Joint pain Flashcards
What is arthritis and how is it classified?
Inflammation of the joint.
Inflammatory: seronegative, seropositive, infectious or crystal induced, e.g. rheumatoid, SLE, psoriatic.
Non-inflammatory (degenerative): e.g. osteoarthritis.
What are the seropositive inflammatory arthritis?
Rheumatoid arthritis. Lupus. Scleroderma. Vasculitis. Sjogren's.
What are the seronegative inflammatory arthritis?
Ankylosing spondylitis.
Psoriatic arthritis.
Reactive arthritis.
IBD arthritis.
Give an example of infectious inflammatory arthritis.
Septic arthritis.
What are the crystal-induced inflammatory arthritis?
Gout.
Pseudogout.
Give an example of non-inflammatory (degenerative) arthritis.
Osteoarthritis.
Screening questions for joint pain?
Do you suffer from any pain or stiffness in your arms, legs, neck or back?
Do you have any difficulty with stairs or steps?
Do you have any difficulty with washing or dressing?
Joint pain: history of presenting complaint
SOCRATES.
Chronology, sudden onset/gradual, recurrent?
Relationship to trauma/exercise?
Joint pain, stiffness, swelling, bone pain, muscle weakness?
Knee- locking, giving way, grinding, clicking?
Morning stiffness: OA <1hr, RA hrs.
Associated symptoms: rash, red eye (iritis), urethritis?- reactive arthritis.
What are the clinical features of osteoarthritis?
Degenerative process- wear and repair- abnormal bone remodelling
Mainly large, weight bearing joints (back, knee, hip, ankle, hands) and DIP.
Asymmetrical.
Usually less deformity.
Morning stiffness <1hr.
What are the clinical features of rheumatoid arthritis?
Autoimmune process. Mainly small joints of hand. PIP (not DIP), MCP, wrists, elbows, neck. Also hips, knees, ankles. Symmetrical. Gross deformity. Tendon rupture. Subluxation. Morning stiffness >1hr.
What are the clinical features of psoriatic arthropathy?
Seronegative inflammatory arthritis (RhF and ACCP -ve).
Personal or FHx of psoriasis.
Similar to RA in distribution, except: > initial oligoarticular involvement > DIP joints > marked dactylitis- swelling of whole finger > sacroiliitis-lower back/hip pain
GALS screen: arms
Hands behind head with elbows back. Supination and pronation of elbow. 'Squeeze my fingers'. Opposition of thumb and fingers. Squeeze metacarpal joints.
GALS screen: legs
Hand over the knee and flex to feel for crepitus.
Passive internal rotation of hip (foot moves externally).
Ankle flex/extend- tibiotalar joint affected in OA.
Eversion and inversion of foot
Supination of foot- subtalar joint affected in RA.
GALS screen: spine
Lateral flexion of cervical spine (mid-cervical region, 1st movement affected in OA cervical spondylosis)- ears towards shoulders
Bending forward- need to ensure the movement does not come from the hips.
What are the clinical features of rheumatoid arthritis in the hands?
Ulnar deviation.
Subluxation at MCP joints.
Rheumatoid nodules.
Boutonnieres deformity [flexion of DIP, hyperextension of PIP]
Swan neck deformity [flexion of DIP, hyperextension of PIP]
Z line thumb- hyperextension of IP, flexion of MCP]
What are the clinical features of osteoarthritis in the hands?
Heberden’s nodes- DIP
Bouchard’s nodes- PIP
Epidemiology of rheumatoid arthritis?
400000 in UK
Females> 3:1
1% of population- low prevalence
Peak age= 40 years, but people of all ages
Epidemiology of osteoarthritis?
Common
Mainly elderly
Women slightly more common than men
Screening questions for MSK disorders
Pain/stiffness- arms, legs, back
Difficulty with washing and dressing
Stairs and steps hard
Factors to ask in HPC
Pain
Sudden/Gradual/recurrent
Trauma
Exercise- how it affects symptoms
joint pain, stiffness, swelling, bone pain, muscle weakness
Knee- locking, grinding, clicking, giving way
Morning stiffness= hours in RA, < one hour in OA
Associated extra-articular symptoms- rash, red eye, urethritis
GALS screen- types of abnormal gait
Trendelenburg gait- hip drops when leg lifted
Parkinsonian gait
Foot drop gait- high stepping
Spastic gait- after stroke- circumduction
Antalgic gait
Rheumatoid arthritis findings on X ray
Joint space narrowing
Bony erosions
Osteoarthritis findings on X ray
Loss of joint space/non uniform joint space narrowing
Osteophytes- Heberden’s/Bouchard’s notes
Subchondral cyst
What is genu varum and genu valgus?
Genu varum= bow legs- knees away from midline
Genu valgus- knock knees -knees towards midline [leg looks like an L]
What condition is genu varum related to?
Osteoarthritis
What is genu valgus a risk factor for?
ACL tear
vaLgus = acL
What investigations do you do for joint pain?
Bloods:
FBC- anaemia, raised WCC
CRP
ESR
Antibodies:
Rheumatoid factor
Anti - CCP
Maybe lupus etc
Uric acid
Joint aspiration - if suspect septic arthritis/crystal arthropathy-gout
Imaging
- X ray [not predictive of severity of osteoarthritis symptoms though- b/c many people have OA changes incidentally
Erosions= inflammatory disease]
- MRI- knees and back
If knee pain- arthroscopy
Management of osteoarthritis
Weight loss
Exercise/ Physical therapy
Analgesia- topical NSAIDS, oral NSAIDS + gastroprotection
TENS- pain relief
Orthotic and walking aids
Surgical- joint replacement
[really functionally limited, disease for >6 months]
Manage social factors- ADLs, occupation effects
Address ICE
Management of rheumatoid arthritis?
Analgesia
Steroids- prevent further inflammation + disease progression
DMARDs- methotrexate, sulfasalazine, hydroxychloroquine
Supportive- Physio, OT, Orthotics/walking aids
Biologics- antiTNFa
Refer EARLY if inflammatory arthritis- even if serology negative
What are adjuvants that can be used alongside other drugs in WHO pain ladder?
Duloxetine Gabapentin Pregabalin Amitriptyline TENS
Case
Mrs LF- 34 year old mother
Bilateral painful swollen wrists for 6 months since birth of child
Bloods:
Negative RhF
CRP 15
Normal X ray wrists
Tried paracetamol + ibuprofen- no benefit
Difficult to pick up baby
Wrists = swollen and tender
How do you manage?
Increase analgesia
Refer to rheumatology
Physiotherapy
Case
Mrs GT- 64 year old lady- BMI of 29
8 month history- painful knees
Mainly right side
Worse on walking downstairs + sitting for a few hours
Tried paracetamol
Has to travel for work - wants letter to say she can use taxis instead of public transport
Crepitus on both knees, otherwise normal
What is the management that is most likely to influence the patient’s condition?
Lose weight
[Exercise therapy helpful]
Diagnosis= osteoarthritis
What is the most important cause of joint pain to rule out?
Septic arthritis
Medical emergency
Needs IV antibiotics
