Approach to Arthritis

Diseases of joints

Evaluation

Joint involvement causes painEnsure joint involvement, and

not muscle or bone

Relevant history Age- young-RA, middle age-gout, old-OA Sex- male-SA, gout; female-RA, SLE F/H- may be +ve in SA, gout, RA, OA Onset- acute-gout, trauma, infection;

insidious-RA, OA Evolution- continuous-OA, intermittent-

gout, migratory-rheumatic fever, additive-Reiter’s

Associated symptoms- fever, rash, eye/GIT/GU involvement

Pattern of joint involvement Joints involved- Large-OA, small-RA Axial-SA, appendicular-RA Upper limb-RA, lower limb-gout Number of joints involved Mono- 1- traumatic, infectious Pauci- 2-4- gout, reactive arthritis Poly- >4- RA, SLE Symmetry Symmetrical- OA, RA, SA Asymmetrical- gout, trauma, infectious

Inflammation Causes pain, redness, swelling,

local temperature, ROM Inflammatory arthritides- RA Signs of inflammation Worst in morning Morning stiffness present Non-inflammatory arthritides- OA Pain & ROM Worst as day passes No morning stiffness

Examination

InflammationCrepitus

Range of movementDeformity

Investigation X-ray of involved joint RA- periarticular erosions in hands/feet, soft tissue

swelling OA- decreased joint space, loss of cartilage, osteophytes CBC, ESR, CRP Synovial fluid exam. Colour, protein, glucose WBC, gram stain, culture Crystals- polarised microscope Serology- ASO, RF, ANA CT scan/MRI

Treatment

Based on diagnosisParacetamol & NSAIDs

Physical/Occupational therapy

Low backache

A common problem

Types

Local- steady dull pain, local tenderness

Referred- from viscera- abd./pelvic

Radicular- restricted to territory of root

Protective- muscle spasm

Pain

Location Severity/intensity Onset & progression Character Aggravating & relieving factors Associated symptoms

Examination Inspection- deformity, asymmetry Palpation- tenderness Straight leg raising test or bending

with knees extended to elicit root pain

Costovertebral tenderness Neuro. exam. of lower extremities Abdominal, PR/PV, peripheral vascular

examination

Investigation

CBC, ESR Ca, PO4, alk. phosphatase PSA SPEP Bone-scan X-ray CT scan/MRI

PIVD L4- Pain & sensory loss in ant. thigh/knee DTR- knee absent L5- Pain hip, groin, posterolateral thigh, lateral calf, 1-3 toes Weakness of extensor of big toe Difficulty walking on heel DTR- normal S1- Pain posterior thigh, posterior calf, 4-5 toe Weakness of foot & toe flexors Difficulty walking on toes DTR-ankle absent

Treatment

Initially medical,If not improved- MRI

Surgical based on MRI findings