Joint pain

Question 1

What is arthritis and how is it classified?

Answer 1

Inflammation of the joint.

Inflammatory: seronegative, seropositive, infectious or crystal induced, e.g. rheumatoid, SLE, psoriatic.

Non-inflammatory (degenerative): e.g. osteoarthritis.

Question 2

What are the seropositive inflammatory arthritis?

Answer 2

Rheumatoid arthritis.
Lupus.
Scleroderma.
Vasculitis.
Sjogren's.

Question 3

What are the seronegative inflammatory arthritis?

Answer 3

Ankylosing spondylitis.
Psoriatic arthritis.
Reactive arthritis.
IBD arthritis.

Question 4

Give an example of infectious inflammatory arthritis.

Answer 4

Septic arthritis.

Question 5

What are the crystal-induced inflammatory arthritis?

Answer 5

Gout.

Pseudogout.

Question 6

Give an example of non-inflammatory (degenerative) arthritis.

Answer 6

Osteoarthritis.

Question 7

Screening questions for 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?

Question 8

Joint pain: history of presenting complaint

Answer 8

SOCRATES.
Chronology, sudden onset/gradual, recurrent?
Relationship to trauma/exercise?
Joint pain, stiffness, swelling, bone pain, muscle weakness?
Knee- locking, giving way, grinding, clicking?
Morning stiffness: OA <1hr, RA hrs.
Associated symptoms: rash, red eye (iritis), urethritis?- reactive arthritis.

Question 9

What are the clinical features of osteoarthritis?

Answer 9

Degenerative process- wear and repair- abnormal bone remodelling
Mainly large, weight bearing joints (back, knee, hip, ankle, hands) and DIP.
Asymmetrical.
Usually less deformity.
Morning stiffness <1hr.

Question 10

What are the clinical features of rheumatoid arthritis?

Answer 10

Autoimmune process.
Mainly small joints of hand.
PIP (not DIP), MCP, wrists, elbows, neck.
Also hips, knees, ankles.
Symmetrical.
Gross deformity.
Tendon rupture.
Subluxation.
Morning stiffness >1hr.

Question 11

What are the clinical features of psoriatic arthropathy?

Answer 11

Seronegative inflammatory arthritis (RhF and ACCP -ve).

Personal or FHx of psoriasis.

Similar to RA in distribution, except: 
> initial oligoarticular involvement
> DIP joints
> marked dactylitis- swelling of whole finger
> sacroiliitis-lower back/hip pain

Question 12

GALS screen: arms

Answer 12

Hands behind head with elbows back.
Supination and pronation of elbow.
'Squeeze my fingers'.
Opposition of thumb and fingers.
Squeeze metacarpal joints.

Question 13

GALS screen: legs

Answer 13

Hand over the knee and flex to feel for crepitus.
Passive internal rotation of hip (foot moves externally).
Ankle flex/extend- tibiotalar joint affected in OA.
Eversion and inversion of foot
Supination of foot- subtalar joint affected in RA.

Question 14

GALS screen: spine

Answer 14

Lateral flexion of cervical spine (mid-cervical region, 1st movement affected in OA cervical spondylosis)- ears towards shoulders

Bending forward- need to ensure the movement does not come from the hips.

Question 15

What are the clinical features of rheumatoid arthritis in the hands?

Answer 15

Ulnar deviation.
Subluxation at MCP joints.
Rheumatoid nodules.
Boutonnieres deformity [flexion of DIP, hyperextension of PIP]
Swan neck deformity [flexion of DIP, hyperextension of PIP]
Z line thumb- hyperextension of IP, flexion of MCP]

Question 16

What are the clinical features of osteoarthritis in the hands?

Answer 16

Heberden’s nodes- DIP

Bouchard’s nodes- PIP

Question 17

Epidemiology of rheumatoid arthritis?

Answer 17

400000 in UK
Females> 3:1
1% of population- low prevalence
Peak age= 40 years, but people of all ages

Question 18

Epidemiology of osteoarthritis?

Answer 18

Common
Mainly elderly
Women slightly more common than men

Question 19

Screening questions for MSK disorders

Answer 19

Pain/stiffness- arms, legs, back

Difficulty with washing and dressing

Stairs and steps hard

Question 20

Factors to ask in HPC

Answer 20

Pain
Sudden/Gradual/recurrent
Trauma
Exercise- how it affects symptoms

joint pain, stiffness, swelling, bone pain, muscle weakness

Knee- locking, grinding, clicking, giving way

Morning stiffness= hours in RA, < one hour in OA

Associated extra-articular symptoms- rash, red eye, urethritis

Question 21

GALS screen- types of abnormal gait

Answer 21

Trendelenburg gait- hip drops when leg lifted
Parkinsonian gait
Foot drop gait- high stepping
Spastic gait- after stroke- circumduction
Antalgic gait

Question 22

Rheumatoid arthritis findings on X ray

Answer 22

Joint space narrowing

Bony erosions

Question 23

Osteoarthritis findings on X ray

Answer 23

Loss of joint space/non uniform joint space narrowing
Osteophytes- Heberden’s/Bouchard’s notes
Subchondral cyst

Question 24

What is genu varum and genu valgus?

Answer 24

Genu varum= bow legs- knees away from midline

Genu valgus- knock knees -knees towards midline [leg looks like an L]

Question 25

What condition is genu varum related to?

Answer 25

Osteoarthritis

Question 26

What is genu valgus a risk factor for?

Answer 26

ACL tear vaLgus = acL

Question 27

What investigations do you do for joint pain?

Answer 27

Bloods: FBC- anaemia, raised WCC CRP ESR Antibodies: Rheumatoid factor Anti - CCP Maybe lupus etc Uric acid Joint aspiration - if suspect septic arthritis/crystal arthropathy-gout Imaging - X ray [not predictive of severity of osteoarthritis symptoms though- b/c many people have OA changes incidentally Erosions= inflammatory disease] - MRI- knees and back If knee pain- arthroscopy

Question 28

Management of osteoarthritis

Answer 28

Weight loss Exercise/ Physical therapy Analgesia- topical NSAIDS, oral NSAIDS + gastroprotection TENS- pain relief Orthotic and walking aids Surgical- joint replacement [really functionally limited, disease for >6 months] Manage social factors- ADLs, occupation effects Address ICE

Question 29

Management of rheumatoid arthritis?

Answer 29

Analgesia Steroids- prevent further inflammation + disease progression DMARDs- methotrexate, sulfasalazine, hydroxychloroquine Supportive- Physio, OT, Orthotics/walking aids Biologics- antiTNFa Refer EARLY if inflammatory arthritis- even if serology negative

Question 30

What are adjuvants that can be used alongside other drugs in WHO pain ladder?

Answer 30

``` Duloxetine Gabapentin Pregabalin Amitriptyline TENS ```

Question 31

Case Mrs LF- 34 year old mother Bilateral painful swollen wrists for 6 months since birth of child Bloods: Negative RhF CRP 15 Normal X ray wrists Tried paracetamol + ibuprofen- no benefit Difficult to pick up baby Wrists = swollen and tender How do you manage?

Answer 31

Increase analgesia Refer to rheumatology Physiotherapy

Question 32

Case Mrs GT- 64 year old lady- BMI of 29 8 month history- painful knees Mainly right side Worse on walking downstairs + sitting for a few hours Tried paracetamol Has to travel for work - wants letter to say she can use taxis instead of public transport Crepitus on both knees, otherwise normal What is the management that is most likely to influence the patient's condition?

Answer 32

Lose weight [Exercise therapy helpful] Diagnosis= osteoarthritis

Question 33

What is the most important cause of joint pain to rule out?

Answer 33

Septic arthritis Medical emergency Needs IV antibiotics