial fingers and thumb C6, C7 Ulnar side of forearm, ring and little fingers C8 Medial aspect of arm T1 Chest Thoracic spine Buttocks, knees, legs Lumbar spine Lateral aspect of upper arm Shoulder Forearm Elbow Anterior thigh, knee Hip Thigh, hip Knee 10 Site Does the pain originate from: A joint (arthralgia) A muscle (myalgia) Other soft tissue- ligaments, tendons, tendon sheaths, bursae, etc. The site may be: Well localized and suggest the diagnosis e.g. the first metatarsophalangeal joint in gout. In several joints suggesting an inflammatory arthritis. Site How many joints are involved? One joint is a monoarthritis 2–4 joints is oligoarthritis >4 is polyarthritis Location Small or large joints? Extremities or spine? Different patterns of joint involvement help the differential diagnosis. Severity Severe pain Trauma Gout Compartment syndrome Complex regional pain syndrome Impaired/reduced joint sensation Diabetes mellitus Leprosy Syringomyelia Syphilis Painless Charcot joints 13 Timing Is the timing Progressive or fluctuant? Waxing and waning? Affected by the time of day? Examples: Several years with normal examination Fibromyalgia Several weeks, early morning stiffness and loss of function Inflammatory arthritis “Flitting” pain starting in one joint and moving to others over several days Rheumatic fever or gonococcal arthritis Intermittent, with resolution between episodes Palindromic rheumatism 14 Associated Symptoms Always ask as part of your HPI if the patient has noticed other symptoms. May help narrow your differential and reduce the number of review of systems questions you’ll need to ask later. For example, a patient with great toe pain may also mention that the toe is red, hot and swollen. This significantly increases your suspicion of gout or infection. The patient not listing other symptoms does NOT mean there aren’t any. It just means those symptoms didn’t come to mind when you asked OR that the patient doesn’t actually associate those symptoms with his or her chief complaint. Swelling Site, extent, time course Speed of onset Rapid ( 60 years Osteoarthritis Gout or pseudogout Polymyalgia rheumatica Osteoporotic fracture Septic bacterial arthritis 23 Inflammatory vs. Noninflammatory Inflammatory Infectious Crystal-induced Immune-related Reactive Idiopathic Noninflammatory Trauma Repetitive use Degenerative changes Fibromyalgia 4 Cardinal Features of Inflammation: Swelling Warmth Redness Pain *Morning stiffness >60 minutes suggests inflammation 24 Localized vs. Diffuse Single joint Injury Monoarticular arthritis Extra-articular causes (bursae, tendons, tendon sheaths, ligaments) Multiple joints Symmetric RA SLE Ankylosing spondylitis Asymmetric Psoriatic Reactive IBD-associated 25 Symptom Disorder Butterfly (malar) rash on the cheeks SLE Scaly plaques on extensor surfaces, pitted nails Psoriatic arthritis Heliotrope rash on the upper eyelid Dermatomyositis Papules, pustules, or vesicles with reddened bases on the distal extremities Gonococcal arthritis Expanding erythematous “target” or “bull’s eye” patch early in an illness Lyme disease (erythema chronicum migrans) Painful subcutaneous nodules (esp. pretibial) Sarcoidosis, Behcet disease (erythema nodosum) Palpable purpura Vasculitis Hives Serum sickness, drug reaction Erosions or scaling on the penis and crusted scaling papules on the soles and palms Reactive (Reiter) arthritis (with urethritis, uveitis) The maculopapular rash of rubella Arthritis of rubella Nailfold capillary changes Dermatomyositis, systemic sclerosis Clubbing of the fingernails Hypertrophic osteoarthropathy Red, burning, and itchy eyes (conjunctivitis), eye pain and blurred vision (uveitis) Reactive (Reiter) arthritis, Behcet syndrome, ankylosing spondylitis Scleritis RA, IBD, vasculitis Preceding sore throat Acute rheumatic fever or gonococcal arthritis Oral ulcerations RA (usually painless); Behcet disease Pneumonitis; interstitial lung disease RA, systemic sclerosis Diarrhea, abdominal pain, cramping IBD, reactive arthritis from Salmonella, Shigella, Yersinia, Campylobacter, scleroderma Urethritis Reactive (Reiter) arthritis, gonococcal arthritis Mental status change, facial or other weakness, stiff neck Lyme disease with central nervous system involvement 26 Low Back Pain Causes Nonspecific (>90%) Nerve root entrapment with radiculopathy or spinal stenosis (~5%) Pain from a specific underlying cause (1%-2%) Determine if: Midline vs. off the midline Radiation to the buttock or lower extremity Associated bowel or bladder dysfunction “Red flags” for underlying systemic disease 27 “Red Flags” for LBP from Underlying Systemic Disease Age 50 History of cancer Unexplained weight loss, fever, or decline in general health Pain lasting more than 1 month or not responding to treatment Pain at night or present at rest History of IV drug use, addiction, or immunosuppression Presence of active infection or HIV infection Long-term steroid therapy Saddle anesthesia, bladder or bowel incontinence Neurologic symptoms or progressive neurologic deficit Recent significant trauma (fracture) Sexual dysfunction Bilateral “sciatica” 28 “Yellow Flags” for LBP A history of anxiety, depression, chronic pain, IBS, chronic fatigue, social withdrawal Belief that the diagnosis is severe (cancer) Can lead to catastrophizing and avoidance of activity Lack of belief that the patient can improve Expectation that only passive, rather than active, treatment will be effective Ongoing litigation or compensation claims Work, MVA 29 Common Spinal Problems Mechanical back pain Prolapsed intervertebral disc Spinal stenosis Ankylosing spondylitis Compensatory scoliosis from leg-length discrepancy Cervical myelopathy Pathological pain/deformity Osteoporotic vertebral fracture resulting in kyphosis Cervical rib Scoliosis Spinal instability 30 Neck Pain Radiation into the arm or scapula Arm weakness, numbness or paresthesia Red flag symptoms 31 Causes of Abnormal Neck Posture Loss of lordosis or flexion deformity Acute lesions, RA, trauma Increased lordosis Ankylosing spondylitis Torticollis SCM contracture, trauma Pharyngeal/parapharyngeal infection Lateral flexion Erosion of lateral mass of atlas in RA 32 Causes of Thoracic Spine Pain Adolescents and Young Adults Scheuermann’s disease Axial spondyloarthritis Disc protrusion (rare) Middle-aged and Elderly Degenerative change Osteoporotic fracture Any Age Tumor Infection 33 Common Causes of Arthralgia (Joint Pain) Infective Viral – Rubella, parvovirus B19, mumps, hepatitis B, chikungunya Bacterial – staphylococci, mycobacterium tuberculosis, Borrelia Fungal Postinfective Rheumatic fever Reactive arthritis Inflammatory Rheumatoid arthritis Systemic lupus erythematosus Ankylosing spondylitis Degenerative Osteoarthritis Tumor Primary – osteosarcoma, chondrosarcoma Metastatic – lung, breast, prostate Systemic tumor effects – hypertrophic pulmonary osteoarthropathy Crystal Formation Gout, pseudogout Trauma Motor vehicle accidents Others Chronic pain disorders – fibromyalgia Hypermobility Spectrum Disorder (formerly Benign Joint Hypermobility Syndrome) 34 Causes of Shoulder Girdle Pain Rotator Cuff Degeneration Tendon rupture Calcific tendonitis Subacromial bursa Calcific bursitis Polyarthritis Capsule Adhesive capsulitis Head of humerus Tumor Osteonecrosis Fracture/dislocation Joints Glenohumeral, sternoclavicular: inflammatory arthritis, OA, dislocation, infection Acromioclavicular – subluxation, OA 35 Bone Conditions Associated with Pathological Fracture Osteoporosis Osteomalacia Primary or secondary tumor Osteogenesis imperfecta Renal osteodystrophy Parathyroid bone disease Paget’s disease 36 Common Causes of Muscle Pain (Myalgia) Infective Viral – coxsackie, cytomegalovirus, echovirus, dengue Bacterial – streptococcus pneumoniae, Mycoplasma Parasitic – schistosomiasis, toxoplasmosis Traumatic Tears Hematoma Rhabdomyolysis Inflammatory Drugs Alcohol withdrawal Statins Triptans Metabolic Hypothyroidism Hyperthyroidism Addison’s disease Vitamin D deficiency Neuropathic Polymyalgia rheumatica Myositis Dermatomyositis 37 Taking the History- PMH Identify co-morbid factors e.g., diabetes mellitus, steroid therapy, osteoporosis, fractures, ischemic heart disease, stroke and obesity. Identify known MSK diseases Identify medications Drug Possible Adverse Musculoskeletal Effects Glucocorticoids Osteoporosis, myopathy, osteonecrosis, infection Statins Myalgia, myositis, myopathy Angiotensin-converting enzyme inhibitors Myalgia, arthralgia, positive ANA Antiepileptics Osteomalacia, arthralgia Immunosuppressants Infections Quinolones Tendinopathy, tendon rupture Family History Inflammatory arthritis (first-degree relative) Osteoarthritis Osteoporosis Variable polygenic inheritance Gout “Do any bone or joint problems run Spondyloarthritis (HLA B27) in your family?” Charcot-Marie-Tooth disease Osteogenesis imperfecta Ehlers-Danlos syndrome Single gene defects Marfan’s syndrome Muscular dystrophies 39 Social History Smoking – RA Alcohol – Gout, fractures due to falls, myopathy, neuropathy, rhabdomyolysis Sexual history – reactive arthritis, gonococcal arthritis, HIV, and hepatitis B Occupational history – Is the patient working full- or part-time, on sick leave or receiving benefits? Has the patient had to take time off work because of the condition? If so, is the patient's job at risk? Litigation may be pending in personal injury cases and occupation-related complaints (e.g., repetitive strain disorder, hand vibration syndrome and fatigue fractures). Army recruits, athletes and dancers are at particular risk of fatigue fractures. Functional difficulties – including ability to hold and use items such as pens, tools and cutlery. How does the condition affect activities of daily living (e.g., washing, dressing and toileting)? Can patients use stairs and do they need aids to walk? Ask about functional independence, especially cooking, housework and shopping. **Can also be HPI** 40 Review of Systems Yes/No questions that help you focus in on a specific diagnosis Can use to rule in/rule out alternate diagnoses Some may be offered during the HPI, others you will need to specifically ask during the ROS There’s no set number of questions you have to ask. You ask as many as are necessary to develop a working diagnosis Depending on the situation your questions may be: General “Have you noticed any bowel changes?” Specific “Have you had bloody diarrhea?” There are MANY ROS questions to choose from… General: fever, chills, fatigue, weight change, (or other suggested topics such as; pain, night sweats, sleep patterns, malaise) Skin, hair, and nails: rash, lumps, sores, itching, (or other suggested topics such as; color change, texture change; excessive sweating, dryness, changes in hair or nails) Head: headaches, dizziness, loss of consciousness, severe head injuries, concussions Eyes: redness, excessive tearing, double vision, blurred vision, (or other suggested topics such as; visual acuity, eye pain with bright lights, glaucoma, history of trauma, glasses or contact lenses, last eye examination, spots, specks, flashing lights, cataracts) Ears: hearing change, discharge, tinnitus, vertigo, (or other suggested topics such as; infections, use of hearing aids, pain) Nose: nosebleeds, sinus trouble, nasal stuffiness, itching, (or other suggested topics such as; change of smell, frequency of colds, obstruction, postnasal discharge, sinus pain, hay fever) Throat and mouth: change in voice, sore throats, ulcers, postnasal drainage, (or other suggested topics such as; bleeding or swelling of gums, recent tooth abscesses or extractions, change in taste, dental caries, condition of teeth and gums, dentures, last dental examination, sore tongue, dry mouth) Neck and Lymph nodes: tenderness, lumps, swollen glands, goiter, pain or stiffness in the neck Chest and lungs: cough, sputum (color, character and quantity), wheezing, shortness of breath, (or other suggested topics such as; pain with breathing; problems breathing, cyanosis, coughing up blood, night sweats, exposure to tuberculosis; date and result of last chest x-ray examination, bronchitis, emphysema, pleurisy) Breasts: lumps, tenderness, nipple discharge, last mammogram, (or other suggested topics such as; galactorrhea, breast self-awareness/breast self-examination, development, pain) Heart and blood vessels: chest pain, shortness of breath, loss of consciousness, palpitations, (or other suggested topics such as; paroxysmal nocturnal dyspnea (number of pillows needed for sleep), edema, previous myocardial infarction, estimate of exercise tolerance, past electrocardiogram or other cardiac tests, heart trouble, high blood pressure, rheumatic fever, heart murmur) Peripheral vasculature: pain in legs with walking or activity (claudication), tendency to bruise or bleed, leg cramps, varicose veins, past clots in veins Hematologic: anemia, easy bruising or bleeding, any known blood cell problem, past transfusions and any reactions to them Gastrointestinal: nausea, vomiting, diarrhea, constipation, (or other suggested topics such as; appetite, trouble swallowing, regurgitation, heartburn, indigestion, food intolerance, vomiting blood regularity of bowels, change in stool frequency, consistency, color or contents (e.g., clay-colored, tarry, fresh blood, mucus, undigested food), hemorrhoids; jaundice, history of ulcer, gallstones, gallbladder or liver problems, hepatitis, polyps, tumor; previous diagnostic imaging (where, when, findings), abdominal pain, excessive belching or passing gas) Endocrine: unexplained weight change, thyroid trouble, heat or cold intolerance, excessive hunger or thirst, (or other suggested topics such as; changes in facial or body hair or distribution, increased hat and glove size, skin striae, excessive sweating) Genitourinary: burning or pain on urination, urgency, frequency, nocturia, (or other suggested topics such as; bloody urine, polyuria, discolored urine, hesitancy, dribbling, loss in force of stream, passage of stone; edema, stress incontinence, hernias, urinary infections, flank or suprapubic pain) Musculoskeletal: joint stiffness, muscle or joint pain, limitation of motion or activity, (or other suggested topics such as; redness, swelling, heat, bony deformity, arthritis, gout, backache, tenderness, weakness) Neurologic: loss of consciousness, seizures, weakness or paralysis, (or other suggested topics such as; changes sensation or coordination, tremors, loss of memory, fainting, blackouts, tingling or ‘pins and needles’, other involuntary movements) Psychiatric: anxiety, depression, mood changes, suicidal or homicidal thoughts or ideations, (or other suggested topics such as; difficulty concentration, agitation, tension, irritability, sleep disturbances, nervousness, memory changes) Females reproductive: last menstrual period (LMP), date of last Pap smear, (or other suggested topics such as; age at menarche, regularity, frequency, duration and amount of flow, bleeding between periods or after intercourse, premenstrual tension, itching, age at menopause, menopausal symptoms, postmenopausal bleeding, libido, frequency of intercourse, pain during intercourse, sexual difficulties, infertility, discharge, itching, sores, lumps) Pregnancies: number, living children, multiple births, miscarriages, abortions, duration of pregnancy, (or other suggested topics such as; each type of delivery, any complications during any pregnancy or postpartum period or with neonate; use of oral or other contraceptives) Male reproductive: difficulty with erections, testicular pain or masses, (or other suggested topics such as; emissions, libido, infertility, hernias, discharge from or sores on the penis) Review of Systems How do you choose what to ask? Based on the chief complaint and HPI For any joint pain, always ask the following JOINT questions: Is the joint red? Is it warm? Is it swollen? Is it stiff? Do any other joints hurt? Is there locking/triggering/clicking/popping? Generally, ask the following NEURO questions as well: Do you have any weakness? What about numbness/tingling/burning? It’s also good to ask other MSK questions such as: Do any of your muscles hurt? Also ask questions from other systems as needed Review of Systems Questions from other systems can also be very helpful, especially if you suspect systemic disease. If you suspect infection: Have you had a fever? Chills? Ask about skin and nail changes. It may be sufficient to ask “any skin changes?” but you may need to be more specific: Any rash on your face? Any nodules under your skin? Do your fingers ever change color? Ask about bowel changes. Ask about respiratory symptoms. Ask about eye symptoms. Again, get specific if needed: Dry eyes? Ask about mouth symptoms. Ulcers? Dry mouth? *Essentially, ask the symptoms of any conditions that are in your differential diagnosis.* Physical Exam Examine the overall appearance for pallor, rash, skin tightening and hair changes. Look at the skin, subcutaneous tissues and bony outline of each area. Before palpating, ask the patient which area is painful or tender. Feel for warmth, swelling, stability and deformity. Assess if a deformity is reducible or fixed. Assess active before passive movement. Do not cause the patient additional pain. **The exception here is that MOST clinicians actually test most hip motions and some of the ankle ones passively due to difficulty explaining to patient. Compare one limb with the opposite side. (Ideally) expose the joint above and below the one in question. In suspected systemic disease, examine all joints and fully examine all systems. “Special Tests” AFTER completing the basics, you should then perform “special tests” such as anterior drawer or Neer to help confirm or rule out suspected diagnoses. You should not go straight to special testing. You should always start with the BASICS!!! Physical Exam Skin, nails and soft tissue The skin and related structures are the most common sites of associated lesions. The skin and nail appearances in psoriasis may be hidden, e.g. the umbilicus, natal cleft, scalp. The rash of SLE is induced by ultraviolet light exposure. Small, dark red vasculitic spots due to capillary infarcts occur in many systemic inflammatory disorders, including rheumatoid arthritis, SLE and polyarteritis nodosa. These indicate active disease. Common sites are the nail folds, finger and toe tips and other pressure areas. Raynaud's phenomenon is episodic ischaemia of the fingers precipitated by stimuli such as cold, pain and stress. There is a typical progression of colour changes: blanching (white) is followed by cyanosis (blue), and reactive hyperaemia (red). There is associated dysaesthesia (altered sensation) and pain. Raynaud's phenomenon is common in otherwise healthy individuals but is a frequent feature in systemic sclerosis and SLE. In systemic sclerosis, the thickened, tight skin produces a characteristic facial appearance. In the hands, flexion contractures, calcium deposits in the finger pulps and tissue ischemia leading to ulceration may occur. The telangiectasias of systemic sclerosis are purplish, blanch with pressure and are most common on the hands and face. Reactive arthritis has extra-articular features and is associated with skin and nail changes similar to those of psoriasis, together with conjunctivitis, circinate balanitis (painless superficial ulcers on the prepuce and glans;, urethritis and superficial mouth ulcers. Subcutaneous nodules in rheumatoid arthritis most commonly occur on the extensor surface of the forearm. They are firm and non-tender, and may also be felt at sites of pressure or friction, e.g. the sacrum or Achilles tendon. Multiple small nodules can occur in the hands and are particularly associated with methotrexate therapy. Rheumatoid nodules are strongly associated with a positive rheumatoid factor and can occur at other sites, e.g. the lungs. Bony nodules in osteoarthritis affect the hand and are smaller and harder than rheumatoid nodules. They occur on the lateral aspects of the interphalangeal (IP) joints. At the DIP joints they are called Heberden's nodes, and at the proximal interphalangeal (PIP) joints, Bouchard's nodes. Gouty tophi are firm, white, irregular subcutaneous crystal collections (monosodium urate monohydrate). Common sites are the olecranon bursa, helix of the ear and extensor aspects of the fingers, hands, knees and toes. The overlying skin may ulcerate, discharge crystals and become secondarily infected. Other extra-articular features. Common Musculoskeletal Investigations Investigation Urinalysis Protein Blood Hematological Complete blood count Indication/Comment Glomerular disease (SLE, vasculitis) Secondary amyloid in RA and other chronic arthropathies Drug adverse events (myocrisin, penicillamine) Glomerular disease (SLE, vasculitis) ESR/plasma viscosity CRP Anemia in inflammatory arthritis, blood loss after trauma Neutrophilia in sepsis and very acute inflammation (acute gout) Leukopenia in SLE, Felty’s dyndrome and adverse effects of antirheumatic drug therapy Non-specific indicator of inflammation or sepsis Acute-phase protein Biochemical Urea and creatinine Uric acid Calcium Alkaline phosphatase Angiotensin-converting enzyme Urinary albumin:creatinine ratio ↑ in renal impairment (secondary amyloid in RA or adverse drug effect) May be ↑ in gout. May be normal during acute attack. ↓ in osteomalacia, normal in osteoporosis ↑ in Paget’s disease, metastases, osteomalacia and immediately after fractures ↑ in sarcoidosis Glomerular disease (vasculitis, SLE) Serological Immunoglobulin M rheumatoid factor Anti-cyclic citrullinated peptide antibody (ACPA) Antinuclear factors Anti-Ro, Anti-La Anti-double-stranded DNA Anti-Sm Anti-ribrocucleoprotein Antineutrophil cytoplasmic antibodies ↑ titers in 60-70% cases of TA, may be low in other connective diseases. Present in 15% of normal population. Superseded by anti-cyclic citrullinated peptide antibodies Present in 60-70% of cases of RA and up to 10 years before onset of disease. Highly specific for RA. Occasionally found in Sjogren’s syndrome. ↑ titers in most cases of SLE, low titers in other connective tissue diseases and RA Sjogren’s syndrome SLE SLE Mixed connective tissue disease Granulomatosis with polyangiitis, polyarteritis nodosa, Chur-Strauss vasculitis 48 Common Musculoskeletal Investigations Investigation Indication/Comment Other Schirmer tear test, salivary flow test Keratoconjunctivitis sicca (dry eyes), Sjogren’s syndrome Imaging Plain radiography (x-ray) Ultrasonography Magnetic resonance imaging Computed tomography Dual-energy x-ray absorptiometry Isotope bone scan Joint aspiration/biopsy Synovial fluid microscopy Polarized light microscopy Bacteriological culture Biopsy and histology Fractures, erosions in RA and psoriatic arthritis, osteophytes and jointspace loss in osteoarthritis, bone changes in Paget’s disease, pseudofractures (Looser’s zones) in osteomalacia Detection of effusion, synovitis, cartilage breaks, enthesitis and erosions in inflammatory arthritis. Joint and bone structure, soft-tissue imaging High-resolution scans of thorax for pulmonary fibrosis Gold standard for determining osteoporosis. Usual scans are of lumbar spine, hip and lateral vertebral assessment for fractures Increased uptake in Paget’s disease, bone tumor, infection, fracture, infrequently used due to high radiation dose. Inflammatory cells, e.g. ↑ neutrophils in bacterial infection Positively birefringent rhomboidal crystals – calcium pyrophosphate (pseudogout) Negatively birefringent needle-shaped crystals – monosodium urate monohydrate (gout) Organism may be isolated from synovial aspirates Synovitis – RA and other inflammatory arthritides 49 References Bickley, Lynn S., et al. Bates Guide to Physical Examination and History-Taking. 12th ed., Wolters Kluwer Health/Lippincott Williams & Wilkins, 2017. Innes, J. Alastair, et al. Macleods Clinical Examination. 14th ed., Elsevier, 2018. 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