The approach to JOINT PAIN/STIFFNESS
In the clinical assessment it is important first to establish whether the presentation is that of a monarthritis or polyarthritis . Then check the distribution and the symmetry or asymmetry thereof. Other information that is useful includes:
1.Location and the exact joints involved
2.Onset, duration, diurnal pattern 3.Duration of pain and stiffness each day
4.Functional impairment
5.Precipitating and relieving factors and medications consumed so far
6.Progression over time and space
7.Associated other features, such as rash, weight loss, ocular symptoms, oral symptoms, genital symptoms
8.Muscle ache, headache, fever
Arthritis
Differential diagnoses that need to be considered include:
• rheumatoid arthritis
• osteoarthritis
• gouty arthritis / crystal arthropathy
• seronegative arthropathy
• mechanical trauma
• polymyalgia rheumatica.
OSTEOARTHRITIS
Approach to the patient
History
Osteoarthritis is the most common form of arthritis. Patients usually present with chronic joint pain and loss of functionality or mobility. Osteoarthritis usually affects the feet, knees, hips, spine and hands, but other joints can also be affected, especially the shoulders, ankles and wrists. If there is involvement of uncommon sites (second, third metacarpophalangeal joints) think of secondary causes such as calcium pyrophosphate dihydrate (CPPD) or haemochromatosis. Ask about joint pain and transient morning stiffness, and evening stiffness. Ask what factors precipitate the pain. Secondary osteoarthritis can set in due to overuse or previous joint injury, and therefore it is important to enquire about such associations. Check how the disease has been managed and any side effects associated with therapy. Ask about physical therapeutic modalities that have been tried and the success thereof. Ask about surgical interventions and joint replacements in detail. Some genetic associations have been identified, and so enquiring about the family history is of value.
Examination
Perform detailed examinations of the joints involved. Define the pattern of distribution of the disease. Assess joint movement actively and passively. In the hands, look for Heberden’s nodes in the distal interphalangeal joints and Bouchard’s nodes in the proximal interphalangeal joints. Feel for joint tenderness. Look for joint crepitus and also any evidence of joint effusion. Assess muscle strength to check for any muscle wasting.
Investigations
1.Joint X-ray—looking for subchondral sclerosis, subchondral cysts, joint space narrowing, osteophytes
2.MRI of the joint if required
3.Markers of inflammation—ESR, CRP (which should be normal)
4.Joint aspirate and microscopy in the setting of effusion
5.Arthroscopy for complicated cases
Management of OSTEOARTHRITIS
1.Physical therapeutic modalities are very important in relieving joint pain as well as improving functionality.
2Analgesics and NSAIDs, COX-2 inhibitors
3.Local injection of steroids or hyaluronic acid
4.Joint replacement surgery
5.Address the precipitating factors—weight loss etc.
