Joint Pain

Question 1

What are the associated morbidities of MSK diseases?

Answer 1

• Restrict activities of daily living
• Cause lost work days
• Source of lifelong pain

Question 2

Describe articular and periarticular pain.

Answer 2

• Articular pain is a true joint.
• Periarticular pain is defined as pain in structures around a joint e.g. tendonitis, bursitis, enthesitis.

Question 3

Which joints commonly become affected by bursitis?

Answer 3

• Trochanteric bursitis (pain in lateral thigh)
• Olecranon bursitis (pain in posterior elbow)
• Pre-patellar bursitis (pain above patella - ‘Housemaid’s knee’)
• Infrapatellar bursitis (pain below the patella - ‘Clergyman’s knee’)

Question 4

Compare and contrast arthralgia and arthritis.

Answer 4

• Arthralgia
  
  • ​Joint pain with tenderness but no inflammation
  • May not necessarily imply joint disease
• Arthritis
  
  • ​Joint inflammation or structural damage
  • True joint disease

Question 5

What are the different sources of hip pain?

Answer 5

Question 6

What are the systemic and articular causes of arthralgia?

Answer 6

• Systemic causes
  
  • ​Depression
  • Fibromyalgia
  • Thyroid disorders
  • Infections (viral infections, influenza)
• Articular causes
  
  • ​Repetitive use of joint
  • Mechanical injury
  • Early OA
  • Early presentation of rheumatic disease

Question 7

What are the different types of arthritis in adults?

Answer 7

• Degenerative
  
  • ​OA
• Inflammatory
  
  • ​Rheumatoid arthritis
  • Sero-negative arthritis
    
    • Crystal arthropathies
    • Ankylosing spondylitis
    • Psoriatic arthropathy

Question 8

What is the definition of osteoarthritis?

Answer 8

A chronic joint disorder in which there is progressive softening and disintegtation of articular cartilage accompanied by new growth of cartilage and bone at the joint margin (osteophytes) and capsular fibrosis (stiffness).

Question 9

Describe the aetiology of osteoarthritis.

Answer 9

• Primary idiopathic
  
  • ​Most common
• Secondary
  
  • ​Post-traumatic
  • Infection
  • Avascular necrosis
  • Developmental dysplasia of the hip (DDH)
  • Perthes’
    
    • An avascular necrosis which affects children
  • Slipped upper femoral epiphysis (SUFE)
    
    • Paediatric condition

Question 10

Why does OA happen?

Answer 10

• Disparity between:
  
  • Stress applied to articular cartilage
  • Strength of articular cartilage to resist stress
• Applies to both articular and meniscal cartilage
• Weak cartilage
  
  • Age
  • Stiff
    
    • Chondrocalcinosis
  • Soft
    
    • Inflammation
    • Infection
  • Abnormal bony support
    
    • AVN
      
      • Bone becomes a chalky substances and crumbles because it is living tissue and it dies if it has no blood supply.
    • Neoplasia
    • Metabolic conditions
    • Trauma

Question 11

Describe the history of a patient presenting with osteoarthritis.

Answer 11

• Pain
  
  • Duration - and change over time
  • Site
  • Radiation
  • Limiting activity
    
    • ADLs
    • Recreation
  • Sleep disturbance
    
    • Night pain
  • Analgesic requirements
    
    • Pain ladder
    • Maximum dosage
• Function
  
  • Walking distance
  • Walking aids - which hand?
  • Stairs
  • Self-care
    
    • Foot care - hips
    • Washing - shoulders
  • ADLs - shopping, cleaning, cooking
  • Hobbies
  • Occupation
• Other symptoms
  
  • Swelling
  • Stiffness
    
    • Early morning (rheumatoid)
    • After inactivity
  • Deformity
    
    • Caused by capsular fibrosis
    • Results in ligament contracture
  • Instability
  • Other joints involved
    
    • Systemic inflammatory conditions tend to be polyarticular.
    • Arthritic conditions tend to be monoarticular.

Question 12

Define rheumatoid arthritis.

Who is affected by it?

Describe its aetiology.

Answer 12

• A chronic systemic inflammatory disease, characterised by potentially deforming symmetrical polyarthritis and extra-articular features.
• Prevalence ~1% in the UK
• 3 : 1 females : males
• Peak onset 40-50
• Genetic, environmental and infective factors involved in disease

Question 13

Describe the pathogenesis and pathology of rheumatoid arthritis.

Answer 13

• Pathogenesis
  
  • Cause remains unknown
  • Toxic substances found in synovium
  • Destruction of joints
  • Immunological disturbances identified
  • Autoimmune disease
  • B cell involvement (picture)
• Pathology
  
  • ​Disease of the synovium
  • Inflammation due to infiltration of lymphocytes, macrophages etc.
  • Proliferation of cells results in ‘pannus’ formation

Question 14

Describe the inflammatory pathway which leads to rheumatoid arthritis.

Answer 14

• Inflammatory cycle is bad for the whole body so we try to arrest it.
• In rheumatoid arthritis the response of the joint is that the synovium hypertrophies and releases inflammatory mediators which is what we are trying to stop with the MABs.

Question 15

What are the symptoms of rheumatoid arthritis?

Answer 15

• Joint pain (usually worse on waking)
• Morning stiffness (can vary in duration)
• General symptoms:
  
  • Fatigue
  • Malaise
  • Bone ‘ache’
• Patients feel pain in a single joint in OA - this is the difference in presentation between this and rheumatoid - rheumatoid patients complain of generalised aching.

Question 16

What are the signs associated with rheumatoid arthritis?

Answer 16

• Swelling
• Tenderness
• Reduced ROM
• Deformities (if untreated over long-term)
• Extra-articular features e.g. nodules, anaemia of chronic disease, pleural effusion