1. Musculoskeletal manifestations
Rheumatoid Arthritis
Musculoskeletal manifestations
Iraj Salehi-Abari MD.,
Internist
Rheumatologist

2. Introduction: The most common inflammatory arthritis
I. Salehi A.
Introduction:
The most common inflammatory arthritis
A chronic progressive systemic disease
Autoimmune disease
Hallmark: Chronic erosive polyarthritis
Iran Criteria of RA

4. Epidemiology: All races Incidence: 30/100,000 Overal prevalence: 1%
I. Salehi A.
Epidemiology:
All races
Incidence: 30/100,000
Overal prevalence: 1%
Prevalence in old women: 5%
F/M ratio: 2-3/1
Peak onset age: y/o
Iran Criteria of RA

5. Epidemiology: Incidence of RA: 25-55 y/o: increases
I. Salehi A.
Epidemiology:
Incidence of RA:
25-55 y/o: increases
55-75 y/o: plateaus
After 75 y/o: decreases
Iran Criteria of RA

6. Epidemiology: Peak onset age of RA in Iran: F/M ratio of RA in Iran:
Iraj Salehi-Abari.
Epidemiology:
Peak onset age of RA in Iran:
y/o
F/M ratio of RA in Iran:
3/ [Iraj Salehi-A., 2012, Rheumatol Int]
Rheumatoid A

7. Epidemiology: Incidence of RA: Prevalence of RA:
Iraj Salehi-Abari.
Epidemiology:
Incidence of RA:
Has been decreasing in recent decades
Prevalence of RA:
Plateaus in recent decades
Rheumatoid A

8. Clinical manifestations:
I. Salehi A.
Clinical manifestations:
Constitutional
Articular: almost all
Peri-articular
Extra-articular (systemic)

9. Constitutional: Weight loss Fatigue Malaise Depression
I. Salehi A.
Constitutional:
Weight loss
Fatigue
Malaise
Depression
Cachexia: severe RA
Fever > 38.3 c (101 F):
Systemic vasculitis
Infection

10. Articular involvement:
I. Salehi A.
Articular involvement:
Peripheral synovial joints
Polyarthritis: common in course
Oligoarthritis: common in initiation
Monoarthritis: rare
No axial involvement except neck
Iran Criteria of RA

11. Articular manifestation:
Peripheral joints, (no Axial)
Poly, Oligo, Monoarthritis
Chronic, Acute
Symmetric, Asymmetric
Distal to Proximal
Upper > Lower
MCP, PIP, Wrist
DIP: rare
Additive, Synchronized

12. Initial clinical presentations*:
Iraj Salehi A.
Initial clinical presentations*:
Oligo/polyarthritis (> 2 joints): %
Duration > 6 weeks: %
Hand involvement: %
Symmetric involvement: %
Morning stiffness > 1 hour: %
No extra-articular involvement:
. Only olecranon Rheumatoid nodules: %
*. Salehi I et al (2012) Early diagnosis of rheumatoid arthritis: an introduction to the newly designed Iran Criteria for Rheumatoid Arthritis. Rheumatol Int. doi: /s

13. Clinical articular hallmarks:
I. Salehi A.
Clinical articular hallmarks:
Chronic symmetric polyarthritis
Small > Small + Large > Large joints
Hand (wrist, MCP, PIP) joints: Key joints
Morning stiffness > 1 hour
DIP involvement: uncommon
Deformities in advanced (very late) phase
Iran Criteria of RA

14. Clinical articular hallmarks:
I. Salehi A.
Clinical articular hallmarks:
The earliest involved joints are typically the small joints of the hands and feet
Iran Criteria of RA

15. In undifferentiated arthritis if:
I. Salehi A.
In undifferentiated arthritis if:
Higher number of tender and swollen joints
Positive RF
Positive a nti-CCP
Higher scores for physical disability more likely to be diagnosed later with RA

16. In established RA: The most common involved joints are: Wrists MCPs
I. Salehi A.
In established RA:
The most common involved joints are:
Wrists
MCPs
PIPs
But the uncommon involved joints are:
DIPs

17. Periarticular manifestations:
I. Salehi A.
Periarticular manifestations:
CTS
Olecranon bursitis
TTS
Tenosynovitis
Trigger Finger
Plantar fasciitis
Shoulder periarthritis

18. Typical (Classic) RA A middle aged female with
I. Salehi A.
Typical (Classic) RA
A middle aged female with
Chronic symmetric polyarthritis
MCPs, PIPs, Wrists, MTPs (early)
Elbow, Knee, Ankle, Shoulders
Morning stiffness > 1 hour
Rheumatoid nodule
Positive RF &/or anti-CCP
Elevated ESR

19. Extra-articular manifestations:
I. Salehi A.
Extra-articular manifestations:
Rheumatoid nodules
Eyes: Epi/scleritis, Sjogren’s syndrome
Lungs: ILD,…, Pleural effusion
Cardiac: Coronary/non-Coronary
Vascular: Vasculitis, Atherosclerosis,…
Hematologic: Anemia, Felty’s syndrome,…
Muscular: Myopathy, Myositis
Nervous system
Kidney
Iran Criteria of RA

20. Arthritis: Swelling 2 p. Tenderness T Warmth 1 p.
Limitation of motion 1 p.
Redness p.
Arthritis > T + 2 p.

21. Hands: Symmetrical swelling of Tenosynovitis
MCPs
PIPs
Wrist
Tenosynovitis
Reduced grip strength
Trigger finger
CTS
Tendon rupture
Piano-key sign
‘’Boxing glove’’appearance

22. Elbow: Flexion contracture Bulging of lateral groove
Compressive ulnar neuropathy
Olecranon bursitis
Rheumatoid nodule

23. Shoulder:
‘’Frozen’’shoulder
Rotator cuff injury
Anterior bulging sign

24. Foot: MTPs: Instep: Diffuse swelling Heel pain: Plantar fasciitis
Window sign
Hallux valgus
Bunion
Instep: Diffuse swelling
Heel pain:
Plantar fasciitis
Retrocalcaneal bursitis

25. Foot: Ankle: 1rt, 2nd joints TTS Pes planovalgus: Flat foot
Overriding of toes
Hammer toe
Malet toe
Cock-up toe
Calosis

26. Knee: Synovial thickening Effusion: LOM: Flexion, Extension
Patellar tap sign
Fluid wave
LOM: Flexion, Extension
Baker’s cyst: Foscher’s sign
Ruptured Baker cyst
Pseudothrombophlebitis

27. Hip: Very Late LOM Patrick’s test(FABER test)
Pain in groin, thigh, Low back
Referred pain to knee
Trochanteric bursitis

28. Sternoclavicular joint Cricoarytenoid joint: 30%
TMJ
Sternoclavicular joint
Cricoarytenoid joint: 30%
Morning hoarseness
Morning stridor
Morning dysphagia
Ear articulation:
Conductive hearing loss
Morning hearing loss

29. Cervical Spine: C1-C2 subluxation Subaxial subluxation
Horizontal
Anteroposterior
Lateral
Rotationally
Vertical
Subaxial subluxation
Neck pain (Rotation)
Radicular pain
Spinal cord compression