Introduction to Rheumatology (Signs and Symptoms)

Being someone with an undying love for the cardiovascular system, everything else used to feel like noise—especially specialties like rheumatology. But now, I’ve decided to strip it down to its clinical core. No cramming. No fluff. Just clarity.

So let’s start simple:

What does rheumatology actually involve? What do rheumatologists do?

If I walk into a rheumatology clinic as a young doctor, what kind of patients am I going to see? What will they complain about? What clues will I need to pick up during their history and examination?

This is where it gets interesting.

Rheumatology is the study of diseases that affect the musculoskeletal system—especially joints, bones, muscles, and the connective tissues that hold everything together.

But it’s not just about bones cracking or joints hurting. Most of the conditions here are systemic, meaning they can affect multiple organs—skin, eyes, kidneys, lungs, blood vessels—and mimic almost anything. That’s why clinical reasoning is key.

To quote my material:

“Rheumatology is a subspecialty of medicine that deals with the study of non-traumatic diseases of the musculoskeletal system as well as the systemic autoimmune connective tissue diseases.”

Now, let’s break this down. From this, we get two things to answer my earlier question:

As a young doctor walking into a rheumatology clinic, what am I expecting my patients to complain of?

Well, the material just said it’s a disease that affects:

1. Musculoskeletal System = Muscles + Skeleton

You know the sweet part of the chicken or turkey you eat?
Yeah—you’re eating the chicken’s muscles. That’s muscle.
They’re a type of connective tissue. Same as bone.
Skeleton = bone.

I’ll be using the chicken reference again later—stay tuned.

2. Systemic Autoimmune Connective Tissue Diseases

Now, autoimmune just means the body is attacking itself.
Systemic means it’s affecting the whole body.
And connective tissue? That just tells you the body isn’t discriminating—bones, muscles, joints, skin—it’s attacking everything.

But wait—do I even know what a connective tissue is?

It’s a tissue that connects different parts of the body.
Honestly, I won’t even lie 😂. I used to think of it as "some background tissue doing support work."
But turns out, there are different types—and they’re kind of important if your immune system decides to go rogue.

Here are the major types of connective tissue, with examples I can actually picture:

  • Loose connective tissue:
    The packaging material of the body—think of it like bubble wrap.
    Found under the skin, around blood vessels and organs.
    Examples: Areolar tissue (loose, spongey), adipose tissue (fat).

  • Dense connective tissue:
    This one’s tougher. Fewer cells, more fibers.
    Examples: Tendons (muscle to bone), ligaments (bone to bone).

  • Cartilage:
    Smooth, rubbery stuff that cushions joints.
    Examples: Hyaline cartilage (in your joints), elastic cartilage (in your ear), fibrocartilage (in your intervertebral discs).

  • Bone:
    Yes, bone is connective tissue too. It’s mineralized and hard, but it still fits the definition—cells embedded in a matrix that connects and supports.

  • Blood:
    Yup. Surprise. Blood is a connective tissue too.
    The cells are floating in plasma (the matrix), and it connects systems all over the body.

So when we say connective tissue disease, we’re not just talking joints and skin—we’re talking blood, fat, bones, cartilage, tendons… the whole body.
Now that’s systemic.

I hope you know that a tissue is just one big ball of cells mooshed together?

Now, let’s get back into our pretend world:

I’m a fancy young medical officer now, and all the knowledge I have is what rheumatology is. I’m walking into a rheumatology clinic to do what doctors do—treat patients.
(Would this happen in real life? Absolutely not. Nobody’s giving me a medical license just for knowing what rheumatology means 😅. But for the sake of our story, let’s pretend I’m a superhuman doc who can treat people using just definitions. Lol.)

Back to the story
From my very vast 🌚 knowledge bank, I now know that the patients in my clinic will either have problems with their bone or muscle—not because they were victims of trauma (because rheumatology doesn’t deal with injuries from trauma!).

So maybe I’ll see a patient who says:

“Doctor, my leg hurts badly—I didn’t fall, I didn’t hit it anywhere.”

But that’s just one part.

It could be systemic, let’s not forget.

I could also have a patient complaining not just of isolated bone or muscle pain—they could have rashes, headaches, fever.
It doesn’t mean the nurse on duty sent them to the wrong clinic, right?

So you see, that systemic part was important after all.

A naive version of myself would be arguing with the nurse to send that patient with a psoriatic scar to the dermatology clinic.

Damn! Hypostuffaemia.

So this young doctor now has enough “stuff” to rock the doctor's seat like a professional. I walk in, and the nurse sends in my first patient.

Presenting complaint?
You know what, let’s name this patient. He’s John, because John taught me rheumatology today—he gets a feature.

John’s complaint?

“Doctor, my knee hurts a lot. Even right now, it hurts badly.”

I ask, “Which part of your knee?”
And I’m grinning in my head because uuuuuhhhh joint pain—I know this patient is a rheumatology patient. Let me do my showmanship.

I squat down. Inspect. Palpate. Try to move.

John goes,

“Arrgghhh! Arrgghhh! No, no, please, don’t move it. It hurts! I just told you it hurts.”

Then I realize...

  • I forgot to take permission before moving my patient’s leg. I'm lucky I didn’t get slapped.
  • I know it’s just a story, but thank God John is a nice dude. 😭

Anyway—based on my knowledge bank—I confidently confirm this is a rheumatology case. As a knowledgeable doctor (lol), I don’t even bother asking if he has other symptoms. I’m just super glad I was able to diagnose one patient. I rush to document.

Guess what I wrote?
Trust me, you can’t.

  • Presenting complaint – Joint pain (Wrong! Because a patient will not likely say “my joint hurts” 😂)

  • Diagnosis – Rheumatic disease (Well… to be fair, at this point, can you blame me? I only know what rheumatology means.)

Anyway, I document. I prescribe pain relief for John and send him home.
Then I request for the next patient—feeling like an upcoming Ben Carson.

Only for me to open my material and see this:

“A disease affecting the joint itself is termed an arthritis, while that affecting the supporting structures around the joint is labelled as rheumatism.”

Oh boy.

I have messed up badly.

I just made an error in John’s case note.

First off, I didn’t even investigate properly to know if the pain he felt in the knee was from the joint itself… or from the supporting structures. I just gave him an erroneous diagnosis.

Now I’m running down the hallway, yelling at the nurse to call John back so I can clerk him properly.

At this point though, I’m genuinely curious:

What makes up the joint itself? What are the supporting structures? How do I even tell the difference when a patient complains of “knee pain”?

Let’s break down the questions one by one:

What Makes Up the Joint Itself?

A typical synovial joint (the kind most of us picture in the knee, shoulder, or elbow) is made up of these key components:

  • Articular Cartilage:
    A smooth layer covering the ends of the bones. It minimizes friction and helps absorb shock during movement.

  • Subchondral Bone:
    The bone just beneath the cartilage that provides structural support.

  • Joint Capsule:
    A fibrous envelope surrounding the joint. It has two layers:

    • An outer fibrous layer for strength and stability.
    • An inner synovial membrane that produces synovial fluid.

  • Synovial Fluid:
    This is the lubricating fluid contained within the joint capsule. It nourishes the cartilage and reduces friction.

  • Intra-articular Structures (when applicable):
    Certain joints have additional structures like:

    • Menisci in the knee (crescent-shaped cartilaginous disks that cushion the joint).
    • Labrum in the shoulder or hip (fibrocartilaginous rings that deepen the joint socket).

These elements make up the joint “proper” or the articular compartment.

What Are the Supporting Structures?

Supporting structures are tissues immediately adjacent to the joint, and they help stabilize, protect, and facilitate its function. These include:

  • Ligaments:
    Tough bands of fibrous tissue that connect bone to bone, stabilizing the joint.

  • Tendons:
    Connect muscles to bones. They are responsible for transmitting the force generated by a muscle to move the joint.

  • Bursae:
    Small, fluid-filled sacs that cushion the friction between moving structures such as tendons, ligaments, and bones.

  • Muscles:
    While not exclusively “supporting” in the sense of static structures, they are essential for the dynamic stability of a joint.

  • Other Soft Tissue Structures:
    For example, the joint’s surrounding fascia and sometimes additional fibrocartilaginous structures (like an articular disc) that provide cushioning.

Together, these supporting structures help determine the joint’s stability, range of motion, and response to external forces. In rheumatology, problems might involve either the joint compartment (leading to arthritis) or these supporting structures (contributing to “periarticular” syndromes or what some texts call rheumatism).

[Insert image of a joint showing the articulating bones and supporting structures]

So basically, if I had asked the right follow-up questions, done a proper examination, and understood these differences, I might have realized John wasn’t necessarily dealing with arthritis or rheumatic disease or whatever intelligent disease I gave him.
He could’ve had bursitis… or tendonitis… or even something neurogenic!

But no. I went all-in on “rheumatic disease” with my Ben Carson swagger.

John, if you’re reading this, I’m sorry. Come back. Please.

John came back—phew! I got so lucky. I tell the next patient, who's already seated and eating in my office, to excuse me and wait outside. The dude's furious, but I don't care; I barely made it ten minutes into practicing with my license intact. 🥹

Now, I need to ask questions to determine if John's ailment is rheumatic or arthritic. Dear heavens! I didn't even examine earlier for systemic features. I would have definitely lost my license, bruh.

🩺 How to Take a History to Differentiate Between Rheumatic and Arthritic Conditions

When assessing a patient like John, presenting with joint pain, it's crucial to gather a comprehensive history to distinguish between different rheumatological conditions. Here's how to approach it:

1. Characterize the Pain:

  • Onset: When did the pain start? Was it sudden or gradual?

  • Duration and Pattern: Is the pain constant or intermittent? Are there periods of flare-ups and remissions?

  • Location and Symmetry: Which joints are affected? Are both sides of the body involved?

  • Severity and Impact: How severe is the pain? Does it limit daily activities?

2. Morning Stiffness:

  • Ask about stiffness upon waking.

  • Duration: Stiffness lasting more than 30 minutes may suggest inflammatory arthritis, such as rheumatoid arthritis.

3. Systemic Symptoms:

  • Inquire about associated symptoms like fever, fatigue, weight loss, or malaise.

  • These may indicate systemic involvement, common in autoimmune conditions.

4. Functional Impact:

  • Assess how the symptoms affect daily life.

  • Can the patient perform routine tasks, or is there significant limitation?

5. Personal and Family History:

  • Explore any personal history of autoimmune diseases.

  • Ask about family history of conditions like rheumatoid arthritis, lupus, or psoriasis.

6. Previous Interventions:

  • Has the patient tried any treatments?

  • What medications or therapies have been used, and what was the response?

7. Review of Systems:

  • Conduct a thorough review to identify any other organ systems involved.

  • This helps in detecting systemic rheumatological diseases.

By systematically gathering this information, you can better differentiate between various rheumatological conditions and tailor your diagnostic and management approach accordingly.

Investigating the Source of Pain: Joint Versus Supporting Structures

When you’re evaluating a patient (like our dear John), your clinical exam helps you differentiate the origin of pain:

  • History:

    • Location of Pain:
      Ask the patient where exactly the pain is. Joint pain is often described as deep, aching, and localized to the joint. In contrast, pain from supporting structures may be more diffuse or localized to areas adjacent to the joint.

    • Onset and Pattern:
      Inflammatory joint pain, for example, tends to be associated with morning stiffness lasting over an hour. Pain from ligaments or tendons may be more related to movement or specific activities.

  • Inspection:

    • Swelling and Redness:
      Swelling that looks like it’s coming from inside the joint (effusion) points to intra-articular pathology (e.g., arthritis). Soft-tissue swelling or localized swelling along the tendon might suggest tendinitis or bursitis.

  • Palpation:

    • Localized Tenderness:
      If you palpate directly over the joint line (where the bones meet) and it’s tender, that suggests joint involvement. If the tenderness is found over the tendons, ligaments, or bursae adjacent to the joint, then the supporting structures are more likely involved.

  • Range of Motion – Active and Passive:

    • Active Motion:
      When the patient moves the joint on their own, pain might be due to muscle or tendon issues.

    • Passive Motion:
      When you move the joint without the patient’s muscle activity, pain that occurs right at the joint line (and sometimes accompanied by clicking or popping) suggests intra-articular pathology.

    • Differences Between Active and Passive Movement:
      If the pain is significantly worse during active movement compared to passive, it may indicate that the surrounding muscles or tendons are the source because the movement exacerbates their strain.

  • Special Tests and Imaging:

    • Special Tests:
      Certain clinical tests help isolate specific structures. For example, the McMurray test in the knee can suggest meniscal tears (an intra-articular problem).
    • Imaging:
      X-rays may show joint space narrowing or bony changes for arthritis, while ultrasound or MRI can better visualize soft tissue abnormalities affecting supporting structures.

Putting It All Together

So when you’re standing in that clinic hall, if John says, “My knee hurts,” you need to determine:

  • Is the pain coming from the joint itself (indicating arthritis) or from the structures around the joint (indicating ligament, tendon, or bursae issues)?

  • You’ll rely on a careful history and focused clinical exam—asking the right questions, inspecting the joint, palpating for tenderness, and noting differences between active and passive movement.

  • This clinical reasoning will guide you to order the appropriate tests (blood work, X-ray, ultrasound, etc.) and ensure you make the correct diagnosis.

Okay, I've read all these medical jargons, I have more stuff now. I need to ask John the right questions to know where his pain is coming from.

Examination mind map:

Summary of diagnostic possibilities from the exam:

  • Tenderness along the medial joint line: Could suggest a meniscal tear or osteoarthritis.

  • Instability with the Lachman test: Points towards possible ACL injury, but could also be a sign of general knee instability.

  • Tenderness on the inside of the knee with valgus stress: Suggests a potential MCL injury.

  • Clicking during the McMurray test: A potential meniscal tear.

  • No fluid: Ruling out effusion as a sign of significant joint inflammation, but still leaves room for a mechanical issue like a meniscal tear.

By putting all this together, we’re leaning towards a meniscal tear, but early osteoarthritis can’t be ruled out until we get more data from the MRI.

At this point, I'm ready to call the nurse to chaperone just to flex because what is all this intelligence? I'm grinning because I know what I'll do next, I'll call her to come and order investigations. That's what she gets for eyeing me(even though I didn't had knowledge, even though😶‍🌫️)

You've gathered so much up till this point, now what investigations do you think I will need to do, uhm? Or do do you hypostuffaemia too? 😂

Anyways, as an upcoming Ben Carson , I don't know about you, this is what I'll do:

Haha, I see you’re all ready to flex with the nurse! 😎 Go ahead and give her a piece of your mind, doctor-to-be style! But let’s talk investigations, shall we?

Based on John’s presentation and the possible diagnoses we’ve gathered, we’ll need a set of investigations to confirm what’s going on. Here’s what we’d typically consider:

1. MRI of the Knee (Gold Standard for Meniscal Tears)

  • What it rules out: An MRI will allow us to directly visualize the meniscus, ligaments, and cartilage. This is the best test for confirming a meniscal tear or ligament injury (ACL, MCL). It will also help us assess any other soft tissue damage.

  • Why we need it: Since we’re suspecting a meniscal tear (due to the clicking and tenderness), the MRI is essential to confirm or rule that out. It can also show if there’s any associated cartilage damage that might point towards early osteoarthritis.

2. X-rays of the Knee

  • What it rules out: An X-ray is great for ruling out bone fractures, joint effusion, and early osteoarthritis. It can show us if there’s any narrowing of the joint space, subchondral sclerosis, or osteophytes, which would point towards arthritis.

  • Why we need it: While X-rays can’t detect soft tissue issues like meniscal tears, they’re crucial to check for joint degeneration or trauma that could explain John’s symptoms. If arthritis is the culprit, the X-ray will show the typical signs.

3. Joint Aspiration (if Effusion is Suspected in the Future)

  • What it rules out: This test isn’t needed right now since there's no visible effusion, but it would help rule out infection (septic arthritis) or crystal-induced arthritis (like gout or pseudogout) if any fluid were present. The synovial fluid can be analyzed for cell count, crystals, or microorganisms.

  • Why we need it: If we start seeing any swelling or effusion in the future, aspiration will be key to exclude any inflammatory or infectious processes.

4. Blood Tests (for Inflammatory Markers)

  • What it rules out: Blood tests like C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) could help rule out an inflammatory or autoimmune condition like rheumatoid arthritis or psoriatic arthritis, especially if there's concern about inflammation. It can also help us gauge the general inflammatory response in case of an infection.

  • Why we need it: Since John is young and doesn't have a significant history of chronic conditions, his symptoms are more likely related to mechanical or traumatic causes. However, if we’re seeing systemic signs like fever or generalized swelling, we’d want to rule out inflammatory arthritis or infection.

5. Ultrasound (Optional, if We Suspect Soft Tissue Injuries)

  • What it rules out: An ultrasound could be helpful in assessing soft tissue injuries, such as patellar tendinitis, bursitis, or ligament injuries (although less sensitive than MRI). It can also help visualize any fluid accumulation that might suggest bursitis or inflammation.

  • Why we need it: If John had more localized symptoms or a recent history of direct trauma, an ultrasound could be useful to assess for tendinopathy or inflammation. It’s less invasive than an MRI and can give us a quick look at soft tissues.

Let’s wrap it up like an aspiring genius, Dr. Ben Carson style:

"John, based on the exam and what we've discussed, I’m ordering the following investigations:

  1. MRI of the knee – this will confirm if you have a meniscal tear or any ligament injuries, and will help us evaluate the condition of your cartilage.

  2. X-rays of the knee – we need this to rule out bone fractures and check for early signs of osteoarthritis.

  3. Blood tests – especially CRP and ESR, to check for any signs of inflammation or autoimmune processes.

  4. Joint aspiration – just in case we see any effusion in the future, so we can rule out infection or crystal arthritis.

Once we have the results from these investigations, we’ll know exactly what’s going on, and then we can make the best plan to get you back on track. Don’t worry, we’ll get you sorted."

So, flexing those Ben Carson skills! 😎 What's next?