Andrew J. Gross, MD, chief of the UCSF Rheumatology Clinic, helps providers sort out the common complaints of pain in the hand, shoulder, back and elsewhere. He presents a systematic approach to distinguishing inflammatory causes – including lupus and rheumatoid arthritis – from noninflammatory causes, and reveals how subtle differences in symptoms point to certain conditions, which tests are useful (and which are essentially useless), and when referral is warranted.
I focus this talk on on sort of detecting and and working up people with inflammatory conditions more than happy to come back and talk in the future of course about um non inflammatory conditions, including particularly fibromyalgia and chronic fatigue. But I'm not going to focus as much on that today. Um So let's get started. Um I don't have any disclosures. Uh and the as I mentioned, the main focus is distinguished inflammatory arthritis from non inflammatory arthritis. Um We'll talk about some key features of polymer al dramatic to uh talk about inflammatory back pain that's supposed to run in the middle back pain. Um and also talk about the patient who shows up with a swollen knee. So uh sub acute monolithic yards. Right? So four broad concepts here. Okay, and I'm gonna spend the majority of my time talking about that first topic. I'm distinguishing inflammatory arthritis from non inflammatory arthritis. Um I have a lot of slides. I'm going to go through them quickly because I think you guys you probably are familiar with many of these concepts. Um But just putting chat if you want me to slow down or go back to something. Um Okay so and all this is gonna be case based. So um first case 29 year old woman with three weeks of joint pain especially affecting the hands and wrists as well as knees and feet. Uh Real systems is pretty unremarkable except for some fatigue. Uh And importantly on exam you appreciate some tender pip so hip M. C. P. Joints and risks no skin rashes. Um I think for many um providers approaching the joint examines sometimes can be a little bit overwhelming. I've heard doctors lament that they wish they had something like a tricorder to say what's going on and I think we'll get to that someday. But for the time being um I have to sort of put on our thinking caps and go through this and uh systematic way to try to tease apart. And I'm always starting with the concept of it, does this person have an inflammatory condition potentially there in a benefit from um drugs that suppress inflammation versus non inflammatory conditions are often require other approaches. Um and so I'll get into lupus and rheumatoid arthritis and even spinal arthritis. And talk, I'm not going to talk as much about crystal arthritis, but happy talk at length about gout. Um and even some viral infections, chronic bacterial. But the key thing there is that most of these conditions, people complain about morning stiffness um in these affected joints that usually lasts for a while, at least an hour. Um it's not a perfect test, but it's a helpful question. I always ask patients about, do you have morning stiffness, how long does that last? Um Very, very often people with non inflammatory conditions like osteoarthritis, they'll say they're stiff in the morning But usually with a little bit of movement activity 5, 10, 15 minutes, it's gone, it's much much better. Um So helpful. Very first question separating these two these two issues out. But what else can we do? So um so what are what are the things I can do to sort of sort this apart? And this is where I really encourage people to take a systematic approach. Obviously these are kind of clinical clues that we all use all the time. Um you know, certainly we all know that uh 72 year old male with um with chest pain brings to mind a very different differential diagnosis than a 28 year old young woman. Um Family history can be apart important, especially osteoarthritis, one of the most strongly inherited um, rheumatic diseases, um, Oscar arthritis and of course they aren't there disease acute, sub acute chronic. Um but really when when for rheumatologists, one of the the the other key things that we focus on is a pattern of joint involvement in particular. Also the extra articular manifestations. And very last. And something I really want to emphasize at the very bottom of this list is a diagnostic testing. You know, as a resident commented to me the other day. So much of rheumatology is in the history, the testings at the end. And that's really that she really remarked on that after spending time in the human biology clinic where it's flipped, we're obviously in the hematology clinic. You want to see that cbc. But the rheumatology clinic we care so much more about the history and the exam. And it's only at the end where we're going to those those tests to help confirm or refute our the our clinical suspicions. So I'll talk more about that. Um So pattern joint involvement. Let me talk a little bit about that. So um so just to kind of keep everyone a little bit sort of on their toes since it's late in the afternoon on Tuesday hard to continue to concentrate but a little thinking exercise here. So all the following conditions commonly involve the M. C. P. Joint risks and these like our patient except for where which you know that you guys ponder that movement. I wish we had our our remote things. I don't have that set up um to record answers. But of course the answer here is Oscar arthritis. So Oscar arthritis isn't one of the conditions that commonly affects it. The tps wrists and knees. Oscar arthritis much more commonly is going to go after the dip joints, the pip joints and especially the base of the thumb faces them. Sometimes that gets confused with the risk but it's really just the basis of them. Um As opposed to inflammatory arthritis so much more often it's going to hit the M. C. P. Joints and risks. And that's something that right away I'll ask people coming into my office about complaining about hand pain. Is it you know focus on the risks and the MTP joints or is it the other joints And that's it. That's going to help me a lot distinguishing out people with non inflammatory pain from things like rheumatoid arthritis or lupus less commonly CPP. Or viral infections like parvo virus. So super helpful to go through that. Um So back to our patients again so she has the involvement of her hands and wrists as well as knees and feet. Um And on exam there's somewhat tender pipes m. Cps and risks. So that's now pushing me in the direction of inflammatory arthritis. And now I'm getting a little bit more interested in funding birthrights. Okay well so what our next steps if I'm I'm not confident that I can palpate swelling of those joints um And what else can I do to help to help figure this out? So the next thing I definitely wouldn't want to do with a young woman with hand pain in this distribution would be looking for extra articular manifestations. And then of course we all do this. So we're all taking the review of systems and going through all these things and and this is really where it's so important to tease apart conditions like lupus or psoriatic arthritis from conditions like rheumatoid arthritis because of course rheumatoid arthritis very often. Not always but very often does not have extra articular manifestations whereas lupus pretty much extra articular manifestations is a hallmark of that disease. And certainly with psoriatic arthritis you're looking for psoriasis. So um so super important to be able to look for extra articular manifestations and so just just talk that has me to want to talk a little bit more about lupus. Since so often we get referrals for the question of whether someone has lupus or some and associated disease. So just a quick, quick reminder of lupus that the majority of people with lupus have skin rashes. These are skin rashes that do not come and go. So you know sometimes people say well I go in the sun and I turned bright red. That's not a lupus rash. So lupus rash, it actually takes a while for the lymph of plasma citic infiltrate the immune cells to go into the skin. Set up. Shop there start reacting to the immune complex deposition that the basement membrane just below the epithelial level layer. And so that takes days or even a couple of weeks to set up after prolonged sun exposure or not, it takes even longer to go away. So if someone says they have a rash that comes and goes and of course of hours or or just a couple of days, that doesn't sound very lupus. See to me um The classic distribution is of course on the backs of the hands, on the arms, on the chest and on the face, all sun exposed areas. Um Usually of course sparing the nasal labial fold because that's in shadow. Um. Uh Certainly looking for a discord rash which is a scarring rash often on the head. Um All super helpful things to pick up. And if you're concerned about a rash. So helpful. I just really want to emphasize so helpful to refer to a dermatologist who is comfortable doing biopsies because when we do a biopsy and see that interface dermatitis, that's so helpful to diagnosing lupus. Again, with that biopsy showing this interface dermatitis classic of autoimmune rash consistent with lupus or sometimes dramatic sinusitis. So really want to emphasize picking up those classic skin rashes in that classic kind of presentation, sending to the dermatologist. That's the kind of work have been super helpful to us. Um Other things to ask about oral ulcers, often paying less in lupus. These are not the typical at this ulcers that people describe often one at a time that painful. Often people with Lucas have multiple ulcers in the mouth, but they might not have noticed that sometimes you take a look. Um Small joint arthritis super common in that distribution of inflammatory arthritis not in the back lupus very rarely affects the spine. So pain all over is not necessarily implicit. Anyway serious. I just the merry nephritis also common manifestations obviously picked up on labs as well as human to logic abnormalities and then of course the blood tested. So um so with that that kind of that gets us to the diagnostic testing. So let's talk a little bit more about that. So I talked about the pattern, joint involvement, talked about extra articular manifestations and then diagnostic testing and again once again emphasizing doing the diagnostic testing if those other parts of the history are all lining up consistent with lupus or some other inflammatory conditions. So for lupus um one of the things that we get a lot is referrals for people with joint pain or positive. And a, so I just want to talk a little bit about that house. N. A. N. A. Test help me determine information as a room thing like Lucas. Okay, so the key thing here, it all is that while the A. N. A. Is extremely sensitive for lupus, so if the A. N. A. Is negative, I feel a lot better that a patient does not have lupus. So if you're really suspicious of lupus and you get that DNA test is negative. Rethink, rethink the differential diagnosis but a positive DNA, that's not as helpful. Let me just point out something um There's a lot of different sides I can show you on this, but I think this is when I think hopefully will be most helpful to you. It's just remind everyone that the majority of people walking around with a positive ana are perfectly healthy and these are super common in healthy people At a low tire of 1 to 40, Roughly 15% of the population of healthy women has that. So 1 to 40 15% At higher titles, that number goes down. But even at 1-3 20 Up to 5% of healthy women have that. So um and and that that that goes up even more as people get older um on top of that, other conditions can show up with a positive. DNA is not particularly meaningful, including fibromyalgia, um autoimmune, thyroid. It's very commonly in a positive chagrin syndrome as well, lupus only probably accounts for 2% of people with a positive and a, so a positive ana is just not a very helpful test. It doesn't separate out at all whether someone has a room thing or whether they just are perfectly healthy. So I really want to just can't emphasize enough that an A. N. A. Test is not the go to test. And of course a nasr associated all with things like ankle losing spondylitis or septic arthritis or or other things like that. So not a very helpful test. So what tests are more helpful in lupus? Well there's a bunch of them so. Well the answer is quite sensitive the lack of specificity but on the other hand the double stranded DNA antibody is quite specific as well as the smith antibody although it's much less sensitive. So certainly if you're thinking about lupus getting that double strain of D. N. A. And that smith anybody super helpful. Second really helpful thing in lupus is detecting HIPPA complementing via low levels of compliments. One of the things that happens lupus is that it's basically these anybody's against self antigens and those immune complexes get deposited all over the body and activate complement and basically uses up the whole all the compliments of the body. And so very typically people with lupus will have low levels of compliments. So definitely check it c. three and c. four if you're suspicious of that. The other thing I would be quite helpful is that elevator inflammatory markers? Um So high said rate in particular and then finally I love getting cbc's and people I suspect have lupus. It is the poor man's test for lupus because it's really good at detecting things are super common lupus including lucca pina and particularly lymph apnea. So low lymphocyte counts is definitely something I'm looking for in a work up of lupus. Um So super helpful to get the cbc with diff to look for. Um low uh low numbers of lymphocytes in the blood. And the second thing that can be helpful is also looking for thrombosis subpoena that can be more subtle. So that can be like a platelet count of like 120. So not necessarily, you know, not to play the account necessarily 10. All that can happen lupus but having that low end of normal uh play the count or mildly throughout the city. But I'm seeing someone with a play. The count of 300. You know this can still have lupus but it's so common that people have a kind of a low platelet level. That's really helpful to pick up. So those are the tests I think are really super helpful for you all be ordering if you suspect lupus. And again I really want to emphasize. So a patient with inflammatory arthritis or typical skin rashes, especially if they've been confirmed to be due to interface dermatitis by the dermatologist. So those are some of the tests that that I'm looking for it in the lupus. Work up in combination with that appropriate history um suggesting sort of consistent with lupus. Okay, um I want to go back to our patients again. So again, our patient did not have any extra articular manifestations. Didn't have any skin rashes, just had this um sort of inflammatory arthritis type presentation. It's a little bit more consistent with rheumatoid arthritis and the absence of extra articular manifestations. So, when I'm thinking about rheumatoid arthritis, all right, so we help the joints. This person has this prolonged morning stiffness. They have this characteristic distribution of evolved joints in their hips and their wrists as well as maybe the pips. Maybe some knee pain, maybe some pain in their toes. Sometimes people describe it as I'm walking barefoot in my toes or the bottom of my toes is really a key. Um So but you know you maybe you you press on the giant screen you're just not sure whether their joints are swollen, you're not sure whether they have an inflammatory arthritis. So what test can you get? Um Well of course one of the good starting place is the rheumatoid factor in the sea and the CCP. Anyway. So how will that help? All right. So some lab tests in rheumatoid arthritis. So of course the set rate and crp are often elevated rheumatoid arthritis. So very helpful test to get. But the rheumatoid factor in CCP they are particularly helpful. Um Combined they're about 80% sensitive. So probably eight out of 10 people with rheumatoid arthritis have either a rheumatoid factor or a CCP anybody. So that means one in five people don't have either of those tests. So don't forget that those aren't tests are not diagnostic of of rheumatoid arthritis. I don't mean that you have rheumatoid arthritis. Um that there's some people will be um what's called zero negative both those will be negative. Um If you pick up a CCP anybody you feel pretty good about the diagnosis of rheumatoid arthritis or pre rheumatoid arthritis at least because that is such a specific test. So CCP anybody super specific. So you pick that up like right away pretty concerned about rheumatoid arthritis. On the other hand the rheumatoid factor not so specific rheumatoid factor can show up in all sorts of different things. Chronic infections like sub acute bacterial endocarditis or just an acute viral infections, parvovirus, very common inventory factor, pasta. Um People with M. A. Theological malignancies. Um uh People with other autoimmune diseases including lupus can be rheumatoid factor positive and of course route to a factory can simply show up as people get older. So um so it's important to remember that the rheumatoid factor has a differential diagnosis. You don't automatically conclude that someone has rheumatoid arthritis is worthwhile doing some other testing. Including for example chronic hepatitis B and C. Which often the rheumatoid factor positive. Um So those are really helpful tests but the rheumatoid factor is limited by non specificity. The other tests that you that's super helpful for you all to get be the said rating crp showing some science of systemic information. Okay so those are the lab tests that I focus on. What other tests can you all obtain to help work up a patient for rheumatoid arthritis when you're suspicious of it Again with that prolonged morning stiffness, a pattern of joint involvement. Um uh a pattern inflammatory arthritis, weather testing yet. So two other ones. So I always appreciate the playing film. So in early rheumatoid arthritis often doesn't show much of anything. But sometimes people actually have had pain for a while and aren't entirely straightforward about it. So getting the hand and foot x rays can be super helpful as if they show subtle signs of inflammation. Like you can see in this person with this sort of this kind of room in here a little divot right there in the M. C. P. Joint as well as in the in the risk where you can see that the bones seem to all have collapsed together. That can be really helpful for picking up signs of inflammatory arthritis. So really want to emphasize the value of the plain films. Been working up someone with chronic joint pain to help identify signs of inflammatory arthritis and of course can be really helpful for picking up signs of degenerative arthritis or osteoarthritis. Um One other thing that I'd encourage you all to make use of it, UCSF is the ultrasound, so again, a person with inflammatory joint pain, but it's only been going on for a couple of months, not that long. Um Maybe they have a high set rate, you think that maybe their joints were swollen but you're not quite sure. One other way to pick that up would be with ultrasound. So UCSF musculoskeletal radiology is very proficient at this easy enough to order from UCSF, you just send a wreck with the UCSF and usually they're pretty quick about scheduling these, it's usually within a couple of weeks um can take a whole lot longer to get them are an MRI that's really helpful test for picking up signs of joint inflammation, ST Vitus um As well as helpful for evaluating other causes of of of of hand pain, including just kind of degenerate tendon. Open these. So I really want to emphasize the use of ultrasound to help distinguish inflammatory arthritis from non inflammatory arthritis patients where you're just not sure. So consider wearing the ultrasound. Um I don't know if other organizations do that. Besides stanford, stanford certainly does. Um But I haven't seen too much musculoskeletal ultrasound from um from the solar system. So uh if it's available to go for it but just make sure that they're comfortable doing that. Um ultrasound departments often will do it. But if they don't have a whole lot experience of it, sometimes interpretation cannot be great. Okay, so those are the tests that I think are super helpful um When you're just not sure but you're suspicious of inflammatory arthritis. Um So when to refer to a rheumatologist? Um Well considered referring when the pattern joint involvement is consistent with inflammatory arthritis. Um And especially if there's an elevated separator and or crp again suggesting that there's really inflammatory process at hand um Super helpful. Um I think we would be happy to see anybody with a positive ccP anybody such a specific test. Um if you're suspicious of lupus, but again, suspicious of lupus doesn't mean joint pain and a positive DNA. It really means uh more features consistent with lupus as well as some of those other blood tests that we talked that I talked about before. Um Or if you pick up signs of centimeters on the ultrasound. So if the ultrasound report comes back, uh cinema is consistent with inflammatory arthritis. Love to see those patients. Um What to do with the patient who does not have inflammatory arthritis. Well, um, I think one of the things that that we really are challenged by is we try hard y'all to get your patients in quickly. Um and you know, our goal is to do that within a month, if not a couple of weeks. But one of the things that we just don't can't do is be able to see every patient with chronic pain or fatigue. Um If if we were seeing all those people, we wouldn't see anything else. So, one of the things that that um, that's really helpful is if you can send the people with who you really suspect have inflammatory arthritis. Um but try to manage yourself as best you can. Um the non inflammatory things. And so someone with a hand pain and non inflammatory arthritis. I think of course you all know the youth and sets in Thailand all that stuff. But the one thing that I think was really helpful for those people is hand therapy. I always have to set it up with folks that you know you're not going to feel better tomorrow. Good seeing a hand therapist. Um And in fact often the hand therapist make a lot of suggestions that seem to people almost like a waste of time because it seems so trivial. But actually the clinical data is that people who follow hand therapy recommendations closely. Especially for Oscar arthritis. About half of people have a pretty good improvement in pain. So um so I think some setup and really encouraging people to see the hand therapist and follow the recommendations and do the exercises every day can be really helpful. Um And of course I think I want to emphasize that sending a person just for a positive and a not so helpful. It's much more helpful to look for those more specific signs of lupus since the A. N. A. Is such a non specific test. Okay, so that's my my my quick whirlwind approach to the person with hand pain. Um especially a younger person. So now I'm going to switch gears a little bit. Um, so second case uh 66 year old man comes to see you complaining of shoulder pain, pain came on suddenly about three weeks ago, initially affecting his right shoulder and then the left. Um pain radiates down into the upper arms and someone who crosses upper back exacerbated by shoulder abduction with their arms. Um also complains more recently, a new lower on set back and hip discomfort. So you diagnosed him with polymer gramatica. All of the following symptoms tipped you off to the diagnosis of PMR. Except for which, Okay, So morning stiffness lasting more than 45 minutes. Pain, stiffness affecting the lower back and pelvis, girl pain, stiffness from Cruz with activity. Said rate greater than 40 And a and a 12,320 or higher. So which one of those? Okay, so hopefully paying attention to the last part of talk. You picked up on the fact that that and they tested. That's how helpful. Right? So again, non specific test and it's not even associated with following valderrama. So not a helpful test in that case. Um I really want to emphasize that prolonged morning stiffness in the in the shoulder girl and the hip girl region um uh stiffness improves with activity and that high inflammatory market. So some tips about PMR. So here's again the presentation of it, the distribution of involvement. It tends to not exactly be articular, it's not really an arthritis, it's more sort of a bursitis, if anything, um especially in the shoulder girdle region, upper back neck as well as in the hip girdles and sometimes into the thighs for some patients. Um It's very uncommon in people under the age of 16, very uncommon. So here's uh the epidemiology from the Mayo Clinic from back in 83 um where they showed that the older you are, the more likely you are to get PMR. And so in uh someone in their in their 70's 1 in 900 As opposed to someone under the age of 51 in a million. So really be cautious about diagnosing someone under the age of 50 with PMR and be somewhat cautious about diagnosing someone in their fifties. It happens, but it's much less common than someone who is considerably older than that. Um Said raise helpful, often elevated in but can be below 40 and somewhere between 10 and 20% of patients and those folks very often though the crp is elevated. So I really I often will get both this europea and the set rate and and nearly all patients but at least one of them will be elevated. And then as I as mentioned, the anti test is not associate with PMR. Um important for everyone to remember important safety tip 15% of people with PMR we'll have giant soda arteries, 15% PM our patients will have G. C. A. And of course that's super important to pick up because often retreat G. C. Was considerably higher doses of predniSONE as well as other steroid sparing agents. And if you miss it of course someone can lose their vision and um and you know, everyone feels terrible if a patient goes blind. So super important to ask about symptoms of G. C. A. The most important thing is asking about a new onset of head pain. Also very commonly people have scalp tenderness. I can't uh It's stunning to me how often women with with G. C. A. At least before the pandemic told me that they stopped going to the hairdresser reviews, it's too painful. Um uh Draw a clarification with chewing important to distinguish that from TMJ or TMJ. The first couple of bites really hurt. Draw classification is more like this gnawing sort of discomfort or numbness and more that they choose to ask if you chew a piece of steak, does your mouth feel funny? Um And then of course if someone has a recent loss of vision amorosa few jacks where they get it back. That should be a real big warning sign just to send the person the er get them started on high dose steroids right away. Okay. Um some things that patients often tell me when they have PMR. Um These are these are uncanny. How often people tell me these things, I feel like I'm 100 years old. I need to crawl out of bed in the morning or the or the other variations. That is I need my spouse to pull me out of bed in the morning. It's just uncanny. How often my patients tell me that I feel okay as long as I keep moving because I stiffen up like the tin man as soon as I sit down. Super common statement. And and then the last one which I find a little bit less helpful in truth is that pregnancy is a miracle. Yes, you feel fantastic when when you treat someone with PMR and next day they walked into office and they're like oh my goodness, that was a miracle. Um But I caution everyone that pregnancy can make a lot of things feel better temporarily. At least they can even make back pain feel better. Doesn't necessarily mean it's a great test for inflammatory conditions. So just don't rely too much on response to predniSONE as a litmus test for indicating that someone has inflammatory conditions. Okay, so that's um those are the key things features a PMR. Just some things to keep in mind as Min Rikers of PMR. So other reasons why someone would complain about presenting pain and stiffness in the shoulder, girdle, hip girdle region and the most common of which is gonna be all star race. Super common for people advance. So a to have a lot of stiffness um and and sometimes can be pretty hard to tease apart. Um Diffuse idiopathic skeletal high prosthesis, another sort of bone forming disease. And also cause a lot of stiffness very apparent on x rays on the spine. Hyper calcium mia less commonly makes it to my office but certainly a common cause of diffuse pain and stiffness. And then of course fiber village. Um it's all those conditions of course are associated with the normal separates europea. But if they have a high separator crp then I think about other conditions, especially ankle is the latest in younger patients. Things that do not present with central stiffness lupus in particular. Lot of people I often see that mistake. Um but it really doesn't affect the uh the axial spine. Um uh And another thing that that sometimes gets mistaken is polymer science or to matter myocarditis. So it's important remember that Maya's itis can have stiffness but really the dominant presentation of a myocarditis, inflammatory muscle disease is weakness. People have a really hard time doing things and it's insidious in most of the time so that people will say, you know, you asked him to try to squat down and they just they can't possibly do that. Um Pain and stiffness is is a much lesser manifestation of muscle disease. Much of the inflammatory process is taking on muscle fibers but doesn't cause a whole lot of symptoms with that. Okay, so that's PMR. So when to refer to a rheumatologist, so we're happy to see patients with PMR very often of course you guys are perfectly capable of managing it. Um and that's totally fine with us but but some things that might have you want to send to us if you're if you're having a hard time managing the patient is especially if the patients not responding to predniSONE or you're having a really hard time tapering the patient down, definitely feel comfortable to send it to us. Um We'll reassess for other conditions. Um And we'll also work with patients on getting them from pregnancy in the room. Must always pretty effective at that. Um. Uh If you're patient again re flares whenever you try to taper the presence on those and especially if the person has any symptoms of D. C. A. Send us an urgent referral and we'll help out with that. Or you can even send the person to the U. C. S. F. E. R. And the E. R. Is getting increasingly proficient at the work up for G. C. A. And involving us and our consul team can go right down to the er and see the patient there. So certainly feel free for a patient where you're worried about G. C. A. To send right on into the U. C. S. F. D. R. Um And what we'll do is is often again the blood test looking for that high said rates europea. Um lately we'll get an MRI of their head looking for signs of inflammation of temporal arteries. And then we'll involve our ophthalmologist looking for signs of of regulatory involvement. Um And then uh and and get the patient set up for a temporary bias. Right Okay so that's the PM are part of this. So in the last 20 minutes may just refer to last cases. So this one focuses on a younger man with more actual pain more pain up and down the spine. How do we how do you evaluate that? Of course. You know the you know low back pain is dime a dozen but there's occasional cause of inflammatory back pain And how do you pick up that? So 32 year old man comes to see you complaining about for back pain pain came on about seven weeks ago, but this could be low back pain too. You know, it's his pain and stiffness in his neck and lower back. This is worse recently as well. It's been present on and off for a couple years, complaints about an hour of morning stiffness in his hips, in his back, cervical spine, flexion rotation, as well as lumbar fly inspection. Or seem to be just a little bit limited for a young person. Um, straight leg raises, un remarkable, no ridiculous symptoms. Hip rotation also seems a little bit limited. Just seems like it doesn't go as far as what you'd expect for a for a young man. The remainder of the joint examination is unremarkable. So not a super helpful exam other than some kind of limited range of motion. So which of the following conditions is most likely the cause of this man's shoulder, neck and lower back pain, ankle losing spondylitis, holly Melandri romantica, rheumatoid arthritis, lupus, C. P. P. D. Okay, so, um, so what I'm trying to guide you all towards the ankle isn't spinal ace in this case, as you know, we just talked about how pollen, mild gramatica really unlikely in a young person. Um, and this person is in the 30s, rheumatoid arthritis is a peripheral joint disease that doesn't seem right lupus. He doesn't have doesn't associate with the actual complaints and doesn't have the and he doesn't have any extra articular manifestations. And see PPD is also a disease usually of older people and typically actually spares a little response. So just reviewing distributions of joint involvement get really important to the rheumatologist If that's going to really help us. zero in on the differential diagnosis. So the rheumatoid arthritis are talked about having the hips, hips and wrists as well as the toes. Um Story ac arthritis tends to be scattered in different areas. I'm gonna come back to that ankle losing spon delay is really axial. So it's the spine, the hips sometimes the shoulders and the knees. Big stuff. Um And then finally Oscar arthritis. And I think y'all are probably pretty aware of this. The classic places roster arthritis more the D. I. P. And P. I. P. Joints especially when women especially women with a family history of it. Um spine disease. So certainly the cervical spine in the lumbar spine usually sparing the thoracic spine. The hips obviously and the knees especially if people are overweight. And then of course the first Mtp joint that Alex values. Um So really sort of helpful to kind of keep these patterns in mind. And so really now zeroing in on this young man who has this actual type presentation and what's happening in axial in an ankle losing spondylitis. Is this this inflammatory process causing the bone to proliferate and kind of reach across the spine. And so it kind of grows across the disk and ultimately kind of creates that bamboo spine appearance. So that's sort of that with the bridging over the disk and that that bony sort of fusion of the spine is in what really limits people's range of motion. And that same sort of bony proliferation happens in the shoulders and the knees and the hips to also limit range of motion in those locations. So that's kind of what's the trigger for the limitation and range of motion. Um And so the X rays are super helpful in someone who you're suspicious of inflammatory arthritis in the spine. So here's uh the interviews of the lumbar spine. I'm also getting an ap pelvis can also be super helpful to look for sacrilegious. So an ap pelvis also super helpful. Now also looks at the hips. What you can see in this case is that you can't see this person's sacrilegious sack. Really. I joined at all. So they have fusion of the of the right S. I. Joint here. So classic scientist. And close expand the lightness on the left side, on the left side of the the S. I. Joint looks kind of ready. Um Not important for you all to know that, but just a reminder that the plain X rays are super helpful for picking up ankle losing finalists. Okay. And then of course, here's the bamboo spine showing that the bony overgrowth over the disk and the result of that is this is this young man who who has a terrible time bending now because the spine issues. All right. Um It's worthwhile pointing out that while many people develop radiographic signs of bank losing finalists, it can take awhile and some people never develop it. So, if you're really suspicious of ankles and finally getting an MRI of the secretly iliac joints early on can be super helpful. Don't worry about them. The patient having back pain. Focus on the sacroiliac joints are the first things you get affected in an enclosing spondylitis. So getting an MRI of the pelvis is the most helpful test. If you're looking for early signs of enclosing spinal lights, Get that MRI of the pelvis. Um Okay, so I want to point out something that can be really helpful to you all for uh, for detecting in separating inflammatory back pain from non inflammatory back pain. So, all the following symptoms are associated with inflammation. That's fine spondylitis, except for which pain stiffness improves with exercise, onset of back pains, insidious back pain and stiffness gets worse at night, burning and pain in the thighs with walking symptoms beginning before age 40. So all these are associated with spon delays or things like, including ankle isn't finalized, except for which, and what I'm trying to get you toward here is that burning pain in the thighs with walking really sounds like spinal stenosis, which is more lumbar, spagnolo sis with impingement into the canal there. Um, and, and giving that classic symptoms of a few to classification where people are walking and as they walk, their thighs get straight to burn and get numb and they have to usually stop and bend over or sit down. Um That's in contrast to ankle closing spondylitis, where the key things and and closing spon spontaneous pain and stiffness improves with exercise. Um Whereas often non inflammatory back pain is going to get worse with exercise over time. Um uh pain and stiffness gets worse at night. Let me qualify that a little bit. So I think anyone who's had back pain, it's actually experienced pain at night. But the key thing here is that very often people with non inflammatory pain can readjust and get more comfortable, not all the time for the most severe patients, but most people can kind of find a comfortable position and ankle isn't finalized. People go to sleep and stay asleep for a while, just fine. The problem is that everything starts to kind of gel up or become very tight the longer they've been still. So people, as people lie still everything starts to gel up and so now in the early morning people start to get very uncomfortable and so that's where people often will say waking up at 345 o'clock in the morning really stepped. In fact, some people even say I have to get out of bed and walk it off before I can go back to bed And then almost always ankle Aziz finalised. It started before age 40. No of course not inflammatory backing it happens all the time before he toward as well. Okay. Um skip that. So inflammatory back pain. Um some other things that you can do and working up for for those symptoms of inflammatory back pain Checking. h. l. a. b. Which is present in probably nine out of 10 people with the ankle losing spondylitis. Family history of ankle isn't finalized. Super helpful. Or history of lots of back problems from a young age on elevated crp. Very helpful as well, separate. Not quite as much. So in an close in spondylitis, but getting the Crp super helpful. You can see a general theme area of of that those inflammatory markers being high inflammatory diseases. So super helpful to check the separate and therapy and then finally the sacrilegious on imaging x rays or MRI. So those are some of the things that you can do if you're suspicious that someone coming into your office is this seems doesn't seem right for just plain old non inflammatory musculoskeletal back pain. Really concerned about something more sinister going on. Here's some of the testing that you can do. All right. So Last case in our last maybe 10 minutes. Um, so I'm gonna take your arthritis different themes. So 45 year old man come see you with left knee swelling for seven days, No recent uh prior trauma that he remembers, although sometimes the passes and maybe 18. Um no, that like we have systems in remarkable no fevers and rashes, physical examination unremarkable except the next race war. Right? So to identify the cause of the knee swelling, what's the best next test cash rate, MRI of the knee? X ray of the need? Cbc with diff rheumatoid factor. CcP, anybody. So I think most everyone probably knows the answer to this one that that the the aspiration they need is going to give you your most bang for your buck in terms of trying to figure out what's going on. Um and that's because the it's going to be a really good way to distinguish inflammatory arthritis from non inflammatory arthritis. Um, and that's important when you think about the differential diagnosis of me of my articular swelling of the knee. So here's an Italian study of about 300 patients who showed up with isolated knee swelling. Um And you can see that the majority, so 55% had Osteoarthritis um or something related to it. Um Some prior trauma, like, so the majority will have osteoarthritis, you know, if someone like that, you can just manage pretty conservatively, you know, and said physical therapy, et cetera. But for the rest of the group, there can be a pretty broad differential diagnosis, so almost half of other patients will have something else and often something else that you probably need to do something about. So that includes uh syriac arthritis, another spagnolo through these pseudo gout gout, um infectious causes as well as some some more unusual causes. So um and even cancer. So and the only way that you're going to be able to distinguish Oscar arthritis from all those other causes is by taking fluid out of that joint and looking to see if it's inflammatory. Um So you can easily do this yourself and send the fluid off the quest. And here's some codes if you need them. Um The other way to do this is just send them on over to U. C. S. F. And the same folks who are doing those musculoskeletal uh ultrasound to look for sinusitis can do ultrasound guided aspiration underneath. So super easy way to do it. Um Obviously you probably want to mark it urgent to get the patient in pretty quickly and they can do that. It will take fluid out. It is important for you to order the tests that you want. And the two key tests that you want is a cell count in the crystal search and if you're suspicious about it, um septic arthritis also, don't forget most of his time. Um except for staph aureus, which is gonna make the person want to go to the emergency room right away. A lot of the other kinds of septic arthritis are not going to be associated with a positive culture from the fluid. For example, TB we're gonna caucus or even limousines. Okay, so don't forget to order the cbc cell count and crystal search from the food. Just a reminder to everyone. Low levels of white cells are associated with non inflammatory arthritis. You know, somewhere in the range of less than 2000 cells at UCSF is going to be um they move the decimal point over so it's going to be less than two. Um Uh in contrast, the inflammatory arthritis is going to be 2000 and maybe as high as 50,000. And then I started thinking about infectious arthritis or or or or crystal disease when you have those really, really high white counts of puss. Um and if you're doing it yourself, a poor man's test for looking for inflammatory fluid is simply, can you read read through the fluid. So if you can read through so often you just take a look at the numbers on the syringe and you flip the syringe around, you can still see the numbers on the other side. That's a non inflammatory arthritis versus if the fluid is more hazy and you can't read through it, that's going to be more consistent with inflammatory arthritis, but super helpful to send the fluid for the for the cell count just to prove the point. Um So back to our differential diagnosis. So I just want to include people in that If you see a higher white blood cell count number. So 5000, were the most common causes of that is going to be either Sponder arthritis or psoriatic arthritis, something in that, that family of Sponder authorities. So let me just talk a little bit about those for a moment. So in the family of Sponder arthritis, there's a lot of different forms, but the key ones to remember, it's going to be psoriatic arthritis, IBD associated arthritis, reactive arthritis and ankle isn't finalized. The most important thing to remember. Um So, and one of the most common forms is going to show up with a mano tiki arthritis and the story out of arthritis. So, just some quick, quick tips about psoriatic arthritis. So To record what happens, about 15% of people with Psoriasis, so pretty common. Um and 1% of all people have breasts. Um It particularly affects people with a history of scalp psoriasis, or psoriasis that effects of fingernails, so lots of pits for the fingernails. But particularly you want to take a look at people's scalps. Sometimes I asked, hey, do you have your diagnosed with psoriasis? People say no, but then I'll say, well have you had problems with dandruff over the course of your life? Have you had problems with itchy scalp and really dry skin in your scalp? And um and sometimes people that say that they will they will pick things up. Um Sometimes people even describe having really dry skin around their ears or even in their ears. Um So all places that can be super helpful and associated with a higher frequency of of psoriatic arthritis. And just everyone in the whole population of psoriasis patients. Um Of course other places to look for psoriasis we all know is on the extensive surfaces of the the arms and legs. Um But some other places that sometimes go undetected is in the navel. Um I mentioned in the years in the buttocks and the gluteal cleft, um Sometimes uh in the general's, especially in men on the penis around the testicles, and then occasionally you can have inverse psoriasis where it's actually in the axle to um or in the groins. Um less common. Um if you have any question about psoriasis, super helpful. Once again, a common theme here to send to the dermatologist say, hey, is this psoriasis and super helpful? Actually get the biopsy confirming that it is easy enough sometimes for a dermatologist to confuse eczema with psoriasis, that can be mistaken. So, having that biopsy is super helpful to distinguish those two different issues. Um So some examples of psoriasis, So of course there's on toes. And what I'm also pointing out here is that this fifth toe is swollen and maybe the 4th and 5th toes. Um That's a dactyl itis. So inflammation of the whole digit can be associated with psoriatic arthritis and other forms of arthritis. You can see, of course the plaque on the extensive service of the arm. You can see it on the hands and sometimes it can be really sort of red like that. Can even mimic things like dramatic mastitis. Um And then around the fingers and also sometimes mimicking lupus. But you can see the dis trophic fingernails with lots of pits there too. So lots of different ways that psoriasis will show up. So um So I've been yammering on for about 55 minutes now, so I'll spare you any more. But to summarize, just want to reemphasize to to that super important to use that systematic approach, really focusing on the history, the pattern of joint involvement, extra articular manifestations to help identify people who seem like they can have an inflammatory condition only after I go through that history and pick up features of inflammatory arthritis. Do I then turn to the appropriate blood tests um And other studies, including imaging studies to help diagnose inflammatory threats. Um definitely boy diagnosing someone with PMR is under age 50 Um recognise inflammatory back pain. So again we're reminding you that the person usually starts under the age of 40. It's morning stiffness at least a half an hour. Often paying that weeks people up at night, but nor towards the latter part of the night because they get so stiff and especially um paying the stiffness that improves with activity. People feel a lot there as long as I keep in motion. Um And then finally super important if someone shows up a swollen knee and you're not certain that it's osteoarthritis. So important to aspirate the fluid can't say enough how often it does not get done and delays the diagnosis of inflammatory arthritis. Um So someone who shows up with a swollen knee, maybe a high set rate, maybe some science of psoriasis, so helpful to get that fluid aspirated if you don't feel comfortable time, do it yourself and feel free to prefer over the UCSF musculoskeletal radiology, they can do that easily enough under some kind of