Rafael Grau, MD, is Professor of Medicine and Fellowship Program Director in the Rheumatology Section of the University of Arizona School of Medicine. He was previously the director of the division of rheumatology at Indiana University. Dr. Grau coordinated the Indiana University rheumatology rotation for the internal medicine residency program and directed the scleroderma clinic. Before joining Indiana University he was attending rheumatologist at Maricopa Medical Center in Phoenix. Dr. Grau's areas of interest include: systemic sclerosis, vasculitis and medical education as it pertains to musculoskeletal diseases. He also directs the division's scleroderma clinic.
These resources are intended to serve as a complement to the outpatient experience we provide residents and students who rotate through the rheumatology clinic. Busy clinics allow less formal instruction and trainees must turn to other sources to complement their clinical experience. It is a fact that most rheumatologic problems will be dealt with by primary care physicians particularly as the number of rheumatologist fail to keep up with the population growth and changing demographics. A proper foundation in the diagnosis and basic workup of musculoskeletal diseases will go a long way in compensating for the scarcity of rheumatologists. As always, the information shared with you represents a distillate of the rheumatology experience of many respected colleagues. I am happy to share these pearls of wisdom with you.
-Rafael Grau, MD
The most common reason for a rheumatology consult is musculoskeletal pain, followed by abnormal laboratory tests. Musculoskeletal pain must first be sorted out into either articular or nonarticular origin with subsequent teasing out of cardinal features that lead to a subset of diagnostic possibilities. It is amazing (and satisfying) how far one can go by following these basic precepts.
Most of the pertinent information regarding musculoskeletal disorders is gathered by the history and physical examination. Ancillary studies (laboratory and imaging studies) provide only a small portion of important information. For this reason a well executed history and physical examination is crucial for the diagnosis. In fact, pinning your diagnostic impression on laboratory tests is a sure way to get into trouble.
3 Musculoskeletal Pictorial
4 Musculoskeletal examination video
A key element in a musculoskeletal examination is the regular interaction with the patient during the evaluation. This approach can illicit information regarding tenderness, range of motion and function. Further historical details may be volunteered by the patient as the examination proceeds. It is important to perform a general physical examination in the context of the musculoskeletal examination. Certain portions of the examination such as breast evaluation, gynecological or rectal examination are performed if the circumstances dictate the need. Here are two examinations executed by experienced rheumatologists.
Soft tissue rheumatism is defined as clinical conditions arising from the tendons, bursas and ligaments. They are very common and frequently seen in adult practice. Rheumatologists encounter these problems in their more severe forms. The diagnosis is usually straightforward and management is effective if one is familiarized with these localized musculoskeletal problems.
6 Core Lectures
These lectures are provided to broaden the knowledge base of trainees and include a more robust discussion of clinical diagnosis skills as well as key ancillary modalities.