• widespread musculoskeletal pain and stiffness, nonrestorative sleep, fatigue, multiple symmetrical painful tender points, and normal laboratory evaluation.
• symmetric tender points
• normal lab values
• can treat with amitriptyline, improving sleep, and start aerobic conditioning
• if have anxiety or depression, treat it

• DDx include gout, pseudogout, RA, spondyloarthritides, SLE, and Septic Arthritis
• ASPIRATE FIRST!
• Septic arthritis has joint fluid >50,000/uL leukocytes with 90% neutrophils
• Gout joint fluid has 2000-50,000/uL leukocytes
• Empiric antibiotic can be started if suspect septic arthritis - Ceftriaxone if don't think it's Staph or Pseudomonas
• Gout can be treated with colchicine and NSAIDs but in CKD, have to use prednisone because the other two will worsen renal function.

• Diagnosed by joint aspiration 
• Polarized light microscopy showing negatively birefringent needle shaped MSU crystals
• Increasing Uric Acid increases incidence of gout but during an acute attack uric acid levels are not helpful.

• Can be infectious, crystalline, or traumatic
• Crystalline and infectious will have extreme pain on any passive motion
• Olecrenon bursitis is associated with pain on full elbow flexion
• Must exclude infectious and crystalline and the only way to do that is with ASPIRATION.
• X-ray can detect trauma but cannot exclude the other two.

• Twisting foot injury with foot in weight-bearing position and a popping or tearing sensation
• swelling over hours
• ligamentous injury swells immediately
• Pain walking, climbing stairs, knee locks
• Pain along joint line
• McMurray test

• Result of forceful stress or direct blows to the knee while the extremity is bearing weight.
• Valgus Stress - Medial Collateral Ligament
• Varus Stress - Lateral Collateral Ligament
• Hyperextension - Posterior Cruciate Ligament
• Excessive Medial rotation on planted foot - Anterior Cruciate Ligament
• Immediate swelling
• popping or tearing sensation

• Most common cause of knee pain in active adults younger than 45.
• Pain with going down steps
• Stiffness and pain at rest when knee is flexed for extended period
• Pain when patella is moved firmly along the femur
• Treat with rest and NSAIDs

• Nearly always unilateral and often asymptomatic
• History of trauma to the knee or crawling
• tenderness of entire bursal sac
• collection of fluid directly over patella

• Obtain x-ray if patient has any of the following 3 signs: 

1. Age >55
2. Tenderness at head of fibula or patella
3. Inability to flex to 90 degrees or bear weight both immediately after injury and during evaluation.

• Treatment is RICE:
  • Rest
  • Ice
  • Compression
  • Elevation
• NSAIDs for pain
• If patient does not respond to symptomatic treatment, consider MRI

• Inflammation of the supraspinatus and/or infraspinatus that often involves the subacromial bursa
• common overuse injury
• painful compression of rotator cuff tendons and aubacromial bursa between humeral head and acromion with arm elevation
• pain with reaching overhead and lying on affected shoulder
• Abduction test - pain at 60-70 degrees is mod impingement. Pain at <45 degrees is severe impingement
• Pain with resisted mid-arc abduction is specific for this
• Treat with NSAIDs, ice, exercises, limit reaching over head and lifting

• Positive Drop-arm test
• arm weakness, esp with abduction or external rotation

• Decreased range of shoulder motion
• Main symptom is stiffness rather than weakness or pain

• Overuse injury
• bicipital groove is tender
• anterior shoulder pain with resisted forearm supination or elbow flexion

• Usually due to trauma
• gradual onset of pain and stiffness over months to years

• Episodic
• Positively birefringent rhomboid crystals
• Chondrocalcinosis in fibrocartilage of knee meniscus, sympisis pubis, glenoid and acetabular labra, and triangular cartilage of wrist is PATHOGNOMONIC for CPPD (Pseudogout)
• Can coexist with OA

• Tophi are long term manifestations of chronic gout
• Postmenopausal women on diuretics = tophaceous gout of DIP joints
• Treat with allopurinol to decrease serum urate to 6mg/dL to dissolve tophi.
• Decreasing urate may cause gout attack so colchicine is indicated, but can be discontinued once patient's urate level is stable and free of gout for >6 months.

• Diabetes
• Elevated AST/ALT
• Arthropathy - MCP joints or large joints
• Fatigue
• Impotence - hypogonadotropic hypogonadism
• Initial test: Transferrin saturation if >/=45%, need further testing for hemochromatosis
• Patient has bronzing of skin

• Pain with ambulation initially, pain at rest in advance disease
• Deep aching pain in affected joints
• morning stiffness < 30 mins
• Usually involves knee, hip, DIP, PIP and first carpometacarpal joints
• Squaring of first carpometacarpal joint
• Joint crepitus or decreased range of motion
• Bony enlargement of affected joints - Heberden's nodes (DIP), Bouchard's nodes (PIP)
• Dx on History and Clinical Exam
• Synovial fluid: Clear, viscous, noninflammatory, leukocytes <2000/uL
• Treatment is withe acetominophen which is just as effective as NSAIDs or naproxen but doesn't cause GI bleed.
• Diet and exercise improves function and pain in overweight and obese adults with knee OA
• Intra-articular corticosteroid injection is best used to treat acute exacerbation of knee arthritis 

• Symmetric polyarthritis primarily affecting hands, fingers, wrists, shoulders, elbows, hips, knees, ankles, feet, and cervical spine
• Affects MCP joints and maybe PIP joints, but never DIP joints
• Usually spares first CMC, DIP joints and thoracic, lumbar, and sacral spine
• Soft tissue swelling rather than bony enlargement of OA
• Radiographic evidence: Juxta-articular osteopenia or marginal erosions, ulnar styloid erosion
• Fatigue and prolonged morning stiffness or stiffness after prolonged immobility
• Dx: 4 out of 7 of the following criteria:

1.  
   1. Morning stiffness lasting at least 1 hour before improvement
   2. Soft tissue swelling in at least 3 different joints observed by a physician (PIP, MCP, wrist, knee, elbow, ankles, MTP)
   3. Swelling of the PIP, MCP, or wrist joint
   4. symmetric joint swelling
   5. Subcutaneous nodules over a bony prominence or extensor surface or in juxta-articular regions
   6. Positive RF
   7. Radiographic periarticular osteopenia and/or marginal erosions in hand and wrist joints

Myositis and Malignancies

(Dermatomyositis, Polymyositis, and Inclusion-body Myositis)

• Associated with malignancies
• Malignancy often evident at the time of myositis
• Search for malignancies in older patients
• Do not search for malignancies in younger patients
• Use endoscopic and imaging to search for pharyngeal, gastrointestinal, pulmonary, intra-abdominal, and pelvic malignancies
• Asian patients: refer to ENT to rule out nasopharyngeal cancer

• subacute onset of proximal muscle weakness
• elevated creatine kinase (10-50X normal)
• Usual CC is fatigue and generalized weakness
• May have respiratory insufficiency, esophageal dysmotility, dyspnea from cardiomyopathy
• Prox muscle weakness + Elevated Creatine Kinase = Need for muscle biopsy and/or electromyography
• Heliotrope rash and Gottron's sign indicate Dermatomyositis

• Sexually active patients
• migratory arthalgias followed by oligoarthritis
• wrist tenosynovitis
• tender necrotic pustules on an erythematous base, especially on the distal extremities
• May require 72 hours for therapy to take effect
• Cultures may be negative
• If respond to therapy, Dx is established
• Once Dx with gonnorrhea, must check for other STDs, Chlamydia and HIV

• SA is monoarticular in 80-90%
• Need arthrocentesis
• Non-gonococcal septic arthritis is usually caused by gram positive bacteria (strep and staph) 
• S. aureus accounts for 37-65% of all cases in patients without RA.
• In patients with RA, S. aureus accounts for 75-90% of all cases of septic arthritis, making other organisms unlikely.
• Patients who have had genitourinary procedures, UTIs, DM, contiguous decubitus ulcers, and prostheses are more at risk for SA and vertebral OM
• Radiographic evidence is delayed 7-10 days but shouldn't delay diagnosis
• Sternoclavicular SA is seen in IV drug users and can present with other findings like breast abscess
• Treat with IV antibiotics and joint drainage. Oral antibiotics are not acceptable as disease is usually fast progressing.

• Can be diffuse or limited aka CREST Syndrome
• Diffuse - skin involvement proximal to elbows and knees
• Limited - Skin involvement stops distal to elbows and knees
• Both forms involve skin changes to face
• Both can have Reynauds
• Both have sclerodactyly prox to MCP joints
• CREST - Calcinosis, Reynaud's, Esophageal Dysmotility, Scleroldactyly, Telangiectasias
• Both can be associated with Interstitial Lung Disease and Pulmonary hypertension

• Symmetric polyarthritis involving same joints as RA
• Rash, mucosal ulcers, and constitutional symptoms
• Malar rash
• nondeforming synovitis
• Pancytopenia
• 11 Diagnosing criteria: SOAP BRAIN MD
  • Serositis (pleuritis, pericarditis)
  • Oral or nasopharyngeal ulcerations (painless)
  • Arthritis (nonerosive) involving more than two peripheral joints with synovitis
  • Photosensitivity
  • Blood dyscrasias (Coombs'-positive hemolytic anemia with reticulocytosis or leukopenia <4000/µL on more than two occasions, or lymphopenia <1500/µL on two occasions, or thrombocytopenia < 100,000/µL)
  • Renal disease (persistent proteinuria >500 mg/day or cellular casts in the absence of infection)
  • Antinuclear antibody (titer of >1:80)
  • Immunologic disorder (anti–double-stranded DNA antibody, anti-Smith antibody, antiphospholipid antibody, positive lupus anticoagulant, or false-positive rapid plasma reagin [RPR] or VDRL test)
  • Neurologic disorder (seizures or psychosis)
  • Malar rash
  • Discoid rash (erythematous raised patches with scaling and follicular plugging)
• ANA is present in 95% of SLE patients
• Anti-dsDNA antibody is highly specific for SLE, can be used to confirm diagnosis

• inflammation of extracranial branches of the carotid artery
• Affects elderly population
• headaches, optic nerve ischemia, polymyalgia rheumatica
• scalp tenderness, carotidynia, jaw claudication
• Most have elevated ESR, 10-24% will not
• Needs temporal artery biopsy to confirm diagnosis
• Treat with prednisone, symptoms will resolve usually within 1 week

• Mononeuropathy multiplex (neuropathy of many individual nerves)
• Peripheral Nervous System Neuropathies - Acute onset of asymmetrical weakness, sensory loss, and severe pain
• Can be seen with SLE, PAN, leprosy, sarcoidosis, amyloidosis, and HNPP (Hereditary neuropathy with predisposition to pressure palsies)

• History of pain and morning stiffness in the axial joints and proximal muscles
• Absence of marked muscle weakness, joint swelling, pain, warmth, or restricted movement
• Most common in Pts >50 years old
• 90% will have elevated ESR
• Can be associated with Giant Cell Arteritis
• Treatment is with prednisone and symptoms should resolve within 24 hours
• if concurrent GCA, need higher dose prednisone