Arthritis

Objectives

After completion of this module the student should be able to:


1. List components of the patient history relevant to the diagnosis and management of arthritic problems commonly encountered in the Comprehensive Care Clinic.
2. Correlate relevant basic physical, radiological and laboratory findings with the most appropriate common arthritic disease process.
3. Devise a plan for the management of osteoarthritis in the outpatient setting.
4. Briefly discuss the general classes of medication used in treating osteoarthritis and potential risks and benefits of each group.

Introduction

Joint pain is one of the most common problems encountered in ambulatory medicine.  Medical conditions that cause joint pain are numerous; however, three arthritic conditions account for the majority of joint pain problems seen in Comprehensive Care Clinic.  This module is designed to address the identification and practical management of these most common conditions.

Evaluation

Evaluation of joint complaints generally should include a complete history and physical exam with appropriate laboratory and radiological studies with special attention to the components listed below.
 

Medical history:

 Is there a history of joint injuries, obesity, osteoporosis or other bone disease?
 What medications and home treatments have been tried and what was their effect?

Family History:

 Do any family members have arthritis?
 What is their relationship and what type of arthritis do/did they have?

Social History:

 Has there been any exposure to communicable disease such as hepatitis or gonorrhea?
 Is there a history of wilderness exposure that might have led to a tick bite?

Localization of joint pain:

 Which joint or joints are involved?
 Does the pain migrate from joint to joint?

Nature of the joint pain:

Is the pain constant or intermittent?
Is the pain worse with movement or weight bearing?
Does the pain occur at rest?

Onset of symptoms:

Was the onset abrupt or gradual?
What was the patientís age at onset?

Duration of symptoms

Associated joint symptoms:

 Do the joints involved lock up or give way?
 Is there any joint stiffness?   If so, when does it occur and how long does it last?
 Has there been any joint swelling or redness or increased warmth?

Pertinent systemic or remote symptoms:

 Has there been any fatigue, weakness, weight loss, fever, rash, dysuria or urethral discharge?


Physical Examination should include identification of the affected joint or joints and any pattern of distribution, if present.  Each involved joint should be examined for deformity, swelling, redness, tenderness and increased warmth.  Both passive and active range of motion should be determined and the presence or absence of crepitus noted.  Remember that not all complaints of joint pain originate in the joint, but rather the surrounding structures such as bursae, tendons and muscles or may represent referred pain.

Evaluation for any systemic signs possibly related to arthritic symptoms, such as fever, skin rash, nail pitting, jaundice and urethral discharge should be incorporated into the examination.

Radiological examination of involved joints should include identification of any osteophyte formation, loss of joint space or destruction of adjacent bone.

Laboratory evaluation may include erythrocyte sedimentation rate, serum rheumatoid factor, complete blood count and serum uric acid.  Renal function and hepatic function should be evaluated before selecting certain treatment options.

Joint fluid may be collected and submitted for cell count, gram stain, culture, protein, and polarizing microscopy for crystals as indicated.

 

Diagnosis

Osteoarthritis accounts for more than 90% of the arthritis diagnoses in Comprehensive Care Clinic.  There is a predilection for involvement of the weight bearing joints such as the knees, hips, ankles, lumbar spine and joints subjected to earlier traumas or occupational repetitive use.  Obesity, osteoporosis and advanced age are all risk factors. A family history of osteoarthritis is often present, this is especially true of osteoarthitic changes of the DIP joints (Heberdenís nodes), which commonly appear in females as a presumed autosomal dominant trait and less frequently in males as an apparent autosomal recessive trait.  The onset is gradual and once present, chronic and set in affected joints.  Joint swelling, redness, increased warmth or stiffness or jelling of the joint at rest (all signs of inflammation) is usually limited, if present at all.  The pain is generally worse with movement or weight bearing and may be accompanied by grinding or popping of the joint.

On examination the affected joints may exhibit crepitus on motion and deformity secondary to osteophytic changes.  Laboratory examination of the blood is of little help in making the diagnosis.  Radiographic examination is usually confirming, typically showing osteophyte formation, joint space narrowing and sclerosis of periarticular bone.
 

Gout is the second most common arthritic diagnosis in Comprehensive Care Clinic.  Of the sites likely to be affected, the 1st MTP joint is the most common followed by the other joints of the foot, ankles and knees, with involvement of other joints less frequently and generally involves only one joint at a time.  Risk factors include male gender, history of hyperuricemia or hypertension, excessive alcohol intake, obesity and positive family history.

The onset of pain is sudden and intense and associated with swelling, redness, tenderness and warmth of the joint caused by precipitation of needle shaped sodium urate monohydrate crystals in and around the joint.  These patients often present hobbling into the clinic wearing only a sock or slipper on the affected foot.

Although, the diagnosis is often made based on clinical findings, confirmation is only possible after demonstration of the presence of urate crystals in joint fluid by polarizing microscopy.  Measurement of increased serum uric acid provides some support to the diagnosis and is essential for long term treatment planning but is not a prerequisite for making the diagnosis of acute gout.

Rheumatoid Arthritis is a chronic systemic inflammatory disease that should be suspected if there is a history of constant pain, swelling, stiffness and increased warmth of the involved joints.  These symptoms may be migratory from joint to joint and frequently occur in a symmetrical pattern involving both of the right and left hands, wrists, hips, knees, ankles, and other joints in any combination.  Stiffness or jelling of the joints is often noticed after periods of inactivity, such as on awakening, and typically persist for an hour or more.  Systemic signs of chronic inflammation such as fatigue, weight loss and low grade fever are not uncommon.  Involved joints are often swollen, warm and may exhibit loss of range of motion.  Long-standing inflammation can lead to joint destruction producing such characteristic deformities as subluxation and ulnar deviation of the MCP joints and fusion of the carpal bones.  Rupture of tendons and tendon sheaths result in the swan-neck or boutonniere deformities of the fingers.

Laboratory findings helpful in diagnosis include measurement of an elevated erythrocyte sedimentation rate and a positive serum rheumatoid factor.  A complete blood count might determine the presence of a normocytic, normochromic anemia of chronic disease and is required for adequate interpretation of the erythrocyte sedimentation rate.
   

Intervention

Effective treatment of osteoarthritis is centered on protecting the joints by reducing their workload and increasing their support and safe control of pain.  Weight reduction or job duty modification should be considered and recommended where appropriate.  Isometric muscle strengthening of muscles surrounding the joint add support, this is especially true of the knees where isometric quadricep exercises are most beneficial.  Supportive, shock absorbing shoes and proper walking techniques are frequently advisable.

Consideration should be given to comorbid conditions and the presence or absence of an inflammatory component when selecting a medication for pain relief.  Acetaminophen in the form of Arthritis Strength Tylenol is effective in relieving pain on walking or motion and has an acceptable safety profile when used by patients without liver or kidney disease.  If there is pain at rest or stiffness or swelling, anti-inflammatory medications such as ibuprofen, naproxen and other NSAIDS should be considered if the patient has no history of peptic ulcer disease or kidney disease or other contraindication.  When NSAIDS are unacceptable, one of the newer cyclo-oxygenase2 specific inhibitors, celecoxib or rofecoxib, can be tried.  Application of topical capsaicin is often helpful for treating the knees.  When appropriate, a course of weekly injections with viscosupplements Hylan G-F or Hyaluronan made from roosters' combs may bring relief.

Alternative forms of treatment include the use of glucosamine sulfate, chondroitin sulfate, DMSO, aloe, magnet application and acupuncture.  Ongoing clinical trials indicate that of these choices, glucosamine sulfate and acupuncture hold the most promise for benefit; there is little to no evidence that magnets or aloe are helpful.  DMSO is best avoided because of potential adverse side effects.

When all other options have been exhausted, the patient should be referred to Orthopedics for evaluation for arthroscopic surgery or joint replacement.

Gout is best treated in the acute phase with either indomethacin or colchicine.  If hyperuricemia is present, allopurinol or probenicid may be used after the acute phase as a prophylactic therapy.  Be aware that institution of these agents may precipitate an acute attack if started alone.  Where appropriate, dietary modification and weight reduction is advisable.

The treatment of rheumatoid arthritis includes many of the same elements used for osteoarthritis plus disease modifying agents such as methotrexate.  It is most appropriate to seek the guidance of a rheumatologist when treating this form of arthritis in the Comprehensive Care Clinic.


R. Roberts, MD
updated 8/30/05


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