2.4 Inflammatory Arthritis, Tendinopathies & Concussion

ABPMR Physical Medicine and Rehabilitation Board Exam Study Guide Exam

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1 Chapter 1: Introduction & Exam Overview

1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown

2 Chapter 2: Musculoskeletal Medicine

2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns

3 Chapter 3: Spinal Cord Injury Rehabilitation

3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications

4 Chapter 4: Stroke & Neuromuscular Rehabilitation

4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder

5 Chapter 5: Electrodiagnostics (EMG/NCS)

5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies

6 Chapter 6: Traumatic Brain Injury

6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols

7 Chapter 7: Chronic Pain & Interventional Spine

7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy

8 Chapter 8: Amputee Rehabilitation & Prosthetics

8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain

9 Chapter 9: Pediatric Rehabilitation

9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders

10 Chapter 10: Prosthetics, Orthotics & Assistive Technology

10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping

11 Chapter 11: Medical Rehabilitation & Outcomes

11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation

12 Chapter 12: Cardiopulmonary Rehabilitation

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management

13 Chapter 13: Foundational Rehabilitation Concepts

13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

2.4 Inflammatory Arthritis, Tendinopathies & Concussion

Key Takeaways Explain This Topic AI

Rheumatoid arthritis affects MCP and PIP joints, sparing DIP joints; anti-CCP antibody has highest specificity; C1-C2 subluxation risk requires cervical spine clearance.

Ankylosing spondylitis is HLA-B27 positive, features bilateral sacroiliitis, enthesitis, and leads to bamboo spine; evaluated via modified Schober test.

Monosodium urate crystals in gout are needle-shaped and negatively birefringent (yellow); CPPD crystals are rhomboid-shaped and positively birefringent (blue).

Concussion return-to-play follows a 6-step protocol with minimum 24 hours per step; symptom recurrence requires stepping back to the previous asymptomatic step.

Last updated: July 2026

2.4 Inflammatory Arthritis, Tendinopathies & Concussion

Physical Medicine and Rehabilitation encompasses non-surgical rheumatology, sports medicine, and concussion management. Mastery of diagnostic crystal analysis, inflammatory joint patterns, tendon repair biology, and return-to-play protocols is vital for clinical board examinations.

Rheumatoid Arthritis (RA)

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease characterized by persistent synovial inflammation (pannus formation), articular cartilage destruction, and juxta-articular bone erosions.

Joint Distribution and Deformities

RA classically presents as a symmetrical inflammatory polyarthritis affecting small joints of the upper and lower extremities:

Target Joints : Metacarpophalangeal ( MCP ) joints, Proximal Interphalangeal ( PIP ) joints, wrist joints, and Metatarsophalangeal ( MTP ) joints.

Spared Joints : Distal Interphalangeal ( DIP ) joints and thoracolumbar spine are characteristically spared.

Cervical Spine Involvement : Cervical spine involved in up to 80% of patients. Transverse ligament erosion leads to atlantoaxial subluxation (C1-C2 instability) . Preoperative flex-ext cervical radiographs are mandatory prior to general anesthesia intubation or cervical spine manipulation.

Classic Hand Deformities : Swan-neck deformity (PIP hyperextension with DIP flexion), Boutonnière deformity (PIP flexion with DIP hyperextension), ulnar deviation of MCP joints, and Z-deformity of thumb.

Serology and Radiography

Serology : Anti-Cyclic Citrullinated Peptide (anti-CCP) antibodies possess higher specificity (~95%) than Rheumatoid Factor (RF) for diagnosis and prognosticating erosive disease.

Radiography : Periarticular osteopenia, uniform joint space narrowing, and marginal bony erosions.

Seronegative Spondyloarthropathies and Ankylosing Spondylitis

The seronegative spondyloarthropathies share common genetic, clinical, and radiographic features: negative test for RF/anti-CCP, strong association with HLA-B27 , presence of enthesitis (inflammation at tendon insertion sites, such as Achilles insertion), and axial skeleton involvement.

Ankylosing Spondylitis (AS)

Chronic inflammatory arthritis predominantly affecting axial skeleton and sacroiliac joints in young adults (onset <45 years).

Sacroiliitis : Bilateral, symmetric sacroiliitis is the radiographic hallmark.

Spinal Fusion : Ascending marginal syndesmophytes (bony bridges connecting vertebral bodies) result in complete spinal ankylosis, known as "bamboo spine" .

Schober Test : Measures lumbar spine mobility. Marks placed at S2 spinous process and 10 cm superiorly. Flexion should increase distance by >5 cm (total >15 cm); <5 cm indicates restricted lumbar flexion.

Extra-articular Manifestations : Acute anterior uveitis (most common extra-articular feature, ~30–40%), ascending aortitis, aortic regurgitation, and apical pulmonary fibrosis.

Crystal-Induced Arthropathies

Crystal arthropathies present with acute monoarthritis and require synovial fluid aspiration and polarized light microscopy for definitive diagnosis.

Gout vs. Calcium Pyrophosphate Deposition Disease (CPPD)

Gout : Caused by deposition of Monosodium Urate (MSU) crystals in joints and soft tissues (tophi). Under compensated polarized light microscopy, MSU crystals appear needle-shaped and exhibit strong negative birefringence (yellow when parallel to red compensator plate axis). Classically affects 1st MTP joint ( podagra ).

CPPD (Pseudogout) : Caused by deposition of Calcium Pyrophosphate Dihydrate crystals. Under polarized light microscopy, CPPD crystals appear rhomboid-shaped and exhibit weak positive birefringence (blue when parallel to red compensator plate axis). Radiographic hallmark is chondrocalcinosis (linear calcification of hyaline or fibrocartilage, most commonly knee menisci, triangular fibrocartilage complex [TFCC] of wrist, pubic symphysis).

Feature Gout (MSU) CPPD / Pseudogout
Crystal Shape Needle-shaped Rhomboid-shaped
Birefringence Strong Negative Birefringence Weak Positive Birefringence
Color Parallel to Red Axis Yellow Blue
Classic Joint Site 1st MTP joint (Podagra) Knee, wrist (TFCC), pubic symphysis
Radiographic Hallmark Punched-out erosions with overhanging edges Chondrocalcinosis
Tendinopathy Pathophysiology & Eccentric Rehabilitation

Historically termed "tendinitis," histopathological studies confirm that chronic tendon pain results from tendinopathy (tendinosis) —a degenerative process rather than active prostaglandin-driven inflammation.

Histopathology of Tendinopathy

Absence of inflammatory cells; presence of disarrayed collagen fibers, hypervascularity with neovascularization, increased mucoid ground substance, and tenocyte hyperplasia.

Eccentric Exercise Rehabilitation

Eccentric loading exercise protocols (e.g., Alfredson protocol for Achilles tendinopathy, heavy slow resistance loading) are the gold standard non-surgical intervention.

Mechanism : Eccentric contraction applies controlled mechanical tensile stress to tendon without high peak impact forces.

Physiologic Effect : Stimulates tenocyte mechanotransduction, promotes parallel collagen fiber alignment, increases tensile strength, reduces neovascularization, and remodels tendon matrix.

Concussion Management & Return-to-Play Protocol

Sport-related concussion (SRC) is a traumatic brain injury induced by biomechanical forces (direct blow to head, neck, or body). It reflects a functional disturbance rather than structural injury; standard neuroimaging (CT, MRI) is characteristically normal.

Diagnosis, SCAT6 Assessment and Acute Management

Diagnosis relies on clinical assessment tools such as the SCAT6 (Sport Concussion Assessment Tool 6), incorporating symptom checklists, cognitive screening (orientation, immediate memory, concentration), balance testing ( Modified Balance Error Scoring System - mBESS ), and neurological screening. Initial management requires brief relative physical and cognitive rest (24–48 hours) followed by gradual symptom-thresholded return to light activities.

Graduated Return-to-Sport (RTS) Step-Wise Protocol

Athletes must progress through a 6-step protocol. Each step requires a minimum of 24 hours . If any symptoms recur, athlete must stop activity, rest for 24 hours, and drop back to previous asymptomatic step.

Step 1: Symptom-limited activity : Daily activities that do not provoke symptoms (reading, gentle walking).

Step 2: Light aerobic exercise : Walking, stationary cycling at slow-to-medium pace; no resistance training.

Step 3: Sport-specific exercise : Running drills, skating drills; no head impact activities.

Step 4: Non-contact training drills : Complex training drills (passing), progressive resistance training.

Step 5: Full contact practice : Following medical clearance, normal training activities.

Step 6: Return to sport : Unrestricted normal game play.