Rheumatology‎ > ‎

Imaging Characteristics

Red flags for back pain 
  • Cause: Infection or malignancy or trauma 
  • Co-morbid condition: Hx of malignancy, corticosteroid use, severe trauma
  • Acute back pain: (<4-6 weeks) with neurological deficit 
    • Presence of neurological symptoms 
      • Symptoms not localized to a single unilateral nerve root 
      • Progressive weakness 
    • Cauda equina syndrome 
      • Urinary retention, Fecal incontinence 
      • Saddle anesthesia 
  • One cannot wait 4-5 weeks for evaluation or imaging 
    • Concern for osteomyelitis, especially epidural abscess 
      • Objective fever, immunosuppressed patient, recent bacteremia 
    • Concern for malignancy and vertebral instability 
      • Also work, up should be expedited 

Treatment options for Chronic Back Pain

  • Depends on the cause 
    • Mechanical vs. Inflammatory low back pain 
  • For mechanical 
    • Non-pharmacological 
      • Supervised or unsupervised exercise  and therapy programs (PT)
      • If has functional limitations, the Cognitive behavioral therapy
    • Pharmacological 
      • Tylenol 
      • NSAIDS
      • Muscle relaxants 
      • Dulexetine daily (30 mg - then to 60 mg daily) selective serotonin-norepinephrine reuptake inhibitor (SNRI)
      • Tricyclic antidepressants 
      • IN general, AVOID OPIATES (pain management)
      • In general, AVOID BENZODIAZEPINE
  • For Inflammatory low back pain, how to recognize it (treating like mechanical low back pain will not help improve, although I will say NSAIDS will work on many)

Inflammatory back pain (age <45yr, duration > 3 months, insidious onset, stiffness > 30 min, improvement with exercise, no improvement with rest, awakening from pain especially in the second half of the night with improvement on arising, alternating buttock pain) (2 or more suspicious; 4 or more considered diagnostic for Inflammatory back pain)
Enthesitis (heel) 
Crohn’s disease/ulcerative colitis 
Good response to NSAIDs 
Family history for SpA
Elevated CRP

OA definition, diagnosis, and top 3 risk factors 

Primary vs. Secondary (trauma, inflammation)

Osteoarthritis (OA) is a disease of the entire joint, characterized by degradation of the articular cartilage, hypertrophy of bone at the margins (i.e., osteophytes), subchondral sclerosis, and a range of biochemical and morphologic alterations of the synovial membrane and joint capsule.

Risk factors for developing OA include age, joint location , obesity, genetic predisposition, joint malalignment, trauma, and sex (female more than male).

Morphologic changes in early OA include articular cartilage surface irregularity, superficial clefts within the tissue, and altered proteoglycan distribution.

Late OA changes include deepened clefts, increase in surface irregularities, and eventual articular cartilage ulceration, exposing the underlying bone. Chondrocytes form clusters or clones in an attempt at self-repair.

Increased recognition that there is alow level inflammation happing in the OA joints.

matrix metalloproteinases (MMPs), pro-inflammatory cyto- kines IL1, , and mediators such as nitric oxide (NO) and prostaglandin E(PGE2

Osteophytes consist of newly formed fibrocartilage and bone and are most commonly formed at the peripheral margins of joints the interface between cartilage and the periosteum. Osteophytes are thought to arise through chondrogenic differentiation of pro- genitor cells, most commonly from within the periosteum.118 As such, osteophytes may be a cellular repair response to the altered growth factor environment after joint injury, and in certain cases, osteophytes can contribute to the stability of the joint

OA vs RA in early disease 

Bony bumps on the finger joint closest to the fingernail are called Heberden's nodes.Bony bumps on the middle joint of the finger are known as Bouchard's nodes

Really make sure it is not an inflammatory arthritis 
  • pain in am vs with activity 
  • stiffness in am >1 hr vs < 30 min
  • other features of inflammation - Swollen joint that is red, hot, tender 
  • exam: bony enlargement
    • DIP, 1st CMC 
    • Creptius on knee 
    • TTP in the medial aspect of the knee 
  • Synovial fluid: < 2000 cell count 
  • Imaging: Assymetric narrowing of the large joints ;  1st CMC, DIP , with osteophytes 

Top 3 risk factors 
    Age, Joint location (Hip and Knees more than ankle in weight bearing joitns, 1st CMC, DIP), 

OA is, in fact, the most common chronic disease in later life; more than 80% of people older than 75 years are affected, 


  1. Hand pain, aching, or stiffness on most days of prior month

  2. Hard tissue enlargement of 2 of 10 selected jointsa

  3. Fewer than 3 swollen MCP joints

  4. Hard tissue enlargement of 2 DIP joints

  5. Deformity of 2 of 10 selected jointsa

Diagnosis requires items 1-3 and either 4 or 5


Knee: Clinical6

  1. Knee pain for most days of prior month

  2. Crepitus with active joint motion

  3. Morning stiffness lasting 30 min

  4. Bony enlargement of the knee on examination

  5. Age 38 yr

Diagnosis requires 1 + 2 + 4, or 1 + 2 + 3 + 5, or 1 + 4 + 5


Knee: Clinical and Radiographic6

  1. Knee pain for most days of prior month

  2. Osteophytes at joint margins

  3. Synovial fluid typical of osteoarthritis

  4. Age 40 yr

  5. Morning stiffness lasting 30 min

  6. Crepitus with active joint motion

Diagnosis requires 1 + 2, or 1 + 3 + 5 + 6, or 1 + 4 + 5 + 6