CLINICAL RHEUMATOLOGICAL PEARLS FOR INTERNISTS The 1rst Kuwait-North American Update in Internal Medicine Conference 8-9 February 2014 CLINICAL RHEUMATOLOGICAL PEARLS FOR INTERNISTS Henri A. Ménard, MD, FRCP (C) Professor of Medicine McGill University McGill University Health Center

BASIC CLINICAL RHEUMATOLOGY THREE CONTRIBUTIONS The Knee The Spine The Hindfoot

THE KNEE What is the normal temperature of the knee? The normal knee is always colder than the rest of the leg. (Ménard, Can. Med. Ass. J. 1974)

Δ Temperature FEELING THE KNEE + + AGE (years) Threshold < 2 > 65 Threshold Dr H Ménard, McGill 2012

FEELING THE KNEE + + + + + NORMAL KNEE PROBLEM VENOUS PROBLEM ARTERIAL PROBLEM + HIP PROBLEM (referred pain) Dr H Ménard, McGill 2012

THE SPINE Dr H Ménard, McGill 2012

PHYSICAL EXAMINATION OF JOINTS What do you do when you examine joints? A. You vary the intra-articular pressure.

Range Of Motion And Intra-Articular Pressure PAIN PRESSURE (mmHg) MAX Full Flexion Extension R e s t i n g Dr H Ménard, McGill 2012

THE OSLERIAN APPROACH Osler’s original clinical discoveries were OBSERVATIONAL. His major contribution was the emphasis on INTERACTION WITH THE PATIENT. Osler taught us that THE PATIENT, NOT THE DISEASE, IS THE ENTITY And that WE ARE TREATING PATIENTS, NOT IMAGES, NOR TESTS! THE PATIENT HAS ALL THE QUESTIONS AND ALL THE ANSWERS.

The Clinical Diagnostic Approach Consists In Answering Two Questions Where is the lesion ? What is the lesion ?

THE ANTERIOR SPINE

INNERVATION OF POSTERIOR SPINE Vertebral Body Medulla Facet Joint Nerve Root Posterior Rami Paravertebral Muscles Ganglion

Flexion Extension POSTERIOR Lower Intra-Articular Pressure Higher Intra-Discal Pressure POSTERIOR Extension Higher Intra-Articular Pressure Lower Intra-Discal Pressure

Where is the lesion? NEITHER ANTERIOR FLEXION POSTERIOR EXTENSION

The best surprise is no surprise What is the lesion? R. Deyo, Ann Int Med 2002 Mechanical (97%) All the rest (~1%) Visceral (2%) The best surprise is no surprise

RATIONALE THE BASIC PRINCIPLE OF THE MSK EXAM IS FOR THE EXAMINER TO INCREASE PRESSURE IN OR STRESS A MSK STRUCTURE BY PERFORMING PASSIVE OR ACTIVE RANGE OF MOTION OR APPLYING EXTERNAL PRESSURE. IF THE STRUCTURE IS ABNORMAL THE PATIENT WILL FEEL DISCOMFORT OR PAIN AND THAT WILL PROVOKE A VARIABLE BUT OBSERVABLE ANTALGIC GUARDING REACTION. IN THE SPINE, EXTENSION AND LATERAL/POSTERIOR-LATERAL FLEXIONS EXPLORE POSTERIOR STRUCTURES. BECAUSE FACET JOINTS AND PARA-SPINAL MUSCLES SHARE THE SAME INNERVATION, ROM SOLLICITING POSTERIOR STRUCTURES SHOULD CHANGE THE SPINAL MUSCLE KINOPHYSIOLOGY.

HYPOTHESIS FOR THE EARLY DIAGNOSIS OF AS The earliest objective manifestation of inflammation in mobile spondyles is a clinically detectable antalgic contraction of the lumbar para-vertebral muscles during early passive lumbar extension reflecting an increased intraarticular pressure in the inflammed joints.

THE MÉNARD & MORNEAU TEST (The M&M TEST) During a standardized passive extension of the L-spine, the para-vertebral muscles are normally felt to relax. The test is abnormal if relaxation is not felt or if muscles contract. That is interpreted as a posterior (facet joint) problem.

Palpation Of The Paravertebral Muscles Bergeron S et al. 2009

Lumbar Paraspinal Muscles EMG During Extension ( ) seconds microvolts/sec NORMAL microvolts/sec seconds SPONDYLITIS Bergeron S et al. (Ménard HA) CAN Annual 2009 Meeting, Vancouver

Quantitative M&M by Surface EMG P< 0.002 C B n=10 - 18 ± 0.9 - 15,9 ± 2.3 Normal Inactive AS Active AS + 7.5 ± 1.6 C n=6 A n=28 Microvolt/sec Change During Extension Mean ± sem Student test p = 0.6 A C p < 0.0000002 A B A D (OA) – 18.2 ± 1.4 ns Bergeron S et al. 2009

ROM For Posterior Problems: Para-Vertebral Muscle Contraction Improving PRESSURE Min Max Grey Zone AS Worsening OA Initial Extension Full Resting Posture

In back pain with an inflammatory pattern, one should expect EARLY DIAGNOSIS OF AS In back pain with an inflammatory pattern, one should expect A relatively less painful antero-flexion A contraction of the lumbar para-vertebral muscles in early extension. 11/20/2018 HA Ménard

Take Home Message A young person with LBP may or may not have any of the current “early” AS clinical features but if he refuses to extend his lumbar spine because of pain, he has a real posterior spine problem. He should IMMEDIATELY be given a trial of full dose of NSAIDs, sent for HLA B27 and PA pelvis x-ray and, be referred to a rheumatologist for further evaluation and treatment.

FORGET THIS OSLER’S QUOTATION "When a patient with arthritis comes through the front door, I want to leave by the back door". Times are changing HA MÉNARD, Jan 2013

THANK YOU FOR YOUR ATTENTION QUESTIONS ? COMMENTS ?

THE IDIOPATHIC HINDFOOT Q. When was the last time you saw an idiopathic degenerative hindfoot problem? The last time you missed a case of hemochromatosis with the so-called silent HFE mutation. with a normal or abnormal biochemical phenotype With a major and/or minor HFE mutation (work in progress on OA type 2)