Joint Pain Lecture Flashcards
What percentage of GP consultations are due to musculoskeletal problems?
25%
How are cases of arthritis classified?
Inflammatory e.g. RA, SLE, psoriatic arthritis
Non-inflammatory (degenerative)e.g. OA
Give examples of each type of arthritis.
Name 2 causes of seronegative and seropositive arthritis.
Seropositive - RA, lupus, scleroderma, vasculitis, sjorgen’s syndrome
Seronegative - ankylosing spondylitis, psoriatic arthritis, reactive arthritis, IBD arthrtitis
Describe the epidemiology of RA.
- •Around 400,000 people estimated to have rheumatoid in the UK
- •Incidence is low - around 5 cases per 10,000 people developing RA per year
- •Prevalence of RA - about 1% population
- •3 x more common in women than in men.
- •Peak age - 40s but can occur in people of all ages.
- About one new case per GP per year
Describe the epidemiology of OA.
- •Affects about 8.5 million people in the UK
- •Knee OA in one general practice, prevalence of 5.5% over age 45
- •Radiographic evidence high prevalence (44% of those over 70)
- •Mainly elderly
- •Women slightly more common than men
- 20x more common than OA
What questions should you ask in the history related to 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?
- •Be careful with the terms ‘stiffness’ and ‘weakness’ and ‘pain’ used when the patient really means ‘pins and needles’
When is RA worst?
Pain and stiffness are worst in the morning and this will last for hours
What is the duration of morning stiffness in OA?
<1 hour
List 3 associated symptoms in reactive arthritis?
- Rash
- Red eye (iritis)
- Urethritis
Describe the features of OA.
- •Degenerative process
- •Mainly large weight bearing joints (back, knee, hip, ankle, hands) and DIP
- •Asymmetrical
- •Usually less deformity
- •Morning stiffness < 1 hour
Describe the features of RA.
- •Autoimmune process
- •Mainly small joints of hand
- PIP (not DIP), MCP, wrists elbows, neck
- (But also hips and knees and ankles)
- •Symmetrical
- •Gross deformity
- •Tendon rupture
- •Morning stiffness
- > 1 hour
What markers are negative in psoriatic arthropathy making it seronegative?
RhF and ACCP –ve
What are the differences between psoriatic arthropathy and RA?
Similar to RA in distribution – EXCEPT
- Initial oligoarticular involvement
- DIP joints
- Marked dactylitis
- sacroiliitis
Why is GALS useful?
- Quick screening tool for joint problems
- Can help differentiate between OA and RA
List the types of GAIT.
- •Antalgic gait
- •Spastic gait (circumduction)
- •Foot drop gait (high stepping)
- •Parkinsonian gait
- •Trendelenburg gait
How do you test ARMS in the GALS test?
- Hands behind head with elbows back
- Supination and pronation of elbow
- ‘Squeeze my fingers’
- Opposition of thumb and fingers - tip of thumb to tip of other fingers
- Squeeze metacarpal joints
How do you test LEGS in GALS test?
- Hand over the knee to feel for crepitus
- Internal rotation of hip (foot moves externally)
- Ankle flex / extend - tibiotalar joint affected in OA
- Supination of foot – subtalar joint affected in RA
How do you assess the spine in GALS?
- Lateral flexion of cervical spine (mid cervical region, first movement affected in OA cervical spondylosis)
- Bending forward - need to ensure the movement does not come from the hips
Stiff spine in ankylosing spondylitis is common.
What is trendelenburg gait?
What are the clinical features of RA hands?
- •Ulnar deviation
- •Subluxation at MCP joints
- •Rheumatoid nodules
What are clinical features of OA hands?
1 – Heberden’s nodes - DIP
2 – Bouchard’s nodes - PIP
What is Boutonnières deformity?
- Hyperextension at DIP
- Flexion deformity at PIP
What is Swan neck deformity?
- •Flexion deformity of DIP
- •Hyperextension of PIP
What are Z shaped thumbs?
- •Hyperextension of the interphalangeal joint
- •Fixed flexion and subluxation of the metacarpophalangeal joint.
What would you see on X ray in OA?
Bony erosions
Genu varum - bow legs
Genu vlagus - knock knees
What investigations would you do for joint pain?
- Blood tests (anaemia,↑WBC, uric acid, CRP, ESR)
- •Rheumatoid factor
- •Anti cyclic citrullinated peptide (anti CCP)
- (Present in only about 70% RA)
- Imaging (MRI knees and back)
- Synovial fluid analysis (septic arthritis, gout)
- Arthroscopy
How do you manage osteoarthritis?
What are the conservative treatments of OA?
What is the management of rheumatoid arthritis?
Pharmacological:
- Analgesia (as in OA, simple analgesia first)
- Steroids
- DMARDS (disease modifying anti-rheumatic drugs e.g. methotrexate, sulphasalazine, hydroxychloroquine)
- Biological agents (Tumour necrosis factor inhibitors e.g. etanercept, infliximab)
Supportive (involving MDT)
- Physio
- OT
- Orthotics
- PLUS all the HOLISTIC care
When should you make an early referral when you suspect RA?
Refer early if inflammatory arthritis is suspected
- Especially small joints hand and feet
- More than one joint
- Three months from onset of symptoms
Even if inflammatory markers and rheumatoid factor are negative
What is the WHO pain ladder? What adjuvants would you use?
Adjuvants
Increasingly used for chronic pain especially of nerve origin
- Gabapentin - anticonvulsant medication used to treat partial seizures, neuropathic pain, hot flashes, and restless legs syndrome.
- Pregabalin - to treat epilepsy, neuropathic pain, fibromyalgia, restless leg syndrome, and generalized anxiety disorder
- Amitryptiline - for mental disorders
- TENS - transcutaneous electrical nerve stimulation
