Musculoskeletal Signs and Symptoms

  • H. Ralph Schumacher
  • Lan X. Chen


Pain or swelling of a single joint merits prompt evaluation to identify patients in need of urgent and aggressive care (1). Although there are many minor and easily managed causes of monarthritis, infectious arthritis with its risk of prolonged morbidity (and even mortality, if untreated) requires that this very serious problem always be considered. The underlying causes of monarthritis are divided into two groups: inflammatory diseases (Table 3A-1) and mechanical or infiltrative disorders (Table 3A-2). Triage into one of these categories is the first step in the differential diagnosis of monarthritis.


Rotator Cuff Carpal Tunnel Syndrome Tendon Sheath Hallux Valgus Reactive Arthritis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Baker DG, Schumacher HR. Acute monarthritis. N Engl J Med 1993;329:1013–1020.PubMedGoogle Scholar
  2. 2.
    Pinals Robert S. Sarah’s knee: a famous actress with chronic, inflammatory monoarthritis. J Clin Rheumatol 2004;10:13–15.PubMedGoogle Scholar
  3. 3.
    Schumacher HR. Palindromic onset of rheumatoid arthritis: clinical, synovial fluid, and biopsy studies. Arthritis Rheum 1982;25:366–369.Google Scholar
  4. 4.
    VanLinhoudt D, Schumacher HR. Acute monosynovitis or oligoarthritis in patients with quiescent rheumatoid arthritis. J Clin Rheumatol 1995;1:46–53.Google Scholar
  5. 5.
    Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore) 2004;83:139–148.Google Scholar
  6. 6.
    Gatter RA, Schumacher HR, eds. A practical handbook of synovial fluid analysis. Philadelphia: Lea & Febiger; 1991:14–23.Google Scholar
  7. 7.
    Yu KH, Luo SF, Liou LB, et al. Concomitant septic and gouty arthritis: an analysis of 30 cases. Rheumatology (Oxford) 2003;42:1062–1066.Google Scholar
  8. 8.
    Hoving JL, Buchbinder R, Hall S, et al. A comparison of magnetic resonance imaging, sonography, and radiography of the hand in patients with early rheumatoid arthritis. J Rheumatol 2004;31:663–675.PubMedGoogle Scholar
  9. 9.
    Schumacher HR, Kulka JP. Needle biopsy of the synovial membrane: experience with the Parker-Pearson technic. N Engl J Med 1972;286:416–419.PubMedGoogle Scholar
  10. 10.
    van der Heijden IM, Wilbrink B, Schouls LM, et al. Detection of mycobacteria in joint samples from patients with arthritis using genus specific PCR and sequence analysis. Rheumatology 1999;38:547–553.PubMedGoogle Scholar
  11. 11.
    Rahman MU, Cheema S, Schumacher HR, Hudson AP. Molecular evidence for the presence of chlamydia in the synovium of patients with Reiter’s syndrome. Arthritis Rheum 1992;35:521–529.PubMedGoogle Scholar
  12. 12.
    Goldenberg DL, Reed JI. Bacterial arthritis. N Engl J Med 1985;312:764–771.PubMedGoogle Scholar
  13. 13.
    Boulware DW, Lopez M, Gum OB. Tuberculosis podagra. J Rheumatol 1985;12:1022–1024.PubMedGoogle Scholar
  14. 14.
    Rivier G, Gerster JC, Terrier P, Cheseaux JJ. Parvovirus B19 associated monarthritis in a 5 year old boy. J Rheumatol 1995;22:766–777.PubMedGoogle Scholar
  15. 15.
    Punzi L, Ramonda R, Sfriso P. Erosive osteoarthritis. Best Pract Res Clin Rheumatol 2004;18:739–758.PubMedGoogle Scholar
  16. 16.
    Stevens KJ, Theologis T, McNally EG. Imaging of plant thorn synovitis. Skeletal Radiol 2000;29:605–608.PubMedGoogle Scholar
  17. 17.
    Schumacher HR, Habre W, Meador R, Hsia EC. Predictive factors in early arthritis: long-term follow-up. Semin Arthritis Rheum 2004;33:264–272.PubMedGoogle Scholar
  18. 18.
    American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. Arthritis Rheum 1996;39: 1–8.Google Scholar
  19. 1.
    Pinals RS. Polyarticular joint disease. In: Klippel JH, ed. Primer on the rheumatic diseases, 12th ed. Atlanta: Arthritis Foundation; 2001:160–165.Google Scholar
  20. 2.
    Hübscher O. Pattern recognition in arthritis. In: Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH, eds. Rheumatology, 3rd ed. London: Mosby; 2003:191–197.Google Scholar
  21. 3.
    Sergent JS. Polyarticular arthritis. In: Harris ED, Budd RC, Firestein GS, et al., eds. Kelley’s textbook of rheumatology, 7th ed. Philadelphia: Elsevier Saunders; 2005:514–521.Google Scholar
  22. 4.
    McCarty DJ. Differential diagnosis of arthritis: analysis of signs and symptoms. In: Koopman WJ, Moreland LW, eds. Arthritis and allied conditions, 15th ed. Philadelphia: Lippincott, Williams & Wilkins; 2005:37–49.Google Scholar
  23. 5.
    El-Gabalawy HS, Duray P, Goldbach-Mansky R. Evaluating patients with arthritis of recent onset: studies in pathogenesis and prognosis. JAMA 2000;284:2368–2373.PubMedGoogle Scholar
  24. 6.
    Visser H, le Cessie S, Vos K, et al. How to diagnose rheumatoid arthritis early: a prediction model for persistent (erosive) arthritis. Arthritis Rheum 2002;46:357–365.PubMedGoogle Scholar
  25. 7.
    Pinals RS. Polyarthritis and fever. N Engl J Med 1994; 330:769–774.PubMedGoogle Scholar
  26. 8.
    American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. Arthritis Rheum 1996;39:1–8.Google Scholar
  27. 9.
    Jansen LM, van Schaardenburg D, von der Horst- Bruinsma IE, Dijkmans BA. One year outcome of undif-ferentiated polyarthritis. Ann Rheum Dis 2002;61:700–703.PubMedGoogle Scholar
  28. 1.
    Andersson GBJ. The epidemiology of spinal disorders. In: Frymoyer JW, ed. The adult spine: principles and practice, 2nd ed. New York: Raven Press; 1977:93–133.Google Scholar
  29. 2.
    Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine 1995;20:11–19.Google Scholar
  30. 3.
    Borenstein DG, Wiesel SW, Boden SD. Low back and neck pain: comprehensive diagnosis and management, 3rd ed. Philadelphia: Saunders; 2004.Google Scholar
  31. 4.
    van den Hoogen HJM, Koes BW, Deville W, van Eijk JTM, Bouter LM. The prognosis of low back pain in general practice. Spine 1997;22:1515–1521.PubMedGoogle Scholar
  32. 5.
    Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992;268:760–765.PubMedGoogle Scholar
  33. 6.
    Kohles SS, Kohles DA, Karp AP, et al. Time-dependent surgical outcomes following cauda equina syndrome diagnosis: comments on a meta-analysis. Spine 2000;25: 1515–1522.Google Scholar
  34. 7.
    Tsiodras S, Falagas ME. Clinical assessment and medical treatment of spine infections. Clin Orthop 2006;444: 38–50.PubMedGoogle Scholar
  35. 8.
    Nicholas JJ, Christy WE. Spinal pain made worse by recumbency: a clue to spinal cord tumors. Arch Phys Med Rehabil 1986;67:598–600.PubMedGoogle Scholar
  36. 9.
    Cooper RG. Understanding paraspinal muscle dysfunction in low back pain: a way forward? Ann Rheum Dis 1993;52:413–415.PubMedGoogle Scholar
  37. 10.
    Agency for Health Care Policy and Research. Acute low back problems in adults, clinical practice guideline. Rockville, MD: Agency for Health Care Policy and Research; 1994. Publication no. 95-0642.Google Scholar
  38. 11.
    Nordin M, Balague F, Cedraschi C. Nonspecific lower-back pain. Clin Orthop 2006;443:156–167.PubMedGoogle Scholar
  39. 12.
    Boos N, Semmer N, Elfering A, et al. Natural history of individuals with asymptomatic disc abnormalities in magnetic resonance imaging: predictors of low back pain-related medical consultation and work incapacity. Spine 2000;25:1484–1492.PubMedGoogle Scholar
  40. 13.
    Komori H, Okawa A, Haro H, Muneta I, Yamamoto H, Shinomiya K. Contrast-enhanced magnetic resonance imaging in conservative management of lumbar disc herniation. Spine 1998;23:67–73.PubMedGoogle Scholar
  41. 14.
    Awad JN, Moskovich R. Lumbar disc herniations: surgical versus nonsurgical treatment. Clin Orthop 2006;443: 183–197.PubMedGoogle Scholar
  42. 15.
    Boden SD. The use of radiographic imaging studies in the evaluation of patients who have degenerative disorders of the lumbar spine. J Bone Joint Surg Am 1996;78: 114–124.PubMedGoogle Scholar
  43. 16.
    Atlas SJ, Delitto A. Spinal stenosis: surgical versus nonsurgical treatment. Clin Orthop 2006;443:198–207.PubMedGoogle Scholar
  44. 17.
    Hammerberg KW. New concepts on the pathogenesis and classification of spondylolisthesis. Spine 2005;30(Suppl 6):S4–S11.PubMedGoogle Scholar
  45. 18.
    Perennou D, Marcelli C, Herisson C, Simon L. Adult lumbar scoliosis: epidemiologic aspects in a low-back pain population. Spine 1994;19:123–128.PubMedGoogle Scholar
  46. 19.
    Rizzi PE, Winter RB, Lonstein FE, Denis F, Perra JH. Adult spinal deformity and respiratory failure. Surgical results in 35 patients. Spine 1997;22:2517–2531.Google Scholar
  47. 20.
    Helliwell PS, Evans PF, Wright Y. The straight cervical spine: does it indicate muscle spasm? J Bone Joint Surg Br 1994;76:103–106.PubMedGoogle Scholar
  48. 21.
    Carette S, Fehlings MG. Cervical radiculopathy. N Engl J Med 2005;353:392–399.PubMedGoogle Scholar
  49. 22.
    Bernhardt M, Hynes RA, Blume HW, White AA III. Cervical spondylotic myelopathy. J Bone Joint Surg Am 1993;75:119–128.PubMedGoogle Scholar
  50. 23.
    Fehlings MG, Skaf G. A review of the pathophysiology of cervical spondylotic myelopathy with insights for potential novel mechanisms drawn from traumatic spinal cord injury. Spine 1998;24:2730–2737.Google Scholar
  51. 24.
    Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of the Quebec Task Force on Whiplash- Associated Disorders: redefining “whiplash” and its management. Spine 1995;20:1S–73S.PubMedGoogle Scholar
  52. 25.
    Freeman MD, Croft AC, Rossignol AM, Weaver DS, Reiser M. A review and methodologic critique of the literature refuting whiplash syndrome. Spine 1999;24:86–96.PubMedGoogle Scholar
  53. 1.
    Hazleman B, Riley G, Speed C. Soft tissue rheumatology. Oxford: Oxford Medical Publications; 2004.Google Scholar
  54. 2.
    Khan KM, Cook JL, Bonar F, et al. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med 1999;27:393–408.Google Scholar
  55. 3.
    Genovese, MC. Joint and soft-tissue injection. A useful adjuvant to systemic and local treatment. Postgrad Med 1998;103:125–134.PubMedGoogle Scholar
  56. 4.
    Kisner C, Colby LA. Therapeutic exercise: foundations and techniques, 3rd ed. Philadelphia: FA Davis; 1996.Google Scholar
  57. 5.
    Biundo JJ, Hughes GM. Rheumatoid arthritis rehabilitation: practical guidelines. J Musculoskeletal Med 1991; 8:85–96.Google Scholar
  58. 6.
    Neer CR. Impingement lesions. Clin Orthop 1983;173: 70–77.PubMedGoogle Scholar
  59. 7.
    Goupille P, Sibilia, J. Local corticosteroid injections in the treatment of rotator cuff tendinitis (except frozen shoulder and calcific tendinitis). Clin Exp Rheumatol 1996;14: 561–566.PubMedGoogle Scholar
  60. 8.
    Frieman BG, Albert TJ, Fenlin JM Jr. Rotator cuff disease: a review of diagnosis, pathophysiology and current trends in treatment. Arch Phys Med Rehabil 1994;75:604–609.PubMedGoogle Scholar
  61. 9.
    Naredo AE, Aguado P, Padron M, et al. A comparative study of ultrasonography with magnetic resonance imaging in patients with painful shoulder. J Clin Rheumatol 1999; 5:184–192.PubMedGoogle Scholar
  62. 10.
    Dacre JE, Beeney N, Scott DL. Injections and physiotherapy for the painful stiff shoulder. Ann Rheum Dis 1989;48:322–325.PubMedGoogle Scholar
  63. 11.
    Weinstein PS, Canoso JJ, Wohlgethan JR. Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. Ann Rheum Dis 1984;43:44–46.PubMedGoogle Scholar
  64. 12.
    Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am 1999;81:259–278.PubMedGoogle Scholar
  65. 13.
    Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology: epicondylitis and hand stenosing tendinopathy. J Clin Rheumatol 2004;10:33–40.PubMedGoogle Scholar
  66. 14.
    Kijowske R, DeSmet AA. Magnetic resonance imaging findings in patients with medial epicondylitis. Skeletal Radiol 2005;34:196–202.Google Scholar
  67. 15.
    Tomaino MM, Towers MD. Clinical presentation and radiographic findings of distal biceps tendon degeneration: a potentially forgotten cause of proximal radial forearm pain. Am J Orthop 2004;33:31–34.PubMedGoogle Scholar
  68. 16.
    Hamilton W, Ramsey ML. Rupture of the distal tendon of the biceps brachii. U Penn Orthop J 1999;12:21–26.Google Scholar
  69. 17.
    Skoff HD. “Postpartum/newborn” deQuervain’s tenosyn-ovitis of the wrist. Am J Orthop 2001;30:428–430.PubMedGoogle Scholar
  70. 18.
    Anderson BC, Manthey R, Brouns MC. Treatment of de Quervain’s tenosynovitis with corticosteroids. Arthritis Rheum 1991;34:793–798.PubMedGoogle Scholar
  71. 19.
    Costa CR, Morrison WB, Carrino JA. MRI features of intersection syndrome of the forearm. AJR Am J Roentgenol 2003;181:1245–1249.PubMedGoogle Scholar
  72. 20.
    Stern PJ. Tendinitis, overuse syndromes, and tendon injuries. Hand Clinics 1990;6:467–475.PubMedGoogle Scholar
  73. 21.
    Kishner S, Biundo JJ. Posterior interosseous neuropathy in rheumatoid arthritis. J Clin Rheumatol 1996;2:1080–1084.Google Scholar
  74. 22.
    Burke DT, Burke MM, Stewart GW, Cambré A. Splinting for carpal tunnel syndrome: in search of the optimal angle. Arch Phys Med Rehabil 1994;75:1241–1244.PubMedGoogle Scholar
  75. 23.
    Wu JS, Morris JD, Hogan GR. Ulnar neuropathy at the wrist: case report and review of the literature. Arch Phys Med Rehabil 1985;66:785–788.PubMedGoogle Scholar
  76. 24.
    Anderson B, Kaye, S. Treatment of flexor tenosynovitis of the hand (“trigger finger”) with corticosteroids. Arch Intern Med 1991;151:153–156.PubMedGoogle Scholar
  77. 25.
    Nimigan AS, Ross DC, Gan BS. Steroid injections in the management of trigger fingers. Am J Phys Med Rehabil 2006;85:36–43.PubMedGoogle Scholar
  78. 26.
    Williams CS, Riordan DC. Mycobacterium marinum infections of the hand. J Bone Joint Surg Am 1973;55: 1042–1050.PubMedGoogle Scholar
  79. 27.
    Cordova A, Tripoli M, Corradino B, et al. Dupuytren’s contracture: an update of biomolecular aspects and therapeutic perspectives. J Hand Surg 2005;30:557–562.Google Scholar
  80. 28.
    Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology III: trochanteric bursitis. J Clin Rheumatol 2004;10:123–124.PubMedGoogle Scholar
  81. 29.
    Shbeer MI, O’Duffy D, Michet CJ Jr, et al. Evaluation of glucocorticosteroid injection for the treatment of trochanteric bursitis. J Rheumatol 1996;23:2104–2106.Google Scholar
  82. 30.
    Wyant GM. Chronic pain syndromes and their treatment. III. The piriformis syndrome. Can Anaesth Soc J 1979; 26:305–308.PubMedGoogle Scholar
  83. 31.
    Fishman LM, Dombi GW, Michaelsen C, et al. Piriformis syndrome: diagnosis, treatment, and outcome—a 10 year study. Arch Phys Med Rehabil 2002;83:295–301.PubMedGoogle Scholar
  84. 32.
    Ramsey ML, Toohey JS, Neidre A, et al. Coccygodynia: treatment. Orthopedics 2003;26:403–405.PubMedGoogle Scholar
  85. 33.
    Galloway MT, Jokl P. Patella plica syndrome. Ann Sports Med 1990;5:38–41.Google Scholar
  86. 34.
    Wang JC, Shapiro MS. Pellegrini–Stieda syndrome. Am J Orthop 1995;24:493–497.PubMedGoogle Scholar
  87. 35.
    Peers KH, Lysens RJ. Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations. Sports Med 2005;35:71–87.PubMedGoogle Scholar
  88. 36.
    Papagelopoulos PJ, Sim FH. Patellofemoral pain syndrome: diagnosis and management. Orthopedics 1997;20: 148–157.PubMedGoogle Scholar
  89. 37.
    Gill SS, Gelbke MK, Mattson SL, et al. Fluoroscopically guided low-volume peritendinous corticosteroid injection for Achilles tendinopathy. A safety study. J Bone Joint Surg Am 2004;86:802–806.PubMedGoogle Scholar
  90. 38.
    Churchhill RS, Sferra JJ. Posterior tibial tendon insufficiency. Its diagnosis, management, and treatment. Am J Orthop 1998;27:339–347.Google Scholar
  91. 39.
    Kinoshita M, Okuda R, Morikawa J, et al. The dorsiflexion-eversion test for diagnosis of tarsal tunnel syndrome. J Bone Joint Surg Am 2001;83:1835–1839.PubMedGoogle Scholar
  92. 40.
    Calabro JJ. Costochondritis. N Engl J Med 1997;296: 946–947.Google Scholar
  93. 41.
    Wise CM, Semble L, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients. Arch Phys Med Rehabil 1992;72: 147–149.Google Scholar
  94. 1.
    Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160–172.Google Scholar
  95. 2.
    Granges G, Littlejohn G. Pressure pain threshold in pain-free subjects, in patients with chronic regional pain syndromes, and in patients with fibromyalgia syndrome. Arthritis Rheum 1993;36:642–646.PubMedGoogle Scholar
  96. 3.
    Arnold LM, Hudson JI, Hess EV, et al. Family study of fibromyalgia. Arthritis Rheum 2004;50:944–952.PubMedGoogle Scholar
  97. 4.
    Buskila D, Neumann L. Genetics of fibromyalgia. Curr Pain Headache Rep 2005;9:313–315.PubMedGoogle Scholar
  98. 5.
    Russell IJ, Orr MD, Littman B, et al. Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome. Arthritis Rheum 1994;37:1593–1601.PubMedGoogle Scholar
  99. 6.
    Julien N, Goffaux P, Arsenault P, Marchand S. Widespread pain in fibromyalgia is related to a deficit of endogenous pain inhibition. Pain 2005;114:295–302.PubMedGoogle Scholar
  100. 7.
    Crofford LJ. Neuroendocrine abnormalities in fibromyalgia and related disorders. Am J Med Sci 1998;315:359– 366.PubMedGoogle Scholar
  101. 8.
    Gracely RH, Geisser ME, Giesecke T, et al. Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain 2004;127:835–843.PubMedGoogle Scholar
  102. 9.
    Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA 2004;292:2388–2395.PubMedGoogle Scholar
  103. 10.
    Hadler NM. Fibromyalgia, chronic fatigue, and other iatrogenic diagnostic algorithms. Do some labels escalate illness in vulnerable patients?. Postgrad Med 1997;102:161–166, 171.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • H. Ralph Schumacher
    • 1
  • Lan X. Chen
    • 2
  1. 1.Department of Medicine/RheumatologyUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of Medicine/RheumatologyUniversity of PennsylvaniaPhiladelphiaUSA

Personalised recommendations