1. 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

2. 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

3. 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

4.
The knee

5. 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

6. 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

7. 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.

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

9. 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.

10. 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.

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

12.
The knee

13. The knee (but shallower)

15. 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

17. 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!

18. 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

19. 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

20. 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

21. 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

22. 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

23.
The shoulder

24. The shoulder, but more so

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

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

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

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

32. 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