It is currently estimated that approximately 41 million people in the United States have a musculoskeletal condition. Of these, more than 50% have some limitation of functional activity and many have to stop work entirely. Musculoskeletal and rheumatic symptoms account for about 15% of physician visits. The purpose of this manual is to concentrate the knowledge explosion in musculoskeletal disease to a succinct and easily retrievable form in order to improve the lives of our patients.

Extraordinary advances have occurred in the field of rheumatology since the third edition of this manual was published in 1993, and they are featured in the body of our manual as well as in the Appendix on Therapeutics. These include the use of tumor necrosis factor alpha antagonists for the treatment of refractory rheumatoid arthritis, the ascendancy of the use and effectiveness of combination disease-modifying regimens in the treatment in inflammatory arthropathies, and the availability of Cox-2- specific nonsteroidal antiinflammatory drugs that are safer for the gastrointestinal tract. Disease modification is a reality today in rheumatology, not only in rheumatoid arthritis and systemic lupus erythematosus, but also in our treatment of Lyme disease, septic arthritis, gout, vasculitides such as Wegener’s granulomatosis, polyarteritis nodosa, Kawasaki’s disease, and the antiphospholipid syndrome.

Nearly all chapters are authored or coauthored by present and/or past members of the Division of Rheumatic Disease or the Department of Orthopedic Surgery at Hospital for Special Surgery in New York City. As is often the case in clinical medicine, some problems have more than one potential solution; in these instances, for the sake of clarity and brevity, we identify the areas of controversy, then detail the approach employed at our Hospital. In all instances, our physicians have tried to carefully balance their years of experience with an evidence-based approach to their diagnostic and therapeutic choices.

Although medical information is ever expanding and increasingly complex, the time to absorb it is limited. Given the increasing clinical, academic, social, and family pressures, the physician needs to have a “reliable, old friend” to enable him or her to rapidly make accurate, state-of-the-art clinical decisions. This fourth edition of the Manual of Rheumatology and Outpatient Disorders is designed to distill a massive body of knowledge to a user-friendly form for the busy clinician. Our aim is to bring the “laboratory bench” to the office and bedside so as to meet the needs of internists, family physicians, rheumatology trainees, house officers, and students.