This document provides information about various types of arthritis from an expert in rheumatology. It begins with an introduction to arthritis and how it can originate from the joint or surrounding tissues. It then discusses the diagnostic approach and evaluation of a patient with arthritis. The rest of the document discusses specific types of arthritis in more detail, including septic arthritis, gout, osteoarthritis, and rheumatoid arthritis. It provides information on clinical features, investigations, diagnosis, and management for each type.
3. INTRODUCTION
• Joint pain can originate from the joint itself or
from the surrounding tissues.
• More than 100 rheumatic conditions
• Overlap in clinical presentations
• Initial presentation may not lead to a precise
diagnosis in up to 50% of cases
• Over time most patients will have characteristic
features of a disease
4. INTRODUCTION, CONT.
• Patients will typically complain of:
• “Dr I have Arthritis”
• Pain specific to certain joints or groups of joints
• “My Body Is Sore!”
• Careful History and Physical examination is required to
discern between pathologies and to make a diagnosis.
• DIAGNOSIS CAN BE MADE BASED ON HISTORY AND
PHYSICAL EXAM FINDINGS 80-90% OF THE TIME
5. THE RHEUMATOLOGIC HISTORY
• Pain is the cardinal symptom of musculoskeletal disorders
DIAGNOSTIC APPROACH :
• Establish the demographics of the patient: Age Gender
Ethnicity Family History
• Characterize joint pain and ask about associated features
• Characterize the pain: Inflammatory vs. Non inflammatory
• Constitutional symptoms
6. EVALUATION OF A PATIENT WITH
ARTHRITIS IN RHEUMATOLOGY OPD
• Articular or non articular
• Inflammatory or non inflammatory
• Acute or chronic
• Monoarticular or polyarticular
• Extra articular signs
7. HISTORY
CONT.
History of presenting complaints
•Onset
•progression
•distribution of disease
•stiffness
•aggravating or relieving factor
•diurnal variation
•other systemic feature
•functional disability
General systematic medical history.
Past medical and surgical history.
Family history.
Drug history.
8. HISTORY
CONT.
Where is the Pain?
•Which joints are involved
•Mono / Polyarticular
For how long have you had pain?
•Acute
•Chronic (>6weeks)
•Intermittent?
History of Trauma?
9. HISTORY CONT.
•Early morning?
•Constant during the day?
•Night waking?
When do you get the pain?
•Work
•Repetitive Stress of joint
•Food / Drink
Aggravating Factors
10. HISTORY
CONT.
• Relieving Factors:
• Rest
• Analgesia – simple; NSAIDS; Opiates
• Effect on Activities of Everyday Living.
• Age and Gender of Patient.
12. CHRONOLOGY OF COMPLAINTS CONT.
•Monoarticular (one joint involved)
•Oligo- or pauci- articular (2-4 joints are involved)
•Polyarticular (> 4 joints are involved)
Extent of articular involvement
•Symmetrical: upper and lower limb; e.g. RA, SLE
•Asymmetrical: e.g. psoriatic arthritis, spondylo-arthropathy, gout
•Involvement of axial skeletal: e.g. AS, OA, RA (only cervical
spine)
Distribution of joint involvement
14. PHYSICAL
EXAMINATION
Head to toe evaluation:
Rashes,
telangiectasias,
nail changes,
pigmentation changes
Peripheral pulses,
bruits
Back exam
Joint exam
17. ARTICULAR AND NON-ARTICULAR PAIN
ARTICULAR
• Deep or diffuse pain.
• Painful or limited range of
movement - both active and
passive
• Swelling of joint
• Crepitation.
• Joint instability.
• Locking of joint.
• Deformity.
NON-ARTICULAR
• localised pain
• Point or local tenderness
• Painful active movements
but not on passive
• Physical findings are remote
from joint capsule.
• swelling, crepitation, joint
instability, deformity are rare.
18. ARTICULAR AND NON-ARTICULAR
PAIN
• Articular structures include the synovium, synovial fluid,
articular cartilage, intraarticular ligaments, joint capsule,
and juxta-articular bone.
• Non articular (or periarticular) structures include:
supportive extra articular ligaments, tendons, bursae,
muscle, fascia, bone, nerve, and overlying skin,
32. INTRO
• Medical Emergency!
• Rapid onset monoarticular joint inflammation
• Rapid destructive joint disease
• Morbidity and mortality of 10%
• Patients with septic arthritis already have a bacteraemia!
33. RISK FACTORS
• Extremes of Age
• Pre-existing joint disease
• Immunosuppression
• Prosthetic hip / knee joint / Joint surgery
• Skin Infection
• Rheumatoid Arthritis.
• Diabetes Mellitus.
• Elderly patients over age 80 years old.
• Intravenous drug use (unusual joints affected).
34. AETIOLOGY
• Young sexually active adults
• Neisseria gonorrhoeae (most common, and more common in women
• Staphylococcus aureus
• Streptococcus
• Older adults
• Staphylococcus aureus (50%)
• Streptococcus species
• Gram Negative Bacilli
• Most common organism Staph. Aureus, however important to rule out
disseminated gonococcal infection in young sexually active patient.
35. CLINICAL FEATURE OF SEPTIC
ARTHRITIS
• Acute onset
• Typical joints include knee and hip
• Swollen joint.
• Erythema
• Warm joint.
• Held in position of least resistance
36. CLINICAL FEATURE OF SEPTIC
ARTHRITIS
Joints affected in bacterial infection
• Septic Knee (50% of cases),
• Hip (children),
• Ankle,
• Shoulder
Joints affected with intravenous
Drug Abuse
• SI joint,
• SC joint.
• Pubic symphysis,
• Vertebral spaces
37. INVESTIGATION:
• Joint Aspiration and MCS
• Sterile procedure
• Fluid may appear purulent / turbid, bloodstained or normal
• Infective Markers
• Blood Culture
38. MANAGEMENT:
• Hospitalization
• Analgesia
• IV Antibiotics: e.g. Cloxacillin 200mg / kg / day
• Surgical Drainage
• Rehabilitation
• Oral Antibiotics: e.g. Flucloxacillin 100mg / kg / day for 3
weeks
44. CLINICAL FEATURE GOUT:
• Joint Inflammation - Asymmetric joint involvement.
May only involve one side with the first attack
• Acute , intermittent and recurrent
• Chronic Tophaceous Gout
• Severe pain (Worst ever)
• Extreme tenderness
• Swelling, erythema and hot joint.
• Fever and chills
45. MOST COMMON JOINTS
• 1st Metatarsophalangeal joint (MTP) – 50%
• Ankle
• Midfoot
• Knee
• Small joints of hand
• Wrist
• Elbow
48. INVESTIGATION:
• It is a clinical diagnosis
• investigations is to rule out other pathology:
• Aspiration of Synovial Fluid: Sodium urate crystals / Neutrophils
• Serum Urate / Uric Acid: No bearing on diagnosis and
management as often is normal during attacks
• UEC
• FBC / ESR - Rule out myeloproliferative disorders
• X-rays
52. OSTEOARTHRITIS
• Most common form of arthritis.
• Results from disparity between stress applied to a joint
and the ability of the joint to withstand the stress
• Degenerative disorder characterised by progressive loss
of articular cartilage, capsular fibrosis and new bone
formation
53. OSTEOARTHRITIS
• Prevalence directly increases with age:
• Almost universal after 65 years but only 50% of patients
are symptomatic
• Associated functional impairment
• Primary - No demonstrated cause
• Secondary - Due to abnormal stress on joint
• Marginal osteophytes
54. CLINICAL FEATURES OF OSTEOARTHRITIS
• Pain: Aggravated by stress on joint / motion; and
relieved by rest.
• Stiffness: Progressive loss of range of motion (initially
after use of joint). Typically Morning stiffness of short
duration (<30 minutes)
• Crepitus
• Deformity
• Swelling - Persistent or intermittent
55. DISTRIBUTION OF OSTEOARTHRITIS
• Typical joints involved:
• Small joints in hands
• DIP (Heberden’s Nodes)
• PIP (Bouchard's Nodes)
• First CMC joint (thumb)
• Hip / Knee / Feet and Shoulder joint.
• Cervical and lumbar spine
58. INVESTIGATION:
• It is a clinical diagnosis.
• X ray is non essential but may help in differentiating OA
from other arthritis
• XR Features of OA:
• Joint space narrowing
• Subchondral sclerosis
• Osteophyte formation
• Bone Cysts formation.
• No osteopenia
• Evidence of previous disorders e.g. trauma or congenital
problem.
59.
60.
61. MANAGEMENT: EARLY
• Reduce Load: Reduce weight / Avoid abnormal
loading / Use walking stick
• Increase Movement: Physiotherapy
• Pain Relief:
• Simple analgesia
• NSAIDS if inflammatory component noted.
• Hyaluronic Acid (still no compelling evidence)
62. MANAGEMENT: LATE
• This is when there's failure of conservative
management
• Joint debridement
• Osteotomy
• Arthroplasty
• Arthrodesis
• Decompression
63. MANAGEMENT: LATE
When to Operate
• Patient’s symptoms are interfering with ADL
• Benefits of surgery outweigh risks
• Preventative surgery
66. RHEUMATOID ARTHRITIS
• Symmetrical, deforming small and large joint polyarthritis,
often associated with systemic disturbance and extra articular
features
• 3% of population
• Affects all ethnic groups
• Peak incidence 4-6th decades
• Lowest in Black Males / Highest in White Females
• Pathology is based on synovial proliferation with inflammatory
destruction of the joint
67. CLINICAL FEATURE RHEUMATOID
ARTHRITIS:
• 1. Morning stiffness: in and around the joint lasting 1 hr before maximal improvement.
• 2. Arthritis of 3 or more joint area observed by the physician: 14 possible joint area
involved are Right &Left PIP,MCP, wrist, elbow, knee, ankle and MTP joint.
• 3. Arthritis of hand joints: wrist, MCP & PIP joint.
• 4. Symmetrical arthritis.
• 5. Rheumatoid nodule.
• 6. Serum Rheumatoid factor (supports diagnosis – 20% are seronegative).
• 7. Radiographic changes – erosion or bony decalcification in or adjacent to involved
joints.
• NEED TO HAVE 4 OF 7
68. SCORING CRITERIA- AMERICAN
COLLEGE OF RHEUMATOLOGY 2010
• A. Joint involvement
• 1 large joint: 0
• 2-10 large joints: 1
• 1-3 small joints (+/- large joints): 2
• 4-10small joints (+/- large joints): 3
• >10 joints (at least 1 small joints): 5
69. SCORING CRITERIA- AMERICAN
COLLEGE OF RHEUMATOLOGY 2010
• B. Serology. At least 1 test result is needed for scoring:
• Neg RF+ & ACPA* (</= ULN**): 0
• Low positive RF or ACPA (</=3 X ULN): 2
• High positive RF or ACPA(>3 X ULN): 3
• *ACPA – Anti-citrullinated protein antibody
• **ULN – upper limit of normal
• +RF – Rheumatoid Factor
70. SCORING CRITERIA- AMERICAN
COLLEGE OF RHEUMATOLOGY 2010
• C. Acute phase reactants (at least 1 test result needed for
classification)
• Normal CRP or ESR: 0
• Abnormal CRP or ESR: 1
72. NB
• Score >/= 6/10 is RA
• Large joints: shoulders, elbows, hips, knees, ankles
• Small joints: PIP, MCP, MTP, wrists (Spares DIP)
• Diff diagnosis: SLE, Psoriatic arthritis, etc.
• Duration of symptoms is as self reported by patient
79. INVESTIGATION:
• Confirmed according to clinical criteria
• Rheumatoid Factor : Not positive in all patients, and
Not all positive pts. have RA
• X-ray Features:
• Periarticular Soft Tissue Swelling
• Joint Space Narrowing
• Bony erosions
• Subchondral cysts
• Periarticular Osteopenia
83. 1. STOP SYNOVITIS:
• NSAIDS: Gives Symptomatic relief, non curative
• DMARDS:
• Corticosteroids:
• Ineffective Response to DMARDs
• Acutely ill
• Significant systemic disease
• Social Problems
84. 1. STOP SYNOVITIS: DMARDS:
• Chloroquine:
• Safe, little need for laboratory follow up / Inexpensive / Ocular Toxicity
• METHOTREXATE (MTX):
• Low dose is the Gold Standard for DMARDS
• Rapid Disease Suppressing effect
• Baseline UEC / LFT and Hep Screen
• LFT’s 4-8 weeks
• DOSAGE IS WEEKLY
• NEVER GIVE WITH COTRIMOXAZOLE (Haemotoxic)
• Others : Gold / Sulphasalazine / D-Penicillamine / Azathroprine
85. MANAGEMENT CONT.:
2. Prevent Deformity
• Physiotherapy
• Occupational Therapy
• Surgery – Tendon Repair or replacement
3. Reconstruct
• Arthrodesis
• Arthroplasty
4. Rehabilitate
• Accompanies all stages of treatment
• OT and work training
90. ANKYLOSING SPONDYLITIS
• Inflammatory arthropathy with emphasis on involvement
of spine and sacroiliac joints.
• Characterised by progressive stiffening and fusion of the
axial skeleton.
• Sacroiliatis / Syndesmophytes / Bamboo spine /
Inflammatory Backache
91. CLINICAL FEATURES:
• Young males (20’s-30’s / 3:1 Male: Female Ratio)
• Chronic insidious onset
• Recurrent episodes of low back pain and stiffness
• Radiation to buttocks and thighs (symmetrical)
• Marked after rest and improve with movement
92. ON EXAMINATION
• Pain on SI joint compression
• Restriction of movement of lumbar spine
• Limited Chest expansion
• Schober’s Test is positive
97. MANAGEMENT:
• Relieve Pain and Stiffness
• Maintain maximal mobility
• Avoid deformity
• NSAIDS particularly long acting, given at night may
provide symptomatic relief
• Surgery: Osteotomy of spine to correct deformity
Arthroplasty of destroyed joints
99. FIBROMYALGIA
• Common cause of multiple regional musculoskeletal pain and disability
• No underlying identifiable pathology
• Assoc. physiological abnormalities of sleep patterns and pain processing
• Reduced amount of Delta sleep during night
• Reduced threshold to pain perception and tolerance at characteristic
sites throughout the body.
• Associated with other medically unexplained symptoms in other
systems of the body
100. CLINICAL FEATURES:
• Multiple body pains – Eventually affecting all body quadrants
• Both arms, legs, neck , back
• Reported disability is marked – Able to dress, eat, groom
• Unable to work etc
• Fatigability is often marked – (especially in morning)
• On Examination
• No overt musculoskeletal pathology (may have signs of other
arthropathy not consistent with symptoms)
• Hyperalgesia at recognised trigger points producing a wince / withdrawal
101.
102. CLINICAL FEATURES CONT’D:
• Criteria for Fibromyalgia:
• Appropriate symptoms including pain in all body quadrants
• Positive Hyperalgesic tender sites in each arm and leg and
axially
• Negative control tender sites.
• (Pressure on Forehead, squeezing distal radius/ulna,
pressure over proximal fibular head does not elicit any pain)
103. INVESTIGATION:
• Fibromyalgia is not associated with test abnormalities
• Tests are based on ruling out organic pathology
• FBC - Anemia, lymphopenia of lupus
• ESR, CRP - Inflammatory disease
• TFT’s - Hypothyroidism
• CMP - Hyperparathyroidism
• ANA - Lupus
104. MANAGEMENT:
• Education for patient and family
• Sleep hygiene
• Graded aeorobic exercise programme
• Low dose amitriptyline
• Fluoxetine
106. MUSCULOSKELETAL MANIFESTATIONS
OF SYSTEMIC DISEASE
• Many systemic diseases result in musculoskeletal
symptoms and signs.
• A thorough history and PE is essential to avoid treating
patient’s musculoskeletal symptoms rather than their
systemic disease
• “ALL THAT ACHES IS NOT ONLY BONE”