ALGORITHM FOR MUSCULOSKELETAL COMPLAINTS

Musculoskeletal Complaint

Initial rheumatic history and physical exam to determine

Is it articular?
Is it acute or chronic?
Is inflammation present?
How many/which joints are involved?

Nonarticular condition
Consider

Trauma/fracture
Fibromyalgia
Polymyalgia rheumatica
Bursitis
Tendinitis
Myopathy/myositis

Acute

Consider

Acute arthritis
Septic arthritis
Gout
Pseudogout
Reactive arthritis
Initial presentation of chronic arthritis

Chronic

Is inflammation present?

Is there prolonged morning stiffness?
Is there soft tissue swelling?
Are there systemic symptoms?
Is the ESR or CRP elevated?

Chronic noninflammatory arthritis

Osteoarthritis

Unlikely to be osteoarthritis
Consider

Osteonecrosis
Charcot arthritis
Hemochromatosis

Chronic inflammatory arthritis

Chronic inflammatory mono/oligoarthritis
Consider

TB/Fungal infection
Psoriatic arthritis
Reactive arthritis
Pauciarticular JIA

Chronic inflammatory polyarthritis

Consider

Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis

Rheumatoid arthritis

Unlikely to be rheumatoid arthritis
Consider

SLE
Scleroderma
Polymyositis

End

Is it articular?

Yes

No

Is complaint >6 wk?

Yes

No

Yes

No

Are DIP, CMC1, hip or knee joints involved?

Yes

No

How many joints involved?

1-3

>3

Is involvement symmetric?

Yes

No

Are PIP, MCP, or MTP joints involved?

Yes

No

CMC, carpometacarpal; CRP, C-reactive protein; DIP, distal interphalangeal; ESR, erythrocyte sedimentation rate; JIA, juvenile idiopathic arthritis; MCP, metacarpophalangeal; MTP, metatarsophalangeal; PIP, proximal interphalangeal; PMR, polymyalgia rheumatica; SLE, systemic lupus erythematosus.

Is it acute, focal, or monoarticular?

Yes

No

Consider “red flag” condition

Gout
Septic arthritis
Fracture
Vascular ischemia
Carpal tunnel syndrome