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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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Chapter 16
383
Musculoskeletal
symptoms and signs
Approach to the patient with musculoskeletal
complaints 384
Muscle weakness + pain 386
Monoarthritis 390
Polyarthritis 392
Pain or limitation of movement—
in the hand and wrist 395
at the elbow 396
at the shoulder 397
at the neck 398
of the back: with sudden onset over seconds
to hours originally 399
of the back: with onset over days to months
originally 401
of the hip 403
of the knee 405
of the foot and ankle 407
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CHAPTER 16 Musculoskeletal symptoms and signs
384
Approach to the patient with
musculoskeletal complaints
Patients with disorders of nerves, muscle, or the neuromuscular junction
can present with a similar constellation of symptoms. Diseases of the
nerve (e.g., polyneuropathy), muscle (e.g., myopathy), and neuromuscular
junction (e.g., myasthenia gravis) may present with varying degrees of
sensory loss and weakness. Nevertheless, specific patterns of sensory and
motor disturbances help differentiate between disorders.
Weakness can arise from dysfunction of nerve, neuromuscular junc-
tion, or muscle, and may be a difficult symptom for patients to quantify
and localize. Frequently, patients will complain of pain and associated
weakness. However, since pain may limit the action and mobility of a
joint, the finding of weakness in the setting of pain may not indicate true
neurological dysfunction.
It is important to distinguish myalgias (muscle pain) from arthralgias
(joint pain). Additionally, many musculoskeletal symptoms are part of a
systemic illness, so constitutional symptoms are always important to
elicit.
For muscular complaints, the pattern of symptoms is important to
ascertain: which muscle groups are involved (localized to one extremity,
proximal vs. distal, etc.) and whether there is accompanying weakness.
Family history may give you a clue (e.g., inherited muscle storage diseases
or a family history of autoimmune disease). The degree of impairment of
activities of daily living should always be part of a musculoskeletal
assessment.
For joint complaints, the pattern of joint involvement is also important
and can give clues to the underlying illness. Monoarticular arthritis has a
different differential diagnosis than that of polyarticular arthritis. Associated
morning stiffness usually suggests inflammatory arthritis.
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CHAPTER 16 Musculoskeletal symptoms and signs
386
Muscle weakness + pain
Many patients who complain of weakness are not weak when muscle
strength is formally tested. A careful history and physical examination will
help in determining the distinction between asthenia (motor impairment
due to pain or joint dysfunction) and true weakness.
Patients with a variety of systemic disorders (cardiopulmonary and
joint disease, anemia, cachexia, depression) may interpret difficulties in
performing certain tasks as weakness. These patients may be functionally
limited but not truly weak. True weakness due to a decrease in muscle
power must be differentiated from limitation due to dyspnea, chest pain,
joint pain, fatigue, poor exercise tolerance, paresthesias, or spasticity.
Muscle complaints should be further characterized by the muscle groups
involved, exacerbation with exercise, and the presence of fasciculations.
Muscle pain is relatively uncommon in patients with many types of
myopathy and true weakness, but is often a problem for patients with
overexertion, cramps, or fibromyalgia.
The physical examination should include not only testing of muscle
strength but also a careful search for one of the disorders that can cause
the perception of weakness.
Some differential diagnoses and typical outline evidence
Primary muscle disorders
Normal
response to
strenuous
exercise
Suggested by: fit, healthy, unaccustomed exercise
1–2 days before
Confirmed by: spontaneous resolution
Primary
thyroid disease—
both hyper- and
hypothryodism
Suggested by: onset over weeks to months.
Predominant fatigue. Can have proximal muscle
weakness. Also cold intolerance, weight loss
Confirmed by: iTSH, dFT4
Cushing’s syndrome
(also steroid
myopathy)
Suggested by: proximal muscle weakness with
atrophy, first affecting the lower extremities and
then the upper extremities, signs of Cushing’s
syndrome
Confirmed by: normal CPK, muscle biopsy showing
atrophy of type II muscle fibers, laboratory
evidence of Cushing’s syndrome (iurinary free
cortisol or non-suppression on dexamethasone
suppression test)
Hyperparathyroidism Suggested by: proximal weakness (legs involved
more than arms), fatigue, musculoskeletal pain,
and hyperreflexia, iCa
2+
Confirmed by: iPTH (parathyroid hormone)
MUSCLE WEAKNESS + PAIN1
387
Inflammatory
myositis
Polymyositis
Dermatomyositis
Suggested by: onset over weeks to months.
Predominant weakness of proximal muscles;
dermatomyositis accompanied by heliotrope rash
and Gottren’s rash over metacarpophalangeal
(MCP) and proximal interphalangeal (PIP) joints
and photosensititvity. Associated malignancy can
occur.
Confirmed by: CPK
i; autoantibody, including
anti-nuclear antibody (ANA), anti-SRP, anti Jo-1,
anti-Mi-2, anti-Ku and anti-PM-Scl, and anti-hPMS-1;
electromyography (EMG) and muscle biopsy
Inflammatory
myositis
Inclusion body
myositis
Suggested by: onset over months. Predominant
weakness; proximal > distal
Confirmed by: CPK
i, EMG and muscle biopsy,
with minimal inflammation and characteristic
basophilic rimmed vacuoles within muscle
sarcoplasm
Polymyalgia
rheumatica
Suggested by: onset over weeks or months, stiff,
painful, and tender proximal muscles. Fatigue,
fever in elderly person
Confirmed by: iiESR. Rheumatoid factor nega
t
ive,
prompt response to low-dose prednisone, no
other cause
Glycogen storage
disorder (McArdle’s
disease)
Suggested by: familial history, early adulthood with
exercise intolerance, fatigue, myalgia, cramps,
myoglobinuria, poor endurance, muscle swelling,
and fixed weakness; brief rest after development
of muscle stiffness, and myalgias can lead to re-
sumption of physical activity without significant
symptoms
Confirmed by: low venous lactate after ischemic
response to exercise, muscle biopsy, genetic
testing
Phosphofructokinase
(PFK) deficiency
(glycogen storage
disease VII, Tarui
disease)
Suggested by: childhood onset with fatigue, muscle
cramps, and exercise intolerance. A high carbohy-
drate meal or administration of glucose prior to
exercise aggravates symptoms, due to decreased
availability of free fatty acids and ketones.
Confirmed by: serum creatine kinase i. Red blood
cell PFK activity reduced to one-half normal.
Sometimes mild hemolytic anemia, mild hyper-
bilirubinemia, hyperuricemia, due to increased
degradation of purine nucleotides in muscle. The
ischemic forearm exercise test shows no rise in
lactate levels; muscle biopsy
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CHAPTER 16 Musculoskeletal symptoms and signs
388
Myotonic dystrophy
Suggested by:
skeletal muscle weakness and
myotonia, cardiac conduction abnormalities, cata-
racts, testicular failure, hypogammaglobulinemia,
and insulin resistance.
Muscles involved: facial muscles, levator palpebrae
superficialis, temporalis, sternomastoids, distal
muscles of the forearm, hand intrinsic muscles
(leading to compromised finger dexterity), and
ankle dorsiflexors (causing bilateral foot drop)
Confirmed by: EMG, genetic testing
Neuromuscular dysfunction
Myasthenia gravis Suggested by: onset over weeks or months.
Fluctuating skeletal muscle weakness, often with
true muscle fatigue. Ptosis or diplopia, bulbar
muscle weakness manifests as hoarseness,
expressionless face if facial muscles involved,
drooped-head syndrome if neck muscles involved
Confirmed by: bedside tests (Tensilon test and ice
pack test). Acetylcholine receptor antibody
(AChR-Ab) or against a receptor-associated
protein, muscle-specific tyrosine kinase (MuSK-Ab)
Eaton Lambert
syndrome
Suggested by: slowly progressive proximal muscle
weakness, frequently associated with autonomic
dysfunction; weakness may improve with repeti-
tive movement. Frequently early manifestation of
occult malignancy, especially small cell lung cancer
Confirmed by: EMG and antibodies to voltage-gated
calcium channel (VGCC)
MUSCLE WEAKNESS + PAIN1
389
Primary neurological disorders
Multiple
sclerosis (MS)
Suggested by: relapses and remissions of CNS
dysfunction. Onset between 15 and 50 years o
f
age, associated optic neuritis, L’hermitte’s sign,
internuclear ophthalmoplegia, fatigue, Uhthoff’s
phenomenon
Confirmed by: MRI, CSF analysis, evoked potentials
Amyotrophic lateral
sclerosis (ALS)
Suggested by: combination of upper motor neu-
ron (weakness, hyperreflexia, and spasticity) and
lower motor neuron (atrophy and fascicula
t
ions)
signs and symptoms. Asymmetric limb weakness
is the most common presentation.
Confirmed by: clinical picture and EMG.
Primary motor
sensory
neuropathies,
including
Charcot–Marie–
Tooth disease
Suggested by: distal calf muscle atrophy, atroph
y
of hand and foot muscles, loss of reflexes, pes
cavus foot deformity, hammer toes
Confirmed by: EMG and sural nerve biopsy
Other
Fibromyalgia Suggested by: variable onset—weeks to years.
Diffuse pain and stiffness and sleep disturbance
(nonrestorative sleep). Important to exclude
sleep apnea
Confirmed by: absence of another condition,
tender points
Celiac disease
and other
malabsorption
states
Suggested by: arthralgias, myalgias, iron-deficiency
anemia, osteoporosis
Confirmed by: small bowel biopsy, IgA anti-tissue
transglutaminase, IgA endomysial antibody, or
anti-gliadin antibody
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CHAPTER 16 Musculoskeletal symptoms and signs
390
Monoarthritis
One joint is affected by pain, swelling, overlying redness, stiffness, and
local heat (±fever).
Some differential diagnoses and typical outline evidence
Acute septic
arthritis
Suggested by: extremely painful, hot, red joint, high
fever
Confirmed by: iiWBC. Joint aspiration: synovial fluid
turbid. Culture growing Staphylococcus, Streptococcus,
gram-negative organisms (rare), gonococci, or TB
Gout
Suggested by: one acutely inflamed joint (frequently
the first MTP joint) at a time, but other joints in
hands, arms, legs, and feet can be involved. Tophi on
ears and along extensor tendon sheaths
Confirmed by: urate crystals (negatively birefringent in
plane-polarized light) present on joint aspiration.
Elevated serum uric acid insufficient for diagnosis
Pseudogout
(Ca
2+
pyrophosphate
arthropathy/
chondrocalcinosis)
Suggested by: one painful joint (usually knee), especially
in elderly or history of hyperparathyroidism or hypothy-
roidism or osteoarthritis or hemochromatosis
Confirmed by: joint aspiration: synovial crystal deposits
positively birefringent in plane-polarized light.
Chondrocalcinosis on X-ray
Reactive arthritis
Suggested by: asymmetric mono- or oligoarthritis,
urethritis, conjunctivitis, especially in a young man,
with a history of diarrhea or urethritis that occurred
2–6 weeks previously. Also suggested by associated
plantar fasciitis, achilles tendonitis
Confirmed by: rheumatoid factor negative (i.e.,
seronegative). Urinalysis: first glass of a 2-glass urine
test shows debris in urethritis
Osteoarthritis
Suggested by: monoarthritis of weight-bearing joint,
especially in joint with a history of remote trauma or
in an obese patient
Confirmed by: joint aspiration:non-inflammatory fluid,
joint space narrowing and osteophytes on X-ray
MONOARTHRITIS1
391
Traumatic
hemarthrosis
Suggested by: acutely inflamed joint after trauma
Confirmed by: joint aspiration: aspiration of blood
from joint
Psoriatic arthritis
Suggested by: inflamed joint or sausage digit, pitting
and thickening of fingernails
Confirmed by: psoriatic plaques on elbows
and extensor surfaces of limbs, scalp, behind ears
and around navel. Rheumatoid factor negative
(i.e., seronegative).
Leukemic joint
deposits
Suggested by: acutely inflamed joint, diagnosis
of leukemia
Confirmed by: exclusion of other diagnoses,
particularly septic arthritis; in patient without known
leukemia, peripheral blood smear and/or bone marrow
consistent with leukemia
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