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MusculoskeletalComplaints

P A R T

I

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3

C O N T E X TThe approach to a patients musculoskeletal complaint isa standardized, often sequential search for what can andwhat cannot be managed by the examining doctor. Thereis always an ultimate decision: rule in or rule out referableconditions.

The crucial decision with acute traumatic pain is torule out fracture (and its complications such as neu-ral or vascular damage), dislocation, and gross instability.

The crucial decision with nontraumatic pain is torule out tumors, inflammatory arthritides, infec-tions, or visceral referral.

There appears to be a misinterpretation regarding theamount of information necessary to make diagnostic ormanagement decisions. One error is to think of all jointsas distinctly different because the names of structures,disorders, or orthopaedic tests are different for each joint.Another error is to make the assumption that the joint op-erates as an independent contractor without accountabilityto other joints. The first error leads to an overspecial-ization effort that often leaves the doctor unwilling toattack the vast amount of individual information for eachjoint. The second error leads the examiner to an approachthat excludes important information that may contributeto the diagnosis of a patients complaint. Each is an errorin extremes: the first is that too much knowledge is as-sumed necessary; the second assumes that too little base-line information is needed for making diagnostic andtreatment decisions.

A general approach to evaluation of any joint (and sur-rounding structures) utilizes the perspective that a jointis a joint. Although a specific joint may function differ-ently because of its bony configuration, structurally, it iscomposed generally of the same tissues. Most joint regions

have bone, ligaments, a capsule, cartilage and synovium,surrounding tendons and muscles, associated bursae,blood vessels, nerves, fat, and skin. All of these structuresmay be injured by compression or stretch. Compressionmay lead to fracture in bones or neural dysfunction innerves. Stretch leads to varying degrees of tendon/muscle, ligament/capsule, neural/vascular, or bone/epiphyseal damage ranging from minor disruption to fullrupture. Joints can be further divided into weight bear-ing and non-weight bearing. Non-weight-bearing jointsmay be transformed into weight-bearing joints throughvarious positions such as handstands or falls with the up-per extremity, hyperextension of the spine, or any axialcompression force to the joint. Weight-bearing jointsare generally more susceptible to chronic degenerationand osteoarthritis.

Bones and joints are also susceptible to nonmechani-cal processes that involve seeding of infection or canceras well as the development of primary cancer and the im-munologically based rheumatoid and connective tissue dis-orders. Clues to rheumatoid and seronegative arthritidesinclude a pattern of involvement with a specific predilec-tion to a joint or groups of joints coupled with laboratoryinvestigation.

The approach to evaluation of a neuromusculoskele-tal complaint is also directed by a knowledge of commonconditions affecting specific structures (regardless of thespecific names). Following is a list of these structures andthe disorders or conditions most often encountered witheach:

bone tumor, primary or metastatic osteochondrosis/apophysitis fracture osteopenia (osteoporosis) osteomyelitis

General Approach to MusculoskeletalComplaints

C H A P T E R

1



soft tissue1. muscle

strain or rupture trigger points atrophy myositic ossificans muscular dystrophy rhabdomyositis

2. tendon tendinitis tendinosis paratenonitis rupture

3. ligament sprain or rupture

4. bursa bursitis

5. fascia myofascitis

joint arthritis subluxation/fixation (chiropractic) synovitis infection joint mice dislocation/subluxation (medical)

G E N E R A L S T R AT E G Y

HistoryClarify the onset.

Is the complaint traumatic? Is there a history of overuse? Is the onset insidious?

Clarify the type of complaint.

Is the complaint one of pain, numbness or tingling,stiffness, looseness, crepitus, locking, or a combi-nation of complaints?

Localize the complaint to anterior, posterior, me-dial, or lateral if applicable.

Clarify the mechanism if traumatic (for extremities seeTable 11).

If there was a fall onto a specific region or structurewithin that region, consider fracture, dislocation, orcontusion.

Determine whether there was an excessive valgusor varus force, internal or external rotation, or flex-

ion or extension. Consider ligament/capsule ormuscle/tendon.

If there was sudden axial traction to the joint, con-sider sprain or subluxation.

If there was axial compression to the joint, considerfracture or synovitis.

Determine whether the mechanism is one of overuse.

In what position does the patient work? Does the patient perform a repetitive movement

at work or during sports activities? Consider mus-cle strain, tendinitis, trigger points, or peripheralnerve entrapment.

If insidious, determine the following:

Are there associated systemic signs of fever,malaise/fatigue, lymphadenopathy, multiple af-fected areas, etc?

Are there local signs of inflammation includingswelling, heat, or redness?

Is there local deformity? Is there associated weakness, numbness, tingling, or

other associated neurologic dysfunction?

Determine whether the patient has a current or past his-tory or diagnosis of his or her complaint or other relateddisorders.

Are there associated spinal complaints or radiationfrom the spine? Consider subluxation, nerve rootentrapment, or compression.

Does the patient have a diagnosis of another arthri-tide, systemic disorder such as diabetes, or past his-tory of cancer?

Does the patient have visceral complaints such asabdominal or chest pain, fever, weight loss, or othercomplaints?

Evaluation

With trauma, palpate for points of tenderness andtest for neurovascular status distal to the site of in-jury; obtain plain films to rule out the possibility offracture/dislocation.

Palpate for swelling, masses, and warmth. Determine whether swelling is present and if so,

whether it is intra- or extra-articular. If extra-articular, attempt to differentiate between bursalversus vascular inflammation.

If deformity or mass is evident, attempt to differ-entiate between soft versus bony tissue. The mostcommon soft-tissue causes would include lipomas,neuromas, and ganglions (or other cyts), or fascialherniation.

4 Musculoskeletal Complaints



General Approach to Musculoskeletal Complaints 5

TA B L E

11 Joint-Specific Injury Mechanism

Mechanism Possible Structure(s) Damaged

ShoulderFall on an outstretched arm (extended elbow) Rotator cuff tear

Glenoid labrum tear

Posterior dislocation

Clavicular fracture

Arm forced into abduction/external rotation Anterior dislocation

Anterior musculature strain

Blow to the shoulder area Fracture

Acromioclavicular separation

Dislocation

Fall onto top of shoulder Shoulder pointer

Acromioclavicular separation

Distal clavicular fracture

Traction injury to arm Plexus injury

Medical subluxation

ElbowDirect fall on tip of elbow or fall on hand with elbow flexed Olecranon fracture

Fall on hand with extended elbow Radial head fracture

Hyperextension injury to elbow Elbow dislocation

Supracondylar fracture in children

Severe valgus stress Capitellum fracture

Avulsion of medial epicondyle

Medial collateral ligament sprain or rupture

Sudden traction of forearm Radial head subluxation

Wrist/handFall on dorsiflexed hand Navicular fracture

Epiphyseal and torus fractures in children

Carpal dislocation,or instability

Hyperextension or abduction of thumb Gamekeepers thumb (ulnar collateral ligament damage)

Axial compression of thumb Bennetts fracture

Dislocation

Hyperextension of finger Volar plate injury

Jersey finger (rupture of flexor digitorum profundus)

Dislocation

Hyperflexion of finger Avulsion of central slip

Mallet finger (rupture of extensor tendon)

Valgus/varus stress injury to finger Collateral ligament or volar plate injury

Axial compression Capsular irritation

Fracture

HipFall on hip Fracture

Synovitis(continued)



With no history of trauma or overuse, consider theuse of special imaging, including MRI or CT; bonescan for cancer seeding screen or for stress frac-ture; electrodiagnostic studies if persistent neuro-logical findings are present; laboratory if systemicfindings are present; or synovial fluid analysis ifswelling is present or if an arthritide is suspected butin need of differentiation (see Table 12).

Palpate and challenge the ligaments and capsule ofthe joint.

Challenge the musculotendinous attachments withstretch, contraction, and a combination of con-traction in a stretched position.

Measure the functional capacities of the region in-volved; determine any associated biomechanicalfaults that may be contributing to the problem.

Management

Refer fracture/dislocation, infection, and tumorsfor orthopaedic management.

Refer or comanage rheumatoid and connective tis-sue disorders.

If the problem is one of instability without liga-ment rupture, stabilize the joint through an ap-propriate exercise program using a brace initially,if necessary, to assist.

If the problem is weakness, strengthen the associ-ated muscle.

Functionally retrain the individual for a return to dailyactivities and occupational or sport requirements.

Use manipulation/mobilization for articular dysfunction.


TA B L E

11 Joint-Specific Injury Mechanism (continued)

Mechanism Possible Structure(s) Damaged

Hip (continued)Fall on hip Hip pointer

Trochanteric bursitis

Blow to flexed,adducted hip Posterior dislocation

KneeHyperextension Anterior cruciate ligament tear

Sudden deceleration Anterior cruciate ligament tear

Blow to a flexed knee at proximal tibia or hyperflexion Posterior cruciate ligament tear

Blow to anterior knee/patella Irritation of plica

Patellar fracture

Bursitis

Infrapatellar fat pad irritation

Valgus force Medial collateral ligament tear

Pes anserine strain

Rotational injury with foot fixed on ground Meniscus

Rotational injury with a valgus force Anterior cruciate ligament,meniscus,medial collateral ligament

Foot/anklePlantarflexion,inversion of ankle Ankle sprain with possible associated bifurcate ligament damage,fracture,

or peroneal tendon snapping from torn retinaculum

Eversion injury to ankle Deltoid ligament sprain or rupture

Fracture

Dislocation

Hyperextension of great toe Turf-toe injury to capsular ligaments

Landing on heels Fat pad irritation

Ankle or tibial fracture




TABL

E

12

Syn

ovi

al F

luid

Exa

min

atio

n

Typ

eEx

amp

les

Co

lor

Cla

rity

WB

C (p

er

L)P

MN

sC

ult

ure

Glu

cose

Vo

lum

e

Norm

alCle

arTra

nspa

rent

50

,000

75%

or m

ore

Usua

lly po

sitive

3.5

(Pur

ulent

)inf

ectio

nth

an se

rum

Note:

Joint

aspir

ation

findin

gs fo

r hem

orrh

agic

caus

es,in

cludin

g hem

ophil

ia,tra

uma (

with

or w

ithou

t fra

cture)

,neu

ropa

thic

arth

ropa

thy,P

VS,a

nd be

nign n

eopla

sms (

e.g.,h

eman

giom

a) ar

e dom

inate

d by b

lood i

n the

joint

.

Lege

nd:W

BC =

whit

e bloo

d cell

;PM

N =

polym

orph

onuc

lear le

ukoc

ytes;P

VS =

pigm

ente

d villo

nodu

lar sy

novit

is;IB

D =

infla

mm

atory

bowe

l dise

ase (

includ

es ul

cerat

ive co

litis

and r

egion

al en

terit

is)



H I S T O R YA mnemonic approach to the patients complaints may behelpful in organizing the vast number of possibilities.Beginning with a description of the patients complaint,a list of common causes may be attached. WIRS Pain isa mnemonic for weakness, instability, restricted move-ment, surface complaints, and pain.

WeaknessWeakness may be due to pain inhibition, muscle strain, orneurologic interruption at the myoneural junction, pe-ripheral nerve, nerve root, or spinal cord and above.Weakness may be a misinterpretation by the patient wheninstability or a loose joint is present or the patient has stiff-ness that must be overcome by increased muscularactivity.

InstabilityInstability is due to either traumatic damage to ligamen-tous or muscular support or due to the inherent loosenessfound in some individuals joints. This inherent loosenessis usually global and can be identified in other joints oracquired as a result of repetitive overstretch positioning.Instability is most apparent when the joint is positionedso that muscles have less mechanical advantage (e.g.,overhead shoulder positions) or when a quick movementdemand is faster than the reaction time for the corre-sponding muscles (cutting or rotating knee movements).

Restricted MovementRestricted movement may be due to pain, muscle spasm,stretching of soft tissue contracture, or mechanical block-age by osteophytes, joint mice, fracture, or effusion.

Surface ComplaintsSuperficial complaints include skin lesions, cuts/abrasions, swelling, and a patients subjective sense ofnumbness or paresthesias.

PainPain is nonspecific; however, the cause usually will be re-vealed by combining a history of trauma, overuse, or in-sidious onset with associated complaints and significantexamination findings. It is important to determine localpain versus referred pain. Following are some guidelines:

Referred pain from scleratogenous sources: Scler-atogenous pain presents as a nondermatomal pat-tern with no hard neurologic findings such assignificant decrease in myotomal strength or deeptendon reflex changes. Although the term is usedbroadly, here we are referring mainly to facet- anddisc-generated pain.

Referred pain from visceral sources: In most casesa historical screening of patients will reveal pri-mary or secondary visceral complaints. It is im-portant to know the classic referral zones, such asscapular/shoulder pain with cholelithiasis and me-dial arm pain with cardiac ischemia.

Bone pain: Bone pain is deep pain, commonly worsein the evening. Trauma may indicate an underlyingfracture requiring radiographic evaluation. An over-use history may be suggestive of a stress fracturerequiring a radiographic evaluation. If results ofthe radiograph are negative, but a stress fracture isstill suspected, a bone scan is warranted.

A careful history will usually indicate the diagnosis or,at the very least, narrow down the possibilities to two orthree. Physical examination and imaging studies moreoften are used as a confirmation of ones suspicion(s).Generalizing a history approach allows the doctor to ad-dress any complaint regardless of region. Generally speak-ing, damage to structures locally is due to (1) exceedingthe tensile stress of ligaments, capsule, muscles, and ten-dons; (2) compression of bone; (3) demineralization ofbone; or (4) intrinsic destructive processes involvingarthritides (e.g., pannus formation with rheumatoid arthri-tis [RA], crystal deposition with gout or pseudogout), in-fections, or cancer. Although the first two categories arealmost always the result of trauma or overuse, the lattertwo are more commonly insidious. Traumatic and over-use disorders are classically local with regard to signs andsymptoms, whereas arthritides and cancer are often eithergeneralized or stereotypical based on the type.

Suspicion of specific structures is based on a basicknowledge of what causes damage to any similar structureregardless of which region or joint is involved. Ligamentor capsular injury is often the result of excessive force onthe opposite side of the ligament/capsule. For example,a valgus stress (outside to inside force) to the knee willcause an injury to the medial collateral ligament; a varusforce, the lateral collateral ligament. Although more dra-matically evident in an acute injury, it must be rememberedthat low-level, chronic stresses are often the cause of lig-amentous or capsular sprain. Muscle injury can be di-vided into stretch injury and contraction injury. Oftenwhen ligaments are damaged, muscle/tendon groups arealso involved. Muscle/tendons often act as static stabilizerssimply because when they cross the joint they are in theway when outside forces stretch that joint. Additionally,muscles will often contract in an attempt to protect thejoint and either incur damage or impose more damage tothe joint. This occurs especially when a joint is in exten-sion (such as the knee and elbow) or in neutral (such asthe wrist and ankle). Contraction injury is divided intoconcentric and eccentric. Usually an overexertion prob-lem, concentric injury often occurs when too heavy aweight is lifted or a sudden explosive muscle activity is re-quired. Concentric injury occurs as the muscle is short-ening. Eccentric injury occurs while the muscle islengthening. Although eccentric injury may occur withlifting, this pattern is frequently seen with overuse orrepetitive activity and/or injuries that challenge the de-celerator or stabilizer role of the muscle.




Tendons are susceptible primarily to overstrain froma sudden, forceful muscle contraction or from overuse.Occasionally, direct trauma may damage or inflame thetendon or its sheath. Rheumatoid and connective tissuedisorders can also affect the synovial lining or paratenon.Sometimes the use of various terminologies in the de-scription of tendon disorders is confusing. Newer ter-minology replacing older nomenclature causes some ofthis difficulty, coupled with new theories as to the typesof tendon pathology that occur related to its structureand function.1 Following is an updated list:

ParatenonitisThis term is replacing tenosynovi-tis, tenovaginitis, and peritendinitis. It is charac-terized by inflammation of only the paratenon (linedby synovium or not). Clinical signs are swelling,pain, crepitation along the tendon, local tender-ness, and warmth.

TendinitisNow used in place of strain or tear of atendon. This term refers to symptomatic degenera-tion of a tendon with vascular disruption and an in-flammatory repair response. Stages include: acute, < 2 weeks; sub-acute, 46 weeks; and chronic, > 6 weeks. Three subgroups include: (1) purely in-flammatory with acute hemorrhage and tearing,(2) inflammation that is in addition to preexistingdegeneration, and (3) calcification and tendinosisthat is chronic.

TendinosisThe newer term used to indicate in-tratendinous degeneration due to atrophy (due toaging, microtrauma, vascular compromise, etc.).This is considered noninflammatory with hypocel-lularity, variable vascular ingrowth, local necrosis,and/or calcification, with accompanying fiber dis-orientation. Palpable nodules can be found, such asin the Achilles, with or without tenderness.

Paratenonitis with tendinosisThis describes aparatenon inflammation associated with intra-tendinosis degeneration. Unlike tendinosis, thiscombination of pathologies presents clinically witha possible palpable tendon nodule, with accompa-nying signs of swelling and inflammation.

Bursae are protective cushions placed strategically atpoints of friction, particularly between muscle/tendon andbone. Although there are standard bursae in most indi-viduals, adventitious bursae may develop at sites of repet-itive friction in individuals performing specific activities.Bursae may be deep or superficial. Superficial bursae aresusceptible to direct traumatic forces. Deep bursae aremore susceptible to compression by bone or soft tissuestructures. Compression is often position specific such asduring overhead movements with the shoulder. Bursitismay be secondary to other soft tissue involvement suchas calcific tendinitis.

When musculoskeletal pain does not have an obvious me-chanical or traumatic cause, a search is initiated for my-ofascial disorders, arthritides, psychologic factors, connectivetissue disorders, cancer, and infection (see Table 13).

Arthritis has a geriatric connotation, yet it may af-fect any age group. The term simply means that the jointis affected. Generally, arthritis is due to degeneration ordestruction that is age-related or trauma related, infec-tious, inflammatory, and/or autoimmune. Based on thecause, arthritis may present as a monoarthopathy (i.e.,single joint), oligoarthopathy (24 joints), or as a poly-arthropathy ( 5 joints). When a single joint is involved,gout (first toe), infectious (direct infection or indirectspreading from another source such as gonococcal), ortrauma should be considered. When multiple joints areinvolved a distinction in thinking occurs differentiatingdegenerative, inflammatory (primarily rheumatoid andrheumatoid variants), and crystalline induced (primarilygout, pseudo-gout, amyloidosis, etc.). Seronegatives andenteropathic arthropathies tend to be oligoarticular,whereas RA and LE tend to involve more joints.

When considering arthritis as a cause of joint pain, thereare several other general factors that when considered sep-arately and then clustered together provide a good toolfor narrowing the large list of possibilities. The sequenceof how these factors are considered may change given thepresentation of the patient, yet the discussion will begin withage. There are very few arthritides that affect the young.Primarily, juvenile rheumatoid arthritis or arthritis sec-ondary to other diseases would be considered. For theyoung to middle-aged adult, primarily inflammatory and/orautoimmune arthritides are considered, including:

Seronegative arthritides (i.e., negative for rheuma-toid factor) including ankylosing spondylitis (AS),Reiters, and psoriatic

Rheumatoid arthritis (RA) Scleroderma Lupus erythematosis (LE) Osteitis condensins illi Synoviochondrometaplasia

For onset in the senior, the primary considerationsinclude:

Degenerative joint disease; osteoarthritis (OA) Diffuse idiopathic skeletal hyperostosis (DISH) Hypertrophic osteoarthropathy Gout Pseudogout; calcium pyrophosphate dihydrate

(CCPD) deposition disease

Considering gender, males are more prone toward AS,Reiters, gout, hypertrophic osteoarthropathy, and sec-ondary OA. Females are more prone toward juvenile andadult RA, LE, scleroderma, and osteitis condensins illi, as





TABL

E

13

Sele

cted

Art

hri

tic

Dis

ord

ers

Typ

eFe

atu

res

Man

agem

ent I

ssu

es

Deg

ener

ativ

ePr

imar

y Oste

oarth

ritis

Age o

f Ons

et

Gene

rally

>45

y/o

Gend

er P

redo

min

ance

Ra

tio of

fem

ale to

male

= 10

:1Co

mm

on Jo

ints

Invo

lved

Hi

ps,k

nees

,SI jo

int,A

C join

t,firs

t MCP

,first

MC t

rape

zium

,DI

P join

ts of

hand

s

Ofte

n init

ially

asym

ptom

atic;

grad

ual in

creas

e in j

oint s

tiffn

ess a

nd pa

in.De

form

ity m

ay be

appa

rent (

e.g.,H

erbe

rden

s nod

es in

hand

s).M

ay ev

entu

ally l

ead t

o join

t sub

luxat

ion an

d ins

tabil

ity.

Radio

logra

phica

lly:Th

e dist

ribut

ion is

asym

met

ric,w

ith no

n-un

iform

loss

of jo

int sp

ace,

oste

ophy

te fo

rmat

ion,su

bcho

ndra

l scle

rosis

(ebu

rnat

ion),s

ubch

ondr

al cy

sts.

Man

agem

ent in

early

and m

iddle

stage

s sho

uld in

clude

stren

gthe

ning a

roun

d inv

olved

joint

s.If w

eight

-bea

ring j

oint,b

egin

with

non-

weigh

t-bea

ring a

nd pr

ogres

s cau

tious

ly to

weigh

t-bea

ring i

f pos

sible.

Main

tena

nce o

f nor

mal

joint

mot

ion an

d fun

ction

may

be fa

cili-

tate

d by a

djus

ting/

man

ipulat

ion or

mob

ilizat

ion.D

ietar

y app

roac

hes i

nclud

e gluc

osam

inean

d cho

ndro

itin s

ulfate

.Med

ical m

anag

emen

t may

inclu

de re

com

men

datio

ns fo

r NSA

IDs,i

npa

rticu

lar,C

OX-2

inhib

itors.

Som

e med

ical s

pecia

lists

may

reco

mm

end v

iscos

upple

men

tatio

n(in

jectio

n of h

yalur

onic

acid

into t

he de

gene

rative

joint

).This

is of

ques

tiona

ble va

lue.In

som

ejoi

nts,j

oint r

eplac

emen

t is ne

cess

ary.

Seco

ndar

y Oste

oarth

ritis

Age o

f Ons

et

>25

y/o

Gend

er P

redo

min

ance

Eq

ual

Com

mon

Join

ts In

volv

ed

GH,A

C,SI,

hip,e

lbow,

knee

,foot

,han

d

Caus

e is s

econ

dary

to ot

her d

isord

ers o

r dise

ases

/injur

ies su

ch as

trau

ma,

sept

ic or

infla

mm

a-to

ry ar

thrit

is,sli

pped

epiph

yses

,dys

plasia

s,fra

cture/

disloc

ation

,ava

scula

r nec

rosis

,och

rono

-sis

,and

acro

meg

aly.S

imila

r rad

iogra

phic

pres

enta

tion.

Man

agem

ent in

early

and m

iddle

stage

s sho

uld in

clude

stren

gthe

ning a

roun

d inv

olved

joint

s.If w

eight

bear

ing,b

egin

with

non-

weigh

tbea

ring a

nd pr

ogres

s cau

tious

ly to

weig

ht-

bear

ing if

poss

ible.M

ainte

nanc

e of n

orm

al joi

nt m

otion

and f

uncti

on m

ay be

facil

itate

d by

adjus

ting/

man

ipulat

ion or

mob

ilizat

ion.D

ietar

y app

roac

hes i

nclud

e gluc

osam

ine an

d cho

n-dr

oitin

sulfa

te.M

edica

l man

agem

ent m

ay in

clude

reco

mm

enda

tions

for N

SAID

s,in p

artic

ular,

COX I

I inhib

itors.

Som

e med

ical s

pecia

lists

may

reco

mm

end v

iscos

upple

men

tatio

n (inj

ectio

nof

hyalu

ronic

acid

into t

he de

gene

rative

joint

).This

is of

ques

tiona

ble va

lue.In

som

e join

ts,joi

nt re

place

men

t is ne

cess

ary.

Erosiv

e Oste

oarth

ritis

Age o

f Ons

et

405

0 y/o

Gend

er P

redo

min

ance

Fe

male

Com

mon

Join

ts In

volv

ed

Inter

phala

ngea

l joint

s of h

and

Infla

mm

atory

varia

nt of

DJD

char

acte

rized

by ca

rtilag

e deg

ener

ation

and s

ynov

ial pr

olifer

a-tio

n.Ac

ute e

pisod

es th

at ap

pear

sim

ilar t

o inf

lamm

atory

/syn

ovial

arth

ritis;

chro

nicall

y may

evolv

e to s

ublux

ation

and d

evelo

pmen

t of H

erbe

rden

s nod

es.R

adiol

ogica

lly si

mila

r to O

Aw

ith ad

dition

al fin

ding o

f cen

tral e

rosio

ns.

Man

agem

ent in

early

and m

iddle

stage

s sho

uld in

clude

stren

gthe

ning a

roun

d inv

olved

joint

s.If w

eight

bear

ing,b

egin

with

non-

weigh

tbea

ring a

nd pr

ogres

s cau

tious

ly to

weig

ht-

bear

ing if

poss

ible.D

ietar

y app

roac

hes i

nclud

e gluc

osam

ine an

d cho

ndro

itin s

ulfate

.Med

ical

man

agem

ent m

ay in

clude

reco

mm

enda

tions

for N

SAID

s,in p

artic

ular,C

OX II

inhibi

tors.

In ad

-dit

ion,th

e foll

owing

anti-

inflam

mato

ry m

edica

tions

may

be su

gges

ted:

DM

ARDs

Di

seas

e-m

odify

ing an

tirhe

umat

ic dr

ugs (

e.g.,m

etho

trexa

te [R

heum

atrex

and

Trexa

l],hy

droc

hloro

quine

[Plaq

uenil

],and

leflu

nom

ide [A

rava]

).The

se ar

e tox

ic an

d may

take

wee

ks to

mon

ths t

o wor

k,ye

t are

highly

effec

tive.

Bi

ologic

agen

tsred

uce t

he pr

oduc

tion o

f tiss

ue ne

crosis

facto

r (TN

F) (e

.g.,E

mbr

el an

dRe

mica

de us

ually

give

n tog

ethe

r with

met

hotre

xate

)

Dege

nerat

ive Sp

ine D

iseas

eAg

e of O

nset

>

30 y/

oGe

nder

Pre

dom

inan

ce

Equa

lCo

mm

on Jo

ints

Invo

lved

Sp

ecific

spina

l invo

lvem

ent a

t C5-

C7,T2

-T5,

T10-

T12,

L4-S

1w

ith ad

dition

al inv

olvem

ent o

f unc

over

tebr

al,co

stove

rtebr

al,dis

cove

rtebr

al,an

d apo

phys

eal

(face

t) joi

nt in

volve

men

t

Rang

e fro

m as

ympt

omat

ic to

seve

rely s

ympt

omat

ic w

ith pa

in an

d stif

fnes

s.Rad

iogra

phic

tocli

nical

corre

lation

is po

or.M

ay co

ntrib

ute t

o IVF

narro

wing

and s

pinal

steno

sis.R

adiog

raph

icfin

dings

inclu

de di

sc sp

ace n

arro

wing

,hyp

ertro

phy o

f sm

aller

joint

s suc

h as f

acet

s and

cos-

tove

rtebr

al,sy

novia

l cys

ts,Sc

hmor

ls no

des,a

nd in

tradis

cal v

acuu

m ph

enom

ena a

re co

mm

on.

In m

iddle

stage

s,join

t and

caps

ular la

xity m

ay le

ad to

sublu

xatio

n and

listh

esis.

Man

agem

ent in

early

and m

iddle

stage

s sho

uld in

clude

stren

gthe

ning o

f the

spina

l mus

cles

with

a fo

cus o

n abd

omina

l stre

ngth

ening

and e

xten

sor s

treng

then

ing an

d stre

tching

.The

three

-joint

com

plex m

odel

stres

ses t

he ne

ed to

cons

ider t

he in

terre

lation

ship

of fa

cets

joint

and i

nver

terv

ebra

l disc

joint

s in t

he pr

ogres

sion o

f DJD

of th

e spin

e.Main

tena

nce o

f nor

mal

joint

mot

ion an

d fun

ction

may

be fa

cilita

ted b

y adj

ustin

g or m

anipu

lation

or m

obiliz

ation

.Di

etar

y app

roac

hes i

nclud

e an a

nti-i

nflam

mato

ry di

etar

y reg

imen

and u

se of

gluc

osam

inean

d cho

ndro

itin s

ulfate

.Med

ical m

anag

emen

t may

inclu

de re

com

men

datio

ns fo

r NSA

IDs,i

npa

rticu

lar,C

OX II

inhibi

tors

for p

ain m

anag

emen

t.




TABL

E

13

Sele

cted

Art

hri

tic

Dis

ord

ers

(co

nti

nu

ed)

Typ

eFe

atu

res

Man

agem

ent I

ssu

es

Diffu

se Id

iopat

hic Sk

eleta

lHy

pero

stosis

(DISH

) (sy

nony

ms:

anky

losing

hype

rosto

sis,

Fores

tiers

dise

ase)

Age o

f Ons

et

50 y/

o and

olde

rGe

nder

Pre

dom

inan

ce

Male

Com

mon

Join

ts In

volv

ed

Spine

;pred

omina

ntly

T7-T

11 (c

alcific

ation

of an

terio

r long

i-tu

dinal

ligam

ent)

with

30%

perip

hera

l joint

invo

lvem

ent

Foun

d in 2

5% of

men

and 1

5% of

wom

en >

50 y/

o (co

mm

on).M

ay be

asym

ptom

atic;

whe

nsy

mpt

omat

ic,sim

ilar c

ompla

ints a

ssoc

iated

with

DJD

such

as st

iffne

ss an

d pain

;20%

of pa

-tie

nts r

epor

t dsy

phag

ia;oc

casio

nal c

ompla

ints i

nvolv

ing th

e Ach

illes t

endo

n,ex

tens

or w

ad of

wris

t/for

earm

,plan

tar f

ascia

,and

quad

ricep

s ten

don (

may

find e

nthe

smop

hyte

s at c

orre-

spon

ding s

ites);

abou

t a qu

arte

r of p

atien

ts ha

ve di

abet

es.R

adiog

raph

ically

:Diff

use,t

hick,

hy-

pero

stosis

prim

arily

alon

g the

ante

rolat

eral

aspe

ct of

spine

(flo

wing

wax

app

eara

nce)

;50%

of pa

tient

s also

have

ossif

icatio

n of t

he PL

L,es

pecia

lly in

the c

ervic

al sp

ine.

Man

agem

ent in

early

and m

iddle

stage

s sho

uld in

clude

stren

gthe

ning o

f the

spina

l mus

cles

with

a fo

cus o

n abd

omina

l stre

ngth

ening

and e

xten

sor s

treng

then

ing an

d stre

tching

.Diet

ary

appr

oach

es in

clude

an an

ti-inf

lamm

atory

diet

ary r

egim

en an

d use

of gl

ucos

amine

and c

hon-

droit

in su

lfate,

yet D

ISH ap

pear

s to f

ollow

its ow

n cou

rse of

prog

ressio

n spe

cific

to th

e ind

ivid-

ual b

ut ge

nera

lly al

ways

prog

ressiv

e.Med

ical m

anag

emen

t may

inclu

de re

com

men

datio

nsfo

r NSA

IDs,i

n par

ticula

r,COX

-2 in

hibito

rs fo

r pain

man

agem

ent.

Neuo

rpat

hic (N

euro

troph

ic)Ar

thro

path

yAg

e of O

nset

Va

riable

Gend

er P

redo

min

ance

Va

riable

Com

mon

Join

ts In

volv

ed

Knee

,hip,

ankle

,spine

,shou

lder,e

lbow,

wris

t,foo

t

Varia

ble up

per m

otor

and l

ower

mot

or le

sions

caus

e a co

mbin

ation

of lo

ss of

prop

rioce

ption

and p

ain pe

rcept

ion le

ading

to jo

int de

struc

tion.

Cond

ition

s inc

lude s

yring

omye

lia,d

iabet

es,

tabe

s dor

salis

,mult

iple s

clero

sis,C

harco

-Mar

ie-To

oth d

iseas

e,pro

longe

d use

d of in

tra-

artic

ular c

ortic

oste

roids

,per

niciou

s ane

mia,

and l

epro

sy,am

ong o

ther

s.A so

mew

hat s

epar

atebu

t rela

ted c

ause

is sp

inal c

ord d

amag

e res

ulting

in pa

raple

gia or

quad

ripleg

ia w

hich r

esult

sin

usua

lly as

ympt

omat

ic bo

ny an

kylos

is.Ra

diogr

aphic

ally n

euro

path

ic ar

thro

path

y is s

een a

sjoi

nt co

llaps

e,pse

udoa

rthro

sis,fr

agm

enta

tion,

and d

eform

ity.

Treat

men

t is di

recte

d tow

ard th

e prim

ary d

iseas

e.If in

weig

htbe

aring

joint

s,mec

hanic

al as

sista

nce i

s ofte

n req

uired

.In se

vere

case

s,am

puta

tion i

s nec

essa

ry.

Syno

vioch

ondr

omet

aplas

ia (id

iopat

hic sy

novia

l os

teoc

hond

rom

atosis

)

Age o

f Ons

et

305

0 y/o

Gend

er P

redo

min

ance

M

ale to

fem

ale ra

tio =

3:1

Com

mon

Join

ts In

volv

ed

Knee

,hip,

ankle

,elbo

w,w

rist

Syno

vioch

ondr

omet

aplas

ia,as

the n

ame i

mpli

es,is

a sy

novia

l met

aplas

ia th

at re

sults

in th

efo

rmat

ion of

carti

lage t

hat t

hen f

orm

s loo

se bo

dies i

n the

joint

.This

proc

ess i

s usu

ally i

dio-

path

ic bu

t may

be th

e res

ult of

trau

ma.T

he pa

tient

will

repor

t incre

asing

pain,

swell

ing,cr

epi-

tus,a

nd lo

cking

due t

o the

loos

e bod

ies.R

adiog

raph

ically

the l

oose

bodie

s can

be se

en if

radio

paqu

e.Som

etim

es er

osion

may

occu

r as i

n the

app

le-co

rede

form

ity of

the h

ip.

Syno

vecto

my f

or m

ost p

atien

ts.Jo

int re

place

men

t may

be re

com

men

ded f

or ol

der p

atien

ts.

Infl

amm

ato

ryPo

sitive

for R

heum

atoid

Facto

r(S

eropo

sitive

)

Rheu

mato

id Ar

thrit

is (R

A)Ag

e of O

nset

25

55 y

/oGe

nder

Pre

dom

inan

ce

Fem

ale to

male

ratio

= 2/

3:1Co

mm

on Jo

ints

Invo

lved

Ha

nd,fo

ot,w

rist,k

nee,e

lbow,

GH jo

int,A

C join

t,and

cerv

ical

spine

(atla

ntoa

xial)

Caut

ion w

ith rh

eum

atoid

cond

ition

s is u

npred

ictab

le fla

re-up

s.Give

n tha

t som

e of t

he th

era-

pies e

mplo

yed b

y chir

opra

ctic a

re m

echa

nical,

includ

ing ad

justin

g,so

ft-tis

sue t

hera

py,a

ndph

ysiot

hera

py,it

is im

porta

nt to

keep

in m

ind th

at th

is is

an in

flam

mato

ry co

nditi

on an

d can

be ex

acer

bate

d by t

hese

ther

apies

.




TABL

E

13

Sele

cted

Art

hri

tic

Dis

ord

ers

(co

nti

nu

ed)

Typ

eFe

atu

res

Man

agem

ent I

ssu

es

RA ( c

ontin

ued)

A sy

mm

etric

,bila

tera

l,poly

artic

ular d

isord

er of

the s

ynov

ial m

embr

ane r

esult

ing in

joint

pain,

swell

ing,a

nd de

struc

tion.

Also

invo

lved a

re lig

amen

ts,te

ndon

s,and

bursa

e.The

diag

nosti

ccri

teria

inclu

des:D

eform

ities

such

as Bo

uton

niere,

swan

-nec

k,ph

alang

eal d

eviat

ion,a

ndar

thrit

is m

utali

ns;m

ornin

g stif

fnes

s tha

t lasts

long

er th

an on

e hou

r,spe

cific

swell

ing of

sev-

eral

joint

s (inc

luding

the P

IP joi

nts,M

CP jo

int,a

nd w

rist),

rheu

mato

id no

dules

,pos

itive

for

rheu

mato

id fac

tor,a

nd ra

diogr

aphic

evide

nce t

hat in

clude

s ero

sions

or pe

riarti

cular

oste

ope-

nia or

both

in ha

nds o

r wris

ts or

both

.Nee

d fou

r or m

ore o

f the

abov

e for

at le

ast 6

wee

ks.

Addit

ional

sym

ptom

s may

inclu

de fa

tigue

,ano

rexia,

weigh

t loss,

and m

uscu

lar pa

in/sti

ffnes

s.Sp

ecial

conc

ern i

s for

atlan

to-a

xial in

stabil

ity du

e to l

igam

ent e

rosio

n and

a res

ulting

risk o

fex

cess

ive m

ovem

ent le

ading

to sp

inal c

ord c

ompr

essio

n.

Inco

rpor

ate an

ant

i-inf

lamm

atory

diet

regim

en (s

ee Ta

ble 1

9).

Med

ical m

anag

emen

t inclu

des:

NS

AIDs

CO

X-1 i

nhibi

tors

(e.g.

,ibup

rofen

,nap

roxe

n) or

COX-

2 inh

ibito

rs (e

.g.,V

ioxx,

Celeb

rex)

Co

rtico

stero

ids

DMAR

Ds

Dise

ase-

mod

ifying

antir

heum

atic

drug

s (e.g

.,met

hotre

xate

[Rhe

umat

rex an

dTre

xal],

hydr

ochlo

roqu

ine [P

laque

nil],a

nd le

fluno

mide

[Arav

a]).T

hese

are t

oxic

and m

ayta

ke w

eeks

to m

onth

s to w

ork,

yet a

re hig

hly ef

fectiv

e.

Biolo

gic ag

ents

Redu

ce th

e pro

ducti

on of

tissu

e nec

rosis

facto

r (TN

F) (e

.g.,E

mbr

el an

dRe

mica

de us

ually

give

n tog

ethe

r with

met

hotre

xate

).May

be ad

mini

stered

as in

fusio

nth

erap

y.

Juve

nile C

hron

ic Ar

thrit

isAg

e of O

nset

5

10 y/

oGe

nder

Pre

dom

inan

ce

Varia

ble ba

sed o

n spe

cific

disor

der

Com

mon

Join

ts In

volv

ed

Hand

,foot

,wris

t,kne

e,elbo

w,he

el,hip

,and

cerv

ical s

pine

Seve

ral ty

pes i

nclud

ing:

Ju

venil

e-on

set a

dult R

Asa

me f

inding

s as R

A

Still

s dise

ase

mor

e of a

syste

mic

disea

se

Juve

nile o

nset

of se

rone

gativ

e arth

ropa

thies

se

e eac

h diso

rder

Ra

diogr

aphic

ally s

imila

r with

the p

ossib

le ad

dition

of gr

owth

distu

rban

ces o

f bon

e and

ep

iphys

eal c

ompr

essio

n fra

ctures

Caut

ion w

ith rh

eum

atoid

cond

ition

s is u

npred

ictab

le fla

re-up

s.Give

n tha

t som

e of t

he th

era-

pies e

mplo

yed b

y chir

opra

ctic a

re m

echa

nical,

includ

ing ad

justin

g,so

ft-tis

sue t

hera

py,a

ndph

ysiot

hera

py,it

is im

porta

nt to

keep

in m

ind th

at th

is is

an in

flam

mato

ry co

nditi

on an

d can

be ex

acer

bate

d by t

hese

ther

apies

.M

edica

l man

agem

ent in

clude

s:

NSAI

Ds

COX-

1 inh

ibito

rs (e

.g.,ib

upro

fen,n

apro

xen)

or CO

X-2 i

nhibi

tors

(e.g.

,Viox

x,Ce

lebrex

)

DMAR

Ds

Dise

ase-

mod

ifying

antir

heum

atic

drug

s (e.g

.,met

hotre

xate

[Rhe

umat

rex an

dTre

xal],

hydr

ochlo

roqu

ine [P

laque

nil],a

nd le

fluno

mide

[Arav

a]).T

hese

are t

oxic

and m

ayta

ke w

eeks

to m

onth

s to w

ork,

yet a

re hig

hly ef

fectiv

e.

Biolo

gic ag

ents

Redu

ce th

e pro

ducti

on of

tissu

e nec

rosis

facto

r (TN

F) (e

.g.,E

mbr

el an

dRe

mica

de ar

e usu

ally g

iven t

oget

her w

ith m

etho

trexa

te).M

ay be

adm

iniste

red as

infu

sion

ther

apy.

Co

rtico

stero

ids

Rarel

y nee

ded.

Nega

tive f

or Rh

eum

atoid

Facto

r(S

erone

gativ

e)

Anky

losing

Spon

dylit

is (A

S)Ag

e of O

nset

15

35 y

/oGe

nder

Pre

dom

inan

ce

Male

to fe

male

ratio

= 4:

1 to 1

0:1Co

mm

on Jo

ints

Invo

lved

SI

joint

,thor

acolu

mba

r spin

e,cer

vical

spine

,sym

phys

is pu

bis,

hip,sh

oulde

r,and

heel

Com

plaint

s ofte

n beg

in w

ith SI

pain

and p

rogr

ess t

o low

back

and t

hora

cic st

iffne

ss.

Even

tuall

y the

re m

ay be

a de

creas

e in c

hest

expa

nsion

.Per

ipher

al joi

nt in

volve

men

t occ

urs i

nap

prox

imate

ly 50

% as

does

radia

ting p

ain to

the l

ower

extre

mity

.Area

s of c

once

rn in

clude

iri-

tis (2

0% of

case

s),ao

rtic i

nsuf

ficien

cy,a

neur

ysm

s,pulm

onar

y fibr

osis,

pleur

itis,I

BD,a

nd am

y-loi

dosis

.Labo

rator

y find

ings i

nclud

e an i

ncrea

sed E

SR du

ring a

ctive

phas

es,n

egat

ive fo

r RA

and L

E fac

tors;

HLA

B-27

,pos

itive

in 80

% (p

ositi

ve in

68%

of ge

nera

l pop

ulatio

n).

Radio

grap

hicall

y the

re are

clas

sic si

gns,i

nclud

ing sy

mm

etric

al inv

olvem

ent o

f the

SI jo

ints,

ligam

ent c

alcific

ation

,and

marg

inal s

ynde

smop

hyte

s,eve

ntua

lly le

ading

to t

rolle

y-tra

ck

sign,

and b

ambo

o spin

e.

Caut

ion w

ith rh

eum

atoid

cond

ition

s is u

npred

ictab

le are

flare-

ups.G

iven t

hat s

ome o

f the

ther

apies

emplo

yed b

y chir

opra

ctic i

s mec

hanic

al,inc

luding

adjus

ting,

soft-

tissu

e the

rapy

,an

d phy

sioth

erap

y,it is

impo

rtant

to ke

ep in

mind

that

this

is an

infla

mm

atory

cond

ition

and

can b

e exa

cerb

ated b

y the

se th

erap

ies.

Med

ical m

anag

emen

t inclu

des:

NS

AIDs

CO

X-1 i

nhibi

tors

(e.g.

,ibup

rofen

,nap

roxe

n) or

COX-

2 inh

ibito

rs (e

.g.,V

ioxx,

Celeb

rex)

DM

ARDs

Di

seas

e-m

odify

ing an

tirhe

umat

ic dr

ugs (

e.g.,m

etho

trexa

te [R

heum

atrex

and

Trexa

l],hy

droc

hloro

quine

[Plaq

uenil

],and

leflu

nom

ide [A

rava]

).The

se ar

e tox

ic an

d may

take

wee

ks to

mon

ths t

o wor

k,ye

t are

highly

effec

tive.

Bi

ologic

agen

tsRe

duce

the p

rodu

ction

of tis

sue n

ecro

sis fa

ctor (

TNF)

(e.g.

,Em

brel

and

Rem

icade

are u

suall

y give

n tog

ethe

r with

met

hotre

xate

).May

be ad

mini

stered

as in

fusio

nth

erap

y.

Corti

coste

roids

Ra

rely n

eede

d




TABL

E

13

Sele

cted

Art

hri

tic

Dis

ord

ers

(co

nti

nu

ed)

Typ

eFe

atu

res

Man

agem

ent I

ssu

es

Reite

rs Sy

ndro

me

Age o

f Ons

et

153

5 y/o

Gend

er P

redo

min

ance

M

ale to

fem

ale ra

tio =

5:1 t

o 50:1

depe

nding

upon

stud

yCo

mm

on Jo

ints

Invo

lved

SI

joint

,foot

,hee

l,ank

le,kn

ee,h

ip,sp

ine;m

ore r

arely

the

uppe

r ext

remity

Uret

hriti

s and

othe

r eye

com

plaint

s ofte

n foll

owing

a ST

D or

gastr

ointe

stina

l infec

tion.

Kerra

titis,

kerra

tode

rma,

and k

erato

sis of

nails

may

be fo

und.

Syste

mic

findin

gs m

ay in

clude

fever,

weigh

t loss,

thro

mbo

phleb

itis,o

r am

yloido

sis.La

b find

ings m

ay in

clude

posit

ive H

LA-

B27 (

75%

),leu

kocy

tosis

,ane

mia,

and e

levate

d ESR

.Rad

iogra

phica

lly SI

joint

is pr

omine

nt,

antla

nto-

axial

insta

bility

,non

marg

inal s

ynde

smop

hyte

s.Sim

ilar t

o pso

riatic

arth

ritis,

a sing

ledig

it may

be in

volve

d (sa

usag

e fing

er) a

nd en

thes

opat

hies a

re co

mm

on as

in A

S.M

onito

r for

aorti

c reg

urgit

ation

in ch

ronic

case

s.

Caut

ion w

ith rh

eum

atoid

cond

ition

s is u

npred

ictab

le fla

re-up

s.Give

n tha

t som

e of t

he th

era-

pies e

mplo

yed b

y chir

opra

ctic a

re m

echa

nical,

includ

ing ad

justin

g,so

ft-tis

sue t

hera

py,a

ndph

ysiot

hera

py,it

is im

porta

nt to

keep

in m

ind th

at th

is is

an in

flam

mato

ry co

nditi

on an

d can

be ex

acer

bate

d by t

hese

ther

apies

.M

edica

l man

agem

ent in

clude

s:

NSAI

Ds

COX-

1 (e.g

.,ibu

prof

en,n

apro

xen)

or CO

X-2 i

nhibi

tors

(e.g.

,Viox

x,Cele

brex

)

DMAR

Ds

Dise

ase-

mod

ifying

antir

heum

atic

drug

s (e.g

.,met

hotre

xate

[Rhe

umat

rex an

dTre

xal],

hydr

ochlo

roqu

ine [P

laque

nil],a

nd le

fluno

mide

[Arav

a]).T

hese

are t

oxic

and m

ayta

ke w

eeks

to m

onth

s to w

ork,

yet a

re hig

hly ef

fectiv

e.

Biolo

gic ag

ents

Redu

ce th

e pro

ducti

on of

tissu

e nec

rosis

facto

r (TN

F) (e

.g.,E

mbr

el an

dRe

mica

de ar

e usu

ally g

iven t

oget

her w

ith m

etho

trexa

te).M

ay be

adm

iniste

red as

infu

sion

ther

apy.

Co

rtico

stero

ids

Rarel

y nee

ded

Psor

iatic

Age o

f Ons

et

205

0 y/o

Gend

er P

redo

min

ance

Ge

nera

lly eq

ual

Com

mon

Join

ts In

volv

ed

Hand

,foot

,SI jo

int,th

orac

olum

bar s

pine,a

nd ce

rvica

l spin

e

Only

abou

t 5%

of th

ose w

ith sk

in dis

ease

have

the j

oint in

volve

men

t.The

re are

vario

us pa

t-te

rns,y

et m

any t

imes

the p

roxim

al an

d dist

al IP

joint

s are

involv

ed.A

defo

rming

type

may

lead t

o arth

ritis

mut

ilans

.In ad

dition

to po

ssibl

y hav

ing sc

aly pa

tches

of sk

in (p

soria

sis) o

n the

exte

nsor

surfa

ces o

f the

knee

s and

elbo

ws,p

atien

ts m

ay al

so ha

ve na

il cha

nges

,inclu

ding p

it-tin

g,dis

color

ation

,and

splin

terin

g.In

som

e cas

es hy

pero

stosis

occu

rs at

the S

C join

t.Oth

er sk

inles

ions m

ay oc

cur in

the h

ands

and f

eet.L

ab in

clude

s HLA

-B27

antig

en (6

0% of

case

s),m

ildan

emia,

eleva

ted E

SR du

ring a

ctive

perio

ds,o

ccas

ionall

y elev

ated u

ric ac

id lev

els.

Radio

grap

hicall

y the

invo

lvem

ent o

f the

hand

s is s

imila

r to R

A.In

addit

ion,o

ne di

git is

ofte

naff

ecte

d (sa

usag

e fing

er) a

nd tu

ft res

orpt

ion an

d pro

liferat

ion (i

vory

phala

nx) o

ccur.

In th

esp

ine,n

onm

argina

l syn

desm

ophy

tes m

ay be

seen

.

Caut

ion w

ith rh

eum

atoid

cond

ition

s is u

npred

ictab

le fla

re-up

s.Give

n tha

t som

e of t

he th

era-

pies e

mplo

yed b

y chir

opra

ctic a

re m

echa

nical

includ

ing ad

justin

g,so

ft-tis

sue t

hera

py,a

ndph

ysiot

hera

py,it

is im

porta

nt to

keep

in m

ind th

at th

is is

an in

flam

mato

ry co

nditi

on an

d can

be ex

acer

bate

d by t

hese

ther

apies

.Whe

n arth

ritis

is pr

esen

t,cyc

lospo

rine,m

etho

trexa

te,an

dac

itret

in are

used

.Met

hotre

xate

is as

socia

ted w

ith he

patic

toxic

ity;cy

closp

orine

asso

ciate

dw

ith hy

perte

nsion

and n

ephr

otox

icity

;and

acitr

etin

is as

socia

ted w

ith el

evate

d ser

um lip

ids,

muc

ocut

aneo

us to

xicity

,and

terat

ogen

icity.

New

drug

s are

being

mar

kete

d tha

t,alth

ough

highly

prom

ising

,are

extre

mely

expe

nsive

.Thes

e dru

gs ar

e par

t of a

new

clas

s of m

edica

tions

calle

d im

mun

e mod

ulato

rs (a

lso kn

own a

s biol

ogica

l resp

onse

mod

ifiers

or b

iolog

ics)

.The

mec

hanis

m fo

r the

se ne

w dr

ugs i

s eith

er to

bloc

k and

redu

ce ab

norm

al T-

lymph

ocyte

activ

ityor

the i

nflam

mato

ry re

spon

se.E

xam

ples a

re ale

facep

t and

etan

ercep

t.(Th

e ce

pte

nding

is an

indica

tion o

f the

drug

s effe

ct,w

hich i

s fus

ion of

a rec

epto

r to t

he Fc

porti

on of

hum

an Ig

GI.)

Ente

ropa

thic

(ass

ociat

ed w

ith

inflam

mato

ry bo

wel d

iseas

e [IB

D])

Age o

f Ons

et

Varia

bleGe

nder

Pre

dom

inan

ce

Varia

bleCo

mm

on Jo

ints

Invo

lved

SI

joint

and s

pine;

occa

siona

lly pe

riphe

ral jo

int in

volve

men

t

Man

y inf

lamm

atory

diso

rder

s affe

cting

the G

I trac

t may

resu

lt in a

n arth

ritis

simila

r to t

hese

rone

gativ

e arth

ritide

s.Diso

rder

s inc

lude C

rohn

s,ulc

erat

ive co

litis,

Whip

ples d

iseas

e,and

in-

fectio

ns,in

cludin

g Salm

onell

a,Sh

igella

,and

Yersi

nia.In

testi

nal b

ypas

s sur

gery

may

also

be re

-lat

ed.Th

e freq

uenc

y of IB

D an

d AS i

s abo

ut 15

%.La

borat

ory r

evea

ls HL

A-B2

7 in 9

0% of

thos

ew

ith IB

D an

d arth

ritis.

Radio

grap

hic fin

dings

are s

imila

r to A

S,inc

luding

SI in

volve

men

t and

the s

pine.

Caut

ion w

ith rh

eum

atoid

cond

ition

s is u

npred

ictab

le fla

re-up

s.Give

n tha

t som

e of t

he th

era-

pies e

mplo

yed b

y chir

opra

ctic a

re m

echa

nical,

includ

ing ad

justin

g,so

ft-tis

sue t

hera

py,a

ndph

ysiot

hera

py,it

is im

porta

nt to

keep

in m

ind th

at th

is is

an in

flam

mato

ry co

nditi

on an

d can

be ex

acer

bate

d by t

hese

ther

apies

.Use

anti-

inflam

mato

ry ap

proa

ches

in di

et an

d sup

ple-

men

t rec

omm

enda

tions

and p

hysio

ther

apy m

anag

emen

t.M

edica

l man

agem

ent in

clude

s:

NSAI

Ds

COX-

1 (e.g

.,ibu

prof

en,n

apro

xen)

or CO

X-2 i

nhibi

tors

(e.g.

,Viox

x,Cele

brex

)

DMAR

Ds

Dise

ase-

mod

ifying

antir

heum

atic

drug

s (e.g

.,met

hotre

xate

[Rhe

umat

rex an

dTre

xal],

hydr

ochlo

roqu

ine [P

laque

nil],a

nd le

fluno

mide

[Arav

a]).T

hese

are t

oxic

and m

ayta

ke w

eeks

to m

onth

s to w

ork,

yet a

re hig

hly ef

fectiv

e.

Biolo

gic ag

ents

Redu

ce th

e pro

ducti

on of

tissu

e nec

rosis

facto

r (TN

F) (e

.g.,E

mbr

el an

dRe

mica

de ar

e usu

ally g

iven t

oget

her w

ith m

etho

trexa

te)

Co

rtico

stero

ids




TABL

E

13

Sele

cted

Art

hri

tic

Dis

ord

ers

(co

nti

nu

ed)

Typ

eFe

atu

res

Man

agem

ent I

ssu

es

Syste

mic

Lupu

s Ery

them

atosis

(SLE

)Ag

e of O

nset

20

45 y

/oGe

nder

Pre

dom

inan

ce

Fem

ale m

ore t

han m

aleCo

mm

on Jo

ints

Invo

lved

Ha

nd an

d oste

onec

rosis

,spec

ificall

y of fe

mur

(hea

d and

cond

yles)

and s

omet

imes

shou

lder (

hum

eral

head

)

A sy

stem

ic au

toim

mun

e diso

rder

char

acte

rized

by m

ulti-s

yste

m in

volve

men

t res

ulting

inge

nera

lized

findin

gs su

ch as

feve

r,ano

rexia,

weigh

t loss,

mala

ise,a

nd w

eakn

ess.V

iscer

al in-

flam

mat

ion oc

curs.

Skin

affec

ts inc

lude r

ashe

s (e.g

.,but

terfl

y mala

r ras

h).P

olyar

thrit

is is

com

-m

on.Li

ke m

any p

atien

ts w

ith au

toim

mun

e rhe

umato

id co

nditi

ons,t

endo

ns ar

e wea

kene

dan

d may

rupt

ure.L

abor

atory

reve

als an

emia

with

leuc

open

ia an

d plas

ma p

rote

in ab

norm

ali-

ties (

prot

ein el

ectro

phor

esis

usua

lly or

dered

due t

o glob

ulin i

ncrea

se).A

ntinu

clear

antib

ody

and L

E cell

s pres

ent.A

false

-pos

itive

syph

ilis te

st m

ay oc

cur.R

adiog

raph

ically

a sy

mm

etric

,no

nero

sive y

et de

form

ing ar

thro

path

y is s

een.

Oste

onec

rosis

may

be se

en du

e to t

he di

seas

eor

due t

o trea

tmen

t (co

rtico

stero

ids).

Give

n tha

t som

e of t

he th

erap

ies em

ploye

d by c

hirop

racti

c are

mec

hanic

al,inc

luding

adjus

t-ing

,soft-

tissu

e the

rapy

,and

phys

iothe

rapy

,it is

impo

rtant

to ke

ep in

mind

that

this

is an

in-

flam

mato

ry co

nditi

on an

d can

be ex

acer

bate

d by t

hese

ther

apies

.Pro

tecti

on of

the s

kininc

ludes

avoid

ing su

nligh

t,and

it is

impo

rtant

whe

n exp

osed

to us

e a su

nbloc

k with

SPF 1

5 or

high

er.Pr

imar

y trea

tmen

t is pr

ediso

ne fo

r joint

pain,

cuta

neou

s les

ions,a

nd re

nal a

nd CN

Sinv

olvem

ent.O

ther

med

ical th

erap

ies in

clude

antim

alaria

ls (h

ydro

xych

loroq

uine)

and

NSAI

Ds.In

fectio

n is c

omm

on du

e to i

mm

unos

upres

sion a

nd is

the c

ause

of de

ath i

n one

-third

of ca

ses.B

lacks

and H

ispan

ics fa

ir wor

se.P

erica

rditi

s is f

ound

in 25

% of

patie

nts.A

lso,sc

reen-

ing fo

r ren

al fu

nctio

n is i

mpo

rtant

to de

term

ine di

seas

e acti

vity.

Scler

oder

ma (

prog

ressiv

e sys

tem

icsc

leros

is)Ag

e of O

nset

20

30 y

/oGe

nder

Pre

dom

inan

ce

Fem

ale m

ore t

han m

aleCo

mm

on Jo

ints

Invo

lved

Ha

nd,w

rist,f

oot,r

ibs,a

nd,m

ore r

arely,

the s

pine

There

are t

wo ty

pes o

f this

colla

gen-

vasc

ular d

iseas

e:on

e with

syste

mic

involv

emen

t (pr

o-gr

essiv

e) an

d one

with

out (

locali

zed)

.Scle

rode

rma i

s cha

racte

rized

by in

volve

men

t of m

ulti-

ple or

gans

inclu

ding s

kin,h

eart,

lungs

,kidn

eys,G

I trac

t,and

mus

culos

kelet

al sy

stem

;there

fore,

signs

and s

ympt

oms a

re qu

ite va

riable

.Mus

cle w

eakn

ess,i

nclud

ing dy

spha

gia;R

ayna

uds

phen

omen

on;h

yper

pigm

enta

tion;

vitilig

o and

telan

giecta

sias;a

nd th

icken

ing an

d tigh

tenin

gof

the s

kin of

the f

ace,h

ands

,and

feet

.Labo

rator

y find

ings i

nclud

e an e

levate

d ESR

(60

70%

),pos

itive

RF (2

040

%),p

ositi

ve A

NA (3

596

%),a

nd a

high p

rote

in lev

el in

syn-

ovial

fluid.

Radio

grap

hicall

y the

re are

peria

rticu

lar an

d sub

cuta

neou

s calc

ificat

ions i

nclud

ingpa

rasp

inal,p

halan

geal

tuft,

and s

uper

ior rib

eros

ions.

Man

agem

ent is

for v

ariou

s asp

ects

of th

e dise

ase.F

ollow

ing ar

e com

binat

ions o

f med

ical a

ndco

nser

vativ

e app

roac

hes:

Rayn

auds

Ca

lcium

chan

nel b

locke

rs

Perip

hera

l adr

energ

ic blo

cker

s

Prot

ectiv

e mea

sures

again

st co

ld,ce

ssat

ion of

smok

ing,a

nd de

creas

ed us

e of c

affein

e and

othe

r sym

path

omat

ics

Rena

l

Initi

ally A

CE in

hibito

rs;m

ay le

ad to

dialy

sis or

kidn

ey tr

ansp

lant

Pulm

onar

y hyp

erte

nsion

M

ay re

quire

oxyg

en or

lung

tran

splan

t in se

rious

case

s

Esop

hage

al ref

lux

Avoid

larg

e mea

ls an

d a re

cum

bent

posit

ion af

ter m

eals

Av

oid sy

mpa

thom

amet

ic su

bsta

nces

and c

erta

in fo

ods

H2

inhib

itors

and/

or pr

oton

-pum

p inh

ibito

rs

Arth

ralgi

as

NSAI

Ds

Give

n tha

t som

e of t

he th

erap

ies em

ploye

d by c

hirop

racti

c are

mec

hanic

al,inc

luding

adjus

t-ing

,soft-

tissu

e the

rapy

,and

phys

iothe

rapy

,it is

impo

rtant

to ke

ep in

mind

that

this

is an

in-

flam

mato

ry co

nditi

on an

d can

be ex

acer

bate

d by t

hese

ther

apies

.

Derm

atom

yosit

is an

d Poly

myo

sitis

Age o

f Ons

et

510

y/o a

nd ag

ain at

205

0 y/o

Gend

er P

redo

min

ance

Fe

male

to m

ale ra

tio =

2:1

Com

mon

Join

ts In

volv

ed

Soft

tissu

es pr

imar

ily of

the t

high,

leg,a

nd ar

m

Give

n tha

t som

e of t

he th

erap

ies em

ploye

d by c

hirop

racti

c are

mec

hanic

al,inc

luding

adjus

t-ing

,soft-

tissu

e the

rapy

,and

phys

iothe

rapy

,it is

impo

rtant

to ke

ep in

mind

that

this

is an

in-

flam

mato

ry co

nditi

on an

d can

be ex

acer

bate

d by t

hese

ther

apies

.Pro

tecti

on of

the s

kin w

ithSP

F 15 o

r high

er is

impo

rtant

;pro

vide p

hysic

al th

erap

y to k

eep m

uscle

stret

ch an

d stre

ngth

.




TABL

E

13

Sele

cted

Art

hri

tic

Dis

ord

ers

(co

nti

nu

ed)

Typ

eFe

atu

res

Man

agem

ent I

ssu

es

Derm

atom

yosit

is an

d Poly

myo

sitis

( cont

inued

)De

rmato

myo

sitis

affec

ts sk

in an

d mus

cle,w

herea

s,poly

myo

sitis

affec

ts pr

imar

ily m

uscle

.The

affec

t is in

flam

mat

ion an

d deg

ener

ation

of st

riate

d mus

cle w

ith a

laying

dow

n of s

heet

-like

calci

ficat

ions i

n sof

t tiss

ue.A

bout

half o

f pat

ients

have

arth

ritis

whil

e one

-third

have

Rayn

auds

phen

omen

on.D

isabil

ity oc

curs

due t

o pro

gres

sive s

ymm

etric

,pro

ximal

mus

clewe

akne

ss.La

borat

ory f

inding

s inc

lude C

PK el

evat

ions a

nd el

evat

ions i

n urin

ary c

reatin

ine le

v-els

.EM

G rev

eals

a pro

ximal

myo

path

y as d

oes m

uscle

biop

sy.R

adiog

raph

ically

,there

is so

fttis

sue a

troph

y cou

pled w

ith sh

eet-l

ike so

ft tis

sue c

alcific

ation

s and

som

etim

es os

sifica

tion.

Like o

ther

infla

mm

atory

cond

ition

s,the

re is

phala

ngea

l tuft

resor

ption

.

If dys

phag

ia is

pres

ent,s

peec

h the

rapy

shou

ld be

emplo

yed.

Infla

mm

atory

aspe

ct m

ay be

man

aged

med

ically

with

pred

nison

e,im

mun

osup

pres

sive t

hera

py su

ch as

met

hotre

xate

oraz

athio

prine

.App

roxim

ately

50%

go in

to re

miss

ion in

5 ye

ars,w

ith an

appr

oxim

ate 75

% 8-

year

surv

ival.T

hose

who

do no

t rem

iss re

main

on th

erap

y.

Mixe

d Con

necti

ve Ti

ssue

Dise

ase

Age o

f Ons

et

205

0 y/o

Gend

er P

redo

min

ance

Fe

male

mor

e tha

n male

Com

mon

Join

ts In

volv

ed

Hand

,wris

t,and

foot

This

grou

p of c

ondit

ions i

s an o

verla

p of s

ever

al sp

ecific

dise

ases

such

as RA

,SLE

,der

mato

-m

yosit

is,an

d scle

rode

rma.

Labo

rator

y find

ings i

nclud

e spe

cific

findin

gs fo

r eac

h diso

rder

and

pres

ence

of rib

onuc

lease

-sen

sitive

extra

ctable

nucle

ar an

tigen

.Rad

iogra

phic

findin

gs ar

eth

ose f

or ea

ch di

sord

er an

d inc

lude j

oint d

estru

ction

with

marg

inal e

rosio

ns an

d sof

t tiss

ueca

lcific

ation

.

Caut

ion w

ith rh

eum

atoid

cond

ition

s is u

npred

ictab

le fla

re-up

s.Give

n tha

t som

e of t

he th

era-

pies e

mplo

yed b

y chir

opra

ctic a

re m

echa

nical,

includ

ing ad

justin

g,so

ft-tis

sue t

hera

py,a

ndph

ysiot

hera

py,it

is im

porta

nt to

keep

in m

ind th

at th

is is

an in

flam

mato

ry co

nditi

on an

d can

be ex

acer

bate

d by t

hese

ther

apies

.

The m

edica

l man

agem

ent a

ppro

ach w

ould

includ

e tho

se fo

r the

unde

rlying

diso

rder

s.See

man

agem

ent u

nder

each

.

Hype

rtrop

hic O

steoa

rthro

path

y(M

arie-

Bam

berg

er sy

ndro

me o

r pu

lmon

ary o

steoa

rthro

path

y)

Age o

f Ons

et

406

0 y/o

Gend

er P

redo

min

ance

Pr

imar

ily m

aleCo

mm

on Jo

ints

Invo

lved

Fin

gers

(club

bing)

;per

iostit

is in

tibia,

fibula

,radiu

s,and

ulna

There

is a

triad

of pe

riphe

ral a

rthrit

is w

ith cl

ubbin

g of t

he fin

gers

and p

erios

titis

of th

e dist

allon

g bon

es.Th

is pr

oces

s app

ears

to be

seco

ndar

y to p

roce

sses

in th

orax

or ab

dom

en,m

ost

com

mon

ly,br

onch

ogen

ic ca

rcino

ma,

and s

eem

s to b

e neu

rova

scula

r due

to va

gus n

erve

dys-

func

tion.

Patie

nts o

ften h

ave s

igns o

nly of

the u

nder

lying

diso

rder.

Radio

grap

hic fin

dings

in-

clude

the d

igita

l club

bing a

nd lo

ng bo

ne sy

mm

etric

al pe

riosti

tis.

Iden

tifica

tion o

f the

unde

rlying

diso

rder

direc

ts ap

prop

riate

trea

tmen

t mea

sures

.In so

me

case

s the

hype

rtrop

hic os

teoa

rthro

path

y may

impr

ove o

r disa

ppea

r with

effec

tive c

are.Th

ism

ay in

clude

chem

othe

rapy

for t

umor

s or a

ntibi

otic

ther

apy f

or ch

ronic

pulm

onar

y inf

ectio

n.In

som

e cas

es va

goto

my o

r perc

utan

eous

vaga

l bloc

kade

is ne

cess

ary f

or sy

mpt

omat

ic rel

ief.

NSAI

Ds an

d sim

ilar a

gent

s are

used

initi

ally f

or sy

mpt

om co

ntro

l.

Oste

itis C

onde

nsins

Illi

Age o

f Ons

et

204

0 y/o

Gend

er P

redo

min

ance

Fe

male

to m

ale ra

tio =

9:1

Com

mon

Join

ts In

volv

ed

Sacro

iliac

This

bilate

ral d

isord

er af

fects

female

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