Arthritis CIS

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 Readings
CMDT2017
8269,17034,171314
RobbinsandCotran Pathologicbasisof
disease
12089

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 Case
A58yo malepresentswithacomplaintof
progressivediffusehippainoverthelast
severalmonths.Itgotworseafterhereturned
fromafamilyvacation,andhasnowstartedto
botherhimwhilehestryingtosleep,which
madehimfinallyscheduletheappt.Hehas
noticedstiffnessafteralotofwalking.Hehas
triedheatwhichhasnothelped.Thepainis
worstdeepinhisgroinregionwithsome
radiationposteriorly.
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 Case
Otherquestionstoask?

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 History
OPPQRSTA?
PMH?
FH?

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 Case
A58yo malepresentswithacomplaintofprogressivediffuse
hippainoverthelastseveralmonths.Hedescribesitasa
constantache.Itgotworseafterhereturnedfromafamily
vacation,andhasnowstartedtobotherhimwhilehestryingto
sleep,whichmadehimfinallyscheduletheappt.Hehasnoticed
stiffnessafteralotofwalking.Thepainisworsewithgoingupor
downstairs.Hehastriedheatwhichhasnothelped,andhehas
nottriedanymedication.Thepainisworstdeepinhisgroin
regionwithsomeradiationposteriorly,andrangesfrom37/10
onapainscale. Hehasnothadproblemswithhishipbefore.He
hasnoknownFHofsignificantmusculoskeletal/jointproblems.
PMH Denies
PSH Appendectomy

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 Exam
Howwouldyoustructureandperformyour
exam?

Wouldyouorderanyadditionaldiagnostic
studies?

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 Exam
Observe/inspect
Palpate
ROM
Motor/sensory/reflex
Specialtesting
Hipcompartments

Otherdiagnostics
Imaging?

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 Case
DifferentialDx?

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 Differential
OA
RA
Psoriaticarthritis
Goutyarthritis
Hemochromatosis
Infectiousarthritis
Other softtissueabnormality
.

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 question
Whichofthefollowingfindingssupportsyour
numberonedifferential?
A.MCPinvolvement
B.Warmthtotouchofaffectedjoints
C.Prolongedmorningjointstiffness
D.ElevatedESR
E.Heberdensnodes

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 question
Whichofthefollowingfindingsraisesyour
indexofsuspicionforadifferentdiagnosis
fromyourdifferentiallist?
A.Osteophytesonxray
B.Jointlinetenderness
C.Oligoarticular involvement
D.Uratecrystalsinsynovialfluid
E.Jointspaceloss

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 OA DifferentialDx
RA
Morningjointstiffness,RF,ElevatedESR,CRP,antibodytocycliccitrullinated peptide(CCP)
LongstandingRAmaydevelopsecondaryOA
PsoriaticArthritis
Maytarget1DIP,nailchanges
CrystallineArthritis
Synovialfluid uratecrystals,gout
Hemochromatosis
Feoverload
MCP,wrists
Infectious
Leukocytosis
Synovialorbloodculture
OtherSofttissueabnormalities
Labralimpingement/tear

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 Osteoarthritis(OA)
DegenerativeJointDisease(DJD)
Mostcommonjointdisease
Characteristicallynoninflammatory
Lackofsystemicsymptoms
Painrelievedbyrest,ifpresent morningjoint
stiffness=brief
Oligoarticular
Generalized
Agingphenomenon
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 OA/DJDCharacteristics
Bony changes in joint shape
Crepitus
Malalignment/Instability
Limited ROM
Joint line tenderness
Cool effusions
Spasm or atrophy of adjacent muscles

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 ?Riskfactors?
Systemic Local
Age Musclestrength
Obesity Proprioception
Genetics Repetitiveuse
Gender Jointconfiguration
Menopause Trauma

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 question
Whichofthefollowingjointsorregionsis
quitecommonlyaffectedbyOA?
A.MCP
B.Thoracicspine
C.wrist
D.Cervicalspine

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Osteoarthritis
Graphic105815Version1.0.UpToDate

Common
Cervical spine
Lumbar spine
1st CMC
PIP
DIP
Hip
Knee
1st MTP

Lesscommon
Shoulder
Thoracicspine
Elbow
Wrist
MCP
Ankle
Subtalar

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 question
Whichofthefollowingmaybeexpectedonan
xrayofthispatientship?
A.spondylosis
B.widenedjointspace
C.sclerosisoffemoralhead
D.tophi

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Imaging

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 OARadiographicfindings
Jointspacenarrowing
Osteophytesandmarginallipping
Subchondralthickening
Bonecysts
Jointmice

Radiographicfindingsdontalwaysdirectlycorrelateto
degreeofsymptoms

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Images

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 OA

Degenerationofarticularcartilage
Synovialjoints
Structure/functionfailure
Chondrocytes=biochemical,mechanicalstress
Breakdownofmatrix

Why?

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 OA
Damagefrom physicalforces
Chondrocytesreact
releasedegradativeenzymes
inadequaterepairresponse
dropout,cartilageloss,bonechanges,
loosebodies(jointmice)
Fundamentaldefectivecartilagefailsunder
normaljointloading
TypeIIcollagengenedefect
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 OA
Subchondralbone=newarticularsurface
Friction,boneeburnation
Sclerosis,smallfracture,synovialfluidcontaining
cyst
Alteredbonecontour,lipping
Osteophyteatmarginasfibrocartilageandhyaline
cartilageossify.

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26
 OAheredity
RiskofOA=sumofmultiplegenes
Geneticallyheterogeneous
Heritablecomponent
Particularlyhandandhip
Generalizedosteoarthritischaracterizedby
osteophytesoftheDIP (Heberdens nodes)
andPIP joints(Bouchards nodes)

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 OA
Progressive deterioration
loss of articular cartilage
loss of structure & function
Primary
Aging or Idiopathic
Genetic: Nodal OA
Secondary
disorders that damage joint surfaces

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OAcharacteristics
Alteredchondrocytefunction
Lossofcartilage
thinning
Subchondralbonethickening
sclerosis
Remodelingofbone
Marginalspurs
osteophytes
Subchondralbone
Cysticchanges
Mildreactivesynovitis

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OA Findings

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Imaging

Thisplainfilmdemonstratescompletelossof
thearticularcartilageatallfourDIPjoints,
largeosteophytes,andankylosis oftheDIP
jointofthemiddlefinger.
CourtesyofBruceCAnderson,MD.
Graphic55802Version2.0UpToDate

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Principalmanifestationsof
osteoarthritis
Graphic108692Version1.0.UptoDate
Patientcharacteristics
Ageofonset >40years*
Symptoms
Affectsoneorafewjointsatatime
Insidiousonset slowprogressionoveryears
Variableintensity
Pain
Maybeintermittent
Increasedbyjointuseandrelievedbyrest
Nightpaininsevere osteoarthritis
Shortlived(<30minutes)andearlymorning or
Stiffness
inactivityrelated
Some(eg,nodalosteoarthritis)patientspresent
Swelling
withswellingand/ordeformity
Constitutionalsymptoms Absent
Physicalexamfindings
Swelling(bonyovergrowth fluid/synovial
hypertrophy)
Attitude
Appearance
Deformity
Musclewasting(global allmusclesactingover
thejoint)
Absenceofwarmth
Swelling(effusionifpresentisusuallysmalland
Palpation cool)
Jointlinetenderness
Periarticulartenderness(especiallyknee,hip)
Crepitus(knee,thumbbases)
Rangeofmotion Reducedrangeofmovement
Weaklocalmuscles

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Clinical distinction between rheumatoid
arthritis and osteoarthritis
Graphic57005Version5.0.UpToDate

Feature Rheumatoidarthritis Osteoarthritis

Metacarpophalangeal Distalinterphalangeal
Primaryjointsaffected
Proximalinterphalangeal Carpometacarpal
Heberden'snodes Absent Frequentlypresent
Jointcharacteristics Soft,warm,andtender Hardandbony
Ifpresent,worseafter
Worseafterresting(eg,
Stiffness effort,maybedescribed
morningstiffness)
aseveningstiffness
Positiverheumatoid Rheumatoidfactor
factor negative
Laboratoryfindings AntiCCPantibody
PositiveantiCCPantibody
negative
ElevatedESRandCRP NormalESRandCRP

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 OASubsets
Generalized
Spine,hand,+other
Nodal
Spondylosis
FacetjointOA,frequently+DDD
Erosive
Rare,DIPmorecommonthatPIP
Hyperostosis
Chondromalaciapatellae

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Images

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 Hyperostosis
DiffuseIdiopathicSkeletalHyperostosis(DISH)
>50yoa,M>F
Frequentlybutnotalwaysasymptomatic
Cervicalspine=dysphagia
Osteophytosis ofspine
spans>34segments
Paraspinous Ligaments=calcifications/ossification
Flowingwaxappearanceonanteriorvertebralbodies
Preservationofdiscspace
SomeassociationwithDM

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Images

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 ManagementofOA
NoCure
Paincontrol
Minimizedisability
Function,activitylevel
Improvequalityoflife
Education
Surgery
Nonpharmacologic
OMTtoaddresscompensatorychanges
Exercise,PT,OT,wt loss,acupuncture

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 question
Whichofthefollowingpharmacologic
interventionswouldyourecommendfirstin
thecaseofthis58yo male?
A.glucosamine,chondroitin
B.intraarticularglucocorticoids
C.acetaminophen
D.narcoticanalgesic

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 Pharmacologictreatment
Acetaminophen
NSAID
TopicalNSAID
Capsaicin
Intraarticularglucocorticoids

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 Otherpharmacotherapy
Ifsymptomaticreliefinadequate,consider:
Intraarticularhyaluronicacid
Plateletrichplasma
Glucosamineandchondroitin
Opioidanalgesics

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 Objectives
DiscussandperformaproblemfocusedHistoryand
Physicalonapt withjointpain
Constructadifferentialdxforjointpain
Knowthetypicalpresentingsymptoms,expectedexam
findings,andradiologicfindingsassociatedwithOA
Reviewthepathologicchangesanddistinguishing
featuresinOA
DiscusstreatmentoptionsforOA
KnowthejointscommonlyassociatedwithOA
ReviewsubsetsofOA

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