1. 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

2. BASIC CLINICAL RHEUMATOLOGY
THREE CONTRIBUTIONS
The Knee
The Spine
The Hindfoot

3. 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)

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

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

6. THE SPINE
Dr H Ménard, McGill 2012

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

8. 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

9. 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.

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

11. THE ANTERIOR SPINE

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

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

14. Where is the lesion?
NEITHER
ANTERIOR
FLEXION
POSTERIOR
EXTENSION

15. 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

16. 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.

17. 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.

18. 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.

19. Palpation Of The Paravertebral Muscles
Bergeron S et al. 2009

20. 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

21. 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 < A B
A D (OA) – 18.2 ± 1.4 ns
Bergeron S et al. 2009

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

23. 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

24. 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.

25. 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

26. THANK YOU FOR YOUR ATTENTION
QUESTIONS ?
COMMENTS ?

27. 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)