MODULE 1

Joint Ache
Scenario 1
A woman 58 years old, a housewife, complains about the
ache on her knees that she has suffered for 3 months,
especially when she walks. She has difficulty to stand up from
the squad position. She feels stiffness in the morning
continuously for about 10 15 minutes. The knees are
swollen, but there are no sign of redness. She also feels ache
on the fingers, asymmetrically. The patient also suffers from
diabetes and has a regular treatment in endocrine clinic. Her
weight is 65 kg and 162 cm tall

Keywords:
1.

A 58 years old woman

2.

Pain during walking in the knees for almost 3 months

3.

Feeling stiff about 10-15 minutes in the morning

4.

Having difficulty to stand up from squatting

5.

No redness in swollen legs

6.

Diabetes patien and receive regular treatment

7.

Her weight is 65 kg and 162 cm tall

8.

Asymmetrical pain in the fingers

Clarification of words:
1.

squat position = frog position

2.

asymmetric ache = non-symmetrical pain

3.

stiffness = inflexibility

Differential diagnosis:
1. osteoarthritis
2. Rheumatoid arthritis
3. Gout arthritis

SIGN AND SYMPTOMS:

OA can cause a crackling noise (called "crepitus") In smaller joints, such as at the fingers, hard
bony enlargements, called Heberden's nodes (on the distal interphalangeal joints) and/or
Bouchard's nodes (on the proximal interphalangeal joints), may form, and though they are not
necessarily painful, they do limit the movement of the fingers significantly. OA at the toes leads
to the formation of bunions, rendering them red or swollen.
OA commonly affects the hands, feet, spine, and the large weight bearing joints, such as the hips
and knees, although in theory, any joint in the body can be affected. As OA progresses, the
affected joints appear larger, are stiff and painful, and usually feel worse, the more they are used
throughout the day, thus distinguishing it from rheumatoid arthritis.when the affected joint is
moved or touched, and patients may experience muscle spasm and contractions in the tendons.
Occasionally, the joints may also be filled with fluid. Humid and cold weather increases the pain
in many patients.The main symptom is acute pain, causing loss of ability and often stiffness.
"Pain" is generally described as a sharp ache, or a burning sensation in the associated muscles
and tendons.

QUESTION
1)
2)
3)
4)
5)
6)

What is the cause of morning stiffness in this disease?

What is the relation between DM and the disease?
Why doesnt the pain symetrical ?
What is the correlance between obesity and jont pain?
What is the relation between sex,and age in joint pain
Why does the patient having the difficulties to stand up from squat position?

ANSWERS
1. Not everyone with arthritis feels stiff in the morning. Instead of stiffness, some complain
they hurt more in the morning or describe discomfort without pain. The duration of
symptoms in the morning is an important clue as to what type of arthritis you may have. For
example, rheumatoid arthritis or lupus patients often complain of prolonged morning
stiffness or pain which may last 45 minutes or longer.
On the other hand, osteoarthritis patients symptoms typically improve within 30 minutes but
may be aggravated during the day with use of the affected joints. Stiffness in legs usually
gives the people an impression that it may be due to some potential health risk of the bones
like arthritis or osteoarthiritis. However, stiffness in legs due to bone problems occurs mostly
in older people. For majority of the people, stiffness in legs is due to under oxygenation of
the leg muscles thereby leading to the build up of lactic acid. This gives the feeling of muscle
cramps and stiffness in legs that can be at times painful. Some people, who experience
stiffness in legs after sleeping, may find it difficult to walk immediately after they wake up.
They may experience pain when they keep their feet on the floor. Due to sedentary lifestyle,
the muscles of the legs are often held in contracted positions for longer periods of time and
so it can lead to stiffness in legs. Based on medical investigations, doctors have agreed that
there is no specific cause of stiffness in legs and they have come to the conclusion that they
usually increase with the aging process. In severe diseases, the person may feel stiffness in
legs but that may be due to weaknesses in the legs.
In osteoarthritis, joints are commonly sore, stiff, and painful after sleep or after resting them
for a while. After getting up, the joints "loosen up" as they move around and are used. In the
spine, the small facet joints are a common source of arthritis and back pain. The facet joints
work as hinge joints similar to the hinges on a door. In a young, non-arthritic person, the

joints glide smoothly over one another. However, as the joints become arthritic, they function
more as a rusty hinge joint on a door that squeaks when you first try to move it. However, as
you swing the door open and closed, open and closed, the door becomes looser and glides
more smoothly. It is a similar phenomenon with the rest of the joints. With rest, the joint fluid
is soaked up by the cartilage within the joint similar to how a sponge soaks up water. When
the joint is used, the cartilage is "squeezed" and the joint fluid bathes the joint. The more the
joint is used, the more the joint fluid coats and lubricates the inner joint.
2.

Diabetes mellitus is a metabolic disease in which there is an excess amount of glucose in the
body. This might happen due to the decrease production of insulin or due to the cells in the
body does not respond well to the insulin produced. Basically, there are three types of
diabetes mellitus widely known as Type I diabetes, Type 2 diabetes and gestational diabetes.
Type I diabetes results from the body's failure to produce insulin, and presently requires the
person to inject insulin. Type 2 diabetes results from insulin resistance, a condition in which
cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency.
Gestational diabetes is a type of diabetes which only occurs to pregnant women. Gestational
diabetes is a condition in which pregnant women, who have never had diabetes before, have
a high blood glucose level during pregnancy. It may precede development of type 2 DM.
Pain in knee joint is closely related to arthritis. Arthritis is a musculoskeletal disorder in
which it affects the joints of the body whether due to metabolism, infection, inflammation, or
degeneration and many more causes. Joint pain which happen because of metabolism is
called osteoarthritis. Osteoarthritis is a wear and tear arthritis which means that the
cartilage at the joint will degenerate faster if it is repeatedly used beyond its capabilities to
withstand the pressure. The cartilage will slowly degenerate, and slowly exposing the bone to
the synovial fluid, making the bone to be in contact with it. The cartilage which degenerates
will turns into fragments and tiny pieces and will accumulate in the synovial fluid. Due to the
degeneration of cartilage, the growth of bone is slightly becoming abnormal as there is no
bone-shaper which is cartilage, and this will results in the over growth of bone called
osteophytes.
Diabetes mellitus is associated with a variety of musculoskeletal disorders. Several
studies conducted in patients with Diabetes Mellitus, shows that most of them mainly suffer
from the degenerative, non-inflammatory type. Musculoskeletal disorders are a common

finding among patients with type 2 diabetes. Obesity, accumulation of abnormally

glycosylated by-products, glycosylation of proteins; microvascular abnormalities with
damage to blood vessels and nerves; and collagen accumulation in skin and periarticular
structures have been proposed as potential pathogenesis mediators of these connective tissue
abnormalities.
Diabetes mellitus (DM) affects connective tissues in many ways and causes different
alterations in periarticular and skeletal systems. Several musculoskeletal disorders have been
described in these patients which can be divided into three categories; which are first,
disorders which represent intrinsic complications of diabetes, such as limited joint mobility
or diabetic cheiroarthropathy, stiff hand syndrome, and diabetic muscular infarction, second,
disorders with an increased incidence among diabetics, such as Dupuytrens disease, shoulder
capsulitis, neuropathic arthropathy, osteopenia (in type 1 DM), flexor tenosynovitis, septic
arthritis, acute proximal neuropathy, proximal motor neuropathy, pyomyositis and the diffuse
idiopathic skeletal hyperostosis (DISH) syndrome, the diagnosis of which depends on the
radiographic recognition of a minimum of two bridges connecting three consecutive
vertebrae in diabetics usually complaining of backache, and finally c. disorders for which a
possible association with diabetes has been proposed but not proven yet, such as
osteoarthritis and the carpal tunnel syndrome.
Diabetes is not clearly a risk factor for osteoarthritis (OA). However, obesity is a risk
factor for both conditions. Several studies have reported an association of early OA and
diabetes. Both large and small joint OA have been reported to be increased in type 2 diabetes.
However, OA of the weight-bearing joints in the affected type 2 diabetic patients may be
related to their obesity and not to the diabetes itself. It is not yet known whether diabetes is a
risk factor for OA independent of obesity.
3. Asymmetrical is (not "matching") swelling in individual joints that are not part of a pair. One
knee and an elbow instead of both knees. In everyday life, certain activity such as repeated
knee bending, heavy lifting and carrying involve repeated heavy use of particular joints over
long period of time. It is a condition associated with wear and tear of that particular joint.
4. Obesity or excessive weight gain associated with increased risk for theemergence of good
joint pain in women nor in men. Obesity appears to not only associated with pain in joints
that bear the burden, but also with other joints, such as hands orsternoklavikula. Therefore, as

well as mechanical factors that play a role, there is another factor that is suspected to play a
role in the incidence of metabolic connection. Therefore, it can be concluded that patients
with obesity over the range of affected joints ache.
5. As a person ages, the water content of the cartilage decreases due to a reduced proteoglycan
content, thus causing the cartilage to be less resilient. Without the protective effects of the
proteoglycans, the collagen fibers of the cartilage can become susceptible to degradation and
thus exacerbate the degeneration.
Since men and women vary in body size, one might assume that men have greater cartilage
volume. Men had larger femoral and patellar cartilage volumes than women, independently
of age, height, weight, and bone volume. Sex differences in patellar cartilage volume were
magnified with increasing age . In a study of nine healthy German men and nine women in
their early 20 s without a history of athletic or heavy physical activity, confirmed lower
cartilage volumes in women than men and showed that this sex difference was related
primarily to differences in joint surface area or bone size rather than cartilage thickness,
where differences were less pronounced and not statistically significant.
The smaller joint surfaces in women might explain sex differences in knee OA because of
higher articular pressures with smaller surface area. Using healthy men and women, the
authors confirmed that men have greater knee subchondral bone area, cartilage thickness, and
cartilage volume compared with women, after adjustment for height and weight . Estimated
tibial or patellar pressures, using the metric of body weight/joint surface area, however, were
equivalent in men and women, suggesting that smaller joint surfaces in women were not a
likely explanation for sex differences in knee OA .
These authors found that total subchondral bone area and cartilage volume were strongly
associated in young healthy men and women. However, while cartilage volume and bone
area were strongly related to height in women, their associations with height in men were
weak and inconsistent, leading the authors to suggest the possibility that different factors are
responsible for bone and cartilage growth in men and women .
Women had a higher annual rate of cartilage volume loss than men in all knee compartments,
although only tibial cartilage loss was statistically significantly different by sex. These sex
differences first appeared at age 40 and increased with age . Importantly, there were no
significant sex differences in the crude annual percentage change or in the annual percentage
change adjusted for age, BMI, and offspring/control status in cartilage volume in any plates;

sex differences were evident only after further adjustment for baseline cartilage volume and
bone size, and this could have inflated the difference. The composition of this convenience
sample was intriguing; the sample consisted of offspring of people who had undergone knee
arthroplasty for knee OA and the rest were from the general population. Interestingly, the
magnitude of cartilage loss was higher in off spring than the general population, suggesting a
high risk for the development of cartilage loss and presumably, later, for the development of
knee OA . Women were also three times more likely than men to have increases in tibial
cartilage defects over time.
Gender is another critical factor for osteoarthritis of the knee. An increase in body weight has
been associated with osteoarthritis of the knee in women but not statistically significant in
men. Reduced quadriceps muscle strength relative to body weight may be a risk factor for
osteoarthritis of the knee in women. Quadriceps strength was found to be about 15% to 18%
less among women with radiographic evidence of osteoarthritis of the knee compared with
normal subjects. This relationship did not hold true for men. Estrogen deficiency may also
play a role in the development of osteoarthritis in women. Postmenopausal estrogen
replacement therapy may have a moderately protective effect on the incidence and
progression of radiographic osteoarthritis of the knee in elderly women.
6. Almost all elderly people have experienced knee pain, because the knee joint is one of the
main bearer of weight and many suffer wear and tear and stretch in each of the activity level
is. But the risk the greater the wear and wounded; when the job involves a lot of knee joint as
many squats. Osteoarthritis results from wear and tear and rip at the knee, can cause
symptoms of knee pain, when you over 50 years of age. Regular contact with the elderly.
Therefore knee pain in older people need to watch out the occurrence of osteoarthritis.
Osteoarthritis causes pain and stiffness felt movement at the joints, usually the rest of the
body joints, like knees, hips and spine. When coupled with obesity can lead to the elderly can
not do aktivitasnya daily. Osteoarthritis of the knee raised to attack pain and stiffness in the
joints, especially when it comes to stand and walk after sitting for long time.
Osteoarthritis is caused by cartilage or bone network is broken up dipersendian pain
arises. Function of cartilage / cartilage that is dipersendian as bearings to withstand the
motion.
So that the bones and joints stay strong and healthy, as a key element is the joint fluid for
lubricating and nutrition proteoglycan as water storage and collagen molecules as guardian of

the stability of proteoglycan molecules. Fixed at the time get older, the production of
proteoglycan and collagen in the body to be reduced, consequently the joint protection layer
becomes thin, resulting in bone and joint stiffness.

PROGNOSIS
The disease was diagnosed by considering the patients medical history, physical examination,
and images of infected joints. The diagnosis focused on two major goals. First, to differentiate
types of joints pain and arthritis. Secondly, to determine the cause or pathomechanisme of the
disease.
Accurate diagnosis should is necessary so that an appropriate treatment can be considered. In
diagnosing disease, typically, the doctors in this case, WE need to do a physical examination.
In this examination, we observe any signs or symptoms associated, such as joint swelling, joint
tenderness, decreased of range of motion in joints, visible joint damage, crepitus and pattern of
affected joints.
An x-rays also could be among the steps to diagnosed the disease, as doctors could detect the
abnormalities of bones or affected joints. X-rays can reveal osteophyte at the joints margin,
joints space narrowing, and sclerosis. Eventhough x-rays revealed the apperance of joints, it is
not always correlated to certain disease we might think off.
Thus, laboratory test should also be made, and it is normal procedure for joints pain patients, as
we could detect the disease approximately.
Besides that, the doctors could use America College of Rheumatology (ACR) criteria that has
been established for diagnosing rheumatology problem.

TREATMENT
Every patients has a different survival towards the disease. Some patients might become worse,
some might maintain and some patient might have a healthy improvement. The condition is
depends on the lifestyle of the patients.

Non-Pharmacological Therapy
Education and Information
Purpose of education and information so that patients know some specifics about the illness, how
to secure it so that the disease is not increased severe and permanent joints can be used
Physical Therapy and Rehabilitation
These therapies are used to train patients to fixed joints can be used and to train patients to
protect joints
Weight Loss
Excessive body weight has been a factor that will aggravate OA disease. Therefore weight should
always be on guard so as not greater, when greater, then the weight loss should be sought.
Pharmacological Therapy
Oral Analgesics Non-opiate
In general, patients have tried to treat his own illness, especially in the case megurangi and
relieve pain
Analgesic topical
Topical analgesic we can easily obtain also in consumption of pain patients to meredahkan
Medication non-steroidal antiinflammatory
When the analgesic medicines that were given would not work in general, patients come to the
doctor, this drug effect analgetik other member is also member-inflammatory effects. OA patients
because so many elderly have to be careful in giving this type of drug. So pick a cure for the
minimal and modest attire.
Chondroprotective Agent

Does the Agent is chondroprotective drugs that can protect and stimulate repair (repair) joint
cartilage in OA patients. Some researchers classify these drugs in slow acting anti Osteoarthritis
Drugs (SAAODs) or Disease Modifying Osteoarthritis Drugs Anti.
Surgical therapy
This therapy is given when pharmacological therapy failed to reduce pain and also to make
correction in the event of joint deformities that interfere with daily activities.
Non-pharmacological therapy
i.
ii.
iii.

Education and Information

Physical Therapy and Rehabilitation
Weight Loss

Pharmacological Therapy
i.
ii.
iii.
iv.
v.

Analgesics non-opiate oral

Topical Analgesic
Medication non-steroidal anti-inflammatory
Chondroprotective
steroids intra-artikuler

Surgical Therapy
i.
ii.
iii.
iv.

Malaligment, valgus knee deformity, Varus

Arthroscopic debridement and joint lavage
Osteotomi
total joint Artroplasti

REFERENCES
Mercks manual
Harrisons Manual
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552988/

http://clinical.diabetesjournals.org/content/19/3/132.full