Joint Pain Lecture

Question 1

What percentage of GP consultations are due to musculoskeletal problems?

Answer 1

25%

Question 2

How are cases of arthritis classified?

Answer 2

Inflammatory e.g. RA, SLE, psoriatic arthritis

Non-inflammatory (degenerative)e.g. OA

Question 3

Give examples of each type of arthritis.

Answer 3

Question 4

Name 2 causes of seronegative and seropositive arthritis.

Answer 4

Seropositive - RA, lupus, scleroderma, vasculitis, sjorgen’s syndrome

Seronegative - ankylosing spondylitis, psoriatic arthritis, reactive arthritis, IBD arthrtitis

Question 5

Describe the epidemiology of RA.

Answer 5

• •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

Question 6

Describe the epidemiology of OA.

Answer 6

• •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

Question 7

What questions should you ask in the history related to joint pain?

Answer 7

• •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’

Question 8

When is RA worst?

Answer 8

Pain and stiffness are worst in the morning and this will last for hours

Question 9

What is the duration of morning stiffness in OA?

Answer 9

<1 hour

Question 10

List 3 associated symptoms in reactive arthritis?

Answer 10

• Rash
• Red eye (iritis)
• Urethritis

Question 11

Describe the features of OA.

Answer 11

• •Degenerative process
• •Mainly large weight bearing joints (back, knee, hip, ankle, hands) and DIP
• •Asymmetrical
• •Usually less deformity
• •Morning stiffness < 1 hour

Question 12

Describe the features of RA.

Answer 12

• •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

Question 13

What markers are negative in psoriatic arthropathy making it seronegative?

Answer 13

RhF and ACCP –ve

Question 14

What are the differences between psoriatic arthropathy and RA?

Answer 14

Similar to RA in distribution – EXCEPT

• Initial oligoarticular involvement
• DIP joints
• Marked dactylitis
• sacroiliitis

Question 15

Why is GALS useful?

Answer 15

• Quick screening tool for joint problems
• Can help differentiate between OA and RA

Question 16

List the types of GAIT.

Answer 16

• •Antalgic gait
• •Spastic gait (circumduction)
• •Foot drop gait (high stepping)
• •Parkinsonian gait
• •Trendelenburg gait

Question 17

How do you test ARMS in the GALS test?

Answer 17

• 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

Question 18

How do you test LEGS in GALS test?

Answer 18

• 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

Question 19

How do you assess the spine in GALS?

Answer 19

• 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.

Question 20

What is trendelenburg gait?

Answer 20

Question 21

What are the clinical features of RA hands?

Answer 21

• •Ulnar deviation
• •Subluxation at MCP joints
• •Rheumatoid nodules

Question 22

What are clinical features of OA hands?

Answer 22

1 – Heberden’s nodes - DIP

2 – Bouchard’s nodes - PIP

Question 23

What is Boutonnières deformity?

Answer 23

• Hyperextension at DIP
• Flexion deformity at PIP

Question 24

What is Swan neck deformity?

Answer 24

• •Flexion deformity of DIP
• •Hyperextension of PIP

Question 25

What are Z shaped thumbs?

Answer 25

• •Hyperextension of the interphalangeal joint
• •Fixed flexion and subluxation of the metacarpophalangeal joint.

Question 26

What would you see on X ray in OA?

Answer 26

Bony erosions

Question 27

Answer 27

Question 28

Answer 28

Genu varum - bow legs

Genu vlagus - knock knees

Question 29

What investigations would you do for joint pain?

Answer 29

• 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

Question 30

How do you manage osteoarthritis?

Answer 30

Question 31

What are the conservative treatments of OA?

Question 32

What is the management of rheumatoid arthritis?

Answer 32

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

Question 33

When should you make an early referral when you suspect RA?

Answer 33

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

Question 34

What is the WHO pain ladder? What adjuvants would you use?

Answer 34

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