I know my cholesterol is high, but that doesn’t hurt. Musculoskeletal medicine for the internist. Part 1 - Shoulder and knee William Fuller, MD Instructor in Medicine, CUMC

Learning Objectives Develop an anatomic framework for differential diagnosis of musculoskeletal complaints Relate the physical exam to this framework Select maneuvers to confirm a diagnosis

What’s in a joint? “Joints” vary wildly in their components Contain multiple components capable of producing pain Bones Cartilage Bursae Ligaments Tendon/Muscles Synovium Structure involved dictates natural history and best treatment options Goal of H&P is to figure out what hurts

http://www.knee-pain-explained.com/knee-joint-anatomy.html The knee

The Musculoskeletal History and Physical With a nod to Dr. Bob Cato at the Penn Center for Primary Care: History Inspect Touch Move Extra Maneuvers OPQRST Effusion? Deformity? Skin changes? Warmth? Effusion? Tenderness to palpation? Active and passive ROM Situational, significant variation in sensitivity/specificity

Bones History - Acute traumatic (not subtle) or degenerative (rarely overuse). Inspect - Deformity Touch - Pain on joint lines (often hard to get to), fracture sites Move - Crepitus, pain throughout ROM Extra Maneuvers - Extreme ROM

Cartilage History - Usually subacute, occasionally acute. Inspect - Usually nothing. Touch - Pressure on the affected cartilage hurts. Move - Usually painless (while non-weightbearing). Extra Maneuvers - Intentionally create pressure.

Bursae History - Overuse, occasionally trauma. Inspect - Local (non-synovial) swelling. Touch - Localized pain. Move - Usually OK. Extra Maneuvers - None.

Ligaments History - Usually acute trauma. Inspect - Swelling for days. Touch - Generalized pain due to swelling. Move - Painful PASSIVE ROM at extremes. Extra Maneuvers - Drawer tests.

Tendon/Muscle History - Overuse > acute traumatic. Inspect - Nothing, except rare circumstances. Touch - If palpable, pain. Move - Pain ON STRETCH. Extra Maneuvers - Fancy stretches or palpation.

Synovium History - Variable (diverse group of diseases) Inspect - Effusion! Touch - Diffuse tenderness. Move - Micromotion tenderness. Extra Maneuvers - Usually unnecessary (can ballot for effusion).

http://www.knee-pain-explained.com/knee-joint-anatomy.html The knee

The knee (but shallower)

Knee case one 75F with a history of obesity, T2DM, and HTN presents for follow up of hypertension. Describes chronic knee pain, worse with standing and walking. History Inspect Touch Move Extra Maneuvers

When to image? To rule out a no-miss diagnosis To confirm a diagnosis/end the search Surgical planning Review possible implications of imaging BEFORE you get it!

140 patients with OA Saline actually did non-significantly better for pain, with a 1.9 vs 1.2 point reduction Faster cartilage loss with triamcinolone

Knee case two 19F with an unremarkable PMH presents with chronic severe knee pain worse with stair climbing and improved with rest. History Inspect Touch Move Extra Maneuvers

Knee case three 53F with obesity, dyslipidemia, and HTN presents with 2 weeks of severe left anterior knee pain. History Inspect Touch Move Extra Maneuvers

Knee case four 61M with history of hyperlipidemia and gout presents with worsening left chronic knee pain and a sensation that his knee is going to give out. History Inspect Touch Move Extra Maneuvers

205 patients with meniscal tear clinically and no obvious trauma, no OA Sham surgery actually outperforms menisectomy on 2 quality of life measures, post-exercise pain Imagine that WITH OA, outcomes would be even less impressive

https://www.webmd.com/pain-management/picture-of-the-shoulder The shoulder

The shoulder, but more so

Shoulder case one 63M with HTN presents with progressive R shoulder pain and weakness x3 months. No obvious trauma or other inciting event.

Shoulder case two 89M with CAD s/p CABG, multiple myeloma on rev/dex, HTN. Presents with worsening chronic bilateral shoulder pain R > L.

Shoulder case three 49M presents with persistent shoulder pain and weakness three days after slipping on ice down his front stairs.

Shoulder case four 64F with T2DM, last A1c 11.1%, presents with significant gradually worsening R shoulder pain after a fall 2 months prior.

Learning Objectives Develop an anatomic framework for differential diagnosis of musculoskeletal complaints Relate the physical exam to this framework Select maneuvers to confirm a diagnosis