Joints

Question 1

Define arthritis

Answer 1

Arthritis – literally inflammation of the joint

Question 2

2 types of arthritis

Answer 2

Inflammatory
e.g. RA
SLE
Psoriatic arthritis

Non – inflammatory (degenerative)
e.g. OA

Question 3

Classify the inflammatory arthritis

Answer 3

Seropositive (RA, lupus, scleroderma, sjorgens, vasculitis)

Seronegative (ankylosing spondyliis, psoriatic arthritis, reactive arthritis. inflammatory bowel disease arthritis)

Infectious (septic arthritis)

Crystal induced (gout, pseudogout)

Question 4

Who is RA more common in

Answer 4

3 x more common in women than in men.

Peak age - 40s but can occur in people of all ages.

Question 5

Which is more common OA, or RA

Answer 5

OA

Question 6

Who does OA affect

Answer 6

Mainly elderly

Women slightly more common than men

Question 7

Screening questions for MSK

Answer 7

Do you suffer from any pain or stiffness in your arms, legs, neck or back?

Do you have any difficulty with washing or dressing?

Do you have any difficulty with stairs or steps?

Be careful with the terms ‘stiffness’ and ‘weakness’ and ‘pain’ used when the patient really means ‘pins and needles

Question 8

HPC for MSK

Answer 8

• Pain
• Chronology, sudden onset / gradual, recurrent?
• Relationship to trauma / exercise?

Ask specifically about…
Joint pain, stiffness, swelling, bone pain, muscle weakness

Knee – locking, giving way, grinding, clicking

Morning stiffness – (OA <1 hour, RA hours)

Associated symptoms (rash, red eye (iritis), urethritis – reactive arthritis)

Question 9

History for MSK

Answer 9

Family history
PMH (other autoimmune diseases, psoriasis, other infections)

DH - what have they tried so far

SH – impact on life, describe a typical day, what have they had to give up?

Question 10

What is OA

• What kind of process
• What joints does it affect
• Symmetrical?
• Deformity?
• Morning stiffness?

Answer 10

Not osteoporosis…

Degenerative process

Mainly large weight bearing joints (back, knee, hip, ankle, hands) and DIP

Asymmetrical

Usually less deformity

Morning stiffness < 1 hour

Question 11

What is RA

• What kind of process
• What joints does it affect
• Symmetrical?
• Deformity?
• Morning stiffness?

Answer 11

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 12

What type of arthritis is psoriatic arthropathy

Which condition is the distribution similar to, but how is it different

Answer 12

Seronegative inflammatory arthritis (RhF and ACCP –ve)

Similar to RA in distribution – EXCEPT

Initial oligoarticular involvement
DIP joints
Marked dactylitis
sacroiliitis

Question 13

How does GALS work to illicit symptoms

Answer 13

Mainly testing the joint where the capsule is tightest and symptoms are more likely to occur
Can help to differentiate between OA and RA

Question 14

Arms in GALS?

Answer 14

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 fingers)

Squeeze metacarpal joints

Question 15

Legs in in GALS?

Answer 15

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 16

Spine in GALS

Answer 16

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

Question 17

Gait in GALS

Answer 17

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

Question 18

Clinical features of RA hands

Answer 18

Ulnar deviation

Subluxation at MCP joints

Rheumatoid nodules

(bony erosions on xray)

Question 19

Clinical features of OA hands

Answer 19

1 – Heberden’s nodes (DIP)

2 – Bouchard’s nodes (PIP)

Question 20

Boutonnieres deformity description

Answer 20

Hyperextension at DIP

Flexion deformity at PIP

Question 21

Swan neck deformity

Answer 21

Flexion deformity of DIP

Hyperextension of PIP

Question 22

Z shaped thumbs describe

Answer 22

Hyperextension of the interphalangeal joint

Fixed flexion and subluxation of the metacarpophalangeal joint.

Question 23

What happens in RA to the synovial membrane

Answer 23

Swollen inflamed synovial membrane

Question 24

What is genu varum and genu valgus

Answer 24

Genu varum - bowlegs

Genu valgus – knock knees

Question 25

Investigations for joint pain

Answer 25

1. Blood tests (anaemia,↑WBC, uric acid, CRP, ESR)
   Rheumatoid factor
   Anti cyclic citrullinated peptide (anti CCP)
   (Present in only about 70% RA)
2. Imaging
   MRI knees and back
3. Synovial fluid analysis (septic arthritis, gout)
4. Arthroscopy

Question 26

Management of osteoarthritis

Answer 26

Exercise
Physical therapy
Weight loss
TENS
Orthotics and walking aids
Analgesia (simple analgesia and topical NSAIDs before oral NSAIDs and opioids)
Consider surgical referral

Question 27

Management of rheumatoid arthritis (pharmacological and supportive)

Answer 27

RA:
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 treatment: 
Physio
OT
Orthotics
PLUS all the HOLISTIC care

Question 28

Which drugs are increasingly being used as adjuvant for WHO pain ladder for chronic pain especially of nerve origin

Answer 28

Gabapentin
Pregabalin
Amitryptiline
TENS