Approach to Arthritis
Arthralgia is a subjective symptom of pain within a joint.
Arthritis is an objective finding of inflammation of the joint on exam. Physical exam findings that demonstrate arthritis include heat/warmth, redness, swelling/effusion, pain, and loss of function.
It is important to distinguish arthritis from inflammation of surrounding structures (bursitis, tendonitis, etc.). Arthritis is usually worse with movement of the affected joint.
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Acute Arthritis |
Infection, Trauma/hemathrosis ,Crystal deposition (Gout), Reactive |
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Chronic arthritis |
Signs of Inflammation |
Monoarticular |
Indolent infection Early oligoarticular Early polyarticular |
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Oligoarticular |
Early polyarticular Seronegative arthritis |
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Polyarticular |
rheumatoid arthritis, SLE, Psoraiatic arthritis Polymyositis, dermatomyositis |
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No Signs of Inflammation |
Osteoathritis |
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Epidemiology:
Osteoarthritis is the most common type of arthritis worldwide, is more commonly found in older patients and is usually progressive in nature.
Acute monoarticular pain is usually caused by crystal deposition (gout, calcium pyrophosphate deposition), but it is very important to rule out infectious causes of joint disease. If infectious arthritis treated early in its course, will prevent long term joint damage.
Clinical Manifestations Acute Joint Pain
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Infection |
Trauma |
Crystal Deposition |
Reactive |
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Fever |
History of injury |
Recurrent exacerbations |
Infectious illness |
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Red, hot swollen joint More commonly large joints Poly or monoarthritis |
Rapid swelling of knee |
Monoarticular Red, hot, swollen joints Gout often affects 1st metatarsophalangeal joint (podagral) |
Swelling and pain (but no redness) Associated Uveitis, urethritis, conjunctivitis, |
Clinical Manifestations of Chronic Joint Pain
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Rheumatoid arthritis |
Osteoarthritis |
Systemic lupus erythematosus |
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Age varies considerably Stiff after resting (morning stiffness) |
Usually > 40 years old Stiff after effort (evening stiffness) |
Common in reproductive years, 14 – 40 F : M = 9 : 1 |
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Metacarpohalangeal Proximal interphalangeal |
Knee, hip, spine, Disatal Interphalangeal, Carpometacarpal |
Non-erosive, symmetric; involving 2 or more small or large peripheral joints |
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Heberden’s nodes absent Joint soft, warm, tender Symmetric joint involvement |
Heberden’s , Bouchard nodes frequently present Joint hard and bony Assymetric joint involvement |
Less stiffness |
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Extra-articular affection: Pericarditis – Myocarditis Caplan's syndrome Pulmonary hypertension Hepatosplenomegaly |
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Extra- articular affection Photosensitivity Scleritis Pericarditis – Myocarditis Vasculitis, anemia pulmonary hypertension Lupus nephritis, cerebritis |
Investigations
1. Erythrocyte sedimentation rate (ESR)
2. CRP
3. Complements
4. Serological tests:
Non specific antibodies:- may be +ve in all rehumatological diseases, inflammation or even in normal population.
1. Rheumatoid Factor (RF): +ve in 80% of RA and 20% of SLE
2. Lupus Erythrematosis (LE) cells: +ve in 80% of SLE and 20% of RA
3. Antinuclear antibody (ANA): +ve in 95-100% of SLE and 30% of RA
Specific antibodies:
1- Anti CCP (cyclic citrullinated peptide) --- rheumatoid arthritis - Specific
2- Anti double stranded DNA SLE (80%) - Specific
3- Anti-sm (anti-smith Ab, NOT anti smooth muscle Ab): SLE – Specific
5. Evaluation of synovial fluid (cell count, differential, culture, gram stain, crystal analysis)
6. Radiographic study of affected joints
Treatment